Temporomandibular joint (TMJ) disorders (TMD) are a family of problems related to your jaw joints which are very complex structures. If you have had symptoms like pain or a “clicking” sound, you’ll be glad to know that these problems are more easily diagnosed and treated than they were in the past. These symptoms occur when the jaw joints and the chewing muscles (muscles of mastication) do not work together correctly. TMJ stands for temporomandibular joint, which is the name for each joint (right and left) that connects your jaw to your skull. Since some types of TMJ problems can lead to more serious conditions, early detection and treatment are important.
Frequently no one treatment can resolve TMJ disorders completely and most treatments take time to become effective. Dr. Bowler can help you to have a healthier and more comfortable jaw. If you would like to speak to Dr. Bowler about a TMJ condition please call our office in Charlestown to arrange a consultation, Charlestown Office Phone Number 02 4942 1211.
Trouble With Your Jaw?
TMJ disorders develop for many reasons. You might clench or grind your teeth, tightening your jaw muscles and stressing your TM joint. You may have a damaged jaw joint due to injury or disease. Injuries and arthritis can damage the joint directly or stretch or tear the muscle ligaments. As a result, the disc within the joint, which is made of cartilage and functions as the “cushion” of the jaw joint, can slip out of position. Whatever the cause, the results may include a malaligned bite, pain, clicking or a grating noise when you open your mouth, or restriction when attempting to opening your mouth wide.
Do You Have a TMJ Disorder?
- Are you aware of grinding or clenching your teeth?
- Do you wake up with sore, stiff muscles around your jaws?
- Do you have frequent headaches or neck aches?
- Does the pain get worse when you clench your teeth?
- Does stress make your clenching and pain worse?
- Does your jaw click, pop, grate, catch, or lock when you open your mouth?
- Is it difficult or painful to open your mouth, eat, or yawn?
- Have you ever injured your neck, head, or jaws?
- Have you had problems (such as arthritis) with other joints?
- Do you have teeth that no longer touch when you bite?
- Do your teeth meet differently from time to time?
- Is it hard to use your front teeth to bite or tear food?
- Are your teeth sensitive, loose, broken or worn?
The more times you answered “yes”, the more likely it is that you have a TMJ disorder. Understanding TMJ disorders will also help you understand how they are treated.
There are various conservative and surgical treatment options that Dr. Bowler can utilize to improve the harmony and function of your jaw.
Once an evaluation confirms a diagnosis of TMJ disorder, Dr. Bowler will determine the proper course of treatment. It is important to note that treatment always works best with a team approach of self-care combined with professional care. The initial goals are to relieve the muscle spasms and joint pain. This is usually accomplished with a pain reliever, anti-inflammatory, or muscle relaxant. Steroids can be injected directly into the joints to reduce pain and inflammation. Self-care treatments can often be effective as well and include:
- Resting your jaw
- Keeping your teeth apart when you are not swallowing or eating
- Eating soft foods
- Applying ice and heat
- Exercising your jaw
- Practicing good posture
Stress management techniques such as biofeedback or physical therapy may also be recommended, as well as a temporary, clear plastic appliance known as a splint. A splint (or nightguard) fits over your top or bottom teeth and helps keep your teeth apart, thereby relaxing the muscles and reducing pain. There are different types of appliances used for different purposes. A nightguard helps you stop clenching or grinding your teeth and reduces muscle tension at night. It also helps to protect the cartilage and joint surfaces. An orthotic stabilization appliance is worn 24 hours/day, or just at night, to help you maintain your jaw into a proper position. Appliances also help protect tooth wear.
What About Surgery?
Surgical options for TMJ conditions include arthrocentesis, arthroscopy, open joint repair surgery (arthroplasty) and total joint replacements (TJR) which is an option generally reserved for severe or previously operated cases.
The joints are investigated with CT scans and MRIs where symptoms are severe or pathology is suspected before a decision is made regarding arthroscopy or surgery. Dr. Bowler does not usually consider TMJ surgery unless the jaw can’t open, is dislocated and non-reducible, the patient has severe pain and/or has severe degeneration. Other indications include patient unsuccessful appliance treatment or failed previous surgery.
If your TMJ disorder is associated with problems related to how your teeth fit together you may need treatment such as bite adjustment (equilibration), orthodontics with or without jaw reconstruction, or restorative dental work with or without TMJ procedures.
The temporomandibular joint can be examined arthroscopically. This involves a day stay general anaesthetic in hospital and the insertion of a very fine videoarthroscope into the jaw joint via a tiny puncture to allow careful investigation of the contents of the joint. It is also possible to carry out certain limited surgical procedures through the arthroscope.
Arthrocentesis is a little simpler and involves the positioning of 2 needles into the upper joint space to allow a washout of the joint. Local anaesthetic and steroids can then be injected into the joint. This procedure also involves a day stay general anaesthetic in hospital and can be carried out with or without arthroscopy.
Open Joint Surgery
Where severe pathology exists, an open operation may be indicated. There is a range of procedures utilised encompassing simple joint exploration and debridement through to discectomy and a joint reconstruction possibly using grafted material such as muscle, dermis, cartilage or fat. This involves a night in hospital and frequent review over at least 3 months.
Total Joint Replacement Surgery
Where the TMJ pathology is very severe or the patient has already had open surgery performed unsuccessfully, it can become necessary to carry out a total joint replacement. This is frequently done using a “patient fitted” custom device fabricated by TMJ Concepts in California. Dr Bowler has placed over 150 of these devices – the largest series in Australia.
This operation usually involves a single stage procedure where a custom joint is previously fabricated on a biomodel made from your CT scan. The surgery to insert the device takes approximately 4 hours and involves small external incisions and an abdominal fat graft to obtain fat to insert into the new joint space. You are generally kept in hospital for 2 nights. With this operation it is possible to function immediately.
Some more complex cases require staged surgery where the diseased joint is removed and a silicone spacer inserted in the first operation. Post-operative scans are sent to the USA where a custom joint is fabricated on a biomodel showing the space from the surgical resection. A device is fabricated to fit the biomodel and whilst you are waiting for the device to be made unfortunately you will need to be maintained in intermaxillary fixation (jaws wired) – usually a period of approximately 8 weeks. The device is then inserted as a second stage procedure again using small external incisions and an abdominal fat graft. Both stages are operations which take 4-5 hours to perform and you are kept in hospital for 2 nights for each stage.
Occasionally a costochondral graft (rib) may be utilised to act as a total joint replacement but this operation is used far less frequently these days due to the superior performance of custom devices. For further information on these devices, please go to the following website: www.tmjconcepts.com
Post Operative Care for TMJ Surgery
Post-operative care following open TMJ surgery involves a significant amount of post-operative physiotherapy and multiple regular outpatient visits up until a year post op. You will be supplied with a detailed post op instructions (see Post Op Care in this website)
Frequently a jaw exercising device called a Therabite is utilised to encourage patients to mobilise their joints following surgery. For more information on the Therabite Jaw Motion Rehabilitation System please go to: www.atosmedical.com
Further information regarding temporomandibular joint conditions and surgical procedures can be obtained from the American Society of TMJ Surgeons website on: www.astmjs.org.
Case Study #1
“A 24 year old female patient presenting with long standing right sided TMJ pain, crepitus and limited movement. Investigated with CT’s and MRI’s and treated with an arthroplasty involving excision of a perforated disc.”
MRI showing disc perforation
CT scan showing erosion on condylar head
Central disc perforation seen at surgery
12 months post-operative appearance
12 months post-operative jaw opening
Case Study #2
“A 23 year old female patient presenting with right sided TMJ pain, crepitus and a changed occlusion with a premature contact on the right and an open bite on the left. Diagnosed as progressive condylar resorption and treated with a custom TMJ total joint replacement.”
Pre-operative uncorrected malocclusion
Coronal CT showing resorbing right condyle
Pre-operative OPG radiograph
Post-operative OPG radiograph
Post-operative corrected malocclusion
6 weeks post operative appearance
Case Study #3
“A 22 year old female patient from the middle east who had an accident and multiple surgery as a child resulting in total jaw ankylosis. She sought treatment in Australia in 2009 and underwent surgery involving bilateral release of her severe ankylosis and a staged reconstruction using bilateral custom TMJ total joint replacements.”
Bilateral total TMJ ankylosis
Initial 3D CT scan
6 weeks post operative appearance
Jaw opening at 6 weeks post operative
Coronal post operative CT scan
Post operative 3D CT scan
Back home 12 Months post operative
4 Years post operative & graduation from university