TMJsurgeon.com….Studies of successful outcome and failure.

A perception of non-surgical clinicians is that surgery of the human jaw joint is to be the absolute last resort to management of orthopedic problems with the jaw joint.  Unfortunately as also seen in a previous blog reporting  recommended standards of care reported in the orthodontic literature (See August, 2010), even MRI imaging in symptomatic patients is rarely performed or recommended by some  professional societies which represent those groups of providers.  This model is contrary to the standards of orthopedics in management of other orthopedic systems of the body. Some of these societal parameters categorize this as a psychological or stress disorder.  As shown in this web site with both MRI and surgical images of disease, nothing could be further from the truth in some cases.

 Unfortunately, there can be patients with undiagnosed surgical disease, who develop chronic pain states that become much more difficult to manage when all dental related therapies applied have proven unsuccessful.  Often these patients are subjected to non surgical treatments that can take years to complete before any outcome is known or definitive imaging ever obtained.

As suggested in previous blogs with MRI examples of significant problems in adolescent patients, significant problems can occur in younger groups of patients.  The National Institutes of Health in the US estimate that on the average and at any time, 10 million US citizens have issues of severity meriting management and 10% of these have advanced surgical disease.  MRI Studies of adolescents undergoing orthodontic treatment have shown to levels of statistical significance that younger, growing patients in their adolescent years undergoing orthodontic treatment will have a 10% penetration of significant “TMJ disorder” and numbers identical to adult populations.(5)   Preventing progression to disability and functional impairment is paramount in these patients as well.

A previous blog discussed the Wilkes/Schellhas/Piper staging criteria when MRI examination is performed.  Long term post operative studies are clear that the Wilkes II derangement has much higher success rate than Wilkes III.  This has proven to be the case with both arthroscopy and open surgery (arthroplasty).   (1,2)  In some instances, the reason for this diminished success between these stages may be due to the presence of joint impingement that was unappreciated preoperatively. (6)

There are many reasons for decreasing success among surgical/MRI stages as  a recent report has indicated that time plays a very important role in surgical success.  After 6-12 months of continuous joint instability and pain, arthroscopic surgery begins to become less successful, according to a recent report delivered to a joint meeting of American, British, and European TM joint surgeons.  Pain improvement and functional  results drop significantly with arthrocentesis and arthroscopic surgery within the group of patients who had unmanaged joint impairment for 6-12 months and greater than 1 year prior to arthroscopic intervention. (3)

  A complimentary and separate study published in 1994 revealed that advancing arthrosis begins in Wilkes Stage III.  In a study of MRI characteristics of condyle degenerative processes, only 2 of 18 patients with Wilkes II derangement  had condyle arthrosis or early stage of degeneration.  In Stage III, 22 of 26 did.  In Wilkes stage II,the patient reported time frame of constant pain and joint instability  was less than 1 year in 14 of 18 cases.  Wilkes III patients reported unmanaged symptoms in for greater than 1-2 years in 24 of 26 instances (7).  Therefore, gross sustained orthopedic instability with this time frame is long enough for cartilage of the joint to become significantly damaged due to advancing inflammatory destruction of cartilage from unstable and damaging shear forces.

A study of Wilkes II cases revealed a 98% surgical success rate in Wilkes II cases, but success decreased to 85% in Wilkes III and patients with longer standing dysfunction in separate and independent evaluations  of arthroscopy and arthroplasty (1,2).  The fundamental reason is that the quality of elasticity in the joint is much better in earlier stages.  Advice to prolong surgery in the face of significant and progressive joint instability that does not respond to reasonable non surgical treatment for 6 months is a reasonable indicator that definitive diagnosis with MRI or diagnostic arthroscopy be made and in advancing cases, and definitive joint repair procedures considered if derangement is advanced. 

Specific conditions merit specific surgical procedures.  A prospective designed multicenter study evaluating 4 different surgical  procedures showed good results of 95% or greater relative to pain and  improvement in dysfunction to levels of statistical significance when a specific procedure was applied to a specific pre-operative condition. (4)

As in orthopedic surgery, definitive diagnosis and interceptive management to correct significant pain and joint dysfunction is very important and age is an independent variable to consider.  The most important factors are becoming clear that  duration of symptoms, appropriate staging and application of the operation to match the level of disease.

Time is of the essence in this orthopedic joint system.

1.  Kirk, WS Jr:  “Risk factors and initial surgical failures of TMJ arthrotomy and arthroplsty:  a four to nine year evaluation of 303 surgical procedures. Jnl Craniomand Practice (Cranio) 1998;  16(3):  154-61.

2.  Murakami K.  Five years results of TMJ artroscopic surgery correlated to stage of internal derangement.  Lecturre, American society of Temporomandibular Joint Surgeons. Palm Desert, California.  February 28, 1997.

3. Machon, V:  Chronic closed lock of the TM Joint.  Comparison of two therapeutical methods:  arthrocentisis and arthroscopical lavage”  Lecture:  European Society of Temporomandibular Joint Surgeons, Rome, Italy,  April 16, 2011.

4.  Hall, HD, Indresano AT, Kirk, WS, et al:  Prospective multicenter comparison of 4 temporomandibular joint operations.  J Oral and Maxillofacial Surgery, 2005;  63:  1174-9.

5. Nebbe B, Major PW. “Prevalence of TMJ disc displacement in a pre-orthodontic adolescent sample.  Angle Orthodontic, 2000, 70: 454-63.

6.  Kirk W and Kirk B:  Indications for primary arthroplasty of the temporomandibular joint.  OMS Clinics of North America.  September, 2006.

7. Kirk, WS Jr:  “Sagittal Magnetic Resonance Image Characteristics and Surgical Findings of Mandibular Condyle Surface Disease in Staged Internal Derangements”  Jnl Oral/Maxifac Surg.  1994  52: 64-68.

Tags: TMD, tmj, TMJ Arthroplasty, TMJ Arthroscopic Surgery, TMJ Surgery