Management Strategy for Chronic Recurrent Temporomandibular Joint Dislocation: A Prospective Study

Abstract

Various approach strategies have been followed for management of temporomandibular joint (TMJ) dislocation. In this study, a total of 12 patients (21 TM joints) with chronic recurrent TMJ dislocations were managed surgically by articular eminectomy due to unsatisfactory outcomes of conservative management methods. An improvement in pain, range of jaw movements and maximal mouth opening was achieved in 10 patients (83.3%).

Introduction

Temporomandibular joint (TMJ) dislocation can be defined as the complete loss of articular relationship between the articular fossa of the temporal bone and the condyle-disk complex during wide mouth opening, which is often locked in anterior abnormal position [1]. The other types namely medial, lateral, superior into the middle cranial fossa, and posterior are rare and are mostly associated with trauma [2].

The term “chronic recurrent”, or “habitual” should be reserved for repeated episodic dislocations. The term “long-standing” is applied to those cases in which it has lasted for longer than a month [3]. The pathogenesis of chronic recurrent dislocation of the TMJ has been attributed to trauma, abnormal chewing habits, TMJ ligaments and capsule laxity, and masticatory muscles disorders. Even some drugs, such as fenotiazine or neurological disorders causing muscular hyperactivity (e.g. Parkinson’s disease), have been considered to have a role in TMJ dislocation [4]. First method for reducing acute TMJ dislocation was described by Hippocrates (500 BC), and modern techniques are based on this description [5]. Although it is possible to treat Chronic recurrent TMJ dislocation conservatively with simple manual reduction, these treatments are usually unsuccessful on long term basis. Nevertheless, many surgical approaches have been proposed in literature, eminectomy provide better result as per various surgeons hereby, in this In this study, we report the management of 12 patients (21 TM joints) with chronic recurrent TMJ dislocations by a treatment strategy which includes conservative manual reduction under local anesthesia when unresolved, further managed by autologous blood infusion into the TMJ cavity followed by surgery.

Patients and Methods

This is a retrospective study done during the time period from February 2015 and March 2018, patients with chronic recurrent TMJ dislocation were managed with this 3 step treatment strategy consisting of conservative manual reduction under local anesthesia when unresolved, further managed by autologous blood infusion into the TMJ cavity followed by surgery. management strategy. In twelve patients (21 TM Joints), age ranging from 19 to 64 years, with mean age of 41.5 years, out of which 7 (58.3%) were female and 5 (41.6%) were male with chronic recurrent TMJ dislocation managed with this 3 step treatment strategy consisting of conservative manual reduction under local anesthesia when unresolved, further managed by autologous blood infusion into the TMJ cavity followed by surgery (Figs. 1, 2, 3; Tables 1, 2, 3).

Fig. 1.

Simulation of anterior dislocation on left side TMJ in a dry skull

Fig. 2.

Osteotomy cut in the ‘base’ of the right articular eminence with the use of Endural incision

Fig. 3.

Post-operative radiograph showing flattening of articular eminence. Note: Arch bars for providing guided MMF

Table 1.

Pre-operative values of various parameters

Age/sex	Inter incisal-dimension (mm)	Location	Associated problem	TMJ clicking	Preauricular pain	Occlusal distrubance	Parafunctional activity
19/F	48	Bilateral	Connective tissue disorder	+++	+++	Absent	Bruxism
21/F	42	Bilateral	Under antidepressants	+++	+++	Absent	Absent
47/F	37	Bilateral	Absent	++	+	Present	Absent
38/M	45	Unilateral	Absent	++	++	Absent	Absent
64/F	41	Unilateral	Absent	+++	+	Absent	Absent
55/F	39	Unilateral	Under antidepressants	++	+++	Present	Absent
61/M	40	Unilateral	Parkinsonism	++	++	Absent	Absent
52/M	38	Unilateral	Absent	+++	+	Present	Absent
49/F	46	Unilateral	Under antidepressants	+	++	Absent	Bruxism
32/M	34	Unilateral	Absent	++	+++	Present	Absent
29/F	39	Unilateral	Absent	+++	+	Present	Nail biting
31/M	44	Unilateral	Absent	+++	++	Absent	Tongue thrusting

Table 2.

Characteristics of patients post-operatively

Age/sex	Preauricular pain	Inter-incisal dimension	TMJ-clicking sound	Occlusion
19/F	+	55	+	Satisfactory
21/F	_	53	_	Satisfactory
47/F	_	44	_	Unsatisfactory
38/M	+	53	_	Satisfactory
64/F	–	50	+	Unsatisfactory
55/F	–	44	+	Satisfactory
61/M	+	54	_	Unsatisfactory
52/M	–	49	+	Satisfactory
49/F	–	52	+	Satisfactory
32/M	+	48	_	Satisfactory
29/F	+	43	_	Unsatisfactory
31/M	–	50	_	Unsatisfactory

Table 3.

Complications and recurrence in follow-up period

Age/sex	Recurrence	5th and 7th CN damage	Followup period	Perforation of AE cells	Ostitis externa	Malocclusion
19/F	Yes	Absent	1 year	No	No	No
21/F	Yes	Absent	1.5 years	No	No	No
47/F	No	Absent	2.5 years	No	No	No
38/M	No	Absent	1.5 years	No	No	No
64/F	No	Present	2 years	No	No	No
55/F	No	Absent	2 years	No	No	No
61/M	No	Present	2.5 years	No	No	No
52/M	No	Present	1 year 8 months	No	No	No
49/F	No	Absent	2 year 4 months	No	No	No
32/M	No	Present	2 year 8 months	No	No	No
29/F	No	Absent	2 years	No	No	No
31/M	No	Present	1 year 10 months	No	No	No

Inclusion criteria

• Age 18–70 years

• TMJ dislocation more than 15 times per week for 3 months

• Medically healthy adult (ASA classification I-II,)

Exclusion criteria

• Longstanding TMJ dislocation without reduction and

• Acute dislocation cases were excluded.

In all the cases, a postoperative follow-up of at least 1 year (mean = 1.7 years) was carried out.

Most of the patients reported with complaint of inability to close their mouth, pain in and around the TMJ region during mouth opening and mastication, Clicking or popping sound of TMJ during opening and closing movements of the mandible since 7–8 month without any prior history of trauma. On examination they had difficulty in speaking, mastication, swallowing and profuse drooling of saliva, posterior molar gagging and anterior open bite, forwardly postured mandible with restricted movements, distinct hollowness can be felt in both the preauricular regions and with extremely apprehensive behavior in nature. Preoperative Clinical parameters such as 1. Interincisal dimension (mm), 2. Location (Unilateral/Bilateral), 3. Associated problem (any connective tissue disorder/medication etc.,) 4. Clicking sound (±), 5. Preauricular pain (±), 6. Parafunctional activity (bruxism/abnormal oral habits) were assessed pre-operatively. Data obtained was compiled on a MS Office Excel Sheet (v 2010, Microsoft Redmond Campus, Redmond, Washington, United States). Data was subjected to statistical analysis using Statistical package for social sciences (SPSS v 21.0, IBM).

Management Strategy

All patients were conventionally and conservatively treated, for at least 3 months with manual reduction under local anesthesia injected into the depression in the glenoid fossa left by the dislocated condyle and surrounding masticatory muscles to overcome the resistance of the severe muscle spasm. Initially attention was given to reduce tension, anxiety and muscle spasm by reassuring the patient, tranquilizer or sedative drugs, pressure and massage to the area followed by manipulation. Immobilization was be carried out, by giving Barton’s bandage to the patient for a period of 10–14 days and patient was kept on semisolid diet. This allowed the joints to get adequate resting period. Anti-inflammatory, analgesic drugs were prescribed for a period of 3–5 days. The patient was warned to avoid excessive mouth opening and support the chin, while yawning. On persistent symptoms and recurring dislocation following 3 months of treatment, the next step of treatment which is injection of autologous blood into the joint space to restrict the mandibular movements was carried out. The pathophysiology of injecting autologous blood is by the induction of fibrosis in the upper joint space, the pericapsular tissues, or both followed by a gradual and controlled range of motion exercises after 2 weeks of the injection therapy [3]. Dietary restrictions, physiotherapy by elastic rubber traction with interdental wiring and ligature wires or intermaxillary fixation (IMF) with elastic bands were useful to achieve the reduction and mandibular anterior repositioning splints. When forementioned conservative methods proved to be ineffective and unsuccessful, patients were considered for surgery.

Radiologic investigations such as MRI/CT scans were obtained before surgery to analyze the bone thickness in different parts of the eminence, for detection of pneumatisation of the eminence and to know about the status of articular disc. Eminectomy is a well-established procedure for chronic recurrent TMJ dislocation and many surgeons used this method with satisfactory results thus authors agreed the same. Endaural incision was used to expose the eminence and TMJ. A round stainless steel bur was used to mark grooves for orientation on the part of the eminence to be osteotomized. A fissure bur was used to define the cuts followed by chisel and mallet to perform the resection. The rough bony edges were smoothened by a vulcanite trimming bur. TMJ movements were checked for normalcy and following achievement of hemostasis, closure of wound was done in layers. Within the first 3 weeks following surgery, the patients were advised not to open their mouth wide in order to encourage the formation of adhesions. From the fourth week, the patients were advised to start jaw opening exercises by standing in front of a mirror, so that they could restrain their muscle activity to open the mouth in proper manner. Postoperatively 1. preauricular pain (±), 2. TMJ clicking sound (±), 3. Occlusion (satisfactory/unsatisfactory), 4. Interincisal dimension (mm) were assessed.

Result

Among 12 patients two (16.7%) patient got successfully treated conservatively with injection of autologous blood into joint capsule, out of two patient both were completely edentulous (complete dentures were given for both the patient to counteract neuro-muscular imbalance), remaining 10 (83.3%) patients underwent surgical management. Ten (83%) patients were satisfied with the results, had stable joints, and could chew normally. Two (17%) patients developed a recurrence as a result of severe injury to the joint 6 months postoperatively, which was corrected by a second surgery. Two patients with antidepressant medication and connective tissue disorder, developed dislocation on 3rd and 5th month follow up respectively. All patients had limited mouth opening during the immediate postoperative period, ranging between 15 and 25 mm (mean 19) during the first month. Gradual improvement was noticed and in 3 months postoperative, it ranged between 28 and 38 mm (mean 32). By postoperative 6^th month, it had increased from 35 to 42 mm (mean 39). One year postoperatively, mouth opening was in the range 37–52 mm (mean 40.5 mm), and then stabilized. Temporary paralysis of the frontal branch of the facial nerve in five patients resulted from intraoperative traction on the tissues, and had resolved within 3 months. The preauricular pain and clicking that had been present in all patients preoperatively reduced gradually through the postoperative period and range of jaw movements improved in 1 year follow up. None of the patient had perforation of articular eminence cell, ostitis externa or any occlusal disturbance postoperatively.

Discussion

In the case of non-reducible recurrent TMJ dislocation, the primary treatment consists of the Hippocratic manual repositioning method adopted by Fordyce [6] and Gahhosand Ariyan [5] and described by Bradley [7]. 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 [8]. 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 as 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 [9]. The use of autologous blood in recurrent dislocation was reported by Brachmann [10] in 1964 and is very popular nowadays. It is based on the principle to restrict mandibular movements by inducing fibrosis in the upper joint space, the pericapsular tissues, or both. Surgical treatment procedures for treating Chronic recurrent TMJ subluxation can be broadly classified into basic principles of anti-translatory procedures, like capsular plication, capsulorrhaphy, coronoid anchorage to the zygoma, scarification of the temporal tendon [11], etc.; obstructing procedures, such as articular eminence augmentation; [12] obstruction clearance procedures such as condylectomy, eminectomy [13] etc.; and reduction of muscular forces, as by lateral pterygoid/temporalis myotomy [10, 11] or pterygoid dysjunction [14].

Dautrey’s procedure is usually not recommended for patients over the age of 30 years [15] because the increasing hardness and brittleness of bone makes it difficult to achieve a green stick fracture at the distal end of the arch. Lawler [15] who reported on 10 cases, suggested that patients aged over 32 years were probably not suitable for this technique because a fracture might occur more readily at the distal end of the zygomatic arch resulting in a loose piece of bone with no natural tensional lock between the cut end of the arch and the articular eminence. Such a loose piece of bone usually resorbs. It becomes necessary, therefore, to fix the arch at the distal end.

Eminectomy, as first described by Myrhaug in 1951, is the physical removal of the articular eminence to enable free movement of the condyle. The primary indication is for the management of recurrent or chronic mandibular dislocations [16]. It has also been used in the past for the treatment of non-reducing disc displacement without reduction (NDDR) [17, 18]. A number of relative contraindications for eminectomy have been described in the literature, including chronic mandibular dislocations with associated shallow articular eminences and radiographic evidence of a vascularised eminence [19]. The presence of pneumatisation of the articular eminence is believed to be the only ‘absolute’ contraindication to eminectomy due to the risk of intracranial spread of inflammation, as well as an increased chance of temporal bone fracture perioperatively [20]. The presence of pneumatisation can be identified from radiological investigations including orthopantomograms (OPG), computed tomography (CT) and magnetic resonance imaging (MRI) [21].

After eminectomy articular eminence gives more freedom to the condyle thus condylar path during the mandibular movement got changed into a new rotational and new hyper translator movement. Eminectomy helps by making the non reducing disc into a reducing disc, eliminates pain in the joint and improves TMJ mobility.

We have presented ten cases of chronic recurrent dislocation of the TMJ that were treated successfully by removal of the articular eminence. Although surgery of the TMJ area may be hazardous if approached without caution, we feel that the complications associated with this procedure are minimized if adequate care is taken in flap design and tissue dissection. On the basis of the excellent results of the eminectomy procedures reported in the literature and of our own experience with this procedure, we feel that this is the preferred surgical option for chronic recurrent dislocation of the TMJ if conservative methods go inadequate.

Conclusion

In the present study, the case selection was based on applying three different treatment modalities on a sequential pattern. Within the limitations of the study, we recommend our management strategy for chronic recurrent TMJ dislocation as it suggests to opt for a surgery when other comparatively less invasive approaches fail to provide a satisfactory outcome. However, congregating results from future multicenter studies are needed that involve large sample size and longer follow-up.

Funding

No funding was received for the study.

Compliance with Ethical Standards

Conflict of interest

There are no conflicts of interests for the authors.

Informed Consent

Informed consent was obtained from all individual participants and parents of the subjects included in the study.