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

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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 60.0% due to spontaneous cause. The presence of neurological condition caused a 2.28-fold risk for recurrence of luxation. Only 1.9% of patients underwent surgical intervention. The risk ratio for mortality within 12 months of primary contact was 1.52-fold higher in recurrent luxation patients than in non-recurrent cases. 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. temporomandibular luxation neurological condition geriatric age oral and maxillofacial surgery Introduction Luxation of the temporomandibular joint (TMJ) may occur if mandibular condyle dislocation takes place anteriorly over the articular tuberculum of the temporal bone [ 1 ]. The simultaneous masticatory muscle spasm blocks the relocation of the condyle behind the articular eminence [ 2 ]. The condition is often acute and may cause pain or at least discomfort because the normal position of the lower jaw has changed. Thorough anamnesis and clinical examination are essential for setting the right diagnosis. Radiology can also be useful to ensure diagnosis. Jaw deviation, inability to close the mouth, and a non-palpable condyle on the posterior side of the articular eminence of temporal bone can indicate TMJ luxation [ 3 ]. In bilateral luxation, there is no deviation, however, the mandible is in a prognathic position [ 4 ] . Although TMJ luxation is a rare condition relative to joint luxations of other parts of the body and its frequency in the emergency department is only 5.3 cases per year [ 5 ], for some patients the condition is recurrent. Significant predisposing factors have not been found [ 3 ], although neurological conditions and changes in connective tissue as in TMJ joint capsule have been reported to be related particularly to recurrent TMJ luxation [ 6 ]. Treatment of luxation is manual reduction at the emergency stage [ 7 ]. For patients with recurrent TMJ luxation, the acute repositioning of TMJ can only be considered a temporary treatment and needs to be followed by preventive measures [ 2 ]. Preventive treatments include non-surgical approaches such as intermaxillary fixation or injection of botulinum toxin into jaw muscles or the TMJ [ 2 , 6 ]. Surgical methods aim to reform the mandibular condyle, the articular eminence [ 6 ]. This study investigated the etiology, diagnostics, and treatment of TMJ luxation and particularly the aetiological factors leading to recurrent TMJ luxation, as there is a lack of known predictive factors. The hypotheses were that luxation is predominantly spontaneous, surgical intervention is infrequently considered, and recurrent luxation is more common in the elderly. Patients And Methods Study design A retrospective cohort study at a tertiary trauma centre’s oral and maxillofacial surgery emergency unit (Töölö Hospital Emergency Department, Helsinki University Hospital (HUH), Finland) over a 14-year period from 1 January 2007 to 20 October 2020 was conducted. The oral and maxillofacial emergency service is provided by the Department of Oral and Maxillofacial Surgery, HUH, which has a catchment area of more than 1.6 million inhabitants. Patients with the following ICD diagnoses were identified from an electronic patient management system: 1) S03.4: sprain and strain of the jaw, 2) S03.0: dislocation of the jaw, 3) S03.5: sprain and strain of the joints and ligaments of other and unspecified parts of the head, 4) K07.62: recurrent TMJ dislocation, and 5) K07.69: unspecific TMJ dysfunction. Study variables The primary outcome was type of TMJ luxation (i.e., recurrent or non-recurrent), and secondary outcomes were need for and type of surgical intervention. The primary predictor variables comprised age, sex, presence of neurological condition, and mechanism of luxation, which was classified as follows: 1) spontaneous, 2) yawning, vomiting, or eating, 3) dentist visit or gastroscopy, 4) injury, 5) medical seizure, and 6) habit or exercise. Other variables registered were other general condition(s), regular medication used, type of living conditions, and referral unit. Related to TMJ luxation, we recorded clinical parameters, radiographic interventions, need for manual reduction, and aftercare instructions. Mortality during the study period was also recorded. TMJ luxation was defined as recurrent if the condition had occurred at least twice in the lifetime. Data analysis Descriptive statistics analyses were conducted. Chi-square test was used to evaluate statistical significance between variables, and 2x2 table for risk-ratio calculation. Ethical considerations The internal review board of the Head and Neck Center of HUH (Helsinki, Finland) approved the study. Patient consent was not required due to the retrospective nature of the study. Results The electronic patient record search produced a sample of 800 patients whose medical records were manually re-evaluated. Excluded were patients with any other clinical condition than TMJ dislocation, resulting in the inclusion of 260 patients with confirmed TMJ dislocation. Table 1 presents the descriptive statistics of 260 patients with TMJ luxation. The incidence was slightly higher (58.1%) among women, and the average age of patients was 51.4 years. The two most common causes by far were spontaneous luxation (40.0%) and yawning, vomiting, or eating (36.2%). Of all luxations, 61.9% were recurrent. Neurological (31.2%) and cardiovascular (27.3%) conditions were the most common general illnesses, and the rate of mortality during the study period was 28.1% in the entire population. Table 2 presents status, radiography, and intervention under primary evaluation for TMJ patients. Of cases, 57.3% were bilateral. Manual reduction was needed for 91.9% of patients and was successful for 69.2% without any medication. Intravenous relaxants and sedation were the most common medications required. Surgical treatment was planned for 15 patients but was cancelled for patients` anaesthesiologic contraindications for general anaesthesia, and five patients perished before the planned surgery. Eminectomy was carried out for five patients (1.9%). Table 3 presents the comparison of 99 patients with non-recurrent TMJ luxation and 161 patients with reported or clinically confirmed recurrent TMJ luxation under primary evaluation. Patients aged at least 65 years were more common among the recurrent (63.6%) than non-recurrent (36.4%) group, although the difference was not significant. By contrast, the difference in relation to cause of luxation between the groups was significant ( P = 0.003). Spontaneous luxation was by far more common among the recurrent group (71.2%), whereas injury caused the luxation among non-recurrent patients (81.3%). Dental panoramic radiograph was the predominant radiological intervention for both the recurrent (50.9%) and non-recurrent (49.1%) group, however, for patients in these groups radiological diagnostic tool was only used in 51.8% and 48.2%, respectively ( P = 0.019). Altogether 68.5% of recurrent and 31.5% of non-recurrent patients perished during the study period ( P = 0.173). Table 4 shows the comparison of 99 patients with non-recurrent and 67 patients with recurrent re-admittance needing TMJ luxation. Spontaneous luxation was significantly more common in the recurrent (60.0%) than the non-recurrent group (40.0%), whereas dentist visit (100.0%), gastroscopy (100.0%), or injury-related luxation (100.0%) occurred solely in patients with non-recurrent luxation ( P < 0.001). Radiographic diagnostics was significantly more often done for non-recurrent luxation patients than for recurrent patients (87.1% and 12.8%, respectively, P < 0.001). Dental panoramic radiograph was the most common type of imaging. Surgical treatment was considered more often with recurrent luxation patients (p < 0.001). The rate of mortality within the study period was significantly higher among recurrent (55.8%) than non-recurrent (44.2%) patients (p = 0.006). Table 5 presents the risk ratio in a 2x2 table between the presence of neurological condition, geriatric age, female sex, mortality, and recurrence of TMJ luxation. Neurological condition caused a 2.28-fold and geriatric age a 1.57-fold risk for luxation to recur, the difference being significant ( P < 0.001 and P = 0.016, respectively). Notable was also the higher risk for mortality in general (RR 1.67, P = 0.006) and within 12 months of primary contact (RR 1.52, P = 0.046) in the recurrent luxation group compared with the non-recurrent group. Discussion This study investigated the aetiology, diagnostics, and treatment of TMJ luxation and particularly the aetiological factors leading to recurrent TMJ luxation, as there is a lack of known predictive factors. Our hypotheses were confirmed. Luxations were most often spontaneous, surgical intervention was infrequently considered, and recurrent luxation was more common among elderly patients. Our results showed that TMJ luxation is typically bilateral and recurrent. Recurrent TMJ luxation is often associated with neurological and cardiovascular conditions. Also, recurrent TMJ luxation can also be used as a factor to predict death when the interval between luxations becomes shorter. The average age of the patients was 51.4 years and over half were women. Patients with recurrent TMJ luxation were older than those with non-recurrent TMJ luxation. Other studies have found that mean age of TMJ luxation patients was around 40 years [ 8 , 9 ]. TMJ luxation was rare in children and adolescents in our data, and most TMJ luxations in children have been shown to be caused by trauma [ 10 ]. Typically, TMJ luxation was spontaneous. Yawning, vomiting, and eating were common mechanisms of TMJ luxation. Yawning and other spontaneous events have been mentioned as a common cause in other studies as well [ 1 , 4 , 8 ]. Differences exist in the prevalence of trauma in TMJ luxation. The incidence of TMJ luxation caused by an injury in present study was 6.2% corresponding to the rate of previous studies which has varied from 20% [ 8 ] or as high as 60% [ 4 ]. These differences could be explained by where the study was conducted and the definition used for trauma. We showed that patients with neurological and cardiovascular conditions were at higher risk for TMJ luxation. For example, changes in musculartonus in neurological conditions could increase the recurrence of TMJ luxation [ 1 ]. Also, epilepsy, connective tissue disorders [ 4 ], and oromandibular dystonia [ 11 ] have been described to be risk factors for TMJ luxations. As the present study shows, neurological conditions are important background diseases. Therefore, close co-operation with the neurological and geriatric departments is important when planning individual treatments, particularly in view of our finding that recurrence of TMJ luxation is a predictor for death. The most common clinical findings in TMJ luxation were jaw deviation, pain, and inability to close the mouth. Radiography was not often used as a diagnostic method because the diagnosis could be confirmed based on the clinical findings alone. The question then arises of whether differential diagnoses have been sufficiently excluded, i.e., fractures of the mandibula or mandibular condyle. The radiographic method used under primary evaluation was panorama tomography, and it was completed in 21% of cases. This is in accord with previous findings stating that imaging is rarely needed in the acute situation, but when performed it demonstrates the condyle’s anterior position in relation to the articular eminence [ 12 ]. Radiography has been shown to be useful in patients for differential diagnoses or to provide information for further treatment planning [ 7 ]. In addition, imaging is recommended in trauma cases since it is important to differentiate fractures from luxation. Manual reduction of TMJ luxation was usually possible without medication. However, when medication was needed the most common choice was intravenous sedation. General anaesthesia or local anaesthetic injections to the TMJ were rarely used. Local anaesthesia has been proposed for use when performing manual reduction since the condition is very painful [ 13 ]. The success rate of manual reduction is high when it is carried out immediately after the luxation [ 7 ]. One reason why TMJ luxation patients are taken to the emergency room could be the lack of expertise in performing the manual reduction procedure at the referring centre. Over half of the referrals came from general practitioners, who could with ease learn the procedure. Overall, the treatment alternatives focused on non-surgical measures, and surgery was indicated in only a few cases. Patients eligible for surgery had recurrent TMJ luxation, which affected their quality of life. It has also been shown that complications are rare in surgical treatment of TMJ. If complications occur, they are usually infections or damage to adjacent structures. Generally, in TMJ surgery arthroscopy is considered to minimize complications compared with open surgery, which is often the choice in surgical treatment of TMJ luxation [ 14 ]. One systematic review of the treatment options for recurrent TMJ luxation summarized that there is no good-quality evidence on which treatments lead to long-term elimination of recurrent luxation. The options included, for example, eminectomy, miniplanting of the articular eminence, and down-fracture of the zygomatic arch. The authors noted that surgeons empirically consider eminectomy as the `gold standard`[ 15 ]. It is noteworthy that these data cover patients from one clinic during a certain period, and it is likely that some patients previously received treatment for TMJ luxation at another clinic or hospital. Thus, the number of recurrent TMJ luxation patients might be even higher. A strength of our study was the large size of the patient population, as the previous literature has mainly been based on case-reports. The study also revealed a relationship between mortality and recurrent luxation, highlighting the importance of collaboration between specialties when considering surgical treatment. A weakness of the study is its retrospective nature; a prospective study would have provided information on prosthodontic treatment. Conclusions To summarize, we showed that TMJ luxation is often bilateral, recurrent, and more common in women. Most of the luxations are spontaneous and these are often associated with geriatric age and neurological conditions. In these patient groups, recurrent TMJ luxation can predict death. Declarations Author`s contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Reetta Tarhio, Miika Toivari, Johanna Uittamo and Johanna Snäll. The first draft of the manuscript was written by Reetta Tarhio and all authors commented on previous/later versions of the manuscript. All authors read and approved the final manuscript. Ethical approval The internal review board of the Head and Neck Center of HUH (Helsinki, Finland) approved the study. Informed consent Patient consent was not required due to the retrospective nature of the study. Conflict of interest The authors declare that they have no conflict of interests. Funding The researchers received funding from the Helsinki University Central Hospital Fund References Liddell A, Perez DE. Temporomandibular joint dislocation. Oral Maxillofac Surg Clin North Am. 2015;27(1):125-36. https://doi.org/10.1016/j.coms.2014.09.009 Abrahamsson H, Eriksson L, Abrahamsson P, Häggman-Henrikson B. Treatment of temporomandibular joint luxation: a systematic literature review. Clin Oral Investig. 2020;24(1):61-70. https://doi.org/10.1007/s00784-019-03126-1 Hillam J, Isom B. Mandible Dislocation. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2022, StatPearls Publishing LLC.; 2022. Akinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med. 2011;7:10. https://doi.org/10.1186/1746-160X-7-10 Lowery LE, Beeson MS, Lum KK. The wrist pivot method, a novel technique for temporomandibular joint reduction. J Emerg Med. 2004;27(2):167-70. https://doi.org/10.1016/j.jemermed.2004.03.007 Tocaciu S, McCullough MJ, Dimitroulis G. Surgical management of recurrent TMJ dislocation-a systematic review. Oral Maxillofac Surg. 2019;23(1):35-45. https://doi.org/10.1007/s10006-019-00746-5 Prechel U, Ottl P, Ahlers OM, Neff A. The Treatment of Temporomandibular Joint Dislocation. Dtsch Arztebl Int. 2018;115(5):59-64. https://doi.org/10.3238/arztebl.2018.0059 Agbara R, Fomete B, Obiadazie AC, Idehen K, Okeke U. Temporomandibular joint dislocation: experiences from Zaria, Nigeria. J Korean Assoc Oral Maxillofac Surg. 2014;40(3):111-6. https://doi.org/10.5125/jkaoms.2014.40.3.111 Sang LK, Mulupi E, Akama MK, Muriithi JM, Macigo FG, Chindia ML. Temporomandibular joint dislocation in Nairobi. East Afr Med J. 2010;87(1):32-7. https://doi.org/10.4314/eamj.v87i1.59949 Sicard L, O'Hana D, Khonsari RH, Kaddour Brahim A. Bilateral Dislocation of the Temporomandibular Joint in Children. J Oral Maxillofac Surg. 2018;76(11):2307-15. https://doi.org/10.1016/j.joms.2018.04.004 Gray AR, Barker GR. Idiopathic blepharospasm-oromandibular dystonia syndrome (Meige's syndrome) presenting as chronic temporomandibular joint dislocation. Br J Oral Maxillofac Surg. 1991;29(2):97-9. https://doi.org/10.1016/0266-4356(91)90090-r Whyte A, Boeddinghaus R, Bartley A, Vijeyaendra R. Imaging of the temporomandibular joint. Clin Radiol. 2021;76(1):76.e21-76.e35. https://doi.org/10.1016/j.crad.2020.06.020 Sharma NK, Singh AK, Pandey A, Verma V, Singh S. Temporomandibular joint dislocation. Natl J Maxillofac Surg. 2015;6(1):16-20. https://doi.org/10.4103/0975-5950.168212 Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015;27(1):109-24. https://doi.org/10.1016/j.coms.2014.09.008 de Almeida VL, Vitorino Nde S, Nascimento AL, da Silva Júnior DC, de Freitas PH. Stability of treatments for recurrent temporomandibular joint luxation: a systematic review. Int J Oral Maxillofac Surg. 2016;45(3):304-7. https://doi.org/10.1016/j.ijom.2015.10.022 Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables14.xlsx Cite Share Download PDF Status: Published Journal Publication published 29 Apr, 2023 Read the published version in Clinical Oral Investigations → Version 1 posted Editorial decision: Major revision 07 Mar, 2023 Reviews received at journal 28 Feb, 2023 Reviewers agreed at journal 28 Feb, 2023 Reviewers invited by journal 28 Feb, 2023 Submission checks completed at journal 24 May, 2022 Editor assigned by journal 24 May, 2022 First submitted to journal 21 May, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1679642","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":108544089,"identity":"07bda413-ff79-4400-96cc-01c39273dec1","order_by":0,"name":"Reetta Tarhio","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIie3PsUoDMRzH8V+WuJzN+g9I7xVydHDpw/QWJxHHDqUGhHQR5ysVn0GXzgmB63L1CRwqQlevi5OI12vXlBsd8l0Cf/4fkgCx2P8ugcXYogemmVYQPLzKtAXoQCoLfiTSdCFgZk/2I0DqwP7l7H71WU8wFYu1s7vn9z4X3nwUt6BegFxUZa5tCaK3m5GbL7cDTvkse1Gg0F+IrjNtefOwKlH+fOlzQ8zIjcI0SNKvnba/zdmSJ39nhGvJiVsSpp0BqZZoP+LIjTz5sOQqK9aPJF8b4orSZ4YaUigKkzO/qcffQ9GvkkFdT3wqxGorH36GlOqAOcoOk1gsFot17w8pXVk3aCXK+QAAAABJRU5ErkJggg==","orcid":"","institution":"University of Helsinki and Helsinki University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Reetta","middleName":"","lastName":"Tarhio","suffix":""},{"id":108544091,"identity":"dba28105-3019-4397-8047-6627207a503a","order_by":1,"name":"Miika Toivari","email":"","orcid":"","institution":"South Carelia Central Hospital, University of Helsinki","correspondingAuthor":false,"prefix":"","firstName":"Miika","middleName":"","lastName":"Toivari","suffix":""},{"id":108544093,"identity":"2b000dd0-d7a1-47e5-a67c-1a11be49003a","order_by":2,"name":"Johanna Snäll","email":"","orcid":"","institution":"University of Helsinki and Helsinki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Johanna","middleName":"","lastName":"Snäll","suffix":""},{"id":108544094,"identity":"38348088-6740-446c-836c-e52d6199453a","order_by":3,"name":"Johanna Uittamo","email":"","orcid":"","institution":"University of Helsinki and Helsinki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Johanna","middleName":"","lastName":"Uittamo","suffix":""}],"badges":[],"createdAt":"2022-05-21 12:29:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1679642/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1679642/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00784-023-05024-z","type":"published","date":"2023-04-29T20:38:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44727053,"identity":"e6dc5fdc-a56c-4ea6-a791-094b37ec5022","added_by":"auto","created_at":"2023-10-16 20:51:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":212011,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1679642/v1/fc1c084b-98b6-4d18-95ab-cb1d2496574a.pdf"},{"id":21928129,"identity":"93c1c026-4013-4251-a19c-e31ff402c61e","added_by":"auto","created_at":"2022-05-26 16:09:42","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19956,"visible":true,"origin":"","legend":"","description":"","filename":"Tables14.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-1679642/v1/64ed089c3b3d46282d58e0a2.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Causes and treatment of temporomandibular luxation – a retrospective analysis of 260 patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLuxation of the temporomandibular joint (TMJ) may occur if mandibular condyle dislocation takes place anteriorly over the articular tuberculum of the temporal bone [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The simultaneous masticatory muscle spasm blocks the relocation of the condyle behind the articular eminence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The condition is often acute and may cause pain or at least discomfort because the normal position of the lower jaw has changed.\u003c/p\u003e \u003cp\u003eThorough anamnesis and clinical examination are essential for setting the right diagnosis. Radiology can also be useful to ensure diagnosis. Jaw deviation, inability to close the mouth, and a non-palpable condyle on the posterior side of the articular eminence of temporal bone can indicate TMJ luxation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In bilateral luxation, there is no deviation, however, the mandible is in a prognathic position [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eAlthough TMJ luxation is a rare condition relative to joint luxations of other parts of the body and its frequency in the emergency department is only 5.3 cases per year [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], for some patients the condition is recurrent. Significant predisposing factors have not been found [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], although neurological conditions and changes in connective tissue as in TMJ joint capsule have been reported to be related particularly to recurrent TMJ luxation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTreatment of luxation is manual reduction at the emergency stage [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For patients with recurrent TMJ luxation, the acute repositioning of TMJ can only be considered a temporary treatment and needs to be followed by preventive measures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Preventive treatments include non-surgical approaches such as intermaxillary fixation or injection of botulinum toxin into jaw muscles or the TMJ [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Surgical methods aim to reform the mandibular condyle, the articular eminence [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study investigated the etiology, diagnostics, and treatment of TMJ luxation and particularly the aetiological factors leading to recurrent TMJ luxation, as there is a lack of known predictive factors. The hypotheses were that luxation is predominantly spontaneous, surgical intervention is infrequently considered, and recurrent luxation is more common in the elderly.\u003c/p\u003e"},{"header":"Patients And Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA retrospective cohort study at a tertiary trauma centre\u0026rsquo;s oral and maxillofacial surgery emergency unit (T\u0026ouml;\u0026ouml;l\u0026ouml; Hospital Emergency Department, Helsinki University Hospital (HUH), Finland) over a 14-year period from 1 January 2007 to 20 October 2020 was conducted. The oral and maxillofacial emergency service is provided by the Department of Oral and Maxillofacial Surgery, HUH, which has a catchment area of more than 1.6 million inhabitants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients with the following ICD diagnoses were identified from an electronic patient management system: 1) S03.4: sprain and strain of the jaw, 2) S03.0: dislocation of the jaw, 3) S03.5: sprain and strain of the joints and ligaments of other and unspecified parts of the head, 4) K07.62: recurrent TMJ dislocation, and 5) K07.69: unspecific TMJ dysfunction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy variables\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary outcome was type of TMJ luxation (i.e., recurrent or non-recurrent), and secondary outcomes were need for and type of surgical intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary predictor variables comprised age, sex, presence of neurological condition, and mechanism of luxation, which was classified as follows: 1) spontaneous, 2) yawning, vomiting, or eating, 3) dentist visit or gastroscopy, 4) injury, 5) medical seizure, and 6) habit or exercise.\u003c/p\u003e\n\u003cp\u003eOther variables registered were other general condition(s), regular medication used, type of living conditions, and referral unit. Related to TMJ luxation, we recorded clinical parameters, radiographic interventions, need for manual reduction, and aftercare instructions. Mortality during the study period was also recorded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTMJ luxation was defined as recurrent if the condition had occurred at least twice in the lifetime.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDescriptive statistics analyses were conducted. Chi-square test was used to evaluate\u0026nbsp;statistical significance between variables, and 2x2 table for risk-ratio calculation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe internal review board of the Head and Neck Center of HUH (Helsinki, Finland) approved the study. Patient consent was not required due to the retrospective nature of the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe electronic patient record search produced a sample of 800 patients whose medical records were manually re-evaluated. Excluded were patients with any other clinical condition than TMJ dislocation, resulting in the inclusion of 260 patients with confirmed TMJ dislocation.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;1 presents the descriptive statistics of 260 patients with TMJ luxation. The incidence was slightly higher (58.1%) among women, and the average age of patients was 51.4 years. The two most common causes by far were spontaneous luxation (40.0%) and yawning, vomiting, or eating (36.2%). Of all luxations, 61.9% were recurrent. Neurological (31.2%) and cardiovascular (27.3%) conditions were the most common general illnesses, and the rate of mortality during the study period was 28.1% in the entire population.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;2 presents status, radiography, and intervention under primary evaluation for TMJ patients. Of cases, 57.3% were bilateral. Manual reduction was needed for 91.9% of patients and was successful for 69.2% without any medication. Intravenous relaxants and sedation were the most common medications required. Surgical treatment was planned for 15 patients but was cancelled for patients` anaesthesiologic contraindications for general anaesthesia, and five patients perished before the planned surgery. Eminectomy was carried out for five patients (1.9%).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;3 presents the comparison of 99 patients with non-recurrent TMJ luxation and 161 patients with reported or clinically confirmed recurrent TMJ luxation under primary evaluation. Patients aged at least 65 years were more common among the recurrent (63.6%) than non-recurrent (36.4%) group, although the difference was not significant. By contrast, the difference in relation to cause of luxation between the groups was significant (\u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.003). Spontaneous luxation was by far more common among the recurrent group (71.2%), whereas injury caused the luxation among non-recurrent patients (81.3%). Dental panoramic radiograph was the predominant radiological intervention for both the recurrent (50.9%) and non-recurrent (49.1%) group, however, for patients in these groups radiological diagnostic tool was only used in 51.8% and 48.2%, respectively (\u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.019). Altogether 68.5% of recurrent and 31.5% of non-recurrent patients perished during the study period (\u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.173).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;4 shows the comparison of 99 patients with non-recurrent and 67 patients with recurrent re-admittance needing TMJ luxation. Spontaneous luxation was significantly more common in the recurrent (60.0%) than the non-recurrent group (40.0%), whereas dentist visit (100.0%), gastroscopy (100.0%), or injury-related luxation (100.0%) occurred solely in patients with non-recurrent luxation (\u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.001). Radiographic diagnostics was significantly more often done for non-recurrent luxation patients than for recurrent patients (87.1% and 12.8%, respectively, \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.001). Dental panoramic radiograph was the most common type of imaging. Surgical treatment was considered more often with recurrent luxation patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The rate of mortality within the study period was significantly higher among recurrent (55.8%) than non-recurrent (44.2%) patients (p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;5 presents the risk ratio in a 2x2 table between the presence of neurological condition, geriatric age, female sex, mortality, and recurrence of TMJ luxation. Neurological condition caused a 2.28-fold and geriatric age a 1.57-fold risk for luxation to recur, the difference being significant (\u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.001 and \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.016, respectively). Notable was also the higher risk for mortality in general (RR 1.67, \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.006) and within 12 months of primary contact (RR 1.52, \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.046) in the recurrent luxation group compared with the non-recurrent group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the aetiology, diagnostics, and treatment of TMJ luxation and particularly the aetiological factors leading to recurrent TMJ luxation, as there is a lack of known predictive factors. Our hypotheses were confirmed. Luxations were most often spontaneous, surgical intervention was infrequently considered, and recurrent luxation was more common among elderly patients.\u003c/p\u003e \u003cp\u003eOur results showed that TMJ luxation is typically bilateral and recurrent. Recurrent TMJ luxation is often associated with neurological and cardiovascular conditions. Also, recurrent TMJ luxation can also be used as a factor to predict death when the interval between luxations becomes shorter.\u003c/p\u003e \u003cp\u003eThe average age of the patients was 51.4 years and over half were women. Patients with recurrent TMJ luxation were older than those with non-recurrent TMJ luxation. Other studies have found that mean age of TMJ luxation patients was around 40 years [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. TMJ luxation was rare in children and adolescents in our data, and most TMJ luxations in children have been shown to be caused by trauma [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTypically, TMJ luxation was spontaneous. Yawning, vomiting, and eating were common mechanisms of TMJ luxation. Yawning and other spontaneous events have been mentioned as a common cause in other studies as well [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Differences exist in the prevalence of trauma in TMJ luxation. The incidence of TMJ luxation caused by an injury in present study was 6.2% corresponding to the rate of previous studies which has varied from 20% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] or as high as 60% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These differences could be explained by where the study was conducted and the definition used for trauma. We showed that patients with neurological and cardiovascular conditions were at higher risk for TMJ luxation. For example, changes in musculartonus in neurological conditions could increase the recurrence of TMJ luxation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Also, epilepsy, connective tissue disorders [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and oromandibular dystonia [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] have been described to be risk factors for TMJ luxations. As the present study shows, neurological conditions are important background diseases. Therefore, close co-operation with the neurological and geriatric departments is important when planning individual treatments, particularly in view of our finding that recurrence of TMJ luxation is a predictor for death.\u003c/p\u003e \u003cp\u003eThe most common clinical findings in TMJ luxation were jaw deviation, pain, and inability to close the mouth. Radiography was not often used as a diagnostic method because the diagnosis could be confirmed based on the clinical findings alone. The question then arises of whether differential diagnoses have been sufficiently excluded, i.e., fractures of the mandibula or mandibular condyle. The radiographic method used under primary evaluation was panorama tomography, and it was completed in 21% of cases. This is in accord with previous findings stating that imaging is rarely needed in the acute situation, but when performed it demonstrates the condyle\u0026rsquo;s anterior position in relation to the articular eminence [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Radiography has been shown to be useful in patients for differential diagnoses or to provide information for further treatment planning [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In addition, imaging is recommended in trauma cases since it is important to differentiate fractures from luxation.\u003c/p\u003e \u003cp\u003eManual reduction of TMJ luxation was usually possible without medication. However, when medication was needed the most common choice was intravenous sedation. General anaesthesia or local anaesthetic injections to the TMJ were rarely used. Local anaesthesia has been proposed for use when performing manual reduction since the condition is very painful [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The success rate of manual reduction is high when it is carried out immediately after the luxation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. One reason why TMJ luxation patients are taken to the emergency room could be the lack of expertise in performing the manual reduction procedure at the referring centre. Over half of the referrals came from general practitioners, who could with ease learn the procedure.\u003c/p\u003e \u003cp\u003eOverall, the treatment alternatives focused on non-surgical measures, and surgery was indicated in only a few cases. Patients eligible for surgery had recurrent TMJ luxation, which affected their quality of life. It has also been shown that complications are rare in surgical treatment of TMJ. If complications occur, they are usually infections or damage to adjacent structures. Generally, in TMJ surgery arthroscopy is considered to minimize complications compared with open surgery, which is often the choice in surgical treatment of TMJ luxation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. One systematic review of the treatment options for recurrent TMJ luxation summarized that there is no good-quality evidence on which treatments lead to long-term elimination of recurrent luxation. The options included, for example, eminectomy, miniplanting of the articular eminence, and down-fracture of the zygomatic arch. The authors noted that surgeons empirically consider eminectomy as the `gold standard`[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It is noteworthy that these data cover patients from one clinic during a certain period, and it is likely that some patients previously received treatment for TMJ luxation at another clinic or hospital. Thus, the number of recurrent TMJ luxation patients might be even higher.\u003c/p\u003e \u003cp\u003eA strength of our study was the large size of the patient population, as the previous literature has mainly been based on case-reports. The study also revealed a relationship between mortality and recurrent luxation, highlighting the importance of collaboration between specialties when considering surgical treatment. A weakness of the study is its retrospective nature; a prospective study would have provided information on prosthodontic treatment.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo summarize, we showed that TMJ luxation is often bilateral, recurrent, and more common in women. Most of the luxations are spontaneous and these are often associated with geriatric age and neurological conditions. In these patient groups, recurrent TMJ luxation can predict death.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor`s contribution \u003c/strong\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Reetta Tarhio, Miika Toivari, Johanna Uittamo and Johanna Sn\u0026auml;ll. The first draft of the manuscript was written by Reetta Tarhio and all authors commented on previous/later versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval \u003c/strong\u003eThe internal review board of the Head and Neck Center of HUH (Helsinki, Finland) approved the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent \u003c/strong\u003ePatient consent was not required due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest \u003c/strong\u003eThe authors declare that they have no conflict of interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003eThe researchers received funding from the Helsinki University Central Hospital Fund\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLiddell A, Perez DE. Temporomandibular joint dislocation. Oral Maxillofac Surg Clin North Am. 2015;27(1):125-36. https://doi.org/10.1016/j.coms.2014.09.009\u003c/li\u003e\n\u003cli\u003eAbrahamsson H, Eriksson L, Abrahamsson P, H\u0026auml;ggman-Henrikson B. Treatment of temporomandibular joint luxation: a systematic literature review. Clin Oral Investig. 2020;24(1):61-70. https://doi.org/10.1007/s00784-019-03126-1\u003c/li\u003e\n\u003cli\u003eHillam J, Isom B. Mandible Dislocation. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright \u0026copy; 2022, StatPearls Publishing LLC.; 2022.\u003c/li\u003e\n\u003cli\u003eAkinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med. 2011;7:10. https://doi.org/10.1186/1746-160X-7-10\u003c/li\u003e\n\u003cli\u003eLowery LE, Beeson MS, Lum KK. The wrist pivot method, a novel technique for temporomandibular joint reduction. J Emerg Med. 2004;27(2):167-70. https://doi.org/10.1016/j.jemermed.2004.03.007\u003c/li\u003e\n\u003cli\u003eTocaciu S, McCullough MJ, Dimitroulis G. Surgical management of recurrent TMJ dislocation-a systematic review. Oral Maxillofac Surg. 2019;23(1):35-45. https://doi.org/10.1007/s10006-019-00746-5\u003c/li\u003e\n\u003cli\u003ePrechel U, Ottl P, Ahlers OM, Neff A. The Treatment of Temporomandibular Joint Dislocation. Dtsch Arztebl Int. 2018;115(5):59-64. https://doi.org/10.3238/arztebl.2018.0059\u003c/li\u003e\n\u003cli\u003eAgbara R, Fomete B, Obiadazie AC, Idehen K, Okeke U. Temporomandibular joint dislocation: experiences from Zaria, Nigeria. J Korean Assoc Oral Maxillofac Surg. 2014;40(3):111-6. https://doi.org/10.5125/jkaoms.2014.40.3.111\u003c/li\u003e\n\u003cli\u003eSang LK, Mulupi E, Akama MK, Muriithi JM, Macigo FG, Chindia ML. Temporomandibular joint dislocation in Nairobi. East Afr Med J. 2010;87(1):32-7. https://doi.org/10.4314/eamj.v87i1.59949\u003c/li\u003e\n\u003cli\u003eSicard L, O'Hana D, Khonsari RH, Kaddour Brahim A. Bilateral Dislocation of the Temporomandibular Joint in Children. J Oral Maxillofac Surg. 2018;76(11):2307-15. https://doi.org/10.1016/j.joms.2018.04.004\u003c/li\u003e\n\u003cli\u003eGray AR, Barker GR. Idiopathic blepharospasm-oromandibular dystonia syndrome (Meige's syndrome) presenting as chronic temporomandibular joint dislocation. Br J Oral Maxillofac Surg. 1991;29(2):97-9. https://doi.org/10.1016/0266-4356(91)90090-r\u003c/li\u003e\n\u003cli\u003eWhyte A, Boeddinghaus R, Bartley A, Vijeyaendra R. Imaging of the temporomandibular joint. Clin Radiol. 2021;76(1):76.e21-76.e35. https://doi.org/10.1016/j.crad.2020.06.020\u003c/li\u003e\n\u003cli\u003eSharma NK, Singh AK, Pandey A, Verma V, Singh S. Temporomandibular joint dislocation. Natl J Maxillofac Surg. 2015;6(1):16-20. https://doi.org/10.4103/0975-5950.168212\u003c/li\u003e\n\u003cli\u003eHoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015;27(1):109-24. https://doi.org/10.1016/j.coms.2014.09.008\u003c/li\u003e\n\u003cli\u003ede Almeida VL, Vitorino Nde S, Nascimento AL, da Silva J\u0026uacute;nior DC, de Freitas PH. Stability of treatments for recurrent temporomandibular joint luxation: a systematic review. Int J Oral Maxillofac Surg. 2016;45(3):304-7. https://doi.org/10.1016/j.ijom.2015.10.022\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"temporomandibular luxation, neurological condition, geriatric age, oral and maxillofacial surgery","lastPublishedDoi":"10.21203/rs.3.rs-1679642/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1679642/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjectives\u003c/p\u003e\u003cp\u003eWe aimed to clarify the aetiology, 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.\u003c/p\u003e\u003cp\u003ePatients and materials\u003c/p\u003e\u003cp\u003eA 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.\u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eOf luxation, 61.9% was recurrent and 60.0% due to spontaneous cause. The presence of neurological condition caused a 2.28-fold risk for recurrence of luxation. Only 1.9% of patients underwent surgical intervention. The risk ratio for mortality within 12 months of primary contact was 1.52-fold higher in recurrent luxation patients than in non-recurrent cases.\u003c/p\u003e\u003cp\u003eConclusions\u003c/p\u003e\u003cp\u003eTMJ 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.\u003c/p\u003e\u003cp\u003eClinical relevance\u003c/p\u003e\u003cp\u003eOur 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.\u003c/p\u003e","manuscriptTitle":"Causes and treatment of temporomandibular luxation – a retrospective analysis of 260 patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-26 16:09:40","doi":"10.21203/rs.3.rs-1679642/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-03-07T10:46:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-02-28T15:23:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cf65f41b-0c15-4ac3-a5f1-15c49b24503a","date":"2023-02-28T13:46:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-02-28T13:40:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-24T21:39:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-24T21:39:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Clinical Oral Investigations","date":"2022-05-21T12:16:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"df1e3586-b27f-4f5c-8395-c85f51432465","owner":[],"postedDate":"May 26th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:43:52+00:00","versionOfRecord":{"articleIdentity":"rs-1679642","link":"https://doi.org/10.1007/s00784-023-05024-z","journal":{"identity":"clinical-oral-investigations","isVorOnly":false,"title":"Clinical Oral Investigations"},"publishedOn":"2023-04-29 20:38:07","publishedOnDateReadable":"April 29th, 2023"},"versionCreatedAt":"2022-05-26 16:09:40","video":"","vorDoi":"10.1007/s00784-023-05024-z","vorDoiUrl":"https://doi.org/10.1007/s00784-023-05024-z","workflowStages":[]},"version":"v1","identity":"rs-1679642","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1679642","identity":"rs-1679642","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}