CC
A 35-year-old female reports a restricted mouth opening, which has not responded any previous treatments, and an intermittent pain 5 of 10 during function and 2 of 10 while resting on her right temporomandibular joint (TMJ) area.
HPI
The patient is a lecturer and reports a 2-year history of right-sided jaw pain that sometimes gives trouble with chewing. The pain is worsening and is severe enough to limit her diet to soft foods and restrict her speaking and lecturing. She also reports a previous asymptomatic right-sided jaw click, present for many years, which stopped about the time she developed the right-sided restriction and pain. She has occasional neck tension, ringing ears, and a change in hearing.
PMHX/PDHX/medications/allergies/SH/FH
The patient’s past medical history is noncontributory. She is allergic to aspirin. She uses over-the-counter vitamin supplements. She is aware of a nighttime clenching issue. Her dentist fabricated a nightguard, which she has been using for a long time. She has been having physiotherapy, massage therapy and acupuncture, self-treatment such as warm compresses, and diet modification. None could provide major help for jaw opening or pain.
Examination
General. The patient is a well-developed and well-nourished female in no apparent asymmetry.
Maxillofacial. There is tenderness on palpation of the masseter, temporalis, sternocleidomastoid, and trapezius muscles bilaterally. The patient has some restriction and tension with movement of her neck. She has right capsular tenderness on preauricular and endaural palpation. There is no clicking or crepitus on either palpation or auscultation of the TMJs. The patient has a maximal interincisal opening of 25 mm, with deviation to the right and moderate pain. Her lateral excursive movements are 8 mm to the right and a painful 4-mm movement to the left (suggesting decreased right TMJ condylar translation). Protrusive movement is 7 mm and deviates to the right with pain. She reports pain in the right joint when biting on a tongue blade placed between the molar teeth on the left side (positive Mahan test result, suggesting a right intracapsular source of pain). Intraoral examination reveals scalloped tongue margins and linea alba presence bilaterally. Bilateral lateral and medial pterygoid muscles are also tender during examination (Stelzenmueller W, Umstadt H, Weber D, 2016).
A panoramic radiograph reveals no osseous abnormalities but a deep articular fossa and a steep anterior wall angle on the right TMJ. Magnetic resonance imaging (MRI) reveals right anterior disk dislocation without reduction (ADDwoR) and left anterior disk dislocation with reduction (ADDwR) ( Fig. 68.1 ). Subtle effusion on the left TMJ and mild effusion on the right TMJ are also reported.
Assessment
Bilateral myofascial pain dysfunction, painful ADDwoR of the left TMJ with effusion, Wilkes stage III (see Wilkes staging in the section on internal derangement of the temporomandibular joint earlier in this chapter), and (ADDwoR) of the right TMJ.
Treatment
The patient is instructed on the first line of treatment both for myofascial pain dysfunction (MPD) and internal derangement of the TMJ, which is conservative management. This may include an occlusal splint, nonsteroidal antiinflammatory drugs (NSAIDs) with or without muscle relaxants, extraoral heat or ice compression, a nonchewing diet, physical opening exercises, and massage therapy. After 4 weeks, her follow-up revealed no improvement achieved with conservative techniques. Therefore, next-step interventions with minimally invasive techniques should be considered.
The minimally invasive surgical treatments are arthrocentesis and arthroscopy (Al-Moraissi E, 2014), (Murakami K, 2022). Possible association of MPD should always be considered as a contributing condition and be treated simultaneously with those surgical methods. Failure of one or both surgical procedures may necessitate an open joint procedure, such as arthroplasty. All surgical procedures should be reserved for intracapsular sources of pain or limited function.
Arthrocentesis
The first-line surgical treatment choice for acute or chronic closed lock ADDwoR, arthralgia, anchored disk in the early stages, synovitis, and capsulitis tat are not responsive to the conservative treatment, and initial degenerative changes of the TMJ is arthrocentesis (Nitzan DW, Naaman HL, 2022). Mostly the superior joint space (rarely the inferior joint space) is distended and irrigated, and usually some medications or biomaterials are placed into the joint cavity. A 0.9% saline solution or more preferably lactated Ringer’s (LR) solution is used for the distension and irrigation of the upper joint space. By applying the LR solution with pressure, the distension can be achieved to increase the vertical joint space. This vertical space improvement allows the articular disk to return its original place. With the irrigation, removal of inflammatory molecules and degraded loose proteins and disruption of immature adhesions causing the stuck disk can be achieved. The procedure may result in an improvement in pain and range of motion clinically. Additionally, reduction of the frequency of clicking can also be expected. It should always be supported with the continuation of conservative treatments postoperatively. This can be accomplished under local anesthesia or sedation. Contraindications for TMJ arthrocentesis are fibrous and osseous ankylosis, local infectious or malignancies, multiple previous attempts, and psychiatric illness (Nitzan DW, Naaman HL, 2022).
This method can be done with double needles as first described by Murakami et al. (K Murakami, 2022; KI Murakami, Iizuka, & Matsuki, 1987) or single special needle which has two lines inside, one for fluid entry and one for exit. There is no evidence that dual-puncture is superior to single-puncture arthrocentesis (Şentürk, Yazıcı, & Gülşen, 2018). The following case demonstrates the double-puncture technique. Examination is repeated to identify the muscles for botulinum toxin (BTX) treatment. Initially, 90 units of BTX is administered to the temporalis, masseter, and lateral and medial pterygoid muscles bilaterally. The surgical field is prepared and draped. The landmarks are identified by drawing a line extending from the superior aspect of the tragus to the lateral canthus of the eye. The A point, 10 mm anterior from the tragus and 2 mm inferior along the tragocanthal line, is marked and serves as the initial puncture site. The B point is 20 mm anterior of the tragus and 10 mm inferior along the tragocanthal line and serves as the second puncture point ( Fig. 68.2 ). Palpating the TMJ while opening and closing to figure out the joint localization and anatomy is a key for proper insertion of the needles besides the A and B points. One percent plain lidocaine is used for local infiltrations to superficial tissues and intra- and periarticular spaces. A mouth probe or a bite block would be useful to keep the mouth open to increase the joint surface for needle entries. An 18-gauge needle is connected to an irrigation tubing and flushed with LR solution and then is inserted into the superior joint space through the A point. To distend the joint space with hydraulic pressure, 2 to 5 cc LR solution is applied using a 60-mL syringe filled with LR. A second 18-gauge needle can then be inserted into the joint space via point B. Successful placement of the two needles is confirmed by the outlet of LR solution from the second needle. The joint space is then irrigated with 120 to 200 mL of LR solution ( Fig. 68.3 and 
). On completion of the irrigation, one needle can be removed, and an adjuvant medication (e.g., hyaluronic acid or corticosteroid) can be injected into the joint space through the remaining needle. The mandible is then manipulated by closing and opening maximally. The remaining needle is then removed, and pressure is applied to the injection site for 2 to 3 minutes. Postoperative pressured compression, NSAIDs, a soft diet, and occlusal splint use are suggested. Starting by the next day, mouth-opening exercises should be instructed. Two weeks later, the patient had a 36-mm interincisal maximum mouth opening and complete elimination of the pain during function.
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