Arthroscopy: New Tool in Jaw Disorders : Technique Used on Knees Adapted by Oral Surgeons
When her condition was at its worst, Vicki Gimenez could make cooked pasta sound crunchy.
“I’d go to eat spaghetti,” she said, “and people would look and say, ‘What’s that noise?’ ”
It was her jaw. For nearly two years, Gimenez, 35, had suffered from intermittent pain in the left side of the jaw, cracking and popping noises in the joint there and, as the condition worsened, increasing inability to open her mouth wide enough to eat even a sandwich. The jaw would lock occasionally, forcing Gimenez to “work my jaw sideways until it cracked and opened again.”
Gimenez was one of an estimated 20 million Americans who suffer, to varying degrees, from disorders caused by malfunction of the temporomandibular joint (TMJ), which connects the lower jaw to the rest of the skull.
Those afflicted experience a range of symptoms, from clicking and popping of the joint when they chew, to headaches and dizziness, to great pain when they try to open the jaw even slightly.
The disorders are treatable but, until almost a year ago, anyone suffering from a TMJ disorder who required surgery faced an operation that involved opening large areas of the face containing significant nerves and blood vessels.
In recent months, however, the same technique that has enabled athletes with knee injuries to leap off the disabled list in a matter of days has found its way into the repertoire of the oral surgeon.
Minuscule Incisions
Arthroscopy, the technique of using tiny optical instruments inserted into the surgical site through minuscule incisions to diagnose and treat joint disorders, was presented to more than 300 oral surgeons and other physicians from throughout the world late last month at Memorial Hospital in Long Beach.
The organizers of the three-day Symposium on TMJ Arthroscopy and Arthroscopic Surgery, as it was called, were a pair of Orange County oral surgeons, Christopher Davis and Ronald Kaminishi, who say they are among only 15 to 25 practitioners in the United States who are performing such surgery.
Arthroscopy for the jaw, although new to the United States, has been performed in Japan by, among others, an oral surgeon named Masatoshi Ohnishi, said Kaminishi, who lives in Orange. However, the knowledge stayed in Japan because a paper Ohnishi published on the subject in 1974 was written in Japanese and was never translated, he added.
Also, said Davis, a Seal Beach resident, the sophisticated optical instruments needed for the procedure had not been universally available until recent months.
But, Kaminishi said, “after this symposium, I think you’ll see a lot of things happening, a lot of people starting to use it. We’ve got the instruments now.” He added that even more delicate surgical instruments are needed for the jaw than for the knee. “When you’re working on the TMJ, it’s like working on a peanut compared to the knee, which is like working on a softball. Before we just didn’t have the equipment to do it.”
Nonprofit Organization
The symposium was sponsored by the Southern California Oral and Maxillofacial Surgery Foundation, a nonprofit research and education organization. Davis and Kaminishi are members of the foundation’s board of directors.
Although treatment is complex, the cause of most TMJ disorders, Davis and Kaminishi said, is relatively simply to explain: Part of the joint acts like a doorstop.
The jaw, said Kaminishi, moves up and down as a hinge, which accounts for about a third of its total function, and rotates forward and side to side, which accounts for the rest. A normal jaw should be able to open about two inches and rotate freely, he said.
However, a cartilege-like buffer in the joint, called the articular disc, can become displaced, moving forward of the joint and jamming against it when the jaw attempts to open. This is the most common TMJ disorder, Kaminishi said, and can account for everything from clicking of the jaw to an inability to chew.
“We’ve seen people whose faces just turn white from not wanting to move their jaw,” Kaminishi said. “And because their jaw muscles tighten so much automatically in order to try to ease the pain of movement, those muscles can spasm and cause pain of their own.”
Davis, who said he and Kaminishi have been performing arthroscopic TMJ surgery for about a year, said the surgery should be used “only after attempts at conservative therapy” such as physical therapy, medication or dental splints to realign the jaw.
This is what happened in Giminez’s case. She said she visited two dentists and an oral surgeon, all of whom prescribed splints, before Davis prescribed arthroscopic surgery.
After spending a night in the hospital, Gimenez, who lives in Lakewood, said she now has “no problem with pain, no cracking, no symptoms that I know of. I’m going to need to wear braces at night for a couple of years to hold the jaw in place, but after 2 1/2 years of what I went through, I can’t say enough (about the surgery).”
Andrea Eiler, 17, a high school student from Buena Park, said that before Davis performed her surgery in February she “couldn’t open my mouth wide enough to put two fingers in it. Sometimes I had to press my hands against my jaw to get my mouth to open. I had the clicking and popping and sometimes the jaw would lock and I had headaches.”
About a month after her surgery, she returned to a regular diet, the symptoms gone.
Fairly Long Recovery Before
“With the old surgery, the recovery time was fairly long,” Davis said. “You’d be in the hospital for two or three days and off work for a week to 10 days. With arthroscopy, you go home right away and you’re back to work in about three days.”
The surgeon’s fees for TMJ outpatient arthroscopic surgery, Davis said, run roughly $1,500 to $2,500, while conventional open joint surgery fees run $4,000 to $4,700. (These figures do not include the cost of a hospital stay, which for an outpatient could be part of one day and cost around $1,200. Conventional jaw surgery, Davis said, can require a hospital stay of up to four days at a cost of about $5,000.)
Although the arthroscopy is done in a hospital, the patient usually is released the same day, Davis said.
Both Gimenez and Eiler said their operations left scars that are all but invisible, the result of the need for only tiny incisions in front of the ear.
The surgery is performed, Davis said, by first inserting a hypodermic needle near the surgery site and filling the area below the skin and around the joint with fluid to allow free movement and drainage of the joint, and to aid in visibility. Near the needle, a 1/6-inch incision is made and a stainless steel tube is inserted. A powerful light source in the form of a fiber optic bundle, along with a tiny telescope attached to a video monitor, are then inserted through the tube. One of a handful of surgical options can then be performed, Davis said, such as clearing away with a tiny rotating blade any scar tissue and blood clots that inhibit movement, or moving the articular disc.
Used in Other Procedures
Also, Davis said, arthroscopy is used in other procedures besides corrective surgery. It is used, he said, in biopsies and to confirm or establish diagnoses that can’t be done through more conventional methods, such as X-rays, manipulation or the injection of dyes.
TMJ arthroscopy is not a cure-all, Kaminishi said. In many cases it is not even a substitute for more major maxillofacial surgery. But, he added, when it is used, both doctors and patients seem to agree that less is more.
“I’m very impressed with its potential,” said Dr. Donald Phillips, co-director of the USC facial pain and temporomandibular joint clinic. “I think it will enable people to have more accurate diagnostic information that’s less invasive because it allows you to see the joint structures directly. At this point I think it’s where knee arthroscopy was about 10 years ago. Right now it’s more of a diagnostic tool, and it’s going to require a lot of specialized instruction to learn. But it’s being received with a tremendous amount of enthusiasm.”
Kaminishi said his patients would agree.
“With joint problems, you don’t talk to people about being normal, you talk to them about improving. But we’ve been surprised with the success of this surgery. It’s exceeded our expectations. As far as pain goes, I’ve had patients grade what they feel on a scale of 1 to 10, and before the surgery they started with a range of between 7 and 9. After, they’ve been down to about 3 or 4.
“It’s not a cure-all or a miracle healing, but that’s fairly dramatic relief.”
