Joint Disorders (TMD, TMJ)

What Is TMD?

TMD treatment may vary from conservative care to complex surgery. Depending on the diagnosis, Dr. Movahed will make the proper recommendation for a predictable outcome. If non-surgical treatment is unsuccessful or if there is clear joint damage, surgery may be indicated.

Surgery can involve either arthroscopy (the method identical to the orthopedic procedures used to inspect and treat larger joints such as the knee) or repair of damaged tissue by a direct surgical approach. In certain cases which are not responsive to conservative measures or if the TMJ anatomy is compromised, total joint replacement may be deemed as the proper treatment.

Surgery: Combined Joint And Orthognathic Surgery

In a certain number of cases after the completion of our comprehensive maxillofacial evaluation, Dr. Movahed would recommend a combined procedure.

This procedure is reserved in cases that the TMJ native anatomy is compromised due to the presence of a tumor (condylar hyperplasia), traumatic incident (fracture), connective tissue autoimmune disorder (juvenile idiopathic condylar resorption, psoriatic arthritis), and etc.

Condylar Hyperplasia- In cases in which facial asymmetry or extensive active protrusion has taken place due to overgrowth of the condyle, the site of growth has to be addressed along with the resulting facial asymmetry.

This would include the removal of the growth site with the proper protocol and during the same surgery, performing the corrective jaw surgery.

Combination of OSA and TMD or Connective Tissue Autoimmune Disorder- In cases in which facial asymmetry or extensive active protrusion has taken place due to overgrowth of the condyle, the site of growth has to be addressed along with the resulting facial asymmetry.

This would include the removal of the growth site with the proper protocol and during the same surgery, performing the corrective jaw surgery.

How Do You Treat TMD?

CPAP is generally recommended as the initial managing device in patients with OSA and requires titration and follow-up for proper setting of the device. A certain number of patients are not tolerant of CPAP/BIPAP devices and seek an absolute surgical treatment for their OSA.

Surgery may be a good alternative for some patients, but it’s important to keep in mind that no surgical procedure is universally successful.

Uvulopalatopharyngoplasty (UPPP) has been advocated for in the past as a treatment in the management of OSA. This procedure shortens and stiffens the soft palate by partially removing the uvula and reducing the edge of the soft palate.

The UPPP procedure is known to be less than 30% effective and has severe postoperative discomfort and morbidity.

Dental/anteriorly positioning devices have been successful when used in a group of patients. It should be known, however, that these devices will not alleviate the obstruction at the level of the soft palate, which accounts for a large group of OSA patients.

On a routine basis, Dr. Movahed reviews the patient’s airway in a comprehensive fashion. His study of the airway includes the three-dimensional mapping of the airway and pinpointing the most vulnerable site of obstruction.

Additionally, a study of the nasal airway is performed in order to assess the status of the septum in case of any deviation or turbinates in case of hypertrophy (enlargement). An in-office pharyngoscopy procedure is also performed while the patient is awake in order to assess the tone and stiffness of the pharyngeal soft tissue. Based on the findings that are shared with our patients, the proper surgical modality is proposed and reviewed.

Surgery: Maxillomandibular Advancement (MMA) – This procedure surgically moves the upper and lower jaws forward along with the soft tissues of the tongue and palate, opening the upper airway. As a well studied and published surgical modality with a success rate of over 95%, this procedure will resolve the patient’s OSA, or at least decrease the Apnea Hypoapnea Index to or below 8.

Counterclockwise rotation (CCW) – Dr. Movahed performs his MMA surgery with a CCW rotation/movement which will result in an increased airway space in comparison to straight advancement. This surgical modality will also allow the patient to achieve a better aesthetic result. In order to achieve a stable result with MMA/CCW, Dr. Movahed performs a comprehensive evaluation of the temporomandibular joints and jaw skeleton.