ANESTHESIA/FACIAL PAIN

Temporomandibular Joint Disorder

Management in Oral and
Maxillofacial Surgery
Louis G. Mercuri, DDS, MS
Purpose: This article discusses why the management of temporomandibular joint disorder (TMD) cases
leads to some oral and maxillofacial surgeons to actively avoid attracting such patients to their practices,
offers some evidence-based explanations, and provides recommendations for resolution that will benefit
not only the specialty, but more importantly the patients it serves.
Materials and Methods: A review of the reasons some surgeons state they do not wish to manage TMD
cases is presented, followed by an updated review of the TMD and orthopedic literature discussing not
only the importance of a proper diagnosis but also the impact of comorbid conditions, genetics, clinical
experience, and patient expectations important to achieving good TMD management outcomes.
Results: The literature shows that the frustration clinicians and TMD and orthopedic patients have had
in the past are related to initial misdiagnosis leading to multiple failed procedures, failed materials and
devices, failure to understand the impact of comorbid conditions and genetic features on outcomes, clini-
cians’ experience in complex cases, and unrealistic outcomes expectations by the clinician and the
patient.
Conclusion: Although it is not reasonable to believe that every graduate of an oral and maxillofacial sur-
gery residency will have an interest in management of TMD cases in their future practices, those who will
must understand the importance of the issues of proper diagnosis, the relation of TMD patient comorbid-
ities and prior management to final outcomes, honest awareness of their experience and ancillary support
to manage complex cases, and how essential a realistic prognosis is to a successful outcome for the clini-
cian and the patient.
Ó 2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 75:927-930, 2017

Ten years ago, I penned a Letter to the Editor of the
Journal of Oral and Maxillofacial Surgery titled
‘‘Are We Getting Out of TMJ Surgery?’’1 This letter
was prompted by what I heard while on hold as I
returned calls to oral and maxillofacial surgeons’
offices. I was struck by the fact that the recorded
menu of services most surgeons offered patients,
although inclusive of most services commonly
provided by our specialty, excluded the manage-
ment of temporomandibular joint (TMJ) disor-
ders (TMDs).
This registered as odd to me, because TMD manage-
ment has been considered one of the core compe-
tencies in our residency programs. Further, surgical
management of intra-articular TMJ problems is one
of the required components for program certification
by the Commission on Dental Accreditation (CODA).
So I wondered why would offices not offer this service
to patients?
During the ensuing phone conversations, I asked
surgeons why their menu of services did not include
TMD management. Table 1 presents some of the

Visiting Professor, Department of Orthopedic Surgery, Rush Address correspondence and reprint requests to Dr Mercuri: 604
University Medical Center, Chicago, IL; Clinical Consultant, TMJ Bonnie Brae Place, River Forest, IL, 60305; e-mail: lgm@tmjconcepts.
Concepts, Ventura, CA. com
Conflict of Interest Disclosures: Dr. Mercuri is a compensated Received October 15 2016
clinical consultant and shareholder in TMJ Concepts (Ventura, Accepted October 25 2016
CA). All other authors do not have any relevant financial relation- Ó 2016 American Association of Oral and Maxillofacial Surgeons
ship(s) with a commercial interest. 0278-2391/16/31066-7
http://dx.doi.org/10.1016/j.joms.2016.10.033

927
928
Table 1. SOME OF RESPONSES GIVEN AS TO WHY
SURGEONS SAY THEY DO NOT OFFER TMJ
MANAGEMENT SERVICES TO PATIENTS
The patients are too difficult to deal with and never get
better
The reimbursement is low or nil
Other areas of patient management are more rewarding
My practice is office based; I gave up hospital OR privileges
to avoid trauma call
TMJ is a nothing but big black hole
Never got a handle on it during my residency
I’m uncomfortable with these patients
These patients belong at a multidisciplinary ‘‘university’’
center
No interest in the subject at all
No data to support treatment options are currently
available
Too much liability
Never saw a TMJ surgery during my residency
I send all my TMJ patients to the ‘‘experts’’
I learned my lesson with Proplast-Teflon
Abbreviations: OR, operating room; TMJ, temporomandib-
ular joint.
Louis G. Mercuri. TMD Management in OMS. J Oral Maxillofac
Surg 2017.
answers I received. Obviously, patients with TMD
were not the high-priority patients these surgeons
wished to attract to their practices.
Then I thought about all the services oral and maxil-
lofacial surgeons are trained to deliver and who they
must compete with for those patients. As presented
in Table 2, for every service provided by oral and
maxillofacial surgeons, there are at least 2 competing
dental or medical specialties, except for the TMJ! So
what is it about the management of TMJ cases that
causes surgeons to avoid them?
Examining the responses listed in Table 1 provides
clues. Many clinicians have been frustrated with the
management of TMD cases by a misinterpretation of
the etiology of the disorder, the inability to make the
appropriate diagnosis, the failure to appreciate the
impact of comorbid conditions in these patients,
and, most importantly, a failure to provide an honest
and realistic prognosis for the diagnosis and proposed
management plan.
Some clinicians have developed a narrow, mecha-
nistic philosophy (‘‘tunnel vision’’) for the manage-
ment of patients with TMD. Turp et al2 stated that
the experience of the past 150 years in the diagnosis
and management of chronic orofacial pain conditions
has shown that a mechanistic, narrow approach is
likely to produce iatrogenic harm (eg, unnecessary
root canal therapy, extractions, restorations, TMJ sur-
gery, etc). Mohl and Ohrbach3 discussed how this
TMD MANAGEMENT IN OMS
Table 2. SERVICES PROVIDED BY ORAL AND
MAXILLOFACIAL SURGEONS AND COMPETING
DENTAL AND MEDICAL SPECIALTIES
Anesthesia ASA, ASDA, CRNA
Exodontia GD, Perio, Endo, etc
Preprosthetic surgery GD, Perio, Prosth
Dental implants GD, Perio, Prosth, Endo, etc
Orthognathic surgery PRS, CFS, ENT
Cosmetic surgery PRS, ENT, Derm, Ophth, etc
Trauma PRS, ENT, CFS
Pathology GD, Perio, PRS, ENT, H&NS
Temporomandibular joint ?
Abbreviations: ASA, American Society of Anesthesiology;
ASDA, American Society of Dental Anesthesiology; CFS,
craniofacial surgeons; CRNA, certified registered nurse anes-
thetists; Derm, dermatology; Endo, endodontics; ENT,
otorhinolaryngology; GD, general dentistry; H&NS, head
and neck surgeons; Ophth, ophthalmology; Perio, periodon-
tics; Prosth, prosthodontics; PRS, plastic and reconstructive
surgery.
Louis G. Mercuri. TMD Management in OMS. J Oral Maxillofac
Surg 2017.
comes about. Chief among the causes they cited are
clinicians clinging to what they learned in training
(right, wrong, or outdated), an unwillingness to
change the way they manage patients, failure to keep
up with the literature, and their adherence to charis-
matic TMJ cult gurus.
TMD is a collective term used to embrace different
clinical problems that involve the masticatory muscula-
ture and the TMJ.4 Masticatory muscle or extra-articular
TMD disorders are not primary to the TMJ, involve
masticatory and often cervical myositis, and are
managed noninvasively. In contrast, intra-articular con-
ditions involve the TMJ and have evident clinical, labo-
ratory, and imaging evidence for invasive management.
A clinician who does not understand the differences
can make a misdiagnosis. Misdiagnosis leads to ineffec-
tive management of either condition, but the conse-
quences can be more serious when an invasive
approach is taken for a primary extra-articular condi-
tion.5 This scenario only leads to feelings of frustration,
anxiety, and ultimately depression in the patient and
the clinician.
In medicine, comorbidity is the presence of at least
1 additional disease or disorder co-occurring with
(concomitant or concurrent with) a primary disease
or disorder; in the countable sense of the term, a
comorbidity is each additional disorder or disease.6 It
is well documented that patients with TMD have
several comorbid conditions.6-11 Table 3 lists some
examples. The orthopedic literature also shows that
the larger the number of preoperative comorbidities,
the poorer the outcomes.11-15
LOUIS G. MERCURI
Table 3. COMORBID CONDITIONS OFTEN
ASSOCIATED WITH TEMPOROMANDIBULAR JOINT
DISORDER
Sinus disease GI problems
Depression or anxiety Smoking
Migraine headache Fainting or dizzy spells
Allergies Panic attacks
Earaches or tinnitus Night sweats
Fibromyalgia Concentration issues
Sleep disorders Irritable bowel syndrome
Interstitial cystitis Chronic fatigue syndrome
Drug abuse Somatic symptom disorder
Abbreviation: GI, gastrointestinal.
Louis G. Mercuri. TMD Management in OMS. J Oral Maxillofac
Surg 2017.
Further, studies of patients with TMD have shown
that the presence of comorbid conditions can explain
why 50% of patients seeking care for TMD pain, some
of whom were multiply operated on or exposed to
failed materials or devices, still report experiencing
pain 5 years later; and 20% of patients with chronic
pain develop long-term disability from their pain.16-22
Therefore, it is important that any comorbid
conditions and their effects on outcomes be known
and considered by clinicians managing patients
with TMD.
The effect of genes as one of the variables associated
with the etiology of the TMDs has become a topic of
interest and research.23 The increasing scientific evi-
dence suggests that genetic factors can play an impor-
tant role in the pathology of TMDs. However, their
underlying mechanisms in TMDs remain largely
unknown.24,25
Sangani et al26 performed a systematic review to
identify genes associated with TMDs. They concluded
that although most studies had been performed in
small samples, 28 of 31 studies identified genes to be
causal or associated with TMDs. In total, 112 genes
were identified to be meaningfully and specifically
associated with TMDs. This systematic review pro-
vided a list of accurate genes associated with TMDs
and suggested a genetic contribution to the pathology
of the TMDs. These findings led them to conclude that
gene mutations are a causative factor for the incidence
of TMDs.
Other variables that the clinician must consider are
the patient’s willingness to comply with the manage-
ment plan, any pending litigation related to the onset
of symptoms, and drug or alcohol abuse resulting
from chronic pain. Knowledge of these variables and
the effects of prior management failures, comorbid
conditions, genetics, and chronic centrally mediated
pain have on patients with TMD should allow
929
clinicians to appropriately manage any functional or
end-stage disease process in this unique patient
population.
This starts with understanding that the primary goal
of intra-articular TMD management is restoration of
function and form, not complete pain relief. There-
fore, surgeons must constantly remind themselves
and these patients that any notable decrease in pain
is only a secondary benefit that could occur in some
cases.27 When surgeons promise 100% pain relief,
this only adds to the unreasonable, unrealistic, and
unattainable outcomes these types of patients might
already have developed.
It also has been well documented that the more
prior invasive TMJ surgeries patients undergo, espe-
cially if they were misdiagnosed with extra-articular
TMD, the lower the chances for good subjective out-
comes (pain, estimation of jaw function, diet consis-
tency) after joint replacement.28-33 This mimics the
results in other joints as reported in the orthopedic
literature.12,14,15
To complicate some of these cases further, there are a
group of these patients who not only have undergone
multiple prior failed TMJ invasive procedures, but also
have been exposed to failed or failing alloplastic mate-
rials (eg, Proplast and Teflon, silicone rubber) or devices
(eg, metal-on-metal or metal-on-polymethylmethacrylate
total joint replacements, hemiarthroplasty). The litera-
ture shows that despite good functional and form out-
comes, subjective outcomes are lower than for
patients never exposed to such failures.31-33
Therefore, surgeons must explain these factors to
this group of patients to assure appropriate outcomes
expectations.
Before considering management of this last group of
patients, the clinician must honestly assess his or her
experience, technical limitations, and the personnel
and clinical resources available. Establishing the failure
mechanism in each case is essential to avoid repeating
it. Performance of adequate pre-revision planning to
assure proper mandibular function, dental occlusion,
and facial esthetics is paramount. If joint replacement
is indicated, then the surgeon must choose the most
appropriate replacement system for the problem asso-
ciated with each specific case. Most importantly, the
surgeon must be sure the patient is fully informed as
to the realistic outcome expectations.34
Management of TMD cases, especially those
requiring surgery, is time consuming and can be frus-
trating for the surgeon and the patient. However, if
the clinician has made the right diagnosis, understands
the patient variables discussed earlier, performs the
surgery correctly, and uses the right equipment, the
results will be professionally satisfying for the clinician
and most importantly will provide the best outcome
for the patient.
930
Although it is not reasonable to believe that every
graduate of an oral and maxillofacial surgery residency
will have an interest in management of patients with
TMD in their future practices, those who will must
understand the importance of proper diagnosis, the
relation of TMD patient comorbidities and prior man-
agement to final outcomes, an honest awareness of
their experience and ancillary support to manage com-
plex cases, and how essential a realistic prognosis is to
a successful outcome.
If clinicians follow these caveats, oral and maxillofa-
cial surgery will continue to be at the forefront in the
management of these cases. Perhaps TMD manage-
ment will be a service that will be added to their phone
message again!
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