subluxation and dislocation of temporomandibular joint

© Ramaiah University of Applied Sciences

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Faculty of Dental Sciences

Subluxation and Dislocation of Temporomandibular joint

Dr Zeeshan Arif


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CONTENTS• Introduction

• Definition

• Epidomology

• Pathogenesis

• Classification

• Etiology

• Predisposing factors• Unilateral acute dislocation• Bilateral acute dislocation• Management • Non surgical management • Surgical management • Conclusion• References


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Introduction

• As far back as 3000 BC in Egypt, Hippocrates first reported a dislocation of the mandible.

• His method of reduction has survived the ages and is still being used in modern times.

• Mandibular condylar dislocation is uncommon, compared to the other joints in the body.


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Definition

• Hypertranslation refers to the excessive anterior movement of the condyle during opening.

• The term subluxation is defined as a self reducing partial dislocation of the tmj during which the condyle passes anterior to the articular eminence.

• The term dislocation can be defined as long lasting inability to close the mouth due to the complete translation of the condyle anterior to the articular eminence.


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Epidomology

• Uncommon compared to other dislocations

• 3 % incidence

• Uncommon in extremes of age

• Higher incidence in females

• Malagaigne et al- 57% cases were in females out of 240 patients (1981)


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• Most commonly occurs in anterior direction in relationship with the articular eminence

• Superior, posterior, and adjacent medial dislocations are associated with the fracture of the mandible.

• These are rare


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The pathogenesis of chronic recurrent TMJ dislocation is attributed to a combination of factors including

• laxity of the TMJ ligaments,

• weakness of the TMJ capsule,

• an unusual eminence size or projection,

• Muscle hyperactivity or spasms,

• Trauma

• Abnormal chewing movements that do not allow the condyle to translate back.

Pathogenesis


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• Dislocation of the acute type causes ligament, capsule and disk injury.

• This results in a inflammatory reaction and joint effusion.

• Painful limitation and spasm of the masticatory muscles are maintained by neural reflexes from the injured joint structures

• The reflex spasms spread bilaterally over the entire group of masticatory muscles


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• Alteration in collagen chemistry might account for joint hypermobility.

• Another factor which influences the mobility of any synovial joint is its lubrication.

• Increase in friction due to decreased synovial fluid may bring about incoordination between articular surfaces, with decreased mobility and joint instability


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• Is an excessive range of movement occurring in one or more joints as a result of a pathological process

• May be isolated or generalized

• Isolated

– Neuropathic arthropathy

– Traumatic rupture of ligaments from injuries

– Rheumatoid arthritis and related disorders

– Late osteoarthrosis

Acquired hypermobility


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Generalized

• Acromegaly

• Joint laxity during pregnancy

• hyperparathyrioidism

• Chronic alocholism


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Occlusal factors

• Long term overclosure and loss of physiological vertical dimension can contribute to subluxation and dislocation

• Overclosure produces stretching and loosening of joint ligaments and joint laxity


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• Spontaneous dislocation of the mandible due to extrapyramidal reactions to prochlorperazine

• All Antipsychotic drugs

Drug associated dislocation


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• Hysteria can be the cause of habitual dislocation

• Psychosomatic disorder observed most often in young females and may follow minor trauma to the jaw

• Habitual dislocation may be the presenting feature of an underlying psychiatric disturbance

Psychogenic dislocation


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Classification

Anterior mandibular dislocation can be classified as

• 1. Acute

• 2. Chronic recurrent (habitual) subluxation

• 3. Long-standing.


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Etiology

Causes of Acute Dislocation

• a. Extrinsic forces or iatrogenic causes

• b. Intrinsic or self-induced forces


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Extrinsic or iatrogenic causes


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Intrinsic or self-induced


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Predisposing factors

• Laxity of ligaments, capsule and abnormality of skeletal form.

• Previous injuries, occlusal disharmonies can bring about laxity of the capsule.

• Flattened eminence and shallow fossa,

• systemic diseases like Parkinson‘s disease, epilepsy, EhlersDanlos syndrome

• The use of antipsychotic drugs may cause extrapyramidal reactions and dislocation.


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Unilateral acute dislocation

• difficulty in mastication and swallowing.

• Speaking may be difficult and profuse drooling of saliva

• A deviation of the chin toward contralateral side is seen.

• The mouth is partly open and the affected condyle cannot be palpable.

• In obese person, absence of condyle from the glenoid fossa may not be apparent, but in others a definite depression will be seen and felt in front of the tragus.


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Bilateral acute dislocation

• pain, inability to close the mouth, tense masticatory muscles, difficulty in speech, excessive salivation, protruding chin.

• The mandible is postured forward and movements are restricted.

• Posterior gagging and anterior open bite.

• Patient will complain of pain in the temporal region rather than the joint and may be extremely apprehensive.

• The distinct hollowness can be felt in both the preauricularregions.

• Associated muscle spasm contributes to the fixed position of the condyles


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Imaging


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Management

Acute dislocation

• The major problem in reduction of dislocation is overcoming the resistance of the severe muscle spasm.

• Therefore, initially attention is given to reduce tension, anxiety and muscle spasm.

This can be achieved by

• (i) reassuring the patient

• (ii) tranquilizer or sedative drugs

• (iii) pressure and massage to the area

• (iv) manipulation.


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Depending on the amount of associated muscle spasm and pain experienced by the patient plus patient cooperation, the acute dislocation can be reduced by the operator as follows:

• 1. Manipulation without any form of anaesthesia.

• 2. Manipulation with local anaesthesia.

• 3. Manipulation under general anaesthesia/sedation with muscle relaxants.


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• A simple technique - Johnson

• LA is injected into the depression in the glenoid fossa left by the dislocated condyle.

• Spontaneous reduction, in bilateral cases with the injection of one point can occur with a swallow in 1 to 10 minutes

Johnson W.B. New method for reduction of acute dislocation of the

temporomandibular articulations. J Oral Surg. 1958;16:501–504


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Manual manipulation


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• In 1981, Lewis modified it in his way by stating that the patient should be made to sit down and the clinician should stand in front of him/her or at 11o’ clock position.

• Few authors have further modified the technique by changing the position of the thumb from the occlusal surface of the teeth to the anterior border of the ramus.

• In 1987, Awang described another simple, safe, and rapid method in managing acute dislocation. According to him, induction of the gag reflex by probing the soft palate creates a reflex neuromuscular action that resulted in the reduction.


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• Deep temporal nerve block is achieved by first locating the anterior temporalis muscle.

• This muscle is palpated just above the zygomatic bone, where a depression can be felt.

• Deep to this portion of the temporalis muscle is the greater wing of the sphenoid bone.

• The anesthetic needle is directed into this area until it hits the sphenoid bone.


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• Immobilization can be carried out, by giving barrel bandage to the patient for the period of 10 to 14 days and patient is kept on semisolid diet.

• This will allow to give rest to the joint.

• Anti-inflammatory, analgesic drugs should be prescribed for the period of 3 to 5 days.

• The patient is warned to avoid excessive oral opening and support the chin, while yawning in future.


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Longstanding dislocation

• longer than one month.

• Frequently, this follows extraction of teeth or tonsillectomy under general anaesthesia, where the jaw is excessively forced open.

• Dislocation may then remain unnoticed, if not examined postoperatively.

• passive acceptance of the condition by the patient.

• In these cases, with passage of time, additional muscle spasm and fibrotic changes occur in the ligaments and muscles, thus increasing the severity of the problem


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Chronic recurrent dislocation

• repeated episodes of dislocation, where there is abnormal anterior excursion of the condyles beyond the articular eminence, but the patient is able to manipulate it back into normal position.

• So here the condylar head moves, unassisted, forward and backward over the articular eminence.

• This recurrent, incomplete, self-reducing, habitual dislocation is termed as hypermobility or chronic subluxation of the TMJ.


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The triad

• ligamentous and capsular flaccidity

• eminential erosion

• flattening and trauma


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• In such predisposed individuals, the acts of yawning, vomiting, laughing may precipitate subluxation.

• It is also seen in severe epilepsy, dystrophia myotonia and the Ehlers-Danlos syndrome.

• It can be also seen in professionals like teachers, speakers or musicians.

• With each episode of subluxation, there is further stretching of the capsular ligament, which aggravates the condition and leads to further recurrence.


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Ehlers-Danlos syndrome

• This is a rare inherited disorder of the connective tissue, in which recurrent dislocation of the TMJ is seen.

• Four cardinal symptoms are as follows:

1. Hyperelasticity of the skin.

2. Fragility of the skin.

3. Hypermobility of the joints.

4. Fragility of the blood vessels.


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Chronic subluxation with pain

• It is not necessarily painful.

• But in some of the patients, sudden sharp and severe pain occurs when the mouth is opened widely.

• Occasionally the problem is of such a magnitude, that the patient becomes reluctant to masticate food.


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Non surgical management

• The conservative method includes the use of various sclerosingagents like alcohol, sodium tetradecyl sulfate, sodium psylliate, morrhuate sodium, and platelet-rich plasma that has been injected into the joint space.

• In case of chronic dislocation, elastic rubber traction with arch bars and ligature wires/intermaxillary fixation (IMF) with elastic bands are useful to achieve the reduction.


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Use of sclerosing solution injections into the joint space

• Objective is to produce fibrosis and tightening of the capsular ligaments, thus limiting motion of the mandible and preventing subluxations and dislocations

• Sodium psylliate provided consistently best results.

• But is no longer available.

• Sodium morrhuate has failed to produce good results.

• Sodium tetradecyl sulfate, which was developed for mildly sclerosing varicose veins and haemorrhoids, can be used with caution, as allergic or anaphylactic reactions have been reported.


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Use of autologous blood

• The use of autologous blood in recurrent dislocation was reported by Brachmann in 1964 and is very popular nowadays.

• In an animal study, Gulses et al., demonstrated that there are significant fibrotic changes histologically evident in both retrodiscal and pericapsular tissues.

• The volume of blood to be used ranges 2-4 mL in the upper joint space and 1-1.5 m L in the pericapsular structures, repeated twice a week for 3 weeks.


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• Head bandage is required for the period of 3-4 weeks.

• However, some authors have reported degeneration in the articular cartilage and permanent joint destruction.

• Alons et al., reported that there is no noticeable damage to the cartilage and the interposing disc on histopathologicalexamination. (rat study)

• The only reported disadvantage of this technique is severe restriction in the mandibular range of motion.

• Machon et al. advocated that the patient should start jaw rehabilitation by a gradual and controlled range of motion exercises after 2 weeks of the autologous blood injection therapy.


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Caromed facelift bandage A.S.R. Pinto et al British Journal of Oral and Maxillofacial Surgery

47 (2009) 323–324


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Use of botulin toxin

• Another newer conservative method is the application of botulinum toxinA (BTX-A) in recurrent TMJ dislocation.

• Previously, BTX-A was used in the management of facial wrinkles, masseteric and temporalis muscle hypertrophies,, hemifacial spasm, sialorrhea, and masticatory myalgia.

• The intended effect of the BTA is to weaken the lateral pterygoid muscles sufficiently to prevent dislocations, while producing only slight impairment to maximal opening.


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• It acts by causing temporary weakening of the skeletal muscle by blocking the Ca2+-mediated release of acetylcholine

• Because the effect is temporary, repeated administration is required after 2 weeks for better results.

• The adverse effect involves diffusion into the adjacent tissues, transient dysphagia, nasal speech, nasal regurgitation, painful chewing, and dysarthria.

• It is contraindicated in a few conditions like hypersensitivity to BTX and myasthenia gravis, pregnant and lactating women.


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Surgical procedures

In 1976, Miller and Murphy divided surgical procedures to correct recurrent condylar dislocation into five categories:

• 1. Capsule tightening procedure.

• 2. Creation of a mechanical obstacle or block.

• 3. Direct restraint of the condyle.

• 4. Creation of a new muscle balance.

• 5. Removal of mechanical obstacle.


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1. Capsule tightening procedures

• These procedures were apparently effective over a short period.

• Capsulorrhaphy—consists of shortening the capsule by removing a section and suturing it to make it tight.


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• Reinforcement of the joint capsule by turning down a strip of temporal fascia and suturing to the capsule


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• A disadvantage to this therapy is violation of the intracapsularspace, which can produce complications such as hemarthrosis, degenerative changes to the joint, or both.


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• Ligamentorrhaphy involves the surgical fixation (or anchoring) of the lateral ligament of the capsule to the periosteum of the overlying zygomatic arch, followed by MMF for 1 week.


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2. Creation of a mechanical obstacle

• A) Lindermann performed an osteotomy on the eminence and turned it down in front of the condylar head to prevent its forward movement.


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B) Mayor advocated a placement of a graft (taken from the zygoma) over the eminence to increase the size and height.


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• In all these methods the main drawback is that the ‘buttee’ is not deep enough or strong enough”

• Average width of zygomatic arch in the range of 2.9 to 3.7mm

• Such a narrow buttress may not provide adequate width to impede or arrest the condyle which is making a medial movement on opening

• The buttress will effectively block the condyle in axial opening, but ‘medial escape’ is readily accomplished and the operation may fail if it relies solely on the bony buttress


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Findlay reported the use of L-shaped plates anchored in the zygomatic process and projecting it anterior to the condyle.

B. C. Vasconcelos, G. G. Porto, F. T. B. Lima: Treatment of chronic mandibular dislocations using miniplates: follow-up of 8 cases and literature review. Int. J. Oral Maxillofac. Surg. 2009; 38: 933–936.


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Long-term results following miniplate eminoplasty for the treatment of recurrent dislocation and habitual luxation of the temporomandibular joint

Int. J. Oral Maxillofac. Surg. 2003; 32: 474-479.


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Titanium screw implantation to the articular eminence for the treatment of chronic recurrent dislocation of the temporomandibular joint H. Y. Oztan, et al Int. J. Oral

Maxillofac. Surg. 2005; 34: 921–923


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• Oblique osteotomy of articular eminence and zygomatic root

• 8-10 mm of height of eminence

• Width of graft should be enough to prevent the medial escape of condyle.


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3. Direct restrain of condyle

• Procedures directed towards restraining the condyle from abnormal forward movements have been attempted for over half a century.

• Temporalis fascia turned down and sutured to the lateral surface of the articular capsule.

• These techniques are complicated and have questionable long-term results.


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4. Creation of new muscle balance

• This procedure involves excision of the insertion of the lateral pterygoid muscle at the condylar neck and joint capsule.

• disable the lateral pterygoidmuscles, allowing only rotational movement of the condyle.

• MMF for 7 to 10 days.

• Its disadvantages include difficulty in visualization and the risk of bleeding in this highly vascular site.

• Muscle tissue may reattach during healing, placing the long-term efficacy of the procedure in doubt.


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Scarification of temporalis tendon/temporalis myotomy:-

• Majority of tendinous fibers are stripped from the ramus and sutured to the reflected periosteum and oral mucosa in a fashion that creates tissue disorientation and subsequent scar formation which will lead to horizontal scar

• may tighten the tendon and limit the range of motion.


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5. Removal of mechanical obstacles

a. Removal of torn meniscus or meniscectomy

• Torn meniscus, which was thought as the obstacle, is removed.

• This technique became very popular, but unfortunately the undesirable results like protracted pain, grating, roughening of the condylar head, and an occasional ankylosis were noticed.


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B.The high condylectomy

• The shortened head of the condyle will have less tendency to lock in front of the articular eminence.

• It involves excision of the superior portion of condylar head, above the attachment of the lateral pterygoid muscle, so that the balance of the muscle function is not disturbed


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C. Eminectomy

• In 1951, Myrhang first reported this procedure.

• The rationale for this procedure is to allow the condylar head to move forward and backward free of obstruction, by the excision of the articular eminence, instead of attempting to restrict the forward movement of the condylar head


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Dislocation of the temporomandibular jointChristopher W. Shorey, and John H. Campbell, et al

Oral Med Oral Pathol Oral Radiol Endod 2000;89:662-8)


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• The success of any surgical procedure used to correct functional disorders of the TMJ is largely dependent on correctly establishing the cause and identifying the predisposing factors

• The degree of joint laxity and duration of dislocation make the definite treatment more challenging.

• Surgical plan should be developed based on the extent of the disease, age and health of the patient and previous treatment

• Equally important post-operative follow up.

Conclusion


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References

• Okeson -Management of temporomandibular disorders and occlusion- Sixth edition

• David A. Keith. Surgery of the Temporomandibular Joint. Second edition

• John E. Norman, Paul Bramley. A textbook and colour atlas of the Temporomandibular Joint, Diseases, Disorders, Surgery.

• Fonseca, Marciani, Turvey. Oral and Maxillofacial Surgery. Second edition

• Dislocation of the temporomandibular jointChristopher W. Shorey, and John H. Campbell, et al Oral Med Oral Pathol Oral Radiol Endod 2000;89:662-8)


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• B. C. Vasconcelos, G. G. Porto, F. T. B. Lima: Treatment of chronic mandibular dislocations using miniplates: follow-up of 8 cases and literature review. Int. J. Oral Maxillofac. Surg. 2009; 38: 933–936.

• Long-term results following miniplate eminoplasty for the treatment of recurrent dislocation and habitual luxation of the temporomandibular joint Int. J. Oral Maxillofac. Surg. 2003; 32: 474-479.

• Dautrey’s Procedure in Treatment ofRecurrent Dislocation of the Mandible Kiran Shrikrishna Gadre, et al J Oral Maxillofac Surg 68:2021-2024, 2010

• Caromed facelift bandage A.S.R. Pinto et al British Journal of Oral and Maxillofacial Surgery 47 (2009) 323–324


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• Glenotempororal osteotomy and bone grafting for the management of chronic recurrent temporomandibulardislocation- medra et al – BJOMS- 2007

• A Safe and Effective Way for Reduction of TemporomandibularJoint Dislocation- Yi-Chieh Chen et al. Annals of plastic surgery 2007

• Use of Masseteric and Deep Temporal Nerve Blocks for Reduction of Mandibular Dislocation- Andrew L. Young et al. Americal society of anaesthesiology, 2009

• Temporomandibular Joint Dislocation Reduction Technique A New External Method vs. the Traditional-Mojtaba MohamadiArdehali et al. Annals of plastic surgery. 2009

subluxation and dislocation of temporomandibular joint

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