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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 3  |  Page : 173-177

Glenotemporal osteotomy with autogenous symphysis interpositional bone graft for temporomandibular joint subluxation


Department of Oral and Maxillofacial Surgery, SRM Dental College, Chennai, Tamil Nadu, India

Date of Web Publication22-Aug-2016

Correspondence Address:
Guru Prasad Thulasi Doss
New No: 16, Shanthi Street, Vetri Nagar Extension, TVK Nagar, Chennai - 600 082, Tamil Nadu
India
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DOI: 10.4103/0976-433X.188796

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  Abstract 

Chronic recurrent subluxation of the temporomandibular joint (TMJ) is known to have repeated episodes of joint dislocation, which are self-reducible in nature. Subluxation of TMJ accounts to multifactorial etiology. Accordingly, various treatment modalities have been postulated and performed to achieve functional outcomes for the patient. Conservative, surgical, and various treatment options have been discussed in the literature to correct the same. Glenotemporal osteotomy has been one such treatment modality to treat recurrent subluxation or dislocation of the jaws. This is a case report on a recurrent subluxating condyle treated by glenotemporal osteotomy with interpositional bone graft from the symphysis region.

Keywords: Chronic recurrent temporomandibular joint, glenotemporal, osteotomy, subluxation, surgical


How to cite this article:
Doss GT, Balasubramanian S, Andavar G, Raja KK. Glenotemporal osteotomy with autogenous symphysis interpositional bone graft for temporomandibular joint subluxation. SRM J Res Dent Sci 2016;7:173-7

How to cite this URL:
Doss GT, Balasubramanian S, Andavar G, Raja KK. Glenotemporal osteotomy with autogenous symphysis interpositional bone graft for temporomandibular joint subluxation. SRM J Res Dent Sci [serial online] 2016 [cited 2020 Jul 7];7:173-7. Available from: http://www.srmjrds.in/text.asp?2016/7/3/173/188796


  Introduction Top


Hypermobility is characterized by an excessive mobility of the temporomandibular joint (TMJ) which exhibits a greater range of motion than normal.[1] The mean maximal interincisal opening amidst the Indian population for males is 51.3 mm (range 39–70 mm) and for females is 44.3 mm (range 36–56 mm). Many studies have shown that mouth opening varies according to the gender and age (Posselt).[2] According to the consensus judgment on the Permanent Impairment Conference 1995, the normal range of motion for mouth opening ranges from 40 to 50 mm.

Hypermobility can lead to subluxation or dislocation of the TMJ. Subluxation presents as an abnormal excursion of the condyle anterior to the articular eminence which is characteristically self-reducing and occurs following stretching or loosening of the ligaments and the capsule surrounding the TMJ. Subluxation is considered a variant of hypermobility where the maximal interincisal opening is >65 mm 2.

Hypermobility of TMJ manifests clinically in one of the following three ways.[3] Each clinical entity varies in their relationship of the condyle to the articular fossa and eminence.

  • Hypertranslation
  • Subluxation
  • Dislocation.


In hypertranslation, the condyle moves in front and above the articular eminence during mouth opening which may be physiological for some individuals. The pathogenesis of chronic recurrent subluxation are attributed to the three factors,[4] namely:

  • Trauma to the joint
  • Flaccidity of the ligaments
  • Flattening of the articular eminence.


Hypermobile joints exhibit subluxation or dislocation concomitant to extensive mouth opening, yawning, laughing, vomiting, and seizure attacks. It can also be iatrogenically prompted during general anesthesia induction, endoscopic procedures, long-standing dental treatments, and during hyperextension.

Hypermobility is observed frequently in patients with connective tissue disorders, TMJ disorders (temporomandibular disorders) and internal derangement, loss of teeth and occlusal discrepancies, loss of vertical dimension, trauma, incomplete healing following primary injury, neuromuscular incoordination, psychogenic disorders, and due to ingestion of certain drugs.[2]

Hypermobility of the jaws at times can lead to acute dislocation which is disturbing and economically a burden on the patient who needs to seek medical care. Depending on the frequency and duration of the condition, subluxation or dislocation can either be acute immediate, chronic recurrent (habitual), and long-standing (longer than a month) in nature.[2]

The management of hypermobility has been subjected to many discussions and controversies since its etiology being indistinct. A thorough history and clinical examination are critical in accomplishing successful treatment outcomes. It remains a challenge to the clinicians, who are confronted with many treatment modalities, categorized as both conservative and surgical as available in the literature.[5]

Glenotemporal osteotomy [6] of the TMJ (Norman) with interpositional bone grafts to augment the height of the articular eminence is one of the likely surgical modalities for TMJ subluxation. Bone grafts can be harvested from calvarium, symphysis, ramus, and iliac region. This case report confers on the articular eminence augmentation with symphysis autogenous interpositional bone graft to prevent recurrent subluxation of TMJ.


  Case Report Top


A 31-year-old female reported to the Department of Oral and Maxillofacial Surgery, with complaints of pain in the right lower tooth region. The patient was attended for her complaint while she was noticed having chronic recurrent subluxation that was evident during tooth extraction. Patient was clinically examined, patient underwent routine investigations and was informed about her clinical condition. Patient was advised and counseled for the treatment options pertaining to her presenting problem.

Patient was advised for routine blood investigations, chest X-ray taken, and anesthetic fitness obtained. Under general anesthesia, patient was painted, draped, vestibular incision placed, layer-wise dissection done, and graft harvested from the symphysis region measuring 2 cm × 2 cm [Figure 1]. Graft was preserved in saline. Preauricular incision was placed, layer-wise dissection done, capsule identified, [Figure 2] and Norman's procedure performed. Autogenous interpositional symphysis graft was secured in the glenotemporal osteotomy site. Donor graft was placed in the recipient site [Figure 3] and layer-wise closure done. Patient was extubated and recovery uneventful. Patient had temporary facial weakness on the operated side, which subsided after 3 weeks. Patient was put on physiotherapy exercises for her muscle weakness. Patient was followed up postoperatively (1 week, 3 weeks, 1 month, 3 months, 6 months, and 1 year, respectively) [Figure 4].
Figure 1: Symphysis graft harvested – mucovestibular approach

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Figure 2: Articular eminence exposed – preauricular approach

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Figure 3: Graft placed in recipient site

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Figure 4: Preoperative radiograph and postoperative radiograph

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  Discussion Top


Physiological maximal translation is defined as the point where the greatest convexity of the condyle meets the greatest convexity of the eminence with articular disc (Quinn). The insertion of the anterior TMJ capsule at the temporal bone constitutes an anatomic boundary of the joint. Translation of the jaw normally occurs after the first 20–25 mm of mouth opening, when condylar translation exceeds this site, the joint is classified as hypermobile (Johanson and Isberg). Both subluxation of the joint and premature translation of the mandible can have long-term consequences leading to TMJ dysfunction and internal disk derangement if left uncorrected. TMJ disorders are more commonly seen in females as compared to males, most commonly ranging from 20 to 40 years.

Subluxation or partial dislocation is not an uncommon problem. Chronic subluxation presents as repeated episodes of dislocation where the condyle passes unassisted, forward and backward past the articular eminence. Chronic subluxation is a self-reducing condition where the condyle once translates past the articular eminence is set back into the fossa by the patient in contrast to dislocation where the patient needs medical assistance. This recurrent, incomplete, self-reducing habitual dislocation is termed as hypermobility or chronic subluxation.[7]

In chronic recurrent habitual subluxation, the joint is subjected to a vicious cycle where recurrent episodes further weakens or stretches the capsular ligament, which upsurges the clinical signs of recurrence. Joint mobility has been determined using grading systems (Beighton's Criteria) which define and measure specific joint movements that are based on a numerical scoring system.

Subluxation of the condyle is psychologically distressing for the patient when it hinders their daily routine. Patients susceptible to hypermobility seek medical care when their normal routine is affected or when they turn symptomatic.

Authors have proposed that chronic stretching of the capsular and lateral ligaments, known in the earlier literature as “lax ligaments,” predispose the TMJ to complete or partial dislocation. Ligament laxities, unsynchronized muscle function, and morphological alterations of the condyle and eminence are considered predisposing etiologies for joint subluxation.[4]

The goals of treatment should include restoring the capsule and ligament surrounding the joint and restraining condylar translation. Variety of treatment modalities is available for treating chronic recurrent dislocating TMJ. Treatments can be surgical (Humphrey, 1856) or conservative in nature.

Conservative therapy includes restriction of mandibular motion (jaw exercises), local anesthetics injection, physiotherapy, prosthetic restoration of vertical height, and temporary immobilization using maxillomandibular fixation, injection of botulinum toxin to the muscles of mastication, autologous blood injections (Brachmann, Hasson, Machon), prolotherapy, and intracapsular sclerosing agents.

Sclerosing agents, in general, have an unacceptably low rate of success and should not be considered permanent treatment. Injecting a sclerosing agent into the TMJ capsule and ligament produces scarring of the stretched tissues. This approach is useful to control pain and to improve patient's perception of the chronic condylar dislocation but does not reduce recurrence rates (Guarda-Nardini et al., 2008).

Botulinum toxin injection in the management of TMJ dislocations still needs treatment parameters to be standardized and defined. In addition, changes in salivary consistency, swallowing, speech, and facial muscle weakness have been reported as possible complications of botulinum toxin injections (Clark, 2003). The recommendation of electromyographic guidance for identification of the pterygoid muscle before injection makes this less amenable to regular outpatient dental practice.

TMJ autologous blood injection serves as an alternative, minimally invasive, and effective procedure which is economical and can be performed on an outpatient basis. It eliminates the need for surgical incisions and tissue dissection and related postoperative complications such as facial nerve injuries, pain, and infection. Only a few published case reports and animal studies (Candrl et al., 2011) with clinical and radiological assessments are available on injection of autologous blood into the TMJ for recurrent dislocation. The mechanism of action and histopathological entity is still unclear and until this is addressed, this technique should be used with caution in young individuals and patients with articular degeneration.

However, conservative modalities provide only temporary alleviation of symptoms, and not very promising in many cases with demerits of its own and recurrence is common. Long-standing subluxation and patients not responding to conservative therapy are intervened surgically.

Miller and Murphy advocated surgical procedures to treat condylar dislocation and chronic recurrent subluxation which can be grouped under five categories; (1) capsule tightening, (2) creation of obstacle or block, (3) removal of mechanical obstacle, (4) creation of muscle balance, and (5) direct restraint of the condyle.

Surgical methods are focused on limiting function, which can be either blocking or nonblocking. Surgical management centers on alteration of the ligamentous attachments, muscular architecture, and bony anatomy.[4] Blocking surgical procedures augment the articular eminence which forms an anterior barrier to the slide of the condyle. Nonblocking techniques reduce the height of the articular eminence which if prominent, presents as an obstacle to the reduction of condyle into the glenoid fossa.

Surgical options include eminoplasty using bone grafts, either onlay or interpositional from multiple donor sites which include symphysis, ramus, iliac and calvarium, eminectomy or discectomy, down-fracturing of the zygomatic arch and anterior disc repositioning, capsulorrhaphy by plication [8] (Boudreaux and Spire) using electrothermal and chemical modalities, bone plating, lateral pterygoid myotomy, temporalis scarification, and temporalis tendon redirection. Tethering techniques have been described using wire, fascia lata, and temporalis fascia.

It is argued that eminectomy [9] offers the best chance for long-term resolution of recurrent dislocation, and remains the gold standard for recurrent luxations, provided care is taken to completely remove the most medial portion of the eminence. The possible shortcoming with eminectomy is repeated dislocations can continue, damaging the meniscus, worsening the joint, progressing to internal derangement and loss of function.

Symphysis autogenous graft was opted for in this case according to patient consent though resorption [10] with autogenous grafts is undesirable sequelae. The patient was followed up to 1 year with a successful outcome. Irrespective of the surgical modality employed, postoperative scarring provides significant benefit to the patient. Long-term follow-up is needed to evaluate the outcome.

To conclude, though many modalities are discussed and cited in the literature,[5] the diversity of techniques employed suggest some uncertainty with reference to the diagnosis and the accuracy of interpretation of postoperative results. The rationale for operative intervention, the choice of the surgical procedure, the need for recurrent surgery or the odds of adverse sequelae should weigh heavily in the decision to use any treatment modality.

Acknowledgment

The Authors would like to acknowledge and thank Dr. Aswath for his contributions for editing the pictures submitted in the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Schultz LW. Twenty years' experience in treating hypermobility of the temporomandibular joints. Am J Surg 1956;92:925-8.  Back to cited text no. 1
    
2.
Sahoo NK, Bhardwaj PK. Radiographic assessment of changes in articular tubercle after Dautrey's procedure. J Oral Maxillofac Surg 2013;71:249-54.  Back to cited text no. 2
    
3.
Quiroz NJ, Picco DMI, Ramírez MJ, Cruz PS. Pre-condylar stop: Surgical alternative for the treatment of mandibular chronic luxation modification of Norman technique experience with 12 patients. Rev Odontol Mex 2013;17:7-14.  Back to cited text no. 3
    
4.
Shorey CW, Campbell JH. Dislocation of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:662-8.  Back to cited text no. 4
    
5.
Torres DE, McCain JP. Arthroscopic electrothermal capsulorrhaphy for the treatment of recurrent temporomandibular joint dislocation. Int J Oral Maxillofac Surg 2012;41:681-9.  Back to cited text no. 5
    
6.
Costas López A, Monje Gil F, Fernandez Sanromán J, Goizueta Adame C, Castro Ruiz PC. Glenotemporal osteotomy as a definitive treatment for recurrent dislocation of the jaw. J Craniomaxillofac Surg 1996;24:178-83.  Back to cited text no. 6
    
7.
Malik NA. Textbook of Oral and Maxillofacial surgery. Temporomandibular Joint: Afflictions and Management. New Delhi, India: Jaypee Brothers Publishers; 2008.  Back to cited text no. 7
    
8.
Sanders B, Newman R. Surgical treatment for recurrent dislocation or chronic subluxation of the temporomandibular joint. Int J Oral Surg 1975;4:179-83.  Back to cited text no. 8
    
9.
Undt G, Weichselbraun A, Wagner A, Kermer C, Rasse M. Recurrent mandibular dislocation under neuroleptic drug therapy, treated by bilateral eminectomy. J Craniomaxillofac Surg 1996;24:184-8.  Back to cited text no. 9
    
10.
Reininger D, Cobo-Vázquez C, Monteserín-Matesanz M, López-Quiles J. Complications in the use of the mandibular body, ramus and symphysis as donor sites in bone graft surgery. A systematic review. Med Oral Patol Oral Cir Bucal 2016;21:e241-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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