53

Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com

CASE REPORT

Chronic Protracted Temporomandibular Joint Dislocation:
A Report of Two Cases Along With Systematic Literature
Review
Jeevan Lata MDS
1
, Nitin Verma MDS
2
, Palvi Gupta MDS
3
1-Professor & Head, 2- Assistant Professor 3- Junior Resident,
Department of Oral & maxillofacial surgery,
Punjab Govt. Dental College & Hospital, Amritsar, India.


ABSTRACT:
Temporomandibular joint (TMJ) dislocation commonly follows extreme opening
of the mouth while eating, yawning, laughing, long standing dental treatment etc.
Acute Temporomandibular dislocations are often quickly recognized and
effectively treated by manual reduction method of Hippocrates. But dislocations
that persist for more than 3 weeks, classified as chronic protracted, may or may not
be effectively reduced by closed reduction. They often require the invasive
procedures to place the condyle back into the glenoid fossa. This article reports
two cases of chronic protracted dislocation having unusual etiology treated
systematically along with review of literature.

Key words: Temporomandibular joint, Chronic protracted dislocation

Cite this Article: Jeevan L, Nitin V. Palvi G: Chronic Protracted Temporomandibular Joint
Dislocation: A Report of Two Cases Along With Systematic Literature Review, Journal of Head
& Neck physicians and surgeons Vol 2 Issue 1 2014 : Pg 53-66


54

INTRODUCTION:

The temporomandibular joint (TMJ) is the articulation of mandibular bones with
skull base. A healthy joints first movement is rotation followed by translation in
the downward and forward direction along the posterior slope of its articular
eminence. These movements are facilitated by the integrity of the ligaments and
activity of the muscles associated with the joint [1]. Subluxation and
dislocation of the temporomandibular joint are very unpleasant and distressing
conditions to patients. Temporomandibular joint dislocation is defined as an
excessive forward movement of the condyle beyond the articular eminence with
complete separation of the articular surfaces and fixation in that position i.e. open
locked [2]. However, in subluxation of the joint in which, the patient is able to
close his or her mouth without assistance. Although, the clinical presentation of
these two conditions is different, radiographically they are indistinguishable having
the condylar position anterior to articular eminence [3] Studies have shown that
condyle has a variable range of motion; not limiting to the confines of glenoid
fossa [3]. Clinical and radiographic analysis has indicated that approximately 70%
of the population can subluxate their temporomandibular joint [1].

The factors related to the anatomy of the joint like morphology of the condyle,
glenoid fossa, articular eminence, zygomatic arch mainly determine the type and
direction of temporomandibular joint dislocation. In addition, other associated
factors are yawing, prolonged dental procedures, general anesthetic procedures,
excessive tooth abrasion, loss of dentition (leading to over-closure), and trauma
etc. However, drugs with extra pyramidal side effects like phenothiazine,
metoclopramide etc, which are commonly used in the treatment of psychiatric
disorders, have been reported to cause recurrent temporomandibular joint
dislocation [1,3,4]. Based upon the duration of occurrence, Temporomandibular
joint dislocation is classified as acute, chronic protracted or chronic recurrent [5].

Treatment of the temporomandibular joint dislocation was first described by
Hippocrates early in the 5
th
century and is still been used as the first method to
reduce dislocation [6]. Majority of the dislocations are acute in nature and treated
by immediate manual reduction with high success rates. In concurrence to the
rarity of chronic temporomandibular joint dislocation, no standard method of

55

evaluating or treating them has been documented in the literature [3]. The aim of
this article is to report two cases of chronic protracted dislocation having unusual
etiology treated systematically along with review of literature.

CASE REPORTS:

The following cases reported to the department of oral and maxillofacial surgery,
Punjab Government Dental College and Hospital, Amritsar. Routine blood and
urine tests were done. For the management of their respective complaints,
informed consent was taken from the patients with proper explanation of the
various treatment modalities including the surgical procedures.

Case 1:

A 49 year old male patient presented with a chief complaint of inability to close
mouth since four months. History revealed that patient underwent an abdominal
surgery about five months back. During postoperative period, he developed some
complication, for which patient remained on ventilator support for about two
weeks. After recovery, patient had difficulty in mastication and speech. Initially, he
was given analgesics and multivitamins for same. But the condition didnt
improved. After 15 days, he went back for no improvement in his condition.
Thereafter, he was referred to a local dentist who diagnosed him with bilateral
TMJ dislocation and attempted closed reduction of the joint but was unsuccessful
and was kept on regular follow-ups. Later, patient reported to our institution for
further treatment.


On clinical examination, he had gross facial asymmetry, prognathic mandible with
evident pre-auricular hollow on both the sides [Fig 1]. Temporomandibular joint
movements were feeble bilaterally. On intraoral examination, posterior gagging of
occlusion with anterior open bite was noted. The panoramic radiograph [Fig 2a]
and computed tomography images [Fig 2b] revealed bilateral dislocation of the
temporomandibular joint with mild cortical erosions on right condyle. Thus patient
was diagnosed with chronic protracted bilateral dislocation of temporomandibular

56

joint. The surgery was planned for reduction of the joint under general anesthesia.
Erich arch bar were placed in upper and lower dentate segments.

The patient was intubated with induction anesthesia of Propofol (10cc) and
maintained with Nitrous oxide (60%), Oxygen (40%) and Halothane (1%). Inj.
Succinyl choline (2cc) was given i.v as muscle relaxant. After doing endotracheal
intubation, closed reduction was attempted by applying bilateral digital pressure on
mandibular molar region to reduce the dislocated condyles but, was unsuccessful.
Then decision was made to expose the mandibular angle extra-orally. Bilateral
Risdon incisions were given to expose the angle and downward and backward
traction was applied by passing wires though it. Still, the dislocation was
irreducible.

So, open reduction of temporomandibular joint dislocation was decided. The
preauricular incision was given to expose the temporomandibular joint [Fig 3]. On
exposing the joint, condyles were found to be locked in front of articular eminence.
Even under direct vision condyles failed to go back. Then bilateral high condylar
shave was done by using rotatory round burs no. 6 & 8 under the constant
irrigation of saline [Fig 4]. After this the condyles were positioned into their
glenoid fossa. Subsequently, layer-wise suturing done and suction drain was placed
bilaterally. Maxillomandibular fixation was planned for three weeks. Later,
occlusion was guided for another one week by elastics followed by night elastics
for another one week. Post-operative panoramic radiograph showed proper
reduction of the condyles into their respective glenoid fossa [Fig 5].

The patient was then followed-up post-operatively at weekly interval for two
months & thereafter at monthly intervals for two years. On follow-up visits, patient
experienced a full range of mandibular movements [Fig 6].


57




Fig 1 Pre-operative clinical photograph showing bilateral TMJ dislocation
Fig 2a Pre-operative orthopantomogram showing bilateral anterior dislocation of TMJ
Fig 2b Pre-operative 3D CT scan showing condylar head anterior to the glenoid fossa in both
sides.



Fig 3 Pre-auricular incision given

58

Fig 4 High condylar shave done
Fig 5 Post-operative orthopantomogram after 3 months
Fig 6 Occlusion after 9 months

Case 2:
Another patient, aged 65 year old reported to our institution with a chief complaint
of inability to close mouth since 4 months. He gave history of dislocation of jaw
about two years back, which was successfully treated in a private clinic. His
medical history revealed an attack of cerebrovascular stroke. MRI report showed a
non-hemorrhagic infarct in right middle carotid artery region involving fronto-
temporo-parietal region. After the attack, patient again had dislocation of jaw but
he evaded the treatment, in the anticipation that the deviated open jaw is because of
the hemiparesis. He had been referred to our department for the management of
open mouth condition by his neurophysician.

On examination, there was a hemiparesis of the left upper half of the body. He had
left facial droop, paralysis of left arm and an expressive dysphagia due to difficulty
in mastication. There was an evident preauricular hollow [Fig 7] on both sides with
leptocephalic appearance [Fig 8] of face. Temporomandibular joint movements
were slightly palpable. On intraoral examination, patient was partially edentulous
with inability to occlude teeth [Fig 9]. Panoramic radiographs confirmed the
clinical diagnosis of bilateral dislocation of temporomandibular joint [Fig 10].
On admission, patient was already taking telmisartan 2.5 twice daily and
aspirin150 once daily. After assessment of the general physical status of the
patient, reduction of the dislocated joint was planned under general anesthesia

Pre-operatively, Erich arch bar were placed on upper and lower dentate segments.
The patient was intubated with induction anesthesia of Propofol (10cc) and
maintained with Nitrous oxide (60%), Oxygen (40%) and Halothane (1%).
Intravenous Inj. Succinyl choline (2cc) was given as muscle relaxant. Bilateral
digital pressure was applied on mandibular molar region to reduce the dislocated
condyles. Further, the condyles were successfully reduced and positioned in
glenoid fossa with proper occlusion [Fig 11]. Inter-maxillary fixation was done and

59

maintained for a period of two weeks. Later, occlusion was guided for another one
week by elastics. Post-operatively liquid and semi-solid diet was advised with
administration of analgesics and anti-inflammatory agents for a period of three
days. Post-surgical recovery sequel was uneventful with proper occlusion [Fig 12].
The post-operative follow-up was done at weekly interval for two months and at
monthly intervals for two years.


Fig 7 Pre-operative appearance of face showing preauricular hollow on both sides
Fig 8 Pre-operative lepocephalic appearance of face
Fig 9 Pre-operative occlusion


60


Fig 10 Pre-operative orthopantomogram showing bilateral dislocated condyles
Fig 11 Post-operative orthopantomogram
Fig 12 Post-operative occlusion after 6 months

DISCUSSION:

Temporomandibular joint dislocation is a common presentation that is usually
reported as an acute episode of unilateral or bilateral displacement of condyles
anterior to articular eminence [7]. Temporomandibular joint dislocation can be
classified as partial (subluxation) or complete (luxation). In partial dislocation,
condyles are found to be present in the confines of temporomandibular joint
capsule whereas in complete dislocation, condyles lie completely out of the
glenoid fossa. Often, failure to diagnose or inappropriate treatment in the initial
stage results in prolonged malposition of an acutely displaced condyle leading to
chronic dislocation [7]. Long standing history of about 5 months was due of
inappropriate treatment in case 1 and failure to diagnose the problem in case 2.

We found male predominance in our cases which was same as reported in study on
96 Nigerian of temporomandibular joint dislocation [8]. On the contrary, Caminiti
and Weinberg reported four cases of long-standing temporomandibular joint
dislocation with female predominance [3].The pathophysiology of
temporomandibular joint dislocation includes the abnormal position of condyles
out of the glenoid fossa with spasm of masticatory muscles hampering its
movement back to its natural anatomical position [9]. Additionally, the duration of
dislocation plays an important role for prognosis. Longer duration predisposes to
fibrous adhesions refraining condyles to move back to their normal position. This
was found to be present in case 1, with CT scan showing mild cortical erosions
over the right condyle. But, our second patient (case 2) couldnt get CT scan done
due to his low socio-economic status.




61


There is no standard evaluation and treatment method for acute
temporomandibular joint dislocation in the literature, but the best method is
immediate effective reduction [8]. Hippocrates was first to describe manual
reduction in the fifth century B.C. Ambroise Pare (1633) described the use of an
object that would act as a wedge in the molar regions as the chin is elevated to lift
the condyles off their locked position [3]. In chronic and recurrent dislocations,
different options of their management have been divided into nonsurgical
(conservative approach), and surgical methods (indirect approach and direct
approach). Conservative approach included Hippocratess manual reduction under
local or general anesthesia. Another method is the use of heavy anterior elastic
traction using arch bar or IMF screws with mouth prop in the posterior teeth acting
as fulcrum and Class III vector for the posterior wires [10]. But, chronic and long
standing dislocations are difficult to reduce manually. Gottlieb (1952) reported
only three of 24 long-standing cases that were successfully reduced by manual
reduction [11]. On the contrary, successful manual reduction of prolonged
dislocations, up to 16 months, has also been described by Hayward in 1965 [12].

In our institution, firstly conservative approach was used in both the cases. We
decided to apply the Hippocratic manual reduction method under general
anesthesia. This was planned keeping in mind the long duration of the
temporomandibular joint dislocations and failure in closed method could be easily
switched to an open TMJ surgery. We were able to successfully reduce the
dislocation in case 2 but we failed in case 1 with manual reduction. This is
explained on the basis of practical categorization of chronic dislocations done by
Littler BO 1980: reduction resisted by muscular spasm and reduction resisted by
non-muscular forces like fibrous adhesions, articular cartilage impaction [13]. In
case 2, there was perhaps muscular spasm of the masticatory muscles which was
relieved by muscle relaxants resulting in reduction of the condyles by manual
reduction only. But in case 1, there were fibrous adhesions present which were not
amenable to muscle relaxation and manual reduction.





62


Table 1: Systematic review of literature on the various treatment modalities of chronic
protracted dislocation


Fordyce GL,1965 [15]

Defined long standing TMJ dislocation as one existing for more
than a month
Adekeye et al, 1976 [16] Received 24 cases, out of which four were reduced manually and
20 required open procedures.
Stakesby lewis JE, 1981
[17]
Applied traction intra-orally at sigmoid notch to reduce the
condyles
Hammersley, 1986 [18] Performed open reduction in two out of three cases and advocated
simultaneous detachment of lateral pterygoid insertion
El-attar A and Ord RA
1986 [14]
Used traction with intra-osseous wires passed through angle of
mandible.
Caminiti MF, Weinberg
S,1998 [3]
Reported four long-standing cases with variability in their
management.
Smith WP, Johnson PA ,
1994 [19]
Introduced the term reducible and irreducible and proposed
mandibular set back procedure for the latter.
Terakado et al, 2004 [20] Used Intermaxillary screws in case of an edentulous mandible to
apply traction force with elastics to reduce bilateral mandibular
dislocation.
Aquilina et al, 2004 [21] Used Botulinum toxin A to reduce muscle spasm after reduction to
prevent relapse.
Ugboka et al, 2005 [8] In multi-centric study, received 96 cases of TMJ dislocation(29
long-standing)
Lee et al, 2006 [22] Proposed midline mandibulotomy for the treatment of long
standing dislocations.
Debnath SC et al, 2006
[7]
Treated a case with bilateral vertical oblique osteotomy of ramus
for the reduction of long standing cases.
Rattan V, Rai S, 2007 Proposed a stepwise treatment algorithm for long standing

63

[23] dislocations.
Rattan V, Rai S, 2013
[24]
Treated two cases with midline mandibulotomy and modified their
previous algorithm.


In case 1, further indirect approach was used. We applied traction with intra-
osseous wire passed at bilateral mandibular angle region via Risdon incision. El-
attar A and Ord RA 1986 had reported the treatment of long standing
temporomandibular joint dislocation by this method. But, it didnt help us in
reducing dislocation [14]. Then we used direct approach for reduction. Bilateral
condyles were opened via conventional preauricular incision and high condylar
shaving was done to place the condyles back into the glenoid fossa. This is in
concurrence with the Caminiti and weinberg (1998) who reported that 2 cases out
of 4 were reduced via direct approach after unsuccessful closed reduction attempts
[3]. Both patients were kept on Maxillomandibular fixation but for different
intervals (In case 1 for 3 weeks and in case 2 for 2 weeks). Additional 1 week
given in case 1 was done to counteract the presence of psuedoarthrosis as evident
on CT scan.

In conclusion, Chronic protracted TMJ dislocations should be treated
systematically from the conservative methods to invasive procedures for the best
benefit of the patient.

REFERENCES

1. Shorey CW, Campbell JH, DDS, Dislocation of the temporomandibular joint. Oral Med
Oral Pathol Oral Radiol Endod 2000;89:662-8.
2. Vasconcelos BC, Porto GG, Neto JP, Vasconcelos CF. Treatment of chronic mandibular
dislocations by eminectomy: Follow-up of 10 cases and literature review. Med Oral Patol
Oral Cir Bucal. 2009 Nov 1;14(11):e593-6.

64

3. Caminiti MF, Weinberg S. Chronic Mandibular Dislocation: The Role Of Non-Surgical
and Surgical Treatment. J Can Dent Assoc. 1998 Jul-Aug;64(7):484-91
4. Akinbami BO. Evaluation of the mechanism and principles of management of
temporomandibular joint dislocation. Systematic review of literature and a proposed new
classification of temporomandibular joint dislocation. Head & Face Medicine 2011;7:10
5. Rowe NL, Killey HC. Traumatic injury of the mandibular joint. In: Fractures of the facial
skeleton Traumatic injury of the mandibular joint. 2nd Ed. Edinburg and London:
Livingstone;1968.
6. Kumar S, Thangaswamy V. Chronic Traumatic Unilateral Dislocation of
Temporomandibular Joint. Journal of Indian Academy of Dental Specialists 2010;1(1):46
7. Debnath SC, Kotrashetti SM, Halli R, Baliga S. Bilateral vertical-oblique osteotomy of
ramus (external approach) for treatment of a long-standing dislocation of the
temporomandibular joint: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2006;101:e79e82
8. Ugboko VI, Oginni FO, Ajike SO, Olasoji HO, Adebayo ET. A survey of
temporomandibular joint dislocation: aetiology, demographics, risk factors and
management in 96 Nigerian cases. International Journal of Oral and Maxillofacial
Surgery 2005 July;34(5):499502
9. Kim CH, Kim DH. Chronic dislocation of temporomandibular joint persisting for 6
months: a case report. J Korean Assoc Oral Maxillofac Surg 2012;38:305-9
10. Rao P. Conservative treatment of bilateral persistent anterior dislocation of the mandible.
J Oral Surg 1980;38:51-52
11. Gottleib I. Long-standing dislocation of the jaw. J Oral Surg 1952;10:25-32

65

12. Hayward, J.R. Prolonged dislocation of the mandible. J Oral Surg 1965;23:585-595
13. Littler BO. The role of local anesthesia in the reduction of long-standing dislocation of
the temporomandibular joint. British journal of oral surgery 1980;18:81-85
14. El-Attar A. and Ord R.A. Longstanding mandibular dislocations: report of a case, review
of the literature. Br Dent J 1986;160:91
15. Fordyce GL. Long-standing bilateral dislocation of the jaw. Br J Oral Surg 1965;2:222-
225.
16. Adekeye EO, Shamia RI and Cove P. Inverted L-shaped ramus osteotomy for the
prolonged bilateral dislocation of the temporomandibular joint. Oral Surg Oral Med Oral
Pathol 1976;41:568-577.
17. Stakesby lewis JE. A simple technique for reduction of long-standing dislocation of the
mandible. Br J Oral Surg. 1981 Mar;19(1):52-56
18. Hammersley N. Chronic bilateral dislocation of the temporomandibular joint. Br J Oral
Maxillofac Surg. 1986 Oct;24(5):367-375.
19. Smith WP, Johnson PA. Sagittal split mandibular osteotomy for irreducible dislocation of
the temporomandibular joint. A case report. Int J Oral Maxillofac Surg. 1994
Feb;23(1):16-18
20. Terakado N, Shintani S, Nakahara Y, Yano J, Hino S, Hamakawa H. Conservative
treatment of prolonged bilateral mandibular dislocation with the help of an intermaxillary
fixation screw. Br J Oral Maxillofac Surg. 2006 Feb;44(1):62-63.
21. Aquilina P, Vickers R, McKellar G. Reduction of a chronic bilateral temporomandibular
joint dislocation with intermaxillary fixation and botulinum toxin A. Br J Oral Maxillofac
Surg. 2004 Jun;42(3):272-273

66

22. Lee SH, Son SI, Park JH, Park IS, Nam JH. Reduction of prolonged bilateral
temporomandibular joint dislocation by midline mandibulotomy. Int J Oral Maxillofac
Surg. 2006 Nov;35(11):1054-1056.
23. Rattan V, Rai S. Management of Long-standing Anteromedial Temporomandibular Joint
Dislocation. Asian Journal of Oral and Maxillofacial Surgery 2007;19(3);155-159.
24. Rattan V, Rai S, Sethi A. Midline Mandibulotomy for Reduction of Long-Standing
Temporomandibular Joint Dislocation. Craniomaxillofacial Trauma and Reconstruction
2013;6(2):127-132.

Acknowledgement- None
Source of Funding- Nil
Conflict of Interest- None Declared
Ethical Approval- Not Required
Correspondence Addresses :
Dr. Palvi Gupta, Junior Resident,,
Department of Oral & maxillofacial surgery,
Punjab Govt. Dental College & Hospital, Amritsar, India.
Pincode 145001
Mob: 9888762994
Email address: palvi.27nov@gmail.com