Int. J. Oral Maxillofac. Surg.

2005; 34: 231–237

doi:10.1016/j.ijom.2004.06.006, available online at http://www.sciencedirect.com

Invited Review Paper

TMJ Disorder

The role of surgery in the

G. Dimitroulis
St. Vincent’s Hospital, Suite 5, 10th Floor, 20
Collins Street, Melbourne, Vic. 3000, Australia

management of disorders of the

temporomandibular joint:
a critical review of the literature
Part 2
G. Dimitroulis:The role of surgery in the management of disorders of the
temporomandibular joint: a critical review of the literature Part 2. Int. J. Oral
Maxillofac. Surg. 2005; 34: 231–237. # 2004 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The literature is unequivocal in its support for surgery in the

management of certain disorders of the Temporomandibular joint (TMJ).
Unfortunately, the literature on TMJ surgery is based more on observation than
science since randomised clinical trials comparing surgical treatment of the TMJ
with medical treatment and no treatment (i.e., placebo) do not exist. Because the
application of scientific principles in clinical studies which involve surgical
intervention are ethically unfeasible, the true benefit of surgical intervention for
Temporomandibular Disorders (TMD) may never be conclusively established.
Waiting for properly designed, placebo controlled, random clinical trials will only
Key words: temporomandibular joint; surgery;
impede the progress of surgical experience and frustrate the decision making for
indications; arthroscopy; arthrocentesis;
both clinicians and patients. Therefore, the current recommendations for surgery review.
must rely on the best available evidence. The aim of this, the second of two
papers, is to scrutinize the role of TMJ surgery in light of the controversies that Accepted for publication 8 June 2004
have appeared in the literature in recent years. Available online 10 November 2004

In part 1, we looked at the evolution
and molecular basis for surgical inter-
vention for TMJ disorders15a. Part 2 will
concentrate on the clinical controversies
of TMJ surgery that have appeared in
the literature over the last two decades.
The primary role of surgery is the physi-
cal debridment, repair and removal of
diseased tissues that cause pain and dys-
function within the TMJ. As a conse-
quence, the primary aim of surgery is to
reduce the symptoms of pain and to
improve the function of the joint. The
0901-5027/030231+07 $30.00/0
more localised the symptoms are to the
TMJ, the more effective the surgical
intervention19.
Building on Schwartz’s psychophysio-
logical theory of TMJ pain86, Laskin
introduced the term myofascial pain
and dysfunction (MPD) to distinguish
between those TMD patients with pri-
marily muscular related symptoms and
those with primarily joint related symp-
toms50. This simple concept significantly
improved the diagnostic awareness of
distinguishing between the two groups
# 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
of patients with TMD. Patients with
MPD are obviously not suitable for surgi-
cal intervention, whereas those with
articular (i.e., joint) symptoms may be
generally considered as potential surgical
candidates19. In clinical practice most
patients have a combination of muscle
and joint problems that require careful
evaluation to determine which of the two
is the primary or dominant component
and which is the secondary or reactive
component. Therefore, if the muscle
component is the primary cause, it must
232 Dimitroulis
be attended to by non-surgical means
before the need for surgical intervention
can be properly assessed13. Conversely,
when it can be demonstrated that the
muscle symptoms are reactive to what is
primarily a joint problem, then attention
should be focused to the joint which, in
turn, should lead to spontaneously resolu-
tion of the muscle symptoms. The aim of
this paper is to scrutinize the role of TMJ
surgery in light of the controversies that
have appeared in the literature in recent
years.
Indications for TMJ surgery
Indications for surgery in the manage-
ment of TMD may be divided into rela-
tive and absolute19. Absolute indications
are reserved for cases where surgery has
an undisputed central role. Uncommon
disorders such as tumours28,36, growth
anomalies52,95 and ankylosis8,42 of the
TMJ fall into this category70. Relative
indications involve cases where surgery
has a less clearly defined role, especially
where the option of non-surgical man-
agement plays a predominant role. The
relative indications for surgery in TMD
management are important because they
involve the most common disorders,
namely, TMJ internal derangement
involving disc position and integrity and
osteoarthrosis. In the literature, the pri-
mary indication for TMJ surgery is
invariably the failure of non-surgical
therapy. Unfortunately, failed non-surgi-
cal therapy may often be the result of
misdiagnosis or incomplete diagnosis
which is known to occur in up to 20%
of patients being treated non-surgically
for TMD. This far exceeds the 5% of
TMD patients often quoted in the litera-
ture as being suitable candidates for
TMJ surgery13,19. What the literature
often fails to emphasise is that about
75% of patients who fail to respond to
non-surgical treatment are also not suita-
ble candidates for surgery. Furthermore,
‘failed non-surgical treatment’ as a pre-
requisite for surgical intervention is
debatable because invasive treatment
modalities such as TMJ arthrocentesis or
arthroscopic lavage could well be con-
sidered as an early treatment option in
selected cases such as closed lock of the
TMJ15a.
What distinguishes the surgical candi-
dates from the rest of the group who
have fail non-surgical treatment are the
clinical and radiological presentation of
the disease. The key clinical features of
potential surgical candidates include
symptoms of pain and dysfunction well
localised to the TMJ19. Dysfunction may
include painful clicking, crepitus or
hypomobility of the joint. In the absence
of pain, the severity of the dysfunction
must be taken into account in terms of
the degree of disability reported by the
patient. The difficulty lies where patients
with similar levels of dysfunction often
report different degrees of disability23.
Surgical intervention should, ideally, be
based on objective criteria such as
whether a patient’s maximum interinci-
sal mouth opening (MIO) is sufficient
for routine dental care. A patient’s psy-
chosocial and cultural background is
also important in determining whether
surgical intervention is appropriate as
some patients may choose to avoid sur-
gery for whatever reason. This is parti-
cularly important when one considers
there are studies that show improvement
in TMD symptoms without treatment83.
Since historical evidence suggests that
TMD is not always a progressive disor-
der11,30, short-term relief may be
obtained through medication or arthro-
centesis depending on the diagnosis.
Radiological evidence of disease in
bone (i.e., tomograms or CT-scans) or
soft tissue (i.e., MRI’s) provides the
essential diagnostic ammunition in mak-
ing the case for surgical interven-
tion9,37,44,84. The findings of radiology,
however, should never be interpreted in
isolation. The decision for surgical inter-
vention must be based primarily on the
clinical findings in conjunction with fac-
tors such as the impact of the disease on
the well-being of the patient and the
prognosis of the disease when no treat-
ment is provided. Radiological investi-
gations should only play a supportive
role12. Over reliance on imaging may
lead to over treatment as there are often
cases where disc displacement and con-
dylar degeneration are found in asymp-
tomatic patients20,35,46,48. Surgical
intervention based on imaging studies
without reference to clinical findings
cannot be condoned. The only exception
is the obvious presence of insidious
tumours, which are rare28,36,70.
The literature appears to support the
view that surgery for common TMD
such as TMJ internal derangement and
osteoarthrosis are often considered under
two conditions. The first is when the
TMD is refractory to appropriate non-
surgical therapies and the second is
where the TMJ is the source of pain
and/or dysfunction that results in signifi-
cant impairment to the patient13,19.
Essentially, the most important prerequi-
site for surgery should be an accurate
and complete diagnosis. ‘Failed non-sur-
gical treatment’ as often quoted in the
literature may well be interpreted as
‘wrong diagnosis’ and therefore cannot
be accepted as a legitimate prerequisite
for surgical intervention. What this sug-
gests is that with an accurate diagnosis,
early surgical intervention may well be
the most appropriate course of action,
thereby eliminating the frustration of
ineffective non-surgical treatment mod-
alities.
According to the literature, internal
derangement of the TMJ which presents
as closed lock (i.e., disk displacement
without reduction) has been shown to be
effectively managed with TMJ arthro-
centesis (i.e., acute onset closed lock)
and TMJ arthroscopy (i.e., long standing
or chronic closed lock)10,14,15,67–69. Pain-
ful TMJ internal derangement where
there is little or no restriction of man-
dibular function (i.e., reducing disk dis-
placement) appears to respond to
condylotomy procedures where condylar
sag results in increased joint space and
relief of intra-articular pressure2,19,33.
Arthrotomy of the TMJ is reserved for
advanced stages of TMJ internal
derangement and osteoarthrosis19,22.
The general quality of the literature on
TMJ surgery is sub-optimal. Randomised
clinical trials comparing surgical treat-
ment of TMD with medical treatment
and no treatment (i.e., placebo) do not
exist. Because such studies are unfeasi-
ble, the true benefit of surgical treatment
for TMD may never be conclusively
established. The purists of evidence based
medicine will, therefore, ignore the
results of the studies on TMJ surgery
because of the bias and poor design
inherent in all such studies published to
date. According to RESTON & TURKEL-
77
SON , one way of determining whether
surgery does benefit some patients with
TMD is to undertake a meta-analysis of
published results. Instead of comparing
pre- and post-operative figures within
each study, they used published estimates
of improvements in untreated patients as
control values. Their meta-analysis sug-
gests that TMJ arthrocentesis and arthro-
scopy are effective in the management of
patients with TMJ disk displacement
without reduction. RESTON & TURKELSON77
also note that while the evidence for the
role of specific surgical procedures in
certain patients is reliable, better designed
clinical trials are needed to determine the
degree or magnitude of the benefits of
surgery. Even though the studies to date
are suboptimal, the results cannot be
ignored. Therefore, the current recom-

mendations for surgery must rely on the
best available evidence. Waiting for bet-
ter designed, placebo controlled, random
clinical trials will only frustrate the deci-
sion making for both clinicians and
patients77.
Minimally invasive procedures
Although miniaturised arthroscopy spe-
cially adapted to the TMJ first appeared
in the Japanese literature71 in 1975, a
decade passed before other surgeons
began to show interest in its application
for TMJ disorders54,79. What transpired
within a few short years thereafter was a
rapid evolution from diagnostic to thera-
peutic applications5,6,22,54,81. As sur-
geons became accustomed to the highly
technical procedure of small joint arthro-
scopy, simple lavage and lysis of adhe-
sions within the TMJ rapidly led to
complex operative procedures ranging
from synovial sulcus ablation to disk
suturing40,55,56. Miniaturised operative
instruments were developed for TMJ
surgical arthroscopy such as rotating
shavers, electrocautery tips and even
Holmium Yag lasers which helped deb-
ride, cut, remove and coagulate
damaged, diseased or inflamed tissues
within the joint40,47,55,72.
While major advances were being
made in the development of new and
highly sophisticated surgical arthro-
scopic techniques, most surgeons were
satisfied with the unmistakable benefits
of simple arthroscopic lavage and lysis.
Multiple studies reported 80–90% suc-
cess rate with arthroscopic lavage and
lysis for the management of patients
with painful limitation of mouth opening
resulting from closed lock of the
TMJ10,15,39,49,64,65,67,82,88. On the other
hand, data derived from surgical arthro-
scopy techniques is much harder to
interpret as different surgical techniques
were used to treat different conditions
ranging from closed lock to fibrous
ankylosis of the TMJ57. It was therefore
impossible to draw any uniform conclu-
sions about the effectiveness of any of
the heterogenous variety of procedures
reported for TMJ surgical arthroscopy.
Surgeons advocating surgical TMJ
arthroscopy were often at pains to
emphasise the reduced morbidity of
arthroscopic surgery compared to open
surgery19,40. The most significant omis-
sion in all the presentations and papers
on surgical arthroscopy was the length
of time the procedure took to achieve its
objectives as opposed to the same proce-
dure being approached through an
Role of surgery in disorders of TMJ
arthrotomy. To claim that operative TMJ
arthroscopy has the advantage of
reduced morbidity obviously does not
take into account the significantly
increased anaesthesia time compared to
convential open joint procedures.
Furthermore, working within the con-
fined space of the TMJ capsule for 2–
3 h surely entails a significant level of
morbidity to intra-articular tissues which
are constantly prodded and scraped by
the numerous instruments including the
arthroscope itself96.
While the studies published on TMJ
arthroscopic lavage and lysis are often
less than ideal in terms of design and
execution, the studies on TMJ surgical
arthroscopy are generally of poorer qual-
ity55–57,78. The major problem is the sur-
gical arthroscopy papers were focused
more on the actual technical aspects of
the procedure with little attention paid
to the all important inclusion-exclusion
criteria for patient entry into the study
and the outcome parameters in terms of
pain levels, mouth opening and jaw
function103. By the very nature of surgi-
cal arthroscopy, multiple procedures
were often undertaken in each joint, so
it is difficult to compare the outcomes
when each patient within the same study
had a different procedure performed57. It
is like trying to compare apples with
bananas.
After surgical arthroscopy peaked in
popularity in the early 1990s, it has
since waned in recent years as few sur-
geons are prepared to invest the extra
time and effort towards upgrading their
skills to undertake surgical arthroscopy
procedures. This is largely because sur-
gical arthroscopy has failed to provide
any firm evidence that the results are
superior to simple arthroscopic lavage
and lysis. In other words, it is difficult
to justify patients being subjected to the
added expense and increased potential
morbidity of surgical arthroscopy when
the literature does not support its role as
being superior to that of lavage and
lysis80,103.
Open TMJ surgery
In the field of open TMJ surgery, there
are three main controversies. One is the
role of disc repositioning surgery in light
of the results of TMJ arthroscopy and
arthrocentesis16,17. Another is whether
disc replacement is at all necessary fol-
lowing discectomy procedures31,58. The
third controversy is the use of alloplastic
or prosthetic devices in the management
of end-stage TMJ disease51.
233
While the removal of a fibrotic,
deformed or diseased disc is justified31,
the preservation of a healthy, freely
mobile disc is equally essential to healthy
TMJ function19,21,73. In his review of disc
preservation surgery, DOLWICK17 points
out that the role of disc repositioning sur-
gery for the management of TMJ internal
derangement has significantly diminished
in the light of the success of less invasive
procedures such as TMJ arthroscopy and
arthrocentesis16,20. Although the literature
appears to support the successful applica-
tion of disc repositioning procedures in
80–95% of cases, DOLWICK17 suspects the
reported successes may have been over-
stated. MONTGOMERY et al.63 found that
while disc repositioning surgery had sig-
nificantly reduced pain and dysfunction
in 51 subjects evaluated up to 6 years
post-operatively, they also found the
improvement in disc position was short
lived and not maintained over the follow-
up period for most patients. While there
is a small but significant minority of
patients who continue to suffer from
pain and joint dysfunction following disc
preservation procedures, DOLWICK17,98
recommends less morbid procedures such
as arthroscopy should be the preferred
treatment. As far as disc preservation pro-
cedures are concerned, the goal should be
the elimination of mechanical interfer-
ence to smooth joint function rather than
the repositioning of the disc to a normal
position16,17,20.
A diseased or deformed disc that inter-
feres with the smooth function of the
joint and is beyond salvage is a candidate
for discectomy. Discectomy of the TMJ
has the distinction of having the longest
follow up studies of any procedure for
the management of TMJ internal
derangement58. At least four stu-
dies24,87,91,93 looked at patients at least
20 years or more following TMJ discect-
omy and found complete resolution in
pain and restriction free diet in almost all
patients reviewed. An interesting out-
come in all discectomy patients reviewed
showed significant changes in the condy-
lar morphology, not only of the operated
joint but also evident on the unoperated
joint. AGERBERG & LUNDBERG1 suggested
that the altered radiographic morphology
in both the operated and unoperated
joints were the result of altered joint
loading following discectomy7,90. Animal
studies have found the condylar alteration
following discectomy to resemble degen-
erative joint disease at the histological
level38,106. Clinical studies involving
magnetic resonance imaging, however,
lend support for the opinion that the
234 Dimitroulis
radiographic changes of the condyle are
adaptive rather than degenerative because
the reduced symptoms do not correlate
with the significant condylar changes
seen following discectomy25,31,34. The
mechanism of pain relief and improve-
ment in function over the long-term fol-
lowing discectomy is still unknown. The
confusion is further compounded by the
results of non-surgical studies which
show a natural tendency for symptoms of
internal derangement to improve with
time11,30,66,83.
Despite the success of long-term stu-
dies of TMJ discectomy, there is a per-
ception among surgeons that disc
replacement is required to help reduce
the significant joint remodeling that is
seen following discectomy alone61. The
disasters which followed the early use of
alloplastic interpositional implants18,
such as sialastic3,101,102 and proplast-
teflon as disc replacement materi-
als37,45,99, gave way to the increased use
of autogenous grafts. Temporalis
flaps26,27,74, auricular cartilage32,53,100
and dermis grafts29,59,62 have been
reported with seemingly good results.
Unfortunately, most autogenous grafts
have been used to replace the initial
failed alloplastic implants which means
there were few cases reported of autoge-
nous grafts placed at the time of the dis-
cectomy. According to MCKENNA58 there
are too few data and too many variables
to show that autogenous graft placement
at the time of discectomy produces
superior results to discectomy alone.
This is inspite of the numerous animal
studies which appear to demonstrate the
benefits and advantages of the various
interpositional grafts following discect-
omy which have so far not been ade-
quately demonstrated in appropriate
clinical studies92,94,97. Therefore, the
routine use of disc replacement materials
and grafts following discectomy is not
currently supported by the literature
because long term results of discectomy
alone are far superior to short-term dis-
cectomy with grafts and disk preserva-
tion procedures58,90.
The use of alloplastic materials to
reconstruct or replace diseased tissues of
the TMJ began with disastrous results
when sialastic and then teflon-proplast
implants were used to replace the articu-
lar disc following TMJ discectomy proce-
dures in the late 1970s and early
1980s18,19,37,43,85,101. Before these
implants were withdrawn from the mar-
ket in 1988, it has been reported that up
to 20,000 such devices were implanted in
the United States alone89. Equally devas-
tating were the more complex partial and
total joint replacement devices such as
the Vitek-Kent protheses which contained
proplast-teflon that resulted in the famil-
iar bone erosion and foreign body giant
cell reactions in the surrounding tis-
sues18,51. Despite the disasters, prominent
surgeons like LOUIS MERCURI60, LARRY
WOLFORD105 and PETER QUINN76 continue
to advocate the use of alloplastic joint
reconstruction for a wide variety of TMJ
disorders such as ankylosis, inflammatory
joint disease such as rheumatoid arthritis
and also the multiply operated patients
with mutilated joints.
MACINTOSH51 suggests that our contin-
ued fascination with alloplastic joint
reconstruction stems largely from the
successful application of similar devices
in other joints, most notably the
hip. Unfortunately, those who advocate
the prosthetic joints fail to realise the
very different and unique biomechanics
and physiology of the TMJ compared to
other joints. Most importantly, candi-
dates for TMJ reconstruction are consid-
erably younger than those who generally
undergo hip replacement, for example.
Therefore, evaluations of 12–24 months
for TMJ joint replacements are meaning-
less to a 30- to 40-year-old patient who
has a potential life expectancy of up to
40 years or more51. The complexity of
present day TMJ prostheses reflect the
demands of close adaptation to natural
tissues which is essential for success.
Custom joint prostheses made from
stereolithographic models go some way
towards closely adapting to the existing
anatomy thereby minimising extensive
sacrifice of recipient tissues. Unfortu-
nately, the high expense and limited
availability of the stereolithographic pro-
cess means that the vast majority of
prosthetic TMJ components are prefabri-
cated off-the-shelf devices. Therefore,
the mandibular ramus, glenoid fossa and
articular eminence must be radically
adjusted to enable a close fit for the
unyielding alloplastic components. That
means that with every failure of an
implanted device, more of the natural
tissues have to be sacrificed to accom-
modate a new replacement device. Over
a 30–40 year life-span that would mean
that a good quality total joint may need
to be replaced at least two to three times
if the average life-span is, say, 10–15
years like it is for successful prostheses
used in peripheral joints of the human
body.
Another argument for the limitation of
alloplastic prosthetic devices for TMJ
reconstruction is that, unlike other joints
in the body where prosthetic joints are
the only option, the TMJ can be recon-
structed with autogenous grafts51. While
metatarsal and sternoclavicular grafts
have been reported104, the costochondral
or rib graft is the most commonly used
autogenous replacement for missing
mandibular condyles75. The main advan-
tage of using autogenous tissues to
reconstruct the TMJ is the ability to
easily adapt the graft to fit the defect,
unlike alloplastic implants where the
defect has to be prepared to accommo-
date the inflexible dimensions of the
prosthesis. MACINTOSH51 advocates a
combination of costochondral graft and
dermis lining the glenoid fossa as the
most suitable autogenous tissue recon-
struction of a mutilated TMJ. While
infection, fibrosis and ankylosis are still
possible with autogenous reconstruction,
additional complications such as hard-
ware loosening, severe inflammatory
response and foreign body reaction as
well as heterotopic bone formation are
found when alloplastic devices are used
to reconstruct the TMJ.
Studies have shown that the longer
the duration of the symptoms and the
greater the number of treatments (parti-
cularly failed treatments), the less likely
the patient will respond favourably to
further treatment4. This suggests that
prosthetic TMJ replacements are perhaps
the most likely procedures to fail con-
sidering that most candidates for pros-
thetic joints are long-standing failures.
Conclusion
The literature is unequivocal in its sup-
port for surgery in the management of
certain disorders of the TMJ. As far as
the common disorders such as TMJ
internal derangement (i.e., disc pathosis)
and osteoarthrosis are concerned, more
research is required to better define the
unique benefits of surgery that cannot be
derived from other treatment regimes.
The fact that non-surgical treatment
options work well in the management of
the more common TMD such as internal
derangement and osteoarthrosis means
that surgery is often relegated to the
treatment option of last resort. This is an
unfortunate general perception because
the benefits of early surgical interven-
tion, especially with arthrocentesis, are
gradually being realised. Essentially the
treatment for TMD should be tailored to
the diagnosis and not be restricted by
the belief that minimal intervention is
best. More harm is done by inappropri-
ate conservative treatment that fails, thus

worsening the prognosis for a more dis-
ease-directed surgical procedure. While
favouring those treatment modalities that
offer the greatest healing potential with
minimal morbidity19 sounds great, per-
haps it is better to excise a diseased disc
in the early stages than to expect the
patient to put up with their suffering in
the hope that an occlusal splint may be
worth a try for 3–6 months. This is a
dilemma that Oral and Maxillofacial
Surgeons will need to resolve and unfor-
tunately the literature is not very clear
when it comes to examples such the one
just described.
While surgery of the TMJ has been
pivotal in the management of uncommon
disorders such as ankylosis and neoplasia,
controversy still surrounds the role of sur-
gery in the management of the more
common disorders such as internal
derangement (i.e., disk pathosis) and
osteoarthrosis19. Even though the litera-
ture on TMJ surgery is largely positive, it
is important to temper the positive out-
comes reported with the limitations of
bias and poor study design inherent in
such studies. Ethically, it is almost
impossible to perform sham operations
on human subjects in order to determine
whether the surgical procedure in ques-
tion is indeed more effective than a
placebo response. While animal studies
have provided some insight into the
effects of surgical intervention on the
TMJ3,38,41,92,94,106, the results are difficult
to extrapolate to humans because of the
vastly different and complex biomecha-
nics of the human TMJ. Studies in mole-
cular biology are providing more useful
information than animal experiments ever
did, but the fundamental limitation in this
area of research lies in the interpretation
of the data collected.
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