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Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.07.008, available online at http://www.sciencedirect.com
Systematic Review TMJ Disorders
Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic review and meta-analysis
E. A. Al-Moraissi1,2 1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Yemen; 2Department of Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
E.A. Al-Moraissi: Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic review and meta-analysis. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. The aim of this study was to assess whether arthroscopy or arthrocentesis is most effective and feasible in the management of internal derangement of the temporomandibular joint (TMJ), specifically in relation to joint movement and pain. A comprehensive electronic search without date or language restrictions was performed in January 2014. Inclusion criteria were the following: study in humans; randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies; comparison of arthrocentesis and arthroscopy in the treatment of internal derangement. Six publications were included in the review, two RCTs, two CCTs, and two retrospective studies. Two studies showed a low risk of bias and four studies showed a moderate risk of bias. There were statistically significant differences between arthrocentesis and arthroscopy with regard to maximal inter-incisal opening and pain reduction, but no difference between the two groups for postoperative complications. The results of this metaanalysis on the management of internal derangement of the TMJ revealed arthroscopy to have superior efficacy to arthrocentesis in increasing joint movement and decreasing pain. Both arthroscopy and arthrocentesis have comparable postoperative complication rates. However, the current meta-analysis is incomplete due to the paucity of good quality studies in the high-impact, peer-reviewed literature; therefore, further better-designed studies are required 0901-5027/000001+09
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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to address this important question before final conclusions can be drawn as to the true comparative outcomes of TMJ arthrocentesis versus TMJ arthroscopy.
Keywords: internal derangement; TMJ; arthrocentesis; arthroscopy; maximal inter-incisal opening; pain; meta-analysis; complications. Accepted for publication 14 July 2014
Temporomandibular joint disorder (TMD) is a term that encompasses a number of overlapping conditions. Approximately 10% of the population are affected, and the disorder appears to occur most often in younger females.1 One of the most common forms of TMD is internal derangement. It has been reported that 80% of patients with signs and symptoms of TMD have some form of internal derangement of the temporomandibular joint (TMJ).2 Internal derangement is an intra-articular condition in which there is a disruption in the normal relationship of the articular disc of the TMJ to the articular eminence and the condyle when the joint is at rest or in function.3 Internal derangement of the TMJ includes conditions like anchored disc phenomenon, disc displacement with reduction, painful click, and closed lock. Patients with internal derangement of the TMJ often complain of pain, joint sounds, and a limitation in mouth opening. Most patients with internal derangement can be treated successfully with non-surgical therapy.4 Non-surgical therapies include pharmacotherapy, TMJ splints, and physical therapy. Patients who do not respond to non-surgical therapy may require more invasive procedures, such as arthrocentesis and arthroscopy. Farrar estimated that up to 25% of the entire population have an internal derangement, which is usually initially treated with non-surgical methods.5 More recently, studies utilizing magnetic resonance imaging reported that the articular disc was displaced in 35% of asymptomatic volunteers.6,7 Over the past 15 years, arthroscopic surgery, arthrocentesis, and physical therapy have commonly been used as therapeutic interventions for permanent TMJ disc displacement.8 Lavage of the TMJ was first conducted using arthroscopy by Ohnishi.9 Subsequently it was determined that visualization of the joint was not necessary to accomplish the treatment objectives; thus, arthrocentesis alone has been used as a modification of TMJ arthroscopic lavage in the treatment of this condition.10,11 Arthrocentesis of the TMJ was first described by Nitzan10 as a relatively easy, minimally invasive, and highly efficient procedure, and it is currently
used widely in the treatment of various internal derangements as well as for diagnostic purposes. The procedure may be performed under local anaesthesia, with or without sedation, and its primary purpose is to clear the joint of inflammatory cells, degradation products of the inflamed synovium, blood, and pain mediators that are believed to be by-products of intraarticular inflammation.12 Some studies have suggested that both arthrocentesis and arthroscopic lavage provide a significant reduction in pain and increase the maximal mouth opening on follow-up.13–15 Although arthroscopy shows better outcomes in terms of improvements in functional outcome, there is no difference in the degree of pain control with either of the techniques. Therefore, because arthrocentesis is technically easier to perform compared to arthroscopic lavage, arthrocentesis is highly recommended for the relief of pain in patients with painful clicking in the TMJ that does not respond to non-invasive medical management.16 To the best of the author’s knowledge, no meta-analysis has compared arthrocentesis and isolated lysis and lavage arthroscopy in the treatment of internal derangement with regard to maximal inter-incisal opening (MIO), pain, and the incidence of postoperative complications. The aim of this study was to determine whether arthroscopy or arthrocentesis is most effective and feasible in the management of internal derangement of the TMJ, specifically in relation to joint movement and pain.
Materials and methods Eligibility criteria
This analysis included studies in humans, including randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies aimed at comparing arthrocentesis and arthroscopy in the treatment of anchored disc phenomenon, closed lock, anterior disk displacement with or without reduction (ADDR/ADDWR), capsulitis, and synovitis. Further, any controlled clinical trial comparing arthroscopy and arthrocentesis in the treatment of internal
derangement with regard to pain and jaw function (MIO, excursive movements, and protrusive movements) was eligible. The following were excluded: case reports, technical reports, animal studies, in vitro studies, review papers, and uncontrolled studies. Search methods for the identification of studies
This systematic review and meta-analysis was conducted according to the PRISMAEquity 2012 checklist.17 A comprehensive electronic search without date or language restrictions was performed in January 2014 using the following electronic databases: PubMed, Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, CINAH, and Electronic Journal Center. The following search terms were used: ‘‘TMJ arthrocentesis’’ AND/OR ‘‘TMJ arthroscopy’’ AND ‘‘TMJ internal derangement’’, ‘‘TMJ intra articular disorders’’, ‘‘TMJ lavage’’, ‘‘TMJ lysis’’, ‘‘TMJ locking’’. A manual search of oral and maxillofacial surgery-related journals was also performed, including the International Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, Journal of Cranio-Maxillofacial Surgery, Journal of Craniofacial Surgery, and Journal of Maxillofacial and Oral Surgery. The reference lists of the identified studies and relevant reviews on the subject were also scanned for possible additional studies. Moreover, online databases providing information on clinical trials in progress were checked (https://clinicaltrials. gov; http://www.centerwatch.com/ clinicaltrials; http://www.clinicalconnection.com). Data collection process
The author carefully assessed the eligibility of all studies retrieved from the databases. In the final analysis the following
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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Arthroscopy vs. arthrocentesis for TMJ derangement data were extracted (when available) from the included studies: authors, year of publication, study design, number of patients, gender (male/female), mean age in years, follow-up period, anaesthesia, intra-articular injection, lavage (pressure/volume), duration of the problem, diagnostic problem subgroup, preoperative and postoperative MIO, and success rate. Authors were contacted for possible missing data. Risk of bias in individual studies
A methodological quality rating was performed by combining the proposed criteria of the MOOSE statement,18 STROBE statement,19 and PRISMA statement,20 in order to verify the strength of scientific evidence in clinical decision-making. The classification of the risk of bias potential for each study was based on the five following criteria: (1) random selection in the population, (2) definition of inclusion/exclusion criteria, (3) report of losses to follow-up, (4) validated measurements, and (5) statistical analysis. A study that included all of these criteria was classified as having a low risk of bias. A study that did not include one of these criteria was classified as having a moderate risk of bias. When two or more criteria were missing, the study was considered to have a high risk of bias. Summary measures
For the continuous data, due to all studies using the same scale, the weighted mean difference (WMD) was used to calculate the MIO (in millimetres) and pain (by visual analogue scale; VAS). If the trials reported the standard deviation (SD) of the mean change from baseline, the author used the conservative approach to estimate the SD using the following for21 mula :ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi q ðpreoperative SDÞ2 þðpostoperative SDÞ2 2
For those trials that reported both the baseline and final means with standard deviations, the author used the final value rather than the change in scores.21 Synthesis of results
Meta-analyses were conducted only if there were studies of similar comparisons, reporting the same outcome measures. For binary outcomes, a standard estimation of the odds ratio (OR) by random effects model was calculated if heterogeneity was detected, otherwise a fixed effect model was used with a 95% confidence interval (CI). For continuous data, the
WMDs of the final values were used to construct forest plots. The data were analyzed using the statistical software Review Manager (version 5.2.6; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark, 2012). Assessment of heterogeneity
The significance of any discrepancies in the estimates of the treatment effects of the different trials was assessed by means of Cochran’s test for heterogeneity and the I2 statistic, which describes the percentage total variation across studies that is due to heterogeneity rather than chance. Heterogeneity was considered statistically significant if P < 0.1. A rough guide to the interpretation of I2 given in the Cochrane handbook21 is as follows: (1) from 0 to 40% the heterogeneity might not be important, (2) from 30% to 60% may represent moderate heterogeneity, (3) from 50% to 90% may represent substantial heterogeneity, and (4) from 75% to 100% may represent considerable heterogeneity. Investigation of publication bias
A funnel plot (plot of the effect size versus standard error) was drawn. Asymmetry of the funnel plot may indicate publication bias and other biases related to the sample size, although asymmetry may also represent a true relationship between trial size and effect size.
3
Characteristics of the studies included
Detailed characteristics of the studies included are shown in Tables 1 and 2. Two RCTs,23,24 two CCTs,22,26 and two retrospective studies25,27 were included in the meta-analysis and critical appraisal. A total of 281 patients were enrolled in the six studies, 147 in the arthroscopy group and 134 in the arthrocentesis group. All of the patients in the included studies had undergone a period of unsuccessful conservative non-surgical treatment. The follow-up period was 1–2 years in three studies23–25 and ranged from 1 month to 6 months in the other studies.22,26,27 The arthroscopies were performed under general anaesthesia using one cannula with double needles in all of the included studies except one,27 in which they were carried out under local anaesthesia. During the arthroscopies, the synovial membrane and the fossa were inspected to check for adhesions and disc perforations. The upper compartment was washed out and swept with a blunt probe to release any adhesion that could restrict the disc. No other intervention was performed. Arthrocentesis was carried out according to the technique of Nitzan et al.28 under local anaesthesia, using two needles inserted into the upper compartment. The intra-articular injection material was a lactated ringer’s solution or saline, with a final instillation of sodium hyaluronate in two studies25,27 and betamethasone in one study.23 Risk of bias within studies
Sensitivity analysis
If there were sufficient included studies, it was planned to conduct a sensitivity analysis to assess the robustness of the review results by repeating the analysis with the following adjustment: exclusion of studies with a high risk of bias. Results Study selection
The study selection process is summarized in Fig. 1. The electronic search resulted in 740 records. Three additional articles were identified by hand-searching. After the initial screening of titles and abstracts, 300 duplicate articles were excluded. Of the remaining 443 studies, 374 were excluded for not being related to the topic. Assessment of the full-text of the remaining 69 articles led to the exclusion of 63 because they did not meet the inclusion criteria. Thus, a total of six publications were included in the review.22–27
Concerning the quality assessment of the studies, two showed a low risk of bias23,24 and four showed a moderate risk of bias22,25–27 (Table 3). Maximal inter-incisal opening (MIO)
All of the studies (281 patients; 147 in the arthroscopy group and 134 in the arthrocentesis group) evaluated the MIO over follow-up periods ranging from 1 month to 2 years. The improvement in MIO after arthroscopy was better than the improvement obtained after arthrocentesis. There was a statistically significant difference between the two groups (fixed: WMD 1.86 mm, 95% CI 2.93 to 0.79; P = 0.0006). There was heterogeneity among studies (x2 = 27.16, df = 5; P < 0.0001; I2 = 82%). Therefore a sensitivity analysis was performed through exclusion of the retrospective, low impact factor, and non-peer-reviewed studies. Only the two RCTs23,24 were included
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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Fig. 1. Flow diagram of the article selection process.
in the analysis. The results remained in of arthroscopy (fixed: favour WMD = 5.28 mm, 95% CI 7.10 to 3.46; P = 0.00001). There was no heterogeneity among studies (x2 = 0.68, df = 1; P = 0.41; I2 = 0%) (Fig. 2). Pain
All of the studies assessed pain using a VAS (281 patients; 147 in the arthroscopy group and 134 in the arthrocentesis group). There was a statistically significant difference in pain reduction between arthroscopy and arthrocentesis patients (fixed: WMD = 0.44, 95% CI 0.57 to 0.31; P = 0.00001). There was heterogeneity among studies (x2 = 41.73, df = 5;
P < 0.00001; I2 = 88%). A sensitivity analysis was performed to improve the robustness of results; the retrospective, low impact factor, and non-peer-reviewed studies were excluded25–27, and only the RCTs23,24 were included in the analysis. The results remained in favour of arthroscopy (fixed: WMD = 0.57, 95% CI 0.72 to 0.43, P = 0.00001). The test of heterogeneity indicated that there was clinical diversity (x2 = 7.71, df = 1; P = 0.005; I2 = 87%) (Fig. 3). Postoperative complications
Four studies23,24,26,27 reported postoperative complications following arthroscopy and arthrocentesis. In the study by Goudot
et al.,24 one patient in the arthroscopy group presented a transient frontal palsy and one patient developed cervico-facial oedema, while in the arthrocentesis group, two cases of severe bradycardia (one asystole) were observed. In the study by Xu et al.,27 one patient in the arthroscopy group presented a transient frontal palsy (duration 3 months) and one patient developed cervico-facial oedema; in the arthrocentesis group, one case of cervico-facial oedema was observed. There was no statistically significant difference between the two groups with regard to the incidence of postoperative complications (fixed: OR 1.15, 95% CI 0.30–4.43; P = 0.84). There was an absence of heterogeneity among the studies
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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Authors
Year
Study design
Number of patients AC (group 1)
Gender
Age, years
Follow-up
Anaesthesia
IA injection
Lavage
Group 1: 17 F, 3 M Group 2: 23 F, 2 M Groups 1 and 2: 19 F
Group 1: mean 32.7 Group 2: mean 31.2 Group 1: mean 28.5 Group 2: mean 33 Range 15–56 Groups 1 and 2: mean 38, range 16–72
6 months
Group 1: LA Group 2: GA
NR
Group 1: 2 needle Group 2: dual-port
1 week, 1, 3, 4, 12, and 26 months
Group 1: LA Group 2: GA
Group 1: RLS + steroid Group 2: RLS + steroid
Group 1: 2 needle Group 2: dual-port
1 year
Group 1: LA Group 2: GA
Groups 1 and 2: RLS Group 1: RLS + SH Group 2: RLS + SH Group 1: saline Group 2: saline Groups 1 and 2: RLS + SH
Duration of problem
Diagnostic problem subgroup
AS (group 2)
Murakami et al.22
1995
CCT prosp.
20
25
Fridrich et al.23
1996
RCT, prosp.
8
11
Goudot et al.24
2000
RCT prosp.
29
33
Groups 1 and 2: 46 F, 16 M
Hobeich et al.25
2007
RS
25
32
Groups 1 and 2: 12 M, 45 F
Groups 1 and 2: range 16–54
18–28 months
Group 1: LA Group 2: GA
Tan and Krishnaswamy26
2012
CCT prosp.
11
9
Group 1: LA Group 2: GA
2013
RS
41
37
Group 1: range 16–40 Group 2: range 20–63 Group 1: range 34–39 Group 2: range 30–73
1 week 1 month
Xu et al.27
Group 1: 8 F, 3 M Group 2: 7 F, 2 M Group 1: 30 F, 11 M Group 2: 29 F, 8 M
Over 3 months
Groups 1 and 2: LA
Group 1: 6.85 months Group 2: 5.64 months NR
Closed lock
Group 1: 2 needle Group 2: cannula with double needle 100–200 ml NR
NR
54 ADDWR 8 ADDR
Groups 1 and 2: 1–2 years
ADDWR
Group 1: 2 needle 100–200 ml Group 2: cannula with double needle 200 ml Group 1: 2 needle Group 2: two cannulas High pressure 500 ml
Group 1: 1–9 months Group 2: 1–6 years NR
3 painful click 17 closed lock (due to DD or ADP) ADD
7 ADDWR 12 ADDR
IA, intra-articular; AC, arthrocentesis; AS, arthroscopy; F, female; M, male; CCT, controlled clinical trial; RCT, randomized clinical trial; prosp., prospective study; RS, retrospective study; NR, not reported; LA, local anaesthesia; GA, general anaesthesia; RLS, Ringer’s lactate solution; ADDWR, anterior disc displacement without reduction; ADDR, anterior disc displacement with reduction; SH, sodium hyaluronate; DD, disc displacement; ADP, anchored disc phenomenon. * Group 1, arthrocentesis; group 2, arthroscopy.
Arthroscopy vs. arthrocentesis for TMJ derangement
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
Table 1. Characteristics of the studies comparing arthroscopy and arthrocentesis included in the review.*
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Table 2. Preoperative and postoperative mean pain scores and maximal inter-incisal opening. Pain (VAS)
Authors
MIO (mm) Arthroscopy
Arthrocentesis Preop. Murakami et al.22 Fridrich et al.23 Goudot et al.24 Hobeich et al.25 Tan and Krishnaswamy26 Xu et al.27
Postop.
5.7 6.45 5.6 5.75 6.67 5.32
2.4 1.7 0.9 2.55 2.11 0.73
Preop. 4.8 6.6 5.7 5.71 6 6.08
Arthrocentesis
Arthroscopy
Postop.
Preop.
Postop.
Preop.
Postop.
3.0 2.3 1.9 2.32 3.5 2.21
30.6 33 29.4 31.75 26.56 25.9
42.5 41 33.8 41.60 39.56 35.7
27.5 30 29.0 32.07 30.25 24.2
42.1 47.5 38.6 40.68 36.88 37.1
Statistical analysis
Estimated potential risk of bias
VAS, visual analogue scale; MIO, maximal inter-incisal opening. Table 3. Critical appraisal of the studies included (quality assessment).
Authors
Published 22
Murakami et al. Fridrich et al.23 Goudot et al.24 Hobeich et al.25 Tan and Krishnaswamy26 Xu et al.27
Random selection in population
1995 1996 2000 2007 2012 2013
No Yes Yes No No No
Defined inclusion/ exclusion criteria Yes Yes Yes Yes Yes Yes
Loss of follow-up Yes Yes Yes Yes Yes Yes
Validated measurement Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes
Moderate Low Low Moderate Moderate Moderate
Fig. 2. Forest plot showing the weighted mean difference in the MIO between the arthrocentesis and arthroscopy groups.
(x2 = 0.49, df = 2; P = 0.78; I2 = 0%) (Fig. 4). Assessment of publication bias
No significant publication bias was observed for the studies included (Fig. 5). Discussion
The role of lavage with the accompanying procedure of arthrolysis has shown excellent success rates in the treatment of TMD. This procedure has been shown to reduce pain and improve joint mobility, sometimes even in patients suffering the advanced stages of degeneration and dysfunction.28–31 There are two different
approaches to lavage and arthrolysis: arthrocentesis and arthroscopic lavage. Various studies have compared the two techniques and have suggested that they vary in terms of prognosis, complications, and long-term outcomes.22,23,25 In this study, the results of the metaanalysis revealed a statistically significant difference in favour of arthroscopy with respect to MIO and pain. These results may be attributed to the efficacy of arthroscopy in releasing the negative pressure on the disc, releasing adhesions, distending or widening the narrowed joint space, reducing surface friction, and altering the viscosity of the synovial fluid.32 These results are, however, inconsistent with the results of other studies.12,22,23,25
Concerning pain, there was a significant advantage of arthroscopy over arthrocentesis (P = 0.00001). This may be because the larger diameter portal with high pressure used in arthroscopic lavage enables more extensive removal of inflammatory mediators resulting in a subsequent greater reduction in pain.27 A total of 281 patients enrolled in six studies22–27 were included in the qualitative and quantitative analysis: two RCTs,23,24 two CCTs,22,26 and two retrospective studies.25,27 Two studies showed a low risk of bias23,24 and four studies showed a moderate risk of bias.22,25–27 The diagnostic problem subgroups were ADDWR/ADDR in three studies23–25,27 and closed disc and painful joints with
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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Arthroscopy vs. arthrocentesis for TMJ derangement
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Fig. 3. Forest plot showing the weighted mean difference in pain scores (VAS) between the arthrocentesis and arthroscopy groups.
Fig. 4. Forest plot showing the incidence of postoperative complications between the arthrocentesis and arthroscopy groups.
Fig. 5. Funnel plot showing a symmetrical distribution without systematic heterogeneity of the individual study treatment effects compared with standard error, indicating a lack of publication bias in the meta-analysis.
the anchored disc phenomenon in three studies.22,26 Arthrocentesis and arthroscopy are not without risks. Generally, the potential complications of arthroscopy can also occur in arthrocentesis, but the incidence and extent of complications are lesser in arthrocentesis28. Damage to the facial and auriculo-temporal nerves, perforation of the external auditory canal and tympanic membrane, and breach of the base of the skull33 have been reported as complications after arthroscopy. Transient facial nerve paralysis caused by local
anaesthesia and swelling of the pre-auricular area due to fluid extravasation may result from arthrocentesis. In the present study, there was no statistically significant difference between the two groups with regard to the incidence of postoperative complications (fixed: OR 1.15, 95% CI 0.30–4.43; P = 0.84). Nitzan believes 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, therefore the success rates with arthrocentesis are similar to
those of arthroscopic lysis or lavage.34 However, Sanders maintains that in cases of chronic closed lock, intracapsular lysis using probes between the disc and fossa is necessary to release superior compartment adhesions.35 With regard to age and the duration of the problem, the author of the current study believes that the chronicity of joint symptoms and older age could be considered poor indicators in the prediction of the outcome of both procedures. Although, the results of this study revealed a superiority of arthroscopy over
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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arthrocentesis in improving jaw function and reducing pain, there are a number of disadvantages to arthroscopy: it requires general anaesthesia and the use of an operating room, it is relatively more invasive, there is greater postoperative morbidity, it is a more expensive procedure, and it has a greater potential for complications. Whereas serious complications such as arterio-venous fistula, facial, trigeminal, and auditory nerve injury, otitis media, perforation of the glenoid fossa, extradural haematoma, broken instruments in the joint, and perforation of the tympanic membrane and middle ear resulting in deafness have occurred with arthroscopy,24,27,36–42 the only major complication reported with arthrocentesis has been one case of an extradural haematoma.42 These advantages of arthrocentesis support the contention that it should be the initial surgical treatment of choice for internal derangements that do not respond to medical management.43 In conclusion, arthroscopy lysis and lavage was found to have superior efficacy in improving MIO and reducing pain when compared to arthrocentesis. Further, the incidence of postoperative complications was comparable for the two techniques. However, the current meta-analysis is incomplete due to the paucity of good quality studies in the high-impact, peerreviewed literature and, therefore, more better-designed studies are required to address this important question before final conclusions can be drawn as to the true comparative outcomes of TMJ arthrocentesis versus TMJ arthroscopy. Funding
None. Competing interests
None. Ethical approval
Not required. Patient consent
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2. Paesani D, Westesson PL, Hatala M, Tallents RH, Kurita K. Prevalence of temporomandibular joint internal derangement in patients with craniomandibular disorders. Am J Orthod Dentofacial Orthop 1992;101:41–7. 3. Emshoff R, Rudisch A. Temporomandibular joint internal derangement and osteoarthrosis: are effusion and bone marrow edema prognostic indicators for arthrocentesis and hydraulic distention? J Oral Maxillofac Surg 2007;65:66–73. 4. Randolph CS, Greene CS, Moretti R, Forbes D, Perry HT. Conservative management of temporomandibular disorders: a posttreatment comparison between patients from a university clinic and from private practice. Am J Orthod Dentofacial Orthop 1990;98: 77–82. 5. Farrar WB. Letter: Myofascial pain dysfunction syndrome. J Am Dent Assoc 1981;102: 10–1. 6. Katzberg RW, Westesson PL, Tallents RH, Drake CM. Anatomic disorders of the temporomandibular joint disc in asymptomatic subjects. J Oral Maxillofac Surg 1996;54:147–53. 7. Ribeiro RF, Tallents RH, Katzberg RW, Murphy WC, Moss ME, Magalhaes AC, et al. The prevalence of disc displacement in symptomatic and asymptomatic volunteers aged 6–25 years. J Orofac Pain 1997;11:37–47. 8. Kropmans TJ, Dijkstra PU, Stegenga B, de Bont LG. Therapeutic outcome assessment in permanent temporomandibular joint disc displacement. J Oral Rehabil 1999;26: 357–63. 9. Ohnishi M. Arthroscopy and arthroscopic surgery of the temporomandibular joint (TMJ). Rev Stomatol Chir Maxillofac 1990;91:143–50. 10. Nitzan DW. Arthrocentesis—incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2006;18:311–28. 11. Monje-Gil F, Nitzan D, Gonza´lez-Garcia R. Temporomandibular joint arthrocentesis. Review of the literature. Med Oral Pathol Oral Cir Bucal 2012;17:e575–81. 12. Barkin S, Weinberg S. Internal derangements of the temporomandibular joint: the role of arthroscopic surgery and arthrocentesis. J Can Dent Assoc 2000;66:199–203. 13. Guarda-Nardini L, Manfredini D, Ferronato G. Short-term effects of arthrocentesis plus viscosupplementation in the management of signs and symptoms of painful TMJ disc displacement with reduction. A pilot study. Oral Maxillofac Surg 2010;14:29–34. 14. Machon V, Hirjak D, Lukas J. Therapy of the osteoarthritis of the temporomandibular joint. J Craniomaxillofac Surg 2011;39: 127–30. 15. Goudot P, Jaquinet AR, Hugonnet S, Haefliger W, Richter M. Improvement of pain and after arthroscopy and arthrocentesis of the temporomandibular joint: a comparative
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study. J Craniomaxillofac Surg 2000;28:39– 43. Dolwick MF, Dimitroulis G. Is there a role for temporomandibular joint surgery? Br J Oral Maxillofac Surg 1994;32:307–13. Welch V, Petticrew M, Tugwell P, Moher D, O’Neill J, Waters E, et al. PRISMA-Equity Bellagio Group PRISMA-Equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity. PLoS Med 2012;9:e1001333. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting, meta-analysis of obstudies in epidemiology servational (MOOSE) group. J Am Med Assoc 2000; 283:2008–12. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453–7. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 (updated March 2011). The Cochrane Collaboration; 2011. Murakami K, Hosaka H, Moriya Y, Segami N, Iizuka T. Short-term treatment outcome study for the management of temporomandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:253–7. Fridrich KL, Wise JM, Zeitler DL. Prospective comparison of arthroscopy and arthrocentesis for temporomandibular joint disorders. J Oral Maxillofac Surg 1996;54:816–20. Goudot P, Jaquinet AR, Hugonnet S, Haeiger W, Richter M. Improvement of pain and after arthroscopy and arthrocentesis of the temporomandibular joint: a comparative study. J Craniomaxillofac Surg 2000;28: 39–43. Hobeich JB, Salameh ZA, Ismail E, Sadig WM, Hokayem NE, Almas K. Arthroscopy versus arthrocentesis. A retrospective study of disc displacement management without reduction. Saudi Med J 2007;28:1541–4. Tan DB, Krishnaswamy G. A retrospective study of temporomandibular joint internal derangement treated with arthrocentesis and arthroscopy. Proc Singap Healthc 2012; 21:73–8. Xu Y, Lin H, Zhu P, Zhou W, Han Y, Zheng Y, et al. A comparative study between use of arthroscopic lavage and arthrocentesis of temporomandibular joint based on
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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28.
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computational fluid dynamics analysis. PLOS ONE 2013;8:e78953. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991;49:1163–7. Gonza´lez-Garcı´a R, Rodrı´guez-Campo FJ. Arthroscopic lysis and lavage versus operative arthroscopy in the outcome of temporomandibular joint internal derangement: a comparative study based on Wilkes stages. J Oral Maxillofac Surg 2011;69:2513–24. Zhu Y, Zheng C, Deng Y, Wang Y. Arthroscopic surgery for treatment of anterior displacement of the disc without reduction of the temporomandibular joint. Br J Oral Maxillofac Surg 2012;50:144–8. Leibur E, Jagur O, Mu¨u¨rsepp P, Veede L, Voog-Oras U. Longterm evaluation of arthroscopic surgery with lysis and lavage of temporomandibular joint disorders. J Craniomaxillofac Surg 2010;38:615–20. Nitzan DW, Mahler Y, Simkin A. Intra-articular pressure measurements in patients with suddenly developing, severely limited mouth opening. J Oral Maxillofac Surg 1992;50:1038–42. Patel S, Jerjes W, Upile T, Hopper C. TMJ arthroscopy: rare neurological complications
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associated with breach of base of skull. Br J Oral Maxillofac Surg 2010;48:18–20. Nitzan DW. Arthrocentesis for management of severe closed lock of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994;6:245–7. Sanders B. Arthroscopic management of internal derangements of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994;6:259–69. Preisler SA, Koorbusch GF, Olson RA. An acquired arteriovenous fistula secondary to temporomandibular joint arthroscopy: report of a case. J Oral Maxillofac Surg 1991;49:187–90. Carter JB. Complications of temporomandibular joint arthroscopy. In: Thomas , Bronstein , editors. Arthroscopy of the temporomandibular joint. Philadelphia: WB Saunders; 1991. p. 310–22. Greene MW, Van Sickels JE. Survey of TMJ arthroscopy in oral and maxillofacial surgery residency programs. J Oral Maxillofac Surg 1989;47:574–6. Applebaum EL, Berg LF, Kumar A, Mafee MF. Otologic complications following temporomandibular joint arthroscopy. Ann Otol Rhinol Laryngol 1988;97:675–9. Tsuyama M, Kondoh T, Seto K, Fukuda J. Complications of temporomandibular joint arthroscopy: a retrospective analysis of 301
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lysis and lavage procedures performed using the triangulation technique. J Oral Maxillofac Surg 2000;58:500–5. 41. Gonza´lez-Garcı´a R1. Rodrı´guez-Campo FJ, Escorial-Herna´ndez V, Mun˜oz-Guerra MF, Sastre-Pe´rez J, Naval-Gı´as L, et al. Complications of temporomandibular joint arthroscopy: a retrospective analytic study of 670 arthroscopic procedures. J Oral Maxillofac Surg 2006;64:1587–91. 42. Carroll TA, Smith K, Jakubowski J. Extradural hematoma following temporomandibular joint arthrocentesis and lavage. Br J Neurosurg 2000;14:152–4. 43. Laskin DM. Arthrocentesis for the treatment of internal derangements of the temporomandibular joint. Alpha Omegan 2009; 102:46–50.
Address: Essam Ahmed Al-Moraissi Department of Oral and Maxillofacial Surgery Faculty of Dentistry Thamar University Thamar Yemen. Tel: +967 21141477753, 009 67777788939. E-mails: [email protected], [email protected]
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.07.008, available online at http://www.sciencedirect.com
Systematic Review TMJ Disorders
Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic review and meta-analysis
E. A. Al-Moraissi1,2 1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Yemen; 2Department of Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
E.A. Al-Moraissi: Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic review and meta-analysis. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. The aim of this study was to assess whether arthroscopy or arthrocentesis is most effective and feasible in the management of internal derangement of the temporomandibular joint (TMJ), specifically in relation to joint movement and pain. A comprehensive electronic search without date or language restrictions was performed in January 2014. Inclusion criteria were the following: study in humans; randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies; comparison of arthrocentesis and arthroscopy in the treatment of internal derangement. Six publications were included in the review, two RCTs, two CCTs, and two retrospective studies. Two studies showed a low risk of bias and four studies showed a moderate risk of bias. There were statistically significant differences between arthrocentesis and arthroscopy with regard to maximal inter-incisal opening and pain reduction, but no difference between the two groups for postoperative complications. The results of this metaanalysis on the management of internal derangement of the TMJ revealed arthroscopy to have superior efficacy to arthrocentesis in increasing joint movement and decreasing pain. Both arthroscopy and arthrocentesis have comparable postoperative complication rates. However, the current meta-analysis is incomplete due to the paucity of good quality studies in the high-impact, peer-reviewed literature; therefore, further better-designed studies are required 0901-5027/000001+09
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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to address this important question before final conclusions can be drawn as to the true comparative outcomes of TMJ arthrocentesis versus TMJ arthroscopy.
Keywords: internal derangement; TMJ; arthrocentesis; arthroscopy; maximal inter-incisal opening; pain; meta-analysis; complications. Accepted for publication 14 July 2014
Temporomandibular joint disorder (TMD) is a term that encompasses a number of overlapping conditions. Approximately 10% of the population are affected, and the disorder appears to occur most often in younger females.1 One of the most common forms of TMD is internal derangement. It has been reported that 80% of patients with signs and symptoms of TMD have some form of internal derangement of the temporomandibular joint (TMJ).2 Internal derangement is an intra-articular condition in which there is a disruption in the normal relationship of the articular disc of the TMJ to the articular eminence and the condyle when the joint is at rest or in function.3 Internal derangement of the TMJ includes conditions like anchored disc phenomenon, disc displacement with reduction, painful click, and closed lock. Patients with internal derangement of the TMJ often complain of pain, joint sounds, and a limitation in mouth opening. Most patients with internal derangement can be treated successfully with non-surgical therapy.4 Non-surgical therapies include pharmacotherapy, TMJ splints, and physical therapy. Patients who do not respond to non-surgical therapy may require more invasive procedures, such as arthrocentesis and arthroscopy. Farrar estimated that up to 25% of the entire population have an internal derangement, which is usually initially treated with non-surgical methods.5 More recently, studies utilizing magnetic resonance imaging reported that the articular disc was displaced in 35% of asymptomatic volunteers.6,7 Over the past 15 years, arthroscopic surgery, arthrocentesis, and physical therapy have commonly been used as therapeutic interventions for permanent TMJ disc displacement.8 Lavage of the TMJ was first conducted using arthroscopy by Ohnishi.9 Subsequently it was determined that visualization of the joint was not necessary to accomplish the treatment objectives; thus, arthrocentesis alone has been used as a modification of TMJ arthroscopic lavage in the treatment of this condition.10,11 Arthrocentesis of the TMJ was first described by Nitzan10 as a relatively easy, minimally invasive, and highly efficient procedure, and it is currently
used widely in the treatment of various internal derangements as well as for diagnostic purposes. The procedure may be performed under local anaesthesia, with or without sedation, and its primary purpose is to clear the joint of inflammatory cells, degradation products of the inflamed synovium, blood, and pain mediators that are believed to be by-products of intraarticular inflammation.12 Some studies have suggested that both arthrocentesis and arthroscopic lavage provide a significant reduction in pain and increase the maximal mouth opening on follow-up.13–15 Although arthroscopy shows better outcomes in terms of improvements in functional outcome, there is no difference in the degree of pain control with either of the techniques. Therefore, because arthrocentesis is technically easier to perform compared to arthroscopic lavage, arthrocentesis is highly recommended for the relief of pain in patients with painful clicking in the TMJ that does not respond to non-invasive medical management.16 To the best of the author’s knowledge, no meta-analysis has compared arthrocentesis and isolated lysis and lavage arthroscopy in the treatment of internal derangement with regard to maximal inter-incisal opening (MIO), pain, and the incidence of postoperative complications. The aim of this study was to determine whether arthroscopy or arthrocentesis is most effective and feasible in the management of internal derangement of the TMJ, specifically in relation to joint movement and pain.
Materials and methods Eligibility criteria
This analysis included studies in humans, including randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies aimed at comparing arthrocentesis and arthroscopy in the treatment of anchored disc phenomenon, closed lock, anterior disk displacement with or without reduction (ADDR/ADDWR), capsulitis, and synovitis. Further, any controlled clinical trial comparing arthroscopy and arthrocentesis in the treatment of internal
derangement with regard to pain and jaw function (MIO, excursive movements, and protrusive movements) was eligible. The following were excluded: case reports, technical reports, animal studies, in vitro studies, review papers, and uncontrolled studies. Search methods for the identification of studies
This systematic review and meta-analysis was conducted according to the PRISMAEquity 2012 checklist.17 A comprehensive electronic search without date or language restrictions was performed in January 2014 using the following electronic databases: PubMed, Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, CINAH, and Electronic Journal Center. The following search terms were used: ‘‘TMJ arthrocentesis’’ AND/OR ‘‘TMJ arthroscopy’’ AND ‘‘TMJ internal derangement’’, ‘‘TMJ intra articular disorders’’, ‘‘TMJ lavage’’, ‘‘TMJ lysis’’, ‘‘TMJ locking’’. A manual search of oral and maxillofacial surgery-related journals was also performed, including the International Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, Journal of Cranio-Maxillofacial Surgery, Journal of Craniofacial Surgery, and Journal of Maxillofacial and Oral Surgery. The reference lists of the identified studies and relevant reviews on the subject were also scanned for possible additional studies. Moreover, online databases providing information on clinical trials in progress were checked (https://clinicaltrials. gov; http://www.centerwatch.com/ clinicaltrials; http://www.clinicalconnection.com). Data collection process
The author carefully assessed the eligibility of all studies retrieved from the databases. In the final analysis the following
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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Arthroscopy vs. arthrocentesis for TMJ derangement data were extracted (when available) from the included studies: authors, year of publication, study design, number of patients, gender (male/female), mean age in years, follow-up period, anaesthesia, intra-articular injection, lavage (pressure/volume), duration of the problem, diagnostic problem subgroup, preoperative and postoperative MIO, and success rate. Authors were contacted for possible missing data. Risk of bias in individual studies
A methodological quality rating was performed by combining the proposed criteria of the MOOSE statement,18 STROBE statement,19 and PRISMA statement,20 in order to verify the strength of scientific evidence in clinical decision-making. The classification of the risk of bias potential for each study was based on the five following criteria: (1) random selection in the population, (2) definition of inclusion/exclusion criteria, (3) report of losses to follow-up, (4) validated measurements, and (5) statistical analysis. A study that included all of these criteria was classified as having a low risk of bias. A study that did not include one of these criteria was classified as having a moderate risk of bias. When two or more criteria were missing, the study was considered to have a high risk of bias. Summary measures
For the continuous data, due to all studies using the same scale, the weighted mean difference (WMD) was used to calculate the MIO (in millimetres) and pain (by visual analogue scale; VAS). If the trials reported the standard deviation (SD) of the mean change from baseline, the author used the conservative approach to estimate the SD using the following for21 mula :ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi q ðpreoperative SDÞ2 þðpostoperative SDÞ2 2
For those trials that reported both the baseline and final means with standard deviations, the author used the final value rather than the change in scores.21 Synthesis of results
Meta-analyses were conducted only if there were studies of similar comparisons, reporting the same outcome measures. For binary outcomes, a standard estimation of the odds ratio (OR) by random effects model was calculated if heterogeneity was detected, otherwise a fixed effect model was used with a 95% confidence interval (CI). For continuous data, the
WMDs of the final values were used to construct forest plots. The data were analyzed using the statistical software Review Manager (version 5.2.6; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark, 2012). Assessment of heterogeneity
The significance of any discrepancies in the estimates of the treatment effects of the different trials was assessed by means of Cochran’s test for heterogeneity and the I2 statistic, which describes the percentage total variation across studies that is due to heterogeneity rather than chance. Heterogeneity was considered statistically significant if P < 0.1. A rough guide to the interpretation of I2 given in the Cochrane handbook21 is as follows: (1) from 0 to 40% the heterogeneity might not be important, (2) from 30% to 60% may represent moderate heterogeneity, (3) from 50% to 90% may represent substantial heterogeneity, and (4) from 75% to 100% may represent considerable heterogeneity. Investigation of publication bias
A funnel plot (plot of the effect size versus standard error) was drawn. Asymmetry of the funnel plot may indicate publication bias and other biases related to the sample size, although asymmetry may also represent a true relationship between trial size and effect size.
3
Characteristics of the studies included
Detailed characteristics of the studies included are shown in Tables 1 and 2. Two RCTs,23,24 two CCTs,22,26 and two retrospective studies25,27 were included in the meta-analysis and critical appraisal. A total of 281 patients were enrolled in the six studies, 147 in the arthroscopy group and 134 in the arthrocentesis group. All of the patients in the included studies had undergone a period of unsuccessful conservative non-surgical treatment. The follow-up period was 1–2 years in three studies23–25 and ranged from 1 month to 6 months in the other studies.22,26,27 The arthroscopies were performed under general anaesthesia using one cannula with double needles in all of the included studies except one,27 in which they were carried out under local anaesthesia. During the arthroscopies, the synovial membrane and the fossa were inspected to check for adhesions and disc perforations. The upper compartment was washed out and swept with a blunt probe to release any adhesion that could restrict the disc. No other intervention was performed. Arthrocentesis was carried out according to the technique of Nitzan et al.28 under local anaesthesia, using two needles inserted into the upper compartment. The intra-articular injection material was a lactated ringer’s solution or saline, with a final instillation of sodium hyaluronate in two studies25,27 and betamethasone in one study.23 Risk of bias within studies
Sensitivity analysis
If there were sufficient included studies, it was planned to conduct a sensitivity analysis to assess the robustness of the review results by repeating the analysis with the following adjustment: exclusion of studies with a high risk of bias. Results Study selection
The study selection process is summarized in Fig. 1. The electronic search resulted in 740 records. Three additional articles were identified by hand-searching. After the initial screening of titles and abstracts, 300 duplicate articles were excluded. Of the remaining 443 studies, 374 were excluded for not being related to the topic. Assessment of the full-text of the remaining 69 articles led to the exclusion of 63 because they did not meet the inclusion criteria. Thus, a total of six publications were included in the review.22–27
Concerning the quality assessment of the studies, two showed a low risk of bias23,24 and four showed a moderate risk of bias22,25–27 (Table 3). Maximal inter-incisal opening (MIO)
All of the studies (281 patients; 147 in the arthroscopy group and 134 in the arthrocentesis group) evaluated the MIO over follow-up periods ranging from 1 month to 2 years. The improvement in MIO after arthroscopy was better than the improvement obtained after arthrocentesis. There was a statistically significant difference between the two groups (fixed: WMD 1.86 mm, 95% CI 2.93 to 0.79; P = 0.0006). There was heterogeneity among studies (x2 = 27.16, df = 5; P < 0.0001; I2 = 82%). Therefore a sensitivity analysis was performed through exclusion of the retrospective, low impact factor, and non-peer-reviewed studies. Only the two RCTs23,24 were included
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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Fig. 1. Flow diagram of the article selection process.
in the analysis. The results remained in of arthroscopy (fixed: favour WMD = 5.28 mm, 95% CI 7.10 to 3.46; P = 0.00001). There was no heterogeneity among studies (x2 = 0.68, df = 1; P = 0.41; I2 = 0%) (Fig. 2). Pain
All of the studies assessed pain using a VAS (281 patients; 147 in the arthroscopy group and 134 in the arthrocentesis group). There was a statistically significant difference in pain reduction between arthroscopy and arthrocentesis patients (fixed: WMD = 0.44, 95% CI 0.57 to 0.31; P = 0.00001). There was heterogeneity among studies (x2 = 41.73, df = 5;
P < 0.00001; I2 = 88%). A sensitivity analysis was performed to improve the robustness of results; the retrospective, low impact factor, and non-peer-reviewed studies were excluded25–27, and only the RCTs23,24 were included in the analysis. The results remained in favour of arthroscopy (fixed: WMD = 0.57, 95% CI 0.72 to 0.43, P = 0.00001). The test of heterogeneity indicated that there was clinical diversity (x2 = 7.71, df = 1; P = 0.005; I2 = 87%) (Fig. 3). Postoperative complications
Four studies23,24,26,27 reported postoperative complications following arthroscopy and arthrocentesis. In the study by Goudot
et al.,24 one patient in the arthroscopy group presented a transient frontal palsy and one patient developed cervico-facial oedema, while in the arthrocentesis group, two cases of severe bradycardia (one asystole) were observed. In the study by Xu et al.,27 one patient in the arthroscopy group presented a transient frontal palsy (duration 3 months) and one patient developed cervico-facial oedema; in the arthrocentesis group, one case of cervico-facial oedema was observed. There was no statistically significant difference between the two groups with regard to the incidence of postoperative complications (fixed: OR 1.15, 95% CI 0.30–4.43; P = 0.84). There was an absence of heterogeneity among the studies
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Authors
Year
Study design
Number of patients AC (group 1)
Gender
Age, years
Follow-up
Anaesthesia
IA injection
Lavage
Group 1: 17 F, 3 M Group 2: 23 F, 2 M Groups 1 and 2: 19 F
Group 1: mean 32.7 Group 2: mean 31.2 Group 1: mean 28.5 Group 2: mean 33 Range 15–56 Groups 1 and 2: mean 38, range 16–72
6 months
Group 1: LA Group 2: GA
NR
Group 1: 2 needle Group 2: dual-port
1 week, 1, 3, 4, 12, and 26 months
Group 1: LA Group 2: GA
Group 1: RLS + steroid Group 2: RLS + steroid
Group 1: 2 needle Group 2: dual-port
1 year
Group 1: LA Group 2: GA
Groups 1 and 2: RLS Group 1: RLS + SH Group 2: RLS + SH Group 1: saline Group 2: saline Groups 1 and 2: RLS + SH
Duration of problem
Diagnostic problem subgroup
AS (group 2)
Murakami et al.22
1995
CCT prosp.
20
25
Fridrich et al.23
1996
RCT, prosp.
8
11
Goudot et al.24
2000
RCT prosp.
29
33
Groups 1 and 2: 46 F, 16 M
Hobeich et al.25
2007
RS
25
32
Groups 1 and 2: 12 M, 45 F
Groups 1 and 2: range 16–54
18–28 months
Group 1: LA Group 2: GA
Tan and Krishnaswamy26
2012
CCT prosp.
11
9
Group 1: LA Group 2: GA
2013
RS
41
37
Group 1: range 16–40 Group 2: range 20–63 Group 1: range 34–39 Group 2: range 30–73
1 week 1 month
Xu et al.27
Group 1: 8 F, 3 M Group 2: 7 F, 2 M Group 1: 30 F, 11 M Group 2: 29 F, 8 M
Over 3 months
Groups 1 and 2: LA
Group 1: 6.85 months Group 2: 5.64 months NR
Closed lock
Group 1: 2 needle Group 2: cannula with double needle 100–200 ml NR
NR
54 ADDWR 8 ADDR
Groups 1 and 2: 1–2 years
ADDWR
Group 1: 2 needle 100–200 ml Group 2: cannula with double needle 200 ml Group 1: 2 needle Group 2: two cannulas High pressure 500 ml
Group 1: 1–9 months Group 2: 1–6 years NR
3 painful click 17 closed lock (due to DD or ADP) ADD
7 ADDWR 12 ADDR
IA, intra-articular; AC, arthrocentesis; AS, arthroscopy; F, female; M, male; CCT, controlled clinical trial; RCT, randomized clinical trial; prosp., prospective study; RS, retrospective study; NR, not reported; LA, local anaesthesia; GA, general anaesthesia; RLS, Ringer’s lactate solution; ADDWR, anterior disc displacement without reduction; ADDR, anterior disc displacement with reduction; SH, sodium hyaluronate; DD, disc displacement; ADP, anchored disc phenomenon. * Group 1, arthrocentesis; group 2, arthroscopy.
Arthroscopy vs. arthrocentesis for TMJ derangement
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
Table 1. Characteristics of the studies comparing arthroscopy and arthrocentesis included in the review.*
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Table 2. Preoperative and postoperative mean pain scores and maximal inter-incisal opening. Pain (VAS)
Authors
MIO (mm) Arthroscopy
Arthrocentesis Preop. Murakami et al.22 Fridrich et al.23 Goudot et al.24 Hobeich et al.25 Tan and Krishnaswamy26 Xu et al.27
Postop.
5.7 6.45 5.6 5.75 6.67 5.32
2.4 1.7 0.9 2.55 2.11 0.73
Preop. 4.8 6.6 5.7 5.71 6 6.08
Arthrocentesis
Arthroscopy
Postop.
Preop.
Postop.
Preop.
Postop.
3.0 2.3 1.9 2.32 3.5 2.21
30.6 33 29.4 31.75 26.56 25.9
42.5 41 33.8 41.60 39.56 35.7
27.5 30 29.0 32.07 30.25 24.2
42.1 47.5 38.6 40.68 36.88 37.1
Statistical analysis
Estimated potential risk of bias
VAS, visual analogue scale; MIO, maximal inter-incisal opening. Table 3. Critical appraisal of the studies included (quality assessment).
Authors
Published 22
Murakami et al. Fridrich et al.23 Goudot et al.24 Hobeich et al.25 Tan and Krishnaswamy26 Xu et al.27
Random selection in population
1995 1996 2000 2007 2012 2013
No Yes Yes No No No
Defined inclusion/ exclusion criteria Yes Yes Yes Yes Yes Yes
Loss of follow-up Yes Yes Yes Yes Yes Yes
Validated measurement Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes
Moderate Low Low Moderate Moderate Moderate
Fig. 2. Forest plot showing the weighted mean difference in the MIO between the arthrocentesis and arthroscopy groups.
(x2 = 0.49, df = 2; P = 0.78; I2 = 0%) (Fig. 4). Assessment of publication bias
No significant publication bias was observed for the studies included (Fig. 5). Discussion
The role of lavage with the accompanying procedure of arthrolysis has shown excellent success rates in the treatment of TMD. This procedure has been shown to reduce pain and improve joint mobility, sometimes even in patients suffering the advanced stages of degeneration and dysfunction.28–31 There are two different
approaches to lavage and arthrolysis: arthrocentesis and arthroscopic lavage. Various studies have compared the two techniques and have suggested that they vary in terms of prognosis, complications, and long-term outcomes.22,23,25 In this study, the results of the metaanalysis revealed a statistically significant difference in favour of arthroscopy with respect to MIO and pain. These results may be attributed to the efficacy of arthroscopy in releasing the negative pressure on the disc, releasing adhesions, distending or widening the narrowed joint space, reducing surface friction, and altering the viscosity of the synovial fluid.32 These results are, however, inconsistent with the results of other studies.12,22,23,25
Concerning pain, there was a significant advantage of arthroscopy over arthrocentesis (P = 0.00001). This may be because the larger diameter portal with high pressure used in arthroscopic lavage enables more extensive removal of inflammatory mediators resulting in a subsequent greater reduction in pain.27 A total of 281 patients enrolled in six studies22–27 were included in the qualitative and quantitative analysis: two RCTs,23,24 two CCTs,22,26 and two retrospective studies.25,27 Two studies showed a low risk of bias23,24 and four studies showed a moderate risk of bias.22,25–27 The diagnostic problem subgroups were ADDWR/ADDR in three studies23–25,27 and closed disc and painful joints with
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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Fig. 3. Forest plot showing the weighted mean difference in pain scores (VAS) between the arthrocentesis and arthroscopy groups.
Fig. 4. Forest plot showing the incidence of postoperative complications between the arthrocentesis and arthroscopy groups.
Fig. 5. Funnel plot showing a symmetrical distribution without systematic heterogeneity of the individual study treatment effects compared with standard error, indicating a lack of publication bias in the meta-analysis.
the anchored disc phenomenon in three studies.22,26 Arthrocentesis and arthroscopy are not without risks. Generally, the potential complications of arthroscopy can also occur in arthrocentesis, but the incidence and extent of complications are lesser in arthrocentesis28. Damage to the facial and auriculo-temporal nerves, perforation of the external auditory canal and tympanic membrane, and breach of the base of the skull33 have been reported as complications after arthroscopy. Transient facial nerve paralysis caused by local
anaesthesia and swelling of the pre-auricular area due to fluid extravasation may result from arthrocentesis. In the present study, there was no statistically significant difference between the two groups with regard to the incidence of postoperative complications (fixed: OR 1.15, 95% CI 0.30–4.43; P = 0.84). Nitzan believes 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, therefore the success rates with arthrocentesis are similar to
those of arthroscopic lysis or lavage.34 However, Sanders maintains that in cases of chronic closed lock, intracapsular lysis using probes between the disc and fossa is necessary to release superior compartment adhesions.35 With regard to age and the duration of the problem, the author of the current study believes that the chronicity of joint symptoms and older age could be considered poor indicators in the prediction of the outcome of both procedures. Although, the results of this study revealed a superiority of arthroscopy over
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
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arthrocentesis in improving jaw function and reducing pain, there are a number of disadvantages to arthroscopy: it requires general anaesthesia and the use of an operating room, it is relatively more invasive, there is greater postoperative morbidity, it is a more expensive procedure, and it has a greater potential for complications. Whereas serious complications such as arterio-venous fistula, facial, trigeminal, and auditory nerve injury, otitis media, perforation of the glenoid fossa, extradural haematoma, broken instruments in the joint, and perforation of the tympanic membrane and middle ear resulting in deafness have occurred with arthroscopy,24,27,36–42 the only major complication reported with arthrocentesis has been one case of an extradural haematoma.42 These advantages of arthrocentesis support the contention that it should be the initial surgical treatment of choice for internal derangements that do not respond to medical management.43 In conclusion, arthroscopy lysis and lavage was found to have superior efficacy in improving MIO and reducing pain when compared to arthrocentesis. Further, the incidence of postoperative complications was comparable for the two techniques. However, the current meta-analysis is incomplete due to the paucity of good quality studies in the high-impact, peerreviewed literature and, therefore, more better-designed studies are required to address this important question before final conclusions can be drawn as to the true comparative outcomes of TMJ arthrocentesis versus TMJ arthroscopy. Funding
None. Competing interests
None. Ethical approval
Not required. Patient consent
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Address: Essam Ahmed Al-Moraissi Department of Oral and Maxillofacial Surgery Faculty of Dentistry Thamar University Thamar Yemen. Tel: +967 21141477753, 009 67777788939. E-mails: [email protected], [email protected]
Please cite this article in press as: Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.008
