Abstract
Long-standing dislocation of the temporomandibular joint (TMJ) is rare. The management of this disorder is still controversial. This paper presents the authors’ experience of managing long-standing dislocation of the TMJ, and their attempt to develop guidelines for the management of this problem. They also show magnetic resonance images of two patients with long-standing dislocation of the TMJ.
Dislocation of the temporomandibular joint (TMJ) is a common condition, and can be categorized into three groups: acute; habitual; and long-standing . Acute dislocation is the most common and is defined as a sudden onset of the condyle being displaced anteriorly beyond the articular eminence, which cannot be reduced by the patient . This can be managed by manipulating the mandibular condyle downward and backward into the glenoid fossa with or without local anaesthesia or sedation. Habitual dislocation or chronic recurrent dislocation is relatively rare, and is defined as repeated episodes becoming more frequent and progressively worse . Surgical treatment, including myotomy , eminectomy , the LeClerc procedure , and augmentation of the articular eminence with a bone graft , is usually indicated for habitual dislocation. Long-standing dislocation or protracted dislocation is rarer, and is defined as dislocation not reduced immediately . The management of this rare entity ranges widely, from closed reduction to complicated surgical procedures, depending on the duration of the dislocation. The selection of a proper procedure is controversial. The purpose of this paper is to present the authors’ experience of six cases of long-standing dislocation and to try to provide guidelines for the management of this disorder and also to present the MRI features of long-standing dislocation of the TMJ.
Patients and methods
Six cases of long-standing dislocation of TMJ presented in the authors’ clinic from 2001 to 2008. Two patients with similar histories will be presented first. They were male, over 75 years old, with different systemic diseases and they stayed in the intensive care unit (ICU) for more than 8 weeks. The dislocation was found by their families following discharge from the ICU. The authors tried conventional manipulation in the outpatient clinic without sedation, and failed to reduce the condyle; because these two patients were drowsy, old and weak, their families declined further management.
Case 3 was a 72-year-old female who suffered from chronic obstructive pulmonary disease (COPD) and stayed in ICU for 2 weeks. After discharge, her family found she could not close her mouth as usual, and she came to the authors’ clinic for treatment. Closed reduction was performed 3 weeks later under deep sedation in the operating room. It took about 15 min to reduce the condyle by closed reduction. This patient was edentulous, and her jaws were fixed with an extraoral bandage for 2 weeks, with no recurrence at 6 months’ follow up.
Case 4 was a 68-year-old male, also suffering from COPD. Following a stay in ICU for 2 months, the authors treated him with manipulation, assisted by wire traction at the mandibular angles. Incisions were made in the submandibular areas without myotomy or extensive periosteal reflection. It took about 40 min to reduce the condyle into the genoid fossa, but the occlusion was not aligned with his dentures. It was difficult to reduce by traction at the mandible angle by wires. The patient was edentulous. Arch bars were placed on his complete dentures, and fixed to the upper denture by three screws and the lower denture by four circum mandibular wires. Intermaxillary fixation (IMF) was applied with four 26-gauge wires. The dislocation relapsed on the second day postoperatively. The patient and family abandoned the treatment and discharged the patient.
Case 5 was a 33-year-old male, who found his bite changed and noted swelling over his left cheek. On visiting his dentist in a general hospital, pericoronitis and cellulitis were diagnosed. The dentist gave him medication and local irrigation, and asked him to return in 1 week, but the patient found the swelling subsided during the week, and he thought the bite would ‘come back soon’. The patient had a sleeping disorder and used a mild tranquillizer that allowed him to tolerate the discomfort of dislocation. After 3 weeks the occlusion was still abnormal, so he returned to the dentist and dislocation was noted. The dentist tried to manipulate the mandible back to a normal position, but failed. The patient was referred to the authors’ clinic, 30 days after his dislocation. The authors checked the patient’s CT scans ( Fig. 1 ) and MRI. They had no success in reducing the 30-day long-standing dislocation, but the patient wanted to try manipulation under general anaesthesia and declined open reduction. The authors tried to manipulate by closed reduction, but after 1 h, failed to reduce the condyle into the glenoid fossa. The patient was discharged the next day and gave up further treatment. After 10 weeks from the onset, the patient returned and asked for the operation. The authors performed open reduction under general anaesthesia. An incision was made in front of the ramus, extending the buccal vestibule at the first molar (as for vertical osteotomy of the ramus), then detached the periosteum of the ramus, the posterior aspect of mandible, mandibular angle, coronoid process, sigmoid notch and part of condyle. The authors made a 1.5 cm incision under both mandibular angles, and inserted the stripper for the posterior mandibular border into the sigmoid notch instead of using wire at the angle to assist conventional reduction ( Fig. 2 ). It was difficult to reduce the condyle into the glenoid fossa because the scar tissue was very strong. It took about 1 h to push the condyle into the glenoid fossa; the incisors were in normal relation but a posterior open bite was found, about 1.5 mm. The authors placed IMF with 26-gauge wires and used elastic traction to correct the occlusion. After 1 week the occlusion came back to the centric occlusion ( Fig. 3 ). The elastic bands were removed and the IMF wire was continued for another 3 weeks (total 4 weeks). The patient was asked to do mouth opening exercises. His mouth opening was 20 mm at 1 month. The patient was asked to have a postoperative MRI to reveal the final position of the disc and the condition of the space and retrodiscal tissue, but he refused.
Case 6 was a 54-year-old male, who had been involved in a traffic accident on 10 July 2008. He did not seek treatment immediately but his left condyle protruded in the preauricular area and the mandible shifted to the right side on 11 November 2008. He visited his dentist for help, and dislocation was suspected. He did not seek help immediately, but when the condition did not improve, he visited his dentist again and was referred to the authors’ department on 4 December 2008. A panorex showed the right condyle fractured and malunited. His left condyle was located anteriorly to the articular eminence. The patient was partially edentulous and could not tolerate the pain in his lower jaw. It was decided to perform a closed reduction under general anaesthesia on 8 December 2008 (27 days after dislocation) and if that failed to reduce the condyle, open reduction with same procedures as in case 5 would be performed. It was not difficult to reduce his mandible using the closed method under general anaesthesia, and his jaws were fixed with IMF screws and wires. After 3 months’ follow up, there has been no recurrence.
Discussion
Long-standing TMJ dislocation is rare. In 1952, G ottlieb presented 24 cases of long-standing dislocation of the TMJ . In 1986, W ijmenga et al. presented three new cases of long-standing dislocation of the TMJ and reviewed 37 cases from 1952 to 1982 . Since then only a few case reports have been presented. The definition of long-standing dislocation is not clearly described. The authors suggest it should be defined as ‘an acute dislocation left untreated or inadequately treated for more than 72 h’ because acute inflammation has slowed down and repairing granulation starts forming.
Dislocation of the condyle causes muscle spasm, fibrotic change of soft tissue and soft tissue in-growth into the glenoid fossa making reduction difficult. There is no consensus on what is considered a significant period of time for reduction of a long-standing dislocation of the TMJ. Most agree that the longer the dislocation, the more difficult the reduction of the condyle . Based on their experience, the authors suggest that when the dislocation is of less than 3 weeks’ duration, closed reduction without local anaesthesia or sedation should be tried first; if this fails there is a good chance of reduction using closed reduction, under deep sedation or general anaesthesia without the aid of wire traction or myotomy. When the dislocation lasts for more than 30 days, the authors have had no success in using conventional reduction, even under general anaesthesia. When dislocation has persisted for 4–12 weeks it can be treated by open reduction, after stripping the periosteum of the ramus area as widely as possible, then using conventional manipulation with the assistance of wire traction at the mandibular angle or insertion of a U-shape stripper into the sigmoid notch to pull the mandible downward (in the way used for case 5). It is easier to pull the mandible downward with the stripper than using wire . The authors have limited experience in treating long-standing dislocation of more than 3 months. According to the literature review , manual reduction may be possible even after 6 months , but dislocations of more than 6 months generally require complicated surgical procedures, such as condylectomy, condylotomy, myotomy and a TMJ prosthesis , or other methods to correct the occlusion and reduce the mandible to the normal relationship with the maxilla. The treatments suggestions are in Table 1 . D eng et al. presented endoscopy-assisted reduction for a long-standing dislocation in 2007 , which could be used only for dislocations of less than 4 weeks, and in some special conditions. How much muscle or periosteal stripping should be done is another consideration; the authors found it hard to reduce the condyle into the glenoid fossa when the temporalis muscle is detached from the coronoid process completely. The spasm of muscles and fibrotic change of soft tissue in the anterior and inner surface of ramus and TMJ capsule might be the main reasons for difficulty in reduction.
