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Braz J Oral Sci. July/September 2002 - Vol. 1 - Number 2 A long-term evaluation of arthroscopy
of the temporomandibular joint using
holmium YAG laser

Renato Mazzonetto1
Sandra de Cássia S. Sardinha2

Abstract:
Daniel B. Spagnoli3
The aim of this in vivo study was report the long-term results of arthroscopic laser surgery for treatment of TMJ internal drangements 1DDS, PhD - Assistant Professor, Departmentof Oral and Maxillofacial Surgery, Piracicaba Dental School, University of This report included 45 patients (42 women and 03 men) with an average age of 36.7 years old (14 to 66 years). There were 69 joints 2MS, DDS – Resident of Oral Maxillofacial involved. The criteria for inclusion were patients who had complained Maxillofacial Surgery, Piracicaba Dental of TMJ pain and dysfunction and had remained refractory to School, University of Campinas – Unicamp nonsurgical treatment for at least 3 months without resolution of the problem. All patients filled out a questionnaire preoperatively and 3DDS, PhD - Clinical Assistant Professor, postoperativelly for assessment of their signs and symptoms. The Louisiana State University, Health Science range of interincisal opening was measured preoperatively and at 1, Center, and in private practice, Charlotte, NC. 7, 30, and 60 days after the surgery. The postoperative questionnaire, radiographic evaluation, and the last measure of range of motion were performed with one year or more after the surgical procedures. The preoperatively and postoperativelly scores were compared and tested for statistically significant differences by the paired t-test (P>0.05).
Forty-five patients (69 joints) have been followed postoperativelly for an average of 28.6 months. Maximal interincisal opening improved from a mean of 25.95mm to 35.91mm (+9.96mm) in seven days after the surgery; to 39.86mm (+3.95mm) after thirty day and; to 40.92mm (+1.06mm) after 60 days. The last measurement of maximal interincisal opening made after one year or more showed a mean of 42.15mm. All postoperative VAS pain scores showed a statistical significant improvement (p<0.05). The overall success rate for arthroscopy arthroplasty with Holmium YAG laser was 93.3% (42 of 45 patients) in a mean follow-up of 28.6 months. No complications Based on the results we can conclude that arthroscopic arthroplasty with Holmium laser is a safe and effective tool for the treatment of Key Words:
Temporomandibular Joint, Internal Derangements of the Temporomandibular Joint, Arthroscopy, Holmium YAG Laser.
Correspondence to:
Renato Mazzonetto
Faculdade de Odontologia de Piracicaba –
UNICAMP
Av. Limeira, 901 – Vila Areião
CEP: 13.141-900 – Piracicaba/SP/Brazil
e-mail: mazzonettomz@fop.unicamp.br
A long-term evaluation of arthroscopy of the temporomandibular joint using holmium YAG laser Introduction
YAG laser has been used. Like others kind of lasers, Holmium With the development of arthroscopy and the direct Laser has affinity for water, and this property allows to be visualization of components of joint compartment, the absorbed by aqueous tissue, which then converts its energy prominent role of articular cartilage degeneration, clinically to heat with subsequent ablation of tissue. Although not known as osteoarthritis, in temporomandibular joint (TMJ) being a “cold laser”, the technically Ho: YAG laser produced signs and symptoms was increasingly appreciated1. New almost no heat in the TMJ. The average intra-articular studies show that osteoarthritis and synovitis are the major increase in temperature recorded is 10o F. Because of pathoses of TMJ that lead to joint dysfunction5.
Holmium’s ability to pass through water and its ability to Patients usually respond to nonsurgical treatment but some coagulate, it becomes an excellent laser for the surgeon in are refractory. In such cases, surgical procedure is necessary, and in this aspect arthroscopy has been effective2.
Although the long-term outcome of arthroscopic surgery Many surgical procedures previously performed by has been reported10,13,15,20, few are the studies in the literature arthrotomy now may be performed by arthroscopy. Further, using the Holmium Laser as a surgical tool to perform a relatively conservative arthroscopic procedures may be different number of arthroscopic procedures. In this paper, sufficiently effective to eliminate the need for more complex we report the long-term results of arthroscopic laser surgery arthroscopic and surgical arthrotomy procedures, especially for treatment of TMJ internal derangements.
when treating internal derangements.
The major advantage of arthroscopic surgery is that it is a Material and Methods
minimally invasive surgical procedure and results in less peri articular tissue disruption and preservation of vascular and This report includes 45 patients (42 women and 03 men) with lymphatic drainage of the joint9. Other advantages include an average age of 36.7 years old (14 to 66 years). There were direct visualization of pathologic tissue; biopsy; removal of adhesions; direct injection of steroid into inflamed synovial The criteria for inclusion were patients who had complained tissues; removal of osteoarthritic fibrillation tissue; and of TMJ pain and dysfunction (Wilkes19 class II-III) (Table 1) correlation of clinical findings with the actual joint and had remained refractory to nonsurgical treatment (splint therapy, nonsteroids inflammatory drugs, physical therapy, Many procedures of operative arthroscopy have been and others) for at least 3 months without resolution of the reported in the literature. In spite of the significant variability problem (Table 2). A probable etiology of the TMJ internal in the arthroscopic technique used, the clinical results are derangement was also investigated. Exclusion criteria remarkably consistent. Success rates for TMJ arthroscopy, included compromised present illness, and physical or mental as determined by decreased pain and improved range of handicap that would preclude the patient’s ability to answer motion, have varied from 79% to 93% 4,11,14,15,16,17.
Murakami et al.14 in 1995 compared the efficacy of nonsurgicaltherapy, arthrocentesis, and arthroscopy in 108 patients with Table 1 – Preoperative Symptoms (69 joints, 45 patients)
TMJ internal derangements and closed-lock. The nonsurgicaltherapy group had a success rate of 55.6%, the arthrocentesis SYMPTOMS
group had a success rate of 70%, and the arthroscopy groupwho underwent lysis and lavage had a success rate of 91%.
Because statistical comparison of the arthrocentesis group and arthroscopy group did not indicate any significant differences, the authors concluded that both therapies are effective modality in treating patients with acute limitationof mandibular opening refractory to medical management.
Hori et al.4 in 1999 studied the efficacy of a combined treatment using hydraulic lavage, arthroscopy surgery andrehabilitative therapy in the releasing of severe adhesionsaround the eminence and the synovial portion of the TMJ.
The diagnosis of class II-III of internal derangement was The results demonstrated na improvement in condylar head determined by a patient evaluation and imaging modalities.
movement in adhesions concentrated in the posterior and/ The patient evaluation consisted of a pre visit questionnaire or the anterior synovial portion of the upper TMJ for assessment of their signs and symptoms, history of present illness, clinical examination, and clinical differential The first laser used in TMJ arthroscopy was the neodymium- diagnosis. The imaging modalities included panoramic yttrium-garnet laser (Nd: YAG) but most recently Holmium: radiographs and magnetic resonance imaging (MRI).
A long-term evaluation of arthroscopy of the temporomandibular joint using holmium YAG laser Table 2 – Previous Treatment (45 patients)
lavage associated with release of adhesions and posteriorcauterization with Holmium YAG Laser, followed by injection TYPE OF TREATMENT
Table 3- Diagnostic Before Operation (69 joints).
DIAGNOSTIC
SynovitisOsteoarthritis/Degenerative Joint Disease Articular Disc Disorder/Dislocation (Reduction) * All findings were confirmed during arthroscopic surgery Patient evaluation was not blinded. The same surgeon (DBS)performed preoperative evaluation and the arthroscopicsurgery in all patients.
In presence of osteoarthritis, debridement with motorized All patients filled out a self-assessment questionnaire shaver and vaporization with Holmium YAG Laser in order to preoperatively and postoperativelly. The questionnaire remove the fibrillated or degenerated fibrocartilage was consisted of a visual analogue scale (VAS), with one item on level of pain most of time, one item about the effect of pain In presence of synovitis, the redundant synovial tissue was on normal diet, and one item about the effect of pain on daily living. One final question about their perception of tolerability In presence of hypermobility, the arthroscopic technique of of the surgery was also applied. The ROM was measured choice was posterior cauterization or sclerosis of the preoperatively, and seven, thirty, sixty days, and 18 months retrodiscal tissue with Holmium YAG Laser9.
or more postoperativelly. The postoperative questionnaire In cases of small disc perforations, laser discoplasty and and radiographic evaluation were performed 18 months or disc mobilizations were performed8,15.
more after the surgical procedures. The preoperatively and In all patients after the indicated procedure, a completely postoperativelly scores were compared and tested for and thoroughly irrigation of the joint with saline solution to statistically significant differences by the paired t-test be free of any loose debris was performed, and 1cc of (P>0.05). Postoperative radiographic evaluation was done betametazone, 1cc of bupivacaine with epinephrine 1:200.000 and 1cc of sodium hyaluronate were placed in the superiorjoint space. Both cannulas were removed and a suture of 5- 0 nylon was placed in each cannula site. A stabilization All the arthroscopic surgeries were procedures made under occlusal appliance (splint) was placed in the mouth in all general anesthesia with nasoendotracheal intubation, using patients at the end of the surgery. the same type of instruments. A double portal arthroscopictechnique using a TMJ 2.3mm Set (Stryker Corp., Kalamazoo, MI, USA) was used for all cases. The landmarks for Forty-five patients (69 joints) have been followed arthroscopic surgery including the Holmlund & Hellsing line3, postoperativelly for an average of 28.6 months. In general, the 10-2 point and the 25-10 point were drawn in the face.
there were no disparities between the clinical findings, MRI Local anesthetic with Xylocaine with epinephrine was placed and arthroscopy findings. Regarding the probable etiology into the skin at these points and then the superior joint space for TMJ internal derangements 71.1% had positive history was insufflated using an 18-gauge catheter with normal for microtrauma (grinding, clenching, jaw posturing, nail saline. Following insufflation and a small skin incision at the biting, and gun chewing), 26.6% had history of macrotrauma, 10-2 point with a number 15 blade, a sharp trocar and cannula and 8.8% of unknown causes (Table 4).
were introduced into the superior joint space. The arthroscope Maximal interincisal opening improved from a mean of was then placed for joint inspection.
25.95mm to 35.91mm (+9.96mm) in seven days after the The surgical procedures were performed according to five surgery; to 39.86mm (+3.95mm) after thirty days; to 40.92mm (5) diagnostic categories, alone or associated (Table 3).
(+1.06mm) after 60 days. The last measurement of maximal In presence of closed lock and disc dislocation with reduction interincisal opening made after one year or more showed a (painful clicking), the surgical technique used were lysis and A long-term evaluation of arthroscopy of the temporomandibular joint using holmium YAG laser Table 4 – Probably Etiology (45 patients)
A success categorization of a particular subject was basedprimarily on whether the subject showed statistically significant improvement in both range of interincisal opening and pain scores. Given these criteria, the overall success rate for arthroscopy arthroplasty with Holmium YAG laserwas 93.3 % (42 of 45 patients) in a mean follow-up of 28.6 months. Two patients classified in a success group showed a significant improvement in pain scores. They showed no pain most of the time and a slight pain, less than beforesurgery occasionally. Their range of interincisal opening showed an improvement after surgery. In failure patients, two still remain in pain and one, even not showing no pain, his range of interincisal opening didn’t improved with thetreatment.
Table 5 – Range of Interincisal Opening
Discussion
In our study, all patients who underwent arthroscopic surgery
Pre Operation 7 days 30 days 60 days 1 year with Holmium YAG laser had a preoperative diagnosis ofpain secondary to stage II-III of internal derangement (Wilkes19) who had not responded to conventional nonsurgical treatment (splint therapy, nonsteroidal inflammatory drugs, physical therapy). Our indication forarthroscopy was the same as those found in the The probable etiologic factors described in the literature1,2,9 such as trauma to face (macrotrauma) and joint overloading (microtrauma) were also found in our study as major factorscontributing to TMJ internal derangement.
All postoperative VAS pain scores showed a statistical According to the literature, the most common arthroscopic significant improvement (p<0.05). Pain and dysfunction procedure was lysis and lavage. However, lateral capsular scores were reduced significantly (Table 6).
release, posterior cauterization, debridement, abrasionarthroplasty, suturing, or laser techniques were alsodescribed12,18. The techniques performed in our study were Table 6 – Comparison of baseline and postoperative
used according to the surgical findings. In presence of closed measurements in 45 patients
lock and disc dislocation with reduction (painful clicking),the surgical technique used was lysis and lavage associatedwith release of adhesions and posterior cauterization with Variable
Preoperative
Postoperative
Holmium YAG Laser, followed by injection of steroids. In presence of osteoarthritis, debridement with motorized shaver and vaporization with Holmium Laser in order to remove the fibrillated or degenerated fibrocartilage was performed. Inpresence of synovitis, the redundant synovial tissue was removed with Holmium YAG laser. In presence of Means followed by different character were significantly hypermobility, the arthroscopic technique of choice wasposterior cauterization or sclerosis of the retrodiscal tissue with Holmium YAG Laser. In cases of small disc perforations,laser discoplasty and disc mobilizations were performed. All The postoperative radiographs did not show any progressive techniques were well described for arthroscopic surgery in changes such as condylar resorption or mandibular fossa degeneration at one year or more after surgery.
Holmium YAG laser vastly improves the ability to remove The final question asked from each patient, regardless they and sculpt diseased tissues when compared to mechanical would have this surgery again, if needed, 45 patients (100%) instrumentation9. Operating time is reduced owing to the small size of the delivered tip and the ability to manipulate A long-term evaluation of arthroscopy of the temporomandibular joint using holmium YAG laser the fiberoptic handpiece, which allowed easy access to all high. The rate of recovering is excellent. Holmium YAG laser recesses of the TMJ. No cher or debris exist because there is a safe and effective tool for the treatment of TMJ internal only minimal tissue damage. Clinical studies have demonstrated that the Holmium YAG laser is a safe andeffective modality for the delivery of energy in the TMJ8.
References
When the laser surgery has been employed the benefits Dijkgraaf CL, Spijkervet FKL, DeBont LGM. Arthroscopicfindings in osteoarthritic temporomandibular joints. J Oral include the following: decreased operating time, increased precision, expanded accessibility, minimized blood loss, Dolwick MF. Intra-articular disc displacement. Part I. Its decreased hemarthrosis, non contact ability to vaporize questionable role in temporomandibular joint pathology. J Oral pathology, reduced postoperative pain, and recovery time.
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study of 4,831 joints, after arthroscopic surgery 91.6% of all Releasing sever adhesions around the eminence and the synovial patients had good or excellent motion and 91.3% had good portion of the temporomandibular joint: a clinical study of or excellent pain reduction10. Others reports in the literature combined treatment using hydraulic lavage, arthroscopic surgery showed success rates ranging from 76%20 to 83%5 for and rehabilitative therapy. J Oral Sci 1999; 41:61-6.
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paresis, hearing loss, infections, and broken instruments.
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