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British Journal of Oral and Maxillofacial Surgery 46 (2008) 119–122

Available online at www.sciencedirect.com

lenotemporal osteotomy and bone grafting in theanagement of chronic recurrent dislocation and

ypermobility of the temporomandibular joint.M. Medra a,∗, A.M. Mahrous b,1

Department of Cranio-Maxillo-facial, Oral and Plastic Surgery, Faculty of Dentistry, Alexandria University, EgyptDepartment of General Surgery, Maxillo-facial and Plastic Surgery Unit, Faculty of Medicine, El-Minia University, Egypt

ccepted 19 August 2007vailable online 1 November 2007

bstract

hronic recurrent dislocation of the temporomandibular joint (TMJ) is rare and has many causes. Although it is possible to start treating itonservatively, these treatments are usually unsuccessful. Over the years, many operations have been done including operating on the muscles,he articular capsule, the articular meniscus, and the condyle. At present, the most widely accepted techniques are those used on the articularminence. It may be reduced (eminectomy), favouring free movement of the condyles, or an obstacle may be interposed to prevent excessiveovement of the condyles. These later techniques include Norman’s (glenotemporal osteotomy with interpositional bone grafting). Other

echniques include Dauterey’s procedure, on which onlay bone grafts or bone substitutes are inserted in a subperiosteal pocket inferior to therticular eminences.

We report a prospective study of 60 patients who had a bilaterally modified glenotemporal osteotomy, 40 who had chronic dislocations ofhe temporomandibular joints and the other 20 who had severe hypermobility of the joints. Bone grafts, iliac or calvarial, were inserted at the

steotomy between the zygomatic arch and the articular eminence, and fixed either by wires, mini-plates or microplates, and screws. Stableesults were obtained and retained during long-term follow up of 1–8 years.

2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

eywords: Chronic; Recurrent; Dislocation; Temporomandibular joint; Osteotomy

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ntroduction

nterior mandibular dislocation may be classified as acute,hronic, recurrent (habitual), and long-standing. Acute dis-ocation of the temporomandibular joint (TMJ) is a conditionhere the condyle moves suddenly ventral to the artic-lar eminence and becomes locked in front of it. The

erm “chronic”, “chronic recurrent”, or “habitual” shoulde reserved for repeated episodic dislocations. The term

∗ Corresponding author at: 9 Khalil El-Masry Str., Roushdy, Alexandria,gypt. Tel.: +20 3 5466488; fax: +20 3 4868922.

E-mail address: prof ahmedmedra@hotmail.com (A.M. Medra).1 Tel.: +20 122375099.

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266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofaciadoi:10.1016/j.bjoms.2007.08.004

long-standing” is applicable to those in whom it has lastedor longer than a month.1

Chronic recurrent dislocation (Fig. 1) of the jaw has vari-us causes that involve traumatic factors, hereditary, acquiredeurological illness, and ingestion of certain medicines.2–4

ncoordination of the neuromuscular activity of the chewinguscles, and articular anatomical alterations such as a flat

minence or abnormal condylar morphology, have an impor-ant role.5 On other occasions, there is no obvious cause.ertain factors such as a lack of teeth and articular laxity

ould predispose.6

A radiograph will confirm the diagnosis and indicate theosition of the highest point of the displaced condyle ante-ior and superior to the lowest point of the articular eminence

l Surgeons. Published by Elsevier Ltd. All rights reserved.

120 A.M. Medra, A.M. Mahrous / British Journal of Oral and Maxillofacial Surgery 46 (2008) 119–122

Fig. 1. Recurrent dislocation of temporomandibular joint, class III malocclusion. Tpatient’s permission).

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ig. 2. Panoramic radiograph showing the condyles displaced anteriorly tohe articular eminence.

Fig. 2)1 (Norman JE. Glentemporal osteotomy and a mod-fied dowel graft. Paper presented at European Associationor Maxillofacial Surgery; 1994).

We report our experience with a modified Norman’s pro-

edure in patients with chronic recurrent dislocation andypermobility of the TMJ (Fig. 3).

ig. 3. Patient with severe hypermobility. The mouth wide open, but theatient cannot close it without assistance.

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he patient cannot close her mouth without assistance (published with the

atients and methods

his study included 60 patients: 40 with chronic recurrentislocation and 20 with hypermobility of the TMJ. Thereere 40 women and 20 men, whose ages ranged between 18

nd 36 years (mean 27). Forty patients had chronic recur-ent dislocation, and on clinical examination they all hadad multiple episodes of dislocation of the joints bilater-lly that had required admission to hospital on at least oneccasion for reduction of the dislocation by manipulationnder general anaesthesia or sedation. It was possible tovaluate mouth opening in 36 patients but was not in thether four because of pain and the fear of dislocation. Theean mouth opening in the first group was 46 mm (range

6–55). In the 20 patients with hypermobility, mouth openinganged from 55 to 60 mm (mean 58). Clinical examina-ion showed the usual signs and symptoms of dysfunctionf the TMJ including preauricular and facial pain, jointoises during mandibular movements, and disturbance ofandibular movements caused by abnormal muscular activ-

ty that caused excessive mouth opening with the condylesn anterior relation to the eminence. Radiographic exami-ation showed that the condyles were completely displacednterior to the articular eminences, but patients could closeheir mouths without assistance: the condyles were sublux-ted.

urgical technique

ll patients were operated on under general anaesthesia

ith nasotracheal intubation. The operation started with areauricular incision with temporal extension. Dissectionontinued until the deep temporal fascia was reached, thenhe root of the zygomatic arch was identified, followed by

f Oral and Maxillofacial Surgery 46 (2008) 119–122 121

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A.M. Medra, A.M. Mahrous / British Journal o

ubperiosteal exposure of the zygomatic arch to protect therontal branch of the facial nerve. The articular eminence waslso exposed keeping the soft tissues attached to its lowerortion.

A horizontal osteotomy separated the articular eminencerom the zygomatic arch using a micro-reciprocating saw orne fissure bur. The osteotomy should be at least 1.5 cm deep

n the articular eminence.A fine osteotome was then used to separate the articular

minence from the zygomatic arch.The capsule was preserved in all cases; all the work was

xtracapsular. The periosteum of the inner surface of the emi-ence was also left intact to avoid resorption of the eminence.he gap was about 3–5 mm wide.

A bone graft was harvested from either the iliac crestn = 40) or from the outer table of the skull (split calvarial)n = 20). When cranial bone was used, the incision extendednto the temporoparietal area.

The bone grafts were trimmed and then interposed in thepace created by the osteotomy and the bone was broughtogether. In 10 patients, wire was used to stabilise thesteotomy and the graft. An important step in the operations to leave adequate space in front of the condyle so that itan move freely when the mouth is opened. The bone grafthould not impinge on the condyle.

In 40 patients titanium miniplates were used forsteosynthesis,5 and in 10 a microplate and microscrews weresed.

esults

atients were followed up from 1 to 8 years (mean 3). Allatients were satisfied with the results, had stable joints,nd could chew normally. One developed a recurrence asresult of severe injury to the joint 6 months postoperatively,hich was corrected by reoperation. No other patient devel-ped recurrent dislocation during follow up. All patients hadimited mouth opening during the immediate postoperativeeriod, ranging between 15 and 25 mm (mean 19) during therst month. This gradually improved so that 3 months post-peratively it ranged between 28 and 38 mm (mean 32). Bymonths postoperatively, it had increased from 35 to 42 mm

mean 39) (Fig. 4). One year postoperatively, mouth openingas in the range 38–45 mm (mean 42), and then stabilised.emporary paralysis of the frontal branch of the facial nerve

n five patients resulted from traction on the tissues, and hadesolved within 3 months. The articular pain and clicking thatad been present in all patients preoperatively disappeared,nd mandibular movement improved. Three patients had painuring opening of the mouth because the wires used to fix theone graft were impinging on the condyles; the wires were

emoved and the pain went. Postoperative radiographs imme-iately after operation and then yearly showed the bone graftso have been well incorporated without reduction in verticaleight.

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nd split calvarial bone graft.

iscussion

any operations have been described for the treatment ofhronic recurrent dislocation of the jaw. Eminectomy may failo solve the underlying problem as the condyle may continueo dislocate, and at the end cause serious articular damagerom repeated injury.6 Dautrey’s procedure 7 may be followedy internal displacement of the mandibular condyle if it ismall because of the limited cross-section of the lateromedialygomatic arch, and it is not applicable in all age groupsecause of the risk of fracture; elasticity decreases as agencreases. There is also the risk of relocation of fragments.

In his study on the role of midtemporal shortening for theanagement of dislocation, Sherif (Sherif AE. Midtempo-

al shortening for correction of chronic recurrent mandibularislocation: a retrospective study and addition of a new surgi-al modality. Paper presented at the 81st General Session ofhe International Association for Dental Research 2003.) saidhat all patients improved with no recurrences. Zeigler et al.8

eported 19 patients of 21 who improved after an injection ofotulinum toxin into the lateral pterygoid muscle.

Glenotemporal osteotomy with interpositional bone graftot only increases the height of the articular eminence butlso increases its width, and so avoids the medial escape of

he condyle. The operation is totally extracapsular. Karaboutareported good results with the use of hydroxyapatite as an

nterpositional biocompatible material, yet the patient’s own

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1facial and craniofacial surgery. J Oral Maxillofac Surg 1986;

22 A.M. Medra, A.M. Mahrous / British Journal o

one may usefully be used as graft material. It can be obtainedt the same operation, and the iliac crest provides enoughone with good osteoinductive capacity, although it does tendo resorb. There is also the problem of morbidity of the donorite in the form of postoperative discomfort.10 The currentashion is to incorporate cranial bone11 from the temporopari-tal area, so taking advantage of a single incision.12 Despitehe fact that this bone is usually thin, unlimited amounts maye obtained, and there is no morbidity if the graft is takenarefully. Published complications, such as scalp infection,eroma, dural tear, arachnoid bleeding, and haematoma wereot encountered in the current series. The bone has the sameharacteristics as the cut bone, with less tendency to resorb.

Osteosynthesis was good regardless of whether it hasire or plate osteosynthesis. Problems such as intra-articular

nfection, rejection, looseness of screws, or free moving for-ign bodies within the joints, were not encountered. However,ome authors do not favour the introduction of foreign mate-ials like screws or plates into the joint and prefer wiresteosynthesis to avoid these problems.13 Costas Lopez etl.6 mentioned that it is not always necessary to use anysteosynthesis because of the tendency for the space left byhe osteotomy to be obliterated if the periosteum of the medialart of the articular eminence is preserved.

eferences

1. Gray AR, Barker GR. Idiopathic blepharospasm-oromandibulardystonia syndrome (Meige syndrome) presenting as chronic temporo-mandibular joint dislocation. Br J Oral Maxillofac Surg 1991;29:94–7.

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nd Maxillofacial Surgery 46 (2008) 119–122

2. Riquet-Bricard C, Souyris F, Venault B. Chronic luxation of themandible. A props of 2 recent cases. Rev Stomatol Chir Maxillofac1994;95:6–11.

3. Wilson A, Mackay L, Ord RA. Recurrent dislocation of the mandiblein a patient with myotonic dystrophy. J Oral Maxillofac Surg1989;47:1329–32.

4. Kai S, Kai H, Nakayama E, et al. Clinical symptoms of open lock positionof the condyle. Relation to anterior dislocation of the TMJ. Oral SurgOral Med Oral Pathol 1992;74:143–8.

5. Mercier J, Adam P, Billet J, Cudia G. Luxation chronique et negligeede particulation temporo-mandibulaire (Chronic and neglected luxa-tion of the temporomandibular joint). Rev Stomatol Chir Maxillofac1993;94:65–75.

6. Costas Lopez A, Monje Gil F, Fernandez Sanroman J, Goizueta AdameC, Castro Ruiz PC. Glenotemporal osteotomy as a definitive treat-ment for recurrent dislocation of the jaw. J Craniomaxillofac Surg1996;24:178–83.

7. Dautrey J, Pepersack W. Functional surgery of the temporomandibularJoint. Clin Plast Surg 1982;9:591–601.

8. Zeigler CM, Haag C, Muhling J. Treatment of recurrent TMJ disloca-tion with intramuscular botulinum toxin injection. Clin Oral Investig2003;7:52–5.

9. Karabouta I. Increasing the articular eminence by the use of blocksof porous coralline hydroxyl apatite for treatment of recurrent TMJdislocation. J Craniomaxillofac Surg 1990;18:107–13.

0. Marx RE. Philosophy and particulars of autogenous bone grafting. Oraland Maxillofac Surg Clin North Am 1993;5:599–612.

1. Harsha BC, Turvey TA, Powers SK. Use of autogenous cranial bonegraft in maxillofacial surgery: a preliminary report. J Oral MaxillofacSurg 1986;44:11–9.

2. Jackson IT, Helden G, Marx R. Skull bone grafts in maxillo-

44:949–55.3. Smith WP. Recurrent dislocation of the temporomandibular joint: a

new combined augmentation procedure. Int J Oral Maxillofac Surg1991;20:98–9.