- Email: [email protected]
Clinical Application of Ultrathin Arthroscopy in the Temporomandibular Joint for Treatment of Closed Lock Patients
J Oral Maxillofac Surg 67:1039-1045, 2009
Clinical Application of Ultrathin Arthroscopy in the Temporomandibular Joint for Treatment of Closed Lock Patients Young-Kyun Kim, DDS, MSD, PhD,* Jae-Hyung Im, DDS,† Hoon Chung, DDS, MSD, PhD,‡ and Pil-Young Yun, DDS, MSD, PhD§ Purpose: The purpose of this study was to evaluate the treatment outcome of temporomandibular joint
(TMJ) lysis and lavage using ultrathin TMJ arthroscopy. Patients and Methods: Closed lock patients who had not shown response to the conservative treatment for more than 3 months were included in this study. The clinical data were collected using standard protocol including questionnaire. Under the informed consent, TMJ lysis and lavage were performed using ultrathin arthroscopy. For the evaluation of the treatment outcome, maximum mouth opening (MMO) and visual analog scale (VAS) were used. Results: A total of 15 patients were included in this study. Concerning arthroscopic findings, fibrillation and adhesion were detected in 9 patients. Synovial hyperemia and ecchymosis was detected in 6 patients. There were no complications related with arthroscopic procedure in this study. Improvement of mouth opening more than 5 mm was detected in 14 patients. VAS score was reduced more than 60%, and VAS was recorded no more than 2 postoperatively in 12 patients. Good outcome was obtained in 12 patients (80%) from the total 15 patients. Conclusion: From the clinical outcomes, TMJ lysis and lavage using ultrathin TMJ arthroscopy could be considered as an alternative treatment for the closed lock patients. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:1039-1045, 2009 It is generally accepted that the main symptoms of temporomandibular joint (TMJ) disease are mouth opening limitation (MOL) and TMJ pain. TMJ hypomobility, so-called closed lock, usually resulted in
*Associate Professor, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seoul, Korea. †Resident, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seoul, Korea. ‡Chairman, Korean Association for Temporomandibular Joint Corporation, Seoul, Korea. §Assistant Professor, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seoul, Korea. Address correspondence and reprint requests to Dr Yun: Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea; e-mail: pilyoung@ snubh.org © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6705-0017$36.00/0 doi:10.1016/j.joms.2008.12.040
MOL. In the past, closed lock was considered the result of deformed and anteriorly displaced disc.1 With the help of an advanced imaging technique, many related conditions on the pathologic mechanism of closed lock have been suggested. Nitzan and Dolwick2 proposed that MOL was due to the complete lack of disc gliding caused by tissue adherence to the fossa, at the posterior slope of the eminence. The causes of such adherence were suggested as fibrous adhesions, increased friction between damaged rough surfaces, increased viscosity of synovial fluid, or possibly a vacuum effect. As the conservative options for the treatment of closed lock, physical therapy, medication, joint pumping and manipulation, superior joint space injection, and arthrocentesis can be considered. Recently, the usefulness of arthroscopic TMJ lysis and lavage procedure has been proven.3,4 The application of arthroscopy in TMJ has advantages in diagnosis as well as in treatment because it is possible to examine joint space and to remove the inflammation products and adhesion tissue in the joint space minimizing damage to the articular structures.
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ULTRATHIN ARTHROSCOPY IN TMJ
FIGURE 1. The procedure of TMJ lysis and lavage using ultrathin arthroscopy. A, Ultrathin arthroscopy and 18-gauge needle were inserted at the puncture sites. B, A blunt probe was inserted for lysis of fibrous adhesion. C, Hyaluronic acid was injected. D, Puncture sites were sutured with a 5-0 nylon. Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
to January 2007, closed lock patients (MMO ⬍30 mm) who had not shown response to the conservative treatment for more than 3 months were included in this study. The clinical data were collected using standard protocol including a questionnaire. All patients had preoperative panoramic radiographs and TMJ magnetic resonance imaging (MRI) for the assessment of TMJ morphology. Under the informed consent, TMJ lysis and lavage were performed using ultrathin TMJ arthroscopy.
In this study, ultrathin TMJ arthroscopy was applied as a minimally invasive treatment method for the closed lock patients. The purpose of this study was to evaluate the treatment outcome of TMJ lysis and lavage using ultrathin TMJ arthroscopy.
Patients and Methods Among the TMD patients who visited Seoul National University Bundang Hospital from March 2004
Table 1. SUMMARY OF CASES I: CLINICAL CHARACTERISTICS OF THE PATIENTS
Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Age
Gender
No Treatment Period (mo)
Conservative Treatment Period (mo)
Number of Additional Symptoms
Site
18 34 34 21 64 24 20 49 46 21 27 35 43 31 15
F F F M F F F F F F M F M F F
10 4 15 10 22 8 60 5 36 72 24 3 4 36 12
3 24 14 4 24 3 5 4 3 3 5 29 24 4 3
1 2 3 3 2 1 3 1 2 1 3 3 3 2 3
Right Left Right Left Right Left Left Right Both Left Left Left Left Both Left
Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
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KIM ET AL
Table 2. PREOPERATIVE SIGNS AND SYMPTOMS OF THE PATIENTS
Signs and Symptoms
Number of Patients
Mouth opening limitation Pain Joint noise Muscle tenderness Mouth opening deviation Morning stiffness Headache Malocclusion Tinnitus Neck/shoulder/back pain
15 15 8 7 5 3 3 3 2 2
Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
postoperatively. Patients were assessed at 6 weeks after surgery. EVALUATION OF THE TREATMENT OUTCOME
Maximum mouth opening (MMO) check was done by measuring interincisal distance. To evaluate the degree of the patients’ subjective pain, a 10-cm visual analog scale (VAS) was used. The VAS score ranged between 0 and 10. The criteria of good outcome were 1) the improvement of mouth opening equal to or more than 5 mm in comparison with preoperative assessment, 2) more than 60% reduction of VAS, 3) VAS of equal to or less than 2 at postoperative assessment, and 4) no recurrence of symptoms.5,6 STATISTICAL ANALYSIS
ARTHROSCOPIC PROCEDURE AND POSTOPERATIVE MANAGEMENT
Arthroscopic procedure was performed under general anesthesia. The line connecting outer canthus and tragus was marked on the skin. Primary puncture site was marked at the point of 10 mm anterior and 2 mm inferior from the tragus. Secondary puncture site was marked at the point of 10 mm anterior, 10 mm inferior from the primary puncture site. An 18-gauge needle was inserted at the primary puncture site and pumping was done with normal saline. An 18-gauge needle was inserted at the secondary puncture site and normal saline drainage was confirmed. After removal of the needle at the primary puncture site, ultrathin trocar was inserted and 20 cc of Hartman solution was injected for the test of patency. Then, ultrathin arthroscope (0° scope, MGB scopy, Japan) was inserted. Hartman solution (100-200 cc) was connected at the lateral side of arthroscope and TMJ lysis and lavage was done under the direct vision. After the procedure, hyaluronic acid (Hyruan plus, LG Biosci Co, Seongnam, Korea) was injected. Sutures were done at the puncture site with 5-0 nylon (Fig 1). Pressure dressing was done at the puncture site. Antibiotics and analgesics were prescribed for 7 days
Correlation between clinical factors and treatment outcome was estimated. Fisher’s exact test was executed to evaluate statistical significance. The comparison of preoperative and postoperative values of MMO and VAS was performed by Wilcoxon signed ranks test (P ⬍ .05). The statistical evaluation was performed with SPSS 15.0 (SPSS Inc, Chicago, IL).
Results A total of 15 patients were included in this study. Three patients were male, 12 patients were female. The patients’ age ranged between 15 and 64 years (mean: 32.1 years). Bilateral TMJ examination was performed in 2 patients. No treatment period (the duration from onset of TMJ symptoms to treatment start) ranged between 3 and 72 months (mean: 21.4 months). Conservative treatment period ranged between 3 and 29 months (mean: 10 months) (Table 1). In addition to MOL (⬍30 mm) and TMJ pain, most patients complained of 1 or more temporomandibular disorder (TMD)-related symptoms such as joint noise (in 8 patients), muscle tenderness (in 7 patients), mouth opening deviation (in 5 patients), morning stiffness (in 3 patients), headache (in 3 patients),
FIGURE 2. Anterior erosive changes of both mandibular condyles were shown on panoramic radiograph (A) and transcranial view (B) (case 9). Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
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ULTRATHIN ARTHROSCOPY IN TMJ
FIGURE 3. Anterior disc displacement without reduction of left TMJ is observed on TMJ MRI (case 4). A, Closed position, B, open position. Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
malocclusion (in 3 patients), tinnitus (in 2 patients), and neck/shoulder/back pain (in 2 patients) (Table 2). Preoperative panoramic radiographs showed definite remodeling changes such as osteophyte, flattening, and erosion in 9 patients (Fig 2). There were no specific findings in 6 patients. Preoperative TMJ MRI was taken, and disc anterior displacement without reduction was confirmed in all patients (Fig 3). In preoperative bone scan findings, the increases of uptake in the involved TMJ were found in 9 patients (Fig 4). As for arthroscopic findings, fibrillation and adhesion were detected in 9 patients. Synovial hyperemia and ecchymosis were detected in 6 patients (Fig 5). There were no complications related with arthroscopic procedure in this study. Preoperative mean amount of mouth opening was 24.1mm and postoperative mean amount of mouth opening was 34.7 mm. Improvement of mouth opening more than 5 mm was detected in 14 patients. In the subjective evaluation of pain improvement, VAS score was reduced more than 60% and VAS was recorded no more than 2 postoperatively in 12 patients (Table 3). Good outcome was obtained in 12 (80%) of 15 patients. The follow-up period after arthroscopic treatment ranged from 10 to 40 months (mean: 21.5 months). In 3 patients, poor outcome was obtained. In case 4, mild improvement of mouth opening was found after arthroscopic treatment but TMJ pain continued. In case 3, there was no improvement of mouth opening and pain at the time of 4 months after surgery. In case 15, sufficient improvement of
mouth opening was obtained. However, the symptoms recurred.
Discussion The simplest treatments using arthroscopy are lysis and lavage. Lysis is the sweeping procedure of the
FIGURE 4. Increased hot uptake of right TMJ area was detected on bone scan (case 1). Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
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KIM ET AL
FIGURE 5. Ultrathin arthroscopic finding. Fibrous adhesion and synovial hyperemia were observed. Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
adhesion tissue using blunt probe in the articular cavity. Lavage is the method of irrigation of superior joint space through inflow and outflow cannula (or needle) using normal saline or Hartman solution.7,8 Previously, advanced arthroscopic procedures, such as isolation of anterior portion of articular capsule from external pterygoid muscle, electrocauterization of posterior ligament, and disc repositioning and pla-
cation, using special equipment (ie, laser, electrocautery, shaver system) were introduced.9-12 There have been many reports on the usefulness of arthroscopic lysis and lavage. Sorel et al13 reported on the long-term advantages of arthroscopic treatment of TMJ chronic pain. Politi et al14 recommended lessinvasive treatment to manage chronic closed lock patients because there was no difference between
Table 3. SUMMARY OF CASES II: RESULTS OF TMJ LYSIS AND LAVAGE USING ULTRATHIN ARTHROSCOPY
Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Pre-MMO (mm)
Post-MMO (mm)
Pre-VAS
Post-VAS
Treatment Outcome
Complication
25 23 30 20 28 27 20 21 30 27 20 17 25 24 27
38 35 32 25 33 35 33 38 35 35 30 33 38 40 35
9 7 10 7 8 7 8 8 7 9 7 8 8 9 9
0 0 9 5 2 0 0 2 1 2 2 2 2 2 5
Good Good Poor Poor Good Good Good Good Good Good Good Good Good Good Poor
— — — — — — — — — — — — — — —
Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
1044 open surgery (ie, high condylectomy, meniscoplasty, and so forth) and arthroscopic lysis and lavage. Sembronio et al15 reported a successfully treated septic arthritis case using arthroscopic lysis and lavage. Indresano16 treated 64 patients using arthroscopic lysis and lavage and reported a 83% success rate. Hamada et al6 introduced visually guided irrigation technique and reported good clinical outcomes. White17 reported good clinical outcome including pain relief, mouth opening, and functional improvement using arthroscopic lysis and lavage, and insisted that there was no significant difference of the treatment effect between advanced arthroscopic surgery and arthroscopic lysis and lavage. It is known that arthroscopic procedure is relatively safe, and most complications can be solved without any permanent changes. Tsuyama et al18 reported 10.3% complications after arthroscopic procedure. The major portion of complication was otologic problems (8.6%) including blood clots in the external auditory meatus, perforation of tympanic membrane, laceration on external auditory meatus, partial hearing loss, ear fullness, and vertigo. Neurological injury occupied 1.7%, including the fifth and the seventh cranial nerve injury. Arthroscopic procedure has potential risk of TMJ injury, bringing on secondary osteoarthritis. If large-diameter arthroscopy (⬎2 mm) is used, there is more chance of injury. So, to minimize iatrogenic injury, ultrathin arthroscopy was designed and used clinically. There are 2 types of TMJ arthroscopes: rod lens type and fiberoptic type. The image was definite but there is a possibility of lens fracture and iatrogenic injury during the insertion procedure. The diameter of the commonly used arthroscope was 1.9 to 2.7 mm. Recently, to minimize iatrogenic injury, 1.2 to 1.4 mm was developed and used. The other side, fiberoptic type, is flexible and has many advantages including easy manipulation in articular cavity and less iatrogenic trauma. However, the quality of image resolution is not as excellent.19-21 There were no complications in relation to the ultrathin arthroscopic procedure in this study. This study had a limitation in that it was difficult to evaluate treatment outcomes using ultrathin TMJ arthroscopy in comparison with other treatments. However, as a minimally invasive procedure, it was obvious that TMJ lysis and lavage using ultrathin TMJ arthoroscopy was a safe procedure. Also, 80% of patients showed good outcome. Interestingly, although it was not significant (P ⫽ .077), 3 patients showing poor outcome were all included in the patient group who complained of more than 3 TMD-related symptoms. It was suspected that the patients who had complicated symptoms or combined diagnosis would show poor response to the TMJ lysis and lavage using ultrathin TMJ arthroscopy. For these
ULTRATHIN ARTHROSCOPY IN TMJ
patients, multidirectional approaches should be considered. On the base of clinical experience, ultrathin TMJ arthroscopy has many advantages: 1) higher diagnostic value by providing direct vision in the articular cavity, 2) visual effect of patient instruction by taking an image of the pathologic state, 3) effective removal of lyses of adhesion tissue using a probe and biopsy, and 4) minimizing iatrogenic injury using an ultrathin trocar and arthroscope. From the clinical outcomes, TMJ lysis and lavage using ultrathin TMJ arthroscopy could be considered as an alternative treatment for the closed lock patients.
References 1. Farrar WB, Katzberg RW, Helms CA: Internal derangement of the temporomandibular joint: Fact or friction. J Prosthet Dent 49:415, 1983 2. Nitzan DW, Dolwick MF: An alternative explanation for the genesis of closed-lock symptoms in the internal derangement process. J Oral Maxillofac Surg 49:810, 1991 3. Nitzan DW, Dolwick MF, Heft M: Arthroscopic lavage and lysis of the temporomandibular joint: A change in perspective. J Oral Maxillofac Surg 48:798, 1990 4. Kurita K, Goss AN, Ogi N, et al: Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction. J Oral Maxillofac Surg 56:1394, 1998 5. Holmlund AB, Axelsson S, Gynther GW: A comparison of discectomy and arthroscopic lysis and lavage for the treatment of chronic closed lock of the temporomandibular joint: A randomized outcome study. J Oral Maxillofac Surg 59:972, 2001 6. Hamada Y, Kondoh T, Holmlund AB, et al: One-year clinical course following visually guided irrigation for chronic closed lock of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101:170, 2006 7. Moses JJ, Sartoris D, Glass R, et al: The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 47:674, 1989 8. Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol 62:361, 1986 9. Davis EL, Kaminishi RM, Marshall MW: Arthroscopic surgery for treatment of closed lock. J Oral Maxillofac Surg 49:704, 1991 10. McCain JP, de la RUA H: Principles and practice of operative arthroscopy of the human temporomandibular joint. Oral Maxillofac Surg Clin North Am 1:135, 1989 11. Tarro AW: Arthroscopic treatment of anterior disc displacement: A preliminary report. J Oral Maxillofac Surg 47:353, 1989 12. Koslin MG, Martin JC: The use of Holmium laser for temporomandibular joint arthroscopic surgery. J Oral Maxillofac Surg 51:122, 1993 13. Sorel B, Piecuch JF: Long-term evaluation following temporomandibular joint arthroscopy with lysis and lavage. Int J Oral Maxillofac Surg 29:259, 2000 14. Politi M, Sembronio S, Robiony M, et al: High condylectomy and disc repositioning compared with arthroscopic lysis, lavage, and capsular stretch for the treatment of chronic closed lock of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103:27, 2007 15. Sembronio S, Albiero AM, Robiony M, et al: Septic arthritis of the temporomandibular joint successfully treated with arthroscopic lysis and lavage: Case report and review of the
KIM ET AL literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103:e1, 2007 16. Indresano AT: Arthroscopic surgery of the temporomandibular joint: Report of 64 patients with long-term follow-up. J Oral Maxillofac Surg 47:157, 1989 17. White RD: Arthroscopic lysis and lavage as the preferred treatment for internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 59:313, 2001 18. Tsuyama M, Kondoh T, Seto K, et al: Complications of temporomandibular joint arthroscopy: A retrospective analysis of 301 lysis and lavage procedures performed using the triangulation technique. J Oral Maxillofac Surg 58:500, 2000
1045 19. Yoshida H, Fukumura Y, Tojyo I, et al: Operation with a single-channel thin-fibre arthroscope in patients with internal derangement of the temporomandibular joint. Br J Oral Maxillofac Surg 46:313, 2008 20. Kurita K, Ogi N, Toyama M, et al: Single-channel thin-fiber and Nd:YAG laser temporomandibular joint arthroscope: Development and preliminary clinical findings. Int J Oral Maxillofac Surg 26:414, 1997 21. Kurita K, Ogi N, Miyamoto K, et al: Diagnostic evaluation of an ultrathin 15,000 fiberoptic arthroscope: Comparison of arthroscopic and histologic findings in a sheep model. J Oral Maxillofac Surg 63:319, 2005
Clinical Application of Ultrathin Arthroscopy in the Temporomandibular Joint for Treatment of Closed Lock Patients Young-Kyun Kim, DDS, MSD, PhD,* Jae-Hyung Im, DDS,† Hoon Chung, DDS, MSD, PhD,‡ and Pil-Young Yun, DDS, MSD, PhD§ Purpose: The purpose of this study was to evaluate the treatment outcome of temporomandibular joint
(TMJ) lysis and lavage using ultrathin TMJ arthroscopy. Patients and Methods: Closed lock patients who had not shown response to the conservative treatment for more than 3 months were included in this study. The clinical data were collected using standard protocol including questionnaire. Under the informed consent, TMJ lysis and lavage were performed using ultrathin arthroscopy. For the evaluation of the treatment outcome, maximum mouth opening (MMO) and visual analog scale (VAS) were used. Results: A total of 15 patients were included in this study. Concerning arthroscopic findings, fibrillation and adhesion were detected in 9 patients. Synovial hyperemia and ecchymosis was detected in 6 patients. There were no complications related with arthroscopic procedure in this study. Improvement of mouth opening more than 5 mm was detected in 14 patients. VAS score was reduced more than 60%, and VAS was recorded no more than 2 postoperatively in 12 patients. Good outcome was obtained in 12 patients (80%) from the total 15 patients. Conclusion: From the clinical outcomes, TMJ lysis and lavage using ultrathin TMJ arthroscopy could be considered as an alternative treatment for the closed lock patients. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:1039-1045, 2009 It is generally accepted that the main symptoms of temporomandibular joint (TMJ) disease are mouth opening limitation (MOL) and TMJ pain. TMJ hypomobility, so-called closed lock, usually resulted in
*Associate Professor, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seoul, Korea. †Resident, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seoul, Korea. ‡Chairman, Korean Association for Temporomandibular Joint Corporation, Seoul, Korea. §Assistant Professor, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seoul, Korea. Address correspondence and reprint requests to Dr Yun: Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea; e-mail: pilyoung@ snubh.org © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6705-0017$36.00/0 doi:10.1016/j.joms.2008.12.040
MOL. In the past, closed lock was considered the result of deformed and anteriorly displaced disc.1 With the help of an advanced imaging technique, many related conditions on the pathologic mechanism of closed lock have been suggested. Nitzan and Dolwick2 proposed that MOL was due to the complete lack of disc gliding caused by tissue adherence to the fossa, at the posterior slope of the eminence. The causes of such adherence were suggested as fibrous adhesions, increased friction between damaged rough surfaces, increased viscosity of synovial fluid, or possibly a vacuum effect. As the conservative options for the treatment of closed lock, physical therapy, medication, joint pumping and manipulation, superior joint space injection, and arthrocentesis can be considered. Recently, the usefulness of arthroscopic TMJ lysis and lavage procedure has been proven.3,4 The application of arthroscopy in TMJ has advantages in diagnosis as well as in treatment because it is possible to examine joint space and to remove the inflammation products and adhesion tissue in the joint space minimizing damage to the articular structures.
1039
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ULTRATHIN ARTHROSCOPY IN TMJ
FIGURE 1. The procedure of TMJ lysis and lavage using ultrathin arthroscopy. A, Ultrathin arthroscopy and 18-gauge needle were inserted at the puncture sites. B, A blunt probe was inserted for lysis of fibrous adhesion. C, Hyaluronic acid was injected. D, Puncture sites were sutured with a 5-0 nylon. Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
to January 2007, closed lock patients (MMO ⬍30 mm) who had not shown response to the conservative treatment for more than 3 months were included in this study. The clinical data were collected using standard protocol including a questionnaire. All patients had preoperative panoramic radiographs and TMJ magnetic resonance imaging (MRI) for the assessment of TMJ morphology. Under the informed consent, TMJ lysis and lavage were performed using ultrathin TMJ arthroscopy.
In this study, ultrathin TMJ arthroscopy was applied as a minimally invasive treatment method for the closed lock patients. The purpose of this study was to evaluate the treatment outcome of TMJ lysis and lavage using ultrathin TMJ arthroscopy.
Patients and Methods Among the TMD patients who visited Seoul National University Bundang Hospital from March 2004
Table 1. SUMMARY OF CASES I: CLINICAL CHARACTERISTICS OF THE PATIENTS
Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Age
Gender
No Treatment Period (mo)
Conservative Treatment Period (mo)
Number of Additional Symptoms
Site
18 34 34 21 64 24 20 49 46 21 27 35 43 31 15
F F F M F F F F F F M F M F F
10 4 15 10 22 8 60 5 36 72 24 3 4 36 12
3 24 14 4 24 3 5 4 3 3 5 29 24 4 3
1 2 3 3 2 1 3 1 2 1 3 3 3 2 3
Right Left Right Left Right Left Left Right Both Left Left Left Left Both Left
Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
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Table 2. PREOPERATIVE SIGNS AND SYMPTOMS OF THE PATIENTS
Signs and Symptoms
Number of Patients
Mouth opening limitation Pain Joint noise Muscle tenderness Mouth opening deviation Morning stiffness Headache Malocclusion Tinnitus Neck/shoulder/back pain
15 15 8 7 5 3 3 3 2 2
Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
postoperatively. Patients were assessed at 6 weeks after surgery. EVALUATION OF THE TREATMENT OUTCOME
Maximum mouth opening (MMO) check was done by measuring interincisal distance. To evaluate the degree of the patients’ subjective pain, a 10-cm visual analog scale (VAS) was used. The VAS score ranged between 0 and 10. The criteria of good outcome were 1) the improvement of mouth opening equal to or more than 5 mm in comparison with preoperative assessment, 2) more than 60% reduction of VAS, 3) VAS of equal to or less than 2 at postoperative assessment, and 4) no recurrence of symptoms.5,6 STATISTICAL ANALYSIS
ARTHROSCOPIC PROCEDURE AND POSTOPERATIVE MANAGEMENT
Arthroscopic procedure was performed under general anesthesia. The line connecting outer canthus and tragus was marked on the skin. Primary puncture site was marked at the point of 10 mm anterior and 2 mm inferior from the tragus. Secondary puncture site was marked at the point of 10 mm anterior, 10 mm inferior from the primary puncture site. An 18-gauge needle was inserted at the primary puncture site and pumping was done with normal saline. An 18-gauge needle was inserted at the secondary puncture site and normal saline drainage was confirmed. After removal of the needle at the primary puncture site, ultrathin trocar was inserted and 20 cc of Hartman solution was injected for the test of patency. Then, ultrathin arthroscope (0° scope, MGB scopy, Japan) was inserted. Hartman solution (100-200 cc) was connected at the lateral side of arthroscope and TMJ lysis and lavage was done under the direct vision. After the procedure, hyaluronic acid (Hyruan plus, LG Biosci Co, Seongnam, Korea) was injected. Sutures were done at the puncture site with 5-0 nylon (Fig 1). Pressure dressing was done at the puncture site. Antibiotics and analgesics were prescribed for 7 days
Correlation between clinical factors and treatment outcome was estimated. Fisher’s exact test was executed to evaluate statistical significance. The comparison of preoperative and postoperative values of MMO and VAS was performed by Wilcoxon signed ranks test (P ⬍ .05). The statistical evaluation was performed with SPSS 15.0 (SPSS Inc, Chicago, IL).
Results A total of 15 patients were included in this study. Three patients were male, 12 patients were female. The patients’ age ranged between 15 and 64 years (mean: 32.1 years). Bilateral TMJ examination was performed in 2 patients. No treatment period (the duration from onset of TMJ symptoms to treatment start) ranged between 3 and 72 months (mean: 21.4 months). Conservative treatment period ranged between 3 and 29 months (mean: 10 months) (Table 1). In addition to MOL (⬍30 mm) and TMJ pain, most patients complained of 1 or more temporomandibular disorder (TMD)-related symptoms such as joint noise (in 8 patients), muscle tenderness (in 7 patients), mouth opening deviation (in 5 patients), morning stiffness (in 3 patients), headache (in 3 patients),
FIGURE 2. Anterior erosive changes of both mandibular condyles were shown on panoramic radiograph (A) and transcranial view (B) (case 9). Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
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ULTRATHIN ARTHROSCOPY IN TMJ
FIGURE 3. Anterior disc displacement without reduction of left TMJ is observed on TMJ MRI (case 4). A, Closed position, B, open position. Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
malocclusion (in 3 patients), tinnitus (in 2 patients), and neck/shoulder/back pain (in 2 patients) (Table 2). Preoperative panoramic radiographs showed definite remodeling changes such as osteophyte, flattening, and erosion in 9 patients (Fig 2). There were no specific findings in 6 patients. Preoperative TMJ MRI was taken, and disc anterior displacement without reduction was confirmed in all patients (Fig 3). In preoperative bone scan findings, the increases of uptake in the involved TMJ were found in 9 patients (Fig 4). As for arthroscopic findings, fibrillation and adhesion were detected in 9 patients. Synovial hyperemia and ecchymosis were detected in 6 patients (Fig 5). There were no complications related with arthroscopic procedure in this study. Preoperative mean amount of mouth opening was 24.1mm and postoperative mean amount of mouth opening was 34.7 mm. Improvement of mouth opening more than 5 mm was detected in 14 patients. In the subjective evaluation of pain improvement, VAS score was reduced more than 60% and VAS was recorded no more than 2 postoperatively in 12 patients (Table 3). Good outcome was obtained in 12 (80%) of 15 patients. The follow-up period after arthroscopic treatment ranged from 10 to 40 months (mean: 21.5 months). In 3 patients, poor outcome was obtained. In case 4, mild improvement of mouth opening was found after arthroscopic treatment but TMJ pain continued. In case 3, there was no improvement of mouth opening and pain at the time of 4 months after surgery. In case 15, sufficient improvement of
mouth opening was obtained. However, the symptoms recurred.
Discussion The simplest treatments using arthroscopy are lysis and lavage. Lysis is the sweeping procedure of the
FIGURE 4. Increased hot uptake of right TMJ area was detected on bone scan (case 1). Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
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KIM ET AL
FIGURE 5. Ultrathin arthroscopic finding. Fibrous adhesion and synovial hyperemia were observed. Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
adhesion tissue using blunt probe in the articular cavity. Lavage is the method of irrigation of superior joint space through inflow and outflow cannula (or needle) using normal saline or Hartman solution.7,8 Previously, advanced arthroscopic procedures, such as isolation of anterior portion of articular capsule from external pterygoid muscle, electrocauterization of posterior ligament, and disc repositioning and pla-
cation, using special equipment (ie, laser, electrocautery, shaver system) were introduced.9-12 There have been many reports on the usefulness of arthroscopic lysis and lavage. Sorel et al13 reported on the long-term advantages of arthroscopic treatment of TMJ chronic pain. Politi et al14 recommended lessinvasive treatment to manage chronic closed lock patients because there was no difference between
Table 3. SUMMARY OF CASES II: RESULTS OF TMJ LYSIS AND LAVAGE USING ULTRATHIN ARTHROSCOPY
Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Pre-MMO (mm)
Post-MMO (mm)
Pre-VAS
Post-VAS
Treatment Outcome
Complication
25 23 30 20 28 27 20 21 30 27 20 17 25 24 27
38 35 32 25 33 35 33 38 35 35 30 33 38 40 35
9 7 10 7 8 7 8 8 7 9 7 8 8 9 9
0 0 9 5 2 0 0 2 1 2 2 2 2 2 5
Good Good Poor Poor Good Good Good Good Good Good Good Good Good Good Poor
— — — — — — — — — — — — — — —
Kim et al. Ultrathin Arthroscopy in TMJ. J Oral Maxillofac Surg 2009.
1044 open surgery (ie, high condylectomy, meniscoplasty, and so forth) and arthroscopic lysis and lavage. Sembronio et al15 reported a successfully treated septic arthritis case using arthroscopic lysis and lavage. Indresano16 treated 64 patients using arthroscopic lysis and lavage and reported a 83% success rate. Hamada et al6 introduced visually guided irrigation technique and reported good clinical outcomes. White17 reported good clinical outcome including pain relief, mouth opening, and functional improvement using arthroscopic lysis and lavage, and insisted that there was no significant difference of the treatment effect between advanced arthroscopic surgery and arthroscopic lysis and lavage. It is known that arthroscopic procedure is relatively safe, and most complications can be solved without any permanent changes. Tsuyama et al18 reported 10.3% complications after arthroscopic procedure. The major portion of complication was otologic problems (8.6%) including blood clots in the external auditory meatus, perforation of tympanic membrane, laceration on external auditory meatus, partial hearing loss, ear fullness, and vertigo. Neurological injury occupied 1.7%, including the fifth and the seventh cranial nerve injury. Arthroscopic procedure has potential risk of TMJ injury, bringing on secondary osteoarthritis. If large-diameter arthroscopy (⬎2 mm) is used, there is more chance of injury. So, to minimize iatrogenic injury, ultrathin arthroscopy was designed and used clinically. There are 2 types of TMJ arthroscopes: rod lens type and fiberoptic type. The image was definite but there is a possibility of lens fracture and iatrogenic injury during the insertion procedure. The diameter of the commonly used arthroscope was 1.9 to 2.7 mm. Recently, to minimize iatrogenic injury, 1.2 to 1.4 mm was developed and used. The other side, fiberoptic type, is flexible and has many advantages including easy manipulation in articular cavity and less iatrogenic trauma. However, the quality of image resolution is not as excellent.19-21 There were no complications in relation to the ultrathin arthroscopic procedure in this study. This study had a limitation in that it was difficult to evaluate treatment outcomes using ultrathin TMJ arthroscopy in comparison with other treatments. However, as a minimally invasive procedure, it was obvious that TMJ lysis and lavage using ultrathin TMJ arthoroscopy was a safe procedure. Also, 80% of patients showed good outcome. Interestingly, although it was not significant (P ⫽ .077), 3 patients showing poor outcome were all included in the patient group who complained of more than 3 TMD-related symptoms. It was suspected that the patients who had complicated symptoms or combined diagnosis would show poor response to the TMJ lysis and lavage using ultrathin TMJ arthroscopy. For these
ULTRATHIN ARTHROSCOPY IN TMJ
patients, multidirectional approaches should be considered. On the base of clinical experience, ultrathin TMJ arthroscopy has many advantages: 1) higher diagnostic value by providing direct vision in the articular cavity, 2) visual effect of patient instruction by taking an image of the pathologic state, 3) effective removal of lyses of adhesion tissue using a probe and biopsy, and 4) minimizing iatrogenic injury using an ultrathin trocar and arthroscope. From the clinical outcomes, TMJ lysis and lavage using ultrathin TMJ arthroscopy could be considered as an alternative treatment for the closed lock patients.
References 1. Farrar WB, Katzberg RW, Helms CA: Internal derangement of the temporomandibular joint: Fact or friction. J Prosthet Dent 49:415, 1983 2. Nitzan DW, Dolwick MF: An alternative explanation for the genesis of closed-lock symptoms in the internal derangement process. J Oral Maxillofac Surg 49:810, 1991 3. Nitzan DW, Dolwick MF, Heft M: Arthroscopic lavage and lysis of the temporomandibular joint: A change in perspective. J Oral Maxillofac Surg 48:798, 1990 4. Kurita K, Goss AN, Ogi N, et al: Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction. J Oral Maxillofac Surg 56:1394, 1998 5. Holmlund AB, Axelsson S, Gynther GW: A comparison of discectomy and arthroscopic lysis and lavage for the treatment of chronic closed lock of the temporomandibular joint: A randomized outcome study. J Oral Maxillofac Surg 59:972, 2001 6. Hamada Y, Kondoh T, Holmlund AB, et al: One-year clinical course following visually guided irrigation for chronic closed lock of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101:170, 2006 7. Moses JJ, Sartoris D, Glass R, et al: The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 47:674, 1989 8. Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol 62:361, 1986 9. Davis EL, Kaminishi RM, Marshall MW: Arthroscopic surgery for treatment of closed lock. J Oral Maxillofac Surg 49:704, 1991 10. McCain JP, de la RUA H: Principles and practice of operative arthroscopy of the human temporomandibular joint. Oral Maxillofac Surg Clin North Am 1:135, 1989 11. Tarro AW: Arthroscopic treatment of anterior disc displacement: A preliminary report. J Oral Maxillofac Surg 47:353, 1989 12. Koslin MG, Martin JC: The use of Holmium laser for temporomandibular joint arthroscopic surgery. J Oral Maxillofac Surg 51:122, 1993 13. Sorel B, Piecuch JF: Long-term evaluation following temporomandibular joint arthroscopy with lysis and lavage. Int J Oral Maxillofac Surg 29:259, 2000 14. Politi M, Sembronio S, Robiony M, et al: High condylectomy and disc repositioning compared with arthroscopic lysis, lavage, and capsular stretch for the treatment of chronic closed lock of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103:27, 2007 15. Sembronio S, Albiero AM, Robiony M, et al: Septic arthritis of the temporomandibular joint successfully treated with arthroscopic lysis and lavage: Case report and review of the
KIM ET AL literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103:e1, 2007 16. Indresano AT: Arthroscopic surgery of the temporomandibular joint: Report of 64 patients with long-term follow-up. J Oral Maxillofac Surg 47:157, 1989 17. White RD: Arthroscopic lysis and lavage as the preferred treatment for internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 59:313, 2001 18. Tsuyama M, Kondoh T, Seto K, et al: Complications of temporomandibular joint arthroscopy: A retrospective analysis of 301 lysis and lavage procedures performed using the triangulation technique. J Oral Maxillofac Surg 58:500, 2000
1045 19. Yoshida H, Fukumura Y, Tojyo I, et al: Operation with a single-channel thin-fibre arthroscope in patients with internal derangement of the temporomandibular joint. Br J Oral Maxillofac Surg 46:313, 2008 20. Kurita K, Ogi N, Toyama M, et al: Single-channel thin-fiber and Nd:YAG laser temporomandibular joint arthroscope: Development and preliminary clinical findings. Int J Oral Maxillofac Surg 26:414, 1997 21. Kurita K, Ogi N, Miyamoto K, et al: Diagnostic evaluation of an ultrathin 15,000 fiberoptic arthroscope: Comparison of arthroscopic and histologic findings in a sheep model. J Oral Maxillofac Surg 63:319, 2005