111 N. Wabash Ave Suite 2011 • Chicago, IL 60602
If I can't avoid it, I'll go through it,
but I don't want to.
—a 59-year-old lawyer
Will the second surgery be worth the risk?
It worries me.
—a 23-year-old student
At one time surgery was a treatment of choice,
or the first treatment considered, for people who had clear,
detectable, and demonstrable joint damage. However, surgery
is seldom advisable until more conservative treatment has
been attempted without appreciable or satisfactory success.
WEIGHING THE ADVANTAGES
In most cases, Phase I treatment will bring
significant relief to the patient. The patient can cope with
any symptoms that remain. In other words, Phase I may not
relieve all symptoms entirely in a patient who has some joint
derangement, but many people would rather live with occasional
discomfort than risk surgery. This is a subjective judgement,
and only the patient can decide when standard treatment has
brought enough relief.
Susan Morgan had been told that she had a perforated
cartilage disc, and corrective surgery had been recommended.
She had some popping and clicking in the joint, but her headaches
were more bothersome to her. Examination showed that her muscles
were in spasm. It was suggested that she could try a less
invasive method of treatment and if that was successful go
on to Phase II to correct her tooth-gearing problem. If Phase
I was unsuccessful, the surgical option was still open to
her. A very large percentage of such surgeries can be avoided.
Phase I treatment relieved almost all of Ms.
Morgan's discomfort. However, because she did have a perforated
disc, she continued to have the popping and some pain around
the joint. The pain was intermittent and too slight to make
her choose surgery. She also was aware that if the perforated
disc gave her problems later, she could make another decision
about surgery. This was about five years ago, and so far Ms.
Morgan has no symptoms that she considers important enough
to warrant surgery.
The important consideration about surgery is
that once it's done, it can't be taken back. And surgery on
the temporomandibular joint is major surgery with all the
associated risks. The single biggest risk of any major surgery
is general anaesthesia, and this risk shouldn't be taken lightly.
TMJ surgery involves separating the two parts
of the jaw joint. Plastic surgery techniques are used to prevent
disfigurement and scarring from the incision. Generally the
incision is made in the fold of skin just in front of the
When a disc is repaired, the joint is dislocated
and the disc is examined and sewn back together. Sometimes
the disc is replaced with a synthetic material. The surgery
also involves a hospital stay, varying from patient to patient,
but often a week to ten days. During the recovery period,
the patient experiences swelling and discomfort while the
tissues heal. Total recovery time can be several months. If
this surgery were shown to consistently correct the symptoms
of TMJ in the majority of cases, it might be worth it. But
while these surgeries are most often done with a high level
of skill and care, many patients end up disappointed because
the problems may remain after the healing period is over.
For this reason, surgery should be considered as an absolute
last resort in treating the symptoms of TMJ. When the pain
is caused by a torn disc or a problem in the joint, surgery
can completely resolve the patient's pain. Thus, while a last
resort, TMJ surgery is not unsuccessful in all cases.
A SECOND TRY
Sometimes a second surgery is suggested because
the first surgery didn't resolve the patient's problems. However,
sometimes patients do not want to risk second surgical attempts.
This is often because they were made worse in the first operation.
Linda James was such a patient. She was referred for an evaluation
before a second surgery was scheduled. The first surgery was
done because of pain around the joint. No joint derangement
showed up on X-rays.
Ms. James was considering a second surgery
because the first one made her unable to open her mouth any
wider than a centimeter. The normal opening distance is three
or four centimeters (about an inch and a half). She was unable
to eat, talk, or laugh normally. But her distress came from
the worsening of her pain.
There had been no way to predict that surgery
would make this patient worse off. The surgery itself was
done well, and Ms. James's problems may have been a result
of the healing process. Whenever body tissues are cut into,
scar tissue can develop. It's possible that her inability
to open her mouth was a result of scar tissue rendering the
muscles inelastic—unable to stretch enough to open the
mouth to a normal width. Examination showed Ms. James' Lateral
pterygoid muscles were in spasm. It was recommended that she
try TMJ treatment before the second surgery.
Because of the limited range of movement of
Ms. James's mouth, treating her involved fabricating a customized
impression tray just to take the impression on which the splint
was made. Her jaw movement was so limited that it was difficult
to get access to the external pterygoid muscles to give her
the needle-puncture treatment. However, over a period of months,
the pain gradually subsided, and she was able to open her
mouth another centimeter wider.
When treatment of the muscles had gone as far
as possible, Ms. James had to decide about surgery. Because
her pain was gone, she decided against risking another surgery.
She had learned to accommodate herself to the inability to
open her mouth normally. She was afraid to risk losing that
gain. Whether the surgery would have been successful is an
unknown; it might have resolved her problem. In these cases,
the patients must decide what risks are worth taking.
MAKING THE DECISION
In general, TMJ surgery is least justified
when there are muscle spasms. A damaged disc does not necessarily
justify surgery, especially when muscle spasms are present.
Arthritis doesn't automatically justify surgery either, especially
because the pain is probably coming from the muscle spasms
and not from the arthritic condition.
One patient had two surgeries to correct derangement
of the joint caused by arthritis. In this kind of surgery,
the bone is contoured, and the disc is repaired if needed.
In this patient's case, the surgery eliminated the crackling
sounds. Unfortunately, the patient's pain remained, and he
still needed muscular treatment and permanent correction of
the gearing problems.
Patients usually decide about surgery based
on the amount of discomfort they have lived with before muscular
treatment and the percentage of discomfort remaining afterward.
For many people, being rid of 70 to 80 percent of the pain
is satisfactory, and they choose not to risk surgery.
The dilemma for patients is knowing whether
they are among the small percentage of patients who will benefit
from surgery. Again, this comes down to an evaluation of muscle
spasms. In Gary Hynes's case, surgery was a logical choice.
He was quite sure he had TMJ and came for an evaluation. His
main complaints were clicking and popping in the joint and
joint pain. The popping sounds could be heard with a stethoscope.
However, he had no other signs or symptoms of TMJ. He was
evaluated three times when he had the pain, just to be sure
that no spasms or other signs of TMJ were present.
In such cases, the only logical treatment choice
is surgery. Of course Mr. Hynes could decide simply to cope
with the pain. But this case illustrates that not all people
complaining of symptoms in the joint itself have pain caused
by muscle spasms.
Any person who is advised to have non emergency
surgery should get a second opinion. This includes people
who have pain in or around the temporomandibular joint. If
the problem is caused by muscle spasms, the patient should
try non-surgical treatment, as described in Chapter 10. Only
when that possibility has been eliminated should surgery be