Autologous blood injection for treatment of recurrent

temporomandibular joint dislocation

Oscar Hasson, DDS,a and Oded Nahlieli, DMD,b Rehovot and Ashkelon, Israel
KAPLAN MEDICAL CENTER AND BARZILAI MEDICAL CENTER

Objective. The purpose of this study was to reintroduce a rather simple, safe, minimally invasive, and rapid alternative proce-
dure for the treatment of recurrent dislocation of the condyles.
Study design. Subjects were 3 patients (5 joints) who suffered from recurrent condyle dislocation. The technique consisted of
visually identifying a line from tragus to the eye angle. Then the articular fossa point was identified in this line, 10 mm anteri-
orly to tragus and 2 mm below the line. A 19-gauge needle was inserted at the articular fossa point. After injection of saline
in the superior compartment, 5 cc of autologous blood drawn from the cubital fossa was injected (4 cc in the superior
compartment and 1 cc in the pericapsular tissue). After this an elastic bandage was applied and left for the first 24 hours.
Patients were advised to constrain their mandibular motion and to eat only soft foods for a week. They received cephalosporin
antibiotics and nonsteroidal anti-inflammatory drugs for 7 days. A week after the procedure, supervised physiotherapy was
started and the patients were encouraged to increase their mandibular opening to 40 mm.
Results. Postoperative recoveries were uneventful. Dislocation of condyles did not reoccur; however, patient no. 3 experi-
enced an episode of unilateral subluxation. At follow-up all patients presented with normal mouth opening.
Conclusion. Bleeding resulted from the introduction of a needle for injection in the pericapsular tissue. Blood coming
from this wound, associated with autologous blood injected in the superior compartment, generates a bed for fibrous
tissue formation in the region, creating a limitation of mandibular movement, thus ceasing dislocation of the condyles.
Temporomandibular joint autologous blood injection is a simple procedure performed on an outpatient basis that we
advise as an alternative treatment for patients with recurrent dislocation of the condyles.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:390-3)

Dislocation of the condyles is a rather common situa- patients will present an inferiorly extended articular
tion that is often seen in emergency rooms, where eminence, which will function as a mechanical barrier.
patients present with difficulty/impossibility of closing Once the condyle transpasses the eminence, muscle
the mouth, usually after yawning, laughing, or spasm between protractor muscles, which will
vomiting. The condition may also occur after excessive continue to push the condyle forward while the
mouth-opening during dental treatment or other elevator muscles try to push the mandible back, will
medical procedures while the patient is under general keep the condyle anterior to the eminence, thus
anesthesia. creating the open-lock condition.
It is believed that condylar dislocation may occur as There are reports in literature of many different
a combination of 3 factors: laxity of mandibular and surgical and nonsurgical techniques used to treat
capsular ligaments, large bony eminence, and muscle patients with recurrent condyle dislocation. Surgical
spasm. The laxity of mandibular and temporo- techniques address the capsular ligaments (advising
mandibular joint (TMJ) capsule ligaments will permit surgical tightening) or the articular bony structure
the condyle to go far anterior during mandibular (advising surgically reducing or extending it).1-3 The
opening, transpassing the articular eminence. Some nonsurgical techniques consist of injecting different
substances into the TMJ area. Injecting chemical mate-
rials into the TMJ as a method of treatment of recurrent
condylar dislocation has been previously described.
aFormerly, Attending Surgeon, Department of Oral and Maxillo- Blindly4,5 or by means of arthroscopic vision, different
Facial Surgery, Barzilai Medical Center, Ashkelon, Israel; currently,
Senior Surgeon, Department of Oral and MaxilloFacial Surgery,
chemical agents were injected in the superior compart-
Kaplan Medical Center, Rehovot, Israel. ment region in an attempt to create fibrosis in the
bChairman, Department of Oral and MaxilloFacial Surgery, Barzilai capsular tissue. To date, very little has been written
Medical Center, Ashkelon, Israel. about injecting autologous blood into the TMJ.6,7
Received for publication Nov 16, 2000; returned for revision Mar 2, In 1973, Schulz6 was the first to report experience
2001; accepted for publication Mar 29, 2001.
Copyright © 2001 by Mosby, Inc.
with autologous blood injection into the TMJ as treat-
1079-2104/2001/$35.00 + 0 7/12/116602 ment for recurrent condyle dislocation. Sixteen
doi:10.1067/moe.2001.116602 patients with recurrent dislocation were included in his

390
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Hasson and Nahlieli 391
Volume 92, Number 4

article. Autologous blood was injected in the affected vised physiotherapy was advised until mandibular
side twice a week for 3 weeks, and all patients had the opening and lateral and protrusive movements were
jaw immobilized with intermaxillary fixation for 4 normal.
weeks. At a 1-year follow-up, 10 patients of the sample
were symptom-free. Jacobi-Hermanns and Tetsch7 CASE REPORTS
reported 19 patients who had condyle dislocation treated All patients were treated in the Department of Oral and
with autologous blood injection. All patients received MaxilloFacial Surgery (OMFS) at the Barzilai Medical Center
in Ashkelon, Israel. There were no complications after the
only one injection in the affected side, and the jaws were
procedure, and at follow-up all patients presented with normal
immobilized by intermaxillary fixation for 14 days. At 18 mouth opening.
months’ follow-up, 17 patients were still symptom-free.
The injection of substances into the TMJ was aban- Case 1
doned because of the lack of security in injecting into the An otherwise healthy 55-year-old man was referred to the
proper region. However, better understanding of the OMFS department with recurrent bilateral condylar disloca-
components of the TMJ area and the introduction of tion. Clinically, his mandibular lateral and protrusive move-
anatomical landmarks, determined on the basis of arthros- ments were normal. He limited his mandibular opening
copies and arthrocentesis studies, made possible the because he feared that his mouth would remain open. Plain
return of this nonsurgical modality as a treatment for radiographs revealed bilateral extended articular eminence.
recurrent condyle dislocation. The patient was scheduled to undergo a bilateral eminectomy
Autologous blood injection is a simple technique that while under general anesthesia. In the operating room after
can be performed on an outpatient basis. Blood injected nasotracheal intubation, the patient presented unstable blood
pressure, which did not respond well to intravenous therapy.
into the superior compartment of the TMJ and in the peri-
Because of this unstable condition, the anesthesiologist
capsular tissue will cause scarring and fibrous tissue advised that only a short procedure be performed. As an alter-
formation that, we believe, will reduce mandibular move- native procedure, a bilateral TMJ autologous blood injection
ments, stopping recurrent dislocations of the condyles. was performed as described. Because both joints were
The purpose of this article was to describe the autolo- involved, 5 cc of autologous blood was drawn from each
gous blood injection procedure for the treatment of recur- cubital fossa. His recovery was uneventful. Three years after
rent dislocation of the condyle and to report our experi- the procedure, he was doing well without any further condylar
ence with this minimally invasive technique. dislocation.

DESCRIPTION OF THE TECHNIQUE Case 2

The technique may be applied while the patient is A healthy 40-year-old man reported to the OMFS clinic
under local anesthesia, local anesthesia combined with with recurrent dislocation of his left condyle. He had no
sedation, or general anesthesia. After preparing the history of trauma to the condylar region. Clinically, lateral and
protrusive mandibular movements were normal. This patient
patient in the usual manner, the surgeon must visually
also limited his mouth-opening for fear of his mouth
identify a line from the tragus of the ear to the eye angle. remaining open. The radiographic examination revealed a
The articular fossa point (AF) is found on this line, 10 slightly extended left articular eminence. Under local anes-
mm anterior to the tragus of the ear and 2 mm inferior to thesia and conscious sedation, the patient had TMJ autologous
the line. Local anesthesia of the auricular temporal nerve blood injection performed in the left TMJ region. His
is applied to the patient, and a 19-gauge needle is recovery was uneventful, and he went home on the same day.
inserted in the AF point. After injection of Marcaine At follow-up 1 year after the procedure, he was doing well
0.5%, 3 cc of saline is injected, causing distention of the and dislocation did not reappear.
superior compartment. Right location of the needle is
confirmed by protrusive movement of the mandible Case 3
during injection of the saline. The 19-gauge needle is left A healthy 25-year-old woman was referred to the OMFS
in the AF point. Then, 5 cc of blood is drawn from the department with recurrent bilateral condyle dislocation.
patients’ cubital fossa, and the syringe is connected to During the clinical examination, the patient limited the
the previous inserted needle and blood is injected—4 cc opening of the mandible, for fear of her mouth staying open.
Protrusive and lateral movements were normal. The radio-
in the superior compartment and 1 cc in the pericapsular
graphic examination revealed bilateral extended articular
tissue. After this an elastic bandage is applied and left for eminence. Under general anesthesia, she had a bilateral
the first 24 hours. After the procedure, patients are eminectomy. Her recovery was uneventful. Postoperative
instructed to constrain their mandibular movement for 7 mandibular motion was free, and the patient did not complain
days. Soft foods were indicated for a week, and of recurrent bilateral dislocation. However, at the routine 1-
cephalosporin antibiotics and nonsteroidal anti-inflam- year postoperative examination, the patient complained of
matory drugs were prescribed for 7 days. Then, super- reappearance of bilateral dislocation of the condyles, which
392 Hasson and Nahlieli ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
October 2001

was interfering with her daily activities. Because she was a bilateral eminectomy before autologous TMJ blood
scheduled for an ear, nose, and throat procedure under general injection, had 1-time unilateral condylar subluxation.
anesthesia, a bilateral TMJ autologous blood injection was Blood is injected in 2 regions, in pericapsular tissue
also performed. Other than some sourness in her left TMJ and in the superior compartment of the joint. Bleeding
area, the postoperative recovery was uneventful. Eighteen
will result from the introduction of a needle for injec-
months after the procedure, she reported only 1 episode of
tion in the pericapsular tissue. We believe that blood
unilateral subluxation of the condyle.
coming from this wound, associated with autologous
blood injection, will create a bed for fibrous tissue
DISCUSSION
formation in the region. The role of blood injected in
Laughing, yawning, vomiting, and forced mandibular the superior compartment of the joint is not fully
opening during dental treatment or some medical proce- understood, however, we speculate that autologous
dures, such as endoscopies and direct bronchoscopies, blood injected in this area combined with blood
can cause the dislocation of the condyle. Once the mouth coming from the wounded pericapsular tissue may lead
is forced open, excessive looseness of the mandibular and to formation of adhesions in this compartment. Yet, we
capsular ligaments occurs. This looseness may cause must keep in mind that restrained mandibular move-
hypermobility of the mandible, which may lead to dislo- ment is the key to the success of the procedure. In a
cation of the condyle. review of the literature we found authors performing
Hypermobility is characterized by an excessively intermaxillary fixation after autologous blood injec-
loose TMJ that permits excessive mandibular move- tion.6,7 We believe that elastic bandaging is enough to
ments during opening. Hypermobility is subdivided permit primary clot formation, and the pain that
into 2 categories: subluxation and dislocation. Some follows the injections will also restrain mandibular
authors may also introduce hypertranslation as a hyper- movements, permitting the injected blood to settle and
mobility subgroup.1 Although hypertranslation is char- create fibrosis. TMJ blood injection is a closed proce-
acterized as an excessive opening of the mandible with dure in which the area of blood delivery is not directly
the condyle moving to the most inferior portion of the seen. However, on the basis of the success of arthro-
articular eminence, it is very difficult to clinically centesis and lavage of the TMJ,8-10 once we confirm
differentiate this condition from that of a normal the right position of the needle inserted in the AF point
opening. During subluxation the condyle goes far ante- by visualization of the protrusion of the mandible after
riorly, transpassing the articular eminence without injection of saline, 4 cc of blood can be safely injected
staying locked anteriorly.1 This situation usually does in the superior compartment. Then, the needle is
not concern patients. However, patients with condyle moved outward 1 cm and 1 cc of blood is injected in
dislocation will seek treatment because this is a condi- the pericapsular tissue.
tion that interferes with their daily activities. Most of It is well known that blood in the TMJ area after
these patients will restrain their mandibular opening trauma to the condylar region or after TMJ surgery,
when laughing, yawning, or biting because they are especially when patients have their jaws immobilized
afraid of getting their mandible too far anteriorly to the (the case when an interpositional graft is used), may
eminence, which could cause the mandible to lock lead to unpleasant results, such as mandibular asym-
while open (dislocation). metry or fibrous or bony ankylosis. In the aforemen-
There are many different surgical techniques tioned situations, patients should receive proper atten-
described in the literature that are used as treatments tion and begin mandibular physiotherapy. By
for recurrent condylar dislocation.1-3 They address the intentionally injecting blood into the joint area, we are
capsular ligaments or the area of articular eminence, creating a similar situation. Yet, here we permit
and most of them are an inpatient procedure performed controlled clot formation by limiting only immediate
with the patient under general anesthesia. These proce- physiotherapy and mandibular movements. However, it
dures require surgical access to the TMJ area; some is imperative to follow patients closely to prevent the
require bony structure handling. The TMJ autologous appearance of limited mouth-opening.
blood injection serves as an alternative, minimally TMJ autologous blood injection is a simple and safe
invasive nonsurgical procedure that can be performed procedure that we advise as an alternative procedure for
in an outpatient basis. With this technique there is no patients with recurrent bilateral condyle dislocation.
need for surgical incisions and tissue dissection,
decreasing postoperative complications such as facial REFERENCES
nerve injuries, pain, and infection.
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complications were reported. Only patient no. 3, who had Company; 1992. p. 2006-12.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Hasson and Nahlieli 393
Volume 92, Number 4

2. Srivastava D, Rajadnya M, Chaudhary MK, Srivastava JL. The injection as therapy for habitual temporomandibular joint luxa-
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Surgery 1978;7:1-6. joint arthrocentesis: a simplified treatment for severe, limited
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6. Schulz S. Evaluation of periarticular autotransfusion for therapy Department of Oral and MaxilloFacial Surgery
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7. Jacobi-Hermanns E, Tetsch P. pericapsular autologous blood oshasson@yahoo.com

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