Last February I had a fourth MRI scan to check both TMJs, as my symptoms changed significantly since the eminectomy (described here). Soon after I had a consultation with Mr. C. (my oral/maxillo-facial surgeon) to discuss the its results. Unfortunately my right TMJ could not be visualised due to scarring artifacts related to the latest surgery. On the left side the scan showed signs of slight disc degeneration, which explains the pain I've been having recently on the left TMJ. Because of these new findings on the left, Mr. C. requested blood analysis to test for rheumatoid arthritis. Thankfully the tests came back negative - the rheumatoid factor and the C-reactive protein values were quite low (more information here). So it's not all bad news! :)
Because the right TMJ could not be visualised on the MRI scan, Mr. C. asked for an urgent x-ray to at least check the bone structure. The results were inconclusive, although it seems that the outline of the condyle is slightly different compared to a previous x-ray. If this change of the condyle shape is real (not related to slight different perspectives between the x-rays), it may be caused by bone degeneration. This would explain the constant crepitus, grating and discomfort I have. It points out to a more advanced/late stage of deterioration of the right TMJ.
Mr. C. proposed a new surgery... He called it "exploratory surgery", as he can't really assess my current condition without opening the joint. What comes afterwards depends on the findings:
- if the disc and its ligaments are damaged, they will be repaired, positioning the disc back to its proper place (all my symptoms suggest that the disc remains anteriorly displaced);
- if there is bone degeneration, any inflamed areas will be removed and smoothed to prevent further deterioration;
- any scar tissue affecting the proper functioning of the TMJ will also be removed.
Mr. C. has no intention of replacing the disc with a graft, even if it is damaged. He thinks that the disc must be kept for as long as possible, because a damaged but repairable disc still works better than any graft. Total joint replacement is out of question - I am too young to start replacing joints, and he is quite confident this surgery will improve significantly my current condition and give me a good 10 years without any major issues.
I asked Mr. C. if this procedure could be done through arthroscopy, instead of opening the joint completely (arthroplasty). Arthroscopies are known for being less invasive and have reduced recovery periods. However, Mr. C. does not perform arthroscopies. He argues that an arthroscopy can actually be more "violent" to the TMJ than an arthroplasty. To insert the scope (camera) and other tools into such small joint (the TMJ volume capacity is only around 1cc.), it is necessary to inject a lot of fluid to create enough space to work. According to Mr. C., this forced fluid pressure inside the TMJ during an arthroscopy can actually cause more damage than opening the joint completely. Also, whilst injecting the fluid, adhesions and other scar tissues may be broken apart, making it difficult to visualise and assess properly the joint condition. He also added that more frequently than not intra-capsule fluid samples are taken to be tested during surgeries; the fluids injected during an arthroscopy dilute or wash the intra-capsule contents, making the test results less reliable.
Despite his recommendation against an arthroscopy, he offered to forward my case to a trusted colleague who would perform it, if that was my choice.
I accepted Mr. C.'s "exploratory" arthroplasty. I like his relatively conservative approach. Although I am aware this surgery won't resolve my TMJD for good, I prefer this to a more radical procedure in which my TMJ's bits and bobs could be forever removed. This was actually suggested by a surgeon in Portugal with whom I had a consultation to ask for a second opinion. If I was to be treated by this surgeon, my disc would be removed and replaced by a muscle graft made from a flap of my temporalis muscle slid between the joint... No, thank you - I rather keep my little disc for a while longer!
At the time of the consultation (March 2013), Mr. C. said the surgery was likely to be done in June (sometime this month). However, until now I have no date for it. I have phoned the hospital several times to request any information, but so far there is not even an estimate.
I guess I just have to keep on waiting and hoping...
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