Treatment of temporomandibular joint luxation: a systematic literature review

Treatment of temporomandibular joint luxation: a systematic literature reviewhttp://www.diva-portal.org
This is the published version of a paper published in Clinical Oral Investigations.
Citation for the original published paper (version of record):
Abrahamsson, H., Eriksson, L., Abrahamsson, P., Häggman-Henrikson, B. (2020) Treatment of temporomandibular joint luxation: a systematic literature review Clinical Oral Investigations, 24(1): 61-70 https://doi.org/10.1007/s00784-019-03126-1
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REVIEW
Helene Abrahamsson1 & Lars Eriksson2
& Peter Abrahamsson3 & Birgitta Häggman-Henrikson1,4
Received: 20 November 2018 /Accepted: 16 October 2019 /Published online: 15 November 2019 # The Author(s) 2019
Abstract Objectives To evaluate the effectiveness of surgical and nonsurgical treatment of temporomandibular joint (TMJ) luxation. Materials andmethods This systematic literature review searched PubMed, the Cochrane Library, andWeb of Science databases to identify randomized controlled trials on TMJ luxation treatment published between the inception of each database and 26 March 2018. Results Two authors assessed 113 unique abstracts according to the inclusion criteria and read nine articles in full text. Eight articles comprising 338 patients met the inclusion criteria, but none of these evaluated surgical techniques. Three studies including 185 patients concerned acute treatment with manual reduction of luxation while five studies including 153 patients evaluated minimally invasive methods with injection of autologous blood or dextrose prolotherapy for recurrent TMJ luxation. These studies reported that mouth opening after treatment was reduced and that independent of type of injection, recurrences of TMJ luxation were rare in most patients. Conclusions In the absence of randomized studies on surgical techniques, autologous blood injection in the superior joint space and pericapsular tissues with intermaxillary fixation seems to be the treatment for recurrent TMJ luxation that at present has the best scientific support. Well-designed studies on surgical techniques with sufficient numbers of patients, long-term follow-ups, and patient experience assessment are needed for selection of the optimal surgical treatment methods. Clinical relevance Autologous blood injection combined with intermaxillary fixation can be recommended for patients with recurrence of TMJ luxation.
Keywords Hypermobility . Luxation . Prolotherapy . TMJ dislocation . TMJ reduction
Introduction
Temporomandibular joint (TMJ) luxation (dislocation) is rare, but when it occurs, it has a high impact on the individual and usually requires urgent medical attention. In the acute stage, TMJ luxation severely affects oral health due to the severity of the pain or discomfort and the reduced ability to speak, chew,
and eat [1]. Furthermore, psychological and social impact are high and TMJ luxation can therefore be regarded as one of the most severe conditions in dentistry [2].
TMJ hypermobility can be classified as a subluxation or a luxation. TMJ subluxation is a condition where the condyle translates anteriorly of the articular eminence during jaw opening and briefly catches in an open position before returning to the fossa spontaneously [3] or with manual self- manipulation by the patient. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) classification scheme [4] was expanded in 2014 to include less common, but clinically important disorders. According to these, the Diagnostic Criteria for Temporomandibular Disorders (DC/ TMD), subluxation should have a positive history that the jaw has been caught in a wide open position and the patient had to do a self-maneuver to be able to close the jaw [5]. During TMJ luxation, the patient is unable to self return to the fossa without the help of a clinician to maneuver the jaw
* Birgitta Häggman-Henrikson [email protected]
1 Department of Orofacial Pain and Jaw Function, Malmö University, 205 06 Malmö, Sweden
2 Department of Oral Surgery and Oral Medicine, Malmö University, Malmö, Sweden
3 The Maxillofacial Unit, Halmstad Hospital, Halmstad, Sweden 4 Department of Odontology/Clinical Oral Physiology, Umeå
University, Umeå, Sweden
Incidence
Although a retrospective study by Agbara et al. at a uni- versity hospital in Nigeria reported that TMJ luxation was associated with yawning, higher age, and male gender, in general, the TMJ joints are more flexible in women and therefore more likely to luxate [6]. However, the inci- dence of TMJ luxation is low; two medical emergency departments, with 100,000 annual visits combined, report- ed an average of 5.3 cases annually of TMJ luxation over a period of 7 years [7]. Bilateral luxation of the TMJ is most common with the mandible in a straight open posi- tion [8], whereas with a single-sided luxation, the mandi- ble is deviated to the opposite side, with a partially open mouth. Luxation of the TMJ represents 3% of all cases of reported dislocated joints in the body [9].
TMJ luxation can be acute or chronic [10]. Acute TMJ luxationmay occur as a result of external trauma, sudden wide mouth opening while yawning, taking a large bite, or laughing. In the clinical situation, TMJ luxation may occur after excessive mouth opening during dental treatment or oth- er oro-pharyngeal procedures [11]. A patient with a history of a TMJ luxation is more likely to have a recurrence [12]. It has been proposed that abnormalities in the stabilizing structures of the TMJ may be associated with luxation. The main factors for joint stability are the ligaments and muscles together with the anatomy of the bony components of the joint [13], which means that the pathophysiology is multifactorial [14]. Concerning the anatomy of the TMJ, a steep articular emi- nence or an abnormal condylar shape [14] are risk factors for luxation.
Pathogenesis
When the TMJ condyle luxates into an anterior position of the eminence, a reflex is generated that sets the masticatory mus- cles into a spasm; this hinders the condyle from moving back to its normal position [15]. Systemic diseases associated with muscular spasm and muscular dystonia have been reported to increase the risk for TMJ luxation [14]. Some brands of anti- psychotic medications could also contribute to the risk of TMJ luxation due to their side effects of dystonia [16]. Benign hypermobility, which often is hereditary, is another predispos- ing factor for TMJ luxation [17, 18]. In patients with Ehlers- Danlos syndrome, hypermobility is common and associated
with a weak capsule and ligament laxity [19]; these patients are at risk for recurrent TMJ luxation.
Acute therapy
Manual repositioning of the mandibular condyle into the glenoid fossa is the first choice for acute treatment and con- sidered to be the best approach [2]. In patients with recurrent conditions, this acute treatment can be regarded as a tempo- rary solution, and additional preventative measures may be required.
Preventive therapy
The preventive treatment of TMJ luxation can be either non- surgical or surgical. Jaw exercises are one example of nonsur- gical treatment that aims to improve muscle strength and co- ordination after TMJ luxation. Jaw exercises are considered to have a moderate effect on the ability to prevent repeated lux- ation, but the scientific evidence is weak. Other nonsurgical methods include intermaxillary fixation (IMF) [20]; prolotherapy, which is injection of sclerosing or proliferant solutions [21] or autologous blood into the TMJ [22]; and botulinum toxin injection into the masseter and pterygoid muscles [23, 24].
Several surgical procedures for creating an obstacle at the eminence have been suggested for limiting the anterior move- ment of the condylar head to hinder recurrent TMJ luxation. Examples are down fracture of the zygomatic arch, also known as Dautrey’s procedure [25], miniplating, bone grafting, and alloplastic materials attached to the articular em- inence have also been described. Soft tissue surgery for restricting condyle movement has been suggested, i.e., myotomy of the lateral pterygoids, lateral pterygoid muscle tendon scarification, scarification of the temporalis tendon [26], and capsule plication. Another surgical strategy, eminectomy, clears the path of the condylar head by removing the eminence and is the recommended procedure for achiev- ing total release of condylar translation [15].
In conclusion, several methods have been proposed for the treatment of TMJ luxation.
The aim of this systematic review was to evaluate clinical randomized controlled trials (RCTs) on the effectiveness of surgical and nonsurgical treatment of TMJ luxation that had been published over the last 50 years.
Materials and methods
Inclusion and exclusion criteria
Clinical RCT studies published in English, Swedish, or German on patients diagnosed with TMJ luxation were
62 Clin Oral Invest (2020) 24:61–70
considered. Non-RCT studies as well as data already reported in other studies (dual publication), studies on TMJ fractures, and studies with fewer than 10 patients were excluded.
Literature search
The search strategy was designed to identify studies on treat- ment of TMJ luxation and encompassed all articles in PubMed, the Cochrane Library, and Web of Science. The initial search included studies published from the inception of each database until 31 October 2015; an update search was carried out 26 March 2018. We used these search terms: “Temporomandibular joint” (MeSH) OR “TMJ” (MeSH) AND “Luxation” OR “Subluxation” OR “Dislocation “OR “Open lock “OR “Hypermobility “OR “JHS” OR “Joint Hypermobility Syndrome” and limited the search to random- ized controlled trials. Table 1 provides the full search strategy for PubMed. A hand search of the reference lists in the includ- ed articles was done to identify additional studies. Grey liter- ature was not included, and authors were not contacted for additional information.
Procedures
Two of the authors (HA, BHH) independently read all titles and abstracts that were found in searches to identify potential- ly eligible studies for inclusion. If one of the reviewers deemed an article as potentially of interest, it was included
for full-text assessment. All potentially eligible articles were then retrieved as full-text articles to determine if they met the inclusion criteria. Disagreement was resolved by discussion among the investigators. Authors were not contacted for miss- ing information. One of the reviewers was an experienced orofacial pain researcher and the other, an orofacial pain reg- istrar. One author (HA) carried out the data extraction which was reviewed by another author (BHH).
These data were extracted from the RCTs:
& Clinic setting & Inclusion and exclusion criteria & Number of patients & Age and gender of patients & Number of drop outs & Treatment method & Follow-ups & Results & Authors’ conclusions
Quality assessment
Two authors (HA, BHH) independently evaluated the quality of each identified article. The quality of each study was assessed using a tool for RCT studies from the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), which SBU
Table 1 Full search strategy on PubMed, 26 March 2018 Search Search string No. of articles
Temporomandibular joint
2 TMJ [MeSH] 26,047
Luxation or subluxation
4 Luxation 3,526
5 Subluxation 43,945
6 Dislocation 63,547
10 Joint hypermobility syndrome 2,220
11 #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 73,406
Study design
718,112
Clin Oral Invest (2020) 24:61–70 63
Results
Altogether, 113 unique articles were identified after re- moval of duplicates (Fig. 1). Following the initial screening of all abstracts, nine articles were reviewed in full text by applying the inclusion and exclusion criteria. One article, Sato et al. [1] did not meet the inclusion criteria and was excluded. The eight remaining articles (Tables 2 and 3) met the inclusion criteria. Six articles were considered to be at moderate risk of bias and the remaining two articles low risk (Table 4).
Reports on surgical techniques and acute therapy
No RCT studies that evaluated surgical techniques were iden- tified. Three of the included articles described acute manage- ment of TMJ luxation and evaluated methods for manual re- positioning. In an external approach proposed by Ardehali et al., the physician places both hands externally, one hand on each of the patient’s cheeks. Themandibular angle is pulled anteriorly; at the same time, pressure is applied to the coronoid process on the opposite side, with a gentle movement the condylar head is then pushed back into the glenoid fossa on one side. This approach, termed the external approach for reduction of TMJ luxation, was less successful (55%) com- pared to the conventional method (86%) [28]. A later study by the same author compared conventional repositioning, the ex- ternal approach, and a wrist pivot method, and reported no significant differences between the techniques concerning successful reduction [29]. Xu et al. evaluated a supine position
Fig. 1 Flowchart of articles included and excluded in the study
64 Clin Oral Invest (2020) 24:61–70
Ta bl e 2
m et ho ds
n (n
= 3)
in th e pr es en ts ys te m at ic re vi ew
A rt ic le Fi rs t
au th or
Y ea r
St ud y sa m pl e S et tin
g N um
be r of
T re at m en t
O ut co m e m ea su re s
R es ul ts
A ut ho rs ’ co nc lu si on s
C om
01 6
A cu te T M J di sl oc at io n
Te rt ia ry
ot or hi no -l ar yn go lo gy
To ta l: 90
(4 7%
0 (6 0%
(5 3%
m et ho d (i nt ra or al )
co m pa re d w ith
ex tr ao ra la nd
w ri st pi vo tm
et h-
re du ct io n Su
cc es sf ul
M et ho d:
E xt ra or al :6
7% W ri st pi vo t: 97 %
M or e su cc es sf ul
re du ct io ns
fo r w ri st
pi vo tm
et ho d
ex tr ao ra lm
et ho d
(p < 0. 01 )
et ho d
sh ou ld
as th e fi rs tl in e of
tr ea tm
tr ea tm
lu xa tio
n
O nl y ac ut e sh or t- te rm
ou tc om
A cu te no nt ra um
at ic T M J
di sl oc at io n
H os pi ta lc lin
ic
(4 5%
S up in e te ch ni qu e: 20
(6 2%
m et ho d (i nt ra or al )
co m pa re d w ith
Su pi ne
po si tio
Fi rs tt ry
R ed uc tio
re du ct io n (V A S)
C on ve nt io na li nt ra or al
m et ho d:
R ed uc tio
R ed uc tio
tim e (p
su pi ne
po si tio
e an d re du ce d pa in
pe rc ep tio
th at th e su pi ne
po si tio
n te ch ni qu e m et ho d
m ig ht
al te rn at iv e to
th e
ac ut e
di sl oc at io n
O nl y ac ut e sh or t- te rm
ou tc om
00 9
of T M J
Te rt ia ry
ot or hi no -l ar yn go lo gy
58 at te m pt s in
55 pa tie nt s
C on ve nt io na lm
et ho d:
29 (4 1%
29 (6 2%
pa re d
re po si tio
re du ct io n Su
cc es sf ul
C on ve nt io na lm
et ho d:
55 .2 %
(9 5%
C I
et ho d fo r T M J
re du ct io n co ul d be
a go od
av oi d
un su cc es sf ul
th e
et ho d
st ill is th e go ld st an da rd
O nl y ac ut e sh or t- te rm
ou tc om
e A ut ho rs ’ co nc lu si on
no t
in lin
U nc le ar
th e ne w pr op os ed
m et ho d co m pa re d to
th e co nv en tio
na l
et ho d.
sc al e
Ta bl e 3
in je ct io n of
au to lo go us
bl oo d or
de xt ro se
(n = 5)
in th e pr es en ts ys te m at ic re vi ew
A rt ic le Fi rs ta ut ho r
Y ea r
S et tin
g N um
be r of
T re at m en t
O ut co m e
m ea su re s
R es ul ts
A ut ho rs ’ co nc lu si on s
C om
To ta l: 37
)2 5 ye ar s
10 %
) 24
(8 9%
)2 7
(6 7%
)2 4
co m pa re d w ith
10 % ,
M M O
R ed uc tio
(S D )
Pl ac eb o:
10 %
de xt ro se :5 4. 3 (5 .9 )– 39 .4
(4 .2 )
20 %
de xt ro se :5 2. 1 (6 .9 )– 41 .2
(5 .4 )
30 %
de xt ro se :5 4. 0 (7 .4 )– 39 .4
(4 .5 )
T he re
di ff er en ce
be tw ee n th e
pl ac eb o gr ou p an d th e
de xt ro se
of an y
de xt ro se
T M J
N o re cu rr en ce
of lu xa tio
ns R el at iv el y sh or t
fo llo
M J
cl in ic
(7 1%
co m pa re d w ith
30 %
M M O
(V A S)
(S D )
Pl ac eb o:
30 %
de xt ro se :4 6. 1 (6 .9 )– 43 .3
(5 .9 )
de xt ro se
gr ou ps
T he se
de xt ro se
is no
m or e ef fe ct iv e th an
pl ac eb o
T M J
hy pe rm
ob ili ty
n of
of lu xa tio
n du ri ng
od
T M J di sl oc at io n
O ut pa tie nt
O ra la nd
To ta l: 48
F 16
A B I co m pa re d to :I M F
A B I+ IM
F M M O
as in te ri nc is al
di st an ce )
of di sl oc at io n
R ed uc tio
ye ar
(n um
IM F:
9. 13
M M O re du ct io n al lg
ro up s (p
M O re du ct io n
A B I+ IM
re cu rr en ce s
N S be tw ee n A B I an d IM
G gr ou ps
A B I is a si m pl e an d sa fe
te ch ni qu e fo r tr ea tm
en to
f T M J di sl oc at io n in
th e
cl in ic .
ov er co m e by
m ul tip
ow ev er ,t he
be st cl in ic al re su lts
ar e
n of
F.
n no tp
su bg ro up s
R ef ai 20 11
B ila te ra lT
M J
or di sl oc at io n
O ut pa tie nt
O ra la nd
To ta l: 12
)3 0 ye ar s
D ex tr os e: 6 (1 00 % ) 23
ye ar s
co m pa re d w ith
10…