Arthrocentesis—Incentives for Using This Minimally Invasive Approach for Temporomandibular Disorders

Comparing anxiety levels and patient comfort during single- and double-puncture arthrocentesis

OBJECTIVE

To compare the comfort and anxiety levels of patients undergoing two different temporomandibular joint (TMJ) arthrocentesis techniques.

METHODS

Fifty female patients were randomly assigned into two groups of 25 based on the treatment modality: Group 1, single-puncture Type-1 arthrocentesis (SPA); Group 2, conventional double-puncture arthrocentesis (DPA). Preoperative and postoperative anxiety was scored with the State-Trait Anxiety Inventory-S (STAI-S) questionnaire. Blood pressure and heart rate were assessed preoperatively during the application of local anesthesia and at needle insertion into the joint cavity, the 5th and 10th minute of the procedure, and end of the procedure.

RESULTS

STAI-S scores were lower postoperative than preoperative in both groups. Heart rate and mean arterial pressure were highest during anesthesia and needle insertion (p < 0.005). Changes in heart rate, mean arterial pressure, and STAI-S scores were statistically similar between the groups.

CONCLUSION

DPA and SPA were tolerated similarly by the patients.

Temporomandibular Joint Facts and Foibles

The purpose of this article is to dispel some of the major foibles associated with the etiology and management of TMJ disorders, while presenting some of the facts based on the scientific literature to date. To appreciate this kind of update, the reader must be an "out of the box thinker" which requires openness to new ways of seeing the world and a willingness to accept new concepts based on evolving evidence.

Arthrocentesis Versus Level 1 Arthroscopy in Internal Derangement of Temporomandibular Joint

Introduction

Internal derangement of the temporomandibular joint is defined as an abnormal position of the articular disc in relation with mandibular condyle and articular eminence presenting as disc displacement with or without reduction.

Methodology

This study was conducted on thirty patients diagnosed with Internal derangement of TMJ consisting of 8 males and 22 females averaging 34.6 years. Two groups Conventional Arthrocentesis (Group A) and Level 1 Arthroscopy (Group B) consisted of 15 cases each divided alternately. Clinical evaluation parameters included VAS for pain, maximal interincisal opening, deviation on mouth opening, range of motion including lateral excursion & protrusion movements recorded at 1 week, 1 month & 6 months postoperatively. Wilke's Staging according to MRI findings was recorded preoperatively and 6 months postoperatively.

Results

At 6 month follow-up, average reduction in VAS for pain & deviation on mouth opening was 72.43% & 24.73% in Group A and 77.66% & 65.41% in Group B, respectively. Average increase in MIO, right & left excursion & protrusion movements was 29.55%, 31.33%, 20.12% & 32.45% in Group A and 34.94%, 41.37%, 39.29% and 36.51% in Group B, respectively. Improved results were obtained clinically for all Wilke's stages in both groups with more number of patients improving in Group B.

Conclusion

On comparing results, improvement was observed in various clinical evaluation parameters of both the groups at 6 months follow-up. However, statistically significant & better results were obtained for the Arthroscopy group.

Arthrocentesis vs conservative therapy for the management of TMJ disorders: A systematic review and meta-analysis

OBJECTIVE

Arthrocentesis is being widely used as an invasive treatment modality for managing temporomandibular joint (TMJ) disorders. The current review aimed to assess if arthrocentesis as the first line of therapy leads to better outcomes as compared to conservative management of TMJ disorders.

METHODS

PubMed, Scopus, Embase, Web of Science, and CENTRAL were searched up to 20th June 2022 for randomized controlled trials comparing TMJ arthrocentesis vs conservative management as first-line therapy for TMJ disorders.

RESULTS

Eight trials were included. Our analysis indicated significantly reduced pain scores in patients undergoing TMJ arthrocentesis as compared to conservative therapy at 1 month (MD: -0.82 95% CI: -1.43, -0.20 I²=56% p = 0.01) and 6 months (MD: -1.38 95% CI: -2.45, -0.32 I²=86% p = 0.01), but not at 3 months of follow-up (MD: -0.66 95% CI: -1.68, 0.37 I²=82% p = 0.21). The results were not stable on sensitivity analysis. There was no difference in MMO between the TMJ arthrocentesis and conservative therapy groups at 1 month (MD: -0.06 95% CI: -3.67, 3.54 I²=88% p = 0.97), 3 months (MD: -0.35 95% CI: -3.95, 3.25 I²=89% p = 0.85) and 6 months (MD: 0.00 95% CI: -3.34, 3.34 I²=86% p = 0.10).

CONCLUSION

Analysis of a small number of trials with high inter-study heterogeneity indicates that first line TMJ arthrocentesis may result in a significant but small improvement in pain scores but without any additional improvement in MMO as compared to conservative therapies. Current evidence does not provide strong support for the use of TMJ arthrocentesis as the first line of therapy for TMDs.

Validity of IL-6 and Arthrocentesis in the Cause and Management of Internal Derangement of TMJ

Purpose

The aim of this clinical study was to evaluate the level of Interleukine-6 (IL-6), pre and post arthrocentesis to validate it as a biomarker in the Internal Derangement (ID) of TMJ.

Material and Methods

This study included 30 patients (20 females and 10 males) of Temporo-Mandibular Dysfunction (TMD) with Disc displacement without reduction (DDwoR) Wilkes stage III, who were refractory to conservative management. Arthrocentesis was performed as a therapeutic modality. Synovial fluid aspirates were obtained prior to arthrocentesis and post arthrocentesis with 300 ml of Ringer Lactate solution into the superior joint compartment for the assessment of level of IL-6. The clinical parameters used for correlating the level of IL-6 were degree of pain (VAS I), chewing ability (VAS II), Maximal Mouth Opening (MMO) in both pre and post op phase with the follow-up period of 01 day, 01 week, 01 month, 03 month and 06 month and the results were compared. ELISA was performed to analyze the levels of IL-6 in the aspirates. The clinical parameters and the level of IL-6 were recorded and analyzed statistically.

Results

The study showed ID of TMJ (Wilkes stage III) s are more prevalent in females especially in the fourth decades of life with the mean age of 38.4 years. The post operative assessment in terms of pain, maximum mouth opening, lateral movements of the mandible and the levels of IL-6 were found to be statistically significant with a P value <0.01.

Conclusion

This study validates the role of IL-6 as a definitive biomarker for the pathogenesis of ID of TMJ Wilkes stage III and arthrocentesis proved to be a minimally invasive therapeutic modality for its management.

Comparison of intraarticular injection of platelet-rich plasma following arthrocentesis, with sodium hyaluronate and conventional arthrocentesis for management of internal derangement of temporomandibular joint

Aim:

The aim of the study is to compare the efficacy of platelet-rich plasma (PRP) for the management of internal derangement of temporomandibular joint (TMJ).

Settings and Design:

Thirty-three patients were selected from the pool of patients visiting the department of oral and maxillofacial surgery. Simple randomization was done.

Subjects and Methods:

Patients with anterior disc displacement without reduction (DDWOR) were indicated for arthrocentesis. Group A patients are treated with PRP, Group B patients with sodium hyaluronate following arthrocentesis, and Group C patients were treated with arthrocentesis alone. Postoperative pain and maximal incisal opening are the primary outcomes evaluated.

Statistical Analysis Used:

The collected data were analyzed with IBM. SPSS statistics software 23.0 version and the one-way ANOVA with Tukey's post hoc test were used.

Results:

The mean age is 33 years, with female predominance. The statistical significant differences (P < 0.05) in pain and MIO between the 3 groups at the end of 3^rdweek, 4^thweek, and 3^rd month postoperatively are seen in PRP group comparative to other groups.

Conclusions:

Our study has concluded that the intraarticular injection of PRP is an effective management for anterior DDWOR of TMJ than intraarticular injection of sodium hyaluronate and arthrocentesis in, reducing the pain and improving the interincisal distance in patients with DDWOR, thus providing a rapid recovery and improved quality of life.

An additional lysis procedure during arthrocentesis of the temporomandibular joint

BACKGROUND

Arthrocentesis of the temporomandibular joint (TMJ) is an easy, highly efficient, minimally invasive procedure for treating temporomandibular joint disorders (TMDs). However, in some cases of mouth opening limitation (MOL), routine arthrocentesis is ineffective due to severe fibrotic adhesion in the superior joint space of the TMJ. In this condition, mechanical lysis of the adhesions might be needed to resolve the MOL, as well as other symptoms, such as chronic pain. Currently, this can be achieved by arthroscopic surgery or open TMJ surgery. The objective of this study was to introduce and evaluate our trial of the adhesion lysis procedure during arthrocentesis of the TMJ using normal 18-gauge needles.

RESULTS

In this study, 40 patients with MOL due to disc derangement underwent conventional arthrocentesis at first and then physical detachment was conducted using the same needle. The change in maximum mouth opening (MMO) and the pain at the TMJ were recorded before, during, and after treatment according to our protocol. The mean increase in MMO after conventional arthrocentesis was 6.6 ± 4.2mm. The mean increase in MMO after the detachment procedure with the same needle was 4.2 ± 2.0 mm. The MMO in ten patients was significantly increased after the detachment procedure than after arthrocentesis alone. In all cases, the pain intensity in the TMJ significantly decreased over time, whereas the MMO increased over time. No adverse effect was observed in all joints during our observation periods.

CONCLUSION

We confirmed that our simple lysis procedure with the same needle of the arthrocentesis of the TMJ could not only improve the MMO more than after a conventional arthrocentesis but also resolve severe adhesion of the joint space that was ineffective by conventional arthrocentesis. Although this additional lysis procedure is simple, it might reduce the number of cases of more invasive procedures such as arthroscopic surgery or open TMJ surgery.

Does arthroscopy cause more complications than arthrocentesis in patients with internal temporomandibular joint disorders? Systematic review and meta-analysis

The objective of this study was to compare, through a systematic review with a meta-analysis, the relative risks of arthroscopy and arthrocentesis in the temporomandibular joint. MEDLINE/PUBMED, EMBASE, Cochrane Library (CENTRAL), Web of Science, SCOPUS were the researched databases, as well as grey literature and manual searches. The search results showed 656 studies, but only five met the eligibility criteria. The evaluation included 194 joints (104 patients): 101 were arthroscopy and 93 arthrocentesis. Complications were observed in four patients undergoing arthroscopy (two with temporary facial paralysis and two with prolonged cervical oedema) and in three patients undergoing arthrocentesis (two with severe bradycardia and one with prolonged cervical oedema). The meta-analysis demonstrated a relative risk of 0.99 for complications after arthroscopy compared with arthrocentesis, but the results showed no statistical differences. In conclusion, this systematic review suggests that there is no increased risk of complications with arthroscopy than arthrocentesis. When complications were present, they were temporary.

Is Arthroscopic Disk Repositioning Equally Efficacious to Open Disk Repositioning? A Systematic Review

PURPOSE

Temporomandibular joint disc repositioning surgery is 1 of the treatment modalities used for treating anterior disc displacement of the temporomandibular joint. The procedure can be arthroscopic disc repositioning or open disc repositioning. This systematic review measured and compared the efficacy of arthroscopic and open disc repositioning procedures.

MATERIALS AND METHODS

The authors conducted a systematic review without meta-analysis by performing a literature search electronically and manually covering arthroscopic and open disc repositioning studies published up to July 2020 in Pubmed, Embase, and Cochrane databases. Surgical outcomes such as changes in maximal incisal opening (MIO) and pain scores, temporomandibular joint noises, diet consistency, malocclusion, and postoperative complications were extracted and analyzed.

RESULTS

A total of 28 studies were included in the review and split into those assessing open disc repositioning (n = 13) and those assessing arthroscopic disc repositioning (n = 15). The average age of the study patients in the included studies was 31.5 ± 6.8 years, and women represented 83.3% of the study population. Both arthroscopic and open disc repositioning showed to be efficacious in reducing pain and increasing MIO. Due to heterogeneity in study designs and data reporting between the studies, no quantitative analysis was performed, and the groups were not directly compared.

CONCLUSIONS

Both arthroscopic and open disc repositioning led to significant improvements in clinical outcomes based on pain scores and MIO. This study highlights the need for comparative studies of the 2 techniques with well-documented case selection including standardized diagnosis based on Wilkes stages and rigorous outcomes assessment including patient reported outcomes.

Treatment of Temporomandibular Joint Arthritis with Triamcinolone Acetonide and Hyaluronic Acid Injection: An Observational Study

Temporomandibular joint (TMJ) arthritis is a common cause of orofacial pain with distressing symptoms. The patients most commonly females are often anxious and worried due to the typical gritty sound produced during chewing moments. In other cases there is pain followed by decreased mouth opening. Currently the treatment is not standardised though the clinicians are treating these disorders either by oral medications; splintage or by injections. Though local injection of Triamcinolone acetonide and Hyaluronic acid is an innovative therapy yet it is elusive of much research. The main aim of the present study is to evaluate the efficacy of with Triamcinolone acetonide and Hyaluronic acid in treating temporomandibular joint arthritis. The present study is a prospective non randomized clinical trial of 100 patients in a tertiary referral centre. The patients diagnosed with temporomandibular joint arthritis were treated with local infiltration of 40 mg triamcinolone acetonide along with 20 mg of hyaluronic acid; one injection every week for 4 weeks. The pre-treatment and post-treatment data was compared using student paired t test and Mann-Whitney U test. Majority of the patients showed relief in symptoms like pain (87/96) and clicking sounds (81/88) and the difference was statistically significant (p < 0.05). Though other symptoms like restrictive mouth opening; discomfort on lateral and medial movement were also relieved in 9/15 patients and 21/23 patients respectively however the difference was not statistically significant. We highly recommend the use of Triamcinolone acetonide and hyaluronic acid injection in TMJ arthritis as it helps in relieving pain and clicking of sound in majority of the patients. The treatment is an out-patient department procedure with almost no side effects in most of the patients. The cost effectiveness of the treatment is another benefit.

Do intra-articular injections of analgesics improve outcomes after temporomandibular joint arthrocentesis?: A systematic review and meta-analysis

OBJECTIVES

Intra-articular analgesics are increasingly being used after temporomandibular joint (TMJ) arthrocentesis but without clear evidence on its efficacy. The aim of this study was to review the role of intra-articular analgesic injected after TMJ arthrocentesis in improving post-operative outcomes.

METHODS

PubMed, Embase, Scopus, BioMed Central, CENTRAL and Google Scholar databases were searched from inception up to 15th April 2020. Randomised controlled trials (RCTs) on adult patients with temporomandibular joint disorders (TMDs) comparing any intra-articular analgesic with control after arthrocentesis were included. Risk of bias was assessed by Cochrane Collaboration's Risk of Bias-2 tool.

RESULTS

Nine RCTs were included. Four studies used non-steroidal anti-inflammatory drugs (NSAIDs) and five used opioids after arthrocentesis. Descriptive analysis of NSAID studies indicated that intra-articular NSAIDs may not improve pain and maximal mouth opening (MMO) after TMJ arthrocentesis. Meta-analysis indicated a statistically significant reduction of pain with the use of opioids at 1 week, 1, 3, and 6 months. Similarly, MMO was significantly improved with intra-articular opioids at 1 week, 1 and 6 months. Data were analysed from a limited number of studies with a small sample size. The quality of the included studies was low.

CONCLUSIONS

Low-quality evidence suggests that intra-articular NSAIDs may have no effect on pain and MMO after TMJ arthrocentesis. Intra-articular opioids may improve pain and MMO at short-term follow-up. Results are to be interpreted with caution considering several limitations of the review. Further high-quality trials with large sample size are needed to provide better 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.

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.

The use of arthrocentesis in patients with temporomandibular joint disc displacement without reduction

The aim of this study was to evaluate the efficacy of the use of the arthrocentesis in patients with disc displacement without reduction (DDWOR). Two hundred and thirty-four (234) patients with DDWOR were evaluated and the following data collected: gender; affected side; age (years); duration of the pain (months); patient's perception of pain (measured by Visual Analogue Scale [VAS 0-10]); maximal interincisal distance (MID) (mm); and joint disc position, determined by magnetic resonance imaging. Data were obtained in two different moments: before the arthrocentesis (M1) and three or four months later (M2). Paired t-Student Test, Scores Test and Wilcoxon Test showed a statistical significant difference (p<0.0001) between the M1 and M2 for the variables VAS and MID. There was an alteration in the joint disc position in 93.88% of the cases after arthrocentesis. There was no association between the general characteristics of the patients on the M1 and the results of the arthrocentesis (p>0.05). It can be concluded that the arthrocentesis is efficient in reducing the pain, in increasing interincisal distance, and altering the joint disc position in patients with DDWOR regardless gender, age side and pain duration.

Arthrocentesis of Temporomandibular Joint- Bridging the Gap Between Non-Surgical and Surgical Treatment

The temporomandibular joint forms one of the most fascinating and complex synovial joints in the body. Movements of the temporomandibular joint are regulated by an intricate neurological controlling mechanism, which is essential for the system to function normally and efficiently. Lack of such harmony may cause disruptive muscle behavior or structural damage to any of the components. The management of refractory pain and dysfunctions in the temporomandibular joint poses challenge both to the oral physician and maxillofacial surgeon. Arthrocentesis is a simple, minimally invasive technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. This review provides a full comprehensive overview of the literature about the various technical and prognostic aspects in relation to arthrocentesis of the temporomandibular joint, and every clinician must take into account this consideration when performing this procedure in treating patients with temporomandibular disorders.

The use of intra-articular analgesics to improve outcomes after temporomandibular joint arthrocentesis: a review

PURPOSE

The aim of this review was to assess the efficacy of intra-articular analgesics in improving outcomes after temporomandibular joint (TMJ) arthrocentesis.

MATERIAL AND METHODS

An electronic search of PubMed, Scopus, and Google scholar databases was performed for papers in English published up to December 2017 reporting the use of intra-articular analgesics after TMJ arthrocentesis. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), comparative studies, retrospective studies, and case series were included while case reports, technical reports, animal studies, cadaveric studies, and review papers were excluded.

RESULTS

Of the six studies included in the review, three were RCTs, two were randomized comparative studies, and one was a retrospective study. Both opioids and non-steroidal anti-inflammatory drugs have been used after TMJ arthrocentesis. Morphine, tramadol, fentanyl, buprenorphine, tenoxicam, and COX-2 inhibitors are the drugs used till date. Placebo-controlled studies reported improved outcomes after TMJ arthrocentesis with morphine and fentanyl but no such results with buprenorphine and tenoxicam. Tramadol was found to be better than COX-2 inhibitor. The quality of literature was not high.

CONCLUSIONS

There is inconclusive evidence in literature on the benefits of using intra-articular analgesics after TMJ arthrocentesis. Well-designed high-quality RCTs with standard protocol studying the effects of intra-articular opioids and NSAIDS after TMJ arthrocentesis would provide stronger evidence on its use.

Evaluation of effusion and articular disc positioning after two different arthrocentesis techniques in patients with temporomandibular joint disc displacement without reduction

OBJECTIVE

To evaluate joint effusion and positioning of the articular disc through magnetic resonance imaging (MRI) before and after two different arthrocentesis techniques.

METHODS

Twenty-six patients with dislocation of the articular disc without reduction (ADDwoR) were included and randomly divided into two groups: single needle arthrocentesis with distention of the upper compartment of the TMJ (A1) and conventional arthrocentesis with 2 needles (A2).

RESULTS

A statistically significant difference was observed between the different effusion categories (p = 0.009). No differences were found comparing both treatment modalities concerning the position of the mandibular condyle and the articular disc.

CONCLUSION

Conventional arthrocentesis was able to change the effusion variable, whereas the single needle arthrocentesis was not. Both techniques were responsible for altering the position of the mandibular head or the disc-head complex, projecting them to a more anterior position related to the increase in the final maximum interincisal distance.

Arthrocentesis with different irrigation volumes in patients with disc displacement without reduction: One-year follow-up

Objective: This study evaluated the clinical efficacy of arthrocentesis when varying the irrigation volume in patients with disc displacement without reduction (DDWOR). Methods: Thirty DDWOR patients were equally divided into two groups: G1 (50 mL) and G2 (200 mL). Information was compared for pain, the maximum interincisal distance (MID), protrusion, and right and left laterality. Results: Arthrocentesis was able to reduce the pain and increase the MID, protrusion, and both laterality values significantly one year after the procedure (p < 0.001) in both groups. However, comparisons between the groups revealed no significant difference (p > 0.05). Furthermore, changes in volume did not affect the arthrocentesis results (p = 0.626, odds ratio = 1.625; 95% confidence interval = 0.230-11.461). Conclusion: Arthrocentesis techniques using 50- and 200-mL irrigation volumes were both effective, with no significant differences between techniques observed after one year of follow-up.

A comparison of the effects of Methylprednisolone Acetate, Sodium Hyaluronate and Tenoxicam in the treatment of non-reducing disc displacement of the temporomandibular joint

Background

This clinical study aimed to radiologically and clinically compare the effect of intra-articular injection of methylprednisolone, sodium hyaluronate or tenoxicam following arthrocentesis with that of arthrocentesis alone in patients with non-reducing disc displacement.

Material and Methods

A total of 44 patients radiographically diagnosed with non-reducing disc displacement of the temporomandibular joint (TMJ) were randomly divided into four treatment groups, as follows: Group 1, arthrocentesis alone; Group 2, arthrocentesis plus methylprednisolone acetate; Group 3, arthrocentesis plus sodium hyaluronate; Group 4, arthrocentesis plus tenoxicam. Maximum mouth opening (MMO), lateral movement, pain severity and tenderness of TMJ and muscles of mastication on palpation were measured before treatment and at 1 week and 1, 3 and 6 months after treatment. Disc position, presence or absence of disc reduction, level of effusion, joint movement and joint space were also evaluated using magnetic resonance imaging (MRI) before treatment and 6 months after treatment.

Results

No significant differences in treatment success were found among the four groups. MRI findings did not vary significantly among the groups, but pre- and post-operative MRI findings varied significantly within all four groups (p<0.001).

Conclusions

According to the data from this study, it may be concluded that either arthrocentesis alone or arthrocentesis with methylprednisolone acetate or sodium hyaluronate or tenoxicam intra-articular injections are similarly effective and promising methods in the treatment of TMJ with non-reducing disc displacement.

Key words:Non-reduction disc displacement, arthrocentesis, methylprednisolone, sodium hyaluronate, tenoxicam.

Predictors of arthrocentesis outcome on joint effusion in patients with disk displacement without reduction

OBJECTIVES

The aim of this study was to investigate the preoperative variables in patients with articular disk displacement without reduction that may influence the results of arthrocentesis on joint effusion (JE).

STUDY DESIGN

The records of 203 patients with clinical signs and symptoms of unilateral painful disk displacement without reduction and JE, confirmed by magnetic resonance imaging (MRI), and treated with arthrocentesis were selected. The following preoperative data were recorded: sex; age; joint side; pain duration; pain intensity, measurement with the visual analogue scale; and maximum interincisal distance (MID). All patients underwent a second MRI examination 3 to 4 months postoperatively to assess JE. The sample was then divided into 2 groups: group 1 (n = 160) comprised patients with no signs of JE; and group 2 (n = 43) comprised patients still showing signs of JE. Univariate and multivariate analyses were used to compare the groups.

RESULTS

Among the studied variables, pain duration (P = .0175), pain intensity (P < .0001), and MID (P = .0085) were shown to affect arthrocentesis outcomes. The longer the pain duration (odds ratio [OR] = 0.930), the more intense was the pain (OR = 0.346), and the smaller the MID (OR = 0.562), the less were the chances of arthrocentesis completely eliminating JE.

CONCLUSIONS

Pain duration, pain intensity, and MID can be used as predictors for the effect of arthrocentesis on JE outcomes and considered during treatment planning.

Single-Needle Arthrocentesis with Upper Compartment Distension versus Conventional Two-Needle Arthrocentesis: Randomized Clinical Trial

The objective of this study was to compare single-needle arthrocentesis with distension of the upper compartment of the temporomandibular joint (TMJ) with the conventional two-needle arthrocentesis. Twenty-six patients with articular disc displacement without reduction (DDWOR) were included in the study and assigned to two groups (n = 13): single-needle arthrocentesis with distension of the upper compartment of the TMJ (1N) and conventional two-needle arthrocentesis (2N). The maximum interincisal distance (MID) and TMJ pain as measured by the visual analog scale (VAS) were compared. MID and VAS data were obtained: before (T1), seven days after (T2), fifteen days after (T3), one month after (T4), three months after (T5), six months after (T6), nine months after (T7), and one year after the arthrocentesis procedures (T8). Considering each group individually, results of the VAS scores and MID measurements showed a significant difference between T1 and T2–T8 (p < 0.001) in both groups. Between two groups, results show no significant differences (p > 0.05). Both techniques tested were effective in reducing pain and increasing MID. Due to the advantages over the conventional two-needle arthrocentesis, single-needle arthrocentesis with distension of the upper compartment should be considered as the first treatment option for patients with painful hypomobilized TMJ of DDWOR.

Clinical and radiological outcome of arthrocentesis followed by autologous blood injection for treatment of chronic recurrent temporomandibular joint dislocation

Background

This study was conducted to evaluate the functional outcome and MRI findings of arthrocentsis followed by autologous blood injection (ABI) into the joint space for management of chronic recurrent TMJ dislocation.

Material and Methods

Total ten patients with bilateral chronic recurrent condylar dislocation were included in the study. Arthrocentesis of both TMJ was performed on each patient, followed by the injection of 2 ml of autologous blood into the superior joint compartment and 1 ml onto the outer surface of the joint capsule. Preoperative and postoperative assessment included; thorough history, clinical examination of TMJ, maximal mouth opening, frequency of dislocation, TMJ radiographs (open and closed mouth position), MRI, recurrence and presence of facial nerve paralysis.

Results

At the end of 3 months follow-up 8 patients (80%) had successful outcome with no further episodes of dislocation, whereas two patients reported with recurrence. Post-operative MRI showed significant improvement after ABI, compared to pre-operative MRI. There were no degenerative changes to the bony and soft tissue components of TMJ.

Conclusions

ABI is a simple, safe, minimally invasive and cost-effective technique for treatment of chronic recurrent TMJ dislocation. MRI evaluation showed an improvement in the anatomical and spatial relationship of the osseous and soft tissue components of the TMJ.

Key words:TMJ lavage, luxation, fibrosis, magnetic resonance imaging.

Complications and post-operative sequelae of temporomandibular joint arthrocentesis

OBJECTIVE

 To evaluate intraoperative complications and postsurgical sequelae associated with arthrocentesis of the TMJ, including injection of Sodium Hyaluronate.

METHODS

This retrospective study evaluated 433 arthrocentesis procedures performed in 315 patients between January 2009 and August 2016. The authors reviewed the complications identified during the procedure and the follow-up period.

RESULTS

Temporary swelling of the periarticular tissues (95.1%) or the external auditory canal (23.5%), ipsilateral temporary open bite (68.8%), frontalis and orbicularis oculis paresis (65.1%), preauricular hematoma (0.4%), and a case of vertigo (0.2%) were the complications detected.

CONCLUSIONS

TMJ arthrocentesis remains a procedure with a minimum number of important complications. If present, complications are generally temporary, caused by the anesthetic effect or by the soft tissue edema created by the fluid extravasation created by the irrigation procedure, and can be managed on an outpatient basis.

Comparison of the efficiency of irrigation of single and double-needle techniques of temporomandibular joint arthrocentesis: A cadaver study

OBJECTIVE

To compare the efficacy of the double- and single-needle arthrocentesis techniques in removing methylene blue from the temporomandibular joint (TMJ) space.

METHODS

This study was performed in 20 TMJs from 10 fresh cadavers. A total of 1 ml of 10 μM methylene blue solution was injected into the upper joint spaces, just prior to irrigation. Ten arthrocentesis procedures were carried out using the double-needle technique, and the remaining 10 were completed using the single-needle technique. The photo-absorbance values of methylene blue solution injected into and removed from the joint space were measured at a 665 nm wavelength. Statistical analysis was performed using Shapiro-Wilks test and t-test.

RESULTS

The t-test analysis showed no statistically significant difference between the two methods in the removal of methylene blue.

CONCLUSION

According to the results of the present study, the single-needle technique may be a good alternative with the advantages of easier application in cases where it is not possible to perform the double-needle technique.

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.

Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short-Term Reduction of Temporomandibular Joint Pain After Arthrocentesis? Part 1

PURPOSE

Arthrocentesis has been used for the management of patients with temporomandibular joint (TMJ) pain, with good success. The additional use of hyaluronic acid (HA) or corticosteroid (CS) remains controversial. The purpose of this study was to compare HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis.

MATERIALS AND METHODS

This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then the instillation of HA, CS, or LR. Patients were evaluated clinically at 1 and 3 months. The primary outcome variable was pain at 1 month (by visual analog scale). Secondary outcome variables were pain at 3 months and analgesic consumption. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant.

RESULTS

One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for the final analysis. The mean age of patients in the HA, CS, and LR groups was 39.6, 44.3, and 51.8 years, respectively (P = .02). There was no difference among groups in time to follow-up at 1 month (P = .11). The mean decrease in pain in the CS group was 19% for right-side procedures (P = .12) and 36% for left-side procedures (P = .02). The mean decrease in pain in the HA group was 31% for right-side procedures (P = .01) and 34% for left-side procedures (P = .01). The mean decrease in pain in the LR group was 43% for right-side procedures (P < .01) and 37% for left-side procedures (P < .01). There was no difference in pain decrease among groups (P = .55). There was no difference in the use of narcotic (P = .52) or nonsteroidal anti-inflammatory drugs (P = .71) among groups.

CONCLUSION

Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in decreasing TMJ pain.

Arthroscopic lysis and lavage for internal derangement of the temporomandibular joint

INTRODUCTION

Arthroscopy of the temporomandibular joint (TMJ) is a valuable diagnostic and therapeutic tool for various intra-articular disorders, especially internal derangement (ID) of the TMJ.

OBJECTIVES

To evaluate the efficacy and safety of a standardized arthroscopic procedure for the treatment of two stages of ID; early/intermediate stage and intermediate/late stage.

MATERIALS AND METHODS

Retrospective analysis of medical records of 78 patients (99 joints) treated by arthroscopic lysis and lavage in the authors' department during a 5-year period. Patients were diagnosed preoperatively as suffering from ID of the TMJ. The results were stratified according to the stage of ID. Three outcome variables were used to assess efficacy of treatment: Maximal interincisal opening (MIO), level of pain on a visual analog scale (VAS), and frequency of intermittent locking episodes. In addition, complications were reported.

RESULTS

Mean MIO of the group of patients with intermediate/late stage ID increased from 27 ± 4.7 mm preoperatively to 38 ± 5.4 mm postoperatively (P < 0.0001). For the group of patients with early/intermediate stage ID, mean MIO did not change significantly after arthroscopy (39.1 ± 6.2 mm compared to 41.4 ± 5 mm, P = 0.06), however, subjective evaluation of pain on a VAS decreased from 7.2 ± 1.2 preoperatively to 3.4 ± 2.2 postoperatively (P < 0.0001), and 80% of the patients (25 of 31) denied experiencing intermittent locking episodes after treatment (P < 0.0001).

CONCLUSION

Arthroscopic lysis and lavage is a safe and effective therapeutic modality for the treatment of both mild and advanced stages of ID.

Arthrocentesis A Minimally Invasive Method for TMJ Disc Disorders - A Prospective Study

BACKGROUND

Temporomandibular joint (TMJ) disc disorders are one of the major concerns to the mankind and doctors in day to day life due to its complex nature and failure to treat these kinds of conditions successfully.

OBJECTIVES

The aim of the present study was to evaluate the efficacy of arthrocentesis in patients suffering from TMJ disc disorders.

MATERIALS AND METHODS

A total of 50 subjects suffering from TMJ disc disorders were selected and treated by arthrocentesis. The subjects were followed up for a period of one year.

RESULTS

The mean maximal mouth opening prior to arthro-centesis was 32.13mm and after the procedure the mean maximal mouth opening was 46.6mm. The mean right and left lateral movements before arthrocentesis were 7.15mm and 7.59mm respectively, and the mean right and left lateral movements of 9.49 and 9.31 respectively were present after the procedure. The mean degree of pain before arthrocentesis was 8.7, and after the procedure the mean degree of pain was 1.13 as per the visual analogue scale.

CONCLUSION

The findings of this study suggested potential utility of arthrocentesis in the management of TMJ disc disorders.

Ultra-thin Rigid diagnostic and therapeutic arthroscopy during arthrocentesis: Development and preliminary clinical findings

Arthroscopy is useful to detect early changes in the temporomandibular joint (TMJ).

Despite great advances in arthroscopy, many arthroscopic surgeries have now been replaced by arthrocentesis. We propose a simple diagnostic and therapeutic method having operative rigid ultra-thin arthroscopy with 16 gauge needle size combined with arthrocentesis.

Early magnetic resonance imaging control after temporomandibular joint arthrocentesis

Temporomandibular joint (TMJ) lysis and lavage arthrocentesis with viscosupplementation are an effective treatment for acute disc displacement (DD) without reduction. Clinical success seems to be related to multiple factors despite the lack of understanding of its mechanisms. The authors present a case report of 17-year-old women with acute open mouth limitation (12 mm), right TMJ pain-8/10 visual analog scale, right deviation when opening her mouth. The clinical and magnetic resonance imaging (MRI) diagnosis was acute DD without reduction of right TMJ. Right TMJ arthrocentesis was purposed to the patient with lysis, lavage, and viscosupplementation of the upper joint space. After 5 days, a new MRI was performed to confirm upper joint space distension and disc position. Clinical improvement was obtained 5 days and 1 month after arthrocentesis. Upper joint space increased 6 mm and the disc remained displaced. We report the first early TMJ MRI image postoperative, with measurable upper joint space.

Can MRI Observations Predict Treatment Outcome of Lavage in Patients with Painful TMJ Disc Displacement without Reduction?

Objectives

The purpose of this study was to examine magnetic resonance imaging findings in patients with painful disc displacement without reduction of the temporomandibular joint to determine whether the findings were able to predict treatment outcome of lavage and a control group treated with local anaesthesia without lavage in a short-term: 3-month perspective.

Material and Methods

Bilateral magnetic resonance images were taken of 37 patients with the clinical diagnosis of painful disc displacement without reduction. Twenty-three patients received unilateral extra-articular local anaesthetics and 14 unilateral lavage and extra-articular local anaesthetics. The primary treatment outcome defining success was reduction in pain intensity of at least 30% during jaw movement at the 3-month follow-up.

Results

Bilateral disc displacement was found in 30 patients. In 31 patients the disc on the treated side was deformed, and bilaterally in 19 patients. Osteoarthritis was observed in 28 patients, and 13 patients had bilateral changes. Thirty patients responded to treatment and 7 did not, with no difference between the two treated groups. In neither the treated nor the contralateral temporomandibular joint did treatment outcome depend on disc diagnosis, disc shape, joint effusion, or osseous diagnoses. Magnetic resonance imaging findings of disc position, disc shape, joint effusion or osseous diagnosis on the treated or contralateral side did not give information of treatment outcome.

Conclusions

Magnetic resonance imaging findings could not predict treatment outcome in patients treated with either local anaesthetics or local anaesthetics and lavage.

Single puncture arthrocentesis of temporomandibular joint; introducing a novel device: A pilot study

INTRODUCTION

Arthrocentesis is a method of irrigating the temporomandibular joint (TMJ) with a therapeutic substance. It is usually performed by dual puncture with two needles to the joint space. Several studies have shown that arthrocentesis of the upper compartment of the TMJ may be a highly effective method to restore normal maximal mouth opening and functioning. Nonetheless, the classical two needle technique has some limitations, such as the low tolerability and difficulty in performing it in the presence of intra-articular adherences. The adoption of a single puncture technique for both fluid injection and aspiration might have some advantages with respect to the traditional two needle approach in terms of time of execution, tolerability, and retention of medication.

MATERIALS AND METHODS

A single puncture technique with a self fabricated device is used to assess the efficacy of this device. This study involved 20 patients of age ranging between 20- 64 years diagnosed with TMD. Patients follow up done at 3(rd), 14(th), 45(th) and 90(th) day and assessment of pain, mouth opening, clicking and deviation done with comparison of pre and post-operative data.

RESULTS

The procedure was successful in all the patients. Most of the patients reported reduction in pain more than half of the previous value and two patients reported only moderate reduction. There was a clinically significant improvement in mouth opening, clicking and deviation.

CONCLUSION

Arthrocentesis is effective in treating TMJ internal derangement and restoring its function. Single puncture arthrocentesis, is a minimally invasive, simple, inexpensive & highly efficient procedure that can be performed under local anaesthesia.

Arthrocentesis and temporomandibular joint disorders: clinical and radiological results of a prospective study

Purpose. We evaluated the efficacy of arthrocentesis in the treatment of temporomandibular joint (TMJ) disorders. Material and Methods. In this prospective clinical case series, 30 consecutive patients with TMJ disorders underwent arthrocentesis using saline and sodium hyaluronate injections. Outcome measures were TMJ pain, maximum mouth opening (MMO), joint noises, and anatomical changes in the TMJ architecture. Patients were evaluated using cone-beam computed tomography (CBCT) and magnetic resonance imaging (MRI) at the beginning of treatment and 60 days after the last arthrocentesis. Pretreatment and posttreatment clinical parameters were compared using paired and unpaired t-tests, and McNemar's test was used to evaluate CBCT and MRI changes (P < 0.05). Results. At 1-year follow-up examinations, visual analogue scale scores indicated that pain was reduced significantly and mean postoperative MMO was increased significantly. CBCT findings showed no significant change, and MRI showed only slight reductions in inflammatory signs. Conclusions. Within the limitations of this study, we can conclude that arthrocentesis is a simple, minimally invasive procedure with a relatively low risk of complications and significant clinical benefits in patients with TMJ disorders. This trial is registered with NCT01903512.