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Case Reports in Dentistry
Volume 2019, Article ID 6810461, 5 pages
https://doi.org/10.1155/2019/6810461
Case Report
Long-Term Follow-Up following Condylotomy in a Case of
Traumatic Unilateral Anterosuperior Mandibular
Condyle Dislocation
Syed Nabil , Elavarasi Kuppusamy, Rifqah Nordin, Abdul Jabar Nazimi ,
and Roszalina Ramli
Oral and Maxillofacial Surgery, Faculty of Dentistry, The National University of Malaysia, Jalan Raja Muda Abdul Aziz,
50300 Kuala Lumpur, Malaysia
Correspondence should be addressed to Syed Nabil; dr_syednabil@yahoo.com.my
Received 1 April 2019; Accepted 8 May 2019; Published 14 May 2019
Academic Editor: Wen Lin Chai
Copyright © 2019 Syed Nabil et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Anterosuperior temporomandibular joint dislocation is rare. Manual reduction of such dislocation is difficult especially when
treatment is delayed. Therefore, it has an increased likelihood of needing surgical intervention to achieve reduction. The authors
report a case of an anterosuperior temporomandibular dislocation in a 19-year-old male following a motor vehicle accident.
Difficulties were encountered in reducing the dislocation necessitating surgically assisted reduction. The long-term outcome
following management by condylotomy is reported. This present report also reviews the literature regarding the classification
and management of this uncommon dislocation.
1. Introduction
Temporomandibular joint dislocation (TMJD) is an abnormal condition in which the head of the condyle displaces
from its usual position in the glenoid fossa in the squamotemporal portion of the cranial base [1]. TMJD can involve
only one or bilateral joints, and it can be dislocated either
anteriorly, laterally, medially, posteriorly, or superiorly [1].
The cause of TMJD can either be traumatic or nontraumatic
[2]. Nontraumatic dislocations are more common and precipitated by events such as forceful or excessive opening of
the mouth during laughing, yawning, and dental or endoscopy treatment, during anesthetic intubation, and during eating or as consequences of seizures [1]. The nontraumatic
TMJD is caused by the laxity of the surrounding connective
tissue and generally can be managed by conservative reduction [2]. Traumatic TMJD meanwhile has been reported to
occur following a fall, road traffic accident, domestic accident,
or interpersonal violence [1]. TMJD can also be classified as
acute, recurrent/habitual, or long-standing/chronic based
on the dislocation duration [3]. Acute dislocation is the most
frequent. When acute dislocations are not reduced for more
than 72 hours, it can be defined as long-standing dislocations
[4]. Recurrent or habitual dislocation occurs in repeated episodes and may become more frequent if left untreated [3].
A subtype of TMJD that is notoriously difficult to
reduce is the anterosuperior dislocation (ASD) [5, 6]. ASD
is described as a condition where the condyle is displaced
anteriorly beyond the articular eminence then superiorly
medial to the zygomatic arch to enter into the temporal fossa
[6]. This type of dislocation is uncommon with only a handful
of cases reported. The authors report a case of ASD in an
intact condyle following a motor vehicle accident. Additionally, this article would describe the long-term outcome of such
case following management with intraoral condylotomy.
2. Case Report
A 19-year-old man was brought to the emergency department following a road traffic accident after his motorcycle
skidded and hit the road divider. His Glasgow Coma Scale
(GSC) on initial examination was 12/15. He sustained
2
laceration of his upper lip and tongue, comminuted fracture
of the right mandible parasymphysis, and avulsed teeth 11,
12, 41, 42, 43, and 44 (Figure 1). He was intubated immediately for airway protection. An emergency head CT scan
showed that he also sustained depressed fracture of the frontal bone with subdural and epidural hemorrhage. CT scan
also showed right parasymphysis mandible fracture and dislocated left condyle (Figure 2(a)). The left condyle was dislocated anteriorly and superiorly into the infratemporal fossa
medial to the zygomatic arch. There were no fractures of
the condyle and zygomatic arch.
He underwent emergency craniotomy with evacuation
of blood clot by the neurosurgical team. In the same setting,
the facial laceration injury was sutured and an arch bar
with intraosseous wiring was placed to stabilize the fractured
mandible. Condyle dislocation reduction was also attempted.
Due to the orotracheal intubation tube, the occlusion was not
assessed following reduction. The patient was then transferred to the intensive care unit (ICU) subsequently with
the orotracheal intubation kept in place. Following extubation 5 days later, it was noted that the patient kept his
mouth open without any closure movement. There was
also excessive drooling of saliva due to the inability to
close his mouth. On examination, his mandible movement
appeared restricted and the mandible was unable to move in
any direction. He was not obeying instruction well. Multiple
manual reduction attempts at bedside were unsuccessful.
An open reduction and internal fixation was planned for
the right parasymphysis of mandible fracture, and it was
planned to perform reduction of the dislocated condyle on
the left side. Owing to the patient’s neurological injury, the
surgery could only be done 2 weeks after the injuries were
sustained. In view of the ASD condyle and the prolonged
period of dislocation, we anticipated difficult reduction. This
was discussed with the patient and his family, and it was
decided if the need for open or surgical reduction arises, they
prefer surgical approach to be done intraorally. During the
surgery under general anesthesia with muscle relaxation, initial attempts were made to reduce the left condylar dislocation by using manual traction by Hippocratic method and
then with the assistance of a mouth gag but proved to be
unsuccessful. Our next attempt was to release the intraosseous wiring at the parasymphysis fracture site effectively rendering the mandible in two separate pieces to simulate
mandibulotomy-assisted reduction as described by previous
clinicians [7, 8]. Once this was not successful, we went ahead
with an intraoral condylotomy on the left side by piezoelectric surgery. First, a coronoidectomy was done to get access
to the condyle. Then, the condylar neck was osteotomized
using the piezosurgery, and the mandible was then able to
be pushed back into occlusion. Finally, open reduction and
fixation of the right parasymphysis fracture was performed
and stable occlusion was achieved.
Postoperative CT scan confirmed the reduction of the
dislocation (Figure 2(b)). There was a slight deviation of the
jaw to the left and mouth opening was 19 mm. Occlusion
was acceptable and elastics were placed for 6 weeks. Jaw
exercises were encouraged, and review after 2 months
postoperatively showed improvement in mouth opening
Case Reports in Dentistry
Figure 1: Facial injury sustained.
at 40 mm with stable occlusion. The patient was then
referred to a prosthodontist for further rehabilitation and
treatment of the missing teeth.
On 1-year follow-up, the patient presented with no complaint. Clinically, there was no tenderness at the joint or muscle of mastication on palpation or during movement.
However, there was mild asymmetry of the jaw with the chin
deviated 2 mm to the left (Figure 3). Mouth opening was
maintained at 40 mm with deviation to the left on opening
(Figure 4). Occlusion was good with upper and lower dentures in place. CT scan shows union between the condyle
head and the condylar process stump (Figure 2(c)). Its
position remains as seen immediately after surgery. The
stump of the condylar process meanwhile has remodeled to
form a neocondyle.
3. Discussion
The description of ASD can be rather confusing. Several previous authors used different terms for dislocation of the condyle medial to the zygomatic arch similar to this reported
case including superolateral dislocation (SLD) [9], anteromedial dislocation (AMD) [2], and ASD [6]. We describe our
case as ASD as the condyle is anterior and superior to its original position in the glenoid fossa. Technically, the terms SLD
and AMD for such dislocation are inaccurate as the condyle
is not located medial/lateral to the glenoid fossa but instead
is medial/lateral to the zygomatic arch. To add further confusion, ASD has been suggested to be included under lateral
dislocation classification. Allen and Young first attempted
to classify cases of lateral TMJD to types I and II for lateral
subluxation and lateral complete dislocation, respectively
[10]. Later, Satoh et al. suggested further refinement of lateral
TMJD by dividing type II to subtypes IIA, IIB, and IIC [11].
They described unhooked condyle in lateral TMJD (type
IIA), laterally hooked condyle above the zygomatic arch
(type IIB), and lodgment of the condyle under a fractured
zygomatic arch (type IIC) [11]. The next revision of this classification was made by Prabhakar and Singla who described
the condyle of an intact mandible being medial to unfractured zygoma [6]. Type III as defined by Prabhakar and
Case Reports in Dentistry
3
(a)
(b)
(c)
Figure 2: CT scan image of the left temporomandibular joint at (a) day 1 of trauma, (b) two days postsurgery, and (c) one year postsurgery.
(a)
(b)
Figure 3: Extraoral presentation on closing and opening of the mouth one year postsurgery.
Singla is more precisely an anterior-superior dislocation (as
described by the authors themselves); thus, together with
type IIC from Satoh et al. has deviated from the “lateral”
TMJD classification as described initially by Allen and Young
[6, 10, 11]. Further refinement was made to complete the type
III classification to type IIIA or type IIIB based on the presence or absence of mandibular fracture [5]. Most recently,
Rahman et al. analyzed previous classification and suggested
a complete classification for lateral TMJD [12]. While the
classification is comprehensive, it technically lumps together
an anterior vector dislocation (anterosuperior) with a lateral
vector dislocation (lateral and superolateral).
Untreated or persistent acute condyle displacement due
to failure to diagnose or inadequate treatment rendered for
the patient can lead to “long standing” TMJD [3]. Once the
condyle becomes abnormally positioned for a period of time,
it causes muscle spasm, soft tissue fibrosis, and soft tissue
ingrowth into the glenoid fossa [2–4]. Thus, prolonged dislocations will be more difficult to be repositioned [2–4]. Several
authors agree with this and further suggest the use of the
duration of the dislocation as a guide in managing longstanding TMJD cases [2, 4]. Huang et al. suggested closed
reduction in a dislocation of less than 3 weeks, open reduction using wire traction at the angle of mandible for a
4
Case Reports in Dentistry
(a)
(b)
Figure 4: Occlusion on biting and opening of the mouth with dentures one year postsurgery.
dislocation persisting more than 4-12 weeks, and more
complicated surgical procedures such as condylectomy, condylotomy, myotomy, and TMJ prosthesis for dislocations
persisting for more than 6 months [4]. Rattan and Rai meanwhile proposed trial of manual reduction and anterior traction using elastics before proceeding with indirect open
reduction with the use of transosseous wires or hooks, direct
open reduction via preauricular approach in TMJD that persist for more than one month, and orthognathic surgical procedure in cases of more than 6 months [2]. There is no
consensus yet on when should an acute dislocation phase
ends and the long-standing starts [3]. Huang et al. define a
dislocation which has been left untreated or inadequately
treated for more than 72 hours while Rattan et al. suggest a
longer period of 1 month [2, 4]. In the presented case,
the dislocation was attempted to be reduced at 14 days.
The difficulty in manual reduction clearly shows the extent
of spasm, fibrosis, and tissue ingrowth to be well advanced.
There is also a possibility of a mechanical obstruction with
the condyle under the zygomatic arch. Hence, an invasive
procedure was eventually needed involving condylotomy
and coronoidectomy on the left side as described by Pappachan et al. [13].
In ASD, the need for surgical reduction should be anticipated. From the literature, it is noted that in the nine
previously reported cases, 56% (5/9) of the cases with this
type of dislocation need open surgery reduction [5]. The
remaining 33% (3/9) had assisted manual reduction such
as the use of mouth gags [9] and zygomatic bone hook
traction [5, 14]. Furthermore, the period of time before
reduction in cases of ASD further contributes to the failures
in manual reduction [5]. Several surgical modalities have
been reported in the management of difficult cases of
TMJ dislocation. These include direct reduction via preauricular incision [2], condylectomy [15], condylotomy [13],
inverted L-shaped ramus osteotomy [16], bilateral verticaloblique osteotomy of ramus [17], and midline mandibulotomy [7]. In the reported case, after conservative attempts
and using of the right parasymphysis fracture to simulate
midline mandibulotomy reduction failed, we proceed to
perform condylotomy. Due to the expected shortening of
the ramus height, long-term undesirable changes that could
possibly develop include the presence of malocclusion, the
deviation to the operated side when opening the mouth,
loss of lateral excursion, TMJ dysfunction symptoms, and
open bite [18, 19]. Clinical examination at 1-year postsurgery showed deviation of the mandible to the left side on
jaw opening and the chin was noted to be shifted 2 mm
to the left when resting. The patient however gained an
excellent range in mouth opening with good occlusion,
and normal function of the jaw was restored. Radiographically, although the left condyle head was still at its dislocated position, the stump of the condylar process has
remodeled to form a neocondyle allowing satisfactory functioning of the jaw. While this shows acceptable outcome, a
long-term effect of a unilateral shortening of the ramus
height is still not clear. Previous reported case of condylotomy for anteriorly displaced condyles also reported similar
favorable outcome [13, 20].
Condylotomy can be performed transorally, which
avoids the cutaneous scar and risk for facial nerve injury.
Risks to the other surrounding structures such as maxillary
artery meanwhile differ among the different devices used to
perform the osteotomy. Osteotomy around the condyle can
be performed using piezosurgery, drill, saw, osteotome, and
even gigli saw. The use of piezosurgical instruments has the
advantage of not damaging the soft tissue and at the same
time allowing and improving precision in osteotomy. This
allows access to this limited area with minimal damage to
the surrounding tissue. The fact that the joint was dislocated
anteriorly provides an advantage for the surgeon to access the
condyle in the reported case.
In summary, ASD is a rare occurrence of condyle dislocation anterior to the glenoid fossa and should not be classified
together with lateral vector dislocations. When ASD is
identified, surgical management should be anticipated and
planned due to the low likelihood of success for manual
reduction especially when treatment provision is delayed.
There is no proper evidence to suggest or guide which surgical intervention would provide the best long-term outcome
for the management of ASD. Condylotomy especially with
piezoelectric surgery is a viable and safe option especially
when intraoral approach is preferred.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Case Reports in Dentistry
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