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Efficiency of arthroscopic lysis and lavage for internal derangement of the temporomandibular joint correlated with Wilkes classification
Vol. 106 No. 3 September 2008
ORAL AND MAXILLOFACIAL SURGERY
Editor: James R. Hupp
Efficiency of arthroscopic lysis and lavage for internal derangement of the temporomandibular joint correlated with Wilkes classification Wenko Smolka, MD, DMD, FEBOMFS,a Chie Yanai, DDS, PhD,b Koord Smolka, MD, DMD, FEBOMFS,c Tateyuki Iizuka, MD, DDS, PhD, FEBOMFS,d Berne, Switzerland DEPARTMENT OF CRANIOMAXILLOFACIAL SURGERY, UNIVERSITY OF BERNE
Objectives. To compare the outcome of arthroscopic lysis and lavage of TMJ with internal derangement of Wilkes stages II, III, IV, and V. Study design. Arthroscopic lysis and lavage was performed in 45 TMJ of 39 patients with internal derangement. The cases were divided into 4 groups corresponding to Wilkes stages II, III, IV, and V. Two parameters were compared pre- and postoperatively: pain and mouth opening. Statistical significance was determined using the 2 test. Results. Overall success rate was 86.7% (Wilkes stage II 90.9%, Wilkes stage III 92.3%, Wilkes stage IV 84.6%, Wilkes stage V 75%). There were no statistically significant differences between the success rates for Wilkes stages II, III, IV, and V. Conclusion. Arthroscopic lysis and lavage should be performed as a standard operation for internal derangement of the TMJ after failure of conservative treatment in all Wilkes stages. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:317-23)
Internal derangement (ID) of the temporomandibular joint (TMJ) is one of the most common forms of temporomandibular disorders (TMD).1 The term ID comprises anterior disc displacement with or without reduction, perforation of the articular disc or of the retrodiscal tissue, and various degenerative changes of the disc and/or the articulating surfaces.2 The most
a
Senior Maxillofacial Surgeon, Department of Cranio-Maxillofacial Surgery, University of Berne, Switzerland. b Clinical Fellow, Department of Cranio-Maxillofacial Surgery, University Berne, Switzerland & Assistant Professor, Oral and Maxillofacial Surgery, The Nippon Dental University Hospital at Tokyo, Japan. c Senior Maxillofacial Surgeon, Department of Cranio-Maxillofacial Surgery, University of Berne, Switzerland. d Chief Professor, Department of Cranio-Maxillofacial Surgery, University of Berne, Switzerland. Received for publication Jul 31, 2007; returned for revision Nov 22, 2007; accepted for publication Dec 6, 2007. 1079-2104/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2007.12.007
commonly used classification to describe the severity of ID was proposed by Wilkes in 1989.3 The Wilkes classification consists of 5 stages based on clinical, radiologic, and intraoperative findings, varying from a slight forward displacement with symptom-free normal joints to essentially degenerative arthritic changes with severe clinical symptoms (Table I). The primary treatment of ID of the TMJ is conservative management. Occlusal splint insertion and physical treatment are the most common options.4,5 Around 90% of all TMD can be successfully treated by these conservative methods.6 The 10% that are refractory to nonsurgical procedures need more invasive treatment, such as arthroscopic surgery. The standard technique involves lysis and lavage of the superior joint space under direct arthroscopic vision.7-11 This procedure improves both TMJ pain and mouth opening. Indresano postulated that advanced arthroscopic surgery, such as laser surgery, is indicated in higher Wilkes stages, based on his experience with an unspecified number of cases.12 To prove this recommendation, 317
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Table I. Clinical and radiologic criteria for Wilkes staging of temporomandibular joint internal derangement (Wilkes 1989) Stage I II
III
IV V
Clinical findings
Radiologic findings
No significant mechanical symptoms, no pain or limitation of motion First few episodes of pain, occasional joint tenderness and related temporal headaches, increase in intensity of clicking, joint sounds later in opening movement, beginning transient subluxations or joint locking Multiple episodes of pain, joint tenderness, temporal headaches, locking, closed locks, restriction of motion, difficulty (pain) with function Chronicity with variable and episodic pain, headaches, variable restriction of motion, and undulating course Crepitus on examination, scraping, grating, grinding symptoms, variable and episodic pain, chronic restriction of motion, difficulty with function
Slight forward displacement and good anatomic contour of disc
comparison of different arthroscopic techniques at different stages of ID is necessary; however, such comparisons are rare in the literature. Bronstein and Merrill noticed higher success rates of arthroscopic surgery in lower than in advanced Wilkes stages.13 Murakami et al. found no significant differences in the efficiency of arthroscopic surgery between different stages of TMD.14 However, these studies do not focus on a specific arthroscopic treatment, using different operation techniques in different Wilkes stages. It is still unknown whether there are differences in efficiency of arthroscopic lysis and lavage in relation to the severity of the TMD. We published preliminary data correlating Wilkes stages to the final success rate of arthroscopic lysis and lavage in a small number of patients.15 This previous report showed that the treatment was less successful for stages IV and V (71.4% and 75%) than for stages II and III (80% and 85.7%). However, because of the small number of samples in each group of that study, no statistical analysis could be performed. The aim of the present study is to evaluate the outcome of a standard arthroscopic lysis and lavage of the TMJ in different ID of varying severity and to find out if there is any statistically significant difference in the success rate of this arthroscopic treatment for Wilkes stages II, III, IV, and V. PATIENTS AND METHODS Forty-five TMJ of 39 patients who underwent arthroscopic lysis and lavage between 1997 and 2006 to treat ID were studied prospectively. Nine patients were male and 30 female. There was an age range from 17 to 80 years at the time of surgery, with a mean of 37 years. The duration of the patient‘s symptoms before the first visit ranged from 2 months to 10 years (mean 23.9
Slight forward displacement and beginning anatomic deformity of disc, slight thickening of posterior edge of disc
Anterior displacement with significant anatomic deformity/prolapse of disc, moderate to marked thickening of posterior edge of disk, no hard tissue changes Increase in severity over intermediate stage, early to moderate degenerative remodeling, hard tissue changes Gross anatomic deformity of disc and hard tissue, essentially degenerative arthritic changes, osteophytic deformity, subcortical cystic formation
months). All patients underwent prior unsuccessful nonsurgical treatment that included a series of physical therapy of the TMJ and masticatory muscles. The physical therapy consisted of isometric, active-assistive, and self-stretching exercises as well as condylar mobilization. The exercises were carried out within a pain-free range. The patients were encouraged to perform the exercises by themselves at home for 20 min, 3 times a day. The period of nonsurgical therapy ranged from 2 to 36 months (mean 6.9 months). Arthroscopic lysis and lavage was performed within 1 month of reevaluation after unsuccessful conservative treatment. The surgical procedure was carried out under general anesthesia. To reach the TMJ arthroscopically the inferolateral approach described by Murakami and Ono was used.16 Examination of the upper compartment of the TMJ was performed using a 30° telescope (Karl Storz, Tuttlingen, Germany). Fibrous adhesions in the joint space, if present, were released for lysis using a blunt trocar. After inspection of the joint space, the upper compartment was irrigated with 200 mL isotonic saline solution for lavage. In all cases, no antibiotics or steroid injections were given. After arthroscopic lysis and lavage, physical treatment, including self-traction mouth-opening exercises, was performed for 1 to 2 months after surgery. Before the arthroscopic treatment, the patients were examined clinically as well as radiologically using magnetic resonance imaging (MRI). Clinical examination consisted of palpation of the temporomandibular region and masticatory muscles and auscultation of the TMJ. Mandibular movements such as maximal mouth opening, lateral movements, and protrusion were measured. Any mandibular deviation on mouth opening or pain when moving the jaw was recorded. Limited mouth opening was defined as less than 36 mm interincisal distance on
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Fig. 1. Examples of arthroscopic findings in stage II, III, IV, and V. A, Hypervascularization and hyperemia of the posterior attachment in a joint classified as Wilkes stage II. B, Adhesions found in Wilkes stages III. C, Fibrillation observed in a Wilkes stage IV. D, Perforation of the disc in a case of Wilkes stage V.
maximal opening. Protrusion and laterotrusion were judged as limited when the jaw movement was not more than 7 mm. Based on the clinical and radiologic findings, a Wilkes stage was assigned to each joint preoperatively.3 According to Wilkes stages II, III, IV, and V, the cases were divided into 4 groups. Preoperatively, all patients filled out a visual analog scales (VAS) with a range from 0 to 100 for evaluation of the pain level. Additionally, pain during chewing and the effect of pain on daily living were evaluated. Pain during chewing was divided into 4 classes. Class 1 means that the patient tolerates normal diet without interference. Class 2 describes patients tolerating normal diet but noticing moderate pain. Patients of class 3 tolerate normal diet only occasionally and usually eat soft diet. Class 4 patients tolerate only soft diet. The effect of pain on daily living was staged as none, slight, moderate, severe, and debilitating. To verify the preoperative diagnosis, intraoperative arthroscopic findings were compared with the preoperative Wilkes staging. The arthroscopic findings recorded were: hypervascularization of the posterior attachment, adhesions, synovitis and hyperemia of the capsule, fibrillation,
perforated disc, and subchondral bone exposure. Definitive determination of the Wilkes stages was carried out after arthroscopic diagnosis. The clinical examinations, VAS and pain questionnaires were administered again a minimum of 6 months after surgery. To evaluate the treatment outcome for patients with different Wilkes stages the pre- and postoperative data were compared. The success of the treatment was determined using data for range of maximal mouth opening and degree of pain reduction indicated on the VAS. As an objective marker for treatment success, a postoperative interincisal mouth opening more than 36 mm was set. Additionally, a postoperative pain level of less than 25 on the VAS was considered a successful outcome. Pre- and postoperative mouth opening and pain levels on the VAS were evaluated for each Wilkes stage. Statistical significance was determined using the 2 test. P ⬍ .05 was considered to be statistically significant. RESULTS Based on the clinical, radiologic, and arthroscopic findings, 11 joints were preoperatively classified as
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Table II. Arthroscopic findings for 45 temporomandibular joints No. of Joints Arthroscopic finding
Wilkes stage II (n ⫽ 11)
Wilkes stage III (n ⫽ 13)
Wilkes stage IV (n ⫽ 13)
Wilkes stage V (n ⫽ 8)
Hypervascularization (posterior attachment) Adhesions Synovitis and hyperemia (capsule) Fibrillation Perforated disc Subchondral bone exposure
3 0 11 0 0 0
13 9 12 0 0 0
13 13 13 13 0 0
8 8 8 8 8 8
Wilkes stage II, 13 as stage III, 13 as stage IV, and 8 as stage V (Fig. 1). The clinical findings of patients with Wilkes stage II were mainly clicking and beginning transient subluxations. The patients reported to have a few episodes of pain for the first time of their life. Patients with Wilkes stage III, IV, and V mainly suffer from locking, restriction of mandibular movements and multiple episodes of pain. In higher Wilkes stage (IV and V), additional crepitation, scraping and grating often occurred. For definitive preoperative staging the radiologic criteria for Wilkes staging of TMD were necessary.3 Intraoperative arthroscopic findings are listed in Table II. Hypervascularization and hyperemia of the posterior attachment was found in all cases regardless of the stages of internal derangement. Adhesions were observed in all Wilkes stages except stage II. Fibrillation was a sign of stages IV and V. Perforation of the disc and subchondral bone exposure were related only to Wilkes stage V. At the postoperative follow-up, the number of cases with limited jaw movements, clicking, crepitation, arthralgia, and myalgia was markedly decreased (Table III). A remarkable increase in mouth opening and reduction of pain was observable in each Wilkes stage postoperatively. The level of pain experienced during chewing preand postoperatively is shown in Fig. 2, and joint distribution according to the effect of pain on daily life is shown in Fig. 3. The cases could be classified clearly into 2 groups, with either satisfactory or poor clinical outcome. In 39 of the cases remarkable improvements in both mouth opening and pain were present. These cases showed a satisfactory clinical outcome. Residual postoperative symptoms, including limited mouth opening, limited laterotrusion to the contralateral side, limited protrusion, locking, and TMJ arthralgia, were mainly present in 6 cases which were unresponsive to the treatment and showed a poor clinical outcome. Joint distribution between satisfactory and poor clinical outcome is shown in Table IV for each Wilkes stage. In the group of patients with poor clinical outcome,
Table III. Distribution according to TMJ signs and symptoms (45 joints) at pre- and postoperative stages (mean follow-up 16.7 months) Preoperative
Postoperative
No. of joints
%
No. of joints
%
42
93.3
11
24.4
15
33.3
5
11.1
15 17 15 26 45 39
33.3 37.8 33.3 57.8 100 86.7
5 11 7 7 5 5
11.1 24.4 15.6 15.6 11.1 11.1
Limited interincisal mouth opening Limited jaw movement to contralateral side Limited protrusion Clicking Crepitation Locking TMJ arthralgia Masticatory myalgia TMJ, Temporomandibular joint.
number of joints 30
preoperative 25
postoperative
25
23
21 20 14
15 10
4
5 0
0 normal diet with no pain
1 normal diet with moderate pain
2
normal diet with severe pain
only soft diet
Fig. 2. Patient distribution for pain during chewing at preand postoperative stages.
postoperative mouth opening ranged from 15 mm to 36 mm (mean 24.4 mm). The VAS pain levels were unchanged in 3 cases at 75, and increased in 3 cases by 5%-15%, to 75-90. All the patients with TMJ disturbances in this group had severe pain while eating a normal diet and therefore preferred a soft diet. Furthermore, the effect of pain on their daily life was classified
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postoperative 25
significant. In addition, the correlation between stages II and III and stages IV and V was also not statistically significant (Table IV).
preoperative
23
20 16 15
10 10
7
5
6
2 0
0
0
0 none
slight
moderate
severe
debilitating
Fig. 3. Patient distribution for the effect of the TMJ symptoms on daily living at pre- and postoperative stages.
Table IV. Distribution of joints with satisfactory and poor clinical outcome
Wilkes stage II III IV V Total
No. of joints
Joints with satisfactory clinical outcome
Joints with poor clinical outcome
Success rate of joints
11 13 13 8 45
10 12 11 6 39
1 1 2 2 6
90.9% 92.3% 84.6% 75.0% 86.7%
Correlation of success rate between each stage in 45 joints: P ⫽ .184. Correlation of success rate between stages II-III and IV-V in 45 joints: P ⫽ .874.
as severe or debilitating. All joints in this group were therefore subjected to open joint surgery. For the group with satisfactory clinical outcome (n ⫽ 39), postoperative mouth opening of greater than 40 mm (range 40 mm to 50 mm) was recorded for 34 joints. The 5 remaining cases had mouth opening between 36 mm to 37 mm. Twenty-five cases showed a postoperative score of 0 on the VAS for pain. All cases in this group had a score for pain under 25 on the VAS, with postoperative pain reduction averaging 79.5%. Of these, 25 patients were able to eat a normal diet without pain and 14 were able to eat normal diet with moderate pain (Fig. 2). Whereas in 23 cases there was no effect and in 16 cases a sight effect of the TMJ symptoms on daily living (Fig. 3). Treatment of these 39 cases was considered to be successful. The postoperative follow-up ranged from 6 months to 5 years, with a mean of 16.7 months. The overall success rate was 86.7%, based on a success rate of 90.9% for Wilkes stage II, 92.3% for stage III, 84.6% for stage IV, and 75% for stage V. The success rate of correlation between each stage was not statistically
DISCUSSION Success rates of arthroscopic lysis and lavage for the treatment of ID have ranged from 80% to 86%.17-20 In those earlier studies, the success rates were calculated based on 2 main criteria: improvement of mandibular movement and reduction of pain levels. Mandibular movement was considered to be satisfactory when interincisal mouth opening was ⬎35-38 mm after surgery. The reduction of pain levels was evaluated using VAS for pain. The treatment was considered to be successful when pain levels of ⬍20-33 on the VAS were achieved after surgery. The criteria to evaluate the success rate in the present study are similar. The overall success rate of the present study of 86.7% falls within the success rates previously reported in the literature. Nitzan et al. evaluated the treatment outcome of arthroscopic lysis and lavage of 20 patients with TMD.17 Only 2 joints had to be reoperated. A staging according to Wilkes was not performed. Kurita et al. treated 14 patients with ID of the TMJ.18 The overall success rate was 86%. According to their results it was concluded that patients with greater limitations on mouth opening should undergo earlier surgical intervention. Dimitroulis reported of 56 patients who underwent arthroscopic lysis and lavage because of TMD.19 A good to excellent improvement was achieved in 66%, a mild improvement in 18%, and no improvement in 16%. Significant improvement in 16 of 20 patients (80%) after arthroscopic lysis and lavage for ID of the TMJ was described by Kondoh et al.20 However, the question remained of whether the severity of ID affected the success rate of arthroscopic lysis and lavage in cases of TMD. To this end, prior staging of ID according to the Wilkes classification is helpful. In the present study, the clinical criteria for Wilkes classification correlated very well with the arthroscopic findings. However, to perform a sufficient preoperative staging, both clinical and radiologic criteria are necessary. Our results confirm that a reliable preoperative Wilkes staging based on clinical and radiologic findings is possible. Some earlier studies correlated outcome of arthroscopic surgery to the severity of ID according to Wilkes classification.13,14 Bronstein and Merrill reported a success rate of 96% for stage II, 83% for stage III, 88% for stage IV, and 63% for stage V disease.13 The operative techniques used in their study widely varied from simple lavage to disc manipulation and reduction, sclerosis of the posterior attechment, arthroscopic ablation or debridement arthroplasty, anterior synovial and lateral
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pterygoid release, and arthroscopic osteoplastic arhtroplasty. Murakami et al. reported an overall success rate of 90% with no significant differences between stages III, IV and V.14 In their study, treatment of stages III and IV consisted of lysis and lavage, and treatment of stage V comprised advanced arthroscopic procedures such as arthroscopic synovectomy, discoplasty, and debridement using electric cautery or holmium-YAG laser. Therefore, Murakami et al. offer no results of the efficacy of arthroscopic lysis and lavage in Wilkes stage V in that study. Correlations of Wilkes stages to the success rate of arthroscopic lysis and lavage of ID of the TMJ was reported by us previously.15 Lysis and lavage was less successful for stages IV and V (71.4% and 75%) than for stages II and III (80% and 85.7%). However, because of the small number of samples in each Wilkes stage, no statistical analysis could be performed in that study. Based on the results of the present study, there are no statistically significant differences in the success rates of Wilkes stage II, III, IV and V for arthroscopic lysis and lavage. Controversy remains mainly over the treatment of severe cases of ID. Opinions vary regarding the kind of operation to use in case of Wilkes stage V. Holmlund et al. reported a success rate of only 50% after arthroscopic lysis and lavage in patients with chronic closed lock and osteoarthrosis, which corresponds to Wilkes stage V.21 Murakami et al. found a success rate of 93.3% for joints with Wilkes stage V which were treated by advanced arthroscopic laser surgery.14 Indresano contended, based on his experience with an unspecified number of cases, that arthroscopic lysis and lavage are not sufficient in higher stages of ID and recommended advanced arthroscopic surgery for treatment of these cases.12 McCain also stated, based on his experience, that stage V patients with disc perforation and marked joint fibrosis do not respond well to arthroscopic manipulation and are better served by open arthrotomy.22 On the other hand, an extensive literature review showed no definite difference in long-term outcome with regard to range of motion and postoperative pain based on the type of procedure used, such as advanced surgical procedures or only lysis and lavage.23 In the present study, an attempt was made to compare outcome of a standard arthroscopic treatment for various stages of internal derangement. Our cases that were classified as total failure were almost equally distributed in all stages. The success rates of our study showed no statistically significant difference between Wilkes stages. Even so, our overall success rate of 86.7% was considered to be satisfactory. Therefore, we conclude that arthroscopic lysis and lavage is, as a
minimally invasive operation, the preferred surgical procedure for all different stages of internal derangement after failure of conservative treatment. In the present study, 6 joints with poor outcome after arthroscopic lysis and lavage had been operated on using open surgery. In a retrospective study comparing open or advanced arthroscopic surgery for ID including Wilkes stages III-V, no significant differences were found when comparing subgroups (Wilkes stages III-V) or both groups (open/advanced arthroscopic surgery) of patients 5 years after TMJ surgery.2 Therefore, we think that advanced arthroscopic surgery would be a choice for the patients with poor outcome after simple arthroscopic lysis and lavage. However, further studies are necessary to analyze cases with unsatisfactory outcome after arthroscopic lysis and lavage for ID, including possible clinical and pathologic factors. CONCLUSION There were no statistically significant differences in the success rates of arthroscopic lysis and lavage in Wilkes stage II, III, IV, and V. Because arthroscopic lysis and lavage is a minimally invasive surgical procedure, it should be performed as a standard operation for ID of the TMJ after failure of conservative treatment. REFERENCES 1. Emshoff R, Rudisch A. Temporomandibular joint internal derangement and osteoarthrosis: are effusion and bone marrow edema prognostic indicators for arthrocentesis and hydraulic distention? J Oral Maxillofac Surg 2007;65:66-73. 2. Undt G, Murakami K, Rasse M, Ewers R. Open versus arthroscopic surgery for internal derangement of the temporomandibular joint: a retrospective study comparing two centres’ results using the Jaw Pain and Function Questionnaire. J Craniomaxillofac Surg 2006;34:234-41. 3. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989;115:469-77. 4. Chung SC, Kim HS. The effect of the stabilization splint on the TMJ closed lock. Cranio 1993;11:95-101. 5. Mongini F, Ibertis F, Manfredi A. Long-term results in patients with disk displacement without reduction treated conservatively. Cranio 1996;14:301-5. 6. Randolph CS, Greene CS, Moretti R, Forbes D, Perry HT. Conservative management of temporomandibular disorders: posttreatment comparison between patients from a university clinic and from private practice. Am J Orthod Dentofacial Orthop 1990;98:77-82. 7. Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1986;62: 361-72. 8. Moses JJ, Sartoris D, Glass R, Tanaka T, Poker I. The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 1989;47:674-8. 9. McCain JP, Sanders B, Koslin MG, et al. Temporomandibular
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10.
11.
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13.
14.
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16.
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18.
joint arthroscopy: a 6-year multicenter retrospective study of 4831 joints. J Oral Maxillofac Surg 1992;50:926-30. Koslin MG, Martin JC. The use of holmium laser for temporomandibular joint arthroscopic surgery. J Oral Maxillofac Surg 1993;51:122-3. Murakami K, Segami N, Okamoto M, Yamamura I, Takahashi K, Tsuboi Y. Outcome of arthroscopic surgery for internal derangement of the temporomandibular joint: long-term results covering 10 years. J Craniomaxillofac Surg 2000;28:264-71. Indresano AT. Surgical arthroscopy as preferred treatment for internal derangements of the temporomandibular joint. J Oral Maxillofac Surg 2001;59:308-12. Bronstein SL, Merrill RG. Clinical staging for TMJ internal derangement: application to arthroscopy. J Craniomandib Disord 1992;6:7-15. Murakami K, Tsuboi Y, Bessho K, Yokoe Y, Nishida T, Iizuka T. Outcome of arthroscopic surgery to the temporomandibular joint correlates with stage of internal derangement: five-year follow-up study. Br J Oral Maxillofac Surg 1998;36:30-4. Smolka W, Iizuka T. Arthroscopic lysis and lavage in different stages of internal derangement of the temporomandibular joint: correlation of preoperative staging to arthroscopic findings and treatment outcome. J Oral Maxillofac Surg 2005;63:471-8. Murakami K, Ono T. Temporomandibular joint arthroscopy by inferolateral approach. Int J Oral Maxillofac Surg 1986;15: 410-7. Nitzan DW, Dolwick F, Heft MW. Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective. J Oral Maxillofac Surg 1990;48:798-801. Kurita K, Goss AN, Ogi N, Toyama M. Correlation between
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19.
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22.
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preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction. J Oral Maxillofac Surg 1998;56:1394-7. Dimitroulis G. A review of 56 cases of chronic dosed lock treated with temporomandibular joint arthroscopy. J Oral Maxillofac Surg 2002;60:519-24. Kondoh T, Dolwick MF, Hamada Y, Seto K. Visually guided irrigation for patients with symptomatic internal derangement of the temporomandibular joint: a preliminary report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:544-51. Holmlund A, Gynther G, Axelsson S. Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint. Int J Oral Maxillofac Surg 1994;23:262-5. McCain JP. Discussion; Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction. J Oral Maxillofac Surg 1998;56:1397-9. White RD. Arthroscopic lysis and lavage as the preferred treatment for internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 2001;59:313-6.
Reprint requests: Wenko Smolka, MD, DMD, FEBOMFS Senior Maxillofacial Surgeon Department of Craniomaxillofacial Surgery University of Berne, Inselspital CH-3010 Berne Switzerland [email protected]
ORAL AND MAXILLOFACIAL SURGERY
Editor: James R. Hupp
Efficiency of arthroscopic lysis and lavage for internal derangement of the temporomandibular joint correlated with Wilkes classification Wenko Smolka, MD, DMD, FEBOMFS,a Chie Yanai, DDS, PhD,b Koord Smolka, MD, DMD, FEBOMFS,c Tateyuki Iizuka, MD, DDS, PhD, FEBOMFS,d Berne, Switzerland DEPARTMENT OF CRANIOMAXILLOFACIAL SURGERY, UNIVERSITY OF BERNE
Objectives. To compare the outcome of arthroscopic lysis and lavage of TMJ with internal derangement of Wilkes stages II, III, IV, and V. Study design. Arthroscopic lysis and lavage was performed in 45 TMJ of 39 patients with internal derangement. The cases were divided into 4 groups corresponding to Wilkes stages II, III, IV, and V. Two parameters were compared pre- and postoperatively: pain and mouth opening. Statistical significance was determined using the 2 test. Results. Overall success rate was 86.7% (Wilkes stage II 90.9%, Wilkes stage III 92.3%, Wilkes stage IV 84.6%, Wilkes stage V 75%). There were no statistically significant differences between the success rates for Wilkes stages II, III, IV, and V. Conclusion. Arthroscopic lysis and lavage should be performed as a standard operation for internal derangement of the TMJ after failure of conservative treatment in all Wilkes stages. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:317-23)
Internal derangement (ID) of the temporomandibular joint (TMJ) is one of the most common forms of temporomandibular disorders (TMD).1 The term ID comprises anterior disc displacement with or without reduction, perforation of the articular disc or of the retrodiscal tissue, and various degenerative changes of the disc and/or the articulating surfaces.2 The most
a
Senior Maxillofacial Surgeon, Department of Cranio-Maxillofacial Surgery, University of Berne, Switzerland. b Clinical Fellow, Department of Cranio-Maxillofacial Surgery, University Berne, Switzerland & Assistant Professor, Oral and Maxillofacial Surgery, The Nippon Dental University Hospital at Tokyo, Japan. c Senior Maxillofacial Surgeon, Department of Cranio-Maxillofacial Surgery, University of Berne, Switzerland. d Chief Professor, Department of Cranio-Maxillofacial Surgery, University of Berne, Switzerland. Received for publication Jul 31, 2007; returned for revision Nov 22, 2007; accepted for publication Dec 6, 2007. 1079-2104/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2007.12.007
commonly used classification to describe the severity of ID was proposed by Wilkes in 1989.3 The Wilkes classification consists of 5 stages based on clinical, radiologic, and intraoperative findings, varying from a slight forward displacement with symptom-free normal joints to essentially degenerative arthritic changes with severe clinical symptoms (Table I). The primary treatment of ID of the TMJ is conservative management. Occlusal splint insertion and physical treatment are the most common options.4,5 Around 90% of all TMD can be successfully treated by these conservative methods.6 The 10% that are refractory to nonsurgical procedures need more invasive treatment, such as arthroscopic surgery. The standard technique involves lysis and lavage of the superior joint space under direct arthroscopic vision.7-11 This procedure improves both TMJ pain and mouth opening. Indresano postulated that advanced arthroscopic surgery, such as laser surgery, is indicated in higher Wilkes stages, based on his experience with an unspecified number of cases.12 To prove this recommendation, 317
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Table I. Clinical and radiologic criteria for Wilkes staging of temporomandibular joint internal derangement (Wilkes 1989) Stage I II
III
IV V
Clinical findings
Radiologic findings
No significant mechanical symptoms, no pain or limitation of motion First few episodes of pain, occasional joint tenderness and related temporal headaches, increase in intensity of clicking, joint sounds later in opening movement, beginning transient subluxations or joint locking Multiple episodes of pain, joint tenderness, temporal headaches, locking, closed locks, restriction of motion, difficulty (pain) with function Chronicity with variable and episodic pain, headaches, variable restriction of motion, and undulating course Crepitus on examination, scraping, grating, grinding symptoms, variable and episodic pain, chronic restriction of motion, difficulty with function
Slight forward displacement and good anatomic contour of disc
comparison of different arthroscopic techniques at different stages of ID is necessary; however, such comparisons are rare in the literature. Bronstein and Merrill noticed higher success rates of arthroscopic surgery in lower than in advanced Wilkes stages.13 Murakami et al. found no significant differences in the efficiency of arthroscopic surgery between different stages of TMD.14 However, these studies do not focus on a specific arthroscopic treatment, using different operation techniques in different Wilkes stages. It is still unknown whether there are differences in efficiency of arthroscopic lysis and lavage in relation to the severity of the TMD. We published preliminary data correlating Wilkes stages to the final success rate of arthroscopic lysis and lavage in a small number of patients.15 This previous report showed that the treatment was less successful for stages IV and V (71.4% and 75%) than for stages II and III (80% and 85.7%). However, because of the small number of samples in each group of that study, no statistical analysis could be performed. The aim of the present study is to evaluate the outcome of a standard arthroscopic lysis and lavage of the TMJ in different ID of varying severity and to find out if there is any statistically significant difference in the success rate of this arthroscopic treatment for Wilkes stages II, III, IV, and V. PATIENTS AND METHODS Forty-five TMJ of 39 patients who underwent arthroscopic lysis and lavage between 1997 and 2006 to treat ID were studied prospectively. Nine patients were male and 30 female. There was an age range from 17 to 80 years at the time of surgery, with a mean of 37 years. The duration of the patient‘s symptoms before the first visit ranged from 2 months to 10 years (mean 23.9
Slight forward displacement and beginning anatomic deformity of disc, slight thickening of posterior edge of disc
Anterior displacement with significant anatomic deformity/prolapse of disc, moderate to marked thickening of posterior edge of disk, no hard tissue changes Increase in severity over intermediate stage, early to moderate degenerative remodeling, hard tissue changes Gross anatomic deformity of disc and hard tissue, essentially degenerative arthritic changes, osteophytic deformity, subcortical cystic formation
months). All patients underwent prior unsuccessful nonsurgical treatment that included a series of physical therapy of the TMJ and masticatory muscles. The physical therapy consisted of isometric, active-assistive, and self-stretching exercises as well as condylar mobilization. The exercises were carried out within a pain-free range. The patients were encouraged to perform the exercises by themselves at home for 20 min, 3 times a day. The period of nonsurgical therapy ranged from 2 to 36 months (mean 6.9 months). Arthroscopic lysis and lavage was performed within 1 month of reevaluation after unsuccessful conservative treatment. The surgical procedure was carried out under general anesthesia. To reach the TMJ arthroscopically the inferolateral approach described by Murakami and Ono was used.16 Examination of the upper compartment of the TMJ was performed using a 30° telescope (Karl Storz, Tuttlingen, Germany). Fibrous adhesions in the joint space, if present, were released for lysis using a blunt trocar. After inspection of the joint space, the upper compartment was irrigated with 200 mL isotonic saline solution for lavage. In all cases, no antibiotics or steroid injections were given. After arthroscopic lysis and lavage, physical treatment, including self-traction mouth-opening exercises, was performed for 1 to 2 months after surgery. Before the arthroscopic treatment, the patients were examined clinically as well as radiologically using magnetic resonance imaging (MRI). Clinical examination consisted of palpation of the temporomandibular region and masticatory muscles and auscultation of the TMJ. Mandibular movements such as maximal mouth opening, lateral movements, and protrusion were measured. Any mandibular deviation on mouth opening or pain when moving the jaw was recorded. Limited mouth opening was defined as less than 36 mm interincisal distance on
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Fig. 1. Examples of arthroscopic findings in stage II, III, IV, and V. A, Hypervascularization and hyperemia of the posterior attachment in a joint classified as Wilkes stage II. B, Adhesions found in Wilkes stages III. C, Fibrillation observed in a Wilkes stage IV. D, Perforation of the disc in a case of Wilkes stage V.
maximal opening. Protrusion and laterotrusion were judged as limited when the jaw movement was not more than 7 mm. Based on the clinical and radiologic findings, a Wilkes stage was assigned to each joint preoperatively.3 According to Wilkes stages II, III, IV, and V, the cases were divided into 4 groups. Preoperatively, all patients filled out a visual analog scales (VAS) with a range from 0 to 100 for evaluation of the pain level. Additionally, pain during chewing and the effect of pain on daily living were evaluated. Pain during chewing was divided into 4 classes. Class 1 means that the patient tolerates normal diet without interference. Class 2 describes patients tolerating normal diet but noticing moderate pain. Patients of class 3 tolerate normal diet only occasionally and usually eat soft diet. Class 4 patients tolerate only soft diet. The effect of pain on daily living was staged as none, slight, moderate, severe, and debilitating. To verify the preoperative diagnosis, intraoperative arthroscopic findings were compared with the preoperative Wilkes staging. The arthroscopic findings recorded were: hypervascularization of the posterior attachment, adhesions, synovitis and hyperemia of the capsule, fibrillation,
perforated disc, and subchondral bone exposure. Definitive determination of the Wilkes stages was carried out after arthroscopic diagnosis. The clinical examinations, VAS and pain questionnaires were administered again a minimum of 6 months after surgery. To evaluate the treatment outcome for patients with different Wilkes stages the pre- and postoperative data were compared. The success of the treatment was determined using data for range of maximal mouth opening and degree of pain reduction indicated on the VAS. As an objective marker for treatment success, a postoperative interincisal mouth opening more than 36 mm was set. Additionally, a postoperative pain level of less than 25 on the VAS was considered a successful outcome. Pre- and postoperative mouth opening and pain levels on the VAS were evaluated for each Wilkes stage. Statistical significance was determined using the 2 test. P ⬍ .05 was considered to be statistically significant. RESULTS Based on the clinical, radiologic, and arthroscopic findings, 11 joints were preoperatively classified as
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Table II. Arthroscopic findings for 45 temporomandibular joints No. of Joints Arthroscopic finding
Wilkes stage II (n ⫽ 11)
Wilkes stage III (n ⫽ 13)
Wilkes stage IV (n ⫽ 13)
Wilkes stage V (n ⫽ 8)
Hypervascularization (posterior attachment) Adhesions Synovitis and hyperemia (capsule) Fibrillation Perforated disc Subchondral bone exposure
3 0 11 0 0 0
13 9 12 0 0 0
13 13 13 13 0 0
8 8 8 8 8 8
Wilkes stage II, 13 as stage III, 13 as stage IV, and 8 as stage V (Fig. 1). The clinical findings of patients with Wilkes stage II were mainly clicking and beginning transient subluxations. The patients reported to have a few episodes of pain for the first time of their life. Patients with Wilkes stage III, IV, and V mainly suffer from locking, restriction of mandibular movements and multiple episodes of pain. In higher Wilkes stage (IV and V), additional crepitation, scraping and grating often occurred. For definitive preoperative staging the radiologic criteria for Wilkes staging of TMD were necessary.3 Intraoperative arthroscopic findings are listed in Table II. Hypervascularization and hyperemia of the posterior attachment was found in all cases regardless of the stages of internal derangement. Adhesions were observed in all Wilkes stages except stage II. Fibrillation was a sign of stages IV and V. Perforation of the disc and subchondral bone exposure were related only to Wilkes stage V. At the postoperative follow-up, the number of cases with limited jaw movements, clicking, crepitation, arthralgia, and myalgia was markedly decreased (Table III). A remarkable increase in mouth opening and reduction of pain was observable in each Wilkes stage postoperatively. The level of pain experienced during chewing preand postoperatively is shown in Fig. 2, and joint distribution according to the effect of pain on daily life is shown in Fig. 3. The cases could be classified clearly into 2 groups, with either satisfactory or poor clinical outcome. In 39 of the cases remarkable improvements in both mouth opening and pain were present. These cases showed a satisfactory clinical outcome. Residual postoperative symptoms, including limited mouth opening, limited laterotrusion to the contralateral side, limited protrusion, locking, and TMJ arthralgia, were mainly present in 6 cases which were unresponsive to the treatment and showed a poor clinical outcome. Joint distribution between satisfactory and poor clinical outcome is shown in Table IV for each Wilkes stage. In the group of patients with poor clinical outcome,
Table III. Distribution according to TMJ signs and symptoms (45 joints) at pre- and postoperative stages (mean follow-up 16.7 months) Preoperative
Postoperative
No. of joints
%
No. of joints
%
42
93.3
11
24.4
15
33.3
5
11.1
15 17 15 26 45 39
33.3 37.8 33.3 57.8 100 86.7
5 11 7 7 5 5
11.1 24.4 15.6 15.6 11.1 11.1
Limited interincisal mouth opening Limited jaw movement to contralateral side Limited protrusion Clicking Crepitation Locking TMJ arthralgia Masticatory myalgia TMJ, Temporomandibular joint.
number of joints 30
preoperative 25
postoperative
25
23
21 20 14
15 10
4
5 0
0 normal diet with no pain
1 normal diet with moderate pain
2
normal diet with severe pain
only soft diet
Fig. 2. Patient distribution for pain during chewing at preand postoperative stages.
postoperative mouth opening ranged from 15 mm to 36 mm (mean 24.4 mm). The VAS pain levels were unchanged in 3 cases at 75, and increased in 3 cases by 5%-15%, to 75-90. All the patients with TMJ disturbances in this group had severe pain while eating a normal diet and therefore preferred a soft diet. Furthermore, the effect of pain on their daily life was classified
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postoperative 25
significant. In addition, the correlation between stages II and III and stages IV and V was also not statistically significant (Table IV).
preoperative
23
20 16 15
10 10
7
5
6
2 0
0
0
0 none
slight
moderate
severe
debilitating
Fig. 3. Patient distribution for the effect of the TMJ symptoms on daily living at pre- and postoperative stages.
Table IV. Distribution of joints with satisfactory and poor clinical outcome
Wilkes stage II III IV V Total
No. of joints
Joints with satisfactory clinical outcome
Joints with poor clinical outcome
Success rate of joints
11 13 13 8 45
10 12 11 6 39
1 1 2 2 6
90.9% 92.3% 84.6% 75.0% 86.7%
Correlation of success rate between each stage in 45 joints: P ⫽ .184. Correlation of success rate between stages II-III and IV-V in 45 joints: P ⫽ .874.
as severe or debilitating. All joints in this group were therefore subjected to open joint surgery. For the group with satisfactory clinical outcome (n ⫽ 39), postoperative mouth opening of greater than 40 mm (range 40 mm to 50 mm) was recorded for 34 joints. The 5 remaining cases had mouth opening between 36 mm to 37 mm. Twenty-five cases showed a postoperative score of 0 on the VAS for pain. All cases in this group had a score for pain under 25 on the VAS, with postoperative pain reduction averaging 79.5%. Of these, 25 patients were able to eat a normal diet without pain and 14 were able to eat normal diet with moderate pain (Fig. 2). Whereas in 23 cases there was no effect and in 16 cases a sight effect of the TMJ symptoms on daily living (Fig. 3). Treatment of these 39 cases was considered to be successful. The postoperative follow-up ranged from 6 months to 5 years, with a mean of 16.7 months. The overall success rate was 86.7%, based on a success rate of 90.9% for Wilkes stage II, 92.3% for stage III, 84.6% for stage IV, and 75% for stage V. The success rate of correlation between each stage was not statistically
DISCUSSION Success rates of arthroscopic lysis and lavage for the treatment of ID have ranged from 80% to 86%.17-20 In those earlier studies, the success rates were calculated based on 2 main criteria: improvement of mandibular movement and reduction of pain levels. Mandibular movement was considered to be satisfactory when interincisal mouth opening was ⬎35-38 mm after surgery. The reduction of pain levels was evaluated using VAS for pain. The treatment was considered to be successful when pain levels of ⬍20-33 on the VAS were achieved after surgery. The criteria to evaluate the success rate in the present study are similar. The overall success rate of the present study of 86.7% falls within the success rates previously reported in the literature. Nitzan et al. evaluated the treatment outcome of arthroscopic lysis and lavage of 20 patients with TMD.17 Only 2 joints had to be reoperated. A staging according to Wilkes was not performed. Kurita et al. treated 14 patients with ID of the TMJ.18 The overall success rate was 86%. According to their results it was concluded that patients with greater limitations on mouth opening should undergo earlier surgical intervention. Dimitroulis reported of 56 patients who underwent arthroscopic lysis and lavage because of TMD.19 A good to excellent improvement was achieved in 66%, a mild improvement in 18%, and no improvement in 16%. Significant improvement in 16 of 20 patients (80%) after arthroscopic lysis and lavage for ID of the TMJ was described by Kondoh et al.20 However, the question remained of whether the severity of ID affected the success rate of arthroscopic lysis and lavage in cases of TMD. To this end, prior staging of ID according to the Wilkes classification is helpful. In the present study, the clinical criteria for Wilkes classification correlated very well with the arthroscopic findings. However, to perform a sufficient preoperative staging, both clinical and radiologic criteria are necessary. Our results confirm that a reliable preoperative Wilkes staging based on clinical and radiologic findings is possible. Some earlier studies correlated outcome of arthroscopic surgery to the severity of ID according to Wilkes classification.13,14 Bronstein and Merrill reported a success rate of 96% for stage II, 83% for stage III, 88% for stage IV, and 63% for stage V disease.13 The operative techniques used in their study widely varied from simple lavage to disc manipulation and reduction, sclerosis of the posterior attechment, arthroscopic ablation or debridement arthroplasty, anterior synovial and lateral
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pterygoid release, and arthroscopic osteoplastic arhtroplasty. Murakami et al. reported an overall success rate of 90% with no significant differences between stages III, IV and V.14 In their study, treatment of stages III and IV consisted of lysis and lavage, and treatment of stage V comprised advanced arthroscopic procedures such as arthroscopic synovectomy, discoplasty, and debridement using electric cautery or holmium-YAG laser. Therefore, Murakami et al. offer no results of the efficacy of arthroscopic lysis and lavage in Wilkes stage V in that study. Correlations of Wilkes stages to the success rate of arthroscopic lysis and lavage of ID of the TMJ was reported by us previously.15 Lysis and lavage was less successful for stages IV and V (71.4% and 75%) than for stages II and III (80% and 85.7%). However, because of the small number of samples in each Wilkes stage, no statistical analysis could be performed in that study. Based on the results of the present study, there are no statistically significant differences in the success rates of Wilkes stage II, III, IV and V for arthroscopic lysis and lavage. Controversy remains mainly over the treatment of severe cases of ID. Opinions vary regarding the kind of operation to use in case of Wilkes stage V. Holmlund et al. reported a success rate of only 50% after arthroscopic lysis and lavage in patients with chronic closed lock and osteoarthrosis, which corresponds to Wilkes stage V.21 Murakami et al. found a success rate of 93.3% for joints with Wilkes stage V which were treated by advanced arthroscopic laser surgery.14 Indresano contended, based on his experience with an unspecified number of cases, that arthroscopic lysis and lavage are not sufficient in higher stages of ID and recommended advanced arthroscopic surgery for treatment of these cases.12 McCain also stated, based on his experience, that stage V patients with disc perforation and marked joint fibrosis do not respond well to arthroscopic manipulation and are better served by open arthrotomy.22 On the other hand, an extensive literature review showed no definite difference in long-term outcome with regard to range of motion and postoperative pain based on the type of procedure used, such as advanced surgical procedures or only lysis and lavage.23 In the present study, an attempt was made to compare outcome of a standard arthroscopic treatment for various stages of internal derangement. Our cases that were classified as total failure were almost equally distributed in all stages. The success rates of our study showed no statistically significant difference between Wilkes stages. Even so, our overall success rate of 86.7% was considered to be satisfactory. Therefore, we conclude that arthroscopic lysis and lavage is, as a
minimally invasive operation, the preferred surgical procedure for all different stages of internal derangement after failure of conservative treatment. In the present study, 6 joints with poor outcome after arthroscopic lysis and lavage had been operated on using open surgery. In a retrospective study comparing open or advanced arthroscopic surgery for ID including Wilkes stages III-V, no significant differences were found when comparing subgroups (Wilkes stages III-V) or both groups (open/advanced arthroscopic surgery) of patients 5 years after TMJ surgery.2 Therefore, we think that advanced arthroscopic surgery would be a choice for the patients with poor outcome after simple arthroscopic lysis and lavage. However, further studies are necessary to analyze cases with unsatisfactory outcome after arthroscopic lysis and lavage for ID, including possible clinical and pathologic factors. CONCLUSION There were no statistically significant differences in the success rates of arthroscopic lysis and lavage in Wilkes stage II, III, IV, and V. Because arthroscopic lysis and lavage is a minimally invasive surgical procedure, it should be performed as a standard operation for ID of the TMJ after failure of conservative treatment. REFERENCES 1. Emshoff R, Rudisch A. Temporomandibular joint internal derangement and osteoarthrosis: are effusion and bone marrow edema prognostic indicators for arthrocentesis and hydraulic distention? J Oral Maxillofac Surg 2007;65:66-73. 2. Undt G, Murakami K, Rasse M, Ewers R. Open versus arthroscopic surgery for internal derangement of the temporomandibular joint: a retrospective study comparing two centres’ results using the Jaw Pain and Function Questionnaire. J Craniomaxillofac Surg 2006;34:234-41. 3. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989;115:469-77. 4. Chung SC, Kim HS. The effect of the stabilization splint on the TMJ closed lock. Cranio 1993;11:95-101. 5. Mongini F, Ibertis F, Manfredi A. Long-term results in patients with disk displacement without reduction treated conservatively. Cranio 1996;14:301-5. 6. Randolph CS, Greene CS, Moretti R, Forbes D, Perry HT. Conservative management of temporomandibular disorders: posttreatment comparison between patients from a university clinic and from private practice. Am J Orthod Dentofacial Orthop 1990;98:77-82. 7. Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1986;62: 361-72. 8. Moses JJ, Sartoris D, Glass R, Tanaka T, Poker I. The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 1989;47:674-8. 9. McCain JP, Sanders B, Koslin MG, et al. Temporomandibular
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joint arthroscopy: a 6-year multicenter retrospective study of 4831 joints. J Oral Maxillofac Surg 1992;50:926-30. Koslin MG, Martin JC. The use of holmium laser for temporomandibular joint arthroscopic surgery. J Oral Maxillofac Surg 1993;51:122-3. Murakami K, Segami N, Okamoto M, Yamamura I, Takahashi K, Tsuboi Y. Outcome of arthroscopic surgery for internal derangement of the temporomandibular joint: long-term results covering 10 years. J Craniomaxillofac Surg 2000;28:264-71. Indresano AT. Surgical arthroscopy as preferred treatment for internal derangements of the temporomandibular joint. J Oral Maxillofac Surg 2001;59:308-12. Bronstein SL, Merrill RG. Clinical staging for TMJ internal derangement: application to arthroscopy. J Craniomandib Disord 1992;6:7-15. Murakami K, Tsuboi Y, Bessho K, Yokoe Y, Nishida T, Iizuka T. Outcome of arthroscopic surgery to the temporomandibular joint correlates with stage of internal derangement: five-year follow-up study. Br J Oral Maxillofac Surg 1998;36:30-4. Smolka W, Iizuka T. Arthroscopic lysis and lavage in different stages of internal derangement of the temporomandibular joint: correlation of preoperative staging to arthroscopic findings and treatment outcome. J Oral Maxillofac Surg 2005;63:471-8. Murakami K, Ono T. Temporomandibular joint arthroscopy by inferolateral approach. Int J Oral Maxillofac Surg 1986;15: 410-7. Nitzan DW, Dolwick F, Heft MW. Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective. J Oral Maxillofac Surg 1990;48:798-801. Kurita K, Goss AN, Ogi N, Toyama M. Correlation between
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preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction. J Oral Maxillofac Surg 1998;56:1394-7. Dimitroulis G. A review of 56 cases of chronic dosed lock treated with temporomandibular joint arthroscopy. J Oral Maxillofac Surg 2002;60:519-24. Kondoh T, Dolwick MF, Hamada Y, Seto K. Visually guided irrigation for patients with symptomatic internal derangement of the temporomandibular joint: a preliminary report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:544-51. Holmlund A, Gynther G, Axelsson S. Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint. Int J Oral Maxillofac Surg 1994;23:262-5. McCain JP. Discussion; Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction. J Oral Maxillofac Surg 1998;56:1397-9. White RD. Arthroscopic lysis and lavage as the preferred treatment for internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 2001;59:313-6.
Reprint requests: Wenko Smolka, MD, DMD, FEBOMFS Senior Maxillofacial Surgeon Department of Craniomaxillofacial Surgery University of Berne, Inselspital CH-3010 Berne Switzerland [email protected]