Evaluation of the effects of temporomandibular joint arthrocentesis with hyaluronic acid injection on mandibular condyles using fractal dimension analysis: A retrospective study

Internal derangement (ID), including disc displacements, is the most common disorder of the temporomandibular joint (TMJ) (Emshoff and Rudisch, 2007; Goiato et al., 2016; De Riu et al., 2019; Marzook et al., 2020). Approximately 25% of the population is considered to have TMJ ID (Neeli et al., 2010).

Patients with TMJ ID may have chronic pain, inability to chew, limitation of mouth opening and decline in quality of life (Okeson, 2007; Goiato et al., 2016). ID treatments aim to restore the lost function of the TMJ and reduce the pain of patients. Conservative treatments for TMJ disorders are recommended first before advancing to surgical treatments if favorable results are not obtained (Emshoff and Rudisch, 2007; Al-Moraissi et al., 2020; Hosgor, 2020).

Arthrocentesis with hyaluronic acid (HA) injection has frequently been performed in TMJ ID in recent years. Clinical studies have reported that arthrocentesis with HA injection is superior to either arthrocentesis performed alone or intra-articular HA injection performed alone (Gurung et al., 2017; Yilmaz et al., 2019; Hosgor, 2020). The literature has reported positive clinical results when performing one or many arthrocenteses with HA injections (Manfredini et al., 2009; Yilmaz et al., 2019; Santagata et al., 2020).

The positive effects of HA on bone defects and wound healing have been previously reported (Koca et al., 2019; Marin et al., 2020). However, studies showing changes in hard tissues after arthrocentesis with HA injection performed on the TMJ are limited. Hard tissue changes in the mandibular condyle can be examined using the fractal dimension (FD) analysis method.

FD analysis is a quantitative concept that measures complexity (Sánchez and Uzcátegui, 2011). FD values calculated from radiographs give information about trabecular bone microstructure. Higher FD values indicate more dense and complex bone structures, whereas lower FD values indicate less dense and complex bone structures (Arsan et al., 2017). FD analysis has been used in dental implant applications (Wilding et al., 1995), root canal treatments (Chen et al., 2005; Uğur Aydın et al., 2019), maxillofacial surgical procedures such as orthognathic surgeries (Heo et al., 2002) and cyst operations (Koca et al., 2010) for treatment and recovery follow-up. Moreover, FD analysis has been used to evaluate morphological changes in the mandibular condyle (Coşgunarslan et al., 2020; Gumussoy and Duman, 2020; Memiş, 2022). Also, FD analysis was previously used for the evaluation of trabecular bone structure in hip and knee diseases (Fazzalari and Parkinson, 1997; Wolski et al., 2009; Hirvasniemi et al., 2019).

This retrospective study aimed to evaluate the effect of arthrocentesis with HA injection performed on patients with TMJ ID on mandibular condyles using FD analysis.

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