Case 2

A 68 year old edentulous female presented to our department with a 12 month history of chronic dislocation of her left temporomandibular joint. The patient reported the onset of her dislocation to be secondary to the extraction of her dentition. The patient reported that after the extractions and placement of immediate dentures she had a persistent malocclusion and deviation of her chin to the right. She was referred to our practice by an outside OMFS who was unable to reduce her with IV sedation. A panoramic image demonstrated anterior dislocation of her left condyle. Chair side manual reduction was attempted without any success. Due to the duration of her dislocation, it was suspected that fibrosis might have occurred in the joint space and that manual reduction would likely be best accomplished in the OR under general anesthesia. It was also discussed with the patient that an open joint procedure may have to be utilized in order to properly reduce the condyle and prevent future occurrence. The patient was taken to the operating room and placed under general anesthesia with a nasoendotracheal tube and relaxed with a neuromuscular blocking agent.   Once under general anesthesia with muscular paralysis, the patient was reduced with manual manipulation. Confirmation of proper centric relation (CR) with seating of the left condyle in the glenoid fossa was confirmed by noting the correct fit and occlusion of her complete upper and lower dentures, which were fabricated prior to her initial dislocation. At this point, maxillomandibular fixation was chosen as the initial treatment option to allow for ligamentous restriction and cicratrization in the joint space to prevent repeated episodes. The patients upper and lower dentures were skeletally fixated with circumandibular and circumpalatal 24 gauge stainless steel wires, and the patient was placed into MMF utilizing arch bars (which had been secured to her existing dentures pre-operatively) and heavy elastics.

Post-operatively, the patient was maintained in MMF for 2 weeks and then placed into heavy guiding elastics. During this period, she was continually followed on a weekly basis to monitor for dislocation. While in heavy guiding elastics, the patient exhibited a recurrence of her dislocation. This was able to be reduced chair side and she was replaced in MMF. It was likely that significant muscular tone with possible spasm in her left pterygoid muscle was resulting in persistent dislocation of the left condyle.   The patient was treated with Botox per the described protocol and maintained in MMF for 1 week to allow for the Botox to take effect. The patient has remained stable without recurrent dislocation at continued follow-up.