I regularly see patients with facial pain and have a particular interest in temporomandibular disorders. During my higher training I gained experience in the full remit of treatments from conservative management strategies through to total alloplastic joint replacement. I have also more recently learnt minimally invasive diagnostic and therapeutic techniques such as temporomandibular joint (TMJ) arthroscopy and arthrocentesis.

I have co-authored papers and book chapters on subjects as diverse as training in TMJ surgery, outcomes from alloplastic joint replacements, classifications systems for extended custom TMJ replacements and the non-surgical management of recurrent dislocation of the TMJ.

In my NHS practice I am one of a handful of surgeons in the United Kingdom able to provide custom total alloplastic replacements of the TMJ. I am able to perform TMJ arthroscopy in the private sector using the Nexus CMF system, a 1.9mm 30deg reusable scope that has enabled advanced level arthroscopy for the first time in the West Midlands region on the back of my work in London and hands on training at Nexus CMF in Utah, USA.

I am a Full Members of the European Society of Temporomandibular Joint Surgeons (ESTMJS) and am a former National Lead for the British Association of Oral and Maxillofacial Surgeons (BAOMS) TMJ Sub-Specialty Interest Group (SSIG), formerly the British Association of TMJ Surgeons (BATS).

Many people use the term TMJ to refer to the problems they are having! The term TMJ is actually shorthand for temporomandibular joint and refers to the joint between the condyle of your mandible (lower jaw) and the glenoid fossa (skull base). The joints are unique in that they both function together at the same time to open or close your mouth. In addition, TMJs are ginglymoarthroidal joints as they hinge open (the initial bit of opening) and then slide forwards (allowing you to open fully). In between the two surfaces of the joint is an articular meniscus or disc made out of cartilage.

Well, problems with the TMJ and the associated muscles are often referred to using an umbrella term of TMD or temporomandibular disorder(s). There a various ways of classifying these but in summary they may be:

• Problems with the associated muscles around the TMJ, often as a result of habitual clenching and/or grinding, sometimes termed myofascial pain;
• Problems with the joint itself as a result of internal joint derangement, in which the movements are not as smooth as they should be on opening and/or closing;
• Problems with the joint due to degenerative diseases such as arthritis
• Pyschosocial problems due to stress and/or anxiety, sometimes termed “functional overlay”

Often these problems can co-exist and overlap. For instance, the pain from mild internal joint derangement may aggravate pre-existing anxiety. This in turn makes the pain harder to bear, setting up a cycle.

Symptoms of TMD vary from person to person (and depend upon the causative pathologies), but common ones include:

• Pain
• Limitation of mouth opening (trismus)
• Jaw locking
• Crunching, grinding and/or clicking noises
• Associated headache

Remember that disc in the joint? In some people this can slip a little further forwards in the joint, a phenomenon known as anterior disc displacement (ADD). This is not uncommon and it is important to note that if you have a painless click, you require no treatment! The disc has no innervation centrally, but at the back (the retrodiscal tissues), there are pain receptors......so anterior disc displacement can be painful. The click is caused by the disc reducing or being “recaptured” by the condylar head of the lower jaw as it slides forwards in the socket. Some people call this anterior disc displacement with reduction (ADDwR).

Sometimes the disc cannot be recaptured. This is called anterior disc displacement without reduction (ADDwoR). This is when the initial rotation movement in the joint can take place, but the translation component is impossible as the disc is stuck! So a little bit of opening is possible but not all the way. Some people may have had preceding symptoms of clicking and pain that gradually progressed to this point, or it can happen out of the blue.

Some people have arthritis of their joints. Like any other joint in the body, the TMJ can become inflamed and ultimately start to degenerate. This may be due to “wear and tear” (osteoarthritis) or it may be due to a co-existing inflammatory arthritis (e.g. rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, etc.). People with inflammatory arthritides are often best managed in conjunction with a rheumatologist to see what medical management can offer (e.g. disease modifying drugs, biologics) before resorting to surgery.

Remember the muscles around the joint? Sometimes they are more of an issue than the joint itself! This is often the case in people who habitually clench and/or grind their teeth. You may not be aware that you are doing this, as it is often not a conscious habit and can happen during sleep (often your partner will pick it up before you do!). This causes myofascial pain and accompanying headaches with relatively little contribution from the joint itself.

As TMD is multifactorial in terms of the underlying causes, treatment is similarly often multimodality and may be done in a stepwise fashion according to response. Common treatments include:

• TMJ physiotherapy and exercises;
• Medication
• Stress relief
• Occlusal appliances (splints)
• TMJ arthroscopy
• Open TMJ surgery (TMJ arthroplasty)
• Total prosthetic (alloplastic) TMJ replacement

The majority of patients with TMDs will respond to simple treatments. I will often ask patients to imagine they had an issue with their knee.....if you saw and orthopaedic surgeon and he or she recommended surgery without trying some simple things you might start to worry! Simple things will usually include the following:

• TMJ physiotherapy exercises that can be either self-directed or under the guidance of a physiotherapist with a specific interest in the TMDs;
• Analgesia (pain killers) and I will usually recommend topical ibuprofen 5% gel to minimize systemic side effects;
• Avoiding hard or chewy foods (if you had a problematic knee you might not run a marathon, so you might need to give steak a miss for a while);
• Resting the joint whenever possible
• Using a warm compress for relief

I will often ask patients if they wish to try a lower occlusal appliance (commonly referred to as a “splint” rather erroneously). This is a device to be worn at night times. Opinions are divided on the efficacy of these and the mechanism of action, but I often find it is worth attempting on the basis that everything should be tried before proceeding to irreversible and/or invasive treatments. I have some patients who have found immense benefit from their occlusal appliance.

If you have predominantly myofascial pain and have not responded to the simple management techniques outlined above I will often discuss the following treatment options:

• A hard bite-raising appliance with complete occlusal coverage as a habit breaker;
• The use of a low dose tricyclic antidepressant such as amitriptyline or nortriptyline;
• A trial of botulinum toxin A injections into the muscles around the joint

Botulinum toxin A is best known for its role in non-surgical cosmetic treatments, smoothing out wrinkles. It works by paralyzing muscles so can help immensely in relaxing the tension in the muscles around the jaw. Beyond this, it has analgesic (painkiller) properties independent of its neuromuscular action that are the subject of ongoing research. My preference tends to be to use Dysport® within my TMJ practice.

A small proportion of patients with TMDs will fail to respond to conservative management and have ongoing issues with internal joint derangement. I am one of a small number of surgeons in the West Midlands region able to provide TMJ arthroscopy and the only one working privately. This involves introducing a small camera into the joint to visualize the joint directly and examine for any degenerative changes and/or damage to the articular disc. At the same time I am able to lavage (washout) the joint and break up adhesions as well as introduce intra-articular treatments such as steroids (e.g. Depo-Medrone®) to reduce inflammation and relieve pain.

More recently, I have attended advanced training at Nexus CMF in Utah, USA. I have now introduced the Nexus CMF 1.9mm 30deg scopes with advanced operative kit enabling level 2 arthroscopy for the first time in the region, encompassing triangulated second puncture, release of adhesions, synovial biopsy and targeted deposition of intra-synovial medications.

With this advanced armamentarium available, there is significant scope for preserving your native joint and I continue to advance my knowledge and training with a particular focus on minimally invasive treatments.

I am one of a handful of surgeons able to provide total joint replacement of the TMJ in the United Kingdom. This treatment is reserved for a very small minority of patients who have advanced degenerative changes to the joint, high pain scores and significant loss of function and who have additionally failed to respond to minimally invasive management techniques. The system I use is the custom Stryker TMJ Concepts prosthesis, which is bespoke and made for each individual patient.