Case Report

TMJ Disorders
Treatment of long term anterior
dislocation of the TMJ
D. A. Baur, J. R. Jannuzzi, U. Mercan, Faisal A. Quereshy: Treatment of long term
anterior dislocation of the TMJ. Int. J. Oral Maxillofac. Surg. 2013; 42: 10301033.
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.
D. A. Baur
1
, J. R. Jannuzzi
2
,
U. Mercan
3
, Faisal A.Quereshy
1
1
Department of Oral and Maxillofacial
Surgery, Case Western Reserve University
and University Hospitals/Case Medical
Center, Cleveland, OH, USA;
2
Private
Practice, Dry Creek Oral, Head & Neck and
Facial Surgery, Englewood, CO, USA;
3
Faculty of Dentistry, Samsun, Turkey
Abstract. Acute dislocation of the temporomandibular joint (TMJ) is a relatively
common occurrence; chronic long-term dislocation is rare. Variance in the duration
of dislocation and anatomical considerations make the treatment for long-standing
dislocation complex and controversial. This paper attempts to review the literature
associated with chronic TMJ dislocation treatment options and presents the authors
experience with a particularly long term dislocation.
Key words: temporomandibular joint; disloca-
tion; management..
Accepted for publication 8 November 2012
Available online 9 January 2013
Dislocation of the temporomandibular
joint (TMJ) typically occurs when the
mandibular condyle becomes displaced
out of the glenoid fossa and anterior to
the articular eminence, although rare
reports also describe posterior,
1
lateral,
and superior dislocations. One or both
mandibular condyles can be affected with
the majority of cases occurring bilater-
ally.
2
Some authors differentiate subluxa-
tion, as displacement of the condyle which
can be self-reduced by the patient, and
dislocation as displacement that cannot
be reduced by the patient.
3
Dislocation of the TMJ is a fairly com-
mon condition which occurs for a variety of
reasons. Predisposing and etiological fac-
tors for condylar dislocation include
extreme mouth opening during yawning
(46%), motor vehicle accidents and other
trauma, dental treatments, medications,
especially the anti-emetics metoclopra-
mide and compazine which produce extra
pyramidal effects, joint hypermobility
associated with systemic diseases such as
EhlersDanlos and Marfan syndromes,
congenital joint weakness, intubation, and
psychogenic and neurological disorders.
4,5
Classication of the dislocation can be
divided into acute (most common), habi-
tual, recurrent, and long-standing or
chronic. No clear guidelines or standards
have been set to dene a duration distin-
guishing chronic from acute dislocation.
Huang et al. suggest that chronic disloca-
tion be dened as acute dislocation left
untreated or inadequately treated for 72 h
or more.
2
Most commonly, mandibular disloca-
tion is an acute anterior dislocation and
can be manipulated downward and back-
ward into the glenoid fossa with or without
local anaesthesia or sedation. Habitual or
recurrent dislocation is repeated episodes
of dislocation becoming more and more
frequent and progressively worse. Long-
standing or chronic dislocation is extre-
mely rare, but causes signicant discom-
fort and quality of life issues for the
patient.
Case report
A 73-year-old otherwise healthy female
was referred to the authors clinic with the
chief complaint of inability to close her
mouth. Four months prior to presentation,
she recalled yawning and states she was
unable to close her mouth afterward. She
was fully edentulous with upper and lower
complete dentures, and had no prior his-
tory of TMJ dislocation. At the time of
dislocation, she presented to an outside
hospital and was misdiagnosed as having
had a stroke. She was admitted and a work
up for cerebrovascular accident was per-
formed and found to be negative. She was
discharged still in open lock and went to
see her general dentist. The dentist was
unable to reduce her mouth opening and
referred her to a maxillofacial surgeon.
Owing to restrictions and limitations in
her insurance plan, there were delays in
presenting to the oral and maxillofacial
surgeon. On presentation to the surgeon,
she was diagnosed with anterior disloca-
tion of the TMJ and unsuccessful attempts
were made to reduce the open lock with
local anaesthetic in the ofce and under
general anaesthesia and muscle relaxants
in the operating room. On presentation to
the authors clinic she had been dislocated
for 12 weeks. She complained of inability
to masticate, swallow, and difculty with
Int. J. Oral Maxillofac. Surg. 2013; 42: 10301033
http://dx.doi.org/10.1016/j.ijom.2012.11.005, available online at http://www.sciencedirect.com
0901-5027/0801030 +04 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
speaking. She continued to wear her den-
tures, but the occlusion was signicantly
altered and non-functional.
She had complete maxillary and man-
dibular dentures, downward and forward
displacement of the chin with signicant
anterior open bite. No palpable condyle in
the pre-auricular region. Tenderness to
palpation in the pre-auricular region was
noted.
Radiologic examination was underta-
ken with a panoramic radiograph and
computed tomography (CT). The panorex
showed bilateral anteriorly displaced man-
dibular condyles well beyond the articular
eminences (Fig. 1). The CT conrmed the
panoramic ndings and also showed cup-
ping of the lateral pole of the condyle
consistent with pseudoarticulation with
the zygomatic arch (Fig. 2).
With the history provided, the authors
again attempted unsuccessfully to reduce
the dislocation with local anaesthesia in
the ofce. At this point surgical interven-
tion was indicated and discussed with the
patient.
Once under general anaesthesia, manual
attempts were made to reduce the con-
dyles unsuccessfully. At that time, bilat-
eral incisions were made with a
periauricular approach to the TMJ. The
glenoid fossas were found to be empty of
the mandibular condyles and contained
signicant dense scar tissue. The condyles
were found anterior to the eminence and
medial to the zygomatic arch. The authors
attempted to reposition the condyles
manually to the original position; but
owing to the dense brosis and mastica-
tory muscle shortening, these attempts
also failed.
A clinical decision was made at that
time that the patient would require a con-
dylectomy in order to reduce the mandible
in its appropriate position. In considera-
tion of the patients edentulism and the
ramus shortening bilateral condylectomies
would cause, the authors decided to recon-
structed the TMJ with an alloplastic total
joint prosthesis (Biomet Microxation,
Jacksonville, FL, USA). The condylec-
tomies were performed and the patient
was placed in intermaxillary xation
(IMF) utilizing her dentures to estabilish
proper jaw relations (Fig. 3). The ramus
was accessed via a submandibular
approach, and the fossa components and
mandibular components were secured.
The IMF was released and the occlusion
was checked and found to be reproducible
and stable with good range of motion. The
patient was not left in IMF postopera-
tively.
The patient was discharged the follow-
ing day. She was followed at 1, 2, 4 and
8 weeks postoperatively (Fig. 4). At
8 weeks she had had no further episodes
of dislocation. She opened her mouth to
35 mm, and was eating a regular diet with
no complaints and was pleased with the
outcome. At the 7 month follow-up, the
patient was pain free with a good range of
motion.
Discussion
Dislocation of the TMJ is one of the rarest
types of joint dislocations, accounting for
approximately 3% of all joint disloca-
tions.
1
Signs and symptoms of TMJ dis-
location include inability to close the
mouth, depression of preauricular skin,
excessive salivation, and tense spastic
muscles of mastication, with severe TMJ
pain.
Long-standing TMJ dislocation usually
occurs when a case of acute dislocation is
left untreated or is inadequately treated.
Over time the anterior positioning of the
condyle results in soft tissue becoming
brosed, and muscle spasms. The more
time that has elapsed from the initial dis-
location increases the severity of these
changes and results in increased difculty
and more complex procedures needed to
reduce the joint. In 2011, Huang et al.
presented 6 cases of long standing TMJ
dislocation. In their series, they found that
Treatment of long term TMJ anterior dislocation 1031
Fig. 1. Panorex demonstrating condyles out of fossa.
Fig. 2. (A and B) CT scans with three dimensional reconstruction.
dislocations lasting for more than 30 days
could not be treated by conventional
manipulation even under general anaes-
thesia. Despite having limited experience
in treating long-standing dislocation of
more than 3 months, they suggested that
when long-standing dislocation has per-
sisted for 412 weeks it is best treated by
open reduction.
2
Their ndings suggest
surgical procedures are probably neces-
sary to correct dislocations greater than
3 months despite some conicting litera-
ture stating that manual reduction may be
possible up to 6 months.
There have been many reports of meth-
ods to reduce TMJ dislocations surgically.
There are currently no guidelines or pro-
tocols for which surgical method is best
and for which situations. Studies have
reported some of the surgical treatments
for long-standing dislocation of TMJ to be
condylectomy, condylotomy with or with-
out coronoidotomy, coronoidectomy
alone, inverted L-shaped ramus osteot-
omy, modied vertical ramus osteotomy,
myotomy, periosteal stripping, traction
with wire to lower border, and meniscect-
omy.
6,7
Lee et al. showed in their case
report reduction of prolonged bilateral
TMJ dislocation by midline mandibulot-
omy.
8
An intraoral approach was used to
perform mandibulotomy and each hemi-
mandible was manipulated independently
to obtain reduction. Other authors have
used a closed condylotomy technique.
9
In
this technique the condylar neck was
bisected with a Gigli saw via an intra oral
approach. The condylar head typically
displaces in an anteromedial direction,
thus eliminating the effect of spasticity
of the lateral pterygoid muscle. Traction
of the mandible by wire from the man-
dibular angle or zygomatic hooks placed
into the sigmoid notch has also been
demonstrated as a method of obtaining
reduction.
In the report by Huang et al.
2
a sug-
gested treatment strategy was proposed.
This indicated that dislocations of greater
than 3 weeks be treated by closed
reduction with or without local anaesthe-
sia, and deep sedation or general anaes-
thesia if unsuccessful. For dislocations of
13 months, they suggest open reduction
with stripping of periosteum and muscles
and traction with wire or other retractors.
The recommendation for more than
6 months was open reduction and condy-
lectomy, condylotomy, myotomy and/or a
TMJ prosthesis. For 36 months duration,
they suggested attempts at stripping as in
the 13 month group, and if unsuccessful,
following the recommendations for more
then 6 months.
In this case, a series of surgical inter-
ventions were performed in an attempt to
reduce the TMJ. The authors thought that
the best available option was total TMJ
reconstruction (Biomet Microxation,
Jacksonville, FL, USA) to return the
patient to normal function predictably,
because of the brosis and scaring. In
2007 Mercuri et al. presented a 14 year
follow-up of patients who were tted with
alloplastic total TMJ reconstruction and
showed a signicant reduction in pain
score, increase in mandibular function
and diet consistency score, and 85%
reported quality of life scores that showed
improvement from baseline.
10
Funding
N/A.
Competing interests
Dr. Baur is a paid consultant for Novartis
Pharmaceuticals.
Ethical approval
N/A.
References
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1032 Baur et al.
Fig. 3. IMF using existing dentures and IMF screws (KLS-Martin, LP, Jacksonville, FL, USA).
Fig. 4. Postoperative panorex of TMJ prosthesis in place.
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Address:
Dale A. Baur
Department of Oral and Maxillofacial
Surgery
Case Western Reserve University
2124 Cornell Road
Cleveland
OH 44106-4905
USA
Tel: +1 216 368 3102;
Fax: +1 216 368 4338
E-mail: dale.baur@case.edu
Treatment of long term TMJ anterior dislocation 1033