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TMJ SUBLUXATION AND DISLOCATION

1. TMJ ( SUBLUXATION & DISLOCATION) Presented by: Md Mahbubul Hoda Moderator: Dr. (Col) Suresh Menon

2. Content Introduction Anatomy TMJ movements Classification of TMJ hypermobility Etiology and pathogenesis Clinical features Investigation Management References

3. Introduction The TMJ is considered a ginglymo-diarthrodial joint ; a joint with both rotational and translatory movements. One of the key features that distinguishes the TMJ from other joints in the body is that it is bilateral diarthrosis Articulating surface of the joint is covered with fibro- cartilage rather than hyaline cartilage.

4. TMJ components are glenoid fossa, articular eminence, mandibular condyle, articular disk, ligaments, synovial membrane & capsule. Dislocation A non self-limiting displacement of the condyle , outside of its functional positions ; from glenoid fossa . Most commonly occurs in antero -superior direction. Subluxation A self limiting displacement of the condyle , outside of its functional positions; glenoid fossa .

5. TEMPOROMANDIBULAR JOINT (Anatomy ) Main components of the TMJ : Condyle Articular eminence and mandibular fossa Articular disc Articular capsule Ligaments

6. CONDYLAR HEAD The condyle of the mandible is composed of cancellous bone covered by thin layer of compact bone. The trabeculae are grouped in such a way that they radiate from the neck of the mandible and reach the cortex at right angles, thus giving maximum strength to the condyle.

7. MANDIBULAR FOSSA (GLENOID FOSSA) Dense cortical bony surface of temporal bone Posterior to articular eminence Posterior non-articular fossa is formed by tympanic plate Thin at the roof of the fossa and tympanic plate

8. The unique feature of the TMJs is the articular disc . The disc is composed of fibrocartilaginous tissue which is positioned between the two bones that form the joint. The disc divides each joint into two- The lower joint compartment formed by the mandible and the articular disc is involved in rotational movement-this is the initial movement of the jaw when the mouth opens The upper joint compartment formed by the articular disc and the temporal bone is involved in translational movements-this is the gliding motion of the jaw as it is opened widely.

9. Disk can be divided into Anterior band Intermediate zone Posterior band The intermediate zone is thinnest & is generally the area of function between the mandibular condyle & the temporal bone. The disk is flexible & homogenous structure despite separate zones.

10. The articular disk is attached to the capsular ligament anteriorly, posteriorly, medially & laterally. Some fibers of the superior head of the lateral pterygoid muscle insert on the disk at its medial aspect, apparently serving to stabilize the disk to the mandibular condyle during function.

11. Retrodiskal Tissue Posteriorly the articular disk blends with a highly vascular, highly innervated, bilaminar zone. The superior aspect- contains elastic fibers and is termed the superior retrodiskal lamina , which attaches to the tympanic plate & functions as a restraint to disk movement in extreme translation.

12. The inferior aspect of the retrodiskal tissue, termed the inferior retrodiskal lamina. It consists of collagen fibers without elastic tissue & functions to connect the articular disk to the posterior margin of the articular surfaces of the condyle . It serves as a check ligament to prevent extreme rotation of the disk on the condyle in rotational movements.

13. TMJ LIGAMENTS

14. FUNCTIONS Of LIGAMENTS Accessory ligaments may limit border movements of the mandible Fibrous capsule & temporomandibular ligaments may limit the extreme lateral movements in wide opening of mandible

15. FIVE LIGAMENTS 1. Collateral Ligament 2. Capsular Ligament 3. Temporomandibular Ligament 4. Sphenomandibular Ligament 5. Stylomandibular Ligament Made up of collagenous tissues (do not stretch). Act as restraining devices to limit and restrict sudden joint movement.

16. TMJ Movements Normal mandibular opening should be between 40 to 54mm, and decreased in the amounts for incisal opening is always be questioned. There are two principal motions of the temporomandibular joint are rotation and translation. The 1 st movement of a normal, healthy joint is that of condyle, rotating to around 25mm of interincisal opening. The next is a forward movement of condyle to full range of opening from 40-50 mm.

17. In a normal, healthy TMJ there is an approximate ratio 4:1 between maximum opening and maximum translation. Jaw opening is accomplished through the action of the suprahyoid muscles (rotation) and the lateral pterygoid muscles (translation; protractor). Jaw elevation is accomplished by mainly by elevator muscles; masseter , temporalis , medial pterygoid . Note- Balance between protractor and elevators keep condyle in its functional position.

18. Classification of TMJ H ypermobility Subluxation Dislocation Recurrent Habitual (Psychogenic)

19. Hypermobility- Excessive anterior movement of the condyle at maximum mouth opening without strain or symptoms. Subluxation- Condylar subluxation is an incomplete joint dislocation. The atricular surface maintain partial contact and the condyle is able to return to glenoid fossa voluntarily. Dislocation- Dislocation is a complete separation of the articular surfaces with fixation in an abnormal position. Relocation of the condyle in its normal position in the glenoid fossa does not occur voluntarily.

20. Recurrent dislocation- Dislocation which take place repeatedly and which last for short or long intervals are referred to as recurrent dislocation. Chronic dislocation- A chronic condition where patient is able to dislocate and reduce at will and the condition is often referred to as habitual dislocation

21. Etiopathogensis Acute anterior dislocation- Intrinsic factors- Wide yawn, Vomiting, laughing, wide biting, seizures. Extrinsic factors- Traumatic dislocation, specially when the mouth is in open position . Manipulation of the jaw while intubation Prolonged dental extraction with wide mouth opening

22. Laxity of ligaments, capsule and abnormalities of skeletal form are predisposing factors in both acute and chronic forms of dislocation. Spontaneous dislocation occur due to a break in the timing of muscular action in the phase of closing. Steps involves in normal closing- Relaxation of inferior belly of lateral pterygoid Retraction and elevation of the mandible. Dislocation- (Muscular factor) Protractors fail to relax at appropriate time and elevators contract to dislocate mandible.

23. Other important factors which predispose to TMJ hypermobility are- Shape of the bone The disk Muscular power Laxity of the ligaments and joint capsule.

24. Occlusal factors- Overclosure produces stretching and loosening of joint ligaments and increased joint laxity results in subluxation. Occlusal disturbances may also be related to bruxism . The damaging effects of bruxism on joint structures and its role in initiating muscles disturbances is a one of the etiological factor of recurrent dislocation. Drug associated- Prochlorperazine predisposes the TMJ for dislocation O Hara VS. Extrapyramidal reactions in patient receiving Prochlorperazine ; M Engl J Med 1958, Vol 2 (259-286)

25. Psychogenic dislocation- Hysteria can be the cause of habitual dislocation of the mandible. It is a psychosomatic disorder observed most often in young females and may be associated with minor trauma of the jaw, in which ligament become relaxed and recurrent/habitual dislocation can easily occur for psychogenic gain .

26. Clinical examination Spontaneous dislocation from a wide yawn is often bilateral, but a blow to the chin with the mouth open usually creates a unilateral dislocation. Bilateral dislocation- Pain Inability to close mouth Tense masticatory muscles Difficulty in speech Excessive salivation Protrusive chin with open bite

27. Hollowing in front of tragus Lateral pole of the condyle produces protuberance anterior to and below the articular eminence, which can usually be seen and palpated Pain is more experienced in temporal fossa rather than in joint space Unilateral dislocation Mandible swung away from the side of dislocation. The deviation produces a lateral cross and open bite on the contralateral side. Hollowing in front of tragus is ispsilateral

28. Radiographic examination Transcranial radiographs and lateral tomograms are important in identification and documentation of dislocation. MRI help in identification of disc, ligament associated dislocation of the condyle .

29. Management To decide the treatment plan, it is important to understand the etiology and duration of the dislocation. Acute dislocation- Immediate attention for relief of pain and anxiety and to minimize damage to the joint structure. Treatment- Reduction and immobilization for 4 weeks. Chronic dislocation- i ) Exercise to gain better masticatory muscles control ii) Management by surgery indicated for long standing and chronic dislocation.

30. Acute dislocation Reassurance of the patient. Reducing tension, anxiety, and muscle spasm Sedative or muscles relaxants can be used. Methods of reducing dislocated temporomandibular joint- Johnson described a method of self reduction, in which injection of local anesthetic into the depression of glenoid fossa results in spontaneous reduction of dislocated unilateral/bilateral joints in 1-10 minutes, when patient is asked to do swallowing. JOHNSON WB: New method for reduction of acute dislocation of the temporomandibular articulations; J oral Surg 1958. Vol 16(501)

31. 2) Adams method- ( 1 st described by Hippocrates) Two persons method . 1 st person should stabilize the head and other will use finger to reduce the dislocated condyle . Steps Ask the patient to open the mouth wide Move the jaw towards dislocated side And then quickly the operator must open the jaw and locate it in neutral position by downward and backward motion.

32. Roth’s method- Roth F. A new method of manipulation for the replacement of lower jaw when dislocated. Lancet 1893:41 (751)

33. Yurino’s method- Yurino M: New method for reduction of acute anterior dislocation of the mandible; J Maxillofacial Surg , 1983;41 (751)

34. Symptomatic treatment Patients with subluxation and dislocation often suffer arthralgia and myalgia and symptomatic treatment is necessary. NSAID’S relieve locomotor system pain. An injection of a steroid such as methylprednisolone gives excellent results in persistent synovitis in hypermobility syndrome

35. Long standing dislocation The difficulty in reducing mandibular dislocation increases with the time. Use of general anesthesia and muscles relaxant is useful aids in reduction of chronic dislocation of condyle , where ligament and muscles gets damage and fibrosed . There are high chances of recurrence in chronic case after reduction, so these cases are advised for Intermaxillary fixation for 10-15 days

36. Non surgical treatment of recurrent dislocation Recurrent dislocation is the condition, where patient can self reduce the condyle . This condition associated with hyperlaxity of the ligaments, muscle hyperactivity, coexisting internal disc derangement and hypermobility syndrome. So it is important to manage these condition before surgical intervention. Patient is advised for limited mouth opening and to change the mechanics of opening ,where to avoid translatory movements

37. Physical therapy Synchronized isometric contraction exercise of masticatory opening muscles and their antagonists should be performed on regular basis. Poswillo - Described exercise to train the suprahyoid muscle to stabilized the mandible and reduce the forward movements of the condyle in the early opening phase. Steps- (Initially in front of the mirror) Claps both hands behind the nape of the neck With the mouth closed and the teeth touching lightly, contract the muscles beneth the chin

38. 3) Attempt to pull the chin back into the neck without opening the mouth ( see the contraction of suprahyoid muscles) Note- It should be done for 3-5 minutes each hour for 1 st month and then exercise should be done indefinitely once or twice in a day to prevent a return to paranormal function. Gradually try to open mouth and do exercise, when the art of exercise learn and try to improve mouth opening with exercise.

39. Occlusal treatment Occlusal disturbances, such as cuspal interferences and nonocclusion due to missing teeth with loss of vertical support, should be corrected to prevent their contributing to the instability of the joint Appliances can be helpful in those individuals with coexisting internal derangement of the disk, bruxism and muscle hyperactivity

40. Chemical capsulorrhaphy The injection of sclerosing agents into the supporting ligaments or into the joint has been described by many authors as reliable method . The objective is to produce fibrosis and tightening of the capsular ligament, thus liming motion of the mandible and preventing subluxation and dislocation. The use of sodium psylliate emulsion in oil, alcohol and homogenous blood has been advocated. Disadvantage- Unpredictable limitations Possibility of damaging facial nerve (rare)

41. Injection of 0.5ml sclerosant into upper joint space (2-3 episodes within a month) is useful. 0.5ml of sodium tetradecyl sulphate solution infiltrated into lateral capsular ligament is also preferable, maxillomandibular fixation is indicated for 2 weeks. Matsushita K, Abe T, Fujiwara T. OK-432 ( Picibanil ) sclerotherapy for recurrent dislocation of the temporomandibular joint in elderly edentulous patients: case reports. Br J Oral Maxillofac Surg 2007;45: 511–3 .

42. Intra- articular blood injections are aimed at initiating an intra- and peri -capsular inflammatory response, perpetuated by transferred platelets and damaged nonplasma blood constituents. This inflammation creates fibrosis and adhesions, as is seen in the post-traumatic hemarthrosis model. Fibrosis and cicatricial maturation cause a physiologic decrease in compliance to the periarticular soft tissues, culminating in a decrease in range of motion (ROM). Machon V, Abramowicz S, Paska J, et al. Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation. J Oral Maxillofac Surg 2009;67:114–9.

43. Botulinum Toxin- Botulinum toxin type A induces a dose-related weakness of skeletal muscle by inhibition of acetylcholine release at the neuromuscular junction. Most frequently, the targeted muscle is the lateral pterygoid , which is often implicated in myospasm associated with dislocation. That being said, it may also be infiltrated into any of the masticatory musculature. 25 to 50 units of botulinum toxin type A are deposited directly into the muscle belly, aspirating prior to injection to avoid inadvertent intravascular injection Fu K, Chen HM, Sun ZP, et al. Long term efficacy of botulinum toxin type A for the treatment of habitual dislocation of the temporomandibular joint. Br J Oral Maxillofac Surg 2010;48:281–4 .

44. Autologous blood injection for the treatment of recurrent mandibular dislocation In this study done by R Coser et al eleven patients diagnosed with recurrent dislocation of the joint that could not be self-reduced, received bilateral injections of autologous blood in the superior joint compartment and pericapsular region. During a follow-up period ranging from 24 to 35 months, eight patients (72.7%) did not show new episodes of dislocation.

45. The most advocated treatment for recurrent dislocation is eminectomy , which involves a skin incision, with the risk of damaging the facial nerve, requires general anaesthesia, and presents an average success rate of 85% according to the literature. Autologous blood injection is a simple, rapid, minimally invasive, and cost-effective technique, with a low possibility of complications, and is a feasible alternative treatment before surgical intervention

46. Injection of 2 ml autologous blood in the upper joint space and 1 ml in the pericapsular region R . Coser , H. da Silveira , P. Medeiros, F.G. Ritto : Autologous blood injection for the treatment of recurrent mandibular dislocation. Int. J. Oral Maxillofac . Surg. 2015;

47. Surgical management Indications a) Disabling recurrent dislocation b) Long standing dislocation ( Not responding to non surgical methods) Contraindication Psychological disturbances associated dislocation Epileptic patients

48. Classification of surgical treatment In 1976, Miller and Murphy divided surgical procedure for TMJ dislocation- Capsule tightening procedure Capsulorraphy , placement of vertical incision, reinforcement of the joint capsule Creation of a mechanical obstacle or block Direct restraint of the condyle Temporalis fascia sutured to capsule, walford procedure Creation of a new muscle balance Removal of mechanical obstacle

49. 1. Capsule tightening procedure The capsule tightening procedure also known as capsular plication . This involves exposure of capsule followed by an incision vertically through the body of ligaments. The incision margins are then overlapped and sutured.

50. This technique violates the joint cavity so to overcome this, several sutures are placed along the inferior aspect of capsule to tighten the capsular ligament.

51. Fig: capsulorrhaphy (arrow indicating the sutures placed)

52. 2. Blocking procedures- Blocking procedures to interfere with translation are designed to create an obstacle to the condylar opening. This operation includes soft tissue and bony procedure. Soft tissue- Konjetzny’s procedure- The posterior ligament of the disk is released and the anterior attachment is preserved. The disk is pulled anteriorly and inferiorly and is anchored vertically in front of condyle by suturing it to lateral pterygoid muscle inferiorly and to the capsule laterally

53. Bony procedure- This can be accomplished using a titanium miniplate, interpositional bone graft, or blocks of hydroxyapatite . Autogenous grafting can be completed using various graft donor sites; however, the most frequently described techniques typically use iliac crest or cranium. Mayers (1933) resected a 1.5cm segment of the zygomatic arch and grafted it into a furrow, he created in the articular eminence. ( Leclerc and Girad ) Lindemann made an oblique osteotomy to increase the height of articular tubercle.

54. Grafting in front of condyle Leclerc and Girad procedure Lindemann procedure Aaron Lidde, Daniel E. Perez: Temporomandibular Joint Dislocation; Oral Maxillofacial Surg Clin N Am 27 (2015) 125–136

55. Dautrey’s procedure- ( Gosserez & Dautrey 1967) G KiShrikrishna , K Deepak, R Shandilya , S Shishir : Dautrey’s Procedure in Treatment of Recurrent Dislocation of the Mandible; J Oral Maxillofac Surg 68:2021-2024, 2010

56. Dautrey’s procedure- ( Gosserez & Dautrey 1967) Mayer was the first to report the displacement of the zygomatic arch (or a segment of it) to obstruct the condylar path . Le Clerc and Girard performed a vertical osteotomy of the zygomatic arch and lowered the proximal segment and placed a thicker part of the zygoma into the path of the condyle. The procedure was refined by Gosserez and Dautrey in 1967. Currently, the procedure is known as“Dautrey’s procedure.” In this procedure, the zygomatic arch is osteotomized downward and forward just in front of the articular eminence to create a mechanical obstruction. This procedure gained popularity during its initial years but somehow was lost thereafter for quite some time. . G KiShrikrishna , K Deepak, R Shandilya , S Shishir : Dautrey’s Procedure in Treatment of Recurrent Dislocation of the Mandible; J Oral Maxillofac Surg 68:2021-2024, 2010

57. 3 . DIRECT RESTRAIN OF CONDYLE Anchoring procedures Reduce or eliminate the anterior or translational motion of the condyle . This includes Capsulorrhaphy Capsular plication Flaps secured to the capsule Autogenous and alloplastic slings between the condyle and zygomatic process Daniel E. Torres, Joseph P. McCain: Arthroscopic electrothermal capsulorrhaphy for the treatment of recurrent temporomandibular joint dislocation. Int. J. Oral Maxillofac . Surg . 2012; 41: 681–689.

58. Walford’s Procedure Two Mitek mini anchors have been threaded with two No. 2 Ethilon sutures Mitek anchoring Larry M. Wolford et al: Mitek anchors for treatment of chronic mandibular dislocation; Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:495-8)

59. 4 . CREATION OF NEW MUSCULAR BALANCE Lateral pterygoid myotomy - The rationale for this procedure is to reduce or eliminate the muscular forces thought to be responsible for pulling the mandible into dislocated position. Boman , 1949 1 st described this procedure

60. . Procedure- Transoral / preauricular incisions can be used to approach. Open the mouth (Maximum). A vertical incision is then created, extending from the coronoid process, along the ascending ramus to the distal of the most posterior tooth

61. Soft tissues are elevated from the medial mandible, followed by blunt/scissor dissection to visualize the lateral pterygoid . The lateral pterygoid is then detached from the condyle /anterior capsule. Sindet -Pedersen S. Intraoral myotomy of the lateral pterygoid muscle for treatment of recurrent dislocation of the mandibular condyle . J Oral Maxillofac Surg 1968;46:445–9 .

62. 5 . Eliminate blocking factors in the condylar path of closure Operations have been designed to eliminate obstacles in the condylar path that may either trigger a dislocation or mechanically prevent reduction of condyle into glenoid fossa . Hyperactive muscles pulls condyle anterior to the eminence and a toen or displaced disk caught behind the condyle may act as an obstracle for closure resulting in dislocation. Rx Diskectomy Eminectomy

63. Diskectomy The decision to remove the disk is made in situations in which the disk is so deranged that few options exist. Instability of the disk because of perforation, fragmentation, loss of elasticity, or persistent pain after disk repositioning may require diskectomy . Once the joint is exposed, the disk is excised, leaving as much synovium as possible.

64. Eminectomy 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 .

65. 6.. Combined procedures Lateral pterygoid myotomy with diskectomy - 1 st described by Boman , which prevents translation by lateral pterygoid myotomy and remove obstruction by diskectomy . 2) Condylotomy – (Ward et al 1975) It is an osteotomy through the condylar neck till the lower border of the mandible. This allows the condyle to displace anteriorly and sag inferiorly.

66. 3) Condylectomy – This is the last option in treating dislocation of TMJ. Results in facial and occlusal deformity. This procedure both restricts forward motion and removes blocking factors. Scarification of lateral pterygoid only allows rotational movements and avoid translation. Shortening of mandible results in open bite deformity and retrusion of themandible . High condylectomy is more conservative approach.

67. Condylotomy Condylectomy

68. Transfer of temporalis pedicle to anterolateral aspect of capsule. Interposition of illiac bone on arch to prevent further forward movements of condyle R. Kummoona : Surgical reconstruction of the temporomandibular joint for chronic subluxation and dislocation. Int. J. Oral Maxillofac . Surg. 2001; 30: 344–348.

69. Conclusion There are myriad etiologies that can create acute or chronic TMJ dislocations. Accordingly, it is up to the astute practitioner to create a patient- centered treatment algorithm when deciding on which treatment modality to employ. As important as symptom palliation is, the underlying cause of dislocation should be analyzed, and thoughtful consideration should be given to etiology , so long-term resolution may be attained .

70. References Temporomandibular disorders –Andrew S Kaplan, Leon A. Assael Surgery of TMJ- David A. Keith 2 nd edition 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 R. Kummoona : Surgical reconstruction of the temporomandibular joint for chronic subluxation and dislocation. Int. J. Oral Maxillofac . Surg. 2001; 30: 344–348.

71. O Hara VS. Extrapyramidal reactions in patient receiving Prochlorperazine ; M Engl J Med 1958, Vol 2 (259-286) JOHNSON WB: New method for reduction of acute dislocation of the temporomandibular articulations; J oral Surg 1958. Vol 16(501) Roth F. A new method of manipulation for the replacement of lower jaw when dislocated. Lancet 1893:41 (751) Matsushita K, Abe T, Fujiwara T. OK-432 ( Picibanil ) sclerotherapy for recurrent dislocation of the temporomandibular joint in elderly edentulous patients: case reports. Br J Oral Maxillofac Surg 2007;45: 511–3 Machon V, Abramowicz S, Paska J, et al. Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation. J Oral Maxillofac Surg 2009;67:114–9

72. Fu K, Chen HM, Sun ZP, et al. Long term efficacy of botulinum toxin type A for the treatment of habitual dislocation of the temporomandibular joint. Br J Oral Maxillofac Surg 2010;48:281–4. Daniel E. Torres, Joseph P. McCain: Arthroscopic electrothermal capsulorrhaphy for the treatment of recurrent temporomandibular joint dislocation. Int. J. Oral Maxillofac . Surg . 2012; 41: 681–689. Aaron Lidde, Daniel E. Perez: Temporomandibular Joint Dislocation; Oral Maxillofacial Surg Clin N Am 27 (2015) 125–136 G KiShrikrishna , K Deepak, R Shandilya , S Shishir : Dautrey’s Procedure in Treatment of Recurrent Dislocation of the Mandible; J Oral Maxillofac Surg 68:2021-2024, 2010

73. Daniel E. Torres, Joseph P. McCain: Arthroscopic electrothermal capsulorrhaphy for the treatment of recurrent temporomandibular joint dislocation. Int. J. Oral Maxillofac . Surg . 2012; 41: 681–689 A. Ybema , L. G. M. De Bont , F. K. L. Spijkervet : Arthroscopic cauterization of retrodiscal tissue as a successful minimal invasive therapy in habitual temporo mandibular joint luxation. Int. J. Oral Maxillofac . Surg . 2013; 42: 376–379.

74. Thank you