Issues

[introspect160]

I did bring up the stability issue and he insisted it was a stable movement.

[introspect160]

I've been reading some Wolford studies, and untreated TMJ's is scary stuff. This study has given me major pause with proceeding with this surgery (I have institutional access, but you can read the abstract for free):

https://journals-scholarsportal-info.myaccess.library.utoronto.ca/details/02782391/v61i0006/655_citjdaos.xml?q=Changes+in+temporomandibular+joint+dysfunction+after+orthognathic+surgery&search_in=anywhere&date_from=&date_to=&sort=relevance&op=AND&search_in=JOURNAL&sub=

Assuming I have displaced discs, how much would it cost for me to get Mitek anchor surgery by Wolford? I'm pretty sure no one in Canada will do this. I'm thinking I could get the TMJ dealt with in the US and then get the MMA surgery in Canada.

[april]

In terms of TMJ, I haven't had anything diagnosed. Popping in my left TMJ and a weird mouth opening angle are the main two issues. Does popping mean the disc is displaced?

Yeah when my TMJ first started (like 10 years ago) I had a weird mouth angle on opening too. Eventually the opening evened itself out when both sides became displaced... but was left with arthritis.

Can you get an MRI done? That's the best way for them to see your discs etc.

It's a tough predicament. I'm in it too! Once you surgically invade the joint capsule (fat grafts, muscle grafts, miteks, whatever), the fix is usually only temporary. All roads thereon lead to TJR. And if you're not in any PAIN right now, you might be left with it after miteks. I personally don't trust any TMJ research by Wolford on miteks (but that's up to you). Can't see the abstract btw. Can you see Gunson?

[introspect160]

Does Gunson do remote consultations?

In terms of getting on MRI, I'm not sure how I'd go about that in Canada unless an oral surgeon referred it.

Here's a summary of the study:

Changes in temporomandibular joint dysfunction after orthognathic surgery
Authors: Larry M. Wolford, Oscar Reiche-Fischel, Pushkar Mehra
Journal of Oral and Maxillofacial Surgery; June 2003 Volume 61(Issue6)Page, p.655To-660

Purpose: We sought to evaluate the effects of orthognathic surgery on temporomandibular joint (TMJ)
dysfunction in patients with known presurgical TMJ internal derangement who underwent double-jaw
surgery for the treatment of dentofacial deformities.
Patients and Methods: Treatment records of 25 patients with magnetic resonance imaging and
clinical verification of preoperative TMJ articular disc displacement who underwent double-jaw surgery
only were retrospectively evaluated, with an average follow-up of 2.2 years. Signs and symptoms of TMJ
dysfunction, including pain, range of mandibular motion, and presence/absence of TMJ sounds, were
subjectively (visual analog scales) and objectively evaluated at presurgery (T1), immediately postsurgery
(T2), and at longest follow-up (T3). Surgical change (T2-T1) and long-term stability of results (T3-T2)
were calculated using the superimposition of lateral cephalometric and tomographic tracings.
Results: Presurgery, 16% of the patients had only TMJ pain, 64% had only TMJ sounds, and 20% had
both TMJ pain and sounds. Postsurgery, 24% of the patients had only TMJ pain, 16% had only TMJ sounds,
and 60% has both TMJ pain and sounds. Thus, presurgery 36% of the patients had TMJ pain, and
postsurgery, 84% had pain. Average visual analog scale pain scores were significantly higher postsurgery
and none of the patients with presurgery TMJ pain had relief of pain postsurgery. In addition, 6 patients
(24%) developed condylar resorption postsurgically, resulting in the development of Class II open bite
malocclusion.
Conclusions: Patients with preexisting TMJ dysfunction undergoing orthognathic surgery, particularly
mandibular advancement, are likely to have significant worsening of the TMJ dysfunction postsurgery.
TMJ dysfunction must be closely evaluated, treated if necessary, and monitored in the orthognathic
surgery patient.

[CCW]

Yes, he does.

Popping doesn't mean anything, especially without pain. People with perfect jaws can have it. Jaw deviation on opening can be an indication for disc displacement or just muscle tightness. Get an MRI if  you're concerned. Surgeons usually don't care unless you have TMJ arthritis with or without ICR.

[kavan]

Does Gunson do remote consultations?

In terms of getting on MRI, I'm not sure how I'd go about that in Canada unless an oral surgeon referred it.

Here's a summary of the study:

Changes in temporomandibular joint dysfunction after orthognathic surgery
Authors: Larry M. Wolford, Oscar Reiche-Fischel, Pushkar Mehra
Journal of Oral and Maxillofacial Surgery; June 2003 Volume 61(Issue6)Page, p.655To-660

Purpose: We sought to evaluate the effects of orthognathic surgery on temporomandibular joint (TMJ)
dysfunction in patients with known presurgical TMJ internal derangement who underwent double-jaw
surgery for the treatment of dentofacial deformities.
Patients and Methods: Treatment records of 25 patients with magnetic resonance imaging and
clinical verification of preoperative TMJ articular disc displacement who underwent double-jaw surgery
only were retrospectively evaluated, with an average follow-up of 2.2 years. Signs and symptoms of TMJ
dysfunction, including pain, range of mandibular motion, and presence/absence of TMJ sounds, were
subjectively (visual analog scales) and objectively evaluated at presurgery (T1), immediately postsurgery
(T2), and at longest follow-up (T3). Surgical change (T2-T1) and long-term stability of results (T3-T2)
were calculated using the superimposition of lateral cephalometric and tomographic tracings.
Results: Presurgery, 16% of the patients had only TMJ pain, 64% had only TMJ sounds, and 20% had
both TMJ pain and sounds. Postsurgery, 24% of the patients had only TMJ pain, 16% had only TMJ sounds,
and 60% has both TMJ pain and sounds. Thus, presurgery 36% of the patients had TMJ pain, and
postsurgery, 84% had pain. Average visual analog scale pain scores were significantly higher postsurgery
and none of the patients with presurgery TMJ pain had relief of pain postsurgery. In addition, 6 patients
(24%) developed condylar resorption postsurgically, resulting in the development of Class II open bite
malocclusion.
Conclusions: Patients with preexisting TMJ dysfunction undergoing orthognathic surgery, particularly
mandibular advancement, are likely to have significant worsening of the TMJ dysfunction postsurgery.
TMJ dysfunction must be closely evaluated, treated if necessary, and monitored in the orthognathic
surgery patient.

I've emphasized the KEY WORDS in this study; [patients with known presurgical TMJ internal derangement]. You need to distinguish whether or not it is actually KNOWN that you have the type of derangement mentioned in the study from you SELF ASSESSMENT of TMJ. I would also suggest digging up studies where the TM Joint takes on a BETTER POSITION via double jaw surgery.

Another KEY PHRASE in the study is; [WITH CLINICAL VERIFICATION]. Presently, you have NO clinical verification that you have the TYPE of TMJ that is a risk for the surgery.

Also, if you're really curious/alarmed by this study and whether or not your situation is a risk for double jaw surgery, you could consult directly with one of the authors; Puskar Mehra who is in Boston MA. (Wolford's protege).

When ever getting freaked out by journal articles of something you THINK you MIGHT have, it's best to consult directly with the authors (or one of them). You should also know that the authors of that article do the TM JOINT REPLACEMENTS.

RE:

.... In terms of TMJ, I haven't had anything diagnosed. Popping in my left TMJ and a weird mouth opening angle are the main two issues. ..

.

[introspect160]

Hi Kavan and CCW,

Thanks, these are both great points. In Canada you can't simply get an MRI by paying...need to get in a queue and be referred by a specialist. What is the best approach? Should I talk to Tocchio and ask him if he could get the joints scanned? What if he refuses? See another surgeon? I'm assuming the wait time for a non-critical MRI in Canada would be up to a year (longer than getting the actual surgery itself).

Also, I will contact the author of that study to get some clarity.

[kavan]

Sorry. I don't know much to anything about navigating the bureaucracy in Canada (nor in other countries). Maybe just ask the doctor if he thinks you have an arthritis condition to the jaw that would increase your risks for jaw dysfunction after the surgery.

[april]

I'm assuming the wait time for a non-critical MRI in Canada would be up to a year (longer than getting the actual surgery itself).

Wow. They don't do MRI's privately over there?


You could get a cone beam CT (if you haven't already had one). It won't show them the discs, but will show them if there's any bone changes and they can also see the joint space (or in the case of a disc displacement - a LACK OF joint space). Show your surgeon the study and see what he has to say.

[april]

Ok, so they DO have private MRI centres - but holy s**t, they are expensive.

https://canadadiagnostics.ca/services/mri/
http://www.canmagnetic.com/scans-rates/

And I was complaining about my $350 (AUD) scan.

[introspect160]

Yeah, it is insanely expensive, but might be worth it rather than waiting forever. I could also go down to Buffalo to get it done.

I just came across this pan xray of me and I took a look at the condyles. My left condyle is shorter than my right and has a abnormal shape. Is this normal variance or is something off? It is my left TMJ that causes issues. Here it is.

Seriously considering a consult with Gunson.


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[introspect160]

Another update:

I called Tocchio's office to ask if I could get my TMJ's MRI'ed. His secretaries talked to him (they won't give out an email address), and they called me back and told me that oral surgeons are not allowed to requisition an MRI in Canada. It must be done by a doctor. Is it just me or is that messed up?!

Anyway, I talked to my psychiatrist who diagnosed the sleep apnea, and she said she wasn't willing to requisition it either because it is outside her area of speciality. She recommended that I contact Tocchio again and see if he can get an ENT at his hospital to do it. I doubt my family doctor would requisition it either, but may be worth a try.

Which brings up another point...what do I even say to Tocchio? "Hey, I think you're wrong and I need to have my TMJs assessed." If I were a fax mac of 35 years and having taught at the U of T I would be insulted if someone brought up studies insinuating that my assessment plan was inadequate.