Risk-factors associated with new-onset temporomandibular joint disorder syndrome in patients who underwent mandibular fracture surgery : A retrospective study

doi:10.21203/rs.3.rs-4986355/v1

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Risk-factors associated with new-onset temporomandibular joint disorder syndrome in patients who underwent mandibular fracture surgery : A retrospective study

https://doi.org/10.21203/rs.3.rs-4986355/v1

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Objective: To study the incidence and related risk factors for new-onset temporomandibular joint disorder after mandibular surgery to provide clinical guidance.

Materials and methods: The medical records of patients who underwent open reduction and internal fixation formandibular fractures between September 2020 andJune 2023 were retrospectively analysed, and their personal information and the incidence and pathogenic factors of temporomandibular joint disorder before surgery were recorded. Patients were followed up at 3 months, 6 months, and 1 year after surgery to investigate the incidence and pathogenic factors of postoperative temporomandibular joint disorder.

Results: A total of 121 patients were included in this study, 33 of whomdeveloped temporomandibular joint disorder, accounting for 27.27% of the study population, and 88 patients who did not develop temporomandibular joint disorder, accounting for 72.73% of the study population. Univariate analysis revealed significant differences in abnormal occlusion and healing rates, unilateral chewing rates, and deep overbite of the anterior teeth rates (P <0.05). There was no significantdifference in age, sex, fracture area, cause of trauma, infection rate, bruxism rate, empty chewing rate, or postoperative anxiety rate between the two groups (P >0.05). Binary logisticregression analysis revealed that abnormal occlusion and healing (OR=0.044) and unilateral chewing (OR=0.142) may be risk factors for new-onset temporomandibular joint disorder after maxillofacial fracture surgery.

Conclusion: During the follow-up period, long-term postoperative occlusal habits should be established, and attention should be given the patients’ postoperative psychological state. Accurate digital reconstruction of the occlusal relationship is needed fortreating mandibular fractures.

mandibular fracture

temporomandibular joint disorder syndrome

retrospective analysis

prevention

Temporomandibular joint disorder (TMD) is a disease commonly diagnosed in oral clinics that causes pain in the maxillofacial region and affects patients’ chewing function and quality of life ^{[1, 2]}. Previous studies have shown that TMD can be caused by clinically relevant factors ^[3–5] such as joint hypermobility, oral and maxillofacial trauma, and inflammation in the joint area. Moreover, social and psychological factors are also closely related to the onset of TMD ^[6]. At present, some scholars generally believe that TMD is caused by multiple overlapping factors, but the main cause of this disease has not yet been fully elucidated.

The mandibular condyle is an important component of the temporomandibular joint and mandible, and mandibular fracture is also the most common facial fracture ^[7]. Most temporomandibular joints are acutely damaged due to mandibular trauma, resulting in acute joint inflammation, widening of the joint space and bone marrow inflammation ^[8], which are the pathogenic factors of TMD. Symptoms such as pain in the masticatory muscles, malocclusion, malunion, and wound infection are common complications after open reduction and internal fixation of mandibular fractures ^[9]. Some scholars consider these postoperative complications to be pathogenic factors of TMD in the study of its pathogenesis ^[10]. Therefore, some scholars believe that mandibular fracture is one of the pathogenic factors of TMD ^{[11, 12]}.. However, long-term follow-up studies have shown that mandibular trauma has little effect on the TMJ ^[13]. The incidence of new-onset TMD in patients with mandibular fractures from a long-term follow-up perspective is unknown. The postoperative complications that may cause TMJ disorders deserve further study.

The use of digital surgery, computer-assisted navigation technology and 3D printing technology in the diagnosis and treatment of oral and maxillofacial trauma has improved surgical efficiency and precision ^[14–16]. Traditional open reduction and internal fixation is rarely discussed in current research on the correlation between maxillofacial trauma and temporomandibular joint disease. ^{[11, 17]} Owing to the use of digital surgical technology for treating maxillofacial fractures, research on postoperative complications can guide future research to overcome the shortcomings of digital fracture repair and reconstruction and further improve the diagnosis and treatment of maxillofacial fractures.

This study included patients with mandibular fractures who were hospitalized and underwent open reduction and internal fixation with the assistance of digital surgical technology. The patients' age, sex, fracture site, postoperative complications, and level of postoperative anxiety were statistically analysed. This retrospective case‒control study explored the relevant factors influencing new-onset TMD after mandibular fracture and provided a reference for the further development of digital diagnosis and treatment of maxillofacial fractures.

2.1 Research subjects

A case‒control study involving patients who visited the First Affiliated Hospital of Anhui Medical University for maxillofacial fractures between September 2020 and June 2023 was conducted. The inclusion criteria were as follows: 1. Patients who were over 16 years old, 2. who underwent digital diagnosis and treatment; 3. who had complete medical records and imaging data; and 4. whose fracture line involved the mandible. The exclusion criteria were as follows: 1. Patients with condylar fractures, 2. who were taking drugs that affect the bones (such as bisphosphonates); 3. who were diagnosed with multiple underlying diseases; 4. who underwent orthodontic treatment; 5. who had no symptoms of temporomandibular joint disorder before trauma; and 6. who were lost to follow-up. This study was approved by the Clinical Ethics Committee of the First Affiliated Hospital of Anhui Medical University (Quick-PJ 2021-10-27).

2.2 Perioperative Management

The patient was admitted to the hospital for routine preoperative examination and maxillofacial CT three-dimensional reconstruction. The patient's maxillofacial fractures were digitally reconstructed based on CT DICOM image data. A virtual maxillofacial model of the patient was 3D printed for planning the surgery and preforming the internal fixation devices. The patient underwent open reduction and internal fixation under general anaesthesia. Anti-inflammatory and detumescence treatments were administered for 3 days after surgery, and intermaxillary fixators remained in place for 1–2 weeks after surgery.

2.3 Observation indicators

The main observation indicators were as follows: 1) basic clinical characteristics: age, sex, cause of injury, and fracture site; 2) postoperative complications and risk factors related to temporomandibular joint disorder syndrome ^{[18, 19]}, including infection, abnormal occlusion and healing, nonunion, bruxism, empty chewing, unilateral chewing, deep overbite of the anterior teeth, and postoperative anxiety. The patients returned for follow-up examinations 3 months and 6 months after surgery to record the changes in observation indicators. The patients returned for follow-up examinations 1 year after surgery to record the above observation indicators as statistical results. Temporomandibular joint disorder syndrome was diagnosed based on the following criteria ^[20] : 1. Muscle dysfunction, 2. Disk displacement, 3. Arthralgia, arthritis, arthritis, 4. Excessive activity of the temporomandibular joint, and 5. Tension-type pain with tenderness of the temporalis muscle.

2.4. Statistical analysis

Data were imported into SPSS 27.0 statistical software for statistical analysis. The Shapiro-Wilk test was used to test the normality of the data. The independent samples t test was used to analyse significant differences in normally distributed continuous data, and the Wilcoxon test was used to analyse nonnormally distributed data. Enumeration data were analysed using the χ2 test or Fisher's exact test. Multivariate analysis of the risk factors with significant differences was performed after single-factor analysis, and a p value <0.05 was considered to indicate statistical significance.

A total of 121 patients were successfully followed up and included in this study; 33 patients (Group A) developed temporomandibular joint disorder, accounting for 27.27%, and the composition is shown in Fig. 1. There were 88 patients (Group B) who did not develop temporomandibular joint disorder, accounting for 72.73%. During the follow-up period, 10 patients in Group B developed symptoms of temporomandibular joint disorder 3–6 months after surgery, but the symptoms were no longer present at the one-year follow-up after surgery. One patient experienced mild pain in the temporomandibular joint area when the face was exposed to cold air. None of the patients experienced symptoms of nonunion after surgery. The univariate analysis showed significant differences in abnormal occlusion and healing, unilateral chewing, and deep overbite of the anterior teeth (bite) (P <0.05). There was no significant differences in age, sex, fracture area, cause of trauma, infection rate, bruxism rate, empty chewing rate, or postoperative anxiety rate between the two groups (P >0.05). Detailed information is shown in Table 1.

Table 1

Basic data of patients
	Group A(n = 33)	Group B (n = 88)	Statistics	P value
Age(years)	40.18 ± 13.53	39.36 ± 13.74	Z=-0.253	0.800
Sex			χ² = 0.715	0.398
Male	21(63.63%)	63(71.59%)
Female	12(36.37%)	25(28.41%)
Fracture area			χ² = 2.162	0.339
Mandibular fracture	14(42.42%)	50(56.81%)
Mandibular fracture + Maxillary fractures	11(33.33%)	24(27.27%)
Panfacial fractures	8(24.25%)	14(15.92%)
Causes of Fractures			χ² = 0.387	0.824
Traffic accidents	12(36.36%)	33(37.50%)
Drop	6(18.18%)	23(26.14%)
Fall down	15(45.46%)	43(36.36%)
Postoperative complication
Infections	1(3.03%)	2(2.27%)	0	1
Malunion and Malocclusion	26(78.79%)	15(17.04%)	χ² = 40.839	<0.001
Risk factors associated with TMD
Sleep bruxism	6(18.18%)	17(19.32%)	χ² = 0.020	0.887
Unilateral chewing	19(57.58%)	18(20.45%)	χ² = 15.579	<0.001
Postoperative anxiety and depression	5(15.15%)	4(4.54%)	χ² = 2.532	0.112
Empty chewing	2 (6.06%)	7 (7.95%)	0.000	1
Anterior teeth overbite	4 (12.12%)	0 (0.00%)	7.565	0.006

Binary logistic regression analysis was performed to analyse the factors influencing new-onset temporomandibular joint disorder syndrome after mandibular fracture surgery. Considering new-onset temporomandibular joint disorder syndrome as the dependent variable, the influencing factors with significant differences in the univariate analysis, such as abnormal occlusion and abnormal healing, unilateral chewing, and deep overbite of the anterior teeth, were included in the unconditional logistic regression analysis model. The results showed that abnormal occlusion, abnormal healing and unilateral chewing may be risk factors for new-onset temporomandibular joint disorder syndrome after maxillofacial fracture surgery. See Table 2. The ROC curve showed that abnormal occlusion, abnormal healing, and unilateral chewing had diagnostic value for new-onset temporomandibular joint disorder after surgery. See Fig. 2.

Table 2

Analysis of the factors influencing new TMD
Factors	B	SE	Wald	P	OR	95% CI
Factors	B	SE	Wald	P	OR	Lower	Upper
Malunion and Malocclusion	-3.120	0.620	25.356	0.001	0.044	0.013	0.149
Unilateral chewing	-1.955	0.601	10.572	0.001	0.142	0.044	0.460
Anterior teeth overbite	-23.803	17896.015	0	0.999	0.999	0	0

Based on clinical experience, the larger the fracture area, the more difficult the surgery, and the more likely occlusal abnormalities and abnormal healing are to occur. Therefore, we studied the relationship between the fracture area and occlusal abnormalities, abnormal healing, and unilateral chewing in depth. There was no significant difference between the two groups (P >0.05) (Table 3).

Table 3

Relationship between fracture area, malocclusion and malunion
Fracture area	Malunion and Malocclusion occurred	Malunion and Malocclusion have not occurred	χ²	P value
Mandibular fracture	18	46	5.234	0.073
Mandibular fracture + Maxillary fracture	11	24
Panfacial fractures	12	10

The aetiology of TMD is complex and diverse. Biomechanical, neuromuscular, biopsychosocial and neurobiological factors, as well as trauma, are considered the causes of temporomandibular joint disorders, and trauma can be further divided into microtrauma or macrotrauma ^{[21, 22]}. There is extensive research suggesting that direct trauma to the mandible is a cause of TMD ^[23]. The incidence of TMD in the general population is approximately 5%-12% ^[24]. In this study, the incidence of new-onset TMD in fracture patients was approximately 27%, which is higher than the incidence in the general population and consistent with previous research results. Trauma, as a factor contributing to new-onset TMD, has a multifaceted impact on patients and the temporomandibular joint. First, direct trauma to the mandible can cause damage to the temporomandibular joint and surrounding soft tissues, resulting in inflammatory reactions. Strong external forces can cause displacement or even deconstruction of the temporomandibular joint. This will increase the incidence of TMD. Second, if trauma causes mandibular fractures, the process and quality of surgical treatment can also be considered factors contributing to new-onset TMD. Therefore, the aetiological study of new TMD after mandibular fracture surgery has positive significance for the diagnosis and treatment of patients with mandibular fractures.

The effects of mandibular fracture and open reduction and internal fixation on the temporomandibular joint include the following: 1) effects on the masticatory muscles, 2) anxiety during the perioperative and postoperative periods, and 3) effects on the occlusal relationship.

The movement of the mandible is the result of joint action of the bilateral masticatory muscles. There is no significant difference in the chewing activity of the normal population ^[25]. During open reduction and internal fixation of maxillofacial fractures, it is necessary to sever the muscles that assist the bone to expose the fracture ends for reduction and fixation. Reattachment of severed muscles to the bone during the healing process requires adequate time. When the areas where masticatory muscles are attached such as the corners and chin of the mandible are fracture, the strength among the bilateral muscles becomes imbalanced. For two weeks after surgery, doctors usually recommend that patients eat a well-balanced diet to facilitate recovery of the surgical area. When patients adopt a healthy lifestyle, including eating a well-balanced diet, after surgery and undergo treatment for perioperative and postoperative anxiety, they develop long-term habits that promote health and wellbeing. Due to the two objective factors of bilateral masticatory muscle strength imbalance and the patient's subconscious intention to protect the surgical area, patients tend to limit chewing to one side after surgery. This study revealed that unilateral chewing after surgery for mandibular fracture may influence the development of new-onset TMD after surgery. Moreover, doctors instruct patients in performing mouth opening exercises to minimize the risk of injuring the surgical area, but there is a lack attention to the long-term oral function of patients after surgery. Therefore, we believe that guiding patients' chewing habits after surgery, timely treatment for postoperative anxiety, and physical therapy for bilateral masticatory muscles can help patients recover more effectively and prevent the occurrence of postoperative TMD.

Accurate reconstruction of the occlusal relationship and anatomical reduction of fractures are important for evaluating the effect of treatment for jaw fractures. The two factors usually cause each other, so this study analysed them as one factor. Moreover, malocclusion and malunion are common complications after surgery to correct maxillofacial fracture. In this study, malocclusion and malunion were considered the most significant postoperative factors affecting new-onset TMD after fracture surgery and were also the postoperative complications with the highest incidence rates. Owing to the application of digital technology in oral and maxillofacial surgery, treatment for maxillofacial fractures is becoming more personalized and minimally invasive, and great achievements have been made in the precise reconstruction of maxillofacial contours. However, there is a lack of in-depth research on how to accurately restore the occlusal relationship in fracture patients. Occlusal guides fix the occlusal relationship during orthognathic surgery and have good clinical effects in the treatment of TMD ^[26]. There are also reports of occlusal guides assisting in the reconstruction of occlusal relationships in patients with fractures ^[14], but how to accurately reconstruct the original occlusal relationship digitally and how to obtain dentition models for digital design when mouth opening is limited still requires further research and discussion.

This study also has shortcomings. The diagnosis of TMD relies solely on clinical examinations, without combining them with imaging analysis and discussion. Previous studies have shown that most patients with TMD experience articular disc displacement ^[27], and articular disc displacement is also considered the cause of pain ^[28]. However, studies have shown that articular disc displacement was detected in one-third of patients without TMD who underwent MRI. Clinical symptoms are more practical for diagnosing TMD. ^[31] Most patients have mild TMD symptoms and no functional impairment. Conservative treatment is the first choice for TMD treatment, so MR examination was not included in this study.

Based on the findings of this study, we believe that abnormal occlusion, abnormal healing and unilateral chewing are possible risk factors for new-onset TMD in patients with mandibular fractures after surgery. Moreover, during the follow-up period, good occlusal habits should be established for long-term use, the patients’ postoperative psychological state should be evaluated, and an accurate digital reconstruction of the occlusal relationship should be created to assist in treating mandibular fractures, as doing so can promote healing and avoid the occurrence of TMD.

Acknowledgements

Thanks to Mingen Yang and Tingyu Li for help with data collection.

Ethical approval

All human samples were collected with the patients' written informed consent and approval from the Institute Research Medical Ethics Committee of The First Affiliated Hospital of Anhui Medical University (Hefei, China).

Funding

This work was supported by the Clinical Research Project of the First Affiliated Hospital of Anhui Medical University (LCJY2021YB001)

Data availability

All data included in this study are available upon request by contact with the corresponding author.

Informed consent

Written informed consent was obtained from all subjects for the publication of their data.

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No competing interests reported.

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Risk-factors associated with new-onset temporomandibular joint disorder syndrome in patients who underwent mandibular fracture surgery : A retrospective study

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Abstract

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1. Introduction

2. Materials and Methods

2.1 Research subjects

2.2 Perioperative Management

2.3 Observation indicators

2.4. Statistical analysis

3. Results

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

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