J Oral Maxillofac Surg

49.1163-1167, 1991

Temporomandibular Joint Arthrocentesis:

A Simplified Treatment for Severe, Limited
Mouth Opening

DORRIT W. NITZAN, DMD,* M. FRANKLIN DOLWICK, DMD, PHD,t

AND GARZA ALEJANERO MARTINEZ, DMD*

Seventeen patients complaining of suddenly occurring, severe, and per-

sistent limited mouth opening were treated by irrigation of the upper com-
partment of the affected temporomandibular joint with lactated Ringer’s
solution. This simple treatment was found to be highly effective in rees-
tablishing normal opening and relieving pain for a follow-up period of 4 to
14 months.

It has been suggested that internal derangement
of the temporomandibular joint (TMJ) generally
progresses from the first stage, where there is click-
ing accompanied by normal maximal mouth open-
ing (MMO), to the stage where clicking gradually
ceases concomitantly with varying degrees of re-
striction in opening (closed lock).‘,’ The latter stage
is customarily attributed to a nonreducible, anteri-
orly displaced disc acting as an obstacle to the glid-
ing condyle. ’ s When conservative means fail to
provide a solution to the disorder, surgical disc re-
pair and repositioning are used to reestablish nor-
mal MM0.h,8-‘0
A turning point has occurred in light of the re-
cently observed efficacy of arthroscopic lysis and
lavage of the superior joint compartment in reestab-
lishing normal MM0 in patients with severe closed
lock.““4 The success of this treatment is remark-
able considering that the approach does not include
repositioning and recontouring of the disc.
These findings”-‘4 suggest the use of only TMJ
* Senior Lecturer, Department of Oral and Maxillofacial Sur-
gery, The Hebrew University-Hadassah School of Dental Med-
icine, Jerusalem, Israel.
t Professor and Chairman, Department of Oral and Maxillo-
facial Surgery, University of Florida, Gainesville, FL.
$ Fellow, Department of Oral and Maxillofacial Surgery, Uni-
versity of Florida, Gainesville, FL.
Address correspondence and reprint requests to Dr Nitzan:
Department of Oral and Maxillofacial Surgery. Hebrew Univer-
sity-Hadassah School of Dental Medicine, PO Box 1172, Jeru-
salem 91010. Israel.
0 1991 American Association of Oral and Maxillofacial
geons
0278-239119114911-0006$3.00/0
upper compartment irrigation tarthrocenthesis) for
sudden, severe (~30 mm), and persistent limited
mouth opening. The apparent efficacy of this sim-
plified treatment places in question the need for re-
establishing normal disc shape and location for cor-
rection of this disorder.
Material and Methods
Patients. This study involved 17 joints in 17 pa-
tients (14 females and 3 males) with suddenly oc-
curring severe and persistent limited mouth opening
stemming from the TMJ and unassociated with
macrotrauma. The symptoms had been present
from 2 months to 5 years (mean, 11.8 ? 12.9
months) (Table 1). The patients ranged in age from
16 to 65 years (mean, 32.6 t 11.5 years). The chief
complaint was limited mouth opening associated
with pain located in the affected TMJ, especially
when opening was forced. Most patients did not
remember any cause initiating their complaints.
Two patients associated the pain with dental treat-
ment, and one patient with yawning.
The patients were diagnosed, treated, and fol-
lowed in the Department of Oral and Maxillofacial
Surgery either at the Hadassah-Hebrew University
Hospital, Jerusalem, Israel, or at the University of
Florida, Gainesville.
TMJ evaluation. Evaluation of the patients in-
volved a careful history and clinical examination.
All details were recorded in a questionnaire by the
Sur-
examiner. The history included demographic data,
chief complaints, initial symptoms, duration of
symptoms, history of noise or limited mouth open-

1163
1164 TEMPOROMANDIBULAR JOINT ARTHROCENTESIS

Table 1. General Information on Patients The method of arthrocentesis. Two points were
Undergoing TMJ Arthrocentesis marked over the skin of the affected joint indicating
Duration of the articular fossa and eminence. This was followed
Patient Age Limitation by injection of a local anesthetic to block the auric-
No. Wr) Sex Joint (mo) ulotemporal nerve. “-i* A 19-gauge needle was then
1 37 F L 12 inserted into the superior compartment at the artic-
2 41 M R 60 ular fossa (posterior mark), followed by the injec-
3 16 F R 8 tion of 2 to 3 mL of Ringer’s (Hadassah, Jerusalem)
4 34 F R 6
solution to distend the joint space. Another 19-
5 36 F L 7
6 21 M R 14
gauge needle was then inserted into the distended
7 22 F L 9 compartment in the area of the articular eminence
8 40 M L 3 to enable a free flow of the solution through the
9 ‘7 F R 12 superior compartment. The lactated Ringer’s solu-
10 30 F R 13
tion was connected to one of the needles and suffi-
11 24 F R 7
12 37 F L 7
cient pressure to assure free flow of 200 mL during
13 19 F R 2 a 15 to 20-minute period was achieved by placing
14 44 F L 2 the infusion bag at an elevation of 1 m above the
15 65 F L 4 level of the joint (Fig 1). During the procedure, the
16 25 F R 19
exact timing of reestablishment of normal MM0
17 36 F L IS
was determined by having the patient make re-
peated attempts to open the mouth. On termination
of the procedure, 1 mL (6 mg) Celestone Soluspan
ing, and previous treatments. Patients were also (Schering, Germany) was injected into the joint
asked about clenching and grinding habits. space followed by removal of the needles.
Pain level and location were determined by the Postoperative medication consisted of Naproxen
patient’s self-assessment using a facial diagram and (Teva, Israel) sodium 275 mg three times daily and
two visual analog scales (VAS).” By drawing cir- diazepam 2.5 to 5 mg/d before bedtime to be taken
cles on the diagram, the patient indicated the pain- for 2 weeks in association with the use of a bite
ful areas. One VAS (ranging from 0 to 15) was used appliance at night. All patients were started on a
to assess the level of pain (VAS I). Another (ranging physiotherapy program immediately following the
from 0 to 1.5)was used to assess the level of distur-
bance in jaw function (VAS II). The clinical exam-
ination included evaluation of MM0 as measured
by the distance between the incisal edges of the
upper and lower central incisors; determination of
the range of lateral and protrusive movements of
the mandible, as measured by the distance between
the upper and lower midlines on lateral and forward
movements; evaluation of the characteristics of the
limitation in the jaw motion (mechanical origin,
pain, persistence, intermittence, timing); and the
presence of joint noises judged clinically as none,
early, or late clicks and crepitus. The criteria for
inclusion in the study were persistent, sudden, dis-
abling, but not necessarily painful, limited MM0 of
less than 30 mm clearly originating in the TMJ. Lim-
itation was associated with impeded lateral move-
ments toward the unaffected side, as well as devi-
ation toward the affected side in opening and pro-
trusion movements. When opening was forced,
pressure or pain was exacerbated in the affected
joint. Patients with evidence of fibrous adhesions
were excluded. All patients had proved refractory FIGURE 1. Two needles inserted in the upper compartment of
to conservative treatment (medication, bite appli- the right temporomandibular joint. Note the free flow of fluid via
ance, physiotherapy, and manipulation of the joint). the anterior needle.
NITZAN.DOLWICK,AND MARTINEZ 1165

procedure to maintain and/or increase their range of
jaw motion.
Foflo~wp. At least 4 months postoperatively,
the patients were evaluated by a self-assessment
questionnaire and by clinical examination. Three
VASs were also used WAS I, VAS II, and VAS III;
ranging from - 7 to + 7) for self-evaluation of im-
provement/deterioration compared with the status
before the procedure was performed. Clinical ex-
amination included measurement of MMO, devia-
tion on opening, lateral and protrusion movements,
and determining the presence of clicks.
Statistical analysis. Both paired and unpaired t
tests were used to compare pretreatment and post-
treatment differences in MMO, level of pain, and
level of dysfunction. The presence of an improve-
ment effect was tested using a z-tailed t test.
Results
Objective findings following treatment. As seen
in Table 2, 4 to 14 months following arthrocentesis
the patients had a significant increase in mouth
opening (P < .OOl), from a range of 12 to 30 mm
(mean, 24.1 -+ 5.6 mm) prior to the procedure to 35
to 50 mm (mean, 42.7 ? 4 mm) following arthrocen-
tesis. Lateral movement toward the unaffected joint
significantly improved as well (P < .0057), from a
range of 2 to 6 mm (mean, 3.75 ? 2.9) to 8 to 13 mm
(mean, 10.5 -C 1.O mm). The mean gain in MM0 and
lateral movement toward the unaffected side was
18.6 * 6.8 mm and 6.9 2 1.4 mm, respectively.
Twelve of the 17 patients had experienced clicking
in the affected joint before limitation had occurred.
However, following arthrocentesis, only four pa-
tients had a click.
Subjective findings following treatment. Al-
though the patients’ main complaint was the limited
mouth opening, a considerable degree of pain was
experienced and was reflected as a mean rating of
8.75 ? 2.82 mm (range, 3 to 13 mm) on a scale of 0
to 15 (VAS I) (Table 3). This range decreased sig-
nificantly (P < .OOl) following arthrocentesis and
reached a mean value of 2.31 ? 2.55 mm (Table 3).
The functional disturbance as reported by the pa-
tients was, as expected, high at the time of diagno-
sis and reached a value of 10.24 -+ I .72 mm (range,
8 to 13 mm) on a scale of 0 to I5 (VAS II). This level
decreased significantly (P < .OOl) following arthro-
centesis to 2.16 +- 3 mm (range, 0.9 to 11 mm) with
a mean gain of 8.1 k 3.1 mm on the same scale.
Patient no. 2. who had the longest duration of
symptoms, showed a marked increase in MM0 fol-
lowing treatment; however, no significant decrease
in pain and dysfunction was reported (Table 3).
The overall success rate as determined from the
patients’ self-assessment was 6.4 ? 0.9 (out of 7), a
significant 91% improvement (P = .0057) (Table 3).
A comparison between the two patient groups in-
dicates that similar outcomes (increase in MM0 and
decrease in pain level and jaw dysfunction) were
obtained at the two treatment centers (Table 4).

Table 2. Improvement in MYO, Lateral Movements, and Decrease in Clicking Following

TMJ Arthrocentesis
Lateral Motion
Toward Unaffected
MM0 (mm) Joint (mm) Clicking
Patient Follow-up
No. (mo) Before lmmed~ately After At Follow-up Before After Before Llmltatlon At Follow-up

I 14 30 42 45 5 IO
2 I2 18 42 40 3 8
3 9 28 38 38 3 IO
4 9 21 38 42 2 IO
5 18 38 47 2 10
6 8 I5 43 42 4 13
7 8 28 38 50 3 IO
8 6 30 37 43 6 II
9 5 12 38 43 4 9
10 4 22 38 42 3 II
11 12 28 _ 40 - - +
12 II 18 _ 42
13 II 32 48
14 9 28 40
15 9 26 50
16 7 29 40
17 6 27 35 +

- , Measurements not available.

1166 TEMPOROMANDIBULAR JOINT ARTHROCENTESIS

Table 3. Patient Self-Assessment Following Arthrocentesis

Degree of Pain Degree of

;o to 15) Dysfunction (0 to 15)
Improvement/Deterioration
Patient No. Before At Folloa-up Before At Follow-up ( - 7 to + 7) at Follow-up
1 8.5 3 8.5 2 7
2 II II I1 II 4.2
3 10.5 0 IO 0 I
4 9.5 0 IO 0 7
5 12 2 I? 0 6.5
6 NA 0 NA 2 I
7 0 8 0 7
8 0 9 0 7
9 8.5 2.5 13 0.9 6
10 8 1.5 12 0 7
II 7.5 1.0 13 7.4 4.8
12 8 3 IO 3.0 5.6
13 9.5 2.5 x.5 0.5 7
14 7.5 2.0 8.0 3.0 7
I5 6.0 2.8 10.6 3.2 6.8
16 13.0 1.5 12.0 1.5 6.8
17 11.0 4.0 8.2 2.0 5.0

Abbreviation: NA. measurements not available

Discussion 4). In the follow-up period, ranging from 4 to 14

The common treatment for closed lock when re-
fractory to conservative treatment is surgical con-
touring and repositioning of the disc. A turning
point in therapy occurred when arthroscopic lysis
and lavage”-‘s and use of hydraulic pressureI in
the upper compartment were first applied for inter-
nal derangement and found highly effective in rees-
tablishing normal MM0 in joints with closed lock.
Efficacy was found to be correlated with the degree
of limitation. ‘* The effectiveness of this approach
was claimed to be due to release of the trapped,
anteriorly displaced disc by the basic arthroscopic
instrumentation, thereby enabling its reposition-
ing. 13.14
In the present study we examined the value of
lavage of only the upper compartment for releasing
a closed lock in a select group of patients who were
considered as candidates for surgical intervention.
Arthrocentesis proved to be highly effective, pro-
viding significant improvement in MM0 and lateral
movement toward the unaffected side in all patients
treated independently in two centers (Tables 2,
months, no deterioration in jaw function was noted.
On the contrary, as reflected in Table 2. physiother-
apy following such treatment produced further im-
provement. It should be noted that the same phys-
iotherapy proved useless for these patients prior to
arthrocentesis.
Although limited MM0 was the main complaint,
most patients also seemed to experience a high level
of pain. Both the pain level and disturbance in jaw
function decreased dramatically following treat-
ment (Table 3). Patient no. 2, who experienced the
longest duration of symptoms, was the only one
who still experienced severe pain and functional
limitation despite significant improvement in MMO.
The validity of these results is further confirmed by
the fact that similar outcomes were obtained in the
two groups diagnosed and treated in independent
centers (Table 4).
Thirteen of 17 patients did not have clicks follow-
ing the arthrocentesis. This was a unexpected find-
ing. Three patients (patients 6, 7, 8) did not experi-
ence clicks even prior to the onset of severe, limited
MMO. This certainly suggests that such limitation

Table 4. Mean Increase in MM0 and Decrease in Pain Level and Joint Dysfunction Following
TMJ Arthrocentesis Performed Independently at Two Centers

Degree of Pain Degree of

MM0 (mm) (0 to 15) Dysfunction (0 to 15)
No. of Follow-up
Patients (mo) Before After Before After Before After

Center 1 10 4to 14 22.7 2 5.5 42.2 i- 3.6 8.8 + 2.8 2.3 + 3.5 10.2 + 1.7 1.7 2 3.6
Center 2 7 6to 12 26.8 + 4.3 41.4 2 6.6 8.8 2 2.3 2.4 5 .9 10 + 2.3 2.9 + 2.2
NITZAN, DOLWICK. AND MARTINEZ
may occur in joints with normally placed disc, and
gives the attribution of an incorrect disc shape and
location very questionable status in the etiology of
the disorder. Clicking probably ceased in the joints
of the other 10 patients as a result of the disc be-
coming nonreducible.
The basis for the efficiency of this approach is not
clear. However, the role of the nonreducible disc in
obstructing the condylar path, and thereby severely
restricting MMO, is questionable. We speculate
that sliding of the disc is totally prevented by its
adherence to the fossa, which occurs more often in
deranged joints, but may likewise affect joints with
normally placed discs. This inability of the disc to
slide, which is persistent in nature, but readily re-
versed by simple lavage, might result from adhesive
forces originating from an increase in synovial fluid
viscosity or from a vacuum effect created between
the disc and fossa. Such events may occur as a
result of extended pressure applied to the joint,
which may be a consequence of parafunctional hab-
its such as clenching. Such pressure is claimed to
force the synovial fluid away,” allowing the adher-
ence of the disc to the posterior slope of the artic-
ular eminence. The injected fluid enables the disc to
slide and thereby reestablishes normal maximal
opening in a selected group of patients.
This study has demonstrated the efficacy of arth-
rocentesis of the upper TMJ compartment in cases
of suddenly occurring, severe, and persistent lim-
ited MM0 originating in the joint. It is suggested
that this simple, less invasive, inexpensive, and
highly efficient procedure, which can be performed
under local anesthesia, be tried before surgery is
used in these cases.
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