Arthroscopy Versus Arthrocentesis and Versus Conse

Int. J. Oral Maxillofac. Surg.
2024; 53: 503–520

https://doi.org/10.1016/j.ijom.2024.01.006, available online at https://www.sciencedirect.com
Meta-Analysis
TMJ Disorders
Arthroscopy versus
Y.H. Tang, N.B. van Bakelen,
B. Gareb, F.K.L. Spijkervet
arthrocentesis and versus Department of Oral and Maxillofacial

Surgery, University Medical Center
Groningen, Groningen, the Netherlands
conservative treatments for

temporomandibular joint
disorders: a systematic review
with meta-analysis and trial
sequential analysis
Y. H. Tang, N. B. van Bakelen, B. Gareb, F. K.L. Spijkervet: Arthroscopy versus
arthrocentesis and versus conservative treatments for temporomandibular joint
disorders: a systematic review with meta-analysis and trial sequential analysis. Int.
J. Oral Maxillofac. Surg. 2024; 53: 503–520. © 2024 The Authors. Published by
Elsevier Inc. on behalf of International Association of Oral and Maxillofacial
Surgeons. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
Abstract. The aim of this systematic review was to assess the efficacy of
arthroscopy compared to arthrocentesis and to conservative treatments for
temporomandibular joint disorders. Thirteen controlled studies on various
patient outcomes were included after a systematic search in seven electronic
databases. Meta-analyses were conducted separately for arthroscopic surgery
(AS) and arthroscopic lysis and lavage (ALL), and short-term (< 6 months),
intermediate-term (6 months to 5 years), and long-term (≥5 years) follow-up
periods were considered. No significant differences in pain reduction and
complication rates were found between AS or ALL and arthrocentesis.
Regarding improvement in maximum mouth opening (MMO), both AS at Keywords: Therapeutic irrigation;
intermediate-term and ALL at short-term follow-up were equally efficient when Temporomandibular joint disc; Osteoarthritis;
compared to arthrocentesis. However, at intermediate-term follow-up, ALL was Joint diseases; Internal derangement;
Arthralgia; Pain; Minimally invasive surgical
superior to arthrocentesis for MMO improvement (mean difference 4.9 mm,
procedures; Mouth; Craniomandibular dis
95% confidence interval 2.7–7.1 mm). Trial sequential analysis supported the orders.
conclusion of the meta-analysis for MMO improvement for ALL versus
arthrocentesis studies at intermediate-term follow-up, but not for the other Accepted for publication 9 January 2024
meta-analyses. Insufficient evidence exists to draw conclusions regarding other Available online 28 January 2024
0901-5027/530503 + 18 © 2024 The Authors. Published by Elsevier Inc. on behalf of International Association of Oral and Maxillofacial
Surgeons. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
504 Tang et al.
patient outcomes or about comparisons between arthroscopy and conservative

treatments. Due to the low quality of the primary studies, further research is
warranted before final conclusions can be drawn regarding the management of
temporomandibular joint disorders.
Disorders of the temporomandibular analysis published in 2015 compared the criteria and the subsequent selection of
joint (TMJ) occur in approximately efficacy of arthroscopy with arthrocentesis articles, as outlined below.
30% of the adult population and en in the management of ID of the TMJ, and Population (P): studies were eligible for
compass primarily, but not exclusively, concluded that arthroscopy resulted in inclusion if the study population en
the conditions internal derangement more favourable outcomes than ar compassed patients diagnosed with the
(ID) and degenerative joint disease throcentesis with regard to pain reduction following temporomandibular disorders
(DJD)1. Due to their often debilitating and improvement in mouth opening, (TMD) as classified by the Diagnostic
nature, TMJ disorders have a sig while having similar complication rates8. Criteria for Temporomandibular
nificant impact on the quality of life of However, that review also noted that Disorders14: TMJ arthralgia, ID of the
patients2. more high-quality studies would be TMJ (i.e., disc displacement with or
Treatment options for TMJ disorders needed before final conclusions could be without reduction, and any synonyms
vary from conservative non-surgical ap drawn. Since then, several new studies such as closed lock and anchored disc
proaches to minimally invasive and open comparing the two treatment modalities phenomenon), and DJD of the TMJ (i.e.,
joint surgeries. Typically, conservative have been conducted9–11. Additionally, no osteoarthritis or osteoarthrosis). Further
treatment modalities are the first choice pair-wise systematic review has been per more, studies involving participants with
for initial therapy and consist primarily of formed to date that presents direct evi more general TMJ disorders (i.e., TMJ
counselling, splints, physiotherapy, and dence of the efficacy of arthroscopy versus arthropathy, intra-articular or capsular
medications (i.e., non-steroidal anti-in conservative treatments, and no review disorder of the TMJ, TMJ synovitis, and
flammatory drugs (NSAIDs) and muscle has included outcome variables other craniomandibular disorder) were also eli
relaxants). Minimally invasive surgical than pain reduction, improvement in gible for inclusion. The exclusion criteria
treatments, such as arthroscopy and ar maximum mouth opening (MMO), and were studies involving patients younger
throcentesis, are only considered if con complication rates. An updated sys than 16 years of age and those with pa
servative treatment modalities have failed tematic review, complying with the tients who suffered from congenital or
to adequately reduce pain or improve highest review standards, is therefore acquired dentofacial deformities, rheu
function3. However, there is growing evi needed to provide a more comprehensive matic disorders, connective tissue dis
dence that using minimally invasive overview of the current evidence re orders, or bony ankylosis of the TMJ.
therapies as an initial treatment may be garding the efficacy of TMJ arthroscopy. Intervention (I): the intervention
more efficient at reducing clinical symp Hence, the aim of the current sys group in the study had undergone TMJ
toms when compared to conservative tematic review was to assess the efficacy arthroscopy (i.e., diagnostic arthro
treatments4–6. and feasibility of AS and ALL as scopy, arthroscopic lysis and lavage,
TMJ arthroscopy allows the visualiza treatment modalities for TMJ disorders arthroscopic surgery, level I–III ar
tion of the inner tissues of the upper TMJ versus arthrocentesis and versus con throscopy). Due to the differences in
compartment for diagnostic purposes and servative treatments, by analysing joint the therapeutic manoeuvres performed
subsequent targeted treatment of the vi pain, MMO, mandibular function, between arthroscopic interventions, the
sualized tissues, i.e., the lysis of adhesions, joint blocks and noises, mandibular pooling of all arthroscopy types was
injection of medication into the inflamed range of motion, quality of life, safety, considered inappropriate. The inter
tissue, and electrocauterization/coblation and costs/cost-effectiveness. vention group was, therefore, stratified
of redundant and hyperaemic tissue. into ALL and AS for all of the ana
Technical advancements over the years lyses. ALL was defined in accordance
Methods
have resulted in the differentiation of ar with the technique described by
throscopy according to its complexity and This systematic review was performed and Sanders15 and with level I arthroscopy7,
level of invasiveness. The different mod reported in accordance with the Cochrane where visualization of the upper joint
alities of arthroscopy vary in their ther Handbook for Systematic Reviews of compartment is established in combi
apeutic manoeuvres, ranging from simple Interventions (version 6.3)12 and the Pre nation with joint lavage and an instru
diagnostic arthroscopy (level I) or ar ferred Reporting Items for Systematic ment sweep for lysis of any present
throscopic lysis and lavage (ALL) to more Reviews and Meta-Analyses (PRISMA) adhesions. AS was defined as the pro
advanced arthroscopic surgery (AS), guidelines13. The research protocol was cedure where any additional surgical
without (level II) or with (level III) disc registered in the International Prospective manoeuvres on top of ALL were per
repositioning and fixation procedures7. Register of Systematic Reviews (PROSP formed, as also described for level II or
Despite its widespread application in ERO; CRD42022324103) prior to the in level III arthroscopy7. This often en
the treatment of TMJ disorders, arthro itial literature search. compasses the introduction of addi
scopy has received minor attention re tional portals and includes techniques
garding its efficacy in comparison to other such as anterolateral capsular release,
Eligibility criteria and data items
treatment modalities, such as arthrocent (electro)coagulation of hypervascular
esis or conservative non-surgical treat The PICOTS format was used to for (retrodiscal) tissues, and/or manipula
ments. A systematic review with meta- mulate the inclusion and exclusion tion/fixation of the articular disc7.
Arthroscopy vs arthrocentesis for TMJ disorders 505
Control (C): the control group con registers were PubMed, Embase, Web modality, and pre- and postoperative
sisted either of (1) arthrocentesis with of Science, Cochrane Library, Scopus, treatment regimens), and the type of
lavage of the TMJ using any technique Clinicaltrials.gov, and the International disorder treated. If multiple outcome
(i.e., single/double needle use) or (2) Clinical Trials Registry Platform measures from different follow-up per
conservative non-surgical treatments of (ICTRP). The latest search date was iods were reported in a single study, all
any modality or a combination of these February 15, 2023. No language or of the outcome measures from each
modalities; i.e., soft diet advice, medi publication date restrictions were ap follow-up time-point were collected. If
cations such as NSAIDs and muscle plied. In addition, the grey literature multiple reports were published for a
relaxants, physiotherapy, and/or was searched. The reference lists of re single study, the outcome measures
splints/oral appliances. levant trials and systematic reviews on were checked for duplication and, if
Outcomes (O): the primary study the same topic were screened, and ex present, the duplicates were removed.
outcome was pain during mandibular perts on the study subject (N.B.vB. and All of the reported continuous pain
movement and/or function, assessed F.K.L.S.) were asked about relevant scores were recalculated to a numerical
using a visual analogue scale (VAS) or articles. VAS scale of 0–100 mm (the higher the
another continuous numerical scale. value the greater the pain) to allow
Secondary study outcomes included between-study comparisons and quan
Study selection process
pain at rest assessed using a VAS or titative analyses.
another continuous numerical scale, After de-duplication following the An attempt was made to contact the
MMO in millimetres, mandibular method of Bramer et al.17, two re corresponding authors of included ar
function (assessed for instance using viewers (Y.H.T. and N.B.vB.) in ticles in the event that additional study
the Mandibular Function Impairment dependently assessed the titles and data were required for both the quali
Questionnaire (MFIQ)16 or with regard abstracts of the records found in the tative and quantitative analyses. The
to chewing ability), joint blocks and literature search to identify those eli additional data were only included in
noises, mandibular range of motion gible for full-text assessment. Records the current study if the authors could
(i.e., lateral and protrusive move that lacked sufficient information in the provide the neccessary data.
ments), quality of life, safety (i.e., title and abstract were also selected for
complication rates), and costs/cost-ef full-text assessment. The full-text as
Quality assessment
fectiveness. sessment was performed by the same
Time points (T): the outcome mea two independent reviewers. After each The assessment of methodological and
sures were stratified into three follow- stage, the assessments were de-blinded clinical heterogeneity of the included
up time ranges for the analyses: short- and a consensus meeting was held be studies was conducted independently
term (< 6 months), intermediate-term tween the two reviewers to resolve any by two reviewers (Y.H.T. and
(6 months to 5 years), and long-term disagreements. If there was a lack of N.B.vB.). Any inconsistencies were re
(≥5 years). If multiple measurements consensus, a third reviewer (F.K.L.S.) solved through discussion in a con
were reported from the same study would be asked to aid in the decision- sensus meeting. The methodological
population that were within a single making. The inter-observer agreement heterogeneity assessment was per
follow-up range, the latest reported (Cohen’s kappa and percentage of formed for all of the included studies,
outcome measurement in that range agreement) was calculated for both while the clinical and statistical het
was used for the quantitative analyses. stages. erogeneity assessments were only per
Study design (S): the study types that formed for the studies that were
were eligible for inclusion were rando included in the quantitative analyses,
Data collection process
mized controlled trials (RCTs), pro by meta-analysis.
spective non-randomized controlled A predefined standardized form was The risk of bias in the RCTs was
clinical trials (CCTs), and retrospective used to collect the data from the eligible assessed using the Cochrane Risk of
cohort studies with a control group. studies. One reviewer (Y.H.T.) col Bias Tool for Randomized Trials, ver
Case reports, conference abstracts, re lected the data from all of the reports, sion 2 (RoB 2)18. Five domains were
views, letters to the editor, and expert while the second reviewer (N.B.vB.) assessed to obtain an indication of
opinions were excluded. Furthermore, reviewed 15% of the reports in whether the study had either a low risk
the studies had to have included at least dependently. The agreement between of bias, some concerns of bias, or a high
10 participants and been published in a the reviewers regarding the data col risk of bias. The validated Methodolo
peer-reviewed journal. No restriction lection was required to be ≥90%. If this gical Index for Non-Randomized Stu
was placed on language or publica was not the case, the second reviewer dies (MINORS) was used to assess the
tion date. had to evaluate all of the remaining risk of bias in the non-randomized
reports, followed by a consensus studies19. Using this tool, the studies
meeting. were assessed for 12 items that were
Search strategy and information sources
The following data were collected then scored as either 0 (not reported), 1
With the help of a biomedical literature from each study: authors and publica (reported but inadequate), or 2 (re
specialist, a sensitive electronic litera tion date, primary and secondary out ported and adequate).
ture search was performed in seven come measures, baseline patient The assessment of the certainty of
electronic databases and trial registers characteristics (age, sex, and number of the body of evidence for outcomes
using controlled vocabulary (medical patients), study design, specifications of was performed using the Grading of
subject heading, MeSH) and free text the treatments in each study arm (i.e., Recommendations Assessment,
terms (Supplementary Material Table type, technique, additional in Development and Evaluations
S1). The electronic databases and traoperative injections, anaesthesia (GRADE) approach 20 by two
506 Tang et al.
independent reviewers (Y.H.T. and in both arms were excluded, was also questioning the experts on the subject9,11,
N.B.vB.). The quality of the evidence performed. Regarding the continuous ultimately leading to the inclusion of 13
was rated high, moderate, low, or variables suitable for quantitative ana studies in the qualitative review. Finally,
very low for each quantitatively lysis, the mean difference (MD) and nine studies were included in the quanti
analysed study outcome, after being corresponding 95% CI were calculated tative analyses9–11,30,33–37. The third re
potentially up- or downgraded based as effect measures12. If studies only re viewer was not consulted in the study
on factors as described by the ported the standard deviations (SDs) of screening and selection process.
GRADE working group system (e.g. the baseline and postoperative outcome Supplementary Material Table S2 pro
downgrading quality of evidence due scores, the SDs of the changes were vides an overview of the records that were
to inconsistency or inaccuracy of the estimated from the baseline measure excluded after full-text reading, including
results). ments, with a correlation coefficient of the reasons. The agreement between the
The clinical heterogeneity between the 0.512,24. The meta-analyses and forest two reviewers regarding the data collec
studies included in the quantitative ana plots were synthesized in R version tion was 100%.
lyses was systematically evaluated using 4.2.2 (R Core team; R Foundation for
the Clinical Diversity In Meta-analyses Statistical Computing, Vienna, Aus
Study characteristics
(CDIM) tool21. The clinical heterogeneity tria), using the meta package, version
of each meta-analysis was measured on an 6.1–025. A random-effects model with From the 13 included studies, a total of
ordinal scale based on four domains, i.e., the DerSimonian–Laird estimator26 609 study participants were included in
setting diversity, population diversity, in was used, based on the assumption that this review. One study compared ar
tervention diversity, and outcome di there was a high likelihood of clinical throscopy with both arthrocentesis and
versity, with a total of 11 items. Each item heterogeneity between the studies27. conservative treatment30, while the re
was scored 0 (low diversity), 1 (moderate Sensitivity analyses were performed maining studies compared arthroscopy
diversity or unknown), or 2 (high di based on the study design (inclusion of with either arthrocentesis or con
versity) and assigned an equal weight, re only RCTs) and per diagnosis of the servative treatment.
sulting in a total score of 0–22. A total study participants (i.e., ID, DJD, or
score of 0–11 indicated low clinical het arthralgia).
Studies involving arthroscopy versus
erogeneity, 12–18 indicated moderate As traditional meta-analyses are
arthrocentesis
clinical heterogeneity, and 19–22 indicated prone to type I errors (i.e., false-posi
high clinical heterogeneity between the tive findings), additional trial sequential Ten studies compared arthroscopy and
studies. analyses (TSA) were performed28. The arthrocentesis9–11,30,32–37, and of these,
TSA, with a random-effects model three were RCTs11,34,35, two were
(DerSimonian–Laird estimator), was CCTs10,32 (one study reported two groups
Effect measures and data synthesis
performed using Trial Sequential Ana without statistically comparing them32),
Inter-observer agreement, examined by lysis Viewer version 0.9.5.10 Beta (Co and five were retrospective cohort studies
Cohen’s kappa statistic and the per penhagen Trial Unit, Centre for with a control group9,30,33,36,37 (Table 1a).
centage of agreement, was calculated Clinical Intervention Research, Rig The studies were published between 1995
using IBM SPSS Statistics version 23 shospitalet, Copenhagen, Denmark)29. and 2023 and included a total of 430 pa
(IBM Corp., Armonk, NY, USA). TSA was used to determine the re tients, the majority of whom were female.
A summary effect estimate was cal quired information size (RIS) (i.e., the Four studies involved AS11,30,32,33 and six
culated if two or more studies reported sample size needed for the meta-ana studies reported ALL9,10,34–37 as the in
similar study outcomes12. If study sub lysis) of each outcome to provide an tervention. None of the studies reported
jects had been excluded from an ana indication of the robustness of the the use of level III AS. The studies re
lysis in the original study for reasons conclusion from the meta-analysis. ported results for one or several post
other than the exclusion criteria set by Statistical heterogeneity was con operative follow-up time-points, ranging
the current review (i.e., the excluded sidered substantial if I2 was ≥50%12. A from 1 day to 5 years. One study included
subjects would fit within the scope of P-value < 0.05 was considered statisti patients diagnosed with either ID or
the current review), and the outcome cally significant in all of the analyses. DJD9, while the other studies included
data were available for the excluded patients with a diagnosis of ID. Among
subjects, these subjects were included in the studies, the arthroscopic procedures
the effect measures calculation. Results varied to a greater extent than the ar
Dichotomous variables were pre throcentesis procedures (Table 1a). The
Study selection
sented as events and totals, from which preoperative and postoperative treatment
the odds ratio (OR) and 95% con After the initial and updated search, a regimens varied considerably between the
fidence interval (CI) were calculated. total of 1619 unique records were identi studies (Table 2a).
The Mantel–Haenszel fixed-effects fied for title and abstract screening
method was used due to the limited (Fig. 1). Based on this screening, 28 re
Studies involving arthroscopy versus
number of events12. Studies with zero cords were selected for full-text reading.
conservative treatments
events in both arms were included in The inter-observer agreement was high
the main meta-analysis with a re (Cohen’s kappa coefficient (κ) = 0.88; Four studies involved conservative
ciprocal continuity correction of the percentage of agreement = 99.6%). After non-surgical treatment regimens as the
opposite arm (i.e., correction = 1/ the full-text assessment, 11 records were control group30,31,38,39, of which three
(sample size of opposite arm))22,23. A selected for inclusion10,30–39 (κ = 1.00; studies were RCTs31,38,39 and one study
sensitivity analysis using conventional percentage of agreement = 100%). Two was a retrospective cohort study with a
methods, where studies with zero events additional records were identified after control group (Table 1b)30. The studies,
Fig. 1. Flow diagram of the study record identification and selection process.
published between 1993 and 2014, in judgement31. There was no ‘high risk of the study outcomes were only reported
cluded a total of 204 patients, the ma bias’ assessment for any of the domains in a graphical manner with no between-
jority of whom were female. Three (Fig. 2). MINORS was used to assess the group comparisons, therefore not al
studies reported on AS30,38,39 and one risk of bias of the seven CCTs and ret lowing qualitative or quantitative ana
study on ALL31 as the intervention. rospective cohort studies9,10,30,32,33,36,37. lysis in the context of this study32. Of
One study reported the use of level III The score for each study ranged from 13 the remaining three studies comparing
AS39. The studies recorded one or sev to 16 on a scale of 0–24 (Fig. 3). AS and arthrocentesis, one reported
eral postoperative follow-up time- short-term results for pain (1 month),
points, ranging from 1 month to 5 with no statistically significant differ
Primary outcome—pain
years. One study included patients with ence between the two groups11. All
movement restricting arthralgia38, None of the studies made a distinction three studies reported intermediate-
while the other studies included pa between the pain score during man term results for pain (range 6–24
tients with a diagnosis of ID. There was dibular movement/function and when months), with no significant difference
a high heterogeneity in the conservative at rest, therefore general pain VAS between the groups after pooling the
treatment procedures between the stu scores were used to represent the main data (MD 2.2, 95% CI −15.4 to 19.7; I2
dies (Table 1b). The preoperative and study outcome. = 87%, very low quality;
postoperative treatment regimens Fig. 4A)11,30,33. None of the studies
varied considerably between the studies comparing AS and arthrocentesis re
Studies comparing arthroscopy versus
(Table 2b). ported long-term results for pain.
arthrocentesis
Among the six studies comparing
All 10 studies involving arthroscopy ALL and arthrocentesis, three reported
Risk of bias in the studies
and arthrocentesis investigated the pain short-term results for pain (range 1–3
The risk of bias assessment for the six VAS scores using a numerical scale months), with no significant difference
RCTs using the RoB 2 tool resulted in (Supplementary Material Table between the groups after pooling the
‘some concerns’ as the overall judgement S3a)9–11,30,32–37. The pain scores im data (MD 2.8, 95% CI −8.9 to 14.6; I2
for five studies11,34,35,38,39, primarily due to proved significantly at follow-up com = 61%, very low quality;
the lack of information regarding con pared to the scores at baseline, in both Fig. 4B)10,36,37. Of note, patients who
cealment of the allocation sequence, de groups in all 10 studies. were excluded from one study36 based
viations from the intended interventions, One study involving AS and ar on criteria other than those of the cur
and the statistical analyses employed. One throcentesis reported an improvement rent review were included in this meta-
study had a low risk of bias as the overall in pain over time for both groups, but analysis. Two studies reported
508 Tang et al.
Table 1a. Characteristics of included studies involving arthroscopy versus arthrocentesis.

Arthroscopy versus arthrocentesis
Study Number of Sex distribution, % Age (years),
Author (year) design patients female mean (SD) Study population
Arthroscopy/arthrocentesis groups
Arthroscopic surgery as intervention
Murakami et al. (1995)30 Retro. 25/20 92/85 33 (17)/ 31 (14) ID (Wilkes 3 closed lock)
Sanromán (2004)32 CCT 16/8 NA NA ID (closed lock)
Hobeich et al. (2007)33 Retro. 28/20 NA 31 (7)/ 31 (8) ID (ADDwoR)
Atteya et al. (2020)11 RCT 20/20 95/80 38 (11)/ 32 (9) ID (Wilkes 2–3)
Arthroscopic lysis and lavage as intervention
Fridrich et al. (1996)34 RCT 11/8 100/100 32 (11)/ 28 (9) ID (ADDwR + ADDwoR)
Goudot et al. (2000)35 RCT 33/29 NA NA ID (ADDwR + ADDwoR)
Tan and Krishnaswamy Retro. 11/9 73/78 40 (15)/ 28 (9) ID (closed lock + painful
(2012)36 click)
37
Xu et al. (2013) Retro. 37/41 78/73 36 (NA)/ ID (ADD)
38 (NA)
Rajpoot et al. (2023)10 CCT 15/15 67/80 NA ID (Wilkes 2–5)
Talaat et al. (2022)9 Retro. 32/32 75/59 NA ID (ADDwoR w/ limited
MO) + DJD
Intervention Control
Author (year)
Therapy type (lavage fluid) Co-Int. Anaesth. Therapy type (lavage fluid) Co-Int. Anaesth.
Murakami et al. (1995)30 ALL + ALCR (NA)a C GA Arthrocentesis (Ringer)a C LA
Sanromán (2004)32 ALL + coagulation (NA)a SH GA Arthrocentesis (Ringer)a SH LA
33
Hobeich et al. (2007) ALL + coagulation (Ringer)a SH GA Arthrocentesis (Ringer)a SH LA + IVS
Atteya et al. (2020)11 ALL + ALCR + coagulation SH GA Arthrocentesis (Ringer)a SH LA
(Ringer)a
Fridrich et al. (1996)34 ALL (Ringer)a C GA Arthrocentesis (Ringer)a C IVS
Goudot et al. (2000)35 ALL (Ringer)b - GA Arthrocentesis (saline)a - LA
Tan and Krishnaswamy ALL (saline)b - GA Arthrocentesis (saline)a - LA
(2012)36
Xu et al. (2013)37 ALL (Ringer)a SH LA Arthrocentesis (Ringer)a SH LA
Rajpoot et al. (2023)10 ALL (Ringer)b - GA Arthrocentesis (Ringer)b - LA
Talaat et al. (2022)9 ALL (saline)b SH GA Arthrocentesis (saline)b SH LA
ADD anterior disc displacement; ADDwoR, anterior disc displacement without reduction; ADDwR, anterior disc displacement with
reduction; CCT, prospective non-randomized controlled trial; DJD degenerative joint disease; ID, internal derangement; MO, mouth
opening; NA, not available; RCT, randomized controlled trial; Retro., retrospective cohort study with control group; SD standard
deviation.
ALCR, anterolateral capsular release; ALL, arthroscopic lysis and lavage; Anaesth., anaesthesia; C, corticosteroids; Co-Int., co-in
tervention; GA, general anaesthesia; IVS, intravenous sedation LA, local anaesthesia; NA, not available; SH, sodium hyaluronate.
a
Dual portal (arthroscopy) or dual puncture (arthrocentesis) technique.
b
Single portal (arthroscopy) or single puncture (arthrocentesis) technique.
intermediate-term results for pain Studies comparing arthroscopy versus difference between the groups. Three stu
(range 6–12 months), with no sig conservative treatments dies on AS versus conservative treatment
nificant difference between the groups reported intermediate-term pain results
after pooling the data (MD −4.4, 95% Out of the four studies comparing ar (range 6–12 months), with no significant
CI −16.0 to 7.2; I2 = 31%, very low throscopy with conservative treat difference between the groups30,38,39.
quality; Fig. 4C)10,35. One study com ments, three investigated pain VAS None of the studies that compared AS
paring ALL and arthrocentesis re scores using a numerical scale and conservative treatments reported any
ported long-term results for pain (60 (Supplementary Material Table long-term pain results.
months), with no significant difference S3b)30,38,39. Quantitative analysis was Only one study compared ALL with
between the two groups9. considered unfeasible due to the limited conservative treatments; this study found
Sensitivity analyses including only amount of suitable data. no statistical difference between ALL and
RCTs or based on the diagnosis (only Among the studies comparing AS and medical management/non-surgical re
possible for ID) did not yield any conservative treatment, two investigated habilitation regarding pain intensity and
differences in outcome when com pain in the short term (range 1–3 frequency over the course of 60 months,
pared to the conventional meta-ana months)38,39. Both of these studies re however the outcomes were measured on
lyses. ported no statistically significant a dichotomous scale31.
Table 1b. Characteristics of included studies involving arthroscopy versus conservative treatment.
Arthroscopy versus conservative treatment
Study Number of Age (years),
Author (year) design patients Sex distribution, % female mean (SD) Study population
Arthroscopy/conservative treatment groups
Stegenga et al. (1993)38 RCT 9/12 NA NA Arthralgia
Murakami et al. Retro. 25/63 92/76 33 (17)/ 30 (16) ID (Wilkes 3
(1995)30 closed lock)
McNamara et al. RCT 10/10 NA NA ID (ADD)
(1996)39
Schiffman et al. RCT 23/29 85/90 32 (2)/ 34 (2) ID (ADDwoR
(2014)31 closed lock)
23/23 85/100 32 (2)/ 30 (2)
Intervention Control
Author (year)
Therapy type (lavage fluid) Co-Int. Anaesth. Conservative treatment technique
Stegenga et al. (1993)38 ALL + ALCR + coagulation (saline)a C+ GA Self-exercise + physiotherapy
AB
Murakami et al. (1995)30 ALL + ALCR (NA)a C GA 1–2 weeks NSAIDs and muscle relaxants +
physiotherapy + 12 weeks splint
39
McNamara et al. (1996) ALL + ALCR + coagulation + NA GA Physiotherapy + splint
discopexy (NA)a
Schiffman et al. (2014)31 ALL (Ringer)b C GA Self-exercise + 6 days methylprednisolone +
6 weeks NSAIDs and muscle relaxants
Above-mentioned management +
physiotherapy + cognitive behavioural
therapy + splint
ADD anterior disc displacement; ADDwoR, anterior disc displacement without reduction; ID, internal derangement; NA, not available;
RCT, randomized controlled trial; Retro., retrospective cohort study with control group; SD standard deviation.
AB, antibiotics; ALCR, anterolateral capsular release; ALL, arthroscopic lysis and lavage; Anaesth., anaesthesia; C, corticosteroids;
Co-Int., co-intervention; GA, general anaesthesia; NA, not available; NSAIDs, non-steroidal anti-inflammatory drugs.
a
Dual portal (arthroscopy) or dual puncture (arthrocentesis) technique.
b
Single portal (arthroscopy) or single puncture (arthrocentesis) technique.
All of the studies reported a sig term results for MMO (range 6–24 to 7.1; I2 = 18%, low quality;
nificant reduction in pain over time for months), which showed no significant Fig. 5C)10,34,35. One study comparing
both groups. difference between the groups after ALL and arthrocentesis reported long-
pooling the data (MD 1.1, 95% CI term results for MMO (60 months),
−1.1 to 3.2; I2 = 0%, very low quality; with no significant difference between
Secondary outcomes Fig. 5A)11,30,33 . None of the studies the two groups9.
comparing AS and arthrocentesis Sensitivity analyses including only
Studies comparing arthroscopy versus reported long-term results for MMO. RCTs or based on the diagnosis (only
arthrocentesis Of the studies comparing ALL and possible for ID) did not yield any dif
All 10 studies comparing arthroscopy arthrocentesis, three reported short- ferences in outcome compared to the
and arthrocentesis reported the im term results for MMO (range 1–3 conventional meta-analyses.
provement in MMO (Supplementary months), with no significant difference Three studies with arthrocentesis as
Material Table S3a)9–11,30,32–37. A sig between the groups after pooling the the control group reported on man
nificant improvement in MMO was data (MD −1.4, 95% CI −8.1 to 5.3; I2 dibular function, each using a different
seen in both groups in all 10 studies. = 89%, very low quality; measurement tool (Supplementary
One study on AS and arthrocent Fig. 5B)10,36,37. Of note, patients ex Material Table S3a)9,30,34. One study
esis depicted MMO only in a gra cluded from one study36 based on cri on AS reported the jaw function score
phical manner without a between- teria other than those of the current (numerical scale of 0–20) and dietary
groups comparison, therefore not review were included in this meta-ana evaluation score (numerical scale of
allowing analysis in the context of lysis. Three studies reported inter 0–72) at intermediate-term follow-up (6
this study 32. None of the AS and ar mediate-term results for MMO (range months)30. AS improved the dietary
throcentesis comparative studies re 6–24 months), with a significant differ evaluation score significantly, but not
ported short-term results for MMO. ence favouring arthroscopy after the jaw function score. Arthrocentesis,
Three studies reported intermediate- pooling the data (MD 4.9, 95% CI 2.7 on the other hand, improved both
510 Tang et al.
Table 2a. Pre- and postoperative treatment regimens in the included studies involving arthroscopy versus arthrocentesis.
Study
Author (year) design Preoperative treatment Postoperative treatment
Murakami et al. (1995)30 Retro. Arthroscopy group: none or after 1–2 weeks of Self-exercise
NSAIDs and muscle relaxants, physiotherapy and
up to 12 weeks splint
Arthrocentesis group: none
Sanromán (2004)32 CCT 4–6 months of soft diet advice, NSAIDs, Self-exercise, 2 weeks of NSAIDs and
physiotherapy, and splint splint
Hobeich et al. (2007)33 Retro. Splint Self-exercise, 2 weeks of NSAIDs and
muscle relaxants
Atteya et al. (2020)11 RCT 6 months of conservative treatment (non-specified) Self-exercise, 2 months of soft diet
advice, 3 days of NSAIDs and
antibiotics
Fridrich et al. (1996)34 RCT Soft diet advice, NSAIDs, moist heat, ice therapy, 1 week of soft diet advice, 4 weeks of
habit modification, physiotherapy, and splint NSAIDs, physiotherapy and splints
Goudot et al. (2000)35 RCT 6 months of self-exercise, psychological support, Self-exercise, 2 weeks of soft diet
physiotherapy, and splint advice, and physiotherapy
Tan and Krishnaswamy Retro. 3–8 weeks of NSAIDs and muscle relaxants and Soft diet advice, NSAIDs,
(2012)36 splint physiotherapy, and splint
37
Xu et al. (2013) Retro. NA NA
Rajpoot et al. (2023)10 CCT NA Self-exercise, 2 weeks of soft diet
advice, analgesics, antibiotics
Talaat et al. (2022)9 Retro. 2 months of soft diet advice, NSAIDs, Self-exercise, 3 days of NSAIDs and
physiotherapy, and splint. splint
CCT, prospective non-randomized controlled trial; NA, not available; NSAIDs, non-steroidal anti-inflammatory drugs; RCT, rando
mized controlled trial; Retro., retrospective cohort study with control group.
scores at the follow-up. The second at the follow-up34. All three studies re joint noises, with no statistically sig
study, which was on ALL, scored dis ported no significant difference between nificant difference between them.
ability in the long term (5 years) on a arthroscopy and arthrocentesis. Three studies reported the mandibular
categorical scale from 0 to 69. In that Regarding joint blocks and noises, only range of motion (Supplementary Material
study, both treatments improved the one study comparing ALL and ar Table S3a)10,32,37. One study on AS re
disability scores significantly. The third throcentesis described the subjective in ported maximum contralateral and pro
study, also involving ALL, looked at tensity of joint noises at intermediate-term trusive mandibular movements solely in a
the intermediate-term chewing ability follow-up (6–24 months) based on a graphical manner, therefore not allowing
(6–24 months) using a 0–100 numerical 0–100 numerical scale (Supplementary further analysis32. The second study re
scale and found that both treatments Material Table S3a)34. Both treatments ported superior efficacy of ALL over ar
significantly improved chewing ability decreased the subjective intensity of the throcentesis (MD 1.1 mm) for the
Table 2b. Pre- and postoperative treatment regimens in the included studies involving arthroscopy versus conservative treatment.
Study
Author (year) design Preoperative treatment Postoperative treatment
Stegenga et al. RCT Explanation, self-exercise, soft diet advice Arthroscopy group: physiotherapy, ice massage,
(1993)38 and self-exercises
Murakami et al. Retro. Arthroscopy group: none or after 1–2 weeks Arthroscopy group: self-exercises
(1995)30 of NSAIDs and muscle relaxants,
physiotherapy and up to 12 weeks of
splint use
McNamara et al. RCT 12 months of explanations, self-exercise, soft Arthroscopy group: conservative treatment
(1996)39 diet advice, and medication (not further (physiotherapy and splint)
specified)
Schiffman et al. RCT Arthroscopy group: physiotherapy and Arthroscopy group: medical management
(2014)31 cognitive behavioural therapy (education, self-exercise, methylprednisolone,
NSAIDs, muscle relaxants) and physical
rehabilitation (physiotherapy, cognitive behavioural
therapy, splint)
NSAIDs, non-steroidal anti-inflammatory drugs; RCT, randomized controlled trial; Retro., retrospective cohort study with control
group.
group at the short-term and inter

mediate-term follow-ups (3 and 12
months) based on analysis of variance
with repeated measures39. The other
two studies involving AS and con
servative treatment reported an im
provement in MMO for both groups,
with no between-group difference in the
short term (1 month)38 or intermediate
term (6 months)30,38. The only study
with ALL as the intervention reported
a significant improvement in MMO
over the long-term follow-up period (60
months) for the ALL, physical re
habilitation, and medical management
groups, but with no difference between
the three groups31.
All four studies comparing arthro
scopy with conservative treatments re
ported mandibular function, but used
different measurement tools
(Supplementary Material Table S3b). Of
the three studies involving AS, one used
the Helkimo Clinical Dysfunction Index
score40 (on a numerical scale of 0–25) at
the short-term and intermediate-term
follow-ups (3 and 12 months)39. Another
noted the categorical global pain impact
Fig. 2. Risk of bias assessment of the randomized controlled trials using the Cochrane scores41 (range 0–5) and the converted
Risk of Bias Tool 2. ALL, arthroscopic lysis and lavage; AS, arthroscopic surgery. Mandibular Functional Impairment
Questionnaire (MFIQ) scores16 (range
improvement in contralateral movement the five studies involving ALL versus 1–3) at short-term and intermediate-term
at short-term follow-up (3 months)37. The arthrocentesis, there was no significant follow-up (1 and 6 months)38. The third
third study reported a superior effect of difference between the two groups (OR study reported the Activities of Daily
ALL over arthrocentesis for the im 1.2, 95% CI 0.3 to 4.5; I2 = 0%, very Living scores (range 0–72) and jaw
provement of left lateral (MD 1.0 mm), low quality; Fig. 6A)9,34–37. A sensi function scores (range 0–20) at inter
right lateral (MD 0.7 mm), and protrusive tivity analysis, in which studies with mediate follow-up (6 months)30. The
movement (MD 0.3 mm) at intermediate- zero events in both arms were excluded, study involving ALL reported man
term follow-up (6 months)10. All of the also resulted in no significant difference dibular function impairment as a di
studies reported an improvement in between the groups regarding the chotomous outcome, over a period of 60
mandibular range of motion over time for complication rate (OR 1.2, 95% CI 0.3 months31. In all of the studies, a sig
both groups. to 4.7; I2 = 0%, very low quality; nificant treatment effect was seen over
The complication rates for both Fig. 6B). time, with no between-group differences.
treatments were described in seven None of the studies that compared Only one study comparing arthro
studies, one involving AS11 and six in arthroscopy with arthrocentesis re scopy and conservative treatment re
volving ALL9,10,34–37 as the interven ported the effect of either treatment on ported on joint blocks and noises
tion. One study looked at safety per quality of life or the costs/cost-effec (Supplementary Material Table S3b).
complication type instead of per study tiveness of the treatments. ALL and conservative treatments did
participant10. In that study, transient not improve joint clicking or joint cre
facial nerve paralysis, fluid extravasa pitus over time and there was no be
Studies comparing arthroscopy versus
tion, and bleeding occurred in 66.6%, tween-groups difference over a 60-
conservative treatments
46.6%, and 26.6%, respectively, of the month period31. The same study in
participants in the arthrocentesis group A quantitative analysis of the sec vestigated mandibular range of motion
and 0.0%, 26.6%, and 40.0%, respec ondary outcomes was not performed and reported that lateral and protrusive
tively, of those in the ALL group10. The for studies using conservative treat movements improved after both ALL
other six studies reported the presence ments as the control group, due to a and conservative treatments over a
of complications per study participant, lack of suitable data. All four studies period of 60 months (Supplementary
which ranged between 0% and 6.1% comparing arthroscopy versus con Material Table S3b)31. There were no
among the treated participants in the servative treatment included MMO as differences between the groups.
arthroscopy group and between 0% and an outcome (Supplementary Material One study involving AS reported
6.9% in the arthrocentesis group. The Table S3b)30,31,38,39. Among the studies quality of life using a total well-being
study comparing AS and arthrocentesis involving AS, one reported a reduced score, based on the West Haven–Yale
reported no complications in either of MMO in the AS group and improved Multidimensional Pain Inventory42 and
the groups. After pooling the data of MMO in the conservative treatment the General Health Questionnaire43, at
512 Tang et al.
among the studies in the meta-analysis

regarding safety (complication rate)
was moderate, mainly due to the het
erogeneity between the study interven
tion group treatments and the control
group treatments (CDIM score 12)
(Supplementary Material Table S4g).
TSA was performed only for the study
outcomes with pooled data, hence only
for those studies that had compared ar
throscopy with arthrocentesis. Regarding
pain on a VAS, the RIS (i.e., the sample
size needed in the meta-analysis) was not
reached and the conventional and
O’Brien–Fleming boundaries were not
crossed in any of the three meta-analyses
(AS vs arthrocentesis at intermediate-
term follow-up, ALL versus arthrocent
esis at short-term follow-up, and ALL
versus arthrocentesis at intermediate-
term follow-up) (Supplementary
Material Table S5). Therefore, TSA in
dicates that the current available evi
dence from these meta-analyses may be
inconclusive due to potential false neutral
outcomes. For MMO, TSA did not
support the conclusions from the meta-
analyses involving AS versus ar
throcentesis at intermediate-term follow-
up and ALL versus arthrocentesis at
short-term follow-up, since the RIS was
not attained and the boundaries were not
crossed (Supplementary Material Table
S5). However, the RIS was attained and
the boundaries were crossed for the
Fig. 3. Risk of bias assessment of the non-randomized studies with arthrocentesis as the
meta-analysis involving ALL versus ar
control, using the Methodological Index For Non-Randomized Studies (MINORS).
throcentesis on MMO at intermediate-
term follow-up (Supplementary Material
short-term and intermediate-term resulted in a very low quality of evi Table S5). For this analysis, TSA sup
follow-ups (1 and 6 months) dence for the outcomes improvement in ports the conclusion that ALL may be
(Supplementary Material Table S3b)38. pain and complication rates. Regarding superior to arthrocentesis in improving
There was no significant difference be the improvement in MMO, a very low MMO. Finally, TSA did not support the
tween the groups or improvement quality of evidence judgement was ob conclusions drawn from the meta-ana
over time. tained for the outcomes of AS versus lysis regarding safety (complication rates)
None of the studies comparing ar arthrocentesis at intermediate-term (Supplementary Material Table S5).
throscopy and conservative treatments follow-up and ALL versus arthrocent
reported the safety or complication esis at short-term follow-up. For ALL
rates of the procedures (Supplementary versus arthrocentesis at intermediate-
Discussion
Material Table S3b). term follow-up, a low quality of evi
One study looked at the costs of the dence judgement was obtained. All The aim of this systematic review was
treatments based on the average costs outcomes had an initial assessment of to compare the efficacy and feasibility
incurred per study participant low quality of evidence due to the in of two arthroscopic techniques (AS and
(Supplementary Material Table S3b)31. clusion of non-randomized studies. ALL) with arthrocentesis and also with
Medical management resulted in the Downgrading occurred due to incon conservative treatment regimens for
lowest average costs ($1385, range sistency or imprecision (Table 3). TMJ disorders. AS at intermediate-
$410–$3555), followed by rehabilitation The assessment of clinical diversity term follow-up and ALL at short-term
($2379, range $1375–$5240) and then among the studies, using the CDIM and intermediate-term follow-ups were
by ALL ($7890, range tool21, resulted in a judgement of low equally efficient to arthrocentesis at
$5830–$15,940)31. clinical heterogeneity for all of the reducing pain. Additionally, AS at in
meta-analyses performed for the out termediate-term follow-up and ALL at
comes pain by VAS score (CDIM score short-term follow-up were equally effi
Certainty of the evidence
range 9–11) and MMO (CDIM score cient to arthrocentesis at improving
Assessment of the certainty of the evi range 8–10) (Supplementary Material MMO, but ALL was superior to ar
dence using the GRADE approach Table S4a–f). The clinical diversity throcentesis with regard to the
Fig. 4. Pooled results for the reduction in VAS pain score in the studies comparing arthroscopy versus arthrocentesis. In all studies, the
study participants were treated for a type of internal derangement. Trial sequential analysis did not support the conclusions drawn in
each of the three meta-analyses regarding the reduction in pain score, indicating potentially false neutral results. Abbreviations: VAS,
visual analogue scale; AS, arthroscopic surgery; ALL, arthroscopic lysis and lavage; SD, standard deviation; MD, mean difference; 95%
CI, 95% confidence interval.
improvement in MMO at intermediate- heterogeneity between the conservative between the procedures suggests that
term follow-up. TSA only supported treatment methods used in these stu both interventions have equal potential
the conclusion that ALL may be su dies, the performance of meta-analyses in alleviating pain through the removal
perior to arthrocentesis in improving was considered inappropriate. of inflammatory mediators from the
MMO in the intermediate term. There The finding that arthroscopy and joint space. Two recent studies found
was no difference in complication rates arthrocentesis are equally efficient at that an additional subsynovial corti
between the procedures. The data re reducing pain is in accordance with the costeroid injection during TMJ arthro
garding mandibular function, joint notion that joint lavage facilitates the scopy is more effective at alleviating
blocks and noises, mandibular range of removal of the proinflammatory cyto pain when compared to no injec
motion, quality of life, and costs/cost- kines and degradation products44,45 tion49,50. It should be noted that none
effectiveness were too heterogeneous or that contribute to synovitis46,47. Syno of the studies included in the current
scarce to draw any conclusions from. vitis, in turn, has been found to be as review performed this procedure. Sub
Only a limited number of studies com sociated with the intensity of pain synovial injections cannot be per
pared arthroscopy with conservative experienced by patients48. Hence, the formed during arthrocentesis as this
treatment regimens. Due to the high observed similarity in pain reduction requires direct visualization of the
514 Tang et al.
Fig. 5. Pooled results for the improvement in MMO in the studies comparing arthroscopy versus arthrocentesis. In all studies, the study
participants were treated for a type of internal derangement. Trial sequential analysis did not support the conclusions drawn in the meta-
analyses regarding the improvement in MMO for AS versus arthrocentesis at intermediate-term follow-up or ALL versus arthrocentesis
at short-term follow-up, indicating potentially false neutral results (A, B). However, trial sequential analysis supported the conclusions
drawn in the meta-analysis involving ALL versus arthrocentesis at intermediate-term follow-up (C). Abbreviations: MMO, maximum
mouth opening; AS, arthroscopic surgery; ALL, arthroscopic lysis and lavage; SD, standard deviation; MD, mean difference; 95% CI,
95% confidence interval.
inflamed tissues. This highlights the possible. This could explain why the The findings of this study present a
potential advantages of arthroscopy results indicate a superiority of ALL general tendency that patients with
over arthrocentesis in providing addi over arthrocentesis for the improve TMJ disorders experience a reduction
tional therapeutic options. Further re ment in MMO at intermediate-term in clinical symptoms over time regard
search is warranted to establish the follow-up. Surprisingly, AS did not less of the treatment received. This
efficacy of co-interventions during ar lead to a better improvement in MMO, finding is in line with numerous non-
throscopy. while ALL did at intermediate-term comparative reports in the literature
In TMJ disorders, limited mouth follow-up. It is hypothesized that suggesting beneficial effects of arthro
opening is partly attributed to the for during electrocautery, a procedure that scopy52–54, arthrocentesis55,56, and
mation of intra-articular adhesions51. is only possible during AS, thermal conservative treatments57,58 on
Since arthroscopy allows direct visua shrinkage of the intra-articular tissue symptom reduction based on pre- and
lization of the joint, a more targeted may occur, leading to less improvement post-treatment differences. However, in
lysis of any intra-articular adhesions is or even a reduction in MMO. a significant proportion of patients,
Fig. 6. Pooled results for the complication rate in the studies comparing arthroscopy versus arthrocentesis. Study participants were
treated for a type of internal derangement in all studies except the study by Talaat et al.9, in which participants suffering from internal
derangement or osteoarthritis were selected. A sensitivity analysis in which this study was excluded showed no influence on the results.
Trial sequential analysis did not support the conclusion drawn from the meta-analysis with a reciprocal continuity correction regarding
the complication rate, indicating potentially false neutral results (A). Abbreviations: ALL, arthroscopic lysis and lavage; OR, odds ratio;
95% CI, 95% confidence interval.
TMD symptoms have a propensity to study participants diagnosed with ID separate arthroscopic technique would
decrease in severity or to resolve on suffered concurrently from DJD and not have affected the study findings.
their own over time59,60. This, there vice versa. Moreover, since all of the The findings of the current study do
fore, emphasizes the need to conduct studies reported pain scores, it is con not completely correspond with those
comparative studies and analyse them ceivable that only ID and DJD patients of a previous systematic review with
systematically, in order to evaluate the were included who were simultaneously meta-analysis published in 20158, which
‘true’ therapeutic effects of the different experiencing arthralgia, i.e., painful ID concluded that arthroscopy is superior
treatment modalities. The current study and/or DJD. to arthrocentesis in reducing pain and
focused exclusively on comparative The arthroscopy group in the current improving mouth opening, while the
studies involving arthroscopy. Despite review was stratified into two techni two have similar complication rates.
the fact that several studies have com ques based on the complexity of the These differences could be explained by
pared arthrocentesis with conservative treatment, instead of the commonly methodological differences between the
treatments4–6, it was considered beyond used three-level classification described two reviews. First, the previous review
the scope of the current review to assess by McCain7. The decision for this ap performed fixed-effects meta-analyses
such studies systematically. proach was based on the notion that for the continuous outcomes, which
The studies included in this review the repositioning and/or fixation of the ignore heterogeneity12, despite the clear
examined populations with various articular disc, which plays a central presence of statistical and methodolo
conditions, including function-limiting part in level III arthroscopy, has no gical heterogeneity between studies
arthralgia38, ID and DJD9, or only influence on clinical symptom severity (e.g., difference in study design, ar
ID10,11,30–37,39. It should be noted that or treatment outcomes63–65. Hence, throscopic techniques, setting, and
these conditions are often associated distinguishing between level II and level study population). To account for the
with each other and occur simulta III arthroscopy would not have led to observed heterogeneity, a random-ef
neously61,62, and that having one con additional insights in the current study. fects model is preferred27. Secondly, the
dition does not exclude the other, Furthermore, since the only study in previous systematic review utilized end-
despite the studies making a clear dis volving level III arthroscopy39 was not point values to synthesize effect mea
tinction between them. Hence, it could included in any meta-analysis, con sures instead of change-from-baseline
be that a significant proportion of the sidering level III arthroscopy as a scores. The use of end-point values may
516 Tang et al.
Table 3. Summary of findings table (GRADE assessment).

Follow-up term MD (95% CI) between Number of participants Certainty of the evidence
Arthroscopy type (months) interventions (studies) (GRADE)
Outcome: Pain reduction by VAS score (0–100 mm, higher is worse)
AS Intermediate (6–24) 2.2 (−15.4; 19.7) 133 (3) Very lowa,b
ALL Short (1–3) 2.8 (−8.9; 14.6) 128 (3) Very lowa,b
ALL Intermediate (6–12) − 4.4 (−16.0; 7.2) 92 (2) Very lowb
Outcome: MMO improvement (mm)
AS Intermediate (6–24) 1.1 (−1.0; 3.2) 133 (3) Very lowb
ALL Short (1–3) − 1.4 (−8.0; 5.3) 128 (3) Very lowa,b
ALL Intermediate (6–24) 4.9 (2.7; 7.1) 111 (3) Low
Number of Certainty of the
Illustrative comparative risk (95% CI) participants evidence
Arthroscopy type Statistical method OR (95% CI) (studies) (GRADE)
Assumed risk – AC Comparative risk – ALL
Outcome: Complication rate
ALL Reciprocal continuity 1.2 (0.3; 4.5) 34 per 1000 41 per 1000 (11; 137) 243 (5) Very lowb
correction
ALL Conventional 1.2 (0.3; 4.7) 39 per 1000 47 per 1000 (12; 160) 204 (3) Very lowb
AC, arthrocentesis; ALL, arthroscopic lysis and lavage; AS, arthroscopic surgery; CI, confidence interval; GRADE, Grading of
Recommendations, Assessment, Development, and Evaluations; MD, difference in means; MMO, maximum mouth opening; OR, odds
ratio; VAS, visual analogue scale.
a
Downgraded one level due to inconsistency: unexplained heterogeneity that was not accounted for in the analyses (I2 > 50%).
b
Downgraded one level due to imprecision: sample size lower than required/optimal information size.
be appropriate for study designs invol current available evidence may be in authors realized that the scope of the
ving randomization procedures12, but conclusive due to insufficient sample review could be enhanced to provide a
they do not account for potential sizes. This may also have been caused more comprehensive overview of the
baseline imbalances between groups in by the fact that none of the studies current evidence regarding TMJ ar
non-randomized studies. Since most of included in the meta-analyses per throscopy. Since the addition of these
the studies in that review did not allo formed a prospective sample size cal extra analyses would not interfere or
cate the study participants randomly, culation. Furthermore, several of the influence the procedures or the results
biased effect measures may have been non-randomized studies included in in this study as specified in the pro
used. Therefore, the choice to use end- this study implemented a subject in tocol, no bias was introduced because
point values in the previous review may clusion procedure based on factors of it.
have influenced the accuracy of the such as clinical symptom severity or The current systematic review offers
data. Additionally, no stratification of the patients’ preference. Hence, these the most comprehensive analysis of the
postoperative follow-up periods or ar study designs may not have accounted efficacy of TMJ arthroscopy compared
throscopic techniques during the ana for the effect of time as a factor for to arthrocentesis as treatment for TMJ
lysis of the outcomes was performed in symptom reduction, or corrected for disorders to date. Furthermore, it ap
that specific study. It is important to the severity of the symptoms at base pears that this review is novel in pro
note that, when applying random-ef line, leading to imbalances between the viding an overview of the available
fects models and change-from-baseline groups. Consequently, these studies are literature comparing TMJ arthroscopy to
scores in the meta-analysis of the pre prone to selection bias by indication. conservative treatment regimens. The
vious review, no difference in pain score Additionally, in the current quantita strengths of this study include a pre-re
reduction or MMO improvement is tive analyses, despite stratification of gistered, robust and transparent metho
found between arthroscopy and ar the data based on arthroscopy type and dology, which is in accordance with the
throcentesis. follow-up period, and a low to medium latest Cochrane Handbook for
Several limitations need to be ac clinical judgement based on the CDIM Systematic Reviews and the PRISMA
knowledged concerning the quality of tool, a certain degree of heterogeneity guidelines. Furthermore, attempts were
the evidence presented in the current persists between studies, mainly re made to reach out to authors to retrieve
review. Only one included study had a garding the included diagnoses, the any absent data in order to enhance the
low risk of bias judgement, and only a preoperative treatment regimens, and completeness of the data collection pro
few RCTs on TMJ arthroscopy have co-intervention use. Although sensi cedure. An overview of the authors
been conducted. The inclusion of non- tivity analyses based on diagnosis did contacted, the reasons for the contact,
randomized comparative studies may not change the results or conclusions, it and the resultant outcome is provided in
have introduced bias in the results of cannot be ruled out for certain that the Supplementary Material Table S6. In
the individual studies and, conse identification of true therapeutic effects order to improve the reliability of the
quently, reduced the strength of the may have been complicated because of conclusions drawn, additional TSA were
evidence provided in this review. this heterogeneity. Finally, the inclu performed. Finally, the use of the CDIM
Additionally, TSA indicated that the sion of AS was not stated in the a tool allowed for a comprehensive as
RIS was not reached in any but one of priori stated study protocol. During sessment of the clinical diversity between
the meta-analyses, implying that the the performance of the study, the studies.
Due to the limited availability of high- arthrocentesis. Furthermore, advance Competing interests
quality studies, resulting in low to very ments in the development of surgical
None.
low quality of evidence, additional re instruments have led to the possibility
search is necessary to establish definitive of performing arthroscopy under local
conclusions. The current heterogeneity anaesthesia, using smaller portals53,72. Acknowledgement. The authors would
between clinics and lack of methodologi This development presents an inter like to thank Ms S van der Werf,
cally robust studies underscore the sig esting focus for further research, as it biomedical information specialist at
nificance and necessity of adhering to could lead to a lesser burden for pa the University of Groningen, for her
appropriately drafted protocols and stan tients by eliminating the need for gen aid in the development and execution
dardized guidelines prior to reaching final eral anaesthesia, as well as to greater of the search strategy.
conclusions. Adhering to internationally efficiency regarding time and costs.
accepted guidelines may lead to a more Lastly, although many clinics advocate
consistent performance of therapies for the use of minimally invasive therapies
TMJ disorders regarding technique, after conservative treatments have been Appendix A. Supporting
timing, the use of co-interventions, and exhausted, an increasing body of evi information
the pre- and postoperative treatment re dence suggests that these may be per
gimens. Although the authors emphasize formed at an earlier stage to allow Supplementary data associated with
the importance of uniformity for research faster joint recuperation5,6. The current this article can be found in the online
purposes, they are aware that it may also review did not aim to explore the de version at doi:10.1016/j.ijom.2024.
be a challenge in daily practice, as TMD bate on the timing of minimally in 01.006.
treatments are often individualized to fit vasive procedures, but rather to
the specific needs of the patient. highlight the existing knowledge gap References
Nonetheless, acting in accordance with that should be addressed in future re
guidelines allows a more comprehensive search. 1. Valesan LF, Da-Cas CD, Réus JC,
and standardized approach to outcome In conclusion, based on qualitative Denardin ACS, Garanhani RR, Bonotto
registration, setting follow-up intervals, and quantitative analyses of the cur D, Januzzi E, de Souza BDM. Prevalence
statistical analysis and data reporting, rently available data, TMJ arthroscopy of temporomandibular joint disorders: a
which in turn can allow proper conclu results in similar pain reduction and systematic review and meta-analysis. Clin
Oral Investig 2021;25:441–53. https://doi.
sions to be drawn. Future research should complication rates to arthrocentesis.
org/10.1007/s00784-020-03710-w
consider reporting outcome measures Additionally, arthroscopic lysis and la
2. Almoznino G, Zini A, Zakuto A, Sharav
other than pain scores and MMO in order vage is superior to arthrocentesis in
Y, Haviv Y, Hadad A, Chweidan H,
to gain a better understanding of the increasing maximum mouth opening at Yarom N, Benoliel R. Oral health-related
therapeutic effects of different treatments intermediate-term follow-up. However, quality of life in patients with tempor
for TMJ disorders. Currently, there is a these conclusions should be interpreted omandibular disorders. J Oral Facial Pain
lack of evidence regarding the impact of with caution due to the low quality of Headache 2015;29:231–41. https://doi.org/
treatments on outcomes such as man the primary studies and the low to very 10.11607/ofph.1413
dibular functioning, quality of life, and low quality of evidence. There is in 3. Wieckiewicz M, Boening K, Wiland P,
costs/cost-effectiveness. Intensifying re sufficient evidence available to draw Shiau YY, Paradowska-Stolarz A.
search efforts and using validated ques any conclusions regarding the effects of Reported concepts for the treatment
tionnaires such as the MFIQ16 may arthroscopy versus arthrocentesis on modalities and pain management of tem
address this gap. Additionally, the au mandibular function, joint blocks and poromandibular disorders. J Headache
thors believe that the rate of symptom noises, mandibular range of motion, Pain 2015;16:1–12. https://doi.org/10.
reduction, rather than only the efficacy at quality of life, and costs/cost-effective 1186/s10194-015-0586-5
final follow-up, should be considered ness. Furthermore, there is insufficient 4. Diraçoğlu D, Saral IB, Keklik B, Kurt H,
when evaluating the efficacy of treatment evidence from the comparison of TMJ Emekli U, Ozçakar L, Karan A, Aksoy C.
modalities. Proper study designs in future arthroscopy and conservative treatment Arthrocentesis versus nonsurgical
studies, such as following study partici regimens to draw any conclusions re methods in the treatment of tempor
pants early on and at several follow-up garding their efficacy in clinical omandibular disc displacement without
reduction. Oral Surg Oral Med Oral
time-points, and the use of regression symptom reduction.
Pathol Oral Radiol Endod 2009;108:3–8.
analyses66, are essential for evaluating the
https://doi.org/10.1016/j.tripleo.2009.01.
speed of recovery.
005
In the context of future research, 5. Tang YH, Vos LM, Tuin AJ, Huddleston
Ethical approval
several topics may be considered as re Slater JJR, Gareb B, van Bakelen NB,
levant. Although this study did not Not applicable. Spijkervet FKL. Arthrocentesis versus
focus on the use of intra-articular sub non-surgical intervention as initial treat
stances such as hyaluronic acid and ment for temporomandibular joint ar
platelet-rich plasma as additional thralgia: a randomized controlled trial
Patient consent
treatment modalities, the number of with long-term follow-up. Int J Oral
studies on this subject is increasing67–71. Not applicable. Maxillofac Surg 2023;52:595–603. https://
Addressing these subjects in future re doi.org/10.1016/j.ijom.2022.08.018
search would allow further insight into 6. Tatli U, Belidayi ME, Ekren O, Salimov F.
the potential therapeutic benefits of Comparison of the effectiveness of three
Funding different treatment methods for tempor
these substances and their roles as ad
juvants in relation to arthroscopy and None. omandibular joint disc displacement
518 Tang et al.
without reduction. Int J Oral Maxillofac association for Dental Research; Karam O, Kong Z, Korang SK, Koster
Surg 2017;46:603–9. https://doi.org/10.1016/ Orofacial Pain Special Interest Group, G, Lai B, Liang N, Lundstrøm LH,
j.ijom.2017.01.018 International Association for the Study Marker S, Meyhoff TS, Nielsen EE,
7. Hakim MA, McCain JP, Ahn DY, of Pain. Diagnostic Criteria for Nørskov AK, Munch MW, Risom EC,
Troulis MJ. Minimally invasive endo Temporomandibular Disorders (DC/ Rygård SL, Safi S, Sethi N, Sjövall F,
scopic oral and maxillofacial surgery. TMD) for Clinical and Research Lauridsen SV, van Bakelen N, Volbeda
Oral Maxillofac Surg Clin North Am Applications: recommendations of the M, van der Horst ICC, Gluud C, Perner
2019;31:561–7. https://doi.org/10.1016/j. International RDC/TMD Consortium A, Møller MH, Keus E, Wetterslev J. A
coms.2019.07.001 Network* and Orofacial Pain Special new tool to assess clinical diversity in
8. Al-Moraissi EA. Arthroscopy versus ar Interest Group. J Oral Facial Pain meta-analyses (CDIM) of interventions. J
throcentesis in the management of in Headache 2014;28:6–27. Clin Epidemiol 2021;135:29–41. https://
ternal derangement of the 15. Sanders B. Arthroscopic surgery of the doi.org/10.1016/j.jclinepi.2021.01.023
temporomandibular joint: a systematic temporomandibular joint: treatment of 22. Sweeting MJ, Sutton AJ, Lambert PC.
review and meta-analysis. Int J Oral internal derangement with persistent What to add to nothing? Use and
Maxillofac Surg 2015;44:104–12. https:// closed lock. Oral Surg Oral Med Oral avoidance of continuity corrections in
doi.org/10.1016/j.ijom.2014.07.008 Pathol 1986;62:361–72. https://doi.org/10. meta-analysis of sparse data. Stat Med
9. Talaat WM, Hamdoon Z, Ghoneim MM. 1016/0030-4220(86)90282-3 2004;23:1351–75. https://doi.org/10.1002/
Minimally invasive surgeries for the 16. Stegenga B, de Bont LG, de Leeuw R, sim.1761
treatment of temporomandibular dis Boering G. Assessment of mandibular 23. Cheng J, Pulleneyagum E, Marshall J,
orders: prognostic indicators and persis function impairment associated with Iorio A, Thabane L. Impact of including
tence of treatment outcomes over a 5-year temporomandibular joint osteoarthrosis or excluding both-armed zero-event stu
follow-up. Advances in Biomedical and and internal derangement. J Orofac Pain dies on using standard meta-analysis
Health Sciences 2022;1:34–44. 1993;7:183–95. methods for rare event outcome: a simu
10. Rajpoot D, Anchlia S, Bhatt U, Dhuvad 17. Bramer WM, Giustini D, de Jonge G, lation study. BMJ Open 2016;
J, Patel H, Mansuri Z. Arthrocentesis Holland L, Bekhuis T. De-duplication of 6:e010983https://doi.org/10.1136/
versus level 1 arthroscopy in internal de database search results for systematic re bmjopen-2015-010983
rangement of temporomandibular joint. J views in EndNote. J Med Libr Assoc 24. Smaïl-Faugeron V, Fron-Chabouis H,
Maxillofac Oral Surg 2023;22:94–101. 2016;104:240–3. https://doi.org/10.3163/ Courson F, Durieux P. Comparison of
https://doi.org/10.1007/s12663-021- 1536-5050.104.3.014 intervention effects in split-mouth and
01627-9 18. Sterne JAC, Savović J, Page MJ, Elbers parallel-arm randomized controlled
11. Atteya AM, Warda MH, Fata MM, RG, Blencowe NS, Boutron I, Cates CJ, trials: a meta-epidemiological study.
Medra AM, Monje-Gil F. Prospective Cheng HY, Corbett MS, Eldridge SM, BMC Med Res Methodol 2014;
randomized study between arthrocentesis Emberson JR, Hernán MA, Hopewell S, 14:64https://doi.org/10.1186/1471-2288-
and operative arthroscopy in the man Hróbjartsson A, Junqueira DR, Jüni P, 14-64
agement of temporomandibular joint in Kirkham JJ, Lasserson T, Li T, 25. Balduzzi S, Rücker G, Schwarzer G.
ternal derangement. Alexandria Dent J McAleenan A, Reeves BC, Shepperd S, How to perform a meta-analysis with R:
2020;46:58–65. Shrier I, Stewart LA, Tilling K, White a practical tutorial. Evid Based Ment
12. Higgins JPT, Thomas J, Chandler J, IR, Whiting PF, Higgins JPT. RoB 2: a Health 2019;22:153–60. https://doi.org/
Cumpston M, Li T, Page MJ, Welch VA. revised tool for assessing risk of bias in 10.1136/ebmental-2019-300117
Cochrane handbook for systematic re randomised trials. Res Methods Report 26. DerSimonian R, Laird N. Meta-analysis
views of interventions, version 6.3 (up 2019;366:l4898. in clinical trials. Control Clin Trials 1986;
dated February 2022). Cochrane; 2022. 19. Slim K, Nini E, Forestier D, 7:177–88. https://doi.org/10.1016/0197-
13. Page MJ, McKenzie JE, Bossuyt PM, Kwiatkowski F, Panis Y, Chipponi J. 2456(86)90046-2
Boutron I, Hoffmann TC, Mulrow CD, Methodological index for non-rando 27. Borenstein M, Hedges L, Higgins J,
Shamseer L, Tetzlaff JM, Akl EA, Brennan mized studies (MINORS): development Rothstein HR. A basic introduction to
SE, Chou R, Glanville J, Grimshaw JM, and validation of a new instrument. ANZ fixed-effect and random-effects models
Hróbjartsson A, Lalu MM, Li T, Loder J Surg 2003;73:712–6. https://doi.org/10. for meta-analysis. Res Synth Methods
EW, Mayo-Wilson E, McDonald S, 1046/j.1445-2197.2003.02748.x 2010;1:97–111. https://doi.org/10.1002/
McGuinness LA, Stewart LA, Thomas J, 20. Atkins D, Best D, Briss PA, Eccles M, jrsm.12
Tricco AC, Welch VA, Whiting P, Moher Falck-Ytter Y, Flottorp S, Guyatt GH, 28. Wetterslev J, Jakobsen J, Gluud C. Trial
D. The PRISMA 2020 statement: an up Harbour RT, Haugh MC, Henry D, Hill sequential analysis in systematic reviews
dated guideline for reporting systematic re S, Jaeschke R, Leng G, Liberati A, with meta-analysis. BMC Med Res
views. BMJ 2021;29(372):n71. https://doi. Magrini N, Mason J, Middleton P, Methodol 2017;17:39https://doi.org/10.
org/10.1136/bmj.n71 Mrukowicz J, O’Connell D, Oxman AD, 1186/s12874-017-0315-7
14. Schiffman E, Ohrbach R, Truelove E, Phillips B, Schünemann HJ, Edejer T, 29. Thorlund K, Engstrom J, Wetterslev J,
Look J, Anderson G, Goulet JP, List T, Varonen H, Vist GE, Williams Jr JW, Brok J, Imberger G, Gluud C. User
Svensson P, Gonzalez Y, Lobbezoo F, Zaza S, GRADE Working Group. manual for trial sequential analysis
Michelotti A, Brooks SL, Ceusters W, Grading quality of evidence and strength (TSA). Copenhagen, Denmark:
Drangsholt M, Ettlin D, Gaul C, of recommendations. BMJ 2004; Copenhagen Trial Unit; 2011.
Goldberg LJ, Haythornthwaite JA, 328:1490. https://doi.org/10.1136/bmj. 30. Murakami KI, Hosaka H, Moriya Y,
Hollender L, Jensen R, John MT, De 328.7454.1490 Segami N, Iizuka T. Short-term treat
Laat A, de Leeuw R, Maixner W, van 21. Barbateskovic M, Koster TM, Eck RJ, ment outcome study for the management
der Meulen M, Murray GM, Nixdorf Maagaard M, Afshari A, Blokzijl F, of temporomandibular joint closed lock.
DR, Palla S, Petersson A, Pionchon P, Cronhjort M, Dieperink W, Fabritius A comparison of arthrocentesis to non
Smith B, Visscher CM, Zakrzewska J, ML, Feinberg J, French C, Gareb B, surgical therapy and arthroscopic lysis
Dworkin SF. International RDC/TMD Geisler A, Granholm A, Hiemstra B, Hu and lavage. Oral Surg Oral Med Oral
Consortium Network, International R, Imberger G, Jensen BT, Jonsson AB, Pathol Oral Radiol Endod 1995;80:253–7.
https://doi.org/10.1016/S1079-2104(05) E, Rodríguez-Almagro D, Lomas-Vega 50. Oren D, Dror AA, Khalil TH, Zoabi A,
80379-8 R. Validity and reliability of the Helkimo Zigron A, Kablan F, Srouji S.
31. Schiffman EL, Velly AM, Look JO, Clinical Dysfunction Index for the diag Comparisons between lysis and lavage,
Hodges JS, Swift JQ, Decker KL, nosis of temporomandibular disorders. intra-articular steroid injections, and
Anderson QN, Templeton RB, Lenton Diagnostics 2021;11:472. https://doi.org/ three-point subsynovial steroid injections
PA, Kang W, Fricton JR. Effects of four 10.3390/diagnostics11030472 using operative single-cannula ar
treatment strategies for tempor 41. Gentile DA, Woodhouse J, Lynch P, throscopy—a retrospective analysis. J
omandibular joint closed lock. Int J Oral Maier J, McJunkin T. Reliability and Craniomaxillofac Surg 2022;50:336–42.
Maxillofac Surg 2014;43:217–26. https:// validity of the global pain scale with https://doi.org/10.1016/j.jcms.2022.03.002
doi.org/10.1016/j.ijom.2013.07.744 chronic pain sufferers. Pain Phys 2011; 51. Murakami KI, Segami N, Moryia Y,
32. Sanromán JF. Closed lock (MRI fixed 14:61–70. https://doi.org/10.36076/ppj. Iizuka T. Correlation between pain and
disc): a comparison of arthrocentesis and 2011/14/61 dysfunction and intra-articular adhesions
arthroscopy. Int J Oral Maxillofac Surg 42. Kerns R, Turk D, Rudy T. The West in patients with internal derangement of
2004;33:344–8. https://doi.org/10.1016/j. Haven–Yale Multidimensional Pain the temporomandibular joint. J Oral
ijom.2003.10.005 Inventory (WHYMPI). Pain 1985; Maxillofac Surg 1992;50:705–8. https://
33. Hobeich J, Salameh Z, Ismail E, Sadig 23:345–56. doi.org/10.1016/0278-2391(92)90102-6
W, Hokayem N, Almas K. Arthroscopy 43. Goldberg D, Hillier V. A scaled version 52. McCain JP, Sanders B, Koslin MG,
versus arthrocentesis: a retrospective of the General Health Questionnaire. Quinn JD, Peters PB, Indresano AT.
study of disc displacement management Psychol Med 1979;9:139–45. Temporomandibular joint arthroscopy: a
without reduction. Saudi Med J 2007; 44. Kaneyama K, Segami N, Nishimura M, 6-year multicenter retrospective study of
28:1541–4. Sato J, Fujimura K, Yoshimura H. The 4,831 joints. J Oral Maxillofac Surg 1992;
34. Fridrich KL, Wise JM, Zeitler DL. ideal lavage volume for removing brady 50:926–30. https://doi.org/10.1016/0278-
Prospective comparison of arthroscopy kinin, interleukin-6, and protein from the 2391(92)90047-4
and arthrocentesis for tempor temporomandibular joint by arthrocent 53. Hossameldin RH, McCain JP. Outcomes
omandibular joint disorders. J Oral esis. J Oral Maxillofac Surg 2004; of office-based temporomandibular joint
Maxillofac Surg 1996;54:816–20. https:// 62:657–61. https://doi.org/10.1016/j.joms. arthroscopy: a 5-year retrospective study.
doi.org/10.1016/S0278-2391(96)90526-1 2003.08.031 Int J Oral Maxillofac Surg 2018;47:90–7.
35. Goudot P, Jaquinet A, Hugonnet S, 45. Gulen H, Ataoglu H, Haliloglu S, Isik K. https://doi.org/10.1016/j.ijom.2017.06.025
Haefliger W, Richter M. Improvement of Proinflammatory cytokines in tempor 54. Machoň V, Šedý J, Klíma K, Hirjak D,
pain and function after arthroscopy and omandibular joint synovial fluid before Foltán R. Arthroscopic lysis and lavage
arthrocentesis of the temporomandibular and after arthrocentesis. Oral Surg Oral in patients with temporomandibular
joint: a comparative study. J Med Oral Pathol Oral Radiol Endod 2009; anterior disc displacement without re
Craniomaxillofac Surg 2000;28:39–43. 107:e1–4. https://doi.org/10.1016/j. duction. Int J Oral Maxillofac Surg 2012;
https://doi.org/10.1054/jcms.1998.0103 tripleo.2009.02.006 41:109–13. https://doi.org/10.1016/j.ijom.
36. Tan DBP, Krishnaswamy G. A retro 46. Nishimura M, Segami N, Kaneyama K, 2011.07.907
spective study of temporomandibular Suzuki T, Miyamaru M. 55. Nitzan D, Svidovsky J, Zini A, Zadik
joint internal derangement treated with Proinflammatory cytokines and arthro Y. Effect of arthrocentesis on sympto
arthrocentesis and arthroscopy. Proc scopic findings of patients with internal matic osteoarthritis of the tempor
Singapore Healthc 2012;21:73–8. https:// derangement and osteoarthritis of the omandibular joint and analysis of the
doi.org/10.1177/201010581202100112 temporomandibular joint. Br J Oral effect of preoperative clinical and
37. Xu Y, Lin H, Zhu P, Zhou W, Han Y, Maxillofac Surg 2002;40:68–71. https:// radiological features. J Oral
Zheng Y, Zhang Z. A comparative study doi.org/10.1054/bjom.2001.0742 Maxillofac Surg 2017;75:260–7. https://
between use of arthroscopic lavage and 47. Sandler NA, Buckley MJ, Cillo JE, doi.org/10.1080/00016350601083554
arthrocentesis of temporomandibular Braun TW. Correlation of inflammatory 56. Carvajal W, Laskin D. Long-term eva
joint based on computational fluid dy cytokines with arthroscopic findings in luation of arthrocentesis for the treat
namics analysis. PLoS One 2013; patients with temporomandibular joint ment of internal derangements of the
8:e78953https://doi.org/10.1371/journal. internal derangements. J Oral Maxillofac temporomandibular joint. J Oral
pone.0078953 Surg 1998;56:534–43. https://doi.org/10. Maxillofac Surg 2000;58:852–5. https://
38. Stegenga B, de Bont LGM, Dijkstra PU, 1016/S0278-2391(98)90446-3 doi.org/10.1053/joms.2000.8201
Boering G. Short-term outcome of ar 48. Celotti C, Martin-Granizo R, De La Sen 57. Kirk Jr WS, Calabrese DK. Clinical
throscopic surgery of tempor O. Correlation of arthroscopic findings evaluation of physical therapy in the
omandibular joint osteoarthrosis and with clinical–radiological signs and management of internal derangement of
internal derangement: a randomized symptoms of temporomandibular joint the temporomandibular joint. J Oral
controlled clinical trial. Br J Oral dysfunction: retrospective study of 829 Maxillofac Surg 1989;47:113–9. https://
Maxillofac Surg 1993;31:3–14. https:// joints. Int J Oral Maxillofac Surg 2022; doi.org/10.1016/s0278-2391(89)80099-0
doi.org/10.1016/0266-4356(93)90089-F 51:1069–73. https://doi.org/10.1016/j. 58. Kai S, Kai H, Tabata O, Shiratsuchi Y,
39. McNamara DC, Rosenberg I, Jackson ijom.2022.01.010 Ohishi M. Long-term outcomes of non
PA, Hogben J. Efficacy of arthroscopic 49. Martins I, Radaic P, Marchi L, Barreto surgical treatment in nonreducing ante
surgery and midlaser treatments for G, Pastore G. Assessment of post riorly displaced disk of the
chronic temporomandibular joint ar operative pain in patients undergoing temporomandibular joint. Oral Surg Oral
ticular disc derangement following motor temporomandibular joint arthroscopy Med Oral Pathol Oral Radiol Endod 1998;
vehicle accident. Aust Dent J 1996; with infiltration of dexamethasone 85:258–67. https://doi.org/10.1016/S1079-
41:377–87. https://doi.org/10.1111/j.1834- disodium phosphate in different con 2104(98)90005-1
7819.1996.tb06023.x centrations. A randomized controlled 59. Kurita K, Westesson P, Yuasa H, Toyama
40. Alonso-Royo R, Sánchez-Torrelo CM, trial. J Craniomaxillofac Surg 2023; M, Machida J, Ogi N. Natural course of
Ibáñez-Vera AJ, Zagalaz-Anula N, 51:89–97. https://doi.org/10.1016/j. untreated symptomatic temporomandibular
Castellote-Caballero Y, Obrero-Gaitán jcms.2023.02.001 joint disc displacement without reduction.
520 Tang et al.
J Dent Res 1998;77:361–5. https://doi.org/ 48:798–801. https://doi.org/10.1016/0278- by temporomandibular joint arthroscopy.

10.1177/00220345980770020401 2391(90)90335-Y J Craniofac Surg 2020;31:637–41. https://
60. Sato S, Kawamura H, Nagasaka H, 65. Emshoff R, Rudisch A. Are internal de doi.org/10.1097/SCS.0000000000006098
Motegi K. The natural course of anterior rangement and osteoarthrosis linked to 70. Yilmaz O, Korkmaz Y, Tuzuner T.
disc displacement without reduction in changes in clinical outcome measures of Comparison of treatment efficacy be
the temporomandibular joint: follow-up arthrocentesis of the temporomandibular tween hyaluronic acid and arthrocentesis
at 6, 12, and 18 months. J Oral joint? J Oral Maxillofac Surg 2003; plus hyaluronic acid in internal derange
Maxillofac Surg 1997;55:234–8. https:// 61:1162–7. https://doi.org/10.1016/S0278- ments of temporomandibular joint. J
doi.org/10.1016/S0278-2391(97)90531-0 2391(03)00676-1 Craniomaxillofac Surg 2020;47:1720–7.
61. Stegenga B. Osteoarthritis of the tem 66. Caruana E, Roman M, Hernandez- https://doi.org/10.1016/j.jcms.2019.07.030
poromandibular joint organ and its re Sanchez J, Solli P. Longitudinal studies. J 71. Zotti F, Albanese M, Rodella L,
lationship to disc displacement. J Orofac Thorac Dis 2015;7:E537–40. https://doi. Nocini P. Platelet-rich plasma in
Pain 2001;15:193–205. org/10.3978/j.issn.2072-1439.2015.10.63 treatment of temporomandibular joint
62. Bertram S, Rudisch A, Innerhofer K, 67. Hosgor H. Is arthrocentesis plus hya dysfunctions: narrative review. Int J
Pümpel E, Grubwieser G, Emshoff R. luronic acid superior to arthrocentesis Mol Sci 2019;20:277. https://doi.org/
Diagnosing TMJ internal derangement alone in the treatment of disc displace 10.3390/ijms20020277
and osteoarthritis with magnetic re ment without reduction in patients with 72. Weedon S, Ahmed N, Sidebottom AJ.
sonance imaging. J Am Dent Assoc 2001; bruxism? J Craniomaxillofac Surg 2020; Prospective assessment of outcomes fol
132:753–61. https://doi.org/10.14219/ 48:1023–7. https://doi.org/10.1016/j.jcms. lowing disposable arthroscopy of the
jada.archive.2001.0272 2020.07.008 temporomandibular joint. Br J Oral
63. Dolwick MF. Intra-articular disc dis 68. Marzook H, Abdel Razek A, Yousef E, Maxillofac Surg 2013;51:625–9. https://
placement part I: its questionable role in Attia A. Intra-articular injection of a doi.org/10.1016/j.bjoms.2013.06.004
temporomandibular joint pathology. J mixture of hyaluronic acid and corticos
Oral Maxillofac Surg 1995;53:1069–72. teroid versus arthrocentesis in TMJ in Correspondence to: Department of Oral
https://doi.org/10.1016/0278-2391(95) ternal derangement. J Stomatol Oral and Maxillofacial Surgery
90126-4 Maxillofac Surg 2020;121:30–4. https:// University Medical Center Groningen
64. Nitzan D, Dolwick M, Heft M. doi.org/10.1016/j.jormas.2019.05.003 PO Box 30.001
Arthroscopic lavage and lysis of the 69. Sakalys D, Dvylys D, Simuntis R, 9700 RB Groningen
temporomandibular joint: a change in Leketas M. Comparison of different in the Netherlands.
perspective. J Oral Maxillofac Surg 1990; traarticular injection substances followed
E-mail: n.b.van.bakelen@umcg.nl

Arthroscopy Versus Arthrocentesis and Versus Conse

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Arthroscopy Versus Arthrocentesis and Versus Conse

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Int. J. Oral Maxillofac. Surg.

2024; 53: 503–520

arthrocentesis and versus Department of Oral and Maxillofacial

conservative treatments for

patient outcomes or about comparisons between arthroscopy and conservative

Table 1a. Characteristics of included studies involving arthroscopy versus arthrocentesis.

group at the short-term and inter

among the studies in the meta-analysis

Table 3. Summary of findings table (GRADE assessment).

J Dent Res 1998;77:361–5. https://doi.org/ 48:798–801. https://doi.org/10.1016/0278- by temporomandibular joint arthroscopy.

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Arthroscopy Versus Arthrocentesis and Versus Conse

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Arthroscopy Versus Arthrocentesis and Versus Conse

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

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Did you find this document useful?

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Copyright:

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Arthroscopy Versus Arthrocentesis and Versus Conse

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Copyright:

Available Formats

Int. J. Oral Maxillofac. Surg.

2024; 53: 503–520

arthrocentesis and versus Department of Oral and Maxillofacial

conservative treatments for

patient outcomes or about comparisons between arthroscopy and conservative

Table 1a. Characteristics of included studies involving arthroscopy versus arthrocentesis.

group at the short-term and inter­

among the studies in the meta-analysis

Table 3. Summary of findings table (GRADE assessment).

J Dent Res 1998;77:361–5. https://doi.org/ 48:798–801. https://doi.org/10.1016/0278- by temporomandibular joint arthroscopy.

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group at the short-term and inter