Prolotherapy versus Arthrocentesis in the Management of a Hypermobile Temporomandibular Joint-A Systematic Review

Shivangi Gaur and Madhulaxmi M^*

^*Correspondence: Madhulaxmi M, Department of Oral & Maxillofacial Surgery, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, India, Email:

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Introduction

Temporomandibular joint (TMJ) is an articulation formed bilaterally by the head of the condyle of mandible and glenoid or mandibular fossa of the temporal bone [1, 2]. Biomechanics and neuromuscular control of TMJ comprises of the muscles of mastication, lateral and accessory ligaments as well as neural impulses transmitted by the mandibular division of trigeminal nerve [3–5].

Temporomandibular joint capsule is the most vital structure which stabilizes the joint and it is reinforced by the lateral ligament [2, 6, 7].

yawning and laughing, while the reduction can be achieved without professional assistance [5, 8].

Morphological factors like shape of the condyle, glenoid fossa, articular eminence, zygomatic arch and squamotympanic fissure influence the direction and type of dislocation of the head of the condyle from the glenoid fossa.

Other factors such as age, type of dentition, etiology, duration of hypermobility and function of the masticatory muscles contribute significantly in the pathogenesis and management of temporomandibular joint dislocation [9]. TMJ dislocation is rare, but it impacts the individual gravely and requires immediate medical attention.

Dislocation or hypermobility is generally categorized as habitual dislocation, complete (luxation) or partial (subluxation), unilateral or bilateral, acute, and chronic protracted or chronic recurrent [10, 11]. Anterior dislocation of the condyle is the most commonly encountered type [12].

Other types include superiorly into the middle cranial fossa, medial, lateral and posterior, which are rare and commonly associated with trauma [13–16]. Acute dislocation is the displacement of condylar head anterior to the articular eminence and its inability to revert to its original position [17].

Acute TMJ dislocation severely affects overall and oral health of the individual due to pain and discomfort while speaking and mastication. Since the social and psychological implications are high, TMJ dislocation should be considered as a debilitating condition.

Management of TMJ dislocation involves moving the condyle backwards into the glenoid fossa by manual manipulation with/out local anaesthesia or sedation [18]. In chronic TMJ subluxation, the patient is able to manually maneuver the mandible into normal position [19].

However in acute TMJ luxation the pain due to muscular spasm and intra-articular effusion due to this openlocking situation, the patient is unable to self maneuver the mandible and needs the help of an experienced practitioner. Thus, in subluxation cases the condyle can be relocated through self manipulation by the patient, but in TMJ luxation this is not possible [20].

Conservative treatment modalities to manage acute dislocation include manual reduction with/out anaesthesia or sedation, gag reflex assisted reduction and manual reduction under general anaesthesia [18, 21].

For the management of chronic protracted dislocation the conservative treatment modalities include manual reduction with/out anaesthesia or sedation, manual reduction under general anaesthesia, elastic traction with intermaxillary fixation, traction with bone hooks and mandibular guidance therapy [22, 23].

Conservative treatment for recurrent dislocation includes avoiding wide opening of the mouth during daily activities, physiotherapy, use of occlusal splints, chemical capsuloraphy using intra articular and/or extra articular sclerotic agents (like alcohol, sodium tetradecyl sulphate, sodium psyliate, sodium monoruate), autologous blood capsuloraphy, PRP capsuloraphy, botulinum toxin, prolotherapy, arthrocentesis [24–28]. Surgical techniques include eminoplasty (reduction or augmentation), interpositional eminoplasty, lateral pterygoid myotomy, condylectomy, temporalis tendon scarification, miniplates and capsular plication [29–33].

Prolotherapy is also known as proliferation therapy. It was first introduced by Louis Schultz in 1937 for treatment of painful TMJ subluxation [34]. This therapeutic injection technique has been in use in clinical practice for decades and is used to treat various chronic conditions.

Over the years it has been given different names such as proliferative injection therapy, proliferant injection, sclerotherapy, regenerative injection therapy, and growth factor stimulation injection therapy. It consists of scheduled injections of an irritant solution at or near multiple sites of connective tissue dysfunction over a period of several months, which is assumed to cause reinflammation and subsequent symptomatic relief.

However, the clinical outcome of TMJ dislocation treated with dextrose prolotherapy has been evaluated in only a limited number of studies [35–39].

TMJ arthrocentesis is a minimally invasive treatment which is defined as the lavage of the joint space without visualising using sterile needles and sterile irrigants, which could be drugs or other therapeutic substances [40]. It functions by removing intra-articular adhesions by hydraulic pressure from irrigants in the upper joint space and reducing the pain by removing inflammatory mediators from the joint space [41].

Symptomatic relief is achieved due to the removal of these inflammatory mediators and changes in intraarticular pressure. The aim was to systematically evaluate the efficacy of prolotherapy compared with arthrocentesis in the management of TMJ hypermobility.

Structured question

In the non-surgical management of temporomandibular joint hypermobility, is dextrose prolotherapy superior to arthrocentesis or vice versa in post treatment sequelae?

Pico analysis

• Population: Temporomandibular joint hypermobility.

• Intervention: Prolotherapy.

• Comparison: Arthrocentesis.

• Outcome: Pain relief.

Materials and Methods

This review was done in accordance with guidelines given by Cochrane Handbook of Systematic Review.

Inclusion criteria

Studies were selected using the following inclusion criteria. All studies including:

• All types of studies including patients with temporomandibular joint hypermobility.

• Studies using prolotherapy and arthrocentesis for management of temporomandibular joint hypermobility.

• Studies published in English language only.

Exclusion criteria

Studies were excluded based on the following exclusion criteria.

• Studies which used surgical techniques for temporomandibular joint hypermobility.

• Studies which included temporomandibular joint dysfunction.

• Ongoing studies in which results have not yet been published

Search method for the identification of studies

To identify the studies to be included for detailed evaluation in systematic review, following search strategy was developed for each database searched:

• PubMed (All types of study design published from 2001-2021).

• The Cochrane Central Register of clinical Trials (All types of study design published from 2001-2021).

• Google Scholar (All types of study design published from 2001-2021).

Pubmed search strategy

Advanced search of PubMed search engine was used using the following keywords:

Temporomandibular joint OR TMJ OR Temporomandibular joint pain OR TMJ pain OR (Temporomandibular disorders) OR (TMD) OR (Hypermobility) OR (Subluxation) OR (Luxation) OR (Dislocation) AND (Prolotherapy) OR (Dextrose prolotherapy) OR (Proliferation therapy) AND (y_10[Filter]) AND (clinicaltrial[Filter]) AND (Pain) OR (Mouth opening) OR (Clicking) AND (y_10[Filter]) AND (clinicaltrial[Filter]) OR (Arthrocentesis) AND (Temporomandibular joint) OR (TMJ)) OR (Temporomandibular joint pain)) OR (TMJ pain) OR (Temporomandibular disorders) OR (TMD) OR (Hypermobility) OR (Subluxation) OR (Luxation) OR (Dislocation) AND ((y_10[Filter]) AND (clinicaltrial[Filter])AND (Pain) OR (Mouth opening) OR (Clicking) AND ((y_10[Filter]) AND (clinicaltrial[Filter]). This search yielded 40 studies (Figures 1 A to Figure 1C).

Figure 1A: Image showing the PubMed search strategy.

Figure 1B: Image showing the PubMed search strategy.

Figure 1C: Image showing the PubMed search strategy.

Cochrane search strategy

following keywords- Temporomandibular joint, TMJ, hypermobility, subluxation, dislocation, prolotherapy, proliferation therapy, dextrose prolotherapy, arthrocentesis, pain score, maximum interincisal opening, clicking with Cochrane Library publication dates between 2001 to 2021, in Trials. This search yielded 1 study (Figure 2).

Figure 2:Image showing the Cochrane search strategy.

Google scholar search strategy

Google Scholar search engine was searched using the following keywords Temporomandibular joint, TMJ, hypermobility, subluxation, dislocation, prolotherapy, proliferation therapy, dextrose prolotherapy, arthrocentesis, pain score, maximum interincisal opening, clicking with year of publication range set as 2001-2021. This search yielded 8 studies.

Data collection and analysis

Selection of studies

One author (Shivangi Gaur) carried out the search strategy for the individual data bases. The total number of titles obtained were scanned and evaluated independently by two authors, SG and (Madhulaxmi M) to identify the relevant studies. The studies duplicated in the different data bases were excluded. In case of any disagreement between the two authors, final decision was obtained by discussion between the two authors. Abstracts of the studies were evaluated when complete information regarding the groups and participants included was not mentioned in the title. The abstract evaluation was carried out independently by two authors SG and MM to identify the final studies to be included based on the inclusion and exclusion criteria. Full text articles were evaluated when the abstracts did not provide adequate information regarding the groups compared. Figure 3 gives the PRISMA flow diagram for the included studies (Figure 3). All the irrelevant studies were excluded and the reasons for the exclusion were noted in the characteristics of excluded studies (Table 1). The final studies included by the discussion of both the authors were further evaluated for the quality of studies following the guidelines given by Cochrane Handbook of systematic review. This was done independently by both the authors and any discrepancy was resolved by discussion between both the authors.

Figure 3:Prisma flowchart showing included studies.

Table 1: Characteristics of excluded studies.

Results

Study selection

The systematic search from the electronic databases of PubMed revealed 40 studies, Cochrane library revealed 1 study and Google Scholar revealed 8 studies. No studies were obtained from hand searching. After removal of duplicates 47 studies were identified. After title scanning, 5 studies were identified. After abstract scanning 3 articles were eliminated as they did not meet the inclusion criteria. Full text articles for the other 2 studies were obtained for more detailed evaluation. The bibliography of these full text articles was scanned to include studies apart from the electronic databases. No relevant studies were found from the cross-reference. A total of 2 studies met the inclusion and exclusion criteria of the intended research.

Study characteristics

Characteristics of the included studies were mentioned and the Outcome of these studies were assessed using clinical parameters (Tables 4 and Table 5).

Table 4: Characteristics of included studies.

Table 5: Characteristics of included studies.

Refai et al [35] had a placebo controlled, prospective, randomized, double-blind clinical study design where twelve patients with painful subluxation or dislocation of the TMJ were assigned to the two groups. Patients in the interventional group received four injections of dextrose solution (2 mL of 10% dextrose and 1 mL of 2% mepivacaine) for each TMJ, each 6 weeks apart, whereas patients in the placebo group received four injections of placebo solution (2 mL of saline solution and 1 mL of 2% mepivacaine) for each TMJ, each 6 weeks apart. Outcome measures were assessed at each appointment just before the procedure and 3 months after the last injection. The outcome measures were a verbal scale for pain on palpation of the joint, clicking sound, maximal mouth opening (MMO),and frequency of luxations (number of episodes of locking per month). Both groups exhibited significant improvement in pain on palpation of the TMJ and frequency of luxations however there was no significant change in clicking sound. Only MMO showed a statistically significant difference between the groups throughout the post treatment phase. There was a significant reduction in MMO in interventional group in the 12th post operative week. However, the placebo group showed no significant difference in MMO throughout the study periods. For the last 2 periods of observation intervals, the placebo group exhibited statistically significantly mean MMO values than the interventional group. By the 12th postoperative week, the percentages of decrease in MMO were significantly greater in the interventional group.

Dolwick et al [42] recruited only female patients unsuccessfully treated with conventional treatment modalities. 24 patients that were recruited and randomly allocated to one of the two groups, either experimental or placebo group. In both groups, after local anesthesia was injected TMJ arthrocentesis was done. Joint lavage was done with 100 mL Ringer’s lactate solution by a single investigator. Depending upon the group allocation group, triamcinolone acetonide (steroid) or Ringer’s lactate solution (placebo) was injected into superior joint space. Patients were blinded to the study and were evaluated at baseline, 2, 6 and 12 weeks after arthrocentesis using VAS for primary outcome pain measures (pain intensity, pain unpleasantness, and chewing pain). Significant decrease in VAS pain scores were found between the baseline and post-treatment observation period for both the groups. The study group had statistically significantly less pain on chewing at 6-12 weeks as compared to placebo group. Mean maximum mandibular opening with/out pain were significantly higher in study group during the post treatment observation period than at baseline, whereas the placebo group exhibited higher mouth opening at 6 weeks. At the end of 12 weeks more patients in the study group (75%) had normal mandibular opening without pain (38 mm) as compared with the placebo group (20%). The proportion of patients with more than 50% improvement in pain on chewing in the study group (90%) was significantly higher than that in the placebo group (<40%) (Figures 4 and Figure 5).

Figure 4:Risk of bias summary: Judgement about each risk of bias item for each included study.

Figure 5:Risk of bias graph: Judgement about each risk of bias item presented as percentage among included studies.

Discussion

The purpose of this systematic review was to identify the efficacy of prolotherapy and arthrocentesis for management of TMJ disorders was first described in the scientific literature in 1937.The first published article on prolotherapy, short for “proliferation injection therapy” and now also known as regenerative injection therapy (RIT), focused on treating the TMJ. The basic principle of prolotherapy is to inject a substance that will cause a low-grade inflammatory process within the joint, drawing in fibroblasts that strengthen the attachments of tendons and ligaments. The process stabilizes the joint, improves the range of motion in a hypomobile joint, helps prevent dislocation in a hypermobile joint, and relieves pain.

The face and TMJ are highly innervated and sensitive areas. Injections in this area must be as atraumatic as possible. To this end, we routinely use a 30-gauge, oneinch needle. We also use a dextrose solution whenever possible, as it causes less post-injection soreness than fish oil or pumice, and pumice is difficult to express through a 30-gauge needle. Compounding pharmacies can provide pre-mixed solutions, but we mix our solutions directly in the syringe. This consists of drawing up 0.75mL of 50% dextrose, 0.75mL of bacteriostatic water, and 1.5mL of 2% lidocaine into a 3-mL syringe for each TMJ. Using a 25-gauge needle to draw up the solutions speeds the process, then the needle is changed to 30-gauge and the syringe is shaken and the air expressed. The result is a dextrose concentration of approximately 12.5%. The precise concentration of dextrose is not critical so long as it is strongly hypertonic and causes adequate cell wall lysis to attract fibroblasts and begin the regenerative process.

Since TMJ disc displacement usually is anterior, our priority is to accomplish repair of the extended or torn posterior disc attachment. We locate the posterior joint space by cleansing the skin immediately anterior to the ear with alcohol and palpating the lateral pole of the condyle as the patient opens and closes. The target is the depth of the depression that forms immediately anterior to the tragus of the ear as the condyle translates forward and down. This can be marked with a washable felt-tip pen, if desired. Then, a disposable bite block is placed between the patient’s anterior teeth to keep the patient from closing the condyle back into the fossa and onto the needle. The injection needle penetrates the skin at the marked point and is directed medially and slightly anteriorly to avoid penetration into the ear. Surface skin and connective tissue is deceptively thick in this location and the needle usually penetrates to, or nearly to, its full one-inch length before encountering the medial wall of the fossa. Slight negative pressure is exerted on the plunger to confirm that the needle tip is not in a vessel, even though no vessels of any size are expected to be encountered within the fossa. One mL of Prolotherapy solution is deposited here.

The second target is the anterior disc attachment, where the disc connects to the superior portion of the lateral pterygoid muscle. This muscle often is foreshortened or in spasm in cases of chronic disc displacement. Injecting the Prolotherapy solution here can strengthen the tendinous attachment of this muscle to the disc at the same time the anesthetic component anesthetizes and elongates the muscle, which can allow the disc to reposition itself over the condyle and often produces an immediate reduction in TMJ clicking. We locate this target area at the same time we palpate the location of the posterior joint space, note the location of the slight depression just anterior to the condyle when the mouth is closed, and mark this point with washable ink. Marking this point before injecting the posterior aspect of the joint is advisable, as it becomes much more difficult to palpate this depression after the posterior joint recess has been injected. For this injection, the bite block is removed and the patient is instructed to close gently, moving the condyle back into the fossa. We insert the needle at the marked point, again directing the tip medially and angulated slightly anteriorly to, or nearly to, its full one-inch length. Aspiration is performed and another 1mL of Prolotherapy solution is injected here.

Most TMD patients have some chronic masseter tension and pain with resultant strain on its attachment to the zygomatic arch. The third mL of Prolotherapy solution is used to address this problem. We palpate the masseter attachment along the inferior border of the zygomatic arch at the same time that we palpate and mark the posterior and anterior aspects of the condyle, and mark the area of the masseter that is most tender to palpation. Asking the patient to clench the teeth makes the masseter stand out, and the area that is most rigid to palpation is usually the most tender as well. The patient is told to relax the jaw, and the final mL is injected directly into this area, again at or near the full one-inch length of the needle.

The injection sites are wiped with alcohol, which removes the washable ink as well, and a pulse is taken for the medical record and to confirm that the patient has relaxed and is ready for discharge.

Our standard program is to repeat the injections three times, at two-week, four-week, and six-week intervals. This totals four injection appointments over twelve weeks. We palpate the joints for pain and noise, and palpate the affected muscles for pain, at each appointment. We also measure the range of jaw motion interincisally and record all these findings. Patients typically report some improvement after the first injection appointment but often have some increased discomfort shortly before the second appointment. The following appointments generally produce more benefit, quieter joints, and symptom relief without rebound. We expect the healing process to continue for at least twelve more weeks and schedule a final recall three months out.

Dextrose is a corn product and must not be used in patients with a corn allergy. Also, an alternative local anesthetic must be used in patients who are allergic to lidocaine.

At the one-inch depth of needle penetration, the areas described above have no major blood vessels and intravascular injections are not a significant risk with this technique, especially if aspiration is performed before each injection. Some authorities have stated that the lumen of a 30-gauge needle is too small to admit red blood cells, but clinical experience in injecting other, more vascular areas has shown that blood can easily be drawn up through this small needle. On rare occasion, the local anesthetic will diffuse forward and partially paralyze the lower eyelid. When this happens, it is immediately apparent and the patient is told to make a conscious effort to blink that eye frequently for the next hour or so, until the anesthetic effect diminishes, to lubricate the eye and prevent a corneal abrasion. Fairskinned patients may display some minor bruising for a day or two but this is more common if the operator has difficulty locating landmarks and moves the needle laterally after insertion. The most common side effect is a temporary change in the dental occlusion. Until the 2mL of injection solutions dissipates from the joint, which may take one to four days, the condyle will rest lower in the fossa and the posterior teeth may not fully occlude. It is important to warn the patient that this is likely, and to be careful to chew food carefully and thoroughly before swallowing.

Conclusion

TMJ hypermobility is a debilitating disorder. However within the limitations of this review there is evidence that the concomitant use of prolotherapy with arthrocentesis may be superior in the management of TMJ hypermobility as compared to their individual use. The authors suggest formulation of well-designed randomised controlled trials to formulate a step ladder like treatment protocol for the management of TMJ hypermobility. This will help to achieve optimum amelioration of the quality of life of the individual.

References

1. Alomar X, Medrano J, Cabratosa J, et al. Anatomy of the temporomandibular joint. In Seminars in Ultrasound, CT and MRI 2007; 28:170-183.
2. Maini K, Dua A. Temporomandibular joint syndrome. In: Stat Pearls 2020.
3. Gauer R, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Family Physician 2015; 91:378-86.
4. Deodato F, Trusendi R, Giorgetti R, et al. Predisposition for temporomandibular joint disorders: loose ligaments. CRANIO®. 2006; 24:179-183.
5. Hillam J, Isom B. Mandible Dislocation. In: StatPearls. Treasure Island (FL): Stat Pearls Publishing 2020.
6. Dimitroulis G. The use of dermis grafts after discectomy for internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 2005; 63:173–178.
7. Runci Anastasi M, Centofanti A, Arco A, et al. Histological and immunofluorescence study of discal ligaments in human temporomandibular joint. J Functional Morphol Kinesiol 2020; 5:90.
8. Rybalov OV, Yatsenko PI, Yatsenko OI, et al. Hypermobility of the articular heads of the temporomandibular joint: pathology or variant of the norm?. Wiadomosci Lekarskie 2019; 72:1883-1889.
9. Abrahamsson H, Eriksson L, Abrahamsson P, et al. Treatment of temporomandibular joint luxation: A systematic literature review. Clin Oral Investig 2020; 24:61–70.
10. Tuijt M, Parsa A, Koutris M, et al. Human jaw joint hypermobility: Diagnosis and biomechanical modelling. J Oral Rehab 2018; 45:783-789.
11. Gupta S, Sharma AK, Purohit J, et al. Comparison between intra-articular platelet-rich plasma injection versus hydrocortisone with local anesthetic injections in temporomandibular disorders: A double-blind study. Natl J Maxillofac Surg 2018; 9:205–208.
12. Stolbizer F, Saiegh J, Andrada MM. Anterior dislocation of the temporomandibular joint: a simplified non-traumatic manual technique. J Man Manip Ther 2020; 28:246–50.
13. Oberman B, Setabutr D, Goldenberg D. Traumatic dislocation of intact mandibular condyle into middle cranial fossa. Am J Otolaryngol 2014; 35:251-253.
14. Jolly SS, Rattan V, Rai S, et al. Traumatic posterior dislocation of bilateral mandible condyles into external auditory canal treated with midline mandibulotomy: A rare case report and review of literature. J Maxillofac Oral Surg 2020; 19:642–646.
15. Silveira RL, Ranuzia I, Melo MFS, et al. Traumatic anterosuperior dislocation of the intact mandibular condyle into the temporal fossa. Craniomaxillofac Trauma Reconstr 2018; 11:296–301.
16. Rahman T, Hashmi GS, Ansari MK. Traumatic superolateral dislocation of the mandibular condyle: case report and review. Br J Oral Maxillofac Surg 2016; 54:457–459.
17. Valesan LF, Da-Cas CD, Réus JC, et al. Prevalence of temporomandibular joint disorders: A systematic review and meta-analysis. Clin Oral Investig 2021; 25:441–453.
18. Akinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med 2011; 7:1-9.
19. Kuttenberger JJ, Hardt N. Long-term results following miniplate eminoplasty for the treatment of recurrent dislocation and habitual luxation of the temporomandibular joint. Int J Oral Maxillofac Surg 2003; 32:474-479.
20. Sato J, Segami N, Nishimura M, et al. Clinical evaluation of arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: Comparative study with conventional open eminectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endodont 2003; 95:390-395.
21. Cuevas Queipo de Llano A, Monje Gil F, Gonzalez García R, et al. Long-term dislocation of the mandible: Is there an algorithm to success? Intraoperative decision and review of literature. J Maxillofac Oral Surg 2020; 19:12–16.
22. Jeyaraj P, Chakranarayan A. A conservative surgical approach in the management of longstanding chronic protracted temporomandibular joint dislocation: A case report and review of literature. J Maxillofac Oral Surg 2016; 15:361–370.
23. Shakya S, Ongole R, Sumanth KN, et al. Chronic bilateral dislocation of temporomandibular joint. Kathmandu Univ Med J 2010; 8:251–256.
24. Majumdar SK, Krishna S, Chatterjee A, et al. Single injection technique prolotherapy for hypermobility disorders of TMJ using 25 % dextrose: A clinical study. J Maxillofac Oral Surg 2017; 16:226–230.
25. Sajeev N, Kamath SK, Manjunath KS, et al. Combination of arthrocentesis and prolotherapy for chronic tmj pain-a case report. J Pearldent 2020; 11:43-49.
26. Zhou H, Xue Y, Liu P. Application of auriculotemporal nerve block and dextrose prolotherapy in exercise therapy of TMJ closed lock in adolescents and young adults. Head Face Med 2021; 17:11.
27. Caminiti MF, Weinberg S. Chronic mandibular dislocation: the role of non-surgical and surgical treatment. J Can Dent Assoc 1998; 64:484–91.
28. Machon V, Abramowicz S, Paska J, et al. Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation. J Oral Maxillofac Surg 2009; 67:114-9.
29. Tocaciu S, McCullough MJ, Dimitroulis G. Surgical management of recurrent TMJ dislocation-a systematic review. Oral Maxillofac Surg 2019; 23:35–45.
30. Tocaciu S, McCullough MJ, Dimitroulis G. Surgical management of recurrent dislocation of the temporomandibular joint: A new treatment protocol. Br J Oral Maxillofac Surg 2018; 56:936–940.
31. Segami N, Kato K, Noguchi T, et al. Surgical strategy for long-standing dislocation of the temporomandibular joint: experience with 16 medically compromised patients. Br J Oral Maxillofac Surg 2019; 57:359–364.
32. Balaji SM, Balaji P. Surgical management of chronic temporomandibular joint dislocations. Indian J Dent Res 2018; 29:455–458.
33. Isler SC, Cakarer S, Yalcin BK, et al. Management of the bilateral chronic temporomandibular joint dislocation. Ann Maxillofac Surg 2018; 8:154–157.
34. Schultz LW. A curative treatment for subluxation of the temporomandibular joint or of any joint. J Am Dent Assoc Dental Cosmos 1937; 24:1947-1950.
35. Refai H, Altahhan O, Elsharkawy R. The efficacy of dextrose prolotherapy for temporomandibular joint hypermobility: A preliminary prospective, randomized, double-blind, placebo-controlled clinical trial. J Oral Maxillofac Surg 2011; 69:2962–2970.
36. Kilic SC, Gungormus M. Is dextrose prolotherapy superior to placebo for the treatment of temporomandibular joint hypermobility? A randomized clinical trial. Int J Oral Maxillofac Surg 2016; 45:813-819.
37. Zhou H, Hu K, Ding Y. Modified dextrose prolotherapy for recurrent temporomandibular joint dislocation. Br J Oral Maxillofac Surg 2014; 52:63-66.
38. Saadat A, Khedr M, Saad K, et al. Dextrose prolotherapy in the treatment of recurrent temporomandibular joint dislocation (clinical study). Egyptian J Oral Maxillofac Surg 2018; 9:157-62.
39. Abdullakutty A, Sidebottom A. Is dextrose prolotherapy effective in managing recurrent temporomandibular joint (TMJ) dislocations-a prospective study. British J Oral Maxillofac Surg 2018; 56:e93-4.
40. Nitzan DW. Temporomandibular joint arthrocentesis: Biologic basis and treatment outcome. In Management of Temporomandibular Joint Degenerative Diseases 1996; 113-123.
41. Soni A. Arthrocentesis of temporomandibular joint-bridging the gap between non-surgical and surgical treatment. Annals Maxillofac Surg 2019; 9:158.
42. Dolwick MF, Diaz D, Freburg-Hoffmeister DL, et al. A randomized, double-blind, placebo-controlled study of the efficacy of steroid supplementation after temporomandibular joint arthrocentesis. J Oral Maxillofac Surg 2020; 78:1088-99.