Temporomandibular Joint Disease Surgery

Dr. Maury Hafernik D.D.S. ImageMPD vs. Intra-articular Disease

This page is likely the most controversial on this entire site. You may "surf the net" and find about as many opinions as you would like on this subject.........does your doctor think that surgery is the answer? Splint therapy the answer? Is the splint made correctly?? Etc, etc, etc...

BASIC  DEFINITIONS
  1. Intra-articular disease - this is the damaging changes that occur to the jaw joint, such as degenerative joint disease (DJD), unusual growth and development, and other rarer causes. These are changes to the bony and soft tissue components - changes that for the most part are irreversible.

  2. Myofascial pain disease (MPD) - in a very simple explanation - the muscular and ligament pains that occur due to overuse and tearing. This is quite often reversible.

These two entities above are often grouped together as "TMJ". They may exist at the same time, but they are NOT the same. 

TREATMENT OPTIONS

Intra-articular disease - most often approached as being surgical. 

  1. Arthrocentesis - needles are placed into the joint and a solution is washed through the joint space. This is meant to primarily break up adhesions in the joint and hopefully "free up" the disc. Big limitation is that there is NO direct visualization of the joint. This procedure is most often performed in the office.

  2. Arthroscopic surgery - As the name implies - a "scope" is used to look directly into the joint space. There are minimal incisions made to perform this procedure. Most often used for disc problems such as adhesions and dislocations. This surgery does require general anesthesia and all the associated costs that go along with that.

  3. Open joint surgery - Much more invasive than arthroscopic procedures but required when performing any of the following -
    a. Joint reconstruction.
    b. Prosthetic joint replacement.

Myofascial pain disease (MPD) - nonsurgical in approach.

  1. Physical therapy.

  2. Drug therapy - non-steroidal anti-inflammatory and muscular relaxation meds most commonly.

  3. Splint therapy - to allow the jaw joint (TMJ) to assume its most correct position which in turn will allow the muscular and ligament tissues to "relax". For much more detailed information on splint therapy click here
    NOTE - splint therapy cannot reverse the damages caused by intra-articular disease. If a joint is not badly damaged, a person may be able to avoid further breakdown and surgery with correct splint therapy and associated bite corrections. 

CONCLUSIONS

This conclusion is based on my personal experiences and those of practitioners that have been my mentors for the past 25 years. In my opinion, surgery is never the first choice of therapy. There are always exceptions to this - one coming to mind is acute macrotrauma (such as severe whiplash) where there has been instantaneous intra-articular change that has taken place. But, the most common TMJ patient that is seen is a person who has had problems for a long while with pain and\or dysfunction with both MPD and intra-articular disease. The major problem with surgery is that it treats the symptom NOT the cause. Almost always the cause of problems is a persons occlusion (bite) and surgery does NOT address this in anyway.

I am NOT saying that TMJ surgery is NEVER required...... there are times it is. But at the same time  most surgeries that I have been exposed to have been after the fact and had failed to achieve stability or long-term success.  There is no such thing as non-invasive surgery. All surgery is invasive by nature and I have seen the failures much more than I have seen successes. There are certain muscular and orthopedic truths that can not be addressed in this limited forum that leads towards non-surgery. Splint therapy is both therapeutic and diagnostic when administered correctly.

[Wisdom Teeth] [Orthognatic Surgery]  [Fractures] [Chin]
[Oral Pathology] [Extraction Instructions] [TMJ Surgery]

 

Extraction Instructions

One of the main goals of modern dentistry is the prevention of tooth loss. All possible measures should be taken to preserve and maintain your teeth because the loss of a single tooth can have a major impact upon your dental health and appearance. However, it is still sometimes necessary to remove a tooth. Here are some of the reasons a tooth may need to be extracted.

  • Severe Decay
  • Advanced periodontal disease
  • Infection or abscess
  • Orthodontic correction
  • Malpositioned teeth
  • Fractured teeth or roots
  • Impacted teeth

If you've just had a tooth extracted or your dentist has recommended that a tooth be extracted, the following information will help you get through the first few days after your extraction. Should anything occur that seems out of the normal, do not hesitate to call your dentist. 

POSTOPERATIVE INSTRUCTIONS

  • DO NOT DISTURB THE WOUND: In doing so you may invite irritation, infection and/or bleeding. Be sure to chew on the opposite side for 24 hours and keep anything sharp from entering the wound (i.e. eating utensils etc. ).
  • DO NOT SMOKE FOR 12 HOURS: Smoking will promote bleeding and interfere with healing.
  • BRUSHING: Do not brush your teeth for the first 8 hours after surgery. After, you may brush your teeth gently, but avoid the area of surgery.
  • MOUTH WASH: Avoid all rinsing for 24 hours after extraction. This is to insure the formation of a healing blood clot which is essential to proper wound healing. Disturbance of this clot can lead to increased bleeding or the loss of the blood clot. If the clot is lost, a painful condition called dry socket may occur. You may use warm salt water or mild antiseptic rinses after 24 hours only if prescribed.
  • DO NOT SPIT OR SUCK THROUGH A STRAW: This will promote bleeding and may dislodge the blood clot causing a dry socket.
  • BLEEDING: When you leave the office, you will be given verbal instructions regarding the control of postoperative bleeding. A rolled up gauze pad will be placed on the extraction site and you will be asked to change this dressing every 20 minutes or so depending on the amount of bleeding that is occurring. It is normal for some blood to ooze from the area of surgery. We will also give you a package of gauze to take with you to use at home if the bleeding should continue. Should you need to use the gauze at home, remember to roll it into a ball large enough to cover the wound. Hold firmly in place, by biting or with finger pressure, for about 20-30 minutes. If bleeding still continues, you may fold a tea bag in half and bite down on it. Tea contains Tannic Acid , a styptic, which may help to reduce the bleeding.
  • PAIN: Some discomfort is normal after surgery. Analgesic tablets ( i.e. Aspirin, Tylenol etc. ) may be taken under your dentist's direction. Prescription medication, which may have been given to you, should also be taken as directed. If pain continues, call your dentist.
  • SWELLING: To prevent swelling, apply an ice pack or a cold towel to the outside of your face in the area of the extraction during the first 12 hours. Apply alternately, 20 minutes on then 20 minutes off, for an hour or longer if necessary.
  • DIET: Eat normal regular meals as soon as you are able after surgery. Cold, soft food such as ice cream or yogurt may be the most comfortable for the first day. It is also important to drink plenty of fluids.

    REPORT ANY UNUSUAL OCCURRENCES IMMEDIATELY !

    If you have any questions regarding these directions, call your dentist for clarification.

[Wisdom Teeth] [Orthognatic Surgery]  [Fractures] [Chin]
[Oral Pathology] [Extraction Instructions] [TMJ Surgery]

 

Oral Pathology

The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and coral pink in color. Any alteration in this appearance could be a warning sign for a pathological process. The most serious of these is oral cancer. The following can be signs at the beginning of a pathologic process or cancerous growth:  

  • Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth

  • A sore that fails to heal and bleeds easily

  • A lump or thickening on the skin lining the inside of the mouth

  • Chronic sore throat or hoarseness

  • Difficulty in chewing or swallowing

These changes can be detected on the lips, cheeks, palate, gum tissue around the teeth, tongue, face, and/or neck. Pain is not always necessary to define a pathology and, curiously, is not often associated with oral cancer. However, any patient with facial and/or oral pain without an obvious cause or reason may also be at risk for oral cancer.  

We would recommend performing a oral cancer self examination monthly and remember that your mouth is one of your body's most important warning systems. Do not ignore suspicious lumps or sores, please contact us so we may help you.  

If you feel that you or someone you know have any of the symptoms that have been discussed or if you have any questions and / or concerns, please do not hestitate to contact our office so we may be of some assitance to you. 

[Wisdom Teeth] [Orthognatic Surgery]  [Fractures] [Chin]
[Oral Pathology] [Extraction Instructions] [TMJ Surgery]

 

Chin Reconstruction

surg14

There are multiple ways to change the appearance of a person's chin. In some cases a perceived weak" or "receding" chin is not the problem at all but in fact, the chin is in the right place and it is the remainder of the facial skeleton which is inappropriately positioned. Certainly if there is a major skeletal facial discrepancy, that should be corrected first. We will talk about orthognathic surgery (the process by which such discrepancies are corrected) in a future column. We will talk here about the different ways that the appearance of the chin alone can be surgically altered.

surg15.jpg (3971 bytes)

The chin point can be augmented with materials from the patient's own body (autografting) or with materials from outside the body (allografting) and each has it's own advantages and disadvantages.

In autograft procedures, the surgeon will section the chin from the remainder of the lower jaw, move it forward and reattach it with the aid of plates, wires and/or screws. All of this is done from an incision inside the mouth so that no scars are visible when you look at the patient. The major benefit is the knowledge that the tissue is 100% biocompatible (because it is the patient's OWN chin simply moved forward). For every 5 mm (1/5th inch) the bony chin is moved forward, the soft tissue chin (what you see) will move forward about 4.5 mm (e.g.. just a little bit less). The results tend to be quite stable though some amount of relapse is not terribly unusual. The larger the original move, the larger the relapse is likely to be.

surg16.jpg (3813 bytes) In allograft procedures, the same or a smaller incision is used inside the mouth and a prosthesis is placed in front of the bony chin to give the same effect. You should know that some surgeons use an incision under the chin to do this but this leaves a visible scar, however small, and most of the time, oral maxillofacial surgeons will prefer to hide the scar in the mouth unless there are other procedures being done at the same time such as liposuction under the jaw and neck.   

There are many different materials which have been used over the course of time for augmenting the chin and there have also been problems with reaction to the augmentation material, resorption of the augmentation material or resorption of the chin bone itself (as often happens with silicone implants). Today, one of the nicest options for many patients is the use of a relatively new biocompatible compound. We say it is relatively new because it's major components have both been used in orthopedic surgery for years but only recently have these materials been made available in the form of combined biocompatible implants for facial augmentation. In fact, cheek, chin, mandibular angle (angle of the jaw) and paranasal implants are all available as well as custom created implants fashioned from three dimensional CT scans of the facial skeleton. With the use of this newer material, this procedure too tends to be reasonably stable. The same can not be said for many previous chin implant procedures. 

[Wisdom Teeth] [Orthognatic Surgery]  [Fractures] [Chin]
[Oral Pathology] [Extraction Instructions] [TMJ Surgery]

 

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Dr. Maury Hafernik
11645 Angus Road, Suite 10
Austin, Texas 78759
P: (512) 345-5552

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