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Chapter 10: Temporomandibular Joint Surgery

TMJ pathophysiology, diagnosis, arthrocentesis, arthroscopy, open joint procedures, total joint replacement, and navigation-assisted TMJ surgery.

Introduction

Temporomandibular disorders (TMD) affect an estimated 5-12% of the population, though only a small fraction of these patients require surgical intervention. When conservative management fails, the oral and maxillofacial surgeon possesses a graduated surgical armamentarium ranging from minimally invasive arthrocentesis to total alloplastic joint replacement. This chapter addresses the pathophysiology, diagnostic workup, and surgical management of TMJ disorders at the level expected of the practicing OMS surgeon.

TMJ Anatomy and Pathophysiology

Functional Anatomy

The TMJ is a ginglymoarthrodial (hinge and sliding) diarthrodial joint:

  • Articular surfaces: Mandibular condyle (convex) and glenoid (mandibular) fossa of the temporal bone (concave), with the articular eminence forming the anterior wall.
  • Articular disc: Biconcave fibrocartilaginous structure that divides the joint into superior and inferior joint spaces. The disc is avascular in its central thin zone; vascular and innervated at its periphery (bilaminar zone/retrodiscal tissue).
  • Disc attachments: Anterior -- lateral pterygoid muscle (superior head) and joint capsule; posterior -- bilaminar zone (superior stratum = elastic, attaches to tympanic plate; inferior stratum = collagenous, attaches to condylar neck); lateral and medial -- collateral ligaments to condylar poles.
  • Ligaments: Temporomandibular (lateral) ligament (primary stabilizer), sphenomandibular ligament, stylomandibular ligament.
  • Innervation: Auriculotemporal nerve (branch of V3), masseteric nerve, deep temporal nerves.
  • Blood supply: Superficial temporal artery, maxillary artery (middle meningeal, deep auricular, anterior tympanic branches).

Pathophysiology of Internal Derangement

The Wilkes classification remains the most clinically useful staging system for internal derangement:

Stage Clinical Imaging Surgical Findings
I (Early) Painless clicking; no restriction Slight disc displacement, normal morphology Disc displacement, normal morphology
II (Early/Intermediate) Occasional painful clicking; intermittent locking; headaches Slight disc displacement, thickening of posterior band Early disc deformity
III (Intermediate) Frequent pain; joint tenderness; locking; restricted motion; headaches Disc displacement with reduction; moderate deformity Disc displacement with significant deformity; no hard tissue changes
IV (Intermediate/Late) Chronic pain; restricted motion Disc displacement (often without reduction); degenerative osseous changes Disc perforation or severe deformity; adhesions; flattened eminence; osteophytes
V (Late) Variable pain; crepitus; chronic restricted motion Disc perforation; arthritic changes; osteophytes; subchondral cysts; sclerosis Gross disc perforation; erosion of articular surfaces; fibrillation of cartilage; osteophytes

Other TMJ Pathology

  • Myofascial pain dysfunction (MPD): Most common TMD diagnosis; muscular origin without true joint pathology. Does NOT require surgical intervention.
  • Osteoarthritis / degenerative joint disease (DJD): Progressive degradation of articular surfaces; condylar flattening, erosion, osteophyte formation.
  • Rheumatoid arthritis: Bilateral symmetric condylar erosion; anterior open bite from loss of condylar height. Managed medically; surgery for end-stage disease.
  • Ankylosis: Fibrous or bony fusion of the condyle to the fossa; results in severe restriction of mandibular movement. Causes include trauma, infection, or prior surgery.
  • Condylar hyperplasia: Unilateral continued growth of the condyle after skeletal maturity; progressive facial asymmetry, contralateral crossbite, ipsilateral open bite.
  • Condylar hypoplasia: Underdevelopment; may be congenital (hemifacial microsomia) or acquired (childhood condylar fracture with growth arrest).
  • Synovial chondromatosis: Metaplasia of the synovial membrane producing cartilaginous loose bodies within the joint.
  • Neoplasia: Rare; osteochondroma (most common benign tumor), chondrosarcoma, synovial sarcoma.

TMD Diagnosis

History and Examination

Key historical elements:

  • Pain characteristics: location, onset, duration, quality, exacerbating/relieving factors
  • Joint sounds: clicking (disc displacement with reduction), crepitus (DJD)
  • Functional limitation: restricted opening, locking (closed lock = disc displacement without reduction)
  • Parafunctional habits: clenching, bruxism, nail biting
  • Prior treatment: splint therapy, physical therapy, medications, injections
  • Psychosocial assessment: anxiety, depression, catastrophizing, sleep disturbance

Physical examination:

  • Range of motion: Maximum interincisal opening (MIO; normal 40-55 mm), lateral excursion (normal 8-12 mm per side), protrusion (normal 8-10 mm).
  • Opening pattern: Deviation (returns to midline = disc displacement with reduction) vs. deflection (does not return = unilateral restriction).
  • Palpation: TMJ (preauricular, intra-auricular), masticatory muscles (masseter, temporalis, medial/lateral pterygoid), cervical muscles.
  • Auscultation: Stethoscope or palpation for clicks, pops, crepitus.
  • Dental examination: Occlusion, wear facets, tooth mobility, evidence of bruxism.

Imaging

MRI: Gold standard for soft tissue (disc position and morphology):

  • Sagittal and coronal oblique images in closed and open mouth positions
  • T1-weighted: Anatomy, disc morphology
  • T2-weighted/proton density: Effusion, inflammation, disc signal changes
  • Sensitivity/specificity for disc displacement: greater than 90% (Tasaki et al., J Dent Res 1996)

CBCT/CT: Osseous morphology:

  • Condylar erosion, flattening, osteophytes, sclerosis, subchondral cysts
  • Ankylosis assessment
  • Condylar hyperplasia workup (CT with 3D reconstruction for volumetric comparison)

Bone scan (SPECT): Condylar hyperplasia workup:

  • Technetium-99m bone scan comparing uptake between condyles
  • Greater than 10% difference in uptake indicates active growth (Pogrel, Br J Oral Maxillofac Surg 1985)
  • Guides decision: if active growth, condylectomy may be indicated; if growth ceased, orthognathic surgery alone may suffice.

Conservative Management

Surgical Caution

The vast majority of TMD patients (85-90%) improve with conservative, non-surgical management. Surgical intervention should only be considered after an adequate trial of conservative therapy (minimum 3-6 months) has failed, and when there is a clear structural/pathologic diagnosis amenable to surgical correction. Myofascial pain dysfunction (the most common TMD diagnosis) is NOT a surgical condition.

Non-Surgical Treatment

Self-care education:

  • Soft diet, jaw rest, avoidance of wide opening, heat/ice therapy
  • Habit awareness and elimination (clenching, gum chewing)

Pharmacotherapy:

  • NSAIDs (ibuprofen, naproxen) as first-line
  • Muscle relaxants (cyclobenzaprine 10 mg at bedtime) for myofascial pain
  • Tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) for chronic pain and sleep disruption
  • Short-course corticosteroids for acute inflammatory flares

Physical therapy:

  • Manual therapy (joint mobilization, myofascial release)
  • Therapeutic exercises (active/passive range of motion, stretching)
  • Modalities (ultrasound, TENS, low-level laser therapy)

Occlusal splint therapy:

  • Stabilization splint (flat plane, full-arch, maxillary): Reduces bruxism forces, allows muscular relaxation, provides diagnostic information
  • NOT designed to permanently alter occlusion
  • Anterior repositioning splint: Temporarily positions mandible forward to recapture displaced disc; use is controversial and limited to short-term

Injections:

  • Intra-articular corticosteroid: Triamcinolone 10-20 mg into the superior joint space. Provides short-term anti-inflammatory effect. Limit to 2-3 injections per year (repeated steroid injections can cause cartilage degradation).
  • Botulinum toxin (Botox): 25-50 units per masseter and/or temporalis for myofascial pain / bruxism-related TMD. Off-label but supported by evidence (Guarda-Nardini et al., J Oral Maxillofac Surg 2008).
  • Hyaluronic acid (viscosupplementation): Intra-articular injection; improves joint lubrication and may have anti-inflammatory properties. Sodium hyaluronate (Synvisc, Hyalgan).

Arthrocentesis (CPT: 20605)

Indications

  • Acute closed lock (disc displacement without reduction, less than 3-6 months duration)
  • Internal derangement Wilkes stage II-III
  • Inflammatory arthropathy with effusion
  • Failed conservative management

Technique

Arthrocentesis is a lavage procedure of the superior joint space performed under local anesthesia (with or without sedation):

  1. Anesthesia: Auriculotemporal nerve block plus local infiltration of the preauricular region. V2 block optional.
  2. Landmarks: Canthal-tragal line (Holmlund-Hellsing line). Entry point 1: 10 mm anterior to the tragus and 2 mm below the canthal-tragal line (posterior recess of the superior joint space). Entry point 2: 10 mm anterior to the first point and 7 mm below the line (anterior recess).
  3. Puncture: 18-gauge needles inserted into the superior joint space at points 1 and 2.
  4. Lavage: 200-300 mL of lactated Ringer's or normal saline is irrigated through the first needle while egressing through the second needle (or a single-needle technique with intermittent aspiration/injection).
  5. Manipulation: After lavage, gentle mandibular manipulation to attempt disc recapture or lysis of adhesions.
  6. Corticosteroid injection: Optional instillation of triamcinolone acetonide (20-40 mg) or hyaluronic acid after lavage.

Outcomes:

  • Success rate for acute closed lock: 70-90% improvement in pain and function (Nitzan et al., J Oral Maxillofac Surg 1991).
  • Mechanism: Washout of inflammatory mediators and pain-producing substances (bradykinin, interleukins, prostaglandins), lysis of adhesions, and improved joint lubrication.
  • Less effective for chronic closed lock (greater than 6 months) or advanced degeneration (Wilkes IV-V).

TMJ Arthroscopy (CPT: 29800-29804)

Indications

  • Internal derangement (Wilkes II-IV) refractory to conservative management and arthrocentesis
  • Adhesive capsulitis
  • Synovial chondromatosis (for diagnosis and removal of loose bodies)
  • Diagnostic arthroscopy when imaging is inconclusive
  • Disc repositioning (advanced operative arthroscopy)

Technique

TMJ arthroscopy is performed under general anesthesia:

  1. Equipment: 1.9 mm (small-joint) arthroscope; 2.4-2.7 mm cannula/sheath systems; video camera; light source; inflow/outflow channels.
  2. Access: Posterolateral approach into the superior joint space using the same landmarks as arthrocentesis (Holmlund-Hellsing line). A single-puncture technique is standard for diagnostic arthroscopy; double-puncture for operative procedures.
  3. Systematic examination: Posterior recess, intermediate zone, anterior recess, medial capsule, disc surface, condylar surface. Normal synovium is smooth, pale, and glistening. Abnormal findings include adhesions, synovitis, fibrillation, disc perforation, and chondromalacia.
  4. Operative procedures through the arthroscope:
    • Lysis and lavage: Sweeping of adhesions with the blunt trocar or arthroscope tip, combined with high-volume irrigation.
    • Synovial biopsy: For inflammatory or neoplastic conditions.
    • Loose body removal: Synovial chondromatosis.
    • Disc repositioning (suture or thermal): Anterior release of disc attachments, repositioning, and fixation with suture (Mitek anchor) or laser/electrocautery tightening of the posterior attachment (disc plication). More technically demanding; reserved for surgeons with advanced arthroscopic expertise.
    • Motorized shaver debridement: Removal of fibrillated cartilage or inflamed synovium.
    • Laser ablation: Holmium:YAG or diode laser for synovectomy, posterior attachment scarification.

Outcomes:

  • Success rate: 80-90% improvement in pain and function for appropriately selected patients (McCain et al., J Oral Maxillofac Surg 1992).
  • Complications: Rare (less than 2%). Include auriculotemporal nerve paresthesia, otologic injury (perforation of the glenoid fossa into the middle cranial fossa), extravasation into tissue planes, facial nerve injury (extremely rare with proper technique), and instrument breakage.

Clinical Pearl

Arthroscopic lysis and lavage has outcomes comparable to disc repositioning for Wilkes II-III disease, suggesting that the lavage and adhesion release rather than disc position per se is the primary therapeutic mechanism (Murakami et al., Int J Oral Maxillofac Surg 1995). This supports a minimally invasive approach as the initial surgical intervention for most cases of internal derangement refractory to conservative care.

Open Joint Procedures

Open TMJ surgery is indicated when minimally invasive procedures fail or when the pathology demands direct visualization and access.

Surgical Approaches

Preauricular approach (standard):

  • Incision along the helical root extending into the preauricular skin crease, then inferior into the neck skin crease.
  • Dissection through the temporoparietal fascia (superficial temporal fascia), then through the TMJ capsule.
  • Facial nerve protection: The temporal branch of CN VII crosses the zygomatic arch in the superficial temporal fascia (temporoparietal fascia). Dissecting deep to this layer protects the nerve. An incision through the periosteum of the zygomatic arch root, then entering the joint capsule from above, provides a safe corridor.

Endaural approach:

  • Incision within the external auditory canal and tragal region.
  • Less visible scar; limited exposure. Primarily for arthrotomy and condylectomy.

Retromandibular (Risdon) approach:

  • For access to the condylar neck (subcondylar fractures, condylectomy).
  • Risk to the marginal mandibular branch of CN VII.

Al-Kayat and Bramley approach:

  • Extended preauricular with temporal extension providing wide access to the zygomatic arch and TMJ. Often used for ankylosis surgery and total joint replacement.

Disc Repositioning (Meniscopexy)

Indications: Wilkes III-IV with anteriorly displaced disc that has not responded to arthroscopic management.

Technique:

  1. Preauricular approach with access to the superior and inferior joint spaces.
  2. Release of anterior disc attachments.
  3. Repositioning of the disc over the condyle.
  4. Fixation: Mitek bone anchor in the posterior condylar neck with sutures passed through the posterior band of the disc. Alternative: wedge resection of redundant retrodiscal tissue (plication).
  5. Capsular closure.

Surgical Caution

Long-term outcomes of open disc repositioning are debated. While short-term results are favorable (70-90% improvement), disc re-displacement may occur over time. Some evidence suggests that disc position is less important for long-term function than the overall health of the articular surfaces and joint homeostasis. Discectomy (disc removal) without replacement often produces comparable long-term results (Eriksson & Westesson, J Oral Maxillofac Surg 2001).

Discectomy

Removal of the articular disc. Historically controversial, but long-term data supports its efficacy:

  • Indications: Wilkes IV-V with severely deformed, perforated, or degenerative disc; failed disc repositioning.
  • Technique: Access via preauricular approach; identify and excise the disc, preserving the lateral and medial capsular attachments.
  • With or without replacement:
    • No replacement: The retrodiscal tissue undergoes fibrotic metaplasia and functions as a pseudodisc. Long-term outcomes are generally favorable (Eriksson & Westesson, J Oral Maxillofac Surg 2001: 40-year follow-up showing good function in most patients).
    • Autogenous replacement: Temporalis muscle flap (most common), auricular cartilage, dermal graft.
    • Alloplastic replacement: Fat graft (dermal fat graft), Proplast-Teflon (historical -- REMOVED from market due to catastrophic foreign body giant cell reaction and joint destruction), Silastic (historical). Alloplastic disc replacements are generally avoided.

Eminectomy

Surgical reduction of the height of the articular eminence:

  • Indications: Chronic recurrent TMJ dislocation (subluxation/luxation) refractory to conservative measures.
  • Technique: Preauricular approach; eminence is reduced with bur to create a flat articular surface that allows the condyle to translate freely without locking anterior to the eminence.
  • Alternatives: Autogenous bone graft augmentation of the eminence (Dautrey procedure), injection of autologous blood into the retrodiscal tissues, eminence mini-plate/screw obstruction.

Condylectomy

High condylectomy (proportional or full):

  • Indication: Active condylar hyperplasia confirmed by SPECT scan with uptake differential greater than 10%.
  • Proportional condylectomy: Removal of 3-5 mm of the superior condylar surface (the active growth zone). Combined with orthognathic surgery for correction of the resultant asymmetry in many cases.
  • Low condylectomy: Removal at the condylar neck level. Reserved for tumors (osteochondroma) or severe pathology.

Ankylosis Surgery

TMJ ankylosis (fibrous or bony) produces severe functional impairment:

Kaban Protocol (modified):

  1. Aggressive excision of the ankylotic mass and fibrous/bony bridge.
  2. Ipsilateral coronoidectomy (to address contracted temporalis).
  3. Contralateral coronoidectomy if MIO does not reach greater than 35 mm after step 2.
  4. Lining of the glenoid fossa with temporalis fascia flap or an alloplastic fossa component.
  5. Reconstruction of the ramus-condyle unit: costochondral graft (pediatric) or total joint prosthesis (adult).
  6. Early aggressive physiotherapy (immediate postoperative active range of motion exercises).
  7. Long-term follow-up with physiotherapy compliance.

Clinical Pearl

The single most important factor in preventing re-ankylosis is aggressive early and sustained postoperative physiotherapy. Passive and active range-of-motion exercises should begin within 24-48 hours of surgery and continue for a minimum of 6-12 months. Use of continuous passive motion (CPM) devices in the immediate postoperative period is advocated by some authors. Without disciplined physiotherapy, re-ankylosis rates approach 30-50% regardless of the surgical technique used.

Total Joint Replacement (TJR)

Indications

  • End-stage TMJ disease (Wilkes V) with failure of prior surgical interventions
  • Severe inflammatory arthropathy (rheumatoid, psoriatic, ankylosing spondylitis) with joint destruction
  • Ankylosis (particularly re-ankylosis after prior surgery)
  • Condylar resorption (idiopathic, autoimmune)
  • Failed autogenous reconstruction (costochondral graft failure)
  • Neoplasm requiring condylectomy
  • Multiple previous joint operations (multiply-operated joint)
  • Simultaneous TJR with orthognathic correction in end-stage TMJ disease

Systems

Stock (off-the-shelf) prostheses:

System Manufacturer Components Key Features
Zimmer Biomet TMJ (formerly TMJ Concepts) Zimmer Biomet Custom fossa (UHMWPE-lined titanium mesh) + custom condyle (CoCrMo alloy with titanium ramus component) Patient-specific based on CT; both components custom
Biomet Microfixation (stock) Zimmer Biomet Stock fossa (UHMWPE) + stock condyle (CoCrMo) in multiple sizes Off-the-shelf; immediate availability; less expensive; available in multiple sizes
TMJ Concepts (custom) Now Zimmer Biomet Fully custom fossa and condyle Historical gold standard for custom TJR; patient-specific design from CT data

Patient-Specific Prostheses (Custom TJR):

Custom devices are manufactured from CT data using CAD/CAM technology:

  • Workflow: CT scan with protocol, 3D model, virtual planning session, custom prosthesis design, manufacturing (4-6 weeks), intraoperative fitting.
  • Advantages: Precise fit; accommodates abnormal anatomy (prior surgery, ankylosis, heterotopic bone); incorporates orthognathic movements (the condylar component can be designed to reposition the mandible).
  • Disadvantages: Cost (\(15,000-\)25,000 per side for device alone); 4-6 week manufacturing lead time; cannot accommodate intraoperative changes in surgical plan.

Surgical Technique (General Principles)

  1. Approach: Modified Al-Kayat preauricular approach for the fossa component; retromandibular/submandibular approach for the condyle/ramus component.
  2. Fossa preparation: Remove residual disc/scar tissue; prepare the fossa surface with bur to accept the fossa component. For stock systems, create a flat surface; for custom, match the presurgical plan.
  3. Fossa fixation: Multiple screws through the fossa component into the zygomatic arch/root and temporal bone.
  4. Condylectomy: Remove the condyle at the predetermined level.
  5. Ramus preparation: Decorticate the lateral ramus for prosthesis seating.
  6. Condyle/ramus component fixation: Position the mandible in the planned occlusion (splint or IMF); fixate the ramus component with multiple screws.
  7. Fat graft: Autogenous abdominal or retro-auricular fat grafted around the prosthesis to reduce heterotopic bone formation and fibrous adhesion.

Critical Safety

Fat graft placement is critical in TJR surgery. The fat graft serves as a biological barrier preventing heterotopic bone formation at the prosthetic joint interface, which is the primary cause of decreased range of motion or re-ankylosis after TJR. Sufficient fat (10-20 mL per side) should be harvested (typically from the periumbilical abdomen) and packed around the articulating surfaces and surrounding tissues.

Outcomes

  • Pain improvement: 80-95% of patients report significant pain reduction (Mercuri et al., J Oral Maxillofac Surg 2007).
  • Function: Mean MIO improvement from 20-25 mm to 35-40 mm.
  • Longevity: 10-year prosthesis survival rates of 90-95% reported (Sanovich et al., Int J Oral Maxillofac Surg 2014).
  • Complications: Heterotopic bone formation (10-20%), infection (1-3%), facial nerve weakness (transient 10-15%, permanent less than 1%), material wear, device loosening.

Costochondral Graft (CCG) vs. Total Joint Prosthesis

Parameter Costochondral Graft Alloplastic TJR
Biological Autogenous; potential for growth (advantage in pediatric patients, disadvantage in adults -- unpredictable) Non-biological; no growth
Age Preferred in patients under 18 (growth center replacement) Preferred in adults and skeletally mature patients
Re-ankylosis risk Higher (~15-30%) Lower (~5-10%)
Donor morbidity Chest wall pain, pneumothorax risk (rare), chest scar No donor site
Predictability Variable growth and remodeling; may require secondary surgery Predictable; prosthetic position is fixed
Longevity Lifelong if successful; but unpredictable resorption/overgrowth 10-20+ year device life expected; revision may be needed

Clinical Pearl

In the adult multiply-operated TMJ, alloplastic total joint replacement is generally preferred over costochondral graft due to its greater predictability, lower re-ankylosis rate, and ability to simultaneously correct skeletal discrepancy. Costochondral grafting remains the standard for pediatric TMJ reconstruction where growth potential is needed, with the understanding that the graft may require monitoring for overgrowth and potential secondary surgery at skeletal maturity.

Intraoperative navigation is increasingly applied to TMJ surgery:

Applications

  • Ankylosis surgery: Navigation assists in identifying the extent of the bony/fibrous mass and guiding the gap arthroplasty to ensure adequate resection while protecting the middle cranial fossa superiorly and the internal maxillary artery medially.
  • Condylectomy: Precise identification of tumor margins (osteochondroma).
  • Custom TJR placement: Verification that the prosthesis is positioned according to the virtual plan.
  • Skull base proximity: Navigation provides real-time awareness of proximity to the middle cranial fossa floor, minimizing risk of intracranial penetration during ankylosis release or fossa preparation.

Technique

  • Preoperative CT is loaded into the navigation system (Brainlab, Stryker, Medtronic).
  • Patient registration using surface matching or fiducial markers.
  • Real-time instrument tracking displayed on the navigation screen overlaid on the patient's CT.
  • Particularly valuable in revision surgery with distorted anatomy where conventional landmarks are unreliable.

Coding Reference

CPT Codes -- TMJ Surgery

Code Description
20605 Arthrocentesis, aspiration and/or injection, intermediate joint (TMJ)
21010 Arthrotomy, temporomandibular joint
21050 Condylectomy
21060 Meniscectomy (discectomy), temporomandibular joint
21070 Coronoidectomy
21240 Arthroplasty, temporomandibular joint, with or without autograft
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement
29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy
29804 Arthroscopy, temporomandibular joint, surgical

ICD-10 Codes

Code Description
M26.60 Temporomandibular joint disorder, unspecified
M26.61 Adhesions and ankylosis of TMJ
M26.62 Arthralgia of TMJ
M26.63 Articular disc disorder of TMJ
M26.69 Other specified disorders of TMJ
M19.011-M19.019 Primary osteoarthritis, shoulder (used analogously; TMJ-specific codes under M26)
S03.0 Dislocation of TMJ
D16.5 Benign neoplasm of lower jaw bone (condylar tumors)

Key References

  1. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg. 1991;49(11):1163-1167.
  2. McCain JP, Sanders B, Koslin MG, Quinn JH, Peters PB, Indresano AT. Temporomandibular joint arthroscopy: a 6-year multicenter retrospective study of 4,831 joints. J Oral Maxillofac Surg. 1992;50(9):926-930.
  3. Wilkes CH. Internal derangements of the temporomandibular joint: pathological variations. Arch Otolaryngol Head Neck Surg. 1989;115(4):469-477.
  4. Mercuri LG, Edibam NR, Giobbie-Hurder A. Fourteen-year follow-up of a patient-fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg. 2007;65(6):1140-1148.
  5. Eriksson L, Westesson PL. Long-term follow-up after temporomandibular joint discectomy with and without replacement. J Oral Maxillofac Surg. 2001;59(Suppl 1):42.
  6. Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg. 1990;48(11):1145-1151.
  7. Guarda-Nardini L, Manfredini D, Salamone M, Salmaso L, Tonello S, Ferronato G. Efficacy of botulinum toxin in treating myofascial pain in bruxers. J Oral Maxillofac Surg. 2008;66(4):657-661.
  8. Wolford LM, Mercuri LG, Schneiderman ED, Movahed R, Allen W. Twenty-year follow-up study on a patient-fitted temporomandibular joint prosthesis: the Techmedica/TMJ Concepts device. J Oral Maxillofac Surg. 2015;73(5):952-960.
  9. AAOMS Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (ParCare), 6th Edition.