Braz. j. . vol.81 número4

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

A

prospective

study

of

138 arthroscopies

of

the

temporomandibular

joint

夽

,

夽夽

Paulo

Alexandre

da

Silva

a,∗

,

Maria

Teresa

de

Fatima

Fernandes

Lopes

b

,

Fernando

Silva

Freire

b

a_Department_of_Oral_and_{Maxillofacial}_Surgery_and_Traumatology_(OMFST),_Medical_Center,_Hospital_Vivalle_São_José_dos_Campos,

SãoJosédosCampos,SP,Brazil

b_Departament_of_Oral_and_{Maxillofacial}_Surgery_and_{Traumatology,}_Instituto_Educacional_de_Ciências_da_Saúde_(IECS

Facsete/Ciodonto),SeteLagoas,MG,Brazil

Received25August2013;accepted31August2014 Availableonline9June2015

KEYWORDS

Arthroscopy; Temporomandibular joint;

Temporomandibular jointdisorders; Temporomandibular jointdysfunction syndrome;

Temporomandibular articulardisk

Abstract

Introduction:Internalderangements(ID)ofthetemporomandibular joint(TMJ)havea mul-tifactorial etiology and are most often treated conservatively by splints, physical therapy andmedications. Onlyin2---5%ofcasesarethetreatmentsurgical,eitherbyarthroscopyor arthrotomy.

Objective:Toevaluateimprovementofmouthopening,painreliefduringfunction,positionof thearticulardiskandcomplicationsfollowingArthroscopicLyseandLavage(ALL).

Methods:Aprospectivestudyof78patients(138TMJs)withTMJID,5malesand73females, meanage29.7years,treatedbetweenJanuary2010andApril2013,whowererefractoryto conservativetreatment,hadlimitedmouthopeningandpainlocalizedtotheTMJduring func-tion,andwhoweresubmittedtoTMJALLandfollowedforaperiodof12months,withperiodic reviews.

Results:ALLwaseffectivein93.6%ofcases,with85.3%experiencingimprovementinmouth openingand91.2%inpainreductionduringfunction,63%improvementindiskpositionanda rateofcomplicationsof6.2%.

Conclusion:InthisstudytheALLexhibitedahighrateofsuccesswithlowmorbidityininternal derangementsoftheTMJ.

夽 _Please_cite_this_article_as:_da_Silva_PA,_Lopes_MTFF,_Freire_FS._A_prospective_study_of₁₃₈_{arthroscopies}_of_the_{temporomandibular}_joint.

BrazJOtorhinolaryngol.2015;81:352---7.

夽夽_Institution:_IECS_Instituto_Educacional_de_Ciências_da_Saúde,_Sete_Lagoas,_MG,_Brazil.

∗_{Corresponding}_author.

E-mail:[email protected](P.A.daSilva).

http://dx.doi.org/10.1016/j.bjorl.2014.08.021

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PALAVRAS-CHAVE

Artroscopia; Articulac¸ão

temporomandibular; Transtornosda articulac¸ão

temporomandibular; Discodaarticulação temporomandibular; Síndromeda disfunçãoda articulação

temporomandibular

Estudoprospectivode138artroscopiasdaarticulac¸ãotemporomandibular

Resumo

Introdução: Osdesarranjos internos (DI)daarticulação temporomandibular (ATM),possuem etiologiamultifatorial, sendotratados namaioriadas vezesde formaconservadora através splints,fisioterapiaemedicamentos.Apenas2%a5%doscasostemindicaçãocirúrgica,seja atravésdeartroscopiaouartrotomia.

Objetivo: Avaliarmelhoradaaberturabucal,melhoradador,posicionamentododiscoarticular ecomplicac¸õespósLiseeLavagemArtroscópica(ALL).

Método: Estudoprospectivocomumaseriede78pacientes(138ATMs)comDIdaATM,sendo5 homense73mulheres,commédiaetáriade29,7anos,atendidosentrejaneirode2010eabril de2013,refratáriosaotratamentoconservador,apresentandolimitaçãodeaberturabucale dorlocalizadaem ATMem função,sendosubmetidos àALL daATMeacompanhadosporum períodode12meses,comavaliaçõesperiódicas.

Resultados: AALLfoieficienteem93,6%doscasosestudados,com85,3%melhoranaabertura bucale91,2%nareduçãodadoremfunção,63%demelhoranaposiçãodiscalemRMdecontrole eíndice6,2%decomplicações.

Conclusão:NopresenteestudoaALLmostrou-seumtratamentocomumaltoíndicedesucesso, combaixamorbidade,nosdesarranjosinternosdaATM.

Introduction

Internaldisorders(ID)ofthetemporomandibularjoint(TMJ) haveamultifactorial etiology,andtheirtreatment consti-tutesasignificantchallengeforcliniciansandsurgeons.For years,thesedisordersweretreatedconservatively,mostly by the use of splints and anti-inflammatory agents. Sur-gical treatment is indicated in only 2---5% of cases, and in most cases it is performed by arthrotomy. In 1975, Ohnishi1 _was _the _first _surgeon _to _use _an _arthroscope _in

TMJ,when thisauthorstudied itsmovements and arthro-scopicanatomy. Inthe80s, severalauthors2---5 _contributed

tothedevelopmentof TMJarthroscopy, withdescriptions of various techniques and an understanding of the inter-nal changes viewedarthroscopically.Fromthe end of the 80stonow, therehasbeen greatprogress inarthroscopy, mainly due to a better quality of magnetic resonance imaging (MRI) studies and also to an understanding of the pathophysiology of ID. Bronstein and Merrill6

corre-latedthestagesofWilkes7_with_their_arthroscopic_findings;

NitzanandEtsion8_reported_on_the_{interrelationship}_of_the

lubricationprocessandarticulardiskdisplacement;others developedandintroducedseveralarthroscopictechniques, withexcellent results,such asdisksuture,9,10 _co-ablation

withradiofrequency,11,12 _laser_ablation,12 _drug_injection,12

diskfixation,13_and_eminectomy.14

Arthroscopic Lyseand Lavage(ALL) wasfirstdescribed in theliterature as‘‘Lysis’’by Sanders4 _in _1986. _In_1992,

inamulticenterUSstudy,resultsof4861TJMarthroscopic procedureswerecollected,andamongalltechniques per-formed,85%wereALL.Thus,ALLwasnotedtobethemost frequentlyperformedprocedureinTMJarthroscopyandwas reported tohave a global improvement indexof 91.3%.15

With this technique, fibrosis and adhesions are disrupted by instrumentation through the working cannula, while

maintainingacontinuousflowof0.9%salineorRinger’s solu-tion.Thus,theproductofthebreakdownofadhesionsand alsoitsinflammatorycomponentsareeliminated,promoting abetteranatomicalandphysiologicalconditionand allow-ingbettermobilizationofTMJanddecreasedpain.16_The_aim

ofthisstudywastoevaluatethesuccessrateofthe arthro-scopiclysisandlavage(ALL)procedureinpatientswithTMJ internaldisorders,inrelationtoimprovingtheoralopening, decreasingpainsymptoms,articulardiskpositioninginthe post-proceduralMRI,andcomplicationsofthetechnique.

Methods

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Table1 RelationshipbetweenpatientsandaffectedTMJs.

Patients Unilateral Bilateral TotalofTMJs

78 24 58 138

Table2 RelationshipbetweenTMJsandWilkesstage.

TMJs WilkesII WilkesIII WilkesIV WilkesV

138 42 57 31 8

accountinformationobtainedfromhistory,toruleout pos-sibleinvolvementof systemicfactors,suchasrheumatoid arthritisandfemalehormonaldysfunction,amongothers.At theinitialclinicalexamination,patientshadanaverageof 21.2mmofmouthopeningand/orlocalizedpaininfunction (meanVASof6.75,andpositiveforajointloadtest).Among 138ATMsstudied,42wereinWilkesstageII,57inWilkesIII, 31inWilkesIV,and8inWilkesV(Table2).Allpatients under-wentgeneralanesthesiawithnasalintubation.Inallcases, patientsreceivedantibioticprophylaxiswithcephalothin2g atinductionofanesthesia.Inallprocedures,1.9mm, zero-degreeopticaldevice,sleeves,sharpandbluntperforators, adhesionknives,an exploratoryprobe,andabipolar elec-trode(Karl StorzEndoscopy, Tuttlingen,Germany)(Fig.1) were used. ALL was performed with a puncture, sweep and triangulation technique described by McCain et al.17

under irrigation with Ringer’s. Instrumentation was per-formedforremovalofadhesions,synovitiscauterizationand mobilizationofthearticulardisk(Figs.2---5).Attheendof theprocedure,sodiumhyaluronateinfiltration,20mg(TBR Polireumin®_Pharma,_São_Paulo,_SP,_Brazil),_was_performed.

All arthroscopicprocedures were performed by the same professional.Patientswere discharged after 12---24h, and naproxensodium500mg12/12hfor3dayswasprescribed. Patientswereinstructedtomaintainasoftdietfor30days, use a Michigan myorelaxant plate, limit mouth opening, and perform laterality and mandibular protrusion passive exercises during the first 15 days, and return to physical

Figure1 OpticsandinstrumentsusedinALL.

Figure2 ALLbeingperformedwiththeopticaldevicein posi-tion,refluxneedleandtriangulationforinstrumentation.

therapy after this period. Physical therapy and plate use weremaintainedfor6monthspostoperatively.Allpatients were evaluated postoperatively at 24h, 72h, 7 days, 15 days,21daysand30days,andthenmonthly.During follow-up, pain improvement in function (VAS and load testing) andimprovedmouthopeningamplitudewereevaluated.All complications arising fromALL werealso evaluated, with the exceptionof: painat the puncturesite; discrete pos-terioropenbite,andtransientlimitationofmouthopening (sucheventsareexpectedintheearlydays,beinginherent

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Figure4 Instrumentationwithknife,withremovalof adhe-sionsintheintermediatezone(betweeneminenceandarticular disk).

Figure5 StraightprobeintoposteriorrecessofTMJ mobiliz-ingthedisktoitsanatomicalposition,afteradhesionremoval.

tothe procedure). A control magnetic resonance imaging (MRI)studyafter6monthswasobtainedfordisk position-ingassessmentinrelationtotheinitialMRI.At6months,in thecaseofpersistenceorworseningoftheclinicalpicture, arthrotomywasindicated.The totalfollow-up ofpatients was12months.

Results

Of 78 enrolled patients, after 6 months of follow-up, 5 (6.4%)didnotobtaina favorableresult,duetopersistent limitation of mouth opening. This represented 9 ATMs (3 WilkesVand6WilkesIV),i.e.,6.52%forall138joints stud-ied.Inthesecases,discopexywithuseofmini-anchorswas

Wilkes II Wilkes III Wilkes IV Wilkes V 0

25 50 75 100

Mouth opening improvement Pain relief

Figure 6 Relationship between means (in percentage) of mouth opening improvement and pain relief, compared to WilkesstagesfoundduringTMJarthroscopy.

performed,obtainingtheresolutionoftheclinicalpicture, withsignificantimprovementinmouthopening.Thesuccess rateofALLwas93.59%consideringall78patientsenrolled; and93.48%when considering all138ATMs treated. Inthe item ‘‘mouth opening improvement’’ and considering all 78 patients, the overall index was85.3%, withvariations inthemeansobtained:68.7%forWilkesVpatients;83.2% forWilkesIV;92.5%forWilkesIII,and96.8% forWilkesII. Thesmallestandthelargestlengthswere36mmand52mm, respectively,withaglobalmeanof45mm.Stillconsidering the78patientsstudied,‘‘improvementofpaininfunction’’ occurredin91.2%, withvariationsinthe meansobtained: 81.9%forWilkesVpatients;89.2%for WilkesIV;95.4%for WilkesIII, and98.3%for WilkesII.The lowest andhighest VASscoreswere6and10,respectively,withaglobalmean of9.2(Fig.6).Aftersixmonths,controlMRIsshowedthat in 63% of cases, there wasimprovement in articular disk position,with itslocation between 11 and 12h (at rest), comparedwithinitialMRIs,wherethediscsweredisplaced. Eleven cases (7.9%) of post-ALL complications in our 138 ATMsoccurred,asfollows:5casesoffluidaccumulationin thesite(3.6%),3casesofhearingfullnessand/orloss(2.2%), 2casesofearcanallacerations(1.4%),and1caseof paral-ysisofthetemporalbranchoffacialnerve(0.7%)(Table3). Allcomplications were transient, not requiring additional treatment.

Discussion

Arthroscopic lysis and lavage has been successfully employedininternaldisorders(ID)ofTMJrefractoryto con-servativetherapywithocclusalsplintsandphysiotherapy.In thisstudy,allpatientswerepreviouslytreatedwithsplints and physiotherapy, and were referred for the procedure because there was persistence of limited mouth opening and/orintra-articularpain.

In the literature, the success rate for improving oral openingandpainsymptomsvary.SandersandBuoncristiani18

describedtheirclinicalexperienceusingALLandobtained excellentresultsin82% oftheirpatients witha maximum inter-incisalopening(MIO)ofnotlessthan40mm,andlittle ornoTMJpain.Indresano19_obtained_a_73%_success_rate_in_a

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Table3 Post-ALLcomplications.

TMJs Localfluid accumulation

Hearingfullness Earcanallaceration Paralysisofthetemporal branchoffacialnerve

Total

138 3.6% 2.2% 1.4% 0.7% 11(7.9%)

recommendedmovementswithcannulaandblunttrocarin theanterior-posteriordirection, andobtainedareduction ofpainin92%of237patientsundergoingALL;theseauthors alsoreportedimprovementinmouthopeningtogreaterthan 40mmwithMIOin78%.Perrotetal.21 _observed_decreased

painandincreasedjointmobilityinaprospectivestudyof76 jointstreatedwithALL; thewholegroupwastreatedwith corticosteroidinjection.Clarketal.22_observed_a_reduction

of painin 57% of patients and improvement in the range of mandibular movement in 83%. In a follow-up study of 63patients over4 years,Moore23 _concluded_that _ALL_was

beneficialin87%ofpatients.Kuritaetal.24_reported_an

over-allresponse rate of 86% whenusing ALLfor treatingTMJ internaldisorders.InpatientsundergoingALL,Dimitroulis25

reportedgoodresultsin66%,slightimprovementin18%,and noimprovementin16%.GonzalezGarciaetal.26_showed_that

ALLwasaseffectiveassurgicalarthroscopywithrespectto postoperativepainreductionormouthopeningincreaseat anystageofthefollow-upperiod.Kondohetal.27 _reported

a80%successratewiththeuseofALLforTMJinternal dis-order.SorelandPiecuch28 _reported_a_long-term_beneficial

effectofALLforthetreatmentofchronicTMJpain,noting that95%oftheirpatientswhowerefollowedfor4.4years hadnosignificantcomplaintsandhadasignificantincrease inmouthopening.Someauthorsobservedthatthesuccess rateofALLdependsontheWilkesstagefortheTMJ. Bron-steinandMerrill6_observed_96%_of_success_for _stage_II,_83%

forstageIII,88%for stageIV,and63%for stageV.Smolka andIizuka29_observed_a_average_success_rate_of_86.7%,

ran-gingfrom75% to92.3%according tothestage intowhich theTMJwas.Thesevariationsinresultswerealsoobserved inthepresentstudy,withvariationsaccordingtotheWilkes stage,butglobalmeansthatwereconsistentwiththe stud-iesreviewedduringthestudyperiod.Inthepresentstudy, we didnot recommendrepeatedarthroscopy for patients whose ALL failed by the clinical criteria, because of the largedisplacementandmoreadvancedprocessof degenera-tionofthediscs(WilkesIVandV).Instead,weoptedforan arthrotomyanddiscopexywithmini-anchors,although we agreethat,insomecases,oneshouldconsiderundertaking arepeatarthroscopybeforethisarthrotomy,assuggestedin thestudybyAbd-Ul-Salametal.30_In_our_study,_we_observed

in the control RMs a new disk positioning, closer to its anatomicalposition.Thisnewarticulardiskpositionafter theALLprocedurewasalsoobservedbyClarketal.31_;_Moses

andTopper32_believe_that_this_new_articular_disk_position_is

notrelatedtoitsrepositioning,butsecondarytodisk mobi-lizationandtotheremovalofadhesionsandinflammatory degenerativeproducts.

Withrespecttocomplications,Tsuyamaetal.33

experi-enced10.3%in301casesofALL; 8.6%ofthesecaseswere otologiccomplicationsand1.7%werelesionsofthe trigem-inalandfacialcranialnerves.Theseauthorsconcludedthat ahighlevelofunderstanding oftheregionalanatomywill

help in reducing complications associated with the com-pletion of ALL. Based on10 yearsof clinical experience, Carlsetal.34 _reported_a_complication_rate_of _1.77%_in₄₅₁

TMJarthroscopiesin373patients.Thesecomplicationswere transient and mainly related to V and VII cranial nerves. Ina studyof2034 patients,Zhangetal.35 _observed_a _low

rate of complications, namely: 5 bleedings, 5 neuroprax-ias,3instrumentbreakage,2foreignbodyreactionsand2 tympanicmembraneperforations.Gonzalez-Garciaetal.36

observed1.34%ofcomplications,asfollows:earcanal lac-eration, auriculotemporalnerve paresthesias,facialnerve paralysis and impaired visual acuity --- all of them being transient complications. Severalother complicationshave beenreportedintheliterature,suchasinfections,37

arteri-ovenousfistulas,38_{pseudoaneurysms,}39_bradycardias40,41_and

asystoles,42 _all _being _very _rare. _In _this _study, _our _rate _of

complicationswassituatedwithintherangeobservedinthe literature,andalloccurrencesweretransient,notrequiring additionaltreatment.

Conclusion

Lysisandarthroscopiclavage(ALL) isa minimallyinvasive treatment,withefficientresultsinpatientswithTMJ inter-naldisordersrefractorytoconservativetherapy.ALLresults in asignificant improvement inthe rangeof mouth open-ing,decreasespaininfunctionandimprovesarticulardisk position.Inaddition,thisprocedurecarriesalow complica-tionrate.Therefore,ALLisasafeprocedureinthehandsof surgeonswhohavemasteredthetechnique.Furtherstudies areneeded,includingalong-termfollow-up,toconsolidate theresults.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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