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Arthrocentecis andArthroscopy
AnisTebyanian
1 Introduction
TMJ disorders and associated pain and dysfunction are increasingly prevalent in the modern age,
largely due to parafunctional habits such as bruxism. These habits stem from psychological stressors and manifest physically through unconscious
clenching and grinding of the teeth. The substantial masticatory force exerted during these actions
can have detrimental effects on the related muscles and the TMJ itself, leading to pain, limited
mouth opening, and inability to chew food properly. These symptoms can signicantly impact
one’s quality of life, causing discomfort and difculty in performing daily activities related to
eating and speaking. Other causes of TMD are
trauma, arthritis, dentofacial deformity all of
which can result in alteration or destruction of
TMJ and related structures.
1.1 Internal derangement of TMJ
Refers to abnormal position of the articular disk
in relation to the condylar head within the glenoid
fossa. This condition is considered a progressive
disorder with symptoms that can vary depending
on the severity of the derangement. As the internal
A. Tebyanian (*)
Olney Center for Oral and Maxillofacial Surgery,
Olney, MD, USA
e-mail: dr.tebyanian@olneyoralfacialsurgery.com
derangement (ID) progresses, several changes can
occur including posterior ligament elongation,
disk deformation or perforation, and complete
displacement of the disc out of glenoid fossa.
The most famous classication system for
internal derangement is Wilkes classication and
shows ve stages of disease progression based on
clinical, radiographic, and pathological features.
There are several treatment modalities available for TMJ disorders, and the choice of treatment depends on the severity and specic
symptoms experienced by the patient. Here is a
review of ofce-based Arthrocentesis and a brief
overview of Arthroscopy.
(A) Arthrocentesis is a minimally invasive pro-
cedure that can be safely performed in ofce
setting for the treatment of symptomatic
internal derangements such as disc displacement without reduction. Arthrocentesis
has shown successful results in treating
patients with Wilkes classication of I–III
(Fig.1). This procedure involves irrigation
and lavage of the joint to reduce inammatory mediators responsible for pain and to
break soft adhesions that limit the mobility
of the disc.
(B) Arthroscopy is similar to arthrocentesis, but
the scope provides direct visualization of the
joint structures like the medial synovial
drape, pterygoid shadow, retro-discal
synovium, articular disc, and anterior recess.
Studies have demonstrated that arthroscopy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
B. C. Stack Jr. et al. (eds.), Craniofacial Pain, https://doi.org/10.1007/978-3-031-57563-1_9
151
152
A. Tebyanian
Stage I Painless clicking, no restriction on opening
Stage II
Stage III
Stage IV Chronic pain, restricted motion, locking, crepitus
Stage V
Fig. 1 Wilkes classication. (Adapted from Wilkes CH.Internal derangements of the temporomandibular joint: pathological variations. Arch Otolaryngol Head Neck Surg 1989;115:469–7)
First few episodes of pain, Temporal headache,
increase in clicking intensity
Multiple episodes of pain, Restricted motion,
headache, Locking, pain with function
Chronic variable pain, crepitus, grinding, grating,
chronic restriction on motion, and function
Slight anterior disc displacement with
reduction
Mild to moderate anterior disc
displacement with reduction, Slight
deformity of the disk
Moderate to severe anterior disc
displacement without reduction,
oderate disc deformity, no changes in
bony contours
Significant disc deformity and
displacement, moderate
changes in osseous contour
Gross deformity of disc and osseous
anatomy, osteophyte formation
is more effective than arthrocentesis in lysing adhesions and increasing joint mobility.
There are three levels of arthroscopic procedures performed based on initial diagnosis and
operator skill level.
• Level I is arthrocentesis with visual diagnos-
tics. It uses a single puncture entry for the
scope and one anterior needle for outow of
the irrigant. Once the scope is inside the joint,
a systematic sweep from anterior to posterior
recess will readily show the anatomy and
involved pathology of the joint for proper
diagnosis. The rest of the procedure is similar
to arthrocentesis (Fig.2).
• Level II uses two puncture points, one for
thescope and the other for a working cannula.
The working cannula port will allow lasers,
coblation, rotary instruments, and other
mechanical instruments to reduce and better
mobilize the disc and break the more prominent adhesions.
• Level III, also called advanced or operative
arthroscopy, is more surgically invasive and
uses two or more puncture points to use cannulas along with the scope to perform endoscopic debridement, myotomy of lateral
pterygoid muscle for anterior release of the
disc, disc reduction, and rigid disc xation.
Advanced arthroscopy is a very sensitive technique and requires further training enabling
clinicians to perform open surgical procedures
endoscopically (Fig.3).
Arthrocentesis involves ushing and irrigat-
ing the superior joint space to push the disc
apart from the glenoid fossa, remove inammatory byproducts and debris, and improve joint
mobility by breaking down adhesions. While it
may not be suitable for advanced cases, it serves
as a preferred initial surgical option for the
Arthrocentecis andArthroscopy
Fig. 2 Level I arthroscopy. (Verde etal. Approach to TMJ Intermediate Space by Triangulation. J Oral Maxillofac Surg
2023)
153
Fig. 3 Level III arthroscopy. (Verde etal. Approach to TMJ Intermediate Space by Triangulation. J Oral Maxillofac
Surg 2023)
majority of cases that do not respond to conservative treatments. The indications for arthrocentesis include failed conservative treatment,
anterior disc displacement without reduction,
TMJ trauma with associated hemarthrosis,
symptomatic arthropathies such as osteoarthritis
or rheumatoid arthritis, and situations where
patients opt against more invasive surgical procedures. Arthrocentesis is contraindicated in the
presence of tumor, degenerative bone osteophytes, disc perforation, overlying skin infection, and condylar ankylosis.
154
Fig. 4 An example of an arthrocentesis needle with irrigation and suction ports
A. Tebyanian
2 Techniques
The two commonly used techniques for arthrocentesis are as follows:
(A) Single-puncture technique: In this approach,
a single needle cannula with two lumens
(one for inow and the other for outow) is
inserted into the joint. The irrigation and
lavage of the joint will be performed through
this single puncture site (Fig.4).
(B) Double-puncture technique: In this method,
two needles are placed into the joint at two
separate sites. One needle is used for inow,
while the other is used for outow during the
irrigation and lavage process.
In this chapter, we will review the more common and well-studied double-puncture
technique.
3 Preparation
Arthrocentesis can be performed under local
anesthesia or IV sedation depending on clinician
and patient preferences. Patients should be positioned in a semi-reclined position, and their hair
should be secured away from surgical eld using
sterile towels and antibiotic ointment. External
auditory canal should be protected from uid and
Fig. 5 External anatomical landmarks. (Nitzan, D.W.,
Naaman, H.L., (2022) Arthrocentesis; What, When, and
Why. Atlas Oral Maxillofacial Surg Clin N Am 30,
137–145)
blood with soft cotton. Subsequently, the surgical
eld is prepared using Betadine solution. Aside
from the surgeon, who will wear a sterile gown
and gloves, two additional surgical assistants will
be required, but they will not need to wear sterile
gloves. One of the assistants will be responsible
for handling and stabilizing the mandible during
the procedure, wearing non-sterile gloves for this
task. The other assistant’s role will involve pushing the uid into the joint under appropriate
hydraulic pressure and suctioning the outow
irrigant.
The operator draws a canthal-tragal line from
the middle of the tragus to the ipsilateral lateral
canthus. This topography avoids injury to upper
branches of the facial nerve. The rst puncture
point (A) will be marked at 10–12mm anterior
to mid-tragus, 2mm inferior to this line. This is
the posterior extent of glenoid fossa and should
be palpated by ngertip with mandible placed in
protrusion. The second point (B) will estimate
the height of the articular eminence and will be
marked 20 mm anterior to mid-tragus and
10mm below the canthal-tragal line. These two
points will be a good estimate landmark for
inow- outow needle position (Figs.5 and 6).
Arthrocentecis andArthroscopy
155
Fig. 7 Inow and outow access for irrigation and
lavage
Fig. 6 Anatomical landmarks marked on patient
4 Procedure
Auriculotemporal block and local inltration into
the joint will be done with 1–2 carpules 2% lidocaine with 1:1,000,000 epinephrine. Superior
joint space will then be entered at point A with
18G needle directed in anterior–medial–inferior
45° angle. One easy and safe technique is to
touch the tip of the needle to the zygomatic arch
and slowly walk the needle into the superior joint
space. Then the joint will be insufated with
2–5cc of LR via a syringe connected to the 18G
needle. With the needle held in place, the syringe
will be detached and IV irrigation line will be
attached to the needle. A second needle previously attached to IV irrigation line will be placed
into the joint capsule anteriorly at point B while
the assistant holding the mandible in protrusion.
The second needle will serve as outow line
(Fig.7). The joint will be irrigated with 250cc of
LR drawn in 60cc syringes and is pushed under
Fig. 8 Joint lavage with adequate pressure and volume,
with proper outow stream of the irrigant. (Adopted from
Nitzan, D.W., Naaman, H.L., (2022) Arthrocentesis;
What, When, and Why. Atlas Oral Maxillofacial Surg
Clin N Am 30, 137–145)
moderate to high pressure by the assistant while
outow can be let to drip in kidney basin held
away from the surgical eld.
During the lavage, it is very important to pay
attention to the position of the two needles to prevent their dislocation, which can block the outow or potentially penetrate through the thin
surrounding bony walls. As long as the outow is
consistent with the inow uid volume, the needles should be properly positioned and held in
156
A. Tebyanian
place by the operator and lavage continued to the
end (Fig. 8). After the lavage is completed, the
anterior needle will be removed, and using the
posterior needle, adjuncts like steroid, liquid
PRF, or PRP can be injected into the superior
joint space and then the posterior needle will be
removed. This will conclude the sterile portionof
the procedure. Then using the dominant hand, the
operator will open the mandible to almost the
maximum extent along with excursive movements to manipulate and loosen the joints multiple times. At the completion of joint manipulation,
the Maximal Intraincisal Opening (MIO) should
be around 40 mm with minimal resistance to
opening.
5 Additives
There have been multiple studies clearly demonstrating that the use of adjuncts like steroids or
hyaluronic acid with arthrocentesis signicantly
improves outcome. Long-acting corticosteroids
like triamcinolone acetonide or methylprednisolone acetate have robust anti-inammatory properties that last weeks to months and helps reduce
pain and improve function by suppressing the
inammatory cytokines like TNF-alpha, interleukins, or interferon-gamma.
With the new advancements in the eld of
regenerative medicine, platelet-rich brin, which
is a second generation of platelet concentrate
with longer growth factor bioavailability, has
shown to promote healing, reduce inammation,
and potentially improve the condition of the joint
and surrounding tissue. Platelet-rich brin (PRF)
provides a concentrated collection of growth factors including platelet-derived growth factor
(PDGF), transforming growth factor beta (TGFbeta), and vascular endothelial growth factor
(VEGF), and it can be obtained in either solid or
liquid form. Liquid PRF, also known as injectable PRF (i-PRF), consists of liquid brinogen
mixed with growth factors. Once injected, brinogen transforms into brin and takes on a gel-like
solid state. The process of creating i-PRF involves
using a horizontal centrifuge and specic liquid
PRF tubes. The centrifugation is conducted at
300g for 5 min. To collect the i-PRF from the
tube, an 18G needle is used to penetrate through
the tube lid. Approximately, 0.5–1 cc of i-PRF
can be harvested from each tube. It is important
to administer i-PRF promptly into the joint before
clotting occurs to maximize its effectiveness
(Fig. 6). This author uses 40mg Kenalog and
2cc of i-PRF as additives with arthrocentesis.
6 Clinical Pearls
(a) Multiple studies have investigated irrigant
volume required to sufciently reduce the
pro-inammatory proteins from the joint.
Most studies have concluded that 200cc is
sufcient to achieve statistically signicant
reduction in pro-inammatory mediators.
This author’s protocol uses 250cc of LR as
irrigation volume for arthrocentesis.
(b) Adequate hydraulic pressure is required to
stretch the joint space and break down the
adhesions between the disc and glenoid
fossa that limit the joint mobility. It has
been reported that 40 KPa (kilopascal
units) is sufcient to achieve this goal.
Using an irrigation pump is one way to
ensure that the irrigant is being ushed
into the joint under sufcient pressure, but
this requires additional equipment. Instead,
theclinician can roughly estimate the adequate pressure to inject the uid by observing the outow stream to stay continuous
during the lavage.
7 Complications
A potential complication may arise if one or
both needles are misplaced outside of the joint
during the procedure causing the uid to inltrate the surrounding tissue. This can be identied by rapid swelling of the surrounding tissue.
If such an occurrence happens, the lavage process should be halted immediately, and needles
should be repositioned to ensure proper outow
Arthrocentecis andArthroscopy
157
and prevent further tissue inltration. The
extravasated uid will be either drained through
the skin pores or absorbed naturally over the
course of the next several days. Other complications can be injury to the branches of facial
nerve, injury to the eighth cranial nerve or tympanic disruption, perforation of the glenoid
fossa, and communication with middle cranial
fossa and subsequent cerebrospinal uid leak,
skin hematoma or hemarthrosis, and postoperative infection and pain.
8 Post-op Care
The patient will be prescribed postoperative antibiotics such as Keex to prevent infection. Pain
management will involve the use of nonsteroidal
anti-inammatory medication like ibuprofen
800mg TID with foodand/or mild strength narcotics like tramadol. As a prophylactic measure,
this author typically has patients start the antibiotic 1h prior to the surgery. To aid in the healing
process, the patient will be put on a non-chew
diet for 3–4 weeks. Additionally, they will be
instructed to perform mouth opening and excursive movement exercises multiple times a day.
References
Alkan A, Kilic E.A new approach to arthrocentesis of the
temporomandibular joint. Int J Oral Maxillofac Surg.
2009;38:85–6.
Dolwick MF, etal. A randomized, double-blind- placebo-
controlled study of the efcacy of steroid supplementation after temporomandibular joint arthrocentesis. J
Oral Maxillofac Surg. 2020;78:1088–99.
Gonzalez-Garcia R. The current role and the future of
minimally invasive temporomandibular joint surgery.
Oral Maxillofac Surg Clin N Am. 2015;27:69–84.
Grossmann E, Poluha RL. Comparison between TMJ
arthrocentesis techniques with different needle positions: a randomized single-blind controlled clinical
trial. J Cranio-Maxillo-Facial Surg. 2021;49:368–72.
Iskik G, et al. Does the use of injectable platelet- rich
brin after arthrocentesis for disc displacement without reduction improve clinical outcomes? J Oral
Maxillofac Surg. 2023;81:689–97.
Kaneyama K, etal. The ideal lavage volume for removing
bradykinin, interleukin-6, and protein from temporomandibular joint by arthrocentesis. J Oral Maxillofac
Surg. 2004;62:657–61.
Nitzan DW, Naaman HL. Arthrocentesis; what, when,
and why. Atlas Oral Maxillofac Surg Clin N Am.
2022;30:137–45.
Nitzan DW, Price A. The use of arthrocentesis for the
treatment of osteoarthritic temporomandibular joints.
J Oral Maxillofac Surg. 2001;59:1154–9.
Verde L, et al. Temporomandibular Joint: Approach
to the Intermediate Space by Triangulation With
Transillumination Reference. J Oral Maxillofac Surg
2023;81:684–88.
Wilkes CH. Internal Derangement of Temporomandibular
Joint, Pathological Variation. Arch Otolarnygol Head
Neck Surg. 1989;115:469–77.
Yura S, Totsuka Y.Relationship between effectiveness of
arthrocentesis under sufcient pressure and conditions
of temporomandibular joint. J Oral Maxillofac Surg.
2005;63:225–8.
Yura S, Totsuka Y, Yoshikawa T. Can arthrocentesis
release intracapsular adhesions? Arthroscopic ndings
before and after irrigation under sufcient hydraulic
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Part II
Advanced Topics
The Neurological Aspects
oftheTrigeminal Cranial Complex
andIts Role intheTMJ Dysfunction
andMultiple Movement Disorders
AnthonyB.Sims
Abbreviations
ABCFP American Board of Craniofacial Pain
DHS Doctor of Humanitarian Services
IMD Integrative Medical Doctor
WONM World Organization of Natural Medi-
cine
1 Introduction
Aside from the brain, the masticatory system
plays a major role in the functions and physiology of the head. The principal nerve to this masticatory system is the trigeminal nerve (cranial
nerve (CN) 5). Since CN 5 is embryologically
developed from the neural crest cells and the neural tube, as are the brain and spinal cord structures, it too should be considered a major
component in the inuence of the latter. CN 5 has
a very intricate and complex integration with
almost all the cranial nerves, the structures that
developed from the mesencephalon, metencephalon, and myelencephalon, along with the craniofacial complex of the maxilla, mandible, and
temporomandibular joint (TMJ).
The term “movement disorders” is described
as neurological syndromes in which there is
either an excess of movement (hyperkinesias) or
a paucity of voluntary and automatic movements
A. B. Sims (*)
Columbia, MD, USA
unrelated to weakness or spasticity (hypokinesias) [1]. Some movement disorders are thought
to be associated with pathological changes in the
basal ganglia (i.e., Parkinson’s disease [PD],
idiopathic torsion dystonia, Tourette syndrome
[TS], and essential tremor [ET]). ET is the most
common movement disorder followed by idiopathic PD and dystonia. The greatest attention to
movement disorders concentrates on PD with all
others being secondary. Diagnosing a patient
with movement disorders involves (1) the probable etiology of the disorder, (2) understanding
whether it is isolated or associated with another
neurological disorder, and (3) understanding the
pattern of the disorder (see Table1). Illustrative
cases are contained in Chap. 14.
What is not usually considered is that the trigeminal cranial complex, though originating
from neural embryonic tissue, could be a factor in
the disturbances known as movement disorders.
Through commonly known anatomical and physiological principles, denitions of neurological
diagnoses, diagnostic examinations, evaluations,
and treatments, it may be that the trigeminal cranial nerve holds an answer to some of the disorders that have previously been attributed to
disorders of the brain, cerebellum, and/or basal
ganglia. This chapter shows relevant content both
anatomically and physiologically as to why the
CN 5 system should not be ignored when diagnosing and/or treating those with movement
disorders.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
B. C. Stack Jr. et al. (eds.), Craniofacial Pain, https://doi.org/10.1007/978-3-031-57563-1_10
161
162
Evaluation of movement disorders
Table 1
Neurologic physical exam
Brain
Cerebellum
Cranial nerves
Mental status exam
Reasoning and cognition
Spine/periphery
Motor/strength
Sensation
Dysesthesias
Reex testing
Nerve conduction testing
Visual evoked response (VER)
Auditory evoked response (ABR or BAER)
Muscle testing
Electromyography
Muscle biopsy
Imaging
Brain
Spine
Periphery
Extremities
2 Embryology oftheTrigeminal
Nerve
The origin of the word trigeminal is taken from the
Latin “tri-” equaling three and “-geminal” meaning a mass connected to a common point. There
are “three” signicant branches arising from trigeminal nerve that have four denitive nuclei in
the brain stem. They are classied as follows:
• Sensory nuclei: (1) mesencephalic trigeminal
nucleus located in the midbrain, (2) principal/
chief/main trigeminal nucleus located in the
pons, and (3) spinal trigeminal nucleus located
in the medulla and spinal cervical region
• Motor nucleus: trigeminal motor nucleus
located in the pons
These types of nuclei form early during neural
development and sensory afferent bers are sent
to the brain stem in the ventral medial pons.
These structures form from the structures known
as the rst pharyngeal and/or branchial arch. The
branchial arches are embryologic structures that
A. B. Sims
develop into anatomic structures. The branchial
arches give rise to the lower face, neck, and part
of the upper thorax, while the frontonasal process
gives rise to the forehead and nose. The structures formed by the branchial arches are the result
of contributions from the three primary germ layers: endoderm, mesoderm, ectoderm, as well as
neural crest cell derivatives.
The endoderm of the branchial arches develops into endocrine viscera of the neck, including
the thymus, thyroid, and parathyroid glands. The
mesoderm cell layer forms vasculature and musculature structures from endothelial cells and
myoblasts, respectively, in the head, neck, and
upper thorax. Ectoderm gives rise to nervous
system derivatives, while the lateral domain of
surface ectoderm gives rise to the skin. The neural ectoderm crest cells migrate to give rise to the
bones of the skull, jaw, ear, as well as cartilage
found in the head and neck. The peripheral nervous system itself derives from a dual origin of
surface ectoderm [2].
Structures of the rst branchial arch include:
• Bones: maxilla, zygoma, vomer, palatine,
mandible, squamous portion of the temporal
bone, malleus, and incus
• Muscles: tensor veli tympani, tensor veli pala-
tine, anterior belly of the digastric, mylohy-
oid, masseter, temporalis, lateral and medial
pterygoids
• Nerves: trigeminal and its divisions
2.1 The Trigeminal Nuclei
In understanding the trigeminal nerve, we must
rst have knowledge of the different trigeminal
nuclei: (A) mesencephalic trigeminal nucleus:
proprioceptive information from the face; (B)
principal trigeminal nucleus: light touch and discriminative information from the face; (C) spinal
trigeminal nucleus: pain and temperature information from the face; and (D) trigeminal motor
nucleus: motor efferent bers for somatic control
of mastication (masseter and pterygoids).