The International Headache Society sites TM joint disorder/pathology as a viable cause of headache (Section 11.7 of Guidelines/Classification of Headache…www. i-h-s.org…{see guidelines/classifications}.  The previous blog was to provide the “academic” argument for viable consideration of significant TM joint pathology and associated headache.

There are very few articles in the Oral/maxillofacial surgical literature that have looked specifically at headache response after TM joint surgery.  I would appreciate anyone forwarding me references to the contrary to put in my reference library.  The following is a n excerpt of a paper published in the North Carolina Medical Journal that I wrote in 1993 that looked specifically at headache response to treatment for significant derangement/arthrosis of the TM joint.  The results of those days are comparable to what is happening today….only I think the percentages of patients with no significant improvement is less…because the surgical methods are better now than at that time.  Regardless, here are the results.

METHODS

Questionaires were sent to 83 consecutive patients who had undergone surgery ( of the joint itself, no other jaw surgery)  during a three year period between 1986 to 1988.  76 were returned for a response rate of 91.6% (unusually high with patient populations and a study of this sort…ed. comment)  All patients had intrinsic disease of the TM joint(S) documented by MRI.  A non surgical treatments had failed (physical therapy, occlusion (bite) management, splint appliances, anagesics, anti-inflammatory medications, joint injections (arthrocentesis/steroids), and even specific medications prescribed for headache that was thought to be migraine or vascular headace.  All patients had negative neurologic evaluation pre operatively or these issues ruled out by their primary physician or neurologis pre operatively.  The questionnaire asked about the patient’s present headache status compared to that of the pre operative state. Specifics of a numerical pain/headache severity scale (visual analog scale data) and a subjective duration of present headache were evaluated.

Four categories were used to determine frewquency of pain: 1, constant;  2) 1-3 times per week; 3) one time per month; 4)  no headache pain.

Patients were asked to locate headache both in the the pre operative state and the post operative state.  The following regions were used as locales: frontal, temporal, retro-orbital )behind the eye) mid sagittal (top of the head) occipital (back of the head), sinuses {frontal and maxillary} and the upper cervical regions (upper neck)

Patients localized facial pain to: the joint(s) , deep ear, temple, upper jaw, lower jaw.

Patients were asked how long the pain and joint dysfunction had been present before surgery:  0-6 months;  6-12 months;   1-2 years;  2-5 years;  greater than 5 years.

Patients were asked:  “If you had two or more types of headache, could you distinguish other types of headache from those associated with joint arthritis?”

Finally, patients were asked whether they were using: 1) More;  2)the same 3) less;  or 4)no medication to control headache pain after surgery.

RESULTS

The patients ranged in age from 18 to 57 with a mean of 39 years.  66 of 76 patients (89.5%) reported constant symptoms for at least 1year of   of jaw pain, chewing pain, inability to eat a normal diet, jaw joint locking, and progressive difficulty with mouth opening due to any of the above.

32 patients (42.1%) had symptoms for greater than five years {See editorial commment below).  Only 8 patients had symptoms for less than one year.

70 of 76 patients (92.1%) described constant pain, well-localized in the TM joint or pain that felt like a constant ear ache. (otalgia)Prior to surgery, 52 patients (68.4%) had constant headache  and 18 more (23.7%) reported several significant headaches per week.

There was no specific localization of reported headache that was more dominant than any other location.

32 patients in this study had disc/capsule repair arthroplasty for Wilkes II-III derangement.  44 patients had discectomy procedure because chronic inflammatory and biomechanical destruction had made repair impossible. Wilkes IV-V.   (See previous blogs for examples of this type of tissue condition compared to normal specimens). No distiction was made between these two surgical procedures as it related to long-term pain response.  No disc replacement substitutions of any type were placed in these patients.

4 years after TMJ surgery for advanced derangement, Pain and headache sympoms had improved.The following tables list the results of  the 76 patient responses:

Headache Frequency

69 patients provided responses about whether they could distinguishh types of headache.  49 respondents stated that they could distinguish headaches arising from TM joint disease/dysfunction/arthritis from other headaches, 20 could not.

The most signigicant reported result in my estimation after 4 years post operatively was that 55 of the 70 respondants (78.6%) indicated that they needed less medication or no medication to control headache after surgery and had been able to no longer require continual medical evaluation/treatment for headache “of unknown origin”.

DISCUSSION

There are many (hundreds) of potential, interconnecting biological causes for severe chronic headache….as the classification system of the International Headache Society would attest.  The National Institutes of Health estimate that 10 million Americans will have advanced TM joint disorder.  Consistent data in the literature suggests 10% of this number will have advanced jaw joint disease capable of creating significant human impairment. This web site is dedicated to presentation of concern to that population and MRI/surgical photos of that level of disease are and will be provided in this web site. (Also consult ASTMJS.org)

Most dental and medical providers are taught that “TMJ headache” is a  muscular disorder of the muscles that move the lower jaw. No one can argue that when the jaw joints are orthopedically unstable, that chronic muscular dysfunction will be part of the picture….similar to other orthopedic joint problems of the musculoskeletal system.   However, such a theory would logically suggest that headache in these patients be localized, if solely muscular, to the muscles that operate the jaw.  This was not the finding in this study as headache localization could be anywhere….as suggested by the finding that there was no predominant localization and many patients had headache which was confused with a vascular headache or migraine phenomenon. (See previous blog and discussion on severe inflammatory destruction of jaw joint “cartilage” and vasoactive substances produced and found in advanced joint derangement/arthrosis).

Anectdotes after 30 years of surgery experience.

Over 40% of my patients in this study had significant headache symptoms for over 5 years before considering surgery “as a last resort”.  Part of this is due to the age old bias beteen among health care providers as a group for many reasons. For many of these patients, a physicians advice to “go see your dentist” was the recommendation when joint pathology was suspected.  Most all dutifully did and underwent numerous dental related treatments with no improvement.  Not a single patient in this group (remember, this was 18 years ago), ever had detailed imaging (MRI) of the jaw joints before being referred for treatment…or during any dental related treatment.   Sadly, today, things are not much better when extensive dental treatment is undertaken to treat “TMJ and associated chronic headache”.  Thankfully today, physicians are more apt to request imaging of their patients if they wish to rule out this condition.

Headache localization in patients with derangements that are not terribly advanced but early in their history.. but dysfunctional non the less are usually localized by them as temporal or retro orbital.  Advanced degenerative cases are associated with a generalized “cephalgia” or a headache that can be anywhere, and often diagnosed as a vascular or “migraine” type headache…See IHS website and classifications.  These are types that often require a multiple medical approach in the peri-operative period.  (Treated as muscular and vascular…see previous blog)

It all relates to a duration of signs/symptoms evaluation.  Chronic unstable joint dysfunction for greater than 1 year, non responsive to acceptable and reasonable dental related treatment, often leads to secondary chronic headache in individuals who have progressive biomechanical dysfunction of the jaw joint capable of tissue destruction.   It is important to image and treat at an early stage, to prevent needless chronic pain  and advanced joint degeneration of all sorts for becoming part of the package.

Most all epidemiologic surveys of patients show that significant pain and problems are seen in women far more than men.  A biomechanical explanation has been provided in this web site.

The following quote is is a summary statement in this paper that was consistent with this group of patients studied and continues to be true today in my clinical/practice experience….and I might suggest all who manage this health problem…see  ASTMJS.org :

“The predominance of TMJ syndrome (pain complaints) in women may be theoretically explained by experimental (neurological) dat.   Bereiter, (and many others now…this was a classic paper) demonstrated that systemic estrogens increase the size of receptive fields of trigeminal nerve mechano-pain receptors.  This change occurs even after  resection of the nerve origin at the base of the brain (animal studies and after trigeminal nerve surgeries for cranial nerve neralgias that create incapacitating human facial pain)  suggesting hormonal induced  changes at peripheral regions (structures outside the central nervous system that receive their sensory input from the trigeminal nerve ).   The effects of domestic jaw trauma, hormone-induced or mediated inflammatory destruction of fibroelastic tissues of the TM joint system, osteoporosis-induced degenerative diseasee, and periodontal bone loss with posterior tooth loss may also contribute to the high incidence of this condiditon in women. ”

“Analysis of my patients who did not get well reveals principles found in other joint systems.  Patients with long-standing joint pain and destruction , never previously diagnosed carry a poorer prognosis for a satisfactory result than those diagnosed much earlier. ……Patients who have had long-standing internal derangement (greater than 2 years) and no ressponse to reasonable non-surgical/medical management (3 months) may improve but continue to have pain consistent with occasional but chronic arthralgia.  This type of patient made up the majority of those who only had a fair result by my estimation.  In my experience, patients with long-standing degenerative disease or arthrosis have pain syndromes that are difficulty to manage.”   To that, add patients who have had significant documented “vascular or migraine” headache since childhood, and may have sustained a jaw injury later in life creating a TMJ derangement…. are a particular challenge.

Finally,  a paper like this invites risk..  and that was my greatest concern when it was published after review by the editors at Duke University…risk of an uniformed, desperate patient to seek out  TMJ surgery  with the specific goal to “”cure my headaches.”  These patients have always scared me personally and anyone who works in this field…..

Never should one have any expectation of hoped for successful headache management unless they can document four fundamental and consistent issues:  one….they have had all other serious potential causes for chronic headache ruled out by a certified neurologist or other medical provider(s)…..2) that there is documentation with imaging of significant jaw joint intrinsic disease and that significant orthopedic dysfunction/well localized joint or ear ache type pain that  is not responting to:….3)  All reasonable and acceptable non surgical dental and medical management….and..4) the patient is psychologically stable, oriented, and consistent with ability to relate cause and affect….reasonable people accept there are no guarantees in our individual and collective life experiences.

Kirk, Jr. William S. :  “Chronic Temporomandibular Joint Disease and Head Pain/Response to Surgery”  North Carolina Medical Journal, January 1993, Volume 54, Number 1, PP.30-32 and 45.

Bereiter DA, Standord Lf, and Barker , DJ:  Hormone -induced enlargement of receptive fields in trigeminal mechanoreceptive neurons. II Possible mechanisms. Brain Research, 1980; 184;  411-23.

The above photo is of the intact disc/capsule adapted over the mandibular condyle. The previous blog shows the disc/capsule divided  in the mid sagittal plane.

The above photo is from a patient with not only significant orthopedic dysfunction of the jaw joint but chronic, daily and unremitting headache that lasted for years until finally referred for surgery.  The view is of the superior disc surface which will articulate with the glenoid fossa.

This is the inferior disc surface of the same specimen.  This surface articulates with the condyle of the jaw.  Note the differences int the two surfaces.  Note the significant amount of inflammation present in the entire disc tissue and the effects of longstanding  destructive shear and translational damage throughout the entire specimen.  After surgery, joint function improved significantly. But relative to pain and headache, the most satisfying result in this case and hundreds like it was the significant decrease in headache frequency, duration and intensity that was part of a satisfying long term result of appropriate early  diagnosis and treatment.

The presence of this degree of inflammation in the fibrocartilage  TMjoint disc/capsule tissues is significant due to a number of factors. The synovial nature of the TM joint and the highly vascular posterior  attachment of the disc/capsule to the tympanic plate of the temporal bone (that separates the ear from the TM joint) is a direct conduit that allows access of biochemicals produced by inflammation and tissue destruction into the regional blood supply with many potential effects. 

When the mouth opens and the jaw joint translates, the tissues that compose the posterior joint attachment fill with blood very rapidly.  As the jaw closes and the teeth engage, this blood is compressed rapidly out of the attachment.  The posterior attachment is like a sponge  actually is what is referred to biologically as an arterial-venous fistula (A-V fistula).  This mechanism allows a rapid clearance of metabolites through a healthy synovial lining and system which is necessary to protect the integrity of a fibrous tissue system that is required to maintain its natural elasticity for life long function.  After injury and onsent of chronic instability, infection, other systemic arthritic disease processes  (rheumatoid arthritis, psoriatic arthritis, connective tissue diseases etc) inflammation begins to be a part of the destructive process along with unbalanced shear and torque forces in a progressively unstable joint.  Patients with longstanding  orthopedic joint disease and advanced arthritis almost always have increased volume and diameter of vascular structures surrounding the joint capsule. This is most likely due to an elevation of substances that cause vasodilitation as explained below. 

Significant headache is a common complaint of patients with progressive and longstanding instability or derangement of the jaw joint.  Surprisingly, in the neurological classifications of headache and etiologies of headache requiring the expertice of neurologic specialists in medicine, rarely is chronic TM joint arthritis or the effects of longstanding derangement acknowledged as a potential primary cause of unremitting headache pain, and the condition considered as a viable mechanism of recalcitrant headache treatment.   This is unfortunate and is a primary example of a significant disconnect in the training of physicians and dentists in this area. Headache issues with “TMJ syndrome” are generally described in dental education as being due to chronic “muscle spasm” from various causes varying from malocclusion induced myospasm to bruxism induced muscle tetany producing excessive lactic acidosis, similar to what happens when we excercise beyond our abilities at the time.  Neurological medicine for some mysterious reason has not paid much attention to over 20 years of evidence based data and studies provided by biochemical assays and joint fluid analysis studies compiled by surgical data, most of the early data produced by members of the American Society of TM joint surgeons and reproduced and recomfirmed multiple times and independently  by other researchers in the oral and maxillofacial surgical field  throughout the world.

A second mechanism is true vascular cephalgia or vascular headaches which are complex neurological and biochemical phenomena.  Migraine headache is the extreme neurobiological bad actor that is the prototype vascular headache phenomenon.  In inflamed TM Joints, many different biochemicals that are “vasoactive” substances have been identified… Substance P, is just one of many vasoactive substances that is elevated in the central nervous system blood supply in many types of vascular headaches.   It is found in significantly elevated quantities within joint fluids in cases of TM joint arthropathy as exhibited in these specimens. The centenal work by Moskowicz in the the 80s directed neurologic and pharmacologic research on the development of  medications whose mechanisms are to minimize the effects of these incapacitating headaches.

Substance P is produced in relatively high quantities in the Trigeminal nerve, or the complex motor and sensory nerve that supplies most of the neurologic innervation of structures from beneath the jaw line to the forehead, scalp, ear regions, the teeth, sinuses, eyes.  There are portions of this formidable cranial nerve system that surround arteries in the brain.  Mechanisms of vascular headache can be kicked into gear when Substance P and other biochemicals are elevated in all types of inflammatory disease processes that occur along the paths of this complex cranial nerve system (the 5th). which is a mixed motor (movement) and sensory (feeling) system.   Consequently, “TMJ headache” as reported by patients can be a very troublesome and complex mixed headache of both muscular tension and vascular components.

Often, muscle relaxants are sole prescribed for “TMJ headache” felt to be due to muscle spasm.  The mechanism for many of these drugs (Flexeril, Valium, Soma) work relatively well for muscle spasm induced conditions in muscle groups innervated by the spinal nerves.  Unfortunately, they do not seem to work as well  with the Trigeminal or cranial nerve muscles  because of the complex nature of this part of the nervous system….these drugs just work better with back, neck and extremity muscle spasm conditions. …not so great with the jaw…..this is most likely due, again, to the complex nature of the nerve itself being a complicated  mixed motor and sensory  dually dependent components .  Chronic headache medical management should include consideration of medication designed to reduce the effects of Substance P and other similar substances in this clinical setting.

Chronic headache from cervical disc disease of the neck is accepted as a condition of etiology. Consideration of the evidence in the literature in oral and maxillofacial surgery of repeated studies demonstrating destructive and vasoactive substances in diseased jaw joints should be given consideration as well.

References:  (The following references are some of the classics from neurological research concerning Substance P and its effects in cranial vascular circulation, vasoactivity, and the trigeminal nerve system that is the complex portion of the nervous systems operating in this area of the body.)

1. Moskowitz,MA:  The Neurobiology of Vascular Head Pain.  Annals of Neurology1984; 16: 157-168.

2. Lembeck F.  Peripheralo substance P neuronsL  afferent, efferent or both functions?  In Skrabanek P, Poell D (eds):  Substance P. Dublin: Dublin Press, 1983, pp 81-5.

3. Schellhas KP, Wilkes CH, Baker CC.  Facial pain, headache, and temporomandibular joint inflammation.  Headache 1989; 29:229-32.

4. Schellhas KP, Internal derangement of the temporomandibular joint: radiologic staging with clinical, surgical, and pathologic correlation.  Magnetic Resonance Imaging 1989: 7: 495-515.

5.  Evinsson L, McCullough J, Uddman R. :  Substance P, immunohistochemical localization and effect upon cat pial arteries in vitro and in vivo.  J Physiology 1981;  318: 251-8.

6.  Godsby PJ, Edvinsson L, Ectman R.  Release of vasoactive peptides in the extracerebral circulation of humans and the cat during activation of the trigeminovascular system.  Annals of Neurology, 1988;  23: 193-6.

7. Bereiter DA, Standord LF, Barker DJ:  Hormone induced enlargement of receptive fields in trigeminal mechanoreceptive neurons. II.  Possible mechanisms.  Brain Research 1980;  184;  411-423.

 The above photos are of the human disc/capsule and the mandibular condyle along with the lateral pterygoid muscle which is the small but powerful muscle that opens the jaw. There are two views of this cadaver specimen which shows a sagittal (from the lateral, outside to inside) view and a coronal view (front to back)…the views that are taken with MRI examination of the jaw joint. I have found that visualizing the actual anatomy helps greatly in talking to patients about the objectives of treatment and for their own understanding. I hope this helps you as well.

There are many myths about “TMJ”….sometimes they are perpetuated by the professions that “manage” patients. Also, realize that this website is dedicated to orthopedic problems of the human jaw joint that create issues with well localized “ear” pain as well as a myriad of chronic conditions that arise out of misdiagnosis over time. This blog will serve as a first in a series relative to expanding into understanding other pain issues such as chronic headache associated with “TMJ”, muscular pain, etc. We will also talk (in another blog to come) about an ugly history in TMJ surgery in the 1980′s that was based on using artificial materials placed that were designed to act as an artificial “disc”….you can’t fool mother nature and she taught us a lesson once again in this era that paralleled a similar problem in the development of modern orthopedic hip replacement.

In our photos above, we are viewing only one joint. The mandible or jaw is the only bone and orthopedic system in the body with a dual joint operating system. Jaw movement is complex. Movement of the lower jaw is a complex orthopedic mechanism. Dual movement of both joints simultaneously, complinentary create the simple notion that the lower jaw is like a loosely held with a kind of fluid movement or “floating bone” , under the contol of pairs of muscle groups on either side of the midline. We have looked at biomechanical principles and the concept of angular momentum elsewhere in other blogs and the web site. What you see is a remarkable orthopedic apparatus.

Patients, who have received consultation and/or treatment for “TMJ” often are first presented that the joint has a “disc” or “meniscus” which are terms for other cartilage components of other joint systems of the body (spine and knee respectively). One fundamental misunderstanding that is prevalent is that the “disc” of the TMJ is somehow an entity of its own. Often what is visualized is a two dimensional view and this is incomplete.

As you see in the photos, the condyle (ball) of the jaw is in close adaptation to a 3-dimensional fibrous tissue cap(disc/capsule) that fits like a cup over the condyle. The complexity of jaw movements result in an infinite number of forces that are generated simultaneously in both joints by the movement of the jaw. The net effect that with an orthopedic system that has such complex mobility, only a tissue with natural elasticity can perform the job, day after day. If you were to take a mass of the “disc/capsule” you would get the feeling it was similar to the feel of soft leather or any similar material that when wadded into a ball, it would resume its original shape when let go. An analogy of the relationship of the disc/capsule to the condyle is that of a cap fastend on top of a soda bottle….the center of the cap is the “disc”, the crimped part of the cap below the rim of the mouth of the bottle the perimeter ligament attachments that fastens and hold the cap on the bottle. 

This fundamental property is the most important characteristic of the nature of the “cartilage” in the TMjoint. In fact it is not cartilage, it is fibroelastic tissue and is under constant load, movement and activity, and has to respond to increased demand under specific conditions. With mouth opening, the entire shape of the disc/capsule changes as it adapts to the various curvatures and movements of the condyle as it glides forward and past the various curvatures of the fossa or joint socket at the base of the skull.

With orthopedic problems of the jaw joint, a derangement is an incoordination, during movement and a dysfunction between the boney structures of a joint and the key cartilage components of the joint. Jaw popping,clicking, locking, inability to load the jaw joint with chewing force and mouth opening incoordination are all signs of a TMJ orthopedic derangement. Does this mean that every jaw joint that pops or clicks is or will be a problem? Not necessarily as the literature is clear that jaw popping or clicking can be a common (not necessarily normal) finding in humans….much of it is due to the complex movement of the joint…and the transformation of kinetic energy (energy of movement on soft joint tissues to sound when there is an occasional hesitation to movement from some cause. Also, with the ear directly next to the joint, sounds can be common….if our ear was anatomically located next to the knee….it would sound like a creaky floor every time we walk. So….noise by itself is not always a predictor of a pathology that will worsen.

What is critical is identifying the degree of instability of the disc/capsule and what is the cause of the instability in the first place. Biomechanics and studies are clear that when a derangement is created in the laboratory during studies, the most vulnerable region of the joint capsule attachment to the condyle is in the extreme lateral to lateral posterior portion of the attachment. Here is the “achilles heel” of this orthopedic system. An injury to the jaw, hyper extension injury can cause rupture of this region of the disc/capsule attachment to the condyle. Pain and joint popping (orthopedic instability) get worse over time due to the fundamental reality that the gliding movement of the jaw joint with attempted mouth opening creates shear and torque forces which cause further detachment and/or plastic deformity of the disc/capsule  over time.  Morphologic tissue changes in the character of the fibrous tissue are like a callous that forms overtime in the palms of our hands or soles of our feet.  These changes occur most frequently between the surfaces of the condyle where it contacts the naturally concave cupped surface of the disc/capsule.

 If the derangement is caused by a developing boney impingement from the socket or fossa (not pictured here…see previous blog with surgery photos of a lateral fossa impingement)  projecting into the disc/capsule during mouth opening, often the joint can get stuck such that it does not allow the joint to glide to allow mouth opening….or it can get stuck open creating a subluxation or dislocation. These are significantly painful events that are fundamentally orthpedic dysfunctions internal to the joint….not muscle spasticity as often suggested.

It has been shown that it takes over 640 Newtons of force to break the bone just below the condyle of the human jaw in the region called the condylar neck ( ) This is the most frequent site for a jaw fracture. It has also been shown, that it takes 10% or less of the force required to cause the fracture, to cause a tear or detachment of the disc/capsule from this lateral perimeter attachment of the disc/capsule to the condyle. ( ) Such forces are quite prominent in cases of childhood falls or with any blow to the jaw, or hyperextension injury (sprain) due to excessive mouth opening during a blow to the jaw, flexion/extension injury to the jaw etc…..that are incidents or forces not strong enought to cause fracture. We all have an intuitive understanding how ligament cartilage injury occurs in other joint systems (cruciate ligament tears in the knee, Ligament tears in the foot/ankle, disc rupture in the spine, and rotator cuff tears in the shoulder). Unfortunately, the mechanisms of potential myriads of TMJ injury is often ignored in all circles…..and this is unfortunate….especially in the growing child.

One of the important functions of the disc/capsule is  that its proper adaptation over and function with the condyle is critical for condylar growth and consequently,  with growth and development of the lower jaw. Our long bones grow from each end at the growth or epiphyseal plates….the jaw achieves most of its growth at the condyles of the jaw, there is no epiphyseal growth plate, rather an overall 3 dimensional volumetric increase in the size of the condyle during the skeletal growth years of life.  All jaw movements and even chewing of food creates reactive or tension forces delivered to the condyle by a properly adapted disc/capsule….this is another uniqueness of the jaw joint in that microstructure of the organization of fibrous tissue is designed to resist tension forces…where other joints of the body are designed to accomodate compression forces through weight bearing resistance design. If you remove this structure from a growing animal, growth at this joint can be  severely impacted. That is why identifying children at risk is extremely important…particularly those who have had jaw trauma and may have had a significant injury capable of creating a significant detachment of the disc/capsule from the condyle. Development of asymmetries or crooked jaws is a common association and sequela.

Lastly, Athanasiou and Detamore are two bioengineers who have dedicated much of their careers to the study of TM joint function and its structural design,. With the expertice of individuals such as these scientists, much of the myths and mistaken concepts of the past will eventually disappear. They have suggested that the proper way to look at the TMjoint disc/capsule and its relationship to its surrounding boney relationships with the condyle and fossa is to think of the disc/capsule as a trampoline…..when we chew food and exert compression loading to the joint, the “disc” portion of the structure is the trampoline center which we jump on….as we jump on it, it changes its shape to adapt to our weight compacting into it…..the springs of the perimeter of the trampoline is where much force is distributed and their integrity is key to the trampoline’s function….if one by one a spring breaks….the trampoline is no longer functional……it becomes loose and flacid and can no longer spring back….the trampoline becomes useless. In addition, if we cary this analogy further….a loose, poorly attached or weaking disc/capsule attachment (s) become even more damaged over time during the phenomenon of mouth opening where the condyle glides forward……an unstable capsule then is subjected to even more tissue damage due to the generation of unstable shear forces within the main body of the disc (trampoline).

Such physical realities point to the explanation as to why patients who develop significant orthopedic problems in the jaw joint do so much earlier (20-30 years on the average) compared to similar conditions in other joint systems of the body…..the tissue that makes up the human jaw joint “cartilage” must have significant inherent elasticity and “rebound” much like that trampoline….whenever the first few springs begin to break…the inherent forces generated in the joint will take over and progressive joint failure may result….if not perceived early enough.  A typical story of a patient with surgical orthopedic disease or dysfunction of the jaw joint is that they first began to notice the problem during their teen or skeletal developing years.  Instability of the jaw, popping, locking became more frequent and louder…sometimes loud enough for others to hear.  It was amusing for a while, but later pain began to develop, the fit of the teeth perceptually changed and other symptoms set in…..many begin to become impaired in their 20s and 30s. 

Next blog…the blood supply and nerve supply to the human jaw joint and its association with referred pain and headache.

Dr. W. Kirk, Jr.
Charlotte

Dr Peter Quinn, DMD, MD is past chairman of the Department of Oral And Maxillofacial Surgery at the University of Pennsylvania, Current President of the American Society of Temporomandibular Joint Surgeons  (ASTMJS.org), and currently is the Chief of the Medical/Surgical staffs at the University of Pennsylvania in Philadelphia. His job is to administratively represent all physicians at HUP. He has developed the total TM joint prosthesis that is referred to elsewhere in this website/blogs that is currently produced by Biomet Corporation, the world’s largest producer of orthopedic prosthetics. This is produced with his permission. His response was sent to the American Journal of Orthodontics relative to what was recently published in their journal. This was referenced in the previous blog on this site.

RE: Guest Editorial/ Managing Patients with Temporomandibular Disorders: A “New Standard of Care”..July, 2010

It was with a sense of great disappointment that many of us read what was purported to be a new “standard of care” for temporomandibular disorders. The American Society of Tempormandibular Joint Surgeons (ASTMJS) is a multidisciplinary organization of clinicians, oral and maxillofacial surgeons, ENT surgeons, oral medicine specialists, orthopedic surgeons and radiologists who, over the past quarter century, have attempted to define a rational approach to a small subset of patients within the broader “TMD” classification that may ultimately need appropriate surgical intervention.

Since Dr. Green , in his paper, said that the “AADR recognizes that temporomandibular disorders encompasses a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles and all associated tissues, “that clearly can be interpreted as an all encompassing diagnosis.” The ASTMJS guidelines for diagnosis and management of disorders involving the temporomandibular joint  (See ASTMJS.org)and related musculoskeletal structures concentrates more on internal derangement since we feel that again a small proportion of those patients may ultimately require a surgical approach. We do state (in the ASTMJ Guidelines) that “Non-surgical treatment should be considered for all symptomatic patients with internal derangement or osteoarthritis.” We clearly agree with the statement that the vast majority of patients who have myofascial complaints should have treatment based “:on the use of conservative reversible and evidence based therapeutic modalities.” (AADR Guidelines)

What is concerning is to give the impression that “TMD type pain” should all be managed “within a biopsycho-
social framework”. This would be a kin to saying that all orthopedic disorders should be treated within the same biopsychosocial framework. It is difficult to conceive that the most used , and probably the most complicated joint in the body would not be prone to a disorder that could not be treated with conservative medical care. In the United States alone, there are close to 900,000 hip and knee replacements and I think it would be difficult to find a rheumatologist or orthopedic surgeon who would feel that these all should have been dealt with in a non-operative fashion.

I have had the priviledge tof being a member of a multidisciplinary TMJ and Facial Pain Clinic at the University of Pennsylvania for over 20 years. Our operative intervention rane (arthroscopy and or open joint surgery) is less thatn 3% of our patient population. We use the standard Wilkes classification for all patients, and exhaust all conservative therapy before considering any intervention. We clearly recognize that there has been over – use of surgical treatments at time in the past and we are committed to an evidence-based approach to surgical interventions now and in the future. In the last month alone, we had surgical patients with diagnoses that include traumatic osteoarthritis, rheumatoid arthritis, synovial chondromatosis, and a malunited condylar fracture. it is naive, and somewhat irresponsible, for the authors to think that these guidelines will not be used by third party insurers to deny treatment to patients with temporomandibular joint disorders that not amenable to the conservative approach. If one searches the internet using “temporomandibular joint disorders”, the first two websites (WEBMD and Wikipedia) both include references to surgery (arthrocentesis, arthroscopy and open joint surgery) as appropriate when conservative therapy fails or when the initial diagnosis would dictate that approach. If even public websites acknowledge a broader “orthopedic” approach to temporomandibular joint disorders, it would be less confusing for patients if “professional organization” gudelines were as inclusive of all potential treatment modalities.”

Dr. Peter Quinn, DMD, MD, President, American Society of Temporomandibular Joint Surgeons.

University of Pennsylvania, Philadelphia, Pa.

Final comments,  Dr. Kirk……

Many patients who develop “TMJ” that has progressed to severe state report to me that their condition began in adolescence. This website/blog is dedicated to presenting the orthopedic problems found in the jaw joint (TMJ) and relate it to orthopedic conditions that the patients/public are familiar with and have enough common sense to relate to from their own life experiences. For a professional publication of the dental profession to publish a position that puts secondary emphasis on appropriate and timely imaging of patients…particularly patients who could be at an age of vulnerability and in orthodontic treatment and in their growth and development years…..and relates that patients who come to providers with complaints be looked at in generic fashion,….is in this day and time misguided…….Publications in the orthodontic literature have suggested that the incidence of  significant TM joint derangement match those of adults who are managed with “TMJ”….relatively 1 in 10.  Why consider to first manage with a psychosocial model of disease or management when life long consequences can be significant….growth and development impacted, and a joint system that is known to exhibit significant degenerative arthrosis at the extreme end of the spectrum 20 to 30 years earlier than similar degrees of arthrosis in a knee or hip ?

These are the types of patients who are unfortunately created when viewed  as having a  primary muscular disorder, a psychological disorder, or disorder of the fit of their teeth….all the while ignoring a medical/orthopedic model of significant disease in a subset of patients…..progression of disease due to no consideration of dysfunctional orthopedic biomechanics and not delegating imaging of these patients to a secondary level of management.  

W. Kirk
Charlotte, NC

You know what they say….”The more things change, the more they stay the same”. Nothing could be more complimentary to this statement than a recent editorial that appeared in the American Journal of Orthodontics and Dentofacial Orthopedics in the July 2010 issue (1). Rarely do things of this nature become circulated among formal professional societies as rapidly as did this article. It is a summary of a position of the American Association for Dental Research (AADR). The formal statement contains 18 selected references. There is no contribution from any surgical society or information which addresses orthopedic disease or injury of the human jaw joint. It is unclear just what is to be done with this statement. Unfortunately, it supports a bias of 40 years or greater that people with “TMD” can simply manage their disorder themselves and that it is too multifactorial to comprehend.

Here are some excerpts from this editorial, published in what generally used to be accepted as the premiere journal for the specialty of dental orthodontics:

1. It is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be based primarily on the patient’s hitory, clinical examination, and when indicated TMJ radiology or other imaging procedures……This is truely a dental model of patient evaluation and management. With the pathology of TMJ disease not being taught to either dental or medical students in the US to any degree not to mention anything about dysfunctional biomechanics and how it destroys a human jaw joint over time….it is no wonder that this is such a controversial area. One can imagine physcians being trained to ignore extensive knowledge of all pathology of synovial joints, ramifications of injury, growth and development problems and dyfunctional conditions coming up with such a simpletonian initial statement such as this.

2. “In addition, various standarized and validated psychometric tests may be used to assess the psychosocial dimensions of each patient’s TMD problem.” …..In the 1960′s, the author of this editorial and a colleague authored a paper that influenced dental education to this day. It emphasized basically that much pain that individuals experience with this condition is psychological, self limiting, due to stress in their lives etc, etc. There was not even any acknowledgement that the human jaw joint can be injured in various ways, have specific synovial disease processes, and develop significant orthopedic abnormalities similar to any other joint in the body (not to mention photographs of pathology presented in this web site). Basically, such a statement continues to be taught in professional health care education…..In my personal experience, sure, patients with chronic pain become psychologically depressed or develop other issues when they are told they can manage their own problem….if they just cut out all the stress in their lives. Unbelievable…..no wonder there are so many frustrated people out there.
This statement, to me, is an indictment of the educational system for the past 40 years….presently it does little to mimick a medical model of evaluation at all….and perpetuates the accepted protocols that we can actually know all we need to know about a patient by just sitting down and listening to their story….if we get around to it, imaging studies might be of some use…etc etc.

The rest of the statement goes on to recommend that “conservative” treatment be exhausted….which is a good thing….but the problem with this this approach is that there is no education or emphasis on the 10% of patients with “TMD” (imagine that in orthopedics with the sophistication of knowledge of knee biomechanics and various conditions/classifications, that the best medical science could do is come up with “knee syndrome” or how about TFD…tibiofemoral disorder)…….

ASTMJS  (See ASTMJS.org) several years ago made requests to be allowed to show photographs of orthopedic disease of the human jaw joint and introduce the paradigm of dysfunctional/painful biomechanics. We were not invited to participate. The committee that put out this statement was actually a Neuroscience Group…..which means academicians who do wonderful but unfortunately are overbearing in that bias relative to cause…unappreciated injury….and long term effect on a human being. This approach is similar to the old parody of blind mice, feeling the legs of an elephant, and trying to debate just what it was that they were experiencing. A myoptic approach to be sure….and unfortunately one that is taught to students research relative to understanding the complicated neuro/biochemical mechanisms of chronic pain….

I guess what is the most disturbing about this statement is that it often is said that the operating room is the ultimate objective laboratory in health care. Here, obvious visual tissue  disease and injury unamenable to conservative health care methodologies are witnessed and entities that require surgery are acknowledged by reasonable providers….except those who create statements which for whatever reason choose to ignore true surgical disease not amenable to non surgical treatment. ASTMJS, several years ago approached members of this committee, on behalf of patients who had become significantly impaired from jaw joint fractures, ankylosis of the joint, ravages of arthritic disease and development of malocclusion etc. etc. It was our hope that the American Dental Association would petition the American Medical Association to  acknowledge and include these patients as human beings who deserved to be formally recognized in the AMA’s Guide to Impairment and Disability. Our request could not even get by individuals, some of whom represent this committee. The AMA was counting on support from the ADA that never came. In today’s world of correlation of imaging and surgical photographic confirmation, it is time for the dental model neuro/phycho/biochemical pain is…” something we can counsel you about providers“, to understand and acknowledge that their bias is just that….they are ignoring some very important data and science from other fields. My bias is that there are just as many patients who have been victimized by this mindset  (many make up large numbers now in patient advocacy groups)….one that is not willing to look at an orthopedic model of joint disease. 

Enough of my grandstanding…..and it is not that surgeons have not had their own biases distract their thinking as well. Over 25 years ago, we had our own version of the Gulf oil disaster happen in the world of TMJ surgery. We’ll talk about it next blog.

Charles S. Greene, editorial, “Managing patients with temporomandibular disorders: A new “standard of care”. Am J Orthod Dentofacial Orthop 2010; 138, 3-4.

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`One of the most basic non-surgical management tools in the armanentarium of providers managing patients in this field is the occlusal orthotic (bite splint).  From a surgical standpoint, the sole purpose of the oral orthotic is to separate the teeth and prevent the condyle of the mandible from seating and loading the articular disc/capsule of the TMJ.  Some non-surgical providers will maintain patients on occlusal orthotics for months or years, often changing “splints” to meet an ever changing or exclusive management philosophy of the provider. (Provide ways for jaw muscles to relax, “deprogram” muscles from the interference of the influence of the way the teeth contact, etc.)

In their defense, orthotics or splints have been shown to be an effective way to manage joint pain in meta-analysis of the dental literature on the subject. (1)  However, the problem often becomes one of difficult practical options for the patient.  And, what about people with multiple missing teeth ?….

The fundamental question in management should be what happens if the orthotic is discontinued, say, during the act of chewing function.  If joint pain and instability are corrected while the orthotic is worn, this is a good thing.  However, most patients can not or will not be able to wear the devices continuously during everyday life.  Likewise, they can not be worn indefinitely during chewing and loading function as they are very inefficient and cumbersome to eat with.   When pain returns during routine chewing loading of the joint or attempted mouth opening, it just might be that mother nature is giving one a clue that all is not well.  Rarely do non-surgical providers incorporate the use of MRI or other specifically sensitive imaging testing to assess their treatment.  This is unfortunate.
Our non-surgical protocols are to place patients in orthotics that adapt to the lower jaw.  The position of the lower jaw is determined by a radiograph called a tomogram, which is a thin cut image of the joint.  The orthotic is constructed and the teeth separated enough to provide a centered  condyle/fossa position with a significant increase in joint space compared to when teeth are in contact.  This generally requires a slight forward posturing (edge/edge incisor tooth  position) of the mandible.  We ask our patients to wear the orthotic 16-18 hours a day for a month, including night time.  We construct one for the lower jaw because they do not interfere with speech function as much as maxillary (fit to the upper teeth) orthotics or splints.  They can be tolerated better at work or school.  Also, the mandible can be manipulated slightly to decompress a painful and compromised joint.  We do not want the  patient to alter the diet nor eat with the orthotic in place.  It is during this time that we want to ascertain how this joint will function during routine chewing function and loading.  After all, painless joint stability during eating is the goal of any therapy.  If a patient improves with the orthotic but joint instability and pain progressively returns during routine mastication loading, this is significant.

If symptoms do not improve after one month of orthotic wear, we will examine the patient with MRI imaging in the dental occluded position,and  open mouth position, with and without the orthotic.

In general, the decision to suggest TMJ surgery to a patient comes when MRI imaging reveals a significant derangement or  impingement along with a joint that continues to be significantly unstable in all examined range of motion.  Patients will continue to complain of significant pain and jaw  incoordination  when eating, despite wearing the splint for significant hours each day.  Comparison of the images with the teeth in their natural occlusion position  together and the splint in the mouth gives the provider an idea of how effective the splint is in overcoming  various orthopedic pathologies in the joint  when teeth come in contact or the mouth opens.

In reality, A TMJ derangement or this physical impingement problem is not too dissimilar to the concept of impingement syndrome of the shoulder where different curvatures of the achromion (equivalent to socket/fossa of the shoulder joint) and the head of the humerus (condyle of the upper arm) pinch down on the rotator cuff of the shoulder joint in various degrees and position of the  shoulder/arm rotation and abduction.

For surgical patients, I obligate surgery  patients to wear the surgical orthotic continuously for one month post operatively.  This does two things.  When the disc/capsule of the joint is repaired, the critical area of repair receives the maximum amount of physical force in the joint region when the teeth engage.  To that end, we do not want this region of the TMJ disc/capsule loaded until tensile strength of the repair site is assured.  (generally 4-6 weeks).  Likewise, since the joint is a synovial (fluid making) joint, there will likely be a post operative effusion temporarily (fluid in the joint) from the operation.  Taking loads off the joint during this time improves patient comfort based on their feedback along with MRI data (see below).

Finally, a word about bruxism.  Bruxism or jaw/teeth clenching or grinding  is a human fact of life, first described by ancient Egyptian physicians and the famous Greek physician Galen long before the time of Christ.  It can be physically apparent to any of us during stress or other emotionally charged periods of consciousness.  For many, it can occur at night during sleep and is a common physiologic reflex that is, for most, uncontrollable.  In orthopedic surgery, certain lifestyle considerations are taken into account when specific types of joint surgeries are performed.  With jaw joint surgery, long term bruxism can not go uanappreciated in the surgery patient and it is our advice to patients to consider the use of the orthotic at night indefinitely, to protect against joint loading that can be higher and occur for longer periods of time then when we eat a meal.

1.  Forssell H, Kalso E et al:  “Occlusal treatments in temporomandibular disorders:  a qualitative systematic review of randomized controlled trials.”  Pain 1999, 83:  549-60.

2. rinchuse D and McMinn, J:  “Summary of evidence based systematic reviews of temporomandibular disorders “  Am J Orthod Dentofacial orthopedics, 2006;  130a;  715-720.

3.  Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculaskeletal Structures.  The American society of Temporomandibular Joint Surgeons.  2004 (See ASTMJS.org)

#1                                                                                                                                                                                                                                              #2

#5

The above surgical photographs and MRI are of a 27 year old patient with greater than 10 years of progressing pain and mechanical TMJ locking.  Patient related onset of symptoms to teen years.   This is an open arthroplasty procedure, generally performed when significant bone surface abnormalities (Type II impingement)  exist in the fossa (socket) of the TMJ at the base of the skull. This type of disease will not respond to any non surgical dental related treatment or orthotic (splint) therapy. Symptoms generally are associated with advancing  TMJ pain, joint locking in either the closed postion or occasionally stuck open, and significant pain and inability to load the joint to chew food.

#1 is initial exposure of the lateral rim of the glenoid fossa along its anterior-posterior extent from an incision of about 3 cm in length in front of the ear.  Care is taken to approach the joint from behind neural and vascular structures in the area.  Once the joint is exposed, the superior joint compartment (the TMJ has two joint spaces between the fibrous tissue disc/capsule that divides and separates the fossa from the condyle).  In this view, one can see sharp, jagged bone spur or impingement processes which have grown down into the disc/capsule. An incomplete tear of the superior/lateral disc capsule can be seen just below the lateral rim and one of the largest bone spurs (osteophytes).  See previous blog on biomechanics of the TMJ which explains the probable mechanism of development of impingement processes.  (Reference below 1)

#2 Represents initial relief of the impingement.  Bone tissues of the lateral rim of the fossa are relieved/sculpted to begin to match the anterior/posterior and medial/lateral curvature of the glenoid fossa.  This is because the TMJ mechanically must function with compatible curved surfaces which a mechanical engineer would describe as curvilinear general plane motion.

#3 Gross curvature sculpting is continued

#4   Final bone surface sculpting  of the fossa is completed with rotary diamond and hand diamond instruments.  At this point, the disc/capsule is placed such that its inferior concave morphology is congruent with the convex curvature of the mandibular condyle.  Generally, the disc/capsule is extremely loose or flacid due to excessive shear and torque which have hyperextended or torn the lateral capsular attachment to the lateral pole of the condyle.  These attachments are oversewn or reinforced to maintain the adaptation of the disc/capsule during all range of jaw motion.  These motions are at this point to make certain there are no bone impingement interferences impeding rotary or translating TMJ function.

#5.  This is the coronal MRI of this joint.  Note the sharp downward projecting dark pointed projection (Type II impingement) making contact with the condyle and the disc/capsule.  There are different mechanisms in which impingements exert their pathology:  Compression/occlusion impingement when the bone spur digs into the disc/capsule/condyle when the teeth engage during chewing loading of the joint OR   Translation impingement….when the process cuts into the disc/capsule as the entire mechanism condyle/disc/capsule glide forward during mouth opening.

PRACTICAL POINTS OF TMJ SURGICAL ARTHROPLASTY FOR IMPINGEMENT

One of the most common dental management tools for “TMJ” is the oral orthotic or “bite splint”.  The orthotic can be a very useful tool for pain management if a patient has periodic bouts of pain due to joint inflammation or swelling from various causes. These would be the majority of patients managed conservatively or non-surgically.  The analogy in orthopedic medicine would be the individual who whould wear a joint orthotic (knee bracing, spinal bracing etc.) for joint support, pain or protective management and did not yet exhibit joint pathology meriting surgery.

  Bite splints can be fitted to the upper or lower teeth.  Often the concept of effectiveness is that these are used at night to manage night time tooth grinding or clenching (bruxism).  Many times they are constructed to fit on the upper teeth.  Our practice generally will employ an orthotic to be fitted to the lower jaw. Many of  our patients with documented joint derangement or other arthritic processes will have employed a bite splint for years.  Surgical patients will  need continuous wear when referred to us during phases of pre-operative pain and diagnostic  management. The orthotic that is applied to the teeth on the lower jaw  does not interfere with speech and other functions ( when a patient is require to wear the appliance at work, school etc) as much as a splint that adapts to the teeth in the upper jaw.  

  With this group of patients,  MRI documents that a TMJ can be decompressed with an oral orthotic and slight forward posture of the lower jaw to a near edge to edge incisor teeth postion.  This can be successful in improving  joint stability and pain.  However, if and when the patient removes the orthotic to function normally and chew food, if pain and joint instability return under these orthopedic loads, this is significant.

I find that many patients and dental providers can be perplexed when all appropriate efforts to manage a patient with splint therapy fails.  If a significant boney impingement process exists and has not been diagnosed, splint therapy will not be successful.

The following coronal MRI scan shows such a situation.  Here, the MRI has been taken with the orthotic in place in the mouth.  The inner 2/3 of the TMJ disc/capsule has been decompressed, however, even with the splint in place, a severe impingement can not be overcome.  Note in the lateral 1/3 of the joint space that there is no visible fibrous tissue disc signal of similar with of the disc in more central and medial aspects.  This joint would still exhibit significant orthopedic instability, be painful particularly with jaw movement to the effected joint side (lateral jaw movements) and could not be loaded with routine chewing force loads.

Protocols for determining surgical intervention involve this process or treatment protocols.  Whenever a patient has worsening joint instability, pain, etc. and continuous wear of a orthotic is not successful for up to 4-6 weeks, we recommend MRI imaging with and without the oral orthotic in place.  If the MRI documents continued existence of the derangement in sagittal views (Wilkes II-III) and the coronal view demonstrates a significant impingement with the orthotic in place. we will recommend surgical arthroplasty.  In this particular case, the patient was 27 years old.  Arthroplasty and removal of the impingement with disc/capsule repair was successful.  The patient eventually was able to discontinue any further day time use of the appliance and eventually recovered to be able to enjoy a regular diet again with minimal restriction.

In an operated patient, I recommend continued use at night indefinitely.  Bruxism is generally not a reversable phenomenon and is one aspect of long term care that must be acknowledged and respected.  Bruxism can generate joint loads that are higher and more sustained than some of those required for eating.  Therefore, we want to construct a surgical and post surgical orthotic with MRI proven abliity to increase joint space and take load off the disc/capsule.

 It was stated in a previous blog that the most common developmental pediatric/adolescent impingement occurs along the lateral rim of the glenoid fossa.  It mimics impingement of the shoulder joint.  Since the TMJ exhibits complicated combinations of rotation and translation (gliding forward) during mouth opening, it is important to understand how and when it might develop.  An impingement is basically characterized by significantly narrowed joint space in the lateral 1/3 of the joint space.  This creates points of contact between the fossa and lateral condyle on the fibrous disc/capsule where load is excessive. As time goes by,  when the joint is loaded during chewing food and mouth opening, dysfunctional forces associated with shear and torque create instability of the disc/capsule bound by ligament attachements to the condyle.  Initially, this instability of the TMJ disc/capsule is characterized by jaw popping.  Over time,  TMJ pain and joint locking may accelerate and become impairing in some cases.  This can occur in patients in their late teens to early 20′s for reasons previously discussed.  The following image is of an 11 year old patient with a classic developing lateral impingement.  This child was unusual in that she had significant developing impingements in both TMJs.