Diagnosis and Management of Temporomandibular
Joint Pain and Masticatory Dysfunction
Franklin M. Dolwick, Shelly Abramowicz, Shahrokh C. Bagheri
M anagement of patients with masticatory pain and dysfunction
is one of the most challenging problems confronting oral and
maxillofacial surgeons. The problem exists because of the diverse
collection of conditions affecting the masticatory system that have
similar symptoms and signs of pain or dysfunction, or both. Several
diagnostic classification systems are used but are often non-specific
and confusing. Selection of the appropriate treatment protocol is
controversial, with treatment decisions being based on one’s philoso-
phy of the cause of the condition. Frequently, the approach to diag-
nosis and treatment of a patient with masticatory pain and dysfunction
is more complicated than necessary. Although the pathophysiology
Chapter
98  
of masticatory pain and dysfunction is complex and poorly under-
stood, the approach to most patients should be relatively simple.
The senior author has divided patients with masticatory pain and
dysfunction into two general categories, muscular conditions and
temporomandibular joint (TMJ) disorders. At the most basic level
the surgeon must decide whether the pain or dysfunction, or both,
are arising from masticatory muscles or the TMJ. TMJ surgery is
not recommended for muscle disorders because it will not decrease
the pain and dysfunction and will most likely make them worse.
Only patients with pain and dysfunction arising within the TMJ are
candidates for TMJ surgery.
860 Current Therapy in Oral and Maxillofacial Surgery
BOX 98-1  Diagnostic Classification of Masticatory Pain and Dysfunction Conditions
A. Masticatory muscle disorders
1. Myofascial pain and dysfunction
a. Nocturnal bruxism
b. Habitual daytime parafunction
i. Clenching
ii. Postural
c. Trauma—whiplash
2. Myositis, myospasm, etc.
3. Neoplasias
B. Temporomandibular joint disorders
1. Disc derangement disorders (internal derangement)
a. Anchored disc phenomenon
b. Disc displacement with reduction
c. Disc displacement without reduction
d. Disc perforation
2. Osteoarthritis (non-inflammatory disorders)
3. Inflammatory disorders
a. Capsulitis/synovitis
b. Polyarthritides
i. Rheumatoid arthritis
ii. Juvenile rheumatoid arthritis
iii. Psoriatic arthritis
iv. Others
4. Hypermobility disorders
a. Subluxation
The purpose of this chapter is to present a simple practical
approach to the diagnosis and management of patients with masti­
catory pain and dysfunction. Emphasis will be placed on identi­
fication of patients who will benefit from surgical intervention
and selection of the surgical procedure that will provide the greatest
benefit for the patient’s specific problem with the least risk for
complications.
CLASSIFICATION
Several classifications of conditions associated with masticatory
pain and dysfunction have been proposed. Some are based on symp-
toms and signs, some on disease categories, and others on research
criteria. The senior author has used a simple diagnostic classification
system that should include most conditions (Box 98-1).
Despite differences in opinion about which operation to perform,
there are a group of disorders for which the role of surgery is not
disputed, including all of the TMJ disorders except for the disc
derangement and arthritic disorders. This chapter focuses on the
diagnosis and management of patients with most common mastica-
tory pain and dysfunction disorders who have either masticatory
muscle or disc derangement disorders. For the purposes of this
chapter, disc derangement disorders and osteoarthritis will be dis-
cussed together because they are commonly found together.
However, they can certainly occur as distinct disorders.
DIAGNOSIS
At the most basic level, the surgeon must decide whether a patient
with masticatory pain and dysfunction has a muscular, joint, or
combination of a muscular and joint problem. It is assumed that
non-masticatory system causes of the pain have been eliminated.
The diagnosis is based on a thorough history, clinical examination,
and laboratory and imaging studies.
b. Dislocation
i. Acute
ii. Chronic recurrent
iii. Chronic
5. Hypomobility disorders
a. Extra-articular (pseudo)
b. Intra-articular (true)
i. Fibrous
ii. Osseous
iii. Combination of fibrous and osseous
6. Traumatic injuries
a. Soft tissues
b. Fractures
i. Intracapsular
ii. Extracapsular
7. Congenital or developmental disorders
a. Aplasias
b. Hypoplasias
c. Hyperplasias
8. Unusual diseases and disorders
a. Benign
b. Malignant
i. Primary
ii. Metastatic
The history may be the most important part of the evaluation. It
should include the chief complaint and a detailed history of the
present illness. The clinical examination should be a systematic
evaluation of the TMJs for tenderness, joint noise, range of motion
with and without pain, and pain on loading. The muscles of mastica-
tion and the cervical muscles should be palpated and areas of tender-
ness noted. Finally, the teeth and occlusion should be assessed. A
thorough evaluation of the soft tissues of the oral cavity should also
be done. Routine imaging such as a panographic x-ray should be
obtained to evaluate the osseous structures of the teeth, their sup-
porting structures, and the TMJs. The need for more advanced
imaging or laboratory studies is determined from findings on the
preliminary evaluations.
MUSCULAR PAIN AND DYSFUNCTION
The concept of myofascial pain and dysfunction (MPD) was intro-
duced by Laskin in the 1960s. It refers to a group of muscle disorders
characterized by diffuse facial pain and limited mouth opening. It
can involve problems with the TMJ, muscles of the face, and associ-
ated head and neck structures. Frequently, when patients have non-
specific signs and symptoms of facial pain of unknown etiology,
they are wrongly labeled as having a TMJ problem. In the authors’
experience, the majority of patients seen by surgeons with com-
plaints of facial pain and dysfunction have muscular problems.
Recent advances in the understanding of muscular pain and
dysfunction have supported the theory that the cause of MPD is
often multifactorial. Biologic, behavioral, environmental, social,
emotional, and cognitive factors contribute to the development of
signs and symptoms. More specifically, there are various predispos-
ing risk factors, such as female gender, anxiety and depression,
and a stressful lifestyle. There are multiple perpetuating factors,
including acute jaw trauma, sudden changes in occlusion, and exces-
sive jaw activity. Secondary gain such as sympathy or avoidance
of an unpleasant activity such as work may also perpetuate the
 Diagnosis and Management of Temporomandibular Joint Pain and Masticatory Dysfunction
symptoms. The significance of large skeletal discrepancies such as
open-bite malocclusion, overjet greater than 6 mm, and missing
posterior teeth is unclear, but such discrepancies may predispose
patients to MPD.
Although many factors contribute to MPD, the single most com-
monly identifiable cause is a parafunctional habit such as tooth
clenching or grinding, which often occurs secondary to stress and
anxiety. In fact, more than 68% of patients treated for MPD report
that they clench their teeth. Importantly, bruxism can overload the
TMJ and contribute to the development of, perpetuate, and maintain
TMJ disc derangements.
Patients with masticatory muscle pain and dysfunction have
diffuse, poorly localized pain that is frequently, but not always worse
in the morning. Patients generally report sleep disturbances and
believe that the pain disrupts their sleep. As noted, more than 68%
of patients report that they grind or clench their teeth. They may
complain of sore teeth and frequently complain of jaw tiredness and
fatigue when eating. They often complain of limited and painful
mouth opening. Patients with MPD may also complain of head-
aches, earaches, and cervical pain. The findings on physical exami-
nation are diffuse tenderness to palpation of the masticatory and
cervical muscles, especially along the temporalis insertion. The
TMJs are either non-tender or minimally tender to palpation, and
there is no pain in the TMJ on loading. Mandibular opening may be
limited to 30+ mm, and patients will frequently hesitate (guard)
during opening, but they can usually be encouraged to open wider.
The intraoral examination helps eliminate dental causes as a source
of the pain. The number and condition of the teeth, including occlu-
sal wear facets, sore teeth, craze lines, and mobility, are documented.
Such findings are an indication that patients are grinding their teeth,
although absence of these signs does not eliminate bruxism. Findings
on routine radiographic examination are frequently normal, but
occasional abnormalities may be observed. The surgeon must
remember that patients with severe TMJ signs may occasionally also
have MPD as a perpetuating factor.
Because more than 80% of patients with MPD respond favorably
to non-surgical interventions, all factors should be addressed with a
focus on non-invasive methods that are reversible. The first step
should include a thorough explanation of the findings. The patient
should be educated and reassured that the pain usually resolves with
simple treatment and that a more serious condition does not exist.
The patient should be prescribed a home care program that includes
jaw rest, a soft diet, limitation of wide mouth opening, and applica-
tion of warm moist heat. After a period of jaw rest, muscle massage
and physical therapy, including stretching and strengthening exer-
cises, should be encouraged. The physical therapy program should
be kept simple with exercises consisting of opening and closing
the mouth, protrusion, and right and left lateral excursion of the
mandible.
Most patients will benefit from an occlusal appliance, especially
if they grind their teeth. The appliance should be a simple flat-plane
splint that covers all the teeth, and all the teeth should touch the
splint evenly in centric occlusion and in a centric relationship.
The splint should have a shallow anterior guidance that separates
the teeth during excursive movements. The idea is not to reposi-
tion the mandible, but to allow the muscles to rest and to decrease
TMJ loading. The splint also protects the occlusal surfaces of the
teeth from damage during bruxism. It should generally be worn only
at night. Frequent adjustments may be necessary, especially when
first given to the patient.
Medical therapy should include a non-narcotic analgesic such
as a non-steroidal anti-inflammatory medication and, if sleep dis­
turbances exist, a sleep medication such as a low-dose tricyclic
861
antidepressant. Some tricyclic antidepressants have analgesic prop-
erties independent of their antidepressant effect and may be useful
for patients who have both pain and sleep disturbances. In our expe-
rience, cyclobenzaprine has similar benefits. The combination of
non-steroidal anti-inflammatory drugs and a low-dose tricyclic anti-
depressant appears to be most beneficial. Patients who have signifi-
cant behavioral problems, stress, anxiety, or depression will benefit
from psychological evaluation and treatment.
It is important to recognize that the patient’s signs and symptoms
will resolve slowly over a period of weeks to months and that they
will frequently recur. However, most patients with MPD will
improve with conservative treatment. It is also important to encour-
age patients that they will improve and that severe problems rarely
occur. If the patient is not improving, re-evaluation should be under-
taken to determine whether the diagnosis and treatment are appropri-
ate. TMJ surgery is not recommended for patients with MPD even
if the signs and symptoms are severe and persistent. TMJ surgery
will not resolve and will usually make it worse.
RELATIONSHIP OF BRUXISM TO
INTERNAL DERANGEMENT
Grinding and clenching of the teeth have been shown to adversely
load the TMJ. This is especially true of clenching, which causes
continued compressive loading of the TMJ tissues. Excessive
loading of the joint causes damage to the joint tissues through
mechanical, biochemical, and hypoxia-reperfusion mechanisms. In
hypoxia-reperfusion injury, the soft tissues become temporarily
hypoxic because of excessive loading of the soft tissues, and as
reperfusion occurs, free radicals, which are thought to break down
hyaluronic acid, are produced. This leads to a failure of the joint
lubrication system and results in microscopic changes in articular
cartilage, disc stickiness, disc displacement, and eventually degen-
eration of the articular surfaces of the TMJ.
Though not proven, there is considerable evidence to support this
hypothesis. Because MPD may be a significant cause of internal
derangement, they are frequently found together. The occurrence of
MPD and internal derangement together results in difficulty diag-
nosing the patient’s condition. It is our opinion that failure to rec-
ognize this relationship, as well as failure to manage MPD before
TMJ surgery for internal derangement, is the primary reason for
surgical failure. When MPD is present, it must be managed appro-
priately if surgical success is to be achieved.
INTERNAL DERANGEMENT
Internal derangement of the TMJ was reintroduced into the literature
in the 1970s by Farrar and McCarty. During the 1970s and 1980s it
gained wide popularity as the cause of TMJ pain and dysfunction.
The primary clinical focus was on TMJ disc displacement and defor-
mity as the cause of TMJ pain and dysfunction, which eventually
led to TMJ osteoarthritis. The introduction of TMJ arthroscopy and
the recognition that simple lysis and lavage of the upper joint space
of the TMJ frequently resulted in decreased pain and improved range
of motion led to re-evaluation of the significance of disc position.
At the present time, internal derangement is thought to be a dynamic
process involving biomechanical, biochemical, and cellular changes,
including disc displacement and deformity, synovitis and changes in
synovial fluid, degenerative changes in the articular surface, and
fibrosis. The shift in thinking from a predominantly mechanical
focus to a biologic focus has resulted in a significant change in
sur­gical treatment from mainly open surgery to arthrocentesis and
arthroscopy.
862 Current Therapy in Oral and Maxillofacial Surgery

Patients with internal derangement have well-localized TMJ pain

that is continuous and becomes worse with mandibular functions
such as chewing and talking. They report that their TMJ either
makes noise (i.e., clicking or crepitus) or previously made noise but
no longer does. Patients usually complain that their jaw either does
not open smoothly or is limited in its opening. Patients frequently
complain of catching or locking sensations. Many patients report
that their jaw is locked closed. Clearly, the focus of the patient’s
complaints is well localized to the TMJ.
Physical examination demonstrates pain and dysfunction that are
well localized to the TMJ. The affected TMJ is tender to palpation,
and TMJ pain is reported when the joint is loaded. There is interfer-
ence with smooth joint movement in the form of deviation associ-
ated with TMJ clicking or limited opening with pain. Excursive
movements are limited toward the unaffected side and usually cause
increased pain in the affected joint.
A preliminary diagnosis of internal derangement can generally
be made from the clinical examination. Definitive diagnosis and
clinical staging of the disc derangement require magnetic resonance
imaging (MRI). Based on the clinical findings and MRI, the disc
A
derangement should be classified according to the Wilkes classifica-
tion system. Classification of the internal derangement is especially
important for reporting outcomes of clinical treatment.
MRI of the TMJ is necessary to evaluate the position and
shape of the articular disc and to confirm the diagnosis of internal
derangement before open TMJ surgery (Fig. 98-1). The absolute
indications for MRI are not specific, other than before open TMJ
surgery when the diagnosis has not been confirmed by other imaging.
MRI does provide valuable information about disc shape that
cannot be obtained by other means. MRI also provides information
about the presence of joint effusion, marrow edema, and the integ-
rity of the articular surfaces. It is the imaging technique of choice
for evaluating the soft tissues of the TMJ. The correlation of TMJ
pain with MRI findings is poor, so the diagnosis must always be
made from a comparison of the clinical history, physical examina-
tion, and findings on MRI. The diagnosis should never be based
solely on MRI.
Most patients with pain and dysfunction caused by internal
derangement will experience resolution of their symptoms with non-
surgical treatment. In fact, in many patients the symptoms resolve
without treatment. Therefore, it is prudent to treat patients with non- B
surgical therapies before surgical options are considered. Fig. 98-1  n  A, T1-weighted magnetic resonance image (MRI) in
Non-surgical treatment of TMJ internal derangement is similar the closed-mouth position showing anterior disc displacement. 
to that for MPD. The objectives of treatment are to reduce pain, B, T1-weighted MRI in the open-mouth position showing recapture
eliminate inflammation from the joint, eliminate or reduce adverse or reduction of the disc.
TMJ loading, and restore TMJ mobility.
The first step in treatment is to educate the patient about internal
derangement of the TMJ. The patient should be reassured that the
pain and dysfunction usually resolves with simple treatment and that Most patients will have a decrease in symptoms in about 4 to 6
a more serious condition rarely develops. The patient should be weeks. Patients who continue to have significant TMJ pain and
provided with a home care program that includes jaw rest, a soft dysfunction should be re-evaluated for surgical treatment.
diet, and limitation of jaw opening. Medical therapy should include
a non-steroidal anti-inflammatory analgesic. As the pain begins to
resolve, simple range-of-motion exercises should be started. These
SURGICAL TREATMENT
exercises include gentle unforced mandibular opening and excursive Controversy continues to surround the role of surgery in the manage-
movements. ment of TMJ pain and dysfunction. Nonetheless, advances have
Since bruxism may be an important cause of internal derange- been made with the introduction of new and less invasive techniques
ment, many patients will require the treatment protocol for MPD; such as arthrocentesis and arthroscopy. The role of surgery has
specifically, an occlusal appliance and sleep medications should be evolved since the idea of internal derangement gathered momentum
provided. The occlusal appliance should be a flat-plane appliance during the 1970s. During this time, renewed interest was focused on
and not a jaw-repositioning device. The objective of treatment with the importance of disc displacement and deformity as the cause of
an appliance is to rest the muscles of mastication and reduce adverse TMJ pain and dysfunction. Open joint procedures were developed
loading of the TMJ. to reposition and reshape the displaced or deformed disc. Though at
 Diagnosis and Management of Temporomandibular Joint Pain and Masticatory Dysfunction
first thought to be highly successful, the long-term results proved
to be less successful. The success of simpler procedures such
as lavage and lysis by arthrocentesis or arthroscopy has raised
serious doubts about the pathologic significance of disc position as
the cause of TMJ pain and dysfunction. Evidence is accumulating
that inflammation of the synovium, changes in synovial fluid, and
microscopic changes in the articular surfaces are more significant in
causing the pain and dysfunction and may be a cause of the disc
displacement.
The successful application of less invasive procedures has estab-
lished the surgeon’s role in the management of TMJ pain and dys-
function. With the increased surgical options available to present-day
surgeons, it seems prudent that selection of the surgical procedure
with the highest probability of success and the least morbidity
should be the objective. Since the likelihood of successful manage-
ment is determined by the accuracy of the diagnosis, the most
important ingredient for success is case selection.
INDICATIONS FOR TEMPOROMANDIBULAR
JOINT SURGERY
The indications for TMJ surgery have been consistent for many
years, and the criteria are clearly defined:
1. The TMJ is the source of pain or dysfunction that results in
significant impairment in daily activities.
2. Non-surgical treatment fails to resolve the problem.
3. A TMJ intracapsular pathologic condition or anatomic derange-
ment is documented that may be a major source of the patient’s
pain or dysfunction.
Although the indications for surgery may appear clear, they are
in fact non-specific. The first criterion, significant pain or dysfunc-
tion localized to the TMJ, may be the most important. If the pain or
dysfunction is originating within the TMJ, surgical intervention will
probably be successful. However, if it is not originally within the
joint, not only will surgical intervention be unsuccessful, but the
patient’s pain or dysfunction may also become worse. Therefore, it
is prudent that the surgeon make an accurate diagnosis.
At the most elementary level the surgeon must decide whether
the source of the patient’s pain and dysfunction is muscle, joint, or
a combination of muscle and joint. Unfortunately, the latter seems
to be most common. The surgeon must then determine that the
muscular pain is manageable with non-surgical treatment before
proceeding with surgical intervention. The principal criteria for
determining that the pain originates in the TMJ are pain localized
to the joint, pain on loading the joint, increased pain during function,
pain that is least in the morning and worst in the evening, and evi-
dence of mechanical problems within the joint. It seems clear that
the more localized the pain and dysfunction are to the TMJ, the more
likely intervention involving the joint will be successful. Conversely,
the more diffuse the pain, the less likely that surgical intervention
will be successful.
The second criterion, refractory to non-surgical treatment, is
also non-specific. There is no clear agreement on a protocol for
conservative or non-surgical treatment. However, most surgeons
understand what non-surgical treatment involves. It typically
includes a combination of patient education, medications, physical
therapy, an occlusal appliance, and occasionally behavioral modifi-
cations. Because most patients will respond successfully to these
treatments or sometimes improve over time without treatment, sur-
gical consideration should be reserved for patients who fail to
respond successfully over a reasonable period. Again, it must be
emphasized that only patients whose pain and dysfunction are
863
arising from within the TMJ are surgical candidates. Patients whose
pain is arising from the muscles of mastication or other non-TMJ
sources are not surgical candidates even if their pain and dysfunction
are refractory to treatment.
The third criterion, documentation of an intracapsular TMJ
pathologic condition or anatomic derangement, generally requires
TMJ imaging. The correlation of pain with imaging findings such
as disc derangement, dysfunction, and degeneration is poor.
Therefore, imaging should be used only to confirm and support the
clinical findings. Surgery should not be performed on the basis of
imaging alone.
Surgical interventions include arthrocentesis, arthroscopy,
condylotomy, and open joint procedures. Randomized clinical
trials comparing these procedures do not exist, so the surgeon’s
experience usually determines the procedure selected. Each proce-
dure has specific benefits, as well as risks. Therefore, the procedure
with highest potential for success, the lowest risk, and the most
cost-effectiveness should be chosen for the patient’s specific
condition.
TEMPOROMANDIBULAR JOINT ARTHROCENTESIS
Though included among the surgical procedures, arthrocentesis in
reality is a non-surgical procedure. Despite being invasive, the risk
for injury to the overlying soft tissues and the joint structures is
negligible. Arthrocentesis is the least invasive of the surgical tech-
niques. The concept was based on the observation that simple lysis
and lavage of the upper joint space via arthroscopy was highly suc-
cessful in re-establishing normal range of mouth opening in patients
with closed lock of their TMJ.
The technique involves the insertion of two 18-gauge needles
into the superior joint space of the TMJ. The procedure is usually
performed with intravenous conscious sedation and local anesthesia
but can be performed with local anesthesia only. The patient is
seated inclined at a 45-degree angle with the head turned to the
opposite side to provide an easy approach to the affected joint. After
preparation of the preauricular area, the external auditory meatus is
blocked with cotton. A line is drawn from the middle of the tragus
to the lateral canthus. The posterior needle is inserted along the
canthotragal line, 10 mm from the middle of the tragus and 2 mm
below the line. Palpation of the glenoid fossa during movement of
the condyle confirms the location. After injecting a local anesthetic,
the posterior needle is placed by directing it at a 45-degree angle
from posterior to anterior and from inferior to superior. The needle
is directed toward the middle of the glenoid fossa. Once the lateral
aspect of the glenoid fossa is felt, the needle is directed more hori-
zontally and advanced into the middle of the upper joint space. The
upper joint space is distended with approximately 2 mL of Ringer
solution. Confirmation of placement of the needle into the upper
joint space is made by observing the mandible’s movement during
injection or by backflow into the syringe when pressure is released.
The anterior needle is inserted approximately 5 to 10 mm below the
canthotragal line. Confirmation of correct placement is made by
observing outflow from the posterior needle. Slight adjustment of
the needles may need to be made if the outflow is sluggish. The
upper joint space is then irrigated with 100 to 300 mL of Ringer
solution. The outflow is intermittently occluded during the irrigation
to distend the joint space. After completion of the irrigation, medica-
tion (steroid or hyaluronic acid) may be placed in the upper joint
space. Once the procedure is completed, the mandible is moved
through opening, excursive, and protrusive movements. The range
of motion and presence of any mechanical interference to movement
are noted.
864 Current Therapy in Oral and Maxillofacial Surgery
After the procedure the patient is given a mild analgesic and
instructed to perform range-of-motion exercises. This is continued
for about a week.
Temporary facial nerve weakness or paralysis as a result of the
local anesthetic may occur during arthrocentesis. This is transient
and disappears in about 30 to 60 minutes. For this reason a short-
acting local anesthetic should be used. Other transient complications
include preauricular swelling from either extravasation of fluid or
hematoma and occlusal changes from distention of the upper joint
space. These complications are temporary and generally resolve
within 24 hours.
Studies of the outcome of arthrocentesis for painful limited
opening have shown consistently improved mouth opening and
decreased pain. In groups of patients with disc displacement resis-
tant to conservative treatment, the results of arthrocentesis were
not significantly different from those seen with arthroscopic lysis
and lavage in decreasing pain and improving mouth opening.
Arthrocentesis may also be beneficial in treating any condition
involving inflammation in the upper joint space of the TMJ.
Since arthrocentesis is a simple outpatient procedure that has no
significant complications associated with it and is cost-effective, it
is probably the first surgical procedure that should be used in patients
with TMJ pain and dysfunction.
The mode of action of arthrocentesis is not known. Its benefit is
probably derived from several factors, such as breaking up the
stickiness of the disc and fine adhesions by distending the joint and
removing inflammatory products from the joint.
TEMPOROMANDIBULAR JOINT ARTHROSCOPY
TMJ arthroscopy developed as a spinoff from the technologic
advances made by orthopedic surgeons in arthroscopy of large
joints. Miniaturization of the arthroscopic telescope made it possible
to apply this technology to the TMJ. TMJ arthroscopy was first
introduced into the literature in 1975, but it was not until almost a
decade later that the concept of TMJ arthroscopy became popular.
Intense interest in TMJ arthroscopy developed in the early 1980s,
and it is now widely used.
Arthroscopy is very much an equipment-dependent procedure
that relies considerably on complex technology. Despite the mini-
mally invasive nature of arthroscopy, until recently it has been
commonly performed under general anesthesia in the operating
room. It takes a fair degree of skill and ability to conceptualize a
three-dimensional space on a two-dimensional screen image, as well
as a high degree of manual dexterity, particularly for operative
procedures.
TMJ arthroscopy involves placing an arthroscopic telescope (1.8
to 2.6 mm in diameter) in the upper joint space of the TMJ and then
attaching a camera to the arthroscope to project the image onto a
television monitor. A second access instrument is placed approxi-
mately 10 to 15 mm in front of the arthroscope. This access point
provides an outflow portal for irrigation and access for inserting
instrumentation into the joint space. The upper joint space is exam-
ined systematically starting posteriorly by identifying the posterior
attachment tissue. The synovial lining is inspected for the presence
of inflammation, such as increased capillary hyperemia. The junc-
tion of the posterior band of the disc and posterior attachment tissues
can be identified. Movement of the joint allows the identification of
clicking or restricted movement of the disc. The articular cartilage
of the fossa and eminence can be inspected for degenerative changes
such as softness, fibrillation, or tears as the arthroscope is moved
through the joint space. The joint space can also be evaluated for
the presence of adhesions, loose bodies, or other pathology. The
integrity of the disc and posterior attachment or perforations of the
tissue can be identified.
The final step is to move the arthroscope into the anterior part of
the upper joint space. Frequently, inflammation and adhesions can
be observed in this location. Lysis of adhesions is accomplished by
sweeping either the arthroscope or the irrigation cannula through the
adhesions and tearing them. After completion of the examination,
the joint space is thoroughly irrigated to remove debris, blood clots,
and inflammatory products. Before removing the instruments, medi-
cations such as steroids may be injected either into the joint space
or directly into inflamed tissues.
Sophisticated operative techniques ranging from ablation of
adhesions with lasers to plication of the disc with sutures or anchor
devices have been developed. These techniques require considerable
technical skill, and consequently, only a few surgeons use these
advanced techniques.
TMJ arthroscopy is performed as an outpatient procedure, and
the patient is discharged after recovery from anesthesia. A pressure
dressing is usually placed for 12 to 24 hours postoperatively.
Postoperative care includes a non-chewing soft diet for a few days,
range-of-motion exercises for several days, an occlusal appliance,
and analgesics as necessary for pain control.
Multiple studies have reported 80-90% success rates with
arthroscopic lysis and lavage for the management of patients with
painful limited mouth opening. The majority of patients have
decreased pain and improved mouth opening. Murkami and col-
leagues have shown in 5- and 10-year follow-up that arthroscopic
lysis plus lavage is successful for all stages of internal derangement,
and the results are comparable to those reported with open surgery.
Data from advanced surgical arthroscopic techniques such as disc
repositioning are difficult to interpret, and it is unclear whether the
outcomes are better than those achieved with simple lysis and
lavage.
The recent development of 1.2-mm arthroscopic telescopes has
allowed arthroscopic lysis and lavage to be performed in the office
under either conscious intravenous sedation or local anesthesia. The
optics of these small arthroscopes are excellent, and superb visual-
ization of the joint structures can be obtained. The techniques are
similar to hospital-based arthroscopy. Only lysis and lavage can be
performed with the 1.2-mm arthroscope. Use of the 1.2-mm arthro-
scope provides a technique that has the simplicity of arthrocentesis
and many of the advantages of arthroscopy. The preliminary results
of office-based arthroscopy are similar to those observed with
arthrocentesis and hospital-based arthroscopy for patients with
painful limited mouth opening.
MODIFIED CONDYLOTOMY
The modified condylotomy is a variation of the intraoral vertical
ramus osteotomy used in orthognathic surgery. The idea of osteoto-
mizing the condylar process for the treatment of TMJ pain was
derived from observations that patients who had sustained condylar
fractures rarely complained of TMJ problems. In the 1980s,
Nickerson developed the modified condylotomy as a means of treat-
ing TMJ patients. The aim of the procedure is to surgically reposi-
tion the condyle anteriorly and inferiorly beneath the displaced disc,
which effectively increases the joint space. Although some authors
recommend modified condylotomy for all stages of internal derange-
ment, it seems to be most useful for treating patients with painful
TMJ internal derangements and good mouth opening.
The modified condylotomy is performed under general anesthe-
sia, usually as an outpatient procedure, but an overnight stay in the
 Diagnosis and Management of Temporomandibular Joint Pain and Masticatory Dysfunction
hospital may be required. An incision is made along the anterior
border of the mandibular ramus. After exposure of the lateral aspect
of the mandibular ramus, a vertical cut is made posterior to the
lingual aspect from the coronoid notch to the mandibular angle.
Once the condylar segment has been mobilized, the medial ptery-
goid muscle is stripped from the inferior aspect of the segment. The
mandible is then immobilized with maxillomandibular fixation.
Although the surgery is simple, there is a period of fixation for 2 to
3 weeks followed by training elastics so that the occlusion is
maintained.
The most significant potential complication of the modified
condylotomy of the mandible is excessive condylar sag resulting
in malocclusion. Hall reported a complication rate of only 4%,
primarily minor occlusal discrepancies.
The reported outcomes have been excellent. Hall reported
good pain relief in about 90% of 400 patients treated over a
9-year period. In follow-up studies, a 94% success rate for reduc-
tion in patients with disc displacement has been reported.
Interestingly, 72% of those patients had normal disc position when
evaluated with follow-up MRI studies. The success rate in a group
of patients with disc displacement without reduction was slightly
less at 88%.
Despite the simplicity of the procedure and its high success rate,
it has not become widely used. The reasons for this are unclear but
are most likely related to the necessity for maxillomandibular fixa-
tion and fear of excessive condylar sag resulting in an unstable
occlusion.
OPEN JOINT SURGERY
Open TMJ surgery is the most controversial procedure performed
in the TMJ because the outcomes are somewhat unpredictable and
open joint surgery has significant potential complications. Open
joint surgery is recommended for patients with internal derangement
and osteoarthritis who have failed to respond to simpler surgical
procedures or have failed previous open surgery. In patients with
previous surgery, the surgeon must be hesitant to perform repeated
surgery because the success rate is very low; in fact, after two sur-
geries it may approach zero. The surgeon must be very certain that
the source of the pain or dysfunction is arising from within the joint.
Severe mechanical interference such as loud, hard clicking with or
without intermittent locking is an indication to perform open surgery
without performing simpler procedures because experience indi-
cates that simpler procedures are rarely successful in these cases.
Open TMJ surgery provides the surgeon with an unlimited scope of
procedures ranging from simple lavage and débridement to complete
removal of the disc.
Open joint surgery is performed under general anesthesia in the
hospital and usually requires a 1- to 2-day stay. The most common
surgical approach is via a preauricular endaural incision. Other
approaches include the standard preauricular and postauricular inci-
sions. Surgical access to the joint is essentially the same regardless
of the site of incision. Exposure of the capsule is performed carefully
by using a modified Al-Kayat Bramley approach through the tem-
poral fascia to protect the temporal branches of the facial nerve.
After exposure of the capsule, the upper joint space is entered, and
it is inspected for the presence of adhesions. The contour and integ-
rity of the fossa and eminence are evaluated, and finally, the disc is
visualized. Evaluation of the disc includes assessment of its color,
position, mobility, shape, and integrity. After this evaluation of the
hard and soft tissues of the joint, a decision is made to either reposi-
tion the disc or remove it.
865
Disc Repositioning
If the disc is intact and can be repositioned without tension, disc
repositioning can be performed by removing excess tissue from the
superior aspect of the posterior attachment tissues. The lower joint
space is not usually entered. The disc is then repositioned and sta-
bilized with sutures. Preoperative MRI of the joint can be useful in
evaluating the status of the disc. Disc repositioning is usually per-
formed in patients with Wilkes II or III internal derangements. Bone
recontouring of the glenoid fossa or articular eminence (or both) is
generally performed, especially in patients with gross mechanical
interference. Frequently, the lateral aspect of the articular eminence
is very prominent and needs to be reduced. The goal of disc-
repositioning surgery is to eliminate mechanical interference to
smooth joint function. After completion of the intra-articular proce-
dures, the soft tissues are closed.
Immediately after surgery, the patient may experience swelling
in front of the ear and a slight change in occlusion with limited
mouth opening. The swelling and change in occlusion resolve in
about 2 weeks. Range-of-motion exercises are started immediately
and continued until the patient no longer has morning joint stiffness.
All patients experience numbness in front of the ear, which resolves
in about 6 weeks. Patients normally have moderate discomfort that
lasts about 1 to 2 weeks. The most significant complication associ-
ated with open surgery is injury to the facial nerve. Even though
total facial nerve paralysis is possible, it is rare. An inability to raise
the eyebrow is the most commonly observed finding and occurs in
about 5% of patients. It generally resolves in about 3 months. A soft
diet is recommended for 3 months.
The literature indicates that disc-repositioning surgery is success-
ful in 80-95% of cases; however, experience indicates that this may
be an overestimate. Dolwick and Nitzan evaluated 152 patients who
underwent TMJ disc-repositioning surgery over a 9-year period
between 1980 and 1988 and found a 70-80% rate of improvement
in about 90% of the patients up to an 8-year follow-up period.
Unfortunately, 5.3% reported that they were worse following
surgery. Furthermore, it was also found that the majority of those
who did report improvement after surgery continued to experience
symptoms of pain, joint noise, and decreased range of motion,
though to a far lesser extent than before surgery. Abramowicz
reported a 20-year follow-up study on 20 patients from the Dolwick
and Nitzan report. All 20 patients were doing well, but most reported
some symptoms of pain and decreased range of motion. With
MRI, Montgomery evaluated 51 subjects up to 6 years after disc-
repositioning surgery and found that disc position was not main-
tained. Despite this finding, most patients were significantly
improved, thus confirming that preservation of a healthy, freely
mobile disc is justified.
Discectomy
A diseased or deformed disc that interferes with smooth function of
the joint and cannot be repositioned should be removed. Only the
portion of the disc that is diseased and deformed needs to be
removed. The synovial tissues should be preserved as much as pos-
sible. After removal of the disc, just minimal bone recontouring
should be performed. Exposure of bone marrow may result in
heterotopic bone formation. To minimize the risk for heterotopic
bone formation, placement of an interpositional fat graft into the
joint space is recommended. The fat graft fills the space created by
removal of the disc and prevents the formation of a hematoma. After
completion of the intra-articular procedures, the joint space is irri-
gated and the soft tissues are closed.
866 Current Therapy in Oral and Maxillofacial Surgery

The postoperative findings are the same after discectomy as

described for disc repositioning. The postoperative recommenda-
tions are also the same except that a soft diet is recommended for
6 months.
The complications associated with discectomy are similar to
those seen with disc repositioning. Growth of heterotopic bone is
more common after discectomy than after other TMJ surgical pro-
cedures. This can be a significant complication that results in anky-
losis. Occasionally, degeneration of the condyle may occur and
result in malocclusion. The frequency of occurrence of heterotopic
bone formation and condylar resorption is unclear.
Long-term follow-up data on discectomy procedures have been
published. There are four studies with at least 30 years’ follow-up
in which excellent reduction in pain and improvement of function
in most patients have been reported. Bjorland and Larhein found
that 10 years after discectomy, 19 of 24 patients reported no pain
and had an average mandibular opening of 41.7 mm.
Postoperative imaging studies of patients after discectomy gener-
ally show changes in condylar morphology. These changes are
thought to be adaptive and not degenerative. Most patients will have
crepitant joint noise after discectomy.
PEARLS AND PITFALLS
• Surgery on the TMJ continues to have a small but important role
in the management of specific temporomandibular disorders.
• Appropriate case selection is a mandatory requirement for surgi-
cal intervention to achieve a successful outcome.
• Past problems with TMJ surgery have been related to indiscrimi-
nant aggressive intervention. With the introduction of less 
invasive surgical techniques, successful outcomes are more 
predictable and complications are less likely to occur.
• Surgery on the TMJ is best performed by surgeons who maintain
the philosophy that surgery should aim to avoid further harm to
the joint and err on the side of more conservative procedures.
The benefits and limitations of each surgical procedure are
readily determined on an individual case basis.
• The goal is to determine the most appropriate technique that 
will yield the highest probability of success with the lowest
morbidity.
• Surgeons should acquaint themselves with the benefits derived
from surgery and always keep in mind that a team approach to
the management of patients with pain or dysfunction and careful
case selection are the most important ingredients for a successful
outcome.

BIBLIOGRAPHY
Abramowicz S, Dolwick MF: Twenty-year
follow-up study of disc repositioning surgery
for temporomandibular joint internal derange-
ment, J Oral Maxillofac Surg 68:239-242,
2010.
Al-Belasy FA, Dolwick MF: Arthrocentesis for
the treatment of temporomandibular joint
closed lock: a review article, Int J Oral
Maxillofac Surg 36:773-782, 2007.
Alpaslan GH, Alpaslan C: Efficacy of temporo-
mandibular joint arthrocentesis with and
without injection of sodium hyaluronate in
treatment of internal derangements, J Oral
Maxillofac Surg 59:613-618, 2001.
Auerbach SM, Laskin DM, Frantsue LM, et al:
Depression, pain, exposure to stressful life
events, and long-term outcomes in temporo-
mandibular disorder patients, J Oral Maxillofac
Surg 59:628-633, 2001.
Bjørnland T, Larheim TA: Discectomy of the tem-
poromandibular joint: 3-year follow-up as a
predictor of the 10-year outcome, J Oral
Maxillofac Surg 61(1):55-60, 2003.
Blake DR, Merry P, Unsworth J, et al: Hypoxic-
reperfusion injury in the inflamed human joint,
Lancet 1:289-293, 1989.
Boering G: Temporomandibular joint arthrosis:
an analysis of 400 cases, Leiden, 1966,
Stafleu.
Boyd RL, Gibbs CH, Mahan PE, et al:
Temporomandibular joint forces measured at
the condyle of Macaca arctoides, Am J Orthod
Dentofacial Orthop 7:472-479, 1990.
Brooks SL, Westesson PL, Erickson L, et al:
Prevalence of osseous changes in the temporo-
mandibular joint of asymptomatic persons
without internal derangement, Oral Surg Oral
Med Oral Pathol 3:118-122, 1992.
Carlsson GE: Long-term effects of treatment of
craniomandibular disorders, Cranio 3:337-
342, 1985.
Carlsson GE, Egermark I, Magnusson T: Predictors
of bruxism, other oral parafunction, and tooth
wear over a 20-year follow-up period, J Orofac
Pain 17:50-57, 2003.
Carvajal WA, Laskin DM: Long-term evaluation
of arthrocentesis for the treatment of internal
derangements of the temporomandibular
joint, J Oral Maxillofac Surg 58:852-855,
2000.
Clark GT: A critical evaluation of orthopedic
interocclusal appliance therapy: design, theory
and overall effectiveness, J Am Dent Assoc
108:359-364, 1984.
Conti PC, dos Santos CN, Koqawa EM, et al: The
treatment of painful temporomandibular joint
clicking with oral splints: a randomized clini-
cal trial, J Am Dent Assoc 137:1108-1114,
2006.
Dahlstrom L: Conservative treatment in cranio-
mandibular disorder, Swed Dent J 16:217-230,
1992.
de Bont LG, Boering G, Liam RS, et al:
Osteoarthritis and internal derangement of the
temporomandibular joint: a light microscopic
study, J Oral Maxillofac Surg 44:634-643,
1986.
de Leeuw R, Boering G, Stegenga B, et al: Clinical
signs of TMJ osteoarthrosis and internal
derangement 30 years after nonsurgical treat-
ment, J Orofac Pain 8:18-24, 1994.
de Leeuw R, Boering G, Stegenga B, et al:
Symptoms of temporomandibular joint osteo-
arthrosis and internal derangement 30 years
after non-surgical treatment, Cranio 13:81-88,
1995.
de Leeuw R, Boering G, Stegenga B, et al:
Radiographic signs of temporomandibular
joint osteoarthrosis and internal derangement
30 years after nonsurgical treatment, Oral Surg
Oral Med Oral Pathol Oral Radiol Endod
79:382-392, 1995.
de Leeuw R, Boering G, Van der Kuijl B, et al:
Hard and soft tissue imaging of the temporo-
mandibular joint 30 years after diagnosis of
osteoarthrosis and internal derangement, J
Oral Maxillofac Surg 54:1270-1280, 1996.
Dimitroulis G: The role of surgery in the manage-
ment of disorders of the temporomandibular
joint: a critical review of the literature; Part 1,
Int J Oral Maxillofac Surg 34:107-113, 2005.
Dimitroulis G: The role of surgery in the manage-
ment of disorders of the temporomandibular
joint: a critical review of the literature; Part 2,
Int J Oral Maxillofac Surg 34:231-273,
2005.
Dimitroulis G, Dolwick MF, Martinez A:
Temporomandibular joint arthrocentesis and
lavage for the treatment of closed lock: a
follow-up study, Br J Oral Maxillofac Surg
33:23-37, 1995.
Dimitroulis G, McCullough M, Morrison W:
Quality of life survey of patients prior to and
following temporomandibular joint discec-
tomy, J Oral Maxillofac Surg 68:101-106,
2010.
Dolwick MF: Clinical diagnosis of temporoman-
dibular joint internal derangement and myo-
fascial pain and dysfunction, Oral Maxillofac
Surg Clin North Am 1:1-6, 1989.
Dolwick MF: Intra-articular disc displacement
part 1: its questionable role in temporoman-
dibular joint pathology, J Oral Maxillofac Surg
53:1069-1072, 1995.
Dolwick MF: The role of temporomandibular
joint surgery in the treatment of patients with
internal derangement, Oral Surg Oral Med
Oral Pathol Oral Radiolol Endod 83:150-155,
1997.
Dolwick MF: Disc preservation surgery for the
treatment of internal derangements of the tem-
poromandibular joints, J Oral Maxillofac Surg
59:1047-1050, 2001.
 Diagnosis and Management of Temporomandibular Joint Pain and Masticatory Dysfunction
Dolwick MF: Temporomandibular joint surgery
for internal derangement, Dent Clin North Am
51:195-208, 2007.
Dolwick MF, Aufdemorte TB: Silicone induced
foreign-body reaction and lymphadenopathy
after temporomandibular joint arthroplasty,
Oral Surg Oral Med Oral Pathol 59:449-452,
1985.
Dolwick MF, Dimitroulis G: Is there a role for
temporomandibular joint surgery? Br J Oral
Maxillofac Surg 32:307-313, 1994.
Dolwick MF, Dimitroulis G: A re-evaluation of
the importance of disc position in temporo-
mandibular disorders, Aust Dent J 41:184-187,
1996.
Dolwick MF, Katzberg RW, Helms CA: Internal
derangement of the temporomandibular joint:
fact or fiction? J Prosthet Dent 49:415-418,
1983.
Dolwick MF, Katzberg RW, Helms CA, et al:
Arthrotomographic evaluation of the temporo-
mandibular joint, J Oral Surg 37:793-799,
1979.
Dolwick MF, Nitzan DW: TMJ disk surgery:
8-year follow-up evaluation, Fortschr Kiefer
Gesichtschir 35:162-167, 1990.
Dolwick MF, Riggs RR: Diagnosis and treatment
of internal derangements of the temporoman-
dibular joint, Dent Clin North Am 27:561-572,
1983.
Dolwick MF, Sanders B: TMJ internal derange-
ment and arthrosis—surgical atlas, St Louis,
1985, CV Mosby.
Dworkin SF, LeResche L: Research diagnostic
criteria for temporomandibular disorders:
review, criteria, examinations and specifica-
tions, critique, J Craniomandib Disord 6:301-
355, 1992.
Emshoff R, Brandlmaier I, Bertram S, et al:
Relative odds of temporomandibular joint pain
as function of magnetic resonance imaging
findings of internal derangement, osteoarthro-
sis, effusion, and bone marrow edema, Oral
Surg Oral Med Oral Pathol Oral Radiol
Endod 95:437-445, 2003.
Emshoff R, Puffer P, Strobl H, et al: Effect of
temporomandibular joint arthrocentesis on
synovial fluid mediator level of tumor necrosis
factor-alpha: implications for treatment
outcome, Int J Oral Maxillofac Surg 29:176-
182, 2000.
Emshoff R, Rudisch A, Bosch R, et al: Effect of
arthrocentesis and hydraulic distention on the
temporomandibular joint disk position, Oral
Surg Oral Med Oral Pathol Oral Radiol
Endod 89:271-277, 2000.
Emshoff R, Rudisch A, Bosch R, et al: Prognostic
indicators of the outcome of arthrocentesis: a
short-term follow-up study, Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 96:12-18,
2003.
Ericksson L, Westesson PL: Long-term evaluation
of meniscectomy of the temporomandibular
joint, J Oral Maxillofac Surg 43:263-269,
1985.
Ericksson L, Westesson PL: Temporomandibular
joint discectomy, Oral Surg Oral Med Oral
Pathol 74:259-272, 1992.
Farrar WB: Diagnosis and treatment of anterior
dislocation of articular disc, N Y J Dent
41:348-351, 1971.
Farrar WB, McCarty WL: Inferior joint space
arthrography and characteristics of condylar
paths in internal derangements of TMJ, J
Prosthet Dent 41:458-463, 1971.
Feinberg SE: Use of composite temporalis muscle
flaps for disc replacement, Oral Maxillofac
Surg Clin North Am 6:335-337, 1994.
Fridrich KL, Wise JM, Zeitler DL: Prospective
comparison of arthroscopy and arthrocentesis
for temporomandibular joint disorders, J Oral
Maxillofac Surg 54:816-820, 1996.
Goudot P, Jaquinet AR, Hugonnet S, et al:
Improvement of pain and function after
arthroscopy and arthrocentesis of the tem­
poromandibular joint: a comparative study,
Craniomaxillofac Surg 28:39-43, 2000.
Greene CS, Laskin DM: Long-term status of TMJ
clicking in patients with myofascial pain and
dysfunction, J Am Dent Assoc 117:461-465,
1988.
Hall MB: Meniscoplasty of the displaced tem-
poromandibular joint meniscus without violat-
ing the inferior joint space, J Oral Maxillofac
Surg 42:788-792, 1984.
Hall HD: The role of discectomy for treating inter-
nal derangements of the temporomandibular
joint, Oral Maxillofac Surg Clin North Am
6:287-294, 1994.
Hall HD, Indresano AT, Kirk WS, et al: Prospective
multicenter comparison of 4 temporomandibu-
lar joint operations, J Oral Maxillofac Surg
63:1174-1179, 2005.
Hall HD, Link JL: Diskectomy alone and with ear
cartilage interposition grafts in joint recon-
struction, Oral Maxillofac Surg Clin North Am
1:32-40, 1989.
Hall HD, Navarro EZ, Gibbs SJ: One-and three-
year prospective outcome study of modified
condylotomy for treatment of reducing disc
displacement, J Oral Maxillofac Surg 58:7-17,
2000.
Hall HD, Navarro EZ, Gibbs SJ: Prospective
study of modified condylotomy for treatment
on nonreducing disk displacement, Oral Surg
Oral Med Oral Pathol Oral Radiol Endod
89:147-158, 2000.
Hall HD, Nickerson JW: Is it time to pay more
attention to disc position? J Orofac Pain 8:90-
95, 1994.
Hall HD, Nickerson JW, McKenna SJ: Modified
condylotomy for treatment of the painful
temporomandibular joint with a reducing
disc, J Oral Maxillofac Surg 51:133-142,
1993.
Haskin CL, Milam SB, Cameron IL: Pathogenesis
of degenerative joint disease in the human
temporomandibular joint, Crit Rev Oral Biol
Med 6:248-277, 1995.
Henny FA, Baldridge OL: Condylectomy for the
persistently painful temporomandibular joint,
J Oral Surg 15:24-27, 1957.
Holmlund AB: Surgery for TMJ internal derange-
ment: evaluation of treatment outcomes and
criteria for success, Int J Oral Maxillofac Surg
22:75-77, 1993.
867
Holmlund AB, Gynther GW, Axelsson S:
Diskectomy in treatment of internal derange-
ment of the temporomandibular joint.
Follow-up at 1, 3 and 5 years, Oral Surg Oral
Med Oral Pathol 76:266-271, 1993.
Holmlund AB, Gynther GW, Axelsson S: Efficacy
of arthroscopic lysis and lavage in patients
with chronic locking of temporomandibular
joint, Int J Oral Maxillofac Surg 23:262-265,
1994.
Huang YL, Pogrel A, Kaban LB: Diagnosis and
management of condylar resorption, J Oral
Maxillofac Surg 55:114-119, 1997.
Indresano AT: Surgical arthroscopy as the pre-
ferred treatment for internal derangements of
the temporomandibular joint, J Oral Maxillofac
Surg 59:308-312, 2001.
Ireland VE: The problem of the clicking jaw, J
Prosthet Dent 3:200-203, 1953.
Israel HA: Current concepts in the surgical man-
agement of temporomandibular joint disor-
ders, J Oral Maxillofac Surg 52:289-294,
1994.
Israel HA: The use of arthroscopic surgery for the
treatment of temporomandibular joint disor-
ders, J Oral Maxillofac Surg 57:579-582,
1999.
Katzberg RW, Dolwick MF, Helms CA, et al:
Arthrotomography of the temporomandibular
joint, AJR Am J Roetgenol 134:995-1003,
1980.
Kendell BD, Frost DE: Arthrocentesis, Atlas Oral
Maxillofac Surg Clin North Am 4:1-14, 1996.
Kiehn CL: Meniscectomy for internal derange-
ment of the temporomandibular joint, Am J
Surg 83:364-373, 1952.
Kircos LT, Ortendahl DA, Mark AS, et al:
Magnetic resonance imaging of the TMJ disc
in asymptomatic volunteers, J Oral Maxillofac
Surg 45:852-854, 1987.
Koslin MG, Martin JC: The use of holmium laser
for temporomandibular joint arthroscopic
surgery, J Oral Maxillofac Surg 51:122-124,
1993.
Kozeniauskas JJ, Ralph WJ: Bilateral arthro-
graphic evaluation of unilateral temporoman-
dibular joint pain and dysfunction, J Prosthet
Dent 60:98-105, 1988.
Kurita H, Uehara S, Yokochi, et al: A long-term
follow-up study of radiographically evident
degenerative changes in the temporomandi­
bular joint with different conditions of disk
displacement, Int J Oral Maxillofac Surg
35:49-54, 2006.
Kurita H, Westesson PL, Yuasa H, et al: Natural
course of untreated symptomatic temporoman-
dibular joint disc displacement without reduc-
tion, J Dent Res 77:361-365, 1998.
Lanz AB: Discitis mandibularis, Zentralbl Chir
36:289-291, 1909.
Larheim TA: Role of magnetic resonance imaging
in the clinical diagnosis of the temporoman-
dibular joint, Cells Tissues Organs 180:6-21,
2005.
Larheim TA, Westesson P, Sano T: Tempo­
romandibular joint disk displacement: com-
parison in asymptomatic volunteers and
patients, Radiology 218:428-432, 2001.
868 Current Therapy in Oral and Maxillofacial Surgery
Laskin DM: Etiology of the pain and dysfunction
syndrome, J Am Dent Assoc 79:147-150, 1969.
Lewis EL, Dolwick MF, Abramowicz S, et al:
Contemporary imaging of the temporoman-
dibular joint, Dent Clin North Am 52:875-890,
2008.
McCain JP: Arthroscopy of the human temporo-
mandibular joint, J Oral Maxillofac Surg
46:648-652, 1988.
McCain JP, de la Rua H: Principles and practice
of operative arthroscopy of the human tem-
poromandibular joint, Oral Maxillofac Surg
Clin North Am 1:135-152, 1989.
McCain JP, Podrasky AE, Zabiegalski NA:
Arthroscopic disc repositioning and suturing:
a preliminary report, J Oral Maxillofac Surg
50:568-573, 1992.
McCain JP, Sanders B, Koslin MG, et al:
Temporomandibular joint arthroscopy—a
6-year multicenter retrospective study of 4831
joints, J Oral Maxillofac Surg 50:926-930,
1992.
McCarty WL, Farrar WB: Surgery for internal
derangement of the temporomandibular joint,
J Prosthet Dent 42:191-196, 1979.
McKenna SJ: Discectomy for the treatment of
internal derangements of the temporomandib-
ular joint, J Oral Maxillofac Surg 59:1051-
1056, 2001.
Mejersjo C, Carlsson GE: Long term results
of treatment for temporomandibular pain-
dysfunction, J Prosthet Dent 49:809-815,
1983.
Mercuri LG: The use of alloplastic prostheses
for temporomandibular joint reconstruction,
J Oral Maxillofac Surg 58:70-75, 2000.
Merrill RG: Historical perspectives and compari-
sons of temporomandibular joint surgery for
internal derangements and arthropathy, Cranio
4:74-78, 1986.
Milam SB, Schmitz JP: Molecular biology of tem-
poromandibular joint disorders: proposed
mechanisms of disease, J Oral Maxillofac
Surg 53:1448-1454, 1995.
Montgomery MT, Gordon SM, Van Sickels JE,
et al: Changes in signs and symptoms follow-
ing temporomandibular joint disc reposition-
ing surgery, J Oral Maxillofac Surg 50:320-328,
1992.
Moses JJ, Poker I: TMJ arthroscopic surgery: an
analysis of 237 patients, J Oral Maxillofac
Surg 47:790-794, 1989.
Murakami KI, Iizuka T, Matsuki M, et al:
Recapturing the persistent anteriorly displaced
disk by mandibular manipulation after
pumping and applying hydraulic pressure to
the upper joint cavity of the temporomandibu-
lar joint, Cranio 5:17-24, 1987.
Murakami KI, Segami N, Okamoto M, et al:
Outcome of arthroscopic surgery for internal
derangement of the temporomandibular joint:
long-term results covering 10 years, J
Craniomaxillofac Surg 28:264-271, 2000.
Murakami KI, Tsuboi Y, Bessho K, et al: Outcome
of arthroscopic surgery to the temporoman-
dibular joint correlates with stage of internal
derangement: five-year follow-up study, Br J
Oral Maxillofac Surg 36:30-34, 1998.
Nickerson JW: Natural course of osteoarthrosis as
it relates to internal derangement of the tem-
poromandibular joint, Oral Maxillofac Surg
Clin North Am 1:27-46, 1989.
Nitzan DW: The process of lubrication impair-
ment and its involvement in temporomandi­
bular joint disc displacement: a theoretical
concept, J Oral Maxillofac Surg 59:36-45,
2001.
Nitzan DW, Dolwick MF: An alternative explana-
tion for the genesis of closed-lock symptoms
in the internal derangement process, J Oral
Maxillofac Surg 48:810-815, 1991.
Nitzan DW, Dolwick MF, Heft MW: Arthroscopic
lavage and lysis of the temporomandibular
joint: a change in perspective, J Oral
Maxillofac Surg 48:798-801, 1990.
Nitzan DW, Dolwick MF, Martinez GA:
Temporomandibular joint arthrocentesis: a
simplified treatment for severe limited mouth
opening, J Oral Maxillofac Surg 49:1163-
1167, 1991.
Nitzan DW, Nitzan U, Dan P, et al: The role of
hyaluronic acid in protecting surface-active
phospholipids from lysis by exogenous phos-
pholipase A(2), Rheumatology 40:336-340,
2001.
Nitzan DW, Price A: The use of arthrocentesis for
the treatment of osteoarthritic temporoman-
dibular joints, J Oral Maxillofac Surg 59:1154-
1159, 2001.
Nitzan DW, Samson, Better H: Long-term
outcome of arthrocentesis for sudden-onset,
persistent, severe closed lock of the temporo-
mandibular joint, J Oral Maxillofac Surg
55:151-157, 1997.
Ohnishi M: [Arthroscopy of the temporomandibu-
lar joint,] J Jpn Stomat 42:207-212, 1975.
Ohnishi M: Arthroscopic laser surgery and sutur-
ing for temporomandibular disorders. Tech­
niques and clinical results, Arthroscopy 7:
212-216, 1991.
Pringle JH: Displacement of the mandibular
meniscus and its treatment, Br J Surg 6:385-
388, 1918.
Quinn PD: Alloplastic reconstruction of the tem-
poromandibular joint, Selected Readings Oral
Maxillofac Surg 7:1, 2000.
Rasmussen OC: Description of population and
progress of symptoms in a longitudinal study
of temporomandibular arthropathy, J Dent Res
89:196-203, 1981.
Reston JT, Turkelson CM: Meta-analysis of surgi-
cal treatments for temporomandibular articular
disorders, J Oral Maxillofac Surg 61:3-10,
2003.
Sanders B: Arthroscopic surgery of the tempo­
romandibular joint: Treatment of internal
derangement with persistent closed lock,
Oral Surg Oral Med Oral Pathol 62:361-372,
1986.
Sato S, Goto S, Kawamura H, et al: The natural
course of nonreducing disc displacement of the
TMJ: relationship of clinical findings at initial
visit to outcome after 12 months without treat-
ment, J Orofac Pain 11:315-320, 1997.
Sato S, Goto S, Nasu F, et al: Natural course of
disc displacement with reduction of temporo-
mandibular joint: changes in clinical signs and
symptoms, J Oral Maxillofac Surg 61:32-34,
2003.
Schiffman EL, Look JO, Hodges JS, et al:
Randomized effectiveness study of four thera-
peutic strategies for TMJ closed lock, J Dent
Res 86:58-63, 2007.
Schwartz LJ: Pain associated with the TMJ, J Am
Dent Assoc 51:394-398, 1955.
Silver CML: Long-term results of meniscectomy
of the temporomandibular joint, Cranio 3:46-
57, 1984.
Stengenga B, de Bont LGM, Boering G, et al:
Tissue responses to degenerative changes in
the temporomandibular joint, J Oral Maxillofac
Surg 49:1079-1088, 1991.
Takaku S, Toyoda T: Long-term evaluation of
discectomy of the temporomandibular joint,
J Oral Maxillofac Surg 52:722-726, 1994.
Thilander B: Innervation of the temporomandibu-
lar disc in man, Acta Odontol Scand 22:151-
156, 1964.
Toller PA: Osteoarthritis of the mandibular
condyle, Br Dent J 134:223-231, 1973.
Tolvanen M, Oikarinen VJ, Wolf J: A 30 year
follow-up study of temporomandibular joint
meniscectomies: a report on five patients,
Br J Oral Maxillofac Surg 26:311-313, 1988.
Undt G, Murakami I, Rasse M, et al: Open versus
arthroscopic surgery for internal derangement
of the temporomandibular joint: a retrospec-
tive study comparing two centres’ results using
the Jaw Pain and Function Questionnaire,
J Craniomaxillofac Surg 34:234-241, 2006.
Westesson PL: Arthrography of the temporoman-
dibular joint, J Prosthet Dent 51:535-540,
1984.
Westesson PL, Rohlin M: Internal derangement
related to osteoarthrosis in temporomandibular
joint autopsy specimens, Oral Surg Oral Med
Oral Pathol 57:17-22, 1984.
Wilkes C: Internal derangement of the TMJ, Arch
Otolaryngol Head Neck Surg 115:469-474,
1989.