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TECHNICAL NOTES

J Oral Maxillofac Surg


68:2021-2024, 2010

Dautreys Procedure in Treatment of


Recurrent Dislocation of the Mandible
Kiran Shrikrishna Gadre, MDS,* Deepak Kaul, MDS,
Shandilya Ramanojam, MDS, and Shishir Shah, MDS

The temporomandibular joint (TMJ) is the most com- the condylar path. LeClerc and Girard3 performed a
plex joint in the human body. This joint is in use even vertical osteotomy of the zygomatic arch and low-
when no activity seems to be apparent. It is the most ered the proximal segment and placed a thicker
used, as well as the most abused, joint. This abuse brings part of the zygoma into the path of the condyle.
with it a number of problems, one of which is hyper- The procedure was refined by Gosserez and Dau-
mobility of the TMJ. Hypermobility of the joint can trey4 in 1967. Currently, the procedure is known as
result in recurrent dislocation of the mandible which, Dautreys procedure. In this procedure, the zygo-
although uncommon, is a distressing condition. matic arch is osteotomized downward and forward
Various methods have been tried for the treatment of just in front of the articular eminence to create a
this disorder. The treatment modalities have been either mechanical obstruction. This procedure gained
conservative or surgical. Although initially conservative popularity during its initial years but somehow was
treatment is preferred, when it fails, the only option lost thereafter for quite some time.
remaining is surgical. In patients with chronic recurrent Recently, many investigators have been using this
dislocation, conservative treatment such as maxilloman- procedure, but few have reported their findings.
dibular fixation (MMF) and injections of sclerosing solu- Therefore, the aim of the present study was to under-
tions often result in failure. Thus, such cases require stand the philosophy behind the procedure and to
surgical management. evaluate the efficacy of fixation in this procedure to
The surgical procedures can be categorized un- achieve better outcomes.
der 2 main headings: 1) procedures that enhance
the path of condylar movement; and 2) those that
inhibit the path of condylar movement. The most
common procedure in the first category is eminec-
Materials and Methods
tomy, as described by Myrhaug1 in 1951. It includes In the present retrospective study, 20 patients
a reduction in the height of the articular eminence (12 males and 8 females, mean age 37.55 years)
such that the condyle will readily slip back into the with bilateral chronic recurrent dislocation of the
fossa if subluxation occurs. However, it has been TMJ with or without symptoms such as pain and
found to encroach on the physiologic pattern of clicking were selected and treated using Dautreys
condylar movement. procedure during a 5-year period (2001 to 2006).
Mayer2 was the first to report the displacement of The total number of procedures performed was 40.
the zygomatic arch (or a segment of it) to obstruct None of the patients were medically compromised
or had any psychiatric disorder. The youngest was
Received from the Department of Oral and Maxillofacial Surgery, 14 years and the oldest was 60 years of age (Table
Bharati Vidyapeeth Dental College and Hospital, Pune, Maharash- 1). The total number of joints treated was 40. The
tra, India. duration of symptoms ranged from 3 months to 11
*Professor. years. All patients had undergone several manual
Former Resident. reductions and other treatment modalities such as
Former Resident. MMF, injections of sclerosing solutions, and emi-
Former Resident. nectomy. No abnormality was detected on the pre-
Address correspondence and reprint requests to Dr Gadre: Sun- operative TMJ radiographs (right and left transcra-
rise 2122, Vijaynagar Colony, Behind Kaveri Hotel, Pune, Maharash- nial view of the TMJ in the closed and open mouth
tra 411-030 India; e-mail: kiran_gadre@hotmail.com positions). A comparison of the preoperative and
2010 American Association of Oral and Maxillofacial Surgeons postoperative interincisal opening (IIO) values was
0278-2391/10/6808-0047$36.00/0 performed. The IIO amount was recorded at 1, 6,
doi:10.1016/j.joms.2009.10.015 12, 18, and 36 months postoperatively. The subjec-

2021
2022 DAUTREYS PROCEDURE FOR RECURRENT MANDIBLE DISLOCATION

Table 1. RESULTS OF DAUTREYS PROCEDURE IN 20 PATIENTS (40 JOINTS)

Mouth Opening (mm)


Pt No. Gender Age (yr) Baseline 1 mo 6 mo 12 mo 18 mo Follow-Up (mo) Recurrence

1 Male 23 52 26 36 38 38 60 No
2 Male 51 56 30 32 36 36 57 No
3 Female 17 47 24 30 39 41 51 No
4 Female 43 53 32 37 41 41 51 No
5 Male 57 46 28 29 37 36 47 No
6 Female 33 39 36 40 41 42 42 No
7 Male 29 48 29 39 38 38 42 No
8 Female 47* 42 27 36 42 43 42 No
9 Male 24 54 24 32 40 41 37 No
10 Male 55 55 33 30 40 41 35 No
11 Male 21 47 31 42 42 43 31 No
12 Female 19 49 28 37 45 45 34 No
13 Male 56* 50 35 42 41 41 34 No
14 Male 44 38 31 31 39 41 31 No
15 Female 37 45 25 29 37 37 29 No
16 Female 22 51 24 35 41 40 31 No
17 Male 53 33 29 39 39 39 30 No
18 Male 14 42 31 41 42 42 28 No
19 Female 46 36 29 35 38 39 22 No
20 Male 60 56 26 32 36 36 19 No
Mean 47 31 35 40 40
Abbreviation: Pt No., patient number.
*Bone graft use.
Arch fracture occurred.
Gadre et al. Dautreys Procedure for Recurrent Mandible Dislocation. J Oral Maxillofac Surg 2010.

tive description of the overall well-being of the prefer a nasal septal osteotome to perform these ma-
patient was noted. neuvers. The arch is kept in its new position by the
In Dautreys procedure,5 the zygomatic arch is inherent elasticity of the bone.
cut downward and forward just in front of the
articular eminence and then locked under the em-
inence, preventing excessive forward movement of
the condyle.
We prefer a preauricular approach with temporal
extension from the variety of available approaches.
Along the temporal fascia, the zygomatic arch and
capsule of the TMJ are easily reached. The fascia and
periosteum are horizontally incised only at the root of
the zygoma. Next, the posterior portion of the arch
and the superolateral aspect of the capsule are ex-
posed. Care should be taken not to strip the fascial
and periosteal attachment from the anterior portion
of the zygomatic arch, especially at the zygomatico-
malar suture.5 If their attachment is stripped off, a
true fracture will occur at the suture, and the conti-
nuity and elasticity of the arch will be lost, defeating
the purpose. The osteotomy cut should start postero-
superiorly on the zygomatic arch in front of the artic-
ular eminence and end anteroinferiorly (Fig 1). At the
distal fragment of the zygomatic arch, firm and con-
trolled pressure should be applied to create a green
stick fracture anterior to the osteotomy site. The frag- FIGURE 1. Osteotomy.
ment is then mobilized laterally and then downward Gadre et al. Dautreys Procedure for Recurrent Mandible Dislo-
and finally locked under the articular eminence. We cation. J Oral Maxillofac Surg 2010.
GADRE ET AL 2023

cations occurred in any patient. Also, no patient de-


veloped postoperative infection or experienced in-
jury to the temporal branch of the facial nerve. None
of the patients had experienced postoperative pain or
clicking throughout the follow-up period. The post-
operative radiographs at the end of 12 and 18 months
showed no pathologic changes in the joints.

Discussion
Recurrent dislocation of the mandible is defined as
a displacement of the condyle in front of the articular
eminence where it is held by spasm of the muscles of
mastication. When this occurs, the patient requires
medical assistance to reduce the condyle back into
the glenoid fossa.6
A variety of treatment modalities have been used
for chronic recurrent dislocation of the mandible.
Both medical and surgical modalities have been ex-
tensively tried. Most of them have had limitations in
the form of recurrence, morbidity, functional impair-
ment, and a lack of satisfactory results. This has left
the patient with chronic recurrent dislocation of the
mandible in jeopardy.
Medical treatments have also been tried, including
FIGURE 2. Fixation with miniplates and screws. the injection of sclerosants into the joint to produce
capsular fibrosis and eliminate excessive condylar
Gadre et al. Dautreys Procedure for Recurrent Mandible Dislo-
cation. J Oral Maxillofac Surg 2010. movement.7
Of the surgical modalities, enhancing the condylar
path has normally been accomplished by either con-
To avoid any movement or displacement at the dylectomy8 or eminectomy.1,9,10 To inhibit the con-
osteotomy site, rigid fixation with a 2- or 1.5-mm dylar movement, both soft and hard tissue procedures
4-holed plate and screws 6 mm in length was done in have been used.
all cases (Fig 2). MMF is not needed postoperatively. Soft tissue operations have included plication of the
Excessive mouth opening was prohibited for 21 days. capsule,11,12 detachment of the lateral pterygoid mus-
cle from the condyle with capsulorrhaphy,13 menisec-
tomy,14 and scarification of the temporalis tendon.15
Results Hard tissue procedures have included displace-
In all the cases, we achieved total resolution of the ment of the zygomatic arch (or a segment of it) to
recurrent dislocation immediately after surgery. The obstruct the condylar path,2 placing a thicker part
follow-up ranged from 19 to 60 months. After 1 of the zygoma into the path of the condyle by
month, the minimal and maximal IIO were 24 and 36 performing vertical osteotomy of the zygomatic
mm, respectively. A gradual increase occurred in the arch,3 and posteroanterior slanting osteotomy of
IIO postoperatively that had settled within a range of the eminence.4,6,16-20
35 to 45 mm by 12 months postoperatively. The Various heterogeneous materials have been used to
maximal improvement in the IIO without subluxation restrict the condylar pathway, such as a stainless steel
from 1 to 18 months was 17 mm, and the minimum pin,21 vitallium mesh,22 a Dacron strip to ligate the
was 6 mm. The IIO was unchanged thereafter. Other zygomatic arch to the condyle,23-25 and on-lay bone
symptoms such as pain and clicking had also resolved grafting.26
by 3 months postoperatively. Fixation with miniplates Although the procedures enhancing the path of
and screws in all cases provided stable results for a condylar movement can lead to increased laxity of the
long period. None of the patients required plate re- ligaments of the TMJ and can cause additional injury
moval. The results we achieved were favorable, and to the meniscus, Dautreys procedure restores the
no recurrence developed in any of our patients. Other normal functional and physiologic movement of the
than postoperative pain and edema, no major compli- TMJ without abnormal forward excursion. Proce-
2024 DAUTREYS PROCEDURE FOR RECURRENT MANDIBLE DISLOCATION

dures such MMF and other soft tissue procedures also 4. Gosserez M, Dautrey J: Osteoplastic bearing for treatment of
temporomandibular luxation. Transaction of Second Congress
temporarily prevent abnormal forward excursion.
of the International Association of Oral Surgeons Copenhagen,
In 2 cases, grafting was needed. In the first, the Munksgaard. Int J Oral Surg IV:261, 1967
height of the zygomatic arch was inadequate. The 5. Dautrey J: Reflexions sur la chirugie de particulation temporo-
second patient had been treated with eminectomy mandibulaire. Stomologica Belg 72:577, 1975
6. Lawler MG: Recurrent dislocation of the mandible: Treatment
elsewhere 10 years previously and had recurrent pain of ten cases by the Dautrey procedure. Br J Oral Surg 20:14,
owing to increased laxity of the ligaments of the TMJ. 1982
The bone was harvested from the mastoid region, 7. Schultz LW: Report of ten years experience treatment, hyper-
which was in the vicinity of the surgical site. mobility of the TMJ. J Oral Surg 5:202, 1947
8. Litzow TJ, Royer RQ: Treatment of long standing dislocation of
In 1 case (a 60-year-old man), a complete fracture of the mandible: Report of one case. Mayo Clin Proc 37:399, 1962
the zygomatic arch anteriorly on one side occurred 9. Irby WB: Surgical correction of chronic dislocation of the
that was recognized and fixed with miniplates and temporomandibular joint not responsive to conservative ther-
apy. J Oral Surg 15:307, 1957
screws.
10. Hale RH: Treatment of recurrent dislocation of the mandible:
The IIO at which the dislocation occurred varied Review of literature and report of case. J Oral Surg 30:527,
greatly from 33 to 56 mm. 1972
Published reports have suggested the need for fix- 11. Hudson HNG: Operation for recurrent subluxation of TMJ. BMJ
2:254, 1945
ation of the osteotomized fragments.6 Several studies 12. Sanders B, Newman R: Surgical treatment for recurrent dislo-
have reported that Dautreys original procedure cation or chronic subluxation of the TMJ. Int J Oral Surg 4:179,
(without fixation) is effective, and no fixation is need- 1975
ed.18,20 Poirier et al27 stated that the use of 13. Bowman K: New operation for luxation in TMJ. Acta Chir
Scand 99:96, 1949
miniplates for fixation avoids recurrence. Revington28 14. Dingman RO, Moorman WC: Menisectomy in the treatment of
concluded that the reason for the recurrence was that lesions of the TMJ. J Oral Surg 9:214, 1951
the small condylar head was able to pass anteromedi- 15. Gould JF: Shortening of temporalis tendon for hypermobility of
TMJ. J Oral Surg 36:781, 1978
ally to the downward fractured zygomatic arch. In the
16. Sailer HF, Anotnioni N: Ergebnisse der LeClercOperation bei
first operation, the downward fractured zygomatic habitueller Kiefergelenk und Diskusluxation. Fortschr Kiefer
arches were still in a satisfactory position without Gesichts Chir 25:43, 1980
fixation. In the second operation, the zygomatic arch 17. Chausse JM, Richter M, Bettex A: Deliberate, fixed extra-artic-
ular obstruction. Treatment of choice for subluxation and true
was pushed further medially; therefore, wire ligatures recurrent dislocation of the temporomandibular joint. J Crani-
were required. If the condylar width had been nor- omaxillofac Surg 15:137, 1987
mal, the fixation would not have been necessary. 18. Izuka T, Hidaka Y, Murakami K, et al: Chronic recurrent ante-
Except in 1 case, in which biodegradable implants rior luxation of the mandible. Int J Oral Maxillofac Surg 17:170,
1988
were used, the others were performed using stainless 19. Srivastava D, Rajadnya M, Chaudhary K, et al: The Dautrey
steel implants. Irrespective of the plating system used, procedure in recurrent dislocation: A review of twelve cases.
the outcome was the same. We believe fixation pro- Int J Oral Maxillofac Surg 23:229, 1993
20. Kobayashi H, Yamazaki T, Okudera H: Correction of recurrent
vides not only rigidity to the osteotomy site during
dislocation of the mandible in elderly patients by the Dautrey
healing, but also allows the arch and graft to be procedure. Br J Oral Maxillofac Surg 38:54, 2000
positioned and retained in an optimal position, thus 21. Findlay IA: Operation for arrest of excessive condylar move-
reducing the risk of recurrence. ment. J Oral Surg, Anesth Hosp D Serv 22:110, 1964
22. Howe AG, Kent JN, Farrell CD, et al: Implant OD articular
Dautreys surgical procedure is extremely effective eminence for recurrent dislocation of TMJ. J Oral Surg 36:523,
for the treatment of chronic recurrent dislocation of 1978
the mandible without restricting the normal mouth 23. Georgiade N: Ligation of the condyle to the zygomatic arch:
opening. Fixation provides better rigidity of the os- Surgical correction of chronic luxation of mandibular condyle.
Plastic Reconstr Surg 36:339, 1965
teotomized segment and reduces the risk of recur- 24. Merril RG: Habitual subluxation and recurrent dislocation in a
rence. patient with Parkinsons disease: Report of a case. J Oral Surg
26:473, 1968
25. Boudreaux RE, Spire ED: Plication of the capsular ligament of
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