Int. J. Oral Maxillofac. Surg.

2009; 38: 326–331

doi:10.1016/j.ijom.2008.11.016, available online at http://www.sciencedirect.com

Clinical Paper
TMJ Disorders

Maxillo-mandibular counter- L. P. Pinto1, L. M. Wolford2,

P. H. Buschang3, F. H. Bernardi4,
J. R. Gonçalves5, D. S. Cassano2

clockwise rotation and

1
Department of Restorative Dentistry,
Pharmacology, Dental and Nursing School,
Federal University of Ceará, Fortaleza, Brazil;
2
Department of Oral and Maxillofacial

mandibular advancement with Surgery, Baylor College of Dentistry, A&M

University System, Dallas, Texas, United
States; 3Department of Orthodontics &

TMJ Concepts1 total joint Center for Craniofacial Research and

Diagnosis, Baylor College of Dentistry, The
Texas A&M System University Health Science
Center, Dallas, Texas, United States;

prostheses 4
Department of Pathology and Legal
Medicine, Medical School, Federal University
of Ceara, Fortaleza, Brazil; 5Pediatric
Dentistry Department - Araraquara Dental

Part III – Pain and dysfunction School, Sao Paulo State University, Brazil

outcomes
L. P. Pinto, L. M. Wolford, P. H. Buschang, F. H. Bernardi, J. R. Gonçalves, D. S.
Cassano: Maxillo-mandibular counter-clockwise rotation and mandibular
advancement with TMJ Concepts1 total joint prostheses. Int. J. Oral Maxillofac. Surg.
2009; 38: 326–331. # 2008 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. 47 end-stage TMJ patients with high occlusal plane angulation, treated with
TMJ custom-fitted total joint prostheses and simultaneous maxillo-mandibular
counter-clockwise rotation were evaluated for pain and dysfunction presurgery (T1)
and at the longest follow-up (T2). Patients subjectively rated their facial pain/
headache, TMJ pain, jaw function, diet and disability. Objective functional changes
were determined by measuring maximum interincisal opening (MIO) and
laterotrusive movements. Patients were divided according to the number of previous
failed TMJ surgeries: Group 1 (0–1), Group 2 (2 or more). Significant subjective pain
and dysfunction improvements (37–52%) were observed (0.001). MIO increased
14% but lateral excursion decreased 60%. The groups presented similar absolute
changes, but Group 2 showed more dysfunction at T1 and T2. For patients who did
not receive fat grafts around the prostheses and had previous failure of proplast/teflon
and or silastic TMJ implants, more than half required surgery for TMJ debridement
Keywords: temporomandibular joint; TMJ re-
and removal of foreign body giant cell reaction and heterotopic bone formation. End-
construction; custom-made total prosthesis;
stage TMJ patients can be treated in one operation with TMJ custom-made total joint pain; dysfunction.
prostheses and maxillo-mandibular counter-clockwise rotation, for correction of
dentofacial deformity and improvement in pain and TMJ dysfunction; Group 1 Accepted for publication 18 November 2008
patients had better results than Group 2 patients. Available online 6 January 2009

0901-5027/040326 + 06 $36.00/0 # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Temporomandibular disorder (TMD) is a
collective term embracing a number of
clinical problems that involve the masti-
catory musculature, the temporomandibu-
lar joint (TMJ) and associated structures8.
A typical TMD patient presents with pain/
discomfort in the jaw, mainly in the region
of the TMJ and/or muscles of mastication,
and limitation of mandibular function16.
Many of these patients can be managed
with non-surgical therapies, but some end-
stage TMJ patients require surgical TMJ
repair or reconstruction.
The patient can develop end-stage TMJ
as a result of trauma19, osteoarthritis20,
reactive arthritis9, ankylosis17, idiopathic
condylar resorption1, connective tissue/
autoimmune diseases2 (CTAD; e.g. rheu-
matoid arthritis, psoriatic arthritis, lupus,
scleroderma, Sjögren’s syndrome, anky-
losing spondylitis) or other TMJ patholo-
gies. The joint structures can be destroyed
following the use of alloplastic implants,
such as Proplast-Teflon (Vitek Inc., Hous-
ton, TX), Silastic (Dow-corning Inc, Mid-
land, MO), acrylic, bone cements and
metal-on-metal articulations10,23. Loss of
mandibular ramus height, secondary to
condylar resorption, associated with many
of these conditions can produce mandib-
ular retrusion, anterior open bite, Class II
malocclusion, increased mandibular
occlusal plane angulation, limited jaw
function, masticatory dysfunction, altered
speech, airway problems, and mild, mod-
erate to severe pain10.
Some patients have multiple failed TMJ
procedures, usually related to inappropri-
ate selection of surgical procedures or
poorly performed surgery. Other patients
have had repeated orthognathic surgeries
to correct malocclusions and jaw deformi-
ties, with subsequent relapse occurring
because of unrecognized or ignored TMJ
pathology4,7,10,30. Autogenous tissues
used to reconstruct the TMJ have a high
failure rate in patients with two or more
previous failed surgeries, CTAD, reactive
arthritis or foreign body giant cell reac-
tions (FBGCR) related to failed alloplastic
implants. Failure is the result of continu-
ing/worsening pain, poor jaw function,
occlusal/skeletal instability and the need
for surgical reintervention4,10. These
patients are often difficult to manage
because of their chronic pain status, sys-
temic disorders, previous unfavorable
treatment experiences and associated psy-
chological effects. Custom-made TMJ
total joint prostheses have been shown
to reconstruct the TMJs effectively10,15.
Dentofacial deformities and airway pro-
blems are often present in end-stage TMJ
patients26. Previous publications have
Maxillo-mandibular counter-clockwise rotation 327
Table 1. Pre- and postoperative subjective evaluation.
Facial pain and headaches no pain 0 1 2 3 4 5 6 7 8 9 10 worse pain imaginable
TMJ pain no pain 0 1 2 3 4 5 6 7 8 9 10 worse pain imaginable
Jaw function normal 0 1 2 3 4 5 6 7 8 9 10 cannot move jaw
Diet no restriction 0 1 2 3 4 5 6 7 8 9 10 liquids only
Disability none 0 1 2 3 4 5 6 7 8 9 10 totally disabled
Questions asked1. Rate your average daily level of Facial Pain and Headaches on a scale of 0
to 10 where 0 equals no pain and 10 equals worst pain imaginable.2. Rate your average daily
level of TMJ Pain on a scale of 0 to 10 where 0 equals no pain and 10 equals worst pain
imaginable.3. Rate your Jaw Function; which is the ability to open your jaw, move it side to
side, and chew, where 0 equals normal function without any impairment and 10 equals no
function; jaws are ‘frozen’.4. Rate your Diet where 0 equals the ability to chew any consistency
of food without difficulty and 10 equals liquids only.5. Rate your level of Disability. How much
do your TMJ and jaw problems, as well as pain and headaches interfere with your abilities to
perform normal daily activities? 0 equals no interference (no disability), 10 equals bedridden and
unable to take care of yourself (totally disabled).
reported functional, esthetic26 and airway advancement with custom-fitted total joint
benefits13 with the counter-clockwise rota- prostheses and simultaneous maxillary
tion of the maxillo-mandibular complex. osteotomies with counter-clockwise rota-
Some patients previously exposed to tion of the maxillo-mandibular complex
Proplast-Teflon and/or Silastic (PT-S) and occlusal plane. The study demo-
TMJ implants have experienced FBGCR, graphics are presented in Table 1, in Part
heterotopic bone formation and fibrous or I5 of this study. 43 patients were treated
bony TMJ ankylosis associated with pain with bilateral TMJ total joint prostheses
and dysfunction. Autologous fat grafts and 4 patients had a unilateral prosthesis
packed around the articulating area of and sagittal split osteotomy on the con-
the prostheses minimize excessive joint tralateral side. The occlusal plane angle
fibrosis and heterotopic calcification, was decreased in all subjects by posterior
decreasing the pain, improving the range down-grafting the maxilla and/or anterior
of motion, and significantly decreasing the maxillary upward positioning with coun-
need for secondary surgical intervention in ter-clockwise rotation of the maxillo-man-
prosthetic TMJ reconstruction27,28. dibular complex. Mean patient age at the
The purpose of this study was to eval- time of surgery was 34.5 years (range 14–
uate pain and dysfunctional changes after 57 years). The surgical technique and
TMJ reconstruction with mandibular postoperative management are described
advancement with custom-fitted total joint in Part I5 of this study. All osteotomies
prostheses and maxillo-mandibular coun- were rigidly stabilized using bone plates
ter-clockwise rotation. It was hypothe- and screws without using post-surgical
sized that this surgical approach would maxillo-mandibular fixation, but light
reduce pain and dysfunction. It was also force vertical elastics were used on most
thought that previously failed TMJ sur- patients for a minimum of 2–4 weeks to
geries and PT-S exposure would interfere control the occlusion and provide vertical
with the outcomes and that autologous fat support for the mandible until the muscles
transplantation around the TMJ prosthesis of mastication reattached to the mandible
would decrease the need for secondary and regained function.
surgical intervention. The custom-made TMJ total joint pros-
theses used in this study were originally
developed in 1989 by Techmedica Inc.
Patients and methods
(Camarillo, CA) and since 1996, have been
This retrospective study evaluated treat- manufactured by TMJ Concepts Inc (Ven-
ment records from a single private prac- tura, CA). These prostheses are CAD/CAM
tice, from 1990 through 2003, of patients (Computer Assisted Design/Computer
with end-stage TMJ pathology, retruded Assisted Manufacture) devices designed
maxilla and mandible, and high occlusal to fit the specific anatomical requirements
plane angle. All patients were operated on of each patient. The specific characteristics,
by one of the authors (LMW) at Baylor as well as the design and composition of the
University Medical Center, Dallas, TX, prostheses, have been reported3,29.
USA. Patients were selected according The 47 female patients were assessed at
to the inclusion and exclusion criteria presurgery (T1) and at the longest avail-
presented in Part I5 of this study. The able follow-up (T2). The same examiner
patient population was the same as that administered a questionnaire and assessed
in Parts I5 and II6 of this study and the ranges of motion on all of the patients.
included 47 female patients, who under- Patients rated themselves in five cate-
went TMJ reconstruction and mandibular gories: facial pain/headache, TMJ pain,
328 Pinto et al.

jaw function, diet and disability. Subjec- changes ( 0.001) from T1 to T2 At T1, Group 2 presented greater com-
tive ratings (Table 1) were made using a (Table 2). Facial pain/headache decreased promised levels for all criteria compared
scale ranging from 0 to 10: for pain rat- 2.8 points, representing an improvement with Group 1 (Table 3). The absolute
ings, 0 = no pain to 10 = worst pain ima- percentage (IP) of 43%; TMJ pain changes from T1 to T2 were similar in
ginable; for jaw function, 0 = normal to decreased 3.2 points, IP 52%; jaw function Groups 1 and 2 for all criteria except
10 = no function; for diet, 0 = no restric- improved 2.3 points, IP 37%; diet improved lateral excursions, which showed a greater
tion to 10 = liquids only; and for disabil- 2.2 points, IP 39%; and disability decreased decrease for Group 1 (Table 4). Consider-
ity, 0 = no disability to 10 = totally 2.1 points, IP 47%. MIO increased 14%, ing the initial difference and the similar
disabled. During the follow-up evalua- from 31.1 at T1 to 35.4 mm at T2, but amounts of change for both groups, the
tions, the patients had no access to their lateral excursion decreased 60%, from overall final result was significantly better
previous reports. When different pain 4.3 to 1.7 mm. for Group 1 than for Group 2 (Table 5).
levels were reported for the right and left TMJ pain improvement was correlated Of 47 female patients, 18 had previous
sides, the higher value was used. with reduction of facial pain/headache TMJ exposure to PT-S implants (Table 6);
Objective functional assessments were (r = 0.65) and dietary improvement (r = 17 were in Group 2 (n = 22, 77%). 8 of the
performed by measuring the maximum 0.3). Dietary improvement was correlated 47 patients (17%) required additional sur-
interincisal opening (MIO) and lateral with improved jaw function (r = 0.56) and gical intervention after placement of the
excursion movements at T1 and T2. MIO increase (r = 0.3). MIO and jaw TMJ total joint prosthesis. Seven of these
MIO measurements were taken using a function improvements were also corre- patients were in Group 2 (7 of 22, 32%)
ruler with the jaws at maximum opening lated (r = 0.32). and were previously exposed to PT-S TMJ
without assistance, measuring between the Group 1 (average 0.2 previous failed implants. Six of these patients required
lower and upper incisors tips. In cases of TMJ surgery, included 25 female patients reoperation for bilateral TMJ debridement
anterior open bite, the amount of open bite with 48 TMJ Concepts/Techmedica cus- for removal of FBGCR and heterotopic
was subtracted from the maximal opening. tom-made total joint prostheses (23 bilat- bone formation, which caused pain and
With anterior deep bite, the amount of eral and 2 unilateral cases), followed for dysfunction. None of these 6 patients had
vertical dental overlap was added to the an average of 3.1 years. Their average age fat grafts at the initial TMJ reconstruction.
opening to estimate the actual result. Lat- was 33 years (range 14–57 years). Group 2 During the reoperation, the TMJ total joint
eral excursion was the average between included 22 female patients with 2 or more prostheses were not removed but debride-
the left and right maximum excursion previous failed TMJ surgeries (average ment was performed around the prostheses
without assistance, measured using a ruler 3.9, range 2–16) with 42 TMJ Concepts/ and fat grafts were packed around them.
between the upper and lower dental mid- Techmedica custom-made total-joint Severe hypersensitivity to chromium–
lines. The relative improvement percen- prostheses (20 bilateral and 2 unilateral cobalt alloy was the cause for reinterven-
tages were determined by comparing cases) followed for an average of 3.5 tion in the seventh patient in Group 2,
the changes as a percentage of the star- years. Their average age was 36.5 years whose mandibular prosthetic components
ting values using the following formula: (range 20–51 years). were replaced with titanium-alloy compo-
Improvement percentage (IP) = 100 
(T2 T1)/T1.
Table 2. Presurgical (T1) and the longest follow-up (T2) values for the total sample group
Patients were divided in two groups (n = 47).
accordingly to the number of previous
TMJ surgeries: Group 1 included patients T1 T2
with 0–1 previous TMJ surgeries (n = 25); Mean (SD) Mean (SD) IP P
Group 2 included patients with 2 or more Facial pain/headache 6.5 (2.8) 3.7 (3.2) 43 <.001
previous TMJ surgeries (n = 22). This TMJ pain 6.1 (3.0) 2.9 (3.6) 52 <.001
study also investigated outcomes related Jaw function 6.3 (2.3) 4.0 (2.1) 37 <.001
to: previous TMJ exposure to PT-S Diet 5.6 (2.3) 3.4 (2.1) 39 <.001
implants; the placement of fat grafts Disability 4.5 (3.0) 2.4 (2.7) 47 .001
around the prostheses; and requirement MIO (mm) 31.1 (10.5) 35.4 (7.3) 14 <.001
for additional surgical intervention. Lateral excursion (mm) 4.3 (3.2) 1.7 (0.9) 60 <.001
The paired t-test was used to evaluate IP: improvement percentage; MIO: maximal interincisal opening; SD: standard deviation; p:
the changes from T1 to T2; t-tests were probability of significant treatment change.
used to compare the groups. The level of
significance (p) was predetermined at
Table 3. Presurgical (T1) comparison for Group 1 (0–1 previous failed TMJ surgery, n = 25)
<0.05. The correlation (r) between the and Group 2 (2 or more previous failed TMJ surgeries, n = 22).
changes was evaluated by Pearson pro-
duct–moment correlations. Group 1 Group 2
Mean (SD) Mean (SD) p
Results Facial pain/headache 6.0 (2.9) 7.0 (2.5) .187
TMJ pain 5.2 (3.0) 7.0 (2.7) .036
For all 47 female patients, the average Jaw function 5.7 (1.9) 7.0 (2.5) .046
number of previous open TMJ operations Diet 4.9 (2.1) 6.4 (2.3) .022
per patient was 2.0 (range 0–16), the aver- Disability 3.8 (3.0) 5.7 (2.8) .097
age age at surgery was 34.6 years (range MIO (mm) 35.2 (8.8) 26.5 (10.6) .003
14–57 years), and the average post surgical Lateral excursion (mm) 5.8 (3.2) 2.6 (2.3) <.001
follow-up was 3.4 years (range 1–11.9 MIO: maximal interincisal opening; SD: standard deviation; p: probability of significant group
years). All criteria showed significant difference.
 Maxillo-mandibular counter-clockwise rotation 329

Table 4. Treatment changes (T1–T2) comparison for Group 1 (0–1 previous TMJ surgery, jaw function, diet, disability and MIO.
n = 25) and Group 2 (2 or more previous TMJ surgeries, n = 22). There were no significant differences in
Group 1 Group 2 the absolute improvements of Groups 1
and 2, but relative improvements (i.e.
Mean (SD) IP Mean (SD) IP p
compared with their starting value) were
Facial pain/headache 3.2 (3.0) 52 2.5 (2.5) 34 .378 greater in the patients who had fewer TMJ
TMJ pain 3.8 (3.3) 73 2.5 (3.0) 36 .136 surgeries compared with those who had
Jaw function 2.1 (2.4) 37 2.6 (3.2) 37 .515 multiple previous failed TMJ surgeries.
Diet 2.0 (2.0) 41 2.4 (2.8) 38 .631
Earlier studies14,15,29 have shown greater
Disability 2.2 (2.9) 61 1.5 (2.3) 37 .51
MIO (mm) 2.5 (7.5) 7 6.2 (8.4) 24 .11 improvements in pain and dysfunction for
Lateral excursion (mm) 4.1 (3.4) 71 0.9 (2.3) 38 <.001 patients with fewer TMJ surgeries. Post-
hoc power analyses of the results indicate
that, due to sample size and variability, the
Table 5. Post-surgical (T2) comparison for Group 1 (0–1 previous failed TMJ surgery, n = 25) statistical power is insufficient to rule out
and Group 2 (2 or more previous failed TMJ surgeries, n = 22). the possibility that treatment differences
Group 1 Group 2 do not exist.
In this study, the improvements of var-
Mean (SD) Mean (SD) P
ious criteria were associated. Reconstruc-
Facial pain/headache 2.9 (2.8) 4.6 (3.5) .006 tion of the TMJ, debridement of the
TMJ pain 1.4 (2.6) 4.5 (3.7) .001 heterotopic bone and reduction of FBGCR
Jaw function 3.6 (2.0) 4.4 (2.0) .17 might be expected to relieve facial pain/
Diet 2.9 (1.7) 4.0 (2.3) .049
headache, decrease TMJ pain and produce
Disability 1.5 (1.9) 3.6 (3.0) .011
MIO (mm) 37.8 (6.4) 32.8 (7.4) .013 dietary improvements. Physiological stu-
Lateral excursion (mm) 1.7 (1.0) 1.6 (0.8) .509 dies have shown that experimental pain in
the masticatory muscles can impair mas-
MIO: maximal interincisal opening; SD: standard deviation; p: probability of significant group
difference.
ticatory motor functions22. It is reasonable
to expect dietary improvement associated
with improved jaw function. An associa-
Table 6. Demographics: Group 1 (0–1 previous failed TMJ surgery) and Group 2 (2 or more tion between diet, jaw function (subjec-
previous failed TMJ surgeries). tive) and the increase in the MIO
Total sample group (n = 47) Group 1 (n = 25) Group 2 (n = 22) (objective) was also expected, because
Previous exposure to PT-S: 18 (36%) 1 (4%) 17 (77%) associations between these criteria have
Fat grafts: 29 (61.7%) 16 (64%) 13 (59%) been reported11.
FBGCR and heterotopic bone 0 (0%) 6 (27%), without FG Limited lateral excursion was observed
formation: 6 (12%) after TMJ reconstruction with total joint
Metal hypersensitivity: 1 (2%) 0 (0%) 1 (5%), with FG prosthesis. Less decrease in lateral excur-
Infection: 1 (2%) 1 (4%), with FG 0 (0%) sion occurred in patients who had multiple
PT-S: Proplast-Teflon/Silastic; FBGCR: foreign body giant cell reaction. previous TMJ surgeries14,15 because they
presented with compromised lateral
nents. Fat grafts were placed around the normal life activities. The pain and dys- excursion presurgery. Limited post-sur-
prostheses during this patient’s first TMJ function displayed by the patients are the gery ranges of lateral excursion for both
reconstruction and also at replacement cardinal features of TMD16. Psychological groups may be related to the condylect-
surgery. In Group 1, the only patient depression, neuroticism, anxiety, reduced omy, detachment of the lateral pterygoid
who required surgical reintervention had energy and activity levels, cognitive muscle to remove the condyle and subse-
pre-existing immunodysfunction pro- impairment, alterations in rhythmicity quent fibrosis that may occur around TMJ
blems and developed bilateral infections and vegetative functions have been asso- prostheses.
shortly after surgery. This patient had fat ciated with pain21,24. Joint stiffness with The more compromised initial condi-
grafts placed around the prostheses during limited range of mandibular motion, diet tion of the patients with 2 or more TMJ
the initial TMJ reconstruction and had no restriction and limited ability to carry out surgeries (Group 2) may be associated
previous TMJ exposure to PT-S. Debride- normal life activities are also associated with PT-S exposure. Approximately
ment, placement of irrigating catheters with jaw dysfunction12,16,21. End-stage 77% of Group 2 patients had TMJ expo-
and antibiotics were the treatment with TMJ patients often present with significant sure to these alloplasts and it has been well
salvage and maintenance of the pros- dentofacial deformities and compromised established that such patients present
theses. All of these patients, at the com- quality of life. higher mean long-term pain and dysfunc-
pletion of this study, were more than 1- Prior to treatment, pain and dysfunction tion levels than unexposed patients14,15,29.
year post reintervention. were greater in patients with multiple The FBGCR and heterotopic bone forma-
operated joints than in patients who had tion, due to the PT-S residual particles, are
none or one previous TMJ surgery. Sig- related to TMJ pain and dysfunction and
Discussion
nificant improvement are unlikely after may explain the more compromised con-
End-stage TMJ patients can present high two TMJ surgeries4, unless treated with dition of these patients10,14,25. Patients
levels of chronic facial pain/headache, custom-made total joint prosthesis14,15,29. with previous Proplast-Teflon implant
TMJ pain, decreased jaw function, diet The present study demonstrated that the failure are also associated with somatiza-
restriction, limited range of mandibular treatment resulted in substantial improve- tion conditions and their more compro-
motion and limited ability to carry out ment for facial pain/headache, TMJ pain, mised outcomes could be a result of a bias
330 Pinto et al.
in their perception of pain18. Surgeons and
patients should be aware that, although
there is functional improvement, the
long-term pain status of patients pre-
viously exposed to PT-S will likely be
higher compared with patients not
exposed to these implants.
These results indicate that fat grafts
decrease the need for reintervention. In
this sample, more than half of the patients
who did not have fat grafts developed
FBGCR or heterotopic bone formation.
None of these complications were
observed in patients who received fat
grafts, even those exposed to PT-S. Not
all of the patients in the study received fat
grafts because this surgical technique was
not routinely incorporated until 1992. Fat
grafts can eliminate dead space, prevent-
ing blood clot formation, which otherwise
could provide a matrix for fibrous
ingrowth and pluripotential cell migration
into the area that could develop bone and
dense fibrous tissues. Also, in patients
with previous PT-S implants, the fat grafts
block out large areas in which FBGCR
could redevelop27,28.
The effectiveness of the TMJ Concepts/
Techmedica custom-made total-joint pros-
theses to treat pain and dysfunction had
been previously documented14,15,29. This
study evaluated TMJ reconstruction and
mandibular advancement with total joint
prostheses and simultaneous maxillo-man-
dibular complex counter-clockwise rota-
tion. High occlusal plane angulation with
the associated dentofacial deformities and
airway problems (decreased oropharyngeal
airway, snoring, sleep apnea) are common
in end-stage TMJ patients26. Counter-
clockwise rotation of the maxillo-mandib-
ular complex can optimize the correction of
dentofacial deformities by improving func-
tion and esthetics26 as well as improve the
pharyngeal airway space and velopharyn-
geal anatomy13. Even though the alteration
of the occlusal plane produces additional
benefits that were not assessed in this study,
pain and dysfunction improvements were
similar to those reported in previous stu-
dies.
The goals of any TMJ reconstruction
are to: improve mandibular form and func-
tion; decrease or eliminate pain; reduce
disability; and prevent further morbidity.
The surgical maxillo-mandibular counter-
clockwise rotation and the TMJ recon-
struction with custom-made total joint
prostheses can simultaneously maximize
facial form and function, decrease TMJ
pain, and improve airway outcomes, in a
single surgical procedure, for patients with
previous multiple TMJ surgeries and as a
primary procedure, when indicated.
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