Artículo Clínico

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Arthroscopy for the internal derangement of TMJ: clinical outcome from a prospective evaluation
La artroscopia en el daño interno de la ATM: resultados clínicos de un estudio prospectivo

 

F.J. Avellá Vecino¹, C.I. Salazar Fernández², S. Gallana Álvarez¹, A. Rollón Mayordomo², F. Mayorga Jiménez², J.M. Pérez Sánchez³

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1 Médico Residente.
2 Médico Adjunto.
3 Jefe del Servicio. Servicio de Cirugía Máxilofacial y Estomatología del Hospital Universitario Virgen Macarena, Sevilla, España.

Correspondencia:
F.J. Avellá Vecino
C/ José Rodríguez Guerrero 9
41009 Madrid, España.
e-mail: javiavella@terra.es

 

Introduction

The temporomandibular dysfunction syndrome (TMJD) is a multifactorial clinical picture for which a step by step treatment based on seriousness is advocated.¹ In spite of having used varied techniques for the treatment of TMJD,² none has had full acceptance, which reflects the lack of knowledge surrounding this syndromic picture in regards to etiology, pathology and natural history. The studies on the surgical treatment3 of this disease have demonstrated improvement in mouth opening and pain, however, they are limited due to the defects that are frequently associated to retrospective clinical studies: poor definition of the patient group, lack of control group, observer bias, loss of patients to follow- up, etc.

Our objective is to demonstrate the clinical efficacy of joint lysis and lavage by a prospective study of patients with internal joint derangement treated by arthroscopy of the temporomandibular joint (TMJ) in a homogeneous group.

Material and method

A prospective follow-up study was performed from February 1996 to April 2001, in order to assess the long term clinical-radiological results after arthroscopic surgery (joint lysis and lavage) of 22 joints (13 patients) with diagnosed TMJD treated in the University Hospital Virgen Macarena of Seville. The follow-up range varied from a minimum of 12 months to a maximum of 63 months, with a mean of 27 months and a median of 26 months.

Inclusion criteria for arthroscopic surgery were those established by the American Association of Surgery of the TMJ:⁴

• TMJD of one or both TMJ, clinically diagnosed and verified by MRI.

• Symptoms refractory to conservative treatment maintained for 6 months (NSAIDs + muscle relaxants + analgesics, physiotherapy, myorelaxation splints and occlusal rehabilitation).

The patients filled out a clinical questionnaire before surgical treatment that included demographic data, clinical symptoms, symptom duration, history of articular noises, alteration of mandibular movement pattern, existence of parafunctions, recent orthodontic treatments, background of facial traumatisms and articular pathology. The joint pain was measured by a visual analogue scale (0-10).

The clinical examination included: maximum intraincisal opening (MIO), maximum protrusion and maximum mandibular laterotrusion (expressed in mm), measurements by millimetric curve ruler. Palpation and auscultation of the TMJ were performed to assess the presence of articular noises (snapping sound, crackling sounds), as well as the moment of oral opening-closure in which they occur. Furthermore the chewing muscles (pain, contracture) and occlusion of each patient (Angle class, canine guidelines, middle line, occlusion stability, lack of teeth) were examined.

All the patients underwent a panoramic X-ray, lateral Xray of the face in Schuller project with closed mouth and in maximum opening and MRI of the TMJ. In the MRI, images were obtained in the sagittal (perpendicular to the major axis of the mandibular condyle) and coronal plane, in 4 progressive oral openings. The parameters of the MRI were reception time = 200 ms, echo time = 15 ms, rotation angle of 45º and vision field of 170 mm. The cut thickness was 3 mm. The articular meniscus position was studied in relationship with the glenoid fossa and mandibular condyle, morphology of meniscus (Biconcave, biplanar, biconvex, folded and amorphous De Leew classification)⁵ of the mandibular condyle and of the glenoid fossa. At one year of arthroscopic treatment, a MRI study was repeated in all the patients with the same technical characteristics described and was performed and assessed by the same physicians who had assessed the initial MRI.

Surgical technique: All the patients were operated under general anesthesia by the same surgeon and with the same instrumental. Arthroscopies were performed by posterolateral approach of the articulation with a double pathway (arthroscopy and lavage pathway); a TMJ mini-scope set arthroscopy (Stryker^®) with a 30° angle was used. All the joints were treated by lysis of adhesions with a blunt obturator, performing anteroposterior and lateromedial movements, and lavage of the articular cavity with 200-500 ml of Ringer lactate solution as well as mandibular manipulation. In the cases of synovitis, 3 mg of intraarticlar betametasone were administered. In all the cases, antibiotic prophylaxis was performed with 2 g i.v. Augmentine.

The postoperative treatment consisted in liquid/soft diet for 1 month, NSAIDs + analgesics + muscle relaxants for 10 days, nighttime myorelaxation splint for 1 month and physiotherapy for 3 months.

All the patients were examined by the same surgeon, who performed the arthroscopic surgery, at one week, one month, 3, 6 and 12 months of the arthroscopy and then every 6 months. The following variables were assessed: articular pain and articular noises (n=22 articulations), maximum interincisal opening, maximum protrusion and mandibular laterotrusion, diet tolerated by the patient (capacity to receive the usual diet and chew meat), use of myorelaxation splint (n=13 patients), arthroscopic findings, technique complications and consumption of its resources.

A descriptive statistical study was performed on the continuous variables (means and standard deviations). The comparative study of the pre- and postsurgical variables was performed with The Wilcoxon and McNemar tests. The Mann-Whitney U test was administered to compare pain and the mandibular mobility parameters between the early (II-III) and late stages (IV-V) of the disease in each time (presurgical and at one year of follow-up). We define statistical significance for a p value less than or equal to 0.05.

Results

A total of 22 articulations (13 patients) with a mean age of 31 years (19-65 years) were treated. They presented some predisposing background of TMJD in 92% of the cases. As can be seen in Table 1, 21 articulations were painful, the main symptom being pain in 10 patients (76%)

The data collected in the X-ray study and MRI, and the distribution by stages according to Wilkes classification6 are shown in Table 2. Thus, in stage II, we found that the X-ray was harmless while the resonance demonstrated an anterior reducible disk displacement. In stage III, the rectification of the posterior slope of the condyle and/or decrease of the articular space together with the irreducible meniscus displacement was detected in the MRI. In stage IV, articular effusion and early signs of articular degeneration appear in the MRI as well as signs of arthrosis in the X-ray. Finally, in stage V, the perforation of the posterior ligament is added to all the above as a finding of the resonance.

After the arthroscopy, the pain improved in 80% of the cases (17 joints) and the MIO, protrusive and right and left laterotrusive parameters improved in 100%, 92%, 84%, and 92% respectively. In 63% of the cases, the noises disappeared, improving in 7 articulations. The evolution of these variables over time appears in Figures 1 to 5.

The pre- and postsurgical comparative study at 12 months of follow- up of the values of pain, MIO, protrusion, laterotrusion, articular noises and diet tolerated variables shows improvement in all these variables with statistical significance (Table 3). These data were maintained at the end of the study followup, as well as by stages (Table 4). The improvement in the MIO and pain was significantly greater for stages II-III than for the advanced stages of the disease. A total of 38% (5 patients) required post-arthroscopy myorelaxation splint.

The X-ray findings of the MRI performed at one year of the arthroscopy improved (irreducible to reducible, from reducible to normal) in 27% of the articulations affects (n=6), these being Wilkes Stages II – III. In the rest of the cases, the MRI remained similar without revealing severe progressive changes.

All the patients presented improvement in some or all the variables analyzed. Following the Murakami criteria7: we consider excellent results when there is no pain, the MIO is 40-50 mm, the protrusive and laterotrusion movements are greater or equal to 6 mm, there is absence of noises, the patient can have a normal diet and there is improvement in the post-arthroscopy MRI study. We consider satisfactory results to be a MIO of 30-35 mm, mild pain (1-3 according o the visual analogue scale), minimum dietary restriction and findings in the post-arthroscopy MRI similar to the presurgical study. According to these criteria, we have had a success rate (excellent) of 23% (3 patients) and satisfactory results of 77% (10 patients), there being advanced stages of the disease in 50% of these cases (5 patients).

No postsurgical complication was detected. The use of technique resources, measured by hospital stay, surgical time, CORT infiltration was: mean hospital stay of 2.4 days (2-3 days), mean surgical time of 1.30 h (60-115 minutes) 61% of the patients required articular infiltration with corticosteroids due to synovitis.

Discussion

Since Onishi⁸ performed an arthroscopy for the first time in Japan in 1975, this technique has been widely developed in the United States and Europe, its success being published in the literature.

In 1990, in a prospective study of 76 articulations treated by lysis and lavage, Perrott et al.⁹ obtained an increase of the mean MIO of 29.91 ± 10.1 mm to 37.93 ± 10.52 mm, this being statistically significant, as well as decrease of pain measured with the analogue and categorized visual scale (none, middle, moderate and severe) with a mean follow-up of 12.56 ± 2.87 months for only 34 articulations of the total. The comparison of the postarthroscopy MRI (between 1 and 17 months) with the previous images did not show differences in regards to disk position in 25 of the 29 articulations studied. In 1991, Clark et al.¹⁰ performed a prospective two year postarthroscopy follow-up study of 22 articulations (18 subjects) with internal derangement of the TMJ, obtaining a 57% decrease in pain, and an increase in the MIO mean of 13 mm, both being statistically significant. In 1996, Murakami et al.⁷ published a study with a mean followup of 50 months (from 3 to 5 years) after arthroscopic surgery of 24 TMJs (women) with internal joint derangement in Wilkes stage V, performing capsular anterolateral release by electrocauterization, assessing the MIO, pain, and articular dysfunction with a pre- and postoperatory VAS as well as the presence of cracking sounds to the auscultation and palpation. They obtained statistically significant differences between the mean pre- and postsurgical values, with a MIO mean of 33 to 38.8 respectively, and decrease of pain from 7 to 1.3.

In our study, we assess the clinical-radiological results after the administration of lysis and lavage by arthroscopy in patients diagnosed of TMJD. Being aware of the disadvantages of a sample size that is not large, we performed a prospective study with a mean follow-up of 27 months (range: 12 to 63 months) without data losses during it. As in the previously mentioned studies, we demonstrated the utility of the arthroscopy as a treatment of internal joint derangement of the TMJ by lysis and lavage, after obtaining a statistically significant improvement in pain, MIO, protrusion, right and left laterotrusion, and crackling sounds in 80%, 100%, 92%, 84%, 92% and 63% of the patients respectively, 77% of the patients being able to carry out a normal diet and only 38% requiring postarthroscopy myorelaxation splint. In addition, this improvement in the variables occurs in both the early as well as advanced stages of TMJD, it being maintained during the follow-up period. However, the improvement of the MIO is significantly greater when the technique is applied in the early stages of the disease.

We coincide with the results presented by Moses¹¹ et al. in a prospective study of 152 articulations with anterior disk displacement treated by arthroscopic lysis and lavage, with a mean follow-up of 19 months, that obtains an improvement in disk mobility in 80% of the patients, although with persistence of anterior disk displacement in 92% of them detected by the MRI. In our study, we also carried out an analysis of the pre- and post-arthroscopy X-ray findings obtained by MRI, that show an improvement in the meniscus displacement in only 27% of the articulations, most of them being early stages of the disease.

Based on the comparison of the results obtained with lysis and lavage and other arthroscopic techniques found in the literature, the lack of difference in the clinical results between them can be stated. Thus, Miyamoto,¹² after applying lysis and lavage in 41 articulations with internal articular derangement in Wilkes stage III, compared to lysis and lavage plus anterolateral capsular release in 73 articulations in the same stage, concluded that the only statistically significant difference is the lower oral opening obtained in the first group at one month of evolution; a difference that becomes equaled at 12 months of followup. Thus, the great similarity of the results would support treatment with arthroscopic lavage and lysis compared to other techniques, since the arthroscopy is a minimally invasive procedure, causes less surgical trauma and is associated to lower morbidity, the recovery of the patient being faster. However, controlled clinical trials are necessary to compare the effectiveness of the different arthroscopic techniques as well as clinical-pathological concordance studies in the pathology of TMJ.

Conclusions

1. Arthroscopic surgery (lysis and lavage of the upper space with mandibular manipulation) is a useful and effective technique for TMJD, both in early as well as late stages of the disease.

2. Pain, MIO, protrusion, laterotrusion and articular noises significantly improve. It makes it possible for the patient to have a normal diet.

3. It is shown that the improvement of the interincisal opening with arthroscopic lysis and lavage is greater in the early stages of TMJD.

4. It is a minimally invasive and morbid technique.

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