Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review

Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review

YIJOM-3700; No of Pages 5 Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2017.05.012, available online at http://...

882KB Sizes 31 Downloads 84 Views

YIJOM-3700; No of Pages 5

Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2017.05.012, available online at http://www.sciencedirect.com

Case Report TMJ Disorders

Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review

N. Srinath, D. N. Umashankar, C. Naik, J. Biradar Department of Oral and Maxillofacial Surgery, Krishnadevaraya College of Dental Sciences, Bangalore, Karnataka, India

N. Srinath, D.N. Umashankar, C. Naik, J. Biradar: Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review. Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx. ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Dislocation of the temporomandibular joint, which represents 3% of all dislocated joints reported in the body, occurs when the mandibular condyle is displaced anteriorly beyond the articular eminence. Although anterior dislocation of the mandibular condyle is well documented in the literature, superior, lateral, and posterior dislocation of the condyle is rare. Only a few reports documenting superolateral dislocation with anterior mandible fractures have been published in the past. However such dislocations without any associated fractures are even rarer. This report documents a case of superolateral dislocation of an intact mandible in a 48-year-old woman following a traumatic incident. This paper also reviews previously documented case reports and focuses on the causative mechanism, dynamics, and management of such dislocations.

Dislocation of the mandible is one of the earliest afflictions of the jaws to be described in the literature. Hippocrates, in the 5th century BC, described this condition and its management. His method of reduction has survived the ages and is used in modern times. In 1832, Sir Astley Cooper proposed principles for the diagnosis and treatment of dislocation of the lower jaw and coined the terms ‘subluxation’ (incomplete dislocation) and ‘luxation’ (complete dislocation). Subluxation is an incomplete joint dislocation in which the articular surfaces maintain partial contact

0901-5027/000001+05

and the condyle is able to return to the glenoid fossa voluntarily or aided by selfmanipulation. Dislocations can be either acute, which cannot be self-reduced, or chronic – also known as habitual or recurrent dislocation. Complete dislocation of the mandibular condyle may occur in four directions viz., anterior, posterior, lateral, and superior. Dislocation is more common in the anterior direction (owing to the pull of the lateral pterygoid muscle) than in the other three directions, which are rare. Lateral displacement of the intact mandibular

Key words: trauma; mandibular condyle; superolateral dislocation; temporomandibular joint. Accepted for publication 18 May 2017

condyle was first reported in 1849 by Robert and is a rare complication of injury to the mandible.1 A case of superolateral dislocation of the intact mandibular condyle (SDIMC) without a concomitant fracture of the mandible, occurring following a trauma, is reported herein. To date, 28 cases of superolateral dislocation have been documented in the English language literature, with only two of these cases showing such a dislocation without any associated facial fracture. This report reviews the literature on superolateral dislocation of the intact condyle, provides an

ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Srinath N, et al. Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.05.012

YIJOM-3700; No of Pages 5

2

Srinath et al.

insight into the possible causative mechanism, and provides information for the diagnosis and management of such cases. Case report

A 48-year-old woman was referred for the complaint of inability to open her mouth and chew for 2 days. The patient reported having fallen in the bathroom following an episode of fainting. The patient could not describe the exact nature of the trauma, but vaguely remembered having fallen against the left side of her face, following which there was bleeding through her right ear of brief duration. After evaluation by a neurosurgeon and otolaryngologist, the patient was referred to the department of oral and maxillofacial surgery. Clinical examination revealed lower facial asymmetry with the mandible deviated towards the right. There was a sutured wound over the chin and the patient had marked trismus with a maximum inter-incisal opening (MIO) of 7 mm. There was a noticeable prominence in the right pre-auricular region. An intraoral examination showed a grossly deranged occlusion with a crossbite on the right side (Fig. 1). There was no evidence of any tenderness or step deformity at the anterior mandible. A panoramic radiograph and postero-anterior radiographs of the skull obtained earlier were inconclusive. Computed tomography (CT) with three-dimensional reconstruction was performed. The CT scan revealed superolateral dislocation of the right mandibular condyle with no evidence of any fracture of the condyle, anterior mandible, or other facial bones (Figs 2 and 3). After an unsuccessful attempt at closed reduction under local anaesthesia, the patient was treated under general anaesthesia on day 4 post-injury. Bimanual reduction was successfully carried out by applying outward and downward pressure over the molar region, and the pre-injury occlusion was re-established. The MIO achieved intraoperatively was 39 mm. Maxillomandibular fixation (MMF) was applied for 10

Fig. 1. Intraoral photograph showing a grossly deranged occlusion with a crossbite on the right side and open bite on the left side.

Fig. 2. Three-dimensional CT image showing superolateral dislocation of the right condyle (yellow arrow).

Fig. 3. Axial section CT image showing superolateral dislocation of the right condyle (yellow arrow).

days, following which rigorous physiotherapy was started. At 3 weeks posttreatment, the patient’s occlusion was satisfactory (Fig. 4). At the 4-week follow-up, the patient’s mouth opening was 35 mm; however she continued to show deviation of the jaw to the right on mouth opening. Discussion Fig. 4. Intraoral photograph showing the occlusion at 3 weeks post-treatment.

A search of the PubMed database was performed to identify all relevant case

Please cite this article in press as: Srinath N, et al. Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.05.012

YIJOM-3700; No of Pages 5

Superolateral dislocation of the intact condyle reports published from 1969 to 2016. The following key words were used: superolateral dislocation; intact condyle; temporomandibular joint trauma; unusual dislocation. All case reports documenting superolateral dislocation with condylar fracture and those reporting anterosuperior dislocations were excluded from the review. A total of 17 publications documenting 28 cases of superolateral dislocation of the intact condyle were found (Table 1).1–17 Among these, only two cases had presented with dislocation without any associated facial fracture.2,3 Allen and Young proposed a classification for dislocation of the intact mandibular condyle.1 However this classification has been used inappropriately in cases with an associated fracture of the condyle, such as a sagittal split, where the lateral stump becomes lodged lateral to the zygomatic arch. For dislocation of the intact condyle, the authors propose that three terms be used judiciously: ‘superolateral dislocation’, in which the condyle is locked superiorly and lateral to the zygomatic arch; ‘superior dislocation’, in which the condyle fractures the glenoid fossa and communicates with the middle cranial fossa; and ‘anterosuperior dislocation’, in which the condyle is displaced anterosuperiorly but medial to the zygomatic arch. The reason for excluding superolateral dislocation with condyle fracture from the present review is that the management of such dislocations differs from that of the intact condyle and may require internal fixation of the condyle and/or prolonged MMF. Allen and Young classified superolateral dislocation of the intact condyle into two types: type I, lateral subluxation; and type II, complete dislocation, in which the condyle is forced laterally and then superiorly to enter the temporal fossa.1 Satoh et al. further classified type II into three subtypes, namely IIA, in which the condyle is not hooked above the zygomatic arch; IIB, in which the condyle is hooked above the zygomatic arch; and IIC, in which the condyle is lodged within the zygomatic arch which is fractured.4 With this classification, the case presented herein would be classified as IIA. In view of reported cases of SDIMC without associated fracture of the mandible, Tauro et al. suggested a modification to the existing classification, in which type II is complete dislocation with an associated fracture of the anterior mandible and type III is complete dislocation without an associated fracture of the anterior mandible.5 As per this classification, the case

presented herein falls into type III. Apart from this case, only four other such cases that fall into type III have been reported in the literature.2,3,6,7 SDIMC have commonly been reported in the younger age group (mean age 30.9 years). The female to male prevalence ratio was found to be 1:6, which clearly shows a male predominance. The most common aetiology was road traffic accidents (85.7%), followed by fall (14.3%). Eleven of the 28 cases of SDIMC identified were associated with bilateral superolateral dislocation with an anterior mandible fracture. Of all the SDIMC cases documented in the literature, four had no associated anterior mandible fracture. According to the classifications of Allen and Young1 and Satoh et al.4, nearly 82% of the cases were type II dislocation, with subtype B being the most common (75%), followed by subtype A (20.8%). Only one case that fits into type IIC has been reported to date.7 Li et al. suggested that the mandible rotates around a vertical axis for such an unusual dislocation to occur.6 Tauro et al. suggested that more than one impact is necessary for superolateral dislocation to occur, as the first impact would fracture the anterior mandible and the subsequent impact would force the condyle out of the glenoid fossa superolaterally.5 The present authors believe that four factors determine the type of dislocation: the anatomy of the condylar head, capsule of the temporomandibular joint, pterygoid and masseter muscles, and elasticity of the anterior mandible. In a partially open mouth position, the pterygomasseteric sling will provide a minimal splinting effect, which facilitates lateral dislocation of the condyle. This possibly explains the mechanism in the case presented herein, as the patient’s pterygoid and masseter muscles would have been in a relaxed position during the episode of transient loss of consciousness. The anterior mandible has to flex considerably for such a dislocation to occur without an associated fracture. All four reported cases of SDIMC without mandible fracture were in the younger age group. SDIMC without an associated fracture in a 48-year-old patient, as presented here, is surprising. There is general agreement among most authors that the first choice of treatment for SDIMC is closed reduction under suitable anaesthesia. Those cases not responding to closed reduction will require open reduction. However, the present authors consider it important to try to predict the success or failure of

3

closed reduction beforehand. The following factors may be useful to predict the difficulty of closed reduction: (1) The delay before definitive treatment. If the delay is more than 2 weeks, a satisfactory result with closed reduction is less likely. (2) The type of dislocation. Cases in which the condyle is lodged within the zygomatic arch (type IIC) or the condyle is hooked above the zygomatic arch (type IIB) are more likely to require open reduction than the other types (type I and type IIA). (3) The presence of an associated mandibular fracture. An anterior mandible fracture will facilitate closed reduction by manipulation. Out of the four cases reporting SDIMC without anterior mandible fracture, three required open reduction. (4) The age of the patient. The case presented here was that of a middle-aged patient with no other facial fracture. However the dislocation was type IIA and the patient received early treatment (4 days), which facilitated closed reduction. Some authors have used exposure of the angle of the mandible to apply traction using wires.8,9 Kim et al. used a percutaneous bone hook for traction at the sigmoid notch for the reduction of a dislocated condyle.10 Those cases not responding to open reduction methods eventually require a condylectomy. Postoperative MMF is necessary irrespective of the type of reduction method used. The duration of MMF will vary depending on the delay in treatment and the presence of associated fractures of the mandible. Amongst those authors who specified the duration of MMF, this varied from 1 week to 5 weeks. In the case presented here, MMF was applied for 10 days, and this was followed by physiotherapy. The prognosis of treatment depends upon regular follow-up and rigorous physiotherapy exercises in the post MMF period. Early treatment and a successful reduction will usually provide adequate mouth opening, as well as lateral excursion. However deviation of the mandible to the ipsilateral side while opening may persist, as such dislocation often occurs with avulsion of the lateral pterygoid muscle. This was observed in the case presented here at the 6-week follow-up. In summary, SDIMC is easily diagnosed based on clinical findings and the use of CT scans. Early intervention is more likely to give favourable results. Closed reduction under suitable anaesthesia is the first choice of treatment in such dislocations. The importance of a long follow-up and physiotherapy should not be underestimated.

Please cite this article in press as: Srinath N, et al. Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.05.012

Allen and Young (1969)

Age, years Sex Aetiology 1

Associated facial fracture

Side Type Subtype

16 50 36 22 30 31 48 42 28

M M M M M M M M M

RTA RTA RTA RTA RTA Fall RTA RTA RTA

25 Tauro et al. (2010)5 Hegde et al. (2010)2 32 Papadopoulos and Edwards (2010)7 16 12 Amaral et al. (2011) 15 Kim et al. (2013)10 54

M M M F M

RTA RTA RTA RTA RTA

Singh et al. (2013)9

22

M

RTA

Symphyseal and ZMC Right Parasymphyseal Left Parasymphyseal B/L Symphyseal Left Parasymphyseal Right Symphysis and right condyle Left Symphysis (B/L) and coronoid B/L Symphysis and right condyle Left Left zygoma, maxilla Left (no mandiblee) Symphysis Left None Left Right zygomatic arch (no mandible) Right Symphysis, right condyle, right ZMC, NOE, and frontal sinus Left Symphyseal B/L Left Right Left parasymphysis B/L

Gupta et al. (2014)13 Mishra and Mishra (2015)3

35 33 35 28 25 29 30 42

M M M F M F M M

RTA Fall RTA RTA RTA RTA RTA Fall

Symphyseal Right parasymphysis Left parasymphysis None Left parasymphysis, left ZMC, nasal Symphysis, maxillary dentoalveolar Symphysis, left Le Fort I Right incomplete parasymphysis fracture

B/L Left B/L Right Right Left B/L B/L

41 25 14 32 30

M M F M M

RTA Fall RTA RTA RTA

Symphysis, B/L Le Fort III, palatal split, NOE complex Symphysis Symphysis Symphysis Left parasymphysis

Left B/L B/L B/L Left

Ferguson et al. (1989)8 Satoh et al. (1994)4 Kapila and Lata (1996)11 Li et al. (2009)6

Rajkumar et al. (2015)14 Saikrishna et al. (2016)15 Patil et al. (2016)16 Sharma et al. (2016)17

b

Delay before Open/closed reduction of definitive treatment, days the condyle

MMF

I II I I II II II II II

– NS – – NS B A B B

8 15 <1 <1 <1 NS 13 7 NS

Closed Closed Closed Closed Closed Closedc Closedd Closed Closed

NS NS NS NS NS NS 3 weeks 3 weeks NS

II II II II I II

B B C B B

3 14 NS <1 4

Closed Open Open Closed Closede

NS 2 weeks 2 weeks 2 weeks 1 week

II

2

Closedc

NS

II II I II II II II NS

B (right) A (left) B B – B A A A NS

<1 NS NS NS NS NS NS 4

NS 4 weeks NS NS NS 4 weeks NS 3 weeks

II II II II II

B B B B B

7 2 4 3 20

Closed Closed Closed Open Closed Closed Closed Open (left) Closed (right) Open Closed Closed Closed Open

5 2 2 2 2

weeks weeks weeks weeks weeks

B/L, bilateral; F, female; M, male; MMF, maxillomandibular fixation; NOE, naso-orbito-ethmoidal; NS, not specified; RTA, road traffic accident; ZMC, zygomatico-maxillary complex. a Type: type I = lateral subluxation; type II = complete dislocation. b Subtypes of type II: A = condyle not hooked above the zygomatic arch; B = condyle hooked above the zygomatic arch; C = condyle lodged within the zygomatic arch which is fractured. c Angle region exposed for traction. d Required bilateral condylectomy later. e Using a bone hook.

Srinath et al.

Article

a

YIJOM-3700; No of Pages 5

4

Please cite this article in press as: Srinath N, et al. Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.05.012

Table 1. Review of 17 cases documented as superolateral dislocation of an intact mandibular condyle.

YIJOM-3700; No of Pages 5

Superolateral dislocation of the intact condyle Funding

None. Competing interests

6.

None. Ethical approval

7.

An exemption from ethical approval was granted by the Institutional Ethics Committee, since this is a case report. 8.

Patient consent

Written consent was obtained from the patient to publish the clinical photographs.

9.

References 1. Allen FJ, Young AH. Lateral displacement of the intact mandibular condyle. A report of five cases. Br J Oral Surg 1969;7:24–30. 2. Hegde S, Kamath VV, Deepa M, Priya A. Superolateral dislocation of the mandibular condyle not associated with fracture: a case report. J Maxillofac Oral Surg 2010;9:424– 7. 3. Mishra S, Mishra YC. Superolateral dislocation of the mandibular condyle: a series of seven cases. J Maxillofac Oral Surg 2015;14:943–8. 4. Satoh K, Suzuki H, Matsuzaki S. A type II lateral dislocation of bilateral intact mandibular condyles with a proposed new classification. Plast Reconstr Surg 1994;93:598– 602. 5. Tauro D, Lakshmi S, Mishra M. Superolateral dislocation of the mandibular condyle:

10.

11.

12.

13.

report of a case with review of literature and a proposed modification in the classification. Craniomaxillofac Trauma Reconstr 2010;3:119–23. Li Z, Li ZB, Shang ZJ, Wu ZX. An unusual type of superolateral dislocation of mandibular condyle: discussion of the causative mechanisms and clinical characteristics. J Oral Maxillofac Surg 2009;67:431–5. Papadopoulos H, Edwards RS. Superolateral dislocation of the condyle: report of a rare case. Int J Oral Maxillofac Surg 2010;39:508–10. Ferguson JW, Stewart IA, Whitley BD. Lateral displacement of the intact mandibular condyle. Review of literature and report of case with associated facial nerve palsy. J Craniomaxillofac Surg 1989;17:125–7. Singh V, Gupta P, Khatana S, Bhagol A. Superolateral dislocation of bilateral intact condyles—an unusual presentation: report of a case and review of literature. Craniomaxillofac Trauma Reconstr 2013;6:205–10. Kim BC, Kang Samayoa SR, Kim HJ. Reduction of superior-lateral intact mandibular condyle dislocation with bone traction hook. J Korean Assoc Oral Maxillofac Surg 2013;39:238–41. Kapila BK, Lata J. Superolateral dislocation of an intact mandibular condyle into the temporal fossa: a case report. J Trauma 1996;41:351–2. Amaral MB, Bueno SC, Silva AA, Mesquita RA. Superolateral dislocation of the intact mandibular condyle associated with panfacial fracture: a case report and literature review. Dent Traumatol 2011;27:235–40. Gupta A, Shah S, Garg R, Uppal SK, Mittal RK. Traumatic superolateral dislocation of intact mandibular condyle with symphyseal

14.

15.

16.

17.

5

segmental fracture—a case report. Journal of Evolution of Medical and Dental Sciences 2014;3:469–72. Rajkumar K, Sharma S, Singh V, Saini V. Bilaterally superolateral dislocation of intact mandibular condyle treated with unilateral open reduction and TMJ capsulorrhaphy: a rare case report and review of literature. University Journal of Dental Sciences (Aligahr Muslim University) 2015;1:67–70. Saikrishna D, Shyam Sundar S, Mamata KS. Superolateral dislocation of intact mandibular condyle: a case report and review of literature. J Maxillofac Oral Surg 2016;15:309–14. Patil SG, Patil BS, Joshi U, Rudagi BM, Aftab A. Superolateral dislocation of bilateral intact mandibular condyles: a rare case series. J Maxillofac Oral Surg 2017;16: http://dx.doi.org/10.1007/s12663212–8. 016-0928-0. Epub 2016 Jun 8. Sharma D, Khasgiwala A, Maheshwari B, Singh C, Shakya N. Superolateral dislocation of an intact mandibular condyle into the temporal fossa: case report and literature review. Dent Traumatol 2017;33:64–70. http://dx.doi.org/10.1111/edt.12282. Epub 2016 May 20.

Address: Charudatta Naik B-104 Ambika CHS V B Phadke Road Mulund East Mumbai 400081 Maharashtra India Tel.: +91 9819014417 E-mail: [email protected]

Please cite this article in press as: Srinath N, et al. Superolateral dislocation of the intact mandibular condyle: report of a rare case with a review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.05.012