YIJOM-3474; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2016.07.010, available online at http://www.sciencedirect.com

Randomised Controlled Trial

TMJ Disorders

Effect of an early supervised N. Capan1, S. Esmaeilzadeh1,

A. Karan1, D. Dıracoglu1, U. Emekli2,
A. Yıldız1, A. Baskent1, C. Aksoy1

rehabilitation programme
1
Department of Physical Medicine and
Rehabilitation, Istanbul University, Istanbul
Faculty of Medicine, Istanbul, Turkey;
2
Department of Plastic, Reconstructive and

compared with home-based Aesthetic Surgery, Istanbul University,

Istanbul Faculty of Medicine, Istanbul, Turkey

exercise after
temporomandibular joint
condylar discopexy: a
randomized controlled trial
N. Capan, S. Esmaeilzadeh, A. Karan, D. Dıracoglu, U. Emekli, A. Yıldız, A.
Baskent, C. Aksoy: Effect of an early supervised rehabilitation programme compared
with home-based exercise after temporomandibular joint condylar discopexy: a
randomized controlled trial. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. #
2016 Published by Elsevier Ltd on behalf of International Association of Oral and
Maxillofacial Surgeons.

Abstract. The goal of rehabilitation after temporomandibular joint (TMJ) surgery is to

achieve a normal range of motion. The aim of this study was to compare the impact
of a comprehensive and early supervised rehabilitation programme with home-
based exercise after TMJ condylar discopexy. Patients diagnosed with disc
displacement without reduction were randomized to the study and control groups.
After baseline assessments, the same surgical condylar discopexy procedure was
applied to both groups. Following surgery, the study group patients underwent a
supervised exercise programme conducted by a physiotherapist in the outpatient
clinic. This comprised 30-min sessions 3 days per week for 8 weeks in the hospital.
The control group patients performed the same exercise programme at home.
Maximum mouth opening (MMO), protrusion, and right and left lateral movements
were measured. Based on the results, the supervised rehabilitation programme
yielded significantly better outcomes for pain at rest and with activity, MMO, and
protrusion compared with the home-based exercise programme. Also certain
parameters of quality of life improved significantly in the study group. In
conclusion, exercise therapy is the cornerstone of rehabilitation of the TMJ, and a

0901-5027/000001+08 # 2016 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.

Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
YIJOM-3474; No of Pages 8
2 Capan et al.
supervised rehabilitation programme after TMJ surgery is effective in improving
functional parameters.
The main symptoms and dysfunctions re-
lated to temporomandibular disorders
(TMDs) are associated with altered con-
dyle–disc function. Temporomandibular
joint (TMJ) disc displacement without
reduction (DDw/oR) is commonly seen
in TMDs. Disc displacement can only
occur in the intercuspal occlusal position
(disc displacement with reduction (DDw/
R)) or during condylar movements when
opening the mouth (DDw/oR).1
The newly recommended Research Di-
agnostic Criteria (RDC) for TMDs have
been demonstrated to be valid for the most
common pain-related TMDs and for TMJ
intra-articular disorders.2 TMDs are con-
sidered the most frequent causes of chron-
ic orofacial pain.3 Disc displacement is a
clinical condition in which the disc is
dislocated from the condyle, most fre-
quently anteromedially, and does not re-
turn to its normal position with condylar
movement. Macrotrauma and micro-
trauma are the most common causes of
DDw/oR.1
The majority of patients with TMDs can
be treated successfully with conservative
non-surgical therapies, and surgical inter-
ventions are required for only a small
proportion of the TMD population. All
non-surgical treatment options must be
exhausted before invasive methods are
undertaken for the management of TMDs.
Conservative treatment consists of medi-
cation, physical therapy, occlusal splints,
manipulation, and intra-articular injec-
tions (hyaluronic acid, corticosteroids,
prolotherapy, or irrigation with saline).4
The success of conservative treatment is
reported to be above 80%. Symptoms
typically resolve within 2–4 weeks in
50% of patients, and a surgical interven-
tion is required in only 5%.5 When symp-
toms begin, arthroscopy, lysis and lavage,
and injections may be effective for estab-
lishing normal maximum mouth opening
(MMO) and pain relief.6–8 Procedures that
are sometimes used to correct minor dis-
orders include condylar discopexy, emi-
nectomy, and arthroplasty. In severe cases
where there is irreversible resorption and
joint degeneration, prosthetic TMJ devices
can be the best choice.9,10
Mitek (DePuy Mitek, Raynham, MA,
USA) has developed an anchor system for
attaching soft tissues to bone in ligament
Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
repair, which is used in orthopaedic sur-
gery. This system has a cylindrical titani-
um body with two wings. Dr L. M.
Wolford in Dallas, Texas, has adapted this
system for repositioning the TMJ disc.11,12
After condylar discopexy, physiothera-
py is an essential part of the treatment for
an effective MMO. Physiotherapy pre-
vents hypomobility and ankylosis and
must include TMJ opening and closing
exercises. There are many benefits to the
use of a physiotherapy rehabilitation pro-
gramme starting within the first 24 h after
surgery, not least its important role in
preventing the formation of abnormal fi-
brous tissue. Successful outcomes of ap-
propriate postoperative rehabilitation
programmes conducted after TMJ surgery
have been reported in terms of pain relief,
the restoration of joint function, and pro-
tection against harmful injury. Exercises
can improve muscle vascularity, increase
muscle mass and protein metabolism, de-
crease muscle fatigability, and increase
strength. If the exercise programme is
performed regularly, the reversal of atro-
phic and degenerative changes within the
joints and restoration of the normal anato-
my of the internal fibrous structure can be
achieved.13–15
The aim of this study was to investigate
the impact of a comprehensive and multi-
component early supervised rehabilitation
programme in comparison with home-
based exercise after TMJ condylar disco-
pexy, and to determine the effect on man-
dibular movements and patient quality of
life (QOL).
Materials and methods
Study design and patient evaluation
The current study was a prospective, ran-
domized, controlled interventional trial,
which was conducted in the Department
of Physical Medicine and Rehabilitation
of Istanbul University Istanbul Faculty of
Medicine, Turkey. All patients were in-
formed of the type and purpose of the
diagnostic procedures and had given their
written consent for participation and the
execution of the study. The study was
approved by the Ethics Committee in con-
formity with the Declaration of Helsinki.
Keywords: temporomandibular disorders; con-
dylar discopexy; rehabilitation.
Accepted for publication 29 July 2016
The study inclusion and exclusion criteria
are listed in Table 1.
The diagnosis of DDw/oR was based on
magnetic resonance imaging (MRI) to
confirm the clinical diagnosis and a com-
prehensive examination of TMJ move-
ments.
Forty consecutive patients, who were
referred to the TMJ unit, were studied.
Eligible participants were allocated ran-
domly to one of two groups in the order of
their presentation to the outpatient clinics,
using computer-generated random num-
bers. The participant flow chart and study
profile are shown in Fig. 1.
It is necessary to provide some motiva-
tion for patients with TMDs to perform
exercises consistently. Both the study and
the control group were informed prior to
undergoing surgery about exercises and
diet, and their clinical importance during
rehabilitation.
Table 1. Study inclusion and exclusion crite-
ria.
Inclusion criteria
1. Clinical diagnosis of temporomandibular
DDw/oR
a. History of reduction in mandibular
opening >6 months
b. Unassisted mandibular opening 35 mm
c. TMJ pain (VAS >5 cm)
d. Deflection of the mandibular opening
pathway to the ipsilateral side
e. Restrictions in lateral movements of the
ipsilateral side
f. No longer present joint sounds
2. MRI diagnosis of DDw/oR
3. Despite all conventional conservative
treatment methods, have not received an
adequate response
4. No previous TMJ surgery
Exclusion criteria
1. Presence of other disorders involving the
TMJ (e.g., degenerative joint disease or
collagen vascular disease)
2. History of major jaw trauma
3. Dentofacial deformity
4. Psychiatric illness
5. Chronic headache
6. Inflammatory disorders
7. Bleeding disorders
8. Neurological disorders
DDw/oR, disc displacement without reduc-
tion; TMJ, temporomandibular joint; VAS,
visual analogue scale; MRI, magnetic reso-
nance imaging.
YIJOM-3474; No of Pages 8

Supervised rehabilitation vs. home-based exercise 3

Assessed for eligibility (n=50) The surgeon used a modified pre-auricular

incision to gain access to the TMJ. The disc
was freed and mobilized by blunt and sharp
Excluded (n=10)
• Not meeng inclusion criteria (n=7) dissection from the lateral, and mainly
• Declined to parcipate (n=3) anterior, ligamentous attachments, and
was observed to fit into its anatomical
Randomizaon (n=40) position. This step of the surgical operation
was carried out with great care to minimize
postsurgical adhesions. With the help of a
standard Mitek device, a 2  10-mm hole
was drilled in the posterior region of the
Intervenon Group; n=20 Control Group; n=20 head of the condyle, approximately 7–
9 mm below the top and slightly lateral
to the midsagittal plane of the condylar
Baseline Assessment head. The Mitek anchor with 2–0 Ethibond
(Duraon of symptoms, funconal parameters, quality of life, parafunconal habits) sutures was placed in the hole with the
inserter part of the device and secured in
Surgical Procedure the bone by locking. Sutures were then
placed through the posterior bands of the
disc and the tissues fixed by tying the
Ethibond sutures so that the disc was posi-
Intervenon Group; n=20 Control Group; n=20 tioned anatomically. After meticulous hae-
mostasis, the capsule, subcutaneous tissues,
Follow-up and skin were closed properly in layers.

Lost to follow-up (n=4) Lost to follow-up (n=5)

Unable to come to hospital for exercise (n=1)
Addional surgical procedure needed (n=3)
Intervenon Group (n=16)
Stascal Analysis
Fig. 1. Participant flow and study profile.
Demographic data (age, sex, body mass
index, current occupation) were obtained
at the baseline assessment. After the base-
line assessment, all patients underwent the
same surgical procedure.
For the study group, a supervised exer-
cise programme was applied after surgery
in the outpatient clinic by a physiothera-
pist. This comprised a 30-min session 3
days per week for 8 weeks in the hospital.
On the other days of the week, the patients
completed the programme at home in a 30-
min session each day. In the control group,
a home-based exercise programme was
applied and the exercises were reviewed
every 2 weeks. The control group per-
formed the exercises at home in a 30-
min session each day for 8 weeks.
Clinical evaluations were undertaken be-
fore surgery and at 2 months after surgery.
Outcome measurement
All patients underwent the same surgical
procedure (condylar discopexy). Function-
al parameters were the primary outcomes.
Had orthognathic surgery (n=1)
Addional surgical procedure needed (n=4)
Control Group; (n=15)
MMO, protrusion, and right and left lateral
movements were measured. The patient
was asked to open their mouth to the
maximum degree and MMO was measured
using a micrometer caliper. In addition,
patients were asked to rate their pain on
a 10-cm visual analogue scale (VAS), with
0 indicating no pain and 10 indicating
severe pain. Pain was evaluated at rest
and in active movement. The pressure–pain
thresholds at trigger points were also deter-
mined using algometric measurements for
the masseter and temporal muscles.
Patient QOL was assessed in terms of
feelings of depression, appetite, quality of
sleep, difficulty in chewing, effectiveness
at work, and nervous tension. These items
were scored according to the level of
impact from 0 to 4, where 0 = none,
1 = mild, 2 = moderate, 3 = bad, and
4 = severe.
Surgical treatment
All surgeries were performed under general
anaesthesia with nasotracheal intubation.
Postoperative follow-up
Both the study and control group patients
were discharged from hospital on average
24 h after surgery and were advised to take
a soft diet and to apply cold packs for 2–
4 min three times per day on the operated
site for a period of 1 week.
Starting immediately after the opera-
tion, a non-steroidal anti-inflammatory
drug, meloxicam 15 mg, was given orally
once a day and the patients were instructed
to take their medication for 2 weeks.
Physical therapy
Preoperative posture exercises, cold pack
application, and dietary practices, and
postoperative exercise training were given
to both the study and control group
patients. For the study group patients, a
supervised rehabilitation programme was
applied in the outpatient clinic. After sur-
gery, the exercise programme was con-
ducted by a physiotherapist, 3 days a
week for 8 weeks, in the hospital. The
patients were asked to do all of the exer-
cises at home three times per day. In the
first postoperative week, physical therapy
consisted of cold pack application, mas-
sage, rotation exercises (Fig. 2), and pos-
ture exercises. After the first postoperative
week, exercises other than translational
(rotation, active assisted self-stretching,
self-mobilization) were introduced. After
that, mandibular opening and closing exer-
cises and stimulation of MMO (by keeping
the mouth open at the widest range limit for
a few seconds) were initiated.

Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
YIJOM-3474; No of Pages 8
4 Capan et al.
Fig. 2. Active rotation exercises.
From the fourth postoperative week on-
wards, forced mouth opening exercises
were introduced with the use of wooden
spatulas inserted between the posterior
teeth. The proposed therapy was performed
Table 2. Postoperative physical therapy pro-
gramme for both groups.a
Between 1 and 7 days
Cold application: three times a day for 2–
4 min
Liquid diet
Posture exercises
Soft tissue massage: encouraged to apply
gentle massage to the painful areas regularly
three times a day for 5–10 min
Resting tongue position instruction
Controlled active rotation exercises: three
sessions per day, 20 times per session (Fig. 2)
A mouth-opening exercise until the
exercise causes slight pain: three sessions per
day, 20 times per session
Between 7 and 30 days
Moist heat applied to the symptomatic
muscle: three times a day for 20 min before
exercise programme
Soft tissue massage: three times a day for 5–
10 min
Massage: immediately after the hot pack
application, massage the masseter with both
hands from the top to the bottom, 24 times per
min
Soft diet
Posture exercises
Excluding translation, controlled rotational
movement exercises, active assistive self-
stretching, and self-mobilization
Between 4 and 6 weeks
Continue to pain control
Massage
Soft diet
Forced fully active exercise is given
Strengthening and endurance exercises
Active resistance exercise is added to the
opposite side to begin to shift towards the
mouth
Between 6 and 8 weeks
All of the above and co-ordination
exercises are recommended (exercises of
opening and closing the mouth slowly in front
of a mirror)
a a 2
The control group was recalled every 2
weeks for programme revision.
Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
independent samples t-test was used for
between-group comparisons with regard
to changes in variables. The significance
level was set at P < 0.05.
Results
Participant characteristics
Forty patients fulfilled the inclusion crite-
ria and were randomized by a computer
randomization programme. The mean du-
ration of symptoms was >3 years before
the initial consultation for 56.3% of sub-
jects in the study group and 40% in the
three times a week for a period of 2 control group.
months. Patients were encouraged to main- Of the 40 eligible participants, nine
tain the exercise routine at home. Details of individuals withdrew from the study after
the programme used in the study group are the operation. One participant in the study
shown in Table 2. group was unable to continue the exercise
A home-based exercise programme was programme. Additional surgical interven-
applied in the control group, and the con- tions were required for three patients in the
trol group subjects were recalled to the study group and four in the control group
clinic every 2 weeks for programme revi- (eminectomy, plication, shaving, or other
sion. The rehabilitation programme was TMJ surgery). The remaining patient
the same as that used in the study group. dropped out of the control group because
The control group performed the exercises they had to undergone orthognathic
surgery. Thus the study group consisted
at home in a 30-min session per day for 8
weeks. of 16 individuals (15 female and one male)
and the control group consisted of 15
individuals (15 female).
The mean age of patients in the study
Statistical analysis
group was 31.00  5.91 years (range 15–
SPSS version 17.0 software (SPSS Inc., 63 years) and in the control group was
Chicago, IL, USA) was used for all statisti- 32.20  6.02 years (range 17–61 years).
cal analyses. Homogeneity between the two Twenty-two joints were assessed in both
groups was assessed using the x2 test, the the study group and control group: four
Mann–Whitney U-test, or the independent right, six left, and six bilateral TMJs in the
samples t-test. Within-group comparisons study group; five right, three left, and
of repeated measurements in the two groups seven bilateral TMJs in the control group.
were made using the Wilcoxon signed-rank There was no significant difference in
test or paired samples t-test to examine patient sex, current occupation, or number
the differences occurring at measurement of involved joints between the two groups
intervals. The Mann–Whitney U-test or (P > 0.05) (Table 3). Moreover, there was
Table 3. Characteristics of the participants at baseline, and the homogeneity of variables
between the study and control groups.
Variables Study group Control group P-value
Sex, n (%) 0.325a
Female 15 (93.8) 15 (100)
Male 1 (6.2) 0 (0)
TMJ, n (%) 0.561a
Right 4 (25.0) 5 (33.3)
Left 6 (37.5) 3 (20.0)
Bilateral 6 (37.5) 7 (46.7)
Current occupation, n (%) 0.602a
Housewife 10 (62.5) 11 (73.3)
Employed 3 (18.7) 3 (20.0)
University student 3 (18.7) 1 (6.7)
Age (years), mean (SD) 31.0 (5.9) 32.2 (6.0) 0.841b
BMI (kg/m2), mean (SD) 22.2 (2.6) 22.5 (1.5) 0.707b
TMJ, temporomandibular joint; SD, standard deviation; BMI, body mass index.
x test.
b
Independent samples t-test.
YIJOM-3474; No of Pages 8

Supervised rehabilitation vs. home-based exercise 5

P-value (change)
Between-groups
no significant difference between the two
groups in the baseline assessments of all
outcome measures (age, functional param-
eters, VAS for pain during activity, VAS

0.001d
0.001d
0.462d
0.241d
0.017c
0.004c

0.664c
0.336c
0.007c
0.018c
0.446c
0.008c

0.249c
0.160c

0.752c
0.677c
for pain at rest, algometry measurements,
and QOL).
Sixty-eight percent of the patients were
housewives, 19% were employed, and

Within-group
13% were university students. At the
end of study, the statistical analysis was

P-value

0.001b
0.001b
0.001b
0.001b
0.002a
0.001a

0.001a
0.001a
0.001a
0.001a
0.001a
0.001a

0.001a
0.001a

0.001a
0.001a
performed with the data from the 31 par-
ticipants (16 in the study group, 15 in the
control group); data related to the partici-
pants who withdrew were not included in
the final analysis.

Change, %
55.5
45.1

22.1

71.4
14.5

61.9
63.6
56.2
50.0
57.1
50.0

28.5
28.5

84.6
84.6
50
Functional parameters
Table 4 summarizes the results of the
within- and between-groups comparisons
of all functional outcome measure assess-
1.6 (1.2)
3.4 (0.9)

(1.6)
(0.7)
(0.9)
(0.8)

(0.9)
(0.9)
(0.7)
(0.6)
(0.6)
(0.6)

2.7 (0.2)
2.7 (0.2)

2.4 (0.2)
2.4 (0.2)
Postop.
ments pre-surgery and at 2 months after

4.2
4.8
4.7

0.8
0.8
0.7
1.5
1.2
1.6
27.6
surgery.
Table 4. Within- and between-group comparisons of the outcome measures; results are presented as the mean (SD) values.

The intra-group analyses showed sta-

tistically significant improvements from
Control group

the baseline values in both groups for

3.6 (1.5)
6.2 (1.1)

(2.3)
(0.7)
(0.8)
(1.3)

(0.9)
(0.8)
(1.0)
(0.7)
(0.4)
(0.5)

2.1 (0.2)
2.1 (0.2)

1.3 (1.1)
1.3 (0.1)
MMO, protrusion, and right and left lateral
Preop.

movements (P < 0.05).

22.6
2.8
2.8
5.5

2.1
2.2
1.6
3.0
2.8
3.2
Regarding differences in functional pa-
rameters between the two groups, the
improvements in values between the sec-
ond month evaluation and the baseline
Within-group

measurement were significantly greater

P-value

in the study group than in the control

0.001b
0.001b
0.001b
0.001b
0.001a
0.001a

0.001a
0.001a
0.001a
0.001a
0.001a
0.001a

0.001a
0.001a

0.001a
0.001a
group for MMO and protrusion. The in-
crease in MMO in the study group was
9.56 mm and in the control group was
5 mm. The between-groups differences
Change, %

for right and left lateral movements were

not statistically significant.
103.7
77.7
72.4

41.3

79.3
12.5

92.3
85.0
83.3
76.6
65.3
77.1

28.5
28.5

71.4
71.4

Pain
Over the 2 months, pain at rest and activity
0.8 (1.1)
1.6 (1.3)

(3.0)
(1.1)
(1.0)
(0.8)

(0.5)
(0.6)
(0.6)
(0.8)
(0.7)
(1.0)

2.7 (0.2)
2.7 (0.2)

2.4 (0.2)
2.4 (0.2)

(VAS), as well as the algometry values,

Postop.

decreased significantly in both groups

5.5
5.2
2.8

0.1
0.3
0.3
0.7
0.9
0.8
32.8

(P < 0.05). In the between-groups com-

SD, standard deviation; VAS, visual analogue scale.

parison, there was a significant difference

between the study and control groups in
Study group

terms of pain at rest and during activity

(0.8)
(1.0)

(2.7)
(0.7)
(0.8)
(1.0)

(1.2)
(0.6)
(0.5)
(0.5)
(0.6)
(0.7)

(0.2)
(0.2)

(0.2)
(0.1)

after 2 months (P < 0.05). However, the

Preop.
3.6
5.8

2.7
2.9
3.2

1.3
2.0
1.8
3.0
2.6
3.5

2.1
2.1

1.4
1.4
23.2

between-group comparisons of the algo-

Temporal muscle algometry (kg/cm2)

Masseter muscle algometry (kg/cm2)

metry values revealed no statistically sig-

nificant difference after 2 months
Independent samples t-test.
Wilcoxon signed-rank test.

(P > 0.05).
Functional parameters (mm)
Maximal mouth opening

Mann–Whitney U-test.
Right lateral movement

Paired samples t-test.

Pain with activity (VAS)

Left lateral movement

Effectiveness at work

Feeling of depression
Difficulty in chewing

Quality of life
Pain at rest (VAS)

Nervous tension
Quality of sleep

There were significant improvements in

Quality of life

QOL scores in both groups after surgery.

Protrusion

Comparing the two groups, although there

Appetite
Measures

Right

Right

was no significant difference in feeling of

Left

Left

depression, appetite, or quality of sleep, the

b

d
a

study group subjects had a significantly

Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
YIJOM-3474; No of Pages 8
6 Capan et al.
decreased difficulty in chewing, improved
effectiveness at work, and reduced nervous
tension than the control group subjects
(P < 0.05).
Discussion
Overall effectiveness
The present trial compared the effects of a
supervised rehabilitation programme with
a home-based exercise programme after
TMJ surgery. Based on the results, the
supervised rehabilitation programme
yielded significantly better outcomes re-
garding pain at rest and with activity,
MMO, and protrusion compared with the
home-based exercise programme. Howev-
er, there were no inter-group differences in
algometry measurements. Although there
were no significant differences in the be-
tween-groups analysis in terms of feeling
of depression, appetite, and quality of
sleep, there were significant improvements
in the study group for difficulty in chewing,
effectiveness at work, and nervous tension.
Surgery
Although TMD symptoms are a relatively
common condition, with a 40% reported
prevalence in the population, few need
treatment.16 The disc of the joint is dis-
located in an anterior and medial position
in DDw/oR and conservative treatment is
the first option. If this fails and symptoms
and pain do not diminish, disc replacement
surgery is an option for these patients.17
Many different surgical open proce-
dures have been proposed to eliminate
pain and improve mandibular function
in patients affected by TMDs. The litera-
ture supports disc repositioning surgery,
which is a successful procedure that is
associated with fewer complications than
discectomy.18 All participants in the pres-
ent study underwent the same surgical
procedure (condylar discopexy); Mitek
mini anchors were placed to facilitate
repositioning of the joint disc over the
condylar head, thus facilitating physiolog-
ical movement and function of the joint
structures in condylar discopexy.11
Functional outcomes
The findings of this study coincide with
those reported by others in terms of mean
age. The mean age of patients in the study
group was 31.00  5.91 years and in the
control group was 32.20  6.02 years,
which correlates with the study by Mehra
and Wolford,19 in which the mean age of
patients was 32.6 years (ranging between
Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
14 and 57 years). This is also in agreement
with the study of Sato et al., in which the
mean age of patients with DDw/oR was
29.2 years (range 16–45 years),20 and with
the study of Anderson et al., who reported
a mean age of 28.1 years (range 14–48
years).21
The majority of TMD patients are fe-
male and aged between 20 and 40 years.
The female to male patient prevalence is
reported to vary from 3:1 to 8:1. In the
present study, 96.8% of the patients were
female. Ruiz Valero et al., whose study
group patients had a mean age of 33.5
years, reported a sex distribution ratio of
1:1.7 (18 men vs. 32 women).22 Also, the
sex distribution ratio in the study of Mehra
and Wolford11 was 1:5.5 (16 men vs. 89
women), which concurs with the 1:2 male
to female ratio reported in the literature,
confirming the greater prevalence of
DDw/oR in women. The condyle structure
is more retroverted in females, which
causes the increased frequency of TMD
in women and also predisposes them to
higher rates of DDw/oR.23
MMO and protrusion were significantly
improved in the study group. Vázquez-
Delgado et al. also demonstrated an im-
provement in MMO and lateral move-
ments, and a reduction in pain after a
postoperative rehabilitation programme
for internal derangement of the TMJ; how-
ever, the patients’ diagnosis in that study
was not the same and they did not have a
control group.24 They also reported a sta-
tistically significant reduction in TMJ
pain, facial pain, headaches, noises asso-
ciated with the TMJ, and disability, and
improvements in jaw function and diet.24
The functional parameters improved in
both groups in this study, but more signif-
icantly in the study group. The control
group was also well motivated to perform
the exercise programme, which may ac-
count for the lack of statistically signifi-
cant difference in the algometric
parameters between the groups.
Rehabilitation programme
Exercise is an important complement to
any operation, and therapeutic exercises
are considered effective in the manage-
ment of TMDs.25 The principal aims of
exercise in TMDs are to improve muscular
coordination, relax tense muscles, and
increase muscular strength.26 When com-
prehensive rehabilitation was conducted,
mobility of the TMJ, which was impaired
considerably by the operation, improved
more significantly during the 2 months
after the operation in the study group than
in the control group.
Overall, postoperative supervised exer-
cise therapy has many benefits on func-
tional parameters. Supervised stretching
and relaxation exercises aim to decrease
the tension of the muscle fibres, and are
prescribed as a first-choice therapy when
pain is present.27 The coordination exer-
cises increase the coordination of the mus-
cles and improve joint muscle function
and mobility.25 Active exercises and pos-
tural training are recommended in the
management of TMDs in a systematic
review.28
In a Cochrane review, Furlan et al. pro-
posed massage in combination with exer-
cises and education, as was used in the
present study.29 Muscular strength is
mainly achieved by isometric exercises
and isotonic exercises, but the important
decision is when to begin the proper exer-
cises. How and where to do the exercises
was demonstrated in this study; however,
the patient’s awareness is increased when
the exercises are supervised and this is
important in achieving treatment success.
Training the patient regularly on how to do
the exercises and checking if the exercises
have been performed correctly are mea-
sures that should be taken in order to
reduce patient errors and increase the ef-
fectiveness. In order to correctly perform
the physiotherapy programme, it is also
very important to motivate and carefully
instruct the patient to achieve good com-
pliance. Home-based exercise regimens
have to be checked very carefully. A
review of home-based exercise regimens
for the management of non-specific TMDs
revealed that the evidence for the efficacy
of home-based physical exercise is weak,
largely due to the limited number of ran-
domized clinical trials available in the
literature.30
The combination of a surgical interven-
tion and an appropriate post-surgical re-
habilitation programme has shown
significant success in restoring joint func-
tion, relieving pain, and preventing further
injury. Oh et al. demonstrated the overall
effectiveness of supervised physiotherapy
for post TMJ surgery patients.31 The
authors ordered an exercise programme
to be undertaken in the outpatient clinic
for the study group, and subjects in the
non-treatment group received no physio-
therapy after their discharge from the hos-
pital.
Göçmen et al. evaluated outcomes fol-
lowing the use of Mitek mini anchors in
TMJ discopexy and assessed the patient
satisfaction of seven patients.32 A total of
12 disc repositioning procedures were
performed in these patients and a remark-
able improvement in MMO was shown;
YIJOM-3474; No of Pages 8
however, there was no mention of any
exercise programme after the intervention.
Guarda-Nardini et al. conducted post-
surgical rehabilitation after total TMJ re-
placement and revealed that an open op-
eration and rehabilitation were effective at
eliminating or reducing pain, and that the
overall satisfaction of the patients was
good.33 It is important to note that none
of the studies mentioned above stated
whether the diagnosis and surgical proce-
dures were homogeneous. Also, they did
not mention a detailed rehabilitation pro-
gramme.
Quality of life
Few studies investigating the effects of
TMDs on QOL have been reported in
the literature. QOL was evaluated in the
present study, and although there was no
significant difference between the groups
in depression, appetite, or quality of sleep,
the study group patients experienced sig-
nificant improvements in difficulty in
chewing, effectiveness at work, and ner-
vous tension compared to the control
group. Karacayli et al. evaluated the
effects of chronic pain on oral health-
related QOL in patients with DDw/oR.
The patients’ oral health-related QOL over
the previous 6 months was evaluated using
an Oral Health Impact Profile-14 (OHIP-
14) questionnaire.34 It was found that the
OHIP-14 score was significantly higher in
patients with DDw/oR than in healthy
controls. Consistent with the present find-
ings, any particular interventions led to
some improvement in patient QOL.
Limitations and strengths of the study
This study had several limitations that
should be considered when interpreting
the results. First, the relatively small sam-
ple size of the groups may not yield ade-
quate statistical power; therefore, both the
positive and negative findings must be
interpreted with caution. Second, the con-
trol group performed the prescribed exer-
cises at home. If they had been telephoned
every week for motivation, the real effec-
tiveness of home-based exercise could
easily have been demonstrated. However,
the control group exercises were checked
every 2 weeks. Third, the follow-up period
of this study was 2 months, which is not
long enough to observe and compare the
exact effects of long-term home-based or
supervised rehabilitation programmes.
Despite these limitations, this study had
a number of strengths. A major strength of
this study was the random allocation of
participants and that the same surgical
Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
Supervised rehabilitation vs. home-based exercise
procedure was performed for the same
diagnosis. Another strength of the study
was the assessment of the QOL. Further-
more, all rehabilitation and training ses-
sions in both the study and control group
were supervised by the same physiothera-
pist, which is important in terms of stan-
dardization of the training programme.
In conclusion, while there is growing
documentation and interest in the surgical
procedures of the TMJ, there is a lack of
information on postoperative rehabilita-
tion protocols. The selection of an appro-
priate and comprehensive postoperative
rehabilitation protocol has a strong influ-
ence on functional outcomes. Therefore,
in light of the present results, it may be
inferred that an early supervised postoper-
ative rehabilitation protocol has clinical
importance and excellent outcomes in
terms of improving function, pain, and
patient QOL.
Although therapeutic supervised exer-
cises present a promising future after sur-
gery for TMDs, there is a lack of published
studies in the literature to perform a real
comparison with the present results.
Funding
No funding to declare.
Competing interests
No competing interests to declare.
Ethical approval
This study was approved by the Ethics
Committee of the Istanbul University
Istanbul Faculty of Medicine in conformi-
ty with the Declaration of Helsinki (num-
ber 625).
Patient consent
Not required.
Acknowledgements. We would like to
thank the patients who consented to be
enrolled in this study.
References
1. Okeson JP. Management of temporomandib-
ular disorders and occlusion. 7th ed. Else-
vier; 2013.
2. Schiffman E, Ohrbach R, Truelove E, Look
J, Anderson G, Goulet JP, et al. International
RDC/TMD Consortium Network, Interna-
tional association for Dental Research; Oro-
facial Pain Special Interest Group,
International Association for the Study of
7
Pain. Diagnostic criteria for temporoman-
dibular disorders (DC/TMD) for clinical
and research applications: recommendations
of the International RDC/TMD Consortium
Network and Orofacial Pain Special Interest
Group. J Oral Facial Pain Headache 2014;
28:6–27.
3. Rollman GB, Gillespie JM. The role of
psychosocial factors in temporomandibular
disorders. Curr Rev Pain 2000;4:71–81.
4. Shaffer SM, Brismée JM, Sizer PS, Courtney
CA. Temporomandibular disorders. Part 2:
Conservative management. J Man Manip
Ther 2014;22:13–23.
5. Bertolucci LE, Uriell P, Swaffer C. Postoper-
ative physical therapy in temporomandibular
joint arthroplasty. Cranio 1989;7:214–22.
6. McCain JP. Arthroscopy of the human
temporomandibular joint. J Oral Maxillofac
Surg 1988;46:648–52.
7. Nitzan DW, Dolwick MF, Martinez GA.
Temporomandibular joint arthrocentesis. A
simplified treatment for severe limited
mouth opening. J Oral Maxillofac Surg
1991;49:1163–7.
8. 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
1995;33:23–6.
9. Guarda-Nardini L, Manfredini D, Berrone S,
Ferronato G. Total temporomandibular joint
prosthesis as a surgical option for severe
mouth opening restriction. A case report of
a bilateral intervention. Reumatismo
2007;59:322–37.
10. Quinn PD. Surgery for internal derangement.
In: Quinn PD, editor. Color atlas of tempo-
romandibular joint surgery. St. Louis:
Mosby; 1998. p. 55–99.
11. Mehra P, Wolford LM. The Mitek mini
anchor for TMJ disc repositioning: surgical
technique and results. Int J Oral Maxillofac
Surg 2001;30:497–503.
12. Mercuri LG. The use of alloplastic prosthe-
ses for temporomandibular joint reconstruc-
tion. J Oral Maxillofac Surg 2000;58:75–80.
13. Storum KA, Bell WH. The effect of physical
rehabilitation on mandibular function after
ramus osteotomies. J Oral Maxillofac Surg
1986;44:94–9.
14. Austin BD, Shupe SM. The role of physical
therapy in recovery after temporomandibular
joint surgery. J Oral Maxillofac Surg 1993;
51:495–8.
15. Lo LJ, Lin CL, Chen YR. A device for
temporomandibular joint exercise and tris-
mus correction: design and clinical applica-
tion. J Plast Reconstr Aesthet Surg 2008;
61:297–301.
16. Gonçalves DA, Dal Fabbro AL, Campos JA,
Bigal ME, Speciali JG. Symptoms of tempo-
romandibular disorders in the population: an
epidemiological study. J Orofac Pain
2010;24:270–8.
17. Yuasa H, Kurita K, Treatment Group on
Temporomandibular Disorders. Randomized
YIJOM-3474; No of Pages 8
8 Capan et al.
clinical trial of primary treatment for tempo-
romandibular joint disk displacement with-
out reduction and without osseous changes: a
combination of NSAIDs and mouth-opening
exercise versus no treatment. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2001;
91:671–5.
18. Spallaccia F, Rivaroli A, Basile E, Cascone
P. Disk repositioning surgery of the tempo-
romandibular joint with bioabsorbable an-
chor. J Craniofac Surg 2013;24:1792–5.
19. Mehra P, Wolford LM. Use of the Mitek
anchor in temporomandibular joint disc-
repositioning surgery. Proc (Bayl Univ
Med Cent) 2001;14:22–6.
20. Sato S, Nasu F, Motegi K. Natural course of
nonreducing disc displacement of the tempo-
romandibular joint: changes in chewing
movement and masticatory efficiency. J Oral
Maxillofac Surg 2002;60:867–72.
21. Anderson DM, Sinclair PM, McBride KM. A
clinical evaluation of temporomandibular
joint disk plication surgery. Am J Orthod
Dentofacial Orthop 1991;100:156–62.
22. Ruiz Valero CA, Marroquin Morales CA,
Jimenez Alvarez JA, Gomez Sarmiento JE,
Vallejo A. Temporomandibular joint menis-
copexy with Mitek mini anchors. J Oral
Maxillofac Surg 2011;69:2739–45.
23. Parker MW. A dynamic model of etiology in
temporomandibular disorders. J Am Dent
Assoc 1990;120:283–90.
24. Vázquez-Delgado E, Valmaseda-Castellón
E, Vázquez-Rodrı́guez E, Gay-Escoda C.
Please cite this article in press as: Capan N, et al. Effect of an early supervised rehabilitation programme compared with home-based
exercise after temporomandibular joint condylar discopexy: a randomized controlled trial, Int J Oral Maxillofac Surg (2016), http://
Long-term results of functional open surgery
for the treatment of internal derangement of
the temporomandibular joint. Br J Oral Max-
illofac Surg 2004;42:142–8.
25. Moraes Ada R, Sanches ML, Ribeiro EC,
Guimarães AS. Therapeutic exercises for the
control of temporomandibular disorders.
Dental Press J Orthod 2013;18:134–9.
26. Rashid A, Matthews NS, Cowgill H. Phys-
iotherapy in the management of disorders of
the temporomandibular joint—perceived ef-
fectiveness and access to services: a national
United Kingdom survey. Br J Oral Maxillo-
fac Surg 2013;51:52–7.
27. Fricton J. Myogenous temporomandibular
disorders: diagnostic and management con-
siderations. Dent Clin North Am 2007;
51:61–83.
28. Medlicott MS, Harris SR. A systematic re-
view of the effectiveness of exercise, manual
therapy, electrotherapy, relaxation training,
and biofeedback in the management of
temporomandibular disorder. Phys Ther
2006;86:955–73.
29. Furlan AD, Brosseau L, Imamura M, Irvin E.
Massage for low back pain. CDS Rev
2002;2:CD001929.
30. Michelotti A, de Wijer A, Steenks M, Farella
M. Home-exercise regimes for the manage-
ment of non-specific temporomandibular
disorders. J Oral Rehabil 2005;32:
779–85.
31. Oh DW, Kim KS, Lee GW. The effect of
physiotherapy on post-temporomandibular
joint surgery patients. J Oral Rehabil
2002;29:441–6.
32. Göçmen G, Varol A, Karatas B, Basa S.
Evaluation of temporomandibular joint
disc-repositioning surgery with Mitek mini
anchors. Natl J Maxillofac Surg 2013;
4:188–92.
33. Guarda-Nardini L, Manfredini D, Ferronato
G. Total temporomandibular joint replace-
ment: a clinical case with a proposal for post-
surgical rehabilitation. J Craniomaxillofac
Surg 2008;36:403–9.
34. Karacayli U, Mumcu G, Cimilli H, Sisman
N, Sur H, Gunaydin Y. The effects of chronic
pain on oral health related quality of life in
patients with anterior disc displacement with
reduction. Community Dent Health 2011;
28:211–5.
Address:
Nalan Capan
Department of Physical Medicine and
Rehabilitation
Istanbul Faculty of Medicine
Istanbul University
Millet Cad
Capa
Fatih
34093 Istanbul
Turkey
Tel.: +90 0532788460
fax: +90 02126214997
E-mail: nalancapan@gmail.com