Case Report

TMJ Disorders

Int. J. Oral Maxillofac. Surg. 2013; 42: 1030–1033http://dx.doi.org/10.1016/j.ijom.2012.11.005, available online at http://www.sciencedirect.com

Treatment of long term anteriordislocation of the TMJD. A. Baur, J. R. Jannuzzi, U. Mercan, Faisal A. Quereshy: Treatment of long termanterior dislocation of the TMJ. Int. J. Oral Maxillofac. Surg. 2013; 42: 1030–1033.# 2012 International Association of Oral and Maxillofacial Surgeons. Published byElsevier Ltd. All rights reserved.

Abstract. Acute dislocation of the temporomandibular joint (TMJ) is a relativelycommon occurrence; chronic long-term dislocation is rare. Variance in the durationof dislocation and anatomical considerations make the treatment for long-standingdislocation complex and controversial. This paper attempts to review the literatureassociated with chronic TMJ dislocation treatment options and presents the authors’experience with a particularly long term dislocation.

0901-5027/0801030 + 04 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surge

D. A. Baur1, J. R. Jannuzzi2,U. Mercan3, Faisal A.Quereshy1

1Department of Oral and MaxillofacialSurgery, Case Western Reserve Universityand University Hospitals/Case MedicalCenter, Cleveland, OH, USA; 2PrivatePractice, Dry Creek Oral, Head & Neck andFacial Surgery, Englewood, CO, USA;3Faculty of Dentistry, Samsun, Turkey

Key words: temporomandibular joint; disloca-tion; management..

Accepted for publication 8 November 2012Available online 9 January 2013

Dislocation of the temporomandibularjoint (TMJ) typically occurs when themandibular condyle becomes displacedout of the glenoid fossa and anterior tothe articular eminence, although rarereports also describe posterior,1 lateral,and superior dislocations. One or bothmandibular condyles can be affected withthe majority of cases occurring bilater-ally.2 Some authors differentiate subluxa-tion, as displacement of the condyle whichcan be self-reduced by the patient, anddislocation as displacement that cannotbe reduced by the patient.3

Dislocation of the TMJ is a fairly com-mon condition which occurs for a variety ofreasons. Predisposing and etiological fac-tors for condylar dislocation includeextreme mouth opening during yawning(46%), motor vehicle accidents and othertrauma, dental treatments, medications,especially the anti-emetics metoclopra-mide and compazine which produce extrapyramidal effects, joint hypermobilityassociated with systemic diseases such asEhlers–Danlos and Marfan syndromes,congenital joint weakness, intubation, andpsychogenic and neurological disorders.4,5

Classification of the dislocation can bedivided into acute (most common), habi-tual, recurrent, and long-standing orchronic. No clear guidelines or standardshave been set to define a duration distin-guishing chronic from acute dislocation.Huang et al. suggest that chronic disloca-tion be defined as acute dislocation leftuntreated or inadequately treated for 72 hor more.2

Most commonly, mandibular disloca-tion is an acute anterior dislocation andcan be manipulated downward and back-ward into the glenoid fossa with or withoutlocal anaesthesia or sedation. Habitual orrecurrent dislocation is repeated episodesof dislocation becoming more and morefrequent and progressively worse. Long-standing or chronic dislocation is extre-mely rare, but causes significant discom-fort and quality of life issues for thepatient.

Case report

A 73-year-old otherwise healthy femalewas referred to the authors’ clinic with thechief complaint of inability to close her

mouth. Four months prior to presentation,she recalled yawning and states she wasunable to close her mouth afterward. Shewas fully edentulous with upper and lowercomplete dentures, and had no prior his-tory of TMJ dislocation. At the time ofdislocation, she presented to an outsidehospital and was misdiagnosed as havinghad a stroke. She was admitted and a workup for cerebrovascular accident was per-formed and found to be negative. She wasdischarged still in open lock and went tosee her general dentist. The dentist wasunable to reduce her mouth opening andreferred her to a maxillofacial surgeon.Owing to restrictions and limitations inher insurance plan, there were delays inpresenting to the oral and maxillofacialsurgeon. On presentation to the surgeon,she was diagnosed with anterior disloca-tion of the TMJ and unsuccessful attemptswere made to reduce the open lock withlocal anaesthetic in the office and undergeneral anaesthesia and muscle relaxantsin the operating room. On presentation tothe authors’ clinic she had been dislocatedfor 12 weeks. She complained of inabilityto masticate, swallow, and difficulty with

ons. Published by Elsevier Ltd. All rights reserved.

Treatment of long term TMJ anterior dislocation 1031

Fig. 1. Panorex demonstrating condyles out of fossa.

speaking. She continued to wear her den-tures, but the occlusion was significantlyaltered and non-functional.

She had complete maxillary and man-dibular dentures, downward and forwarddisplacement of the chin with significantanterior open bite. No palpable condyle inthe pre-auricular region. Tenderness topalpation in the pre-auricular region wasnoted.

Radiologic examination was underta-ken with a panoramic radiograph andcomputed tomography (CT). The panorexshowed bilateral anteriorly displaced man-dibular condyles well beyond the articulareminences (Fig. 1). The CT confirmed thepanoramic findings and also showed cup-

Fig. 2. (A and B) CT scans with three dimensi

ping of the lateral pole of the condyleconsistent with pseudoarticulation withthe zygomatic arch (Fig. 2).

With the history provided, the authorsagain attempted unsuccessfully to reducethe dislocation with local anaesthesia inthe office. At this point surgical interven-tion was indicated and discussed with thepatient.

Once under general anaesthesia, manualattempts were made to reduce the con-dyles unsuccessfully. At that time, bilat-eral incisions were made with aperiauricular approach to the TMJ. Theglenoid fossas were found to be empty ofthe mandibular condyles and containedsignificant dense scar tissue. The condyles

onal reconstruction.

were found anterior to the eminence andmedial to the zygomatic arch. The authorsattempted to reposition the condylesmanually to the original position; butowing to the dense fibrosis and mastica-tory muscle shortening, these attemptsalso failed.

A clinical decision was made at thattime that the patient would require a con-dylectomy in order to reduce the mandiblein its appropriate position. In considera-tion of the patients edentulism and theramus shortening bilateral condylectomieswould cause, the authors decided to recon-structed the TMJ with an alloplastic totaljoint prosthesis (Biomet Microfixation,Jacksonville, FL, USA). The condylec-tomies were performed and the patientwas placed in intermaxillary fixation(IMF) utilizing her dentures to estabilishproper jaw relations (Fig. 3). The ramuswas accessed via a submandibularapproach, and the fossa components andmandibular components were secured.The IMF was released and the occlusionwas checked and found to be reproducibleand stable with good range of motion. Thepatient was not left in IMF postopera-tively.

The patient was discharged the follow-ing day. She was followed at 1, 2, 4 and8 weeks postoperatively (Fig. 4). At8 weeks she had had no further episodesof dislocation. She opened her mouth to35 mm, and was eating a regular diet withno complaints and was pleased with theoutcome. At the 7 month follow-up, thepatient was pain free with a good range ofmotion.

Discussion

Dislocation of the TMJ is one of the raresttypes of joint dislocations, accounting forapproximately 3% of all joint disloca-tions.1 Signs and symptoms of TMJ dis-location include inability to close themouth, depression of preauricular skin,excessive salivation, and tense spasticmuscles of mastication, with severe TMJpain.

Long-standing TMJ dislocation usuallyoccurs when a case of acute dislocation isleft untreated or is inadequately treated.Over time the anterior positioning of thecondyle results in soft tissue becomingfibrosed, and muscle spasms. The moretime that has elapsed from the initial dis-location increases the severity of thesechanges and results in increased difficultyand more complex procedures needed toreduce the joint. In 2011, Huang et al.presented 6 cases of long standing TMJdislocation. In their series, they found that

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.

dislocations lasting for more than 30 dayscould not be treated by conventionalmanipulation even under general anaes-thesia. Despite having limited experiencein treating long-standing dislocation ofmore than 3 months, they suggested thatwhen long-standing dislocation has per-sisted for 4–12 weeks it is best treated byopen reduction.2 Their findings suggestsurgical procedures are probably neces-sary to correct dislocations greater than3 months despite some conflicting litera-ture stating that manual reduction may bepossible 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 bestand for which situations. Studies havereported some of the surgical treatmentsfor long-standing dislocation of TMJ to becondylectomy, condylotomy with or with-out coronoidotomy, coronoidectomyalone, inverted L-shaped ramus osteot-omy, modified vertical ramus osteotomy,

myotomy, periosteal stripping, tractionwith wire to lower border, and meniscect-omy.6,7 Lee et al. showed in their casereport reduction of prolonged bilateralTMJ dislocation by midline mandibulot-omy.8 An intraoral approach was used toperform mandibulotomy and each hemi-mandible was manipulated independentlyto obtain reduction. Other authors haveused a closed condylotomy technique.9 Inthis technique the condylar neck wasbisected with a Gigli saw via an intra oralapproach. The condylar head typicallydisplaces in an anteromedial direction,thus eliminating the effect of spasticityof the lateral pterygoid muscle. Tractionof the mandible by wire from the man-dibular angle or zygomatic hooks placedinto the sigmoid notch has also beendemonstrated as a method of obtainingreduction.

In the report by Huang et al.2 a sug-gested treatment strategy was proposed.This indicated that dislocations of greaterthan 3 weeks be treated by closed

reduction with or without local anaesthe-sia, and deep sedation or general anaes-thesia if unsuccessful. For dislocations of1–3 months, they suggest open reductionwith stripping of periosteum and musclesand traction with wire or other retractors.The recommendation for more than6 months was open reduction and condy-lectomy, condylotomy, myotomy and/or aTMJ prosthesis. For 3–6 months duration,they suggested attempts at stripping as inthe 1–3 month group, and if unsuccessful,following the recommendations for morethen 6 months.

In this case, a series of surgical inter-ventions were performed in an attempt toreduce the TMJ. The authors thought thatthe best available option was total TMJreconstruction (Biomet Microfixation,Jacksonville, FL, USA) to return thepatient to normal function predictably,because of the fibrosis and scaring. In2007 Mercuri et al. presented a 14 yearfollow-up of patients who were fitted withalloplastic total TMJ reconstruction andshowed a significant reduction in painscore, increase in mandibular functionand diet consistency score, and 85%reported quality of life scores that showedimprovement from baseline.10

Funding

N/A.

Competing interests

Dr. Baur is a paid consultant for NovartisPharmaceuticals.

Ethical approval

N/A.

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Address:Dale A. BaurDepartment of Oral and Maxillofacial

SurgeryCase Western Reserve University2124 Cornell RoadClevelandOH 44106-4905USATel: +1 216 368 3102;Fax: +1 216 368 4338E-mail: dale.baur@case.edu