Dislocation of the temporomandibular joint (TMJ) can involve 1 or both condyles and represent 3% of all reported dislocated joints in the body.1 Condylar displacement is most frequently bilateral. The condyles may be displaced anterior, posterior, medial, lateral, or superior to the glenoid fossa but anterior dislocation is the most common.2 Condyles are suddenly displaced anteriorly, beyond the articular eminence. This condition is also referred to as “open lock.”
Dislocation pathogenesis is multifactorial. Predisposing and triggering factors for condylar dislocation include, but are not limited to: extreme mouth opening (yawning, vomiting, singing), trauma, iatrogenic (dental treatments, laryngoscopy), medications with extra pyramidal effect (dystonia)3–7 (antiemetics like metoclopramide, antipsychotics, propranolol). Joint hypermobility can be seen in diseases with defects in collagen synthesis like Ehlers-Danlos and Marfan's syndrome,8 making dislocation possible. Seizure activity can result in mandibular hyperextension. Variations in anatomy like elongation of the articular eminence9,10 can make the patient more prone to perpetuation of the dislocation.
Clinically, dislocation is characterized by the inability to close the mouth after wide opening, associated with an anterior open bite and/or lateral deviation of the mandible if the dislocation is unilateral. Palpation reveals a depression in the preauricular region and sometimes a palpable condyle anterior to the joint.8 Pain can be severe.
Dislocation of the temporomandibular joint can be categorized into 3 groups: acute, recurrent, and chronic.11
Acute dislocation is the most common. It can often be reduced by downward and backward manual manipulation of the mandible.
Recurrent dislocation is relatively rare. Episodes of dislocation are more frequent and worse enough to suggest treatment. No consensus exists regarding the most effective treatment for recurrent TMJ dislocation. Many surgical treatments have been proposed over the years,11 including eminectomy, lateral pterygoid myotomy, the LeClerc (or Dautrey) procedure, augmentation of the articular eminence with a bone graft. Postoperative scarring probably provides a significant portion of the surgical benefit. Less invasive procedures have also been reported including the injection of autogenous blood or sclerosing agents, arthroscopic scarification of the retrodiscal tissues, and capsule plication. Botox injections in the lateral pterygoid have also been described for treatment of recurrent TMJ dislocation.
Long-standing (more than 1 month) chronic dislocation is rare. It is a sequela of an unrecognized acute dislocation. Most surgeons agree that the longer the dislocation persists, the more difficult the reduction of the condyles becomes.12 Progressive fibrosis resulting from this condition prevents the restoration of an appropriate anatomical condylar position. Chronic dislocation can be very challenging to treat and requires invasive surgical intervention to correct the malocclusion and restore both facial form and masticatory function.
In this report, 2 patients of chronic TMJ dislocation and 1 patient of chronic recurrent dislocation are described.
A healthy 51-year-old man was referred to the main author in December 2013. In December 2012, the patient experienced a seizure episode during which he dislocated his jaw. The condition was initially unrecognized. In February 2013, he presented to an oral and maxillofacial surgeon. Under general anesthesia, the left TMJ was reduced by manipulation but the right side remained dislocated. The patient continued to have difficulty with mouth opening and chewing. He was edentulous but not wearing dentures because of his jaw alignment distortion. The patient was taking Methadone for pain management.
Clinical examination revealed a normocephalic male with mild asymmetry and mild deviation of the chin to the left. Palpation of the muscles of mastication did not elicit pain but he had severe pain during palpation of both TMJ. His mouth opening was 25 mm (Fig. 1).
Intraoral examination revealed edentulous maxilla and mandible with adequate keratinized mucosa.
The panoramic tomography revealed a dislocated right condyle (Fig. 2).
A cone-beam computed tomography (CBCT) showed severe erosive changes with condylar destruction on the right side. The right condyle was positioned anteriorly, articulating with the inferior aspect of the articular eminence (Fig. 3). The left TMJ showed advanced signs of degenerative joint disease (DJD). A diagnosis of long-standing anterior dislocation with fibrous ankylosis on the right side and severe osteoarthritis on the left side was made.
Given the degree of pain, dysfunction, and advanced destruction of both condyles, bilateral total joint replacement (TJR) with custom fabricated TMJ alloplastic implants was recommended. The TMJ reconstruction using 3-dimensional (3D) CT imaging and computer-assisted design (Medical Modeling, Denver, CO) was used (Fig. 4). Mandibular position correction was also planned at the same time. Using a virtual model of the prosthesis, an alloplastic system composed of a metallic (Cr-Co-Mb) mandible-condylar component and a polyethylene glenoid fossa was custom manufactured for both joints (Zimmer-Biomet, Jacksonville, FL).
Custom gunning splints were virtually designed to help stabilize the edentulous mandible during surgery and correct the occlusal alignment (Fig. 5).
The surgery was carried out in March 2014 under intubated general anesthesia and induced hypotension to minimize blood loss. The mandibular ramus and both condyles were accessed via preauricular and retromandibular incisions. Figure 6 shows the anterior displaced right condyle (Fig. 6A) and the aspect of the specimen after resection (Fig. 6B).
Postoperative recovery was uneventful. Mild right temporal nerve weakness resolved within a few months. Three years after surgery, the patient was pain free with good function. His mandibular range of motion was 35 mm.
Figure 7 shows the prosthetic devices on a cephalogram and Figure 8 shows the 3 years’ postoperative clinical pictures.
A healthy 51-year-old woman was referred in December 2016 to the main author. Her main complaint was a recurrent chronic left TMJ dislocation with persistent severe pain. Her pain was so debilitating that it prevented her from working. Her problems began at the age of 18 following 3rd molar extraction. Regular dislocation of her TMJs began at the age of 32.
The CBCT showed an advanced left condylar head degeneration (Fig. 9).
The patient also complained about severe right TMJ pain, secondary to severe osteoarthritis. Bilateral TMJ total joint reconstruction with custom prostheses was proposed to the patient.
She underwent surgery in April 2017. The patient's normal occlusion was maintained. The right and left condyles and coronoid processes were removed through preauricular and retromandibular approaches. Figure 10 shows the left TMJ specimen after resection. Figure 11 shows the adaptation of the custom left TMJ prosthesis on the native mandible and glenoid fossa. The postoperative recovery was uneventful. Figure 12 shows the postoperative radiographs taken 1 week after surgery.
After 2 years of follow-up, she is pain free and has good function with an interincisal opening of 35 mm.
This 61-year-old woman was referred in March 2017 by an ENT surgeon for bilateral chronic TMJ dislocation of 7 months duration. This was the first episode and the patient could not recall the trigger event leading to the dislocation. She had an attempt at manual reduction under sedation in January 2017 with no success. She reported severe pain and difficulty with function. Medical comorbidities included schizophrenia. Figures 13 and 14 show the preoperative clinical photographs taken during the first consultation. Figure 15 is a 3D reconstruction of both dislocated TMJs.
Given the severe degeneration in both condyles, TJR with custom prostheses and simultaneous correction of the occlusion was recommended. Six months prior to surgery, teeth 24 and 47 were extracted to facilitate occlusal alignment. Orthodontics was not possible for this patient. Reconstruction was facilitated by virtual surgical planning (Fig. 16).
The patient underwent surgery in May 2018. The right and left condyles and coronoid processes were removed through preauricular and retromandibular approaches. Her postoperative recovery was uneventful. Figure 17 shows the postoperative pictures taken 3 months after surgery. The patient's pain had completely resolved, and she was chewing a full diet. A mild left marginal mandibular nerve neuropraxia is resolving.
Different treatment modalities can be considered for management of recurrent TMJ dislocation. The injection of sclerosing agents (alcohol, ethacridine, sodium psylliate, morrhuate sodium, sodium tetradecyl sulfate) in the superior joint has a low success rate and should not be considered a safe treatment.2 The rationale for injecting these agents is founded on causing intracapsular fibrosis and thus limiting jaw movement. The ability to control the extent of fibrosis is not predictable thus risking undesirable fibrous ankylosis.
Autogenous blood injection has been reported.13–17 Fibrosis formation in the superior joint space is again the goal though the mechanism of action is still unclear.18 The volume of blood used ranges between 2 and 4 mL in the superior joint space and 1 and 1.5 mL in the pericapsular structures, repeated twice a week for 3 weeks.19 A head bandage to restrict mandibular movements for 3 to 4 weeks has been proposed. Patients with autologous blood injected around the pericapsular tissues and into the superior joint space had less recurrence of dislocation than those with injection into the superior space alone.10 A systematic review published in 201520 report successful results but there remain concerns about the potential for articular degeneration, fibrosis, and ankylosis.
Botulinum toxin A (Botox) has been injected in the lateral pterygoid muscle to prevent recurrent dislocation. It acts by temporarily weakening of skeletal muscle by blocking the Ca2+-mediated release of acetylcholine from the nerve endings of the neuromuscular junction. Repeated injections are usually necessary. Botox is particularly useful when recurrent dislocation is due to neurogenic disorders with tardive dyskinesia and dystonia.21,22 Local diffusion can lead to adverse affects like transient dysphagia, nasal speech, nasal regurgitation, and dysarthria.8 Botox is contraindicated in diseases affecting neuromuscular transmission like myasthenia gravis and in pregnant and lactating women.
Eminectomy is the most commonly performed surgery for recurrent dislocation.23 The rationale for surgery is to “clear the path” for the dislocated condyle to easily return into the glenoid fossa, rather than being blocked anteriorly by the eminence. This technique has satisfactory results and surgeons empirically consider eminectomy to be the gold standard for treatment of recurrent dislocation. Pneumatization of the zygomatic arch and eminence should be recognized before surgery to avoid intraoperative perforation of the basal skull. Arthroscopic eminoplasty has also been described.24 It has been proposed that the success of eminectomy is secondary to the resultant scar formation that ultimately “blocks the path” of the condyle, preventing it from leaving the joint socket.25
Arthroscopic retrodiscal tissue scarification and disc plication26,27 has a reported high success rate. It is a minimally invasive procedure. The senior author favors this procedure when the TMJ is otherwise not degenerated.
Zygomatic arch down fracture (Leclerc or Dautrey procedure) is a well-known surgical technique for treatment of recurrent dislocation.28,29 A greenstick fracture is performed at the zygomaticotemporal suture. The major risk is a complete arch fracture. This procedure should be avoided in elderly patients where osteoporosis may increase the propensity to adverse fracture.
Metallic obstacles like miniplating of the articular eminence30–33 have been used successfully in selected patients but hardware fracture appeared as a relatively frequent complication (25%)34 as well as subsequent resorption of the condylar head.10
Increasing the articular eminence height with hydroxyapatite (HAP), silicon, or autogenous bone (iliac or calvarial bone graft) has been suggested. However, displacement of HAP and silicon implant has been reported as well as immune reactions to the implant material. Iliac crest bone grafts have been reported to be prone to rapid resorption. Calvarial harvest can have serious complications (dural tears, arachnoidal bleeding, scalp infections).2
Muscle surgery has also been described for treatment of recurrent dislocation. Lateral pterygoid myotomy and shortening of the temporalis tendon have been used but have not been proved very efficient.35
Long-standing dislocation causes muscle spasm, and articular degeneration, ankylosis, and pericapsular fibrosis making reduction difficult. If the anatomy is preserved, conservative treatment is a reasonable first step with closed reduction under general anesthesia. If this technique is not effective, minimally invasive surgical procedures like traction with a bone hook over the sigmoid notch or to the lower border with wires can be considered.7 Conservative management by placing posterior acrylic bite blocks and application of elastic traction to reduce the dislocation has been used.36
A multitude of surgical treatments has been reported for the treatment of long-standing dislocation of the TMJ which has failed conservative reduction: myotomy, condylotomy, condylectomy, menisectomy, eminectomy.9,37,38
Managing the occlusion without operating the TMJ when anatomy and joint function are preserved has been reported. The inverted L-shaped ramus osteotomy, vertical ramus osteotomy, and sagittal split osteotomy have been described.10,13 There is also a report of midline mandibulotomy.39
Long-standing dislocation can lead to ankylosis (patient 1). Long-term adverse loading secondary to aberrant joint biomechanics can induce progressive articular degeneration (patient 2).
The TJR has been described for treatment of ankylosis after traumatic dislocation of the condyle in the middle intracranial fossa.40,41 The TJR for long-standing dislocation is minimally reported.9 In the case of concomitant DJD, the results were favorable.
Optimal treatment of condylar dislocation requires early reduction to avoid late complications. The goals of reduction are to re-establish a functional occlusion and anatomy and to reduce pain.
Recurrent and long-standing dislocation often requires surgical management. Significant intra-articular adhesions and fibrosis can make closed reduction impossible.
This report presents 3 patients, 2 of the rare condition of chronic long-standing TMJ dislocation and 1 of long-standing chronic recurrent dislocation. All the 3 patients had concomitant severe DJD. The use of custom alloplastic total TMJ prostheses facilitated reconstruction of the TMJs with simultaneous correction of the occlusion. All the 3 patients have had very favorable results both in terms of pain control and improved function. There has been no further dislocation in these patients.
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