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Epidemiology, Diagnosis, and Treatment of

Temporomandibular Disorders

Article  in  Dental clinics of North America · July 2013

DOI: 10.1016/j.cden.2013.04.006 · Source: PubMed

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E p i d e m i o l o g y, D i a g n o s i s , an d
Tre a t m e n t o f Tem p o ro m a n d i b u l a r
D i s o rd e r s
Frederick Liu, DDS, MD*, Andrew Steinkeler, DMD, MD

KEYWORDS
 Temporomandibular disorders  Epidemiology  Diagnosis  Treatment

KEY POINTS
 Temporomandibular disorder (TMD) is a multifactorial disease process caused by muscle
hyperfunction or parafunction, traumatic injuries, hormonal influences, and articular
changes.
 Symptoms of TMD include decreased mandibular range of motion, muscle and joint pain,
joint crepitus, and functional limitation or deviation of the jaw opening.
 Only after failure of noninvasive options should more invasive and nonreversible treat-
ments be initiated.
 Treatment can be divided into noninvasive, minimally invasion, and invasive options.
 Temporomandibular joint replacement is reserved for severely damaged joints with end-
stage disease that has failed all other more conservative treatment modalities.

EPIDEMIOLOGY

Temporomandibular disorders (TMD) are a broad group of clinical problems involving

the masticatory musculature, the temporomandibular joint, surrounding bony and soft
tissue components, and combinations of these problems.1 Symptoms of TMD include
decreased mandibular range of motion, pain in the muscles of mastication, temporo-
mandibular joint (TMJ) pain, associated joint noise with function, generalized myofas-
cial pain, and a functional limitation or deviation of the jaw opening.1 The prevalence of
TMD is thought to be greater than 5% of the population.2 Lipton and colleagues3
showed that about 6% to 12% of the population experience clinical symptoms of
TMD. Patients with TMD symptoms present over a broad age range; however, there
is a peak occurrence between 20 and 40 years of age.4

Department of Oral and Maxillofacial Surgery, School of Dental Medicine, University of

Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19103, USA
* Corresponding author.
E-mail address: [email protected]

Dent Clin N Am 57 (2013) 465–479

http://dx.doi.org/10.1016/j.cden.2013.04.006 dental.theclinics.com
0011-8532/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
466 Liu & Steinkeler

TMD symptoms are more prevalent in women than men. Contrary to the known
increased health risk in postmenopausal women of conditions such as heart disease
and stroke, women tend to develop TMD during their premenopausal years.1 The rea-
sons behind the sexual disequilibrium in TMD prevalence are not entirely clear, but
some have suggested a hormonal influence.5–7 In fact, both animal and human studies
have suggested that sex hormones may predispose to TMJ dysfunction and cartilag-
inous breakdown.5–7 Elevated levels of estrogen have been found in patients with
TMD.1 However, no definitive link between these hormones and causation of TMD
has been established.
TMD is thought to be a multifactorial process secondary to muscle hyperfunction or
parafunction, traumatic injuries, hormonal influences, and articular changes within the
joint. Various investigators have found correlations between occlusion and TMJ symp-
toms. Mohlin and Kopp8 showed an association between occlusal interferences and
myofascial pain and dysfunction. They found links between posterior crossbite with
muscular discomfort. Patients with deep bites, class II malocclusion, and anterior
open bites may also be predisposed to myofascial pain.9–12

DIAGNOSIS AND CLASSIFICATION

In general, TMD can be divided into articular and nonarticular disorders. These disor-
ders are synonymous with intracapsular and extracapsular conditions, respectively.
Most nonarticular disorders present as myofascial pain focused to the muscles of
mastication (Fig. 1). In fact, more than 50% of TMD is myofascial pain. Other nonar-
ticular disorders include chronic conditions, such as fibromyalgia, muscle strain,
and myopathies. Myofascial pain and dysfunction is theorized to arise from clenching,
bruxism, or other parafunctional habits. The result is masticatory musculature strain,
spasm, pain, and functional limitation.2 Emotional stress also predisposes to clench-
ing and bruxism, which contributes to myofascial pain.13 Symptoms include chronic
pain in the masticatory muscles, radiating pain to the ears, neck, and head. Myofascial
pain can be treated with combinations of nonsteroidal antiinflammatory medications,
occlusal guards, physical therapy, muscle relaxants, and injectable local anesthetic/
steroid combinations into the masticatory muscle insertion points.

Fig. 1. Musculoskeletal structures of TMJ (lateral and medial views).

 Treatment of Temporomandibular Disorders 467

Articular disorders (internal derangement) can be divided into inflammatory and

noninflammatory arthropathies. Inflammatory articular disorders include rheumato-
logic processes, such as rheumatoid arthritis (RA), seronegative spondylopathies,
such as ankylosing spondylitis, psoriatic arthritis, gout, and infectious arthritis. Nonin-
flammatory articular disk disorders include osteoarthritis, joint damage from prior
trauma or surgery, or other cartilage or bone disorders (Table 1). Mechanistically,
articular disorders occur as a result of an altered balance of anabolic and catabolic cy-
tokines. This cytokine imbalance creates an inflammatory milieu, which leads to oxida-
tive stress, free radicals, and ultimately joint damage.2
Internal derangement equates to changes in the disk-condyle relationship.14 Disk
displacements are categorized as disk displacement with reduction or disk displace-
ment without reduction (Fig. 2). The fibrocartilage disk is typically displaced anterome-
dially but rarely may be displaced laterally or posteriorly.15–17 Anatomically, disk
displacement with reduction is interference between the mandibular condyle with
the articular disk during jaw opening or closing. This interference may generate click-
ing, popping, or crepitus in the joint, which can be associated with discomfort. Clicking
alone, however, is not diagnostic of articular disk displacement. During disk displace-
ment with reduction, the condyle meets the posterior aspect of the disk, which then
reduces to its proper position between the condyle and glenoid fossa.14,17 Articular
disk displacement is associated with TMD. One study found magnetic resonance im-
aging (MRI) evidence of disk displacement in 84% of symptomatic patients with TMD
versus 33% of asymptomatic patients.18 MRI findings, however, should not solely
dictate treatment because disk displacement may occur in asymptomatic patients.
Disk displacement without reduction results in a closed lock whereby the condylar
movement is physically blocked by the anteriorly displaced disk. Acute closed clock
is associated with limited mandibular opening and severe pain.14,17 Physical examina-
tion should include a general assessment of the head and neck, palpation of the masti-
catory muscles, occlusal analysis, examination of the jaw opening and closing, and
palpation of the TMJ. Palpation of the muscles of mastication may elicit mild to severe
pain. Masseters are palpated with fingers positioned over the angle of the mandible.
The temporalis muscles are palpated along the temple with the jaw relaxed and
clenched. The pterygoid muscles are palpated intraorally along the medial aspect of
the mandibular ramus between the tonsillar pillars.

Table 1
Articular and nonarticular disorders

Articular Disorders Nonarticular Disorders

Osteoarthritis Myofascial pain
Trauma Acute muscle strain
Infectious arthritis Muscle spasm
Prior surgery (iatrogenic) Fibromyalgia
Gout/pseudogout (crystal-arthropathies) Chronic pain conditions
Rheumatoid arthritis/juvenile RA Myotonic dystrophy
Psoriatic arthritis
Ankylosing spondylitis

Adapted from Ghali GE, Miloro M, Waite PD, et al, editors. Peterson’s principles of oral and maxil-
lofacial surgery. 3rd edition. Shelton (CT): People’s Medical Publishing House—USA; 2012. ISBN-10:
1-60795-111-8, ISBN-13: 978-1-60795-111-7. STAT!Ref Online Electronic Medical Library. Available
at: http://online.statref.com/document.aspx?fxid5100&docid51212. Accessed January 26, 2013.
1:56:41 PM CST (UTC -06:00).
468 Liu & Steinkeler

Fig. 2. Motion mechanics seen in temporomandibular joint with anteriorly displaced disc
and resultant closed lock.

In general, articular disorders are classified according to the Wilkes’ Staging Clas-
sification for Internal Derangement of the TMJ (stages I–V). Wilkes’ classification is
based on clinical, radiologic, and anatomic findings (Box 1).19 For research purposes,
a more detailed diagnostic classification is used. This classification is known as the
Research Diagnostic Criteria for TMD (RDC/TMD). The RDC/TMD classification sys-
tem is divided into 3 axes: axis I (muscle disorders), axis 2 (disk disorders), and axis
3 (arthralgias).20
Diagnosing TMD requires a focused history and physical examination. Pain and
limited range of motion are accepted symptoms of TMJ dysfunction. Radiographic
studies can also be used as supplemental diagnostic tools.
Periapical radiographs can be used to rule out dental pathologies as a cause of
referred pain. Cone beam computed tomography scans and panoramic radiographs
will provide detailed imaging of the joint’s bony structures but not the articular disk.
MRI is the modality of choice for examining the disk position and morphology (gold
standard). MRI may also show degenerative bony changes. MRI findings should not
alone dictate treatment strategies. One must combine patients’ clinical presentation,
signs, and symptoms along with TMJ imaging when developing a treatment plan. On
MRI, joint effusions are radiographic signs of inflammation.21 Inflammation indicates
a transition from adaptive to pathologic changes within the joint. The MRI diagnosis
of anterior disk displacement uses the most superior aspect of the condyle
(12-o’clock position) as a reference point.21 Anterior disk displacement is defined
radiographically when the posterior disk tissue is located anterior to the 12-o’clock
condylar position. Disk displacement may occur in asymptomatic patients such
that all radiographic findings must be placed in clinical context before beginning
TMJ treatments.
 Treatment of Temporomandibular Disorders 469

Box 1
Wilkes’ staging for internal derangement of the TMJ

I. Early stage
A. Clinical presentation: no pain or decreased range of motion, possible clicking
B. Radiographic presentation: disk anteriorly positioned, normal bony contours
C. Anatomic correlation: anterior displacement, normal anatomic form of bone, and disk
II. Early/intermediate stage
A. Clinical presentation: episodes of pain, opening clicks, intermittent locking
B. Radiographic presentation: anterior disk displacement, thickened posterior disk, bony
contours normal
C. Anatomic correlation: early disk deformity, anterior displacement, normal bony
contours
III. Intermediate stage
A. Clinical presentation: many painful episodes, intermittent closed locking, multiple
functional symptoms, decreased range of motion
B. Radiographic presentation: anterior disk displacement with disk deformity
C. Anatomic correlation: marked disk displacement and deformity, normal bony contours
IV. Intermediate/late stage
A. Clinical presentation: increased pain relative to earlier stages
B. Radiographic presentation: bony changes, such as flattened eminence, condylar
deformity, osteosclerotic changes
C. Anatomic correlation: adhesions of disk, bony changes, evidence of osteoarthritis,
osteophytes, no disk perforations
V. Late stage
A. Clinical presentation: episodic or continuous pain, crepitus, limited range of motion at
all times, constant functional difficulties
B. Radiographic presentation: disk perforations, gross deformities of bony structures and
cartilage, progressive arthritic changes
C. Anatomic correlation: gross hard and soft tissue changes, perforations, adhesions,
subcortical cysts

Adapted from Bronstein S, Merrill B. Disorders of the TMJ. Oral and Maxillofacial Surgery
Clinics North America. Philadelphia: Saunders; 1989.

TREATMENT

The treatment of TMJ osteoarthrosis and internal derangement can be divided into 3
broad categories: noninvasive, minimally invasive, and invasive management. The
specific management plan can vary depending on the specific diagnosis and severity
of TMJ disorder; however, the underlying principles of treatment apply universally.
1. Multidisciplinary approach involving multiple specialties, including general den-
tistry, oral medicine, orofacial pain, orthodontics, oral surgery, physical therapy,
and psychiatry may be necessary to fully address the problem from all angles.
2. There is progression of treatment only after failure of more conservative modalities.
The least invasive and most reversible treatments should be tried first. Only after a
470 Liu & Steinkeler

failure to alter the disease process and clinical symptoms should more invasive and
often nonreversible treatments be initiated.

Goals of treatment
1. Decreasing joint pain
2. Increasing joint function and opening
3. Preventing further joint damage
4. Improving overall quality of life and reducing disease-related morbidities

NONINVASIVE TREATMENT OPTIONS

Occlusal or Stabilization Splints
Physicians have used various types of splints since the eighteenth century for the
treatment of TMJ disorders.22 Today the use of splints has become one of the most
common in office initial treatments for TMD-associated pain. Since their inception,
splints are thought to work by unloading the condyle and in effect protecting the
TMJ and articular disk from degeneration and excessive articular strain.22 Although
there are varying designs, they all function similarly to disengage the condylar head
from the fossa and articular disk (see Table 1).
A recent meta-analysis of randomized controlled trials evaluating intraoral orthope-
dic appliances for TMD showed that hard stabilization appliances have good evidence
of modest efficacy in the treatment of temporomandibular joint dysfunction (TMJD)
pain compared with nonoccluding appliances and no treatment. Other types of appli-
ances, including soft stabilization appliances, anterior positioning appliances, and
anterior bite appliances, have some evidence of efficacy in reducing TMD pain.23
However, a Cochrane Database review of stabilization splint therapy for TMJ pain
revealed that there is insufficient evidence either for or against the use of stabilization
splint therapy.24 Clearly further randomized controlled studies with larger sample sizes
and longer duration of follow-up are needed to study the effectiveness of splint ther-
apy for TMD pain (Table 2).

Pharmacotherapy
Pharmacologic therapy in conjunction with other treatment modalities often plays an
important role in the management of articular disk and TMJ disorders. The aim of phar-
macotherapy can be divided into 2 main goals25:
1. Treatment of the underlying disease process
2. Alleviation of disease associated symptoms, such as pain and swelling
There are various classes of medications that function to target each of the 2 treat-
ment goals (see Box 1). Oftentimes it is necessary to use a combination of medica-
tions to treat both the pain as well as the inflammatory disease process, depending

Table 2
Major types of occlusal splints used in TMD therapy

Splint Type Design

Stabilization splint Hard acrylic with full coverage of maxillary and mandibular dentition
in centric occlusion
Repositioning splint Hard acrylic with full coverage of maxillary or mandibular dentition
with inclines to guide mandible to a more anterior position
Soft splint Similar to hard stabilization splints but made from a more inexpensive
pliable material
 Treatment of Temporomandibular Disorders 471

on the severity of disease. However, care must be taken to avoid the prolonged use of
certain medications, in particular analgesics, to prevent drug tolerance and depen-
dency. The health provider’s ultimate goal should be symptomatic relief for a period
of time in the hopes that this will break the disease cycle and lead to permanent
improvement.
Despite the frequent use of pharmacologic agents, numerous review articles have
shown insufficient evidence to support or not support the effectiveness of pharmaco-
logic interventions for pain in patients with TMJ disorders.26,27 There is an obvious
need for further randomized controlled trials to study the effectiveness of pharmaco-
logic interventions to treat pain associated with TMD (Table 3).

Physical Therapy
Physical therapy is commonly used in the outpatient setting to relieve musculoskeletal
pain, reduce inflammation, and restore oral motor function. Physical therapy plays an
adjunctive role in virtually all TMJ disorders treatment regimens. Various physical ther-
apy modalities are available to the outpatient health provider (see Table 2). Although
the evidence is weak, there are numerous systematic review articles that support the
efficacy of exercise therapy, thermal therapy, and acupuncture to reduce symptoms,
such as pain, swelling, and TMJ hypomobility (Table 4).29–31

MINIMALLY INVASIVE TREATMENT OPTIONS

Intra-articular Injections
Different therapeutic solutions can be injected directly into the TMJ space and allow
for the targeted treatment of inflammation and joint degeneration (see Table 3). The
TMJ has 2 unconnected cavities, superior and inferior, partitioned by the articular
disk. The superior space injection is the commonly used technique. However, a recent
review article showed that an inferior space injection, or simultaneous upper and lower
spaces injections, seemed to be more effective with increasing mouth opening and
decreasing TMJ-associated pain (Table 5).35

Table 3
Types of medication used in TMD treatment

Class Examples Function

NSAIDs Ibuprofen, naproxen, diclofenac, Reduce inflammation and pain
aspirin, etodolac
Opioids Codeine, oxycodone, morphine, Reduce pain
hydromorphone, meperidine
Corticosteroids Prednisone, dexamethasone, Reduce inflammation and pain
hydrocortisone
Muscle relaxants Cyclobenzaprine, carisoprodol, Reduce muscle spasm
baclofen
Antidepressants Amitriptyline, trazodone, Reduce muscle tension
fluoxetine, sertraline
Anxiolytics Alprazolam, lorazepam, Reduce tension and muscle spasm
oxazepam, diazepam, buspirone

Abbreviation: NSAIDs, nonsteroidal antiinflammatory drugs.

Data from List T, Axelsson S, Leijon G. Pharmacologic interventions in the treatment of tempo-
romandibular disorders, atypical facial pain, and burning mouth syndrome. A qualitative system-
atic review. J Orofac Pain 2003;17(4):301–10.
472 Liu & Steinkeler

Table 4
Description of treatment modalities for articular disk and TMJ osteroarthrosis

Modality Description
Exercise therapy Techniques include manual therapy, postural exercises, muscle stretching,
and strengthening exercises.28 Passive and active stretching of muscles
or range-of-motion exercise are performed to increase oral opening
and decrease pain.28
Thermal therapy It involves the superficial application of a dry or moist heat/cold pad
directly to the affected area typically in 20-min intervals. It is used in
conjunction with exercise therapy in the treatment of inflammation
and TMJ hypomobility.
Acupuncture It is thought to stimulate the production of endorphins, serotonin, and
acetylcholine within the central nervous system, or it may relieve pain
by acting as a noxious stimulus. Treatments involve placement of
needles in the face and hands and are typically given weekly for
a total of 6 wk.29

Arthrocentesis/Arthroscopy
Arthrocentesis and arthroscopy are safe and quick minimally invasive procedures that
are used in patients who are resistant to more conservative treatment modalities.
Oftentimes they are combined with immediate postoperative intra-articular injections
and the use of occlusal splints, pharmacotherapy, and physical therapy during the
recovery period (Tables 6 and 7).38

INVASIVE TREATMENT OPTIONS

Arthroplasty
TMJ arthroplasty involves the reshaping of the articular surface to remove osteo-
phytes, erosions, and irregularities found in osteoarthritis refractory to other treatment
modalities.34 These patients frequently also present with articular disk degeneration or
displacement, which can be repositioned, repaired, or entirely removed. All such pro-
cedures should be performed by an experienced oral surgeon under general anes-
thesia, and this is done using an open surgical approach through a periauricular

Table 5
Types of intra-articular injections used in treatment of TMJ and articular disk disorders

Hyaluronic Acid Corticosteroids

Benefits A natural component of TMJ Reduction of inflammatory factors
synovial fluid and lubricates and and reducing the activity of the
maintains the normal internal immune system
environment of the joints32
Adverse effects Mild pain and swelling at injection Infection and destruction of
site, mostly transient33 articular cartilage; avoid
long-term repeat injections34
Efficacy Improved long-term clinical signs Same short-term and long-term
of TMD and overall improvement improvements in symptoms,
of symptoms in comparison with clinical signs, and overall
placebo; no difference in condition compared with
radiological progression of hyaluronic acid32
disease32
 Treatment of Temporomandibular Disorders 473

Table 6
Arthrocentesis for TMD treatment

Arthrocentesis
Description Saline lavage of the superior joint space, hydraulic pressure and
manipulation to release adhesions, and elimination of intra-articular
inflammatory mediators (Fig. 3)36,37; less invasive than arthroscopy and
can be done in outpatient setting with local anesthesia and
intravenous sedation
Indication  Limited opening with anteriorly displaced articular disk without
reduction
 Chronic pain with good range of movement and displaced articular
disk with reduction
 Degenerative osteoarthritis
Contraindications  TMJ with bony or fibrous ankylosis
 Extracapsular source of pain
 Patients who have not undergone noninvasive treatment modalities
Efficacy Recently reported 83.5% treatment success rate in patients with internal
derangement and osteoarthritis (as defined as an improvement in
maximum jaw opening and a reduction in pain level and mandibular
dysfunction)38

Data from Fonseca RJ. Oral and maxillofacial surgery. Chicago: Saunders; 2000.

skin incision (Fig. 5). Complications are rare but can include wound infection, facial
nerve injury, permanent occlusal changes, relapsing joint pain, and life-threatening
vascular injuries.42 As with all TMJ-related surgeries, early postoperative physical
therapy and range-of-motion exercises are vital to achieving long-term functional
improvements.
 Disk repositioning: Reposition the disk back to its normal anatomic position in
patients with internal derangement. This procedure is most effective in disks
that are normal appearing (white, firm, shiny) with minimal displacement.
 Disk repair: Small disk perforations can be repaired with a tension-free primary
closure.
 Discectomy alone: Removal of the articular disk is indicated in patients with
severe disk perforation, complete loss of disk elasticity, and who are persistently
symptomatic even after disk repositioning.43 Although studies have shown there

Fig. 3. Minimally invasive treatment of TMD: Arthrocentesis.

474
Table 7
Arthroscopy for TMD treatment

Arthroscopy
Description Involves insertion of an arthroscope and inspection of the TMJ under
fluid distention under general anesthesia; allows for irrigation of joint
space, lysis of these adhesions, and mobilization of the joint under
direct visualization39 (Fig. 4)
Indication  Limited opening and pain secondary to internal derangement
 TMJ hypomobility secondary to fibrosis or adhesions
 Degenerative osteoarthritis
Contraindications  TMJ with severe bony or fibrous ankylosis
 Extracapsular source of pain
 Patients who have not undergone noninvasive treatment modalities
 Practitioner with lack of open joint surgery experience
Efficacy A large multicenter study reports more than 90% success rate as defined
as improved mobility, pain, and function.40 Arthroscopy led to greater
improvement in opening after 12 mo than arthrocentesis; however,
there was no difference in pain.41

Data from Fonseca RJ. Oral and Maxillofacial Surgery. Chicago: Saunders; 2000.

Fig. 4. Arthroscopic view of temporomandibular joint space showing evidence of multiple

disk adhensions.
 Treatment of Temporomandibular Disorders 475

Fig. 5. Open surgical approach made through outlined periauricular and endural skin
incision.

is generally an improvement in pain and maximal mouth opening following the

surgical removal of the disk, patients also exhibited signs of fibrous adhesions,
narrowing of joint space, and osteophyte formation on MRI.44–46
 Discectomy with graft replacement: The placement of a graft is thought to pro-
tect the joint from further degeneration and prevent the formation of fibrous ad-
hesions. The use of autogenous sources, such as temporalis flaps, auricular
cartilage, and dermal grafts, results in superior clinical outcomes compared
with alloplastic grafts.42 Studies have showed that autogenous grafts actually
did not prevent remodeling of the joint but may help to reduce the onset of crep-
itus resulting from discectomy alone.47,48 However, it was shown that discec-
tomy with dermis graft replacement does result in a statistically significant
improvement in pain, chewing, and general health (Box 2).

Total Joint Replacement

TMJ replacement is intended primarily at restoration of form and function, and any
pain relief gained is only a secondary benefit.47 The need for TMJ replacement typi-
cally indicates severely damaged joints with end-stage disease that has failed all other
more conservative treatment modalities. Autogenous costochondral bone grafts have
been frequently used in TMJ reconstruction in the past because of its gross anatomic
similarity to the mandibular condyle, ease of adaptation to the recipient site, and its
demonstrated growth potential in juveniles.49 However, because of potential
harvest-site morbidity and failure during the transplantation process or from functional

Box 2
Criteria for successful TMJ disk surgery

1. Mild, brief pain of no concern to patients

2. Vertical range of motion greater than 35 mm and lateral range of motion greater than 6 mm
3. Ability to tolerate a regular diet
4. Stabilization of any degenerative radiological changes
5. Absence of symptoms for at least 2 years
6. Absence of significant surgical complications

Data from Holmlund AB. Surgery for TMJ internal derangement. Evaluation of treatment and
criteria for success. Int J Oral Maxillofac Surg 1993;22:75–7.
476 Liu & Steinkeler

Fig. 6. Total joint replacement consisting of a fossa and condylar component held in place
by screw fixation.

loading, the use of alloplastic materials has become increasingly more popular in the
adult population.42 Currently, various custom and stock titanium joint designs are
available, which consist of both a fossa and a condylar component held in place by
screw fixation (Fig. 6). Studies have shown that both custom and stock alloplastic

Box 3
Indications and relative contraindications for TMJ alloplastic replacement

Indications
1. Ankylosis or reankylosis with severe anatomic abnormalities
2. Failure of autogenous grafts in patients who underwent multiple operations
3. Destruction of autogenous graft tissue by pathosis
4. Severe inflammatory joint disease that results in anatomic mutilation of the total joint
components and functional disability
5. Failure of Proplast-Teflon implant (Vitek Inc, Houston, Texas)
6. Failure of Vitek-Kent total or partial joints (Vitek, Inc, Houston, Texas)
Relative contraindications
1. Pediatric patients with immature facial skeleton
2. Patients with unrealistic expectations or lack of understanding of procedure
3. Uncontrolled systemic disease
4. Allergy to implant material
5. Active infection at implantation site

Data from Dimitroulis G. A critical review of interpositional grafts following temporomandib-

ular joint discectomy with an overview of the dermis-fat graft. Int J Oral Maxillofac Surg
2011;40:561–8.
 Treatment of Temporomandibular Disorders 477

TMJ replacements resulted in statistically significant improvement in pain level, jaw

function, and incisal opening (Box 3).50,51

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