“Surgical treatments are controversial, often irreversible, and should be avoided where possible. There have been no long-term clinical trials to study the safety and effectiveness of surgical treatments for TMJ disorders. Nor are there standards to identify people who would most likely benefit from surgery. Failure to respond to conservative treatments, for example, does not automatically mean that surgery is necessary. If surgery is recommended, be sure to have the doctor explain to you, in words you can understand, the reason for the treatment, the risks involved, and other types of treatment that may be available.” (National Institutes of Health brochure on TMJ Disorders)
Arthrocentesis is often the first surgical procedure that will be recommended for a patient who has a displaced disc. It can be done as an in-office procedure, when it involves the placement of two hypodermic needles into the joint, or as an outpatient procedure in the hospital if it is done arthroscopically. In the office, it can be done either under local anesthesia and IV sedation or general anesthesia. In the hospital, it is generally performed under general anesthesia as an outpatient.
Once the joint is numb or you are put to sleep, the needles or the arthroscope are placed into the joint, and it the joint space is flushed with a sterile saline solution or a lactated Ringers solution. The purpose of this procedure is to remove tissue breakdown products and reduce inflammation. The surgeon will generally also manipulate the jaw to remove any scar tissue that may have formed. Removal of this tissue can also be done arthroscopically. At the end of the procedure, some surgeons also inject a steroid into the joint.
Following the procedure, your joint and the surrounding area will be numb. If your doctor has given you a prescription for pain medication, this would be the best time to take it, as the pain will begin when the numbing medication wears off. You might have some swelling for a few days; however, most people are able to function normally after two to three days. There are generally no limits on physical activity or use of the jaw; usually the surgeon will recommend a jaw exercise program and a soft diet.
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TMJ arthroscopy is a procedure done with two hypodermic needles that is a little more invasive than an arthrocentesis. This procedure is almost always done in an outpatient facility in the hospital. An arthroscope is used to look inside your joint to see what may be causing your TMJ problems. Some surgeons will not only look inside and wash out the joint, but also perform surgical procedures to remove scar tissue, smooth the bone and even attempt to reposition the disc.
You will be checked in prior to your surgery time and an IV will be started. The anesthesiologist will visit and take a look at your mouth opening and discuss the anesthetic procedure. Usually, before the surgery, the surgeon will visit you to discuss what he/she will be doing and how you will feel when you wake up. You should have had a pre-operative appointment to discuss all of this information. Don’t hesitate to ask any questions you may have. No question is a dumb question.
After this, the anesthesiologist or nurse will probably give you some medicine to help you relax, and then, you are off to the operating room. You may or may not remember this. If you do, you will notice that the room is very cold and that there are a lot of people buzzing around getting ready for your surgery. Take a deep breath and close your eyes – try not to let it bother you. After all, they are all there to make sure you are okay. If at any point you aren’t okay, speak up!
An arthroscopy may take between 30 minutes and two hours. When you wake up, you will be in the recovery room. You might feel jaw pain from the surgery. Let the nurses know if you are in pain, because they are there to give you medication and make sure you are comfortable.
Recovery time from this surgery is several days to a week. You will probably want to take off from work for three days or so, but make sure the time off is flexible in case you need extra time. Your surgeon may tell you to maintain a soft diet for a few weeks. After several days, you will probably start jaw exercises or physical therapy.
As with all surgeries, there are advantages and disadvantages to this procedure. It allows the surgeon to look into the joint space and remove any adhesions or other abnormal tissue. The recovery is shorter and easier than with an open joint procedure and the scar is smaller (virtually undetectable). However, this surgery takes longer than an arthrocentesis done with only hypodermic needles and requires general anesthesia.
Arthrotomy, also known as Arthroplasty, is an open joint procedure (an incision is made a few inches long over the joint so your doctor can operate on the joint itself) done under general anesthesia in the hospital. The surgery may last between one to two hours. The recovery is significantly longer (3-8 weeks) and more painful than the TMJ Arthrocentesis or TMJ Arthroscopy.
An incision is made along the ear (similar to what is done for a face lift) and the joint space is opened so that the surgeon can see it. This allows for the removal of adhesions, osteophytes (bone spurs), fibrous or bony ankylosis (fusion) and/or tumors, etc. This reshaping of the joint is called Arthroplasty.
The surgeons can also repair discs, condyle, and the temporalis muscle through various open joint procedures:
- Arthroplasty. Reshaping of the condyle and fossa when there are arthritic changes.
- Re-contouring of the bone of condyle head to remove disease/damaged part).
- Removal of the condyle completely.
- Discoplasty. Surgically putting the disc back into its normal position when it is displaced.
- Discectomy. Disc removal. Some surgeons use a temporalis muscle or skin graft to replace the disc. Others do not put anything in its place.
- Temporalis Muscle Graft. A piece of your temple muscle (temporalis) is slid into the joint space to prevent bone on bone contact.
- Temporary Silicone Implants. Silicone sheeting has been used in the past to act as a pseudo-disc. Silicone sheeting specifically marketed for the TMJ was voluntarily withdrawn from the market in 1993. After the TMJ implant fiasco of the early nineties, the FDA asked for pre-market approval on ALL devices to be implanted in the TMJ. No company submitted the required safety testing or pre-market approval paperwork for silicone. If a doctor mentions using silicone, he is doing it off-label. Beware! The FDA says on its Consumer Information page, “FDA is presently working with manufacturers to appropriately label silicone sheeting with warnings against its use in the TMJ implant.”
Since the early 1970s, oral surgeons have been using various biomaterials to replace the disc or even the entire joint. Most of these artificial implants have never been tested and have not been proven to be safe and effective. Although some of them have been recalled due to serious problems, several remain on the market. Even autogenous replacements, which use the part of the patient’s own body, can cause significant problems.
Orthognathic surgery is used to correct severe jaw abnormalities, such as a severe under-bite, over-bite, open bite or uneven or asymmetrical jaws. It involves cutting the jaw bones and repositioning them to a desired alignment. Orthodontic treatment often accompanies this procedure. This is a complex surgery and involves having the procedure done in a hospital setting. All of the incisions are located inside of the mouth and plates and screws are used to secure the bones into place.
Also, during orthognathic surgery, surgeons may perform one or more of these procedures to align the jaws:
- Bilateral Sagittal Split. Manipulates the lower jaw.
- Distraction Osteogenesis. Gradual lengthen of bone, cutting the lower or upper jaw bone and applying an expansion device called a distractor. The distractor is secured with screws and a small portion is visible outside of the body and is turned daily for 2-3 weeks to promote bone growth.
- Manipulates the chin bone.
- Le Fort 1. Manipulates the upper jaw.
TMJ Total Joint Implants
Preparing for Surgery Checklist
This information has been developed by patients who have been through the TMJ surgical procedures and have offered advice to help make the process easier.
The Most Important Tip!
Keep a positive mindset – seek support from family and friends!
- Bring a button-up shirt or a top with a large head to opening to wear after surgery.
- Buy several pairs of button-up pajamas and shirts that do not have to be put on over your head.
- Get your prescriptions filled before surgery.
- Plan and prepare non-chew meals in advance.
- Purchase a food processor or blender.
- Have straws available for drinking.
- Shop for food and plenty of liquids so you have these items on hand when you return from the hospital. Nutrition/sports drinks are good options.
- Test out different types of protein powder before surgery so you can find the type you like.
- Have ice packs available for use at home or stock up on frozen peas, corn, or other vegetables for moldable ice packs.
- Purchase a gel cold/hot pack.
- Purchase a back wedge pillow to put in your bed to make sleeping and resting easier.
- Purchase a pillow to support your neck or roll up and tape a towel.
- Buy a child-sized toothbrush for when you cannot open your mouth very wide. Don’t forget the mouthwash.
- If your mouth is wired shut, consider buying a Zip’N Squeeze® which makes eating much easier.
- Purchase ChapStick® to help soothe your lips.
- Purchase Toothettes™ (oral swabs) to keep your mouth clean if wired shut.
Ask the Doctor Tips
- Ask about donating your own blood ahead of time so that, if needed, you may receive it during or after surgery.
- Ask your doctor if any of the medications you take should be stopped or others begun prior to surgery. If so, how long before surgery should they be stopped or started?
- Ask your doctor for dental wax if you will be having arch bars or your jaw is wired shut.
- Discuss with your doctor what will be done to manage any post-surgical pain you may have.
- Discuss with your doctor how to maintain proper nutrition.
- Ask about how to manage nausea post-surgically, should it occur.
Miscellaneous Planning Tips
- Consider having someone take care of your children and pets for the first couple of days after surgery.
- Learn the hospital policy for visiting hours, parking and phone/TV billing.
- Evaluate your need for discharge planning, home therapy and rehabilitation after surgery.
- Try to be at a healthy weight before surgery.
- Set up your bed area at home prior to surgery so that you will not have to do it when you return from the hospital.
- Have plenty of reading material. Tackle the stack of books and magazines you’ve been meaning to browse for the last few months.
- Consider getting an online subscription for TV shows and movies in case you don’t feel like reading.
- Make travel arrangements if surgery is out of town. Some patients have told us a long car ride is much worse than a short plane ride.
- Plan what clothes you will wear home and take a pillow or two in the car to use on the way home.
- Have a list of people and their contact information for your loved ones to notify after your surgery has been completed.
- Have someone with you 24/7 for the first few days who is in charge of managing your meds. Have them help you set out your medications and note the time to take it and what pills were included. If this is written down it will make things easier and you can take your meds at night.
- Post-surgery pain is the most severe the first few days. Once you make it past this point, the pain should begin to subside.
- Sometimes, there is temporary or permanent damage to the nerve that allows the upper eyelid to open and close. You should tape your eye shut or wear an eye patch to avoid irritation and scarring of the cornea. If your eye is dry, artificial tears work well to keep it moist.
- Many patients experience spasming in jaw muscles after surgery. If you do, contact your surgeon and she/he may prescribe a muscle relaxant. Moist heat and massage can also be helpful.
- Much of the swelling goes down after the first week, but it’s not uncommon for some of the swelling to last longer. Intermittent application of cold is generally recommended for the first 24 hours after surgery to minimize swelling, and intermittent moist heat should be used thereafter to help get rid of the swelling. Bruising can take up to six weeks to subside.
- Notify your doctor immediately if you experience any severe symptoms such as trouble breathing, severe pain, heavy bleeding, fever, or difficulty closing your eyes.
- If your jaw is wired shut, the tightness will decrease after the first week.
- It is important for proper healing to maintain your nutrition and drink plenty of liquids. Initially, it may be easier to eat small amounts every few hours than to eat a large amount at regular mealtimes.
- If you are prescribed antibiotics, be sure to finish the amount prescribed.
- A Waterpik® can be very helpful in keeping your teeth clean and mouth fresh if you are wired shut.
- If you are wired shut, take your wire cutters everywhere you go in case of an emergency.
- Don’t rush to eat solid foods. Take it slow. Give your jaw and muscles plenty of time to heal. Follow your doctor’s recommendations regarding your diet.
Those of us with TMJ disorders present unique problems when having to undergo general anesthesia for surgery. Since we generally cannot open our jaws properly or keep them open for an extended period of time, the anesthesiologist may have great difficulty trying to sedate us. But we have options for mitigating the situation. First and foremost, we need to be our own advocates! Next, consider the following suggestions:
- Get a medical alert bracelet or pendent.
- Alert your family and/or friends to your oral disability.
- Obtain and make multiple copies (so that you always have one with you) of the Anesthesia & Me© Checklist from the American Society of Anesthesiologists. This checklist includes every problem that could interfere with your intubation.
- To determine if your surgeon and anesthesiologist are board-certified, go to American Board of Medical Specialties.
- If you are having elective surgery, discuss with your surgeon all the medical issues that might affect your intubation.
- Prior to surgery, arrange a phone call or visit with the anesthesiologist to discuss your anesthesia options and alert him/her to your TMJ problems.
- As an alternative, and depending upon the length of your surgery, you may want to discuss spinal or epidural anesthesia. However, these alternatives may cause more serious problems than throat intubation.
- In teaching hospitals, residents who are going to specialize in anesthesiology may actually perform the intubation. If you would prefer not to have a resident anesthesiologist assigned to your case, add that requirement to the surgical consent form.
- Some community hospitals employ nurse anesthetists when board-certified anesthesiologists are not available. Ask about this ahead of time. If you are having major surgery and this option causes you concern, consider having your operation in a larger hospital with board-certified anesthesiologists.
- If you are asked to sign additional paperwork in the pre-op area, make sure you fully understand the terms of what you are signing. If possible, ask that a family member or friend be allowed in the pre-op area to be your health care advocate.
- Here is a layman’s article on the procedures of intubation and when the different types of intubation should be used.
We are grateful to the late Dr. Daniel Laskin, former Adjunct Clinical Professor and Chairman Emeritus at Virginia Commonwealth University School of Dentistry, Oral and Maxillofacial Surgery, for his many years as our clinical advisor and for writing the content in this section.