Surgical management of temporomandibular joint (TMJ) pathology has evolved toward minimally invasive and arthroscopic techniques; however, open surgery remains essential when structural disease exceeds the corrective capacity of arthroscopy—advanced internal derangement, significant degenerative change, disc perforation, dense adhesions, or failed prior procedures. The objective is restoration of stable biomechanics: re-establishing the condyle–disc–fossa relationship, eliminating mechanical obstruction, and preserving condylar height. Modern TMJ surgery is a continuum; arthroscopy is the preferred approach for early and intermediate derangements, while open procedures are indispensable when advanced pathology, osseous modification, or concurrent reconstruction is required. ^,

Clinical evaluation documents maximum interincisal opening (MIO), end-feel, joint sounds, occlusal stability, deviation/deflection pattern, and response to prior interventions. Progressive loss of opening, recurrent locking, or failed minimally invasive therapy indicates structural pathology. MRI evaluates disc morphology, position, mobility, perforation, and synovitis; CBCT defines osteophytes, condylar morphology, and eminence anatomy. Imaging findings are interpreted through a functional lens—they must explain the patient’s mechanical symptoms to justify surgery.

Decision frameworks for approach selection ( Table 1 ) and disc viability ( Table 2 ) guide operative planning; final determination of disc salvageability is always confirmed intraoperatively under direct visualization.

Open TMJ surgery is performed under general anesthesia with nasotracheal intubation, which preserves intraoperative occlusal assessment and jaw manipulation. Perioperative medications include prophylactic cefazolin (2 g IV within 60 minutes of incision) and dexamethasone (8–12 mg IV at induction). If the patient’s cardiac status permits, administration of an anticholinergic agent (eg, glycopyrrolate) may be considered to reduce oral secretions.

The patient is placed supine with the head turned contralateral to the operative side, ensuring the zygomatic arch is parallel to the floor. The operative field includes the preauricular region, temporal scalp, and lateral orbit; the mouth is covered with a Tegaderm or Ioban to maintain a sterile field and can be accessed intraoperatively as needed. When abdominal fat harvest is planned, the periumbilical donor site is prepped concurrently.

Safe open TMJ surgery depends on correct plane selection. Temporal branch weakness most commonly reflects traction or dissection in an unsafe fascial plane rather than direct nerve injury. Three incision options are available: standard preauricular (preferred for most procedures), endaural (improved scar camouflage), and invis-incision (maximal cosmesis); a superior temporal extension is added when fascial graft harvest or extended exposure is required ( Fig. 1 ).

( A – C ) Incision designs for open TMJ surgery. Three representative incision patterns are shown. ( A ) The preauricular incision placed anterior to the tragus, suitable for direct access with minimal posterior extension. The incision is hidden inferiorly within a skin crease. ( B ) The endaural incision that follows the contour of the tragus and natural contours of the root of helix and lobule for improved scar camouflage. ( C ) Invis-incision approach that aims to virtually eliminate scar visibility.

Stepwise dissection and joint access:

• 1.

  Incise skin and subcutaneous tissue in the preauricular crease after epinephrine infiltration. There are 2 planes of dissection, one superior to the arch and one inferior to the arch. Superiorly, identify the superficial musculoaponeurotic system (SMAS) and superficial temporal fascia. Inferior to the arch, carry your dissection along the tragus in an avascular plane down to the capsule. Connect your superior and inferior incisions once you have identified tragal pointer at the inferior aspect of your dissection.

• 2.

  Once you identify the root of the zygoma and zygomatic arch, use Bovie electrocautery to incise down to bone. Incise periosteum over the arch and dissect subperiosteally toward the eminence, exposing the arch and lateral joint capsule. Define your superior joint space with a Freer or periosteal elevator.

• 3.

  Perform a horizontal capsulotomy at the level of the articular eminence using a Bovie or blade, entering the superior joint space. Confirm entry by direct visualization of the fibrocartilaginous articular surface.

• 4.

  Systematically inspect the superior joint space with a small retractor. Perform dynamic mandibular manipulation to localize mechanical obstruction before any instrumentation.

• 5.

  Access the inferior joint space selectively—only when disc mobilization or repositioning is planned—via the posterior attachment or separate inferior capsulotomy.

Arthroplasty eliminates mechanical interference and restores smooth condylar translation while preserving condylar height. Indications include osteophytes or irregular articular surfaces restricting translation, commonly alongside disc pathology requiring open access. Arthroplasty is a broad term that can reference alteration of the bony condyle, fossa or both. Depending on your targeted treatment, disc preserving measures should be implanted. If you are targeting the bony condyle, your intervention will take place in the inferior joint space; however if you are operating on the fossa complex, your targeted treatment will be in the superior joint space.

• 1.

  Enter superior joint space (above the disc) and position retractors. Dynamically manipulate the mandible through full excursive range before any instrumentation—static inspection consistently underestimates functional obstruction.

• 2.

  If targeting the condyle, visualize the disc in its entirety. Place a straight hemostat along the posterior aspect of the disc, along the bilaminar zone, at the junction of the retrodiscal tissue and posterior ligaments. Use Bovie electrocautery to release the disc along the retrodiscal tissue, taking care to not violate the articular disc. The disc can now be mobilized and reflected anteriorly for access to the inferior joint space and condylar head.

• 3.

  Contour the fossa and condylar head with a small round or diamond bur (2–4 mm) under continuous irrigation. Piezoelectric devices reduce soft tissue risk when precision adjacent to capsular structures is required. Remove bone incrementally.

• 4.

  Reassess mandibular translation after each increment. Endpoint is physiologic gliding, not geometric normalization. Overresection risks irreversible occlusal change.

• 5.

  Irrigate copiously to remove bone debris. Reassess disc mobility after arthroplasty—bony correction often improves disc position and clarifies whether additional disc procedures are required.

• 6.

  Once you are satisfied with your arthroplastic maneuvers, you can reposition the disc into its native position. Use 3-0 Vicryl sutures to secure the disc back to the retrodiscal tissue and ligaments ( Fig. 2 ).

  

  Intraoperative views demonstrating inspection and conservative contouring of the superior joint space during open temporomandibular joint arthroplasty. Left: After capsulotomy and entry into the superior joint space, retractors expose the articular eminence and superior joint compartment for direct visualization and dynamic assessment of translation. Right: A small round/diamond bur under copious irrigation is used to perform incremental contouring of a focal osteophyte/irregular articular surface. Bone removal is conservative with repeated mandibular manipulation to confirm restoration of smooth physiologic translation while preserving condylar height and native joint anatomy.

A related but distinct indication for open joint arthroplasty arises in patients with persistent pain following total joint prosthetic reconstruction. In these cases, focal synovial entrapment, fibrous adhesions, or residual heterotopic bone around prosthetic components may produce mechanical irritation despite otherwise well-positioned hardware. Targeted open arthroplasty to clear restrictive tissue and restore smooth prosthetic translation can provide meaningful symptom relief without necessitating revision of the prosthesis itself ( Fig. 3 ).

Intraoperative images of a TMJ total joint replacement arthroplasty in which a patient started experiencing pain 10 years status postalloplastic joint replacement. Intraoperative findings were consistent with synovial entrapment. The synovium around the condylar head was biopsied and removed using grasping forceps and cautery.

Disc viability is confirmed by direct evaluation—not imaging alone. This can be done arthroscopically or under open technique. Assess posterior band thickness, surface integrity, and perforation, then evaluate disc mobility with a blunt probe. Release adhesions before judging mobility, as adhesions mimic intrinsic rigidity. Gently assess elastic recoil; a disc that collapses or buckles under minimal tension is unlikely to function after repositioning. Refer to Table 2 . Tissue handling must be atraumatic; keep the field moist to minimize postoperative fibrosis.