Avoiding complications in TMJ surgery: practical strategies for safer outcomes

The goals in temporomandibular joint (TMJ) surgery are straightforward: to restore function, reduce complications, and improve patient outcomes. The TMJ is a complex anatomical site, and even routine procedures can present unexpected challenges. Complications most feared by surgeons are often preventable—provided each case is approached with respect for anatomy, thorough preparation, and an openness to continual learning.

Common complications in TMJ surgery

Common complications in TMJ surgery, as observed over decades of clinical experience, include:

• Nerve injuries: Most frequently affecting the facial and inferior alveolar nerves, with significant impact on patient function and quality of life.
• Vascular injuries: Damage to the maxillary artery or pterygoid plexus can escalate rapidly, necessitating decisive intervention.
• Infection: Rare in primary TMJ surgery, but far more serious in joint replacement, where periprosthetic infections prove stubborn and costly.
• Malocclusion, heterotopic bone formation, and accidental injury: Issues such as malocclusion, unexpected bone growth, or injury to the dura or ear may not be dramatic but remain clinically important.
• Minor lapses: Many complications stem from small errors, such as omitting a scan, rushing an exposure, or presuming anatomical consistency.

Consequently, the TMJ provides little margin for error. It is surrounded by branches of the facial nerve, major vessels like the maxillary and superficial temporal arteries, the parotid gland, and the thin roof of the middle cranial fossa. Risks include crossing into the external auditory canal or encountering difficult anatomy from prior interventions. Regardless of experience, the anatomy demands full attention and humility.

How to minimize risks in TMJ surgery and avoid complications

Successful TMJ surgery depends on a blend of careful planning, technical precision, and adaptability when faced with unexpected findings. Emphasis on fundamentals such as imaging, nerve protection, bleeding control, and infection prevention, not only lowers complication rates but also leads to better patient recovery. The following sections outline key steps and considerations, with practical solutions for common intraoperative challenges.

Imaging and planning: your best insurance in TMJ surgery

Thorough imaging forms the foundation of effective TMJ surgery. High-resolution CT scans are routine, supplemented by MRI or CT angiography when necessary. Digital planning and 3D modeling assist in anticipating anatomical variations, guiding the placement of patient-specific implants, and creating surgical guides. For complex cases, particularly revisions and ankylosis, virtual planning allows rehearsal of procedures, risk assessment, and development of contingency plans.

Technique and nerve protection

Facial nerve injury remains one of the most significant complications. Preferred approaches include endaural or extended preauricular incisions, with careful marking of safe zones and subperiosteal dissection at each stage. Hydrodissection using local anesthetic and adrenaline facilitates gentle tissue handling; however, moderation is necessary to maintain the ability to detect nerve function.

Staying close to the tragus and zygomatic arch, maintaining precision in incisions, and thoughtful use of periosteal elevators all contribute to risk reduction. Intraoperative nerve mapping or navigation, when available, further enhances safety.

Patience serves as the best safeguard. The temptation to rush, especially when cases appear straightforward, can lead to avoidable complications. The TMJ does not reward overconfidence.

Bleeding prevention and management

Vascular injuries can be dramatic, underscoring the importance of anticipation. Preoperative scans should be reviewed for vessel location and variations, especially in revision surgery and ankylosis.

Most intraoperative bleeding is managed with packing and cautery, although ligation may be required in select cases. Familiarity with the retromandibular approach to the terminal branch of the external carotid artery is essential. For patients with multiple previous surgeries or distorted anatomy, preoperative CT angiography or, in rare instances, embolization may be considered.

Piezoelectric surgery offers improved precision and is gentle on soft tissues, reducing the risk of bone chip seeding and subsequent heterotopic bone formation.

Infection prevention and pragmatism

Periprosthetic joint infection presents one of the greatest challenges in TMJ replacement. Protocols typically include antibiotics before incision, sometimes soaking the implant in vancomycin, limiting operating room personnel, and strict barrier techniques. Rescrubbing between intraoral and extraoral fields prevents the catastrophic Periprosthetic joint infection specially in Total Joint replacement patients. Fat packing with abdominal fat is important to prevent heterotopic bone formation.

If infection occurs, timing is critical. Early infections may respond to debridement and antibiotics (DAIR protocol), while chronic cases often require staged revision with spacers.

Adapting Techniques in Complex TMJ Surgery

TMJ ankylosis and revision surgeries demand exceptional planning and flexibility. Patient-specific guides and implants, enabled by digital planning, are invaluable. Pediatric cases require particular caution: costochondral grafts should be kept thin and fat packing utilized to avoid overgrowth and heterotopic bone formation. When unexpected findings arise, such as dural exposure or entry into the external auditory canal, transposition of temporalis fascia or delayed implant placement may be warranted. Sometimes, caution is the most prudent approach.

Sustain success through postoperative care of TMJ surgery

Emphasis must be placed on physiotherapy and close follow-up, as surgery is not the conclusion, but the beginning of recovery. Patients should be informed of signs to watch for, such as infection or reduced mouth opening, and be aware that rehabilitation is as important as the operation itself. Early detection and intervention can prevent long-term issues and improve outcomes.

What experience has taught me

TMJ surgery is rarely routine, regardless of the number of cases performed. Complications are real and serve as humbling reminders, but preparation, teamwork, and a willingness to seek assistance make a measurable difference. Digital planning and advanced imaging have raised standards, yet experience and caution remain the most reliable tools. Ongoing professional development, including opportunities such as the AO CMF Course—Temporomandibular Joint Surgery (with Human Anatomical Specimens, further supports evidence-based practice and ensures surgeons remain at the forefront of TMJ surgical care.

Lessons continue to emerge, whether from complications or from patient recovery. It is important to remain curious, be prepared, and not to hesitate to seek input from peers and mentors when another perspective is needed. The specialty advances when lessons are shared openly, and collective learning benefits all.