Further Reading: Arthroscopic Surgery using the McCain Technique – A New Option for Conservative Management of the Problematic TMJ
We are pleased to announce that the Cincinnati Center for Corrective jaw Surgery is now offering arthroscopic surgery to care for patients who present with jaw joint problems unresponsive to conservative management. Problems can include pain, limited opening, and internal TMJ conditions that range from clicking and locking of the joint to painful degenerative arthritis.
Size matters when it comes to successfully treating joint problems with arthroscopic surgery. The TMJ is not only small but it is surrounded by important anatomic structures that must be protected during the process of inserting the arthroscope and maneuvering it to fix the problem. Making arthroscopic surgery of the TMJ so challenging is the fact that the nerve that controls the movement of the facial muscles runs close to it in the tissue overlying it. Also, the middle ear sits just behind the joint so gaining entry to the joint without damaging the middle ear is tricky.
The TMJ is so small that it holds less than a teaspoonful of fluid. It is hard to believe that a joint so small with so little in it could cause so much pain and so much misery for so many people. Joint problems include clicking and popping in the joint with opening and closing of the mouth and pain from displacement of the joint disc. In other joints like the knee and shoulder these symptoms can be decreased by cleaning out inflammatory chemical particles in the joint and placing medications in the joint to lubricate it and decrease inflammation in the lining of the joint space. But unlike other joints, accomplishing this feat has been problematic because of potential complications with middle ear and surrounding nerves to the face and because of the relative size of the join to the size of the arthroscope going into it.
With the introduction of the McCain Arthroscope and the McCain Arthroscopic Surgical Technique, many of the complications with arthroscopic surgery of the TMJ have been greatly reduced.
This spring, I introduced the McCain Arthroscopic Technique and the McCain Arthroscope designed by Dr. Joseph McCain of the University of Miami. The arthroscope designed by Dr. McCain is unique for its size and ease of use. Dr. McCain is broadly recognized as one of the founding fathers of TMJ arthroscopy. I was trained by Dr. McCain in late winter of 2016 and during the spring of 2017 and I follow the McCain Technique for TMJ arthroscopic surgery.
The arthroscope Dr. McCain designed is special. He has been involved in the design since 1990 and the current scope is the result of a group of skilled engineers in Germany who designed the scope to Dr. McCain’s specifications. The scope has the most sophisticated optics available in small joint arthroscopy and provides excellent images given its micro size of 1.8 millimeters. Sixteen arthroscopes could be set side by side within an inch! See figure 1.
In figure 2, a healthy meniscus is seen overlying the condyle as it translates on the slope of the eminence to maximal opening. In figure 3, the hyperemic tissue of the posterior attachment is seen in a painful joint with anterior displacement of the meniscus upon opening.
The McCain Technique is minimally invasive. The procedure is quick and very effective with a success rate of 90%. More importantly it is safer than previously described arthroscopy techniques. The joint approach Dr. McCain teaches minimizes failed entry into the joint also minimizes complications associated with improper placement of the scope in the small upper joint compartment. Also, the small diameter of the scope allows for more mobility of the scope in the joint space which means more opportunity to break adhesions and clean inflammatory debris out the joint space.
According to the American Association of Oral and Maxillofacial Surgeons, 35 million people in this country suffer from varying degrees of TMJ dysfunction or TMD. Approximately 10% of this group will seek treatment for joint symptoms that do not respond to conservative therapy. The other 90% can be well managed with conservative therapy, therapy that can be initiated by and managed by the family dentist.
Our treatment algorithm begins with the dentist:
A. Prior to our consultation with the patient, we ask that the dentist fabricate an occlusal guard for the patient and initiate conservative treatment for any overlying muscle overloading or joint overloading as a result of clenching and bruxism.
B. If the dentist is comfortable with the management of the patient’s pain thru the use of anti-inflammatory medications, we request that these medications be added to the treatment regime if not contraindicated for medical reasons. Ibuprofen is to be avoided because of its anti-chondrocyte activity.
C. Amitriptyline or Clonazepam can be given by the dentist to decrease nocturnal bruxism. Clonazepam should be used only for one week as a trial. Patients who respond to it should be switched to Amitriptyline thereafter.
Most patients will be successfully managed at this point but those who continue to have pain need a referral to our office and further work up. These patients usually continue to suffer from:
1. Painful palpation of the lateral capsule of the TMJ.
2. Painful clicking, grating or popping of the joint
3. Painful opening or lateral movements of the lower jaw.
At the patient’s initial appointment I and my staff will evaluate them and obtain a history of their conservative treatment. Traditionally we will add or adjust medications and initiate aggressive physical therapy. To aid in our diagnosis, we will obtain a CBCT of the joints and, based upon our findings, consider an MRI scan following ADA protocols for imaging to determine meniscus status and position.
After further diagnostic imaging and targeted physical therapy we will see the patient back in our office and evaluate their progress. If less than sufficient from the patient’s perspective I will suggest minimally-invasive arthroscopic surgery if it is warranted from the findings of our imaging studies. A diagnostic arthroscopic procedure includes complete lavage of the superior joint space, a 7 point arthroscopic examination of the joint and installation of Na+ Hyaluronate along with a stem cell aspirant, platelet rich plasma or steroids. Successful treatment nears 90% in patients who have been properly worked up and well managed with conservative therapy.
To be sure, arthroscopic surgery of the TMJ is to be reserved for refractory cases of TMD. Proper vetting of the patient and strict adherence to accepted conservative management principles is key for success. While other conservative treatments such as two needle lysis and lavage of the TMJ are known to be successful, my preference for the McCain Arthroscope and Arthroscopic Technique is based upon the following reasons:
1. Minimally invasive entry into the joint with the McCain Technique
2. High success rate for superior joint puncture and navigation of the joint space owing to the small ( 1.8 mm) size of the arthroscope
3. Superior camera optics for the size of the scope allowing for accurate diagnosis of disc position and synovial tissue disease.
4. Second needle visualization in the joint to ensure complete irrigation of the joint space and removal of joint debris.
5. Easy second needle switch to second port for the introduction of instruments to debride the joint and release adhesions.
6. Direct visualization and the instillation of medicaments.
Please contact the Cincinnati Center for Corrective Joint Surgery for more information concerning arthroscopic surgery of the TMJ using the Dr. Joseph McCain approach to diagnostic arthroscopy.