Superolateral dislocation of an intact mandibular condyle into the temporal fossa: case report and literature review
CASE REPORT
Divashree Sharma1, Ankit
Khasgiwala2, Bharat Maheshwari3, Charanpreet Singh4, Neelam Shakya3
1Department of Dentistry, Shyam Shah Medical College, Rewa, MP, India;2Orofacial Cleft and Craniofacial Anomalies, Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India;3Department of Oral and Maxillofacial Surgery, Government College of Dentistry, Indore, MP, India;
4Consultant Oral and Maxillofacial Surgeon, Ludhiana, Punjab, India
Key words: superolateral dislocation; con- dyle; mandible fracture
Correspondence to: Divashree Sharma, Department of Dentistry, Shyam Shah Medical College, F -7/2, New Doctors’ Colony, Arjun Nagar, Rewa 486001, MP, India
Tel.: +91 7879068161
e-mail: divashri.19.sharma@gmail.com Accepted 29 March, 2016
Abstract – Temporomandibular joint dislocation refers to the dislodge- ment of mandibular condyle from the glenoid fossa. Anterior and antero- medial dislocations of the mandibular condyle are frequently reported in the literature, but superolateral dislocation is a rare presentation. This report outlines a case of superolateral dislocation of an intact mandibular condyle that occurred in conjunction with an ipsilateral mandibular parasymphysis fracture. A review of the clinical features of superolateral dislocation of the mandibular condyle and the possible techniques of its reduction ranging from the most conservative means to extensive surgical interventions is presented.
Dislocation of the temporomandibular joint (TMJ) is described as a non-self-limiting displacement of the condyle, outside its functional positions within the gle- noid fossa and posterior slope of the articular eminence (1, 2). It is characterized by complete separation of the joint with fixation of the condyle in an abnormal posi- tion (3). Anterior and anteromedial are, by far, the most commonly presenting directions of condylar dislo- cation whilst lateral and superolateral dislocations are the rarest types (4–6). Because such dislocations are very rare in occurrence, they are often misdiagnosed and neglected. This report describes a rare case of superolateral dislocation of an intact mandibular con- dyle that occurred in conjunction with an ipsilateral parasymphysis fracture.
Case report
A 30-year-old, conscious and well-oriented male patient reported to the Department of Oral and Maxillofacial Surgery, Government College of Dentistry, Indore, India, 20 days after a road traffic accident that resulted in the injuries. The patient gave a history of left ear
bleed at the time of injury. On examination, extra-oral findings included a laceration over the chin measuring about 29 1 cm with marked retrusion of left side of the chin, which was tendered on palpation. Decreased mandibular height on the left side with deviation towards the left on mouth opening was evident. A bony hard, tender elevation of around 39 2 cm was palpable on the left preauricular region. (Fig. 1) He was not able to close his mouth, and all mandibular movements were extremely restricted and painful.
Intra-oral examination revealed an anterior open bite and crossbite on the left side. There was a step defect between the left lower central incisor and lateral inci- sor. An orthopantomograph (OPG) revealed a left parasymphysis fracture, and the image of the intact left condyle was seen to be overlapping on the articular eminence suggesting its dislocation. The contralateral condyle was intact and in its normal position in the glenoid fossa (Fig. 2). Facial nerve testing of the patient did not reveal any injury. A computed tomo- graphic scan (CT scan) was not performed because of the financial concerns of the patient. After correlating the clinical and the radiological findings, a diagnosis of
superolateral dislocation of the left mandibular condyle associated with an ipsilateral parasymphysis fracture was reached.
Initially, closed manual reduction was attempted under local anaesthesia, but this was not productive owing to the time elapsed between injury and treat- ment. The second attempt for closed manual reduction was made under general anaesthesia, but it was also unsuccessful. A left submandibular incision was made to expose the angle region. Two traction wires were passed through it, and force was applied with the help of these wires to pull the entire fragment downwards.
This manoeuvre also proved to be futile. Subsequently, an Alkayat–Bramely incision was made on the left side and the condyle was exposed. It was dislocated out of the glenoid fossa and was hooked over the zygomatic arch. The disc was found to be dislocated antero-medi- ally. The condyle was unhooked from the arch and manipulated back into the fossa with the help of a Molt #9 periosteal elevator. The disc was repositioned over the condyle and sutured with the articular capsule in the mandibular fossa laterally. The fractured parasymphysis was then reduced and fixed with a single 2-mm miniplate intra-orally. An intra-operative mouth opening of 36 mm and satisfactory occlusion were achieved. The patient was subjected to intermaxillary
fixation (IMF) with elastics for 2 weeks, and postoper- ative healing was uneventful (Figs 3 and 4). At 6- month follow up, the mouth opening was satisfactory with a good range of mandibular movement.
Discussion
Allen and Young (7) subdivided such dislocations into:
type I dislocations (lateral subluxation), in which the condyle has been laterally dislocated out of the fossa, and type II dislocations (complete dislocation), in which the condyle has passed laterally and then superi- orly to enter the temporal fossa outside the zygomatic arch (7). Satoh et al. (8) further classified type II dislo- cations into type IIA, in which the condyle is not hooked above the zygomatic arch; type IIb, in which the condyle is hooked above the zygomatic arch; and type IIc, in which the condyle is lodged inside the zygo- matic arch, which is fractured. The present case was classified as a type IIB dislocation based on the intra- operative findings. The reported cases of type IIB dislo- cation are listed in Table 1.
Allen and young (7) suggested that an associated fracture of the anterior mandible, near the symphysis, is a prerequisite for a type II dislocation. A study by Rattan (12) also emphasized that for the cases with lat- eral dislocation of the mandibular condyle, there Fig. 1. Pre-operative lateral view of the patient revealing a
bulge in the TMJ region.
Fig. 2. Orthopantomogram revealing an intact laterally dislocated left condyle and ipsilateral parasymphysis fracture.
Fig. 3. Post-operative photograph of the patient after 72 h.
should always be a history of trauma to the side of the chin and an associated fracture in the symphyseal or body region (usually on the contralateral side) facilitat- ing the rotation and movement of the ramus, which will contribute to the superolateral dislocation of the condyle.
Contrary to this, some reports suggest that supero- lateral dislocations can take place without any associ- ated mandibular fracture (14, 15, 18, 19). According to Li et al. (14), for such dislocation to occur, the prereq- uisite factors are multiple multidirectional impacts of force, wide open mouth and flabby joint capsule and pterygoid muscles. Tauro et al. (20) separately catego- rized complete dislocations associated with fracture of anterior mandible under Type II and complete disloca- tion without associated fracture of anterior mandible under type III dislocations.
Apart from the usual clinical features of the anterior mandible fracture, if at all present, the patient with a superolateral dislocation of the condyle will present with a bony hard swelling and bulge in the affected temporal and preauricular region causing changes in the facial profile. Dislocation of the TMJ leads to the stretching of the ligaments around the joint and intra- articular effusion, causing painful mandibular move- ments. The muscle spasms and joint pain make speech and mastication difficult (3, 21).
An anterior open bite and a crossbite with loss of ramus height on the affected side are characteristic fea- tures. A slight retrusion of the anterior mandible is evi- dent in cases of superolateral dislocation associated with a fracture in the mandible. The condylar head migrates laterally and superiorly in the temporal space and can often be palpated, but sometimes the palpation may become difficult because of the oedema associated with the injury.
Facial nerve damage may also occur during the lat- eral displacement of the intact ramus/condyle because the extrapetrosal peripheral segment of the facial nerve lies in close proximity to the ramus (14). Although not very frequently reported in the literature, it is wise to evaluate the condition of the facial nerve and docu- ment it before the treatment.
Anterior dislocation of the contralateral condyle occurring in conjunction with the lateral dislocation of
the condyle in question is also reported in some cases (5).
Worthington (22) has linked some diagnostic fea- tures to superolateral dislocation: malocclusion persist- ing after the reduction of jaw fracture, persistence of an open bite, persistent restriction of mandibular move- ment and an apparent loss of ramus height with eleva- tion of the ramus fragment and facial asymmetry.
The crucial importance of an accurate and prompt diagnosis in the treatment planning of such cases necessitates that CT scans should ideally be per- formed in such cases to assess the type of dislocation (20).
For all types of acute dislocations, closed reduction with or without anaesthesia is the simplest, least trau- matic and safest approach. It should be the preferred and the first attempted method of treatment (23–25).
Intra-oral bimanual reduction is the preferred non-sur- gical method, others being slow elastic traction with splints or IMF, placing a mouth gag in between the occlusal surfaces of molars and opening it wide to open the patient’s mouth and then rotating it to pull in the outlocated condyle.
A method involving application of heavy manual traction simultaneous to a downward traction applied with a wire twister engaging a loop of wire that was attached to the molars using an arch bar is described (18).
The repositioning of displaced intact mandibular condyles by application of a percutaneous traction force with a bone hook placed at sigmoid notch (26) and the use of traction with the help of wires placed in holes drilled in the exposed angle region are also reported in literature (10, 16, 27).
It is predicated that classical bimanual intra-oral manual reduction manoeuvre imparts unnecessary pres- sure to the unaffected side which may cause problems in the healthy TMJ (28) and the thumbs of the physi- cian are at risk of being bitten by the patient which may cause traumatic damage or infection (29). To overcome these drawbacks, a method of placement of mouth props or approximately 3-cm-thick gauze pad in the affected molar region and applying an upward pressure on the chin extra-orally have been proposed (30).
Fig. 4. Post-operative Orthopantomogram.
Table1.ReportedcasesoftypeIIBsuperolateraldislocation Authorand yearof publicationInvolved SideDislocationConditionAssociatedmandibularfractureTreatmentperformedTreatmentoutcome Brusatiand Paini(9)LeftExternaldislocationofleftcondylethathadbeen thrustupinfrontoftheearMidlinefractureofthemandible andfractureofleftcoronoid process
ClosedreductionWithfacialpalsy,notdescribed RightUpwardandlateraldislocationoftheright mandibularcondyleFractureoftherightmandibular bodyandleftcondyleOpenreductionWithfacialpalsy,fulljawmotion Ferguson etal.(10)
LeftLateraldisplacementofthecondylethatwas hookedabovethezygomaticarchandleftfacial palsy Rightcondyle+symphysis fracture Afteranunsuccessfulattemptofmanualreduction,leftangle wasexposedviaextra-oralapproachandtractionforcewas appliedthroughaholedrilledinangleregion.
Thefacialnerveparalysishadfully resolved4monthsafterinjury. To(11)RightTherightcondyledislocatedsuperolaterallylying abovethezygomaticarchinthetemporalfossa.Fractureofsymphysisand fracturedislocationofleft condyle.
Openreductionviapreauricularincision.Post-operativeOPGon 54thdayrevealedabifidcondyle.Mouthopening17mmat 6months Rattan(12)RightMedialportionoftherightcondylewasfractured andlateralfragmentwashookedonthezygomatic arch
Leftsymphysealfractureofthe mandibleOpenreductionviapreauricularapproach.Thefracturedmedial portionofcondylewasremovedfromglenoidfossa.The laterallydislocatedportionwasleveredintotheglenoidfossa
At18monthsfollowup,the patient’smouthopeningwas 30mmandtheocclusionwas satisfactory BilateralBoththecondyleswerehookedaboveandfusedto zygomaticarch.Thepatientreportedwith deterioratingmouthopening18monthsafter interpositionarthroplastywithsiliconerubber blockhadbeenperformedontheleftTMJat othercentre.
Symphysealfractureofthe mandibleTherightTMJwasexposedviaanextendedpreauricular incision.Interpositionarthroplastyandbilateralcoronoidectomy wasperformed.
After9monthsoffollowup,a3.5- cmopeningwasmaintained Hsieh etal.(13).RightThecondylarheadswereplacedlaterallyawayfrom glenoidfossawiththerightcondylehookedabove thezygomaticarch.
SymphsealfractureManualreductionunderGA41mmmouthopeningand8mm lateralexcursionwereachieved withgoodocclusion Lietal.(14)LeftLeftcondylewashookedabovethezygomaticarch withcoronoidprocesspenetratingintothe temporalfossa WithoutassociatedMandible fractureClosedreduction3.6cmmouthopeningandnormal mandibularmovement Hegde etal.(15)LeftLeftcondylewaspalpableabovethezygomaticarchWithoutassociatedMandible fractureAfteranunsuccessfulattemptofmanualreduction,AlKhayat– Bramleyincisionwasmadeandopenreductionwas performed.
NA Singh etal.(16)
BilateralBoththeintactcondylesweredislocatedlaterally andsuperiorly,crossingtheintactzygomatic arches
LeftparasymphysisfractureRightangleofmandiblewasexposedviasmallsubmandibular incision.Tractionwasappliedthroughawireheldwithawire tightenerpassedthroughaholedrilledinangleregion. Channelretractorwasengagedinthesigmoidnotchtopull thecondyledownwardinthefossa(Finck’stechnique).Once therightcondylewasreduced,theleftcondylewasmanually reducedwiththehelpofamouthgag At6-monthfollowup,thepatient maintainedamaximalincisal openingof34mmwithadequate mandibularfunctionanda satisfactoryocclusion
Table1.Continued Authorand yearof publicationInvolved SideDislocationConditionAssociatedmandibularfractureTreatmentperformedTreatmentoutcome ShenL etal.(17)
LeftIIBSymphysealfractureManualreductionofcondylardislocation.34mmmouthopening BilateralIIBSymphysealfractureMandibularsagittalsplitramusosteotomy+manualreduction ofcondylardislocation.33mmmouthopening LeftIIBSymphysealfracture+left condylarfractureMandibularsagittalsplitramusosteotomy+manualreduction ofcondylardislocation.30mmmouthopening RightIIBSymphysealfractureManualreductionofcondylardislocation.Mouthopeningachievedwas 34mm LeftIIBSymphysealfracture+left condylarfractureMandibularsagittalsplitramusosteotomy+manualreduction ofcondylardislocationMouthopeningachievedwas 38mm BilateralIIBSymphysealfractureMandibularsagittalsplitramusosteotomy+manualreduction ofcondylardislocationMouthopeningachievedwas 27mm Rahman etal.(18)LeftLeftcondylewassagitallyfracturedandthelateral fragmentwashookedonthezygomaticarch.Noassociatedmandibular fractureManualreductionandapplicationofdownwardtractionforce withaloopofwireattachedtothemolarsusinganarchbar withawiretwister.
Mouthopeningofaround30mm wasachieved. Mishraand Mishra(19)LeftSuperolateraldislocationoftheintactcondyle(type IIB)ontheleftsideRightcondylarfractureand rightparasymphysisfractureReductionofleftcondylewasperformedunderdeepsedation bylateralandinferiormovementofleftramus.NA RightSuperolateralcondylardislocationoftheintact condyle(typeIIB)wasseenontherightside.Noassociatedmandibular fracturesOpenreductionoftherightcondylewasperformedunderGA bypreauricularapproach.Occlusionandmouthopeningwere achievedpost-operatively BilateralBilateralsuperolateraldislocationofthemandibular condyles(typeIIB)wasevident.MidsymphysealfractureClosedmanipulationofthemandibleunderGANA
Closed reduction methods are successful in cases in which early diagnosis of the injury has been made.
Studies have shown good results with closed reduction of superolateral dislocation of mandibular condyle (18– 20). Delay in the reduction may make closed reduction impossible because of the development of fibrosis within the joint cavities, myospasm, bony union or a combination of these (5, 21).
This case report supports the finding that the tech- niques of closed reduction may work for type I, IIA, IIIA and possibly IIC and IIIC dislocations; however, type IIB and IIIB may require an open reduction to ‘unhook’ the condyle from the zygomatic arch (5, 8, 10, 31). In cases with long-standing type II or type III dislocations, general anaesthesia should be preferred for reduction because if the closed reduction attempt fails, open reduction can be attempted simultaneously. In difficult and long-standing cases of superolateral dislocations, open reduction/radi- cal surgery is advocated (3).
The open reduction techniques may vary from direct exposure of condyle and reduction; coronoidec- tomy performed through posterior vestibular incision followed by attempts to reduce the superolaterally dislocated condyle by placement of a Seldin elevator lateral to ramus and applying a downward and med- ial pressure (5), utilizing an intra-oral Keens vestibu- lar incision to pass a zygomatic hook to engage the sigmoid notch and exerting a downward and lateral force to reduce the dislocation (17) or performing a mandibular sagittal split ramus osteotomy for condy- lar reduction through submandibular and preauricular incisions (17).
Condylectomy with or without arthroplasty is indi- cated in fibro-osseous ankylosis of the joint induced by unsuccessful or imperfect reduction (7). Superolat- eral dislocation usually occurs along with a midsym- physeal, contralateral parasymphyseal or body fracture of the mandible (9). The case reported here is unusual, because to the best of the authors’ knowl- edge this is the only case when unilateral superolat- eral dislocation of the condyle occurred along with an ipsilateral parasymphysis fracture except for a case reported by Brusati and Paini (9) where a superolat- eral dislocation was seen with an ipsilateral body fracture.
Conclusion
Superolateral dislocations of the mandibular condyle are not frequently encountered in clinical practice and demand special attention in diagnosis and treatment planning. It is still debatable that whether an associ- ated mandibular fracture is a prerequisite for such dis- locations to occur or not. Early reduction is advisable for this rare condition of superolateral dislocation. The decision of the preferred treatment modality (either closed or open reduction) depends on the time elapsed since injury, the degree and type of dislocation, other associated mandibular fractures and the general condi- tion of the patient. Open reduction should only be undertaken after the closed methods have been exhausted. Closed manual reduction can suffice in cases
with type I, type IIA, IIC, IIIA and type IIIC disloca- tions, but for type IIB and IIIB cases open reduction may often may be required.
Acknowledgement None.
Conflict of interest
The authors confirm that they have no conflict of interest.
Funding None.
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