Comparative Study Between the Outcome of Intra-articular Injection of Platelet Rich Plasma Versus Hyaluronic Acid in Arthroscopic Management of Temporomandibular Degenerative Joint Diseases: A Randomized Clinical Trial
Phase: NA
Conditions: Temporomandibular Joint Disorders
Sponsor: Sohag University

 
Comparative Study Between the 
Outcome of Intra-articular Injection of 
Platelet Rich Plasma Versus 
Hyaluronic Acid in Arthroscopic 
Management of Temporomandibular 
Degenerative  Joint Diseases: A 
Randomized Clinical Trial 
 
NCT04936945 
11/5/2023 
 
 

 
Introduction 
The temporomandibular joint (TMJ) is known as ginglymo-arthrodial joint and is 
mainly formed by articulations between the mandibular condyle and the glenoid fossa 
of the temporal bone. The joint articular  disc is formed of dense avascular fibrous 
connective tissue lying between the condyle and the glenoid fossa this position splits 
the joint cavity into superior and inferior joint spaces.(Zhang and Yu, 2012) 
Temporomandibular disorders (TMD) is a group of pathologies affecting the TMJ 
and masticatory muscle system which include internal derangement (ID), arthralgia, 
osteoarthritis, myofascial pain. most of those disorders have similar symptoms include 
pain, joint sounds and limited mouth opening.(McNeill, 1997)  
Internal derangement (ID) of the TMJ is a disruption within the joint with a 
progressive displacement of the disc from its normal position in relation to the 
condyle and the articular portion of the temporal bone. When there is a tear in the 
retrodiscal ligament, the articular disc may be displaced forwards. Anterior disc 
displacement with reduction refers to an unnatural forward movement of the disc 
during opening, which reduces on closing, Anterior disc displacement without 
reduction is an unnatural forward displacement of the articular disc, which does not 
reduce when the mouth is closed.(Okeson, 2019) 
Osteoarthritis (OA) is a progressive degenerative disease associated with damage 
to the cartilage and surrounding tissues. Which is characterized by stiffness, pain, and 
loss of function. Temporomandibular joint osteoarthritis is a common disorder among 
the population, is more prevalent in females than in males. Biological and mechanical 
events including bruxism, overloading, and unilateral chewing, as well as genetic 
factors and internal derangement are causative factors in the development of TMJ 
OA. Temporomandibular joint OA causes not only focal degeneration of the joint 
cartilage, but also osseous erosion, flattening, sclerosis, and osteophyte formation at 
the joint margins.(Kiliç et al., 2015) 

Wilkes first established a classification correlating clinical and radiologic signs 
with operative findings now it is the most commonly used classification system that 
consists of five stages varying from asymptomatic slight forward displacement of the 
disc to excessively degenerative arthritic changes with sever clinical symptoms. 
(Wilkes, 1989)  
Primary goals of the treatment for TMJ internal derangement are to increase the 
range of motion and relieve the functional pain. The current  conservative methods 
suggested for ID include patient behavioral education, resting the jaw, soft diet, 
pharmacological therapy, splint therapy and physical therapy. Usually, TMJ 
arthroscopy is considered as a treatment of choice after failure of conservative 
treatment methods.(Rajapakse et al., 2017) 
Prior to the early 1970s, Surgery was the commonly used method for treatment of 
internal derangements of the temporomandibular joint (TMJ), Surgical treatment 
involving repair and restoration of the articular disc to its normal position 
(discoplasty) or removal of the disc (discectomy). The introduction of arthroscopic 
examination of the temporomandibular joint was first described by Ohnishi. Initially, 
it was described as a diagnostic technique with simple lysis, lavage and medicament 
insertion, This new technique has revolutionized primary management of painful and 
restricted joints. (Ohnishi, 1975) Now arthroscopy is widely used for both 
examination and treatment of TMD which is considered feasible, safe and minimally 
invasive with marked reduction in the number of open TMJ surgery.(Zhu et al., 2012) 
The therapeutic management of  degenerative joint disease (DJD) is focused on 
establishing normal range of mandibular motion and improving the functional pain. 
Conservative non-invasive modalities are the first line of treatment, For patients with 
persistent symptoms and more sever degeneration , minimally invasive treatments 
may be applied, such as arthrocentesis, arthroscopic lysis and lavage with injection of 
corticosteroids, hyaluronic acid, and platelet-rich plasma.(Bousnaki et al., 2018) 
Hyaluronic acid (HA) is a high molecular weight glycosaminoglycan produced 
naturally by synovial cells and is the principal component of the synovial fluid, 
Although the mechanism of action of HA is not fully explained, most 
of authors consider that the therapeutic effects of exogenous HA are related to an 

increase in the quality of the synovial fluid, especially in joints undergoing 
degenerative processes.(Escoda Francolí et al., 2010)  
Platelet-rich plasma (PRP) is a biological therapy based on the use of the patient's 
own plasma with a cocktail of cytokines and proteins; although the mechanism of 
action of PRP is not well known, it is considered that growth factors participate in cell 
activation and secretion processes that accelerate and promote the regeneration of 
damaged tissue, Recent clinical studies have demonstrated the beneficial role of the 
injection of PRP, especially in degenerative articular pathologies such as osteoarthritis 
of the knee, showing improved clinical outcomes compared with HA.(Vaquerizo et 
al., 2013) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Aim of Work 
The aim of this study is to evaluate the efficacy of  intra-articular injection of 
platelet rich plasma versus hyaluronic acid following diagnostic arthroscopy in the 
management of patients suffering from degenerative temporomandibular joint (TMJ).  
Patients and Methods 
All the regulations of the ethical committee of the faculty of medicine in Sohag 
university will be followed. Each patient will have private file with non-disclosure  
policy at data presentation where all presented data do not contain any personal 
information specifying the identity of any of the patients. 
     This is a prospective randomized study of 20 patients with TMJ  degenerative 
joint diseases Wilkes IV, V. 
Patients will be divided into two groups; 
Group A: will be treated with operative arthroscopy plus intra-articular platelet rich 
plasma. 
Group B: will be treated with operative arthroscopy plus intra-articular hyaluronic 
acid. 
Inclusion criteria 
- 
All patients with reduced mouth opening and/or painful maximum 
mouth opening. 
- 
Joint pain. 
- 
Patients with radiological evidence of DJD. 
- 
Patients with unsuccessful medical conservative treatment for at 
least two months. 
- 
Unilateral or bilateral TMJ involvement. 
- 
Wilkes stages IV and V  

 
 
Exclusion criteria 
- 
Patients with bony ankylosis . 
- 
Patients with advanced resorption of the glenoid fossa. 
- 
Patients with infection or tumors around joint area 
- 
Patients unfit for intervention medically.  
- 
Patients who refused to share in the study. 
Patients assessment: 
pre-operative: 
- 
Full medical, dental and operative history. 
- 
Complete head, neck and physical examination . 
- 
Full TMJ evaluation including masticatory muscles system, clicking, 
deviation of the mandible, range of motion including maximal 
interincisal opening in millimeters and pain using  visual analogue 
scale from (0-100) With filled standardized charts. 
- 
Routine laboratory investigations  
- 
Relevant radiological evaluation as MRI or CT scan. 
- 
Informed consent. 
Post-operative assessment: 
     Anti-inflammatory drugs routinely prescribed for 2 weeks with soft diet for 6 
weeks. Exercises will be  explained to the patient to improve mouth opening 
immediately after surgery. 
 Follow up: 
follow up assessments will be at 1 week ,3 weeks , then every month afterwards till 6 
months 

Primary outcomes will include maximal interincisal opening (MIO) in millimeters 
and a 100 -point visual analogue scale (VAS) for the assessment of pain intensity, 
with 0 as the absence of pain and 100 as the worst pain imaginable. 
Ethical consideration:- 
Informed consent will be taken from all cases. 
Ethical approval will be taken from the scientific ethics committee. 
Statistical analysis:- 
     The collected data will be statistically analyzed using Statistical Package for the 
Social Science (SPSS version 16, Chicago, USA) program and expressed in tables 
and charts. All results will be discussed, and then conclusions and recommendations 
will be suggested based on the results. 
List of abbreviations:- 
Temporomandibular Joint 
TMJ 
Temporomandibular Disorders 
TMD 
Osteoarthritis 
OA 
Internal Derangement 
ID 
Degenerative joint disease 
DJD 
Hyaluronic Acid 
HA 
Platelet Rich Plasma 
 
 PRP 
Maximal Interincisal Opening  
MIO 
Visual Analogue Scale  
VAS 
 

 
 
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