Arthocentesis

Description: Arthocentesis, or joint aspiration, is not truly a surgery and is often performed in the doctors office. TMJ Arthrocentesis is a procedure where the doctor injects saline into the joint to expand the area to possibly allow the disc to move back into place. The doctor then drains the fluid from the joint, to be evaluated. The doctor often injects more solution into the joint to further clean or flush it out. Medication--sterioid or aneshetics--are sometimes injected into the joint. This procedure is sometimes called joint flushing or disc floating.

Post-procedure care: Compressive, cold therapy, pain medication.

 Arthroscopy

Indications: Internal derangements, adhesions, fibrosis, and degenerative joint disease

Description: TMJ arthroscopic surgery is a form of surgery in which a very thin (1/8th inch in diameter) surgical telescope is placed into your upper TMJ space through a very small (1/4 inch) incision directly in front of your ear.  This instrument is used to determine what type of damage exists within your joint and perform corrective maneuvers such as a lysis (breaking up) of adhesions (scar tissue), removal of loose bodies by lavage (washing out the joint), biopsy (tissue sample), and placement of steroid medication.  

TMJ arthroscopic surgery usually works by freeing the disk from being held in a forward position within the socket by adhesions (scar tissue).  Breaking of these adhesions (lysis of adhesions) releases the disk and allows it either to return to a normal or more normal position and allows increased mobility of joint structures.

Post-procedure care: Thermal therapy, pain medication, aggressive physical therapy including motion therapy, close and frequent follow up,

(Please see our Post-surgical Rehabilation page for more information.)

Arthroplasty

Indications: Dislocated/damaged discs, bony aberrations and ankylosis, severe adhesions

Description: TMJ arthroplasty is an open joint surgery performed in patients who have intolerable and/or intractable TMJ pain.  Most patients have failed non-surgical treatment and/or arthroscopic surgery. This is the surgery of choice for patients with bony intracapsular ankylosis. Open joint procedures include discoplasty (meniscoplasty, repair and/or relocation of the disc), discectomy (meniscectomy, removal of the disc with or without replacement), condylectomy, condylotomy, and total or partial joint replacement.

Arthroplasty is an open TMJ surgery involved making an incision over the joint area in front of the ear. The incision usually extends from inside the sideburn area, then in front of the top of the ear then extending into the ear itself.  The part that extends into the ear is placed there to hide incision from view.  This “skin flap” is then reflected forward to expose the underlying layers. 

The fascial layer is exposed and reflected, exposing the TMJ capsule.  The capsule is opened, revealing the disk (meniscus).  This is usually the structure causing your symptoms.  The disk is carefully examined, its position, thickness, smoothness, and flexibility is noted. The bony surfaces of the TMJ are examined:  special care is taken to identify rough surfaces, sharp edges, cavities or anatomical abnormalities.  If the disk is healthy enough it is repaired; repair involves pulling the disk into a more normal position and holding it there with stitches (sutures). 

If the disk is abnormally stretched out it is “tightened” by taking a wedge of tissue out behind the disk and suturing the edges together.  If the disk is damaged beyond repair it must be removed; if an excessively damaged disk is not removed it may continue to cause the same symptoms after surgery.  This final decision to repair or remove the disk is made after directly examining the disk at surgery. 

After the disk is repaired/removed the bony surfaces are examined; any excessively rough surfaces are smoothed out with surgical files. If the disc was removed the surgeon will decide whether to not replace the disc, to implant a temporary disc, or to replace it with a graft of tissue from the patient.

Post-procedure care: Thermal therapy, pain medication, aggressive physical therapy including motion therapy, close and frequent follow up,

(Please see our Post-surgical Rehabilation page for more information.)

Total or Partial Joint Replacement

Indications: Post-tumor resection, post-trauma/fracture, microsomia, surgically mutilated joints, anklosis, serverely degenerated joints.

Description: TMJ total joint replacement (TJR) is an open joint surgery performed in patients who have intolerable and/or intractable TMJ pain and severe joint damage.  Most patients have failed multiple modalities of previous treatment including non-surgical treatment and often multiple surgeries. TJRs include replacing the condyle with metal or a rib graft, the  

A TMJ TJR surgery requires two incisions.  An upper incision is made over the joint area in front of the ear.  A lower incision is made in a skin crease (if present) in the upper neck.  The upper incision usually extends from inside the sideburn area, then in front of the top of the ear then extending into the ear itself.  The part that extends into the ear is placed there to hide incision from view.  This “skin flap” is then reflected forward to expose the underlying layers.  The fascia layer is exposed and reflected, exposing the TMJ capsule.  The capsule is opened and the bones of the joint examined, special care is taken to identify rough surfaces, sharp edges, cavities or anatomical abnormalities.  The disk (meniscus) usually has been removed during a previous surgery.

The lower incision is then made through the tissues of the neck until the mandible (lower jaw) is encountered.  This incision exposes the part of the lower jaw where the condylar prosthesis is screwed into place.  The lower incision is connected to the upper incision through a tunnel under the tissues.

The fossa (socket) is smoothed down with power tools.  The condyle is cut off to allow room for the metal replacement.  The fossa prosthesis is placed into the natural fossa and held in place with wires or screws.  The condyle is then fitted into position and attached to the lower jaw with two or three screws. Most prosthetic joints are now custom made for each individual patient.

In a rib graft, instead of prosthesis' being implanted, the condyle is cut down and a section of the patients rib is attached in its place. This rib graft acts as a new condyle within the joint.

Just before the incisions are made the patient’s jaws are often wired together.  This is done so that when the TMJ TJR procedure is done the teeth will be in the right position.  The jaws will be wired together generally for a few days to a week after surgery.

The upper incision is similar to the front part of a facelift incision and is therefore very cosmetic.  Usually the only visible part of the scar is just in front of the upper part of the ear.  The rest of the scar is hidden in the sideburn area and inside the ear.  The lower incision is usually camouflaged nicely by the skin crease in which it lies.  Usually the incisions are almost entirely undetectable.

Post-procedure care: Thermal therapy, pain medication, aggressive physical therapy including CPM, close and frequent follow up, yearly evaluation with imaging

(Please see our Post-surgical Rehabilation page for more information.)

Orthognathic

Indications: Trauma, arthritis, ankylosis, congential condition, cosmetic

Description: Orthognathic surgery is corrective jaw surgery which realigns poorly fitting upper and lower jaws.  Orthognathic surgery literally means “jaw straightening” surgery (gnathos – jaw, ortho-straighten).  This is a very sophisticated form of treatment which is usually performed by a specialist with training in corrective jaw surgery. 

Orthognathic surgery is used to correct three types of problems:

Functional (bad bite)

These procedures are commonly used to correct bite problems (malocclusion) which are too great to correct with orthodontic treatment (braces) alone.  For example, the lower jaw and teeth may be too far back (under-bite) or too far forward.  The upper jaw and teeth may also be too far forward or back.  Correction of these problems will usually result in better chewing, and sometimes better speech.

Cosmetic (appearance)

In a certain number of people an “underbite” or “overbite” condition exists which results in one or both of the jaws being too “long” or “short”, resulting in less than ideal cosmetic appearance with an imbalance of facial features.  The upper jaw may be too long with excessive display of gum tissue with smiling.  There also may be an asymmetry (crookedness) to the lower face.  If the imbalance of the jaws is corrected, usually there is a noticeable improvement in the cosmetic appearance.

TMJ (jaw joint) problems

In other individuals the jaw disharmony or malocclusion will result in a painful condition of one or both Temporomandibular joints (clicking, popping, limited oral opening, jaw, head and neck pain).  With realignment of the jaws the joint condition will often improve.  Dental splint therapy may be necessary before either orthodontic treatment or jaw surgery.

Post-procedure care:Compressive and Thermal therapy for pain and swelling, pain medication, soft foods, follow up visits

(Please see our Post-surgical Rehabilation page for more information.)