Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. 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. The technique of arthrocentesis is discussed together with the indications and contraindications of the procedure. Further, the presentation includes modifications of the standard technique.

2. Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Anatomical landmarks for needle entry

10. 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)

12. 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)

13. 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

14. In 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

15. 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

16. Double-needle cannula
Double-needle cannula

18. 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.

19. 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 the
temporomandibular 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 for
temporomandibular joint arthrocentesis: clinical report. Eur J Dent; 1:179,
2007.
10. Rehman KU, Hall T. Single needle arthrocentesis. Br J Oral Maxillofac
Surg; 47: 403, 2009.