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Many patients that have been told that they have “tmj” are not necessarily in need of TMJ surgery. That is because these patients typically have spasm of the muscles of mastication created usually by habits such as clenching or grinding or injury to these muscles. They are constantly in a state of contraction or spasm without relief. They build up poor oxygenation and acids that create pain. With rest, soft diet, no gum chewing, no clenching, and sometimes physical therapy, these patients improve.
The patient with true pathology in the joint fall into those with tumors, disturbances of growth of the bone or cartilage, fractures/dislocations of the joint bone or cartilage, and degeneration of the cartilages and tissues from arthritis. Other problems we encounter are those that have a fusion of the joint to the skull base or those that were born without this joint.
Surgery in this area falls into many categories of reconstruction. Some patients require complete reconstruction or replacement of the joint while others may only need a simple arthroscopic examination and release of adhesions with application of medications.
The analysis of these problems is complex. A through history of how the patient has come to have these problems is very important. Any medications that have been used as well as previous treatments are important to the overall treatment plan and prognosis.
The clinical evaluation will include palpation, ascultation and measurements of how the jaw moves through its range of motion.
Typically a screening film of a panoramic radiograph is used to evaluate for obvious changes in the condyle of the lower jaw. Tomography, CT scanning, and MRI scanning will allow for more details as needed to plan for surgery.
One of the most important points to remember if you are to have surgery in this area is to follow the pre- and post-treatment exercise and diet instructions carefully. If too much stress is placed on a healing joint this can create more scarring and need for more surgery. The therapy, splints and soft diets used allow the joint to maintain mobility and heal without placing undue pressure. It is really up to the patient to comply in this area or no matter how beautiful the joint appears after surgery it will not heal properly.
Surgical procedures:
Arthroscopy: cameras are used to examine the joint for scar tissue and perforations of the cartilages. Adhesions can be released by this method and the tissues mobilized to some extent to improve range of motion and decrease pain. Medications can be applies under direct vision if necessary.
Arthrotomy: the work horse of joint surgery. A small incision in the crease in front of the ear allows us to directly look into the joint. Tissues can be repaired or replaced. Allows for greater mobilization of the joint tissues or access for biopsy.
Total joint replacement: used as a way to manage the patient with extreme degeneration of this joint. Prostheses are typically custom made to adapt to the socket and ball of a severely degenerated joint. Just like in orthopedic surgery of the hip and knee this mechanical joint will last about 10- 15 years and then need to be replaced again.
A total joint reconstruction may also be achieved with natural tissues and bones that are moved from one place to another in the body. These cases are usually reserved for the patient that has been born without a joint or if the joint is fused to the skull. A newer technique is to take the patients own jaw and grow a joint with a technique of distraction osteogenesis. | 
