Materials and Methodology Design of the study: Randomized controlled Trial (RCT) Site of the study: department of oral and maxillofacial surgery faculty of dentistry Ain shams university Criteria of inclusion: study done on 40 patients have the following criteria
1. Age range 18-60 years both gender
2. Patient have gone on noninvasive therapy (occlusal stent) for three months without good prognosis
3. Internal derangement of TMJ (ant. Disc displacement with reduction)
4. Localized TMJ pain
Criteria of exclusion:
1. Psychiatric illness
2. Previous TMJ surgery
3. Suffering from joint trauma
4. Cellulitis or severe laceration of pre-auricular skin covering TMJ
Intervention:
The patients divided into two groups. Group one contains 20 patients will be treated by arthrocentesis with lactate ringer only (control group). Group 2 contains 20 patients will be treated by arthrocentesis with lactate ringer followed by injection with piroxicam 2 ml (40mg) (study group). The patient should have done MRI shows internal derangement. Maximum mouth opening should be measured before procedure.
Arthrocentesis technique will be done under aseptic condition using betadine (betadine: /7.5/m/v povidone iodine USP Nile Company, under license by Switzerland), auriculotemporal nerve block anesthesia was included using carpule of mepivacaine (mepivacaine HCL2% with levonordefrin 1:20000, Alexandria Co. Pharmaceuticals, Alexandria, Egypt) and field infiltration at sites of joint penetration. External auditory canal is protected from accumulation of blood and fluid by a cotton pellet. A line should be 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 should be 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 is introduced into second mark (outlet). 200ml of lactate ringer solution is introduced into inlet syringe the joint is manipulated by closing opening lateral movement and protrusion to allow flow of solution and release of adhesions and inflammatory mediators. Then the lactate ringer is collected in kidney dish through the outlet syringe. This technique should be done in both groups (1\&2). In group 2 only after this procedure is done, we use the first needle in injection of 2 ml (40mg) piroxicam (feldene:1 ml ampoule piroxicam manufactured by Pfizer S.A.E) into the joint space. After injection is done the joint should be manipulated in different directions.
After the procedures for both groups postoperative medication should be prescribed which is antibiotics. Post-operative instruction should be followed. Which is 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. 8 Data collection: data will be collected twice inter examiner relatability. Measurements and assessment: Follow-up for the first day there may be numbness around the auricle which affect hearing sensation end by the end of local anesthetic effect. Also, edema may occur which need prescription of antiedematous and anti inflammatory. then follow up after 1 week then after 2 weeks then after month then after 3 months then after 6 months. In the follow up we must notice the maximum mouth opening without pain, lateral excursion during opening and closing mouth and visual analogue scale of pain.
Statistics: independent simple T-test. 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.
