The Efficacy of Platelets Rich Plasma Injection in the Superior Joint Space of the Tempromandibular Joint Guided by Ultra Sound in Patients with Non-reducing Disk Displacement

Abstract

Objective

The objective of this study was to determine average improvement during the rest and active mouth opening after ultrasound guided platelets rich plasma injection in the tempromandibular superior joint space for the patients complaining from non-reducing disk displacement.

Patients and Methods

Thirty-four patients with non-reducing disk displacement underwent guided ultrasound injection of platelet rich plasma to the upper joint space. The extent of maximal mouth opening, chewing efficiency, sound intensity of the TMJ, and tenderness of the TMJ and the masticatory muscles at rest, motion and mastication were thoroughly assessed at the beginning of the study and scheduled for next follow-up at 1st, 3rd, and 6th months.

Results

Injection with platelets rich plasma was significantly more effective in improvements of the extent of maximal mouth opening, statistics result demonstrated a significant reduction in the VAS values of pain at rest, motion and mastication compared to the baseline VAS values.

Conclusion

PRP injection to the upper temporomandibular joint space provided improvement in signs and symptoms of patient with non-reducing disk displacement of the temporomandibular joint.

Introduction

Temporomandibular joint (TMJ) disorder is one of the most difficult clinical problems to diagnose and manage in the field of oral and maxillofacial surgery [1]. It has been suggested that classification, diagnosis, and treatment of TMJ pain and dysfunction can be based on the position and shape of the TMJ disc [2].

Temporomandibular disorders (TMD) usually involve temporomandibular joint (TMJ), masticatory muscles, and other relevant structures accompanying with craniofacial pain, limited mouth opening, sounds such as clicking or crepitus, and irregular or deviating jaw function and often complicated by symptoms of chronic head and neck pain [3–5].

TMJ disorder is also well known as a stress-related psychosomatic disorder [6, 7]. It affects the quality of life sharply, with a prevalence of 10 % to 70 % in the population, and is more epidemic in women between 20 and 40 years of age [8, 9].

In the past, treatment of TMJ dysfunction that did not respond to conservative treatment was the surgical disc repair and repositioning to reestablish the normal maxillomandibular opining (MMO) [10, 11]. Arthroscopy [12], simple lysis and lavage, and the use of hydraulic pressure in the upper joint space were found to be highly effective in reestablishing normal MMO and relieving the symptoms [13], despite the disc position not having been corrected.

Intra-articular injection of drugs is an effective way to treat TMD [14]. Studies of TMJ injections have focused on decreased pain after injection in patients with both pain and limited mouth opening secondary to inflammatory disorders of the joint, such as arthritis and capsulitis [15–17].

Platelets rich plasma (PRP) has recently been used successfully for the treatment of knee degenerative pathologic disorders, because it is safe and has the potential to reduce pain and improve function [18, 19].

Many studies have been conducted on the clinical effect of platelet-rich plasma on bone regeneration and periodontal regeneration [20, 21], but the application of PRP in cartilage repair is relatively new and no published studies have investigated its use in the treatment of TMJ degenerative disease.

The objective of this study was to determine average improvement during the rest and active mouth opening after ultrasound guided platelets rich plasma injection in the temporomandibular superior joint space for patients complaining from non-reducing disk displacement with complete evaluation of improvement criteria in relation to chewing efficiency and reduction in sound intensity during different post-operative times.

Materials and Methods

Thirty-four patients who presented to the Department of Oral and Maxillofacial Surgery at Al-yarmouk Teaching Hospital (Baghdad, Iraq) were consecutively diagnosed with non-reducing disk displacement (NDD) in the temporomandibular joint (TMJ) were included in this prospective clinical trial study and referred to Radiology Department at Al-Karah Hospital for final management. The protocol of this study was approved by the local hospital committee for Research Ethics Concerning Human Subjects according to Helsinki guidelines. Each of the participanting patients who had signed an informed consent were provided with their information sheet and contact details of the investigators.

The patients who were included in this study consisted of 13 males and 21 females, with an average age of 35.6 ± 16.4 years (range 19–61 years). Their clinical examination consisted of bilateral TMJ palpation and measurement of the distance between maxillary and mandibular incisal edges (MIO). Their average MIO was 26.4 ± 11.3 mm (range 18–38 mm). Average duration of symptoms was 2.4 ± 1.3 years (range 9 months to 3.8 years).

NDD is clinically characterized by a history of bilateral clicking followed by limitation in opening ability without clicking. In all patients NDD was confirmed by 3D-computerized tomography scan.

The criteria for including a patient in this study were the following: bilateral constant or frequent pain of the TMJ with a range of motion for maximal mouth opening of less than 38 mm at the beginning of the study, no history of TMJ trauma, pathosis or any treatment, and clinical signs and symptoms that could be observed after the beginning of the study for 6 months.

The patients received ultrasound guided platelets rich plasma injection in the superior joint space.

The average interval from the appearance of limitation of mouth opening without clicking to the initial visit to our department (locking duration) was 7.4 months ± 5.4 (range 2–14 months).

For each treated patient, a number of parameters were assessed: preoperative TMJ pain at rest, motion and mastication which were assessed by a 100 mm visual analogue scale (VAS) with the end points marked as “no pain” and “worst pain ever experienced”. Absence of pain was scored as 0, if pain was present the patient was asked to select a field from 1 to 100 mm. For each patient, the appropriate score was recorded in the questionnaire by one operator. The average VAS at rest was 33.5 ± 22.4 (range 11–55 months) while at motion it was 44.7 ± 11.4 (range 21–53) and at mastication 52.6 ± 33.7 (range 26–72); subjective chewing efficiency (0–100 VAS, with 0 being the best efficiency ever and 100 the worst efficiency ever). The average VAS chewing efficiency was 62 ± 27 (range 44–81); as well as the severity of joint sound (click) (0. no sound, 100. a joint sound that is easily perceptible from outside by another person), sound intensity (VAS) was 79.3 ± 12.8 (range 65–89).

Procedures

PRP was prepared using is 50 ml of whole blood withdrawn and centrifuged in a tube containing 10 ml of culture medium with 250 μ/ml of preservative free heparin.

The blood was first centrifuged for 5 min at 1100 rpm, subsequently, the yellow plasma containing the buffy coat with platelets and leucocytes was centrifuged again at 3000 rpm for 10 min. PRP gel was formed by mixing PRP with thrombin and CaCl.

Intervention

First, local anesthesia was administered to the auriculotemporal nerve followed by locating the articular fossa at a point 10 mm anterior to the tragus and 2 mm inferior to the tragal canthal line. In this location a 27-gauge needle guided by ultrasound was inserted into the upper joint space (UJS) of the TMJ, and the correct placement was confirmed by movement of the mandible when 1 ml of PRP was gently injected guided by ultrasound.

A second injection was made in the UJS also guided by ultrasound. The joint was flushed with approximately 0.5 ml of PRP, which injected around the capsule. This procedure was repeated on the opposite side in the same manner. This therapy was repeated once every 3 months for 1 year for the patients who need additional injections. None of the cases of trismus resolved immediately after the last injection. The patients returned for follow-up after 1, 2, 4 weeks, 3, 6 months, and 1 year.

The extent of maximal mouth opening, noise of the TMJ, and tenderness of the TMJ and the masticatory muscles were thoroughly documented at the beginning of the study, first, third and at the 6-month follow-up. The inter incisal distance at attempted full mouth opening was measured with millimeter rules. Noise of the TMJ, tenderness of the TMJ, and the masticatory muscles were evaluated by palpation.

The clinical evaluation was conducted according to the following criteria: a level of pain that is of little or no concern to the patient, the range of motion for maximal mouth opening of 35 mm or more, lateral excursive and protrusive movements of more than 4 ram, improvement of the ability to masticate a normal or nearly normal diet, a functional and stable occlusion, and a limited period of disability and an acceptable clinical appearance.

For the procedure to be considered unsuccessful, the following must exist: the presence of tenderness of the TMJ or a range of motion less than 35 mm for maximal mouth opening. Changes of the range of motion for maximal mouth opening were analyzed, and the difference from that at the beginning of the study was evaluated at each follow-up with a biostatistics test.

The degree of mouth opening and all other variables were evaluated at baseline within 1, 3 and 6 months post injection were compared and analyzed using Statistical Package for Social Sciences Version 13.0 (SPSS Inc., Chicago, IL). The mean scores were calculated and the differences were compared and tested with the paired samples t test (2 tailed).

Results

Repeated PRP injection was performed in 13 of the 34 patients who showed some improvement but did not reach the successful criteria after PRP injection. Repeat PRP was performed in mean 2.7 ± 1.3 (range 1.5–4) months after PRP second injection and was successful in all these 13 patients.

The significant improvements were immediately noticed after first follow up with the treatment and were maintained during the follow-up period with maximum mouth opening as shown in Table 1. At the end of follow up the mean of the maximum opening was 41.5 ± 8.65 (range 35–54).

Table 1.

Comparison of mean mouth opening, chewing efficiency, sound intensity of the TMJ, and tenderness of the TMJ and the masticatory muscles at rest, motion and mastication in pre- and postoperative study periods

	Base line	One month post injection	Three months post injection	Six months post injection
Maximum mouth opening	26.4 ± 11.3	33.5 ± 9.74‡	39.4 ± 7.34†	41.5 ± 8.65‡
Pain intensity (VAS) at rest	33.5 ± 22.4	29.8 ± 19.7*	25 ± 16.8*	18.3 ± 17.9‡
Pain intensity (VAS) at motion	44.7 ± 11.4	40.6 ± 7.8†	35.9 ± 8.6*	29.7 ± 5.7‡
Pain intensity (VAS) at mastication	52.6 ± 33.7	43.8 ± 11.7‡	41.76 ± 12.3*	31.5 ± 17.6†
Chewing efficiency (VAS)	62 ± 27	58.4 ± 21	56 ± 23	51 ± 27*
Sound intensity (VAS)	79.3 ± 12.8	54.6 ± 14.6†	41.8 ± 21.5*	2.9 ± 15†

* P < .01; † P < .001; ‡ P < .0001

MMO was highly statistically significant (P ≤ 0.0001) and after 1 month post injections when compared with the base line value. A similar significant positive effect was reported for the 3 months post injections (P ≤ 0.001) and 6 months post injections (P ≤ 0.0001) as shown in Table 1.

Statistics result demonstrated a significant reduction in the VAS values of pain during rest, motion, and mastication as compared with the baseline VAS values as shown in Table 1.

The changes in joint clicking sound intensity after PRP injection were found to have statistically significant decrease from pre injection till the 6th month after injection; however, there was little significant change in the chewing efficiency as shown in Table 1.

Discussion

TMJ PRP injection is surgically minimally invasive. This procedure can be performed at an outpatient clinic and so far no complications have been experienced due to TMJ PRP injection. Thus, the TMJ PRP injection in comparison with the long-term NSAID therapy and invasiveness of TMJ arthrocentesis is lower in various side effects [2, 11].

Clinically, conservative methods such as medical treatment, occlusal splints, or restrictive therapies are used as the first step in the management of TMJ disc joint displacement with quite efficient results. When they fail to relieve the pain and/or improve adequate jaw function intra-articular injections are generally used as a minimally invasive treatment choice.

Techniques for temporomandibular joint lavage and injections have been the subject of several investigations over the past two decades. Despite of the encouraging findings reported in the literature, it seems that available data are inconclusive as for the actual mechanism of action [22].

Nowadays, the majority of data on TMJ disc joint displacement is got from the use of low molecular weight hyaluronic acid injections [23, 24]. With the trend of using viscosupplementation therapy and hyaluronic acid injections following arthrocentesis for larger joints, this approach has gained popularity as treatment option [25].

To the best of our knowledge, no comparable studies are available in the literature where a selected group of patients with non-reducing disk displacement (NDD) in the temporomandibular joint (TMJ) has been treated with ultra-sound guided TMJ PRP injection compared with the previous studies which have focused mainly on the clinical symptoms after TMJ injections and hyaluronic acid injections [15, 23, 26].

This study showed that PRP injection is effective as a primary treatment of non-reducing disk displacement (NDD) in the temporomandibular joint (TMJ). This therapy significantly reduced the scores of all the visual analogue scales criteria and increased maximal mouth opening.

The data of this study revealed that improvement rates increased in a short time until the first postoperative month and was followed by a more gradual increase from the first to the sixth months. Therefore, the optimal duration of this therapy is considered to be 6 months. For patients who have not improved with this therapy after 6 months an additional injection and treatment is considered but not included in this study.

Mechanism for leading the patients to better condition with this treatment remains obscure. Injection of PRP into the joint spaces could improve the micro condition within the joint space. It can relieve the clinical symptoms in short term and possibly prevent TMJ disease progression in long term. Due to the fact that PRP is a natural source of autologous GFs, it also improves cartilage repairs in degenerative knee pathologic disorder [19, 27, 28].

The rationale for the use of PRP was that a great amount of GFs are released from the activated platelets [29]. Working synergistically, these biologically active proteins stimulate the proliferation and differentiation of fibroblasts, osteoblasts, chondrocytes, and mesenchymal stem cells [30].

Overall, PRP injection in this study led to an improvement in signs and symptoms of the patient with non-reducing disk displacement of the temporomandibular joint. Further study of a larger number of patients with a longer follow-up period should be performed to further evaluate this new approach to the management of temporomandibular joint dysfunction.

Conclusion

Based on this observation, intra-articular superior joint TMJ PRP injection is regarded as a simple and method safe, with potential beneficial effects, and is a cost-effective method that proved to be successful in the treatment of Non reducing Disk Displacement (NDD) in the temporomandibular joint (TMJ). However, more clinical trials are still needed to confirm the conclusions.

Compliance with Ethical Standards

Conflict of interest

All the authors declare that they have no conflict of interest.

Ethical Standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.