diagnostics

Review
Temporomandibular Disorders: Current Concepts and
Controversies in Diagnosis and Management
Dion Tik Shun Li and Yiu Yan Leung *

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong,
Hong Kong, China; [email protected]
* Correspondence: [email protected]; Tel.: +852-28890511

Abstract: Temporomandibular disorders (TMD) are a group of orofacial pain conditions which are
the most common non-dental pain complaint in the maxillofacial region. Due to the complexity of
the etiology, the diagnosis and management of TMD remain a challenge where consensus is still
lacking in many aspects. While clinical examination is considered the most important process in the
diagnosis of TMD, imaging may serve as a valuable adjunct in selected cases. Depending on the
type of TMD, many treatment modalities have been proposed, ranging from conservative options to
open surgical procedures. In this review, the authors discuss the present thinking in the etiology and
classification of TMD, followed by the diagnostic approach and the current trend and controversies
in management.

Keywords: temporomandibular disorders; temporomandibular joint; TMD; facial pain; craniomandibu-

lar disorders







Citation: Li, D.T.S.; Leung, Y.Y.

Temporomandibular Disorders: 1. Introduction
Current Concepts and Controversies The diagnosis and management of the most common cause of non-dental pain in the
in Diagnosis and Management. maxillofacial region, namely temporomandibular disorders (TMD), remains a challenge for
Diagnostics 2021, 11, 459. https://
clinicians to this day, despite extensive clinical research into the topic. This is because TMD
doi.org/10.3390/diagnostics11030459
is a broad term comprising of different conditions with complex etiologies, with symptoms
that vary in intensity. Intriguingly, some signs and symptoms resolve spontaneously even
Academic Editor: Luis
without treatment, whereas others persist for years despite all treatment options having
Eduardo Almeida
been exhausted. More perplexing is that while some may have a recognizable physical
basis, many cases of TMD also involve a significant biopsychosocial component [1–3]
Received: 17 February 2021
Accepted: 5 March 2021
with various associated psychological symptoms, such as depression and anxiety [4–6].
Published: 6 March 2021
Numerous treatment modalities have been proposed over the years, with some becoming
obsolete while others are gaining in popularity. Nevertheless, it seems that there is no single
Publisher’s Note: MDPI stays neutral
solution for every case as many different symptoms are included in TMD. Controversies
with regard to jurisdictional claims in
exist in the literature regarding the diagnosis and the management protocol for TMD, hence
published maps and institutional affil- the selection of treatment modality may often be largely influenced by the expertise of the
iations. treating healthcare provider.
In general, TMD is believed to affect anywhere between 5 and 15% of adults in the
population [7–10], yet TMD related symptoms have been reported to be present in up to
50% of adults [11]. Interestingly, there is evidence that the prevalence of TMD appears
Copyright: © 2021 by the authors.
to be on the rise in recent years [12–16]. A recent systematic review and meta-analysis in
Licensee MDPI, Basel, Switzerland.
2021 concluded that the prevalence of TMD was 31% for adults and 11% for children and
This article is an open access article
adolescence [17]. The fact that TMD encompasses a broad assortment of clinical diseases is
distributed under the terms and partially responsible for the wide range of prevalence rate estimates among studies, as the
conditions of the Creative Commons classification of different types of TMD, the distinction between disease and non-disease,
Attribution (CC BY) license (https:// as well as whether to include those with inactive disease as having TMD, may all be
creativecommons.org/licenses/by/ subject to the partialities of the assessing clinical researchers. In addition, studies that
4.0/). are questionnaire-based might over-estimate the prevalence of TMD, as the symptoms of

Diagnostics 2021, 11, 459. https://doi.org/10.3390/diagnostics11030459 https://www.mdpi.com/journal/diagnostics

Diagnostics 2021, 11, 459 2 of 15

many other conditions, such as headache not caused by TMD, dental pain, neuropathic
conditions, and otological diseases, can mimic the presentation of TMD.
TMD represents a significant and complex health problem, with opinions regarding the
appropriate course of management often equivocal. In this review, we discuss the current
concepts in the etiology and diagnosis of TMD, followed by an up-to-date management
approach from a surgeons’ perspective.

2. Etiologies and Classifications

As an umbrella term for pain and dysfunction of the temporomandibular regions,
TMD encompasses a wide variety of clinical conditions. The etiologies of TMD are multi-
factorial and can be attributed to both physical and psychosocial factors [18–20]. The
physical causes can broadly be divided into arthrogenous, and the more common myoge-
nous origins. Many believe that TMD symptoms of arthrogenous origin may be related
to internal derangement of the TMJ, which can be defined as a disruption of the internal
aspect of the joint, and usually pertains to an articular disc that has been displaced. Al-
though internal derangement does not necessarily lead to pain, it is generally believed
that internal derangement precedes degenerative joint diseases, namely osteoarthritis [21].
Osteoarthritis is associated with pain and functional impairment of the TMJ, and is char-
acterized by subchondral bony changes such as cortical erosion and marginal lipping,
secondary to pathological changes of the cartilaginous articular disc [22]. Note that the
term “osteoarthrosis” has been used as a synonym of osteoarthritis, but also has been
used to describe degenerative joint changes of non-inflammatory cause [22]. The sever-
ity of internal derangement has been classified by Wilkes into five stages with relations
to pain, mouth opening, disc location and anatomy [21]. The classification ranges from
painless clicking of the joint (Stage I) to severe pain of the joint with severe degenerative
bony changes (Stage V), which has served as an aid to guide treatment options in the
management of arthrogenous TMD.
While structural anomalies of the TMJ may predispose the patients to symptoms of
TMD [23], it should be noted that not all those with structural abnormalities suffer from
the same level of clinical symptoms. Apart from physical causes, the association between
biopsychosocial factors and TMD has been described by many [1–4,19,24]. Similar to other
chronic pain conditions, such as back pain and headache, it appears that there are those in
the population who are at risk for developing symptomatic TMD, who also share a certain
psychological profile and dysfunction [25,26]. Higher levels of depression and somatization
are associated with TMD of arthrogenous and myogenous origins [27]. Moreover, in those
with pre-existing TMD, symptoms may be exacerbated during times of stressful events.
For example, recent studies have suggested that the during periods of lockdown and social
isolation due to the ongoing COVID-19 pandemic, an impact was found on the prevalence
of depressive symptoms, stress, as well as pain related to TMD [28,29]. The finding that
psychological variables are closely tied to the development of TMD has been confirmed by
the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study, which
found that TMD onset was strongly associated with somatic symptoms, while previous
life events, perceived stress and negative affect were also associated with the incidence of
TMD [30].
What makes the diagnosis and classification of TMD complicated at times is that many
patients present with multiple diagnoses of TMD simultaneously, and it is impossible
to isolate the condition to a single particular cause. When discussing about TMD, most
clinical researchers refer to those pain conditions that are most commonly seen. However,
one must not forget that disorders related to the TMJ include those that are less routinely
encountered. Importantly, the presentation of these uncommon conditions of the TMJ may
initially mimic those of the more common TMD, yet the management approach may be
completely different. For example, a patient who presents with ankylosis of the TMJ may
initially present with signs and symptoms similar to closed-lock due to disc displacement,
but the standard treatment for ankylosis is surgical release of ankylosis, while conservative
Diagnostics 2021, 11, 459 3 of 15

or minimally invasive options, such as arthrocentesis, are usually indicated for closed-lock
of the TMJ due to disc displacement.
The crude classification of the most common diagnoses of TMD into arthrogenous,
myogenous, or of mixed origin is helpful in steering the clinician into the appropriate
path in the initial phases of management. However, more specific diagnoses are usually
required, especially if the management progresses beyond conservative options. In the past,
classification was often confusing, with many different terminologies referring to similar
entities. Today, the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) is
the most widely accepted and standardized tool for assessment and classification of TMD,
with sensitivity and specificity established for the most common diagnoses of TMD [31].
Recognizing that TMD contains a structural as well as a biopsychosocial component, the
DC/TMD consists of two Axes in its assessment. Axis-I contains a protocol for a prescribed
physical examination to arrive at specific physical diagnoses of TMD with regard to the joint
and musculature, while Axis-II contains several instruments to assess the psychological
state of the patient.
There are 12 most common diagnoses of TMD described in Axis-I of the DC/TMD,
which are divided into painful conditions (myalgia, local myalgia, myofascial pain, myofas-
cial pain with referral, arthralgia, headache attributed to TMD) and non-painful conditions
(disc displacement with reduction, disc displacement with reduction with intermittent
locking, disc displacement without reduction with limited opening, disc displacement
without reduction without limited opening, degenerative joint disease, subluxation) [31]
(Table 1). Note that in many cases, multiple diagnoses are present at any timepoint in a
single patient, and that diagnoses may change as the disease progresses or resolves. For
example, a patient with complaints of joint clicking with pain in the TMJ and masseter
muscle, and headache during mouth opening may be diagnosed with having local myal-
gia, arthralgia, disc displacement with reduction, and headache attributed to TMD. The
classification of TMD also includes those that are less common, but clinically important
diseases [32]. Some of these less common diagnoses include fractures of the TMJ, manifesta-
tions of systemic diseases, as well as rare conditions such as neoplasms and developmental
disorders (Table 2) [32]. However, when these diagnoses do not fit the clinical symptoms,
other conditions should also be considered.

Table 1. Common diagnoses of temporomandibular disorders (TMD) and their clinical findings.

Painful Conditions Clinical Findings

Familiar pain in the masseter or temporalis
Myalgia
upon palpation or mouth opening
Familiar pain in the masseter or temporalis
Local Myalgia
localized to the site of palpation
Pain in the masseter or temporalis spreading
Myofascial pain beyond the site of palpation but within the
confines of the muscle
Pain in the masseter or temporalis beyond the
Myofascial pain with referral
confines of the muscle being palpated
Familiar pain in the TMJ upon palpation or
Arthralgia
during function
Headache in the temple upon palpation of the
Headache attributed to TMD
temporalis muscle or during function
Diagnostics 2021, 11, 459 4 of 15

Table 1. Cont.

Non-Painful Conditions Clinical Findings

Disc displacement with reduction Clicking in the TMJ upon function
Disc displacement with reduction with Clicking in the TMJ with reported episodes of
intermittent locking limited mouth opening
Disc displacement without reduction with Limited mouth opening affecting function,
limited opening with maximum assisted opening < 40mm
Disc displacement without reduction without Limited mouth opening affecting function,
limited opening with maximum assisted opening of ≥ 40mm
Degenerative joint disease Crepitus of the TMJ upon function
History of jaw locking in an open mouth
Subluxation
position, cannot close without a self-maneuver
Modified from Schiffman et al., 2014 [31].

Table 2. Some less common diagnoses of temporomandibular disorders (TMD).

I. TMJ
A. Joint pain
1. Arthritis
B. Joint disorders
1. Hypomobility disorders other than disc disorders
a. Adhesions/Adherence
b. Ankylosis (Fibrous or Osseous)
2. TMJ dislocations
C. Joint diseases
1. Systemic arthritides
2. Condylysis/Idiopathic condylar resorption
3. Osteochondritis dissecans
4. Osteonecrosis
5. Neoplasm
6. Synovial Chondromatosis
D. Fractures
E. Congenital/Developmental disorders
1. Aplasia
2. Hypoplasia
3. Hyperplasia
II. Masticatory Muscles
A. Muscle pain
1. Tendonitis
2. Myositis
3. Spasm
B. Contracture
C. Hypertrophy
D. Neoplasm
E. Movement Disorders
1. Orofacial dyskinesia
2. Oromandibular dystonia
F. Masticatory muscle pain related to central/systemic pain disorder
1. Fibromyalgia/widespread pain
III. Associated Structures
A. Coronoid hyperplasia
Modified from Peck et al., 2014 [32].

3. Diagnostic Approach
The signs and symptoms of TMD may mimic other orofacial pain conditions. Although
precise physical diagnosis into the type of TMD is helpful in developing an appropriate
Diagnostics 2021, 11, 459 5 of 15

treatment plan, it might not be straight forward in every case. Taking a patients’ history is an
important part of diagnosing the TMJ condition. The acquisition of history follows the usual
format. Apart from the chief complaint, inquiries should be made regarding any history
of trauma or previous episodes, aggravating factors, such as eating, talking, yawning or
spontaneous background pain, and any previous investigations or treatment. The severity
of pain should also be graded using a visual analogue scale (VAS), so treatment progress
can be quantitatively monitored. A past and current medical history, including a full
medications list, may reveal any comorbidities that may be related to TMD. The clinician
should note any habits such as smoking, drinking and recreational drug use, and any
history of clenching or bruxism as complained by the patients’ bed partner. Additionally,
the clinician should ask questions regarding stress and level of life satisfaction, and whether
there are any recent life events, such as change of job or loss of a loved one. Although
most clinicians treating TMD may be experienced with acquiring a clinical history, some
may not be comfortable with taking a psychological history. If desired, the clinician may
employ the numerous psychosocial instruments available to aid in their diagnosis, such
as those in Axis-II of DC/TMD [31]. When necessary, the patient may be referred for a
psychological assessment.
Most clinicians who treat orofacial pain believe clinical examination is the most crucial
process of diagnosing TMD. The location of pain, and whether the pain is localized,
remains within or spreads beyond the confines of the muscle, should be confirmed with
palpation, which is done at rest and during mandibular function. Clicking or crepitus
upon mandibular function might be quite obvious in some cases, and the detection might
be aided by the use of a stethoscope. Intriguingly, the presence or location of clicking
detected by the clinician might be different from that reported by the patient, and this
should be documented. The range of mouth opening measured should include pain-free
maximum mouth opening, maximum unassisted mouth opening, and maximum assisted
mouth opening. Any deviation of the mandible may indicate differential obstruction of
the movement of the mandibular condyle in rotation and/or translation. An intra-oral
examination is performed to rule out any mucosal pathologies of the oral cavity and
oropharyngeal region, as well as to assess the state of the dentition.

3.1. Imaging and Other Investigations

Imaging is considered to be a useful adjunct in the diagnosis of TMD. Although the
diagnostic information provided by plain radiographs like orthopantomogram is limited,
they are convenient, simple and serve to rule out some of the differential diagnoses of the
bony TMJ, such as fractures, ankylosis, growth disturbances, as well as neoplasms. For
the most common types of TMD which clinical presentation is typical, many units might
not routinely employ additional imaging. This is due to availability and cost, and that
additional imaging might not alter the initial management plan. However, when further
information is desired, magnetic resonance imaging (MRI) is the gold standard for TMJ
imaging, and is useful in assessing the status of the osseous, as well as the non-osseous
structures of the TMJ, such as the masticatory muscles, ligaments and the cartilaginous
disc [33] (Figure 1). Classification systems, such as Wilkes [21], combine clinical and MRI
findings to stage the extent of internal derangement in order to guide treatment protocol.
MRI is therefore considered mandatory prior to any surgical intervention.
While MRI is the most commonly used diagnostic imaging for the common diagnoses
of TMD, other imaging modalities are also employed for specific indications. Cone-beam
computed tomography (CBCT) has been used to further assess the osseous structure of the
TMJ [34–36]. This may be desirable in cases of TMJ ankylosis, benign bony neoplasms or
overgrowth, or for the planning of osseous surgery, such as for eminectomy for recurrence
TMJ dislocation. However, for most other diagnoses of TMJ, the value of CBCT is not
well-established since the information provided in terms of soft tissues is limited [36].
Moreover, the use of ultrasound as a diagnostic tool for TMD has been suggested [15,37,38].
Ultrasound has the advantages of being non-invasive, cheap, and widely available in many
Diagnostics 2021, 11, 459 6 of 15

health institutions, yet the effectiveness as a diagnostic method remains to be confirmed [15].
For some inflammatory conditions of the TMJ, such as osteoarthritis and joint inflammation,
bone scintigraphy may be of value as a diagnostic tool [39–43]. Moreover, bone scintigraphy
Diagnostics 2021, 11, 459 has been proposed as a method for the evaluation of active TMJ condylar growth, but 6 ofit16
has been shown that both the sensitivity and specificity are low for this indication [44].

Figure1.1.Magnetic
Figure Magneticresonance
resonanceimaging
imaging (MRI)
(MRI) showing
showing anteriorly
anteriorly displaced
displaced disc
disc in both
in both thethe close
close and
and open mouth position in a patient presented with lock jaw.
open mouth position in a patient presented with lock jaw.

Whilefrom
Apart MRIthe is the most commonly
different used diagnostic
imaging modalities imaging
available, otherfor the commonare
investigations diagno-
not
ses of TMD,
commonly other
done for imaging modalities
most diagnoses are also
of TMD, employed
except in specificfor indications.
specific indications. Cone-
For example,
beaminvestigations
blood computed tomography may be done (CBCT) has been
for TMD related used to furtherconditions,
to systemic assess the osseous structure
such as rheuma-
of the TMJ [34–36]. This may be desirable in cases of TMJ ankylosis,
toid arthritis or gout. In the case of uncertain diagnoses of rare diseases or neoplasms, benign bony neo-
plasms or overgrowth, or for the planning of osseous surgery, such
tissue biopsies might be taken, which may be done by fine-needle aspiration, arthroscopic as for eminectomy for
orrecurrence
open jointTMJ dislocation. However, for most other diagnoses of TMJ, the value of CBCT
approach.
is not well-established since the information provided in terms of soft tissues is limited
3.2. Diagnosis
[36]. Moreover, of TMDthe use of ultrasound as a diagnostic tool for TMD has been suggested
[15,37,38]. Ultrasound
Recognizing the causes has the advantages
of pain of being non-invasive,
and dysfunction related to TMD cheap, and widely
is important avail-
in order
to guide treatment decisions. For instance, different treatment options are often employedto
able in many health institutions, yet the effectiveness as a diagnostic method remains
bethe
for confirmed
treatment[15]. For some inflammatory
of myogenous conditions
versus arthrogenous TMD. ofMoreover,
the TMJ, in such as patients
those osteoarthritis
who
and joint
present with inflammation,
TMD symptoms bone scintigraphy
without mayphysical
an obvious be of value cause,aswho
a diagnostic
also suffer tool
from[39–43].
psy-
Moreover,
chological bone scintigraphy
comorbidities, may behas bestbeen proposed
treated as a method
by counselling for the evaluation
and psychological of active
intervention.
TMJThecondylar growth, but
most important it has
part been
of the shown that
diagnosis both the
of TMD is tosensitivity and the
differentiate specificity
common are
diseases fromindication
low for this those clinically
[44]. significant, but unusual conditions, as well as conditions
that are morefrom
Apart serious which urgent
the different imagingattention is needed.
modalities For example,
available, some neoplasms,
other investigations are not
such as chondrosarcoma
commonly done for mostofdiagnoses
the TMJ of may initially
TMD, exceptshare signs and
in specific symptoms
indications. Foras some
example,
ofblood
the common diagnoses
investigations may ofbe TMD,
done for such
TMDas pain at the
related preauricular
to systemic region such
conditions, and limited
as rheu-
opening. Anotheror
matoid arthritis example
gout. Inthat
therequires urgent attention
case of uncertain diagnoses is temporal arteritis,orwhich
of rare diseases is an
neoplasms,
inflammatory
tissue biopsies condition
might beof the temporal
taken, which may vessels
be done withbysome TMD-like
fine-needle symptoms,
aspiration, such as
arthroscopic
headache, painapproach.
or open joint in the temporal region, and limited mouth opening. However, temporal
arteritis is a medical emergency which may cause permanent blindness if not treated
promptly. Some
3.2. Diagnosis of of
TMD the differential diagnoses of orofacial pain that may mimic TMD are
listed Recognizing
in Table 3 [45]. the causes of pain and dysfunction related to TMD is important in order
to guide treatment decisions. For instance, different treatment options are often employed
for the treatment of myogenous versus arthrogenous TMD. Moreover, in those patients
who present with TMD symptoms without an obvious physical cause, who also suffer
from psychological comorbidities, may be best treated by counselling and psychological
intervention.
The most important part of the diagnosis of TMD is to differentiate the common dis-
eases from those clinically significant, but unusual conditions, as well as conditions that
are more serious which urgent attention is needed. For example, some neoplasms, such
as chondrosarcoma of the TMJ may initially share signs and symptoms as some of the
common diagnoses of TMD, such as pain at the preauricular region and limited opening.
Another example that requires urgent attention is temporal arteritis, which is an inflam-
Diagnostics 2021, 11, 459 7 of 15

Table 3. Differential diagnosis of temporomandibular disorders (TMD).

Neuropathic Pain
Trigeminal neuralgia
Glossopharyngeal neuralgia
Postherpetic neuralgia
Traumatic neuralgia
Burning mouth syndrome
Atypical odontalgia
Atypical facial pain
Odontogenic Pain
Dental caries
Periodontal disease
Dental abscess
Dental sensitivity
Cracked tooth syndrome
Periocoronitis
Intracranial Pain
Tumours
Aneurysms
Bleeding
Infection
Pain from Other Adjacent Structures
Ear
Nose
Throat
Eyes
Sinus
Salivary glands
Lymph nodes
Vasculature
Cervical region
Headaches not Attributed to TMD
Migraine
Cluster headache
Tension-type headache
Temporal arteritis
Referred Pain
Psychogenic Pain
Modified from Kumar et al. (2013) [45].

4. Treatment Modalities—A Change in Paradigm?

The goals of treatment for TMD include reduction of pain and improvement of jaw
function. Additionally, treatment with the goal of behavioural change may be important
in the reduction of tension and parafunction. Currently, physically restoring the disc
position in the case of internal derangement is not the primary treatment objective as it may
not be relevant to clinical improvement [46,47], unless of course if there is inflammation
related to disc displacement then it should be addressed. Symptoms of TMD should be
addressed promptly, as chronic pain becomes more difficult to manage due to psychological
deterioration and somatization [2,19]. Since conservative options are less likely to cause
any harm, they are usually indicated in the early stages of treatment. This is especially true
when definitive diagnosis is difficult to ascertain and treatment is performed empirically.
However, there is no agreement on how long conservative treatment should be attempted
before progressing to other options when clear benefits are not observed. Although the
treatment of TMD has shifted away from open procedures which were once popular,
 addressed promptly, as chronic pain becomes more difficult to manage due to psycholog-
ical deterioration and somatization [2,19]. Since conservative options are less likely to
cause any harm, they are usually indicated in the early stages of treatment. This is espe-
cially true when definitive diagnosis is difficult to ascertain and treatment is performed
empirically. However, there is no agreement on how long conservative treatment should
Diagnostics 2021, 11, 459 8 of 15
be attempted before progressing to other options when clear benefits are not observed.
Although the treatment of TMD has shifted away from open procedures which were once
popular, the demonstrated success of minimally invasive options may indicate that they
maydemonstrated
the be considered as anofearly
success optioninvasive
minimally for those cases may
options refractory to that
indicate conservatory
they may ap-
be
proaches.
considered as an early option for those cases refractory to conservatory approaches.

4.1.
4.1. Conservative
Conservative Options
Options
The
The initial
initial management of of TMD
TMD may may include
includevarious
variousmedications,
medications,such suchasasanalge-
anal-
gesics, non-steroidalanti-inflammatory
sics, non-steroidal anti-inflammatorydrugs drugs(NSAIDs),
(NSAIDs), anxiolytics,
anxiolytics, and anti-depressants.
anti-depressants.
Occlusal
Occlusal appliances
appliances of of various
various designs
designs are are routinely
routinely prescribed,
prescribed, which
which represent
represent aa non-
non-
invasive
invasive option with with minimal
minimalrisksrisks(Figure
(Figure2).2).TheThe
useuse of occlusal
of occlusal splint
splint therapy
therapy has
has been
been
shown shown to reduce
to reduce painpain intensity
intensity andand increasemaximal
increase maximalmouth
mouthopening
opening [48]. However,
However,
whether
whetherthe theeffect
effectofofananocclusal
occlusalsplint is due
splint to the
is due placebo
to the effect
placebo has been
effect questioned,
has been and
questioned,
that the evidence of its efficacy remains to be low [49,50]. A systematic review
and that the evidence of its efficacy remains to be low [49,50]. A systematic review in 2018 in 2018 by
Alkhutari et al. has suggested that the use of occlusal splint may improve
by Alkhutari et al. has suggested that the use of occlusal splint may improve patient-cen- patient-centred
treatment outcomes,
tred treatment whichwhich
outcomes, may bemaymore bethan
moremerely a placebo
than merely effect [51].
a placebo Multiple
effect designs
[51]. Multiple
are available,
designs such as hard,
are available, suchsoft, and anterior
as hard, soft, and repositioning splint. At present,
anterior repositioning there
splint. At is no
present,
consensus on which design is superior, as results from different studies
there is no consensus on which design is superior, as results from different studies are are equivocal in
terms of the efficacy of different designs of occlusal splints [50,52].
equivocal in terms of the efficacy of different designs of occlusal splints [50,52].

Figure2.
Figure 2. Occlusal
Occlusalsplint
splintfor
forthe
themanagement
managementofoftemporomandibular
temporomandibulardisorders
disorders(TMD)
(TMD)and
andbruxism.
brux-
ism.
Physiotherapy has been suggested to be an important part in the management of
TMDPhysiotherapy
[53,54], which has
maybeen suggested to
be particularly be an
useful forimportant
myalgia orpart in the management
myofascial pain. Under- of
TMD [53,54], which may be particularly useful for myalgia or myofascial
standing the loading of the stomatognathic system, and the existence of any tension andpain. Under-
standing the loading
parafunctions, of theinstomatognathic
is important system, and
delivering physiotherapy theasexistence
such of any tension
muscle training and
and chang-
ing of behaviour. Evidence shows that physiotherapy is effective in treatment of TMD,and
parafunctions, is important in delivering physiotherapy such as muscle training in
changing the
particular of behaviour. Evidence associated
headache symptoms shows thatwith
physiotherapy is effective
the condition; in treatment
future research of
into this
TMD,
area in particular
will the headache
further ascertain symptoms
these findings associated
[54]. with theTMD,
For myogenous condition;
Botoxfuture research
injection and
dry-needling techniques have been suggested [55,56]. Note that Botox is not considered
a standard treatment option for TMD, while dry-needling, or acupuncture, may be an
effective method to reduce tension in some patients. Additionally, initial results regard-
ing extracorporeal shock wave therapy for myogenous TMD appear to show positive
results [57,58].
There has been increasing evidence demonstrating that psychosocial assessment serves
as a powerful tool in terms of predicting treatment outcome [59,60]. For those patients
with a significant psychosocial component, counselling seems to be a promising treat-
ment adjunct [50,61–63], which might be most beneficial when included in a multimodal
approach [50]. Other conservative treatment options for TMD include stress reduction
 be an effective method to reduce tension in some patients. Additionally, initial results re-
garding extracorporeal shock wave therapy for myogenous TMD appear to show positive
results [57,58].
There has been increasing evidence demonstrating that psychosocial assessment
serves as a powerful tool in terms of predicting treatment outcome [59,60]. For those pa-
Diagnostics 2021, 11, 459 9 of 15
tients with a significant psychosocial component, counselling seems to be a promising
treatment adjunct [50,61–63], which might be most beneficial when included in a multi-
modal approach [50]. Other conservative treatment options for TMD include stress reduc-
tion techniques
techniques andmodification.
and diet diet modification.
In theInpast,
the past, a causative
a causative relationship
relationship between
between occlu-
occlusion
sionTMD
and and TMD hadsuggested,
had been been suggested, but
but it is it isconsidered
now now considered an outdated
an outdated theory theory not sup-
not supported
ported
by byevidence,
robust robust evidence, andadjustment
and occlusal occlusal adjustment is an irreversible
is an irreversible treatment
treatment which is nowhich
longeris
no longer by
supported supported
the recentbyliterature
the recent[64–67].
literature [64–67].

4.2.
4.2.Minimally
MinimallyInvasive
InvasiveOptions—Arthroscopy,
Options—Arthroscopy,Arthrocentesis
ArthrocentesisandandIntra-Articular
Intra-ArticularInjections
Injections
In
Inthe
the1980s,
1980s,thetheavailability
availabilityofofMRI
MRIhashasled
ledclinicians
clinicianstotoacknowledge
acknowledgethe thestructural
structural
anomalies
anomaliesrelated
relatedtotoTMD.
TMD.This
Thishas
hasresulted
resultedininaaboom
boomof ofopen
openjoint
jointsurgeries,
surgeries,which
whichwerewere
unfortunately ineffective in the most part. For those cases of TMD that are
unfortunately ineffective in the most part. For those cases of TMD that are arthrogenous arthrogenous and
not responsive to conservative treatment, more focus has since been shifted
and not responsive to conservative treatment, more focus has since been shifted to mini- to minimally
invasive procedures
mally invasive which have
procedures whichshown
have promising clinical clinical
shown promising results. results.
Arthroscopy
Arthroscopy of the TMJ was initially pioneered by theJapanese
of the TMJ was initially pioneered by the Japanesein inthe
the1970s
1970s[68,69],
[68,69],
and
and later popularized by the Americans [70–72]. TMJ arthroscopy may involve lysisand
later popularized by the Americans [70–72]. TMJ arthroscopy may involve lysis and
lavage
lavageof ofthe
thesuperior
superiorjoint
jointspace,
space,as aswell
wellas asoperative
operativeprocedures,
procedures,such suchasasrepositioning
repositioning
of
ofaa displaced
displaced disc, arthroplasty, and
disc, arthroplasty, and removal
removal of ofinflamed
inflamedtissues
tissuesandandadhesions.
adhesions.The The
ef-
efficacy of arthroscopy has since been well-recognized [73–79], and has
ficacy of arthroscopy has since been well-recognized [73–79], and has been found that the been found that
the therapeutic
therapeutic effect
effect was was mainly
mainly duedue to lysis
to lysis andand lavage
lavage butbut
notnot
discdisc position
position [80].
[80]. It was
It was due
due to this finding that a modification was made, where lysis and lavage
to this finding that a modification was made, where lysis and lavage was performed with- was performed
without arthroscopic view. This was termed arthrocentesis which was first described by
out arthroscopic view. This was termed arthrocentesis which was first described by
Nitzan et al., in 1991 [81], with efficacy that has since been well-documented [46,82–94]
Nitzan et al., in 1991 [81], with efficacy that has since been well-documented [46,82–94]
(Figure 3).
(Figure 3).

Figure3.3.Arthrocentesis
Figure Arthrocentesisperformed
performedunder
underlocal
localanaesthesia.
anaesthesia.

In addition to the shift from open joint surgery to minimally invasive treatment for
those cases not responsive to conservative treatment, recent literature seems to support
that minimally invasive options may be attempted early for arthrogenous TMD [95,96],
and this may represent a paradigm shift in the management protocol. A recent integrated
review and meta-analysis performed by the authors of this article showed that arthrocen-
tesis was beneficial, whether it was performed as an initial treatment, as an early or late
treatment with regard to conservative treatment [97]. However, the best timing to perform
arthrocentesis is still unclear due to the paucity of research on the topic, which warrants
more future well-designed clinical trials [97].
Although both arthroscopy and arthrocentesis have been shown to be beneficial in
the treatment of TMD, it is unclear which method produces better clinical results. In a
systematic review and meta-analysis by Al-Moraissi, it was revealed that arthroscopy was
Diagnostics 2021, 11, 459 10 of 15

superior to arthrocentesis in pain reduction and jaw function improvement, with similar
complication rates for both methods [78]. However, other studies have shown comparable
results with the two procedures [98,99]. Nevertheless, arthrocentesis has been suggested
to be attempted first due to simplicity and cost-effectiveness, with a similar or potentially
lower complication rate [99].
Several modifications have been suggested for the conventional arthrocentesis, which
involves two puncture needles into the superior joint space guided by landmarks in
relations to adjacent structures, followed by lavage with an irrigation solution. For ex-
ample, single-puncture techniques employ specially designed devices, and may have
both the inflow and outflow fluid going through a single cannula but with different ports.
Although single-puncture techniques may appear more simple than double-puncture
arthrocentesis, most studies to date have shown a similar clinical outcome between the two
techniques [83,100–102]. In addition, ultrasound-guided arthrocentesis has been proposed
to increase the accuracy of puncture into the superior joint space [103–106]. However, a
recent systematic review by Leung et al. has shown that no additional benefit is seen with
ultrasound-guided arthrocentesis compared to conventional arthrocentesis [107]. Further-
more, different pharmacological agents for intra-articular injection have been proposed,
with the common ones including hyaluronic acid, corticosteroid, analgesics, and platelet-
rich plasma [93,96,108,109]. Although promising results are seen in some studies, there
is currently no consensus regarding which intra-articular injection agent is superior over
the others.
Despite the reported efficacy, arthroscopy is seldom required in TMD patients, even
in cases of true arthrogenous disorders. Additionally, arthrocentesis is still considered to
be a controversial procedure [87], despite the documented efficacy and low complication
rates. The reasons for this controversy are as follows. Firstly, some cases of TMD improve
with mere conservative options, or even without treatment. Additionally, many cases of
TMD are due to multiple etiologies, which may require a multimodal approach before
any clear clinical improvement can be appreciated. In addition, intra-articular injection
of corticosteroids is a simple and very effective treatment, which may be attempted prior
to arthrocentesis. In short, minimally invasive procedures may be the answer in those
patients with true arthrogenous TMD not responsive to conservative treatment options,
whose condition also lack a significant biopsychosocial component.

4.3. Open Joint Surgery

Open surgical treatment for TMD is now uncommon, and is reserved for specific
indications as well as end-stage diseases. Though, surgery may be the only viable option
in some conditions, such as ankylosis and neoplasms, which require release of ankylosis
and removal of tumour, respectively. Pending on the availability of equipment and skills,
there is now an option of arthroscopic surgery for procedures that were only performed
with an open-joint approach in the past. These procedures include disc repositioning
procedures, removal of osteophyte, removal of pathologic tissue, and biopsy of the TMJ. In
recent years, much work has been done regarding replacement of the TMJ with alloplastic
prosthesis [110–116] with an observed improvement in prognosis and longevity. Due to
this success, it is likely that we will see a continuous increase in popularity of alloplastic
replacement of the TMJ for conditions such as end stage arthritic conditions, ankylosis,
post-tumour resection, and developmental anomalies of the TMJ.

5. Conclusions
TMD represents a divergent group of orofacial pain symptoms which shares simi-
larities with other chronic pain conditions. The etiology of TMD is often multi-factorial,
and precise causes for the symptoms may be difficult to pinpoint. In the past, focus has
been placed on the physical origins of TMD, but an at least equally significant psychosocial
factor is now well-recognized. Consequently, a multimodal approach, which might include
counselling and psychological therapy, is being increasingly advocated. Most instances of
Diagnostics 2021, 11, 459 11 of 15

TMD are managed conservatively and empirically during the early phases of treatment, yet
lingering in the conservative phase for an extended period when clinical improvement is
unclear is not recommended. Though open joint surgery is rare nowadays and is reserved
for specific situations, we may be in the midst of a changing paradigm which favours early
minimally invasive procedures.

Author Contributions: Both authors are responsible for all parts of the work. All authors have read
and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Von Korff, M.; Ormel, J.; Keefe, F.J.; Dworkin, S.F. Grading the severity of chronic pain. Pain 1992, 50, 133–149. [CrossRef]
2. Ismail, F.; Eisenburger, M.; Lange, K.; Schneller, T.; Schwabe, L.; Strempel, J.; Stiesch, M. Identification of psychological comorbidity
in TMD-patients. Cranio 2016, 34, 182–187. [CrossRef] [PubMed]
3. List, T.; Jensen, R.H. Temporomandibular disorders: Old ideas and new concepts. Cephalalgia 2017, 37, 692–704. [CrossRef]
[PubMed]
4. Bitiniene, D.; Zamaliauskiene, R.; Kubilius, R.; Leketas, M.; Gailius, T.; Smirnovaite, K. Quality of life in patients with temporo-
mandibular disorders. A systematic review. Stomatologija 2018, 20, 3–9. [PubMed]
5. Resende, C.; Rocha, L.; Paiva, R.P.; Cavalcanti, C.D.S.; Almeida, E.O.; Roncalli, A.G.; Barbosa, G.A.S. Relationship between
anxiety, quality of life, and sociodemographic characteristics and temporomandibular disorder. Oral Surg. Oral Med. Oral Pathol.
Oral Radiol. 2020, 129, 125–132. [CrossRef] [PubMed]
6. Dahlstrom, L.; Carlsson, G.E. Temporomandibular disorders and oral health-related quality of life. A systematic review. Acta
Odontol. Scand. 2010, 68, 80–85. [CrossRef]
7. Goncalves, D.A.; Camparis, C.M.; Speciali, J.G.; Franco, A.L.; Castanharo, S.M.; Bigal, M.E. Temporomandibular disorders are
differentially associated with headache diagnoses: A controlled study. Clin. J. Pain 2011, 27, 611–615. [CrossRef]
8. Lim, P.F.; Smith, S.; Bhalang, K.; Slade, G.D.; Maixner, W. Development of temporomandibular disorders is associated with greater
bodily pain experience. Clin. J. Pain 2010, 26, 116–120. [CrossRef] [PubMed]
9. Facial Pain. Available online: http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/FacialPain/ (accessed on 9 June 2019).
10. Lipton, J.A.; Ship, J.A.; Larach-Robinson, D. Estimated prevalence and distribution of reported orofacial pain in the United States.
J. Am. Dental Assoc. 1993, 124, 115–121. [CrossRef] [PubMed]
11. Locker, D.; Slade, G. Prevalence of symptoms associated with temporomandibular disorders in a Canadian population. Community
Dent. Oral Epidemiol. 1988, 16, 310–313. [CrossRef]
12. Magnusson, T.; Egermark, I.; Carlsson, G.E. A longitudinal epidemiologic study of signs and symptoms of temporomandibular
disorders from 15 to 35 years of age. J. Orofac. Pain 2000, 14, 310–319.
13. Ebrahimi, M.; Dashti, H.; Mehrabkhani, M.; Arghavani, M.; Daneshvar-Mozafari, A. Temporomandibular Disorders and Related
Factors in a Group of Iranian Adolescents: A Cross-sectional Survey. J. Dent. Res. Dent. Clin. Dent. Prospect. 2011, 5, 123–127.
[CrossRef]
14. Manfredini, D.; Piccotti, F.; Ferronato, G.; Guarda-Nardini, L. Age peaks of different RDC/TMD diagnoses in a patient population.
J. Dent. 2010, 38, 392–399. [CrossRef] [PubMed]
15. Klatkiewicz, T.; Gawriolek, K.; Pobudek Radzikowska, M.; Czajka-Jakubowska, A. Ultrasonography in the Diagnosis of
Temporomandibular Disorders: A Meta-Analysis. Med. Sci. Monit. 2018, 24, 812–817. [CrossRef] [PubMed]
16. Sena, M.F.; Mesquita, K.S.; Santos, F.R.; Silva, F.W.; Serrano, K.V. Prevalence of temporomandibular dysfunction in children and
adolescents. Rev. Paul. Pediatr. 2013, 31, 538–545. [CrossRef] [PubMed]
17. Valesan, L.F.; Da-Cas, C.D.; Reus, J.C.; Denardin, A.C.S.; Garanhani, R.R.; Bonotto, D.; Januzzi, E.; de Souza, B.D.M. Prevalence of
temporomandibular joint disorders: A systematic review and meta-analysis. Clin. Oral Investig. 2021. [CrossRef] [PubMed]
18. Rollman, G.B.; Gillespie, J.M. The role of psychosocial factors in temporomandibular disorders. Curr. Rev. Pain 2000, 4, 71–81.
[CrossRef] [PubMed]
19. Auerbach, S.M.; Laskin, D.M.; Frantsve, L.M.; Orr, T. Depression, pain, exposure to stressful life events, and long-term outcomes
in temporomandibular disorder patients. J. Oral Maxillofac. Surg. 2001, 59, 628–633. [CrossRef]
20. Toh, A.Q.J.; Chan, J.L.H.; Leung, Y.Y. Mandibular asymmetry as a possible etiopathologic factor in temporomandibular disorder:
A prospective cohort of 134 patients. Clin. Oral Investig. 2021. [CrossRef] [PubMed]
21. Wilkes, C.H. Internal Derangements of the Temporomandibular Joint: Pathological Variations. Arch. Otolaryngol. Head Neck Surg.
1989, 115, 469–477. [CrossRef]
22. Mercuri, L.G. Osteoarthritis, osteoarthrosis, and idiopathic condylar resorption. Oral Maxillofac. Surg. Clin. N. Am. 2008,
20, 169–183. [CrossRef]
23. Bertram, S.; Rudisch, A.; Innerhofer, K.; Pümpel, E.; Grubwieser, G.; Emshoff, R. Diagnosing TMJ internal derangement and
osteoarthritis with magnetic resonance imaging. J. Am. Dent. Assoc. 2001, 132, 753–761. [CrossRef]
Diagnostics 2021, 11, 459 12 of 15

24. Turk, D.C.; Gatchel, R.J. Psychological Approaches to Pain Management: A Practitioner’s Hand Book; The Gilford Press: New York, NY,
USA, 2002.
25. Dworkin, S.F.; Massoth, D.L. Temporomandibular disorders and chronic pain: Disease or illness? J. Prosthet. Dent. 1994, 72, 29–38.
[CrossRef]
26. Suvinen, T.I.; Reade, P.C. Temporomandibular disorders: A critical review of the nature of pain and its assessment. J. Orofac. Pain
1995, 9, 317–339. [PubMed]
27. Yap, A.U.; Tan, K.B.; Chua, E.K.; Tan, H.H. Depression and somatization in patients with temporomandibular disorders. J.
Prosthet. Dent. 2002, 88, 479–484. [CrossRef] [PubMed]
28. Saccomanno, S.; Bernabei, M.; Scoppa, F.; Pirino, A.; Mastrapasqua, R.; Visco, M.A. Coronavirus Lockdown as a Major Life
Stressor: Does It Affect TMD Symptoms? Int. J. Environ. Res. Public Health 2020, 17, 8907. [CrossRef]
29. Medeiros, R.A.; Vieira, D.L.; Silva, E.; Rezende, L.; Santos, R.W.D.; Tabata, L.F. Prevalence of symptoms of temporomandibular
disorders, oral behaviors, anxiety, and depression in Dentistry students during the period of social isolation due to COVID-19. J.
Appl. Oral Sci. 2020, 28, e20200445. [CrossRef]
30. Fillingim, R.B.; Ohrbach, R.; Greenspan, J.D.; Knott, C.; Diatchenko, L.; Dubner, R.; Bair, E.; Baraian, C.; Mack, N.; Slade, G.D.;
et al. Psychological factors associated with development of TMD: The OPPERA prospective cohort study. J. Pain Off. J. Am. Pain
Soc. 2013, 14, T75–T90. [CrossRef] [PubMed]
31. Schiffman, E.; Ohrbach, R.; Truelove, E.; Look, J.; Anderson, G.; Goulet, J.P.; List, T.; Svensson, P.; Gonzalez, Y.; Lobbezoo, F.; et al.
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of
the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Groupdagger. J. Oral Facial Pain Headache
2014, 28, 6–27. [CrossRef] [PubMed]
32. Peck, C.C.; Goulet, J.P.; Lobbezoo, F.; Schiffman, E.L.; Alstergren, P.; Anderson, G.C.; de Leeuw, R.; Jensen, R.; Michelotti, A.;
Ohrbach, R.; et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J. Oral Rehabil. 2014,
41, 2–23. [CrossRef] [PubMed]
33. Al-Saleh, M.A.; Alsufyani, N.A.; Saltaji, H.; Jaremko, J.L.; Major, P.W. MRI and CBCT image registration of temporomandibular
joint: A systematic review. J. Otolaryngol. Head Neck Surg. 2016, 45, 30. [CrossRef]
34. Al-Saleh, M.A.; Jaremko, J.L.; Alsufyani, N.; Jibri, Z.; Lai, H.; Major, P.W. Assessing the reliability of MRI-CBCT image registration
to visualize temporomandibular joints. Dentomaxillofac. Radiol. 2015, 44, 20140244. [CrossRef] [PubMed]
35. Ladeira, D.B.; da Cruz, A.D.; de Almeida, S.M. Digital panoramic radiography for diagnosis of the temporomandibular joint:
CBCT as the gold standard. Braz. Oral Res. 2015, 29, S1806-83242015000100303. [CrossRef]
36. Larheim, T.A.; Abrahamsson, A.K.; Kristensen, M.; Arvidsson, L.Z. Temporomandibular joint diagnostics using CBCT. Dentomax-
illofac. Radiol. 2015, 44, 20140235. [CrossRef]
37. Su, N.; van Wijk, A.J.; Visscher, C.M.; Lobbezoo, F.; van der Heijden, G. Diagnostic value of ultrasonography for the detection
of disc displacements in the temporomandibular joint: A systematic review and meta-analysis. Clin. Oral Investig. 2018,
22, 2599–2614. [CrossRef]
38. Talmaceanu, D.; Lenghel, L.M.; Bolog, N.; Popa Stanila, R.; Buduru, S.; Leucuta, D.C.; Rotar, H.; Baciut, M.; Baciut, G. High-
resolution ultrasonography in assessing temporomandibular joint disc position. Med. Ultrason. 2018, 1, 64–70. [CrossRef]
39. Choi, B.H.; Yoon, S.H.; Song, S.I.; Yoon, J.K.; Lee, S.J.; An, Y.S. Comparison of Diagnostic Performance Between Visual and
Quantitative Assessment of Bone Scintigraphy Results in Patients With Painful Temporomandibular Disorder. Medicine 2016,
95, e2485. [CrossRef]
40. Epstein, J.B.; Rea, A.; Chahal, O. The use of bone scintigraphy in temporomandibular joint disorders. Oral Dis. 2002, 8, 47–53.
[CrossRef] [PubMed]
41. Kang, J.H.; An, Y.S.; Park, S.H.; Song, S.I. Influences of age and sex on the validity of bone scintigraphy for the diagnosis of
temporomandibular joint osteoarthritis. Int. J. Oral Maxillofac. Surg. 2018, 47, 1445–1452. [CrossRef] [PubMed]
42. Lee, Y.H.; Hong, I.K.; Chun, Y.H. Prediction of painful temporomandibular joint osteoarthritis in juvenile patients using bone
scintigraphy. Clin. Exp. Dent. Res. 2019, 5, 225–235. [CrossRef] [PubMed]
43. Park, K.S.; Song, H.C.; Cho, S.G.; Kang, S.R.; Kim, J.; Jun, H.M.; Song, M.; Jeong, G.C.; Park, H.J.; Kwon, S.Y.; et al. Open-Mouth
Bone Scintigraphy Is Better than Closed-Mouth Bone Scintigraphy in the Diagnosis of Temporomandibular Osteoarthritis. Nucl.
Med. Mol. Imaging 2016, 50, 213–218. [CrossRef]
44. Chan, B.H.; Leung, Y.Y. SPECT bone scintigraphy for the assessment of condylar growth activity in mandibular asymmetry: Is it
accurate? Int. J. Oral Maxillofac. Surg. 2018, 47, 470–479. [CrossRef] [PubMed]
45. Kumar, A.; Brennan, M.T. Differential diagnosis of orofacial pain and temporomandibular disorder. Dent. Clin. N. Am. 2013,
57, 419–428. [CrossRef]
46. Alpaslan, G.H.; Alpaslan, C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate
in treatment of internal derangements. J. Oral Maxillofac. Surg. 2001, 59, 613–618. [CrossRef]
47. Nitzan, D.W.; Dolwick, M.F.; Heft, M.W. Arthroscopic lavage and lysis of the temporomandibular joint: A change in perspective.
J. Oral Maxillofac. Surg. 1990, 48, 798–801. [CrossRef]
48. Zhang, C.; Wu, J.Y.; Deng, D.L.; He, B.Y.; Tao, Y.; Niu, Y.M.; Deng, M.H. Efficacy of splint therapy for the management of
temporomandibular disorders: A meta-analysis. Oncotarget 2016, 7, 84043–84053. [CrossRef] [PubMed]
Diagnostics 2021, 11, 459 13 of 15

49. Riley, P.; Glenny, A.M.; Worthington, H.V.; Jacobsen, E.; Robertson, C.; Durham, J.; Davies, S.; Petersen, H.; Boyers, D. Oral splints
for temporomandibular disorder or bruxism: A systematic review. Br. Dent. J. 2020, 228, 191–197. [CrossRef]
50. Al-Moraissi, E.A.; Farea, R.; Qasem, K.A.; Al-Wadeai, M.S.; Al-Sabahi, M.E.; Al-Iryani, G.M. Effectiveness of occlusal splint
therapy in the management of temporomandibular disorders: Network meta-analysis of randomized controlled trials. Int. J. Oral
Maxillofac. Surg. 2020, 49, 1042–1056. [CrossRef]
51. Alkhutari, A.S.; Alyahya, A.; Rodrigues Conti, P.C.; Christidis, N.; Al-Moraissi, E.A. Is the therapeutic effect of occlusal
stabilization appliances more than just placebo effect in the management of painful temporomandibular disorders? A network
meta-analysis of randomized clinical trials. J. Prosthet. Dent. 2020. [CrossRef] [PubMed]
52. Seifeldin, S.A.; Elhayes, K.A. Soft versus hard occlusal splint therapy in the management of temporomandibular disorders
(TMDs). Saudi Dent. J. 2015, 27, 208–214. [CrossRef]
53. Incorvati, C.; Romeo, A.; Fabrizi, A.; Defila, L.; Vanti, C.; Gatto, M.R.A.; Marchetti, C.; Pillastrini, P. Effectiveness of physical
therapy in addition to occlusal splint in myogenic temporomandibular disorders: Protocol of a randomised controlled trial. BMJ
Open 2020, 10, e038438. [CrossRef]
54. van der Meer, H.A.; Calixtre, L.B.; Engelbert, R.H.H.; Visscher, C.M.; Nijhuis-van der Sanden, M.W.; Speksnijder, C.M. Effects of
physical therapy for temporomandibular disorders on headache pain intensity: A systematic review. Musculoskelet. Sci. Pract.
2020, 50, 102277. [CrossRef] [PubMed]
55. Kutuk, S.G.; Ozkan, Y.; Kutuk, M.; Ozdas, T. Comparison of the Efficacies of Dry Needling and Botox Methods in the Treatment
of Myofascial Pain Syndrome Affecting the Temporomandibular Joint. J. Craniofacial Surg. 2019, 30, 1556–1559. [CrossRef]
56. Connelly, S.T.; Myung, J.; Gupta, R.; Tartaglia, G.M.; Gizdulich, A.; Yang, J.; Silva, R. Clinical outcomes of Botox injections for
chronic temporomandibular disorders: Do we understand how Botox works on muscle, pain, and the brain? Int. J. Oral Maxillofac.
Surg. 2017, 46, 322–327. [CrossRef]
57. Kim, Y.H.; Bang, J.I.; Son, H.J.; Kim, Y.; Kim, J.H.; Bae, H.; Han, S.J.; Yoon, H.J.; Kim, B.S. Protective effects of extracorporeal
shockwave on rat chondrocytes and temporomandibular joint osteoarthritis; preclinical evaluation with in vivo(99m)Tc-HDP
SPECT and ex vivo micro-CT. Osteoarthr. Cartil. 2019, 27, 1692–1701. [CrossRef]
58. Schenk, I.; Vesper, M.; Nam, V.C. Initial results using extracorporeal low energy shockwave therapy ESWT in muscle reflex-
induced lock jaw. Mund Kiefer Gesichtschir. 2002, 6, 351–355. [CrossRef] [PubMed]
59. Dworkin, S.F.; Turner, J.A.; Mancl, L.; Wilson, L.; Massoth, D.; Huggins, K.H.; LeResche, L.; Truelove, E. A randomized clinical
trial of a tailored comprehensive care treatment program for temporomandibular disorders. J. Orofac. Pain 2002, 16, 259–276.
60. Türp, J.C.; Jokstad, A.; Motschall, E.; Schindler, H.J.; Windecker-Gétaz, I.; Ettlin, D.A. Is there a superiority of multimodal as
opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature. Clin.
Oral Implant. Res. 2007, 18 (Suppl. 3), 138–150. [CrossRef]
61. Conti, P.C.; Correa, A.S.; Lauris, J.R.; Stuginski-Barbosa, J. Management of painful temporomandibular joint clicking with different
intraoral devices and counseling: A controlled study. J. Appl. Oral Sci. 2015, 23, 529–535. [CrossRef]
62. de Resende, C.; de Oliveira Medeiros, F.G.L.; de Figueiredo Rego, C.R.; Bispo, A.S.L.; Barbosa, G.A.S.; de Almeida, E.O. Short-
term effectiveness of conservative therapies in pain, quality of life, and sleep in patients with temporomandibular disorders: A
randomized clinical trial. Cranio 2019, 1–9. [CrossRef]
63. de Barros Pascoal, A.L.; de Freitas, R.; da Silva, L.F.G.; Oliveira, A.; Dos Santos Calderon, P. Effectiveness of Counseling on
Chronic Pain Management in Patients with Temporomandibular Disorders. J. Oral Facial Pain Headache 2020, 34, 77–82. [CrossRef]
64. Delgado-Delgado, R.; Iriarte-Álvarez, N.; Valera-Calero, J.A.; Centenera-Centenera, M.B.; Garnacho-Garnacho, V.E.; Gallego-
Sendarrubias, G.M. Association between temporomandibular disorders with clinical and sociodemographic features: An
observational study. Int. J. Clin. Pract 2021, e13961. [CrossRef]
65. Al-Ani, Z. Occlusion and Temporomandibular Disorders: A Long-Standing Controversy in Dentistry. Prim. Dent. J. 2020, 9, 43–48.
[CrossRef]
66. Manfredini, D.; Lombardo, L.; Siciliani, G. Temporomandibular disorders and dental occlusion. A systematic review of association
studies: End of an era? J. Oral Rehabil. 2017, 44, 908–923. [CrossRef]
67. Kakudate, N.; Yokoyama, Y.; Sumida, F.; Matsumoto, Y.; Gordan, V.V.; Gilbert, G.H.; Velly, A.M.; Schiffman, E.L. Dentist Practice
Patterns and Therapeutic Confidence in the Treatment of Pain Related to Temporomandibular Disorders in a Dental Practice-Based
Research Network. J. Oral Facial Pain Headache 2017, 31, 152–158. [CrossRef] [PubMed]
68. Onishi, M. Arthroscopy of the temporomandibular joint (author’s transl). Kokubyo Gakkai Zasshi 1975, 42, 207–213. [CrossRef]
[PubMed]
69. Murakami, K.; Ono, T. Temporomandibular joint arthroscopy by inferolateral approach. Int. J. Oral Maxillofac. Surg. 1986,
15, 410–417. [CrossRef]
70. Sanders, B. Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock.
Oral Surg. Oral Med. Oral Pathol. 1986, 62, 361–372. [CrossRef]
71. Sanders, B.; Buoncristiani, R. Diagnostic and surgical arthroscopy of the temporomandibular joint: Clinical experience with 137
procedures over a 2-year period. J. Craniomandib. Disord.: Facial Oral Pain 1987, 1, 202–213.
72. McCain, J.P. Arthroscopy of the human temporomandibular joint. J. Oral Maxillofac. Surg. 1988, 46, 648–655. [CrossRef]
73. McCain, J.P.; Sanders, B.; Koslin, M.G.; Quinn, J.H.; Peters, P.B.; Indresano, A.T. Temporomandibular joint arthroscopy: A 6-year
multicenter retrospective study of 4,831 joints. J. Oral Maxillofac. Surg. 1992, 50, 926–930. [CrossRef]
Diagnostics 2021, 11, 459 14 of 15

74. Reston, J.T.; Turkelson, C.M. Meta-analysis of surgical treatments for temporomandibular articular disorders. J. Oral Maxillofac.
Surg. 2003, 61, 3–10. [CrossRef]
75. Schiffman, E.L.; Velly, A.M.; Look, J.O.; Hodges, J.S.; Swift, J.Q.; Decker, K.L.; Anderson, Q.N.; Templeton, R.B.; Lenton, P.A.;
Kang, W.; et al. Effects of four treatment strategies for temporomandibular joint closed lock. Int. J. Oral Maxillofac. Surg. 2014,
43, 217–226. [CrossRef]
76. Dimitroulis, G. Outcomes of temporomandibular joint arthroscopy in patients with painful but otherwise normal joints. J.
Craniomaxillofac. Surg. 2015, 43, 940–943. [CrossRef]
77. McCain, J.P.; Hossameldin, R.H.; Srouji, S.; Maher, A. Arthroscopic discopexy is effective in managing temporomandibular joint
internal derangement in patients with Wilkes stage II and III. J. Oral Maxillofac. Surg. 2015, 73, 391–401. [CrossRef]
78. Al-Moraissi, E.A. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint:
A systematic review and meta-analysis. Int. J. Oral Maxillofac. Surg. 2015, 44, 104–112. [CrossRef]
79. Liu, X.; Zheng, J.; Cai, X.; Abdelrehem, A.; Yang, C. Techniques of Yang’s arthroscopic discopexy for temporomandibular joint
rotational anterior disc displacement. Int. J. Oral Maxillofac. Surg. 2019, 48, 769–778. [CrossRef]
80. Machoň, V.; Levorová, J.; Hirjak, D.; Beňo, M.; Drahoš, M.; Foltán, R. Does arthroscopic lysis and lavage in subjects with Wilkes
III internal derangement reduce pain? Oral Maxillofac. Surg. 2021. [CrossRef] [PubMed]
81. Nitzan, D.W.; Dolwick, M.F.; Martinez, G.A. Temporomandibular joint arthrocentesis: A simplified treatment for severe, limited
mouth opening. J. Oral Maxillofac. Surg. 1991, 49, 1163–1167. [CrossRef]
82. Alpaslan, C.; Kahraman, S.; Guner, B.; Cula, S. Does the use of soft or hard splints affect the short-term outcome of temporo-
mandibular joint arthrocentesis? Int J. Oral Maxillofac. Surg. 2008, 37, 424–427. [CrossRef] [PubMed]
83. Bayramoglu, Z.; Tozoglu, S. Comparison of single- and double-puncture arthrocentesis for the treatment of temporomandibular
joint disorders: A six-month, prospective study. Cranio 2019, 1–6. [CrossRef]
84. Carvajal, W.A.; Laskin, D.M. Long-term evaluation of arthrocentesis for the treatment of internal derangements of the temporo-
mandibular joint. J. Oral Maxillofac. Surg. 2000, 58, 852–855. [CrossRef]
85. Diracoglu, D.; Saral, I.B.; Keklik, B.; Kurt, H.; Emekli, U.; Ozcakar, L.; Karan, A.; Aksoy, C. Arthrocentesis versus nonsurgical
methods in the treatment of temporomandibular disc displacement without reduction. Oral Surg. Oral Med. Oral Pathol. Oral
Radiol. Endod. 2009, 108, 3–8. [CrossRef] [PubMed]
86. Emshoff, R.; Rudisch, A. Determining predictor variables for treatment outcomes of arthrocentesis and hydraulic distention of
the temporomandibular joint. J. Oral Maxillofac. Surg. 2004, 62, 816–823. [CrossRef]
87. Monje-Gil, F.; Nitzan, D.; Gonzalez-Garcia, R. Temporomandibular joint arthrocentesis. Review of the literature. Med. Oral Patol
Oral Cir. Bucal 2012, 17, e575–e581. [CrossRef] [PubMed]
88. Neeli, A.S.; Umarani, M.; Kotrashetti, S.M.; Baliga, S. Arthrocentesis for the treatment of internal derangement of the temporo-
mandibular joint. J. Maxillofac. Oral Surg. 2010, 9, 350–354. [CrossRef] [PubMed]
89. Nitzan, D.W.; Price, A. The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joints. J. Oral Maxillofac.
Surg. 2001, 59, 1154–1159. [CrossRef]
90. Nitzan, D.W.; Samson, B.; Better, H. Long-term outcome of arthrocentesis for sudden-onset, persistent, severe closed lock of the
temporomandibular joint. J. Oral Maxillofac. Surg. 1997, 55, 151–157. [CrossRef]
91. Nitzan, D.W.; Svidovsky, J.; Zini, A.; Zadik, Y. Effect of Arthrocentesis on Symptomatic Osteoarthritis of the Temporomandibular
Joint and Analysis of the Effect of Preoperative Clinical and Radiologic Features. J. Oral Maxillofac. Surg. 2017, 75, 260–267.
[CrossRef]
92. Polat, M.E.; Yanik, S. Efficiency of arthrocentesis treatment for different temporomandibular joint disorders. Int. J. Oral Maxillofac.
Surg. 2020, 49, 621–627. [CrossRef]
93. Toameh, M.H.; Alkhouri, I.; Karman, M.A. Management of patients with disk displacement without reduction of the temporo-
mandibular joint by arthrocentesis alone, plus hyaluronic acid or plus platelet-rich plasma. Dent. Med. Probl. 2019, 56, 265–272.
[CrossRef]
94. Yilmaz, O.; Korkmaz, Y.T.; Tuzuner, T. Comparison of treatment efficacy between hyaluronic acid and arthrocentesis plus
hyaluronic acid in internal derangements of temporomandibular joint. J. Craniomaxillofac. Surg. 2019, 47, 1720–1727. [CrossRef]
95. Vos, L.M.; Huddleston Slater, J.J.; Stegenga, B. Arthrocentesis as initial treatment for temporomandibular joint arthropathy: A
randomized controlled trial. J. Craniomaxillofac. Surg. 2014, 42, e134–e139. [CrossRef] [PubMed]
96. Al-Moraissi, E.A.; Wolford, L.M.; Ellis, E., 3rd; Neff, A. The hierarchy of different treatments for arthrogenous temporomandibular
disorders: A network meta-analysis of randomized clinical trials. J. Craniomaxillofac. Surg. 2020, 48, 9–23. [CrossRef] [PubMed]
97. Li, D.T.S.; Wong, N.S.M.; Li, S.K.Y.; McGrath, C.P.; Leung, Y.Y. Timing of Arthrocentesis in the Management of Temporomandibular
Disorders: An Integrative Review and Meta-analysis. Int. J. Oral Maxillofac. Surg. 2021. [CrossRef]
98. Hobeich, J.B.; Salameh, Z.A.; Ismail, E.; Sadig, W.M.; Hokayem, N.E.; Almas, K. Arthroscopy versus arthrocentesis. A retrospective
study of disc displacement management without reduction. Saudi Med. J. 2007, 28, 1541–1544. [PubMed]
99. Laskin, D.M. Arthroscopy Versus Arthrocentesis for Treating Internal Derangements of the Temporomandibular Joint. Oral
Maxillofac. Surg. Clin. N. Am. 2018, 30, 325–328. [CrossRef]
100. Monteiro, J.; de Arruda, J.A.A.; Silva, E.; Vasconcelos, B. Is Single-Puncture TMJ Arthrocentesis Superior to the Double-Puncture
Technique for the Improvement of Outcomes in Patients With TMDs? J. Oral Maxillofac. Surg. 2020, 78, 1319.e1311–1319.e1315.
[CrossRef] [PubMed]
Diagnostics 2021, 11, 459 15 of 15

101. Nagori, S.A.; Roy Chowdhury, S.K.; Thukral, H.; Jose, A.; Roychoudhury, A. Single puncture versus standard double needle
arthrocentesis for the management of temporomandibular joint disorders: A systematic review. J. Oral Rehabil. 2018, 45, 810–818.
[CrossRef]
102. Folle, F.S.; Poluha, R.L.; Setogutti, E.T.; Grossmann, E. Double puncture versus single puncture arthrocentesis for the management
of unilateral temporomandibular joint disc displacement without reduction: A randomized controlled trial. J. Craniomaxillofac.
Surg. 2018, 46, 2003–2007. [CrossRef] [PubMed]
103. Bhargava, D.; Thomas, S.; Pawar, P.; Jain, M.; Pathak, P. Ultrasound-guided arthrocentesis using single-puncture, double-lumen,
single-barrel needle for patients with temporomandibular joint acute closed lock internal derangement. Oral Maxillofac. Surg.
2019, 23, 159–165. [CrossRef]
104. Antony, P.G.; Sebastian, A.; Annapoorani, D.; Varghese, K.G.; Mohan, S.; Jayakumar, N.; Dominic, S.; John, B. Comparison of
clinical outcomes of treatment of dysfunction of the temporomandibular joint between conventional and ultrasound-guided
arthrocentesis. Br. J. Oral Maxillofac. Surg. 2019, 57, 62–66. [CrossRef]
105. Bilgir, E.; Yildirim, D.; Senturk, M.F.; Orhan, H. Clinical and ultrasonographic evaluation of ultrasound-guided single puncture
temporomandibular joint arthrocentesis. Cranio 2020, 1–10. [CrossRef]
106. Hu, Y.; Zhang, X.; Liu, S.; Xu, F. Ultrasound-guided vs conventional arthrocentesis for management of temporomandibular joint
disorders: A systematic review and meta-analysis. Cranio 2020. [CrossRef]
107. Leung, Y.Y.; Wu, F.H.W.; Chan, H.H. Ultrasonography-guided arthrocentesis versus conventional arthrocentesis in treating
internal derangement of temporomandibular joint: A systematic review. Clin. Oral Investig. 2020, 24, 3771–3780. [CrossRef]
108. Haigler, M.C.; Abdulrehman, E.; Siddappa, S.; Kishore, R.; Padilla, M.; Enciso, R. Use of platelet-rich plasma, platelet-rich growth
factor with arthrocentesis or arthroscopy to treat temporomandibular joint osteoarthritis: Systematic review with meta-analyses.
J. Am. Dent. Assoc. 2018, 149, 940–952.e942. [CrossRef]
109. Liu, Y.; Wu, J.S.; Tang, Y.L.; Tang, Y.J.; Fei, W.; Liang, X.H. Multiple Treatment Meta-Analysis of Intra-Articular Injection for
Temporomandibular Osteoarthritis. J. Oral Maxillofac. Surg. 2020, 78, 373.e371–373.e318. [CrossRef]
110. Chowdhury, S.K.R.; Saxena, V.; Rajkumar, K.; Shadamarshan, R.A. Evaluation of Total Alloplastic Temporomandibular Joint
Replacement in TMJ Ankylosis. J. Maxillofac. Oral Surg. 2019, 18, 293–298. [CrossRef]
111. Bhargava, D.; Neelakandan, R.S.; Dalsingh, V.; Sharma, Y.; Pandey, A.; Pandey, A.; Beena, S.; Koneru, G. A three dimensional (3D)
musculoskeletal finite element analysis of DARSN temporomandibular joint (TMJ) prosthesis for total unilateral alloplastic joint
replacement. J. Stomatol. Oral Maxillofac. Surg. 2019, 120, 517–522. [CrossRef] [PubMed]
112. Mercuri, L.G. Costochondral Graft Versus Total Alloplastic Joint for Temporomandibular Joint Reconstruction. Oral Maxillofac.
Surg. Clin. N. Am. 2018, 30, 335–342. [CrossRef]
113. Lotesto, A.; Miloro, M.; Mercuri, L.G.; Sukotjo, C. Status of alloplastic total temporomandibular joint replacement procedures
performed by members of the American Society of Temporomandibular Joint Surgeons. Int. J. Oral Maxillofac. Surg. 2017,
46, 93–96. [CrossRef] [PubMed]
114. Ramos, A.; Mesnard, M. Christensen vs Biomet Microfixation alloplastic TMJ implant: Are there improvements? A numerical
study. J. Craniomaxillofac. Surg. 2015, 43, 1398–1403. [CrossRef]
115. Neelakandan, R.S.; Raja, A.V.; Krishnan, A.M. Total Alloplastic Temporomandibular Joint Reconstruction for Management of
TMJ Ankylosis. J. Maxillofac. Oral Surg. 2014, 13, 575–582. [CrossRef]
116. Burgess, M.; Bowler, M.; Jones, R.; Hase, M.; Murdoch, B. Improved outcomes after alloplastic TMJ replacement: Analysis of a
multicenter study from Australia and New Zealand. J. Oral Maxillofac. Surg. 2014, 72, 1251–1257. [CrossRef] [PubMed]