Vol. 89 No.

6 June 2000

REVIEW ARTICLE

Dislocation of the temporomandibular joint

Christopher W. Shorey, DDS, a and John H. Campbell, DDS, MS, b Indianapolis, Ind
INDIANAUNIVERSITY

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:662-8)

Dislocation of the temporomandibular joint (TMJ) Dislocation of the TMJ represents 3% of all reported
occurs when the mandibular condyle is displaced ante- dislocated joints in the body. 10 However, most authors
riorly beyond the articular eminence. There are regard recurrent dislocation as a rare entity. As with
multiple causes for its occurrence, and treatments other temporomandibular disorders, the highest inci-
range from relatively conservative methods to complex dence of recurrent dislocation is reported among female
surgical intervention. Although "success" rates and subjects, although the reasons for this are not well
length of follow-up for the available treatments are understood) 1 Signs and symptoms of acute and chronic
highly variable, this article will assess interventions dislocation are the same and include (1) inability to
reported in the English literature in an attempt to close the mouth, (2) preauricular depression of the skin,
provide the clinician with a clearer understanding of (3) excessive salivation, (4) tense, spasmatic muscles of
outcomes and potential complications. mastication, and (5) severe pain of the TMJ.l°
In 1832, Sir Astley Cooper proposed principles for
diagnosis and treatment of dislocation of the lower PRECIPITATING FACTORS
j a w ) He introduced the terms complete dislocation Some factors associated with the onset of habitual
(luxation) and imperfect dislocation (subluxation), dislocation include, but are not limited to, yawning,
and other authors have further delineated the 2 condi- singing, sleeping with the head resting on the forearm,
tions. 2-6 Subluxation is generally defined as a manipulation of the mandible while patient is under
displacement of the condyle out of the glenoid fossa general anesthesia, excessive tooth abrasion, severe
and anterosuperior to the articular eminence, which malocclusion, loss of dentition (leading to overclosure),
can be reduced by the patient (self-reduced). Clinical and trauma.6,12,13 Patients undergoing psychiatric or
and radiographic analysis have indicated that approxi- psychological chemotherapy can also experience recur-
mately 70% of the population can subluxate the TMJ. 7 rent dislocation as a side effect of certain medications. 14
In contrast, dislocation is a similar displacement of the Several authors have proposed that abnormalities in
condyle, which cannot be self-reduced. Whatever the the stability factors of the TMJ may be associated with
underlying cause, with each successive dislocation, dislocation.l,6,8A1,15-17 The stability of any joint
further episodes tend to occur more easily. 8 When depends on 3 factors: (1) the integrity of the ligaments
dislocation in a patient becomes more frequent and associated with the joint, (2) the activity of the muscu-
progressively worse, the condition is referred to as lature acting on the joint, and (3) the bony architecture
habitual or recurrent dislocation. 9 of the joint surfaces. 15
Myrhaug related the bony architecture to disloca-
aFellow, Department of Oral Surgery, Medicine, and Pathology, tion. 11 He observed that a deep overbite was frequently
Indiana University. associated with a deep glenoid fossa and a steep artic-
bAssistant Professor, Department of Oral Surgery, Medicine, and ular eminence, which he surmised to be conducive to
Pathology, Indiana University. dislocation. Other authors have postulated that chronic
Received for publication April 29, 1999; returned for revision July stretching of the capsular and lateral ligaments, known
15, 1999; acceptedfor publication Feb 10, 2000.
Copyright© 2000 by Mosby,Inc. in earlier literature as "lax ligaments," predispose the
1079-2104/2000/$12.00 + 0 7/12/106693 TMJ to dislocation. 6,13 Abnormalities of the neuro-
doi:10.1067/moe.2000.106693 muscular mechanisms controlling muscles of mastica-

662
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Shorey and Campbell 663
Volume 89, Number 6

tion have also been associated with dislocation. 1 Bell 16 Immobilization of the mandible by maxillomandibular
implied that a period of critical importance exists when fixation (MMF) may be used by itself or in concert with
the condyle reduces from a subluxated position. If a other treatment modalities for habitual dislocation. As
spasm of the musculature occurs when the condyle the sole therapy, immobilization has been recommended
approaches the crest of the articular eminence on its for a period of 3 to 6 weeks to facilitate healing of the
return to the glenoid fossa, then dislocation is a highly presumably damaged ligament(s)) 1 As an adjunctive
probable outcome. Finally, some authors have specu- treatment to sclerosing agents, it may aid the develop-
lated on a combined ligamentous/muscular cause, that ment of a mature fibrosis within the joint capsule. 18
is, the disk-condyle relationship and TMJ dislocation. However, MMF alone or with concomitant use of scle-
The relative position of the anterior band of the disk to rosing agents has typically failed to achieve permanent
the condyle may, in some instances, cause a mechan- satisfactory results.6,9,11,21.22 In addition, compliance in
ical block, thus precipitating dislocation.8a 7 maintenance of MMF for the prescribed period has
proven challenging for some individuals. 23
THERAPY The suboptimal efficacy of these relatively conserva-
The treatments of recurrent dislocation may be orga- tive treatments led to the concept of "strengthening"
nized according to the stability factors into (1) alter- the ligaments by surgical intervention. This particular
ation of the ligaments, (2) alteration of the associated procedure has been advocated for people with exces-
musculature, and (3) alteration of the bony anatomy.25 sive overclosure caused by loss of the dentition,
Each will be addressed in turn. followed by chronic subluxation that later progressed
into recurrent dislocation. Attempts to strengthen the
Ligament alteration capsular ligament were initially accomplished by sur-
One treatment modality affecting ligament function is gically exposing the fascia of the temporalis muscle
the introduction of a sclerosing agent into the capsular and suturing a flap of fascia onto the capsular liga-
space of the TMJ. The therapeutic intent is to cause ment. u Others have advocated capsular plication. 24-26
fibrosis with resultant tightening of the capsule. 6,13,18In In 1945, Hudson 25 described this technique that used a
effect, this procedure could prevent or limit exaggerated preauricular approach to the capsular ligament, fol-
condylar movement. Alcohol, Rivanol (aethacridin), lowed by an incision vertically through the body of the
5% sodium psylliate (Sylnasol), sodium morrhuate, 3% ligament. The incision margins were then overlapped
sodium tetradecyl sulfate, and autologous blood have and sutured. A disadvantage to this therapy is violation
been used individually as sclerosing agents. 13a5.18-20 of the intracapsular space, which can produce compli-
The reviewed literature reported 135 patients treated by cations such as hemarthrosis, degenerative changes to
intracapsular injection of one of these substances, with the joint, or both. 27 This problem may be circumvented
a cumulative cure rate of 72%. Length of follow-up by simply placing silk sutures along the inferior aspect
ranged from 0 to 18 months, with no long-term out- of the ligament, with a short subsequent period of
comes reported. MME 24 If additional tightening of the joint capsule is
According to Schultz, 13 several hundred patients needed, then the procedure may further be modified to
were treated by sclerosis under his direction without incorporate ligamentorrhaphy. Ligamentorrhaphy
any complications or deleterious effects; however, no involves the surgical fixation (or anchoring) of the
record of patient selection, length of follow-up, and lateral ligament of the capsule to the periosteum of the
type of follow-up was documented. The administration overlying zygomatic arch, followed by MMF for 1
of sclerosing agents is associated with side effects, week. Fabrication of a prosthesis to reestablish proper
which may include pain, muscle tenderness, occlusal vertical dimension of occlusion has been recom-
disharmony or malocclusion, temporary nerve paresis, mended to reduce recurrence. 12 We found only 12
and excessive salivation. 6.15 Some authors reasoned capsular plications reported in the English literature.
that the stronger the reaction of the body to the scle- All 12 operations proved "successful," with reported
rosant, the more effective the treatment. 6 However, in follow-up periods ranging from 4 months to 5 years,
order to maintain freedom from dislocation, multiple except for 1 case, which was followed for 11 years. 12,24
treatments are often necessary) 3 Exaggerated mouth Its true efficacy awaits the report of a larger series with
opening (eg, yawning) may threaten the integrity of the long-term follow-up.
fibrosis and release the limitation achieved, resulting in
recurrent dislocation or subluxation. 13 For this reason, Muscle alteration
sclerosing agents may be considered reversible and The second classification of treatment involves the
may best be limited to patients with "lax" capsular alteration of TMJ-associated musculature. Active phys-
ligaments in whom surgery would be hazardous.6,15 ical therapy has been advocated for patients afflicted
664 Shorey and Campbell ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
June 2000

with habitual dislocation. 9 Strengthening the supra- A potential advantage of the Georgiade method is that
hyoid muscles to counterbalance the action of the the Dacron mesh suture may provide a medium for
lateral pterygoid muscles could theoretically reduce the fibrous tissue penetration. However, long-term efficacy
likelihood of dislocation. The equipment to perform of this procedure has not been reported.
this type of physiotherapy, however, is elaborate and Closed condylotomy has likewise been performed to
involves considerable compliance by the patient. indirectly affect the lateral pterygoid muscle. 3°,31 This
A more recently reported treatment modality for intraoral procedure bisects the condylar neck with a
alteration of the musculature is the use of type A botu- Gigli saw. The condylar head typically displaces in an
linum toxin (BTA). Botulinum toxin is derived from anteromedial direction, thus eliminating the effect of
the anaerobic, gram-positive rod clostridium botu- spasticity of the lateral pterygoid muscle. Of patients
linum, and type A is 1 of 8 types currently recog- who underwent this procedure, 81% were reported to
nized. 28 An extraoral preauricular transcutaneous be free of dislocation, according to a follow-up ques-
approach to injection (similar to the administration of tionnaire with a reported follow-up of 1 to 6 years.
sclerosing agents) is recommended. The site of injec- However, the usefulness of this intervention has been
tion is approximately 1 cm anterior to the condyle in a limited by the potential for serious bleeding from the
slightly opened-mouth position. Electromyogram internal maxillary artery.
monitors facilitate-the location of the needle into the In contrast to any indirect approach, the bilateral
lateral pterygoid~muscle. Once the tip of the needle is release of the lateral pterygoid muscles will directly
in position and is aspirated to ensure no blood vessel alter the musculature. 32 This procedure involves exci-
penetration, an appropriate amount of BTA (usually up sion of the insertion of the lateral pterygoid muscle at
to 500 mouse units [MU]) is injected. The intended the condylar neck and joint capsule. The operation
effect of the BTA is to weaken the lateral pterygoid attempts to disable the lateral pterygoid muscles,
muscles sufficiently to prevent dislocations, while allowing only rotational movement of the condyle.
producing only slight impairment to maximal opening. This is accomplished from an intraoral approach,
It does not appear to have an immediate effect, followed by MMF for 7 to 10 days. Only 5 cases were
requiring 4 to 5 days after administration before onset reported, with a maximal follow-up period of 18
of relief. BTA is a temporary and completely reversible months. However, the authors reported no recurrence.
treatment for recurrent dislocation. Multiple injections, Its disadvantages include difficulty in visualization
given every 2 to 4 months (maximum 1013MU each), and the risk of bleeding in this highly vascular site.
may be necessary to achieve long-term effects. For Muscle tissue may reattach during healing, placing the
obvious reasons this therapy is contraindicated in long-term efficacy of the procedure in doubt.
patients with diseases that impair neuromuscular func- Another direct intraoral procedure involves scarifica-
tion (eg, myasthenia gravis). It has been reported that tion of the temporalis tendon at its area of insertion,
treating oromandibular dystonia with BTA injected along the ascending ramus. 33 In this procedure, the
into the lateral pterygoid muscle resulted in a transient majority of the tendinous fibers are stripped from the
dysphagia in 8% of the patients. 28 Only one case report ramus and sutured to the reflected periosteum and oral
has been documented in regard to the treatment of mucosa in a fashion that creates tissue disorientation
recurrent dislocation; a controlled clinical trial has yet and subsequent scar formation. Theoretically, this
to prove evidence of its efficacy.28 suturing technique will create a horizontal scar, which
Alteration of the jaw opening musculature can also may tighten the tendon and limit the range of motion. 34
be performed surgically, either by a direct or an indi- This procedure is highly technique-sensitive, and
rect approach. Indirect approaches involve ligating the complications include profound swelling (lasting 5-10
mandible to the craniofacial complex to limit the extent days) and buccal nerve hypoesthesia, caused by the
of muscular movement. 29 The ligation of the coronoid location of the intraoral incision.33, 34 No long-term
process to the zygomatic arch with either wire or studies have been conducted to ascertain the efficacy of
animal tendon of slow absorbability has been this procedure. In addition, only 11 cases have been
reported. 11 In 1965, Georgiade29 modified the proce- reported to date. Gould 34 commented on a gradual
dure by drilling small holes into the extracapsular trend toward relapse after analyzing similarly-treated
portion of the condylar neck and through the zygo- patients at l-year follow-up appointments. 34,35 Five
matic arch just anterior to the articular tubercle. A days after surgery, the interincisal distance measure-
Dacron (Mersilene) mesh suture was threaded through ment began to increase in 100% of patients followed.
the 2 holes and tightened enough to prevent dislocation This 5-day period was confluent with the period of
by manipulating the mandible under direct vision. This reported edema, which strongly suggests that this
procedure may be done bilaterally and without MMF. procedure does not produce the desired effect.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Shorey and Campbell 665
Volume 89, Number 6

Bony alteration tion. 49 The mediolateral relationship of the condylar

The third methodology for treatment of habitual head to the glenoid fossa and zygomatic arch should be
dislocation involves alteration of the bony anatomy. 15 assessed before surgery to assure that the arch will actu-
In 1883, Reidel performed the first condylectomy for ally engage the condyle. Overall, a cure rate of 91% was
the treatment of dislocation, and this procedure was reported among a total of 58 cases, with a recurrence of
subsequently advocated by Henny and Baldridge. 9,36 only 9%. Approximately 5% of patients incurred a
The resulting pseudoarthrosis (or nearthrosis) may zygomatic arch fracture, 8% reported to have temporary
limit the range of mandibular motion.9,37 facial nerve paresis, and 7% complained of postopera-
In 1933, Mayer 38 was the first to describe the tive pain and clicking of the TMJ. Follow-up periods
displacement of the zygomatic arch to augment the ranged from 6 months to 5 years.
articular eminence and obstruct the path of the trans- Iliac or calvarial bone grafts may also be used to
lating condyle. Leclerc and Girard modified the proce- augment the articular eminence for prevention of dislo-
dure, and Dautrey further altered the technique. 39-42 cation.27,50 After reflecting the periosteum from the
The Dautrey procedure was designed to avoid interfer- zygomatic arch and articular eminence, the capsule can
ence with normal movements, but to prevent abnormal be displaced posteriorly to create a space for graft
forward excursive movements. 21 A preauricular inci- placement. Alternatively, various osteotomies of the
sion exposes the zygomatic arch and capsular ligament, zygomatic arch may be performed for graft insertion.
the periosteum is reflected from the arch, and an Variable degrees of iliac bone graft resorption have
oblique osteotomy is performed on the zygomatic arch. been reported,46,51 whereas calvarial grafts have been
A greenstick fracture should occur at the zygomatico- suggested to show no appreciable lOSS.46 However, use
temporal suture, thus giving the segment some rebound of the cranium as a donor site is not without complica-
elasticity to provide stability in its altered position. 39 tion. Dural tears, arachnoid bleeding with subsequent
MMF is not necessary for postoperative stability. 39,42,43 hematoma, and scalp infections are possible adverse
This procedure may be advantageous in that it does not sequelae. 52 A severe decrease in maximal opening has
violate the joint space and allows immediate, normal been reported as another potential complication. 27 In
anterior movement with little limitation in maximal comparing reported cases of iliac crest bone grafts and
opening. The main disadvantage is the risk of fracture calvarial grafts, 6 of 39 iliac crest grafts had a recur-
of the distal segment, which might require bone plate or rence of dislocation. All 12 calvarial grafts were
wire fixation. 23,44,45 Iizuka et al21 recommended that without recurrence. However, the length of follow-up
care be taken to avoid reflection of periosteum from the was staggered, with the iliac crest grafts reporting a
zygomatico-temporal suture, lest a true fracture result follow-up of 1 to 14 years and the calvarial grafts
when repositioning the arch. 21,44 In order to prevent or reporting a follow-up of 5 to 20 months.
reduce the likelihood of sutural fracture, this procedure In light of possible resorption of iliac grafts, Whear
should only be attempted in younger individuals (under et a153 advocated the use of bovine cartilage (chon-
age 40, approximately) because of increasing brittle- droplast). Of 7 cases performed, there were no reports
ness of the skeletal system with age. 43,46 One study, of recurrent dislocation. Length of follow-up, however,
however, reported that even with complete fracture of was not indicated. According to the authors, cartilage is
the distal segment, the use of wire or bone plate fixation dimensionally stable when used as a graft material, and
did not present any complications and held the distal the gradual calcification of the graft can further
segment in place. 39 enhance its stability.
Another potential problem associated with the The use of L-shaped pins, vitallium mesh implants,
Dautrey procedure is the resorption of the distal and miniplates to enhance the eminence have been
segment. 45,47 Bone resorption (and remodeling) was reported in the literature. 54-57 Accumulating evidence
noted radiographically on follow-up studies in all the indicates that these appliances are prone to fracturing
patients from one study. 42 In another article, the interin- or loosening under functional loads. 56,57 Destruction of
cisal distance was reported to increase over many the anterior portion of the condylar head has also been
months after surgery, which may indicate resorption of reported as a possible complication. 57
the down-fractured segment. 21,48 Another reported The incorporation of silicone blocks has been advo-
disadvantage is that the arch tends to engage only the cated in similar osteotomy procedures. 58 The allo-
lateral third of the condylar head with mandibular plastic material, trimmed into the shape of a wedge,
movement. 49 An attempt to place the down-fractured may be inserted into the surgically developed space.
arch as far medially as possible is necessary to fully Twenty-three joints were operated on with this proce-
engage the translating condyle, and fixation of the dure, with no recurrence noted after a follow-up period
segment may be necessary to stabilize this medial posi- ranging from 1 to 4 years. However, this material may
666 Shorey and Campbell ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
June 2000

]able I. Comparisons of reported treatment modalities mended to avoid the possibility of sepsis. 66 The poten-
No. o f Follow- % without tial postoperative complications of eminectomy are
Procedure cases up recurrence recurrent subluxation and the formation of osteo-
Sclerosing agent6,13A8 135 0-18 mo 72% phytes, along with crepitus and pain. 67,68 Subluxation
Intermaxillary fixation9,11,21,22 6 NRD NRD may be prevented in some instances by subsequent scar
Capsular plication 24-26 12 4 mo-5 y 100% formation around the joint. 7,69 The formation of osteo-
Physical therapy9 NRD NRD NRD phytes has been observed many years after surgery and
Botox injections 28 1 20 mo NRD
can produce mild crepitus. 68 Postoperative crepitus and
Ligation of mandible 11,29 7 NRD NRD
Condylotomy30,31 21 1-6 y 81% pain may be alleviated by smoothing the roughened
Lateral pterygoid myotomy32 5 2-18 mo 100% bony surface and by active postoperative physical
Muscle scarification 33-35 11 Up to 1 y NRD therapy. 67,7° A loss of condylar guidance is expected,
Condylectomy36, 37 NRD NRD NRD either partially or completely. Reportedly, the joint
Zygomatic arch down- 58 6 too-5 y 91%
fracture21,23,38-45,47-49
remains clinically stable, without gross deficiency in
Iliac crest bone graft27,46,50 39 1-14 y 65% mastication. 71 According to the literature, 175 cases
Calvarial bone graft50,51 12 5-20 mo 100% have been reported. Of these, 95% were free of recur-
Chondroplast52 7 NRD 100% rence, with follow-up ranging from 4 months to 9
Metallic implants53-57 22 1 mo-2.5 y 95% years, and only 5% of cases had recurrence of disloca-
Synthetic, nonmetallic alloplasts58 23 1-4 y 100%
Eminectomy5,7,10,11,35,59-74 175 4 mo-9 y 95%
tion. Approximately 12% of cases reported temporary
facial nerve paresis, and less than 5% showed crepitus
NRD, No reported data.
caused by radiographic osteophytes. The eminectomy
procedure has been recommended for patients who
habitually dislocate and have a disability that inhibits
act as a foreign body, may elicit an immune reaction, controlled muscular movements (eg, Parkinson's
and could also be displaced as a result of functional disease, multiple sclerosis, and Huntington's chorea)
movements. 53 Similar problems of displacement were and for patients undergoing neuroleptic drug therapy,
reported with porous coralline hydroxyapatite placed which can cause akinesia and dyskinesia. 14,72
into the space. 59 Overall, eminences augmented by
either the zygomatic downfracture procedure or inter- SUMMARY
positional grafts probably act initially as a mechanical Many treatment modalities are available for mitiga-
block, but long-term success may be focused around tion of pain and dysfunction of the habitually dislo-
the formation of a surgical scar. 45 cating temporomandibular joint. In most cases, more
Another treatment modality that involves the alter- conservative methods provide only temporary allevia-
ation of bony anatomy is the reduction of the articular tion of symptoms, and recurrence is common. Surgical
eminence, otherwise known as eminectomy. 5,60-64 In intervention has generally been considered the more
1951, Myrhaug 11 first reported eminectomy for treat- effective definitive treatment. No matter which surgical
ment of recurrent dislocation. He rationalized that intervention is undertaken, it should be realized that
removal of the obstacle (ie, the articular eminence) in postoperative scarring probably provides a significant
the path of the condyle would eliminate the possibility portion of the surgical benefit. Evidence suggests that
of dislocation. Blankestijn et a135 further modified immobilizing the joint after any surgical procedure will
Myrhaug's procedure by exposing the eminence result in fibrosis, which may make assessment of effi-
without violating the intracapsular space. cacy of the actual surgical procedure difficult. Some
When treating a case of failed bilateral eminectomy, authors have claimed that signs of recurrence were
Loh and Yeo23 observed that the most medial portion of related to early mobilization of the joint and that MMF
the eminence had not been reduced. The removal of the is always indicated.
entire eminence was subsequently recommended True comparisons of the reported treatment morali-
because the condyle interacts intimately with the ties are difficult because of differing periods of follow-
medial portion of the eminence. However, surgical up and different definitions of success (Table I).
access to this area is difficult and may account for at Several factors should suggest caution before using
least some operative failures. 58 some of the procedures reviewed here. Studies that do
Potential anatomic complications of the eminectomy not report length of follow-up, or that report follow-up
procedure include pneumatization of the eminence and less than 1 year, should not be viewed as other than
resultant dural tear during its removal. 65,66 The pilot data. Likewise, series incorporating fewer than 25
frequency of such occurrences are rare; however, the patients should be viewed with caution. Techniques
administration of parenteral antibiotics is recom- reported in only 1 series with a single clinician may not
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Shorey and Campbell 667
Volume 89, Number 6

a c h i e v e t h e s a m e results w h e n a p p l i e d b y others. T h e 14. Undt G, Weichselbraun A, Wagner A, Kermer C, Rasse M.

l i k e l i h o o d o f p e r m a n e n t a d v e r s e s e q u e l a e or n e e d f o r Recurrent mandibular dislocation under neuroleptic drug
therapy, treated by bilateral eminectomy. J Craniomaxillofac
r e p e a t s u r g e r y s h o u l d w e i g h h e a v i l y in t h e d e c i s i o n to Surg 1996;24:184-8.
u s e a n y t r e a t m e n t modality. 15. Leopard PJ. Surgery of the non-ankylosed temporomandibular
With these considerations in mind, we believe that joint. Br J Oral Maxillofac Surg 1987;25:138-48.
16. Bell WE. A biological approach to temporomandibular joint
certain treatment modalities should be avoided. subluxation. Dent Clin North Am 1959:779-90.
Sclerosing agents, in general, have an unacceptably 17. Dingman RO, Moorman WC. Meniscectomy in the treatment of
l o w r a t e o f s u c c e s s a n d s h o u l d .not b e c o n s i d e r e d lesions of the temporomandibular joint. J Oral Surg 1951;9:214-24.
18. Jacobi-Hermanns E, Wagner B, Tetsch E Investigations on
permanent treatment. The addition of MMF has not recurrent condyle dislocation in patients with temporo-
improved outcomes significantly. Capsular plications mandibular joint dysfunction: a therapeutical concept. Int J Oral
h a v e b e e n r e p o r t e d t o o r a r e l y to b e c o n s i d e r e d m a i n - Surg t981;10:318-23.
19. Littler BO. The role of local anesthetic in the reduction of long
s t r e a m t r e a t m e n t , as h a v e p h y s i c a l t h e r a p y a n d b o t u - standing dislocation of the temporomandibular joint. Br J Oral
linum toxin injection. Zygomatic arch downfracture, Surg 1980;18:81-5.
w i t h or w i t h o u t grafting, a p p e a r s to o f f e r a h i g h d e g r e e 20. Qiu WL, Ha Q, Hu QC. Treatment of habitual dislocation of the
temporomandibular joint with subsynovial injection of scle-
of resolution of dislocation, although the number of rosant through arthroscope. Proc Chinese Acad Med Sci &
r e p o r t e d c a s e s is less t h a n h a l f t h a t o f e m i n e c t o m y . Peking Union Med Coil 1989;4:196-9.
With an impressive success rate, we believe that 21. Iizuka T, Hidaka Y, Murakami K, Nishida M. Chronic recurrent
anterior luxation of the mandible. Int J Oral Maxillofac Surg
e m i n e c t o m y offers t h e b e s t c h a n c e f o r l o n g - t e r m r e s o - 1988; 17:170-2.
l u t i o n o f r e c u r r e n t d i s l o c a t i o n , p r o v i d e d t h a t c a r e is 22. Dingman RO, Constant E. A fifteen year experience with
t a k e n to c o m p l e t e l y r e m o v e t h e m o s t m e d i a l p o r t i o n o f temporomandibular joint disorders. Evaluation of 140 cases.
Plast Reconstr Surg 1969;44:119-24.
the eminence. 23. Loh FC, and Yet JE Subsequent treatment of chronic recurrent
Although additional studies may yield improved dislocation of the mandible after eminectomies. Int J Oral
t h e r a p e u t i c t e c h n i q u e s , it a p p e a r s t h a t s u r g i c a l i n t e r - Maxillofac Surg 1989;18:352-3.
24. Boudreaux R, Spire E. Plication of the capsular ligament of the
v e n t i o n c u r r e n t l y r e m a i n s t h e m a i n s t a y in m a n a g e m e n t temporomandibular joint: a surgical approach to recurrent dislo-
o f this u n c o m m o n c l i n i c a l entity. cation or chronic subluxation. J Oral Surg 1968;26:330-3.
25. Hudson HN. Operation for recurrent subluxation of temporo-
mandibular joint. Br Med J 1945;2:354.
26. MacFarlane WI. Recurrent dislocation of the mandible: treat-
REFERENCES ment of seven cases by a simple surgical method. Br J Oral Surg
1. Castle T. A manual of surgery. 3rd ed. Boston: Munroe and 1977; 14:227-9.
Francis; 1832. p. 355-8. 27. Rehrmann A, Kreidler J. Late results after arthroereisis of the
2. Caminiti ME Weinberg S. Chronic mandibular dislocation. The temporomandibular joint by autoplastic bone graft. J Maxillofac
role of nonsurgical and surgical treatment. J Can Dent Assoc Surg 1973;1:99-103.
1998;64:484-91. 28. Daelen B, Thorwirth V, Koch A. Treatment of recurrent disloca-
3. Gottlieb I. Long-standing dislocation of the jaw. J Oral Surg tion of the temporomandibular joint with type A botulinum
1952;10:25-32. toxin. Int J Oral Maxillofac Surg 1997;26:458-60.
4. Husted E. Surgical diseases of the temporomandibular joint. 29. Georgiade N. The surgical correction of chronic luxation of the
Acta Odont Scand 1956/57; 14:119-51. mandibular condyle. Plas Reconstr Surg 1965;36:339-42.
5. Irby W. Surgical correction of chronic dislocation of the 30. Albury CD. Modified condylotomy for chronic nonreducing
temporomandibular joint not responsive to conservative therapy. disk dislocations. Oral Surg Oral Med Oral Path Oral Radiol
J Oral Surg 1957;15:307-12. Endod 1997;84:234-40.
6. McKelvey LE. Sclerosing solution in the treatment of chronic 31. Tasanen A, Lamber MA. Closed condylotomy in the treatment
subluxation of the temporomandibular joint. J Oral Surg of recurrent dislocation of the mandibular condyle. Int J Oral
1950;8:225-36. Surg 1978;7:1-6.
7. Pogrel MA. Articular eminectomy for recurrent dislocation. Br J 32. Sindet-Pedersen S. Intraoral myotomy of the lateral pterygoid
Oral Maxillofac Surg 1987;25:237-43. muscle for treatment of recurrent dislocation of the mandibular
8. Kai S, Kai H, Wakayama E, Tobata O, Tashiro H, Miyajima T, condyle. J Oral Maxillofac Surg 1988;46:445-9.
et al. Clinical symptoms of open lock position of the condyle. 33. Maw RB, McKean TW. Scarification of the temporal tendon for
Relation to anterior dislocation of the temporomandibular joint. treatment of chronic subluxation of the temporomandibular
Oral Surg Oral Med Oral Path 1992;74:143-8. joint. J Oral Surg 1973;1:22-5.
9. Hale RH. Treatment of recurrent dislocation of the mandible. 34. Gould JR Shortening of the temporalis tendon for hypermobility
Review of literature and report of cases. J Oral Surg of the temporomandibular joint. J Oral Surg 1978;36:781-3.
1972;30:527-30. 35. Blankestijn J, Boering G. Myrhaug's operation for treating
10. Lovely FW, Copeland RA. Reduction eminoplasty for chronic recurrent dislocation of the temporomandibular joint. J
recurrent luxation of the temporomandibular joint. J Can Dent Craniomandibular Prac 1985;3:246-50.
Assoc 1981;3:179-84. 36. Henny FA, Baldridge OL. Condylectomy for persistent painful
11. Myrhaug H. New method of operation for habitual dislocation of temporomandibular joint. J Oral Surg 1957;15:24-7.
mandible. Acta Odontol Scand 1951 ;9:247-61. 37. Wijmenga JPH, Boering G, Blankestijn J. Protracted dislocation
12. Sanders B, Newman R. Surgical treatment for recurrent disloca- of the temporomandibular joint. Int J Oral Maxillofac Surg
tion or chronic subluxation of the temporomandibular joint. Int 1986;15:380-8.
J Oral Surg 1975;4:179-83. 38. Mayer L. Recurrent dislocation of the jaw. J Bone Joint Surg
13. Schultz LW. Report of ten year's experience in treating hyper- 1933;15:889-96.
mobility of the temporomandibular joint. J Oral Surg 39. Chansse JM, Richter M, Bettex A. Deliberate, fixed extra artic-
1947;5:202-7. ular obstruction. Treatment of choice for subluxation and true
668 Shoreyand Campbell ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
June 2000

recurrent dislocation of the temporomandibular joint. J 60. Baumstark RJ, Harrington S, Markowitz NR. A simple method
Craniomaxillofac Surg 1987;15:137-40. of eminoplasty for correction of recurrent dislocation of the
40. Dantrey J. Reflexions sur la chirurgie de Farticulation temporo- mandible. J Oral Surg 1977;35:75-6.
mandibulaire. Acta Stomatol Belg 1975;72:577-81. 61. Frey VM, Zweig BE, Itkin AB. Surgical correction of chronic
4l. Leclerc GC, Girard C. Un nouveau procede de butee dans le dislocation of the mandible via eminectomy. Report of three
traitement chirurgical de la luxation recidivante de la machoire cases. Clin Prey Dent 1984;6:13-7.
inferieure. Mem Acad Chit 1943;69:437-59. 62. Kerstens HCJ, Tuinzing DB, van der Kwast WAM. Eminectomy
42. Undt G, Kermer C, Piehslinger E, Rasse M. Treatment of recur- and discoplasty for correction of the displaced temporo-
rent mandibular dislocation, part I: Leclerc blocking procedure. mandibular joint disc. J Oral Maxillofac Surg 1989;47:150-2.
Int J Oral Maxillofac Surg 1997;26:92-7. 63. Kwast van der WAM. Surgical management of habitual luxation
43. Lawlor MG. Recurrent dislocation of the mandible: treatment of of the mandible, lnt J Oral Surg 1978;7:329-32.
ten cases by the Dautrey procedure. Br J Oral Surg 1982;20:14-21. 64. Mizuno A, Suzuki S, Motegi K. Articular eminectomy for long-
44. Srivastava D, Rajadnya M, Chaudhary MK, Srivastava L. The standing luxation of the mandible: report of two cases. Int J Oral
Dautrey procedure in recurrent dislocation: a review of 12 cases. Maxillofac Surg 1988;17:303-6.
Int J Oral Maxillofac Surg 1994;23:229-31. 65. Oatis GW, Baker DA. The bilateral eminectomy as definitive
45. To EWH. A complication of the Dautrey procedure. Br J Oral treatment. A review of 44 patients. Int J Oral Surg 1984;13:294-8.
Maxillofac Surg 1991;29:100-1. 66. Sanders B, Frey N, McReynolds J. An evaluation of temporo-
46. Costas Lopez A, Monje Gil F, Fernandez Sanroman J, Goizueta mandibular articular eminence reduction as a treatment for recur-
Adame C, Castro Ruiz E Glenotemporal osteotomy as a definite rent dislocation and chronic subluxation. The potential benefits
treatment for recurrent dislocation of the jaw. J Cranio- versus the anatomical hazards. Oral Health 1980;70:30-4.
maxillofac Surg 1996;24:178-83. 67. Cherry CQ, Frew AL. Bilateral reductions of articular eminence
47. Smith WP. Recurrent dislocation of the temporomandibular for chronic dislocation: review of eight cases. J Oral Surg
joint. A new combined augmentation procedure. Int J Oral 1977:35:598-600.
Maxillofac Surg 1991 ;20:98-9. 68. Undt G, Kermer C, Rasse M. Treatment of recurrent mandibular
48. Ten Cate AR. Oral histology: development, structure, and func- dislocation, part II: eminectomy. Int J Oral Maxillofac Surg
tion. 4th ed. St Louis: CV Mosby; 1994. p.432. 1997;26:98-102.
49. Revington PJD. The Dautrey procedure--a case for reassess- 69. Westwood RM, Fox GL, Tilson HB. Eminectomy for the treat-
ment. Br J Oral Maxillofac Surg 1986:24:217-20. ment of recurrent temporomandibular joint dislocation. J Oral
50. Hammersley N. Chronic bilateral dislocation of the temporo- Surg 1975;33:774-9.
mandibular joint. Br J Oral Maxillofac Surg 1986;24:367-75. 70. Helmau J, Laufer D, Minkov B, Gutman D. Eminectomy as
51, Fernandez-Sanroman J. Surgical treatment of recurrent surgical treatment for chronic mandibular dislocations, lnt J Oral
mandibular dislocation by augmentation of the articular Surg 1984;13:486-9.
eminence with cranial bone. J Oral Maxillofac Surg 71. Weinberg S. Eminectomy and meniscorhaphy for internal
1997:55:333-8. derangements of the temporomandibular joint: rationale and
52.~ Jackson IT, Helden G, Marx R. Skull bone grafts in maxillofa- operative technique. Oral Surg Oral Med Oral Pathol
cial and craniofacial surgery. J Oral Maxillofac Surg 1986; 1984;57:241-9.
44:949-52. 72. Price RB. Surgical correction of recurrent dislocation of a
53. Whear NM, Langden JD, Macpherson DW. Temporomandibular mandibular condyle in a patient with Huntington's chorea: a
joint eminence augmentation by down-fracture and inter-posi- case report. Br J Oral Maxillofac Surg 1985;23:118-22.
tional cartilage graft. A new surgical technique. J Oral 73. Courtemanche AD, Son-Hing QR. Eminextomy for chronic
Maxillofac Surg 1991;20:357-9. recurring subluxation of the temporomandibular joint. Ann Plast
54. Buckley MJ, and Terry BC. Use of bone plates to manage Surg 1979;3:22-5.
chronic mandibular dislocation: report of cases. J Oral 74. Sensoz O, Ustuner ET, Celebioglu S, Mural M. Eminectomy for
Maxillofac Surg 1988;46:998-1002. the treatment of chronic subluxation and recurrent dislocation of
55. Findlay IA. Operation for attest of excessive condylar move- the temporomandibular joint and a new method of patient eval-
ment. J Oral Surg 1964;22:110-7. uation. Ann Plast Surg 1992;29:299-302.
56. Howe AG, Kent JN, Farrell CD, Poldmore SJ. Implant of artic-
ular eminence for recurrent dislocation of the temporo-
mandibular joint. J Oral Surg 1978;36:523-6.
57. Puelacher WC, Waldhart E. Miniplate eminoplasty: a new Reprint requests:
surgical treatment for TMJ-dislocation. J Craniomaxillofac Surg John H. Campbell, DDS, MS
1993;21:176-8. Assistant Professor
58. Schade GJ. Surgical treatment of habitual luxation of the Department of Oral Surgery, Medicine, and Pathology
temporomandibular joint. J MaxiUofac Surg 1977;5:146-50. Indiana University
59. Karabouta I. Increasing the articular eminence by the use of 1001 W 10th St, Room 4201
blocks of porous coralline hydroxyapatite for treatment of recur- Indianapolis, IN 46202
rent TMJ dislocation. J Craniomaxillofac Surg 1990; 18:107-9. johhcamp @ iupui.edu