Secondary Logo

Journal Logo

Original Articles

Total Joint Replacement After Condylar Destruction Secondary to Long-Standing Dislocation of the Temporomandibular Joint

Sarlabous, Mathilde DMD, FRCDC*; Psutka, David J. DDS, FRCDC

Author Information
Journal of Craniofacial Surgery: June 2020 - Volume 31 - Issue 4 - p 989-995
doi: 10.1097/SCS.0000000000006317
  • Open

Abstract

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.

CLINICAL PRESENTATIONS

Patient 1

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).

FIGURE 1
FIGURE 1:
Preoperative pictures. (A) At rest. (B): During mouth opening, which was limited.

Intraoral examination revealed edentulous maxilla and mandible with adequate keratinized mucosa.

The panoramic tomography revealed a dislocated right condyle (Fig. 2).

FIGURE 2
FIGURE 2:
Panoramic tomography showing the anterior dislocation of the right condyle (arrow).

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.

FIGURE 3
FIGURE 3:
Cone-beam computed tomography of the condylar heads. (A) Sagittal view of the right side. (B) Sagittal view of the left side. (C) Coronal view of the right side. (D) Coronal view of the left side. Arrows show erosion associated with degenerative joint disease.

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).

FIGURE 4
FIGURE 4:
Three-dimensional imaging using computed tomography data shows: (A) preoperative situation, (B) planned resection margins (in red), and (C) custom design of the Zimmer-Biomet prosthetic joints.

Custom gunning splints were virtually designed to help stabilize the edentulous mandible during surgery and correct the occlusal alignment (Fig. 5).

FIGURE 5
FIGURE 5:
Virtual design of the gunning splints to help stabilize the maxillo-mandibular relationship in this edentulous patient. (A) Splints fitting on stone models. (B) Virtual design of the splints. (C) “Occlusion” fitted in the operating room thanks to the gunning splints.

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).

FIGURE 6
FIGURE 6:
(A) Operative picture showing the right condyle anteriorly displaced (arrow) and (B) right condyle after resection. Note the advanced degeneration of the condylar head.

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.

FIGURE 7
FIGURE 7:
Postoperative cephalogram shows the bilateral prosthesis showing a proper position of the prosthetic condyles into their fossa.
FIGURE 8
FIGURE 8:
Postoperative pictures. (A) At rest with restored facial symmetry and (B) Showing good mouth opening.

Patient 2

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).

FIGURE 9
FIGURE 9:
Cone-beam computed tomography showing the advanced arthritic changes of the left condyle. (A) Frontal view showing loss of joint space left. (B) Sagittal view showing a large osteophyte (arrow).

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.

FIGURE 10
FIGURE 10:
Left temporomandibular joint specimen: articular disc (arrow head), condylar head (large arrow), and coronoid process (thin arrow).
FIGURE 11
FIGURE 11:
Left temporomandibular joint custom prosthesis. (A) Footplate adapted the mandibular ramus. (B) Left prosthetic condyle articulates with the condylar fossa.
FIGURE 12
FIGURE 12:
Postoperative radiographs. (A) Panoramic tomography. (B) Posterior-anterior radiograph. (C) Lateral cephalogram.

After 2 years of follow-up, she is pain free and has good function with an interincisal opening of 35 mm.

Patient 3

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.

FIGURE 13
FIGURE 13:
Preoperative pictures: (A) facial view at rest (note the anterior open bite), (B) showing mouth opening, (C) profile view.
FIGURE 14
FIGURE 14:
Intraoral pictures: (A) frontal view showing the open bite, (B) lateral view.
FIGURE 15
FIGURE 15:
Three-dimensional reconstruction of the right (A) and left (B) temporomandibular joint.

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).

FIGURE 16
FIGURE 16:
Three-dimensional imaging using computed tomography data shows (A) pre-operative situation, (B) planned resection margins (in red) and corrected occlusion, and (C) custom design of the Zimmer-Biomet prosthetic joints.

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.

FIGURE 17
FIGURE 17:
Postoperative pictures 3 months after surgery. (A) At rest. (B) During mouth opening. (C-D) Restored occlusion.

DISCUSSION

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.

CONCLUSION

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.

REFERENCES

1. Shorey CW, Campbell JH. Dislocation of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89:662–668.
2. Martins WD, Ribas M, de O, et al. Recurrent dislocation of the temporomandibular joint: a literature review and two case reports treated with eminectomy. Cranio J Craniomandib Pract 2014; 32:110–117.
3. Solomon S, Gupta S, Jesudasan J. Temporomandibular dislocation due to aripiprazole induced dystonia. Br J Clin Pharmacol 2010; 70:914–915.
4. Zakariaei Z, Taslimi S, Tabatabaiefar MA, et al. Bilateral dislocation of temporomandibular joint induced by haloperidol following suicide attempt: a case report. Acta Med Iran 2012; 50:213–215.
5. Kodama M, Fujiwara M. Risperidone-induced dislocation of the temporomandibular joint. J Clin Psychiatry 2012; 73:176.
6. Aghabiklooei A, Elahi H, Mostafazadeh B. Temporomandibular joint dislocation due to acute propranolol intoxication. Int Med Case Rep J 2010; 3:59–61.
7. Luyk NH, Larsen PE. The diagnosis and treatment of the dislocated mandible. Am J Emerg Med 1989; 7:329–335.
8. Shakya S, Ongole R, Sumanth KN, et al. Chronic bilateral dislocation of temporomandibular joint. Kathmandu Univ Med J (KUMJ) 2010; 8:251–256.
9. Baur DA, Jannuzzi JR, Mercan U, et al. Treatment of long term anterior dislocation of the TMJ. Int J Oral Maxillofac Surg 2013; 42:1030–1033.
10. 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.
11. Matthews NS. Springer International Publishing, Dislocation of the Temporomandibular Joint: A Guide to Diagnosis and Management. New York, NY: 2018.
12. Huang I-Y, Chen C-M, Kao Y-H, et al. Management of long-standing mandibular dislocation. Int J Oral Maxillofac Surg 2011; 40:810–814.
13. Coser R, da Silveira H, Medeiros P, et al. Autologous blood injection for the treatment of recurrent mandibular dislocation. Int J Oral Maxillofac Surg 2015; 44:1034–1037.
14. Hegab AF. Treatment of chronic recurrent dislocation of the temporomandibular joint with injection of autologous blood alone, intermaxillary fixation alone, or both together: a prospective, randomised, controlled clinical trial. Br J Oral Maxillofac Surg 2013; 51:813–817.
15. Machon V, Abramowicz S, Paska J, et al. Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg 2009; 67:114–119.
16. Bayoumi AM, Al-Sebaei MO, Mohamed KM, et al. Arthrocentesis followed by intra-articular autologous blood injection for the treatment of recurrent temporomandibular joint dislocation. Int J Oral Maxillofac Surg 2014; 43:1224–1228.
17. Daif ET. Autologous blood injection as a new treatment modality for chronic recurrent temporomandibular joint dislocation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109:31–36.
18. Candirli C, Yüce S, Cavus UY, et al. Autologous blood injection to the temporomandibular joint: magnetic resonance imaging findings. Imaging Sci Dent 2012; 42:13–18.
19. Sharma NK, Singh AK, Pandey A, et al. Temporomandibular joint dislocation. Natl J Maxillofac Surg 2015; 6:16–20.
20. Varedi P, Bohluli B. Autologous blood injection for treatment of chronic recurrent TMJ dislocation: is it successful? Is it safe enough? A systematic review. Oral Maxillofac Surg 2015; 19:243–252.
21. Vázquez Bouso O, Forteza González G, Mommsen J, et al. Neurogenic temporomandibular joint dislocation treated with botulinum toxin: report of 4 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109:e33–e37.
22. Fu K-Y, Chen H-M, Sun Z-P, et al. Long-term efficacy of botulinum toxin type A for the treatment of habitual dislocation of the temporomandibular joint. Br J Oral Maxillofac Surg 2010; 48:281–284.
23. Vasconcelos BC, Porto GG, Neto JP, et al. Treatment of chronic mandibular dislocations by eminectomy: follow-up of 10 cases and literature review. Med Oral Patol Oral Cirugia Bucal 2009; 14:e593–e596.
24. Segami N, Kaneyama K, Tsurusako S, et al. Arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: preliminary study. J Craniomaxillofac Surg 1999; 27:390–397.
25. Undt G. Temporomandibular joint eminectomy for recurrent dislocation. Atlas Oral Maxillofac Surg Clin North Am 2011; 19:189–206.
26. Torres DE, McCain JP. Arthroscopic electrothermal capsulorrhaphy for the treatment of recurrent temporomandibular joint dislocation. Int J Oral Maxillofac Surg 2012; 41:681–689.
27. Ybema A, De Bont LGM, Spijkervet FKL. Arthroscopic cauterization of retrodiscal tissue as a successful minimal invasive therapy in habitual temporomandibular joint luxation. Int J Oral Maxillofac Surg 2013; 42:376–379.
28. Gadre KS, Kaul D, Ramanojam S, et al. Dautrey's procedure in treatment of recurrent dislocation of the mandible. J Oral Maxillofac Surg 2010; 68:2021–2024.
29. da Costa Ribeiro R, dos santos BJ, Provenzano N, et al. Dautrey's procedure: an alternative for the treatment of recurrent mandibular dislocation in patients with pneumatization of the articular eminence. Int J Oral Maxillofac Surg 2014; 43:465–469.
30. Vasconcelos BC, Porto GG, Lima FTB. Treatment of chronic mandibular dislocations using miniplates: follow-up of 8 cases and literature review. Int J Oral Maxillofac Surg 2009; 38:933–936.
31. Shibata T, Yamashita T, Nakajima N, et al. Treatment of habitual temporomandibular joint dislocation with miniplate eminoplasty: a report of nine cases. J Oral Rehabil 2002; 29:890–894.
32. Cavalcanti JR, Vasconcelos BC, Porto GG, et al. Treatment of chronic mandibular dislocations using a new miniplate. Int J Oral Maxillofac Surg 2011; 40:1424–1427.
33. Kahveci R, Simsek ME, Akin S, et al. Treatment of recurrent temporomandibular joint dislocation. J Maxillofac Oral Surg 2013; 12:379–381.
34. de Almeida VL, Vitorino N, de S, et al. Stability of treatments for recurrent temporomandibular joint luxation: a systematic review. Int J Oral Maxillofac Surg 2016; 45:304–307.
35. Sindet-Pedersen S. Intraoral myotomy of the lateral pterygoid muscle for treatment of recurrent dislocation of the mandibular condyle. J Oral Maxillofac Surg 1988; 46:445–449.
36. Pradhan L, Jaisani MR, Sagtani A, et al. Conservative management of chronic TMJ dislocation: an old technique revived. J Maxillofac Oral Surg 2015; 14: (Suppl 1): 267–270.
37. Marqués-Mateo M, Puche-Torres M, Iglesias-Gimilio M-E. Temporomandibular chronic dislocation: the long-standing condition. Med Oral Patol Oral Cirugia Bucal 2016; 21:e776–e783.
38. Klüppel L-E, Olate S, Serena-Gomez E, et al. Efficacy of eminectomy in the treatment of prolonged mandibular dislocation. Med Oral Patol Oral Cirugia Bucal 2010; 15:e891–e894.
39. Lee S-H, Son S-I, Park J-H, et al. Reduction of prolonged bilateral temporomandibular joint dislocation by midline mandibulotomy. Int J Oral Maxillofac Surg 2006; 35:1054–1056.
40. Rikhotso ER, Bobat MA. Total alloplastic joint reconstruction in a patient with temporomandibular joint ankylosis following condylar dislocation into the middle cranial fossa. J Oral Maxillofac Surg 2016; 74:2378.e1–2378.e5.
41. Zamorano GM, Nuñez LF, Alvarez LA, et al. Temporomandibular joint ankylosis after condylar dislocation into the middle cranial fossa: a case report. Rev Stomatol Chir Maxillo-Faciale Chir Orale 2016; 117:351–356.
Keywords:

Custom total joint replacement; long-standing dislocation; temporomandibular joint

© 2020 by Mutaz B. Habal, MD.