Seminars in Orthodontics 30 (2024) 271−276

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Seminars in Orthodontics
journal homepage:

Degenerative disorders of temporomandibular joint- Current practices and

treatment modalities
Vaibhav Gandhi a, Gauri Sharma b, Eliane H Dutra c, Po-Jung Chen d, Sumit Yadav e,*
a
Calgary, Alberta, Canada
b
University of Connecticut, USA
c
Assistant Professor Division of Orthodontics UConn Health, USA
d
Assistant Professor Department of Growth and Development UNMC College of Dentistry and Children’s Hospital, USA
e
Professor and Chair Department of Growth and Development UNMC College of Dentistry and Children’sHospital, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Degenerative Joint Disorders (DJD) of the Temporomandibular Joint (TMJ) represent a challenging and multifac-
Degenerative joint disorder eted group of conditions that severely impact the joint’s function and quality of life. This comprehensive review
Osteoarthritis delves into the etiology, pathogenesis, clinical manifestations, and contemporary management strategies of TMJ-
Temporomandibular Joint
OA. While systemic illnesses, aging processes, hormonal factors, and behavioral factors have been implicated in
its development, recent evidence highlights the pivotal role of mechanical overloading in initiating a series of
degenerative changes within the TMJ.
Painful joints, a hallmark of TMJ-OA, result from the soft tissues around the affected joint and reflexive muscle
spasm, following Hilton’s law, which innervates the joint’s muscles and overlying skin. This self-preservation
reflex protects against further joint damage. Moreover, painful symptoms may arise from subchondral bone
destruction.
Recognizing the importance of understanding the biomechanical environment within the TMJ, this review under-
scores its relevance in identifying the mechanisms behind TMJ pain and disability. Furthermore, it discusses the
potential application of tissue engineering in TMJ reconstruction, emphasizing the need to learn from past TMJ
implant experiences.
In the context of treatment, the review highlights the significance of managing TMJ-OA, focusing on restoring function
and reducing pain. Treatment modalities span from non-invasive therapies to surgical options, with the latter reserved
for cases unresponsive to conservative approaches and severely affecting an individual’s quality of life.
This review serves as a vital resource for both clinicians and researchers, offering insights into the multifaceted
nature of TMJ-OA and the evolving landscape of its diagnosis and management, incorporating biomechanical con-
siderations and potential advances in tissue engineering. Understanding the complexities of TMJ-OA is instrumen-
tal in enhancing the care and well-being of individuals affected by this condition.

Introduction softer than hyaline cartilage and, therefore, could not be load-bearing.4
Later on, researchers presented multiple human and animal studies and
The temporomandibular joint (TMJ) is a complex ginglymoathrodial concluded that TMJ is a load-bearing joint under the function and fibro-
joint with articular surfaces formed by mandibular condyle and glenoid cartilaginous tissues, including the disc and mandibular condylar carti-
fossa of the squamous part of temporal bone. It stands out as distinct lage, have important functions in stress distribution.5−12
since it’s the sole weight-bearing joint in the body that connects to its Temporomandibular disorders (TMDs) is an umbrella term that refers
opposite counterpart through a single bone, the mandible.1 Unlike other to group of disorders affecting musculoskeletal and neuromuscular condi-
synovial joints in body, which have hyaline cartilage covering the articu- tions, including the masticatory musculature, TMJ, and/or their associated
lar surfaces, the articular surfaces of the TMJ are lined by fibrocartilage; structures.13 Being a significant public health problem and affecting
therefore, it is thought to be more resistant to degeneration over time.2,3 approximately 5−12 % of overall population, TMDs are most common
Initially, Wilson reported that the fibrocartilage of the TMJ condyle was cause of chronic pain of non-dental origin in the orofacial area.14−15

* Corresponding author at: Department of Growth and Development UNMC College of Dentistry and Children’s Hospital Room 2436, Box 830740 4000 East Campus
Loop South Lincoln, d 68583-0740, USA.
E-mail address: [email protected] (S. Yadav).

https://doi.org/10.1053/j.sodo.2023.12.007

1073-8746/© 2023 Elsevier Inc. All rights reserved.

V. Gandhi et al. Seminars in Orthodontics 30 (2024) 271−276

Osteoarthrosis is primarily not an inflammatory disorder, and osteoarthrosis. Additionally, excessive, or imbalanced stress within the
changes in the cartilage and bony structure can develop without any TMJ can induce internal derangement of joint. When examining the
clinical symptoms. TMJ Osteoarthritis (TMJ-OA) is a major component mechanical factors contributing to TMJ internal derangement and osteo-
of TMDs and is most common degenerative joint disease affecting arthrosis, factors such as trauma, parafunction, unstable occlusion, func-
TMJ.1,16 Among individuals with TMDs, 11 % have been found to have tional overloading, and heightened joint friction, all come into play.31−33
symptoms of TMJ-OA.17 The epidemiological data for the TMJ-OA
greatly varies due to differences in diagnostic criteria and disparity in Sign and symptoms of TMJ-OA
the demographic populations.18 Benhardt et al. reported 25 % of individ-
uals between age of 20−49 years to be affected by TMA-OA.19 In The predominant symptom in any TMJ arthritic condition is pain
another research, Schimitter et al. found a prevalence of TMJ-OA to be associated with joint. This pain emanates from soft tissues surrounding
70 % among individuals aged 73−75 years, although most patients had the impacted joint and the masticatory muscles, which go into a protec-
mild pain, and clinical signs of OA were not common.20 Toller PA and tive reflex spasm. This response aligns with Hilton’s law, an orthopedic
Mejersjo C, in two independent studies, reported the prevalence of TMJ- principle that posits that nerves responsible for supplying a joint also
OA between 8−16 % of the population.21,22 TMJ-OA may be unilateral innervate muscles involved in joint’s movement and the skin covering it.
or bilateral and has a strong predilection for women of younger age and This inherent self-preservation reflex safeguards an injured or patholog-
men and women of older age are equally susceptible to TMJ-OA.23 ically affected joint by inducing reflexive contraction of the surrounding
According to the Research Diagnostic Criteria for Temporomandibu- musculature in response to intra-articular injury or pathology. This protec-
lar Disorders (RDC/TMD), numerous scoring options are used to evalu- tive mechanism aims to prevent further damage to the joint. Additionally,
ate the condition of the osseous structures of TMJ associated with OA.24 pain may also originate from subchondral bone as it deteriorates due to
The mineralized or calcified components of the TMJ are assessed for fea- the arthritic process and has major nerve innervation.
tures that indicate remodeling or degenerative changes; based on these On the other hand, continuous and advancing chronic inflammation
changes, the joint can be characterized as normal, indeterminate, or within the TMJ can lead to the deterioration of tissues, sometimes with-
affected by osteoarthritis.25 TMJ-OA could affect hard and/or soft tissue out causing pain for extended periods. The observed clinical manifesta-
structures, including cartilage, subchondral bone, synovial membrane tions can range from a complete absence of signs or symptoms to a
and, ligament and masticatory muscles, thus resulting in alterations of combination of pain, swelling, exudation, tissue breakdown, or growth
TMJ modeling and remodeling and leading to abrasion and deteriora- disturbances. Moreover, the inflammatory activity varies over time, con-
tion of mandibular condylar cartilage.26,27 The joint changes in TMJ-OA tributing to fluctuations in both symptoms and observable signs in this
can vary between affected individuals and changes can occur in the persistent condition.34
form of condylar flattening, sclerosis, resorption, erosion, sub-condylar Other commonly observed and significant signs and symptoms of
cyst, or osteophyte formation.28 Degenerative changes in the form of TMJ arthritis encompass compromised joint function, advanced stage
erosion, sclerosis, or resorption of articular eminence are also character- ankylosis, joint instability, and facial deformity resulting from a reduc-
istic of TMJ-OA.29 tion in the posterior mandibular vertical dimension. This reduction is
caused by pathological osteolysis, which diminishes the height of the
Etiology of TMJ-OA condyle and condyloid process, ultimately leading to a condition known
as apertognathia.16,35
Bone remodeling is a crucial biological reaction to normal functional
demands to maintain equilibrium of joint structure, function, and occlu- Management of degenerative joint disorder of TMJ
sal relationships.30 Two possible explanations were proposed for the
pathophysiology of the degenerative changes of the TMJ resultant from A range of therapeutic options are available for TMJ-OA, depending
dysfunctional osteochondral tissue remodeling.31 upon severity and duration of condition. Management of TMJ-OA is
broadly divided into four treatment categories: non-invasive, minimally
Decreased adaptive capacity of the articulating structures of joint (The host- invasive, invasive, or surgical intervention, and finally, salvage modali-
adaptive capacity factor) ties.16 The decision for surgical management of TMJ-OA should be
reserved when the non-invasive modalities have already failed and/or
The host-adaptive capacity of TMJ may be determined by factors following the assessment of the patient’s mandibular form and function
such as advancing age, systemic illness, and hormonal influences. This and based on the effect of this condition on the patient’s quality of life.35
element could play a role in the dysfunctional remodeling of the TMJ,
even when biomechanical stresses remain within the normal physiologi- Non-invasive therapy for management of TMJ-OA
cal range. Age is evidently a predisposing factor, as the occurrence and
severity of the condition seem to rise with the aging process. Fibrocarti- Oral appliances
lage metabolism in TMJ can also be impacted by systemic illnesses,
potentially affecting the joint’s adaptive capabilities. Systemic condi- Occlusal splints have long been used in the treatment of TMJ-OA
tions which may cause TMJ-OA are autoimmune disorders, endocrine with the purpose of reducing micro trauma because of parafunctional
disorders, nutritional imbalances, metabolic diseases, and infectious ill- habits, reducing muscle hyperactivity, and preventing involuntary over-
nesses. Additionally, hormonal factors can significantly influence the loading of the joint.16,36,37 Furthermore, oral appliances assist in
remodeling of the mandibular condyle. In such instances, degenerative decreasing the frequency and duration of muscle activity in some
disorders in the TMJ might be attributed to underlying systemic patients; they may also relieve masticatory muscle co-contraction/pain
diseases.16 and, along with a soft diet, decrease the loads delivered across the TMJ
articulation under function.38 Reconstruction of occlusion to provide
Excessive or sustained physical stress to the TMJ articular structures bilateral occlusal stability temporarily during the early stages of man-
exceeding normal adaptive capacity. agement also decreases the potential for unilateral joint overload.39
However, evidence on occlusal splint therapy for the treatment of TMJ-
Even though the host-adaptive capacity is optimal, the TMJ can still OA is controversial. Ismail et al. reported a favorable response to stabili-
suffer from the negative effects of excessive or imbalanced mechanical zation/relaxation splint by alleviating the symptoms.40 Kuttila et al. con-
stress. This can lead to the overloading of osteochondral tissues, ulti- ducted a controlled study on the effects of occlusal splint therapy in
mately causing the development and advancement of TMJ patients with severe TMJ-OA and observed a significant reduction in

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clinical signs and symptoms.41 On the other hand, Forssell and Kalso showed that a single intra-articular injection of methylprednisolone
published a systematic review and reported that the clinical effective- diluted with lidocaine remarkably decreased joint pain and other symp-
ness of occlusal splint therapy in relieving pain is modest as compared to toms of TMJ-OA for 4 to 6 weeks.58 Ringold et al. observed improve-
other pain management modalities. They also added that none of the ment in TMJ mobility and pain relief following the first triamcinolone
occlusal adjustment studies provided evidence supporting the use of this injection, nevertheless, further injections did not produce obvious
treatment method.42 improvement.59 The main limitations of repeated intra-articular steroid
injections are the risks of infection and the destruction of articular carti-
Medications lage. Repeated intra-articular corticosteroid injections have been impli-
cated in the "chemical condylectomy" phenomenon in the TMJ.60 Intra-
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, articular injections of steroids should be considered only in persons with
should be used on a time-contingent basis to take advantage of their evidence of acute high inflammation of the joint. Multiple injections of
pharmacokinetics. A short-term (5-7 days) oral corticosteroids may be steroids should not be used.16
considered to ‘‘jump-start’’ the anti-inflammatory process and would
then be followed by a longer course of NSAIDs. Muscle relaxants may Arthrocentesis and arthroscopy
help control the reflex masticatory muscle co-contraction and pain.43
The value of TMJ arthroscopy may be in early diagnosis and manage-
Physical therapy ment of arthritic processes affecting the TMJ, especially early-stage
arthritic disease, to avoid the complications of open bite and ankylosis.
Different means of physical therapy can be supplemented with other TMJ arthrocentesis is a technique that effectively manages intracapsular
treatment modalities to increase effectiveness in reducing signs and pain conditions such as inflammation (retrodiscitis, osteoarthritis) and
symptoms of TMJ-OA. Superficial warm and moist heat or localized cold displaced disk mobility conditions within TMJ. The lavaging action
may relieve pain sufficiently to permit exercise. All kinds of heavy-load- decreases inflammatory mediators and cytokines that are responsible for
ing exercises that can compress the joint should be avoided.44 Therefore, pain and lubricates superior joint space to allow the disk to move with-
muscle-strengthening exercises, for the most part, are best done isomet- out restriction.61,62 Nitzan and Price, conducted a 20-month follow up
rically, in a position that does not cause pain.45 A study by Nicolakis study on 36 patients with TMJ-OA treated by arthrocentesis and
et al. on active and passive jaw movements, manual therapy techniques, observed decreased maximal interincisal opening (MIO) and TMJ pain.
correction of body posture, and relaxation techniques was conducted for Additionally, dysfunction associated with 26 joints (68.4 %) improved
the management of 20 consecutive patients who had TMJ-OA. After significantly, and need for corrective surgery was eliminated for those
treatment (mean, 46 days), pain at rest was reduced in the 20 persons patients.33 Several studies reported that arthrocentesis alone and in con-
by 80 %, and there was no functional impairment in 37 % of the 20 per- junction with intra-articular corticosteroid injections after arthrocente-
sons (seven persons).46 sis resulted in substantial clinical improvements in pain complaints and
painless MIO.63,64 Another study on 79 patients (83 joints) with TMJ-
Minimally invasive therapy OA concluded that arthrocentesis obviated surgical intervention in 81 %
of patients with symptomatic TMJ-OA. When combined with stable
Hyaluronic acid occlusion, controlled loading, and adequate function, arthrocentesis
could provide the joint conditions for adaptation, self-correction, and
The efficacy of hyaluronic acid (HA), a large linear glycosaminogly- adjustment, leading to a long-lasting asymptomatic state.65
can available for injection, in the treatment of osteoarthritis has been
the subject of research in different joints within the body. Exogenous Invasive or surgical therapy
visco-supplementation has been proven to improve jaw function and
relieve pain in patients with TMJ-OA for its functions in lubricating, A significant variation can be observed regarding the outcome of
anti-inflammation, and maintaining intra-articular homeostasis.47 Sev- minimally invasive procedures, depending upon at what stages of the
eral double-blinded studies conducted on the hip, knee, and shoulder arthritic process the arthroscopic was performed and whether any intra-
were shown to provide significantly better results with HA after 2 capsular therapeutic agents have been supplemented with the proce-
months of follow-up than controls. However, no significant difference dure. Late-stage marked fibrosis or ankylosis makes arthroscopy
was observed in the radiographic progression of the disease.48−50 Neo impossible and contraindicates its usefulness.66 While most persons
et al. concluded that HA may have a role in preventing the progression with TMJ-osteoarthrosis can be successfully managed with non-inva-
of TMJ-OA from a study in sheep that underwent five repeated injections sive/minimally invasive procedures, there is a small percentage of per-
of sodium hyaluronate over 14 months into their experimentally sons with osteoarthrosis (<20 %) who have such severe pathology, pain,
induced TMJ osteoarthritis.51 Alpaslan and Alpaslan conducted a study and dysfunction that invasive surgical management must be
on TMJ arthrocentesis with and without the addition of sodium hyaluro- considered.35
nate and they found positive results with both procedures; however,
patients having arthrocentesis with addition of sodium hyaluronate had Arthroplasty
superior results.52 On the other hand, Bertolami et al. reported that
sodium hyaluronate in TMJ-OA showed no significant difference in out- Dingman and Grabb introduced the method of reshaping the articu-
comes as compared to the placebo or saline control group.53 lar surfaces to eliminate osteophytes, erosions, and irregularities found
in osteoarthritis refractory to other treatment modalities.67 Although it
Corticosteroid alleviates the pain and discomfort, this technique is not free of risk fac-
tors such as mandibular dysfunctions, dental malocclusions, facial asym-
Because of highly effective anti-inflammatory function of corticoste- metry and the potential worsening of the bony articular degeneration,
roids, intra-articular corticosteroid injection gradually became a popular disc loss or damage, and possible bony or soft tissue ankylosis.
therapeutic modality for local treatment of painful joints, including the
TMJ, knee, shoulder, and elbow joints.54−56 Hemiarthoplasty
Kopp et al. conducted a randomized, blinded study on the use of cor-
ticosteroid injections on TMJ-OA patients and showed decreased symp- To eliminate the possible risk factors of arthroplasty alone, technique
toms and improved joint mobility for up to 2-years.57 Alstergren et al. for interposing autogenous tissues (e.g. the vascularized local temporalis

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muscle flap appears to present the most applicable data for managing the Consequently, orthodontists play a pivotal role in not only identifying
arthritic TMJ) was introduced.68 One of the most important roles of the and screening for Temporomandibular Disorders (TMD) but also in
temporalis muscle flap is the maintenance of functional movements. actively intervening in the management of degenerative joint disorders
Several different alloplastic implantable materials have been advocated as integral members of the TMJ care team. Patients with TMJ-OA neces-
for hemiarthroplasty reconstruction of the temporomandibular joint. sitate a comprehensive, multidisciplinary approach, involving collabora-
However, Henry and Wolford presented the contraindications for the tion between an orthodontist and a maxillofacial surgeon, to achieve the
use of the temporalis muscle/fascia graft: failed Proplast-Teflon (Vitek, optimal outcomes in terms of facial aesthetics, functional proficiency,
Houston, Texas) or Silastic (Dow Corning, Midland, Michigan) with con- and TMJ stability.
tinuing foreign body giant cell reaction, progressive osteoarthritis, and
two or more prior surgeries.69−74 Conclusion

Osteotomy When it comes to addressing the degenerative issues in the TMJ, the
primary treatment objectives for affected individuals are to restore
Individuals with active TMJ-OA and either concomitant or resultant proper function and alleviate pain. The treatment approaches employed
maxillofacial skeletal discrepancies and treated only with orthognathic to achieve these objectives can range from non-invasive therapies to
surgery often have poor outcomes and significant relapse. Pre-existing minimally invasive and, in some cases, invasive surgical interventions.
TMJ pathology, with or without symptoms can lead to unfavorable The majority of individuals can be effectively managed through non-
orthognathic surgery outcomes, includes internal derangement, progres- invasive means, and it is important to recognize the significance of dis-
sive condylar resorption, osteoarthritis, condylar hyperplasia, osteo- ease prevention and conservative management as integral components
chondroma, congenital deformities, and non-salvageable joints.75,76 of the overall treatment for those with TMJ issues.
Since the foundation of orthognathic surgery resides in the health and The decision to pursue surgical management for TMJ-osteoarthrosis
stability of the TMJ, any pathology of the hard and soft tissue structures should be informed by an assessment of the individual’s response to
of the TMJ can lead to a poor base for any maxillofacial functional skele- non-invasive treatments, an evaluation of their mandibular structure
tal reconstruction. Successful outcomes have been reported, however, and function, and an understanding of how the condition affects their
using orthognathic surgical procedures to manage maxillofacial skeletal quality of life.
discrepancies in patients who have idiopathic condylar resorption While systemic illness, the aging process, hormonal influences, and
(ICR).77 behavioral factors have all been associated with the development of
TMJ-osteoarthrosis, there is a growing body of evidence to suggest that
Distraction osteogenesis (DO) mechanical overloading may serve as an initiating factor for a sequence
of degenerative changes in the TMJ. These changes can lead to condylar
In severe cases of the ICR, distraction osteogenesis could be a poten- resorption and deformity. Consequently, examining the biomechanical
tial surgical treatment to correct skeletal deformities. Osteoclastic activi- environment within the TMJ holds the potential for a more comprehen-
ties in the TMJ have been reported following a gradual distraction of the sive understanding of the mechanisms that trigger TMJ pain and disabil-
mandible. All cases of mandibular hypoplasia requiring surgical man- ity. This understanding, in turn, can aid in accurate diagnosis and the
agement must be critically assessed for the traumatic, functional, or met- development of effective treatment plans for individuals with TMJ
abolic risk factor of the TMJ-OA or ICR.78 degenerative disorders.

Salvage procedures or total joint replacement Patient consent

In the extreme cases of the ICR, the only viable option to salvage the Patient consent is not required.
remaining hard tissue of TMJ would be the total joint replacement. For
mandibular condylar reconstruction and regaining facial form and func- Author contributions
tion, there are several autogenous tissues which have been used. Vascu-
larized rib, iliac crest, fibular free flaps, iliac bone-free grafts, clavicle, All authors attest that they meet the current ICMJE criteria for
and sternoclavicular joint are the sites of interest to harvest autogenous authorship.
tissue for mandibular condylar reconstruction. The costochondral graft
has been the autogenous bone most frequently recommended for the Funding
reconstruction of the TMJ, due to its ease of adaptation to the recipient
site, its gross anatomical similarity to the mandibular condyle, its low No funding or grant support received.
morbidity, its reported low morbidity rate at the donor site, and its dem-
onstrated growth potential in juveniles.79 However, orthopedists recom- Declaration of Competing Interest
mend alloplastic reconstruction when total joint replacement is required
for management of a non-growing person affected by either low-inflam- The authors declare that they have no known competing financial
matory or high-inflammatory arthritic disease.80 There is a common interests or personal relationships that could have appeared to influence
consensus amongst surgeons that when mandibular condyle is exten- the work reported in this paper.
sively damaged, degenerated, or lost, as in arthritic conditions, replace- The author (SY), serving as editorial board member, was not
ment with either an autogenous graft or alloplastic implant is an involved in the peer review or final decision-making process for the
acceptable approach to achieve optimal symptomatic and functional manuscript.
improvement.
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