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British Journal of Oral and Maxillofacial Surgery xxx (2020) xxx–xxx

Comparison of intraoperative outcomes with single and

double puncture techniques of arthrocentesis of the
temporomandibular joint
Shakil Ahmed Nagori a,∗ , Anson Jose b , Ajoy Roychoudhury c
a Oral & Maxillofacial Surgeon, 21 Corps Dental Unit, c/o 56 APO
b Faculty, Department of Oral & Maxillofacial Surgery, Army Dental Centre (Research & Referral), New Delhi
c Professor & Head of Department, Department of Oral & Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi

Accepted 8 April 2020

Abstract

Evidence of differences in operator-related outcomes between single and double puncture arthrocentesis is limited. The purpose of this
prospective study was to compare intraoperative outcomes with single puncture types 1 and 2, and double puncture, arthrocentesis. A total
of 59 patients with 60 temporomandibular joints (TMJ) were treated sequentially by single puncture type 1 (n = 20), single puncture type
2 (n = 20), and double puncture arthrocentesis (n = 20). Total operating time, incidence of dislocation of the needle, preauricular swelling,
and ease of operation were compared. Single puncture type 2 arthrocentesis took significantly less time than type 1 (p < 0.0001) or double
puncture arthrocentesis (p < 0.0001), but there was no difference in operating time between single puncture type 1 and the double puncture
technique (p = 0.25). There were significantly fewer dislocations of the needle with single puncture type 1 (p = 0.041) and single puncture type
2 (p = 0.033) than with double arthrocentesis. Single puncture type 2 arthrocentesis was easier than the single puncture type 1 (p = 0.001) or
double puncture technique (p < 0.0001). Extravasation of fluid caused swelling in seven patients after double puncture, and in three patients
each after single puncture types 1 and 2, arthrocentesis. Our results indicate that the single puncture type 2 technique is easiest and requires
the least operating time. There was no difference between single puncture type 1 and double puncture arthrocentesis in terms of operating
time or ease of the procedure. There were fewer operative dislocations of the needle with the single than with the double puncture technique.
© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: temporomandibular joint; arthrocentesis; single-puncture; double puncture

Introduction triangulation, positioning of the needle, and frequent intraop-

Arthrocentesis of the temporomandibular joint (TMJ) is a
simple, minimally-invasive procedure that is widely used in
the management of temporomandibular disorders.1 The tradi-
tional double puncture technique involves the insertion of two
needles into the upper joint space.2 Difficulties in accurate
∗ Address: Dr Shakil Ahmed Nagori, 21 Corps Dental Unit, c/o 56 APO.
Tel: 917045501333
E-mail address: drshakilnagori@gmail.com (S.A. Nagori).
erative needle dislocations lead to longer operating times and
are often encountered with the double puncture technique.3
To overcome these difficulties, several single puncture
techniques have been developed. Senturk and Cambazoglu4
have classified these into two types: single puncture type 1
and type 2. Single puncture type 1 involves the inflow and
outflow of fluid through the same needle or cannula lumen,3
whereas in type 2 the inflow and outflow are through differ-
ent ports and lumens but involve the same cannula. Examples
of this method include the use of the Shepard cannula5 or

https://doi.org/10.1016/j.bjoms.2020.04.011
0266-4356/© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Nagori SA, et al. Comparison of intraoperative outcomes with single and double puncture techniques
of arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.04.011
YBJOM-5985; No. of Pages 5
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McCain cannula,6 soldering of two needles in a Y-shape,7 use

of concentric needles,8 and use of one,9 or two, intravenous
catheters.10
Studies in which type 1 or type 2 have been compared with
double puncture arthrocentesis have reported no significant
differences in the reduction of pain and improvement in max-
imal mouth opening (MMO) with any of the techniques.11–14
A recent systematic review reported differences between sin-
gle and double puncture arthrocentesis in operator-related
outcomes such as the ease of operation, and the operat-
ing time. As the primary aim behind the development of
single puncture techniques was to simplify the procedure,
there is also a need for studies that compare the diffi-
culty of single puncture types 1 and 2, and double puncture
arthrocentesis.15 We have therefore designed a prospective
study that compared intraoperative variables with the three
types of arthrocentesis. Fig. 1. Injection of fluid in single puncture type 1 arthrocentesis in open
mouth position.

Material and methods

We prospectively included adult patients with stage 3 and 4

disorders of the TMJ based on Wilkes classification16 who
complained of a painful joint, restriction of mouth opening,
and no relief with at least three months of conservative treat-
ment. Patients with a history of previous arthrocentesis or
TMJ surgery, hypomobility as a result of bony or muscular
pathology, infected joints, severe systemic illness, or who
were uncooperative or pregnant, were excluded. Patients had
single puncture type 1, type 2, or double puncture, arthro-
centesis sequentially in groups of three. Institutional ethics
approval was given, and informed written consent obtained
from all patients (Supplemental data, online only).

Arthrocentesis
All patients had arthrocentesis under local anaesthesia by
a single operator (SN) who was experienced in all three
techniques with no preference for any particular one. The
Holmlund-Hellsing line was outlined. The point of entry of
the first needle was marked 10 mm in front of the tragus and
2 mm below the line. For the double puncture technique, a
second point was marked 20 mm in front of the tragus and
10 mm below the canthal-tragus line.
Single puncture type 1 was done using a single 21-gauge
needle inserted at the first entry point using the technique
described by Guarda-Nardini et al.3 Ringer’s lactate solution
3-4 ml was injected into the joint with the mouth open. The
patient was then asked to close the mouth to achieve outflow
through the same needle (Figs. 1 and 2). Ringer’s lactate
100 ml was then used for lavage.
Single puncture type 2 arthrocentesis was done using
the “double intravenous catheter technique”.10 A 16-gauge
catheter 45 mm long was first inserted into the joint space at
the first needle entry point. The needle was then completely
Fig. 2. Outflow of fluid in single puncture type 1 arthrocentesis during mouth
closure.
withdrawn and the catheter hub cut off from the junction
so that only the catheter tube remained in situ (Fig. 3). The
needle of a 22 gauge catheter was then inserted into the 16
gauge catheter tube that was already inside the joint until
about 5 mm of the needle stayed outside the catheter tube.
This position kept the needle tip just beyond the catheter
tube inside the joint. The joint was lavaged using Ringer’s
lactate 100 ml, with the 22-gauge needle functioning as the
input port and the 16-gauge catheter tube functioning as the
output port (Fig. 4).
Double puncture arthrocentesis required two 21 gauge
needles. After the needle had been inserted into the first
entry point with the mouth open, the joint was distended
with Ringer’s lactate 3-4 ml. The second needle was then
inserted followed by a further 100 ml lavage. Antibiotics and
anti-inflammatory drugs were prescribed postoperatively for
three days.

Please cite this article in press as: Nagori SA, et al. Comparison of intraoperative outcomes with single and double puncture techniques
of arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.04.011
YBJOM-5985; No. of Pages 5
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S.A. Nagori et al. / British Journal of Oral and Maxillofacial Surgery xxx (2020) xxx–xxx
Fig. 3. 16-gauge catheter tube inside the joint.
Fig. 4. Joint lavage carried out via 21 gauge needle inside the 16-gauge
catheter tube.
Outcomes
We recorded the total operating time (mins) from the inser-
tion of the first needle and catheter until complete removal of
all needles and catheters. The number of needle dislocations
during the procedure was recorded. Needle dislocation was
defined as sudden cessation of outflow of the irrigant during
the course of arthrocentesis as a result of the perceived move-
ment of the needle or catheter out of the joint. The ease of the
procedure was recorded at the end by the operating surgeon
on a 10 point Likert scale with 0 indicating extremely simple
and 10 indicating extremely difficult. Preauricular swelling
Please cite this article in press as: Nagori SA, et al. Comparison of intraoperative outcomes with single and double puncture techniques
of arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.04.011
3
Table 1
Participants in the study.
Type of arthrocentesis Mean (SD) Sex
age (years)
Single puncture type 1 34 (9) 14 men, 11 women
Single puncture type 2 34 (9) 9 men, 11 women
Double puncture 36 (10) 11 men, 8 women
p Value 0.89 0.27
was recorded as either present or absent at the end of the
procedure.
Statistical analysis
Data were analysed using “R” software (V.3.5.1) (The R
Foundation for Statistical Computing), and the Shapiro–Wilk
test was used to evaluate the normality of the data. The sig-
nificance of differences between categorical variables was
assessed using the chi squared test, and that between con-
tinuous variables by the Kruskal-Wallis rank-sum test with
the Dunn post hoc test with Benjamini-Hochberg adjusted p
values.
Sample size and power analysis
An a priori estimation of sample size was made based on the
results of Senturk et al.15 The mean number of relocations
of cannulas reported by the authors was entered in G*Power
software. With ␣ = 0.05, and power = 0.80, we found that at
least a total of 57 joints were required for this study. A similar
estimation based on the reported operating time required a
sample size of 39 joints. A post-hoc power analysis was also
made to estimate the power of the study to detect significant
differences between outcome variables.
Results
Fifty-nine patients (58 unilateral and 1 bilateral) were
included in the study. A total of 60 joints were grouped to
receive single puncture type 1 (n = 20) or type 2 (n = 20), or
double puncture arthrocentesis (n = 20). Patients’ sex and age
are shown in Table 1.
The results are summarised in Table 2. One patient who
had double puncture arthrocentesis had an injury to the
superficial temporal artery that lead to an intraoperative
haemorrhage. Bleeding was seen after insertion of the poste-
rior needle, and was successfully managed by the application
of pressure. Postoperative swelling of the pterygomandibular
space was seen in one patient 24 hours after single punc-
ture type 1 arthrocentesis. This was managed by continuous
airway monitoring together with intravenous antibiotics and
anti-inflammatory drugs. No other major complications were
noted. The power of the study was >80% to detect significant
differences between all three continuous variables.
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Table 2
Comparison of outcomes. Data are mean (SD).
Type of arthrocentesis Duration of
procedure (mins)
Single puncture type 1 12 (2)
Single puncture type 2 7 (2)
Double puncture 11 (3)
p Value* <0.0001
p Value (post hoc test) <0.00011
0.252
<0.00013
*Kruskal-Wallis test with Dunn post hoc test and Bejamini-Hochberg adjusted p values except for “No of patients with swelling”, for which the chi squared
test was used.
1 Single puncture type 1 compared with type 2; 2 Single puncture type 1 compared with double puncture; and 3 Single puncture type 2 compared with double
puncture.
VAS = visual analogue scale.
Discussion
The single puncture type 1 technique of arthrocentesis was
reported in 2008 to overcome the difficulties of the double
puncture technique.3 It was postulated that the omission of
the second needle would reduce interference, provide better
access to the joint, and reduce the trauma of the intervention,
thereby decreasing postoperative pain and discomfort. Since
then, several trials have compared it with double puncture
arthrocentesis.11,14,17 Manfredini et al17 and Guarda-Nardini
et al14 found no difference between the two techniques in a
sample of patients with osteoarthritis in terms of reduction
of pain, MMO, tolerability of treatment, and perceived effec-
tiveness. A recent blinded, randomised, controlled trial also
reported no significant difference in postoperative outcomes
between single puncture type 1 and double puncture arthro-
centesis in patients with anterior disc displacement without
reduction.11
While the technique of single puncture type 1 has been
standard across studies, different kinds of type 2 devices have
been compared with the double puncture technique. Senturk
et al13 compared the single puncture type 2 technique using
two 20-gauge needles soldered into a Y-shape with the dou-
ble puncture technique, and found no significant difference
in pain or MMO. In 2018, Folle et al12 in a single-blinded
RCT, found no difference in postoperative outcomes after
arthrocentesis using a double-lumen cannula and the double
puncture technique.
When we reviewed current relevant publications, there
seemed to be no apparent difference between either a vari-
ant of single puncture or double puncture in terms of clinical
efficacy.1 In clinical practice, therefore, the choice of arthro-
centesis would primarily be the quickest and easiest method.
Given the limited evidence, the primary aim of our study
was to clarify such intraoperative differences among the three
techniques. We found that single puncture type 2 took sig-
nificantly less operating time than both type 1 and double
puncture arthrocentesis. Similar results have been reported
by Senturk et al.15 The mean duration of single puncture type
2 in their study (5.55 (1.13) mins) was significantly less than
Please cite this article in press as: Nagori SA, et al. Comparison of intraoperative outcomes with single and double puncture techniques
of arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.04.011
No of dislocations Ease of operation No of patients
of needle (VAS) with swelling
0.25 (0.44) 5 (1) 3
0.15 (0.37) 4 (1) 3
0.65 (0.75) 5 (2) 7
0.022 <0.0001 0.20
0.731 0.0011 -
0.0412 0.352
0.0333 <0.00013
that in type 1 (9.36 (3.17) mins) and double puncture arthro-
centesis (8.45 (2.88). Talaat et al18 also showed that type
2 requires significantly less operating time than the double
puncture technique.
This distinction can be explained by the single cannula sys-
tem used in the single puncture type 2 technique that results
in close contact of both input and output ports, unlike double
puncture arthrocentesis that requires some time to achieve
adequate triangulation in the joint. The longer time required
by single puncture type 1 is explained by, first, the limited
capacity of the TMJ capsule and, secondly, the single inflow
and outflow port of the system. Only 3-4 ml of solution at a
time can be injected into the joint space, which has to flow
out through the same port and so results in longer operating
time.3
One of the most common problems of double punc-
ture arthrocentesis is needle dislocation. We found that the
number of needle dislocations was significantly higher with
double puncture than with both the single puncture type 1
and type 2 techniques. Dislocation of needles out of the joint
space usually results in blockage of fluid outflow or injec-
tion of fluid into the periarticular tissues, which results in
preauricular oedema. This may explain the higher (but not
significantly higher) incidence of preauricular swelling in the
double puncture group. Similar results were reported by Sen-
turk et al15 who found more needle relocations with double
puncture arthrocentesis (n = 8) than with single puncture type
1 (n = 4) and type 2 (n = 2). Their results were, however, not
significant (p = 0.07), and they recognised that the small sam-
ple size (n = 11 in each group) might have influenced their
results.
We found that the time required for adequate triangula-
tion in the dual puncture technique, number of intraoperative
needle dislocations, and the total length of the procedure,
influenced the overall ease of operation. The single puncture
type 2 was the most operator-friendly, compared with both the
other two techniques. Our results corroborate the outcomes
of the study by Senturk et al.15 While the ease of the single
puncture type 2 technique may be explained by its rapidity
and few needle dislocations, single puncture type 1 was no
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more operator-friendly than double puncture arthrocentesis.
The double puncture technique may have its inherent difficul-
ties, but once triangulation has been achieved and the needle
positions are maintained, joint lavage is rapid and easy. On
the other hand, single puncture type 1 requires considerable
time, and the injection-ejection process has to be repeated at
least 40 times for 100 ml of solution.3
Some limitations of our study must be mentioned. First,
and most importantly, the outcomes of the study were
recorded by a single operator and “ease of operation” was
measured on a subjective Likert scale, which could have
introduced a large amount of operator-related bias. The expe-
rience of the operator could have influenced intraoperative
outcomes. It is important that the results are interpreted bear-
ing in mind this inherent risk of bias. Secondly, patients were
grouped in a sequential manner and not randomised. Thirdly,
the lack of a stable group of patients precluded comparisons
of patient-related outcomes. Lastly, we used a specific tech-
nique of single puncture type 2 arthrocentesis. The difference
between our technique and other type 2 techniques described
is not known.
Nevertheless, to our knowledge this is the first prospective
study that has compared intraoperative variables among the
three methods of arthrocentesis. Our results indicate that the
single puncture type 2 technique is easiest to do, and requires
least operating time. There is no difference between type
1 and double puncture arthrocentesis in terms of operating
time or ease of the procedure. There are fewer intraoperative
needle dislocations with single puncture than with the double
puncture technique.
Funding
None.
Ethics statement/confirmation of patients’ permission
Ethics approval was obtained from the Institution’s Ethics
Committee. Informed written consent was obtained from all
patients, who consented to the publishing of photographs.
Conflict of interest
We have no conflicts of interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at https://doi.org/10.1016/
j.bjoms.2020.04.011.
Please cite this article in press as: Nagori SA, et al. Comparison of intraoperative outcomes with single and double puncture techniques
of arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.04.011
5
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