Dr. Bhavik Miyani, Resident Doctor in Department of Oral & Maxillofacial Surgery, NPDCH, Visnagar.

1. #6th Journal Club Presentation
PRESENTED BY,
DR. BHAVIK MIYANI,
2ND YEAR PG,
DEPARTMENT OF OMFS.
GUIDED BY,
DR. ANIL MANAGUTTI,
DR. SHAILESH MENAT,
DR. RUSHIT PATEL.
06-02-2020 1

2. Autologous Blood Injection for the
Treatment of Recurrent Mandibular
Dislocation
INTERNATIONAL JOURNAL OF ORAL AND
MAXILLOFACIAL SURGERY - 2015
ARTICLE IN PRESS
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3. TMJ dislocation
 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.
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4. Pathophysiology of mandibular dislocation
Involves the combination of three factors:
1) Loosening of the capsule and the TMJ ligaments,
2) A prominent eminence, and
3) Muscular spasm.
 Initially, loosening of the capsule and ligaments allows the condyle to perform non-
physiological and excessive motions, bypassing the articular eminence.
Since the eminence works as a mechanical barrier to control mandibular motion,
this non-functional bypass leads to spasm of the associated musculature.
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.
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5. Other aetiological factors associated with TMJ dislocation are
1) Trauma,
2) Use of anti-emetics and phenothiazine, which produce
extrapyramidal effects
3) Systemic diseases such as rheumatoid arthritis , and
psychogenic and neurological disorders.
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6. Aim of the study
To Evaluate The Effectiveness Of Autologous
Blood Injection In The Treatment Of
Recurrent Temporomandibular Joint
Dislocation.
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7. There is the formation of an organized coagulum and fibrous tissue, which keep
the joint motions limited. Finally, this fibrous tissue develops and results in the
permanent limitation of motion.
An inflammatory reaction and oedema in the adjacent tissues and reduction of
joint motion.
Initially, the joint compartment and pericapsular tissues are stretched by the
blood injection.
Injections of autologous blood in the TMJ follow the pathophysiology of
bleeding in any joint of the body.
Physiology behind using the autologous blood for mandibular dislocation
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8. 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.
Patients and Methods
The radiographic examination assessed
◦ Panoramic and TMJ radiography, in the
closed and open mouth positions,
◦ to assess the position of the condyle in
relation to the articular eminence and
◦ presence of osteophytes and remodelling.
The clinical examination assessed
• the maximum incisal opening (MIO),
• number of episodes of dislocation,
• necessity of professional assistance for
reduction,
• vertical dimension of the lower facial
third.
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9. Inclusion Criteria
 Psychiatric conditions;
 Connective tissue syndromes,
such as Marfan and Ehler Danlos;
 Parafunctional habits; and
 Short lower facial third, since this
leads to joint instability.
Exclusion Criteria
 Patient showing at least three
episodes of TMJ dislocation in a 6-
month period, necessitating a
trained professional for reduction;
 No previous history of TMJ
treatment, either conservative or
surgical; and
 Age > 15 years.
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10. 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.
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11. 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.
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12. 3 ml of autologous blood was collected from
the brachial vein and 2 ml of blood was
injected into the upper joint space and 1 ml in
the pericapsular region, in accordance with
the protocols described by Machon et al.
The same procedure was performed on the opposite side. The same surgeon
performed all procedures.
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13. Postoperative Care
o An elastic facial bandage was applied immediately after
the procedure and kept in place 24 hrs a day for 2 weeks,
with the aim of limiting mouth opening to a maximum of
20 mm.
o 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.
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14. o After this initial period, patients were advised to wear the bandage only while sleeping.
o Non-steroidal anti-inflammatories were prescribed for 3 days, and a liquid/soft diet was
maintained for 3 weeks.
o Mandibular movements were developed progressively during the course of the follow-
up appointments by means of supervised physiotherapy.
o 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.
o During these examinations MIO was measured and possible complications were
assessed, such as pain and recurrent dislocations.
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15. Patient information—initial assessment.
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16. o Initially 23 patients selected,
10 were excluded - they were able to self reduce the condylar dislocation and
2 were excluded - they presented fewer than three episodes in a 6-month period.
o The final sample comprised 11 patients with chronic recurrent TMJ dislocation;
8 were women and 3 were men,
their average age was 27.8 years (range 15–60 years).
o The average duration of symptoms - 63.9 months, ranging from 4 months to 16 years.
o The number of dislocations prior to the procedure ranged from 3 to 60 episodes (average
13.4 episodes)
Patient information—initial assessment.
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17. Results after autologous blood injection.
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.
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18. o Bone remodelling was observed in 4 patients bilaterally and in 3 patients
unilaterally. No osteophytes were observed on the condylar surface.
o 3 patients (27.3%) relapsed during the follow-up period, which ranged from 24
to 35 months (average of 29.6 months).
o 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.
o Thus, of the 11 patients initially treated, eight (72.7%) did not show episodes
of recurrent mandibular dislocation after the proposed procedure.
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19. Advantages of injections of autologous blood for temporomandibular
joint dislocation
o a fast and safe technique,
o minimum morbidity,
o no injury to the facial nerve
o no scars
o less invasive procedure
o accomplished in the ambulatory care setting
o cost-effective
o In the immediate postoperative period, six patients (54%) reported local
discomfort and a sensation of auricular buzzing, which ceased during the
follow-up.
o One patient reported two episodes of bleeding from the external ear
canal, which also stopped spontaneously.
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20. Discussion
o Historically, the gold standard treatment for recurrent TMJ dislocation is
eminectomy, with success rates higher than 85%.
o Disadvantages -
Invasive procedure,
Requiring a hospital stay and skin incision,
Increased risk of facial nerve injury
Unaesthetic scars
Performed with rotatory instruments so irregular areas and bone spicules
may be left behind inadvertently and lead to crepitation or relapse.
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21. o Compared to eminectomy, autologous blood injection showed a success
rate of 72.7% after a minimum follow-up of 24 months.
o It is the authors’ opinion that this technique should be used as an initial
attempt to treat recurrent TMJ dislocation. Due to its simplicity, one may
even consider a second attempt of blood injection after an initial
recurrence.
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22. o A reduction in MIO was observed in 6 of the 11 patients in the present
study (54.5%), suggesting the formation of fibrosis and adhesions.
o In the 3 patients referred for surgery, there was an increase in mouth
opening after the injection, showing a failure of the proposed technique.
o Another 2 patients also presented an increase in mouth opening, but
without further dislocations. It is speculated that the initial measurement
was probably an underestimate, due to the fear of the patient experiencing a
new episode of TMJ dislocation during the initial assessment.
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23. o Researchers who are in opposition to the use of autologous blood believe
that exposure of the joint to the blood promotes permanent joint
destruction, degeneration of the cartilage, and apoptosis of chondrocytes.
o The use of a control group represents an ethical issue in this type of
study, since individuals with a healthy TMJ should not be submitted to
injections in articulations, while patients with a TMJ disease should not be
denied treatment just to serve as a control group. Therefore only the test
group could be formed.
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24. Conclusion
Autologous blood injection is a simple procedure that
is rapid, minimally invasive, and cost-effective, and
presents a low possibility of risks. Thus it represents a
feasible alternative initial treatment, before a surgical
procedure is indicated. However, more studies should
be performed to further validate this technique.
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25. Clinical Implication And Critical Appraisal
o The results of the present study are in accordance with study performed by
Machon et al. in 2009 (JOMS) that involved 25 patients and presented a
success rate of 80% after a mean follow-up of 12 months.
o However that study included both dislocations that demanded professional
assistance for reduction and those that could be self reduced, while the
present study excluded dislocations that could be self reduced.
o Another important difference was the follow-up period, which was a mean
29.6 months in the present study.06-02-2020 25

26. The results of the present study are also in accordance with study
performed by Bayoumi et al. in 2014 (IJOMS) that involved 15 patients and
presented a success rate of 80% after a mean follow-up of 12 months.
In that study An orthopantomogram (OPG) was taken at the preoperative
visit and a cone beam computed tomography (CBCT) was taken at 1 year
postoperative. Any osseous changes in the condyle were evaluated. But in
present study only the OPG and TMJoint radiography was used.
Another important difference was the follow-up period, which was a mean
29.6 months in the present study.
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27.  Thirty patients were randomly divided into 2 equal groups (15 patients in
each). Group A was treated only by autologous blood injection into the
superior joint space (SJS), whereas group B received autologous blood
injections to the SJS and the pericapsular tissues (PT).
 At the end of the follow-up period of 1 year, injection of autologous blood to
the SJS and PT gave a higher success rate (80%) than its injection only into
the SJS (60%).
 Present study also coincide with above study as autogenous blood injection
was given in SJS and PT.
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28.  Candirli et al. in 2012 performed the MRI investigation to
determine the early effect of ABI on cartilage such as
impairment in the cartilage matrix turnover and changes in
chondrocyte metabolism and thus cartilage destruction in
14 patients.
 In spite of using panoramic and TMJ view of radiography,
degenerative and destructive changes of cartilage can be
better observed by the MRI in present study
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29. J Craniofac Surg. 2011 Nov;22(6):2202-4.
Histopathologic evaluation of autologous blood injection
to the temporomandibular joint.
Candrl C1, Yüce S, Yldrm S, Sert H.
 Candirli et. al evaluated the histopathologic effects of autologous blood
injection in 8 rabbit temporomandibular joints. Only fibrin accumulations
were seen in the tissue samples after 1month. There was no evidence of
degeneration in the joint cartilage and a fibrous bed was not formed in the
injected regions.
 In spite of radiograph, histological evaluation should be done to confirm the
Bone remodeling, permanent joint destruction, degeneration of the
cartilage, and apoptosis of chondrocytes, presence of osteophytes in
present study
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30. A total of 16 healthy adult pig were used in this study. 5ml Autologous blood were injected
on one side and on other side 5 ml of 0.9% saline was used. TMJ capsules and retrodiscal
ligaments were examined four weeks following the injections.
Histological 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.
Contradiction to above study, in present study such Histological evaluation was not done.
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31. o This study included 11 patients with unknown etiology ,
study with large no. of patients is still needed to get more
conclusive result for routine clinical application.
o More over, long term follow up of this procedure is also
required to see the degenerative changes or ankylosis of
TMJoint.
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