|Year : 2017 | Volume
| Issue : 2 | Page : 112-116
Long-standing temporomandibular joint dislocation: A rare experience
Kapil Malik, Subhas C Debnath, Apurba K Adhyapok, Kriti Hazarika
Department of Oral and Maxillofacial Surgery, Regional Dental College, Guwahati, Assam, India
|Date of Web Publication||25-Jul-2017|
Department of Oral and Maxillofacial Surgery, Regional Dental College, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
Long-standing temporomandibular joint (TMJ) dislocations persist for more than a month are most challenging to treat. The management of such condition varies widely, from closed reduction to complicated surgical procedures. The choice of an appropriate methodology is questionable. At present, there are no standard rules or conventions for the ideal strategy in different circumstances. This paper attempts to present the experience of managing two cases of long-standing TMJ dislocations.
Keywords: Condyle, dislocation, long-standing, management, temporomandibular joint
|How to cite this article:|
Malik K, Debnath SC, Adhyapok AK, Hazarika K. Long-standing temporomandibular joint dislocation: A rare experience. Saudi J Oral Sci 2017;4:112-6
|How to cite this URL:|
Malik K, Debnath SC, Adhyapok AK, Hazarika K. Long-standing temporomandibular joint dislocation: A rare experience. Saudi J Oral Sci [serial online] 2017 [cited 2020 Jul 13];4:112-6. Available from: http://www.saudijos.org/text.asp?2017/4/2/112/211571
| Introduction|| |
A true dislocation of the temporomandibular joint (TMJ) is an abnormal condition, in which the condyle is displaced from the glenoid fossa and requires manipulation to return to its normal position.
TMJ dislocations can be further subclassified into acute, chronic recurrent, chronic persistent, or long-standing dislocations. Untreated cases of acute TMJ dislocation, if persisting for more than a month, are classified as long-standing or persistent and are uncommon.
Long-standing dislocations are further subclassified as reducible and irreducible depending on their response to reduction techniques. TMJ dislocations occur frequently as a consequence of protracted dental procedures, blows or injury to the mandible, bronchoscopy, and anesthesia procedures. Apart from these, various muscular disorders, such as oromandibular dystonia, or some psychiatric conditions  can induce TMJ dislocations. Late presentation for dislocation treatment may be due to ignorance, improper medical service provided, financial restrictions, far distance from a specialized healthcare facility among others. Delays in treatment lead to muscular spasm and fibrosis in and around the TMJ, with resultant more difficult reduction of the dislocation. Due to the rarity of these conditions, surgeons may have limited experience in their management. Definitive guidelines regarding management are also lacking in the literature.
The purpose of this paper is to present the experience in managing two cases of long-standing TMJ dislocations.
| Case Report|| |
Patient number 1
A 50-year-old female presented to the Department of Oral and Maxillofacial Surgery, Regional Dental College and Hospital, Guwahati, with an inability to close her mouth for the past 5 months. The patient was unable to close her mouth after a yawn. The patient did not report to a health facility due to financial restraints and distance from a specialized health-care facility. On presentation, she had lower fixed prosthetic restoration. She complained of difficulty in swallowing and speech as well as forwarded chin.
Clinical examination showed downward and forward displacement of the chin [Figure 1] with bilateral hollowness on preauricular regions anterior to the tragus. The patient could open and close her mouth, with a maximum interincisal opening of 15 mm. The mandible was found to be in prognathic relationship to the maxilla, with the presence of anterior open bite [Figure 2]. Tenderness to palpation in the preauricular region was noted. Orthopantomogram showed bilateral anterior dislocation of condyles in front of the articular eminences [Figure 3]. The diagnosis of bilateral TMJ dislocation was made, and manual reduction was attempted after injecting 2% lignocaine into the glenoid fossa bilaterally. Manipulation was attempted without success. Since the bilateral new joint formation had produced satisfactory functional movement in the joints or formation of pseudojoint, interference with the existing articulation was not considered advisable.
|Figure 1: Preoperative clinical photographs showing elongated face with open bite|
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|Figure 3: Orthopantomogram of the patient showing bilateral anteriorly dislocated condyle|
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Under anesthesia, manual reduction was tried first without success, followed by transosseous wire traction technique at the angle of the mandible. This procedure also failed to reduce the mandibular condyles. Thereby, inverted “L” osteotomy was performed bilaterally [Figure 4] through submandibular incisions, and mandible was repositioned with incisal overbite. Proximal segments were placed lateral and fixed with self-tapping screws. Intermaxillary fixation (IMF) was done and kept for 4 weeks. Occlusion achieved was satisfactory. The postoperative course was uneventful [Figure 5], and no evidence of recurrence was noted in 1-year follow-up. The patient could masticate and swallow.
|Figure 4: Intraoperative photograph showing inverted “L” ramus osteotomy|
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|Figure 5: Postoperative orthopantomogram showing bilateral osteotomy fixed with screws|
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Patient number 2
A 34-year-old male patient to the Department of Oral and Maxillofacial Surgery, Regional Dental College and Hospital, Guwahati, with psychiatric illness reported with inability to close mouth for 4 months. The patient was hospitalized in a psychiatric ward, and 4 months back, he shouted with his mouth wide open, followed by inability to close his mouth. The patient was unaware of his condition, and after being discharged from the medical hospital, he was referred to the Oral and Maxillofacial Surgery Department for management. On presentation, the patient's mouth was found open and the mandible was anteriorly displaced [Figure 6]. Depressions anterior to the tragus were visible bilaterally, and the condyles were fixed and palpable in front of the ears. Intraoral findings included anterior displacement of the lower jaw and anterior open bite [Figure 7] with an interincisal distance of 15 mm. Anterior displacement of both condyles was seen on the panoramic radiograph [Figure 8]. According to the findings from the history and physical examination, a diagnosis of irreducible long-standing condylar dislocation was established. Under general anesthesia, manual reduction and transosseous wire traction were attempted. These procedures failed to bring the condyles into their appropriate position. Therefore, bilateral vertical osteotomies [Figure 9] and [Figure 10] were carried out, and the mandible was guided to the normal occlusion. IMF was applied. Proximal and distal segments were fixed with two-hole miniplate and screws. The occlusion achieved was satisfactory [Figure 11]. The postoperative course was uneventful, and no evidence of recurrence was noted for 8 months.
|Figure 6: Preoperative clinical photographs showing elongated face with open bite|
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|Figure 8: Orthopantomogram of the patient showing bilateral anteriorly dislocated condyle|
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|Figure 9: Intraoperative photograph showing vertical ramus osteotomy (right side) fixed with miniplate|
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|Figure 11: Intraoperative occlusion achieved with intermaxillary fixation|
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| Discussion|| |
TMJ dislocation diagnoses can be easily made from the symptoms, signs, and typical clinical appearance. Patient's history should be taken to rule out drug-induced, muscular, psychiatric, or chronic recurrent dislocations. The role of the attending clinician is of utmost importance in early identification and management of the condition, to reduce the morbidity and complications associated with long-standing dislocations. Delays in treatment can lead to spasm of the masticatory muscles as well as fibrosis and scarring of the retro- and peri-discal tissue associated with intra- and extra-articular hemorrhage in posttraumatic cases.
Mandibular osteotomy can be considered as an alternative treatment to correct facial contour when a kind of articulation of the dislocated condyle is formed which permits a certain degree of jaw movement, after a nonreducible long-standing dislocation of the TMJ. In all these procedures, a new formed joint of the condyle (nearthrosis/pseudojoint) in its anterior position allows sufficient degree of jaw movement. Moreover, attempts for repositioning the condylar head to a posterosuperior location are not always possible because of fibrosis and scar formation in the joint capsule between the disk, condyle, and articular eminence.
The attending surgeon should treat the patient in a stepwise manner, starting with a minimally invasive conservative technique and progressing to a more invasive surgical procedure. Manual reduction under local anesthesia was first advocated by Johnson (1958). Local anesthesia is required to overcome muscle spasm produced by soft tissue damage associated with dislocation and reflexes during the actual reduction of the dislocation. Manual reduction under general anesthesia and muscle relaxants should be tried once the manipulation under local anesthesia has failed. Hayward  reduced two cases 3 and 16 months after the onset of the condition, whereas Hogan and Nally  and Fordyce  were successful after 22 and 6 months, respectively. Lello  described a technique based on the principle of traction with posterior fulcrum, in which simultaneous traction with three zygomatic bone hooks inserted into the sigmoid notches and beneath the chin rotate the mandible about the mouth prop fulcrum in a closing direction.
Various proposed treatment algorithms in the literature have been mentioned. Rattan et al. (2013) emphasized that manual reduction under intra-articular local anesthesia should be tried initially. If unsuccessful, this should be followed by anterior traction with elastics (with the help of arch bars/IMF), manual reduction (under general anesthesia), indirect traction at the angle or the sigmoid notch, midline mandibulotomy, should be attempted in sequence. In case of anticipated difficulty, like in the case of long-standing or traumatic etiology, etc., the author recommended to skip indirect traction at the angle and perform midline mandibulotomy due to the amount of fibrosis in and around the joint. Direct invasive exposure of the TMJ should be the last resort and should be tried only when all other means of reduction have failed. Huang et al. (2011) proposed closed reduction for dislocations lasting for <3 weeks. Open reduction, stripping periosteum and muscles, and traction with wire or retractor under general anesthesia for dislocation lasting between 4 and 12 weeks and open reduction: condylectomy, condylotomy, myotomy, and TMJ prosthesis for dislocation lasting for more than 6 months is recommended.
In the above-mentioned case reports, ramus osteotomy seemed to be the appropriate option considering the formation of pseudojoint. Vertical ramus osteotomy can be accomplished either extra- or intra-orally. The surgical procedure is more comfortable and has less complication in comparison with other procedures using preauricular incisions for condylectomy or eminectomy. Despite the extra-glenoid position of condyles, the function of the joint is good and the relationship between the proximal and distal segments is acceptable. The inverted “L” osteotomy overcomes the lack of bone contact as in vertical ramus osteotomy. However, it requires an extraoral approach with a significant risk of damage to lower branches of the facial nerve. Vertical ramus osteotomy technique may result in the impingement of the coronoid on the condylar processes after repositioning of the mandible. Such encroachment was avoided in inverted “L” osteotomy since the relative positions of the coronoid and condylar processes were maintained.
| Conclusion|| |
On encountering long-standing TMJ dislocation, most dental surgeons try to reduce the joint using manual common Hippocratic methods that usually fail. Knowledge about the etiology, period of dislocation, changes which took place in the joint, and various nonsurgical and surgical techniques to treat such condition are important in the management of such cases. No standard treatment conventions or algorithms have been set down for the management of such dislocations in the literature. The choice of the technique used depends entirely on the surgeon.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]