Management of chronic unilateral temporomandibular joint dislocation with a mandibular guidance prosthesis: A clinical report

Tuncer Burak Ozcelik, DDS, PhD,a and Zafer Ozgur Pektas, DDS, PhDb Baskent University, Faculty of Dentistry, Adana, Turkey
Recurrent or chronic dislocation of the temporomandibular joint is relatively rare and often results in facial asymmetry, impairment of function, and discomfort. Although manual reduction is the primary choice of treatment, patients presenting with recurrent or prolonged dislocations require conservative and surgical methods to limit forward movement of the mandibular condyle. This clinical report presents a 75-year-old woman with severe mandibular deviation and subsequent facial asymmetry caused by a chronic unilateral temporomandibular joint dislocation that was treated with a mandibular guidance prosthesis combined with physical therapy. (J Prosthet Dent 2008;99:95-100) Recurrent or chronic temporomandibular joint (TMJ) dislocation is a distressing clinical condition which is characterized by a condyle that slides over the articular eminence, catches briefly beyond the eminence, and then returns to the fossa.1-6 Chronic TMJ dislocations are relatively rare and frequently associated with intraarticular effusion, muscle spasms, and joint pain, causing facial asymmetry, mandibular deviation, and severe discomfort which interferes with speech and mastication.1-3,7 Radiographically, the articular eminence is frequently atrophic and the glenoid fossa is generally flattened.2 Congenital joint weakness, excessive mouth opening during yawning, dental or otorhinolaryngological treatment, neurogenic muscular hyperactivity, systemic diseases resulting in the hypermobility of the TMJ, pyschogenic and neurologic disorders, drugs (especially antiemetics and phenothiazines) which produce extrapyramidal effects, trauma,3,5,8 weakness or laxity of the capsule, and internal derangement of the TMJ1,2 account for the etiological and predisposing factors for condylar dislocation. Classifications were proposed
a

for TMJ dislocations and are based on the number of affected TMJs (unilateral or bilateral), the direction of the displacement (anterior, posterior, medial, lateral),9,10 and the duration of the dislocation as acute, chronic (prolonged), or recurrent, as described by Adekeye et al.3 Various conservative and surgical methods have been introduced for treating dislocations. Manual reduction of the dislocated TMJ is the primary choice of treatment. However, this frequently fails in patients with chronic or recurrent dislocations, and alternative treatment modalities are required for these patients. Nonsurgical therapies include intermaxillary fixation, injection of sclerozing agents11 and injection of autologous blood around the TMJ to create fibrosis,12 and botulinum toxin injection into the lateral pterygoid muscles.13 The current surgical procedures include either creation of a mechanical obstacle to limit the forward excursion of the condylar head,6,14-17 or removal of obstacles in the condylar path with an eminectomy18 or with a more recently described method, arthroscopic eminoplasty.19 This article presents the manage-

ment of a chronic unilateral temporomandibular joint dislocation with a mandibular guidance prosthesis (MGP) combined20,21 with physical therapy for a patient referred with the complaint of severe mandibular deviation and subsequent facial asymmetry. The patient initially presented with a misdiagnosis of a possible facial paralysis or a disorder of the facial motor activity, which, in fact, was caused by chronic dislocation.

CLINICAL REPORT
A 75-year-old white woman was referred with a preliminary diagnosis of facial paralysis due to facial asymmetry in the beginning of 2004. She reported an asymmetric face and deviation of the mandible for approximately 8 to 12 months. The patient also reported shifting her mandible unconsciously to the left any time she was nervous or distressed. She reported a consistent shift of the mandible to the left which interfered with her eating and speech for approximately 6 months. During this period, she also had difficulties with her existing prosthesis, which was fabricated by a nondentist in a rural region (Fig. 1).

Postdoctoral Fellow, Department of Prosthodontics. Assistant Professor, Department of Oral and Maxillofacial Surgery.

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Her medical history was significant, with an abdominoperineal resection and partial nephrectomy due to a rectal carcinoma in 1999, followed by multiple chemotherapy sessions. In 2002, she was referred to the Department of Psychiatry, where a diagnosis of major depression was established and psychotropic drugs were prescribed for 2 years. She reported complaints of asymmetric face, and speech and masticatory disturbance in 2003, initially, when she was still under the supervision of her psychiatrist. The severity of her symptoms increased in 2004 when her daughter died. Extraoral examination revealed a mandibular protrusion and deviation to the left. Although a commissural droop and slurred speech were evident, there was no eyelid droop or eye deviation at the right side. The functions of facial nerves were examined by asking the patient to raise both eyebrows, smile, and show the mandibular teeth. During these movements, no bilateral differences were recorded. Palpation of the masticatory muscles and functional manipulation did not reveal any painful muscle. The patient was edentulous except for the maxillary incisors and canines, left mandibular canine, and second premolar, as determined by intraoral examination. A reverse articulation was present on the left side and slight limitation was observed in the maximum interincisal opening and right mandibular movement. The bimanual manipulation technique for mandibular guidance proposed by Dawson22 was used to orientate the patients mandible to the centric relation (CR) position, in which it was easily placed, to evaluate the reverse articulation. This manipulation and positioning resolved the left side reverse articulation. However, subsequent instruction for opening and closing movements resulted in a mandibular protrusion and simultaneous mandibular deviation to the left. When these symptoms were considered, a recurrent or chronic unilateral dislocation of temporomandibular joint (TMJ) was determined to be the likely diagnosis rather than facial paralysis. Subsequent to the clinical examination, magnetic resonance imaging was performed to establish a defini-

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tive diagnosis. The relationship of the left TMJ was determined to be normal in closed and open positions, whereas a derangement in the condyle disc relationship (Fig. 2, A) and condylar dislocation was observed in the right TMJ in open position (Fig. 2, B). Fur-

1 Mandibular deviation to left caused by chronic TMJ dislocation.

B
2 A, Magnetic resonance image view showing derangement of condyle disc relationship of right TMJ in closed mouth position. B, Open mouth position.

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thermore, flatness of the glenoid fossa with atrophy of the articular eminence was observed. The patient and her family refused any surgical intervention due to the age of the patient, psychological status, and remarkable medical history, including an abdominoperineal resection and partial nephrectomy due to a rectal carcinoma in 1999, followed by multiple chemotherapy sessions and a major depression in the following period. Therefore, the only treatment alternative was a conventional approach. Lateral pterygoid-directed botulinum toxin injection, which is currently described as the treatment of choice for recurrent or chronic TME dislocation, was considered as an alternative option.13 However, although the application is a minimally invasive technique, it was not considered due to the fact that a majority of patients require the use of additional lateral pterygoid-directed botulinum toxin injections, and complications including dysphasia, nasal speech, painful mastication, nasal regurgitation, and dysarthria may develop following this treatment.12,13 In light of these considerations, a decision was made in favor of rehabilitation with the fabrication of an attachment-retained maxillary removable partial denture (RPD) and an MGP. The treatment plan also included physical therapy to maintain an accurate and repeatable centric occlusion position. The preliminary impressions were made with irreversible hydrocolloid (Cavex outline; Cavex Holland BV, Haarlem, Netherlands). The resultant diagnostic casts were surveyed (AF200; Amann Girrbach AG, Koblach, Austria) to determine the RPD design options. Then a definitive treatment plan for maxillary and mandibular RPDs was developed. The mouth preparation for fabrication of the RPD began with removing the existing restorations, as they were nonfunctional and ill-fitting, with poor esthetics. The maxillary incisors, canines, and mandibular left canine and second premolar were prepared with chamfer finish lines, and provisional restorations (Imident; Imicrly Dis Malzemeleri ve San ve Tic Ltd, STI, Konya, Turkey) were fabricated. After a week, definitive impressions of the prepared maxillary and mandibular teeth were made using a vinyl polysiloxane impression material (Speedex; Coltene/Whaledent Inc, Cuyahoga Falls, Ohio). Surveying of the definitive cast (AF200; Amann Girrbach AG), waxing, casting, milling, and finishing procedures for the fixed metal-ceramic restorations (Metaplus VK; AZ & Partner AG, Reiden, Switzerland and IPS d.SIGN; Ivoclar Vivadent, Schaan, Liechtenstein) were performed conventionally (Fig. 3).23 The patrix of the extracoronal ball attachments (OT Cap; Rhein83 Srl, Bologna, Italy) were placed at the distal surfaces of the canines in the maxillary fixed metal ceramic restoration (Metaplus VK; AZ & Partner AG, IPS d.SIGN; Ivoclar Vivadent) to increase retention and stability of the attachment-retained RPD. Also, a fixed partial denture (Metaplus VK; AZ & Partner AG, IPS d.SIGN; Ivoclar Vivadent) was fabricated between the left mandibular canine and second premolar conventionally.23 Extracoronal attachments were not considered in the mandible due to the inadequate number of abutment teeth. The mandibular fixed partial dentures were cemented (Meron; VOCO, Cuxhaven, Germany), while maxillary fixed metal-ceramic restorations with extracoronal ball attachments remained uncemented before making the definitive impression for the maxillary RPD. The definitive impressions for the framework of the maxillary and mandibular RPDs were made with a medium silicon impression material (Monopren transfer; Kettenbach GmbH & Co KG, Eschenburg, Germany) and a custom tray (Imibase; Imicrly Dis Malzemeleri ve San ve Tic Ltd, STI, Konya, Turkey). Final casts were made and mounted in a semiadjustable articulator (Stratos 100; Ivoclar Vivadent). The mandibular RPD design included a metal guidance flange on the defect (right) side to retain acrylic resin (Steady-Resin; Scheu-Dental GmbH, Iserlohn, Germany). This acrylic resin-retained metal guidance flange contacted the right buccal surface of the maxillary prosthesis without traumatizing the alveolar mucosa of the edentulous ridge while preventing mandibular deviation during function. Also, the mandibular RPD was retained by a cast circumferential retentive clasp assembly in a 0.25-mm undercut to provide retention and stability. The frameworks for the RPDs were cast from a cobalt-chrome-molybdenum alloy (Wironit; BEGO, Bremen, Germany) and evaluated intraorally for fit, retention, and stability. After arranging the artificial teeth (Yamahachi acrylic resin teeth; Yamahachi Dental Mfg Co, Gamagori City, Japan), the RPDs were evaluated intra-

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3 Trial evaluation of metal substructures.

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orally in terms of esthetics, speech, and functional fit. Finally, prostheses were completed and occlusal adjustment was performed conventionally.24 Afterward, the completed and adjusted RPDs were remounted to a semiadjustable articulator (Stratos 100; Ivoclar Vivadent) in centric relation to fabricate the acrylic resin-retained metal guidance flange (Steady-Resin; Scheu-Dental GmbH) extending from the distal surface of the maxillary second premolar area along the first and second molars on the defect (right) side (Fig. 4). Fixed metal-ceramic restorations were cemented (Meron; VOCO) the day before initial placement of the RPD (Fig. 5). After the adjustment of intaglio surfaces, a group function occlusal scheme was developed for the patient, and then the patient was advised to return for subsequent recall appointments for evaluation of oral tissues. The insertion appointment was followed by the commencement of physical therapy, which consisted of an isometric coordinating exercise to control excessive translation. Patient education was provided by using a mirror while the patient was asked to place the tip of the tongue against the palate. Then the patient attempted to move the mandible to adjust to the centric occlusion position with light pressure, using the index fingers. The patient was recalled for 24 months at 6-month intervals. She reported difficulties in functioning for the first 3 months. However, remarkable improvement was noted in mastication after 6 months. At the end of 24 months, marked abrasion was observed at the buccal surface of the maxillary premolars and molars of the maxillary RPD and at the acrylic resin-retained metal guidance flange of the mandibular RPD, confirming the contribution of the MGP in maintaining a proper occlusion (Fig. 6). Also a space was evident as a result of this abrasion which was then repaired by adding autopolymerizing acrylic resin (Steady-Resin; Scheu-Dental GmbH) to the acrylic-retained metal guidance

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

5 Intraoral view of definitive prosthesis.

6 Twenty-four months after insertion of prostheses. Note abrasion at buccal surface of maxillary premolars and molars and of acrylic resin-retained metal guidance flange of mandibular RPD. flange (Fig. 7). The patient stated that she could comfortably use her prosthesis and easily manipulate her mandible when she was last seen at the end of 24 months.

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programming of mandibular movements via proprioception.21 In particular, a comprehensive explanation of the etiology, detailed instructions to maintain the mandible in the centric occlusion position during functioning, and practicing of this technique were key factors to improve the efficacy of the treatment provided. Although this procedure was effective for this specific patient, it has several disadvantages. This prosthesis was more bulky than conventional RPDs, which may require more postinsertion appointments and longer adaptation time periods. Another significant disadvantage is the abrasion at the contact surface of the maxillary RPD due to the acrylic resin-retained metal guidance flange of the mandibular RPD during function after a period of time. Therefore, this type of prosthesis may need repair occasionally.

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

DISCUSSION
Facial paralysis is characterized by a unilateral sudden loss of muscular control of the face, resulting in an inability to close the eye, wink, raise the eyebrow, or smile on the affected side. The corner of the mouth usually droops, causing drooling of saliva onto the skin. The eye usually waters, probably as a result of the inability to close the eyelid properly. There is also a mask-like appearance to the facial features on the affected side and speech becomes slurred.25 Although the presented patient manifested some of the aforementioned features of facial paralysis (commissural droop, slurred speech, and facial asymmetry), a comprehensive clinical and radiographical examination revealed a mandibular deviation due to a chronic unilateral TMJ dislocation on the left side. Management of chronic TMJ dislocation poses a clinical challenge, and current treatment alternatives may involve surgical intervention.3-10,11-13 The presented treatment method, including MGP and physical therapy, was considered to be the most beneficial for this patient, with several advantages, such as its noninvasive, reversible (guidance flange may be removed when necessary), and simple nature. Generally, the literature describes the use of an MGP for patients presenting with extensive soft

tissue loss, radiotherapy, classical radical neck dissection, or segmental mandibular resection, to prevent the mandibular deviation.20,21 However, the use of the mandibular guidance prosthesis for management of chronic TMJ dislocation resulting in mandibular deviation has not been previously reported. The mandibular guidance prosthesis used for the described patient was indicated since a surgical procedure was not an option. Furthermore, it was also noted that the patients mandible could be manually placed into the centric occlusion position without excessive force. It should be noted that close follow up in the patients early adaptation period is mandatory for the success of this approach to confirm the maintenance of a repeatable centric occlusion position. The abrasion of the acrylic resin-retained metal flange and the buccal surface of the maxillary premolars and molars of the RPD over time demonstrates the efficacy of the treatment process. The flanges could have been fabricated from metal to prevent the abrasion; however, acrylic resin was used for the base of the maxillary RPD. The presence of maxillary and mandibular natural teeth contributed to the success of the present treatment modality. The natural teeth provided support for the retention and stability of the prosthesis and also facilitated the mandibular guidance and the re-

SUMMARY
Patients with recurrent or chronic unilateral dislocation of the temporomandibular joint may present with facial asymmetry due to mandibular deviation, impairment of function, and discomfort. As presented in this clinical report, the use of surgical interventions may be restricted in these patients, and for that reason, a mandibular guidance prosthesis combined with physical therapy may be a treatment alternative.

REFERENCES
1. Okeson JP. Management of temporomandibular disorders and occlusion. 6th ed. St Louis: Elsevier Health Sciences; 2007. p. 191-3, 423-4. 2. Kaplan JA, Assael LA. Temporomandibular disorders: diagnosis and treatment. Philadelphia: W B Saunders; 1991. p. 488. 3. Adekeye EO, Shamia RI, Cove P. Inverted L-shaped ramus osteotomy for prolonged bilateral dislocation of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1976;41:568-77. 4. Caminiti MF, Weinberg S. Chronic mandibular dislocation: the role of non-surgical and surgical treatment. J Can Dent Assoc 1998;64:484-91. 5. Kummoona R. Surgical reconstruction of

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the temporomandibular joint for chronic subluxation and dislocation. Int J Oral Maxillofac Surg 2001;30:344-8. 6. Undt G, Kermer C, Piehslinger E, Rasse M. Treatment of recurrent mandibular dislocation. Part I: Leclerc blocking procedure. Int J Oral Maxillofac Surg 1997;26:92-7. 7. Chin RS, Gropp H, Beirne OR. Long-standing mandibular dislocation: report of a case. J Oral Maxillofac Surg 1988;46:693-6. 8. Moore AP, Wood GD. Medical treatment of recurrent temporomandibular joint dislocation using botulinum toxin A. Br Dent J 1997;183:415-7. 9. Allen FJ, Young AH. Lateral displacement of the intact mandibular condyle. A report of five cases. Br J Oral Surg 1969;7:24-30. 10.Zecha JJ. Mandibular condyle dislocation into the middle cranial fossa. Int J Oral Surg 1977;6:141-6. 11.Kobayashi H, Yamazaki T, Okudera H. Correction of recurrent dislocation of the mandible in elderly patients by the Dautrey procedure. Br J Oral Maxillofac Surg 2000;38:54-7. 12.Martinez-Perez D, Garcia Ruiz-Espiga P. Recurrent temporomandibular joint dislocation treated with botulinum toxin: report of 3 cases. J Oral Maxillofac Surg 2004;62:244-6. 13.Ziegler CM, Haag C, Muhling J. Treatment of recurrent temporomandibular joint dislocation with intramuscular botulinum toxin injection. Clin Oral Investig 2003;7:52-5. 14.Dingman RO, Dingman DL, Lawrence RA. Surgical correction of lesions of the temporomandibular joints. Plast Reconstr Surg 1975;55:335-40. 15.Lawlor MG. Recurrent dislocation of the mandible: treatment of ten cases by the Dautrey procedure. Br J Oral Surg 1982;20:14-21. 16.Iizuka T, Hidaka Y, Murakami K, Nishida M. Chronic recurrent anterior luxation of the mandible. A review of 12 patients treated by the LeClerc procedure. Int J Oral Maxillofac Surg 1988;17:170-2. 17.Srivastava D, Rajadnya M, Chaudhary MK, Srivastava JL. The Dautrey procedure in recurrent dislocation: a review of 12 cases. Int J Oral Maxillofac Surg 1994;23:229-31. 18.Undt G, Kermer C, Rasse M. Treatment of recurrent mandibular dislocation, Part II: Eminectomy. Int J Oral Maxillofac Surg 1997;26:98-102. 19.Segami N, Kaneyama K, Tsurusako S, Suzuki T. Arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: preliminary study. J Craniomaxillofac Surg 1999;27:390-7. 20.Sahin N, Hekimoglu C, Aslan Y. The fabrication of cast metal guidance flange prostheses for a patient with segmental

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mandibulectomy: a clinical report. J Prosthet Dent 2005;93:217-20. 21.Beumer III J, Curtis TA, Marunick MT. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St. Louis: Ishiyaku EuroAmerica; 1996. p. 184-6. 22. Dawson PE. Evaluation, diagnosis, and treatment of occlusal problems. 2nd. ed. St Louis: Mosby; 1988. p. 35-9. 23.Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 4th. ed. St. Louis: Mosby; 2006. p. 555-708, 740-773. 24.Phoenix RD, Cagna DR, DeFreest CF. Stewarts clinical removable partial prosthodontics. 3rd ed. Chicago: Quintessence Publishing Co; 2003. p. 367-95. 25.Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2nd ed. Philadelphia: WB Saunders; 2001. p. 741-62. Corresponding author: Dr Tuncer Burak Ozcelik Baskent niversitesi Ksla Saglk Yerleskesi Kazm Karabekir Mahallesi 59. Sokak No: 91 Yregir Posta Kodu 01120 Adana TURKEY Fax: +90 322 322 79 79 E-mail: tbozcelik@yahoo.com Copyright 2008 by the Editorial Council for The Journal of Prosthetic Dentistry.

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