Arthrocentesis of the temporomandibular joint: a minimally invasive therapy for temporomandibular disorders

Grossmann, Eduardo

doi:10.5935/2595-0118.20240064-en

Arthrocentesis of the temporomandibular joint is a minimally invasive procedure used to treat arthrogenic temporomandibular joint disorders (TMDs). This technique has proven to be effective and safe, gaining relevance over the years as an alternative to traditional surgical treatment. Arthrocentesis of the temporomandibular joint (TMJ) was initially described¹ in 1991, with the aim of treating severe limitation of mouth opening with pain, especially for patients with disc displacement without reduction.

This technique involves the insertion of needles² or cannulae³ into the TMJ, with the aim of promoting washing and removing inflammatory mediators, allowing the release of intra-articular adhesion and promoting an improvement in joint mobility⁴. This procedure is often used in patients who do not respond to conservative therapies, such as drugs and physical therapy⁵. Studies⁶ demonstrate that, compared to non-surgical treatments, arthrocentesis offers greater pain relief and improved joint function in short and long term.

Arthrocentesis is more effective when combined with the injection of substances such as hyaluronic acid or platelet-rich fibrin (PRF)⁷, which help promote joint regeneration and reduce or eliminate pain, in addition to promoting adequate mouth opening⁸. Furthermore, ultrasound-guided techniques have shown promising results, providing greater precision and safety in performing the procedure⁹, especially when performed in the lower compartment¹⁰.

Since its introduction, several modifications to the arthrocentesis technique have been proposed. One of these innovations is the use of single-needle arthrocentesis, which simplifies the procedure and reduces tissue trauma, while maintaining clinical efficacy¹¹. Studies¹² comparing single and double needle techniques suggest that both are effective, with a slight advantage of the double needle technique in terms of more efficient removal of inflammatory mediators. Furthermore, methods that use special devices, such as cannula with fused needles, have also been developed to simplify the procedure and improve clinical results¹³, ¹⁴.

Although arthrocentesis is a widely accepted procedure with few complications, such as facial edema, pre-auricular hematoma, VII nerve paresis or paralysis, local hemorrhage, unilateral open bite and vertigo, which are transient¹⁵, some challenges still need to be overcome. The main one is the variability in clinical results, which may be associated with factors such as the severity of the disc displacement, the time of development of the condition and the presence of severe intra-articular adhesions¹⁶. Another limitation is related to the ideal irrigation volume, since larger volumes can provide better removal of inflammatory cytokines¹⁷, such as interleukin-6, but also increase the risk of complications¹⁵.

In addition, arthrocentesis may be ineffective in cases of chronic joint dysfunctions with severe disc degeneration, where arthroscopy or more invasive surgical interventions may be necessary⁴. Long-term follow-up is essential to assess the continued efficacy of arthro-centesis and to identify possible recurrences¹⁸.

The future of arthrocentesis looks promising, especially with the advancement of image-guided techniques, such as ultrasound, which provide TMJ visualization and can improve therapeutic results¹⁹. Furthermore, combinations of arthrocentesis with platelet-rich plasma²⁰, ²¹, ²² and, mainly, with PRF⁷, are the best options for joint regeneration and to accelerate the healing process⁷, ²⁰, ²¹, ²².

REFERENCES

¹ Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg. 1991;49(11):1163-70.
² Grossmann E, Pasqual GV, Poluha RL, Iwaki LCV, Iwaki Filho L, Setogutti ÊT Single-Needle arthrocentesis with upper compartment distension versus conventional two-needle arthrocentesis: randomized clinical trial. Pain Res Manag. 2017;2017:2435263.
³ Grossmann E, Poluha RL. Double-puncture versus single-puncture arthrocentesis: a randomized controlled trial with 3 years of follow-up. J Oral Facial Pain Headache. 2022;Spring;36(2):141-6.
⁴ Nitzan DW Arthrocentesis incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am. 2006;18(3):311-28.
⁵ Monje-Gil F, Nitzan D, González-Garcia R. Temporomandibular joint arthrocentesis. Review of the literature. Med Oral Patol Oral Cir Bucal. 2012;17(4):e575-81.
⁶ Diraçoğlu D, Saral IB, Keklik B, Hanefi Kurt DT, Emekli U, Ozçakar L, Ayse KA, Aksoy C. Arthrocentesis versus nonsurgical methods in the treatment of temporomandibular disc displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108(1):3-8.
⁷ Xu J, Ren H, Zhao S, Li Q, Li C, Bao G, Kang H. Comparative effectiveness of hyaluronic acid, platelet-rich plasma, and platelet-rich fibrin in treating temporomandibular disorders: a systematic review and network meta-analysis. Head Face Med. 2023;19(1):39.
⁸ Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements. J Oral Maxillofac Surg. 2001;59(6):613-9.
⁹ Leung YY, Wu FHW, Chan HH. Ultrasonography-guided arthrocentesis versus conventional arthrocentesis in treating internal derangement of temporomandibular joint: a systematic review. Clin Oral Investig. 2020;24(11):3771-80.
¹⁰ De Nordenflycht D, Tesch RS. Advantages of ultrasound guidance for TMJ arthrocentesis and intra-articular injection: A narrative review. Dent Med Probl. 2022;59(4):647-56.
¹¹ Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(4):483-6.
¹² Şentürk MF, Tüzüner Öncül AM, Cambazoğlu M. Prospective short term comparison of outcomes after single or double puncture arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg. 2016;54(1):26-9.
¹³ Bhargava D, Thomas S, Pawar P, Jain M, Pathak P. Ultrasound-guided arthrocentesis using single-puncture, double-lumen, single-barrel needle for patients with temporomandibular joint acute closed lock internal derangement. Oral Maxillofac Surg. 2019;23(2):159-65.
¹⁴ Rahal A, Poirier J, Ahmarani C. Single-puncture arthrocentesis--introducing a new technique and a novel device. J Oral Maxillofac Surg. 2009;67(8):1771-3.
¹⁵ Vaira LA, Raho MT, Soma D, Salzano G, Dell’aversana Orabona G, Piombino P, De Riu G. Complications and post-operative sequelae of temporomandibular joint arthrocentesis. Cranio. 2018;36(4):264-7.
¹⁶ Kim YH, Jeong TM, Pang KM, Song SI. Influencing factor on the prognosis of arthrocentesis. J Korean Assoc Oral Maxillofac Surg. 2014;40(4):155-9.
¹⁷ Kaneyama K, Segami N, Nishimura M, Sato J, Fujimura K, Yoshimura H. The ideal lavage volume for removing bradykinin, interleukin-6, and protein from the temporomandibular joint by arthrocentesis. J Oral Maxillofac Surg. 2004;62(6):657-61.
¹⁸ Guarda-Nardini L, Meneghini M, Zegdene S, Manfredini D. Temporomandibular joint arthrocentesis in patients with degenerative joint disease: comparison of long-term effectiveness with or without intra-articular injection of sodium hyaluronate. J Oral Maxillofac Surg. 2020;78(9):1484.e1-1484.e8.
¹⁹ Torres-Gaya J, Boscà-Ramón A, Marqués-Mateo M, Valverde-Navarro A, García-San Segundo MM, Puche-Torres M. Temporomandibular joint arthrocentesis guided by ultrasonography: an anatomical study. J Stomatol Oral Maxillofac Surg. 2021;122(4):E27-E31.
²⁰ Cömert Kiliç S, Güngörmüş M, Sümbüllü MA. is arthrocentesis plus platelet-rich plasma superior to arthrocentesis alone in the treatment of temporomandibular joint osteoarthritis? a randomized clinical trial. J Oral Maxillofac Surg. 2015;73(8):1473-83.
²¹ Kanemitsu K, Oka S, Sato J, Segami N. Short-term treatment outcomes after arthrocentesis plus platelet-rich plasma injection for temporomandibular joint osteoarthritis: a pilot study. Cranio. 2020;38(1):68-76.
²² Raga TJ, Grande-Batalla JA, Alemany-López E, Figueiredo R, Valmaseda-Castellón E. Treatment of internal derangement of the temporomandibular joint with arthrocentesis and platelet-rich plasma injection: a randomized controlled clinical trial. J Craniomaxillofac Surg. 2019;47(5):641-6.

Publication Dates

Publication in this collection
15 Nov 2024
Date of issue
2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹ Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg. 1991;49(11):1163-70.

[2] ² Grossmann E, Pasqual GV, Poluha RL, Iwaki LCV, Iwaki Filho L, Setogutti ÊT Single-Needle arthrocentesis with upper compartment distension versus conventional two-needle arthrocentesis: randomized clinical trial. Pain Res Manag. 2017;2017:2435263.

[3] ³ Grossmann E, Poluha RL. Double-puncture versus single-puncture arthrocentesis: a randomized controlled trial with 3 years of follow-up. J Oral Facial Pain Headache. 2022;Spring;36(2):141-6.

[4] ⁴ Nitzan DW Arthrocentesis incentives for using this minimally invasive approach for temporomandibular disorders. Oral Maxillofac Surg Clin North Am. 2006;18(3):311-28.

[5] ⁵ Monje-Gil F, Nitzan D, González-Garcia R. Temporomandibular joint arthrocentesis. Review of the literature. Med Oral Patol Oral Cir Bucal. 2012;17(4):e575-81.

[6] ⁶ Diraçoğlu D, Saral IB, Keklik B, Hanefi Kurt DT, Emekli U, Ozçakar L, Ayse KA, Aksoy C. Arthrocentesis versus nonsurgical methods in the treatment of temporomandibular disc displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108(1):3-8.

[7] ⁷ Xu J, Ren H, Zhao S, Li Q, Li C, Bao G, Kang H. Comparative effectiveness of hyaluronic acid, platelet-rich plasma, and platelet-rich fibrin in treating temporomandibular disorders: a systematic review and network meta-analysis. Head Face Med. 2023;19(1):39.

[8] ⁸ Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements. J Oral Maxillofac Surg. 2001;59(6):613-9.

[9] ⁹ Leung YY, Wu FHW, Chan HH. Ultrasonography-guided arthrocentesis versus conventional arthrocentesis in treating internal derangement of temporomandibular joint: a systematic review. Clin Oral Investig. 2020;24(11):3771-80.

[10] ¹⁰ De Nordenflycht D, Tesch RS. Advantages of ultrasound guidance for TMJ arthrocentesis and intra-articular injection: A narrative review. Dent Med Probl. 2022;59(4):647-56.

[11] ¹¹ Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(4):483-6.

[12] ¹² Şentürk MF, Tüzüner Öncül AM, Cambazoğlu M. Prospective short term comparison of outcomes after single or double puncture arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg. 2016;54(1):26-9.

[13] ¹³ Bhargava D, Thomas S, Pawar P, Jain M, Pathak P. Ultrasound-guided arthrocentesis using single-puncture, double-lumen, single-barrel needle for patients with temporomandibular joint acute closed lock internal derangement. Oral Maxillofac Surg. 2019;23(2):159-65.

[14] ¹⁴ Rahal A, Poirier J, Ahmarani C. Single-puncture arthrocentesis--introducing a new technique and a novel device. J Oral Maxillofac Surg. 2009;67(8):1771-3.

[15] ¹⁵ Vaira LA, Raho MT, Soma D, Salzano G, Dell’aversana Orabona G, Piombino P, De Riu G. Complications and post-operative sequelae of temporomandibular joint arthrocentesis. Cranio. 2018;36(4):264-7.

[16] ¹⁶ Kim YH, Jeong TM, Pang KM, Song SI. Influencing factor on the prognosis of arthrocentesis. J Korean Assoc Oral Maxillofac Surg. 2014;40(4):155-9.

[17] ¹⁷ Kaneyama K, Segami N, Nishimura M, Sato J, Fujimura K, Yoshimura H. The ideal lavage volume for removing bradykinin, interleukin-6, and protein from the temporomandibular joint by arthrocentesis. J Oral Maxillofac Surg. 2004;62(6):657-61.

[18] ¹⁸ Guarda-Nardini L, Meneghini M, Zegdene S, Manfredini D. Temporomandibular joint arthrocentesis in patients with degenerative joint disease: comparison of long-term effectiveness with or without intra-articular injection of sodium hyaluronate. J Oral Maxillofac Surg. 2020;78(9):1484.e1-1484.e8.

[19] ¹⁹ Torres-Gaya J, Boscà-Ramón A, Marqués-Mateo M, Valverde-Navarro A, García-San Segundo MM, Puche-Torres M. Temporomandibular joint arthrocentesis guided by ultrasonography: an anatomical study. J Stomatol Oral Maxillofac Surg. 2021;122(4):E27-E31.

[20] ²⁰ Cömert Kiliç S, Güngörmüş M, Sümbüllü MA. is arthrocentesis plus platelet-rich plasma superior to arthrocentesis alone in the treatment of temporomandibular joint osteoarthritis? a randomized clinical trial. J Oral Maxillofac Surg. 2015;73(8):1473-83.

[21] ²¹ Kanemitsu K, Oka S, Sato J, Segami N. Short-term treatment outcomes after arthrocentesis plus platelet-rich plasma injection for temporomandibular joint osteoarthritis: a pilot study. Cranio. 2020;38(1):68-76.

[22] ²² Raga TJ, Grande-Batalla JA, Alemany-López E, Figueiredo R, Valmaseda-Castellón E. Treatment of internal derangement of the temporomandibular joint with arthrocentesis and platelet-rich plasma injection: a randomized controlled clinical trial. J Craniomaxillofac Surg. 2019;47(5):641-6.