Recurrent Mandibular Dislocation in Geriatric Patients: Treatment and Prevention by a Simple and Non-invasive Technique

Abstract

Dislocation is defined as the complete loss of articular relationship between the articular fossa of the temporal bone and the condyle-disk complex. Most common aetiology of dislocation is wide mouth opening, trauma and use of certain drugs. It is classified as acute, chronic and recurrent. Chronic recurrent dislocation of mandible is a distressing condition especially for geriatric patients. Various non-surgical methods of reduction include Hippocratic method, Awang’s gag reflex method, wrist-pivot technique, combined ipsilateral staggering technique, recumbent approach, intermaxillary fixation, injection of a sclerosing solution, autologus blood transfusion and botulinum toxin. In geriatric population, the ridges become atrophic with time and use of any method of reduction which exerts force on mandible increases chances of fracture of mandible. Awang’s gag reflex method is a non invasive technique which helps in treatment of chronic recurrent dislocation in geriatric patients. Along with this technique the use of a cervical collar has been reported in this article, which not only acts as a restrainer but also is helpful for cervical spondylosis, a common condition encountered in geriatric population.

Introduction

Dislocation of the mandible is a relatively common maxillofacial emergency seen in the maxillofacial practice and may occur in up to 5 % of the population during their lifetime [1]. Dislocation is defined as the complete loss of articular relationship, during mouth-wide opening, between the articular fossa of the temporal bone and the condyle-disk complex [2]. In case of dislocation, the condyle is not in its regular position and may be placed anterior, posterior, superior, medial or lateral to the glenoid fossa. However displacement of the head of the condyle out of the glenoid fossa is also greatly influenced by the morphology of the condyle, glenoid fossa, articular eminence, zygomatic arch and squamotympanic fissure. The mentioned factors mainly determine the type and direction of dislocation. In addition age, dentition, cause and duration of the dislocation as well as the function of the masticatory muscles contribute significantly in the mechanism and management of temporomandibular joint dislocation.

Mandible dislocations can be unilateral or bilateral, although the latter is more common. Rowe and Killey (1968) classified the condition into acute, chronic and recurrent. Chronic recurrent dislocations can be classified into five types based on aetiology [3]. Type I: Patients had few previous episodes and their condyles were repositioned by physician without anaesthesia. Type II: Patients had more than few episodes previously and condyles were repositioned by physician or maxillofacial surgeon with local or general anaesthesia. Type III: Patients had more than few episodes due to a systemic disorder and they need surgical reconstruction. Type IV: Patients had previous and failed surgical treatments and they need further surgical reconstruction. Type V: Patients who cannot receive intermaxillary fixation due to local and systemic problems.

Dislocation can be caused by intrinsic trauma: overextension injury (yawning, vomiting, wide bite or seizure disorder), extrinsic trauma: trauma (flexion–extension injury to mandible, intubation under general anaesthesia, endoscopy, dental extraction, forceful hyperextension), connective tissue disorders (hyper mobility syndromes, Ehler–Danlos syndrome, Marfan’s syndrome), miscellaneous causes (internal derangement, desynchronous muscle function, contralateral intra-articular obstruction, lost vertical dimension, occlusal discrepancies), psychogenic (habitual dislocation, tardive dyskinesia), drug induced: (phenothiazines) [4].

Chronic recurrent dislocation can be treated either conservatively or with surgical intervention. Conservative treatment includes Hippocratic method, wrist-pivot technique, combined ipsilateral staggering technique, recumbent approach, intermaxillary fixation, injection of a sclerosing solution, autologous blood transfusion or botulinum toxin. Surgical measures include creation of obstruction (Dautry procedure, use of bone mini-plates and placing graft on articular eminence), removal of obstruction (eminectomy or high condylar shaving), capsule tightening procedures (capsulorrhaphy or reinforcement of joint capsule), turning down temporal fascia flap to reinforce the capsule of joint or formation of the external sling by ligating the fascia through drill holes in both the zygomatic arch and the condyle [5].

An alternative conservative treatment modality that is the gag reflex procedure was introduced by Awang in 1987. In this technique, the soft palate is rubbed across with a dental probe to initiate relaxation of the lateral pterygoid muscle and spontaneous reduction and closure of the mouth with or without local anaesthesia. This paper describes two cases in which joint dislocation was successfully resolved by stimulation of gag reflex and its further prevention was done by addition of a cervical collar in geriatric patients.

Case Report 1

A 63-year-old female, presented to the Department of OMFS, D.A.V. Dental College and Hospital, Yamunanagar complaining of inability to close her mouth. This incident happened when patient was laughing 2 h before reporting to the department. The patient gave history of two similar episodes during past few months when she opened her mouth wide while yawning. In both the episodes, the dislocation got reduced by itself when she manipulated her lower jaw. But this time she failed to do so and reported to our department. General physical examination revealed that the patient had an elongated face and was not able to close her mouth. On palpation, TMJ and masticatory muscles were non-tender. Bilateral depression was found in the preauricular region with the condyle being palpated 3–4 cm in front of the depression on either side. Intraoral examination revealed completely edentulous upper and lower jaws. Diagnosis of bilateral chronic recurrent condylar dislocation of TMJ was given after radiographic examination. Mandible was reduced by using Awang’s technique. After reduction the joint was immobilized with the help of a cervical collar which acted as a restrainer. The patient was advised not to open the mouth wide and continue wearing the cervical collar. Post –operative X-ray showed condylar heads properly seated in the glenoid fossa (Figs. 1–3).

Fig. 2.

Stimulation of palate by gag reflex

Fig. 1.

Clinical frontal profile of patient having TMJ dislocation

Fig. 3.

Restrainer-Cervical collar in place

Case Report 2

A 70-year-old female presented to the department of OMFS D.A.V. Dental College and Hospital, Yamunanagar complaining of inability to close her mouth and difficulty in talking. This accident happened when patient was yawning with wide open mouth 1 h before reporting to department. Patient gave history of two similar episodes in past one year in which one got reduced by itself and other was reduced by an ENT surgeon. On palpation, TMJ and masticatory muscles were non-tender and bilateral depression was palpable in the preauricular region. Radiographic findings confirmed bilateral dislocation of the temporomandibular joint. A mouth mirror was used to elicit the gag reflex by probing the soft palate. Immediately following the gag action, she could close her mouth and felt great relief. The mandible was immobilised and she was discharged on the same day. She was advised not to carry out excessive jaw movements and to have a soft diet for several days. An additional cervical collar was provided to prevent recurrent dislocation. Post operative x-rays revealed complete reduction of mandible.

Both the patients were followed-up for a time period of 1 year, during which they had no episode of dislocation. In fact both the patients found cervical collar very useful and they were removing the collar only while taking bath. We advised them not to wear it at night time.

Discussion

Anterior mandibular dislocation is the most common dislocation of the TMJ which represents 3 % of all articular body luxation. When this condition progresses and becomes frequent it is termed as recurrent dislocation or habitual dislocation. The problem can affect any age group from under the age of 10 years up to 79 years but more common in 2nd and 3rd decades. Highest frequency of TMJ luxation is found in females, the cause for this is still unknown [5]. In case of subluxation, the condylar head translates anterior to the articular eminence of the temporal bone, but then reduces spontaneously. In anterior dislocation, the condylar head is displaced anteriorly out of the glenoid fossa but does not spontaneously reduce back to its normal position.

Dislocation occurs when the normal coordinated sequence of mandibular retraction followed by elevation is interrupted such that the mandible is elevated before retraction and the condyles are locked anterior to the articular eminence. The condition is characterised by the inability to close the mouth with protrusion of the mandible, spasm and tension in the masticatory muscle, excessive salivation and difficulty in speech. Depression may be noted in preauricular area normally occupied by condyles. A typical facial expression due to anxiety related to the thought of not being able to close the mouth is seen on the patient’s face. It occurs as a combination of three factors mainly: Laxity of mandibular and capsular ligaments, large bony eminence and spasm of masticatory muscles.

There are many conservative methods for reduction of dislocated mandible. Among these, the Hippocratic method is the most commonly used non-surgical method. In Hippocratic method the operator stands in front of the patient and his/her thumbs are covered by gauze or finger splint. Force is applied firmly in downward direction over the molar region, and chin is rotated upward and then pushed posteriorly [1].

Second method is the wrist-pivot technique [6] in which operator stands in front and thumbs are placed at the apex of the mentum of the mandible with the fingers wrapped laterally around the mandible onto the occlusal surface of the mandibular molars of the patient. The operator’s thumbs apply an upward force on the mentum, whereas the operator’s fingers apply a downward force on the body of the mandible. The operator’s wrists move in the direction of ulnar deviation with slight flexion. As a result, the condyles rotate inferiorly and posteriorly back into the glenoid fossa.

Third method is combined ipsilateral staggering technique [7] in which the operator stands at the side of the patient and thumb exerts downward pressure intraorally on the ipsilateral lower molar teeth and condyle is moved to its original position.

Fourth approach is recumbent approach in which the patient lies recumbent while the operator stands in front of the patient and applies force caudally and posteriorly on the mandible similar to the Hippocratic technique [1].

All these methods are useful if the patient is having molars over which force can be exerted. But in older age groups where molars are absent and mandible is weak, force application becomes difficult and overzealous force application over the atrophic mandible can lead to fracture of mandible [1, 8, 9], although no cases have been reported till date.

The method of reducing dislocation by the stimulation of the gag reflex is a simple, rapid and safe method for use in geriatric patients. The ‘autoreduction’ of the condyle following the induced gag reflex minimises any additional trauma. In addition, the associated components of the gag reflex such as the closure of the glottis, tongue retraction and the momentary arrest of respiration protect the airway from inhalation of any foreign bodies during the reduction manoeuvre [8].

The cervical collar acts as a useful adjunct in preventing dislocation by acting as a restrainer as it prevents the wide opening of the jaw, which may precipitate dislocation. It has been documented in various studies that usually people above 60 years of age develop cervical spondylosis. Magnetic resonance imaging, computed tomography or X-rays reveal cervical spondylosis in up to 95 % of persons older than age 65 and the use of cervical collar in cases of cervical spondylosis is well documented [10]. Generally after reduction of dislocated condyle patient is provided with a bandage around the face and is asked not open his/her mouth wide. But the patient finds difficulty in eating and drinking because of the bandage, which further deteriorates the general health of the patient. Thus addition of a cervical collar to geriatric population not only helps in management of cervical spondylosis but also decreases recurrent mandibular dislocation by acting as a restrainer, as was seen in our patients.

Surgical intervention of the joint has role only in cases which are complicated by dense fibrous or bony tissue that prevents reduction by conventional methods. But surgery in case of old age group patients is related to its own complications due to the adverse systemic condition of these patients, if any.

Thus, Awang’s gag reflex method along with the use of cervical collar is a simple, non invasive technique for treatment and prevention of recurrent chronic dislocation in geriatric patients.

Conclusion

Even though, various surgical and non-surgical methods have been tried from time to time for the treatment of recurrent chronic dislocation cases, the gag reflex method along with the use of cervical collar is a very efficient method of treatment and prevention of this condition in geriatric patients. This method does not produce any anatomical or morphological changes in the joint area as no surgery is to be done. Further, addition of a cervical collar as a restrainer helps in prevention of this problem. In developing countries like India where cost is a very important factor and patients usually cannot afford surgery, this method provides an excellent way for relief from this misery.