TMJ Arthrocentesis

What is Jaw Joint Arthrocentesis?
TMJ / Jaw Joint Arthrocentesis (the washing out
of the jaw joint space) is a procedure during
which the jaw joint is washed out with sterile
saline ± anti-inflammatory steroids, long-acting
local anæsthetics, painkillers or collagen
components.

TMJ / Jaw Joint Arthrocentesis reduces jaw joint pain,
improves jaw joint function and reduces jaw joint clicking.
TMJ / Jaw Joint Arthrocentesis of the (upper) joint space
reduces jaw joint pain by:

• diluting / flushing out the inflammatory chemicals from the jaw joint
  
• increasing mandibular (lower jaw) movements by removing intra-articular adhesions (scarring within the joint space)
  
• eliminating the negative pressure within the jaw joint
  
• recovering disc and fossa space and improving disc mobility (return the disc of cartilage to its normal position within the joint) which reduces the mechanical obstruction caused by the anterior (forward) position of the disc.
  

The majority of restricted opening is secondary to upper
joint space problems, particularly ‘anchored disc’
phenomenon, where arthrocentesis is particularly beneficial.

When is Jaw Joint Arthrocentesis used?
Indications for arthrocentesis are:

• dislocation of the articular disc ± reduction
  
• limitations of mouth opening originating in the jaw joint
  
• joint pain and other internal derangements of the TMJ.

What does the treatment involve?
TMJ / Jaw Joint Arthrocentesis usually takes place under aGeneral Anæsthetic - this means you will be asleep for the
entire procedure.  Whilst you are asleep, two small
needles will be inserted into the TMJ / Jaw Joint.  One of
these needles allows sterile saline to be pumped into the
joint under pressure whilst the other needle allows the
saline to drain out of the joint.

What are the possible complications?
Complications after puncture of the TMJ depend on the
anatomy of the joint and its relations.

Possible complications of TMJ / Jaw Joint Arthrocentesis 
also depend on the technique used.  The complication rate
following TMJ / Jaw Joint Arthrocentesis is given as
between 2 - 10%.

Complications usually present in the immediate post-
operative phase and are mostly associated with fluid
collection and vascular injury.

• Facial Muscle Weakness (< 1.0%) (temporary / permanent) resulting from injury to the Facial Nerve whilst gaining access to the jaw joint space.  The most common problem resulting from this, is the inability to wrinkle the brow, raise the eyebrow or gain tight closure of the eyelids.
  

• Numbness (< 2.5%) (temporary / permanent) of certain areas of skin in the region of the jaw joint and sometimes in more remote areas of the face or scalp.
  

• Bleeding within the jaw joint which cannot be adequately controlled and could require immediate intervention by open joint surgery.
  

• Ear problems (< 9.0%), including inflammation of the ear canal, middle / inner ear infections, vertigo, perforation of the ear-drum and temporary / permanent hearing loss.
  

• Instrument Separation (that is, the needle breaks off within the joint space) which may require open joint surgery.
  

• Facial Scarring from the entry injection.
  

• Damage to the jaw joint surface during the arthrocentesis procedure, usually of a reversible nature but which could permanently affect joint function.
  

• Unsuccessful entry into the jaw joint or inability to accomplish the desired procedure because of limited motion of the jaw joint / scarring.
  

• Worsening of present TMJ symptoms which may require repeat arthrocentesis, arthroscopy or open joint surgery.
  

• Changes in the bite after arthrocentesis which may affect chewing functions.  In addition, there may be temporary / permanent limited mouth opening.
  

• Post-operative infection requiring additional treatment.
  

• Adverse / Allergic reactions to any of the medications used in the procedure.
  

• Pre-Auricular Hæmatoma.
  

• Extravasation of fluid from the jaw joint into the surrounding tissues.
  

Preauricular Incision For TMJ surgery

General considerationsThe preauricular approach can be used to access and treat fractures in the mandibular condylar head and neck region. Many surgeons perform temporal mandibular joint (TMJ) surgery and routinely use this incision to access the superior portion of the mandibular condylar process.

The illustration demonstrates the access and the amount of exposure.

Neurovascular structures
Branches of the facial nerve may be involved in this incision and dissection.
The superficial temporal artery and vein are commonly encountered in this surgical approach. The vessels should be conserved if possible.

Exposure offered by extraoral approachesSubmandibular approach

Retromandibular

• Transparotid
• Retroparotid

Preauricular approach

Facelift incision (rhytidectomy)

Skin incision

General consideration
Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. The two options currently available are the use of local anesthetic or a physiologic solution with vasoconstrictor alone.

Use of a local anesthetic with vasoconstrictor may impair the function of the facial nerve and impede the use of a nerve stimulator during the surgical procedure. Therefore, consideration should be given to using a physiological solution with vasoconstrictor alone or injecting the local anesthetic with vasoconstrictor very superficially.

Make the incision in a preauricular skin crease.

Dissection

Locating temporalis fascia
Carry the incision through the skin and subcutaneous tissues to the depth of the temporalis fascia. The temporalis fascia is a glistening white tissue layer that is best appreciated in the superior portion of the incision.

The superficial temporal vessels may be retracted anteriorly with the skin flap (sectioning some posterior and superior branches) or left in place (sectioning frontal branches).

The zygomatic arch can easily be palpated at this point of the dissection. The lateral pole of the mandibular condyle can also be palpated. This can be facilitated by having a surgical assistant manipulate the jaw.

Incising temporalis fasciaMake an oblique incision parallel to the frontal branch of the facial nerve, through the superficial layer of the temporalis fascia above the zygomatic arch.

Dissection of the joint capsuleInsert the periosteal elevator beneath the superficial layer of the temporalis fascia and strip the periosteum off the lateral zygomatic arch.

Dissection will be carried inferiorly to expose the capsule of the TMJ.

Coronal view of dissection to the lateral portion of the zygomatic arch and mandibular condyle region.

Note: the frontal branch of the facial nerve is protected within the superficial layer of the deep temporalis fascia.

Optional: capsule incision

In the rare case of treating condylar head fractures the TMJ capsule is incised in an open manner.

Dissection can be carried inferiorly in a subperiosteal plane to reach the neck of the mandibular condyle.
A disadvantage of this approach is that the surgeon can reach only a limited portion of the condylar neck region.

Wound closure

If the TMJ capsule has been incised to access the condylar head it must be closed as the first step.

The temporalis fascia is closed as the next step.

Skin and subcutaneous sutures are placed.

A pressure dressing may be placed over this wound according to surgeon’s preference.

Arthroscopy for Temporomandibular Joint Disorder

Arthroscopy is a word derived fro the Greek words for "joint" and "examine." It is a type of surgery in which a tiny fiber optic camera and is inserted through a small incision directly into the joint. Because it provides a clearer image of the actual joint space than any other imaging technology, arthroscopy was originally used to diagnose problems in a joint. However, the technique has been refined over the last few years, and surgeons are now able to insert very small surgical instruments through nearby incisions, and to actually perform the surgery by looking at a video image of the joint space on a screen.

While some TMD surgery must still be done using open joint surgery, many or most surgical procedures can now be conducted arthroscopically. For example, arthroscopy can be used to correct many disc displacements, to remove torn or frayed pieces of the cartilage, to repair discs, to perform some menisectomies, or to rinse out the joint space (a procedure called arthrocentesis, or lavage).

Arthroscopy has multiple benefits over open surgery to the joint, because it is much less invasive. Arthroscopic surgery has a lower chance of infection and other post-operative complications, and less post-operative scarring. It also can usually be done as a day procedure. Patients feel less post-operative pain and recover full use of their jaw much more quickly than after open surgery.

Treatment

The surgery takes approximately 3 hours and patients generally go home the same day after a short recovery from the anesthesia. Small (around 3mm) incisions are made over the jaw, through which a tiny fiber optic camera and instruments are inserted directly into the joint. The camera projects an extremely accurate image of the joint onto a screen, and the surgeon uses this image to guide the surgery.

Patients generally experience minimal post-operative pain, and are able to eat and drink right after the surgery. Full recovery may take one to three weeks, during which patients may have to limit their diet to soft foods and to work with a physical therapist.

Buccal advancement flap

Caldwell-Luc operation

The Caldwell-Luc operation (in the Oral Surgical use of
the procedure) is used for the:

• Removal of tooth roots within the sinus
  
• Removal of dental cysts within the sinus
  
• Closure of mouth-sinus communications (oro-antral fistulæ)
  
• Reduction of facial fractures especially those involving the orbital floor
  

In the Ear, Nose & Throat sense, the Caldwell-Luc 
procedure is used for:

• Treatment of chronic sinusitis
  
• Removal of antral polyps and cysts & antro-choanal polyps
  
• Removal of antral mucocœles
  
• A route to the ethmoid and sphenoid sinuses
  
• Visualisation of the orbital floor for decompression
  
• Vidian (nerve of the Pterygoid Canal) neurectomy
  
• Various forms of tumour surgery and
  
• Access to the pterygo-maxillary fossa (the space
  

behind the maxillary sinus).

The procedure can be carried out under Local 
Anaesthetic though it may be a pleasanter experience all 
round for it to be carried out under General Anaesthetic.

A small cut is made between the upper lip and gum and a
bone window is made (giving access to the maxillary 
sinus) in the anterior wall of the maxillary sinus.
The natural opening of the sinus into the nasal cavity is 
often enlarged at the same time to improve drainage of 
normal secretions and reduce the chance of recurrent 
disease.

Occasionally, a new opening (naso-antral window) is also 
created between the nose and maxillary sinus.