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

Short-term results of autologous blood injection for treatment of habitual TMJ luxation

ABSTRACT: Many surgical and nonsurgical methods for the treatment of temporomandibular joint (TMJ) hypermobility have been published. The purpose of this study was to evaluate the results after autologous blood injection in and around the TMJ for the treatment of habitual luxation. Twenty-five patients were diagnosed as having habitual TMJ luxation and treated with autologous blood injection into the upper joint space and around the joint capsule (group A). A control group of 15 patients with the same diagnosis were subjected to physiotherapy with muscular exercise (group B). Patients in group A were reevaluated 3 months after treatment and those in group B were reevaluated after 3 months of physiotherapy. A statistically significant reduction in maximal mouth opening and TMJ sounds was noted only in group A, whereas the reduction for group B was minimal. These measurements show that intraauricular and periauricular autologous blood injection results in remission of signs and symptoms of TMJ luxation in the short term.     

Ultrasound-guided versus blind temporomandibular joint injections: a pilot cadaveric evaluation

Temporomandibular disorders are painful conditions that require precise injection therapy in selected patients. This pilot cadaveric study was undertaken to compare the accuracy of temporomandibular joint (TMJ) injection between the anatomical landmark-based (blind) technique and an ultrasound-guided technique. TMJ injections using the blind technique or the ultrasound-guided technique were performed in 10 non-embalmed cadavers. After dissection, the accuracy of the TMJ injections was found to be significantly greater for the ultrasound-guided injections than for the blind technique (blind 55% vs. ultrasound 95%, P = 0.008). For injections into the upper joint space of the TMJ, the success rate of the injection was comparable for the two techniques (blind 80% vs. ultrasound 100%, P = 0.474). However, ultrasound-guided injections into the lower joint space had a much higher success rate than the blind technique (blind 30% vs. ultrasound 90%, P = 0.020). The blind technique was associated with a considerable proportion of failed or inappropriate injections, especially for lower joint space injections. Ultrasound-guided TMJ injections were accomplished with a higher accuracy than the conventional blind technique, especially in the case of injections targeting the lower joint space of the TMJ.     

Total reconstruction of the temporomandibular joint. Up to 8 years of follow-up of patients treated with Biomet® total joint prostheses

12 patients underwent temporomandibular joint (TMJ) reconstruction with Biomet total joint prostheses. Indications for TMJ reconstruction included ankylosis, rheumatoid arthritis, degenerative joint disease and condylar resorption. Five patients had unilateral procedures, seven had bilateral. The follow-up ranged between 2 and 8 years. Amongst the ankylotic patients the mean jaw-opening capacity increased from 3.8 mm preoperatively to 30.2 mm 1 year after surgery, and in most of those patients the opening capacity remained stable over the years. The other patients maintained a mean opening capacity of more than 35 mm. Joint related pain and interference with eating were eliminated after TMJ reconstruction. There were no permanent facial nerve disturbance, no postoperative infections and no device related complications. The outcome supports prosthetic TMJ reconstruction as a useful treatment modality in patients with advanced TMJ disease.     

Changes in condylar and joint disc positions after bilateral sagittal split ramus osteotomy for correction of mandibular prognathism

The effect of combined orthodontic and orthognathic treatment was studied retrospectively in 24 patients with skeletal class III malocclusions with mandibular hyperplasia, particularly the effect on temporomandibular joint (TMJ) disc position. The patients underwent preoperative orthodontic treatment, orthognathic surgery, and postoperative orthodontic treatment. The patients were studied clinically, radiographically with lateral cephalometric radiograph and MRI to locate the position of the TMJ disc in relation to the glenoid fossa. One patient had less pain after treatment, one lost abnormal joint clicking sounds after treatment. There were no TMJ symptoms in 20 of the 24 preoperatively and postoperatively. 48 sagittal MRI images showed that the disc length before treatment was 3.040–12.928 (mean 8.289 ± 2.028) and after treatment was 3.699–11.589 (mean 8.097 ± 1.966); results were not significant (p > 0.05). Maximum disc displacement before treatment was 6.090 (mean 1.383), after treatment it was 11.931 (mean 2.193); results were not significant (p > 0.05). The results suggest that combined orthodontic and orthognathic treatment (including bilateral SSRO and rigid internal fixation) can be used safely to correct skeletal class III malocclusion with mandibular hyperplasia without causing additional TMJ symptoms.     

Hearing changes after temporomandibular joint arthroscopy: a prospective study

Temporomandibular Joint (TMJ) arthroscopy is considered an effective and safe minimally invasive surgical approach. While the long-term outcomes of arthroscopy tend to be positive and free of secondary effects, patients occasionally complain about their hearing following the treatment. The aim of this prospective study was to investigate possible hearing changes associated with TMJ arthroscopy. Pure-tone audiograms were performed in patients two weeks before TMJ arthroscopy and repeated six weeks after intervention. A total of 15 patients (mean age of 41.73 ± 16.36) were enrolled; 25 TMJ arthroscopies were performed (five unilateral and ten bilateral). Statistically significant differences were found between preoperative and postoperative audiograms in the frequencies 256 Hz (P = 0.011) and 8 kHz (P = 0.058, borderline). For the frequency 256 Hz the difference was favourable, but not superior to 5 dB. For the frequency 8 kHz, in three patients the TMJ arthroscopy resulted in a decrease of 10 dB. However, no clinical hearing changes or complaints were observed in the involved patients. No differences in audiograms between level 1 or 2 arthroscopy were observed. The study reinforces the safety of the TMJ arthroscopy level 1 and 2 with the reported protocol. The authors recommend larger studies to validate the results, specially for frequency 8 kHz.     

Surgical complications related to temporomandibular joint arthroscopy: a prospective analysis of 39 single-portal versus 43 double-portal procedures

Temporomandibular joint (TMJ) arthroscopy is a minimally invasive surgical procedure proposed for diverse TMJ intra-articular disorders. A prospective study was designed with the aim of investigating intraoperative and postoperative surgical complications for single and double-portal TMJ arthroscopy. All interventions were performed by one surgeon with the same surgical protocol. A total of 55 patients were enrolled, resulting in 82 TMJ arthroscopies (28 unilateral and 27 bilateral). A total of 39 single portal (47.57%) and 43 double-portal (52.43%) arthroscopies were performed. No severe and irreversible complications were observed. Most complications were resolved after 4 weeks. Double-portal was associated with more complications (n = 23) compared with single-portal TMJ arthroscopy (n = 14), with a statistically significant difference found between single and double-portal TMJ arthroscopy in two intraoperative complications: intra-articular bleeding (P = 0.044) and oedema of the preauricular area (P = 0.042). This study confirms the safety of TMJ arthroscopy for single and double-portal procedures, with the authors suggesting a multicentre study, in an effort to minimize any possible bias.     

Histological evaluation of the changes in temporomandibular joint capsule and retrodiscal ligaments following autologous blood injection

IntroductionIn recent years injection of autologous blood into the temporomandibular joint (TMJ) has been reintroduced as a treatment of chronic recurrent TMJ dislocation. The effects of this treatment on components of the TMJ is not fully understood. The purpose of this article is to evaluate the effects of autologous blood on TMJ capsule and the retrodiscal ligament.Material and methodsA total of 16 healthy adult country bred pig were used in this study. Autologous blood were injected into the upper joint space (4 ml) and around the capsule of TMJ unilaterally (1 ml). This procedure was then repeated on the opposite side only by using 5 ml of 0.9% saline. TMJ capsules and retrodiscal ligaments were examined four weeks following the injections.ResultsHistological examination of TMJs injected with autologous blood revealed fibrotic changes in 81.25% of the retrodiscal ligaments and 56.25% of the capsular areas. Whilst no changes were seen in the retrodiscal ligaments nor in the capsules of TMJs injected with saline alone.ConclusionThere is little published clinical data on the use of autologous blood injection and as such the mechanism of action is still unclear. The rate of induction of fibrosis within the retrodiscal ligaments in this study were similar to previously reported studies and case series. However, further studies to evaluate the mechanism of this safe and simple technique are needed.     

Irrigation fluid volume requirement for conventional arthrocentesis of the temporomandibular joint: a cadaver study

Temporomandibular joint (TMJ) arthrocentesis is considered an effective and minimally invasive procedure for certain conditions related to temporomandibular disorders. The ideal irrigation volume for arthrocentesis lavage has not yet been defined. Therefore, the aim of this study was to evaluate the efficacy of different saline solution volumes in removing methylene blue from the TMJ space of fresh human cadavers. Nineteen cadavers were selected and 1 ml of 10 μM methylene blue solution was injected into the upper joint space unilaterally. Conventional arthrocentesis was then conducted by infusion of 300 ml of 0.9% saline solution, collecting a 1-ml sample from the drained quantity for every 25 ml injected. Finally, the samples were assayed by measuring photo absorbance of the methylene blue solution. There was a statistically significant difference between the irrigation volumes regarding the removal of methylene blue solution from the joint space (P < 0.001), specifically between the first 25 ml and 200 ml (P = 0.014), 225 ml (P = 0.001), 250 ml (P < 0.001), and 275 ml (P = 0.001). Based on this ex vivo study, a 25-ml perfusion volume appears to be sufficient for joint lavage in conventional arthrocentesis of the TMJ.     

The sequential treatment of temporomandibular joint ankylosis with secondary deformities by distraction osteogenesis and arthroplasty or TMJ reconstruction

The purpose of this study was to evaluate the sequential treatment of patients with temporomandibular joint (TMJ) ankylosis and secondary deformities by distraction osteogenesis and subsequent arthroplasty or TMJ reconstruction. This study included 40 patients treated at a stomatological hospital in China; they ranged in age from 9 to 53 years (mean age 24.5 years). Ten of these patients were diagnosed with unilateral TMJ ankylosis and 30 with bilateral TMJ ankylosis. Twenty-seven patients also presented obstructive sleep apnoea–hypopnoea syndrome (OSAHS). All patients underwent distraction osteogenesis as the initial surgery, followed by arthroplasty or TMJ reconstruction. Some patients underwent orthognathic surgery to improve occlusion and face shape along with or after arthroplasty or TMJ reconstruction. The therapeutic effects were evaluated in terms of the improvements in maximum inter-incisal opening (MIO), appearance, and respiratory function. After the completion of treatment, all patients showed improvements in MIO and appearance, and the symptom of snoring disappeared. The airway space was significantly increased. Patient follow-up ranged from 6 to 85 months (mean 28.3 months), and four patients experienced relapse. This study suggests that treating TMJ ankylosis with secondary deformities by distraction osteogenesis as the initial surgery and arthroplasty or TMJ reconstruction as the second-stage treatment may achieve favourable outcomes, especially for patients with OSAHS; however, some patients may require orthognathic surgery.     

Outcomes of office-based temporomandibular joint arthroscopy: a 5-year retrospective study

Temporomandibular joint (TMJ) arthroscopy is a minimally invasive surgical approach for intra-articular TMJ diseases. Office-based arthroscopy using the smallest TMJ scope allows for good visualization, as well as the ability to lavage the joint in an office setting. This study aimed to assess the efficacy of an office-based TMJ arthroscopic technique. A retrospective evaluation of 363 patients with a TMJ disorder was performed. These patients underwent office-based arthroscopy using the OnPoint 1.2 mm Scope System (Biomet Microfixation, Jacksonville, FL, USA) in Florida, USA, from July 2007. The following outcomes of the procedure were assessed: improvement in painless range of mandibular motion, pain on loading, and functional jaw pain; these were evaluated using a visual analog scale (VAS) over an average follow-up period of 263.81 ± 142.1 days. The statistical analysis was performed using IBM SPSS Statistics version 20. Statistically significant improvements in TMJ pain and function, and other variables (P = 0.001) were shown following TMJ arthroscopic lysis and lavage. Office-based arthroscopy using the OnPoint System was demonstrated to be a safe and efficient procedure for the treatment of patients with TMJ disorders as the first level of the algorithm of care.     

Preliminary evaluation of histological changes found in a mechanical arthropatic temporomandibular joint (TMJ) exposed to an intra-articular Hyaluronic acid (HA) injection, in a rat model

Objective

This study investigates the histological effects of Hyaluronic acid injections in the treatment of induced temporomandibular joint (TMJ) osteoarthritis in rats.

Study design

Twenty-four male Wister rats were subjected to induced mechanical osteoarthritis by manual hypermobility for 10 successive days. Animals were then divided into two groups; group I (control) and group II (experimental). Ten days after the induction of hypermobility, the right TMJ of the experimental animals was injected with a dose of 0.12 mg HA intra-articularly and 0.12 mg saline was injected into the left joint; while animals in the control group were left without any treatment. Two rats from group I were killed at one, two and six weeks; while 6 animals from group II were killed at one, two and four weeks post injection.

Results

The disk of the right joints in the experimental animals was of normal thickness and there was an increase in the thickness of the fibrocartilagenous layer. In the left joint; ulcerative changes in the disk were evident where the fibres were not well oriented and scalloped areas in the temporal bone area were present denoting osteoclastic activity.

Conclusions

Repeated intra-articular TMJ injection of Hyaluronic acid appears to be a safe and effective way of inhibiting the progression of osteoarthritic changes in the joint through development of articular cartilage and reducing fibrous tissue proliferation.     

Airway space changes after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: three-dimensional assessment

This study focused on three-dimensional (3D) airway space changes and stability following simultaneous maxillomandibular counterclockwise rotation, mandibular advancement, and temporomandibular joint (TMJ) reconstruction with custom-made total joint prostheses (TMJ Concepts^®). Cone beam computed tomography (CBCT) scans of 30 consecutive female patients with irreversibly compromised TMJs were obtained at the following intervals: T1, presurgery; T2, immediately after surgery; and T3, at least 6 months after surgery. The CBCT volumetric datasets were analysed with Dolphin Imaging^® software to evaluate surgical and postsurgical changes to oropharyngeal airway parameters. The average changes in airway surface area (SA), volume (VOL), and minimum axial area (MAA) were, 179.50 mm², 6302.60 mm³, and 92.23 mm², respectively, at the longest follow-up (T3 ? T1) (P ≤ 0.001). Significant correlations between the amount of mandibular advancement and counterclockwise rotation of the occlusal plane and 3D airway changes were also found (P ≤ 0.01). The results of this investigation showed a significant immediate 3D airway space increase after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses, which remained stable over the follow-up period.     

A cohort study of patients with juvenile idiopathic arthritis and arthritis of the temporomandibular joint: outcome of arthrocentesis with and without the use of steroids

The purpose of this study was to evaluate the effects of intra-articular temporomandibular joint (TMJ) treatment in patients with juvenile idiopathic arthritis (JIA). The inclusion criteria were met by 21 patients (38 joints). Joints were randomly selected for either arthrocentesis alone (n = 17) or arthrocentesis with the additional use of triamcinolone hexacetonide (n = 21) using a closed single-needle system. Measurements of pain and function were performed at baseline and at follow-up after 3 and 8 months. Pain on opening and lateral excursion improved significantly after injections. Pain decreased significantly from baseline to first and second control on a visual analogue scale (VAS) for overall pain (49–18–8) and overall function (41–19–4). Significant improvement was recorded for pain on palpation of muscles and joints. There was no statistically significant difference between the treatment modalities, with or without glucocorticoid injection. Arthrocentesis in the TMJ treatment of patients with JIA may be beneficial and steroids had no additional effect. Further studies are needed to evaluate the long-term effects on the TMJ structures and on condylar growth from arthrocentesis and intra-articular steroid injections.     

Effects of four treatment strategies for temporomandibular joint closed lock

A previous randomized controlled trial (RCT) by Schiffman et al. (2007)¹⁵ compared four treatments strategies for temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock). In this parallel group RCT, 106 patients with magnetic resonance imaging (MRI)-confirmed TMJ closed lock were randomized between medical management, non-surgical rehabilitation, arthroscopic surgery, and arthroplasty. Surgical groups also received rehabilitation post-surgically. The current paper reassesses the effectiveness of these four treatment strategies using outcome measures recommended by the International Association of Oral and Maxillofacial Surgeons (IAOMS). Clinical assessments at baseline and at follow-up (3, 6, 12, 18, 24, and 60 months) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing. TMJ MRIs were performed at baseline and 24 months, and TMJ tomograms at baseline, 24 and 60 months. Most IAOMS recommended outcome measures improved significantly over time (P ≤ 0.0003). There was no difference between treatment strategies relative to any treatment outcome at any follow-up (P ≥ 0.16). Patient self-assessment of treatment success correlated with their ability to eat, with pain-free opening ≥35 mm, and with reduced pain intensity. Given no difference between treatment strategies, non-surgical treatment should be employed for TMJ closed lock before considering surgery.     

Relationship between the canthal–tragus distance and the puncture point in temporomandibular joint arthroscopy

This study investigated whether a relationship exists between the length of the canthal–tragus line and the distance from the tragus at which the puncture point for arthroscope insertion should be made. On one side of 11 cadaver heads, a puncture point was marked 7 mm from the midtragus and 2 mm below the canthal–tragus line. On the other side, the distances were 10 mm and 2 mm, respectively. The arthroscope trocar and cannula were inserted at the marked points. The anatomical location of the arthroscope after insertion was confirmed by open dissection with the arthroscope in place. Following dissection, the canthal–tragus line was measured on each side of the cadaver's head. For measurements >70 mm, puncture points 10 mm from the midtragus led to insertion of the arthroscope inside the upper joint compartment. For measurements ≤70 mm, puncture points 7 mm from the midtragus led to insertion of the arthroscope inside the upper joint compartment. This suggests that for canthal–tragus distances of >70 mm, the arthroscope should be inserted 10 mm from the midtragus and for distances ≤70 mm it should be inserted at 7 mm for the greatest likelihood of entering the upper joint compartment of the TMJ.     

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: Part I - Skeletal and dental stability

The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total joint prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9 ± 8.0°. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9 ± 3.5 mm at the lower incisor tips, 12.4 ± 5.4 mm at Point B, 17.3 ± 7.0 mm at menton, 18.4 ± 8.5 mm at pogonion, and 11.0 ± 5.3 mm at gonion. Vertically, the lower incisors moved upward ?2.9 ± 4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the maxillo-mandibular complex was a stable procedure for these patients at the longest follow-up.     

Surgical induction of TMJ bony ankylosis in growing sheep and the role of injury severity of the glenoid fossa on the development of bony ankylosis

ObjectiveThe purpose of this paper is to summarize our experiences in creating an animal model of TMJ bony ankylosis based on 2 sequential experiments.MethodsTwo sequential experiments were performed with the aim of creating a model of TMJ bony ankylosis. Seven growing sheep were used in the first experiment, in which 1 was served as a control animal. Condylar fracture with disc preservation was performed on the control side. On the contralateral side, condylar fracture, excision of the lateral 2/3 disc and injury to the glenoid fossa were performed to induce bony ankylosis. Three animals were sacrificed respectively at 3 and 6 months after surgery. In the second experiment, 7 growing sheep were used. The only difference of modeling between the 2 experiments was that more serious injury to the glenoid fossa was made in the ankylosis-induced side in experiment 2. Three, 2, and 2 animals were sacrificed respectively at 1, 3, and 6 months postoperatively. The TMJ complexes were examined by computed tomography (CT) and histological evaluation.ResultsIn experiment 1, only fibrous ankylosis was observed in the ankylosis-induced side both at 3 and 6 months postoperatively. In experiment 2, CT and histological evaluation showed that the outcomes of the ankylosis-induced side were fibrous-bony ankylosis, fibrous-bony ankylosis, and bony ankylosis respectively at 1, 3, and 6 months after surgery.ConclusionThrough summarizing the differences of the modeling and the different outcomes in the 2 experiments, we concluded that severe damage to the glenoid fossa played an important role in the development of TMJ bony ankylosis.     

Gap arthroplasty of temporomandibular joint ankylosis by transoral access: a case series

This article describes a technique of gap arthroplasty in temporomandibular joint (TMJ) ankylosis performed by transoral access. The treatment of TMJ ankylosis by creating an adequate gap is of paramount importance in preventing any future recurrence and this can be achieved only when good access is gained to this complex anatomical joint. Five patients with TMJ ankylosis (eight TMJ) were treated by gap arthroplasty using an intraoral approach. The average mouth opening before surgery was 8.6 mm and the average mouth opening achieved postsurgery was 37.9 mm. The average follow-up time was 13 months and none of the patients had any recurrence or significant complications during or after surgery. Our technique relies on the use of a stable landmark to trace the superior-most extent of the ankylotic mass thereby facilitating the removal of the entire mass including the medial extent. We found that even though transoral access is technically challenging and took an average time of 84 min, it has many advantages over conventional extraoral approaches in terms of facial scars and facial nerve injury. The authors also emphasize the importance of good postoperative physiotherapy and presurgical patient counselling to prevent future recurrences.     

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: Part II – Airway changes and stability

The purpose of this study was to evaluate the anatomical changes and stability of the oropharyngeal airway and head posture following TMJ reconstruction and mandibular advancement with TMJ Concepts custom-made total joint prostheses and maxillary osteotomies with counter-clockwise rotation of the maxillo-mandibular complex. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). The lateral cephalograms of 47 patients were analyzed to determine surgical and post-surgical changes of the oropharyngeal airway, hyoid bone and head posture. Surgery increased the narrowest retroglossal airway space 4.9 mm. Head posture showed flexure immediately after surgery (?5.6 ± 6.7°) and extension long-term post surgery (1.8 ± 6.7°); cervical curvature showed no significant change. Surgery increased the distances between the third cervical vertebrae and the menton 11.7 ± 9.1 mm and the third cervical vertebrae and hyoid 3.2 ± 3.9 mm, and remained stable. The distance from the hyoid to the mandibular plane decreased during surgery (?3.8 ± 5.8 mm) and after surgery (?2.5 ± 5.2 mm). Maxillo-mandibular advancement with counter-clockwise rotation and TMJ reconstruction with total joint prostheses produced immediate increase in oropharyngeal airway dimension, which was influenced by long-term changes in head posture but remained stable over the follow-up period.