Available online at www.sciencedirect.

com

ScienceDirect

British Journal of Oral and Maxillofacial Surgery 62 (2024) 632–636

Optimising needle depth in temporomandibular joint

arthrocentesis: a magnetic resonance-based study for safety
and efficacy
glu a,⇑, Elif Ezgi Söylemez a, Banu Karaalio

Sümer Münevvero
glu b, Ceylan Güzel a
a _
Department of Oral & Maxillofacial Surgery, School of Dentistry, Istanbul Medipol University, Istanbul, Turkiye
b _
Department of Radiology, Istanbul Medipol University, Istanbul, Turkiye

Received 12 March 2024; revised 14 May 2024; accepted in revised form 30 May 2024
Available online 4 June 2024

Abstract

The aim of this paper was to determine the optimal needle depth for temporomandibular joint (TMJ) arthrocentesis using magnetic res-
onance imaging (MRI), with the aim of improving procedural safety and efficacy in clinical practice. A retrospective analysis of 264 TMJ
MRIs from 132 patients at Istanbul Medipol Mega University Hospital was conducted. T2-weighted MRI sequences were utilised to measure
distances from skin to joint capsules at varying needle entry points, applying the double puncture technique. The study adhered to ethical
standards with appropriate approvals. The analysis revealed significant gender-related variations in needle depths (females showing shorter
distances than males, p < 0.05). No significant gender differences were found in condylar angles. An inverse correlation between age and
condylar angle suggested age-related anatomical changes. Crucially, a 20 mm needle depth was identified as safer and more effective than the
previously recommended 25 mm. This study underscores the necessity of revising needle depth to 20 mm in TMJ arthrocentesis. These find-
ings hold significant implications for improving procedural safety and catering to demographic variations.
Ó 2024 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights are reserved, including those for
text and data mining, AI training, and similar technologies.

Keywords: TMJ Arthrocentesis; MRI; Needle Depth

Introduction The complexity of temporomandibular disorders and their

profound impact on patients’ quality of life necessitate a re-
The temporomandibular joint (TMJ), a critical component in evaluation and refinement of TMJ arthrocentesis techniques,
our ability to speak, chew, and yawn, is a specialised syn- with an acute focus on needle depth to improve both safety
ovial joint comprising the mandibular condyle and the gle- and efficacy. The diagnosis and treatment of these disorders
noid fossa of the temporal bone.1 It is rather troubling that are critical in the formulation of medical intervention and
temporomandibular disorders, which substantially impair treatment strategies. TMJ arthrocentesis, often trivialised, is
these essential functions, are rampant, presenting with symp- actually a straightforward, cost-effective, and efficient
toms such as pain, restricted jaw movements, and mastica- minimally-invasive procedure for conditions such as arthral-
tory difficulties.2 gia, internal derangement, and degenerative joint disease.3,4
However, the efficacy and safety of this procedure hinge
on the precise determination of the safe needle penetration
⇑ Corresponding author at: Tem Avrupa Otoyolu Çıkısßı, Medipol Mega depth within the joint capsule, which is a detail often
_
Hastaneler Kompleksi No:1, Bağcılar, Istanbul, Turkiye. overlooked.
E-mail addresses: [email protected] (S. Münevveroğlu), Magnetic resonance imaging (MRI) is the gold standard
[email protected] (E. E. Söylemez), [email protected] technique for radiological diagnosis of TMJ diseases.5
(B. Karaalioğlu), [email protected] (C. Güzel).

https://doi.org/10.1016/j.bjoms.2024.05.009
0266-4356/Ó 2024 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights are reserved, including those for
text and data mining, AI training, and similar technologies.

Downloaded for Anonymous User (n/a) at Sri Ramachandra Institute of Higher Education and Research from ClinicalKey.com by Elsevier on
December 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 S. Münevvero

glu et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 632–636 633

MRI is a non-invasive and high-resolution imaging that ified needle entry points were calculated. This approach
plays a pivotal role in revealing the detailed anatomical struc- yielded four distinct data points: anterior lateral (AL), ante-
ture of the TMJ and evaluating associated pathologies. rior medial (AM), posterior lateral (PL), and posterior medial
The aim of this study is to determine the optimal needle (PM), as shown in Figure 2. Additionally, the condylar angle
depth for TMJ arthrocentesis using MRI. Given that the was assessed to provide a more comprehensive understand-
depth can vary significantly among patients due to anatomi- ing of TMJ structure (Fig. 3). For the measurement of condy-
cal differences, this study seeks to provide insights that can lar angles, MRI images were carefully reoriented and
help tailor needle depth more accurately to individual patient resliced according to the Frankfurt horizontal plane to ensure
profiles, improving safety and efficacy in treating temporo- consistent sagittal plane orientation. Furthermore, for each
mandibular disorders, a point that should not be understated. patient, images were aligned to maintain an equal distance
from the tragus to the mid-sagittal plane on each side, facil-
Material and methods itating accurate and consistent measurements within individ-
ual assessments.
Ethical approval for this retrospective study was duly The MRI measurements were conducted by a radiologist
obtained from the Ethics Committee of Istanbul Medipol specialising in the field. To ensure reliability, a subset of 40
University. The study included 264 TMJ MRIs from 132 patients was randomly selected for repeat measurements by
white patients, aged between 16 and 68 years, all of whom the same radiologist at a different time. Intra-examiner relia-
were scanned at our university hospital. Patients with TMJ bility was confirmed with kappa values for AL (j = 0.88),
ankylosis and pathologies were excluded from the study. AM (j = 0.85), PL (j = 0.90), PM (j = 0.87), and condylar
Individuals were segmented into age cohorts as follows: angle (j = 0.92).
patients of 15–24 years were classified as youths, 25–44 IBM SPSS Statistics 22 software (IBM SPSS Inc) was
years as young adults, 45–60 years as middle-aged, and those used for statistical analysis. The Student’s t test was used
60 years and older were categorised as elderly. to compare data between genders and different anatomical
The MRI methodology employed the Holmlund Helsing sides. ANOVA was carried out to analyse differences
line (HHL) to establish needle insertion points. The posterior between age groups and a correlation analysis was conducted
needle entrance was marked 10 mm anterior to the tragus and to explore the relationship between the condylar angle and
2 mm below the HHL, while the anterior entrance was set age groups.
20 mm anterior to the tragus and 10 mm under the HHL
(Fig. 1). Measurements were conducted using high- Results
resolution T2-weighted STIR images in the axial plane. This
imaging protocol was chosen for its enhanced ability to The participant pool comprised 91 females and 41 males,
delineate the hypointense joint capsule and its borders ranging in age from 16 to 68 years, with a mean (SD) age
clearly, and to allow for the precise evaluation of joint effu- of 32.89 (12.64) years. The study identified gender-based
sion. On these T2-weighted axial slices, the distance from the differences in measurements, with females demonstrating
skin to both the medial and lateral joint capsules at the spec- significantly shorter distances than males across all metrics

Fig. 1. Sagittal magnetic resonance image slice illustrating the Holmlund-Helsing line and the anterior and posterior entry points (marked with asterisks) for
temporomandibular joint arthrocentesis.

Downloaded for Anonymous User (n/a) at Sri Ramachandra Institute of Higher Education and Research from ClinicalKey.com by Elsevier on
December 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
634 S. Münevvero

glu et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 632–636

Fig. 2. Axial magnetice resonance image section showing the anterior-medial (AM), anterior-lateral (AL), posterior-medial (PM), and posterior-lateral (PL)
distances for temporomandibular joint arthrocentesis needle placement.

Fig. 3. Measurement of the condylar angle on an axial magnetice resonance image slice, demonstrating the methodology for assessing temporomandibular
joint structure.

Table 1 25 mm. However, the mean (SD) PM measurement for

Gender-based comparison of needle penetration measurements and condy- females was 26.6 mm (4.2) mm, and for males, it was
lar angles. Data are mean (SD) and mm unless otherwise stated. 29 mm (5.3) mm. Additionally, the mean (SD) AM measure-
Variable Female Male p value ment for females was 25.6 mm (4.5) mm, and for males, it
AL 13.9 (3.1) 15.2 (3.3) 0.005* was 27.2 mm (5.0) mm.
AM 25.6 (4.5) 27.2 (5.0) 0.01* Regarding age-related variations, no statistically signifi-
PL 14.8 (2.9) 16.5 (3.3) 0.000* cant differences were observed in the measurements or
PM 26.6 (4.2) 29 (5.3 0.000*
condylar angle across age groups (p > 0.05). A weak inverse
Condylar angle 22.12 (9.3° 22.97 9.5° 0.502
correlation between age and condylar angle was noted
AL = anterior lateral; AM = anterior medial; PL posterior lateral = ; PM = (p = 0.038, r = 0.128), indicating a tendency for the condy-
posterior medial.
*
Statistically significant (p < 0.05).
lar angle to diminish with age. All measurements positively
correlated with one another, as detailed in Table 2.
The analysis of the condylar angles revealed an inverse
(p < 0.05). No significant gender difference was noted in the relationship with both the medial measurements (PM and
condylar angle (p > 0.05), with details provided in Table 1. AM) and PL, with statistical significance. The correlation
In our data, 79 out of 264 PM measurements (29.9%) and coefficient of this inverse relationship was particularly higher
99 out of 264 AM measurements (37.5%) were below in the medial measurements (p < 0.001 for PM, r = 0.323;

Downloaded for Anonymous User (n/a) at Sri Ramachandra Institute of Higher Education and Research from ClinicalKey.com by Elsevier on
December 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 S. Münevvero

glu et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 632–636 635

Table 2
Pearson correlation coefficients between temporomandibular joint measurements and condylar angle.
Posterior lateral Posterior medial Anterior lateral Anterior medial Condylar angle
Posterior lateral:
Pearson correlation 1 0.543** 0.515** 0.465** -0.159**
p value 0.000* 0.000* 0.000* 0.010*
Posterior medial:
Pearson correlation 0.543** 1 0.306** 0.382** -0.323**
p value 0.000* 0.000* 0.000* 0.000*
Anterior lateral:
Pearson correlation 0.515** 0.306** 1 0.415** -0.068
p value 0.000* 0.000* 0.000* 0.269
Anterior medial:
Pearson correlation 0.465** 0.382** 0.415** 1 -0.313
p value 0.000* 0.000* 0.000* 0.000*
Condylar angle:
Pearson correlation -0.159** -0.323** -0.068 -0.313** 1
p value 0.010* 0.000* 0.269 0.000*
*
Statistically significant (p < 0.05).
**
Correlation is significant at the 0.01 level (2-tailed).

p < 0.001 for AM, r = 0.313; p = 0.010 for PL r = 0.159). review, without considering variations based on entry point
The AL distances did not exhibit a statistically significant or gender.9 Our study identified statistically significant gen-
change in relation to the condylar angle. Additionally, a der differences in measurements but supports the conclusion
direct proportional relationship was observed among all mea- that a 20 mm depth is generally suitable. Despite identifying
sured distances, suggesting consistent anatomical scaling these gender differences, the absence of significant age-
within the TMJ dimensions. Crucially, the data indicate that related changes in our measurements further reinforces the
higher condylar angles are associated with a need for shal- applicability of a 20 mm needle depth across a wide range
lower needle depths. Specifically, as the condylar angle of patients. This supports the practicality and safety of adopt-
increases - reflecting a more pronounced tilt of the mandibu- ing a 20 mm approach, which simplifies clinical procedures
lar condyle in the axial plane - the required needle depth cor- and potentially minimises the risk of iatrogenic complica-
respondingly decreases. tions. Although we observed a weak inverse correlation
Finally, the comparison of measurements between the between age and the condylar angle, it did not alter our pre-
right and left sides showed no statistically significant differ- vious recommendation concerning the depth of the needle,
ences (p > 0.05), suggesting symmetrical TMJ measurements which demonstrates the efficacy of a uniform approach. In
on both sides. contrast to the deeper insertion depth of about 25 mm sug-
gested by Nitzan and Soni for accessing the upper joint
Discussion space,10,11 a depth of 20 millimetres may be a safer alterna-
tive to ensure that the needle remains within the joint capsule,
Optimising needle depth in TMJ arthrocentesis is paramount based on the findings of our study.
to circumvent iatrogenic complications, such as nerve paral- Incorporating our findings into clinical practice, the pro-
ysis due to canula perforation or mechanical damage, a risk nounced inverse relationship between condylar angles and
highlighted in a case report by Aliyev et al.6 A comprehen- required needle depths suggests the need for a tailored
sive understanding of the optimal needle depth is therefore approach in TMJ arthrocentesis. Individuals with higher
not just recommended, but essential. condylar angles may benefit from shallower needle insertion
In this study, we used MRI to determine needle depth for to avoid complications associated with deeper penetration.
TMJ arthrocentesis due to its non-invasive nature and supe- This supports the idea of adapting needle depth guidelines
rior soft tissue imaging capabilities, crucial for accurate to better match patient-specific anatomical variations, while
anatomical assessments.7 While MRI avoids the ionising further research is encouraged to confirm these findings
radiation risks associated with CT scans and provides more across diverse populations.
detailed structural visualisation than ultrasound, it lacks the The selective request for MRI in patients with clinical
real-time procedural feedback available in intraoperative symptoms of temporomandibular disorders led to an intrigu-
techniques. Nevertheless, MRI was selected for its ability ing gender disparity in our study, with a significant prepon-
to safely and precisely map TMJ anatomy in a pre- derance of female participants (91 females to 41 males). This
procedural setting, which is vital for minimising risks in clin- gender distribution aligns with the findings of Alrizqi and
ical applications.8 Aleissa, who reported a higher incidence of temporo-
Sß entürk et al proposed a needle insertion depth of approx- mandibular disorders in females,12 and is echoed in Shim-
imately 20 mm for TMJ arthrocentesis in their literature shak and DeFuria’s research, which also showed a female-

Downloaded for Anonymous User (n/a) at Sri Ramachandra Institute of Higher Education and Research from ClinicalKey.com by Elsevier on
December 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
636 glu et al. / British Journal of Oral and Maxillofacial Surgery 62 (2024) 632–636
S. Münevvero

to-male ratio of 3:1 in temporomandibular disorders, a ratio Written informed consent was duly collected from all
similar to our study.13 individual participants included into this study.
In this study, the analysis did not incorporate the body
mass index of the included patients, nor did it account for Declaration of Generative AI and AI-assisted
age-related changes in collagen and connective tissue among technologies in the writing process
elderly individuals. Considering body mass index is particu-
larly important as it can significantly affect anatomical land- During the preparation of this work the authors used
marks and, consequently, the needle depth required for safe ChatGPT 4.0 in order to enhance readability and check gram-
and effective TMJ arthrocentesis. These factors were not sys- mar for British English. After using this tool/service, the
tematically considered in the assessment of variations in the authors reviewed and edited the content as needed and takes
20 mm depth measurement. full responsibility for the content of the publication.
Another limitation of this study is the absence of patient
classification based on specific complaints, which has hin- References
dered more detailed analysis. Future research should address
this by including larger cohorts with diverse complaints to 1. Liang W, Li X, Gao B, et al. Observing the development of the
temporomandibular joint in embryonic and post-natal mice using
enable broader generalisation of the results. This study offers
various staining methods. Exp Ther Med 2016;11:481–489.
valuable insights for novice surgeons and trainees, who can 2. Ferreira MC, Porto de Toledo I, Dutra KL, et al. Association between
benefit from tailored depth guidelines for procedural safety chewing dysfunctions and temporomandibular disorders: a systematic
and effectiveness. Experienced practitioners typically rely review. J Oral Rehabil 2018;45:819–835.
on palpation and tactile feedback, underscoring the study’s 3. Tvrdy P, Heinz P, Pink R. Arthrocentesis of the temporomandibular
joint: a review. Biomed Pap Med Fac Univ Palacky Olomouc Czech
relevance for those still mastering the technique.
Repub 2015;159:31–34.
4. Neeli AS, Umarani M, Kotrashetti SM, et al. Arthrocentesis for the
Conclusion treatment of internal derangement of the temporomandibular joint. J
Maxillofac Oral Surg 2010;9:350–354.
This study offers vital insights into the anatomical landmarks 5. Lee YH, Won JH, Kim S, et al. Advantages of deep learning with
convolutional neural network in detecting disc displacement of the
that are crucial for safely and effectively implementing the
temporomandibular joint in magnetic resonance imaging. Sci Rep
double-puncture technique in TMJ arthrocentesis, establish- 2022;12:11352.
ing the practicality of a 20 mm needle depth as a safe and 6. Aliyev T, Berdeli E, S ß ahin O. An unusual complication during
reliable guideline for both needle entry points. arthrocentesis: N. facialis paralysis, with N. lingualis and N. alveolaris
inferior anesthesia. J Dent Anesth Pain Med 2019;19:115–118.
7. Santler G, Kärcher H, Simbrunner J. MR imaging of the TMJ. MR
Conflict of interest
diagnosis and intraoperative findings. J Craniomaxillofac Surg
1993;21:284–288.
We have no conflicts of interest. 8. Patel J, Nilesh K, Parkar MI, et al. Clinical and radiological outcome of
arthrocentesis followed by autologous blood injection for treatment of
Funding chronic recurrent temporomandibular joint dislocation. J Clin Exp Dent
2017;9:e962–e969.
ß entürk MF, Yazici T, Gülsßen U. Techniques and modifications for
9. S
No funding was obtained for this study. TMJ arthrocentesis: a literature review. Cranio 2018;36:332–340.
10. Nitzan DW. Arthrocentesis–incentives for using this minimally inva-
Ethics statement/confirmation of patient permission sive approach for temporomandibular disorders. Oral Maxillofac Surg
Clin North Am 2006;18 311-28vi.
11. Soni A. Arthrocentesis of temporomandibular joint - bridging the gap
This study as a retrospective analysis, was conducted in line
between non-surgical and surgical treatment. Ann Maxillofac Surg
with the ethical norms set by both institutional and national 2019;9:158–167.
research committees, aligning with the 1964 Helsinki decla- 12. Alrizqi AH, Aleissa BM. Prevalence of temporomandibular disorders
ration and its subsequent amendments or equivalent ethical between 2015–2021: a literature review. Cureus 2023;15:e37028.
standards. Ethics approval was procured from the Ethics 13. Shimshak DG, DeFuria MC. Health care utilization by patients with
temporomandibular joint disorders. Cranio 1998;16:185–193.
Committee of Istanbul Medipol University, stamped with
approval number E-10840098-772.02-7788.

Downloaded for Anonymous User (n/a) at Sri Ramachandra Institute of Higher Education and Research from ClinicalKey.com by Elsevier on
December 18, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.