YIJOM-2912; No of Pages 5

Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2014.05.004, available online at http://www.sciencedirect.com

Clinical Paper
TMJ Disorders

Arthrocentesis followed by intra- A. M. Bayoumi, M. O. Al-Sebaei,

K. M. Mohamed, A. O. Al-Yamani,
A. M. Makrami

articular autologous blood Department of Oral and Maxillofacial Surgery,

Faculty of Dentistry, King Abdulaziz University,
Jeddah, Saudi Arabia

injection for the treatment of

recurrent temporomandibular
joint dislocation
A.M. Bayoumi, M.O. Al-Sebaei, K.M. Mohamed, A.O. Al-Yamani, A.M. Makrami:
Arthrocentesis followed by intra-articular autologous blood injection for the
treatment of recurrent temporomandibular joint dislocation. Int. J. Oral Maxillofac.
Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. 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 Key words: temporomandibular joint; TMJ
chronic dislocation; TMJ subluxation; habitual
percent of the subjects (12 patients) had a successful outcome with no further
TMJ subluxation; TMJ arthrocentesis; TMJ
episodes of dislocation and required no further treatment at their 1-year follow-up, pain; TMJ eminectomy; TMJ surgery; max-
whereas three patients had recurrent dislocation as early as 2 weeks after treatment. imum incisal opening; TMJ blood injection.
Autologous blood injection is a safe, simple, and cost-effective treatment for
chronic recurrent TMJ dislocation. Accepted for publication 12 May 2014

Temporomandibular joint (TMJ) disloca- occurs as a result of everyday activities, a combination of factors, including laxity
tion is an excessive forward movement such as yawning and laughing. It may of the TMJ ligaments, weakness of the
of the condyle beyond the articular occur after excessive mouth opening dur- TMJ capsule, unusual eminence size
eminence with complete separation of ing dental treatment and general and projection, muscle hyperactivity or
the articular surfaces and fixation in anaesthesia. The pathogenesis of chronic spasm, trauma, and abnormal chewing
that position. This condition typically recurrent TMJ dislocation is attributed to movements that do not allow the condyle

0901-5027/000001+05 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Bayoumi AM, et al. Arthrocentesis followed by intra-articular autologous blood injection for the
treatment of recurrent temporomandibular. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.05.004
YIJOM-2912; No of Pages 5

2 Bayoumi et al.

to translate back into the normal posi- were included in the study. The inclusion
tion.1 criteria were at least two episodes of
Many surgical and non-surgical techni- bilateral TMJ dislocation in the past 6
ques for the treatment of patients with months necessitating a visit to the emer-
chronic recurrent condyle dislocation are gency room or to a trained professional to
presented in the literature. Surgical inter- reduce the dislocation. The patients were
ventions aim at restricting condylar move- diagnosed and treated in the oral and
ment by creating a mechanical obstruction maxillofacial surgery department of the
along the condylar path or by removing a study hospital.
mechanical obstacle along the condylar All of the participating patients were
path.2 The decision depends on predispos- over 18 years of age and in good medical
ing factors and the TMJ morphology. condition. The preoperative assessment
The more complex and invasive meth- consisted of a thorough history and phy-
ods of treatment might not necessarily sical examination to determine the max-
offer the best treatment option and out- imum incisal opening (MIO), presence of
come, and less invasive approaches should pain and sounds, frequency of dislocation,
be utilized appropriately before adopting and rate of recurrence. For all of the Fig. 1. The first injection site in the articular
fossa point (AF), located at a point 10 mm
the more invasive surgical techniques. patients, panoramic imaging in closed
anterior to the tragus and 2 mm inferior to the
Chronic recurrent dislocation may be and open positions showed the presence tragal–canthal line.
approached with conservative procedures, of condyles anterior to the articular emi-
including injection of botulinum toxin to nence. The patients were diagnosed with
various muscles of mastication,3,4 injec- chronic recurrent TMJ condyle dislocation
tion of sclerosing agents,5 and autologous based on the clinical and radiographic
blood injection into the peri-capsular tis- criteria established by Nitzan.13
sue and superior joint space.6–8
In 1973, Schulz reported his experience
Surgical technique
with autologous blood injection into the
TMJ as treatment for recurrent condyle The patients underwent bilateral TMJ
dislocation.8,9 Autologous blood injection arthrocentesis, under conscious sedation
into the TMJ was abandoned for reasons or general anaesthesia, followed by the
that are unclear;9 it has recently been injection of 2 ml of autologous blood into
reintroduced. the superior joint compartment and 1 ml
Blood injections into the TMJ follow onto the outer surface of the joint capsule.
the pathophysiology of bleeding in the The same surgical team, following an
joints elsewhere in the body, such as the identical protocol each time, performed
knee and the elbow.10 During the first few the procedure. The steps of the procedure
Fig. 2. A second 19-gauge needle is inserted
hours or days, an inflammatory reaction were discussed in detail with the patients,
in the superior joint space, at a point 20 mm
takes place,11 resulting in the release of as were the possible risks and complica- anterior to the tragus and 5 mm inferior to the
inflammatory mediators by platelets along tions, which included, but were not limited tragal–canthal line, for fluid to exit during the
with the accumulation of dead and injured to, postoperative pain, trismus, swelling, TMJ arthrocentesis.
cells, leading to oedema of the joint tissue. and facial nerve injury.
This inflammatory reaction diminishes The patient’s face was prepared in the
joint mobility. Thereafter, a combination usual and sterile manner. Local anaesthe- fossa; 2 ml of blood was injected into the
of organized blood clots and loose fibrous sia (2% lidocaine with 1:100,000 epi- superior joint space and 1 ml was injected
tissue forms, which further decreases joint nephrine) was applied to the onto the outer surface of the TMJ capsule
mobility. These tissues mature, causing a auriculotemporal nerve. The articular (Fig. 3). The same procedure was per-
permanent limitation of joint movement.10 fossa point (AF) was located at a point formed on the contralateral TMJ. An elas-
This exposure of cartilage to blood results 10 mm anterior to the tragus and 2 mm tic bandage was applied around the
in a disturbance of the cartilage matrix inferior to the tragal–canthal line (Fig. 1). patient’s head and left in place for the first
turnover12 and a decrease in chondrocyte At this location, a 19-gauge needle was 24 h.
metabolism, causing localized contrac- inserted into the superior joint space of the
tion.11 TMJ; the correct location of the needle
Postoperative care
The purpose of this study is to report our was confirmed by movement of the mand-
experience with autologous blood injec- ible during the fluid injection. A second After the procedure, all of the patients
tion into the TMJ as a minimally invasive 19-gauge needle was inserted into the were instructed to restrict their mandibular
treatment for recurrent TMJ condyle dis- superior joint space, 20 mm anterior to movement and were limited to a soft diet
location. the tragus and 5 mm inferior to the tra- for 1 week. Antibiotics (cephalosporin)
gal–canthal line, for fluid to exit through and non-steroidal anti-inflammatory drugs
during the TMJ arthrocentesis (Fig. 2). (ibuprofen) were prescribed for 1 week.
Materials and methods The joint was flushed with approxi- The patients received specific instructions
mately 250 ml of normal saline. The sec- to guide their postoperative rehabilitation
Subjects
ond needle was removed after the TMJ and establish controlled mouth opening.
Fifteen consecutive patients with bilateral arthrocentesis. Next, 3 ml of blood was During the first 2 weeks, the patients wore
chronic recurrent TMJ condyle dislocation withdrawn from the patient’s anticubital a head dressing at all times, restricted

Please cite this article in press as: Bayoumi AM, et al. Arthrocentesis followed by intra-articular autologous blood injection for the
treatment of recurrent temporomandibular. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.05.004
YIJOM-2912; No of Pages 5

Treatment of recurrent TMJ dislocation 3

Fig. 3. Autologous blood injection into the

TMJ: 2 ml of blood was injected into the Fig. 5. OPG image showing bilateral dislocation of the condyles.
superior joint space and 1 ml was injected
onto the outer surface of the TMJ capsule.

mouth opening to 20 mm, and followed a The MIO was measured by asking the Results
soft food diet. Starting at 2 weeks, the patient to open maximally without dislo-
Of the 15 patients, 12 were females and
patients began jaw rehabilitation via gra- cation, while the operator’s hands were
three were males; their average age was
dual and controlled range of motion exer- placed on the pre-auricular area to ensure
28.3 years (range 21–36 years). In general,
cises in front of a mirror. They wore the the patient did not proceed to dislocation.
all of the patients tolerated the procedure
head dressing only while sleeping and the An orthopantomogram (OPG) was
without serious complications. There were
soft diet was modified as tolerated. Phy- taken at the preoperative visit and a cone
no cases of facial nerve weakness, no
siotherapy was advised until the mandib- beam computed tomography (CBCT) was
deviation in mouth opening, and no scars.
ular opening and lateral and protrusive taken at 1 year postoperative. Any osseous
Most of the patients generally reported 2
movements were normal. changes in the condyle were evaluated.
days of soreness, and pain relief typically
Figure 5 shows a preoperative OPG of one
occurred within the first week. Table 1
of the subjects with bilateral condylar
Clinical assessment summarizes these results.
dislocation.
The patients returned for follow-up after 1
week, 2 weeks, 4 weeks, 3 months, 6 Maximum incisal opening
months, and 1 year. The patients reported Statistical analysis
the severity of postoperative pain, joint MIO, measured between the maxillary and
The significance of the difference between
sounds, and the number of TMJ disloca- mandibular incisor edges, ranged from 36
the pre- and post-procedure MIO was
tion episodes. The clinical examination to 45 mm, with an average of 41.3 mm. At 1
assessed with the paired t-test. A prob-
consisted of checking for the presence year, the average postoperative MIO was
ability value < 0.05 was considered sta-
of facial nerve injury, taking the MIO 34.6 mm, ranging from 30 to 41 mm. The
tistically significant. The statistical
measurement, and palpation of the TMJ mean difference between the pre- and post-
analysis was carried out using IBM SPSS
during mouth opening and closing (Fig. 4). procedure MIO was 6.73  1.45 mm and
software, version 20 (IBM Corp., Armonk,
was assessed by paired t-test; the difference
NY, USA).
was significant at P < 0.001. Table 2 sum-
marizes the MIO measurements of the
study subjects.
Table 1. Summary of the results of the 15
patients who underwent bilateral TMJ blood
injections. Episodes of dislocation
Percentage of
One week after the injection, all of the
patients (n = 15)
patients reported no TMJ dislocation. Two
Post-procedure 1 week: 0% weeks after the injection, 12 patients
TMJ dislocation 2 weeks: 20% (80%) reported no TMJ dislocation and
episodes (n = 3)
three patients (20%) continued to have
4 weeks: 0%
3 months: 0% dislocation. The remainder of the patients
6 months: 0% experienced no dislocation, as reported at
1 year: 0% the subsequent follow-up visits at 4 weeks,
Facial nerve weakness 0% 3 months, and 6 months. The three patients
Deviation 0% who continued to experience dislocation at
Average decrease 6.73  1.45 mm 2 weeks after the injection refused to
in MIO (P < 0.001) receive another injection and decided to
TMJ, temporomandibular joint; and MIO, proceed with open TMJ surgery. For these
Fig. 4. Measuring the postoperative MIO. maximum incisal opening. three patients, the number of episodes of

Please cite this article in press as: Bayoumi AM, et al. Arthrocentesis followed by intra-articular autologous blood injection for the
treatment of recurrent temporomandibular. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.05.004
YIJOM-2912; No of Pages 5

4 Bayoumi et al.

Table 2. Maximum incisal opening measurements and TMJ dislocation, before and after the In 1973, Schulz treated 16 patients by
TMJ blood injection procedure. injection of autologous blood into the
Post-procedure affected TMJ twice a week for 3 weeks,
Patient Gender Age, years MIO preop., mm MIO 1 year, mm TMJ dislocation followed by immobilization via intermax-
1 M 21 45 40 2 weeks illary fixation for 4 weeks. At the 1-year
2 M 30 44 36 No follow-up, 10 patients were symptom-
3 M 33 40 32 No free.8 In 1981, Jacobi-Hermanns et al. man-
4 F 28 45 41 2 weeks aged 19 TMJ dislocation patients with
5 F 22 41 32 No autologous blood injection, and 17 patients
6 F 26 42 35 No were symptom-free at the end of the
7 F 28 42 33 No 18-month follow-up period.15 More
8 F 26 40 32 No
recently, autologous blood injection has
9 F 24 39 33 No
10 F 35 40 33 No been used to treat patients with chronic
11 F 34 42 35 No TMJ dislocation. In 2009, Machon et al.
12 F 22 36 30 No treated 25 patients diagnosed with chronic
13 F 36 42 36 No recurrent TMJ dislocation with bilateral
14 F 22 44 38 2 weeks injections of autologous blood into the
15 F 34 38 33 No upper joint space and bilaterally around
Mean 41.3 34.6 the TMJ capsules. Twenty patients had a
TMJ, temporomandibular joint; M, male; F, female; and MIO, maximum incisal opening. successful outcome and required no further
treatment after the 1-year follow-up.1 In
2011, Jitender Aurora et al. successfully
dislocation ranged from twice a day to Autologous blood injection is a simple treated a 22-year-old with recurrent bilat-
once a week. procedure and is considered a non-invasive eral TMJ dislocation using autologous
CBCT imaging was done at 1 year post- technique for the treatment of recurrent blood injection in the upper joint space
operative. No osseous changes were noted TMJ dislocation.6 Some successful non- and around the capsule; after the 1-year
on the radiographic images for all of the surgical treatment methods have been follow-up, there was no recurrence.16 In
participants in the study (Fig. 6). described, including the use of a sclerosing 2012, Candirli et al. used magnetic reso-
agent; however, many side effects, includ- nance imaging (MRI) to evaluate the
ing facial nerve damage, have been effects of autologous blood injection in
Discussion reported.14 The use of Botox, which shows 14 patients who were imaged preopera-
Chronic recurrent TMJ dislocation requires fewer side effects, is another reported treat- tively and at 1 month postoperatively. All
surgical or non-surgical management. ment method.3 of the patients showed no TMJ dislocation 1
month after the injection.17
The main purpose of autologous blood
injection is the limitation of mandibular
movements. The pathophysiology of
blood injection resembles that of knee
or elbow joint bleeding. The influence
of injected blood on articular cartilage
has been debated. Some investigators con-
sider that even a single exposure of the
cartilage to blood results in a long-lasting
change in chondrocyte metabolism that
might lead to cartilage destruction.12
Other researchers have found that autolo-
gous blood injection results in a temporary
change in the cartilage, with no evidence
of permanent damage.11
In this study, autologous blood injection
was applied to 15 patients. At the end of
the 1-year follow-up period, the symptoms
had improved in 12 patients, with an
average postoperative maximal mouth
opening of 34 mm. The treatment results
were evaluated by physical examination
and were in agreement with those of pre-
vious studies.
In conclusion, autologous blood injec-
tion in the superior joint compartment and
around the capsule has been shown to be a
safe, simple, and cost-effective method for
Fig. 6. Postoperative CBCT image of the right and left condyles at 1 year postoperative. The the treatment of chronic recurrent TMJ
condyles are in the correct position with no apparent bony changes. dislocation. This treatment technique

Please cite this article in press as: Bayoumi AM, et al. Arthrocentesis followed by intra-articular autologous blood injection for the
treatment of recurrent temporomandibular. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.05.004
YIJOM-2912; No of Pages 5

Treatment of recurrent TMJ dislocation 5

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Tel.: +966 5076664286
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E-mail: Amrbayoumi@hotmail.com
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Please cite this article in press as: Bayoumi AM, et al. Arthrocentesis followed by intra-articular autologous blood injection for the
treatment of recurrent temporomandibular. . ., Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.05.004