Joint injections or Arthrocentesis is a minimally invasive procedure where one or two needles are inserted into the jaw joint (TMJ) and fluid is injected into the joint. This washes away inflammatory byproducts and lubricate the joint. We use saline, steroid, blood or PRF to inject into the space. This is a good option for inflammatory arthritis flare ups and acute closed lock.
We also use injection therapy to inject muscles (botox), tendons (steroids), and nerves (local anesthesia.) These can be very helpful with TMJ dysfunction symptoms.
Arthrocentesis is most useful in flareups of joint arthritis. There are four common situations:
- Acute closed lock – this happens when your disc (the thing that pops in the jaw) to get stuck, limiting your ability to open your mouth. Often times this gets better with rest, stretching but if after 2 weeks it has not improved, arthrocentesis is very helpful.
- Inflammatory arthritis flareup – people with juvenile idiopathic, rheumatoid, or psoriatic arthritis can have flare ups that respond very well to arthrocentesis and steroid injection.
- Chronic TMD flareups – A derangement of the disc can be a lifelong problem and like other joints, wear and tear arthritis (osteoarthritis) can develop. To help prolong more invasive surgery and to treat persistent episodes of pain, arthrocentesis can help. We use steroid, prf or hyalagan to inject these joints.
- Chronic dislocation – Some people have repeated visits to the emergency room because their jaw gets stuck open. If this happens repeatedly, we offer two options – blood injections or eminectomy. Blood injections are done after arthrocentesis and are the more minimally invasive option.
Absolutely. The most common TMJ disorders are best managed without surgery. Joint flare ups can be successfully managed with jaw rest, medication and time. More than 95% of people with TMJ symptoms improve without any surgery. If your symptoms continue despite conservative measures, we can see you for an evaluation.
Often when considering surgery, we obtain a MRI to evaluate the joint in more detail to offer you surgical solutions based on your anatomy. With arthrocentesis, a MRI isn’t necessary. The procedure is rather generic and improves most joint flare ups independent of the joint anatomy. Arthrocentesis is a great temporary solution to temporary joint conditions.
There are multiple options that we offer:
- Saline – rinsing the joint with sterile salt water allows the inflammation within the joint to be washed out. This allows for a reset of the joint contents and an improvement in pain symptoms.
- Steroid – Corticosteroids can reduce inflammation in the joint and help with pain. With inflammatory arthritis, steroids can be very helpful. They may even soften scar tissue within the joint to allow your joint to be more mobile. The down side is that they can change the bone in unfavorable ways with repeated injections.
- Platelet rich fibrin (PRF) – This is a portion of your own blood that has concentrated growth factors to help the joint repair. Your blood is spun in a centrifuge to split up the components. Platelet rich plasma (PRP) has been used in the past as it contains growth factors, fibrin glue and platelets. PRF has become more popular because it has less processing and easier to use.
- Blood – Injecting your blood into your jaw joint may sound crude but it is helpful for chronic dislocation of the TMJ. The idea is to form some scar within the joint to limit mobility and often times two or three rounds of blood injections are needed to help with chronic dislocation.
- Hyaluronic acid – HA is sometimes used to provide lubrication to the joint. For some people, they want us to use this and we can help!
Risks with arthrocentesis are very low. The most common risk is that your joint symptoms are either no better or minimally better with the procedure. Many people experience temporary eye lid weakness from the local anesthesia given during surgery. This resolves in a few hours. Long term facial weakness, facial numbness, change in the way the teeth fit (occlusion), infection, or bleeding are all very rare (<1%.)
This procedure is done under IV sedation in the clinic. The surgery is relatively short with most people being here for 45-60 minutes (10-15 minutes for procedure). We recommend a soft diet and immediate movement of the jaw. Most people have weakness in their eyebrow after this surgery. This is from the numbing medication There is swelling in the area that gets better in 1-2 days.
We inject other things than joints to help TMJ disorders. They are: muscles, nerves and tendons.
Muscle Injections
Generally muscles that have grown too large (hypertrophy) from overuse or are in spasm can benefit from muscle therapy. We favor nonsurgical approaches such as massage, physical therapy and rest. If the muscles are so large that you cannot break the cycle of dysfunction, or if conservative approaches haven’t helped, muscle injections can. Botox is by far the most common medication we use. Botox partially paralyzes the muscle for about 6-8 weeks. During that time it weakens (atrophies.) We inject botox in the masseter, temporalis, lateral pterygoid and sometimes the mentalis. This can be very helpful for muscle pain but it also decreases the forces on your joints. Having us inject the muscles help minimize leakage of botox to adjacent muscles and help dial in the appropriate dose.
Before and after botox to the masseters. Notice the decrease in bulk of muscle and change in face shape.
Tendon Injections
We find that temporalis tendonitis is common in people with TMJ flareups. The temporalis is a big muscle on the side of your head and it attaches to the jaw via at a point called the coronoid process. It looks like a sharks dorsal fin on either side of the lower jaw.
Tendonitis of the temporalis tendon shows up as pain in your cheek towards the back of your teeth. Usually there is a very tender spot if you feel the inside of your cheek and reach as far back as you can. That is the temporalis tendon. This can improve with rest, massage, ice and stretching.
A common situation of tendonitis is repeat local anesthesia injections at the dentist. People sometimes find that they can’t open their mouths after dental treatment and the most common cause is temporalis tendonitis.
A very simple thing is for us to inject the area with a steroid and local anesthesia. If this works and the pain returns, we can discuss a tendon release, but for many people one round of injections is all that is needed.
Steroid injection into the temporalis tendon.
The coronoid process – where the temporalis tendon attaches. A tendon release is called a coronoidectomy, a straightforward procedure that dramatically helps with mouth opening in people with contracture of the tendon.
Nerve injections
Lastly, local anesthesia injections to nerves can help temporarily alleviate pain. Nerve injections can also help with diagnosing the problem. We use these as adjuncts to the overall picture.
