|Year : 2022 | Volume
| Issue : 4 | Page : 394-399
Comparative analysis of autologous blood injection and conservative therapy for the management of chronic temporomandibular joint dislocation
Jigna S Shah, Kinjal Joshi, Swati Jha, A Mathumathi
Department of Oral Medicine and Radiology, Government Dental College and Hospital, Ahmedabad, Gujarat, India
|Date of Submission||15-Jul-2021|
|Date of Decision||02-Dec-2022|
|Date of Acceptance||05-Dec-2022|
|Date of Web Publication||09-Dec-2022|
Department of Oral Medicine and Radiology, Govt. Dental College and Hospital, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To evaluate the efficacy, safety, and stability of TMJ autologous blood injection for the treatment of recurrent TMJ dislocation in an effort to standardize the procedure and compare it with the conservative management. Materials and Methods: Twenty patients diagnosed with chronic recurrent TMJ dislocation (complete/incomplete) were treated by conservative method, and five patients who did not respond to conservative therapy were treated by injections of autologous blood into the upper joint space and around the TMJ capsules. Statistical Analysis Used: Statistical analysis of collected data was done using SPSS version 23. The values were evaluated statistically with t-test and Kruskal–Wallis test for descriptive, intergroup, and intragroup comparison. Results: Hundred percent of successful outcome and required no further treatment at their 3-month follow-up in autologous blood injection. Conclusion: This procedure has proven to be safe, simple, and cost-effective for the treatment of chronic recurrent TMJ dislocation.
Keywords: Autologous blood injection, chronic recurrent TMJ dislocation (complete/incomplete), conservative therapy
|How to cite this article:|
Shah JS, Joshi K, Jha S, Mathumathi A. Comparative analysis of autologous blood injection and conservative therapy for the management of chronic temporomandibular joint dislocation. J Indian Acad Oral Med Radiol 2022;34:394-9
|How to cite this URL:|
Shah JS, Joshi K, Jha S, Mathumathi A. Comparative analysis of autologous blood injection and conservative therapy for the management of chronic temporomandibular joint dislocation. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Feb 2];34:394-9. Available from: http://www.jiaomr.in/text.asp?2022/34/4/394/363022
| Introduction with Review|| |
The temporomandibular joint (TMJ) is a specialized joint between the mandible and the temporal bone of the skull. Hypermobility of the TMJ is divided into two groups: subluxation and dislocation. Dislocation may be classified as acute, chronic, and recurrent. Mandibular dislocation is defined as a nonreducing displacement of the mandibular condyle in front of and superior to the articular eminence, resulting in the inability to close the mouth. The resultant stretching of the ligaments around the joint is associated with severe simultaneous spasm of the mouth opening and closing muscles and joint pain. It may be reducible when it returns spontaneously to the glenoid cavity—it is referred to as subluxation.
The etiology of recurrent dislocation is not known. The pathogenesis of chronic recurrent TMJ dislocation is attributed (either complete or incomplete) to a combination of factors including laxity of the TMJ ligaments, weakness of the TMJ capsule, an unusual eminence size or projection, muscle hyperactivity or spasms, trauma, and abnormal chewing movements that do not allow the condyle to translate back.,, Certain systemic diseases, like Parkinson's disease, epilepsy, Ehlers–Danlos syndrome, and antipsychotic drugs which may cause extra pyramidal reactions, have also been attributed as predisposing factors.,,
The most common clinical symptom for complete dislocation is the inability to close the oral cavity, i.e., “open lock,” difficulty in speech, drooling of saliva, and lip incompetency. In acute dislocation, pain in the preauricular region is present, but chronic recurrent dislocation is rarely associated with it. Usually, bilateral and at times unilateral dislocation may lead to deviation of the chin to the contralateral side. Palpation over the preauricular region may suggest emptiness in the joint space. The patient may look anxious. While subluxation is only partially a pathological condition, that is, if there is pain and discomfort in the joints and masticatory muscles. The classic clicking sound in the terminal phases of mouth opening can be a sign of subluxation of the condyle which travels anteriorly along the articular eminence in order to adapt.
Various conservative, minimally invasive and surgical treatments have been employed to treat chronic recurrent TMJ dislocations (CRTMJD). The conservative approaches include restriction of the mandibular movement (plus muscle relaxants prescription and soft diet) and applications of local anesthetic. The minimally invasive procedures include injection of botulinum toxin to the muscles of mastication, injection of sclerosing agents, and autologous blood injection (ABI) into the TMJ. When the nonsurgical modalities are not successful in treating a patient with recurrent TMJ dislocation, surgical approaches will be considered. These approaches include capsular plication, reduction, or augmentation of the articular eminence, temporalis tendon scarification, lateral pterygoid myotomy, and condylectomy. Removal of etiological and predisposing factor after management of dislocation will prevent further development of luxation.
ABI to the TMJ as a treatment of CRTMJD was first reported by Brachmann in 1964. Schulzre described the technique for the treatment with good results. This technique is simple, noninvasive, and safe and can be performed under local anesthesia or intravenous sedation on outpatient basis. The reported overall success rate of autologous blood injection is approximately 80%. The action mechanism of TMJ autologous blood injection is not fully understood. However, the pathophysiological reaction to blood injected into the superior joint space and the pericapsular tissue of the TMJ would be scarring and fibrous tissue formation. Therefore, the concept behind autologous blood injection is promotion of fibrosis within the capsular tissue and consequently restraining the motion of mandibular excursion.,,,,
The purpose of this study is to evaluate the efficacy, safety, and stability of TMJ autologous blood injection for the treatment of recurrent TMJ dislocation in an effort to standardize the procedure and compare it with the conservative management.
| Materials and Method|| |
A total of 20 patients (12 males and 8 females) who diagnosed with CRTMJD presented to the Department of Oral Medicine and Radiology were selected. Out of 20 subjects, 16 were having incomplete dislocation and 4 had complete dislocation. Written informed consent had been taken from all patients before procedure. All 20 subjects were treated by conservative management and five subjects by ABI. Their clinical examination consisted of bilateral TMJ and muscles of mastication palpation and measurement of the distance between maxillary and mandibular incisal edges (MIO). Radiographic panoramic TMJ (TMJ OPG) imaging showed both condyles to be anterior to the articular eminence. Magnetic resonance imaging (MRI) and diagnostic blood tests were carried out in subjects planned for ABI.
All patients were instructed to restrict the mandibular motions by soft diet with bilateral chewing, spoon feeding, support chin while yawning, wear chin strap whole day for 1 week and only during night for the next 1 week. For patients with MPDS and complete dislocation along with above instructions, topical applications of 1% diclofenac gel over preauricular region, hot and cold fermentation over preauricular region, and muscle relaxant with NSAID (chlorzoxazone 500 mg, aceclofenac 100 mg, and paracetamol 325 mg) were prescribed thrice a day for 7 days. [Figure 1] [Step 1 to 5] show all steps of autologous blood injection. Follow-up was noted in graphs. Subjects in the study and procedures followed were under the ethical standards of Helsinki Declaration (2013), and the clinical protocol for the study was approved by the Institutional Ethics Committee (IEC GDCH/OMR.9/2019 dated 10/04/2019).
Sample size selection: It was done as per the below formula
n (sample size) = [Z2 S2]/d2
S is standard deviation of sample mean = 9.5
Z = 1.96, i.e., 95% of C.I.
d = 5% precision
n (sample size) = [Z2 S2]/d2 = [(1.96) 2 (9.5)2]/52 = 14
Hence, 20 patients can be included.
| Results|| |
The average MIO was 46.86 for conservative group and 46.02 mm for autologous group at baseline. On first-week follow-up, the mean mouth opening was 45.51 mm in conservative group and 24.54 mm in autologous group. On first-month and third-month follow-up, mean mouth opening was 43.3 mm in conservative group. The mean mouth opening of autologous group was 35.8 mm in first month and 38.56 in third-month follow up. The intergroup comparison of mean reduction in mouth opening at baseline was statically not significant (p-0.760), and 1-week, 4-week, and 12-week interval difference was statistically significant. The intragroup comparison of mean reduction in mouth opening from baseline to 3-month follow-up was statically not significant (p-0.274) in conservative group and highly significant (p-0.000) in autologous group.
At baseline, the mean VAS score was 3.2 and 4 in conservative and autologous groups, respectively. On first-week follow-up, it was reduced to 0.33 and 0.8 in conservative and autologous groups, respectively. At 1-month follow-up, conservative group was having mean VAS score of 0.06 and no pain in third-month follow-up. Autologous group was not reported with pain in both 1-month and 3-month follow-up. The intergroup comparison of mean reduction in VAS score was statically not significant (p < 0.05) at baseline, 1-week, 4-week, and 12-week interval. The intragroup comparison of mean reduction in VAS score from baseline to 3-month follow-up was statically highly significant (p-0.000) in conservative group and significant (p- 0.007) in autologous group.
At baseline, 13 (86.6%) out of 15 (100%) subjects treated with conservative management and 4 (80%) out of 5 (100%) subjects treated with autologous were found to have clicking sound. On first-week, first-month, and third-month follow-up, out of 13 (86.6%) conservative subjects, 12 (92.3%) had no improvement in clicking and 1 (6.6%) had relief from clicking. Out of 4 (80%) autologous subjects, 3 (75%) subjects had good relief in clicking and 1 (25%) had no relief. On 1-month and 3-month follow-up, all 4 (100%) autologous subjects had good relief from clicking. The intergroup comparison of mean reduction in clicking at baseline was statically not significant (p-0.725), and 1-week, 4-week, and 12-week interval difference was statistically significant. The intragroup comparison of mean reduction in clicking from baseline to 3-month follow-up was statically nonsignificant (p-0.392) in conservative group and significant (p- 0.019) in autologous group.
Average number of episodes of dislocation was 8.5 a day at baseline. On follow-up, dislocation was not reported from first week to 3-month follow-up. The intragroup comparison of mean reduction in dislocation from baseline to 3-month follow-up was statically significant (p-0.007) in autologous group.
| Discussion|| |
Hypermobility of the TMJ may cause injury to the disk, the capsule, and the ligaments, leading to progressive internal derangement.,, An acute TMJ dislocation of more than four weeks can be called a long-standing, protracted, or recurrent dislocation., In the present study, all the cases had a dislocation (complete or incomplete) for more than 4 weeks with the least duration of 12 weeks. Factors responsible for late presentations in our environment included financial constraints, ignorance, distance from specialized healthcare facilities, and missed diagnoses by skilled healthcare professionals.,
The most common age-group of patients with dislocation was found to be 21–40 years in our study which are similar to various studies, because younger subjects were more prone for trauma, disimpaction, or parafunctional habits which is contrast to other studies., Least common age-group was found to be 10–20 yrs. and above 40 yrs. due to the loss of laxity in older age-group and underdeveloped condyle in younger age-group.
The most common gender found to be male in our study which is similar to other study because female patients may not present to the hospital frequently as partial dislocation will not cause pain and males are more prone for trauma. Contrast to our study, female predominance seen in various studies,,,, but the reason for this female predisposition is not yet fully understood.
The most common chief complaint reported with partial/complete dislocation subjects was pain in TMJ or muscle region due to the associated spasm of muscles of mastication followed by clicking sound due to hypermobility of joint. All complete dislocation subjects were reported with difficulty in closing the mouth which is similar to other studies.
Similar to previous findings,,, all 20 TMJ dislocations observed in our study were anterior dislocation. In our study, only two (10%) subjects had unilateral complete dislocation in which one subject had idiopathic peak-shaped condyle on affected side that leads to frequent dislocation, and both subjects had disk abnormalities in the unaffected joint. Thus, chronic unilateral dislocation may affect the opposite unaffected joint due to excessive load.
TMJ dislocation is prevalent in patients with TMJ internal derangement, joint laxity, occlusal disturbances, loss of vertical height, neurological disorders, or as a result of trauma. In our study, yawning was found to be the most common etiology of both partial and complete TMJ dislocation which is similar to other studies,, because it may lead to gradual laxity of the restraining joint ligaments which predisposes to increased range of condylar movement. Other than that, occlusal disturbance, loss of vertical height due to generalized attrition, and trauma were also seen in our study. In contrast to our study, trauma was found to be the most common etiology in other studies.
In our study, 6 out of 16 partial dislocation subjects were reported with no pain, and all 4 complete dislocation patients were reported with pain because pain was caused by muscle spasm and partial dislocation alone will not produce any pain. The frequency of dislocation ranged from 4 to 15 per day which was more than other studies like 1 average episode of dislocation per day, 3/day to 2/week dislocation episodes, and twice a week dislocation episode.
The diagnosis of TMJ dislocation is mainly clinical; however, different imaging modalities can assist in patient assessment, treatment planning, and follow-up. TMJ OPG was the only imaging modality used to assess the patients in this study because it is cheap and widely available at most centers. Hence, TMJ OPG was enough to diagnose and evaluate the dislocation subjects who were undergone for conservative management. OPG was advised to assess the status of impacted teeth.
Partial dislocation subjects were successfully treated by conservative management without any complications. All four complete dislocation and one partial dislocation subjects who did not responded to the conservative management were underwent for autologous blood injection in our study. Long-standing partial dislocation may lead to complete dislocation or other disk abnormalities. Hence in our study, one partial dislocation patient who did not get relief from conservative management was treated by autologous blood injection for permanent results.
Critical evaluation of protocols followed by various authors revealed greater success rates in case of use of both intraarticular and pericapsular injections as compared to either intraarticular or pericapsular injections alone., A clinical study reported greater reduction in maximum mouth opening in patients treated with both superior joint space and pericapsular tissues injection as compared to those treated with injection into superior joint space only. Hence in our study, we had injected autologous blood in both intraarticular and pericapsular regions.
Exogenous bleeding (intraarticular injection) does not have same effect as endogenous bleeding. Yet, we must keep in mind that restrained mandibular movement is the key to the success of the procedure. In the view of the literature, we found authors performing intermaxillary fixation after autologous blood injection.,,, In our study, elastic bandage was used to restrict mandibular motion which was enough to permit primary clot formation, and the pain that follows the injections will also restrain mandibular movements, permitting the injected blood to settle and create fibrosis.
The digital radiographic imaging of TMJ showed absence of any destructive changes to its bony components after autologous blood injection which coincides with the results of other studies.,, The five patients who had been treated with autologous blood injections had functional range of motion with mean MIO of 38.56 mm with average decrease in maximal mouth opening of 5.5 mm after 3-month follow-up which is similar to other studies., Conservative group had average decrease in mouth opening of 1.5 mm after 3-month follow-up.
This study showed no appreciable complications in any case including recurrence or facial nerve injury, whereas certain studies found the complications.,,, After autologous blood injection, muscle relaxant with anti-inflammatory was given for 1 week instead of antibiotic as mentioned in other studies,, because irrigation of joint space was done before injection and anti-inflammatory is enough to prevent inflammation. Mild pain with the mean of 0.8 VAS score was noted in the first week of autologous blood injection followed by no pain was reported in first-month and third-month follow-up. In conservative management, eight patients with MPDS were successfully treated with pharmacological therapy with complete relief in third-month follow-up. Followed by symptom relief, patients had advised for removal of etiological factor after 1 week in conservative group and after 3 months in autologous group for the permanent result.
Patients with clicking sound (13 out of 15 conservative and 1 out of 4 autologous group) reduced completely in three subjects of complete dislocation after 1 week and in one subject after 1 month. Our study is in correlation with other study. But in conservative management, 12 out of 13 subjects did not got relieved from clicking as habitual luxation will not reduce by its own without any blockade in their path. Thus, autologous blood clot was forming barrier for the excessive anterior translation of condyle.
There is no predictive indicator for success of treatment by nonsurgical means including autologous blood injection. However, the cases who do not respond positively in the initial 3 weeks of treatment should be considered as failure case. In such condition, surgical methods should be opted. Five patients out of 20 had the chief complaint of TMJ dislocation, and in them, all five did not report any episode of dislocation in 3-month follow-up, which is 100% success rate. The finding was higher than other studies., This was contradicted to other study which stated that autologous blood injection had limited success in patients with very frequent dislocation where there was a history of other TMJ disorders like disc displacement. Hence in our study, preoperative MRI was taken to rule out other disk abnormalities and improved outcome of treatment.
| Conclusion|| |
Following conclusions have drawn from our study:
- Complete dislocation will cause difficulty in closing the mouth along with pain in TMJ region, and partial dislocation may or may not associate with pain [Table 1].
- Yawning was found to be the most common cause of chronic recurrent dislocation (either complete or partial) followed by malocclusion/partial edentulism [Table 2].
- All partial dislocation was bilateral, and complete dislocation can be unilateral or bilateral.
- Altered shape of condyle may be one of the causes of dislocation [Table 2].
- A simple TMJ OPG was enough to diagnose dislocation. MRI was needed only before invasive procedure to rule out other soft tissue abnormality.
- Muscle spasm associated with partial dislocation was successfully managed by pharmacological therapy, and pain associated with complete dislocation was completely reduced after 1 week of autologous blood injection [Figure 2].
- Complete chronic recurrent dislocation can be successfully managed with autologous blood injection without any postoperative complication [Figure 2].
- Partial dislocation can be successfully managed with conservative management, and unresponded subjects can undergo for autologous blood injection.
- Early diagnosis and treatment of partial dislocation will help to prevent the further damage of TMJ.
- Chin strap was enough to restrict the mandibular motion in chronic dislocation subjects [Figure 2].
- Autologous blood injection could be a promising alternative to surgery for recurrent TMJ dislocation, particularly in patients who are not eligible for surgical procedures.
|Figure 2: Graphical representation of post-treatment follow-up. A histogram showing the change in maximal mouth opening, VAS score, clicking sound, and frequency of dislocation at intervals after conservative and autologous treatment|
Click here to view
We could conclude from this study that injection of autologous blood to the TMJ in patients with chronic recurrent dislocation is a simple, safe, and cost-effective technique.
Limitation and future prospectus
Further research is necessary on large sample size, and long-term follow-up is required for all dislocation patients. Post-treatment radiographic evaluation (MRI) is needed to evaluate effect of autologous blood on articular disk and joint space.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]