Diagnosis and Management of Temporomandibular Disorders 1

GUIDELINES
Approved by the College – November 2018
This is replacing the document last
published in July 2009.

Diagnosis and Management of

Temporomandibular Disorders

The Guidelines of the Royal College of Dental CONTENTS

Surgeons of Ontario contain practice parameters INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

and standards that should be considered by all

EDUCATIONAL REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ontario dentists in the care of their patients. These
PROFESSIONAL RESPONSIBILITIES
Guidelines may be used by the College or other Patient History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
bodies to determine if appropriate standards of Special Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
practice and professional responsibilities have Non-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
• TMD and Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
been maintained.
Surgical Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

6 Crescent Road
Toronto, ON Canada M4W 1T1
T: 416.961.6555 F: 416.961.5814
Toll Free: 800.565.4591 www.rcdso.org

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 2 Guidelines | November 2018

Introduction A decision to treat and how to treat should be based on

a detailed and relevant clinical history, a careful clinical
examination, and preference given to conservative,
Temporomandibular disorders (TMDs) is a general term
reversible therapies.
for a variety of conditions involving pain or dysfunction in
the joints and other structures of the jaw. Most of these
TMD symptoms may mimic other pain conditions and vice
disorders are poorly understood. They can be difficult to
versa. The practitioner must have an understanding of
diagnose and treat, because of the complex factors that
other causes of orofacial pain in order to diagnose and
may be involved.
treat TMDs successfully.

Like all chronic pain conditions, TMDs (especially those of

These guidelines are not an exhaustive treatise on
myofascial origin) are often associated with psychological,
diagnostic and treatment strategies for all forms of orofacial
social and behavioural components. Symptoms may
pain; the focus is on the diagnosis and management of
include anxiety, depression, frustration and anger, as
TMDs. Every patient is unique and, therefore, requires
well as behaviours like bruxism (excessive teeth grinding
individualized management. Other causes of facial pain not
or jaw clenching), poor posture, lack of exercise, poor
originating from the temporomandibular apparatus may
dietary and sleep habits, drug dependencies and other
need to be considered, including, but not limited to, the
tension-related habits.
neuralgias (e.g. trigeminal neuralgia, atypical facial pain),
demyelinating diseases, CNS tumours, peripheral
Each of these symptoms or behaviours may complicate the
tumours, vascular headaches, muscle contraction-
clinical picture. There may be many factors that create pain
type (tension-type) headaches, dentoalveolar disease,
and cause it to reoccur.
sinus disease, ear disease, salivary gland disease and
psychiatric/psychological disorders.
Patients have a critically important role to play. While
dentists and other oral health care practitioners may
The guiding principle of any treatment must be “primum
recommend and provide long-term care plans, patients
non nocere” or, freely translated, “above all, do no harm.”
must be informed of, and assume responsibility for, their
Failure to respond to conservative treatment does not
part in their own care. In particular, patients must change
mean irreversible or invasive therapies are inevitable.
or reduce lifestyle risk factors that contribute to TMDs and
There must always be clear indications that a specific
treatment failure. For example, patients may need to:
invasive or irreversible treatment approach is appropriate
· commit to daily exercise
and the risks and benefits of the treatment versus the
· adopt a healthier diet and sleep patterns
untreated symptoms are carefully weighed.
· moderate the use of drugs and other chemicals
· develop realistic expectations and self-sufficiency
The dentist should consider collaborating with other
· make use of the social support of family, friends
health care professionals, including the patient’s physician
and colleagues.
or appropriate medical or dental specialists, particularly
when the dentist lacks experience or the management
Ultimately, the success of treatment will very much
of the patient’s condition begins to exceed their
depend on how well the patient accepts and follows a new
competence to manage independently.
daily routine. They will need the help of their dentist to
understand what needs to be done.
The patient must be well aware of the risks before
initiating any procedure that may permanently alter the
There is no evidence to support the idea that TMDs are
dentition or jaw relationships. Truly informed consent
always progressive. On the contrary, there is considerable
is vital. Re-evaluation during the course of treatment is
evidence indicating that, in many cases, clinical remission
equally important to ensure that the diagnosis is correct
occurs without treatment. The need for treatment and the
and the course appropriate.
nature of the treatment should be considered carefully.

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 Diagnosis and Management of Temporomandibular Disorders 3

Educational Requirements Continuing education programs or short courses that

promote one method of treatment or a product or that
focus on specific diagnostic tools are usually inadequate.
The majority of patients presenting in the dental
Practitioners who have taken one or many short courses
office with signs and symptoms of a TMD can be
should recognize that these do not impart specialty status.
assessed and treated appropriately by any properly
trained general dentist. Appropriate education and
An oral and maxillofacial surgeon who has successfully
training (undergraduate or continuing education
completed a residency in an accredited program may
programs) should:
have had adequate opportunity to assess and operate on
· promote the concept of diagnosis-based treatment
patients with TMDs. Additional training might be necessary
with conservative, reversible treatment modalities
where the training program did not provide adequate
· emphasize the multifactorial, biological and
exposure to all diagnostic and therapeutic modalities.
functional basis of TMD
· foster an understanding of the anatomy, physiology
Continuing education in the diagnosis and management
and pathology of the temporomandibular joints,
of TMD is widely available and should represent a part of
associated musculature and related structures, as
the clinician’s continuing dental education activities if they
well as the behavioural and psychosocial aspects of
are to remain competent in the management of patients
these and related chronic pain disorders
with this complex of disorders. Acceptable courses
· expose the student or practitioner to the various
should be evidence-based and conform to the practice
options in conservative patient management
parameters and standards set out in this document.
· include a discussion of the potential adverse effects
of the various treatment modalities
· instill in students and practitioners the importance of
cooperating and collaborating, where appropriate, Professional Responsibilities
with other health practitioners who have been
trained to diagnose and render rational treatment PATIENT HISTORY
of TMDs. These include other dentists, dental
specialists, physiotherapists, psychologists, As with all dental treatment, a careful medical and dental
physicians and various medical specialists history should be obtained before any treatment is
· allow the student or practitioner to determine when contemplated. TMD investigation and treatment must
treatment is warranted and discourage therapy that only be initiated after any specific odontogenic basis for
is unnecessary, impractical or potentially detrimental the patient’s complaint has been ruled out. Overlapping
to the patient conditions need to be considered and addressed. For
· teach the student or practitioner to critically those patients with a history of TMDs, this checklist can be
evaluate the literature and research on new used to ensure that the necessary information has been
concepts, treatment methods and diagnostic aids, obtained and recorded.
equipping him or her to reject concepts, treatment
modalities or devices that lack scientific validation Medical history
· result in the student or practitioner having an 1. Past medical history
understanding of the other painful disorders and 2. Present and ongoing medical/dental diagnoses
diseases that afflict the craniofacial complex, equip and therapy
him or her with the knowledge and capability to 3. Past and current medications
differentiate these from TMDs and treat or refer the
patient accordingly.

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 4 Guidelines | November 2018

Pain Altered Sensation

1. Localized facial/jaw pain · site(s)
· nature of pain, constant or episodic · nature (e.g. tingling, numbness, hyperesthesia)
· site, radiation pattern · constant or episodic
· precipitating or aggravating factors · precipitating factors
· relieving factors, conditions, treatment · relationship to other symptoms
· severity
Tinnitus
2. Earaches · bilateral or unilateral
· bilateral or unilateral · association with other symptoms
· association with other symptoms
Perceived hearing loss
3. Headaches · bilateral or unilateral
· site · association with other symptoms
· constant or episodic
· relationship to other symptoms Related cognitive, emotional or mood changes
· duration and frequency · e.g. loss of energy, appetite, memory, concentration,
· precipitating factor(s) feelings or appearance of depression/sadness
· other related symptoms (e.g. photophobia,
phonophobia, nausea) Sleep disturbance
· relationship to jaw or temporomandibular joint- · difficulty falling asleep, staying asleep, nightmares
related symptoms · quality of sleep
· relieving factors, conditions, treatment
Duration of each of the symptoms
4. Neck, shoulder, back pain
· constant or episodic Relationship of onset to specific events
· relationship to other symptoms · e.g. trauma, other injuries, stress, treatment,
· precipitating factor(s) general anesthesia
· relationship to jaw or temporomandibular joint-
related symptoms Parafunctional habits
· relieving factors, conditions, treatment · night-time bruxism (sleep bruxism)
· severity · clenching, nail-biting, chewing gum
(daytime, nocturnal, frequency)
Limitation of mandibular movement · onset
· constant or episodic
· precipitating and aggravating factors Previous treatment for the patient’s complaints
· relieving factors, conditions, treatment and its effectiveness
· history of open or closed locks

Joint noises CLINICAL EXAMINATION

· nature (clicking, popping, grinding)
· side (left, right, both) Conduct a thorough clinical examination and record
· constant, episodic all findings in order to exclude other causes for the
· association with jaw function patient’s symptoms and to determine the type of TMD
and the extent of any disability related to the patient’s
symptoms. This is critical to making a correct diagnosis

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 Diagnosis and Management of Temporomandibular Disorders 5

and developing a treatment plan to address the needs of · Occlusion

the particular patient. It is inappropriate for the dentist’s − note status of patient’s occlusion and any
physical examination to extend beyond the head, neck changes such as open bite
and shoulder region. − whether occlusal relationships are functional

Consider this checklist: Other

· trigger points for pain
General extra-oral · altered sensitivity (e.g. pin-prick, light touch)
· Observation of the patient’s general appearance, · oral mucosal lesions or disorders
demeanour, gait
· Facial swelling or significant asymmetry
· Palpable lymph nodes SPECIAL INVESTIGATION

Temporomandibular apparatus Additional investigative procedures will be dictated by

· Palpation of: the results of the history and clinical examination. In most
− the temporomandibular joints both facially and cases, minimal or no further investigation is indicated
via the external auditory meatus in order to initiate treatment. Should the patient be
− the muscles of mastication and facial musculature unresponsive to initial conservative therapy, additional
both extra- and intra-orally investigation may be indicated.
· Limitation of mandibular movement
− inter-incisal opening (measured, assisted and Radiographic Investigation
unassisted) Radiographic investigation may be indicated if the clinical
− path of mandibular movement during opening or evaluation, or the medical or dental history suggest:
closing (deviation or deflection)
− condylar movements 1. An abnormality of the osseous components of the
− lateral movement of the mandible, symmetrical jaws or joints
− protrusive movement of the mandible, Investigations may include panoramic radiography
symmetrical (to rule out significant osseous or dental disease in
− presence or absence of pain on opening, the mandible or maxilla or severe condylar changes)
protrusive or lateral movement of the mandible or more detailed investigation using cone beam
· Joint noise computed tomography, computerized tomography or
− audible or palpable nuclear bone scans.
− nature (clicking, popping, grinding)
− bilateral or unilateral 2. A disc displacement of the joints
− on opening, closing or both Magnetic resonance imaging (MRI) is the optimal
− early or late modality to assess positional, functional and
morphologic abnormality of the articular disc.
Intra-Oral Although non-invasive, it requires referral to a primary
· Dentition care provider. MRI studies should only be considered
− missing teeth when the results would affect the course of treatment.
− state of repair of dentition Since disc displacements have been documented
− dentures (full or partial, adequate or inadequate) in asymptomatic individuals, imaging of the disc
− presence or absence of dental or periodontal is only justified when the displacement is likely to
disease be clinically significant or the patient has failed to
− wear facets respond to conservative treatment.
− percussion sensitivity
− thermal sensitivity where indicated

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 6 Guidelines | November 2018

3. An extra-articular disorder The concept of “neuromuscular occlusion” is based

Radiographs of the dentition or other structures on the diagnostic value of electromyography for
anatomically related to the temporomandibular TMDs and treatment is based on the use of electrical
stimulation of the muscles of mastication to establish
joints, such as the salivary glands, sinuses, cranium
appropriate occlusal positioning. Controlled studies
or neck, may be indicated to rule out other dental or suggest that there is a wide range of results and
craniofacial disease. Other imaging techniques might inconsistent findings using electromyography, which
be indicated depending on the clinical diagnosis (e.g. minimize its usefulness as a diagnostic test for TMD.
ultrasound imaging for soft tissue lesions). Specifically, differences between TMD patients and
healthy controls were not consistent. Regarding the
clinical efficacy of TMD treatment based on electrical
Consult a radiologist or similarly qualified specialist when
stimulation of the muscles of mastication, there is
radiographic investigation not normally performed in insufficient data from well controlled studies to rule
a dental office is indicated. They can recommend the out a placebo effect. Until properly controlled studies
procedures with optimal safety and economy that would are available, there is insufficient evidence to support
yield the most useful information. the clinical use of these techniques.

Dentists must exercise reasonable clinical judgment

Laboratory Investigation
and carefully weigh the risks and benefits of any
Laboratory investigation is only necessary if previous treatment versus the untreated signs and symptoms.
investigation (history/physical examination) has suggested
an infectious, metabolic or autoimmune disorder.

Other Consultations DIAGNOSIS

In selected cases, a consultation with other healthcare
professionals (family physician, neurologist, Treatment must always be diagnosis-based. The treatment
otolaryngologist, physiatrist, rheumatologist, psychologist should be directed at the factors apparently causing
or psychiatrist) may be indicated. the symptoms or dysfunction. The mere presence of a
disorder is not always justification for treatment as many
The clinical value of a number of diagnostic aids currently are self-limiting or asymptomatic. Although there is no
in use has not been demonstrated in well-controlled and one uniformly accepted classification for TMD, diagnoses
scientifically based studies; these include jaw tracking can include:
devices, EMG recording and sonography (Doppler). These
aids may have some use for research purposes but may · Masticatory muscle disorders – myospasm, myofascial
not necessarily facilitate diagnosis or patient treatment. pain, pain as a component of systemic disorders such
as fibromyalgia, chronic fatigue syndrome
· Disc displacement – with or without reduction,
intermittent/continuous limited opening
· Joint hypermobility – subluxation, luxation
· Arthritides – osteoarthritis, rheumatoid arthritis,
psoriatic arthritis, septic arthritis, gout, pseudogout,
lupus erythematosis, capsular inflammation
· Congenital/developmental abnormalities –
condylar hyperplasia, condylar hypoplasia/aplasia,
coronoid hyperplasia

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 Diagnosis and Management of Temporomandibular Disorders 7

The differential diagnosis, however, must also include Most TMDs are managed rather than definitively treated.
the following: Available modalities include:
· Reassurance and patient education
· Direct traumatic injuries, such as: · Medication:
− fractures of the condyle, condylar neck, coronoid − analgesics
process or temporal bone − muscle relaxants
− joint dislocation, subluxation or ligamentous/ − anti-inflammatory drugs (NSAIDs)
capsular disorders − tricyclic amines (antidepressants) (TCAs)
· Post-traumatic stress disorders and centrally − anticonvulsants (gabapentin)
mediated complex pain syndromes, such as: − compounded topical ointments
− fibromyalgia
− complex regional pain syndrome Some drugs may be contraindicated in selected cases
− centrally mediated neuropathic pain (e.g. NSAIDs in patients with gastrointestinal disorders,
· Neoplasms (of the components of the NSAID sensitive asthma, TCAs in patients with cardiac
temporomandibular joints or related structures conduction disorders). The practitioner must be familiar
or metastatic) with the potential drug interactions and side effects
· Idiopathic pain and dysfunctions (long- and short-term use) of any medication prescribed
and be prepared to deal with adverse reactions. The
Other causes of facial pain not originating from dentist should consider collaborating with other health
the temporomandibular apparatus may need care professionals, particularly when appropriate
to be considered, including, but not limited to, pharmacotherapy involves the use of drugs with which
the neuralgias (e.g. trigeminal neuralgia, atypical the dentist lacks experience or complications begin to
facial pain), demyelinating diseases, CNS tumours, exceed their competence to manage independently.
vascular headaches, muscle contraction-type For more information, see the Guidelines on The Role of
(tension-type) headaches, dentoalveolar disease, Opioids in the Management of Acute and Chronic Pain in
sinus disease, ear disease, salivary gland disease, Dental Practice.
and psychogenic disorders.
· Therapy by a dentist or other registered health
The final diagnosis may be a combination of more than professional, experienced in the management
one of the above. of TMDs, including:jaw exercises (e.g. relaxation,
rotation, stretching, isometrics and postural)
− application of superficial heat or cold
NON-SURGICAL MANAGEMENT − massage
− manual mobilization
In most cases, initial management should be directed − ultrasound*
towards the relief of symptoms. There is no demonstrated − low-intensity laser*
value for the treatment of asymptomatic joint noises. − TENS (transcutaneous electrical nerve
The concept of routine irreversible alteration of the stimulation)
patient’s temporomandibular joints, jaws, occlusion or − acupuncture
dentition, is not supported by sound scientific studies.
Failure to manage a patient’s symptoms with a conservative * There is some evidence that some of these can reduce
patient’s symptoms facilitating mobilization and reducing pain
method does not necessarily imply nor guarantee the
thus allowing jaw exercises to proceed.
success of another more invasive technique.

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 8 Guidelines | November 2018

· Psychological, psychotherapeutic or psychiatric · Trigger/tender point injections, where indicated, for

treatment by appropriately qualified practitioners, the muscles of mastication
including behavioural modification therapy, cognitive − local anesthetics (without vasoconstrictor in
behavioural therapy and mindfulness muscles) Note: These may also be considered as
· Stabilization type of occlusal appliances (intra-oral part of the examination when used in a selective
appliances designed to provide even and balanced manner to aid in isolation of a possible source of
occlusal contact without either forcefully altering the pain and therefore might be administered into
mandibular rest position or permanently altering the other anatomical sites (e.g. as a nerve block).
dental occlusion) − corticosteroids
− botulinum toxin – there is some evidence that it
Long-term, constant or permanent anterior is of value for myalgia, particularly that related
repositioning of the mandible, such as with to myospasm or muscle hyperactivity when
orthodontics or fixed / removable prosthodontics, is traditional methods fail.
not validated by well controlled, well designed scientific
research. Additionally, partial occlusal coverage
Ontario dentists who wish to use botulinum toxin may
appliances with limited interarch contacts must be used
do so, but only for procedures that are within the
with caution to avoid the risk of permanent occlusal
scope of practice of dentistry. More specifically, Ontario
changes or aspiration. dentists may inject botulinum toxin intra-orally for
either therapeutic or cosmetic purposes, or extra-orally
for therapeutic purposes, but in either case only if they
Oral appliances may be used to maintain the tongue are appropriately trained and competent to perform
or jaw in a position to relieve or improve snoring and the procedure/s.
sleep-disordered breathing (SDB). However, these
appliances may cause or worsen temporomandibular Ontario dentists who wish to use botulinum toxin
joint pain, joint noise development, pain in the muscles are expected to successfully complete a course
of mastication and permanent changes in occlusion, of instruction that includes pharmacological and
which may include an increase in anterior overbite or physiological characteristics of this neurotoxin, as well
development of an open bite. as possible adverse reactions and their management. In
addition, Ontario dentists who wish to use botulinum
The use of oral appliances in the management of toxin extra-orally for therapeutic purposes, such as for
snoring and SDB requires a team approach, involving the management of certain TMDs and other oral-facial
dentists and physicians who are trained and competent conditions, are expected to pursue more extensive
in this field. The main roles of the dentist are to screen training.
for SDB, but not to diagnose it, and to provide therapy
in appropriate cases. The patient must be referred to It is not within the scope of practice of dentistry and
a sleep physician or family physician to review their Ontario dentists are NOT authorized to inject botulinum
overall medical history and assess for the presence of toxin extra-orally for cosmetic purposes.
obstructive sleep apnea.
Council adopts a new position on the use of botulinum
The dentist must perform a clinical assessment of the toxin and dermal fillers by Ontario dentists.
patient, including general and oral health, and the
prognosis for soft and hard tissues to be affected by
the use of an oral appliance. The patient must be fully
informed of the potential and probable risks of using
If treatment such as that described above successfully
an oral appliance. Dentists must assess for and manage
reduces the patient’s symptoms, restoration to function of
side effects of oral appliance therapy as they develop.
a non-functional (unstable) occlusion may be warranted.
There is inadequate research demonstrating any value

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 Diagnosis and Management of Temporomandibular Disorders 9

to occlusal adjustment or alteration, except where the A collaborative/cooperative approach between the
patient’s occlusion is non-functional (e.g. cannot chew dentist and physician is best; however, it must be
adequately). Dental treatment may be indicated to correct recognized that the diagnosis and treatment of headache
previous restorative or prosthetic treatment that has is not within the scope of practice of dentistry. While a co-
resulted in an iatrogenic malocclusion. morbid headache may resolve with treatment of the TMD,
it is not part of the dentist’s therapeutic plan. At times,
Treatment modalities for which there are no the “cause and effect” relationship between tension-type
generally accepted scientific or empirical basis headache and TMD can be unclear. No such relationship
should not be employed. has been proven for TMD and migraine headache.

TMD and Headache SURGICAL INTERVENTION

Headache has long been accepted as a symptom of TMDs. In some cases, surgical intervention may be indicated.
In most cases, the headache is secondary to the facial In all cases, the surgical procedures described below
muscular pain. More recently, the presentation of certain must only be performed by those dentists who have
types of headache and TMD as comorbid conditions has completed a formal post-graduate program in oral and
been recognized. It has been demonstrated that tension- maxillofacial surgery that is suitable for certification in the
type headache (muscle contraction type headache) and Province of Ontario.
TMD are potentially comorbid painful muscular disorders.
In addition, the possible comorbidity of migraine Before considering surgical intervention, a diagnosis must
headaches and TMD has also been elucidated as a result have been made that is based on a thorough history,
of central sensitization. physical examination and the results of any necessary
adjunctive diagnostic tests. In addition, all appropriate
Comorbid presentations should be considered differently conservative treatment modalities should have been
from headache as a secondary outcome of a TMD. prescribed over a suitable period of time.
When comorbidity exists, both diagnoses must be firmly
established by appropriate healthcare practitioners using Where conservative therapy has failed to modify the
standardized diagnostic criteria, followed by treatment patient’s TMD, it does not necessarily follow that surgical
of both conditions with appropriate evidence-based intervention will result in a positive therapeutic effect.
modalities. Generally, the diagnosis and treatment of the Surgical intervention is generally part of a process of
TMD is best managed by a dentist or dental specialist, and management, rather than a cure, with some notable
the primary headache by a physician or medical specialist exceptions such as closed lock of the mandible.
who can use various tools to confirm the nature of the
headache. It is imperative to rule out a central neurological Where there is no obvious causal relationship between
disorder or lesion where the headache is primary. the patient’s complaints and the anatomical, clinical or
pathological abnormality of TMD, surgery cannot, with
The approach to treatment must first involve the reasonable certainty, be expected to be helpful and,
identification of any causative, predisposing or indeed, could be harmful. Similarly, if the patient presents
perpetuating factor and their elimination or reduction. with chronic pain, assessment and management of
Treatment of the TMD should follow the same principals, the psychosocial effects of the chronic pain disorder
regardless of a comorbid headache. Similarly, and understanding of the effectiveness of chronic
management of the headache should be based on pain management strategies are appropriate prior to
accepted principles, including patient education, considering a surgical procedure. This may require the
pharmacotherapy and behavioural approaches. assistance of other healthcare professionals, such as the
patient’s family physician.

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 10 Guidelines | November 2018

Pain or other dysfunctions of the temporomandibular joint Finally, the patient should be informed that the post-
and surrounding regions may be the result of disorders operative management is an integral and important
unrelated to TMD. The surgeon must be satisfied that part of the overall treatment strategy. This may include
consideration has been given to rule out other causes physiotherapy, medical, psychological, dental and
or factors. Therefore, other healthcare providers may be pharmacological support. Post-operative management
consulted when signs and symptoms or the diagnosis may continue for several years. Where the patient has
warrants such consultation. These may include a a pre-existing chronic pain disorder, arrangements for
patient’s physician, a neurologist, an otolaryngologist, a ongoing pain management should be in place prior to
rheumatologist, physiatrist or psychiatrist. surgical intervention. While the surgeon will assist in pain
management in the initial postoperative period, long-
The following surgical procedures are generally accepted term pain management is best managed by the patient’s
by experienced temporomandibular joint surgeons physician or other healthcare providers.
and by the American Society of Temporomandibular
Joint Surgeons for patients with surgically manageable Long-term post-operative care and follow up is
disorders, such as disc displacement or osteoarthritis of imperative to ensure an optimal surgical outcome.
the temporomandibular joint(s). The experienced surgeon Initially this may include wound care, application of heat/
skilled in TMD surgery further enhances the validity and cold, dietary control, medication, and physiotherapy
outcome of such procedures. either professionally or self-administered focusing on
mobilization amongst other desired functional outcomes.
1. Intra-articular injections Later, this may include periodic functional subjective and
2. Arthrocentesis objective assessments as required.
3. Arthroscopic procedures
4. Arthrotomy/Arthroplasty There is no scientifically validated evidence in support of
5. Disc surgery surgery to treat “simple” otherwise asymptomatic clicking
6. Coronoidotomy/Coronoidectomy as the only presenting symptom without associated
7. Condylotomy locking or pain. Equally, there is little evidence in support
8. Reduction of recurrent or chronic dislocation of the suggestion that surgical or orthodontic correction
9. Joint replacement may be indicated in selected of a malocclusion will predictably alter the course of an
patients with joint destruction or ankylosis. This may intra-articular disorder. Patients with a significant TMD,
include prosthetic devices or autogenous grafts. a concurrent severe malocclusion (in particular an open
bite deformity or a severe class II malocclusion with a
Once a surgical procedure is indicated, the appropriate deep overbite) and where the malocclusion may be a
risks, sequelae and possible complications should be predisposing exacerbating factor in their disorder, might
explained to the patient including possible outcomes of no benefit by surgical (orthognathic surgery) or orthodontic
surgical treatment. Risks and benefits should be explained. correction of the malocclusion as part of an overall
management strategy. Correction of a malocclusion is
The patient should be advised that signs and symptoms best considered on its own merits and should not be
of a TMD may be the result of a combination of several considered as the primary treatment with respect to
problems. Accordingly, surgical management may control management of a TMD.
some signs and symptoms, but not all.

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 Diagnosis and Management of Temporomandibular Disorders 11

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