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Management of long-standing temporomandibular joint dislocation: case series

Elmorsy, Khairy A.

Egyptian Journal of Oral & Maxillofacial Surgery: May 2014 - Volume 5 - Issue 2 - p 39–44
doi: 10.1097/01.OMX.0000444062.94444.fd
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Background Acute mandibular dislocation is a very painful condition that causes severe functional limitations. Manual reduction, with or without pharmacological assistance, is the treatment of choice and should be performed as early as possible. In rare situations, mandibular dislocation may not be perceived by the patient and remains undiagnosed or misdiagnosed for a long period, which develops a long-standing condition. Morphological changes of the joint and associated structures will prevent successful manual reduction even with the patient under general anesthesia. This article aimed to share the author’s experience in management of two unique cases of protracted mandibular dislocation.

Patients and methods The present article reported two patients who have long-standing temporomandibular joint dislocation due to trauma, which could not be treated conservatively and must be treated surgically. One patient had a very long-standing dislocation for 14 years, which was treated by bilateral sagittal split osteotomy, and the other one had a unilateral protracted temporomandibular joint dislocation for 6 months, which was treated with condylotomy and condylar refixation in place after returning her occlusion back to its normal position.

Results After 1-year follow-up, both patients were doing well from functional and esthetic points of view, with complete satisfaction with the treatment they received.

Conclusion The cases of long-standing dislocation need to be defined according to the time and cause of dislocation, and more opinions are required to form practicable guidelines for management of each case individually.

Department of Oral and Maxillofacial Surgery, Cairo University, Cairo, Egypt

Correspondence to Khairy A. Elmorsy, PhD, Department of Oral and Maxillofacial Surgery, Cairo University, 11553 Cairo, Egypt Tel: +20100 661 1113; e-mail: khairy.elmorsy@dentistry.cu.edu.eg

Received November 20, 2013

Accepted December 17, 2013

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Introduction

Mandibular dislocation is defined as a nonreducing displacement of the mandibular condyle in front of and superior to the articular eminence, resulting in inability to close the mouth 1. Long-standing dislocation or protracted dislocation is rare, and is defined as dislocation not reduced immediately and has persisted for more than 1 month 2. The management of this rare entity ranges widely, from closed reduction to complicated surgical procedures, depending on the duration of the dislocation. The selection of a proper procedure is controversial 3.

Rowe and William’s 4 described the use of a bone hook passed over the sigmoid notch, by a small incision below the angle and a subperiosteal tunnel, so as to exert a downward traction on the condyle. Lewis 5 described the use of a Bristow’s elevator through the temporal fascia in the same manner that is used for the Gillies approach of elevation of the depressed zygomatic bone or arch. The tip of the elevator is directed posteriorly to contact the anterior aspect of the dislocated condyle, and strong force is then exerted in a downward and posterior direction. El-Attar and Ord 6 reduced old bilateral dislocation by traction hooks inserted into bur holes in the angle of the mandible. Terakado et al. 7 described a conservative treatment for chronic mandibular dislocation with the help of intermaxillary fixation screws and elastic traction. Botulinum toxin injection along with intermaxillary fixation screws has been reported successful in reduction of chronic dislocation, especially in neuromuscular disorders that cause dislocation of the mandible 8.

With passage of time, additional muscle spasm and fibrotic changes occur in the ligaments and muscles, increasing the severity of the problem; hence, the difficulty in reducing the joint increases proportionately with time 9. Hayward 10 stated that ‘the longer the mandible remains dislocated, the more difficulties there are in the management of the condition’ because of more severe muscle spasm and fibrotic periarticular changes. Wijmega et al.11 found 37 patients in the literature of the previous three decades, and concluded that a wide variety of methods of treatment have been reported without the question as to which method is the most efficient being answered.

There are many surgical methods for the management of prolonged dislocation of the temporomandibular joint (TMJ), such as surgical closed reduction (traction procedure) 3, mandibular swing procedure by median mandibulotomy 12, condylotomy 13, condylectomy 14, inverted L-shaped osteotomy 15, oblique bilateral osteotomy 2, and eminectomy 16. These techniques achieve better results than do the conservative methods, which have a propensity to fail for many reasons 12, including masticatory muscle spasm, shortening and subsequent fibrosis of temporalis and pterygoid muscles, intra-articular and periarticular fibrosis, and meniscal displacement.

The aim of the present study was to briefly describe two methods for treatment of prolonged bilateral condylar dislocation: utilizing the bilateral sagittal split osteotomy procedure and refixation condylotomy for treatment of unilateral dislocation. These techniques are considered new techniques compared with the previously mentioned surgical methods of correction of TMJ dislocations.

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Patients and methods

Two female Egyptian patients with TMJ dislocation due to trauma for more than 4 months presented to the Department of oral and maxillofacial surgery, Faculty of Oral and Dental Medicine, Cairo University from 2010 to 2012. Their medical history was insignificant, and they were not under any medications. The dislocation in both cases was as follows:

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Case number 1

A 54-year old woman presented to the department complaining of severe mandibular protrusion and severe disturbance in occlusion of her teeth 14 years ago due to trauma, seeking correction of her occlusion and facial profile. She received no treatment because she was kept from seeking any kind of treatment. She started to try eating and moving her mandible and gradually adapted by time with the new articulation until some contact of remaining posterior teeth occurred; particularly, her molars were not in occlusion.

Clinical examination showed the following.

  • Preauricular depression anterior to the tragus of the ear in the region of TMJ fossa on both sides.
  • No tenderness or pain was noticed on any side in the temporal or in the TMJ regions.
  • Mandibular protrusion with little anterior open bite and incompetent lips (Fig. 1).
  • She could open and close her mouth almost normally without any pain; the interincisal distance on maximal mouth opening was normal (4.5 cm) (Fig. 2).
  • Anterior and posterior cross bite (class III occlusion) (Fig. 3).
Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Orthopantogram (Fig. 4) revealed class III bilateral anterior and superior displacement of both condyles with respect to articular eminence.

Fig. 4

Fig. 4

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Surgical procedures

The patient was subjected to general anesthesia, and bilateral sagittal split osteotomy was performed to correct the mandibular protrusion and anterior open/cross bite (Fig. 5). After surgery, the osteomatized bone segments were fixed using four positional bicortical screws at one side and three screws on the other side to fix the bone bearing teeth in the new position. Thereafter, the jaws were immobilized with maxillomandibular fixation (MMF) in the new occlusion for 3 weeks. Little spot grinding was performed after removal of MMF for getting maximum teeth contact.

Fig. 5

Fig. 5

The patient was then followed up postoperatively at 3, 6, and 12 months; the patient was symptom-free with good profile (Fig. 6) and normal mouth opening (Fig. 7).

Fig. 6

Fig. 6

Fig. 7

Fig. 7

Postoperative orthopantogram showed good bone healing (Fig. 8), and lateral cephalometric radiograph showed acceptable maxillomandibular relationship (Fig. 9).

Fig. 8

Fig. 8

Fig. 9

Fig. 9

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Case 2

A 37-year old female patient presented to the department suffering from pain related to left TMJ since 6 months following trauma, and she was admitted to the ICU for a long time and was hospitalized for more than 4 months for the management of long bones and vertebrae fractures. On clinical examination, the following was noticed.

  • Preauricular depression anterior to the tragus of the ear in the region of TMJ fossa on the left side with pain and tenderness at the region, denoting that the condyle was dislocated.
  • Anterior and posterior open bite with mandibular shift to the right side (Fig. 10).
  • She could not open or close her mouth normally (Fig. 11).
Fig. 10

Fig. 10

Fig. 11

Fig. 11

TMJ tomogram showed dislocation of the left condyle anteriorly in front of and superior to the articular emenence (Fig. 12).

Fig. 12

Fig. 12

Under general anesthesia, reduction of the condyle was tried conservatively before and after opening the joint but failed. Thereafter, condylotomy – reduction of the jaw and refixation of the condylar process in place using two miniplates, one at the anterior border and the other one at the lateral border of the condyle – was performed (Figs 13 and 14).

Fig. 13

Fig. 13

Fig. 14

Fig. 14

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Results

The patient was then followed up at 3, 6, and 12 months postoperatively; the patient was symptom-free, with good occlusion (Fig. 15) and normal mouth opening (Fig. 16).

Fig. 15

Fig. 15

Fig. 16

Fig. 16

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Discussion

However, the goal of treatment of any TMJ dislocation is the return of the condyle back to its original anatomical position, and manual reduction maneuvers are usually attempted before any surgical procedures, either under local or general anesthesia. These trials were not a logical approach in the first patient of this study because of severe fibrosis. This fibrosis occurred because of long-standing dislocation, particularly in such cases because of trauma. Many authors concluded that, if the dislocation occurred long time ago, reduction can be complicated considerably by intensified muscles, tendons tension, or scar formation in and around the region of the condyle or glenoid fossa 9,10.

Sagittal split osteotomy used in case 1 is a simple and easy procedure in comparison with other surgical procedures suitable for treatment of such cases, which are performed away from the temporomandibular joint area with the possibility of nerve damage and scar formation, especially in this case as the patient can open and close her mouth normally without any pain or limitations of jaw movement. This method can correct the occlusion and the face profile without opening the joint.

Of course this technique is not suitable for all cases, but it was a perfect technique for this case because a new joint was already formed, the patient could move her mandible normally without any complaints, and nonfunctioning original fossae due to absence of the condyles for that long time existed. It was not a logical approach to return the condyles back to their original fossae; hence, the case was managed using this technique.

Proper fixation is important for such case to prevent relapse because with the passage of time additional muscle spasm and fibrotic changes occur in the muscles, especially in dentulous patients. Three screws to fix the osteotomy, which is used routinely in regular sagittal split osteotomy, did not seem enough to maintain the moved bones in place against the muscle pull. The author suggests keeping MMF for 3 weeks after new occlusion is regained.

In case 2, however, it seemed very logic to try to return the condyle back safely, either under local or general anesthesia first, according to Chin et al.’s 17 recommendations for TMJ dislocation management. We could not return the dislocated condyle back to the glenoid fossa, probably because of severe fibrosis that occurred due to internal bleeding in and around the joint associated with bleeding due to trauma. Of course resistance for reduction of the condyle in this situation is different from the cases of dislocation that occurred because of gradual lengthening of TMJ capsule and ligaments. Hence, condylotomy allowed us to return the jaw back to the normal position and to solve the problems as some authors recommended in similar cases 14. Thereafter, the decision to refix the condyle back in place was taken after jaw reduction and MMF. This new modality of treating TMJ dislocation was proved to be successful as measured by stable long-term follow-up; particularly, this was the first dislocation incidence for her.

After reviewing different types of dislocations and their duration, we can conclude that the cause and duration of long-standing dislocation needs to be defined, and more case reports and opinions are required to form practical guidelines for management of each case in the future.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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