Treatment of temporomandibular joint internal derangement using MESNA injection.

INTRODUCTION: The development of temporomandibular disorders specifically emphasizes the biochemical changes occurring in the synovial fluid at different stages of temporomandibular joint disease. Research has indicated that inflammation may be a primary reason behind the pain and dysfunction in temporomandibular joint diseases. Since its clearance several years ago, MESNA (sodium 2-mercaptoethanesulfonate) has been used in various formulations as a mucolytic drug in the respiratory domain. It operates by disrupting the disulfide bonds present between polypeptide chains within mucus. MESNA exhibits minimal tissue distribution, with the material being swiftly and thoroughly eliminated via the kidneys. OBJECTIVES: To assess the efficacy of injecting MESNA directly into the Temporomandibular Joint to treat internal derangement. MATERIALS AND METHODS: A randomized clinical trial was conducted on sixty patients who exhibited non-responsiveness to conventional treatment and were diagnosed with TMJ anterior disc displacement with reduction. The patients were chosen from the outpatient clinic of the Oral and Maxillofacial Surgery Department at Tanta University Faculty of Dentistry. Two equal groups of patients were randomly assigned to each other. Group I (Mesna group) received intra-articular injection with MESNA solution. Group II (Standard group) received arthrocentesis with lactated ringer solution followed by injection of Hyaluronic Acid (HA). The data was gathered by functional examinations such as maximum interincisal opening (MIO) and clicking. A Visual Analogue Scale (VAS) assessed pain severity before and after treatments. RESULTS: Both MESNA and HA showed significant improvement up to six months of the follow-up compared to preoperative status, as evidenced by better mouth opening, lateral excursion, lower clicking, and reduced pain score in patients with TMDs. MESNA showed significant improvement during follow-up compared to HA. CONCLUSION: Compared to HA, MESNA showed a more noticeable improvement during the follow-up period.

IncobotulinumtoxinA in refractory temporomandibular disorder due to disk dislocation: A prospective study.

INTRODUCTION: Temporomandibular disorders (TMD) may include conditions involving the temporomandibular joint and/or masticatory muscles. Approximately 20 % of patients are refractory to first-line therapies. This study aims to evaluate the effects and safety of incobotulinumtoxinA in the treatment of refractory TMD due to disk dislocation. MATERIAL AND METHODS: A quasi-experimental one-arm prospective study was conducted. Target population included individuals with a diagnosis of TMD due to disk dislocation. Patients were treated with electromyography or ultrasound guided injection of incobotulinumtoxinA in the masticatory muscles (20 U into each masseter and pterygoideus lateralis). Pain was assessed using the pain numerical rating scale, maximum unassisted mouth opening was measured in mm, and adverse events were registered at baseline, week 4, week 12 and week 24 post-treatment. Statistical analysis used the Wilcoxon test for the comparison of paired samples and the Mann-Whitney U test for independent samples, considering a p-value ≤ 0.05 as significant. RESULTS: 51 patients with 75 painful temporomandibular joints due to disk dislocation (38 with reduction and 37 without) were included. A significant reduction in pain from a pre-treatment mean of 6.08/10 to a post-treatment mean of 2.04/10 (week 4), 3.18/10 (week 12), and 3.65/10 (week 24) was observed (p < 0.001). A significant decrease in maximum unassisted mouth opening from a pre-treatment mean of 36.45 mm to a post-treatment mean of 32.29 mm at week 4 was observed (p < 0.001). DISCUSSION: Botulinum toxin injection of the masticatory muscles is safe and seems equally effective in reducing pain in patients with refractory TMD due to disk dislocation.

Effect of dextrose prolotherapy on internal derangement of the temporomandibular joint.

OBJECTIVE: This study aimed to evaluate the effect of dextrose prolotherapy in treating internal derangement of the temporomandibular joint. PATIENTS AND METHODS: A total of 20 patients with temporomandibular joint internal derangement were enrolled in the study. The diagnosis of internal derangement was confirmed by magnetic resonance imaging (MRI). The posterior and anterior disc attachment, as well as the most tender part of the masseter muscle, were injected with 12.5% dextrose. Pain, maximum mouth opening, clicking, and deviation were assessed immediately before treatment, as well as at 2-, 4-, and 12- weeks post-treatment. RESULTS: There was a significant improvement in the four clinical variables at the three-time intervals. Pain at two weeks was reduced by 60% (6 vs. 3.75) and by 200% (6 vs. 1.9) at 4 weeks. The maximum mouth opening was increased by 6.4 mm at 2 weeks and 7.85 mm at 4 weeks. The percentage of patients with clicking decreased from 70%, preoperatively- to 50% at 2 weeks, 15% at 4 weeks, and 5% at 12 weeks. The ratio of patients with deviation was decreased from 80% preoperatively to 35% at 2 weeks, 15% at 4 weeks, and 5% at 12 weeks. CONCLUSIONS: Prolotherapy is a safe and effective treatment for alleviating the symptoms of internal derangement of the temporomandibular joint.

Ultrasound-guided lateral pterygoid muscle botulinum toxin: an injection for recurrent temporomandibular joint dislocation in a brain injury patient.

Botulinum toxin type A (BTX-A) injection using nerve stimulation or electromyography for recurrent temporomandibular joint (TMJ) dislocation has been reported for several years. However, using the available equipment like a nerve stimulator or an electromyograph is uncommon, and ultrasound guidance is convenient and requires no additional resources. In this report, we used ultrasound as a tool to achieve BTX-A injections in a patient with a traumatic brain injury to treat her TMJ dislocation. One week after the injections, she had no more dislocation. She remained symptom free during the 3 months of follow-up, and her clinical symptoms improved without significant complications. This is the first report using ultrasound guidance for BTX-A injections to treat recurrent TMJ dislocation. This treatment is an effective and safe technique that could be performed timely and locally without referral to a center with electromyography facilities.

Clinical negligence in temporomandibular joint surgery.

This study reviewed the medical reports of 25 patients (21 female and 4 male) who were found to have been treated inappropriately by temporomandibular joint (TMJ) surgery. One of more Breaches of Duty and resultant harms (Causation) were identified for each of the patients in this series. Their ages ranged from 18-64 (mean 36.2, median 35) years. A narrative review of free text data revealed six main patterns of Breach of Duty which were to do with consent, inadequate pre-surgical imaging, injection of botulinum toxin into jaw muscles, TMJ arthroplasty, management of TMJ dislocation and subluxation, and failure or reluctance to request second opinions. Harms identified included surgical damage to the TMJ, facial nerve dysfunction, and social isolation. One sum claimed was in excess of £1 million.

Penthrox enables quicker management of fractures, dislocations and more: learning lessons from expedited care of trauma patients during the COVID-19 pandemic.

INTRODUCTION: Methoxyflurane is an historical anaesthetic agent that has undergone a renaissance with the introduction of a smaller dose in a handheld 'Penthrox' device. The benefits of Penthrox include its ease of use, with disposable individual packets, and the need for less monitoring and staff, when compared with deeper sedation. The literature acknowledges its use for analgesia and in the management of anterior shoulder dislocation but in no other procedural orthopaedic circumstance. METHODS: Following institutional approval, we undertook a retrospective review of all incidences of Penthrox use to facilitate minor procedures within a 2-month period starting 24 March 2020. Time to procedure and success were recorded using the surrogate markers of patient attendance and x-Ray occurrence times. RESULTS: Some 101 Penthrox doses were given to 89 patients over 97 unique episodes between 24 March and 26 May 2020. No complications were recorded following the use of Penthrox during this period. Patient demographics were explored. Fracture manipulations and casting (n=54) had a 100% success rate in achieving adequate and safe reduction. Joint dislocations (n=34) were treated with varying success. Native elbow dislocations were reduced most successfully (4/4, 100%). Native shoulder dislocations were seen in 17 patients and successful relocation was seen in 11 cases, giving a success rate of 65%. CONCLUSIONS: This is the first study, outside anterior shoulder dislocations, to report on the efficacy of Penthrox within emergent orthopaedic scenarios. We have demonstrated Penthrox to be a safe tool for helping to manage trauma procedures in the emergency department.

Bilateral Temporomandibular Joint Dislocation Following Arthrocentesis Plus Hyaluronic Acid Injection.

Arthrocentesis plus intra-articular hyaluronic acid (HA) injection for temporomandibular joint (TMJ) disorders is known to be a safe and minimally invasive surgical procedure. Arthrocentesis plus HA injection has a pain-reducing effect on TMJ disorders. It is also a palliative treatment that yields positive results in terms of clinical findings such as clicking and mouth opening. Even though some complications have been reported after the performance of this highly successful procedure, the development of bilateral TMJ dislocation after arthrocentesis plus intra-articular HA injection has not been reported to date. This case report presents bilateral TMJ dislocation following arthrocentesis plus intra-articular HA injection that developed within a few hours and resisted manual Hippocrates manoeuvre in a 21-year male. Herein, his treatment with systemic corticosteroid therapy, myorelaxant and anti-inflammatory drugs is also presented. Key Words: Arthrocentesis, Hyaluronic acid, Joint dislocation, Temporomandibular joint, Steroids.

Velopharyngeal dysfunction following botulinum toxin type A injection to the lateral pterygoid muscles for recurrent jaw dislocation.

Complications related to lateral pterygoid muscle (LPM) botulinum toxin A (BtA) injection for recurrent temporomandibular joint dislocation are uncommon. No cases of velopharyngeal dysfunction (VPD) following LPM BtA injection have been reported to date. This report details the perioperative and follow-up findings for a patient developing VPD following LPM BtA injection.

PrEvention of posttraumatic contractuRes with Ketotifen 2 (PERK 2) - protocol for a multicenter randomized clinical trial.

BACKGROUND: Injuries and resulting stiffness around joints, especially the elbow, have huge psychological effects by reducing quality of life through interference with normal daily activities such as feeding, dressing, grooming, and reaching for objects. Over the last several years and through numerous research results, the myofibroblast-mast cell-neuropeptide axis of fibrosis had been implicated in post-traumatic joint contractures. Pre-clinical models and a pilot randomized clinical trial (RCT) demonstrated the feasibility and safety of using Ketotifen Fumarate (KF), a mast cell stabilizer to prevent elbow joint contractures. This study aims to evaluate the efficacy of KF in reducing joint contracture severity in adult participants with operately treated elbow fractures and/or dislocations. METHODS/DESIGN: A Phase III randomized, controlled, double-blinded multicentre trial with 3 parallel groups (KF 2 mg or 5 mg or lactose placebo twice daily orally for 6 weeks). The study population consist of adults who are at least 18 years old and within 7 days of injury. The types of injuries are distal humerus (AO/OTA type 13) and/or proximal ulna and/or proximal radius fractures (AO/OTA type 2 U1 and/or 2R1) and/or elbow dislocations (open fractures with or without nerve injury may be included). A stratified randomization scheme by hospital site will be used to assign eligible participants to the groups in a 1:1:1 ratio. The primary outcome is change in elbow flexion-extension range of motion (ROM) arc from baseline to 12 weeks post-randomization. The secondary outcomes are changes in ROM from baseline to 6, 24 & 52 weeks, PROMs at 2, 6, 12, 24 & 52 weeks and impact of KF on safety including serious adverse events and fracture healing. Descriptive analysis for all outcomes will be reported and ANCOVA be used to evaluate the efficacy KF over lactose placebo with respect to the improvement in ROM. DISCUSSION: The results of this study will provide evidence for the use of KF in reducing post-traumatic joint contractures and improving quality of life after joint injuries. TRIAL REGISTRATION: This study was prospectively registered (July 10, 2018) with ClinicalTrials.gov reference: NCT03582176.

Quais métodos de tratamento para luxação recidivante da ATM com maior evidência científica? / What treatment methods for recurrent TMJ dislocation have the most scientific evidence?

OBJETIVO: Esse estudo se propos a identificar quais os métodos mais eficazes no tratamento das luxações redicivantes de ATM e suas evidências científicas. METODOLOGIA: Foi desenvolvida uma revisão sistemática seguindo as recomendações PRISMA, tendo como estratégia de busca em cinco diferentes bases de dados (Pubmed, Scopus, Medline, The Cochrane Library, Web of science). Como critérios de inclusão, selecionamos artigos nos idiomas inglês, português e espanhol; estudos realizados em humanos, e os relatos/série de casos que deveriam ter uma amostra mínima de 10 pacientes, com tempo mínimo de acompanhamento de cada paciente de 1 ano para todos os tipos de estudos. Foram excluídos artigos que não responderam à pergunta de pesquisa, assim como, aqueles que não apresentaram pontuação superior a 10 no STROBE (estudos observacionais) e CONSORT (ensaios clínicos) e que não apresentassem todos os elementos necessários quando da publicação de série de casos (Guidelines to the writing of case studies). Os artigos inicialmente foram selecionados por dois pesquisadores independentes, pelo título e posteriormente, foram submetidos aos critérios de inclusão e exclusão, e após essa seleção, foram aplicados os "Check lists" STROBE, CONSORT e GUIDELINESS, de acordo com o tipo de artigo. Dessa maneira cada artigo selecionado recebeu uma pontuação que definiu a sua permanência na pesquisa. Os resultados dessa seleção e avaliação, foram organizados em uma tabela e também foi aplicado o teste para analisar possíveis vieses, apenas nos ensaios clínicos, validado pela The Cochrane Library. RESULTADOS: Vinte artigos foram incluídos na revisão, nos quais apenas 4 eram ensaios clínicos. Dos 20 artigos, 4 eram nível II, 3 evidências nível III e 13 nível IV, sendo 10 artigos para tratamentos não invasivos, concentrando a maioria no uso da injeção autóloga de sangue na ATM e 10 artigos para o tratamento cirúrgico, destacando principalmente a eminectomia como procedimento principal. CONCLUSÃO: Dos procedimentos minimamente invasivos, a injeção de sangue autólogo é o que apresenta maior evidência e resultados favoráveis, sendo este melhor documentado. Já para o tratamento invasivo, por meio de cirurgia, o procedimento de Dautrey apresentou potencial resolutivo semelhante ao procedimento de eminectomia e se mostrou um procedimento promissor. Baseados nas análises das evidências científicas até o momento, pode-se observar que há uma necessidade em propor trabalhos com nível de evidência mais altos sobre o assunto, pois até o momento, há poucos ensaios clínicos disponíveis e ainda apresentam alto índice de viés incerto, prejudicando conclusões mais definitivas (AU).

OBJECTIVE: This study aims to identify which methods are most effective in treating recurrent TMJ dislocations and their scientific evidence. METHODOLOGY: A systematic review was developed following the PRISMA recommendations, having as search strategy in five different databases (Pubmed, Scopus, Medline, The Cochrane Library, Web of science). As inclusion criteria, we selected articles in English, Portuguese and Spanish; studies carried out in humans, and the reports / case series that should have a minimum sample of 10 patients, with a minimum follow-up time for each patient of 1 year for all types of studies. Articles that did not answer the research question were excluded, as well as those that did not score more than 10 in the STROBE (observational studies) and CONSORT (clinical trials) and that did not present all the necessary elements when the publication of the case series ( Guidelines to the writing of case studies). The articles were initially selected by two independent researchers, by title and later, were submitted to the inclusion and exclusion criteria, and after this selection, the "Check lists" STROBE, CONSORT and GUIDELINESS were applied, according to the type of article. In this way, each selected article received a score that defined its permanence in the research. The results of this selection and evaluation were organized in a table and the test was also applied to analyze possible biases, only in clinical trials, validated by The Cochrane Library. RESULTS: Twenty articles were included in the review, of which only 4 were clinical trials. Of the 20 articles, 4 were level II, 3 evidence level III and 13 level IV, 10 articles for noninvasive treatments, with the majority concentrating on the use of autologous blood injection in the TMJ and 10 articles for surgical treatment, highlighting mainly eminectomy as the main procedure. CONCLUSION: Of the minimally invasive procedures, the injection of autologous blood is the one with the greatest evidence and favorable results, which is better documented. As for invasive treatment, by means of surgery, the Dautrey procedure showed a resolving potential similar to the eminectomy procedure and proved to be a promising procedure. Based on the analysis of the scientific evidence to date, it can be seen that there is a need to propose studies with a higher level of evidence on the subject, as so far, there are few clinical trials available and still have a high rate of uncertain bias, undermining more definitive conclusions (AU).

Injectable Agents Versus Surgery for Recurrent Temporomandibular Joint Dislocation.

Recurrent temporomandibular joint dislocation (TMJD) is a distressing entity to the patient and a therapeutic challenge to the treating provider. Absence of high-level evidence in literature among currently available treatment options creates a lack of consistency in management. This article reviews the current literature on common injectable agents used and the open surgical techniques. Based on the findings, an injectable agent is the initial treatment of choice for recurrent TMJD, with capsulorraphy and eminectomy being used in nonresponding patients.

Botulinum Neurotoxin Injection for the Treatment of Recurrent Temporomandibular Joint Dislocation with and without Neurogenic Muscular Hyperactivity.

The aim of this study was to compare treatment outcomes following intramuscular injection of botulinum neurotoxin (BoNT) in patients with recurrent temporomandibular joint dislocation, with and without muscle hyperactivity due to neurological diseases. Thirty-two patients (19 women and 13 men, mean age: 62.3 years) with recurrent temporomandibular joint dislocation were divided into two groups: neurogenic (8 women and 12 men) and habitual (11 women and 1 man). The neurogenic group included patients having neurological disorders, such as Parkinson’s disease or oromandibular dystonia, that are accompanied by muscle hyperactivity. BoNT was administered via intraoral injection to the inferior head of the lateral pterygoid muscle. In total, BoNT injection was administered 102 times (mean 3.2 times/patient). The mean follow-up duration was 29.5 months. The neurogenic group was significantly (p < 0.001) younger (47.3 years) than the habitual group (84.8 years) and required significantly (p < 0.01) more injections (4.1 versus 1.7 times) to achieve a positive outcome. No significant immediate or delayed complications occurred. Thus, intramuscular injection of BoNT into the lateral pterygoid muscle is an effective and safe treatment for habitual temporomandibular joint dislocation. More injections are required in cases of neurogenic temporomandibular joint dislocation than in those of habitual dislocation without muscle hyperactivity.

Evaluation of the Efficacy of Different Concentrations of Dextrose Prolotherapy in Temporomandibular Joint Hypermobility Treatment.

PURPOSE: The aim of this study was to compare and evaluate the efficacy of different concentrations of dextrose prolotherapy for the treatment of temporomandibular joint (TMJ) hypermobility. PATIENTS AND METHODS: A prospective, randomized clinical trial including patients with subluxation or dislocation was performed. The study comprised 40 patients. Patients were randomly divided into 4 groups: control group, 10% dextrose, 20% dextrose, and 30% dextrose group. Patients in all groups received injections into 4 different areas of each TMJ in 4 sessions at monthly intervals. Visual analog scale of TMJ pain intensity, maximum mouth opening (MMO), joint sounds, and frequency of luxations were recorded preoperatively and postoperatively after 1 month of last injection. The collected data were then statistically analyzed. RESULTS: Each group showed postoperatively significant improvement in TMJ pain, significant decrease in both MMO and joint sound. Besides that, TMJ locking was not observed in any patient during the follow-up period. There were no statistically significant differences throughout the study intervals between the groups. CONCLUSION: It was concluded that there was no significant difference between control group and dextrose groups and there is no superiority of any concentration of dextrose over the others in TMJ prolotherapy, and all treatment procedures were efficient in improvement of clinical symptoms related to TMJ hypermobility. If dextrose is used as a proliferant, it can be said that 10% dextrose can be sufficient in TMJ hypermobility treatment.

Incarcerated Plantar Dislocation of the First Metatarsophalangeal Joint: Reduction Using Intra-articular Saline Injection.

Plantar dislocation of the first metatarsophalangeal (MTP) joint is exceedingly rare, and in prior reported cases, simple closed manipulation easily enabled reduction. We present here the first reported plantar dislocation that failed closed manipulation. We also report a technique involving injection of saline into the joint to facilitate reduction. The saline insufflation likely relieves buttonholing of the metatarsal head through the dorsal joint capsule. For first MTP joint plantar dislocations that fail reduction with manipulation, we recommend attempting injection of the joint with saline prior to subjecting the patient to open reduction. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.

Case Report: Ultrasound-Guided Infraclavicular Brachial Plexus Block for a Case with Posterior Elbow Dislocation.

BACKGROUND: The interest in regional anesthesia procedures for the management of upper-extremity emergencies has increased. Toward that end, supraclavicular, interscalene, or infraclavicular approaches, with or without ultrasound guidance, are used for brachial plexus nerve blocks. Although many studies have reported on the use of ultrasound-guided supraclavicular and interscalene brachial plexus blocks for upper-extremity dislocations, very few studies have reported on the use of ultrasound-guided infraclavicular brachial plexus blocks. CASE REPORT: We present an adult patient with posterior elbow dislocation that is treated with reduction after applying an ultrasound-guided infraclavicular brachial plexus block. Additionally, we describe the infraclavicular block in detail and demonstrate the technique using images. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Based on our experience, the ultrasound-guided infraclavicular block is a fast, safe, and efficient anesthesia technique that can be an excellent alternative to sedoanalgesia and other brachial plexus blocks for the management of elbow dislocations in the emergency department.

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.

The aim was to analyse the short-term and long-term therapeutic efficacy of dextrose prolotherapy for dislocation or subluxation (hypermobility) of the temporomandibular joint (TMJ). Sixty-one patients with symptomatic hypermobility of the TMJ were included in this single-arm prospective study, in which they were each given four sessions of intra-articular and pericapsular injections six weeks apart. Each injection comprised 10% dextrose/mepivacaine solution 3ml. Clinical outcomes including severity of pain on movement according to the numerical rating scale (NRS), maximal interincisal opening, clicking, and frequency of locking were measured before treatment (T1), during treatment (T2) (just before the third session of injections), at the short-term follow-up (T3) (three months after treatment), and at the long-term follow-up (T4) (1-4 years after treatment). Condylar translation and osseous changes of each joint were evaluated at T1 and T4 using tomography. There was significant reduction in all variables by T2 (p<0.001, p<0.001, p=0.006, and p<0.001). The pain scores (p<0.001) and clicking (p<0.001) had decreased significantly by T3. Linear tomograms of each joint at T1 and T4 showed no alteration in the morphology of the bony components of the joint, and at T4, tomographic open views of all joints showed condylar hypertranslation. Dextrose prolotherapy provided significant and sustained reduction of pain and recovery of constitutional symptoms associated with symptomatic hypermobility of the TMJ without changing either the position of the condyle or the morphology of the bony components of the joint.

[Intra-articular injections of hyaluronic acid for anterior disc displacement of temporomandibular joint].

Anterior disc displacement (ADD) of temporomandibular joint (TMJ) is regarded as one of the major findings in temporomandibular disorders (TMD). It is related to joint noise, pain, mandibular dysfunction, degenerative change and osteoarthritis. In the mean time, the pathological changes were found in synovial membrane and synovial fluid. Hyaluronic acid is a principal component of the synovial fluid which plays an important role in nutrition, lubrication, anti-inflammation and cartilage repair. The synthesis, molecule weight, and concentration of hyaluronic acid are decreased during TMD and cause TMJ degenerative changes. The clinical conditions, pathological changes, the mechanism of action for hyaluronic acid and the treatment of anterior disc displacement of TMJ are discussed in this article.

Botulinum toxin used to treat recurrent dislocation of the temporomandibular joint in a patient with osteoporosis.

Recurrent dislocations of the temporomandibular joint (TMJ) can be debilitating. We describe a patient with osteoporosis who presented to our regional centre where we have limited resources. We injected botulinum toxin into both of her lateral pterygoid muscles, and six months later she has not required further injections and has had no issues with tolerance of the procedure. Botulinum toxin is a safe, conservative approach to recurrent dislocations of the TMJ and can be given accurately by an experienced surgeon without the use of an electromyogram.