A Comparative Study Between Concentric Single-Needle Puncture Technique and Conventional 2-Needle Technique for Temporomandibular Joint Arthrocentesis Plus Corticosteroid Injections

Abstract

The purpose of the study was to compare 2 techniques of arthrocentesis, to find out the efficacy of one over the other at various parameters, and to contribute to the scarce literature of these 2 techniques. Forty patients reported with a chief complaint of pain in temporomandibular joint (TMJ), clicking in TMJ, and restricted mouth opening were included in this study. Twenty patients were divided into 2 groups, all reporting with temporomandibular disorders. Group A was treated with 2-needle technique of arthrocentesis, while group B underwent concentric needle technique of arthrocentesis under local anesthesia with Ringer’s lactate solution. The operating time was found to be less in concentric needle technique (mean: 25.36 min) compared to 2-needle technique (mean: 42.82 min), and the difference was found to be statistically significant. Concentric needle technique proved to be a better alternative for TMJ arthrocentesis as it has quite a lot of advantages over 2-needle technique.

Introduction

Temporomandibular disorders (TMDs) are a group of musculoskeletal and neuromuscular conditions that involve the joint complex, surrounding musculature, and osseous components.[1,2] Arthrocentesis for lysis and lavage of temporomandibular joint (TMJ) was first described by Nitzan et al. Arthrocentesis showed better function, increased the range of motion, and reduced pain after irrigation of the superior TMJ space.[3,4] The rationale for washing the superior joint compartment of the patient in an open mouth position provides sufficient pressure to release joint adherences and to allow fluid outflow during the closure.[5] In this study, the concentric needle and 2-needle techniques were compared as part of a short-term investigation comparing 6 parameters that will help to decide which technique is superior.

Even though in the literature a lot of articles talk about these 2 techniques individually, a comparative study is very scarce. So, this study was done to compare tolerability and efficiency of the 2-needle approach with concentric needle approach for TMJ arthrocentesis.[6] The latter approach adopted concentric needle for saline injection and ejection.[6] This produced higher intra-articular pressure during saline inflow, breaks adherences, and is less traumatic than the 2-needle entry, due to the insertion of a concentric needle within the superior joint compartment [6].

Materials and Method

This study was conducted in the Department of Oral and Maxillofacial Surgery. The study was approved by the Institutional Review Board. Forty patients who reported to the Department of Oral and Maxillofacial Surgery with a chief complaint of unilateral pain in TMJ, unilateral clicking in TMJ, and restricted mouth opening were selected for this study. All patients had pain lasting for more than 3 months. They have been treated previously with muscle relaxants, hot fermentation, advised to keep limited mouth opening, and restrict jaw movements. Twenty patients were included in each group randomly. Group A was treated with the 2-needle technique of arthrocentesis under local anesthesia, while group B underwent concentric needle technique of arthrocentesis under local anesthesia using Ringer’s lactate solution, following which corticosteroid injections were administered. Informed consent was taken from all the patients included in this study.

The 2-needle technique refers to the technique used by Nitzan et al.[4] in which one needle is inserted in the superior joint space for Ringer’s lactate inflow and the second needle is for outflow. Lavage was done with 250 to 300 mL of Ringer’s lactate solution. After lavage, 1 needle was removed, and with the first needle in situ, 1 mL of corticosteroid (dexamethasone 4 mg) was injected into the superior joint space and 1 mL in the outer surface of the TMJ capsule [7].

The single-needle technique refers to the procedure described by Guarda-Nardini et al.,[6] in which lavage of TMJ with a single puncture only (150–200 mL) and postlavage corticosteroid (dexamethasone 4 mg) were injected in a similar manner in the same dose [7].

The treatment outcome of TMJ arthrocentesis was evaluated using 2-needle and concentric needle techniques with a follow-up at baseline, at the end of treatment, and at 1, 3, and 6 months.

The parameters measured were as follows:

• Mouth opening was measured with a metallic scale.
• Postoperative pain relief, pain at rest, and pain on chewing were measured by 10-point visual analog scale, as described by Guarda-Nardini et al., with 0 being the absence of pain and 10 being the worst pain ever.
• Subjective chewing efficacy was also measured on a 0- to 10-point visual analog scale (0 being worst efficiency ever and 10 being the best efficiency ever).
• The operative time was measured in minutes using a simple stopwatch.
• Limitation of jaw functions was measured by Likert type scale (using 5-point scale, with 0 being the absence of limitation and 4 being a severe limitation).
• Tolerance of treatment and the effectiveness of treatment were measured by Likert-type scale (0 being the lowest and 4 the maximum values).
• The lateral deviation was measured in millimeter, as described by Guarda-Nardini et al.

All the procedures were performed by a single investigator (A.K.) in accordance with a random sequence of intervention, and the outcome parameters were recorded by a resident of the department who was blinded to the treatment protocol for all patients. The operator was not blinded with respect to the treatment modality. A complete effort was undertaken to make the patients blinded by giving them an explanation regarding the benefits of arthrocentesis, and they were also motivated by saying that this is the most suitable treatment for the problem they are undergoing. Informed consent was taken from all patients.

Results on continuous measurements were presented on mean ± SD (min-max). Independent “t” test and Mann-Whitney U test have been used to find the significance of study parameters on an ordinal scale between the 2 groups.

Results

Twenty TMJ (13 males and 7 females) were treated using concentric needle technique, having a mean age as 25.18 ± 10.33. Similarly, 20 TMJ (11 males and 9 females) were treated using 2-needle technique, having a mean age of 25.18 ± 10.333 and 24.73 ± 7.28, respectively (

Table 1. Distribution of Study Objects.

Abbreviation: SD, standard deviation.

).

Of the 20 TMJ treated using concentric needle technique, 15 were treated on the right side and 5 on the left side. In the 2-needle technique, of 20 TMJ, 8 were treated on the right side and 12 on the left side (Table 1).

Mouth Opening

In concentric needle technique, mouth opening was found to be decreasing immediately postoperative (mean: 36.45) and after 1 week (mean: 30.55), but it increased after 1 month (mean: 37.09) and kept increasing till 6 months (mean 44.91) when compared with preoperative mouth opening (mean: 40.64;

Table 2. Comparison of Operating Time and Mouth Opening in 2 Techniques.

).

In 2-needle technique, mouth opening was found to be slightly increased immediately postoperative (mean: 37.09) but decreased after 1 week (mean: 31.64) and again increased after 1 month (mean: 34.91); it again decreased after 3 months (mean: 33) and again increased after 6 months (mean: 37.36) when compared with preoperative mouth opening (mean: 36.91). The difference in mouth opening between concentric needle technique and 2-needle technique at 3- and 6-month interval was found to be statistically significant (Table 2 and Figure 1).

Operating time was found to be less in concentric needle technique (mean: 25.36 min) compared to 2-needle technique (mean: 42.82 min), and the difference was found to be statistically very highly significant (p value < 0.001; Table 2 and Figure 2).

Postoperative Pain

In concentric needle technique, postoperative pain was found to be decreasing immediately (mean: 2.36), and it kept on decreasing till 6 months (mean: 0.82;

Table 3. Comparison of Postoperative Pain, Pain at Rest, Pain on Chewing, Effectiveness of Chewing, Limitation of Jaw Function, Tolerance, and Effectiveness in 2 Techniques.

). In 2-needle technique, postoperative pain was found to be decreasing till 3 months (mean: 0.55), but it increased slightly after 6 months (mean: 0.91; Table 3).

There was no statistically significant difference in post-operative pain between the concentric needle technique and the 2-needle technique at any time interval (Table 3).

Pain at Rest

In concentric needle technique, pain at rest was found to be the same immediately postoperative (mean: 1.55), it decreased after 1 week (mean: 1.27), and remains the same till 1 month and then it decreased further at 3 months (mean: 0.36) and 6 months (mean: 0.18) when compared with preoperative pain at rest (mean: 4.55; Table 3).

In 2-needle technique, pain at rest was found to be increased immediately postoperative (mean: 1.82); it decreased after 1 week (mean: 1.09) and kept on decreasing till 3 months (mean: 0.36), but it increased after 6 months (mean: 1.27) when compared with preoperative scenario (mean: 4.09; Table 3).

There was no statistically significant difference in pain at rest between the concentric needle technique and the 2-needle technique at any time interval (Table 3).

Pain on Chewing

In concentric needle technique, pain on chewing was found to be decreasing immediately postoperative (mean: 4.45) and it kept on decreasing till 6 months (mean: 1.0) when compared with preoperative pain on chewing (mean: 5.18; Table 3).

In 2-needle technique, pain on chewing was found to be decreasing immediately postoperative (mean: 3.64), and it kept on decreasing till 3 months (mean: 0.36), but it increased after 6 months (mean: 1.27) when compared with preoperative scenario (mean: 4.45; Table 3).

There was no statistically significant difference in pain on chewing between the concentric needle technique and the 2-needle technique at any time interval (Table 3).

Effectiveness of Chewing

In concentric needle technique, effectiveness of chewing was found to be increased immediately postoperative (mean: 0.64), and it kept on increasing till 3 months (mean: 3.36); it achieved maximum efficacy after 6 months (mean: 4.45) when compared with preoperative effectiveness (mean: 0.36; Table 3).

In 2-needle technique, effectiveness of chewing was found to be decreased immediately postoperative (mean: 0.00), and it then kept on increasing till 3 months (mean: 2.00); it achieved maximum efficacy after 6 months (mean: 3.45) when compared with preoperative scenario (mean: 1.45; Table 3).

There was no statistically significant difference in the effectiveness of chewing between the concentric needle technique and the 2-needle technique at any time interval (Table 3).

Limitation of Jaw Function

In concentric needle technique, limitation of jaw function was found to be decreasing immediately postoperative (mean: 4.27), and it kept on decreasing; it becomes nil after 3 months and remains nil after 6 months too when compared with preoperative limitations (mean: 4.45; Table 3).

In 2-needle technique, limitation of jaw function was found to be decreasing immediately postoperative (mean: 2.45), and it kept on decreasing; it becomes nil after 3 months, but after 6 months, little limitation was there (mean: 1.24) when compared with preoperative scenario (mean: 3.36; Table 3).

There was no statistically significant difference in limitation of jaw function between concentric needle technique and 2-needle technique at any time interval (Table 3).

No complications like major bleeding or fluid extravasations were seen in any of the cases.

Discussion

Internal derangements and inflammatory degenerative disorders can be managed effectively using arthrocentesis.[3,6] The technique of arthrocentesis has always been a topic of discussion, and many techniques were described in the literature to minimize tissue trauma and improve efficacy.[6,8] Still the available data on TMJ arthrocentesis and injections used in the management of inflammatory-degenerative disease gave only preliminary ideas.[9] Previous studies have demonstrated the effectiveness of arthrocentesis alone[6] or they have talked about the efficacy of corticosteroids in TMJ disorders,[10] but using both these treatments together is missing in the literature. In a study, Manfredini et al.[11] compared 6 different treatment protocols (different combinations of single-/multisession arthrocentesis with or without drug injection) and reported that no significant differences existed between the treatment groups.

Clinical trials comparing different arthrocentesis techniques are required to prevent complications associated with earlier techniques such as facial nerve injury, external auditory meatus swelling, and preauricular hematoma.[12] Since there is very little literature with substantial results regarding the comparison of concentric needle and 2-needle techniques of arthrocentesis, we did this study to compare the effectiveness and tolerability of these 2 approaches to the TMJ. Previously, only studies by Guarda-Nardini et al.[6] and Senturk et al.[13] reported that both the techniques were quite similar in all aspects when used in arthrocentesis. The article of Senturk et al. focuses mainly on the surgeons’ perspective and lacks details on the patient evaluation. Even a meta-analysis by Nagori et al.[14] analyzed 5 trials on these techniques and found that both techniques were equally significant in TMJ disorders.

In our study, the postoperative mouth opening was found to be more in the concentric needle technique as compared to the 2-needle technique. Guarda-Nardini et al.[6] had similar results in mouth opening after using the concentric needle technique for TMD.

Since the volume of fluid that can be injected/ejected with a concentric needle is much less than that with the 2-needle technique, the former technique is more desirable as it creates more pressure leading to more joint lavage and hence better mouth opening.[6,15] In our study at 6 months, the effectiveness of the 2-needle and concentric needle protocols in terms of pain relief and reduction in pain on chewing was similar, both resulting in improvement with respect to baseline levels of pain.[6] Our findings were similar to that of and Hall[5] as well as Guarda-Nardini et al.[6] Similar findings in pain relief were seen in arthrocentesis utilizing different medications such as corticosteroids, lignocaine, hyaluronic acid, and dextrose in studies done by Gouveia et al.[16] and Skármeta et al. [17].

The operating time was significantly less in the concentric needle technique in our study. This finding was consistent with those found in the study by Guarda-Nardini et al.[6] This was because the concentric needle technique needed marking of a single Holmund line and puncture at 1 point, while the 2-needle technique required 2 points of insertion. Moreover, faster execution time and positioning of a concentric needle allow safer and more stable access to the joint space, while the stability of the first needle can become questionable while trying to place the second needle in the 2-needle technique [6].

Chewing efficacy, the range of jaw motions, and lateral deviation had no significant difference in both groups.[6] Subjective and perceived efficacy with treatment tolerability was also similar in both techniques.[6] Other than the clinical implications from a technical point of view, some joints are hard to access with 2 needles due to adherence, which prevent good entry points into the joint cavity, suggesting that the concentric needle approach should be preferred in those selected cases.[6] These technical observations were also seen in studies done by Rehman and Hall,[5] Alkan and Kilic,[18] and Guarda-Nardini et al.[6] Postoperative immediate corticosteroid was administered to reduce inflammation and effusion, decrease pain, and increase the range of motions in synovial joints [19].

Conclusion

It is quite a big challenge for surgeons to manage TMJ disorders, especially those presenting with pain, limited mouth opening, and/or asymptomatic clicking.[15] Many noninvasive and invasive techniques are available, but most cases can be treated by arthrocentesis of the joint locally.[15] A simple process of joint irrigation (arthrocentesis) enables lysis of intra-articular adhesions, change in the viscosity of the joint, and clearance of various substances in the joint fluid [15].

From this study, it can be concluded that the concentric needle technique is better than the 2-needle technique as it is less time-consuming and minimally invasive with better mouth opening. Previously, only Guarda-Nardini et al.[6] have done a comparative study on these 2 techniques, and their study showed no significant difference among the 2 techniques. Contrary to that, our study shows that a single puncture technique is better in a few parameters. So, this study adds to the literature advantages of one technique over the other in the field of arthrocentesis. As a recommendation for the future, longer follow-up periods would be required to monitor treatment outcomes [6].