V.N. Okoje, T.O. Aladelusi, and T.A. Abimbola
Department of Oral and Maxillofacial Surgery, University College Hospital, Ibadan
Aim: The study presents a case series which evaluates the presentation, management and outcome of TMJ dislocation in a tertiary health centre in Nigeria.
Materials and methods: Case review of 11 patients with TMJ dislocation seen in the University College Hospital (UCH) Ibadan over a period of 10 years. The criteria for the diagnosis of TMJ dislocation were based on history, clinical examination and radiologic findings.
Results: Mean age of patients was 44.4 years (SD +/-15.9years); age range was 25-65 years with 4 males and 7 females. Aetiology was trauma in 4 cases, wide mouth opening in 6 cases and unknown in a patient. There were 7 acute presentations, 2 recurrences and 2 chronic presentations; bilateral anterior presentation in 10 cases, unilateral (right) anterior presentation in 1 case. 4 of the acute cases were successfully managed using the Hippocrates manoeuvre, 1 had the manoeuvre under GA, and 2 had spontaneous reduction. All recurrent cases were successfully managed with the Hippocrates manoeuvre and IMF. Fifty percent of the chronic cases were successfully managed with the Hippocrates manoeuvre. Follow up was < 2 weeks in 7 of the cases.
Conclusion: The pattern of presentation of TMJ dislocation in the above named hospital was anterior dislocation, the female gender predominance, aetiology of wide mouth opening, as well as early presentation. A conservative method of management – the Hippocrates manoeuvre – was effective in most cases irrespective of duration of dislocation. Most patients had a poor attitude to follow up.
Keywords: Temporomandibular joint, Dislocation, Conservative management
Dr. T.O. Aladelusi
Dept. of Oral and Maxillofacial Surgery,
University College Hospital,
Temporomandibular joint (TMJ) is a bilateral synovial articulation between the condyle of the mandible and glenoid fossa of the temporal bone. It is a bi-arthroidal hinge joint that allows the complex movements necessary for mastication, deglutition, talking and yawning. It is one of the most complex as well as most utilized joints in the human body.1
In certain situations, when the condylar head goes beyond the glenoid fossa in either an anterior, posterior, medial, lateral, or superior direction, a TMJ dislocation results. The principles for diagnosis and treatment of TMJ dislocation were proposed by Sir Astley Cooper who introduced the terms complete dislocation (luxation) and imperfect dislocation (subluxation) in 1932.2 These terms have been further expantiated upon or discussed by several authors. TMJ dislocation (“Open lock”) is a painful condition in which there is complete displacement of the mandibular condyles from its articulating surface within the glenoid fossa, this displacement is not reduce-able by the patient, hence necessitating presentation in the hospital3. Subluxation, however refers to a condition in which the joint is transiently displaced without complete loss of the articulating function, and is usually self-reduced by the patient2. TMJ subluxation and dislocation though uncommon, accounting for less than 3% of all reported dislocated joint in the body,2 and are very unpleasant and distressing conditions to patients.4
Despite a variety of classification systems, temporomandibular joint dislocation is most commonly divided into three categories: acute, chronic persistent, and chronic recurrent.3 Acute dislocations could be spontaneous but it is usually associated with aetiologies, including excessive mouth opening during vomiting, yawning, laughing and singing; forceful mouth opening for endotracheal intubation; and prolonged mouth opening during a lengthy dental/ ENT procedure and endoscopy. There have also been reports of acute dislocation following seizures, trauma and spasm of the masseter, temporalis, and internal pterygoid muscles resulting in trismus thus preventing return of the condyle to the temporal fossa.
Patients with TMJ dislocation often present with inability to close the mouth, depression of the preauricular area, severe pain in the TMJ region and associated muscles, hypersalivation, elongation of facial profile, tension of muscles of mastication, amongst others.2 Acute TMJ dislocation is associated with more severe limitation in jaw functions. This is alarming to the patients prompting early presentation usually within the first day of occurrence, as seen in majority of the patients in this study. Patients with history of recurrence also presented very early probably due to an awareness of where to seek health care services. This finding is similar to reports by Ugboko et al which suggested that early presentation is due to the discomfort and disfigurement encountered by the patients.4 Acute dislocations are typically isolated events, which when managed appropriately, usually have no long-term sequelae.5
Acute dislocations may however predisposes an individual to progressing to the spectrum of chronic dislocations. Chronic dislocations include acute dislocations that are not self-limiting and progress without treatment (usually referred to as chronic persistent), and chronic recurrent dislocations, wherein individuals experience multiple, recurrent dislocations as a result of everyday activities. Chronic recurrent dislocations can create significant interference in a patient’s everyday life, and can become both physically and emotionally distressing.5
Frequent dislocation may be seen in patients with altered structural components of the joint which include lax capsule, weak ligaments, small/short and atrophic condyle, atrophic articular eminence, elongated articular eminence, hypoplastic zygomatic arch and small, poorly grooved glenoid fossa and in patient with connective tissue disease, such as Ehlers-Danlos syndrome (EDS), Marfan’s syndrome or muscular dystonias3,5. Factors associated with the onset of habitual dislocation include excessive yawning, singing, sleeping with the head resting on the forearm, manipulation of the mandible while the patient is under general anaesthesia, excessive tooth abrasion, severe malocclusion, edentulism (leading to overclosure), trauma and drugs, especially the anti-emetics (metoclopramide) and phenothiazines (compazine),
which produce extra pyramidal effects.4
TMJ dislocations could also be classified based on site (unilateral or bilateral) and direction of displacement of the condylar head (anterior, posterior, medial, lateral, superior). The most common type of temporomandibular joint (TMJ) dislocation is anterior dislocation, dislocations may however occur in any direction especially when associated with condylar fractures3,6.
This article presents a case series and discusses the aetiology, types, presentation, management and outcome of TMJ dislocation seen in a tertiary health care centre in Nigeria. It also discusses the initial management, including techniques for reduction of the acute anterior dislocation of the TMJ.