Below are answers to many questions you may have about jaw pain surgery or TMJ surgery, a form of reconstructive surgery performed in Denver, CO by surgeon, Randolph C. Robinson, MD, DDS, FAACS:
The temporomandibular joint is the jaw joint that allows the mouth to open and close for talking and chewing. Joints are named based on the bones on either side of the joint. So in the case of the TMJ, the mandible or jawbone articulates with the temporal bone at the base of the skull.
Everybody has two TMJs, one on the right and one on the left, and when the jaw moves, both joints move. The joint is located just in front of the ear canal.
TMJ disorders can be caused by several things, including trauma, malocclusion, stress, grinding the teeth and skeletal growth deformity. Some systemic diseases, such as rheumatoid arthritis, can also affect the TMJs.
If you’re suffering from a possible TMJ condition, contact our office to schedule an appointment with Dr. Randy Robinson. At Robinson Cosmetic Surgery, here in Lone Tree, CO, we’re here to help.
There are three main categories of TMJ disorders. The first is called myofascial pain dysfunction (MPD). This problem usually involves spasms and pain associated in the muscles that move the joint, such as in the temporal area or along the jaw line. Despite the pain, the joint itself is usually non-tender. Migraine headaches may also be associated with this condition.
Patients may experience some associated neck and shoulder pain and the muscle spasms are usually related to some type of stress, trauma or malocclusion (misaligned bite). The treatment for myofascial pain dysfunction involves physical therapy, muscle relaxants, and possibly a splint between the teeth in order to help relax the muscles and achieve a balanced bite. Botox may also be used in some extreme cases.
Balancing the bite is similar to putting a lift in a shoe for someone who has leg length differences that cause back, hip and knee pain. Further treatment may involve orthodontics and jaw surgery, or new crowns and bridges to help stabilize the bite.
The second type of TMJ disorder involves a true internal derangement of the temporomandibular joint. Inside the joint is a disc, and this disc slides on top of the articular head of the lower jaw, called the condyle, as the mouth opens. It is possible for this disc to be displaced resulting in accompanying joint sounds, such as popping and clicking. Many people have pops and clicks in their joints without degenerative changes, while degenerative changes are usually signaled by pain in the joint.
The disc may be completely dislocated anterior to the joint so that opening is limited. With internal derangement, associated muscle pain may occur, but usually pain exists directly in front of the ear. Patients usually find it beneficial to eat a soft diet.
Usually magnetic resonance imaging (MRI) is needed in order to confirm the diagnosis of an internal derangement in the joint. Internal derangements, like myofascial pain dysfunction, can be treated with physical therapy, muscle relaxants, and splint therapy but only to a limited degree. If the conservative measures fail, TMJ surgery may be necessary.
The third type of TMJ problem is called idiopathic condylar resorption, or ICR. This degenerative process causes the condyles to shrink away. The cause is not understood but may relate to bite problems, especially openbites, in female patients. It is characterized by low or high levels of pain with bite changes. X-rays show the destructive bone pattern.
The treatment of ICR involves a combination of anti-inflamatory, anti-arthritic, anti-bruxism, and anti-oxidant medications including pyroxicam (Feldene), doxycycline, amitriptyline and vitamin C and vitamin A. Occasionally, it is necessary to use secondary anti-inflamatory medications such as simvastatin (Zocor) and entanercept (Embrel).
After stabilizing the condylar resorption then the jaw and bite can be rebuild using TMJ reconstruction, orthodontics, orthognathic surgery, and new crowns depending on the needs of the patient. Many patients with ICR have recessive chins and only hit on their back teeth. Without arresting the progression of the disease first then the resorption may continue.
Surgery on the TMJ is usually performed under a general anesthetic on an outpatient basis. There are three main surgeries for the TMJ: Arthroscopy, Open Arthroplasty with or without disc replacement, and Total or Partial Joint Reconstruction. The surgery chosen must be tailored to meet the needs of the patient. The highlights of each are outlined below.
In the Arthroscopic procedure two small holes are made in front of the ear. A small tube with a camera (endoscope) is passed into the joint space, and the joint is explored. This visualization helps clarify the diagnosis, as well as irrigating the joint free of any debris.
Instruments can be used in conjunction with the scope in order to breakup any adhesions (arthritic scarring) inside the joint and to help mobilize the disc. The incisions are closed with sutures that are removed in one week. Physical therapy will usually begin one week following the surgery.
The second type of TMJ surgery is called Open Arthroplasty with or without disc replacement. It involves making a short incision in front of the ear and exploring the joint directly. The incision in front of the ear is usually very esthetic and in the same position as a facelift incision.
With an open joint procedure, it is actually possible to reposition the disc and reshape any damaged bone. Occasionally, if the disc is completely degenerated or torn, it must be completely removed.
Historically, various materials have been used to replace the disc, including synthetic materials, ear cartilage, and temporalis fascia muscle (the large “biting” muscle on the side of the head). In many cases it is not necessary to replace the disc at all, if physical therapy alone can keep the bones and the joint from fusing together. If there is a risk of fusing because of repeated surgery or significant arthritis then a partial joint replacement may be necessary as described below.
The third type of temporomandibular joint surgery is Total or Partial Joint Reconstruction. The reconstruction is typically performed using a person’s rib or a portion of the collar bone or a metal prosthetic joint. The reconstruction involves not only an incision in front of the ear, but also one in the lower part of the jaw just onto the neck.
The Partial Joint Reconstruction involves removing the disc and replacing it with a metal fossa or liner to keep the joint from becoming bone on bone. This technique has become more popular and was developed by Dr. Bob Christiansen. The metal joints are usually custom made for each individual patient based on a 3D CT scan and a plastic reproduction of the patient’s joint. The metal is usually an alloy of cobalt and chromium.
Orthognathic surgery (surgery to correct jaw growth problems) is sometimes used combined with TMJ surgery in order to help establish the jaw into a more stable position to decrease the internal forces inside the joint.
Immediately after surgery, a moderate amount of swelling will occur. It will last approximately three to four days before it begins to go down.
Depending on the extent of surgery, some bruising may appear in front of the ear or onto the neck and cheek. If a rib graft is harvested, you may have some discomfort in taking a full, deep breath. Despite this experience, deep breathing is important so that the lungs do not develop an infection.
The sutures are removed after one week, and if the teeth are not wired together, physical therapy is begun at that time. This therapy initially involves some stretching and mobility exercises in order to keep the joint from scarring. Physical therapy is important. When patients do not follow this regimen, they may not ever be able to open their mouths as far.
After surgery, the patient is prescribed a course of antibiotics, steroids and pain medicine. A non-steroidal anti-inflammatory agent will also be given on a longer term basis during the healing phase.
Possible complications of TMJ surgery include: continued degenerative changes inside the joint, with little relief from pain or little improvement in function, bleeding, and infection. Also nerve injury may follow surgery, including numbness in front of the ear or damage to the nerve which moves the eyebrow and/or the lower lip. Further, surgery may change the bite and/or damage the teeth.
A risk associated with harvesting rib grafts is that the lungs may partially deflate, requiring use of a tube to re-inflate the lungs through the outside of the chest.
If you have questions regarding the surgery, make sure your surgeon answers each concern thoroughly.
- Do not eat or drink anything after midnight the night before surgery so that your stomach is completely empty. If you are likely to be nauseated, consult with your surgeon about anti-nausea medications you can take before surgery.
- Wear loose, comfortable clothing that is easy to put on and take off.
- Bring someone with you who can take you home and be with you – attentive to your needs with walking, eating, bathing, and resting – for the first 48 hours following surgery.
- Take no aspirin products, ibuprofen, or vitamin E two weeks before surgery, unless otherwise directed by your surgeon.
- Begin taking 1000 mg vitamin C , in four 250 mg doses, daily one month prior to surgery.
- Prepare for any physical therapy that may be necessary following surgery.
- Keep head elevated on two pillows for two weeks or sleep in a lounge chair so the head remains elevated.
- Apply ice to the face in front of the ear for the first 24 to 36 hours.
- Eat a “non-chew,” soft diet until instructed to do otherwise.
- Take medication as directed.
- Apply ointment as directed to the incision sites.
- If a rib graft was taken, make sure to take deep breaths at least four times per day for five minutes to decrease the chance of lung infections.
- Beginning one week following surgery, perform physical therapy stretching exercises as directed. Taking your pain medicine or anti-inflammatory agents at least 30 minutes prior to beginning physical therapy can be helpful. Apply heat to the face for approximately 10 to 15 minutes before stretching exercises.
- Call your surgeon with any questions and especially if:
- temperature is greater than 101.0° F by mouth
- excessive bleeding or rapid swelling occurs
- pain is unrelieved by prescribed pain medications
- breathing is difficult
- you experience sudden shift of the bite
- Continue multi-vitamins and 1,000 mg vitamin C, in four 250 mg doses, daily for six weeks after surgery.
Talk to a Top Jaw Pain/TMJ Surgery Specialist Today
If you’d like to talk to specialized oral surgeon in Denver about your options for surgical treatment for jaw pain or TMJ, contact the office of Dr. Randolph Robinson to schedule an appointment (a physicians order may be required). Contact your insurance company for coverage details.