A Comparison of Arthrocentesis, Arthroscopy and Arthroplasty in the Treatment of Temporomandibular Joint Dysfunction
Condition: Temporomandibular Joint Dysfunction
MeSH terms: Joint Diseases; Temporomandibular Joint Disorders; Temporomandibular Joint Dysfunction Syndrome
Study type: Interventional

Summary: 
      Many patients suffer from a disorder known as temporomandibular joint dysfunction. This
      disorder has jaw joint pain and limited function as key elements. Many treatments have been
      advocated over the last 40 years, many of them deleterious. Currently treatment can be
      divided into four categories. The first is non-surgical and involves vocal rest, soft diet,
      heat, anti-inflammatory medications, muscle relaxants, splint therapy and physical therapy.
      All patients benefit to some degree utilizing one or more non-surgical approaches.
      Controversy exists with respect to which of the next three categories of treatment is ideal.
      Some advocate arthrocentesis which involves placing two small needles into the joint to allow
      irrigation and instillation of anti-inflammatory medication. This is a minimally invasive
      procedure performed under local anesthetic alone or with intravenous sedation. Others
      advocate arthroscopy which involves placing an arthroscope (a thin tube about 2mm in diameter
      with optical elements allowing one to see inside a joint) to visualize the inside of a joint.
      Furthermore the joint can be irrigated, scar bands removed, ligaments stretched and
      medication instilled. This is performed under a general anesthesia. Depending on the study,
      success for both arthrocentesis and arthroscopy has been reported to be about 80-90%. Still
      there are others who recommend arthroplasty which is an open joint surgical procedure that
      allows the surgeon to enter the joint and directly repair or remove the damaged cartilage
      disc within the joint. This is performed under a general anesthesia. Similar success rates of
      80-94% have been reported. It is clear that some patients only require arthrocentesis, others
      arthroscopy and others arthroplasty. We currently do not have any real mechanism of
      predicting which patients will benefit the most from which procedure.

      This study will enable patients undergoing each procedure to be followed closely with the
      hope that we can determine objective factors that will allow us to stratify patients into one
      of the three surgical options: arthrocentesis, arthroscopy or arthroplasty. Our current
      approach is empiric and typically proceeds from arthrocentesis to arthroscopy to
      arthroplasty. All patients in this study will be offered the opportunity to have
      arthrocentesis performed. It is anticipated that a minority will achieve long-term benefit in
      terms of pain and function. We hope to be able to identify those factors which will predict
      which patients will benefit so that future patients selected to have arthrocentesis will have
      much higher success rates. Patients who fail to improve with arthrocentesis or who initially
      decline that procedure will be offered the opportunity to undergo arthroscopy. It is
      anticipated that a majority of patients will achieve long-term benefit in terms of pain and
      function. Again it is hoped that we can identify those factors which will predict which
      patients will benefit so that future patients selected to have arthroscopy will have even
      higher success rates. Patients who fail to improve with arthroscopy or who initially decline
      both arthrocentesis and arthroscopy will be offered the opportunity to undergo arthroplasty
      provided that clinical and radiographic evidence exists to support the presence of either a
      diseased or displaced cartilage disc.

      Our ability to adequately treat patients with temporomandibular joint dysfunction will be
      significantly improved if we can better stratify patients and follow an evidence based
      surgical algorithm that provides the greatest opportunity for success while reducing
      potential complications. Each of these surgical procedures is the standard of care throughout
      the USA but unfortunately the choice of which procedure to perform is often empiric and
      guided more by training and surgical experience.
    


Intervention name(s): arthrocentesis; arthroscopy; arthroplasty
Intervention type(s): Procedure; Procedure; Procedure
Intervention description(s): Irrigate the TMJ with lactated ringers; The TMJ will be inspected with an arthroscope and the joint irrigated with lactated ringers; The disc will be surgically repositioned with open surgery
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: arthrocentesis; arthroscopy; arthroplasty