Between Arthrocentesis And Arthroscopic Approaches
Background and Historical Perspective:
Temporomandibular Syndrome is a somewhat general descriptive term comprising several distinct pathologies, all related to the various structures of the temporomandibular joint. TMJ symptomatology ranges from general myofascial discomfort which can often be addressed by conservative (non-invasive) approaches to profoundly pathological interarticular mechanical malfunctions requiring extensive surgical repairs.
In general, the vast majority of TMJ symptoms are temporary in duration and resolve either spontaneously, or with conservative treatment consisting of rest, anti- inflammatory agents, muscle relaxants, physical therapy, dental devices and/or bite adjustments, behavior modification and external application of thermal compresses.
A comprehensive evaluation is essential to accurate diagnosis, particularly since stress management problems and repressed aggression sometimes manifest as myofascial pain.
Surgical intervention should therefore always be considered as a last resort and limited to intracapsular pathology associated with significant pain and mechanical malfunction. Where surgery is indicated, the traditional choices have been arthrocentesis, arthroscopy, arthrotomy and arthroplasty, in that order, in keeping with the general principle of addressing TMJ issues as conservatively as possible. (1)
Highly invasive surgical treatment such as arthrotomy are never without potential complication, and always entail significant and prolonged patient discomfort, necessitating extensive post-operative rehabilitation, particularly in the case of arthroplasty. The relatively recent development of minimally invasive techniques such as arthrocentesis and arthroscopy offer the maxillofacial specialist surgical approaches to address many TMJ problems that do not resolve with conservative (non-surgical) treatments, but which are not appropriately addressed by arthrotomy.
Even minimally invasive techniques present the risk of potential complications unique to each procedure, so a comprehensive risk/benefit analysis and careful evaluation is also essential as between arthrocentesis and arthroscopy on a case-by-case basis.
Arthrocentesis is primarily indicated where conservative treatment fails to resolve
TMJ symptoms, particularly in cases involving sudden onset, or acute closed locking of the temporomandibular joint absent any previous history of TMJ related complaints. (2)
The procedure is usually performed in an office setting, under general anesthesia and is not associated with significant post-operative discomfort. Different variations of arthrocentesis enable the surgeon to direct his attention to specific problems that he suspects lie at the root of a particular patient's TMJ symptoms.
In its most common incarnation, two needles are employed in a lavage technique whereby one functions as an input catheter for inserting a cleansing solution directly into the temporomandibular joint. The second needle simply provides an output catheter for aspirating fluids. Alternatively, the surgeon may employ only one intracapsular injection whereby lubricating agents and various other medications are introduced directly into the expanded joint spaces.
Arthrocentesis allows a general insufflation and cleansing of the joint space in conjunction with lysis and removal of adhesive tissues, while providing some limited access to portions of the condyle surface itself.(3) On the other hand, the procedure affords no direct viewing of internal structures, so lysis is only possible in a very general and incomplete fashion.(4) Similarly, while it allows for direct manipulation or repositioning to relieve acute joint lock under anesthesia, it does not present a direct avenue to addressing disk malfunctions. In this regard, pre-operative evaluation and diagnosis are particularly important in the decision between arthrocentesis and arthroscopy.(5) Conversely, a significant advantage to arthrocentesis over arthroscopy is the relative lack of resulting scar tissue associated with the former. Several clinical studies link maximal long-term post-surgical increase in jaw opening ability to lack of scar tissue formation, further supporting the importance of this consideration, in particular. (6)
In the last thirty years, the arthroscope has completely revolutionized surgery in many specialties. It provides an invaluable diagnostic instrument and permits complicated restorative and reconstructive procedures that formerly required invasive open surgery with all of its attendant trauma, risks, post-operative discomfort, rehabilitation and costs. With respect to TMJ issues, the arthroscope now presents a viable and often very satisfactory choice of procedures, where formerly, the choice was between merely palliative relief and highly invasive, open surgery.
Where pre-operative evaluation and preliminary diagnosis leads the surgeon to suspect significant disk involvement or displacement, arthroscopy provides a valuable tool through which more aggressive surgical techniques can be employed.(7) Complete rather than partial) lysis or removal of adhesions and fibrillated fibrocartilage obviously provides more comprehensive relief from TMJ symptoms originating from friction and adhesion induced misalignment. Where indicated, the arthroscope permits actual posterior repositioning…