Temporomandibular Disorder Surgery covers a wide range of painful oral and facial symptoms involving the joint and surrounding facial muscles. Conditions primarily involving the soft tissues, the most common of which is bruxism (grinding) can be managed successfully with non-surgical modalities (bite guard, diet, heat, anti-inflammatories).
True problems involving the joint itself, the most common of which is a disc displacement (internal derangement) may also respond favorably to the modalities. Those patients who continue to have persistent pain and jaw dysfunction, and fail to respond well to non-surgical modalities, may elect to consider a surgical procedure to treat the joint.
RANGE OF SURGICAL OPTIONS
Surgical options fall into the following categories:
Arthrocentesis – an office based procedure involving the irrigation of the joint using small needles, usually performed under sedation. Reserved for patients with inflammation of the joint, or acute disc displacement.
Arthroscopic surgery – can be either diagnostic or therapeutic. It is performed through 2 or 3 puncture sites in front of the ear. Clinical conditions that respond well to this procedure are a chronically displaced disk with a locked joint. It can also be therapeutic for a patient with inflammatory arthritis. It is very difficult to anatomically reposition a displaced disc via arthroscopic surgery. The goals of this procedure are to remove inflammatory tissue from the joint, free up scar tissue and increase joint mobility. It is commonly performed with sedation/general anesthesia on an outpatient basis.
Arthroplasty – classic, open surgical approach to treating disc displacement. Common indications are for a clicking joint or locked joint caused by a displaced disk. A small incision is placed cosmetically through a crease in front of the ear. The main requirement for this approach includes management of the disc/cartilage with a healthy mandibular condyle (ball joint). If the disk is salvageable, it can be repositioned, and then secured to the condyle with a permanent stitch. If the disc is damaged beyond repair, it must be removed.The decision to replace the disk is made at the time of surgery either with artificial or natural material. This procedure is indicated only if the mandibular condyle is healthy, as determined by a pre-operative MRI scan. Arthroplasty is normally performed under general anesthesia in an outpatient setting.
Fused joint (Ankylosis)
Depending upon age, amount of damage to the temporomandibular joint, and previous surgeries, replacement of all (total) or part (partial) of the joint structures may be indicated. Indications for this surgery include:
Severe TMJ degenerative arthritis
- Inflammatory arthritis that has not responded to other therapies
- If the tissues of the joint fuse (ankylosis) causing loss of motion in the joint, resulting in inability to open the mouth properly
- If bite changes and/or facial appearance has changed as a result of a TMJ problem
- Severe internal worsening (internal derangement) that does not respond to other therapies
- If previous attempts at surgery by opening the joint have failed to resolve the problem
- Loss of normal anatomy of the joint due to trauma or pathology of the TMJ
TYPES OF JOINT REPLACEMENTS
Depending on the patient’s age and condition, joint replacement can be performed with either natural or artificial materials. For an actively growing patient, the use of a patient’s own rib is preferred. For an adult, we prefer the use of a metallic joint replacement, which has been shown to have long lasting success in many patients. Joint replacements can be used of standard (stock) sizes or customized (patient specific) to fit each individual patient.
Partial joint replacement
Stock Joint Replacement
The Custom Joint Replacement Process
A specially formatted CT scan is taken of the facial bones, and the data is sent to the joint manufacturer. An extremely accurate anatomic model is manufactured from the computerized data that is used to design the implants.
Once the design process is approved by both the surgeon and the manufacturer, the joint is manufactured. Joint prostheses can be made as metal against polymer, designed by computer (CAD CAM) or by a direct wax, which is then cast as a metal against metal joint.
Patient-specific prosthesis wax-up
Titanium/PTFE patient specific prosthesis
Completed prosthesis ready for insertion
The Surgical Procedure
Although each replacement is unique for each patient’s condition, most patients can expect a 1-2 day stay in the hospital. Surgical braces, or standard orthodontic appliances, are applied to line up the teeth during the procedure and are removed postoperatively. Patients that also have a jaw deformity or bite discrepancy may also undergo jaw repositioning at the same time. Although the jaws are not wired shut after the surgery, physical therapy is required as soon after the procedure as possible. This involves use of a hand held jaw exerciser and frequent visits to the therapist. A non-chew diet can be expected for the first 2-4 weeks following surgery.
Pre-op patient for joint replacement with jaw deformity
Preoperative open bite
Dr. Sultan has been specially trained in the use of both partial and total joint replacements. He has taken part in educational meetings and performed surgery both nationally and abroad. He is one of the few surgeons in South Florida experienced to perform these procedures