ARTÍCULO CLÍNICO

 

Chronic recurring dislocation treatment: Norman glenotemporal osteotomy

Luxación crónica recidivante. Tratamiento: osteotomía glenotemporal de Norman

 

 

L. Pingarrón Martín¹, J.L. Cebrián Carretero², J. González Martín-Moro², J.M. López-Arcas¹, M. Chamorro Pons³, I. Navarro Cuellar¹, M. Burgueño García⁴

¹ Médico Residente.
² Médico Adjunto.
³ Jefe de Sección.
⁴ Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario La Paz, Madrid. España

Correspondence

 

 

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ABSTRACT

Background. Various surgical procedures have been used to limit mandible opening in patients with recurrent dislocations of the temporo mandible joint (TMJ). These include intracapsular injection of sclerosing agents and tethering of the mandible. Other methods include obstruction of the condylar translation by downfracturing the zygomatic arch or by bone graft augmentation of the tuberculum and creating a mechanical impediment using Vitallium mesh or a stainless steel pin.
Objective. To evaluate the author's experience in the treatment of recurrent dislocation of the mandible when both components, the osseous (eminence) and the muscular one (lateral pterigoideum), are treated.
Material and methods. From January 1997 to August 2008, twenty-five patientes, 30 years old of averaged age, are affected by recurrent luxation (> 3 episodes/year). Twenty-one of them are treated primarily and four of them because of recurrences. The operative procedure is developed under general anesthesia, incising along the zygomatic arch using blunt dissection so that the front wall of the articular capsule can be exposed completely. An L-shaped plate is fixed bicortically with pins.
Results. Radiological and clinical follow-up after the surgical treatment (6 to 36 months postoperatively) manifest the absence of lost graft, no recurrence, completed or partial pain remission, adequate mouth aperture and absence of important complications.
Conclusion. The technique described for restricting TMJ movements in cases of chronic dislocation is relatively simple. The function of the TMJ was immediately normalized and no supplementary treatment was necessary.

Key words: Recurrent dislocation; Recurrent luxation; Glenotemporal osteotomy; Temporo mandible joint; Mini plate.

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RESUMEN

Introducción: Varios procedimientos quirúrgicos se han utilizado para limitar la apertura mandibular en pacientes con luxaciones recidivantes de la articulación temporomandibular (ATM). Éstas incluyen la inyección de agentes esclerosantes y el bloqueo mecánico mandibular. Otros métodos se basan en bloquear la traslación del cóndilo mandibular mediante la fractura del arco zigomático o mediante injerto óseo con aumento de la eminencia articular y la creación de un impedimento mecánico usando malla de vitalio o tornillos de acero inoxidable.
Objetivo: Evaluar la experiencia de los autores en el tratamiento de las luxaciones recidivantes de mandíbula cuando se tratan ambos componentes: el óseo (eminencia) y el muscular (pterigoideo lateral).
Material y métodos: 25 pacientes afectados de luxación recidivante (> 3 episodios/año) entre Enero 1997-Agosto 2008 con una edad media de 30 años; 21 de ellos son tratados de manera primaria y 4 por recidivas. Se realiza la técnica quirúrgica bajo anestesia general, incidiendo a lo largo del arco zigomático con una disección roma hasta exponer la pared anterior de la cápsula articular. Colocación de placa en "L" con fijación bicortical con tornillos.
Resultados: Tras seguimiento radiológico y clínico tras la intervención (de 6 a 36 meses), se objetiva la ausencia de pérdidas de injerto, sin recidivas, remisión completa o parcial del dolor, buena apertura oral y ausencia de complicaciones importantes.
Conclusión: La técnica descrita para restringir los movimientos de la ATM en casos de la dislocación crónica es relativamente simple, normalizando la función articular de forma inmediata sin necesitar tratamiento suplementario.

Palabras clave: Luxación recidivante; Osteotomía glenotemporal; Articulación temporomandibular; Miniplaca.

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Introduction

Joint dislocation is defined by complete separation of the joint surfaces resulting in the abnormal position of the condyle, usually anterior, exceeding the eminence and unable to return to the joint phase.

Recurring mandible dislocation is a very common pathology that requires permanent treatment. Affected patients often travel from one emergency room to another to remedy these increasingly frequent and difficult to treat episodes.

Chronic dislocation of the temporo mandibular joint occurs frequently in patients with mental retardation (Sonnenberg et al., 1985; Becking and Tuinzing, 1991), those who have suffered brain damage (Ohkawa et al., 1996) and in those with various syndromes (Gay Escoda, 1987).

The physiopathalogical mechanism of these injuries is not clearly explained. Excluding pharmaceuticals that can cause extra pyramidal syndrome, parafunction and joint ligament dislocation are frequent causes of chronic condyle dislocation. Treatment methods for this pathology are very controversial and differ in their therapeutic and surgical approaches. These methods of restricting mandible movements include the lower fraction of the zygomatic arch and vitallium mesh or stainless steel pin implants.

Almost all of these approaches focus their attention on eliminating or augmenting joint eminence.¹

Glenotemporal osteotomy of Norman consists of a green stick osteotomy in the joint eminence. It is inferiorly dislocated to augment its vertical dimension and at the same time augment the eminent incline preventing anterior dislocation. ²

These two interventions deal with one of dislocations' causing factors, the bone, but they are not free from recurrences because the muscular component remains unaltered.

The lateral pterygoid muscle has a movable insertion in the neck of the jaw, in the capsule and the TMJ.

The sphenoid head is activated during the closing of the mandible during chewing, swallowing and grinding and dental tightening. While the pterygoid is activated during mouth opening and mandible protrusion. As a whole the muscle drives forward, of the condyle mandible, joint disc, and the TMJ capsule. The muscle acts as an antagonist for the temporal muscle in its mandibular retraction.

The objective of this article is to discuss the authors' experience in treating recurring jaw dislocation when both the bone(eminence) and muscular(lateral pterygoid) components are treated.

 

Material and Method

Between August 1997 and August 2008 25 patients affected by recurring mandible dislocation were operated. All of the patients had needed at least on one occasion, hospital care to treat dislocation. Manual maneuvers were used with or without local anesthetic or sedative.

Before operating RMN was used to evaluate the condition of the joint. For the post operative evaluation and follow up the evaluation was carried out with TC. The range of mouth opening could not be measured before operation because of the pain symptoms and the tendency in many patients to dislocate when opening the mouth wide.

21 of the 25 patients had primary treatment. One of the patient's surgeries was after a failed Norman (green stick glenotemporal osteotomy) surgery where the autologous implant was interjected but not fixed with plates. 12 months after surgery the TC reported implant reabsorbing and forward movement of the condyle joint. In the 3 remaining patients failed surgery followed a Myrhag technique (joint eminectomy) Patients ages ranged from 17 to 58 and the average age was 30.

There were 19 women and 6 men, 3 of the women had bilateral TMJ affectation.

In 23 of the cases the graft was obtained from the calvarium of the patient themselves using the same surgical approach ascending to the temporoparietal region. Given that the implant is not excessively thick, it's a matter of total thickness; in spite this no additional neurosurgical complications are expected. In one of these cases the procedure was carried out using a meniscopexy and in the other patient, given the severe pain joint pain the temporal muscle interposition was used to carry out meniscectomy.

In one case the graft was taken from the homo lateral iliac crest of the operated TMJ. For this a second team of surgeons worked simultaneously to minimize operation time.

In just one patient the inserted graft was not auto graft, resorting to the placement of the hydroxiapatite.

The radiological follow up was taken using post surgical TC 6 and 12 months after surgery (except in 2 patients in 2008 that had not yet reached the 12 month date)

After 1 month and the following 3, 6, 12, 24, and 36 month patients underwent clinical evaluation.

 

Surgical technique

The technique described in this article looks at the elevation of the tubercle joint. This restricts the mandible condyle journey prior to the gliding and anterior loading of the tubercle.

Under local anesthetic using nasotrachial tubation, a 1.5 centimeter Al-Kayat incision is made along the zygomatic arch (with, in the case of calvarium graft, an extension to the temporal region).

Using blunt dissection we arrive at the deep temporal fascia at which time the zygomatic arch is identified. At this time we continue in a flat subperiostic to protect the frontal branch of the facial nerve. It also exposes the cheek bone until the joint eminence and anterior wall of the joint capsule are identified (Figs. 1-2).

The insertion of the soft periarticular tissue is kept in the inferior portion.

The next phase frees the pytergoid lateral muscle at a capsular and meniscus joint level.

Afterwards oblique green stick fracture is carried out, separating the cheek bone from the joint eminence. For this it is advisable to use a reciprocate saw or a fine fissure drill. Osteomy in joint eminence should be at least 15 mm deep. A fine osteotomy allows for the separation of the joint eminence and the zigomatic arch prior to the placement of the graft. Periostium of the internal surface should be preserved to avoid reabsorbing of the eminence.

The bone graft adapts and interjects in the osteotomy segment (Fig. 3) (design 1)

To carry out the bone synthesis, a titanium plate, in shape of an "L", with two holes on the short arm is placed. The long arm is situated in front of the joint eminence to as an obstructer while the short arm is bicortically fixed to the zygomatic arch with two pins (Figs. 4-5). (Figure 6)

To test if the plate efficiently restricts joint movements the mandible rotates from the axis of the hinge in a way that the condyle is displaces previously.

Finally the pins are completely tightened and the incision is closed.

 

Results

In this series there were no losses of grafts placed at the level of bone joint eminence. During surgery there were no serious complications in terms of bleeding or exposure of the "duramater". Pain directly following surgery was reported as light-moderate with a good handling of conventional intervening analgesia. During the first month after surgery the patients had mouth opening limitation of 20-25 mm. This situation had completely resolved itself at the 3 month clinical check-up. Through out the clinical follow up none of the patients had another dislocation and all of them had good oral openings.

The pain completely went away in 23 patients. The other 2 patients still had some pain but it was considerably less. Physical therapy of the joint started on the tenth day after surgery.

 

Discussion

Hyper mobility of the joint and lax ligament syndromes are considered inherent diseases characterized by generalized hyper mobility in all joints.(Kirk et al.1967, Jesse et al. 1980, and Finterbush and Pogrund 1982). Bates et al 1984 found a strong relationship in women between the looseness of the TMJ and the looseness of the wrist and elbow.

There is a tendency to think of a multifactorial etiology, in which there are inconsistencies in the skeletal chewing muscles in addition to the anatomical fact that the joint eminence of the temporal muscle is underdeveloped.

Multiple interventions have been devised to permanently treat dislocation. Among these diverse techniques are the recently abandoned intracapsular injections of sclerosing iodine, alcohol and sodium solutions (McKelvey, 1950); the new introduction of sclerotherapy of intraarticular and periartiuclar injections of autologous blood,^3,4 the mechanical block of mandible movements by means of lower fracture of the Zygomatic arch or use of bone grafts (Dingman et al., 1975; Boudreau and Tideman, 1976). Other techniques include condyle movement restriction by implanting mesh or steel pins (Findlay, 1964; Howe et al, 1978) and eminectomy (Myrhaugh, 1951).⁵

Many cases that use mini plates have been published.⁶

Meanwhile Buckley and Terry (1988) managed chronic dislocation by anchoring a plate to the zygomatic arch to limit condyle mandible movement. Puelacher and Waldhart (1993) used mini plates to lengthen tubercule joint which restricts the excessive forward movement of the condyle. Through the use of synthetic bone plates to elevate the tubercule joint condyle movement is restricted.

Glenotemporal osteomy with bone graft placement not only increases the height of the joint eminence but it also increases its width which avoids condyle dislocation. At all phases placement is carried out in an extra capsular manner.

Karabouta⁷ reported good results using hydroxiapatite as the biocompatible material interjected in the bone fragment, in spite of the fact that bone from the same patient can be used as graft material. This autologous bone can be found in the iliac crest at the time of surgery. The donor site must have a sufficient amount of bone and good bone conductivity. However, the disadvantage f this kind of graft is that it tends to be reabsorbed and adds problems to the morbidity of the donor zone as well as temporary discomforts when walking.⁸

The current tendency is to obtain the graft from the calvarium in the temporoparietal region. The main advantage is that the bone is obtained from the same enlarged preauricular incision.⁹ Despite being a generally fine bone graft, unlimited quantities of bone graft can be obtained without added morbidity as long as the surgery is carried out carefully.

We can encounter a series of potential complications with this type of intervention. These complications include facial paralysis due to zygomatic nerve damage when making preauricular incision, bleeding due to damage to the middle meningeal artery and anterior auricular, scalp infection, seroma and arch fracture. Other complications include: damage to the external auditory canal y complications in the donor graft zone when obtaining the graft from the calvarium (fracture of the internal table and repositioning of the dura have not been documented in any of the series published in the literature in the past few years).^{8, 10-11}

The receiving bone has the same characteristics as the autologous graft which decreases the chances of reabsorbing.

The series published by Medra et al,⁸ provides the same favorable results whether bone synthesis was with wires or with plates. However, some of the authors do not agree with introducing strange materials, such as mini plates and pins. They do support the use of wires for bone synthesis to avoid infection, pin loss or foreign intraarticular bodies. Costa Lopez et al.¹ agree that it isn't always necessary to use bone synthesis given the physiological tendency to obliteration, from the space left in the osteomy, provided that the periostium of the central area of the joint eminence is well preserved during intervention.

The evolution of the series that the authors present shows that articulated joints work normally after the first month post surgery. They show no oral opening limitation between 25 and 35 mm. Extra information is the subjective satisfaction of patients with their surgeries and the absence of recurring dislocation.

 

Conclusions

The technique described to restrict the ATM movements in chronic dislocation cases is relatively simple.

In order to avoid the weakening of the plate it should be fixed with two or three pins that are bi cortically anchored into the zygomatic arch.

It is important to only concentrate on the treatment of the bone, it being of great importance to the stability of the long term results, the muscular component treatment with detachment of the pytergoid lateral muscle of the disc and the joint capsule. The function of the ATM was immediately standardized without the need for supplementary treatment.

 

 

Correspondence:
Lorena Pingarrón Martín
Servicio de Cirugía Oral y Maxilofacial.
Hospital Universitario La Paz
c/ Paseo de la Castellana 261,
28046 Madrid. España
E-mail: lorenapingarron@yahoo.es

Recibido: 25.11.2008
Aceptado: 11.05.2009

 

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