Subluxation and dislocation of temporo mandibular joint

1. Subluxation and Dislocation of
Temporomandibular joint
1
GUIDED BY :DR. NEHA VYAS
PREPARED BY : DR. AKSHAY SHAH

2. CONTENT
2
• Introduction
• Definition
• Epidomology
• Pathogenesis
• Predisposing factors
• Etiology
• Classification
• Unilateral acute dislocation
• Bilateral acute dislocation
• Management
• Non surgical management
• Surgical management
• References

3. Introduction
3
• Subluxation and dislocation of the temporomandibular
joint (TMJ) are very unpleasant and distressing conditions to
patients .
• Mandibular condylar dislocation is uncommon, compared to the
other joints in the body.

4. Definition
4
• 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 and its not self limiting.

5. (a)Normal anatomical position of the condyle sitting beneath the glenoid fossa an
posterior to the articular eminence. (b) In anterior-superior dislocation, the condy
locked anterior-superior to the articular eminence

6. 6

7. Epidomology
• Uncommon compared to other joint dislocations
• 3 % incidence
• Uncommon in extremes of age
• Higher incidence in females
• 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.
The Treatment of Temporomandibular Joint Dislocation
A Systematic Review
2018 Feb 2.
Ulla Prechel, , Peter Ottl, Prof. Dr. med. dent., Oliver M. Ahlers, PD Dr. med.
dent., and Andreas Neff, Prof.
Dr. med. Dr. med. den

8. 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 articular eminence size or projection,
• Muscle hyperactivity or spasms,
• Trauma
• Abnormal chewing movements that do not allow the
condyle to translate back.
Pathogenesis
8

9. • 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
9

10. • 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
10

11. Predisposing factors
• Laxity of ligaments, capsule.
• 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.
11

12. Etiology
12
Causes of Acute Dislocation
• a. Extrinsic forces or iatrogenic causes
• b. Intrinsic or self-induced forces

13. Intrinsic or self-induced
13
Intrinsic trauma
• Vomiting
• Yawning
• Opening mouth wide
• Seizures
• stress

14. Extrinsic or iatrogenic
causes
14
Extrinsic trauma :
• Trauma sustained while
the mouth is open
• Dental/ENT procedures
• Direct laryngoscopy
• Endoscopy

15. Anatomic
• Steep eminence
• Abnormal condylar shape
• Internal derangement
• Occlusal discrepancy
Connective tissue disorders
• Ehlers-Danlos syndrome
• Marfan syndrome

16. Neurogenic disease
• Epilepsy
• Parkinson’s disease
• Huntington’s disease
• Muscular dystrophy
• Dystonia
Pharmacology
• Phenothiazines
• Metoclopramide

17. Classification
17

18. • 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.
18
Unilateral acute dislocation

19. Cardinal Signs and Symptoms
• Difficulty eating
• Inability to bring the teeth together
• Jaw deviation on opening and closing
• Preauricular pain

20. 20

21. 21

22. 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 ovements
are restricted.
• Posterior gagging and anterior open bite.
• Patient will complain of pain in the temporal region
rather than the joint.
• The distinct hollowness can be felt in both the
preauricular regions.
• Associated muscle spasm contributes to the fixed
position of the condyles
22

23. 23

24. Imaging
24

25. 25

26. CBCT

27. TMJ VIEW

28. MRI VIEW
Normal TMJ anatomy on MRI. Closed mouth and open mouth

29. Management
29
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
1. Manipulation without any form of anaesthesia.
2. Manipulation with local anaesthesia.
3. Manipulation under general anaesthesia/sedation with
muscle relaxants

30. Reduction Techniques
Stimulating a patient’s gag reflex has been proposed as a
method of reducing a dislocated TMJ without the use of force by
an operator.
The operator uses an instrument, such as a tongue depressor
or mouth mirror, to trigger a gag reflex from the patient’s
posterior soft palate or pharyngeal walls.
It is likely that the gag will both relax the spastic elevator
muscles, while simultaneously triggering the depressor
muscles, thereby allowing spontaneous reduction in some
cases.

31. Hippocratic Method
The traditional Hippocratic method for bimanual reduction is the
most widely described technique
This technique involves placing gauze-wrapped thumbs over
the molar or retromolar/ ascending ramus area of the patient’s
mandible with the remaining fingers wrapped around the body
of the mandible.
First, a downward directed force is applied to distract the
condyle down the anterior slope of the eminence. This is
followed by a posteriorly directed force to reposition the condyle
past the peak of the eminence back into its normal resting
position in the glenoid fossa.

32. Wrist Pivot Reduction
An anterior fulcrum is created by applying upward
force on the menton (chin point) with both thumbs.
Effort is exerted by placing fingers on the occlusal
surfaces of the bilateral mandibular molars and
applying downward pressure.
The contrasting upward force on the anterior fulcrum
and downward pressure on the mandibular molars
causes an outward rotation, or “pivot” of the wrists,

33. 33
Interdental Block reduction

34. Extraoral Reduction
In intraoral bimanual reduction technique, the use of a bite
block can induce the risk of bite injury following reduction.
Extraoral reduction techniques were developed to completely
remove this risk.
dislocation of the condyle will cause extraoral visual and
palpable prominence of the anterior ramus and coronoid
process. On the dislocated side, the operator will place their
thumb on the anteriorly positioned coronoid process with
their remaining fingers bracing around the mastoid process

35. (a) Extraoral reduction—on the ipsilateral side, the operator’s thumb is
applying posterior pressure on the visually exaggerated coronoid process,
with the remaining fingers bracing the mastoid process.
(b) Extraoral reduction—on the contralateral side, the
operator fulcrums his thumb off the patient’s
malar bone and applies anterior force with the
remaining fingers braced around the angle of the mandible

36. 36

37. Post-Reduction Management
Goals of post-reduction management center around avoiding re-
dislocation of the condyle and allowing sufficient time to heal .
This is accomplished by a period of restriction or immobilization of the
joint .
period of restriction/immobilizationshould be followed for 7 days.
Post reduction management—the
patient’s head is wrapped with an
elastic bandage, and they are
instructed to use a closed fist to
restrict excessive mouth opening

38. Chronic recurrent dislocation
38
• 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.
The triad:
• ligamentous and capsular flaccidity
• Articular eminence erosion
• Continuous trauma .

39. • 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
• pain, inability to close the mouth, tense masticatory muscles,
difficulty in speech, excessive salivation, protruding chin.

40. • 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.
• The distinct hollowness can be felt in both the preauricular regions.
• Associated muscle spasm contributes to the fixed position of the
condyles.
• It is also seen in severe epilepsy, dystrophia myotonia and the
Ehlers-Danlos syndrome.

41. 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.
41

42. IMAGING
same as acute dislocation

43. Management
Non surgical management
Autologous blood injection.
Sclerotherapy
Botulinum toxin
prolotherapy
surgical management
Capsule tightening procedure.
Creation of a mechanical obstacle or block.
Creation of a new muscle balance.
Removal of mechanical obstacle

44. Autologous Blood Injection
44
• Autologous blood injection (ABI) presents a number of
advantages including ease of performance, low cost and
low complication.
• The protocol described by Machon et al.
3 mL of autogenous blood, 2 mL being injected into
the upper joint space and 1 mL to the pericapsular
region.
The principle behind the technique is the inciting of a
physiological response of inflammation and oedema with
resultant reduction in joint motion.

45. Histological evaluation demonstrated fibrotic changes in
the capsule and retrodiscal tissues. Inflammatory
mediators released by platelets cause vasodilatation and
oedema of the periarticular tissues, diminishing compliance
of the joint and reducing mobility.
Organized clot leads to joint stiffness over time with
maturation of fibrous tissue

46. 46

47. Use of sclerosing solution injections into
the joint space
47
It was first described as early as 1950 by McKelvey
A wide variety of exogenous sclerosants has been tried including
iodine, ethanolamine oleate, alcohol (100% ethanol), bleomycin,
tetracycline, cyclophosphamide and OK-432 (Picibanil), sodium
tetradecyl sulphate (STS), sodium tetradecyl sulphate (STS )more
widely used in the management of venous varicosities as a
sclerosant.

48. Prepared by diluting the drug with equal parts of saline and 2%
lignocaine, it can be introduced into the superior joint
compartment and pericapsular tissue.
Objective is to produce fibrosis and tightening of the capsular
ligaments, thus limiting motion of the mandible and preventing
subluxations and dislocations

49. Use of botulin toxin
• Another newer conservative method is the pplication of
botulinum toxinA (BTX-A) in recurrent TMJ dislocation.
• Botulinum toxin is produced by the anaerobic bacterium
Clostridium
• 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.

50. Injection of Botox® through the sigmoid
notch into lateral pterygoid muscle
schematically represented on a
stereolithographic model
Injection of Botox® through sigmoid
notch into lateral pterygoid muscle
demonstrated on a patient

51. • acts by blocking the release of acetylcholine into the synaptic
cleft at the motor end plate, thus interrupting neuromuscular
transmission.
• It cause 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.
51

52. PROLOTHERAPY
infiltration of a nonpharmacologic solution into pericapsular,
tendinous tissues, with aims of initiating a mixed inflammatory
process.
This inflammatory process is thought to initiate localized
fibrous proliferation, causing an increase in tissue robustness,
which increases joint stability and bolsters joint laxity.
various solutions have been used, including: dextrose,
psyllium seed oil, and various combinations of dextrose,
glycerin, and phenol

53. In this technique an auriculotemporal nerve block is given
then 2 mL of 10% to 50% dextrose may then be infiltrated
into the superior joint space ,retrodiscal tissues, periarticular
tissues, or a combination thereof.
Upon completion of the procedure, patients are put on a soft
diet and jaw rest for 2 weeks. Patients are then followed,
with repeat injections as needed in the event of recurrent
dislocation.

54. Surgical procedures
54
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. Creation of a new muscle balance.
• 4. Removal of mechanical obstacle.

55. 1. Capsule tightening
procedures
55
• 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.

56. • A disadvantage to this therapy is hampered the
intracapsular space, which can produce complications
such as hemarthrosis, degenerative changes to the joint,
or both.
56

57. • 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.
57

58. 2. Creation of a mechanical
obstacle
58

59. The Dautrey (LeClerc) Procedure
Zygomatic arch down-fracture (LeClerc or Dautrey procedure) is
a well-known and popular surgical technique for treatment of
recurrent dislocation
Mayer in 1933 was the first to advocate the surgical
displacement of a portion of the zygomatic arch inferiorly to block
excessive translation of the TMJ condyle [8]. In 1943, LeClerc
and Girard improved the technique when they described a
method whereby a thicker portion of the zygomatic arch is
osteotomized and down-fractured, in order to block excessive
translation of the mandibular condyle.
The procedure was modified by Dautrey and Gosserez in 1967.

60. 60

61. • In all these methods the main drawback are:
• 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 surgery may fail.
61

62. 69
© Ramaiah University of Applied Sciences
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.

63. Metallic Obstacles: Miniplates and
Screws
Various heterogeneous materials have been used to restrict the
condylar pathway: stainless steel pins, titanium plates and
screws, and Vitallium mesh (alloy of Co-Cr-Mo).
Various plate designs have been described: T-shaped titanium
plate , L-shaped plate , and custom-manufactured plate.
The miniplate eminoplasty:
It is minimally invasive technique with low recurrence rate of
dislocation.
Once the articular eminence has been visualized, an L plate is
placed, with the short arm fixed laterally to the eminence with 2 -6
mm screws and the long arm being contoured and placed along
the eminence, inferiorly, to act as a mechanical obstruction.

64. 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.
64

65. 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
65

66. 3. Creation of new muscle
balance
66
• 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.

67. 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.
67

68. 4. Removal of mechanical
obstacles
68
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.

69. 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
69

70. C. Eminectomy
• In 1951, Myrhang first
reported this
pocedure.
• 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.
70

71. Eminectomy procedure. (a) Protection of the intra-articular structures with the Dunn-
Dautrey retractors. (b) Postage stamp of the eminence. (c) Removal of the eminence
with an osteotome. (d) 2 cm depth of removed eminence

72. • 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
72

73. References
73
• Nigel Shaun Matthews-Dislocation of the Temporomandibular
Joint- A Guide to Diagnosis and Management
• Okeson -Management of temporomandibular disorders and
occlusion- Sixth edition
• Fonseca
• Temporomandibular Joint Dislocation
Aaron Liddell, DMD, MDa, Daniel E. Perez, DDS
• Dislocation of the temporomandibular joint Christopher W.
Shorey, and John H. Campbell, et al
• The Treatment of Temporomandibular Joint Dislocation A
Systematic Review Ulla Prechel, , Peter Ottl.
• A NEW APPROACH TO THE REDUCTION OF ACUTE
DISLOCATION OF THE TEMPOROMANDIBULAR JOINT: A
REPORT OF THREE CASES M. N. AWANG, B.O.S. (M'sia), M.Sc.
(Lond) (1987)