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Systematic Review
TMJ Disorders
Arthroscopy versus
arthrocentesis in the
management of internal
derangement of the
temporomandibular joint:
a systematic review and
meta-analysis
E. A. Al-Moraissi1,2
1
Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Thamar
University, Yemen; 2Department of Oral and
Maxillofacial Surgery, Faculty of Oral and
Dental Medicine, Cairo University, Cairo,
Egypt
Abstract. The aim of this study was to assess whether arthroscopy or arthrocentesis
is most effective and feasible in the management of internal derangement of the
temporomandibular joint (TMJ), specifically in relation to joint movement and
pain. A comprehensive electronic search without date or language restrictions
was performed in January 2014. Inclusion criteria were the following: study in
humans; randomized or quasi-randomized controlled trials (RCTs), controlled
clinical trials (CCTs), and retrospective studies; comparison of arthrocentesis
and arthroscopy in the treatment of internal derangement. Six publications were
included in the review, two RCTs, two CCTs, and two retrospective studies. Two
studies showed a low risk of bias and four studies showed a moderate risk of
bias. There were statistically significant differences between arthrocentesis and
arthroscopy with regard to maximal inter-incisal opening and pain reduction, but
no difference between the two groups for postoperative complications. The
results of this meta-analysis on the management of internal derangement of the
TMJ revealed arthroscopy to have superior efficacy to arthrocentesis in
increasing joint movement and decreasing pain. Both arthroscopy and
arthrocentesis have comparable postoperative complication rates. However, the
current meta-analysis is incomplete due to the paucity of good quality studies in
the high-impact, peer-reviewed literature; therefore, further better-designed
0901-5027/010104 + 09
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
105
The author carefully assessed the eligibility of all studies retrieved from the databases. In the final analysis the following
106
Al-Moraissi
Detailed characteristics of the studies included are shown in Tables 1 and 2. Two
RCTs,23,24 two CCTs,22,26 and two retrospective studies25,27 were included in the
meta-analysis and critical appraisal. A
total of 281 patients were enrolled in the
six studies, 147 in the arthroscopy group
and 134 in the arthrocentesis group.
All of the patients in the included studies had undergone a period of unsuccessful
conservative non-surgical treatment. The
follow-up period was 12 years in three
studies2325 and ranged from 1 month to 6
months in the other studies.22,26,27
The arthroscopies were performed under general anaesthesia using one cannula
with double needles in all of the included
studies except one,27 in which they were
carried out under local anaesthesia. During the arthroscopies, the synovial membrane and the fossa were inspected to
check for adhesions and disc perforations.
The upper compartment was washed out
and swept with a blunt probe to release any
adhesion that could restrict the disc. No
other intervention was performed. Arthrocentesis was carried out according to the
technique of Nitzan et al.28 under local
anaesthesia, using two needles inserted
into the upper compartment.
The intra-articular injection material
was a lactated ringers solution or saline,
with a final instillation of sodium hyaluronate in two studies25,27 and betamethasone in one study.23
Risk of bias within studies
Sensitivity analysis
107
108
Authors
Year
Study
design
Number of patients
AC
(group 1)
Gender
Age, years
Follow-up
Anaesthesia
IA injection
Lavage
Group 1:
17 F, 3 M
Group 2:
23 F, 2 M
Groups 1
and 2:
19 F
Group 1:
mean 32.7
Group 2:
mean 31.2
Group 1:
mean 28.5
Group 2:
mean 33
Range 1556
Groups 1 and
2: mean 38,
range 1672
6 months
Group 1: LA
Group 2: GA
NR
Group 1: 2 needle
Group 2: dual-port
1 week,
1, 3, 4, 12,
and 26 months
Group 1: LA
Group 2: GA
Group 1:
RLS + steroid
Group 2:
RLS + steroid
Group 1: 2 needle
Group 2: dual-port
1 year
Group 1: LA
Group 2: GA
Groups 1
and 2: RLS
Group 1:
RLS + SH
Group 2:
RLS + SH
Group 1:
saline
Group 2:
saline
Groups 1 and
2: RLS + SH
Duration of
problem
Diagnostic
problem
subgroup
AS
(group 2)
Murakami et al.22
1995
CCT
prosp.
20
25
Fridrich et al.23
1996
RCT,
prosp.
11
Goudot et al.24
2000
RCT
prosp.
29
33
Groups 1
and 2: 46 F,
16 M
Hobeich et al.25
2007
RS
25
32
Groups 1
and 2: 12 M,
45 F
Groups 1 and 2:
range 1654
1828 months
Group 1: LA
Group 2: GA
Tan and
Krishnaswamy26
2012
CCT
prosp.
11
Group 1: LA
Group 2: GA
2013
RS
41
37
Group 1:
range 1640
Group 2:
range 2063
Group 1:
range 3439
Group 2:
range 3073
1 week
1 month
Xu et al.27
Group 1:
8 F, 3 M
Group 2:
7 F, 2 M
Group 1:
30 F, 11 M
Group 2:
29 F, 8 M
Over
3 months
Groups 1 and 2: LA
Group 1:
6.85 months
Group 2:
5.64 months
NR
Closed lock
Group 1: 2 needle
Group 2: cannula
with double needle
100200 ml
NR
NR
54 ADDWR
8 ADDR
Groups 1 and
2: 12 years
ADDWR
Group 1: 2 needle
100200 ml
Group 2: cannula
with double needle 200 ml
Group 1: 2 needle
Group 2: two cannulas
High pressure
500 ml
Group 1:
19 months
Group 2:
16 years
NR
3 painful click
17 closed lock
(due to DD
or ADP)
ADD
7 ADDWR
12 ADDR
IA, intra-articular; AC, arthrocentesis; AS, arthroscopy; F, female; M, male; CCT, controlled clinical trial; RCT, randomized clinical trial; prosp., prospective study; RS, retrospective study; NR, not
reported; LA, local anaesthesia; GA, general anaesthesia; RLS, Ringers lactate solution; ADDWR, anterior disc displacement without reduction; ADDR, anterior disc displacement with reduction;
SH, sodium hyaluronate; DD, disc displacement; ADP, anchored disc phenomenon.
*
Group 1, arthrocentesis; group 2, arthroscopy.
Al-Moraissi
Table 1. Characteristics of the studies comparing arthroscopy and arthrocentesis included in the review.*
109
Authors
MIO (mm)
Arthroscopy
Arthrocentesis
Preop.
Murakami et al.22
Fridrich et al.23
Goudot et al.24
Hobeich et al.25
Tan and Krishnaswamy26
Xu et al.27
Postop.
5.7
6.45
5.6
5.75
6.67
5.32
2.4
1.7
0.9
2.55
2.11
0.73
Preop.
4.8
6.6
5.7
5.71
6
6.08
Arthrocentesis
Arthroscopy
Postop.
Preop.
Postop.
Preop.
Postop.
3.0
2.3
1.9
2.32
3.5
2.21
30.6
33
29.4
31.75
26.56
25.9
42.5
41
33.8
41.60
39.56
35.7
27.5
30
29.0
32.07
30.25
24.2
42.1
47.5
38.6
40.68
36.88
37.1
Statistical
analysis
Estimated
potential
risk of bias
Authors
Published
22
Murakami et al.
Fridrich et al.23
Goudot et al.24
Hobeich et al.25
Tan and Krishnaswamy26
Xu et al.27
Random selection
in population
1995
1996
2000
2007
2012
2013
No
Yes
Yes
No
No
No
Defined inclusion/
exclusion criteria
Yes
Yes
Yes
Yes
Yes
Yes
Loss of
follow-up
Yes
Yes
Yes
Yes
Yes
Yes
Validated
measurement
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Moderate
Low
Low
Moderate
Moderate
Moderate
Fig. 2. Forest plot showing the weighted mean difference in the MIO between the arthrocentesis and arthroscopy groups.
No significant publication bias was observed for the studies included (Fig. 5).
Discussion
110
Al-Moraissi
Fig. 3. Forest plot showing the weighted mean difference in pain scores (VAS) between the arthrocentesis and arthroscopy groups.
Fig. 4. Forest plot showing the incidence of postoperative complications between the arthrocentesis and arthroscopy groups.
Fig. 5. Funnel plot showing a symmetrical distribution without systematic heterogeneity of the individual study treatment effects compared with
standard error, indicating a lack of publication bias in the meta-analysis.
anaesthesia and swelling of the pre-auricular area due to fluid extravasation may
result from arthrocentesis. In the present
study, there was no statistically significant
difference between the two groups with
regard to the incidence of postoperative
complications (fixed: OR 1.15, 95% CI
0.304.43; P = 0.84).
Nitzan believes that a major part of the
success of surgical arthroscopy in the
treatment of severe closed lock is attributable to the lavage rather than to the surgical instrumentation, therefore the success
rates with arthrocentesis are similar to
None.
Competing interests
None.
Ethical approval
Not required.
Patient consent
Not required.
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temporomandibular pain. In: Sessle BJ, Bryant PS, Dionne RA, editors. Temporomandibular disorders and related pain
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Al-Moraissi
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Address:
Essam Ahmed Al-Moraissi
Department of Oral and Maxillofacial
Surgery
Faculty of Dentistry
Thamar University
Thamar
Yemen.
Tel: +967 21141477753, 009 67777788939.
E-mails: dr_essamalmoraissi@yahoo.com,
dressamalmoraissi@gmail.com