**Abstract**

Disc repositioning for temporomandibular joint dysfunction (TMD) is a known and established procedure. Indications for the surgery and outcomes vary. A review of the available literature on the indications, surgical technique, and outcomes of TMJ Meniscopexy as a means of management of temporomandibular joint disease was performed. This was carried out using PubMed, MEDLINE, Scopus, and Google Scholar and was limited to the past 11 years using key medical search terms relevant to the subject area while being consistent with our exclusion criteria. The search yielded a total of 23 articles containing 3 reviews, 6 technical notes, 11 retrospective studies, and 3 prospective studies. Multiple techniques were described in the literature including arthroscopic techniques (n = 4), open suturing techniques (n = 4), mini-anchor techniques (n = 9), and splint-assisted surgery (n = 1). Several variables were used to determine success including both qualitative and quantitative measures determined clinically, through MRI or via patient questionnaire. When considering various combinations of these functional outcomes, all studies showed a significant improvement post-operatively. This demonstrates the success of disc repositioning procedures as an option in certain cases of TMD. Although there is evidence to show improvement in functional outcomes associated with Meniscopexy as a means of TMD management, there remains to be a lack of high-level evidence to further support this.

**Keywords:** temporomandibular joint, meniscoplasty, meniscopexy, disc repositioning, temporomandibular joint dysfunction

#### **1. Introduction**

Temporomandibular joint dysfunction (TMD) is the most common cause of non-odontogenic pain in the oro-facial region, having a significant impact on quality of life [1].

TMD is a common term used to describe a range of disorders affecting the temporomandibular joint. TMD can affect the temporomandibular joint (TMJ), the jaw muscles, or both, TMD has also been associated with ear and neck pain. Patients demonstrate clinical signs such as pain from the TMJ, muscle pain, TMJ sounds including clicking and crepitus, restricted mouth opening and deviation on mouth opening or closing [2].

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/ TMD) presented by Dworkin and LeResche in 1992 classified TMD patients

according to their physical diagnosis (axis I) and pain-related disability and psychological status (axis II). Axis I is divided into three groups. Group I is muscle disorders, Group II disc displacements and Group III consists of joint disorders as seen in the box below [3] (**Table 1**, **Figure 1**).

Classification systems have been conceived to further classify and delineate the specific groups discussed above. The Wilkes classification is used to classify TMJ Internal Derangement (**Table 2**).

The causes of TMD are wide and varied due to the homogeneity demonstrated in the classification. They include a wide range of direct injuries, such as fractures of the mandibular condyle, systemic diseases, including as immune mediated arthritis, growth disturbances and tumours. Non-functional movements of the mandible such as bruxing and tooth-clenching are clinically correlated with a variety of jaw muscle symptoms and are associated with internal joint disk derangements. It has been postulated however that these behaviours are not established causes of TMD but may only be propagating factors [5].

Malocclusion, previously thought to be causative is no longer widely established as an important factor in TMD. It has also been demonstrated that orthodontic treatment neither increases nor decreases the chances of developing TMD [5].

Different approaches have been described for the management of TMD depending on severity and aetiology. Initial management is non-surgical. This can range from physical therapy, occlusal appliance therapy, drug therapies, intra-articular injections, diet alteration and life style adaptation. Studies have demonstrated 70–80% of cases can be treated successfully with non-surgical interventions [4, 6].

Occlusal splint therapy has been reported with success. Various types of splints exist with distinctive indications and functions. The stabilisation splint is widely used; it is a hard acrylic splint and provides a temporary and removable ideal occlusion. Affording an occlusion reduces atypical muscle activity and produces neuromuscular balance to the TMJ [7].

Occlusal modification was proposed as a treatment however meta-analysis showed no evidence that it was beneficial in the management of TMD. Physiotherapy has been shown to be beneficial for a select group of patients [6].

Should conservative management strategies prove unsuccessful they may be followed by surgical intervention. These include menisectomy, disc repositioning, condylotomy and joint replacement. These procedures are aggressive and invasive with risks and complications of their own. Arthocentsis is considered less invasive and refers to lavage of the upper joint space, hydraulic pressure and manipulation to liberate adhesions and improve motion. Another less invasive procedure, TMJ arthroscopy is widely undertaken [8].

A review of arthroscopy and arthrocentesis found no statistically significant difference between these interventions in terms of pain, however a statistically significant difference in favour of arthroscopy was discovered in maximum incisal opening. The review concluded that there is insufficient reliable evidence to either encourage or disprove the use of arthrocentesis for treating patients with TMD and that further high quality studies are needed before firm conclusions can be stated [9].

Disc repositioning as a treatment for internal derangement of the temporomandibular disc was first reported to have been performed by Annandale in 1887 [10]. However, it was not until Wilkes first described the nature of the temporomandibular joint (TMJ) in TMD using arthrography in 1987 that surgical procedures such as disc repositioning were accepted as a means of management [11]. Notably, McCarty and Farrar were first to describe a rationale and technique for arthroplasty and disc repositioning for internal derangement of the TMJ in 1988 [12]. Since then, there

**103**

**Table 1.**

*RDC/TMD criteria for axis I diagnoses [3].*

*Review of Current Practice for Temporomandibular Joint Meniscopexy Surgery*

**reduction:**

consecutive trials

consecutive trials,

in opening;

less than 35 mm;

unassisted opening

with reduction.

**opening:**

than 7 mm;

of 3 consecutive trials.

**Group I—Muscle disorders Group II—Disc displacements Group III—Joint disorders**

**IIIa. Arthralgia:**

be absent.

arthrosis.

• Pain in one or both joint sites (lateral pole and/or posterior attachment) during palpation • Pain in the region of the joint, pain in the joint during maximum unassisted opening, pain in the joint during assisted opening, and pain in the joint during lateral excursion • For a diagnosis of simple arthralgia, coarse crepitus must

**IIIb. Osteoarthritis of the TMJ:** • Arthralgia as defined in IIIa; • Either coarse crepitus in the joint or radiologic signs of

**IIIc. Osteoarthrosis of the TMJ:**

• Absence of all signs of arthralgia;

arthrosis.

• Either coarse crepitus in the joint or radiologic signs of

• Reciprocal clicking in TMJ (click on both vertical opening and closing, occurring at point 5 mm greater than interincisal distance on opening than closing and is eliminated on protrusive opening), reproducible on 2 out of 3

• Clicking in TMJ either opening or closing, reproducible on 2 out of 3

• Click during lateral excursion or protrusion, reproducible on 2 out

**IIb. Disc displacement without reduction with limited opening:** • History of significant limitation

• Maximum unassisted opening

• Passive stretch increases opening by less than 4 mm over maximum

• Contralateral excursion less than 7 mm and/or uncorrected deviation to ipsilateral side on opening • Absence of joint sound or presence of joint sounds not meeting criteria for disc displacement

**IIc. Disc displacement without reduction, without limited** 

• History of significant limitation of mandibular opening; • Maximum unassisted opening greater than 35 mm

• Passive stretch increases opening by greater than 5 mm over maximum unassisted opening; • Contralateral excursion greater

• Presence of joint sounds not meeting criteria for disc displace-

• Where available, arthrography or magnetic resonance reveals disc displacement without reduction.

ment with reduction;

**IIa. Disc displacement with** 

*DOI: http://dx.doi.org/10.5772/intechopen.93403*

**Ia. Myofascial pain:** • Report of pain or ache in the jaw, temples, face, preauricular area, or inside the ear at rest or during

• Pain on palpation of temporalis, masseter, lateral pterygoid area • At least one of the painful sites must be on the same side as the complaint of

**Ib. Myofascial pain with limited opening:** • As above with painless unassisted mandibular opening less than 40 mm. • Maximum assisted opening (passive stretch) less than 5 mm greater than painless unassisted opening.

function.

pain.


*Oral and Maxillofacial Surgery*

the box below [3] (**Table 1**, **Figure 1**).

causes of TMD but may only be propagating factors [5].

Internal Derangement (**Table 2**).

interventions [4, 6].

neuromuscular balance to the TMJ [7].

arthroscopy is widely undertaken [8].

according to their physical diagnosis (axis I) and pain-related disability and psychological status (axis II). Axis I is divided into three groups. Group I is muscle disorders, Group II disc displacements and Group III consists of joint disorders as seen in

Classification systems have been conceived to further classify and delineate the specific groups discussed above. The Wilkes classification is used to classify TMJ

The causes of TMD are wide and varied due to the homogeneity demonstrated in the classification. They include a wide range of direct injuries, such as fractures of the mandibular condyle, systemic diseases, including as immune mediated arthritis, growth disturbances and tumours. Non-functional movements of the mandible such as bruxing and tooth-clenching are clinically correlated with a variety of jaw muscle symptoms and are associated with internal joint disk derangements. It has been postulated however that these behaviours are not established

Malocclusion, previously thought to be causative is no longer widely established

Occlusal splint therapy has been reported with success. Various types of splints exist with distinctive indications and functions. The stabilisation splint is widely used; it is a hard acrylic splint and provides a temporary and removable ideal occlusion. Affording an occlusion reduces atypical muscle activity and produces

A review of arthroscopy and arthrocentesis found no statistically significant difference between these interventions in terms of pain, however a statistically significant difference in favour of arthroscopy was discovered in maximum incisal opening. The review concluded that there is insufficient reliable evidence to either encourage or disprove the use of arthrocentesis for treating patients with TMD and that further

Disc repositioning as a treatment for internal derangement of the temporomandibular disc was first reported to have been performed by Annandale in 1887 [10]. However, it was not until Wilkes first described the nature of the temporomandibular joint (TMJ) in TMD using arthrography in 1987 that surgical procedures such as disc repositioning were accepted as a means of management [11]. Notably, McCarty and Farrar were first to describe a rationale and technique for arthroplasty and disc repositioning for internal derangement of the TMJ in 1988 [12]. Since then, there

high quality studies are needed before firm conclusions can be stated [9].

Occlusal modification was proposed as a treatment however meta-analysis showed no evidence that it was beneficial in the management of TMD. Physiotherapy has been shown to be beneficial for a select group of patients [6]. Should conservative management strategies prove unsuccessful they may be followed by surgical intervention. These include menisectomy, disc repositioning, condylotomy and joint replacement. These procedures are aggressive and invasive with risks and complications of their own. Arthocentsis is considered less invasive and refers to lavage of the upper joint space, hydraulic pressure and manipulation to liberate adhesions and improve motion. Another less invasive procedure, TMJ

as an important factor in TMD. It has also been demonstrated that orthodontic treatment neither increases nor decreases the chances of developing TMD [5]. Different approaches have been described for the management of TMD depending on severity and aetiology. Initial management is non-surgical. This can range from physical therapy, occlusal appliance therapy, drug therapies, intra-articular injections, diet alteration and life style adaptation. Studies have demonstrated 70–80% of cases can be treated successfully with non-surgical

**102**

**Figure 1.** *PRISMA flow diagram, illustrating method by which screening of articles was undertaken.*

have been multiple variations and modifications in technique that have been proposed by surgeons, each in an attempt to improve outcome [13]. Examples of such innovations are the introduction of orthopaedic suture anchors to with the hope of stabilising the disk more reliably and the advent of arthroscopy as an approach to repositioning the disc [14, 15].

The authors aim to look at current practice for meniscopexy, give an overview of the different TMJ articular disc repositioning techniques described as well as analysing clinical studies to establish their success by looking at measured functional outcomes. This enables us to scrutinise different approaches allowing us to conclude as to whether Meniscopexy remains to be a viable treatment modality in the management of TMD.

**105**

**2. Methods**

*The Wilkes classification [4].*

**Table 2.**

• TMD

• TMJ

the time of writing of this paper (**Table 3**). The Key Terms we used included:

• Temporomandibular joint disorders

• Temporomandibular joint

• Meniscopexy/Discopexy

*Review of Current Practice for Temporomandibular Joint Meniscopexy Surgery*

No restricted motion

painful clicking. Intermittent locking. Headaches

Joint tenderness, headaches. Locking. Restricted motion. Painful chewing

headache. Restricted motion

crepitus. Painful function

**Stage Clinical Imaging Surgical**

Slightly forward disc, reducing. Normal osseous contours

Slightly forward disc, reducing. Early disc deformity. Normal osseous contours

Anterior disc displacement. Reducing early progressing to non-reducing late. Moderate to marked disc thickening. Normal osseous contours

Anterior disc displacement nonreducing. Marked disc thickening. Abnormal bone contours

Anterior disc displacement non-reducing with perforation and gross disc deformity. Degenerative osseous

changes

Normal disc form. Slight anterior displacement. Passive incoordination

(clicking)

changes

Degenerative remodelling of bony surfaces. Osteophtyes. Adhesions. Deformed disc without perforation

Gross degenerative changes of disc and hard tissue. Perforation and multiple adhesions

Anterior disc displacement. Thickened disc

Disc deformed and displaced. Variable adhesions. No bone

Evidence was searched, using the Ovid Medline, Embase, Scopus and Cochrane Library medical databases. A literature search was carried out, in accordance with Prisma guidelines, on the PubMed/MEDLINE database as well as SCOPUS, Embase, Cochrane library medical databases and Google Scholar using key medical subject headings (MeSH) relevant to TMJ meniscopexy restricted to the past 11 years from

*DOI: http://dx.doi.org/10.5772/intechopen.93403*

I Early Painless clicking.

II Early/Intermediate Occasional

III Intermediate Frequent pain.

IV Intermediate/Late Chronic pain,

V Late Variable pain. Joint


*Review of Current Practice for Temporomandibular Joint Meniscopexy Surgery DOI: http://dx.doi.org/10.5772/intechopen.93403*

**Table 2.**

*Oral and Maxillofacial Surgery*

**104**

**Figure 1.**

repositioning the disc [14, 15].

the management of TMD.

have been multiple variations and modifications in technique that have been proposed by surgeons, each in an attempt to improve outcome [13]. Examples of such innovations are the introduction of orthopaedic suture anchors to with the hope of stabilising the disk more reliably and the advent of arthroscopy as an approach to

*PRISMA flow diagram, illustrating method by which screening of articles was undertaken.*

The authors aim to look at current practice for meniscopexy, give an overview of the different TMJ articular disc repositioning techniques described as well as analysing clinical studies to establish their success by looking at measured functional outcomes. This enables us to scrutinise different approaches allowing us to conclude as to whether Meniscopexy remains to be a viable treatment modality in *The Wilkes classification [4].*
