Int. J. Oral Maxillofac. Surg.

2013; 42: 218–222

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Research Paper
TMJ Disorders

A new surgical classification for G. Dimitroulis

Maxillofacial Surgery Unit, Department of
Surgery, St. Vincent’s Hospital Melbourne,
The University of Melbourne, Australia

temporomandibular joint
disorders
G. Dimitroulis: A new surgical classification for temporomandibular joint disorders.
Int. J. Oral Maxillofac. Surg. 2013; 42: 218–222. # 2012 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The role of temporomandibular joint (TMJ) surgery is ill-defined, so a

universal classification is needed to collate the evidence required to justify the
surgical interventions undertaken to treat TMJ disorders. The aim of this article is to
introduce a new classification that divides TMJ disorders into 5 categories of
escalating degrees of joint disease that can be applied to TMJ surgery. Using a
category scale from 1 to 5, with category 1 being normal, and category 5 referring to
catastrophic changes to the joint, the new classification will provide the basis for
enhanced quantitative and descriptive data collection that can be used in the field of
TMJ surgery research and clinical practice. It is hoped that this new classification
Keywords: temporomandibular joint; surgery;
will form the basis of what will eventually become the universal standard surgical classification; disorders.
classification of TMJ disorders that will be adopted by both researchers and
clinicians so that ultimately, the role of TMJ surgery will be based on evidence Accepted for publication 8 November 2012
rather than conjecture. Available online 31 December 2012

The role of temporomandibular joint which can only be derived from universal code. It is from these codes that data
(TMJ) surgery is not well defined.1 Part medical codes. Universal medical codes can be collected and analysed for the
of the reason is that hard evidence is are collected from classifications and what purpose of providing the hard evidence
lacking since, unlike orthopaedic surgery, the field of TMJ surgery needs is a uni- needed to determine whether TMJ surgery
there is no universal classification that versal classification in order to collate the is effective in providing material benefit to
allows the collection of standard data that evidence required to justify the surgical patients.1 In other words, the hard evi-
can be used to compare the various tech- interventions undertaken to treat TMJ dis- dence for TMJ surgery can only be secured
niques published in the literature. Tempor- orders. The aim of this article is to intro- with a universally recognized surgical
omandibular disorder (TMD) specialists duce a new surgical classification that classification of TMJ disorders.
have been proactive in establishing the includes all TMJ specific disorders that Presently, there are 3 main classifica-
Research Diagnostic Criteria (RDC) for can be applied to future studies related to tions related to TMD; the Research Diag-
TMD and have used this as the basis for TMJ surgery. nostic Criteria (RDC) for TMD,2 the
assessing various non-surgical strategies.2 Wilkes Classification4 for TMJ internal
The field of TMJ surgery has only man- derangement, and the most recent Amer-
aged to come up with what constitutes Reasons for classification ican Academy of Orofacial Pain (AAOFP)
successful TMJ surgery outcomes.3 Medical classification is the process of Classification of TMD.5 The RDC-TMD
Evidence is needed to define the role of transforming descriptions of diagnoses classification2 is the most widely used
TMJ surgery, and evidence needs data and procedures into universal medical by TMD researchers who stress the

0901-5027/020218 + 05 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Surgical classification for TMJ disorders 219

importance of psychosocial dysfunction Table 1. Criteria for new TMJ surgical clas- Table 3. Category 1: Normal TMJ.
(Axis II) as opposed to physical disorders sification. Clinical presentation
(Axis I) and come up with a wide variety Simple – easy to understand and remember TMJ pain
of complex calculations that often have Clear – unambiguous description of each No joint noises
little bearing on clinical practice. The category No history of locking or dislocation
Focused – on the TMJ Full range of jaw movement
RDC-TMD has remained firmly
Inclusive – of all TMJ disorders and diseases Normal chewing
embedded in the research world with little Specific – so that patient populations can be Radiological features
use in clinical practice. easily defined and compared OPG – normal condyles
The Wilkes classification4 is the most Universal – adopted by all TMD clinicians MRI – normal TMJ
widely used classification that has been and researchers Diagnosis
adopted by surgeons who treat TMJ dis- Joint contusion – acute trauma
orders. Its widespread adoption is linked Myofascial pain
to its simplicity in describing escalating criteria for the new classification are given Ear pathology – otalgia
joint pathology in 5 stages, but it concen- in Table 1. The purpose of this new clas- Neuropathic
trates on only 2 disorders (internal sification (Table 2) is to specify the role of Psychogenic
Treatment
derangement and osteoarthritis) and fails TMJ surgery in all TMJ disorders in a Medication  splint
to include other TMJ disorders such as graded fashion across a spectrum of 5 Surgery has no role
ankylosis and tumours which are covered categories of escalating degrees of joint
by a host of other sub-classifications6,7 disease.
that will not be elaborated here. other ailments that may be contributing to
The AAOFP classification of TMD5 has or exacerbating the TMJ arthralgia.
Category 1: TMJ normal joint
refocused its attention on articular disor-
ders with a more widespread appreciation No surgery is required. In this category
Category 2: TMJ minor changes
of joint disease, not confined to internal (Table 3), a patient may present with pain
derangement, but also ankylosis, trauma specifically centred around the TMJ but All joint components are salvageable. In
and even developmental conditions of the report no history of locking, dislocation or this category (Table 4) a patient may
TMJ are listed. The masticatory muscle difficulty chewing. There are no audible or present with intermittent TMJ pain, joint
disorders are listed simply as local, gen- palpable joint noises and the patient exhi- clicking and occasional locking. Plain
eral and centrally mediated which reflects bits a full range of jaw movement with films demonstrate normal condyles but
the poor understanding of extra-articular symmetrical opening. Plain films, mag- MRI may show mild disc displacement
disorders related to TMD. While the netic resonance imaging (MRI) and com- with reduction or excess fluid in the joint
AAOFP classification5 of TMD is a vast puted tomography (CT) scans show indicative of inflammation (Fig. 2). TMJ
improvement on the cumbersome RDC- normal joint with no radiological abnorm- arthrocentesis may be appropriate for
TMD,2 there is still a problem when it alities (Fig. 1). The patient may have cases of acute onset closed lock and
comes to data collection as the AAOFP sustained recent acute trauma following TMJ arthroscopy may demonstrate mild
classification does not allow for degree of whiplash, fall or assault or experienced an inflammation with occasional adhesions.
disability which is quantifiable like the ear infection. In long standing cases the Both procedures may help unlock a stuck
Wilkes Classification.4 TMJ arthralgia may be secondary to myo- joint, but the primary treatment modality
In 1994, Dolwick and Dimitroulis8 pub- fascial pain, fibromyalgia or part of a remains conservative (i.e. anti-inflamma-
lished a table which divided indications neuralgia or psychosomatic disorder. tory medication, jaw rest, soft diet).
for TMJ surgery into relative and absolute. TMJ surgery has no role in these situations
Relative indications were stipulated for and patients must be carefully assessed for
Category 3: TMJ moderate changes
common TMJ disorders such as internal
derangement and osteoarthrosis, while Table 2. Surgical classification of TMJ
Most joint components are salvageable. In
absolute indications were reserved for less disorders. this category (Table 5), patients report
common TMJ disorders such as ankylosis Category 1 painful long-standing closed lock (>2
and neoplasia of the TMJ. Surgical indica- TMJ normal months), joint swelling or painful recur-
tions such as this only indicate when TMJ No surgery required or indicated rent dislocation of the TMJ. The patient
surgery should be considered, but does not Category 2 may report difficulty chewing with mod-
stipulate what kind of surgery is required TMJ minor changes (all joint components erate to severe pain levels exacerbated by
and for which disease. are salvageable) jaw function. Mandibular opening is
TMJ arthrocentesis/arthroscopic lavage restricted either because of fear of dislo-
Category 3 cation or actual joint pain which often
New classification TMJ moderate changes (most joint results in deviation of the mandible to
components are salvageable)
In the development of a new classification, TMJ operative arthroscopy/TMJ
the affected side. Because of the restricted
it is essential to purge the weaknesses and arthroplasty mouth opening joint noises are often
build on the strengths of previous classi- Category 4 absent. While plain films may show nor-
fications. Dozens of new medical classifi- TMJ severe changes (few joint mal condylar morphology, MRI shows
cations are introduced to the literature components are salvageable) non-reducing disc displacement. The disc
every year, but history has shown that TMJ discectomy  condylar surgery may exhibit mild contour deformity and
only the simplest, such as the classic Le Category 5 there may be a prominent articular
Fort classification for midface injuries,9 TMJ catastrophic changes (nothing in the eminence that obstructs the backward path
that are easy to remember and simple to joint is salvageable) of the translated condyle (Fig. 3). Diag-
TMJ resection  total joint replacement
understand are universally adopted. The nostically, the patient may have suffered
220 Dimitroulis

Table 5. Category 3: Moderate TMJ changes.

Clinical presentation
Painful chronic closed lock
Recurrent joint swelling
Painful recurrent dislocation
Radiological features
OPG – normal condyles
MRI – disc displacement without reduction
Disc normal or mildly deformed contour
Prominent eminence
Diagnosis
Moderate TMJ internal derangement
Recurrent TMJ dislocation
TMJ synovial chondromatosis
Dislocated condylar fracture
Treatment
TMJ arthroscopy (operative)
TMJ arthroplasty – disc plication/
repositioning  eminectomy
Modified condylotomy
ORIF fractured condyle
Fig. 1. Normal TMJ. Category 1 joint which demonstrates a normal TMJ on MRI. The main
presentation is TMJ arthralgia but TMJ surgery is not indicated if there are no functional
disturbances. Category 1 patients offer researchers the ideal control group with which to
Category 5: TMJ catastrophic changes
compare surgical outcomes in other categories.
No joint components are salvageable.
an acute event such as a fracture disloca- ties of the condylar head which are better Patients in this category (Table 7) report
tion of the condylar head or simply dis- seen on cone-beam CT scans. MRIs intolerable low grade joint pain and joint
location of the condyle. In long standing demonstrate severely degenerate, dis- crepitus with constant locking and inabil-
cases, the patient may be suffering from placed and deformed articular discs ity to chew anything solid. Plain films
moderate TMJ internal derangement or (Fig. 4) which may sometimes demon- show obvious degenerative changes to
synovial chondromatosis. In category 3 strate perforations. Early condylar the condyle which is better depicted on
cases, the patient would benefit from changes such as osteophytes and small cone-beam CT scans which show irregular
operative TMJ arthroscopy, modified con- subcondral cysts with loss or thinning of articular surface and large subchondral
dylotomy, TMJ arthroplasty consisting of cartilage layer may be seen on cone-beam cysts. MRI shows severely degenerated
disc repositioning with or without emi- CT scans. The clinical picture is that of disc which is often difficult to visualize
nectomy, or open reduction and internal severe TMJ internal derangement with with low signal from the condyle that
fixation of displaced condylar fractures. early osteoarthritis. This category may appears irregular and deformed. Diagnos-
also include rare metabolic, inflammatory tically, these patients suffer from TMJ
or developmental disorders of the TMJ. osteoarthritis or degenerative joint disease
Category 4: TMJ severe changes
TMJ discectomy with or without debride- that may be the result of multiple previous
Few joint components are salvageable. In ment, shaving or surgical reduction of the operations. Where the joint pain is absent
this category (Table 6), patients report condylar head, articular eminence and or tolerable, the patient may have TMJ
constant joint pain with painful crepitus glenoid fossa is the mainstay of treatment. osteoarthrosis or in rare cases, TMJ anky-
and mildly limited mouth opening. Chew-
ing is very painful and yawning is almost
impossible without provoking severe pain.
Plain films show radiological signs of
early changes in condylar morphology
such as flattening and beak type deformi-

Table 4. Category 2: Minor TMJ changes.

Clinical presentation
Intermittent joint pain
Joint clicking
Occasional locking
Radiological features
OPG – normal condyles
MRI – disc displacement with reduction
Disc and condyle normal contour
Diagnosis
Early TMJ internal derangement Fig. 2. Minor TMJ changes. Category 2 joint showing disc displacement on MRI that has
Joint inflammation/adhesions resulted in locking and pain on function. TMJ arthrocentesis or TMJ arthroscopic lavage may be
Treatment useful in these cases, although non-surgical measures are still important. Future studies may look
TMJ arthrocentesis at whether TMJ arthrocentesis/arthroscopy significantly reduce the treatment time span com-
TMJ arthroscopic lavage pared to conservative measures alone in category 2 patients.
 Surgical classification for TMJ disorders 221

Table 6. Category 4: Severe TMJ changes.

Clinical presentation
Constant joint pain
Painful crepitus
Mildly limited mouth opening
Painful chewing
Radiological features
OPG – early condylar changes
CT scans – mild to moderate condylar
degeneration
MRI – severely degenerated, displaced
and deformed disc
Early condylar changes – osteophytes,
flattening
Diagnosis
Advanced TMJ internal derangement
Rare TMJ disorder – metabolic,
inflammatory or developmental joint disease
Treatment
TMJ discectomy  condyloplasty/shave
Debridement of glenoid fossa
Reduction of eminence

The classification not only describes the

clinical and radiological features of each
Fig. 3. Moderate TMJ changes. Category 3 joint showing dislocation of TMJ with condyle stuck category, but also suggests the degree of
beyond the articular eminence. In cases of recurrent TMJ dislocation, operative TMJ arthro- surgical intervention. Thus when a study
scopy, modified condylotomy or TMJ eminectomy with disc plication may be appropriate. presents results on the treatment outcomes
Whichever technique is the most effective can only be determined by randomized clinical of category 3 patients, for example, read-
studies involving category 3 patients. ers will immediately understand the cri-
teria for category 3 patients that were
losis (Fig. 5), condylysis or tumour. common TMJ disorders treated by oral and involved in the study and future meta-
Patients in this category would benefit maxillofacial surgeons (internal derange- analyses of treatment options for category
from condylectomy, discectomy and total ment and osteoarthrosis). The new classi- 3 patients will be easier to assess and
joint replacement where feasible. fication embodies the simplicity of the analyse because of the standardized clas-
Wilkes classification4 by keeping the 5 sification.
stages of disease but broadening the defini- The major theme behind each category
Discussion
tion of each category to include other less is whether any of the joint components are
For many years, the Wilkes classification4 common TMJ disorders such as disloca- salvageable by surgery, regardless of the
has served as the unofficial standard tions and tumours as well as ankylosis. diagnosis. A scale of 1–5 with progressive
classification for TMJ surgeons worldwide. In the development of a new surgical increased severity of joint disease allows
The simplicity of the stages described and classification for TMJ disorders it was numerical quantification to aid data col-
escalating disease level with each stage necessary to include all disorders that lection, with category 1 being normal and
made it universally applicable to the most are amenable to surgical intervention. category 5 referring to catastrophic

Table 7. Category 5: Catastrophic TMJ

changes.
Clinical presentation
Intolerable low grade pain
Constant crepitus
Locking
Malocclusion
Unable to chew anything solid
Radiological features
OPG – obvious degenerative changes to
condyle
MRI – disc destroyed/difficult to see
CT scan – condyle severely degenerate
Diagnosis
TMJ osteoarthritis
TMJ condylysis
TMJ ankylosis
Fig. 4. Severe TMJ changes. Category 4 joint showing severely displace, deformed and TMJ tumour
degenerate disc on MRI with degenerate bony changes in the condyle. The disc is unsalvageable Treatment
so TMJ discectomy is most appropriate with perhaps a high condylar shave. Future studies may TMJ resection
look at whether disc repair is possible in category 4 patients. TMJ total joint replacement
222 Dimitroulis

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translated by Tessier P. Plast Reconstr Surg
described in the literature is glaringly surgeons.
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tion, the TMJ patient populations will be
Funding Address:
better defined and easily compared, parti-
cularly when it comes to multicentre clin- None. George Dimitroulis
ical trials.1 Suite 5
Having presented this new classification 10th Floor
Competing interests 20 Collins Street
as a means of research data collection and Melbourne
communication between clinicians, it None declared. Vic 3000
must be emphasized that this is only a Australia
preliminary attempt at trying to standar- Tel.: +61 3 9654 3799;
Ethical approval
dize understanding of TMJ disorders. As it fax: +61 3 9650 3845
is a new classification, there will be plenty Not required. E-mail: [email protected]