Athrocentesis: What, When, and Why?

The introduction of temporomandibular joint (TMJ) arthroscopy by Onishi in 1970 (results published in 1975 and 1980) opened a new modality for TMJ treatment. The efficiency of arthroscopic lavage and lysis led in the 1990s to its simplification: TMJ arthrocentesis. Always associated with load control, physiotherapy, and elimination of any occlusal hazards, arthrocentesis, a simple procedure, entails less expensive and more available tools and is performed under local anesthesia. Although lacking direct visual inspection of the joint structures, it has become quite popular. Arthrocentesis is most efficient in localized joint pain and limited joint movements such as closed lock, anchored disc phenomenon, osteoarthritis, and various inflammatory diseases. In clicking joint, the results are somewhat controversial. The efficiency of arthrocentesis elicited many enquiries that led to the study and a better understanding of joint function and dysfunction and the actual role of disc location. The release of closed lock without disc repositioning was quite surprising; it improved our understanding of the pathogenesis of closed lock and led to the discovery of the anchored disc phenomenon. This was followed by the awareness of the joint-lubrication system and, in turn, alternative suggestions for the pathogenesis of TMJ disc displacement with and without reduction, open lock, and osteoarthritis, and ultimately by the development of an effective bio-lubricant. Awareness of the role of joint overloading led to the development of an interocclusal appliance that reduces intraarticular pressure; it has become a "must" support for arthrocentesis and any surgical intervention. In our view, arthrocentesis is the definitive indication of the need for surgical intervention and, therefore, should be the first in the cascade of interventions in TMJ disorders.

"Closed Reduction" Principles Can Manage Diverse Conditions of Temporomandibular Joint Vertical Height Loss: From Displaced Condylar Fractures to Idiopathic Condylar Resorption.

PURPOSE: The aim of this case series was to describe a modification of the classic "closed reduction" technique to manage unilateral or anterior open bite owing to a loss in vertical height (LVH) caused by several disorders and pathologies other than displaced condylar fractures. MATERIALS AND METHODS: The protocol included insertion of an occlusal appliance to increase the height of the premature contact and the width of the open bite, stabilization of the dental arches by rigid arches, and the use, during sleep, of rubber bands in the open bite region to pull the mandible cranially. In addition, when awake, the patient performed physiotherapy exercises to guide the mandible into maximum intercuspation. The increased open bite enhanced the effect of the rubber bands in guiding the mandible into the original habitual occlusion and the rigid arches served to minimize tooth eruption. RESULTS: The present cases showed the favorable outcome of this low-risk treatment in the re-establishment of the original habitual occlusion within 1 to 4 weeks and without reconstruction of the LVH. CONCLUSION: The efficacy of this complication-free approach to correct occlusion in various conditions of LVH suggests that this protocol should be applied before venturing into surgical intervention.

Effect of Arthrocentesis on Symptomatic Osteoarthritis of the Temporomandibular Joint and Analysis of the Effect of Preoperative Clinical and Radiologic Features.

PURPOSE: To evaluate the long-term outcome of arthrocentesis in patients with symptomatic temporomandibular joint (TMJ) osteoarthritis that was unresponsive to nonsurgical interventions. MATERIALS AND METHODS: Seventy-nine patients (83 joints) with symptomatic TMJ osteoarthritis that had not responded to nonsurgical interventions and who underwent arthrocentesis were included in this study. Demographic, clinical, and radiologic data, including assessment of pain, dysfunction, improvement, and satisfaction, and maximal mouth opening were analyzed. RESULTS: The analysis included 67 female patients (84.8%) and 12 male patients (15.2%), 13 to 70 years old, who were followed for 56.9 ± 6.7 months. Sixty-four (81%) reacted favorably to arthrocentesis. For these patients, maximal mouth opening increased from 26.3 ± 0.8 to 39.24 ± 0.9 mm (P < .001). Pain and dysfunction scores decreased from 6.92 ± 0.2 to 2.36 ± 0.3 (P < .001) and from 7.37 ± 0.2 to 2.24 ± 0.4 (P < .001), respectively. Overall score for patient satisfaction with arthrocentesis was 8.78 ± 0.3. The procedure had no lasting complications. Remarkably, the severity of preoperative pain, dysfunction, and range of motion and of radiographic changes did not correlate with the outcome of arthrocentesis. The severity of preoperative or postoperative signs and symptoms was not correlated with the severity of radiographic changes. CONCLUSIONS: For most patients, arthrocentesis offers long-term favorable outcomes for symptomatic TMJ osteoarthritis that has not responded to nonsurgical treatments and otherwise would have required surgical arthroplasty. Severity of preoperative clinical and computerized tomographic findings is not predictive for the success of arthrocentesis. In addition, the lack of correlation between the clinical and radiologic findings negates the commonly used Wilkes classification, which presumes that the clinical signs and symptoms deteriorate together with radiologic changes.

Is entire removal of a post-traumatic temporomandibular joint ankylotic site necessary for an optimal outcome?

PURPOSE: Temporomandibular joint (TMJ) ankylosis that occurs after TMJ condylar fracture constitutes a treatment challenge. The purpose of the present study is shed light on an alternative treatment approach for certain such cases where the displaced condylar head or part of it can be detected in computed tomography. The leading principle of this protocol is accurate removal of the ankylotic mass only, leaving the condyle-disc apparatus un-touched. PATIENTS AND METHODS: The study is based on such cases of post trauma ankylosis where the displace condyle was detected. Thirteen cases are reported (10 unilateral and 3 bilateral) age ranged from 8 to 51 years (mean 20). All patients were treated according to the presented protocol that emphasizes the significance of preserving the condyle-disc apparatus while accurately removing the ankylotic mass. To achieve the required precision, 3-dimensional computed tomography was used. An integral part of the treatment plan is intensive guided physiotherapy, which is intended to re-establish normal joint function, the original occlusion and facial symmetry (in growing individuals). RESULTS: The patients were followed up for 6 to more than 60 months. After guided physiotherapy, all patients had significant postoperative improvement in maximal mouth opening from a mean of 18.4 mm (range 8 to 28) to a mean of 41.2 mm (range 35 to 50). All patients had returned to their original occlusion. In all the growing patients, a marked improvement in facial symmetry was observed. CONCLUSIONS: In post trauma ankylosis the displaced head of the condyle and disc should be searched for using computed tomography. If detected we recommend its preservation while accurately remove only the ankylotic mass. Using this approach, in addition to achieving adequate mandibular motion, good occlusion, and normal facial growth, major surgery, with all its inconveniences and potential complications, is avoided.

Temporomandibular joint arthrocentesis. Review of the literature

The treatment of the temporomandibular joint (TMJ) is still controversial. TMJ arthrocentesis represents a form of minimally invasive surgical treatment in patients suffering from internal derangement of the TMJ, especially closed lock. It consists of washing the joint with the possibility of depositing a drug or other therapeutic substance. Resolution of symptoms is due to the removal of chemical inflammatory mediators and changes in intra-articular pressure. Numerous clinical studies regarding this technique have been published. The goal of this paper is to review all clinical articles that have been published with regard to the critique of this technique. 19 articles with different designs fulfilling selection guidelines were chosen. A series of clinical and procedure variables were analyzed. Although the mean of improvement was higher that 80%, further research is needed to determine more homogeneous indications for TMJ athrocentesis (AU)

Temporomandibular joint arthrocentesis. Review of the literature.

The treatment of the temporomandibular joint (TMJ) is still controversial. TMJ arthrocentesis represents a form of minimally invasive surgical treatment in patients suffering from internal derangement of the TMJ, especially closed lock. It consists of washing the joint with the possibility of depositing a drug or other therapeutic substance. Resolution of symptoms is due to the removal of chemical inflammatory mediators and changes in intra-articular pressure. Numerous clinical studies regarding this technique have been published. The goal of this paper is to review all clinical articles that have been published with regard to the critique of this technique. 19 articles with different designs fulfilling selection guidelines were chosen. A series of clinical and procedure variables were analyzed. Although the mean of improvement was higher that 80%, further research is needed to determine more homogeneous indications for TMJ athrocentesis.

Aneurysmal bone cyst of mandibular condyle: a case report and review of the literature.

An aneurysmal bone cyst (ABC) in the right mandibular condyle and ramus of a 37-year-old woman was surgically resected and immediately reconstructed with a costochondral graft. She was followed up for 5 years. A review of the 10 cases of condylar-ABC available in the literature revealed mean age of 16.8 (± 7.6) years, with equal distribution between men and women. In all cases symptoms included swelling and asymmetry, while temporomandibular disorder/dysfunction symptoms were reported in 50%. Parasthesia was not reported, except for self-limited postoperative neuropathy. Curettage or resection was employed equally and recurrence rates were 60% after curettage, 20% after resection; which are higher than reported in non-condylar-ABC's. All recurrences occurred within 12 months. Thus close post-operative follow up, for at least 12 months, is warranted.

Liposomes act as effective biolubricants for friction reduction in human synovial joints.

Phospholipids (PL) form the matrix of biological membranes and of the lipoprotein envelope monolayer, and are responsible for many of the unique physicochemical, biochemical, and biological properties of these supermolecular bioassemblies. It was suggested that phospholipids present in the synovial fluid (SF) and on the surface of articular cartilage have major involvement in the low friction of cartilage, which is essential for proper mobility of synovial joints. In pathologies, such as impaired biolubrication (leading to common joint disorders such as osteoarthritis), the level of phospholipids in the SF is reduced. Using a human-sourced cartilage-on-cartilage setup, we studied to what extent and how phospholipids act as highly effective cartilage biolubricants. We found that large multilamellar vesicles (MLV), >800 nm in diameter, composed of 1,2-dimyristoyl-sn-glycero-3-phosphocholine (DMPC) or of a mixture of DMPC and 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) are superior lubricants in comparison to MLV composed of other phosphatidylcholines. Introducing cholesterol into liposomes resulted in less effective lubricants. DMPC-MLV was also superior to small unilamellar vesicles (SUV), <100 nm in diameter, composed of DMPC. MLV are superior to SUV due to MLV retention at and near (<200 microm below) the cartilage surface, while SUV penetrate deeper into the cartilage (450-730 microm). Superiority of specific PL compositions is explained by the thermotropic behavior (including compressibility) of the lipid bilayer. Correlating physicochemical properties of the MLV with the friction results suggests that MLV having lipid bilayers in the liquid-disordered phase and having a solid-ordered to liquid-disordered phase transition temperature slightly below physiological temperature are optimal for lubrication. High phospholipid headgroup hydration, high compressibility, and softness are the common denominators of all efficient PL compositions. The high efficiency of DMPC-MLV and DMPC/DPPC-MLV as cartilage lubricants combined with their resistance to degradation at 37 degrees C supports further evaluation of these MLV for treatment of joint impairments related to poor lubrication. This work also demonstrates the relevance of basic physicochemical properties of phospholipids to their activities in biological systems.

The clinical characteristics of condylar hyperplasia: experience with 61 patients.

PURPOSE: Much reported variation and discord exist regarding mandibular condylar hyperplasia (CH). This study evaluated some of the characteristics of this disorder in a series of 61 patients with active CH. PATIENTS AND METHODS: A total of 61 patients with active temporomandibular CH who had been evaluated in our departments were included. Demographic, clinical, radiologic, and bone scintiscan data were collected and analyzed. Asymmetries were classified as transverse, vertical, or combined. RESULTS: CH was diagnosed during the growth period in 22 patients, and 39 patients were older than 20 years (range, 11 to 80 years). In 66% of the patients, the main complaint was progressive facial asymmetry; and in the remainder, the main complaint was pain, dysfunction, or both. Transverse asymmetry predominated (52%), and vertical or combined asymmetry occurred in 31% and 16% of patients, respectively; asymmetry type was independent of age. The occlusal plane deviated in 48% of the patients. Laterality was significantly gender-biased (females, 72% right; males, 64% left; P = .017). The condylar head shape was normal in 15% of patients, deformed in 27%, and enlarged in 58%; the condylar neck was elongated in 69% and enlarged in 19%. All of these changes were uncorrelated with the type of asymmetry (vertical, transverse, or combined). CONCLUSIONS: CH may occur at any age and is more prevalent in females. Clinicians should be aware that only some patients complain primarily of facial asymmetry, and that symptoms of temporomandibular disease also may be present. Because there is no correlation between the radiologic findings and the clinical evaluation, classification should be simplified and based on clinical manifestation only--in other words, the direction of asymmetry.

Arthrocentesis--incentives for using this minimally invasive approach for temporomandibular disorders.

TMJ arthrocentesis is a nonarthroscopic lavage performed through two needles that are introduced into the upper compartment of the joint. Complemented by joint unloading and physiotherapy, this procedure often replaces surgical intervention in the TMJ. The procedure is highly efficient for resolving TMJ disorders caused by adhering forces or friction that are eliminated by lavage, such as intermittent clicking, anchored disc phenomenon, and open lock, and releases approximately 70% of the symptomatic TMJ osteoarthritis. The outcomes are sufficiently effective to prevent further surgical intervention. Arthrocentesis is a valuable diagnostic tool and the aspirated fluid can be used efficiently for diagnosis, therapy, and research of TMJ disorders.

TMJ lubrication system: its effect on the joint function, dysfunction, and treatment approach.

Normal temporomandibular joint (TMJ) movements primarily depend on free sliding of the disc down the slope of the eminence. Therefore, understanding the lubrication system and how aberrations in this system contribute to TMJ is important. Its effect on dysfunctions, such as disc displacement, anchored disc phenomenon, open lock, and osteoarthritis, are discussed in this article.

Do stable nitroxide radicals catalyze or inhibit the degradation of hyaluronic acid?

Reactive oxygen-derived species and particularly OH radicals can degrade hyaluronic acid (HA), resulting in a loss of viscosity and a subsequent decrease in its effectiveness as a joint-lubricating agent. The production of OH in the vicinity of HA can be catalyzed by bound redox-active metals, which participate in the Haber-Weiss reaction. Damage to HA can also occur as a result of hypochlorite formed by myeloperoxidase (MPO). The protective reagents commonly used to inhibit oxidative stress-induced degradation of HA include antioxidative enzymes, such as SOD and catalase, chelators that coordinate metal ions rendering them redox-inactive, and scavengers of radicals, such as OH, as well as nonradical reactive species. In recent years, stable cyclic nitroxides have also been widely used as effective antioxidants. In many cases, nitroxide antioxidants operate catalytically and mediate their protective effect through an exchange between their oxidized and reduced forms. It was anticipated, therefore, that nitroxides would protect HA from oxidative degradation as well. On the other hand, nitroxides serve as catalysts in many oxidation reactions of alcohols, sugars and polysaccharides, including hyalouronan. Such opposite effects of nitroxides on oxidative degradation are particularly intriguing and the aim of the present study was to examine their effect on HA when subjected to diverse forms of oxidative stress. The results indicate that nitroxides protect HA from OH radicals generated enzymatically or radiolytically. The protective effect is attributable neither to the scavenging of OH nor to the oxidation of reduced metal, but to the reaction of nitroxides with secondary carbohydrate radicals-most likely peroxyl radicals.

Temporomandibular joint "open lock" versus condylar dislocation: signs and symptoms, imaging, treatment, and pathogenesis.

PURPOSE: In the temporomandibular joint (TMJ) "open-lock" condition the condyle is entrapped in front of the lagging disc and cannot slide back under the fossa. The aim of this retrospective study was to describe the signs and symptoms and imaging of TMJ "open lock" versus condylar dislocation and clarify its pathogenesis. The study stresses the efficacy of arthrocentesis in restoring the functional capacity of the joint, while obviating the need for surgical intervention. PATIENTS AND METHODS: The study included 5 patients (3 females and 2 males; ages ranging from 11 to 26 years) presenting 6 open-lock joints that did not respond to conservative treatment. The TMJs postarthrocentesis status in 5 joints (follow-up period, 6 to 32 months) was determined by patient self-assessment and clinical examination. RESULTS: Five TMJs had recurrent open lock and were treated by arthrocentesis. They reacted favorably to the treatment and the open-lock events were eliminated. The first case was apparently misdiagnosed as condylar dislocation, and unnecessary surgical intervention was performed. CONCLUSIONS: Arthrocentesis is a safe and rapid procedure that prevents recurrence of open-lock conditions. This disorder should be distinguished from recurrent condylar dislocation, which requires surgical intervention.