Oral Maxillofacial Surg Clin N Am 18 (2006) 345–368
A Biomechanical Basis for Primary Arthroplasty
of the Temporomandibular Joint
William S. Kirk, Jr, DDSa,*, Benjamin S. Kirk, MS, PhDb
a
600 South College Street, Suite 1100, Charlotte, NC 28202, USA
b
301 Clear Creek Meadows Drive, League City, TX 77573, USA
Since the development of arthroscopic surgical
techniques of the temporomandibular joint (TMJ),
open arthrotomy and reconstructive arthroplasty
are often considered overly aggressive for manag-
ing impairing TMJ derangements [1–3]. Surgeons
who developed and refined arthroscopic tech-
niques have appropriately tried to apply a less in-
vasive surgical procedure [4–7]. Focusing almost
entirely on the superior joint space, arthroscopy
fundamentally addresses and assumes that the fac-
tors creating orthopedic instability, dysfunction,
pain, immobility, and patient impairment are di-
rectly influenced by inflammatory adhesions and
other pathologic factors, and remedied by opera-
tive procedures within the superior compartment
[8–10]. Likewise, various inflammatory mediators
in a deranged or arthritic joint can be managed
through simple arthroscopic lysis and lavage, aid-
ing in definitive pain management [11–14] but
sometimes causing incomplete long-term manage-
ment of orthopedic instability and immobility of
the joint [15]. Consequently, the development of
technological advances and improvements in mi-
croarthroscopic operative capabilities and the in-
troduction of arthrocentesis into the clinical
armamentarium [16–18] have almost created
a managed surgical mindset that dictates arthro-
centesis first, arthroscopy second, and finally, if
the patient still shows no improvement, surgical
arthroplasty.
The surgical literature does not show a de-
finitive advantage of one technique over another,
* Corresponding author.
E-mail address: bkirk22oms@yahoo.com
(W.S. Kirk).
1042-3699/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2006.03.006
particularly in most retrospective studies that
comprise most examples of research in the clinical
literature [19]. Most reports of arthrocentesis in-
volve short-term follow-up [20]. Likewise, the
reported early successes of these interventions
spawned an entirely new concept of TMJ orthope-
dic dysfunction [21] that attempted to challenge
traditional understanding of how a TMJ derange-
ment was dysfunctional [22].
Critics of this field often question any useful
purpose of surgical intervention and call for
studies with placebo controls [23]. A general 8%
to 12% rate of unsuccessful initial surgical out-
comes, regardless of surgical technique [24], may
explain this position. Arthrocentesis failures are
reported to be even higher when clinically signifi-
cant derangement, condylar disease, or osteoarth-
rosis exists [25]. Payers of health care services
believe these initial failure rates to be unaccept-
ably high when overall nonsurgical and surgical
patient care cost analyses are considered [26]. Sep-
arate evaluation of failures concludes that pain
management and functional improvement rarely
occurs with multiple surgical or therapeutic en-
counters [27]. Mercuri [28] even suggested that
worthwhile improvement rarely occurs beyond
two to three surgical interventions, regardless of
the technique used. Any more than this rarely im-
proves orthopedic function or subjective pain.
Nevertheless, a comparative meta-analysis of
the nonsurgical and surgical literature by non-
clinicians suggests surgery is specifically effective
in significant-type cases of arthropathy, and
successes underestimated. Reston and Turkelson
[24] concluded that surgery seems significantly
beneficial when absolutely no response or, at
best, marginal response to nonsurgical treatment
oralmaxsurgery.theclinics.com
346 KIRK & KIRK
occurs. However, better-designed random clinical
trials are needed with better categorization of pre-
operative diagnoses for evaluating all available
surgical procedures. To improve initial surgical
results to a high 90th percentile of long-term suc-
cess, surgeons must use a procedure that addresses
all potential orthopedic disease at the first surgical
encounter. Current literature suggests that success-
ful initial outcomes appear to be Wilkes stage–spe-
cific for arthroscopic and open arthrotomy
techniques. Initial unsuccessful outcomes are
more prevalent at the stage III level of derange-
ment only to improve again at stages IV–V [29–31].
A fundamental misunderstanding may exist of
contributing pathologic conditions, causes, and
biomechanical principles of diseased and operated
TMJs that are significant and influence initial
failure. The ability of arthroscopy to manage
adhesive capsulitis of the superior compartment
of the TMJ is well documented [32–35]. However,
the TMJ is a complicated two-compartment, four-
surfaced joint system in which disease or injury to
any component could result in painful, dysfunc-
tional, and progressively impairing derangement.
This article discusses surgical management of
clinically significant derangements of the TMJ and
addresses basic biomechanical principles of normal
and pathologic TMJ orthopedics, the significance
of longstanding joint derangements, and what
conditions supersede all others and dictate that
open arthrotomy and reconstructive arthroplasty
should be the definitive initial surgical procedure.
Biomechanics for temporomandibular joint
surgeons
General plane motion and shear mechanics
According to established classical physical law
(Newton’s third), any and all forces of directed
motion in any mechanical system are balanced by
equal and opposing forces generated and exerted
on structures within the system. From an orthope-
dic and biomechanical perspective, muscular forces
that generate static loading, rotation, and trans-
lation of the TMJ condyle are balanced by equal
and opposing forces generated in the disc/capsule
and the peripheral attachments to the condyle and
fossa. These reactive forces are created in an
opposite direction to all force vectors generated
during these static, rotation, and translation force
loads exerted within the system.
From an orthopedic standpoint, the magnitude
of translation that occurs in the TMJ distinguishes
it from other orthopedic systems. Whenever
a mechanical system exhibits rotation and trans-
lation simultaneously, it exhibits general plane
motion (GPM). Translation occurs along a fixed
plane and rotation occurs about an axis perpen-
dicular to the fixed plane. However, the articulat-
ing surfaces of the TMJ are not flat but curved.
Hence, from a purely mechanical standpoint, the
joint is an example of curvilinear GPM and all
potential paths of displacement must occur along
functionally coordinated and congruent curved
paths [36]. For optimal joint function, all motion
must be coordinated among all four curved artic-
ulating surfaces (fossa, superior disc surface, con-
dyle, and inferior disc surface) with no impedance
occurring along these congruent paths. This func-
tion is necessary because in curvilinear GPM, in-
finite individual intersecting planes of motion are
created and intersect during the full range of mo-
tion. There will be an infinite number of potential
points of contact located along three dimensional
planes of motion (Fig. 1).
When opposing force vectors remain balanced
or complimentary during collisions of the many
congruent curved planes of movement, the lami-
nar pattern of fibroblasts within the TMJ disc/
capsule remain laminar. However, when congru-
ency is lost, competing vectors with different
accelerations or velocities are created. By physical
law, this result can create potentially destructive
intrinsic forces within the disc/capsule complex,
primarily shear and destabilizing torques (Fig. 2).
Surgical specimens clearly show the destructive
nature of inherent, unstable shear (Fig. 3). Coupled
with other destructive forces created in chronic
joint instability and mechanical dysfunction, dis-
eases of the inferior and lateral joint compartments
Fig. 1. Rotational shear vectors.
 PRIMARY TMJ ARTHROPLASTY
Fig. 2. Derangement shear vectors.
supersede those of superior and medial compart-
ments in most surgical specimens.
Static and rotational force moments and torque
Traditionally, discussions of TMJ biomechan-
ics generally focused on static or compressive
loads distributed to articular tissues [37]. How-
ever, these concepts involved limited planes of dis-
tributed and reactive forces, namely forces with
envisioned vertical or perpendicular vectors of
compression among the condyle, disc/capsule,
and glenoid fossa. These models significantly limit
mechanical understanding of multiple potential
forces simultaneously acting on the disc/capsule
in three dimensions during condylar rotations.
During any rotational movement of a body
about an axis, separate and opposing forces
(moments) are created that are perpendicular to
the direction of rotation of the body and will com-
pete as the direction of rotation changes between
clockwise and counterclockwise directions. In
strict and accepted physical terms, laterally di-
rected moments (þM) are created in response to
counter-clockwise rotations (
F). Medially di-
rected moments (
M) are created in response to
opening clockwise directed rotational forces
(þF). In addition, these paired force moments
(
M/þM) will create additional paired or coupled
force moments at their extremes, or at the attach-
ments of the TMJ disc/capsule complex to the os-
seous perimeters of the condyle and fossa. These
new forces are designated as torques occurring lat-
erally (þmt) and those occurring medially (
mt).
347
These forces are perpendicular to þM/
M and in
a third plane of dimension (Fig. 4) [36].
When moment forces (
M/þM) created by
mouth opening and closing forces (þF/
F) are
balanced and equal, distributed torques (
mt/
þmt) are in equilibrium and a net displacing torque
is neutralized or 0. In unstable rotating orthopedic
movements of the TMJ, unopposed, inherent
lateral and medially directed moments are created,
as are torques between the condyle and maladapt-
ing and incongruent fibrous tissue disc/capsule.
Moments and torque are also created in any
static or compression loading of any structure
[38]. During static loading of the TMJ, downward
and upward loads are placed on the disc from the
condyle and fossa, respectively. These loads also
create moments within the disc/capsule and its at-
tachments, which are parallel to one another and
perpendicular to the planes of compression force.
These moment forces will spread throughout the
entire disc/capsule complex. Likewise, torque is
created at the medial and lateral extreme of any
loaded structure, such as the condylar poles spe-
cifically, and the attachments of the disc/capsule
complex to their various osseous attachments. If
congruency of all structures is matched and vari-
ous forces equalized, unopposed moments or tor-
ques are equalized and net 0. If orthopedic
instability exists because of noncongruency, tor-
que is created within the system and can become
potentially damaging at any point of least resis-
tance (Fig. 5).
In Fig. 5, two coupled torques are created at
the lateral and medial poles in both joint space
348 KIRK & KIRK

Fig. 3. Surgical specimens showing greater destruction of lower disc surface compared with superior disc surface. Left
side images are various morphologies of superior disc surfaces in late stage (III–IV) derangements. Right side images are
respective matching lower disc surfaces. Three-dimensional image shows concentrated damage created by osteophyte re-
moved from condyle surface and pictured lateral to the disc specimen.
 PRIMARY TMJ ARTHROPLASTY 349

Fig. 4. Rotational moments and torque.

compartments. A downward static force (þF) is
generated by the glenoid fossa on the superior sur-
face of the disc. An upward static force (
F) is
generated by the upward closure of the condyle
into the inferior surface of the disc/capsule. Mo-
ments spreading through the fibrous disc/capsule
and perpendicular to þ/
F are generated. Fi-
nally, coupled torques are generated laterally
and medially. Although the generated net torque
is 0 in an optimally performing joint with func-
tionally congruent parts, a primary and secondary
torque is exerted in the extreme recesses of the su-
perior and inferior joint spaces, or more specifi-
cally, the capsular attachments to the osseous
structures in these areas. For example, in the lat-
eral superior compartment of the joint and disc/
capsule attachment, a major torque (
Mt) is cre-
ated by downward force (þF) and a lesser torque
(þmt) is created by the upward movement of the
condyle and disc/capsule into the fossa exerting

F. Conversely, in the lower joint space, a major
torque (þMt) is created by the upward
F and
a lesser torque (
mt) is created by þF. Orthope-
dic stability of the disc/capsule at the lateral pole
occurs when all torque is in equilibrium. In dis-
equilibrium, orthopedic instability may eventually
occur and potentially progress because of the pro-
gression of dysfunctional and unstable torque.

Fig. 5. Static loading moments and torque of the TMJ.

350 KIRK & KIRK

Also in Fig. 5, þMt and
Mt create converg-

ing force vectors in the lateral superior joint space
directed down and away from the lateral rim of
the glenoid fossa. In the inferior lateral joint
space, converging vectors are directed upward
and into the attachment of the capsule. These con-
verging vectors are significant. Unbalanced or un-
opposed converging force vectors will create
tensile forces generated along the lateral margins
of the joint space and (by way of Wolfe’s law) cre-
ate a narrowing of the joint space through apposi-
tional bone growth along the lateral glenoid fossa
or changes in the morphology of the lateral pole
of the condyle.
Conversely, torque vectors are directed into the
fossa in the superior medial recess of the joint. In the
inferior–medial recess, torque is directed such that
the capsular attachment will be directed toward the
medial pole of the condyle and remain close.
These directional differences of torque in four
distinct recesses of the joint may explain the
predominant pattern of observed osseous and
disc pathology in the lateral regions of the joint Fig. 6. Rotational force momentum.
compared with that in the medial region. Classic
studies by Oberg and colleagues [39], later repeated
and confirmed by Kondoh and colleagues [40], In Fig. 6, muscular forces create opening and
established this phenomenon from a pathologic closing velocities of the jaw that can be measured
standpoint. The phenomenon of early ‘‘clicking’’ at any time experimentally (eg, mm/s). These
in TMJs during jaw movement and joint loading opening and closing velocities create force mo-
results from unopposed torque of the disc/capsule mentum (FM) and angular velocity (u) that is
caused by a progressive loss of equilibrium of generated throughout the axis of rotation, partic-
forces placed on and generated within the disc/cap- ularly from the medial to the lateral pole of the
sule. Noise is created as dissipated energy from condyle. According to physical law, the farther
fibroelastic tissue, which gradually changes histo- away from the origin or application of a rotational
morphometrically and becomes incapable of ab- force along a given axis of rotation, the greater the
sorbing the energy generated by dysfunctional velocity of movement or angular momentum at
torque. The influence of chronic unopposed tis- that point. Therefore, in an orthopedic system
sue-destructive torque within the system most such as the TMJ (a single bone with two joint sys-
likely initiates the elevation of certain painful in- tems located at the lateralmost extreme of the
flammatory and pain mediators via both oxidative moveable system), the lateralmost aspects of the
and mechanical tissue destruction (Fig. 3) [40–47]. joints experience the greatest relative velocities
of opening and closing rotation. The velocity at
L is determined by: (y) ¼ (u) r2, where r2 is the
Angular momentum and rotational mechanics
radius or length of the moment arm FM
L [36].
Many attempts have been made to define The velocity of rotation at M will be (y) ¼ (u)
a center of rotation (IC) of the mandible [48]. De- r1, where r1 is the length of the moment arm FM–
spite its debated anatomic location, opening and M. Differential measurable magnitudes of open-
closing jaw muscle function distributes a force ing and closing velocities at the lateral pole of
momentum generated within the confines of the the condyle are calculable by (y) ¼ r2
r1 (u).
body and rami of the mandible as the condyles ro- Consequently, the additional length of the mo-
tate about their individual axis. Angular velocities ment arm between M and L cause differences in
can be mathematically predicted to differ in mag- angular momentum and therefore potential differ-
nitude from the medial to lateral poles of the con- ences in energy conversion between the medial
dyle (Fig. 6). and lateral poles during mandibular rotation. In
 PRIMARY TMJ ARTHROPLASTY
chronic derangement and joint instability, shear
and torque within the system receive energy to ex-
ert influence on the system by this phenomenon.
Eccentric motion mechanics
Total movement of the mandible does not just
consist of rotation and translation. Side-to-side or
eccentric bodily movement of the mandible and
rotation and translation of the joints indicates that
the mandible acts as a freely moveable or ‘‘float-
ing’’ structure. Controlled by pairs of complimen-
tary and opposing muscle functional groups that
gradually exert force momentum with numerous
force vectors, three-dimensional movement of the
mandible with a dual-operating joint system is
unlike any other orthopedic system of the body.
Considering the principles of angular momen-
tum, eccentric movement of the mandible and
associated rotations and translations of the con-
dyles can be viewed essentially as movement of an
isosceles triangle that significantly influences
forces generated in each individual joint. When
calculating potential rotational velocities (see
Fig. 6), the angular momentum (u) exerted over
the radius (r) or moment arm nearly doubles (in
a symmetric mandible when points L are equidis-
tant from the mid-sagittal plane) in lateral shifting
or eccentric movements of the mandible (Fig. 7).
Fig. 7. Eccentric motion force momentum.
351
The moment arm r (see Fig. 6) increases to a lon-
ger moment arm IC over which muscular force
momentum is distributed.
In Fig. 7, left eccentric mandibular movement
consists of a slightly rotating and laterally shifting
left condyle and a translating right condyle. The
base of the triangle (IC) is a longer radius (inter-
condylar width) over which momentum is exerted
to the translating right condyle.
The ratio of the length of the base of the
isosceles triangle IC to the individual radii of each
rotating condyle (r) can be calculated if the
isosceles triangle is broken down to two right
triangles. To calculate IC with relation to r, a can
be calculated if intercondylar angle q is known.
In Fig. 7:
IC ¼ 2a r2 ¼ a2 þb2 1c ¼ 2a
q ¼ 140 ¼ 24 a2 ¼ r2
b2 1c ¼ 2ðrO1
cos24Þ
4¼70 ðb ¼ rcos4Þ a¼rO1
ðcos70 Þ2¼
2
cos4 ¼ :342 a2 ¼ r2
ðrcos4Þ rO1
ð:342Þ2 ¼
2 2 2
a ¼ r ð1
cos 4Þ rO1
ð:117Þ then
a ¼ rO1
cos2 4 a ¼ rð:939Þ
1c ¼ 2a ¼ 2ð:939rÞ
1c ¼ 1:88r
Therefore, when calculating potential force
exerted at the lateral pole of the condyle in lateral
eccentric jaw movement, F ¼ u IC, force generated
during eccentric lateral movements is nearly twice
that of hinge rotation in a symmetric mandible.
This force will change as the obtuse angle q
changes. However, even with a range variable of
140 to 160 for most humans [49], this variable
will not be significant enough to negate the princi-
ple that lateral excursion functional movements of
the mandible exert nearly twice the force to the
lateral condylar pole as do rotational opening or
closing movements.
Differential load potentials between the superior
and inferior joint compartments
Simple observation of the TMJ anatomy shows
two compartments that are significantly different
in design and square area about which load is
distributed and internal reactive forces are gener-
ated. The articulating surface areas of superior
disc/capsule surface and glenoid fossa are nearly
twice those of the lower disc and condylar surfaces
measured in classic anatomic studies [39]. Previ-
ous surgical studies have shown significant mor-
phologic pathologic differences between the
lower compartment and upper compartment in
352 KIRK & KIRK

Wilkes stage III–V derangement conditions
[50,51], which must be considered when applying
initial surgical treatment (Fig. 8).
Reactive TMJ force loads are difficult to
calculate because of the infinite ways the muscles
of mastication deliver a specific bite force. Many
attempts have been made to calculate ranges of
reactive load potentials in the TMJ. Using a math-
ematical computer program and a system of
Cartesian coordinates based on human cadaver
studies, Koolstra and associates [52] calculated
a range of reactive TMJ force loads in varying po-
sitions of the mandible and dental contacts. Mea-
sured reactive joint force will differ between molar
tooth contacts (lower) and incisor tooth contacts
(higher) and in eccentric positional loading of
the mandible (asymmetric). Consequently, a range
of TMJ force (210–510 N) resulted mirroring that
shown in other studies. However, these data did
not look at potential force differentials between
the upper and lower joint space compartments,
but rather calculated reactive loads within the
total joint.
Taking the average square area of potential
static articulating contacts of the fossa and
condyle measured by Oberg and colleagues [39],
the average or calculable square area for the gle-
noid fossa will be 437 mm2 (23  19 mm) and
the average condylar square area will be 200 mm2
(20  10 mm). Therefore, calculations of potential
load differences between each compartment
generating a reactive force to any given mus-
cular force load can be made by simply applying
pressure ¼ force/area (P ¼ F/A). Using the range
of calculated reactive loads provided by Koolstra
and colleagues [52] (210–510 N), simple estimation
of pressure loads can be calculated for each com-
partment. For the potential upper joint space pres-
sure ranges, P ¼ 210 N/437 mm2 ¼ 69.6 psi at the
low range of calculated estimates and 510 N/437
mm2 ¼ 169.6 psi at the higher range of estimates.
For the potential lower joint space pressure ranges,
P ¼ 210 N/200 mm2 ¼ 152.3 psi at the low range of
calculated estimates and 510 N/200 mm2 ¼ 369.8
psi at the higher range of estimates.
Regardless of the methodology used to de-
termine calculated and theoretical potential force
loads in the TMJ, that a reactive force is distrib-
uted over a smaller square area or volume in the
lower joint space shows the potential for any given
force load to create a reactive opposing force load
in the inferior joint compartment that exceeds that
of the superior joint space by a factor of nearly 2.2
(eg, 152.3 psi/69.6 psi ¼ 2.2 and 369.8 psi/169.6
psi ¼ 2.2).
If the surfaces of the condyle or fossa have
significant osseous irregularities, (osteopytes, see
Fig. 3D) force distribution over an even smaller
square area of the joint may cause these ratios
to be more diverse and destructive in isolated re-
gions. Destruction of the inferior articulating sur-
face of the disc has been shown to increase in
advancing joint derangement (Wilkes stage III,
IV) until disc/capsule rupture occurs (stage V).
The destruction of the inferior surface exceeds
that of the superior disc/capsule surface [50]
(Fig. 3). If concentrated force vectors develop
from a developmental or degenerative process on

Fig. 8. (A) Cadaver specimen with normal, intact and congruent disc/capsule adaptation to mandibular condyle. Lateral
attachments 1 and 2 (LA 1 and 2) correspond to the region where rupture creates derangement consistently in laboratory
studies as shown by Eriksson and colleagues [56]. Note larger size of articulating surface area compared with inferior disc
surface shown in B. (B) Cadaver specimen exhibiting anatomic congruency of the inferior disc/capsule to the articular
surface of the mandibular condyle (foreground). Note the contiguous relationship of the ‘‘disc’’ to the surrounding lateral
capsular attachments (1 and 2), posterior attachment region (pa) and the periosteum attachment (ps) to the superiormost
region of the posterior ramus. In a nondiseased and anatomically congruent disc/capsule, gross anatomic distinctions of
these regions are difficult to distinguish. Note significantly smaller articular surface area of the inferior joint space com-
pared with the articular surface area of the corresponding superior disc/capsule in A.
 PRIMARY TMJ ARTHROPLASTY
an area of the condylar surface, the differential of
force generation between the structures of the
superior and inferior joint compartments will be
potentially significant and always lead to an ad-
vanced disease state of the inferior compartment
when significant disequilibria of all loading forces
and torque is reached (significant disc/capsule
instability).
Nitzan and Dolwick [17] suggested a mecha-
nism of acute joint locking caused by negative
pressure within the superior joint space that pre-
vents disc/capsule and condylar translation. Acute
joint locking in previously asymptomatic patients
or patients who do not have advanced derange-
ment is tenable, not because of negative pressure
but rather relative pressure gradients created be-
tween the joint compartments during static load-
ing. With less positive pressure developing in the
superior joint space, such a pressure gradient
could create a vacuum-type differential between
two differing positive pressure regions created in
the same closed system. Such a mechanism could
theoretically be present when absolute congruency
exists among all four articulating surface compo-
nents, or when other factors such as increased sy-
novial fluid viscosity contributes to the condition
[53,54]. This explanation would support arthro-
centesis of the superior joint compartment for
managing acute onset joint locking, particularly
in previously asymptomatic patients. However, it
should not be considered a definitive management
technique for chronic derangement, particularly if
significant lower compartment disease is present
and the potential for further degeneration and
dysfunction exists [55].
Practical surgical applications
of temporomandibular joint biomechanics
Biomechanical principles argue that converging
forces in any and all ranges of joint motion are
greatest in the lateralmost compartments, and
specifically in the disc/capsule ligament attach-
ments to the mandibular condyle (LA1 and LA2,
Fig. 8). Eriksson and colleagues [56] showed that
weakness or rupture in this area of disc/capsule
attachment consistently creates derangement,
whereas weakness or ruptures in other areas does
not. Differential force magnitude created by rota-
tional angular momentum, static, and rotational
torque is likely greatest in this region, and eccentric
jaw movements further increase these forces. Sig-
nificant long-term joint instability could lead to fur-
ther weakness of this area and eventual rupture of
353
the entire attachment. Basic mechanical principles
would argue that significant instability in an ortho-
pedic system that exhibits curvilinear general plane
motion would interfere with the maintenance of
congruency of critical articulating components, in-
creasing the threshold of further destabilization
and destruction. As disease or significant morpho-
logic changes of the condyle or disc/capsule in-
stability increase, biomechanical analysis would
argue that beyond a certain threshold or derange-
ment stage, deterioration of the inferior joint space
components is inevitable unless some functional
congruency of articulating components can be re-
stored. Those who argue that unstable chronic de-
rangement is not a potential precursor to further
destruction, arthrosis, or joint failure must chal-
lenge the arguments of biomechanics and patho-
logic reactive forces. Failure to do so ignores
another biomechanical reality, that an aging dys-
functional disc/capsule does not have the viscoelas-
tic properties necessary to meet the full functional
demands of complete TMJ function unless some
mechanism creates significant functionally congru-
ent readaptation of incongruent, anatomic func-
tional components [57,58]. Furthermore, the only
interpositional material capable of meeting the
unique biomechanical functional demands of this
joint system over the long term is one that has sim-
ilar viscoelastic properties to a TMJ disc/capsule
that is free of disease. Currently, no synthetic or bi-
ologic materials precisely meet that requirement
[59–63].
A generic approach to surgical pathology
of temporomandibular joint derangement
An initial surgical intervention would seem-
ingly be based on an accurate preoperative di-
agnosis and generally accepted and understood
implications of nontreatment and its long-term
consequences. However, the initial use of arthros-
copy, arthroplasty, meniscectomy, condylotomy
(or other orthognathic/orthodontic procedures),
and now arthrocentesis for TMJ intervention is
currently under debate, particularly among oral
and maxillofacial surgeons. The present and
future cost issues [64] and created pathways of pa-
tient management by payers of health care ser-
vices [65] complicate this issue and are particular
to managed health care systems. Recent literature
emphasizes that the choice of initial surgical man-
agement should be based on its limited invasive
qualities rather than discussions of potential
differing orthopedic disease states that must be
354 KIRK & KIRK
identified before the initial intervention and defin-
itively addressed [16,66].
Progress in TMJ surgery has been hampered
by two significant phenomena: the unfortunate
use of Proplast/Teflon and other synthetic
implants in the 1980s [67–71] and a poor basic
understanding of biomechanics by operating
surgeons in general. Poor biocompatibility, a lam-
inar construction of significantly dissimilar mate-
rials unable to resist translation shear, and poor
stability of the alloplast unfortunately created
a negative attitude toward all joint surgery. If sur-
geons had received proper biomechanical training,
the failure of these devices would have been pre-
dicted. Instead, rather than focusing on under-
standing significant pathologic derangement
processes and their diagnoses that do not respond
to nonsurgical therapy, management protocols
have become somewhat generic and are used
initially because of their inherent conservatism.
A conservative means justifies the use of conserva-
tive, generic surgical intervention, and the litera-
ture does not show specific surgical procedures
being applied to meet specific orthopedic patho-
logic processes.
Indications for initial use of arthroplasty
or meniscectomy
Lateral joint compartment impingements
Historically, imaging studies such as arthrog-
raphy and then MRI eventually created derange-
ment staging parameters that are based on a
two-dimensional imaging concept [72–75]. Reduc-
ing and nonreducing disc displacements are primar-
ily sagittal dimensional descriptions that may not
describe subtle disease states and potential ortho-
pedic dysfunction in the third dimension or coro-
nal plane of the joint system. Diagnostic imaging
of TMJ derangement in the coronal plane is equally
important and may show significant clinical objec-
tive findings and explain subjective dysfunction
complaints when deeper sagittal examinations are
unremarkable (Figs. 17, 18, and 19).
As noted in the discussion of chronic joint
instability (see Fig. 5), biomechanical analysis pre-
dicts converging torque vectors in the lateralmost
aspects of the joint space, one directed inferiorly
from the lateral rim of the glenoid fossa by capsu-
lar attachments and another directed superiorly
from the lateral condylar pole and into the capsu-
lar/disc attachments. If tensile forces are created
and sustained, appositional bone growth along
the rim of the glenoid fossa will create simple pro-
gressive narrowing of the joint space in this re-
gion. This lateral impingement may explain the
patterns of perforation and destruction shown
by Westesson [40], and could also cause increased
shear, particularly during translation. Therefore,
primary arthroplasty is indicated as the initial sur-
gical intervention when significant narrowing of
the lateral compartment exists, when condyle
and fossa arthrosis exists, and when concomitant
rupture of the disc/capsule attachment at L1 and
L2 (Fig. 8) is suspected. Its chief advantage is
the ability to examine all four surfaces of joint
anatomy and effectively reinforce the inferior
and lateral disc/capsule attachments (L1 and L2)
to the lateral condyle periosteum or capsular
attachments.
Basic biomechanical analysis would argue that
reinforcement and stability of these attachments
are necessary to ensure long-term surgical success
of any surgical intervention. This function, and
reestablishment of functional congruency of all
four articulating surfaces of the joint, must be
accomplished by whatever means at the initial
surgical encounter. Therefore, the first surgical
encounter must address all areas of disease
contributing to orthopedic dysfunction and en-
sure resistance to forces generated in the lateral
compartment. Otherwise, any intervention may
fail and secondary or tertiary procedures may be
required that yield less satisfactory results because
of irreversible qualitative tissue deterioration.
Significant TMJ impingement conditions are
usually associated with significant pain in eccen-
tric mandibular movement, particularly toward
the side of the impingement. In all cases, patients
present with longstanding orthopedic instability,
failure of orthotic decompression, and inability to
load the affected joint with any significant force
required for routine mastication. The full extent
of these conditions can only be appreciated with
quality coronal imaging, preferably MRI. A key
technical note is that the magnitude of lateral
impingement often makes it impossible to in-
troduce arthroscopic instruments or cannulate
and visualize structures because of acute curva-
ture of lateral fossa architecture. These conditions
should be diagnosed initially when considering
surgical technique so that unnecessary or un-
successful arthroscopic procedures, intraoperative
conversion, or secondary arthroplasty procedures
are not performed (see Fig. 10). Another technical
consideration is that usually the volume of bone
that must be removed along the lateral fossa rim
 PRIMARY TMJ ARTHROPLASTY 355

is significant and cannot be managed efficiently by Type II impingement

most microarthroscopes used in TMJ surgery.
Coronal plane pathology of the
temporomandibular joint
Type I impingement
In type I impingement, congruency of struc-
tures is lost because of lateralmost joint space
narrowing by bone apposition along the rim, or
developmental mediolateral width discrepancies
between the fossa and condyle (Figs. 9 and 14).
The impingement interferes greatly with transla-
tion, creating significant narrowing of the lateral
component of the superior joint space and may
or may not be associated with joint locking during
attempted translation. The condyle may exhibit
early reaction and lateral pole and surface mor-
phologic abnormalities (osteophytes) that increase
shear even further, creating tears in the inferior
laminar attachments to the condyle. Impingement
is generally limited to the lateralmost aspect of the
joint. Sagittal MRI views of central or medial re-
gions of the joint are often unremarkable or reveal
minimal stages of derangement (Wilkes stage II
derangement) and less tissue destruction. This
condition can be successfully managed with ar-
throplasty if fossa rim impingement is successfully
relieved, small condyle osteophytes are removed,
and adequate reattachment and reinforcement of
quality tissues occurs at the lateral, inferior at-
tachments to the condyle (L1 and L2) (see Fig. 8).
In type II impingement, osseous hyperplasia
along the lateral curvature of the fossa is more
extreme, sometimes extending 30% to 50% along
the mediolateral dimension. This condition is
generally seen in longstanding derangements,
advancing arthrosis, and potential cranial base
developmental deformities or asymmetries. This
type of impingement is almost always associated
with total rupture of the disc/capsule in the lateral
aspect and rarely presents with repairable quality
tissue. Discectomy and fossa contouring arthro-
plasty are generally required. Sagittal MRI images
are generally associated with Wilkes stage III or
greater derangement (Figs. 10, 11, and 15).
Type III impingement
In type III impingement, congruency of struc-
tures is lost because of gross joint space narrowing
from bone apposition along the lateral fossa rim,
and osteophytes or gross morphologic changes of
the lateral condyle (Fig. 12). Arthroplasty is the
only viable initial surgical choice because of its
ability to address condylar surface abnormalities.
Complete lateral disc/capsule rupture is com-
monly seen and discectomy is often required be-
cause of inferior disc surface destruction from
shear. However, when condylar osteophytes are
small and articular disc surface damage is mini-
mal, condyloplasty, relief of the fossa rim im-
pingement, and physical readaptation of the
disc/capsule over the condyle (creating functional

Fig. 9. (A) Schematic of type I impingement. Note narrowing of lateral joint space by appositional bone growth or
asymmetry and significant width differences between the fossa and condyle. (B) Surgical example of type I impingement.
Note significant hyperemia of lateral superior disc surface and medial migration of hyperemic response. Note fibrillation
and destruction of superior/lateral attachment of the disc/capsule (LC) and osseous impingement located along the pos-
terior slope of the articular eminence (I).
356 KIRK & KIRK

Fig. 10. (A) Schematic of type II lateral impingement. A greater volume of appositional bone projects inferiorly from
rim of the glenoid fossa toward the apex of the fossa. Type II differs from type I in that rupture of the lateral disc/capsule
has occurred. (B, C) Surgical view of type II impingement. Note bone impingement (I) into disc/capsule. In C, impinge-
ment has been removed, showing full extent of damage from impingement and rupture (r) of disc/capsule with under-
lying condyle visible.

congruency) can yield satisfactory results. The key MRI diagnosis of lateral compartment
to this procedure is anchorage of the disc/capsule impingement
at L1-L2 to condylar periosteum or lower capsu-
Coronal imaging is necessary to diagnose and
lar attachments to the condyle and surgical recre-
categorize degree of lateral compartment impinge-
ation of adequate lateral joint space sufficient to
ment (Fig. 13). For several reasons, it is recom-
allow unimpeded translation and eccentric man-
mended that the TMJ be imaged in the sagittal
dibular movement to the affected side. However,
and coronal dimensions in centric dental occlu-
usually destruction of disc tissues is extreme
sion and with an oral orthotic (bite plate, splint,
and repair with good quality tissue is impossible
etc.) in place. First, sagittal imaging of the joint
(Fig. 16).

Fig. 11. (A) Arthrotomy exposure of type II impingement. Note loss of sigmoid curvature of lateral fossa and apposi-
tional bone extending medially, and hyperemia and fibrillation of lateral disc/capsule region. (B) Postrelocation of disc/
capsule to a congruent relationship with mandibular condyle. LA 1 and LA 2 have been secured and reinforced. The
lateral fossa rim has been relieved. Note redefinition of sigmoid curvature and more depth of the fossa is now visible.
 PRIMARY TMJ ARTHROPLASTY 357

Fig. 12. (A) Schematic of type III impingement. Note greater surface area of involvement with appositional activity ex-
tending deeper into the glenoid fossa and reactive appositional activity of the lateral condyle. (B) Intraoperative view of
inferior joint space and large appositional activity of lateral one third of condyle. See MRI in Fig. 16C.

without the orthotic confirms Wilkes stage of de-
rangement under maximum occlusal load. Imag-
ing with the orthotic confirms whether the device
has any ability to adequately decompress the joint
and perhaps restore some semblance of anatomic
or functional congruency. In addition, coronal
imaging without the orthotic indicates the degree
of osseous impingement during function. Using
the orthotic provides a better visual image of the
fossa and condyle and relative degrees of joint
space among the lateral, central, and medial re-
gions, and sometimes shows higher signal inten-
sity from hyperemic tissues (Fig. 14A), condylar
abnormalities (Figs. 16B, and 17B), and ruptures
of the disc/capsule to the lateral condyle (Figs.
15B and 18B).
Surgical technique
The approach to the TMJ has been described
by Dolwick [76] and others. This section provides
technical suggestions for primary arthroplasty or
discectomy during surgery for Wilkes stage
III–V derangement.
Exposure of the TMJ lateral capsule should
continue along temporalis fascia and inferiorly
below the condyle to approximately the midcon-
dylar neck. This part of the procedure should be
performed using blunt means to avoid neural and
vascular structures and the superior portion of
parotid gland in the area. Blunt dissection (using
a Freer elevator) should be continued just anterior
and posterior of the condyle so that the entire
lateral pole and condylar neck just below the pole
can be digitally palpated. Blunt dissection should
also expose the zygomatic arch, fossa, superior
joint space, condylar pole, and superior condylar
neck, and terminate when all are easily palpable.
Injecting 2 to 4 cm3 of bupivacaine into the supe-
rior joint space distends the joint space and pro-
tects the superior disc surface from sharp entry
into the superior joint space. Entry is made with
small ophthalmology knives (eg, number 66, 67,
or 69 Beaver blade) while a 0.5- to 1-mm nerve
hook retracts the disc/capsule interiorly, defining
and enlarging the incision. Further blunt dissec-
tion can be used to free the disc/capsule if it is ad-
herent to the fossa. Posterior blunt dissection is
carried to the posterior fossa wall stopping short
of the petrotympanic fissure. It is then carried an-
teriorly and just beyond the articular tubercle to
allow full view of the entire lateral glenoid fossa
rim and medially to the medial pole. If the lateral
disc/capsule attachment is torn or ruptured, the
tissues in the posterolateral region (L1, L2) must
be cauterized because this region can be vascular.
The portion of the lateral ligament that was
divided entering the superior joint space is
grasped with a Gerald forceps and retracted
inferiorly while sharply dividing it from inferior
capsular and periosteal attachments covering the
358 KIRK & KIRK

Fig. 13. Normal coronal imaging. (A-D) Four examples of compatible condyles and fossae with no lateral impingement.
Despite differences in joint space among these joints, note relative magnitude of lateral joint space compared with more
central regions of the joint. Note congruent relationship of disc/capsule, condyle, and fossa and integrity of lateral disc/
capsule attachment. All views taken in centric dental occlusion.

lateral pole and periosteal attachments just below
the pole. This maneuver defines and comes
through the inferolateral synovial sulcus and
allows access to inferior capsular attachments
for later disc/capsule reinforcement. A vertical
incision is made just posterior to the condyle
through the posterior portion of the lateral
ligament, generating an anteriorly based triangu-
lar flap that is bluntly generated and sutured with
a tack suture to expose the lateral condyle, pole,
and superior 3 to 4 mm of the condylar neck and
remaining capsule and periosteal attachments.
Then the inferior joint space is distended with an
injection of bupivacaine. Inspection of the L1, L2
region of the capsular attachment will generally
show a rupture or near rupture. The inferior joint
space is entered below the condylar pole. Blunt
and sharp dissection should allow visualization of
the entire lower disc surface from just anterior to
the bilaminar zone to the freed region opposite the
 PRIMARY TMJ ARTHROPLASTY 359

Fig. 14. (A) Type I impingement. Note narrowing of lateral joint space caused by osseous hyperplasia and acute curva-
ture of inferior aspect of the lateral rim of the fossa, and the higher signal intensity of lateral disc/capsule tissues. Com-
pare with surgical view, Fig. 9B. (B) Bilateral coronal views. Type I impingement in patient’s left joint (right) compared
with more normal right side. Note decreased signal intensity of the lateral fossa rim and marked narrowing of lateral
joint space. (C) Bilateral type I impingement. Note high signal intensity in the right side (left) that represents rupture
of the lateral disc/capsule and medial displacement of disc/capsule.

articular eminence, and no further attempt is
needed to divide any part of the posterior bilami-
nar zone. The lateral fossa rim and lateral fossa
wall is exposed superiorly to just short of the top
portion of the zygomatic arch. A Wilkes retractor
is placed carefully so that pins are high enough on
the arch to allow full access for fossa rim relief
and low enough on the condyle neck to not
interfere with lateral capsule reinforcement.
Preoperative coronal MRI should provide
a preoperative diagnosis relative to extent of
medial fossa encroachment by any fossa
360 KIRK & KIRK

Fig. 15. (A) Type II impingement. Note degree of hyperplasia compared with type I with more medial extension. Note
thinning of lateral disc compared with more central region. (B) Bilateral coronal views. Note type II impingement in
patient’s left joint. Normal right joint. High signal intensity in lateralmost region is consistent with tearing or rupture
of disc/capsule in area LA 1. Surgical correlation is shown in Fig. 10B and C.

impingement process, and any other abnormali-
ties such as condylar surface irregularities and
osteophytes. If inspection of the inferior disc
surface shows extensive shear damage and rupture
of the inferoposterior disc/capsule attachment and
quality of articular disc/capsule tissue too poor to
complete effective and stable repair (see Fig. 3),
discectomy is performed with the Wilkes retractor
opened to allow good visual access to the medial
pole. Again, small ophthalmology knives are
used to sharply divide and remove the disc portion
from the anterior, posterior, and medial capsular
attachments. The anterior or medial capsule at-
tachments should never be violated. Posterior sy-
novial tissues are then sutured together in the
posterior attachment area. Procedures such as lat-
eral impingement processes and condyloplasty are
now performed. No interpositional material is
placed.
If disc/capsule tissues have not sustained
irreversible shear damage in the lower compart-
ment, reparative arthroplasty can be performed in
type I, II, and rare instances of type III impinge-
ment. Repair begins with the condyle in
a translated position, just opposite the articular
eminence. If convexities exist on the lower disc
surface, they are removed. Condyle irregularities
are removed and the lateral rim of the glenoid
fossa is relieved to remove any and all impinge-
ment. The fundamental consideration is the elas-
ticity of the disc capsule and reestablishment of
congruency of articular components, as seen in
Fig. 20. A small incision in the posterior attach-
ment may be necessary to allow posterior and lat-
eral rotation and adaptation of the disc/capsule to
the condyle. An incision of only 2 to 3 mm is gen-
erally all that is required. Deeper incisions are not
recommended. The lateral attachments must be
reinforced well through individual sutures to the
lateral inferior capsular attachment (L1) and the
posterior lateral attachment (L2). Anchoring de-
vices advocated by Fields and Wolford [77] can
also be considered. The Wilkes retractor is now
removed and joint range of motion is checked. If
lateral impingement is still present, further relief
of the rim of the fossa and lateral eminence are
performed protecting the superior disc/capsule
surface. After osseous recontouring of the lateral
 PRIMARY TMJ ARTHROPLASTY 361

Fig. 16. (A) Early type III lateral impingement. Note early osteophyte formation of lateral condyle, loss of signal inten-
sity of lateral disc/capsule attachment, and medial rotation of disc/capsule. (B, C) Type III impingement. Note signifi-
cant morphologic or developmental condylar deformities creating significant impingement in lateral joint space. Surgical
view of C is shown in Fig. 12B. (D) Bilateral coronal views showing type III lateral impingement in patient’s left joint.
Compare with more concentric image in patient’s right joint. Note rupture of capsular attachment in patient’s left joint
and reactivity of lateral condyle.

fossa is completed, the triangular flap containing
the lateral ligament generated earlier is used to
close the capsule of the joint and the is incision
closed in layers. Temporary pressure dressings
are placed.
Postoperative care
One disadvantage of arthroplasty repair is
a more prolonged recovery compared with ar-
throscopic procedures. Another disadvantage can
be some loss of contralateral eccentric movement
away from the operated joint [19]. Both condi-
tions are influenced by critical reinforcement of
the L1, L2 lateral capsule attachments.
An important study by Ben Amor and col-
leagues [78] provides actual physical thresholds of
force required to cause detachment of natural, un-
injured, or operated lateral attachments of the
disc/capsule in the L1, L2 regions. These regions
have a shear detachment threshold of 55.8 N for
L1 and 29 N for L2 (range, 20–40 psi), which
are less than 10% of the calculated reactive forces
calculated by Koolstra and colleagues [52] during
362 KIRK & KIRK

Fig. 17. (A) Sagittal MRI and Wilkes stage III derangement. This view does not show degree of osseous disease as seen
in Fig. 18B. (B) Coronal view of joint shown in Fig. 18A. Note significant osteophyte of lateral condylar pole and dis-
ruption of lateral disc/capsule attachment. Patient had previous unsuccessful superior compartment arthroscopic proce-
dure. Pain and gross instability during translation continued.

mandibular function. Because mastication is 3. Physical therapy protocols developed by Ro-

a complex orthopedic maneuver that includes ec- cabado [79] are encouraged. Manual range of
centric mandibular movement, great care must motion and postoperative pain management
be taken to prevent premature loading of an oper- modalities such as phonophoresis, ultra-
ated joint. TMJ surgical failures can be not only sound, and heat are begun approximately
technique-sensitive but also influenced by prema- 10 days postoperatively and are generally
ture loading and function. necessary for only 2 to 4 weeks in uncompli-
So that occlusal engagement and compressive cated cases. Reasonable expectations of ter-
loads do not introduce destructive torque to the minal range of motion goals are necessary.
repaired L1, L2 region, the following regimen is A 10% to 15% decrease in vertical jaw open-
recommended: ing is expected after arthroplasty repair. Pas-
sive range of motion devices can be used and
1. Continuous wear of mandibular orthotic
continued by the patient after active physical
(providing increase of interdental spacing
therapy is terminated and subjective range of
by 3 to 4 mms) for 1 month, followed by
motion goals are met [80]. The treating phys-
gradual discontinuance of the orthotic until
ical therapist must understand TMJ
posterior occlusion is reestablished without
biomechanics and that physical medical
pain or joint soreness. Occasional minor oc-
modalities (eg, manual mobilization tech-
clusion adjustment may be required after 2
niques, phonophoresis, ultrasound, electrical
to 3 months. Continue nighttime or sleep-
stimulation) are often delivered at signifi-
duration wear indefinitely to protect against
cantly lower thresholds than for rehabilita-
potential bruxism loads. Continue to moni-
tion of other orthopedic systems.
tor patient compliance periodically for up
4. Patients and general dentists must be edu-
to 1 year after surgery.
cated in the risks associated with prolonged
2. Slow diet progression. Altered, nonchewing
mouth opening (eg, dental appointments, fu-
diets are recommended for the first month,
ture anesthetic intubations) to guard against
with gradual progression to tolerance of
iatrogenic hyperextension injury. General
a regular diet. Return to full mastication re-
dentists who may need to perform rehabi-
quired to manage foods such as most meats
litative occlusal procedures must be com-
and raw vegetables is not recommended for
municated with so that prolonged dental
at least 2 months, and only to patient toler-
appointments do not create potential transla-
ance thereafter. Any foods requiring signifi-
tion shear at the repaired regions during pro-
cant repetitive motion or increased bite
longed mouth opening. Prolonged dental
force to masticate is strongly discouraged.
 PRIMARY TMJ ARTHROPLASTY 363

Fig. 18. (A) Coronal imaging, lateral disc/capsule rupture. Sagittal MRI of TMJ 8 years after previous arthroplasty pro-
cedure. Sagittal relationship between condyle and disc has been maintained for 8 years since the initial operation. Patient
sustained hyperextension injury in a motor vehicle accident and returned for follow-up in pain and with limited range of
motion. (B) Coronal view of joint in A. Note increased signal intensity opposite the lateral pole of the left condyle. Repeat
surgery revealed rupture of the disc/capsule attachment at LA 1. In this image, LA 1 is now adherent to the lateral fossa
and rim of the glenoid fossa. Note maintenance of lateral joint space created after relief of type I impingement 8 years
previously. Repeat surgery and reattachment of capsule to condyle at LA 1 and 2 corrected damage from the injury.

appointments should be avoided for at least 6
months, if possible. Small to medium rubber
bite blocks or props are recommended during
dental procedures to allow patients to exert
closing muscle forces rather than opening
or prolonged lateral pterygoid force.
Summary
Surgeons who perform surgery on the TMJ
must be familiar with mechanical and biomechan-
ical factors that influence an orthopedic system
exhibiting curvilinear general plane motion. Any
surgical procedure must restore functional con-
gruency among all four articulating joint surfaces.
Any intervention should limit significant ortho-
pedic instability of the joint to eliminate the
progressive influence of torque and shear to the
lateral attachment of the disc/capsule to the
mandibular condyle. Significant MRI spectra are
likely among individuals who exhibit normal and
asymptomatic anatomic congruency of articulat-
ing components and those who have undergone
surgery or are asymptomatic and exhibit imaging
abnormalities in the sagittal dimension. Regard-
less of imaging characteristics, these patients
exhibit good painless mobility and function be-
cause of acquired or surgically corrected func-
tional congruency of joint components [81–88]. If
gross joint instability or progressive disease is not
present in early to intermediate derangement, bio-
mechanical analysis would argue that destructive
influences of shear and torque can be minimized.
Biomechanical analysis of chronic TMJ dys-
function also argues that destruction of the lower
364 KIRK & KIRK

Fig. 19. (A) Coronal plane imaging, condylar pole ‘‘peaking.’’ Sagittal view of patient with well-localized pain to the
lateral pole of the mandibular condyle and with pain on eccentric movement toward the affected side. Patient reported
mild to moderate joint instability for 5 years. (B) Coronal view of Fig. 20A shows sharp peaking process of lateral con-
dylar pole seen in early type III impingement development. Note adaptation of disc/capsule around peaking process. (C)
Early development peaking of lateral condylar pole. Compare with lateral condyle images in Fig. 16. Note thinning of
lateral aspect of disc but capsular attachment remains intact.

joint compartment supersedes that of the superior
joint compartment beyond a certain Wilkes stage
derangement (III–V). Various degrees of tissue
destruction and influences found in this compart-
ment of the joint must be appreciated, diagnosed
preoperatively, and addressed at the initial surgi-
cal intervention to eliminate their influences on
the instability of the system and further soft tissue
destruction. Biomechanical principles would also
argue that discectomy can be a viable initial
operation in Schellhas/Wilkes late-stage derange-
ments when gross articular soft tissue destruction
is present because of varying types of osseous
impingement. This operation essentially reduces
the system from a four-surface incongruent sys-
tem to a two-surface congruent system. No studies
of TMJ surgical procedures match the long-term
clinical effectiveness of this procedure reported by
Silver [89–91] and others when performed without
interpositional material.
Future training of surgeons who perform TMJ
surgery must include basic mechanical and bio-
mechanical parameters. An understanding of three-
dimensional functional and biomechanical princi-
ples is necessary to diagnose impairing TMJ
derangement and choose the initial surgical modal-
ity. During at least the past decade, discussions of
surgical management of TMJ derangements have
focused on the use of ever-increasing conservative
methodology. A conservative means justifies using
surgical intervention in patients who have clinically
significant derangement. However, these discus-
sions have not included a basic consideration of
pathologic biomechanics and techniques necessary
 PRIMARY TMJ ARTHROPLASTY 365

Fig. 20. Surgical arthroplasty reestablishing disc/capsule congruency with arthroplasty repair. (A) Condyle is in trans-
lated position beneath articular eminence. Articular disc/capsule is rotated medially and trapped beneath eminence. (B)
Disc/capsule has been relocated posteriorly and laterally in preparation of readaptation at L1-L2 region of lateral–
posterior attachments.

to correct all influences of the dysfunction. Evalua-
tion of all types of potential, contributing, three-di-
mensional types of pathology and better-designed
long-term, random clinical trials of all surgical pro-
cedures and arthrocentesis are needed.
In the future, before initial TMJ surgery is
decided, diagnostic parameters must include
three-dimensional imaging diagnoses, use of vary-
ing sagittal and coronal derangement classifica-
tion diagnoses, and the acknowledgment that
surgery is not necessarily a ‘‘last resort’’ treat-
ment, particularly when surgical success is much
more satisfactory in earlier-stage disease when
performed by experienced surgeons. The mindset
that requires initial arthrocentesis followed by re-
peated arthroscopy if that fails is bound to create
another round of surgical misconceptions and pa-
tients who have not experienced rehabilitation.
Principally, biomechanical principles must be ob-
served and understood and the objectives and
abilities of any given procedure evaluated so
that surgical consequences are fully appreciated
preoperatively and not discovered as a result of
accident or failure.
Acknowledgments
This article is dedicated to the memory and
career of H. David Hall, DMD, MD, Professor
and Chairman Emeritus, Department of Oral
Surgery, Vanderbilt University Medical Center,
Nashville, Tenn. May 15, 1931–February 24, 2005.
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