Review

Advantages of ultrasound guidance for TMJ arthrocentesis

and intra-articular injection: A narrative review
Diego De Nordenflycht1,A–F, Ricardo de Souza Tesch2,B–F
1
Faculty of Dentistry, Universidad Andres Bello, Viña del Mar, Chile
2
Regenerative Medicine Laboratory, Petrópolis Medical School, Brazil

A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;
D – writing the article; E – critical revision of the article; F – final approval of the article

Dental and Medical Problems, ISSN 1644-387X (print), ISSN 2300-9020 (online) Dent Med Probl. 2022;59(4):647–656

Address for correspondence

Diego De Nordenflycht
Abstract
E-mail: [email protected] Ultrasound (US) is a widely available, low-cost, non-invasive, and safe medical imaging method that
enables real-time observation. Ultrasound offers several advantages for dentomaxillofacial images, such
Funding sources
None declared
as portability, the possibility of dynamic and repeated examinations, patient comfort, and availability.
It is a useful tool for recognizing the temporomandibular joint (TMJ) structures and their involvement
Conflict of interest during the course of different pathological processes, such as articular disk displacement, joint effusion and
None declared cortical erosion. In addition to its diagnostic use, US has been proposed as an auxiliary tool in minimally
invasive procedures for arthrogenic temporomandibular disorders (TMD) to achieve an accurate puncture,
Acknowledgements
None declared
recognize joint spaces and reduce surgical trauma. While US is widely used for large joints to visualize
internal structures and guide the injection, this technique has only recently gained popularity for the TMJ
procedures. Hence, the literature on this topic is scarce.
Received on December 2, 2021
Reviewed on February 15, 2022 The present review describes the potential advantages and the clinical technique of US guidance for TMJ
Accepted on February 20, 2022
arthrocentesis and intra-articular injection (IAI).
Keywords: ultrasonography, temporomandibular joint disorders, arthrocentesis, interventional ultra-
Published online on December 30, 2022
sonography

Cite as
De Nordenflycht D, Tesch RdS. Advantages of ultrasound
guidance for TMJ arthrocentesis and intra-articular injection:
A narrative review. Dent Med Probl. 2022;59(4):647–656.
doi:10.17219/dmp/146820

DOI
10.17219/dmp/146820

Copyright
Copyright by Author(s)
This is an article distributed under the terms of the
Creative Commons Attribution 3.0 Unported License (CC BY 3.0)
(https://creativecommons.org/licenses/by/3.0/).
648 D. De Nordenflycht, R. Tesch. US for TMJ arthrocentesis and injections

Introduction ally performed based on anatomical landmarks (the

blind technique), with a potential risk of damage to the
Temporomandibular disorders (TMD) encompass surrounding structures. To improve the precision of the
a group of musculoskeletal and neuromuscular condi- procedure and reduce potential surgical damage, US has
tions that involve the temporomandibular joints (TMJs), recently been suggested as an aid to guide punctures
masticatory muscles and associated tissues.1 Temporo- during arthrocentesis and IAIs.
mandibular disorders have been categorized into myoge- The aim of the present review is to describe the poten-
nous (masticatory muscular problems) and arthrogenous tial advantages and the clinical technique of US guidance
(problems with the TMJ components), the latter includ- for TMJ arthrocentesis and IAIs.
ing internal derangements, arthralgia, osteoarthritis, and
osteoarthrosis, which can be manifested by TMJ pain,
TMJ noises during jaw function, jaw deviation, and func- Methodology
tional limitation.2
Temporomandibular disorders are a significant pub- An electronic search of the medical literature was per-
lic health problem affecting approx. 5–12% of the gen- formed on July 30, 2021 and revised on January 25, 2022.
eral population, and they are the second most common The search was carried out in the PubMed, Scopus and
musculoskeletal condition (after lower back pain).3 Google Scholar databases, using controlled vocabulary.
Temporomandibular disorders have been identified The authors used both MeSh (Medical Subject Headings)
as the main cause of non-dental orofacial pain, with terms and free-text keywords for searching relevant arti-
the most common symptoms being pain aggravated cles. The keywords used were: “temporomandibular joint
by mandibular function, limited mouth opening and disorders”; “arthrocentesis”; “injection”; “ultrasound”;
joint sounds (described as “clicking”, “popping” and and “ultrasonography”. The search strategy was adapted
“crepitus”).1 Orofacial pain affects patients’ social func- for each database. The search was limited to articles in
tioning, and physical and psychological well-being. peer-reviewed journals that were written in the English
Likewise, the chronic nature of the pain substantially language. The process was repeated across all databases
reduces quality of life,4 probably due to the anxiety, to ensure that no relevant articles were lost during the
stress, depression, physical and social disability, im- identification phase.
paired work capacity, decreased productivity, social Studies conducted on patients (or cadavers) that re-
costs, and reduced economic income, which under- ceived TMJ injections and/or arthrocentesis guided by
scores the need for medical attention.5 US were considered for inclusion. Studies on humans
General therapeutic goals for TMD involve restor- of both genders without age limitation were taken into
ing function, reducing pain, improving quality of life, consideration. Studies included clinical trials (random-
and reducing the need for future treatment. However, ized and non-randomized), prospective and retrospective
since pain is an individual experience and each patient observational studies, case reports, case series, cadaveric
is exposed to different risk factors, each case should re- studies, and technical notes, without restriction on the
ceive a customized therapeutic approach. Additionally, publication date. Only articles available as full texts that
the structural damage may present different degrees presented the descriptors in their title, abstract or main
of progression, and therefore a therapeutic goal may be text were included. Narrative reviews, in vitro studies,
different for each patient.6 The management of TMD duplicates between databases, and studies not reporting
consists of a combination of medical-behavioral strat- relevant data were excluded. No limits were applied with
egies, including non-invasive ones (i.e., patient educa- regard to the publication status. After verifying the avail-
tion, relaxation techniques, coping strategies, home self- ability of articles, the titles and abstracts of all the records
care programs, biobehavioral therapy, physical therapy, obtained through the literature search were screened, and
pharmacotherapy, and orthopedic therapy with occlusal the full texts of the records meeting the inclusion criteria
appliances), and minimally invasive and open surgical were retrieved for examination. After screening, the bibli-
procedures. In the majority of cases (75–90%), which ography of the included studies and review articles on the
are either joint or muscular TMD, positive results can subject were hand-searched for any missed references.
be obtained from conservative and reversible interven- All the reported outcomes and methods were identified,
tions,7 but in patients refractory to conservative treat- and they were recorded in a standardized data extraction
ment and/or where anatomical-structural disorders are sheet formulated in Microsoft Excel with information
a substantial source of pain and limitation, minimally about: authors; the year of publication; the study design;
invasive procedures can be considered.8 Recent litera- the condition to be treated (a TMD diagnosis); the num-
ture suggests that arthrocentesis, followed by the intra- ber of case subjects; the technique; the joint space (upper
articular injection (IAI) of different therapeutic agents, or lower); the US transducer; the drug injected; the num-
may be effectively used to treat arthrogenous TMD.2 ber of control subjects; the route of US scanning; and the
During these procedures, needle insertion is tradition- main results.
Dent Med Probl. 2022;59(4):647–656 649

Results Temporomandibular joint arthrocentesis (first described

in 1991 by Nitzan et al.) is a simple, minimally invasive, in-
Search results expensive, and highly effective procedure that involves the
irrigation of the upper joint space to remove the synovial
The flowchart for article selection is shown in Fig. 1. After fluid and inflammatory elements.28 Its main purpose is to
the removal of duplicate articles, a total of 141 records were clean the joint space, remove inflammatory products, re-
identified, and then screened based on title and abstract. Af- lease disk adhesions, reduce pain, and mobilize the joint, for
ter the inclusion/exclusion criteria were applied, 13 articles which several techniques have been described in the litera-
were full-text reviewed and 3 additional records were identi- ture.29 Şentürk and Cambazoğlu classified these techniques
fied through the manual search of the reference lists from the based on the number of punctures – either double-punc-
retrieved articles, and were added for a total of 16 articles. ture arthrocentesis (DPA) or single-puncture arthrocente-
Among the selected articles, 4 were randomized clinical trials sis (SPA).30 Single-puncture arthrocentesis is subclassified
(RCTs),9–12 1 was a non-controlled clinical trial (CT),13 3 were by the number of needles into 2 categories: type 1 (single-
retrospective studies (RSs),14–16 1 was a case report (CR),17 needle cannula method); and type 2 (double- or dual-needle
2 were technical notes (TNs),18,19 3 were cadaveric studies cannula method).29 Recent evidence suggests that SPA is as
(Cad),20–22 and 2 were systematic reviews.23,24 The details efficacious as DPA for pain reduction and mandibular range
of the included primary studies are presented in Table 1. improvement; moreover, there is no superiority of SPA over
DPA with regard to the secondary operator-related factors
(e.g., the ease of operation, the operating time) and patient-
related outcomes (e.g., the range of motion improvement,
patient satisfaction).31,32 In general, arthrocentesis can im-
prove jaw function and reduce pain in patients with disk dis-
placement without reduction and osteoarthritis. However,
there are inconsistent findings about its possible superiority
over other kinds of treatment for TMJ pain, with the excep-
tion of its superiority over splints.33 Furthermore, a meta-
analysis by Al-Moraissi et al. showed that non-invasive pro-
cedures had significantly lower therapeutic quality in terms
of pain reduction and improvement of mouth opening,
which supports a paradigm shift in the treatment of arthrog-
enous TMDs.2 This recent evidence, although based on pri-
mary studies of very low to moderate quality, indicates that
minimally invasive procedures (particularly in combination
with the IAI of platelet-rich plasma (PRP), HA or CSs) are
significantly more effective than the conservative treatment
in reducing pain and improving mouth opening in the short
and medium term in arthrogenous TMD cases. Therefore,
minimally invasive procedures should be considered as first-
Fig. 1. Flowchart of the literature selection process
line treatment.2 Nonetheless, a systematic review by Li et al.
suggests that when conservative treatment fails, early arthro-
centesis may result in the greatest improvement in mouth
Minimally invasive procedures for TMJ pain opening and pain relief; however, when it is applied as initial
treatment, without attempting the conservative treatment at
The literature describing TMJ pain management sug- first, the outcome may be less satisfactory.34
gests that non-invasive strategies should precede invasive Temporomandibular joint arthrocentesis seems to be
procedures25; this conservative approach proposes to per- very safe given that a minimal number of major complica-
form all non-interventional procedures before executing tions have been reported, and the ones reported are gener-
minimally invasive procedures, such as IAI and arthro- ally transitory, mostly due to the effect of anesthetic drugs
centesis to restore jaw function and relieve pain.2 The IAI or the extravasation of fluids to the surrounding soft tis-
of hyaluronic acid (HA) alleviates pain and the functional sues.35 While the permanent complication rate is 0%, some
symptoms of TMD.25–27 However, other drugs, such as short-term complications have been reported, such as facial
corticosteroids (CSs) and non-steroidal anti-inflammatory nerve injury, preauricular hematoma, superficial temporal
drugs (NSAIDs), can be used with satisfactory results.25 In artery injury, the development of an arteriovenous fistula,
a systematic review, Ferreira et al. reported that HA ap- joint bleeding, intracranial perforation, severe bradycardia,
peared to be more effective for pain resolution as compared needle breakage inside the joint, failed needle insertion,
to placebo or other therapies in arthrogenous TMD.26 the leakage of the washing liquid into the extra-articular
650 D. De Nordenflycht, R. Tesch. US for TMJ arthrocentesis and injections

Table 1. Primary studies on the ultrasound(US)-guided temporomandibular joint (TMJ) interventional procedures

US-guided procedure
Control
Condition case
Study Drug (blind Route of
Study to be subjects joint US Main results
design technique injected technique) scanning
treated (TMJs) space transducer n
n
15 MHz
Parra et al. 83 linear with US guidance, the needle tip was
RS JIA IAI U or L CSs – CP
201014 (180) or 8 MHz located intra-articularly in 91%
curvilinear
efficacy of 92.06%;
in 100% – pain resolution,
Habibi et al. 34
RS JIA IAI NR NR CSs – NR in 71.4% – chewing dysfunction diminished,
201215 (63)
in 92.8% – jaw deviation diminished
with US guidance
Dayisoylu et al. 9 7 MHz
TN NR DPA U HA – CP technique description
201318 (NR) linear
Levorova et al. NR 7.5–14 MHz
TN NR IAI L NR – CP technique description
201519 (NR) linear
US-guided arthrocentesis was not more
Sivri et al. 10
RCT DD DPA U NR HA DPA CP successful than the conventional technique
20169 (NR)
and it took more time
high- US guidance increased the efficacy of IAI,
Chakraborty et al. structural 1
CR IAI NR frequency CSs – CP especially in the presence of TMJ structural
201617 abnormality (1)
linear abnormality
Ayoub US-guided IAI to the upper joint space
34
Al-Delayme et al. CT DD IAI U NR PRP – NR brought the alleviation of signs and
(NR)
201713 symptoms
no statistical differences in short-term
Resnick et al. 23 high-
RS JIA IAI NR CSs type II SPA NR outcomes, but the procedure times were
201716 (35) frequency
longer for the image-guided group
the US-guided group showed a significant
reduction of pain in the immediate
Antony et al. 40
RCT DD DPA U NR – DPA CP postoperative period; however, it showed no
201910 (NR)
significant alleviation of the overall symptoms
as compared to the blind technique
no significant difference in pain between
Bhargava et al. 10 12 MHz the groups, US-guided SPA minimized
RCT DD type II SPA U CSs type II SPA CP
201911 (NR) linear the number of attempts of needle
manipulation
US guidance was effective in type II SPA in
Şentürk et al. 12 the long term; however, it did not improve
RCT DD type II SPA U NR – type II SPA CP
201912 (12) the outcome results as compared to the
blind technique
the accuracy of US-guided IAI was
significantly greater as compared to the
blind technique (95% vs. 55%), the success
Cha et al. 10 5–20 MHz coloured rate for IAI into the upper joint space
Cad NR IAI U and L IAI CP
201920 (10) linear agents was similar for both techniques, US-
guided IAI into the lower joint space had
a much higher success rate than the blind
technique (90% vs. 30%, p = 0.020)
IAI was successful in all cases, the median
Champs et al. 13
Cad NR IAI U and L NR NR – CP time period between the skin puncture
201921 (25)
and IAI was 23 s
high-frequency US linear probe
(7.5–20 MHz) and US preset in the MSK
mode helped to reach the optimal image
Torres-Gaya et al. NR 13–6 MHz definition, the US probe placed oblique
Cad NR DPA U NR – OP
202122 (NR) linear relative to the zygomatic arch facilitated
orientation and puncture, introducing the
needle parallel to the probe major axis
allowed greater precision and safety
RS – retrospective study; TN – technical note; RCT – randomized clinical trial; CR – case report; CT – clinical trial; Cad – cadaveric study; JIA – juvenile
idiopathic arthritis; DD – disk displacement; IAI – intra-articular injection; DPA – double-puncture arthrocentesis; SPA – single-puncture arthrocentesis;
U – upper; L – lower; CS – corticosteroids; HA – hyaluronic acid; PRP – platelet-rich plasma; CP – coronal plane; OP – oblique plane; MSK – musculoskeletal;
NR – not reported.
Dent Med Probl. 2022;59(4):647–656 651

space, damage to the joint surface, and allergic reactions.29 tion,40 probe selection and the configuration of equipment,
One promising strategy proposed to prevent some of these all of which may generate differences in the interpretation
drawbacks is US guidance for needle insertion. of the results.41 Nevertheless, researchers have proposed
the use of US as a promising screening tool for the evalua-
Ultrasound fundamentals tion of maxillofacial structures, such as TMJs.11,36,37,39,41

Ultrasound is a widely available, low-cost, non-invasive, Ultrasonographic features of TMJ

and safe medical imaging method that enables real-time
observation.19,23 In this method, images are obtained The TMJ area has some particularities, including a small
based on the propagation and reflection of high-frequency examination area, limited access to deep structures and a high
sound waves in tissues. Ultrasounds are oscillating sounds risk of sound reflecting from the bone tissue, which can make
with frequencies from 2 MHz to 20 MHz, which are be- image interpretation very complex.38 Soft tissue visualization
yond the upper limit that humans can hear.36 These sound is severely limited by bone, as sound energy is almost com-
waves are emitted by a transducer placed on the patient’s pletely absorbed by soft-tissue interfaces and the bone tis-
skin, combined with a water-soluble gel as a coupling sue. Thus, the external placement of the transducer enables
agent.37 The transducer acts as a transmitter and a receiver only the acquisition of the lateral third of the joint, and only
of acoustic energy, and then transforms it into images.38 in the axial and coronal planes.37 Therefore, the main disad-
The emitted US waves are partly reflected when they pass vantage of US in the TMJ area is the limited imaging of the
through tissues, with a reflection coefficient that depends upper and medial parts of the condyle and the disk; these
on the characteristics of different anatomical structures. structures are hidden by the acoustic shadowing caused by
Ultrasound offers several advantages for dentomaxillofa- the rebounding and absorption of US waves by the zygomatic
cial images, such as portability, the possibility of dynamic bone.12,19,20,42 The TMJ images produced by US depend on
and repeated examinations, patient comfort, and avail- the echogenicity of tissues as follows: the condylar head and
ability.39 Sonograms (US images) are sections of the region the articular eminence are hypoechoic and appear black39;
of interest, of a particular thickness, generated along the face the bone margins are hyperechoic and appear white39; the
of the transducer, which are composed of different shades connective and muscular tissues are isoechoic (an interme-
of gray, where the brightness/darkness depends on the fre- diate reflection of sound waves) and appear heterogeneously
quency of the reflected echoes, which in turn depends on gray23,39; the joint capsule surface is highly reflective of sound
the ability of a tissue/structure to reflect or absorb sounds; waves, creating a hyperechoic line (white)11,23,39,42; the articu-
this concept is known as echogenicity. In sonograms, tissues lar disk appears as a thin, hypo-to-isoechoic, homogeneous
are classified according to their echogenicity: hyperechoic band11,23,42; articular fluid-filled spaces are hypoechoic and
or echogenic (very bright) – highly reflective tissues, such appear black,11,23,42 although these are virtual cavities that
as bone or cartilage; moderately echogenic (bright), such as are generally not detectable unless joint effusion is present38;
glands; hypoechoic (fairly dark), such as blood vessels and bone marrow is usually hypoechoic and appears black.38
muscles; and anechoic (very dark), such as liquids and air.36 In most publications, TMJ US monitoring is based on
A US examination is a procedure that is highly depen- the standardized protocol of Emshoff et al.43 Most studies
dent on the skill and experience of the operator. Differences have adopted similar protocols, which include transver-
of opinion between researchers/clinicians may be due to the sal and longitudinal scans to evaluate the joint compart-
lack of standardization in the performance of the examina- ments in the coronal, axial and oblique planes (Fig. 2).41

Fig. 2. Ultrasound (US) probe orientation for the observation of the temporomandibular joint (TMJ) in the axial and coronal planes
652 D. De Nordenflycht, R. Tesch. US for TMJ arthrocentesis and injections

During the longitudinal scanning, the probe is placed over results; however, their routine use is not feasible in The
TMJ, perpendicular to the zygomatic arch and parallel to MJ procedures due to cost and the need for a hospital en-
the mandibular ramus, and inclined until the best view vironment.23 On the other hand, it has been postulated
is achieved; then static and dynamic evaluations are per- that US-guidance minimizes trauma to the joint, and im-
formed (Fig. 3).38 The performance of the US diagnostics proves the accuracy and efficiency of the procedure. Fur-
is outside the scope of the present review and has been thermore, real-time images, the lack of ionizing radiation
extensively described for 3 main diagnostic domains: disk and easy access make US a promising aid for minimally
displacement; joint effusion; and cortical erosion.38,40–42,44 invasive TMJ procedures, such as arthrocentesis and
It has been suggested that US can complement a clinical IAI.23 While US is widely used for large joints to visual-
examination as an initial evaluation tool.40 ize internal structures and guide IAI, this technique has
only recently gained popularity for the TMJ procedures.
Ultrasound-guided minimally invasive Hence, the literature on this topic is scarce. The articles
regarding US-guided TMJ arthrocentesis or IAI available
procedures for TMJ pain
in PubMed, Scopus and Web of Science, published since
In addition to its diagnostic use, US has been proposed 2010 are listed in Table 1 (the main characteristics are
as a useful tool in interventional procedures, such as US- provided to facilitate the comparison of the studies). The
guided peripheral venous access, central venous access, uncontrolled RT by Parra et al. from 2010 was the first
abscess drainage, the aspiration of hip and shoulder joints, to report the accuracy of US-guided TMJ IAI; they ob-
pleural effusions, paracentesis, and TMJ arthrocentesis.11 served that the needle was located intra-articularly in 91%
It has been suggested that US may allow more precise ex- of cases.14 Dayisoylu et al. (2013) were the first to describe
ecution with real-time observation.45 The lysis and lavage a reliable technique for US-guided TMJ arthrocentesis,
of the upper joint space is an effective method for control- which was suggested to be “better than arthroscopy” with
ling TMJ pain, so identifying this space is important for regard to cost-benefits.18
a satisfactory procedure.11 However, the traditional blind Ultrasound-guided punctures may approach the target
technique (based on anatomical landmarks) requires ex- (joints, vessels or nerves) from a position perpendicular
perience to reach the upper joint space and carries a po- or parallel to the US beam, referred to as ‘out-of-plane’
tential risk of damage to the collateral disk ligaments and and ‘in-plane’, respectively (Fig. 4). The in-plane approach
the adjacent soft tissue, especially if multiple attempts are enables the operator to visualize the needle shaft and tip,
made.18,20 Furthermore, the confirmation of the correct as it is directed toward the target, but it requires skill and
needle placement can sometimes be ambiguous in clini- may result in a false sense of security, despite having been
cal practice.20 Given the complex TMJ anatomy, clinicians demonstrated to result in faster and more accurate per-
have used image-guided techniques to aid the verification formance. On the other hand, the out-of-plane technique
of the needle position, and reduce potential damage to is more difficult and relies on tissue movement or fluid
joint tissues and neurovascular structures, or needle pen- localization rather than strict needle visibility to confirm
etration in the middle cranial fossa during minimally in- its position.46 In the TMJ US-guided injections using the
vasive procedures.12,21,23 Some image-guided techniques out-of-plane approach, the correct position of the needle
using magnetic resonance imaging (MRI) or cone-beam is achieved by extending and narrowing the joint space
computed tomography (CBCT) have shown promising by the infiltration and aspiration of fluid, respectively.19

Fig. 3. Ultrasound (US) anatomy of the temporomandibular joint (TMJ) in the coronal plane
Dent Med Probl. 2022;59(4):647–656 653

Fig. 5. In-plane needle insertion for upper joint space injection under
ultrasound (US) guidance (the needle is marked with white arrows for
academic reasons)

Fig. 4. Needle and probe orientation in ultrasound (US)-guided procedures

A – in-plane (long axis) approach; B – out-of-plane (short axis) approach.

Champs et al. validated a longitudinal US-guided in-plane

approach for TMJ IAI, in which the needle is inserted
at an angle of 30°, with the US probe in the preauricu-
lar region, approx. 1 cm in front of the tragus, parallel to
the mandibular ramus and perpendicular to the zygo-
matic arch.21 This technique proposes a direct visual-
ization of the needle all the way to the joint with great
precision and provides noticeably higher accuracy during
puncture.21 Most clinical and cadaveric studies use the
coronal route of scanning and in-plane needle insertion
(Fig. 5),9–12,14,17–21 whereas other reports did not report
these technical details.13,15,16
Most articles describing TMJ minimally invasive proce-
dures (and daily clinical practice) are based on washing-
out the upper joint space in both the US-guided and blind
techniques. Nevertheless, some evidence has demonstrat-
ed that IAI directed to the lower or both TMJ spaces has Fig. 6. In-plane needle insertion for lower joint space injection under
ultrasound (US) guidance (the needle can be seen in light blue and
a better effect than IAI into the upper space alone.47 Lower
is marked with a white arrow for academic reasons)
joint space injection is believed to be a difficult procedure
because of a narrow space, a small volume and the ‘hid- a similar level of success for the blind and US-guided tech-
den’ location. The blind technique for lower joint space niques.20 However, for the lower joint space, the US-guided
injection was described by Li et al.47 Clinical information technique had a significantly higher success rate (90% vs.
on US-guided IAI into the lower joint space appears to be 30%) and the blind technique was associated with a consid-
very limited.20 Levorova et al. reported a technique for US- erable proportion of unsuccessful/inappropriate injections
guided TMJ intra-articular infiltration directed toward the to the lower joint space.20 To date, only 4 controlled CTs
lower joint space (Fig. 6).19 Cha et al., in a cadaver-based that compare the blind and US-guided techniques for TMJ
study, observed that upper joint space injection showed arthrocentesis have been published.9–12 Two of them used
654 D. De Nordenflycht, R. Tesch. US for TMJ arthrocentesis and injections

DPA9,10 and the others used type II SPA11,12 (the compari- 5) after reaching the upper or lower joint spaces, HA,
son of these studies is presented in Table 1). Şentürk et al., CSs or platelet concentrates should be injected slowly;
in a CT, reported the longest follow-up (1 year) in a com- 6) washing the articular space with saline or Ringer’s lac-
parison between the blind and US-guided techniques for tate solution if arthrocentesis is intended; 7) close the in-
TMJ arthrocentesis.12 The results show that US guidance jection area using a sticking plaster with light pressure to
is effective in type 2 SPA, as it aids the visualization of the avoid the formation of hematoma; and 8) use ice or cold-
needle during puncture; however, it did not resolve pain pack applications and NSAIDs after the procedure.48
or improve the range of motion as compared to the blind
technique.12 The clinical effectiveness of US guidance for
TMJ arthrocentesis and IAI is mostly analyzed based on Conclusions
4 aspects: pain reduction; the range of movement; needle
positioning (or repositioning) attempts; and the total pro- This review summarizes the recent evidence regarding
cedure time. The literature comparing US-guided arthro- the use of US as an auxiliary tool in minimally invasive
centesis vs. the blind technique is scarce. Two systematic procedures for arthrogenic TMD. Ultrasound guidance
reviews have been published recently,23,24 in which very has shown promising advantages; it reduces the number
similar conclusions were reached, since they both selected of needle placement attempts, minimizes trauma to TMJ,
the same articles for the final analysis.9–12 Both reviews improves the accuracy and efficiency of joint injections,
found no significant differences in pain reduction and the results in a significantly greater pain reduction in the im-
maximum mouth opening, no conclusive results were ob- mediate postoperative period, provides easier access to
served in reducing needle repositioning, and also data on both joint spaces, and has a significantly higher success
the potential to reduce the procedure time was inconclu- rate when lower joint space injection is attempted. Future
sive.23,24 Although achieving access to the joint space oc- research is required to confirm the impact US may have
cupies most of the surgical time, studies show that the total on the clinician’s performance, and the consequent ben-
time is longer in the US-guided procedures, since a US ex- efit to the patient.
amination itself requires additional time.9 These conclu-
sions are shared by all studies, as some publications suggest Ethics approval and consent to participate
that US guidance would improve the precision of needle
placement, especially when the lavage of the lower joint Not applicable.
space is performed.20 Cadaver-based studies observed that
US-guided IAI and arthrocentesis techniques had a high- Data availability
er accuracy when the needle was located inside the joint
spaces,20,21 as they provide the image verification of having The datasets generated and/or analyzed during the cur-
punctured the joint space and the real-time screen visual- rent study are available from the corresponding author on
ization of the distension of the space after infiltrating flu- reasonable request.
id.22 Antony et al. observed that the US-guided technique
resulted in a significantly greater pain reduction in the Consent for publication
immediate postoperative period.10 Bhargava et al. found
that in type 2 SPA, US guidance minimized the number Not applicable.
of attempts of needle manipulation as well as possible
complications, and provided easier access to the upper ORCID iDs
joint space.11 Additionally, Anthony et al. suggested that in Diego De Nordenflycht  https://orcid.org/0000-0003-0416-5470
patients with obesity, US-guided arthrocentesis could be Ricardo de Souza Tesch  https://orcid.org/0000-0002-2060-0981
more precise in locating the joint spaces, whereas the blind
technique arthrocentesis required multiple punctures to References
achieve successful lavage.10 1. De Leeuw R, Klasser GD, eds. Orofacial Pain: Guidelines for Assessment,
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