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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 398-404  

Comparison of autologous blood prolotherapy and 25% dextrose prolotherapy for the treatment of chronic recurrent temporomandibular joint dislocation on the basis of clinical parameters: A retrospective study


1 Department of Dentistry, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
2 Department of General Surgery, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
3 Department of Community Medicine, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India

Date of Submission13-Dec-2021
Date of Acceptance12-Apr-2022
Date of Web Publication10-Dec-2022

Correspondence Address:
Dr. Sandeep Kumar Pandey
Department of Dentistry, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.njms_509_21

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   Abstract 


Introduction: Prolotherapy is a nonsurgical regenerative injection technique and effective treatment method for the treatment of temporomandibular joint (TMJ) dislocation. Autologous blood and dextrose are commonly used agents for prolotherapy and the aim of this study is to compare the autologous blood injection prolotherapy and 25% dextrose prolotherapy for the treatment of chronic recurrent TMJ dislocation.
Method: This is a retrospective cohort study of 20 patients with chronic recurrent TMJ dislocation who were treated by either autologous blood (Group A) or 25% dextrose Prolotherapy (Group B). After prolotherapy, the patients were kept on follow-up and evaluated for maximum mouth opening (MMO), pain at visual analog scale (VAS), mandibular movements, frequency of dislocation, and TMJ sound. The collected data were then statistically analyzed.
Results: Group A showed better results in terms of reduction in MMO, mandibular movements as compared to Group B, and a statistically significant difference was found starting from 2 weeks post prolotherapy till 6 months follow-up. Whereas group B showed better results regarding reduction in pain intensity on VAS Scale at all follow-up visits. No statistically significant difference was found between both groups regarding reduction in the frequency of dislocation and TMJ sounds.
Conclusion: Both autologous and dextrose prolotherapy gives promising results for the treatment of recurrent TMJ dislocation, however, regarding reduction in MMO and improvement in lateral and protrusive mandibular movements, autologous blood gave better results whereas 25% Dextrose was found to be more effective in terms of reduction of pain in recurrent TMJ dislocation cases.

Keywords: MMO, prolotherapy, TMJ dislocation


How to cite this article:
Pandey SK, Baidya M, Srivastava A, Garg H. Comparison of autologous blood prolotherapy and 25% dextrose prolotherapy for the treatment of chronic recurrent temporomandibular joint dislocation on the basis of clinical parameters: A retrospective study. Natl J Maxillofac Surg 2022;13:398-404

How to cite this URL:
Pandey SK, Baidya M, Srivastava A, Garg H. Comparison of autologous blood prolotherapy and 25% dextrose prolotherapy for the treatment of chronic recurrent temporomandibular joint dislocation on the basis of clinical parameters: A retrospective study. Natl J Maxillofac Surg [serial online] 2022 [cited 2023 Jan 27];13:398-404. Available from: https://www.njms.in/text.asp?2022/13/3/398/363084




   Introduction Top


Temporomandibular joint (TMJ) dislocation is a condition in which condyle gets displaced anterior to an articular eminence which in turn leads to various discomfort to the patient like inability to close the mouth, anterior open bite, pain in masticatory muscles, and problems in speech. This problem usually occurs in conditions that lead to excessive mouth opening such as laughing, eating, yawning, during dental procedures as well as during laryngoscopy and endotracheal intubation.

In initial and acute stages, dislocated condyle can be reduced manually by the patient itself but as it becomes recurrent or chronic, it requires urgent intervention in order to reduce the dislocated condyle.

Many treatment modalities have been reported which include conservative, minimally invasive, and surgical means. In conservative means, patients are generally managed by restriction of excessive lower jaw movement, soft diet, and jaw support while yawning. Surgical intervention includes eminectomy,[1] dautrey's procedure,[2] capsular plication,[3] temporalis tendon scarification,[4] lateral pterygoid myotomy[5] and L-shaped ramus osteotomy[6], etc., Minimally invasive methods include injection of the sclerosing agent in the TMJ region, botulin toxin injection in lateral pterygoid muscles, and prolotherapy.

Prolotherapy is also known as proliferation therapy/regenerative injection therapy/growth factor stimulation injection therapy in which a non-pharmacological irritant solution such as autologous blood[7],[8],[9],[10],[11],[12] or dextrose[13],[14] is injected into the region of the TMJ. This causes the initiation of an inflammatory process which triggers the release of growth factors and this leads to fibrosis in capsule and ligament which results in either complete cure or reduction in episodes of TMJ dislocation. In literature, some reports have been published that have suggested results of autologous blood prolotherapy[7],[8],[9],[10],[11],[12] and dextrose prolotherapy[13],[14] but no literature has been found about the comparison of dextrose and autologous blood prolotherapy in the treatment of TMJ dislocation. The motive behind executing this article is to compare autologous blood prolotherapy and 25% dextrose prolotherapy for the treatment of chronic recurrent temporomandibular joint dislocation on the basis of clinical parameters.


   Materials and Methods Top


Study design

This was a retrospective study which was conducted in the Department of Dentistry. Patients with chronic recurrent bilateral dislocation of TMJ who were managed by either autologous blood or 25% Dextrose Prolotherapy were included in this study. The study was approved by GIMS Institutional Ethics Committee, Greater Noida [GIMS IEC-ECR/1224]. Informed consent was signed by each patient enrolled in the study. The diagnosis of recurrent TMJ dislocation was based on history, clinical examination, and radiographic evaluation. Patients represented with clinical symptoms of recurrent TMJ dislocation such as multiple episodes of inability to close mouth due to lockjaw in the open position, difficulty in swallowing and speech, excessive mandibular movements and on palpation, pain, and depression were noted in preauricular area. For confirmation of the diagnosis of TMJ dislocation, orthopantomogram [Figure 1] and TMJ view [open and closed mouth, [Figure 2]] were done which showed the location of the condylar head anterior to the articular eminence. All the patients were treated by the same surgeon. Records of patients related to it were maintained in the register and at every follow-up visit, their data was updated. The register included the age and gender of the patients, diagnosis, treatment delivered, the clinical variables before prolotherapy and follow up notes including clinical details. Follow up was carried out after the procedure at the interval of 1 week, 2 week, 1 month, 3 month, and 6 months. The data were screened according to inclusion and exclusion criteria and total of 20 patients were recruited for this study in which 10 patients were treated with Autologous blood prolotherapy (Group A) and 10 patients were treated with 25% dextrose prolotherapy (Group B). Inclusion criteria for data selection were patients with bilateral chronic recurrent Temporomandibular joint dislocations with maximum mouth opening (MMO) more than 40 mm, recurrent dislocation of TMJ more than two times a week, pain and sounds in joints and age between 18 to 60 years. Patient with any previous invasive procedures on TMJ was excluded.
Figure 1: Orthopantomogram

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Figure 2: TMJ view (open and closed mouth) showing condylar dislocation

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Following clinical parameters were used to evaluate the outcome of prolotherapy:

  1. Maximum mouth opening (MMO) as distance in mm between the incisal edges of maxillary and mandibular central incisors
  2. Presence of pain (VAS) - TMJ pain was rated from 0 (no pain), 1-3 (mild pain), 4-6 (moderate pain), 7-9 (severe pain) to 10 (worst pain) on a visual analog scale (VAS).
  3. Frequency of dislocation
  4. Right laterotrusion (mm)
  5. Left laterotrusion (mm)
  6. Protrusion (mm)
  7. Presence or absence of TMJ sound.


Prolotherapy technique

A strict aseptic protocol was followed for the patient's preparation and after proper preparation of the target site, external auditory meatus was blocked with cotton socked in Neosporin ointment, and auriculo-temporal nerve block was given (1:200,000 LA with Adrenaline). A cantho-tragal line was drawn and the point was marked 10 mm anterior to tragus and 2 mm below the cantho-tragal line. At this point, an 18-gauge needle was inserted into superior joint space. For autologous blood prolotherapy, 3 ml of autologous blood was withdrawn from the patient's anticubital fossa, out of which 2 ml was injected into the upper joint space and 1 ml was injected around the capsule (pericapsular tissues). This procedure was then repeated on the opposite side in the same manner. For Dextrose prolotherapy, 3 ml of 25% dextrose was taken in a 5 ml syringe out of which 2 ml was injected into the upper joint space and 1 ml was injected around the capsule (pericapsular tissues). The same procedures were repeated on the opposite joint also.

Follow up

A bandage was placed for the initial 1 week and patients were instructed to avoid wide mouth opening and all patients were advised to take a soft diet for 2 weeks. Antibiotics (Tab Amoxicillin) and non-steroidal anti-inflammatory drugs were prescribed for 5 days. Patients were kept on regular follow up and evaluated clinically after the procedure at the interval of 1 week, 2 week, 1 month, 3 month, and 6 month post-injection regarding maximum mouth opening (MMO) as distance in mm between the incisal edges of maxillary and mandibular central incisors, presence of pain (VAS), episode of dislocation per week, Right laterotrusion (mm), left laterotrusion (mm), protrusion (mm) and the presence or absence of TMJ sound.

Statistical analysis

After all the data was collected, the result was subjected to statistical analysis using SPSS version 22. The quantitative data were expressed in mean and standard deviation while the categorical data were expressed in proportion and percentages. Chi-square test and Fisher exact test were applied for comparing proportions across study groups and t-test, Mann Whitney test was applied to compare means across the groups. P value below 0.05 was considered statistically significant. Adjusted P values were also presented using the Multivariate analysis. For Multivariate analysis, we have applied linear regression and adjusted for age and sex while calculating estimates for group differences.


   Results Top


Total of 20 patients were recruited who underwent prolotherapy procedures for recurrent TMJ dislocation. Out of them, 10 patients were treated by autologous blood prolotherapy and 10 with 25% Dextrose prolotherapy. In Group A, the mean age was 34.8 ± 7.69 and in group B, the mean age was 34.1 ± 10.50. The male to female ratio was found to be 1:1 in both groups.

[Table 1] reveals that there was a statistically significant difference (P value < 0.05) was found between Group A and Group B regarding MMO starting for 2nd week post prolotherapy till 6 month follow up. Group A gave better improvement as the extent of reduction in mouth opening was found to be greater than Group B.
Table 1: Comparison between Group A and Group B groups according to MMO

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The 25% dextrose prolotherapy was found to be better as compared to autologous blood prolotherapy regarding reduction in pain intensity on VAS Scale at all follow-up visits [Graph 1]. In comparison of pain intensity in Group A and Group B, a statistically significant difference was found at 2nd week, 1 month, 3rd month, and 6th month follow up.



There was a statistically significant difference was found in groups A and B regarding protrusion at 1st month and 6th-month post prolotherapy [Table 2].
Table 2: Comparison between Group A and Group B according to Protrusion

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[Table 3] and [Table 4] reveal that there was a significant difference was found in Group A and Group B regarding right and left laterotrusion starting for 1st-week post prolotherapy till 6 months follow up. Autologous blood prolotherapy gave better results regarding reduction in right and left laterotrusion.
Table 3: Comparison between Group A and Group B according to Right Laterotrusion

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Table 4: Comparison between Group A and Group B according to Left Laterotrusion

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There was no statistically significant difference was found between Group A and Group B regarding the frequency of dislocation and TMJ sound [Graph 2] and [Graph 3].




   Discussion Top


TMJ dislocation takes place due to the number of factors that stop the mandibular condyle to translate back to the glenoid fossa which in turn leads to chronic recurrent TMJ dislocation. These include a combination of factors such as weakness of the TMJ capsule, laxity of TMJ ligaments, hyperactivity or spasm of the lateral pterygoid muscle, or a decrease in the height of articular eminence. Dislocation of condyle leads to several discomforts such as pain in the preauricular region, inability to close the mouth, and difficulty in speech. Various surgical, non-surgical, and minimally invasive treatment methods have been used to treat TMJ dislocation. In the treatment of recurrent TMJ dislocation, minimally invasive treatment methods should be utilized appropriately before adopting surgical treatment modalities. Autologous blood and dextrose can be used as a proliferating agent to treat recurrent dislocation of TMJ and here we compared the autologous blood prolotherapy and 25% dextrose prolotherapy for the treatment of recurrent dislocation of TMJ.

Due to weak TMJ capsule and laxity of TMJ ligaments, the patient's mouth opening becomes more than normal and as a result, the joint starts dislocating again and again leading to recurrent dislocation of TMJ. In prolotherapy, the injected blood/dextrose leads to the inflammatory reaction which in turn induces fibrosis and scarring in the surrounding soft tissue which leads to a reduction in joint hypermobility.

A varying degree of success has been seen with different concentrations of dextrose. Refai et al.[15] and Reeves et al.[16] used 10% dextrose, Topol et al.[17] and Cömert Kiliç et al.[14] used 12.5% dextrose, Rabago et al.[18] used 15% dextrose, Majumdar et al.[19] used 25% dextrose while Zhou et al.[20] used 50% dextrose concentration for prolotherapy. More than 10% dextrose concentration has been found to be effective inducing sufficient inflammation so here we used 25% dextrose for prolotherapy. A similar concentration was used by Majumdar et al.[19] for treatment of TMJ hypermobility and they had also shown promising results.

Brachmann.[21] in 1964 was the first who successfully treated 60 patients with recurrent dislocation by autologous blood injection in the TMJ. Daif,[7] Schulz,[8] Jacobi Hermanns et al.,[9] Machon et al.,[10] and Hegab AF[22] have also used autologous blood prolotherapy for TMJ dislocation patients. Daif[7] in 2010 reported a 60% success rate with autologous blood injection if blood was injected in superior joint space only but the success rate was increased up to 80% if blood was injected both in superior joint space and peripheral tissue.

In the present study, it was seen that there was the statistically significant difference was found between autologous blood prolotherapy and 25% dextrose prolotherapy regarding MMO starting from 2nd week post prolotherapy till 6 month follow up. Autologous Blood Prolotherapy gave better improvement than 25% dextrose prolotherapy in terms of reduction in maximum mouth opening. In the present study, reduction in MMO in group A was found to be from 46.7 ± 1.81 mm to 38.5 ± 1.89 mm at 6 months post prolotherapy. These results are comparable to the study done by Triantafillidou et al.[23] in which reduction in MMO was from 49.76 ± 0.90 mm to 42.96 ± 0.97 mm at the end of treatment using autologous blood injection. Reduction in MMO in group B in the present study was from 46.95 ± 1.38 mm to 40.2 ± 1.55 mm. According to the study by Refai et al.[15] who used 10% dextrose prolotherapy, reduction in MMO was from 50.38 ± 7.63 mm to 46.15 ± 7.02 mm whereas study done by Cömert Kiliç et al.[14] who used 12.5% dextrose prolotherapy, reduction in MMO was 46.14 ± 6.89 mm to 43.29 ± 5.92 mm at the end of the treatment.

In the present study, a statistically significant difference was found between autologous blood prolotherapy and 25% dextrose prolotherapy regarding pain intensity at 2nd week, 1st month, 3rd month, and 6th month follow up. About 25% dextrose prolotherapy gave better results as compared to autologous blood prolotherapy regarding reduction in pain intensity (VAS scale) at all follow up visits. There was a reduction in pain intensity from 5.1 ± 1.52 to 1.7 ± 0.48 in group A while in group B, it was found to be from 5.4 ± 1.26 to 0.8 ± 0.79. According to the study by Cömert Kiliç et al.,[14] mean preoperative pain was 4.30 ± 2.57 which was reduced to 0.89 ± 1.45 at the end of the follow-up after 12.5% dextrose prolotherapy. In the study by Refai et al.,[15] it was shown that the mean pain before treatment was 6.72 ± 2.78 which was reduced to 0.61 ± 1.57 at the last follow up visit after 10% dextrose prolotherapy. Significant reduction in TMJ pain after 10% dextrose prolotherapy has also been seen by Ungor et al.[24]

In the present study, patients in both groups experienced a reduction in protrusion, right and left laterotrusion post prolotherapy. The difference was statistically significant in favor of autologous blood prolotherapy starting from 2nd week post prolotherapy till 6 month follow up in comparison with dextrose prolotherapy regarding right and left laterotrusion. Cömert Kiliç et al.[14] found out significant improvement in the lateral motion of the mandible with 12.5% dextrose prolotherapy. Khamis et al.[25] has also shown improvement in protrusive and right lateral movement with autologous blood prolotherapy.

In the present study both the groups showed good results regarding the reduction in the frequency of dislocation, however, there was no statistically significant difference was found between both the groups at all the follow up visits.

A study by Machon et al.[10] revealed that 20 out of 25 patients showed no recurrent episode of TMJ dislocation after autologous blood injection. Zhou et al.[20] noticed an appreciable improvement in the number of episodes of dislocation in TMJ hypermobility cases using 50% dextrose prolotherapy. Refai et al.[13] found that the mean frequency of luxation was significantly decreased and at end of the study, none of the patients had locking episodes after 10% dextrose prolotherapy.

There was no statistically significant difference was found between autologous blood prolotherapy and 25% dextrose prolotherapy regarding TMJ sounds. Ungor et al.[24] found that 8/10 patients had clicking sound before treatment and after 10% dextrose prolotherapy, the clicking sound was lost in seven patients. Triantafillidou et al.[23] also noted the reduction in TMJ sound after autologous blood prolotherapy.


   Conclusion Top


Prolotherapy should be considered as the first line of treatment for recurrent TMJ dislocation and surgical options should be kept in reserve and carried out in patients who are having recurrence after prolotherapy. We found that regarding reduction in maximum mouth opening and improvement in lateral and protrusive mandibular movements, autologous blood prolotherapy gave better results whereas 25% dextrose prolotherapy was found to be more effective in terms of reduction of pain in recurrent TMJ dislocation cases. There was no statistically significant difference was found regarding the reduction in the frequency of dislocation and TMJ sound in both groups. We conclude that 25% dextrose prolotherapy is more beneficial in recurrent TMJ dislocation patients with pain; however, both autologous blood prolotherapy and 25% dextrose prolotherapy are simple, safe and cost-effective treatment modalities for recurrent TMJ dislocations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Westwood RM, Fox GL, Tilson HB. Eminectomy for the treatment of recurrent temporomandibular joint dislocation. J Oral Surg 1975;33:774-9.  Back to cited text no. 1
    
2.
da Costa Ribeiro R, dos santos BJ Jr, Provenzano N, de Freitas PH. Dautrey's procedure: An alternative for the treatment of recurrent mandibular dislocation in patients with pneumatization of the articular eminence. Int J Oral Maxillofac Surg 2014;43:465-9.  Back to cited text no. 2
    
3.
Boudreaux RE, Spire ED. Plication of the capsular ligament of the temporomandibular joint: A surgical approach to recurrent dislocation or chronic subluxation. J Oral Surg 1968;26:330-3.  Back to cited text no. 3
    
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Maw RB, McKean TW. Scarification of the temporal tendon for treatment of chronic sublaxation of the temporomandibular joint. J Oral Surg 1973;31:22-5.  Back to cited text no. 4
    
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Adekeye EO, Shamia RI, Cove P. Inverted L-shaped ramus osteotomy for prolonged bilateral dislocation of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1976;41:568-77.  Back to cited text no. 6
    
7.
Daif ET. Autologous blood injection as a new treatment modality for chronic recurrent temporomandibular joint dislocation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:31–6.  Back to cited text no. 7
    
8.
Schulz S. Evaluation of periarticular autotransfusion for therapy of recurrent dislocation of the temporomandibular joint. Dtsch Stomatol 1973;23:94-8.  Back to cited text no. 8
    
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Jacobi-Hermanns E, Tetsch P. Pericapsular autologous blood injection as therapy for habitual temporomandibular joint luxation. Deutsche Zahnarztliche Zeitschrift 1981;187:90.  Back to cited text no. 9
    
10.
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Kato T, Shimoyama T, Nasu D. Autologous blood injection into the articular cavity for the treatment of recurrent temporomandibular joint dislocation: A case report. J Oral Sci 2007;49:237-41.  Back to cited text no. 12
    
13.
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;69:2962–70.  Back to cited text no. 13
    
14.
Cömert Kiliç S, Güngörmüş M. Is dextrose prolotherapy superior to placebo for the treatment of temporomandibular joint hypermobility? A randomized clinical trial. Int J Oral Maxillofac Surg 2016;45:813-9.  Back to cited text no. 14
    
15.
Refai H. Long-term therapeutic effects of dextrose prolotherapy in patients with hypermobility of the temporomandibular joint: A single-arm study with 1-4 years' follow up. Br J Oral Maxillofac Surg 2017;55:465-70.  Back to cited text no. 15
    
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Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med 2000;6:68-74, 77-80.  Back to cited text no. 16
    
17.
Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil 2005;86:697-702.  Back to cited text no. 17
    
18.
Rabago D, Zgierska A, Fortney L, Kijowski R, Mundt M, Ryan M, et al. Hypertonic dextrose injections (prolotherapy) for knee osteoarthritis: Results of a single-arm uncontrolled study with 1-year follow-up. J Altern Complement Med 2012;18:408-14.  Back to cited text no. 18
    
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Majumdar SK, Krishna S, Chatterjee A, Chakraborty R, Ansari N. Single injection technique prolotherapy for hypermobility disorders of TMJ Using 25% Dextrose: A clinical study. J Maxillofac Oral Surg 2017;16:226-30.  Back to cited text no. 19
    
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22.
Hegab AF. Treatment of chronic recurrent dislocation of the temporomandibular joint with injection of autologous blood alone, intermaxillary fixation alone, or both together: A prospective, randomised, controlled clinical trial. Br J Oral Maxillofac Surg 2013;51:813–7.  Back to cited text no. 22
    
23.
Triantafillidou K, Venetis G, Markos A. Short-term results of autologous blood injection for treatment of habitual TMJ luxation. J Craniofac Surg 2012;23:689-92.  Back to cited text no. 23
    
24.
Ungor C, Atasoy KT, Taskesen F, Cezairli B, Dayisoylu EH, Tosun E, et al. Short-term results of prolotherapy in the management of temporomandibular joint dislocation. J Craniofac Surg 2013;24:411-5.  Back to cited text no. 24
    
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Khamis N, Osman S, Mohamed N. Comparative study between 2 types of prolotherapy in treatment of chronic recurrent temporomandibular joint dislocation. Alexandria Dent J 2019;44:101-7.  Back to cited text no. 25
    


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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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