Arthocenthesis oral surgery/ dental implant courses by Indian dental academy

TEMPOROMANDIBULAR JOINT ARTHROCENTESIS : A simplified treatment for joint pain and limited mouth opening.

INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com

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INTRODUCTION Internal derangement of the TMJ has been managed by various methods over the years. The common methods are pharmacologic therapy, occlusal splints, Arthroscopic surgery , Arthrocentesis and Maxillofacial surgery .

Arthrocentesis by definition refers to the lavage of the joint space to release adhesions or anchored disc phenomenon & improve joint mobility. ( David Frost 1999)

Arthrocentesis was first used by Orthopedic surgeons for Traumatic Synovitis, Haemarthrosis, Pseudogout, Lupus Erythematosis & Septic Arthritis.

Temporomandibular Joint Arthrocentesis was first reported

by Nitzan et al. The objective of management of any disease process is the full restoration of function with improvement of quality & quantity life. www.indiandentalacademy.com

Interestingly it has been proved that no surgical procedure has been able to effectively reposition the Artricular Disc of the TMJ with longterm satisfaction.  The least invasive & the most predictable treatment that can be readily available to patients is the objective.

Arthrocentesis meets these requirements

. It is a simple and minimally invasive procedure with a reasonable success rate and minimal complications.

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INDICATIONS

Acute or chronic limitation of jaw motion due to anteriorly displaced disc. Hypomobility due to restriction of condylar translation. Patients with chronic TMJ pain who show an adequate range of motion despite an anteriorly displaced disc . To manage pain & dysfunction in patients who have undergone previous surgery that failed to relieve pain and limitation function. In patients showing radiographic changes of degenerative Arthritis.

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POTENTIAL COMPLICATIONS:

Infection. External auditory canal perforation. Bite changes.Fluid extravasation into the soft tissues. Haematoma.

However these potential complications have never been reported to date !

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AIMS AND OBJECTIVES To study the effectiveness of Artrocentesis in:

TMJ pain.

Limited mouth opening due to Internal Derangement.

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MATERIALS AND METHODS This study involved 26 joints of 26 patients ( 8 males and 18 females) with persistent limited mouth opening stemming from the TMJ and unassociated with macrotrauma. The symptoms had been present from 1 month to 2yrs.Patient age ranges from 18yrs to 67yrs. The chief complaint was limited mouth opening associated with pain located in the affected TMJ especially when opening was forced. Most patients did not remember any cause initiating symptoms. All patients were treated at the department of Oral & Maxillofacial surgery, Saveetha Dental College, Chennai.

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VAS 1 FOR MEASURING PAIN 1

2

3

4

5

6

7

8

9

10 11 12 13 14 15

VAS 2 FOR MEASURING DISABILITY 1

2

3

4

5

6

7

8

9

10 11 12 13 14 15

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Clinical examination Evaluation of Maximal mouth opening (MMO) as measured between the edges of the incisors. Determination of range of lateral and protrusive movements of the mandible as measured by the distance between the upper and lower midlines on lateral and forward movements. Evaluation of the characteristics of limitation of jaw motion.  Presence of joint noises judged clinically as none, early , or late clicks and crepitus.

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INCLUSION CRIETERIA

Persistent , sudden , disabling , but not necessarily painful, limited MMO of less than 30mm , clearly originating from the TMJ. Limitation was associated with impeded lateral movements towards the unaffected side, as well as deviation towards the affected side in opening and protrusive movements. When opening was forced, pressure or pain was exacerbated in the affected joint.

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FOLLOW-UP:

At least 4 months post-operatively the patients were evaluated by self-assessment questionnaire and by clinical examination. Two VASs( VAS 1 & 2 ) were used for self evaluation of improvement / deterioration compared with the status before the procedure was performed.

Clinical examination included measurement of MMO, deviation on opening , lateral and protrusion movements and determining the presence of clicks.

STATISTICAL ANALYSIS: Both paired and unpaired t-tests were used to compare pre-treatment and post-treatment differences in MMO, level of pain and dysfunction. The presence of an improvement effect was tested using Z- tailed t-test.

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Table 1. General Information on Patients Undergoing TMJ Arthrocentesis Age (yrs)

Sex

Joint

Duration of Limitation (months)

1

28

F

L

2

2

47

F

L

12

3

18

F

L

8

4

33

F

R

9

5

42

M

L

3

6

21

M

L

2

7

33

F

R

3

8

47

M

R

1

9

67

M

R

4

10

64

M

R

7

11

35

F

L

6

12

26

F

R

5

13

28

F

L

4

14

39

M

L

3

15

42

F

L

3

16

33

F

R

4

17

25

M

L

5

18

24

F

R

6

19

40

F

L

10

20

33

F

R

12

21

44

F

R

14

22

61

M

L

20

23

64

F

L

9

24

37

F

R

12

25

36

26

41

Patient No.

www.indiandentalacademy.com F R F

L

18 7

Table -2: Improvement in MMO, Lateral movements, and Decrease in Clicking Following TMJ Arthrocentesis.

MMO (mm)

Lateral Motion Towards Unaffected Joint (mm)

Clicking

PT No.

Follow up (months)

Before

Immediately After

At follow-up

1

4

28

40

43

2

4

27

38

3

6

18

4

5

5

Before

After

Before Limitation

at follow-up

4

10

+

-

40

5

10

+

-

30

33

3

9

+

-

15

26

30

2

8

+

-

4

20

27

29

5

10

+

-

6

4

29

35

36

5

9

-

-

7

6

25

30

26

6

6

-

-

8

8

26

38

40

4

11

+

-

9

8

24

39

40

4

13

+

-

10

9

16

27

30

6

8

-

-

11

7

18

25

22

3

4

-

-

12

7

26

38

37

6

7

-

-

13

4

28

38

39

5

9

-

-

14

6

30

40

40

7

11

+

-

15

10

24

37

39

5

11

+

-

16

5

26

36

37

4

10

-

-

17

8

16

36

37

3

9

-

-

18

6

18

28

35

5

10

+

-

19

7

27

32

28

5

4

+

-

20

9

28

40

40

6

10

-

-

21

10

29

37

38

8

9

-

-

22

6

28

35

36

6

10

+

-

23

4

15

20

18

7

8

-

-

24

5

16

37

35

4

10

-

-

25

4

30

38

36

5

9

+

-

26

7

17

40

38

3

7

+

-

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Table 3: Patient Self-Assessment Following Arthrocentesis

Degree of Pain (0 – 15)

Degree of Dysfunction (0 - 15)

PT. No

Before

At follow-up

Before

At Follow-up

1

8

3

9

3

2

10

3

10

4

3

11

4

10

4

4

9

5

12

6

5

12

4

12

6

6

10

2

8

5

7

8

8

9

9

8

8

0

10

0

9

9

9

12

10

10

7

0

14

0

11

8

7

15

13

12

7

0

14

0

13

7

1

13

6

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Table 3: Patient Self-Assessment Following Arthrocentesis Cont…

Degree of Pain (0 – 15)

Degree of Dysfunction (0 - 15)

PT. No

Before

At follow-up

Before

At Follow-up

14

9

2

7

8

15

7

3

6

2

16

6

2

8

6

17

13

2

9

8

18

14

4

11

8

19

12

12

12

11

20

11

2

15

12

21

7

1

12

12

22

9

0

9

0

23

12

11

7

8

24

14

3

6

3

25

13

4

5

2

26

8

2

5

0

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Table 4: Mean Increase in MMO and Decrease in Pain Level and Joint Dysfunction Following TMJ Arthrocentesis Performed Independently at Two Centers.

MMO (mm)

No. of Patients

Follow-up (months)

26

4-10

Before

23.8+5.3

Degree of Pain (0-15)

After

34.6 + 3.4

Degree of Dysfunction (0-15)

Before

After

9.2 + 2.7

3.6 + 4.4

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Before

After

10 + 1.9

5.6 + 2.3

RESULTS ď&#x192;&#x2DC;Objective findings following treatment: As seen in Table 2, 4 to 14 months following arthrocentesis the patients had a significant increase in mouth opening (P < .001), from a range of 15 to 30 mm (mean, 23.8 + 5.3mm) prior to the procedure to 18 to 43 mm (mean, 34.6 + 3.4 mm) following arthrocentesis.

ď&#x192;&#x2DC;Lateral movement toward the unaffected joint significantly improved as well (P < .0057), from a range of 2 to 7 mm (mean, 4.3 + 2.7) to 4 to 13 mm (mean, 8.9 + 1.2 mm). 14 of the 26 patients had experienced clicking in the affected joint before limitation had occurred. However, following arthrocentesis , none of the patients had a click.

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Subjective findings following treatment: Although the patientâ&#x20AC;&#x2122;s main complaint was the limited mouth opening, a considerable degree of pain was experienced and was reflected as a mean rating of 9.2 + 2.7 mm (range, 6 to 14 mm) on a scale of 0 to 15 (VAS I) (Table 3). This range decreased significantly (P < .001) following arthrocentesis and reached a mean value of 3.6 + 4.4 mm (Table 3).

The functional disturbance as reported by the patients was, as expected, high at the time of diagnosis and reached a value of 10 + 1.9 mm (range, 5 to 15 mm) on a scale of 0 to 15 (VAS II). This level decreased significantly (P < .001) following arthrocentesis to 5.6 + 2.3 mm (range, 0 to 13 mm)..

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CONCLUSION The study has demonstrated the efficacy of arthrocentesis of the upper compartment in cases of suddenly occurring, severe & persistant limited MMO originating from the joint. It is a simple and minimally invasive procedure, does not involve the morbidity of GA and still maintains a track record of zero complications. It can be performed in the simplest of clinical settings and does not require major armamentarium. We emphasize that Arthrocentesis must be tried on every patient who requires surgery for Internal Derangement.  Our study confirms a reasonable success rate, but it requires a longer followup and more number of patients to establish this as minimal invasive treatment of TMJ pain, which has failed by other non-invasive conservative methods.

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