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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 34-44

Minimally invasive surgeries for the treatment of temporomandibular disorders: Prognostic indicators and persistence of treatment outcomes over a 5-year follow-up


1 Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates; Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates; Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Suez Canal University, Ismaillia, Egypt
2 Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates; Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
3 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Sinai University, Arish, Egypt

Date of Submission23-Oct-2021
Date of Decision02-Dec-2021
Date of Acceptance06-Dec-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Wael M Talaat
Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, University Dental Hospital Sharjah, Office 125, P.O. Box: 27272.
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/abhs.abhs_14_21

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  Abstract 

Background: Patients refractory to conservative treatment of temporomandibular disorders (TMD) are candidates for more invasive treatments such as arthroscopy and arthrocentesis. The aim of the present study was to identify the predictors of long-term success and the persistence of treatment outcome for temporomandibular joint (TMJ) arthroscopic lysis and lavage and arthrocentesis for the treatment of TMD. Methods: An analysis of 64 minimally invasive surgeries used to treat disk displacement without reduction in group I (n = 36), and osteoarthritis in group II (n = 28) was conducted. Success was identified as a pain score ≤ 3, disability score ≤ 2, and maximal mouth opening greater than 35 mm. Results: The overall success rate was 85.9%. The difference in success rate between groups was not significant (P = 0.441). Preoperative predictors of success in group I were fewer tender muscles (P < 0.01), shorter duration of symptoms (P = 0.046), lower pain (P < 0.01), and lower disability (P = 0.0104), whereas in group II there were fewer tender muscles (P < 0.01), less limitation in opening (P < 0.01), and lower disability (P = 0.0131). Conclusion: Arthroscopy and arthrocentesis were equally efficient after 5 years. Fewer tender muscles and lower disability preoperatively were common predictors of success. Pain recorded at 1 year, and maximum opening and disability recorded at 3 months were maintained after 5 years.

Keywords: Arthrocentesis, arthroscopic lysis and lavage, arthroscopy, disk displacement without reduction, osteoarthritis, temporomandibular disorders, temporomandibular joint, temporomandibular joint pain


How to cite this article:
Talaat WM, Hamdoon Z, Ghoneim MM. Minimally invasive surgeries for the treatment of temporomandibular disorders: Prognostic indicators and persistence of treatment outcomes over a 5-year follow-up. Adv Biomed Health Sci 2022;1:34-44

How to cite this URL:
Talaat WM, Hamdoon Z, Ghoneim MM. Minimally invasive surgeries for the treatment of temporomandibular disorders: Prognostic indicators and persistence of treatment outcomes over a 5-year follow-up. Adv Biomed Health Sci [serial online] 2022 [cited 2022 Aug 18];1:34-44. Available from: http://www.abhsjournal.net/text.asp?2022/1/1/34/335719




  Background Top


TMD are a common and entangled group of disorders affecting the soft tissue and bony components of the TMJ [1]. Among patients with TMD, 80% were reported to have internal derangement. Pain, joint sounds, and limitation of mouth opening are the predominant symptoms, and they are often disabling if the condition is left untreated [2]. Osteoarthritis of the TMJ often occurs in conjunction, or as a sequela of internal derangement, and involves degenerative changes in the soft tissue and bony components of the joint [3].

One of the commonly used classifications for TMD is the research diagnostic criteria for temporomandibular disorders (RDC/TMD), which has two assessment components: Axis I involves a clinical evaluation of signs and symptoms, whereas Axis II is an assessment of the psychosocial dysfunction and pain-related disability [4,5]. Another popular classification is that proposed by Wilkes, which classifies TMD into five stages according to the severity of the clinical and radiologic findings [6].

The main objective in managing TMD is to reduce pain and restore normal function. Conservative treatment has been recommended as the starting point in the management process. Reports about success rates of different forms of nonsurgical treatment have been contradicting, ranging from 36% [7] to 88% [8]. Patients refractory to conservative treatments are usually candidates for more invasive forms of treatment.

Open joint surgery was the principal treatment approach for patients not responding to conservative treatment in the past. Nowadays, open joint surgeries are indicated only after minimally invasive approaches fail. Procedures such as discectomy, eminoplasty, and disk plication are successful in reducing pain and increasing the range of mouth opening, but the associated risk is high [9,10]. Patients who do not improve after conservative treatment, minimally invasive and open joint surgeries are indicated for TMJ replacement. Currently, the minimally invasive approaches, such as arthroscopy and arthrocentesis, are the treatment modalities of choice for managing TMD. The use of the arthroscope in the TMJ was first described by Onishi in 1975 [11]. Since then, a lot of progress has been achieved with respect to the use of arthroscopy in managing TMD [12-20]. Arthroscopic lysis and lavage have proven to be efficient in treating osteoarthritis and internal derangement of the TMJ by breaking the adhesions inside the joint, washing out the inflammatory mediators, and eliminating the suction effect of the disk to the fossa [15]. In 1987, Murakami et al. [21] introduced arthrocentesis of the TMJ. They applied the same concept of lysis and lavage of the joint without the need for visualization. The double-puncture arthrocentesis technique as used today was first described by Nitzan et al., [22] whereas later several proposals for single puncture arthrocentesis were introduced [23-25].

The choice of either the arthroscopic lysis and lavage or arthrocentesis technique for the treatment of TMD is controversial, especially when both techniques share the same mode of action, and the indications for both techniques are overlapping [20]. The choice will depend on several factors, including the cost, available resources, and the surgeon’s experience. Each technique has its own advantages and disadvantages. Several studies have compared arthrocentesis and arthroscopic lavage of the TMJ for the treatment of TMD [26-33]; however, the follow-up periods in many of these studies were relatively short, and the results were indecisive. The aim of this study was to identify the predictors of success and the persistence of treatment outcome after 5 years for arthroscopic lysis and lavage and arthrocentesis, with viscosupplementation for the treatment of TMD.


  Materials and methods Top


The clinical records of patients who had undergone TMJ arthroscopic lysis and lavage and arthrocentesis by one of the authors from January 2012 to August 2015 were retrieved and individually analyzed for inclusion in this study. Inclusion criteria included: (1) a unilateral diagnosis of disk displacement without reduction with limited opening (RDC/TMD group IIb) or osteoarthritis (RDC/TMD group IIIb), which was confirmed by magnetic resonance imaging (MRI) or cone-beam computed tomography (CBCT) or both; (2) failure to respond to conservative treatment after 2 months; (3) limited maximal mouth opening (MMO) <35 mm; (4) joint noise in the form of crepitus; and (5) pain score of 6 or more on a 10-point visual analog scale (VAS). Patients were excluded if they had incomplete medical records or if they had a history of TMJ surgery or a history of malignancy. The study was conducted at the department of Oral and Maxillofacial Surgery, College of Dentistry, Suez Canal University, Egypt, and it was approved ethically by the Research Ethics Committee at Suez Canal University (reference no. 2017/45). The study was conducted in accordance with the principles of the World Medical Association Declaration of Helsinki (version 2002). All patients signed an informed consent form that was approved by the Research Ethics Committee. Informed consent to publish images in an online open-access publication was also obtained from the concerned patients.

Standardized questionnaires adopted from RDC/TMD [4] were used preoperatively and on each postoperative evaluation session to assess the TMJ pain and level of disability. Pain was assessed on a 10-point VAS, with 0 indicating no pain, and 10 indicating the worst pain; however, the disability level was measured on a disability scale and was graded by points according to the RDC/TMD Axis II, where no disability = 0 points, mild disability = 1 to 2 points, moderate disability = 3 to 4 points, and severe disability = 5 to 6 points. The preoperative and postoperative clinical examinations were done according to the RDC/TMD assessment instruments [4]. The history and duration of symptoms were recorded. Patients were then referred for radiologic assessment by using MRI. CBCT was used if arthritic bony changes were suspected.

After a clinical and radiographic examination, patients who were diagnosed with either disk displacement without reduction with limited opening (RDC/TMD group IIb) or osteoarthritis (RDC/TMD group IIIb) were referred for conservative treatment. The conservative treatment was carried out for 2 months and included jaw rest, soft diet, nonsteroidal anti-inflammatory drugs, physiotherapy, and soft stabilizing occlusal splint. Patients who did not respond to conservative treatment and accordingly had undergone minimally invasive surgeries were divided into two diagnostic groups: Group I consisted of patients with disk displacement without reduction with limited opening, whereas group II consisted of patients with osteoarthritis. Group I was subdivided into two groups: Group Ia consisted of patients who underwent arthroscopic lysis and lavage of the affected joints [Figure 1]A, and group Ib consisted of patients who underwent single-puncture arthrocentesis of the affected joints [Figure 1]B. Group II was subdivided into two groups: Group IIa consisted of patients who underwent arthroscopic lysis and lavage, and group IIb consisted of patients who underwent single-puncture arthrocentesis of the affected joints.
Figure 1: (A) Arthroscopic lysis and lavage technique. (B) Single-needle arthrocentesis technique

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Arthroscopic lysis and lavage were performed under general anesthesia by using a 2.3 mm 30 degree arthroscope with a cannula of 2.4 mm internal diameter (Stryker Co., San Jose, CA, USA). The trocar and cannula were inserted at a point 10 mm in front of the tragus, and 2 mm below the canthal-tragus line in cases where the canthal-tragus distance was ≥70 mm. In cases where the canthal-tragus distance was <70 mm, the location for insertion was marked as 7 mm in front of the tragus and 2 mm below the canthal-tragus distance [34]. Lavage of the upper joint compartment was done by using 300 ml of normal saline. The trocar was moved in a gliding action from the anterior recess to the posterior recess to break the adhesions. After the procedure, 1 ml of commercially available low-molecular-weight sodium hyaluronate (Hyalgan; Fidia, Abano Terme, Italy) was injected for viscosupplementation. Single-puncture arthrocentesis was performed under local anesthetic in an outpatient setting. The procedure involved the insertion of a Y-shaped dual-port cannula (Shepard cannula, Normed, Tuttlingen, Germany) into the upper joint compartment. The point of insertion was identical to that of the arthroscopy procedure. The joint was irrigated by 300 ml of normal saline. Viscosupplementation was then followed by an injection of 1 ml commercially available low-molecular-weight sodium hyaluronate (Hyalgan; Fidia, Abano Terme, Italy).

The postoperative care for all patients in both groups involved the prescription of nonsteroidal anti-inflammatory drugs for 3 days after surgery. All patients completed a standardized exercise protocol that started 1 day after surgery and lasted for four weeks. In patients with muscle spasms, a soft stabilizing occlusal splint was used immediately after surgery for 6 months. All patients were scheduled for evaluation on postoperative day 1, and 3 and 6 months, and one, three, and 5 years later. The outcome parameters recorded on the postoperative visits were subjective pain evaluation on a 10-point VAS, the maximal mouth opening measured as the interincisal distance between the upper and lower incisors, the subjective level of disability indicated on a scale from 0 to 6 points, joint sounds, and postoperative complications.

The treatment outcome was evaluated at the 5-year follow-up session and was categorized as either success or failure. Success was identified as a pain VAS score equal to or less than 3, disability score equal to or less than 2, and maximal mouth opening more than 35 mm. Failure was identified as incapacity to achieve one or more of the scores required for success. The recorded variables that were analyzed to assess their relation to the treatment outcome were the gender, age, preoperative duration of symptoms, preoperative muscular involvement, preoperative pain VAS, preoperative maximal mouth opening, and disability scores.

Statistical analysis

Quantitative variables were described by the mean and standard deviation and the upper and lower limits of the 95% confidence interval of the mean. Paired-sample t test was used for testing measurements within the same group, whereas independent-sample t test was used for comparing the mean changes between groups. Chi-squared test and Fisher exact test were used for categorical data. General Linear Model (GLM) repeated-measures ANOVA, with time as the within-subjects factor and group as the between-subjects factor, was used for the analysis of change in treatment outcome variables with time. Due to the significant Mauchly’s Test of Sphericity results, Greenhouse-Geisser correction was applied. Bonferroni method was applied for multiple comparisons. Significance level was set at P < 0.05. Statistical analysis was performed by using SPSS (version 17).


  Results Top


In total, 86 arthroscopic lysis and lavage and arthrocentesis operations met the criteria for inclusion in this study. Twenty-two operations were excluded, mainly due to the presence of incomplete medical records. The clinical records of the remaining 64 patients were retrieved and individually analyzed. Patients who did not respond to conservative treatment and accordingly had undergone minimally invasive surgeries (n = 64; 43 females, 21 males; age range 18 to 52 years, mean 36.5 ± 9.6) were divided into two diagnostic groups: Group I consisted of 36 patients (23 female, 13 male; age range 18 to 52 years, mean 37.56 ± 11.11) with disk displacement without reduction with limited opening, whereas group II consisted of 28 patients (20 female, 8 male; age range 21 to 52 years, mean 35.14 ± 7.18) with osteoarthritis. Group I was subdivided into two groups: Group Ia consisted of 18 patients (13 female, 5 male) who underwent arthroscopic lysis and lavage of the affected joints, and group Ib consisted of 18 patients (10 female, 8 male) who underwent single-puncture arthrocentesis of the affected joints. Group II was subdivided into two groups: Group IIa consisted of 14 patients (11 female, 3 male) who underwent arthroscopic lysis and lavage, and group IIb consisted of 14 patients (nine female, five male) who underwent single-puncture arthrocentesis of the affected joints. The mean follow-up period was 5.4 years. The overall success rate according to the defined criteria for the entire patients’ population was 85.9% (n = 55). The difference in success rate between the two diagnostic groups (group I and group II) was not statistically significant (P = 0.441).

Preoperative demographic and clinical variables (gender, age, duration of symptoms, muscle tenderness, Wilkes stage)

The difference in success rate in relation to gender was not statistically significant in group I (P = 0.541), in group II (P = 0.447) or when considering the two diagnostic groups collectively (P = 0.971). The mean age of patients with successful outcome in group I was 37.38 ± 10.94, in group II was 35.09 ± 7.5, and in the entire patients’ population was 36.42 ± 9.64. The mean age of patients with a failure outcome in group I was 39 ± 14.17, in group II was 35.4 ± 6.19, and in both groups together was 37 ± 9.9. The difference in success rate in relation to age was not statistically significant in group I (P = 0.787), in group II (P = 0.931), or when considering the two diagnostic groups collectively (P = 0.867).

The mean preoperative duration of symptoms in months for the entire patients’ population was 16.61 ± 11.58, for group I was 15.44 ± 10.8, and for group II was 18.11 ± 12.55. Patients with successful outcome had a significantly shorter preoperative duration of symptoms in group I (P = 0.046), and in the two diagnostic groups collectively (P < 0.01). However, the duration of symptoms could not be correlated with the treatment outcome in group II (P = 0.103) [Figure 2]A. All the patients with unsuccessful outcome had tenderness in one or more jaw muscles preoperatively. In failure outcome cases, three patients (33.3%) had four tender muscles, two patients (22.2%) had three tender muscles, three patients (33.3%) had two tender muscles, and one patient (11.1%) had one tender muscle. Patients with successful outcome had a significantly lower number of tender jaw muscles during the preoperative examination compared with patients with unsuccessful outcome (P < 0.01). In the successful outcome cases, 36 patients (65.5%) had no tender muscles, three patients (5.5%) had four tender muscles, three patients (5.5%) had three tender muscles, six patients (10.9%) had two tender muscles, and seven patients (12.7%) had one tender muscle.
Figure 2: (A) Preoperative duration of symptoms in relation to treatment outcome. (B) Change of mean pain visual analog scale (VAS) with time. (C) Change of mean maximal mouth opening (MMO) with time. (D) Change of mean disability scores with time

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When classifying patients according to Wilkes stages, [6] there was no statistically significant difference between the different stages in relation to the treatment outcome in both groups and in the entire patients’ population (p > 0.05) [Table 1].
Table 1: Relationship between treatment outcome and Wilkes stage

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Treatment outcome variables (pain, maximal mouth opening, disability, complications)

Pain

Pain levels significantly decreased in the arthroscopic lysis and lavage group (group Ia + group IIa) (P < 0.001) and in the arthrocentesis group (group Ib + group IIb) (P < 0.001) [Table 2]. There was no statistically significant difference in pain reduction between arthroscopic lysis and lavage and arthrocentesis at the 5-year follow-up session (P = 0.664). Patients with successful outcome had a significantly lower pain level (1.20 ± 0.93) compared with the unsuccessful cases (4.33 ± 0.71) at the 5-year follow-up session (P < 0.001). In group I, patients with successful outcome had a significantly lower preoperative pain level (7.25 ± 0.84) compared with the unsuccessful cases (8.50 ± 0.58) (P < 0.01). However, in group II, there was no statistically significant difference in preoperative pain level between successful (8.00 ± 0.90) and unsuccessful cases (8.60 ± 0.89) (P = 0.189).
Table 2: Pain VAS and MMO in arthroscopic lysis and lavage and arthrocentesis groups

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Maximal mouth opening

The MMO significantly increased in the arthroscopic lysis and lavage group (group Ia + group IIa) (P < 0.001) and in the arthrocentesis group (group Ib + group IIb) (P < 0.001) [Table 2]. There was no statistically significant difference in MMO between arthroscopic lysis and lavage and arthrocentesis at the 5-year follow-up session (P = 0.068). Patients with successful outcome had a significantly more increase in MMO (41.45 ± 2.72) compared with the unsuccessful cases (35.22 ± 3.60) at the 5-year follow-up session (P < 0.0001). In group I, there was no statistically significant difference in preoperative MMO between successful (29.53 ± 3.56) and unsuccessful cases (27.00 ± 1.41) (P = 0.173). However, in group II, patients with successful outcome had a significantly larger preoperative MMO (27.53 ± 2.55) compared with patients with unsuccessful outcome (23.60 ± 3.36) (P < 0.01).

Disability

Disability scores significantly improved in the arthroscopic lysis and lavage group (group Ia + group IIa) (P < 0.001) and in the arthrocentesis group (group Ib + group IIb) (P < 0.001) [Table 3]. There was no statistically significant difference in disability scores between arthroscopic lysis and lavage and arthrocentesis at the 5-year follow-up session (P = 0.636). Patients with successful outcome had significantly lower disability scores than those with unsuccessful outcome at the 5-year follow-up session (P < 0.001). At 5 years, patients with unsuccessful outcome had the most common disability scores, such as 3 (33%) and 2 (33%) followed by 4 (22.2%), and then 1 (11.1%); however, patients with successful outcome had the most common disability score as 0 (67.3%) followed by 1 (29.1%), then 2 (3.6%), then 3 (0.0%), and 4 (0.0%). Patients with successful outcome had significantly lower preoperative disability scores compared with patients with unsuccessful outcome in both group I (P = 0.0104) and group II (P = 0.0131).
Table 3: Disability scores in arthroscopic lysis and lavage and arthrocentesis groups

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Complications

One of the 14 patients in group IIb had an intraoperative complication, in the form of a perforation of the external auditory canal. This patient recovered without any sequelae after the procedure and had no postoperative complications.

Analysis of change in treatment outcome variables with time

Pain

The difference in pain VAS measured preoperatively was statistically significant compared with all other postoperative scores (3 months (P < 0.001), 6 months (P < 0.001), 1 year (P < 0.001), 3 years (P < 0.001), and 5 years (P < 0.001)). The difference in pain VAS measured at 3 months was statistically significant compared with that measured at 3 years (P = 0.017) and that measured at 5 years (P < 0.01). Pain measured at 6 months was statistically significant only when compared with that measured at 5 years (P = 0.036) [Table 4]. The change in pain VAS with time in group I and group II is shown in [Figure 2B].
Table 4: Analysis of change of pain VAS with time

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Maximal mouth opening

The difference in MMO measured preoperatively was statistically significant compared with all other postoperative scores (3 months (P < 0.001), 6 months (P < 0.001), 1 year (P < 0.001), 3 years (P < 0.001), and 5 years (P < 0.001)) [Table 5]. The change in MMO with time in group I and group II is shown in [Figure 2C].
Table 5: Analysis of change of MMO with time

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Disability

The difference in disability scores measured preoperatively was statistically significant compared with all other postoperative values (3 months (P < 0.001), 6 months (P < 0.001), 1 year (P < 0.001), 3 years (P < 0.001), and 5 years (P < 0.001)) [Table 6]. The change in disability scores with time in group I and group II is shown in [Figure 2D].
Table 6: Analysis of change of disability scores with time

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Analysis of reinterventions

Surgical reinterventions using the same technique were conducted in two patients in group Ia (11.11%), three patients in group Ib (16.67%), two patients in group IIa (14.29%), and three patients in group IIb (21.43%). The mean time of reintervention during the months after the first surgical intervention was 15.29 ± 13.69. The success rate after the reinterventions according to the defined criteria was 60.0% (n = 6). Patients with a successful outcome after the reinterventions were two patients in group Ia (100%), two patients in group Ib (66.67%), one patient in group IIa (50%), and one patient in group IIb (33.33%). The improvement in all treatment outcome variables after the reinterventions was maintained till the end of the follow-up period. Patients with a failure outcome (n = 4) had a mean preoperative duration of symptoms during months of 25.70 ± 8.35, two or more tender muscles, a mean preoperative MMO of 27.00 ± 1.02, and a mean disability score of 5 ± 1. Patients with a failure outcome were referred for operative arthroscopy.


  Discussion Top


Both arthroscopic lysis and lavage and arthrocentesis are regarded as efficient approaches for treating the symptoms of TMD, with each technique having its own advantages and disadvantages. Arthroscopy helps in the diagnosis and treatment planning, and it allows the blunt release of adhesions inside the joint; however, arthrocentesis is more cost-efficient, is usually performed under local anesthesia as an in-office procedure, and allows the inflammatory mediators and debris to be flushed out of the joint for better prognosis [35]. It was suggested that both techniques differ in terms of complications, long-term outcome, and prognosis, [30-32] although the concept behind both techniques is similar, which is the joint lavage [36]. The relapse of symptoms after the initial successful treatment of TMD is a major problem, as it might lead to a more invasive form of treatment. It was suggested that the relapse of symptoms is common when TMJ inflammation is present [35]; however, the predictors of long-term success of both techniques are missing in the literature.

In the present study, the overall success rate for the two diagnostic groups was 85.9%. This was in agreement with other studies that reported the settlement of symptoms in 70%–86% of cases [37-39]. The results of the present study did not confirm a relationship between the age or gender and the treatment outcome, whereas it was suggested in a systematic review that older age might be considered a poor indicator for the prognosis of arthroscopy and arthrocentesis [40]. This was contradicted in another study that concluded that younger age is a predictor of a negative outcome for arthroscopic lysis and lavage [41]. With regard to the preoperative duration of symptoms, the results of the present study showed that the shorter duration of symptoms was a predictor of success for the treatment of disk displacement without reduction; however, this relationship could not be confirmed in cases of osteoarthritis, although there was a tendency toward the same result. This was in accordance with a systematic review suggesting that the chronicity of joint symptoms is a poor indicator for the outcome of both arthroscopy and arthrocentesis [40]. These findings raise concerns about a general attitude of patients with TMD, who tend to ignore their symptoms for a long time before seeking treatment. It was reported that only one fifth of patients who exhibit symptoms will seek treatment, which negatively affects their prognosis [42].

One of the main findings of the present study is the confirmed relationship between the number of tender jaw muscles and the treatment outcome, where the lower number of tender jaw muscles was significantly associated with a successful outcome. These results were in agreement with two other studies that found a positive correlation between the preoperative bilateral involvement of masticatory muscles and the negative surgical outcome [41,43]. The authors believe that controlling the muscular and the psychosocial components is of prime importance for the success of both arthrocentesis and arthroscopy.

There was no influence of the Wilkes stages on the treatment outcome in the present study. This was in accordance with Gonzalez-Garcia and Rodriguez-Campo, [44] who pointed out the importance of reporting data in terms of staging and time of evaluation, because of the changing course of TMD with time. In the present study, both arthroscopic lysis and lavage and arthrocentesis were equally efficient in reducing pain and improving MMO after 5 years. Several studies reported that both techniques are equally efficient in reducing pain, but arthroscopy was more efficient in improving MMO after 12 months [28,45]. Another meta-analysis favored arthroscopy with regard to both pain and MMO, [40] whereas several studies found no differences between both techniques, in agreement with the present study [29-32]. Nitzan argued that the success of minimally invasive surgeries in reducing pain and improving MMO is attributed to the effect of joint lavage, being efficient in releasing the joint adhesions, washing the inflammatory mediators, and widening the narrowed joint space [36]. The authors of the present study believe that the success of both procedures is also closely related to the use of sufficient lavage volume and postoperative viscosupplementation, both of which are crucial for achieving and maintaining the favorable outcomes by preserving the TMJ’s homeostasis.

In patients with disk displacement without reduction (group I), a lower preoperative pain level was a predictor of a successful outcome. However, in osteoarthritis cases (group II), there was no correlation between the preoperative pain level and the treatment outcome. It was previously reported that TMJ inflammation is an indicator for future relapse of symptoms [35]. In osteoarthritis, where inflammation and severe pain are common findings, other factors rather than the preoperative pain level might be influential in predicting the treatment outcome. In patients with osteoarthritis, the preoperative limitation in MMO seemed to correlate with the treatment outcome; however, this correlation was not significant in patients with disk displacement without reduction. This was in full agreement with Ulmner et al., [41] who elaborated the intimate relationship between the degree of inflammation inside the joint (as in osteoarthritis) and the limitation of MMO.

Self-graded disability scores improved significantly in both diagnostic groups. Preoperative disability scores correlated positively with the treatment outcome in both arthroscopic lysis and lavage and arthrocentesis, as well as in both diagnostic groups. Thus, disability can be recognized as a predictor for the treatment outcome. In other studies, the predictors of successful outcome after arthroscopic surgeries were the higher presurgical MMO and the presence of joint adhesions, [46] whereas the predictors of failure outcome were high preoperative pain scores and concurrent use of benzodiazepines [47].

Similar to any surgical procedure, arthroscopy and arthrocentesis are not risk-free. However, the incidence of postoperative complications for both procedures is very low [22,48]. An overall complication rate of 1.34% has been reported [49]. In the present study, one patient in group IIb had a perforation of the external auditory canal; however, there were no sequelae after the procedure, and the patient had no postoperative complications. The authors noticed a high incidence of transient facial nerve paralysis caused by an auriculotemporal nerve block in arthrocentesis procedures. This was resolved spontaneously within 2 h in all patients and, thus, was not considered a complication. The common adverse effects reported after arthroscopic lysis and lavage were pain, temporary malocclusion, and temporary paresthesia in the preauricular area [47].

The analysis of change in treatment outcome variables with time has shown that the pain VAS recorded at the 1-year follow-up session was maintained till the 5-year follow-up session. With regard to both MMO and disability, the values recorded at the 3-month follow-up session were maintained till the 5-year follow-up session. It has been reported that the 10-year outcome of TMJ arthroscopic surgery was acceptable and stable [50].


  Conclusion Top


The overall success rate of minimally invasive surgeries for treating disk displacement without reduction and osteoarthritis was 85.9%. Both arthroscopic lysis and lavage and arthrocentesis were equally efficient in reducing pain, improving disability and MMO after 5 years. The results of the present study did not confirm a relationship between the age, gender, Wilkes stage, and the treatment outcome. In patients with disk displacement without reduction, the lower number of tender jaw muscles, the shorter duration of symptoms, lower pain levels, and disability scores preoperatively were predictors of a successful outcome. However, in osteoarthritis, the lower number of tender jaw muscles, the less limitation in MMO, and lower disability scores preoperatively were predictors of a successful outcome. These results might be valuable for surgeons to estimate the prognosis of minimally invasive surgeries, and communicate their expectations to patients. As a future direction, the results of the present study can be used to build a machine-learning cognitive system that is capable of interpreting the patient’s specific data to assist in formulating the proper management approach of TMD.

Study limitations

The main limitations of this study were the retrospective design, the lack of a control group, and the small sample size. Therefore, the presented data should be interpreted with caution. However, considering the high prevalence of TMD, the findings of this study might encourage the pursuing of future studies with larger sample sizes and a prospective design.

Authors' contribution

WMT: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; supervision; validation; visualization; writing -original draft; writing - review and editing. ZH: Conceptualization; data curation; formal analysis; investigation; project administration; resources; supervision; validation; visualization; writing - original draft; writing - review and editing. MMG: Data curation; formalanalysis; investigation; methodology; project administration; resources; validation; visualization; writing - original draft;writing - review and editing.

Ethical policy and institutional review board statement

The study was approved ethically by the Research Ethics Committee at Suez Canal University (reference no. 2017/45).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Data availability statement

Data are available with the corresponding author (Wael M. Talaat, e-mail: [email protected]) and can be presented on request.



 
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