Oral Maxillofacial Surg Clin N Am 18 (2006) 311328

ArthrocentesisdIncentives for Using This Minimally Invasive Approach for Temporomandibular Disorders
Dorrit W. Nitzan, DMD
The Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, The Hebrew UniversityHadassah School of Dental Medicine, P.O. Box 12272, Jerusalem 91120, Israel

Arthrocentesis is traditionally dened as a procedure in which the uid in a joint cavity is aspirated with a needle and a therapeutic substance is injected. The procedure is generally performed under local anesthesia and strictly sterile conditions. Because of its simplicity, it may be performed repeatedly if necessary [13]. The Aztec Indians, as described approximately 5 centuries ago by Bernardino de Sahagun, realized that an inamed joint was potentially harmful and were the rst to perform therapeutic arthrocentesis using an unspecied thorn. They also described the nature of the aspirated uid, which they compared with the viscid uid from the leaves of the nopal cactus [46]. In the 1960s, joint arthrocentesis became a subject of interest in the medical literature. The method is known to provide symptomatic relief, especially in cases of traumatic synovitis. Various techniques have been developed for performing arthrocentesis in dierent joints, such as the hip [7,8], knee [914], manubrium of the sternum [15], shoulder [16,17], tarsus [18], wrist [19], ankle [20], and even the rst metatarsal and metacarpal phalangeal joints [21,22]. For wider use, greater expertise, and enhanced reliability, physicians are encouraged to practice the procedure on cadavers or simulate it on plastic models before they apply it to patients [2326]. A self-arthrocentesis option was also described [27]. The three-way stopcock was suggested as a useful adjunct in the practice

of arthrocentesis [28]. Microdialysis as a replacement for arthrocentesis to allow collection of serial synovial uid samples was developed in dogs [29]. Studies on arthrocentesis Numerous studies have shown the exceptional diagnostic and therapeutic value of arthrocentesis while emphasizing the low incidence of associated complications, including joint contamination [13,3032] and local irritation caused by introduction of foreign materials [33,34]. Several studies show the high eectiveness of arthrocentesis for macroscopic diagnosis and therapy in emergency care of diseased joints [2,35,36]. Emergency care diagnosis of joint swelling and pain of unknown origin can be assisted by arthrocentesis. For example, when hemarthrosis is suspected, aspiration of blood from the joint conrms the diagnosis and prevents devastating damage caused by hemorrhage pressure and sequelae, such as broadhesions [37]. Numerous tiny globules oating in the blood aspirated from the joint are indicative of intra-articular fracture [38]. Aspiration of pus from a symptomatic joint establishes the diagnosis of septic arthritis, an acute emergent condition requiring immediate care. In such cases, arthrocentesis provides not only rapid diagnosis and samples for culture and antibiotic sensitivity testing but also instantaneous symptomatic relief. The aspiration of relatively clear uid from perfused joints is indicative of acute, nonspecic arthritis, such as pseudogout and lupus erythematosus [3840]. Arthrocentesis is especially critical
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for immediate diagnosis in disputed cases, such as suspicion of septic arthritis in patients who have hemophilia [41] or rheumatoid arthritis controlled by cytotoxic drugs [32]. After macroscopic evaluation, the uid aspirated from a joint can be subjected to further diagnostic workup. Fluid obtained from diseased joints can show a single- or multiple-strain infection [7,4245], and identication of the pathogens enables the joint to be treated with specic antibiotics. The isolation of Streptococcus from a symptomatic joint was the presenting symptom of bacterial endocarditis and led to its diagnosis and treatment [46]. Microscopic analysis of the synovial uid is also a valuable diagnostic tool. Identication of crystals allows innocuous eusion caused by osteoarthritis to be dierentiated from that caused by crystal-induced inammation and the vastly more dangerous septic arthritis [38,47,48]. Determining total white blood cell count and the percentage of polymorphonuclear cells in synovial uid may distinguish between inammatory and noninammatory disease, and is essential for judging therapeutic success [49,50]. The presence of succinic acid and to a lesser extent lactic acid or depressed glucose concentrations in synovial uid is a useful marker in diagnosing septic arthritis [51]. Measuring total protein, albumin, and individual immunoglobulins permits mechanical, acute inammatory, and chronic inammatory processes to be distinguished, especially when compared with serum values [52]. However, the value of biochemical studies of synovial uid has often been challenged [49]. Analytic studies on substances aspirated by arthrocentesis have provided insight into the normal and diseased joint. For example, these analyses showed the importance of kinins in the generation of pain in inamed joints [53], and that the use of kinin agonists and kallikrein inhibitors is warranted. Pain mediators, including prostaglandins and thromboxane B, have been detected in osteoarthritis. Researchers have proposed that IgEcontaining immune complexes are produced intra-articularly, providing evidence for their role in rheumatoid synovitis [54]. Calpain is an intracellular proteinase with proteoglycan-degrading activity that, together with its inhibitor calpastatin, contributes to the turnover of the cartilage matrix in osteoarthritic joints [55]. The concentration of cartilage proteoglycan components in the synovial uid reects the synthesis and degradation of the joint cartilage

matrix and is used for diagnosis, grading, and prediction of outcome of various joint diseases, such as gout, pseudo-gout, and reactive arthritis. Interleukin (IL)-6, when present in the synovial uid of chronically and actively diseased joints (eg, rheumatoid arthritis, psoriatic arthritis), induces antibody activity in the synovial uid but remains restricted to the cytoskeletal components of synoviocytes. Matrix metalloproteinase-1 is also a valuable biomarker for joint disease and its prognosis, but because frequent arthrocentesis could increase its activity, a 2-week interval is recommended between consecutive arthrocenteses [56]. Vascular endothelial growth factor (VEGF) isolated from osteoarthritic joints suggests its role in the development osteoarthritis. The author developed an animal model of VEGF-induced osteoarthritis, which revealed the crucial role of the subchondral bone in the development of osteoarthritis. Repeated arthrocentesis and exercise could also aect synovial uid concentrations of nitric oxide, prostaglandin E2, and glycosaminoglycans in healthy equine joints [18]. Although these ndings represent an already respectable body of knowledge on synovial uid, much remains unknown.

Arthrocentesis of the temporomandibular joint Most studies on TMJ arthrocentesis refer to temporomandibular disorder (TMD), which comprises a wide variety of disorders of the TMJ, the masticatory muscles, or both [58,59]. TMD is a commitment-free term that clinicians and researchers frequently use that avoids well-dened dierential diagnoses, thereby providing poorly dened diagnostic criteria for clinical research and, in many cases, indiscriminate treatment. Pain and dysfunction of the TMJ itself account for a small proportion of TMD conditions, and are often insuciently diagnosed. In addition, the increased use of articial joints and performance of multiple TMJ surgeries [60] have necessitated the treatment approach to TMJ disorders to be reevaluated based on a better understanding of TMJ function and dysfunction. The prime suspects in symptomatic synovial joint are intra- and extra-articular overloading and immobilization. Accurate diagnosis of the cause of overloading and the origin of limitation and pain will lead to appropriate treatment followed by joint rehabilitation. Prompt care using the simplest means is recommended, and surgical intervention requires prudent justication.

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The eectiveness of TMJ arthrocentesis in some disorders and its ineectiveness in others has rened the understanding of TMJ function and dysfunction. Furthermore, this simple procedure dramatically decreased the surgical interventions and their sequelae for various disorders [58,59]. Articular disc displacement in the TMJ was described and identied as a potential clinical problem more than 100 years ago [58]. It was the postulated cause of joint pain, limited mandibular movement, joint sounds, and osteoarthrotic changes in the TMJ. However, the location of the disc has gradually lost importance in TMJ pathology because disc displacement has been diagnosed in normal individuals and often is not associated with joint pain [61,62]. Most importantly, arthrocentesis [6366] or arthroscopic lavage and lysis [63] of the TMJ upper compartment markedly improved function and alleviated pain in disorders such as severe closed lock, without changing the disc position [67,68]. Consequently, the focus shifted from studies on disc position to searching for the intra-articular biomechanical and biochemical events that underlie pain and disc displacement. Diagnosis and treatment should be based on an understanding of TMJ function and the development of dysfunction. Temporomandibular joint performance Lubrication of the temporomandibular joint An ecient lubrication system in the TMJ is absolutely necessary so the disc can slide along the slope of the eminence. Two major constituents are responsible for free joint movement: surfaceactive phospholipids and hyaluronic acid. Surface-active phospholipids, the major boundary lubricants protecting articular surfaces, are highly eective lubricants [69,70]. In the TMJ, Marchetti and colleagues [71] identied an electron-dense layer that was not discernible in disordered joints, postulating that this covering layer maintained proper joint function and prevented conditions conducive to adhesion [71]. Another animal study showed osmiophilic layers with embedded vesicular structures and multilamellar structures with diameters of up to 290 nm [72] that were similar to the surface coat described by others [69,70,73,74]. The osmiophilic droplet cluster in centrifuged synovial uid is degraded after exposure to phospholipase A2, which is specic for phospholipids. The polar lipids in the TMJs consist mostly of phosphatidylcholine, with much lower levels of

phosphatidylethanolamine and sphingomyelin [72]. Phospholipase A2, an enzyme secreted into the synovial uid that acts specically on phospholipids [75], increases friction when added to synovial uid. Hyaluronic acid, a high molecular weight mucopolysaccharide, forms a full uid lm that keeps the articular surfaces separated and prevents friction. In vitro, adherence of hyaluronic acid to phospholipid membranes (liposomes) protects them from hydrolysis by phospholipase A2 [76]. Thus, hyaluronic acid probably plays an important indirect role in joint lubrication by adhering to surface-active phospholipids, which are thereby protected against uncontrolled degradation by phospholipase A2 [72]. A similar defense mechanism has been described at the cellular level [77]. Further in-depth studies on the joints lubrication system might eventually lead to development of appropriate products to prevent and treat TMJ disorders, and improved intra-articular injection materials. Impaired lubrication of the temporomandibular joint Joint function remains normal if its adaptive capacity is not compromised [7881]. Parafunctions, such as clenching, are good examples of repetitive jaw motion associated with possible high TMJ impact loading that convert shearing stresses to compressive stresses [82]. Intra- and extra-articular overloading which exerts many eects on synovial joints [8388] (eg, interruption of the blood supply) is, in addition to other complications, a major reason for collapse of the lubrication system [8991]. When overloaded, the generated hypoxiareperfusion cycle in the joint evokes nonenzymatic release of radical oxygen species (ROS), such as superoxide and hydroxyl anions [89,91]. The highly reactive ROS undergo rapid chemical reactions in various tissues and can destroy important molecules. In addition to the direct oxidative damage to lipids within the inamed human [92], the ROS degrade hyaluronic acid, causing a marked decrease in synovial uid viscosity in vitro [93] The degraded form of hyaluronic acid indirectly aects joint lubrication because it fails to inhibit phospholipase A2 (Fig. 1) [76]. Phospholipase A2 that is secreted into the synovial uid is free to lyse surface-active phospholipids and therefore thins, jeopardizing the continuity of the surface-active phospholipid layer [76]. In the absence of lubricant, the articular surfaces are smooth planes [94], implying large contact

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Fig. 1. The superior compartment of the TMJ. Details of the normal lubrication system (A) and the collapse of the lubrication system (B): free radicals are degrading the hyaluronic acid (HA), enabling lysis of surface-active phospholipids.

areas that, with the surfaces elasticity (such as at the disc) and the high surface energy [12,9597], lead to increased adhesiveness, friction, shear, and rupture of articular surfaces [72,83,98]. The following discussion details the eect of decient lubrication and its resultant friction and adhesive forces on the development of joint dysfunction, and the associated role of arthrocentesis. Temporomandibular joint arthrocentesisdtechnique Murakami and colleagues [99] oered the rst systematic description of TMJ arthrocentesis, which they termed manipulation technique after pumping and hydraulic pressure. Arthrocentesis of the TMJ is a modication of the traditional method, whereby two needles instead of one are introduced into the upper joint space. This adaptation permits massive lavage of the joint, in addition to aspiration and injection [66]. The patient is seated at a 45 angle, with the head turned to the unaected side to provide an easy approach to the aected joint. After proper preparation of the target site, the external auditory meatus is blocked with cotton soaked in

mineral oil. The points of needle insertion are marked on the skin according to the method suggested by McCain for performing arthroscopy. A line is drawn from the middle of the tragus to the outer canthus. The posterior entrance point is located along the canthotragal line, 10 mm from the middle of the tragus and 2 mm below the line (Fig. 2). Murakami and colleagues [99] and Segami and colleagues [100] used the posterior port only for pumping uid into the upper compartment to increase the hydraulic pressure within the joint. The anterior point of entry is placed 10 mm farther along the line and 10 mm below it. These markings over the skin indicate the location of the articular fossa and the eminence of the TMJ (see Fig. 2). A local anesthetic is injected at the planned entrance points, avoiding penetration into the joint and injection into the synovial uid. A 19gauge needle connected to a 1-mL syringe lled with lactated Ringers solution is then inserted into the superior compartment at the articular fossa (posterior point) aided by palpation. The solution is injected and immediately aspirated. The uid in the syringe is often sucked into the joint space, which normally has negative pressure. This procedure is repeated three times to obtain a sucient amount of uid for diagnostic and research purposes. Next, 2 to 3 mL lactated Ringers solution or bupivacaine, 0.5%, are injected to distend the upper joint space and anesthetize the adjacent tissues. A second 19-gauge needle is then inserted into the distended

Fig. 2. Arthrocentesis procedure. Two needles are placed in the anterior and posterior recesses of the upper joint space.

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compartment in the area of the articular eminence to enable free ow of Ringers solution through the superior compartment (see Fig. 2). In cases of sluggish outow, additional needles may be inserted into the distended compartment to enhance the transport of the solution. Zardeneta and colleagues [101] recommended a free ow of 100 mL of Ringers solution because denatured hemoglobin and various proteinases were recovered in this fraction, whereas Kaneyama and colleagues [102] suggested that 300 to 400 mL be used for the washout of bradykinin, IL-6, and proteins. This procedure can be simplied by inserting the second needle next to the rst one, in the posterior rather than the anterior recess, and ushing saline through the upper compartment. During the lavage, the mandible is moved through opening, excursive, and protrusive movements to facilitate lysis of adhesions [100]. At the end of the procedure and after one needle is removed, medication can be injected into the joint space. Hyaluronic acid is one supplement of arthrocentesis [103105], but its eectiveness is still

debated [106]. The potency of hyaluronic acid is minimal if inammatory products in the aected joint are allowed to degrade it, but removing the inammatory products through arthrocentesis allows the hyaluronic acid to remain intact and probably be more eective. A more ecient lubricating supplement is being developed by the author. Temporary facial paresis or paralysis caused by the use of a local anesthetic, or swelling of the neighboring tissues caused by perfusion of Ringers solution may occur during arthrocentesis. However, these eects are transient and disappear within a few hours. Numerous other complications associated with arthrocentesis have been described. A 59-year-old woman remained drowsy and developed a left hemiparesis after TMJ arthrocentesis, caused by an extradural hematoma shown on CT [107]. Fig. 3A shows a woman referred to the authors clinic with severe preauricular infected swelling that developed after arthrocentesis, and Fig. 3B shows the severely limited mouth opening caused by bilateral ankylosis (Fig. 3C)

Fig. 3. Acute infection (A) after arthrocentesis performed without correct diagnosis of the severely limited mouth opening (B) caused by bilateral TMJ ankylosis (C).

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misdiagnosed and treated through arthrocentesis. Correct diagnosis and the appropriate treatment approach should not cause any complications. The major challengers of synovial joints are joint immobilization [108] and joint overloading [84,89,91,109111]. By eliminating inamed synovial uid, releasing the disc, or reducing pain, arthrocentesis decreases the intra-articular overloading and enables joint mobilization. However, to accomplish this, arthrocentesis should be complemented by physical therapy (eg, increasing joint movement and muscle strength and length) and reduction of extra-articular loading (eg, rest, soft diet, medication, relaxation techniques to reduce bruxism, unloading interocclusal appliances [82], replacement of missing posterior teeth, relaxation, behavioral modication techniques, medications).

The role of arthrocentesis in various temporomandibular disorders Arthrocentesis has been widely studied. However, favorable results are usually reported for nonspecic diagnoses such as TMJ disorders or TMJ internal derangement [118124]. Arthrocentesis has been reported to reduce TMJ pain [66,113,117,118,121123,125128], improve function [118122,129], and reduce clicking. Increasing studies conrm the long-term eectiveness of arthrocentesis [64,66,118,121,129131], whereas others claim long-term prospective studies are still needed [124,132]. Diagnostic criteria are insuciently dened, undermining clinical research and leading to inecient treatment and haphazard information being provided to the patient before the procedure. Therefore, the usefulness of arthrocentesis must be related to clearly dened disorders. The clicking joint Clicking could be either intermittent or constant. Constant clicking is caused by displacement of the disc; when the mouth is opened, the displaced disc is reduced to the proper relationship with the condyle, causing the clicking noise. The displaced disc with the condyle then slide down the slope of the eminence. When the mouth is closed, the disc returns to the displaced position, which could also be associated with a clicking sound. On clinical examination, the patient usually presents normal range of motion, but the clicking is sometimes associated with a loud intolerable sound or severe joint pain. The pathogenesis of disc displacement suggests that in addition to other contributing factors, loading of the joint may be linked to displacement of the disc [133]. Although warranted, the eect of arthrocentesis on clicking has not been studied. It seems however that arthrocentesis may reduce the severity of the noise and pain, although it will likely not resolve the symptoms associated with the actual displacement. The relative ineciency of arthrocentesis for treating displacement of the disc is explained by the fact that lavage of the upper joint compartment, either arthroscopic lavage and lysis [63] or arthrocentesis [66], does not change the discs position [67,68]. On the other hand, intermittent clicking was often eliminated by arthrocentesis. Since the displaced disc does not spontaneously return to its normal position, it is postulated that intermittent clicking is caused by a cause of a reversible nature. For example, in

Temporomandibular arthrocentesisdmode of action Lavage of the upper compartment through TMJ arthrocentesis forces apart the exible disc from the fossa, washes away degraded particles and inammatory components, and decreases the intra-articular pressure whenever the joint is inamed. Studies have shown the elimination of products such as ROS, and phospholipase A2, hemoglobin [112], IL-1b, IL-6 [113], substance P [114], tumor necrosis factor [57], bradykinin, proteins [102], b-endorphin [115], prostaglandin E2, leukotriene B4, malondialdehyde, nitric oxide, and myeloperoxidase [116]. The levels of cytokines in TMJ synovial uid after successful and unsuccessful arthrocentesis reect the eect of the procedure on pain [113]. Eliav and colleagues [117] found that the mean electrical detection threshold ratios in areas surrounding the auriculotemporal nerve were signicantly elevated after arthrocentesis, indicating resolution of hypersensitivity. The released disc and elimination of inammatory products and pain allow the rehabilitation of movement, which is the hallmark of joint health. Arthrocentesis is an important diagnostic tool. Available imaging techniques do not unambiguously show severe adhesion or disruptive osteophytes to be the cause of limitation or pain. Failure of lavage implies that surgery is required and legitimate for releasing the joint and rehabilitating its movement. Arthrocentesis is a prerequisite for most TMJ surgical intervention.

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case of friction in the upper compartment following transient overloading (clenching) the disc may lag and clicking can sound when the condyle moves against the lagging disc (Nitzan DW, unpublished data, 1999). In this case lavage of the upper compartment releases the disc and enable both the condyle with the disc to move simultaneously. Limited mouth opening Many studies have described the eectiveness of arthrocentesis in releasing limited mouth opening, but have not been suciently denite. In general, the TMJ accounts for only a few disorders causing limitation, and their response to arthrocentesis varies [119121,125,134]. Denitions such as disc displacement without reduction [118,134,135] or closed lock [26,57,131,136] might be insucient if not based on clear criteria. Closed lock may include patients who have disk displacement, anchored disc phenomenon [137], or even osteoarthritis [138], which each react dierently to arthrocentesis. Disc displacement without reduction. When the disc becomes displaced and nonreducible condylar sliding is obstructed, mouth opening becomes limited. Unless pain occurs, the aected individual may not notice this disorder. Symptomatic disc displacement without reduction is characterized by limited mouth opening (between 30 and 40 mm) that develops gradually with a history of clicking. Pain occurs on forced mouth opening and loading of the aected joint, caused by the overloading and stretching of the unadapted highly innervated retrodiscal tissue. In plain open-mouth radiographs and CT scans, the TMJ always shows evidence of condylar sliding, however limited. In closed- and open-mouth positions, arthrography and MRI show the disc located in front of the condyle, without signs of osteoarthritis. In numerous studies, arthrocentesis released limitation and decreased pain caused by disc displacement [118,123,135,138]. In a study of 19 patients (15 women and 4 men aged 41.4 G 15.64 years) who had evident disc displacement without reduction and presented with a mean maximal mouth opening of 31.9 G 7.1 mm and contralateral movements of 8.2 G 2.9 mm, improvement after arthrocentesis was limited (reaching 36.4 G 6.22 mm and 8.44 G 2.35 mm, respectively). Patient-assessed pain and dysfunction levels decreased slightly, from 8.4 G 3.5 to

5.0 G 3.9, and 6.0 G 3.2 to 5.3 G 4.3, respectively, on a 1 to 10 visual analog scale (unpublished data). Unsurprisingly, arthrocentesis, which cannot change the discs shape or position [67,68], provides only limited relief for these patients. The improvement described by other studies probably occurred among patients who were not strictly dened and who suered from other disorders that respond to arthrocentesis, which are described later. [137,138]. Anchored disc phenomenon. Anchored disc phenomenon is characterized by sudden severe and persistent limited mouth opening ranging from 10 to 30 mm (considerably lower than in disc displacement without reduction) and deviation of the mandibular midline toward the aected side. Movement toward the contralateral side is limited, and on protrusion the mandible deviates toward the ipsilateral side. History of clicking is not obligatory. Although pain does not usually occur in the TMJ on loading, forced mouth opening evokes pain in the aected joint. In long-lasting anchored disc phenomena, the clinical characteristics become less apparent. On plain open-mouth radiographs and CT scans, the TMJ shows evidence of a nonsliding, rotated, normally structured condyle [64,65,138140]. On MRI, the disc appears attached to the articular eminence with the condyle sliding underneath [65,141]. Researchers have suggested that a suction-cup eect, whereby the disc clings to the articular eminence like a rubber cup attaching to a glass surface, is responsible for the limited disc movement [63]. However, because introducing one needle into the upper joint space to abolish the vacuum does not cure this limitation, adhesive forces between the disc and fossa are also implicated [65,140,142]. Joint overloading is believed to damage the normal lubrication of the joint. In the presence of subboundary lubrication, adhesive forces can apparently be generated between the pressed, denuded, smooth, elastic disc and the eminence [65,140,142]. In these situations, even a limited area of adhesion between the two opposing surfaces can suddenly hold the disc from sliding down the slope of the eminence. Forced opening is not recommended because stretching, shear, and rupture of the joints capsule and ligaments may occur when the condyle is pulled away from the adhered disc. Arthrocentesis neutralizes these adhesive forces, separates the exible disc from the rigid

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surface of the eminence, and enables smooth normal opening [6466,139]. Physical therapy and reduced joint loading should reinforce the effects of arthrocentesis. Intensive physical therapy, which is not indicated if the disc is stuck, should be undertaken after disc release. Recurrence is rare in these circumstances, probably because of the low likelihood that the two opposing articular surfaces will again become uncovered and adhere [64]. The dierent clinical signs and symptoms and imaging data of anchored disc phenomenon, disc displacement without reduction, and osteoarthritis are summarized in Table 1. Osteoarthritis. Many studies on osteoarthritis of the TMJ exist [105,117,126,134,140,143147]. In the acute phase of osteoarthritis, patients typically complain of early morning stiness in the TMJ, severe joint pain when the jaw is at rest and moving in all directions, limited mouth opening, and diculty yawning, biting, and chewing. Sometimes the symptoms are accompanied by a sensation of swelling in the TMJ area. Palpation of the aected joint during physical examination might evoke mild to severe pain. Considerable pain in the aected joint is experienced on opening the mouth or moving the jaw laterally in both directions and in the protrusive direction beyond the limits imposed by the disorder (Fig. 4). Crepitation in the arthritic joint, with or without clicking, may occur during jaw movement [148]. History of clicking is variable. Most patients do not describe these typical symptoms [149], but may complain of all or some,

with varying severity. Intense pain and discomfort may alternate with asymptomatic periods. The complaints arise at dierent ages and have varying durations [147]. If painless, patients may not even be aware of a gradually developing severely limited mouth opening [150]. Imaging of an osteoarthritic joint may show only mild changes; however, the advanced stages typically include features such as erosion of the cortical outline, loss of intra-articular space, osteophytes, marginal spurs, subcortical cysts, reduced joint space, and a perforated disc [151155]. The clinical symptoms may be inconsistent with the imaging; mild clinical disease might be associated with severe imaging appearance and vice versa. The variable presentation of osteoarthritis likely results from the various factors associated with the disease. Exposure to these factors is essential for improving insight into the origin of the signs and symptoms, and thereby rening the treatment approach. 1. One factor, overloading, or increased intraarticular pressure, causes disruption of the lubrication system and may gradually cause fatigue and wear of joint elements [76, 82,84,88,95,96,148,150,156]. 2. On the other hand, animal models have shown that sclerosis of the subchondral bone precede cartilage degeneration (Nitzan DW, unpublished data, 2006). Normally, the subchondral bone plate borders the articular cartilage, and both absorb exerted load. The subchondral bone contains fatty bone

Table 1 Comparison of the common clinical signs and symptoms and imaging of the anchored disc phenomenon, disc displacement without reduction, and osteoarthritis Characteristics Occurrence Past clicks Maximal mouth opening Contralateral movement Ipsilateral movement Pain (self-assessment) Dysfunction (self-assessment) MRI (open-mouth position) Anchored disc phenomenon Sudden No (30%) 1525 mm Limited Normal Disc stuck, located above and behind the condyle Disc displacement without reduction Gradual Yes 3045 mm Limited Normal Disc displaced deformed, located in front of the condyle Osteoarthritis Sudden/gradual No or yes 1030 mm Limited Limited None to severe to Eusion / Adhesion / Disc displaced / Deformed / Perforated disc / Very good (70%)

Eect of arthrocentesis

Excellent

Moderate

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Fig. 4. Left TMJ osteoarthritis. Limited maximal mouth opening (A). Midline is marked by interrupted line in closed mouth position (B) with deviation to the left (arrow) (C), limited lateral movements to the right (D), normal to the left (E), and limited protrusion with deviation to the left (F). Special attention should be paid to the severity of the damage to the articular surface and subchondral bone as seen in CT scan of left TMJ (G). Normal maximal mouth opening immediately after arthrocentesis (H). Normal lateral movements to the right (I), to the left (J), and protrusion (K).

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Fig. 4 (continued)

marrow and trabecular bone with subchondral venous plexuses that account for more than 50% of the glucose, oxygen, and water requirements of the cartilage. In addition, normal subchondral bone can attenuate

approximately 30% of the load through the joints, providing protection against damage caused by excessive load. Microfracturing of the subchondral bone caused by overloading is followed by remodeling associated with

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bone sclerosis. This subchondral bone has lesser shock-absorbing capacity, causing the overloaded cartilage to separate from the underlying bone. In addition, the subchondral venous plexuses that are particularly vulnerable to higher compression or shearing forces cannot support the cartilage. The subchondral bone not only fails to nourish the cartilage but also allows cytokines, growth factors, and prostaglandins produced by the subchondral bone tissue to cross the bone cartilage interface [155,157]. 3. Compromised blood supply to the subchondral bone may also induce osteoarthritis. The subchondral bone contains bone marrow and trabecular bone with many arterial terminal branches that end in sinusoids of uneven caliber and are irregularly distributed. This system might be severely damaged in elderly patients and those who have diseases such as thalassanemia or sickle cell anemia (Nitzan DW, unpublished data, 2006) [158]. 4. Immobilization is currently considered among the principal causes of joint deterioration. This deterioration is caused by the absence of natural elimination of the virulent inammatory core, which depends on joint movements that cause the necessary uctuation in intra-articular pressures [108]. However, joint overloading and immobilization are clearly the primary contributing factors to osteoarthritis. Most of the inammatory events are self-corrective. When self-correction fails, the disease becomes self-accelerating. The physicians role is to support the joints potential for selfcorrection by unloading it and recuperating its movements. Arthrocentesis forces apart the joints constituents. It also washes away the inamed synovial uid, thereby reducing pain and the loading eect of the intra-articular pressure. Joint unloading using complementary treatments such as IOA, soft diet, medication, and physiotherapy is essential for overcoming the acute stage of the disorder. Better functional performance, nutrition, waste removal, and joint lubrication will reinstate the joints self-correction. Various studies have shown improved joint function and reduced joint pain after arthrocentesis complemented by joint unloading and physiotherapy [143,146,147,159]. In the authors experience, arthrocentesis obviated the need for corrective surgery in 68.4% of patients who did not respond to other nonsurgical

treatment and were candidates for surgery [147]. After the arthrocentesis, maximal mouth opening increased from 24.4 G 2.7 mm to 43.2 G 3.1 mm, dysfunction level decreased from 11.34 G 0.66 mm to 3.4 G 0.69 mm, and pain level decreased from 9.86 G 0.73 to 3.39 G 0.76 (on a visual analog scale ranging from 0 to 15) after a follow-up period of 6 to 62 months (mean, 20.7 G 20.5 months). These outcomes are not perfect, but are sucient to obviate corrective surgery. Similar reasoning explains the eect of arthrocentesis in treating patients who have TMJ rheumatoid arthritis [160] and those presenting with severe painful TMJ swelling associated with aring in familial Mediterranean fever (Nitzan DW, unpublished data, 2000) [147]. However, in the remaining 31.6% of the patients, similar symptoms were caused by joint pathologies such as bone spicules and brous ankylosis, which are not amenable to lavage (see Table 1). Open lock versus temporomandibular joint condylar dislocation Open lock is characterized by a sudden inability to close the mouth, and is usually released through self-manipulation. Mouth opening during open lock is usually not as extreme as in condylar dislocation, and may range from 25 to 30 mm [161]. In plain radiographs and CT scans, the condyle in open lock is located under the eminence rather than in front, as would be expected in condylar dislocation. MRIs show the condyle to be located in front of the lagging disc (Table 2). The origin of open lock is probably related to diminished lubrication which increases friction between the disc and the eminence. The disc, which normally moves together with the condyle, lags behind it, and consequently the condyle slides under and in front of the disc and cannot return to its former position in the fossa; hence, the mouth remains open. Nonsurgical treatment is usually effective. If not, lavage of the upper compartment can restore sliding of the disc, allowing it to move simultaneously with the condyle. Preventing the condyle from moving in front of the disc provides relief, with rare long-term recurrence [161]. Hemarthrosis Hemarthrosis in the TMJ is characterized by complaints of painful swelling localized in aected joints and occlusal inconvenience. Patients experience limited mouth opening with deviation to the aected side, lateral movements limited to the right and left, and limited protrusion with

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Table 2 Comparison between the clinical signs and symptoms and imaging of open-lock and condylar dislocation Characteristics Age Occurrence Open lock Condylar dislocation

Maximal mouth opening during the event Reduction Dicult but self-corrective Condoyle location on radiographs In front and inferior to eminence and CT MRI (open-mouth position) Trapped condoyle located in front of the lagging disc Treatment Arthrocentesis

Younger Older Spontaneous in joints with internal Maximal opening (yawning, shouting, derangement neurogenic, neuroleptic drugs, joint laxity) Maximal opening with protrusion O Maximal opening Usually professional In front and superior to eminence Condoyle located in front of the eminence Surgery if recurrent

deviation to the aected side. Open-bite is usually diagnosed on the aected side. In the closedmouth position, transcranial radiography usually shows widening of the intra-articular space. Trauma is the most common cause of hemarthrosis, requiring immediate elimination of the blood and reduction of intra-articular pressure either through arthrocentesis or intensive physiotherapy and joint unloading to prevent articular damage and functional sequelae. Analgesics, antiinammatory agents, and antibiotics should be considered. In the emergency department, an inexperienced individual can often be misled by the nonfractured condyle and may send the patient without appropriated directions, causing severe broadhesions to develop. Other systemic diseases or local disorders of the joint may also be associated with hemarthrosis. Coagulation disorders, including acquired diseases such as leukemia, thrombopenia, anticoagulant treatment [162,163] or inherited diseases such as such as hemophilia, von Willebrand disease, and congenital thrombopathies [9], are the main causes of systemic diseases. Hemoglobinopathies, particularly sicklecell disease, are responsible for hemarthrosis in some patients. Local or regional disorders of the joints include tumors, pigmented villonodular synovitis, and degenerative and metabolic diseases. The search for an origin, which is often dicult, should include a review of prior illnesses; a study of coagulation; local clinical, radiologic and biologic investigations; and a study of the synovial uid. Specic therapy is dependent on the cause. Summary TMJ arthrocentesis is a nonarthroscopic lavage performed through two needles that are introduced into the upper compartment of the joint. This

procedure often replaces surgical intervention in the TMJ when complemented by joint uploading and physiotherapy. It is highly ecient in resolving signs and symptoms associated with disorders caused by adhering forces or friction that is eliminated by lavage, such as intermittent clicking, anchored disc phenomenon, and open lock, and is also ecient for releasing limited mouth opening and pain in approximately 70% of patients who have TMJ osteoarthritis. The outcomes are suciently eective to prevent further surgical intervention. Arthrocentesis is clearly inecient in disorders caused by factors that cannot be eliminated by lavage, such as disc displacement with reduction, disc displacement without reduction, and brous adhesions. Knowledge of the eciency and ineciency of arthrocentesis has improved the understanding of TMJ disorders, thus this procedure serves as a valuable diagnostic tool. Furthermore, the aspirated uid can be used for diagnosis, therapy, and research of TMJ disorders. References
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