Dr. Bhavik Miyani, Resident Doctor in Oral & Maxillofacial Surgery, Narsinhbhai Patel Dental College & Hospital, Visnagar.

1. A CASE OF BILATERAL TMJ
DISLOCATION
PREPARED BY,
DR. BHAVIK MIYANI
POST GRADUATE – 1st YEAR.
GUIDED BY,
DR. ANIL
MANAGUTTI
DR. SHAILESH
MENAT

2. NAME :- JAGATJISINH THAKOR
AGE/SEX :- 28 Years/ Male
OCCUPATION :- FARMER
ADDRESS :- MARODA
CONTACT NO. :- 9426275542
OPD NO. :- 6072-G

3.  Patient complain of inability to close
his mouth since 5 days.
CHIEF COMPLAIN

4. HISTORY OF PRESENT ILLNESS
• Patient was relatively asymptomatic before 5 days. Then
he fallen down due long standing position. Patient was an
unconscious for a while at the time of incident.
• No history of bleeding from nose & ear.
• Then patient visited patan civil hospital from there he
was referred to our department with above mentioned
complaints.

5.  PAST MEDICAL HISTORY :-
- No relevant medical history
 PAST DENTAL HISTORY :-
- No relevant past dental history
 DRUG HISTORY :-
- No relevant drug history
 FAMILY HISTORY :-
- No relevant history

6.  PERSONAL HISTORY :-
- Habits :- No harmful habits
- Diet :- Vegetarian
- Marital status :- Married
- Brushing :- Once a day with medium bristle toothbrush in a
morning

7.  GENERAL EXAMINATION :-
• Well Conscious
• Well Cooperative
• Well Oriented to time, place and person
• Built :-Well built
• Nourishment :- Well nourished
• Gait :- Normal
• Vital signs:-
• Temperature: Afebrile
• Blood pressure: 130/84 mmhg
• Pulse rate: 88 beats/min
• Respiratory rate: 14 cycles/min

8. LOCAL EXAMINATION
(A) EXTRA- ORAL EXAMINATION :-
• Face :- Bilaterally asymmetrical due inability to
close his mouth
• Skin and soft tissue :- NAD
• Eyes :- NAD
• Ears :- NAD
• Nose :- NAD
• Lips :- Incompetent
• Jaw movement :- Restricted
• TMJ :- Tenderness on both TMJ & Depression is present

9. FRONT PROFILE
LEFT LATERALRIGHT LATERAL

10. (B) INTRA- ORAL EXAMINATION :-
- Hard Tissue Examination - All the teeth are present except
37
- Soft Tissue Examination -
- Buccal Mucosa - NAD
- Labial Mucosa - NAD
- Palate - NAD
- Gingiva - NAD

11. INVESTIGATIONS
(1) ORTHOPANTOMOGRAM
(2) LATERAL CEPHALOGRAM
(3) TMJ VIEW

12. OPG – BEFORE REDUCTION

13. OPG – AFTER REDUCTION

14. FINAL DIAGNOSIS
• Bilateral TMJ Dislocation

15. • PRE-MEDICATION USED BEFORE MANUAL
REDUCTION.
-IV Diazepam 5 to 10 mg at 5 mg/min.
-IV Fentanyl 0.5 to 1 mcg/kg.
TREATMENT

16. TREATMENT DONE
L.A.
ADMINISTRATION
BIMANUAL REDUCTION

17. TREATMENT DONE
BARTON BANDAGE APPLICATION FOR 2 TO 3
DAYS.

18. DISCUSSION
 Introduction
 Definition, Etiology & Predisposing factors for
Dislocation
 Classification, Clinical presentation & Diagnosis
 Treatment Options
- Nonsurgical
- Surgical
- Recent Advances in Treatment
 Conclusion

19. INTRODUCTION
 Dislocation of mandible is one of the earliest
afflictions of the jaws to be described in the
literatures.
 As far back as 3000 BC in Egypt, Hippocrates first
reported a dislocation of the mandible.
 Mandibular dislocation uncommon compared to
other joint dislocation (3.1%) ( Lovely, Copeland, 1981)
 Higher incidence in females than in males.

20. DEFINITION
“During normal or unstrained opening of the mouth, the
condylar heads translate forward to a position under the apices of the
articular eminence. If oral opening proceeds to its maximum capacity, the
condylar heads move to the anterior slope of the articular eminences in
many normal individuals. Excursion of the condylar heads beyond these
limits may be viewed as abnormal and termed as dislocation.”
- Neelima Malik 3rd edition

21. ETIOLOGY
 Intrinsic Forces/ Self- induced Forces-
• Yawning
• Vomiting
• Wide biting
• Seizures disorder
 Extrinsic Forces/ Iatrogenic Causes-
• Trauma: flexion-extension injury to the mandible
• Intubation with general anesthesia
• Endoscopy
• Dental extraction
• Forceful hyperextension

22. ETIOLOGY
 Miscellaneous causes-
• Internal derangement
• Dyssynchronous muscle function
• Contralateral intra-articular obstruction
• Lost vertical dimension
• Occlusal discrepancies
 Psychogenic-
• Habitual dislocation
 Drug induced-
• Phenothiazines

23. PREDISPOSING FACTORS
 Laxity of ligaments.
 Capsule and abnormality of skeletal form.
 Previous injuries and occlusal
disharmonies can bring about laxity of the
capsule.

24.  Flattened eminence and shallow fossa,
systemic diseases like Parkinson’s disease,
epilepsy, Ehler-Danlos syndrome, etc.
 Use of antipsychotic drugs may cause
extrapyramidal reactions and dislocations.
PREDISPOSING FACTORS

25. CLASSIFICATION
Depending upon side
Unilateral
Bilateral
Depending on the time elapsed
Acute
Chronic recurrent (habitual) subluxation
Long standing

26. AKINBAMI CLASSIFICATION
• TYPE 1- The head of condyle is directly below the tip
of the eminence.
• TYPE 2- The head of condyle is in front of the tip of
the eminence.
• TYPE 3- The head of the condyle is high up in front
of the base of the eminence.

27. UNILATERAL

28. BILATERAL

29. 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

30. OPG

31. CT SCAN

32. TREATMENT
MODALITIES
NON SURGICAL
1.
2. 1. Reduction by manipulation
3. 2. Physical therapy
4. 3. Occlusal therapy
5. 4. Symptomatic treatment
6. 5. Chemical capsulorraphy
7. 6. Ultrasound therapy
8. 7. Intermaxillary fixation
9. 8. Recent Advances
SURGICAL
1. Procedures which are
designed to limit translation,
- Anchoring
- Blocking
- Myotomy
2. To eliminate blocking factors
in the condylar path of closure.
3. Combination of both.

33. NON-SURGICAL MANAGEMENT
BY MANIPULATION

34. MANUAL REDUCTION

35. A SAFE AND EFFECTIVE WAY FOR REDUCTION OF
TEMPOROMANDIBULAR JOINT DISLOCATION
- Yi-Chieh Chen, MD, Chien-Tzung Chen, MD
Annals of Plastic Surgery • Volume 58, Number 1, January 2007

36. PHYSICAL THERAPY
Isometric exercises described by Poswillo

39. OCCLUSAL THERAPY
1. Reduce bruxism
2. Help relax muscles and reduce pain.
3. They also can change jaw posture
enough to stabilize some bite problems and
reduce pressure in joints.

40. SYMPTOMATIC TREATMENT
Arthralgia and myalgia.
NSAID’s can be used.
Intra articular injection of a
steroid - excellent results,
(avoid long-acting
corticosteroids)

41. • Principle:- To induce fibrosis and restrict joint movement.
• 3% sodium tetradecyl sulphate ,
• Sodium psylliate emulsion in oil.
• Sodium morrhuate
• Disadvantage:- Inability to predict the amount of limitation.
CHEMICAL CAPSULORRAPHY

42. ULTRASOUND THERAPY
Promotes collagen synthesis by
human fibroblasts therefore this
may be help in stabilizing the joint.

43. INTERMAXILLARY FIXATION

44. AUTOLOGOUS BLOOD INJECTION

45. • Autologous blood injection as a treatment of recurrent
TMJ dislocation was reported by Brachmann in 1964.
• The therapy is based on the principle to restrict
mandibular movements by inducing fibrosis in upper
joint space, pericapsular tissues or both.
• Autohaemotherapy include the injection of autologous
blood only into pericapsular tissues, upper joint space, or
into both upper joint space and pericapsularly.

46. • The volume of blood to be used ranges from 2 mL to 4 mL in
the upper joint space and 1.0 to 1.5 mL into pericapsular
structures.
• The protocol for mandibular movement restriction ranges
from 7 days to 1 month.
• The method to restrict mandibular movement utilizes
conservative elastic bandage head dressing to an aggressive
approach of maxillomandibular fixation.

48. SURGICAL MANAGEMENT
Three broad categories
I. Procedures which are designed to limit translation,
- Anchoring
- Blocking
- Myotomy
II. To eliminate blocking factors in the condylar path of closure.
III. Combination of both.

49. Procedures to limit
translation

50. ANCHORING PROCEDURES
Flaps secured to the capsule Neiden

51. Merrill used dacron sutures

52. CAPSULORRHAPY & CAPSULAR PLACATION
Sanders & Newman

53. BLOCKING TECHNIQUES
Mayer 1933
Resected 1.5cm segment of
zygomatic arch & grafted it on
to the eminence.

54. LECLERC AND GIRARD METHOD
A vertical osteotomy of the
zygomatic arch & down fracture.
Modified by Dautrey in 1975.
Oblique osteotomy.

55. LINDMAN’S METHOD
Oblique osteotomy of articular tubercle

56. MINIPLATE PLACEMENT OVER ARTICULAR EMINENCE.
(BUCKLEY &TERRY -1988)
Treatment of chronic mandibular dislocations by bone plates: Two Case Reports
Journal of Cranio-Maxillofacial Surgery (2004) 32, 90–92

57. SOFT TISSUE BLOCKING
Fixation of the disc in anterior position

58. MYOTOMIES
Myotomy of the lateral
pterygoid muscle, through an
intraoral incision.
Liberation of the fibres would
help reduce the dislocation.
Silicon sheet interposition.
Laskin

59. Procedures that eliminating
blocking factors

60. EMINECTOMY
Myrhaug 1951

61. DISKECTOMY
A torn / displaced disk caught behind the condyle or a
prominent articular eminence, obstructing the condylar
movement.
Central avascular portion of the disk and the area of
perforation
Dermal graft can be harvested

62. CONDYLOTOMY
Ward et al
↓ Lat pterygoid muscle pull
Segment gets inferiorly
displacement.

63. COMPLETE CONDYLECTOMY
Drawbacks
• Lateral pterygoid muscle 
sacrificed
• Shortening of ramus
• Open bite deformity
• Retrusion of mandible
• Loss of translatory movement.

64. ARTHROCENTESIS
Acute closed lock (meniscus is usually jammed
in front of the condyle) preventing translatory
movement.
Mechanism -By ballooning-up the joint the
potential space becomes real and the meniscus
gets room to reduce to its normal position.
• Sodium hyaluronate can be injected at the end
of the procedure to improve joint lubrication.

66. ARTHROSCOPIC EMINOPLASTY
Segami
Arthroscopy by means of the inferolateral approach
Using an electric shaver in a triangulation technique.
The anterior slope of the eminence was made as smooth
as possible.
(Oral S,Oral Med, Oral Path, Oral Radiol Endod 2003;95:390-5)

67. CONCLUSION
• Management requires a careful and conservative approach, &
basically depends upon the type of dislocation and the amount of
morbidity it has caused to the patient,
• Employ the simplest and most effective method with the least
morbidity for a specific patient.
• It is important to address muscular and psychologic factors
appropriately before considering the patient for surgery.
• Chronic dislocation- IMF for 4-6 weeks.

68. Thank you….