TMJ surgery

Question 1

What symptoms highlight that surgical intervention may be needed?

Answer 1

Pain

Limited opening (if mechanical rather than muscle spasms)

Malocclusion

Dislocation

Facial asymmetry

Question 2

What are the types of TMJ pain and their causes?

Answer 2

Acute = Trauma, acute disc displacement, or a tumour

Chronic = Osteoarthritis, inflammatory arthritidies, or a tumour

Question 3

What causes limited opening?

Answer 3

Adhesions

Disc pathology

Ankylosis

Trauma

Tumour

Coronoid hyperplasia

Question 4

What causes malocclusion/facial asymmetry

Answer 4

Trauma

Joint degeneration

Joint mass: Effusion tumour synovial chondromatosis

Ankylosis

Aplasia, hypoplasia, hyperplasia

Question 5

How is pain investigated during the work up for surgery?

Answer 5

VAS

Pain diagram

Well localised pain that can be pointed to in the TMJ or generalised/referred

Functional pain

Limitations of movement

Joint noise and locking

Dietary modification (are they eating different food because of it?)

Question 6

What are the key points to look for with clinical examination of TMJ?

Answer 6

Joint tenderness to palpation

Joint noises (unreliable but clicking and crepitus)

Pain on loading (contralateral TMJ to area of biting ipsilateral pain doesn’t mean anything)

Range of motion, deviation

Occlusion: Malocclusion, open bites, wear

Question 7

What imaging can be used for TMD?

Answer 7

OPG is a screening tool not good for diagnostics

MRI (soft tissues)

CT scan (bone)

Question 8

What could CT show about TMD?

Answer 8

Erosions of cortical outlines

Loss of joint space

Osteophytes

Subcortical cysts

Multidetector CT scan show disc position

Question 9

What classification is used to know when patients should be treated with surgery?

Answer 9

Wilke’s classification

Question 10

What are the stages of wilke’s classification?

Answer 10

Stage 1 = early with painless click (radiograph shows slight ADD but normal disc anatomy)

Stage 2 = Early intermediate. Occ painful clicking and transient locking (Slight ADD and early disc deformity)

Stage 3 = intermediate, Locking, restriction, frequent pain (ADD disc deformity)

Stage 4 = Locking, restriction, pain (ADD w/o R, disc deformity, bone canges)

Stage 5 = crepitus, chronic restriction, and dysfunction (disc deformity, perforation, flattening, osteophytes, subchondral cysts)

Question 11

What are the signs and symptoms of MPD?

Answer 11

Diffuse poorly localised pain

Cyclic

Frequenly worse in the morning

Sleep disturbance

Bruxism

Tiredness, fatigue

Diffuse muscle tenderness and hypertopgy

Decreased range of motion

Joint noise

Wear facets

Question 12

How is MPD managed?

Answer 12

Explanation

Home care

Meds

Occlusal appliance

PT

Psych mgmt

Botox

Problems resolve slowly over weeks-months

Frequently recurs

Question 13

What are the symptoms of TMJ internal derangements?

Answer 13

Well localised TMJ pain

Continuous pain worse with function

Joint noise

Altered joint mechanics with deviation, intermittent locking, and closed lock

Question 14

What are the symptoms of TMJ OA?

Answer 14

TMJ pain variable occuring at rest and with function

Morning stiffness

Crepitation +/- clicking

Occlusal changes

Question 15

What are the treatment goals of TMJ surgery?

Answer 15

Reduce pain, inflammation, joint loading, and restore mobility.

Most patients will have resolution of symptoms with conservative treatment

Question 16

What are the conservative treatments of TMD?

Answer 16

Explanation

Soft diet

Warm moist heat

NSAIDs, muscle relaxants

Occlusal aplpiances

Question 17

What are the surgical procedures done for TMJ disorders?

Answer 17

Arthrocentesis

Arthroscopy

Open joint (Discopexy, discectomy, reconstruction)

Question 18

What is arthrocentesis?

Answer 18

Simplest TMJ intervention consisting of:

Lavage, examination under anaesthetic, and insertion of medications.

The idea is to wash out the effusion while injecting medication into it.

Question 19

How are patients managed post operatively following arthrocentesis?

Answer 19

Aggressive ROM exercises

NSAIDs

Occlusal appliance

Follow up

Question 20

What are the indications for arthrocentesis?

Answer 20

Painful limited opening (closed lock (Acute or subacute non responsive to conservative management)

Osteoarthritis pain refractory to conservative measures

Inflammatory arthritis for pain management

Others such as hypermobility or trauma

Question 21

What are the results of arthrocentesis like?

Answer 21

Results are good

Question 22

What is arthroscopy?

Answer 22

Cameras inserted into the joint and surgery done through this.

Question 23

What are the indications for arthroscopy?

Answer 23

Interanl derangement

Degenerative joint disease

Synovitis (inflamed synovium)

Painful hypermobility

Hypomobility caused by intrarticular adhesions

Question 24

What kind of procedures would require open TMJ surgery?

Answer 24

Disc procedures

Fixation

Reshape (fossa, condyle)

Biopsy

Ankylosis

Replacements

Question 25

How is the TMJ accessed during TMJ open surgery?

Answer 25

Incision (preauricular or behind the ear submandibular incision for lower half of ramus)

Question 26

What are the indications of open TMJ surgery?

Answer 26

Significant TMJ pain and/or dysfunction

Only when non-surgical treatment has failed

Imaging evidence of disease

Question 27

How can open TMJ surgery repair the disc?

Answer 27

Reposition

Repair

Removal

Replacement (Total TMJ replacement)

Question 28

What are the indications for TMJ replacement?

Answer 28

Degenerative arthritidies (OA and RA)

Fibrous/bony ankylosis

Failed alloplastic reconstruction

Loss of vertical mandibular height and/or occlusal relationship

Failed previous surgeries

Question 29

What factors can cause loss of vertical mandibular height and affect occlusal relationship?

Answer 29

Condylar resorption

Trauma

Developmental abnormality

Pathology