SEARCH

SEARCH BY CITATION

Keywords:

  • acute closed lock;
  • chronic closed lock;
  • disc displacement without reduction;
  • jaw locking;
  • locking duration;
  • temporomandibular joint

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

Temporomandibular joint (TMJ) ‘closed lock’ (CL) is a clinical condition causing TMJ pain and limited mouth opening (painful locking) that is mostly attributed to disc displacement without reduction (DDwoR), or less commonly to anchored disc phenomenon (ADP). Both conditions are described clinically as CL that can be ‘acute’ or ‘chronic’ depending on the duration of locking. There is, however, no consensus about the duration of locking that defines the acute state and its effect on the success of interventions. This review paper, therefore, aims to provide: (i) a narrative review of the pathophysiological need for early intervention in DDwoR and the clinical implications of acute/chronic CL stages on the management pathway; (ii) a systematic review investigating the effects of locking duration on the success of interventions for CL management. Electronic and manual searches until mid-August 2013 were conducted for English-language studies of any design investigating the effects of non-surgical and surgical interventions for acute or chronic CL (DDwoR or ADP). A total of 626 records were identified, and 113 studies were included. Data extraction and quality assessment were completed for all included studies. Included studies were, however, heterogeneous and mostly of poor-quality leading to contradictory and inconsistent evidence on the effect of the duration of locking on treatment outcomes. Future high-quality trials investigating the effect of CL duration on treatment outcome are needed. At present, early intervention by ‘unlock’ mandibular manipulation seems to be the most practical and realistic approach that can be attempted first in every CL patient as an initial diagnostic/therapeutic approach.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

Temporomandibular joint (TMJ) disc displacement without reduction (DDwoR) is a specific subgroup of temporomandibular disorders (TMDs) where the disc is permanently displaced, most frequently anteriorly or anteromedially, to the condyle resulting in a ‘painful locking’ [1-4]. This condition of TMJ pain and locking is known clinically as ‘closed lock’ (CL) [5-8]. The ‘TMJ closed lock’ term does not, however, always exclusively, refer to TMJ DDwoR because another condition suggested in the literature to have the same ‘hypomobility’ symptoms (i.e. anchored disc phenomenon ‘ADP’) [9]. In this review, the ‘closed lock’ term has only been used to describe the clinical symptoms of the ‘two’ conditions (DDwoR and ADP).

Depending on duration of locking, CL can be acute or chronic [7, 10-13]. The definition of acute and chronic CL stages in relation to locking duration and its implications on ‘early’ management is, however, controversial [13, 14]. This controversy is related mostly to unproven effect of locking duration on CL treatment outcomes. This paper, therefore, aims to provide:

  1. A narrative review of:
    1. the evidence from a pathophysiological perspective of the need for early intervention in the DDwoR management pathway
    2. the clinical definition and implications of acute and chronic CL stages.
  2. A systematic review of the effects of locking duration on the success of therapeutic interventions in CL. It is explicitly restricted to examining the evidence for the effect of duration of symptoms on treatment outcome as the evidence for the effect of different treatments on DDwoR would require a systematic review of randomised clinical trials which is the subject of another review currently coming to completion [15].

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

Search methods

A systematic search in Medline database via Ovid for TMJ CL studies was conducted (last update was on: 15th August 2013). The Medline search strategy is available in Appendix S1. Additional searches were also conducted using other sources including hand-searching the reference lists of the included studies and relevant review articles, as well as searching the Google Scholar using ‘disc displacement without reduction’ and ‘closed lock’ keywords.

Criteria for considering studies for the systematic review

Inclusion criteria

Studies of any design investigating the effects of any form of non-surgical and/or surgical interventions on patients with clinical and/or radiological diagnosis of acute or chronic DDwoR were considered in this review as long as the duration of symptoms were reported. Diagnostic criteria accepted were as follows: American Association of Orofacial Pain (AAOP) (acute or chronic DDwoR) [16]; research diagnostic criteria for temporomandibular disorders (RDC/TMD) (IIb or IIc) [17]; Wilkes stages III or IV [18]; or any other bespoke study criteria that were compatible with, or comparable to, the aforementioned criteria. Studies involving CL patients with a ‘static’ or ‘fixed’ disc (i.e. anchored disc phenomenon ‘ADP’) [9, 19] were also included.

Studies that involved other heterogeneous groups of TMD patients (e.g. osteoarthritis, myofacial pain, disc displacement with reduction ‘DDwR’) in addition to patients with DDwoR were considered only if: separate data (e.g. success rate and/or locking duration) were provided in the study for DDwoR patients, or if the sample consisted of ≥ 80% DDwoR patients. Studies involving patients with a confirmed diagnosis of DDwoR disorder with comorbid disorders were also included.

Exclusion criteria

Studies were excluded if they did not report the duration of symptoms of their sample or if they addressed diagnoses other than ‘closed lock’ (DDwoR or ADP). Studies were also excluded if they addressed subject matter other than CL treatment.

Data collection and extraction

Selection of studies

The first reviewer (MA) selected eligible studies based on the inclusion/exclusion criteria with those identified as clearly irrelevant from their title/abstract being excluded. The full texts of all potentially eligible studies were retrieved and examined. Throughout the selection process, any doubt about a study's inclusion meant it was examined by the second reviewer (JD) and the decision to include or exclude the study was made by discussion with the first reviewer to reach a consensus.

Data extraction and management

A standardised table was used for data extraction. The data from eligible studies were extracted and recorded by the first reviewer (MA). The second reviewer (JD) crosschecked the extracted data's validity. The data on duration of symptoms and follow-up period were standardised in months and the data for Visual Analogue Scale (VAS) pain successful outcome were standardised, when possible, to (0–100) scale. If not provided, the mean patient age and locking duration was calculated from the raw data using SPSS statistics version 19.0 for windows1.

Quality assessment

Two independent reviewers (MA & JD) assessed the quality of study design in the included studies using the National Health and Medical Research Council (NHMRC) level of evidence guidelines for intervention trials [20] with slight modification (Appendix S2). The level of evidence in each study was judged by its design as: (I) highest, (II-1), (II-2), (III-1), (III-2), (III-3), or (IV) lowest. Any disagreements concerning the assessment were resolved by discussion to reach a consensus.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

Search results

The search strategy identified a total of 626 records from electronic and manual searches (426 from MEDLINE and 200 from other sources). Of these, the full texts of 395 potentially eligible papers were retrieved and examined. Eventually, 113 studies (of 122 reports) were found eligible and included in the systematic review. The study flow diagram is available in Appendix S3.

Narrative review of DDwoR pathophysiology, and the clinical definition and implications of acute and chronic CL stages

Pathophysiology and progression of DDwoR

Patients with DDwoR are often characterised by distinct combinations of signs and symptoms: history of clicking followed by sudden onset of pain and limited mouth opening (locking without clicking) and impaired contralateral movement [2, 5, 7, 17, 21, 22]. These characteristic symptoms are usually present in ‘acute’ DDwoR [CL] (painful limited opening) as opposed to ‘chronic’ DDwoR (decreased pain-improved opening), which makes the clinical diagnosis of the former more readily achievable. The latter may be difficult to diagnose clinically without magnetic resonance imaging (MRI) [11, 23]. The incidence of DDwoR among TMDs is not fully determined but is estimated to occur in about 2–8% [24-27]. DDwoR is, however, also diagnosed by MRI in people without any clinical signs or symptoms with a reported prevalence of 3% among the asymptomatic general population [23, 28-30].

The two predominant biomedical complaints in DDwoR are TMJ pain and limitation of jaw movements. The exact cause of pain associated with DDwoR is still not fully understood [31]. The displaced disc is thought to play an important role in the pain process [32-34], but it is unlikely to be the only source of pain as disc displacement alone is not always associated with pain [29, 35-40]. In addition to alteration in disc position, other factors have been suggested in the development of pain: joint effusion and inflammatory reactions (e.g. synovitis, capsulitis or retrodiscitis), and capsule impingement and/or retrodiscal tissue compression [31, 41-50].

The other predominant biomedical complaint in DDwoR is the abrupt restriction in jaw movements. This is usually attributed to mechanical obstruction by the displaced disc to the translating condylar movement [1, 2, 5, 21, 51]. This condition is often, almost colloquially, termed as ‘closed lock’ (CL) [5-8]. The ‘closed lock’ term, however, describes a clinical symptom and not an anatomic diagnosis and the condition of CL is not always exclusively attributed to DDwoR. Anchored disc phenomenon (ADP) has also been suggested as potentially responsible for some of the cases of CL [9, 52]. The putative pathogenic processes underpinning ADP are as follows: direct mechanical injury from joint overloading, hypoxia-reperfusion injury, release of free radicals into the synovial fluid, causing degradation of hyaluronic acid and eventually a vacuum effect (suction cup effect). The end result of these proposed pathological processes leads to disc adherence to the roof of the glenoid fossa. The adhered or ‘stuck’ disc then totally prevents the condylar sliding movement producing a more pronounced lock but that responds better to arthrocentesis than DDwoR [9, 52-55]. Whether ADP is a distinct entity from DDwoR, or a differing stage of the same clinical entity, is still debatable [56] due to the degree of similarity between the signs and symptoms of the two conditions. This similarity makes the differentiation of the two conditions based on clinical diagnosis alone virtually impossible and differentiation on the basis of MRI [19] is doubtful as all bar one ADP study [57], involve patients with displaced discs as well as normally positioned discs [55, 58, 59]. Further studies with MRI evidence of a normally positioned disc in CL patients are required to gain a better understanding of ADP and whether it is a separate entity within the ‘closed lock’ category [57, 60].

The course of DDwoR disorder has been shown to be ‘favourable’ [14, 61-66]. Studies on the natural course of ‘chronic’ DDwoR have shown that in about two-thirds of patients, the clinical signs and symptoms tend to resolve or improve over a period of (6–30 months), while the other one-third did not improve or became worse during the observation period [14, 61, 63, 67]. A recent study on the short-term natural course of ‘acute’ DDwoR demonstrated that signs and symptoms resolved in 95% of patients over 3 months of observation [68].

The improvement over the time in some patients with DDwoR may be attributed to stretching and remodelling of the retrodiscal tissues and ‘pseudo’ disc adaptation [44, 69-74]. Despite the increased range of jaw motion and decreased pain, several studies have demonstrated that the displacement of the disc and the deformation of the disc/condyle complex increases [14, 61, 63, 65, 75-81]. There are also some indications that the permanently displaced disc may be correlated with alterations in maxillofacial skeletal morphology in the long term [82-88].

The TMJ is a load-bearing joint and its articular tissues have a remarkable adaptive capacity to mechanical loading [89-91], but this capacity is not infinite. Sustained overloading may increase the susceptibility to degenerative joint disease [31, 71, 92-94] and other risk factors may adversely influence the adaptive capacity of the articular tissues including age, systemic illness, hormonal, nutritional, traumatic, mechanical and genetic factors [91, 92, 95-99]. A degenerative state can, therefore, ensue if functional demands surpass the adaptive capacity or if the affected individual is susceptible to maladaptive responses [92]. In general, the molecular events that underlie TMJ remodelling and adaptation are still not fully understood [92], and the molecular and cellular basis of DDwoR pathophysiology is still unclear, but there is some biochemical evidence of increasing susceptibility to osteoarthritic degeneration in ‘chronic’ CL patients [100-107].

Three models have been proposed that may be involved in the pathogenesis of degenerative TMJ diseases: the direct mechanical trauma model, the hypoxia-reperfusion model and the neurogenic inflammation model [108]. The molecular events and cascades in response to mechanical stress in these models may ultimately lead to an imbalance between catabolic and anabolic events leading to catabolism (degeneration) of the articular tissues in the affected joints [91, 92]. The risk of degenerative changes in joints with DDwoR was shown to be four times greater than in joints with normal disc position [109], and suggestions were made that the propensity for degenerative disease was mediated by an imbalance in the patient's adaptive capacity and functional loading of the TMJ. The study concluded that a careful, individualised, assessment of each DDwoR patient was required to evaluate the various factors that might contribute towards the progression to degenerative disease [109].

At present, the line separating normal adaptive responses from responses that result in (degenerative) disease is ill-defined. It may, therefore, be difficult to predict the DDwoR prognosis in an individual patient [71]. In fact, TMJ DDwoR is a disorder with two possible scenarios. On one hand, it is a benign self-limiting disorder in which most of patients’ symptoms improve with the passage of the time and do not necessarily progress to degenerative joint disease [69, 77, 110, 111]. On the other hand, DDwoR can be also a debilitating disorder causing significant pain and dysfunction that disturbs the patient's quality of life with the potential for persistence of symptoms and degenerative progression in susceptible patients in the longer term [71, 109, 112-115]. Both scenarios are possible in DDwoR patients, and it is still not clear which patients have, or which biomechanical and biochemical factors predict, the greatest risk of progressing to the more advanced stages [116]. This means that it is important to treat all patients early in the time course of DDwoR to prevent disease progress in susceptible patients [117-119]. This ‘early’ management will also prevent progression from an acute to a chronic condition, thereby avoiding the possibility of developing chronic pain and its psychosocial consequences in symptomatic DDwoR patients [120-122]. Any initial active intervention, however, should be simpler and less invasive than waiting for possible symptomatic resolution during the ‘favourable’ natural course of the DDwoR disorder [68].

Clinical definition and implications of acute versus chronic CL stages

The term ‘acute’ is usually related to a temporary state or condition which may or may not be severe, while the term ‘chronic’ is related to a state or condition that is persistent or long lasting and again does not imply anything about severity [123, 124]. Both medical terms are often used as measures of the time scale of a disease rather than its severity. In pain conditions, ‘acute pain’ usually refers to pain of recent onset with a duration ≤1 month (≤30 days), while ‘chronic pain’ usually refers to a persistent pain with a longer duration (≥3 months or ≥90 days) [125, 126]. In a CL condition, the terms ‘acute closed lock’ (ACL) and ‘chronic closed lock’ (CCL) are widely used in the CL literature usually describing the chronicity of DDwoR. The most reliable diagnostic criteria for TMDs [17, 22, 127-129] depend, however, primarily on the patients’ signs and symptoms rather than the duration of symptoms to classify acute versus chronic DDwoR (Appendix S4). In clinical trials involving patients with DDwoR, however, most authors usually define their samples based on the duration of symptoms (i.e. locking duration or time since DDwoR onset), although there is considerable variation in the threshold that defines acute and chronic stages ranging from 1 to 6 months (Appendix S5). In the authors’ opinion, a more appropriate clinical classification of acute and chronic CL could be based on the time scale for the possibility of recapturing the displaced disc to return the DDwoR to its previous condition (i.e. DDwR) with a non-invasive intervention.

In DDwoR (CL), both patient and management factors have been suggested to predict the outcomes. The predictors suggested include the following: age, gender, level of pain, range of mandibular motion, duration of locking, joint inflammation, disc mobility, severity of disc displacement, stage and degree of morphological and pathological changes in disc/condyle complex, and type, frequency, and duration of therapy [114, 130-144]. The role of these factors in predicting CL treatment outcome is, however, still debatable. In fact, these ‘prognostic’ factors may interrelate or interact with each other to a greater or lesser degree and there are still not significant data on the role psychosocial factors may have in predicting outcome in CL. To give an example, the severity of intra-articular pathological changes and the stage of internal derangement may increase with the age of the patient and/or duration of locking. Some of the aforementioned predictive factors are, however, easily accessible through standard history and clinical examination, whereas others require either more advanced imaging (e.g. MRI) or investigations (e.g. arthroscopy). Duration of locking is very simply estimated by self-report, although the accuracy of report may be influenced by several factors including recall bias.

The possible mechanism for jaw locking and DDwoR progression from ‘acute’ to ‘chronic’ has been proposed to begin as a displaced disc obstructing the forward condylar translation resulting in restricted mouth opening (acute stage); the repeated attempts to increase mouth opening then displace the disc gradually farther forward to an anterior position, so the condyle can slide forward, and the mouth opening range increases with the ‘time’ (chronic stage) [2, 116, 145]. From a clinical perspective, the progression from an acute to a chronic DDwoR over the time can affect treatment outcome as patients may respond differently to a similar therapeutic intervention dependent on locking duration [114, 146]. This coupled with the fact that the two most frequently measured outcomes to assess treatment effectiveness tend to improve over time (increased opening and decreased pain) [131], may be one of the reasons for confusing outcomes reported in the literature around the management of DDwoR: the effectiveness of treatments and authors’ findings in their studies may vary because of varying levels of chronicity in their sample. A systematic review of CL studies was, therefore, conducted to investigate the effects of locking duration on the success of therapeutic interventions.

Systematic review of effects of interventions in relation to CL duration

Multiple different non-surgical and surgical treatment modalities have been used for CL management. The interventions identified from the studies included in this review were defined according to their main treatment components: mandibular manipulation (MM); self-management (SM); physiotherapy (PT); splint therapy; combination therapy of splint + PT ± SM; arthrocentesis (AC); arthroscopy (AS); open surgery (OS). A detailed description of each treatment strategy is available in Appendix S6.

To investigate the effects of interventions in relation to locking duration, the characteristics and quality of the included studies were tabulated and summarised in Tables 1-6. The interventions' success rates provided in the tables are based on the success criteria used by each included study. The definition of success was, therefore, highly variable involving both objective and subjective factors with the most frequent measures being mouth opening and pain levels (Tables 1-6).

Table 1. Characteristics of included mandibular manipulation (unlock manipulation ‘UM’ or pumping manipulation ‘PM’) studies
Study (Year)Study designParticipants' characteristicsMain Intervention assessedLongest follow-up duration (months)Success criteriaStudy findings in relation to CL durationOverall success rate%(ITT use)Study design quality
Sample size (drop/exc)Study diagnosisGenderAge (years)Locking duration (months)
MFRangeMeanRangeMean ± SD
  1. RCT, randomised controlled trial; Q-RCT, quasi-randomised controlled trial; PCoSt, prospective comparative study; RCoSt, retrospective comparative study; PCCSt, prospective case–control study; PNCoSt, prospective non-comparative study; RNCoSt, retrospective non-comparative study; FSt, follow-up study; PCS, prospective case series; RCS, retrospective case series; BACS, before-after case series; BACR, before-after case report; CR, case report; AAOMS, American association of oral and maxillofacial surgery; ACL, acute closed lock; ARS, anterior repositioning splint; CCL, chronic closed lock; Ch, chronic; CMI, CranioMandibular Index; cMMO, comfortable ‘painless’ maximum mouth opening; CS, corticosteroids; Ctrl, control; DAL, daily activity limitation; DDwoR, disc displacement without reduction; DR, disc recapturing; drop, drop-outs; dy, day; exc, excluded; Exr, exercises; F, female; GA, general anaesthesia; ID, internal derangement; IL, intermittent locking; ITT, intention-to-treat analysis; IV, intravenous; j, joint; LA, local anaesthesia; LDF, limitation in daily function; LM, lateral movement; M, male; Med, medication; MFIQ, mandibular function impairment questionnaire; mm. millimetres; MMO, maximum mouth opening; mo, month; MR, muscle relaxant; MRI, magnetic resonance imaging; N, number of patients; NS, non-surgical; NSAIDs, non-steroidal anti-inflammatory drugs; OS, open surgery, PrM, protrusive movement; PM, pumping manipulation; PS, pivot splint; PT, physiotherapy; Reh, rehabilitation; S&S, signs and symptoms; SD, standard deviation; SG, successful group; SH, sodium hyaluronate; SM, self-management; SS, stabilisation splint; Sub-ac, sub-acute; S-UM, self-unlock manipulation; UG, unsuccessful group; UM, unlock manipulation; US, ultrasound; VAS, Visual Analogue Scale; W, Wilkes staging of internal derangement; wk, week; yr, year.

  2. a

    Description of Farrar's UM technique [2] is available in Appendix S7 (figure).

  3. b

    Separate data provided are for DDwoR patients only.

  4. c

    Study data are also provided in other tables according to main treatment modality assessed.

Chiba and Echigo (2005) [117]CR1DDwoR (ACL)1210·33Farrar's UMa under LA + ARS137Decreased pain, cMMO≥40 mm, & DR on MRIIV
Correa et al. (2009) [147]CR1DDwoR11836UM under LA + ARS, NSAIDs, cryotherapy24cMMO>40 mmIV
Foster et al. (2000) [148]PNCoSt55(19)22 CL (DDwoR) & 14 IL74815–52243–4813Forced UM under GA + Self-care ± Splint3MMO≥35 mm & subjective improvementThe range of locking duration (6–48) was similar in SG & UG.CL: 40·9% (no ITT)III-3
Helkimo and Hugoson (1988) [149]PCS10DDwoR3717–6329·41–3612·2Farrar's UM under N2O/O2 sedation + SS6Improvement in: pain, jaw dysfunction (Di: I–II), LM, & MMO≥40 mmLonger locking duration in UG 20 (12–36) than in SG 10·8 (1–30).60%IV
Hernandez and Karibe (2004) [150]CR1DDwoR1280·25UM under LA + Med, PT (US), SS, Self-exercises1MMO≥40 mmIV
Jagger (1991) [151]PCS12DDwoR4815–4321·81–93UM (own technique)MMO≥35 mmLocking Duration is not an important factor for UM success66·7%IV
Kai et al. (1993) [152]PCS12bDDwoR11111–6130·330·1–20·5 ± 0·53UM or PM + ARS1Improvement in clinical symptoms & MMO≥40 mm58·3% DR on arthrography.66·7%IV
Kurita et al. (1999) [132]PNCoSt74/215 assessed by MRIDDwoR76732·511·4Farrar's UM + ARS or NSAID or SSFew wksDR on MRINo significant difference in locking duration between successful DR (10 ± 19·1) and no DR (12·8 ± 24·6).18% (no ITT) 9% (ITT)III-3
Liu et al. (2012) [153]RNCoSt3623 CL (DDwoR) & 13 IL63013–3119·8<3UM under LA + ARS6Improvement in: pain, MMO, & jaw dysfunction.DDwoR: 69·6%IV
Martini et al. (1996) [154]PCS13/1500 reportedDDwoR19–5631·40·23–18036·02 ± 53·47UM (own technique) + ARS, PT2–24Absence of pain, MMO≥35 mm, & DR on MRILocking duration is not related to UM success.99·7%IV
Minagi et al. (1991) [135]PCS35DDwoR23312–6835·940·25–183·26 ± 4·09UM (own technique)MMO≥40 mmNo difference in success rate between <1mo (50%) & >1mo (53%) duration.51·4%IV
Mongini et al. (1995; 1996) [113, 155]PCT75 (7)DDwoR76813–4327·80·25–12013·3 ± 21·84Extra-oral UM under LA + ARS, SS, Med, PT18–147No pain or pain present only on jaw movement & MMO≥35 mmNo difference in locking duration between SG & UG. 4·4% DR on MRI.86·8% (no ITT)IV
Muhtarogullari et al. (2013) [156]PNCoSt22DDwoR31914–4827·13·25UM + ARS if unsuccessful DR: SS+ Self-exercises6No pain on palpation, MMO≥40 mm, normal LM & PrM15·9% DR on MRI100%III-3
Murakami et al. (1987) [157]PCS10DDwoR1914–4628·91–94·7PM + CS + ARS6AAOMS criteria: increase in cMMONo difference in locking duration between SG & UG. PM helps to unlock the CL up to about 6mo70%IV
Murakami et al. (1995) [12]cPCoSt108W: III(CL)208831·435·0 ± 8·8 5·6 ± 6·9 6·8 ± 10·2NS: Med/UM/PS, N = 63; AC, N = 20 AS, N = 256VAS pain<20, MMO>38 mm, LM & PrM> 6 mm, & improved DALPatients with >7 mo locking duration did not respond to arthrocentesisNS: 55·6% (Med:15·9% UM:18·9% PS: 33·3%) AC: 70% AS: 91%III-2
Ohnuki et al. (2006) [137]cRCoSt85DDwoR97613–7341·85·1 ± 6·8 10·4 ± 13·1 6·6 ± 8 14·2 ± 22·2SS, N = 11 PM, N = 33 AC, N = 9 AS, N = 3212VAS pain<20 & MMO>38 mmNo significant difference between SG regarding locking duration. 10% DR on MRI among all groups with no difference between groups.Med: 0% SS: 12·9% PM: 44·6% AC: 22% AS:100%III-3
Ozawa et al. (1996) [158]RCS40DDwoR43616– 6838·150·1–12019·58 ± 33·99PM ACL (0·1–0·27),N = 5; CCL (2–120),N = 350·07–3 (ACL:2–3dy CCL:2–3mo)Improvement in pain & MMO≥35 mmHigher success rate in ACL (100%) than in CCL (37·1%). PM able to release acute locking only.68·6%IV
Segami et al. (1990) [139]PCS28DDwoR32514–5725·40·07–244·7Farrar's UM or PM + ARS & NSAIDs2No or slight pain & MMO≥40 mmNo relation between MM technique (UM or PM) & locking duration. 36·7% DR on arthrography.100%IV
Simmons (2002) [159]CR1DDwoR1140·5PM under IV-sedation + ARS24Improvement in: cMMO, LM, PrM, subjective improvement, & DR on MRIIV
Singh (2010) [160]CR1DDwoR (Chronic)13224UM under LA with CS + IMF screws & elastics + ARS0·25Improvement in: VAS pain, cMMOIV
Van Dyke and Goldman (1990) [161]PCS41DDwoR (Acute)≤1·5–2UM under IM-LA (own tech) + ARSMMO≥40 mm92·7%IV
Yoshida et al. (2005) [141]RCT305DDwoR7622918–740·033–<12UM (own technique) + NSAID, N = 204NSAID only, N = 1010·25VAS pain<20, MMO≥36 mm, LM≥6 mm, & DR on MRIUM success rate drops significantly with the increase in locking duration: 1-2dy (100%), <1 wk (98·3%), <2 wk (94·6%), <3 wk (90%), <1 mo (57·1%), <2mo (16·7%), <6mo (0%).UM: 84·3%NSAID:0%II-2
Yoshida et al. (2011; 2013) [114, 162]RCT148DDwoR14819–75400·033–9 0·067–111·57 1·73Self-UM, N = 74 No treatment, N = 7410 minutesAbsence of pain & MMO>38 mmLocking duration was shorter in SG (1·18) than in UG (2·92).S-UM:68% Ctrl:4%II-2
TOTAL19studies 6studies

DDwoR

DDwoR

0·03–180

0·07–120

8·93

7·98

UM

PM

DR average success rate: 44% (range: 4·4%–99·7%)

67·6%

69·9%

Table 2. Characteristics of included self-management (SM) and physiotherapy (PT) studies
Study (Year)Study designParticipants' characteristicsMain interventions assessedLongest follow-up duration (months)Success criteriaStudy findings in relation to CL durationOverall success rate% (ITT use)Study design quality
Sample size (drop/exc)Study diagnosisGenderAge (years)Locking duration(months)
MFRangeMeanRangeMean ± SD
  1. RCT, randomised controlled trial; Q-RCT, quasi-randomised controlled trial; PCoSt, prospective comparative study; RCoSt, retrospective comparative study; PCCSt, prospective case–control study; PNCoSt, prospective non-comparative study; RNCoSt, retrospective non-comparative study; FSt, follow-up study; PCS, prospective case series; RCS, retrospective case series; BACS, before-after case series; BACR, before-after case report; CR, case report; AAOMS, American association of oral and maxillofacial surgery; AC, arthrocentesis; ACL, acute closed lock; ARS, anterior repositioning splint; AS, arthroscopy; CBT, cognitive behavioural therapy; CCL, chronic closed lock; Ch, chronic; CMI, CranioMandibular Index; cMMO, comfortable ‘painless’ maximum mouth opening; CS, corticosteroids; Ctrl, control; DAL, daily activity limitation; DDwoR, disc displacement without reduction; DR, disc recapturing; drop, drop-outs; dy, day; exc, excluded; Exr, exercises; F, female; GA, general anaesthesia; ID, internal derangement; IL, intermittent locking; ITT, intention-to-treat analysis; IV, intravenous; j, joint; LA, local anaesthesia; LDF, limitation in daily function; LM, lateral movement; M, male; Med, medication; MFIQ, mandibular function impairment questionnaire; mm. millimetres; MMO, maximum mouth opening; mo, month; MR, muscle relaxant; MRI, magnetic resonance imaging; N, number of patients; NS, non-surgical; NSAIDs, non-steroidal anti-inflammatory drugs; OS, open surgery, PrM, protrusive movement; PM, pumping manipulation; PS, pivot splint; PT, physiotherapy; Reh, rehabilitation; S&S, signs and symptoms; SD, standard deviation; SG, successful group; SH, sodium hyaluronate; SM, self-management; SS, stabilisation splint; Sub-ac, sub-acute; UG, unsuccessful group; UM, unlock manipulation; VAS, Visual Analogue Scale; W, Wilkes staging of internal derangement; wk, week; yr, year.

  2. a

    Study data are also provided in other tables according to main treatment modality assessed.

Braun (1987) [163]CR1DDwoR1710·75Self-exercises + Iontophoresis1·5Absence of pain, MMO>40 mm, LM>7 mm, improved jaw function, & eating normal dietIV
Cleland and Palmer (2004) [164]BACR1DDwoR12419SM + PT3VAS pain<20, MMO≥40 mm, & improved jaw functionIV
Craane et al. (2012) [165]RCT49 (7)DDwoR24736·6wks–yrsExercises, N = 23 Education only, N = 2613Improvement in: VAS pain, MMO, & MFIQ– (ITT)II-1
Haketa et al. (2010) [145]aRCT52 (14)DDwoR64637·6Over 0·5Self-care+ SS, N = 25; Self-care+ Self-exercise, N = 192Improvement in: VAS pain, MMO, & LDF– (ITT)II-1
Minakuchi et al. (2001; 2004) [166, 167]aRCT69 (8)DDwoR76234

3·89 ± 5·56

2·81 ± 5·09

3·12 ± 5·03

Education only, N = 21

Self-care/NSAIDs, N = 23

SS+ Exercises + Self-care/NSAIDs, N = 25

2Improvement in: VAS pain, MMO, & DAL– (ITT)II-1
Nicolakis et al. (2001) [136]BACS20 (2) 51537·31·2–6015·6Active & passive jaw exercises6Improvement in: VAS pain, MMO, & DLA85% (ITT)III-3
Schiffman et al. (2007; 2013) [168, 169]aRCT108 (12)W: III–IV (DDwoR)89831·72Non–ch <6 – ch≥6

SM + Med, N = 29

SS + PT + CBT, N = 25

AS + CS, N = 26

OS, N = 26

60Self-reported success (Patient satisfaction)SM: 72% Reh: 81% AS: 76·2% OS: 83·3% (ITT)II-1
Srisintorn (1992) [170]CR1DDwoR1292Self-care/NSAID + Self-exercises12cMMO≥40 mmIV
Yuasa and Kurita (2001) [142]RCT60 (NR)DDwoR (15ACL, 45CCL)124816–69Median28

0·53–25·07

0·63–41·8

Median 2·33

Median 3·27

NSAIDs + self-exercise, N = 30

No treatment, N = 30

1AAOMS & IAOMS modified criteria: VAS pain≤33 & MMO≥35 mmCCL (>1 mo) responded better to treatment than non-treatment in comparison with ACL (≤1 mo)SM: 60% Ctrl: 33% (ITT)II-1
Total2studiesDDwoRPT (Stretching exr.)
 7studiesDDwoRSM (self-care/Med/Exr)66%
Table 3. Characteristics of included splint (± other conservative) therapy studies
Study (Year)Study designParticipants' characteristicsMain intervention assessedLongest follow-up duration (months)Success criteriaStudy findings in relation to CL durationOverall success rate% (ITT use)Study design quality
Sample size (drop/exc)Study diagnosisGenderAge (years)Locking duration (months)
MFRangeMeanRangeMean ± sd
  1. RCT, randomised controlled trial; Q-RCT, quasi-randomised controlled trial; PCoSt, prospective comparative study; RCoSt, retrospective comparative study; PCCSt, prospective case–control study; PNCoSt, prospective non-comparative study; RNCoSt, retrospective non-comparative study; FSt, follow-up study; PCS, prospective case series; RCS, retrospective case series; BACS, before-after case series; BACR, before-after case report; CR, case report; AAOMS, American association of oral and maxillofacial surgery; AC, arthrocentesis; ACL, acute closed lock; ADP, anchord disc phenomeon; ARS, anterior repositioning splint; AS, arthroscopy; CBT, cognitive behavioural therapy; CCL, chronic closed lock; Ch, chronic; CMI, CranioMandibular Index; cMMO, comfortable ‘painless’ maximum mouth opening; CS, corticosteroids; Ctrl, control; DAL, daily activity limitation; DDwoR, disc displacement without reduction; DFD, downward flexure deformation; DR, disc recapturing; drop, drop-outs; dy, day; exc, excluded; Exr, exercises; F, female; GA, general anaesthesia; ID, internal derangement; IL, intermittent locking; ITT, intention-to-treat analysis; IV, intravenous; j, joint; LA, local anaesthesia; LDF, limitation in daily function; LM, lateral movement; M, male; Med, medication; MFIQ, mandibular function impairment questionnaire; mm. millimetres; MMO, maximum mouth opening; mo, month; MR, muscle relaxant; MRI, magnetic resonance imaging; N, number of patients; NS, non-surgical; NSAIDs, non-steroidal anti-inflammatory drugs; OS, open surgery, PrM, protrusive movement; PM, pumping manipulation; PS, pivot splint; PT, physiotherapy; Reh, rehabilitation; S&S, signs and symptoms; SD, standard deviation; SG, successful group; SH, sodium hyaluronate; SM, self-management; SS, stabilisation splint; Sub-ac, sub-acute; TENS, transcutaneous electrical nerve stimulation; UFD, upward flexure deformation; UG, unsuccessful group; UM, unlock manipulation; VAS, Visual Analogue Scale; W, Wilkes staging of internal derangement; wk, week; yr, year.

  2. a

    Study data are also provided in other tables according to main treatment modality assessed.

  3. b

    DDwoR patients in study sample ≥ 80%.

  4. c

    Follow-up report of Murakami et al. (1995) study [12].

Choi et al. (1994) [171]PCS10DDwoR1014–55270·75–52 ± 1·61SS + PT3-4MMO≥40 mmDR on MRI is unlikely to happen in CCL100%IV
Diracoglu et al. (2009) [172] aQ-RCT120 (10)DDwoR1610415–6334·1max. of 0·7AC, N = 54 SS + PT, N = 566Improvement in: VAS pain, MMO, LM, & PrMBoth are effective for early DDwoR but AC is superior for pain relief- (no ITT)III-1
Haketa et al. (2010) [145] aRCT52 (14)DDwoR64637·6Over 0·5SS + Self-care, N = 25; Self-care + Self-exercise, N = 192Improvement in: VAS pain, MMO, & LDF– (ITT)II-1
Harth (2012) [173]CR1DDwoR1532Decompression splint + Exercises21cMMO>38 mmIV
Ismail et al. (2007) [174]RCT2621b DDwoR32342·8Less than 6SS, N = 13 SS + Exercises, N = 133Improvement in: pain & MMOII-2
Israel and Syrop (1997) [175]CRs2DDwoR214–280·03–0·5Splint + Self-care/Med + PT0·5-12No pain, MMO≥35 mm, eating normal diet, & patient satisfactionIV
Iwase et al. (2005) [131]RNCoSt52DDwoR84432·1≤12 – >1225·71 ± 56·11SS+ Self-Exercises+ NSAIDs-VAS pain≤30, cMMO≥30 mm, & patient satisfactionNon-responders: 80%>12 mo symptoms' duration & 20%≤12 mo Responders: 75·7%>12 mo & 24·3%≤12 mo71·2%IV
Kai et al. (1998) [71]PNCoSt35DDwoR3515–6337·30·5–484·9SS25-42Improvement in: pain & MMO≥40 mm-55·9%III-3
Kuwahara et al. (1990) [176]PCS8DDwoR (Acute)13–590·5–6Disc recapturing splint6–16MMO>35 mm100%IV
Le Bell and Forssell (1993) [177]PCS22 (2)DDwoR51717–68Median 27< 1 – <12SS + OA (<1mo, N = 15; < 6mo, N = 5; > 6mo but <12mo, N = 2)24Improvement in: pain & jaw movements (Helkimo anamnestic & dysfunction indices: Ai: 0 or 1, Di: II)95·5% (ITT)IV
Lee et al. (2013) [178] aRCoSt43DDwoR34021·9At least 3AC + HS & SS, N = 17; SS then AC + HS, N = 13 SS only, N = 136AAOMS criteria: VAS pain<30 & cMMO≥38 mm or increase cMMO≥10 mmIII-3
Linde et al. (1995) [179]RCT33 (2)DDwoR52617–68Median 370·5–192Median 6SS, N = 16 TENS, N = 151·5VAS Pain reduction ≥50%, MMO≥40 mm, LM≥7 mm, & PrM≥7 mmSS: 53%, TENS: 6% (no ITT)II-2
Minakuchi et al. (2001; 2004) [166, 167] aRCT69 (8)DDwoR76234

3·89 ± 5·56

2·81 ± 5·09

3·12 ± 5·03

Education, N = 21

Self-care/NSAIDs, N = 23

SS+ Exercises + Self-care/NSAIDs, N = 25

2Improvement in: VAS pain, MMO, & DAL– (ITT)II-1
Murakami et al. (1995) [12] aPCoSt108W: III (CL)208831·43

5·0 ± 8·8

5·6 ± 6·9

6·8 ± 10·2

NS: Med/UM/PS, N = 63

AC, N = 20

AS, N = 25

6VAS pain<20, MMO>38 mm, LM & PrM> 6 mm, & improved DALPatients with >7mo locking duration did not respond to arthrocentesisNS: 55·6% (Med:15·9% UM:18·9% PS: 33·3%) AC: 70% AS: 91%III-2
Murakami et al. (2002) [111]FSt c63 (7)W: III (CL)84213– 7533·25·0 ± 8·8Med (NSAIDs + MR), or UM, or PS120Improvement in: VAS pain, Jaw function, & DAL89·3% (ITT)IV
Ohnuki et al. (2006) [137] aRCoSt85DDwoR97613–7341·8

5·1 ± 6·8

10·4 ± 13·1

6·6 ± 8

14·2 ± 22·2

SS, N = 11

PM, N = 33

AC, N = 9

AS, N = 32

12VAS pain<20 & MMO>38 mmNo significant difference between SGs regarding duration of lockingSS: 12·9% PM: 44·6% AC: 22% AS: 100%III-3
Schiffman et al. (2007; 2013) [168, 169] aRCT108 (12)W: III–IV DDwoR89831·72Non–ch <6 – ch≥6SM + Med, N = 29 SS + PT + CBT, N = 25; AS + CS, N = 26; OS, N = 2660Self-reported success (Patient satisfaction)SM: 72% Reh: 81% AS: 76·2% OS: 83·3% (ITT)II-1
Shoji (1995) [180]CR1DDwoR Chronic1166SS1·5Reduced pain & MMO≥35 mmIV
Stiesch-Scholz et al. (2002) [140]PNCoSt55DDwoR74815–7741·96<0·25 – >6PS acute(<3), N = 19 Sub-ac (3–6), N = 19 Ch (>6), N = 1745–50VAS pain=0, MMO≥40 mm, improved LM, PrM, & chewing abilityThe success rate of treatment decreased with longer locking duration: acute (84·2%), Sub-acute (63·2%), & chronic (64·7%). DR in 3 patients with <1 wk.72·7%III-3
Stiesch-Scholz et al. (2005) [181]RCT40DDwoR53518–6433·65

3·83 ± 3·45

4·68 ± 2·9

SS, N = 20

PS, N = 20

3Improvement in: pain, MMO, LM, & PrMII-1
Tanaka et al. (2000) [182]CR1W: IV DDwoR12260Splint + Exercises60Improved pain & MMOIV
Yoshida et al. (2005) [183]PNCoSt40DDwoR4016–6429·85

51·6 ± 57·6

33·6 ± 39·6

SS-UFD, N = 20

SS-DFD, N = 20

6No pain or pain present only on jaw movement & increased MMOOverall: 57·5% UFD: 20% DFD: 95%III-3
TOTAL12studiesDDwoR0·25–19215·53Splint only60·1%
10studiesDDwoR10·28Splint + others84·1%
Table 4. Characteristics of included arthrocentesis (AC) studies
Study (Year)Study designParticipants' characteristicsMain interventions assessedLongest follow-up duration (months)Success criteriaStudy findings in relation to CL duration% Overall success rate (ITT used)Study design quality
Sample size (drop/exc)Study diagnosisGenderAge (years)Locking duration (months)
MFRangeMeanRangeMean ± SD
  1. RCT, randomised controlled trial; Q-RCT, quasi-randomised controlled trial; PCoSt, prospective comparative study; RCoSt, retrospective comparative study; PCCSt, prospective case–control study; PNCoSt, prospective non-comparative study; RNCoSt, retrospective non-comparative study; FSt, follow-up study; PCS, prospective case series; RCS, retrospective case series; BACS, before-after case series; BACR, before-after case report; CR, case report; AAOMS, American association of oral and maxillofacial surgery; AC, arthrocentesis; ACL, acute closed lock; ADP, anchord disc phenomeon; ARS, anterior repositioning splint; AS, arthroscopy; CBT, cognitive behavioural therapy; CCL, chronic closed lock; Ch, chronic; CMI, CranioMandibular Index; cMMO, comfortable ‘painless’ maximum mouth opening; CS, corticosteroids; Ctrl, control; DAL, daily activity limitation; DDwoR, disc displacement without reduction; DR, disc recapturing; drop, drop-outs; dy, day; exc, excluded; Exr, exercises; F, female; GA, general anaesthesia; ID, internal derangement; IL, intermittent locking; ITT, intention-to-treat analysis; IV, intravenous; j, joint; LA, local anaesthesia; LDF, limitation in daily function; LM, lateral movement; M, male; Med, medication; MFIQ, mandibular function impairment questionnaire; mm. millimetres; MMO, maximum mouth opening; mo, month; MR, muscle relaxant; MRI, magnetic resonance imaging; N, number of patients; NS, non-surgical; NSAIDs, non-steroidal anti-inflammatory drugs; OS, open surgery, PM, protrusive movement; PrM, pumping manipulation; PS, pivot splint; P-SH, pumping sodium hyaluronate; PT, physiotherapy; Reh, rehabilitation; S&S, signs and symptoms; SD, standard deviation; SG, successful group; SH, sodium hyaluronate; SM, self-management; SS, stabilisation splint; Sub-ac, sub-acute; Tx, tenoxicam; UG, unsuccessful group; UM, unlock manipulation; VAS, Visual Analogue Scale; W, Wilkes staging of internal derangement; wk, week; yr, year.

  2. a

    Separate data provided are for CL patients only.

  3. b

    Follow-up report of Nitzan and Dolwick (1991) study [9].

  4. c

    Study data are also provided in other tables according to main treatment modality assessed.

  5. d

    Studies seem to share part of their CL study sample in multiple publications.

  6. e

    Follow-up study of Murakami et al. (1995) study [12].

  7. f

    DDwoR patients in study sample ≥ 80%.

  8. g

    Excluded from the total due to intervention difference.

Aktas et al. (2010a) [184]PCoSt25DDwoR22317–6430·40·1–246·76AC alone, N = 13 AC + SH, N = 1212AAOMS criteria: VAS pain≤30 mm, MMO ≥35 mm, & improved jaw functionMean locking duration was higher in UG 9·6 (1–24) than SG 3·92 (0·1-24)Overall 80% AC:84·6%, AC+SH: 75%III-2
Aktas et al. (2010b) [185]RCT21DDwoR41715–5226·430·1–245·29AC alone, N = 14 AC + TX, N = 76AAOMS criteria: VAS pain≤30 mm, MMO ≥35 mm, improved jaw functionOverall 83·3% AC:85·7%, AC+TX: 71·4%II-2
Alpaslan and Alpaslan (2001) [187]RCT15aDDwoR (CL)11415–5331·902–7218·5AC alone, N = 4 AC + SH, N = 113–28Improvement in: pain, MMO, LM, & jaw functionII-2
Alpaslan et al. (2008) [186]RCT67 (12)DDwoR18–5130·10·03–186·73AC alone, N = 14 AC + soft splint, N = 9; AC + hard splint, N = 226Improvement in: pain, MMO, & LM– (no ITT)II-2
Bhargava et al. (2012) [188]CR1DDwoR1323AC + CS1MMO≥35 mm & VAS pain=0IV
Dhaif and Ali (2001) [189]RNCoSt62 (22)ADP95316–5028·90·75–1211·43 ± 8·35AC, N = 4036VAS pain<2, MMO≥38 mm, LM≥5 mm, PrM≥5 mm, improved DLA95%IV
Dimitroulis et al. (1995) [190]FStb46ADP24425–3932·51–8413AC6–30Improvement in: VAS pain, VAS jaw dysfunction (chewing ability), & MMO97·8%IV
Diracoglu et al. (2009) [172]cQ-RCT120 (10)DDwoR1610415–6334·1max. of 0·7AC, N = 54 SS + PT, N = 566Improvement in: VAS pain, MMO, LM, & PrMBoth are effective for early DDwoR but AC is superior for pain relief– (no ITT)III-1
Emshoff and Rudisch (2004) [192]dPNCoSt29DDwoR (ID III)72217–6934·6Non–ch≤6–Ch>6 < 248·76AC (Non–ch, N = 15 Ch, N = 14)2Absence of DDwoR S&S and VAS Pain Reduction≥85%Symptoms' duration was lower in SG (5·28 ± 4·03) than in UG (12·23 ± 6·83).37·9%III-3
Emshoff and Rudisch (2007) [193]dPNCoSt37DDwoR (ID III)63117–6928·38·68 ± 6·9AC2MMO≥35 mm & pain reduction >50%No statistical significant difference in duration of symptoms between SG (9·25 ± 5·53) and UG (7·95 ± 8·5)56·8%III-3
Emshoff et al. (2000) [194]dPNCoSt15DDwoR (ID III)1518–7138·71–95·7AC2Improvement in: VAS pain & MMOIII-3
Emshoff et al. (2003) [195]dPNCoSt38DDwoR (ID III)63217–6933·87·13 ± 6·1AC2Absence of DDwoR symptoms (VAS pain & MMO)No statistical significant difference in duration of symptoms between SG (7·38 ± 5·78) and UG (6·68 ± 6·8).63·2%III-3
Emshoff (2005) [130]dPNCoSt64DDwoR (ID III)65817–6933·4Non–ch ≤6 – ch>612·31AC2Absence of DDwoR symptoms (VAS pain & MMO)The mean duration of symptoms was lower in SG (10·15 ± 9·35) than UG (14·48 ± 21·25) but the difference was not statistically significant.53·1%III-3
Emshoff et al. (2006) [191]dPNCoSt28DDwoR (ID III)82017–6930·9Less than 12AC2Improvement in: VAS Pain on jaw function & MMOIII-3
Gateno (1994) [196]cCRs2DDwoR (ACL)225–310·5–0·7AC3MMO≥38 mm & VAS pain≤4IV
Ghanem (2011) [197]PCoSt20DDwoR (ACL)2024–5434Less than 1AC + CS, N = 10 AC + CS & SS, N = 1012Improvement in: VAS Pain, MMO, LM, PrM, & jaw dysfunctionAC+SS are the treatment of choice for ACL (<1mo) with bruxismOverall: 60% AC: 30% AC+SS: 90%III-2
Hosaka et al. (1996) [198]FSte20 (1)W: III (CL)31·25·6 ± 6·9AC36VAS pain<2, MMO> 38 mm, LM>6 mm, PrM>6 mm, normal diet & improved jaw function, daily activity.78·9%IV
Kaneyama et al. (2007b) [57]PCS14ADP5915–7034·30·5–124 ± 4·1AC1–12No or mild pain, MMO>38 mm, eating normal dietSymptoms' duration was longer in SG (0·5–12) than UG (1–4).64·3%IV
Kaneyama et al. (2007a) [200]PNCoSt66DDwoR46214–73361–242AC + CS2–13No or mild VAS pain, MMO>38 mm, LM>6 mm, & PrM>6 mm77%III-3
Kaneyama et al. (2004) [199]PCS17DDwoR51217–76400·8–6019AC + CS3No or mild VAS pain, MMO>38 mm, LM>6 mm, & PrM>6 mmNo correlation between duration of symptoms and clinical symptoms88%IV
Lee et al. (2013) [178]cRCoSt43DDwoR34021·9At least 3AC + HS & SS, N = 17; SS then AC + HS, N = 13 SS only, N = 136AAOMS criteria: VAS pain<30 & cMMO≥38 mm or increase cMMO≥10 mmIII-3
Mohanavalli et al. (2011) [201]CR1CL128More than 12AC + CS9VAS pain=0, MMO≥40 mm, LM & PrM≥ 6 mm, & improved functionIV
Murakami et al. (1995) [12]cPCoSt108W: III (CL)208831·43

5·0 ± 8·8

5·6 ± 6·9

6·8 ± 10·2

NS: Med. or UM or PS, N = 63

AC, N = 20

AS, N = 25

6VAS pain<20, MMO>38 mm, LM & PrM> 6 mm, & improved DALPatients with >7mo locking duration not respond to ACNS: 55·6% (Med:15·9% UM:18·9% PS: 33·3%) AC: 70% AS: 91%III-2
Ness and Crawford (1996) [202]RCS15CL

0·23–1

4–109

0·6 ACL

38·1 CCL

AC +CS (ACL<4 mo, N = 6; CCL>4 mo, N = 9)MMO >40 mm, no or mild pain, and normal eating64%IV
Nishimura et al. (2001; 2004) [203, 204]PNCoSt10095f DDwoR118913–73Median 310·07–365·67AC + CS0·25No or mild VAS pain & MMO>38 mmThe mean duration of locking was lower in SG 4·33 (0·033–36·5) than UG 8·43 (0·13–36·7) but the difference was not statistically significant.70·9%III-3
Nitzan et al. (1991) [206]PCS17ADP31416–6532·62–6011·8 ± 12·9AC + CS4–14VAS pain≤4 of 15, VAS jaw dysfunction≤4 of 15, MMO≥35 mm, PrM & LM>7 mm, & patient satisfactionOne patient with longest duration of symptoms (60 mo) showed marked increase in MMO but no significant decrease in pain & jaw dysfunction.91%IV
Nitzan (1994) [205]PCS29ADP82113·9AC + CSMean 22·2Improvement in: VAS Pain, VAS jaw dysfunction, & MMO96·5%IV
Nitzan et al. (1997) [55]PNCoSt39ADP83114–5328·90·5–4811·43 ± 8·35AC6–37Improvement in: VAS Pain & VAS jaw dysfunction, MMO≥35 mm, PrM & LM≥5 mm, & patient satisfactionIncreased duration of symptoms seemed to affect joint function and deteriorate it.95%III-3
Ohnuki et al. (2006) [137]cRCoSt85DDwoR97613–7341·8

5·1 ± 6·8

10·4 ± 13·1

6·6 ± 8

14·2 ± 22·2

SS, N = 11

PM, N = 33

AC, N = 9

AS, N = 32

12VAS pain<20 & MMO>38 mmNo significant difference between SGs regarding locking duration.SS: 12·9% PM: 44·6% AC: 22% AS: 100%III-3
Sahlstrom et al. (2013) [207]RCT45 (8)DDwoR44134·9≤3LA only, N = 25 AC, N = 203Reduction in VAS pain≥30% during jaw movementLA: 76% AC: 55% (ITT)II-1
Sakamoto et al. (2000) [138]PCS18DDwoR11717–6733·32·3–4614 ± 12·8AC3AAOMS criteria: MMO≥40 mm & VAS pain<33Symptoms' duration in SG (8·4 ± 5·4) was significantly shorter than in UG (19·6 ± 15·6).50%IV
Sanroman (2004) [58]cPCoSt26 (2)ADP62016–3524·30·23–31·21AS + SH, N = 16 AC + SH, N = 824–36VAS pain≤ 2 of 15, MMO≥35 mm, LM≥7 mm & PrM≥10 mm100%III-2
Sato et al. (1997) [210]PCoSt76DDwoR27411–7429·9

0·1–60

0·1–48

5·9

6·5

Pumping SH g, N = 26

No treatment, N = 50

6AAOMS Criteria: little or no pain, MMO≥35 mm, LM or PrM> 4 mm, eating normal diet & improved jaw function.P-SH: 73·1% Ctrl:36%III-2
Sato et al. (2001) [208]RCoSt146 (25)DDwoR91073 >  – 3≤Pumping SH g, N = 59/72 No treatment, N = 62/7412AAOMS Criteria: Little/no pain & MMO≥35 mmPatients with locking duration for <3 mo are more likely to benefit from treatment than those with locking duration for ≥3 mo.P-SH: 75% Ctrl: 63·5% (ITT)III-3
Sato and Kawamura (2008) [209]PCoSt59DDwoR5913–6134·95

0·2–336

0·03–440

31·6

36·4

Pumping SH g + Self-exercises, N = 23

Pumping SH, N = 36

12AAOMS Criteria: Little/no pain, MMO≥35 mmOverall: 69·49% P-SH+ Ex: 60·9% P-SH only: 75%III-2
Sembronio et al. (2008) [13]PNCoSt33DDwoR23121–7341·80·25–248·5AC + SH + UM (ACL<1, N = 8 CCL>1, N = 25)12VAS pain< 2, MMO >38 mm, ADL <4/16, & improved jaw function, chewing & swallowing, & eating normal dietHigher success rate in ACL (87·5%) than CCL (68%). DR was possible only in ACL and no DR in all CCL cases.72·7%III-3
Thomas et al. (2012) [211]PCS32ACL52718–27231–3AC6Improvement in: VAS pain, VAS jaw dysfunction (chewing ability), & MMO.90·6%IV
Yura et al. (2011) [143]PNCoSt50DDwoR (CCL)54512–71Median 443–48Median 4AC (under high pressure) + CS2Improvement in: MMO≥40 mm, VAS pain at opening≤5 mm, & VAS pain on biting=0III-3
TOTAL32 studiesAll CL0·03–1099·49AC72·5%
27 studiesDDwoR0·03–10910AC65·2%
7 studiesADP0·23–849·54AC91·4%
Table 5. Characteristics of included arthroscopy (AS) studies
Study (Year)Study designParticipants' characteristicsMain interventions assessedLongest follow-up duration (months)Success criteriaStudy findings in relation to CL durationOverall success rate% (ITT used)Study design quality
Sample size (drop/exc)Study diagnosisGenderAge (years)Locking duration (months)
MFRangeMeanRangeMean ± SD
  1. RCT, randomised controlled trial; Q-RCT, quasi-randomised controlled trial; PCoSt, prospective comparative study; RCoSt, retrospective comparative study; PCCSt, prospective case–control study; PNCoSt, prospective non-comparative study; RNCoSt, retrospective non-comparative study; FSt, follow-up study; PCS, prospective case series; RCS, retrospective case series; BACS, before-after case series; BACR, before-after case report; CR, case report; AAOMS, American association of oral and maxillofacial surgery; AC, arthrocentesis; ACL, acute closed lock; ADP, anchord disc phenomeon; ARS, anterior repositioning splint; AS, arthroscopy; CBT, cognitive behavioural therapy; CCL, chronic closed lock; Ch, chronic; CMI, CranioMandibular Index; cMMO, comfortable ‘painless’ maximum mouth opening; CS, corticosteroids; Ctrl, control; DAL, daily activity limitation; DDwoR, disc displacement without reduction; DR, disc recapturing; drop, drop-outs; dy, day; exc, excluded; Exr, exercises; F, female; GA, general anaesthesia; ID, internal derangement; IL, intermittent locking; ITT, intention-to-treat analysis; IV, intravenous; j, joint; LA, local anaesthesia; LDF, limitation in daily function; LM, lateral movement; M, male; Med, medication; MFIQ, mandibular function impairment questionnaire; mm. millimetres; MMO, maximum mouth opening; mo, month; MR, muscle relaxant; MRI, magnetic resonance imaging; N, number of patients; NS, non-surgical; NSAIDs, non-steroidal anti-inflammatory drugs; OS, open surgery, PrM, protrusive movement; PM, pumping manipulation; PS, pivot splint; PT, physiotherapy; Reh, rehabilitation; S&S, signs and symptoms; SD, standard deviation; SG, successful group; SH, sodium hyaluronate; SM, self-management; SS, stabilisation splint; Sub-ac, sub-acute; UG, unsuccessful group; UM, unlock manipulation; US: ultrasound; VAS: Visual Analogue Scale; VGIR: visually guided irrigation; W, Wilkes staging of internal derangement; wk, week; yr, year.

  2. a

    DDwoR patients in study sample ≥ 80%.

  3. b

    Study data are also provided in other tables according to main treatment modality assessed.

  4. c

    Studies seem to share part of their CL study sample in multiple publications.

  5. d

    Separate data provided are for CL patients only.

Casares et al. (1999) [59]PNCoSt26ADP (static disc)2620–5637·53–247·8AS10Pain free & MMO>30 mmA relationship between CL duration and adhesions type was found92·3%III-3
Chen et al. (2010) [212]PCS352W: III–IV 343/419 ja5030215–7233·32–24024·1AS coblation with disc suturing3Improvement in S&S and MRI findings92·8%IV
Clark et al. (1991) [213]PNCoSt1817 DDwoR & 1 ADP11715–5227Sub-ac =3–9 to ch>912·4 ± 12AS21–30Improvement in: VAS pain, jaw function, & MMOLocking duration was not a predictor of AS success or failure.83·3%III-3
Dimitroulis (2002) [120]PCS5649 DDwoR94715–70361·5–123·4AS + CS1·5Improvement in: VAS pain, MMO, & patient satisfaction66%IV
Furst et al. (2001) [214]RCT3226 DDwoR230

42·5 ± 36·1

18·5 ± 17

61·4 ± 61·3

63·3 ± 79·7

AS only

AS + bupivacaine

AS + morphine

AS + bupivacaine & morphine

0·07Pain reductionII-2
Gateno (1994) [196]bCR1CL1243ASNo pain & MMO>40 mm-IV
Go et al. (1996) [215]PCS10CL1020–5931·20·75–3·752·2AS4–68No or mild pain & MMO>30 mm80%IV
Hamada et al. (2003) [218]cPNCoSt69 (39)DDwoR (CCL)52520–6441·61–7215·5AS (2nd VGIR) + SH, N = 30VAS pain<20 & <60% of preoperative level, increased cMMO, & cMMO≥38 mm60% (no ITT)III-3
Hamada et al. (2005) [217]cPNCoSt68 (20)DDwoR (CCL)93920–7042·82–127Median 9·5AS (2nd VGIR), N = 483–36VAS pain=0 & cMMO≥38 mmNo significant correlation between duration of symptoms and treatment outcome with fibrous adhesion.62·5% (no ITT)III-3
Hamada et al. (2006a) [219]cPNCoSt64 (3)DDwoR (CCL)95219–7040·72–127Median 7AS (1st VGIR), N = 6412VAS pain<20 & <60% of preoperative level, increased cMMO, & cMMO≥38 mmNo significant difference in the duration of symptoms between SG 8 (2–108) and UG 5 (2–127).72·1% (no ITT)III-3
Hamada et al. (2006b) [106]cPNCoSt36 (2)DDwoR (CCL)63027–5946·5IQ 3–17Median 7·5AS (VGIR), N = 36VAS pain<20 & <60% of preoperative level, increased cMMO, & cMMO≥38 mmNo significant difference in the duration of symptoms between SG 8 (5·5–17) and UG 6 (3–8).69·4% (no ITT)III-3
Hamada et al. (2008a; 2008b) [216, 220]cPNCoSt58 (2)DDwoR (CCL)84829–56Median 46IQ 3–12·5Median 7AS (1st VGIR), N = 566–13VAS pain<20 & <60% of preoperative level, increased cMMO, & cMMO≥38 mmNo significant difference in duration of symptoms between SG 8 (5·8–12·3) and UG 6 (3–8).67·9% (no ITT)III-3
Holmlund et al. (2001) [121]RCT22 (2)CCL21822–5334·5

2–24

2–60

8·5

20·5

OS, N = 10

AS, N = 10

12VAS pain<20, MMO>35 mm, PrM>5 mm, MFIQ<7No difference in improvement between patients having <6 mo & >6 mo symptoms' duration in both groups.OS: 70%, AS: 50% (no ITT)II-2
Kim et al. (2009) [221]PCS15DDwoR31215–6432·13–7221·4AS (ultrathin) + SH10–40VAS pain ≤20 & <60% of preoperative level, increased MMO≥5 mm, & no recurrence of symptoms.80%IV
Kondoh et al. (2003a) [222]cPNCoSt20DDwoR41620–69441–7217·4AS (VGIR) + SH6VAS pain<20 & <60% of preoperative level, & cMMO>38 mm80%III-3
Kumagai et al. (2010) [223]cPNCoSt45DDwoR (CCL)133224–6536·5More than 3AS (VGIR), N = 452–23VAS pain <20 and <60% of preoperative level, & cMMO≥38 mm71·1%III-3
Kurita et al. (1998) [134]PNCoSt14DDwoR11320–7244·69–16324·9AS + CS13–66AAOMS & IAOMS criteria: No or slight dysfunction (MMO≥35 mm, VAS≤33)No difference in locking duration between SG 27 (9–163) & UG 10 & 14 mo.85·7%III-3
Lewis (1987) [224]CR1DDwoR (CCL)14812AS0·25Little pain & MMO=35 mm-IV
Machon et al. (2012) [225]PNCoSt50Chronic DDwoR(<12 – >12)AS, N = 50 (<12 mo, N = 28; >12 mo, N = 22)6No or minimal pain (0 or 1 out 6), & MMO>35 mmHigher success rate (89%) in patients with shorter duration of symptoms <12 mo than the rate (72%) in those with longer symptoms' duration >12 mo.82%III-3
Murakami (1990) [226]PCS32DDwoR42814–70391–186·6AS2–60Little or no complaints and good jaw opening & functionPatients with ≥6 mo locking duration had poor response to AS. Higher pain relief in patients with <6mo symptoms' duration as compared to patients with longer duration.84·4%IV
Murakami et al. (1995) [12]bPCoSt108W: III (CL)208831·43

5·0 ± 8·8

5·6 ± 6·9

6·8 ± 10·2

NS: Med. or UM or PS, N = 63

AC, N = 20

AS, N = 25

6VAS pain<20, MMO>38 mm, LM & PrM> 6 mm, & improved DALPatients with >7mo locking duration not respond to ACNS: 55·6% (Med:15·9% UM:18·9% PS: 33·3%) AC: 70% AS: 91%III-2
Nakaoka et al. (2009) [227]PNCoSt56 (16)CCLIQ 29–55Median 43IQ 5–12Median 7AS (2nd VGIR), N = 40VAS pain<20 & <60% of preoperative level, increased cMMO, & cMMO≥38 mmNo significant difference in symptoms' duration between SG 8 (5·5–12·5) & UG 5 (3–12).72·5% (no ITT)III-3
Nitzan et al. (1990) [228]PCS208 DDwoR2019–4026·36–9634·8 ± 26·04AS + CS6–24Improvement in: VAS Pain, VAS jaw dysfunction, & MMODDwoR 87·5%IV
Ohnuki et al. (2003) [229]RNCoSt4340 DDwoR43915–6841·412·6 ± 20·1AS + CS + SH12VAS pain<20 & MMO>38 mmNo statistically significant difference in locking duration between SG (14·2 ± 22·2) and UG (7·9 ± 11·4).74·4%IV
Ohnuki et al. (2006) [137]bRCoSt85DDwoR97613–7341·8

5·1 ± 6·8

10·4 ± 13·1

6·6 ± 8

14·2 ± 22·2

SS, N = 11

PM, N = 33

AC, N = 9

AS, N = 32

12VAS pain<20 & MMO>38 mmNo significant difference between SGs regarding locking duration.SS: 12·9% PM: 44·6% AC: 22% AS: 100%III-3
Politi et al. (2007) [230]bRCT20DDwoR (CCL)61425–6742·8

6–27

8–24

15·1

14·7

OS, N = 10

AS + SH, N = 10

12VAS pain≤20, MMO≥35 mm, PrM>5 mm, MFIQ ≤ 7OS: 80%, AS: 70%II-2
Saitoa et al. (2010) [231]PNCoSt64 (3)CCL95219–7040·72–127Median 7AS (VGIR)3–40VAS pain<20 & <60% of preoperative level, & cMMO≥38 mmNo statistically significant difference in locking duration between SG 8 (2–108) and UG 5 (2–127).72·1% (no ITT)III-3
Sanders (1986) [232]PCS21dDDwoR12011–4927·11–12019·62 ± 24·2AS + CS7–10Little pain & improved MMO95·2%IV
Sanroman (2004) [58]bPCoSt26 (2)ADP62016–3524·30·25–31·21AS + SH, N = 16 AC + SH, N = 824–36VAS pain≤ 2 of 15, MMO≥35 mm, LM≥7 mm & PrM≥10 mm100%III-2
Schiffman et al. (2007; 2013) [168, 169]bRCT108 (12)W: III–IV (DDwoR)89831·72Non-ch<6 – Ch≥6SM + Med., N = 29 SS + PT + CBT, N = 25; AS + CS, N = 26; OS, N = 2660Self-reported success (Patient satisfaction)SM: 72% Reh: 81% AS: 76·2% OS: 83·3% (ITT)II-1
Yoshida et al. (2008) [233]PCS55DDwoR2–10·54·25AS (thin fibre & laser)3Improvement in: VAS pain, MMO, & patient satisfaction.94·5%IV
Zhang et al. (2009) [234]RNCoSt1506W: III–IV 1479a281122512–7329·790·5–966·97AS Adhesion group, N = 490; Non-adhesion group, N = 1230Locking duration was significantly higher in adhesion (6·97 ± 8·38) than non-adhesion (5·42 ± 4·34) groupIV
TOTAL32 studiesAll CL0·25–16319·04AS79%
30 studiesDDwoR0·5–16320·37AS77·7%
2 studiesADP0·25–244·51AS96·2%
Table 6. Characteristics of included open surgery (OS) studies
Study (Year)Study designParticipants' characteristicsMain interventions assessedLongest follow-up duration (months)Success criteriaStudy findings in relation to CL durationOverall success rate% (ITT)Study design quality
Sample size (drop/exc)Study diagnosisGenderAge (years)Locking duration (months)
MFRangeMeanRangeMean ± SD
  1. RCT, randomised controlled trial; Q-RCT, quasi-randomised controlled trial; PCoSt, prospective comparative study; RCoSt, retrospective comparative study; PCCSt, prospective case–control study; PNCoSt, prospective non-comparative study; RNCoSt, retrospective non-comparative study; FSt, follow-up study; PCS, prospective case series; RCS, retrospective case series; BACS, before-after case series; BACR, before-after case report; CR, case report; AC, arthrocentesis; ACL, acute closed lock; ARS, anterior repositioning splint; AS, arthroscopy; CBT, cognitive behavioural therapy; CCL, chronic closed lock; Ch, chronic; CMI, CranioMandibular Index; cMMO, comfortable ‘painless’ maximum mouth opening; CS, corticosteroids; Ctrl, control; DAL, daily activity limitation; DDwoR, disc displacement without reduction; DR, disc recapturing; drop, drop-outs; dy, day; exc, excluded; Exr, exercises; F, female; GA, general anaesthesia; ID, internal derangement; IL, intermittent locking; ITT, intention-to-treat analysis; IV, intravenous; j, joint; LA, local anaesthesia; LDF, limitation in daily function; LM, lateral movement; M, male; Med, medication; MFIQ, mandibular function impairment questionnaire; mm. millimetres; MMO, maximum mouth opening; mo, month; MR, muscle relaxant; MRI, magnetic resonance imaging; N, number of patients; NS, non-surgical; NSAIDs, non-steroidal anti-inflammatory drugs; OS, open surgery, PrM, protrusive movement; PM, pumping manipulation; PS, pivot splint; PT, physiotherapy; Reh, rehabilitation; S&S, signs and symptoms; SD, standard deviation; SG, successful group; SH, sodium hyaluronate; SM, self-management; SS, stabilisation splint; Sub-ac, sub-acute; UG, unsuccessful group; VAS, Visual Analogue Scale; W, Wilkes staging of internal derangement; wk, week; yr, year.

  2. a

    Separate data provided are for CL patients only.

  3. b

    Study data are also provided in other tables according to main treatment modality assessed.

  4. c

    DDwoR patients in study sample ≥ 80%.

Holmlund et al. (2001) [121]bRCT22 (2)CCL21822–5334·5

2–24

2–60

8·5

20·5

OS (Discectomy), N = 10

AS, N = 10

12VAS pain<20, MMO>35 mm, PrM>5 mm, MFIQ<7No difference in improvement between patients having <6mo & >6mo symptoms' duration in both groups.OS: 70%, AS: 50% (no ITT)II-2
Kondoh et al. (2003b) [235]PCS7aDDwoR (CL)720–5132·5714–4224·57 ± 9·22Disc Reshaping without repositioning60Improvement in: pain & MMODDwoR 100%IV
Ozkan et al. (2012) [236]RNCoSt46aUni/bilat. DDwoR83818–6334·722·9High condylectomy ± disc repositioning, discectomy, or osteoplasty.18–156Improvement in: pain, MMO, & Patient satisfactionIV
Politi et al. (2007) [230]bRCT20DDwoR (CCL)61425–6742·8

6–27

8–24

15·1

14·7

OS (High condylectomy & disc repositioning), N = 10

AS + SH, N = 10

12VAS pain≤20, MMO≥35 mm, PrM>5 mm, MFIQ ≤ 7OS: 80%, AS: 70%II-2
Schiffman et al. (2007; 2013) [168, 169]bRCT108 (12)DDwoR (W: III–IV)89831·72Non–ch<6 – ch≥6SM + Med, N = 29 SS + PT + CBT, N = 25 AS + CS, N = 26 OS (Arthroplasty), N = 2660Self-reported success (Patient satisfaction).SM: 72% Reh: 81% AS: 76·2% OS: 83·3% (ITT)II-1
Turley (1993) [237]CR1DDwoR (CL)1235Arthroplasty (discectomy with sialistic implant replacement)72MMO≥40 mm, improved function, & stable occlusionIV
Widmark et al. (1997) [238]RCS20 (4)DDwoR11521–713718–15048Discectomy6–42Improvement in: VAS Pain & jaw function (CMI)88% (no ITT)IV
Zhang et al. (2010) [239]PNCoSt81

W: III–IV

69c

235823–7438·50·5–6012·06Disc repositioning by bone anchores0·25DR on MRI96·3%III-3
TOTAL8studiesDDwoR0·5–15021·86OS86·3%
Summary of intervention effects in relation to locking duration

Mandibular manipulation (MM): Nineteen included studies used different unlock manipulation (UM) techniques on DDwoR patients with a mean locking duration of 9 months (range: 0·03–180 months). The most commonly used UM technique is Farrar's technique [2] (described in Appendix S7 ‘Figure’), and the most commonly used splint after recapturing the displaced disc is the anterior repositioning splint (ARS). The UM success rate was variable ranging from 9% to 100% (mean: 68%). Pumping manipulation (PM) was used in six studies on DDwoR patients with a mean locking duration of 8 months (range: 0·07–120 months) and had comparable success rate to UM. Among all the included studies on MM, nine studies used post-operative imaging to assess disc recapturing with a mean success rate of 44% (range: 4–100%) (Table 1).

Self-management (SM) and physiotherapeutic (PT) interventions: Self-management involving self-exercises with medication and self-care instructions and education was used on DDwoR patients in seven studies with a mean success rate of 66%. Only two studies evaluated the jaw stretching exercises by physiotherapists as the sole treatment on patients with DDwoR having locking duration ranging from several weeks to several years with high success rate (Table 2).

Splint therapy: Occlusal splints were used either as a main treatment strategy or as an adjunct treatment to other interventions in the management of DDwoR. In 12 studies, different types of splints were used independently as the sole treatment for DDwoR patients with a mean locking duration of 16 months (range: 0·25–192) with a variable success rate ranging from 13% to 100% (mean: 60%). The adjunctive use of splints with other conservative interventions was employed by 10 studies with DDwoR patients who had a mean locking duration of 10 months resulting in a mean success rate of 84% (range: 71–100%) (Table 3).

Arthrocentesis (AC): Arthrocentesis was used in 32 studies on patients with a mean CL duration of 10 months (range: 0·03–109 months) with a success rate ranging from 22% to 100% (mean: 73%). The AC success rate was, however, higher in ADP (91%) than DDwoR (65%) studies (Table 4).

Arthroscopy (AS): Thirty-two included studies used arthroscopy on patients with a mean CL duration of 19 months (range: 0·25–163 months) with a success rate ranging from 50% to 100% (mean: 79%) (Table 5).

Open surgery (OS): Open joint surgery was used in eight studies on CL patients with a mean locking duration of 22 months (range: 0·5–150 months) with a success rate ranging from 70% to 100% (mean: 86%) (Table 6).

Quality of included studies

Most of the included studies were of poor quality and had various methodological weaknesses in their design. Specifically, most were either uncontrolled studies or had incompletely defined or controlled for other prognostic factors that may influence treatment outcome. The level of evidence was, therefore, generally of a low grade (III–IV).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

There was considerable heterogeneity among the studies included in the systematic review of locking duration. Although the studies were grouped based on their treatment modality, there were considerable variations in the following: study design, diagnostic and inclusion criteria, intervention delivery, techniques and combinations, outcome measures, success criteria and follow-up periods. These findings were, however, expected before undertaking this review as one of the aims of this paper was to investigate whether there is any relationship between treatment outcome and CL duration rather than to identify the scientific evidence for clinical effectiveness of interventions used in managing DDwoR. The latter is best accomplished through a systematic review of randomised clinical trials in DDwoR management which is nearing completion [15].

To the best of the authors' knowledge, this is the first comprehensive and systematic review that examines the effect of duration of locking on treatment outcome. There were, however, some limitations in the review process. A systematic search was performed in only one database for English-language publications. Searching multiple databases without language restrictions may have yielded more results. Furthermore, there were large number of CL studies that did not report the duration of symptoms in their study sample and so we had to exclude them. This was also true for many surgical trials including CL patients' not-responding to non-surgical interventions for more than 3 or 6 months (CCL). Nevertheless, the large number of studies included in this review represented all of the various treatment modalities used for acute and chronic CL management.

The quality assessment of the included studies was based solely on study design. This is a convenient way to summarise the studies according to their designs [20] but does not completely illustrate the strength of the evidence, as study design is only one of several components contributing to this.

The studies included were mostly uncontrolled and did not examine the placebo effect or the possible symptomatic resolution over time [68, 245] and only a few attempted, with adequate statistical power, to analyse the treatment effects by duration of symptoms on a large sample size. This is most likely due to difficulty in recruiting patients with a DDwoR ‘acute/chronic’ diagnosis that may take several years [168, 207]. Given the low incidence of DDwoR among TMDs, a multicentre RCT may be the most appropriate manner by which to examine the effect of CL duration on the outcome of initial non-invasive simple treatments in DDwoR. To organise such a trial, consensus would need to be reached both on the definition of acute and chronic DDwoR to allow stratification of treatment groups, and on the standardised multidimensional outcome measures that are of importance in DDwoR. In the studies included, the most widely used outcomes to assess DDwoR improvement were pain intensity and mouth opening. In addition to these, the authors would suggest to include functional limitation, multidimensional pain assessment and some form of quality of life assessment [241-246]. Standardised, but ‘pragmatic’, success criteria are also needed to yield more rigorous research [169].

Given the clinical and/or statistical heterogeneity of studies included, the main study findings of treatment effect in relation to CL duration were summarised by each individual study in the Tables 1-6. Overall, the evidence for the effect of locking duration on treatment outcome is contradictory and inconsistent. It may seem that the degree of intra-articular pathological changes is more important than the locking duration but this could not be established.

In general, there were a limited number of studies using clear and robust diagnostic criteria, which attempted to examine treatment effects by duration of symptoms. What we are left with is comparisons between interventions targeting many different assumed causative factors of which locking duration forms only a small part. It is doubtful that a single prognostic factor determines successful outcome in CL management, and it has to be acknowledged that it is likely that several, as yet undefined, factors influence the outcome of CL management including not only the biomedical factors but also the patients' psychosocial phenotype (247-252). It does, however, seem entirely reasonable, within the ethos of modern medicine, and consistent with recent guidance on the management of TMDs (253) that until we have a better understanding of these factors, we should avoid invasive interventions in the initial phases of CL management. Following on from this, it makes intuitive sense, therefore, to consider a stepped ‘timely management’ approach to treat patients with symptomatic CL [169], starting with the simplest, least invasive intervention (e.g. self-management with ‘early’ manipulation) and escalating the treatment only if needed (e.g. rehabilitation by splint and/or physiotherapy) and to defer surgery (e.g. first-line arthrocentesis then arthroscopy) for 6 months or more. Differences in DDwoR patients' complaints such as the presence/absence of pain or mouth opening limitation may affect the necessity for a specific treatment, but this stepped approach is, in general, the most realistic.

The simplest, least costly, quickest, and non-invasive approach that can be easily employed (by general practitioners) with symptomatic DDwoR patients at the first point of contact is the ‘unlock’ mandibular manipulation that has some initial evidence to support its efficacy in ‘early’ intervention in DDwoR. Much about this intervention, however, still remains unanswered as there was no consensus on: technique of manual manipulation applied, who delivers the intervention (patient or clinician), and what, if any, post-treatment splint type is further needed to ensure the long-term successful ‘stable’ results. Further research is, therefore, required in this group of interventions and should also include pre- and post-operative MRI to assess the UM effect on disc position [156]. In this review, the time after which the UM should not be attempted could not be determined (i.e. time frame for ‘disc recapturing’ possibility). Nevertheless, this treatment modality can aid both diagnosis and treatment and unlikely to have adverse effects. There are, therefore, few significant contraindications to justify postponement of attempting to treat DDwoR through this simple approach.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

In DDwoR management, several factors can predict the treatment outcomes, one of which is the duration of locking. The effect of locking duration on treatment outcome, however, remains a matter of controversy in the literature. Despite that, clinical staging of DDwoR based on locking duration is one of the few factors that can be easily addressed from patient's history especially in acute closed lock as the patients can usually remember the sudden onset of locking of short duration. Future diagnostic classifications for DDwoR should seek to address and define the acute versus the chronic period in relation to locking duration (i.e. time since DDwoR onset). This classification may then advance understanding and help target the available therapies more effectively. Until we have a better understanding, a stepped approach to CL management is indicated, starting with the simplest, cheapest, quickest, and most practical first diagnostic and treatment approach for this condition at the first given opportunity in the patient's healthcare journey. This intervention based on current evidence would seem to be an ‘unlock’ mandibular manipulation.

Conflicts of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

No ethical approval required. This study funded by the Higher committee for education development in Iraq (HCED) and is undertaken as a part of postgraduate PhD clinical program in the Department of Oral and Maxillofacial Surgery, School of Dental Sciences, Newcastle University, UK. The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information

The review authors would like to thank Ms Linda Errington, Newcastle University library, for her assistance in verifying the Medline search strategy for the systematic review.

  1. 1

    SPSS Inc., Armonk, NY, USA.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information
  • 1
    Farrar WB. Diagnosis and treatment of anterior dislocation of the articular disc. N Y J Dent. 1971;41:348351.
  • 2
    Farrar WB. Characteristics of the condylar path in internal derangements of the TMJ. J Prosthet Dent. 1978;39:319323.
  • 3
    Farrar WB, McCarty WL Jr. Inferior joint space arthrography and characteristics of condylar paths in internal derangements of the TMJ. J Prosthet Dent. 1979;41:548555.
  • 4
    Okeson JP. Management of Temporomandibular Joint Disorders. In: Okeson JP, ed. Management of temporomandibular disorders and occlusion. MO: Mosby, Elsevier Inc.; 7th ed 2013: 325329.
  • 5
    Farrar WB. Differentiation of temporomandibular joint dysfunction to simplify treatment. J Prosthet Dent. 1972;28:629636.
  • 6
    Nadler GL. Three-dimensional radiographic evaluation of condyle poles in ‘closed-lock’ syndrome. Angle Orthod. 1988;58:357368.
  • 7
    Okeson JP. Joint intracapsular disorders: diagnostic and nonsurgical management considerations. Dent Clin North Am. 2007;51:85103.
  • 8
    Weisberg J, Friedman MH. Displaced disc preventing mandibular condyle translation: mobilization technique. J Orthop Sports Phys Ther. 1981;3:6266.
  • 9
    Nitzan DW, Dolwick MF. An alternative explanation for the genesis of closed-lock symptoms in the internal derangement process. J Oral Maxillofac Surg. 1991;49:810815.
  • 10
    Farrar WB, McCarty WL Jr. The TMJ dilemma. J Am Dent Assoc. 1979;63:1926.
  • 11
    Suarez OF, Ourique SA. An alternate technique for management of acute closed locks. Cranio. 2000;18:168173.
  • 12
    Murakami K, Hosaka H, Moriya Y, Segami N, Iizuka T. Short-term treatment outcome study for the management of temporomandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;80:253257.
  • 13
    Sembronio S, Albiero AM, Toro C, Robiony M, Politi M. Is there a role for arthrocentesis in recapturing the displaced disc in patients with closed lock of the temporomandibular joint? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:274280.
  • 14
    Sato S, Goto S, Kawamura H, Motegi K. The natural course of nonreducing disc displacement of the TMJ: relationship of clinical findings at initial visit to outcome after 12 months without treatment. J Orofac Pain. 1997;11:315320.
  • 15
    Al-Baghdadi M, Durham J, Araujo-Soares V, Robalino S, Errington L, Steele J. Interventions for the management of temporomandibular joint disc displacement without reduction (a systematic review). PROSPERO:CRD42012003153 Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003153. 2012
  • 16
    de Leeuw R. Temporomandibular Disorders. In: de Leeuw R, ed. Orofacial pain guidelines for assessment, diagnosis, and management: Chicago: Quintessence Publishing Co Inc; 2008:129204.
  • 17
    Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord. 1992;6:301355.
  • 18
    Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg. 1989;115:469677.
  • 19
    Rao VM, Liem MD, Farole A, Razek AA. Elusive ‘stuck’ disk in the temporomandibular joint: diagnosis with MR imaging. Radiology. 1993;189:823827.
  • 20
    Australian Government NHMRC. How to use the evidence: assessment and application of scientific evidence. Available at: http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp69.pdf. 2013.
  • 21
    Schwartz HC, Kendrick RW. Internal derangements of the temporomandibular joint: description of clinical syndromes. Oral Surg Oral Med Oral Pathol. 1984;58:2429.
  • 22
    Truelove E, Pan W, Look JO, Mancl LA, Ohrbach RK, Velly AM et al. The research diagnostic criteria for temporomandibular disorders III: validity of axis I diagnoses. J Orofac Pain. 2010;24:3547.
  • 23
    Naeije M, Te Veldhuis AH, Te Veldhuis EC, Visscher CM, Lobbezoo F. Disc displacement within the human temporomandibular joint: a systematic review of a ‘noisy annoyance’. J Oral Rehabil. 2013;40:139158.
  • 24
    List T, Dworkin SF. Comparing TMD diagnoses and clinical findings at Swedish and US TMD centers using research diagnostic criteria for temporomandibular disorders. J Orofac Pain. 1996;10:240253.
  • 25
    Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F. Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112:453462.
  • 26
    Poveda-Roda R, Bagan JV, Jimenez-Soriano Y, Fons-Font A. Retrospective study of a series of 850 patients with temporomandibular dysfunction (TMD). Clinical and radiological findings. Med Oral Patol Oral Cir Bucal. 2009;14:e628e634.
  • 27
    Poveda-Roda R, Bagan JV, Sanchis JM, Carbonell E. Temporomandibular disorders. A case-control study. Med Oral Patol Oral Cir Bucal. 2012;17:e794e800.
  • 28
    Katzberg RW, Westesson PL, Tallents RH, Drake CM. Anatomic disorders of the temporomandibular joint disc in asymptomatic subjects. J Oral Maxillofac Surg. 1996;54:147153.
  • 29
    Katzberg RW, Westesson PL, Tallents RH, Drake CM. Orthodontics and temporomandibular joint internal derangement. Am J Orthod Dentofacial Orthop. 1996;109:515520.
  • 30
    Kecik D, Kocadereli I, Saatci I. Condylar disc relationships and vibration energy in asymptomatic class I 9- to 12-year olds. Angle Orthod. 2005;75:5462.
  • 31
    Dolwick MF. Intra-articular disc displacement. Part I: Its questionable role in temporomandibular joint pathology. J Oral Maxillofac Surg. 1995;53:10691072.
  • 32
    Lin WC, Lo CP, Chiang IC, Hsu CC, Hsu WL, Liu DW et al. The use of pseudo-dynamic magnetic resonance imaging for evaluating the relationship between temporomandibular joint anterior disc displacement and joint pain. Int J Oral Maxillofac Surg. 2012;41:15011504.
  • 33
    Lundh H, Westesson PL. Long-term follow-up after occlusal treatment to correct abnormal temporomandibular joint disk position. Oral Surg Oral Med Oral Pathol. 1989;67:210.
  • 34
    Westesson PL, Lundh H. Temporomandibular joint disk displacement: arthrographic and tomographic follow-up after 6 months' treatment with disk-repositioning onlays. Oral Surg Oral Med Oral Pathol. 1988;66:271278.
  • 35
    Isberg A, Stenstrom B, Isacsson G. Frequency of bilateral temporomandibular joint disc displacement in patients with unilateral symptoms: a 5-year follow-up of the asymptomatic joint. A clinical and arthrotomographic study. Dentomaxillofac Radiol. 1991;20:7376.
  • 36
    Kircos LT, Ortendahl DA, Mark AS, Arakawa M. Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg. 1987;45:852854.
  • 37
    Morrow D, Tallents RH, Katzberg RW, Murphy WC, Hart TC. Relationship of other joint problems and anterior disc position in symptomatic TMD patients and in asymptomatic volunteers. J Orofac Pain. 1996;10:1520.
  • 38
    Pereira FJ Jr, Lundh H, Westesson PL, Carlsson LE. Clinical findings related to morphologic changes in TMJ autopsy specimens. Oral Surg Oral Med Oral Pathol. 1994;78:288295.
  • 39
    Tasaki MM, Westesson PL, Isberg AM, Ren YF, Tallents RH. Classification and prevalence of temporomandibular joint disk displacement in patients and symptom-free volunteers. Am J Orthod Dentofacial Orthop. 1996;109:249262.
  • 40
    Yatani H, Sonoyama W, Kuboki T, Matsuka Y, Orsini MG, Yamashita A. The validity of clinical examination for diagnosing anterior disk displacement with reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85:647653.
  • 41
    Gynther GW, Holmlund AB, Reinholt FP. Synovitis in internal derangement of the temporomandibular joint: correlation between arthroscopic and histologic findings. J Oral Maxillofac Surg. 1994;52:913917.
  • 42
    Haley DP, Schiffman EL, Lindgren BR, Anderson Q, Andreasen K. The relationship between clinical and MRI findings in patients with unilateral temporomandibular joint pain. J Am Dent Assoc. 2001;132:476481.
  • 43
    Isacsson G, Isberg A, Johansson AS, Larson O. Internal derangement of the temporomandibular joint: radiographic and histologic changes associated with severe pain. J Oral Maxillofac Surg. 1986;44:771778.
  • 44
    Isberg A, Isacsson G. Tissue reactions associated with internal derangement of the temporomandibular joint. A radiographic, cryomorphologic, and histologic study. Acta Odontol Scand. 1986;44:160164.
  • 45
    Isberg A, Isacsson G, Johansson AS, Larson O. Hyperplastic soft-tissue formation in the temporomandibular joint associated with internal derangement. A radiographic and histologic study. Oral Surg Oral Med Oral Pathol. 1986;61:3238.
  • 46
    Murakami K, Segami N, Fujimura K, Iizuka T. Correlation between pain and synovitis in patients with internal derangement of the temporomandibular joint. J Oral Maxillofac Surg. 1991;49:11591161.
  • 47
    Segami N, Miyamaru M, Nishimura M, Suzuki T, Kaneyama K, Murakami K. Does joint effusion on T2 magnetic resonance images reflect synovitis? Part 2. Comparison of concentration levels of proinflammatory cytokines and total protein in synovial fluid of the temporomandibular joint with internal derangements and osteoarthrosis Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:515521.
  • 48
    Segami N, Nishimura M, Kaneyama K, Miyamaru M, Sato J, Murakami KI. Does joint effusion on T2 magnetic resonance images reflect synovitis? Comparison of arthroscopic findings in internal derangements of the temporomandibular joint Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92:341345.
  • 49
    Segami N, Suzuki T, Sato J, Miyamaru M, Nishimura M, Yoshimura H. Does joint effusion on T2 magnetic resonance images reflect synovitis? Part 3. Comparison of histologic findings of arthroscopically obtained synovium in internal derangements of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:761766.
  • 50
    Westesson PL, Brooks SL. Temporomandibular joint: relationship between MR evidence of effusion and the presence of pain and disk displacement. AJR Am J Roentgenol. 1992;159:559563.
  • 51
    Dolwick MF, Katzberg RW, Helms CA. Internal derangements of the temporomandibular joint: fact or fiction? J Prosthet Dent. 1983;49:415418.
  • 52
    Nitzan DW, Marmary Y. The ‘anchored disc phenomenon’: a proposed etiology for sudden-onset, severe, and persistent closed lock of the temporomandibular joint. J Oral Maxillofac Surg. 1997;55:797802.
  • 53
    Nitzan DW, Etsion I. Adhesive force: the underlying cause of the disc anchorage to the fossa and/or eminence in the temporomandibular joint–a new concept. Int J Oral Maxillofac Surg. 2002;31:9499.
  • 54
    Nitzan DW, Goldfarb A, Gati I, Kohen R. Changes in the reducing power of synovial fluid from temporomandibular joints with ‘anchored disc phenomenon’. J Oral Maxillofac Surg. 2002;60:735740.
  • 55
    Nitzan DW, Samson B, Better H. Long-term outcome of arthrocentesis for sudden-onset, persistent, severe closed lock of the temporomandibular joint. J Oral Maxillofac Surg. 1997;55:151157.
  • 56
    Durham J, Wassell RW. Recent advancements in Temporomandibular Disorders (TMDs). Reviews in Pain. 2011;5:1825.
  • 57
    Kaneyama K, Segami N, Shin-Ichi T, Fujimura K, Sato J, Nagao T. Anchored disc phenomenon with a normally positioned disc in the temporomandibular joint: characteristics and behaviour. Br J Oral Maxillofac Surg. 2007;45:279283.
  • 58
    Sanroman JF. Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy. Int J Oral Maxillofac Surg. 2004;33:344348.
  • 59
    Casares G, Benito C, de la Hoz JL, Benito C. Treatment of TMJ static disk with arthroscopic lysis and lavage: a comparison between MRI arthroscopic findings and clinical results. Cranio. 1999;17:4957.
  • 60
    Hoffman DC. Long-term outcome of arthrocentesis for sudden-onset, persistent, severe closed lock of the temporomandibular joint. Disscusion. J Oral Maxillofac Surg. 1997;55:157158.
  • 61
    Kurita K, Westesson PL, Yuasa H, Toyama M, Machida J, Ogi N. Natural course of untreated symptomatic temporomandibular joint disc displacement without reduction. J Dent Res. 1998;77:361365.
  • 62
    Sato S, Kawamura H. Natural course of non-reducing disc displacement of the temporomandibular joint: changes in electromyographic activity during chewing movement. J Oral Rehabil. 2005;32:159165.
  • 63
    Sato S, Kawamura H, Nagasaka H, Motegi K. The natural course of anterior disc displacement without reduction in the temporomandibular joint: follow-up at 6, 12, and 18 months. J Oral Maxillofac Surg. 1997;55:234238.
  • 64
    Sato S, Nasu F, Motegi K. Natural course of nonreducing disc displacement of the temporomandibular joint: changes in chewing movement and masticatory efficiency. J Oral Maxillofac Surg. 2002;60:867872.
  • 65
    Sato S, Sakamoto M, Kawamura H, Motegi K. Long-term changes in clinical signs and symptoms and disc position and morphology in patients with nonreducing disc displacement in the temporomandibular joint. J Oral Maxillofac Surg. 1999;57:2329.
  • 66
    Sato S, Takahashi K, Kawamura H, Motegi K. The natural course of nonreducing disk displacement of the temporomandibular joint: changes in condylar mobility and radiographic alterations at one-year follow up. Int J Oral Maxillofac Surg. 1998;27:173177.
  • 67
    Lundh H, Westesson PL, Eriksson L, Brooks SL. Temporomandibular joint disk displacement without reduction. Treatment with flat occlusal splint versus no treatment. Oral Surg Oral Med Oral Pathol. 1992;73:655658.
  • 68
    Yura S. Natural course of acute closed lock of the temporomandibular joint. Br J Oral Maxillofac Surg. 2012;50:646649.
  • 69
    de Leeuw R, Boering G, Stegenga B, de Bont LG. Clinical signs of TMJ osteoarthrosis and internal derangement 30 years after nonsurgical treatment. J Orofac Pain. 1994;8:1824.
  • 70
    Hall MB, Brown RW, Baughman RA. Histologic appearance of the bilaminar zone in internal derangement of the temporomandibular joint. Oral Surg Oral Med Oral Pathol. 1984;58:375381.
  • 71
    Kai S, Kai H, Tabata O, Shiratsuchi Y, Ohishi M. Long-term outcomes of nonsurgical treatment in nonreducing anteriorly displaced disk of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85:258267.
  • 72
    Katzberg RW, Tallents RH. Normal and abnormal temporomandibular joint disc and posterior attachment as depicted by magnetic resonance imaging in symptomatic and asymptomatic subjects. J Oral Maxillofac Surg. 2005;63:11551161.
  • 73
    Pereira Junior FJ, Lundh H, Westesson PL. Age-related changes of the retrodiscal tissues in the temporomandibular joint. J Oral Maxillofac Surg. 1996;54:5561.
  • 74
    Scapino RP. Histopathology associated with malposition of the human temporomandibular joint disc. Oral Surg Oral Med Oral Pathol. 1983;55:382397.
  • 75
    Cai XY, Jin JM, Yang C. Changes in disc position, disc length, and condylar height in the temporomandibular joint with anterior disc displacement: a longitudinal retrospective magnetic resonance imaging study. J Oral Maxillofac Surg. 2011;69:e340e346.
  • 76
    de Leeuw R, Boering G, van der Kuijl B, Stegenga B. Hard and soft tissue imaging of the temporomandibular joint 30 years after diagnosis of osteoarthrosis and internal derangement. J Oral Maxillofac Surg. 1996;54:12701280.
  • 77
    Imirzalioglu P, Biler N, Agildere AM. Clinical and radiological follow-up results of patients with untreated TMJ closed lock. J Oral Rehabil. 2005;32:326331.
  • 78
    Kurita H, Ohtsuka A, Kobayashi H, Kurashina K. Resorption of the postero-superior corner of the lateral part of the mandibular condyle correlates with progressive TMJ internal derangement. Int J Oral Maxillofac Surg. 2003;32:363367.
  • 79
    Kurita H, Uehara S, Yokochi M, Nakatsuka A, Kobayashi H, Kurashina K. A long-term follow-up study of radiographically evident degenerative changes in the temporomandibular joint with different conditions of disk displacement. Int J Oral Maxillofac Surg. 2006;35:4954.
  • 80
    Westesson PL. Structural hard-tissue changes in temporomandibular joints with internal derangement. Oral Surg Oral Med Oral Pathol. 1985;59:220224.
  • 81
    Kurita H, Ohtsuka A, Kobayashi H, Kurashina K. Flattening of the articular eminence correlates with progressive internal derangement of the temporomandibular joint. Dentomaxillofac Radiol. 2000;29:277279.
  • 82
    Bertram S, Moriggl A, Rudisch A, Emshoff R. Structural characteristics of bilateral temporomandibular joint disc displacement without reduction and osteoarthrosis are important determinants of horizontal mandibular and vertical ramus deficiency: a magnetic resonance imaging study. J Oral Maxillofac Surg. 2011;69:18981904.
  • 83
    Emshoff R, Moriggl A, Rudisch A, Laimer K, Neunteufel N, Crismani A. Are temporomandibular joint disk displacements without reduction and osteoarthrosis important determinants of mandibular backward positioning and clockwise rotation? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111:435441.
  • 84
    Gidarakou IK, Tallents RH, Kyrkanides S, Stein S, Moss ME. Comparison of skeletal and dental morphology in asymptomatic volunteers and symptomatic patients with unilateral disk displacement without reduction. Angle Orthod. 2003;73:121127.
  • 85
    Gidarakou IK, Tallents RH, Kyrkanides S, Stein S, Moss ME. Comparison of skeletal and dental morphology in asymptomatic volunteers and symptomatic patients with bilateral disk displacement without reduction. Angle Orthod. 2004;74:684690.
  • 86
    Kwon HB, Kim H, Jung WS, Kim TW, Ahn SJ. Gender differences in dentofacial characteristics of adult patients with temporomandibular disc displacement. J Oral Maxillofac Surg. 2013;71:11781186.
  • 87
    Ooi K, Inoueb N, Minowac K, Totsukaa Y. Factors related to the prevalence of anterior disc displacement without reduction and bony changes of the temporomandibular joint in patients with facial asymmetry. Oral Sci Int. 2013;10:6569.
  • 88
    Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal derangements of the temporomandibular joint: effect on facial development. Am J Orthod Dentofacial Orthop. 1993;104:5159.
  • 89
    Beek M, Koolstra JH, van Ruijven LJ, van Eijden TM. Three-dimensional finite element analysis of the cartilaginous structures in the human temporomandibular joint. J Dent Res. 2001;80:19131918.
  • 90
    Smith DM, McLachlan KR, McCall WD Jr. A numerical model of temporomandibular joint loading. J Dent Res. 1986;65:10461052.
  • 91
    Milam SB, Schmitz JP. Molecular biology of temporomandibular joint disorders: proposed mechanisms of disease. J Oral Maxillofac Surg. 1995;53:14481454.
  • 92
    Milam SB. Pathogenesis of degenerative temporomandibular joint arthritides. Odontology. 2005;93:715.
  • 93
    Nitzan D, Benoliel R, Heir G, Dolwick F. Pain and dysfunction of the temporomandibular joint. In: Sharav Y, Benoliel R, ed Orofacial pain and headache. 1st ed. USA: Mosby, Elsevier Ltd; 2008: 149192.
  • 94
    Arnett GW, Milam SB, Gottesman L. Progressive mandibular retrusion–idiopathic condylar resorption. Part I. Am J Orthod Dentofacial Orthop. 1996;110:815.
  • 95
    Castelli WA, Nasjleti CE, Diaz-Perez R, Caffesse RG. Histopathologic findings in temporomandibular joints of aged individuals. J Prosthet Dent. 1985;53:415419.
  • 96
    de Bont LG, Liem RS, Boering G. Ultrastructure of the articular cartilage of the mandibular condyle: aging and degeneration. Oral Surg Oral Med Oral Pathol. 1985;60:631641.
  • 97
    Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J Dent Res. 2008;87:296307.
  • 98
    Arnett GW, Milam SB, Gottesman L. Progressive mandibular retrusion-idiopathic condylar resorption. Part II. Am J Orthod Dentofacial Orthop. 1996;110:117127.
  • 99
    Haskin CL, Milam SB, Cameron IL. Pathogenesis of degenerative joint disease in the human temporomandibular joint. Crit Rev Oral Biol Med. 1995;6:248277.
  • 100
    Kubota E, Imamura H, Kubota T, Shibata T, Murakami K. Interleukin 1 beta and stromelysin (MMP3) activity of synovial fluid as possible markers of osteoarthritis in the temporomandibular joint. J Oral Maxillofac Surg. 1997;55:2027.
  • 101
    Kubota E, Kubota T, Matsumoto J, Shibata T, Murakami KI. Synovial fluid cytokines and proteinases as markers of temporomandibular joint disease. J Oral Maxillofac Surg. 1998;56:192198.
  • 102
    Kubota T, Kubota E, Matsumoto A, Kawai Y, Saito H, Mikuni-Takagaki Y et al. Identification of matrix metalloproteinases (MMPs) in synovial fluid from patients with temporomandibular disorder. Eur J Oral Sci. 1998;106:992998.
  • 103
    Murakami KI, Shibata T, Kubota E, Maeda H. Intra-articular levels of prostaglandin E2, hyaluronic acid, and chondroitin-4 and -6 sulfates in the temporomandibular joint synovial fluid of patients with internal derangement. J Oral Maxillofac Surg. 1998;56:199203.
  • 104
    Paegle DI, Holmlund AB, Hjerpe A. Matrix glycosaminoglycans in the temporomandibular joint in patients with painful clicking and chronic closed lock. Int J Oral Maxillofac Surg. 2003;32:397400.
  • 105
    Shibata T, Murakami KI, Kubota E, Maeda H. Glycosaminoglycan components in temporomandibular joint synovial fluid as markers of joint pathology. J Oral Maxillofac Surg. 1998;56:209213.
  • 106
    Hamada Y, Kondoh T, Holmlund AB, Yamamoto M, Horie A, Saito T et al. Inflammatory cytokines correlated with clinical outcome of temporomandibular joint irrigation in patients with chronic closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102:596601.
  • 107
    Sicurezza E, Loreto C, Musumeci G, Almeida LE, Rusu M, Grasso C et al. Expression of beta-defensin 4 on temporomandibular joint discs with anterior displacement without reduction. J Craniomaxillofac Surg. 2013;41:821825.
  • 108
    Milam SB. Pathophysiology and epidemiology of TMJ. J Musculoskelet Neuronal Interact. 2003;3:382390.
  • 109
    Roh HS, Kim W, Kim YK, Lee JY. Relationships between disk displacement, joint effusion, and degenerative changes of the TMJ in TMD patients based on MRI findings. J Craniomaxillofac Surg. 2012;40:283286.
  • 110
    de Leeuw R, Boering G, Stegenga B, de Bont LG. Symptoms of temporomandibular joint osteoarthrosis and internal derangement 30 years after non-surgical treatment. Cranio. 1995;13:8188.
  • 111
    Murakami K, Kaneshita S, Kanoh C, Yamamura I. Ten-year outcome of nonsurgical treatment for the internal derangement of the temporomandibular joint with closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:572575.
  • 112
    Dimitroulis G. The prevalence of osteoarthrosis in cases of advanced internal derangement of the temporomandibular joint: a clinical, surgical and histological study. Int J Oral Maxillofac Surg. 2005;34:345349.
  • 113
    Mongini F, Ibertis F, Manfredi A. Long-term results in patients with disk displacement without reduction treated conservatively. Cranio. 1996;14:301305.
  • 114
    Yoshida H, Kashiwagi K, Sakata T, Tanaka M, Kawazoe T, Morita S. Prognostic factor of mandibular condylar movement exercise for patients with internal derangement of the temporomandibular joint on initial presentation: Preliminary report. J Craniomaxillofac Surg. 2013;41:356358.
  • 115
    Nitzan DW, Nitzan U, Dan P, Yedgar S. The role of hyaluronic acid in protecting surface-active phospholipids from lysis by exogenous phospholipase A(2). Rheumatology (Oxford). 2001;40:336340.
  • 116
    Barkin S, Weinberg S. Internal derangements of the temporomandibular joint: the role of arthroscopic surgery and arthrocentesis. J Can Dent Assoc. 2000;66:199203.
  • 117
    Chiba M, Echigo S. Longitudinal MRI follow-up of temporomandibular joint internal derangement with closed lock after successful disk reduction with mandibular manipulation. Dentomaxillofac Radiol. 2005;34:106111.
  • 118
    Hall HD. Intra-articular disc displacement Part II: Its significant role in temporomandibular joint pathology. J Oral Maxillofac Surg. 1995;53:10731079.
  • 119
    Holmlund A. Disc derangements of the temporomandibular joint. A tissue-based characterization and implications for surgical treatment. Int J Oral Maxillofac Surg. 2007;36:571576.
  • 120
    Dimitroulis G. A review of 56 cases of chronic closed lock treated with temporomandibular joint arthroscopy. J Oral Maxillofac Surg. 2002;60:519524.
  • 121
    Holmlund AB, Axelsson S, Gynther GW. A comparison of discectomy and arthroscopic lysis and lavage for the treatment of chronic closed lock of the temporomandibular joint: a randomized outcome study. J Oral Maxillofac Surg. 2001;59:972977.
  • 122
    Reissmann DR, John MT, Schierz O, Wassell RW. Functional and psychosocial impact related to specific temporomandibular disorder diagnoses. J Dent. 2007;35:643650.
  • 123
    BMA The British Medical Association Illustrated Medical Dictionary. United Kingdom: Dorling Kindersley Limited, London; 2008.
  • 124
    Concise Colour Medical Dictionary. United States: Oxford University Press Inc., New York; 2010.
  • 125
    Carr DB, Goudas LC. Acute pain. Lancet. 1999;353:20512058.
  • 126
    Dworkin RH, Turk DC, Basch E, Berger A, Cleeland C, Farrar JT et al. Considerations for extrapolating evidence of acute and chronic pain analgesic efficacy. Pain. 2011;152:17051708.
  • 127
    de Leeuw R, Klasser GD. Diagnosis and Management of TMDs. In: de Leeuw R, Klasser GD, ed Orofacial pain guidelines for assessment, diagnosis, and management. 5th ed. USA: Quintessence Publishing Co, Inc; 2013: 127186.
  • 128
    Look JO, Schiffman EL, Truelove EL, Ahmad M. Reliability and validity of Axis I of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) with proposed revisions. J Oral Rehabil. 2010;37:744759.
  • 129
    Schiffman EL, Ohrbach R, Truelove EL, Tai F, Anderson GC, Pan W et al. The research diagnostic criteria for temporomandibular disorders. V: methods used to establish and validate revised Axis I diagnostic algorithms. J Orofac Pain. 2010;24:6378.
  • 130
    Emshoff R. Clinical factors affecting the outcome of arthrocentesis and hydraulic distension of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:409414.
  • 131
    Iwase H, Sasaki T, Asakura S, Asano K, Mitrirattanakul S, Matsuka Y et al. Characterization of patients with disc displacement without reduction unresponsive to nonsurgical treatment: a preliminary study. J Oral Maxillofac Surg. 2005;63:11151122.
  • 132
    Kurita H, Kurashina K, Ohtsuka A. Efficacy of a mandibular manipulation technique in reducing the permanently displaced temporomandibular joint disc. J Oral Maxillofac Surg. 1999;57:784787.
  • 133
    Kurita H, Ohtsuka A, Kurashina K, Kopp S. A study of factors for successful splint capture of anteriorly displaced temporomandibular joint disc with disc repositioning appliance. J Oral Rehabil. 2001;28:651657.
  • 134
    Kurita K, Goss AN, Ogi N, Toyama M. Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction. J Oral Maxillofac Surg. 1998;56:13941397.
  • 135
    Minagi S, Nozaki S, Sato T, Tsuru H. A manipulation technique for treatment of anterior disk displacement without reduction. J Prosthet Dent. 1991;65:686691.
  • 136
    Nicolakis P, Erdogmus B, Kopf A, Ebenbichler G, Kollmitzer J, Piehslinger E et al. Effectiveness of exercise therapy in patients with internal derangement of the temporomandibular joint. J Oral Rehabil. 2001;28:11581164.
  • 137
    Ohnuki T, Fukuda M, Nakata A, Nagai H, Takahashi T, Sasano T et al. Evaluation of the position, mobility, and morphology of the disc by MRI before and after four different treatments for temporomandibular joint disorders. Dentomaxillofac Radiol. 2006;35:103109.
  • 138
    Sakamoto I, Yoda T, Tsukahara H, Imai H, Enomoto S. Comparison of the effectiveness of arthrocentesis in acute and chronic closed lock: analysis of clinical and arthroscopic findings. Cranio. 2000;18:264271.
  • 139
    Segami N, Murakami K, Iizuka T. Arthrographic evaluation of disk position following mandibular manipulation technique for internal derangement with closed lock of the temporomandibular joint. J Craniomandib Disord. 1990;4:99108.
  • 140
    Stiesch-Scholz M, Tschernitschek H, Rossbach A. Early begin of splint therapy improves treatment outcome in patients with temporomandibular joint disk displacement without reduction. Clin Oral Invest. 2002;6:119123.
  • 141
    Yoshida H, Fukumura Y, Suzuki S, Fujita S, Kenzo O, Yoshikado R et al. Simple manipulation therapy for temporomandibular joint internal derangement with closed lock. Asian J Oral Maxillofac Surg. 2005;17:256260.
  • 142
    Yuasa H, Kurita K. Randomized clinical trial of primary treatment for temporomandibular joint disk displacement without reduction and without osseous changes: a combination of NSAIDs and mouth-opening exercise versus no treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91:671675.
  • 143
    Yura S, Ooi K, Izumiyama Y. Relationship between the effectiveness of arthrocentesis under sufficient pressure and conditions of the temporomandibular joint. ISRN dentistry. 2011;2011:15.
  • 144
    Yura S, Totsuka Y. Relationship between effectiveness of arthrocentesis under sufficient pressure and conditions of the temporomandibular joint. J Oral Maxillofac Surg. 2005;63:225228.
  • 145
    Haketa T, Kino K, Sugisaki M, Takaoka M, Ohta T. Randomized clinical trial of treatment for TMJ disc displacement. J Dent Res. 2010;89:12591263.
  • 146
    Frost DE, Kendell BD. Part II: the use of arthrocentesis for treatment of temporomandibular joint disorders. J Oral Maxillofac Surg. 1999;57:583587.
  • 147
    Correa HC, Freitas AC, Da Silva AL, Coelho TK, Castillo DB, Vinholi GH. Joint disorder: nonreducing disc displacement with mouth opening limitation - report of a case. J Appl Oral Sci. 2009;17:350353.
  • 148
    Foster ME, Gray RJ, Davies SJ, Macfarlane TV. Therapeutic manipulation of the temporomandibular joint. Br J Oral Maxillofac Surg. 2000;38:641644.
  • 149
    Helkimo M, Hugoson A. Nitrous oxide-oxygen sedation in the diagnosis and treatment of temporomandibular joint locking: a clinical and methodological study. Cranio. 1988;6:148155.
  • 150
    Hernandez P, Karibe H. Acute disk without reducing displacement. ACTA odontol Venez. 2004;42:18.
  • 151
    Jagger RG. Mandibular manipulation of anterior disc displacement without reduction. J Oral Rehabil. 1991;18:497500.
  • 152
    Kai S, Kai H, Tabata O, Tashiro H. The significance of posterior open bite after anterior repositioning splint therapy for anteriorly displaced disk of the temporomandibular joint. Cranio. 1993;11:146152.
  • 153
    Liu MQ, Chen HM, Yap AU, Fu KY. Condylar remodeling accompanying splint therapy: a cone-beam computerized tomography study of patients with temporomandibular joint disk displacement. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114:259265.
  • 154
    Martini G, Martini M, Carano A. MRI study of a physiotherapeutic protocol in anterior disk displacement without reduction. Cranio. 1996;14:216224.
  • 155
    Mongini F. A modified extraoral technique of mandibular manipulation in disk displacement without reduction. Cranio. 1995;13:2225.
  • 156
    Muhtarogullari M, Ertan AA, Demiralp B, Canay S. Correlation between clinical and magnetic resonance imaging findings in the treatment of anterior disc displacement. Int J Prosthodont. 2013;26:138142.
  • 157
    Murakami KI, Iizuka T, Matsuki M, Ono T. Recapturing the persistent anteriorly displaced disk by mandibular manipulation after pumping and hydraulic pressure to the upper joint cavity of the temporomandibular joint. Cranio. 1987;5:1724.
  • 158
    Ozawa M, Okaue M, Kaneko K, Hasegawa M, Matsunaga S, Matsumoto M et al. Clinical assessment of the pumping technique in treating TMJ arthrosis with closed lock. J Nihon Univ Sch Dent. 1996;38:110.
  • 159
    Simmons HC 3rd. Orthodontic finishing after TMJ disk manipulation and recapture. Int J Orthod. 2002;13:712.
  • 160
    Singh RB, Veena GC, Kokate S, Raj HBS. Temporomandibular disorders (TMD) internal derangement: case report Indian J Dent Adv. 2010;2:298302.
  • 161
    Van Dyke AR, Goldman SM. Manual reduction of displaced disk. Cranio. 1990;8:350352.
  • 162
    Yoshida H, Sakata T, Hayashi T, Shirao K, Oshiro N, Morita S. Evaluation of mandibular condylar movement exercise for patients with internal derangement of the temporomandibular joint on initial presentation. Br J Oral Maxillofac Surg. 2011;49:310313.
  • 163
    Braun BL. Treatment of an acute anterior disk displacement in the temporomandibular joint. A case report. Phys Ther. 1987;67:12341236.
  • 164
    Cleland J, Palmer J. Effectiveness of manual physical therapy, therapeutic exercise, and patient education on bilateral disc displacement without reduction- of the temporomandibular joint: a single-case design. J Orthop Sports Phys Ther. 2004;34:535548.
  • 165
    Craane B, Dijkstra PU, Stappaerts K, De Laat A. Randomized controlled trial on physical therapy for TMJ closed lock. J Dent Res. 2012;91:364369.
  • 166
    Minakuchi H, Kuboki T, Maekawa K, Matsuka Y, Yatani H. Self-reported remission, difficulty, and satisfaction with nonsurgical therapy used to treat anterior disc displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98:435440.
  • 167
    Minakuchi H, Kuboki T, Matsuka Y, Maekawa K, Yatani H, Yamashita A. Randomized controlled evaluation of non-surgical treatments for temporomandibular joint anterior disk displacement without reduction. J Dent Res. 2001;80:924928.
  • 168
    Schiffman EL, Look JO, Hodges JS, Swift JQ, Decker KL, Hathaway KM et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock.[Erratum appears in J Dent Res. 2013 Jan;92(1):98]. J Dent Res. 2007;86:5863.
  • 169
    Schiffman EL, Velly AM, Look JO, Hodges JS, Swift JQ, Decker KL et al. Effects of four treatment strategies for temporomandibular joint closed lock. Int J Oral Maxillofac Surg. In press 2013.
  • 170
    Srisintorn S. Conservative treatment for anterior dislocation of the meniscus. Dent Update. 1992;19:220221.
  • 171
    Choi BH, Yoo JH, Lee WY. Comparison of magnetic resonance imaging before and after nonsurgical treatment of closed lock. Oral Surg Oral Med Oral Pathol. 1994;78:301305.
  • 172
    Diracoglu D, Saral IB, Keklik B, Kurt H, Emekli U, Ozcakar L et al. Arthrocentesis versus nonsurgical methods in the treatment of temporomandibular disc displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:38.
  • 173
    Harth U. Complete anterior disc displacement without reduction - a systematic treatment concept basis: a case example. J Craniomandibular Fun. 2012;4:245258.
  • 174
    Ismail F, Demling A, Hessling K, Fink M, Stiesch-Scholz M. Short-term efficacy of physical therapy compared to splint therapy in treatment of arthrogenous TMD. J Oral Rehabil. 2007;34:807813.
  • 175
    Israel HA, Syrop SB. The important role of motion in the rehabilitation of patients with mandibular hypomobility: a review of the literature. Cranio. 1997;15:7483.
  • 176
    Kuwahara T, Miyauchi S, Maruyama T. Treatment of anterior disk displacement without reduction by ‘disk recapturing bite plane’. J Osaka Univ Dent Sch. 1990;30:97105.
  • 177
    Le Bell Y, Forssell H. A two-year follow-up of temporomandibular joint disk displacement without reduction in 22 subjects. Proc Finnish Dent Soc. 1993;2:4550.
  • 178
    Lee H, Baek H, Song D, Kim H, Kim H, Kim B et al. Effect of simultaneous therapy of arthrocentesis and occlusal splints on temporomandibular disorders: anterior disc displacement without reduction. J Korean Assoc Oral Maxillofac Surg. 2013;39:1420.
  • 179
    Linde C, Isacsson G, Jonsson BG. Outcome of 6-week treatment with transcutaneous electric nerve stimulation compared with splint on symptomatic temporomandibular joint disk displacement without reduction. Acta Odontol Scand. 1995;53:9298.
  • 180
    Shoji YN. Nonsurgical treatment of anterior disk displacement without reduction of the temporomandibular joint: a case report on the relationship between condylar rotation and translation. Cranio. 1995;13:270273.
  • 181
    Stiesch-Scholz M, Kempert J, Wolter S, Tschernitschek H, Rossbach A. Comparative prospective study on splint therapy of anterior disc displacement without reduction. J Oral Rehabil. 2005;32:474479.
  • 182
    Tanaka E, Kikuchi K, Sasaki A, Tanne K. An adult case of TMJ osteoarthrosis treated with splint therapy and the subsequent orthodontic occlusal reconstruction: adaptive change of the condyle during the treatment. Am J Orthod Dentofac Orthop. 2000;118:566571.
  • 183
    Yoshida H, Hirohata H, Onizawa K. Flexure deformation in temporomandibular joint disk displacement without reduction may predict treatment outcome. J Oral Rehabil. 2005;32:648655.
  • 184
    Aktas I, Yalcin S, Sencer S. Prognostic indicators of the outcome of arthrocentesis with and without sodium hyaluronate injection for the treatment of disc displacement without reduction: a magnetic resonance imaging study. Int J Oral Maxillofac Surg. 2010;39:10801085.
  • 185
    Aktas I, Yalcin S, Sencer S. Intra-articular injection of tenoxicam following temporomandibular joint arthrocentesis: a pilot study. Int J Oral Maxillofac Surg. 2010;39:440445.
  • 186
    Alpaslan C, Kahraman S, Guner B, Cula S. Does the use of soft or hard splints affect the short-term outcome of temporomandibular joint arthrocentesis? Int J Oral Maxillofac Surg. 2008;37:424427.
  • 187
    Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements. J Oral Maxillofac Surg. 2001;59:613618.
  • 188
    Bhargava D, Jain M, Deshpande A, Singh A, Jaiswal J. Temporomandibular joint arthrocentesis for internal derangement with disc displacement without reduction. J Maxillofac Oral Surg. 2012;11:16.
  • 189
    Dhaif G, Ali T. TMJ arthrocentesis for acute closed lock: retrospecive analysis of 40 consecutive cases. Saudi Dent J. 2001;13:123127.
  • 190
    Dimitroulis G, Dolwick MF, Martinez A. Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: a follow-up study. Br J Oral Maxillofac Surg. 1995;33:2326.
  • 191
    Emshoff R, Gerhard S, Ennemoser T, Rudisch A. Magnetic resonance imaging findings of internal derangement, osteoarthrosis, effusion, and bone marrow edema before and after performance of arthrocentesis and hydraulic distension of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:784790.
  • 192
    Emshoff R, Rudisch A. Determining predictor variables for treatment outcomes of arthrocentesis and hydraulic distention of the temporomandibular joint. J Oral Maxillofac Surg. 2004;62:816823.
  • 193
    Emshoff R, Rudisch A. Temporomandibular joint internal derangement and osteoarthrosis: are effusion and bone marrow edema prognostic indicators for arthrocentesis and hydraulic distention? J Oral Maxillofac Surg. 2007;65:6673.
  • 194
    Emshoff R, Rudisch A, Bosch R, Gassner R. Effect of arthrocentesis and hydraulic distension on the temporomandibular joint disk position. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89:271277.
  • 195
    Emshoff R, Rudisch A, Bosch R, Strobl H. Prognostic indicators of the outcome of arthrocentesis: a short-term follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:1218.
  • 196
    Gateno J. Closed lock of the temporomandibular joint. Texas Dent J. 1994;111:3235.
  • 197
    Ghanem WA. Arthrocentesis and stabilizing splint are the treatment of choice for acute intermittent closed lock in patients with bruxism. J Craniomaxillofac Surg. 2011;39:256260.
  • 198
    Hosaka H, Murakami K, Goto K, Iizuka T. Outcome of arthrocentesis for temporomandibular joint with closed lock at 3 years follow-up. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;82:501504.
  • 199
    Kaneyama K, Segami N, Nishimura M, Sato J, Fujimura K, Yoshimura H. The ideal lavage volume for removing bradykinin, interleukin-6, and protein from the temporomandibular joint by arthrocentesis. J Oral Maxillofac Surg. 2004;62:657661.
  • 200
    Kaneyama K, Segami N, Sato J, Fujimura K, Nagao T, Yoshimura H. Prognostic factors in arthrocentesis of the temporomandibular joint: comparison of bradykinin, leukotriene B4, prostaglandin E2, and substance P level in synovial fluid between successful and unsuccessful cases. J Oral Maxillofac Surg. 2007;65:242247.
  • 201
    Mohanavalli S, Kannadasan K, Matsa S, Sekhar S. Arthrocentesis - minimally invasive approach for temporomandibular joint closed lock - a case report and review. SRM Univ J Dent Sci. 2011;2:373377.
  • 202
    Ness GM, Crawford KC. Temporomandibular joint arthrocentesis for acute or chronic closed lock. J Oral Maxillofac Surg. 1996;54(Suppl. 3):112113.
  • 203
    Nishimura M, Segami N, Kaneyama K, Sato J, Fujimura K. Comparison of cytokine level in synovial fluid between successful and unsuccessful cases in arthrocentesis of the temporomandibular joint. J Oral Maxillofac Surg. 2004;62:284287.
  • 204
    Nishimura M, Segami N, Kaneyama K, Suzuki T. Prognostic factors in arthrocentesis of the temporomandibular joint: evaluation of 100 patients with internal derangement. J Oral Maxillofac Surg. 2001;59:874877.
  • 205
    Nitzan DW. Arthrocentesis for management of severe closed lock of the temporomandibular joint. Oral Maxillofac Surg Clin North Am. 1994;6:245257.
  • 206
    Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg. 1991;49:11631167.
  • 207
    Sahlstrom LE, Ekberg EC, List T, Petersson A, Eriksson L. Lavage treatment of painful jaw movements at disc displacement without reduction. A randomized controlled trial in a short-term perspective. Int J Oral Maxillofac Surg. 2013;42:356363.
  • 208
    Sato S, Goto S, Kasahara T, Kawamura H, Motegi K. Effect of pumping with injection of sodium hyaluronate and the other factors related to outcome in patients with non-reducing disk displacement of the temporomandibular joint. Int J Oral Maxillofac Surg. 2001;30:194198.
  • 209
    Sato S, Kawamura H. Evaluation of mouth opening exercise after pumping of the temporomandibular joint in patients with nonreducing disc displacement. J Oral Maxillofac Surg. 2008;66:436440.
  • 210
    Sato S, Ohta M, Ohki H, Kawamura H, Motegi K. Effect of lavage with injection of sodium hyaluronate for patients with nonreducing disk displacement of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;84:241244.
  • 211
    Thomas H, Neelakantan RS, Thomas TK. Role of arthrocentesis in the management of acute closed lock of TM joint: a pilot study. J Maxillofac Oral Surg. 2012;11:390393.
  • 212
    Chen MJ, Yang C, Zhang SY, Cai XY. Use of Coblation in arthroscopic surgery of the temporomandibular joint. J Oral Maxillofac Surg. 2010;68:20852091.
  • 213
    Clark GT, Moody DG, Sanders B. Arthroscopic treatment of temporomandibular joint locking resulting from disc derangement: two-year results. J Oral Maxillofac Surg. 1991;49:157164.
  • 214
    Furst IM, Kryshtalskyj B, Weinberg S. The use of intra-articular opioids and bupivacaine for analgesia following temporomandibular joint arthroscopy: a prospective, randomized trial. J Oral Maxillofac Surg. 2001;59:979983.
  • 215
    Go WS, Teh LY, Peck RH, Chew SC, Chua EK. Clinical experience in temporomandibular joint arthroscopy. Ann Acad Med Singapore. 1996;25:679682.
  • 216
    Hamada Y, Holmlund AB, Kondoh T, Nakaoka K, Sekiya H, Shiobara N et al. Severity of arthroscopically observed pathology and levels of inflammatory cytokines in the synovial fluid before and after visually guided temporomandibular joint irrigation correlated with the clinical outcome in patients with chronic closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:343349.
  • 217
    Hamada Y, Kondoh T, Holmlund AB, Iino M, Kobayashi K, Seto K. Influence of arthroscopically observed fibrous adhesions before and after joint irrigation on clinical outcome in patients with chronic closed lock of the temporomandibular joint. Int J Oral Maxillofac Surg. 2005;34:727732.
  • 218
    Hamada Y, Kondoh T, Holmlund AB, Iino M, Nakajima T, Seto K. Visually guided temporomandibular joint irrigation in patients with chronic closed lock: clinical outcome and its relationship to intra-articular morphologic changes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:552558.
  • 219
    Hamada Y, Kondoh T, Holmlund AB, Nakajima T, Horie A, Saito T et al. One-year clinical course following visually guided irrigation for chronic closed lock of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:170174.
  • 220
    Hamada Y, Kondoh T, Holmlund AB, Sakota K, Nomura Y, Seto K. Cytokine and clinical predictors for treatment outcome of visually guided temporomandibular joint irrigation in patients with chronic closed lock. J Oral Maxillofac Surg. 2008;66:2934.
  • 221
    Kim YK, Im JH, Chung H, Yun PY. Clinical application of ultrathin arthroscopy in the temporomandibular joint for treatment of closed lock patients. J Oral Maxillofac Surg. 2009;67:10391045.
  • 222
    Kondoh T, Dolwick MF, Hamada Y, Seto K. Visually guided irrigation for patients with symptomatic internal derangement of the temporomandibular joint: a preliminary report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:544551.
  • 223
    Kumagai K, Hamada Y, Holmlund AB, Gotoh A, Nakaoka K, Arai G et al. The levels of vascular endothelial growth factor in the synovial fluid correlated with the severity of arthroscopically observed synovitis and clinical outcome after temporomandibular joint irrigation in patients with chronic closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109:185190.
  • 224
    Lewis RH Jr. Arthroscopic surgery of the TMJ–treatment of chronic closed lock. Ark Dent J. 1987;58:1417.
  • 225
    Machon V, Sedy J, Klima K, Hirjak D, Foltan R. Arthroscopic lysis and lavage in patients with temporomandibular anterior disc displacement without reduction. Int J Oral Maxillofac Surg. 2012;41:109113.
  • 226
    Murakami KI. The indications of arthroscopic sweep for the patient with internal derangements of the temporomandibular joint (T.M.J.). Rev Stomatol Chir Maxillofac. 1990;91:110119.
  • 227
    Nakaoka K, Hamada Y, Holmlund AB, Saito T, Arai G, Horiuchi T et al. The changes of joint effusion on MRI and arthroscopic findings after visually guided TMJ irrigation correlated to the clinical outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:99104.
  • 228
    Nitzan DW, Dolwick MF, Heft MW. Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective. J Oral Maxillofac Surg. 1990;48:798801.
  • 229
    Ohnuki T, Fukuda M, Iino M, Takahashi T. Magnetic resonance evaluation of the disk before and after arthroscopic surgery for temporomandibular joint disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:141148.
  • 230
    Politi M, Sembronio S, Robiony M, Costa F, Toro C, Undt G. High condylectomy and disc repositioning compared to arthroscopic lysis, lavage, and capsular stretch for the treatment of chronic closed lock of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:2733.
  • 231
    Saitoa T, Yamadaa H, Nakaokaa K, Horiea A, Mishimab A, Nomurac Y et al. Risk factors for the poor clinical outcome of visually guided temporomandibular joint irrigation in patients with chronic closed lock. Asian J Oral Maxillofac Surg. 2010;22:133137.
  • 232
    Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol. 1986;62:361372.
  • 233
    Yoshida H, Fukumura Y, Tojyo I, Yamaguchi A, Tsuji K, Sako J et al. Operation with a single-channel thin-fibre arthroscope in patients with internal derangement of the temporomandibular joint. Br J Oral Maxillofac Surg. 2008;46:313314.
  • 234
    Zhang S, Liu X, Yang C, Cai X, Chen M, Haddad MS et al. Intra-articular adhesions of the temporomandibular joint: relation between arthroscopic findings and clinical symptoms. BMC Musculoskeletal Disord. 2009;10:70.
  • 235
    Kondoh T, Hamada Y, Kamei K, Seto K. Simple disc reshaping surgery for internal derangement of the temporomandibular joint: 5-year follow-up results. J Oral Maxillofac Surg. 2003;61:4148.
  • 236
    Ozkan BT, Pernu H, Oikarinen K, Raustia A. The comparison of outcomes of surgically treated bilateral temporomandibular joint disorder in different groups: a retrospective study. Med Oral Patol Oral Cir Bucal. 2012;17:e1018e1022.
  • 237
    Turley PK. Surgical-orthodontic management of persistent closed lock of the TM joints. Angle Orthod. 1993;63:916.
  • 238
    Widmark G, Dahlstrom L, Kahnberg KE, Lindvall AM. Diskectomy in temporomandibular joints with internal derangement: a follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83:314320.
  • 239
    Zhang S, Liu X, Yang X, Yang C, Chen M, Haddad MS et al. Temporomandibular joint disc repositioning using bone anchors: an immediate post surgical evaluation by Magnetic Resonance Imaging. BMC Musculoskeletal Disord. 2010;11:262269.
  • 240
    Greene CS, Goddard G, Macaluso GM, Mauro G. Topical review: placebo responses and therapeutic responses. How are they related?. J Orofac Pain. 2009;23:93107.
  • 241
    Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005;2:919.
  • 242
    Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9:105121.
  • 243
    Locker D. Measuring oral health: a conceptual framework. Community Dent Health. 1988;5:318.
  • 244
    Locker D, Allen F. What do measures of ‘oral health-related quality of life’ measure? Commun Dent Oral Epidemiol. 2007;35:401411.
  • 245
    Nixdorf DR, John MT, Wall MM, Fricton JR, Schiffman EL. Psychometric properties of the modified Symptom Severity Index (SSI). J Oral Rehabil. 2010;37:1120.
  • 246
    Stegenga B, de Bont LG, de Leeuw R, Boering G. Assessment of mandibular function impairment associated with temporomandibular joint osteoarthrosis and internal derangement. J Orofac Pain. 1993;7:183195.
  • 247
    Dougall AL, Jimenez CA, Haggard RA, Stowell AW, Riggs RR, Gatchel RJ. Biopsychosocial factors associated with the subcategories of acute temporomandibular joint disorders. J Orofac Pain. 2012;26:716.
  • 248
    Maixner W, Diatchenko L, Dubner R, Fillingim RB, Greenspan JD, Knott C et al. Orofacial pain prospective evaluation and risk assessment study–the OPPERA study. J Pain. 2011;11(Suppl):T4T11. e1–2.
  • 249
    Rollman GB, Gillespie JM. The role of psychosocial factors in temporomandibular disorders. Curr Rev Pain. 2000;4:7181.
  • 250
    Bernstein DN, Gatchel RJ. Biobehavioral predictor variables of treatment outcome in patients with temporomandibular disorders. J Appl Biobehav Res. 2000;5:101113.
  • 251
    Mehalick ML, Garofalo JP, Sanders CN, Gatchel RJ. Assessment of the psychological comorbidity, pathophysiological mechanisms, and treatment implications in patients with chronic orofacial pain. Anaplastology. 2013;S2: 18.
  • 252
    Phaik KS. Biopsychosocial characterstics as predictors of treatment outcome of temporomandibular disorder (TMD) patients with symptoms of pain: Thesis, National University of Singapore; 2006.
  • 253
    Greene CS. Diagnosis and treatment of temporomandibular disorders: emergence of a new care guidelines statement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110:137139.

Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Acknowledgement
  10. References
  11. Supporting Information
FilenameFormatSizeDescription
joor12126-sup-0001-Appendix.docxWord document60K

Appendix S1 Medline search strategy.

Appendix S2 A modified designation of levels of evidence.

Appendix S3 Study flow diagram.

Appendix S4 Diagnostic criteria for DDwoR.

Appendix S5 Summary of studies' definition of acute/chronic closed lock stages according to locking duration.

Appendix S6 Description of reviewed interventions.

Appendix S7 Farrar's manipulation technique to ‘unlock’ the jaw.

joor12126-sup-0002-Appendix3(Figure).epsimage/eps76K 
joor12126-sup-0003-Appendix7(Figure).epsimage/eps2845K 

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.