Meta analysis of arthrocentesis and arthroscopy in treatment of internal derangement of temporomandibular joint

Abstract

Internal derangement (ID) of temporomandibular joint (TMJ) is one of the most controversial issues in the oral and maxillofacial field. Diagnosing and treating temporomandibular disorders(TMDs) usually challenge the oral and maxillofacial surgeons in their practice. There is a debate in every single item in this interesting disorder and after years of research and thousands of articles being published, simple questions are still not answered. Is the disc position and shape relevant or not? What is the genuine cause of pain and dysfunction in these patients? Is there a role for inflammatory mediators in predisposing pain or are they only representatives of an adaptation state in the joint ? Is ID a disorder of progressive nature? Do we need magnetic resonance imaging (MRI) in reaching a final diagnosis or its role is diminished after the introduction of arthroscopy (ARCOPY)? The dilemma and confusion extended, as well; to involve the treatment of ID. The fact that there are many suggested treatments for ID in the literature, surgical and non surgical, implies that none of them is satisfactory enough to the patients or their physicians. It has even been proposed that TMJ closed lock signs and symptoms improve regardless of the intervention being used whether this treatment is non surgical or minimally invasive as arthrocentesis (ARSIS) and ARCOPY, or aggressive open arthrotomies.1 These minor or negligible differences in the therapeutic outcome between different treatments, aggressive and non aggressive have impacted considerably the TMJ research. Shift in the treatment of ID from open surgical procedures to the less aggressive ARSIS and ARCOPY has been witnessed in the last decade based on the concept that if both aggressive and non aggressive means are effective, why not use the non aggressive ones. But, although ARSIS and ARCOPY have become the vogue in the treatment of ID, their treatment efficacy has not yet been corroborated. This may be due to the fact that the effectiveness of these modalities have not been correlated with a specific clinical, etiology based diagnosis and thus their use continue to be based on numerous factors including cost, risk-benefit ratio, prior experience, and clinician's best judgment. Moreover, the majority of these publications are case series studies, involving small sample sizes, the presence of control groups are exceptional, and standardized assessment methods are generally lacking. These flawed methodologies have made the potential for bias in these studies significant and thus instead from providing preliminary evidence of treatment efficacy, these studies in general provide data which are discordant and of dubious value.2