Neurosensory assessment in patients with total reconstruction of the temporomandibular joint

Somatosensory sensitivity and postoperative endogenous pain modulation have not been investigated in temporomandibular joint (TMJ) prosthesis patients. The objectives of this study were to assess somatosensory function at the TMJ and examine possible differences in conditioned pain modulation (CPM) between patients with total TMJ prostheses (n = 7) and a reference group of healthy controls (n = 20). Somatosensory abnormalities were assessed using quantitative sensory testing (QST), which encompasses thermal and mechanical testing procedures. CPM was tested by comparing pressure pain thresholds (PPT) before (baseline), during, and after the application of painful and non-painful cold stimuli. PPTs were measured at the TMJ and thenar eminence (control). The effect of CPM on PPT values was tested with analysis of variance. Three patients exhibited mixed somatosensory loss (i.e., decreased thermal and mechanical detection) with mixed hyperalgesia (i.e., increased sensitivity to thermal and mechanical pain) and two patients exhibited mixed loss with only mechanical hyperalgesia. There was a significant decrease in pressure pain sensitivity at both sites during painful cold application in healthy controls (P < 0.001) but not in patients (P = 0.476). In conclusion, QST measures demonstrated somatosensory abnormalities in patients with total TMJ prostheses. Noxious conditioning cold stimuli evoked CPM-like effects in healthy subjects but not in patients with TMJ reconstruction.     

Comparison of intraoperative outcomes with single and double puncture techniques of arthrocentesis of the temporomandibular joint

Evidence of differences in operator-related outcomes between single and double puncture arthrocentesis is limited. The purpose of this prospective study was to compare intraoperative outcomes with single puncture types 1 and 2, and double puncture, arthrocentesis. A total of 59 patients with 60 temporomandibular joints (TMJ) were treated sequentially by single puncture type 1 (n = 20), single puncture type 2 (n = 20), and double puncture arthrocentesis (n = 20). Total operating time, incidence of dislocation of the needle, preauricular swelling, and ease of operation were compared. Single puncture type 2 arthrocentesis took significantly less time than type 1 (p < 0.0001) or double puncture arthrocentesis (p < 0.0001), but there was no difference in operating time between single puncture type 1 and the double puncture technique (p = 0.25). There were significantly fewer dislocations of the needle with single puncture type 1 (p = 0.041) and single puncture type 2 (p = 0.033) than with double arthrocentesis. Single puncture type 2 arthrocentesis was easier than the single puncture type 1 (p = 0.001) or double puncture technique (p < 0.0001). Extravasation of fluid caused swelling in seven patients after double puncture, and in three patients each after single puncture types 1 and 2, arthrocentesis. Our results indicate that the single puncture type 2 technique is easiest and requires the least operating time. There was no difference between single puncture type 1 and double puncture arthrocentesis in terms of operating time or ease of the procedure. There were fewer operative dislocations of the needle with the single than with the double puncture technique.     

Surgical complications related to temporomandibular joint arthroscopy: a prospective analysis of 39 single-portal versus 43 double-portal procedures

Temporomandibular joint (TMJ) arthroscopy is a minimally invasive surgical procedure proposed for diverse TMJ intra-articular disorders. A prospective study was designed with the aim of investigating intraoperative and postoperative surgical complications for single and double-portal TMJ arthroscopy. All interventions were performed by one surgeon with the same surgical protocol. A total of 55 patients were enrolled, resulting in 82 TMJ arthroscopies (28 unilateral and 27 bilateral). A total of 39 single portal (47.57%) and 43 double-portal (52.43%) arthroscopies were performed. No severe and irreversible complications were observed. Most complications were resolved after 4 weeks. Double-portal was associated with more complications (n = 23) compared with single-portal TMJ arthroscopy (n = 14), with a statistically significant difference found between single and double-portal TMJ arthroscopy in two intraoperative complications: intra-articular bleeding (P = 0.044) and oedema of the preauricular area (P = 0.042). This study confirms the safety of TMJ arthroscopy for single and double-portal procedures, with the authors suggesting a multicentre study, in an effort to minimize any possible bias.     

Intraoperative comparison of single- and double-puncture techniques in temporomandibular joint arthrocentesis

The objective of this study was to compare techniques for temporomandibular joint (TMJ) arthrocentesis intraoperatively and to determine the ease of performance of these techniques for the physician. A total of 33 TMJ treatments were done using single-puncture arthrocentesis (SPA) type 1, SPA type 2, and double-puncture arthrocentesis (DPA) (n = 11 in each treatment group) between December 2013 and December 2017. A retrospective analysis of the duration of the procedure (minutes), occurrence of complications, number of cannula relocations, and ease of the procedure was performed. Ease of the procedure was measured using a Likert-type visual analogue scale (VAS; 0–10). All measurement variables were recorded intraoperatively, and related data were analyzed statistically. Significant differences were found between SPA type 2 and the other techniques in terms of procedure duration and ease of the procedure (P < 0.05). No significant differences were found in the occurrence of complications or number of cannula relocations between the techniques (P > 0.05). Compared to the other TMJ arthrocentesis techniques, SPA type 2 is easier, and physicians can perform it in a shorter time.     

Relationship between temporomandibular joint pain and magnetic resonance imaging findings in patients with temporomandibular joint disorders

The purpose of this study was to evaluate abnormal magnetic resonance imaging (MRI) findings related to temporomandibular joint (TMJ) pain. This study included 245 joints of 152 patients with temporomandibular disorders with anterior disc displacement; of these, 129 joints had joint pain whereas 116 joints had no joint pain. MRI was used to evaluate the reduction of anterior disc displacement, joint effusion, mandible condylar morphology, bone marrow oedema of the mandibular condyle, and signal intensity of the posterior disc attachment (PDA) on fat-suppressed T2-weighted images. The odds ratio (OR) for each MRI variable for the pain group versus the no pain group was computed using logistic regression analysis. Univariate logistic regression analysis showed significant correlations between TMJ pain and all MRI findings. Multivariate logistic regression analysis showed significant correlations with joint effusion (P = 0.03, OR 2.21), bone marrow oedema (P < 0.001, OR 11.75), and signal intensity of the PDA (P < 0.001, OR 6.21). These results suggest that bone marrow oedema, high signal intensity of the PDA on fat-suppressed T2-weighted images, and joint effusion, in descending order of influence, are factors related to TMJ pain.     

Effectiveness of treatment with viscosupplementation in temporomandibular joints with or without effusion

The objective of this study was to determine whether the effectiveness of viscosupplementation with hyaluronic acid (HA) in patients with temporomandibular joint (TMJ) degenerative disorders depends on the presence of intra-articular effusion. In this study of case–control design, two groups of 25 patients were recruited: patients with a clinical diagnosis of painful chronic TMJ osteoarthritis and magnetic resonance imaging (MRI) signs of TMJ degeneration, with (effusion group) or without (no effusion group) MRI evidence of TMJ effusion. All patients underwent five weekly single-needle arthrocenteses plus medium molecular weight HA and 6 months of follow-up. Several clinical outcome parameters were assessed. For all variables, analysis of variance (ANOVA) for repeated measures was performed to assess the existence of significant within-group and between-group treatment effects. Over time, both groups showed significant improvements in all outcome parameters, which were maintained at the 6-month follow-up (P < 0.05). Between-group comparisons showed that the treatment effects did not differ significantly for either the primary outcome variable (pain levels: F = 0.849, P = 0.548) or secondary outcome variables (chewing efficiency: F = 0.854, P = 0.544; functional limitation: F = 1.35, P = 0.226; mouth opening: F = 0.658, P = 0.707). The null hypothesis that there are no differences in treatment effectiveness between patients with and without effusion could not be rejected.     

Irrigation fluid volume requirement for conventional arthrocentesis of the temporomandibular joint: a cadaver study

Temporomandibular joint (TMJ) arthrocentesis is considered an effective and minimally invasive procedure for certain conditions related to temporomandibular disorders. The ideal irrigation volume for arthrocentesis lavage has not yet been defined. Therefore, the aim of this study was to evaluate the efficacy of different saline solution volumes in removing methylene blue from the TMJ space of fresh human cadavers. Nineteen cadavers were selected and 1 ml of 10 μM methylene blue solution was injected into the upper joint space unilaterally. Conventional arthrocentesis was then conducted by infusion of 300 ml of 0.9% saline solution, collecting a 1-ml sample from the drained quantity for every 25 ml injected. Finally, the samples were assayed by measuring photo absorbance of the methylene blue solution. There was a statistically significant difference between the irrigation volumes regarding the removal of methylene blue solution from the joint space (P < 0.001), specifically between the first 25 ml and 200 ml (P = 0.014), 225 ml (P = 0.001), 250 ml (P < 0.001), and 275 ml (P = 0.001). Based on this ex vivo study, a 25-ml perfusion volume appears to be sufficient for joint lavage in conventional arthrocentesis of the TMJ.     

Efficiency of arthrocentesis treatment for different temporomandibular joint disorders

This study was performed to determine whether arthrocentesis therapy has different outcomes in three groups of patients with different temporomandibular disorders (TMDs). A clinical trial was conducted including 45 patients with 45 unilaterally affected joints divided into three groups (n = 15): osteoarthritis (OA), disc displacement with reduction (DDWR), and disc displacement without reduction (DDWoR). All patients underwent the same arthrocentesis treatment protocol. The outcome variables, including visual analogue scale evaluations and measurements of mandibular motion (in millimetres), were recorded at baseline and at 1 and 6 months postoperative. Inter-group assessments showed significant short-term differences in joint sounds (P = 0.016) and significant long-term differences in masticatory efficiency (P = 0.046) and protrusive movement (P = 0.048). The estimation of mean changes between baseline and long-term follow-up revealed significant differences in joint sounds (P < 0.001), disruption in daily activities (P = 0.002), maximum mouth opening (P = 0.008), and protrusive movement (P = 0.002) between the groups. Arthrocentesis therapy may be useful to improve clinical symptoms and range of mandibular movement in patients with all three types of TMD. However, the benefit of arthrocentesis may be greater for patients with DDWoR than for those in the other groups.     

Comparison of the outcomes of three surgical treatments for end-stage temporomandibular joint disease

The aim of this study was to determine whether there are any differences between condylectomy, rib grafts, and prosthetic joints (Biomet TMJ stock prosthesis) with regard to outcomes for patients with end-stage temporomandibular joint (TMJ) disease. Fifty-six of a total 127 patients who presented with category 5 end-stage TMJ disease over 3 years (2010–2013) agreed to participate in this retrospective, comparative, cohort study. Patients were divided into four groups: preoperative (n = 16), condylectomy (n = 8), rib graft (n = 16), and prosthetic joint (n = 16). They were assessed for major postoperative complications (i.e., return to theatre) and maximum range of mandibular motion, and all completed a specific quality of life (QOL) questionnaire. Whilst the condylectomy group demonstrated the best mandibular range of motion (P < 0.01), rib graft patients were more likely to experience complications (43.8%) necessitating a return to theatre. The prosthesis group recorded the best mean aggregate QOL score, but the difference compared to the rib graft and condylectomy groups was not statistically significant. The results of this study suggest that for dentate patients, prosthetic joints are highly dependable with no returns to theatre and favourable QOL outcomes. For edentulous patients, condylectomies alone also appear to work well. Future TMJ prosthetic designs should focus on improving mandibular range of motion, as the current stock prosthesis allows only a restricted range, no better than that achieved with rib graft (P > 0.05) and far less than that achieved with condylectomy (P < 0.01).     

The use of pseudo-dynamic magnetic resonance imaging for evaluating the relationship between temporomandibular joint anterior disc displacement and joint pain

The relationship between temporomandibular joint (TMJ) pain and the magnetic resonance imaging (MRI) finding of articular disc displacement is debated. The purpose of this study is to investigate the correlation between TMJ pain and anterior disc displacement (ADD) using pseudo-dynamic MRI. A retrospective review of MRI studies was carried out on 130 TMJs in 65 patients presenting unilateral TMJ pain. The contralateral asymptomatic joints served as the control group. Bilateral oblique sagittal and coronal MRIs as well as pseudo-dynamic studies in the oblique sagittal plane were obtained. The disc–condyle relationship was divided into three subtypes (normal disc position, ADD with reduction, and ADD without reduction), based on the pseudo-dynamic MRI findings. Fisher's exact test was used to determine whether the TMJ pain was linked to ADD. The results showed that TMJ pain was significantly related to ADD (with and without reduction) compared to the group with a normal disc position (P = .0001). A significant correlation was found between TMJ pain and the ADD subtype without reduction, as compared to the ADD subtype with reduction (P = .0156). These data suggest that a displaced disc, particularly in the subtype without reduction, is an important source of pain.     

Effects of four treatment strategies for temporomandibular joint closed lock

A previous randomized controlled trial (RCT) by Schiffman et al. (2007)¹⁵ compared four treatments strategies for temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock). In this parallel group RCT, 106 patients with magnetic resonance imaging (MRI)-confirmed TMJ closed lock were randomized between medical management, non-surgical rehabilitation, arthroscopic surgery, and arthroplasty. Surgical groups also received rehabilitation post-surgically. The current paper reassesses the effectiveness of these four treatment strategies using outcome measures recommended by the International Association of Oral and Maxillofacial Surgeons (IAOMS). Clinical assessments at baseline and at follow-up (3, 6, 12, 18, 24, and 60 months) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing. TMJ MRIs were performed at baseline and 24 months, and TMJ tomograms at baseline, 24 and 60 months. Most IAOMS recommended outcome measures improved significantly over time (P ≤ 0.0003). There was no difference between treatment strategies relative to any treatment outcome at any follow-up (P ≥ 0.16). Patient self-assessment of treatment success correlated with their ability to eat, with pain-free opening ≥35 mm, and with reduced pain intensity. Given no difference between treatment strategies, non-surgical treatment should be employed for TMJ closed lock before considering surgery.     

Effects of arthrocentesis and low-level laser therapy on patients with osteoarthritis of the temporomandibular joint

This retrospective study examined whether arthrocentesis combined with 10 sessions of low-level laser therapy (LLLT) improved the clinical outcomes of patients with temporomandibular joint osteoarthritis (TMJ-OA) compared with arthrocentesis alone. Data from two groups of patients (total: n = 36) with unilateral TMJ-OA were evaluated. The groups were established according to their treatment regimens: Group 1 (arthrocentesis alone; n = 19) and Group 2 (arthrocentesis plus LLLT; n = 17). All patients had been diagnosed in accordance with the Research Diagnostic Criteria for Temporomandibular Joint Disorders (RDC/TMD) (Axis I Group IIIb) protocol. They all underwent the same arthrocentesis protocol, but those in Group 2 also received 10 sessions of LLLT immediately afterwards. The outcome variables were the visual analogue scale scores (VAS 1, VAS 2) for various treatment outcomes and millimetric measurements of mandibular movements over both the short and long term. Intra-group comparisons showed significant short and long-term improvements for both groups, but outcomes were better over the long term than the short term in both. In addition, greater improvements in muscle palpation scores and mandibular movements were achieved in Group 2 than in Group 1. In conclusion, although both techniques improved joint pain and function, a combination with LLLT seemed to have an additional benefit for myofascial components.     

Axis II psychosocial findings predict effectiveness of TMJ hyaluronic acid injections

The objective was to investigate the correlation between levels of depression, somatization, and pain-related impairment, as assessed by the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMDs) axis II, and the treatment outcome of a cycle of five weekly injections of hyaluronic acid immediately following arthrocentesis. 57 consecutive patients with a diagnosis of temporomandibular joint (TMJ) osteoarthritis according to the RDC/TMD underwent the treatment protocol and a follow-up assessment at 6 months. Axis II findings were assessed as potential predictors of improvement in visual analogue scale (VAS) values at the end of the observation period with respect to baseline. The percentage of VAS improvement at the end of treatment was inversely related to all the psychosocial variables. The best fitting model identified pain-related impairment (p < 0.001) and disability points (p < 0.001) as the most significant predictors of VAS changes. The percentage of variance in the outcome variable explained by the significant predictors was high (R² 70.5%). All the RDC/TMD axis II psychosocial scores (depression, somatization, and pain-related impairment levels) were inversely correlated with therapeutic outcome. The clinical relevance of these findings is important, since psychosocial diagnosis may be even more important than physical evaluation in terms of prognostic impact.     

Effect of intra-articular corticosteroid injections on pain and mouth opening in juvenile idiopathic arthritis with temporomandibular involvement: A systematic review and meta-analysis

PurposeThe objective of this study was to investigate the effect of temporomandibular intra-articular corticosteroid injections (IACS) on pain and mouth opening in children with juvenile idiopathic arthritis (JIA) with temporomandibular joint (TMJ) involvement.MethodsSystematic review and meta-analysis methodology was used, beginning with a comprehensive literature search using MEDLINE, PubMed, EMBASE, Web of Science, and the Cochrane library. The population in question was pediatric patients with a JIA diagnosis and TMJ involvement; the intervention was IACS injections to treat TMJ arthritis; a strict control group was not considered necessary; the outcome was clinical signs of improvement of the TMJ arthritis based on pain and mouth opening capacity (MIO). Data on pain and MIO were extracted from the selected studies, and the methodological quality of studies was assessed according to the ROBINS-I tool. Results from the different studies were combined to calculate the pooled proportion with 95% confidence intervals (CIs) for pain resolution, and pooled mean differences with 95% CIs for improvement in MIO. Heterogeneity of the results among studies was tested using I² statistics.ResultsThe initial search yielded a total of 330 articles; 11 of these were selected for inclusion in the review. 325 participants were included from the combined studies, with the mean age of participants ranging from 5.3 to 13.6 years. Between 24 and 137 TMJs were selected for each of the studies. The pooled proportion of patients with pain resolution following IACS injection was 78% (95% CI: 59–90%), with large heterogeneity (I² = 62%). The pooled gain in MIO following IACS injection was 4.38 mm (95% CI: 2.76–6.00), also with high heterogeneity (I² = 67%).ConclusionsThe results suggest that in children diagnosed with JIA with TMJ involvement, IACS injections can help in reducing reported pain and improving mouth opening capacity, albeit with an important variation between studies.     

Changes in condylar and joint disc positions after bilateral sagittal split ramus osteotomy for correction of mandibular prognathism

The effect of combined orthodontic and orthognathic treatment was studied retrospectively in 24 patients with skeletal class III malocclusions with mandibular hyperplasia, particularly the effect on temporomandibular joint (TMJ) disc position. The patients underwent preoperative orthodontic treatment, orthognathic surgery, and postoperative orthodontic treatment. The patients were studied clinically, radiographically with lateral cephalometric radiograph and MRI to locate the position of the TMJ disc in relation to the glenoid fossa. One patient had less pain after treatment, one lost abnormal joint clicking sounds after treatment. There were no TMJ symptoms in 20 of the 24 preoperatively and postoperatively. 48 sagittal MRI images showed that the disc length before treatment was 3.040–12.928 (mean 8.289 ± 2.028) and after treatment was 3.699–11.589 (mean 8.097 ± 1.966); results were not significant (p > 0.05). Maximum disc displacement before treatment was 6.090 (mean 1.383), after treatment it was 11.931 (mean 2.193); results were not significant (p > 0.05). The results suggest that combined orthodontic and orthognathic treatment (including bilateral SSRO and rigid internal fixation) can be used safely to correct skeletal class III malocclusion with mandibular hyperplasia without causing additional TMJ symptoms.     

Comparison of clinical outcomes of treatment of dysfunction of the temporomandibular joint between conventional and ultrasound-guided arthrocentesis

Patients with disorders of the temporomandibular joint (TMJ) who do not respond to non-operative treatment may require invasive procedures such as arthrocentesis and arthroscopy. We divided 80 patients with dysfunction of the TMJ into two groups: a control group who were treated by conventional arthrocentesis, and an experimental group who were treated by ultrasound-guided arthrocentesis. Both groups were monitored three days, one week, and one month postoperatively and the clinical outcomes compared. The experimental group had a significant reduction in the degree of pain in the immediate postoperative period (p = 0.015). However, ultrasound-guided arthrocentesis showed no significant improvement in symptoms overall compared with conventional arthrocentesis. Both techniques seem to be effective in the management of dysfunction of the TMJ.     

Groningen temporomandibular total joint prosthesis: An 8-year longitudinal follow-up on function and pain

Total temporomandibular joint replacement is a surgical procedure for patients with severe temporomandibular joint afflictions affecting quality of life, which have not responded beneficially to previous conventional surgery. The aim of this study was to assess the long-term outcome of the Groningen temporomandibular joint (TMJ) prosthesis in patients with chronic pain and mutilated temporomandibular joints following multiple surgical procedures, with respect to prosthesis failure, the patient's postoperative level of satisfaction and longitudinal changes in maximum mouth opening, functional mandibular impairment and pain. Eight female patients were studied in whom Groningen TMJ prostheses were inserted, two unilaterally and six bilaterally.The Groningen TMJ prosthesis was mechanically successful during 8 years of follow-up in seven out of eight patients with a disc dislocation being seen in one patient (7%). Patients were satisfied, despite the limited improvement of the maximum mouth opening, and pain scores.Although the decline of MFIQ scores during 8 years of follow-up was significant compared to baseline (p = 0.027), the effects of the prosthesis on maximum mouth opening, function and pain were limited. This may be due to persistent chronic pain and the adverse effects of multiple previous surgical procedures.     

Arthrocentesis versus non-surgical intervention as initial treatment for temporomandibular joint arthralgia: a randomized controlled trial with long-term follow-up

Arthrocentesis for arthralgia of the temporomandibular joint (TMJ) is often only indicated when conservative, non-surgical interventions have failed. However, performing arthrocentesis as initial therapy may facilitate earlier and better recuperation of the joint. The aim of this study was to assess the efficacy of this therapy with a long-term follow-up. Eighty-four patients were randomly allocated to receive either arthrocentesis as initial treatment (n = 41) or non-surgical intervention (n = 43). Pain (100-mm visual analogue scale, VAS) and mandibular function impairment questionnaire scores (MFIQ, 0–100) were recorded at 3, 12, and 26 weeks, and ≥ 5 years (median 6.2, interquartile range 5.6–7.4 years). Univariable analyses were performed and linear mixed-effect models were constructed. Patients in the arthrocentesis group experienced significantly lower TMJ arthralgia compared to those treated non-surgically (pain during movement: −10.23 mm (95% confidence interval −17.86; −2.60); pain at rest: − 8.39 mm (95% confidence interval −13.70; −3.08)), while mandibular function remained similar in the two groups (MFIQ −2.41 (95% confidence interval −8.61; 3.78)). Of the final sample, 10 patients (10/39, 26%) in the non-surgical intervention group and two patients (2/34, 6%) in the arthrocentesis group received additional treatment during follow-up. Thus, initial treatment with arthrocentesis reduced TMJ arthralgia more efficaciously than non-surgical intervention in the long term, while maintaining similar mandibular function.     

Outcome of eminectomy combined with discectomy and silastic interpositional graft for temporomandibular joint dysfunction: a retrospective study of 20 years

Internal derangement of the temporomandibular joint (TMJ) is usually treated conservatively, but about 5% require surgical treatment. We designed a retrospective study to assess the long-term outcomes of eminectomy combined with discectomy and silastic interpositional graft in 44 patients who had chronic TMJ dysfunction that had not responded to traditional conservative treatment and arthrocentesis. The maximum mouth opening, pain score, Wilkes stage, and clinical dysfunction index were measured before, and two years after, operation. All the patients showed significant improvement in mouth opening and reduced pain scores (p < 0.0001 in each case). There were no long-term operative complications, and postoperative magnetic resonance scans showed that the silastic interpositional graft was in a stable position with no evidence of degenerative changes on the surfaces of the joint and no lymphadenopathy.     

Clinical protocol for managing acute disc displacement without reduction: a magnetic resonance imaging evaluation

This study investigated the efficacy of a sequential combination of arthrocentesis, mandibular manipulation, and anterior repositioning splint (ARS) in the management of acute temporomandibular joint (TMJ) disc displacement without reduction (DDwoR). Twenty-one consecutive patients diagnosed with acute DDwoR by Diagnostic Criteria for Temporomandibular Disorders and magnetic resonance imaging (MRI) were recruited and managed with this method. Clinical and MRI data were obtained before and at 1 week after treatment. The disc–condyle relationship was determined by disc–condyle angle measurement. Condyle/disc positions were described as x–y coordinates with the summit of the articular fossa as the coordinate origin. Statistical analyses including independent/paired samples t-tests were conducted; significance was set at P < 0.05. Clinical success was observed in 95.2% of patients (20/21) with 22 joints affected by acute DDwoR. After combined treatment and ARS insertion, TMJs with DDwoR showed (a) normal disc–condyle relationships with substantial forward and downward condyle movement and significant disc reduction in closed position, and (b) discs with an intermediate zone located between the condylar head and articular eminence in open position. The combined approach was highly effective in ‘unlocking’ acute TMJ DDwoR and achieving spatial full disc reduction and a normal disc–condyle relationship. The duration of acute DDwoR appears to be critical for success.