TMJ Disorder The Case of the Contemplations and Considerations of Surgery

When it comes to recommending surgery to one of my patients, it is always a difficult decision. The problem with telling a patient they need to do surgery is that by the time they come to see me, quite often the discs are in really bad shape and the pain has been there for quite some time. What this means is that the discs are usually damaged and quite often the condyles (the heads of the jaw bones) are also somewhat damaged as well. It’s kind of like saying your car needs engine repair and it already has 150,000 miles on it, so it’s a bit worn out. Not the best analogy but that’s what I have for you.

Let’s get a little more into what we have to consider. The TM joint is a three-dimensional structure, which is very unlike other joints in the body, like a finger or a knee, which just bend in one direction. So with the TM joint, you have to consider all angles- literally. When you have surgery performed to put that little disc back on top of the condyle, you must consider where the discs have been displaced and is it really possible to get them back into proper position. Think of a baseball – the interior part of the baseball is the condyle and the disc is the leather covering on top of the substructure. Can the surgeon really get the covering back on top of the baseball? If the disc is really damaged, sometimes it has to be removed, yet there is no way to get the whole thing removed- it is simply too close to the cerebral artery so the whole thing cannot be safely removed. So this is the other consideration: Can my surgeon get enough of the damaged disc either put back in place to give the patient relief, or if removal is necessary can he get enough removed to take the pressure off the nerves and blood vessels to get the relief needed? Doing this kind of surgery is not like putting a new muffler on your car – it’s not a definitive thing that is totally predictable.

When you are considering TMJ surgery, you must be aware that the surgeon is cutting through tissue, through blood vessels, and near nerves. All of this usually goes just fine and with a success rate of around 94% (yes, we have a case study on this) there is little to worry about, however, it’s always those 6% of the cases that I have concern with. The interesting thing with what I do is that as a dentist, my patients expect me to get the job done, and get it right the first time. This surgery is actually a medical procedure – it’s done at the hospital by a board-certified surgeon- and due to it’s complexity may have complications. And again, although very safe, the patient has to be aware that post-surgery there might still be some degree of discomfort here and there. There might also be some degree of numbness on the side of the head due to the incisions and scar tissue that forms. And for some people, it just may not work at all. This is because there was just too much damage to begin with.

This is why I wrote today’s blog: I want my patients to understand that surgery is never definitive, final, or the end of all treatment! After surgery you are going to go out into the real world and keep on using those joints. They can and possibly will, break down again which means that even though you have had the surgery and you feel great, you still need to come back every year post treatment to check the joints and make sure they are doing OK. So if the discussion of surgery is on the table, please read all of this carefully and ask any questions before you consider the procedure.