Evidence Based Approach Menia University

8/13/2019 Evidence Based Approach Menia University

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Evidence based approach toevaluate arthrocentesis versusarthroscopy in the treatment of

TMDBY: ALSHAIMAA AHMED SHABAAN

B.D.S. 2002, M.SC. 2008, ALEXANDRIA UNIVERSITY

PH.D. 2012, CAIRO UNIVERSITY


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Content

Temprmandibular joint disorders (definition & Etiology)

Treatment Modalities for Tempromandibular joint disorders

Arthroscopy

ArthocentesisEvidence based approach for arthocentesis vs arthroscopy

Conclusion


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Temprmandibular joint disorders

Temporomandibular disorders (TMDs) represent a widerange of functional changes and pathologicalconditions affecting the temporomandibular joint (TMJ),masticatory muscles, and other components of theoromaxillofacial region.

(De Riu et al, 2013)


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In recent years, TMD has become a frequent cause for seekingmedical assistance. The number of patients with TMDs iincreasing, probably due to psychological tension in modernsociety. (Tvrdy et al, 2013)

It has been estimated that approximately 20% to 30% of the adultpopulation will experience temporomandibular joint dysfunction.(Swift 1998)


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Characteristic symptoms of TMJ disorders include pain, changesin mandibular mobility (reduced mouth opening (hypomobility)or, in contrast, hypermobility and luxation), clicking, and grinding.(De Riu et al, 2013)


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Treatment Modalities

TMJ disorders may be treated conservatively or surgically.

Conservative treatments include the use of bite wafers,rehabilitation exercises, isometric exercises, masticatory musclemassage, analgesic treatment, thermotherapy, and lasertherapy.Surgical treatments can be invasive (open approaches) orminimally invasive, including arthrocentesis and arthroscopy

(Lis


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Arthroscopy

The long-term outcome studies including both lysis and lavage, and operativearthroscopy indicated that an arthroscopic surgery was a highly predictableand reliable procedure. The long-term outcomes by sole arthroscopic lysis andlavage were also reported as excellent. (Gonzalez- Garc a 2011)

Although, operative arthroscopy is a reliable endoscopic surgery for theadvanced intra-articular pathology, it has a limitation. Munoz -(2013) published the long-term results after operative arthroscopy for TMJ discperforation, and the results indicated that the procedure was favorable incases with small perforations, but not for medium/large disc perforations


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Arthroscopy

Despite the good outcome of arthroscopy, studies seemed to support the opinionthat arthroscopy of the TMJ is under-used, and consideration should be given toensure that the trainees are instructed in its use, which is important in the diagnosisand treatment of disorders of the TMJ.

In the UK survey (Thomas et al, 2011) , 41 of 215 (60% of all consultantsresponded that they currently used arthroscopy, and 33 of those (81%) have morethan 5 years experience. During the past year, a total of 8 consultants nationalhave done 20 arthroscopies or more. Number of 33 procedures (81%) was done forboth diagnosis and treatment. Lack of perceived need of patients and lack ofinterest in this specialty were the main reasons given for not doing arthroscopy, lack oftraining being a key secondary reason.


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Arthocentesis

Temporomandibular joint (TMJ) arthrocentesis refers to lavage of theupper joint space, hydraulic pressure and manipulation to releaseadhesions or the anchored disc phenomenon and improve mwas first used to treat acute closed lock by Nitzan et al (Nitza

Arthrocentesis emerging as an alternative, less invasive, treatment forinternal derangement with closed lock (De Riu et al, 2013)

It is a minimally invasive method of treatment, located at the boundarybetween conservative and surgical therapy. It is usually performed onan outpatient basis under local anaesthesia. (De Riu et al, 2013)


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Arthocentesis

Through arthrocentesis the microscopic tissue debris resultingfrom the breakdown of the articular surfaces and the painmediators such as the enzymes and prostaglandins can bewashed out out, and normal lubricating properties of synovialmembrane can also be stimulated .(Guo 2009)

At present there have been many clinical studies reporting theresults of series of temporomandibular joint disorders patientstreated with arthrocentesis and they are uniformly effective(Frost 1992; Hosaka 1996; Ness 1996; Nitzan 1994; Nitzan 1997).


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Evidence based approach forarthocentesis vs arthroscopy


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Search for the evidence Literature

Data Analysis

Possible outcomes


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Murakami K, Hosaka H, Moriya Y, Segami N, Iizuka T. Short-term treaoutcome study for the management of temporomandibular joint closed lock.A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysand lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Sep;80(3):253-7

The success rate was 55.6% in the nonsurgically treated group, 70% in thearthrocentesis group, and 91% in the arthroscopy group. They concluded thatArthrocentesis was considered as an intervening treatment modality betweennonsurgical treatment and arthroscopic surgery on the basis of its short-termoutcome

Claims of bias by Frost &Kendell 1999 (biased hypothesis)


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Fridrich KL, Wise JM, Zeitler DL. Prospective comparison of arthroscopy aarthrocentesis for temporomandibular joint disorders. J Oral Maxillofac Surg.1996 Jul;54(7):816-20.

There was no statistically significant difference in outcome between thetwo groups for any parameter evaluated. Categorization of a particularsubject into a successful outcome was based on statistically significantimprovement in maximum incisal opening and pain scores; the overallsuccess rate was 82% for arthroscopy and 75% for arthrocentesis.


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Goudot P, Jaquinet AR, Hugonnet S, Haefliger W, RichteImprovement of pain and function after arthroscopy aarthrocentesis of the temporomandibular joint: a comparativstudy. J Craniomaxillofac Surg. 2000 Feb;28(1):39-43.

Results show that both arthroscopy and lavage are useful in improving functionand diminishing pain. Arthroscopy shows better results for functional treatmentwhereas arthrocentesis and arthroscopy show similar results in pain control.


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Ahmed N, Sidebottom A, O'Connor M, Kerr HL. Prospective outcomassessment of the therapeutic benefits of arthroscopy and arthrocentesis ofthe temporomandibular joint. Br J Oral Maxillofac Surg. 2012 Dec;50(8):7458.

The study shows improvements in mouth opening, and confirms that painscores can be improved after arthroscopy or arthrocentesis whenconservative approaches have failed. In the hands of a skilled practitioner,arthroscopy can be a useful diagnostic and therapeutic adjunct, which canbe used repeatedly with low morbidity.


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Conclusion

The Current comparative studies of arthroscopy vsarthrocentesis disclosed that both surgical interventions wereeffective for pain reduction and jaw functional recovery. While,they stated that the arthroscopic surgery was more useful as a

diagnostic and therapeutic adjunct and/or showed betterresults in terms of jaw range of motion.

Despite of that, the Superiority of one technique over the othercannot sustained particularly with the non-randomized nature ofthese studies.


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Conclusion

In the most reviewed publications improvement in MMO,decrease in pain level and joint dysfunction on VAS were thecriteria used for defining a successful outcome. But these criteriawere defined with great variation and the border of precision of

the measurement procedure used not reported in any study .The majority of these publications can be criticized for theirflowable methodology : no randomization of patients lack ofcontrol subjects, authors biased and inadequate follow up.


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Evidence Based Approach Menia University