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British Journal of Oral and Maxillofacial Surgery 51 (2013) 469472

Review
How do I manage restricted mouth opening secondary to
problems with the temporomandibular joint?
Andrew J. Sidebottom
Consultant Oral and Maxillofacial Surgeon, Queens Medical Centre, Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, United
Kingdom

Accepted 4 December 2012

Available online 12 February 2013

Abstract

Restricted mouth opening is a common problem that presents to secondary care, and management depends on the primary cause. The
most common differential diagnoses related to the temporomandibular joint (TMJ) include muscle spasm secondary to pain, anchored disc
phenomenon, irreducible anterior disc displacement, rheumatoid diseases, and ankylosis. In this paper each is considered in turn.
2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: TMJ pain; Trismus; TMJ arthroscopy; TMJ discectomy; TMJ replacement; TMJ ankylosis; TMJ anchored disc phenomenon; TMJ anterior disc
displacement; MRI scan; CT scan

Introduction indicated when diagnostic arthroscopy confirms a torn disc

Management of restricted mouth opening depends on the
primary cause, and includes anchored disc phenomenon in
younger patients, irreducible anterior disc displacement usu-
ally in somewhat older patients, and degenerative disease
in elderly patients. Across all age groups rheumatoid dis-
eases and ankylosis can also present. Initial management
in all cases should be conservative with rest, non-steroidal
anti-inflammatory drugs (NSAID) and a bite splint1 unless
clinical findings and orthopantograms (OPG) clearly show
collapse of the joint or ankylosis. When these fail, arthroscopy
or arthrocentesis is often beneficial particularly in dis-
eases related to the disc or lubrication of the joint. Failed
arthroscopy at least provides a diagnosis and can further
guide management. Diagnosis can be supplemented by mag-
netic resonance imaging (MRI)2 although the position of the
disc and mobility do not necessitate surgical correction. Open
joint surgery (discectomy, condylar shave, or eminoplasty) is
Tel.: +44 1159249924x65895; fax: +44 115 8493386.
E-mail addresses: andrew.sidebottom@nuh.nhs.uk,
ajsidebottom@doctors.org.uk
or damage to the surface of the joint, and when symptoms fail
to improve. Where ankylosis or collapse of the joint is pos-
sible then use of three-dimensional computed tomography
(CT) is invaluable to evaluate the surfaces of the joint and
the relation to underlying structures. Vascular imaging may
be helpful when joint replacement is considered and anky-
lotic tissue extends medially. Total joint replacement is the
final common pathway when open surgery, and management
of ankylosis or rheumatoid diseases fail. Outcomes in the
medium term are good, but as long-term outcomes beyond
20 years are still unknown, replacement should be used only
as a last resort and according to guidelines from the National
Institute for Health and Clinical Excellence (NICE).3
Patients who present to secondary care with limited open-
ing (trismus) should initially have a full clinical examination
to discover whether the primary cause is articular or extra-
articular. The latter includes infective or inflammatory causes
with secondary muscle spasm. The history should show
whether there is pain, restriction, locking, and joint noise.
Symptoms of the other joint being involved, local problems
with the head and neck, or other systemic diseases should
also be investigated. Examination should include assessment

0266-4356/$ see front matter 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2012.12.004
470 A.J. Sidebottom / British Journal of Oral and Maxillofacial Surgery 51 (2013) 469472
of the movement of each joint, measurement of mouth open-
ing and lateral deviation, and palpation for muscle spasm,
joint noise, and tenderness. Lateral deviation helps to ascer-
tain whether there is movement in the upper joint space; there
is loss of contralateral movement where this is involved.
Muscle spasm
Masseteric spasm is common secondary to infections in the
region of the angle of the mandible. It presents acutely and
is often associated with facial swelling. The primary cause
should be managed appropriately.
Patients with secondary myofascial pain sometimes have
restricted opening. They will have tenderness and there will
be areas of palpable spasm in the masticatory muscles. Initial
management is with rest, NSAID, and nocturnal bite splints.
Low dose tricyclic medication or botulinum injections4 into
the area of spasm should be considered if a 3-month period
of conservative management fails.
Anchored disc phenomenon
First described in 1991,5 anchored disc phenomenon is proba-
bly more common than most non-specialists would consider.
Patients have acute, severe, restricted opening of less than
25 mm, and unlike many TMJ disorders it is as common in
men as in women and is most common in adolescents and
young adults. While initial management should be conser-
vative, early consideration for arthrocentesis under pressure
using 200 ml of fluid will provide a cure in over 90% of cases.
Arthroscopy may show evidence of the surfaces of the joint
being stuck together (fibrillations), although often no abnor-
mality is found. Arthroscopy involves the manipulation and
measurement of intraoperative mouth opening, which will
cause the appearance of fibrillations where the surfaces have
been forced apart. Arthrocentesis can be repeated if necessary
when intraoperative mouth opening is good, but the patient
does not improve in the short term. Early treatment in this
manner leads to a lower risk of the long-term side effect of
restricted opening.
Irreducible anterior disc displacement
This was once considered to be the main cause of acute
closed lock. The patient may initially have clicking, which
progresses to locking and subsequent restriction according to
the classic course. Increasingly these patients are being recog-
nised as having problems related to lubrication in the joint,
and initial conservative management is often successful.6
MRI in patients who fail to respond to conservative man-
agement will often show that the disc has displaced anteriorly
and does not reduce when the mouth is opened.2 However,
when asked to move the mandible from side to side, move-
ment is often reasonable, which suggests that the disc is
possibly being held anteriorly by a pterygoid muscle spasm
or intra-articular pain and subconscious restriction. An MRI
study on patients who are asked to deviate either way rather
than to protrude would be interesting as it may show a dif-
ferent outcome. However, MRI is not therapeutic and often
under diagnoses and over diagnoses tears in the disc.
Subsequent arthroscopy or arthrocentesis not only aids
diagnosis, but also elicits a cure in over 80%.7 Arthroscopic
examination often shows evidence that the surfaces of the
joint have been stuck together and fibrillations are visible.
Occasional fibrosis can be broken down with the scope, or
rarely a torn disc may be discovered.
Failure to respond to arthroscopy may indicate open
surgery depending on the findings. Fortunately, patients with
an arthroscopically diagnosed torn disc (Wilkes stage 5) can
recover and this finding should not always indicate operation
regardless of outcome.
Once the joint is opened, the upper and lower joint
space should be explored and any adhesions released. If the
condylar head is irregular with osteophytes they should be
smoothed (condylar shave or condyloplasty), and if the emi-
nence is excessively steep or has areas of lost cartilage it can
be reduced to provide more free movement (eminoplasty).
Irreparable damage to the disc necessitates discectomy. The
author does not routinely replace the disc, as this tends to
occur naturally with scar tissue over 6 months. It causes dis-
comfort for up to 6 months but gives an early improvement
in function. Interposition with a temporalis flap causes scar-
ring in the muscle, which in itself may restrict opening. Other
interpositional grafts have been considered but none has been
consistently successful,8 and each has its own related mor-
bidity from the harvest site.
The authors own audit of outcome after failed arthroscopy
and subsequent open operation shows success in roughly
60%, and this is increasingly being seen in other practices
where arthroscopy, not open operation, is considered the first
option.19 Primary open operation should therefore be avoided
as arthroscopy is often successful irrespective of the Wilkes
stage.7,9
The final common pathway if open operation fails is total
joint replacement, assuming that the NICE criteria have been
met.3,10 Open operation should be considered only once
and any abnormality should be treated at this stage. If it
is unsuccessful then further operation is also likely to be
unsuccessful, as all the causes should have been dealt with
initially. Repeated open operation has been shown to cause
an increased likelihood of dysaesthetic pain, and also reduces
the success of total joint replacement.
Rheumatoid diseases
Rheumatoid disorders do not commonly present in the TMJ.
They should be managed with the rest of the disease under
the care of the rheumatologist, potentially with disease-
 A.J. Sidebottom / British Journal of Oral and Maxillofacial Surgery 51 (2013) 469472
modifying drugs. Initial management of the TMJ should
be conservative,11 but if this fails arthroscopy will aid in
diagnosis and also give considerable therapeutic benefit.
Restricted opening may be caused by pain or collapse of
the joint (because of the backward rotation of the gonion and
shortening of the ramus), and a replacement joint should be
considered. It will also cause a progressive deformity in the
anterior open bite and a recessive chin.
Ankylosis is most common in psoriatic arthropathy and
ankylosing spodylitis. Where an OPG suggests ankylosis
a three-dimensional CT will help confirm diagnosis. Joint
space of less than 1 mm makes arthroscopy difficult if not
impossible, so it may be bypassed in these cases. Where
restriction is less than 30 mm the best option is total joint
replacement, potentially surrounding the joint with a free fat
graft.12
Ankylosis
The causes of ankylosis have been discussed previously,13
but in the UK it is most commonly secondary to trauma,
local infection, or rheumatoid disease.
Children present with restricted opening and deviation of
the mandible towards the side of ankylosis because of the
loss of lateral movement and lack of condylar growth. If this
has been long-standing vertical height of the ramus is lost
with associated upward ipsilateral occlusal cant, and a shift
of the centre line towards the affected side. Reconstruction
is controversial and varied. The mainstay in the UK is recon-
struction with a costochondral graft after gap arthroplasty
of more than 1 cm, and it can be combined with an inter-
positional temporalis flap. A recently described aggressive
approach in children seems to produce beneficial effects.14
Unfortunately only around a third of costochondral grafts
are successful in the medium term; the others either collapse
or cause overgrowth.15 This may necessitate revision with a
total joint replacement once growth is complete, which can
correct the vertical position of the ramus and the discrepancy
in the midline. In other parts of the world primary manage-
ment is with gap arthroplasty and interpositional temporalis
flap alone. Both types of procedure have a risk of re-ankylosis
of up to 25%.
A number of colleagues around the world have suggested
primary total joint replacement with the aim of replacing the
mandibular component when growth is complete. Although
it gives a more stable result and reduces the risk of recur-
rence, it necessitates early revision with the increased risk
of damage to the facial nerve, which is associated with revi-
sion operations on the TMJ. The alternative is to distract the
mandible and correct the occlusion once growth is complete.
It is clearly a complex issue and there is no agreed solution.
Primary presentation in adults is with increasingly
restricted mouth opening and painful function13 ; there is
surprisingly little pain at rest. The surgical options include
gap arthroplasty and interpositional grafts, a costochondral
471
graft, or total joint replacement. Around the world the main-
stay of management is gap arthroplasty and interpositional
temporalis flap although it is not as successful as recon-
struction with costochondral grafts.16 Increasingly, total joint
replacement is considered the gold standard because of the
failure of costochondral grafts.17,18 It has been suggested
that a free abdominal fat graft packed around the prosthe-
sis reduces the risk of ankylosis recurring.12 Medium term
outcomes show considerably improved mouth opening and
reduced pain, but unfortunately the long term outcomes of
joint replacement are not known beyond 20 years.18 The TMJ
Special Interest Group of the British Association of Oral and
Maxillofacial Surgeons has set up a national database to ana-
lyse long term outcomes of joint replacement. All surgeons
who do replacements submit their data to this database and
use the outcome for revalidation.
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