Arthrocentesis followed by intra-articular autologous blood injection for the treatment of recurrent temporomandibular joint dislocation

Abstract

Temporomandibular joint (TMJ) dislocation is an excessive forward movement of the condyle beyond the articular eminence with complete separation of the articular surfaces and fixation in that position. This study was conducted to assess autologous blood injection to the TMJ for the treatment of chronic recurrent TMJ dislocation. Fifteen patients with bilateral chronic recurrent condylar dislocation were included in the study. Bilateral TMJ arthrocentesis was performed on each patient, followed by the injection of 2 ml of autologous blood into the superior joint compartment and 1 ml onto the outer surface of the joint capsule. Preoperative and postoperative assessment included a thorough history and physical examination to determine the maximal mouth opening, presence of pain and sounds, frequency of luxation, recurrence rate, and presence of facial nerve paralysis. Eighty percent of the subjects (12 patients) had a successful outcome with no further episodes of dislocation and required no further treatment at their 1-year follow-up, whereas three patients had recurrent dislocation as early as 2 weeks after treatment. Autologous blood injection is a safe, simple, and cost-effective treatment for chronic recurrent TMJ dislocation.

Temporomandibular joint (TMJ) dislocation is an excessive forward movement of the condyle beyond the articular eminence with complete separation of the articular surfaces and fixation in that position. This condition typically occurs as a result of everyday activities, such as yawning and laughing. It may occur after excessive mouth opening during dental treatment and general anaesthesia. The pathogenesis of chronic recurrent TMJ dislocation is attributed to a combination of factors, including laxity of the TMJ ligaments, weakness of the TMJ capsule, unusual eminence size and projection, muscle hyperactivity or spasm, trauma, and abnormal chewing movements that do not allow the condyle to translate back into the normal position.

Many surgical and non-surgical techniques for the treatment of patients with chronic recurrent condyle dislocation are presented in the literature. Surgical interventions aim at restricting condylar movement by creating a mechanical obstruction along the condylar path or by removing a mechanical obstacle along the condylar path. The decision depends on predisposing factors and the TMJ morphology.

The more complex and invasive methods of treatment might not necessarily offer the best treatment option and outcome, and less invasive approaches should be utilized appropriately before adopting the more invasive surgical techniques. Chronic recurrent dislocation may be approached with conservative procedures, including injection of botulinum toxin to various muscles of mastication, injection of sclerosing agents, and autologous blood injection into the peri-capsular tissue and superior joint space.

In 1973, Schulz reported his experience with autologous blood injection into the TMJ as treatment for recurrent condyle dislocation. Autologous blood injection into the TMJ was abandoned for reasons that are unclear; it has recently been reintroduced.

Blood injections into the TMJ follow the pathophysiology of bleeding in the joints elsewhere in the body, such as the knee and the elbow. During the first few hours or days, an inflammatory reaction takes place, resulting in the release of inflammatory mediators by platelets along with the accumulation of dead and injured cells, leading to oedema of the joint tissue. This inflammatory reaction diminishes joint mobility. Thereafter, a combination of organized blood clots and loose fibrous tissue forms, which further decreases joint mobility. These tissues mature, causing a permanent limitation of joint movement. This exposure of cartilage to blood results in a disturbance of the cartilage matrix turnover and a decrease in chondrocyte metabolism, causing localized contraction.

The purpose of this study is to report our experience with autologous blood injection into the TMJ as a minimally invasive treatment for recurrent TMJ condyle dislocation.

Materials and methods

Subjects

Fifteen consecutive patients with bilateral chronic recurrent TMJ condyle dislocation were included in the study. The inclusion criteria were at least two episodes of bilateral TMJ dislocation in the past 6 months necessitating a visit to the emergency room or to a trained professional to reduce the dislocation. The patients were diagnosed and treated in the oral and maxillofacial surgery department of the study hospital.

All of the participating patients were over 18 years of age and in good medical condition. The preoperative assessment consisted of a thorough history and physical examination to determine the maximum incisal opening (MIO), presence of pain and sounds, frequency of dislocation, and rate of recurrence. For all of the patients, panoramic imaging in closed and open positions showed the presence of condyles anterior to the articular eminence. The patients were diagnosed with chronic recurrent TMJ condyle dislocation based on the clinical and radiographic criteria established by Nitzan.

Surgical technique

The patients underwent bilateral TMJ arthrocentesis, under conscious sedation or general anaesthesia, followed by the injection of 2 ml of autologous blood into the superior joint compartment and 1 ml onto the outer surface of the joint capsule. The same surgical team, following an identical protocol each time, performed the procedure. The steps of the procedure were discussed in detail with the patients, as were the possible risks and complications, which included, but were not limited to, postoperative pain, trismus, swelling, and facial nerve injury.

The patient’s face was prepared in the usual and sterile manner. Local anaesthesia (2% lidocaine with 1:100,000 epinephrine) was applied to the auriculotemporal nerve. The articular fossa point (AF) was located at a point 10 mm anterior to the tragus and 2 mm inferior to the tragal–canthal line ( Fig. 1 ). At this location, a 19-gauge needle was inserted into the superior joint space of the TMJ; the correct location of the needle was confirmed by movement of the mandible during the fluid injection. A second 19-gauge needle was inserted into the superior joint space, 20 mm anterior to the tragus and 5 mm inferior to the tragal–canthal line, for fluid to exit through during the TMJ arthrocentesis ( Fig. 2 ).

Fig. 1
The first injection site in the articular fossa point (AF), located at a point 10 mm anterior to the tragus and 2 mm inferior to the tragal–canthal line.

Fig. 2
A second 19-gauge needle is inserted in the superior joint space, at a point 20 mm anterior to the tragus and 5 mm inferior to the tragal–canthal line, for fluid to exit during the TMJ arthrocentesis.

The joint was flushed with approximately 250 ml of normal saline. The second needle was removed after the TMJ arthrocentesis. Next, 3 ml of blood was withdrawn from the patient’s anticubital fossa; 2 ml of blood was injected into the superior joint space and 1 ml was injected onto the outer surface of the TMJ capsule ( Fig. 3 ). The same procedure was performed on the contralateral TMJ. An elastic bandage was applied around the patient’s head and left in place for the first 24 h.

Jan 19, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Arthrocentesis followed by intra-articular autologous blood injection for the treatment of recurrent temporomandibular joint dislocation
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