Consensus report and recommendations on the management of late-stage internal derangement of the temporomandibular joint

Citation: Monje Gil, F.; Martínez Artal, P.; Cuevas Queipo de Llano, A.; Muñoz Guerra, M.; González Ballester, D.; López Arcas, J.M.; López Cedrún, J.L.; Gutiérrez Pérez, J.L.; Martín-Granizo, R.; del Castillo Pardo de Vera, J.L.; et al. Consensus Report and Recommendations on the Management of Late-Stage Internal Derangement of the Temporomandibular Joint. J. Clin. Med. 2024,13, 3319. https:// doi.org/10.3390/jcm13113319 Academic Editor: Lei Liu Received: 29 February 2024 Revised: 19 April 2024 Accepted: 7 May 2024 Published: 4 June 2024 Copyright: © 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Journal of Clinical Medicine Article Consensus Report and Recommendations on the Management of Late-Stage Internal Derangement of the Temporomandibular Joint Florencio Monje Gil 1,*, Patricia Martínez Artal 1,* , Alberto Cuevas Queipo de Llano 1, Mario Muñoz Guerra 2, David González Ballester 1, JoséMaría López Arcas 3, JoséLuis López Cedrún4, JoséLuis Gutiérrez Pérez 5, Rafael Martín-Granizo 6, JoséLuis del Castillo Pardo de Vera 7, Blas García Medina 8, Raúl González-García2, Manuel Moreno Sánchez 1, Ekaitz Valle Rodríguez 9, Jacinto Fernández Sanromán10, Ricardo López Martos 5, Beatriz Peral Cagigal 11 , Marta Redondo Alamillos 12, Miguel Morey Mas 13, Carlos Salcedo Gil 14, Benito Ramos Medina 15 , Adaia Valls Ontañón16, Jorge MasiàGridilla 17 and Alicia Dean Ferrer 18 1Oral and Maxillofacial Surgery Department, University Hospital Badajoz, 06080 Badajoz, Spain; [email protected] (A.C.Q.d.L.); [email protected] (D.G.B.); [email protected] (M.M.S.) 2Oral and Maxillofacial Surgery Department, La Princesa University Hospital, 28006 Madrid, Spain; [email protected] (M.M.G.); [email protected] (R.G.-G.) 3Radiology Department, Infanta Leonor Hospital, 28032 Madrid, Spain; [email protected] 4Oral and Maxillofacial Surgery Department, University Hospital A Coruña, 15008 A Coruña, Spain; [email protected] 5Oral and Maxillofacial Surgery Department, University Hospital Virgen del Rocío, 41013 Sevilla, Spain; [email protected] (J.L.G.P.); [email protected] (R.L.M.) 6Oral and Maxillofacial Surgery Department, Hospital Clínico San Carlos, 28040 Madrid, Spain; [email protected] 7Oral and Maxillofacial Surgery Department, La Paz University Hospital, 28046 Madrid, Spain; [email protected] 8 Oral and Maxillofacial Surgery Department, University Hospital Virgen de las Nieves, 18014 Granada, Spain; [email protected] 9Oral and Maxillofacial Surgery Department, University Hospital Reina Sofía, 30003 Murcia, Spain; [email protected] 10 Oral and Maxillofacial Surgery Department, Hospital Povisa, 36211 Vigo, Spain; [email protected] 11 Oral and Maxillofacial Surgery Department, University Hospital Río Hortega, 47012 Valladolid, Spain; [email protected] 12 Oral and Maxillofacial Surgery Department, University Hospital 12 de Octubre, 28041 Madrid, Spain; [email protected] 13 GBCOM Dental and Maxillofacial Clinic, 07014 Palma de Mallorca, Spain; mmor[email protected] 14 Oral and Maxillofacial Surgery Department, University Hospital Son Espases, 07120 Palma de Mallorca, Spain; [email protected] 15 Oral and Maxillofacial Surgery Department, University Hospital Santa Lucía, 30202 Cartagena, Spain; [email protected] 16 Oral and Maxillofacial Surgery Department, Hospital Sant Joan de Déu, 08950 Barcelona, Spain; [email protected] 17 Oral and Maxillofacial Surgery Department, University Hospital Vall d’Hebron, 08035 Barcelona, Spain; [email protected] 18 Oral and Maxillofacial Surgery Department, Hospital Reina Sofía, 14004 Córdoba, Spain; [email protected] *Correspondence: [email protected] (F.M.G.); [email protected] (P.M.A.) Abstract: Introduction: This report investigates late-stage internal derangement (ID) of the temporomandibular joint (TMJ) with the aim of establishing a more effective and personalized treatment protocol to improve patients’ quality of life (QoL). Material and methods: A consensus was reached among maxillofacial surgeons specializing in LSID, based on a literature research and collective expert experience following the Delphi method. Consensus was considered to be achieved when a response received at least 80% of votes. Results: Four expert groups were established, respectively, focusing on diagnosis, minimally invasive surgery (MIS), open surgery and joint replacement. A comprehensive approach to late-stage ID of the TMJ requires a consensus report. This underscores J. Clin. Med. 2024,13, 3319. https://doi.org/10.3390/jcm13113319 https://www.mdpi.com/journal/jcm J. Clin. Med. 2024,13, 3319 2 of 20 the need for a personalized treatment plan, considering the variability in clinical presentations and progression of this pathology. Our recommendations aim to optimize clinical outcomes and enhance patient QoL. Keywords: temporomandibular joint disorders; temporomandibular joint disk; temporomandibular joint diagnosis and temporomandibular joint surgery 1. Introduction Temporomandibular dysfunction (TMD) syndrome encompasses a heterogeneous array of clinical entities affecting the temporomandibular joint (TMJ), masticatory muscles, and adjacent structures. It represents a complex and multifactorial clinical condition, the etiology and pathogenesis of which are not yet fully understood. TMD manifestations commonly include restricted range of motion and TMJ noises, with chronic pain being the primary motivator for patients seeking treatment [1,2]. The global incidence of TMD in the population stands at 34%, with individuals aged 18–60 years being most susceptible. Across continents, it has been observed that the female population comprises 9% to 56% more cases than males [ 3 ]. The most common cause of TMJ dysfunction is internal derangement of the joint [4]. Late-stage internal derangement (ID) of the temporomandibular joint (TMJ) is characterized by disc displacement, with or without reduction, resulting in mouth opening limitation. Typically, the articular disc displaces anteromedially, conforming to the condyle shape and the anterior slope of the glenoid fossa, influenced by the lateral pterygoid muscle [ 4 , 5 ]. However, when the mandibular condyle fails to pass over the posterior band of the articular disc, reduction fails, leading to limited mouth opening [ 5 ]. Dynamic alterations in TMJ structures may result in morphological consequences such as adherences, disc perforation, and synovial inflammation. The positional alteration of the joint disc may predispose to mechanical disorders, although it is not always the primary cause of functional deficits. Various factors, including traumatic injury, primary arthritis, hormonal influences, highly reactive oxidative radicals from bruxism, and inadequate lubrication, can contribute to disc derangement by compromising the functional integrity of TMJ ligaments [5]. A broad range of treatment options are available for patients with these disorders, including conservative management, minimally invasive surgery (MIS) and open surgery. Nevertheless, despite these multiple therapeutic options, no clear clinical protocol has been established capable of affording a standardized treatment algorithm adapted to the needs of each individual patient. The present consensus report seeks to investigate the currently available therapeutic options in depth, and to discuss future perspectives for improving and optimizing the clinical approach to this disease condition. The document aims to establish the bases for a more effective and personalized surgical treatment protocol capable of improving the quality of life (QoL) of patients with late-stage ID. 2. Materials and Methods 2.1. The Delphi Method A meticulous protocol following the Delphi method has been followed to reach consensus among maxillofacial surgeons on the treatment of late-stage internal temporomandibular joint (TMJ) lesions. The 24 authors are part of the Spanish Society of Oral and Maxillofacial Surgery and also belong to a group of surgeons with prestigious experience in the field of TMJ, not only because of their published articles on the subject but also their experience and extensive participation in other TMJ conferences. The main characteristics of the Delphi methodology are the following: (1) in an iterative process, participants may express their opinions on several occasions and are offered the opportunity to reflect on J. Clin. Med. 2024,13, 3319 3 of 20 these with reference to the majority opinion; (2) anonymity is ensured, decreasing the risk of prestige or leadership bias; and (3) development of the process is controlled by the Delphi coordinators. To address the different aspects, the experts were divided into four groups according to their areas of specialization: diagnosis of late-stage TMJ disorders, minimally invasive surgery (MIS), open surgery, and joint replacement. Our Delphi process was conducted in several rounds, using a series of questionnaires delivered via electronic survey, followed by a meeting of all committee members, in which the findings were discussed, and the recommendations were established to reach the general and well-founded consensus described in detail below. 2.2. Study Design In the initial round, the 24 participants—consisting of oral and maxillofacial surgeons that belong to the Spanish Society of Oral and Maxillofacial Surgery with renowned expertise in TMJ disorders—were asked to recommend diagnostic imaging tools for evaluating suspected advanced internal derangement of the TMJ, and to comment on the correlation between radiological signs and arthroscopic findings in these patients. Subsequent rounds involved refining consensus items based on the responses received, with iterations focusing on areas of disagreement or uncertainty. The Delphi panelists were presented with the summary of the consensus from the previous round and were asked to re-evaluate their earlier responses in light of the group’s feedback. Throughout the Delphi process, anonymity of individual responses was maintained to prevent dominance by any one opinion leader and to minimize the bandwagon effect. The iterative nature of the enquiry and controlled feedback allowed the group to work towards the desired consensus. To finish, the last round was compounded by a meeting of all committee members, in which the findings were discussed, and the recommendations were established to reach the general and well-founded consensus described in detail below. Strong consensus was considered when >95% of participants agreed, consensus was considered when 80–95% of participants were in agreement, and reduced consensus for responses receiving 70–80% of votes. When a response received fewer than 70% of votes, we considered consensus not to have been reached [Table 1]. Table 1. Strength level of consensus. Strong consensus >95% of participants agreed Consensus 80–95% of participants agreed Reduced consensus 70–79% of participants agreed No consensus <70% of participants agreed 3. Diagnosis of Late-Stage Temporomandibular Joint Dysfunction: Analysis of the Literature and Group Consensus 3.1. What Are the Main Symptoms of Late-Stage ID of TMJ? The main symptom in this stage of the disease is preauricular pain of variable intensity. The pain is typically intermittent and worsens with mandibular function and chewing. Other associated symptoms eventually may also appear, such as otological manifestations (otalgia and occasionally fullness sensation in the ear, manifesting on mobilizing the jaw, and which may be accompanied by dizziness), headache (with specific irradiation towards the maxillary region, temporal zone and frontal area), neck pain (typically with specific trigger points that produce intense pain), and pain in the orbital region (“heavy” and constant pain sensation) [1,6–10]. 3.2. What Are the Main Exploration Signs in Late-stage ID of TMJ [11,12]? - Reduced oral aperture, of variable degree and characterized by deviation towards the affected side. J. Clin. Med. 2024,13, 3319 4 of 20 - Normal movement in the ipsilateral direction, but with restriction in the contralateral direction. - The mechanical alterations in the late stages are usually characterized by the presence of crackling or crepitus, and sometimes the absence of clicking sounds. The sounds are perceived during all of the joint movements, though their characteristics may range from subtle to severe intermittent crackling. - Pain is produced in response to palpation of the pre-tragus zone with the mouth closed or open. The exploration of this pain is usually completed with the Krogh Poulsen or Mahan bite test: if the pain in late-stage disease is of joint origin, it is triggered on biting upon a thin flat wedge placed in the contralateral molar sector. - Gross occlusal disorders due to the chronic and progressive evolution of the disorder are much less commonly observed. 3.3. What Imaging Techniques Are Indicated in Late-Stage ID of TMJ? What Are the Radiological Findings? Is There a Clear Correlation between the Radiological Signs and the Arthroscopic Findings in Late-Stage Cases? Panoramic radiography is only of use in ruling out associated disorders in the late stages of joint dysfunction. When severe dysfunction is suspected, magnetic resonance imaging (MRI) should be considered as first choice, based on T2-weighted sequences (mouth closed–mouth open) in sagittal and coronal views. This technique can evidence the following changes: - Disc alterations: the joint disc is usually seen to be in a forward position and often shows deformity. Changes in signal intensity are very common in advanced stages. - Disc perforation: the diagnosis of perforation is difficult to establish and requires great experience on the part of the radiologist, fundamentally using direct or indirect magnetic resonance arthroscopy techniques. - Joint effusion: this reflects joint inflammation and can be identified in the upper or lower joint spaces, or both. - Loss of joint space. - Trabecular bone edema. Formation of subchondral bone cysts. - Irregularity of the joint contour. - Formation of exostosis-osteophytes. - Appositional bone formation of the fossa. Computerized axial tomography (CAT) or cone-beam computed tomography (CBCT) is clearly useful in distinguishing the joint space and in determining degenerative changes at bone level. These radiological techniques are of use in assessing the following changes: - Generalized subchondral sclerosis: this is defined as an area of increased cortical bone density extending towards the trabecular component. - Osteophyte formations. - Bone erosions. - Subchondral cysts. - Flattening of the condylar surface. Furthermore, magnetic resonance imaging (MRI) is the imaging technique of choice for evaluating the TMJ, due to its capacity to identify soft tissue alterations, disc displacement and joint effusion. However, previous studies have revealed a poor correlation between MRI and arthroscopy, apart from the evaluation of disc reduction and disc perforation. The current evidence points to a strong correlation between the presence of effusion as evidenced by MRI and the finding of moderate–severe synovitis, with a poorer correlation between disc position and roofing as observed in the arthroscopic exploration. On the other hand, the CBCT findings only seem to be reliable in the determination of joint space collapse and in the assessment of bone structures. Their correlation with the rest of the arthroscopic findings is very limited [13]. J. Clin. Med. 2024,13, 3319 5 of 20 In this regard, a reduced consensus was achieved, with 78% agreement among voters that there is a clear correlation between radiological signs and arthroscopic findings in patients with advanced stages of internal derangement of the TMJ. According to the findings from the Delphi procedure survey, in the initial round, 71% of participants would recommend CT and MRI as the indicated imaging modalities for a patient suspected of having an advanced stage of internal disorder of the TMJ. However, upon specification in the subsequent round regarding the independent recommendation of CT and MRI, 83.3% of participants would suggest CT [Figure 1] and 94.5% would propose MRI [Figure 2]. Hence, these two tests are deemed optimal in this scenario. J. Clin. Med. 2024, 13, x FOR PEER REVIEW 5 of 20 The current evidence points to a strong correlation between the presence of effusion as evidenced by MRI and the finding of moderate–severe synovitis, with a poorer correlation between disc position and roofing as observed in the arthroscopic exploration. On the other hand, the CBCT findings only seem to be reliable in the determination of joint space collapse and in the assessment of bone structures. Their correlation with the rest of the arthroscopic findings is very limited [13]. In this regard, a reduced consensus was achieved, with 78% agreement among voters that there is a clear correlation between radiological signs and arthroscopic findings in patients with advanced stages of internal derangement of the TMJ. According to the findings from the Delphi procedure survey, in the initial round, 71% of participants would recommend CT and MRI as the indicated imaging modalities for a patient suspected of having an advanced stage of internal disorder of the TMJ. However, upon specification in the subsequent round regarding the independent recommendation of CT and MRI, 83.3% of participants would suggest CT [Figure 1] and 94.5% would propose MRI [Figure 2]. Hence, these two tests are deemed optimal in this scenario. Figure 1. Delphi results regarding use of CT scan in late-stage ID of TMJ. 83% 11% 6% Would you recommend a CT scan as a tool image to complete the diagnosis in a patient with late stage internal derangement (ID) of the temporomandibular joint (TMJ)? Agree Disagree It depends Figure 1. Delphi results regarding use of CT scan in late-stage ID of TMJ. J. Clin. Med. 2024, 13, x FOR PEER REVIEW 5 of 20 The current evidence points to a strong correlation between the presence of effusion as evidenced by MRI and the finding of moderate–severe synovitis, with a poorer correlation between disc position and roofing as observed in the arthroscopic exploration. On the other hand, the CBCT findings only seem to be reliable in the determination of joint space collapse and in the assessment of bone structures. Their correlation with the rest of the arthroscopic findings is very limited [13]. In this regard, a reduced consensus was achieved, with 78% agreement among voters that there is a clear correlation between radiological signs and arthroscopic findings in patients with advanced stages of internal derangement of the TMJ. According to the findings from the Delphi procedure survey, in the initial round, 71% of participants would recommend CT and MRI as the indicated imaging modalities for a patient suspected of having an advanced stage of internal disorder of the TMJ. However, upon specification in the subsequent round regarding the independent recommendation of CT and MRI, 83.3% of participants would suggest CT [Figure 1] and 94.5% would propose MRI [Figure 2]. Hence, these two tests are deemed optimal in this scenario. Figure 1. Delphi results regarding use of CT scan in late-stage ID of TMJ. 83% 11% 6% Would you recommend a CT scan as a tool image to complete the diagnosis in a patient with late stage internal derangement (ID) of the temporomandibular joint (TMJ)? Agree Disagree It depends Figure 2. Delphi results regarding use of MRI in late-stage ID of TMJ. Consensus. 3.4. What Are the Possible Arthroscopic Findings in Late-Stage ID of TMJ? The advanced stages of joint dysfunction may show the following morphological changes in the arthroscopic diagnostic evaluation: J. Clin. Med. 2024,13, 3319 6 of 20 - Roofing 0–25%: in cases characterized by disc displacement without reduction (DDwR), “roofing” will be 0% or almost 0%, corroborating the presence of retrodiscal tissue with a variable number of vessels on the surface of the mandibular condyle [ 14 ]. (Consensus was reached, with 88.8% of voters agreeing that roofing 0–25% is expected in patients with late-stage ID of TMJ, (Figure 3).) J. Clin. Med. 2024, 13, x FOR PEER REVIEW 6 of 20 Figure 2. Delphi results regarding use of MRI in late-stage ID of TMJ. Consensus. 3.4. What Are the Possible Arthroscopic Findings in Late-Stage ID of TMJ? The advanced stages of joint dysfunction may show the following morphological changes in the arthroscopic diagnostic evaluation: - Roofing 0–25%: in cases characterized by disc displacement without reduction (DDwR), “roofing” will be 0% or almost 0%, corroborating the presence of retrodiscal tissue with a variable number of vessels on the surface of the mandibular condyle [14]. (Consensus was reached, with 88.8% of voters agreeing that roofing 0–25% is expected in patients with late-stage ID of TMJ, (Figure 3).) Figure 3. Delphi results: What arthroscopic finding would you expect in a patient with late–stage ID of TMJ? Consensus. - Hyalinization of the retrodiscal tissue: metaplasia and remodeling of the bilaminar zone or posterior ligament [14]. (Strong consensus achieved, 100% of votes agree (Figure 4).) Figure 4. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. 89% 5% 6% Roofing 0-25% Agree Disagree It depends 100% Hyalinization of the retrodiscal tissue Agree Disagree It depends Figure 3. Delphi results: What arthroscopic finding would you expect in a patient with late–stage ID of TMJ? Consensus. - Hyalinization of the retrodiscal tissue: metaplasia and remodeling of the bilaminar zone or posterior ligament [ 14 ]. (Strong consensus achieved, 100% of votes agree (Figure 4).) J. Clin. Med. 2024, 13, x FOR PEER REVIEW 6 of 20 Figure 2. Delphi results regarding use of MRI in late-stage ID of TMJ. Consensus. 3.4. What Are the Possible Arthroscopic Findings in Late-Stage ID of TMJ? The advanced stages of joint dysfunction may show the following morphological changes in the arthroscopic diagnostic evaluation: - Roofing 0–25%: in cases characterized by disc displacement without reduction (DDwR), “roofing” will be 0% or almost 0%, corroborating the presence of retrodiscal tissue with a variable number of vessels on the surface of the mandibular condyle [14]. (Consensus was reached, with 88.8% of voters agreeing that roofing 0–25% is expected in patients with late-stage ID of TMJ, (Figure 3).) Figure 3. Delphi results: What arthroscopic finding would you expect in a patient with late–stage ID of TMJ? Consensus. - Hyalinization of the retrodiscal tissue: metaplasia and remodeling of the bilaminar zone or posterior ligament [14]. (Strong consensus achieved, 100% of votes agree (Figure 4).) Figure 4. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. 89% 5% 6% Roofing 0-25% Agree Disagree It depends 100% Hyalinization of the retrodiscal tissue Agree Disagree It depends Figure 4. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. - Disc perforations: These are most often seen at the junction between the retrodiscal area and the joint meniscus, and are usually related to cases of advanced osteoarthrosis [15,16]. (Consensus, 95% of votes agree (Figure 5).) J. Clin. Med. 2024,13, 3319 7 of 20 J. Clin. Med. 2024, 13, x FOR PEER REVIEW 7 of 20 - Disc perforations: These are most often seen at the junction between the retrodiscal area and the joint meniscus, and are usually related to cases of advanced osteoarthrosis [15,16]. (Consensus, 95% of votes agree (Figure 5).) Figure 5. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Consensus. - Synovial proliferations (“synovial polyps”): these are hyperplastic excrescencies or proliferations of the synovial membrane [17–19]. (Reduced consensus, 72.2% of votes agree.) - Free bone or cartilage bodies: these are fragments of joint cartilage and/or bone that move freely within the joint space [14]. (Reduced consensus 72.2% votes agree). - Advanced synovitis: inflammation of the synovial membrane. It is most frequently observed in the posterior recess, and according to some studies, its magnitude is correlated with increased intensity of the symptoms [17–19]. (Strong consensus, 100% of votes agree [Figure 6]).) o Grade III and IV of the McCain classification: increased vasodilation, even with possible vascular obliteration, and presenting moderate-to-intense hyperemia; or Grade II of the Holmlund classification: capillary hyperemia and synovial hyperplasia. Figure 6. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. 95% 5% Disc perforations Agree Disagree It depends 100% Advanced synovitis Agree Disagree It depends Figure 5. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Consensus. - Synovial proliferations (“synovial polyps”): these are hyperplastic excrescencies or proliferations of the synovial membrane [ 17 – 19 ]. (Reduced consensus, 72.2% of votes agree.) - Free bone or cartilage bodies: these are fragments of joint cartilage and/or bone that move freely within the joint space [14]. (Reduced consensus 72.2% votes agree). - Advanced synovitis: inflammation of the synovial membrane. It is most frequently observed in the posterior recess, and according to some studies, its magnitude is correlated with increased intensity of the symptoms [ 17 – 19 ]. (Strong consensus, 100% of votes agree [Figure 6]).) # Grade III and IV of the McCain classification: increased vasodilation, even with possible vascular obliteration, and presenting moderate-to-intense hyperemia; or Grade II of the Holmlund classification: capillary hyperemia and synovial hyperplasia. J. Clin. Med. 2024, 13, x FOR PEER REVIEW 7 of 20 - Disc perforations: These are most often seen at the junction between the retrodiscal area and the joint meniscus, and are usually related to cases of advanced osteoarthrosis [15,16]. (Consensus, 95% of votes agree (Figure 5).) Figure 5. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Consensus. - Synovial proliferations (“synovial polyps”): these are hyperplastic excrescencies or proliferations of the synovial membrane [17–19]. (Reduced consensus, 72.2% of votes agree.) - Free bone or cartilage bodies: these are fragments of joint cartilage and/or bone that move freely within the joint space [14]. (Reduced consensus 72.2% votes agree). - Advanced synovitis: inflammation of the synovial membrane. It is most frequently observed in the posterior recess, and according to some studies, its magnitude is correlated with increased intensity of the symptoms [17–19]. (Strong consensus, 100% of votes agree [Figure 6]).) o Grade III and IV of the McCain classification: increased vasodilation, even with possible vascular obliteration, and presenting moderate-to-intense hyperemia; or Grade II of the Holmlund classification: capillary hyperemia and synovial hyperplasia. Figure 6. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. 95% 5% Disc perforations Agree Disagree It depends 100% Advanced synovitis Agree Disagree It depends Figure 6. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. - Grade III–IV chondromalacia: softening of the joint cartilage secondary to degeneration produced by joint overload (Strong consensus 100% votes agree, [Figure 7]). In its late stages, we can observe the following: J. Clin. Med. 2024,13, 3319 8 of 20 # Grade III: presence of fibrillation on the joint surface at fossa and eminence level, fading, ulceration and/or rupture of the joint cartilage. #Grade IV: exposure of subchondral bone. J. Clin. Med. 2024, 13, x FOR PEER REVIEW 8 of 20 - Grade III–IV chondromalacia: softening of the joint cartilage secondary to degeneration produced by joint overload (Strong consensus 100% votes agree, [Figure 7]). In its late stages, we can observe the following: o Grade III: presence of fibrillation on the joint surface at fossa and eminence level, fading, ulceration and/or rupture of the joint cartilage. o Grade IV: exposure of subchondral bone. Figure 7. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. - Adherences. The following types have been defined: (a) simple fibrous bands; (b) fibrosynovial bands; (c) pseudowalls. Fibrosynovial bands and pseudowalls are more frequent in the advanced stages of the disease [20]. (Strong consensus, 100% of votes agree (Figure 8).) Figure 8. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. 4. Minimally Invasive Surgery in Late-Stage ID of the Temporomandibular Joint: Research and Group Consensus 4.1. What Does the Minimally Invasive Treatment of Late-Stage ID of TMJ Consist of? The treatment of late-stage ID begins with conservative management, with surgery being reserved for those cases that prove refractory to the initial conservative approach. Arthrocentesis (AC) with lavage of the inflammatory and degenerative elements of the 100% Grade III/IV Chondromalacia Agree Disagree It depends 100% Adherences Agree Disagree It depends Figure 7. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. - Adherences. The following types have been defined: (a) simple fibrous bands; (b) fibrosynovial bands; (c) pseudowalls. Fibrosynovial bands and pseudowalls are more frequent in the advanced stages of the disease [ 20 ]. (Strong consensus, 100% of votes agree (Figure 8).) J. Clin. Med. 2024, 13, x FOR PEER REVIEW 8 of 20 - Grade III–IV chondromalacia: softening of the joint cartilage secondary to degeneration produced by joint overload (Strong consensus 100% votes agree, [Figure 7]). In its late stages, we can observe the following: o Grade III: presence of fibrillation on the joint surface at fossa and eminence level, fading, ulceration and/or rupture of the joint cartilage. o Grade IV: exposure of subchondral bone. Figure 7. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. - Adherences. The following types have been defined: (a) simple fibrous bands; (b) fibrosynovial bands; (c) pseudowalls. Fibrosynovial bands and pseudowalls are more frequent in the advanced stages of the disease [20]. (Strong consensus, 100% of votes agree (Figure 8).) Figure 8. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. 4. Minimally Invasive Surgery in Late-Stage ID of the Temporomandibular Joint: Research and Group Consensus 4.1. What Does the Minimally Invasive Treatment of Late-Stage ID of TMJ Consist of? The treatment of late-stage ID begins with conservative management, with surgery being reserved for those cases that prove refractory to the initial conservative approach. Arthrocentesis (AC) with lavage of the inflammatory and degenerative elements of the 100% Grade III/IV Chondromalacia Agree Disagree It depends 100% Adherences Agree Disagree It depends Figure 8. Delphi results: What arthroscopic finding would you expect in a patient with late-stage ID of TMJ? Strong consensus. 4. Minimally Invasive Surgery in Late-Stage ID of the Temporomandibular Joint: Research and Group Consensus 4.1. What Does the Minimally Invasive Treatment of Late-Stage ID of TMJ Consist of? The treatment of late-stage ID begins with conservative management, with surgery being reserved for those cases that prove refractory to the initial conservative approach. Arthrocentesis (AC) with lavage of the inflammatory and degenerative elements of the TMJ in the advanced stages of the disorder can afford short-term improvement (less than 6 months?) of the pain and joint mobility problems. The infiltration of beneficial substances after arthrocentesis likewise can afford short-term pain and joint mobility improvement J. Clin. Med. 2024,13, 3319 9 of 20 compared with isolated infiltrations of the TMJ. These substances may include PRP. The administration of botulinum toxin in cases accompanied by myofascial syndrome in turn contributes to improve any associated surgical technique [21,22]. Level I arthroscopy (lysis and lavage) is effective in diagnosing intraarticular disease, with the added benefits of arthrocentesis. More advanced arthroscopic techniques (levels II and III) are able to act upon the damaged tissues, reducing inflammation, with the sub-synovial infiltration of corticosteroids (CS) or platelet-rich plasma (PRP), the lysis of adhesions, and disc repositioning and stabilization in advanced cases, affording statistically significant improvement especially of the pain and joint mobility [23]. Arthroscopy of the TMJ can delay the need for open surgery in cases of advanced joint dysfunction [24,25]. Repeat arthroscopy in late-stage situations may not be advised, though further studies may focus on this important question due to the paucity of good-quality studies in the high-impact, peer-reviewed literature and more, better-designed studies [21]. 4.2. Proposal of Minimally Invasive Surgery (MIS) in the Late Stages of Internal Derangement The proposal of minimally invasive surgery (MIS) in the late stages of internal derangement aims to address the complexities of temporomandibular joint (TMJ) disorders through a progressive treatment approach. - Initial management of the pain, joint sounds and limitation of mobility of the TMJ: arthrocentesis and joint lavage with the infiltration of PRP and/or hyaluronic acid (HA). - Addition of botulinum toxin in cases with an associated muscle component (myofascial syndrome). - Cases refractory to the above treatments: level II arthroscopy of the TMJ with direct therapy targeted to the pathological findings. - Cases of disc displacement without reduction (recapture) and disc in good condition: level III arthroscopy of the TMJ with associated discopexy is recommended. - Cases showing poor evolution and in wait of open surgery or joint replacement: corticosteroid infiltrations to reduce the symptoms. Traditionally, MIS techniques are indicated in cases of joint dysfunction unresponsive to conservative management, provided the patient suffers pain and functional disability with an impact upon his or her daily life. However, there is no clear consensus regarding the appropriate timing of the procedure or the best surgical technique. The data obtained from the radiological study can support the indication of MIS, always in correlation with the clinical findings. Independently of the above, it is advisable to perform an MRI study before any surgery is performed on the joint. Minimally invasive surgery is indicated in patients with a decrease in oral aperture (<35 mm) and/or pain (visual analogue score [VAS] > 3/10), and the clinical data are to be correlated with the radiological findings indicating disc displacement, signs of intraarticular inflammation and the presence of degeneration [14,15]. 4.3. Infiltration of Different Substances 4.3.1. Are Local Anesthetics a Valid Option in Late-Stage ID of TMJ? This has not been demonstrated, except for reducing pain over the short term and as part of the surgical management [ 25 ]. (Reduced consensus, as 72.2% of votes agree and 27.8% disagree.) 4.3.2. Are Opiates without Side Effects in the TMJ? This aspect has not been demonstrated in experimental studies [ 21 ]. (Consensus: 89% agreed that opioids have side effects (Figure 9).) J. Clin. Med. 2024,13, 3319 16 of 20 tomy. At present, new mandibular implant designs are being investigated that include a scaffold to favor lateral pterygoid muscle reinsertion and enthesis. Few studies confirming their usefulness have been published, however [83,84]. 6.2.5. Is Adipose Tissue Grafting for Covering the Implant Indicated? The use of autologous adipose tissue grafts from the abdomen to cover the alloplastic TMJ implant aims to obliterate dead spaces and limit hematoma formation. This may reduce the probability of heterotopic ossification by up to 20%. It is indicated in cases characterized by a high risk of ankylosis [ 85 , 86 ]. (No consensus was reached: 61.1% indicated adipose tissue grafting only in cases of TMJ ankyloses and 27.8% always perform this technique.) 6.2.6. Is Coronoidectomy in Joint Replacement Indicated? Coronoidectomy is usually required in patients with ankylosis, severely limited oral aperture, or interference with the zygomatic arch. However, in cases where a lack of stability of the TMJ is expected, coronoidectomy may increase the instability. Therefore, in patients with late-stage TMD, coronoidectomy is not systematically indicated [87]. 6.2.7. Navigation and Guided Surgery Surgical navigation improves the precision of the results of joint replacement and has been shown to be useful for the following [88,89]: - Performing complete, precise and safe resection of the glenoid cavity, where indicated. - Avoiding damage to important structures during surgery. - Increasing safety and reducing uncertainty during the surgical procedure. - Checking the results of placing both implant components intraoperatively and performing any necessary corrections. - Designing trajectories for precise placement of the implant screws. - Performing virtual surgery preoperatively by entering both stock and custom implants in the navigator planning software. 7. Conclusions The consensus report on late-stage temporomandibular joint dysfunction emphasizes the need for a personalized, multi-disciplinary approach to diagnosis and treatment. Accurate diagnosis using MRI and CAT/CBCT is crucial, guiding a treatment progression from conservative methods to more invasive surgeries as needed. The report highlights the significance of patient-specific strategies, including minimally invasive and open surgeries, and considers joint replacement as a final option to enhance quality of life. It underscores the importance of specialist collaboration in managing complex cases and advocates for ongoing research to refine treatment methods, ultimately aiming to improve outcomes and quality of life for patients with late-stage TMD. Author Contributions: Conceptualization, F.M.G.; methodology, F.M.G., R.M.-G., M.M.G., J.F.S. and M.M.M.; software, F.M.G.; validation, F.M.G., R.M.-G., M.M.G., J.F.S. and M.M.M.; formal analysis, F.M.G., R.M.-G., M.M.G., J.F.S. and M.M.M.; investigation, P.M.A., A.C.Q.d.L., M.M.G., D.G.B., J.M.L.A., J.L.L.C., J.L.G.P., R.M.-G., J.L.d.C.P.d.V., B.G.M., R.G.-G., M.M.S., E.V.R., J.F.S., R.L.M., B.P.C., M.R.A., M.M.M., C.S.G., B.R.M., A.V.O., J.M.G. and A.D.F.; resources, P.M.A., A.C.Q.d.L., M.M.G., D.G.B., J.M.L.A., J.L.L.C., J.L.G.P., R.M.-G., J.L.d.C.P.d.V., B.G.M., R.G.-G., M.M.S., E.V.R., J.F.S., R.L.M., B.P.C., M.R.A., M.M.M., C.S.G., B.R.M., A.V.O., J.M.G. and A.D.F.; data curation, F.M.G., R.M.-G., M.M.G., J.F.S. and M.M.M.; writing—original draft preparation, P.M.A., R.M.-G., J.F.S. and M.M.M.; writing—review and editing, F.M.G.; visualization, P.M.A.; supervision, F.M.G.; project administration, F.M.G. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. J. Clin. Med. 2024,13, 3319 17 of 20 Data Availability Statement: The data presented in this study are available on request from the corresponding authors. Acknowledgments: We would like to thank all SECOM members who participated; they were all actively involved in establishing this Consensus report and recommendations on the management of late-stage internal derangement of the temporomandibular joint. Conflicts of Interest: The authors declare no conflicts of interest. References 1. Maini, K.; Dua, A. Temporomandibular Syndrome [Updated 28 April 2022]. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2022. 2. List, T.; Jensen, R.H. Temporomandibular Disorders: Old Ideas and New Concepts. Cephalalgia Int. J. Headache 2017,37, 692–704. 3. Zielinski, G.; Pajak-Zielinska, B.; Ginszt, M. A Meta-Analysis of the Global Prevalence of Temporomandibular Disorders. J. Clin. Med. 2024,13, 1365. [CrossRef] [PubMed] 4. Kaplan, P.A.; Tu, H.K.; Sleder, P.R.; Lydiatt, D.D.; Laney, T.J. Inferior joint space arthrography of normal temporomandibular joints: Reassessment of diagnostic criteria. Radiology 1986,159, 585–589. [PubMed] 5. Askar, H.; Aronovich, S.; Christensen, B.J.; McCain, J.; Hakim, M. Is Arthroscopic Disk Repositioning Equally Efficacious to Open Disk Repositioning? A Systematic Review. J. Oral Maxillofac. Surg. 2021,79, 2030–2041. [PubMed] 6. Mehta, N.R.; Forgione, A.G.; Rosenbaum, R.S.; Holmberg, R. “TMJ” triad of dysfunctions: A biologic basis of diagnosis and treatment. J. Mass Dent. Soc. 1984,33, 173. 7. Magalhães, B.G.; Freitas, J.L.M.; Barbosa, A.C.D.S.; Gueiros, M.C.S.N.; Gomes, S.G.F.; Rosenblatt, A.; Caldas Júnior, A.F. Temporomandibular disorder: Otologic implications and its relationship to sleep bruxism. Braz. J. Otorhinolaryngol. 2017,84, 614–619. [PubMed] 8. Graff-Radford, S.B.; Bassiur, J.P. Temporomandibular disorders and headaches. Neurol. Clin. 2014,32, 525–537. [PubMed] 9. Ciancaglini, R.; Testa, M.; Radaelli, G. Association of neck pain with symptoms of temporomandibular dysfunction in the general adult population. Scand. J. Rehabil. Med. 1999,31, 17–22. [PubMed] 10. Curtis, A.W. Myofascial Pain-Dysfunction Syndrome: The Role of Nonmasticatory Muscles in 91 Patients. Otolaryngol. Head Neck Surg. 1980,88, 361–367. 11. Norman, J.E. Post-traumatic disorders of the jaw joint. Ann. R. Coll. Surg. Engl. 1982,64, 29–34. 12. Konan, E.; Boutault, F.; Wagner, A.; Lopez, R.; Roch Paoli, J.R. Clinical significance of the Krogh-Poulsen bite test in mandibular dysfunction. Rev. Stomatol. Chir. Maxillo-Faciale 2003,104, 253–259. 13. Verhelst, P.J.; Vervaeke, K.; Orhan, K.; Lund, B.; Benchimol, D.; Coucke, W.; Van der Cruyssen, F.; De Laat, A.; Politis, C.; Jacobs, R. The agreement between magnetic resonance imaging and arthroscopic findings in temporomandibular joint disorders. Int. J. Oral Maxillofac. Surg. 2021,50, 657–664. [PubMed] 14. McCain, J.; de la Rua, H.; Le Blanc, W.G. Correlation of clinical, radiographic and arthroscopic findings in internal derangements of the TMJ. J. Oral Maxillofac. Surg. 1989,47, 913–921. [PubMed] 15. Kurita, K.; Bronstein, S.L.; Westesson, P.L. Arthroscopic dignosis of perforation and adhesions of the temporomandibular joint: Correlation with postmortem morphology. Oral Surg. Oral Med. Oral Pathol. 1989,68, 130–134. [PubMed] 16. Sato, F.R.L.; Lima, C.A.A.; Tralli, G.; da Silva, R.A. Is there a correlation between arthroscopic findings and the clinical signs and symptoms of patients with internal derangement of the temporomandibular joint? A prospective study. Int. J. Oral Maxillofac. Surg. 2019,48, 233–238. [PubMed] 17. McCain, J.P. Principles and Practice of Temporomandibular Joint Arthroscopy; Mosby: St Louis, MO, USA, 1996; pp. 42–53+128–165. 18. Holmlund, A.; Axelsson, S. Temporomandibular arthropathy: Correlation between clinical signs and symptoms and arthroscopic findings. Int. J. Oral Maxillofac. Surg. 1996,25, 178–181. [PubMed] 19. Quinn, J.H. Pathogenesis of temporomandibular joint chondromalacia and arthralgia. Oral Maxillofac. Surg. Clin. N. Am. 1989,1, 47–57. 20. Kaminishi, R.M.; Davis, C.L. Temporomandibular joint arthroscopic observations of superior space adhesions. Oral Maxillofac. Surg. Clin. N. Am. 1989,1, 103–109. 21. Al-Moraissi, E.A. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: A systematic review and meta-analysis. Int. J. Oral Maxillofac. Surg. 2015,44, 104–112. [CrossRef] [PubMed] 22. Al-Moraissi, E.A. Open versus arthroscopic surgery for the management of internal derangement of the temporomandibular joint: A meta-analysis of the literature. Int. J. Oral Maxillofac. Surg. 2015,44, 763–770. 23. Martín-Granizo, R.; González-García, R. Arthroscopic Disc Repositioning Techniques of the Temporomandibular Joint Part 2: Resorbable Pins. Atlas Oral Maxillofac. Surg. Clin. N. Am. 2022,30, 185–191. 24. Bergstrand, S.; Ingstad, H.K.; Moystad, A.; Bjornland, T. Long-term effectiveness of arthrocentesis with and without hyaluronic acid injection for treatment of temporomandibular joint osteoarthritis. J. Oral Sci. 2019,61, 82–88. [PubMed] 25. Al-Moraissi, E.A.; Wolford, L.M.; Ellis, E., 3rd; Neff, A. The hierarchy of different treatments for arthrogenous temporomandibular disorders: A network meta-analysis of randomized clinical trials. J. Craniomaxillofac. Surg. 2020,48, 9–23. [PubMed] J. Clin. Med. 2024,13, 3319 18 of 20 26. Bjørnland, T.; Gjærum, A.A.; Møystad, A. Osteoarthritis of the temporomandibular joint: An evaluation of the effects and complications of corticosteroid injection compared with injection with sodium hyaluronate. J. Oral Rehabil. 2007,34, 583–589. [PubMed] 27. Cömert Kiliç, S. Does Injection of Corticosteroid After Arthrocentesis Improve Outcomes of Temporomandibular Joint Osteoarthritis? A Randomized Clinical Trial. J. Oral Maxillofac. Surg. 2016,74, 2151–2158. [PubMed] 28. Dasukil, S.; Arora, G.; Boyina, K.K.; Jena, A.K.; Jose, A.; Das, S. Intra-articular injection of hyaluronic acid versus plateletrich plasma following single puncture arthrocentesis for the management of internal derangement of TMJ: A double-blinded randomised controlled trial. J. Craniomaxillofac. Surg. 2022,50, 825–830. [PubMed] 29. Hegab, A.F.; Hameed, H.I.A.A.; Hassaneen, A.M.; Hyder, A. Synergistic effect of platelet rich plasma with hyaluronic acid injection following arthrocentesis to reduce pain and improve function in TMJ osteoarthritis. J. Stomatol. Oral Maxillofac. Surg. 2023,124, 101340. 30. Ch˛eci´nski, M.; Ch˛eci´nska, K.; Turosz, N.; Kami´nska, M.; Nowak, Z.; Sikora, M.; Chlubek, D. Autologous stem cell transplants in the treatment of temporomandibular joint disorders: A systematic review and meta-analysis of clinical trials. Cells 2022,11, 2709. [CrossRef] 31. Chung, P.Y.; Lin, M.T.; Chang, H.P. Effectiveness of platelet-rich plasma injection in patients with temporomandibular joint osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. 2019,127, 106–116. 32. Cömert Kiliç, S.; Güngörmü¸s, M.; Sümbüllü, M.A. Is Arthrocentesis Plus Platelet-Rich Plasma Superior to Arthrocentesis Alone in the Treatment of Temporomandibular Joint Osteoarthritis? A Randomized Clinical Trial. J. Oral Maxillofac. Surg. 2015,73, 1473–1483. 33. Fernández Sanromán, J.; Fernández Ferro, M.; Costas López, A.; Arenaz Bua, J.; López, A. Does injection of plasma rich in growth factors after temporomandibular joint arthroscopy improve outcomes in patients with Wilkes stage IV internal derangement? A randomized prospective clinical study. Int. J. Oral Maxillofac. Surg. 2016,45, 828–835. [PubMed] 34. Gong, S.; Emperumal, C.P.; AL-Eryani, K.; Enciso, R. Regeneration of temporomandibular joint using in vitro human stem cells: A review. J. Tissue Eng. Regen. Med. 2022,16, 591–604. 35. Sembronio, S.; Tel, A.; Tremolada, C.; Lazzarotto, A.; Isola, M.; Robiony, M. Temporomandibular joint arthrocentesis and microfragmented adipose tissue injection for the treatment of internal derangement and osteoarthritis: A randomized clinical trial. J. Oral Maxillofac. Surg. 2021,79, 1447–1456. [PubMed] 36. Vingender, S.; D˝ori, F.; Schmidt, P.; Hermann, P.; Vaszilkó, M.T. Evaluation of the efficiency of hyaluronic acid, PRP and I-PRF intra-articular injections in the treatment of internal derangement of the temporomandibular joint: A prospective study. J. Cranio-Maxillofac. Surg. 2023,51, 1–6. [CrossRef] [PubMed] 37. González-García, R.; Martín-Granizo, R. Arthroscopic Disc Repositioning Techniques of the Temporomandibular Joint: Part 1: Sutures. Atlas Oral Maxillofac. Surg. Clin. N. Am. 2022,30, 175–183. 38. Guarda-Nardini, L.; Manfredini, D.; Ferronato, G. Arthrocentesis of the temporomandibular joint: A proposal for a single-needle technique. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2008,106, 483–486. [PubMed] 39. Celotti, C.; Martín-Granizo, R.; De La Sen, Ó. Correlation of arthroscopic findings with clinical-radiological signs and symptoms of temporomandibular joint dysfunction: Retrospective study of 829 joints. Int. J. Oral Maxillofac. Surg. 2022,51, 1069–1073. [PubMed] 40. Ivask, O.; Leibur, E.; Akermann, S.; Tamme, T.; Voog-Oras, Ü. Intramuscular botulinum toxin injection additional to arthrocentesis in the management of temporomandibular joint pain. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. 2016,122, e99–e106. [PubMed] 41. Liu, Y.; Wu, J.; Fei, W.; Cen, X.; Xiong, Y.; Wang, S.; Tang, Y.; Liang, X. Is There a Difference in Intra-Articular Injections of Corticosteroids, Hyaluronate, or Placebo for Temporomandibular Osteoarthritis? J. Oral Maxillofac. Surg. 2018,76, 504–514. 42. Martín-Granizo, R.; Maniegas, L.; Colorado, L.; Millon-Cruz, A.; de Pedro, M. Direct infiltration of botulinum toxin into the pterygoid lateral muscle for repositioning of the disc during arthroscopy of the temporomandibular joint. Br. J. Oral Maxillofac. Surg. 2018,56, 769–771. 43. Millon-Cruz, A.; Martín-Granizo, R.; Encinas, A.; Berguer, A. Relationship between intra-articular adhesions and disc position in temporomandibular joints: Magnetic resonance and arthroscopic findings and clinical results. J. Craniomaxillofac. Surg. 2015,43, 497–502. 44. Muñoz-Guerra, M.F.; Rodríguez-Campo, F.J.; Escorial-Hernández, V.; Brabyn, P.J.; Fernández-Domínguez, M.; Naval-Gías, L. Is There a Relationship Between Age, Personal Factors or Surgical Findings, and Outcome after Temporomandibular Joint Arthroscopy? J. Oral Maxillofac. Surg. 2021,79, 1000–1008. [PubMed] 45. Muñoz-Guerra, M.F.; Rodríguez-Campo, F.J.; Escorial-Hernández, V.; Sanz-García, A.; Brabyn, P.J.; Fernández-Domínguez, M. Temporomandibular joint arthroscopy in advanced stages of internal derangement: A retrospective cohort study on the influence of age. Int. J. Oral Maxillofac. Surg. 2022,51, 1579–1586. 46. Xie, Y.; Zhao, K.; Ye, G.; Yao, X.; Yu, M.; Ouyang, H. Effectiveness of intra-articular injections of sodium hyaluronate, corticosteroids, platelet-rich plasma on temporomandibular joint osteoarthritis: A systematic review and network meta-analysis of randomized controlled trials. J. Evid. Based Dent. Pract. 2022,22, 101720. 47. Sheikh, O.; Ali Madadian, M.; Benning, A. Review of current practice for temporomandibular joint meniscopexy surgery. In Oral and Maxillofacial Surgery; IntechOpen: London, UK, 2020. J. Clin. Med. 2024,13, 3319 19 of 20 48. De Santana Santos, T.; Charles Pagotto, L.E.; Nascimento, E.S.; da Cunha, L.R.; Cassano, D.S.; Gonçalves, J.R. Effectiveness of disk repositioning and suturing comparing open-joint versus arthroscopic techniques: A systematic review and meta-analysis. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. 2021,132, 506–513. 49. Gonçalves, J.R.; Cassano, D.S.; Rezende, L.; Wolford, L.M. Disc repositioning: Does it really work? Oral Maxillofac. Surg. Clin. N. Am. 2015,27, 85–107. 50. Tzanidakis, K.; Sidebottom, A.J. Outcomes of open temporomandibular joint surgery following failure to improve after arthroscopy: Is there an algorithm for success? Br. J. Oral Maxillofac. Surg. 2013,51, 818–821. 51. Rodhen, R.M.; Azario de Holanda, T.; Jardim, F.; Oliveira, W.L.; Boscato, N. Invasive surgical procedures for the management of internal derangement of the temporomandibular joint: A systematic review and meta-analysis regarding the effects on pain and jaw mobility. Clin. Oral Investig. 2022,26, 3429–3446. 52. Monje Gil, F. Diagnóstico y Tratamiento de la Patología de la Articulación Temporomandibular, 1st ed.; Ripano S.A.: Madrid, Spain, 2009. 53. Vega, L.; Monje, F.; Gutta, R. Open surgery for disk derangements of the temporomandibular joint. In Surgical Management of Temporomandibular Joint; Monje, F., Ed.; Apple Books: Cupertino, CA, USA, 2014; Volume 2. 54. Sidebottom, A.J. Open Temporomandibular Joint Surgery: Discectomy with or Without Interpositional Reconstruction? Atlas Oral Maxillofac. Surg. Clin. N. Am. 2022,30, 199–204. 55. Werkman, D.F.; Mercuri, L.G.; Troost, J.P.; Aronovich, S. An International Survey on Temporomandibular Joint Surgeon’s Implementation and Management of Discectomy in Treating Temporomandibular Joint Internal Derangement. J. Oral Maxillofac. Surg. 2021,79, 1423–1433. 56. De Merle, M.; Nafiu, O.O.; Aronovich, S. Temporomandibular joint discectomy with abdominal fat graft versus temporalis myofascial flap: A comparative study. J. Oral Maxillofac. Surg. 2017,75, 1137–1143. 57. Ellis, O.G.; Tocaciu, S.; McKenzie, D.P.; McCullough, M.J.; Dimitroulis, G. Risk factors associated with poor outcomes following temporomandibular joint discectomy and fat graft. J. Oral Maxillofac. Surg. 2021,79, 2448–2454. [PubMed] 58. Dimitroulis, G. A critical review of interposition grafts following temporomandibular joint discectomy with an overview of the dermis-fat graft. Int. J. Oral Maxillofac. Surg. 2011,40, 561. 59. Thyne, G.M.; Yoon, J.H.; Luyk, N.H.M.; McMillan, M.D. Temporalis muscle as a disc replacement in the temporomandibular joint of sheep. J. Oral Maxillofac. Surg. 1992,50, 979–987. 60. Muñoz-Guerra, M.F.; Rodríguez-Campo, F.J.; Fernández-Domínguez, M. The auricular cartilage graft used as interpositional material for disc replacement after failed TMJ operative arthroscopy. J. Stomatol. Oral Maxillofac. Surg. 2018,119, 328–336. [PubMed] 61. Tuncel, U.; Kostakoglu, N.; Turan, A.; Markoç, F.; Gokçe, E.; Erkorkmaz, U. The use of temporalis muscle graft, fresh and cryopreserved amniotic membrane in preventing temporomandibular joint ankylosis after discectomy in rabbits. J. Craniomaxillofac. Surg. 2014,42, 1868–1876. 62. Guarda-Nardini, L.; Trojan, D.; Montagner, G.; Cogliati, E.; Bendini, M.; Manfredini, D. Human Amniotic Membrane Positioning in the Surgical Treatment of Temporomandibular Joint Degenerative Disorder. Case Rep. Surg. 2019,2019, 6037191. 63. Lopez-Martos, R.; Martin-Lozano, G.; Ocete-Perez, R.F.; Gonzalez-Perez, L.M.; Gutierrez-Perez, J.L.; Infante-Cossio, P. Application of Human Amniotic Membrane in Temporomandibular Joint Osteoarthritis. J. Craniofac. Surg. 2020,31, e424–e426. 64. Acri, T.M.; Shin, K.; Seol, D.; Laird, N.Z.; Song, I.; Geary, S.M.; Chakka, J.L.; Martin, J.; Salem, A.K. Tissue engineering of the tempormandibular joint. Adv. Health Mater. 2019,8, e1801236. 65. Trindade, D.; Cordeiro, R.; José, H.C.; Ângelo, D.F.; Alves, N.; Moura, C. Biological Treatments for Temporomandibular Joint Disc Disorders: Strategies in Tissue Engineering. Biomolecules 2021,11, 933. [CrossRef] 66. Williamson, R.A.; McNamara, D.; McAuliffe, W. True eminectomy for internal derangement of the temporomandibular joint. Br. J. Oral Maxillofac. Surg. 2000,38, 554–560. [PubMed] 67. Quinn, P.T. Color Atlas of Temporomandibular Joint Surgery; Mosby: St. Louis, MO, USA, 1998. 68. Winston, W.; Benchimol, D.; Jacobs, R.; Lund, B.; Weiner, C.K.; Coucke, W.; Shi, X.-Q. Pre-surgical radiographic and clinical features as predictors for temporomandibular joint discectomy prognosis. Oral Dis. 2022,28, 2185–2193. 69. Yadav, P.; Roychoudhury, A.; Kumar, R.D.; Bhutia, O.; Bhutia, T.; Aggarwal, B. Total Alloplastic Temporomandibular Joint Replacement. J. Maxillofac. Oral Surg. 2021,20, 515–526. [PubMed] 70. Yoda, T.; Ogi, N.; Yoshitake, H.; Kawakami, T.; Takagi, R.; Murakami, K.; Yuasa, H.; Kondoh, T.; Tei, K.; Kurita, K. Clinical guidelines for total temporomandibular joint replacement. Jpn. Dent. Sci. Rev. 2020,56, 77–83. [PubMed] 71. Gerber, S.; Saeed, N. Predictive risk factors for persistent pain following total prosthetic temporomandibular joint replacement. Br. J. Oral Maxillofac. Surg. 2022,60, 650–654. [PubMed] 72. Mercuri, L.G. Subjective and objective outcomes in patients reconstructed with a custom-fitted alloplastic temporomandibular joint prosthesis. J. Oral Maxillofac. Surg. 1999,57, 1427–1430. [PubMed] 73. Sarlabous, M.; El-Rabbany, M.; Caminiti, M.; Psutka, D.J. Alloplastic Temporomandibular Joint Replacement in Patients with Systemic Inflammatory Arthritis and Connective Tissue Disorders. J. Oral Maxillofac. Surg. 2021,79, 2240–2246. [PubMed] 74. Linsen, S.S.; Schön, A.; Mercuri, L.G.; Teschke, M. Unilateral, Alloplastic Temporomandibular Joint Reconstruction, Biomechanically What Happens to the Contralateral Temporomandibular Joint?-A Prospective Cohort Study. J. Oral Maxillofac. Surg. 2021, 79, 2016–2029. [PubMed] J. Clin. Med. 2024,13, 3319 20 of 20 75. Perez, D.E.; Wolford, L.M.; Schneiderman, E.; Movahed, R.; Bourland, C.; Gutierrez, E.P. Does Unilateral Temporomandibular Total Joint Reconstruction Result in Contralateral Joint Pain and Dysfunction? J. Oral Maxillofac. Surg. 2016,74, 1539–1547. 76. Alakailly, X.; Schwartz, D.; Alwanni, N.; Demko, C.; Altay, M.A.; Kilinc, Y.; Baur, D.A.; Quereshy, F. Patient-centered quality of life measures after alloplastic temporomandibular joint replacement surgery. Int. J. Oral Maxillofac. Surg. 2017,46, 204–207. 77. Pinto, L.P.; Wolford, L.M.; Buschang, P.H.; Bernardi, F.H.; Gonçalves, J.R.; Cassano, D.S. Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: Part III—Pain and dysfunction outcomes. Int. J. Oral Maxillofac. Surg. 2009,38, 326–331. [PubMed] 78. Linsen, S.S.; Reich, R.H.; Teschke, M. Pressure pain threshold and oral health-related quality of life implications of patients with alloplastic temporomandibular joint replacement—A prospective study. J. Oral Maxillofac. Surg. 2012,70, 2531–2542. [PubMed] 79. Mercuri, L.G.; Neto, M.Q.; Pourzal, R. Alloplastic temporomandibular joint replacement: Present status and future perspectives of the elements of embodiment. Int. J. Oral Maxillofac. Surg. 2022,51, 1573–1578. [PubMed] 80. Leandro, L.F.; Ono, H.Y.; Loureiro, C.C.; Marinho, K.; Guevara, H.A. A ten-year experience and follow-up of three hundred patients fitted with the Biomet/Lorenz Microfixation TMJ replacement system. Int. J. Oral Maxillofac. Surg. 2013,42, 1007–1013. [CrossRef] [PubMed] 81. Mercuri, L.G.; Edibam, N.R.; Giobbie-Hurder, A. Fourteen-year follow-up of a patient-fitted total temporomandibular joint reconstruction system. J. Oral Maxillofac. Surg. 2007,65, 1140–1148. [CrossRef] [PubMed] 82. Granquist, E.J.; Bouloux, G.; Dattilo, D.; Gonzalez, O.; Louis, P.J.; McCain, J.; Sinn, D.; Szymela, V.; Warner, M.; Quinn, P.D. Outcomes and Survivorship of Biomet Microfixation Total Joint Replacement System: Results from an FDA Postmarket Study. J. Oral Maxillofac. Surg. 2020,78, 1499–1508. [CrossRef] [PubMed] 83. Collins, C.P.; Wilson, K.J.; Collins, P.C. Lateral pterygoid myotomy with reattachment to the condylar neck: An adjunct to restore function after total joint reconstruction. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2003,95, 672–673. [CrossRef] [PubMed] 84. Edward Zebovitz E Total Temporomandibular Joint Prosthetic Reconstruction: The Importance of Lateral Pterygoid Muscle Reattachment to Lateral Excursive and Protrusive Mandibular Movement. J. Oral Maxillofac. Surg. 2021,79, 1191–1194. 85. Van Bogaert, W.; De Meurechy, N.; Mommaerts, M.Y. Autologous Fat Grafting in Total Temporomandibular Joint Replacement Surgery. Ann. Maxillofac. Surg. 2018,8, 299–302. 86. Mercuri, L.G.; Alcheikh, F.; Woolson, R. Outcomes of Total Alloplastic Replacement with Periarticular Autogenous Fat Grafting for Management of Reankylosis of the Temporomandibular Joint. J. Oral Maxillofac. Surg. 2008,66, 1794–1803. 87. Mohanty, S.; Kohli, S.; Dabas, J.; Kumar, R.D.; Bodh, R.; Yadav, S. Fate of the Coronoid Process after Coronoidotomy and Its Effect on the Interincisal Opening: A Clinical and Radiologic Assessment. J. Oral Maxillofac. Surg. 2017,75, 1263–1273. [CrossRef] [PubMed] 88. Neuhaus, M.T.; Zeller, A.N.; Bartella, A.K.; Sander, A.K.; Lethaus, B.; Zimmerer, R.M. Accuracy of Guided Surgery and Real-Time Navigation in Temporomandibular Joint Replacement Surgery. Dent. J. 2021,9, 87. [CrossRef] [PubMed] 89. Dean, A.; Heredero-Jung, S.; Solivera, J.; Sanjuan, A.; Alamillos-Granados, F.J. Computer-assisted and navigated piezoelectric surgery: A new technology to improve precision and surgical safety in craniomaxillofacial surgery. Laryngoscope Investig. Otolaryngol. 2022,7, 684–691. [CrossRef] [PubMed] Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.