Subluxation and dislocation of temporo mandibular joint

Subluxation and dislocation of temporo mandibular joint

1. Subluxation and Dislocation of Temporomandibular joint 1 GUIDED BY :DR. NEHA VYAS PREPARED BY : DR. AKSHAY SHAH

2. CONTEN T 2 Introduction Definition Epidomology Pathogenesis Predisposing factors Etiology Classification Unilateral acute dislocation Bilateral acute dislocation Management Non surgical management Surgical management References

3. Introduction 3 Subluxation and dislocation of the temporomandibular joint (TMJ) are very unpleasant and distressing conditions to patients . Mandibular condylar dislocation is uncommon, compared to the other joints in the body.

4. Definition 4 The term subluxation is defined as a self reducing partial dislocation of the tmj during which the condyle passes anterior to the articular eminence. The term dislocation can be defined as long lasting inability to close the mouth due to the complete translation of the condyle anterior to the articular eminence and its not self limiting.

5. (a) Normal anatomical position of the condyle sitting beneath the glenoid fossa and posterior to the articular eminence. ( b ) In anterior-superior dislocation, the condyle is locked anterior-superior to the articular eminence

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7. Epidomology Uncommon compared to other joint dislocations 3 % incidence Uncommon in extremes of age Higher incidence in females Most commonly occurs in anterior direction in relationship with the articular eminence Superior, posterior, and adjacent medial dislocations are associated with the fracture of the mandible. The Treatment of Temporomandibular Joint Dislocation A Systematic Review 2018 Feb 2. Ulla Prechel , , Peter Ottl , Prof. Dr. med. dent., Oliver M. Ahlers , PD Dr. med. dent., and Andreas Neff, Prof. Dr. med. Dr. med. den

8. The pathogenesis of chronic recurrent TMJ dislocation is attributed to a combination of factors including laxity of the TMJ ligaments, weakness of the TMJ capsule, an unusual articular eminence size or projection, Muscle hyperactivity or spasms, Trauma Abnormal chewing movements that do not allow the condyle to translate back. Pathogenesis 8

9. Dislocation of the acute type causes ligament , capsule and disk injury. This results in a inflammatory reaction and joint effusion. Painful limitation and spasm of the masticatory muscles are maintained by neural reflexes from the injured joint structures The reflex spasms spread bilaterally over the entire group of masticatory muscles 9

10. Alteration in collagen chemistry might account for joint hypermobility. Another factor which influences the mobility of any synovial joint is its lubrication. Increase in friction due to decreased synovial fluid may bring about incoordination between articular surfaces, with decreased mobility and joint instability 10

11. Predisposing factors Laxity of ligaments, capsule . Previous injuries, occlusal disharmonies can bring about laxity of the capsule. Flattened eminence and shallow fossa, systemic diseases like Parkinson‘s disease, epilepsy, EhlersDanlos syndrome The use of antipsychotic drugs may cause extrapyramidal reactions and dislocation. 11

12. E tiolo g y 12 Causes of Acute Dislocation a. Extrinsic forces or iatrogenic causes b. Intrinsic or self-induced forces

13. Intrinsic or self-induced 13 Intrinsic trauma • Vomiting • Yawning • Opening mouth wide • Seizures stress

14. Extrinsic or iatrogenic causes 14 Extrinsic trauma : • Trauma sustained while the mouth is open • Dental/ENT procedures • Direct laryngoscopy • Endoscopy

15. Anatomic • Steep eminence • Abnormal condylar shape • Internal derangement • Occlusal discrepancy Connective tissue disorders • Ehlers- Danlos syndrome • Marfan syndrome

16. Neurogenic disease • Epilepsy • Parkinson’s disease • Huntington’s disease • Muscular dystrophy • Dystonia Pharmacology • Phenothiazines • Metoclopramide

17. Classification 17

18. difficulty in mastication and swallowing. Speaking may be difficult and profuse drooling of saliva A deviation of the chin toward contralateral side is seen. The mouth is partly open and the affected condyle cannot be palpable . In obese person, absence of condyle from the glenoid fossa may not be apparent, but in others a definite depression will be seen and felt in front of the tragus. 18 Unilateral acute dislocation

19. Cardinal Signs and Symptoms • Difficulty eating • Inability to bring the teeth together • Jaw deviation on opening and closing • Preauricular pain

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22. Bilateral acute dislocation pain, inability to close the mouth, tense masticatory muscles, difficulty in speech, excessive salivation, protruding chin. The mandible is postured forward and ovements are restricted. Posterior gagging and anterior open bite. Patient will complain of pain in the temporal region rather than the joint . The distinct hollowness can be felt in both the preauricular regions . Associated muscle spasm contributes to the fixed position of the condyles 22

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24. Imagi n g 24

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26. CBCT

27. TMJ VIEW

28. MRI VIEW Normal TMJ anatomy on MRI. Closed mouth and open mouth

29. Management 29 Acute dislocation The major problem in reduction of dislocation is overcoming the resistance of the severe muscle spasm. Therefore, initially attention is given to reduce tension, anxiety and muscle spasm. This can be achieved by 1 . Manipulation without any form of anaesthesia . 2 . Manipulation with local anaesthesia . 3 . Manipulation under general anaesthesia /sedation with muscle relaxants

30. Reduction Techniques Stimulating a patient’s gag reflex has been proposed as a method of reducing a dislocated TMJ without the use of force by an operator. The operator uses an instrument, such as a tongue depressor or mouth mirror, to trigger a gag reflex from the patient’s posterior soft palate or pharyngeal walls. It is likely that the gag will both relax the spastic elevator muscles, while simultaneously triggering the depressor muscles , thereby allowing spontaneous reduction in some cases.

31. Hippocratic Method The traditional Hippocratic method for bimanual reduction is the most widely described technique This technique involves placing gauze-wrapped thumbs over the molar or retromolar / ascending ramus area of the patient’s mandible with the remaining fingers wrapped around the body of the mandible. First, a downward directed force is applied to distract the condyle down the anterior slope of the eminence. This is followed by a posteriorly directed force to reposition the condyle past the peak of the eminence back into its normal resting position in the glenoid fossa.

32. Wrist Pivot Reduction An anterior fulcrum is created by applying upward force on the menton ( chin point ) with both thumbs. Effort is exerted by placing fingers on the occlusal surfaces of the bilateral mandibular molars and applying downward pressure . The contrasting upward force on the anterior fulcrum and downward pressure on the mandibular molars causes an outward rotation, or “pivot” of the wrists,

33. 33 Interdental Block reduction

34. Extraoral Reduction In intraoral bimanual reduction technique, the use of a bite block can induce the risk of bite injury following reduction. Extraoral reduction techniques were developed to completely remove this risk. dislocation of the condyle will cause extraoral visual and palpable prominence of the anterior ramus and coronoid process. On the dislocated side , the operator will place their thumb on the anteriorly positioned coronoid process with their remaining fingers bracing around the mastoid process

35. ( a ) Extraoral reduction—on the ipsilateral side, the operator’s thumb is applying posterior pressure on the visually exaggerated coronoid process, with the remaining fingers bracing the mastoid process. ( b ) Extraoral reduction—on the contralateral side, the operator fulcrums his thumb off the patient’s malar bone and applies anterior force with the remaining fingers braced around the angle of the mandible

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37. Post-Reduction Management Goals of post-reduction management center around avoiding re-dislocation of the condyle and allowing sufficient time to heal . This is accomplished by a period of restriction or immobilization of the joint . period of restriction/ immobilizationshould be followed for 7 days. Post reduction management—the patient’s head is wrapped with an elastic bandage, and they are instructed to use a closed fist to restrict excessive mouth opening

38. Chronic recurrent d islocation 38 repeated episodes of dislocation, where there is abnormal anterior excursion of the condyles beyond the articular eminence, but the patient is able to manipulate it back into normal position. The triad : ligamentous and capsular flaccidity Articular eminen ce erosion Continuous trauma .

39. difficulty in mastication and swallowing. Speaking may be difficult and profuse drooling of saliva A deviation of the chin toward contralateral side is seen. The mouth is partly open and the affected condyle cannot be palpable. In obese person, absence of condyle from the glenoid fossa may not be apparent, but in others a definite depression will be seen and felt in front of the tragus pain, inability to close the mouth, tense masticatory muscles, difficulty in speech, excessive salivation, protruding chin.

40. The mandible is postured forward and m ovements are restricted. Posterior gagging and anterior open bite. Patient will complain of pain in the temporal region rather than the joint. The distinct hollowness can be felt in both the preauricular regions. Associated muscle spasm contributes to the fixed position of the condyles. It is also seen in severe epilepsy, dystrophia myotonia and the Ehlers- Danlos syndrome.

41. Ehlers-Danlos syndrome This is a rare inherited disorder of the connective tissue, in which recurrent dislocation of the TMJ is seen. Four cardinal symptoms are as follows: Hyperelasticity of the skin. Fragility of the skin. Hypermobility of the joints. Fragility of the blood vessels. 41

42. IMAGING same as acute dislocation

43. Management Non surgical management Autologous blood injection. Sclerotherapy Botulinum toxin prolotherapy surgical management Capsule tightening procedure. Creation of a mechanical obstacle or block. Creation of a new muscle balance. Removal of mechanical obstacle

44. Autologous Blood Injection 44 Autologous blood injection (ABI) presents a number of advantages including ease of performance, low cost and low complication. The protocol described by Machon et al. 3 mL of autogenous blood, 2 mL being injected into the upper joint space and 1 mL to the pericapsular region . The principle behind the technique is the inciting of a physiological response of inflammation and oedema with resultant reduction in joint motion.

45. Histological evaluation demonstrated fibrotic changes in the capsule and retrodiscal tissues. Inflammatory mediators released by platelets cause vasodilatation and oedema of the periarticular tissues, diminishing compliance of the joint and reducing mobility. Organized clot leads to joint stiffness over time with maturation of fibrous tissue

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47. Use of sclerosing solution injections into the joint space 47 It was first described as early as 1950 by McKelvey A wide variety of exogenous sclerosants has been tried including iodine, ethanolamine oleate , alcohol (100% ethanol), bleomycin, tetracycline, cyclophosphamide and OK-432 ( Picibanil ), sodium tetradecyl sulphate (STS), sodium tetradecyl sulphate (STS )more widely used in the management of venous varicosities as a sclerosant .

48. Prepared by diluting the drug with equal parts of saline and 2% lignocaine, it can be introduced into the superior joint compartment and pericapsular tissue. Objective is to produce fibrosis and tightening of the capsular ligaments, thus limiting motion of the mandible and preventing subluxations and dislocations

49. Use of botulin toxin Another newer conservative method is the pplication of botulinum toxinA (BTX-A) in recurrent TMJ dislocation . Botulinum toxin is produced by the anaerobic bacterium Clostridium Previously, BTX-A was used in the management of facial wrinkles, masseteric and temporalis muscle hypertrophies,, hemifacial spasm, sialorrhea, and masticatory myalgia. The intended effect of the BTA is to weaken the lateral pterygoid muscles sufficiently to prevent dislocations, while producing only slight impairment to maximal opening.

50. Injection of Botox® through the sigmoid notch into lateral pterygoid muscle schematically represented on a stereolithographic model Injection of Botox® through sigmoid notch into lateral pterygoid muscle demonstrated on a patient

51. acts by blocking the release of acetylcholine into the synaptic cleft at the motor end plate, thus interrupting neuromuscular transmission . It caus e temporary weakening of the skeletal muscle by blocking the Ca 2+ -mediated release of acetylcholine Because the effect is temporary, repeated administration is required after 2 weeks for better results. The adverse effect involves diffusion into the adjacent tissues, transient dysphagia, nasal speech, nasal regurgitation, painful chewing, and dysarthria. It is contraindicated in a few conditions like hypersensitivity to BTX and myasthenia gravis, pregnant and lactating women. 51

52. PROLOTHERAPY infiltration of a nonpharmacologic solution into pericapsular , tendinous tissues, with aims of initiating a mixed inflammatory process. This inflammatory process is thought to initiate localized fibrous proliferation, causing an increase in tissue robustness, which increases joint stability and bolsters joint laxity. various solutions have been used, including: dextrose , psyllium seed oil, and various combinations of dextrose, glycerin, and phenol

53. In this technique an auriculotemporal nerve block is given then 2 mL of 10% to 50 % dextrose may then be infiltrated into the superior joint space , retrodiscal tissues , periarticular tissues, or a combination thereof. Upon completion of the procedure, patients are put on a soft diet and jaw rest for 2 weeks. Patients are then followed, with repeat injections as needed in the event of recurrent dislocation.

54. Surgical procedures 54 In 1976, Miller and Murphy divided surgical procedures to correct recurrent condylar dislocation into five categories: 1. Capsule tightening procedure. 2. Creation of a mechanical obstacle or block . 3 . Creation of a new muscle balance. 4 . Removal of mechanical obstacle.

55. 1. Capsule tightening procedures 55 These procedures were apparently effective over a short period. Capsulorrhaphy—consists of shortening the capsule by removing a section and suturing it to make it tight.

56. A disadvantage to this therapy is hampered the intracapsular space, which can produce complications such as hemarthrosis, degenerative changes to the joint, or both. 56

57. Ligamentorrhaphy involves the surgical fixation (or anchoring) of the lateral ligament of the capsule to the periosteum of the overlying zygomatic arch, followed by MMF for 1 week. 57

58. 2. Creation of a mechanical obstacle 58

59. The Dautrey ( LeClerc ) Procedure Zygomatic arch down-fracture ( LeClerc or Dautrey procedure) is a well-known and popular surgical technique for treatment of recurrent dislocation Mayer in 1933 was the first to advocate the surgical displacement of a portion of the zygomatic arch inferiorly to block excessive translation of the TMJ condyle [8]. In 1943, LeClerc and Girard improved the technique when they described a method whereby a thicker portion of the zygomatic arch is osteotomized and down-fractured, in order to block excessive translation of the mandibular condyle . The procedure was modified by Dautrey and Gosserez in 1967.

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61. In all these methods the main drawback are: Average width of zygomatic arch in the range of 2.9 to 3.7mm Such a narrow buttress may not provide adequate width to impede or arrest the condyle which is making a medial movement on opening The buttress will effectively block the condyle in axial opening, but ‘medial escape’ is readily accomplished and the surgery may fail . 61

62. 69 © Ramaiah University of Applied Sciences Findlay reported the use of L-shaped plates anchored in the zygomatic process and projecting it anterior to the condyle. B. C. Vasconcelos, G. G. Porto, F. T. B. Lima: Treatment of chronic mandibular dislocations using miniplates: follow-up of 8 cases and literature review. Int. J. Oral Maxillofac. Surg. 2009; 38: 933–936.

63. Metallic Obstacles: Miniplates and Screws Various heterogeneous materials have been used to restrict the condylar pathway: stainless steel pins, titanium plates and screws, and Vitallium mesh (alloy of Co-Cr-Mo). Various plate designs have been described: T-shaped titanium plate , L-shaped plate , and custom-manufactured plate. The miniplate eminoplasty : It is minimally invasive technique with low recurrence rate of dislocation. Once the articular eminence has been visualized, an L plate is placed, with the short arm fixed laterally to the eminence with 2 -6 mm screws and the long arm being contoured and placed along the eminence, inferiorly , to act as a mechanical obstruction.

64. Long-term results following miniplate eminoplasty for the treatment of recurrent dislocation and habitual luxation of the temporomandibular joint Int. J. Oral Maxillofac. Surg. 2003; 32: 474-479. 64

65. Titanium screw implantation to the articular eminence for the treatment of chronic recurrent dislocation of the temporomandibular joint H. Y. Oztan, et al Int. J. Oral Maxillofac. Surg. 2005; 34: 921–923 65

66. 3. Creation of new muscle balance 66 This procedure involves excision of the insertion of the lateral pterygoid muscle at the condylar neck and joint capsule. disable the lateral pterygoid muscles, allowing only rotational movement of the condyle. MMF for 7 to 10 days. Its disadvantages include difficulty in visualization and the risk of bleeding in this highly vascular site. Muscle tissue may reattach during healing, placing the long-term efficacy of the procedure in doubt.

67. Scarification of temporalis tendon/temporalis myotomy:- Majority of tendinous fibers are stripped from the ramus and sutured to the reflected periosteum and oral mucosa in a fashion that creates tissue disorientation and subsequent scar formation which will lead to horizontal scar may tighten the tendon and limit the range of motion. 67

68. 4 . Removal of mechanical obstacles 68 a. Removal of torn meniscus or meniscectomy Torn meniscus, which was thought as the obstacle, is removed. This technique became very popular, but unfortunately the undesirable results like protracted pain, grating, roughening of the condylar head, and an occasional ankylosis were noticed.

69. B.The high condylectomy The shortened head of the condyle will have less tendency to lock in front of the articular eminence. It involves excision of the superior portion of condylar head, above the attachment of the lateral pterygoid muscle, so that the balance of the muscle function is not disturbed 69

70. C. Eminectomy In 1951, Myrhang first reported this p ocedure . The rationale for this procedure is to allow the condylar head to move forward and backward free of obstruction, by the excision of the articular eminence . 70

71. Eminectomy procedure. ( a ) Protection of the intra-articular structures with the Dunn- Dautrey retractors. ( b ) Postage stamp of the eminence. ( c ) Removal of the eminence with an osteotome . ( d ) 2 cm depth of removed eminence

72. The success of any surgical procedure used to correct functional disorders of the TMJ is largely dependent on correctly establishing the cause and identifying the predisposing factors The degree of joint laxity and duration of dislocation make the definite treatment more challenging. Surgical plan should be developed based on the extent of the disease, age and health of the patient and previous treatment Equally important post-operative follow up. Conclusion 72

73. References 73 Nigel Shaun Matthews-Dislocation of the Temporomandibular Joint- A Guide to Diagnosis and Management Okeson -Management of temporomandibular disorders and occlusion- Sixth edition Fonseca Temporomandibular Joint Dislocation Aaron Liddell, DMD, MDa, Daniel E. Perez, DDS Dislocation of the temporomandibular joint Christopher W. Shorey, and John H. Campbell, et al The Treatment of Temporomandibular Joint Dislocation A Systematic Review Ulla Prechel , , Peter Ottl . A NEW APPROACH TO THE REDUCTION OF ACUTE DISLOCATION OF THE TEMPOROMANDIBULAR JOINT: A REPORT OF THREE CASES M . N. AWANG, B.O.S. ( M'sia ), M.Sc. ( Lond ) ( 1987)