Assessment of Concentric Needle Technique for the Management of Temporomandibular Joint Internal Derangement Randomized Controlled Trial (RCT)
Phase: NA
Conditions: TMJ Disc Disorder
Sponsor: Cairo University

 
 
Assessment of concentric needle technique for the management of 
temporomandibular joint internal derangment. 
A Randomized controlled Trial. 
 تقييم
تقنية قنتين متداخلتين متمركزتين فى عالج األضطراب الداخلى لمفصل الفك. 
 
.تجربة منضبطة معشاه 
 
Protocol submitted to 
Faculty of Dentistry, Cairo University 
In partial fulfillment of 
 the requirements for Master Degree in Oral and Maxillofacial Surgery 
 
Submitted by: 
Ahmed Adel Hassan Mahmoud 
B.D.S. Misr International University 2016 
Department of Oral and Maxillofacial Surgery 
Faculty of Dentistry 
Cairo University 
2020 
 
  
 
Supervisors’ signature                                                         Head of department signature 
1-  
2-  
3-  
 
Date  
Protocol checklist  
 Code: Omfs 3.3.7 

 
 
Section and topic 
Item no. Checked item 
Reported 
in 
page 
no. 
Reviewer’s 
check 
I.Administrative information 
1 
2 
3 
4 
5 
Title  
Protocol registration 
Protocol version 
Funding 
Roles and responsibilities  
1 
1 
1 
1 
1 
 
II. Introdution 
 
 
2 
 
A) Background 
and 
Rationale 
6 
Research question 
Statement of the problem 
Rationale for carrying out the trial 
Review of literature 
2 
2 
2 
2,3 
 
B) Objectives  
7 
Aim of study  
3 
 
C) Trial design  
8 
Trial design  
3 
 
III. Methods 
 
 
4 
 
A) Participants, 
intervention 
and 
outcomes 
9  
10 
11 
12 
13 
14 
15 
16 
Study setting  
Eligibility criteria 
Group allocation 
Interventions 
Outcomes 
Participant timeline 
Sample size  
Recruitment  
4 
4 
4 
4,5,6 
6 
7 
7 
7 
 
B) Data 
collection, 
management 
and 
analysis 
17 
18 
19 
Data collection methods 
Data management 
Statistical methods 
8 
8 
8 
 
C) Monitoring  
20 
21 
22 
Data monitoring  
Harms 
Auditing  
9 
9 
9 
 
IV. Ethics and dissemination 
23 
24 
25 
26 
27 
28 
29 
30 
Research ethics approval  
Protocol amendments 
Informed consent 
Confidentiality  
Declaration of interests 
Access to data  
Ancillary and post-trial care 
Dissemination policy 
10 
10 
10 
10 
10 
10 
10 
10 
 
V. Appendices 
31 
Visual analogue scale 
11 
 
 
32 
Patient questionnaire in English 
12 
 
 
33 
Patient questionnaire in Arabic 
13 
 
 
34 
Informed consent 
14 
 
VI. Statement of originality  
35 
Statement of originality 
15 
 

 
 
VII. References 
 
 
16,17 
 
 
 
Evidence based committee (reviewers) 
Name  
Signature  
Date  
1.  
 
 
2.  
 
 
 
Research plan committee 
Name  
Signature  
Date  
1.  
 
 
2.  
 
 
 
 
 
 
 
 
 
 
 
 
 

1
 
 
I- Administrative information: 
1. Title: 
Assesment of concentric needle technique for the management of temporomandibular joint 
internal derangement. 
A Randomized control Trial. 
 
2. Protocol registration: 
 
 
3. Protocol version: 
First version. 
 
4. Funding: 
Self-funding. 
 
5. Roles and responsibility: 
1- Prof. Dalia Radwan Abdel khalek (DRAK) 
- 
Professor of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University. 
- 
The Senior Supervisor responsible for laying out the research plan, auditing the whole 
research process and reviewing surgical planning, interventions and final manuscript. 
 
2- Dr Abdelmoez Mohamed Elsharkawy (AME) 
- 
- Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry,Cairo university 
- 
Associate Supervisor responsible for auditing patients’ inclusion to the study, case 
preparation, supervising the surgical intervention and guidance with manuscript writing. 
 
3- Dr. Mahmoud  Ahmed El Farmway (MAEF) 
- 
Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry,Sinai University El Kantra 
branch. 
- 
Associate Supervisor responsible for auditing patients’ inclusion to the study, case 
preparation, supervising the surgical intervention and guidance with manuscript writing.  
 
4- Ahmed Adel Hassan Mahmoud (AAHM) 
- 
Master’s degree candidate, Department of Oral and Maxillofacial Surgery, Faculty of 
Dentistry, Cairo University. 
- 
Teaching Assistant in Faculty of Dentistry,Sinai University El Kantara branch. 
- 
Principal investigator responsible for patients’ inclusion to the study, case preparation, 
surgical intervention under supervision of instructors, postoperative data collection and 
manuscript writing. 
 
 
 

2
 
 
II- Introduction: 
6. Background and rationale: 
- 
Research question: 
Is the concentric needles technique a better technique than the traditional two-distant 
needles technique in TMJ Arthrocentesis? 
 
- 
Statement of the problem: 
Locating the outflow needle in TMJ arthrocentesis is the challenging step in the two-distant 
needles technique especially for operators with limited experience which might require 
multiple insertions increasing the risk of injury to blood vessels and nerves together with 
patient’s discomfort, pain and escape of fluids into the pericapsular tissues. 
 
- 
Rationale for conducting the research: 
The research population will be divided into two groups. Group A(control group) will be  
treated by two-distant needles arthrocentesis technqiue and Group B will be treated by two 
- concentric needles arthrocentesis technqiue. 
 
- 
Review of literature: 
Internal derangement is a  common dysfunction of the temporomandibular joint. According 
to classification of Research Diagnostic Criteria for TMD there are 3  main types of internal 
TMJ derangement: disc displacement with reduction and disc displacement without 
reduction with limited mouth opening and disc displacement without reduction without 
limited mouth opening. The prevalence of disc displacement is about 41% in TMD patients. 
The most common type is disc displacement with reduction characterized by clicking.123 
Disc displacement with reduction can occur in 33% of asymptomatic individuals.4 
 
 
Arthrocentesis is a simple, safe and minimally invasive technique for the treatment of TMJ 
disorders. Significant improvements have been reported in terms of reduction in TMJ pain 
and clicking in the TMJ following arthrocentesis.567Most common intra-articular injections 
in arthrocentesis procedures are steroids,sodium hyaluronate,saline and lacted ringer 
solution.89Arthrocentesis is effective for washing out bradykinin, interleukin-6 and 
protein.10 
 
 
The technique of two distant needles is done as follows ; Local anaesthetic block of 
auriculotemporal nerve and infiltration into the areas of joint penetration is done first. 
Surgical field is draped and painted with Povidone-iodine 5%.External auditory canal is 
protected from accumulation of blood and fluid using vaselinized gauze.. A line was drawn 
from the lateral canthus of the eye to midpoint of tragus (canthal-tragus line), the first mark 
was made 1mm infront of the tragus and 2mm below the line representing the posterior 
extent of glenoid fossa, and the second mark was made 20 mm anterior to midtragal point 
and 10 mm below canthal-tragus line representing the height of articular eminence.5A 20 

3
 
 
gauge needle is then inserted into the upper joint space at the glenoid fossa and 2ml of 
Ringer’s solution are injected to distend the upper joint space. A second 20 gauge needle 
is inserted in the area of the articular eminence to establish a free flow of the irrigating 
solution through the upper joint space. Then, the joint is irrigated with 100-300 mL of 
Ringer’s solution.11 
 
 
 
The technique of concentric needle is done as follows; a 27-gauge, 50- mm-long needle is 
inserted into a 21-gauge, 38-mm needle. The longer 27-gauge needle does not block the 
end of the larger needle hub from which the solution outflows. In this way, joint irrigation 
is performed through the inner needle with the solution outflow through the outer needle 
hub. Irrigation through this concentric-device combination allows single puncture of the 
TMJ with a single needle.12A horizontal line is drawn from the corner of the eye to the 
tragus and a puncture mark is made 10 mm from the tragus and 0.5 mm below this line.13 
The concentric-needle unit is inserted into the upper joint space while the patient is asked 
to open the mouth halfway to allow entry of the needle. Once it is inside the joint space, 
lavage is performed with lactated Ringer solution.12The advantages of the single-needle 
method include the use of a single puncture for both irrigation and outflow, hence 
achievement of efficient arthrocentesis without the need for a second needle, decreasing 
the risk of losing the correct place during inserting the needle.This also leads to less patient 
discomfort, a lesser risk of infection, and less bleeding.14Another advantage of a single 
puncture technique is that it reduces patient pain in the postoperative period so this reduces 
the need for extra care postoperatively. The amount of local anesthesia is much less for a 
single puncture than that needed for a double-puncture or arthtrocentesis, thus reducing the 
complications due to local anesthetics.A single-needle technique reduces the risk of facial 
nerve injury, because an anteriorly positioned second needle can traumatize the facial 
nerve, which lays anteriorly and medially to the glenoid fossa, just where the second needle 
is inserted.15 
 
 
 
 
 
7. Objective of the study: 
- 
Aim of the study: 
The aim of the study is to evaluate the effectivenes of using two concentric needles in 
comaprsion with the normal traditional two distant needles. 
 
8. Trial design: 
Randomized control trial. 
 
 

4
 
 
III- Methodology: 
A) Participants, intervention and outcomes 
9. Study setting: 
Patients will selected from the outpatient clinic of the Oral and Maxillofacial Surgery 
Department, Faculty of Dentistry, Cairo University. 
 
10. Eligibility criteria: 
a. Inclusion criteria: 
1- Patients with age ranges from 18-60. 
2- Patients with painful clicking.  
3- Patients free of systemic conditions that might affect the TMJ or interfere with 
carrying out the surgical procedure (osteoarthritis, rheumatoid arthritis, 
uncontrolled diabetes). 
 
b. Exclusion criteria: 
1- Patients out of the specified range group 
2- Patients with painless TMJ clicking. 
3- Patients with osteo-arthritic changes of the TMJ. 
4- Patients with systemic conditions that might affect the TMJ or interfere with 
carrying out the surgical procedure (osteoarthritis, rheumatoid arthritis, 
uncontrolled diabetes). 
5- Patients with previous TMJ surgeries. 
 
11. Group Allocation 
Patients will be randomly allocated to one of the two groups using computer randomization.  
 
 
12. Interventions: 
o Diagnostic procedure: 
a) Patient questionnaire: a questionnaire will be recorded by the examiner including: 
Chief complaint, Personal data, medical history. 
b) Consent: Informed consent will be obtained from patients regarding the surgical 
procedure and inclusion in the study.  
c) Clinical examination: oro facial examination with specific emphasis on the TMJ 
regarding pain, clicking, maximum inter-incisal mouth opening and lateral 
excursions. 
 
o operative procedures: 
 
TMJ arthrocentesis will be performed under local anesthesia.   
 
External auditory canal is protected from accumulation of blood and fluid using 
vaselinized gauze. 

5
 
 
 
The surgical field will be scrubbed and draped in a standard sterile fashion. 
 
A-The standard two – distant needles technique: 
Local anaesthetic block of auriculotemporal nerve and infiltration into the areas of joint 
penetration is done first. Surgical field is draped and painted with Povidone-iodine 
5%.External auditory canal is protected from accumulation of blood and fluid using 
vaselinized gauze.. A line was drawn from the lateral canthus of the eye to midpoint of tragus 
(canthal-tragus line), the first mark was made 1mm infront of the tragus and 2mm below the 
line representing the posterior extent of glenoid fossa, and the second mark was made 20 mm 
anterior to midtragal point and 10 mm below canthal-tragus line representing the height of 
articular eminence.5A 20 gauge needle is then inserted into the upper joint space at the 
glenoid fossa and 2ml of Ringer’s solution are injected to distend the upper joint space. A 
second 20 gauge needle is inserted in the area of the articular eminence to establish a free 
flow of the irrigating solution through the upper joint space. Then, the joint is irrigated with 
100-300 mL of Ringer’s solution.  
 
 
 
B-The concentric-needle cannula technique: 
The technique of concentric needle is done as follows; a 27-gauge, 50- mm-long needle is 
inserted into a 21-gauge, 38-mm needle. The longer 27-gauge needle does not block the end 
of the larger needle hub from which the solution outflows. In this way, joint irrigation is 
performed through the inner needle with the solution outflow through the outer needle hub. 
Irrigation through this concentric-device combination allows single puncture of the TMJ with 
a single needle. Local anaesthetic block of auriculotemporal nerve and infiltration into the 
areas of joint penetration is done first. Surgical field is draped and painted with Povidone-
iodine 5%.External auditory canal is protected from accumulation of blood and fluid using 
vaselinized gauze. A horizontal line is drawn from the corner of the eye to the tragus and a 
puncture mark is made 10 mm from the tragus and 0.5 mm below this line. The concentric-
needle unit is inserted into the upper joint space while the patient is asked to open the mouth 
halfway to allow entry of the needle. Once it is inside the joint space, lavage is performed 
with lactated Ringer solution. 
 
 
 
 
 
 
 
 
 
 

6
 
 
o Post-operative care: 
Patients will be prescribed Augmentin 1gm 2 hours before procedure and 24 hours after 
procedure as a prophylaxis.Brufen 600 mg will be taken after the procedure.The patient will 
be instructed to take Alphintern 2 tablets before food 3 times daily. 
 
 
 
 
 
 
 
 
 
 
 
 
13. Outcomes: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prioritization of outcome Outcome 
Method of measurement 
Unit of measurement 
Primary outcome 
pain 
Visual analogue scale 
Score 
Secondary outcome 
complications 
Edema,Nerves 
and 
arteries injuries  
Inspection 
and 
Palpation 

7
 
 
14. Participant timeline: 
 
 
Study Period 
Enrollment 
Allocation 
Post-
allocation 
Time Point 
-t1 
0 
t1 
Enrolment: 
 
 
 
Eligibility 
Screen 
Informed 
Consent 
 
 
 
Pt. preparation 
 
 
 
 
Interventions: 
 
 
 
Surgical 
procedure   
 
 
 
Assessments  
 
 
 
Assessment of 
pain,outflow 
rate 
and 
complications 
 
 
1 day post-
opeartive 
 
15. Sample size: 
20 cases (10 study group+ 10 control group) 
 
16. Recruitment:  
Patients will be selected according to inclusion & exclusion criteria from the outpatient clinic 
of the Oral and Maxillofacial Surgery Department – Cairo University 
Screening of patients will continue until the target population is achieved. 
Identifying and recruiting potential subjects is achieved through patient database. 
 
 
 
 
 
 
 
 

8
 
 
B) Data collection, management and analysis:  
17.  Data collection methods: 
 
Data will be collected by AAHM,DRAK,MAEF,AES 
Telephone numbers of all patients included the study will be recorded as a part of the written 
consent  
All patients will be given a phone call at the time of the pre-determined follow up dates  
 
18. Data management  
 
All data will be entered electronically  
Patient files are to be stored in numerical order and stored in secure and accessible place  
All data will be maintained in storage for 1 year after completion of the study. 
 
19. Statistical method  
 
Using clincal sample size calculator for intervention study; with 0.05 alpha error and power of 
the study 0.80, And sampling ratio is 1. 
 
According to literature In concentric needle technique, 1 day postoperative pain was found to 
be  (mean: 4.100, sd 2.183), and In 2-needle technique, 1 day postoperative pain was found to 
be (mean: 6.600, sd 1.430)16. 
 
Sample size calculated to assess of concentric needle technique for the management of 
temporomandibular joint internal derangment is 20 patients (10 in each arm of the study). 
 
*Sampling technique: * 
A convenient sample of pain of TMJ patients who will come to the outpatient clinic of the Oral 
and Maxillofacial Surgery Department, Faculty of Dentistry, Cairo University  during the study 
period with the inclusion and exclusion criteria will be assigned into study. 
 
Each patient will be randomly allocated to either arm of the study using concealed random 
allocation technique. The random allocation will be repeated till reaching total sample size 
calculated. 
 
 
 
 
 
 
 
 
 
 
 

9
 
 
C)Data monitoring: 
 
 
20. Data monitoring: 
No formal data monitoring committee will be needed since most of studies in Faculty of 
Dentistry are with known minimal risks. 
21. Harms: 
-Pain. 
 
-Swelling and edema. 
 
-Nerves injury: Zygomatic,Temporal and Auricotemporal nerves 
 
-Arteries injury. 
 
To avoid injury to nerves and arteries: sticking to proper anatomical landmarks 
In case of nerve injuries: Stop the insertion of the needle and redirect it 
In case of arteries injuries: -Apply pressure by gauze 
                                            -Use cold packs and antibiotic in case of hematoma 
 
 
22. Auditing:  
Auditing of the study design will be done by the evidence based committee – Faculty of Oral 
and Dental Medicine – Cairo University. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

10
 
 
 
 
 
 
 
IV. Ethics and dissemination: 
23. Research ethics approval: 
This protocol and the template informed consent form will be reviewed by the Ethics 
Committee of Scientific Research - faculty of oral and dental medicine – Cairo University. 
  
24. Protocol amendments: 
Any modifications to the protocol which may impact on the conduct of the study, potential 
benefit of the patient or may affect patient safety, including changes of study objectives, study 
design, sample sizes, study procedures, or significant administrative aspects will require a 
formal amendment to the protocol. Such amendment will be agreed upon by the Council of 
oral and maxillofacial surgery department. 
  
25. Informed consent:  
The Researcher will introduce the trial to patients and will discuss the trial with patients. The 
purpose, the nature of this study and detailed surgical procedure with possible complications 
will be also discussed. Patients will then be able to have an informed discussion with the 
participating consultant. The Researcher will obtain written consent from patients willing to 
participate in the trial. All, consent forms have been translated into Arabic 
  
 
 
26. Confidentiality  
All study-related information will be stored securely. All participant information will be stored 
in locked file cabinets in areas with limited access. All patients’ records will be digitized and 
stored securely on MZ personal computer. 
  
27. Declaration of interests  
The study is self-funded. No conflict of interest 
  
28.  Access to data  
All Principal Investigators will be given access to the data sets. All data sets will be password 
protected. 
  
29. Post-trial care  
All patients will be followed up until complete healing and satisfactory results occur.   
 
30. Dissemination policy  

11
 
 
Study results will be published as partial fulfilment of the requirements for Master degree in 
Oral and maxillofacial surgery. Topics suggested for presentation or publication (International 
Journal of Oral and Maxillofacial Surgery IJOMS) will be circulated to the authors. 
 
 
 
V. 
Appendices:  
31. APPENDIX A:  
 
Visual analogue scale: 
 
 
 
 
 
                      
                                              Figure-1 visual Analogue Scale 16. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

12
 
 
 
 
 
 
 
 
32. APPENDIX B:  
 
Patient questionnaire in English: 
 
 
 
 
 
Name:……………                                   Age:…….                          Sex:……… 
 
1-Do you have trismus ?                                                                                       Yes/No 
2-Do you hear noises or clicking when opening your jaw ?                                 Yes/No 
3-Do you have pain while chewing ?                                                                    Yes/No 
4-Do you have pain around your ears ?                                                                 Yes/No 
5-Have you ever had jaw locking ?                                                                       Yes/No 
6-Have you ever had injury to your face ?                                                            Yes/No 
7-Did you take any medications for TMJ ?                                                          Yes/No 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

13
 
 
 
 
 
 
 
 
33. APPENDIX C: 
 
Patient questionnaire in Arabic: 
 
 
 
                 ........:األسم:................................                                    العمر               
..........:النوع 
 
 
1
-هل تعانى من ضيق فى فتحة الفم ؟                                                                     نعم/ال 
2
-هل تسمع اصوات عندما تفتح الفم ؟                                                                    نعم/ال 
3
-
 هل
تحس باأللم عند مضغ الطعام ؟                                                                    نعم/ال 
4
-هل تحس بألم حول األذن ؟                                                                             
 نعم/ال 
5
-هل تحس بتصلب فى الفك ؟                                                                             نعم/ال 
6
-هل تعرضت ألصابات او جروح فى وجهك ؟                                                       نعم/ال 
7
-هل أخذت اى عالج لمفصل الفك الصدغى ؟                                     
                   نعم/ال 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

14
 
 
 
 
 
 
 
 
 
34. APPENDIX D: 
  
جامعة القاهرة 
 كلية طب الفم وا
ألسنان 
اقرار 
...........................:اسم الشخص         ......
............:السن     
........................:الواصى و صلة قرابته 
............................:التليفون                   
.............................................:العنوان 
1
- 
,لقد اطلعت بعناية و فهمت الغرض من اجراء هذا البحث و طبيعة هذه الدراسة وهى تجربة مقارنه بين القنيه ذات االبره
 متحده المركز و القنيه ذات االبرتين
في عالج التشويش الداخلى لمفصل الفك الصدغى 
 و انا افهم ما هو ضرورى ألجراء
.هذه األجرائات 
2
- لقد ابلغنى الطبيب المعالج بالمخاطر المحتملة للعالج و ه:ى 
-الم 
-تورم 
-اصابة األعصاب 
-اصابة الشرايين 
 
3
-
 أوافق على التصوير والتسجيل، وجميع أنواع األشعة والتي يتعين القيام بها في هذه الدراسة، بشرط عدم
الكشف عن هويت
ى.
 
 
4
-
 لقد قدمت تقريرا
عن حالتى الصحية و اخبرت الطبيب ان كنت اعانى من اى امراض او حساسية.
 
 
5
-اقر انى لن اشارك فى اى بحث اخ منذ بداية هذا البحث و حتى انتهائه.
 
 
:ملحوظة 
-يحق للمريض األنسحاب فى اى وقت من البحث و من حق الطبيب استعمال النتائج 
-يتعهد الطبيب بالحفاظ على سرية المريض 

15
 
 
 
................................:توقيع المريض 
..................................:توقيع الطبيب 
..............................:توقيع المشرف..
 
 
 
 
 
VI. 
Statement of originality: 
35. Statement of originality: 
‘This is to certify that to the best of my knowledge, the content of this thesis is my own work. 
This thesis has not been submitted for any degree or other purposes.’ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

16
 
 
 
 
 
 
 
VII. References: 
1.  
Rammelsberg P, LeResche L, Dworkin S, Mancl L. Longitudinal outcome of 
temporomandibular disorders: a 5-year epidemiologic study of muscle disorders defined by 
research diagnostic criteria for temporomandibular disorders. J Orofac Pain. 2003;17(1). 
2.  
Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F. Research 
diagnostic criteria for temporomandibular disorders: a systematic review of axis I 
epidemiologic findings. Oral Surgery, Oral Med Oral Pathol Oral Radiol Endodontology. 
2011;112(4):453-462. 
3.  
Peroz I, Tai S. Masticatory performance in patients with anterior disk displacement without 
reduction in comparison with symptom‐free volunteers. Eur J Oral Sci. 2002;110(5):341-344. 
4.  
Katzberg RW, Westesson P-L, Tallents RH, Drake CM. Anatomic disorders of the 
temporomandibular joint disc in asymptomatic subjects. J Oral Maxillofac Surg. 
1996;54(2):147-153. 
5.  
AL-Said S., Shawky N, Ragab H. Comparative Study of Arthrocentesis With or Without Using 
Piroxicam in the Management of Temporomandibular Joint Disorders. Alexandria Dent J. 
2015;40(2):160-165. doi:10.21608/adjalexu.2015.59142 
6.  
Hosaka H, Murakami K, Goto K, Iizuka T. Outcome of arthrocentesis for temporomandibular 
joint with closed lock at 3 years follow-up. Oral Surgery, Oral Med Oral Pathol Oral Radiol 
Endodontology. 1996;82(5):501-504. 
7.  
Nishimura M, Segami N, Kaneyama K, Suzuki T. Prognostic factors in arthrocentesis of the 
temporomandibular joint: evaluation of 100 patients with internal derangement. J oral 
Maxillofac Surg. 2001;59(8):874-877. 
8.  
Kaneyama K, Segami N, Nishimura M, Sato J, Fujimura K, Yoshimura H. The ideal lavage 
volume for removing bradykinin, interleukin-6, and protein from the temporomandibular 
joint by arthrocentesis. J oral Maxillofac Surg. 2004;62(6):657-661. 
9.  
Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint 
closed lock: a review article. Int J Oral Maxillofac Surg. 2007;36(9):773-782. 
10.  
Nitzan DW, Samson B, Better H. Long-term outcome of arthrocentesis for sudden-onset, 
persistent, severe closed lock of the temporomandibular joint. J Oral Maxillofac Surg. 
1997;55(2):151-157. doi:10.1016/S0278-2391(97)90233-0 
11.  
Dolwick MF. Arthrocentesis. J Oral Maxillofac Surg. 2009;67(9):15. 
12.  
Öreroğlu AR, Özkaya Ö, Öztürk MB, Bingöl D, Akan M. Concentric-needle cannula method for 
single-puncture arthrocentesis in temporomandibular joint disease: an inexpensive and 

17
 
 
feasible technique. J oral Maxillofac Surg. 2011;69(9):2334-2338. 
13.  
Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified 
treatment for severe, limited mouth opening. J Oral Maxillofac Surg. 1991;49(11):1163-1167. 
14.  
A. Carroll  J. Jakubowski, T KS. Extradural haematoma following temporomandibular joint 
arthrocentesis and lavage. Br J Neurosurg. 2000;14(2):152-154. 
15.  
Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of the temporomandibular joint: 
a proposal for a single-needle technique. Oral Surgery, Oral Med Oral Pathol Oral Radiol 
Endodontology. 2008;106(4):483-486. 
16.  
Talaat W, Ghoneim MM, Elsholkamy M. Single-needle arthrocentesis (Shepard cannula) vs. 
double-needle arthrocentesis for treating disc displacement without reduction. CRANIO®. 
2016;34(5):296-302. 
17. https://assessment-module.yale.edu/im-palliative/visual-analogue-scale.