Comparison of ultrasound-guided and conventional arthrocentesis of the temporomandibular joint

Efficacy of computer-guided versus conventional sodium hyaluronate injection in superior joint space in treatment of temporomandibular joint (TMJ) internal derangement: Comparative randomized controlled trial

OBJECTIVES

evaluate the feasibility and clinical outcomes of computer-guided sodium hyaluronate injection in superior joint space compared to conventional injection for the treatment of TMJ Internal Derangement (TMJ-ID).

PATIENTS AND METHODS

Randomized controlled trial conducted on 40 patients diagnosed with bilateral TMJ-ID divided into two groups. Group A treated with four computer-guided sodium hyaluronate injections in superior TMJ space with one-week intervals. Group B received similar injections but with the conventional method. The intraoperative assessment included total procedural time and patient convenience during the injection. The postoperative evaluation included maximum unassisted mouth opening (MUMO), modified Helkimo's clinical dysfunction index, and pain intensity on a visual analog scale (VAS).

RESULTS

Group A showed better improvement in maximum mouth opening and pain intensity than group B after a week of the second, third and fourth injection. At the six months, group A continued to show better improvement regarding maximum mouth opening, while improvement in pain and TMJ dysfunction was similar in both groups. There were differences between both groups regarding procedural time and patient convenience across the study except the time of the first injection, which was similar in both groups CONCLUSION: Using the virtual planning and injection guide for intra-articular TMJ injection is considered promising to increase the accuracy and efficacy of injectable material securing faster results besides rendering the procedure easily reproducible and simpler to both clinicians and patients. However, the authors could not ensure the long-term superiority of the computer-guided injection technique over the conventional one in light of the results of this study.

Influence of Ultrasound Examination on Diagnosis and Treatment of Temporomandibular Disorders

Background: Disorders of the masticatory muscles and temporomandibular joints as well as the surrounding craniofacial structures are called temporomandibular disorders. These are dental diseases affecting an increasing number of people with a multifactorial etiology. Noninvasive ultrasonography imaging of temporomandibular joints was performed to obtain more detailed information on joint pathologies. Material and Methods: The aim of the study was to assess the influence of ultrasound examinations of the temporomandibular joints on the diagnosis and treatment planning in patients with temporomandibular disorders. The study included 110 patients examined with the use of the Research Diagnostic Criteria for Temporomandibular Disorders questionnaire, axis I and II, after which the initial treatment plan was created. All patients underwent an ultrasound examination of the temporomandibular joints. Results: The results reveal numerous morphological changes within the joint structures in all treatment groups. Comparative statistical analyses of symptoms were performed between study groups. Conclusions: The number of pathologies in the myofascial pain group was much higher than expected and required introduction of additional treatment procedures. Further studies confirming these results and the effectiveness of ultrasound diagnostic of temporomandibular disorders are recommended.

Evaluation of the effectiveness of different puncture points for second cannula in double puncture arthrocentesis of temporomandibular joint

The study at checking if treatment outcomes in double puncture temporomandibular joint (TMJ) arthrocentesis (DPTMJA) changed when the puncture points of the second cannula punctate were changed. Using a retrospective cohort study design, the investigators enrolled a sample of temporomandibular joint disorder (TMD, internal derangement) patients receiving DPTMJA. The decision of whether to perform a modified or traditional arthrocentesis was made by the patients: Patients who accepted the close cannula relationship were evaluated as group 1 (modification group), and those who did not agree as group 2 (traditional group). The predictor variable was puncture points of the second cannula (close to vs. far from the first cannula; group 1 and 2, respectively). The main outcome variables included maximum mouth opening (MMO), and pain assessed using a Likert-type (0-10) visual analogue scale (VAS) before treatment and at 1st day and 3rd months intervals. Appropriate statistics were computed using P < .05 was considered significant. The study sample comprised 32 patients (93.8% females; 50% in each study arm) with an average age of 36.9 ± 15.3 years (range, 18-78). Although, patient age and gender, and baseline VAS in both groups were not significant different (P > .05), the baseline MMO in group 2 was significant higher than that in group 1 (P = .03). The within-group analyses demonstrated the significant improvement of both MMO and VAS at postoperative month 3 (P < .05). However, the between-group analyses rejected the significant differences between the 2 groups at day 1 and month 3 (P > .05). Within the limitations of the study the choice of one or the other technique should be left to the discretion of the surgeon.

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.

Clinical and ultrasonographic evaluation of ultrasound-guided single puncture temporomandibular joint arthrocentesis

Objective: To evaluate the effects of successful TMJ treatment on relief of pain, improvement of mandibular movement and capsular width with clinical and ultrasonography (US) findings. In this study, TMJ changes were evaluated by clinical and US examination after US-guided single-puncture arthrocentesis, which represents a novel approach.Methods: Clinical measurements were obtained before each procedure and at 1 day, 7 days, and 3 months thereafter. Capsular width was measured via the US at the 3-month follow-up.Results: Significant improvements were evident at the short term of 3 months post-arthrocentesis with supportive treatment, including splint therapy and jaw exercises.Conclusion: Arthrocentesis in conjunction with splint therapy and jaw exercises demonstrated significant clinical improvement at the short-term follow-up of 3 months. US imaging can be helpful for follow-up evaluation of the pre- and post-treatment capsule width. Longer follow-up studies are necessary to validate the effectiveness of this treatment protocol.

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.

Puncture points related to the tragal-lateral canthus line in conventional temporomandibular joint arthrocentesis: are they accurate? A cadaver study

PURPOSE

To evaluate the technical success of conventional TMJ arthrocentesis in cadavers, using the tragal-lateral canthus line as an anatomical reference for the puncture points.

METHODS

Ten formalin-treated and 8 fresh cadavers were submitted to the arthrocentesis. A point located 10 mm anteriorly and 2 mm inferiorly to the beginning of the tragal-lateral canthus line (A) and another point 20 mm anteriorly and 10 mm inferiorly (B) were demarked on the cadavers' skin. Following, 1 mL of methylene blue solution was injected through the needle at point A, and then another needle was placed at point B. Saline solution was injected through the first needle, identifying a free flow of bluish solution.

RESULTS

Concerning the formalin-treated cadavers, TMJ arthrocentesis was not successfully performed in any case (0%). In the fresh cadavers, the procedure was properly conducted bilaterally in only one case (12.5%) and unilaterally in 3 cases (37.5%), 2 on the left side (25.0%) and one on the right (12.5%).

CONCLUSION

The traditional points related to the tragal-lateral canthus line seemed not to be accurate references for the insertion of the needles in conventional TMJ arthrocentesis when 1 mL of solution is used initially and the maximum mouth opening is not achieved.

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.

Irrigation fluid volume requirement for conventional arthrocentesis of the temporomandibular joint: a cadaver study

Temporomandibular joint (TMJ) arthrocentesis is considered an effective and minimally invasive procedure for certain conditions related to temporomandibular disorders. The ideal irrigation volume for arthrocentesis lavage has not yet been defined. Therefore, the aim of this study was to evaluate the efficacy of different saline solution volumes in removing methylene blue from the TMJ space of fresh human cadavers. Nineteen cadavers were selected and 1ml of 10μM methylene blue solution was injected into the upper joint space unilaterally. Conventional arthrocentesis was then conducted by infusion of 300ml of 0.9% saline solution, collecting a 1-ml sample from the drained quantity for every 25ml injected. Finally, the samples were assayed by measuring photo absorbance of the methylene blue solution. There was a statistically significant difference between the irrigation volumes regarding the removal of methylene blue solution from the joint space (P<0.001), specifically between the first 25 ml and 200 ml (P=0.014), 225 ml (P=0.001), 250 ml (P<0.001), and 275 ml (P=0.001). Based on this ex vivo study, a 25-ml perfusion volume appears to be sufficient for joint lavage in conventional arthrocentesis of the TMJ.

Computer-Guided Arthrocentesis Using Patient-Specific Guides: A Novel Protocol for Treatment of Internal Derangement of the Temporomandibular Joint

PURPOSE

The aim of the present study was to evaluate the accuracy of 3-dimensionally (3D) printed patient-specific guides (PSGs) to direct the passage of inlet and outlet needles into the superior joint spaces of the temporomandibular joint (TMJ) in preparation for arthrocentesis.

PATIENTS AND METHODS

The present study included 10 patients with 14 TMJs with anterior disc displacement with reduction. A 3D PSG was designed for each patient to lead the inlet and outlet needles into the superior joint space of the TMJ. The PSGs were implemented, and their accuracy for guiding the needles into the superior joint space was assessed.

RESULTS

Both arthroscopic verification and clinical evaluation revealed that direct access to all the predetermined anatomic locations inside the TMJs had been obtained, except for 1 case, during which the patient had failed to maintain the maximum mouth opening during computed tomography scanning.

CONCLUSIONS

The virtual computer-initiated PSGs were beneficial for directing the passage of the needles into the superior joint space.

Evaluation of the efficacy of different treatment modalities for painful temporomandibular disorders

The purpose of this study was to clinically evaluate the efficacies of three treatment methods and to compare their outcomes in patients with painful disc displacement. The study group comprised 45 patients with unilateral temporomandibular disorders who fell into Axis I group II (with limited mouth opening) of the Research Diagnostic Criteria for Temporomandibular Disorders. Magnetic resonance imaging was used for definitive diagnosis. The patients were divided randomly into three groups according to the treatment method: splint therapy, splint therapy with ultrasound-guided arthrocentesis, and splint therapy with low-level laser therapy. Patients were followed up after treatment for 6 months. The groups were compared in terms of pain and functional jaw movements (unassisted mouth opening without pain, maximum unassisted mouth opening, and contralateral movements). At the end of treatment, functional jaw movements were significantly increased while pain values were significantly decreased in all groups (P<0.05). Group 2 had a quicker improvement in terms of mouth opening scores at the end of the first month, and unassisted mouth opening without pain was found to be more than 35 millimetres in all groups at the end of 6 months. All treatment modalities showed effective results on pain and functional jaw movements in the treatment of temporomandibular disorders.

A complex treatment of irreducible displacement of the temporomandibular joint disc and myofascial pain disorders with the use of botulinum toxin

Background. An irreducible displacement of the articular disc (IDD) is one of the TMJ conditions characterized by complexity of clinical manifestations, severity and is always accompanied by myofascial pain disorders. Objective. To improve the results of treatment of patients with TMJ IDD and myofascial pain syndromes. Methods. We performed a clinical examination and treatment of 38 patients with irreducible displacement of the TMJ articular disc and myofascial pain disorders. As additional research methods, we used CBCT, MRI, EMG. A step-by-step treatment was conducted, including a drug therapy, injection of botulinum toxin type A (BTA) in the masticatory, temporal, lateral pterygoid muscles (LPM) bilaterally; repositional splint therapy; arthrocentesis with the lavage of both articular spaces. Results. The overall effectiveness of the treatment was 97.4%. Out of 38 patients, 34 (89.5%) were treated without arthrocentesis with the complete restoration of the mandibular movement volume and elimination of pain syndrome. Conclusions. An effective system has been developed for a sequential complex treatment of TMJ IDD; a new technique has been developed for a periarticular injection access to the LPM allowing administration of a drug to its upper and lower heads. The high efficiency of BTA injections in the treatment of TMJ IDD is due to the mandatory drug administration into 3 muscles: masticatory, temporal and lateral pterygoid. In the treatment of TMJ IDD, arthrocentesis is effective with lavage of the lower and upper articular spaces.

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

PURPOSE

Temporomandibular joint (TMJ) disc derangement is defined as a malpositioning of the articular disc relative to the condyle and eminence. Arthrocentesis of the TMJ is considered by many as the first-line surgical treatment for patients who do not respond to conservative treatment. The aim of this study is to assist needle insertion for temporomandibular joint arthrocentesis using ultrasonography.

MATERIALS AND METHOD

Twenty patients who required arthrocentesis of the TMJ were randomly assigned to two groups A and B undergoing single-puncture arthrocentesis with modified double-lumen single-barrel needle and ultrasound-guided single-puncture arthrocentesis using modified double-lumen single-barrel needle (n = 10 in each group). The number of attempts of needle manipulation, duration of the operative procedural time, and visual analog (VAS) scale score for pain to assess surgical discomfort were the main outcome variables.

RESULTS

None of the patients in either group developed any complication with no significant difference in VAS score for pain between the two study groups. The number of attempts for needle manipulation (mean ± SD) for group A was 2.20 ± 0.789, and for group B, it was 1.10 ± 0.316 (p value, 0.0007); operative procedural time (mean ± SD) for group A was 18.5 ± 3.171 min, and for group B, it was 13.1 ± 1.663 (p value, 0.0002) which was significantly lesser in group A than in group B. The sentence signifies that the number of attempts that was required to re-insert the needle to enter the joint space in Ultrasound guided and conventional method of arthrocentesis.

CONCLUSION

Ultrasound-guided single-puncture arthrocentesis using a customized needle is a promising method to perform joint lavage with minimal trauma and in a precise manner.

Augmented reality for temporomandibular joint arthrocentesis: a cadaver study

Temporomandibular joint (TMJ) arthroscopic procedures require the identification of a skin puncture point. The puncture point is conventionally estimated using the surface anatomy of the canthal-tragus line. However, the conventional puncture technique has been reported to fail at the first attempt in 18% of cases. We propose an augmented reality (AR) system-based method to identify the puncture point on the skin. A three-dimensional virtual model was reconstructed from computed tomography images of a cadaver head, and its rendered image was superimposed on the cadaver head before skin puncture. The skin puncture point was marked on the skin under the guidance of the AR system. The TMJ was punctured through the mark and the endoscope was introduced through the puncture point. The outcome of the procedure was classified as successful or unsuccessful based on the visualization of the TMJ. The system was applied on the left and right sides of three cadaver heads. Puncture with the AR method was successful in all six cases. This study presents a system to provide AR visualization during TMJ arthrocentesis to increase the precision of skin puncture. However, a comparative study of the AR method with the conventional method is required to evaluate its advantages.

Comparison of clinical outcomes of treatment of dysfunction of the temporomandibular joint between conventional and ultrasound-guided arthrocentesis

Patients with disorders of the temporomandibular joint (TMJ) who do not respond to non-operative treatment may require invasive procedures such as arthrocentesis and arthroscopy. We divided 80 patients with dysfunction of the TMJ into two groups: a control group who were treated by conventional arthrocentesis, and an experimental group who were treated by ultrasound-guided arthrocentesis. Both groups were monitored three days, one week, and one month postoperatively and the clinical outcomes compared. The experimental group had a significant reduction in the degree of pain in the immediate postoperative period (p=0.015). However, ultrasound-guided arthrocentesis showed no significant improvement in symptoms overall compared with conventional arthrocentesis. Both techniques seem to be effective in the management of dysfunction of the TMJ.

Vertiginous crisis following temporomandibular joint athrocentesis: a case report

Temporomandibular joint arthrocentesis and arthroscopy have recently exceeded open surgeries for disorders that failed to respond to conservative treatment. The efficacy of arthrocentesis in reestablishing normal mouth opening and reducing pain and dysfunctions is now commonly accepted, but in contrast to arthroscopy, there are no large series studies on arthrocentesis complications. We report the major complication occurred in our experience: a case of a patient that complained of a violent vertigo, without hearing disorders, following the procedure.