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Surgery

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.

WHAT'S INVOLVED

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 ear.

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 considered.