TEMPOROMANDIBULAR JOINT ARTHROCENTESIS :

A simplified treatment for joint pain and limited mouth opening.

INDIAN DENTAL
ACADEMY
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.
Arthrocentesis by definition refers to the lavage of the joint
space to release adhesions or anchored disc phenomenon & improve joint
mobility. ( David Frost 1999)

INTRODUCTION

Internal derangement of the TMJ has been
managed by various methods over the years. The common methods
are pharmacologic therapy, occlusal splints, Arthroscopic surgery ,
Arthrocentesis and Maxillofacial surgery
Arthrocentesis was first used by Orthopedic surgeons for
Traumatic Synovitis, Haemarthrosis, Pseudogout, Lupus Erythematosis
& Septic Arthritis.

Temporomandibular Joint Arthrocentesis was first reported
by Nitzan et al. The objective of management of any disease process
is the full restoration of function with improvement of quality & quantity
life.
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Interestingly it has been proved that no surgical procedure has
been able to effectively reposition the Artricular Disc of the TMJ with
longterm satisfaction.

The least invasive & the most predictable treatment that can be
readily available to patients is the objective.
.

It is a simple and minimally invasive procedure with a reasonable
success rate and minimal complications.

Arthrocentesis meets these requirements
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INDICATIONS
Acute or chronic limitation of jaw motion due to anteriorly displaced
disc.

Hypomobility due to restriction of condylar translation.

Patients with chronic TMJ pain who show an adequate range of
motion despite an anteriorly displaced disc .

To manage pain & dysfunction in patients who have undergone
previous surgery that failed to relieve pain and limitation function.

In patients showing radiographic changes of degenerative Arthritis.

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Infection.

External auditory canal perforation.

Bite changes.Fluid extravasation into the soft tissues.

Haematoma.
However these potential complications have never
been reported to date !
POTENTIAL COMPLICATIONS:
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AIMS AND OBJECTIVES

Limited mouth opening due to Internal Derangement.

TMJ pain.

To study the effectiveness of Artrocentesis in:
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MATERIALS AND METHODS



This study involved 26 joints of 26 patients ( 8 males and
18 females) with persistent limited mouth opening stemming from the
TMJ and unassociated with macrotrauma.

The symptoms had been present from 1 month to 2yrs.Patient age
ranges from 18yrs to 67yrs.

The chief complaint was limited mouth opening associated with pain
located in the affected TMJ especially when opening was forced.

Most patients did not remember any cause initiating symptoms.

All patients were treated at the department of Oral & Maxillofacial
surgery, Saveetha Dental College, Chennai.

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VAS 1 FOR MEASURING PAIN

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
VAS 2 FOR MEASURING DISABILITY
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Clinical examination
Evaluation of Maximal mouth opening (MMO) as measured
between the edges of the incisors.

Determination of range of lateral
and protrusive movements of the mandible as measured by the
distance between the upper and lower midlines on lateral and
forward movements.

Evaluation of the characteristics of limitation
of jaw motion.

Presence of joint noises judged clinically as
none, early , or late clicks and crepitus.


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INCLUSION CRIETERIA
Persistent , sudden , disabling , but not necessarily painful,
limited
MMO of less than 30mm , clearly originating from the TMJ.

Limitation was associated with impeded lateral movements
towards the unaffected side, as well as deviation towards the
affected side in opening and protrusive movements.

When opening was forced, pressure or
pain was exacerbated in the affected joint.


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STATISTICAL ANALYSIS:
Both paired and unpaired t-tests were
used to compare pre-treatment and post-treatment differences in MMO, level
of pain and dysfunction. The presence of an improvement effect was tested
using Z- tailed t-test.

FOLLOW-UP:
At least 4 months post-operatively the patients
were evaluated by self-assessment questionnaire and by clinical
examination. Two VASs( VAS 1 & 2 ) were used for self evaluation of
improvement / deterioration compared with the status before the
procedure was performed.
Clinical examination included measurement of
MMO, deviation on opening , lateral and protrusion movements and
determining the presence of clicks.
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Table 1. General Information on Patients Undergoing TMJ Arthrocentesis

Patient No.
Age (yrs) Sex Joint Duration of Limitation (months)
1 28 F L 2
2 47 F L 12
3 18 F L 8
4 33 F R 9
5 42 M L 3
6 21 M L 2
7 33 F R 3
8 47 M R 1
9 67 M R 4
10 64 M R 7
11 35 F L 6
12 26 F R 5
13 28 F L 4
14 39 M L 3
15 42 F L 3
16 33 F R 4
17 25 M L 5
18 24 F R 6
19 40 F L 10
20 33 F R 12
21 44 F R 14
22 61 M L 20
23 64 F L 9
24 37 F R 12
25 36 F R 18
26 41 F L 7
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Table -2: Improvement in MMO, Lateral movements, and Decrease in Clicking Following TMJ Arthrocentesis.

MMO (mm) Lateral Motion
Towards Unaffected Clicking
Joint (mm)
PT No. Follow up
(months)
Before Immediately
After
At follow-up Before After Before
Limitation
at
follow-up
1 4 28 40 43 4 10 + -
2 4 27 38 40 5 10 + -
3 6 18 30 33 3 9 + -
4 5 15 26 30 2 8 + -
5 4 20 27 29 5 10 + -
6 4 29 35 36 5 9 - -
7 6 25 30 26 6 6 - -
8 8 26 38 40 4 11 + -
9 8 24 39 40 4 13 + -
10 9 16 27 30 6 8 - -
11 7 18 25 22 3 4 - -
12 7 26 38 37 6 7 - -
13 4 28 38 39 5 9 - -
14 6 30 40 40 7 11 + -
15 10 24 37 39 5 11 + -
16 5 26 36 37 4 10 - -
17 8 16 36 37 3 9 - -
18 6 18 28 35 5 10 + -
19 7 27 32 28 5 4 + -
20 9 28 40 40 6 10 - -
21 10 29 37 38 8 9 - -
22 6 28 35 36 6 10 + -
23 4 15 20 18 7 8 - -
24 5 16 37 35 4 10 - -
25 4 30 38 36 5 9 + -
26 7 17 40 38 3 7 + -
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Table 3: Patient Self-Assessment Following Arthrocentesis

Degree of Pain Degree of
(0 15) Dysfunction (0 - 15)
PT. No Before At follow-up Before At Follow-up
1 8 3 9 3
2 10 3 10 4
3 11 4 10 4
4 9 5 12 6
5 12 4 12 6
6 10 2 8 5
7 8 8 9 9
8 8 0 10 0
9 9 9 12 10
10 7 0 14 0
11 8 7 15 13
12 7 0 14 0
13 7 1 13 6
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14 9 2 7 8
15 7 3 6 2
16 6 2 8 6
17 13 2 9 8
18 14 4 11 8
19 12 12 12 11
20 11 2 15 12
21 7 1 12 12
22 9 0 9 0
23 12 11 7 8
24 14 3 6 3
25 13 4 5 2
26 8 2 5 0
Table 3: Patient Self-Assessment Following Arthrocentesis Cont

Degree of Pain Degree of
(0 15) Dysfunction (0 - 15)
PT. No Before At follow-up Before At Follow-up
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Table 4: Mean Increase in MMO and Decrease in Pain Level and Joint
Dysfunction Following TMJ Arthrocentesis Performed Independently at
Two Centers.

MMO (mm) Degree of Pain Degree of
(0-15) Dysfunction (0-15)
No. of
Patients
Follow-up
(months)
Before After Before After Before After
26 4-10 23.8+5.3 34.6 + 3.4 9.2 + 2.7 3.6 + 4.4 10 + 1.9 5.6 + 2.3
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RESULTS
Objective findings following treatment: As seen in Table 2, 4 to 14
months following arthrocentesis the patients had a significant increase in mouth
opening (P < .001), from a range of 15 to 30 mm (mean, 23.8 + 5.3mm) prior
to the procedure to 18 to 43 mm (mean, 34.6 + 3.4 mm) following
arthrocentesis.



Lateral movement toward the unaffected joint significantly improved as well (P
< .0057), from a range of 2 to 7 mm (mean, 4.3 + 2.7) to 4 to 13 mm (mean,
8.9 + 1.2 mm). 14 of the 26 patients had experienced clicking in the affected
joint before limitation had occurred. However, following arthrocentesis , none of
the patients had a click.

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Subjective findings following treatment: Although the patients
main complaint was the limited mouth opening, a considerable
degree of pain was experienced and was reflected as a mean
rating of 9.2 + 2.7 mm (range, 6 to 14 mm) on a scale of 0 to 15
(VAS I) (Table 3). This range decreased significantly (P < .001)
following arthrocentesis and reached a mean value of 3.6 + 4.4
mm (Table 3).
The functional disturbance as reported by the patients was, as
expected, high at the time of diagnosis and reached a value of 10
+ 1.9 mm (range, 5 to 15 mm) on a scale of 0 to 15 (VAS II). This
level decreased significantly (P < .001) following arthrocentesis to
5.6 + 2.3 mm (range, 0 to 13 mm)..
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The study has demonstrated the efficacy of arthrocentesis of the upper
compartment in cases of suddenly occurring, severe & persistant limited MMO
originating from the joint.

It is a simple and minimally invasive procedure, does not involve the morbidity
of GA and still maintains a track record of zero complications. It can be
performed in the simplest of clinical settings and does not require major
armamentarium.

We emphasize that Arthrocentesis must be tried on every patient who requires
surgery for Internal Derangement.

Our study confirms a reasonable success rate, but it requires a longer follow-
up and more number of patients to establish this as minimal invasive treatment
of TMJ pain, which has failed by other non-invasive conservative methods.


CONCLUSION
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