Accepted Manuscript TMJ Arthrocentesis: Outcomes under Intravenous Sedation vs. General Anesthesia Pushkar Mehra, BDS, DMD, Varun Arya, BDS, DMD PII:

S0278-2391(14)01793-5

DOI:

10.1016/j.joms.2014.11.018

Reference:

YJOMS 56576

To appear in:

Journal of Oral and Maxillofacial Surgery

Received Date: 11 November 2013 Revised Date:

24 November 2014

Accepted Date: 28 November 2014

Please cite this article as: Mehra P, Arya V, TMJ Arthrocentesis: Outcomes under Intravenous Sedation vs. General Anesthesia, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/ j.joms.2014.11.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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TMJ Arthrocentesis: Outcomes under Intravenous Sedation vs. General Anesthesia

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Authors:

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1. Pushkar Mehra, BDS, DMD Associate Professor and Chairman, Dept. of Oral and Maxillofacial Surgery, Boston University School of Dental Medicine; Chief, Dept. of Oral and Maxillofacial Surgery, Boston Medical Center 2. Varun Arya, BDS, DMD Resident, Dept. of Oral and Maxillofacial Surgery, Boston University School of Dental Medicine & Boston Medical Center

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Address for correspondence:

Pushkar Mehra, BDS, DMD 100 E. Newton Street, Suite G-407 Boston, MA 02118

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Tel: 617-638-4357 Fax: 617-638-4442 Email: [email protected]

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Abstract Purpose: Although arthrocentesis of the temporomandibular joint (TMJ) has been shown to be an effective, minimally-invasive surgical procedure, there is paucity of literature that compares

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differences in its effectiveness under intravenous (IV) sedation as compared to general anesthesia (GA) with a secure airway.

Patients and Methods: We performed a retrospective analysis of TMJ arthrocentesis patients.

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Patients were divided into two groups based on type of anesthesia (sedation vs. general) and location of surgery (office vs. hospital). VAS scales were used to assess TMJ pain, headaches,

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jaw function, diet and disability. Objective examinations were performed for maximum interincisal opening, lateral excursions and TMJ sounds.

Results: Statistically significant improvements were seen for TMJ pain, headaches, dietary restrictions, jaw function, and disability. Patients reported an 80% satisfaction rate for surgery

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under IV sedation as compared to a 95% satisfaction rate of patients who had surgery under GA. Conclusions: Arthrocentesis is effective for treatment of TMJ pain and acute closed-lock conditions irrespective of the grade of Wilkes classification (I-III). 95% of the patients reported

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immediate resolution/reduction of pain within the first post-operative week. Although, the procedure is effective when done under IV sedation in an office setup, superior clinical outcomes

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were noticed when the procedure was performed with a secure airway under GA.

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Introduction Functional disturbances of the masticatory system, particularly those related to the temporomandibular joint (TMJ) are commonly encountered in clinical practice. Acute closed

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lock conditions have frequently been documented as one of the major source of patient’s TMJ pain or dysfunction1. In the 1980’s and 90’s, open surgery was commonly used for management of TMJ internal derangement as initial treatment, but results were unpredictable2-5. Over the last

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two decades, there has been a paradigm shift in treatment philosophies and the focus of management of TMJ pain and dysfunction has shifted towards non-surgical and minimally

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invasive treatment modalities like arthrocentesis, especially as initial treatment. Internal derangement can predispose a patient to TMJ pain and closed lock. Acute closed lock has been shown to be a consequence of the anterior or antero-medial displacement of an articular disc6-10. For many years, surgical management modalities revolved around invasive

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open-joint procedures where the displaced or deformed disc was reshaped or removed with or without replacement11. With development and introduction of newer successful techniques like TMJ arthroscopy and arthrocentesis, the concept of pathologic disc position being critical has 12-13

. This is due to the fact that significant resolution of TMJ pain and other

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been in question

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symptoms of internal derangement have been seen after arthrocentesis. It has been shown to be effective despite the lasting abnormal disc position. The fundamental doctrine in arthrocentesis is to lavage the upper joint compartment, eliminate the inflammatory products, and to aggressively manipulate the joint14-19.

Studies20-21 have shown that there is a correlation between the

concentrations of pro-inflammatory cytokines in synovial fluid and the degree of degeneration of articular cartilage in patients with internal derangement.

The principal pro-inflammatory

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mediators found in the joint cavity are interleukin-1b (IL-1b), tumor necrosis factor-a (TNF-a), IL-6 and IL-820-24.

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Several literature reviews and data are available describing the clinical procedure of the arthrocentesis and many studies have assessed the therapeutic benefits of this procedure. In general, however, there is little information on the relative efficacy of TMJ arthrocentesis carried

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out under different work environments. The present investigation focuses on the comparison of the effectiveness of TMJ arthrocentesis under intravenous sedation in an office setting vs. the

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effectiveness of TMJ arthrocentesis under general anesthesia in a hospital setting. It also assesses the effectiveness of arthrocentesis with increasing grades of Wilkes internal derangement. Patients and Methods

The study involved a retrospective analysis of TMJ arthrocentesis patients treated over a

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10-year time period (2001-2011) at Boston University Medical Center. All procedures were performed by senior oral and maxillofacial surgery residents with single attending supervision. Inclusion criteria included: 1) Patients with TMJ internal derangement (Wilkes grade I-III)

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verified by MRI examination, 2) Presence of TMJ pain and/or closed lock, 3) No previous TMJ surgical procedures, 4) Treatment with 2-needle arthrocentesis and jaw manipulation, and 5)

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Follow-up greater than 6 months. Exclusion criteria included: 1) Lack of medical records available. Approval for conducting the study was obtained from the Boston University Institutional Review Board. All patients referred for surgical management had failed or had less than an optimal response to conservative therapy. This included some combination of pharmaceutical therapy (NSAIDS, muscle relaxants), physical therapy, and splint treatment.

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For study purposes, all patients were divided into one of the following two groups based on location of surgery and type of anesthesia: a) Group 1: office-based surgery under intravenous sedation, and, b) Group II: hospital–based surgery under general anesthesia with a laryngeal

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mask airway.

The patient positioning and anesthesia technique for each group were standardized. Patients in group 1, who received IV sedation, were all positioned in an upright to semi-upright

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sitting position in a routine surgical/dental chair in the office. After a successful IV access, sedation was initiated with midazolam and fentanyl, followed by propofol infusion through a

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pump. If a patient was combative, intravenous ketamine was supplemented. All patients group 2 had general anesthesia in a hospital setting. They were placed in a supine position on a standard OR table. After midazolam administration in the preoperative area, fentanyl and propofol were used to induce general anesthesia and a laryngeal mask airway (LMA) was placed in all patients.

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General anesthesia was maintained throughout the case using sevoflurane inhalation anesthesia. The surgical technique was also standardized for all patients. A canthal-tragal line was drawn and an entry point marked on the skin at apposition 10 mm anterior to the tragus and 2mm

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inferior to the canthal-tragal line. This point corresponded approximately with the posterior wall of the condylar fossa, which was also further confirmed manually by palpation over the area

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while manipulating the mandible in range of motion movements. Next, infiltration of approximately 1 mL of 1% lidocaine with epinephrine was performed in to the soft tissues overlying the joint space. Inflow and outflow ports were then established with two separate 19guage needles using a standard 2-needle technique15, 26, and 27. The inflow port established at the marked entry point, thereby entering the superior joint space. Next, the outflow port was established slightly anterior to the inflow port. Arthrocentesis was then performed with saline

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solution through 30-60 mL syringes connected to tubing. At the end of the procedure, 5 mg of steroid (Kenalog) in combination with 5 mL of 0.5% plain Marcaine per joint was flushed through the ports prior to needle retrieval. Post-surgical instructions and prescriptions included

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the use of a flat plane maxillary splint, soft diet, and self-administered physiotherapy (range of motion exercises) of the lower jaw.

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To ascertain the treatment effectiveness for the investigation, the outcome variables were divided into subjective and objective parameters, and all patients were categorized using the

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Wilkes classification for internal derangement based on clinical and MRI examinations. For study purposes, the following definitions were used: a) Successful entry with two ports: ability to perform saline lavage with greater than 100 mL using inflow and outflow needle ports and minimal, if any extravasation of fluid outside the joint space, and, b) Aggressive jaw manipulation: mobilization of the mandible with range of motion movements including all

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excursions for 3-5 minutes. Subjective variables assessed included levels of TMJ pain, overall facial pain and headaches on a 10-point visual analog scale (VAS), with 0 being no pain and 10 being the worst pain imaginable (Figure 1). For each patient, other subjective outcome

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parameters analyzed on a similar 10-point scale included: jaw function (0 = unable to open and

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10 = no restriction); diet (0 being liquids and 10 = no restriction); and disability (0 = no disability and 10 = total disability).

Objective examinations involved the measurement of maximal inter-incisal opening, with

and without pain, lateral excursions in millimeters and the presence or absence of TMJ sounds like clicking/popping and/or joint crepitus (Figure 1). All variables were evaluated at two separate time intervals: T1 (preoperative) and T2 (more than 6 months postoperatively). For statistical purposes, the subjective variables assessed on numerical VAS levels were managed as

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continuous variables, whereas data on objective assessment of maximum inter-incisal opening and lateral excursions were managed as discreet values. For all comparisons, a Students t-test was performed and statistical significance for differences was set at a p value < 0.05.

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Results

A total of 426 patients (663 arthrocentesis procedures were performed) fulfilled the

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criteria for the study. Group 1 had 148 patients (135; 91% female and 13; 9% male with an average age of 33.6 years) and Group 2 had 278 patients (245; 88% female and 33; 12% male

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patients with an average age of 39.7 years. In group 1, 55 patients had unilateral surgery and 93 had bilateral surgery yielding a total of 241 arthrocentesis procedures. In group 2, 134 patients had unilateral surgery and 144 patients had bilateral procedures totaling to 422 arthrocentesis procedures. No statistical difference was noted between the two groups relative to subjective parameters assessed at the preoperative (T1) interval (p=0.07) (Table1). No statistical difference

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was noted relative to subjective parameters assessed at the preoperative (T1) interval (p=0.07) (Table1) and between the Wilkes classification grades when compared between the two groups (p=0.08). At the T2 interval, both groups showed improvement with respect to all the outcome

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variables (p = 0.03) (Tables 2 and 3).

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In Group 2, 404 patients out of 430 (94%) had a successful entry with 2 adequate ports when compared to 163 patients out of 233(70%) who received IV sedation. The volume of saline used to lavage the superior joint space was also significantly more in Group 2 (average of 165 mL with a range of 75 – 225 mL) when compared to group 1, where the average volume was 105 mL (Range 10 – 185 mL). Aggressive jaw manipulation was possible in 278 patients out of 278 (100%) of those who received general anesthesia when compared to 66 patients out of 148 (45%) of those who had IV sedation. Overall, Group 1 showed an 80% of subjective patient satisfaction

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compared to 95% of subjective patient satisfaction among those in Group 2. These results are summarized in Table 4.

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A between-group comparison of subjective parameters over time showed that differences were statistically significant for TMJ pain (p-value- 0.02) and headache (p=0.03) (Figure 2a and Figure 2b). Dietary restrictions, jaw function and disability were also statistically significant, but

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to a lesser degree (p=0.048). In terms of the objective parameters, changes in maximum interincisal opening without pain were statistically significant (p=0.046) (Figure 3a and 3b). There

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was minimal increase post-operatively with respect to lateral excursions (p=0.7). Statistically significant improvement was seen in both groups, with results of Group 2 being more effective.

Discussion

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TMJ arthrocentesis has emerged as an effective treatment modality for TMJ pain and dysfunction. The findings of the study suggested that arthrocentesis of the TMJ is effective for treatment of TMJ pain and acute closed lock conditions in patients with Wilkes grades I-III.

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Subjective variables of TMJ pain, headaches, jaw function, diet, disability and objective

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variables of MIO, lateral excursions, and TMJ joint sounds were the parameters used to define the success outcome. In our study, 97% of patients reported immediate resolution/reduction of pain within the first postoperative week. Many studies have been published on the success outcomes of TMJ arthrocentesis. In

1991, Nitzan et al published the first ever study on the outcomes of TMJ arthrocentesis15 and a success rate of 91.8% was reported in this study. There have also been studies that showed a correlation between increasing Wilkes grades of TMJ internal derangement, though no

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statistically significant differences in the success rates have been noted. Murakami et al. reported an overall success rate of 90% with no significant differences between grade III, IV and V in 199825. A more recent study by Smolka et al. in 2005, reported an overall lower success rate of

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78.3% with success rates slightly lower for patients with advanced Wilkes grade, 75% for Grade V, 71.4% for Grade IV than for those of Grade II at 80% and Grade III at 85.7% under the

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Wilkes Grade of TMJ internal derangement28.

If one were to analyze our findings and compare to most previous reports, it is clear that

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TMJ arthrocentesis is clinically effective when done either under IV sedation in an office or under GA in a hospital setting. However, statistically superior clinical outcomes in almost all parameters assessed were found under general anesthesia in our patients. The increased therapeutic success rate of arthrocentesis under GA as compared to office-based setting is likely attributed to ability to: 1) successful entry with two adequate ports, 2) quantity of saline lavage,

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and, 3) in our opinion, especially related to the ability to perform aggressive jaw manipulation. The ability to successfully enter the superior joint space with two adequate ports was

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higher (94%) in patients undergoing procedure under general anesthesia compared to only 70% of the patients who had IV sedation in the office. This is not surprising as the patient under GA is

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relaxed and all muscle factors related to jaw motion or disc function are basically eliminated; patients do not move or resist puncture and these “ideal” conditions are otherwise hard to duplicate in an office-based setting under IV sedation. Safe, more predictable and less repeatable joint punctures are often accomplished if the patient is under GA. One factor, however, that could have also contributed to this difference in our study was the fact that residents performed most procedures as primary surgeons; depending on the level of training and experience of the resident, time and number of punctures required for successful entry can be quite varied. As

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expected, having a patient completely asleep with a secure airway allowed for the clinician(s) to devote much more time for successfully obtaining both functional ports in cases of difficult

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initial entry. Lavage has been shown to a crucial role in providing simple lysis and lavage of the upper joint space. The first ever study on volume of lavage was published in 1997 by Zardeneta et al.

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They reported that the protein concentration in the lavage fluids used for arthrocentesis of patients with TMD fell in a volume-dependent manner and that approximately 100 mL is

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sufficient for therapeutic lavage29. According to the study published by Keiseki et al. in 2004, the concentration of bradykinin, interleukin-6, and protein during arthrocentesis were effectively reduced by more than 200 mL of lavage and with a volume of 300 to 400 mL, the protein and bradykinin were no longer detectable30. Lysis and Lavage works by two basic mechanisms: First, it helps to dilute and remove the pro-inflammatory mediators like IL-1, TNF-A, IL-6 and IL-8.

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Second, it works by hydraulic distension of the superior joint space, which causes lysis of the joint adhesions. In our experience, with our technique, the volume of saline did not seem to be critical beyond 150 mL in either group. When compared, patients who had lysis and lavage with

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greater than 150 mL did not fare better than those with those patients who had lavage volumes

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ranging between approximately 130 and 150 mL. Although most cases in both groups were irrigated with greater than 150 mL, the average volume in the GA group was greater (since we were unable to establish two successful ports in a higher number of patients in Group I, which decreased the average value of that group). We hypothesize that perhaps the hydraulic pressure created by the pumping action of saline lavage in the superior joint space that breaks the adhesions is more critical than the volume of irrigation itself once a 150 mL lavage volume has been achieved.

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An important finding of the study is that aggressive jaw manipulation by itself appears to be most beneficial even when adequate saline lavage is not possible. Joint manipulation under anesthesia is a time-tested technique, which has been followed by orthopedic surgeons for many

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years, and is known to improve joint function and range of motion. Aggressive jaw manipulation in our study was defined as “manual, digital range of motion movements of the mandible for approximately 3-5 minutes at the end of the procedure.” This degree of manipulation is aimed to

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mobilize the disc and further perform lysis of adhesions. We were able to aggressively manipulate the jaw was in only 45% of the patients who were treated in an office under IV

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sedation compared to 100% of patients treated in a hospital with secure airway. This could be postulated as one of the reasons for higher clinical efficacy of TMJ arthrocentesis when performed in an OR with the availability of laryngeal mask airway or endotracheal tube. We found it difficult to perform this degree of dedicated jaw manipulation at the end of the

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procedure in sedated, office-based surgery patients because of two distinct reasons: a) Awake and/or lightly sedated patients did not tolerate such aggressive manipulation, and, b) Deeply sedated patients often required a bite block for airway maintenance and safety which precluded

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jaw translatory and excursive movement for 3-5 minutes.

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General anesthesia has some advantages over IV sedation in light of arthrocentesis. The major advantages are: 1) paralysis of protective reflexes that allows aggressive range of motion exercises 2) eliminating the need for intraoperative patient cooperation. Points to argue against use of general anesthesia are: 1) higher cost 2) longer operating time 3) longer recovery time, and, 4) higher risk of anesthesia related complications. Despite the advantages of a standard surgical technique, single supervising surgeon, large case-load, and uniform preoperative and postoperative assessment, this retrospective review study has the usual drawbacks associated

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with any research dependent on a chart review processes. Additionally, the study methods did not include a systematic follow-up of patients who required repeat procedures in both groups and correlate them to the Wilkes classification. Although none of the patients had previous open joint

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procedures, some did have prior arthrocentesis by other surgeons and this sub-group, although small, was not separately analyzed. We included these patients since, in our experience, unlike open joint surgery, a prior history of attempted arthrocentesis should not make any difference in

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our ability to perform the procedure and/or clinical outcomes and the patients still fit the inclusion criteria as long as they were within the Wilkes Grade I-III (without any bony

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involvement). Although splint therapy was prescribed for all patients postoperatively, up to 35% of patients admitted to not wearing the prescribed splint postoperatively at the T2 interval, potentially altering some outcomes. 62% of these were coincidently in Group 2, and when questioned majority of them stated that they were “happy” with the long-term outcomes and had

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stopped wearing the splint after a few months.

One other coincidental finding of our study was that though the procedure is effective in both settings, approximately 27% of patients required or requested repeat procedures on an

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average of 18 months postoperatively (Range 6-34 months). No consistent pattern could be

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found in these repeat patients and they included almost equivalent numbers from both study groups (51% group 1 and 49% group 2). All of them were reasonably satisfied with initial treatment results, but felt that clinical symptomatology of joint pain and dysfunction was relapsing progressively. The very fact that all 27% agreed to repeat procedures again underlines the effectiveness of this minimally invasive technique in this patient population of internal derangement patients.

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More research, preferably prospective studies and randomized clinical trials are needed to completely validate the use of a hospital setting with secure airway as first choice setting for this minimally invasive surgical procedure. However, based on our experience, this approach should

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certainly be considered as an effective alternative by surgeons for optimal results. Additionally, effects of jaw manipulation in relieving TMJ pain and dysfunction by disc mobilization could perhaps be evaluated by designing a randomized study whereby a control group of patients

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would only be undergoing jaw manipulation and comparing it to a group of patients who have

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TMJ arthrocentesis only.

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Legends Figure 1: Patient evaluation chart used at preoperative and postoperative examination intervals

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Figure 2a: Preoperative and postoperative changes in VAS scores for overall TMJ pain as compared between the two groups.

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Figure 2b: Preoperative and postoperative changes in VAS scores for Group I and II patients classified by Wilkes grade of internal derangement.

Figure 3a: Preoperative and postoperative changes in overall MIO without pain as compared between the two groups.

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Figure 3b: Preoperative and postoperative changes in MIO for Group I and II patients classified by Wilkes grade if internal derangement.

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Table 1: Comparison of outcome variables between study groups at the preoperative interval

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Table 2: Comparison of preoperative and postoperative outcome variables within Group1 (Office-based sedation)

Table 3: Comparison of preoperative and postoperative outcome variables within Group2 (Hospital-based GA)

Table 4: Comparison of specific parameters for both groups.

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Outcome variables

Group 1 (n=148)

Group 2 (n= 278)

8.6 6.3 6.2 6 4.7 4 22% 11% 3%

8.2 7.7 8.6 5 4.2 3 16% 13% 5%

36.3 21.6 12.7 59% 2% 23% 0% 0%

38.7 19.2 10.4 55% 11 % 19% 0% 0%

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(0-10 on VAS) TMJ pain Facial pain Headaches Jaw function Dietary restriction Disability Otalgia Tinnitus Vertigo

MRI 61% 39%

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Disk displacement with reduction Disk displacement without reduction Effusion

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Objective MIO with pain MIO without pain Lateral excursions Click/Pop Crepitus Closed lock history CN V injury CN VII injury

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Subjective

6%

58% 42% 7%

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Table 1. Comparison of outcome variables between study groups at the preoperative interval

Outcome variables GROUP 1

Preoperative Evaluation

Postoperative Evaluation

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(0-10 on VAS) TMJ pain Facial pain Headaches Jaw function Dietary restriction Disability Otalgia Tinnitus Vertigo

8.6 6.3 6.2 6 4.7 4 22% 11% 3%

2.8 2.5 4.1 8 2.4 2 2% 9% 2%

36.7 21.6 12 59% 2% 23% 0% 0%

41.2 33.4 13 50% 2% 8% 0% 0%

MRI 61%

Disk displacement with reduction Disk displacement without reduction Effusion

39%

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6%

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MIO with pain (mm) MIO without pain (mm) Lateral excursions (mm) Click/Pop Crepitus Closed lock history CN V injury CN VII injury

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Objective

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Subjective

N/A N/A N/A

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Table 2. Comparison of preoperative and postoperative outcome variables within Group1: Office-based (sedation).

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8.2 7.9 8.6 5 4.2 5 16% 13% 5%

0.9 0.9 1.5 9 2.0 2 4% 10% 5%

Objective MIO with pain (mm) MIO without pain (mm) Lateral excursions (mm) Click/Pop Crepitus Closed lock history CN V injury CN VII injury

38.7 19.4 10.4 55% 10% 19% 0% 0%

42.9 37.1 9.8 8% 8% 6% 0% 0%

58%

N/A

42%

N/A

7%

N/A

EP

Disk displacement with reduction Disk displacement without reduction Effusion

TE D

MRI

RI PT

Postoperative Evaluation

SC

(0-10 on VAS) TMJ pain Facial pain Headaches Jaw function Dietary restriction Disability Otalgia Tinnitus Vertigo

Preoperative Evaluation

M AN U

Outcome variables GROUP 2 Subjective

AC C

Table 3. Comparison of preoperative and postoperative outcome variables within Group2 (Hospital-based GA)

ACCEPTED MANUSCRIPT

Fig 2. Patient evaluation chart used at preoperative and postoperative examination intervals

Dietary restriction Disability Otalgia Yes

RI PT

TMJ pain Overall Facial Pain Headaches Jaw function

Age: MRN: DOB: Subjective (No pain) 0----1----2----3----4----5----6----7----8----9----10 (Worst imaginable) (No pain) 0----1----2----3----4----5----6----7----8----9----10 (Worst imaginable) (No pain) 0----1----2----3----4----5----6----7----8----9----10 (Worst imaginable) (Unable ) 0----1----2----3----4----5----6----7----8----9----10 (Normal) to open) (None) 0----1----2----3----4----5----6----7----8----9----10 (Liquids only) (None) 0----1----2----3----4----5----6----7----8----9----10 (Completely disabled) Tinnitus Vertigo

No

Yes

No

M AN U

Objective

SC

PATIENT Name:

Yes

No

Maximum Incisior Opening WITHOUT pain : ___________ mm : ___________ mm Maximum Incisior Opening WITH pain Right Lateral excursion: ________mm Left Lateral excursion: ________mm Right Left Click / Pop: Opening: _________ mm Opening: _________ mm Closing: _________ mm Closing: _________ mm Right Left Crepitus: Yes

No

TE D

EP

AC C

CN V

CN VII

Upper Lip Right Left 0-1-2-3 0-1-2-3 Frontal Right Left 0-1-2-3 0-1-2-3

No

Occlusal Analysis

Muscle Tenderness

Right_____ Left_____ Temporalis Right_____ Left_____ Massatter Right_____ Left_____ Lateral Pterygoid Right_____ Left_____ Medial Pterygoid Sternocleidomastoid Right_____ Left_____ Right_____ Left_____ Trapezius Right_____ Left_____ Shoulder Preoperative Neurologic Deficit: 0 = None

Yes

Molar Class: Canine Class: Cross Bite: Open Bite: Deep Bite:

1=Mild

Lower Lip Right Left 0-1-2-3 0-1-2-3 Zygomatic Right Left 0-1-2-3 0-1-2-3 Radiographic

Right_______ Left _______ Right_______ Left _______ Rt _______ Lt______ Ant____

2=Moderate Cheeks Right Left 0-1-2-3 0-1-2-3 Mandibular Right Left 0-1-2-3 0-1-2-3

Panoramic CT Imaging Available Disc Displacement with Disc Displacement without reduction reduction Right_______Left________ Right_______Left________

3= Severe Chin Right Left 0-1-2-3 0-1-2-3 Cervical Right Left 0-1-2-3 0-1-2-3

MRI Joint Effusions Right_______Left________

ACCEPTED MANUSCRIPT

9

8.6

RI PT

10 8.2

8 7 6

SC

Group 1: Office based (Sedation)

5

Group 2: Hospital based (General Anesthesia)

4

2

M AN U

2.8

3

0.9

1 0 Preoperative TMJ pain

Postoperative TMJ pain

AC C

EP

between the two groups.

TE D

Fig 2a. Preoperative and postoperative changes in VAS scores for overall TMJ pain as compared

ACCEPTED MANUSCRIPT

Group I: Office Based (Sedation)

Group II: Hospital Based (General Anesthesia)

9.1 8.5

RI PT

8.1 6.4

2.9

SC

2.6

0.3 0.4

1.3 0.8

M AN U

0.1 0.1

Wilke's Grade Wilke's Grade Wilke's Grade I II III Preoperative TMJ pain

Wilke's Grade Wilke's Grade Wilke's Grade I II III Postoperative TMJ pain

Fig 2b. Preoperative and postoperative changes in VAS scores for Group I and II patients

AC C

EP

TE D

classified by Wilkes grade of internal derangement.

ACCEPTED MANUSCRIPT

40

RI PT

37.1 33.4

35 30

20

21.6

Group 1: Office based (Sedation)

SC

25

19.4

Group 2: Hospital based (General Anesthesia)

M AN U

15 10 5 0

TE D

Preoperative MIO without pain Postoperative MIO without pain

Fig 3a. Preoperative and postoperative changes in overall MIO without pain as compared

AC C

EP

between the two groups.

ACCEPTED MANUSCRIPT

Group I: Office Based (Sedation)

Group II: Hospital Based (General Anesthesia) 40.4

42.6

40.1

39.4 34.1

18.6 14.4

16.5

7.6

Wilke's Wilke's Wilke's Grade I Grade II Grade III Postopeartaive MIO without pain

M AN U

Wilke's Wilke's Wilke's Grade I Grade II Grade III Preoperative MIO without pain

SC

24.5 24.5

RI PT

30.2

Fig 3b. Preoperative and postoperative changes in MIO for Group I and II patients

AC C

EP

TE D

classified by Wilkes grade if internal derangement.

Temporomandibular joint arthrocentesis: outcomes under intravenous sedation versus general anesthesia.

Although arthrocentesis of the temporomandibular joint (TMJ) has been shown to be an effective, minimally invasive surgical procedure, there is a pauc...
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