journal club

1. JOURNAL CLUB PRESENTATION
PRESENTER
MALA. M
GUIDED BY
DR. SANTOSH A NANDIMATH

2. National Journal of Maxillofacial Surgery /
Volume 14 / Issue 2 / May-August 2023

3. INTRODUCTION
 The term “temporomandibular disorders(TMDs)” represents
pain and dysfunction conditions in the masticatory system.
 Various noninvasive management and invasive management
of TMDs have been advocated in the literature.
 Newer methods for stimulating repair or replacing damaged
cartilage, such as matrix metalloproteinase inhibitor,
cytokine inhibitor, artificial cartilage substitute, and growth
factors are being researched extensively.

4. HUMAN PLATELET CONCENTARTES
Platelet concentrates comprise high quantities of key growth factors, which
have the capacity to stimulate cell proliferation, matrix remodeling, and
angiogenesis.
Abdulgani Azzaldeen, Abdulgani Mai, Abu-
Hussein Muhamad. Platelet-rich fibrin (PRF) in
dentistry. Int J Appl Dent Sci 2019;5(4):01-08.

5. Abdulgani Azzaldeen, Abdulgani Mai, Abu-Hussein Muhamad. Platelet-rich fibrin (PRF)
in dentistry. Int J Appl Dent Sci 2019;5(4):01-08.

6. Intra-articular injections of PRP/i-PRF are
minimally invasive and thus have a higher
patient acceptance rate and is the cost-effective
procedure.
In this study, It was hypothesized that i-PRF is
better than PRP in terms of improving the
symptoms and function of patients affected by
TMDs.

7. AIM
To compare the effect of intra-articular injections
of injectable PRF versus PRP in the management
of TMDs.

8. MATERIAL AND METHOD
 Randomized control study was conducted in the Department of
Oral and Maxillofacial Surgery, Saraswati dental college and
hospital, Lucknow, UP, India.
 14 patients (N = 28 joints) within the age group of 20–50 years
diagnosed with internal derangement between December 2018
and January 2021.
 Patients were randomly divided into GROUP I (PRP) and
GROUP II (i-PRF) with seven patients (N = 14 joints) in each.

9. Inclusion criteria
Patients were classified under the
Wilkes classification of internal
derangement (stages I–V) based on
clinical and radiographic evaluation and
willingness to participate in the study.

10. Procedure
The preoperative phase
Detailed case history, clinical TMJ examination,
and magnetic resonance imaging (MRI) (at three
positions: close mouth, open mouth, and 25 mm
mouth opening position) were taken. Patient
education and occlusion rehabilitation (if
required) followed by an occlusal splint were
given to all patients.

11. The operative phase
Following strict aseptic
protocol, an
auriculotemporal nerve
block (2% lidocaine with
1:200000 adrenaline) was
administered. TMJ
arthrocentesis with 200 ml
ringer lactate solution was
performed using a
2-needle technique

12. PRP preparation:

13. 700 RPM
i-PRF

14. INJECTION OF PRP OR i-
PRF
Using a 26-gauge needle,
the intra-articular injection
of 2 ml PRP/i–PRF was
injected in the superior
joint space following the
Holmlund–Hellsing line, at
a distance of 10 mm from
the tragus and 2 mm
inferior to it.

15. The Postoperative phase
 Patients were advised to take a soft diet with
restricted jaw movements for one week.
 No anti-inflammatory drugs were given to
assess the accurate pain response of the
patients after the operative phase.

16. Postoperative evaluation parameters
Clinical evaluation
 It was carried out preoperative and 1 week postoperatively every
month till the end of the treatment (6 months) and final follow-up
at 9 months.
1. Evaluation of Pain
It was evaluated by recording on the visual analog scale (VAS) in
which 0 being no/absence of pain and 10 being worst/unbearable
pain on either side.

17. Evaluation of maximal mouth
opening (MMO)
Using a More Rao Scale, the
distance between the two points
marked in between the incisal
edges of maxillary and mandibular
central incisors was recorded as
mouth opening in mm.

18. Evaluation of lateral and protrusive
movement
 On the two previously marked points, the
More Rao Scale was stabilized at the point
marked on the maxillary central incisor
 patient was asked to deviate the
mandible on one side and the distance
between the two points was measured
and recorded.
 The protrusive movement was recorded
in mm between the incisal edges by
asking the patient to protrude the
mandible forward.

19. Evaluation of TMJ sounds
Patients were asked to do a full range of mandibular
movements vertically and horizontally, and the absence or
presence of joint sounds was recorded on both sides by
auscultation and palpation.
Radiographical evaluation
Evaluation based on MRI was carried out preoperatively
and postoperatively at 9months(3months after completion
of the operative phase).

20. Evaluation of disc position
Sagittal and coronal MRI sections in close and open mouth
positions were viewed, and the position of the meniscus was
evaluated as normal, disc displacement with early reduction
(DDWER), disc displacement with late reduction (DDWLR),
and disc displacement without reduction (DDWR).
Evaluation of joint effusion (JE)
T2-weighted MRI images were evaluated for the absence and
presence of JE where hyperintensity suggested the presence
of fluid, which was interpreted as the presence of JE.

21. RESULTS

26. DISCUSSION
 The therapeutic management of degenerative disorders of
the TMJ is focused on a minimally invasive treatment
modality for relieving the functional pain and establishing
a normal range of mandibular motion in these patients.
 Since the pathogenic pathways are imprecise, noninvasive
methods are preferred as the first-line treatment
modality, and if they are not efficacious, then surgical
treatment is desirable.

27.  Conservative therapy includes occlusal splint
therapy, which eliminates mechanical stress, and
physical therapies that relieve pain.
 Minimally invasive modalities such as lavage and
intra-articular injection techniques to remove
pain and inflammatory mediators of TMD have
been described extensively in the literature.

28. SUPPORTING STUDIES
 Hegab et al. in 2015 (PRP v/s hyaluronic acid (HA) in
TMJ osteoarthritis) revealed significant
improvements over time in terms of pain, MMO,
and joint sounds with better results in PRP than the
HA group where pain began to increase
postoperatively.
 Albilia et al. (2018) (i-PRF in internal derangement)
reported a statistically significant reduction in pain
and an increase in MMO, which was comparable to
PRP.

29.  Yuce et al. (2020)(arthrocentesis vs arthrocentesis plus HA
vs arthrocentesis plus i-PRF) reported a statistically
significant decrease in pain scores (VAS) and a significant
increase in MMO in all three groups throughout the
follow-up and concluded that the arthrocentesis plus i-PRF
group was superior among these three groups.
 Teama et al. (2020)[12] (i-PRF vs arthrocentesis in internal
derangement) reported a significant reduction in pain
intensity and a significant increase in MMO in both groups
with better results in i-PRF cases compared with
arthrocentesis. There was also significant improvement in
TMJ clicking 2 weeks posttreatment that was sustained
thereafter.

30. To restore normal structure and function of TMJ beyond symptomatic relief,
regenerative therapeutics involve bio-supplementation of the joint with
platelet concentrates.
The biochemistry of the pathophysiology of arthralgia and joint
inflammation has been attributed to vasodilation, extravasation, activation
of immune cell communication, differentiation, chemotaxis, and activation
of nociceptive neurons, which is caused due to lack of waste removal and
decreased blood supply, thereby generating higher concentration of pain
mediators such as substance P, serotonin, bradykinin, leukotriene B4, and
prostaglandin E2 and pro-inflammatory cytokines such as interleukins and
tumor necrosis factor-α within the synovial fluid.
The chronic presence of these mediators results in bone remodeling and
degradation of joint morphology.

31. The intra-articular injections of platelet concentrates
possess cellular, biochemical, and angiogenic
characteristics.
i-PRF intra-articular injections in particular, cause a
mechanical tear of adhesions via a mechanism of
hydraulic distension and expansion of the superior joint
space, thereby eradicating the vacuum effect present in
osteoarthritis (OA).
The liquid formulation of PRF spontaneously Polymerize
at approximately ± 15 min.

32.  Platelet concentrates release cytokines and
various growth factors, which play an important
role in providing a supportive environment for
debridement by circulating macrophages and
type A synoviocytes, consequent renovation by
chondrocytes, and type B synoviocytes.

33. The outcome of i-PRF was better than PRP in the study.
 i-PRF induces an organic lavage of synovial fluid by prompt
delivery of immune cells for debridement and repair following the
restoration of the synovium’s capillary network.
The clinical symptoms of all patients improved, and no
complications were observed
The combination of injectable therapeutics together with adjunct
therapy was found to provide improved benefits, the synergy of
which requires further in-depth research.
Conclusion

34. CRITICAL APPRAISAL
Merits
 PRP, and i-PRF injections is regarded as simple and safe
method with potential beneficial effects.
 cost-effective.
 Comparative study.
 Aim of the study well defined.
 Randomized control trial.
 Statistically significant results.

35. Demerits
 Smaller sample size.
 Inclusion and exclusion criteria not
well defined
 Observer bias- not blinded.
 Procedure of arthrocentesis not
explained.
 Procedure of prp or prf preparation-
standardized(?)

36. CROSS REFERENCES
 Diab NAF, Ibrahim AM, Abdallah AM. Fluid Platelet-Rich Fibrin (PRF) Versus Platelet-Rich
Plasma (PRP) in the Treatment of Atrophic Acne Scars: A Comparative Study. Arch Dermatol
Res. 2023 Jul;315(5):1249-1255.
 Manafikhi M, Ataya J, Heshmeh O. Evaluation of the efficacy of platelet rich fibrin (I-PRF)
intra-articular injections in the management of internal derangements of temporomandibular
joints - a controlled preliminary prospective clinical study. BMC Musculoskelet Disord. 2022
May 14;23(1):454.
 Albilia J DMD, MSc, Herrera-Vizcaíno C DDS, Weisleder H BSc, Choukroun J MD, Ghanaati S
MD, DMD, PhD. Liquid platelet-rich fibrin injections as a treatment adjunct for painful
temporomandibular joints: preliminary results. Cranio. 2020 Sep;38(5):292-304.
 Young AL. Internal derangements of the temporomandibular joint: A review of the anatomy,
diagnosis, and management. J Indian Prosthodont Soc. 2015 Jan-Mar;15(1):2-7.
 Soni A. Arthrocentesis of Temporomandibular Joint- Bridging the Gap Between Non-Surgical
and Surgical Treatment. Ann Maxillofac Surg. 2019 Jan-Jun;9(1):158-167.

37. THANK YOU