Ultrasound-guided arthrocentesis using single-puncture, double-lumen, single-barrel needle for patients with temporomandibular joint acute closed lock internal derangement

Ultrasound-Guided Single Puncture Technique to Simultaneously Reach the Upper and Lower Temporomandibular Joint Compartments for Arthrocentesis or Injections Purposes: A Technical Note

Temporomandibular joint (TMJ) arthrocentesis is a widely described and effective technique that promotes lysis and lavage of TMJ compartments, improving pain and mandibular range of motion. Mostly, this technique has been used to reach the upper TMJ compartment, besides effusion may be present also in lower compartment, that, in the absence of disc perforation, may also need to be assessed. Here, we propose an adaptation of arthrocentesis technique aiming to access both upper and lower compartments of the TMJ with a single needle puncture and guided by ultrasound real-time images. The technique was initially established in fresh cadavers and later replicated in 2 patients. Technique modification proved to be efficient and reproducible, reducing the number of perforations and, consequently, possible adverse events. The proposed technique can be applied to arthrocentesis and/or intra-articular injections through the combination of two previously validated techniques, to improve its safety and efficacy.

Analysis of the Use of Sample Size and Effect Size Calculations in a Temporomandibular Disorders Randomised Controlled Trial-Short Narrative Review

BACKGROUND/OBJECTIVES

Temporomandibular disorder (TMD) is the term used to describe a pathology (dysfunction and pain) in the masticatory muscles and temporomandibular joint (TMJ). There is an apparent upward trend in the publication of dental research and a need to continually improve the quality of research. Therefore, this study was conducted to analyse the use of sample size and effect size calculations in a TMD randomised controlled trial.

METHODS

The period was restricted to the full 5 years, i.e., papers published in 2019, 2020, 2021, 2022, and 2023. The filter article type-"Randomized Controlled Trial" was used. The studies were graded on a two-level scale: 0-1. In the case of 1, sample size (SS) and effect size (ES) were calculated.

RESULTS

In the entire study sample, SS was used in 58% of studies, while ES was used in 15% of studies.

CONCLUSIONS

Quality should improve as research increases. One factor that influences quality is the level of statistics. SS and ES calculations provide a basis for understanding the results obtained by the authors. Access to formulas, online calculators and software facilitates these analyses. High-quality trials provide a solid foundation for medical progress, fostering the development of personalized therapies that provide more precise and effective treatment and increase patients' chances of recovery. Improving the quality of TMD research, and medical research in general, helps to increase public confidence in medical advances and raises the standard of patient care.

Intra-articular injections in the TMJ inferior joint space: A scoping review

OBJECTIVE

To perform a scoping review to identify the available evidence regarding intra-articular injections in the inferior joint space (IJS) of the temporomandibular joint (TMJ).

METHODS

An electronic search of the PubMed, Web of Science and Scopus databases was performed using the following terms: "Arthrocentesis", "injection", "joint injection", "technique", "Temporomandibular joint", "Temporomandibular joint disorder". Full-text articles were obtained from the records after applying the inclusion/exclusion criteria. Only articles with full-text access were included.

RESULTS

Thirteen articles were included for analysis-one technical note, three cadavers studies, one animal study, two case reports, five randomised clinical trials and one retrospective study; studies were classified as 'patients-based studies' and 'non-patients-based studies'. Most 'patients-based studies' show moderate or high risk of bias. Techniques were categorised as 'anatomical technique' and 'image-guided technique'. Most 'patients-based studies' show favourable outcomes such as pain reduction, increase in maximum mouth opening, improvement in quality of life and improvement in TMJ dysfunction indexes for the treatment of arthrogenic TMDs. Comparisons between superior and IJS injections are scarce. On the other hand, 'non-patients-based' studies show that image-guided or ultrasound-checked injection techniques achieved a higher effectiveness for needle location than anatomical (or blind) techniques.

CONCLUSION

The amount of available evidence is scarce, heterogeneous in design, and most 'patients-based studies' show moderate or high risk of bias, which demands the generation of new research to obtain definitive conclusions. The tendency observed suggests that intra-articular injections for the IJS of the TMJ are able to relieve TMJ pain, increase mouth opening and improve TMJ dysfunction, and image-guided injection techniques seem to be more effective than anatomical techniques to locate the needle in the IJS.

Is Single Puncture Superior to Double Puncture Arthrocentesis in Patients With Wilkes III Internal Derangement?

BACKGROUND

Arthrocentesis is a minimally invasive procedure with reported efficacy when used for lysis and lavage of the joint for symptomatic internal derangement, irrespective of the technique utilized.

PURPOSE

The purpose of the study was to determine if the single puncture arthrocentesis (SPA) is superior to double puncture arthrocentesis (DPA) with respect to pain reduction and improved maximal mouth opening (MMO) for subjects with acute disc displacement without reduction.

STUDY DESIGN AND SETTING

A single-blinded randomized prospective clinical trial was conducted at the tertiary referral center for temporomandibular joint disorders. All subjects were diagnosed with acute onset disc displacement without reduction based on history and magnetic resonance imaging findings. Subjects were randomized to SPA or DPA.

PREDICTOR VARIABLE(S)

The primary predictor variable was arthrocentesis technique (SPA vs DPA).

MAIN OUTCOME VARIABLE(S)

The primary outcome variables were pain and MMO, measured at 4 weeks. The duration for the procedure was recorded at the time of the surgery.

COVARIATES

Age, sex, and the side affected were recorded.

ANALYSES

Data were analyzed using analysis of variance to compare the primary outcome variables. Levene's, post hoc, and Bonferroni-Holm tests were used for intergroup comparisons with a P value of <0.05 being significant.

RESULTS

Forty subjects completed the study. The mean age for the SPA and DPA groups was 28.3 (±3.9) and 29.1 (±4.1), respectively (P = .52). The sex distribution was 60 and 55% female in the SPA and DPA groups, respectively. The mean pain reduction in the SPA and DPA groups was from 8.30 (±0.86) to 0.90 (±0.78) and from 8.00 (±0.79) to 0.95 (±0.82), respectively (P < .0001). There was no difference in pain reduction between the groups (P = .05). The mean increase in MMO was 34.6 (±2.34) and 33.4 (±2.35) in the SPA and DPA groups, respectively (P < .0001). The difference between the groups was not significant (P = .12). The procedural time in the SPA and DPA groups was 14.15 ± 1.72 and 17.55 ± 1.66, respectively (P < .0001).

CONCLUSION

SPA and DPA arthrocentesis appear to be equally efficacious for pain reduction and increasing MMO. SPA can be completed in less time than DPA and should be considered as a viable alternative to the conventional DPA technique.

Lavage Volume of Arthrocentesis in the Management of Temporomandibular Disorders: A Systematic Review and Meta-Analysis

The aim of this study was to investigate the most effective lavage volume of arthrocentesis in the management of temporomandibular disorders. A comprehensive electronic search, based on the PRISMA guidelines, was performed, which included a computer search with specific keywords, a reference list search and a manual search. The inclusion criteria were the following: a randomized controlled trial, at least 20 subjects who underwent arthrocentesis, mention of the irrigation materials used for the arthrocentesis, mention of the irrigation volumes used for the arthrocentesis, MMO and pain measured as VAS or NRS, were reported as outcome figures, mention of a specific diagnosis or signs and symptoms, and inclusion of the data on the MMO or VAS/NRS at 6-month follow-up. Sixteen publications were enrolled in the meta-analysis, comparing arthrocentesis with a lavage volume <150 mL and arthrocentesis with a lavage volume ≥150 mL, in the efficacy of the improvement in the mouth opening and pain reduction. The results revealed the group with a lavage volume <150 mL had a greater improvement in the mouth opening and pain reduction. However, results are to be interpreted with caution, due to the paucity of the randomized controlled literature and other confounding factors. Further high-quality studies are required to provide a better conclusion to the treatment outcomes of the different lavage volumes.

Temporomandibular joint arthrocentesis guided by ultrasonography: An anatomical study

The temporomandibular joint (TMJ) arthrocentesis is a common procedure in maxillofacial surgery departments for the treatment of TMJ dysfunction. The use of ultrasonography in this area is rare, and in the vast majority of cases only as a diagnostic, and non-therapeutic use. Through this study we propose the equipment and ultrasound parameters necessary to obtain detailed and practical images when using ultrasonography as a therapeutic guide in arthrocentesis of TMJ. In addition, we provide data regarding the placement and working angulations of both the ultrasound probe and the needle that are ideal for facilitating image-guided puncture. It is a simple technique, with a relatively short learning curve, and that can provide considerable intraoperative help to the surgeon.

Temporomandibular Disorders: Current Concepts and Controversies in Diagnosis and Management

Temporomandibular disorders (TMD) are a group of orofacial pain conditions which are the most common non-dental pain complaint in the maxillofacial region. Due to the complexity of the etiology, the diagnosis and management of TMD remain a challenge where consensus is still lacking in many aspects. While clinical examination is considered the most important process in the diagnosis of TMD, imaging may serve as a valuable adjunct in selected cases. Depending on the type of TMD, many treatment modalities have been proposed, ranging from conservative options to open surgical procedures. In this review, the authors discuss the present thinking in the etiology and classification of TMD, followed by the diagnostic approach and the current trend and controversies in management.

Internal derangement of temporomandibular joint: Umbrella perforated screw technique

Introduction:

Umbrella shaped Perforated Screws (UPS) were developed for the use of orthopedic surgery to facilitate anchoring and fixation of the tissue to bone. We here present a retrospective study of Temporomandibular joint Internal derangement (ID) with fixation using this type of screws.

Materials & Methods:

We conducted a retrospective study including patients treated for ID using UPS to reposition the articular disc. The study included patients treated between 1998 and 2005. Patients were selected in concordance with clinical symptoms and signs of severity. All patients had an MRI (open/closed mouth) to confirm the diagnosis. Wilkes classification of temporomandibular disease (TMD) was adopted in the selection criteria.

Results:

Hundred and five patients were included, 92 female and 13 males with average age of 37.56. Dentists or general physicians mainly addressed these patients to our unit. The mean time from symptoms initiating to first consultation was 3.77 years, while the mean timing of surgery after initial consultation was 9.38 months. Patients have presented with various symptoms before the surgery including pain, limitation in eating habits and clicking. 77% of the patients had no or minimal pain post surgery. Hundred and one patients had good eating habits after surgery. Only 34 patients had persistent clicking despite surgery. We had neither infection nor hematoma as complication. Major complication to this technique is frontal paresis (14 patients), which was explained to all patients preoperatively. This paresis recovered in less than 2 months in all patients. We had 89.5% of the patients satisfied with their results.

Conclusion:

UPS are useful in the field of plastic surgery. This novel technique has the advantage of not compromising the vascular supply of the TMJ articular surface. This technique provides a simple, fast and efficient technique for posterior aponeurosis flap fixation. Our overall satisfactory rate was comparable to other studies.

Ultrasound-guided vs conventional arthrocentesis for management of temporomandibular joint disorders: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to compare outcomes between ultrasound (US)-guided arthrocentesis and conventional arthrocentesis for the management of temporomandibular joint disorders (TMDs).

METHODS

PubMed, Embase, Scopus, BioMed Central, CENTRAL, and Google scholar databases were searched up to April 1 2020 for randomized control trials (RCTs) comparing US-guided and conventional arthrocentesis.

RESULTS

Four RCTs were included. Pooled analysis did not demonstrate any statistically significant difference in pain or maximal mouth opening (MMO) scores after 1 week and 1 month of follow-up between US-guided and conventional arthrocentesis. Studies also reported data on intra-operative needle relocations and operating time but with conflicting results.

CONCLUSION

This study indicates that the use of US during arthrocentesis may not improve postoperative pain and MMO in the short term. Data on intra-operative outcomes are scarce and conflicting for any definitive conclusions. Further high-quality adequately powered RCTs are required to strengthen current evidence.

Ultrasonography-guided arthrocentesis versus conventional arthrocentesis in treating internal derangement of temporomandibular joint: a systematic review

OBJECTIVES

This systematic review assessed the clinical question: 'Does ultrasonography (USG)-guided arthrocentesis provide better outcomes than conventional arthrocentesis in patients with temporomandibular disorder (TMD)?'

MATERIALS AND METHODS

The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An initial search was performed on electronic databases-including Medline, PubMed, and Cochrane Library-followed by manual and reference searches until the date September 27, 2019. The articles selected were evaluated for study and patient characteristics, arthrocentesis procedure details, and treatment outcomes (post-operative pain, maximum mouth opening (MMO), procedure time, and attempts of needle positioning). Risk of bias was assessed with the Cochrane Consumers and Communication Review Group's data extraction template and Critical Appraisal Skills Programme (CASP).

RESULTS

Out of the 325 initially identified articles, four studies with 144 patients were included in the final qualitative analysis. No significant differences were found in pain reduction and improved MMO between sample groups receiving conventional arthrocentesis and USG-guided arthrocentesis. Needle positioning attempts and procedural times were conflicting between the two groups.

CONCLUSIONS

This systematic review found that the outcomes of USG-guided arthrocentesis were not superior to conventional arthrocentesis. Conflicting data was found in the attempts of needle positioning and procedural time. Standardized treatment protocols and data from well-designed USG-guided arthrocentesis randomized clinical trials were lacking.

CLINICAL RELEVANCE

Arthrocentesis with or without USG guidance are both effective for treating patients with TMD to reduce pain and to improve MMO. USG-guided arthrocentesis was not found to be superior to conventional arthrocentesis.