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Management of chronic unilateraltemporomandibular joint dislocationwith a mandibular guidance prosthesis:A clinical report

Tuncer Burak Ozcelik, DDS, PhD,aand Zafer Ozgur Pektas,

DDS, PhDbBaskent University, Faculty of Dentistry, Adana, Turkey

aPostdoctoral Fellow, Department of Prosthodontics.bAssistant Professor, Department of Oral and Maxillofacial Surgery.

Recurrent or chronic dislocation of the temporomandibular joint is relatively rare and often results in facial asymme-try, impairment of function, and discomfort. Although manual reduction is the primary choice of treatment, patientspresenting with recurrent or prolonged dislocations require conservative and surgical methods to limit forward move-ment of the mandibular condyle. This clinical report presents a 75-year-old woman with severe mandibular devia-tion and subsequent facial asymmetry caused by a chronic unilateral temporomandibular joint dislocation that wastreated with a mandibular guidance prosthesis combined with physical therapy. (J Prosthet Dent 2008;99:95-100)

Recurrent or chronic temporoman-dibular joint (TMJ) dislocation is adistressing clinical condition which ischaracterized by a condyle that slidesover the articular eminence, catchesbriefly beyond the eminence, and thenreturns to the fossa.1-6 Chronic TMJdislocations are relatively rare and fre-quently associated with intraarticulareffusion, muscle spasms, and jointpain, causing facial asymmetry, man-dibular deviation, and severe discom-fort which interferes with speech andmastication.1-3,7Radiographically, thearticular eminence is frequently atro-phic and the glenoid fossa is generallyflattened.2

Congenital joint weakness, exces-sive mouth opening during yawning,dental or otorhinolaryngologicaltreatment, neurogenic muscular hy-peractivity, systemic diseases result-

ing in the hypermobility of the TMJ,pyschogenic and neurologic disor-ders, drugs (especially antiemeticsand phenothiazines) which produceextrapyramidal effects, trauma,3,5,8weakness or laxity of the capsule, andinternal derangement of the TMJ1,2account for the etiological and pre-disposing factors for condylar dislo-cation. Classifications were proposed

for TMJ dislocations and are based onthe number of affected TMJs (unilat-eral or bilateral), the direction of thedisplacement (anterior, posterior, me-dial, lateral),9,10 and the duration ofthe dislocation as acute, chronic (pro-longed), or recurrent, as described byAdekeye et al.3

Various conservative and surgicalmethods have been introduced fortreating dislocations. Manual reduc-tion of the dislocated TMJ is the pri-mary choice of treatment. However,this frequently fails in patients withchronic or recurrent dislocations, andalternative treatment modalities arerequired for these patients. Nonsurgi-cal therapies include intermaxillary fix-ation, injection of sclerozing agents11and injection of autologous bloodaround the TMJ to create fibrosis,12

and botulinum toxin injection into

the lateral pterygoid muscles.13 Thecurrent surgical procedures includeeither creation of a mechanical obsta-cle to limit the forward excursion ofthe condylar head,6,14-17or removal ofobstacles in the condylar path with aneminectomy18or with a more recentlydescribed method, arthroscopic emi-noplasty.19

This article presents the manage-

ment of a chronic unilateral temporo-mandibular joint dislocation witha mandibular guidance prosthesis(MGP) combined20,21 with physicaltherapy for a patient referred with thecomplaint of severe mandibular de-viation and subsequent facial asym-metry. The patient initially presentedwith a misdiagnosis of a possible fa-cial paralysis or a disorder of the fa-cial motor activity, which, in fact, wascaused by chronic dislocation.

CLINICAL REPORT

A 75-year-old white woman wasreferred with a preliminary diagnosisof facial paralysis due to facial asym-metry in the beginning of 2004. Shereported an asymmetric face and de-viation of the mandible for approxi-mately 8 to 12 months. The patient

also reported shifting her mandibleunconsciously to the left any time shewas nervous or distressed. She report-ed a consistent shift of the mandibleto the left which interfered with hereating and speech for approximately6 months. During this period, shealso had difficulties with her existingprosthesis, which was fabricated by anondentist in a rural region (Fig. 1).

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Her medical history was signifi-cant, with an abdominoperineal re-section and partial nephrectomydue to a rectal carcinoma in 1999,followed by multiple chemotherapysessions. In 2002, she was referred tothe Department of Psychiatry, wherea diagnosis of major depression was

established and psychotropic drugswere prescribed for 2 years. She re-ported complaints of asymmetricface, and speech and masticatory dis-turbance in 2003, initially, when shewas still under the supervision of herpsychiatrist. The severity of her symp-toms increased in 2004 when herdaughter died.

Extraoral examination revealed amandibular protrusion and deviation

to the left. Although a commissuraldroop and slurred speech were evi-dent, there was no eyelid droop or eyedeviation at the right side. The func-tions of facial nerves were examinedby asking the patient to raise both eye-brows, smile, and show the mandibu-lar teeth. During these movements,no bilateral differences were recorded.Palpation of the masticatory musclesand functional manipulation did notreveal any painful muscle. The patientwas edentulous except for the maxil-lary incisors and canines, left mandib-ular canine, and second premolar, asdetermined by intraoral examination.A reverse articulation was present onthe left side and slight limitation wasobserved in the maximum interincisalopening and right mandibular move-ment.

The bimanual manipulationtechnique for mandibular guidance

proposed by Dawson22 was used toorientate the patients mandible tothe centric relation (CR) position, inwhich it was easily placed, to evaluatethe reverse articulation. This manipu-lation and positioning resolved theleft side reverse articulation. However,subsequent instruction for openingand closing movements resulted ina mandibular protrusion and simul-taneous mandibular deviation to the

left. When these symptoms were con-sidered, a recurrent or chronic unilat-

eral dislocation of temporomandibu-lar joint (TMJ) was determined to bethe likely diagnosis rather than facialparalysis.

Subsequent to the clinical exami-nation, magnetic resonance imagingwas performed to establish a defini-

tive diagnosis. The relationship of theleft TMJ was determined to be normalin closed and open positions, where-as a derangement in the condyle discrelationship (Fig. 2, A) and condylardislocation was observed in the rightTMJ in open position (Fig. 2, B). Fur-

1 Mandibular deviation to left caused by chronic TMJ dislocation.

2 A, Magnetic resonance image view showing derangement of

condyle disc relationship of right TMJ in closed mouth position. B,Open mouth position.

A

B

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3Trial evaluation of metal substructures.

thermore, flatness of the glenoid fossawith atrophy of the articular eminencewas observed.

The patient and her family refusedany surgical intervention due to theage of the patient, psychological sta-tus, and remarkable medical history,including an abdominoperineal resec-

tion and partial nephrectomy due toa rectal carcinoma in 1999, followedby multiple chemotherapy sessionsand a major depression in the follow-ing period. Therefore, the only treat-ment alternative was a conventionalapproach. Lateral pterygoid-directedbotulinum toxin injection, which iscurrently described as the treatmentof choice for recurrent or chronic TMEdislocation, was considered as an al-

ternative option.13

However, althoughthe application is a minimally invasivetechnique, it was not considered dueto the fact that a majority of patientsrequire the use of additional lateralpterygoid-directed botulinum toxininjections, and complications includ-ing dysphasia, nasal speech, painfulmastication, nasal regurgitation, anddysarthria may develop following thistreatment.12,13In light of these consid-erations, a decision was made in favorof rehabilitation with the fabricationof an attachment-retained maxillaryremovable partial denture (RPD) andan MGP. The treatment plan also in-cluded physical therapy to maintainan accurate and repeatable centricocclusion position.

The preliminary impressions weremade with irreversible hydrocol-loid (Cavex outline; Cavex HollandBV, Haarlem, Netherlands). The re-

sultant diagnostic casts were sur-veyed (AF200; Amann Girrbach AG,Koblach, Austria) to determine theRPD design options. Then a defini-tive treatment plan for maxillary andmandibular RPDs was developed.

The mouth preparation for fabrica-tion of the RPD began with removingthe existing restorations, as they werenonfunctional and ill-fitting, withpoor esthetics. The maxillary incisors,

canines, and mandibular left canineand second premolar were prepared

with chamfer finish lines, and provi-sional restorations (Imident; ImicrlyDis Malzemeleri ve San ve Tic Ltd, STI,Konya, Turkey) were fabricated. Aftera week, definitive impressions of theprepared maxillary and mandibularteeth were made using a vinyl polysi-loxane impression material (Speedex;

Coltene/Whaledent Inc, CuyahogaFalls, Ohio).

Surveying of the definitive cast(AF200; Amann Girrbach AG), wax-ing, casting, milling, and finishingprocedures for the fixed metal-ceram-ic restorations (Metaplus VK; AZ &Partner AG, Reiden, Switzerland andIPS d.SIGN; Ivoclar Vivadent, Schaan,Liechtenstein) were performed con-ventionally (Fig. 3).23 The patrix of

the extracoronal ball attachments(OT Cap; Rhein83 Srl, Bologna, Italy)were placed at the distal surfaces ofthe canines in the maxillary fixed met-al ceramic restoration (Metaplus VK;AZ & Partner AG, IPS d.SIGN; IvoclarVivadent) to increase retention andstability of the attachment-retainedRPD. Also, a fixed partial denture(Metaplus VK; AZ & Partner AG, IPSd.SIGN; Ivoclar Vivadent) was fab-ricated between the left mandibularcanine and second premolar conven-tionally.23 Extracoronal attachmentswere not considered in the mandibledue to the inadequate number ofabutment teeth.

The mandibular fixed partial den-tures were cemented (Meron; VOCO,Cuxhaven, Germany), while maxil-lary fixed metal-ceramic restorations

with extracoronal ball attachmentsremained uncemented before makingthe definitive impression for the max-illary RPD. The definitive impressionsfor the framework of the maxillary andmandibular RPDs were made witha medium silicon impression mate-rial (Monopren transfer; Kettenbach

GmbH & Co KG, Eschenburg, Germa-ny) and a custom tray (Imibase; Imi-crly Dis Malzemeleri ve San ve Tic Ltd,STI, Konya, Turkey). Final casts weremade and mounted in a semiadjust-able articulator (Stratos 100; IvoclarVivadent).

The mandibular RPD design in-cluded a metal guidance flange onthe defect (right) side to retain acrylicresin (Steady-Resin; Scheu-Dental

GmbH, Iserlohn, Germany). Thisacrylic resin-retained metal guidanceflange contacted the right buccal sur-face of the maxillary prosthesis with-out traumatizing the alveolar mucosaof the edentulous ridge while prevent-ing mandibular deviation during func-tion. Also, the mandibular RPD wasretained by a cast circumferential re-tentive clasp assembly in a 0.25-mmundercut to provide retention andstability.

The frameworks for the RPDs werecast from a cobalt-chrome-molybde-num alloy (Wironit; BEGO, Bremen,Germany) and evaluated intraorallyfor fit, retention, and stability. Afterarranging the artificial teeth (Yama-hachi acrylic resin teeth; YamahachiDental Mfg Co, Gamagori City, Ja-pan), the RPDs were evaluated intra-

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orally in terms of esthetics, speech,and functional fit. Finally, prostheseswere completed and occlusal adjust-ment was performed conventionally.24Afterward, the completed and adjust-ed RPDs were remounted to a semi-adjustable articulator (Stratos 100;Ivoclar Vivadent) in centric relation

to fabricate the acrylic resin-retainedmetal guidance flange (Steady-Res-in; Scheu-Dental GmbH) extendingfrom the distal surface of the maxil-lary second premolar area along thefirst and second molars on the defect(right) side (Fig. 4). Fixed metal-ce-ramic restorations were cemented(Meron; VOCO) the day before initialplacement of the RPD (Fig. 5). Afterthe adjustment of intaglio surfaces, a

group function occlusal scheme wasdeveloped for the patient, and thenthe patient was advised to return forsubsequent recall appointments forevaluation of oral tissues.

The insertion appointment wasfollowed by the commencement ofphysical therapy, which consisted ofan isometric coordinating exercise tocontrol excessive translation. Patienteducation was provided by using amirror while the patient was asked toplace the tip of the tongue against thepalate. Then the patient attempted tomove the mandible to adjust to thecentric occlusion position with lightpressure, using the index fingers.

The patient was recalled for 24months at 6-month intervals. She re-ported difficulties in functioning forthe first 3 months. However, remark-able improvement was noted in mas-tication after 6 months. At the end

of 24 months, marked abrasion wasobserved at the buccal surface of themaxillary premolars and molars of themaxillary RPD and at the acrylic res-in-retained metal guidance flange ofthe mandibular RPD, confirming thecontribution of the MGP in maintain-ing a proper occlusion (Fig. 6). Alsoa space was evident as a result of thisabrasion which was then repaired byadding autopolymerizing acrylic resin

(Steady-Resin; Scheu-Dental GmbH)to the acrylic-retained metal guidance

4 Red arrows indicate acrylic metal guidance flange ofmandibular removable partial denture.

5 Intraoral view of definitive prosthesis.

6Twenty-four months after insertion of prostheses. Noteabrasion at buccal surface of maxillary premolars andmolars and of acrylic resin-retained metal guidance flangeof mandibular RPD.

flange (Fig. 7). The patient stated that

she could comfortably use her pros-thesis and easily manipulate her man-

dible when she was last seen at the

end of 24 months.

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DISCUSSION

Facial paralysis is characterizedby a unilateral sudden loss of mus-cular control of the face, resultingin an inability to close the eye, wink,raise the eyebrow, or smile on the af-fected side. The corner of the mouthusually droops, causing drooling ofsaliva onto the skin. The eye usuallywaters, probably as a result of theinability to close the eyelid properly.There is also a mask-like appearanceto the facial features on the affectedside and speech becomes slurred.25Although the presented patient mani-fested some of the aforementionedfeatures of facial paralysis (commis-sural droop, slurred speech, and fa-cial asymmetry), a comprehensiveclinical and radiographical examina-tion revealed a mandibular deviationdue to a chronic unilateral TMJ dislo-cation on the left side. Managementof chronic TMJ dislocation poses a

clinical challenge, and current treat-ment alternatives may involve surgicalintervention.3-10,11-13

The presented treatment method,including MGP and physical therapy,was considered to be the most ben-eficial for this patient, with severaladvantages, such as its noninvasive,reversible (guidance flange may beremoved when necessary), and sim-ple nature. Generally, the literature

describes the use of an MGP for pa-tients presenting with extensive soft

tissue loss, radiotherapy, classicalradical neck dissection, or segmental

mandibular resection, to prevent themandibular deviation.20,21 However,the use of the mandibular guidanceprosthesis for management of chronicTMJ dislocation resulting in mandib-ular deviation has not been previouslyreported.

The mandibular guidance prosthe-sis used for the described patient wasindicated since a surgical procedurewas not an option. Furthermore, itwas also noted that the patients man-dible could be manually placed intothe centric occlusion position with-out excessive force. It should be notedthat close follow up in the patientsearly adaptation period is mandatoryfor the success of this approach toconfirm the maintenance of a repeat-able centric occlusion position. Theabrasion of the acrylic resin-retainedmetal flange and the buccal surface ofthe maxillary premolars and molars of

the RPD over time demonstrates theefficacy of the treatment process. Theflanges could have been fabricatedfrom metal to prevent the abrasion;however, acrylic resin was used for thebase of the maxillary RPD.

The presence of maxillary andmandibular natural teeth contributedto the success of the present treatmentmodality. The natural teeth providedsupport for the retention and stability

of the prosthesis and also facilitatedthe mandibular guidance and the re-

programming of mandibular move-ments via proprioception.21In partic-ular, a comprehensive explanation ofthe etiology, detailed instructions tomaintain the mandible in the centricocclusion position during function-ing, and practicing of this techniquewere key factors to improve the effi-

cacy of the treatment provided.Although this procedure was ef-

fective for this specific patient, it hasseveral disadvantages. This prosthesiswas more bulky than conventionalRPDs, which may require more post-insertion appointments and longeradaptation time periods. Another sig-nificant disadvantage is the abrasionat the contact surface of the maxillaryRPD due to the acrylic resin-retained

metal guidance flange of the man-dibular RPD during function after aperiod of time. Therefore, this type ofprosthesis may need repair occasion-ally.

SUMMARY

Patients with recurrent or chronicunilateral dislocation of the temporo-mandibular joint may present withfacial asymmetry due to mandibulardeviation, impairment of function,and discomfort. As presented in thisclinical report, the use of surgical in-terventions may be restricted in thesepatients, and for that reason, a man-dibular guidance prosthesis combinedwith physical therapy may be a treat-ment alternative.

REFERENCES

1. Okeson JP. Management of temporoman-dibular disorders and occlusion. 6th ed. StLouis: Elsevier Health Sciences; 2007. p.191-3, 423-4.

2. Kaplan JA, Assael LA. Temporomandibulardisorders: diagnosis and treatment. Phila-delphia: W B Saunders; 1991. p. 488.

3. Adekeye EO, Shamia RI, Cove P. InvertedL-shaped ramus osteotomy for prolongedbilateral dislocation of the temporoman-dibular joint. Oral Surg Oral Med OralPathol 1976;41:568-77.

4. Caminiti MF, Weinberg S. Chronic man-dibular dislocation: the role of non-surgicaland surgical treatment. J Can Dent Assoc

1998;64:484-91.5. Kummoona R. Surgical reconstruction of

7 Space created by abrasion repaired by adding autopolymerized acrylicresin to acrylic resin-retained metal guidance flange.

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the temporomandibular joint for chronicsubluxation and dislocation. Int J Oral Max-illofac Surg 2001;30:344-8.

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9. Allen FJ, Young AH. Lateral displacement ofthe intact mandibular condyle. A report offive cases. Br J Oral Surg 1969;7:24-30.

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15.Lawlor MG. Recurrent dislocation ofthe mandible: treatment of ten cases bythe Dautrey procedure. Br J Oral Surg1982;20:14-21.

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17.Srivastava D, Rajadnya M, Chaudhary MK,Srivastava JL. The Dautrey procedure inrecurrent dislocation: a review of 12 cases.Int J Oral Maxillofac Surg 1994;23:229-31.

18.Undt G, Kermer C, Rasse M. Treatmentof recurrent mandibular dislocation, PartII: Eminectomy. Int J Oral Maxillofac Surg1997;26:98-102.

19.Segami N, Kaneyama K, Tsurusako S, Suzu-ki T. Arthroscopic eminoplasty for habitual

dislocation of the temporomandibularjoint: preliminary study. J CraniomaxillofacSurg 1999;27:390-7.

20.Sahin N, Hekimoglu C, Aslan Y. Thefabrication of cast metal guidance flangeprostheses for a patient with segmental

mandibulectomy: a clinical report. J Pros-thet Dent 2005;93:217-20.

21.Beumer III J, Curtis TA, Marunick MT. Max-illofacial rehabilitation: prosthodontic andsurgical considerations. St. Louis: IshiyakuEuroAmerica; 1996. p. 184-6.

22. Dawson PE. Evaluation, diagnosis, andtreatment of occlusal problems. 2nd. ed. StLouis: Mosby; 1988. p. 35-9.

23.Rosenstiel SF, Land MF, Fujimoto J.Contemporary fixed prosthodontics. 4th.

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24.Phoenix RD, Cagna DR, DeFreest CF.Stewarts clinical removable partial prosth-odontics. 3rd ed. Chicago: QuintessencePublishing Co; 2003. p. 367-95.

25.Neville BW, Damm DD, Allen CM, BouquotJE. Oral and maxillofacial pathology. 2nded. Philadelphia: WB Saunders; 2001. p.741-62.

Corresponding author:Dr Tuncer Burak OzcelikBaskent niversitesi Ksla Saglk YerleskesiKazm Karabekir Mahallesi 59. Sokak

No: 91 Yregir Posta Kodu01120 AdanaTURKEYFax: +90 322 322 79 79E-mail: [email protected]

Copyright 2008 by the Editorial Council forThe Journal of Prosthetic Dentistry.

Ozcelik and Pektas

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