Dislocation

Dislocation is a complete separation of the articular surfaces with fixation in an abnormal position. Anterior dislocation of the condyle in which the normal anatomic relationships within the joint have been completely disrupted occurs with the condyle displaced and fixed anterior to the articular eminence.

The key terms used include hypermobility, acute dislocation, long dislocation, recurrent dislocation and habitual dislocation. Subluxation is substituted for the term dislocation where dislocation is incomplete . luxation and dislocation are synonymous.

Dislocation can occur as a single acute event or as chronic recurring episodes. Dislocations which take place repeatedly and which last for short or long interval are referred to as Recurrent dislocation. A dislocation that remains locked anteriorly for several days years is an longold or long-standing dislocation. The term choric dislocation is most appropriately used in those cases where the patient is able dislocate and reduce at will.

Classification of Temporomandibular joint

I. Temporomandibular joint disorders a. Deviation in form 1. Articular surface defects 2. Disc thinning and perforation b. Disc displacements 1. Disc displacement with reduction 2. Disc displacement without reduction c. Displacement of disc-condyle complex disc1. Hypermobility 2. Dislocation d. Inflammatory conditions 1. Capsulitis and synovitis 2. Retrodiscitise. E.Degenerative diseases 1.0steoarthrosis 2. Osteoarthritis 3. Polyarthritides f. Ankylosis 1. Fibrous 2. Bony

II.masitatory muscles disorder 1. myositis 2. reflex muscle splinting 3. Muscle spasm b. Chronic 1. Myofascial pain 2. Muscle contracture 3. Hypertrophy 4. Myalgia secondary to systemic disease III. Congenital and developmental disorders a. Condylar hyperplasia b. Condylar hypoplasia c. Aplasia d. Condylolysis e. Neoplasms f. Fractures.

Subluxation
Condylar subluxation is an incomplete joint the articular surfaces maintain partial contact and the condyle is able to return to the glenoid fossa voluntarily or aided by self manipulation. The condition is related to internal derangement as the open, incomplete and transient dislocation

Ligaments
The activity and condition of the ligaments associated with the temporomandibular joint are important considerations in dislocation. The temporomandibular ligament and capsules remained taut in all mandibular movements and maintained the mandible in articulation the cranial base Opening movements of the mandible caused the stylomandibular ligaments and sphenomandibular to become slack and floded. floded.

Pathophysiology
Acute anterior dislocation is precipitated by either intrinsic or extrinsic trauma. trauma.  A wide yawn is a frequent cause of spontaneous (intrinsic) dislocation.  Other forms of intrinsic events such as vomiting,singing laughing,screaming, wide biting,&seizures.

Extrinsic traumatic dislocation is due to violence which forces the condyle out of the fossa. External force such as a blow to the mandible,usually mandible,usually with the mouth in an open position, can result in mandibular dislocation. Manipulation of the jaw during intubation for general anaesthesia, endoscopy & dental extraction is another extrinsic cause.

Laxity of ligaments& capsule & abnormalities of skeletal form are predisposing factors in both acute & chronic forms of dislocation. Looseness of the capsule and ligaments can occur from inadequate healing after injuries, hypermobility& from longstanding degenerative joint disease.

Occlusal abnormalities and loss of vertical dimension from loss of teeth can also contribute to laxity & to the occurrence of recurrent dislocation. Acute dislocation found the commonest cause to be a blow on the chin with the mouth open in males and dental extractions in females.

The activity and condition of the ligaments associated with the temporomandibular joint are important considerations in dislocation. The tempromandibular ligament & capusle remained taut in all mandibular movements and mantained the mandible in articulation the cranial base. Opening movements of the mandible caused the stylomandibular ligaments and sphenomandibular to become slack and folded.

Hypermobility
Hypermobility of this joint is characterized by excessive anterior movement of the condyle at maximum mouth opening without strain or symptoms. Hypermobility, subluxation, and dislocation of the temporomandibular joint are interelated conditions, and hypermobility is likely a predisposing factor.

Systemic Hypermobility
Familial hypermobility syndromes looseloosejointed individuals with articular symptoms comprise a very heterogeneous group. In the Ehlers-Danlos syndrome the degree of hypermobility and the incidence of dislocation are closely related. In this condition dislocations of the temporomandibular joint are often recurrent Ehlers-Danlos syndrome the incidence of temporomandibular joint dislocations was 3.3%

Occlusal factors
LongLong-term overclosure and loss of physiologic vertical dimension secondary to loss of dentition can Contribute to subluxation & dislocation. The mechanism of this is thought to be that overclosure produces stretching and loosening of joint ligaments and joint laxity can then lead to subluxation. subluxation.

Asymmetry of the condylar position due to mandibular malposition may be caused by occlusal interferences. Occlusal disturbances may also be related to Bruxism. Recurrent dislocation occurs in which extractions of bilateral distoangular, palatally inclined maxillary third molars eliminated the mandibular dislocation.

DrugDrug-associated dislocation
Spontaneous dislocation of the mandible due to extrapyramidal reactions to prochlorperazine. prochlorperazine. Left facial weakness and wild facial contortions occurred, followed by a unilateral mandibular dislocation.

Psychogenic dislocation
Hysteria can be the cause of habitual dislocation of the mandible. Ligaments are lax and repetitious subluxation or dislocation can easily occur. It is important to recognize early that habitual dislocation may be the presenting feature of an underlying psychiatric disturbance. The degree and duration of the disability are out of all Proportion to the severity of the injury.

Diagnosis
 A thorough History & physical examination is important to evaluate properly all categories of dislocation. It is important to determine the cause & onset of the dislocation. A spontaneous intrinsic dislocation only occurs in an anterior direction. Acute, initial spontaneous and extrinsic traumatic anterior dislocations are treated differently from chronic repetitive dislocation.

A prior history of local joint laxity, internal derangements,& other temporomandibular joint disorders will influence the outcome of treatment and must be ascertained in evaluating the past history. Neurologic & mucoskeletal disorders such as Parkinson's disease & epilepsy and other systemic disorder of hypermobility are important to recognize.

Clinical examination
Spontaneous dislocation from a wide yawn is often bilateral,but a blow to the chin with the mouth open usually create a unilateral dislocation. Bilateral dislocation is associated with pain, inability to close the mouth,tense masticatory muscles, difficulty with speech, excessive salivation a protruding chin and open bite. The lateral pole of the condyle produces a characteristic protuberance anterior to and below the articular eminence which can usually be seen and palpated.

Unilateral dislocation is characterized by the mandible swung away from the side of dislocation. The Devation produces a lateral cross and Open bite on the contra lateral side. Palpation of the muscles and joints is a valuable aid to diagnosis. Tenderness in the joint may indicate a fracture,where as tenderness in the temporal fossa is more characteristic of dislocation.

In subcondylar fracture fracture side is retrusive rather than protrusive & the fractured condyle when palpated does not follow the movement of the mandible. Furthermore crepitius at the fracture site can often be detected. Dislocation alone is not accompanied bycrepitus,bleeding,steps bycrepitus,bleeding,steps in the occulsion & paresthesia. paresthesia. Patient will have the sensation of free fluid in the joint and pain with tender edema about the joint.

Radiographic examination
Plains flims such as transcranial radiograph & lateral tomograms are important in the idenfication & documentation of dislocation. Arthrographic studies with recurrent dislocation have enlabed a differenation to be made between meniscotemporal & meniscocondylar types MRI and CT scanning would to useful to identifying ligament and capsular tears and stretching. Eletromyographic studies in dislocation and subluxction provide valuable information.
DILOCATION WITH CONDYLE ANTERIOR TO DISK & EMINENCE

Non surgical Treatment

The initial acute the longstanding & the chronic recurring dislocations of the mandible require different treatments. The acute dislocation needs immediate attention for relief of pain and anxiety and to minimize damage to the joint structure. Reduction and immobilization for 4 weeks will allow damage ligaments, capsule, and disk to heal. However in chronic case, Immobilization does nothing correct the problem of an unstable joint

The major problem to overcome in all dislocation is muscle contraction. contraction. Treatment is different for troublesome repetitive dislocation where the etiology is psychologic compared with systemic hyermobility without psychologic implications.

Acute dislocation
 Initial treatment is aimed at reducing tension, anxiety, and muscle spasm by using the simplest methods.  A tranquillizer or sedative may aid in gaining then relaxtion needed also pressure and message over coronoid processes can also benefit.  An impressive simple technique is used by injecting local anesthetic is injected into the depression in the glenoid fossa left by the dislocated condyle.

Manipulation is the next step. Hippocrates remains an effective way to manipulate and reduce the dislocated mandible. A common method currently used has the operator standing in front of the patient who is sitting with the head supported. Thumbs are wrapped in gauze and placed on the occlusal surfaces of the mandibular molars or alveolar ridges. The lower border of the mandible is grasped with the fingers and the patient is encouraged to relax and open in the direction of the dislocation. By pressing firmly on the molars and elevating anteriorly with simultaneous backward pressure the condyle is relocated.

Yurino's Method
Places the patient in a supine position without a pillow. The patient is encouraged to relax completely while the operator stands near the patient's head and holds the body of the mandible from the opposite side. The patient is asked to open and close the mouth and, although it is difficult to do so,it is important for the patient to attempt this alone.

 The operator moves the mandible up and down in phase with the patient's opening and closing movements.  The operator then locates the dislocated condyle with his thumb & simultaneously with the patient's closing motion pushes it completely downward while moving the body of the mandible upward.  By this procedure the condyle moves over the articular eminence and slips into the fossa.

Longstanding dislocation
The difficulty in reducing mandibular dislocation increases proportionately with time Muscle relaxation and manipulation are usually successful if carried out immediately or within a few hours. Reduction by forcing the mandible downward with the thumbs in the molar region and simultaneous upward tiliting of the chin was tried first. Condylectomy was the preferred method.

Nonsurgical treatment of recurrent dislocation

Physical therapy: The use of isometric exercises to improve opening and closing patterns is most important. Synchronized isometric contraction exercises of masticatory opening muscles and their antagonists should be performed on a regular basis.

Isometric exercise similar to that described by Poswillo is very helpful. This relatively simple exercise trains the suprahyoid muscles to stabilize the mandible and reduce forward movement of the condyle in the early opening phase. The exercise should be carried out several times a day for 4 weeks until dislocations are no longer a problem. Then the exercise should be done indefinitely once or twice a day to maintain the stability and to prevent a return to paranormal function.

Symptomatic treatment
 Patients with subluxation and dislocation often suffer arthralgia & myalgia and symptomatic treatment is necessary.  Analgesics and nonsteroidal anti-inflammatory antidrugs will relieve locomotor system pain whether in the joint, bone, tendon, ligament, or muscle.  Muscle relaxants and tranquillizers are useful.  An injection of a steroid such as methylprednisone gives excellent results in persistent synovitis in the hypermobility syndrome.  Long-acting corticosteroids should be avoided as Longthey may lead to connective tissues atrophy and weakening of collagenous tissue, which may contribute to increasing joint laxity.

Occlusal treatment
Occlusal disturbances, such as cuspal interfernces and non occlusion due missing teeth with loss of vertical support, should be corrected to prevent their contributing to the instability of the joint. However,appliances However,appliances can be useful in those individuals with coexisting internal derangement of the disk, bruxism, and muscle hyperactivity.

Chemical Capsulorrhaphy
The injection of sclerosing agents into the supporting ligaments or into the Joint . The objective is to produce fibrosis and tightening of the capsular ligaments, thus limiting motion of the mandible and preventing subluxations and dislocations. The use of sodium psylliate emulsion in oil, alcohol,and homogeneous blood has been advocated. The disadvantange in their use is the inability to predict the amount of limitation that will be produced.

Surgery For Subluxation And Dislocation

The indications for surgery include a disabling recurrent dislocation and longstanding dislocation not responsive to closed manipulations and other nonsurgical treatment. Acute dislocation and habit dislocation with significant psychologic influence are rarely indications for surgery.

There are three broad categories of procedures such are: Designed to limit translation To eliminate blocking factors in the condylar path of closure or both. Limiting translation are anchoring, blocking & myotomy procedures. The procedures, that eliminate blocking factors in the condylar path of closure include diskectomy and eminectomy. The combination procedures are condylotomy, condylectomy,high condylectomy, and lateral pterygoid myotomy with diskectomy.

Procedures to limit translation

ANCHORIN'G PROCEDURES: Anchoring procedures reduce or eliminate the anterior or translational motion of the condyle. The operations described in the literature include capsulorrhaphy, capsular plication ligamentopexy, flap secured to the capsule, autogenous and alloplastic slings between the condyle and zygomatic process securing the disk to the capsule and tragus cartilage, anchoring process to the zygoma

Rehn used a I x 6 cm deepidermized skin flap from the occipital region based on cranial periosteum tunneled and secured to the capsule to augment a capsulorrhaphy. capsulorrhaphy. Neiden modified Rehn's procedure by using a temporal fascia flap in a similar manner.

Gordon used fascia lata transplants secured through a vertical hole in the zygomatic process near its base and another horizontal hole in the condyle anteriorly to inhibit anterior movement of the condyle. He also removed the disk before placing the sling. Georgiade & Merrill modified this technique by utilizing wide Dacron sutures and not performing a diskectomy

Blake, believed that the suprahyoid muscles were important in mandibular dislocation and advised that the mandible be limited more anteriorly. He ligated the coronoid process to the zygomatic arch. Laskin, successful cases in which the lateral pterygoid muscle was detached & sheet of silicone rubber was secured over the pterygoid fossa of the condyle to prevent reattachment.

BLOCKING PROCEDURES
Blocking or arthroereisis procedures to interfere with translation are designed to create an obstacle to the condyle in its opening path. The operations in this category inculde soft tissues and bony procedures: The latter increase the height of the articular eminence by osteotomies, bone grafts, & metal implants.

Soft Tissue
 Konjetzny surgically creates a closed lock by the disk .  Konjetzny's procedure produces fixation of the disk in an anterior position (closed lock).  The posterior ligament of the disk is released and the anterior attachment is preserved.  The disk is pulled anteriorly and inferiorly and is anchored vertically in front of the condyle by suturing it to the lateral pterygoid muscle inferiorly and to the capsule laterally.

Bony
Foged,emphasize that there is a loss and flattening of the articular eminence in patients with recurrent and habitual dislocation and they advocated the rebuilding of the eminence to create a block to condylar motion.

Mayer, resected a 1.5 cm segment of the zygomatic arch and grafted it into a furrow he created in the articular eminence. Lindemann, made an oblique osteotomy to increase the height of the articular tubercle. Bone of the tubercle and eminence was tilted inferiorly and anteriorly. He also supplemented this by excision of capsular tissues & replacing the excised tissues with a dermal graft.

Gossere &Dautry The zygomatic arch is cut vertically in front of the joint and lowered. Resistance to forward glide of the condyle is provided by a bony abutment placed directly anterior to the condyle and firmly attached to the zygomatic bone. Posteriolythis pedicled bone of the lateral tubercle and arch is stable and more effective than free bone grafts to the eminence.

Eliminating Blocking Factors In The Condylar Path

Operations have been designed to eliminate obstacles in the condylar path that may either trigger a dislocation or mechanically prevent reduction of the condyle into the glenoid fossa The two procedures which accomplish this are diskectomy and eminectomy.

DISKECTOMY
Diskectomy has been advocated by Ashurst & Axhausen for recurrent dislocation. Lexer modified the approach by using an interpositional adipose tissue graft. Boma,Silver and Simon used dlskectomy for this condition but combined it with lateral pterygoid myotomy.

EMINECTOMY
Eminectomy is an operation currently used to correct recurrent dislocation Eminectomy first described by Myrhaug & Irby has been a commonly used procedure for chronic subluxation and dislocation. dislocation. The reason for the success of this operation may be due to greater freedom of movement between the condyle, disk, and reduced eminence.

 Limited condylar motion can also be attributed to the formation of adhesions between the disk and reduced eminence and ligament scarring.  Eminectomy exposes marrow and leaves a roughened surface. Hemorrhage and increased friction between articular surfaces can lead to adhesions and limitation.

Combined procedures to eliminate blocking and limit translation

The procedures in this category include: lateral pterygoid myotomy with diskectomy, condylotomy, and condylectomy. Lateral Pterygoid Myotomy With Diskectomy: The combination of lateral pterygoid myotomy and diskectomy first described by Boman restricts anterior gliding movement of the condyle and diminates obstruction caused by the disk. Silver & Simon advocated this combination for surgical treatment of recurrent dislocation

Condylotomy
Condylotomy was first described by Ward elt for treatment of painful joints with inter derangement. It has been advocated by Poswillo &Tasanen advocate the intraOral approach to treat subjects with recurrent dislocation.

Condylotomy is an osteotomy through the condylar neck which is performed through an extra oral approach. A similar osteotomy may be achieved by an intraoral approach. Both procedures release the condyle and allow it to displace anteriorly & inferiorly. The procedures reduce the strength of lateral pterygoid muscle by shortening it while allowing it to remain functional.

Condylectomy
High condylectomy is a more conservative operation with preservation of most of the lateral pterygoid muscle and a less significant decrease in vertical height of the ramus. It is preferred over condylectomy and it will also eliminate conflicts with the disk & eminence. Scar formation and partial loss of lateral pterygoid muscle will limit but not eliminate forward glide of the mandible .

A complete condylectomy has the great disadvantage of producing facial and occlusal deformity. It can be considered a procedure that both restricts forward motion and removes blocking factors. The lateral pterygoid muscle is sacrificed, openramus is shortened, producing an open-bite deformity and retrusion of the mandible. mandible. The blocking effect of the condyle on the disk or eminence is removed in this procedure. This operation is a last resort when other operations have failed or in certain long-standing dislocations. long-