- Surgical therapy
- What is the role of temporomandibular jount surgery?
Surgery of the temporomandibular joint has taken on an important role in the primary or secondary treatment of diseases that involve the joint itself and the structures related to it. There pathological conditions of the temporomandibular joint that should be treated only with medical therapy and other conditions that should be treated only surgically and others that need medical treatment initially, but which must be treated surgically in the second istanceif the medical treatment was ineffective. The pathological conditions that require a primary surgical treatment are as follows: growth disorders, fibrous/bony ankylosis and tumors.
The conditions that require secondary surgical treatment are as follows: arthritis and temporomandibular joint disorders.
Surgery is indicated only in 5% of patients with temporomandibular disorders.
Despite the small number of patients, the surgical treatment has recently taken a significant role in the treatment of this disease, thanks to the widespread application of minimally invasive surgical techniques, the arthrocentesis and arthroscopy, which showed excellent results with a low biological cost for patients and therefore have revolutionized, as well as in other fields of medicine, the way to treat the disease.
What are the aims of the temporomandibular jount surgery?
According to the guidelines of the American Society of Temporomandibular Joint Surgeons (ASTMJS), the treatment of dysfunctional pathology, including surgical treatment, therefore, has three goals: reduction of pain, improved joint function and slowing down the progression of the disease. A secondary goal of the therapy should only be the reduction of the interference of the disc due to its negative effect on pain,on the function and its possible role in the development of bone deformities that occur in the late stages of the disease.
Which patients are candidates for surgery of the temporomandibular joint?
Surgery is indicated only in the temporomandibular joint disorders (internal derangement). The guidelines of the American Society of Oral and maxillofacial surgeons (AAOMFS) made the following recommendations: surgery is recommended for patients with pain and dysfunction that do not respond to non-surgical therapies; surgery should not be performed primarily for preventive reasons.
The patient who is a candidate for the surgery of the joint has the following characteristics: localization of pain and dysfunction at the level of the joint, tenderness in the joints and increased pain when chewing. The decision whether to undertake the surgical treatment must be made on the basis of the severity of the symptoms and the inability of the patient to tolerate and live with them.
How long should the non-surgical therapy last before sending the patient to a surgical consultation?
The temporomandibular joint surgery was historically considered a "last resort". Patients underwent multiple attempts using conservative therapy for years and only when these therapies failed, the intervention of the surgeon who has to operate on the joints often with a very difficult situation was required. This old belief has changed thanks to the spread of minimally invasive surgical techniques that are more likely to succeed when the patient is in an early stage of the disease and how soon the surgery is performed.
The current trend is to consider the surgery of temporomandibular joint disorders as an integral part of other therapies (occlusal splints, drug therapy, physiotherapy) to which surgical treatment that can be performed in conjunction with these.
As recommended by the above-mentioned guidelines of the American Society of Temporomandibular Joint Surgeons (ASTMJS), if the pain and dysfunction persist after a short-term conservative treatment, patients should undergo a surgery examination as soon as possible in order to assess the usefulness of associating a minimally invasive surgical treatment.
What are the surgical techniques used and how to proceed in choosing them?
For surgical treatment of functional temporomandibular joint disorders (internal derangement), a minimally invasive approach that involves the following surgical procedures is considered:
- arthrocentesis
- visual arthrocentesis
- diagnostic - surgical arthroscopy
An open approach to the joint with the following surgical options is also considered:
- arthroplasty with repositioning of the disc or discectomy
- condylotomy
Prosthesis replacement of the joint is generally not recommended initially in temporomandibular joint disorders, but may be indicated in patients with very severe joint degeneration, or in patients who have undergone multiple surgeries on the temporomandibular joint.
A very important concept, now shared by all experts and supported by the literature, is that of having to proceed in the choice of surgical procedure, for degrees of invasiveness. Please find below the cascade of procedures, choosing the least invasive and passing to the subsequent more invasive procedures only if they had a previous negative result.