Since normal temporomandibular joint (TMJ) movements depend primarily on the disc freely sliding down the slope of the eminence, understanding how aberrations in the lubrication system contribute to TMJ dysfunction is clearly critically important. It provides a possible explanation for the genesis of disc displacement and helps make us familiar with the clinical appearance and ways of treating limited mouth opening caused by the anchored disc phenomenon (ADP) versus disc displacement without reduction, TMJ open lock versus dislocation and osteoarthritis. This understanding clarifies the efficiency of procedures such as joint hydraulic pump, arthrocentesis and arthroscopic lavage and lysis particularly in ADP, open lock and osteoarthritis.

Annandale, T. (1887) On displacement of the interarticular cartilage of the lower jaw and its treatment by operation. Lancet i 411.
Ireland, V.E. (1951) The problem of the jaw. Proc R Soc Med 44: 363.
Westesson, P.-L., M. Rohlin (1984) Internal derangement related to osteoarthrosis in temporomandibular joint autopsy specimens. Oral Surg Oral Med Oral Pathol 57: 17.
Dolwick, M.F. (1995) Intra-articular disc displacement. I. Its questionable role in temporomandibular joint pathology. J Oral Maxillofac Surg 53: 1069.
Wilkes, C.H. (1989) Internal derangement of the TMJ. Arch Otolaryngol Head Neck Surg 115: 469.
Nannmark, U., L. Sennerby, T. Haraldon (1990) Macroscopic, microscopic and radiologic assessment of the condylar part of the TMJ in elderly subjects: An autopsy study. Swed Dent J 14: 163.
Ferrar, W.B., W.J. McCarty (1990) Inferior joint space arthrography and characteristics of condylar paths on internal derangement of the TMJ. J Prosthet Dent 41: 548.
Isberg, A., S.E. Widmalm, R. Ivarsson (1985) Clinical, radiographic and electromyographic study of patients with internal derangement of the temporomandibular joint. Am J Orthod 88: 453.
Rohlin, M., P.L. Westesson, L. Eriksson (1985) The correlation of the temporomandibular joint sounds with joint morphology in fifty-five autopsy specimens. J Oral Maxillofac Surg 43: 194.
Gay, T., C.N. Bertolami, R.B. Donoff, et al (1987) The acoustical characteristics of the normal and abnormal temporomandibular joint. J Oral Maxillofac Surg 45: 397.
Milam, S.B. (1995) Articular disc replacement and degenerative temporomandibular joint disease; in Sessle, B.J., P.S. Bryant, R.A. Dionne (eds): Temporomandibular Disorders and Related Pain Conditions. Progress in Pain Research and Management. Seattle, IASP Press, vol 4, pp 89–112.
Westesson, P.-L., S.L. Brooks (1992) Temporomandibular joint relationship between MR evidence of effusion and the presence of pain and disc displacement. Am J Roentgenol 159: 559.
Widmalm, S.E., P.-L. Westesson, S.L. Brook, et al (1992) Temporomandibular joint sounds: Correlation to joint structure in fresh autopsy specimens. Am J Orthod Dentofacial Orthop 101: 60.
Ryan, D.E. (1996) Temporomandibular joint disc surgery: Biologic basis and treatment outcome; in Stegenga, B., L.G.M. de Bont (eds): Management of Temporomandibular Joint Diseases. Basel, Birkhäuser Verlag, pp 149–158.
Dolwick, M.F., G. Dimitroulis (1994) Is there a role for temporomandibular joint surgery? Br J Oral Maxillofac Surg 32: 307.
Mercuri, L.G. (1995) Surgical management of temporomandibular joint disorders; in Sessle, B.J., P.S. Bryant, R.A. Dionne (eds): Temporomandibular Disorders and Related Pain Conditions. Progress in Pain Research and Management. Seattle, IASP Press, vol 4, pp 429–442.
Dolwick, M.F. (1995) Temporomandibular joint disk displacement: Clinical perspectives; in Sessle, B.J., P.S. Bryant, R.A. Dionne (eds): Temporomandibular Disorders and Related Pain Conditions. Progress in Pain Research and Management. Seattle, IASP Press, vol 4, pp 79–87.
Hall, D.H. (1995) Intra-articular disc displacement. II. Its significant role in TMJ pathology. J Oral Maxillofac Surg 53: 1973.
Kaplan, P.A., H.K. Tu, P.R. Slender, et al (1986) Inferior joint space arthrography of normal TMJ: Reassessment of diagnostic criteria. Radiology 3: 577.
Kircos, L.T., D.A. Ortendahl, A.S. Mark, et al (1987) MRI of the TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg 54: 852.
Sanders, B. (1986) Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg 62: 361.
Nitzan, D.W., B. Samson, H. Better (1997) Long term outcome of arthrocentesis for sudden-onset, persistent, severe closed lock in the TMJ. J Oral Maxillofac Surg 55: 151.
Montgomery, M.T., J.E. Van Sickels, S.E. Harms, et al (1989) Arthroscopic TMJ surgery: Effects on signs, symptoms and disc position. J Oral Maxillofac Surg 47: 1263.
Moses, J.J., D. Sartoris, R. Glass (1989) The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 47: 674.
Hills, B.A. (1990) Oligolamellar nature of the articular surface. Br J Rheumatol 17: 349–356.
Hills, B.A. (1996) Synovial surfactant and the hydrophobic articular surface. J Rheumatol 23: 1323.
Schwarz, I.M., B.A. Hills (1996) Synovial surfactant: Lamellar bodies in type B synoviocytes and phospholipids in synovial fluid and the articular lining. Br J Rheumatol 35: 821.
Schwarz, I.M., B.A. Hills (1998) Surface-active phospholipids as the lubricating component of lubricin. Br J Rheumatol 37: 21–26.
Hills, B.A. (2000) Boundary lubrication in vivo. Proc Inst Mech Eng 214/1: 83–94.
Higaki, H., T. Murakami, Y. Nakanishi, et al (1998) The lubricating ability of biomembrane models with dipalmitoyl phosphatidylcholine and gamma-globulin. Proc Inst Mech Eng 212: 337.
Williams, P.F., G.L. Powell, M. LaBerge (1993) Sliding friction analysis phosphatidylcholine as a boundary lubricant for articular cartilage. Proc Inst Mech Eng 20: 759.
Pickard, J.E., J. Fisher, E. Ingham, J. Egan (1998) Investigation into the effect of proteins and lipids on the functional properties of articular cartilage. Biomaterials 19: 1807–1812.
Bole, G.G. (1962) Synovial fluid lipids in normal individuals and patients with rheumatoid arthritis. Arthritis Rheum 5: 589–601.
Hills, B.A., B.D. Butler (1984) Identification of surfactants in synovial fluid and their ability to act as boundary lubricants. Ann Rheum Dis 48: 51–57.
Rabinowitz, J.I., J.R. Gregg, J.E. Nixon (1984) Lipid composition of the tissues of human knee joints. Clin Orthop 190: 292–298.
Punzi, L., S. Todesco, G. Toffano, E. Bigon, A. Bruni (1986) Phospholipids in inflammatory synovial effusions. Rheumatol Int 6/1: 7–11.
Hills, B.A., M.K. Monds (1999) Enzymatic identification of the load bearing boundary lubricant in the joint. Br J Rheumatol 37: 137.
Nitzan, D.W., U. Nitzan, P. Dan, S. Yadgar (2001) Hyaluronic acid protects surface active phospholipids from lysis by exogenous phospholipase A2. Rheumatology 40: 336–340.
Dan, P., D. Nitzan, A. Dagan, et al (1996) H2O2 renders cells accessible to lysis by exogenous phospholipase A2: A novel mechanism for cell damage in inflammatory processes. FEBS Lett 383: 75.
De Bont, L.G.M. (1985) Temporomandibular Joint Articular Cartilage Structure and Function. PhD thesis. Groningen, Van Denderen.
Toller, P.A. (1961) The synovial apparatus and temporomandibular joint function. Br Dent J 111: 355–362.
Kopp, S., B. Wenneberg, E. Clemensson (1983) Clinical microscopic and biochemical investigation of synovial fluid from temporomandibular joints. Scand J Dent Res 91: 33–41.
Israel, H.A. (1989) Synovial fluid analysis. Oral Maxillofac Surg Clin North Am 1/1: 85–92.
Marchetti, C., G. Bernasconi, M. Reguzzoni, et al (1997) The articular disc surface in different functional conditions of the human temporomandibular joint. J Oral Pathol Med 26: 278–282.
Ghadially, F.N., N.K. Yong, J.-M.A. Lalonde (1982) A transmission electron microscopic comparison of the articular surface of cartilage processed attached to bone and detached from bone. J Anat 135: 685–706.
Forster, H., J. Fisher (1999) The influence of continuous sliding and subsequent surface wear on the friction of articular cartilage. Proc Inst Mech Eng 213: 329–345.
Norman, A.G., M.J. Kaab (1999) The surface contour of articular cartilage in an intact, loaded joint. J Anat 195/1: 45–56.
Wise, C.M., R.E. White, C.A. Agudelo (1987) Synovial fluid lipid abnormalities in various disease states: Review and classification. Semin Arthritis Rheum 16/3: 222–230.
Rachamin, E., H. Better, A. Dagan, D.W. Nitzan (2001) Electron microscope and biochemical observations of the surface active phospholipids on the articular surfaces and in the synovial fluid of the temporomandibular joint: A preliminary investigation. J Oral Maxillofac Surg 59: 1326–1332.
de Bont, L.G.M., B. Stegenga (1993) Pathology of the TMJ internal derangement and osteoarthrosis. Int J Maxillofac Surg 22: 71.
Stegenga, B., L.G.M. de Bont, G. Boering, et al (1991) Tissue responses to degenerative changes of the TMJ: A review. J Oral Maxillofac Surg 49: 1079.
Nitzan, D.W. (1994) Intra-articular pressure in the functioning human TMJ and its alteration by uniform elevation of the occlusal plane. J Oral Maxillofac Surg 52: 671.
Solberg, W.K. (1986) Temporomandibular disorders: management of internal derangement. Br Dent J 160: 379–385.
Forster, H., J. Fisher (1996) The influence of loading time and lubricant on the friction of articular cartilage. Proc Inst Mech Eng 210:109.
Boyd, R.L., C.H. Gibbs, P.E. Mahan, et al (1990) Temporomandibular joint forces measured at the condyle of Macaca arctoides. Am J Orthod Dentofacial Orthop 97: 472.
Chen, J., L. Xu (1994) A finite element analysis of the human TMJ. J Biomech Eng 116: 401.
Wright, V. (1969) Lubrication and Wear in Joints. Proc Symp Biol Eng Soc Leeds. High Wycombe, Harrison, chap 1, 4, 12, 15, 16, pp 1–14, 29–34, 110–114, 134–140, 142–149.
Mow, V.C., G.A. Ateshian (1997) Lubrication and wear of diarthrodial joints; in Mow, V.C., W.C. Hayes (eds): Basic Orthopaedic Biomechanics, ed 2. Philadelphia, Lippincott-Raven, pp 275–315.
Dowson, D. (1990) Bio-tribology of natural and replacement synovial joints; in Mow, V.C., A Radcliffe, S.L.-Y. Woo (eds): Biomechanics of Diarthrodial Joints. New York, Springer, vol 2, pp 303–345.
Blake, D.R., J. Unsworth, J.M. Outhwaite, et al (1989) Hypoxic reperfusion injury in the inflamed human joint. Lancet ii: 289.
Marry, P., R. Williams, N. Cox, et al (1991) Comparative study of intra-articular pressure dynamics in joints with acute traumatic and chronic inflammatory effusions: Potential implications for hypoxic-reperfusion injury. Ann Rheum Dis 50: 917.
Mapp, P.I., M.C. Grooteveld, D.R. Blake (1995) Hypoxia, oxidative stress and rheumatoid arthritis. Br Med Bull 51: 419.
Grootveld, M., E.B. Henderson, A. Farrell, et al (1991) Oxidative damage to hyaluronate and glucose in synovial fluid during exercise of the inflamed rheumatoid joint. Biochem J 273: 459.
Linn, F.C. (1968) Lubrication of animal joints: The mechanism. J Biochem 1: 193.
Swann, D.A., E.I. Radin, M. Nazimiec, et al (1974) Role of hyaluronic acid in joint lubrication. Ann Rheum Dis 33: 318.
Tabor, D. (1981) Friction – The present state of our understanding. J Lubrication Technol 103: 169.
Etzion, I., M. Amit (1992) The effect of small normal loads on the static friction coefficient for very smooth surfaces. J Tribol 11: 100.
Armstrong, C.G., V.C. Mow, C.R. Wirth (1985) Biomechanics of impact-induced microdamage to articular surface – A possible genesis for chondromalasia patella; in Finerman, G.A.M. (ed): AAOS Symposium on Sports Medicine: The Knee. St Louis, Mosby, pp 54–69.
Radin, E.L., R.B. Martin, D.B. Burr, et al (1984) Effects of mechanical loading on the tissue of rabbit knee. J Orthop Res 2: 221.
Vener, J.M., R.C. Thompson, J.L. Lewis, et al (1992) Subchondrial damage after acute transarticular loading: An in vitro model of joint injury. J Orthop Res 10: 759.
Bloebaum, O.Y.D., K.M. Radley (1995) Three-dimensional surface analysis of young adult human articular cartilage. J Anat 187: 293.
Stanley, H.M., I. Etzion, D.B. Boggy (1990) Adhesion of contacting rough surfaces in the presence of subboundary lubrication. J Tribol 112: 98.
Hills, B.A., K. Thomas (1998) Joint stiffness and ‘articular gelling’: Inhibition of the fusion of articular surfaces by surfactant. Br J Rheumatol 37: 532.
Ward, D.M., R.G. Berhents, J.S. Goldberg (1990) Temporomandibular synovial fluid pressure response to altered mandibular positions. Am J Orthod Dentofacial Orthop 98: 22–28.
Murakami, K.I., T. Iizuka, M. Matsuki, T. Ono (1987) Recapturing the persistent anteriorly displaced disk by mandibular manipulation after pumping and hydraulic pressure to the upper joint cavity of the temporomandibular joint. Cranio 5: 17–24.
Kendell, B., D.E. Frost (1996) Arthrocentesis. Atlas Oral Maxillofac Surg Clin North Am 4/2: 1–14.
Nitzan, D.W., F.M. Dolwick, G.A. Martinez (1991) Temporomandibular joint arthrocentesis: A simplified method for severe limited mouth opening. J Oral Maxillofac Surg 49: 1163–1167.
Zardeneta, G., H. Muckai, B.D. Tiner, et al (1995) Positive correlation between TMJ pain and alpha-hemoglobin recovered by TMJ lavage. J Dent Res 74: 172.
Zardeneta, G., J.P. Schmitz, S.B. Milam (1996) Latent proteases recovered from human TMJ lavage fluid. J Oral Maxillofac Surg 54(suppl 3): 86.
Tenenbaum, H.C., B.V. Freeman, D.J. Psutka, J.I. Baker (1999) Temporomandibular disorders: Disc displacement. J Orofac Pain 13/4: 285–290.
Laskin, D. (1994) Etiology and pathogenesis of internal derangement of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 6: 217.
de Bont, L.G.M., G. Boering, R.S.B. Liem, et al (1986) Osteoarthritis and internal derangement of the TMJ: A light microscopic study. J Oral Maxillofac Surg 44: 634.
Juniper, R.P. (1984) Temporomandibular joint dysfunction: A theory based upon electromyographic studies of the lateral pterygoid muscle. Br J Oral Maxillofac Surg 22: 1.
Jupiter, R.P. (1981) The superior pterygoid muscle. Br J Oral Surg 19: 121.
Frost, H.M. (1977) Musculoskeletal pain; in Alling, C.C., P.E. Mahan (eds): Facial Pain, ed 2. Philadelphia, Lea & Febiger.
Ogus, H. (1987) The mandibular joint: Internal rearrangement. Br J Oral Maxillofac Surg 25: 218.
Mahan, P.E., C.C. Alling (1991) Facial Pain, ed 3. Philadelphia, Lea & Febiger.
Moses, J.J. (1989) Lateral impingement syndrome and endural surgical technique. Oral Maxillofac Surg Clin North Am 1: 165.
Isberg-Holm, A., R. Ivarsson (1980) The movement pattern of the mandibular condyles in individuals with and without clicking. Dent Maxillofac Radiol 9: 55.
Juniper, R.P. (1987) The pathogenesis and investigation of TMJ dysfunction. Br J Oral Maxillofac Surg 25: 105.
Nitzan, D.W. (2001) The process of lubrication impairment and its involvement in temporomandibular joint disc displacement: A theoretical concept. J Oral Maxillofac Surg 59/1: 36–45.
Nitzan, D.W., Y. Marmary (1997) The ‘anchored disc phenomenon’: A proposed etiology for sudden-onset, sever and persistent closed lock of the TMJ. J Oral Maxillofac Surg 55: 797–802.
Benito, C., G. Csares, C. Benito (1998) TMJ static disc: Correlation between clinical findings and pseudodynamic magnetic resonance images. J Craniomand Prac 16/4: 242–251.
Ernandez-Sanroman, J. (2000) Morfología y dinámica de la articulación temporomandibular en pacientes con sospecha clínica de trastorno interno: Estudio prospectivo con resonance magnética. Rev Esp Cirug Oral y Maxilofac 22: 233–240.
Rao, V.M., M.D. Liem, A. Farole, A.A. Razek (1993) Elusive ‘stuck’ disc in the temporomandibular joint: Diagnosis with MR imaging. Radiology 189: 823–827.
Nitzan, D.W., B. Samson, H. Better (1997) Long-term outcome of arthrocentesis for sudden-onset, persistent, severe closed lock of the TMJ. J Maxillofac Surg 55: 151–157.
Nitzan, D.W., A. Goldfarb, I. Gati, R. Kohen (2002) Changes in the reducing power of synovial fluid from temporomandibular joint with ‘anchored disc phenomenon’. J Oral Maxillofac Surg 60: 735–740.
Nitzan, D.W., Y. Etsion (2002) Adhesive force – The underlying cause of the ‘anchored disc phenomenon’. Int J Oral Maxillofac Surg 31/1: 94–99.
Kai, S., H. Kai, E. Nakayama, O. Tabata, H. Tashiro, T. Miyajima, M. Sagaguri (1992) Clinical symptoms of open-lock position of the condyle. Relation to anterior dislocation of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 74: 143–148.
Nitzan, D.W. (2002) Temporomandibular joint ‘open-lock’ vs condylar dislocation: Signs and symptoms, imaging, treatment and pathogenesis. J Oral Maxillofac Surg 60: 506–513.
Kopp, S. (1995) Degenerative and inflammatory temporomandibular joint disorders: Clinical perspectives; in Sessle, B.J., P.S. Bryant, R.A. Dionne (eds): Temporomandibular Disorders and Related Pain Conditions. Progress in Pain Research and Management. Seattle, IASP Press, vol 4, pp 119–131.
Zarb, A.Z., L.D.S. Carlsson (1999) Temporomandibular disorders: Osteoarthritis. Orofacial Pain 13/4: 295–306.
Dolwick, M.F., B. Sanders (1985) TMJ Internal Derangement and Arthrosis. Surgical Atlas. St Louis, Princeton, pp 49, 120, 122.
Gynther, G.W., G. Tronje, A.B. Holmlund (1996) Radiographic changes in the temporomandibular joint in patients with generalized osteoarthritis and rheumatoid arthritis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 81: 613.
Israel, H.A., B.E. Diamond, F. Saed-Nejad, et al (1997) Correlation between arthroscopic diagnosis of osteoarthritis and synovitis of the human temporomandibular joint and keratan sulfate levels in the synovial fluid. J Oral Maxillofac Surg 55: 210.
Radcliffe, A., H.A. Israel, F. Saed-Nejad, et al (1998) Proteoglycans in the synovial fluid of the temporomandibular joint as an indicator of changes in cartilage metabolism during primary and secondary osteoarthritis. J Oral Maxillofac Surg 56: 204.
Quinn, J.H., N.G. Bazan (1990) Identification of prostaglandin E2 and leukotriene B4 in the synovial fluid of painful, dysfunctional temporomandibular joint. J Oral Maxillofac Surg 48: 968.
Poole, A.R., G. Rizkalla, M. Ionescu, et al (1993) Osteoarthritis in the human knee: A dynamic process of cartilage matrix degradation, synthesis and reorganization. Agents Actions Suppl 39: 3.
Cameraman, D. (1989) The biology of osteoarthritis. N Engl J Med 320: 1322.
Kubota, E., H. Imamura, T. Kubota, et al (1997) Interleukin 1β and stromelysin (MMP3) activity of synovial fluid as possible markers of osteoarthritis in the temporomandibular joint. J Oral Maxillofac Surg 55: 20.
Kubota, E., T. Kubota, J. Matsumoto, et al (1998) Synovial fluid cytokines and proteinases as markers of temporomandibular joint disease. J Oral Maxillofac Surg 56: 192.
Birkedal-Hansen, H., W.G.I. Moore, M.K. Bodden, et al (1993) Matrix metalloproteinases: A review. Crit Rev Oral Biol Med 4: 197.
Nitzan, D.W., A. Price (2001) The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joint. J Oral Maxillofac Surg 59: 1154–1159.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.