Efficacy of Injectable PRF in Management of TMJ Internal Derangement

Temporomandibular disorders (TMD) are a significant public health problem affectingapproximately 5‐12% of the overall population and are considered the most common cause ofchronic pain of non‐dental origin in the orofacial region(Hegab et al2021) The internalderangements (IDs) are considered as the most common non‐ inflammatory disorders of theTMJ, since they affect about 10% of the population worldwide and represent approximately41.1% of all temporomandibular disorders. The term "internal derangement" refers toabnormal pathways during the functional movement of the TMJ that mostly involves thearticular disc function, how ever, IDs could be observed even in asymptomatic individuals(Ghonim et al 2022) joint osteoarthritis (TMJ OA) is a common disorder among thepopulation, is more prevalent in females than in males, and increases in prevalence withage.1 Me chanical and biological events including overloading, bruxism, and unilateralchewing, as well as genetics factor ( Co¨mert Kilic et al2016 ) The pathogenesis of thistemporomandibular joint dysfunction has pointed to biochemical factors ,separate from thedisc displacement theory .for example,inflammatory reactions that occur in TMJ are essential for the development andprogression of the disease ,including high levels o inflammatory mediators in thesynovial fluid ,such as interleukin 1 beta ,tumor necrosis factor alpha and others.furthermore, the disintegration of the important component of the synovial fluid, thehyaluronic acid (HA) ,leads to a decrease in viscosity of the synovial fluid anddegeneration of the joint proteoglycans.(Mahmoud Hassan Toamah et al 2019)Temporomandibular joint disorders include disk displacements, with or without reduction,that may be associated with inflammatory changes, such as capsulitis and retrodiscitis,or with degenerative changes, such as temporomandibular joint (TMJ) osteoarthritis andosteoarthrosis.3 Common symptoms include pain, which is aggravated by the mandibularmovement, joints sounds (clicking or crepitus), a decrease in masticatory efficiency, andfunctional limitation in the mandibular movement(Harba, A. and Harfoush, M. 2021) .Injection of intra‐articular medicaments is an accepted therapy for temporomandibularjoint disorders (TMDs)( Jacob, S.M. et al. (2021) Arthrocentesis is minimally invasivetechnique , less expensive than surgical procedures and simple with low morbidity usedfor flushing the TMJ that is done by access to the upper joint compartment (H.A.M.Marzook et al 2020). lavage helps remove the inflammatory mediators and cells . Itis done when conservative treatment fails to treat the TMJ disorders using patienteducation physical therapy, or splints . at first it was done by saline or Ringerssolution to just flush and lavage the joint but then corticosteroids were used to benefitfrom their anti inflammatory action . Hyaluronic acid is also used in arthrocentesis dueto its lubricant effect, Platelet‐rich plasma (PRP) is a biological therapy thatcomprises an autologous concentrate of platelets acquired by blood centrifugation [11].This concentrate has shown potential benefits due to the abundance of growth factorswithin it(Abaddi et al 2022 )it has analgesic ,anti inflammatory and antibiotic effect,helps restore intraarticular acidic acid and stimulates cartilage cells to produceGlycosaminoglycans, regulates the balance angiogenesis within the joint ,induces cellproliferation and cartilage production through cartilage cells ,increases the productionof hyaluronic acid though synovial cells ,achieves high concentration of growth factorsespecially TGF‐B[Mustafa Manafikhi et al 2022] but there is still a concern regarding theuse of anticoagulants in preparation of PRPSeveral studies were done to compare between HAand PRP in management of Temporomandibularjoint disorders . Four of the studies found PRP injections to be superior in terms ofimprovements in mandibular range of motion and pain intensity up to 12 months aftertreatment, while the remaining two studies found similar results for the differenttreatments (Bousnaki M. et al 2018)Two groups were included in the study ; the control group underwent arthrocentesis theninjection of Hyaluronic acid gel whereas the study group underwent arthrocentesis thenadministration of injectable PRF1‐these patients were clinically examined and radiographically using MRIII‐Operative stage : this study was conducted under local anesthesia (LA). 1. after disinfection of the operative field and injection of local anesthesia, areference line was drawn from the outer canthus of the eye to the tragus of the ear[cantho‐ tragal line] . 2. Double injection technique was used , the first point was marked along the thecantho ‐tragal line [Holmlund ‐Hellsing line] 2mm below the line and 10 mm in frontof the tragus. The second point wasmarked 10 mm below the line and 20 mm from thetragus of the ear . 3. control goup was managed by injection of Hyaluronic acid [HA] after lavage of theupper compartment space using saline solution 1. the first needle [20 gauge] was inserted in to the first marked ,point 2 mm below the cantho‐tragal line and 10 mm from the tragus of the ear . 2. the patient was instructed to open protrusively ,20ml of ringer's solution was injected into the upper joint space then 100mm of ringer's solution was injected that flow back out of the upper joint space through the second needle[20 gauge ] that was inserted 20 mm from the tragus of the ear and 10 mm below the cantho‐tragal line. 3. then 2ml of HA was injected through the first needle while the second needle was removed. Throughout the whole procedure, the patient was instructed to open and close the mandible to facilitate the flow of the solution inside the joint . 4. the study group ;arthrocentesis was done with the same steps as in the first group .the injectable platelet rich fibrin I‐ PRF was injected into the upper joint space.Injectable PRF was prepared immediately before arthrocentesis from centrifuging ofblood taking from the ulnar vein in a tube without anticoagulants at 700 rpm for 3minutes , after centrifuging it was separated from the blood hemocytes as I‐PRF wascollected on the top of the tube while the blood hemocytes being precipitated in thebottom of the tube , 2ml of I‐PRF was collected then injected directly into thejoint after arthrocentesis with ringers solution through the first needle .themandible was manipulated in opening , closing and lateral movements to free theadhesion of the disc.III‐Post operative stage :the patients in both groups were instructed to have soft diet, heat fomentation over theTMJ area and keep moving the mandible.Analgesics and antibiotics were prescribed to avoid un necessary complications ofinfection.