Surgical Management of TMJ Disorders

Surgical Management of TMJ Disorders

Related Resources

• Comprehensive Overview of TMJ Disorders
• TMJ Anatomy and Function
• Diagnosis of TMJ Disorders
• Non-Surgical Management of TMJ Disorders
• Recovery, Complications and Advances in TMJ Treatment

Indications for Surgical Intervention

Surgical management of TMJ disorders is typically reserved for cases where conservative measures have failed or specific pathological conditions warrant direct intervention. The decision to pursue surgery should follow a comprehensive evaluation and consider the following indications:

Absolute Indications

• TMJ ankylosis (fibrous or bony)
• Condylar fractures with displacement affecting function
• Developmental anomalies causing functional impairment
• Confirmed neoplastic processes
• Recurrent chronic dislocation unresponsive to conservative measures

Relative Indications

• Internal derangements with persistent pain and dysfunction after 3-6 months of conservative therapy
• Progressive degenerative joint disease with mechanical dysfunction
• Severe hypermobility causing functional limitation
• Failed previous surgery requiring revision

Spectrum of Surgical Interventions

TMJ surgical procedures range from minimally invasive techniques to complex reconstructive surgeries, generally following a progression from least to most invasive.

Arthrocentesis

Technique

Arthrocentesis involves lavage of the superior joint space using needles inserted into specific anatomical landmarks:

1. First entry point: 10mm anterior to tragus, 2mm below the canthal-tragal line
2. Second entry point: 2-3mm anterior to the first point
3. Lavage using 100-300ml of solution (Ringer's lactate or saline)
4. Optional injection of medications (corticosteroids, hyaluronic acid)

Mechanism of Action

• Removes inflammatory mediators
• Lyses early adhesions through hydraulic pressure
• Reduces intra-articular negative pressure
• Disrupts fibrous attachments between disc and fossa
• Enhances disc and condyle mobility

Indications

• Acute closed lock
• Painful limited mouth opening
• Early adhesions
• Disc displacement without reduction
• Osteoarthritis with effusion

Arthroscopy

Technique

TMJ arthroscopy employs small-diameter endoscopes (1.9-2.7mm) inserted into the superior joint space:

1. Triangulation technique with separate portals for visualization and instrumentation
2. Diagnostic sweep followed by therapeutic intervention
3. Irrigation, lysis of adhesions, disc mobilization, and debridement as indicated

Procedures Performed Arthroscopically

• Lysis and lavage – Breaking adhesions and flushing inflammatory mediators
• Disc repositioning – Using sutures or pins in cases of displacement
• Lateral pterygoid myotomy – Releasing muscle spasm
• Synovectomy – Removing inflamed synovium
• Eminence recontouring – For cases with mechanical interference

Indications

• Internal derangements unresponsive to conservative therapy
• Fibroadhesions limiting mobility
• Synovitis requiring debridement
• Disc displacement with persistent symptoms
• Diagnostic confirmation of suspected pathology

Open Joint Surgery (Arthroplasty)

Common Open Joint Procedures

1. Discoplasty
   • Disc repositioning and suturing
   • Discectomy (with or without replacement)
   • Disc repair for perforation or thinning
2. Condylotomy
   • Surgical cutting of the condylar neck without joint entry
   • Allows condyle to position itself more favorably
   • Particularly useful for internal derangements with pain
3. Condylar Recontouring
   • Removal of osteophytes
   • Reshaping of irregular condylar surfaces
   • High condylectomy for specific conditions
4. Eminectomy/Eminoplasty
   • Reduction of articular eminence height
   • Addresses recurrent dislocation
   • Facilitates condylar movement

Surgical Approaches

• Preauricular approach – Most common, provides direct access to joint
• Endaural approach – Through ear canal, limited exposure
• Submandibular approach – For condylar neck access
• Retromandibular approach – Posterior access to ramus and condyle
• Combined approaches – For complex reconstructive needs

Management of TMJ Ankylosis

Classification-Guided Approach (Sawhney)

• Type I (Fibrous adhesions) – Gap arthroplasty or arthroscopic lysis
• Type II (Bony fusion with intact condyle) – Condylectomy with interposition
• Type III (Bone block with atrophic condyle) – Gap arthroplasty with reconstruction
• Type IV (Complete architecture loss) – Joint reconstruction

Surgical Techniques

1. Gap Arthroplasty
   • Creation of 1-1.5cm gap between condyle and fossa
   • May be combined with coronoidectomy for adequate opening
2. Interpositional Arthroplasty
   • Placement of biological or alloplastic material in the created gap
   • Common interpositional materials:
     • Temporalis muscle/fascia flap
     • Dermis-fat grafts
     • Auricular cartilage
     • Alloplastic materials (silicone, Teflon)
3. Reconstruction with Autogenous Grafts
   • Costochondral grafts (gold standard in growing patients)
   • Sternoclavicular grafts
   • Metatarsal grafts
   • Fibular free flaps for extensive defects

TMJ Replacement Surgery

Partial Joint Replacement

• Metallic fossa-eminence prosthesis
• Condylar head replacement
• Patient-specific custom CAD/CAM implants

Total Joint Replacement (TJR)

• Stock prosthetic systems (Christensen, Biomet)
• Custom prostheses for complex cases
• Computer-assisted design and manufacturing

Indications for TJR

• Failed previous TMJ surgeries
• Severe degenerative or inflammatory joint disease
• Post-traumatic conditions with significant structural damage
• Congenital or developmental anomalies
• Ankylosis with extensive bone loss
• Tumor resection requiring reconstruction

Management of Specific Conditions

Acute Dislocation

1. Manual reduction (Hippocratic method)
   
    
   • Bimanual pressure on lower molars
   • Downward and backward direction of force
   • Sedation or muscle relaxants as needed
2. Surgical options for recurrent dislocation
   • Eminectomy (removal of mechanical barrier)
   • Eminence augmentation (creating mechanical obstacle)
   • Capsular plication (tightening the capsule)
   • Lateral pterygoid myotomy

Myofascial Pain Dysfunction Syndrome (MPDS)

1. Minimally invasive options
   • Trigger point injections with local anesthetics
   • Botulinum toxin for muscle hyperactivity
   • Radiofrequency ablation of trigger points
2. Surgical approaches (rarely indicated)
   • Coronoidotomy for coronoid hyperplasia
   • Masseter muscle reduction for hypertrophy

Perioperative Considerations

Preoperative Planning

• Comprehensive imaging (CBCT, MRI)
• Consideration of occlusal relationships
• 3D modeling for complex reconstructions
• Patient-specific implant design when indicated
• Management of concomitant conditions

Anesthetic Considerations

• Typically performed under general anesthesia
• Nasotracheal intubation preferred for access
• Consideration of local anesthesia with sedation for minor procedures
• Nerve blocks for postoperative pain management

Postoperative Care

• Early mobilization protocol
• Structured physical therapy program
• Progressive diet advancement
• Pharmacological management of pain and inflammation
• Regular follow-up for functional assessment