Temporomandibular joint dislocation

Temporomandibular joint dislocation
Temporomandibular joint pathology and management
Oral and maxillofacial surgery

1. TMJ DISLOCATION Presented by Dr. Kamini Dadsena Post graduate Dept. of OMFS

2. CONTENTS Introduction Definitions Classification Cause of Hypermobility Pathogenesis of hypermobility Clinical presentation Diagnosis Treatment options Nonsurgical Surgical conclusion References

3. Introduction Hippocrates – describe the Dislocation and its treatment in 5 th century BC Uncommon condition Incidence- 3%-7% of Gen. population ( Kendall BD, Booth PW. Surgical correction of temporomandibular dislocation. In: Assael LA. Atlas of oral and maxillofacial surgery clinics of North America. Philadelphia: W.B. Saunders; 1996. p. 278-86.) Common in females Staz – incidence of recurrent dislocation of 7% of 240 cases TMDs Malgaigne - review of 76 cases 57% of dislocation in females 71% cases were bilateral Dislocation most commonly occurs in anterior direction Surgery of temporomandibular joint by David A. K eith

4. -Oral Maxillofacial Surg Clin N Am 20 (2008 )

5. Hypermobility - Hypermobility of TMJ characterized by excessive anterior movement of condyle at maximum mouth opening without strain or symptoms.

6. Causes of Hypermobility Intrinsic trauma: overextension injury Yawning Vomiting Wide biting Seizure disorder Extrinsic trauma Flexion-extension injury to the mandible Intubation with general anesthesia Endoscopy Dental extractions Forceful hyperextension Connective tissue disorders: Hypermobility syndromes, Ehlers- danlos syndrome Marfan syndrome Miscellaneous causes: Internal derangement, Dyssynchronous muscle function, Contralateral intra-articular obstruction, Lost vertical dimension, Occlusal discrepancies Psychogenic: Habitual dislocation, Drug induced: Phenothiazine PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

7. Classification Surgery of temporomandibular joint by David A. Keith Textbook of oral surgery by neelima malik Bilateral Unilateral

8. Classification Acute Chronic Long standing Recurrent Habitual Surgery of temporomandibular joint by David A. Keith

9. Classification Based on the position of the head of the condyle to the articular eminence seen on clinico -radiological evaluation Type I - the head of condyle is directly below the tip of the eminence Type II - the head of condyle is in front of the tip of the eminence Type III - the head of condyle is high up in front of the base of the eminence. Akinbami Head & Face Medicine 2011, 7:10 Textbook of oral surgery by neelima malik

10. Pathogenesis Normal joint stability depends on: i . Integrity of joint ligaments Laxity of ligaments Capsular abnormality ii. Bony architecture of joint surfaces iii. Activity of muscles acting on the joint Spontaneous dislocation is due to a break in the timing of muscular action in the first phase of closing Surgery of temporomandibular joint by David A. Keith

11. Clinical presentation Bilateral dislocation Pain Inability to close mouth Tense masticatory muscles Difficulty with speech Excessive salivation A protruding chin Open bite A distinct hollow in front of the tragus Surgery of temporomandibular joint by David A. Keith Textbook of oral surgery by neelima malik

12. Clinical presentation Bilateral dislocation The lateral pole of the condyle produces a characteristic protuberance anterior to and below the articular eminence Coronoid process may create a prominence below the zygoma . Pain is usually experienced in the temporal fossa rather than in the joint. Surgery of temporomandibular joint by David A. Keith

13. Clinical presentation Unilateral dislocation The mandible swung away from the side of dislocation. The deviation produces a lateral gross and open bite on the contralateral side. Occlusion is protrusive The hollow just in front of the tragus is present on the ipsilateral side.   Surgery of temporomandibular joint by David A. Keith

14. Diagnosis History Determine cause & onset. A prior h/o local joint laxity, ID, & other TMJD use of antipsychotic drugs physical examination Neurological and musculoskeletal disorders Radiological examination TEXT BOOK OF ORAL AND MAXILLOFACIAL SURGERY BY BALAJI

15. Radiographic examination

16. Goals of treatment The goals of treatment are- To restrict mandibular translation Remove obstacles Thus preventing mandibular dislocation and locking anterior to the articular eminence. Larry M. Wolford , Mitek anchors for treatment of chronic mandibular dislocation (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:495-8)

17. Treatment Acute dislocation needs immediate attention for relief of pain and anxiety to minimize damage to the joint structure. Reduction & immobilization for 4 week will allow damaged ligament capsule and disk to heal. In chronic cases treatment usually consis t f exercise to gain better muscular control and restraint of opening . Once a dislocation is reduced, the management thereafter depends on an accurate  diagnosis and an understanding of the etiology including local, systemic, and psychologic factors. It is important to know if there is a systemic component and if parafunctional habits and underlying muscle hyperactivity contribute to the problem . Occlusal appliances and intermaxillary fixation are ineffective in laxity of systemic origin because they do nothing to stabilize the loose ligaments . Surgery of temporomandibular joint by David A. Keith

18. Non Surgical Treatment Medications - NSAIDS, Muscle rexaxants , steroids Digital manipulation Psychological management Physical therapy- isometric exercises Occlussal therapy- correction of occlusal interference, restoring the vertical support of occlusion Intermaxillary fixation Injection of sclerosing agents into the TMJ capsule, TMJ ligament, and bilaminar tissue (with or without using arthroscopy) Larry M. Wolford , Mitek anchors for treatment of chronic mandibular dislocation (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:495-8)

19. Extrinsic trauma Blow on the chin while mouth is open, injudicious use of mouth gags during G A. Acute pain, anxiety & inability to close the mouth. Immediate manual reduction followed by 4 week of immobilization. Acute dislocation Surgery of temporomandibular joint by David A. Keith

20. Digital manipulation yurino’s method Bimanual mandibular manipulation Dingman & Natwig PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition L A injection into glenoid fossa & manipulation Manipulation under G.A. with the muscle relaxants. Manipulation under either oral / IV sedation ..

21. Intermaxillary fixation

22. Chemical capsulorraphy Principle – To induce fibrosis and restrict joint movement . 3% sodium tetradecyl sulphate / blood , Sodium psylliate emulsion in oil. Sodium morrhuate Disadv : Inability to predict the amount of limitation. Immobilization of the mandible is an important precaution to avoid early stretching of the newly formed fibrous tissue. Schultz 1947

23. Injection Of Botulinum Toxin Type A The injection of botulinum toxin type A into the lateral pterygoid muscles has also been proposed as a treatment for chronic and recurrent dislocation of the mandible. Ziegler and colleagues reviewed 21 patients treated in this fashion. Injections were given on a 3-month basis with only 2 of 21 patients suffering further dislocations. No adverse side effects were reported in this series. Botulinum toxin type A has an associated latency of 1 week, and its duration of action is between 2 and 3 months. Injections should not be done more often than every 12 weeks to avoid the development of antibodies . An injection dose of between 10 and 50 U into the targeted muscle is usually sufficient. PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

24. Injection Of Botulinum Toxin Type A Clark reviewed the use of botulinum toxin for the treatment of mandibular motor disorders, as well as for the treatment of facial spasm, and expanded on the potential side effects of such treatment. Although local side effects are unusual, the two most common problems encountered were alterations in salivary consistency and an inadvertent weakness of swallowing, speech , and facial muscles. These complications were more commonly reported with lateral pterygoid , soft palate and tongue injections and were found to be dose dependent. PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

25. Chronic dislocations Even though not much help with non surgical tech Conservative line of treatment should be considered first. Surgical management in recurrent cases

26. Surgical Treatment Soft tissue procedures Plication of the TMJ capsule and ligaments , Lateral pterygoid myotomy Temporal muscle myotomy Suturing the articular disk anterior to the condyle Removal of obstruction - Eminectomy Creation of translatory obstruction Osteotomy of the zygomatic arch and down fracturing it below the articular eminence ( Dautrey procedure). Bone graft to articular eminence Metal implants on articular eminence/arch area. Tethering/ Anchoring Placing a nonresorbable suture through the condyle and securing it to the root of the zygomatic arch Mandibular osteotomies condylotomy vertical oblique osteotomy high condylectomy . Larry M. Wolford , Mitek anchors for treatment of chronic mandibular dislocation (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:495-8)

27. Plication of the TMJ capsule and ligaments PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

28. Lateral pterygoid myotomy Bowman Bowman has reported good success with this procedure. but subsequent animal studies have shown lateral pterygoid electromyographic activity returning to baseline several months after the procedure. the long-term efficacy often attributed to this procedure may be secondary to scarring anterior to the joint capsule, thereby limiting condylar excursion PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

29. Myrhaug - Eminectomy in 1951 PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition Oral and Maxillofacial Surgery Edited by Lars Andersson The eminectomy procedure was first introduced by Myrhaug in 1951 as a treatment for chronic and habitual dislocation of the condyle.

30. Myrhaug - Eminectomy in 1951 Drawbacks: hypermobility of the joint with further damage to contiguous tissues significant and often bothersome TMJ noise (clicking and crepitation) with function; the potential for facial nerve injury; recurrent dislocation; and Inadvertent temporal lobe exposure success rates of standard eminectomy procedures - 7 to 33 % Westwood RM, Fox GL, Tilson HB. Eminectomy for the treatment of recurrent temporomandibular joint dislocation. J Oral Surg 1975;33:774–9 . Courtemanche AD, Son- Hing QR. Eminectomy for chronic recurring subluxation of the temporomandibular joint. Ann Plast Surg 1979;3:22–5. PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

31. K onjetzny’s procedure Surgery of temporomandibular joint by David A. Keith Surgicaly creat a close locked condition Disdv - creation of excessive restriction

32. LeClerc and Girald in 1943 PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition Oral and Maxillofacial Surgery Edited by Lars Andersson Chossegros and colleagues reported excellent success using this technique in 36 patients with chronic and recurrent dislocation

33. Dautry’s zygomatic arch osteotomy Mayor’s grafting technique on the eminence PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition Oral and Maxillofacial Surgery Edited by Lars Andersson Bone and cartilage grafts (cranial, iliac crest, rib, tibial ) have been used

34. Condylectomy

35. Condylotomy

36. Tethering / Anchoring Surgery of temporomandibular joint by David A. Keit

37. Conclusion The treatment of hypermobility disorders painful hypertranslation subluxation dislocation should be approached in a careful and conservative manner. The surgeon should employ the simplest and most effective method with the least morbidity for a specific patient. It is also important that muscular and psychologic factors are managed appropriately. PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

38. References Peterson‘s principle of oral and maxillofacial surgery second edition Oral and Maxillofacial Surgery Edited by Lars Andersson Larry M. Wolford, Mitek anchors for treatment of chronic mandibular dislocation(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:495-8) Surgery of temporomandibular joint by David A. Keith Oral Maxillofacial Surg Clin N Am 20 (2008) Akinbami Head & Face Medicine 2011, 7:10 Text book of oral and maxillofacial surgery by balaji Text book of oral and maxillofacial surgery by neelima malik PETERSON‘S PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY Second Edition

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