Keywords

Arthrocentesis; Internal Derangement; TMJ; Temporomandibular Joint Disorders; Maximal Mouth Opening.

Introduction

Temporomandibular joint (TMJ) is a joint between the glenoid fossa of the temporal bone and the condylar process of the mandible [12] and forms the very cornerstone of craniofacial integrity [35] Temporomandibular Disorders is a general term that indicates many clinical conditions involving temporomandibular joints [45] which encompasses a wide spectrum of conditions [26] accounts for the most of the orofacial pain rising from the musculoskeletal origin [40]. Arthrocentesis is an effective treatment for internal derangement of the TMJ [25]. Internal derangement is an orthopaedic term implying a mechanical drawback that interferes with the smooth action of a joint. It is therefore a functional diagnosis and for TMJ, the commonest internal derangement is displacement of the disc [13]. Most of the times, the disc displaces in an anterior, anterolateral and anteromedial direction. This multifactorial disease with multiple symptoms has a wide range of treatment modalities such as acupuncture medication, occlusal splinting and arthrocentesis to try to alleviate the pain and function complaints of patients suffering from TMJ dysfunctions [42]. The posterior band of the disc prolapses anteriorly relative to the superior surface of the condyle, instead of remaining back in its position between the condyle and glenoid fossa. As a consequence, the condyle gets positioned under the posterior disc attachment rather than under the disc, and the condyle closes on the posterior attachment instead of the disc itself.

Arthrocentesis was developed as a modification of TMJ Arthroscopy [37]. It was later found that the mechanical lysis and lavage of the joint was often successful in treating various internal derangements [19]. This procedure is extremely effective in eliminating joint adhesions , removal of inflammatory cytokines, correcting joint function at an early stage and reduction of pain [27]. However, the persistence of the effects on a long term basis is controversial [18]. But its usage as a palliative modality for acute episodes of degenerative changes are effective.

Previously our team had conducted numerous studies which include in vitro studies [20], reviews [33], survey [15, 16, 36, 38] and clinical trials [1, 2, 6, 14, 34, 39, 46]. Now we are focussing on retrospective studies, and the purpose of this study is to evaluate the efficacy of arthrocentesis as a method of treatment for internal derangement of the temporomandibular joint.

Methods and Materials

Study setup

This retrospective study was conducted among patients who reported to the Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Chennai, India with restricted mouth opening and unilateral localised TMJ pain. A total of 86000 patient records were reviewed and analysed from June 2019 to March 2020. There were 22 patients clinically and radiographically (Panoramic and MRI) diagnosed with internal derangement out of which 8 were males and 14 were females.

Inclusion and exclusion criteria

The inclusion criteria of the study was:

● Clinical diagnosis of Anterior disc Displacement without reduction of TMJ
● Radiological diagnosis by MRI
● TMJ pain (Arthralgia)
● Restricted mouth opening with a prior history of click
● Only patients with complete records from the preoperative treatment and followup periods through the beginning of the study were included

The exclusion criteria comprise of:

● Presence of any other disorders involving the TMJ ( e.g. degenerative joint disease or collagen vascular disease)
● History of trauma
● Craniofacial/Dentofacial deformity
● Psychiatric illness
● Chronic headache
● Individuals who are not permanent residents of chennai Study parameters

The following data were extracted for the purpose of the study

● Age of the patient
● Gender of the patient
● Preoperative Maximal mouth opening (MMO)
● Post operative MMO

Data collection

The data related to the stay parameters were obtained from among the patients who reported to the Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Chennai from June 2019 to March 2020. Approval for the study was obtained from the Institutional Ethical Committee of Saveetha University (Ethical approval number SDC/SIHEC/2020/DIASDATA/0619-0320). A written and verbal consent was obtained from patients for treatment and associated complications after the treatment outcome was fully explained to them.

Procedure

The procedure was carried out in complete aseptic conditions. The ear and preauricular skin over the joint was draped and painted using a topical antiseptic solution. A line was extending from the lateral canthus to the posterior or central point of tragus ( Hollmund- Hellsing line). Posterior point of entry- located along canthotragal line 10mm from middle of tragus and 2mm below the canthotragal line. The anterior point of entry was placed 10 mm further and 7mm below the canthotragal line. This marking is the site of eminence of TMJ. The Auriculotemporal nerve was blocked with 2ml of Lignocaine and an 18 gauge needle is introduced into the superior joint space (posterior mark). 2ml of Ringer’s lactate solution is injected into the distended compartment to establish a free flow of the solution through the superior joint space. A syringe filled with Hartmann’s solution was then connected to one of the needles and the fluid=d was injected into the superior joint space. Second needle provides an outflow for the solution collected in a kidney tray. A total volume of 100 ml of solution was used to irrigate for the lavage of the superior joint space.

After lavage completion, needles are to be removed and the patients mandible gently manipulated in the vertical, lateral and protrusive excursions, to help further free the disc. The above procedure followed the technique described by Nitzan et al. (Nitzan, 2006). After treatment, patients were prescribed an analgesic and soft diet for the next week. Patient was asked to report after 1 week for recording the post-operative maximal mouth opening (MMO).

Statistical analysis

The IBM SPSS (version 23.0) software was used to tabulate and analyse the collected data. Non parametric data was analysed using descriptive statistics measuring frequency and percentage. Pearson’s chi square test was used to assess the association between the improvement in MMO after arthrocentesis and age as well as gender.

Results and Discussion

Of the 22 cases, 14 (63.6%) were females and 8 (36.4%) were males (Figure 1). The mean age of patients was 30.36 years with maximum number of patients belonging to the 21-30 (50%) year old age group (Figure 2). All the patients tolerated the procedure well and no complications were observed. This study showed an improvement in the maximal mouth opening in 13 (59.09%) of cases and no improvement in 9 (40.91%) of cases (Figure 3). The preoperative mouth opening ranged from 13 to 39mm with a mean of 30.95mm. The postoperative mouth opening ranged from 21 to 49mm with a mean of 32.79 mm (Table 1). The maximum number of cases showing improvement belonged to 21 to 30 (46%) years of age followed by 31 to 40 (30.7%) of age. The age group of 11 to 20 (7.69%) years of age showed the least number of cases presenting any improvement (Figure 4) . Also there was a slight female predilection showing more number of successful cases among the female population (69%) in comparison to the male population (30.76%) (Figure 5). However the p value for both the tests of association was >0.05, thus it was statistically insignificant.

Temporomandibular joint (TMJ) is one of the most important and versatile joints in the human body [8]. Temporomandibular disorders affect up to 25% of the population [7], its most important feature being pain, followed by restricted mandibular movement and noises from the TMJ. [44] and malocclusion might be one of the causes for it [5]. A paper published in the year 1991 by Nitzan and Dolwick, 1991 stated the technique of arthrocentesis and lavage has broadened the range for this procedure as a simple, non-invasive and an effective technique of persistent acute closed lock of the TMJ. It was first borne out of the use of TMJ arthroscopy not as a diagnostic tool but also as a therapeutic treatment modality showing remarkable improvement in pain, jaw opening and function in a selected number of patients.

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Figure 1:

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Figure 1. The bar graph depicts the Baseline characteristics of Gender. X axis represent gender , Y axis represents frequency of patients. Female (63.64%) patients included were more in this study in comparison to males (36.36%). From the above graph, we can infer that there were greater number of females included in the study.

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Figure 2:

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Figure 2. The pie chart represents Baseline characteristics of Age. 50% of patients were in the age group of 21-30 years. From this pie chart we can infer that maximum number of patients belonged to 21-30 years age group.

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Figure 3:

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Figure 3. The pie chart represents the Frequency of patients showing improvement after Arthrocentesis procedure. 13 cases (59.10%) showed improvement in mouth opening after arthrocentesis and 9 cases (40.9% ) showed no improvement.

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Figure 4:

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Figure 4. The below bar graph depicts the association between age and maximum mouth opening. X axis represents age, Y axis represents maximal mouth opening.Maximum number of successful cases was seen in patients age group in 21-30 years, followed by 31-40 years.Chi-sqaure test was done. p>0.05, statistically significant.Inference: maximum number of successful cases were seen in 21-30 years age group.

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Figure 5:

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Figure 5. the below bar graph depicts the association between gender and maximum mouth opening.X axis depicts gender,Y axis depicts maximum mouth opening. Success rate was seen more in females (69.03%) in comparison to males. Chi- square test was done. p>0.05,statistically significant.Inference: success rate was more in females.

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Table 1:

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Table 1. ShowingPreoperative and postoperative maximal mouth opening (MMO) values.

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When performed with pressure, the elimination of adhesions is the key element in the success of this method [47] Joint mobility increases as a result of the elimination of adhesions [17, 41, 48]. The elimination of inflammatory cytokines by arthrocentesis plays a role in pan reduction [17]. Alpaslan et al., [3] had evaluated MMO after arthrocentesis in patients with internal derangement of the TMJ. After an average follow up period of 22 months, they observed significantly reduced pain and dysfunction with significant increase in MMO. Monje Gil et al [22] reports that arthrocentesis was successful in 80% of studies examined. Some authors have reports that arthrocentesis is successful even in patients with advanced degenerative disease [30].

Sixty three percent of participants in our study were females. Joint disorders are observed more frequently in women than men and the data obtained in our study are favourable to those reported by Giraddi et al [10], Nitzan et al [28]. According to previous studies [22, 41], success of arthrocentesis has been determined according to increased MMO which is in agreement to our present study.

In addition to the effective treatment of acute closed lock, it has also been suggested that TMJ arthrocentesis and lavage may further be useful for management of osteoarthritis, early rheumatoid arthritis and acute intracapsular trauma with hemarthrosis of the TMJ [32]. In a study by Murakami et al [25], the mean patient age of successful cases was 27 years so age could be considered as an outcome of arthrocentesis. This compared favourably to our study, but the age difference was not significant enough to draw a conclusion. In this study, the success rate of the procedure as an initial treatment was 59.09%. Murakami et al [25] stated a success rate of 70%, Fridrich et al [9] showed 75% whereas Hosaka et al [13] showed 79%. This difference could be accounted to the patient population and smaller sample size. Yilmaz et al [47] showed the success rate of the treatment to be 52.5% using AAOMS criteria. The above success rates compare favorably to our study results evaluating the improvement in MMO.

Complications of TMJ arthrocentesis and lavage include extravasation of fluid into surrounding tissue, Facial nerve injury (0.7- 0.6%)[11, 21, 43], Fifth nerve deficit (0.1-2.4%) [21], otic injury (0.5-8.6%) [21, 43], preauricular hematoma, superficial temporal artery aneurysm, arteriovenous fistula, transarticular perforation, intracranial perforations v, extradural hematoma, parapharyngeal swelling and intra articular problems [4].

The limitation of this study includes the evaluation of the treatment as successful or unsuccessful according to patient reactions and the difference in MMO, but requires a more detailed description of the patient’s expectations. Parafunctional habits and history of trauma were not taken into consideration. Further studies regarding the efficacy of arthrocentesis could be done on a larger sample size. Also, Wilke's stages of internal derangement were not evaluated.

TMJ arthrocentesis and lavage in a simple non-invasive and less expensive technique with low morbidity. It can help in restoration of function and reduction of pain in a selected group of patients.

Conclusion

The most important aim of lysis and lavage of the joint are to eliminate inflamed synovial fluid to release the disc, reduce the pain and enable movement of the joint. Within limits, the study shows significant success rate of temporomandibular joint arthrocentesis in the age group 21-30 years with female predilection by evaluation of mouth opening in patients with internal derangement.

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