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Int. J. Oral Maxillofac. Surg.

2015; 44: 104112


http://dx.doi.org/10.1016/j.ijom.2014.07.008, available online at http://www.sciencedirect.com

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

E.A. Al-Moraissi: Arthroscopy versus arthrocentesis in the management of internal


derangement of the temporomandibular joint: a systematic review and
meta-analysis. Int. J. Oral Maxillofac. Surg. 2015; 44: 104112. # 2014 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.

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.

Arthroscopy vs. arthrocentesis for TMJ derangement


studies are required to address this important question before final conclusions
can be drawn as to the true comparative outcomes of TMJ arthrocentesis versus
TMJ arthroscopy.

105

Keywords: internal derangement; TMJ; arthrocentesis; arthroscopy; maximal inter-incisal


opening; pain; meta-analysis; complications.
Accepted for publication 14 July 2014
Available online 7 August 2014

Temporomandibular joint disorder (TMD)


is a term that encompasses a number of
overlapping conditions. Approximately
10% of the population are affected, and
the disorder appears to occur most often in
younger females.1 One of the most common forms of TMD is internal derangement. It has been reported that 80% of
patients with signs and symptoms of TMD
have some form of internal derangement
of the temporomandibular joint (TMJ).2
Internal derangement is an intra-articular
condition in which there is a disruption in
the normal relationship of the articular
disc of the TMJ to the articular eminence
and the condyle when the joint is at rest or
in function.3 Internal derangement of the
TMJ includes conditions like anchored
disc phenomenon, disc displacement with
reduction, painful click, and closed lock.
Patients with internal derangement of the
TMJ often complain of pain, joint sounds,
and a limitation in mouth opening.
Most patients with internal derangement can be treated successfully with
non-surgical therapy.4 Non-surgical therapies include pharmacotherapy, TMJ
splints, and physical therapy. Patients
who do not respond to non-surgical therapy may require more invasive procedures,
such as arthrocentesis and arthroscopy.
Farrar estimated that up to 25% of the
entire population have an internal derangement, which is usually initially treated with non-surgical methods.5 More
recently, studies utilizing magnetic resonance imaging reported that the articular
disc was displaced in 35% of asymptomatic volunteers.6,7
Over the past 15 years, arthroscopic
surgery, arthrocentesis, and physical therapy have commonly been used as therapeutic interventions for permanent TMJ
disc displacement.8 Lavage of the TMJ
was first conducted using arthroscopy by
Ohnishi.9 Subsequently it was determined
that visualization of the joint was not
necessary to accomplish the treatment
objectives; thus, arthrocentesis alone has
been used as a modification of TMJ arthroscopic lavage in the treatment of this
condition.10,11 Arthrocentesis of the TMJ
was first described by Nitzan10 as a relatively easy, minimally invasive, and highly efficient procedure, and it is currently

used widely in the treatment of various


internal derangements as well as for diagnostic purposes. The procedure may be
performed under local anaesthesia, with
or without sedation, and its primary purpose is to clear the joint of inflammatory
cells, degradation products of the inflamed
synovium, blood, and pain mediators that
are believed to be by-products of intraarticular inflammation.12
Some studies have suggested that both
arthrocentesis and arthroscopic lavage
provide a significant reduction in pain
and increase the maximal mouth opening
on follow-up.1315 Although arthroscopy
shows better outcomes in terms of
improvements in functional outcome,
there is no difference in the degree of pain
control with either of the techniques.
Therefore, because arthrocentesis is technically easier to perform compared to
arthroscopic lavage, arthrocentesis is
highly recommended for the relief of pain
in patients with painful clicking in the
TMJ that does not respond to non-invasive
medical management.16 To the best of the
authors knowledge, no meta-analysis has
compared arthrocentesis and isolated lysis
and lavage arthroscopy in the treatment of
internal derangement with regard to maximal inter-incisal opening (MIO), pain,
and the incidence of postoperative complications. The aim of this study was to
determine whether arthroscopy or arthrocentesis is most effective and feasible in
the management of internal derangement
of the TMJ, specifically in relation to joint
movement and pain.

Materials and methods


Eligibility criteria

This analysis included studies in humans,


including randomized or quasi-randomized controlled trials (RCTs), controlled
clinical trials (CCTs), and retrospective
studies aimed at comparing arthrocentesis
and arthroscopy in the treatment of anchored disc phenomenon, closed lock,
anterior disk displacement with or without
reduction (ADDR/ADDWR), capsulitis,
and synovitis. Further, any controlled clinical trial comparing arthroscopy and
arthrocentesis in the treatment of internal

derangement with regard to pain and jaw


function (MIO, excursive movements, and
protrusive movements) was eligible.
The following were excluded: case
reports, technical reports, animal studies,
in vitro studies, review papers, and uncontrolled studies.
Search methods for the identification of
studies

This systematic review and meta-analysis


was conducted according to the PRISMAEquity 2012 checklist.17 A comprehensive
electronic search without date or language
restrictions was performed in January
2014 using the following electronic databases: PubMed, Cochrane Database of
Systematic Reviews, the Cochrane Central
Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, CINAH,
and Electronic Journal Center. The following search terms were used: TMJ
arthrocentesis AND/OR TMJ arthroscopy AND TMJ internal derangement, TMJ intra articular disorders,
TMJ lavage, TMJ lysis, TMJ
locking.
A manual search of oral and maxillofacial surgery-related journals was also performed, including the International
Journal of Oral and Maxillofacial Surgery,
British Journal of Oral and Maxillofacial
Surgery, Journal of Oral and Maxillofacial
Surgery, Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology and Endodontology, Journal of Cranio-Maxillofacial Surgery, Journal of Craniofacial
Surgery, and Journal of Maxillofacial
and Oral Surgery.
The reference lists of the identified studies and relevant reviews on the subject were
also scanned for possible additional studies.
Moreover, online databases providing
information on clinical trials in progress
were checked (https://clinicaltrials.
gov; http://www.centerwatch.com/
clinicaltrials; http://www.clinicalconnection.com).
Data collection process

The author carefully assessed the eligibility of all studies retrieved from the databases. In the final analysis the following

106

Al-Moraissi

data were extracted (when available) from


the included studies: authors, year of publication, study design, number of patients,
gender (male/female), mean age in years,
follow-up period, anaesthesia, intra-articular injection, lavage (pressure/volume),
duration of the problem, diagnostic problem subgroup, preoperative and postoperative MIO, and success rate. Authors were
contacted for possible missing data.
Risk of bias in individual studies

A methodological quality rating was performed by combining the proposed criteria


of the MOOSE statement,18 STROBE
statement,19 and PRISMA statement,20
in order to verify the strength of scientific
evidence in clinical decision-making.
The classification of the risk of bias
potential for each study was based on
the five following criteria: (1) random
selection in the population, (2) definition
of inclusion/exclusion criteria, (3) report
of losses to follow-up, (4) validated measurements, and (5) statistical analysis. A
study that included all of these criteria was
classified as having a low risk of bias. A
study that did not include one of these
criteria was classified as having a moderate risk of bias. When two or more criteria
were missing, the study was considered to
have a high risk of bias.
Summary measures

For the continuous data, due to all studies


using the same scale, the weighted mean
difference (WMD) was used to calculate
the MIO (in millimetres) and pain (by
visual analogue scale; VAS). If the trials
reported the standard deviation (SD) of the
mean change from baseline, the author
used the conservative approach to estimate
the SD using the following for21
mula
:
q
preoperative SD2 postoperative SD2
2

For those trials that reported both the


baseline and final means with standard
deviations, the author used the final value
rather than the change in scores.21
Synthesis of results

Meta-analyses were conducted only if


there were studies of similar comparisons,
reporting the same outcome measures. For
binary outcomes, a standard estimation of
the odds ratio (OR) by random effects
model was calculated if heterogeneity
was detected, otherwise a fixed effect
model was used with a 95% confidence
interval (CI). For continuous data, the

WMDs of the final values were used to


construct forest plots. The data were analyzed using the statistical software Review
Manager (version 5.2.6; The Nordic
Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark, 2012).
Assessment of heterogeneity

The significance of any discrepancies in


the estimates of the treatment effects of the
different trials was assessed by means of
Cochrans test for heterogeneity and the I2
statistic, which describes the percentage
total variation across studies that is due to
heterogeneity rather than chance. Heterogeneity was considered statistically significant if P < 0.1. A rough guide to the
interpretation of I2 given in the Cochrane
handbook21 is as follows: (1) from 0 to
40% the heterogeneity might not be important, (2) from 30% to 60% may represent moderate heterogeneity, (3) from
50% to 90% may represent substantial
heterogeneity, and (4) from 75% to
100% may represent considerable heterogeneity.
Investigation of publication bias

A funnel plot (plot of the effect size versus


standard error) was drawn. Asymmetry of
the funnel plot may indicate publication
bias and other biases related to the sample
size, although asymmetry may also represent a true relationship between trial size
and effect size.

Characteristics of the studies included

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

If there were sufficient included studies, it


was planned to conduct a sensitivity analysis to assess the robustness of the review
results by repeating the analysis with the
following adjustment: exclusion of studies
with a high risk of bias.
Results
Study selection

The study selection process is summarized


in Fig. 1. The electronic search resulted in
740 records. Three additional articles were
identified by hand-searching. After the
initial screening of titles and abstracts,
300 duplicate articles were excluded. Of
the remaining 443 studies, 374 were excluded for not being related to the topic.
Assessment of the full-text of the remaining 69 articles led to the exclusion of 63
because they did not meet the inclusion
criteria. Thus, a total of six publications
were included in the review.2227

Concerning the quality assessment of the


studies, two showed a low risk of bias23,24
and four showed a moderate risk of bias22,2527 (Table 3).
Maximal inter-incisal opening (MIO)

All of the studies (281 patients; 147 in the


arthroscopy group and 134 in the arthrocentesis group) evaluated the MIO over
follow-up periods ranging from 1 month to
2 years. The improvement in MIO after
arthroscopy was better than the improvement obtained after arthrocentesis. There
was a statistically significant difference
between the two groups (fixed: WMD
1.86 mm, 95% CI 2.93 to 0.79;
P = 0.0006). There was heterogeneity
among studies (x2 = 27.16, df = 5;
P < 0.0001; I2 = 82%). Therefore a sensitivity analysis was performed through exclusion of the retrospective, low impact
factor, and non-peer-reviewed studies.
Only the two RCTs23,24 were included

Arthroscopy vs. arthrocentesis for TMJ derangement

107

Fig. 1. Flow diagram of the article selection process.

in the analysis. The results remained in


favour of arthroscopy (fixed: WMD =
5.28 mm, 95% CI 7.10 to 3.46;
P = 0.00001). There was no heterogeneity
among studies (x2 = 0.68, df = 1;
P = 0.41; I2 = 0%) (Fig. 2).
Pain

All of the studies assessed pain using a


VAS (281 patients; 147 in the arthroscopy
group and 134 in the arthrocentesis
group). There was a statistically significant difference in pain reduction between
arthroscopy and arthrocentesis patients
(fixed: WMD = 0.44, 95% CI 0.57 to
0.31; P = 0.00001). There was heterogeneity among studies (x2 = 41.73, df = 5;

P < 0.00001; I2 = 88%). A sensitivity


analysis was performed to improve the
robustness of results; the retrospective,
low impact factor, and non-peer-reviewed
studies were excluded2527, and only the
RCTs23,24 were included in the analysis.
The results remained in favour of arthroscopy (fixed: WMD = 0.57, 95% CI
0.72 to 0.43, P = 0.00001). The test
of heterogeneity indicated that there was
clinical diversity (x2 = 7.71, df = 1;
P = 0.005; I2 = 87%) (Fig. 3).
Postoperative complications

Four studies23,24,26,27 reported postoperative complications following arthroscopy


and arthrocentesis. In the study by Goudot

et al.,24 one patient in the arthroscopy


group presented a transient frontal palsy
and one patient developed cervico-facial
oedema, while in the arthrocentesis group,
two cases of severe bradycardia (one asystole) were observed. In the study by Xu
et al.,27 one patient in the arthroscopy
group presented a transient frontal palsy
(duration 3 months) and one patient developed cervico-facial oedema; in the
arthrocentesis group, one case of cervico-facial oedema was observed.
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). There was an absence of heterogeneity among the studies

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

Arthroscopy vs. arthrocentesis for TMJ derangement


Table 2. Preoperative and postoperative mean pain scores and maximal inter-incisal opening.
Pain (VAS)

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

VAS, visual analogue scale; MIO, maximal inter-incisal opening.


Table 3. Critical appraisal of the studies included (quality assessment).

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.

(x2 = 0.49, df = 2; P = 0.78; I2 = 0%)


(Fig. 4).
Assessment of publication bias

No significant publication bias was observed for the studies included (Fig. 5).
Discussion

The role of lavage with the accompanying


procedure of arthrolysis has shown excellent success rates in the treatment of TMD.
This procedure has been shown to reduce
pain and improve joint mobility, sometimes even in patients suffering the advanced stages of degeneration and
dysfunction.2831 There are two different

approaches to lavage and arthrolysis:


arthrocentesis and arthroscopic lavage.
Various studies have compared the two
techniques and have suggested that they
vary in terms of prognosis, complications,
and long-term outcomes.22,23,25
In this study, the results of the metaanalysis revealed a statistically significant
difference in favour of arthroscopy with
respect to MIO and pain. These results
may be attributed to the efficacy of arthroscopy in releasing the negative pressure on the disc, releasing adhesions,
distending or widening the narrowed joint
space, reducing surface friction, and altering the viscosity of the synovial fluid.32
These results are, however, inconsistent
with the results of other studies.12,22,23,25

Concerning pain, there was a significant


advantage of arthroscopy over arthrocentesis (P = 0.00001). This may be because
the larger diameter portal with high pressure used in arthroscopic lavage enables
more extensive removal of inflammatory
mediators resulting in a subsequent greater
reduction in pain.27
A total of 281 patients enrolled in six
studies2227 were included in the qualitative and quantitative analysis: two
RCTs,23,24 two CCTs,22,26 and two retrospective studies.25,27 Two studies showed
a low risk of bias23,24 and four studies
showed a moderate risk of bias.22,2527
The diagnostic problem subgroups were
ADDWR/ADDR in three studies2325,27
and closed disc and painful joints with

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.

the anchored disc phenomenon in three


studies.22,26
Arthrocentesis and arthroscopy are not
without risks. Generally, the potential
complications of arthroscopy can also occur in arthrocentesis, but the incidence and
extent of complications are lesser in
arthrocentesis28. Damage to the facial
and auriculo-temporal nerves, perforation
of the external auditory canal and tympanic membrane, and breach of the base of
the skull33 have been reported as complications after arthroscopy. Transient
facial nerve paralysis caused by local

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

those of arthroscopic lysis or lavage.34


However, Sanders maintains that in cases
of chronic closed lock, intracapsular lysis
using probes between the disc and fossa is
necessary to release superior compartment
adhesions.35
With regard to age and the duration of
the problem, the author of the current
study believes that the chronicity of joint
symptoms and older age could be considered poor indicators in the prediction of
the outcome of both procedures.
Although, the results of this study
revealed a superiority of arthroscopy over

Arthroscopy vs. arthrocentesis for TMJ derangement


arthrocentesis in improving jaw function
and reducing pain, there are a number of
disadvantages to arthroscopy: it requires
general anaesthesia and the use of an
operating room, it is relatively more invasive, there is greater postoperative morbidity, it is a more expensive procedure,
and it has a greater potential for complications. Whereas serious complications such
as arterio-venous fistula, facial, trigeminal, and auditory nerve injury, otitis media, perforation of the glenoid fossa,
extradural haematoma, broken instruments in the joint, and perforation of the
tympanic membrane and middle ear
resulting in deafness have occurred with
arthroscopy,24,27,3642 the only major
complication reported with arthrocentesis
has been one case of an extradural haematoma.42 These advantages of arthrocentesis support the contention that it
should be the initial surgical treatment
of choice for internal derangements that
do not respond to medical management.43
In conclusion, arthroscopy lysis and
lavage was found to have superior efficacy
in improving MIO and reducing pain when
compared to arthrocentesis. Further, the
incidence of postoperative complications
was comparable for the two techniques.
However, the current meta-analysis is incomplete due to the paucity of good quality studies in the high-impact, peerreviewed literature and, therefore, more
better-designed studies are required to
address this important question before
final conclusions can be drawn as to the
true comparative outcomes of TMJ arthrocentesis versus TMJ arthroscopy.
Funding

None.
Competing interests

None.
Ethical approval

Not required.
Patient consent

Not required.
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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

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