FIGURE 5.1 Sagittal view of the temporomandibular joint. A: Jaw closed. B: Jaw open. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
PATIENT POSITION
- Sitting on the exam table.
- The patient’s hands are folded in his or her lap.
LANDMARKS
1. With the patient seated on the exam table, the clinician stands lateral and posterior to the affected jaw.
2. Palpate the TMJ with the mouth in the closed and then the fully open positions.
3. Identify the sulcus that forms with jaw opening and mark that spot with ink.
4. At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.
5. After the landmarks are identified, the patient should not move the jaw.
6. The patient must keep his or her mouth open until the completion of the procedure.
ANESTHESIA
- Local anesthesia of the skin using topical vapocoolant spray may be used but is not necessary in most patients. If using a spray, make sure that “overspray” of the vapocoolant chemical does not enter the patient’s eyes or external ear canal.
EQUIPMENT
- 3-mL syringe
- 25-gauge, 1-in. needle
- 0.5 mL of 1% lidocaine without epinephrine
- 0.5 mL of the steroid solution (20 mg of triamcinolone acetonide)
- One alcohol prep pad
- Two povidone–iodine prep pads
- Sterile gauze pads
- Sterile adhesive bandage
TECHNIQUE
1. Prep the insertion site with alcohol followed by the povidone–iodine pads.
2. Achieve good local anesthesia by using topical vapocoolant spray.
3. Position the needle and syringe from a posterior approach at a 30-degree angle to the sagittal plane into the sulcus with the tip of the needle directed anteromedial toward the posterior aspect of the TMJ.
4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 5.2).
5. Advance the needle toward the joint until the needle tip is located in the joint capsule. There will be a decrease in resistance when entering the joint capsule. After entering the joint space, the needle will touch the articular surface or the articular disk. Back up the needle 1 to 2 mm.
6. Inject the steroid solution as a bolus into the TMJ articular capsule. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.
7. Following injection of the corticosteroid solution, withdraw the needle.
8. Apply a sterile adhesive bandage.
9. Instruct the patient to move his or her jaw through its full range of motion. This movement distributes the steroid solution throughout the joint capsule.
10. Reexamine the TMJ in 5 min to confirm pain relief.
Related posts:
