Dislocation whether unilateral or bilateral
can be distressing. It imposes both
psychological and physiological trauma, leading
some victims, out of ignorance, to look for
treatment for what is purely physical, in the
metaphysical realms. This delays the right
treatment and can make what initially was a
simple case a complex one.
Proper understanding of the mechanism and
treatment of dislocation will go a long way to
save time, money and improper treatment. Some
have gone from one clinic to another and even to
quacks where injections are given with
unsterilized needles. In this era of HIV/AIDS
explosion, the risk of contracting infection is
high, hence the need for proper understanding
and prompt management of this condition.
CASE 1 : A 20-year-old secondary
school student, obviously distressed, with
worried family members reported on the 26th
April 1999. He had yawned and the mouth did not
close. It remained open for about a month during
which they had gone to some clinics and later to
native doctors. Some used hammer, others used
steam bath whereas some did incantations. The
parents were later advised to go to the
orthopedic hospital clinic. He eventually came
to the University of Nigeria Teaching Hospital
(UNTH) and was referred to the dental
clinic.
CASE 2 :This case is the
senior brother of the first case in a nuclear
family. He was aged 23 years. Reported on the
sixth day of the dislocation. History showed
that it was triggered off by vomiting as a
result of sickness (self-diagnosed malaria). He
was a student of a polytechnic and reported at
the medical center where the doctor expressed
his inability to help. He took no drugs but
contacted the junior brother who had a similar
episode, who then brought him down to Enugu
immediately.
He has not been able to close his mouth and
he could not chew food and depended on foods
that could be swallowed without chewing. This
was the first time dislocation ever occurred on
him.
Teeth present 8-1 1-8
8-1 l-8
Oral hygiene was fair. Because of the
dislocation the lower third molar was
articulating with upper second molar. There was
obvious symmetry indicating bilateral
involvement of the two joints.
X-rays - TMJ views, PA. oblique lateral
right and left were ordered. There was a history
that their mother had a dislocation before she
got married. This information was elicited out
of curiosity when the second case occurred in
the same nuclear family in a space of 17
months.
MANAGEMENT
Treatment consisted of seating the patient
at a low level. The thumb of each hand was
wrapped (protected) to avoid injury from the
teeth when the mandible snaps into place. The
padded thumbs were then placed bilaterally on
the molars as far posteriorly as possible. The
fingers of the hands rested under the body of
the mandible near the symphisis. While this
direction of force was being applied, a backward
force was slowly utilized. The thumb served as a
fulcrum thus lowering the condyle below the
level of the crest of the eminence. The backward
force then placed the condyle n the gleniod
fossa
TREATMENT AND FIXATION
Immediately after the reduction was made,
the area around the joint was massaged and the
patient instructed to avoid opening the mouth to
any great extent. A bandage limiting the motion
of the jaw, yet allowed the patient some four
weeks freedom of mastication, speech and oral
hygiene. This allowed the healing and
contraction of the ligaments.
DISCUSSION
Dislocation : A dislocation may be defined
as variation from normal of the position of the
articulating surfaces of ajoint. There is an
attachment from every side that may be compared
to that of wires holding a tent pole in defiance
of force from any direction. However on some
occasions if the force is great there may be
resultant dislocation. In order for a
dislocation to occur, certain attachments must
release some tension, and consequently there
will be a strained ligament or fractured bone or
a combination of the two. In any form
dislocations are very painful and render the jaw
useless. There are six types of dislocations
each named for its direction of dislocation.
They are superior, posterior, medical, lateral,
inferior and anterior. The first three mentioned
are always associated with fractured bones,
whereas this is not necessarily true in
connection with the latter three named.
The anterior dislocation is by far the most
common, the other five being comparatively
infrequent.
Anatomy: The condylar process stands
up from the posterior part of the ramus and
forms the head and neck of the mandible. The
neck lies immediately anterior to the lobule of
the auricle, the head is in front of the tragus.
Note that the mouth cannot close while the
finger lies in this fossa.
Diagnosis of dislocation : There are
two important classes to making diagnosis:
Inability to close the mouth. Movement of them
is very limited and the mouth is held open,
extremely wide in complete bilateral case. The
unilateral case presents a picture of asymmetry.
The great pain expressed by the patient.
Pressing-the tips of index fingers over the
joint may feel a deep depression due to the
absence of the condyles.
Anterior dislocation : This type of
dislocation is seldom associated with a fracture
and may result from minor accidents.
Mastication, laughing, yawning, sneezing may
induce dislocation. As the mouth opens, the
anterior, superior surface of the condyle rocks
forward contacting the inferior distal surface
of the articular eminence. If, at this time,
some force such as opening the mouth too wide,
forces the condyle anterior to the crest of the
eminence, it becomes locked there with the
coronoid process locked beneath the zygomatic
process of the molar bone. The extreme pain
tends to cause greater muscle contraction;
therefore, in many cases a reduction is no easy
task. Most of the pain is derived from strained
ligaments.
There are two important factors which
influence the case of dislocation: I. The number
of previous dislocation encountered by the
patient 2. The length of time that each
dislocation was allowed to remain as such. In
this connection it is pertinent to recall a case
that resisted manual reduction even under
general anesthesia because the patient
erroneously believed it was the handiwork of
evil men and did not seek for orthodox treatment
for more than a year. In this type, effusion
into the joint, following the injury becomes
organized forming fibrous adhesions. Treatment
required open operation to devest adhesions must
be carried out.
MARKOWITZ and GERRY made a distinction
between complete and incomplete dislocation or
luxation by interpretation of x-rays. If the
condylar head is found to be in front of the
articular eminence but not in a superior
position, it is considered incomplete
dislocation or a subluxation; if the condytar
head is found to be in a position anterior and
superior to the crest of the articular eminence,
it is considered true dislocation or
luxation.
Treatment of chronic dislocation
Some authors advise against open operation
on the joint in chronic cases for fear of
possible ankylosis.
They advocate injection of 95 percent
alcohol and claimed success with several
stubborn cases. The injection is made
immediately against the capsular ligament but
not piercing it. The insertion of temporalis
muscle is also injected.
A third injection is made at the inserting
third of the masseter muscle. These injections
are made bilaterally. HELMAN et al. gave option
of eminectomy (reducing the angle of the plane
of the articular eminence) in chronic
dislocation. When the condyle is dislocated the
head of the condyle is locked just anterior to
the articular eminence. This surgical procedure
allows a normally smooth forward and backward
movement of the condyle as the patient opens and
closes. After reviewing eight cases so treated
they recommended the surgical procedure where
there is chronic dislocation of TMJ and
radiographic evidence of a deep glenoid fossa
and high pronounced eminence.
Bilateral dislocation is not a frequent
occurrence. To have occurred in two siblings
within a period of 17 months raises the question
whether there is a predilection to this
occurrence within this nuclear family. Since
there was history of this occurring to the
mother long before marriage, there is good
reason to suspect a greater susceptibility in
the family for this condition
SUMMARY
Two cases of bilateral dislocation occurred
in two brothers, aged 20 and 23 within a period
of seventeen months. The junior one was the
first victim in the month of April 1999 and the
senior brother later in November 2000. The first
was triggered by yawning whereas the second by
vomiting. Different types of dislocation,
diagnosis and management of dislocation is
presented. The occurrence in two siblings raises
the question of familial predisposition to
dislocation.
RESUME
Nous rapportons deux cas de dislocation
bilatérale chez deux frères ages
de 20 et 23 ans durant une période de 17
mois. Le cadet était le premier victime
de dislocation en avril 1999. lainé en
fut victime, plus tard, en novembre, 2000. Le
premier cas était consécutif
à un bâillement, alors que le
deuxième cas était suite à
un vomissement. Différents types de
dislocation sont présentés, ainsi
que le diagnostic et le traitement. La
présence de dislocation bilatérale
chez deux enfants dun même couple
soulève la question d'une
prédisposition la dislocation
bilatérale chez les membres de cette
famille.
MARKOWITZ HA, GERRY RG. Temporomandibular
joint disease. Oral Surg Oral Med Oral Pathol.
1950;3(1):75-117.
