Arthrocentesis of the temporomandibular joint

Dr. Ahmed M. Adawy Professor Emeritus, Dep. Oral & Maxillofacial Surg.

Former Dean, Faculty of Dental MedicineAl-Azhar University

Arthrocentesis (Greek: arthros, a joint + kentēsis, puncture)Arthrocentesis of the temporomandibular joint refers to lavage of the upper joint space, hydraulic pressure and manipulation to release adhesions of the “anchored disc phenomenon” and improve motion. It was first described by Nitzan and colleagues in 1991(1) to treat acute closed lock jaw. Their study established that the treatment decreased pain, increased maximal incisal opening and showed prolonged relief of symptoms

Arthrocentesis

Through arthrocentesis the microscopic tissue debris resulting from the breakdown of the articular surfaces and the pain mediators can be washed out, and normal lubricating properties of synovial membrane can also be stimulated. Today TMJ arthrocentesis is not only used in the treatment of acute closed lock but in various other temporomandibular joint disorders as well. It has been considered as the first line of surgical treatment for patients with TMJ disorders who do not respond to conservative therapy such as interocclusal devices, physical therapy, drugs, light diet, behavioral and lifestyle changes

Arthrocentesis is a minimally invasive procedure(2), that can be performed under local anesthesia in an out-patient basis. It consists in the lavage of the upper TMJ compartment with a fluid, such as saline or lactated Ringer’s solution, and/or anti-inflammatory, opioid and steroid drugs

Arthrocentesis

Indications

Arthrocentesis is indicated for patients with anterior disc displacement with and without reduction, for disc adhesions, for early adhesiveness next to the fossa and/or the upper aspect of the articular tubercle, with mouth opening limitation, for cases of synovitis/capsulitis, as palliation for acute degenerative rheumatoid arthritis, patients with painful joint noises occurring during mouth opening and/or closing and for hemarthrosis due to recent trauma

Contraindications

Some contraindications for arthrocentesis have been proposed including; psychiatric pathology, fibrous and osseous ankylosis, multiply operated joints, regional infectious disease and tumors of the joint

Arthrocentesis Technique

The technique starts by anaesthetizing the auriculotemporal nerve followed by posterior deep temporal and masseter nerves. This provides optimal region analgesia, preventing the need for sedation. A straight line is drawn from the medial portion of the ear tragus to the lateral corner of the eye. In this line, two needle insertion points are marked. The first, more posterior point will be at a distance of 10 mm from the tragus and 2 mm below the cantotragal line. This is the approximate area of the maximum concavity of the glenoid fossa. The distance is about 25mm from skin to the centre of the joint space

Anatomical landmarks for needle entry

The second point will be 20 mm in front of tragus and 10 mm below this same line. This marking indicates the site of the eminence of the TMJ. After the points of insertion for the two needles have been marked, local anaesthetic is injected at the planned entrance points. Two 19 gauge needles are inserted in the anterior and posterior recesses of the upper joint space. Through one needle, Ringer’s lactate 100–300 ml is injected into the superior joint space. The second needle acts as an outflow portal, which allows lavage of the joint cavity(3)

Arthrocentesis Technique

Arthrocentesis, mode of action:

Arthrocentesis changes synovial fluid viscosity, thus contributing for the translation of the disc and mandible head complex(4). In addition, when performed under pressure and combined with shearing forces generated by jaw manipulation it could break down early adhesions, thus improving mouth opening(5). Pain is decreased or eliminated possibly due to the wash-out of chemical pro-inflammatory mediators(6), associated to the direct action of instilled drugs on intracapsular pain receptors(7)

Complications

There may be zygomatic branch or facial nerve temporal branch paresis caused by local anesthetic block or the edema itself; zygomatic or buccal branch paralysis due to needle trauma; postoperative edema caused by intra-articular solution leakage; periauricular hematoma; perioperative bleeding by vascular injury; and extradural hematoma

Single-needle techniqueIn some cases, however, it is difficult to insert the second needle. This means lavage failure, longer time operation , uncomfortable patients, and there may be increased postoperative morbidity and possible damage to the facial nerve(8). For this reason single needle arthrocentesis has been proposed, in which inflow and out flow go through the same cannula(8). The joint is lavaged with a single needle used for injection and ejection resulting 40 ml of irrigation. However, with a single needle the amount of fluid may be inadequate and the pressure too low

Double-needle cannula

Other modifications include the use of a single cannula with two ports (9), and the use of the so called Shepard cannula that holds two needles together (10). Nevertheless the device that keeps two needles together seems to be relatively thick, which has the potential to damage the nerve. Repetitive use of the device may cause the tips of the needles to blunt, and increase the risk of infection

Double-needle cannula

Double-needle cannula

1.Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg; 49:1163, 1991. 2. Nitzan DW. Arthrocentesis--incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am ; 18: 311, 2006. 3. Tozoglu S, Al-Belasy FA, Dolwick MF. A review of techniques of lysis and lavage of the TMJ. Br J Oral Maxillofac Surg; 49: 302, 2011. 4.Nitzan DW, Etsion I: Adhesive force: the underlying cause of the disc anchorage to the fossa and/or eminence in the temporomandibular joint. A new concept. Int J Oral Maxillofac Surg; 31: 94, 2002. 5.Yura S, Totsuka Y, Yoshikawa T, et al. Can arthrocentesis release intracapsular adhesions? Arthroscopic finding before and after irrigation under sufficient hydraulic pressure. J Oral Maxillofac Surg; 61: 1253, 2003. 6. Kaneyama K, Segami N, Nishimura M, et al. The ideal lavage volume for removing bradykinin, interleukin-6, and protein from the temporomandibular joint by arthrocentesis. J Oral Maxillofac Surg; 62: 657, 2004.

References:

7. Kunjur J, Anand R, Brennan PA, et al. An audit of 405 temporomandibular joint arthrocentesis with intra-articular morphinre infusion. Br J Oral Maxillofac Surg; 41: 29, 2003.8. Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of thetemporomandibular joint: a proposal for a single-needle technique.Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 106: 483, 2008. 9. Alkan A, Bas B. The use of double-needle canula method fortemporomandibular joint arthrocentesis: clinical report. Eur J Dent; 1:179, 2007.10. Rehman KU, Hall T. Single needle arthrocentesis. Br J Oral MaxillofacSurg; 47: 403, 2009.

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