Case 1

Figure 2. Distances from the cutaneous surface (in the proposed site of needle puncture) to both the lateral pterygoid plate and muscle belly are measured.

A 71 year old white female with a medical history significant for small cell lung carcinoma with brain metastasis presented for evaluation of chronic TMJ open lock. Her metastatic brain lesion had been previously treated with resection and radiation. Subsequent to this treatment, she had experienced parkinsonism with rigidity, bradykinesis, and oromandibular dystonia. She had been experiencing chronic temporomandibular joint dislocation associated with her oromandibular dystonia for three years prior to her presentation. Prior to her referral to our department she had been able to self-reduce all episodes in which she had dislocated her TMJ joint. Our first interaction with the patient was when she presented to the ED of one of our hospitals. At this time reduction of her dislocation was performed by the ED faculty with IV sedation. In the subsequent two months, the patient presented more than 10 times with dislocation for which she could not self-reduce. Traditional options at this time included: conscious limitation of opening which was unsuccessful, physically limiting her maximal incisal opening with elastic maxillomandibular fixation, or surgical intervention such as eminectomy. (Figure 2)

The patient’s medical status with Parkinson’s disease and intermittent dysphagia was a contraindication for MMF. While an eminectomy is only a moderately invasive procedure, the patient’s co-morbidities and overall health was a relative contraindication for any surgical intervention. Furthermore, the family was refusing any surgical intervention. This patient, therefore, was considered for management of her chronic dislocation with Botox. The patient had a prior CT scan from one of her ER visits, which was reviewed to determine the lengths from the skin to the belly of the lateral pterygoid muscle and the lateral pterygoid plate. These were found to be 33.35 mm 42.78 mm respectively (see Figure 2).

The patient was treated with our established treatment protocol (see Treatment Protocol). The patient experienced no additional episodes of TMJ dislocation after this treatment.