chronic protracted temporomandibular joint dislocation: a report of two cases along with systematic...

8/12/2019 Chronic Protracted Temporomandibular Joint Dislocation: A Report of Two Cases Along With Systematic Literature

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Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com

CASE REPORT

Chronic Protracted Temporomandibular Joint Dislocation:

A Report of Two Cases Along With Systematic Literature

Review

Jeevan Lata MDS

1

, Nitin Verma MDS

2

, Palvi Gupta MDS

3

1-Professor & Head, 2- Assistant Professor 3- Junior Resident,Department of Oral & maxillofacial surgery,

Punjab Govt. Dental College & Hospital, Amritsar, India.

ABSTRACT:

Temporomandibular joint (TMJ) dislocation commonly follows extreme opening

of the mouth while eating, yawning, laughing, long standing dental treatment etc.

Acute Temporomandibular dislocations are often quickly recognized and

effectively treated by manual reduction method of Hippocrates. But dislocations

that persist for more than 3 weeks, classified as chronic protracted, may or may not

be effectively reduced by closed reduction. They often require the invasive

procedures to place the condyle back into the glenoid fossa. This article reports

two cases of chronic protracted dislocation having unusual etiology treated

systematically along with review of literature.

Key words: Temporomandibular joint, Chronic protracted dislocation

Cite this Ar ticle: Jeevan L, Nitin V. Palvi G:Chronic Protracted Temporomandibular Joint

Dislocation: A Report of Two Cases Along With Systematic Literature Review, Journal of Head& Neck physicians and surgeons Vol 2 Issue 1 2014 : Pg 53-66


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evaluating or treating them has been documented in the literature [3]. The aim of

this article is to report two cases of chronic protracted dislocation having unusual

etiology treated systematically along with review of literature.

CASE REPORTS:

The following cases reported to the department of oral and maxillofacial surgery,

Punjab Government Dental College and Hospital, Amritsar. Routine blood and

urine tests were done. For the management of their respective complaints,

informed consent was taken from the patients with proper explanation of the

various treatment modalities including the surgical procedures.

Case 1:

A 49 year old male patient presented with a chief complaint of inability to close

mouth since four months. History revealed that patient underwent an abdominal

surgery about five months back. During postoperative period, he developed some

complication, for which patient remained on ventilator support for about two

weeks. After recovery, patient had difficulty in mastication and speech. Initially, he

was given analgesics and multivitamins for same. But the condition didnt

improved. After 15 days, he went back for no improvement in his condition.

Thereafter, he was referred to a local dentist who diagnosed him with bilateral

TMJ dislocation and attempted closed reduction of the joint but was unsuccessful

and was kept on regular follow-ups. Later, patient reported to our institution for

further treatment.

On clinical examination, he had gross facial asymmetry, prognathic mandible with

evident pre-auricular hollow on both the sides [Fig 1]. Temporomandibular jointmovements were feeble bilaterally. On intraoral examination, posterior gagging of

occlusion with anterior open bite was noted. The panoramic radiograph [Fig 2a]

and computed tomography images [Fig 2b] revealed bilateral dislocation of the

temporomandibular joint with mild cortical erosions on right condyle. Thus patient

was diagnosed with chronic protracted bilateral dislocation of temporomandibular


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joint. The surgery was planned for reduction of the joint under general anesthesia.

Erich arch bar were placed in upper and lower dentate segments.

The patient was intubated with induction anesthesia of Propofol (10cc) and

maintained with Nitrous oxide (60%), Oxygen (40%) and Halothane (1%). Inj.Succinyl choline (2cc) was given i.v as muscle relaxant. After doing endotracheal

intubation, closed reduction was attempted by applying bilateral digital pressure on

mandibular molar region to reduce the dislocated condyles but, was unsuccessful.

Then decision was made to expose the mandibular angle extra-orally. Bilateral

Risdon incisions were given to expose the angle and downward and backward

traction was applied by passing wires though it. Still, the dislocation was

irreducible.

So, open reduction of temporomandibular joint dislocation was decided. The

preauricular incision was given to expose the temporomandibular joint [Fig 3]. On

exposing the joint, condyles were found to be locked in front of articular eminence.

Even under direct vision condyles failed to go back. Then bilateral high condylar

shave was done by using rotatory round burs no. 6 & 8 under the constant

irrigation of saline [Fig 4]. After this the condyles were positioned into their

glenoid fossa. Subsequently, layer-wise suturing done and suction drain was placed

bilaterally. Maxillomandibular fixation was planned for three weeks. Later,

occlusion was guided for another one week by elastics followed by night elastics

for another one week. Post-operative panoramic radiograph showed proper

reduction of the condyles into their respective glenoid fossa [Fig 5].

The patient was then followed-up post-operatively at weekly interval for two

months & thereafter at monthly intervals for two years. On follow-up visits, patient

experienced a full range of mandibular movements [Fig 6].


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Fig 1 Pre-operative clinical photograph showing bilateral TMJ dislocation

Fig 2a Pre-operative orthopantomogram showing bilateral anterior dislocation of TMJ

Fig 2b Pre-operative 3D CT scan showing condylar head anterior to the glenoid fossa in both

sides.

Fig 3 Pre-auricular incision given


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Fig 4 High condylar shave done

Fig 5 Post-operative orthopantomogram after 3 months

Fig 6 Occlusion after 9 months

Case 2:

Another patient, aged 65 year old reported to our institution with a chief complaint

of inability to close mouth since 4 months. He gave history of dislocation of jaw

about two years back, which was successfully treated in a private clinic. His

medical history revealed an attack of cerebrovascular stroke. MRI report showed a

non-hemorrhagic infarct in right middle carotid artery region involving fronto-

temporo-parietal region. After the attack, patient again had dislocation of jaw but

he evaded the treatment, in the anticipation that the deviated open jaw is because of

the hemiparesis. He had been referred to our department for the management of

open mouth condition by his neurophysician.

On examination, there was a hemiparesis of the left upper half of the body. He had

left facial droop, paralysis of left arm and an expressive dysphagia due to difficulty

in mastication. There was an evident preauricular hollow [Fig 7] on both sides with

leptocephalic appearance [Fig 8] of face. Temporomandibular joint movements

were slightly palpable. On intraoral examination, patient was partially edentulous

with inability to occlude teeth [Fig 9]. Panoramic radiographs confirmed theclinical diagnosis of bilateral dislocation of temporomandibular joint [Fig 10].

On admission, patient was already taking telmisartan 2.5 twice daily and

aspirin150 once daily. After assessment of the general physical status of the

patient, reduction of the dislocated joint was planned under general anesthesia

Pre-operatively, Erich arch bar were placed on upper and lower dentate segments.

The patient was intubated with induction anesthesia of Propofol (10cc) and

maintained with Nitrous oxide (60%), Oxygen (40%) and Halothane (1%).Intravenous Inj. Succinyl choline (2cc) was given as muscle relaxant. Bilateral

digital pressure was applied on mandibular molar region to reduce the dislocated

condyles. Further, the condyles were successfully reduced and positioned in

glenoid fossa with proper occlusion [Fig 11]. Inter-maxillary fixation was done and


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maintained for a period of two weeks. Later, occlusion was guided for another one

week by elastics. Post-operatively liquid and semi-solid diet was advised with

administration of analgesics and anti-inflammatory agents for a period of three

days. Post-surgical recovery sequel was uneventful with proper occlusion [Fig 12].

The post-operative follow-up was done at weekly interval for two months and atmonthly intervals for two years.

Fig 7 Pre-operative appearance of face showing preauricular hollow on both sides

Fig 8 Pre-operative lepocephalic appearance of face

Fig 9 Pre-operative occlusion


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Fig 10 Pre-operative orthopantomogram showing bilateral dislocated condyles

Fig 11 Post-operative orthopantomogram

Fig 12 Post-operative occlusion after 6 months

DISCUSSION:

Temporomandibular joint dislocation is a common presentation that is usually

reported as an acute episode of unilateral or bilateral displacement of condyles

anterior to articular eminence [7]. Temporomandibular joint dislocation can be

classified as partial (subluxation) or complete (luxation). In partial dislocation,

condyles are found to be present in the confines of temporomandibular joint

capsule whereas in complete dislocation, condyles lie completely out of the

glenoid fossa. Often, failure to diagnose or inappropriate treatment in the initial

stage results in prolonged malposition of an acutely displaced condyle leading to

chronic dislocation [7]. Long standing history of about 5 months was due of

inappropriate treatment in case 1 and failure to diagnose the problem in case 2.

We found male predominance in our cases which was same as reported in study on

96 Nigerian of temporomandibular joint dislocation [8]. On the contrary, Caminitiand Weinberg reported four cases of long-standing temporomandibular joint

dislocation with female predominance [3].The pathophysiology of

temporomandibular joint dislocation includes the abnormal position of condyles

out of the glenoid fossa with spasm of masticatory muscles hampering its

movement back to its natural anatomical position [9].Additionally, the duration of

dislocation plays an important role for prognosis. Longer duration predisposes to

fibrous adhesions refraining condyles to move back to their normal position. This

was found to be present in case 1, with CT scan showing mild cortical erosionsover the right condyle. But, our second patient (case 2) couldnt get CT scan done

due to his low socio-economic status.


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There is no standard evaluation and treatment method for acute

temporomandibular joint dislocation in the literature, but the best method is

immediate effective reduction [8]. Hippocrates was first to describe manual

reduction in the fifth century B.C. Ambroise Pare (1633) described the use of anobject that would act as a wedge in the molar regions as the chin is elevated to lift

the condyles off their locked position [3]. In chronic and recurrent dislocations,

different options of their management have been divided into nonsurgical

(conservative approach), and surgical methods (indirect approach and direct

approach). Conservative approach included Hippocratess manual reduction under

local or general anesthesia. Another method is the use of heavy anterior elastic

traction using arch bar or IMF screws with mouth prop in the posterior teeth acting

as fulcrum and Class III vector for the posterior wires [10].But, chronic and longstanding dislocations are difficult to reduce manually. Gottlieb (1952) reported

only three of 24 long-standing cases that were successfully reduced by manual

reduction [11]. On the contrary, successful manual reduction of prolonged

dislocations, up to 16 months, has also been described by Hayward in 1965 [12].

In our institution, firstly conservative approach was used in both the cases. We

decided to apply the Hippocratic manual reduction method under general

anesthesia. This was planned keeping in mind the long duration of the

temporomandibular joint dislocations and failure in closed method could be easily

switched to an open TMJ surgery. We were able to successfully reduce the

dislocation in case 2 but we failed in case 1 with manual reduction. This is

explained on the basis of practical categorization of chronic dislocations done by

Littler BO 1980: reduction resisted by muscular spasm and reduction resisted by

non-muscular forces like fibrous adhesions, articular cartilage impaction [13]. In

case 2, there was perhaps muscular spasm of the masticatory muscles which was

relieved by muscle relaxants resulting in reduction of the condyles by manual

reduction only. But in case 1, there were fibrous adhesions present which were not

amenable to muscle relaxation and manual reduction.


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Table 1: Systematic review of literature on the various treatment modalities of chronic

protracted dislocation

Fordyce GL,1965 [15] Defined long standing TMJ dislocation as one existing for more

than a month

Adekeye et al, 1976 [16] Received 24 cases, out of which four were reduced manually and

20 required open procedures.

Stakesby lewis JE, 1981

[17]

Applied traction intra-orally at sigmoid notch to reduce the

condyles

Hammersley, 1986 [18] Performed open reduction in two out of three cases and advocated

simultaneous detachment of lateral pterygoid insertion

El-attar A and Ord RA

1986 [14]

Used traction with intra-osseous wires passed through angle of

mandible.

Caminiti MF, Weinberg

S,1998 [3]

Reported four long-standing cases with variability in their

management.

Smith WP, Johnson PA ,

1994 [19]

Introduced the term reducible and irreducible and proposed

mandibular set back procedure for the latter.Terakado et al, 2004 [20] Used Intermaxillary screws in case of an edentulous mandible to

apply traction force with elastics to reduce bilateral mandibular

dislocation.

Aquilina et al, 2004 [21] Used Botulinum toxin A to reduce muscle spasm after reduction to

prevent relapse.

Ugboka et al, 2005 [8] In multi-centric study, received 96 cases of TMJ dislocation(29

long-standing)

Lee et al, 2006 [22] Proposed midline mandibulotomy for the treatment of long

standing dislocations.

Debnath SC et al, 2006

[7]

Treated a case with bilateral vertical oblique osteotomy of ramus

for the reduction of long standing cases.

Rattan V, Rai S, 2007 Proposed a stepwise treatment algorithm for long standing


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[23] dislocations.

Rattan V, Rai S, 2013

[24]

Treated two cases with midline mandibulotomy and modified their

previous algorithm.

In case 1, further indirect approach was used. We applied traction with intra-

osseous wire passed at bilateral mandibular angle region via Risdon incision. El-

attar A and Ord RA 1986 had reported the treatment of long standing

temporomandibular joint dislocation by this method. But, it didnt help us in

reducing dislocation [14]. Then we used direct approach for reduction. Bilateral

condyles were opened via conventional preauricular incision and high condylar

shaving was done to place the condyles back into the glenoid fossa. This is in

concurrence with the Caminiti and weinberg (1998)who reported that 2 cases out

of 4 were reduced via direct approach after unsuccessful closed reduction attempts

[3]. Both patients were kept on Maxillomandibular fixation but for different

intervals (In case 1 for 3 weeks and in case 2 for 2 weeks). Additional 1 week

given in case 1 was done to counteract the presence of psuedoarthrosis as evident

on CT scan.

In conclusion, Chronic protracted TMJ dislocations should be treated

systematically from the conservative methods to invasive procedures for the bestbenefit of the patient.

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Oral Cir Bucal. 2009 Nov 1;14(11):e593-6.


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3. Caminiti MF, Weinberg S. Chronic Mandibular Dislocation: The Role Of Non-Surgicaland Surgical Treatment. J Can Dent Assoc. 1998 Jul-Aug;64(7):484-91

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classification of temporomandibular joint dislocation. Head & Face Medicine 2011;7:10

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Kumar S, Thangaswamy V. Chronic Traumatic Unilateral Dislocation of

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temporomandibular joint: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol

Endod 2006;101:e79e82

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12.Hayward, J.R. Prolonged dislocation of the mandible. J Oral Surg 1965;23:585-59513.Littler BO. The role of local anesthesia in the reduction of long-standing dislocation of

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18.Hammersley N. Chronic bilateral dislocation of the temporomandibular joint. Br J OralMaxillofac Surg. 1986 Oct;24(5):367-375.

19.Smith WP, Johnson PA. Sagittal split mandibular osteotomy for irreducible dislocation ofthe temporomandibular joint. A case report. Int J Oral Maxillofac Surg. 1994

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20.Terakado N, Shintani S, Nakahara Y, Yano J, Hino S, Hamakawa H. Conservativetreatment of prolonged bilateral mandibular dislocation with the help of an intermaxillary

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22.Lee SH, Son SI, Park JH, Park IS, Nam JH. Reduction of prolonged bilateraltemporomandibular joint dislocation by midline mandibulotomy. Int J Oral Maxillofac

Surg. 2006 Nov;35(11):1054-1056.

23.Rattan V, Rai S. Management of Long-standing Anteromedial Temporomandibular JointDislocation. Asian Journal of Oral and Maxillofacial Surgery 2007;19(3);155-159.

24.Rattan V, Rai S, Sethi A. Midline Mandibulotomy for Reduction of Long-StandingTemporomandibular Joint Dislocation. Craniomaxillofacial Trauma and Reconstruction

2013;6(2):127-132.

Acknowledgement-None

Source of Funding-Nil

Conflict of Interest-None Declared

Ethical Approval-Not Required

Correspondence Addresses :

Dr. Palvi Gupta, Junior Resident,,Department of Oral & maxillofacial surgery,

Punjab Govt. Dental College & Hospital, Amritsar, India.Pincode145001

Mob: 9888762994Email address:[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]

chronic protracted temporomandibular joint dislocation: a report of two cases along with systematic...

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