Subluxation and dislocation of temporomandibular joint

© Ramaiah University of Applied Sciences
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Faculty of Dental Sciences
Subluxation and Dislocation of
Temporomandibular joint
Dr Zeeshan Arif

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CONTENTS
• Introduction
• Definition
• Epidomology
• Pathogenesis
• Classification
• Etiology
• Predisposing factors
• Unilateral acute dislocation
• Bilateral acute dislocation
• Management
• Non surgical management
• Surgical management
• Conclusion
• References

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Introduction
• As far back as 3000 BC in Egypt, Hippocrates first reported a
dislocation of the mandible.
• His method of reduction has survived the ages and is still being
used in modern times.
• Mandibular condylar dislocation is uncommon, compared to
the other joints in the body.

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Definition
• Hypertranslation refers to the excessive anterior movement of
the condyle during opening.
• 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.

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Epidomology
• Uncommon compared to other dislocations
• 3 % incidence
• Uncommon in extremes of age
• Higher incidence in females
• Malagaigne et al- 57% cases were in females out of 240
patients (1981)

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• 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.
• These are rare

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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 eminence size or projection,
• Muscle hyperactivity or spasms,
• Trauma
• Abnormal chewing movements that do not allow the condyle
to translate back.
Pathogenesis

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• 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

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• 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

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• Is an excessive range of movement occurring in one or more
joints as a result of a pathological process
• May be isolated or generalized
• Isolated
– Neuropathic arthropathy
– Traumatic rupture of ligaments from injuries
– Rheumatoid arthritis and related disorders
– Late osteoarthrosis
Acquired hypermobility

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Generalized
• Acromegaly
• Joint laxity during pregnancy
• hyperparathyrioidism
• Chronic alocholism

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Occlusal factors
• Long term overclosure and
loss of physiological
vertical dimension can
contribute to subluxation
and dislocation
• Overclosure produces
stretching and loosening of
joint ligaments and joint
laxity

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• Spontaneous dislocation of the mandible due to
extrapyramidal reactions to prochlorperazine
• All Antipsychotic drugs
Drug associated dislocation

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• Hysteria can be the cause of habitual dislocation
• Psychosomatic disorder observed most often in young females
and may follow minor trauma to the jaw
• Habitual dislocation may be the presenting feature of an
underlying psychiatric disturbance
Psychogenic dislocation

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Classification
Anterior mandibular dislocation can be classified as
• 1. Acute
• 2. Chronic recurrent (habitual) subluxation
• 3. Long-standing.

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Etiology
Causes of Acute Dislocation
• a. Extrinsic forces or iatrogenic causes
• b. Intrinsic or self-induced forces

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Extrinsic or iatrogenic causes

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Intrinsic or self-induced

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Predisposing factors
• Laxity of ligaments, capsule and abnormality of skeletal form.
• 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.

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Unilateral acute dislocation
• 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.

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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 movements are
restricted.
• Posterior gagging and anterior open bite.
• Patient will complain of pain in the temporal region rather
than the joint and may be extremely apprehensive.
• The distinct hollowness can be felt in both the preauricular
regions.
• Associated muscle spasm contributes to the fixed position of
the condyles

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Imaging

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Management
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
• (i) reassuring the patient
• (ii) tranquilizer or sedative drugs
• (iii) pressure and massage to the area
• (iv) manipulation.

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Depending on the amount of associated muscle spasm and pain
experienced by the patient plus patient cooperation, the acute
dislocation can be reduced by the operator as follows:
• 1. Manipulation without any form of anaesthesia.
• 2. Manipulation with local anaesthesia.
• 3. Manipulation under general anaesthesia/sedation with
muscle relaxants.

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• A simple technique - Johnson
• LA is injected into the depression in the glenoid fossa left by
the dislocated condyle.
• Spontaneous reduction, in bilateral cases with the injection of
one point can occur with a swallow in 1 to 10 minutes
Johnson W.B. New method for reduction of acute dislocation of the
temporomandibular articulations. J Oral Surg. 1958;16:501–504

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Manual manipulation

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• In 1981, Lewis modified it in his way by stating that the patient
should be made to sit down and the clinician should stand in
front of him/her or at 11o’ clock position.
• Few authors have further modified the technique by changing
the position of the thumb from the occlusal surface of the
teeth to the anterior border of the ramus.
• In 1987, Awang described another simple, safe, and rapid
method in managing acute dislocation. According to him,
induction of the gag reflex by probing the soft palate creates a
reflex neuromuscular action that resulted in the reduction.

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• Deep temporal nerve block is
achieved by first locating the
anterior temporalis muscle.
• This muscle is palpated just
above the zygomatic bone,
where a depression can be felt.
• Deep to this portion of the
temporalis muscle is the greater
wing of the sphenoid bone.
• The anesthetic needle is directed
into this area until it hits the
sphenoid bone.

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• Immobilization can be carried out, by giving barrel bandage to
the patient for the period of 10 to 14 days and patient is kept
on semisolid diet.
• This will allow to give rest to the joint.
• Anti-inflammatory, analgesic drugs should be prescribed for
the period of 3 to 5 days.
• The patient is warned to avoid excessive oral opening and
support the chin, while yawning in future.

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Longstanding dislocation
• longer than one month.
• Frequently, this follows extraction of teeth or tonsillectomy
under general anaesthesia, where the jaw is excessively forced
open.
• Dislocation may then remain unnoticed, if not examined
postoperatively.
• passive acceptance of the condition by the patient.
• In these cases, with passage of time, additional muscle spasm
and fibrotic changes occur in the ligaments and muscles, thus
increasing the severity of the problem

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Chronic recurrent dislocation
• 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.
• So here the condylar head moves, unassisted, forward and
backward over the articular eminence.
• This recurrent, incomplete, self-reducing, habitual dislocation
is termed as hypermobility or chronic subluxation of the TMJ.

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The triad
• ligamentous and capsular flaccidity
• eminential erosion
• flattening and trauma

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• In such predisposed individuals, the acts of yawning, vomiting,
laughing may precipitate subluxation.
• It is also seen in severe epilepsy, dystrophia myotonia and the
Ehlers-Danlos syndrome.
• It can be also seen in professionals like teachers, speakers or
musicians.
• With each episode of subluxation, there is further stretching of
the capsular ligament, which aggravates the condition and
leads to further recurrence.

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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:
1. Hyperelasticity of the skin.
2. Fragility of the skin.
3. Hypermobility of the joints.
4. Fragility of the blood vessels.

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Chronic subluxation with pain
• It is not necessarily painful.
• But in some of the patients, sudden sharp and severe pain
occurs when the mouth is opened widely.
• Occasionally the problem is of such a magnitude, that the
patient becomes reluctant to masticate food.

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Non surgical management
• The conservative method includes the use of various sclerosing
agents like alcohol, sodium tetradecyl sulfate, sodium psylliate,
morrhuate sodium, and platelet-rich plasma that has been
injected into the joint space.
• In case of chronic dislocation, elastic rubber traction with arch
bars and ligature wires/intermaxillary fixation (IMF) with
elastic bands are useful to achieve the reduction.

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Use of sclerosing solution injections into the
joint space
• Objective is to produce fibrosis and tightening of the capsular
ligaments, thus limiting motion of the mandible and
preventing subluxations and dislocations
• Sodium psylliate provided consistently best results.
• But is no longer available.
• Sodium morrhuate has failed to produce good results.
• Sodium tetradecyl sulfate, which was developed for mildly
sclerosing varicose veins and haemorrhoids, can be used with
caution, as allergic or anaphylactic reactions have been
reported.

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Use of autologous blood
• The use of autologous blood in recurrent dislocation was
reported by Brachmann in 1964 and is very popular nowadays.
• In an animal study, Gulses et al., demonstrated that there are
significant fibrotic changes histologically evident in both
retrodiscal and pericapsular tissues.
• The volume of blood to be used ranges 2-4 mL in the upper
joint space and 1-1.5 m L in the pericapsular structures,
repeated twice a week for 3 weeks.

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• Head bandage is required for the period of 3-4 weeks.
• However, some authors have reported degeneration in the
articular cartilage and permanent joint destruction.
• Alons et al., reported that there is no noticeable damage to
the cartilage and the interposing disc on histopathological
examination. (rat study)
• The only reported disadvantage of this technique is severe
restriction in the mandibular range of motion.
• Machon et al. advocated that the patient should start jaw
rehabilitation by a gradual and controlled range of motion
exercises after 2 weeks of the autologous blood injection
therapy.

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Caromed facelift bandage
A.S.R. Pinto et al British Journal of Oral and Maxillofacial Surgery
47 (2009) 323–324

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Use of botulin toxin
• Another newer conservative method is the application of
botulinum toxinA (BTX-A) in recurrent TMJ dislocation.
• 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.

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• It acts by causing temporary weakening of the skeletal muscle
by blocking the Ca2+-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.

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Surgical procedures
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. Direct restraint of the condyle.
• 4. Creation of a new muscle balance.
• 5. Removal of mechanical obstacle.

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1. Capsule tightening procedures
• 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.

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• Reinforcement of the joint capsule by turning down a strip of
temporal fascia and suturing to the capsule

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

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• 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.

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2. Creation of a mechanical obstacle
• A) Lindermann performed an osteotomy on the eminence and
turned it down in front of the condylar head to prevent its
forward movement.

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B) Mayor advocated a placement of a graft (taken from the
zygoma) over the eminence to increase the size and height.

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• In all these methods the main drawback is that the ‘buttee’ is
not deep enough or strong enough”
• 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 operation
may fail if it relies solely on the bony buttress

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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.

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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.

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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

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• Oblique osteotomy of articular eminence and zygomatic root
• 8-10 mm of height of eminence
• Width of graft should be enough to prevent the medial escape
of condyle.

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3. Direct restrain of condyle
• Procedures directed towards restraining the condyle from
abnormal forward movements have been attempted for over
half a century.
• Temporalis fascia turned down and sutured to the lateral
surface of the articular capsule.
• These techniques are complicated and have questionable long-
term results.

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4. Creation of new muscle balance
• 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.

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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.

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5. Removal of mechanical obstacles
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.

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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

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C. Eminectomy
• In 1951, Myrhang first
reported this procedure.
• 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,
instead of attempting to
restrict the forward movement
of the condylar head

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Dislocation of the temporomandibular joint
Christopher W. Shorey, and John H. Campbell, et al
Oral Med Oral Pathol Oral Radiol Endod 2000;89:662-8)

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• 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

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References
• Okeson -Management of temporomandibular disorders and
occlusion- Sixth edition
• David A. Keith. Surgery of the Temporomandibular Joint.
Second edition
• John E. Norman, Paul Bramley. A textbook and colour atlas of
the Temporomandibular Joint, Diseases, Disorders, Surgery.
• Fonseca, Marciani, Turvey. Oral and Maxillofacial Surgery.
Second edition
• Dislocation of the temporomandibular joint
Christopher W. Shorey, and John H. Campbell, et al
Oral Med Oral Pathol Oral Radiol Endod 2000;89:662-8)

82
• 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.
• 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.
• Dautrey’s Procedure in Treatment of
Recurrent Dislocation of the Mandible Kiran Shrikrishna Gadre,
et al
J Oral Maxillofac Surg 68:2021-2024, 2010
• Caromed facelift bandage A.S.R. Pinto et al British Journal of
Oral and Maxillofacial Surgery 47 (2009) 323–324

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• Glenotempororal osteotomy and bone grafting for the
management of chronic recurrent temporomandibular
dislocation- medra et al – BJOMS- 2007
• A Safe and Effective Way for Reduction of Temporomandibular
Joint Dislocation- Yi-Chieh Chen et al. Annals of plastic surgery
2007
• Use of Masseteric and Deep Temporal Nerve Blocks for
Reduction of Mandibular Dislocation- Andrew L. Young et al.
Americal society of anaesthesiology, 2009
• Temporomandibular Joint Dislocation Reduction Technique A
New External Method vs. the Traditional-Mojtaba Mohamadi
Ardehali et al. Annals of plastic surgery. 2009

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