الفهرس 
5. IntroductionOnly 14 pages are availabe for public view
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Abstract
Introduction
TMDs (temporomandibular disorders) is musculoskeletal condition that affect Temporomandibular joint. TMJ is multifunction joint that is prone to heavy loads. It is responsible to mastication process, speaking, opening and closing of the mouth. TMDs have two aspects muscular problem or articular problem. The muscular problem is due to muscle of mastication spasm which is called myofascial pain disfunction syndrome. This patient always complains from muscular pain and has trigger points for this pain. The articular problem due to internal derangement of the TMJ. The most common type of internal derangement is anterior disc displacement with reduction or without reduction. The most common complains of these patients are pain, clicking and limited mouth opening. The treatment modalities of TMDs should be gradually. First noninvasive treatment (medications – instruction - occlusal splints). Second minimal invasive treatment which are arthrocentesis, arthroscopy, and acupuncture). Third invasive treatment which is surgical intervention for disc plication or discectomy. Surgical treatment is rarely used due to its complications. Minimally invasive treatments commonly used if the medication does not improve the conditions. Arthrocentesis is most commonly used in treatment of anterior disc displacement with or without reduction. It enhances the mouth opening and decrease the pain as it removes inflammatory mediators and adhesions in the joint. There are some opinions that injection of the joints post arthrocentesis gives better results. The joints could be injected by PRP, steroids, hyaluronic acid, dextrose or NSAIDs. In this study we compared between conventional arthrocentesis and arthrocentesis followed by injection of piroxicam which is NSAIDs. Piroxicam is anti-inflammatory and analgesic that has aquas solution that could be injected in the joint to remove intraarticular adhesions and inflammatory mediators and reduce intra articular pain.
Material and methods
Study Setting: Surgery conducted under General Anesthesia in Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ain Shams University in period from 1\5\2021 to 1\2\2023
Sample Size Calculation: After setting alpha at 0.05 and beta at 0.8. and assessing sample size of (Intra-articular injection of tenoxicam following temporomandibular joint arthrocentesis: a pilot study I Aktas et al. Int J Oral Maxillofac Surg. 2010 May.) We found that the minimal sample size is seven in each group 14 total. However, 20 patients were included to allow for attrition and DROP out of patients
Eligibility criteria:
1-Inclusion criteria:
• Patients who were diagnosed by the RDC/TMD as having disc displacement with reduction
• The same diagnosis was confirmed with the MRI examination.
• Patients who were not responsive to the non-surgical maneuvers and go on mouth splint for 3 months without good results
• Age from 18 years to 6o years.
• Obtaining written informed consents signed by the patients
2- Exclusion criteria:
• Patients suffering from any muscular disorders as myofascial pain or myofascial pain with limitations without intraarticular problem
• If the disc was not visible in the MRI examination.
• Patients who received previous TMJ surgery
• Patients who suffer from any systemic inflammatory joint disorder as rheumatoid arthritis
• Patients who sustained any previous facial trauma or suffered from previous facial fracture.
• Patients with psychiatric disease or substance abuse or have an allergy to the substance used in the study.
Study procedures: Prospective study randomized controlled trial RCT was done on 40 Temporomandibular joints with Temporomandibular joint disorder anterior disc displacement with reduction involved in the study. They divided into two groups.
group A: 20 joints treated by arthrocentesis with lactate ringer followed by injection with piroxicam 1 ml (20mg) (study group).
group B:20 joints treated by arthrocentesis with lactate ringer only conventional (control group)
Procedure:
Arthrocentesis technique had done under aseptic condition using betadine (betadine: /7.5/m/v povidone iodine Nile Company, under license by Switzerland), External auditory canal was protected from accumulation of blood and fluid by a cotton pellet. A line drowned from outer canthus of the eye to ear tragus (canthal tragus line). The first needle (inlet) corresponding to glenoid fossa should be placed 1 cm from mid tragus and 2mm below canthal tragus line. The second needle (outlet) related to articular eminence was placed 1cm from first needle and 1 cm below canthal tragus line. 20-gauge needle was introduced to posterior aspect of glenoid fossa first mark (inlet) and 18-gauge needle was introduced into second mark (outlet). 200ml of lactate ringer solution was introduced into inlet syringe the joint was manipulated by closing opening lateral movement and protrusion to allow flow of solution and release of adhesions and inflammatory mediators. Then the lactate ringer was collected in kidney dish through the outlet syringe. This technique was done in both groups (1&2). In group 2 only after this procedure was done, we had used the first needle in injection of 1 ml (20mg) piroxicam (feldene:1 ml ampoule piroxicam manufactured by Pfizer) into the joint space. After injection was done the joint was manipulated in different directions. After the procedures for both groups postoperative medication was prescribed which were antibiotics, analgesics and anti-inflammatory. Post-operative instructions were followed. Which were soft diet and home physical therapy containing application of moist heat and mandibular exercise as opening, closing, protrusion, extrusion and lateral movement 4 times per day.
Efficacy parameters: Patients’ follow up was done blindly by a clinician who were not involved in the arthroscopic procedure. All patients were recalled after one week then month then after 3 months and 6 months postoperatively. The efficacy parameters included measuring maximum painless mouth opening, and visual analog scale (VAS) according to the RDC/TMD protocol.
Statistical assessment: Independent sample t-test was use to assess the statistical significance of continuous data. Chi-square test was used to assess statistical significance of discrete data
Ethics: the study is approved by ethical committee of Ain Shams University and the patients sign informed consent after the procedures have been described in details.
Results:
We treat 20 patients had TMJ internal derangement bilateral. We divided the patient into two groups. Study group 10 patients had TMJ disc displacmet with reduction bilateral treated by piroxicam injection post arthrocentesis. Control group 10 patients had TMJ internal derangement bilateral treated by arthrocentesis only. Inter group assessment using student T-test for unassisted mouth opening showed that the average mouth opening for maximum un assisted opening was 32.6 ± 2.7 in study group and average mouth opening was 34.3 ±2.6 in case of control. The statical data showed that there is no statical significant between study and control (p=0.171) at three months assessment. Inter group assessment using student T-test showed that the average maximum assisted mouth opening was35.3 ± 2.86for study group and 34.5 ±2.5 for control group. The statical data showed that there is no significant between study and control group (P= 0.5182) at three months assessment. Inter group assessment using student T-test showed that the average maximum mouth opening without pain was30.9 ± 3.414for study group and 31.8 ±3.85 for control group. The statical data showed that there is no significant between study and control group (P= 0.5872) at three months assessment. The chi square test showed that the discrete data of visual analogue scale shows that there was no statical significant in pain level between study and control group at these mouth assessment (p=0.1462)
In our study we compare between conventional arthrocentesis and arthrocentesis followed by intra articular injection of piroxicam. Study had been done on 40 joints in 20 patients. Although the choice of patients involved in this study is done by random allocation, all the patients were females. This proves that TMDs is most common among females. High level of anxiety and stress are more common in female. there is a great relationship between psychological disturbance and TMD. Also the facial muscles of female is more susceptible for secretion of lactic acid due to less blood supply and oxygen. Lactic acid cause muscle fatigue, spasm and affect ligaments. The only one male involved in the study was 26 years old and he was a worker in factory who lifting heavy things. In our study there was a 21 female patient complain from numbness after 2 days from arthrocentesis at retro-auricular area, pre-auricular and at templet at right side. We prescribe vitamin B complex for her and these symptoms subside gradually within 6 weeks. In this condition there is an injury may be occurred to great auricular nerve. It is considered a very rare complication. Also from the rare complication of arthrocentesis is facial nerve paralysis. In our study we were comparing between the study group and control group at these points: maximum mouth opening without pain, maximum unassisted mouth opening, maximum assisted mouth opening and severity of pain. In both groups there is a gradual improvement in the four points of assessment and there is a significant statistical improvement in the preoperative assessment than post operative assessment. This proved by Gupta and ALSaid. In both groups there is increase in maximum mouth opening without pain with nonsignificant statistical different between them. In both groups there is improvement in un assisted mouth opening with nonsignificant statistical difference between them. In both groups there is improvement in assisted mouth opening with nonsignificant statistical difference between them. Both assisted and non-assisted mouth opening becomes nearly values after three month follow up. The pain severity was evaluated in both groups by VAS, there is improvement in pain in both groups with non-significant statistical different between them. Although study group was injected by piroxicam which is analgesic drug but there is no different between the control group in amount of decrease in pain even in the first follow up which is after one week. This pain is due to trauma of the needle at the site of injection. This results shows that the study is non-significant statistically and this is confirmed by A.Gupta and ALSaid.