This document addresses temporomandibular joint (TMJ) and related musculoskeletal structure disorders commonly called temporomandibular disorders (TMD), a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndrome, and craniomandibular disorder (CMD).

Note:  Please refer to the following documents for additional information concerning related topics:

• DRUG.00017 Hyaluronan Injections for Musculoskeletal Conditions in Joints other than the Knee;
• SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery.

Medically Necessary:

Nonsurgical treatments considered medically necessary for temporomandibular disorders include the following:

1. Reversible, removable, intraoral appliances such as removable splints;
2. Pharmacologic therapy (i.e., analgesics, anti-inflammatory drugs, and muscle relaxants);
3. Physical therapy;
4. Therapeutic injections.

Surgical procedures considered medically necessary for temporomandibular disorders when criteria A and B listed below are met include the following:

1. Arthrocentesis;
2. Arthroscopic surgery;
3. Manipulation for reduction of fracture or dislocation;
4. Open surgical procedures, including arthroplasty, condylectomy, disc or meniscus plication, and disc removal when TMD is the result of congenital anomalies, disease, or trauma;
5. TMJ arthroplasty with prosthetic implants may be considered for U.S. Food and Drug Administration (FDA) approved prostheses only. 

Criteria A and B:
A.  Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by BOTH of the following:

• Completion of skeletal growth for individuals under age 18 with long bone x-ray or serial cephalometrics showing no change in facial bone relationships over the last three to six month period (Note: individuals age 18 and older do not require this documentation); and
• Computed tomography (CT), magnetic resonance imaging (MRI), or x-ray of the temporomandibular joint documents joint pathology (e.g. arthritis, bone cyst, fracture, meniscal abnormality, or tumors).

AND

B.  Temporomandibular joint pain or a clinically significant functional impairment, NOT due to a maxillary/mandibular skeletal deformity AND refractory to at least six months of non-surgical treatment to include at least ONE of the following:

• Behavioral therapy; or
• Pharmacologic therapy (i.e., analgesics, nonsteroidal anti-inflammatory drugs, muscle relaxants); or
• Physical therapy; or
• Reversible, removable, intraoral appliances such as removable splints; or
• Therapeutic injections.

Not Medically Necessary:

Nonsurgical treatments considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:

1. Biofeedback;
2. Dental devices for joint range of motion or for development of muscles used in jaw function;
3. Dental prostheses (e.g. dentures; implants);
4. Dental restorations (e.g. bridgework; crowns);
5. Electrogalvanic stimulation (EGS);
6. Iontophoresis;
7. Occlusal equilibration, bite adjustment, irreversible occlusion therapy;
8. Orthodontic services such as braces and application of a mandibular advancement repositioning device.

Surgical procedures considered not medically necessary for temporomandibular disorders include, but not limited to, the following:

1. Dental implants;
2. Dental restorations;
3. Extraction of wisdom teeth;
4. Orthodontic services;
5. TMJ arthroplasty implants that are not FDA approved. 

Diagnostic Testing:
The following procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:

1. Computerized mandibular scan (intended to document deviations in occlusion and muscle spasm by recording muscle activity related to mandibular movement or positioning);
2. Intra-oral tracing or gothic arch tracing (intended to document deviations in jaw positioning);
3. Electromyography (including percutaneous or surface electrode methods);
4. Kinesiography;
5. Somatosensory testing/neuromuscular junction testing;
6. Sonogram (ultrasonic Doppler auscultation);
7. Standard dental x-rays;
8. Thermography;
9. Transcranial or lateral skull x-ray. 

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Temporomandibular disorders (TMD) is a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndromes, and craniomandibular disorder (CMD) that includes a variety of medical and dental conditions involving the masticatory muscles and the temporomandibular joint, as well as contiguous tissue components. 

The most frequent presenting symptom associated with TMD is pain, usually localized in the muscles of mastication, the preauricular area, and/or the TMJ, which may be related to trauma. (such as a blow to the face), inflammatory or degenerative arthritis, or by the mandible being pushed back towards the ears whenever the individual chews or swallows. Sometimes, muscles around the TMJ used for chewing can go into spasm, causing head and neck pain and difficulty opening the mouth normally. Other common complaints reported by individuals include earache, headache, and facial pain. Individuals may also have limited or asymmetric jaw movement and joint sounds that are usually described as clicking, popping, grating, or crepitus in the TMJ.

According to the American Society of Temporomandibular Joint Surgeons (ASTMJS) clinical guidelines for Diagnosis and Management of Disorders involving the Temporomandibular Joint and related Musculoskeletal structures (which have not been updated since 2001):

As in any disease, an understanding of the natural course of the disease is necessary to guide treatment.  Most symptoms resolve over time, but a significant percentage requires a year or more to do so. The seriousness of the symptoms also varies greatly. Consideration should be given to treatment options, the time course for resolution of symptoms, their seriousness, and the progressive nature of the disease. Treatment efforts are directed toward: 1) reduction of pain, 2) improvement of dysfunction, 3) slowing the progression of the joint disease. TMJ arthroplasty is usually attempted after all nonsurgical methods of treatment have failed (ASTMJS, 2001).

Conservative therapy is the mainstay in treating TMD. This therapy may include behavioral change, oral medications for pain, anti-inflammatory injections, and orthotic devices. Surgical treatments, often irreversible, may be recommended for difficult or unresponsive cases. According to the National Institute of Dental and Craniofacial Research (NIDCR), there are no standards to identify people who would most likely benefit from surgery (NIDCR, 2010).  A review of available published evidence regarding the safety and efficacy of various medical and surgical treatment modalities for TMJ revealed inconsistent methodologies in study design and no significant benefit of one treatment over another, in terms of improved clinical outcomes (Fricton, 2010; List, 2010; Schiffman, 2007; Truelove, 2006).  

Several devices that have obtained pre-market approval (PMA) from the U.S. Food and Drug Administration (FDA) for the surgical treatment of TMD include, but are not limited to, the TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis (TMJ Concepts, Camarillo, CA); the TMJ Partial Temporomandibular Joint Replacement System, TMJ Fossa-Eminence Prosthesis System^™ and the TMJ Patient Specific Fossa-Eminence Prosthesis System^™ (TMJ Implants, Inc., Golden, CO); and the Total Temporomandibular Joint (TMJ) Replacement System (Biomet Microfixation [formerly Walter Lorenz Surgical, Inc.,], Jacksonville, FL). The FDA-approved labeling for each of these devices has similar indications, however, to date, the published evidence to support safety, efficacy, and durability of clinical outcomes has been limited.

Analgesics: Medications that provide pain relief.

Arthroplasty:  Surgery to relieve pain and restore range of motion by realigning or reconstructing a joint.

Behavioral therapy: Therapy aimed to help people examine those behaviors and emotions that have a negative impact on their lives and make a conscious effort to bring about positive changes.

Craniomandibular disorder (CMD): A dental term used to describe diseases or disorders of the muscles of the head and neck, with special reference to the masticatory (chewing) muscles.

Disc: Shortened terminology for an intervertebral disc or a TMJ disc; a disk-shaped piece of specialized tissue that separates the bones and provides a cushion between the bones.

Mandible: Bone of the lower jaw.

Meniscus: A cartilage pad between the two joint surfaces within the TMJ, acting as a smooth surface for the joint to move on.

Orthodontics: The specialty of dentistry dealing with the prevention and correction of abnormally positioned or aligned teeth.

Physical therapy: A branch of rehabilitative health that uses specially designed exercises and equipment to help individuals regain or improve their physical abilities.

Temporal bone: A large irregular bone situated at the base and side of the skull, connected with the mandible via the TMJ.

Temporomandibular joint (TMJ): Joint that hinges the mandible to the temporal bone of the skull; one of the most frequently used joints in the entire body, moving whenever a person eats, drinks, or talks.

Peer Reviewed Publications:

1. Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article. Int J Oral Maxillofac Surg. 2007; 36(9):773-782.
2. Ebrahim S, Montoya L, Busse JW, et al.  The effectiveness of splint therapy in patients with temporomandibular disorders: A systematic review and meta-analysis.  J Am Dent Assoc. 2012; 143(8):847-857.
3. Ebrahimi A, Ashford BG. Advances in temporomandibular joint reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2010; 18(4):255-260.
4. Fricton J, Look JO, Wright E, et al. Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. J Orofac Pain. 2010; 24(3):237-254.
5. Hall HD, Indresano AT, Kirk WS, Dietrich MS. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg. 2005; 63(8):1174-1179.
6. Keller EE, Baltali E, Liang X, et al.  Temporomandibular custom hemijoint replacement prosthesis: prospective clinical and kinematic study.  J Oral Maxillofac Surg. 2012; 70(2):276-288.
7. Lindenmeyer A, Sutcliffe P, Eghtessad M, et al.  Oral and maxillofacial surgery and chronic painful temporomandibular disorders--a systematic review. J Oral Maxillofac Surg. 2010; 68(11):2755-2764.
8. Linsen SS, Reich RH, Teschke M.  Mandibular kinematics in patients with alloplastic total temporomandibular joint replacement-a prospective study.  J Oral Maxillofac Surg. 2012; 70(9):2057-2064.
9. List T, Axelsson S. Management of TMD: Evidence from systematic reviews and meta-analyses. J Oral Rehab. 2010; 37(6):430-451.
10. Manfredini D, Rancitelli D, Ferronato G, Guarda-Nardini L.  Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols.  J Oral Rehabil. 2012; 39(4):245-251.
11. Marbach, JJ. Temporomandibular pain and dysfunction syndrome: history, physical examination, and treatment. Rheumatic Dis Clin of North Am. 1996; 22(3):477-498.
12. McKenna SJ. Modified mandibular condylotomy. Oral Maxillofacial Surg Clin N Am. 2006; 18(3):369-381.
13. McLeod NM, Saeed NR, Hensher R.  Internal derangement of the temporomandibular joint treated by discectomy and hemi-arthroplasty with a Christensen fossa-eminence prosthesis.  Br J Oral Maxillofac Surg. 2001; 39(1):63-66.
14. Park J, Keller EE, Reid KI.  Surgical management of advanced degenerative arthritis of temporomandibular joint with metal fossa-eminence hemijoint replacement prosthesis: an 8-year retrospective pilot study.  J Oral Maxillofac Surg. 2004; 62(3):320-328.
15. Schiffman EL, Look JO, Hodges JS, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res. 2007; 86(1):58-63.
16. Truelove E, Huggins KH, Manci L, Dworkin SF.  The efficacy of traditional, low cost, and non-splint therapies for temporomandibular disorder.  J Am Den Assoc. 2006; 137(8):1099-1107.
17. Widmalm S, Brooks S, Sano T, et al. Limitation of the diagnostic value of MR images for diagnosing temporomandibular joint disorders. Dentomaxillofac Radiol. 2006; 35(5):334-338.
18. Wolford LM. Factors to consider in joint prosthesis systems. Proc (Bayl Univ Med Cent). 2006; 19(3):232-238.
19. Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC. Comparison of two temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg. 2003a; 61(6):685-690.
20. Wolford LM, Pitta MC, Reiche-Fishel O. TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg. 2003b; 32(3):268-274.
21. Yuasa H, Kurita K. Randomized clinical trial of primary treatment for temporomandibular joint disk displacement without reduction and without osseous changes: a combination of NSAIDs and mouth-opening exercise versus no treatment. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(6):671-675.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Al-Ani MZ, Davies SJ, Gray RJM, et al. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev. 2009; (1):CD002778. Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002778.pub2/abstract.  Accessed on September 18, 2012.
2. American Association of Oral and Maxillofacial Surgeons (AAOMS). Parameters of care for oral and maxillofacial surgery.  Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region.  2008.  Available at:  http://www.aaoms.org/docs/practice_mgmt/impairment_guidelines.pdf.  Accessed on September 18, 2012. 
3. American Association of Oral and Maxillofacial Surgeons (AAOMS).  Information on TMJ.  Available at:  http://www.aaoms.org/tmj.php.  Accessed on September 18, 2012.
4. American Society of Temporomandibular Joint Surgeons (ASTMJS). Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Revised 2001. Available at: http://www.astmjs.org/guidelines.html. Accessed on September 18, 2012.
5. de Souza RF, Lovato da Silva CH, Nasser M, et al.  Interventions for the management of temporomandibular joint osteoarthritis. Cochrane Database Syst Rev. 2012; (4):CD007261.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007261.pub2/abstract.  Accessed on September 18, 2012.
6. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database Syst Rev. 2008; (1):CD000979.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000979/abstract.    Accessed on September 18, 2012.
7. Luther F, Layton S, McDonald F. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev. 2010; (7):CD006541.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006541.pub2/abstract.  Accessed on September 18, 2012.
8. National Institute for Health and Clinical Excellence (NICE). Interventional Procedure Guidance 329: Total prosthetic replacement of the temporomandibular joint. London, UK. NICE: December 2009. Available at: http://guidance.nice.org.uk/IPG329. Accessed on September 18, 2012.
9. National Institutes of Health (NIH). National Institute of Dental and Craniofacial Research (NIDCR). Temporomandibular joint (TMJ) and muscle disorders. Revised March 2010. Available at: http://www.nidcr.nih.gov/OralHealth/Topics/TMJ/.  Accessed on September 19, 2012.
10. Rigon M, Pereira LM, Bortoluzzi MC, et al.  Arthroscopy for temporomandibular disorders.  Cochrane Database Syst Rev. 2011; (7):CD 006385.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006385.pub2/abstract.  Accessed on September 18, 2012.
11. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis System. Summary of Safety and Effectiveness. No. P980052. Rockville, MD: FDA. July 2, 1999. Available at:   http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=P980052. Accessed on September 18, 2012.
12. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Partial Temporomandibular Joint Replacement System; TMJ Fossa-Eminence Prosthesis System^™ and TMJ Patient Specific Fossa-Eminence Prosthesis System^™.  Summary of Safety and Effectiveness. No. P000035. Rockville, MD:FDA. February 27, 2001. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=P000035. Accessed on September 18, 2012.
13. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Total Temporomandibular Joint Replacement System; TMJ Fossa Eminence/Condylar Prosthesis System^™. Summary of Safety and Effectiveness. No. P000023. Rockville, MD: FDA. January 5, 2001. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=p000023. Accessed on September 18, 2012.
14. U.S. Food and Drug Administration (FDA) Premarket Notification Database. Walter Lorenz Total Temporomandibular Joint (TMJ) Replacement System. Summary of Safety and Effectiveness. No. P020016. Rockville, MD: FDA. September 21, 2005. Available at:  http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=6346. Accessed on September 18, 2012.
15. White SC, Heslop EW, Hollender LG, et al. Parameters of radiologic care: an official report of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(5):498-511.

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