Comprehensive TMJ Treatments

TMJ Corrective Jaw Surgery | Dr. David Mueller, Virginia Facial Surgery

TMJ1The Temporomandibular Joint (TMJ) is a small joint located in front of the ear.  It is made up of the skull base, the temporal bone, and the mandible or lower jaw.  The mandible is the only bone in the body that has two joints – the right and left TMJs.

TMJ disorders have a variety of symptoms. These may consist of headaches, earaches, jaw pain, clogged ears, jaw locking, clicking, popping, grinding, muscle spasms and changes in occlusion (bite).

What causes TMJ Disorders?

TMJ Normal disc position

TMJ Normal disc position

Trauma may play a role in TMJ disorders, but the disease in multi-factorial. There is no scientific proof that sounds, such as clicking and popping, lead to serious problems. In fact, jaw sounds are common. Painless clicking and popping are not considered abnormal and do not warrant treatment. Research disputes the contemporary belief that a bad bite or orthodontic braces can trigger TMJ Disorders. However, our patient statistics show that a majority have a class II malocclusion (large overbite). New research, however, concludes that there is a strong to moderate relationship between depression or anxiety and Temporomandibular joint disorders. This new research found that symptoms of depression were more strongly related to joint pain, while anxiety disorders and symptoms were linked to muscle pain.

In order to properly treat TMJ disorders, it is very important to make the correct diagnosis. The causes of TMJ disorders can be placed into four basic categories.

  • Myofascial Pain Dysfunction (MPD) or parafunctional habits such as tooth grinding and cheek chewing.
  • Internal derangements of the joint characterized by changes in the cartilage.
  • Degenerative joint diseases such as Rheumatoid and Osteoarthritis.
  • Pathology such as tumors

Myofascial Pain Dysfunction (MPD) is now classified as a psycho-physiologic disorder that is usually brought on by stress and anxiety. Clenching and grinding of the teeth then create fatigue in the jaw muscles causing pain, muscle spasms and headaches. Patients also experience difficulty in moving the jaw and joint symptoms. This may in turn cause clicking, popping and locking in the joint. This is why it is important to make the correct diagnosis. MPD symptoms can mimic more advanced TMJ issues. The treatments are vastly different. If you undergo a surgical procedure for a MPD problem, joint problems may be triggered.

TMJ Non-reducing disc on opening and closing

TMJ Non-reducing disc on opening and closing

Internal joint derangements are diagnosed when the cartilage (meniscus or disc) that is located between the bones of the joint becomes displaced or dislocated. A displaced disc can cause clicking or popping sounds, limit jaw movement, including locking or dislocating, and cause pain when the jaw is opened and closed. As the disc is stretched or displaced more forward, the connective tissue attachments that also contain the blood vessels and nerve endings now assumes the role of the cartilage. The problem is that this tissue has none of the shock absorbing characteristics that cartilage does. The disc or its attachments can develop a hole or perforation, which can produce a grating or grinding noise upon opening and closing. All of these findings can cause inflammation and joint effusions which can cause mild to severe pain.

TMJ Degenerative joint disease

TMJ Degenerative joint disease

Degenerative Joint Disease (DJD), or Osteoarthritis, can be the result of trauma, MPD or Internal Joint Derangements that advance without treatment, and Rheumatoid Arthritis (RA). Rheumatic diseases refer to a large group of disorders that cause pain, inflammation and stiffness in the joints, muscles and bone. DJD and RA can both affect the TMJ causing inflammation of the joint tissues. The exact relationship between these conditions is not known.

Pathology and Tumors, although rare, can cause facial pain and TMD symptoms. Most tumors of the TMJ are benign. However, proper work-up, including proper imaging studies, is paramount in making the proper diagnosis.

What will my treatment involve?

TMJ Anterior disc position

TMJ Anterior disc position

The first and most important goal of treatment is to make the proper diagnosis. Once it is determined whether you have MPD, an internal joint derangement, degenerative joint disease or tumor, the treatment phase begins. At Virginia Facial Surgery, Dr. Mueller separates treatments into two main types:  reversible and irreversible therapies. Basically, reversible treatments can be initiated and terminated without permanent changes if they are not effective. All reversible therapies are utilized prior to the consideration of irreversible treatments which are comprised of surgical interventions.  This is where Dr. Mueller’s extensive training separates him from most doctors in Hampton Roads. Dr. Mueller is extensively trained in 100% of the available treatments for TMJ disorders. Most doctors can only provide some of the reversible therapies. For this reason, many doctors treat surgical candidates conservatively because that is the extent of their training.

Reversible therapies include the following:

  • Pharmacologic therapy
  • Splint therapy
  • Diet modification
  • Heat and Ice therapy
  • Sleep evaluation and management
  • Physical therapy including TENS, Myofascial Release, Iontophoresis and Ultrasound
  • Stress modification
  • Psychiatric analysis and therapy
  • Neuromodulators such as Botox, Dysport and Xeomin

Irreversible treatments include the following:

  • Arthrocentesis
  • Lysis and lavage of adhesions
  • Steroids and Sodium Hyaluronate
  • Arthroscopic surgery
  • Open joint arthroplasty
  • Partial or complete meniscectomy
  • Condylectomy
  • Partial prosthetic joint reconstruction – articular fossa-eminence prosthesis
  • Total joint reconstruction – articular fossa-eminence and condylar prostheses

Either CADCAM or stock prostheses

Dr. Mueller trained at the University of Illinois. Michael Reese Hospital TMJ Center. At that time, the FDA had halted the use of all TMJ prostheses in the U.S. due to catastrophic failures with the Teflon-Proplast implant. University of Illinois was one of two centers in the U.S. to treat (remove) these implants, rehabilitate the recipients, and to develop a new TMJ prosthesis. Dr. Mueller assisted Dr. Louis Mercuri in the research phase of the articular fossa-eminence prosthesis which is now the FDA approved TMJ Concepts Total Joint Prosthesis – a CADCAM titanium TMJ prosthesis.

Dr. Mueller only treats un-resolving pain, dysfunction (painful clicking / popping /locking/dislocating), and degenerative / pathologic problems with surgery. Surgery is the final stage of treatment. Dr. Mueller will not perform any surgical procedure unless it is absolutely indicated.

What is involved in my diagnosis?

At Virginia Facial Surgery, Dr. Mueller utilizes a wide array of diagnostic studies to properly diagnose your condition.  A complete history of your symptoms is evaluated first, followed by a complete physical examination, x-rays, tomograms, CT scans, MRI scans, blood tests, and skeletal-facial analysis are all used to evaluate every patient.  Based on the findings of these studies, Dr. Mueller will formulate the proper treatment plan.

Who should treat my TMJ disorder?

First of all, make sure that your surgeon / doctor is board certified by the AAOMS or AMA– ask to see their AAOMS or AMA board certification credentials if they are not displayed on the wall.  Board certification means a great deal when treating TMJ disorders.  TMJ disorders are very complex to diagnose and treat.  There are many self-proclaimed “TMJ gurus” in the community.  Many of these are general dentists, periodontists (gum specialists) and some chiropractors.  Some tout lofty credentials from societies that are not recognized by the American Association of Oral and Maxillofacial Surgeons (AAOMS), The American Dental Association (ADA) or the American Medical Association (AMA).  These societies are closed societies, formed by small groups of doctors who create their own credentials, their own journals and only allow articles of said journals to be written by their members. Reputable surgical, medical and dental journals allow anyone to submit articles for publication and accept them based on their merit, not membership.  These “gurus,” generally take lots of x-rays, write prescriptions and simply make splints.

Furthermore, many of them do not accept insurance and charge thousands of dollars for the x-rays and splints.  Some even recommend full mouth crown and bridge dental work at a cost of $20,000 – $50,000 as a solution in spite of the lack of research showing that occlusion (bite) is a causative factor in temporomandibular disorders. This is very expensive and only results in nice-looking teeth. There is even a group of dentists that claim that they can cure scoliosis (abnormal spine curvatures) by giving patients $50,000 of dental crowns! They have a one-size-fits-all treatment plan. The problem is that many difficult and surgical cases are misdiagnosed and merely treated with a splint.  TMJ disorders are not that simple and all patients are different, requiring different treatment plans. If you are simply clenching and grinding your teeth, there is nothing wrong with a dentist making a splint for you. However, if your symptoms do not improve, Dr. Mueller will be happy to re-evaluate your problem.  Would you take your brand new car with an electrical problem to a shop that only sells, installs and rotates tires? The answer is no. Today’s cars are very complex and require a certified technician to diagnose and treat your car’s problems.  It is the same philosophy with TMJ disorders.

You will also find many blogs or web sites on the internet from the same “gurus” stating that theirs is the only group to treat TMJ disorders because, “there are no actual AMA or ADA specialties in TMJ disorders.”  This is simply false.  Board Certified Oral and Maxillofacial Surgeons, a recognized specialty of the ADA, are indeed specialists in the diagnosis and treatment of TMJ disorders. In fact, it is the only recognized specialty.  Dr. Mueller has helped thousands of patients over the past 20+ years, whether conservatively or surgically, to return to a comfortable life.

Normal appearance of the disc covering the condyle (lower half) in relation to the fossa of the TMJ.

Normal appearance of the disc covering the condyle
(lower half) in relation to the fossa of the TMJ.

Perforation of the condylar head through the disc as seen through the arthroscope.

Perforation of the condylar head through the disc
as seen through the arthroscope.

Hyperplastic, inflamed synovium of the TMJ.

Hyperplastic, inflamed synovium of the TMJ.