Single puncture for TMJ arthrocentesis: An effective technique for hydraulic distention of the superior joint space.

Temporomandibular joint arthrocentesis is a method of flushing out the synovial fluid that is currently performed by providing a double puncture to the upper joint space. The traditional 2-needle technique has some restrictions, such as the difficulty in performing it in the presence of intra-articular adherences and in the female patients, because the space is very small. The adoption of a single-needle for fluid injection might have some advantages with respect to the traditional 2-needle approach in terms of easily, time of execution and tolerability. We describe a single needle technique and we recommend the use.

INTRODUCTION

Temporomandibular joint disorder (TMJ-D) comprehends various pathologic processes.

Usually they have a clinical manifestation of masticatory muscle pain, joint sounds and palpable interferences, articular degeneration, and hypomobility; those signs and symptoms can be found either simultaneously or isolated.

There is no general consent of the best treatment modality, for an acute onset disk displacement with the patient unable to open his mouth (closed lock), and it is mostly based on the clinical experience of the professional.[12]

Arthrocentesis and hydraulic distention of the superior joint space is considered a minimally invasive treatment modality, with low morbidity rates and highly effective in the treatment of patients with TMJ Closed Lock [Figure 1], however the standard technique uses two punctures, in and out port, allowing low pressure irrigation of the superior joint space.

Figure 1

Acute closed lock with 23 mm of mouth opening

The Authors objective is to describe a single puncture technique to irrigate and cause the distention of the superior joint space under high pressure to mobilize the articular disk and release adhesions with better success rates broadening the indications for arthrocentesis. This technique is different that was describes recently by Guarda-Nardini[3] et al. (2008) because we indicate the single needle for obtaining a higher pressure in the upper TMJ space.

TECHNIQUE

Under local anesthesia the first step is to locate the superior joint space during the anesthesia, introduce the needle in the superior joint space, and inject 2 ml of the anesthetic solution [Figure 2]; at that time, usually the patient refers a forward pressure in the mandible confirming that the needle is in the desired location. Next, inject the maximum amount of saline solution in the superior joint space (1) ask the patient to protrude and lateralize the mandible in the highest range that he can. Then (2) ask the patient to try to close his mouth. At that time we disconnect the syringe from the needle (3) and the saline solution will be ejected from the syringe. In the sequence (4) introduce 3 ml of saline solution in the superior joint space raising the intra articular pressure and ask the patient to slowly open the mouth and simultaneously introduce more saline until reach 4 to 5 ml in the totally, disconnect the syringe from the needle and ask the patient to close his mouth causing the saline to be ejected from the needle [Figure 3]. We repeat step (1) two (4) three times and manipulate the patient's mandible in forced maximum opening. No medication is inserted in the articular upper space. We have been using this technique with success since 2001 and recommend its use [Figure 4].

Figure 2

Needle positioned in TMJ supradiscal space. Note drainage of anesthetic solution plus synovial fluid

Figure 3

Drainage under pressing of saline solution by a single puncture

Figure 4

Marked improvement of mouth opening after arthrocentesis with 46 mm