Causes and treatment of temporomandibular luxation-a retrospective analysis of 260 patients

OBJECTIVES

We aimed to clarify the etiology, diagnostic process, and treatment of temporomandibular joint (TMJ) luxation, as the standard care is mainly based on case-reports and systematic studies are lacking. The hypotheses were that luxation occurs spontaneously, recurrence manifests particularly among geriatric patients, and surgery is needed infrequently.

PATIENTS AND MATERIALS

A retrospective study of TMJ luxation patients (n = 260) from 2007 to 2020 was designed and implemented. The primary outcome was type of TMJ luxation (i.e., recurrent or non-recurrent), and secondary outcomes were the need for and type of surgical intervention. Predictor variables comprised age, sex, presence of neurological condition, and mechanism of luxation. Administered treatment and clinical outcomes were recorded.

RESULTS

Of luxation, 61.9% was recurrent and 40.0% due to spontaneous cause. Only 1.9% of patients underwent surgical intervention. The presence of neurological condition caused a 1.34-fold risk for recurrence of luxation and general condition a 1.57-fold risk.

CONCLUSIONS

TMJ luxation is often recurrent, bilateral, and spontaneous. Recurrent luxation is associated with geriatric and neurological conditions, and in this group recurrent TMJ luxation predicted death.

CLINICAL RELEVANCE

Our findings contribute to more effective diagnostics and treatment of TMJ luxation patients. We show that there is a need to standardize diagnostic measures and treatment patterns. Moreover, collaboration with other specialities, especially neurology and geriatrics, is important.

Maxillofacial injuries among ice hockey players: a retrospective study from a Finnish trauma Centre

OBJECTIVE

Ice hockey players are at risk of a variety of injuries. In our investigation, we aimed to evaluate the types of facial fractures, injury mechanisms and need for surgical intervention in professional and recreational ice hockey players.

MATERIAL AND METHODS

This retrospective study included all patients presenting to a tertiary trauma centre with any ice hockey-related facial fracture during the period from January 2013 to July 2020. The primary outcome variable was the need for surgical treatment, and the primary predictor variable was the injury mechanism. Demographic and clinically relevant variables were statistically evaluated and presented.

RESULTS

Of 66 total patients, the most frequent fracture type was isolated mandible fracture (56.1%). Males were overrepresented (98.5%) in the patient population. Puck strikes were the most common mechanism of injury (74.2%). Surgical intervention was performed in nearly half of the patients (48.5%), and was significantly more common in younger patients (p = 0.006). Associated dental injuries were present in 27.3% of the cases and they were significantly associated with puck strikes (p = 0.027).

CONCLUSIONS

Mandible fractures and puck strikes, the most common injury site and fracture mechanism respectively, sustained by ice-hockey players required surgical intervention in the majority of cases.

Mandibular fractures in aged patients - Challenges in diagnosis

BACKGROUND/AIMS

Delayed treatment of a mandibular fracture can lead to complications. Therefore, early diagnosis is important. The aim of this study was to clarify the specific features of mandibular fractures in aged patients and the effect of age on possible missed diagnoses.

MATERIAL AND METHODS

Patients aged over 60 years with a recent mandibular fracture were included in the study. The outcome variable was a missed mandibular fracture during the patient's first assessment in the primary health care facility. Predictor variables were age group, categorized as older adults (aged ≥60 and <80 years), elders (aged >80 years), patient's age as a continuous variable and age sub-group divided into decades. Additional predictor variables were the patient's memory disease and injury associated with intracranial injury. Explanatory variables were gender, injury mechanism, type of mandibular facture, combined other facial fracture, edentulous mandible/maxilla/both, surgical treatment of the mandibular fracture, and scene of injury.

RESULTS

Mandibular fractures were missed in 20.0% of the 135 patients during their first healthcare assessment. Significant associations between missed fractures and age group, gender, fracture type, or injury mechanism were not found. By contrast, memory disorder (p = .02) and site of injury (p = .02) were significantly associated with missed fractures. Fractures were missed more frequently in patients who were in hospital or in a nursing home at the time of injury.

CONCLUSIONS

There is an increased risk of undiagnosed mandibular fractures in the aged population. Small injury force accidents may cause fractures in old and fragile individuals. Careful examination is necessary, especially in patients with memory disorder.

Primary reconstruction of combined orbital and zygomatic complex fractures with patient-specific milled titanium implants - A retrospective study

The aim of this retrospective study was to compare mid-facial symmetry and clinical outcomes between patients treated with patient-specific and standard implants in primary fracture reconstructions of combined orbital and zygomaticomaxillary complex fractures. Patients who underwent primary reconstruction of orbital and zygomaticomaxillary complex fractures during the study period were identified and background and clinical variables and computed tomography images were collected from patient records. Zygomaticomaxillary complex dislocation and orbital volume were measured from pre- and postoperative images and compared between groups. Out of 165 primary orbital reconstructions, eight patients treated with patient-specific and 12 patients treated with standard implants were identified with mean follow-up time of was 110 days and 121 days, respectively. Postoperative orbital volume difference was similar between groups (0.2 ml for patient-specific vs 0.3 ml for standard implants, p = 0.942) despite larger preoperative difference in patient-specific implant group (2.1 ml vs 1,5 ml, p = 0.428), although no statistical differences were obtained in symmetricity or accuracy between the reconstruction groups. Within the limitations of the study it seems that patient-specific implants are a viable option for primary reconstructions of combined zygomaticomaxillary complex and orbital fractures, because with patient-specific implants at least as symmetrical results as with standard implants can be obtained in a single surgery.

"A" stands for airway - Which factors guide the need for on-scene airway management in facial fracture patients?

Background

Numerous guidelines highlight the need for early airway management in facial trauma patients since specific fracture patterns may induce airway obstruction. However, the incidence of these hallmark injuries, including flail mandibles and posterior displacement of the maxilla, is contentious. We aim to evaluate specific trauma-related variables in facial fracture patients, which affect the need for on-scene versus in-hospital airway management.

Methods

This retrospective cohort study included all patients with any type of facial fracture, who required early airway management on-scene or in-hospital. The primary outcome variable was the site of airway management (on-scene versus hospital) and the main predictor variable was the presence of a traumatic brain injury (TBI). The association of fracture type, mechanism, and method for early airway management are also reported. Altogether 171 patients fulfilled the inclusion criteria.

Results

Of the 171 patients included in the analysis, 100 (58.5) had combined midfacial fractures or combination fractures of facial thirds. Altogether 118 patients (69.0%) required airway management on-scene and for the remaining 53 patients (31.0%) airway was secured in-hospital. A total of 168 (98.2%) underwent endotracheal intubation, whereas three patients (1.8%) received surgical airway management. TBIs occurred in 138 patients (80.7%), but presence of TBI did not affect the site of airway management. Younger age, Glasgow Coma Scale-score of eight or less, and oro-naso-pharyngeal haemorrhage predicted airway management on-scene, whereas patients who had fallen at ground level and in patients with facial fractures but no associated injuries, the airway was significantly more often managed in-hospital.

Conclusions

Proper preparedness for airway management in facial fracture patients is crucial both on-scene and in-hospital. Facial fracture patients need proper evaluation of airway management even when TBI is not present.

Paediatric mandibular fracture-a diagnostic challenge?

The purpose of this study was to clarify the frequency of missed mandibular fractures and to identify possible predictive factors for missed diagnosis. This was a retrospective study that included patients <20 years of age with a recent mandibular fracture. The outcome variable was missed mandibular fracture, which was determined when a fracture was not suspected or diagnosed during the patient's first assessment in primary healthcare. The primary predictor variable was age group (i.e. children <13 years or teenagers/adolescents aged 13-19 years). The explanatory variables were sex, mechanism of injury, and type of facial facture. Other variables were clinical symptoms and findings. Mandibular fracture was missed at first contact in 27 of 182 patients (14.8%). Fracture was missed significantly more often in patients <13 years than in older patients (33.3% vs. 8.8%, P<0.001). The only significant symptom or clinical finding that was associated with missed fractures was skin wound of the jaw (P=0.009). There was no association between missed fracture and sex or mechanism of injury. Mandibular fractures in children are often missed at the first healthcare contact. Careful examination is necessary in paediatric mandibular injuries, particularly in the youngest age groups. Consultation should be smooth between paediatric trauma units and maxillofacial surgeons.

Zygomatico-Orbital Fracture-Dislocation in Surgical Treatment: Novel 3-Dimensional Software Automated Analysis

PURPOSE

The human capability to detect the degree of zygomatico-orbital (ZMO) fracture-dislocation in surgical treatment is unknown. The aim of this study was to examine the association between ZMO fracture-dislocation and injury etiology and treatment.

MATERIALS AND METHODS

We implemented a retrospective cross-sectional study, enrolled a sample composed of patients with an isolated unilateral ZMO fracture, and analyzed fracture-dislocation from computed tomography images with an automatic algorithm. The primary predictor variable was mean surface point-to-point dislocation (the mean distance of dislocation for all surface points in isolated ZMO fracture segments between the original position and after virtual repositioning). The primary outcome was the treatment choice (operative vs nonoperative). Other studied variables were gender, age group, injury mechanism, clinical asymmetry, and human-evaluated dislocation on computed tomography images. Descriptive and bivariate statistics were computed, and the threshold for statistical significance was set at P < .05.

RESULTS

The sample consisted of 115 patients with a mean age of 66.3 years, 66.1% of whom were male patients, and the most common cause of injury was falling on the ground (49.6%). Operative treatment was required in 58 patients (50.4%). A significant association was found between mean dislocation and operative treatment. Mean dislocation of operatively versus nonoperatively treated fractures was 2.39 mm versus 1.05 mm (P < .001). Mean fracture-dislocation was greatest in injuries caused by assault (2.41 mm) and smallest in motor vehicle accidents (1.08 mm) and ground-level falls (1.25 mm). The threshold of human-eye detection for ZMO fracture-dislocation was 1.97 mm.

CONCLUSIONS

The results of this study demonstrate that the threshold for operative treatment of ZMO fracture-dislocation is over 2 mm, which the human eye is able to detect. True dislocation is greater in younger patients than elderly patients and in injuries caused by assault compared with falling.

Ethanol inhibits IgE-induced degranulation and cytokine production in cultured mouse and human mast cells

Activated mast cells (MC) can produce a wide variety of potent inflammatory mediators. Excessive alcohol consumption is known to lead to immune deficiency and propensity for pneumonias in particular. As MCs are important in the first line of defence of mucosal membranes we have studied the effect of ethanol (EtOH) on several MC functions. EtOH attenuated dose dependently IgE-induced degranulation of mouse bone marrow derived mast cells (mBMMC) as reflected by the release of granule associated beta-hexosaminidase (beta-hex). A mean of 26 +/- 7% inhibition of beta-hex release was observed in the presence of 5/1000 (86 mM) EtOH and nearly complete inhibition in the presence of 20/1000 (344 mM) ethanol. The IgE-induced degranulation of mBMMC cultured with EtOH for seven days was inhibited to a similar degree as the degranulation of mBMMC exposed to EtOH for only one hour. Inclusion of 5/1000 (86 mM) ethanol in the medium reduced tumour necrosis factor (TNF)-alpha and interleukin (IL)-8 production in human mast cell line (HMC-1) cells by 55 +/- 7% and 19 +/- 5%, respectively, and the presence of 20/1000 (344 mM) ethanol inhibited the expression 81 +/- 12% and 59 +/- 14% respectively. These results suggest that, in contrast to previous assumption, ethanol inhibits several critical MC functions at least in vitro. This inhibition of mediator, and cytokine release in particular, could contribute to the immune deficiency associated with chronic alcohol consumption.

Identification and quantitation of phosphorus metabolites in yeast neutral pH extracts by nuclear magnetic resonance spectroscopy

(31)P NMR spectroscopy offers a possibility to obtain a survey of all low-molecular-weight phosphorylated compounds in yeast. The yeast cells have been extracted using chloroform into a neutral aqueous phase. The use of high fields and the neutral pH extracts, which are suitable for NMR analysis, results in well-resolved (31)P NMR spectra. Two-dimensional NMR experiments, such as proton-detected heteronuclear single quantum ((1)H-(31)P HSQC) and (31)P correlation spectroscopy ((31)P COSY), have been used to assign the resonances. In the phosphomonoester region many of the signals could be assigned to known metabolites in the glycolytic and pentose phosphate pathways, although some signals remain unidentified. Accumulation of ribulose 5-phosphate, xylulose 5-phosphate, and ribose 5-phosphate was observed in a strain lacking transketolase activity when grown in synthetic complete medium. No such accumulation occurred when the cells were grown in yeast-peptone-dextrose medium. Trimetaphosphate (intracellular concentration about 0.2 mM) was detected in both cold methanol-chloroform and perchloric acid extracts.