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Journal of International Dental and Medical Research ISSN 1309-100X Temporomandibular Joint (TMJ) Dislocationhttp://www.ektodermaldisplazi.com/journal.htm Kamil Serkan Agacayak, and et al

Volume 5 Number 3 2012 Page 165

TEMPOROMANDIBULAR JOINT (TMJ) DISLOCATION DURING INTUBATION AND DENTALPROCEDURES

Kamil Serkan AGACAYAK1*, Ibrahim KOSE1, Belgin GULSUN1, Yusuf ATALAY1,Ferhan YAMAN1, Musa Can UCAN1

1. Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Dicle University Diyarbakr /TURKEY.

Abstract

Dislocation of the temporo-mandibular joint (TMJ) is an infrequent condition involving apermanent, to some extent complete, disruption of the joint.1TMJ dislocation may occur as a resultof everyday activities such as yawning or laughing, or during activities that require mouth openingfor a prolonged time, such as dental treatment.1

The data in the literature suggest that the lifetime prevalence of chronic TMJ dislocation is about

3%7% in the general population,2

with a strong female representation.

3

Dislocation may beunilateral or bilateral,4 the latter being more frequent.2 These disorders share symptomscharacterized by pain in the TMJ area and inability to close the mouth.5

Many techniques have been advocated for the treatment recurrent TMJ dislocation. Nonsurgicalapproaches have been proposed to prevent excessive abnormal excursions of the condyleincluding bandages and splints and extra-articular sclerosing agent injections.6

Surgical procedures can be categorized under 2 main headings: 1) procedures that enhancethe path of condylar movement; and 2) those that inhibit it. 7

Case repor t (J Int Dent Med Res 2012; 5: (3), pp. 165-168)

Keywords: Temporomandibular joint, surgical procedures, dislocation.

Received date: 08 February 2011 Accept date: 16 February 2011

Introduction

Temporomandibular joint (TMJ)dislocation is defined as an excessive forwardmovement of the condyle beyond the articulareminence with complete separation of thearticular surfaces and fixation in that position.8 Itis commonly associated with poor developmentof the articular fossa, laxity of the

temporomandibular ligament or joint capsule andexcessive activity of the lateral pterygoid andinfrahyoid muscles due to drug use or disease9.

Many pathogenetic factors have beendescribed for chronic TMJ dislocation, such as

traumatic events, ligament and capsuledegeneration, arthritic diseases, neuromuscularsystem diseases, systemic joint laxity, psychiatricdisorders, and it has also been reported inmentally retarded patients.2,9 There are manymethods for reducing anterior TMJ dislocations.The selection of the correct therapeutic approachis the subject of debate in the literature.10 Manyconservative treatments have been described

over the years for achieving pain relief, such asphysiotherapeutic rehabilitation, cognitivebehavioral treatments, and intra-articularinjections of sclerosing agents.11The Hippocraticmethod is the most frequently described andinvolves the practitioner standing in front of thepatient and placing a gloved thumb on theposterior lower molars bilaterally with fingerswrapped laterally around the mandible. Aconstant inferior force is the applied and themandible is eased back into the glenoid fossaposteriorly.10The wrist pivot method involves the

practitioner standing in front of the patient placinggloved thumbs at the apex of the mentum with

*Corresponding author:

Dr. Kamil Serkan AAAYAK

Dicle Universitesi Dis Hekimlii FakultesiAgz Dis Cene Hast. ve Cerrahisi AD,

21280Diyarbakr, Turkey

E-mail:[email protected]


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fingers inside the mouth on the occlusive surfaceof the mandibular molars. A superior force isapplied through the thumbs and inferior pressurewith the fingers with a pivoting motion from thewrists until the reduction is achieved.8

The extra-oral method requires thepractitioner to apply a posteroinferior force to thecoronoid process with the thumbs. This has theadvantage of reducing the risk of accidentalhuman bite injury to the practitioner.8 Thecombined ipsilateral staggered techniqueinvolves the reduction of each TMJ separately.12The practitioner uses one thumb intraorally toexert inferior pressure to the occlusive surface ofthe lower molars while simultaneously applying

further posteroinferior pressure to the ipsilateralcoronoid process extraorally. The manoeuver isrepeated on the contralateral side to completethe reduction.

All these approaches are useful forcontrolling pain and improving patientsperception of the disorder. But they do notreduce recurrence rates.13 A number of surgicaltechniques have therefore been introduced aspotentially definitive treatments by providingeither a decrease in the articular eminence toease reduction or an obstacle to condylar

displacement.13

The latter techniques adoptedbone grafts to increase height of the articulartubercle or used titanium anchors to avoidcondylar displacement.13

The purpose of this study was to clinicallyevaluate conservative treatment for TMJdislocations, independently of different etiologies.The aimed at assessing conservative techniques,given that these are the most frequently indicatedfor luxation of TMJ.

Case 1

A 19-year-old woman attended theDepartment of Maxillofacial Surgery, University ofDicle, Turkey, seeking treatment for a bilateralTMJ dislocation which occurred during dentaltreatment. She also had swallowing disturbance,excessive salivation, indistinct speech and asevere anterior open bite. Clinical examinationrevealed downward and forward displacement ofthe chin and hollowness on both sides anterior tothe tragus. Panoramic radiographic examinationshowed anterior dislocation of both condyles infront of the articular eminences. This wasconfirmed by computed tomography.

Figure 1. Facial view of case-1 before treatment.

Manipulation was successful. To prevent

postoperative relapse, a maxillomandibularfixation was applied for 10 days. Thepostoperative course was uneventful and noevidence of recurrence was noted. After 3 weeksof physical therapy, with a range of motionexercises, mouth opening improved to 30 mm.The patient could masticate and swallow. Norelapse occurred over the following 14 months.

Figure 2. Facial view of case-1 after treatment.

Case 2

A 56-year-old male, with no past history ofTMJ malfunction, was in intensive care forrestrictive pulmonary syndrome. A patent airwaywas secured by inserting a laryngeal maskairway (LMA). This was achieved withoutdifficulty. During the operation, theanesthesiologist incidentally noticed that thepatients jaw had been deformed and wasprotruding anteroinferiorly. Based on previousexperience, the anesthesiologist identified apreauricular depression and pathologicalprognathism of the lower jaw. The jaw did not
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deviate laterally. Bilateroanterior TMJ dislocationwas diagnosed. According to the patient and herfamily, she had not had TMJ dislocation before.Manual reduction (Hippocratic method) wassuccessfully performed.

Figure 3. Facial view of case-2 before treatment.

S

Figure 4.Facial view of case-2 after treatment.

Discussion

Acute non-traumatic anterior TMJdislocations are an uncommon phenomenon inthe emergency department but require rapiddiagnosis and treatment.8 Typical clinical

features include prognathism, open mouth,tension and spasms of mastication muscles,

excessive salivation, difficulty in phonation andpain in the TMJ region, preauricular swelling andtenderness, with a palpable depressionimmediately posteriorly, corresponding to anteriorcondylar dislocation. Unilateral dislocationspresent with the jaw deviated away from theaffected side.

In our study, we noted inability to closethe mouth, difficulty in phonation and pain. Thereare three factors that predispose a patient toanterior dislocation: poor joint capsule integrity,weak articular eminence morphology, andmuscle hypotonicity. Acute anterior dislocation ofthe TMJ as reported is secondary to laughing,taking a large bite, trauma, convulsions, yawning,

and induction of anesthesia. In our cases, weobserved weak articular eminence morphologyand muscle hypotonicity.

Most anterior TMJ dislocations presentspontaneously after the jaw is opened wideduring yawning, coughing, vomiting, taking alarge bite, convulsions, laughing, chewing,passionate kissing, LMA insertion or followingfacial trauma. The causes in our cases were LMAand dental treatment.

Many treatment modalities are consideredin the resolution of pain and dysfunctions

attendant upon recurrent TMJ luxation. In manycases, conservative methods promote sometemporary relief of symptoms, and recurrence iscommon. Surgical interventions are normallymore effective for definite treatment. Reliablecomparisons of the reports on modalities oftreatment are difficult to find because of unevenperiods of postoperative follow-up and differentdefinitions of success rates.

Following a scan of the different treatmentmodalities in the literature, we identified a rate of95% of cases without recurrence both after

eminectomy and use of metallic implant over thearticular eminence. We determined absence ofpostoperative luxation with the Hippocraticmethod, even though the follow-up period hadbeen variable.

Conclusion

Health care professionals who routinelyexamine, investigate and treat patients by theoral route must be aware of this uncommon butdistressing complication so that prompt

management and safe closed reduction can befacilitated. These cases highlight the importance


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of displaying great care when investigating ortreating elderly patients when any degree ofmouth opening is required.

References

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8. Oliphant R, Key B, Dawson C, Chung D. Bilateraltemporomandibular joint dislocation following pulmonaryfunction testing: a case report and review of closed reductiontechniques. Emerg Med J2008; 25: 435-436

9. Becking AG, Tuinzing DB. Orthognathic surgery for mentallyretarded patients. Oral Surg Oral Med Oral Pathol1991;72:162164.

10. Bakardjiev A. Treatment of chronic mandibular dislocation by

bone plates: two case reports. J Craniomaxillofac Surg 2004;32 (2):9092.

11. Merril RG. Mandibular dislocation and hypermobili ty. OralMaxillofac Surg Clin North Am 1989;1:396413.

12. Thomas ATS, Wong TW, Lau CC. A case series of closedreduction for acute temporomandibular joint dislocation by anew approach. Eur J Emerg Med 2006;13:725.

13. Guarda-Nardini L, Palumbo B, Manfredini D, Ferronato G.Surgical treatment of chronic temporomandibular jointdislocation: A case report. Oral Maxillofac Surg 2008; 12:4346

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