TMJ arthroscopy
In this article, leading consultant oral and maxillofacial surgeon Professor Andrew Sidebottom discusses TMJ arthroscopy for temporomandibular disorder (TMD) in expert detail. He considers patient preparation, its outcomes, and what to expect after the procedure, among other important points.
What is TMD (Temporomandibular disorder)?
The TMJ (temporomandibular joint) is the joint between your lower jaw and the base of your skull. It lies just in front of the small prominence at the middle of your ear and can be felt moving if you run your finger in front of this area. The TMJ is unique in the body in that it’s connected at both ends to the lower jaw and the left and right sides work in a coordinated manner.
Jaw joint problems (often called “TMJ”) can cause pain, limitation of movement, locking and noises (clicking and popping) related to the joint or the muscles that move the joint. This is medically known as temporomandibular disorder (TMD). It’s a common problem which is mostly self-limiting, or can be managed simply with non surgical intervention (please see information sheets on ajsidebottom.co.uk, my Top Doctors site, and my Top Doctors profile).
Occasionally, surgical intervention may be needed when the discomfort and limitation are coming from the joint, and conservative management has been unsuccessful. This usually follows a stepwise course from minimally invasive arthroscopy, or when this fails possibly open surgery, or for end stage cases joint replacement (similar to knee and hip replacement). More information on these procedures can be found on ajsidebottom.co.uk, my Top Doctors site, and my Top Doctors profile.
It's important, if considering whether surgery is required, that you check the experience of the surgeon and what training they’ve had in TMJ surgery. As with any form of surgical intervention, surgeons who’ve been appropriately trained in the sub specialist area and are doing those cases regularly, usually have better outcomes than occasional surgeons. It’s also important to see what other patients have said about the surgeon so you get a better idea of their experience. Top Doctors provides this feedback on an easily accessible web-based platform.
Mr Sidebottom has carried out over 4,000 TMJ arthroscopies, over 500 open TMJ procedures and over 400 TMJ replacement procedures over 25 years of specialist practice. References to his published outcomes are detailed at the bottom of this sheet. He receives referrals from all over the UK and Europe for this surgery.
What should I do before the surgery?
You will have been advised to carry out various non-invasive management strategies including taking a soft diet, muscle massage, wearing a bite splint and often seeing a specialist TMJ physio. You should continue these after surgery until advised to start to wean off them.
If you have significant muscle spasm despite this Mr Sidebottom may advise adjunctive Botox injections to help reduce the muscle spasm. This improves the surgical outcome by about 10 per cent.
Continue to maintain a healthy diet with regular exercise, drinking plenty of water and avoiding alcohol, caffeine and blue screens for the two hours before sleep.
What is TMJ arthroscopy?
TMJ arthroscopy is a minimally invasive procedure to help to improve symptoms of jaw joint pain, limitation of movement or locking. Clicking and popping may be temporarily improved but in themselves do not need treatment.
The procedure is usually carried out under a short-day case general anaesthetic, although it can be performed with just local anaesthetic or with some sedation.
A small stab incision (about 2mm long) is made in front of the ear. Some long-acting local anaesthetic is placed in the joint to help with post-operative pain relief. A small telescope (arthroscope) is placed into the joint with a separate needle in front of it to allow fluid drainage. The joint is fully inspected to check for abnormalities, and this is a much better diagnostic check than an MRI scan. Your joint will be moved to check for range of movement and also to help improve mobility. In addition, the joint is washed out under pressure to get rid of inflammation and scar tissue. This is called level 1 arthroscopy and is indicated in most cases initially.
The procedure takes around 15 minutes per side and the wound is usually closed with sticky stitches. You will not usually require antibiotics during the operation.
What should I expect after the operation?
Immediately after the operation your face, over where the surgery was carried out, will be swollen due to leakage of the fluid used to wash out the joint. Most of this swelling will go down over a couple of hours, but there will be some minor swelling and bruising for a few days.
Mr Sidebottom will come to see you after the procedure to explain the findings and what to do for your follow up care. He’ll additionally arrange for a letter to be delivered to you and your doctor after a few days explaining this, in case you have forgotten. You’ll be sent home with some simple pain killers and advise to exercise the joint regularly to get it moving more normally again. You can wash your hair the day after surgery!
You may have some temporary alteration in your hearing due to fluid or blood leaking into the ear canal. As the swelling goes down and the fluid leaks out of your ear this will improve and largely have settled after 2 to 3 weeks.
You may have some temporary loss of movement of your forehead and eyebrow due to the local anaesthetic injection. This will get better as the anaesthetic wears off.
You will have a feeling that your teeth don’t meet in the same way for a few days due to swelling from the surgery.
You may have a feeling of odd noises around the joint on movement and clicking which had disappeared may come back again as the joint starts to move in the way it did before the joint symptoms caused you pain, restriction or locking.
You may get an initial improvement in symptoms and then a flare of pain after a few weeks. If this occurs Mr Sidebottom will advise you how to manage this at your week 3 follow up appointment.
What are the outcomes of this surgery?
The outcome of TMJ arthroscopy will depend on what the joint looks like. Around 85 per cent (17/20) patients will recover back to having a lot less pain, without locking or restriction over a 3-month period. Those who don’t recover will have an accurate diagnosis which will allow advice for further management. After a few weeks, 1 in 10 people will get a flare of pain, which usually responds to either locally applied anti-inflammatory gel or an occasional steroid injection.
Even if the joint looks damaged, often the washout is enough to allow the joint to settle down without further intervention.
Occasionally further surgery may be needed as detailed in one of the references below on open joint surgery. The decision to progress should wait several weeks to allow for your body to recover, as even after a few months there can be ongoing improvement.
For those patients where the procedure is successful only a small number (around 1 in 10) will need to have this repeated, as the other non-invasive management techniques will prevent the need for further intervention.
Summary
TMJ arthroscopy is a minimally invasive procedure with few side-effects to help to manage ongoing jaw joint pain, restriction and locking where less invasive measures have not fully helped. If you need this procedure, Mr Sidebottom will discuss it in detail with you and provide you with alternative options to consider. He has performed over 4,000 of these procedures in his 25 years as a consultant with published outcomes which rank as the best in the UK.
Publications by Mr Sidebottom
Sidebottom AJ
Leading Article. Current thinking in TMJ management
Br J Oral Maxillofac Surg. 2009: 47; 91-94.
Ahmed N, Sidebottom AJ, O'Connor M, Kerr HL.
Prospective outcome assessment of the therapeutic benefits of arthroscopy and arthrocentesis of the temporomandibular joint.
Br J Oral Maxillofac Surg. 2012; 50 (8); 745-748.
Tzanidakis K, Sidebottom AJ.
How accurate is arthroscopy of the temporomandibular joint? A comparison of findings in patients who had open operations after arthroscopic management failed.
Br J Oral Maxillofac Surg. 2013; 51: 968-70.
Rajapakse S, Ahmed N, Sidebottom AJ
Current thinking about the management of dysfunction of the temporomandibular joint.
Br J Oral Maxillofac Surg 2017; 55: 351-356.
Rajkumar A, Sidebottom AJ
Prospective study of the long-term outcomes and complications after total temporomandibular joint replacement: analysis at 10 years.
Int J Oral Maxillofac Surg 2021; 51: 665-668
Sidebottom AJ
Open Temporomandibular joint Surgery - Discectomy with or Without Interpositional Reconstruction?
Atlas Oral Maxillofac Surg Clin N Am 2022; 30: 199–204
Sidebottom AJ.
Current thinking in open temporomandibular joint surgery. Is this still indicated in the management of articular temporomandibular joint disorder?
Br J Oral Maxillofac Surg. 2024; 62: 324-328.