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.     

L-单甲基-精氨酸对颞下颌关节骨关节病治疗作用的实验研究

目的　研究一氧化氮合酶抑制剂L 单甲基 精氨酸对山羊实验性颞下颌关节骨关节病的治疗作用及可能机制。方法　通过双侧颞下颌关节上腔内注射胶原酶建立骨关节病模型 ,从注射胶原酶第 4周起 ,在左侧关节上腔内每隔 3d注射 0 5 %L 单甲基 精氨酸 0 5ml,共 7次 ,右侧同期注射生理盐水 0 5ml。注射胶原酶后 1 2周处死所有动物 ,取双侧关节标本作组织学检查并根据改良Mankin骨关节病评价标准评分。结果　评分结果 :L 单甲基 精氨酸侧为 3 83 ,而对照侧为 6 33 ,两者比较差异有高度显著性 (P <0 0 1 )。结论　L 单甲基 精氨酸关节腔内注射对山羊实验性颞下颌关节骨关节病的发展有抑制作用 ,其作用机制可能与L 单甲基 精氨酸抑制一氧化氮合酶在关节局部产生过多的一氧化氮有关     

局部激素注射治疗间接性颞颌关节损伤的疗效评价

目的　探讨强的松龙治疗间接性颞颌关节损伤的效果。方法　用自制撞击装置间接性造成 10只山羊双侧颞颌关节损伤 ,分别于伤后 2 h、7天向右侧关节腔内注射强的松龙液 12 .5 mg,同时向左侧关节腔内注射生理盐水作为对照 ,伤后 3月取材。印度墨汁染色后 ,通过体视显微镜和组织学方法进行观察。结果　实验侧关节的组织损害较对照侧明显减轻。结论　强的松龙颞颌关节腔内注射可减轻间接性羊颞颌关节损伤后的组织损害。     

Investigation of an autologous blood treatment strategy for temporomandibular joint hypermobility in a pig model

Many different surgical and non-surgical techniques are used for the treatment of temporomandibular joint (TMJ) hypermobility. One of these methods is autologous blood injection into the TMJ. The fate of the autologous blood used for treatment of recurring condylar dislocation is still not completely understood. The authors used 12 pigs (Sus scrota f. domestica) as a model species for autologous blood delivery into the TMJ. Blood injection was followed by histopathological analysis at different times after treatment (1 h, 1, 2 and 4 weeks). Samples were examined by magnetic resonance imaging, macroscopic and histological methods. The deposition of the remaining blood was observed in the form of clots in the distal parts of the upper joint cavity 1 h and 1 week after treatment. 2 weeks after treatment, small blood clots were still apparent in the distal part of the upper joint cavity. 4 weeks after surgery, no remnants of blood, changes or adhesions were apparent inside the TMJ. No morphological or histological changes were observed in the TMJ after the injection of autologous blood suggesting another mechanism is involved in the hypermobility treatment.     

Change of site of intra-articular injection of hypertonic dextrose resulted in different effects of treatment

Most minimally invasive treatments for dysfunction of the temporomandibular joint (TMJ) are empirical, and aimed at the painful trigger points with the purpose of preventing muscular spasm and restoring normal function. In this prospective study I investigated whether the choice of site of injection of hypertonic dextrose affected the benefits of treatment of internal derangement and pain. I studied 72 patients with pain and clicking as a result of dysfunction of the TMJ. Patients were divided into four groups with four separate sites for intra-articular injection. Dextrose was injected into the superior joint space, inferior joint space, retrodiscal tissue, and anterior capsule injection. Results showed that the retrodiscal site was the most effective for reducing clicking and subsequently improving derangement, while the inferior joint space was the best site for the relief of pain, and the extracapsular site should be used in cases of hypermobility. In conclusion, the injection site should be selected according to the symptoms being treated, and could be used as an adjunct to other sites to improve outcome.     

Comparison of temporomandibular joint function and morphology after surgical and non-surgical treatment in adult condylar head fractures

PurposeThe aim of this study was to evaluate whether surgical treatment can distinctly improve temporomandibular joint (TMJ) function and morphology in adult patients with condylar head fractures (CHFs) when compared with conservative treatment.Patients and methodsA retrospective study was performed to evaluate surgical and conservative outcomes in all patients who had suffered CHFs. In this study, all patients were divided into a surgical group and a conservative group. In the surgical group patients were treated by open reduction and internal fixation (ORIF) combined disc anchorage, while in the conservative group patients were treated by a removable splint combined with intermaxillary elastics. Clinical and radiological outcomes were evaluated and functional outcomes were assessed using the Helkimo index score. Paired t-tests, Wilcoxon signed rank tests, independent t-tests and χ² tests were used to assess inter-group differences.Results75 TMJs in 56 patients were included in this study and were divided into a surgical group (56 TMJs in 40 patients) and a conservative group (19 TMJs in 16 patients). The results showed that the Helkimo index score for TMJ in the surgical group was better than in the conservative group (p_Ai = 0.032, p_Di = 0.001, respectively). Ramus height in the surgical group (61.08 ± 4.04 mm) recovered more than in the conservative group (54.82 ± 3.06 mm) (p = 0.012). Discs became shorter, moved further forward, and became severely distorted in the conservative group (disc length = 7.32 ± 1.35 mm). In contrast, discs became longer, retained a normal disc–condyle relationship, and formed a normal shape in the surgical group (disc length = 11.05 ± 2.07 mm) (p = 0.003). According to the MRI images, joint effusion, retrodiscal tear, and lateral capsular tear were better cured in the surgical group (p = 0.001, p < 0.001, p = 0.012, respectively).ConclusionBased on these results, it seems that surgical treatment of condylar head fractures should be the preferred approach if there are no contraindications for general anesthesia.     

A comparative study on the impact of intra-articular injections of hyaluronic acid,tenoxicam and betametazon on the relief of temporomandibular joint disorder complaints

ObjectiveThe aim of this study was to compare the efficacy of intra-articular injections of three different agents with well known anti-inflammatory properties.Materials and methodBetween April 2010 and January 2013 a total of 100 patients who were diagnosed as temporomandibular joint disorder in the Department of Otolaryngology at Bozok University School of Medicine were prospectively studied. Patients with symptoms of jaw pain, limited or painful jaw movement, clicking or grating within the joint, were evaluated with temporomandibular CT to investigate the presence of cartilage or capsule degeneration.In the study group there were 55 female and 45 male patients who were non-responders to conventional anti-inflammatory treatment for TMJ complaints. The patients were randomly divided into four groups consisting of a control group and three different groups who underwent intra-articular injection of one given anti-inflammatory agent for each group. We injected saline solution to intra-articular space in the control group. Of three anti-inflammatory agents including hyaluronic acid (HA, Hyalgan intra-articular injection, Sodium hyaluronate 10 mg/ml, 2 ml injection syringe, Bilim Pharmaceutical Company, Istanbul, Turkey); betamethasone (CS, Diprospan flacon, 7.0 mg betamethasone/1 ml, Schering-Plough Pharmaceutical Company, Istanbul, Turkey) and; tenoxicam (TX, Tilcotil flacon, 20 mg tenoxicam/ml, Roche Pharmaceutical Company, Istanbul, Turkey) were administered intra-articularly under, ultrasonographic guidance. Following the completion of injections the, changes in subjective symptoms were compared with visual analogue scales, (VAS) scores at 1st and 6th weeks' follow-up visits between four groups.ResultsThe HA group did significantly better pain relief scores compared to the, other groups at 1st and 6th weeks (p < 0.05). TX and CS groups' pain scores were better than control group values (p < 0.05, for both agents). The pain relief effect of TX was noted to decrease significantly between the 1st and 6th week (p < 0.05) (Fig. 1). We did not observe the same pattern in HA, CS and control (saline) groups between 1st and 6th week (p > 0.05).ConclusionWe found that HA produced better pain relief scores when compared to the other anti-inflammatory agents studied. The main disadvantage of HA is its relatively higher cost. Additionally it does not have a reimbursement status by state or private health insurance systems in Turkey. Despite the lower VAS scores, intra-articular TX and CS may be assessed as more economic alternatives to intra-articular HA injections.     

In vivo morphometric analysis of inflammatory condylar changes in rat temporomandibular joint

Oral Diseases (2011) 17 , 499–507 Objective: Injection of complete Freund’s adjuvant (CFA) into the temporomandibular joint (TMJ) causes acute swelling around the joint and subsequent morphological alterations in the condyle. We aimed to evaluate changes in the three‐dimensional architecture of the condyle induced with CFA. Materials and methods: The CFA was injected into the unilateral TMJ of rats and morphological changes in the condyle were assessed repeatedly for 14 days by in vivo micro‐CT. Results: Osseous abnormalities of condyle were first observed at 3–5 days after CFA injection on the tomographic images, and the condylar deformation became more obvious thereafter. Among 12 condyles examined at 14 days postinjection, osteophytosis was observed in all of the specimens and bone erosion coexisted in five condyles. None of the saline‐treated condyles showed architectural changes. Significant changes were detected in the mesiolateral and rostrocaudal widths of the CFA‐treated condyles at 10–14 days postinjection (P < 0.01). The extent of both condylar bone formation and resorption was greater in the CFA‐injected TMJs than in saline‐injected TMJs (P < 0.05). Conclusion: These results indicate that CFA causes dynamic morphological changes in the condyle and that our experimental approach will provide new insights into the subacute inflammatory processes in the TMJ.     

Variations of the attachment of the superior head of human lateral pterygoid muscle

IntroductionThe superior head of the lateral pterygoid muscle (LPM), is closely related to the temporomandibular joint (TMJ) and plays a role in the aetiology of temporomandibular disorders. Increased activity of this muscle has been implicated in the anterior displacement of the TMJ disc. However, there is uncertainty about the manner of the LPM attachment to the disc–condyle complex.AimThe aim of this study was to investigate the exact anatomy of the attachment of the superior head of the LPM (SLPM) to the disc–condyle complex of the TMJ.Material and methodsThirty-six TMJs were examined – both sides of 18 Greek cadavers (eight males and 10 females, mean age 79.6 years). Examination of the attachment of the SLPM was undertaken viewed under the dissecting microscope.ResultsVariation in the attachment of the SLPM was categorized into three types: in type I, the SLPM inserted into the condyle and the disc–capsule complex (55.5%). In type II, the SLPM only inserted into the condyle (27.8%). In type III, the SLPM inserted purely into the disc–capsule complex (16.7%).ConclusionsThis study demonstrates that there are three different attachment types of the SLPM to the disc–condyle complex. The type III variation could be involved in the TMJ pathology. The knowledge of the variations of the SLPM attachment could be useful for precise surgical and pharmaceutical approaches.     

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.     

rhIL-1Ra抑制大鼠颞下颌关节骨关节炎软骨破坏的研究

目的:探讨关节腔内注射重组人IL-1Ra对实验性大鼠颞下颌关节炎软骨关节修复的影响.方法:取SD大鼠24只,用关节腔内注射Ⅱ型胶原酶法建立双侧颞下颌关节骨关节炎模型,1周后,右侧(实验侧)关节腔内一次性注射重组人IL-1Ra5 μg(稀释于0.05 ml生理盐水),左侧(对照侧)注射等量生理盐水.建模后2周、4周各处死12只动物,取颞下颌关节标本进行HE染色、免疫组化染色及RT-PCR检测,用Mankin评分方法评估TMJ组织病理变化程度.另取1只SD大鼠用作空白对照,2周后处死.结果:2周时双侧颞下颌关节软骨均呈现不同程度的关节病损,实验侧和对照侧Mankin计分分别为1.33±0.52和2.00±6.63(P ＞0.05).4周时,实验侧改良和对照侧Mankin评分分别为3.00±0.63和6.50 ±0.84(P＜0.05).AD-AMTS-4、5的蛋白及mRNA表达也低于对照侧(P＜0.05).结论:颞下颌关节腔内注射重组人IL-1Ra能缓解骨关节炎导致的软骨病损,其治疗机制可能是通过抑制ADAMTS-4、5的表达来实现的.     

用木瓜蛋白酶建立兔颞颌关节骨关节炎模型的研究

目的:探讨采用木瓜蛋白酶在兔颞颌关节上腔注射,建立兔颞颌关节骨关节炎动物模型的可行性。方法:对 6只日本大耳白兔行颞颌关节上腔注射,实验侧注射013 ml 116%木瓜蛋白酶溶液,对照侧注射013 ml生理盐水,1 周后重复1次,首次注射后第2、4、6周分批处死实验动物,切取颞颌关节做大体及组织病理学观察。结果:实验侧关节注射木瓜蛋白酶后出现关节软骨变薄、基质分解破坏、滑膜增生等炎症及退行性改变,并随观察时间的延长而进一步发展,但在首次注射后第6周时出现不同程度的修复性改变。结论:兔颞颌关节注射木瓜蛋白酶后的改变与人颞颌关节骨关节炎病理改变具有相似性,可重复,可作为研究颞颌关节骨关节炎病理、发病机理及治疗方法的实验工具。     

Clinical diagnosis of temporomandibular joint arthritis

Evidence‐based clinical diagnostic criteria for temporomandibular joint (TMJ) arthritis are not available. To establish (i) criteria for clinical diagnosis of TMJ arthritis and (ii) clinical variables useful to determine inflammatory activity in TMJ arthritis using synovial fluid levels of inflammatory mediators as the reference standard. A calibrated examiner assessed TMJ pain, function, noise and occlusal changes in 219 TMJs (141 patients, 15 healthy individuals). TMJ synovial fluid samples were obtained with a push–pull technique using the hydroxycobalamin method and analysed for TNF, TNFsRII, IL‐1β, IL‐1ra, IL‐1sRII, IL‐6 and serotonin. If any inflammatory mediator concentration exceeded normal, the TMJ was considered as arthritic. In the patient group, 71% of the joints were arthritic. Of those, 93% were painful. About 66% of the non‐arthritic TMJs were painful to some degree. Intensity of TMJ resting pain and TMJ maximum opening pain, number of jaw movements causing TMJ pain and laterotrusive movement to the contralateral side significantly explained presence of arthritis (AUC 0.72, P < .001). Based on these findings, criteria for possible, probable and definite TMJ arthritis were determined. Arthritic TMJs with high inflammatory activity showed higher pain intensity on maximum mouth opening (P < .001) and higher number of painful mandibular movements (P = .004) than TMJs with low inflammatory activity. The combination TMJ pain on maximum mouth opening and Contralateral laterotrusion <8 mm appears to have diagnostic value for TMJ arthritis. Among arthritic TMJs, higher TMJ pain intensity on maximum mouth opening and number of mandibular movements causing TMJ pain indicates higher inflammatory activity.     

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.     

Repeated sodium hyaluronate injections following multiple arthrocenteses in the treatment of early stage reducing disc displacement of the temporomandibular joint: A preliminary report

PurposeThe aim of this study was to assess the safety and clinical utility of intraarticular injection of sodium hyaluronate for the treatment of symptoms associated with internal derangement of the temporomandibular joint (TMJ).Patients and methodsTwenty patients, who have early stage temporomandibular dysfunction (TMD), were treated with intraarticular sodium hyaluronate injection and arthrocentesis. The patients received sodium hyaluronate (15 mg/ml) (1 ml) injections two times a week first following arthrocentesis with 200 ml Ringer’s Lactate and the second without. The procedure was repeated for three times at weekly intervals for 3 weeks. Pre- and postinjection pain intensity, the presence of joint sounds, and interincisial distance were recorded. These data were evaluated by visual analog scale (VAS).ResultsThe follow-up period was 6 months. There was a statistically significant reduction of pain intensity (p < 0.001) and joint sound (p < 0.001) in all patients. Initial measurement of maximal mouth opening (MMO) was 33.40 ± 3.75 mm. At the end of the follow-up period, the same measurements were repeated and interincisal distance was 49.3 ± 3.74 mm. The difference between these measurements was statistically significant (p < 0.001).ConclusionWe suggest that repeated sodium hyaluronate injections following multiple arthrocenteses with Ringer’s Lactate is an effective and safe method for the treatment of early stage reducing disc displacement of TMJ.     

Simplified anesthesia blocking of the temporomandibular joint

The general dentist's ability to perform an anesthesia block of the temporomandibular joint (TMJ) can be very beneficial, especially when trying to diagnose or treat patients with temporomandibular dysfunction who have joint and/or muscle pain. There are three common types of internal joint disorders--orthopedic, inflammatory, and degenerative--producing pain in the ligaments, TMJ capsule, or retrodiscal tissues. Secondary muscle splinting also may be involved. Subjects with these disorders can have pain, limited opening, or difficulty with extended opening. Dentists providing care for these individuals may need to schedule longer appointments and deal with mid-treatment facial or TMJ pain as well as more postoperative discomfort. An anesthesia block for the TMJ can reduce pain and protective muscle splinting, increase the mandibular range of motion, and assist in providing a more manageable treatment.     

透明质酸酶诱导兔颞下颌关节骨关节病的实验研究

目的：建立兔颞下颌关节骨关节病动物模型。方法：将不同浓度透明质酸酶（ＨＤ）一次性注入两组兔颞下颌关节下腔内,分别于注射后２４ｈ、１、４、８、１２周后处死动物,对颞下颌关节标本进行组织学观察。结果：注射ＨＤ４周后出现关节软骨破坏,关节盘腔原纤维暴露,滑膜慢性炎症等骨关节病表现。结论：本实验研究建立了颞下颌关节骨关节病模型可用于颞与颌关节骨关节病早、中期病变的研究 。     

Diagnosis of retrodiscal tissue in painful temporomandibular joint (TMJ) by fluid-attenuated inversion recovery (FLAIR) signal intensity

The purpose of the present study is to analyze the fluid-attenuated inversion recovery (FLAIR) signal intensity of the retrodiscal tissue in a painful temporomandibular joint (TMJ), and to develop a diagnostic system based on FLAIR data.

Methodology:The study was based on 33 joints of 17 patients referred for MR imaging of the TMJ. Regions of interest were placed over retrodiscal tissue and gray matter (GM) on FLAIR images. Using signal intensities of GM as reference points, signal intensity ratios (SIR) of retrodiscal tissue were calculated. SIRs in painful TMJ were compared with those in painless TMJ. Wilcoxon’s Rank Sum Test was used to analyze the difference in SIRs between the painful and painless groups (P<0·05).

Results:The SIRs of retrodiscal tissue were significantly higher in painful joints than in painless joints.

Conclusion:FLAIR sequences provide a high signal in patients having painful TMJ, and it suggests that retrodiscal tissue in painful TMJ contains elements such as protein.     

透明质酸钠治疗颞下颌关节骨关节病的动物实验研究

目的:评价透明质酸钠对山羊颞下颌关节骨关节病的治疗效果。方法:对8只山羊的双侧颞下颌关节上腔一次性注射胶原酶而诱导骨关节病病变。分2组,4只/组。治疗组,透明质酸钠关节上腔封闭;对照组,关节上腔注射生理盐水。3月后处死,对髁突应用光镜和扫描电镜观察。结果:在光镜和扫描电镜下观察,对照组的髁突、关节盘、关节凹表现为骨关节病变化,治疗组骨关节病表现不明显。结论:通过3个月的观察和研究,证明透明质酸钠关节上腔封闭对颞下颌关节骨关节病具有显著疗效。     

Effect of intra-articular corticosteroid injections on pain and mouth opening in juvenile idiopathic arthritis with temporomandibular involvement: A systematic review and meta-analysis

PurposeThe objective of this study was to investigate the effect of temporomandibular intra-articular corticosteroid injections (IACS) on pain and mouth opening in children with juvenile idiopathic arthritis (JIA) with temporomandibular joint (TMJ) involvement.MethodsSystematic review and meta-analysis methodology was used, beginning with a comprehensive literature search using MEDLINE, PubMed, EMBASE, Web of Science, and the Cochrane library. The population in question was pediatric patients with a JIA diagnosis and TMJ involvement; the intervention was IACS injections to treat TMJ arthritis; a strict control group was not considered necessary; the outcome was clinical signs of improvement of the TMJ arthritis based on pain and mouth opening capacity (MIO). Data on pain and MIO were extracted from the selected studies, and the methodological quality of studies was assessed according to the ROBINS-I tool. Results from the different studies were combined to calculate the pooled proportion with 95% confidence intervals (CIs) for pain resolution, and pooled mean differences with 95% CIs for improvement in MIO. Heterogeneity of the results among studies was tested using I² statistics.ResultsThe initial search yielded a total of 330 articles; 11 of these were selected for inclusion in the review. 325 participants were included from the combined studies, with the mean age of participants ranging from 5.3 to 13.6 years. Between 24 and 137 TMJs were selected for each of the studies. The pooled proportion of patients with pain resolution following IACS injection was 78% (95% CI: 59–90%), with large heterogeneity (I² = 62%). The pooled gain in MIO following IACS injection was 4.38 mm (95% CI: 2.76–6.00), also with high heterogeneity (I² = 67%).ConclusionsThe results suggest that in children diagnosed with JIA with TMJ involvement, IACS injections can help in reducing reported pain and improving mouth opening capacity, albeit with an important variation between studies.