Case Study: TMJ
Dr. Lee now provides a New Option for Conservative Surgical Management of the Problematic TMJ
We are pleased to announce that the Cincinnati Center for Corrective Jaw Surgery is now able to care for patients who suffer from jaw joint problems commonly known as TMJ or TMD with arthroscopic surgery.
What is TMJ & TMD?
TMJ stands for temporomandibular joint – the jaw joint. TMD stands for temporomandibular dysfunction. TMD relates to pain, limited opening, bite problems from muscle overloading and conditions that range from clicking, popping and locking of the jaws to rheumatoid arthritis. It’s hard to believe a joint so small with so little in it (the TMJ holds less than a teaspoonful of fluid) could cause so much pain and misery for so many people.
While arthroscopic surgery of large joints like the knee and shoulder is standard fare and widely available, arthroscopic surgery on smaller joints like the TMJ is less common. Like other joints, these symptoms described above can be decreased by cleaning out inflammation in the joint and placing medications in it – to lubricate it and decrease inflammation in the lining of the joint space. But unlike other joints, accomplishing this feat has been problematic for two reasons. 1) the potential complications with middle ear and surrounding nerves to the face and 2) the relative size of the joint to the size of the arthroscope going into it. Fortunately, these problems have been eliminated or greatly reduced with the introduction of the McCain technique and the McCain arthroscope.
The McCain technique and the McCain arthroscope
In the winter of 2016 and the spring of 2017, I was trained by Dr. Joseph McCain, broadly recognized as one of the founding fathers of TMJ arthroscopy, on the McCain technique using the McCain arthroscope. This spring, I introduced this special technique and tool to the Cincinnati Region.
Dr. McCain has been involved in the design of the arthroscope since 1990. It has the most sophisticated optics available in small joint arthroscopy and provides excellent images given its micro size of 1.8 millimeters, just over one 16th of an inch.
The McCain Technique is minimally invasive. The procedure is quick and very effective with a success rate of 90%. More importantly, it is safer than previously described arthroscopy techniques. Also, the small diameter of the scope allows for more instrumentation of the joint and more mobility of the scope in the joint space.
Our treatment algorithm
According to the American Association of Oral and Maxillofacial Surgeons, 35 million people in this country suffer from varying degrees of TMJ dysfunction or TMD. Approximately 10% of this group will seek treatment for their symptoms. The majority of those patients can be well managed with conservative therapy – therapy that can be initiated by, and managed by, family dentists.
Our treatment algorithm begins with the dentist:
A. Prior to our consultation with the patient, we ask that the dentist fabricate an occlusal guard for the patient and begin conservative treatment of the muscle or joint
B. If the dentist is comfortable managing the patient’s pain through the use of selective anti-inflammatory medications, we request that it be added to the regime, if possible.
C. Additional medications can be given to the patient to decrease grinding and clenching
Most patients will be effectively managed at this point, but those who continue to have pain usually suffer from:
- The lateral capsule of the TMJ is painful to the touch (is this a correct rewording?)
- Painful clicking, grating or popping of the joint
- Painful and limited opening or lateral movements of the lower jaw
When a patient falls into the category above, we request that they be referred to our office for further evaluation and possible treatment. At their initial appointment, Dr. Lee and his staff will evaluate them and obtain a history of their conservative treatment and their response to it. Traditionally, we will add or adjust pharmaceuticals and initiate aggressive physical therapy. From a diagnostic standpoint, we will obtain a CBCT to evaluate the joints and, based upon our findings, consider an MRI to determine meniscus position and status.
After further diagnostic imaging and more aggressive conservative treatment, we will see the patient back in our office to discuss the most minimally-invasive therapy that can be employed – a diagnostic arthroscopic procedure. Successful treatment of cases that have been properly selected and well-managed with conservative therapy nears 90%.
To be sure, arthroscopic surgery of the TMJ is to be reserved for cases of TMD that are not resolved with conservative treatment. Proper vetting of the patient and strict adherence to accepted conservative management principles is key.
Please contact the Cincinnati Center for Corrective Joint Surgery for more information concerning arthroscopic surgery of the TMJ.