Abstract
Arthrocentesis is a technique used for lavage of the inflammatory content of the supradiscal space and lysis of the fibrous strands attaching the articular disc to the superior compartment of the temporomandibular joint (TMJ). The most widely accepted and classical manner in which this technique is performed is through two-needle access to the superior joint space. Nevertheless, it has been reported in the literature that this technique is challenging and has several limitations. Thus, the use of a single-puncture approach has been proposed, which represents a less traumatic and easier to perform technique. The single-puncture approach may have several advantages over the classical two-needle approach in regard to completion time, tolerability, stabilization of the needle, and retention of the intra-articular medication. A single-puncture technique is described herein, which uses an intravenous catheter to provide simultaneous inflow/outflow for low or high volume irrigation of the TMJ. The feasibility and low cost of this technique are primary advantages; peripheral intravenous catheters are one of the most widely used devices for vascular access in the primary and hospital healthcare settings.
The arthrocentesis procedure was first described in the mid 1960s as a therapeutic and diagnostic procedure for acute monoarthritis of the knee and other joints. In 1991, Nitzan et al. described arthrocentesis of the temporomandibular joint (TMJ) as an effective non-surgical method to treat TMJ closed lock. Since then, arthrocentesis has become a popular and widespread technique for lysis and lavage of the TMJ.
Over the years, many techniques using different anatomical landmarks have been described for lysis and lavage of the TMJ. The most widely accepted and classical manner in which this technique is performed is through two-needle access to the superior joint space. Nevertheless, it has been reported in the literature that this technique is challenging and has several limitations. Thus, the use of a single-puncture approach has been proposed, which represents a less traumatic and easier to perform technique. Guarda-Nardini et al. were the first to describe a single-needle arthrocentesis technique for both fluid injection and fluid aspiration. These authors stated that this modified technique may have several advantages over the two-needle approach in regard to completion time, tolerability, stabilization of the needle, and retention of the intra-articular medication, and showed that the single-needle approach did not differ from the two-needle protocol in relation to the clinical outcome.
Technique
The peripheral venous catheter is the most commonly used vascular access system in medicine. A variation of the TMJ arthrocentesis technique reported by Öreroğlu et al. is described, with a single-puncture 20-gauge 30-mm or 32-mm intravenous catheter replacing the two concentric needles.
An auriculotemporal nerve block is performed with local anaesthetic, as well as a subcutaneous anaesthetic block under the skin near to the capsule and puncture zone. The following lines should be drawn prior to the disinfection of the area and insertion of the intravenous catheter, in order to ensure a non-traumatic placement. First, a line should be drawn from the external canthus to the tragus (Holmlund–Hellsing line). Then in open mouth position, the contour of the inferior border of the glenoid fossa should be marked. Next, the puncture site should be outlined on the depression formed between the inferior border of the glenoid fossa and the lateral pole of the condyle. Most of these anatomical landmarks are in agreement with the puncture site as described by Nitzan et al. Disinfection of the pre-auricular area is done with an antiseptic swab, and then the intravenous catheter is inserted in a partially open mouth position. The correct needle placement can be corroborated by the translational movements of the condyle ( Fig. 1 ). Once the intravenous catheter has been placed correctly in the supradiscal space, 3–5 ml of irrigation solution are injected under pressure into the TMJ, until resistance is felt and there is difficulty injecting any further irrigation solution. Full distension of the capsule should be achieved, to allow adherences anchoring the disc to the supradiscal compartment to be broken ( Fig. 2 ).
