Disc Repositioning

Does it Really Work?

João Roberto Gonçalves, DDS, PhDa,*, Daniel Serra Cassano, DDSa,
Luciano Rezende, DDS, MSca, Larry M. Wolford, DMDb

KEYWORDS
 Disc repositioning  3D quantitative findings  Surgical technique and possible pitfalls
 Mitek mini anchor  Treatment alternatives  Lateral cephalometry  Clinical outcomes

KEY POINTS
 The effectiveness of temporomandibular joint (TMJ) disc repositioning is scarce.
 Further guidance for clinicians and patients regarding clinical and surgical options to better treat
TMJ internal derangement are needed, especially regarding skeletal malocclusion that requires
operative interventions.
 The lack of evidence that TMJ articular disc repositioning is an ineffective procedure points to a
future when new TMJ biomarkers will support the technique effectiveness in better studies.
 As a sensitive technique with a wide learning curve, many surgeons have practiced TMJ articular
disc repositioning with a large range of outcomes.

INTRODUCTION randomization, (2b) at least 1 other type of well-

designed quasi-experimental study, (3) well-
Although limited, there is evidence to support the designed, nonexperimental descriptive studies
assumption that temporomandibular joint (TMJ) such as comparative, correlation, and case-
articular disc repositioning indeed works1–5 and controlled studies; and (4) expert committee reports
so far there is no evidence that TMJ articular or opinions, or clinical experience of respected au-
disc repositioning does not work. Despite the con- thorities, or both.
troversy among professionals in private practice Specialized peered-reviewed journals are also a
and academia, TMJ articular disc repositioning is reasonable source of good scientific evidence.
a procedure based on (still limited) evidence; the Although they have known limitations, a worldwide
opposition is based solely on clinical preference accepted metric to evaluate journals’ strength is
and influenced by the ability to perform it or not. the impact factor, which is calculated by the Insti-
tute for Scientific Information7 as the average
DISC REPOSITIONING AND LEVELS OF number of times published papers are cited up
EVIDENCE to 2 years after publication. Dental literature has
very distinct impact factor compared with the
Evidence in health science can be classified in 6 medical literature in most of the specialties. The
distinct hierarchical levels according to the US impact factor of the Journal of Oral and Maxillofa-
Agency for Healthcare Research and Quality6: (1a) cial Surgery, International Journal of Oral and
Meta-analysis of randomized, controlled trials, Maxillofacial Surgery, and British Journal of Oral
oralmaxsurgery.theclinics.com

(1b) at least 1 randomized controlled trial, (2a) at and Maxillofacial Surgery in 2009 were 1.580,
least 1 well-designed controlled study without 1.444, and 1.327, respectively; the New England

a
Department of Pediatric Dentistry, Faculdade de Odontologia de Araraquara, Universidade Estadual
Paulista - UNESP Araraquara School of Dentistry, Araraquara, Brazil; b Departments of Oral and Maxillofacial
Surgery and Orthodontics Texas, A&M University Health Science Center Baylor College of Dentistry, Baylor Uni-
versity Medical Center, 3409 Worth St. Suite 400, Dallas, Texas
* Corresponding author. Av Dr Gastão Vidigal 295, Araraquara, São Paulo, Brazil.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 27 (2015) 85–107

http://dx.doi.org/10.1016/j.coms.2014.09.007
1042-3699/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
86 Gonçalves et al

Journal of Medicine, the Journal of the American Wolford and Cardenas in 19933 detailed
Medical Association, and The Lancet were described idiopathic condylar resorption, its
50.017, 31.171, and 17.457, respectively for the possible etiologies and specific treatment options,
same period. and showed 12 successfully treated clinical cases
A recent study that listed the 100 most cited of open joint TMJ articular disc repositioning with
articles in dentistry8 showed that, among them, the aid of a titanium mini anchor used to hold the
only 6 papers that were published in the 2 jour- disc in place with artificial ligaments. All patients
nals of oral and maxillofacial surgery were showed progressive condylar resorption before
included in the list (Journal of Oral and Maxillofa- the procedure (average of 1.5 mm/y) with progres-
cial Surgery and International Journal of Oral and sive steepening of the occlusal plane angle.
Maxillofacial Surgery), whereas 41 papers that Operative techniques included removal of the hy-
were published on the 3 journals of periodontol- perplastic synovial tissue, repositioning of the
ogy (Journal of Clinical Periodontology, Journal articular discs, and double jaw surgery for mandib-
of Periodontology, and Journal of Periodontal ular advancement of 11 mm (range, 2–18 mm) and
Research) were included in the top 100 papers. decrease of the occlusal plane angle an average of
It was concluded that, in dentistry, there is a 8 (range, 5 –12 ). At a postoperative follow-up
predominance of clinical studies, particularly average of 33 months (range, 18–68) no significant
case series and narrative reviews/expert opin- relapses were observed. In fact, 5 young patients
ions, despite their low evidence level. It is also (<16 years old) at the time of surgery showed a
understandable that randomized, placebo- slight increase in condylar height (average,
controlled, prospective clinical trials are not 0.4 mm; range 0.1 to 1.5).
easily executed, mainly in oral surgery, either Two years later, a retrospective clinical study
for ethical reasons or funding issues.9 In this assessed the outcomes of 105 patients who un-
scenario, scientific evidence levels 2b and 3 derwent TMJ disc repositioning.2 At the longest
should be considered as evidence enough to follow-up (minimum of 1 year after surgery), there
guide clinical protocols in oral and maxillofacial were no detectable condylar changes or mandib-
surgery. A quasi-experimental study is defined ular positional changes. Visual analog scale
as a broad range of nonrandomized intervention assessment showed marked reduction of TMJ
studies, usually made when it is not logistically pain, facial pain, and headaches. TMJ noises,
feasible or ethical to conduct a randomized, disability, and jaw function; in addition, diet also
controlled trial.10 improved significantly. Interincisal opening
The current literature available on the effective- improved slightly, whereas lateral excursive move-
ness of open joint TMJ disc repositioning meets ments decreased.
the “patient-oriented evidence that matters” Another retrospective clinical study design was
(POEM) criterion. To meet POEM, readers should used by Wolford and colleagues1 in 2002 to eval-
take advantage “from original research to clinical uate all patients who had undergone concomitant
experience, remembering that each source of orthognathic and TMJ surgery from 1991 through
medical information is valuable since one learns 1993. All patients who underwent unilateral or
which source is best for the specific information bilateral articular disc repositioning with concom-
being sought.”11 itant mandibular ramus osteotomies or double jaw
Two meta-analyses about the effectiveness of surgery and met the inclusion criteria were
TMJ management concluded that operative inter- included in this study. They compared 70 patients
ventions need further evidence for precise conclu- in 3 groups according to mandibular movement:
sions but pointed out some good results for open Group 1 had mandibular advancement, group 2
joint surgery.3,12 had mandibular setback, and group 3 had the
Mostly, Wolford and coworkers have addressed mandibles remain at the original positions. One
the outcomes of TMJ articular disc repositioning in year after surgery, 20% of patients had pain and
several papers that could be classified according 60% reported complete relief of TMJ pain (before
to the level of evidence 2b or 3, beside abstracts surgery, 80% had pain). Pain was assessed on a
and expert opinions published by their group in visual analog scale from 0 (no pain) to 10 (the
many international scientific meetings held on all worst pain imaginable). Severe pain was still pre-
continents. The main focus of these studies were sent in 7% of the patients 1 year after surgery
orthognathic surgery outcomes in patients with (before surgery, it was 53%). Concomitant TMJ
prior TMJ derangements and because of this, and orthognathic surgery success based on a
most of these studies evaluated patients who un- greater than 35 mm of maximal interincisal open-
derwent TMJ disc repositioning and orthognathic ing and a decrease in pain had an overall success
surgery concomitantly. rate of 91.4%.1
 Does Disc Repositioning Work? 87

To our knowledge, there is no single experi- which can initiate a cascade of events leading to
mental study that showed that articular disc repo- arthritis and other TMJ-related symptoms.23,43
sitioning does not work. No cohort, case-control, Advancement of the mandible especially, in a
retrospective patient data review, single case counterclockwise direction, in a patient with dis-
report, or expert committee report or opinion has placed discs causes the discs to remain displaced
described unsuccessful outcomes after TMJ disc as the condyles seek a superoposterior position in
repositioning. A few expert opinions (the lowest the fossa, potentially overloading the joints and
level of evidence) has expressed against TMJ causing instability in the long term.23 Other authors
disc repositioning.13–15 have reported that patients with preoperative TMJ
symptoms requiring large mandibular advance-
ORTHOGNATHIC SURGERY IN THE PRESENCE ment seem to be at increased risk for condylar
OF DISC DISPLACEMENT AND CLINICAL resorption44,45; thus, in these patients, a logical
OUTCOMES approach would be to return the disc to a normal
anatomic and functional position. Concomitant
Controversy surrounds the appropriate manage- treatment (when the discs are salvageable) may
ment of patients with preexisting internal derange- include articular disc repositioning and stabiliza-
ment of the TMJ who need orthognathic surgery tion using the Mitek anchor (Mitek Surgical Prod-
for correction of malocclusion and jaw defor- ucts, Westwood, MA, USA) technique1,2,23–29 and
mities.16 There are 2 significantly different philoso- orthognathic surgery as indicated.23
phies; the first posits that orthognathic surgical Other factors that may contribute to skeletal
procedures reduce or eliminate TMJ dysfunction relapse and condylar resorption include patient
and symptoms,13,17–20 whereas the second posits age and gender, a high mandibular plane angle,
that orthognathic surgery causes further harmful preoperative orthodontic treatment, bone healing,
effects on the TMJ and thus worsens the symp- condylar positioning, neuromuscular adaptation,
toms and dysfunction postoperatively.14,21,22 The instability of segments, the degree of mandibular
second philosophy proposes appropriate opera- advancement performed, influence of operative
tive management of the TMJ pathology in an initial technique, and time since onset.5,16,46
separate operative procedure or concomitantly Several authors have described of TMJ condi-
with the orthognathic surgery.23 tion that could be possible risk factors for skeletal
Some authors13,17–20 recommend that patients relapse and condylar resorption after orthognathic
with coexisting TMJ dysfunction and skeletal facial surgery, including high mandibular plane angle,
deformities undergo orthodontic preparation fol- shortened posterior facial height, and small poste-
lowed by orthognathic surgery. For the small num- rior/anterior facial height ratio.16,46,47 However,
ber of patients whose TMJ symptoms do not these same characteristics are commonly seen in
resolve and are too severe to permit orthodontic patients with TMJ pathology, and those authors
preparation for orthognathic surgery, TMJ surgery apparently did not recognize that the patients
may be performed before orthognathic treatment. who experienced postoperative relapse and
However, other studies1–3,5,23–42 have shown that condylar resorption likely had preoperative TMJ
concomitant surgical correction of TMJ pathology pathology. Schellhas and colleagues48 investi-
and coexisting dentofacial deformities in a single gated 100 patients clinically and radiographically
operation provides high-quality treatment out- by computed tomography, and high-field sur-
comes for most patients relative to function, es- face-coil MRI to identify risk factors for TMJ
thetics, elimination, or significant reduction in degeneration. In their study, 40 patients (52 joints)
pain, and improved patient satisfaction. underwent an open arthroplasty procedure, in
Preexisting TMJ pathology (symptomatic or not) which the main surgical and pathologic findings
that can cause unfavorable outcomes when only included disc displacement, disc degeneration,
orthognathic surgery is performed include: artic- and cartilage hypertrophy. TMJ internal derange-
ular disc dislocation, adolescent internal condylar ment was posited to be the main cause of both ac-
resorption, condylar hyperplasia, osteochon- quired facial skeleton remodeling and unstable
droma, congenital deformities, reactive arthritis, occlusion in patients with intact dentition and
connective tissue/autoimmune diseases, nonsalv- without previous mandibular fracture. Similar find-
ageable joints, and others. All of these conditions ings were described previously by Schellhas,49
can be associated with dentofacial deformities, who concluded that internal derangement of the
TMJ pain, headaches, myofascial pain, TMJ TMJ is an irreversible and generally progressive
dysfunction, and other problems.23 disorder.
The most common TMJ pathology is anterior The TMJs are the foundation for stable results
and/or medial displacement of the articular disc, in orthognathic surgical procedures; if the TMJs
88 Gonçalves et al

are not stable and healthy (pathologic), then or-

thognathic surgery outcomes may be unsatis-
factory relative to function, esthetics, stability,
and pain. Orthognathic surgery to correct
dentofacial deformities requiring mandibular
advancement cannot eliminate coexisting TMJ
pathology, and those patients may have unsatis-
factory outcomes.16,21–23,50–54
Clinical outcomes of TMJ surgery using Mitek
mini anchor, including mandibular range of motion,
chewing efficiency, pain levels, and disability has
been assessed in several papers.1,2,26,27 Mehra
and Wolford2 evaluated 88 patients with simulta-
neous TMJ disc repositioning using the Mitek
mini anchor and orthognathic surgery and found
that this technique provided significant decreases
in TMJ pain, facial pain, headaches, TMJ noises,
and disability, and significant improvements in
jaw function and diet, along with stable occlusal
and skeletal results.
Many studies used lateral cephalometry to
monitor condylar changes after maxillomandibular
advancement and the influence of articular disc Fig. 1. Landmarks used for cephalometric assessment.
repositioning (Figs. 1 and 2).5 Condylar arthritic The horizontal reference plane (HRP) is constructed at
changes provide mandibular instability and can 7 to the SN plane. The vertical reference plane (VRP)
be detected through lateral cephalometric is constructed perpendicular to the HRP, through the
radiographs.55 Cranial base superimposition in sella (S). The dotted lines indicate the method of
nongrowing patients can accurately detect measuring the menton (Me) relative to reference
condyle remodeling by monitoring mandibular po- planes HRP and VRP. ANS, anterior nasal spine (a point
sition in a longitudinal basis. posterior to the tip of the median, sharp bony process
Various methods and devices are currently used of the maxilla, on its superior surface, where the maxilla
process first enlarges to a width of 5 mm). Ar, articulare;
to diagnose internal derangement of the TMJ,
B, B point; Ba, basion; Go, gonion; Hy, hyoid; LIA, lower
including radiographic measures, such as arthrog- incisor apex; LIE, lower incisor edge; LMT, lower molar
raphy and tomography, and methods that rely on distal cusp tip; LPT2, lower premolar cusp tip; N, nasion;
the assessment of jaw movements. More recently, PNS, posterior nasal spine; S, sella turcica; UIA,
MRI has been used to evaluate the disk position. upper incisor apex; UIE, upper incisor edge; UMT, upper
MRI has gained wide acceptance in evaluating molar mesial cusp tip; US, upper. (From Goncalves JR,
the TMJ and shows a high diagnostic accuracy Cassano DS, Wolford LM, et al. Postsurgical stability of
in determining the articular disk position related counterclockwise maxillomandibula advancement sur-
to the condyle and the articular eminence. gery: affect of articular disc repositioning. J Oral Maxil-
Although arthrography and MRI of the TMJ have lofac Surg 2008;66(4):724–38; with permission.)
become standard in clinical practice and studies
involving internal derangement, cephalometric before treatment. In addition, this might further in-
radiography might also be available. Disk crease the diagnostic value of cephalometric
displacement has been reported to be associated radiographs.
with reduced posterior facial height, reduced Goncalves and colleagues5 reported a retro-
mandibular length, and increased inclination of spective study evaluated the records of 72 pa-
the mandible relative to the cranial reference tients who underwent maxillomandibular surgical
planes in adolescents. However, some authors advancement with counterclockwise rotation of
have reported that no cephalometric measure- the occlusal plane. The sample was divided into
ments can clearly distinguish persons with disk 3 groups to address the influence of TMJ health
displacement of the TMJ from those with normal and articular disc surgical repositioning relative
disk positions. If some characteristic findings to postoperative stability. Group 1, with healthy
from the cephalometric analyses suggest an asso- TMJs, underwent double jaw surgery only. Group
ciation with the progression of internal derange- 2, with articular disc dislocation, underwent artic-
ment, this is an important implication for ular disc repositioning using the Mitek anchor
orthodontic treatment and patient education technique concomitantly with orthognathic
 Does Disc Repositioning Work? 89

with counterclockwise rotation of the occlusal

plane is a stable procedure for patients with
healthy TMJs and for patients undergoing simulta-
neous TMJ disc repositioning using the Mitek an-
chor technique. Those patients with preoperative
TMJ articular disc displacement who underwent
double jaw surgery and no TMJ intervention expe-
rienced significant relapse.
Surgical counterclockwise rotation of the maxil-
lomandibular complex lengthens the functional
moment arm (mandible), thereby increasing
loading to the TMJs owing to stretch and tension
of the suprahyoid muscles, periostium, skin, and
other soft tissue elements. It may take several
months for the soft tissues to adapt and reestab-
lish a state of equilibrium.56 Our previous
studies56–58 have shown that maxillomandibular
advancement with counterclockwise rotation of
the occlusal plane is a stable procedure in patients
with healthy TMJs. Goncalves and colleagues5
showed that the occlusal plane angle was stable
postoperatively in patients with healthy TMJs and
Fig. 2. Distances and planes used to define linear and in articular discs repositioning concomitantly with
angular measurements. Linear measurements include orthognathic surgery patients, but the patients
the distance from the hyoid to the mandibular plane with articular disc dislocation who underwent
(MP-Hy) measured on a perpendicular line from the only orthognathic surgery relapsed significantly
MP; and the distance from the menton to the lower (mean, 2.6 ; range, 2.5 to 13.3 ). The magnitude
incisor edge (Me-LI). Angular measurements include of clockwise rotation strongly indicates condylar
the angle of the occlusion plane (OPA) to the nasium- resorption as the etiologic factor.
sela (N-S line); the angle of the upper incisor to the N-S
Chemello and colleagues56 and Satrom and col-
(UI/NS) line; the angle of the lower incisor to the mandib-
leagues57 reported that mandibular advancement
ular plane (LI/MP); and the incisor angle (LI/UI). (From
Goncalves JR, Cassano DS, Wolford LM, et al. Postsurgical in double jaw surgery (with or without counterclock-
stability of counterclockwise maxillomandibula advance- wise rotation) using rigid internal fixation with healthy
ment surgery: affect of articular disc repositioning. J Oral TMJs is a stable procedure over the long term, with a
Maxillofac Surg 2008;66(4):724–38; with permission.) mean anteroposterior relapse at point B of 6%
regardless of the amount of surgical advancement
surgery. Group 3, with articular disc dislocation, performed. On the other hand, Wolford and col-
underwent orthognathic surgery only. Preopera- leagues16 evaluated 25 consecutive patients (23 fe-
tive characteristics included high occlusal plane males and 2 males) with jaw deformities and
angle, maxillary and mandibular retrusion, and displaced articular discs (confirmed by MRI) who
increased anterior facial height. All 3 patient were treated with orthognathic surgery only,
groups had similar dentofacial deformities and un- including mandibular advancement, and stabilized
derwent orthognathic operative procedures per- with rigid fixation. The average postoperative
formed by the same surgeon in the same manner relapse at point B was 36% of the mandibular
with rigid fixation. Each patient’s lateral cephalo- advancement, and the average distance from the
grams were traced, digitized twice, and averaged condyle to point B decreased by 34%, indicating
to estimate surgical changes and postoperative condylar resorption. Six patients (24%) demon-
stability. The maxillomandibular complex was strated significant postoperative condylar resorp-
advanced and rotated counterclockwise similarly tion (3–8 mm), resulting in class II anterior open
in all 3 groups (Fig. 3). Postoperatively, the bite malocclusion. The increased loading of the
occlusal plane angle increased in G3 (37% relapse TMJs as a result of the mandibular advancement
rate), but remained stable in G1 and G2. Postoper- most likely stimulated the resorption process. New
ative mandibular changes in the horizontal direc- onset or aggravation of TMJ symptoms (eg, pain,
tion demonstrated a significant relapse in G3 at TMJ dysfunction) occurred at an average of
the menton (28%), the B point (28%), and the 14 months after surgery. At the completion of the
lower incisor edge (34%; Fig. 4), but remained sta- study, 48% of patients required TMJ and repeat or-
ble in G1 and G2. Maxillomandibular advancement thognathic surgery. Before surgery, 36% of the
90 Gonçalves et al

Fig. 3. Mean vertical and horizontal surgical changes (anterior nasal spine [ANS], posterior nasal spine [PNS], up-
per incisor edge [UIE], lower incisor edge [LIE], B point [B], menton [Me], gonion [Go], hyoid [Hy]), MP-Hy dis-
tance, and occlusion plane (OPA) for the 3 groups. The red lines indicate presurgery (T1); the blue lines
indicate immediately postoperatively (T2). (From Goncalves JR, Cassano DS, Wolford LM, et al. Postsurgical stabil-
ity of counterclockwise maxillomandibula advancement surgery: affect of articular disc repositioning. J Oral Max-
illofac Surg 2008;66(4):724–38; with permission.)

patients complained of pain or discomfort, but at (16%) had a stable outcome without pain. This study
2.2 years postoperatively, 84% of the patients re- clearly demonstrates the problems associated with
ported a 75% increase in pain intensity compared performing orthognathic surgery only on patients
with the preoperative pain. Only 4 of the 25 patients with coexisting TMJ articular disc dislocations.

Fig. 4. Mean vertical and horizontal postoperative skeletal changes (anterior nasal spine [ANS], posterior nasal
spine [PNS], upper incisor edge [UIE], lower incisor edge [LIE], B point [B], menton [Me], gonion [Go], hyoid
[Hy]), MP-Hy distance, and OPA for the 3 groups. The blue lines indicate immediately postoperatively (T2); the
dashed lines indicate long-term postoperatively (T3). (From Goncalves JR, Cassano DS, Wolford LM, et al. Postsur-
gical stability of counterclockwise maxillomandibula advancement surgery: affect of articular disc repositioning. J
Oral Maxillofac Surg 2008;66(4):724–38; with permission.)
 Does Disc Repositioning Work? 91

3-DIMENSIONAL QUANTITATIVE FINDINGS or medially (Fig. 6). One year after surgery, more
than one half the patients in the 2 groups pre-
Our group has studied 3-dimensional (3D) sented condylar resorptive changes of at least
condylar changes after maxillomandibular surgical 1.5 mm and, interestingly, only the MMA-Drep pa-
advancement with and without TMJ articular disc tients showed bone apposition in localized
repositioning. We have used 3D quantitative condylar regions.
assessment and cranial base voxel-wise auto- Articular disc repositioning seemed to promote
matic registration to compare immediately preop- a protective function that was demonstrated by
eratively (T1), immediately postoperatively (T2), limited condylar resorption at the anchor region
and at least 11 months follow-up (T3). The first and bone apposition at all other condylar surfaces
study4 used iterative closest point rigid deforma- being the lateral pole the most frequent region
tion to assess condylar changes immediate after (Fig. 7). An ongoing study further compared the 2
surgery (T2–T1) and 1-year follow-up (T3–T2). groups mentioned (MMA  MMA-Drep), now
Although it was not a randomized trial, all patients with a surface correspondent analysis based on
who met specific criteria were included in this spherical harmonics (SPHARM-PDM; open-
retrospective study. We found that immediately af- source, available at: http://www.nitrc.org/pro-
ter surgery, condylar displacements differ signifi- jects/spharm-pdm)59,60 that allows correspondent
cantly between the 2 groups. Although patients surface measurements among 2 or more 3D vol-
with normal TMJ submitted to maxillomandibular umes from the same patient. In this study, maxillo-
advancement (MMA) have their condyles dis- mandibular stability was also addressed and it was
placed up, backward, lateral, or medially (Fig. 5), concluded that patients with TMJ disc displace-
patients with articular disc displacement submit- ment submitted to maxillomandibular advance-
ted to maxillomandibular advancement with simul- ment and articular disc repositioning have the
taneous articular disc repositioning (MMA-Drep)
have their condyles moved down, forward, lateral,

Fig. 6. Maxillomandibular advancement disc reposi-

Fig. 5. Maxillomandibular advancement (MMA) group tioning (MMA-Drep) group left condyle superimposi-
left condyle superimposition. Preoperatively (T1) solid tion. Preoperatively (T1) solid 3-dimensional model
3-dimensional model in white and (T2) yellow in wire- in white and (T2) yellow in wiremesh overlay imme-
mesh overlay immediate postoperatively show diate postoperatively show condylar spatial change
condylar spatial change in upward, backward, and in downward, forward, and medial directions.
medial directions. (From Goncalves JR, Wolford LM, (From Goncalves JR, Wolford LM, Cassano DS,
Cassano DS, et al. Temporomandibular joint condylar et al. Temporomandibular joint condylar changes
changes following maxillomandibular advancement following maxillomandibular advancement and
and articular disc repositioning. J Oral Maxillofac articular disc repositioning. J Oral Maxillofac Surg
Surg 2013;71(10):1759.e1–15; with permission.) 2013;71(10):1759.e1–15; with permission.)
92 Gonçalves et al

Fig. 7. (A) Maxillomandibular advancement disc repositioning (MMA-Drep) group left condyle anterior view.
Immediately postoperative (T2) solid 3-dimensional (3D) model in yellow and (T3) 1-year follow-up in purple
show condylar bone apposition in anterior, medial, and lateral surfaces. (B) MMA-Drep Group left condyle pos-
terior view. Immediately postoperative (T2) solid 3D model in yellow and (T3) 1-year follow-up in purple show
condylar bone apposition in posterior surface, and medial and lateral poles. Note bone resorption at the anchor
region. (Courtesy of Larry M. Wolford, DMD, Dallas, TX.)

same stability as patients with normal TMJs sub- computed tomography images,62,63 and with 3D
mitted to maxillomandibular advancement only. quantitative analysis,4,64,65 showing that mandib-
There are 3D quantitative analyses that have sug- ular advancement promotes an upward, backward,
gested that orthognathic surgery does not fix the and medial condyle displacement with likely
TMJs and possibly will increase joint loading change of the disc/condyle spatial relation. Individ-
(observed even in patients with normal TMJs),4 uals who received articular disc repositioning have
demonstrated by the significant reduction of their condyles moved in the opposite direction:
TMJ space. This fact has been demonstrated Downward and forward to make room for the discs
before with plain radiographs,61 cross-sectional that preserved the overall condylar morphology.4
 Does Disc Repositioning Work? 93

The relevance of 3D quantitative assessment anchor is the most adaptable Mitek anchor for
with open-source software specifically designed TMJ disc stabilization. The successful use of the
for this purpose is the automatic algorithm used device for TMJ articular disc repositioning has
that dramatically decreases user interference and been previously reported in the literature by Wolf-
the possibility of unintentional bias.59,66,67 This ord and colleagues.2,24,25,72 The United States
method also increases reliability because open Food and Drug Administration approves the use
source software can be freely evaluated over the of the Mitek mini anchor specifically for use in
Internet and the experiments can be replicated the TMJ.
exactly the same way as initially presented in the The Mitek mini anchor is cylindrical, measuring
literature, without the need for commercial 1.8 mm in diameter and 5.0 mm in length. The
software. body of the anchor is composed of titanium alloy
(titanium 90%, aluminum 6%, vanadium 4%),
SURGICAL TECHNIQUE AND POSSIBLE and its arcs are composed of a nickel–titanium
PITFALLS alloy (Nitinol), utilizing super elastic shape memory
properties. An eyelet in the posterior aspect of the
Annandale first described surgical repositioning of anchor allows placement of sutures that can func-
the displaced temporomandibular articular disc in tion as artificial ligaments (Fig. 8).
188768; however, it was not until 1978 when Wilkes Simultaneous surgical treatment would include
used arthrography to describe the anatomy, form, repositioning the TMJ disc into a normal anatomic,
and function of the TMJ that disc repositioning functional position and stabilize it using the Mitek
became an accepted surgical technique.69,70 anchor (Mitek Surgical Products) tech-
Other surgeons, however, did not experience nique1–3,5,24–26,30 and then performing the indicated
similar success, and this led to the development orthognathic surgery. The Mitek anchor technique
of modified techniques for disc repositioning uses a bone anchor that is placed into the lateral
surgery.2,71–81 Some authors have proposed aspect of the posterior head of the condyle and
arthroscopic suturing techniques to reposition the anchor will subsequently osseointegrate. Two
the disc.82–86 Although various claims have been 0-Ethibond sutures (Ethicon Inc., Somerville, NJ,
made, the reliability of an arthroscopic approach USA) are attached to the anchor and are used as
for predictably repositioning and stabilizing the artificial ligaments to secure and stabilize the disc
disc in the TMJ has not been documented. The to the condylar head (Fig. 9).
aim of this article was to evaluate our treatment
outcomes with the use of the Mitek mini anchor
High Success Rate with Disc Repositioning
in TMJ articular disc repositioning surgery.
Situations where the disc repositioning with the
Mitek Mini Anchor Mitek anchor has a high success rate:

Mitek anchors were originally developed for use in 1. Disc repositioning at the onset of displacement
orthopedic surgery procedures such as rotator within 4 years of displacement provides the
cuff repair, medial and lateral collateral ligament greatest predictability of outcome.
repair, bicep tendon reattachment, and other mus- 2. Adolescent internal condylar resorption pa-
cle, ligament, and tendon repair procedures.2,87,88 tients who are treated within the first 4 years
Although available in various sizes, the Mitek mini of disease onset.

Fig. 8. (A) Body of the Mitek mini anchor is 1.8  5 mm and is composed of titanium alloy with wings of nickel
titanium. (B) A doubled size 0 Ethibond suture has been passed through the eyelet of the Mitek mini anchor and
these sutures function as artificial ligaments to stabilize the disc in the proper position.
94 Gonçalves et al

Fig. 9. (A) In the use of the Mitek anchor to stabilize the articular disc, the joint first is exposed and the excessive
bilaminar tissue excised. To mobilize the disc, the anterior attachment of the disc to the articular eminence is
released so the disc can be positioned over the condyle passively. (B, C) The Mitek Mini Anchor (insert) has an
eyelet that will support two 0-Ethibond sutures that can function as artificial ligaments. The anchor is inserted
into the posterior head of the condyle lateral to the mid-sagittal plane and 5 to 8 mm below the top. One suture
is placed in a mattress fashion through the medial aspect of the posterior part of the posterior band. The other
suture is placed more lateral through the posterior band. (D) Cross-sectional sagittal view shows the Mitek anchor
positioned in the condyle with the artificial ligaments attached to the disc to stabilize it to the condylar head.
(Courtesy of Larry M. Wolford, DMD, Dallas, TX.)

3. No significant intracapsular inflammation, with all anatomic and surgical sequences that
especially in the bilaminar tissues. have proven to be effective and safe. Furthermore,
4. No history of connective tissue autoimmune it highlights possible mistakes that commonly
diseases, such as rheumatoid arthritis, juvenile affect outcomes.
idiopathic arthritis, psoriatic arthritis, Sjögren
syndrome, scleroderma, lupus, or ankylosing Description of Procedure
spondylitis.
5. Good remaining anatomy of the disc. A precise surgical intervention is paramount to
6. Reducing discs provide betters outcomes obtain predictable outcomes; we present a
compared with nonreducing discs. detailed, step-by-step guide for a successful disc
7. No other joint involvement. repositioning surgery.
8. No recurrent gastrointestinal, urinary, or respi-
ratory tract problems. Step 1
9. No history of sexually transmitted diseases. The patient is taken to the operating room and
nasoendotracheal intubation is performed by the
Successful surgical technique is the result of anesthesiologist. This is important, because it aids
careful observation of details through a sequence in the sterility of the field by allowing the surgeon
of steps that have paramount importance. This to isolate the mouth of the patient using a tegaderm
section describes TMJ articular disc repositioning or ioband. It also helps in manipulating the patient’s
 Does Disc Repositioning Work? 95

Fig. 10. (A–C) Preauricular site is injected with 5 mL of 1% lidocaine 1:100,000 epinephrine in a subcutaneous
plane.

Fig. 11. (A) Modified endaural incision with #15 blade. (B) Sharp dissection with fine Iris scissors. (C) Tragal carti-
lage isolated 12 to 15 mm to the subcutaneous tissue.

Fig. 12. (A) Long pickup holding the tragal cartilage backward and the small retractor showing the zygomatic
area. (B) Digital manipulation to identify the zygomatic arch and to feel the condylar head.
96 Gonçalves et al

Fig. 13. (A) Sharp dissection with Dean scissors perpendicular to the arch 8 mm in front of the tragal cartilage. (B)
Blunt dissection carried to the temporalis muscle fascia, below the fat tissue. (C) Blunt dissection is extended ante-
riorly to expose the articular eminence.

mouth while maintaining sterility and it permits the in the wrong place, and potentially injure the frontal
assessment of the occlusion during surgery. branch of cranial nerve VII or the external auditory
canal.
Step 2
Bilateral preauricular sites are injected with 5 mL of Step 5
1% lidocaine 1:100,000 epinephrine in a subcu- At this level, on top of the zygomatic arch, 8 mm in
taneous plane (Fig. 10). front of the tragal cartilage, blunt dissection is
Possible Pitfalls: If you do not inject lidocaine, made with Dean scissors, perpendicular to the
you will have more bleeding during the endaural arch, carried to the temporal muscle fascia,
incision and dissection of the subcutaneous plane. below of the fat tissue. The dissection is extended
anteriorly to expose the articular eminence
Step 3 (Fig. 13).
With a #15 blade, a modified short endaural inci- Possible Pitfalls: Visualizing the superficial layer
sion is made with extension of 5 mm anterosuper- of the deep temporal fascia is key in protecting
iorly and 3 mm anteroinferiorly. Sharp dissection the facial nerve.
with fine Iris scissors is carried from tragal carti-
lage down approximately 12 to 15 mm to the sub- Step 6
cutaneous tissue (Fig. 11). The prearicular With a #9 periosteal elevator, the lateral rim of the
approach is also preferred by some surgeons. glenoid fossa is demarcated (Fig. 14).
Possible Pitfalls: If you do not make the correct
extension of endaural incision, you will not have
a good surgical field to work in the TMJ; if you
do not pay attention in the tragal cartilage during
the sharp dissection, you can damage the carti-
lage, increasing the risk of perforating the external
auditory meatus. The preauricular approach re-
sults in a more visible scar.

Step 4
Digital manipulation is done to identify the zygo-
matic arch and the condyle into the fossa when
the mandible is moved laterally (Fig. 12).
Possible Pitfalls: If you do not do digital manipu- Fig. 14. Lateral rim of the glenoid fossa is
lation to identify the zygomatic arch you can incise demarcated.
 Does Disc Repositioning Work? 97

Fig. 15. (A) Extension of the C incision in the zygomatic arch. (B, C) Using Bovie electrocautery, a circular linear
incision is performed on top of the arch, following the shape of the glenoid fossa.

Possible Pitfalls: This marking helps in delin- Step 10

eating and identifying the condyle and protects The lateral capsular attachments are incised su-
the TMJ before the incision over the zygomatic perficially with a #15 blade 45 from inferior to su-
arch. perior aspect. The superior joint space is entered
superficially with a freer elevator (Fig. 18).
Step 7 Possible Pitfalls: The angulation of the blade is
Using Bovie electrocautery, a curved linear inci- important in protecting the articular disc and the
sion is performed on top of the arch, following use of a freer elevator prevents scuffing and
the shape of the glenoid fossa (Fig. 15). scratching of the fibrocartilage at the fossa,
Possible Pitfalls: The incision has to stay on decreasing the risk of adhesions.
bone on top of the arch to prevent inadvertent
damage to the disc and fibrocartilage of the supe- Step 11
rior joint space. Using Dean scissors, the lateral capsular attach-
ments are cut along the margin of the glenoid
fossa and articular eminence (Fig. 19).
Step 8
With a periosteal elevator, the fossa tissues are re-
flected inferiorly and laterally to expose inner
capsule of the TMJ (Fig. 16).
Possible Pitfalls: If you do not reflect tissues to
expose the inner capsule, you will have difficulty
entering the superior joint space.

Step 9
Approximately 3 mL of 1% lidocaine 1:100,000
epinephrine is injected into the superior joint space
to hydraulically displace the disc inferiorly. You
can observe the mandible moving forward
(Fig. 17).
Possible Pitfalls: This step hydraulically dis- Fig. 16. With a periosteal elevator, the fossa tissues
places the disc inferiorly and makes the access are reflected inferiorly and laterally to expose to the
to the superior joint space safer. lateral capsule of the temporomandibular joint.
98 Gonçalves et al

Fig. 17. (A) Lidocaine 1:100,000 epinephrine is injected into the superior joint space. (B) Anesthetic hydraulically
displace the disc inferiorly to make an incision in the capsule securely. ([B] Courtesy of Larry M. Wolford, DMD,
Dallas, TX.)

Fig. 18. (A) The lateral capsular attachments are incised with a #15 blade. (B) The superior joint space is entered
with a freer elevator.

Fig. 19. (A, B) The lateral capsular attachments are dissect with Dean scissors countering the glenoid fossa beyond
the articular eminence.

Fig. 20. (A, B) Using a #15 blade the lateral capsule is incised 10 mm below the lateral pole of the condyle from
posterosuperior to inferoanterior aspect. ([B] Courtesy of Larry M. Wolford, DMD, Dallas, TX.)
 Does Disc Repositioning Work? 99

Fig. 21. (A) Using a #9 periosteal elevator, the condyle is dissected inferiorly. (B) Using the Dean scissors, the bi-
laminar tissue is cut around the posterior aspect of the condyle.

Possible Pitfalls: Failure to adequately dissect space to reduce the articular disc and the condyle
the capsular attachments at the glenoid fossa may be displaced forward. Also, access and visi-
will cause limited visibility and greater difficulty in bility will be limited.
mobilizing the articular disc.
Step 14
Step 12 In cases of anterior displacement, it is often neces-
Using a #15 blade, the lateral capsule is incised sary to free the disc anteriorly where the ligament
just above the lateral pole of the condyle from attaches from the anterior band of the disc to the
posterosuperior to inferoanterior (Fig. 20). The anterior slope of the articular eminence; some-
incision is made at this level to maintain and maxi- times, it is necessary to release the medial attach-
mize soft tissue attachment and vascularity to the ments as well.
condyle. Possible Pitfalls: The anterior release is critical to
Possible Pitfalls: Care must be taken to minimize passively reposition the disc. Sometimes, a medial
damage to the fibrocartilage of the fossa and release is also necessary.
condylar head, as well as the disc, because injury
to these structures can promote the formation of Step 15
adhesions and degenerative changes Using a Mitek drill bit (2.1 mm diameter) with a
postoperatively. built-in stop, a 2  10-mm hole is made in the pos-
terior head of the condyle. The position of the an-
Step 13 chor may vary slightly from case to case, but is
Using a periosteal elevator, the condyle is re- generally positioned 8 to 10 mm below the supe-
tracted inferiorly to create a space to insert the rior aspect of the condyle, and just lateral to the
Dean scissors and cut the bilaminar tissue around midsagittal plane. It is not necessary to strip soft
the posterior aspect of the condyle until the medial tissue from the posterior condyle for hole prepara-
wall of the fossa is reached (Fig. 21). tion, and generally the hole is drilled through the
Possible Pitfalls: If a piece of the retrodiscal tis- periosteum to maximize soft tissue attachment
sue is not removed, there will not be adequate and blood supply to the condyle.

Fig. 22. (A, B) A doubled size 0 Ethibond suture has been passed through the eyelet of the Mitek mini anchor, and
the loop is cut, thereby yielding 2 separate strands of suture material. ([A] Courtesy of Larry M. Wolford, DMD,
Dallas, TX.)
100 Gonçalves et al

Fig. 23. (A, B) The anchor is then loaded onto an inserting device used to place the anchor in the condyle.

Fig. 24. (A, B) The 1.8-mm titanium Mitek anchor is then placed into the prepared hole. ([A] Courtesy of Larry M.
Wolford, DMD, Dallas, TX.)

Fig. 25. (A–C) The anchor is inserted into the posterior head of the condyle lateral to the mid sagittal plane and 5 to
8 mm below the top. One suture is placed in a mattress fashion through the medial aspect of the posterior part of the
posterior band. The other suture is placed more lateral through the posterior band. These sutures function as artificial
ligaments to stabilize the disc in the proper position. ([A, B] Courtesy of Larry M. Wolford, DMD, Dallas, TX.)
 Does Disc Repositioning Work? 101

Fig. 26. (A) Disc is well-secured in new optimal position. (B) Cross-sectional sagittal view shows the Mitek anchor
positioned in the condyle with the artificial ligaments attached to the disc to stabilize it to the condylar head. ([B]
Courtesy of Larry M. Wolford, DMD, Dallas, TX.)

Possible Pitfalls: The position of the anchor can Step 19

be modified to suit the type of reduction necessary. The surgical site is then profusely irrigated and the
lateral capsule is sutured back into position.
Step 16 Possible Pitfalls: If you do not irrigate the surgi-
Before placing the implant, 1 size 0 polyester or cal site with saline solution, you will increase the
other nonresorbable braided suture is doubled risk of infection. If you do not suture the lateral
and threaded through the eyelet of the anchor capsule, you will not stabilize the disc laterally
(Fig. 22). The suture loop is then cut, thereby mak- and it will take longer to heal the joint.
ing 2 separate strands, and the anchor is placed
into an inserting device (Fig. 23). Step 20
Possible Pitfalls: If you do not use a threader you A layered closure of the incision is completed with
will have difficulty to inserting the 0 Ethibond into 4–0 Polydioxanone (PDS) for the deep tissue of
the eyelet of the anchor. temporomandibular fascia (Fig. 27) and to approx-
imate the subcutaneous tissue of the endaural
Step 17 incision (Fig. 28). The skin is closed in a subcutic-
The 1.8-mm titanium Mitek anchor is then placed ular fashion (Fig. 29).
into the prepared hole using a special delivery de-
vice, and using hand pressure, the trigger is
advanced, delivering the anchor below the cortical CLINICAL CASE
bone level into the softer medullary bone of the A 19-year-old woman presented with bilateral TMJ
condyle (Fig. 24). anteriorly displaced articular discs (confirmed by
Possible Pitfalls: Failure to place the anchor into MRI). Intermediate zone criteria is the location of
an inserting device with the permanent suture into the intermediate zone of the disk in relation to
the eyelet of the anchor will cause difficulty during the condyle and the articular eminence. Using
the insertion of the anchor inside the hole and can this criterion, we can observe articular disc
break the wings. displacement (Fig. 30). She had vertical excess
Step 18
Using an 8-mm modified French-eye needle, the 2
sutures are then attached to the disc in a mattress
or running fashion from the posteromedial to
posterolateral aspect of the disc to reposition it
in correct position on top of the condylar head
(Fig. 25). The sutures are securely tightened and
positioned with a double knot and 3 simple knots
(Fig. 26). The condyle is manipulated in various di-
rections noting the disc and condylar unit moved
harmoniously and the disc well-secured in its
new, optimal position.
Possible Pitfalls: The use of a double knot or a
surgeon’s knot is necessary to secure the suture Fig. 27. A layered closure of the incision is completed
as close as possible to the condylar head and sta- with 4–0 PDS for the deep tissue of temporomandib-
bilize the anchor. ular fascia.
102 Gonçalves et al

Fig. 28. (A, B) Approximation of the subcutaneous tissue of the endaural incision.

Fig. 29. (A–C) To close the skin, 5–0 Prolene is used in a subcuticular fashion.

Fig. 30. (A, B) MRI of a temporomandibular joint showing a significantly anterior displaced articular disc using
Intermediate Zone (IZ) criteria. (C, D) On opening, the disc remains anteriorly displaced and nonreducing with
degenerative changes using IZ criteria. (Courtesy of Larry M. Wolford, DMD, Dallas, TX.)
 Does Disc Repositioning Work? 103

of maxilla, lip incompetence, facial asymmetry, Mitek anchors, bilateral mandibular ramus sagittal
mandible retruded, high occlusal plane angle, split osteotomies and multiple maxillary osteoto-
and class II skeletal and occlusal dentofacial mies for maxillomandibular counterclockwise
deformity (Figs. 31 and 32). She complained of advancement at the pogonion. At 2 years postop-
moderate to severe TMJ pain, headaches, and eratively, the patient demonstrated good stability,
myofascial pain, as well as clicking in the TMJs esthetics, symmetry, smile, and occlusion with
and difficulty eating. After orthodontic preparation, elimination of TMJ pain, headaches, myofascial
surgery was performed in a single operation, pain, and TMJ noise, as well as improved jaw func-
including bilateral TMJ disc repositioning with tion and facial esthetics.

Fig. 31. (A, C) This 19-year-old woman presented with bilateral articular disc displacement and temporomandib-
ular joint (TMJ) dysfunction. The mandible is significantly retruded, with a high occlusal plane angle and associ-
ated facial morphology. (B, D) The same patient 2 years after undergoing bilateral TMJ articular disc repositioning
with Mitek mini anchors and simultaneous double jaw orthognathic surgery. (Courtesy of Larry M. Wolford,
DMD, Dallas, TX.)
104 Gonçalves et al

Fig. 32. (A–C) Preoperative occlusion demonstrating an anterior open bite and class II occlusal relationship. (D–F)
The occlusion remained stable 2 years postoperatively. ([B] Courtesy of Larry M. Wolford, DMD, Dallas, TX.)

SUMMARY 3. Wolford LM, Cardenas L. Idiopathic condylar

resorption: diagnosis, treatment protocol, and out-
Scientific evidence with regard to the effectiveness comes. Am J Orthod Dentofacial Orthop 1999;
of TMJ disc repositioning remains scarce and 116(6):667–77.
needs further efforts to guide clinicians and patients 4. Goncalves JR, Wolford LM, Cassano DS, et al.
among the clinical and surgical options to better Temporomandibular joint condylar changes
treat TMJ internal derangement, mainly when asso- following maxillomandibular advancement and artic-
ciated with skeletal malocclusion that requires sur- ular disc repositioning. J Oral Maxillofac Surg 2013;
gical interventions. Although scarce, we have 71(10):1759.e1–15.
reviewed several papers that showed outcomes af- 5. Gonçalves JR, Cassano DS, Wolford LM, et al. Postsur-
ter TMJ articular disc repositioning. These studies gical stability of counterclockwise maxillomandibular
were undertaken with lateral cephalometric radio- advancement surgery: affect of articular disc reposi-
graphs, tomograms, cone-beam computed tomog- tioning. J Oral Maxillofac Surg 2008;66(4):724–38.
raphy, MRIs, and visual analog scale assessments 6. US Agency for Healthcare Research and Quality.
for reported pain and function. The lack of evidence Evidence-based Practice Centers: evidence-based
that TMJ articular disc repositioning is an ineffective reports. Available at: http://www.ahrq.gov/research/
procedure points to a future when new TMJ bio- findings/evidence-based-reports/index.html. Ac-
markers will support the technique effectiveness cessed March 7, 2014.
in more rigorously controlled studies. 7. Institute for Scientific Information. ISI impact factor
Because this is a sensitive technique with a wide description. Available from: http://thomsonreuters.
learning curve, many surgeons have practiced com/productsservices/science products/a-z/journal
TMJ articular disc repositioning with a large range citation reports.
of outcomes. In this article, we have reviewed all 8. Pitak-Arnnop P. The 100 most cited articles in
the main steps for a successful surgery and the dentistry–some discussions. Clin Oral Investig
most frequent pitfalls that can compromise the 2014;18(2):683–4.
procedure. Adequate training is important for 9. Sandhu A. The evidence base for oral and maxillofa-
achieving the best results possible. cial surgery: 10-year analysis of two journals. Br J
Oral Maxillofac Surg 2012;50(1):45–8.
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