Title	Efficacy Comparison Between Closed-Joint Surgery And Open-Joint Surgery In Treatment Of Pain And Limited Opening In TMD Patients With Disc Displacement without reduction
Clinical Question	In a TMD patient with disc displacement without reduction, is open-joint surgery more effective than closed-joint surgery in pain relief and increased opening?
Clinical Bottom Line	The strongest evidence was found for closed-joint surgery, as compared to open-joint surgery in pain relief and increased opening in a TMD patient with disc displacement without reduction. (See Comments on the CAT below)
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 12524600 Reston/2003 Patients refractory to non-surgical treatment 22 studies comprised of 30 patient groups, totaling 1463 patients n ranged from 11 to 237 among the included studies “To compensate for the lack of parallel control groups in published studies and for the improvement that has been observed in untreated patients, we used historical data from nonsurgical trials to derive 3 estimates of historical control group improvement (0%, 37.5%, and 75%).” Meta-Analysis Key results In a comparison of TMD patients with disc displacement without reduction who were refractory to non-surgical therapies, surgical arthrocentesis and arthroscopy (closed-joint surgeries) were effective for all three control group improvement rates (0%, 37.5%, and 75%). Arthroplasty (open-joint surgery) was effective for the 0% and 37.5% control group improvement rates. The trials were not adequate to determine the magnitude of effectiveness between open- and closed-joint surgeries; therefore the researchers found no statistically significant differences between the effects of closed- and open-joint surgery, but they found the strongest evidence supporting the effectiveness of closed-joint surgery for TMD patients with disc displacement without reduction. 21563153 Rigon/2011 TMD patients Systematic Reviews Key results Seven RCTs met inclusion criteria in this Cochrane Review. The likelihood of bias was high or undetermined for all 6 included studies. Both arthroscopy and non-surgical procedures reduced pain after 6 months. Open surgery was more effective in reducing pain after 12 months. No difference in mandibular functionality was seen or in other outcomes in clinical evaluations.
Evidence Search	("Temporomandibular Joint"[Mesh] OR "Temporomandibular Joint Disorders"[Mesh]) AND "Arthroscopy"[Mesh]
Comments on The Evidence	The authors in paper #1 performed a comprehensive, detailed search for relevant trials and historical data. Individual studies were assessed for validity. The authors reviewed 22 trials. The authors’ included trials had a total of 1463 patients. This article was a meta-analysis. Paper #2 is a more recent Cochrane systematic review.
Applicability	Since closed-joint surgery is less expensive and effective, this procedure should be the first choice for patient with this condition and should be referred to a surgeon who is skilled at performing closed-joint surgery.
Specialty	(General Dentistry) (Oral Surgery)
Keywords
ID#	767
Date of submission	03/30/2011
E-mail	mcbrayer@livemail.uthscsa.edu
Author	Whitney McBrayer
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Edward F. Wright, DDS, MS
Faculty mentor e-mail	wrightE2@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) by Penner, Jeff; Galvan, Daylon & Ibrik, Taj (San Antonio, Texas) on 01/06/2014 There was no new original research on this topic. However, Currie, 2011, PMID: 21979776 , a Cochrane review confirmed the established clinical bottom line with regards to the efficacy of closed joint surgery.