Review Article

Arthrocentesis of Temporomandibular Joint- Bridging the Gap

Between Non-Surgical and Surgical Treatment
Abhishek Soni
Department of Oral Medicine and Radiology, Modern Dental College and Research Center, Indore, Madhya Pradesh, India

Abstract
The temporomandibular joint forms one of the most fascinating and complex synovial joints in the body. Movements of the temporomandibular
joint are regulated by an intricate neurological controlling mechanism, which is essential for the system to function normally and efficiently.
Lack of such harmony may cause disruptive muscle behavior or structural damage to any of the components. The management of refractory
pain and dysfunctions in the temporomandibular joint poses challenge both to the oral physician and maxillofacial surgeon. Arthrocentesis
is a simple, minimally invasive technique that can be used instead of more invasive procedures in patients with pain that fails to respond to
conventional conservative measures. This review provides a full comprehensive overview of the literature about the various technical and
prognostic aspects in relation to arthrocentesis of the temporomandibular joint, and every clinician must take into account this consideration
when performing this procedure in treating patients with temporomandibular disorders.

Keywords: Arthrocentesis, temporomandibular joint, temporomandibular joint disorders

Introduction critically review the published literature with regard to the

critique of this technique and provides an overview of the current
Temporomandibular disorder (TMD) is the most common cause
concepts regarding the arthrocentesis of TMJ, highlighting the
of orofacial pain of nondental origin.[1,2] It is a term used to describe technical considerations in performing the procedure as well as
disorders involving the temporomandibular joints (TMJs), factors affecting the outcome of the procedure. Their possible
masticatory muscles, and occlusion resulting in muscle or TMJ indications and associated complications will also be discussed.
pain, restricted movement, muscle tenderness, and intermittent
joint sounds.[3,4] A treatment strategy for TMDs consists of various
nonsurgical and surgical methods. A nonsurgical approach is Methods
recommended for initial management,[4‑6] and if this failed, To get up‑to‑date information, a web‑based search was
surgical intervention should be considered.[7] However, surgery initiated using PubMed/Medline database, using the key terms
in this region is associated with many risks. Arthrocentesis of “temporomandibular joint,” “temporomandibular disorders,”
TMJ has emerged over the years as a useful technique to manage and “temporomandibular joint arthrocentesis” to determine
TMDs. Arthrocentesis is commonly defined as the lavage of the the scope of coverage in well‑documented articles. The
TMJ without viewing the joint space using sterile needles and search was subsequently refined to temporomandibular joint
sterile irrigants so as to reduce the pain by removing inflammatory arthrocentesis. The sites of specialized scientific journals in
mediators from the joint or to increase the mandibular mobility the areas of oral and maxillofacial surgery, oral medicine, and
by removing intra‑articular adhesions by means of hydraulic
pressure from irrigation of the upper chamber of the TMJ. Address for correspondence: Dr. Abhishek Soni,
Arthrocentesis is generally suggested in patients irresponsive to 263 ‑ Balaji Villa, Shivom Estate, Station Road, Dewas ‑ 455 001,
conservative therapies.[8,9] Madhya Pradesh, India.
E‑mail: drabhishek_soni@rediffmail.com
Numerous clinical studies regarding this technique have been
published in the literature. The present work is an attempt to This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which
Access this article online allows others to remix, tweak, and build upon the work non‑commercially, as long
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DOI: How to cite this article: Soni A. Arthrocentesis of temporomandibular

10.4103/ams.ams_160_17 joint- Bridging the gap between non-surgical and surgical treatment. Ann
Maxillofac Surg 2019;9:158-67.

158 © 2019 Annals of Maxillofacial Surgery | Published by Wolters Kluwer ‑ Medknow

 Soni: Arthrocentesis of temporomandibular joint

other relevant journals were also used. The bibliographies were the TMJ region is often associated with morbidity and fraught
also reviewed to identify additional relevant studies. with many risks, and more often, it does not produce expected
results. Surgery is often considered as an option of last resort.
Arthrocentesis: An Emerging Alternative to TMJ arthrocentesis procedure bridged the gap between surgical
and nonsurgical treatment.[13] The aim of TMJ arthrocentesis is
Surgical Intervention to make an intolerable situation tolerable. It is often considered
Treatment strategies for TMDs are as diverse as the patients to be the highly effective method to restore normal maximal
that present with it. Although in managing the TMDs, one mouth opening and functioning.
should utilize first the conservative treatment; however, in
some circumstances, surgery is usually considered to be the Rationale of Arthrocentesis
definitive treatment modality and sometimes the only treatment
TMDs, either inflammatory or noninflammatory, are
option.[10,11] The right combination of symptomatic history, typically associated with structural alterations in joint
clinical features, and radiological signs will readily reveal tissues, such as cartilage degradation and subchondral bone
whether the TMD patient is an appropriate candidate for alterations secondary to the change in the articular loading.
surgery.[10] There are various conditions where surgery plays In inflammatory TMDs, various mediators of inflammation,
a pivotal role such as:[11,12] particularly cytokines, may be responsible for enzymatic
a. In case to restore and repair the damaged tissue or to degradation of the matrix. Macromolecular degradation of the
remove tissue that cannot be salvaged matrix determines the physical and biological deterioration of
b. To promote healing of tissues by replacing missing the tissues and promotes the disease because the degradation
tissues with grafts, for example, in case of chronically fragments, proteoglycans, and collagen released into the
displaced disc or in case of collapsed articular cartilage synovial fluid generate inflammatory pain.[14] There are
and osteophytes that interfere with the smooth, pain‑free different types of inflammatory and anti‑inflammatory
function of the joint, and cytokines, the balance of which affects the development
c. When there is significant disease affecting the joint. of degenerative and inflammatory changes. Inflammatory
Dolwick and Dimitroulis[11] divided the indications for surgery cytokines include interleukin‑1 (IL‑1), IL‑6, IL‑8, and tumor
into relative and absolute [Table 1]. From a clinical standpoint, necrosis factor‑α while anti‑inflammatory cytokines include
the most common general indication for TMJ surgery is where IL‑4, tissue inhibitors of metalloproteinases (TIMP‑1),
TIMP‑2, and tumor growth factor transforming growth
the joint disorder remains refractory, or not responding to
factor‑β.[15] In the course of the inflammation, monocytes
nonsurgical therapies,[4] or where the source of the pain and
and macrophages quickly release IL‑1 and IL‑6. Fibroblasts
dysfunction is well localized to the TMJ region. Therefore,
and chondrocytes also have this ability, but at the same time,
specific indications for TMJ surgery include the following:[11]
through the action of IL‑6, they release TIMP as well. Further,
• Chronic severe limited mouth opening and gross
synovial cells and mononuclear cells infiltrating the edge of
mechanical interferences such as painful clicking and
the blood vessels also produce IL‑6 in both synovial tissue
crepitus that fail to respond to TMJ arthrocentesis and
and synovial fluid. High levels of IL‑6 in the synovial fluid of
arthroscopy
the TMJ are associated with extensive acute synovitis.[16] In
• Radiologically confirmed degenerative joint disease, addition to this, the current clinical evidence also suggested
with clinical features of intolerable pain and joint that the TMJ pain or dysfunction may be attributed to
dysfunction, is essentially the key criterion for TMJ alterations in joint pressure (negative intra‑articular pressure)
surgical intervention. and biochemical constituents of the synovial fluid (failure of
Controversy still surrounds the role of surgery in the lubrication) which may lead to clicking and derangement of
management of pain and dysfunction of the TMJ. Surgery in the TMJ.[15,17,18]
Arthrocentesis reduces the pain by allowing the elimination
Table 1: Indications for surgery by Dolwick and of inflammatory cells from the joint space and increases the
Dimitroulis mandibular mobility by removing intra‑articular adhesions,
Absolute indication
eliminating the negative pressure within the joint, thus
Ankylosis of TMJ (e.g., fibrous or osseous joint fusion)
recovering disc and fossa space which reduces the mechanical
Neoplasia (e.g., osteochondroma of the condyle) obstruction caused by anterior disc displacement.[15,19‑23]
Dislocation of TMJ either recurrent or chronic
Developmental disorders affecting the TMJ Procedure of Temporomandibular Joint
Relative indication
Internal derangement of TMJ
Arthrocentesis – Technical Considerations
Osteoarthrosis Various techniques for arthrocentesis have been mentioned
Trauma to the TMJ in the literature which itself varies considerably over the
TMJ=Temporomandibular joints period of time. Murakami et al.[24] first described a technique

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 Soni: Arthrocentesis of temporomandibular joint

of TMJ arthrocentesis with pumping irrigation and hydraulic • With the patient’s mouth open, the first needle is inserted
pressure to the upper joint cavity followed by manipulation into the superior joint space in the most posterior point
of the jaw. After that, Nitzan et al.[19] described a technique directing upward, forward, and inward to a depth of
utilizing the insertion of two needles into the upper joint about 20–25 mm, after the tip of the needle has come
compartment, permitting more effective lavage of the joint. into contact with the posterior wall of the articular
In this technique, the landmarks for the insertion of needles eminence[37]
are marked on the skin according to the method suggested by • This is followed by administration of irrigating
McCain et al.[25,26] for arthroscopy (posterolateral approach to solution (Hartmann solution [also known as Ringer’s
the upper joint space). lactate solution] or physiological saline) through the
first needle with the aim of distending the superior joint
Preprocedural considerations
space.[29] This compartment will take up to 5 mL of
TMJ arthrocentesis is a minimally invasive procedure[27,28]
fluid[31]
and can be comfortably performed under local anesthesia
or intravenous conscious sedation or general anesthesia, • Now, the second needle is introduced in the distended
depending on patient comfort and surgeon preference. Before compartment, in front of the first needle at the marked
performing the procedure, the following points should be kept point, allowing the visualization of the solution and
in mind:[29] orienting the flow of the joint lavage solution,[29] as shown
• The surgical field is properly draped and cleaned with in Figure 2.
povidone iodine or similar substance, particularly in Laskin[38] mentioned that it is usually difficult to insert the
preauricular region and ear second needle anterior to the first one, and therefore, he had
• External auditory canal is protected from accumulation inserted the anterior needle in the posterior recess of the upper
of blood and fluid using a cotton pledget joint compartment by placing it 3–4 mm anterior to the first
• The auriculotemporal nerve block is given, and the areas one and suggested this technique to be much easier than the
of joint penetration should be infiltrated. previous method. However, if the second needle is entered
The two‑needle technique anterior to the first one, it is inserted into a narrower region of
The classical technique to perform TMJ arthrocentesis utilizes the upper joint compartment, and this may cause damage to
double access to the joint cavity. This technique uses two needles, the articular disc leading to failure of the outflow of irrigating
one for injecting and the other for aspirating the solution.[30] solution. Alkan and Etöz[39] proposed a new technique, in which
• For two‑needle technique, access is performed by taking the posterior point of entry for the first needle was the same
as indicator the Holmlund–Hellsing line (canthotragal while the second needle is inserted 7 mm anterior from the
line),[31] as depicted in Figure 1. A straight line is drawn middle of the tragus and 2 mm inferior along the canthotragal
on the skin joining the medial portion of the tragus of the line. This second needle was adjusted parallel and almost
ear to the outer canthus of the ipsilateral eye 3 mm posterior to the first until bony contact was made. It was
• Two points are marked on this line for needle insertion. assumed that when the second needle is inserted posterior to
The first, more posterior point will be marked at a the first one in the wider part of the upper joint compartment,
distance of 10 mm from the tragus and 2 mm inferior to the outflow of the solution from the joint cavity is easier to
canthotragal line. This point corresponds to the posterior achieve. They thoroughly irrigated numerous joints with
extent of the glenoid fossa. The second point will be complete success by this technique and suggested that the use
marked at 20 mm anterior to tragus and 10 mm inferior of this landmark as the default technique may be reasonable,
to canthotragal line, which corresponds to the height of as repeated insertions of a needle are uncomfortable both for
articular eminence[19,32‑34] physicians and patients and adversely affect the success of
• The glenoid fossa is thin, with a range of 0.5–1.5 mm.[25,35] the treatment.
The dura and temporal lobe are located beneath the glenoid The positioning of two needles within the joint cavity may cause
fossa. Joints may also be eroded by degenerative arthritis some discomfort to patients, particularly at the time of the first
or previous infections. Hence, it is possible that during the lavage. A study evaluating the efficacy and tolerability of a cycle
procedure, this structure may get perforated. Therefore, of 5 weekly hyaluronic acid injections performed after a classical
the surgeon must be cautious not to insert the needle much
two‑needle arthrocentesis showed that the patient’s perception
into the joint space. About 25 mm depth is enough to reach
of tolerability increased with time. Possible explanation for
to upper joint space[27]
this is that with the sequential arthrocentesis interventions, the
• To increase the joint space during arthrocentesis, the
catabolytes are removed and adhesions are broken down, which
patient is usually asked to open the mouth and deviate
made the insertion of the needles easier and consequently, the
it to the opposite side so as to distract the condyle from
quality of the posttreatment course was improved.[40]
the glenoid fossa thereby increasing joint space. Nagori
et  al.[36] suggested that custom‑made mouth prop is an Recently, a technique using a single needle for both injection
effective tool to hold the mandible in eccentric position and ejection of irrigating solution has been described[31] and
during arthrocentesis gave interesting results over a short period.[41]

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 Soni: Arthrocentesis of temporomandibular joint

The single‑needle technique

The single‑needle approach for the lavage of TMJ was
based on the rationale that pumping saline injection into the
superior joint compartment with the patient in an open mouth
position provides enough pressure to release joint adherences
and to allow fluid outflow when the patient closes his/her
mouth,[33] as shown in Figure 3. The single‑needle technique
provides the underpressure fluid injection to expand the joint
cavity[31] and to break joint adherences that are responsible
for the reduced translatory movement of the condyle.[42,43]
The injection‑ejection process must be performed for up
to 10 repetitions for a total amount of about 40 ml. This
makes the single‑needle technique indicated in the case of
hypomobile joints with strong adherences or joints with
degenerative changes that make the insertion of the second
needle difficult.[31] Figure 1: Holmlund–Hellsing line or canthotragal line

The single‑needle arthrocentesis technique has several

advantages over the traditional two‑needle technique which
are as follows:[31]
• It is a simple, easier, and less invasive technique
• As the positioning of a second needle could interfere with
the stability of the first one in two‑needle technique, the
single‑needle technique provides more sure and stable
access to the joint cavity
• There is reduction in postoperative pain and discomfort
to the patient after the procedure which may be attributed
to the lesser amount of anesthetic needed in the
single‑needle approach. This may further reduce the risks
of postoperative facial nerve paresthesia
• An anteriorly positioned second needle may cause trauma
to the facial nerve, that lies anteriorly and medially to the
glenoid fossa, which is the site where the second needle
Figure 2: Double‑needle arthrocentesis
is usually inserted; single needle approach reduces the
chances of such injuries
• There is reduction in the execution time for the procedure
to perform in single‑needle approach
• A single‑needle technique might allow full retention of
the injected hyaluronic acid within the joint compartment
because the risk of hyaluronic acid flowing out through
the second point of injection is absent.
However, this technique has certain limitations.[29]
• Since the total circulating volume of the irrigating solution
is very low, this technique is hardly able to eliminate
algogenic substances present in the synovial fluid of the
upper TMJ compartment, responsible for pain and bone
and fibrocartilaginous changes
• Even on exerting pressure on the syringe plunger on the
fluid, only a part will return through the needle, regardless
of patients closing their mouth. Part of the fluid may leak Figure 3: Single‑needle arthrocentesis
from the upper compartment toward the face, producing
local edema which may generate intra‑ and post‑operative
arthrocentesis techniques. Sindel et  al.[44] compared the
pain.
efficacy of the double‑  and single‑needle arthrocentesis
Several studies have been performed over the years to techniques and found that the single‑needle technique
compare the efficacy of the double‑ and single‑needle may be a good alternative with the advantages of easier

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 Soni: Arthrocentesis of temporomandibular joint

application in cases where it is not possible to perform Concentric needles unit

the double‑needle technique. Şentürk et al.[45] compared Öreroğlu et  al.[51] use a concentric‑needle cannula system,
the single‑puncture technique with the double‑puncture i.e., using 2 different gauge needles placed in a concentric
technique for arthrocentesis of the TMJ and found that manner for SPA in TMJ and found it to be the least traumatic
arthrocentesis of the TMJ was successful with both and perhaps the most feasible and cost‑effective method for
techniques. Şentürk et  al.[46] also evaluated the long‑term TMJ lavage.
effects of the single‑puncture arthrocentesis (SPA) technique
and found it to be an effective treatment method. Irrigating Solutions for
Modifications in Arthrocentesis Techniques Arthrocentesis – Volume and Pressure
With time, many modifications have been made in arthrocentesis Considerations
methods to make this traditional procedure even simpler and The volume of solution used for lavage of the joint is considered
less invasive. to be very important in performing the arthrocentesis
procedure. A number of irrigating solutions have been used
Double needles in a single cannula in varying quantities and at different pressures.[21,52] The
Alkan and Bas[47] used double needles in a single cannula volume of solution used for TMJ arthrocentesis mentioned
having two adjacent irrigation and aspiration tubes that allow in various published studies varied widely and ranged from
sufficient irrigation and lavage of the joint with the same 50 to 500 mL.[53] Zardeneta et al.,[54] in their study, reported
device under the desired pressure. It is very safe and does not that approximately 100  mL of total perfusate is sufficient
need another puncture to place the additional needle, such as for therapeutic lavage of the joint. However, in the study by
with classic arthrocentesis. However, the major limitation of Kaneyama et al.,[21] they suggested that the ideal lavage volume
this technique is when there are major degenerative changes of perfusate for arthrocentesis is between 300 and 400 mL.
with decreased joint space and presence of osteophytes; it can
be more difficult to enter this instrument into the joint space. Mostly, Ringer’s lactate or physiological saline has been used
for injecting into the superior joint space for arthrocentesis.[55]
Shepard’s single cannula The fibrous tissue of the articular disc has a better tolerance
Rehman and Hall[48] used a similar device called a Shepard for Ringer’s solution than for an isotonic saline solution.[30,56]
cannula that holds two needles together. Nevertheless, Since Ringer’s lactate in comparison to other irrigants is close
the device that keeps two needles together seems to be to Human serum, it is considered to be better tolerated by the
relatively thick, which has the potential to damage the tissues.[56,57]
nerve. Repetitive use of the device may cause the tips of the
The injection of fluid under pressure is a useful way of dealing
needles to blunt and increase the risk of infection. In a study
with the adhesions that are considered to be the main cause
conducted by Talaat et  al.,[49] they compare single‑needle
of anchorage of the disc to the fossa or eminence or both
arthrocentesis (Shepard cannula) with double‑needle resulting in reduced translation of condyle, and their release
arthrocentesis with viscosupplementation for treating disc allows an immediate improvement in mouth opening.[31,58] Yura
displacement without reduction of the TMJ and found that et  al.[59] reported that low‑pressure arthrocentesis (6.7 kPa)
single‑needle technique was easier to perform and required a was unsuccessful in patients with severe adhesions whereas
shorter operative time, and therefore, it can be an alternative arthrocentesis under sufficient pressure  (40 kPa) released
to the standard technique; however, it might add to the cost them. They concluded that because irrigation under sufficient
of the procedure. pressure can remove adhesions and widen the joint space, the
Arthrocentesis technique with automatic irrigation under technique might be useful for patients with closed lock and
high pressure adhesions.
Alkan and Kilic[50] described a modification of the arthrocentesis Guarda‑Nardini et al.[33] in their study suggested that in case
technique described by Nitzan et al.,[19] in which an irrigation of adhesions or little adhesiveness, it is recommended to
pump from a surgical and dental implant motor was connected obstruct one of the needles, increasing the pressure on syringe
to the second needle, and automatic irrigation was initiated plunger while the patient performs opening and laterality
under high pressure. They considered that this modification movements. If the movement is still limited, the assistant
provided the highest hydraulic pressure and made it possible surgeon may perform the same movements aiming at breaking
to irrigate the upper joint space in 2 min with saline solution the possible adhesions and try to reestablish mouth opening
300 ml. However, complications may develop in the pattern equal to or above 35 mm of laterality and protrusive
surrounding tissues as a result of the high pressure if the of at least 4 mm. Similar observation had been reported by
irrigation pump is connected to the first needle without manual Dolwick MF[58], which showed that intermittent distension of
confirmation with the second needle. In addition, if the outlet the joint space by momentary blocking of the outflow needle
needle suddenly blocks during the procedure, the surgeon must and injection under pressure during lavage results in lysis
discontinue the irrigation immediately. of adhesions. Giacomo de Riu et al.[14] in their prospective

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 Soni: Arthrocentesis of temporomandibular joint

clinical study on 30 consecutive patients with TMJ disorders either next to the fossa and/or the upper aspect of the
found a significant reduction in pain in all the patients after articular tubercle, with mouth opening restrictions[29]
arthrocentesis using saline and sodium hyaluronate injections. • In case of closed lock, the central portion of healthy disc
This pain reduction is attributed to high‑pressure irrigation, indeed separates from the fossa, leaving rims fastened to
which washes away inflammatory mediators, providing surface of eminence causing increased negative pressure
immediate pain relief. in closed space between fossa and disc. This pressure
However, it should be kept in mind that the pressure applied difference constitutes a force sufficient to keep the disc
on the syringe during the procedure should be under control compressed against the fossa (suction cup effect).[27,72]
to avoid any complication. Arthrocentesis abolishes this negative pressure, loosens
the adhered disc, and reinstitutes its free sliding
Postarthrocentesis Considerations movement. It also helps the joint to reassume its normal
movement bringing about recovery of intra‑articular
At the end of lavage, it was proposed that steroids or sodium
pressure fluctuations, which in turn allows perfusion of
hyaluronate injection should be administered into the
joint space to alleviate intracapsular inflammation.[60] The nutrients and medications. Thus, in patients with disc
anti‑inflammatory effects of intra‑articular corticosteroids adhesions, there was marked improvement in mouth
are useful for alleviating pain, swelling, and dysfunction opening and decreased deviation.[73]
in patients with inflammatory and noninflammatory joint • It can be used in cases of synovitis/capsulitis not
diseases.[61,62] There are many glucocorticoid preparations, responding to nonsurgical treatment[29]
but methylprednisolone and triamcinolone (40 mg/1 ml) • Substantial concentrations of inflammatory mediators
preparations are long acting and may be preferable.[61] of pain have been found in synovial fluid in patients
with painful dysfunctional TMJs. Lavage of the upper
Postarthrocentesis, the patient should be kept on soft diet
joint space reduces pain by removing inflammation
for a few days. Exercises of range of movement are started
mediators from the joint.[37]
immediately and continued for several days. Analgesics should
• Arthrocentesis procedure can be implemented as palliation
be prescribed as necessary for pain.[25,27,58]
treatment for degenerative osteoarthritis[29,73,74]
Brennan and Ilankovan[63] suggested intra‑articular injection of • Patients of TMJ osteoarthritis complain of early
morphine (10 mg in 1 ml) as a long‑acting analgesic in patients morning stiffness in TMJ, severe joint pain, and
with continuing pain in the TMJ. In a study by Kunjur et al.,[64] limitation in mouth opening and function along with
they performed 405 arthrocentesis (with 50 ml of 0.9% normal swelling in the respective area.[27] These symptoms
saline solution followed by morphine 10 mg [in 1 ml] infusion) arise due to joint overloading and increased
over a 10‑year period for 298 patients and found significant intra‑articular pressure, which leads to sclerosis of
reduction in pain score after arthrocentesis (P < 0.001) and subchondral bone,[18] compromised blood supply
269 patients (90%) found the procedure beneficial. In another
which is due to pain, and absence of elimination of
study, Furst et  al.[65] reported that bupivacaine alone was a
inflammatory substrates which are removed during
better analgesic than morphine alone or the combination of
normal joint mobilization.[27] Arthrocentesis forces
morphine and bupivacaine.
apart the joint constituents and washes away inflamed
synovial fluid, thereby reducing pain and loading
Indications effect thus in turn increasing mouth opening.[75,76]
• Arthrocentesis is used in patients with internal TMDs not • It can be used in patients with painful joint noises occurring
responding to conservative clinical treatment during mouth opening and/or closing.[29] Joint sounds such as
• It is indicated in patients with anterior disc displacement clicking could be intermittent or constant which is caused by
with or without reduction.[29] Arthrocentesis has been displacement of the disc. Arthrocentesis distends the upper
reported to be up to 91% effective in treating patients with joint compartment thereby relieving the lag, and disc‑condyle
anterior disc displacement without reduction[21,66,67] complex moves synchronously reducing the clicking.[75]
• Studies have shown that arthrocentesis can produce
long‑term relief of pain and dysfunction in patients
Contraindications
with internal derangements of the TMJ.[68,69] Frost
et al.[70] reported that arthrocentesis is the first line There are certain conditions where arthrocentesis procedure
are strictly contraindicated. Contraindication for the procedure
procedure for the treatment of acute and chronic
can be either absolute or relative.[37]
closed lock of the TMJ in internal derangement.
Similarly, Thomas et  al.[71] also suggested in their Absolute contraindication
study that arthrocentesis is a very useful technique An inflammatory focus (abscess or cellulitis) at the site of the
for treatment of acute closed lock of TMJ. needle insertion during arthrocentesis is generally considered
• Arthrocentesis can be used in cases of disc adhesions, an absolute contraindication for this procedure.

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 Soni: Arthrocentesis of temporomandibular joint

Relative contraindications • Preauricular hematoma

• Bacteremia • Extradural hematoma
• Adjacent osteomyelitis • Injury to the superficial temporal artery resulting in
• Coagulopathy aneurysm
• Malignant tumor. • Development of arteriovenous fistula and bleeding
into the joint.
Complications
Arthrocentesis procedure is associated with certain Success Rate and Prognosis
postoperative complications and sequelae. The severity of
these complications depends on the anatomy of the TMJ Several studies have found that arthrocentesis is capable of
and its related surrounding structures and also the method recovering normal mouth opening and reducing pain and
employed for the procedure (i.e., the single‑needle or functional disorder. Brennan and Ilankovan[63] stated that
two‑needle approaches). The frequency of these complications arthrocentesis is a relatively simple surgical procedure for
mentioned in the literature ranges between 2% and 10%.[37] In patients with pain that cannot be improved by conservative
a retrospective study by Vaira et al.,[77] they concluded that the treatments. In a clinical comparative prospective study by
complications associated with the arthrocentesis are usually Tutamayi et al.[90] on 45 patients suffering from TMJ pain, it
transient in nature. was found that although both arthrocentesis and conservative
• Injury to the facial nerve (0.7%–0.6%)[78‑80] treatment are effective in the treatment of TMJ dysfunctions,
• Most common complications mainly occur due to arthrocentesis proved to be superior. The overall success
repeated attempt in introducing a needle into the joint rate for arthrocentesis was 87.1% and was 55.9% for
space after an unsuccessful primary needle insertion. conservative treatments. As such, the overall success rate of
In such cases, the single‑needle approach appears to the arthrocentesis procedure mentioned in the literature varies
considerably [Table 2].[53,68,91‑95]
be very suitable.[48,81]
• Fifth nerve deficit (0.1%–2.4%)[78] It is believed that age, duration of symptoms, and oral habits
• Otic injury (0.5%–8.6%)[78,79] may influence the prognosis of arthrocentesis.[95] Nitzan et al.[93]
• Mainly occurs due to close anatomical proximity of stated that after arthrocentesis, recovery of patients 40 years or
TMJ to the middle ear cavity and the cartilaginous older is usually slower, and Guarda‑Nardini et al.[96] reported
wall of the ear canal. Otologic complications include that arthrocentesis using hyaluronic acid is less effective for
perforation of the external auditory canal, the young patients under 45 years. Bruxism is thought to be one
occurrence of blood clots in the external auditory of the major contributing factors to the etiology of TMJ. In
canal, perforation of the tympanic membrane, partial the study conducted by Kim et  al.,[95] it is concluded that
hearing loss, a feeling of fullness of the ear, and clenching and bruxism reduce the therapeutic effect of the
vertigo.[30,78‑80,82‑86] arthrocentesis, and therefore, the success rate of the procedure
• Edema due to leakage of the lavage fluid (Ringer’s is low in patients with these oral habits. Alpaslan et al.[69] also
solution) into the extra‑articular space[30,37] suggested that arthrocentesis is likely to be more effective for
• Needle breakage (0.1%) within the joint[78] patients without bruxism.
• Acute joint inflammation[37]
• This may be accompanied by preauricular edema, Conclusion
redness, pain, and restricted mouth opening It appears reasonable to conclude that TMJ arthrocentesis
• Allergic reaction
is a simple, less invasive, inexpensive, and highly effective
• An allergic reaction to the anesthetics or drugs procedure. It is a method with a minimum number of
that may be administered at the end of the complications and significant clinical benefits. These features
arthrocentesis.[31,78‑80,82‑88]
• Intracranial perforation
• Intracranial perforation following the procedure is Table 2: Success rate of the arthrocentesis procedure
also a serious potential complication. Therefore, mentioned in the literature
the surgeon must be very careful during the needle Author Success rate (%)
introduction and must correct the pressure on the Murakami et al.[91] 70
needle during its insertion to avoid intracranial Hosaka et al.[92] 78.9
perforation.[30,37] Nitzan et al.[93] 91-95
• Local jaw trauma as a function of the number of repeated Murakami et al.[94] 83.8
punctures[29] Carvajal and Laskin[68] 88
• Violent vertigo, without hearing disorders[89] Al‑Belasy and Dolwick[53] 83.2
• Other complications include the following: [37] Kim et al.[95] 83.4

164 Annals of Maxillofacial Surgery  ¦  Volume 9  ¦  Issue 1  ¦  January-June 2019

 Soni: Arthrocentesis of temporomandibular joint

make arthrocentesis a valid treatment option for patients with factor‑alpha: Implications for treatment outcome. Int J Oral Maxillofac
TMJ disorders not responding to nonsurgical therapies. Surg 2000;29:176‑82.
17. Dolwick MF. Intra‑articular disc displacement. Part I: Its questionable
Declaration of patient consent role in temporomandibular joint pathology. J Oral Maxillofac Surg
1995;53:1069‑72.
The authors certify that they have obtained all appropriate 18. Alpaslan C, Bilgihan A, Alpaslan GH, Güner B, Ozgür Yis M,
patient consent forms. In the form the patient(s) has/have Erbaş D, et al. Effect of arthrocentesis and sodium hyaluronate injection
given his/her/their consent for his/her/their images and other on nitrite, nitrate, and thiobarbituric acid‑reactive substance levels in
clinical information to be reported in the journal. The patients the synovial fluid. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2000;89:686‑90.
understand that their names and initials will not be published 19. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint
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20. Dimitroulis G, Dolwick MF, Martinez A. Temporomandibular joint
Financial support and sponsorship arthrocentesis and lavage for the treatment of closed lock: A follow‑up
Nil. study. Br J Oral Maxillofac Surg 1995;33:23‑6.
21. Kaneyama K, Segami N, Nishimura M, Sato J, Fujimura K, Yoshimura H,
Conflicts of interest et al. The ideal lavage volume for removing bradykinin, interleukin‑6,
and protein from the temporomandibular joint by arthrocentesis. J Oral
There are no conflicts of interest. Maxillofac Surg 2004;62:657‑61.
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