TMJSurgeon.com Clashes of Paradigms
In August, comments were posted in response to an editorial written in professional orthodontic literature on a standard of care which played heavily on the psychological nature of jaw joint disease and dysfunction. Since many patients see “TMJ Specialists” and are subject to standards of care advocated by this editorial, I thought I would share a case report that I will operate next month. This patient’s history of “management” occurs far too frequently and is associated with a clinical mindset that such problems are due to chronic “muscle spasm” of the jaw.
Patient A.B. is a 26 year old who came to me on referral because she could not open her mouth far enough to put a spoon in her mouth for feeding. Her history was that 3 years ago, a large steel door struck her in the side of the head. She was not rendered unconscious, but immediately experienced pain and swelling located along the right side of her face and temple. Her right eye swelled shut for a couple of days. Within a week, the patient was referred to an oral and maxillofacial surgeon who appropriately ordered an MRI. Unfortunately, this scan was only taken in two dimensions and the 3rd dimension (coronal views) were not obtained. Both the surgeon and the reporting radiologist missed a very subtle but not uncommon injury when a significant blow is delivered to the side of the head or cheekbone (zygoma) and a thin strut of bone that traverses back toward the ear and blends and contributes structure to the TM joint glenoid fossa…the zygomatic arch. With blows to the side of the head and face, fractures of the zygomatic arch or the thin bone that makes up the socket of the TMJ are common, especially when the trauma comes from a solid object as in this case. In reality, this type of injury can create a fracture accross the fossa or socket and comprise a minimal but nevertheless impairing minor basilar skull fracture. Unfortunately, A.B.’s missed diagnosis set her on an expensive 3 year course of frustration and management by providers biased toward “TMJ” being the result of chronic muscle spasm due to stress of a difficult employment situation since the injury occured at work…..and supervisors who considered her a malingerer.
A.B. was referred in October, 2010. Injury occured in December 2007. During this time, the patient received 4-5 different splint appliances, over 150 muscular injections of Botox, local anesthetic and steroid injections in order to manage “trigger points” of “muscle spasm”, physical and chiropractic therapy……she was also referred for behavioral and psychological counseling to teach her how to manage her chronic pain. Costs to date, will exceed that of an operation and out patient hospitalization. She has been on antidepressant medications and muscle relaxants for over 2 years now and finds it difficult to work and concentrate due to medication induced drowsiness. During all of this treatment, jaw range of motion deteriorated to now 25 % of a normal range of mouth opening. Being able to eat a normal diet is not possible at this point.
A.B. unfortunately did not have repeat or 3 dimensional imaging…..and no provider had a heighted awarness to rule out other processes by ordering repeat imaging when repeated therapies were not successful. When that imaging was repeated, that imaging revealed an ankylosing (fusing) joint as a result of a fracture accross the glenoid fossa of the TMJ. The fracture created a breakdown in the surface architecture of the fossa….the joint during attempted translation or mouth opening became further damaged due to abnormal biomechanical principles and development of a post traumatic advanced arthritis.
A.B. was managed based on a common pattern among dental “TMJ specialists” who are long on therapy aimed at targeting chronic muscle spasm with muscular injections, medications, and psychological counseling….and short on an understanding of cause and effect of significant head and neck trauma.
Operating patients, late after an injury like this creates technical challenge for the surgeon and patient. Thankfully, most improve significantly and can be surgically rehabilitated.
When professional organizational publications perpetuate a model of disease that is so disconnected from cause and effect….and places minimal emphasis on appropriate imaging to diagnose significant conditions….and suggests a muscular condition is responsible and should respond to treatment that ignores significant orthopedic injury/disease….it perpetuates poor science and patient management. Unfortunately, this happens far too often among providers who never image patients during the courses of their non surgical management and view, inappropriately, that surgery is always a last resort.
For patients who have not improved after years of “conservative” management and a treatment methodology that is biased toward muscle spasm,…it is paramount that appropriate imaging be re employed to look for significant disease that may have advanced over time.
WK
Addendum: I operated AB on 12/22/10. Surgery indeed revealed that she had indeed fractured a portion of the zygomatic arch that contributes to the fossa of the TMJ. Her early post operative course is very encouraging. She is almost has 80% of expected future jaw range of motion and is already back at work. The lesson from AB is that when patients do not respond to non surgical management, imaging should be performed to define the circumstances at hand.
