Int. J. Oral Maxillofac. Surg. 2009; 38: 8586 doi:10.1016/j.ijom.2008.11.005, available online at http://www.sciencedirect.

com

Technical Note TMJ Disorders

A new approach to arthrocentesis of the temporomandibular joint

A. Alkan, E. Kilic: A new approach to arthrocentesis of the temporomandibular joint. Int. J. Oral Maxillofac. Surg. 2009; 38: 8586. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. We describe a new temporomandibular joint (TMJ) arthrocentesis technique using the irrigation pump from a surgical and dental implant motor, providing the highest hydraulic pressure reported in the literature for TMJ lavage.

A. Alkan, E. Kilic
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, Kayseri, Turkey

Accepted for publication 3 November 2008

Arthrocentesis is an easy, minimally invasive, highly efcient procedure to decrease joint pain and increase the range of mouth opening in patients with closed lock of the temporomandibular joint (TMJ)6. NITZAN et al.2 rst described TMJ arthrocentesis as the simplest form of surgery in the TMJ, aiming to release the articular disc and to remove adhesions between the disc surface and the mandibular fossa by means of hydraulic pressure from irrigation of the upper chamber of the TMJ. YURA et al.6 conrmed that adhesions are released after irrigation of the upper joint space under sufcient hydraulic pressure. It is not known whether arthrocentesis performed with higher pressure in a short time period is more effective. The authors describe the use of the surgical and dental motor as a new device to accomplish TMJ arthrocentesis with higher pressure.
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Technique

The arthrocentesis technique described by NITZAN et al.2 was used. A line was drawn from the corner of the eye to tragus and the rst mark was made 10 mm from the tragus and 0.5 mm below the line. The second point was marked 20 mm from the tragus and 1 mm below the line. A 21-gauge needle was inserted into the superior joint compartment from the rst point and 5 ml saline solution was injected to widen the upper joint space. A second needle, the same diameter as the rst, was inserted from the second point and it was manually conrmed that upper joint space was irrigated effectively. The silicone tube of the irrigation pump (KaVo, INTRAsurg 300/300 plus, Biberach, Germany) was connected to the second needle and automatic irrigation under high pressure was initiated (Fig. 1). The upper joint space was irrigated with 300 ml saline solution under pressure in all patients for 2 min

(Fig. 2). This technique was not used when effective manual irrigation was impossible.

Discussion

TMJ arthrocentesis is often performed for the treatment of TMJ dysfunction. NITZAN et al.3 reported that the efciency of arthrocentesis under low pressure, which was applied manually using a 10-ml syringe, was not successful in patients with severe adhesions. In contrast, YURA et al.6 reported on the efcacy of arthrocentesis under high pressure using the infusion accelerator for blood bag (maximum pressure exerted, 40 KPa). Their study showed that high pressure removes adhesions and widens joint spaces in patients with chronic closed lock and with adhesions in the upper joint. They also stated that pathologic conditions of the TMJ did not inuence the efcacy of arthrocentesis

# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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Alkan, and Kilic

needle without manual conrmation with the second needle, complications may occur in the surrounding tissues owing to the high pressure. During the procedure, if the outlet needle suddenly blocks, the surgeon must discontinue the irrigation immediately.

References
1. Kaneyama K, Segami N, Nishimura M, Sato J, Fujimura K, Yoshimura H. The ideal lavage volume for removing bradykinin, interleukin-6, and protein from temporomandibular joint by arthrocentesis. J Oral Maxillofac Surg 2004: 62: 657661. 2. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplied treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991: 49: 11631167. 3. Nitzan DW, Price A. The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joints. J Oral Maxillofac Surg 2001: 59: 11541159. 4. Sato S, Goto S, Kasahara T, Kawamura H, Motegi K. Effect of pumping with injection of sodium hyaluronate and the other factors related to outcome in patients with non reducing disk displacement of the temporomandibular joint. Int J Oral Maxillofac Surg 2001: 30: 194198. 5. Yura S, Totsuka Y. Relationship between effectiveness of arthrocentesis under sufcient pressure and conditions of the temporomandibular joint. J Oral Maxillofac Surg 2005: 63: 225228. 6. Yura S, Totsuka Y, Yoshikawa T, Inoue N. Can arthrocentesis release intracapsular adhesions? Arthroscopic ndings before and after irrigation under sufcient hydraulic pressure. J Oral Maxillofac Surg 2003: 61: 12531256. 7. Zardeneta G, Milam SB, Schmitz JP. Elution of proteins by continuous temporomandibular joint arthrocentesis. J Oral Maxillofac Surg 1997: 55: 709716. Address: Alper Alkan Erciyes University Faculty of Dentistry Department of Oral and Maxillofacial Surgery 38039 Melikgazi Kayseri Turkey Tel: +90 352 4374937 29177 Fax: +90 352 4380657 E-mail: alpalkan@hotmail.com

Fig. 1. Use of the irrigation pump from the surgical and dental motor for TMJ arthrocentesis.

Fig. 2. Clinical view of TMJ arthrocentesis under high hydraulic pressure.

under sufcient pressure5. This suggests that their procedure with sufcient pressure has wider applications than arthrocentesis under low pressure. In a similar study, SATO et al.4 stated that pumping with injection of sodium hyaluronate into the TMJ is an effective treatment for nonreducing disc displacement of the TMJ. The authors considered whether the outcome of TMJ arthrocentesis would be more effective when the hydraulic pressure was increased. The clinical outcome of this technique will be published when the study population reaches a sufcient number. ZARDENETA et al.7 stated that approximately 100 ml of total arthrocentesis volume is sufcient for therapeutic lavage of the superior joint space of the human

TMJ. KANEYAMA et al.1 studied the ideal lavage volume for removing bradykinin, interleukin-6 and protein from the TMJ. They performed arthrocentesis with different lavage volumes and concluded that the ideal lavage volume of perfusate for arthrocentesis is between 300 and 400 ml. The authors consider that it is possible to irrigate the upper joint space in 2 min with 300 ml saline solution. Surgical and dental motors are available in all oral and maxillofacial surgery departments, so no additional equipment is required to use this technique. The irrigation pump settings are explained in the instruction booklet. This technique should be performed by surgeons with experience of TMJ arthrocentesis. If the irrigation pump is connected to the rst