Departments of aOral and Maxillofacial Surgery
bOral Medicine and Radiology
cOral and Maxillofacial Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
Correspondence to Sriram Krishnan, MDS, Oral and Maxillofacial Surgery, Maulana Azad Institute of Dental Sciences, MAMC Complex, B.S. Zafar Marg, New Delhi 110002, India Tel: +91 96 506 351 64; e-mail: firstname.lastname@example.org
Received October 16, 2012
Accepted December 19, 2012
Temporomandibular arthrocentesis is a relatively simple technique to address certain dysfunctions of the jaw joint. These dysfunctions include disc displacements, anchored disc phenomenon, and intracapsular inflammation. Temporomandibular joint arthrocentesis provides a minimally invasive approach in resolving certain common temporomandibular joint disorders, but is associated with certain morbidity. We describe a technique of arthrocentesis for minimizing any chance of injury to vital structures, and simplify the technique further.
Temporomandibular joint (TMJ) arthrocentesis was introduced by Nitzan et al. 1 for the management of internal derangement; the technique was minimally invasive and offered an alternative to those patients for whom conservative medical and occlusal management were not effective. Before the advent of arthrocentesis, the cases not responsive to conservative therapy had to be managed through an arthroscopic procedure, failing which a radical surgical management such as arthrotomy and disc plication would be carried out.
Arthroscopy is a highly technique sensitive procedure that requires a dedicated set of fiberoptic endoscopes; it is associated with a high learning curve and many centers, particularly in developing countries, cannot afford the equipment required. In these situations, arthrocentesis offers a solution that is both minimally invasive and leads to a reasonably satisfactory outcome 2.
Arthrocentesis, as originally proposed, used a technique involving the use of two needles that were inserted into the superior joint space at certain points; these points are termed as the McCains points and were marked on a line drawn from the middle of the tragus to the lateral canthus. The entry points were marked along this canthotragal line. The first point corresponding to the glenoid fossa was marked 10 mm from the midtragus and 2 mm below the line and the second point corresponding to articular eminence was marked 10 mm from the first point and 10 mm below the line 3–5.
In our article, we describe a technique of arthrocentesis in which the previously described McCains points are not used, but a more anatomic landmarks-based approach is used to preserve certain anatomic structures that may possibly be damaged using the conventional technique.
Patients and methods
Sixteen patients (four men and 12 women) between 18 and 40 years of age were included in this study. All patients were diagnosed with anterior disc displacement without reduction, hence presenting with restricted mouth opening; in two of the patients, the bilateral joints had been affected and the rest of the 14 patients had unilateral disc derangement (18 joints). These patients, on presentation, were maintained on a conservative treatment regimen of occlusal splint therapy, soft diet, restricted mouth opening, and a short-term course of NSAIDs; this was followed for a minimum period of 21 days. Three patients who presented with pain in the joint region were also subjected to ultrasound physiotherapy. The patients who did not show any improvement in symptoms over this period of therapy were considered for joint lavage through arthrocentesis using our technique.
The procedure is performed under local anesthesia under an auriculotemporal nerve block and an additional infiltration inside the superior joint space is performed. The tragocanthal line is marked and the tragus is then posteriorly retracted gently using the index finger of the nonoperating hand; a point is marked just anterior to the midtragal region just at the anterior margin of the tragal cartilage (Fig. 1). Taking the cartilage as a guide for the first needle, it can be advanced in an anterosuperior direction at 45° to the horizontal plane until the bony obstruction of the glenoid fossa is encountered (Fig. 2).
Once the first needle is inserted, 1 ml of local anesthesia is injected into the needle; the solution will drain out when the patient is asked to make jaw movements, which confirms the position of the needle at the site. The second needle can be inserted as close to the first one around 2 mm anterioinferiorly; once the skin is penetrated, the second needle comes in contact with the first needle. With the bevel of the second needle in contact with the first needle, it can be ‘slid over’ or guided over the first needle to reach the same joint cavity, mimicking the result of a double-needle cannula.
Once both the needles are positioned, 1 ml of Ringer’s lactate solution is injected as a test in the second needle; once the patency of both the needles is confirmed, the joint is lavaged thoroughly with at least 100 ml of the Ringer’s solution (Fig. 3). The positions of the needles are maintained constant by the surgeon and checked during the time of lavage; a firm pressure is also placed over the preauricular region by an assistant to help reduce fluid escape to adjacent spaces.
Immediately following the lavage, digital manipulation is performed to help assist the patient in mouth opening; an attempt is made to achieve a maximal mouth opening (MMO) immediately following the procedure.
Of 16 patients who underwent arthrocentesis through the technique described, 13 patients with unilateral arthrocentesis showed improvements in symptoms with an increase in mouth opening and reduction in joint pain following a single sitting of arthrocentesis. The two patients with bilateral TMJ disorder underwent arthrocentesis of both the joints at different appointments, and hence achieved MMO later than the unilateral patients. One patient with unilateral disc displacement had to undergo a repeat arthrocentesis procedure, following which the mouth opening improved to the desired level. All patients were continued on occlusal appliances and were advised to perform mouth opening exercises.
Mouth opening was measured from the upper to the lower incisal edge and was considered satisfactory if it was above 30 mm. A descriptive analysis was carried out by exporting the collected data on MMO and increase in mouth opening to SPSS 16 for Windows, where the mean MMO for the patients 1 month after arthrocentesis was 36.4 mm (Fig. 4). The mean increase in mouth opening was 12.3 mm; in unilateral cases, the jaw deviation during mouth opening did not resolve. The mouth opening did not reduce till their respective last follow-up for the patients, which ranged from 6 to 38 weeks, with an average follow-up of 29.4 weeks. Three patients who had presented with pain initially reported relief in symptoms following the initial conservative therapy and the arthrocentesis procedure increased their mouth opening. None of the patients had any signs or symptoms of facial nerve injury.
Arthrocentesis is a novel technique for the management of certain intracapsular derangements of the TMJ, and in particular, for anterior disc displacement without reduction. It can be difficult for surgeons to find the exact places for the needles; multiple insertions are often required for the needles to enter the joint space. However, complications are rare in arthrocentesis and are caused more often with arthroscopy 2; still, there may be potential complications that may develop with arthrocentesis, such as damage to capsular tissues, discal tissue, increased risk of facial nerve injury, preauricular hematoma, middle ear injury, and intra-articular instrument breakage. Redundant injury of the capsule by needles can also aggravate inflammation in the joint and increase the incidence of solution extravasation to neighboring tissues when the arthrocentesis is finally performed 6–9. A rare case of extradural hematoma has also been reported with the conventional technique of arthrocentesis, which could have been because of blind triangulation of the needle 10. Once the positioning of the needle is achieved successfully, maintaining the exact place during the lavage can also be challenging.
The two-needle cannula technique 11,12 that has been described by some authors was found to have some shortcomings during some of our previous experiences with it: the needle puncture site was considerably larger, healed at a delayed rate, and formed a scar at the site. During the process of arthrocentesis using this two-needle cannula, a leak may be observed around the penetration point where the double cannula enters, hence increasing the chances of fluid extravasation and difficulty in performing pressure irrigation.
The current technique of arthrocentesis described is a method that is suitable for the anatomical pattern of TMJ; the second point of needle insertion in the traditional technique carries with it the risk of injuring the frontal branch of the facial nerve and rarely the zygomatico-orbital branch. To avoid this complication, the second point of entrance has been modified in our technique in close proximity to the first point. The midportion of the tragus is 5 mm anterior to the tip of the tragus, which is also 5 mm posterior to the anterior wall of the bony external auditory canal, hence placing the frontal branch of facial nerve between 13 and 40 mm 13–16. The first point of insertion is 2 mm anterior to the midportion of the tragus to avoid the neurovascular structures composed of the auriculotemporal nerve and temporal vessels; the second point of insertion is 2 mm anteroinferior to the first to provide an adequate clearance of 8 mm from the temporal branch (Fig. 5). The technique provides a more easy and safe approach to manage the internal derangement of TMJ.
Conflicts of interest
There are no conflicts of interest.
1. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis. A simplified treatment for severe limited mouth opening. J Oral Maxillofac Surg. 1991;49:1163–1167
2. Frost DE, Kendell BD. The use of arthrocentesis for treatment of temporomandibular joint disorders. J Oral Maxillofac Surg. 1999;57:583–587
3. Neeli AS, Umarani M, Katshetti SM, Baliga S. Arthrocentesis for the treatment of internal derangement of the temporomandibular joint. J Maxillofac Oral Surg. 2010;9:350–354
4. Holmuund A, Hellsing G. Arthroscopy of the temporomandibular joint – an autopsy study. Int J Oral Surg. 1985;14:169–175
5. McCain TP. Arthroscopy of the human temporomandibular joint. J Oral Maxillofac Surg. 1988;46:648–655
6. Carls FR, Engelke W, Locher MC, Sailer HF. Complications following arthroscopy of the temporomandibular joint: analysis covering a 10-years period (451 arthroscopies). J Craniomaxillofac Surg. 1996;24:12–15
7. McCain JP, Sanders B, Koslin MG, Quinn JD, Peters PB, Indresano AT. Temporomandibular joint arthroscopy: a 6-years multicenter retrospective study of 4831 joints. J Oral Maxillofac Surg. 1992;50:926–930
8. McCain JP. Complications of TMJ arthroscopy. J Oral Maxillofac Surg. 1988;46:256
9. McCain JP, de la Rua H. Foreign body retrieval: a complication of TMJ arthroscopy. J Oral Maxillofac Surg. 1989;47:1221–1225
10. Carroll TA, Smith K, Jakubowski J. Extradural haematoma following temporomandibular joint arthrocentesis and lavage. Br J Neurosurg. 2000;14:152–154
11. Alkan A, Baş B. The use of double-needle canula method for temporomandibular joint arthrocentesis: clinical report. Eur J Dent. 2007;1:179–182
12. Rahal A, Poirier J, Ahmarani C. Single-puncture arthrocentesis – introducing a new technique and a novel device. J Oral Maxillofac Surg. 2009;67:1771–1773
13. Ellis E III, Zide MF Surgical approaches to the facial skeleton. 1995 Philadelphia Williams and Wilkins
14. McCain JP Principles and practice of temporomandibular joint arthroscopy. 1996 St Louis Mosby-Year Book Inc.:42
15. Al Kayat A, Bramley P. A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg. 1979;17:91–103
16. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg. 1997;99:1224–1233