What are the treatment options for refractory Temporomandibular Joint (TMJ) disorder?

Treatment Options for Refractory TMJ Disorder

For refractory temporomandibular joint (TMJ) disorder, intraarticular lavage without steroids is recommended as the most effective treatment option for both skeletally immature and mature patients, as it provides symptom relief without the risks associated with steroid injections. 1

First-Line Approaches for Refractory TMJ

Conservative Therapies

• Occlusal splints and physical therapy should be tried first for patients with refractory TMJ symptoms and dysfunction 1
  • Splints have documented improvement in JIA-related orofacial dysfunction
  • Various designs include activators and flat stabilizing splints
  • Physical therapy and jaw exercises can help improve function

Pharmacological Management

• Optimal systemic treatment should be considered for active TMJ inflammation 1
  • NSAIDs are recommended as initial therapy
  • For chronic cases, consider:
    • Muscle relaxants
    • Antidepressants (particularly for patients with concurrent depression)
    • Anticonvulsants for neuropathic pain components

Second-Line Interventions

Intraarticular Procedures

1. Intraarticular lavage without steroids

   • Beneficial for TMJ arthritis-related symptoms and dysfunction
   • Can be used in both skeletally immature and mature patients
   • Provides temporary pain relief and improved function 1

2. Intraarticular glucocorticoid injections

   • Skeletally immature patients: Not recommended as first-line treatment; may be used cautiously only in truly refractory cases with significant symptoms
   • Skeletally mature patients: May be indicated for active TMJ arthritis with symptoms
   • Caution: Risk of mandibular growth suppression and intraarticular calcifications in growing patients 1

Surgical Options for Dentofacial Deformity

For patients with TMJ-related dentofacial deformities and controlled TMJ inflammation:

1. Dentofacial orthopedics and orthodontics for skeletally immature patients 1

   • Supports normal mandibular growth and occlusal development
   • Most effective when started early in deformity development

2. Skeletal surgery for persistent deformities 1

   • Options include:
     • Mandibular distraction osteogenesis
     • Orthognathic surgery with TMJ preservation
     • TMJ reconstruction with autologous or alloplastic implants

Special Considerations

Infection Prevention

• TMJ replacement has a low infection rate (0.7%) but significant consequences when infections occur 1
• Risk factors to address before invasive procedures:
  • Metabolic diseases (diabetes)
  • High inflammatory arthritis
  • Immunosuppressive medications
  • Nicotine use (cessation recommended 4-6 weeks before surgery)

Monitoring and Follow-up

• Regular reassessment of TMJ function, pain levels, and range of motion is essential
• Monitor for progressive deviation in mandibular morphology and facial profiles 1
• Contrast-enhanced MRI is the best method to detect active TMJ inflammation 1

Practical Algorithm for Refractory TMJ Management

1. Start with conservative approaches:

   • Occlusal splints and physical therapy
   • Optimal systemic medications (NSAIDs, muscle relaxants)
   • Jaw rest and behavioral modifications

2. If inadequate response after 4-6 weeks:

   • Consider intraarticular lavage without steroids
   • For skeletally mature patients only: consider intraarticular glucocorticoid injection

3. For persistent dentofacial deformity:

   • Skeletally immature: dentofacial orthopedics and orthodontics
   • Skeletally mature or severe cases: consider surgical intervention when TMJ inflammation is controlled

4. For refractory cases with significant psychological components:

   • Add cognitive behavioral therapy
   • Consider adjunctive therapies like acupuncture 2

The management of refractory TMJ disorder requires an interdisciplinary approach with longitudinal evaluation regardless of current disease activity 1. Treatment decisions should be guided by skeletal maturity, level of TMJ inflammatory activity, and stability of dentofacial deformity.