Inverted L-shaped ramus osteotomy for prolonged bilateral dislocation of the temporomandibular joint Emmanuel 0. Adekeye, F.D.S.R.C.S.(Eng.), B.D.S.(Edin.),* Rouben I. Shamia, M.Sc.(Dent.), F.W.A.C.S., F.M.C.D.S.(Nig.), L.D.S.R.C.S.(Eng.),*# and Peter Cove, F.D.S.R.C.S.(Eng.), F.F.D.R.C.S.(Irel.), L.R.C.P., L.R.C.S.(Irel.),*** Kaduna, Nigeria, and London, England In a case of prolonged dislocation of the temporomandibular joints, the mandible was repositioned and normal occlusion was established via a bilateral inverted Lshaped ramus osteotomy. The results were satisfactorily maintained one year after the operation.
B
ilateral dislocation of the temporomandibular joint is usually caused by excessive opening of the mouth during dental and ENT treatment, or by trauma. Less frequently it is associated with opening the mouth widely, as occurs in yawning, or following the use of drugs of the phenothiazine group. Review of the literature since 1949 revealed that etiological factors were mentioned in only nineteen of the twenty-three cases of prolonged bilateral anterior dislocation of the temporomandibular joint reported. Of these, ten cases were due to opening of the mouth widely during dental and ENT treatment; seven were caused by falls and fits ; one occurred after yawning; and one happened spontaneously. The ages of the patients at the time of treatment ranged from 16 to 89 years, with an average of 41 years. In only eighteen cases was the sex recorded; eleven patients were males and seven were females. Most of the patients have obvious deformity and discomfort and, therefore, *Senior Registrar in Oral Surgery, Maxillofacial Unit, Ahmado Bello University Hospital, Kaduna, Nigeria. *‘Senior Consultant and Head of Unit, Maxillofacial Unit, Ahmado Bello University Hospital. ***Rotating Senior Registrar in Oral Surgery, Guy’s Hospital, London, and Queen Victoria Hospital, East Grinstead? England. After July 1, Consultant Oral Surgeon, District General Hospital, York, Yorkshire, England.
Volume Number
Fig.
Inverted
47 5
1. Preoperative
photograph
of patient
showing
L-shaped ramus osteotomy
forward
displacement
569
of the mandible.
seek advice early. The dislocation is almost invariably anterior, and the management of these casesis usually straightforward. Occasionally, however, treatment is delayed and simple methods of reduction may not suffice. In these cases,the condylar dislocation becomes increasingly irreducible manually because of fibrosis within the joint cavities’, 2 and, possibly, shortening of the temporalis and/or external pterygoid muscles.3 Manual methods of reduction have been shown to be effective even in cases of prolonged dislocation,4-6 but as time passes,surgical methods become necessary. Earlier, surgeons favored open operations on the mandibular joints, but in recent years the trend has been toward operations on the other parts of the mandible either to facilitate traction or to correct deformity. METHODS OF TREATMENT Manual reduction
The various methods of manual reduction have been described in a comprehensive review by Gottlieb,? and all involve downward and backward force on the mandible. A relaxant drug, such as diazepam, may be given, or local analgesics may be injected around the joint* or at the insertion of the external pterygoid musdes.s If necessary, these drugs can be used in conjunction with a general anesthetic. Open
reduction
Gottlieb” recommended condylectomy to facilitate reduction in those cases in which conservative measures failed. He thought that open reduction, with perhaps removal of fibrous adhesions, would eventually result in ankylosis.
570
Adekeye,
Shamia,
and
Coue
Oral Burg. May, 1976
Fig. I. Preoperative occlusion with overerupted left lower central incisor. Fig. 3. Shows mouth on full opening before treatment.
Bilateral condylectomy was also employed by Campbell and associates,17who gave a full report on the postoperative position of the mandible. Other authors, such as Hueston,l” Curson,l Glahn,ll and Topazian and Costich,lz favored open reduction without condylectomy and argued that the condyles require removal only when open reduction was impossible or when ankylosis supervened. Operations
not involving
temporomandibular
joint
Surgical approaches to allow the use of more effective traction have been tried. Gottlieb’ mentioned the use of hooks placed around the condylar neck, whereas Hayward5 placed wires through the lower border of the mandible on each side via an open surgical approach. Laskin3 suggested that prolonged dislocations were maintained by shortening of the temporalis muscle fibers and therefore advocated myotomy of the temporalis muscle, which he found to be effective in his three cases. He carried out this procedure through a vertical intraoral incision in the region of the ascending ramus. He pointed out that the coronoid process was in a good position for operation because of the anterior dislocation. Surgical treatment neoarthroses
of the deformity
having
accepted
the
temporomandibular
Several authors have found well-marked false joints in prolonged dislocations with a good range of mandibular movement. They elected to treat the accompanying deformity. Jone,P reported a case in which blind horizontal ramus osteotomy as described by Kostecka was carried out bilaterally in a 16-year-old boy whose mandible had apparently been disloeated for about 10 years. However, a relapse occurred and the anterior open-bite deformity returned. Whinery14 performed a bilateral open condylotomy and stated that no relapse was seen
Volume Number
right
Inverted
41 5
Fig. 4. Lateral oblique mandibular condyle.
radiograph
showing
L-shaped
well-defined
joint
ramus
spaces
osteotomy
around
571
dislocs ted
after 41/2 years. Gorman15 carried out a blind condylotomy in an 89-year-old edentulous patient. The occlusion remained satisfactory during the 6-month follow-up period. Rowe and CaldwelPG reported a case in which an open oblique bilateral ramus osteotomy and coronoidotomy were carried out. Relapse occurred, with an anterior open-bite partly due to problems with fixation during the early postoperative phase. The authors pointed out that in such a procedure the mandible is moved away from the condylar fragments, thus decreasing bony contact. For this reason, Rawls and associates*carried out a modified oblique subsigmoid osteotomy in their caseand after 6 months found no evidence of relapse. CASE REPORT A 25-year-old man was referred to the Maxillofacial Unit, Kaduna, with a history of inability to close the mouth or chew properly. He had had no complaint until 1 year before, when he opened his mouth widely while yawning and was then unable to close it completely again; this was associated with pain in both temporomandibular joint regions. Native medicine was tried for about 11 months, without relief of symptoms; the patient was otherwise well. On examination, a relative mandibular protrusion was evident with downward and forward displacement of the chin (Fig. 1). Characteristic hollows were seen on both sides of the face anterior to the tragi, and the condylar heads were palpated anterior to the eminentia articulares, the left condylar head being slightly tender. The only teeth in occlusion were the last molar teeth. The left lower central incisor was overerupted (Fig. 2). An interincisal distance of 5 mm. was observed in the closed position, increasing to 3.0 cm. when the mouth was opened fully (Fig. 3); this indicated a range of mandibular movement of 2.5 cm. The mandible could be moved only in the sagittal plane. The dentoalveolar structures in both the maxilla and the mandible appeared to be normal in size. Radiographic examination showed bilateral anterior dislocation of the temporomandibular joints. The condylar heads were flat and smooth and displaced anterior to the eminentia. It was apparent that joint spaces were present in the abnormal eondylar positions, which confirmed the clinical impression of new joint formation bilaterally (Figs. 4 and 5). Study models were made subsequent to the extraction of the lower left central incisor when it was possible to articulate the teeth into a satisfactory occlusion. This observation in
572
Adekeye, Shamia,
Oral Surg. May, 1976
and Cove
Fig. 5. Lateral oblique radiograph left mandibular con
B
ilateral dislocation of the temporomandibular joint is usually caused by excessive opening of the mouth during dental and ENT treatment, or by trauma. Less frequently it is associated with opening the mouth widely, as occurs in yawning, or following the use of drugs of the phenothiazine group. Review of the literature since 1949 revealed that etiological factors were mentioned in only nineteen of the twenty-three cases of prolonged bilateral anterior dislocation of the temporomandibular joint reported. Of these, ten cases were due to opening of the mouth widely during dental and ENT treatment; seven were caused by falls and fits ; one occurred after yawning; and one happened spontaneously. The ages of the patients at the time of treatment ranged from 16 to 89 years, with an average of 41 years. In only eighteen cases was the sex recorded; eleven patients were males and seven were females. Most of the patients have obvious deformity and discomfort and, therefore, *Senior Registrar in Oral Surgery, Maxillofacial Unit, Ahmado Bello University Hospital, Kaduna, Nigeria. *‘Senior Consultant and Head of Unit, Maxillofacial Unit, Ahmado Bello University Hospital. ***Rotating Senior Registrar in Oral Surgery, Guy’s Hospital, London, and Queen Victoria Hospital, East Grinstead? England. After July 1, Consultant Oral Surgeon, District General Hospital, York, Yorkshire, England.
Volume Number
Fig.
Inverted
47 5
1. Preoperative
photograph
of patient
showing
L-shaped ramus osteotomy
forward
displacement
569
of the mandible.
seek advice early. The dislocation is almost invariably anterior, and the management of these casesis usually straightforward. Occasionally, however, treatment is delayed and simple methods of reduction may not suffice. In these cases,the condylar dislocation becomes increasingly irreducible manually because of fibrosis within the joint cavities’, 2 and, possibly, shortening of the temporalis and/or external pterygoid muscles.3 Manual methods of reduction have been shown to be effective even in cases of prolonged dislocation,4-6 but as time passes,surgical methods become necessary. Earlier, surgeons favored open operations on the mandibular joints, but in recent years the trend has been toward operations on the other parts of the mandible either to facilitate traction or to correct deformity. METHODS OF TREATMENT Manual reduction
The various methods of manual reduction have been described in a comprehensive review by Gottlieb,? and all involve downward and backward force on the mandible. A relaxant drug, such as diazepam, may be given, or local analgesics may be injected around the joint* or at the insertion of the external pterygoid musdes.s If necessary, these drugs can be used in conjunction with a general anesthetic. Open
reduction
Gottlieb” recommended condylectomy to facilitate reduction in those cases in which conservative measures failed. He thought that open reduction, with perhaps removal of fibrous adhesions, would eventually result in ankylosis.
570
Adekeye,
Shamia,
and
Coue
Oral Burg. May, 1976
Fig. I. Preoperative occlusion with overerupted left lower central incisor. Fig. 3. Shows mouth on full opening before treatment.
Bilateral condylectomy was also employed by Campbell and associates,17who gave a full report on the postoperative position of the mandible. Other authors, such as Hueston,l” Curson,l Glahn,ll and Topazian and Costich,lz favored open reduction without condylectomy and argued that the condyles require removal only when open reduction was impossible or when ankylosis supervened. Operations
not involving
temporomandibular
joint
Surgical approaches to allow the use of more effective traction have been tried. Gottlieb’ mentioned the use of hooks placed around the condylar neck, whereas Hayward5 placed wires through the lower border of the mandible on each side via an open surgical approach. Laskin3 suggested that prolonged dislocations were maintained by shortening of the temporalis muscle fibers and therefore advocated myotomy of the temporalis muscle, which he found to be effective in his three cases. He carried out this procedure through a vertical intraoral incision in the region of the ascending ramus. He pointed out that the coronoid process was in a good position for operation because of the anterior dislocation. Surgical treatment neoarthroses
of the deformity
having
accepted
the
temporomandibular
Several authors have found well-marked false joints in prolonged dislocations with a good range of mandibular movement. They elected to treat the accompanying deformity. Jone,P reported a case in which blind horizontal ramus osteotomy as described by Kostecka was carried out bilaterally in a 16-year-old boy whose mandible had apparently been disloeated for about 10 years. However, a relapse occurred and the anterior open-bite deformity returned. Whinery14 performed a bilateral open condylotomy and stated that no relapse was seen
Volume Number
right
Inverted
41 5
Fig. 4. Lateral oblique mandibular condyle.
radiograph
showing
L-shaped
well-defined
joint
ramus
spaces
osteotomy
around
571
dislocs ted
after 41/2 years. Gorman15 carried out a blind condylotomy in an 89-year-old edentulous patient. The occlusion remained satisfactory during the 6-month follow-up period. Rowe and CaldwelPG reported a case in which an open oblique bilateral ramus osteotomy and coronoidotomy were carried out. Relapse occurred, with an anterior open-bite partly due to problems with fixation during the early postoperative phase. The authors pointed out that in such a procedure the mandible is moved away from the condylar fragments, thus decreasing bony contact. For this reason, Rawls and associates*carried out a modified oblique subsigmoid osteotomy in their caseand after 6 months found no evidence of relapse. CASE REPORT A 25-year-old man was referred to the Maxillofacial Unit, Kaduna, with a history of inability to close the mouth or chew properly. He had had no complaint until 1 year before, when he opened his mouth widely while yawning and was then unable to close it completely again; this was associated with pain in both temporomandibular joint regions. Native medicine was tried for about 11 months, without relief of symptoms; the patient was otherwise well. On examination, a relative mandibular protrusion was evident with downward and forward displacement of the chin (Fig. 1). Characteristic hollows were seen on both sides of the face anterior to the tragi, and the condylar heads were palpated anterior to the eminentia articulares, the left condylar head being slightly tender. The only teeth in occlusion were the last molar teeth. The left lower central incisor was overerupted (Fig. 2). An interincisal distance of 5 mm. was observed in the closed position, increasing to 3.0 cm. when the mouth was opened fully (Fig. 3); this indicated a range of mandibular movement of 2.5 cm. The mandible could be moved only in the sagittal plane. The dentoalveolar structures in both the maxilla and the mandible appeared to be normal in size. Radiographic examination showed bilateral anterior dislocation of the temporomandibular joints. The condylar heads were flat and smooth and displaced anterior to the eminentia. It was apparent that joint spaces were present in the abnormal eondylar positions, which confirmed the clinical impression of new joint formation bilaterally (Figs. 4 and 5). Study models were made subsequent to the extraction of the lower left central incisor when it was possible to articulate the teeth into a satisfactory occlusion. This observation in
572
Adekeye, Shamia,
Oral Surg. May, 1976
and Cove
Fig. 5. Lateral oblique radiograph left mandibular con
