#188 There is a Place for Surgery in Treating TMD

“There is a place for surgery in treating TMD, but it’s not surgery on the TMJ” 

In the 1980’s, just about every Oral and Maxillofacial Surgeon was doing surgery on the Temporomandibular Joint (TMJ) in an attempt to help the thousands of patients who suffered from the symptoms of Temporomandibular Joint Disorder (TMD).  The textbooks, annual meetings, and journals were filled with chapters, lectures, and articles promoting one kind of surgery or another on the TMJ as the best way to make the symptoms disappear.  

There were different types of surgery promoted as having advantages over other competitive types of surgery.  There were surgeries to add things to the joint and there were surgeries that removed things from the joint.  There were surgeries that were done with direct visualization of the joint through an incision in front of the ear and there were surgeries done through an arthroscope and visualized on a television screen as the surgeon manipulated his instruments through tiny puncture wounds. There were surgeries that tried to reconstruct the meniscus/disc within the joint.  For the first 36 years of my 50-year career as an Oral and Maxillofacial Surgeon, I tried them all. 

One of these was a reconstructive procedure that used a material called Proplast/Teflon.  It was touted to be an extremely effective replacement for the meniscus or cartilage cushion that sits between the ball and socket of the TMJ.  The use of Proplast/Teflon turned out to be one of the most destructive types of surgery performed by myself and my temporomandibular surgeon colleagues.  Inside the joint, under the heavy loads of chewing and bruxism, the Proplast and Teflon would fragment and cause a giant cell inflammatory response which is quite different from, and more damaging than, the usual chronic inflammatory response seen in a non-healing joint.  The giant cell inflammation would eat away all the bony structures within the joint and even, if left in place long enough, erode through the skull into the brain.   

The Proplast/Teflon debacle of the 1080’s was the watershed that brought most surgeons to the realization that TMJ Surgery was not an appropriate solution for TMD. 

However, there is a valuable service that Oral and Maxillofacial Surgeons can perform that will have a very positive influence on the health and wellbeing of patients with TMD.   

One of the three primary causes for damage to the TMJ is functional malocclusion.  A functional malocclusion is not just crooked teeth.  It is an occlusion or bite that is so unusual that it causes damage to the TMJ under normal jaw function.  It is a malocclusion that is caused not by crooked teeth but positions of the jaws that don’t match.  It is caused by a growth problem of the jaws, not the teeth.  The growth problems of the jaws can come in many varieties.  It can be too much or too little growth.  It can affect both the upper and the lower jaw.  When the jaws don’t grow properly, the teeth do not fit together properly.  When the teeth and the jaws don’t fit together properly, it overloads the TMJ causing damage within the joint which leads to inflammation within the joint, which leads to all the disparate symptoms of TMD. 

About 10% of the population have a jaw growth problem leading to functional malocclusions and TMD.  It is the Oral and maxillofacial Surgeon, along with the help of an orthodontist, that can do the necessary surgery on the jaws that removes the functional malocclusion thus removing the cause of future joint damage. This type of surgery is called, orthognathic surgery, literally, “Straight Jaw Surgery”. 

Even though surgery directly on the TMJ’s has been shown since the 80’s to be inappropriate, the Oral and Maxillofacial Surgeon is sometimes called upon to “straighten out” the jaw growth problems that lead to Temporomandibular Joint Disorder.  “There is a Place for Surgery in Treating TMD”.