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British Journal of Oral and Maxillofacial Surgery 51 (2013) 469472

Review
How do I manage restricted mouth opening secondary to
problems with the temporomandibular joint?
Andrew J. Sidebottom
Consultant Oral and Maxillofacial Surgeon, Queens Medical Centre, Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, United
Kingdom

Accepted 4 December 2012


Available online 12 February 2013

Abstract

Restricted mouth opening is a common problem that presents to secondary care, and management depends on the primary cause. The
most common differential diagnoses related to the temporomandibular joint (TMJ) include muscle spasm secondary to pain, anchored disc
phenomenon, irreducible anterior disc displacement, rheumatoid diseases, and ankylosis. In this paper each is considered in turn.
2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: TMJ pain; Trismus; TMJ arthroscopy; TMJ discectomy; TMJ replacement; TMJ ankylosis; TMJ anchored disc phenomenon; TMJ anterior disc
displacement; MRI scan; CT scan

Introduction indicated when diagnostic arthroscopy confirms a torn disc


or damage to the surface of the joint, and when symptoms fail
Management of restricted mouth opening depends on the to improve. Where ankylosis or collapse of the joint is pos-
primary cause, and includes anchored disc phenomenon in sible then use of three-dimensional computed tomography
younger patients, irreducible anterior disc displacement usu- (CT) is invaluable to evaluate the surfaces of the joint and
ally in somewhat older patients, and degenerative disease the relation to underlying structures. Vascular imaging may
in elderly patients. Across all age groups rheumatoid dis- be helpful when joint replacement is considered and anky-
eases and ankylosis can also present. Initial management lotic tissue extends medially. Total joint replacement is the
in all cases should be conservative with rest, non-steroidal final common pathway when open surgery, and management
anti-inflammatory drugs (NSAID) and a bite splint1 unless of ankylosis or rheumatoid diseases fail. Outcomes in the
clinical findings and orthopantograms (OPG) clearly show medium term are good, but as long-term outcomes beyond
collapse of the joint or ankylosis. When these fail, arthroscopy 20 years are still unknown, replacement should be used only
or arthrocentesis is often beneficial particularly in dis- as a last resort and according to guidelines from the National
eases related to the disc or lubrication of the joint. Failed Institute for Health and Clinical Excellence (NICE).3
arthroscopy at least provides a diagnosis and can further Patients who present to secondary care with limited open-
guide management. Diagnosis can be supplemented by mag- ing (trismus) should initially have a full clinical examination
netic resonance imaging (MRI)2 although the position of the to discover whether the primary cause is articular or extra-
disc and mobility do not necessitate surgical correction. Open articular. The latter includes infective or inflammatory causes
joint surgery (discectomy, condylar shave, or eminoplasty) is with secondary muscle spasm. The history should show
whether there is pain, restriction, locking, and joint noise.
Symptoms of the other joint being involved, local problems
Tel.: +44 1159249924x65895; fax: +44 115 8493386. with the head and neck, or other systemic diseases should
E-mail addresses: andrew.sidebottom@nuh.nhs.uk,
ajsidebottom@doctors.org.uk
also be investigated. Examination should include assessment

0266-4356/$ see front matter 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2012.12.004
470 A.J. Sidebottom / British Journal of Oral and Maxillofacial Surgery 51 (2013) 469472

of the movement of each joint, measurement of mouth open- ment is often reasonable, which suggests that the disc is
ing and lateral deviation, and palpation for muscle spasm, possibly being held anteriorly by a pterygoid muscle spasm
joint noise, and tenderness. Lateral deviation helps to ascer- or intra-articular pain and subconscious restriction. An MRI
tain whether there is movement in the upper joint space; there study on patients who are asked to deviate either way rather
is loss of contralateral movement where this is involved. than to protrude would be interesting as it may show a dif-
ferent outcome. However, MRI is not therapeutic and often
under diagnoses and over diagnoses tears in the disc.
Muscle spasm Subsequent arthroscopy or arthrocentesis not only aids
diagnosis, but also elicits a cure in over 80%.7 Arthroscopic
Masseteric spasm is common secondary to infections in the examination often shows evidence that the surfaces of the
region of the angle of the mandible. It presents acutely and joint have been stuck together and fibrillations are visible.
is often associated with facial swelling. The primary cause Occasional fibrosis can be broken down with the scope, or
should be managed appropriately. rarely a torn disc may be discovered.
Patients with secondary myofascial pain sometimes have Failure to respond to arthroscopy may indicate open
restricted opening. They will have tenderness and there will surgery depending on the findings. Fortunately, patients with
be areas of palpable spasm in the masticatory muscles. Initial an arthroscopically diagnosed torn disc (Wilkes stage 5) can
management is with rest, NSAID, and nocturnal bite splints. recover and this finding should not always indicate operation
Low dose tricyclic medication or botulinum injections4 into regardless of outcome.
the area of spasm should be considered if a 3-month period Once the joint is opened, the upper and lower joint
of conservative management fails. space should be explored and any adhesions released. If the
condylar head is irregular with osteophytes they should be
smoothed (condylar shave or condyloplasty), and if the emi-
Anchored disc phenomenon nence is excessively steep or has areas of lost cartilage it can
be reduced to provide more free movement (eminoplasty).
First described in 1991,5 anchored disc phenomenon is proba- Irreparable damage to the disc necessitates discectomy. The
bly more common than most non-specialists would consider. author does not routinely replace the disc, as this tends to
Patients have acute, severe, restricted opening of less than occur naturally with scar tissue over 6 months. It causes dis-
25 mm, and unlike many TMJ disorders it is as common in comfort for up to 6 months but gives an early improvement
men as in women and is most common in adolescents and in function. Interposition with a temporalis flap causes scar-
young adults. While initial management should be conser- ring in the muscle, which in itself may restrict opening. Other
vative, early consideration for arthrocentesis under pressure interpositional grafts have been considered but none has been
using 200 ml of fluid will provide a cure in over 90% of cases. consistently successful,8 and each has its own related mor-
Arthroscopy may show evidence of the surfaces of the joint bidity from the harvest site.
being stuck together (fibrillations), although often no abnor- The authors own audit of outcome after failed arthroscopy
mality is found. Arthroscopy involves the manipulation and and subsequent open operation shows success in roughly
measurement of intraoperative mouth opening, which will 60%, and this is increasingly being seen in other practices
cause the appearance of fibrillations where the surfaces have where arthroscopy, not open operation, is considered the first
been forced apart. Arthrocentesis can be repeated if necessary option.19 Primary open operation should therefore be avoided
when intraoperative mouth opening is good, but the patient as arthroscopy is often successful irrespective of the Wilkes
does not improve in the short term. Early treatment in this stage.7,9
manner leads to a lower risk of the long-term side effect of The final common pathway if open operation fails is total
restricted opening. joint replacement, assuming that the NICE criteria have been
met.3,10 Open operation should be considered only once
and any abnormality should be treated at this stage. If it
Irreducible anterior disc displacement is unsuccessful then further operation is also likely to be
unsuccessful, as all the causes should have been dealt with
This was once considered to be the main cause of acute initially. Repeated open operation has been shown to cause
closed lock. The patient may initially have clicking, which an increased likelihood of dysaesthetic pain, and also reduces
progresses to locking and subsequent restriction according to the success of total joint replacement.
the classic course. Increasingly these patients are being recog-
nised as having problems related to lubrication in the joint,
and initial conservative management is often successful.6 Rheumatoid diseases
MRI in patients who fail to respond to conservative man-
agement will often show that the disc has displaced anteriorly Rheumatoid disorders do not commonly present in the TMJ.
and does not reduce when the mouth is opened.2 However, They should be managed with the rest of the disease under
when asked to move the mandible from side to side, move- the care of the rheumatologist, potentially with disease-
A.J. Sidebottom / British Journal of Oral and Maxillofacial Surgery 51 (2013) 469472 471

modifying drugs. Initial management of the TMJ should graft, or total joint replacement. Around the world the main-
be conservative,11 but if this fails arthroscopy will aid in stay of management is gap arthroplasty and interpositional
diagnosis and also give considerable therapeutic benefit. temporalis flap although it is not as successful as recon-
Restricted opening may be caused by pain or collapse of struction with costochondral grafts.16 Increasingly, total joint
the joint (because of the backward rotation of the gonion and replacement is considered the gold standard because of the
shortening of the ramus), and a replacement joint should be failure of costochondral grafts.17,18 It has been suggested
considered. It will also cause a progressive deformity in the that a free abdominal fat graft packed around the prosthe-
anterior open bite and a recessive chin. sis reduces the risk of ankylosis recurring.12 Medium term
Ankylosis is most common in psoriatic arthropathy and outcomes show considerably improved mouth opening and
ankylosing spodylitis. Where an OPG suggests ankylosis reduced pain, but unfortunately the long term outcomes of
a three-dimensional CT will help confirm diagnosis. Joint joint replacement are not known beyond 20 years.18 The TMJ
space of less than 1 mm makes arthroscopy difficult if not Special Interest Group of the British Association of Oral and
impossible, so it may be bypassed in these cases. Where Maxillofacial Surgeons has set up a national database to ana-
restriction is less than 30 mm the best option is total joint lyse long term outcomes of joint replacement. All surgeons
replacement, potentially surrounding the joint with a free fat who do replacements submit their data to this database and
graft.12 use the outcome for revalidation.

Ankylosis References

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