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Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 29-33

Prevalence of Temporomandibular Joint Problems in Candidate Patients for Impacted Third Molar Surgery With and Without the Previous Temporomandibular Disorder: A Prospective Study

1 Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Endodontics, School of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran
3 Department of Periodontics, School of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran

Date of Web Publication6-Sep-2019

Correspondence Address:
Mohamadjavad Karamshahi
No. 48, 31 St, Gisha, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_48_19

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Introduction: Minor surgeries in the mouth region have been associated with a risk of temporomandibular disorders (TMDs). One of the most common surgeries is third molar removal. The aim of this study was to determine the prevalence of temporomandibular joint (TMJ) problems in candidate patients for impacted third molar surgery with and without previous temporomandibular problems. Materials and Methods: In this prospective cohort study, 15 to 30-year-old patients with and without TMD were chosen before third molar surgery. According to the clinical examinations and Research Diagnostic Criteria for TMD questionnaire, frequency of joint click, severity of TMJ pain using visual analog scale (VAS), and maximum mouth opening (MMO) were evaluated at before the surgery and 1 week, 1 month, and 6 months after the surgery. The changes in the click frequency at different times in the two groups were analyzed statistically by Chi-square test and the difference of the parameters of the MMO and VAS values in the two groups were analyzed by Student t test. Results: In the group with TMD, the click had a significant increase 1 week after the surgery. However, 6 months after the surgery, the incidence of click decreased significantly compared to 1 month after the surgery (P = 0.032). MMO at all the times was significantly higher in the group without TMD symptoms (P = 0.012). At all the times, VAS values were higher in the group with TMD symptoms (P = 0.024). The maximum VAS values were observed at 1 week after the surgery (P = 0.041). Conclusion: The reduction in MMO and increase in VAS score in patients with TMD were evident compared to patients without TMD. Furthermore, it seems that the surgical trauma resulting from the removal of the third molars is a predisposing factor for developing TMD.

Keywords: Temporomandibular disorder, temporomandibular joint, third molar

How to cite this article:
Mirmohamadsadeghi H, Alavi O, Karamshahi M, Tabrizi R. Prevalence of Temporomandibular Joint Problems in Candidate Patients for Impacted Third Molar Surgery With and Without the Previous Temporomandibular Disorder: A Prospective Study. Dent Hypotheses 2019;10:29-33

How to cite this URL:
Mirmohamadsadeghi H, Alavi O, Karamshahi M, Tabrizi R. Prevalence of Temporomandibular Joint Problems in Candidate Patients for Impacted Third Molar Surgery With and Without the Previous Temporomandibular Disorder: A Prospective Study. Dent Hypotheses [serial online] 2019 [cited 2023 Jun 2];10:29-33. Available from:

  Introduction Top

Temporomandibular disorder (TMD) is the term recommended by the American Dental Association for what is presumed to be a range of painful conditions affecting orofacial and dental structures.[1] TMD involves the signs and symptoms of temporomandibular joint (TMJ) region, the mastication muscles and ligaments, and its prevalence is around 3.7% to 12% of the adult population and 0.7% to 18.6% of the children population.[2],[3] It causes pain and functional disorders in the TMJ that controls the jaw movement. Symptoms include pain in masticatory muscles, trismus, pain in TMJ, and joint sounds. Some people experience the symptoms transiently that even resolve without any treatment whereas others experience long-term symptoms. TMD affects the life of individuals due to the development of functional disorders. Furthermore, its multifactorial etiology complicates TMD treatment and often necessitates multidisciplinary cooperation for resolving its symptoms adequately.[4] Various etiological factors such as parafunctional habits and undesirable psychological statuses such as stress and trauma have been propounded for the incidence of TMD.[5] Trauma incurred to jaw plays a significant role in the incidence and acceleration of TMD process and those suffering from TMD usually mention a positive history of trauma to the head and neck associated with their TMD.[6] Removal of the third molars has been propounded as a factor with the potential to damage TMJ.[7] Furthermore, the trauma resulting from the surgery of third molars has been reported to be a predisposing factor in the progression of TMD symptoms.[7],[8] The reason is that the process of removing the third molars involves extensive mouth opening for a long time and exertion of considerable forces to the mandible. Each of these factors contributes to the development of muscular and articular pains due to the stretching muscles and ligaments, subluxation of the condyle, and disc dislocation.[7] There are some factors that can affect the incidence of general complications following the removal of the third molars. These factors include age, gender, medical history of the patient, presence of pericoronitis when removing the third molar, unsuitable oral hygiene, smoking, type of tooth impaction, relationship between the impacted tooth and the inferior alveolar nerve, duration of the surgery, the technique of surgery, and anesthesia technique.[9] The high frequency of third molar surgery can result in an increased number of patients who suffer from chronic oral and facial pains.[10] De Angelis et al.[11] suggested that TMD symptoms are common in patients who were referred to the wisdom tooth extraction. Juhl et al.[2] conducted a prospective study that investigated the relationship between third molar surgery and the progression of signs and symptoms of TMD and reported that in the individuals who underwent the third molar surgery, the incidence of TMD did not increase. Due to the limited studies on the relationship between extracting the third molars and incidence of TMD, the present study was conducted with the aim of determining the relationship between the removal of the third molars using the surgical method and TMD.

  Materials and Methods Top

Study design

This prospective cohort study was performed on the patients referred to the Oral and Maxillofacial Surgery Department of Faculty of Shahid Beheshti Dental School in 2017.

Study population

Twenty-seven patients with TMD and 44 patients without TMD, who all were the candidate for impacted third molar surgery, were chosen through convenient sampling method. Before the surgery, the patients in both the groups were thoroughly examined using Research Diagnostic Criteria (RDC)-TMD and the data obtained from them were utilized as the basic information in the statistical investigations. RDC-TMD criteria include clinical assessment of the patient with a questionnaire for investigating the patient history. The questionnaire contained several questions about facial pain, intensity of pain, effect of pain on patient daily routines, TMJ problems, and other nonspecific symptoms. The clinical assessment of TMJ included measuring the TMJ click and crepitus, the extent of mouth opening (maximum mouth opening, MMO), and the TMJ pain. The pain intensity was determined based on visual analog scale (VAS). The distance between the upper central incisal edge and the lower central incisal edge was measured and reported as the maximum extent of mouth opening. Click assessment method was performed by palpating the tip of the condyles of the mandible through gentle pressure of fingers on both sides during mouth opening and lateral and protrusive movements. If the mandible movements were not soft or crepitus or any other unnatural sound was heard or detected in palpation, it was recorded. In the control group, TMD was not diagnosed in the patients, before the surgery. In other words, no signs of parafunctional habits, TMJ pain, click and crepitus, and limited mouth opening less than 40 mm were observed. In the case group, patients had TMD but they were not under treatment. The inclusion criteria were age between 15 and 30 years and American Society of Anesthesiologists (ASA) 1 and 2 groups. The type of impaction of the third molar in the patients was mesioangular B-II according to Pell and Gregory classification. Any complication in the procedure of the surgery and patients who participated or performed any dental treatment in the follow-up periods were excluded from the study.

Surgery procedure

For patients in both the groups, the standard surgical technique was used. Tooth extraction was performed under local anesthesia (lidocaine 2% + epinephrine 1/80,000) through infiltrated buccal anesthesia and standard inferior alveolar nerve (IAN) block. No sedative was given to the patients before or during the surgery and the operation in all patients was performed by two oral and maxillofacial residents within the maximum 1 hour. To perform the operation, a mucoperiosteal flap was raised and the distal and buccal bone was removed and, if necessary, the tooth was sectioned. After extracting the tooth, the flap was returned to its original state and was sutured. One week after the surgery, the sutures were removed and the first follow-up was done. Subsequent follow-ups were performed 1 and 6 months later. In the follow-up sessions, in the group who did not have TMD, any sign of TMJ involvement was recorded and in the group who had TMD before the surgery, TMD changes were evaluated.

Statistical analysis

The frequency of TMJ click was measured by Chi-square test. Comparison of the values of MMO and VAS scores in the two groups and at each time were performed using Student t test. The relationship between age and gender parameters and VAS scores as well as MMO was assessed using Pearson correlation test. P value was considered as 0.05.

Ethical considerations

The protocol was confirmed and registered with the code of IR.SBMU.RIDS.REC.1395.252 at the Ethics Committee in Dentistry Faculty of Shahid Beheshti University of Medical Sciences. Furthermore, the written informed consent form was taken from patients for their participation and follow-up examinations. The impacted third molar surgical operations were performed based on the approved and standard protocol.

  Results Top

A total of 71 patients with the mean age of 24.3 years were evaluated in the study. Out of this number, 28 (39%) had TMD symptoms and 43 (61%) lacked TMD symptoms [Table 1].
Table 1 Distribution of patients, percentage of patients with click, and the mean MMO and VAS scores in the groups

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The rate of click incidence in the group with TMD, 1 week after the surgery, had a significant increase compared to its rate before the surgery. Nevertheless, the incidence rate of the click 1 month after the surgery was similar to that of 1 week after the surgery. Also, 6 months after the surgery, click had significantly decreased compared to 1 month after the surgery (P < 0.001). Similar changes were observed in the group without TMD in terms of click incidence among different times (P < 0.001). Furthermore, click in the group with TMD was significantly higher at all the times compared to the group without TMD (Chi-square test: P = 0.032) [Table 1].

Mean of maximum mouth opening

The difference of MMO at all the times was not significant between the groups with and without TMD (P = 0.65). According to the Student t test, significant differences were observed in terms of MMO among different times in both the groups (P < 0.001) [Table 1].

VAS analysis

According to the Student t test, VAS values between the groups with and without TMD symptoms were significant and higher in the group with TMD (P = 0.041). Furthermore, VAS values among different times were significant in both the groups (P = 0.024). Additionally, the maximum VAS values were observed 1 week after the surgery (P = 0.024) [Table 1].

The mean age of patients in the group with TMD was 24.2 and in the group without TMD was 24.4 years and no significant relationship was observed between age and TMD (P = 0.61). Additionally, a higher prevalence of TMD was reported in the female gender that was significant (P = 0.02).

  Discussion Top

According to the results of the present study, the click incidence rate increased following the surgery in both the groups. The difference of MMO at all the times was not significant between the groups with and without TMD. In terms of VAS, at all the times, values were higher in the group with TMD symptoms and at the time 1 week after the surgery, the maximum VAS values were observed.

It seems that the trauma resulting from surgery in patients who suffer from TMJ develops more complications.[12] Threlfall et al.[13] indicated that extracting the third molars results in increased risk of TMJ disk dislocation. A study investigated the relationship between TMD and surgery of third molars and indicated that the experience of third molars removal is associated with the joint click and limited opening of the mouth.[14] Furthermore, in a cross-sectional study, a relationship was observed between TMD symptoms and a history of third molar extraction.[15] However, in a prospective study, no difference was found between the click before and after third molar surgery.[16] The difference between the results of these studies can be attributed to not mentioning the method of third molar extraction. Possibly, simple extraction without surgery of the third molars also has been used in these studies. According to the results of the current study, reduction in MMO at all the times was not significant between the group with TMD and the group without TMD. Two studies indicated that MMO decreased 1 week after the third molar surgery.[2],[16] Mesgarzadeh et al.[17] also showed that MMO decreased following third molar surgery and this reduction was greater in the group with TMD symptoms. During third molar surgery, the patient’s mouth remains open for a long time and in case of using general or local anesthesia, the protective mechanisms of the patient diminish.[18] In the present study, VAS values were higher in the group with TMD symptoms and the maximum VAS values were observed 1 week after surgery. TMD pains reported in the patients up to 6 months after the surgery reinforce this assumption that surgical processes increased the risk of chronic pains.[19] In previous years, some instructions were presented for the surgery of third molars to prevent postoperative pains and the importance of performing a less traumatic surgery has been emphasized to reduce the risk of joint and muscle problems.[3] Based on the results of the present study, TMD had a higher prevalence among the females, but patients’ age did not significantly correlate to any of the TMD factors. In a retrospective study, no relationship was observed between trismus and age,[17] which is similar to the results of the present study. Grossi et al.[20] reported that gender was one of the predictive factors of postoperative complaints. It has been stated that the low pain threshold in women and use of more anesthesia cartridge can enhance the level of trismus in them. Biological, cultural, hormonal, and environmental factors alone or in combination can lead to further damage in the TMJ structure in women.[20]To determine the causal relations between the extraction of third molars and incidence of TMD, diagnosis of TMD cases should be done before the third molar surgery. In this study, it was performed through clinical examinations and questionnaire. Use of clinical examinations and RDC-TMD questionnaire concurrently is one of the strong aspects of this study. The follow-up period in the patients continued up to 6 months after the surgery that reduced the probability of the overlap of patients’ signs and symptoms in response to the surgery of impacted third molars or TMD in case of choosing shorter time durations.

  Conclusion Top

In both the groups with and without TMD, click increased after the surgery compared to its rate before the surgery. The difference of MMO at all the times was not significant between the groups with and without TMD. However, VAS values were higher in the group with TMD symptoms at all the times, and in the time 1 week after the surgery, the maximum VAS values were observed. It seems that the trauma from removal of the third molars can be a predisposing factor for developing TMD.


The authors are grateful to all of those with whom they have had the pleasure to work during this project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Clark G. Etiologic theory and the prevention of temporo-mandibular disorders. Adv Dent Res 1991;5:60-6.  Back to cited text no. 1
Juhl GI, Jensen TS, Northolt SE, Svensson P. Incidence of symptoms and signs of TMD following third molar surgery: a controlled, prospective study. J Oral Rehabil 2009;36:199-209.  Back to cited text no. 2
Fischer DJ, Mueller BA, Critchlow CW, LeResche L. The association of temporo-mandibular disorder pain with history of head and neck injury in adolescents. J Orofac Pain 2006;20:191-8.  Back to cited text no. 3
Benoliel R, Sharav Y, Tal M, Eliav E. Management of chronic orofacial pain: today and tomorrow. Compend Contin Educ Dent 2003;24:909-20, 922-4, 926-8 passim; quiz 32.  Back to cited text no. 4
Alamoudi N. Correlation between oral para-function and temporomandibular disorders and emotional status among Saudi children. J Clin Pediatr Dent 2002;26:71-80.  Back to cited text no. 5
Pullinger AC, Seligman DA. TMJ osteoarthrosis: a differentiation of diagnostic subgroups by symptom history and demographics. J Craniomandib Disord 1987;1:251-6.  Back to cited text no. 6
Huang GJ, Rue TC. Third-molar extraction as a risk factor for temporo-mandibular disorder. J Am Dent Assoc 2006;137:1547-54.  Back to cited text no. 7
Huang GJ, LeResche L, Critchlow CW, Martin MD, Drangsholt MT. Risk factors for diagnostic subgroups of painful temporomandibular disorders. J Dent Res 2002;81:284-8.  Back to cited text no. 8
Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am 2007;19:117-28.  Back to cited text no. 9
Berge TI. Incidence of chronic neuropathic pain subsequent to surgical removal of impacted third molars. Acta Odontol Scand 2002;60:108-12.  Back to cited text no. 10
De Angelis AF, Chambers IG, Hall GM. Temporomandibular joint disorders in patients referred for third molar extraction. Aust Dent J 2009;54:323-5.  Back to cited text no. 11
Pedersen A. Interrelation of complaints after removal of impacted mandibular third molars. Int J Oral Surg 1985;14:241-4.  Back to cited text no. 12
Threlfall AG, Kanaa MD, Davies SJ, Tickle M. Possible link between extraction of wisdom teeth and temporomandibular disc displacement with reduction: matched case control study. Br J Oral Maxillofac Surg 2005;43:13-6.  Back to cited text no. 13
Akhter R, Hassan NM, Ohkubo R, Tsukazaki T, Aida J, Morita M. The relationship between jaw injury, third molar removal, and orthodontic treatment and TMD symptoms in university students in Japan. J Orofac Pain 2008;22:50-6.  Back to cited text no. 14
Barbosa C, Gavinha S, Soares T, Manso MC. Coincidence and awareness of the relationship between temporomandibular disorders and jaw injury, orthodontic treatment, and third molar removal in university students. J Oral Facial Pain Headache 2016;30:221-7.  Back to cited text no. 15
Huang GJ, Cunha-Cruz J, Rothen M, Spiekerman C, Drangsholt M, Anderson L et al. A prospective study of clinical outcomes related to third molar removal or retention. Am J Public Health 2014;104:728-34.  Back to cited text no. 16
Mesgarzadeh AH, HasanpurKashani A, Jafari M. Effect of surgical removal of impacted third molars on trismus value. Jundishapur Sci Med J 2013;12:41-9.  Back to cited text no. 17
Kamisaka M, Yatani H, Kuboki T, Matsuka Y, Minakuchi H. Four-year longitudinal course of TMD symptoms in an adult population and the estimation of risk factors in relation to symptoms. J Orofac Pain 2000;14:224-32.  Back to cited text no. 18
Nikolajsen L, Sorensen HC, Jensen TS, Kehlet H. Chronic pain following caesarean section. Acta Anaesthesiol Scand 2004;48:111-6.  Back to cited text no. 19
Grossi GB, Maiorana C, Garramone RA, Borgonovo A, Creminelli L, Santoro F. Assessing postoperative discomfort after third molar surgery: a prospective study. J Oral Maxillofac Surg 2007;65:901-17.  Back to cited text no. 20


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