Abstract
The purpose of the present study was to evaluate the effectiveness of autologous blood injection in the treatment of recurrent temporomandibular joint dislocation. Eleven patients diagnosed with recurrent dislocation of the joint that could not be self-reduced, received bilateral injections of autologous blood in the superior joint compartment and pericapsular region. During a follow-up period ranging from 24 to 35 months (average 29.6 months), eight patients (72.7%) did not show new episodes of dislocation. The most advocated treatment for recurrent dislocation is eminectomy, which involves a skin incision, with the risk of damaging the facial nerve, requires general anaesthesia, and presents an average success rate of 85% according to the literature. Autologous blood injection is a simple, rapid, minimally invasive, and cost-effective technique, with a low possibility of complications, and is a feasible alternative treatment before surgical intervention.
The temporomandibular joint (TMJ) is a complex joint with unique characteristics and functions. Among the changes in joint hypermobility, TMJ dislocation refers to the displacement, generally anterior, of the condyle over the articular eminence, with complete separation of the joint surfaces and consequent locking. The patient is unable to close their mouth, which remains locked open until a mechanical reduction is performed.
The pathophysiology of mandibular dislocation involves the combination of three factors: loosening of the capsule and the TMJ ligaments, a prominent eminence, and muscular spasm. Initially, loosening of the capsule and ligaments allows the condyle to perform non-physiological and excessive motions, bypassing the articular eminence. This condition can be seen during simple activities such as laughing and yawning, during long dental consultations, during orotracheal intubation, and in episodes of vomiting. Since the eminence works as a mechanical barrier to control mandibular motion, this non-functional bypass leads to spasm of the associated musculature. Other aetiological factors associated with TMJ dislocation are trauma, the use of anti-emetics and phenothiazine, which produce extrapyramidal effects, systemic diseases such as rheumatoid arthritis, and psychogenic and neurological disorders.
Several methods of treatment have been described for recurrent TMJ dislocation, ranging from conservative procedures to surgical interventions. Among the non-surgical approaches is the use of autologous blood, injected in the upper joint space and pericapsular region. The aim of this approach is to promote fibrosis of the capsular tissue and consequent motion restraint of mandibular excursion. The procedure presents advantages such as ease of performance, low cost, a low complication rate, and greater patient compliance when compared to more invasive alternatives.
Injections of autologous blood in the TMJ follow the pathophysiology of bleeding in any joint of the body. Initially, the joint compartment and pericapsular tissues are stretched by the injection of the material. As a physiological response, an inflammatory reaction and oedema in the adjacent tissues, with a reduction of joint motion, occurs over the following hours or days. After this, there is the formation of an organized coagulum and fibrous tissue, which keep the joint motions limited. Finally, this tissue develops and results in the permanent limitation of motion. Together, exposure of the joint cartilage to blood promotes a change in the turnover of the cartilaginous matrix, a reduction in the metabolism of chondrocytes, and consequently local contraction. The use of an elastic bandage following treatment keeps the joint motions reduced and allows the formation of fibrosis and adhesions in the capsule and pericapsular tissues.
The aim of this study was to describe the technique of autologous blood injection in the superior joint space and pericapsular region and to assess its efficacy in the control of dislocation after a minimum follow-up of 24 months.
Patients and methods
Patients
This clinical trial included patients treated in the oral and maxillofacial centre of the study hospital between the years 2010 and 2013. During the initial screening, 23 patients were selected based on clinical and imaging examinations. The clinical examination assessed the maximum incisal opening (MIO), number of episodes of dislocation, necessity of professional assistance for reduction, and vertical dimension of the lower facial third. Panoramic and TMJ radiography, in the closed and open mouth positions, was evaluated to assess both the position of the condyle in relation to the articular eminence and the presence of osteophytes and remodelling.
Inclusion criteria were the following: (1) patient showing at least three episodes of TMJ dislocation in a 6-month period, necessitating a trained professional for reduction; (2) no previous history of TMJ treatment, either conservative or surgical; and (3) age ≥15 years. Exclusion criteria were the following: (1) psychiatric conditions; (2) connective tissue syndromes, such as Marfan and Ehler–Danlos; (3) parafunctional habits; and (4) short lower facial third, since this leads to joint instability.
The current research was approved by the ethics committee for research of the study institution and all participants signed an informed consent agreement. This study was performed in accordance with the Declaration of Helsinki with regard to medical protocol and ethics.
Surgical technique
MIO was achieved with care not to cause TMJ dislocation. The articular fossa was then localized with the aid of a reference line from tragus to lateral canthus. The auriculo-temporal nerve was blocked and the pericapsular tissue was infiltrated with 2% lidocaine and 1:100,000 epinephrine, respecting the limit of 5.4 ml for each side.
Arthrocentesis was performed in all patients before blood injection. For this procedure, two 18-G needles were inserted into the upper joint space while the patient kept his/her mouth open. The first needle was positioned 10 mm anterior to the tragus and 2 mm below the reference line, until it touched the fossa. The second was then inserted 10 mm anterior to the first needle and 5 mm below the reference line to allow fluid drainage. Two hundred and fifty millilitres of lactated Ringer’s solution were used for joint lavage.
Afterwards, 3 ml of autologous blood was collected from the brachial vein, the draining needle was removed, the blood syringe was connected to the remaining needle, and 2 ml of blood was injected into the upper joint space and 1 ml in the pericapsular region ( Fig. 1 ). In cases of bilateral chronic recurrent TMJ dislocation, the same procedure was performed on the opposite side. The same surgeon performed all procedures.
Postoperative care
An elastic facial bandage (Murena’s Confecções Hospitalares) was applied immediately after the procedure and kept in place 24 h a day for 2 weeks, with the aim of limiting mouth opening to a maximum of 20 mm ( Fig. 2 ). After this initial period, patients were advised to wear the bandage only while sleeping.
Non-steroidal anti-inflammatories were prescribed for 3 days, and a liquid/soft diet was maintained for 3 weeks. Mandibular movements were developed progressively during the course of the follow-up appointments by means of supervised physiotherapy.
Postoperative consultations were done at regular intervals of 1 week, 2 weeks, 1 month, 3 months, 6 months, 12 months, and 24 months up to the last appointment before data collection. During these examinations MIO was measured and possible complications were assessed, such as pain and recurrent dislocations.
Results
Of the 23 patients initially selected, 10 were excluded since they were able to self-reduce the condylar dislocation and two were excluded as they presented fewer than three episodes in a 6-month period. The final sample comprised 11 patients with chronic recurrent TMJ dislocation; eight were women and three were men, and their average age was 27.8 years (range 15–60 years). The average duration of symptoms was 63.9 months, ranging from 4 months to 16 years. The number of dislocations prior to the procedure ranged from 3 to 60 episodes (average 13.4 episodes), but in all cases, the patients needed the assistance of a health care professional to reposition the joint ( Table 1 ).
| Patient | Sex | Age, years | Duration of symptoms | Number of dislocations |
|---|---|---|---|---|
| 1 | Male | 23 | 5 years | 9 |
| 2 | Male | 25 | 1 year | 4 |
| 3 | Female | 27 | 4 months | 14 |
| 4 | Female | 33 | 15 years | 18 |
| 5 | Female | 34 | 16 years | 60 |
| 6 | Male | 20 | 4 months | 5 |
| 7 | Female | 24 | 1 year | 3 |
| 8 | Female | 15 | 1 year | 4 |
| 9 | Female | 60 | 6 months | 6 |
| 10 | Female | 22 | 7 years | 14 |
| 11 | Female | 23 | 7 years | 10 |
On clinical assessment, MIO was a mean 38 mm (range 32–53 mm) before the injection of blood and 39 mm (range 35–48 mm) postoperative.
Bone remodelling was observed in four patients bilaterally and in three patients unilaterally. No osteophytes were observed on the condylar surface. Postoperative radiography presented the same aspects as that obtained preoperatively.
Three patients (27.3%) relapsed during the follow-up period, which ranged from 24 to 35 months (average of 29.6 months). Relapse occurred after 2 months in two patients and after 6 months in one patient. The same protocol was repeated for these three cases, but unsuccessfully. These patients were then put forward for the surgical procedure of eminectomy. Thus, of the 11 patients initially treated, eight (72.7%) did not show episodes of recurrent mandibular dislocation after the proposed procedure. The results are given in Table 2 .
