Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx

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Journal of Cranio-Maxillo-Facial Surgery

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Double puncture versus single puncture arthrocentesis for the

management of unilateral temporomandibular joint disc displacement
without reduction: A randomized controlled trial
Fernanda Stefani Folle a, Rodrigo Lorenzi Poluha b, Enio Tadashi Setogutti c,
Eduardo Grossmann d, *
a
Department of Dentistry, Federal University of Rio Grande do Sul, Rua Ramiro Barcelos, 2492, 90035-004, Porto Alegre, RS, Brazil
b
Department of Dentistry, State University of Maringa
, Mandacaru Avenue, 1550 - 87080-000, Maringa
, Brazil
c
Private Clinic, Sidi Medicina Por Imagem, Av Valter Kess, 655 - 96180-000, Porto Alegre, RS, Brazil
d
Craniofacial Pain Applied to Dentistry, Dentistry Faculty, Federal University of Rio Grande do Sul, Rua Ramiro Barcelos, 2492, 90035-004, Porto Alegre,
Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To compare the clinical efficacy of the conventional double puncture versus single puncture
Paper received 10 June 2018 type 2 arthrocentesis for management of temporomandibular joint disc displacement without reduction
Accepted 18 October 2018 (DDWOR).
Available online xxx
Materials and methods: Twenty-six patients with DDWOR were randomly and blindly allocated into two
treatment groups (N ¼ 13): Group 1, conventional double puncture arthrocentesis; Group 2, single
Keywords:
puncture type 2 arthrocentesis. Data on gender, side of painful joint complaint, age (years), duration of
Temporomandibular joint disorders
joint pain (months), maximum interincisal distance (MID e mm), and pain intensity self-reported with a
Disc displacement without reduction
Arthrocentesis
visual analog scale (VAS; 0e10) were collected. VAS scores and MID were measured before (baseline) and
6 months after arthrocentesis (final).
Results: Both techniques resulted in significantly reduced VAS scores and increased MID (p ¼ 0.001) after
180 days. However, there were no statistically significant differences between techniques (p > 0.05).
Conclusions: The two arthrocentesis methods tested were effective in reducing VAS scores and
increasing MID in patients with DDWOR.
© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction
Temporomandibular disorders (TMD) are a heterogeneous
group of musculoskeletal disorders affecting the masticatory
muscles, temporomandibular joint (TMJ) and associated structures
(Dworkin and LeResche, 1992). Among the most common TMD
conditions are the TMJ disc displacements (Ahmad et al., 2009).
These are divided into articular disc displacement with reduction
(DDWR), and disc displacement without reduction (DDWOR). In
the latter condition, the articular disc remains anteriorly displaced
* Corresponding author. Dentistry Faculty, Federal University of Rio Grande do
Sul, Rua Ramiro Barcelos, 2492, 90035-004, Porto Alegre, RS, Brazil.
E-mail addresses: fernandasfolle@yahoo.com.br (F.S. Folle), rodrigopoluha@
gmail.com (R.L. Poluha), etsetogutti@hotmail.com (E.T. Setogutti), edugdor@gmail.
com (E. Grossmann).
relative to the mandibular condyle with the mouth open and
closed, both in magnetic resonance imaging (MRI) and in clinical
examinations of the TMJ. Clinical DDWOR is mainly characterized
by the presence of pain, mouth opening limitations, and pain
deflection (Dworkin and LeResche, 1992; Ahmad et al., 2009;
Lazarin et al., 2016).
DDWOR treatment should initially be conservative with the use
of reversible therapeutic modalities such as drugs, inter-occlusal
devices and physiotherapy. When these approaches do not pro-
duce the expected results, surgical alternatives should be consid-
ered (Tatli et al., 2017). TMJ arthrocentesis is a minimally invasive
surgical intervention (Nitzan, 2006), with a success rate ranging
between 70% and 91% (Emshoff, 2005). It consists of lavage, without
direct vision, of the upper TMJ compartment with a biocompatible
substance (Nitzan et al., 1991). It aims at diluting local algogenic
substances and breaking adhesions formed between the surfaces of

https://doi.org/10.1016/j.jcms.2018.10.015
1010-5182/© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Folle FS et al., Double puncture versus single puncture arthrocentesis for the management of unilateral
temporomandibular joint disc displacement without reduction: A randomized controlled trial, Journal of Cranio-Maxillo-Facial Surgery,
https://doi.org/10.1016/j.jcms.2018.10.015
2 F.S. Folle et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx

the articular disc and the mandibular fossa with the hydraulic painful joint complaint; age (years); duration of joint pain
pressure created by the irrigation itself (Nitzan et al., 1991). (months); maximum interincisal distance (MID), measured in
Although the conventional double puncture technique for TMJ millimeters with a digital caliper (Mitutoyo®, Takatsu-ku, Kawasaki,
arthrocentesis provides good results with low morbidity rates Kanagawa, Japan); pain intensity, self-reported with a visual analog
(Brennan and Ilankovan, 2006), variations, such as the single puncture scale (VAS; 0e10). Data for the variables MID and VAS were
type 2 (Şentürk and Cambazoglu, 2015), have been used in an attempt collected before (baseline) and 180 days after arthrocentesis (final).
to optimize treatment and to reduce surgical time and morbidity
(Alkan and Baş, 2007; Rehman and Hall, 2009). The literature shows 2.2. Conventional double puncture arthrocentesis
that there is still a need for randomized controlled trials of TMJ
arthrocentesis comparing different techniques (Nagori et al., 2018). Double puncture arthrocentesis was performed only once at the
Such investigations may assist clinicians when deciding about the best affected articulation according to the literature (Nitzan et al., 1991;
method for the treatment of patients with DDWOR. Holmlund and Hellsing, 1985; Neeli et al., 2010; Chandrashekhar
Therefore, the objective of this study was to compare the clinical et al., 2015; Tuz et al., 2016; Şentürk et al., 2017). With the pa-
efficacy of the conventional double puncture versus single punc- tient awake, a straight line was drawn with a marker pen along the
ture type 2 arthrocentesis for management of temporomandibular skin from the middle portion of the auricular tragus to the lateral
joint disc displacement without reduction (DDWOR). The null hy- corner of the eyeball (Holmlund and Hellsing, 1985). In this line,
pothesis being tested is that there are no differences between two points were marked for the insertion of the needles. The first
techniques. posteriormost point was marked at a distance of 10 mm from the
tragus and 2 mm below the tragus-cantal line, while the second
2. Materials and methods point was marked 20 mm in front of the tragus and 10 mm below
the tragus-cantal line (Fig. 1). Next, antisepsis of the whole face was
This randomized controlled trial was conducted in accordance performed with 2% chlorhexidine solution, with emphasis on the
with the ethical standards of the Declaration of Helsinki of 1975, preauricular region and ear. Then, auriculotemporal nerve block,
and approved (N 2.224.751) by the Ethics and Research Committee followed by the masseteric and posterior deep temporal nerve
of the Faculty of Medicine of the Federal University of Rio Grande do block were conducted with lidocaine hydrochloride without vessel,
Sul, Porto Alegre, Brazil. All patients freely signed an informed 1:100.00 with a total volume of 3.6 mL.
consent form before participating in the study. Patients were asked to open their mouths to the maximum, and
a sterile mouth opener was placed between the dental arches on
2.1. Sample the contralateral side of the arthrocentesis to maintain the
mandibular condyle down and forward and to facilitate access to
Sample calculation was conducted with 80% power and 5% sig- the upper TMJ compartment recess. A 40  12-mm needle con-
nificance level. After adding 10% to compensate for possible losses nected to a 5-mL syringe was inserted into the first, posteriormost
and refusals, the final sample size was 26, which was equally point, and 4 mL of saline solution 0.9% was administered in order to
divided into 2 groups (n ¼ 13): Group 1, conventional double distend the joint space. The other needle was inserted into the same
puncture arthrocentesis; Group 2, single puncture type 2 arthro- distended compartment, in front of the first needle (Fig. 2), con-
centesis. Patients were blinded to the procedures and allocated to nected to a 60-cm-long naso probe attached to a suction pump
the groups by a computer-generated randomization draw per-
formed immediately before the procedure. All patients were eval-
uated, diagnosed and treated between August 2017 and November
2017 at the Orofacial Pain and Deformity Center (CENDDOR) in
Porto Alegre, Brazil. All arthrocentesis was conducted by a single
experienced professional (E.G.). Patients were followed for 7, 14, 30,
60, 90 and 180 days. After arthrocentesis, 1 mL of sodium hyalur-
onate (SH) 10 mg (OSTEONIL MINI®, TRB Pharma, Sa ~o Paulo, SP,
Brazil) was infiltrated in the upper TMJ compartment in all patients.
Besides SH injections, no other treatment was applied after
arthrocentesis during the follow-up period.
The sample was composed by individuals of both genders older
than 18 years, with clinical signs and symptoms of intra-articular
TMD compatible with DDWOR, associated with painful joint
complaint (whether acute or chronic, unilateral or bilateral), who
had not responded to conservative treatment (inter-occlusal de-
vice, anti-inflammatory drugs, warm compresses, light diet, and
physiotherapy) for at least 3 months previously. DDWOR diagnosis
was confirmed by a combination of clinical examinations based on
the Research Diagnostic Criteria for Temporomandibular Disorders
(RDC/TMD), Axis I (Schiffman et al., 2014), and magnetic resonance
imaging (MRI) scan reports. Patients with rheumatoid arthritis,
agenesis, hypoplasia and/or malignant neoplasm of the mandibular
condyle, bone ankylosis, previous TMJ surgery, muscular disorders,
or who had previously undergone arthrocentesis alone or in com-
bination with other substances, as well as extremely anxious in-
dividuals, were not considered for the study.
A second evaluator (F.F.) who did not know which groups the Fig. 1. The two needles inserted into the upper joint space in the marked reference
patients belonged to, collected the following data: gender; side of points in relation to the HolmlundHellsing line.

Please cite this article as: Folle FS et al., Double puncture versus single puncture arthrocentesis for the management of unilateral
temporomandibular joint disc displacement without reduction: A randomized controlled trial, Journal of Cranio-Maxillo-Facial Surgery,
https://doi.org/10.1016/j.jcms.2018.10.015
 F.S. Folle et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
Fig. 2. Two needles inserted in the upper TMJ compartment.
(KaVo®, Joinville, Santa Catarina, Brazil), in such a way that the
fluidity and flow of the solution used for the joint lavage could be
visualized. Subsequently, a 120-cm 15C infusion extender (Com-
pojet®, Conceiça ~o do Jacuípe, Bahia, Brazil) was attached to the
posterior needle, coupled to a 60-mL syringe to initiate lavage and
joint lysis. A total of 300 mL of saline solution was used to perform
TMJ arthrocentesis. At the end of the procedure, after occluding the
exit of one of the needles with a sterile disposable plastic device,
1 mL of SH 10 mg was injected into the upper TMJ compartment
through the other needle. Once the needles were removed, the jaw
was manipulated with vertical, protrusive and lateral movements
to facilitate lysis of possible adhesions. The final step comprised
local dressing with sterile gauze and micropore.
2.3. Single puncture arthrocentesis type 2
Single puncture arthrocentesis type 2 was also performed ac-
cording to the literature (Alkan and Baş, 2007; Rehman and Hall,
2009; Singh et al., 2013; Talaat et al., 2016; Şentürk et al., 2018).
Preparation and antisepsis of the face and the intervention side of
the TMJ, as well as all the markings, and anesthetic block were
identical to those performed with the conventional technique. A
double-needle cannula (Muzimed®, Canoas, RS, Brazil) was inserted
10 mm from the tragus and 2 mm below the tragus-cantal line
(Fig. 3). When in place, the patient was asked to open the mouth,
and with one of the entries occluded, the upper TMJ compartment
was distended with 4 mL of 0.9% saline solution. The second needle
in the cannula was then open and the upper compartment was
rinsed with 300 mL of saline solution. After that, 1 mL of SH, 10 mg
was injected. After the double-needle cannula was removed, the
same mandibular movements and local dressing with sterile gauze
and micropore were conducted as described for the conventional
arthrocentesis technique.
2.4. Statistical analysis
Considering the individual as the observational unit, the Fisher
exact test and the chi-square test were used to analyze the variables
Please cite this article as: Folle FS et al., Double puncture versus single puncture arthrocentesis for the management of unilateral
temporomandibular joint disc displacement without reduction: A randomized controlled trial, Journal of Cranio-Maxillo-Facial Surgery,
https://doi.org/10.1016/j.jcms.2018.10.015
3
Fig. 3. Double-needle cannula inserted in the upper TMJ compartment.
gender and side of complaint. The variable age (which presented
normal distribution) was evaluated with Student t-test, while pain
duration (which presented asymmetric distribution) was analyzed
with the nonparametric ManneWhitney test. To compare the var-
iables of interest (MID and VAS) between the two test groups, and
between the data collected before (baseline) and 6 months after the
procedure (final), the Wilcoxon nonparametric test was used. The
Spearman correlation was performed among the set of variables.
All statistical analyzes were conducted with SPSS version 18.0
for Windows® (Microsoft Corporation, Redmond, WA), with
maximum significance level established at 5% (p < 0.05).
3. Results
All 26 patients complete the study. No intercurrences or com-
plications were observed during or after the procedures. Frequency
distribution (%) for the variables gender and side of the complaint,
as well as the means and standard deviations of the variable age,
means and confidence intervals of the variable joint pain duration
are shown in Table 1. No statistically significant differences were
observed between the groups for any of the studied variables
(p > 0.05).
When the data collected at the two evaluation moments
(baseline and final) were compared, both techniques resulted in
significantly increased MID (Table 2) and significantly reduced VAS
scores (Table 3) (p ¼ 0.001). However, there were no statistically
significant differences between techniques (p > 0.05).
When considering the duration of pain before the procedure,
significant correlations were observed between the variables final
MID and VAS scores, with variable coefficients depending on the
stratification performed. In Group 1 (double puncture arthrocent-
esis), it was observed that the longer the pain duration, the lower the
final MID (rS: 0.566; p ¼ 0.044). This may indicate that for this type
of procedure the delay in seeking treatment may significantly
interfere with its outcome. In Group 2 (single puncture arthrocent-
esis type 2), it was observed that the longer the individual experi-
ences pain before the treatment, the higher the baseline and final
VAS scores (rS: 0.671 and 0.620, respectively). Overall, the results
4 F.S. Folle et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx

Table 1
Frequency distribution, means (±SD) and confidence intervals of the descriptive variables.

Variable Double puncture (n ¼ 13) Single puncture type 2 (n ¼ 13) p-value

Gender
Female 12 (92.3%) 11 (84.6%) 0.999
Male 1 (7.7%) 2 (15.4%)
Side of complaint
Right 5 (38.5%) 9 (69.2%) 0.238
Left 8 (61.5%) 4 (30.8%)
Age (years) 30.77 (±7.59) 37.38 (±10.21) 0.073
Pain duration (months) 9 (6e16) 8 (6e8.50) 0.244

Table 2
Maximum intercisal distance (MID, mm) measured before (baseline) and six months after arthrocentesis (final).

Group Moment Median (Inter-quartile interval) p-value

Double puncture (n ¼ 13) Baseline 31.10 (30.12e32.11) 0.001a

Final 42.00 (40.12e43.23)
Single puncture type 2 (n ¼ 13) Baseline 31.28 (29.91e32.17) 0.001a
Final 42.29 (37.87e44.23)
a
Statistically significant.

Table 3
Visual analog scale (VAS, 0e10) pain scores reported before (baseline) and six months after arthrocentesis (final).

Group Moment Median (Inter-quartile interval) p-value

Double puncture (n ¼ 13) Baseline 7.00 (6.00e7.50) 0.001a

Final 0.00 (0.00e0.00)
Single puncture type 2 (n ¼ 13) Baseline 8.00 (7.00e9.00) 0.001a
Final 0.00 (0.00e1.00)
a
Statistically significant.

seem to indicate that initiating treatment of symptoms and signs
early would lead to better outcomes in terms of final pain and MID.
4. Discussion
Arthrocentesis has been proposed as an effective approach for
the treatment of the TMJ in patients with DDWOR (Tatli et al., 2017).
In the present study, the conventional double puncture and single
puncture type 2 arthrocentesis used to treat patients with DDWOR
demonstrated similar clinical outcomes, with both techniques
resulting in significantly increased MID and significantly reduced
pain after 6 months. The lack of statistically significant differences
between the tested groups indicate that one technique cannot be
considered superior to the other. Thus, the null hypothesis was
accepted.
The present results are similar to those previously reported in
the literature (Nagori et al., 2018). Şentürk et al. (2016) compared
the single puncture versus the double puncture TMJ arthrocentesis
technique for treatment of 40 patients (20 per group) with stage 3
and 4 disorders of the TMJ based on the Wilkes classification. The
patients were followed-up for 1 month. Both groups recorded
significant improvements compared with the baseline values for
pain and maximal mouth opening. There were no significant dif-
ferences between the groups (Şentürk et al., 2016).
The beneficial effects of different arthrocentesis techniques on
mandibular mobility result from the removal of adhesions, reduc-
tion or elimination of negative pressure within the joint, distension
of the joint space, and alterations to the viscosity of the synovial
fluid, aiding the translation of the articular disc and mandibular
condyle (Nitzan et al., 1991; Sembronio et al., 2008). The statisti-
cally significant increase in MID found after both arthrocentesis
techniques is in conformity with other studies in the literature in
which the conventional double puncture (Chandrashekhar et al.,
2015) and single puncture type 2 arthrocentesis (Talaat et al.,
2016) arthrocentesis are used.
The main reason for patients with TMJ disorders to seek treat-
ment is the presence of pain (Young, 2015). Although early DDWOR
treatment using more conservative methods may be beneficial,
arthrocentesis seems to be superior when dealing with pain
(Diraçoglu et al., 2009). In the present study, statistically significant
reductions of self-reported pain were found after arthrocentesis in
both groups, in agreement with previous literature
(Chandrashekhar et al., 2015; Talaat et al., 2016; Şentürk et al., 2016;
Nagori et al., 2018). The reduction in pain is expected, since abun-
dant irrigation with biocompatible substances allows the partial
removal of debris from degenerating joint tissues, eliminating
algogenic substances, especially inflammatory mediators (Nitzan,
2006). In this study, the same volume (300 mL) of saline solution
was used with both techniques. The literature shows no significant
difference in TMJ arthrocentesis with different irrigation volumes
in patients with DDWOR (Grossmann et al., 2018). The anesthetic
block of the auriculotemporal nerve, posterior deep temporal and
masseteric nerves may also have contributed to the reduction of
pain. The literature suggests that adequate pain control during the
procedure facilitates the maintenance of needles in the correct
position, decreases painful stimuli to the central nervous system,
and provides greater comfort and confidence to the patient to
perform the requested mandibular movements, regardless of the
arthrocentesis technique employed (Tuz et al., 2016).
The positive results obtained with both tested techniques in this
study can also be derived from the use of sodium hyaluronate
immediately after arthrocentesis. When the combination of
arthrocentesis and sodium hyaluronate was previously used, pain
and mouth opening results tended to be better (Alpaslan and
Alpaslan, 2001; Guarda-Nardini et al., 2012). Sodium hyaluronate
promotes increased joint lubrication by increasing the viscosity of

Please cite this article as: Folle FS et al., Double puncture versus single puncture arthrocentesis for the management of unilateral
temporomandibular joint disc displacement without reduction: A randomized controlled trial, Journal of Cranio-Maxillo-Facial Surgery,
https://doi.org/10.1016/j.jcms.2018.10.015
 F.S. Folle et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
the synovial fluid. It acts as a shock protector, preserving homeo-
stasis, allowing for repair processes to be activated, and normal-
izing the synthesis of endogenous cells. As a result, sodium
hyaluronate can promote increased joint mobility, reducing attri-
tion and noise, and improve the perfusion of synovial fluid nutri-
ents and metabolites to vascular tissues (Grossmann et al., 2015).
Despite the similar results, the single puncture type 2 arthro-
centesis presents some advantages over the conventional double
puncture arthrocentesis, such as increased ease of execution,
reduced procedural time, and trauma limitation (Rehman and Hall,
2009; Singh and Varghese, 2013; Talaat et al., 2016). Additionally,
insertion in a single point makes arthrocentesis even more con-
servative, reducing the risk of nerve damage, as the insertion of a
second needle may cause trauma to the facial nerve (Rahal et al.,
2009). The viscoelastic substance used at the end of the proced-
ure tends to remain in the upper TMJ compartment. The risk of the
substance to leak through the skin is reduced, since there is only
one point of entry, unlike the two-needle technique (Guarda-
Nardini et al., 2008). The main disadvantages of the single punc-
ture type 2 arthrocentesis, however, are that the device needs to be
specially manufactured, which can make the procedure costlier
(Talaat et al., 2016), and insertion difficulties may be encountered
when the upper TMJ space is small (Grossmann, 2012).
Considering that this is a monocentric study with a restricted
population, the results found here should be analyzed with caution.
It would be interesting to replicate such research supplemented
with a control group free of interventions in order to evaluate the
change in synovial fluid concentration and composition. A longi-
tudinal follow-up of the patients, as well as a postoperative MRI
evaluation, would also be important to understand tissue responses
to different arthrocentesis techniques. These may influence or even
help to predict the outcomes of the procedures in the long term.
Regarding the clinical implications, although the findings did not
detect differences at group level, that does not necessarily mean
that no individual differences existed.
5. Conclusion
Considering the proposition, the results obtained, and the lim-
itations of the present study, it can be concluded that the conven-
tional double puncture and single puncture type 2 arthrocentesis
were equally effective in reducing VAS scores and increasing MID in
patients with DDWOR.
Sources of support
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Acknowledgements
The authors would like to thank Mr. Antonio Carlos Correa for
his assistance with the English version of the paper.
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