Clinical and Radiographic Evaluation of Arthroscopic lysis and … Arthroscopic lysis and lavage...

Clinical and Radiographic Evaluation of

Arthroscopic lysis and lavage Versus Arthrocentesis

for Treatment of Temporomandibular Joint Closed

Lock

Thesis submitted for Partial Fulfillment of Requirements for the

Doctor Degree in Oral and Maxillofacial Surgery

BY

Usama Mohamed Abdel-Tawab Taema

B.D.S., Msc.

Assistant Lecturer in the Department of Oral and Maxillofacial

Surgery, Faculty of Oral and Dental Medicine,

Cairo University

2014

SUPERVISORS

Dr. Hamida Refai Hassanien

Professor of Oral and Maxillofacial Surgery

Faculty of Oral and Dental Medicine,

Cairo University,

Cairo. Egypt.

Dr. Nadia Galal

Lecturer of Oral and Maxillofacial Surgery

Faculty of Oral and Dental Medicine

Cairo University

Cairo. Egypt

Dr. Manar Hussien

Assistant professor of clinical radiology

Faculty of Medicine

Cairo University

Cairo. Egypt

DEDICATION

To the candles who lightened my life….

To my Family

Your love, encouragement, support and understanding

made all things possible.

Usama Taema

ACKNOWLEDGEMENT

First of all, thanks to ALLAH for everything he gave us.

I would like to express my deep appreciation for Dr. Hamida Refai,

Professor of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo

University for her incredible support, and constructive criticism.

I would like to express my deep appreciation for Dr. Nadia Galal,

Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo

University for her support, skillful technical assistance.

I am deeply grateful to Dr. walid El Bialy, Ass. Professor of Oral and

Maxillofacial Surgery, Faculty of Dentistry, Future University for his

generous cooperation, great support and encouragement.

I am deeply grateful to Dr. Manar Hussien, Ass. Professor of Clinical

Radiology, Faculty of Medicine, Cairo University for her generous

collaboration, great support and encouragement.

Last but not least, I would like to thank all staff members and

colleagues of the Oral and Maxillofacial Surgery department, Faculty of

Dentistry, Cairo University and all those who helped and supported me

during this work for their cooperation and kind help.

LIST OF CONTENTS

Subject Page No.

List of tables………………………………………………...v

List of figures……………………………………………….vi

List of abbreviations………………………………………..vii

Introduction……………………………………………….…1

Review of literature………………………………………….4

Aim of the study…………………………………………….55

Patients and methods……………………………………….56

Results………………………………………………………80

Discussion……………………………………..……………93

Summary and conclusions……………………..…………..99

References……………………………………..…………....101

Arabic summary………………………..…………………..132

LIST OF TABLES

Table No.

Page

No.

Table 1: Helkimo dysfunction index. 23

Table 2: Wilkes Classification of ID. 24

Table 3:TMD Research Diagnostic Criteria

(Dworkin and LeResche, 1992).

25

Table 4: Data of patients responded to conservative

therapy.

58

Table 5: Demographic data of the participants. 59

Table 6: The mean, standard deviation values

comparison between Numerical rating scores in the

two groups.

81

Table 7: The mean difference, standard deviation

(SD) values for the changes by time in mean

Numerical rating scores of Group I.

81


(SD) values for the changes by time in mean

Numerical rating scores of Group II.

81

Table 9: The mean, standard deviation (SD) values

for comparison between % decreases in Numerical

rating in the two groups.

83


for comparison between MIO in the two groups.

83


(SD) values for the changes by time in mean MIO of

Group I.

84


(SD) values for the changes by time in mean MIO of

Group II.

84

Table 13: The mean, standard deviation (SD) values for

comparison between % increases in MIO in the two groups. 85


for comparison between Helkimo index scores in the

two groups.

86


(SD) values for the changes by time in mean Helkimo

index scores of Group I.

86


(SD) values for the changes by time in mean Helkimo

index scores of Group II.

87


for comparison between % decreases in Helkimo

index in the two groups.

88

Table 18: Comparison of characteristics between the

arthroscopic and the arthrocentesis joints.

90

Table 19: MRI assessment of the therapeutic outcome

in the two groups.

91

Table 20: The frequencies (n), percentages (%) t for

comparison between the MRIs of the two groups.

91

LIST OF FIGURES

Figure No. Page

No.

Fig. 1: Questionnaire and Examination chart. 60

Fig 2: Examples for preoperative MRI for subject

selection and diagnosis.

63

Fig. 3: Arthrocentesis technique. 67

Fig.4: Arthroscopy technique. 71

Fig.5: Normal arthroscopic findings. 75

Fig.6: Abnormal arthroscopic findings. 76

Fig.7: Bar chart representing comparison between

Numerical rating scores in the two groups.

82

Fig.8: Line chart representing changes by time in mean

Numerical rating scores in the two groups.

82

Fig.9: Bar chart representing comparison between %

decreases in Numerical rating scores in the two groups.

82

Fig.10: Bar chart representing comparison between MIO

in the two groups.

84

Fig.11: Line chart representing changes by time in mean

MIO in the two groups.

85

Fig.12: Bar chart representing comparison between %

increases in MIO in the two groups.

85

Fig13: bar chart representing comparison between

Helkimo index scores in the two groups.

87

Fig14: Line chart representing changes by time in mean

Helkimo index scores.

in the two groups

88

Fig15: Bar chart representing comparison between %

decreases in Helkimo index scores in the two groups.

89

Fig16: Examples of postoperative MRI. 90

Fig17: Bar chart representing comparison between MRI

findings in the two groups.

92

LIST OF ABBREVIATIONS

TMJ: Temporomandibular joint.

TMD: Temporomandibular disorders.

ID: Internal derangement.

MRI: Magnetic resonance imaging.

SF: Synovial fluid.

CL: Closed lock.

MIO: Maximum interincisal opening.

MMO: Maximum mouth opening.

NRS: Numerical Rating score.

UJC: upper joint compartment.

ml: milliliter.

mm: millimeter.

cm: centimeter.

DDwR: Disc displacement with reduction.

DDnR: Disc displacement without reduction.

LP: Lateral Pterygoid.

ALL: Arthroscopic Lysis and Lavage.

RDC: Research Diagnostic Criteria.

INTRODUCTION

Introduction

1

Introduction

Internal derangement (ID) of the temporomandibular joint (TMJ) has been

established as a therapeutic challenge in the oral and maxillofacial clinics.

This could be attributed to the lack of complete knowledge regarding their

definite causes and pathogenesis with the subsequent evolution of numerous

concepts, theories and treatment methods leading to confusion in an already

complicated field of study.(1)

Being a painful and incapacitating condition, ID requires early

diagnosis and treatment. A wide variety of conservative and surgical

approaches for its treatment have been proposed (2-6)

.The adoption of

conservative treatment modalities is based on the assumption that

irreversible and invasive therapies are not indicated to treat symptoms in the

absence of a well identified pathogenesis pathway.(7,8)

For this reason,

surgical interventions are reserved for a minority of cases, and are usually

used with caution as well.

Considering these premises, in the case that non-surgical treatments

fail to alleviate the symptoms, minimally invasive surgical procedures were

proposed with encouraging results.(9-11)

The introduction of TMJ Arthroscopy was a turning point in the

treatment of ID. Numerous studies have since proved the value of

arthroscopy for the management of symptomatic TMJs with ID.(12-16)

Arthroscopy was first described by Ohnishi in 1975 .(17)

Holmlund et

al (18)

improved it in 1986 by establishing standardized techniques for local

anesthesia, puncture and photometric documentation. It is a minimally

invasive surgical approach used for diagnosis and treatment of patients with

Introduction

2

persistent, refractory symptoms related to TMJ pathology. Operative

arthroscopy permits surgical management of the pathology that is seen, such

as the removal of adhesions, direct injection of drugs into inflamed synovial

tissues, disc mobilization, and debridement and shaving of osteoarthritic

fibrillation tissue.(19-21)

In contrast to open surgery technique, arthroscopy

offers the surgeon several advantages in investigating and thereby improving

the diagnosis and treatment in patients with TMJ disorders more effectively.

Arthroscopy has proven to be an effective tool for exploration of the joint, in

addition blunt instruments can be used in order to lyse adhesions within the

joint.

Arthrocentesis is a natural consequence to arthroscopic lysis and

Lavage. The physical action of this technique was thought to be responsible

for its success.(22,23)

It has been proved to be simple and relatively less

invasive alternative.(12-14)

Nitzan et al.

(24) were the first to describe arthrocentesis of TMJ as a

treatment concept for severe closed lock symptoms. Orthopedic

arthrocentesis, by definition, refers to needle puncture of a joint space,

aspiration of fluid from that space and injection of a therapeutic substance.

(25,26) Arthrocentesis has proved to be a minimally invasive treatment

modality, relatively safe, reversible and it can be done on outpatients under

local anesthesia which significantly revert the mouth opening to a normal

range. It is an effective method for the re-establishment of normal disc-

condyle-fossa relationship

Introduction

3

Magnetic resonance imaging (MRI) has replaced other imaging

methods for evaluation of soft-tissue abnormalities of the joint and

surrounding region. The anatomy of the joint and the position and structure

of the intra-articular disc can be accurately visualized both at rest and in

motion. (27)

MRI is considered one of the best and most commonly used

modality in TMJ imaging , Nevertheless, poor correlation exists between

signs and symptoms and displacement of the articular disc when determined

on the basis of imaging studies alone.(28)

REVIEW

Of

LITERATURE

Review of Literature

4

REVIEW OF LITERATURE

The challenges posed by temporomandibular disorders (TMDs) span the

research spectrum, from causes to diagnosis through treatment and prevention.

Researchers throughout the health sciences are working together not only to

gain a better understanding of the temporomandibular joint (TMJ) and muscle

disease process, but also to improve quality of life for people affected by these

disorders.

Anatomy of the TMJ

The masticator system is the functional unit of the body primarily

responsible for chewing, speaking, and swallowing. The system is made up of

bones, joints, ligaments, and muscles. In addition, a complex neurologic

controlling system regulates and coordinates all these components together.

The TMJ is an integral part of the masticatory system and is one of the most

complex joints in the body.TMJ is the site of articulation between the cranial

base and mandible. It is the most active joint in the body as it needs to open

and close up to 2000 times/day to account for a full day‟s worth of chewing,

talking, swallowing, yawning, and snoring.(29,30)

It is composed of articular

disc, condyle, glenoid fossa, articular eminence, articular capsule and

temporomandibular ligaments. The TMJ differs from other joints by having

the articular surfaces as well as the central portion of the articular disk

composed of fibro cartilage instead of hyaline cartilage.(31)

Laskin has described the functional condyle disc relationship as

follows: when the mandible is at rest, the disc is located between the

antrosuperior aspect of the condyle and the posterior aspect of the eminence

with the posterior region of the disc is at twelve o'clock position. (32)

The disc


5

is an oval fibrous plate between the condyle and glenoid fossa. It divides the

intrarticular space into an upper and a lower joint compartment. It is a firm but

flexible structure that changes in position during condylar movement. The

shape of the superior surface of the disc is congruent to the glenoid fossa

while its inferior surface is congruent to the surface of the mandibular

condyle.

Anatomically the disc is biconcave and can be divided into three

regions as viewed from the sagittal plane: the anterior band, the central

intermediate zone, and the posterior band. The intermediate zone is thinnest

and is generally the area of function between the mandibular condyle and the

temporal bone.(33)

Posteriorly the disc continues into a thick double layer of

vascularized connecting tissue called the bilaminar zone (the retrodiscal

tissue). Laterally and medially the disc is not directly attached to the capsule

but fused to the medial and lateral poles of the condyle.

Both the superior and inferior joint compartments drop inferiorly

around the condyle to reach its lateral and medial poles. Thus they have a

semilunar shape, both in an antero-posterior and medio-lateral aspect. The

disc is believed to have several roles, such as, cushioning and distributing

joint loads, promoting joint stability during chewing.(34)

The disc, fossa and

condyle are surrounded by an articular fibrous capsule and ligaments.The

capsule limits the movement in the joint during mandibular articulation and

thus prevents luxation.(35,36)

TMJ ligaments can be classified into main and accessory ligaments.

The capsular and temporomandibular ligaments are considered to be the

main or principle TMJ ligaments which protect the joint by maintaining

stability and spatial relationship between the different intrarticular


6

components which is needed for optimum function. The capsule is attached

superiorly to the circumference of the glenoid fossa and the articular

eminence and inferiorly to the condylar neck separating the TMJ into two

compartments. The capsule has two components: an outer fibrous layer and

inner synovial layer. Laterally, the capsule is reinforced by another main

ligament called lateral temporomandibular ligament which is made of outer

oblique fibers and inner horizontal ones. (37)

Two additional, accessory ligaments play a role in the function of the

TMJ: the sphenomandibular ligament and the stylomandibular ligament.

These ligaments prevent excessive protrusive movements of the TMJ, even

though they are not closely associated with articulation. (38)

The synovial membrane is composed of a thin layer of vascularized

connective tissue. It lines the inner surfaces of the joint capsule and all the

surfaces not under shearing or compressive load. Its main function is to

produce synovial fluid. This fluid is composed of a plasma ultra filtrate,

sodium-hyaluronate and a few cells. Synovial fluid participates in the

nutrition of the avascular articular tissue and also lubricates the components

within the joint during movement.(31)

Biomechanics of the TMJ

This unique construction of the TMJ facilitates a mouth opening of

range from 40-60 mm as measured between the upper and lower incisors

where the free rotation of the condyle enables a mouth opening of 15-25 mm

as measured between upper and lower incisors. Then, in the upper

compartment, the free sliding of the condyle with the disc along affords a

mouth opening of 40-60 mm as well as lateral movements of up to 10 mm,

protrusive movements of up to 9mm and retrusive movements of 1mm. (39)


7

This wide range of different mandibular movements can only be

achieved by healthy strong muscles controlled by intricate neural system.

Thus, a proper neuromuscular coordination is needed to facilitate all the

mandibular movements in an accurate way without any aberration. (38,40)

The TMJ is the only joint with a rigid end point of closure, which is

defined by the occlusal surfaces of the teeth. The mandible connects the left

and right TMJs into one functional unit.(40)

It is generally considered to be

load-bearing during masticatory function.(42)

Three motions occur at the mandible, depression (during mouth

opening), protrusion/retrusion (or protraction/retraction) and lateral

excursion (right and left).(43)

TMJ provides for hinging movement in one

plane which occurs in the inferior joint compartment and therefore can be

considered a ginglymoid joint. It also provides for gliding movements which

occurs in the superior joint compartment and classifies it as an arthrodial

joint. Thus it has been technically considered a ginglymoarthrodial joint.(44)

The positioning of the condyle and disc within the fossa, as well as the

constant contact between the condyle, disc, and eminence, is maintained by

continuous activity of the muscles of mastication, particularly the

supramandibular group. (33)

To conclude, TMJ is a complex highly adaptive organ which

constantly adjusts to the functional demands by remodeling and it is really

difficult to comprehend every fine detail in it. That's why it is not strange to

accept that the diseases that affect the TMJ are difficult to diagnose and thus

to treat.(45)


8

Temporomandibular disorders (TMDs):

TMDs, a medical term, was first proposed by Bell in 1982 and has

rapidly gained popularity46

.This term does not suggest merely problems that

are isolated to the joints but includes all disturbances associated with the

masticatory system.

The term TMD is an umbrella term that actually encompasses two groups

of patients: those with true pathology of the TMJ i.e arthrogenic or (TMJ

problems) and those with primary involvement of the masticatory muscles i.e.

myogenic or (myofascial pain-dysfunction syndrome(MPDS)).(47)

Much of the

difficulty encountered in the treatment of TMDs relates to the physician's

failure to distinguish between these two groups because of the similarity of

their signs and symptoms.

The masticatory muscle disorders include myofascial pain dysfunction

syndrome, myospasm, protective muscle co-contraction, and local muscle

soreness. The TMJ disorders include internal derangement (ID), structural

incompatibility of the articular surfaces as adhesions, subluxation,

dislocation as well as inflammatory TMJ disorders as arthritis, capsulitis,

retrodiscitis and osteoarthritis. 48

However, we are going to focus on only ID in our study. ID is now a

worldwide accepted and a well known anatomic disorder which may cause

functional disturbance. 49

ID is one of the most frequent disorders of TMJ. The term is generally

used to denote a mechanical fault in the joint interfering with its smooth

movement.(50-53)

The term therefore includes all types of intracapsular

interferences that obstruct smooth functional joint movements such as disc


9

derangements, disc adherences, disc adhesions, subluxations, and dislocations

of the disc–condyle complex.

ID of the TMJ is not a new pathological entity, the first reported

article describing displacement of the disc of the TMJ as a cause of TMJ

dysfunction was in 1887. (54)

Farrar, in 1972, has rebrought attention of the world to this interesting

disease which was helped by the re-introduction of TMJ arthrography by

Wilkes in 1978. 54

Nevertheless, with regard to the TMJ, the term is typically used

interchangeably with disc displacement.(55)

It has been reported that up to 70%

of persons with TMJ disorders suffer from displacement of the articular disc.

(56)

Joint disc alterations

ID has been associated with characteristic clinical findings, including

pain, joint sounds, and irregular or deviated jaw functions.(51-53)

However,

because a displaced disc does not always lead to clinical symptoms,

Stegenga and de Bont (57)

proposed to replace the word „„displacement‟‟ with

„„derangement,‟‟ which would indicate that the displaced disc actually

interferes with smooth joint movement and causes some type of dysfunction

to the individual.

A disc derangement is defined as a malpositioning of the articular disc

relative to the condyle and eminence. In a normal TMJ, the disc is positioned

over the condylar head with the posterior band situated in the 12 o‟clock

(superior to the condyle) position. Theoretically, a disc may be displaced to

varying degrees and in any direction (ie, anterior, posterior, lateral, or

medial). (58,59)


10

Disc displacement is usually anteromedial; as a result, in oblique

sagittal Magnetic resonance imaging (MRI) projections, the posterior margin

of the disc is seen to lie more anterior than the 12 o‟clock position. In

coronal projections, it is seen that the meniscus does not completely cover

the upper margin of the head of the condyle; instead, it appears displaced

towards the internal zone of the joint. Posterior displacements have been

described but are infrequent.(60,61)

However, posterior disc displacement was

believed to be retrodiscal tissues which behave and function as a joint disc

and this was attributed to articulation of the condyle on the retrodiscal

tissues, which undergo adaptation and repair processes and become fibrotic

and avascular (62,63)

With regard to clinical diagnosis and treatment, two

predominant stages of disc derangements are distinguished. The respective

conditions are called disc derangement with reduction and disc derangement

without reduction.

Disc derangement with reduction is typically defined as a condition in

which the articular disc of the TMJ is (most often anteriorly) displaced while

the mouth is closed and the teeth are together in maximal occlusion. (59, 64)

On

opening, the condyle must surpass the posterior margin of the displaced disc,

in order to secure a more anterior position. This process is referred to as

reduction which produces a sound (click) as a result of the impact of the

condyle against the central (and thinner) portion of the disc. On closing the

mouth, the disc stays behind and slips off the condyle, which may be

accompanied by a clicking sound.(59,65)

In this situation, when a click is

produced both on opening and closing the mouth, the phenomenon is

referred to as a reciprocal click.(65)

Disc derangement without reduction is defined as a condition in which

the condyle is unable to slide or snap back underneath the disc. The

(anteriorly) displaced disc thus does not reduce to its position on top of the


11

condyle during the opening movement. The disc is obstructing further

translation of the condyle and consequently the opening and contralateral

movements are impaired.(59,65)

A particular form of disc displacement without

reduction is acute lock on closing the mouth, defined as the sudden inability to

open the mouth.(66)

. In many cases these situations resolve spontaneously. The

signs and symptoms of disc displacement without reduction are in no way

specific of the disc disorder. (67)

Prevalence:

The literature reports great variability in the prevalence of the clinical

signs and symptoms of TMJ-ID with a peak age ranges between 20 and 40

years. It has been estimated between 4 - 28% of the adult population.(68)

Females are predominantly affected by these disorders. The reported female-

to-male ratio is about 3-4:1 in patients‟ populations.(69)

Women also comprise

about 80% of patients seeking treatment for joint pain.(70)

Female hormones

such as oestrogen and prolactin were thought to adversely affect the adaptive

capacity of the TMJ by tipping the balance of molecular events in favor of

catabolic or destructive tissue degradation.(71)

Disc displacement was not found in 30 infants or young children

imaged by MRI.(72)

However, asymptomatic disc displacement was

documented in 8% of juveniles with a mean age of 11years(73)

and about 30%

of adult volunteers.(74)

TMJ sounds and deviation on opening the jaw occur in

approximately 50% of otherwise asymptomatic persons; these were

considered within the range of normal and do not require treatment.(75)

Symptomatic ID of the TMJ is found in about 20% of the population.(76)

This

could be due to the observation that patients have more advanced pathology

and more disc interference on opening than asymptomatic volunteers.(77)

Despite the high incidence of ID among patients referred for surgical


12

consultation because of symptoms, only a small and yet-to-be determined

fraction of persons with ID become sufficiently symptomic to seek treatment.

Etiology/Pathogenesis

Various hypotheses have been proposed for the etiology of ID. Failure to

find disc displacement in infants and very young children suggests an

acquired nature of the condition.(78)

Nevertheless, genetic and metabolic

factors may contribute by lowering the threshold for tissue damage from

overloads (relative) or trauma and therefore may also be an important factor in

the development of ID.(79)

The pathophysiology of disc displacement is multifactorial and complex.

Under normal physiologic conditions, a balance exists in synovial joints

between tissue breakdown and repair. When the balance is disturbed by a

mechanical, biomechanical, or inflammatory insult the internal cartilaginous

remodeling system may fail, resulting in accelerated tissue breakdown.(80)

A

wide variety of insult has been implicated as etiologic factors of ID.

It was believed that Trauma is the most common etiologic factor in the

development of disc derangement.(59)

Various forms of trauma to the TMJ

structures have been related to symptoms of ID ,many theories discuss this

predicament.

The first theory suggests that Macrotrauma, such as a hit or blow to the

face, may result in direct tissue injury and immediate derangements of the

TMJ components. (81)

Oral intubation and dental/surgical procedures that

involve prolonged mouth opening or excessive forces, such as difficult

extractions, also have the propensity to cause direct tissue injury.(59)

Indirect

trauma, such as flexion-extension (whiplash) neck injuries(82)

may cause or

aggravate ID.


13

The second theory suggested functional overloading (microtrauma)

to be the underlying cause responsible for disc displacement. The articular

components of the TMJ are constructed to withstand and adapt to the

shearing forces that accompany translatory movements. However, these

tissues are not constructed in such a way that they can cope with persistent

compressive loading as, for example, that associated with chronic clenching.

Such loading can impair the integrity of the articular TMJ components,

directly or indirectly, by stimulating the generation of harmful reactive

oxidative species (ROS), which enter into rapid chemical reaction in various

tissues and destroy important molecules, such as hyaluronic acid, collagens,

and proteoglycans, an action that is claimed to predispose to disc

displacement. However, the nature of the damage and the manner by which

it affects disc displacement has not been sufficiently explained. (83)

Microtrauma such as the repetitive loading of clenching and bruxism

possibly are etiologic factors, but a clear relationship has not been

established.(84)

Bruxism is considered to be a combination of parafunctional

clenching and grinding activities exerted both during sleep and while awake,

because both phenomena are not adequately differentiated in most scientific

articles, bruxism appears to be regulated mainly centrally, not peripherally.

Up till now, repetitive activities or microtraumas, like sleep bruxism, are

considered to be important factors in the onset and perpetuation of pain in

TMD.(85)

Occlusal interferences were initially postulated as a cause of bruxism;

though at present emotional stress is considered to be the principal triggering

factor. Other factors that have been related to the origin of bruxism are certain

drugs, central nervous system disorders, and a certain genetic and/or familial

predisposition.(86)


14

Also alterations in occlusion have been identified as predisposing,

triggering or perpetuating factors (87)

. Comparisons were made of a group of

women with internal TMJ derangement versus asymptomatic control

women.(87)

The patients with disc displacement were mainly characterized

by unilateral posterior cross bite and long displacement of centric relation to

the position of maximum intercuspidation. The patients with osteoarthrosis

in turn associated an increased distance between centric relation and

maximum intercuspidation, greater over jet and a reduction in overbite.

Therefore, it was proposed that occlusal alterations may act as cofactors in

the identification of patients with ID, and that some occlusal variables may

be a consequence rather than a cause of ID.

Another theory depended on increased friction and impaired lubrication

in the TMJ as a possible cause for disc displacement. (88)

Intermittent

clicking has been claimed to be connected to chronic or intermittent severe

clenching, a disturbance that increases friction and eventually leads to disc

displacement. This implies that increasing TMJ loading may cause elevation

in the friction coefficient within the TMJ. But, how does excessive loading

affects friction within the joint? It has been argued that detrimental forces

may cause elevation in the concentrations of hyaluronic acid (gelation

phenomenon) and this might induce increased friction. Conversely,

degradation of hyaluronic acid, which is associated with a decrease in

viscosity, has also been proposed as a condition that increases friction.89

However, it should be noted that it is impossible to decide by what means

friction increases and how it then induces disc displacement from the

published material. In short, although it is generally agreed that displacement

of the TMJ disc may be associated with its inability to glide smoothly

because of increased friction or degenerative changes, the mechanism

involved in the process of increasing friction and how this causes


15

displacement of the disc remain unclear. The most accepted and appraised

theory was proposed by Nitzan in 2001(40)

where she claims that collapse of

the lubrication system does play a pivotal role in a chain of events leading up

to increasing friction coefficient within the TMJ and this might cause disc

displacement.

In synovial joints, both boundary lubrication and fluid film lubrication

are required. Boundary lubricants can be explained as those molecules which

are attached to, and cover, each articular surface within the TMJ reducing the

surface energy. While, full fluid film is the component that keeps the articular

surfaces apart.(40,90)

Thus the problem seems to be in the boundary lubricants rather in the

fluid film lubricants. A vast amount of literature is available concerning

boundary lubrication within the TMJ and from the proffered information it

emerges that surface-active phospholipids, in association with lubricin (a

glycoprotein), act as extremely efficient boundary lubricants and as protectors

of the articular surfaces.91

Now, it is mandatory to explain how does the breakdown of the

lubrication system is caused by detrimental loads on the TMJ and how does

this affect the disc position? Lubrication of the joint remains normal as long

as loading does not exceed the functional limits and its adaptive capacity is

not compromised. The major cause of collapse of the lubrication system is

overloading, which has various effects on synovial joints one of them being

a change in the continuous blood supply. On overloading of a joint, the intra-

articular pressure increases. In alert humans, voluntary clenching has

produced high intra-articular pressures in the TMJ, reaching the range of -8

to -200 mm Hg (92)

.When above -40 mm Hg, the intra-articular pressure

surpasses the peripheral arteriolar pressure and which will cause temporary

hypoxia, which is corrected by re oxygenation on cessation of the


16

overloading. Such a hypoxic-reperfusion cycle has been reported to evoke

non enzymatic release of reactive oxidative species (superoxide anions and

hydroxyl anions). Because of their very high reactivity, these reactive

oxidative species may enter into rapid chemical reactions in various tissues

or destroy important molecules. Among other effects of reactive oxidative

species in joints is inhibition of the biosynthesis of hyaluronic acid and its

degradation, causing marked reduction in synovial fluid viscosity.(93)

In its degraded form hyaluronic acid has an indirect effect on joint

lubrication. This is expressed in its inability to protect the continuity of the

surface active phospholipid layer, which is the major boundary lubricant of

the joint. The problem is exacerbated by the fact that the articular surfaces

are of high surface energy, large surface contact and increase surface

elasticity which causes an even greater friction..94

The next pertinent question is, “Which qualities inherent in increased

friction promote disc displacement? The increased friction in the upper

compartment then prevents the disc from sliding in conjunction with the

condyle. On opening of the jaw, the condyle is pulled forward by the inferior

head of the lateral pterygoid muscle, away from the slowed down disc. As a

result, the ligaments fastening the disc to the condyle are gradually stretched.

The now mobile disc gravitates slightly downward and forward. It also has

been proposed that the superior belly of the lateral pterygoid muscle

contributes to the pull of the disc anteriorly on mouth closure. Once the disc

is anteriorly displaced, during mouth opening, the condyle, which is now

located posterior to the loose disc, will gradually push it down the slope of

the eminence, displacing it further forward.40

The role of lateral pterygoid (LP) muscle in disc displacement is still

questionable as reflected by the contradiction of the findings and the


17

conclusions derived from the studies on the insertion of LP muscle inspite of

being based on cadaver dissections.(95)

Since a number of procedural

problems have been encountered that may disturbe the anatomy of the

examined joint. This muscle was also found to be the most difficult

masticatory muscle to asses.(95)

It has been proposed that clicking and/or

locking conditions arise in the TMJ through some form of lack of co-

ordination between the superior head of lateral pterygoid (SHLP) and

inferior head of lateral pterygoid (IHLP).(96)

The lack of co-ordination

between the two heads of the muscle necessitates an important role for the

SHLP in horizontal disc position, an idea that was based on the erroneous

view that the SHLP inserts entirely into the disc.

Manual traction on the SHLP in cadavers has been reported to bring

both disc and condyle forward together.(97)

However, recent evidence points

to the possibility that those SHLP fibers inserting into the disc could activate

independently of other SHLP fibres and could possibly exert forces on the

disc that are not directed simultaneously to the condyle. The possibility that

selective activation within SHLP might occur comes from data suggesting

that the SHLP is functionally heterogeneous.(98)

Local and general hypermobility were believed to play a role in the

etiology of TMD. However, the studies investigated this hypothesis were quiet

contradictory. Conti et al (99)

found no association found between the intra-arti-

cular disorders and systemic hyperlaxity, or between TMJ mobility and

systemic hypermobility.

While Kavuncu et al. (100)

reported that both local and general

hypermobility were more frequently detected in patients with TMD than in the

controls, and that the risk of TMJ dysfunction was greater if the patient

presents both alterations simultaneously.


18

In conclusion, there is not any illegible, worldwide accepted,

evidence based explanation for how does disc displacement occurs and what

are the causes of pain and limitation in these patients.

Classification of ID

The diagnostic process for TMDs is complicated by the multifactorial

etiology and multiplicity of clinical signs and symptoms characterizing such

disorders.

Several attempts were adopted to classify different subtypes of TMDs in trial

to reach a consensus among clinicians which may impact positively TMJ

research. One of the most commonly used classifications is that of Helkimo.

Helkimo (101-104)

(Table 1) published an epidemiologic index, with five

commonly observed physical signs and symptoms, to score "functional

disturbance of the masticatory system". The primary concept of Helkimo‟s

index was that it developed specifically as an epidemiologic survey

examination for investigating the prevalence of "global" TMDs and the need

for treatment. Applying this index to one of the few probability-based study

samples, Helkimo reported that only 18% of the population he studied was

free of all signs and symptoms, and that as many as 47% had at least one

severe TMD symptom. Since the percentage of the population which

voluntarily seeks treatment for TMD is much lower {i.e., closer to 5%),

many challenged the above figures as overestimating the prevalence of TMD

in the general population.

Wilkes (105,106)

classified ID based on clinical, radiographic and surgical

findings (Table 2). Wilkes divided ID into five stages, the first stage is disc

displacement with reduction (DDwR), the second stage is DDwR and

intermittent locking, and the third stage is acute disc displacement without

reduction (DDnR), the fourth stage is chronic DDnR and the fifth stage is

DDnR with degenerative arthritis.


19

The clinical hallmark of stage one DDwR is limited mouth opening,

usually accompanied by deviation of the mandible to the involved side, until

a pop or click (reduction) occurs. After the pop, the patient is able to open

the mouth full with a midline positioning of the mandible.

Stage two features all the aforementioned characteristics, plus

additional episodes of limited mouth opening or even transient subluxation,

which can last for various lengths of time. Patients may describe it as

“hitting an obstruction” when opening is attempted. The “obstruction” may

disappear spontaneously or the patient may be able to manipulate the

mandible beyond the interference. In this stage, few episodes of pain,

occasional joint tenderness and related temporal headaches, increase in

intensity of joint sounds start to be obvious. Closed lock (DDnR or the third

stage) occurs when clicking noises disappear but limited opening persists.

The patient complains of TMJ pain and chronic limited opening.

Examination will reveal deviation of the mandible to the affected side with

mouth opening and protrusive movements in unilateral cases. Stage four or

chronic closed lock is characterized by chronicity with variable episodic

pain, headaches, variable restriction of motion, and undulating course. This

undulating course can be explained as that in chronic closed lock episodes, if

the condition progresses, the condyle may steadily push the disc forward to

achieve almost normal ranges of mouth opening, in spite of the presence of a

non-reducing disc. 107-109

In the last stage, the condition becomes very severe where with

continued mandibular function, the stretched posterior attachment slowly

loses its elasticity, and the patient begins to regain some of the lost range of

motion but as the retrodiscal tissue continues to be stretched and loaded, it

becomes subject to thinning and perforation. This is the real problem since

this means that there will be bony contact between the two articulating


20

surfaces with its subsequent detrimental intraarticular effects. Stage five can

be termed osteoarthrosis (OA) which is best defined as non inflammatory

pathological process caused by increase mechanical loading of the TMJ

which causes degeneration of the articular cartlige and remodeling of the

underlying bone.110

Clinically, these patients suffer from restricted motion

with difficulty in different mandibular functions as yawing, biting and

chewing, and pain both at rest and during different mandibular movements.

Different joint sounds can also be detected as crepitus, scraping, grating and

grinding sounds which all are signs of bone to bone contact between the two

articulating surfaces of the TMJ. In severe terminal cases, the pathologic

osteolysis decreases the height of the condyle and the mandibular ramus

leading to joint instability, malocclusion and facial deformity as

apertognathia.112

Wilkes classification widespread adoption may be attributed to its

simplicity; however it is not without flaws. Wilkes classification depends on

the hypothesis that ID is a progressive disorder which is still not yet proved.

In fact, longitudinal epidemiological studies do not seem to support the idea

of progression. For ten years, Magnusson and others studied 293 subjects

with clicking. At the five-year follow-up, clicking had not changed to

locking in any of the subjects. At the 10-year follow-up, only one of the 293

subjects reported intermittent locking. 113

Additionally, de Bont observed histologically "osteoarthritic changes"

affecting the articular surfaces of the TMJ in 4 of 8 joints with normal disk

condyle relationships. These results support the idea that osteoarthritic

changes may precede disk displacement.114


21

Research Diagnostic Criteria for temporomandibular disorders

(RDC/TMD): 115

Considering the defects in the previously mentioned TMDs classifications, a

group of American researchers published the RDC/TMD in 1992 aiming to

critically revise the TMD diagnostic systems in use at that time, standardize

TMD examination procedures, establish new research diagnostic criteria for

TMDs and assess pain related disability and the psychological status of TMD

patients. The data used to develop RDC/TMD came from longitudinal

epidemiological research supported by the national institute for dental

research (NIDR) which was conducted at the university of Washington.116,117

RDC/TMD is a dual axis diagnostic system for TMDs supported by a

well-designed history and clinical examination protocol which provide

specific reliable, reproducible and valid criteria with high sensitivity and

specificity to define the most common types of TMDs.

The Axis I clinical assessment protocol is designed to render TMD

diagnoses, and the Axis II screening instruments assess psychological status

and pain-related disability. Together, Axis I and Axis II assessments constitute

a comprehensive evaluation of the TMD patient.118

(Table 3).

Dolwick (119)

proposed a classification of ID of TMJ based on the disc

morphology as an important feature of ID which may contribute to

functional impairment of the TMJ. But some categories have been

deliberately omitted because of the infrequency of occurrence; these would

include posterior and lateral disc displacements. This classification

categorized ID into four groups:

1. Deviation in form

a) Frictional disc in-coordination.

b) Articular surface defects.


22

c) Disc thinning and perforation.

2. Disc displacement

a) Partial anteromedial disc displacement.

b) Anteromedial disc displacement with reduction (partial –complete)

c) Anteromedial disc displacement with intermittent locking.

d) Anteromedial disc displacement without reduction (acute – chronic)

e) Anteromedial disc displacement with perforation of retrodiscal tissue.

3. Adhesive disc hypo-mobility.

4. Displacement of disc-condyle complex. (subluxation-dislocation)


23

Table 1: Helkimo dysfunction index

A. Mobility of the mandible

Maximum mouth opening

Maximum laterotrusion ,right left each

Maximum protrusion

Degree of limitation of mobility

0 point : clinically normal mobility

1- 4 points : moderate dysfunction

5 – 20 points : serious dysfunction

>40 mm

31-39 mm

< 30 mm

7 mm

4 – 6 mm

0 – 3 mm

0 points

1 point

5 points

0 points

1 point

5 points

B – TMJ function

No noises , mandibular deviation up tp 2 mm on opening and closing

Noises and deviation greater than 2 mm

Dysfunction and/or lock jaw

0 points

1 point

5 points

C- Muscular system

No tenderness at palpation

Tenderness at palpation of 1 – 3 muscles

Tenderness of more than 3 muscles

0 points

1 point

5 points

D – TMJ arthralgia

No tenderness at palpation

Tenderness laterally

Tenderness dorsally

0 points

1 point

5 points

E – Pain with motion of the mandible

Painless motion , opening , laterotrusion and mediotrusion

Pain at one movement

Pain at more than one movement

0 point

1point

5 points

Sum of A , B , C , D and E : Dysfunction index Di

0 – point : clinically symptoms

1-4 points : slight dysfunction

5 – 9 points : moderate dysfunction

10 – 20 points : severe dysfunction

Di 0

Di 1

Di 2

Di 3


24

Table 2: Wilkes Classification of ID

Early stage

Clinical

No significant mechanical symptoms, other than reciprocal clicking (early in opening movement, late in

closing movement, and soft in intensity); No pain or limitation on opening motion.

Radiologic Slight forward displacement, good anatomic contour of disc, normal tomograms.

Surgical Normal anatomic forms, slight anterior displacement, passive in coordinate (clicking) demonstrable.

Early / intermediate stage

Clinical

First few episodes of pain, occasional joint tenderness and related temporal headaches, beginning major

mechanical problems, increase in intensity of clicking sounds, joint sounds later in opening movement,

and beginning transient subluxation or joint catching and locking .

Radiologic Slight forward displacement, slight thickening of posterior edge or beginning anatomic deformity of disc,

normal tomograms.

Surgical Anterior displacement, early anatomic deformity (slight to mid thickening of posterior edge), and well-

defined central articular area.

Intermediate stage

Clinical

Multiple episodes of pain, joint tenderness, temporal headaches, major mechanical symptoms, transient

catching, locking ,and sustained locking (closed locks), restriction of motion, and difficulty (pain) with

function.

Radiologic Anterior displacement with significant anatomic deformity/prolepses of disc (moderate to marked

thickening of posterior edge), normal tomograms.

Surgical

Marked anatomic deformity with displacement, variable adhesions (anterior, lateral, and posterior

recesses), and no hard tissue changes.

Intermediate /late stage

Clinical

Characterized by chronicity with variable and episodic pain, headaches, variable restriction of motion,

and undulating course.

Radiologic Increase in severity over intermediate stage, abnormal tomograms, and early to moderate degenerative

remodeling hard tissue changes.

Surgical Increase in severity over intermediate stage, hard tissue degenerative remodeling changes of both bearing

surfaces, osteophytic projections , multiple adhesions (lateral , posterior recesses), and no perforation of

disc or attachment.

Late stage

Clinical

Characterized by crepitus on examination; scraping, grating, grinding symptoms; variable and episodic

pain; chronic restriction of motion; and difficulty with function.

Radiologic Anterior displacement, perforation with simultaneous filling of upper and lower compartments, filling

defects, gross anatomic deformity disc and hard tissues, abnormal tomograms, and essentially

degenerative arthritic changes.

Surgical Gross degenerative changes of disc and hard tissues, perforation of posterior attachment. Erosions of

bearing surfaces, and multiple adhesions equivalent to degenerative arthritis (sclerosis, flattening and

anvil shaped condyle, osteophytic projections, and sub cortical cystic formation).


25

Table 3: TMD Research Diagnostic Criteria

AXIS I Diagnostic Categories

I. Muscle Diagnoses

a. Myofascial pain.

b. Myofascial pain with limited opening.

II. Disc Displacements

a. Disc displacement with reduction.

b. Disc displacement without reduction, with limited pening.

c. Disc displacement without reduction, without limited opening.

III. Arthralgia, Arthritis, Arthosis

a. Arthralgia.

b. Osteoarthritis of the TMJ.

c. Osteoarthrosis of the TMJ.

AXIS II Disability measures.

a. Pain intensity and disability.

b. Depression (depression and vegetative symptom scales)

c. Limitations related to mandibular functioning.


26

Clinical manifestations:

ID has been associated with characteristic clinical findings, including

pain, joint sounds, and irregular or deviated jaw functions. (51-53)

However,

pain is the most important symptom of ID for both the patient and the

clinician, and is the main reason why patients with ID seek medical help.

Joint pain

The diagnosis of TMJ pain is challenging because the close proximity

to other anatomic structures makes it difficult to pinpoint the origin of the

pain.

The joint cartilage lacks nerve endings, and is therefore unable to cause pain.

The nerve endings are found in the periarticular soft tissues, specifically in the

disc and capsular ligaments, and in the retrodiscal tissues (bilaminar zone of

Rees). These are mostly free nerve endings, though some receptors with a

more complex structure believed to correspond to mechanoreceptors have

been identified in the lateral portion of the capsule and stylomandibular

ligament.(50)

The most common symptom reported by patients with ID is unilateral

facial pain. The pain may radiate into the ears, to the temporal and

periorbital regions, to the angle of the mandible, and frequently to the

posterior neck. The pain is usually reported as a dull, constant ache that is

worse at certain times of the day. There can be bouts of more severe, sharp

pain typically triggered by movements of the mandible. The pain may be

present daily or intermittently, but many patients have pain-free intervals.(120)

Muscle pain

Muscle tenderness, producing pain or discomfort, is generally found

on both extraoral and intraoral palpation of the masticatory muscles.

Tenderness may also be present in the anterior neck muscles (suprahyoid

muscles and sternocleidomastoid muscles), posterior cervical paraspinal


27

muscles (semispinalis capitus, splenius capitus, and suboccipital muscles),

and the upper shoulder muscles (trapezius and levator scapulae). (121)

TMJ Dysfunction

The mandibular movements usually evaluated in clinical practice are

maximum aperture, forced maximum aperture, lateralization towards either

side, or protrusion. They provide significant information for diagnosing ID.

The normal amplitude of oral aperture is 40-60 mm.(65)

However, there is no

universally accepted standard value beyond which limited oral aperture is

considered to exist. The most widely accepted limit is 40 mm of interincisal

maximum aperture.(65)

Mandibular lateralization in turn is determined by

measuring the displacement of the interincisal line on one and the other side.

Displacements of less than 7 mm are considered to be below the normal

limit.(122)

The limitation of lateral movements is usually due to disc problems

(displacement towards the affected side being normal, while lateralization to

the healthy side is limited).(65)

It was proposed that continuous lateralization

may have deleterious effect upon the TMJ disc as it could perforate disc and

damage lateral anchoring of the disc to the condyle. (123)

Cases with disc displacement with reduction show varying degrees of

limitation in mouth opening. This could be attributed to protective muscle

contraction to protect the affected joint, or muscle spasm as the result of an

increase in metabolic degradation products induced by parafunctional activity,

both limit aperture with the purpose of avoiding pain.(44)

Although with

difficulty, the patient is able to open the mouth a little beyond unforced

maximum aperture.(124)

In the case of a patient with chronic and progressive limitation of oral

aperture preceded by one or more episodes of acute lock, the first suspected

diagnosis should be disc displacement without reduction.(65)

When disc

displacement without reduction is bilateral, the lateralization and protrusion


28

movements are limited. In unilateral presentations deviation is seen towards

the affected side at oral aperture. In some cases metaplastic phenomena

develop in the retrodiscal tissues, which can behave as a pseudo disc thus

allowing patients to recover oral aperture of up to 40-45 mm. (125)

Normally, the mandibular path in maximum aperture follows a vertical

line. Alterations in the path may comprise deviations, when at the end of the

opening movement the mandible is once again centered, or deflections, when

at the end of opening the midline remains deviated. Deviations are usually

caused by disc alterations, and are a consequence of condylar movements to

overcome the disc obstacle. Deflections in turn are usually caused by

limitations in the mobility of one of the two joints. In cases where the origin of

deflection is of a muscular nature secondary to unilateral spasm, protrusion

movements can help clarify the diagnosis, since they show no lateralization

when the underlying cause is muscular.(44)

Joint sounds

TMJ clicking generally indicates discal dislocation. The presence of

joint sounds supports the diagnosis of ID of the TMJ though it also must be

taken into account that the absence of such sounds does not necessarily imply

joint normality. Clicks are brief sounds produced by mandibular movements

associated to disc displacement with reduction, though click-like sounds can

also be produced by joint remodeling or joint hypermobility.(44)

It was reported that ID of the TMJ is a progressive disorder which

usually starts with clicking associated with normal mouth opening (anterior

disc displacement with reduction), to a stage where clicking gradually ceases

but restricted mouth opening ensues (closed lock). This was attributed to a

non-reducible anteriorly displaced articular disc acting as an obstacle to the

gliding condyle. (126)


29

A reciprocal click is usually generated in the more advanced phases of

disc derangement with reduction. Typically, the opening click occurs later

during the opening movement, whereas the closing click often occurs close

to maximal occlusion.(59)

The further away the closing click is produced from

the closed mouth position, the greater the degree of disc dislocation (65)

The

joint clicks disappear as the disc becomes non-reducible and a limitation of

maximum interincisal aperture to about 25 mm or less may develop.( 127)

Crepitants or friction sounds in turn are longer-lasting than clicks, and

may accompany part of the mandibular movement cycle. They are the result

of direct friction of one bone surface against another. Friction sounds are

considered to be a manifestation of osteoarthrosis. Joint sounds are highly

variable in one same individual – a fact that limits the reliability of sound

assessment. Joint sounds are detected by palpation, auscultation or

sonography. (44)

Palpation is less sensitive, since some sounds go undetected. In

contrast, auscultation and sonography offer low specificity, since many

accessory sounds such as friction of the hair or skin, or even blood flow in the

exploratory zone, can induce false positive readings. (128)


30

Imaging studies

The most important diagnostic advances in TMDs during the past 30

years have occurred in imaging techniques for the TMJ. Imaging of the TMJ

and associated structures is necessary to establish the presence or absence of

pathology and stage of disease in order to select the appropriate treatment,

assist in prognosis, and assess patient response to therapy. Imaging results will

influence treatment strategy. Generally, it is recommended that imaging

studies be bilateral because of the high incidence of bilateral joint disease. (129)

Radiographs which can provide this information include plain films,

panoramic films, and tomograms.(130)

In instances where more information is

required, tomography is recommended. (130)

Plain radiographs have been

almost completely replaced by computed tomography (CT) for evaluation of

bony morphology and pathology of the joint, mandibular ramus, and

condyle.(129)

The disc and associated soft tissue structures should be imaged. Magnetic

resonance imaging (MRI) (131)

or arthrography (132)

can provide this

information.

Schiffman et al (133)

found that mandibular dysfunction indices produced

values which were unrelated to the position of the disk in the TMJ as

determined by arthrographic evaluation. Therefore, they suggested that the

clinical significance of a positive arthrogram should not be overemphasized.

However, Manfredini et al (134)

reported that imaging techniques should be

used to gain a better insight within the TMJ.

Magnetic resonance imaging (MRI) has replaced other imaging

methods for evaluation of soft-tissue abnormalities of the joint and


31

surrounding region. The anatomy of the joint and the position and structure of

the intra-articular disk can be accurately visualized both at rest and in motion.

(129) MRI is considerd one of the best and most commonly used modality in

TMJ imaging.

Kinematic MRI allows for depicting sequential positions of the disc

during mandibular movement.(27)

Nevertheless, poor correlation exists

between signs and symptoms and displacement of the articular disk when

determined on the basis of imaging studies alone.(135)

Other head and neck

imaging studies may be necessary such as transcranial views for general

determinations of condylar morphology and position in the fossa.

TMJ Arthroscopy was first described in the 1970s. Arthroscopy is

both a therapeutic and mini-invasive endoscopic method for TMJ space

examination. As a diagnostic tool, arthroscopy permits the surgeon to

identify significant intra-articular pathologies such as osteoarthritis,

synovitis, ID, disc perforation, and adhesions.(17)

Operative arthroscopy

permits surgical management of the pathology that is seen, such as the

removal of adhesions, direct injection of drugs into inflamed synovial

tissues, disc mobilization, and debridement and shaving of osteoarthritic

fibrillation tissue. (136)

However, complications may arise such as

haemorrhage, joint cartilage damage, joint disc perforation, face inervation

damage, midear perforation, intracranial perforations and the risk of

infection. (137,138)


32

TREATMENT:

Treatment of ID has always presented a therapeutic challenge to the oral

and maxillofacial surgeon. One should not expect a single treatment modality

for this malady which is always successful in decreasing the patient's

affliction. On the contrary, there is a wide spectrum of different interventions

which may help in treating ID. In point of fact, treatment of ID is usually like

a treatment ladder starting with the simplest and the least expensive and then

ascending with the more aggressive until resolution of the patient's signs and

symptoms occur. Of course, this is not an absolute concept and there may be

some exceptions for this treatment philosophy.139

As in any disease, an understanding of the natural course of ID is

necessary to guide rational treatment. Since many individuals lacking ideal

mandibular function do not seek treatment, a clinician needs to determine a

patient's deviation from ideal and ability to adapt before recommending any

intervention. Definitive treatment for a disc displacement is to reestablish a

normal condyle-disc relationship. Although this may sound relatively easy, it

has not proved to be so. Most patients with articular disc displacements either

improve spontaneously or can be managed efficiently with appropriate non-

surgical therapy. Some patients, however, may become refractory to

conservative treatment and require surgical intervention to relieve the

troublesome TMJ symptoms.(140)

Generally, treatment efforts are directed toward reduction of pain,

improvement of dysfunction and slowing the progression of ID. Although few

current treatment options appear to affect progression of ID favorably,(141)

this

goal gains importance with accumulating evidence suggesting that progression

to late-stage disease has a deleterious effect on pain resolution(142)

and plays a


33

role in the development of facial deformity.(143)

This could be achieved by

reduction of disc interference, because of its adverse effect on pain,

dysfunction, and its possible role in development of the deformed condyle of

late-stage ID.(144)

As a consequence, treatment of ID is usually started with non surgical

methods and when these methods are exhausted surgical techniques are

attempted. Non surgical techniques include wide range of different

approaches such as behavioral medicine, pharmacological therapy, physical

medicine, and occlusal adjustment.145

while surgical techniques includes

closed and open joint surgery.

Non-Surgical Treatment

Non-surgical treatment should be considered for all symptomatic

patients with ID. For mild or moderate pain and dysfunction, this treatment

alone often suffices.(146)

Considerable percentages of patients with ID respond

well to nonsurgical treatment.(147)

Patients with severe pain and dysfunction

may also be treated non-surgically, but if adequate reduction of symptoms

does not occur within 2-3 weeks, surgical consultation is indicated. In

instances of closed lock, regardless of the degree of pain, early surgical

consultation is indicated. There are mainly four types of treatment that should

be considered for patients with painful ID. These are patient education

(Behavioral medicine), physical therapy, occlusal therapy and

pharmacological therapy.(44)

Behavioral medicine is the initial step in approaching patients with ID. What

a patient does with his occlusion in reacting to a stress seems more important

than any malocclusion that he may have. This psycophysiologic conception

which was expanded by Laskin148

in 1963 led to the emerge of

biopsycological approach in the management of ID and thus many clinicians


34

started to appreciate the significance of controlling the patient's stresses to

achieve good results.148

Patient education, biofeedback, stress management,

relaxation training and counseling are all parts of the behavioral agenda

needed to control the patient's stresses. Patients' education is done by

explaining to them confidently and thoroughly the pathology, prognosis of

their disease in attempt to motivate them to get involved in their treatment

i.e. patients who are aware of their problem will appreciate the provided

treatment and will actively participate in their own treatment. Lack of

motivation, feeling of dissatisfaction and pessimism will compromise any

provided treatment. In addition, patients should be taught to discard any

habits which may excessively load the TMJ. Thumb and pencil suckling,

opening the mouth maximally during yawing, eating sticky food are all

hurtful habits that should be abandoned by the patients. Encouraging the

patients to cut their food into small pieces and may even shift to semi fluid

blenderized diet is also needed to rest the TMJ.

Patient education is intended to help patients understand and avoid

stress-related lifestyle habits.(149)

Patient education is very important in order

to modify the patient‟s behavior and therefore a brief description of the

mechanism of internal derangement should be given. A well informed

patient could play a major role in the treatment since the disorder is of

biomechanical nature and therefore the patient should be instructed to eat

softer food in order to decrease loading of the joint. The patient should also

be informed about the disorders natural course and treatment so that

reasonable expectations can be met. (44,146)

Physical Therapy in conjunction with other methods of treatment is

used to relieve musculoskeletal pain and improve range of motion.(150)

Physical therapy comprises a vast number of different interventions such as

home exercises, heat application, ultrasound therapy, transcutaneous


35

electronic nerve stimulation(TENS), mandibular manipulation, intramuscular

injection of botulinum toxin, and intra-oral appliances.

Home exercises may be helpful in maintaining normal function and

they include gentle stretching exercises done through active opening or

passively by devices as Therabite. (151)

It has been stated that these home

passive rehabilitation programs can result in restoration of normal

mandibular mobility in patients with closed lock over a period of several

months. (151)

Heat therapy whether by moist heat application or by ultrasound

waves will theoretically increase the blood flow to the injured areas

increasing the uptake of the painful metabolic byproducts which will

decrease the pain and improve the function of the TMJ. Transcutaneous

nerve stimulation is used for chronic pain management and it depends on the

idea that stimulation of the superficial nerve endings electronically will

result in overriding the pain input from the injured TMJ. (151)

Another interesting modality in controlling the diffuse pain which is

usually associated with ID is the intramuscular injection of botulinum toxin.

Botulinum toxin is produced by the anaerobic organism Clostriduim

botulinum and is considered to be a pre-synaptic neurotoxin. It causes a dose

dependant weakness in the skeletal muscles by blocking the release of

acetyl- choline from the motor nerve endings as well as lowering the muscle

tone. As a result, loading of the joint will be significantly reduced allowing

the joint to rest and providing it with the opportunity to heal. In addition,

botulinum toxin may have an anti-inflammatory effect in large doses. (152)

Home exercises are an excellent method for treating a patient‟s

symptoms, getting the patient and family members actively involved in the

patient‟s therapy. (153)


36

Occlusal therapy has gained a wide acceptance as one of the initial

modality used for management of ID. A wide variety of occlusal splints has

been used. However, stabilization and anterior repositioning splints are the

most commonly used for treatment of ID. Several authors reported the use of

anterior repositioning appliance to treat TMJ ID. Based upon clinical

experience and the literature; anterior repositioning appliances appear to be

more effective than the flat-plane occlusal splint in eliminating joint

clicking, joint and headache pain, and muscle pain from a dislocated joint.

(154-158) Summer and Westesson

(159) reported that 92% of 75 patients found

pain relief by using an anterior repositioning appliance. Such an orthopedic

device must either cover all the teeth of one arch or incorporate the anterior

determinants of occlusion (such as anterior guidance and canine disclusion)

to avoid intrusion or over eruption of teeth. (160)

Patients must wear this

appliance at all times. (161)

Superior repositioning appliance (gnathologic appliance, centric

relation splint, stabilization splint, flat-plane splint, anti-bruxism appliance,

and occlusal appliance) is used to treat bruxism, muscle hyperactivity, and

muscle pain.(162-164)

The appliance‟s major purpose is to provide neuromuscular

relaxation via the trigeminal afferent neurons, first through the mesencephalic

nucleus and then through the motor nucleus. Through this complex reflex, the

motor innervations to the elevator muscles is adjusted, producing a

neuromuscular relaxated position of the mandible that is independent from the

occluding surfaces of the opposing teeth.(165)

The superior repositioning

appliance covers all of the teeth in either the maxilla or mandible.

Mechanically, there is no difference which arch is used as long as all of the

teeth in the arch are covered; the vertical thickness is kept to a minimum (1.0–

2.0 mm). (166,167)

It is recommended to be worn only at night. After a period of


37

successful splint therapy (normally between two to three months), patients can

be weaned off the splint.(168)

Conti et al (166)

evaluated the effectiveness of partial use of anterior

repositioning appliances in the management of TMJ pain and dysfunction

when compared to stabilization splints and a control group in a one-year

follow-up. They concluded that controlled partial use of repositioning splints

is a beneficial tool in the management of intra-articular pain and dysfunction

Prolonged use of repositioning appliances for ID can cause

undesirable and irreversible changes in dental occlusion, skeletal structure,

and muscle dynamics.(146)

After symptom relief permanent occlusal

modification should be performed in order to gain a lasting effect, a

treatment that may include occlusal equilibration, prosthetic restoration and

orthodontics. Occlusal adjustment, either permanent or temporary, can still

be an appropriate treatment for dental pathology, but its role in the primary

treatment of TMJ disorders is uncertain.(127)

Pharmacological therapy : its main goal in the management of ID is

not to cure the disorder but is aimed at helping patients manage their pain

and/or dysfunction for extended periods of time often used with other

therapies (i.e., physical therapy, appliance therapy).(147)

Several drug classes

have been used in management of ID involving analgesic, corticosteroid, Non

Steroidal Anti Inflammatory Drugs (NSAIDs), muscle relaxant,

antidepressants, and sedative hypnotics. A recent study(169)

concluded that in

patients who have TMJ closed lock, medical management with a 6-day

regimen of oral methylprednisolone (Medrol DOSEPAK) followed by 3 to 6

weeks of NSAIDs therapy worked equally as well over a 5-year period as

arthroscopy or open joint therapy in reducing jaw pain and dysfunction as


38

measured by the Craniomandibular Index.(169)

It was reported that patients

who have severe disc interference disorders and inflammatory conditions,

such as capsulitis, synovitis, and TMJ osteoarthritis/rheumatoid arthritis, may

benefit the most from this class of drugs.(170)

NSAIDs represent first-line drugs for many clinicians treating TMJ

pain. Patients who have early painful disc displacement, capsulitis, synovitis,

and arthritis associated with the TMJ may benefit the most from these drugs.

Low dose tricyclics are effective in controlling pain from night time bruxism,

when doses are adjusted to provide improved sleep.(127)

After psychiatric

consultation, if it is determined that clinical depression is an aggravating

factor, antidepressant medication can be helpful as part of the treatment.(171)

Intra-articular injections:

Growing evidence suggests that patients with a closed lock, especially

one that is long-standing showed significant reduction of pain and

dysfunction after intra-articular injection of sodium hyaluoronate.(147,172)

Yavuz et al.(173)

in their prospective study, 40 TMJs of 33 patients who had

TMD were treated with intra-articular sodium hyaluoronate injections at

weekly intervals for 3 weeks. They concluded that intra-articular hyaluronic

acid injection for the treatment of reducing and non-reducing disc

displacement of TMJ is an effective and safe management.

Also, Yeung and his coworkers(174)

reported that two cycles of intra-

articular injection using high molecular weight sodium hyaluoronate on

alternative weeks looks very positive for patients affected by non-reduced

disc displacement and is encouraged to be used as a primary treatment of

TMD.


39

The intra-articular corticosteroids injection holds promise for control

of TMJ inflammation and prevention of associated morbidities.

Corticosteroid joint injection has been popularized as prompt and lasting

therapy for juvenile idiopathic arthritis.(175)

Steroids possess anti-inflammatory properties. On the cellular level,

steroids are highly lipophilic and are believed to bind to the cell‟s nucleus.

Intra-articular steroids seem to reduce the number of lymphocytes,

macrophages, and mast cells (176,177)

; this, in turn, reduces phagocytosis,

lysosomal enzyme release, and the release of inflammatory mediators.(178)

Inflammation is reduced, particularly through reductions in the release of

interleukin-1, leukotrienes, and prostaglandins (179,180)

. With the reduction of

these inflammatory mediators, pain symptoms often are improved.

Because they are injected locally, intra-articular steroids avoid most of

the systemic effects of oral steroids, including high blood pressure,

osteoporosis (thinning of the bones), Cushing‟s syndrome (weight gain,

moon face, thin skin, muscle weakness and brittle bones), cataracts, slowed

growth, reduced resistance to infection, sudden mood swings and increased

appetite, muscle weakness, skin thinning resulting in easy bruising, peptic

ulceration, and aggravation of diabetes. (24,181)

Unfortunately, intra-articular

corticosteroid injection have deleterious effects on joint tissues such as

destruction of the articular cartilage, infections and progression of existent

joint disease.(172,182)

Opioid receptors have been discovered in the peripheral nervous

system. Mu, delta, and kappa receptors were found on peripheral

nerves.(183,184)

The effectiveness of opiates in inflamed tissues has been

explained by a disruption in the perineurium, allowing for easier access of


40

opioids to neuronal receptors.(184,185)

. It was proposed that the effects of intra-

articular morphine might simply be due to systemic absorption; however, the

plasma concentration achieved from an intra-articular injection was found to

be too low for a systemic effect to be observed.(184)

Within the joint itself, the

relative concentration is high.

Kalso et al (186)

reviewed 36 randomized controlled trials. Four studies

that compared opiates with placebo found greater efficacy for intra-articular

morphine, another four studies that compared intra-articular morphine with

intravenous or intramuscular morphine showed greater efficacy for intra-

articular morphine. (187)

Upon reviewing the literature, different dosages were

used with varying effects. Specifically, the minimum dose tested (0.5 mg) did

not show efficacy, but a dose of 1 mg did. No greater effect was found when a

dose of 1 mg was compared with 2 mg (186,187)

.

Non surgical methods play an imperative role in treating ID.

Sidebottom (188)

declared that more than 80% of the ID patients will benefit

from the conservative techniques and only minority may require more

aggressive intervention. Better results were mentioned by Gaudot et al

(189)

where he stated that from 708 patients consulted his team with clinical

features of temporomandibular dysfunction only 62 underwent surgical

procedures with success rate of nearly 91%.

The best results reported in the literature were by Dolwick et al(190)

and Fridrich et al(191)

where they concluded that only 5% of the patients will

need surgical treatment. Lee et al (192)

reported a relatively lower results

where he avowed that the success rate of non surgical methods is

approximately 60%.


41

Then we can wrap up by acknowledging that non surgical methods are

effective in treating ID with success rate ranging from 60% to 95% (145)

and

that they play the major role in alleviating the patients' suffering. The only

blemish in non surgical means is that the length of time for patients to reach

a normal pain free range of motion may be suboptimum.(145)

When these

non surgical techniques prove to be unsuccessful surgical procedures are

deemed necessary. TMJ surgery ranges from minor minimally invasive

surgeries to aggressive ones. The minimally invasive surgical techniques

include two main entities which are Arthrocentesis and Arthroscopy. These

minimally invasive surgical techniques have filled the large void between the

non surgical methods and the aggressive open TMJ surgeries.

Surgical Treatment

Surgery for treatment of ID has the twin advantages of effectiveness

and a rapid response. Surgical consultation should be offered within 2-3

weeks to patients with documented ID and in whom severe pain and

dysfunction persists after a trial of non-surgical therapy.(147)

Various surgical

procedures have been used for management of ID and could be categorized

into closed and open treatments.

Closed surgical treatment

Closed surgical treatment of ID does not involve surgical exposure of

the TMJ. The currently employed techniques include Arthroscopy and

Arthrocentesis.


42

Arthroscopy: (17, 18, 20,193-198)

With the advent of arthroscopy, arthroscopic surgery gained wide

acceptance and popularity among oral and maxillofacial surgery

TMJ arthroscopy is a surgical modality which has rapidly gained

worldwide acceptance in the last century. It is an equipment dependant

minimally invasive surgical procedure that requires a great skill on the part

of the surgeon and it involves placement of an arthroscopic telescope into the

joint space.(199)

A brief historical review is needed to understand its historical

background.

In 1867 Desormeaux described a mean of examining the genitourinary

passages using an open tube endoscope and he was the first to realize the

importance of a lens system to concentrate the beam of light(200)

. In 1868

Bevan performed the first endoscopic surgical procedure where he extracted

foreign bodies from the esophageous. In 1879, Nitze collaborated with

Benche, an optician, and Leiter, an instrument maker to design the first well

premeditated endoscope. The endoscope had an external diameter of 7 mm

and a prism as an optical system and a burning platinum wire was used as

the light source. In 1882 Nitze developed the first successful photographic

endoscope and he later published the first endoscopic atlas in 1884(200)

. The

first introduction of the endoscopic technology to the joints was in 1920 by

Tagaki who used an endoscope to examine a tubercular knee. In 1931,

Takagi developed a 3.5 mm arthroscope suitable for the examination of

smaller joints using saline dilation(200)

.In 1955 Watanabe, a student of

Takagi performed the first knee arthroscopic surgery to remove a giant cell


43

tumor. Modern arthroscopy was born in 1959 when Takagi, Watanabe, and

Ikeuchi (200)

developed single puncture and multiple puncture (triangulation)

techniques and they performed arthroscopic synovial biopsies, cautery of

intra- articular structures, extraction of loose bodies, resection of tumors, and

partial menisectomies. (200)

This improvement in knee arthroscopic procedures and the ability to

perform a wide range of different surgeries attracted the attention of oral and

maxillofacial surgeons to the capabilities and benefits of arthroscopy. So in

1975 the first report of diagnostic TMJ arthroscopy was made by Ohinishi

(17), 57 years after the earliest attempt at knee arthroscopy. In 1982 Murakami

(19) published descriptions of the arthroscopic anatomy and pathology. In

1985 Holmund and Hellsing (20)

described soft tissue landmarks for

arthroscopic TMJ penetration. The first TMJ arthroscopic lysis and lavage

(ALL) procedure was described by Sanders in 1986. In 1988 Heffez and

Blaustein (200)

described the arthroscopic criteria for normal TMJ disc

position and internally deranged joints.

Until that time operative arthroscopy was still limited by the size of

the instruments and the lack of miniature instruments needed to be engaged

in different procedures in the TMJ. This was changed in 1991 by the

introduction of the fiber-optic laser technology to the field of TMJ

arthroscopy by Indresano and Koslin(201,202)

which had a magnificent impact

on increasing the potentials of operative arthroscopy. Lastly, McCain (203)

developed suturing techniques that allowed operative arthroscopy to compete

open arthroplasty in repositioning the TMJ disc. (204,205)

As described before, arthroscopy is a highly technique sensitive,

equipment demanding procedure. In addition, it needs considerable dexterity

from the surgeon which can be achieved by proper training. In fact, a skillful


44

operator may need a lengthy, learning curve to start mastering arthroscopy.

(204) In consequence; many points should be addressed while dealing with the

TMJ arthroscopy. Arthroscopic equipments, classification and the different

types of performed arthroscopic surgeries are the two principle topics that

will be conversed.

At the outset, an arthroscope or an endoscope can be defined as a

cylinder that conducts light to a cavity and transmits an image back to the

eye. (205)

Arthroscopic equipments and instrumentation can be divided into

three sections.

The first section discusses the arthroscopic proper, the second section

discusses the solid instruments for penetrating the TMJ space, and the last

section discusses the equipments required for adequate illumination. (203)

The arthroscopic proper is the main core of any arthroscope and is

usually made of some essential components regardless the type of the

endoscope. These indispensable components include an ocular lens mounted

on an eyepiece, an illuminating mechanism, a transmitting mechanism

consisting of a series of lenses or a fibers and a working end made of a prism

and an objective (203)

.

The arthroscope can be classified according to the optical principles

upon which it is based into: traditional lens system, rod lens system, and

self-scope lens system. (205)

The traditional lens system and the rod lens

system are examples of rigid endoscopy in which the transmitting

mechanism consists of a series of lenses. The self-scope lens endoscope is

more flexible than the previous ones since it uses glass fibers rather than the

rigid lenses as its transmitting mechanisms. The traditional lens system is

seldom used nowadays since it usually produces images of low contrast. The

self-scope lens system is as well rarely used due to inherent limitations in the


45

degree of brightness, color, resolution, and contrast of the images produced

by this endoscope. This makes the rod lens system the most frequently used

endoscope in the field of TMJ surgery. (203)

Available telescopes also vary in their direction of view or their

viewing angles where the objective lens can be mounted at 0, 10, 25, 30, 70,

and 120 degrees. The most versatile endoscopes are those with either 0 or 30

degree viewing angle. Finally, telescopes used for engaging the TMJ usually

run from 1.8mm to 2.6mm in diameter.(199,203)

The basic instruments required for penetration and joint exploration

can be categorized into capsule penetration instruments, and hand-held

surgical instruments. (205)

for capsule penetration three principal components

are needed: external sheath or cannula, sharp trocar or obturator, and blunt

trocar. Sharp trocars are used to penetrate through the skin and the

underlying tissue layers until the joint capsule is reached then blunt trocars

will be needed for any maneuver in the joint space. External sheaths actually

act as the housing through which trocars and the telescope can reach the

inside of the TMJ. (203)

Hand held instruments include wide range of different instruments

needed to perform diverse arthroscopic operative procedures. Probes are

effective tool in both diagnostic and operative arthroscopy. (203)

By virtue of

the dull hook in its distal end, the probe may be used to practice

triangulation, retract the retrodiscal tissue, and check the consistency of

remodeled retrodiscal tissue and disc. Scissors and punch forceps with long

working arms may be introduced through the external sheath of the second

port to be used for retrieval of foreign, removal of small pieces of tissues,

and incision of adhesions. (205)

Knives are also frequently used in the TMJ

arthroscopic surgery to incise tissues as diseased synovuim or remodeled


46

retrodiscal tissue. The last section in arthroscopic instruments deals with

illumination. The light sources are needed to illuminate inside the joint

cavity for optimum diagnosis and video photography.

Two light sources are available: xenon, and halogen. (203)

Xenon has

the advantage of providing brighter images with better color quality than

halogen light sources. However, xenon light sources are more expensive than

the halogen ones. (206)

Secondly, arthroscopic technique (211)

can be classified according to

the space inspected or the number of the portals used. Classified by the

number of the portals used, arthroscopy can be a single port when only one

opening is made into the joint or as double port arthroscopy when a second

instrument port is used.(207)

Being classified according to spaces, arthroscopy

is actually two types: superior joint arthroscopy or inferior joint arthroscopy.

(211)

Inferior joint arthroscopy can be achieved directly through a puncture

via the lateral capsule or indirectly via a perforation in the remodeled

retrodiscal tissues. Inferior joint arthroscopy is rarely done because of the

confinement of the inferior joint space where the volume of the inferior joint

space is nearly half that of the upper joint space. Moreover, because of the

tight attachment of the medial and lateral capsular ligaments, ready access to

the inferior joint space recesses is significantly limited. (208)

The final issue that should be tackled is the diverse procedures that

can be accomplished by arthroscopy. They can be divided into two major

procedures: diagnostic arthroscopy and operative arthroscopy. (209)

Diagnostic arthroscopy is useful in detecting many forms of joint

pathology affecting the synovuim, the cartilage surfaces, and the retrodiscal


47

tissue. The joint should be examined systematically starting from the

posterior aspect and continuing to the anterior recess. (210)

Diagnostic

examination is done under dilation provided by lactated Ringer's solution to

maintain hemostasis and increase the joint space to allow for adequate

examination. (211)

Operative arthroscopy includes variable sophisticated procedures

ranging from simple irrigation of the joint to disc plication. Nevertheless,

most surgeons limit the use of arthroscopy to simple lysis and lavage (ALL).

(211)

ALL can be accomplished by simple sweeping movement using the

blunt trocar to break the present adhesions which is followed by thorough

joint irrigation to remove any blood clots and debris. (208)

Likewise, irrigating the joint has also the benefit of distending the

joint and breaking the suction cup effect. Capsular release procedures are

also beneficial in improving range of motion in joint with restrictions caused

by ID. (209)

In general, these restrictions can be enhanced by either anterior or

lateral capsular release. Anterior capsular release aims to widen the anterior

wall of the joint which can be accomplished by probes or laser which will

have a weighty effect on joint translation. (208)

Lateral capsular release, on the

other hand, increases lateral excursions and it is achieved by stretching the

lateral wall of the capsule by probes or sharply dissecting it by Holmium:

YAG laser. (212,213)

Last but not least, disc repositioning can be also done by

arthroscopy. This can be done by combining anterior release and contracting

the posterior attachment by laser, injecting sclerosing agents as sodium

morrhuate, or the suturing maneuver described by McCain et al in 1992. (214)

Although TMJ arthroscopy is considered a relatively safe technique, it

is not exempt from complications. Most of these complications may take


48

place during the procedure or immediately after it. In addition, these

complications may vary from minor insignificant ones to serious

complications. These complications may be otologic, neurologic, vascular,

ocular or infections in the joint area. (215)

Vertigo, hearing loss, lacerations of external auditory canal, lesions of

tympanic membrane and blood clots in the external auditory canal are the

otologic complications that may take place during arthroscopic surgery. This

may be attributed to the close proximity of the joint to the external auditory

canal, tympanic membrane, and middle ear. (215)

Injury of nerves in vicinity of the joint area may occur as well during

operative arthroscopy. This includes paresis of facial nerve, injury to the

auriculotemporal nerve and inferior alveolar nerve (215)

.

Moreover, cardiac depression has been reported in the literature and is

caused by stimulation of the trigeminal nerve. This may be caused by

stimulation of the vagus nerve via its central nucleus which receives the

afferent fibers of the trigeminal nerve. Although extremely rare, this

complication may compromise the vital signs of the patient requiring rapid

intervention of the anesthesiologist to re-establish the patient's vital signs.

(216,217)

Bleeding is the most common complication during TMJ arthroscopy.

Usually, it does not cause significant effects other than compromising the

visibility during the procedure. Although alteration of visual accuracy was

also reported as a complication which may accompany arthroscopy, there is

still no clear explanation for its pathogenesis. (215)


49

Infections as otitis media, joint infection, and infratemporal space

infection were reported in conjunction with arthroscopy and they are usually

successfully managed by antibiotics. (218)

Complications of arthroscopy are in general of unusual occurrence,

low in severity and permanence. In fact the largest retrospective study in

literature by McCain et al reported 4% complication when arthroscopy was

performed in 4831 joints in more than 3000 patients. (208)

Furthermore, Garcia

et al reported more recently a 1.34% complication in 670 different

arthroscopic procedures. (215)

Thus; arthroscopy can be considered a safe and

non invasive technique.

Arthrocentesis: (24-26)

Nitzan et al. (24)

were the first to describe arthrocentesis of TMJ as a

treatment concept for severe closed lock symptoms. Orthopedic arthrocentesis,

by definition, refers to needle puncture of a joint space, aspiration of fluid

from that space and injection of a therapeutic substance. (219,220)

Arthrocentesis was based on two treatment modalities; namely

pumping manipulation procedure (220)

and the arthroscopic lysis and

Lavage.(221-223)

It entails placing two needles into the superior joint space for

lysis and Lavage via hydraulic pressure, which will release the displaced disc

and thereby re-establish normal maximal mouth opening. Upon reviewing the

literatures, a wide variety of needles as well as amount and type of irrigating

solutions have been used for Arthrocentesis procedure. The gauge of utilized

needles varies from 18-21. (223)

The joint is irrigated with 50–100 ml of Ringer‟s solution or sterile

normal saline.(172,223)


50

The amount of irrigating solution is arbitrary, with no minimum or

maximum amount having been proven to be within the therapeutic range,(224)

although the ideal volume for Lavage of the UJC has been reported to be

between 300 and 400 ml. (224-225)

There have been many variations in the technique since its emerge in

1991 which all aimed to increase its efficiency and expand its scope. Yura et

al (226)

in 2003 claimed that the standard low pressure Arthrocentesis is not

always effective in chronic closed lock cases as it does not remove adhesions

in the joint space. As a consequence, he modified the standard technique and

used an infusion accelerator of blood bag for irrigation which establishes a

pressure of 40Kpa compared to 6.7Kpa of the standard low pressure

technique and. (226)

Yura also proved by arthroscopic examination before and

after irrigation under sufficient pressure that this high pressure irrigation can

actually release band like adhesions and thus high pressure Arthrocentesis

has wider application in TMDs than low pressure (227)

Alkan et al (228)

achieved the highest pressure reported in literature

(300Kpa) by irrigating the joint via the irrigation pump of the dental implant

motor.

Additionally, Laskin (229)

reported also that changing the standard

portals for the joint space may make Arthrocentesis easier. He found that,

although placement of the posterior needle is usually accomplished easily,

insertion of the anterior one is often more difficult. Even though their placing

in this way may be necessary for complete visualization and for triangulation

of instruments during Arthroscopy, it is not necessary for Arthrocentesis.

Therefore, he suggested placing the posterior needle as in the standard

technique in the posterior recess and inserts the anterior needle as well in the


51

posterior recess by placing it 3-4 mm in front the posterior needle. This

accomplishes the same purpose and is a much easier technique.

Nardini et al (230)

proposed a single needle Arthrocentesis technique

where one needle is placed in the posterior recess as in the standard

technique while the patient is maximally opening his mouth and then the

fluid gets off the joint is when the patient close his mouth elevating the intra-

articular pressure. This technique offers many advantages over the two

needle Arthrocentesis which provides more stable access to the joint space,

this technique also decreases the trauma to joint space and thus decrease

postoperative pain and discomfort. Finally, it decrease the execution time

needed to perform the procedure.

Arthrocentesis has proved to be a minimally invasive treatment

modality, relatively safe, reversible and it can be done on outpatients under

local anesthesia which significantly revert the mouth opening to a normal

range. It is an effective method for the re-establishment of normal disc-

condyle-fossa relationship. (24)

An interesting question is how does arthrocentesis work. Why should

this simple Lavage of the upper joint space (UJC) in patients with TMJ closed

lock (CL) be therapeutic (231)

? It was proposed that Lavage and lysis of the

UJC would eliminate the vacuum effect and alter the viscosity of the synovial

fluid (SF) thereby aiding translation of the disk and condyle. (24,231)

Arthrocentesis is also said to address the three common symptoms of TMJ-

CL: limitation in MMO, pain and dysfunction (232)

. These symptoms are

interrelated where increased pain causes decreased MMO, which in turn

causes dysfunction. Correction of one problem can lead to correction of the

other two (232)

.Thus, Arthrocentesis in combination with shearing forces

generated by joint manipulation is thought to release adhesions, thereby


52

enabling normal MIO.(233)

The washing out of inflammatory mediators (234-236)

as well as the direct action of instilled medications on intra-capsular receptors

have their effect in pain reduction. Improved perfusion of nutrients into the

joint following Arthrocentesis allows some components of repair and

adaptation. (231,235)

Various drugs such as Corticosteroids, Local anesthetic agents,

Morphine, Sodium hyaluoronate have been injected in the TMJ in conjunction

with arthrocentesis to enhance its outcome. It was reported that intra-articular

corticosteroid injection after arthrocentesis provides long-term palliative

effects on subjective symptoms and clinical signs of TMJ pain. Unfortunately,

intra-articular corticosteroid injection has an unpredictable prognosis and also

can cause local side effects on joint tissues.(172)

Sodium hyaluoronate (SH) has

been proposed as an alternative therapeutic agent with similar therapeutic

effects. This highly viscous, high-molecular substance plays an important role

in joint lubrication and protection of the cartilage.(172)

Intra-articular morphine

was used after arthrocentesis. This has been described in orthopedics,

particularly after arthroscopic knee surgery, with good clinical effects, (237,238)

suggesting that opiate receptors may be present within joints. It was found that

the instillation of low dose morphine alone (either 0.1 mg or 1 mg) in patients

with unilateral TMJ pain significantly increased the pain threshold and

improved mouth opening ability. (239)

Open surgical treatment

Criteria to select candidates for these aggressive surgical treatments

may not be clear and non specific. The first criterion is that the pain and

dysfunction is localized only to the joint area. The more diffuse the pain and

dysfunction, the less likely it is that the surgical interventions will be

successful. The second criterion is extremely important as it entails that


53

surgical intervention are only accepted when non surgical techniques and

minimally invasive procedures are exhausted for a considerable time. The

third criterion is an imaging evidence of the disorder. (240)

Open surgical procedures are divided into two main groups: Disc

preservation procedures, and Discectomy. (241-248)

Disc preservation procedures are those techniques in which the disc is

not sacrificed. Although literature support the efficacy of these maneuvers

many surgeons still have the perception that disc repositioning procedures

are not that successful. This may be attributed to the poor unrealistic

expectations of the surgeons and their patients. In addition, the postulation

that appropriate disc reposition is not always needed to achieve reduction in

patient's symptoms has also decreased the interest in these procedures.

Finally, the variation in the surgical techniques used may have confused the

surgeons since the aspects of these procedures have not been accurately

communicated. These techniques include full thickness plication, partial

thickness plication, disc reshaping, condylar shaving, modified

condylotomy, eminence reduction, and various combinations of these

techniques. (241)

Disc repositioning involves removal of tissue from the bilaminar zone

in an amount that corresponded to the degree of the disc displacement. The

disc should then be repositioned over the condyle and sutured to the distal and

the collateral ligaments.(241)

The Modified Condylectomy (242-245)

is a modification of the intraoral

vertical ramus osteotomy used in orthognathic surgery and the aim of this

procedure is to reposition the condyle anteriorly and inferiorly beneath the


54

displaced disc. This will result in a slight increase in joint space, which will

allow the disc to move to a more favorable position.

Alloplastic implants are not generally indicated for initial surgical

treatment of joints with ID .Prosthetic joint replacement may be indicated in

selected patients with severe joint degeneration, destruction, or ankylosis.(246-

249) The remaining of a significant number of patients who have continued

pain or dysfunction following open surgery could be due to failure of open

joint surgery to correct some unknown biochemical disturbances.

Complications are not uncommon after these aggressive open surgical

procedures. Facial nerve injury is the most significant complication.

Although total facial nerve paralysis is possible, it is rare. Inability to raise

the eyebrows is the most commonly observed finding. It occurs in about 5%

of the cases and usually resolves in 3 months. Other complications include

limited mouth opening because of heterotropic bone formation, occlusal

changes, bleeding and infection. (250)

So TMJ surgical interventions are reserved for a minority of cases, and are

usually used with caution as well.

AIM OF THE STUDY

Aim of the study

55

Aim of the study

The purpose of this study was to evaluate the clinical outcome and the

changes in disc position, mobility, and morphology in patients with

temporomandibular joint closed lock in response to arthroscopic lysis and

lavage versus arthrocentesis using magnetic resonance imaging (MRI).

PATIENTS

&

METHODS

Patients and Methods

56


Patients

The current prospective study was conducted on healthy adult Patients

with closed lock (DDnR), based on clinical and MRI findings. They were

selected from those who attained to the outpatient clinic, Oral and

Maxillofacial Surgery Department, Faculty of Oral and Dental Medicine,

Cairo University with ID. They had fulfilled the following inclusion criteria:

Inclusion criteria:

Age ≥ 18 years

Obtaining written informed consents signed by the patients.

Willingness and ability to commit to follow-up

Exclusion criteria:

Patients who received previous TMJ surgery

The selected patients were excluded from the study if they respond to

conservative therapy in the form of:

1. Non-steroidal anti-inflammatory drug (Antiflam*1 50 mg one tablet

twice daily).

2. Muscle relaxant (Myolgen *2one tablet twice daily).

3. Muscle exercises: Passive stretch (finger-thumb), resistant opening, and

minimizes zigzag exercises.

1 *Antiflam 50: Diclofenac potassium 50 mg, Manufactured by T3A Industrial for T3A

pharma, Assiut, Egypt. 2 *Myolgen: Each capsule contains chlorzoxazone 250 mg+Paracetamol 300 mg

Manufactured by GlaxoSmithKline S.A.E. EL Salam City, Cairo, Egypt.


57

4. Superior repositioning occlusal splint (vacuum-formed upper hard

splint of 4 mm. Thickness) was worn day and night.

5. Thermotherapy in the form of hot application for half an hour three

times daily.

6. Soft diet regimen.

The drugs were stopped after two weeks and the patients continued on the

splint alone for additional 8 weeks.

Grouping of the patients

Twelve out of 23 patients (52.17%) did not respond to the used

conservative therapy. Their ages ranged from 22-34 years, with an average

of 29.4 years. They were all females. Tables 4 and 5 show the demographic

data of the selected patients. They were assigned into 1 of 2 equal groups:

Group I:

Arthroscopic lysis and lavage was performed with intra-articular injection of

1ml of Depomedrole*3 (40mg/1ml) at the end of the procedure.

Group II:

Arthrocentesis was performed with intra-articular injection of 1ml of

Depomedrole (40mg/1ml) at the end of the procedure.

Preoperative evaluation:

The participants were reassessed. Preoperative evaluation included

history, detailed medical and Magnetic resonance imaging (MRI)

investigation. Data for each patient were collected in her own questionnaire

and examination chart (Fig. 1)

3 * Depomedrole: 2 ml Ampoule Methylprednisolone acetate Manufactured by Egyptian Int.

Pharmaceutical Industries Co. E.I.P.I.CO, Egypt.


58

Clinical examination

I. TMJ examination:

A. TMJ function:

Maximal inter-incisal opening (MIO) as measured in mm from

maxillary dental midline to mandibular dental midline.

The presence of mandibular deviation or deflection during mouth

opening.

The maximum protrusive movement by measuring the horizontal

distance between the maxillary and mandibular dental midline in mm.

The maximum lateral excursion by measuring the horizontal distance

between the maxillary and mandibular dental midline in mm.

Table 4: Data of patients responded to conservative therapy

Case no. Age(yrs) Sex Site of

complaint

Duration in

months

Chief complaints

1 28 Male Right 9

TMJ pain, limited MMO

2 28 Male Left 12

3 23 Male Right 7

4 23 Male Left 3

5 30 Female Left 4

6 20 Female Left 18 TMJ pain, muscle tenderness

7 20 Female Left 5 TMJ pain, limited MMO

8 29 Female Right 7 TMJ pain, muscle tenderness

9 31 Female Right 8

TMJ pain, limited MMO 10 27 Female Right 2

11 30 Female Right 8


59

Table. 5: Demographic data of the participants

Group Case no Age(years) Site of complaint

Chief complaints Duration in months

I

1 25 Right TMJ pain, limited MMO 12

2 25 Left 12

3 32 Right TMJ pain, limited MMO, muscle tenderness

9

4 22 Left 8

5 22 Right

TMJ pain, limited MMO

8

6 34 Left 24

II 1 33 Right 12

2 32 Right 24

3 32 Left TMJ pain, limited MMO, muscle tenderness

24

4 34 Left TMJ pain, limited MMO

30

5 34 Right 30

6 28 Right 24

B. TMJ palpation:

TMJ was examined by palpation via preauricular and meatal

approaches to determine:-

The presence of TMJ tenderness or pain.

The translatory movement of the condyle during different mandibular

movements.

Joint sounds: the presence or absence of joint sounds.

II. Muscle examination:

The masticatory and sternocleidomastoid muscles were examined by

palpation to determine the presence of tenderness.


60

Fig.1: Questionnaire chart. 1. History: The case history of each patient was taken by direct conversation with him or her. A- Personal history -Name………………………….. -Age…… -Sex…………………… -Occupation……………. -Marital status…………………. . -Address -Phone number………………………………… B-Past dental history -Have you had any teeth problems lead to their extraction, yes or no? ......... -If yes: Was there any relation between extraction and onset of complication? ......... -Have you had any oral appliance, yes or no? .............. -Have you had any dental treatment, yes or no? ................... -If yes: What is the kind? Orthodontic treatment, prosthetic appliance, restorative treatment………………… C-Medical history -Have you had any related discomfort, yes or no? ........... -If yes: What is the type? Headache, hypertension, neck ache, other joint pain, ulcer, colitis, ear pain, or change in hearing? ........... -Have you had any previous treatment for pain or muscle, yes or no? -If yes: What is the type? .................. -Have you had any of the following: rheumatoid arthritis, osteoarthritis, sinus infection, ear infection, blood vessels diseases? - Do you take any medication regularly? ........................... D-Chief complaint and present illness -What is the main problem that brings you here? ................................. -Do symptoms affect one or both sides? ............................................ -How long have you been bothered by this problem? ................................... History of chief complaint: 1-pain -Site of pain. -Nature: sharp, lancinating, dull, referred, aching, deep, superficial, pulsating…………….

-Strength: Pain was evaluated by two methods:

- Patient self-assessment using visual analogue scale ranging from 0- 10.

- Pain was estimated by the patient as severe, moderate, or mild.

-Tolerability: tolerable or not………………..

-Onset; immediate, gradual…………………..

-Duration: For how long? ................................... -Course: Progressive, regressive, fluctuant…………………………… -Location: localized or diffuse Unilateral or bilateral? ........................... -Does pain spread, radiate, or migrate? ....................................... -What events that initiate, precipitate or relief the pain? ............................... -Time of pain (morning, afternoon, evening)………………………. 2-Dysfunction -Do you have any disturbance in jaw movements, yes or no? ....................... -Do you grind or clench your teeth at night or during day, yes or no? .......... If yes, what is the kind? .......................................... -Do you have any other oral habits, yes or no? ............................ -Do you notice any change in your ability to chew? ........... 3-Psychological background Do you consider yourself under stress or depression? ...................... Are you under any psychological treatment? .........................


61

III. Dental occlusion examination:

Inspection of dental occlusion to determine the presence of

malocclusion and its relation to TMJ troubles.

The presence of badly constructed movable or fixed restorations and

dental fillings.

MRI investigation:

MRIs were obtained for all patients preoperatively to confirm clinical

diagnosis (Fig.2).

Image Acquisition:

MRI was ordered in closed and open mouth positions.

Closed mouth position: the patients were instructed to put the posterior

teeth in the position where they fit the best and the clinician should

verify it visually. MR images at closed mouth were oblique sagittal

proton density and T2 weighted images at closed mouth using a

dedicated TMJ surface coil.

Open mouth position: each patient was instructed to open as much as she

can. Open MRI were acquired in proton density algorithm only using a

dedicated TMJ surface coil.

A minimum of 6 sagittal slices were taken for each joint with a slice

thickness of 3mm.

Proton density had repetition time (TR): 2,000.0 and an echo time (TE):

17, 0.

T2 had TR: 2,000.0 and TE: 102, 0.

Non Osseous components assessment criteria using MRI:

Disc position; closed mouth position: normally, in the sagittal plane,

relative to the superior aspect of the condyle, the border between the low


62

signal of the disc and the high signal of the retrodiscal tissue is located

between the 11 and 12 clock positions. If the disc is located anterior to

the 11 clock positions, it is considered displaced.

Disc position; open mouth position: normally, the intermediate zone is

located between the condyle and the articular eminence. if the

intermediate zone is located anterior to the condylar head, the disc is

considered non-reduced displaced

Effusion; T2 closed mouth position: it was considered positive if a

bright signal was seen in either joint space that conforms to the contours

of the disc, fossa/articular eminence, and/or condyle.

Disc diagnosis for TMJ using MRI :

Normal: Disc location is normal in closed and open mouth positions.

Disc displacement with reduction (DDwR): Disc is displaced

anteriorly in closed mouth position and normal in open mouth position.

Disc displacement without reduction (DDnR): Disc is displaced

anteriorly in both closed and open mouth positions.(Fig.3)

Not visible: Neither signal intensity nor outlines make it possible to

define a structure as the disc in the closed-mouth and open-mouth

Standardization of MR and inter-examiner reliability:

The MRI examinations were conducted at the same centre (Kasr el aini

radiology department-Cairo University) to ensure standardization of the

technique. The MR imaging was acquired on MR machine, Intera 1.0 Tesla

superconductive unit with bilateral TMJ surface coil. All MRI images were

reviewed with 2 different clinicians


63

Fig.2: Sagittal proton density MR image for the left joint in the closed mouth position (A) showing anterior disc displacement and in open mouth position (B) showing non reducible disc

Arthrocentesis technique:

The patient head was draped in the usual surgical manner. The ear and the

operated preauricular area were disinfected using Betadin*4 surgical scrub

solution.

Two points were marked on the skin over the articular fossa and eminence

along a line drawn from the middle of the tragus to the outer canthus of the

eye (Fig. 3A).

The posterior inlet point was located 1 cm from the middle of the tragus along

the canthotragal line and 0.2 cm below the line.

The anterior outlet point was located 2 cm from the middle of the tragus and 1

cm below the canthotragal line.

Auriculotemporal nerve block anesthesia was then performed using

Mepecaine L*5 (Fig.3B).

Few drops of local anaethesia were injected subcutaneously at the anterior and

posterior points (Fig.3C).

4 * Betadin: povidine-iodine USP Nile Pharmaceuticals Co., Cairo, Egypt.

5 * Mepecaine L: Mepevacaine Hcl 2% with Levonordefrin 1:20000, Alexandria Co.for

pharmaceuticals, Alexandria, Egypt

A B


64

About 1cm spacer was placed between teeth to increase the intra-articular

space and to stabilize and fix the condylar position at the operated side during

injection.

At the posterior inlet point, a16 gauge cannula was inserted into the superior

joint space and 2 ml of saline was injected through it into the superior joint

space. The joint entry was confirmed by the presence of back pressure during

injection, and the flow back of some drops of the solution from the inlet

needle (Fig.3D). Then 2 ml of Saline was injected into the superior joint space

to distend it (Fig.3E).

At the outlet anterior point another 16 gauge cannula was inserted into the

distended compartment to permit an outflow for the irrigating solution which

was collected in a kidney dish. Manual lavage with 200 ml saline was then

performed to establish free flow of the solution and to release adhesions

(Fig.3F). During lavage the outlet cannula was momentarily blocked with

finger pressure 2 or 3 times, and the patient was instructed to move the

mandible through opening, protrusive, and lateral movements to facilitate

lysis of the joint adhesions.

At the end of the procedure, the outflow cannula was removed and the inlet

cannula was used to inject into the joint space 1 ml of (40mg/1ml)

Depomedrole.

The inlet cannula was then removed and the patient was instructed to gently

manipulate the jaw in vertical, protrusive, and lateral excursion to remove any

excess of intra-articular fluid.

Post operative care and instructions

Each patient was instructed for ice bags application over the operated preauricular

region. The ice bags were applied for 10 minutes followed by 10 minutes rest for

4-6 hours postoperatively in order to decrease post operative edema.


65

All patients were given postoperative medications as following:

o Non steroidal anti-inflammatory drug (Antiflam 50 mg, one tablet twice daily

for 1 week)

o Antibiotic (E-mox*6

500 mg, every 6 hours for 3 days) as a prophylactic

measure in order to overcome any possibility of joint space infection.

Each patient was instructed to apply hot fomentation at TMJ area 24 hours

after injection (for 20 minutes/hour, 6 times daily) to reduce inflammation and

edema.

Course of physiotherapy in the form of muscle exercise was commenced

immediately postoperatively for rehabilitating the muscle length and

strengthens the muscles that surround the joint. The following 3 exercises

were performed

Passive stretch exercise: The patient opened to the full limit of movement and

then gently stretched beyond the restriction assisted by placing the fingers

between the teeth. The stretching was gentle and momentary so as not to

traumatize the muscle tissues. (101,252)

Resistant opening to encourage harmonious bilateral muscular contraction.

The thumb was placed under the chin and the patient opened against gentle

resistance. This exercise was repeated 10 times for 3 periods during the day.

The resistant force provided by the finger was gentle and did not induce

painful symptoms.(101,252)

Minimize Zigzag opening A mirror and a straight edge were used. Patient

practiced making lower midline open and close along a straight line. This

exercise was repeated 10-20 times for 3-4 times during the day. (101)

6 *

E-mox 500 mg: Amoxycilin (as trihydrate) 500 mg Manufactured by Egyptian Int

Pharmaceutical Industries Co. E.I.P.I.CO, Egypt.


66

The patients were instructed to wear the previously performed occlusal splint

day and night and to remove it only for cleaning and at eating time for one

month then it was removed gradually according to the improvement of signs

and symptoms and the patient condition.

Each patient was instructed to receive soft diet only for two weeks in order to

decrease the effort upon TMJ.


67

Fig. 3: Arthrocentesis technique. A: Making 2 points for inlet and outlet needles. B:

Auriculotemporal nerve block anesthesia. C: Subcutaneous injection of local anesthetic at

the outlet needle site. D: Flow back of some drops of the solution from the inlet needle. E:

Distension of the upper compartment. F: Insertion of the outlet needle and manual

washing of the upper compartment with establishment of free flow of the washing

solution.

A B

C D

F E

Outlet

point

Inlet point


68

Arthroscopic lysis and lavage procedure:

Armamentarium:

Delivery system:

a) Cannula (sheath): 2.2 mm protective metallic sheath.

b) Sharp trocar

c) Blunt trocar

Arthroscope proper: arthroscope rod lens type, 2.0 mm 30° angle (KARL

STRORZ, Germany)

Illumination system: Halogen light source with a fiberoptic cable (KARL

STRORZ, Germany)

Documentation system:

a) single chip digital video camera composed of head and a camera

console ( LEMEKE, vision, Germany)

b) Digital video CD recorder and player (Caira Corporation, China)

and DVDs

c) Monitor

Arthroscopic technique:

Arthroscopic procedures were carried out under general anesthesia via

nasotracheal intubation. All the procedures were done by the same specialist

and assistant. The surgical field was scrubbed with betadine solution and the

patient was draped in the usual manner with sterile towels.

Skeletal landmarks including the glenoid fossa and articular eminence

were marked with a marking pen (20)

.The Hollmlund- Hellsing

(canthotragal) line was drawn from the lateral canthus of the eye till the tip

of the tragus of the ear. From the tip of the tragus, a point was marked 10

mm anterior to the tragus along the canthotragal line and 2 mm inferior to


69

the line. This point represented the puncture site into the posterior recess of

the upper joint space. A second point was marked 20 mm anterior to the

tragus along the canthotragal line and 10 mm inferior to it. This point

represented the site of the entry of the outflow needle in the anterior recess

of the upper joint space.

For distension of the superior compartment and in order to avoid

iatrogenic damage to the cartilaginous surfaces during introduction of the

trocar and to provide a degree of hemostasis during the procedures, the

assistant surgeon distracted the mandible anteriorly and inferiorly, and 1.8

mL of 2% mepivacaine with 1:200,000 epinephrine was injected into the

superior joint space. A syringe with a 21-gauge needle, filled with 2-3 mL

lactated Ringer’s solution, was then introduced through the puncture point

into the superior joint space for further insufflation and distention (Fig.4A).

As described by MCcain (138)

, the first puncture was placed at the

maximum concavity of the glenoid fossa using the inferolateral approach. A

sharp trocar protected by an outer cannula was advanced through the

puncture point (10-2mm point) till contacting the bone of lateral crest of the

fossa. Puncture of the capsule was accomplished by rotating the trocar till a

pop was felt (Fig.4B). By use of the locked connections, lactated Ringer’s

solution was introduced into the joint space to confirm the position of the

cannula. (Fig.4C) Once the capsule had been entered, the sharp trocar was

removed to avoid scuffing of the articular surfaces and a blunt trocar was

introduced in the cannula.(Fig.4D) The head of the single ship digit camera

(LEMEKE, vision, Germany) was attached to the ocular end of the

arthroscope (KARL STORZ, Germany). The fiber optic cable of the halogen

light source (KARL STORZ, Germany) was also attached to the caudal end

of the arthroscope (Fig.4E).


70

2.0mm arthroscope was inserted into the cannula and the cannula was

locked. The arthroscopic image was received on the connected monitor and

was used to verify for proper placement in superior compartment. After

receiving arthroscopic image of the superior joint space, capsular distension

and intermittent lavage with Ringer’s lactate were maintained through the

irrigation system. The upper joint compartment was examined from the

posterior pouch via the intermediate zone to the anterior pouch and was

swept clear under constant irrigation. This manipulation allows translation of

the disc along the eminence, allowing the condyle to complete its natural

path.

An outflow cannula was inserted 10 mm anterior and 8 mm inferior to

the first puncture site to allow outflow of the irrigating solution (Fig.4F).

Joint lavage was the achieved using continuous irrigation of 500ml Ringer's

lactate solution. The quality of image was checked and diagnostic sweep

from posterior synovial pouch to anterior synovial pouch was made. The

arthroscopic images were recorded and saved on DVDs as MPEG4 format

using digital video CD recorder and player.

Once the diagnostic examination and lysis and lavage procedures were

finished, termination of the procedure was done first by unlock the

arthroscope from the cannula, followed by cannula and outflow needle

withdrawal. Cloth adhesive strips were applied to the skin punctures. For

each TMJ, the extent, and distribution of various arthroscopic variables were

recorded in a written form immediately after the arthroscopic examination.


71

Fig. 4: Arthroscopic technique. A: Distension of the upper compartment of the TMJ. B: A sharp

trocar in an arthroscopic sheath inserted into upper posterior recess C: 2.0 mm arthroscope fiber

optic light transmission was inserted into the cannula. D & E: Capsular distension and intermittent

lavage with Ringer’s lactate were maintained through the irrigation system. F: Insertion of an

outflow cannula into the upper TMJ space..

C

A B

D

E F


72

Post operative care and instructions

Routine analgesic (Antiflam 50mg Tid) and a routine antibiotic (E-

mox 500mg Tid) were prescribed for the first post operative week. On

second post operative day, passive mandibular exercises were started. The

patients were asked to continue mandibular exercise for at least 1 month.

Patients were instructed to follow a soft diet till the end of the second post

operative week

Description of the normal arthroscopic anatomy:

After the arthroscope was introduced in the superior joint space, sequential

examination started in each procedure based on the protocol suggested by

MCcain (253)

.Seven areas of the superior joint space can be examined. These

areas are:

1. Medial synovial drape

2. Pterygoid shadow

3. Retrodiscal synovium:

a. Zone 1: oblique protuberance

b. Zone 2: retrodiscal synovial tissue attached to posterior glenoid process

c. Zone 3: lateral recess of retrodiscal synovial tissue

4. Posterior slope of articular eminence and glenoid fossa

5. Articular disc

6. Intermediate zone

7. Anterior recess


73

The first area to be arthroscopically examined is the medial synovial

drape which has a gray-white translucent lining and a tense

appearance with distinct superior-to-inferior striae, which serve as the

first classic anatomic landmark. (Fig. 5A)

The second area to be examined is the pterygoid shadow which is

located anterior to the medial synovial drape and frequently well

marked. In normal situations, the pterygoid shadow has a purple

appearance, because of the pterygoid muscle under the synovial

lining.(Fig.5B)

The third area to be examined is the retrodiscal synovium. A key point

within the superior joint space is the synovial membrane with a soft

appearance, located in the posterior side of the posterior synovial

recess. From the lateral side, several folds on the surface of the

synovial membrane appears, and they disappear as long as the disc is

displaced anteriorly. The synovial membrane covers the posterior

insertion of the disc and is reflected superiorly to the temporal fossa.

While the mouth is open, the posterior insertion covered by the

synovial lining appears as a crest or crease. This finding is named

oblique protuberance. The location of the oblique protuberance is in

the middle third of the retrodiscal synovium. The vascular network is

observed throughout the normal synovial membrane.(Fig.5C)

The fourth area of the joint is the posterior slope of the articular

eminence. The fibrocartilage is white and highly reflective with

anteroposterior striae. In the back slope of the eminence, the

fibrocartilage is thick. Toward the glenoid fossa, the fibrocartilage

becomes darker and thinner, and becomes thin without striae over the

glenoid fossa.(Fig.5D )

The articular disc, which is the fifth area to be examined, is milky

white, highly reflective, and without striae. In normal conditions, its


74

surface is smooth and without fibrillations. The red-white line is the

union between the posterior band of the disc and the

synovium.(Fig.5E)

The intermediate zone is the sixth area to be examined. Without

disorders, this area has a white-on-white appearance of the disc

opposite to the eminence. This means as well that the disc completely

roofs the condylar head (100% roofing).(Fig. 5D)

In the anterior recess, the anterior slope of the articular eminence is

evident. The fibrocartilage and the anterior band of the disk maintain

the same color but without striae. In this zone, the anterior band of the

disc, anterior synovial pouch and the pterygoid shadow can be seen.

The junction between the anterior band and the anterior synovuim is

termed the disc synovial crease. The most lateral part of the anterior

synovial crease represents the site of the entry of the outflow needle in

the arthroscopic lysis and lavage or the working cannula in

triangulation procedures


75

Fig.5: Normal arthroscopic findings. Medial synovial drape (MSD) and disc (D) Eminence (Em),

Pterygoid shadow (PS) Retrodiscal synovuim (RDS) A: Normal medial Synovial drape. B: Condyle

opposite eminence. C: Healthy disc. the pterygoid shadow and the posterior band of the disc D:

Intermediate zone (normal white to white appearance). E: Ascending slope of the eminence (black

arrow), the pterygoid shadow and the anterior band of the disc.

A B

C D

E


76

E: Medial drape showing synovitis . F: Moderate synovitis of the retrodiscal synovuim.G: Adhesion.

C

A B

D

E F

G

Fig.6 : Abnormal arthroscopic findings A

& B: On opening, the retrodiscal synovuim is

seen opposite to the eminence (disc

displacement without reduction).C:

retrodiscal synovuim with Mild synovitis,

arrow denotes the end of the retrodiscal

synovuim and beginning of the posterior

band. D: Slight disc fragmentation (arrow).

Significant redundency of the retrodiscal

synovuim


77

Outcome measures

I. Clinical outcome measures

The following outcome measures were clinically assessed and documented

immediately postoperatively, after one week, and three months

postoperatively.

Patients’ subjective pain experience. Each patient rated her pain at

rest and during function on numerical rating scale (NRS) of 0-10 with

zero being no pain and ten corresponds to the worst pain that the

patient ever had.

Maximum mouth opening (MMO). Assessment of MMO was

performed by measuring the distance in mm between the incisal edges

of the upper and lower central incisors using a ruler.

Mandibular dysfunction. Assessment of TMJ dysfunction was

performed using Helkimo’s index.

II. MRI parameters

The disc position, mobility, and morphology were assessed and documented

at the baseline and three months postoperatively.

Disc displacement was classified as normal (no displacement), mild

(disc displacement with reduction), and severe (disc displacement

without reduction).

Disc morphology was clarified in the closed-mouth projection in the

sagittal plane and classified as normal (biconcave- shape), mild

(biplanar or convex-shape), or severe (folded-shape or amorphous).

The disc mobility was determined in the closed- and opened mouth

projection in the sagittal plane. It was classified as mobile (normal) if


78

the disc changed its position relative to the glenoid fossa and the

articular eminence. Disc fixation was considered to be present in case

of lack of the position change.(251)

III. Success criteria

The treatment was considered successful if mouth opening capacity

was at least 35 mm at the end of the study and TMJ pain according to a 10-

graded NRS as assessed by patients as 4 or less.

Statistical analysis

Data were presented as mean and standard deviation (SD) values. Data

were explored for normality using Kolmogorov-Smirnov and Shapiro-Wilk

tests. Maximum inter-incisal opening (MIO) data showed normal

(parametric) distribution while Helkimo index scores, Numerical rating

scores and % changes in different variables showed non-parametric

distribution.

The percentage changes of these parameters were calculated as:

( ) ( )

( )

For parametric data, Student’s t-test was used to compare between the

two groups. Paired t-test was used to study the changes by time in each

group.

For non-parametric data, Mann-Whiteny U test was used to compare

between the two groups. Wilcoxon signed-rank test was used to study the

changes by time in each group.


79

The significance level was set at P ≤ 0.05. Statistical analysis was

performed with IBM®

SPSS®

Statistics Version 20 for Windows.

®

IBM Corporation, NY, USA.

® SPSS, Inc., an IBM Company.

RESULTS

Results

80

Results

Postoperative course:

Generally, all patients in both groups tolerated the treatment

procedures with no major complications. In the arthroscopy group, 2 patients

complained of blocked ears, and two other patients reported vertigo. The

vertigo lasted approximately 24 to 72 hours, and the blocked ears lasted 2 to

6 days.

3 patients from the Arthrocentesis group experienced transient facial

palsy due to the anaethetic technique that resolved within 1-2 hours

postoperatively, 2 patients showed pre-auricular swelling due to fluid

extravasation of the articular capsule that resolved by the second

postoperative day.

Clinical results

Subjective findings:

Tables 6, 7, 8 and 9 summarize the assessments of TMJ pain using

Numeric Rating Scale (NRS). Pre-operatively as well as after 1 week; there

was no statistically significant difference between the two groups. After 3

months, Group I showed statistically significantly lower mean NRS score

than that of Group II (Fig.7).

Both groups showed statistically significant decrease in mean NRS

scores throughout the study periods (Fig.8). Comparison between the

percentages decrease in NRS scores in the two groups showed no

statistically significant difference (Fig.9).

Results

81

Table 6: The mean, standard deviation (SD) values and results

of Mann-Whitney U test for comparison between Numerical

rating scores in the two groups

Group

Period

Group I Group II P-value

Mean SD Mean SD

Pre-operative 7 1.7 8.3 1 0.166

1 week 3.3 1.4 3.7 1.6 0.801

3 months 1.3 0.8 4 2.6 0.026*

*: Significant at P ≤ 0.05

Table 7: The mean difference, standard deviation (SD) values

and results of Wilcoxon signed-rank test for the changes by

time in mean Numerical rating scores of Group I

Period Mean difference SD P-value

Pre-operative – 1 week -3.7 1.8 0.026*

Pre-operative – 3 months -5.7 1.4 0.027*


Table 8: The mean difference, standard deviation (SD) values

and results of Wilcoxon signed-rank test for the changes by

time in mean Numerical rating scores of Group II





Results

82

Fig. 7: Bar chart representing comparison between Numerical rating scores in the two groups

Fig. 8: Line chart representing changes by time in mean Numerical rating scores in the two groups

Fig. 9: Bar chart representing comparison between % decreases in Numerical rating scores in the

two groups

Results

83

Table 9:The mean, standard deviation (SD) values and results of

Mann-Whitney U test for comparison between % decreases in

Numerical rating in the two groups

Group

Period


Mean SD Mean SD

Pre-operative – 1 week 51.4 15.4 55.8 18.7 0.686

Pre-operative – 3 months 81.3 7.8 51.4 29.7 0.078


Objective findings

Maximum interincisal opening (MIO)

Tables 10, 11, 12 and 13 show the assessments of MIO at the study

intervals. Pre-operatively as well as after 1 week; there was no statistically

significant difference between MIO in the two groups. After 3 months,

Group I showed statistically significantly higher mean MIO than Group

(Fig.10).

Table 10: The mean, standard deviation (SD) values and

results Student’s t-test for comparison between MIO in the

two groups

Group

Period


Mean SD Mean SD

Pre-operative 21.3 2.5 20.5 3.3 0.631

1 week 34.8 1.2 33.3 3.8 0.380

3 months 38.7 1.2 34.5 4.3 0.046*


Results

84

Throughout the study periods, there was a statistically significant

increase in mean MIO in both groups (Fig.11) and insignificant difference

between the two groups regarding the percentages increases in MIO (Fig.12).

Fig. 10: Bar chart representing comparison between MIO in the two groups

Table 11: The mean difference, standard deviation (SD) values and

results of paired t-test for the changes by time in mean MIO of Group I


Pre-operative – 1 week 13.5 2.1 <0.001*

Pre-operative – 3 months 17.3 1.9 <0.001*


Table 12: The mean difference, standard deviation (SD) values and

results of paired t-test for the changes by time in mean MIO of Group II


Pre-operative – 1 week 12.8 5.9 0.003*

Pre-operative – 3 months 14 5.7 0.002*


Results

85

Fig. 11: Line chart representing changes by time in mean MIO in the two groups

Table 13: The mean, standard deviation (SD) values and results of

Mann-Whitney U test for comparison between % increases in MIO in

the two groups

Group

Period


Mean SD Mean SD

Pre-operative – 1 week 64.8 16.5 67.4 40.1 0.936



Fig. 12: Bar chart representing comparison between % increases in MIO in the two groups

Results

86

Mandibular dysfunction

Tables 14, 15, 16 and 17 show the assessments of TMJ dysfunction

using Helkimo’s indices at the study intervals. Pre-operatively as well as

after 3 months; there was no statistically significant difference between

Helkimo index scores in the two groups. After 1 week, Group I showed

statistically significantly lower mean Helkimo index score than Group II

(Fig.13).

Table 14: The mean, standard deviation (SD) values and

results of Mann-Whitney U test for comparison between

Helkimo index scores in the two groups

Group

Period

Group I Group II

P-value

Mean SD Mean SD

Pre-operative 21.7 3.9 23 3.3 0.527

1 week 4.7 2.3 10.7 3.8 0.012*

3 months 2.5 0.8 4 2.4 0.162


Table 15: The mean difference, standard deviation (SD)

values and results of Wilcoxon signed-rank test for the

changes by time in mean Helkimo index scores of Group I


Pre-operative – 1 week -17 3 0.027*



Results

87

Throughout the study periods, there was a statistically significant

decrease in mean Helkimo index score in both groups (Fig.14). On

Comparing between the two groups, Group I showed statistically

significantly higher mean percentages decrease in Helkimo index scores than

that in Group II. However, no statistically significant difference existed at

the end of the study (Fig.15).

Fig.13: Bar chart representing comparison between Helkimo index scores in the two groups

Table 16: The mean difference, standard deviation (SD)

values and results of Wilcoxon signed-rank test for the

changes by time in mean Helkimo index scores of Group II



Pre-operative – 3 months -19 3.7 0.027*


Results

88

Success rate

According to our success criteria, the arthroscopic group showed 100%

success while 4 out of 6 cases (66.7%) were successful in the arthrocentesis

group. The remaining two cases showed postoperative improvement but

beyond our success criteria.

Table 17: The mean, standard deviation (SD) values and results of Mann-Whitney

U test for comparison between % decreases in Helkimo index in the two groups

Group

Period


Mean SD Mean SD

Pre-operative – 1 week 78.9 7.4 53 16.1 0.010*



Fig.14: Line chart representing changes by time in mean Helkimo index scores in the two groups

Results

89

Fig.15: Bar chart representing comparison between % decreases in Helkimo index scores in the two groups

Qualitative analysis of MRI

Comparison of characteristics between the arthroscopic and the

arthrocentesis joints is summarized in Table 18, 19 and 20. Both groups

showed improvement in the evaluated parameter by time. Postoperatively,

there was no statistically significant difference between the two groups with

regard to disc position, disc mobility and disc configuration. However,

arthroscopy group showed statistically significant higher prevalence of

condylar translation than arthrocentesis group (Figs. 16,17)

Results

90

Fig.16: Sagittal proton density MR images for left joint in the closed mouth position 3 months after arthroscopic lysis and lavage. Showing anterior disc displacement and in open mouth position Recapture of the disc.

Table 18: Comparison of characteristics between the

arthroscopic and the arthrocentesis joints

Group

Parameters

Group I

Group II

Disc displacement DDwR : 5

DDnR: 1

DDwR: 4

DDnR: 2

Morphologic change of disc Normal: 4

Mild: 1

Severe: 1

Normal, 2

Mild, 0

Severe 4

Disc mobility Mobile: 6

Fixed: 0

Mobile: 5

Fixed: 1

Condylar translation Present: 6

Absent: 0

Present: 3

Absent: 3

Disc position Changed: 5

No change: 1

Changed: 3

No change: 3

A B

Results

91

Table 19: The frequencies (n), percentages (%) and results of

Chi-square test for comparison between the two groups

Group

Parameter

Group I Group II

P-value

n % n %

Disc position 5 83.3 4 66.7 0.505

Disc mobility 6 100 5 83.3 0.296

Disc configuration 5 83.3 2 33.3 0.079

Condylar translation 6 100 2 33.3 0.014*

Table 20 : MRI assessment of the therapeutic outcome in the two groups

MRI Parameter Improve No Change

Disc displacement

Arthroscopic joints

Arthrocentesis joints

5

4

1

2

Morphologic change of the TMJ disc

Arthroscopic joints


4

2

2

4

Disc mobility

Arthroscopic joints


6

5

0

1

Condylar translation

Arthroscopic joints


6

3

0

3

Disc position

Arthroscopic joints


5

3

1

3

Results

92

Fig.17: Bar chart representing comparison between MRI findings in the two groups

DISCUSSION

Discussion

93

Discussion

Arthroscopic lavage and Arthrocentesis are the current minimally

invasive techniques used to treat TMJ closed lock that fail to improve

following a reasonable course of non-surgical therapy. Despite of the great

similarity in methodology and philosophy, comparison between these

methods is important because of the difference in the required training and

skills as well as the cost. Most studies on this subject were retrospective and

uncontrolled centered on the clinical results attending each technique, with

no regard to their influence on disc position, mobility, and morphology.

Arthrocentesis and Arthroscopy work well when the pain is only

localized to the TMJ.(118)

To control the present study, it was imperative to

exclude patients with combined muscular and articular disorders or at least

we did not perform our intervention unless the muscular pain was properly

controlled. In the present study, the entire evaluated parameters were not

significantly different between groups preoperatively which are important as

part of the statistical protocol. Also, the establishment of specific inclusion

criteria is important when judging results.

Within the context of TMJ diseases, one logical parameter of success

was considered to be “changing the impaired mandibular function in

sufficient measure” as the result of restored movement and reducing pain in

the TMJ. In the present study, clinical assessment of both groups showed

statistically significant decrease in mean NRS scores, statistically significant

increase in mean MIO and statistically significant decrease in mean Helkimo

index score throughout the study periods. This could be attributed to the

ability of these techniques to eliminate restrictions on the disc and lateral

capsule, to wash out microscopic debris resulting from the breakdown of the

Discussion

94

articular surfaces, to irrigate the joint of enzymes and prostaglandins and to

stimulate the normal lubricating properties of the synovial membrane (253)

Pain decrease after arthrocentesis was shown to be related to the reduction of

pain and inflammatory mediators (147,254,255)

.The alleviation of clinical signs

and symptoms of closed lock by arthrocentesis and arthroscopic lysis and

lavage in the current study supports their reported effectiveness to relieve

TMJ painful hypomobility (16,147,254,255,256,257,258,259)

The success rate of the arthrocentesis group in our study was 66.7%.

This finding is disappointing compared to that of reported by Nitzan(253)

who

noted the results obtained at three centers (in Japan, Israel and the United

States) to determine the efficacy of arthrocentesis in the management of

closed lock and found that the results in 68 patients presenting with

symptoms of severe closed lock included a maximal-mouth-opening increase

from an average of 25.29 mm to 43.6 mm and that the overall, arthrocentesis

was successful in 94.1% of patients. The lower success rate in the present

study could be attributed to the disadvantage of small sample size that

exaggerates the positive as well as the negative findings. Nevertheless, our

result is within the range reported by Monje-Gil et al (260)

who reported that

in most of the publications reviewed, improvement in maximum jaw opening

and the reduction of pain levels and articular dysfunction on the VAS were

the criteria used to define a successful result. They found that the results of

the studies reviewed show that 612 joints with acute closed lock (disc

displacement without reduction or anchored disc phenomenon) in 586

patients were successfully treated with arthrocentesis with the rate of success

ranged from 64 -100 %. They stated these criteria were defined with

considerable variability, and the precision limits of the measurement

procedure applied were not described in any study and that these are usually

Discussion

95

based on conviction rather than on a research design proper and statistical

analyses.

The success rate of the arthroscopic group in our study was 100% with

the mean of NRS scores was 1.3 ± 0.8 and that of MMO was 38.7± 1.2 mm

at the end of the study. This finding compares favorably to that of

Murakami et al.221

, Fridrich et al261

, Ohnuki et al262

, and Smolka & Iizuka 263

who reported success rates of 91%, 82%, 74%, and 78%, respectively. The

higher success rate in the present study could be attributed to the

disadvantage of small sample size that exaggerates the positive as well as the

negative findings. In a retrospective study, Hansson (264)

investigated what

characterizes a successful and an unsuccessful outcome of TMJ arthroscopic

surgery, Of 67 patients treated with arthroscopic lysis and lavage, he found

46 successful and 21 unsuccessful cases with a success rate of 68.7% that

was considered somewhat disappointing. He stated that one explanation for

this result may be the strict success criteria he used which was almost the

same criteria used in the current study. He found that the mean maximum

preoperative mouth opening among patients with successful outcome was

33.53 (range 20 - 50) mm. The corresponding value among the unsuccessful

cases was 28.90 (range 20 – 51) mm. The difference in terms of mean

maximum preoperative mouth opening in relation to successful or

unsuccessful outcome was statistically significant. These values are much

higher than that of the arthroscopic group in the present study which was

21.3 ± 2.5 mm.

In our study, both groups showed improvement in the evaluated

parameter by time with a range of 33.3 – 83.3 % for arthrocentesis group and

of 83.3 - 100 % for arthroscopic group. Postoperatively, there was no

statistically significant difference between the two groups with regard to disc

position, disc mobility and disc configuration. However, arthroscopy group

Discussion

96

showed statistically significant higher prevalence of condylar translation

than arthrocentesis group. This could be attributed to the relatively higher

hydraulic pressure during arthroscopic lavage compared to the manual

pressure applied during arthrocentesis and emphasizes the concept of

Nitzan(253)

who believed that a major part of the success of surgical

arthroscopy in the treatment of severe closed lock is attributable to the

lavage rather than to the surgical instrumentation. These findings in part

support Sanders’(265)

concept that in cases of chronic closed lock, intra-

capsular lysis using probes between the disc and fossa is necessary to release

superior compartment adhesions. Since all the arthroscopic joints showed

disc mobility while 5 out of 6 showed the same finding in arthrocentesis

joints.

Recapturing the disc with arthrocentesis was observed in 4 out of 6

joints. Disc mobility and morphology after arthrocentesis showed

considerable improvement in 5 and 2 joints respectively. In contrast,

Emshoff et al. (266)

studied patients with MRI but found no change in the

prevalence rates of the types of ID after the treatment, demonstrating that

arthrocentesis is a valuable procedure for alleviating or eliminating pain and

dysfunction and re-establishing MMO rather than re-altering disc position or

shape. Our findings also compare favorably to those of Ohnuki et al (267)

.In

his study, 1 out of 9 joints (11.1%) affected by DDnR and treated with

arthrocentesis showed anterior disc dislocation with reduction on

postoperative MRI.

Also Sembronio et al (268)

performed arthrocentesis and mandibular

manipulation as an initial treatment in 33 patients with closed lock and found

that the disc was recaptured in only 3 cases.

Discussion

97

Our observation is in general agreement with that of Lee and Yoon

(269) who evaluated the clinical outcome and MRI changes of patients with

TMJ internal derangement before and after performance of arthrocentesis

and stabilization splint therapy and found that arthrocentesis and

stabilization splint therapy provide significant improvement in the clinical

outcome, disc position, disc mobility and joint effusion.

Disc mobility, position and morphology after arthrocentesis showed

considerable improvement in 6, 5 and 5 joints respectively. These results are

in general agreement with those of Moses et al (270)

who found improvement

in disc position and morphology following arthroscopic lysis and lavage.

Contradictory, other studies reported an increase in fibrous adhesions after

arthroscopic lysis and lavage (271)

even disc reposition may not always be

successful (262,272)

. Gabler et al (273)

used MRI to assess disc–condyle

relationships before and after arthroscopic surgery for symptomatic TMJ

disorders associated with disc displacement. Disc positions relative to

condyles were found to be generally unchanged. Nevertheless, 11 of 12

patients (92%) were judged to have had successful outcomes based on

criteria that included presence of pain, interincisal opening, protrusive and

excursive mandibular movements and masticatory function. They suggested

that repositioning or reduction of displaced discs is not a prerequisite for

clinical success in symptomatic patients. Our results support the observation

of Ohnuki et al (262)

who studied MRI of TMJ discs before and after

arthroscopic surgery for TMJ disorders, and found that disc mobility

increased, nevertheless deformity of the discs progressed after arthroscopic

surgery and disprove their observation that disc position remained anterior

displaced without reduction after arthroscopic surgery.

Concerning disc mobility, the disc mobility progressed in all the joints

treated with arthroscopy and in 5 out of 6 joints treated by arthrocentesis.

http://www.ncbi.nlm.nih.gov/pubmed?term=Lee%20SH%5BAuthor%5D&cauthor=true&cauthor_uid=19138604

http://www.ncbi.nlm.nih.gov/pubmed?term=Yoon%20HJ%5BAuthor%5D&cauthor=true&cauthor_uid=19138604


Discussion

98

This indicates that the joints with a fixed disc respond well to both

techniques and supports the hypothesis that the rationale of lysis and lavage

of the TMJ is to release the disc, and to enable mobilization of the joint by

flushing the upper joint space. This result was compares favorably to that of

kurita et al (143)

who found improvement in disc mobility in 6 out of 11 joint

treated with arthroscopy

By the end of the present study, arthroscopic group showed significant

reduction of pain and increase in mouth opening and insignificant decrease

of Helkimo index score when compared with those of the arthrocentesis

group. According to our success criteria, the arthroscopic group showed

100% success while 4 out of 6 cases (66.7%) were successful in the

arthrocentesis group. In contrast Nitzan (274)

showed that the mean MIO

following arthrocentesis surpassed arthroscopic surgery due to the formation

of intra-articular scarring inflicted upon the TMJ by arthroscopic surgery.

This finding is in general agreement with those of other studies.(126,253,254)

Fridrich et al (275)

studied 19 patients randomized into one of two groups:

arthroscopic lysis and lavage, or arthrocentesis and patients were followed

26 months postoperatively. There were no statistically significant differences

in outcome between the two groups for any of the parameters evaluated. The

overall success rates were 82% for arthroscopy and 75% for arthrocentesis.

Therapeutic success rates were not significantly different for arthroscopy and

arthrocentesis; both modalities were useful for decreasing TMJ pain while

increasing functional range of mandibular motion. Murakami (221)

reported

that the clinical efficacy of arthrocentesis might be somewhat inferior to that

of arthroscopic surgery. However, the comparison between group differences

of the post-operative data of VAS, pain, jaw dysfunction and jaw opening

revealed no statistical differences.

SUMMARY AND

CONCLUSIONS

Summary and Conclusion

99


The purpose of this study was to evaluate the clinical outcome and the

changes in disc position, mobility, and morphology in patients with

temporomandibular joint closed lock in response to arthroscopic lysis and

lavage versus arthrocentesis using (MRI).

Subjects were chosen to participate in this study suffered from closed

lock, based on clinical and MRI findings. Twelve out of 23 patients

(52.17%) did not respond to the used conservative therapy. Their ages

ranged from 22-34 years, with an average of 29.4 years. They were all

females. They were assigned in into 1 of 2 equal groups:

Group I:

-Arthroscopic lysis and lavage was performed with intra-articular injection of

1ml of Depomedrole (40mg/1ml) at the end of the procedure.

Group II:

-Arthrocentesis was performed with intra-articular injection of 1ml of

Depomedrole (40mg/1ml) at the end of the procedure.

The evaluated parameters include assessment of articular pain (0 – 10

NRS), MMO and mandibular dysfunction as expressed by Helkimo index

scores. The clinical outcome measure parameters were assessed

preoperatively, then 1 week and 3 months postoperatively. The treatment

outcome was judged according to our success criteria. The MRI parameters

including changes in disk position, mobility, and morphology and clinical

outcomes were statistically analyzed.


100

By the end of the present study, arthroscopic group showed significant

reduction of pain and increase in mouth opening and insignificant decrease

of Helkimo index score when compared with those of the arthrocentesis

group. According to our success criteria, the arthroscopic group showed

100% success while 4 out of 6 cases (66.7%) were successful in the

arthrocentesis group.

MRI assessment revealed considerable improvement in the evaluated

parameter by time in both groups. Postoperatively, there was no statistically

significant difference between the two groups with regard to disc position,

disc mobility and disc configuration. However, arthroscopy group showed

statistically significant higher prevalence of condylar translation than

arthrocentesis group

Conclusions

The efficacy of TMJ arthrocentesis and arthroscopy for treatment of

closed lock is emphasized once again to reduce symptoms of pain and

limited mouth opening. However, the clinical efficacy of arthrocentesis is

somewhat inferior to that of arthroscopic surgery. Nevertheless, its

simplicity makes it the treatment of choice when conservative therapy failed.

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ARABIC SUMMARY

132

الملخص العربي

نقذ كا دائا عالج اضطزاتاخ انفصم انفكي انصذغي أيزا يحيزا ظزا نقص فى فسينجيا

أيزاض انفصم انفكي انصذغي .

ذ انذراسح قيد ذأثيز انغسيم انفصهي انظار كالا اكهييكيا اشعاعيا نزض االضطزاتاخ

انفصهيح انفكيح.

اثي عشز يفصم فكي صذغي يصاب تانخهم انذاخهي .أجزيد ذ انذراسح عه

جايعح انقازج . –كهيح طة انفى األسا –ذى اخريار انزض ي قسى جزاحح انفى انج انفكي

ذى خضع انزض نهعالج انرحفظي تاسرخذاو يضاد االنراتاخ يثسطاخ انعضالخ نذج ثالثح

.أشز فهى يسرجيثا نذا انعالج

قسيى انزض ان يجعري:ذى ذ

للمجموعة األولىانظار .

للمجموعة الثانية انثزل.

ذى يزاجعح انزض اكهييكيا اشعاعيا تاسرخذاو انزي انغاطيسي تعذ أسثع تعذ ثالثح أشز.

في ىذه الدراسة وجد تحسن في األعزاض االكلينيكيو للمزضي في المجموعتين لكن اشعاعيا

ام الزنين المغناطيسي وجد تحسن و تغيز اكثزفي البناء الداخلي للمفصل في المجموعو باستخد

. االولي

عهيح انظارغسيم انفصم طزق عالج قياسيح اجحح جذا عانيح انكفاءج تاإلضافح أا فعانح نعالج

غيز انجزاحي .حاالخ انخهم انذاخهي نهفصم انفكي انصذغي عذ عذو جذ طزق انعالج انرحفظي

بزل ان مقابمبانمنظار غسيموان تحهمهنانتصوير اإلشعاعي انسريري و انتقييم

انصدغيا مغهق نهمفصم انفكيان قفمان نعالج

رسالة هقذهة هن

الطبية/ أسامت محمد عبد التواب طعيمت

كجزء هن هقوهات الحصول على

والوجو و الفكيندرجة الذكتوراه في جراحة الفن

قسن جراحة الفن و الوجو و الفكين

كلية طب الفن و األسنان

جاهعة القاىرة

المشرفون

األستاذ الدكتور/ حميدة رفاعي حسىيه

أستار جراحة الفن و الوجو و الفكين


جاهعة القاىرة.

واديه جاللاألستاذ الدكتور/

هذرس جراحة الفن و الوجو و الفكين



األستاذ الدكتور/ مىار حسيه

أستار م بقسن االشعو التشخيصيو

كلية الطب


Clinical and Radiographic Evaluation of Arthroscopic lysis and … Arthroscopic lysis and lavage...

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