(1998) 3630-34 1998 The Britsh Association of Oral and Maxilofacial Surgeons

-a-

Outcome of arthroscopic surgery to the temporomandibular joint correlates with stage of internal derangement:five-year follow-up study
K.-I. Murakami, Y. Tsuboi, K. Bessho, Y. Yokoe, M. Nishida, T. Iizuka
Surgery, Postgraduate School and Faculty of Medicine,

Department of Oral and Maxillofacial Kyoto University, Japan

SUMMARY: We studied the S-year long-term outcome of arthroscopic surgery, and also investigated whether outcome correlates with stage of internal derangement of the temporomandibular joint (TMJ). A consecutive group of 41 patients (56 joints) who had been followed up for between 3 and 5 years were involved in this study. The result was excellent in 22 patients (54%) and fair in 15 (37%). 7114 were excellent and 5114 were fair in stage III, 7112 were excellent and 4112 were fair in stage IV, and 8115 were excellent and 6/15 were fair in stage V. Arthroscopic surgery of the TMJ is an effective and minimally invasive technique for various stages of internal derangement.

INTRODUCTION Temporomandibular joint (TMJ) arthroscopy has been developed as a useful diagnostic device as well as a successful surgical tool since Ohnishis first report in 1975. Arthroscopic surgery for internal derangement of the TMJ with closed lock has been standardized as a simple and minimally invasive surgical procedure by Sanders.* With the considerable development and refinement of surgical skills and equipment, arthroscopic surgery of the TMJ currently has an important role in the diagnosis and treatment of internal derangement and arthrosis. Although the middle to long term outcome of arthroscopic surgery has been reported,3-5 the outcome of treatment correlated with the stages of internal derangement6 has been reported only by Bronstein and Merill. In this paper, we report the 5-year outcome of arthroscopic surgery of the TMJ for various stages of internal derangement.

Success criteria were as follows: the arthralgia disappeared or was only mild, mouth opening was more than 38 mm with lateral and protrusion more than 6 mm, and the patient was able to eat a normal diet. Pain was evaluated from responses to the VAS (mild pain less than two of a maximum of 10) and pain score (mild pain less than four of a maximum of 32) (Fig. 1). Dietary evaluation was assessed from the activities of daily living scores (Fig. 3, questions 2,3,6, and 7). According to Wilkes criteria for staging of the internal derangement of the TMJ,6 there were 19 stage III joints, 13 stage IV joints, 24 stage V joints disease; there were none in either stage I or II. Mean age and distance of jaw opening was higher in the advanced group (Table 1). Surgical procedures Patients with stages III and IV disease were treated by modified arthroscopic lysis and lavage. (Segami N, Murakami K, and Iizuka T: Clinical value and evaluation of operative arthroscopy for internal derangement of the temporomandibular joint. 72nd Annual Meeting and Scientific Sessions of American Association of Oral and Maxillofacial Surgeons, 1990) The technique has been published elsewhere.8 Stage V patients had advanced arthroscopic operations. First, the diagnostic arthroscopy was carried out, then the arthroscopic lysis of adhesions and mobilization of the disc by direct inspection was done under double puncture technique. Advanced arthroscopic procedures composed arthroscopic synovectomy, discoplasty, and debridement. The technique composed anterior release and posterior cauterization9 or debridement of the disc perforation when indicated with electric cautery or laser equipment. We used the Holmium YAG-laser.O In cases of advanced chondromalacia, we did an abrasion arthroplasty with a motorized shaver.
30

PATIENTS AND METHODS We studied consecutive group of 41 patients (56 joints). The mean age at the time of operation was 39 years (range 13-62 years of age), and the mean preoperative jaw opening was 30.3 mm (range 18-29 mm). Follow up ranged from a minimum of 3 years to a maximum of 5 years, 9 months. All patients filled in a questionnaire before and after operation for assessment of their signs and symptoms. The questionnaire consisted of a visual analogue scale (VAS), 8 questions about pain, 5 about jaw dysfunction, and 18 about activities of daily living (Fig l-3). The degree of interincisal opening was also recorded. The significance of differences between groups, and pre- and postoperative data were assessed by using StatView IITM soft and Wilcoxon single rank test. A probability of less than 0.05 was accepted as significant.

Arthroscopic

surgery

to the temporomandibular

joint

31

Ratethe INTENSITY of your USUAL PAINduringthe LAST WEEKby placing a slash (/) somewhere on the line below.

Nopo

Most intense pain imaginable

INSTRUCTIONS: Please checkthe appropriate answerto the followmgquestions. Doesnt HlUt AtAll Hurts A Little Hurts A Lot Almost Unbearable Unbearable PainWithout Relief

A. Jaw Pain Questions 1. DoesIt hurt when you open tilde or yawn? 2. Doeslt hurt when you chew, or use the jaws? 3. Doesit hurt whenyou are not chewmgor using the jaws? 4. Is your pam worseon waking? 5. Do you havepain in front of the earsor ear aches? 6. Do you havejaw muscle(cheek) pain? 7. Do you havepam in the temples? 8. Doyou havepain or soreness m the teeth?
Fig. 1 - Pain questionnaire. Visual analogue

scale and questions

about

jaw pain.

B. Jaw FunctionQuestions 1. Do your jaw jomts makenoiseso that it bothersyou or others? 2. Do you find It difficult to open your mouth wide? 3. Does your jaw everget stuck (lock) asyou open it? 4. Does your jaw everlock open soyou cannot closeit? 5. Is your bite uneomfortable?

No

Maybe A Little

Quite A Lot

AlmostAll The Time

All the Time Without stopping

Fig. 2 - Questionnaire

about

jaw dysfunction.

The five-item

questionnaire

used to assess jaw function.

32

British

Journal

of Oral and Maxillofacial

Surgery

INSTRUCTIONS: Please check in the columns belowhow much these xtivlties USUALLY CAUSE PAIN(doesnot include unusual or prolongedactivity,e.g., driving on a long trip). Doesnt Hurt AtAll Hurts A Little Hurts A Lot Unbearable
AhlOSt Pain Prevents

Activity 1. Walking 2. Eating SoRFood 3. Eating Hard Food 4. Jaw Opening

5. Sleeping 6. Chewing 7. Swallowing 8. Talking

Unbearable

Activity

9. Pushing@ Pulling 10. Resting 11. Driving 12. Dressing

13. sports

14. Reading 15. WatchingTV 16. HouseholdChores 17. Gardening 18. Employment
Fig. 3 - Daily activity questionnaire in relation to TMJ pain and dysfunction. The B-item questionnaire used to assessactivities of daily living; questions 2, 3,6, and 7 were used to evaluate dietary condition. Table 1 -Clinical Stage I II III IV V Total details preoperatively No. of joints 0 0 19 13 24 56 Age (years) Jaw opening (mm) VAS

30.4 (12.4) 40.0 (16.4) 41.6 (14.9)*

29.4 (4.0) 30.8 (5.4) 33.0 (4.4)*

4.3 (2.8) 5.4 (3.4) 5.4 (1.7)

*P < 0.05 compared with stage III. Figures are mean (SD).

The surgical goals were to clean up the joint compartment, reduce joint friction, and preserve the disc as long as possible.

RESULTS

Postoperatively there was a significant increase in the distance that the jaws opened, a reduction in the VAS and pain dysfunction, and improved scores for

activities of daily living (Table 2). The overall success rate was 90%. When the results of the 5-year follow-up study of TMJ arthroscopic surgery were correlated with stages of TMJ internal derangement, there was a relative high success rate in patients with stage V disease, but no significant difference between stages III, IV and V (Table 3). The postoperative radiographic findings showed mild to moderate remodelling, but no severe progressive degenerative changes such as abnormal condylar

Arthroscopic Table 2 - Comparison of baseline VAS Preoperative Postoperative All postoperative *ADL: Activities 4.6 (3.2) 0.9 (2.3) scores were significantly of daily living. and postoperative Pain score 7.8 (5.4) 1.4 (2.1) different from measurements in 56 patients

surgery

to the temporomandibular

joint

33

Jaw function 62 (3.2) 1.8 (1.9) preoperative scores

ADL* 8.5 (3.8) 1.7(2.1) (P < 0.05). Figures

Jaw opening 30.39 (4.9) 43.0 (4.4) are mean (SD)

(mm)

Table 3 of TMJ

Arthroscopic

results

in patients

correlated

with

stages of internal

derangement

Stage 111 IV V Total

No of patients 14 12 15 41 from 3 years

Excellent 7 7 8 22

Result Fair 5 4 6 15

Poor 2 I 1 4 after

Success

rate (%I) 86 92 93 90

*Outcome was judged 4 years. 4 months).

to 5 years and 9 months

operation

(mean

absorption or mandibular fossa perforation. Overall, the postoperative joint noise scarcely bothered the patients.

DISCUSSION

In 1992, Bronstein and Merill published their outcome study of TMJ arthroscopic surgery correlated with Wilkes staging of internal derangement in a short-term follow-up.7 They reported a success rate of 96% for stage II, 83% for stage III, 88% for stage IV, and 63% for stage V disease. A relative low success rate for arthroscopic surgery in patients with stage V disease and patients who had had arthrotomy has been reported. Sanders and Buoncristiani described 5 years experience with arthroscopic lysis and lavage,j and their cumulative success rate for arthroscopic surgery for internal derangement with closed lock was 97% and 92% for arthrosis with degenerative change. Quinn reported good results for arthroscopic abrasion arthroplasty and discoplasty for advanced stages of internal derangement. I2 Our study confirmed a 93% success rate for advanced arthroscopic surgery for stage V disease in a 4-year follow-up study.? These results indicate that TMJ arthroscopic surgery is a reliable, acceptable, and appropriate procedure for various stages of internal derangement. The treatment mechanism of arthroscopy has not been fully explained, we do not know why the lysis and lavage of the upper joint compartment was effective in unlocking the jaw as well as treating intracapsular conditions such as synovitis,4,15 chondromalacia,.i4 and adhesionsI or arthrosisi of the TMJ. Inflammatory mediators such as prostaglandin El, leukotriene B,, neuropeptides, and cytokines have been isolated from the diseased joint fluid in the TMJ, ZI and the biological effect of this procedure is possible that lysis breaks down the adhesions which reduce surface tension and friction; and lavage washes out the intra-articular by-products of the inflammatory process and their

degradation products from the painful and dysfunctional joint compartment. Good long term results have been reported for arthroscopy. Arthrocentesis has been reported as useful minimal invasive procedure for internal derangement with closed lock TMJ. Good short term and long term results have been reported.2 ?4 These results suggest that the procedure would be an alternative procedure to arthroscopic surgery. In our experience, however, arthrocentesis was less effective than arthroscopic surgery for both chronic locking TMJ and for elderly patients.? We are undertaking a study at present that shows that more advanced intracapsular disease is refractory to simple procedures. Internal derangement (stage V) of the TMJ is clinically characterized by joint crepitation induced by disc perforation and degenerative changes as a result of progressive condylar remodelling. In the management of stage V disease and arthrosis, our surgical techniques have shown excellent results. However, some patients who did not respond to arthroscopic surgery were reoperated or switched by conventional open arthrotomy. Open TMJ surgery should include the eminectomy procedure for closed lock,s discectomy without disc substitute,?6 or a high condylectomy.7 In conclusion, we believe that arthroscopic surgery is an effective, minimally invasive, and stable procedure, even for advanced internal derangement of the TMJ.
References
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and Maxillofacial

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20. Kubota E, Imamura H, Kubota T, Shibata T, Murakami K. Interleukin-1B and sromelysin (MMP3) activity of synovial fluid as possible markers of osteoarthritis in the temporomandibular joint. J Oral Maxillofac Surg 1997; 55: 20-27. 21. Nizan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991; 49: 1163-1167. 22. Murakami K. Hosaka H. Moriva Y. Seaami N. Iizuka T. Short-term treatment outcome study fo; the management of temporomandibular joint closed lock: a comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg 1995; 80: 253-257. 23. Hosaka H, Murakami K, Goto K, Iizuka T. Outcome of arthrocentesis for temporomandibular joint with closed lock at 3 years follow-up. Oral Surg 1996; 82: 501-504. 24. Nitzan DW, Samson B, Better H. Long-term outcome of arthrocentesis for sudden-onset, persistent, severe closed lock of the temporomandibular joint. J Oral Maxillofac Surg 1997; 55: 151-157. 25. Stassen LF, Currie WJ. A pilot study of the use of eminectomy in the treatment of closed lock. Br J Oral Maxillofac Surg 1994; 32: 1388141. 26. Wilkes WH. Surgical treatment of internal derangements of the temporomandibular joint. A long-term study. Arch Otolaryngol Head Neck Surg 1991; 117: 6472. 27. Poswillo D. The late effects of mandibular condylectomy. J Oral Surg 1972; 35: 500. The Authors Ken-Ichiro Morakami DDS, DMSc Associate Professor and Associate Head Youichi Tsuboi DDS, DMSc Kazuhisa Bessho DDS, DMSc Yoshiyuki Yokoe DDS Instructor Mitsuo Nishida DDS, DDSc Assistant Professor Tadahiio Iizuka DMD, DMSc Professor and Chairman Department of Oral and Maxillofacial Surgery Postgraduate School and Faculty of Medicine, Kyoto University Sakyoku, Kyoto 606, Japan This study was supported by grant-in-aid for scientific research (project No. 08672299) Japanese Ministry of Education, Science, Sports and Culture. Correspondence and requests for offprints to: Dr Ken-Ichiro Murakami, Department of Oral and Maxillofacial Surgery, Kyoto University Hospital, Sakyoku, Kyoto 606, Japan Paper received 8 July 1996 Accepted 8 March 1997