What Is TMJ Surgery

The temporomandibular joint is the hinge-like joint that connects the lower jaw (mandible) to the base of the skull. There are two TMJs, one at each side of the face, located right in front of the ear. The surrounding muscles assist with jaw movements that enable speaking and chewing.

TMJ disorders or dysfunctions (TMD) are conditions that affect the joints and the surrounding ligaments and muscles. They are twice as common in women and people assigned female at birth than in men and people assigned male at birth, and usually affect people between 20 and 40 years of age.¹

The exact cause of TMJ dysfunction is hard to determine because it is usually a combination of factors.

Common causes of TMDs

• Over use of the muscles surrounding the TMJ, usually caused by habits like grinding and clenching of the teeth
• Malocclusion or uneven bite of the teeth
• Stress
• Trauma to the face or head which affects the muscles, ligaments and nerves surrounding the joint
• Wear and tear of the joint
• Arthritis or displacement of disc within the joint²

Signs and symptoms of TMDs

There is a wide range of signs and symptoms associated with different TMDs, here are the most common ones:³

• Pain or tenderness of the joints or surrounding area
• Restricted mouth opening
• Headaches
• Earache or ringing of the ear (where ear infection is ruled out)
• Pain spreading behind the eye, to the face, neck and back
• Clicking sounds in the joint
• Clenching of the teeth
• Locking of the jaw
• Teeth sensitivity without oral cause
• Malocclusion or change of how the upper and lower teeth bite together

These signs and symptoms could be common with other conditions, therefore it is important to seek professional advice from a dentist or oral and maxillofacial specialist for proper diagnosis and management. Conservative therapy options are preferred before proceeding to more invasive options like bite modifications and TMJ surgery.

Various tests can be done to confirm a TMD:

• Physical examination of the joint to locate the areas of discomfort and examine joint movements
• Dental x-rays
• MRI (magnetic resonance imaging)
• CT scan (computed tomography)

Conservative treatment of TMDs

Conservative treatments have been proven to be very effective for the treatment of temporomandibular disorders, there are a variety of treatment options that can be tried before deciding on surgery.⁴

Medication

• Painkillers and anti-inflammatory drugs: these can help to ease the pain. A dentist or maxillofacial specialist can prescribe stronger painkillers if over-the-counter medications are ineffective
• Tricyclic antidepressants: These drugs are used mostly for the treatment of depression, but small doses can also be used to relieve pain, prevent grinding and clenching and manage sleeplessness
• Muscle relaxants: Used for a short period, to treat the pain caused by muscle spasms

Non-drug therapies

• Oral splints or mouth guards: TMJ pain associated with habits like grinding and clenching of the teeth can be managed by wearing oral splints or guards. These devices reduce the stress on the muscles, which can reduce pain and tenderness
• Physical therapies: Exercising or massaging the muscles of the lower jaw, TMJ and neck can be beneficial to release trigger points and spasms. Physical therapies such as moist heat and cold packs can also reduce inflammation and swelling
• Counseling: can be helpful with understanding the stress factors that trigger and aggravate the pain. Patients with chronic pain will benefit from counseling so that they can manage their pain better

Indications for TMJ surgery

While surgery is considered the last treatment option, it has proven to be effective in treating pain and restoring TMJ function. All dental practitioners and maxillofacial surgeons need to be familiar with the treatment options for TMD. Appropriate diagnosis will enable the clinician to provide their patients with the best treatment plan, whether it be conservative or surgical. 

The general indications for TMJ surgery are:⁵

• TMJ disorders that have not responded to non-surgical treatment
• Pain and discomfort that is located in the TMJ
• Pain on functional movement of the TMJ
• Mechanical interference of the TMJ function

Specific indications for TMJ surgery:

• Chronic severe limited mouth opening
• Advanced deterioration of the joint with intolerable symptoms of pain and joint dysfunction
• Confirmation of severe joint disease on CT scan or MRI

Types of TMJ surgery

There are different types of TMJ surgery depending on the extent of the damage to the joint:⁶

Arthrocentesis

Arthrocentesis is the least invasive TMJ surgery, with a recovery period of a day or two. A long needle is inserted into the joint with fluids to irrigate and flush scar and inflammatory tissues. After irrigation, other medications like corticosteroids can be injected into the joint if needed.

Arthroscopy

Arthroscopy (sometimes called keyhole surgery) is another minimally invasive procedure done under sedation, the recovery period is approximately one week. A small incision is made in front of the ear and a small tube carrying a fiber optic camera and light is inserted into the joint space, this aids in better diagnosis of the diseased joint. Treatment can then be carried out, by inserting surgical instruments to remove scar tissues, irrigate the joint space or realign the joint.

Arthroplasty

Arthroplasty which open TMJ surgery is more invasive. The procedure is typically performed under general anesthesia, and recovery takes two to six weeks. A long incision is made in front of the ear. The surgeon can view the joint and surrounding structures under direct vision. This will allow the surgeon to remove any bone growth, tumours, or anomalies that are causing joint pain and dysfunction.

Total joint replacement

This is the most invasive type of TMJ surgery, and is indicated for end-stage TMJ dysfunction treatment. The main indication for this surgery is a total loss of function of the joint, mainly by extended resorption or defect of the condylar process of the mandible. Extensive discussion and a meticulous diagnosis process should be carried out before the final decision is made.⁷

Risks and complications of TMJ surgery

As with any surgical procedure, TMJ surgery can have complications and side effects. Patients should be informed about the following complications before consenting to surgery:⁸

• Postoperative bleeding and infection are common risks associated with invasive surgery. Medications and regular follow-up are important for prevention and early detection of possible complications
• Pain is expected after TMJ surgery, and is usually managed by taking painkillers medications
• Muscle stiffness and swelling are not uncommon and can last for up to 3 weeks after the surgery. Heat packs and exercises can be used to minimize the discomfort and restore function
• Nerve damage, although rare, can occur after the surgery. Patients can experience temporary or permanent numbness at the TMJ region. Temporary or permanent damage to the facial nerve supplying the facial muscles can occur

Patients need to follow up with their doctors after the surgery to track their progress and to manage the complications early. Post-surgical instructions must also be followed strictly to get the maximum benefit of the surgery. Physical therapy and at-home or at-the-clinic exercises can be described to assist with restoration of the joint function.

Summary

Temporomandibular joint surgery is the last treatment option to manage TMJ disorders and dysfunctions. TMJ surgery can include arthrocentesis, arthroscopy and open joint surgery or arthroplasty. Non-surgical treatments like medications, mouth guards, splints, and physical therapy are usually tried before deciding on a TMJ surgery. Patients’ education is essential to manage expectations and to ensure compliance with the post-surgical recovery process.

If you are experiencing any type of pain, or discomfort in the TMJ area, seeking professional advice is very important, to ensure early diagnosis and management. Your dental specialist will usually go through an intensive diagnosis process including physical examination and x-rays to confirm the diagnosis and start the treatment journey. It is crucial to ensure all treatment options have been exhausted before deciding on surgery.