- Email: [email protected]
Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy
Int. J. Oral Maxillofac. Surg. 2004; 33: 344–348 doi:10.1016/j.ijom.2003.10.005, available online at http://www.sciencedirect.com
Clinical Paper TMJ Disorders
Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy
J. F. Sanroma´n Department of Oral and Maxillofacial Surgery, POVISA Medical Center, C/Salamanca 5, Vigo 36211, Spain
J. F. Sanroma´n:Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy. Int. J. Oral Maxillofac. Surg. 2004; 33: 344–348. # 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Twenty-six patients with a sudden-onset of persistent limited mouth opening and with MRI signs of articular discs fixed to the glenoid fossa were studied. After unsuccessful non-surgical treatment, arthroscopy with sodium hyaluronate infusion was performed in 16 joints. Follow-up ranged from 24 to 60 months (mean: 30.3 months). All patients were clinically assessed preoperatively, and at 1, 3, 6, 9, 12, 18 and 24 months postoperatively. The clinical variables analysed were: joint pain using a visual analogue scale (VAS) (1–15), joint noises (clicking, crepitus or none), history of locking, duration of the symptoms, maximal interincisal opening (MIO), maximal protrusive movement (MP) and maximal contra-lateral movement (ML). MRI images were obtained preoperatively to analyse the morphological and dynamic characteristics of the temporomandibular joint. Eight of the patients who refused to undergo arthroscopy were treated with arthrocentesis. These patients were studied following the same criteria as stated above. Mean age of the group was 24.3 years (16–35 years). 20 patients were female and 6 male. The preop-MRI examination revealed a normal disc position in 16 joints and an anteriorly displaced disc in 10 cases. All of the discs were fixed to the glenoid fossa preventing an anterior translation of the condylar head. After non-surgical treatment only two patients improved while all the other patients showed a severe decrease in the MIO (mean 23:3 2:2 mm), LM (3:8 1:4) and a high pain level (9.7 scale). Sixteen patients underwent arthroscopy. A significant reduction in pain was noted after arthroscopy. Furthermore, a significant increase in MMO and LM was demonstrated postoperatively. Arthroscopic findings included the presence of adherences and synovitis. Eight patients who refused arthroscopy were treated with TMJ arthrocentesis. All such patients improved their symptoms postoperatively. In conclusion both TMJ arthroscopy and arthrocentesis give good results upon treating patients with anchored disc phenomenon (ADP).
Anchored disc phenomenon—ADP—is one of the possible aetiologies of TMJ closed lock16. The following intra-articular disorders are the most common causes of severe limitation of maximal mouth opening: TMJ fibrous or bony ankylosis, 0901-5027/040344 + 05 $30.00/0
osteoarthritis and displacement of the articular disc (internal derangement: disc displacement without reduction) and ADP. ADP is characterised by a sudden, severe, limited mouth opening associated with pain on forced mouth opening16,21.
Key words: TMJ internal derangement; TMJ arthroscopy; TMJ arthrocentesis; TMJ stuck disc; TMJ fixed disc; anchored disc phenomenon. Accepted for publication 17 October 2003
The particular clinical appearance of this entity together with a disc fixed to the glenoid fossa (static or stuck disc) in the MRI study facilitates a final diagnosis21,23. There is a lack of prospective clinical studies that assess the best treatment
# 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Comparison of arthrocentesis and arthroscopy options in cases of ADP5,6,22. To the best of our knowledge, there have been no studies published that deal with the arthroscopic findings in patients with ADP. The aim of this study was to analyse the clinical outcomes of patients with ADP (MRI fixed discs) treated by either arthroscopic lysis and lavage or arthrocentesis. Both the MRI signs and the arthroscopic findings observed were also studied.
Pain VAS
14 12
Arthroscopy
10 8 6 4 2 24
18
15
9
12
6
3
1
IN IT I P R AL EO P
0
Material and methods
Month
Fig. 1. Pain visual analogue scale (1–15). Initial: before non-surgical treatment; Preop: before surgical treatment.
Arthrocentesis
Arthroscopy
24
15 18
9
12
6
3
1
45 40 35 30 25 20 15 10 5 0 IN IT I PR AL EO P
MIO (mm)
Subjects for this study consisted of 26 patients (6 men and 20 women) aged 16–35 years (mean, 24.3 years) from the Department of Oral and Maxillofacial Surgery at Povisa Medical Center, Vigo, Spain with clinical and MRI signs of fixed discs to the fossa. Only patients with unilateral joint involvement were studied. Criteria for exclusion in the study were: prior TMJ surgery, bilateral joint involvement and presence of known connective tissue/autoimmune diseases. All patients were clinically assessed analysing the following variables, by the same clinician: joint pain using a visual analogue scale (VAS) (1–15), joint noises (clicking, crepitus or none), history of locking, duration of the symptoms, maximal interincisal opening (MIO), maximal protrusive movement (MP) and maximal contra-lateral movement (ML). The results of the clinical study are shown in Table 1 and Figs 1–4. The most frequent cause of consultation was a severe decrease in the MIO. Duration of this symptom ranged from 7 to 90 days (mean 36.4 days). MRI images were obtained using a Phillips Gyroscan T-5 (Netherlands) according to the following parameters:
Arthrocentesis
345
Month
Fig. 2. Maximal interincisal opening in mm. Initial: before non-surgical treatment; Preop: before surgical treatment.
A pseudodynamic saggital survey at four consecutive oral apertures: FFE sequences, with TR ¼ 200 ms, TE ¼ 15, A ¼ 50. MRI images in the coronal plane were also obtained. The morphological characteristics of the articular disc (normal, biconvex, biplanar, folded,
Table 1. Clinical and MRI findings preoperatively Normal
Anterior displacement
Disc position (by MRI)
15
11
Disc morphology (MRI) Normal Biconvex Biplanar Other
12 3 5 –
2 4
Duration of locking (days)
35.3
40.5
2/125.3
235.4
Previous dysfunction (patients)/duration (months)
–
MRI disc position (normal or anteriorly displaced); disc morphology (normal-biconcave, biconvex, biplanar, other: folded, abscence). Mean duration in days of the actual closed lock. Previous history of TMJ dysfunction: pain, joint sounds or alteration in opening pattern: number of joints affected.
amorphous or other), the position and mobility of the disc (normal, anteriorly displaced with or without reduction, anteromedial or anterolateral disc displacement, pure medial or lateral disc displacements; normal mobility, hypomobility or fixed), the morphological appearance of the joint (normal, intra-articular effusion, free bodies), and the bone morphology (normal, osteoarthrosis signs: resorption, osteophites, cysts, bone marrow changes: sclerosis, oedema) were studied24,28. The results of the MRI study are shown in Table 1. Only patients with MRI diagnosis of a fixed disc to the fossa entered this study. All of the patients underwent non-surgical treatment that consisted of: soft diet, non-steroidal anti-inflammatory drugs, physical therapy (motion exercises) and control of bruxism, when present, using a flat bite appliance. Patients were clinically reevaluated after 4–6 months (mean: 3.4 months, ranging 3–6.5 months) of non-surgical
Sanroma´ n Arthroscopy
10 9 8 7 6 5 4 3 2 1 0
physiotherapy. Bruxism, when present, was treated as prior to the surgical procedure.
24
12
9
6
3
Statistical analysis
1
IN IT I PR AL EO P
LM (mm)
Arthrocentesis
15 18
346
Month
Fig. 3. Maximal contralateral movement (LM) in mm. Initial: before non-surgical treatment; Preop: before surgical treatment.
Descriptive statistics for categorical and continuous variables were calculated. To assess the significance of trends over time with regard to each variable (MIO, PM, LM and visual analogue pain scale) general linear models were derived. Comparison of the mean values of the variables were made using one-way ANOVA. All significance tests were performed using a probability of type I error 0.05 or less. Results
Arthrocentesis
Arthroscopy
12
PM (mm)
10 8 6 4 2
24
18
15
12
9
6
3
1
IN IT I P R AL EO P
0
Month
Fig. 4. Maximal protusive movement (PM) in mm. Initial: before non-surgical treatment; Preop: before surgical treatment.
treatment. The clinical variables analysed were the same as during initial consultation (Figs 1–4). Only two patients recovered a normal TMJ function with a normalization of MIO after non-surgical treatment. The remaining patients (24) were informed of the possible treatment options. Sixteen patients underwent arthroscopy, and the other eight received arthrocentesis in the affected joint. Arthroscopy
All operations were performed under general anaesthesia as an ambulatory procedure by only one surgeon using the same type of instruments, in the one hospital. A double portal arthroscopic technique was used in all cases27. Careful exploration of the superior joint space was performed recording the dif-
ferent variables as previously described4. Lysis of the adhesions was undertaken when present. Additionally, electro coagulation of the synovitis areas and copious irrigation of the superior joint space with final instillation of 5 ml of sodium hyaluronate (10 mg/ml) at the end of the surgical procedure was performed. For the arthrocentesis procedure, two 21-gauge needles were introduced into the superior joint space after local anaesthetic infiltration of the overlying skin. The joint was irrigated with 200 ml lactated Ringer’s solution using an elevated infusion bag. Upon conclusion, 5 ml of sodium hyaluronate (10 mg/ml) was injected into the joint through one of the needles. All patients were treated postoperatively with NSAIDs for 2 weeks and underwent active self-performed
Mean age of the group was 24.3 years (16–35 years), 20 patients were female and 6 male. The preop-MRI examination revealed that all the discs were fixed to the glenoid fossa preventing an anterior translation of the condylar head. A normally positioned fixed disc position was noted in 15 joints and an anteriorly displaced fixed disc was observed in the remaining 11 joints (Table 1). Most of the discs had a normal biconcave morphology, but in some cases biconvex or biplanar morphologies were noted (Table 1). These abnormal morphologies of the discs were more frequent in the group of patients having anteriorly displaced fixed discs than in the group with a normal fixed disc position. After nonsurgical treatment only two patients improved their symptoms (normalization of MIO). All the other patients showed a severe decrease in the MIO, LM, PM and a high pain level (Figs 1–4). Sixteen patients (8 normally positioned fixed discs and 8 anteriorly displaced fixed discs) underwent arthroscopy. Follow-up ranged from 24 to 36 months (mean 27:3 2 months). After the surgical procedure a significant (P < 0:01) reduction in pain was noted. A significant (P < 0:01) increase in MIO, LM and PM was also demonstrated postoperatively (Figs 1–4). Arthroscopic findings (Table 2) include the presence of adherences, synovitis (hypervascularity, hyperaemia and redundancy of the posterior ligament) both in the anterior and posterior compartments of the superior joint space. Fibrous adherences between the fossa and the disc were only observed in patients with anteriorly displaced fixed discs. Arthroscopic ‘‘roofing’’ of the disc, as an indirect indicator of the position of the disc,
Comparison of arthrocentesis and arthroscopy Table 2. Arthroscopic findings in patients diagnosed by MRI of fixed disc to the fossa (with normal or anteriorly displaced discs) who underwent arthroscopy (N ¼ 16) joints Arthroscopic findings
Normal disc position
Anterior displacement
Fibrous adherences Pseudowalls Other adherences
0 0 8
8 3 0
Synovitis Posterior recess Anteriorrecess
8 1
8 2
Roofing 100–75 75–50 50–25
8 0 0
0 8 0
Chondromalacia
0
1
showed a high correlation with the MRI diagnosis of the case (Table 2). Eight patients who refused arthroscopy (five patients with normally positioned fixed discs and three patients with anteriorly displaced fixed discs) were treated by means of TMJ arthrocentesis. Followup ranged from between 24 and 31 months (mean 25:2 4 months). All patients improved their symptoms postoperatively (Figs 1–4). Discussion
The ADP; a ‘‘new’’ clinical entity described by NITZAN16, accounts for a number of cases presented in the clinic as a TMJ closed lock. The authors18,20 described a possible pathogenesis for ADP: an abrupt adherence of the disc to the fossa may be caused by an alteration of the normal lubrication of the joint as a result of intermittent joint overloading, with secondary activation of oxidative species and degradation of hyaluronic acid. The final result of the breakdown of the lubrication system of the TMJ could be an increased friction between the disc and the bone components of the joint with secondary disc displacement and osteoarthrosis19. If this theory is finally proved, ADP could be one of the first clinical changes observed in the chain of events that would end in a more severe internal derangement-OA of the TMJ13,26. The arthroscopic findings of our study (Table 2): moderate to severe synovitis and adhesions between the articular disc and the glenoid fossa are in accordance with the hypothesis previously described18,19. In this study, non-surgical treatment failed to give good results in patients with ADP (Figs 1–4) and the arthroscopic findings showed that anteriorly
displaced fixed discs are prone to have more advanced pathological alterations (Table 2). Both arthroscopy and arthrocentesis proved to be efficient procedures in managing patients with ADP (Figs 1–4). These techniques, restore and preserve joint physiology without altering the normal joint anatomy, giving good results in treating patients with internal derangement7,9,10,14,15,25,29. Arthrocentesis, a least invasive technique with predictable outcomes1,6,8,15,17 could be the best indicated treatment for patients with ADP. The alternative would be arthroscopy which permits direct visualization of pathological tissues and allows removal of adhesions with injection of anti-inflammatory drugs or coagulation into inflamed synovial tissues10,14,29. The present study did not intend to compare statistically both types of treatments: arthroscopy versus arthrocentesis, so a randomised doubled-blind study was not conducted. Furthermore, patients treated by means of arthrocentesis were patients who refused to undergo arthroscopy, so some kind of bias may exist in the selection of the patients. May be some kind of placebocontrolled studies are needed to evaluate both surgical treatments12. The use of intraarticular sodium hyaluronate is controversial to date, due to the short half-life of this product in the joint space2,3. We feel that instillation of hyaluronate after the surgical procedure could contribute to create a boundary layer lubricant that at least during the first hours allows the patient to begin with a more efficient physiotherapy2,11,18. All patients included in this study were treated with self-rehabilitation and reduction of joint loading both pre and postoperatively. As stated by other
347
authors5,9, the postoperative control of the possible factors that contribute to the pathological condition should be undertaken, in order to decrease the recurrence of the symptoms. To conclude, this prospective study suggests that non-surgical treatment is not the right option for treating patients with ADP. Both arthrocentesis and arthroscopy appear to be useful techniques to treat such patients. Synovitis and adherences in the superior joint space are the most usual pathological signs encountered in patients with ADP. References 1. Alpaslan C, Dolwik F, Heft M. Fiveyear retrospective evaluation of TMJ arthrocentesis. Int J Oral Maxillofac Surg 2003: 32: 263–267. 2. Bertolami CN, Gay T, Clark GT, Rendell J, Shetty V, Liu C, Swann DA. Use of sodium hyaluronate in treating temporomandibular joint disorders. A randomised, double-blind, placebo-controlled clinical trial. J Oral Maxillofac Surg 1993: 51: 232–242. 3. Brown TJ, Laurent UB, Fraser JR. Turnover of hyaluronan in synovial joints: elimination of labelled hyaluronan from the knee joint of the rabbit. Exp Physiol 1991: 76: 125–129. 4. Dijkgraaf LC, Liem RSB, van der Weele LTh, de Bont LGM. Correlation between arthroscopically observed changes and synovial light microscopic findings in osteoarthritic temporomandibular joints. Int J Oral Maxillofac Surg 1999: 28: 83–88. 5. Dolwick MF. The role of temporomandibular joint surgery in the treatment of patients with internal derangement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997: 83: 150–158. 6. Frost DE, Kendell BD. The use of arthrocentesis for treatment of tempromandibular joint disorders. J Oral Maxillofac Surg 1999: 57: 583–587. 7. Goudot P, Jaquinet AR, Hugonnet S, Haefliger W, Richter M. Improvement of pain and function after arthroscopy and arthrocentesis of the temporomandibular joint: a comparative study. J Craniomaxillofac Surg 2000: 28: 39–43. 8. Hosaka H, Murakami K, Goto K, Iizuca T. Outcome of arthrocentesis for temporomandibular joint with closed lock at 3 years follow-up. Oral Surg Oral Pathol Oral Radiol Endod 1996: 82: 501– 506. 9. Israel HA. Current concepts in the surgical management of temporomandibular joint disorders. J Oral Maxillofac Surg 1994: 52: 289–294. 10. Israel HA. The use of arthroscopic surgery for treatment of tempromandibular joint disorders. J Oral Maxillofac Surg 1999: 57: 579–582.
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11. Kopp S, Wenneberg B, Haraldson T, Carlsson GE. The short-term effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint pain and dysfunction. J Oral Maxillofac Surg 1985: 43: 429–435. 12. Laskin DM, Best AIM. Meta-analysis of surgical treatments for temporomandibular articular disorders. Discussion. J Oral Maxillofac Surg 2003: 61: 10–12. 13. Milam SB, Schmitz JP. Molecular biology of temporomandibular joint disorders: proposed mechanisms of disease. J Oral Maxillofac Surg 1995: 53: 1448– 1454. 14. Miyamoto H, Sakashita H, Miyata M, Goss AN. Arthroscopic surgery of the temporomandibular joint: comparison of two successful techniques. Br J Oral Maxillofac Surg 1999: 37: 397–400. 15. Murakami K, Moriya Y, Goto K, Segami N. Four-year follow-up study of temporomandibular joint arthroscopic surgery for advanced stage internal derangement. J Oral Maxillofac Surg 1996: 54: 285–290. 16. Nitzan DW. An alternative explanation for the genesis of closed lock symptoms in the internal derangement process. J Oral Maxillofac Surg 1991: 49: 810–815. 17. Nitzan DW. Arthrocentesis for management of severe closed lock of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994: 6: 245–249.
18. Nitzan DW. The process of lubrication impairment and its involvement in temporomandibular joint disc displacement: a theoretical concept. J Oral Maxillofac Surg 2001: 59: 36–45. 19. Nitzan DW, Etsion I. Adhesive force: the underlying cause of the disc anchorage to the fossa and/or eminence in the temporomandibular joint—a new concept. Int J Oral Maxillofac Surg 2002: 31: 94–99. 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: 1038–1043. 21. Nitzan DW, Marmary Y. The ‘‘Anchored disc phenomenon’’: a proposed aetiology for sudden-onset, severe, and persistent closed lock of the temporomandibular joint. J Oral Maxillofac Surg 1997: 55: 797–802. 22. Nitzan DW, Samson B, Better H. Long-term outcome of athrocentesis for severe closed lock of the temporomandibular joint. J Oral Maxillofac Surg 1997: 55: 151–158. 23. Rao VM, Liem MD, Farole A, Razek AAKA. Elusive ‘‘stuck’’ disk in the temporomandibular joint: diagnosis with MRI imaging. Radiology 1993: 189: 823– 827. 24. Sato S, Sakamoto M, Kawamura H, Motegi K. Disc position and morphology
25.
26.
27.
28.
29.
in patients with nonreducing disc displacement treated by injection of sodium hyaluronate. Int J Oral Maxillofac Surg 1999: 28: 253–257. Sorel B, Piecuch JF. Long-term evaluation following temporomandibular joint arthroscopy with lysis and lavage. Int J Oral Maxillofac Surg 2000: 29: 259–263. Tanaka E, Shibaguchi T, Tanaka M, Tanne K. Viscoelastic properties of the human temporomandibular joint disc in patients with internal derangement. J Oral Maxillofac Surg 2000: 58: 997–1002. Tarro AW. Arthroscopic diagnosis and surgery of the temporomandibular joint. J Oral Maxillofac Surg 1998: 46: 282– 287. Westesson P-L. Structural hard-tissue changes in temporomandibular joint with internal derangement. Oral Surg 1985: 59: 220–224. White RD. Arthroscopic lysis and lavage as the preferred treatment for internal derangement of the tempromandibular joint. J Oral Maxillofac Surg 2001: 59: 313–316.
Address: J.F. Sanroma´ n Rua Areal 50, 30 B, Vigo 36201, Spain. Fax: þ34-986-421439 E-mail : [email protected]
Clinical Paper TMJ Disorders
Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy
J. F. Sanroma´n Department of Oral and Maxillofacial Surgery, POVISA Medical Center, C/Salamanca 5, Vigo 36211, Spain
J. F. Sanroma´n:Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy. Int. J. Oral Maxillofac. Surg. 2004; 33: 344–348. # 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Twenty-six patients with a sudden-onset of persistent limited mouth opening and with MRI signs of articular discs fixed to the glenoid fossa were studied. After unsuccessful non-surgical treatment, arthroscopy with sodium hyaluronate infusion was performed in 16 joints. Follow-up ranged from 24 to 60 months (mean: 30.3 months). All patients were clinically assessed preoperatively, and at 1, 3, 6, 9, 12, 18 and 24 months postoperatively. The clinical variables analysed were: joint pain using a visual analogue scale (VAS) (1–15), joint noises (clicking, crepitus or none), history of locking, duration of the symptoms, maximal interincisal opening (MIO), maximal protrusive movement (MP) and maximal contra-lateral movement (ML). MRI images were obtained preoperatively to analyse the morphological and dynamic characteristics of the temporomandibular joint. Eight of the patients who refused to undergo arthroscopy were treated with arthrocentesis. These patients were studied following the same criteria as stated above. Mean age of the group was 24.3 years (16–35 years). 20 patients were female and 6 male. The preop-MRI examination revealed a normal disc position in 16 joints and an anteriorly displaced disc in 10 cases. All of the discs were fixed to the glenoid fossa preventing an anterior translation of the condylar head. After non-surgical treatment only two patients improved while all the other patients showed a severe decrease in the MIO (mean 23:3 2:2 mm), LM (3:8 1:4) and a high pain level (9.7 scale). Sixteen patients underwent arthroscopy. A significant reduction in pain was noted after arthroscopy. Furthermore, a significant increase in MMO and LM was demonstrated postoperatively. Arthroscopic findings included the presence of adherences and synovitis. Eight patients who refused arthroscopy were treated with TMJ arthrocentesis. All such patients improved their symptoms postoperatively. In conclusion both TMJ arthroscopy and arthrocentesis give good results upon treating patients with anchored disc phenomenon (ADP).
Anchored disc phenomenon—ADP—is one of the possible aetiologies of TMJ closed lock16. The following intra-articular disorders are the most common causes of severe limitation of maximal mouth opening: TMJ fibrous or bony ankylosis, 0901-5027/040344 + 05 $30.00/0
osteoarthritis and displacement of the articular disc (internal derangement: disc displacement without reduction) and ADP. ADP is characterised by a sudden, severe, limited mouth opening associated with pain on forced mouth opening16,21.
Key words: TMJ internal derangement; TMJ arthroscopy; TMJ arthrocentesis; TMJ stuck disc; TMJ fixed disc; anchored disc phenomenon. Accepted for publication 17 October 2003
The particular clinical appearance of this entity together with a disc fixed to the glenoid fossa (static or stuck disc) in the MRI study facilitates a final diagnosis21,23. There is a lack of prospective clinical studies that assess the best treatment
# 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Comparison of arthrocentesis and arthroscopy options in cases of ADP5,6,22. To the best of our knowledge, there have been no studies published that deal with the arthroscopic findings in patients with ADP. The aim of this study was to analyse the clinical outcomes of patients with ADP (MRI fixed discs) treated by either arthroscopic lysis and lavage or arthrocentesis. Both the MRI signs and the arthroscopic findings observed were also studied.
Pain VAS
14 12
Arthroscopy
10 8 6 4 2 24
18
15
9
12
6
3
1
IN IT I P R AL EO P
0
Material and methods
Month
Fig. 1. Pain visual analogue scale (1–15). Initial: before non-surgical treatment; Preop: before surgical treatment.
Arthrocentesis
Arthroscopy
24
15 18
9
12
6
3
1
45 40 35 30 25 20 15 10 5 0 IN IT I PR AL EO P
MIO (mm)
Subjects for this study consisted of 26 patients (6 men and 20 women) aged 16–35 years (mean, 24.3 years) from the Department of Oral and Maxillofacial Surgery at Povisa Medical Center, Vigo, Spain with clinical and MRI signs of fixed discs to the fossa. Only patients with unilateral joint involvement were studied. Criteria for exclusion in the study were: prior TMJ surgery, bilateral joint involvement and presence of known connective tissue/autoimmune diseases. All patients were clinically assessed analysing the following variables, by the same clinician: joint pain using a visual analogue scale (VAS) (1–15), joint noises (clicking, crepitus or none), history of locking, duration of the symptoms, maximal interincisal opening (MIO), maximal protrusive movement (MP) and maximal contra-lateral movement (ML). The results of the clinical study are shown in Table 1 and Figs 1–4. The most frequent cause of consultation was a severe decrease in the MIO. Duration of this symptom ranged from 7 to 90 days (mean 36.4 days). MRI images were obtained using a Phillips Gyroscan T-5 (Netherlands) according to the following parameters:
Arthrocentesis
345
Month
Fig. 2. Maximal interincisal opening in mm. Initial: before non-surgical treatment; Preop: before surgical treatment.
A pseudodynamic saggital survey at four consecutive oral apertures: FFE sequences, with TR ¼ 200 ms, TE ¼ 15, A ¼ 50. MRI images in the coronal plane were also obtained. The morphological characteristics of the articular disc (normal, biconvex, biplanar, folded,
Table 1. Clinical and MRI findings preoperatively Normal
Anterior displacement
Disc position (by MRI)
15
11
Disc morphology (MRI) Normal Biconvex Biplanar Other
12 3 5 –
2 4
Duration of locking (days)
35.3
40.5
2/125.3
235.4
Previous dysfunction (patients)/duration (months)
–
MRI disc position (normal or anteriorly displaced); disc morphology (normal-biconcave, biconvex, biplanar, other: folded, abscence). Mean duration in days of the actual closed lock. Previous history of TMJ dysfunction: pain, joint sounds or alteration in opening pattern: number of joints affected.
amorphous or other), the position and mobility of the disc (normal, anteriorly displaced with or without reduction, anteromedial or anterolateral disc displacement, pure medial or lateral disc displacements; normal mobility, hypomobility or fixed), the morphological appearance of the joint (normal, intra-articular effusion, free bodies), and the bone morphology (normal, osteoarthrosis signs: resorption, osteophites, cysts, bone marrow changes: sclerosis, oedema) were studied24,28. The results of the MRI study are shown in Table 1. Only patients with MRI diagnosis of a fixed disc to the fossa entered this study. All of the patients underwent non-surgical treatment that consisted of: soft diet, non-steroidal anti-inflammatory drugs, physical therapy (motion exercises) and control of bruxism, when present, using a flat bite appliance. Patients were clinically reevaluated after 4–6 months (mean: 3.4 months, ranging 3–6.5 months) of non-surgical
Sanroma´ n Arthroscopy
10 9 8 7 6 5 4 3 2 1 0
physiotherapy. Bruxism, when present, was treated as prior to the surgical procedure.
24
12
9
6
3
Statistical analysis
1
IN IT I PR AL EO P
LM (mm)
Arthrocentesis
15 18
346
Month
Fig. 3. Maximal contralateral movement (LM) in mm. Initial: before non-surgical treatment; Preop: before surgical treatment.
Descriptive statistics for categorical and continuous variables were calculated. To assess the significance of trends over time with regard to each variable (MIO, PM, LM and visual analogue pain scale) general linear models were derived. Comparison of the mean values of the variables were made using one-way ANOVA. All significance tests were performed using a probability of type I error 0.05 or less. Results
Arthrocentesis
Arthroscopy
12
PM (mm)
10 8 6 4 2
24
18
15
12
9
6
3
1
IN IT I P R AL EO P
0
Month
Fig. 4. Maximal protusive movement (PM) in mm. Initial: before non-surgical treatment; Preop: before surgical treatment.
treatment. The clinical variables analysed were the same as during initial consultation (Figs 1–4). Only two patients recovered a normal TMJ function with a normalization of MIO after non-surgical treatment. The remaining patients (24) were informed of the possible treatment options. Sixteen patients underwent arthroscopy, and the other eight received arthrocentesis in the affected joint. Arthroscopy
All operations were performed under general anaesthesia as an ambulatory procedure by only one surgeon using the same type of instruments, in the one hospital. A double portal arthroscopic technique was used in all cases27. Careful exploration of the superior joint space was performed recording the dif-
ferent variables as previously described4. Lysis of the adhesions was undertaken when present. Additionally, electro coagulation of the synovitis areas and copious irrigation of the superior joint space with final instillation of 5 ml of sodium hyaluronate (10 mg/ml) at the end of the surgical procedure was performed. For the arthrocentesis procedure, two 21-gauge needles were introduced into the superior joint space after local anaesthetic infiltration of the overlying skin. The joint was irrigated with 200 ml lactated Ringer’s solution using an elevated infusion bag. Upon conclusion, 5 ml of sodium hyaluronate (10 mg/ml) was injected into the joint through one of the needles. All patients were treated postoperatively with NSAIDs for 2 weeks and underwent active self-performed
Mean age of the group was 24.3 years (16–35 years), 20 patients were female and 6 male. The preop-MRI examination revealed that all the discs were fixed to the glenoid fossa preventing an anterior translation of the condylar head. A normally positioned fixed disc position was noted in 15 joints and an anteriorly displaced fixed disc was observed in the remaining 11 joints (Table 1). Most of the discs had a normal biconcave morphology, but in some cases biconvex or biplanar morphologies were noted (Table 1). These abnormal morphologies of the discs were more frequent in the group of patients having anteriorly displaced fixed discs than in the group with a normal fixed disc position. After nonsurgical treatment only two patients improved their symptoms (normalization of MIO). All the other patients showed a severe decrease in the MIO, LM, PM and a high pain level (Figs 1–4). Sixteen patients (8 normally positioned fixed discs and 8 anteriorly displaced fixed discs) underwent arthroscopy. Follow-up ranged from 24 to 36 months (mean 27:3 2 months). After the surgical procedure a significant (P < 0:01) reduction in pain was noted. A significant (P < 0:01) increase in MIO, LM and PM was also demonstrated postoperatively (Figs 1–4). Arthroscopic findings (Table 2) include the presence of adherences, synovitis (hypervascularity, hyperaemia and redundancy of the posterior ligament) both in the anterior and posterior compartments of the superior joint space. Fibrous adherences between the fossa and the disc were only observed in patients with anteriorly displaced fixed discs. Arthroscopic ‘‘roofing’’ of the disc, as an indirect indicator of the position of the disc,
Comparison of arthrocentesis and arthroscopy Table 2. Arthroscopic findings in patients diagnosed by MRI of fixed disc to the fossa (with normal or anteriorly displaced discs) who underwent arthroscopy (N ¼ 16) joints Arthroscopic findings
Normal disc position
Anterior displacement
Fibrous adherences Pseudowalls Other adherences
0 0 8
8 3 0
Synovitis Posterior recess Anteriorrecess
8 1
8 2
Roofing 100–75 75–50 50–25
8 0 0
0 8 0
Chondromalacia
0
1
showed a high correlation with the MRI diagnosis of the case (Table 2). Eight patients who refused arthroscopy (five patients with normally positioned fixed discs and three patients with anteriorly displaced fixed discs) were treated by means of TMJ arthrocentesis. Followup ranged from between 24 and 31 months (mean 25:2 4 months). All patients improved their symptoms postoperatively (Figs 1–4). Discussion
The ADP; a ‘‘new’’ clinical entity described by NITZAN16, accounts for a number of cases presented in the clinic as a TMJ closed lock. The authors18,20 described a possible pathogenesis for ADP: an abrupt adherence of the disc to the fossa may be caused by an alteration of the normal lubrication of the joint as a result of intermittent joint overloading, with secondary activation of oxidative species and degradation of hyaluronic acid. The final result of the breakdown of the lubrication system of the TMJ could be an increased friction between the disc and the bone components of the joint with secondary disc displacement and osteoarthrosis19. If this theory is finally proved, ADP could be one of the first clinical changes observed in the chain of events that would end in a more severe internal derangement-OA of the TMJ13,26. The arthroscopic findings of our study (Table 2): moderate to severe synovitis and adhesions between the articular disc and the glenoid fossa are in accordance with the hypothesis previously described18,19. In this study, non-surgical treatment failed to give good results in patients with ADP (Figs 1–4) and the arthroscopic findings showed that anteriorly
displaced fixed discs are prone to have more advanced pathological alterations (Table 2). Both arthroscopy and arthrocentesis proved to be efficient procedures in managing patients with ADP (Figs 1–4). These techniques, restore and preserve joint physiology without altering the normal joint anatomy, giving good results in treating patients with internal derangement7,9,10,14,15,25,29. Arthrocentesis, a least invasive technique with predictable outcomes1,6,8,15,17 could be the best indicated treatment for patients with ADP. The alternative would be arthroscopy which permits direct visualization of pathological tissues and allows removal of adhesions with injection of anti-inflammatory drugs or coagulation into inflamed synovial tissues10,14,29. The present study did not intend to compare statistically both types of treatments: arthroscopy versus arthrocentesis, so a randomised doubled-blind study was not conducted. Furthermore, patients treated by means of arthrocentesis were patients who refused to undergo arthroscopy, so some kind of bias may exist in the selection of the patients. May be some kind of placebocontrolled studies are needed to evaluate both surgical treatments12. The use of intraarticular sodium hyaluronate is controversial to date, due to the short half-life of this product in the joint space2,3. We feel that instillation of hyaluronate after the surgical procedure could contribute to create a boundary layer lubricant that at least during the first hours allows the patient to begin with a more efficient physiotherapy2,11,18. All patients included in this study were treated with self-rehabilitation and reduction of joint loading both pre and postoperatively. As stated by other
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authors5,9, the postoperative control of the possible factors that contribute to the pathological condition should be undertaken, in order to decrease the recurrence of the symptoms. To conclude, this prospective study suggests that non-surgical treatment is not the right option for treating patients with ADP. Both arthrocentesis and arthroscopy appear to be useful techniques to treat such patients. Synovitis and adherences in the superior joint space are the most usual pathological signs encountered in patients with ADP. References 1. Alpaslan C, Dolwik F, Heft M. Fiveyear retrospective evaluation of TMJ arthrocentesis. Int J Oral Maxillofac Surg 2003: 32: 263–267. 2. Bertolami CN, Gay T, Clark GT, Rendell J, Shetty V, Liu C, Swann DA. Use of sodium hyaluronate in treating temporomandibular joint disorders. A randomised, double-blind, placebo-controlled clinical trial. J Oral Maxillofac Surg 1993: 51: 232–242. 3. Brown TJ, Laurent UB, Fraser JR. Turnover of hyaluronan in synovial joints: elimination of labelled hyaluronan from the knee joint of the rabbit. Exp Physiol 1991: 76: 125–129. 4. Dijkgraaf LC, Liem RSB, van der Weele LTh, de Bont LGM. Correlation between arthroscopically observed changes and synovial light microscopic findings in osteoarthritic temporomandibular joints. Int J Oral Maxillofac Surg 1999: 28: 83–88. 5. Dolwick MF. The role of temporomandibular joint surgery in the treatment of patients with internal derangement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997: 83: 150–158. 6. Frost DE, Kendell BD. The use of arthrocentesis for treatment of tempromandibular joint disorders. J Oral Maxillofac Surg 1999: 57: 583–587. 7. Goudot P, Jaquinet AR, Hugonnet S, Haefliger W, Richter M. Improvement of pain and function after arthroscopy and arthrocentesis of the temporomandibular joint: a comparative study. J Craniomaxillofac Surg 2000: 28: 39–43. 8. Hosaka H, Murakami K, Goto K, Iizuca T. Outcome of arthrocentesis for temporomandibular joint with closed lock at 3 years follow-up. Oral Surg Oral Pathol Oral Radiol Endod 1996: 82: 501– 506. 9. Israel HA. Current concepts in the surgical management of temporomandibular joint disorders. J Oral Maxillofac Surg 1994: 52: 289–294. 10. Israel HA. The use of arthroscopic surgery for treatment of tempromandibular joint disorders. J Oral Maxillofac Surg 1999: 57: 579–582.
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11. Kopp S, Wenneberg B, Haraldson T, Carlsson GE. The short-term effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint pain and dysfunction. J Oral Maxillofac Surg 1985: 43: 429–435. 12. Laskin DM, Best AIM. Meta-analysis of surgical treatments for temporomandibular articular disorders. Discussion. J Oral Maxillofac Surg 2003: 61: 10–12. 13. Milam SB, Schmitz JP. Molecular biology of temporomandibular joint disorders: proposed mechanisms of disease. J Oral Maxillofac Surg 1995: 53: 1448– 1454. 14. Miyamoto H, Sakashita H, Miyata M, Goss AN. Arthroscopic surgery of the temporomandibular joint: comparison of two successful techniques. Br J Oral Maxillofac Surg 1999: 37: 397–400. 15. Murakami K, Moriya Y, Goto K, Segami N. Four-year follow-up study of temporomandibular joint arthroscopic surgery for advanced stage internal derangement. J Oral Maxillofac Surg 1996: 54: 285–290. 16. Nitzan DW. An alternative explanation for the genesis of closed lock symptoms in the internal derangement process. J Oral Maxillofac Surg 1991: 49: 810–815. 17. Nitzan DW. Arthrocentesis for management of severe closed lock of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994: 6: 245–249.
18. Nitzan DW. The process of lubrication impairment and its involvement in temporomandibular joint disc displacement: a theoretical concept. J Oral Maxillofac Surg 2001: 59: 36–45. 19. Nitzan DW, Etsion I. Adhesive force: the underlying cause of the disc anchorage to the fossa and/or eminence in the temporomandibular joint—a new concept. Int J Oral Maxillofac Surg 2002: 31: 94–99. 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: 1038–1043. 21. Nitzan DW, Marmary Y. The ‘‘Anchored disc phenomenon’’: a proposed aetiology for sudden-onset, severe, and persistent closed lock of the temporomandibular joint. J Oral Maxillofac Surg 1997: 55: 797–802. 22. Nitzan DW, Samson B, Better H. Long-term outcome of athrocentesis for severe closed lock of the temporomandibular joint. J Oral Maxillofac Surg 1997: 55: 151–158. 23. Rao VM, Liem MD, Farole A, Razek AAKA. Elusive ‘‘stuck’’ disk in the temporomandibular joint: diagnosis with MRI imaging. Radiology 1993: 189: 823– 827. 24. Sato S, Sakamoto M, Kawamura H, Motegi K. Disc position and morphology
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in patients with nonreducing disc displacement treated by injection of sodium hyaluronate. Int J Oral Maxillofac Surg 1999: 28: 253–257. Sorel B, Piecuch JF. Long-term evaluation following temporomandibular joint arthroscopy with lysis and lavage. Int J Oral Maxillofac Surg 2000: 29: 259–263. Tanaka E, Shibaguchi T, Tanaka M, Tanne K. Viscoelastic properties of the human temporomandibular joint disc in patients with internal derangement. J Oral Maxillofac Surg 2000: 58: 997–1002. Tarro AW. Arthroscopic diagnosis and surgery of the temporomandibular joint. J Oral Maxillofac Surg 1998: 46: 282– 287. Westesson P-L. Structural hard-tissue changes in temporomandibular joint with internal derangement. Oral Surg 1985: 59: 220–224. White RD. Arthroscopic lysis and lavage as the preferred treatment for internal derangement of the tempromandibular joint. J Oral Maxillofac Surg 2001: 59: 313–316.
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