BILATERALLY SUPEROLATERAL DISLOCATION OF INTACT MANDIBULAR ... · outcomes without any complication. ... mandibular parasymphysis fracture was carried and fracture ... reported intact

University J Dent Scie 2015; 1(2) : 67-70

ABSTRACT: Rare occurrence and often misdiagnosed clinically ,we report a case of 42 year old male patient with very unusual diagnosis of superolateral dislocation of intact mandibular condyle bilaterally following traumatic insult to the mandible. Diffuse edema in the chin area and a left lateral deflection of the mandible, including an open bite and a crepitation in theRight parasymphyseal region. Three-dimensional computed tomography scans were taken, which presented a superior dislocation of both condyles hooked above the zygomatic arch laterally. Both condyles were reduced manually under general anaesthesia, right condyle was reduced but left condyle was repeatedly slipping into dislocated position. To prevent repeated early dislocation of condyle (dislocated superolaterally) the method of capsulorrhaphy by suturing split thickness temporalis Myofascial flap on lateral aspect of capsule was done followed by maxillomandibular fixation for 3 weeks and further active mouth opening exercise in order to prevent fibrosis. No case has been published in literature so far presented the method to prevent repeated slipping of condyle into superolateral dislocated position, ours is the first case with successful postoperative outcomes without any complication.

1 2 3 4Kotak Rajkumar K, Sunil Sharma, Vikas Singh, Vishal Saini 1 2 3 4 Postgraduate Student, Professor and Head, Reader, Vishal Saini, Postgraduate Student, Department of Oral and Maxillofacial Surgery, Mahatma Gandhi Dental College and Hospital, Jaipur

INTRODUCTION : Mandibular condyle fractures are

common following maxillofacial trauma and dislocation of

condyles as result of trauma out from the glenoid fossa is often

associated with it. Displacement occurs anteriorly rather than

posterior, laterally or superiorly. Superolateral Dislocation

with intact mandibular condyle have often been misdiagnosed

because of its rare occurrence. Yoshi et al1 suggested the

possibility of unusual dislocation whenever signs and

symptoms did not match any usual condylar fractures. Allen

and Young2 first published in his series of case reports and

gave classification of dislocation of condyle into type I

(lateral subluxation),where the condyle is laterally displaced

out of the glenoid fossa, and typeII (complete dislocation)

where the condyle is displaced laterally as well as superiorly

entering the temporal fossa

Satoh et al3 also proposed a classification with modification

an added subdivisions in it. dislocation into type IIA, in which

the condyle is not hooked above the zygomatic arch; type IIB

in which the condyle is hooked above the zygomatic arch; and

type IIC in which the condyle is lodged inside the zygomatic

arch, which is fractured. We present a case of Superolateral

dislocation of intact mandibular condyle bilaterally

associated with Right side parasymphysis fracture of

mandible. Unilateral Open reduction for lateral Capsule

repair of Temporomandibular joint was executed to prevent

recurrence and hypermobilty of TMJ postoperatively with the

help of conventional procedure of inferiorly based split

thickness Temporalis myofascial Flap.

CASE REPORT : A 42 years old male patient reported to

emergency unit with the history of fall from height. Patient

was conscious and was under the influence of alcohol all vital

signs were normal with no history of loss of Consciousness.

Patient was complaining of pain and inability to open mouth

with presence of intraoral bleeding. No Positive history of

vomiting and bleeding from ear or nose evaluated. On

extraoral examination swelling and presence of laceration

over the chin region with gross facial assymetry and left

lateral deflection of the mandible was observed.(Figure 1)

On palpation slight preauricular depression and condyles

were palpated above the zygomatic arch. Marked Elevation at

both the region above the zygomatic arch which was tender

indicating the fracture displacement of condyle.

On intraoral Examination classical anterior open bite with

BILATERALLY SUPEROLATERAL DISLOCATION OF INTACTMANDIBULAR CONDYLE TREATED WITH UNILATERAL OPEN REDUCTION AND TMJ CAPSULORRHAPHY : A RARE CASE REPORT AND REVIEW OF LITERATURE.

Journal of Dental Sciences

University

Key Words : Superolateral dislocation, Intact Mandibular Condyle, Temporomandibular Joint, Capsulorrhaphy.

Source of support : NilConflict of interest : None

CaseReport

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bilateral posterior gagging along with unilateral cross bite on

left side and restricted mouth opening was observed. Patient

merely move or open the mouth with mouth opening of less

than 1 cm of interincisal distance. Flaring between lower right

1st & 2nd premolar without bucco-lingual displacement but

lower border of mandible was intact and tender suggested

right parasymphysis fracture only.

On Radiographic Analysis patient underwent Three

dimensional CT scan revealed confirmatory diagnosis of

Right incomplete Parasymphysis fracture and Unusual

Presentation of intact dislocation of condyles superiorly as

well as laterally hooked above and lateral to the zygomatic

arch without any other associated fracture of zygomatic arch

or maxilla.(Figure 2)

The patient was hospitalized and planned for reduction 4

days after admission under General anaesthesia via Fibreoptic

guided Nasotracheal Intubation when patient was fully

relaxed. Bimanual reduction of dislocated condyles by

applying pressure resulted into reduction of right side of the

condyle into its normal anatomic position of glenoid fossa but

multiple attempts on left dislocated condyle was unsuccessful

due to repeated slippage of condyle superolaterally.

Further attempt was made to reduce manually and

Intermaxillary fixation (IMF) was done by applying bigonial

pressure to achive satisfactory pretrauma occlusion on both

the sides with the help of IMF screws . Exposure of left

mandibular parasymphysis fracture was carried and fracture

reduction was done followed by fixation with the help of

2.5mm four hole at the lower border and 2.5mm two hole

plate superiorly and closure of fracture site was achieved with

3-0 absorbable sutures.(Figure 3)

On release of IMF intraoperatively; mandibular mouth

opening and movements was evaluated which was leading to

repeated slippage of left mandibular condyle laterally and

superiorly. Henceforth decision was taken for open reduction

on left side Temporomandibular joint for the repair of

damaged lateral capsule. Laxity of joint was increased due to

tearing of lateral capsule. Alkayat and Bramley Modified

Preauricular approach to the TMJ was executed to expose the

lateral capsule, Temporal fascia, zygomatic root of temporal

bone without damaging facial nerve.(Figure 4)

An inferiorly based split thickness pedicled flap of temporalis

myofascial elevated and was sutured to anterolateral wall of

the capsule as an anchoring procedure once the condyle is

reduced back into the glenoid fossa on IMF.

Figure 1 : Properative Profile View

Figure 2 : Preoprative 3D CT Scan

Figure3: Introperative View Figure 4

Figure 5 : Postoperative

DISCUSSION:

Reduction technique of lateral condylar dislocation was by

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described by Roberts4 in 1849. This consisted of strong

outward pressure on the ramus with inferior traction and

medial pressure on the condylar head.

In our case laceration at chin and wedge type fracture between

lower right first and second premolar suggest a high impact

force from the front and upward direction leads to

superolateral bilateral condylar dislocation, rupturing the

capsule & ligaments and associated with parasymphysis

fracture

It is postulated by the history of patient the mechanism of

dislocation might be due to sudden opening of the jaw on

frightening or screaming of patient, followed by chin hitting

on the floor. The force of the impact displaced the condyles

lateral to the glenoid fossa ,rupturing the capsular and

ligamentous attachments to the condylar head, and drove the

condyles superiorly, laterally to the zygomatic arches.

Allen and Young2, Satoh et al3, and Kapila and Lata5 support

this and emphasize that a fracture of the symphysis and/or

body of the mandible is a prerequisite for the lateral

dislocation of the mandibular condyle. But some authors6,7

reported intact condylar dislocation without mandibular

fracture.

In our case, the fracture of right parasymphysis caused the

flaring at dentoalveolar border, compression at lower border

and rotation of both the ramus leading to lateral dislocation of

the bilateral intact condyles.

Because it is rare often misdiagnosed certain diagnostic

features was addressed by the Worthington et al8 which were

(1) Malocclusion, (2) an open bite, (3) Persistent restriction of

mandibular movement, (4) An apparent loss of ramus height

with elevation of the ramus fragment, (5)Facial asymmetry.

Both the closed and open reduction are suggested for the

management of the same condition , type of treatment

depends on time of treatment after the injury. An early

diagnosis is imperative for successful management of the

dislocation.

Manual/closed reduction: -First choice, simple, less traumatic

& safe It depends on the time lapsed since the trauma. Mouth

props can be used- functioning as fulcrum in molar region

Open reduction -reduced by open traction through holes

drilled at lower border of the angle and downward traction at

the sigmoid notch with the help of channel retractor is also

one of the method published in literature. (Finck's

technique)9

Ferguson et al10. and Kapila and Lata5 were able to reduce

laterally dislocated condyles using strong traction and a wire

through the mandibular angle.

Kim et al11 used bone traction hook placed at the sigmoid notch

through stab incisiosn at the level of notch itself, and reduction

was achieved after applying an outward traction.

Two recent literature of case series by Shen et al12 and

Mishra.S et al13 debated the treatment outcome of open versus

closed reduction in their retrospective studies. Shen et al12

carried out retrospective clinical study on treatment modalities

of 10 patients of superolateral dislocation of condyle. Patients

who had dislocation for less than 1 week had condylar reduction

and rigid internal fixation of the fractures. Mandibular sagittal

split ramus osteotomy and articular reduction and fixation were

performed in seven cases. Maximum mouth opening and

occlusal relationships were compared following treatment

When the dislocated joint had become adherent to the

surrounding tissues and ankylosis developed, mandibular

sagittal split ramus osteotomy was performed with good results.

Mishra.S et13 al reported 7 case series in which six of all were

reduced manually under general anaesthesia and one case

underwent open reduction for the successful outcome.

In our case, both condyles were reduced manually, right condyle

was reduced but left condyle was repeatedly slipping into

dislocated position. In such cases of failure of closed reduction

the only alternative of open reduction proposed by many authors

2,5,13,14 was decided. Henceforth, decision was taken to open

the region to tighten the perforated capsule and fascia.

Capsulorrhaphy and temporal fascial flap are used in

strengthening of a lax capsule for treatment of hypermobile

joint, chronic subluxation and recurrent anterior dislocation.

Critical factors of success depends on the time between injury

and reduction. Delay induces fibro-osseous ankylosis

2,3,,15,16,17 necessitates open reduction, condylectomy with

or without arthroplasty.2 The delay in treatment can lead to

unsatisfactory results and imperfect reduction

In our case, the reduction was done on 4th day after injury

resulting in complete reduction

The average duration of postoperative immobilization

(maxillomandibular fixation) in the literature is 2 weeks 6. The

reduced condyle tends to return to the preoperative position. In

addition, immobilization facilitates healing of the presumably

damaged ligaments.

In our case, maxillomandibular immobilization was done for 3

weeks followed by active mouth opening exercise in order to

prevent fibrosis In published reports, no case has presented the

method to prevent repeated slipping of condyle into

superolateral dislocated position.

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Ours is the first case in which repeated superolateral

dislocation of condyle after manual reduction was

immobilized by capsulorrhaphy and further strengthened by

suturing temporal fascia on lateral aspect of capsule

CONCLUSION : Multiple factors determines the successful

outcome the time of reduction after the injury, and extent of

reduction either open or closed and postoperative

maxillomandibular fixation followed by patient compliance

in terms of postoperative aggressive physiotherapy, are the

major factors

The method of capsulorrhaphy and suturing temporal fascia

on lateral aspect of capsule can be used to prevent repeated

early dislocation of condyle (dislocated superolaterally). This

also prevents laxity of the capsule and reinforces the

temporomandibular ligament.

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CORRESPONDANCE:

Kotak Rajkumar K

IIIrd Yr Postgraduate Student

Mahatma Gandhi Dental College and Hospital, Jaipur.

E-mai : [email protected]

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