The next step in the treatment of persistent temporomandibular joint pain following arthrocentesis: A retrospective study of 18 cases

Temporomandibular joint disorders affect a big portion of the population. There are a variety of treatment methods currently in use. Conservative treatment modalities are followed by more invasive approaches like arthrocentesis or arthroscopy. The aim of the study is to compare the effects of intra-articular tenoxicam injection and arthrocentesis plus viscosupplementation on patients in which a previous arthrocentesis plus viscosupplementation has failed to relieve pain and restore function. The study group consists of 18 TMJs in 16 patients (15 female and 1 male) and the patients were randomly divided into two groups as the arthrocentesis plus viscosupplementation group (n: 8) and tenoxicam injection (n: 10). 20 mg of tenoxicam was injected to the upper compartments of 10 joints without arthrocentesis. The other 8 joints were treated with a second arthrocentesis and sodium hyaluronate injection. VAS scores and maximum mouth opening with and without assistance were recorded in the post operative first week, first month and third month. The results show that there is little benefit in using relatively conservative methods once an arthrocentesis together with viscosupplementation has failed to relieve the patients pain. It is concluded that more invasive procedures should be considered for the patients who do not benefit from arthrocentesis.     

Effects of arthrocentesis and low-level laser therapy on patients with osteoarthritis of the temporomandibular joint

This retrospective study examined whether arthrocentesis combined with 10 sessions of low-level laser therapy (LLLT) improved the clinical outcomes of patients with temporomandibular joint osteoarthritis (TMJ-OA) compared with arthrocentesis alone. Data from two groups of patients (total: n = 36) with unilateral TMJ-OA were evaluated. The groups were established according to their treatment regimens: Group 1 (arthrocentesis alone; n = 19) and Group 2 (arthrocentesis plus LLLT; n = 17). All patients had been diagnosed in accordance with the Research Diagnostic Criteria for Temporomandibular Joint Disorders (RDC/TMD) (Axis I Group IIIb) protocol. They all underwent the same arthrocentesis protocol, but those in Group 2 also received 10 sessions of LLLT immediately afterwards. The outcome variables were the visual analogue scale scores (VAS 1, VAS 2) for various treatment outcomes and millimetric measurements of mandibular movements over both the short and long term. Intra-group comparisons showed significant short and long-term improvements for both groups, but outcomes were better over the long term than the short term in both. In addition, greater improvements in muscle palpation scores and mandibular movements were achieved in Group 2 than in Group 1. In conclusion, although both techniques improved joint pain and function, a combination with LLLT seemed to have an additional benefit for myofascial components.     

Double puncture versus single puncture arthrocentesis for the management of unilateral temporomandibular joint disc displacement without reduction: A randomized controlled trial

Purpose

To compare the clinical efficacy of the conventional double puncture versus single puncture type 2 arthrocentesis for management of temporomandibular joint disc displacement without reduction (DDWOR).

Evaluation of ultrasonography guidance for single-puncture temporomandibular joint arthrocentesis: A randomized clinical study

Objective To evaluate ultrasonography (US) guidance on the single-puncture temporomandibular joint (TMJ) arthrocentesis technique.

Methods Twenty-four patients were randomly divided into two groups (n = 12 in each group), and single puncture arthrocentesis (SPA) was performed with and without US guidance in groups 1 and 2. During the one-year follow-up period, the groups were statistically evaluated by the visual analog scale for pain, maximum mouth opening, lateral excursion, and protrusion within each group and between the two groups.

Results Both treatment groups showed significant improvement, compared to the baseline levels for almost all outcome variables. However, there were no statistically significant differences between groups 1 and 2 (p > 0.05).

Conclusion US guidance can be used for cannula placement in SPA. However, the outcome results are the same with or without its use.     

Single-needle arthrocentesis (Shepard cannula) vs. double-needle arthrocentesis for treating disc displacement without reduction

Objectives: To compare single- vs. double-needle arthrocentesis with viscosupplementation for treating disc displacement without reduction of the temporomandibular joint.

Methods: Fifty-six patients with a magnetic resonance imaging diagnosis of non-reducing disc displacement were included. Arthrocentesis with viscosupplementation was performed on patients in group I using the Y-shaped needle (Shepard cannula) technique; the standard double-needle technique was performed on patients in group II. Patients were evaluated on postoperative day 1, and 1, 3, and 6 months later, patient- and procedure-related parameters were assessed.

Results: In both groups, significant improvement in the baseline levels was achieved (p < 0.01). Both techniques were equally effective at reducing pain and increasing the maximal mouth opening. The single-needle technique was easier to perform and required a shorter operative time (p < 0.01).

Discussion: Single-needle (Shepard cannula) arthrocentesis can be an alternative to the standard technique; however, it might add to the cost of the procedure.     

Evaluation of the effectiveness of different puncture points for second cannula in double puncture arthrocentesis of temporomandibular joint

The study at checking if treatment outcomes in double puncture temporomandibular joint (TMJ) arthrocentesis (DPTMJA) changed when the puncture points of the second cannula punctate were changed.Using a retrospective cohort study design, the investigators enrolled a sample of temporomandibular joint disorder (TMD, internal derangement) patients receiving DPTMJA. The decision of whether to perform a modified or traditional arthrocentesis was made by the patients: Patients who accepted the close cannula relationship were evaluated as group 1 (modification group), and those who did not agree as group 2 (traditional group). The predictor variable was puncture points of the second cannula (close to vs. far from the first cannula; group 1 and 2, respectively). The main outcome variables included maximum mouth opening (MMO), and pain assessed using a Likert-type (0–10) visual analogue scale (VAS) before treatment and at 1st day and 3rd months intervals. Appropriate statistics were computed using P < .05 was considered significant.The study sample comprised 32 patients (93.8% females; 50% in each study arm) with an average age of 36.9 ± 15.3 years (range, 18–78). Although, patient age and gender, and baseline VAS in both groups were not significant different (P > .05), the baseline MMO in group 2 was significant higher than that in group 1 (P = .03). The within-group analyses demonstrated the significant improvement of both MMO and VAS at postoperative month 3 (P < .05). However, the between-group analyses rejected the significant differences between the 2 groups at day 1 and month 3 (P > .05).Within the limitations of the study the choice of one or the other technique should be left to the discretion of the surgeon.     

A systematic review and meta-analysis of randomized controlled trials comparing arthrocentesis with conservative management for painful temporomandibular joint disorder

The aim of this study was to determine whether arthrocentesis is superior to conservative treatment in the management of painful temporomandibular joint disorders with restricted opening. A systematic review was undertaken of prospective randomized controlled trials (RCT) comparing arthrocentesis to conservative management, identified in the MEDLINE and PubMed databases. Inclusion criteria included a 6-month follow-up, with clinical assessment of the patients and painful restricted mouth opening. Data extracted included pain measured on a visual analogue scale and maximum mouth opening measured in millimetres. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2 for RCTs, and a meta-analysis with the random-effects model was undertaken. Of 879 records retrieved, seven met the inclusion criteria; these RCTs reported the results at 6 months for 448 patients. One study had a low risk of bias, four studies had an uncertain risk, and two had a high risk of bias. In the meta-analysis, arthrocentesis was statistically superior to conservative management at 6 months for an increase in maximum mouth opening (1.12 mm, 95% confidence interval 0.45–1.78 mm; P = 0.001; I² = 87%) and borderline superior for pain reduction (−1.09 cm, 95% confidence interval −2.19 to 0.01 cm; P = 0.05; I² = 100%). However, these differences are unlikely to be clinically relevant.     

2种方法治疗颞下颌关节WilkesⅢ~Ⅴ期结构紊乱的疗效比较

目的：评价并比较颞下颌关节上腔灌洗术及颞下颌关节锚固术治疗WilkesⅢ~Ⅴ期结构紊乱的总体疗效。方法选择2011年1月—2014年1月接受颞下颌关节锚固术及关节灌洗术的患者286例,根据治疗方法不同分为A、B 2组,A组164例接受颞下颌关节上腔灌洗术,B组122例接受关节盘复位锚固术,分别于术前、术后6个月对患者的颞下颌关节MRI表现、关节杂音、开口度、关节疼痛视觉模拟评分（VAS）值及头痛进行评价,通过手术前、后对比,评价2种治疗方法的临床效果,并进行长期随访（6~42个月）。采用SPSS13.0软件包对数据进行χ²检验及t检验。结果B组杂音和头痛的治愈率显著大于A组（χ₁²=14.33,χ₂²=57.24,P<0.05）。VAS及开口度的改善效果B组也显著优于A组（t₁=30.30, t₂=21.37, P<0.05）。2组患者治疗前与治疗后随访期内MRI检查结果进行比较,A组患者无关节盘解剖复位病例,9例（5.5%）出现关节盘双板区类盘样改变,B组患者全部达到关节盘解剖复位。结论颞下颌关节灌洗术后伴随临床症状的消失,关节内可以出现双板区类盘样改变,但发生率仅为5.5%。综合临床疗效及影像学表现评价,对WilkesⅢ~Ⅴ期关节结构紊乱的治疗,关节盘锚固术优于关节灌洗术。     

A clinical and tomographic study on temporomandibular joint osteoarthritis

One hundred and twenty two patients with temporomandibular joint (TMJ) disorders were examined by lateral and frontal tomograms. A comparison between clinical and radiographic findings was performed to confirm the clinical characteristics of TMJ osteoarthritis. The patients with radiographic abnormal or suspicious findings showed a significantly higher frequency of TMJ pain and limitation of mouth opening less than 29mm than the patients with normal findings. The TMJs with surface erosion also showed a significantly higher frequency of TMJ pain than the TMJs with normal findings. Therefore, these findings were thought to be one of the distinctive feature of TMJ osteoarthritis. However, 22 patients with unilateral clinically primary symptoms presented bilateral abnormal or suspicious findings and 7 patients with unilateral clinically primary symptoms presented abnormal or suspicious findings only in the TMJ opposite to the clinically primary symptomatic site. Therefore, the necessity of radiographic examination of the clinically unaffected TMJ was concurrently indicated for the treatment planning and for the further research. Dr. Yamada was the Professor of the Department of Oral Radiology April 1982–March 1991     

颞下颌关节紊乱指数临床应用评价

目的 探讨如何采用客观定量的方法评价颞下颌关节功能障碍程度和颞下颌关节紊乱病（temporomandibular disorders,TMD）的治疗效果。方法 分别采用Fricton颞下颌关节紊乱指数和Helkimo临床检查功能障碍指数，定量计算每例患者（共60例）的颞下颌关节紊乱指数，评价不同检查者获得的各项指数的一致性，并应用Fricton颞下颌关节紊乱指数定量评价TMD急性不可复性盘前移位的临床治疗效果。结果 （1）不同检查者获得的各项Fricton紊乱指数值相近；（2）Fricton紊乱指数可明确反映TMD急性不可复性盘前移位治疗后临床功能的改善。结论 评价TMD功能障碍程度或评价TMD治疗效果宜避免使用非客观的、描述性的报告，Fricton紊乱指数是一方便且有效的客观定量指标。     

颞颌关系X线影像特征及其解剖学测量结果相关性分析

目的：探讨颞颌关关节X线影像特征与解剖结构的相关关系。方法：对18具具有稳定咬合关系的36侧颞颌关节颅骨标本分别拍摄TMJ的内,中外1／3的正矢状位片和正后前位片,采用电子测量尺分别测量其显示的髁突内外径,前后径及关节前,上,后间隙值,用游标卡尺测量颅骨标本的髁突内外径和内,中外,1／3的前后径;用印模料取得牙尖交错位时关节间隙厚度,测量内,中,外1／3的层面的前,中,后1／3处印模厚度（关节间隙值）,将X线测量值与解剖测量值进行相关性分析。结果：颞颌关节髁突内外径,中,外1／3的前后径及中,外1／3上间隙值均有显著相关（P＜0．01）,而其它值则无明显相关（P＞0．05）。结论 ：颞颌关节后前位和中1／3正矢状位X线片有实际诊断意义。     

A new approach to arthrocentesis of the temporomandibular joint

We describe a new temporomandibular joint (TMJ) arthrocentesis technique using the irrigation pump from a surgical and dental implant motor, providing the highest hydraulic pressure reported in the literature for TMJ lavage.     

颞下颌关节盘绞锁的自然病程探讨

目的 定期追踪随访颞下颌关节盘绞锁患者,初步了解关节盘绞锁的自然病程和转归.方法 初诊为关节盘绞锁的68例患者中,54例进行24个月的电话追踪随访.根据绞锁的病程发展分为:症状进展组(即发生不可复性盘前移位)、症状消失组、症状持续组,并用统计学方法分析组间年龄、性别、病程、有无疼痛和绞锁发生频率间有无差异.结果 54例随访患者中,症状进展组16例(30%),症状持续组32例(59%),症状消失组6例(11%);3组患者的性别、年龄、初诊时有无疼痛和绞锁发生的频率比较,差异均无统计学意义(P>0.05).结论 关节盘绞锁患者发生不可复性盘前移位的风险增大;关节盘绞锁发展为不可复性盘前移位与患者的性别、年龄、病程、有无疼痛和绞锁频率似无关,有待扩大样本量后进一步研究.

Abstract：

Objective To investigate the clinical natural course of temporomandibular joint(TMJ) intermittent closed lock(ICL) through 24 months follow-up. Methods Sixty-eight patients with ICL were included, and 54 patients finished 24 months follow-up. The disease duration, frequency of joint lock and joint pain were recorded at the patient′s first visit. Telephone interviews were taken for every month, and the frequency of joint lock and joint pain were recorded. According to the development of ICL, the patients were divided into 3 groups: symptom-worsened group, symptom-disappeared group, symptom-persisted group. Results There were 16 patients(30%) whose symptoms worsened into closed lock (disk displacement without reduction), 32 patients(59%) whose symptoms persisted during the 24 months follow-up, and 6 patients′(11%) symptoms disappeared. In symptom-persisted group,the frequency of joint lock decreased in 11/32(34%), increased in 4/32(13%), did not change in 17/32(53%).There was no significant difference in gender, age, frequency of joint lock and joint pain recorded at the first visit among these 3 groups(P>0.05).The disease duration in the symptom-disappeared group was much shorter than the other 2 groups (P<0.05). Conclusions ICL of TMJ was more likely to get worse into closed lock. There seemed no significant relation between the sequelaes of ICL and patients′ gender, age, disease duration, frequency of joint lock and joint pain, and larger sample studies were necessary.     

Injectable platelet-rich fibrin as treatment for temporomandibular joint osteoarthritis: A randomized controlled clinical trial

The purpose of this study was to assess the treatment outcomes of intraarticular injection of injectable platelet-rich fibrin (i-PRF) after arthrocentesis in patients with temporomandibular joint osteoarthritis (TMJ-OA). Patients were randomly assigned to one of two treatment groups: those who received intraarticular injection of i-PRF after arthrocentesis procedure – the i-PRF group; and those who underwent the arthrocentesis procedure alone – the control group. The primary outcome variable was pain, the level of which was measured preoperatively and at 1, 2, 3, 6, and 12 months postoperatively. The secondary outcome variables included maximum mouth opening (MMO), and lateral and protrusive movements. Of the total of 36 patients, 18 were analyzed in the i-PRF group and 18 in the control group. There were significant differences between the groups in terms of pain levels and measurements of MMO, lateral movement, and protrusive movement over the 12 months of follow-up (p < 0.001). Significant increases in pain levels and decreases in measurements of MMO, lateral movement, and protrusive movement were observed in the control group from the 6th to 12th month postoperatively (p < 0.001). In contrast, no significant differences were found in both pain levels and measurements of MMO, lateral, and protrusive movements for the i-PRF group from the 2nd to the 12th month postoperatively. Within the limitations of the study it seems that intraarticular injection of i-PRF after arthrocentesis should be preferred whenever appropriate because when reducing pain intensity and improving functional jaw movement is the priority.