Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth and with me is Dr. Derek Steinbacher, who is here to discuss integrating TMD and corrective jaw surgery, a comprehensive approach. Dr. Steinbacher, thanks for being here. 

Dr. Derek Steinbacher: Thanks, Bill. Thanks very much for having me and looking forward to chatting today. 

Bill Klaproth (host): Absolutely. So, we are as well. Let’s jump into this. First question for you, Dr. Steinbacher, what is TMD, and how is it different from TMJ? 

Dr. Derek Steinbacher: Yeah, so that’s a great question, and one that patients seem to ask pretty regularly. TMJ just refers to the anatomic joint or structures that we’re dealing with, and that’s the temporomandibular joint. Whereas TMD refers more to a comprehensive set of conditions that can affect both the muscles and the bony components, cartilaginous components of the temporomandibular joint. So, it’s pretty nonspecific, TMD, but it can incorporate a lot of these conditions or symptoms affecting the muscles and the bones of the TMJ. 

Bill Klaproth (host): So, if someone is diagnosed with TMD, what are common treatments then for TMD? 

Dr. Derek Steinbacher: Yeah, so that’s a great question, and I think it hinges on what the underlying etiology is, and if this is more of a muscle problem or myofascial muscle pain versus if it’s a true intraarticular joint problem itself. And these things can be interrelated. For instance, if you have muscle spasm, that can worsen intraarticular pain. And similarly, if there’s intraarticular or TMJ arthritis or pain, people can get muscle spasms as a result of that. But we really want to identify these underlying causes first, but we tend to begin with conservative type measures, some behavioral things such as soft diets, some nonsteroidal anti-inflammatories, muscle relaxants, things to help offload the joint and make it such that the muscles are not in such significant use. 

Bill Klaproth (host): So, if those treatments are unsuccessful, what can you do to help alleviate the symptoms of TMD? What options are available? 

Dr. Derek Steinbacher: Yeah, so again it depends a bit on if this is a myofascial predominant condition versus if it’s something affecting the joint and the disc itself, but there are things that help protect your teeth for people that tend to clench and grind in the evening when they’re sleeping. There are bite plates and splints that help bring the joint from compressing the nerve endings in the fossa or in the posterior band, for instance. There are other medical treatments. There’s Botox that can be injected into the muscles. There are muscle relaxants. And then these behavioral things like mentioned, soft diet, trying to not use the jaw bone and jaw muscles as much to try to help offload this. 

Bill Klaproth (host): So, can you explain corrective jaw surgery and how that can help with TMD? 

Dr. Derek Steinbacher: Yeah, so corrective jaw surgery is sort of a general overarching term of procedures that we do as well, and we do these frequently for malocclusion or where the jaws are misaligned in the sense that the teeth are now not coming together properly and you need to move one or both jaws to help the bite. We do this for sleep apnea, where we want to move the jaws in a way that it helps open up the nasal airway, the airway behind the tongue, and it can really help treat or cure sleep apnea. We do this for TMJ types of conditions. The ones I see in particular are something called condylar hyperplasia, where there’s a lot of facial asymmetry that develops because of a TMJ growth issue, and we want to address the facial balance and facial symmetry. We do this surgery for esthetic reasons as well to help project the face or the facial bones in different ways to optimize esthetics. But the TMJ is a very critical component when we’re doing corrective jaw surgery and we need to really think about and consider it and look at some of these diagnoses that we’re speaking of. 

Bill Klaproth (host): So then, who would be an ideal candidate for corrective jaw surgery with TMD? 

Dr. Derek Steinbacher: Yeah, great question. So, the first thing to point out or mention is that we don’t really do corrective jaw surgery in order to treat TMD or TMJ dysfunction. This isn’t really a primary objective of the surgery. And in fact, if there are symptoms or things like arthritis, or there’s an intraarticular condition where the joints are inflamed or affected, we want to get that under control first. Think of it as if you’re building a house. You don’t want the foundation to be cracked or sinking or in some way jeopardized because you’ll build a beautiful house and then things will change or move or have difficulties with that engineering in the long run. So similarly for the TMJ, if there’s arthritis and inflammation, you know, we really want to get to the bottom of this first before doing orthognathic jaw surgery. The caveat to that is the situation where there’s condylar hyperplasia, and this is leading to asymmetry, and then we can do a TMJ procedure concurrently with orthognathic surgery, and/or the situation where there may be such significant joint arthritis or resorption that we’re going to be doing a total joint replacement. So, we do those on both sides concurrently with orthognathic surgery. But let’s be clear that if somebody just comes in with some TMJ pain, some muscle pain orthognathic corrective jaw surgery is not the solution to treat that exactly. 

Bill Klaproth (host): It’s not the initial go-to. 

Dr. Derek Steinbacher: Exactly. 

Bill Klaproth (host): So then, for someone who would need corrective jaw surgery for TMD, what are the risks associated with that? 

Dr. Derek Steinbacher: Yeah, so the greatest example that I see very frequently is this condylar hyperplasia. So one side of the joint, basically the condylar head and neck starts growing and gets longer and pushes the mandible to the opposite side, and there’s some significant asymmetry. So when we do that, we’re correcting both the lower parts of the jaws, but also we’re leveling the areas of the TMJ. So we perform what’s called a high condylectomy or a proportional condylectomy on the side that’s overgrown. And we can do that concurrently with orthognathic jaw surgery. The risks of this, you know, we have to access the joint, and we do this externally. So, we do it up by the temporal hairline, or near where the sideburn is, and then hidden into the ear, basically. So it’s like a facelift type of incision and that tends to heal very, very well, but there is a risk, of course, of creating a scar on that portion of the face. Additionally, there are some blood vessels and nerves that run in that vicinity. The nerve of most importance, I would say, is the frontal branch of the facial nerve that crosses over that area and controls your eyebrow. So we take great care and diligence to make sure we’re testing for and avoiding that nerve. And then we’re able to get into the joint and perform the procedure that we need to do. 

Bill Klaproth (host): Wow, that sounds really complex. There’s a lot going on there. 

Dr. Derek Steinbacher: Yeah, but like I said, the incisions heal really very well, and it can be done very safely, very effectively, and that together with orthognathic surgery in these cases of condylar hyperplasia can give really the best esthetic symmetry and outcomes. 

Bill Klaproth (host): So, how long then would the recovery process be after corrective jaw surgery for TMD? 

Dr. Derek Steinbacher: Good question. So corrective jaw surgery in general, there’s a fairly long recovery period. And by long, I don’t mean hospitalization or being fully out of commission, but some behavioral changes that need to occur that include dietary changes with blenderized food or soft diet for a period of time for a month or six weeks. No sports or heavy lifting or activity for six weeks. But in terms of the bulk of the recovery, it’s really the first week where there’s some edema that continues to come down. And the initial phase of the healing really occurs in that first couple of weeks and people get back their energy and spirits after that and can start thinking about school or work three, four or five weeks later. And adding a TMJ component to this surgery doesn’t really add much to the recovery. So, when it’s done in concert with jaw surgery, the bulk of the recovery comes from the corrective jaw surgery, and adding the TMJ component to it doesn’t really augment that substantially.

 Bill Klaproth (host): So then, can corrective jaw surgery resolve TMJ issues permanently? 

Dr. Derek Steinbacher: Yeah, so that’s why I’m focusing more on this condylar hyperplasia setting because that’s the case where we would do an intraarticular or a surgical TMJ procedure where we will be planning and correcting these symmetries, and in our data and dataset, this really does provide very excellent symmetry and no increased symptoms in the TMJ. What happens with condylar hyperplasia is one side is longer and it can push actually to the opposite side. The condyle on the opposite side, in many instances, can have some symptoms and pain, and by leveling those joints, it alleviates that. So, if you think of the mandible, it’s the only bone in the body that is a single bone with two joints. And you can imagine if one side is longer and one side is shorter, that that can provide an unequal distribution of some of the muscle forces. So, we want to level that, and in our data, you know, it really 80, 90 percent of the time will correct some of the TMJ symptoms that they’ve had. 

Bill Klaproth (host): So, since we’re talking about surgery, when someone comes in with TMD pain without lower jaw asymmetry, would corrective jaw surgery be the treatment of choice for that then? 

Dr. Derek Steinbacher: Yeah, that’s a great question, Bill, and this is really what we want to get across, is that when somebody has TMD, corrective jaw surgery or orthognathic surgery is not the treatment of choice for this. TMD is managed differently, and corrective jaw surgery should not be done in somebody that has active temporomandibular joint disorders. 

Bill Klaproth (host): So then, can corrective jaw surgery resolve TMJ issues permanently? 

Dr. Derek Steinbacher: Yeah, so, as mentioned, we want to make sure that the TMJs are stable, that they’re not changing, there’s not a growth disturbance, there’s not arthritis or inflammation. And when we do jaw surgery, we are, in a way, repositioning the back part of the lower jaw that has the TMJ associated with it. So, it can be difficult to predict how that can affect the TMJ, and certainly, I would never say that doing corrective jaw surgery is intended to improve TMJ function, but in some cases, it does because when we put the jaws in the correct position and the occlusion now is meeting as it should, it can help offload pressure on the TMJs. If you think of it as a three-legged table such as in a cafe, the occlusion is one point of fixation or one of the legs, and then both TMJs are other parts of the legs too. So, we’re trying to distribute those forces as equally as we can. 

Bill Klaproth (host): So then when it comes to corrective jaw surgery for TMD, can you lay this out for us? How does this differ from the other treatments that are available? 

Dr. Derek Steinbacher: Yeah, so a lot of these nonsurgical, initial conservative treatments will address some of the factors that can exacerbate muscle pain and TMJ pain. But corrective jaw surgery by putting the jawbones in the correct place can address some of that underlying skeletal situation and make sure that the severe jaw alignment is now improved, which can help offload the temporomandibular joints. 

Bill Klaproth (host): So, it’s kind of like going to the root of the problem then, when you’re doing the surgical techniques. 

Dr. Derek Steinbacher: Exactly. In cases that we are sure that the TMJ and jaws are contributing to one another, then yes, that’s true. 

Bill Klaproth (host): So, someone listening to this might be thinking, “Man, this sounds really involved.” So, for someone coming in after hearing this, what should patients expect during the consultation process for corrective jaw surgery? 

Dr. Derek Steinbacher: Yeah, an excellent question, and, you know, I think globally, thinking about this, there are kind of two patterns of patients coming in, some with pain and pain is the predominant symptom, and that’s not necessarily who I see that frequently, and that we’re really speaking about. The patients that come for corrective jaw surgery sometimes do notice some pain or asymmetry as we talked about, but they have other goals in mind. They have goals in mind related to fixing their bite, to helping show more teeth when they smile, to improve their facial symmetry, to open their airway, and if possible, alleviate the TMJ issues that they may have. 

Bill Klaproth (host): Absolutely. There’s a lot there and that’s why we have people like you when there are issues like this that people can come to see and get these issues corrected for sure. Dr. Steinbacher, thank you for your time. This has really been informative. As we wrap up talking about integrating TMD and corrective jaw surgery, a comprehensive approach, is there anything you want to add? 

Dr. Derek Steinbacher: You know, thanks for chatting, and I just want to make sure, and I think we’ve stressed this a lot during the interview, but that corrective jaw surgery is not the first-line treatment for TMD. These problems can be interrelated, but there’s a certain sequence and timing and contribution of the TMJs to these problems. We don’t expect that corrective jaw surgery in and of itself is a treatment for TMJ, but there are a lot of TMJ problems that can lead to jaw problems such that both things are required. So, this includes the hyperplasia and asymmetry we talked about, resorption and arthritis that need joint replacements, people that have had trauma and require joint replacements because they can’t open their mouth. But when we’re doing run-of-the-mill corrective jaw surgery, we want to do it in a way that offloads the TMJs, hopefully doesn’t create any TMJ symptoms, and may help alleviate TMJ symptoms. Conversely, if somebody comes in with predominantly TMJ pain, we want to start with conservative treatment. We want to make sure that we get the appropriate imaging and understand where this is coming from. Is this muscle? Is this within the joint? And we’re not jumping into doing corrective jaw surgery to try to treat that until we’ve understood what the underlying etiology is and make sure that we address those problems first related to the muscles and related to any joint inflammation that may occur. 

Bill Klaproth (host): Absolutely. So, a conservative approach first and then take it to the next step if need be. Dr. Steinbacher, thank you so much for your time today. We appreciate it.

Dr. Derek Steinbacher: Great, thank you. Thanks very much.

Bill Klaproth (host): You bet. Once again, that is Dr. Derek Steinbacher. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social channels and don’t forget to subscribe. Thanks for listening.