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TMJ Disorder -TemporoMandibular Joint Message Board

TMJ Disorder -TemporoMandibular Joint Board Index

My wife (31) was diagnosed with TMJ in 2004 after a car accident. 8 months after she received disc fusion on both sides (bilateral). She received relief for 3 years, then progressively got worse and this year the pain became extreme (Ear pain, jaw pain, neck pain, eye pain and 18mm jaw opening). MRI showed the fusions broke and the discs are out of place June 2010 dr. performed arthrocentesis, which gave her relief for about 3 days. Since the arthrocentesis this past June we have met with 4 Dr's, all with very good backgrounds and credentials in maxillofacial surgeries and considered experts in the field.
Dr#1 feels the discs are out of place and they are pressing on nerves causing her the pain, and wants to perform a discectomy, leaving a temporary disc that scar tissue will form around and removing that disc in two weeks. The disc would be removed one side per surgery.
Dr#2 feels the discs are out of place and they are pressing on nerves causing her the pain, and wants to graft the temporalis muscle and make that her new disc.
Dr#3 feels that a strong percent of the population has misplaced discs and the pain is actually coming from Synovitis, Adhesions and muscle clenching and would like to perform arthroscopy to alleviate these problems and thinks this will increase her jaw opening and alleviate the pain. (this procedure being the least invasive)
Dr#4 feels the discs are out of place and they are pressing on nerves causing her the pain, and wants to perform a partial jaw replacement utilizing titanium implants.
At this point she has gone through all the Physical therapy and medications that you would go through before considering a surgery so she is ready to take the next step. But 4 Dr's,4 different answers and all stating a high success rate with their procedure. Anybody's research lead them down this path? Anybody have combinations of these procedures? Any recommendations past on past experience with these procedures?
Here is a response that I have read from a Dr in the UK-

My personal opinion (other surgeons will give you different ones I am sure) is that disc plications and/or disc repairs seldom work long term. My personal practice is not to do them and if symptoms are disabling I offer partial joint replacement.

My opinion and that of my UK colleagues specialising in the area - and a word of warning - published studies should come with a health warning. There are no randomized control trials (level 1 evidence) or well constructed case-matched control studies on tmj plication/arthroplasty - just case reports, retrospective studies and personal opinion (like i am giving now). There is not even an agreed definition of what an arthroplasty is. Disc plication and repair used to be common in the Uk (along with high condylar shaves/condylotomy/ectomy) etc but virtually no surgeon I know is now doing them and at a UK TMJ meeting last year we agreed that it had little place. The problem is the disc is essentially avascular and incapable of repair. To think that a surgeon can put a few sutures in and adjust the position such that it will recreate the complex 3D environment of the TMJ is surgical arrogance. Sutures cut out/dislodge etc. I think in successful cases the joint just adapts. I think it very telling (and i suspect the crux) that US insurance companies wont pay for JR until a patient has had an arthroplasty! This is utter nonsense, unethical and is a classic case of insurance companies not medicine dictating what healthcare is provided. Many years ago when I first started TMJ surgery I came across lots of papers especially in Scandanavian literature that promoted discectomy and authors saying that nothing needed to be put in its place - lots of papers. So I tried it and it was a disaster! Worked well for 6 months then every patient developed arthritis and needed JR. The problem with medical papers is problems seldom get published!
Back to your point - There are increasing studies showing good long term stability with JR lasting 20+ years. The best chance of success is the first operation - you know as well as I that after 3 TJ surgeries neuropathic pain is virtually guaranteed so my aim is to do a 1-stop shop and limit the number of surgeries.
Hi Seafoster.....if it's a disc issue, you can get help going the neuromuscular route with a NM TMD specialist. I am a 20yr. tmd sufferer, and recently (Sept. 09) I entered into neuromuscular tmd treatment with a specialist in Wi. I have no real working discs, but a person can function without discs...if the condyle is in the proper neuromuscular position. The orthodic that was made for me is bringing the condyles out of the joint, in a more down and forward position, creating a better area to function. Also, it has brought my muscle spasms way down. Everything overall is much better. What surgeons won't tell you is that this can be accomplished without surgical intervention, which is very risky, and obviously invasive. I have posted the associations that you can find a good tmd specialist in the Great tmj doctor's thread at the top of the tmj page. Scroll through it and find my post. There is help out there that can be life changing, and you do not need to go into surgery for it. I am about halfway through phase 1, in my orthodic appliance, that I eat with, and wear 24/7.....It has changed my life. ;) BTW---the specialist I go to is a neuromuscular tmd specialist, and a Functional Jaw Orthodontist.
I actually have talked to many TMJ folks in regards to Neuro Muscular Dentistry. This was a answer I have read before from others.....

Non-surgical therapies can be very effective-- As always it comes down to correct diagnosis. IMHO, if someone has a facail/TMJ pain/problem as a result of muscular imbalance this could will help - similar to the almost instantaneous pain and poor function we all get if we loose a heal or walk with one shoe - it just throws the whole pelvis/lower limb musculature out of kilter - all for a 1inch height mismatch so by all means in these situations physio, NM dentistry etc is likely to help. BUT, it will not help a true organic TMJ pathology such as arthritis, fracture, ankylosis, torn discs etc. Occasionaly displaced discs can and do revert to "normal" positioning after years as a result of bone loss and adaptation.
Proper Diagnosis is key--you need the correct path for treatment.
Best of luck~
Obviously if you have a fracture in the jaw or condyle, there needs to be something more invasive other than orthodic therapy, but my dentist has treated tmd patients for 20yrs, post surgicals, and trauma (accidents), and he's never had to resort to sending someone for a TJR. NM dentistry can help TMD on all levels, not just from muscular imbalances. :)
First let me say thank you to anyone that has read and responded, believe me all of your input and experience has been comforting to my wife. With her diagnosis of synovitis, disc displacement & adhesions, we are leaning towards having arthroscopy first because it appears to have a similar success rate of all the surgeries we have heard about, it's less invasive, and the logic behind dealing with the inflammation and getting synovial fluid to flow and act as a lubricant seems logical to us ( if I was able to relay in lay terms correctly what we have heard medically). I have scoured the web for pros and cons, success and failure, of relief from arthroscopy. In all honesty there really isn't one procedure that has worked for every person that received it. I think Based on her diagnosis arthroscopy will be our starting point. And if anyone reading this has had arthroscopy please let us know of your experience...especially in the NY area.....
I agree with Jill, on seeing a neuromuscular dentist. I had an MRI scan showing that I have displaced discs on both sides and synovitis. I also have jaw clicking and pain. I am currently undergoing treatment with a dentist who is using similar methods to what Jill has described.
It corrects the jaw position with a splint, and helps to improve jaw function, and gives the TMJ a chance to heal. I think if arthroscopy is done which cleans the inflammation out of the joint, it would return because the inflammation is the bodies natural reponse to a dysfunctional joint, and arthroscopy isn't treating the dysfunction. In my opinion the best way to improve the TMJ function is with treatment from a TMJ dentist.

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