The surgery explained

Eminectomy.

The surgical procedure that will be performed on my right TMJ, date still unknown.

For several months, Davide and I didn't know the name of the surgery. For several months we lived in despair for not knowing exactly what would be done to help me. To help us.

We were only told by my surgeon (Mr. C.) that a small portion of bone would be removed from my right TMJ, in order to create more space for the disc to return to its original position, hopefully on its own. But we didn't know from where this portion of bone would be removed. We were told by an orthodontic dentist (Mr. P. B.) that this procedure wasn't appropriate for my case, and it would only bring more complications to my already complex situation. We were left in the darkness, a groundless empty space of ignorance - alone, not knowing what to do, or where to go, or in what to believe.

And then, in one of his endless nights of TMJ research, Davide came across a surgical technique that fit the description of the procedure I am waiting for - eminectomy. This is it. It must be it!

In the beginning of April 2012, we flew to Portugal to meet my first oral-maxillofacial surgeon, full of hopes and doubts.

Dr. P. C. welcomed us to his office with the same friendly smile I was received back in 2005. The consultation room was exactly as I remembered it: the sun shinning through the large window, lighting and warming the spacious room, and the stunning views - our beautiful Lisbon seen from above, calmly resting by the river.

As he showed us where to seat, Dr. P. C. said he was quite happy that a long time had passed since he last saw me - he was taking it as a sign of my TMJ not giving me much trouble during these years. I smiled and replied that unfortunately it wasn't the case. And so I started recounting my whole story -  the first dentist and oral-maxillofacial surgery appointments in Cardiff, the soft splint therapies and their failure to help me, the arthrocenthesis and its disappointing and painful results.

Dr. P. C. was surprised. "What do you mean, you can't open your mouth fully? I'm sure you can, but it is just too painful."

"No, I can't. It is physically impossible." He frowned, and I continued: "I had an MRI scan done after the arthrocenthesis. It was confirmed the diagnose of disc anterior displacement without reduction. I can't open my mouth more than 23mm, as the disc is acting like a barrier. But the worse is the pain. I live in constant excruciating pain. And this has happened after the arthrocenthesis." Dr. P. C. looked bewildered. He picked up my file and read through his notes again.

"Ah... Okay... Now I understand what went wrong. When you came here in 2005, I diagnosed you with rupture of the disc ligaments of the right TMJ. An arthrocenthesis should never be performed on discs with ruptured ligaments, as the consequences can be terrible - as you know... In situations where the ligaments are intact, arthrocenthesis proved to be very helpful and produce significant improvements. But they aren't for people with ruptured ligaments. I would never performed an arthrocenthesis on you, as I would know before hand the disc would slip out. However, your surgeon didn't have access to your first MRI scan and probably he wasn't aware of this diagnose. So he did the right thing: he suggested an arthrocenthesis as he was hoping it would help you."

In my mind I was squeezing the neck of Mr. C.'s assistant, as I banged his head against the wall, over and over again. He was the first person who saw me at the Dental Hospital in Cardiff, and I told him several times that I had been diagnosed with rupture of the disc ligaments. At the time, it seemed to me he was ignoring this and focusing the problem on my bruxism. But now I was sure he ignored me. He didn't make any note of this prior diagnose, and Mr. C. was completely unaware of it when he proposed the arthrocenthesis. I don't blame Mr. C. for what happened. But I can't describe how angry I am with his assistant for not listening to me. The mental image of his head being smashed was interrupted by Dr. P. C.: "I guess you came here for an opinion of what should be done next, right?"

I explained him I was on the waiting list for another surgery, this time more complex, involving the removal of a small portion of bone from the TMJ. We didn't know the name of the procedure, but from our research it seemed to be an eminectomy. "Yes", said Dr. P. C., "that would be the surgery I would propose next. I think it is the only procedure that might help you". "Can you please explain us what it is exactly?", Davide asked.

Eminectomy (sometimes referred as eminoplasty) is the surgical procedure in which the articular eminence is removed to provide a normal function of the TMJ. By eliminating this mechanical obstacle and creating an articular planar surface, the condyle glides freely during mouth opening and closure. The best picture I came upon to represent this procedure can be found here.

 Cross-section of a normal TMJ - articular eminence (in pink) to be removed during a eminectomy procedure

(modified from wikipedia.org)

Through a pre-auricular incision with a slight temporal extension (incision in front of the ear, extending to the tempora along the hair line), the TMJ is exposed. With a small drill, closely spaced holes are drilled along a straight line above the eminence, producing a cleavage surface along which the eminence is broken and removed. With specialised tools, the bone is smoothed into a planar surface. And that is it - simple! More space inside the joint for the disc and the condyle to move. Pages 102-111 of the Color Atlas of Temporomandibular joint Surgery show step-by-step images of this procedure.

However, as Dr. P. C. pointed out, my disc has been out of its place and folded on itself for several years now. Due to its cartilaginous nature, it is most likely that the disc is damaged. So before closing the TMJ, the disc must be checked and tests must be performed to ensure normal TMJ function. According to Dr. P. C., if my disc shows significant signs of damage, it must be removed and replaced by a graft.

There are all sorts of grafts (made of skin, fat, cartilage, muscle and artificial materials), none of them fully replacing the function of the disc. However, one type of graft has shown better and more prolonged results - temporalis muscle and fascial graft (explained in pages 93-96 of the Color Atlas of Temporomandibular joint Surgery). Contrary to other types of grafts, the blood supply to the muscle graft is maintained, keeping the muscle tissue alive. And this is why these grafts have been more successful - they are kept alive. Other grafts degenerate with time and die, as blood supply to the tissue is ceased once they are removed from their origin. So, if Dr. P. C. was performing my surgery and if it was confirmed that my disc is severely damaged, he would do a temporalis muscle graft for my right TMJ. This wouldn't be a permanent solution, but it would improve my current condition and hopefully keep me away of further oral-maxillofacial surgeries for a few years.

Regarding the post-op recovery, Dr. P. C. said that usually it is relatively short for eminectomies. Pain-wise it will be bad for the first few days, but soon I will feel a significant improvement in comparison to what I currently live with. If all goes well, I shall start eating normal-ish almost immediately. He doesn't recommend steaks, hamburgers and apples right away or everyday, but eventually I will be able to have one of these every now and again. He actually gives his patients a special medical chewing gum to exercise the muscles and promote healing on the first days after surgery. Imagine - chewing gum! Chewing gum - something I can barely remember what it feels like having in my mouth!

In the end Dr. P. C. added: "No worries - I am sure you are in good hands. From what you've told me, your surgeon is very good, and I wouldn't make a better job than what he is already doing.".

With our hopes restored and seventy euros (€70) poorer, we left Dr. P. C.'s consultation room. For the first time in a long time, I felt content. We couldn't stop smiling and laughing, despite the pain it was causing me. I felt so light that I could float in the air, just like a ballon hold on Davide's hand!

When we were back to Cardiff, we decided to try to get in touch with Mr. C.. We had found several Mr. C.'s email addresses, and I sent a short email to all, asking if it was possible to arrange a meeting to discuss the surgery. We were even willing to pay for a private consultation, if Mr. C. wasn't available at the Dental Hospital. Not even an hour later and to our biggest surprise, Mr. C. kindly replied saying he would be more than happy to meet us, and that he actually has a special slot every week to spend with patients on his surgery waiting list. Why didn't we think of this before? We should've sent an email to Mr. C. ages ago!

A few emails later, we had a full hour appointment with Mr. C. scheduled for May 10th, 2012.