The hierarchy of different treatments for arthrogenous temporomandibular disorders: A network meta-analysis of randomized clinical trials.
- 作者列表："Al-Moraissi EA","Wolford LM","Ellis E 3rd","Neff A
PURPOSE:Different treatment options for patients with arthrogenous Temporomandibular Disorders (TMDs) have been reported. However, evidence regarding the most effective intervention using network meta-analysis (NMA) has not been performed. Thus, we conducted a NMA of randomized clinical trials (RCTs) to identify the most effective treatment of arthrogenous TMDs with respect to pain reduction and improved mouth opening, and to generate a ranking according to their effectiveness. MATERIAL AND METHODS:An electronic search on three major databases was undertaken to identify RCTs published before August 2019, comparing up to fourteen different treatments against control/placebo patients for arthrogenous TMDs with respect to pain reduction and improved mouth opening. The treatment variables were controls/placebo, conservative treatment (muscle exercises and occlusal splint therapy), occlusal splint therapy alone, intraarticular injection (IAI) of hyaluronic acid (HA) or corticosteroid (CS), arthrocentesis with or without HA, CS and platelet-rich plasma (PRP), arthroscopy with or without HA and PRP, open joint surgery, and physiotherapy. Frequentist NMA was performed using STATA software. Studies meeting the inclusion criteria were divided according to the length of follow-up (short-term (≤5 months) and intermediate-term (≥6 months to 4 years) and type of TMJ arthrogenous disorders; internal derangement (ID) and TMJ osteoarthritis (OA). The standardized mean differences (SMD) in post-treatment pain reduction and maximum mouth opening (MMO) were analysed. RESULTS:Thirty-six RCTs were identified that performed comparative outcome assessments for pain and 33 RCTs for MMO. At the short term (≤5 months), IAI-HA (SMD = -2.8, CI: -3.7 to -1.8) and IAI-CS (SMD = -2.11, CI: -2.9 to -1.2) (all very low quality evidence) achieved a substantially greater pain reduction than control/placebo. At intermediate term (≥6 months), a statistically significant decrease in posttreatment pain intensity was observed following Arthroscopy-PRP (SMD = -3.5, CI: -6.2 to -0.82), Arthrocentesis-PRP (SMD = -3.08, CI: -5.44 to -0.71), Arthroscopy-HA (SMD = -3.01, CI: -5.8 to -0.12), TMJ surgery (SMD = -3, CI: -5.7 to -0.28), IAI-HA (SMD = -2.9, CI: -4.9 to -1.09) (all very low quality evidence), Arthroscopy-alone (SMD = -2.6, CI: -5.1 to -0.07, low quality evidence) and Arthrocentesis-HA (SMD = -2.3, CI: -4.5 to -018, moderate-quality evidence) when compared to the control/placebo groups. Relative to MMO, the most effective treatments for short- and intermediate-term improvement were the arthroscopy procedures (PRP > HA > alone, all very low-quality evidence) followed by Arthrocentesis-PRP (very low-quality evidence) and Arthrocentesis-HA (moderate-quality evidence). The non-invasive procedures of occlusal splint therapy, physical therapy, conservative therapy, placebo/control provided significantly lower quality outcomes relative to pain and MMO. CONCLUSION:The results of the present meta-analysis support a paradigm shift in arthrogenous TMJ disorder treatment. There is a new evidence (though on a very low to moderate quality level) that minimally invasive procedures, particularly in combination with IAI of adjuvant pharmacological agents (PRP, HA or CS), are significantly more effective than conservative treatments for both pain reduction and improvement of MMO in both short (≤5 months) and intermediate term (6 months-4 years) periods. In contrast to traditional concepts mandating exhaustion of conservative treatment options, minimally invasive procedures, therefore, deserve to be implemented as efficient first-line treatments (e.g. IAIs and/or arthrocentesis) or should be considered rather early, i.e. as soon as patients do not show a clear benefit from an initial conservative treatment.
目的: 关节源性颞下颌关节紊乱病 (TMDs) 患者的不同治疗方案已有报道。然而，关于使用网络荟萃分析 (NMA) 进行最有效干预的证据尚未进行。因此，我们进行了一项NMA随机临床试验 (rct)，以确定关节源性TMDs在减轻疼痛和改善张口方面最有效的治疗方法。并根据它们的有效性生成排名。 材料和方法: 对三个主要数据库进行电子检索，以确定 2019 年 8 月之前发表的rct，比较关节源性TMDs患者与对照/安慰剂患者在减轻疼痛和改善张口方面的 14 种不同治疗。治疗变量为对照/安慰剂、保守治疗 (肌肉锻炼和咬合夹板治疗) 、单纯咬合夹板治疗、关节内注射 (IAI) 透明质酸 (HA) 或皮质类固醇 (CS)，关节穿刺术伴或不伴HA，CS和富血小板血浆 (PRP)，关节镜伴或不伴HA和PRP，开放关节手术和理疗。使用STATA软件进行Frequentist NMA。符合纳入标准的研究根据随访时间 (短期 (≤ 5 个月) 和中期 (≥ 6 个月至 4 年) 进行划分和TMJ关节疾病的类型; 内部紊乱 (ID) 和TMJ骨关节炎 (OA)。分析治疗后疼痛减轻和最大张口 (MMO) 的标准化平均差异 (SMD)。 结果: 确定了 36 个rct，对疼痛进行了比较结果评估，对MMO进行了 33 个rct。短期 (≤ 5 个月)，IAI-HA (SMD = -2.8，CI: -3.7 至-1.8) 和IAI-CS (SMD = -2.11，CI: -2.9 至-1.2) (所有非常低质量的证据) 获得了比对照/安慰剂大得多的疼痛减轻。在中期 (≥ 6 个月)，关节镜-PRP术后观察到治疗后疼痛强度显著降低 (SMD = -3.5，CI: -6.2 至-0.82)，关节穿刺术-PRP (SMD = -3.08，CI: -5.44 至-0.71)，关节镜-HA (SMD = -3.01，CI: -5.8 至-0.12)，TMJ手术(SMD = -3，CI: -5.7 至-0.28)，IAI-HA (SMD = -2.9，CI: -4.9 至-1.09) (所有极低质量证据)，单独关节镜检查 (SMD = -2.6，CI: -5.1 至-0.07，低质量证据) 和关节穿刺术-HA (SMD = -2.3，CI: -4.5 至-018，中等质量的证据) 与对照/安慰剂组相比。相对于MMO，短期和中期改善的最有效治疗方法是关节镜手术 (PRP> HA> 单独使用，所有证据质量都很低) 其次是关节穿刺-PRP (极低质量证据) 和关节穿刺-HA (中等质量证据)。咬合夹板治疗、物理治疗、保守治疗、安慰剂/对照的非侵入性程序提供了相对于疼痛和MMO显著较低的质量结局。 结论: 本荟萃分析的结果支持关节源性TMJ疾病治疗的范式转变。有一个新的证据 (尽管在非常低至中等质量水平)，微创手术，特别是与辅助药物 (PRP、HA或CS) 的IAI联合，对于短期 (≤ 5 个月) 的疼痛减轻和MMO改善均明显比保守治疗更有效和中期 (6 个月-4 年) 期。因此，与强制用尽保守治疗方案的传统概念相比，微创手术值得作为高效的一线治疗实施 (e。g. IAIs和/或关节穿刺术) 或应考虑相当早，即一旦患者没有从最初的保守治疗中显示出明显的益处。
METHODS:BACKGROUND:The anterior oronasal fistulae neighboring the alveolar cleft could persist or reappear after the alveolar reconstruction with cancellous bone grafting. The persistent symptomatic anterior oronasal fistulae need to be repaired, but surgery remains a challenge in cleft care. Surprisingly, this issue has rarely been reported in the literature. The purpose of this long-term study was to report a single surgeon experience with a therapeutic protocol for persistent symptomatic anterior oronasal fistula repair. METHODS:This is a retrospective study of consecutive patients with Veau type III and IV clefts and persistent symptomatic anterior oronasal fistulae managed according to a therapeutic protocol from 1997 to 2018. Depending on fistula size, patients were treated with local flaps associated with an interpositional graft or two-stage tongue flaps (small/medium or large fistulae, respectively). The surgical outcomes were classified as "good" (complete fistula closure with no symptoms), "fair" (asymptomatic narrow fistula remained), or "poor" (failure with persistent symptoms). RESULTS:Forty-four patients with persistent symptomatic anterior oronasal fistulae were reconstructed with local flaps associated with interpositional fascia or dermal fat grafting (52.3%) or two-stage tongue flaps (47.7%). Most of patients (93.2%) presented "good" outcomes, ranging from 87% to 100% (local and tongue flaps, respectively). Three (6.8%) patients presented symptomatic residual fistula ("poor" outcomes). CONCLUSIONS:For the repair of persistent symptomatic anterior oronasal fistulae, this therapeutic protocol provided satisfactory outcome with low fistula recurrence rate.
METHODS:OBJECTIVE:Methadone is a vital treatment for women with opioid use disorder in pregnancy. Previous reports suggested an association between methadone exposure and Pierre Robin sequence (PRS), a rare craniofacial anomaly. We assessed the association between gestational methadone exposure and PRS. DESIGN/SETTING:This case-malformed control study used European Surveillance of Congenital Anomalies population-based registries in Ireland, the Netherlands, Italy, Switzerland, Croatia, Malta, Portugal, Germany, Wales, Norway and Spain, 1995-2011. PATIENTS:Cases included PRS based on International Classification of Disease (ICD), Ninth Edition-British Paediatric Association (BPA) code 75 603 or ICD, Tenth Edition-BPA code Q8708. Malformed controls were all non-PRS anomalies, excluding genetic conditions, among live births, fetal deaths from 20 weeks' gestation and terminations of pregnancy for fetal anomalies. An exploratory analysis assessed the association between methadone exposure and other congenital anomalies (CAs) excluding PRS. Methadone exposure was ascertained from medical records and maternal interview. RESULTS:Among 87 979 CA registrations, there were 127 methadone-exposed pregnancies and 336 PRS cases. There was an association between methadone exposure and PRS (OR adjusted for registry 12.3, 95% CI 5.7 to 26.8). In absolute terms, this association reflects a risk increase from approximately 1-12 cases per 10 000 births. A raised OR was found for cleft palate (adjusted OR 5.0, 95% CI 2.7 to 9.2). CONCLUSIONS:These findings suggest that gestational methadone exposure is associated with PRS. The association may be explained by unmeasured confounding factors. The small increased risk of PRS in itself does not alter the risk-benefit balance for gestational methadone use. The association with cleft palate, a more common CA, should be assessed with independent data.
METHODS::Orthopedic treatment to improve deficient maxillary growth of cleft lip and palate patients is an important part of treatment. The success of this treatment is strongly dependent on the time of initiation of therapy. There has been a large controversy in the available literature regarding the skeletal age of these patients. The aim of the present study was to compare the skeletal age of cleft lip and palate patients with normal individuals.37 unilateral and 14 bilateral cleft lip and palate patients and 47 healthy individuals participated in this cross-sectional study. The patients were classified into 8 to 10 and 11 to 14-year-old individuals. Cervical vertebral maturational stage of participants was evaluated in the lateral cephalometry. The skeletal age of cleft lip and palate patients was compared with normal controls. Chi-square was used for statistical analysis. There was not a significant difference in the skeletal developmental stage of unilateral and bilateral cleft compared to their normal peers according to their age and sex. Also, significant difference in skeletal maturational stage of cleft lip and palate patients was not found between boys and girls (P = 0.8). Similarly, no significant difference was found in the skeletal age of the 3 studied groups without considering the age and sex of participants (P = 0.5). Regarding the similar skeletal maturational stage of cleft lip and palate patients with normal controls in our study, their maxillofacial orthopedic treatment can be initiated at similar time to normal peers.