Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2019; 64: 90–95

doi: 10.1111/adj.12665

Arthrocentesis in the management of internal derangement

of the temporomandibular joint
KA Briggs,*† O Breik,†‡ K Ito,§ AN Goss¶
*Oral & Maxillofacial Surgery Unit, Gloucester Royal Hospital, Gloucester, UK.
†Oral & Maxillofacial Surgery Unit, The University of Adelaide, Adelaide, South Australia, Australia.
‡Oral & Maxillofacial Surgery Unit, Royal Derby Hospital, Derby, UK.
§Consultant Oral & Maxillofacial Surgeon, Nihon University School of Dentistry at Matsudo, Chiba, Japan.
¶Emeritus Professor, The University of Adelaide, Adelaide, South Australia, Australia.

ABSTRACT
Background: Temporomandibular disorders (TMD) cover a wide spectrum of disorder; myalgic, arthralgic and psy-
chogenic. The procedure of TMJ arthrocentesis has a role in managing patients with arthralgic pain and limitation if
they fail to respond to non-surgical therapy.
Method: The patient records of a single private specialist OMS were searched over the 9-year period of 2006–2014 to
identify patients who had arthrocentesis as part of their multidisciplinary management. The detailed demographic, diag-
nosis, pre and post arthrocentesis procedure were identified and put on a database. Appropriate statistics were per-
formed.
Results: Seventy-six patients had 115 arthrocentesis procedures performed in the study period. Fifty of 76 had improve-
ment in their pain and 16 of 41 had an increased jaw opening of more than 10 mm. There were no complications or
morbidity. Analysis of patient variables generally showed no correlations.
Conclusions: Temporomandibular joint arthrocentesis has a role in the multidisciplinary, multimodality treatment of
arthralgic TMD.
Keywords: Arthrocentesis, internal derangement, temporomandibular disorders.
Abbreviations & Acronyms: MRI = magnetic resonance imaging; OPG = orthopantomogram; TMD = temporomandibular disorders;
TMJ = temporomandibular joint; VAS = visual analogue score.
(Accepted for publication 6 November 2018.)

Intra articular cases of TMD are about 10% of the

INTRODUCTION
total TMD population. They are characterized by
Temporomandibular joint disorders (TMD) are a com- pain, particularly on talking and chewing. The joint is
plex series of presentations in the community. Many tender to palpation. Jaw opening is limited with click-
people remain undiagnosed and put up with the symp- ing or catching or an inability to fully open. Plain
toms or are unaware that treatment can be provided. radiographs such as orthopantomograms (OPGs) are
On presentation to a clinician the first step is to deter- often normal but more detailed investigations such as
mine whether their presenting orofacial pain is a TMD magnetic resonance imaging (MRI) show internal
or other pathology. With TMD the important step is to derangement with or without intra articular effusion
determine whether it is primarily muscular or whether or degenerative osteoarthritic changes. These internal
there is an intra articular problem. It is also essential to derangements can be readily classified in accordance
determine whether the TMD is isolated or is part of an with the Wilkes classification.3
overall musculo skeletal problem such as fibromyalgia Initial management of intra articular TMD should
or rheumatic or osteoarthritic joint disease. Psychologi- follow the standard non-surgical treatment of all types
cal factors also require investigation as they profoundly of TMD, namely – rest, analgesics, exercise and bite
impact on the presentation and outcome.1 These points splints. Sometimes these are effective but in particular
have been fully presented in the recent review article on with acute pain and limitation these non-surgical
TMD in the ADJ Supplement “Contemporary Oral & methods are difficult to implement as they are painful
Maxillofacial Surgery.”2 and do not result in resolution. In these cases the
90 © 2018 Australian Dental Association
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Temporomandibular arthrocentesis

simple minimal invasive procedure of temporo- & Maxillofacial Surgeon with wide orofacial pain
mandibular joint arthrocentesis is indicated.4–7 experience over a 9-year period (2006–2014). The
The corresponding author of this paper has a 50- precise indications for arthrocentesis are pain well
year clinical and research interest in TMD.8,9 Initially localized to the temporomandibular joint with or
the clinical experience was in an academic teaching without limitation of jaw opening. The presentation,
hospital environment with involvement in chronic non-surgical management before and after arthrocen-
pain10 and psychological management of pain.11–13 tesis and any subsequent arthrotomy procedures were
Concurrently detailed animal experiments were con- documented and analysed.
ducted on temporomandibular joint pathology and
surgical reconstruction.14,15 These involved the devel-
METHOD
opment of close multidisciplinary linkages with gen-
eral dentists, physiotherapists, psychologists and Patients who had a temporomandibular arthrocentesis
chronic pain specialists. This multidisciplinary procedure in the 9 year period, 2006–2014, were iden-
approach has been transferred to a private speciality tified from operation records from over 2000 TMD
setting. The patients were managed in accordance patients referred to the senior author for diagnosis and
with a TMD algorithm.16 (Table 1) management of TMD with approximately 25% being
This study looks at a retrospective consecutive ser- primarily arthrogenous. The full demographic and
ies of patients managed by a single experienced Oral management details, both pre and post arthrocentesis

Table 1. Temporomandibular disorders algorithm

1. Accurate Diagnosis Key

2. Diagnosese should be reviewed each visit
3. You must know the diagnosc modifiers* - local v systemic
- macrotrauma
- previous chronic pain
Options

Myalgic Psychologic Arthalgic

OPG Listen OPG

Easiest or most Facts know but ignored: Life events Internal derangement
difficult or abnormal illness, behaviours? Synovial Pathology

Non surgical Rx Non surgical Rx Non surgical Rx

Exercises, physio, exercises, physio, exercises, physio,
splints, pharmacology splints, pharmacology splints, pharmacology

Surgery indications, joint

related, non surg failed, no
med contra, no
psychological
contraindication

Continue non- Chronic pain, multidisciplinary, Arthrocentesis

surgical treatment, psych, pharmacology, surgical Arthroscopy
using what helped revision of iatrogeneris Arthrotomy
so far (‘last op’)

4. Treatment is aimed at reducon in intensity and frequency not at “cure”.

- So pain does not dominate daily existence.
5. If treatment fails either (a) Your diagnosis was wrong.
And/or (b) Your treatment was wrong rather than
“patient’s fault” .

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KA Briggs et al.

procedure, were transferred to a customized database Table 2. Patient demographics

with manual cross checking as required.
Patients 76
A full clinical work up including medical psychologi- Male 14
cal and orofacial aspects was performed. All had basic Female 62
OPG and review of any other images which had been Age 45 (17–74) years
Referral source
taken prior to referral. MRI and/or computer tomogra- Dental 30
phy views were not routinely obtained but ordered if Medical 46
clinically indicated. Post arthrocentesis, all non-respon- Duration of symptoms 4.2 (.2–25) years
Diagnosis
sive cases were reworked up with full imaging. Internal derangement
Pain was clinically assessed by matching the Wilkes 2 (pain & clicking) 25
patients pain report to a visual analogue score (VAS) Wilkes 3 (closed lock) 34
Wilkes 4 & 5 (pain, locking 14
score, with a VAS report of pain over 7 being the and osteoarthritis)
indication for arthrocentesis after failure to respond Rheumatoid arthritis 3
to non-surgical treatment. Jaw limitation was assessed Modifying factors
High stress life events 33
by interincisal measurement in millimetres. Similar Generalized arthritis 20
assessments were made post arthrocentesis. Jaw trauma 18
A standardized arthrocentesis procedure was per- Follow up 5 (1–10) years
formed by a single surgeon.17 Following full informed
consent of the procedure, the patient was admitted to
Table 3. Pre arthrocentesis management
a single private hospital in Adelaide with intravenous
sedation by a specialty anaesthetist. Two millilitres of Non-surgical 72
Marcain was injected into the superior joint space fol- Home exercises 57*
Occlusal splint 30*
lowed by insertion of two needles into the superior Physical therapy 27*
joint space. A minimum of 100 mL of isotonic saline Pharmacological 22*
was flushed through the joint space from one needle No non-surgical treatment prior 4
Post arthrotomy 5
(input) to the other (output). If it was not possible ini-
tially to get a good flow then the joint space was *Most had more than 1 treatment.
pumped until a good flow was obtained. If limited,
the jaw was manipulated until an interincisal opening cent of the primarily arthralgic patients seen. Their
of 40 mm or greater we achieved. Two to four ml of full demographics and diagnosis is presented in
triamcinolone 40 mg was injected into the joint space Table 2.
and lateral ligament and a small 1 cm circular ban- Seventy-two of the 76 patients had received and
dage placed over the injection site. The patient was failed appropriate non-surgical treatment prior to pro-
returned to the recovery room for 2–4 h of monitor- ceeding to arthrocentesis. The four who proceeded
ing and then discharged home. All patients were given directly to arthrocentesis without prior non-surgical
a review appointment and followed up as needed. treatment all had acute closed locks and had consider-
The outcome was monitored by the patient’s subjec- able pain and limitation (Table 3). There were five
tive report of pain and interincisal measurement. Ongo- patients, who in the past had an open surgical proce-
ing advice about future non-surgical management was dure mainly by another surgeon, who had ongoing
offered. Patients who did not respond well either in limitation. These were all tried on non-surgical treat-
terms of pain or limitation were offered repeat arthro- ment first but then had arthrocentesis and manipula-
centesis, chronic pain management or arthrotomy. tion to encourage more opening.
Data analysis was performed using Strata IC A total of 115 joints had an arthrocentesis with an
Software (Version 15 for Mac Apple Inc Cupertino, even spread of unilateral and bilateral procedures.
California USA). Chi square tests were used for analysis Four patients, with five joints, who had incomplete
with the alpha level set at 0.05. Odds ratios were calcu- improvement after the first procedure had a repeat
lated to compare variables as required. procedure at 3 months, with good effect. A further
The study was performed in accordance with retro-
spective case note audit ethical requirements of the
Table 4. Arthrocentesis procedures
Central Northern Health Commission of South
Australia. Unilateral left 25
Unilateral right 24
Bilateral (27 patients) 54
Repeat
RESULTS Within 3 months 5
After 12 month 7
Seventy-six patients had an arthrocentesis procedure Total procedures 115
in the study period which represents less than 15 per
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Temporomandibular arthrocentesis

Table 5. Outcome of first arthrocentesis arthritis was performed but with no statistical
significance.
Pain 76 Patients
Resolution immediate 22
Resolution in 3 months 50
Pain same 25 DISCUSSION
Pain worse 1
Limitation 41 Patients This study shows that the simple minimally invasive
Less than 5 mm improved 14 surgical procedure of temporomandibular joint arthro-
5–10 mm improved 11 centesis does help resolve the pain for 50 of 76
11–15 mm improved 7
16–20 mm improved 5 patients and limitation for 16 of 41 patients who had
21–25 mm improved 2 reduced range of jaw movement. All of these patients
25 mm greater 2 with arthralgic TMD had failed to respond to conven-
tional non-surgical treatment often after several years
of ongoing pain and disability. With those patients
Table 6. Management of patients with ongoing who failed to respond, the diagnostic information was
symptoms carefully re-evaluated and further non-surgical, repeat
arthrocentesis, arthrotomy or chronic pain manage-
Repeat arthrocentesis ment offered. No patient had any complications from
At 3 months 4
After 12 months 5 the arthrocentesis procedure.
Arthrotomy 11 This study also confirms that management of TMD
Chronic pain management 6 requires multidisciplinary skills and experience on the
part of the treating clinician or in their referral base.2
No one diagnosis or treatment resolves all cases of
five patients with seven joints had done well after the TMD. Indeed, a common fault amongst dentists is to
first procedure but represented more than 12 months consider all TMDs the same, namely muscular para-
later with pain. Usually there was an identifiable event function and the only treatment is bite splints. There
such as trauma or high stress life events which retrig- is overwhelming evidence that this is not so. Diagnos-
gered the pain (Table 4). tically although muscular types are most common,
The outcome is presented in Table 5. Fifty of 76 there are several subgroups.1 The treating clinician
were pain free by 3 months post procedure. Twenty- must know the general musculoskeletal state, particu-
five of 76 had no appreciable improvement in pain larly of the neck.18 Arthralgic or joint problems
and one felt the pain was made worse. That patient involve about 15% of all TMD patients presenting
had significant psychological issues and was treated for treatment and again one must be aware of the
with a cryoneurotomy procedure and chronic pain precise type of intra articular pathology, whether
management. there has been trauma to the jaw, either macroscopic
Forty-one patients had jaw limitation of less than or parafunctional. One also needs to know what
30 mm interincisal opening. All had some improve- other pathology is present in other joints. The tem-
ment although it was less than 5 mm in 14 of 41 and poromandibular joint (TMJ) can be involved in gener-
only 16 of 41 had more than 10 mm improvement. alized synovial pathology, a the wide range of
All patients were reviewed at 10 days post surgery connective tissue disorders and rheumatoid pathology.
and advised to continue with further non-surgical Understanding of the patient’s psychological state is
treatment. Forty-seven of 76 did so but 29 of 76 did fundamental to pain. Numerous studies show it is the
not continue with non-surgical treatment as their pain key determinant of the outcome.11–13 There is a group
and limitation had resolved. All were offered further of patients with atypical facial pain where their pain
appointments and were advised in writing to return if experience is not congruent with known anatomical
they had problems. On completion of the study the and pathologic findings to the unwary, this can mimic
average time since the patient had last been seen was muscular types of TMD.19 Although widely used, the
7 years (range 2–12 years). evidence that bite splints are effective, is tenuous.
Patients with ongoing symptoms after arthrocentesis Studies are either short, not randomized or placebo
were carefully reviewed (Table 6). They were offered controlled.20,21 Inadequate definition of patient popu-
ongoing further non-surgical treatment, chronic pain lation, therapies, control treatments, follow ups and
referral (6 patients), repeat arthrocentesis (9 patients) monitoring of patients have led to unclear results.22
or open surgical procedures (11 patients). The most promising line of research into the effects of
Detailed statistical assessment of pair variables, splints is the analysis of intra articular temporo-
including age, gender, referral source, duration of mandibular joint pressure.23 It increases on biting, is
symptoms, diagnosis, pain resolution, limitation reduced at rest and by a bite splint. Regrettably this
resolution, trauma, high stress levels and generalized surgical research is not well-known in the dental
© 2018 Australian Dental Association 93
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KA Briggs et al.

literature and has not been replicated in humans. We 4. Al Moraissi EA. Arthroscopy v. arthrocentesis in the manage-
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This study has the limitation of retrospective analy- Surg 2015;44:104–112.
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Surgically a small group proceeded to further sur- 13. Gerke DC, Richards LC, Goss AN. A multivariate study of
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with discectomy.28 No patient had more extensive pro-
14. Neo H, Ishimaru I-J, Kurita K, Goss AN. The effect of hyaluro-
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have a role in the management of ankylosis or tumours for TMJ ankylosis. J Oral Maxillofac Surg 1999;57:812–817.
but not in TMD. Similarly, although the author was 16. Goss AN, Swann C. Orofacial pain and TMD. Online modules.
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Japan to the Western world29 he prefers either arthro- 17. Goss AN, Swann C. OMS case studies. On line modules.
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Temporomandibular arthrocentesis

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Email: [email protected]
Address for correspondence:
Emeritus Professor Alastair Norman Goss

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