See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/24147487

Temporomandibular Joint: Disorders, Treatments, and Biomechanics

Article  in  Annals of Biomedical Engineering · March 2009

DOI: 10.1007/s10439-009-9659-4 · Source: PubMed

CITATIONS READS

105 3,485

2 authors:

Shirish Ingawale Tarun Goswami

Amgen Wright State University
2 PUBLICATIONS   113 CITATIONS    140 PUBLICATIONS   2,180 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Voice stress analysis View project

Failure Analysis of Medical Devices View project

All content following this page was uploaded by Tarun Goswami on 10 January 2014.

The user has requested enhancement of the downloaded file.

Annals of Biomedical Engineering, Vol. 37, No. 5, May 2009 (Ó 2009) pp. 976–996
DOI: 10.1007/s10439-009-9659-4
Temporomandibular Joint: Disorders, Treatments, and Biomechanics
SHIRISH INGAWALÉ1 and TARUN GOSWAMI1,2
1
Department of Biomedical, Industrial and Human Factors Engineering, Wright State University, 3640, Col. Glenn Hwy,
Dayton, OH 45435, USA; and 2Orthopaedic Surgery and Sports Medicine, Wright State University, Dayton, OH 45435, USA
(Received 5 May 2008; accepted 13 February 2009; published online 28 February 2009)
Abstract—Temporomandibular joint (TMJ) is a complex,
sensitive, and highly mobile joint. Millions of people suffer
from temporomandibular disorders (TMD) in USA alone.
The TMD treatment options need to be looked at more fully
to assess possible improvement of the available options and
introduction of novel techniques. As reconstruction with
either partial or total joint prosthesis is the potential
treatment option in certain TMD conditions, it is essential
to study outcomes of the FDA approved TMJ implants in a
controlled comparative manner. Evaluating the kinetics and
kinematics of the TMJ enables the understanding of structure
and function of normal and diseased TMJ to predict changes
due to alterations, and to propose more efficient methods of
treatment. Although many researchers have conducted bio-
mechanical analysis of the TMJ, many of the methods have
certain limitations. Therefore, a more comprehensive analysis
is necessary for better understanding of different movements
and resulting forces and stresses in the joint components.
This article provides the results of a state-of-the-art investi-
gation of the TMJ anatomy, TMD, treatment options, a
review of the FDA approved TMJ prosthetic devices, and the
TMJ biomechanics.
Keywords—Temporomandibular joint (TMJ), Temporoman-
dibular disorder (TMD), TMJ implants, TMJ biomechanics.
BACKGROUND
Temporomandibular joint (TMJ) connects the
mandible or the lower jaw to the skull and regulates
the movement of the jaw (see Fig. 1). It is a bi-condylar
joint in which the condyles, located at the two ends of
the mandible, function at the same time. The TMJ is
one of the most complex as well as most used joint in a
human body.3,5,40 The important functions of the TMJ
are mastication and speech.
Temporomandibular disorder (TMD) is a generic
term used for any problem concerning the jaw joint.
Injury to the jaw, temporomandibular joint, or muscles
Address correspondence to Shirish Ingawalé, Department of
Biomedical, Industrial and Human Factors Engineering, Wright State
University, 3640, Col. Glenn Hwy, Dayton, OH 45435, USA. Elec-
tronic mail: ingawale.2@wright.edu and shirishingawale@yahoo.com
976
0090-6964/09/0500-0976/0 Ó 2009 Biomedical Engineering Society
of the head and neck can cause TMD. The most com-
mon TMJ disorders are pain dysfunction syndrome,
internal derangement, arthritis, and traumas.18,21,22
With millions of people suffering in the United States
alone,21,32,87,115 TMD is a problem that should be
looked at more fully. Since a large fraction of TMD
causes are currently unexplained, the better
understanding of the etiology of TMDs will help pre-
vent not only occurrence of TMDs but also failure of an
implanted joint in the same way as the joint it replaced.
The TMJ Bioengineering Conference, held in 2006,
underlined the importance of collective research efforts
from four major categories: tissue engineering, bio-
mechanics, clinical community, and biology.22 At
Wright State University, Dayton, Ohio; our research
efforts focus on developing 3-D models of asymptotic
and diseased TMJs of men and women of different age
groups to enable better understanding of joint motion
and forces. The finite element analysis of these models
can provide useful information about the contact
stresses that possibly contribute to the dysfunction of
the joint. The similar approach can also be employed
for comparative evaluation of different TMJ implant
designs.
TEMPOROMANDIBULAR JOINT (TMJ)
TMJ Anatomy
TMJ, a joint that connects the mandible to the skull
and regulates mandibular movement, is a bi-condylar
joint in which the condyles, located at the two ends of
the mandible, function at the same time. The movable
round upper end of the lower jaw is called the condyle
and the socket is called the articular fossa (see Fig. 1).
Between the condyle and the fossa is a disc made of
fibrocartilage that acts as a cushion to absorb stress
and allows the condyle to move easily when the mouth
opens and closes.5,46
The features that differentiate and make the TMJ a
unique joint are its articular surfaces covered by
 TMJ Disorders, Treatments, and Biomechanics
Ligament Disc
Articular fossa
Muscle
Condyle
The temporomandibular joint
FIGURE 1. Anatomical structure of the temporomandibular
joint (TMJ). Source: American Association of Oral and Maxil-
lofacial Surgeons.5
fibrocartilage instead of hyaline cartilage. The bony
structure consists of the articular fossa; the articular
eminence, which is an anterior protuberance continu-
ous with the fossa; and the condylar process of the
mandible that rests within the fossa. The articular
surfaces of the condyle and the fossa are covered with
cartilage.46 A dense fibrocartilaginous disc is located
between the bones in each TMJ. The disc divides the
joint cavity into two compartments (superior and
inferior).46,92 The two compartments of the joint are
filled with synovial fluid which provides lubrication
and nutrition to the joint structures.40,92 The disc dis-
tributes the joint stresses over broader area thereby
reducing the chances of concentration of the contact
stresses at one point in the joint. The presence of the
disc in the joint capsule prevents the bone-on-bone
contact and the possible higher wear of the condylar
head and the articular fossa.9,54,68,92 The bones are
held together with ligaments. These ligaments com-
pletely surround the TMJ forming the joint capsule.
Functioning of TMJ
The most important functions of the TMJ are mas-
tication and speech. Strong muscles control the move-
ment of the jaw and the TMJ. The temporalis muscle
which attaches to the temporal bone elevates the
mandible. The masseter muscle closes the mouth and is
the main muscle used in mastication.45 Movement is
guided by the shape of the bones, muscles, ligaments,
and occlusion of the teeth. The TMJ undergoes hinge
and gliding motion.3 The TMJ movements are very
complex as the joint has three degrees of freedom, with
each of the degrees of freedom associated with a
977
separate axis of rotation. Rotation and anterior trans-
lation are the two primary movements. Posterior
translation and mediolateral translation are the other
two possible movements of TMJ.24
TEMPOROMANDIBULAR DISORDER (TMD)
Temporomandibular disorder (TMD) is a generic
term used for any problem concerning the jaw joint.
Injury to the jaw, temporomandibular joint, or muscles
of the head and neck can cause TMD. Other possible
causes include grinding or clenching the teeth, which
puts a lot of pressure on the TMJ; dislocation of the
disc; presence of osteoarthritis or rheumatoid arthritis
in the TMJ; stress, which can cause a person to tighten
facial and jaw muscles or clench the teeth;
aging.7,15,31,38,48,92,97 The most common TMJ disorders
are pain dysfunction syndrome, internal derangement,
arthritis, and traumas.18,21,22
TMD is seen most commonly in people between the
ages of 20 and 40 years, and occurs more often in
women than in men.21,22,106,107 In 1996, the National
Institutes of Health estimated that 10 million Ameri-
cans had painful TMJ dysfunction and more women
being affected by it than men. Some surveys have
reported that 20–25% of the population exhibit
symptoms of TMD while it is estimated that 30 million
Americans suffer from it, with approximately one
million new patients diagnosed yearly.21,32,87,115
Disc Displacement
Coordinated movement of condyle and disc is
essential to maintain the integrity of the disc. Disc dis-
placement is the most common TMJ arthropathy and is
defined as an abnormal relationship between the artic-
ular disc and condyle.26,97 As the disc is forced out of the
correct position there is often bone on bone contact
which creates additional wear and tear on the joint, and
often causes the TMD to worsen.15,97 Disc displacement
generates a popping sound when the disc is first forced
out of alignment as the mouth opens up and then again
as the disc is forced back into place as the mouth is
closed. Clinically, this popping sound or clicking is
regarded as an initial symptom of the temporoman-
dibular joint internal derangement (TMJ-ID).97
The anterior disc displacement has different degrees
of severity. Wilkes developed staging classifications for
the TMJ related internal derangement, or disc dis-
placement (see Table 1).31,108,109 These stages were
defined based on clinical or radiological findings, or
based on the anatomic pathology of the jaw. The early
stage included slight displacement with clicking, and
no pain or dysfunction. The last stage included
978 S. INGAWALÉ AND T. GOSWAMI

TABLE 1. Wilkes’ staging classification of internal derangement of TMJ with respect to clinical, radiologic, and surgical findings.

I. Early stage
Clinical: No significant mechanical symptoms other then opening reciprocal clicking; no pain or limitation of motion
Radiological: Slight forward displacement; good anatomic contour of the disc; negative tomograms
Anatomic pathology: Excellent anatomic form; slight anterior displacement; passive in-coordination demonstrable
II. Early intermediate stage
Clinical: One or more episodes of pain; beginning major mechanical problems consisting of mid-to-late opening loud clicking; transient
catching, and locking
Radiological: Slight forward displacement; beginning disc deformity of slight thickening of posterior edge; negative tomograms
Anatomic pathology: Anterior disc displacement; early anatomic disc deformity; good central articulating area
III. Intermediate stage
Clinical: Multiple episodes of pain; major mechanical symptoms consisting of locking (intermittent or fully closed); restriction of motion;
difficulty with function
Radiological: Anterior disc displacement with significant deformity or prolapse of disc (increase thickening of posterior edge); negative
tomograms
Anatomic pathology: Marked anatomic disc deformity with anterior displacement; no hard tissue changes
IV. Late intermediate stage
Clinical: Slight increase in severity over intermediate stage
Radiological: increase in severity over intermediate stage; positive tomograms showing early-to-moderate degenerative
changes—flattening of eminence, deformed condylar head, sclerosis
Anatomic pathology: Increase in severity over intermediate stage, hard tissue degenerative remodeling of both bearing surfaces
(osteophytosis); multiple adhesions in anterior and posterior recesses; no perforation of disc or attachments
V. Last stage
Clinical: Characterized by crepitus; variable and episodic pain chronic restriction of motion and difficulty with function
Radiological: Disc or attachment perforation; filling defects; gross anatomic deformity of disc and hard tissues; positive tomograms with
essentially degenerative arthritic changes
Anatomic pathology: Gross degenerative changes of disc and hard tissues; perforation of posterior attachment; multiple adhesions;
osteophytosis; flattening of condyle and eminence; subcortical cyst formation

Sources: Wilkes109; Gadd and Goswami31.

degenerative changes to the disc with possible perfo-
ration, flattening of bones, pain, and restricted
motion.31,109 In an early stage, there is a simple disc
displacement in the closed mouth position, usually
anteriorly, due to weakness of the discal ligaments.78,79
If the displaced disc returns to its normal position when
the mouth is opened, accompanied by a popping sound,
it is referred to as disc displacement with reduction
(see Fig. 2).72,78,86 If the displaced disc does not return
to the normal position and acts as an obstacle during
attempted mouth opening, the joint appears as locked.
This is referred to as disc displacement without reduc-
tion.72,78,86 Almost 70% of TMD patients have disc
displacement.21,26 According to Tanaka et al.97 stress
distributions in the TMJ with a normal disc position are
substantially different from those with anterior disc
displacement. It is suggested that the disc displacement
induces the change of stress distribution in the disc and
the increase of frictional coefficients between articular
surfaces, resulting in the secondary tissue damage.91,93
The internal derangement frequently precedes the onset
of TMJ osteoarthritis.92
Other Factors Causing TMD
Different types of functional malocclusion have
been shown to be partly responsible for signs and
symptoms of TMD. The functional unilateral posterior
crossbite (FUPXB) might be a contributing factor for
mandibular dysfunction.75 The habitual body posture
(HBP) during sleep is also speculated as being one of
the possible reasons for disc displacement.41 A study
conducted by Hibi and Ueda41 suggests that HBP
allows the ipsilateral condyle to displace posteriorly
and this posterior position causes anterior disc dis-
placement. Juvenile chronic arthritis, a chronic arthritis
in childhood with an onset before the age of 16 years
and a duration of more than 3 months, is also reported
as a TMD risk factor.6
Animal studies indicate that the TMJ can adapt to
changing biomechanical stresses allowing affected tis-
sues of the joint to maintain efficient function in the
presence of changing load demands. However, this
adaptability may be adversely affected by several fac-
tors including advanced age, tissue perturbations
caused by previous traumatic injury, enhanced sym-
pathetic tone and hormonal influences.70 Milam and
Schmitz70 suggested that direct mechanical injury,
hypoxia-reperfusion injury, and neurogenic inflam-
mation are the mechanisms involved in degenerative
processes affecting the TMJ. Mechanical stresses lead
to the accumulation of damaging free radicals in affected
articular tissues of susceptible individuals.69,71,74
Free radicals are molecules capable of independent
existence that have one or more unpaired electrons in
their outer orbits.37 If allowed to proceed unchecked,
 TMJ Disorders, Treatments, and Biomechanics
FIGURE 2. A schematic representation of the position of the TMJ disc in three different conditions: a healthy joint, anterior disc
displacement with reduction (ADDWR), and anterior disc displacement without reduction (ADDWOR). Source: Pérez-Palomar and
Doblaré78.
free radical-mediated reactions can be extremely
harmful by damaging extracellular and cellular mole-
cules, and by excessive activation of cellular pro-
cesses.69,71,122 Free radicals may accumulate in articular
tissues of the TMJ as a result of mechanical stresses
generated during functional or parafunctional move-
ments of the jaw, or with clenching or bruxism. Accu-
mulation of free radicals in the articular tissues of the
TMJ can cause significant tissue damage, microblee-
ding, and pain. In individuals predisposed to develop
excessive mechanical stresses in the TMJ because of
unique structural or functional characteristics of mas-
ticatory system, adaptive mechanisms of the TMJ may
be exceeded by free radical accumulation leading to a
dysfunctional state (i.e., disease state).71 Because
hemoglobin constitutes the largest iron store in the
body, it is speculated to be a potential source of redox
active iron which can catalyze the formation of free
radicals that might be damaging to the joint.120–122
Zardeneta et al.122 showed the presence of fibronectin
fragments, which may stimulate proinflammatory
responses, in samples obtained from symptomatic
human TMJs.42
The Gender Paradox
The majority of TMJ patients is female, aged
between 20 and 40 years.21,106,107 The female to male
979
patient prevalence is reported to be varying from 3:1 to
8:1.14,21,22,36,87 Because of the high predilection for the
TMJ symptoms in women compared with men, and
because these symptoms are more common during
childbearing years, some researchers suggest that the
female sex hormones may have a role in the patho-
genesis of the TMJ disorders. Sex hormones are known
to influence the differentiation, growth and develop-
ment, and metabolism of connective tissues. A study
conducted by Abubaker et al.1 suggests that sex hor-
mones affect the extracellular matrix of the TMJ disc
of female and male rats.1 These effects on the bio-
chemical composition of the disc can theoretically alter
the biomechanical properties of the connective tissue
such as those in the TMJ. Unfortunately, it is not yet
known whether the female sex hormones or the
estrogen receptors or some other factors are responsi-
ble for the TMD gender paradox.22
TREATMENT OPTIONS FOR TMD
Treatments for the various TMJ disorders range
from physical therapy and nonsurgical treatments to
various surgical procedures. Usually the treatment
begins with conservative, nonsurgical therapies first,
with surgery left as the last option. The majority of
TMD patients can be successfully treated by non-surgical
980 S. INGAWALÉ
therapies and surgical interventions may be required
for only a small part of TMD population. All non-
surgical treatment options must be exhausted before
undertaking the invasive methods for the management
of TMD. Many of the treatments listed below often
work best when used in combination. The correct
course of action may vary, for example: medication,
therapy, splints, arthrocentesis, discectomy, or pros-
thesis.15 The initial treatment does not always work and
therefore more intense treatments such as joint
replacement may be a future option. The success of
joint replacement surgeries significantly depends on the
number of prior surgeries with better outcomes for
patients with fewer previous TMJ surgeries.66,67,84,112,115
Self-Care
Physical therapy is often used by TMD patients to
keep the synovial joint lubricated, and to maintain full
range of the jaw motion. One such exercise for the jaw
is to open the mouth to a comfortable fully-open
position and then to apply slight additional pressure to
open the mouth fully. Another exercise includes
stretching the jaw muscles by making various facial
expressions.31 Avoiding extreme jaw movements, tak-
ing medications, applying moist heat or cold packs,
eating soft foods are other ways that may keep the
disorder from worsening.40
Splints
Splints are plastic mouthpieces that fit over the upper
and lower teeth (see Fig. 3). They prevent the upper and
lower teeth from coming together, lessening the effects
of clenching or grinding the teeth. The splints also
correct the bite by positioning the teeth in their most
correct and least traumatic position.18 Dental splints
FIGURE 3. A dental guard or splint. Source: Dental Care
Ottawa.20
AND T. GOSWAMI
are often used as a short-term treatment during ortho-
dontic management, before orthodontic therapy, or if
the TMJ disorders occur during dentofacial orthopedic
procedures.25 Bruxism is believed to cause the TMJ
dysfunction due to tooth attrition and subsequent
malocclusion; myofascial strain, fatigue or fibrosis of
masticatory muscles; and capsulitis and adhesions
within the TMJ joint space.47 Splints are used to help
control bruxism,17,19,33,34,47,81,85,95,117 a TMD risk fac-
tor in some cases. Splints are effective in reducing the
intensity of pain for patients with pain in jaw and
masticatory muscles by compensating for or correcting
perceived bite defects of the sufferer.17,19,33 The studies
on evidence-based medicine for splint therapy, how-
ever, have shown equivocal results.2,28,29,57,60,101 The
long-term effectiveness of this therapy has been widely
debated and remains controversial.17,19,85,117
Surgery
Surgery can play an important role in the manage-
ment of TMDs. As different surgical approaches for
treating the same condition are often recommended in
the literature, it is essential to understand which
approach can be more beneficial when surgery is nee-
ded. Conditions that are always treated surgically
involve problems of overdevelopment or underdevel-
opment of the mandible resulting from alterations of
condylar growth, mandibular ankylosis, and benign and
malignant tumors of the TMJ.59 The surgical treatments
such as arthrocentesis, arthroscopy, discectomy, and
joint replacement are discussed below.
Arthrocentesis
Arthrocentesis is the simplest form of surgical
intervention into the TMJ performed under general
anesthesia for sudden-onset, closed lock cases (restricted
jaw opening) in patients with no significant prior history
of TMJ problems.4,18 Arthrocentesis is not only the least
invasive of all surgical procedures but also carries a very
low risk. It involves inserting needles inside the affected
joint and washing out the joint with sterile fluids (see
Fig. 4). Occasionally, the procedure may involve
inserting a blunt instrument inside the joint to dislodge a
stuck disc.4,18,61
Arthroscopy
Arthroscopy is a surgery performed to put the
articular disc back into place. During this surgery a
small incision is made in front of the patient’s ear to
insert a small, thin instrument that contains a lens and
light. This instrument is connected to a video screen,
allowing the surgeon to examine the TMJ and sur-
rounding area. Depending on the cause of the TMD,
 TMJ Disorders, Treatments, and Biomechanics
the surgeon may remove inflamed tissue or realign the
disc or condyle.18,35 However, if the ligament and ret-
rodiscal tissue was previously stretched beyond its
elastic range, then just popping the disc back into place
is only a temporary fix as the joint still would not work
as well as usual. Therefore, an anchor—Mitek mini
anchor—and artificial ligaments have been used for
several years to stabilize the articular disc to the pos-
terior aspect of the condyle (see Fig. 5).27,110,111
When disc repositioning and stabilization are indi-
cated, the Mitek mini anchor system offers significant
advantages over other disc repositioning methods.27,62,114
The Mitek mini anchor has been analyzed in various
studies to assess its performance. A 2-year follow-up
FIGURE 4. Arthrocentesis. Source: Mayo Foundation for
Medical Education and Research.61
FIGURE 5. The Mitek mini anchor for repositioning and sta-
bilization of TMJ disc. It is composed of a titanium alloy body,
5 mm in length and 1.8 mm in diameter. Two nickel titanium
wings provide the intra bony locking mechanism while an
eyelet in the body allows attachment of sutures which func-
tion as artificial ligaments. Source: Wolford.110
981
study showed a success rate of 90% in reference to
incisal opening, jaw and occlusal stability, and signif-
icant reduction in presurgical pain level.110 Fields and
Wolford27 have demonstrated osseointegration of the
Mitek anchor in human condyles. The Mitek anchors
are reported to remain intact and biocompatible for as
long as 59 months.27 Mehra and Wolford62 reported
that, in 105 patients (188 discs) treated with Mitek mini
anchors, the radiographic evaluation for the follow-up
over 14–84 months demonstrated no significant con-
dylar resorption or positional changes of the anchors.
They also reported a statistically significant reduction
in TMJ pain, facial pain, headaches, the TMJ noises
and disability; and improvement in jaw function and
diet. The Mitek mini anchor also provides an effective
method for prevention of condylar dislocation while
permitting some controlled translation.114
Discectomy
Discectomy is a surgical treatment, which is
often performed on individuals with severe TMD, to
remove the damaged and very often dislocating
articular disc without going to a more extreme treat-
ment such as a joint prosthetic.18 However, removal of
the painful pathologic disc causes the TMJ reduced
absorbency and increased loading during articula-
tion.39,90,92 Although materials such as tendon allo-
grafts are advocated for the use of disc replacement,
there are no ideal inter-positional materials that can
protect articular cartilage from degenerative changes
following discectomy.39
Joint Replacement
Joint replacement is a surgical procedure in which
the severely damaged part of the TMJ is removed and
replaced with a prosthetic device. While more conser-
vative treatments are preferred when possible, in severe
cases or after multiple operations, the current end stage
treatment is joint replacement.92 If either a condyle or
a fossa component of the TMJ is replaced, the surgery
is called partial joint replacement. In total joint
replacement, condyle and fossa are both replaced (see
Fig. 6). Joint replacement is performed in certain cir-
cumstances such as bony ankylosis, recurrent fibrous
ankylosis, severe degenerative joint disease, aseptic
necrosis of the condyle, advanced rheumatoid arthritis,
two or more previous TMJ surgeries, absence of the
TMJ structure due to pathology, tumors involving the
condyle and mandibular ramus area, loss of the con-
dyle from trauma or pathology.15,63,83,84,112,113 There
are now long-term studies available in the literature
that support the safety and efficacy of joint replace-
ment under appropriate circumstances.65 However,
before a joint replacement option is ever considered for
982 S. INGAWALÉ
FIGURE 6. Temporomandibular joint replacement. Source:
Mayo Foundation for Medical Education and Research.61
a patient, all non-surgical, conservative treatment
options must be exhausted; and all conservative sur-
gical methodologies should be employed.83,84
TMJ IMPLANT DEVICES
TMJ devices are used as endosseous implants for
articular disc replacements, condylar replacements,
fossa replacements, and total joint prostheses. The
important characteristics for a TMJ implant to be
successful are biocompatible materials; functionally
compatible materials; low wear, and fatigue; adapt-
ability to anatomical structures; rigidly stabilized
components; and corrosion resistant and non-toxic
nature.115 van Loon et al.106 have stipulated the spe-
cific requirements for the TMJ prosthesis to be a suc-
cessful treatment option for the TMD patients (see
Table 2). They highlight the life expectancy of TMJ
implant as one of the most critical requirements. In
order to reduce the frequency of painful revision sur-
gery, a TMJ device should have an expected lifetime of
more than 20 years. As the maximum life of most TMJ
prosthetics is 10–15 years, Gadd and Goswami31 sug-
gested that the locking screws and locking compression
plate for the condylar part of the prosthetic should be
researched to increase implant stability and to avoid
bone loss due to revision surgery.
A total TMJ prosthesis was not described until
1974.50 Till then, surgeons had concentrated on
implanting either a fossa or a condylar head, but not
both.88 Although alloplastic TMJ prostheses were in
use since early 1960s; those became popular in 1980s
with the introduction of the Vitek-Kent prosthesis.
Many other companies then introduced their own de-
signs of alloplastic TMJ devices.113 However, many of
the alloplastic devices failed in delivering the intended
results due to their vulnerability to the repeated
AND T. GOSWAMI
TABLE 2. Design requirements for a TMJ prosthesis.
No. Description
1 Imitation of condylar translation during mouth opening
2 Unrestricted mandibular movements
3 Correct fit to the skull
4 Correct fit to the mandible
5 Stable fixation to the bony structures
6 Expected lifetime of more than 20 years
7 Low wear rate
8 Wear particles tolerated by the body
9 Biocompatible materials
10 Sufficient mechanical strength
11 Simple and reliable implantation procedures
Source: van Loon et al.106
mechanical stresses encountered in the TMJ with
functional movements of the jaw. The predicted in vivo
service life of such devices was one to three years.68
The United States Food and Drug Administration
(FDA), in 1993, halted the manufacture of the TMJ
implants—except for Christensen and Morgan im-
plants which were on the market prior to the enactment
of the medical device law in 1976102—due to lack of
safety and efficacy information to support its indicated
use.113 In 1993, the Dental Products Advisory Panel
reclassified TMJ implants into Class III—the highest
risk category.102,104 This means that all manufacturers
of TMJ devices would be required to submit a Pre-
market Approval Application (PMA)—demonstrating
safety and effectiveness—when called for by the FDA.
On December 30, 1998, the FDA called for PMAs from
all manufacturers of the TMJ implants.102,104 Although
many individuals and research groups introduced dif-
ferent designs of the TMJ prosthetic devices, only four
TMJ implants (from three manufacturers) are ap-
proved by FDA since December 30, 1998: (1) Chris-
tensen/TMJ Implants, Inc., total joint implant, (2)
Christensen/TMJ Implants, Inc., partial joint implant,
(3) Techmedica/TMJ Concepts implant, and (4) Walter
Lorenz/Biomet implant.102,104,105,113
Christensen TMJ Implant
The Christensen TMJ implant system was intro-
duced in early 1960s.32,88 Later, in 1995, it was
described as a total joint replacement system for the
TMJ.88 The Christensen prosthesis system includes
either a partial or total TMJ prosthesis available as a
stock device (see Fig. 7). The Christensen fossa emi-
nence prosthesis (FEP) is fabricated entirely of Cobalt–
Chrome (Co–Cr) alloy and is approximately 20–35 mm
across and 0.5 mm thick with a polished articulating
surface.32,83 This device can support either unilateral or
bilateral partial joint reconstruction. The Christensen
 TMJ Disorders, Treatments, and Biomechanics 983

FIGURE 7. The Christensen prostheses. (a) Fossa eminence prosthesis. (b) Total prosthesis. Source: TMJ Implants, Inc.100

condylar prosthesis has a Co–Cr alloy frame work with

a molded Polymethylmethacrylate (PMMA) head and
is available in three lengths of 45, 50, and 55 mm.
Co–Cr bone screws and drill bits sized to the screws are
used to fix the FEP to the base of the skull and condylar
device to the ramus.32,83,99
Christensen’s implant registry data, from 1993 to
1998, shows that 55% of the patients who received
either partial or total Christensen TMJ prostheses were
under the age of 40, and 83% were under the age of 50.
The number of women in the registry (3081, 87%)
compared with men (434, 12%) emphasizes the gender
paradox.32 A total of 58% of the patients received
partial joint prostheses while total TMJ prostheses
were placed in 42% patients.32
Chase et al.15 studied effectiveness of the Christensen
TMJ prosthesis system in treating patients with severe
TMD. The study dealt with patients who were
recalcitrant to nonsurgical treatments or had had prior
surgical procedures that did not alleviate their symp-
toms. The results of this study indicated that the
Christensen TMJ prosthesis system might offer a
treatment modality for severe TMJ dysfunction with a
high degree of success.15 Wolford et al.112 reported that
a metal condylar head against a metal fossa in the FIGURE 8. The Techmedica/TMJ Concepts prosthesis.
Christensen TMJ prosthesis device can increase the Source: Wolford et al.112
metal wear debris, create stress loading of the fossa
component, cause metalosis and corrosion, and increase devices developed after 1976, due to lack of safety and
exposure of elements in hypersensitive patients. efficacy information to support its indicated use. In
1997, Wolford et al.116 presented a 5-year follow-up
study on 36 patients with 65 TMJs reconstructed with
the Techmedica (now known as TMJ Concepts) total
Techmedica/TMJ Concepts TMJ Implant
joint prosthesis. This study reported the overall success
Techmedica, Inc. developed the joint prosthesis in rate of 90% for long-term occlusal and skeletal sta-
1989 as a custom-made device (see Fig. 8). However, in bility and pain reduction of 89% after reconstruction.
July 1993, FDA halted the manufacture of any TMJ Based on outcomes of this five year study, in 1997, the
984 S. INGAWALÉ
Techmedica/TMJ Concepts implant was approved by
the FDA.110,112,113
The Techmedica/TMJ Concepts total joint pros-
thesis uses materials that are well proven in orthopedic
joint reconstruction for hip and knee replace-
ments.112,113 The fossa component of this device is
made from commercially pure titanium mesh
(ASTM F67 & F1341) with an articular surface made
of ultra-high-molecular-weight polyethylene (UHMWPE
ASTM F648).83,84,99,110,112 The body of condylar
component is made from medical grade titanium alloy
(ASTM F136) with a condylar head of cobalt–chro-
mium–molybdenum alloy (ASTM F1537).83,84,99,110,112
Both the fossa and condylar components are secured
with titanium alloy (Ti–6Al–4V) screws.83
Prior to joint replacement surgery, the patient
undergoes a computed tomography (CT) scan of jaws
according to a specific protocol.83,113,115 Using the CT
data, a 3-dimensional plastic model of the TMJ and
associated jaw structures is made using stereolithographic
technology, a rapid prototyping technology, to produce
an anatomically accurate plastic model.83,99,113,115 This
model allows selective repositioning of the mandible on
the model into a predetermined functional and esthetic
position.113,115 The condyle is removed and any necessary
bony recontouring of the fossa and mandibular ramus is
completed and marked on the plastic model, since all the
alterations on the model must be accurately duplicated on
the patient intraoperatively.99,113 A custom-made Tech-
medica/TMJ Concepts total joint prosthesis conforming
to the patient’s specific anatomical morphology and jaw
interrelationship is then fabricated on the plastic
model.113,115 The data generated in the computer is uti-
lized to guide multi-axis milling systems in shaping the
implants to the anatomy found on the anatomical mod-
els.99 To ensure optimum fit, implant shapes are finalized
by hand contouring with careful attention to anatomical
details.99
Compared to the ‘‘off-the-shelf’’ implant devices, a
patient-fitted Techmedica/TMJ Concepts prosthesis
provides a better fit and stabilization of its components
to the host bone thereby mitigating any micro-move-
ment leading to loosening of the components and
maximizing the opportunity for osseointegration of
components and fixation screws.65,67,112 Osseointegra-
tion can contribute to improved patient function and
decreased micro-movement, which limits overall pros-
thesis wear and stress.112 Based on material selection,
treatment philosophy, and clinical experience, this
implant is reported to have provided the service life of
up to 14 years without evidence of untoward wear or
failure.65,113,115
A prospective study by Wolford et al.115 evaluated
the five to eight year subjective and objective results of
42 consecutive patients who had TMJ reconstruction
AND T. GOSWAMI
using the Techmedica/TMJ Concepts custom made
total joint prosthesis. This study demonstrated that the
Techmedica/TMJ Concepts total joint prosthesis is a
viable technique for TMJ reconstruction as a primary
procedure and for patients with previous multiple TMJ
surgeries and severely damaged joint.
In 2002, Mercuri et al.,67 in a 107 months (standard
deviation 15.5 months) follow-up study of 97 patients
treated with Techmedica/TMJ Concepts, reported a
76% reduction in mean pain score, a 68% increase in
mean mandibular function and diet consistency score,
and a 30% increase in mandibular range of motion
after 10 years. In 2007, Mercuri et al.,65 in a mean
follow-up of 11.4 years (standard deviation 3.0; range
0–14) study of the patient-fitted Techmedica/TMJ
Concepts total reconstruction system, reported a sig-
nificant reduction in pain scores, an increase in man-
dibular function and diet consistency scores, and
improvement in mandibular range of motion after
14 years. Both studies found the long-term quality of
life improvement scores to be statistically related to the
number of previous TMJ operations the patient had
undergone.65,67 Comparison analysis demonstrated
significantly better outcomes for patients with fewer
previous TMJ surgeries and without exposure to allo-
plastic TMJ devices.65,67 In 2008, Mercuri et al.64
published the results of 20 TMJ reankylosis patients
(total of 33 joints) treated with Techmedica/TMJ
Concepts total TMJ prosthesis system with the
autogenous fat grafted around the articulating portion
of the prosthesis at implantation. The follow-up data
for 50.4 ± 28.8 months showed improvement in
reported pain; increased jaw function; diet consistency;
and a significant improvement in postreplacement
maximum interincisal opening and quality of life.
Dingworth et al.23 and Wolford et al.112 published
the results of first direct clinical comparison of pre-
implantation and postimplantation subjective and
objective data from two similar groups of patients who
underwent reconstruction with two different TMJ
reconstruction systems. These studies evaluated 23
patients treated with Christensen prostheses (followed
for a mean of 20.8 months) along with 22 patients
implanted with Techmedica/TMJ Concepts prostheses
(followed for a mean of 33 months). The investigators
reported statistically significant improved outcomes
relative to post-surgical incisal opening, pain, jaw
function, and diet for the Techmedica/TMJ Concepts
prosthesis group compared to the Christensen pros-
thesis group.23,112
W. Lorenz/Biomet TMJ Implant
The W. Lorenz TMJ implant is a ‘‘ball and socket’’
type prosthetic joint similar to a knee or hip implant
 TMJ Disorders, Treatments, and Biomechanics
FIGURE 9. The W. Lorenz/Biomet TMJ prostheses. (a) Con-
dylar prosthesis. (b) Total prosthesis. Source: Biomet Micro-
fixation.11
(see Fig. 9). This device is made of common materials
with over 30 years of successful use in orthopedic joint
replacement.84,103 The condylar component is manu-
factured from Cobalt–Chromium–Molybdenum (Co–
Cr–Mo, ASTM F799) alloy with a roughened titanium
porous coating on the host bone side of the ramal
plate.83,84,103 The ramus of mandibular component is
available in lengths of 45 mm, 50 mm, and 55 mm. The
fossa component is manufactured from a specific grade
of ultra-high molecular weight polyethylene (UHMWPE)
called ArCom which has shown a 24% reduction in wear
compared to traditional UHMWPE.83,84,103 The swan
neck curvature on the medial surface of condylar neck
avoids the inherent fitting problems of the right angle
design found in most metallic condylar prosthesis.83,84
The fossa is available in three sizes with predrilled holes
for the screws. It also has an exaggerated circumferential
lipping to protect the condyle from possible heterotopic
bone formation and to avoid condylar dislocation.83,84
Both the condyle and fossa implants are attached to
bone using self-retaining, self-tapping bone screws made
of titanium alloy (Ti–6Al–4V).83,84,103
After three year follow-up of 50 patients (69 joints;
31 unilateral and 19 bilateral) reconstructed with Lor-
enz/Biomet prosthesis, Quinn83,84 reported significant
improvement in pain intensity, mouth opening, and
functional diet capability. This study also reported one
complication of staph scalp infection, necessitating the
removal of fossa prosthesis after 10 months of service.
According to FDA documentation, a total of 268 joints
(92 unilateral and 88 bilateral) were reconstructed with
W. Lorenz/Biomet total TMJ replacement system after
appropriate non-surgical treatment and/or previous
implant failure.103 The average patient follow-up for
19.6 months demonstrated improvement in patients’
condition through decrease in pain, increase of func-
tion, increase in maximal incisal opening, and satis-
faction with the treatment outcome.103 Barbick et al.7
have demonstrated that the Lorenz/Biomet prosthesis
985
fits satisfactorily in the majority of patients undergoing
surgical Techmedica/TMJ Concepts custom joint
replacement with minimal anatomical reduction. The
Lorenz/Biomet total prosthesis has not been studied in
pregnant women or children, therefore, the safety and
effectiveness for these patients is not known.103 The
safety and effectiveness of revision surgery using a
second set of W. Lorenz/Biomet total TMJ replacement
system implants is not known.
The information about the FDA approved TMJ
implants is summarized in Table 3. Outcomes of some
selective studies of patients treated with FDA
approved total TMJ devices are summarized in
Table 4. Investigating the outcomes of FDA approved
implants in a controlled comparative manner, and
evaluating biological characteristics of failed implants
compared to controls is essential to determine the
mechanism of implant failure. More rigorous com-
parative evaluations of the available implants can be
possible with the advent of the TMJ Implant Registry
and Repository (TIRR).22
ALLOPLASTIC MATERIALS
As the use of an alloplastic material eliminates the
donor site morbidity and the need for tissue harvesting,
several different alloplastic materials have been used to
replace lost articular tissues of the TMJ.65,68 Allo-
plastic materials used as medical devices have tradi-
tionally been viewed as biologically inert substances
that can be designed to achieve desirable mechanical
properties.30,68,123 Silicone rubber and Proplast/Teflon
(PT) were widely used materials in alloplastic TMJ
implants from mid 1970s to late 1980s. Silicone rubber
was used as permanent or temporary interpositional
material in TMJ reconstructive surgery since animal
studies had revealed that silicone rubber implants
placed into the TMJ after discectomy were typically
encapsulated by a fibrous reactive tissue capable of
functioning as a ‘‘pseudo-disc’’.68 Implants composed
primarily of carbon fiber and polytetrafluoroethylene
(PTFE/Teflon or PT) were introduced in the mid 1970s
to reconstruct the TMJ after discectomy.68 Early
reported successes with the use of these materials
included greater implant stability, and soft-tissue
ingrowth into the more porous PT implants.68
Adverse Tissue Responses to Alloplastic Materials
In many TMJ patients, alloplast materials initially
provided pain relief and improved function of the joint.
However, in most patients, these implant materials
(silicone rubber and PT) were found to gradually break
down as they could not sufficiently withstand the
986 S. INGAWALÉ AND T. GOSWAMI

TABLE 3. Summarized information about the FDA approved TMJ implants.

Prosthesis

TMJ implant Property Fossa eminence Condylar Features

Christensen/TMJ Materials Co–Cr alloy Co–Cr alloy. PMMA for head. Mainly a stock device
Implants, Inc. Dimensions 20 mm x 35 mm (across) 45, 50, 55 mm Serves as partial as well as
0.5 mm (thick) total prosthesis
Available sizes 44 3 The company has its own
Accessories Co–Cr bone screws, drill bits Co–Cr bone screws, drill bits implant registry
Some researchers believe
that the metal head
against the metal fossa
can cause more metal
wear debris
Techmedica/TMJ Materials Pure titanium (ASTM F67 & Medical grade titanium A custom-made device
Concepts F1341). UHMWPE (ASTM alloy (ASTM F136). Service life is reported up
F648) for articular surface Co–Cr–Mo alloy (ASTM to 14 years without
F1537) for head evidence of untoward
Dimensions Patient-specific Patient-specific wear or failure
Available sizes Patient-specific Patient-specific
Accessories Ti–6Al–4V alloy screws Ti–6Al–4V alloy screws
W. Lorenz/Biomet Materials A specific grade UHMWPE Co–Cr–Mo alloy (ASTM The ‘swan-neck’ curvature
(ArCom) F799) + of condylar component
Roughened titanium porous offers better fitting of the
coating. device
Dimensions – 45, 50, 55 mm Service life is reported up
Available sizes 3 3 to 3 years without
Accessories Ti–6Al–4V alloy screws Ti–6Al–4V alloy screws evidence of untoward
wear or failure.
Long-term follow-up is
not available

contact stresses generated during functional movements
of the jaw.30,83,110 The structural failure of the implants
resulted in formation of microparticulate implant debris
which elicited a foreign-body response characterized by
the presence of multinucleated giant cells.68 The
breakdown particles provoked the foreign body giant
cell reactions resulting in severe pain, headaches,
inflammation, fibrosis, malocclusion, progressive bone
and soft-tissue destruction, and severely limited joint
function often requiring further surgery.30,83,110,113
Zardeneta et al.123 suggested that the severity of the
biologic response to implant debris may be dependent
largely on the size of the debris particles. Implants
reduced to small particles elicit a more intense
inflammatory response than implants degraded to
larger particles.68,110,123 The inflammatory response to
PT or silicone rubber debris continues despite removal
of the failed implants because these materials are not
substantially degraded in vivo.68,110 Patients with pre-
vious exposure to failed materials and bony destruc-
tion resulting from foreign body inflammatory reaction
are likely to experience high pain and poor long-term
outcomes with alloplastic reconstruction.89 In such
revised reconstruction cases, implants showed the
potential to fragment in situ resulting in nonbiode-
gradable particles that stimulate a giant cell reaction
and lead to degeneration of local structures, pain, and
limitation of mandibular opening.89
The next generation of joint replacements will
incorporate live tissues in an effort to reconstruct the
joint to its normal state. The TMJ tissue engineering
strategies, in the long-term, may need to combine the
disc and mandibular condyle along with other tissues
such as retrodiscal tissue in a single implant.22
Understanding the development and break-
down mechanisms of the TMJ lubrication may enable
us to develop a ‘‘good as new’’ treatment remedy for
TMDs.92
LOADING AND KINEMATICS OF TMJ
Mandibular motions result in static and dynamic
loading in the TMJ. During natural loading of the joint,
combinations of compressive, tensile, and shear loading
occur on the articulating surfaces.92 The analysis of
mandibular biomechanics helps us understand the
interaction of form and function, and mechanism of
TMDs necessary to develop methods to prevent, diag-
nose, and cure joint disorders.10,38,48,52,56,58 It also aids
in the improvement of the design and the behavior of
prosthetic devices, thus increasing their treatment

Device
Christensen TMJ, Inc.
Christensen TMJ, Inc.
Christensen TMJ, Inc.
Christensen TMJ, Inc.
Techmedica TMJ Concepts, Inc.
Techmedica TMJ Concepts, Inc.
Techmedica TMJ Concepts, Inc.
Techmedica TMJ Concepts, Inc.
TABLE 4. Results of the total TMJ reconstruction with FDA approved devices.
Population Number
of prior TMJ
Source Patients Joints surgeries Follow-up Results
Chase et al.15 21 34 2.9 1–10 yr 95% had pain improvement
(Mean = 2.4 yr) 86% had increased ability to eat
91% had improved incisor opening
No failures or complication reported
Quinn83 90 109 ? 36–108 months 9 fractures of the condylar prostheses, at
(Mean = 73.1 months) an average of 5.8 yr after placement,
were reported. These factures were
attributed to uncorrected parafunc-
tional habits and device fixation
Gerard and Hudson32 17 26 ? 12–84 months 82% had a pain improvement
(Mean = 50 months) 88% had improved function
82% had improved interincisal opening
One condylar and one TJR prosthesis
required replacement
Speculand et al.88 45 60 ? 1–120 months 97% had overall functional improvement
(Median = 14.5 months) 77% could eat all types of food
76% reported satisfaction with the
treatment
No prosthesis required replacement
Wolford et al.112 36 65 ? 5 years 90% overall success rate for long-term
occlusal and skeletal stability
89% had pain reduction
Wolford et al.115 38 69 2.9 (range: 0–16) 60–96 months Statistically significant improvement in
(Mean = 73.5 months) incisal opening, jaw function, and pain
level; and long-term stable occulsion in
all cases
Statistically significant decrease in lateral
excursion movements
TMJ Disorders, Treatments, and Biomechanics
Complications occurred in six patients
Mercuri et al.66 58 97 4.2 (range: 0–12) 60–120 months 76% had reduction in mean pain scores
(Mean = 107.4 months) 68% had increase in mandibular function
and diet consistency scores
30% improvement in mandibular range of
motion after 10 years
After 5 years of implantation, one case
required replacement of a ramus
component due to screw loosening
Mercuri et al.65 61 102 4.9 (range: 0–28) 0–14 years Pain levels, mandibular function, diet
(Mean = 11.4 years) consistency, and maximum interincisal
opening increased significantly over
time
85% had improved quality of life
987
988 S. INGAWALÉ AND T. GOSWAMI

efficiency.56 As the TMJ components are difficult to

Significant improvement in pain intensity,

One complication required removal of

22 of the patients have had the joints
reach and as the applications of experimental devices

in function for longer than 3 years

mouth opening, & functional diet

inside the TMJ cause damage to its tissue, the direct
Results methods are not used often.

In Vivo Testing

fossa component
Some of the earlier studies suggest that the TMJ can,
capability. in certain specific combination of muscle forces, be a
force-free joint.13 These studies were contrasted by
observations of Brehnan et al.12 and Hylander45 who
showed through the direct measurements that consid-
erable forces were exerted on the TMJ during occlusion
as well as mastication.13 In face of these contrary
reports, Breul et al.13 performed stress investigation
using MRI scans of the TMJ in five different positions of
Follow-up

occlusion. For each position of the condyle, the

3 years

momentary center of rotation in the head of the man-

dible and the tangent attached to the temporal surface
were determined.13 The line connecting these two points
indicated the direction of the resulting compressive
force. By means of the force and the estimated extension
of the area available to the force transmission, the stress
5.7 (range: 0–13)

distribution was calculated independently from the

of prior TMJ
TABLE 4. continued.

position.13 This analysis showed that the TMJ was

surgeries
Number

subjected to pressure forces during occlusion as well as

during mastication and it was slightly eccentrically
loaded in all positions of occlusion.13
Korioth and Hannam55 indicated that the differen-
tial static loading of the human mandibular condyle
during tooth clenching was task dependent and both
the medial and lateral condylar thirds were heavily
Joints

loaded. Huddleston Slater et al.44 suggested that when

69

the condylar movement traces coincide during chew-

ing, there is compression in the TMJ during the closing
Population

stroke. However, when the traces do not coincide, the

TMJ is not or only slightly compressed during chew-
ing.44 Naeije and Hofman73 used these observations to
Patients

study the loading of the TMJ during chewing and

50

chopping tasks. Mandibular movements of ten healthy

subjects were recorded using a jaw movement record-
ing system during chewing and chopping of a latex-
packed food bolus on the left or right side of the
mouth. Distances traveled by the condylar kinematic
Quinn84
Source

centers were normalized with respect to the distances

traveled during maximum opening.73 The coincidence
of the opening and closing condylar movement traces
were judged without knowing their origin. The analysis
showed that the distances traveled by the condylar
kinematic centers were shorter on the ipsilateral side
than on the contralateral; and the kinematic centers of
Lorenz–Biomet

all contralateral joints showed a coincident movement

pattern during chewing and chopping.73 The indication
Device

that the ipsilateral joint is less heavily loaded during

chewing than the contralateral joint may explain why
 TMJ Disorders, Treatments, and Biomechanics
patients with joint pain occasionally report less pain
while chewing on the painful side.
Hansdottir and Bakke38 evaluated the effect of TMJ
arthralgia on mandibular mobility, chewing, and bite
force in TMD patients (categorized as disc derange-
ments, osteoarthritis, and inflammatory disorders)
compared to healthy control subjects. The pressure
pain threshold (PPT) was measured with an electronic
algometer during slight jaw opening. The PPT value
was determined as the amount of pressure applied at
which the sensation of pressure changed to pain.38
Maximum unassisted jaw opening was measured with
a ruler at the central incisors.38 Unilateral bite force
was recorded with a strain-gauge transducer placed on
the mandibular first molar. The transducer was cov-
ered with polyvinyl chloride tubes for protection, and
the force was measured during maximum clenches (2-s
duration) as the stored peak values on the digital dis-
play.38 The PPT, maximum jaw opening, and bite force
were significantly lower in the patients as compared to
that in controls. The patients were also found to have
longer duration of chewing cycles. The bite force and
jaw opening in patients were significantly correlated
with PPT.38 The most severe TMJ tenderness (i.e.,
lowest PPT) and the most impeded jaw function with
respect to jaw opening and bite force were found to be
more severe in the patients with inflammatory disor-
ders than the patients with disc derangement or oste-
roarthritis.38
In Vitro Testing
Indirect techniques such as humanoid robotic
approach, physical modeling using photo-elastic sys-
tems, moire fringe technique, and laser holographic
interferometry were tried by researchers to evaluate
mandibular biomechanics.8,10,82,90,96 However, these
methods had limited success due to their ability to
evaluate only the surface stress of the model but not its
mechanical properties.
Mechanical Testing
Osteoarthritis of the TMJ is associated with artic-
ular cartilage degradation and eventual joint destruc-
tion due to collagen damage caused by excessive shear
strain.96,119 As shear strain can result in fatigue,
damage, and deformation; data on shear behavior
might help a better understanding of tissue damage in
the articular cartilage.94,96 Previously it was reported
that the shear stress is very sensitive not only to the
frequency and direction of the loading but also to the
amount of shear and compressive strain.94 To char-
acterize the dynamic shear properties, Tanaka et al.96
tested the shear response of cartilage of 10 porcine
989
mandibular condyles using an automatic dynamic
viscoelastometer. The results showed that the shear
behavior of mandibular condylar cartilage is depen-
dent on the frequency and amplitude of the applied
shear strain suggesting a significant role of shear strain
on the interstitial fluid flow within the cartilage.
As TMJs are mostly used dynamically during
habitual tasks, dynamic analyses seem to be the most
appropriate. Beek et al.8 performed sinusoidal inden-
tation experiments and reported that the mechanical
behavior of disc was nonlinear and time-dependent.
Beek et al.10 simulated these experiments using axi-
symmetric finite element model and showed that a
poroelastic material model can describe the dynamic
behavior of the TMJ disc. Tanaka et al.90 carried out a
series of measurements of frictional coefficients on 10
porcine TMJs using a pendulum-type friction tester.
The results showed that the presence of the disc reduces
the friction in the TMJ by reducing the incongruity
between the articular surfaces and by increasing syno-
vial fluid lubrication. This study highlighted impor-
tance of alternatives to discectomy to treat internal
derangement and osteoarthritis of the TMJ.
Finite Element Modeling
The finite element modeling has been used widely in
biomechanical studies due to its ability to simulate the
geometry, forces, stresses and mechanical behavior of
the TMJ components and implants during simulated
function.16,52,53,56,76–80,82,91,94,98 Experimental or clini-
cal validation of theoretical predictions should be the
goal in any simulation endeavor.56 Chen et al.16 per-
formed stress analysis of human TMJ using a two-
dimensional (2D) finite element model developed from
magnetic resonance imaging (MRI). Although there
are limitations for using a 2D finite element model to
estimate stress/strain for a three-dimensional (3D)
joint, it is possible to estimate the relative changes of
the stresses corresponding to a 2D motion of the TMJ.
However, the 3D models are more realistic.16
Figure 10 shows the meshes of the TMJ model. The
maximum von Mises stress, seen at the posterior por-
tion of the disc, was about 8.0 MPa. The compressive
stress (about 8.0 MPa) was much higher than the
tensile stress (3.7 MPa). Due to convex nature of the
condyle, the compressive stresses were dominant in the
condylar region whereas the tensile stresses were
dominant in the fossa-eminence complex owing to its
concave nature.16
Although TMJ is a bicondylar joint, very few finite
element simulations have analyzed the different
responses of two sides of the joint. Beek et al.9 devel-
oped a 3D linear finite element model and analyzed the
biomechanical reactions in the mandible and in the
990 S. INGAWALÉ
FIGURE 10. Meshes of the TMJ model consisting of the disc, condyle and the fossa-eminence complex. Source: Chen et al.16
TMJ during clenching under various restraint condi-
tions. Tanaka et al.91,98 developed a 3D model to
investigate the stress distribution in the TMJ during
jaw opening, analyzing the differences in the stress
distribution of the disc between subjects with and
without internal derangement. In 2008, Tanaka
et al.,93 from the results of finite element model of the
TMJ based on magnetic resonance images, suggested
that increase of the frictional coefficient between
articular surfaces may be a major cause for the onset of
disc displacement.
All of the above mentioned simulations considered
symmetrical movements of mandible, and the models
developed only considered one side of the joint. Pérez-
Palomar and Doblaré76 used the combination of the
finite element models of the TMJ comprising the two
joints and models for soft components to study
clenching of mandible. However, these movements
were considered to be symmetric. In 2005, Koolstra
and van Eijden52 developed a combination of rigid-
body model with a finite element model of both discs
and the articulating cartilaginous surfaces to simulate
the opening movement of the jaw. Using the same
model, Koolstra and van Eijden53 performed finite
element analysis to study the load-bearing and main-
tenance capacity of the TMJ. The results indicated that
the construction of the TMJ permits its cartilaginous
AND T. GOSWAMI
structures to regulate their mechanical properties
effectively by imbibitions, exudation and redistribution
of fluid; and refreshment of this fluid can be performed
during normal function. However, these studies did
not dynamically simulate the TMJ as a two-sided joint
incorporating both discs and the most relevant liga-
ments and considering a nonsymmetrical movement of
the jaw.
In 2006, Pérez-Palomar and Doblaré77 developed a
3D finite element model that included not only the two
discs but also the most important ligaments and the
three body contact between all elements of the joints,
and analyzed biomechanical behavior of the soft
components during a nonsymmetrical lateral excursion
of the mandible to investigate possible consequences of
bruxism. The right lateral movement of the mandible
was performed in which case the right joint becomes
the ipsilateral TMJ (or working side) and the left joint
becomes the contralateral one (or nonworking side)
(see Fig. 11).77 The study reported maximum principal
stresses in the posterior band of the ipsilateral disc (up
to 2.5 MPa) and anterior band of the contralateral
disc; higher compressive stresses (up to 3.2 MPa) in the
posterior band and lateral part of the ipsilateral disc
(as it was compressed posteriorly against the temporal
bone); higher shear stresses (3.2 MPa) in the contra-
lateral disc in the lateral part of the posterior band;
 TMJ Disorders, Treatments, and Biomechanics
FIGURE 11. Schematic diagram of a lateral movement of the
mandible: (I) ipsilateral condyle, (C) contralateral condyle.
Source: Pérez-Palomar and Doblaré.77
and higher tensile stress in the contralateral ligaments
than that in the ipsilateral ligaments.77 This study
suggested that a continuous lateral movement of the
jaw may lead to perforations in the lateral part of both
discs, conforming with the indications by Tanaka
et al.91,94,98 Later, in 2007, Pérez-Palomar and
Doblaré79 suggested that unilateral internal derange-
ment is a predisposing factor for alterations in the
unaffected TMJ side. However, it would be necessary
to perform an exhaustive analysis of bruxism with the
inclusion of contact forces between upper and lower
teeth during grinding.
Nearly 40% of the rear-end impacts during vehicle
accidents produce whiplash injuries.43 Whiplash injury
is considered as a significant TMD risk factor and has
been proposed to produce internal derangements of the
TMJ.49,80 However, this topic is still subject to
debate.22 In 2008, Pérez-Palomar and Doblaré,80
published the results of finite element simulations of
the dynamic response of TMJ in rear-end and frontal
impacts to predict the internal forces and deformations
of the joint tissues. The results, similar to suggested by
Kasch et al.,49 indicated that neither a rear-end impact
at low-velocity nor a frontal impact would produce
damage to the soft tissues of the joint suggesting that
whiplash actions are not directly related with TMDs.80
However; since this study has its own limitations such
as analysis of only one model, for low-velocity impacts,
without any restrictions like contact with some com-
ponent of the vehicle; there is a need for more reliable
finite element simulations to obtain more accurate
numerical results.
Effects of TMJ Surgery
To assess the surgical replacement of TMJ, pre- and
post-surgical in vivo kinetics and kinematics of jaw had
been reported in the literature.51,66,118 TMJ recon-
struction using the partial or total TMJ prosthetics, in
991
most cases, improves range of motion and mouth
opening in the TMJ patients. However, loss of trans-
lational movements of the mandible on the operated
side has been often observed, especially in anterior
direction, owing to various factors like loss of ptery-
goid muscle function, scarring of the joint region and
the muscles of mastication.118 Komistek et al.51
assessed in vivo kinematics and kinetics of the normal,
partially replaced, and totally replaced TMJs. Under
fluoroscopic surveillance, the subjects were asked to
open and close their jaw on a force transducer placed
between their molars nearest the joint. A data acqui-
sition system recorded the bite force. The kinematic
data derived from fluoroscopy and the data output
from the force transducer were input into a mathe-
matical model of the human jaw to determine the
kinetics of the TMJ.51 Less translation was reported in
the implanted fossa and total TMJ joints than in the
normal joints. The study suggests that total TMJ
implants only rotate and do not translate; and the
muscles do not apply similar forces at the joint when
the subject has a total TMJ implant, compared to a
subject who has a normal, healthy TMJ.
In the post-TMJ replacement follow-up studies,
Mercuri et al.67 obtained the measures of mandibular
interincisal opening and lateral excursions from direct
measurements using the measuring scale provided in
the survey, mailed to patients with instructions as to its
use. The assessment showed a 24% and a 30%
improvement in mouth opening after 2 years and
10 years, respectively. On the other hand, at 2 years
post-implantation there was a 14% decrease in left
lateral excursion and a 25% decrease in right lateral
excursion from the pre-implantation data.65,67 As the
loss of lateral jaw movement is a great disadvantage to
total TMJ prosthesis replacement, a future prosthesis
must allow some lateral translation as well as the
anterior movement of mandible on the operated side
when the mouth is opened.105
Most studies have collected the data by subjective
surveys or mandibular incisor motion rather than
condylar motion. Yoon et al.118 followed a kinematic
method that tracks the condylar as well as incisors
path of the TMJ motion. An electromagnetic tracking
device and accompanying software were used to record
the kinematics of the mandible relative to temporal
bone during opening–closing, protrusive, and lateral
movements.118 This was achieved using an electro-
magnetic sensor attached each to the upper and lower
plastic dental brackets, a magnetic source, and a digi-
tizing probe used to locate anatomic points for defining
anatomic coordinate systems and landmarks of inter-
est.118 Mean linear distance (LD) of incisors during
maximal mouth opening for the surgical patient group
was 18% less than the normal subjects. Mean LD for
992 S. INGAWALÉ
FIGURE 12. Condyle kinematics healthy and diseased TMJs
during opening–closing and protrusive movements. Source:
Yoon et al.118
mandibular right and left condyles was symmetrical in
the normal group; however, in the surgical patient
group, measurements for operated condyle and unop-
erated condyle were asymmetric and reduced as com-
pared with normal subjects by 57 and 36%,
respectively (see Fig. 12).118 In protrusive movements,
operated and unoperated condyles of surgical patients
traveled less and significantly differently as compared
with condyles of normal subjects, which moved almost
identically. For the surgical patient group, the mean
incisor LD away from the operated side and toward
the operated side as compared with the normal group
incisors were reduced by 67 and 32%, respectively.118
Various research articles on the TMJ underline the
importance of biomechanical analysis of the natural
joint to better understand the structural and functional
aspects; and of the reconstructed joint to assess the
implant function and performance. Numerous works
have focused primarily on calculating absolute mag-
nitude of TMJ loading with finite element models.
Most of the methods reported in the literature have
certain limitations due to the complex nature of the
joint and also due to certain limitations of the tech-
niques and software packages used for modeling and
analysis. The reported magnitudes of TMJ loading
differ significantly from one another because of dif-
ference in simulation conditions. The direct measure-
ments also indicate a large discrepancies.92 Due to
these reasons; there is currently no universally agreed-
upon value of TMJ loading.92 Therefore, a more
comprehensive biomechanical analysis of the TMJ is
essential for better understanding of the movements,
applied forces, and resultant stresses in the natural
and/or artificial joint components.
CONCLUSION
The temporomandibular disorder (TMD) symp-
toms are exhibited by a large portion—nearly 20 to
AND T. GOSWAMI
25%—of the population and, hence, this problem
should be looked at more fully. Though majority of the
TMD conditions can be successfully managed by var-
ious non-surgical and less-invasive treatments, joint
replacement becomes the only potential remedy for
certain TMD conditions. Assessing the outcomes of
the FDA approved TMJ implants in a controlled
comparative manner, and evaluating biological char-
acteristics of failed implants compared to controls are
essential to determine mechanism of implant failure.
The biomechanical analysis is a useful tool to
understand the normal function, predict changes due
to alterations, and propose methods of artificial
intervention for the treatment of diseased or damaged
TMJ. The patient-specific computer models can be
used to estimate non-measurable TMJ loads through
finite element analysis to understand the underlying
mechanisms of TMD, necessary for developing and
improving the methods to prevent, diagnose and cure
joint disorders.
REFERENCES
1
Abubaker, A. O., P. C. Hebda, and J. N. Gunsolley.
Effects of sex hormones on protein and collagen content
of the temporomandibular joint disc of the rat. J. Oral
Maxillofac. Surg. 54:721–727, 1996. doi:10.1016/S0278-
2391(96)90690-4.
2
Al-Ani, M. Z., S. J. Davies, R. J. M. Gray, P. Sloan, and
A. M. Glenny. Stabilisation splint therapy for temporo-
mandibular pain dysfunction syndrome. Cochrane Data-
base of Systematic Reviews. Issue 1, 2004. Art. No.: CD0
02778. doi:10.1002/14651858.CD002778.pub2. Retrieved
on 01/22/2009, from http://mrw.interscience.wiley.com/
cochrane/clsysrev/articles/CD002778/pdf_fs.html.
3
Alomar, X., J. Medrano, J. Cabratosa, J. A. Clavero,
M. Lorente, I. Serra, J. M. Monill, and A. Salvador.
Anatomy of the temporomandibular joint. Semin. Ultra-
sound CT MRI 28:170–183, 2007.
4
Alpaslan, C., M. F. Dolwick, and M. W. Heft. Five-year
retrospective evaluation of temporomandibular joint
arthrocentesis. Int. J. Oral Maxillofac. Surg. 32:263–267,
2003. doi:10.1054/ijom.2003.0371.
5
American Association of Oral and Maxillofacial Sur-
geons (AAOMS). The temporomandibular joint (TMJ).
Retrieved on 10/14/2007, from http://www.aaoms.org/
tmj.php.
6
Bakke, M., M. Zak, B. L. Jensen, and F. K. Pedersen.
Orofacial pain, jaw function, and temporomandibular
disorders in women with a history of juvenile chronic
arthritis or persistent juvenile chronic arthritis. Oral Surg.
Oral Med. Oral Pathol. Oral Radiol. Endod. 92:406–414,
2001. doi:10.1067/moe.2001.115467.
7
Barbick, M., M. F. Dolwick, S. Rose, and S. Abra-
mowicz. Adaptibility of Biomet Lorenz tmj prosthesis to
joints that were previously treated with the tmj concepts
custom joint prosthesis. Oral Med. Oral Pathol. Oral
Radiol. Endod. 106(2):e17, 2008. doi:10.1016/j.tripleo.
2008.05.058.
 TMJ Disorders, Treatments, and Biomechanics
8 26
Beek, M., M. P. Aarnts, J. H. Koolstra, A. J. Feilzer, and
T. M. G. J. van Eijden. Dynamical properties of the
human temporomandibular joint disc. J. Dent. Res.
80:876–880, 2001. doi:10.1177/00220345010800030601.
9
Beek, M., J. Koolstra, L. van Ruijven, and T. van Eijden.
Three dimensional finite element analysis of the cartilag-
inous structures in the human temporomandibular joint.
J. Dent. Res. 80:1913–1918, 2001. doi:10.1177/002203450
10800101001.
10
Beek, M., J. H. Koolstra, and T. M. G. J. van Eijden.
Human temporomandibular joint disc cartilage as a
poroelastic material. Clin. Biomech. 18:69–76, 2003. doi:
10.1016/S0268-0033(02)00135-3.
11
Biomet Microfixation. Retrieved on 02/04/2009, from
http://www.lorenzsurgical.com/downloads/BMF-7014%20
TMJBro%20(d)4Final.pdf.
12
Brehnan, K., R. L. Boyd, J. Laskin, C. H. Gibbs, and
P. Mahan. Direct measurement of loads at the temporo-
mandibular joint in macaca arctoides. J. Dent. Res. 60:
1820–1824, 1981.
13
Breul, R., G. Mall, J. Landgraf, and R. Scheck. Biome-
chanical analysis of stress distribution in the human
temporomandibular-joint. Ann. Anat. 181:55–60, 1999.
doi:10.1016/S0940-9602(99)80090-9.
14
Campbell, J. H., M. S. Courey, P. Bourne, et al. Estrogen
receptor analysis of human temporomandibular disc.
J. Oral Maxillofac. Surg. 51:1101, 1993.
15
Chase, D. C., J. W. Hudson, D. A. Gerard, R. Russell,
K. Chambers, J. R. Curry, J. E. Latta, and R. W. Christen-
sen. The Christensen prosthesis: a retrospective clinical
study. Oral Surg. Oral Med. Oral Pathol. 80:273–278, 1995.
16
Chen, J., U. Akyuz, L. Xu, and R. M. V. Pidaparti. Stress
analysis of the human temporomandibular joint. Med. Eng.
Phys. 20:565–572, 1998. doi:10.1016/S1350-4533(98)00070-8.
17
Chung, S. C., Y. K. Kim, and H. S. Kim. Prevalence and
patterns of nocturnal bruxofacets on stabilization splints in
temporomandibular disorder patients. Cranio 18:92, 2000.
18
Cleveland Clinic. Health information. Retrieved on 09/21/
2007, from http://www.clevelandclinic.org/health/.
19
Dao, T. T., and G. J. Lavigne. Oral splints: the crutches
for temporomandibular disorders and bruxism? Crit. Rev.
Oral Biol. Med. 9:345–361, 1998. doi:10.1177/104544119
80090030701.
20
Dental Care Ottawa. Retrieved on 04/09/2008, from http://
www.dentalcareottawa.com/Smile%20Spa%20Images/
EQUIPMENT%20PICTURES/SoftSplint.gif.
21
Detamore, M. S., and K. A. Athanasiou. Structure and
function of the temporomandibular joint disc: implica-
tions for tissue engineering. J. Oral Maxillofac. Surg.
61(4):494–506, 2003. doi:10.1053/joms.2003.50096.
22
Detamore, M. S., K. A. Athanasiou, and J. Mao. A call to
action for bioengineers and dental professionals: directives
for the future of TMJ bioengineering. Ann. Biomed. Eng.
35(8):1301–1311, 2007. doi:10.1007/s10439-007-9298-6.
23
Dingworth, D. J., L. M. Wolford, R. M. Talwar,
et al. Comparison of two total joint prosthesis systems
used for TMJ reconstruction. J. Oral Maxillofac. Surg.
56(Suppl. 4):59, 1998.
24
Dutton, M. Orthopaedic Examination, Evaluation, &
Intervention. New York: McGraw Hill, 2004.
25
Eberhard, D., H. P. Bantleon, and W. Steger. The efficacy
of anterior repositioning splint therapy studied by mag-
netic resonance imaging. Eur. J. Orthod. 24:343–352,
2002. doi:10.1093/ejo/24.4.343.
993
Farrar, W. B., and W. L. McCarty, Jr. The TMJ dilemma.
J. Ala. Dent. Assoc. 63:19, 1979.
27
Fields, R. T., and L. M. Wolford. The osseointegration of
Mitek mini anchors in the mandibular condyle. J. Oral
Maxillofac. Surg. 59:1402–1406, 2001. doi:10.1053/joms.
2001.28268.
28
Forssell, H., and E. Kalso. Application of principles of
evidence-based medicine to occlusal treatment for tem-
poromandibular disorders: are there lessons to be learned?
J. Orofac. Pain 18:9–22, 2004; discussion 23–32.
29
Forsell, H., E. Kalso, P. Koskela, R. Vehmanen,
P. Puukka, and P. Alanen. Occlusal treatments in tem-
poromandibular disorders: a qualitative systematic review
of randomized controlled trials. Pain 83:549–560, 1999.
doi:10.1016/S0304-3959(99)00160-8.
30
Fricton, J. R., J. O. Look, E. Schiffman, and J. Swift. Long-
term study of temporomandibular joint surgery with allo-
plastic implants compared with nonimplant surgery and
nonsurgical rehabilitation for painful temporomandibular
joint disc displacement. J. Oral Maxillofac. Surg.
60(12):1400–1411, 2002. doi:10.1053/joms.2002.36091.
31
Gadd, A., and T. Goswami. Temporomandibular disorder
and joint replacement. Biomed. Mater., Paper No. BMW-
RANL-7PJRW3, 2009.
32
Gerard, D. A., and J. W. Hudson. The Christensen tem-
poromandibular joint prosthesis system: an overview.
TMJournal, 2002. Retrieved on 09/20/2007, from http://
tmjournal.com/library/CP-009.pdf.
33
Glaros, A. G., Z. Owais, and L. Lausten. Reduction in
parafuncational activity: a potential mechanism for the
effectiveness of splint therapy. J. Oral Rehabil. 34:97–104,
2007. doi:10.1111/j.1365-2842.2006.01660.x.
34
Glass, E. G., A. G. Glaros, and F. D. McGlynn. Myo-
fascial pain dysfunction: treatments used by ADA mem-
bers. Cranio 11:25–29, 1993.
35
Going, R. B., Jr Arthroscopy in the Conservative Man-
agement of TMD. Temporomandibular Disorders. 2nd ed.
New York: Churchill Livingstone, pp. 217–236, 1994.
36
Gray, R. J. M., S. J. Davies, and A. A. Quayle. Tempo-
romandibular Disorders: A Clinical Approach. London:
British Dental Association, 1995.
37
Halliwell, B., and J. M. C. Gutteridge. Free Radicals in
Biology and Medicine. Oxford: Clarendon Press, 1995.
38
Hansdottir, R., and M. Bakke. Joint tenderness, jaw
opening, chewing velocity, and bite force in patients with
temporomandibular joint pain and matched healthy con-
trol subjects. J. Orofac. Pain 18:108–113, 2004.
39
Haruki, S. Stored tendon allograft for TMJ disc replace-
ment following discectomy in rabbit. J. Oral Maxillofac.
Surg. 63(8):98, 2005.
40
Hebert, L. A. Overcoming TMJ: There is Hope. Greenville,
ME: IMPACC USA, 1996.
41
Hibi, H., and M. Ueda. Body posture during sleep and
disc displacement in the temporomandibular joint: a pilot
study. J. Oral Rehabil. 32:85–89, 2005. doi:10.1111/j.1365-
2842.2004.01386.x.
42
Homandberg, G. A., R. Meyers, and D. L. Xie. Fibro-
nectin fragments cause chondrolysis of bovine articular
cartilage slices in culture. J. Biol. Chem. 267:3597, 1992.
43
Huang, S. C. Dynamics modeling of human temporo-
mandibular joint during whiplash. Bio-Med. Mater. Eng.
9:233–241, 1999.
44
Huddleston Slater, J. J., C. M. Visscher, F. Lobbezoo,
and M. Naeije. The intra-articular distance within the TMJ
994 S. INGAWALÉ
during free and loaded closing movements. J. Dent. Res.
78:1815–1820, 1999. doi:10.1177/00220345990780120801.
45
Hylander, L. W. An experimental analysis of temporo-
mandibular joint reaction force in macaques. Am. J. Phys.
Anthropol. 51:433–456, 1979. doi:10.1002/ajpa.1330510317.
46
Ide, Y., K. Nakazawa, T. Hongo, J. Taleishi, and
K. Kamimura. Anatomical Atlas of the Temporoman-
dibular Joint. Chicago: Quintessence Pub. Co., 1991.
47
Kalamir, A., H. Pollard, A. L. Vitiello, and R. Bonello.
TMD and the problem of bruxism—a review. J. Bodywork
Mov. Ther. 11:183–193, 2007. doi:10.1016/j.jbmt.2006.11.
006.
48
Kang, H., G. Bao, and S. Qi. Biomechanical responses of
human temporomandibular joint disc under tension and
compression. Int. J. Oral Maxillofac. Surg. 35:817–821,
2006. doi:10.1016/j.ijom.2006.03.005.
49
Kasch, H., T. Hjorth, P. Svensson, L. Nyhuus, and T. S.
Jensen. Temporomandibular disorders after whiplash in-
jury: a controlled, prospective study. J. Orofac. Pain
16(2):118–128, 2002.
50
Kiehn, C. L., J. D. Des Prez, and C. F. Converse. A new
procedure for total temporomandibular joint replacement.
Plast. Reconstr. Surg. 53:221–226, 1974. doi:10.1097/0000
6534-197402000-00022.
51
Komistek, R. D., D. A. Dennis, J. A. Mabe, and D. T.
Anderson. In vivo kinetics and kinematics of the normal
and implanted TMJ. J. Biomech. 31:13, 1998. doi:10.1016/
S0021-9290(98)80028-6.
52
Koolstra, J., and T. M. G. J. van Eijden. Combined finite-
element and rigid-body analysis of human jaw joint
dynamics. J. Biomech. 38:2431–2439, 2005. doi:10.1016/
j.jbiomech.2004.10.014.
53
Koolstra, J., and T. M. G. J. van Eijden. Prediction of
volumetric strain in the human temporomandibular joint
cartilage during jaw movement. J. Anat. 209:369–380,
2006. doi:10.1111/j.1469-7580.2006.00612.x.
54
Koolstra, J., and T. M. G. J. van Eijden. Viscoelastic
behavior of the temporomandibular joint disc during
masticatory dynamics. J. Biomech. 39(Suppl. 1):49, 2006.
doi:10.1016/S0021-9290(06)83740-1.
55
Korioth, T. W. P., and A. G. Hannam. Mandibular forces
during simulated tooth clenching. J. Orofac. Pain 8(2):
178–189, 1994.
56
Korioth, T. W. P., and A. Versluis. Modeling the
mechanical behavior of the jaws and their related structures
by finite element (FE) analysis. Crit. Rev. Oral Biol. Med.
8(1):91–104, 1997. doi:10.1177/10454411970080010501.
57
Kreiner, M., E. Betancor, and G. T. Clark. Occlusal sta-
bilization appliances. Evidence of their efficacy. J. Am.
Dent. Assoc. 132:770–777, 2001.
58
Kubein-Messenburg, D., H. Nagerl, and J. Fanghanel.
Elements of a general theory of joints. Anat. Anz. 170:
301–308, 1990.
59
Laskin, D. M. Indications and Limitations of TMJ Sur-
gery. TMDs: Temporomandibular Disorders: An Evi-
dence-Based Approach to Diagnosis and Treatment.
Chicago: Quintessence, 2006.
60
Marbach, J. J., and K. G. Raphael. Future directions in
the treatment of chronic musculoskeletal facial pain: the
role of evidence-based care. Oral Surg. Oral Med. Oral
Pathol. Oral Radiol. Endod. 83:49–183, 1997. doi:10.1016/
S1079-2104(97)90110-4.
61
Mayo Foundation for Medical Education and Research.
Retrieved on 10/10/2007, from http://www.mayoclinic.
org/tmj/.
AND T. GOSWAMI
62
Mehra, P., and L. M. Wolford. The Mitek mini anchor for
TMJ disc repositioning: surgical technique and results.
Int. J. Oral Maxillofac. Surg. 30:497–503, 2001. doi:
10.1054/ijom.2001.0163.
63
Mercuri, L. G. The use of alloplastic prostheses for tem-
poromandibular joint reconstruction. J. Oral Maxillofac.
Surg. 58:70–75, 2000. doi:10.1016/S0278-2391(00)80020-8.
64
Mercuri, L. G., F. A. Ali, and R. Woolson. Outcomes of
total alloplastic replacement with periarticular autogenous
fat grafting for management of reankylosis of the tem-
poromandibular joint. J. Oral Maxillofac. Surg. 66:1794–
1803, 2008. doi:10.1016/j.joms.2008.04.004.
65
Mercuri, L. G., N. R. Edibam, and A. Giobbie-Hurder.
Fourteen-year follow-up of a patient-fitted total tempo-
romandibular joint reconstruction system. J. Oral Max-
illofac. Surg. 65:1440–1448, 2007. doi:10.1016/j.joms.2007.
04.004.
66
Mercuri, L. G., N. R. Edibam, and A. Giobbie-Hurder.
Long-term outcomes after total alloplastic temporoman-
dibular joint reconstruction following exposure to failed
materials. J. Oral Maxillofac. Surg. 62(9):1088–1096,
2004. doi:10.1016/j.joms.2003.10.012.
67
Mercuri, L. G., L. M. Wolford, B. Sanders, et al. Long-term
follow-up of the CAD/CAM patient fitted total temporo-
mandibular joint reconstruction system. J. Oral Maxillo-
fac. Surg. 60:1440–1448, 2002. doi:10.1053/joms.2002.
36103.
68
Milam, S. B. Failed implants and multiple operations.
Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod.
83(1):156–162, 1997. doi:10.1016/S1079-2104(97)90107-4.
69
Milam, S. B. The process of lubrication impairment and its
involvement in temporomandibular joint disc displace-
ment: a theoretical concept (Discussion). J. Oral Maxillo-
fac. Surg. 59:45, 2001. doi:10.1053/joms.2001.19282.
70
Milam, S. B., and J. P. Schmitz. Molecular biology of
temporomandibular joint disorders: proposed mecha-
nisms of disease. J. Oral Maxillofac. Surg. 53:1448–1454,
1995. doi:10.1016/0278-2391(95)90675-4.
71
Milam, S. B., G. Zardeneta, and J. P. Schmitz. Oxidative
stress and degenerative temporomandibular joint disease:
a proposed hypothesis. J. Oral Maxillofac. Surg. 56:214–
223, 1998. doi:10.1016/S0278-2391(98)90872-2.
72
Molinari, F., P. F. Manicone, L. Raffaelli, R. Raffaelli,
T. Pirronti, and L. Bonomo. Temporomandibular joint
soft-tissue pathology. I: Disc abnormalities. Semin.
Ultrasound CT MRI 28(3):192–204, 2007.
73
Naeije, M., and N. Hofman. Biomechanics of the human
temporomandibular joint during chewing. J. Dent. Res.
82(7):528–531, 2003. doi:10.1177/154405910308200708.
74
Nitzan, D. W. Intraarticular pressure in the functioning
human temporomandibular joint and its alteration by
uniform elevation of the occlusal plane. J. Oral Maxillofac.
Surg. 52:671, 1994. doi:10.1016/0278-2391(94)90476-6.
75
Pellizoni, S. E. P., M. A. C. Salioni, Y. Juliano, A. S.
Guimarães, and L. G. Alonso. Temporomandibular joint
disc position and configuration in children with functional
unilateral posterior crossbite: a magnetic resonance
imaging evaluation. Am. J. Orthod. Dentofac. Orthoped.
129(6):785–793, 2006.
76
Pérez-Palomar, A., and M. Doblaré. The effect of collagen
reinforcement in the behavior of the temporomandibular
joint disc. J. Biomech. 39:1075–1085, 2006. doi:10.1016/
j.jbiomech.2005.02.009.
77
Pérez-Palomar, A., and M. Doblaré. Finite element
analysis of the temporomandibular joint during lateral
 TMJ Disorders, Treatments, and Biomechanics
excurision of the mandible. J. Biomech. 39:2153–2163,
2006. doi:10.1016/j.jbiomech.2005.06.020.
78
Pérez-Palomar, A., and M. Doblaré. An accurate simu-
lation model of anteriorly displaced TMJ discs with and
without reduction. Med. Eng. Phys. 29:216–226, 2007.
doi:10.1016/j.medengphy.2006.02.009.
79
Pérez-Palomar, A., and M. Doblaré. Influence of unilat-
eral disc displacement on the stress response of the
temporomandibular joint discs during opening and mas-
tication. J. Anat. 211:453–463, 2007.
80
Pérez-Palomar, A., and M. Doblaré. Dynamic 3D FE
modelling of the human temporomandibular joint during
whiplash. Med. Eng. Phys. 30:700–709, 2008. doi:10.1016/
j.medengphy.2007.07.009.
81
Pierce, C. J., R. J. Weyant, H. M. Block, and D. C. Nemir.
Dental splint prescription patterns: a survey. J. Am. Dent.
Assoc. 126:248, 1995.
82
Pileicikiene, G., E. Varpiotas, R. Surna, and A. Surna.
The three dimensional model of the human masticatory
system, including the mandible, the dentition and the
temporomandibular joints. Stomatologija Balt. Dent.
Maxillofac. J. 9:27–32, 2007.
83
Quinn, P. D. Alloplastic reconstruction of the temporo-
mandibular joint. Sel. Read. Oral Maxillofac. Surg. 7(5):
1–23, 1999.
84
Quinn, P. D. Lorenz prosthesis—total temporomandibu-
lar joint reconstruciton. Oral Maxillofac. Surg. Clin.
North Am. 12(1):93–104, 2000.
85
Raphael, K. G., J. J. Marbach, J. J. Klausner, M. F.
Teaford, and D. K. Fischoff. Is bruxism severity a pre-
dictor of oral splint efficacy in patients with myofascial
face pain? J. Oral Rehabil. 30:17–29, 2003. doi:10.1046/
j.1365-2842.2003.01117.x.
86
Schwartz, H. C., and R. W. Kendrick. Internal derange-
ment of the temporomandibular joint: description of
clinical syndromes. Oral Surg. Oral Med. Oral Pathol.
100
58(1):24–29, 1984. doi:10.1016/0030-4220(84)90358-X.
87
Solberg, W. K., M. W. Woo, and J. B. Houston. Preva-
101
lence of mandibular dysfunction in young adults. J. Am.
Dent. Assoc. 98:25–34, 1979.
88
Speculand, B., R. Hensher, and D. Powell. Total pros-
thetic replacement of the TMJ: experience with two sys-
102
tems 1988–1997. Br. J. Oral Maxillofac. Surg. 38(4):360–
369, 2000. doi:10.1054/bjom.2000.0338.
89
Ta, L. E., J. C. Phero, S. R. Pillemer, H. Hale-Donze,
N. McCartney-Francis, A. Kingman, M. B. Max, S. M.
103
Gordon, S. M. Wahl, and R. A. Dionne. Clinical evalu-
ation of patients with temporomandibular joint implants.
J. Oral Maxillofac. Surg. 60(12):1389–1399, 2002. doi:
10.1053/joms.2002.36089.
90
Tanaka, E., D. A. Dalla-Bona, T. Iwabe, N. Kawai,
104
E. Yamano, T. van Eijden, M. Tanaka, M. Miyauchi,
T. Takata, and K. Tanne. The effect of removal of the disc
on the friction in the temporomandibular joint. J. Oral
Maxillofac. Surg. 64:1221–1224, 2006. doi:10.1016/j.joms.
105
2006.04.017.
91
Tanaka, E., R. del Pozo, M. Tanaka, D. Asai, M. Hirose,
T. Iwabe, and K. Tanne. Three-dimensional finite element
analysis of human temporomandibular joint with and with-
out disc displacement during jaw opening. Med. Eng. Phys.
106
26:503–511, 2004. doi:10.1016/j.medengphy.2004.03.001.
92
Tanaka, E., M. S. Detamore, K. Tanimoto, and
N. Kawai. Lubrication of the temporomandibular joint.
Ann. Biomed. Eng. 36(1):14–29, 2008. doi:10.1007/s10439-
007-9401-z.
995
93
Tanaka, E., M. Hirose, J. H. Koolstra, T. M. G. J. van
Eijden, Y. Iwabuchi, R. Fujita, M. Tanaka, and
K. Tanne. Modeling of the effect of friction in the tem-
poromandibular joint on displacement of its disc during
prolonged clenching. J. Oral Maxillofac. Surg. 66:462–
468, 2008. doi:10.1016/j.joms.2007.06.640.
94
Tanaka, E., N. Kawai, K. Hanaoka, T. van Eijden,
A. Sasaki, J. Aoyama, M. Tanaka, and K. Tanne. Shear
properties of the temporomandibular joint disc in relation
to compressive and shear strain. J. Dent. Res. 83:476–479,
2004. doi:10.1177/154405910408300608.
95
Tanaka, E., K. Kikuchi, A. Sasaki, and K. Tanne. An
adult case of TMJ osteoarthrosis treated with splint
therapy and the subsequent orthodontic occlusal recon-
struction: adaptive change of the condyle during the
treatment. Am. J. Orthod. Dentofac. Orthop. 118:566–571,
2000. doi:10.1067/mod.2000.93966.
96
Tanaka, E., E. B. Rego, Y. Iwabuchi, T. Inubushi, J. H.
Koolstra, T. M. G. J. van Eijden, N. Kawai, Y. Kudo,
T. Takata, and K. Tanne. Biomechanical response of
condylar cartilage-on-bone to dynamic shear. J. Biomed.
Mater. Res. 85(A):127–132, 2008.
97
Tanaka, E., D. P. Rodrigo, Y. Miyawaki, K. Lee,
K. Yamaguchi, and K. Tanne. Stress distribution in the
temporomandibular joint affected by anterior disc dis-
placement: a three-dimensional analytic approach with
the finite-element method. J. Oral Rehabil. 27(9):754–759,
2000. doi:10.1046/j.1365-2842.2000.00597.x.
98
Tanaka, E., D. P. Rodrigo, M. Tanaka, A. Kawaguchi,
T. Shibazaki, and K. Tanne. Stress analysis in the TMJ
during jaw opening by use of a three-dimensional finite
element model based on magnetic resonance images. Int.
J. Oral Maxillofac. Surg. 30:421–430, 2001. doi:10.1054/
ijom.2001.0132.
99
TMJ Concepts, Inc. Description of the Implants. Retrieved
on 10/10/2007, from http://tmjconcepts.com/.
TMJ Implants, Inc. Products. Retrieved on 10/10/2007,
from http://www.tmj.com/products/tmj_partial.php.
Turp, J. C., F. Komine, and A. Hugger. Efficacy of stabil-
ization splints for the management of patients with mastica-
tory muscle pain: a qualitative systmatic review. Clin. Oral
Investig. 8:179–195, 2004. doi:10.1007/s00784-004-0265-4.
United States Food and Drug Administration—Center for
Devices and Radiological Health (US FDA/CDRH).
Retrieved on 08/15/2008, from http://www.fda.gov/cdrh/
consumer/tmjupdate.html.
Unites States Food and Drug Administration. W. Lorenz
total TMJ replacement system—patient information.
Retrieved on 08/16/2008, from http://www.fda.gov/
ohrms/dockets/ac/02/briefing/3889b1_TMJ%20Patient%20
Information%20final.pdf.
Unites States Govermental Accountability Office (GAO).
FDA approval of four TMJ implants—report to con-
gressional requesters, September 2007. Retrieved on 09/
05/2008, from http://www.gao.gov/new.items/d07996.pdf.
van Loon, J. P., L. G. M. de Bont, and G. Boering.
Evaluation of temporomandibular joint prostheses—
review of the literature from 1946 to 1994 and implications
for future prosthesis designs. Int. J. Oral Maxillofac. Surg.
53:984–996, 1995. doi:10.1016/0278-2391(95)90110-8.
van Loon, J. P., L. G. M. de Bont, B. Stegenga, F. K. L.
Spijkervet, and G. J. Verkerke. Groningen temporoman-
dibular joint prosthesis: development and first clinical
application. Int. J. Oral Maxillofac. Surg. 31(1):44–52,
2002. doi:10.1054/ijom.2001.0175.
 996 S. INGAWALÉ
107
Warren, M. P., and J. L. Fried. Temporomandibular
disorders and hormones in women. Cells Tissues Organs
169:187, 2001. doi:10.1159/000047881.
108
Wilkes, C. H. Arthrography of the temporomandibular
joint in patients with the TMJ pain-dysfunction syndrome.
Minn. Med. 61:645–652, 1978.
109
Wilkes, C. H. Internal derangements of the temporo-
mandibular joint. Arch. Otolaryngol. Head Neck Surg.
115:469–477, 1989.
110
Wolford, L. M. Temporomandibular joint devices: treat-
ment factors and outcomes. Oral Surg. Oral Med. Oral
Pathol. Oral Radiol. Endod. 83:143–149, 1997. doi:
10.1016/S1079-2104(97)90105-0.
111
Wolford, L. M., D. A. Cottrell, and S. C. Karras. Mitek
mini anchor in maxillofacial surgery. In: Proceedings of
SMST-94, The First International Conference on Shape
Memory and Superelastic Technologies, Monterey (CA).
MIAS: 477–482, 1995.
112
Wolford, L. M., D. J. Dingwerth, R. M. Talwar, and
M. C. Pitta. Comparision of two temporomandibular joint
total joint prosthesis systems. J. Oral Maxillofac. Surg.
61(6):685–690, 2003. doi:10.1053/joms.2003.50112.
113
Wolford, L. M., and P. Mehra. Custom-made total joint
prosthesis for temporomandibular joint reconstruction.
Proc. Baylor Univ. Med. Center 13:135–138, 2000.
114
Wolford, L. M., M. C. Pitta, and P. Mehra. Mitek anchors
for treatment of chronic mandibular dislocation. Oral
Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 92:495–
498, 2001. doi:10.1067/moe.2001.118283.
115
Wolford, L. M., M. C. Pitta, O. Reiche-Fischel, and P. F.
Franco. TMJ Concepts/Techmedica custom-made TMJ
total joint prosthesis: 5-year follow-up study. Int. J. Oral
Maxillofac. Surg. 32(3):268–274, 2003. doi:10.1054/ijom.
2002.0350.
View publication stats
AND T. GOSWAMI
116
Wolford, L. M., O. Riechel, and P. F. Franco. 5-year
follow-up study on the Techmedica custom-made total
joint prostheses. J. Oral Maxillofac. Surg. 55:110–111,
1997. doi:10.1016/S0278-2391(97)90535-8.
117
Yap, A. U. Effects of stabilization appliances on nocturnal
parafunctional activities in patients with and without signs
of temporomandibular disorders. J. Oral Rehabil. 25:64,
1998. doi:10.1046/j.1365-2842.1998.00194.x.
118
Yoon, H. J., E. Baltali, K. D. Zhao, J. Rebellato,
D. Kademani, K. N. An, and E. E. Keller. Kinematic
study of the temporomandibular joint in normal subjects
and patients following unilateral temporomandibular joint
arthrotomy with metal foss-eminence partial joint
replacement. J. Oral Maxillofac. Surg. 65(8):1569–1576,
2007. doi:10.1016/j.joms.2006.10.009.
119
Zarb, G. A., and G. E. Carlsson. Temporomandibular
disorders: osteoarthritis. J. Orofac. Pain 13:295–306, 1999.
120
Zardeneta, G., S. B. Milam, and J. P. Schmitz. Type I
collagen and fibronectin degeneration by the hydroxyl
radical. J. Oral Maxillofac. Surg. 54:83, 1996. doi:10.1016/
S0278-2391(96)90540-6.
121
Zardeneta, G., S. B. Milam, and J. P. Schmitz. Presence of
denatured hemoglobin deposits in diseased temporoman-
dibular joints. J. Oral Maxillfac. Surg. 55:1242, 1997.
doi:10.1016/S0278-2391(97)90176-2.
122
Zardeneta, G., S. B. Milam, and J. P. Schmitz. Iron-
dependent generation of free radicals: plausible mecha-
nisms in the progressive deterioration of the temporo-
mandibular joint. J. Oral Maxillofac. Surg. 58:302–308,
2000. doi:10.1016/S0278-2391(00)90060-0.
123
Zardeneta, G., H. Mukai, V. Maker, and S. B. Milam.
Protein interactions with particulate Teflon: implications
for the foreign body response. J. Oral Maxillofac. Surg.
54:873–878, 1996. doi:10.1016/S0278-2391(96)90540-6.