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Treatment of long-standing mandibular dislocation
TECHNICAL NOTES J Oral Maxillofac 45:093-696.
Surg
1987
Treatment of Long-Standing Mandibular Dislocation G. E. LELLO,
BDS, FDSRCS, LRCP, MRCS, MBBCH
Several techniques for the reduction of chronically dislocated mandibular condyles have been reported. Gottlieb’ and Fordyce* reviewed the literature pertaining to long-standing dislocation of the temporomandibular joint: Hayward,3 Rowe and Killey,4 Adekeye et al.,5 Lewis6 and Laskin7 have added to the literature in terms of case reports and surgical approaches used to alleviate the problem. Topazian and Costich8 have described the sequential steps for treating protracted mandibular dislocation. Moore9 advocated condylectomy in cases where dislocated condyles have remained unreduced for a long period and when attempts at manual manipulation and reduction of the condyles have failed. Rowe and Williamsto have suggested that reduction of a prolonged or long-standing dislocation may be achieved by manual reduction assisted by the use of relaxants, local analgesia, or general anaesthesia; surgical exposure of the joint; condylotomy; condylectomy; osteotomy of the ramus; or traction via the angle or sigmoid notch through a submandibular incision as described by Rowe and Killey.4 They concluded that if manual reduction cannot be accomplished, condylotomy (a closed or open surgical approach) or condylectomy will give a reasonably satisfactory cosmetic and functional result. In this report, a new technique using a closed approach is described. It employs the principle of establishing a fulcrum on the posterior teeth described by Lewis.”
pation while moving the mandible. The tip of the coronoid process will be felt just posterior to the zygomatic buttress. A zygomatic bone hook is then positioned over the sigmoid notch bilaterally (Fig. 1). The hook is introduced through the skin just posterior to the coronoid process, about midway down the slope of the sigmoid notch (Fig. 2). This is done before a mouth prop is inserted, as further opening of the mandible will bring the notch inferiorly into the vicinity of the parotid duct. A small rubber mouth prop, preferably of the McKesson type, is inserted bilaterally between the molar teeth as far posteriorly as possible. This prop will serve as a fulcrum about which the mandible must be rotated in a closing direction. A third bone hook is pierced through the skin beneath the lower border of the chin, allowing for traction of the mandible in
Method The patient, under nasoendotracheal intubation anaesthesia, is prepared and draped in the usual manner for a surgical intervention in the head region. The condyle is then accurately located by pal-
Professor and Head, Maxillofacial and Oral Surgery, Medical University of Southern Africa, Medunsa, South Africa. Address correspondence and reprint requests to Dr. Lello: Medical University of Southern Africa, P. 0. Medunsa 0204, South Africa.
FIGURE 1. Simultaneous traction on three zygomatic bone hooks inserted into the sigmoid notches and beneath the chin rotate the mandible about the mouth prop fulcrum in a closing direction.
0278-2391/87 $0.00 + .25
893
894
TREATMENT OF LONG-STANDING
a closing direction (Fig. 1). The head is steadied, and the three bone hooks are pulled simultaneously, the coronoid notch hooks assisting the chin hook to rotate the mandible about the mouth prop fulcrum. Steady traction is maintained for approximately one minute, and then reduced for a short period, followed by repeated cycles of a similar nature. From time to time, simultaneous posterior pressure may be exerted by a hand on the chin. The condyles seldom move back over the articular eminence rapidly, as is often seen when manually reducing acutely dislocated condyles, but must instead be relocated in a stepwise fashion. The occlusion is used to control and evaluate the adequacy of the reduction. When condyles are correctly relocated, rotation of the mandible through a short arc, with a repeatable occlusion, indicates that the reduction is adequate. The bone hook puncture wounds rarely require more than an adhesive dressing drawing the edges of the wound together; however, a fine suture may also be inserted. Maxillomandibular fixation is maintained for a period of three weeks.
FIGURE 2. Dislocation of the condyle carries the lowest point of the sigmoid notch antero-inferiorly to the level of the hamulus of the medial pterygoid plate. The branches of the maxillary artery, except for the masseteric (a) and buccal (b), are not endangered by the tip of the hook when it is inserted midway up the anterior slope of the sigmoid notch prior to inserting the mouth prop so as to protect the parotid duct (c).
MANDIBULAR
Transverse
Masseter
DISLOCATION
facial artery
muscle
FIGURE 3. Structures superficial to the normally positioned sigmoid notch. Antero-inferior dislocation of the notch relocates it in the region of the multiple, finer zygomatic branches of the facial nerve.
Discussion In the past four years this technique has been used in eight patients with temporomandibular joints dislocated for periods ranging from four to eight months. All dislocations occurred as a result of trauma, with no preceding history of recurrent dislocation, and all attempts at manually reducing the dislocation under general anaesthesia had failed. The patients reported late for treatment for a variety of reasons, including living in an area far away from, and with little access to, medical facilities; not perceiving a need for treatment initially; and, in one case, being actually forbidden by superstitious parents to seek medical assistance. Greatest concern in connection with this technique is undoubtably the possibility of damage to structures in the cheek by the passage of the bone hook through the skin to engage the sigmoid notch. The anatomy of this area is such that one could reasonably expect to penetrate the parotid gland and duct, the transverse facial artery, the zygomatic branches of the facial nerve, the nerve and vessels to masseter muscle, the buccal artery and nerve, and the masseter muscle (Fig. 3). However, dislocation of the condyles carries the sigmoid notch anteriorly, thereby considerably lessening the chance of the hook passing through the parotid gland, although an accessory lobe, the duct, and the transverse facial artery may nevertheless still be liable to penetration. This risk is lessened by inserting the hook through the skin just posterior to the posterior slope of the coronoid process (Fig. 2) midway down the slope. It is preferable to insert the hook prior to placing the mouth prop, as this obviates further inferior relocation of the notch in the direction and vicinity of the parotid duct and transverse facial artery. It must be realized that this point of insertion in a patient with dislocated con-
895
LELLO
Masseter artery FIGURE 4. Structures deep to the sigmoid notch. Antero-inferior dislocation of the notch relocates it in the region of the buccal artery.
ral pterygoid muscle Deep temporal
ial pterygoid muscle
Maxillary
Buccal nerve and artery
External carotid lnferiir
Lingual nerve and artery
alveolar and
dyles does not differ greatly from the point of insertion of a zygomatic bone hook for the elevation of a fractured zygomatic complex that has been displaced inferiorly: This procedure has been followed with relative safety by surgeons for many years with few, if any, reports of injury to the parotid gland or duct, or facial nerve.12 The zygomatic branches of the facial nerve in the sigmoid notch, when the condyles are dislocated, are both many and slender (Fig. 3), but permanent disturbance of facial muscle function as a consequence of damage to this nerve has not been reported. The maxillary and deep temporal arteries, the inferior alveolar nerve and artery, and lateral and medial pterygoid muscles lie deep to the notch (Fig. 4). The maxillary artery lies medial and inferior to the sigmoid notch, and the first part of the artery (that portion before it passes forward between the two heads of the lateral pterygoid muscle) may be reached by a bone hook point being inserted too far infero-medial to the notch. These relationships hold true for the mandible in the normal, undislocated position. However, when the condyle is dislocated beyond the articular eminence, the sigmoid notch is located further anteriorly over the lateral pterygoid muscle, where the vessel is usually protected by this muscle. Careful manipulation of the point of the hook through the sigmoid notch, and ensuring that the tip travels inferiorly along the medial surface of the ramus, avoids damage to the maxillary artery and lateral and medial pterygoid muscle.
On occasion, one or two drops of serous-type fluid have been seen to come from the cheek puncture wound; however, no subsequent fistulas have occurred. Facial nerve paralysis has not been observed. Infrequently, however, partial temporary paresis, possibly as a result of localized edema, has been noted. No major hemorrhage or hematoma formation has occurred, but on a few occasions minimal bleeding, possibly from punctured masseteric or transverse facial vessels, has been observed. A single skin suture served to control the bleeding. In most cases, the puncture wound oozed a little blood into the adhesive dressing. Scarring proved to be virtually undetectable at a later date, appearing most frequently as a small skin indentation or pit. The occlusion was maintained shortly after release of the maxillomandibular fixation in all patients; however, follow-up has been poor in the majority of cases precluding conclusions about merit in respect to long-term occlusal results.
References 1. Gottlieb 0: Long standing dislocation of the jaw. Oral Surg 10:18, 1952 2. Fordyce CL: Long standing bilateral dislocation of the jaw. Br J Oral Surg 2:222. 1965 3. Hayward JR: Prolonged dislocation of the mandible. Oral Surg 23:585, 1965 4. Rowe NL, Killey HC: Fractures of the Facial Skeleton, 2nd ed. Edinburgh, Livingstone. 1968, pp 179 5. Adekeye EO, Shamia RI, Cove P: Inverted L-shaped ramus
896
TREATMENT OF LONG-STANDING
osteotomy for prolonged bilateral dislocation of the temporomandibular joint. Oral Surg 41568, 1976 6. Lewis JE: A simple technique for long-standing dislocation of the mandible. Br J Oral Surg 1952, 1981 7. La&in DM: Myotomy for the management of recurrent and urotracted mandibular dislocations. Trans 4th Dent Conf bral Surg, Munksgaard, Copenhagen, 1973, p 264 8. Topazian RG, Costich ER: Management of protracted dislocation of the mandible. J Trauma 7:257, 1967
MANDIBULAR
DISLOCATION
9. Moore JR: Surgery of the Mouth and Jaws, 1st ed. Oxford, Blackwell Scientific Publications, 1985, pp 621 10. Rowe NL, Williams J: Maxillofacial Injuries, 1st ed. Edinburgh, Churchill Livingstone, 1985, pp 351 11. Lewis JB: Reduction of dislocation of the mandible. New York Dent J 27:29, l%l 12. Kruger E, Schilli W: Oral and Maxillofacial Traumatology, ~012, 1st ed., Chicago, Quintessence Publishing, 1986, pp 158
Surg
1987
Treatment of Long-Standing Mandibular Dislocation G. E. LELLO,
BDS, FDSRCS, LRCP, MRCS, MBBCH
Several techniques for the reduction of chronically dislocated mandibular condyles have been reported. Gottlieb’ and Fordyce* reviewed the literature pertaining to long-standing dislocation of the temporomandibular joint: Hayward,3 Rowe and Killey,4 Adekeye et al.,5 Lewis6 and Laskin7 have added to the literature in terms of case reports and surgical approaches used to alleviate the problem. Topazian and Costich8 have described the sequential steps for treating protracted mandibular dislocation. Moore9 advocated condylectomy in cases where dislocated condyles have remained unreduced for a long period and when attempts at manual manipulation and reduction of the condyles have failed. Rowe and Williamsto have suggested that reduction of a prolonged or long-standing dislocation may be achieved by manual reduction assisted by the use of relaxants, local analgesia, or general anaesthesia; surgical exposure of the joint; condylotomy; condylectomy; osteotomy of the ramus; or traction via the angle or sigmoid notch through a submandibular incision as described by Rowe and Killey.4 They concluded that if manual reduction cannot be accomplished, condylotomy (a closed or open surgical approach) or condylectomy will give a reasonably satisfactory cosmetic and functional result. In this report, a new technique using a closed approach is described. It employs the principle of establishing a fulcrum on the posterior teeth described by Lewis.”
pation while moving the mandible. The tip of the coronoid process will be felt just posterior to the zygomatic buttress. A zygomatic bone hook is then positioned over the sigmoid notch bilaterally (Fig. 1). The hook is introduced through the skin just posterior to the coronoid process, about midway down the slope of the sigmoid notch (Fig. 2). This is done before a mouth prop is inserted, as further opening of the mandible will bring the notch inferiorly into the vicinity of the parotid duct. A small rubber mouth prop, preferably of the McKesson type, is inserted bilaterally between the molar teeth as far posteriorly as possible. This prop will serve as a fulcrum about which the mandible must be rotated in a closing direction. A third bone hook is pierced through the skin beneath the lower border of the chin, allowing for traction of the mandible in
Method The patient, under nasoendotracheal intubation anaesthesia, is prepared and draped in the usual manner for a surgical intervention in the head region. The condyle is then accurately located by pal-
Professor and Head, Maxillofacial and Oral Surgery, Medical University of Southern Africa, Medunsa, South Africa. Address correspondence and reprint requests to Dr. Lello: Medical University of Southern Africa, P. 0. Medunsa 0204, South Africa.
FIGURE 1. Simultaneous traction on three zygomatic bone hooks inserted into the sigmoid notches and beneath the chin rotate the mandible about the mouth prop fulcrum in a closing direction.
0278-2391/87 $0.00 + .25
893
894
TREATMENT OF LONG-STANDING
a closing direction (Fig. 1). The head is steadied, and the three bone hooks are pulled simultaneously, the coronoid notch hooks assisting the chin hook to rotate the mandible about the mouth prop fulcrum. Steady traction is maintained for approximately one minute, and then reduced for a short period, followed by repeated cycles of a similar nature. From time to time, simultaneous posterior pressure may be exerted by a hand on the chin. The condyles seldom move back over the articular eminence rapidly, as is often seen when manually reducing acutely dislocated condyles, but must instead be relocated in a stepwise fashion. The occlusion is used to control and evaluate the adequacy of the reduction. When condyles are correctly relocated, rotation of the mandible through a short arc, with a repeatable occlusion, indicates that the reduction is adequate. The bone hook puncture wounds rarely require more than an adhesive dressing drawing the edges of the wound together; however, a fine suture may also be inserted. Maxillomandibular fixation is maintained for a period of three weeks.
FIGURE 2. Dislocation of the condyle carries the lowest point of the sigmoid notch antero-inferiorly to the level of the hamulus of the medial pterygoid plate. The branches of the maxillary artery, except for the masseteric (a) and buccal (b), are not endangered by the tip of the hook when it is inserted midway up the anterior slope of the sigmoid notch prior to inserting the mouth prop so as to protect the parotid duct (c).
MANDIBULAR
Transverse
Masseter
DISLOCATION
facial artery
muscle
FIGURE 3. Structures superficial to the normally positioned sigmoid notch. Antero-inferior dislocation of the notch relocates it in the region of the multiple, finer zygomatic branches of the facial nerve.
Discussion In the past four years this technique has been used in eight patients with temporomandibular joints dislocated for periods ranging from four to eight months. All dislocations occurred as a result of trauma, with no preceding history of recurrent dislocation, and all attempts at manually reducing the dislocation under general anaesthesia had failed. The patients reported late for treatment for a variety of reasons, including living in an area far away from, and with little access to, medical facilities; not perceiving a need for treatment initially; and, in one case, being actually forbidden by superstitious parents to seek medical assistance. Greatest concern in connection with this technique is undoubtably the possibility of damage to structures in the cheek by the passage of the bone hook through the skin to engage the sigmoid notch. The anatomy of this area is such that one could reasonably expect to penetrate the parotid gland and duct, the transverse facial artery, the zygomatic branches of the facial nerve, the nerve and vessels to masseter muscle, the buccal artery and nerve, and the masseter muscle (Fig. 3). However, dislocation of the condyles carries the sigmoid notch anteriorly, thereby considerably lessening the chance of the hook passing through the parotid gland, although an accessory lobe, the duct, and the transverse facial artery may nevertheless still be liable to penetration. This risk is lessened by inserting the hook through the skin just posterior to the posterior slope of the coronoid process (Fig. 2) midway down the slope. It is preferable to insert the hook prior to placing the mouth prop, as this obviates further inferior relocation of the notch in the direction and vicinity of the parotid duct and transverse facial artery. It must be realized that this point of insertion in a patient with dislocated con-
895
LELLO
Masseter artery FIGURE 4. Structures deep to the sigmoid notch. Antero-inferior dislocation of the notch relocates it in the region of the buccal artery.
ral pterygoid muscle Deep temporal
ial pterygoid muscle
Maxillary
Buccal nerve and artery
External carotid lnferiir
Lingual nerve and artery
alveolar and
dyles does not differ greatly from the point of insertion of a zygomatic bone hook for the elevation of a fractured zygomatic complex that has been displaced inferiorly: This procedure has been followed with relative safety by surgeons for many years with few, if any, reports of injury to the parotid gland or duct, or facial nerve.12 The zygomatic branches of the facial nerve in the sigmoid notch, when the condyles are dislocated, are both many and slender (Fig. 3), but permanent disturbance of facial muscle function as a consequence of damage to this nerve has not been reported. The maxillary and deep temporal arteries, the inferior alveolar nerve and artery, and lateral and medial pterygoid muscles lie deep to the notch (Fig. 4). The maxillary artery lies medial and inferior to the sigmoid notch, and the first part of the artery (that portion before it passes forward between the two heads of the lateral pterygoid muscle) may be reached by a bone hook point being inserted too far infero-medial to the notch. These relationships hold true for the mandible in the normal, undislocated position. However, when the condyle is dislocated beyond the articular eminence, the sigmoid notch is located further anteriorly over the lateral pterygoid muscle, where the vessel is usually protected by this muscle. Careful manipulation of the point of the hook through the sigmoid notch, and ensuring that the tip travels inferiorly along the medial surface of the ramus, avoids damage to the maxillary artery and lateral and medial pterygoid muscle.
On occasion, one or two drops of serous-type fluid have been seen to come from the cheek puncture wound; however, no subsequent fistulas have occurred. Facial nerve paralysis has not been observed. Infrequently, however, partial temporary paresis, possibly as a result of localized edema, has been noted. No major hemorrhage or hematoma formation has occurred, but on a few occasions minimal bleeding, possibly from punctured masseteric or transverse facial vessels, has been observed. A single skin suture served to control the bleeding. In most cases, the puncture wound oozed a little blood into the adhesive dressing. Scarring proved to be virtually undetectable at a later date, appearing most frequently as a small skin indentation or pit. The occlusion was maintained shortly after release of the maxillomandibular fixation in all patients; however, follow-up has been poor in the majority of cases precluding conclusions about merit in respect to long-term occlusal results.
References 1. Gottlieb 0: Long standing dislocation of the jaw. Oral Surg 10:18, 1952 2. Fordyce CL: Long standing bilateral dislocation of the jaw. Br J Oral Surg 2:222. 1965 3. Hayward JR: Prolonged dislocation of the mandible. Oral Surg 23:585, 1965 4. Rowe NL, Killey HC: Fractures of the Facial Skeleton, 2nd ed. Edinburgh, Livingstone. 1968, pp 179 5. Adekeye EO, Shamia RI, Cove P: Inverted L-shaped ramus
896
TREATMENT OF LONG-STANDING
osteotomy for prolonged bilateral dislocation of the temporomandibular joint. Oral Surg 41568, 1976 6. Lewis JE: A simple technique for long-standing dislocation of the mandible. Br J Oral Surg 1952, 1981 7. La&in DM: Myotomy for the management of recurrent and urotracted mandibular dislocations. Trans 4th Dent Conf bral Surg, Munksgaard, Copenhagen, 1973, p 264 8. Topazian RG, Costich ER: Management of protracted dislocation of the mandible. J Trauma 7:257, 1967
MANDIBULAR
DISLOCATION
9. Moore JR: Surgery of the Mouth and Jaws, 1st ed. Oxford, Blackwell Scientific Publications, 1985, pp 621 10. Rowe NL, Williams J: Maxillofacial Injuries, 1st ed. Edinburgh, Churchill Livingstone, 1985, pp 351 11. Lewis JB: Reduction of dislocation of the mandible. New York Dent J 27:29, l%l 12. Kruger E, Schilli W: Oral and Maxillofacial Traumatology, ~012, 1st ed., Chicago, Quintessence Publishing, 1986, pp 158