A r t h ro s c o p y Ver s u s

A r t h ro c e n t e s i s f o r Tre a t i n g
I n t e r na l D e r a n g e m e n t s of t h e
Tem p o ro m a n d i b u l a r J o i n t
Daniel M. Laskin, DDS, MS

KEYWORDS
 Internal derangement  Arthroscopy  Arthrocentesis  Disc displacement  Complications

KEY POINTS
 In treating internal derangements of the temporomandibular joint, re-establishing joint mobility is
more important than restoring disc position.
 It is not necessary to visualize the joint to successfully treat internal derangements.
 Arthrocentesis is as effective as arthroscopy in treating internal derangements.
 Arthrocentesis has fewer and less serious complications.

Prior to the early 1970s, the surgical treatment of
internal derangements of the temporomandibular
joint (TMJ) involved either restoration of the intra-
articular disc to its normal position (discoplasty)
or removal of the disc (discectomy). However,
the introduction of arthroscopic surgery for the
management of internal derangements by Ohnishi
in 19751 and the subsequent development of the
technique by Murakami and Ito2 in Japan and
Sanders in the United States3 represented a major
advancement in the treatment of such conditions,
because it involved a less invasive approach.
Although initially this procedure consisted mainly
of irrigation of the joint and the breaking up of ad-
hesions (lysis and lavage), various surgical manip-
ulations similar those performed arthroscopically
in other joints were subsequently introduced by
some surgeons. It soon became evident that in
the treatment of patients with internal derange-
ments, restoring joint mobility rather than disc po-
the diffusion of nutriments and the elimination of
inflammatory breakdown products, and ultimately
resulted in transformation of the painful anteriorly
displaced retrodiscal tissue into a more fibrotic
functional pseudodisc.4
The success reported with arthroscopic man-
agement of internal derangements ultimately led
to the introduction of arthrocentesis for the treat-
ment of closed lock in the TMJ by Nitzen, Dolwick
and Martinez in 1991.5 This procedure involved
lavage of the TMJ via 2 hypodermic needles intro-
duced into the upper joint space and lysis of adhe-
sions hydraulically and by manual manipulation of
the mandible. Subsequently, the procedure was
also reported to have been used successfully for
the treatment of painful TMJ clicking6 and TMJ
osteoarthritis7 and rheumatoid arthritis.8
However, because arthrocentesis does not
involve visualization of the joint structures or the
use of additional surgical manipulations, it raises
oralmaxsurgery.theclinics.com

sition was the important factor. This produced a the question of whether arthroscopy should be
better distribution of forces within the joint, the preferred initial treatment for internal derange-
allowed more physiologic function by improving ments of the TMJ. Because reports on other

Disclosure: The author has nothing to disclose.

Department of Oral and Maxillofacial Surgery, Virginia Commonwealth University School of Dentistry, 521
North 11th Street, Richmond, VA 23298-0566, USA
E-mail address: dmlaskin@vcu.edu

Oral Maxillofacial Surg Clin N Am 30 (2018) 325–328

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326 Laskin
conditions for which arthroscopic surgery and
arthrocentesis have been used are limited, this
discussion will focus only on internal derange-
ments, comparing both individual studies and
those in which both procedures were used by
the same surgeons. Because some arthroscopic
studies involved only lysis and lavage and others
involved lysis and lavage plus such procedures
as joint debridement, abrasion arthroplasty, lateral
capsular release, lateral pterygoid muscle detach-
ment, and disc repositioning, these 2 groups will
also be compared.
ARTHROSCOPY VERSUS ARTHROCENTESIS
IN SEPARATE STUDIES
There have been numerous studies in which
internal derangements have been treated either
arthroscopically or by arthrocentesis. An extensive
review of arthroscopic surgery was reported by
Israel in 1999,9 which involved data from 11 studies
published between 1987 and 1996. Although most
of the 3955 patients had nonreducing anterior disc
displacement, some had only clicking. Arthro-
scopic lysis with lavage was the most frequent pro-
cedure, but some patients were also treated with
various surgical manipulations. The results showed
a mean success rate of 84%, with an average in-
crease in maximum mouth opening of 10.4 mm
and 82% of patients reporting less pain. Similar re-
sults have been reported by Alvarez and col-
leagues10 (61 patients, 4-year follow-up, 81.4%
success), Murakami and colleagues11 (33 patients,
10-year follow-up, 83.8% success), Sorel and
Piecuch12 (22 patients, 2 to 10.8-year follow-up,
91% success), and White13 (66 patients, 8-year
follow-up, 76% success). The average success
rate for these 5 studies is 83%.
The long-term effectiveness of arthrocentesis
was reported to be 85% by Frost and colleagues14
(40 patients, 14-month follow-up). Nitzen, Samson,
and Better15 reported a 95% success rate, whereas
Hosaka and colleagues16 reported 79% success
(20 patients, 3-year follow-up), and Carvajal and
Laskin17 had an 88% success rate (26 patients,
49 months). The mean success rate for these 4
studies is 87%. In a review of 14 articles from the in-
ternational literature, Al-Belasy and Dolwick18 found
an 83.2% success rate. Thus, based on individual
studies, arthrocentesis is as effective as arthros-
copy for the treatment of internal derangements.
ARTHROSCOPY VERSUS ARTHROCENTESIS
IN THE SAME STUDIES
Because of the possible variations in individual
studies, as well as the greater potential for bias,
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they are not as reliable as comparative studies
done at a single institution. A review of the litera-
ture revealed 2 such early studies19,20 that should
arthroscopy to be somewhat better, but since that
time 5 studies21–25 in which this type of compari-
son was made, showed no significant difference
(Table 1).
DISCUSSION
The results of the preceding comparisons provide
strong evidence that the 2 procedures are compa-
rable in effectiveness. However, it has been
claimed that arthroscopic surgery has the advan-
tage of allowing the surgeon to look into the joint
and directly treat any pathology that exists. To
address this issue, one needs to compare the re-
sults from studies on arthroscopic lysis and lavage
alone with studies on lysis and lavage plus other
surgical maneuvers reported in the literature.
Table 2 shows that there is no significant differ-
ence. Moreover, in 2 comparison studies of arthro-
scopic lysis and lavage with lysis and lavage plus
arthroscopic surgery from the same institution by
Gonzalez-Garcia and colleagues,31,32 no statisti-
cal difference was noted. Thus, if lysis with lavage
alone is effective, it is not necessary to look into
the joint, and arthrocentesis can be the initial treat-
ment for internal derangements.
Other advantages of arthrocentesis include less
invasiveness, no need for special instruments, less
postoperative morbidity, lower cost, and low po-
tential for complications. The numerous complica-
tions of arthroscopic surgery are listed in Box 1.33
The only significant complication of arthrocentesis
has been 1 case of an extradural hematoma.34
The successful management of patients with
close lock using arthrocentesis, despite the fact
that the intra-articular disc is still in an anteriorly
Table 1
Success of arthroscopy and arthrocentesis
compared in the same study
Arthroscopy
Author Arthrocentesis
Kropmans et al,21 1999 No significant
difference
Goudot et al,22 2000 No significant
difference
Sanroman.23 2004 No significant
difference
Hobeich et al,24 2007 No significant
difference
Tan & Krishnaswamy,25 2012 No significant
difference
 Arthroscopy Versus Arthrocentesis 327

SUMMARY
Table 2
Success treating temporomandibular joint The similarity of success in treating internal de-
internal derangements with arthroscopic lysis rangements of the temporomandibular joint with
and lavage alone or with arthroscopic surgery
arthroscopy or arthrocentesis, plus the advantage
added
of greater simplicity, lower cost, and fewer compli-
Lysis, cations of the latter procedure, suggests that
Lysis and Lavage Lavage DSurgery it should generally be the initial treatment in
most instances. Although there have been a few
Sanders & 90% Moses & 92%
studies on the successful use of arthrocentesis
Buoncristiani,26 Poker,28
1987 1989 for osteoarthritis and rheumatoid arthritis, further
investigation of its effectiveness and comparison
Indresano,27 1989 83% Davis et al,29 86%
1991
to arthroscopic management are needed.
Sorel & Piecuch,12 91% Mosby,30 93%
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