A specific subset of TMJ disorders including internal derangement, degenerative joint disease, rheumatoid arthritis, infectious arthritis, synovial chondromatosis, ankylosis, recurrent mandibular dislocation and condylar hyperplasia and hypoplasia are all amenable to surgical intervention.
The decision to perform TMJ surgery must be based upon firm clinical and imaging evidence that a mechanical disruption of the joint structures has occurred and that the degree of limitation in function that has been imposed on the patient justifies the surgery. While TMJ surgery usually does reduce the patient’s daily pain level, TMJ surgery should never be done solely to relieve pain in the absence of significant functional impairment. If the pain is generally well localized to the side of the face, if this pain is increased with TMJ function, and if the patient has not obtained adequate relief from an appropriate nonsurgical treatment protocol [including but not limited to physical therapy, altered diet, medications and an intraoral appliance], then this patient may represent a surgical candidate.
At this stage in treatment planning it is important to determine if the patient may not be a surgical candidate for other reasons. The psychosocial aspect of chronic facial pain must be considered and the surgeon should evaluate the emotional influences on cognitive processes such as decision-making. A patient’s emotional instability, habituation to pain medications, or an impaired cognitive state are all reasons to not consider the patient an appropriate surgical candidate, despite clinical evidence of the patient presenting with a TMJ surgical indication.
In some situations the need for TMJ surgery is unequivocal, such as tumors and neoplasms of the joint, as well as selected fractures of the condyle. There are other situations, with impaired function that is not accompanied by pain, yet TMJ surgical intervention is indicated. These include intracapsular conditions such as aberrant growth (hyperplasia/hypoplasia), ectopic bone formation, synovial chondromatosis, and intracapsular ankylosis, as well as extracapsular conditions such as coronoid elongation. The preceding conditions are not likely to respond to the nonsurgical protocol described above. When any of these condition progressively worsen, resulting in significantly impaired jaw function, a surgical consultation is advised.
It is helpful to explain to the patient that all TMJ surgery is a “controlled injury” in that multiple healthy tissues and structures are impacted during access to the temporomandibular joint, and that surgery poses risk of nerve damage, scar tissue formation and infection. The anticipated benefits of the surgery must outweigh the risk. It should never be stated that the surgical procedure will provide a “cure”, but rather that it has the potential to facilitate the rehabilitation of their TMJ related pain and dysfunction to a more functional state.
The variety of surgical techniques and their risks and benefits is beyond the scope of this description. Articles with additional information are available in the Scientific Literature section under Surgery (TMJ).
