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 Table of Contents  
Year : 2022  |  Volume : 19  |  Issue : 2  |  Page : 96-100

Temporomandibular joint dislocation: A 7-year retrospective study in Two Nigerian Teaching Hospitals

1 Department of Dental and Maxillofacial Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
2 Department of Dental and Maxillofacial Surgery, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
3 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
4 Faculty of Dental Sciences, Department of Oral and Maxillofacial Surgery, Usmanu Danfodiyo University, Sokoto, Nigeria

Date of Submission23-Feb-2022
Date of Decision29-Apr-2022
Date of Acceptance19-May-2022
Date of Web Publication23-Nov-2022

Correspondence Address:
Moshood Folorunsho Adeyemi
Department of Dental and Maxillofacial Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Kwara State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njbcs.njbcs_15_22

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Context: Temporomandibular joint (TMJ) dislocation constitutes about 3% of all reported joint dislocations worldwide. The study presents our experience with TMJ dislocation and its management at two tertiary healthcare centers in Nigeria. Materials and Methods: A retrospective study of patients managed for TMJ dislocation at two healthcare facilities over a period of 7 years was conducted. The diagnosis was clinical with confirmation by radiographic findings. Bio-data, predisposing conditions, duration of onset of presenting complaints, and treatment techniques were documented. Cases were classified as unilateral (right or left) or bilateral and they were further sub-classified as acute (less than or equal to 2 weeks of presentation to the clinic), chronic (greater than 2 weeks of presentation to the clinic), or recurrent (more than one episode of dislocation before presentation). Results: A total of 25 cases were analyzed. There was a slight male preponderance 13 (52%) observed with a male/female ratio of 1.1: 1. The mean age is 35.52 ± 17.36 years and a range of 15-80 years. Majority 18 (72%) of the patients were diagnosed with acute TMJ dislocation. The principal predisposing factor was yawning 12 (48%) and most of the patients had bilateral TMJ dislocation 19 (76%). Hippocratic maneuver was the treatment main method of choice in 14 (56%) of the patients. Conclusion: Bilateral TMJ dislocation was the most common pattern seen in our environment.

Keywords: Dislocation, elastic traction, management, temporomandibular joint

How to cite this article:
Adeyemi MF, Ernest MA, Ibikunle AA, Taiwo AO, Ochingwa ID, Ile-Ogedengbe B. Temporomandibular joint dislocation: A 7-year retrospective study in Two Nigerian Teaching Hospitals. Niger J Basic Clin Sci 2022;19:96-100

How to cite this URL:
Adeyemi MF, Ernest MA, Ibikunle AA, Taiwo AO, Ochingwa ID, Ile-Ogedengbe B. Temporomandibular joint dislocation: A 7-year retrospective study in Two Nigerian Teaching Hospitals. Niger J Basic Clin Sci [serial online] 2022 [cited 2023 Jun 8];19:96-100. Available from: https://www.njbcs.net/text.asp?2022/19/2/96/361887

  Introduction Top

The Temporomandibular Joint (TMJ) is a ginglymo-diarthroidal synovial joint with peculiar characteristics, including translational and transitional.[1],[2],[3] Movement within the joint is highly controlled by a combination of musculoskeletal, neural, ligamental, and mechanical factors. A derangement in any of these factors may result in joint pathologies, including joint dislocation.[4] Subluxation and luxation are terms used to define displacement of the condylar head beyond the glenoid fossa.[3],[4],[5] However, subluxation indicates a form of dislocation that is self-reducible, while luxation refers to one in which the patient needs assistance in achieving reduction.[3],[4],[5]

TMJ dislocation constitutes about 3% of all reported joint dislocations worldwide.[6] The etiological factors include intrinsic factors such TMJ capsular laxity and shallow glenoid fossae; syndromic factors such as Marfan's and Ehlers Danlos syndrome.[3],[5],[7],[8],[9] Additionally, trauma and pharmacological factors have also been implicated.[8],[9],[10] Interestingly, physiological activities such as yawning has also been associated with it.[3],[8],[11] According to Okoje et al.[2] and Akinbami[8] TMJ dislocation may be classified as acute (less than or equal to 2 weeks at presentation to the clinic), chronic (greater than 2 weeks at presentation to the clinic), or recurrent (frequency of more than one episode at presentation). It may also be further classified as unilateral or bilateral.

However, it is often amenable to treatment, which may be conservative or invasive in nature.[8],[12] In spite of the availability of multiple treatment options for it, it still constitutes a significant source of debilitation to patients. The management of TMJ dislocation depends on a number of factors. These include, the type of dislocation, duration, its severity, available armamentarium, technological or skill limitations, etc.[2],[7],[13],[14] Regardless of the mode of treatment, the aim is always to restore form and function of the joint. The outcome of this study would add to the evidence based treatment options and the epidemiology of these conditions. It will also encourage early treatment. Delayed treatment would result into negative effect of quality of life and high risk of bony ankylosis. This will lead in long term to subsequent damage to the TMJ structure. This bi-center study aims to present the pattern of TMJ dislocation observed among patients managed for TMJ dislocation.

  Materials and Methods Top

A 7-year review of the management of TMJ dislocation across two tertiary healthcare institutions located in the Northwestern and North-central parts of Nigeria. The relevant records of patients who were managed on account of TMJ dislocation at the dental and maxillofacial departments of both hospitals between January 2012 and December 2018 were retrieved.

Ethical consideration

Approval to carry out this study was obtained from the research ethic committee of Kwara state ministry of health Ilorin to conduct the study with reference number ERC/MOH/2022/01/010. A written informed consent was obtained from the respondents. Information extracted from the patients records included demographic data, aetiology, relevant drug history such as antipsychotic drugs use, medical conditions such as epilepsy, duration of the condition before presentation in days, history of recurrence, treatment type, treatment outcome where applicable. The dislocations were classified as unilateral or bilateral, acute or chronic, and recurrent types. All diagnoses and classification were arrived at based on clinical and radiologic features. The radiologic evaluations were done using plane radiographs. They were further sub-classified as recurrent or isolated TMJ dislocation. Patients who had self-reducing TMJ dislocation were termed to have had subluxation and were excluded from this study.

TMJ dislocation that presented within a 14-day period of onset of injury was classified as acute, those that presented after a 14-day period of onset of injury were classified as chronic, while those who have had more than one episode before presentation were classified as recurrent based on Okoje et al.[2] and Akinbami.[8] Treatment offered include gag reflex, manual reduction alone, reduction and immobilization with elastic traction and surgical repositioning.

Descriptive analysis of the data retrieved was done and reported in frequencies, proportions, and ratios. The IBM SPSS Statistics for Windows, version 19 (IBM Corp., Armonk, N.Y., USA) was used in analysis.

  Results Top

A total of 25 patients, out of 30 patients were reviewed for TMJ dislocations. Five patients were excluded due to the incomplete nature of data obtained from their records. A male majority 13 (52%) was observed with a male/female ratio of 1.1: 1. The age distribution showed a mean age is 35.52 ± 17.36 years and a range of 15-80 years. The peak incidence was observed in the third decade of life 8 (32%), while the least incidence was seen in the 8th and 6th decades of life with only 1 (4%) case recorded for each age group [Figure 1]. Twelve (48%) of the patients presented within 24 hours of the incident [Figure 2]. Majority 18 (72%) of the patients were diagnosed with acute TMJ dislocation, having presented in less than or equal to 14 days of the incident and without prior history of such. A prevalence of 52% (13) of the patients had recurrent episode. The incidence of recurrence was higher in male 76.92% (10) compared to the female, 23.07% (3) respectively. A total of 5 (20%) patients gave history of use of antipsychotic drugs.
Figure 1: Depicts the age distribution of the patients

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Figure 2: Shows the distribution of the duration of symptoms before presentation

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The principal predisposing factor was yawning 12 (48%), followed by trauma 6 (24%), including sporting injury [Table 1]. Most of the patients had bilateral TMJ dislocation 19 (76%). Majority of the patients were classified as having acute TMJ dislocation 18 (72%), leaving 7 (28%) cases classified as chronic TMJ dislocation. Most of the cases were treated using the Hippocratic maneuver 14 (56%). Hippocratic maneuver alone or alongside adjuncts such as the use of sedatives, analgesics, muscle relaxants or local anesthesia was utilized in most of the cases in this series. The use of a posterior bite plane and application of supero-posteriorly directed traction was done in a few of the patients seen in this series Mandibular condylectomy was performed in one patient who had long-standing dislocation and a positive history of road traffic accident.
Table 1: Etiological Factors and Treatment Modalities

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Where Hippocratic maneuver was utilized, it was done under local anesthesia using 2% lignocaine 1:100,000 adrenaline [Table 1] through the intra-articular region using preauricular region as a landmark. Other treatment modalities were also used, especially in patients diagnosed with chronic TMJ dislocation [Table 1]. The treatment outcome; The incidence of recurrent dislocation reported in the study was 7 (50%) of patients and the majority within the group had more than one episode of recurrence. The least interval of recurrence reported in this study was 24 hrs, others ranged from 2 months to 5 years.

  Discussion Top

TMJ dislocation is a distressing condition that requires treatment within the shortest possible period following the incident.[14],[15],[16],[17],[18] Its management depends on adequate evaluation of the conditions with respect to its aetiology, mode of presentations, and associated clinical conditions.[17],[18]

The diagnosis of TMJ dislocation is often based on clinical presentation evidenced by protrusion of the mandible, drooling of saliva, inability to close the mouth, absence of condylar head in the mandibular fossa and pain or discomfort.[5],[8] However, the use of imaging techniques such as ultrasound and plain radiographs have been used as adjuncts.[19],[20] Moreover, advanced imaging techniques, including computed tomography scan and magnetic resonance imaging have also been utilized.[21] These come with attendant costs and in some cases, exposure to radiation.

Its presentation may be acute, chronic, or recurrent.[5],[8] Interestingly, the dislocation may remain unnoticed in some patients and patients may tolerate this condition for weeks or months.[21],[22] The time between dislocation and reduction is absolutely crucial because once dislocation has taken place, spasms of the masseter, and pterygoid muscles may worsen over time, causing the mandible to remain distracted in the dislocated position.[2],[3],[23] If no treatment occurs for more than 2 weeks, fibrosis and initiation of pathologic changes within and/or around the joint becomes increasingly probable.[5],[23]

A slight male dominance was seen in this study. This is in congruence with the reports of Ugboko et al.[3] and Agbara et al.[24] However, it is at dissonance with the reports by Okoje et al.[2] and Sang et al. who posted female dominance of 63.6% and 69%, respectively.[2],[3] Conversely, Papoutsis et al. reported a balanced gender distribution. The observation in this study may be due to the patriarchal nature of the societies in the vicinities of both hospitals.[11] Females are often secluded and frequently require male permission before seeking healthcare.[25],[26] Additionally, female economic empowerment is below par, hence females may find healthcare costs prohibitive.[21],[26],[27]

The age distribution observed in this study gives a mean value that is analogous to the values described in multiple studies.[2],[8],[26] Remarkably, while the peak age group of incidence seen in this study is similar to some reports, it differs significantly from the peak reported in a number of studies.[3],[12] Ugboko et al.[3] in a Nigerian study reported a peak age-group of 20-29 years, whereas Sang[12] reported the 3rd to 5th decades as the peak age-group of incidence.[3],[12]

Bilateral TMJ dislocation was seen more commonly than its unilateral counterpart. This is in congruence with the reports of various studies in the literature.[2],[16],[28] This observation may be related to the peculiar nature of the TMJs. The TMJs are unique in that they move synchronously, thus for appreciable movement to occur in one joint, there must be significant or commensurate movement in the contralateral joint. Moreover, traumatic events involving one side typically results in the transmission of the force to the contralateral joint.[29] Systemic predisposing factors are also likely to affect both joints in a similar way.

In this study, less than half of the patients presented within the first 24 hours. This is similar to the observations of several authors in this part of the world.[2],[24] This may be related to the penchant of patients to pursue unorthodox treatment of their ailments in our climes.[30],[31] It has been reported by several authors that patients often only seek orthodox healthcare after they have attempted other forms of treatments.

Yawning was the most commonly reported predisposing factor which is in congruence with multiple studies.[3],[12] However, it is in disagreement with the report by Güven.[16] It should be noted though, that the study by Guven was specific for patients who were managed for chronic recurrent TMJ dislocation.[21] It must be stated that trauma was the second most frequently cited causative event in this study. Trauma, as espoused in this study encompassed assault and road traffic accidents. It is therefore instructive that perhaps, controlled yawning and deliberate limitation of mouth opening during yawning would help in limiting the incidence of TMJ dislocation.

Hippocratic maneuver alone or alongside adjuncts such as the use of sedatives, analgesics, muscle relaxants, or local anesthesia was utilized in most of the cases in this series. This is similar to various studies.[32],[33] Many authors reported the use of Hippocratic maneuver, with or without adjuncts in the management of acute TMJ dislocation. However, in series limited to chronic or recurrent TMJ dislocation, surgical techniques including Dautrey's procedure and eminectomy have been more commonly performed.[5],[8],[26] Chronicity often results in the provocation of fibrosis in and around the joint, thus changing its anatomical outlook and reducing its conduciveness for the mandibular condylar head.[6],[30] Moreover, spasms occur in the muscles around the joint, making downward distraction of the mandible, which is necessary for repositioning difficult to achieve. This then results in recurrent dislocations or difficulty in repositioning the dislocated TMJ.

The use of a posterior bite plane and application of supero-posteriorly directed traction was done in a few of the patients seen in this series [Figure 3]a,[Figure 3]b,[Figure 3]c.[26] Characteristically, they all had long standing dislocations, which required the gradual resetting of the musculoskeletal TMJ apparatus. Authors have opined that the use of traction allows the musculoskeletal apparatus to gradually recondition itself, while returning to the normal anatomy.[34],[35] This gives time for spastic muscles to relax, lengthen and readapt to the status quo ante.
Figure 3: (a) TMJ dislocation at presentation. (b) Reduction of TMJ dislocation with Orthodontic Elastic Band. (c) Complete reduction of TMJ dislocation

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Mandibular condylectomy was performed in one patient who had long standing dislocation and a positive history of road traffic accident. He had an undiagnosed TMJ dislocation which he has sought care for without success. Furthermore, another case had unilateral coronoidectomy and reduction of the dislocated joint under general anesthesia. Such cases, especially those with traumatic aetiologies may have had an undiagnosed fracture dislocation which was not identified and managed early enough. This may then lead to accelerated consolidation around the TMJs, making reduction extremely difficult or impossible as the glenoid fossa becomes filled with fibrous tissue. While these procedures may be considered radical in nature, they are still utilized in certain cases.

Treatment of recurrent TMJ dislocation typically differs from what obtains for the acute and chronic forms. This includes the identification and management of the etiological factors such as occlusal, systemic and psychological problems. Typical conservative treatment may be unsuccessful, leaving the clinician little other choice than to perform a surgical intervention.[21],[36] Management methods include, capsulorrhaphy, meniscectomy, eminectomy, use of fascial slings, capsular ligament plication, mandibular condylectomy, and zygomatic arch down fracture. Despite this, the condition may still relapse after a while.[5],[21],[36]

  Conclusion Top

TMJ dislocation is a condition of clinical significance. It has a wide variety of etiological factors, the most prevalent of which is wide mouth opening often occasioned by yawning. Late presentation of this condition is a fairly common occurrence in our environment and could make its management difficult. This makes management of these cases quite daunting. The use of bite planes and traction, though not very commonly used in other climes, is still valuable in the management of this condition in our environment.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

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