Key points
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Arthrocentesis is a minimally invasive option for anterior disc displacement without reduction, symptomatic anterior disc displacement with reduction, early degenerative joint disease, and joint arthralgia refractory to conservative measures.
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Single-port and dual-port techniques yield comparable clinical outcomes; selection is guided by joint anatomy, surgeon experience, and therapeutic objectives.
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Adjunctive intra-articular therapies (eg, platelet-rich plasma and hyaluronic acid) may improve pain and functional recovery following arthrocentesis.
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Complications are uncommon when anatomic landmarks are respected, and lavage pressure is controlled.
Abbreviations
| TMDs | temporomandibular joint disorders |
| TMJ | temporomandibular joint |
Introduction: nature of the problem
Temporomandibular joint disorders (TMDs) represent a broad spectrum of conditions involving the temporomandibular joint, the muscles of mastication, and associated structures. Common intra-articular pathologies include anterior disc displacement and degenerative joint disease. TMDs affect an estimated 5% to 12% of the general population, with a higher prevalence among women between 20 to 40 years of age. Patients may present with
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Joint arthralgia with associated myofascial involvement and/or headache
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Mechanical symptoms (eg, clicking, popping, intermittent locking, or crepitus)
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Functional limitations in mastication, range of motion, and speech
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Otologic symptoms (eg, otalgia, aural fullness, and tinnitus)
Chronic or refractory symptoms may contribute to psychosocial sequelae, including sleep disturbances, anxiety, and depression.
Initial management of TMDs is typically conservative. First-line interventions include oral appliances, pharmacologic therapy (eg, nonsteroidal anti-inflammatory drugs, muscle relaxants), physical therapy, and behavioral modifications.
Arthrocentesis of the temporomandibular joint aims to reduce pain and improve joint mobility through mechanical lavage and hydraulic lysis of adhesions associated with intra-articular inflammation. ,,,, First described by Nitzan in 1991 as a less-invasive alternative to arthroscopy, arthrocentesis has since evolved into a well-established intermediate intervention for patients who fail conservative therapies and do not require arthroscopic or open surgical intervention.
Surgical technique
Preoperative planning
Successful temporomandibular joint arthrocentesis begins with careful patient selection and diagnostic evaluation. Ideal candidates include individuals with the following:
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Acute or subacute intra-articular arthralgia
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Anterior disc displacement without reduction
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Inflammatory arthropathies
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Early degenerative joint disease
Arthrocentesis is generally less effective in patients with end-stage degenerative joint disease (eg, advanced osseous remodeling and disc perforation), in the presence of active joint infection, or when symptoms are primary myofascial in origin.
Preoperative MRI of the temporomandibular joint (TMJ) remains the gold standard for evaluating intra-articular pathology. MRI delineates disc position and morphology, joint effusion, capsular thickening, adhesions, and retrodiscal tissue integrity. The choice of lavage technique (single-port vs dual-port) and the selection of adjunctive injectate should be guided by joint anatomy, surgeon experience, and specific therapeutic objectives ( Table 1 ).
Table 1
Summary of clinical scenarios and recommended management strategies for temporomandibular joint arthrocentesis
| Clinical Scenario | Recommended Management |
|---|---|
| Mild symptoms responsive to conservative therapy (eg, oral appliance, nonsteroidal anti-inflammatory drugs, physical therapy, behavioral modification) | Continue nonoperative management |
| Persistent intra-articular pain/limited opening despite appropriate conservative therapy (typically ≥3 mo) | Consider arthrocentesis |
| Predominantly myofascial symptoms without clear intra-articular pathology | Optimize conservative and myofascial-directed therapy before minimally invasive intervention |
| Active joint infection, fibrous or osseous ankylosis, suspected neoplastic pathology, or advanced degenerative joint disease with severe structural changes | Arthrocentesis generally not recommended; consider open surgical management when appropriate |
| Need for extensive lavage, hydraulic lysis of adhesions, or treatment of significant inflammatory burden | Dual-port arthrocentesis favored |
| Limited joint access, technically difficult anatomy, or primary objective of intra-articular medication delivery | Single-port arthrocentesis favored |
| Inflammatory arthropathy or early degenerative joint disease with persistent symptoms following lavage | Consider adjunctive intra-articular therapy (eg, corticosteroid, PRP, HA) |
| Recurrent symptoms or limited improvement following prior arthrocentesis | Repeat arthrocentesis or arthroscopy may be considered based on imaging findings and symptom severity |
| Persistent structural pathology, advanced degenerative disease, ankylosis, or failure of minimally invasive management | Consider arthroscopy or open surgical intervention |
Abbreviations: HA, hyaluronic acid; PRP, platelet-rich plasma.
Preparation and patient positioning
The patient is initially placed in a supine position with the head slightly elevated. The head is rotated contralaterally to the side being treated to optimize exposure of the preauricular region. Standard antiseptic preparation and sterile draping of the operative field are performed ( Figs. 1 and 2 ). Arthrocentesis can be performed under local anesthesia alone, local anesthesia with intravenous sedation, or general anesthesia, based on patient comfort and surgeon preference. If a nasal canula is placed during sedation, then the tubing is positioned and taped superior to the surgical field.
Dual port procedure set up.
Patient prep under sedation. Tape nasal canula above the field.
Local anesthesia typically involves local infiltration at the planned needle entry sites. The auriculotemporal nerve and joint capsule are anesthetized ( Fig. 3 ). Care should be taken to prevent excessive soft tissue distortion, which may obscure anatomic landmarks and compromise accuracy.
Local infiltration.
Surgical approach
Accurate identification of surface anatomy is critical for safe and effective temporomandibular joint arthrocentesis. The canthotragal (Holmlund-Hellsing) line ( Fig. 4 ) serves as the primary axis, extending from the lateral canthus to the midpoint of the tragus. Palpation of the preauricular region during mandibular translation can assist in confirming condylar position and joint orientation. Appropriate landmark identification and entry angle control can minimize the risk of fluid extravasation, neurovascular injury, and improve lavage efficiency.
Canthotragal line, single port posterior insertion.
Surgical procedure
Dual-port (dual-needle) arthrocentesis
The initial puncture is performed using a 19 to 21 gauge needle attached to a 3-mL syringe containing lactated Ringer’s solution. The needle is inserted at the posterior entry point, located approximately 10 mm anterior to the tragus and 2 mm inferior to the canthotragal line, to access the superior joint space ( Fig. 5 ). Needle is advanced anteriorly and superiorly toward the glenoid fossa. The trajectory of the needle is approximately 45° medially relative to the sagittal facial plane. The depth varies depending on the patient’s tissue thickness but is typically not deeper than 20-25 mms. It is helpful to have an assistant slightly protrude and open the mandible, as the operator palpates with their nondominant hand the condylar translation during the movement. The needle is advanced slowly and gently to allow for tactile discrimination as the tip of the needle comes into contact with the temporal bone at which point the needle is slightly withdrawn and repositioned to enter more medially into the superior joint space. A sudden reduction in in tissue resistance and a subtle pop is appreciated. Correct needle placement is confirmed by aspiration of clear synovial fluid or negative pressure. A pumping maneuver, in which a small volume of fluid is injected and aspirated, producing visible fluid movement within the syringe can be observed. This maneuver should also result in observable mandibular movement ( Fig. 6 ). Subsequently, 1 to 2 mL of solution is injected to distend the joint space. Excessive resistance during injection may suggest extra-articular location, intracapsular fibrosis or some form of obstruction.
Posterior point insertion.
Verifying placement with gentle mandible manipulation.
A second needle is then inserted at the anterior entry point, approximately 20 mm anterior to the tragus and 10 mm inferior to the canthotragal line, without attachment to a syringe ( Fig. 7 ). The vector is directed posteriorly and slightly superomedial. The depth is slightly less—around 15 to 22 mm. Proper positioning is confirmed by spontaneous efflux of fluid from the needle hub. Failure to obtain outflow should result in repositioning the needle before proceeding with irrigation. Once a bidirectional outflow has been established, extension tubing is attached, and joint lavage is performed by infusing 150 to 300 mL of solution, depending on the underlying pathology and the severity of the inflammatory disease, through the posterior needle while allowing passive drainage through the anterior needle ( Figs. 8 and 9 ). Lavage is conducted using gentle, continuous pressure, ensuring that fluid inflow corresponds with outflow and that no extravasation into surrounding tissues occurs. Adequate lavage is characterized by low-resistance inflow and continuous outflow with absence of periarticular swelling. Initial flow may be blood-tinged and an endpoint is generally reached when outflow is visibly clearer with less particulate. An endpoint can be established not just thru the irrigation volume and appearance of the fluid, but with functional improvement observed in increased maximal opening or translation, reduction in joint resistance and smoother excursive movements.
