Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction

JOSEPH

1397

P. McCAIN

out reduction who were refractory to nonsurgical treatment. This strengthens the reliability of the results. Overall, the success rate (86%) of arthroscopic lysis and lavage in this study was comparable to that of other studies in the literature.7-9 It can be concluded that limitation of mouth opening to less than 22 mm may be a relative contraindiction to arthroscopic lysis and lavage .

References 1. Goss AN, Bosanquet AG: Temporomandibular joint arthroscopy. J Oral Maxillofac Surg 44:614, 1986 2. Sanders B: Arthroscopic surgery of the temporomandibuiar joint: Treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Path01 62:361, 1986 3. Moses JJ, Sartoris D, Glass R, et al: The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disk position and mobilicy. J Oral Maxiilofac Surg 47:674,1989 4. Nitzan DW, Dolwick MF, Heft MW: Arthroscopic lavage and lysis of the temporomandibular joint: A change in perspective. J Oral Maxillofac Surg 48:498, 1990 5, Perrott DH, Alborzi AA, Kaban LB, et ai: A perspective evaluation of the effectiveness of temporomandibular joint arthroscopy. J Oral Maxillofac Surg 48:1029,1990 6. Clark GT, Moody DG, Sanders B: Artbroscopic treatment of temporomandibular joint locking resulting from disk derangement: Two-year results. J Oral Maxillofac Surg 49:157, 1991 7. Davis CL, Kaminishi RM, Marshall MW: Artbroscopic surgery for treatment of closed lock. J Oral Maxillofac Surg 48:704,

1991 8. Montgomery dibular joint out reduction.

J Oral

56:

MT, Sickels JE, Harms SE: Success of temporomanarthroscopy in disk displacement with and withOral Surg Oral Med Oral Patbol71:651, 1991

9. McCain JP, Sanders B, Koslin MG, et al: Temporomandibular arthroscopy: A 6-year multicenter retrospective study of 4831 joints. J Oral Maxillofac Surg 50:926, 1992 10. Mosby EL: Efficacy of temporomandibular joint arthroscopy: A retrospective study. J Oral Maxiiiofac Surg 51:17, 1993 11. McCain JP: Arthroscopy of the human temporomandibuiar joint. J Oral Maxillofac Surg 46:648, 1988 12. Tarro AW: Arthroscopic diagnosis and surgery of the temporomandibular joint. J Oral Maxillofac Surg 46:282, 1988 13. Moses JJ, Poker ID: TMJ artbroscopic surgery: An analysis of 237 patients. J Oral Maxillofac Surg 47:790, 1989 14. Ad Hoc Study Group on TMJ Meniscus Study: 1984 Criteria for TMJ meniscus surgery. AAOMS, November 1,1984 15. Goss AN: Toward an international consensus on temporomandibular joint surgery. Int J Oral Maxillofac Surg 22:78,1993 16. Wilkes HC: Internal derangements of tire temporomandibular joint: Pathological variations. Arch Otolaryngol Head Neck Surg 115469, 1989 17. Bjornland T, Rorvik M, Haanas H, et al: Degenerative changes in the temporomandibular joint after diagnostic arthroscopy: An experimental study in goats. Int J Oral Maxiilofac Surg 23:41, 1994 18. Kurita K, Westesson P-L, Stemby N, et al: Histologic features of the temporomandibular joint disk and posterior disk attachment: Comparison of symptom-free persons with normally positioned disks and patients with internal derangement. Oral Surg Oral Med Oral Path01 67:635,1989 19. Yuasa H, Kurita K, Toyama M, et al: Arthroscopy on the lower space of the temporomandibular joint with high quality thin solid fiber scope under fluoroscopy. J Jpn Sot TMJ 8:33, 1996 20. Ku&a K, Westesson P-L, Yuasa H, et al: Natural course of untreated symptomatic temporomandibular joint disc displacement without reduction. J Dent Res 77:361, 1998 21. 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

Maxiilofac Surg 1397-l 398. 1998

Discussion Correlation Between Preoperative Mouth 0 ening and Surgical Outcome After Art R roscopic Lysis and Lavage in Patients With DISC Displacement Without Reduction Joseph Private

P. McCain, Practice,

Miami,

DMD Florida

The authors of this report have indicated that a preoperative vertical opening of 22 mm or greater is a reliable, clinical sign in predicting a successful outcome in patients with “closed lock,” Wilkes stage III, IV, and V temporomandibular joint disease treated with arthroscopic lysis and lavage. Although the sample size is small, use of consecutive patients strengthens the study. Also, the standard evaluation form and the timing and length of follow-up enhance the validity of the results. However, the preoperative nonsurgical management was variable. Ideally, all patients should

have received the same treatment, particularly when there is such a small sample size. The 3.2 mm arthroscopeusedin this study is large for the temporomandibular joint. with this size arthroscope the incidence of intraoperative scuffing is increased and negotiating all parts of the joint is difficult, especiallyin the more fibrosed joints. There were also variations in the technique, such as the use of shavers and cautery. Improper use of these modalities can promote postoperative arthrofibrosis and/or synovitis. It is also not clear whether one or multiple surgeons performed the surgery. This is important because the procedure is highly operator dependent. The use of intraoperative irttra-articular steroids, postoperative physical therapy, and postoperative nonsteroidal

anti-inflammatory drugs was consistent in the protocol. However, these agents add variables to the evaluation of the arthroscopic procedure. Postoperative physical therapy in some form is essential,but intra-articular steroids and nonsteroidal anti-inflammatory drugs are probably not necessary.

1398 The female/male distribution in this study is consistent with other studies. The age range and mean age are also consistent with the distribution of the Wilkes-staged patients.’ The average initial mouth opening on presentation before any treatment of 28 mm is consistent with the findings in patients with closed lock. The fact that all patients had fibrous adhesions in the upper compartment is also inconsistent with my clinical observations.* Gross adhesions in the joint only occur about 25% of the time. The success of the procedure in this study is impressive. My own clinical experience agrees with the fact that stage IV internal derangements respond most favorably to lysis and lavage surgery. Stage III internal derangements also respond well, with the exception of the patient who returns postoperatively with painful clicking.3 In these cases, I would suggest a more delinitive arthroscopic or open surgical repair be performed.* The question of whether or not repairs should be done initially or secondarily is open to discussion. I would suggest that in these cases one should evaluate whether or not the problem is unilateral or bilateral on the preoperative magnetic resonance imaging. lf the patient has a bilateral stage III internal derangement, perhaps only lysis and lavage should be performed on the symptomatic side. If the patient has a preoperative magnetic resonance image showing one side that is normal and the other side with a stage III internal derangement, then I would suggest a more definitive repair be performed on that patient to parallel the built-in control on the opposite side. Bilateral symptomatic cases should be corrected to normal (ie, disc repair in stages III or IV, partial arthroscopic discectomy or open, complete discectomy with implant in stage V). The two failed cases occurred in stage III and stage V patients. The stage III internal derangement patient had a preoperative mouth opening of 19 mm and severe synovitis was found at the time of the arthroscopic examination. No comment is made about the arthroscopic findings in the other stage III case as a comparison. The authors chose to perform discectomy and synovectomy on the patient and

DISCUSSION note good long-term pain relief and improved mouth opening. Personally, I would have chosen a either an arthroscopic or open disc repair in a failed stage III patient.* The second failure, a stage V internal derangement patient with a progressive ankylosis after nonsurgical and surgical management, responded well to an arthrotomy to eliminate the ankylosis. A more vigorous arthroscopic debridement may have benefited this patient and obviated the need for open surgery at a later date. However, it has been my experience that patients with stage V internal derangement and a large central perforation and marked joint fibrosis do not respond well to arthroscopic manipulation and are better served by open arthrotomy techniques with the placement of space maintainers or partial or complete joint replacement. Both failed cases did poorly with nonsurgical therapy. One could suggest that an earlier surgical intervention in these cases may have been beneficial. The results of this study are consistent with others previously rep0rted.l Commonly, patients who have stage III to V internal derangements have mouth openings in the 20 to 30 mm range. The authors have brought this important clinical sign to our attention. My compliments to them on their contribution to our continued pursuit of understanding the diagnosis and surgical management of temporomandibular joint internal derangements and osteoarthritis.

References 1. McCain JP, Sanders B, Koslin MG, et al: Temporomandibular joint arthroscopy: A 6 year multicenter study of 4831 joints. J Oral Maxillofac Surg 50:926, 1992 2. McCain JP, de la Rua H, LeBlanc WG: Correlation of clinical, radiographic, and arthroscopic findings in internal derangement of the TMJ. J Oral Maxillofac Surg 47:913, 1989 3. McCain JP: Principles and Practice of Temporomandibular Joint Arthroscopy. St Louis, MO, Mosby, 1996 4. McCain JP, Podrowsky AE, Zabiegalski NA: Arthroscopic disc repositioning and suturing: A preliminary report. J Oral Maxillofat Surg 48:760, 1990