Literature Review
Recurrent dislocation of the temporomandibular joint: a literature review and two case reports treated with eminectomy Wilson Denis Martins1, Marina de Oliveira Ribas1, Julio Bisinelli1, Beatriz Helena S. Franc¸a1, Guilherme Martins2 1
Pontifical Catholic University of Parana´, Curitiba, Brazil, 2UNINGA´, Maringa´, Parana´, Brazil
Aims: Dislocation of the temporomandibular joint (TMJ) is a troublesome condition that occurs in a chronic or acute form. It is a distressing and highly embarrassing situation that may occur as a result of daily activities such as yawning, laughing, or during events that require keeping the mouth open for a long time. This review aims to present and discuss different conservative and surgical techniques to treat patients with a dislocated mandible, and to present two cases of surgical treatment. Methodology: A search of the literature was completed (Medline, PubMed) using the keywords TMJ dislocation, TMJ luxation, mandibular dislocation and surgical and non-surgical methods of treatment for this condition. Results: Eminectomy (Myrhaug’s surgery) has been used with satisfactory results. Most of reports present large series of patients with more than one year of follow-up and no recurrence of complications. Is less invasive and take a short operation time; need no bone transplantation or placing any kind of foreign body into the joint. Conclusion: Eminectomy results in long-term resolution of recurrent TMJ dislocations, when compared with others surgical techniques. Keywords: Temporomandibular joint, Myrhaug, Dislocation, Eminectomy, Surgery
Introduction Dislocation or luxation of the temporomandibular joint (TMJ) is a troublesome condition that occurs in a chronic or acute form. It is defined as an excessive forward movement of the condyle beyond the articular eminence (AE), with complete separation of the articular surfaces and fixation (‘locking’) in that position.1 TMJ dislocation is a highly distressing and sometimes embarrassing situation for the patient. It may occur as a result of everyday activities, such as yawning or laughing, or during events that require keeping the mouth open for a long time.2,3 TMJ dislocation is generally seen in hospital emergency rooms and dentistry offices. Patients present with an inability to close the mouth, usually after some traumatic episode, e.g. yawning, laughing, vomiting, or excessive mouth
Correspondence to: Wilson Denis Martins, Pontifical Catholic University of Parana´, Av. Repu´blica do Lı´bano, 462 – CEP 82520-500 Curitiba, Brazil. Email: [email protected]
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opening during dental treatment or medical procedures conducted under general anesthesia. The main characteristic of TMJ luxation is the inability to close the mouth, with or without pain. Dislocation (or luxation) must be differentiated from subluxation, a common, self-improving condition. It is generally accepted that the first method for reducing acute TMJ dislocation was described by Hippocrates (500 BC), and modern techniques are based on this description.4,5 The literature concerning TMJ dislocation was reviewed for the current study, and two cases of surgical treatment are presented. In addition, a practical classification of the causative factors of TMJ dislocation is proposed.
Concepts and Definitions Temporomandibular (TMJ) dislocation or luxation occurs when the condyle moves outside the glenoid fossa, locking anteriorly to the AE. The condyle may be positioned anterior, posterior, medial or lateral to
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wide open, with only limited movement. Swallowing and speaking may be very difficult, and profuse drooling is frequently present. A radiograph confirms the diagnosis.8,19 Elapsioprearticularis is a radiographic term sometimes used to describe an image in which the condylar position is anterior to the AE, as seen in TMJ dislocation.9,15
Pathogenesis of dislocations Figure 1 Simulation of a right anterior TMJ dislocation in a dry skull.
the fossa, but anterior and superior dislocation are most common. The condition is also known as ‘open lock’.6,7 Figure 1 presents a simulation of an anterior TMJ dislocation in a dry skull, used for didactic purposes. The articular disc is represented by a piece of felt. The locking action is maintained by the protective contracture (spasms) of masticatory muscles, which leads to luxation. When the episodes become more frequent, the condition is termed habitual, chronic or recurrent TMJ dislocation.8 Caminiti and Weinberg9 stated that some confusion exists regarding the meaning of the terms subluxation and luxation. During dislocation (or true luxation), a joint is displaced from its articulations and requires manipulation (in most cases) to return to its normal position. Reduction may be manual (closed) or, in extremely rare cases of longstanding dislocation, surgical (open).10–13 These true dislocations of the TMJ may be further subdivided into acute and chronic recurrent or chronic persistent dislocations. A subluxation (or habitual subluxation) is an incomplete, painless, self-reducing TMJ dislocation in which the patient is able to close his or her mouth without assistance.14–16 Subluxation is generally asymptomatic, but is sometimes painful. The condyle may be displaced anterior to the AE of the temporal bone. When subluxations are asymptomatic, they should be viewed as normal variations and require no surgical treatment.16,17 Several studies show that there is an acceptable variation in the TMJ’s range of motion.16–18 Mandibular dislocation may be unilateral or bilateral. Unilateral dislocation is characterized by deviation to the contralateral side and laterognathism. The mouth is partially open, and the affected condyle is impalpable. Bilateral dislocation is more common than unilateral dislocation. In bilateral dislocation, the chin is central, and the mouth is
There are various causative factors in TMJ dislocation. The authors have divided them into triggering factors and predisposing factors. The triggering factors that cause mandibular dislocation and subsequent locking are well known and extensively described in the literature. They include several trauma situations,13 including yawning,20 laughing, vomiting6 and excessive mouth opening during dental treatment or medical procedures.21,22 The term triggering factor, as proposed here, seems to be applicable to every event or immediate cause of dislocation, with or without previous existing factors. Using this concept, it seems reasonable to consider any cause or event resulting in acute dislocation as a triggering factor for that particular locking episode, whether the episode is primary (first occurrence) or recurrent (repetitive). Otherwise, there is no consensus among authors regarding the predisposing factors for TMJ dislocation. The pathogenesis is generally attributed to a combination of factors, including laxity of the articular ligaments, and weakness of the capsule, trauma,19 unusual eminence size;12 muscle hyperactivity;6 internal derangements of the TMJ;14 occlusal disturbances, loss of vertical height and neurological disorders;3,23 muscular dyskinesias;24 connective tissue disorders;13 psychiatric disorders25 and the drugs used to treat them (phenothiazines, haloperidol and thiothixene); and a genetic predisposition toward joint laxity, as in Ehler-Danlosand Marfan’s syndromes.26 It is worth mentioning that in many TMJ dislocation cases reported in the reviewed literature, no relevant history or predisposing factor was provided. Assuming that at least a clinical examination and a sound anamnesis were performed in such cases, it seems reasonable to suppose that otherwise healthy patients may present eventual acute dislocations when submitted to a triggering factor or event.
Treatment of dislocations Reduction (repositioning) of the dislocated mandible According to the literature, different conservative and surgical techniques were used to treat patients with a dislocated mandible.27,28 In the case of nonreducible, acute TMJ dislocation, the primary
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Figure 2 Reduction of a bilateral TMJ dislocation using the Hippocratic method. The patient was sedated.
treatment consists of the Hippocratic manual repositioning method adopted by Fordyce28 and Gahhos and Ariyan29 and described by Bradley.30 The technique consists of standing in front of the seated patient and pressing the thumbs on the occlusal surfaces of the lower molar or on the external oblique ridge. The fingers are placed extraorally, under the angle of the mandible, and the chin is pulled further down from the dislocated position before being pressed horizontally backwards (Fig. 2). This procedure may be difficult because of the neuromuscular reflex (muscle spasm). In cases in which the procedure fails or the patient is very apprehensive, intravenous diazepam sedation or a Propofol bolus is indicated.31
Non-surgical treatment for recurrent mandibular dislocations A variety of conservative treatments have been used for recurrent, repetitive TMJ dislocations. Non-interventional methods include the application of local anesthetics and splints,23 mandibular range-of-motion restriction, a soft diet and physiotherapy,32 the use of intracapsular or extracapsular sclerosing agents,19 botulinum toxin injections to various muscles of mastication,33 and autologous blood injections.3,27,34 Botulinum toxin is derived from the anaerobic, Gram-positive rod Clostridium botulinum (Type A botulinum). It is indicated for treating recurrent dislocation as a result of impaired muscle coordination secondary to oromandibular dystonia and early neuroleptically induced and brain stem syndromes of various origins.8,34 The method requires repeated injections every 2 to 4 months and is contraindicated in myasthenia gravis and in pregnant and lactating women.33 Shorey35 discussed the many treatment modalities for mitigating the pain and discomfort of the 112
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habitually dislocated TMJ, and concluded that more conservative methods only temporarily alleviate symptoms, and recurrence is common. Furthermore, he stated that certain treatment modalities should be avoided. The injection of sclerosing agents (i.e. alcohol, ethacridine, sodium psylate, sodium morrhuate), in general, has an unacceptably low rate of success and should not be considered a safe treatment. The rationale for injecting these agents is to cause fibrosis and limit jaw movement, but the extent of fibrosis cannot be controlled.19 Machon et al.3 obtained success in 80% of patients with recurrent dislocation who were treated with an autologous intra-articular blood injection. In the cases in which the procedure was unsuccessful (20%; five patients), bilateral eminectomies were successfully completed. Additional successes with this technique have been reported.27,36–39
Surgical treatment for recurrent mandibular dislocations Norman and Bradley19 presented a criticism of the great number of treatments and what they called ‘increasing ingenuity’ in surgical management of the TMJ dislocation, stating, ‘the number of operations is inversely proportional to their efficacy’.
Surgery that limits the condylar path Displacement of the zygomatic arch or a segment of it Lindemann (1925) was the first to utilize a bone chip from the zygomatic arch to treat TMJ dislocation.39 Mayer40 recommended using a larger piece of the zygomatic process for the displacement of the zygomatic arch or a segment of the arch, with the objective of obstructing the condylar path. The technique was improved by Leclerc and Girard.41 Another technique used to create an obstacle to anterior condylar excursion is a posterior–anterior slanting osteotomy of the eminence.42 After a critical review of the literature, Norman and Bramley19 recommend the glenotemporal osteotomy, even ‘at a risk of adding to the plethora of operations enthusiastically recommended by colleagues’. Placement of an obstacle using different materials Metallic obstacles have been used successfully in selected cases. Such obstacles include L-shaped steel pins and miniplates,1,43,44 and titanium screws.45 However, the use of these metallic materials has been associated with an increased incidence of fracture and loosening under functional loads, requiring further operations to remove the device and select a new treatment.1 VOL .
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Karabouta46 proposed increasing the AE with blocks of porous coralline hydroxylapatite. However, its use has been associated with displacement under functional loads. The use of wedge-shaped silicon blocks has also been associated with displacement and has been reported to evoke immune reactions, a more severe complication.8 Iliac or calvarial bone grafts have been suggested for augmenting the AE.47 Iliac bone grafts seem to have rapid resorption; however, calvarial graft complications were seen at the donor site and included dural tears, arachnoidal bleeding, hematomas and scalp infection.8 Wolford et al.48 presented a new technique that provides an effective method for the prevention of condylar dislocation. They used two Mitekmini bone anchors with osseointegration potential. One anchor is placed in the lateral pole of the condyle, and the other is placed in the posterior root of the zygomatic arch. Muscle and tendon surgery Two techniques have been used to treat hypermobility. The first is the lateral pterygoidmyotomy, as proposed by Bowman in 1949 and used by SindetPetersen49 and Laskin.50 The objective is to limit the mandibular translation and allow only rotational movement of the condyle. Some drawbacks of this method are reunion of the muscle during healing, a risk of bleeding in the area, and an impaired view of the site. The second technique is shortening the temporalis tendon. This method was proposed by Gould,51 but no further references to this technique were found in the literature.
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habitually dislocated TMJ, and concluded that zygomatic arch fracture, with or without grafting, and Myrhaug’s eminectomy appeared to be the best techniques for resolving dislocations, although the number of reported cases of zygomatic arch fracture is less than half that of eminectomy. Some authors noted a particular detail of the technique: the AE has to be removed up to its most medial portion.12,56 Since Myrhaug’s description, the eminectomy has been modified or performed in conjunction with other TMJ procedures.24,36,57 Eminectomies were performed in patients with a preoperative diagnosis of anterior disc displacement with reduction.58 In some cases, eminectomy alone has restored normal TMJ function. In the same study, eminectomy with subsequent discoplasty was performed in 30 patients with internal derangements, with excellent results (86.8% of the patients felt better). Weinberg59 described an interesting association that used direct plication of the fibrous disc to the capsule (meniscoraphy) plus eminectomy, and produced satisfactory results in a notable number of patients (n533) with internal derangements. Possible complications of eminectomy were pointed out, that should be considered when performing open or arthroscopic eminoplasty: lesions of the facial and trigeminal nerves as well damage to other adjacent structures must be taken into account. Pneumatization of the zygomatic arch and eminence should be recognized before indicating eminectomy, to avoid intraoperative perforation of the cells.60,61
Surgeries that enhance the condylar path
Case Reports Case 1
Myrhaug11 first reported eminectomy as a treatment for dislocation.The rationale for this procedure is to allow the condylar head to move forward and backward, free of obstruction by the excision of the AE, instead of attempting to restrict the forward movement of the condylar head. Although dislocation takes place, painless reduction will occur automatically. Since Myrhaug’s description was published, his technique has been performed with satisfactory results, and its efficacy has been confirmed in the literature.23,51–55 In the United States, Myrhaug’s technique was popularized by Irby,56 who obtained good results in the treatment of 30 patients. Shorey35 reviewed the treatment modalities available to mitigate the pain and dysfunction of the
A 30-year-old woman was taken by her general dentist to the hospital’s emergency room with a dislocated TMJ (Fig. 3). A brief history revealed that she had undergone endodontic therapy in the dental office, and the mandible became ‘locked after 10 minutes of mouth opening. The dentist immediately applied a reduction maneuver with negative results. Clinical and radiographic examinations revealed a bilaterally dislocated TMJ (Figs. 3 and 4). The patient was very apprehensive and in intense pain. It was evident that a reflex muscle spasm had occurred, and the clinicians decided to reduce the dislocation under Propofol sedation applied by the anesthesiologist. The TMJ reduction was easily achieved, and the patient was discharged from the hospital after an eight-hour observation period.
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Figure 5 Access to the zygomatic arch.
Figure 3 Frontal aspect of the patient.
During subsequent appointments, a more complete history revealed that the patient had presented repeated TMJ dislocations in the previous two years. The dislocations were associated with yawning (two episodes), eating (one episode) and sleeping (one episode), and the patient was repeatedly taken to the hospital’s emergency room for reduction. A detailed anamnesis and medical examination failed to reveal
Figure 4 Transcranial radiographs showing empty right and left glenoid fossa and both condyles situated anteriorly to the AE. Dotted lines: glenoid fossa, articular eminence and condyles.
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any disease or condition other than the TMJ problem. The patient described herself as a ‘usually worried and anxious person’. After obtaining written consent, the patient was admitted to the hospital, scheduled for surgery and submitted to bilateral eminectomies under general anesthesia.
Figure 6 Holes in the ‘base’ of the right articular eminence.
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Figure 9 The bony surface was regularized before suturing the periosteum.
Figure 7 Eminectomy completed.
The joint was accessed via preauricular incision and the zygomatic arch, glenoid fossa and temporal fossa were exposed (Fig. 5). Special care was taken to incise and detach the periosteum covering the AE. Holes were drilled
following the hypothetical ‘base’ of the AE (using a no. 7 round bur) (Fig. 6). The holes were united with a no. 702 cylindrical bur and the eminence was removed with chisels (Figs. 7 and 8). The rough bone surfaces were regularized with round burs and bone files; the periosteum was sutured (Figs. 9 and 10). The removed eminences (with a spherical calotte shape) are shown in Fig. 10. Post-operative was uneventful, and the patient was discharged after two days. The procedure was successful; at one year of follow-up, the patient had no further TMJ dislocations.
Case 2 A 55-year-old woman presented for consultation with a history of repetitive, unilateral dislocation of the
Figure 8 After removal of the eminence, the posterior band of the articular eminence is visible.
Figure 10 Removed left and right articular eminences.
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Figure 11 Discoplasty – a deep wedge of the posterior attachment was removed (right temporomandibular joint).
right TMJ in the last eight months. In most situations, reduction was achieved spontaneously; however, for the last dislocation, she had to be taken to the hospital emergency room. She revealed that reiteration of the dislocation produced local pain and severe eating difficulties, causing anxiety and impairing her normal life. Surgical exploration of her right TMJ was proposed, with the possibility of an eminectomy. The procedure was conducted under general anesthesia. An eminectomy of the right TMJ was performed, following the surgical steps described in Case 1. The articular disc was found fully displaced in an anterior position, and a subsequent discoplasty with disc repositioning was completed (Figs. 11 and 12). The patient has been followed for two years and has had no more TMJ dislocation episodes.
Discussion TMJ dislocation is an emergency situation that requires immediate attention from a physician or dentist because the patient generally presents with acute pain and is often embarrassed by the situation. Many treatment modalities are available to mitigate the dysfunction and suffering caused by recurrent TMJ dislocation. Most authors agree that conservative
methods provide only temporary alleviation of symptoms, and recurrence is common.19 Surgical intervention has been considered the most effective treatment, and it seems reasonable to indicate a surgical procedure for correcting this troublesome situation.1,4,6,7–15,19,23,28,51–59 Norman and Bradley19 raised a serious criticism of the great number of treatments and what they called ‘increasing ingenuity’ in the surgical management of TMJ dislocation, stating, ‘the number of operations is inversely proportional to their efficacy’. Consequently, surgeons may face a dilemma about indicating surgery. Accurate comparisons of the reported surgical modalities are difficult because of differing follow-up and different definitions of success.36 With these considerations in mind, and based on the reviewed literature and the outcomes of the presented cases, it is reasonable to conclude that: (i) eminectomy has been used with satisfactory results and efficacy by a significant number of surgeons. Most of the reports present large numbers of patients with more than one year of follow-up and no recurrences of complications (ii) eminectomy is less invasive than other techniques. Its other advantages include a short operation time with no need for postoperative maxillary– mandibular immobilization, bone transplantation or placing any kind of foreign body in the form of alloplastic material (iii) eminectomy and its modifications and associations offer a good chance for the long-term resolution of recurrent TMJ dislocations.
Disclaimer statements Contributors None. Funding None. Conflicts of interest None. Ethics approval The ethical committee of the PUCPR approved this study. The patients signed an informed consent form.
References
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Figure 12 Discoplasty – the disc was repositioned and the posterior band was sutured to the bilaminar zone (posterior attachment).
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37 Daif ET. Autologous blood injection as a new treatment modality for chronic recurrent temporomandibular joint dislocation. O Surg O Med O Pathol O Radiol Endod. 2010:109:31–6. 38 Kato T, Shimoyama T, Nasu D, Kaneko T, Horie N, Kudo I. Autologousbloodinjection into the articular cavity for the treatment of recurrent temporomandibular joint dislocation: a case report. J Oral Sci. 2007;49:237–9. 39 Lindemann A. Die chirurgischebehandlung der Erkraunkungen des Kiefergelenkes. Z Stomat. 1925;23:395–406. 40 Mayer L. Recurrent dislocation of the jaw. J Bone Joint Surg. 1933;15:22–5. 41 Leclerc GC, Girard C. Un nouveau proce´de´ de dute´edansletraitementchirurgical de laluxationrecidivante de lamachoireinferieur. Mem Acad Chir. 1943;69:457–659. 42 Gosserez M, Dautrey R, Dornier R, et al. Luxationstemporomandibullaires et bute´earthropastiques. Rev Stomatol. 1964;65:690. 43 Bakardjiev A. Treatment of chronic mandibular dislocation by bone plates: two case reports. J Craniomandibular Surg. 2004;32:90. 44 Puelacher WC, Waldhart E. Miniplate eminoplasty: a new surgical treatment for TMJ dislocation. J Craniomaxillofac Surg. 1993;21:176–8. 45 Oztan HY, Ulusal B, Turegun M, Deveci M. Titanium screw implantation to the articular eminence for the treatment of chronic recurrent dislocation of the temporomandibular joint. Int J Oral Maxillofac Surg. 1985;34:921–7. 46 Karabouta I. Increasing of the articular eminence by the use of blocks of porous coralline hydroxylapatite for treatment of recurrent TMJ dislocation. J Craniomaxillofac Surg. 1990;18:107–13. 47 Medra AM, Mahrous AM. Glenotemporal osteotomy and bone grafting in the management of chronic grafting in the management of chronic recurrent dislocation and hypermobility of TMJ. Br J Oral Maxillofac Surg. 2008;46:119–22. 48 Wolford LM, Pitta MC, Mehra P. Mitekanchors for treatment of chronic mandibular dislocation. O Surg O Med O Pathol O Radiol Endod. 2001;92:495–8. 49 Sindet-Petersen S. Intraoral myotomy of lateral pterygoid muscle for treatment of recurrent dislocation of mandibular condyle. J Oral Maxillofac Surg. 1988;46:445–9. 50 Laskin DM. Myotomy for the management of recurrent and protracted mandibular dislocation. Trans 4th International Conference on Oral Surgery in Amsterdam. Copenhagen: Munskaard; 1973. p. 264. 51 Gould JF. Shortening of the temporalis tendon for hypermobility of the TMJ. J Oral Surg. 1978;36:781. 52 Helman J, Laufer D, Minkov B, Gutman D. Eminectomy as surgical treatment for chronic mandibular dislocation. Int J Oral Surg. 1984;13:486–9. 53 Cherry CQ, Frew AL Jr. Bilateral reductions of articular eminence for chronic dislocation: review of eight cases. J Oral Surg. 1977;35:598–600. 54 Goode RL, Linchan JW, Shorago G. Recurrent mandibular dislocation relieved by removal of articular eminence. Arch Otolaryngol Head Neck Surg. 1973;98:97–9. 55 Souza LCM, Tenorio-Cabezas N, Dias OS. Eminectomia no tratamento da luxac¸a˜o recidivante do coˆndilo mandibular. Rev Paulista Odontol. 1998;1:16–20. 56 Irby WB. Surgical correction of chronic dislocation of the TMJ not responsive to conservative therapy. J Oral Surg. 1957;15:307–12. 57 Oatis GW, Baker DA. The bilateral eminectomy as definitive treatment:a review of 44 patients. Int J Oral Surg. 1984;13:294–8. 58 Gay-Escola C. Eminectomy associated with redirectioning of the temporal muscle for treatment of recurrent TMJ dislocation. J Craniomaxillofac Surg. 1987;15:355–8. 59 Weinberg S. Eminectomy and meniscorhaphy for internal derangements of the temporomandibular joint. Rationale and operative technique. O Surg O Med O Pathol. 1984;57:241–9. 60 Kerstens HCJ, Tuinzin DB, van der Kwast WAM. Eminectomy and discoplasty for correction of the displaced temporomandibular joint disc. J Oral Maxillofac Surg. 1989;47:150–2. 61 Wolford LM, Pitta MC, Mehra P. Mitek anchors for treatment of chronic mandibular dislocation. O Surg O Med O Pathol O Radiol Endod. 2001;92:495–8.
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Recurrent dislocation of the temporomandibular joint: a literature review and two case reports treated with eminectomy Wilson Denis Martins1, Marina de Oliveira Ribas1, Julio Bisinelli1, Beatriz Helena S. Franc¸a1, Guilherme Martins2 1
Pontifical Catholic University of Parana´, Curitiba, Brazil, 2UNINGA´, Maringa´, Parana´, Brazil
Aims: Dislocation of the temporomandibular joint (TMJ) is a troublesome condition that occurs in a chronic or acute form. It is a distressing and highly embarrassing situation that may occur as a result of daily activities such as yawning, laughing, or during events that require keeping the mouth open for a long time. This review aims to present and discuss different conservative and surgical techniques to treat patients with a dislocated mandible, and to present two cases of surgical treatment. Methodology: A search of the literature was completed (Medline, PubMed) using the keywords TMJ dislocation, TMJ luxation, mandibular dislocation and surgical and non-surgical methods of treatment for this condition. Results: Eminectomy (Myrhaug’s surgery) has been used with satisfactory results. Most of reports present large series of patients with more than one year of follow-up and no recurrence of complications. Is less invasive and take a short operation time; need no bone transplantation or placing any kind of foreign body into the joint. Conclusion: Eminectomy results in long-term resolution of recurrent TMJ dislocations, when compared with others surgical techniques. Keywords: Temporomandibular joint, Myrhaug, Dislocation, Eminectomy, Surgery
Introduction Dislocation or luxation of the temporomandibular joint (TMJ) is a troublesome condition that occurs in a chronic or acute form. It is defined as an excessive forward movement of the condyle beyond the articular eminence (AE), with complete separation of the articular surfaces and fixation (‘locking’) in that position.1 TMJ dislocation is a highly distressing and sometimes embarrassing situation for the patient. It may occur as a result of everyday activities, such as yawning or laughing, or during events that require keeping the mouth open for a long time.2,3 TMJ dislocation is generally seen in hospital emergency rooms and dentistry offices. Patients present with an inability to close the mouth, usually after some traumatic episode, e.g. yawning, laughing, vomiting, or excessive mouth
Correspondence to: Wilson Denis Martins, Pontifical Catholic University of Parana´, Av. Repu´blica do Lı´bano, 462 – CEP 82520-500 Curitiba, Brazil. Email: [email protected]
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ß W. S. Maney & Son Ltd 2014 DOI 10.1179/0886963413Z.00000000017
opening during dental treatment or medical procedures conducted under general anesthesia. The main characteristic of TMJ luxation is the inability to close the mouth, with or without pain. Dislocation (or luxation) must be differentiated from subluxation, a common, self-improving condition. It is generally accepted that the first method for reducing acute TMJ dislocation was described by Hippocrates (500 BC), and modern techniques are based on this description.4,5 The literature concerning TMJ dislocation was reviewed for the current study, and two cases of surgical treatment are presented. In addition, a practical classification of the causative factors of TMJ dislocation is proposed.
Concepts and Definitions Temporomandibular (TMJ) dislocation or luxation occurs when the condyle moves outside the glenoid fossa, locking anteriorly to the AE. The condyle may be positioned anterior, posterior, medial or lateral to
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wide open, with only limited movement. Swallowing and speaking may be very difficult, and profuse drooling is frequently present. A radiograph confirms the diagnosis.8,19 Elapsioprearticularis is a radiographic term sometimes used to describe an image in which the condylar position is anterior to the AE, as seen in TMJ dislocation.9,15
Pathogenesis of dislocations Figure 1 Simulation of a right anterior TMJ dislocation in a dry skull.
the fossa, but anterior and superior dislocation are most common. The condition is also known as ‘open lock’.6,7 Figure 1 presents a simulation of an anterior TMJ dislocation in a dry skull, used for didactic purposes. The articular disc is represented by a piece of felt. The locking action is maintained by the protective contracture (spasms) of masticatory muscles, which leads to luxation. When the episodes become more frequent, the condition is termed habitual, chronic or recurrent TMJ dislocation.8 Caminiti and Weinberg9 stated that some confusion exists regarding the meaning of the terms subluxation and luxation. During dislocation (or true luxation), a joint is displaced from its articulations and requires manipulation (in most cases) to return to its normal position. Reduction may be manual (closed) or, in extremely rare cases of longstanding dislocation, surgical (open).10–13 These true dislocations of the TMJ may be further subdivided into acute and chronic recurrent or chronic persistent dislocations. A subluxation (or habitual subluxation) is an incomplete, painless, self-reducing TMJ dislocation in which the patient is able to close his or her mouth without assistance.14–16 Subluxation is generally asymptomatic, but is sometimes painful. The condyle may be displaced anterior to the AE of the temporal bone. When subluxations are asymptomatic, they should be viewed as normal variations and require no surgical treatment.16,17 Several studies show that there is an acceptable variation in the TMJ’s range of motion.16–18 Mandibular dislocation may be unilateral or bilateral. Unilateral dislocation is characterized by deviation to the contralateral side and laterognathism. The mouth is partially open, and the affected condyle is impalpable. Bilateral dislocation is more common than unilateral dislocation. In bilateral dislocation, the chin is central, and the mouth is
There are various causative factors in TMJ dislocation. The authors have divided them into triggering factors and predisposing factors. The triggering factors that cause mandibular dislocation and subsequent locking are well known and extensively described in the literature. They include several trauma situations,13 including yawning,20 laughing, vomiting6 and excessive mouth opening during dental treatment or medical procedures.21,22 The term triggering factor, as proposed here, seems to be applicable to every event or immediate cause of dislocation, with or without previous existing factors. Using this concept, it seems reasonable to consider any cause or event resulting in acute dislocation as a triggering factor for that particular locking episode, whether the episode is primary (first occurrence) or recurrent (repetitive). Otherwise, there is no consensus among authors regarding the predisposing factors for TMJ dislocation. The pathogenesis is generally attributed to a combination of factors, including laxity of the articular ligaments, and weakness of the capsule, trauma,19 unusual eminence size;12 muscle hyperactivity;6 internal derangements of the TMJ;14 occlusal disturbances, loss of vertical height and neurological disorders;3,23 muscular dyskinesias;24 connective tissue disorders;13 psychiatric disorders25 and the drugs used to treat them (phenothiazines, haloperidol and thiothixene); and a genetic predisposition toward joint laxity, as in Ehler-Danlosand Marfan’s syndromes.26 It is worth mentioning that in many TMJ dislocation cases reported in the reviewed literature, no relevant history or predisposing factor was provided. Assuming that at least a clinical examination and a sound anamnesis were performed in such cases, it seems reasonable to suppose that otherwise healthy patients may present eventual acute dislocations when submitted to a triggering factor or event.
Treatment of dislocations Reduction (repositioning) of the dislocated mandible According to the literature, different conservative and surgical techniques were used to treat patients with a dislocated mandible.27,28 In the case of nonreducible, acute TMJ dislocation, the primary
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Figure 2 Reduction of a bilateral TMJ dislocation using the Hippocratic method. The patient was sedated.
treatment consists of the Hippocratic manual repositioning method adopted by Fordyce28 and Gahhos and Ariyan29 and described by Bradley.30 The technique consists of standing in front of the seated patient and pressing the thumbs on the occlusal surfaces of the lower molar or on the external oblique ridge. The fingers are placed extraorally, under the angle of the mandible, and the chin is pulled further down from the dislocated position before being pressed horizontally backwards (Fig. 2). This procedure may be difficult because of the neuromuscular reflex (muscle spasm). In cases in which the procedure fails or the patient is very apprehensive, intravenous diazepam sedation or a Propofol bolus is indicated.31
Non-surgical treatment for recurrent mandibular dislocations A variety of conservative treatments have been used for recurrent, repetitive TMJ dislocations. Non-interventional methods include the application of local anesthetics and splints,23 mandibular range-of-motion restriction, a soft diet and physiotherapy,32 the use of intracapsular or extracapsular sclerosing agents,19 botulinum toxin injections to various muscles of mastication,33 and autologous blood injections.3,27,34 Botulinum toxin is derived from the anaerobic, Gram-positive rod Clostridium botulinum (Type A botulinum). It is indicated for treating recurrent dislocation as a result of impaired muscle coordination secondary to oromandibular dystonia and early neuroleptically induced and brain stem syndromes of various origins.8,34 The method requires repeated injections every 2 to 4 months and is contraindicated in myasthenia gravis and in pregnant and lactating women.33 Shorey35 discussed the many treatment modalities for mitigating the pain and discomfort of the 112
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habitually dislocated TMJ, and concluded that more conservative methods only temporarily alleviate symptoms, and recurrence is common. Furthermore, he stated that certain treatment modalities should be avoided. The injection of sclerosing agents (i.e. alcohol, ethacridine, sodium psylate, sodium morrhuate), in general, has an unacceptably low rate of success and should not be considered a safe treatment. The rationale for injecting these agents is to cause fibrosis and limit jaw movement, but the extent of fibrosis cannot be controlled.19 Machon et al.3 obtained success in 80% of patients with recurrent dislocation who were treated with an autologous intra-articular blood injection. In the cases in which the procedure was unsuccessful (20%; five patients), bilateral eminectomies were successfully completed. Additional successes with this technique have been reported.27,36–39
Surgical treatment for recurrent mandibular dislocations Norman and Bradley19 presented a criticism of the great number of treatments and what they called ‘increasing ingenuity’ in surgical management of the TMJ dislocation, stating, ‘the number of operations is inversely proportional to their efficacy’.
Surgery that limits the condylar path Displacement of the zygomatic arch or a segment of it Lindemann (1925) was the first to utilize a bone chip from the zygomatic arch to treat TMJ dislocation.39 Mayer40 recommended using a larger piece of the zygomatic process for the displacement of the zygomatic arch or a segment of the arch, with the objective of obstructing the condylar path. The technique was improved by Leclerc and Girard.41 Another technique used to create an obstacle to anterior condylar excursion is a posterior–anterior slanting osteotomy of the eminence.42 After a critical review of the literature, Norman and Bramley19 recommend the glenotemporal osteotomy, even ‘at a risk of adding to the plethora of operations enthusiastically recommended by colleagues’. Placement of an obstacle using different materials Metallic obstacles have been used successfully in selected cases. Such obstacles include L-shaped steel pins and miniplates,1,43,44 and titanium screws.45 However, the use of these metallic materials has been associated with an increased incidence of fracture and loosening under functional loads, requiring further operations to remove the device and select a new treatment.1 VOL .
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Karabouta46 proposed increasing the AE with blocks of porous coralline hydroxylapatite. However, its use has been associated with displacement under functional loads. The use of wedge-shaped silicon blocks has also been associated with displacement and has been reported to evoke immune reactions, a more severe complication.8 Iliac or calvarial bone grafts have been suggested for augmenting the AE.47 Iliac bone grafts seem to have rapid resorption; however, calvarial graft complications were seen at the donor site and included dural tears, arachnoidal bleeding, hematomas and scalp infection.8 Wolford et al.48 presented a new technique that provides an effective method for the prevention of condylar dislocation. They used two Mitekmini bone anchors with osseointegration potential. One anchor is placed in the lateral pole of the condyle, and the other is placed in the posterior root of the zygomatic arch. Muscle and tendon surgery Two techniques have been used to treat hypermobility. The first is the lateral pterygoidmyotomy, as proposed by Bowman in 1949 and used by SindetPetersen49 and Laskin.50 The objective is to limit the mandibular translation and allow only rotational movement of the condyle. Some drawbacks of this method are reunion of the muscle during healing, a risk of bleeding in the area, and an impaired view of the site. The second technique is shortening the temporalis tendon. This method was proposed by Gould,51 but no further references to this technique were found in the literature.
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habitually dislocated TMJ, and concluded that zygomatic arch fracture, with or without grafting, and Myrhaug’s eminectomy appeared to be the best techniques for resolving dislocations, although the number of reported cases of zygomatic arch fracture is less than half that of eminectomy. Some authors noted a particular detail of the technique: the AE has to be removed up to its most medial portion.12,56 Since Myrhaug’s description, the eminectomy has been modified or performed in conjunction with other TMJ procedures.24,36,57 Eminectomies were performed in patients with a preoperative diagnosis of anterior disc displacement with reduction.58 In some cases, eminectomy alone has restored normal TMJ function. In the same study, eminectomy with subsequent discoplasty was performed in 30 patients with internal derangements, with excellent results (86.8% of the patients felt better). Weinberg59 described an interesting association that used direct plication of the fibrous disc to the capsule (meniscoraphy) plus eminectomy, and produced satisfactory results in a notable number of patients (n533) with internal derangements. Possible complications of eminectomy were pointed out, that should be considered when performing open or arthroscopic eminoplasty: lesions of the facial and trigeminal nerves as well damage to other adjacent structures must be taken into account. Pneumatization of the zygomatic arch and eminence should be recognized before indicating eminectomy, to avoid intraoperative perforation of the cells.60,61
Surgeries that enhance the condylar path
Case Reports Case 1
Myrhaug11 first reported eminectomy as a treatment for dislocation.The rationale for this procedure is to allow the condylar head to move forward and backward, free of obstruction by the excision of the AE, instead of attempting to restrict the forward movement of the condylar head. Although dislocation takes place, painless reduction will occur automatically. Since Myrhaug’s description was published, his technique has been performed with satisfactory results, and its efficacy has been confirmed in the literature.23,51–55 In the United States, Myrhaug’s technique was popularized by Irby,56 who obtained good results in the treatment of 30 patients. Shorey35 reviewed the treatment modalities available to mitigate the pain and dysfunction of the
A 30-year-old woman was taken by her general dentist to the hospital’s emergency room with a dislocated TMJ (Fig. 3). A brief history revealed that she had undergone endodontic therapy in the dental office, and the mandible became ‘locked after 10 minutes of mouth opening. The dentist immediately applied a reduction maneuver with negative results. Clinical and radiographic examinations revealed a bilaterally dislocated TMJ (Figs. 3 and 4). The patient was very apprehensive and in intense pain. It was evident that a reflex muscle spasm had occurred, and the clinicians decided to reduce the dislocation under Propofol sedation applied by the anesthesiologist. The TMJ reduction was easily achieved, and the patient was discharged from the hospital after an eight-hour observation period.
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Figure 5 Access to the zygomatic arch.
Figure 3 Frontal aspect of the patient.
During subsequent appointments, a more complete history revealed that the patient had presented repeated TMJ dislocations in the previous two years. The dislocations were associated with yawning (two episodes), eating (one episode) and sleeping (one episode), and the patient was repeatedly taken to the hospital’s emergency room for reduction. A detailed anamnesis and medical examination failed to reveal
Figure 4 Transcranial radiographs showing empty right and left glenoid fossa and both condyles situated anteriorly to the AE. Dotted lines: glenoid fossa, articular eminence and condyles.
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any disease or condition other than the TMJ problem. The patient described herself as a ‘usually worried and anxious person’. After obtaining written consent, the patient was admitted to the hospital, scheduled for surgery and submitted to bilateral eminectomies under general anesthesia.
Figure 6 Holes in the ‘base’ of the right articular eminence.
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Figure 9 The bony surface was regularized before suturing the periosteum.
Figure 7 Eminectomy completed.
The joint was accessed via preauricular incision and the zygomatic arch, glenoid fossa and temporal fossa were exposed (Fig. 5). Special care was taken to incise and detach the periosteum covering the AE. Holes were drilled
following the hypothetical ‘base’ of the AE (using a no. 7 round bur) (Fig. 6). The holes were united with a no. 702 cylindrical bur and the eminence was removed with chisels (Figs. 7 and 8). The rough bone surfaces were regularized with round burs and bone files; the periosteum was sutured (Figs. 9 and 10). The removed eminences (with a spherical calotte shape) are shown in Fig. 10. Post-operative was uneventful, and the patient was discharged after two days. The procedure was successful; at one year of follow-up, the patient had no further TMJ dislocations.
Case 2 A 55-year-old woman presented for consultation with a history of repetitive, unilateral dislocation of the
Figure 8 After removal of the eminence, the posterior band of the articular eminence is visible.
Figure 10 Removed left and right articular eminences.
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Figure 11 Discoplasty – a deep wedge of the posterior attachment was removed (right temporomandibular joint).
right TMJ in the last eight months. In most situations, reduction was achieved spontaneously; however, for the last dislocation, she had to be taken to the hospital emergency room. She revealed that reiteration of the dislocation produced local pain and severe eating difficulties, causing anxiety and impairing her normal life. Surgical exploration of her right TMJ was proposed, with the possibility of an eminectomy. The procedure was conducted under general anesthesia. An eminectomy of the right TMJ was performed, following the surgical steps described in Case 1. The articular disc was found fully displaced in an anterior position, and a subsequent discoplasty with disc repositioning was completed (Figs. 11 and 12). The patient has been followed for two years and has had no more TMJ dislocation episodes.
Discussion TMJ dislocation is an emergency situation that requires immediate attention from a physician or dentist because the patient generally presents with acute pain and is often embarrassed by the situation. Many treatment modalities are available to mitigate the dysfunction and suffering caused by recurrent TMJ dislocation. Most authors agree that conservative
methods provide only temporary alleviation of symptoms, and recurrence is common.19 Surgical intervention has been considered the most effective treatment, and it seems reasonable to indicate a surgical procedure for correcting this troublesome situation.1,4,6,7–15,19,23,28,51–59 Norman and Bradley19 raised a serious criticism of the great number of treatments and what they called ‘increasing ingenuity’ in the surgical management of TMJ dislocation, stating, ‘the number of operations is inversely proportional to their efficacy’. Consequently, surgeons may face a dilemma about indicating surgery. Accurate comparisons of the reported surgical modalities are difficult because of differing follow-up and different definitions of success.36 With these considerations in mind, and based on the reviewed literature and the outcomes of the presented cases, it is reasonable to conclude that: (i) eminectomy has been used with satisfactory results and efficacy by a significant number of surgeons. Most of the reports present large numbers of patients with more than one year of follow-up and no recurrences of complications (ii) eminectomy is less invasive than other techniques. Its other advantages include a short operation time with no need for postoperative maxillary– mandibular immobilization, bone transplantation or placing any kind of foreign body in the form of alloplastic material (iii) eminectomy and its modifications and associations offer a good chance for the long-term resolution of recurrent TMJ dislocations.
Disclaimer statements Contributors None. Funding None. Conflicts of interest None. Ethics approval The ethical committee of the PUCPR approved this study. The patients signed an informed consent form.
References
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Figure 12 Discoplasty – the disc was repositioned and the posterior band was sutured to the bilaminar zone (posterior attachment).
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