ANESTHESIA/FACIAL PAIN

Temporomandibular Joint Discectomy

With Abdominal Fat Graft Versus
Temporalis Myofascial Flap:
A Comparative Study
Matt DeMerle,* Olubukola O. Nafiu, MD, MS,y and Sharon Aronovich, DMDz
Purpose: Open temporomandibular joint (TMJ) arthroplasty with discectomy has been described as a
primary surgical treatment and as a secondary treatment when minimally invasive procedures have failed.
The aim of the present study was to compare TMJ discectomy with a fat graft versus TMJ discectomy with a
temporalis graft using the pain score and maximal interincisal opening (MIO).
Patients and Methods: We performed a retrospective study of patients who had undergone TMJ arthro-
plasty and discectomy with an abdominal fat graft or an interpositional temporalis flap at the University of
Michigan from 1999 to 2014. The predictor variable was the type of surgical intervention. The main outcome
variables were the pain score and MIO. Additional outcome variables were diet, medication use, the presence
of myofascial pain, and occlusal outcomes. The statistical analysis included the mean  standard deviation, a
1-way analysis of variance for continuous data, and Pearson’s c2 test for categorical variables.
Results: The study cohort included 50 patients, of whom 30 had undergone discectomy with a fat graft
and 20 had undergone discectomy with a temporalis myofascial graft. The mean pain scores were
decreased by 78.3% in the myofascial flap group and 52.8% in the fat graft group. Changes in MIO showed
a statistically significant increase in the fat graft group but only approached statistical significance in the
myofascial flap group.
Conclusions: The patients who had undergone TMJ arthroplasty and discectomy with a temporalis
myofascial flap showed significantly greater improvement in pain scores and marginal improvement in
the MIO compared with patients who had received an abdominal fat graft.
Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial
Surgeons
J Oral Maxillofac Surg 75:1137-1143, 2017

Patients with temporomandibular joint (TMJ) degener-
ative joint disease commonly present with pain,
limited mandibular range of motion, and difficulty
with mastication. When these symptoms persist
despite medical or nonoperative treatment, surgical
intervention might be indicated. Open TMJ arthro-
plasty with discectomy has been described as a pri-
mary surgical treatment and as a secondary
operation for cases in which minimally invasive inter-
ventions have failed to improve patient symptoms.1
The need to replace the articular disc remains a matter
of controversy, with a paucity of comparative studies
available. Although several short- and long-term
studies have indicated good clinical outcomes with
discectomy alone, others have reported continued
pain and limited mouth opening for a significant

Received from University of Michigan, Ann Arbor, MI. Address correspondence and reprint requests to Dr DeMerle:
*DDS Candidate, School of Dentistry. School of Dentistry, University of Michigan, 1011 North University
yAssistant Professor, Division of Pediatric Anesthesia, Avenue, Ann Arbor, MI 48104; e-mail: mdemerle@umich.edu
Department of Anesthesiology. Received May 10 2016
zClinical Assistant Professor, Department of Oral and Accepted November 30 2016
Maxillofacial Surgery. Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral
Conflict of Interest Disclosures: None of the authors have any and Maxillofacial Surgeons
relevant financial relationship(s) with a commercial interest. 0278-2391/16/31209-5
http://dx.doi.org/10.1016/j.joms.2016.11.028

1137
1138 COMPARATIVE STUDY OF TMJ DISCECTOMY WITH 2 DIFFERENT GRAFTS
percentage of patients.2-8 Moreover, radiographic
follow-up data have revealed significant degenerative
changes at the articular surfaces after discectomy
alone. Some surgeons believe these changes represent
adaptive remodeling and lack correlation with clinical
symptoms; however, others believe disc replacement
is necessary to prevent adhesion formation and pro-
gressive osteoarthritis and to achieve good clin-
ical results.
The materials used to replace the articular disc have
included alloplast grafts, autografts, and local flaps.
Examples of these include silicone and Proplast (Vitek
Inc, Houston, TX) implants, silicone sheets, autoge-
nous dermal graft, dermis-fat graft, auricular cartilage
graft, temporoparietal fascia flap, and temporalis myo-
fascial flap. Controversy exists regarding the need for
disc replacement after discectomy.9-16 In addition,
disc replacement could have significant
disadvantages. Autogenous grafts have the associated
morbidity of a second surgical site and possible
degradation once placed under functional loads;
alloplastic material such as silicone sheets must be
removed 3 weeks after the initial surgery, thus,
necessitating an additional procedure; and alloplast
grafts such as the Teflon-Proplast implants have under-
gone fragmentation with destructive foreign body
giant cell reactions requiring removal and additional
reconstructive surgeries.
In 1989, Feinberg and Larsen described the tem-
poralis muscle–pericranial flap (TMPF) for disc
replacement in TMJ surgery.17 Compared with
autogenous grafts, the advantages of the TMPF
include a vascularized flap in close proximity to
the TMJ that obviates the need for a distant donor
site, a disc-like separation of the articular surfaces
to decrease adhesion formation or ankylosis after
surgery, prevention of postoperative articular flat-
tening (remodeling), and a functional tissue
attached to the coronoid process anteriorly to simu-
late disc-like movement with anterior translation.17
The possible disadvantages of the TMPF for disc
replacement include increased surgical time, an
additional 2- to 3-cm extension to the usual incision
needed, extended anterior dissection with the risk of
facial nerve deficits, and a risk of hematoma forma-
tion at the harvest site, temporal hollowing, ipsilat-
eral posterior open bite secondary to flap
thickness, and temporal tendonitis or myofascial
pain secondary to muscle flap compression.
The purpose of the present study was to determine
the value of using an interpositional temporalis myo-
fascial flap after discectomy. We hypothesized that
no significant clinical differences would be found in
the outcomes between patients undergoing TMJ dis-
cectomy with a temporalis myofascial flap vs an
abdominal fat graft. The specific aims of the present
study were 1) to compare the change in pain scores
and maximal interincisal opening (MIO) in the 2
groups; 2) to assess the effects of these interventions
on diet and occlusion; and 3) to determine their effect
on opioid use.
Patients and Methods
To address the research purpose, we designed and
implemented a retrospective study of patients who
had undergone TMJ arthroplasty and discectomy
with an interpositional temporalis flap or an abdom-
inal fat graft at the University of Michigan from 1999
to 2014. All procedures were performed by faculty in
the Department of Oral and Maxillofacial Surgery.
Our institutional review board granted exempt status
for the present study.
We collected the demographic, diagnostic, clinical,
and operative data. These included gender, age, a spe-
cific diagnosis of the TMJ condition treated, disc sta-
tus, number of previous surgeries, pain level, diet
consistency tolerated, associated myofascial pain
(determined by the presence of muscular myalgia at
rest, on palpation, or on function), the presence of
an open bite (anterior or posterior) or other malocclu-
sion, joint sounds, opioid use, muscle relaxant use,
nonsteroidal anti-inflammatory drug (NSAID) use,
adjunctive physical therapy, occlusal splint therapy, a
diagnosis of anxiety or depression, the type of surgery
performed, perioperative complications, and follow-
up duration. The primary outcome variable was the
pain score from 0 to 10, 10 indicating the most severe
pain. The secondary outcome variable was the MIO,
measured in millimeters between the maxillary and
mandibular central incisors on active opening. The
other outcome variables included diet consistency
tolerated (regular diet, soft foods, or liquids only),
occlusal outcomes (normal, posterior open bite, ante-
rior open bite, or other malocclusion), the prevalence
of opioid and NSAID use, and the presence or absence
of myofascial pain.
We included adult patients who had undergone TMJ
arthroplasty and discectomy with a fat graft (fat graft
group) or discectomy with a temporalis myofascial
flap (flap group) at the University of Michigan for the
treatment of TMJ degenerative joint disease or other
pathologic entities of the TMJ. We excluded patients
who had undergone other types of TMJ procedures
such as arthroplasty with disc repair, eminectomy, or
total joint replacement. We also excluded patients
with a primary neuropathic pain condition and those
who did not have pre- or postoperative data available
for pain levels and the maximal mouth opening. In
addition, patients with an inadequate follow-up dura-
tion, defined as less than 1 month after surgery,
were excluded.
DEMERLE, NAFIU, AND ARONOVICH
TMJ arthroplasty was performed using a preauricu-
lar or endaural approach. The cases of discectomy
and interpositional temporalis flap placement were
performed according to the method described by Fein-
berg and Larsen.17 Discectomy with an autogenous
abdominal fat graft involved the harvest and place-
ment of a morselized adipose tissue graft between
the condyle and glenoid fossa.
STATISTICAL ANALYSIS
Statistical analysis was performed using PASW Statis-
tics, version 18.0, for Windows (SPSS Inc, Chicago, IL).
We performed basic descriptive statistics, including
the mean  standard deviation. Within-group and
between-group differences were analyzed using a
1-way analysis of variance for continuous data and
Pearson’s c2 test for categorical variables. Regression
analysis and backward model selection were used
to assess the predictors for the change in
outcome variables.
Results
We identified 284 patients who had undergone TMJ
arthroplasty for internal joint derangements and anky-
losis. After excluding patients with insufficient data,
65 patient records were examined for the demo-
graphic and clinical data. We excluded 4 patients
who had had primary neuropathic pain according to
the descriptors of the preoperative pain quality. The
discectomy-alone group included only 7 patients;
however, these patients were also excluded owing to
the small comparative sample size. Additionally, we
excluded 4 patients with ankylosis in the fat graft
group, because no matching comparison group was
present in the flap group. The final study cohort
included 50 patients, of whom 30 had undergone dis-
cectomy with an abdominal fat graft and 20 had under-
gone discectomy with a temporalis muscle flap. Of
these 50 patients, 47 (94%) were women. The mean
age of the study cohort was 45.4  13.2 years, and
the average follow-up duration was 6.7  6.2 months
(range 2 to 26). In both groups, anterior disc displace-
ment without reduction was the most common diag-
nosis, followed by arthralgia with unspecified disc
status (Table 1).
The overall prevalence of preoperative opioid use was
26%, and 38.0% of patients were taking NSAIDs preoper-
atively. Postoperatively, only 12% of patients continued
to use opioids, and 18% reported using NSAIDs. Patients
taking opioids preoperatively had higher baseline mean
pain scores compared with their peers without preoper-
ative opioid use (8.62  1.6 vs 7.1  1.9; F = 6.34;
P = .01). Similarly, preoperative NSAID use was signifi-
cantly associated with higher mean baseline pain scores
(7.9  2.1 vs 6.7  2.1; P = .041). However, a history of
1139
Table 1. DIAGNOSIS PREVALENCE STRATIFIED BY
PROCEDURE TYPE
Discectomy + Fat Discectomy With
Diagnostic Category Graft (n = 30) TMF (n = 20)
Arthralgia 9 5
ADDwR 2
ADDwoR 16 12
Disc perforation 2 2
Osteoarthritis 1
Synovial 1
chondromatosis
Abbreviations: ADDwR, anterior disc displacement with
reduction; ADDwoR, anterior disc displacement without
reduction; TMF, temporalis myofascial.
DeMerle, Nafiu, and Aronovich. Comparative Study of TMJ Discec-
tomy With 2 Different Grafts. J Oral Maxillofac Surg 2017.
depression or anxiety was not significantly associated
with higher preoperative pain scores in our study sub-
jects. The mean pain scores decreased by 78.3% in the
flap group (P < .001), 52.8% in the fat graft group
(P < .001), and 62.6% in the overall sample (P < .001;
Fig 1). Changes in the MIO are shown in Figure 2. The
MIO increased significantly for the flap group
(P = .004), but the difference only approached signifi-
cance in the fat graft group (P = .050). A comparison
of patient variables between the 2 groups revealed signif-
icantly greater improvement in pain scores and margin-
ally greater improvement in the MIO for the flap
group (Table 2).
Notably, 80% of the patients in the fat graft group
had undergone previous operative procedures
FIGURE 1. Change in pain score stratified by for the combined
sample and surgical group. F/U, follow-up visit.
DeMerle, Nafiu, and Aronovich. Comparative Study of TMJ Discec-
tomy With 2 Different Grafts. J Oral Maxillofac Surg 2017.
1140 COMPARATIVE STUDY OF TMJ DISCECTOMY WITH 2 DIFFERENT GRAFTS

In the fat graft group, 1 patient had undergone previ-

ous arthrocentesis and modified condylotomies, and
another patient had undergone 4 previous surgeries,
including bilateral disc plications, discectomies with
dermal graft placement, costochondral rib grafts, ar-
throcentesis, and steroid injections.
Overall, fewer patients required postoperative opi-
oids 3 months after surgery compared with those
requiring opioids preoperatively (27.9 vs 13.1%;
c21df = 4.07; P = .04). A significant decrease in opioid
use was seen in the flap group (P = .030). Preopera-
tively, although 30% of the patients in the flap group
were using a muscle relaxant, only 15% reported using
one postoperatively. Postoperative myofascial pain
was decreased overall, with only a small proportion
of patients reporting muscular myalgia (Table 3). Surgi-
FIGURE 2. Change in maximal interincisal opening for the com-
cal success by procedure type is listed in Table 4. An
bined sample and stratified by surgical group. F/U, follow-up visit. MIO of 35 mm or more was achieved in 55% of the
DeMerle, Nafiu, and Aronovich. Comparative Study of TMJ Discec- flap group and 40% of the fat graft group. Pain scores
tomy With 2 Different Grafts. J Oral Maxillofac Surg 2017. of 2 or less were reported by 66.6% of the flap group
and 31.5% of the fat graft group.
A simple regression analysis demonstrated a signifi-
compared with only 45% of the patients in the flap
cant association between the predictor and outcomes
group. However, this difference was not statistically
variables. Specifically, the use of the flap procedure
significant. The vast majority of patients who had
was associated with a 7.25-point reduction in the
undergone previous surgery had undergone arthro-
mean pain score and a 4.38-point greater reduction
centesis. In the flap group, 1 patient had previously
compared with the fat graft group (P = .0031). The pri-
undergone right TMJ disc plication with eminectomy.
mary predictor variable was not associated with the
MIO. Multivariate regression analysis and backward
model selection were used to assess the predictors
Table 2. BASELINE CLINICAL AND PERIOPERATIVE for the changes in outcome variables, including the
FEATURES STRATIFIED BY SURGICAL TECHNIQUE
pain score and MIO. We found that the use of opioids
Fat Group Flap Group
Variable (n = 30) (n = 20) P Value
Table 3. BASELINE CLINICAL AND POSTOPERATIVE
Age (yr) 42.6  11.6 47.9  15.0 .164 OPIOID, NSAID, AND MUSCLE RELAXANT USE
Follow-up (mo) 7.6  7.1 5.3  4.2 .192 STRATIFIED BY SURGICAL TECHNIQUE
Pain score
Preoperatively 7.2  1.6 8.3  1.6 .018* Fat Graft Flap Group
Postoperatively 3.4  2.3 1.8  1.7 .024* Variable Group (n = 30) (n = 20) P Value
(n = 26) (n = 15)
MIO (mm) Opioid use (%)
Preoperatively 27.5  7.3 27.6  7.6 .975 Preoperatively 20.0 35.0% .194
Postoperatively 30.5  7.2 34.4  5.9 .051* Postoperatively 20.6 0.0% .030*
Patients with previous 24 (80) 9 (45) .124 NSAID use (%)
TMJ surgery Preoperatively 29.4 50.0% .130
Patients with 3 1 .524 Postoperatively 26.6 5.0% .050
additional Muscle relaxant use (%)
postoperative Preoperatively 5.9 30.0% .016*
symptoms Postoperatively 17.6 15.0% .801
Complications 1 (3.33) 2 (10) .786 Myofascial pain (%)
Preoperatively 38.2 35.0% .812
Data presented as mean  standard deviation or n (%). Postoperatively 20.6 10.0% .313
Abbreviations: MIO, maximal interincisal opening; TMJ,
temporomandibular joint. Abbreviation: NSAISD, nonsteroidal anti-inflammatory drug.
* Statistically significant. * Statistically significant.
DeMerle, Nafiu, and Aronovich. Comparative Study of TMJ Discec- DeMerle, Nafiu, and Aronovich. Comparative Study of TMJ Discec-
tomy With 2 Different Grafts. J Oral Maxillofac Surg 2017. tomy With 2 Different Grafts. J Oral Maxillofac Surg 2017.
DEMERLE, NAFIU, AND ARONOVICH
Table 4. DISTRIBUTION OF SUCCESSFUL RESULTS STRATIFIED BY PROCEDURE TYPE
Fat Flap Group (n = 30)
Criteria Preoperatively
MIO $35 mm 3 (10)
Pain score #2/10* 0 (0)
Data presented as n (%).
Abbreviation: MIO, maximal interincisal opening.
* Minimal to no pain.
DeMerle, Nafiu, and Aronovich. Comparative Study of TMJ Discectomy With 2 Different Grafts. J Oral Maxillofac Surg 2017.
preoperatively was the only predictor for the change
in pain score. Patients requiring opioids before surgery
had a decrease in the pain score that was 5 points
greater than that of patients not requiring opioids
before surgery (P = .016). None of the variables of
interest were predictors for the change in MIO.
One patient in the fat graft group experienced an
infection and 2 patients in the flap group experienced
complications. The latter included 1 patient who
developed a hematoma requiring evacuation and 1 pat-
ient who developed a hematoma, permanent paresis
of the temporal branch of cranial nerve 7, and hypoes-
thesia of the auriculotemporal nerve region.
Discussion
The purpose of the present study was to determine
the value of using an interpositional temporalis myo-
fascial flap after discectomy. We hypothesized that
no significant clinical difference would be found in
the outcomes between patients undergoing TMJ dis-
cectomy with a temporalis myofascial flap vs TMJ dis-
cectomy with an abdominal fat graft. The specific aims
of the present study were 1) to compare the change in
pain scores and MIO between the 2 groups; 2)
to assess the effects of these interventions on diet
and occlusion; and 3) to determine their effects on
opioid use.
In our comparative study, we found that compared
with the fat graft group, the patients who had under-
gone discectomy with a temporalis myofascial flap
experienced a significantly greater reduction in pain
(P = .024) and achieved marginally greater increases
in the maximal mouth opening (P = .051). In addition,
the flap group had a significantly larger reduction in
opioid use and a meaningful reduction in NSAID use
postoperatively. The procedure type remained signifi-
cantly associated with the mean pain score after a sim-
ple regression analysis, with the use of the flap
procedure associated with a 7.25-point reduction in
the mean pain score and 4.38-point greater reduction
compared with the fat graft group (P = .0031). On
1141
Flap Group (n = 20)
Postoperatively Preoperatively Postoperatively
12 (40) 6 (30) 11 (55)
19 (6) 0 (0) 12 (8)
multivariate regression analysis, preoperative opioid
use was a significant predictor for the change in pain
score (P = .016). Perioperative opioid use was thus a
significant confounding factor that might have been
influenced by the pain management strategies in use
at the time treatment was rendered. Despite concerns
that using muscle as interpositional tissue might
increase comorbid myofascial pain complaints, an
overall reduction in myofascial pain was observed.
Moreover, no difference was found in the incidence
of postoperative myofascial pain reported between
the 2 groups. Data on diet consistency and occlusal
outcomes were missing.
In 1989, Feinberg and Larsen17 reported on the
technique for harvesting and insetting a pedicled tem-
poralis muscle–pericranial flap that was used in the
present study. Their study included 13 patients
(19 TMJs), including 2 patients who underwent multi-
ple operation and several patients with persistent pain
and dysfunction after disc plications, discectomies
with dermal fat grafts, or disc replacement with the
Teflon-Proplast implant. They reported improved
function, with a 13.7-mm increase in the MIO from
21.1 to 34.8 mm. Only 1 patient had no improvement
in mouth opening.17
Smith et al18 reported on the use of the temporalis
myofascial flap as an interpositional material in the
TMJ of 23 patients (28 joints) who had undergone pre-
vious surgery with alloplastic or autogenous materials.
In their technique, a zygomatic arch osteotomy was
performed to access the mid-portion of the temporalis
muscle. The superficial belly of the temporalis muscle
was elevated after identifying the intramuscular fascia.
The average pain scores decreased from 8.2 preopera-
tively to 3.4 postoperatively (59% reduction), and the
mean MIO increased by 8.2 mm.18 In their study sam-
ple, 78% of the patients achieved good to excellent
results in terms of diet, and 80% of the patients were
satisfied or very satisfied. Although they reported a
slightly smaller reduction in pain scores, all the
patients included in their study had undergone previ-
ous open TMJ surgery, including 11 patients with
1142 COMPARATIVE STUDY OF TMJ DISCECTOMY WITH 2 DIFFERENT GRAFTS
multiple operations. The likelihood is greater that the
patients who had undergone multiple operations
because of chronic pain would have some degree of
allodynia and hyperalgesia secondary to central and
peripheral sensitization. This might account for the
persistent pain after surgery.
Among the patients who received a temporalis
myofascial flap in our study, only 45% had undergone
a previous surgical intervention, with most of those
being arthrocentesis. This could also explain our find-
ings of improved pain scores and MIO compared with
the fat graft group. Among the patients who under-
went discectomy with an abdominal fat graft, 80%
had undergone previous surgery (arthrocentesis pre-
dominantly), including 1 patient who had undergone
disc plications, placement of dermal grafts, and a cost-
ochondral rib graft and 1 patient with previous arthro-
centesis and modified condylotomies. Tzanidakis and
Sidebottom1 examined the success rate of open TMJ
surgery in patients in whom initial TMJ arthroscopy
had failed. Of 31 patients with various diagnoses,
they reported a success rate of 61%, with a lower suc-
cess for patients with more advanced Wilkes staging.
This might indicate that patients with previous sur-
geries will have lower response rates to subsequent
surgical interventions.1
The use of the temporalis myofascial flap in the TMJ
has been debated. An animal study by Thyne et al19
raised doubt about this approach after they demon-
strated avascular necrosis of the interposition tempo-
ralis flap, followed by degeneration and eventual
contact between the condyle and fossa in a sheep dis-
cectomy model.
Thyne et al19 did note that the coronoid process of
the sheep made it very difficult to lift the flap and
that the space available to rotate the flap underneath
the zygomatic arch was very small, potentially
compromising the vascular pedicle. In addition, the
temporalis fascia in sheep was less prominent and con-
tained a large amount of fat. These differences in anat-
omy and factors related to surgical technique could
have been responsible for the loss of viability found.19
The viability of the temporalis flap has also been
studied in humans. Umeda et al20 reported on the sta-
tus of the temporalis flap in 7 of 81 patients who had
undergone previous surgery. Four patients underwent
TMJ magnetic resonance imaging that revealed a soft
tissue signal consistent with muscle and/or fat in the
joint. In addition, the operative findings in 4 patients
revealed a well-positioned flap lining the glenoid fossa
that bled on incision. Histologic assessment from
biopsy specimens of the temporalis muscle flap
showed viable muscle tissue with nuclei. They
concluded that the temporalis flap remains biologi-
cally active and serves as a satisfactory TMJ lining
when inferiorly based.20
Rotskoff21 stressed that temporalis myofascial flaps
tend to fail on the medial aspect of the joint. This
area is difficult to access for suturing the flap and is
most often the thinnest portion of the flap. Patients
who undergo temporalis flap procedures tend to
have degenerative joint disease and, as such, will
have a decreased joint space. Rotskoff21 stressed the
importance of creating adequate space in the fossa
for placement of the flap, along with proper visualiza-
tion using optical magnification. Other techniques
used to facilitate insetting of the flap have included a
Wilkes retractor for vertical TMJ distraction to sepa-
rate the condyle and fossa and the use of a bone anchor
placed in the posterior aspect of the condylar head.
In conclusion, our study found significant improve-
ments in the pain scores and mouth opening after TMJ
arthroplasty with discectomy and temporalis myofas-
cial flap reconstruction. However, our study had
several limitations. We had a small sample size repre-
senting only 17.6% of the 284 patients treated during
the 15-year study period. This increases the potential
that significant correlations were identified by random
chance and reduced our power to detect potentially
real correlations. Also, the inherent bias and weak-
nesses associated with a retrospective study design
were present. Our mean follow-up period was
6.7 months, and we recognize that short-term changes
in pain levels and MIO might not guarantee long-term
improvement. Despite our goal to report on other
functional changes, the data related to diet consis-
tency and occlusion postoperatively were lacking.
Additional comparative prospective studies are
needed to evaluate the outcomes of open TMJ surgery
using validated instruments such as the jaw function
limitation scale and the graded chronic pain scale.
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