Unrecognized bilateral temporomandibular joint dislocation after general anesthesia with a delay in diagnosis and management: a case report

Neonatal Temporomandibular Joint Dislocation: A Case Report and Literature Review

Neonatal temporomandibular joint (TMJ) dislocation is rare. The purpose of this study is to describe a case of neonatal TMJ dysfunction and to review the literature on this topic. A six-day-old female was seen with both parents for evaluation of a dislocating jaw. Her mother had been breastfeeding successfully but noticed that there was a noticeable click every time the baby swallowed. Her jaw came out and down as she fed and then returned to the normal position. Over the last few days, her mother felt that only one side was involved as her jaw movement seemed asymmetrical. Her primary care physician had witnessed the click during the sucking reflex. The patient had a normal appearance and was otherwise healthy. The pediatric otolaryngologist observed deviation of the jaw toward the left with a palpable click upon mouth opening and spontaneous reduction with mouth closing. The symptoms resolved over the following month. The literature review showed few cases of TMJ dislocation in infants, most of which described fixed dislocation related to vomiting or crying. Due to the development of the TMJ in infancy characterized by joint laxity and a flat mandibular fossa, malfunctioning of the hinge joint mechanism could be expected to be more common early in life.

Surgical Reduction of Chronic Bilateral Traumatic Dislocation of the Mandibular Condyles With Erosion of the Middle Fossa Floor: Case Report With Surgical Video

BACKGROUND

Dislocation of the mandibular condyle (MC) is not a common condition, but when a traumatic case involves erosion of the middle fossa floor, it becomes a much more complicated and even rarer pathology.

OBJECTIVE

To describe the management of traumatic dislocation of the MCs with erosion of the middle fossa floor. We provide a step-by-step surgical video demonstrating reestablishment of the condylar position and occlusion.

METHODS

A 65-yr-old woman with rheumatoid arthritis presented after a ground-level fall. She was admitted to the intensive care unit with simultaneous complex medical conditions, intubated, and medically treated for over a month. She was seen in outpatient follow-up 2 mo later and noted to have an anterior open bite and bilateral temporomandibular joint pain. Computed tomography of the face showed bilateral dislocation of the MCs with erosion of the middle fossa floor.

RESULTS

Open surgical treatment with bilateral eminectomies was performed to obtain adequate reduction, involving a multidisciplinary team including neurosurgery, oral-maxillofacial surgery, and otolaryngological surgery. She did well postoperatively.

CONCLUSION

Multiple factors predispose a patient to MC dislocation, but we believe the catalyst in this case was significant manipulation of the jaw during endotracheal intubation. A chronic postoperative open bite can lead to much more difficult treatment, given bony erosion and fibrotic tissue formation. This case highlights the challenges of diagnosis and treatment of a bilateral traumatic dislocation and provides a surgical video reference description of repair and resolution.

Evaluation of Temporomandibular Joint by Anesthetists in Florida When Conducting Orotracheal Intubation-A Pilot Study

Background: Orotracheal intubation has been considered a risk factor for the development or exacerbation of disorders related to the temporomandibular joint (TMJ). The objective of this pilot study was to evaluate TMJ assessment performed by anesthetists in Florida when conducting orotracheal intubation. Methods: An online questionnaire was created using Qualtrics. The survey included 22 questions related to demographics, TMJ related to anesthesia procedures, and education/awareness regarding TMJ related to intubation. Descriptive statistics and cross-tabulation analysis were performed. Results: One hundred and eight providers participated (mean 46 years-old ± 12; 59% female). About 50% reported to always evaluate TMJ prior non-emergency intubation. Of those, 56% used an alternative intubation technique based on the TMJ status and 60% never/rarely evaluated TMJ post-intubation. Twenty-five percent reported they did not know of possible intubation effects on TMJ and 47% reported that they did not receive adequate information/education on TMJ management related to intubation in school. After participation, 81% reported to be more aware of the importance of evaluating TMJ. Conclusions: Only half of the providers who frequently performed intubation in Florida evaluated TMJ prior to intubation. This survey increased the awareness regarding the importance of evaluating TMJ when conducting intubation. This may contribute to reducing TMJ issues associated with non-emergency intubations.

Bilateral Dislocation of Mandibular Condyles following General Anesthesia-An Overlooked Problem: A Case Report

Dislocation of mandibular condyles can occur following excessive mouth opening or traumatic injury to the temporomandibular joint. It can also occur during general anesthesia that at times may go un-noticed in the modern-day theater setup. Here, we describe a case of bilateral dislocation of mandibular condyle following orotracheal intubation for general anesthesia. Right condyle was dislocated into temporal fossa.

The Treatment of Temporomandibular Joint Dislocation

BACKGROUND

The estimated incidence of temporomandibular joint dislocation in Germany is at least 25/100 000 per year. A correct diagnosis and the initiation of appropriate treatment without delay are essential if permanent damage to the joint is to be avoided.

METHODS

This review is based on pertinent publications retrieved by a systematic search in the PubMed, Cochrane, Embase, and ZB Med databases.

RESULTS

The initial search yielded 24 650 hits; duplicates were removed and 136 studies were chosen for further analysis. The diagnosis of temporomandibular joint dislocation is generally made clinically from the finding of a lower jaw that is fixed in the open position. Acute dislocations are manually repositioned at once. The most common method is Hippocratic repositioning, in which the physician's thumb is placed laterally next to the teeth and the other fingers are placed on the lower surface of the lower jaw. The physician then exerts pressure, first caudally, then dorsally. Repositioning is carried out in two steps. For dislocations that have been present for a longer time, manual repositioning may be ineffective and surgery may be needed. Recurrent dislocation can be treated in a minimally invasive way with botulinum toxin injections or autologous blood therapy. Surgery may be needed if these methods are ineffective.

CONCLUSION

There have been no more than a few randomized, controlled trials of treatments for temporomandibular joint dislocation, in particular concerning minimally invasive and open surgical treatments, and therefore only limited evidence-based conclusions can be drawn. Nonetheless, the diagnostic and therapeutic standards that have been established in recent years have gained wide international acceptance.

Spontaneous Temporomandibular Joint Dislocation

Dislocation of the temporomandibular joint (TMJ) is the displacement of the head of the condyle from its normal position in the glenoid fossa. Anterior dislocations are the most common type of TMJ dislocations. Prognathism of the lower jaw, anterior crossbite, and open bite are the classic features in bilateral TMJ dislocations.The treatment of acute TMJ dislocation involves manual reduction with or without general anesthesia. The use of maxillomandibular fixation is reserved for chronic, more complex dislocations. Determining the presence of a predisposing factor is very important in guiding the correct treatment and management for this condition.The authors present a case of acute spontaneous temporomandibular joint dislocation where multiple predisposing factors were recognized, requiring treatment with maxillomandibular fixation after manual reduction.

Temporomandibular joint dislocation: a retrospective study from a Swiss urban emergency department

Purpose

Temporomandibular joint (TMJ) dislocation is an uncommon and debilitating condition of the facial skeleton. The condition may be traumatic or nontraumatic, in an acute or chronic form, and with bilateral or monolateral expression.

Patients and methods

In this study, conducted from May 2012 to July 2016, we retrospectively analyzed TMJ dislocations treated in the Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, by focusing on the following parameters: age, gender, reason, localization, frequency, and therapy.

Results

Thirty-two patients were included. The mean age was 42.06 years and there was no predominant gender. Most cases of TMJ dislocation were nontraumatic (93.7%). Dislocations were mostly bilateral (59.4%) and appeared in a chronic situation and with repetitive events (62.5%). Thirty-one patients received conservative treatment, which consists of reposition of the TMJ with (38.7%) or without (61.3%) analgosedation. Only one patient needed surgical reposition due to previous surgical treatment.

Conclusion

This is the first attempt to evaluate TMJ dislocations in Switzerland in an acute hospital setting. To our knowledge, there are no other studies that systematically analyze these injuries by focusing on the patients’ characteristics. Surgical reposition is only indicated in complicated and very rare situations. Conservative approaches are commonly used and should be exhausted before any surgery.

Reduction of bilateral dislocation of TMJ and Rendu Osler Weber syndrome: case report and physiopathological model

Temporomandibular joint dislocation (TMJ) is an infrequent clinical situation, representing 3% of all the human body’s dislocations. The etiological factors reported are associated to alterations typical of the joint or of the muscular-ligament apparatus, or to clinical conditions that may cause dislocation. We present the case of a 46-year-old patient with hereditary hemorrhagic telangiectasia with bilateral dislocation of the TMJ. There are several potential causes (antipsychotics, intubation, etc.) although the deposit of manganese in the basal ganglia that produce extrapyramidal symptoms could be the most consistent cause.

Delayed Management of Unrecognized Bilateral Temporomandibular Joint Dislocation: A Case Report

Temporomandibular joint (TMJ) dislocation is a common occurrence, but diagnosis can be missed if patients do not complain. Delayed presentation complicates the management of a straightforward reduction. We present a case of a 24-year-old man who had bilateral TMJ dislocation of unknown duration after motor vehicle accident. The accident left him bedridden with speech difficulty. He was totally dependent on Ryles' and percutaneous endoscopic gastrotomy tubes for feeding. Computed tomography revealed dislocation of condyles anterior to articular eminences. The bilateral TMJ dislocations were reduced surgically via bicoronal with preauricular extension approaches. However, the surgery was challenging due to tissue changes around the joint accompanied by masticatory muscles atrophy. Postoperatively, he was placed on intermaxillary fixation for 2 weeks followed by elastics training. Three months later, the patient's mastication returned completely to function. Delayed management of bilateral TMJ dislocation is undoubtedly challenging and somewhat frustrating; nevertheless, we manage to achieve satisfactory outcome in improving the patient's quality of life.

Implication of general anaesthetic and sedation techniques in temporomandibular joint disorders - a systematic review

The purpose of this study was to conduct a systematic review of the literature on temporomandibular joint damage directly related to general anaesthesia and sedation. We searched MEDLINE, SCOPUS and the COCHRANE Library for titles and abstracts containing terms related to the subject. The search delimiters were analytical and descriptive studies with abstracts in Spanish, German, English or French, with no time limit. The search was updated in January 2015. Of the 398 articles found, 89 were duplicates and only 28 were of interest. Of these, 23 (82.14%) were case and case series reports, 4 (14.28%) were longitudinal studies and 1 (3.57%) was a cross-sectional study. General anaesthesia and sedation are risk factors for temporomandibular joint damage because of the drop in muscle tone caused by the drugs employed and because of airway management manoeuvres involving the joint. Joint complications have been described with spontaneous ventilation as well as with ventilation assisted by a face or laryngeal mask and with intubation. They are more frequent in women and/or patients with previous temporomandibular problems. Proper assessment is required both before and after anaesthesia or sedation in order to foresee and avoid or minimize temporomandibular complications. The data should be treated with caution, as the evidence of case and case series reports is not of a high standard and the small number of analytical studies is not entirely comparable. General anaesthesia and sedation techniques can influence the onset of temporomandibular joint disorders. More studies are needed to provide better clinical evidence.

A Missed Case of Occult Bilateral Temporomandibular Dislocation Mistaken for Dystonia

A 24-year-old male with a history of psychiatric disorder and no prior significant temporomandibular joint (TMJ) pathology presented to the emergency department for “lockjaw.” Plain film X-rays of the mandible were read as unremarkable by an attending radiologist, leading to the initial diagnosis of medication-induced dystonic reaction. Following unsuccessful medical treatment a maxillofacial computed tomography (CT) was ordered. CT confirmed bilateral dislocation, illustrating the importance of clinical judgment, and limitations of certain radiographic images. The authors believe this case to be the first reported case in the medical literature of bilateral anterior TMJ dislocation with a false negative X-ray.