Oral Surgery ISSN 1752-2471
CASE REPORT
Traumatic long-standing unilateral dislocation of TMJ
a case report
M.R. Mohd Razi1, A.K. Zamhari2 & S.W. Lee2
1
Department of Paediatric Dentistry, Hospital Umum Sarawak, Kuching, Sarawak 93586, Malaysia
2
Department of Oral Surgery, Hospital Umum Sarawak, Kuching, Sarawak 93586, Malaysia
Key words:
dislocation, paediatric, TMJ
Correspondence to:
Dr Mohd Ridzuan Mohd Razi
Klinik Pakar Pergigian
Hospital Umum Sarawak, Jalan Tun
Ahmad Zaidi Adruce 93586 Kuching
Sarawak
Malaysia
Tel.: +60 8241 3480 (ofce)
Fax: +60 8224 2751
email: ridzuan.razi@yahoo.com
Accepted: 21 December 2014
doi:10.1111/ors.12151
Introduction
Temporomandibular joint (TMJ) dislocation occurs
when the mandibular condyle is displaced anteriorly
beyond the articular eminence, hence, completely out
of the glenoid fossa. It can be categorised into three
groups: acute, long-standing and recurrent1,2. Long-
standing dislocation of TMJ refers to an acute dislocation
left untreated or inadequately treated for more than
72 h during which the acute inflammation process has
slowed down and repairing granulation tissue starts
forming3. Bilateral anterior dislocation of the TMJ is not
uncommon, unilateral dislocations, however, are rare4.
This article presents an unusual case of traumatic
long-standing unilateral dislocation of TMJ in adoles-
cent which was managed by manual reduction and
intermaxillary fixation (IMF).
Case report
History
A fit and healthy 15-year-old boy was referred to our
clinic for management of facial pain around both TMJ
Oral Surgery 9 (2016) 35--39.
2015 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Abstract
This article aims to report a rare case of traumatic long-standing unilateral
dislocation of temporomandibular joint (TMJ). To the best of our knowl-
edge, this is the first reported case of unilateral TMJ dislocation in the pae-
diatric population. A healthy 15-year-old boy presented to our department
complaining of facial pain around the TMJ region. A diagnosis of unilateral
left TMJ dislocation associated with myofacial pain was made based on
history, clinical and radiographic examinations. Manual reduction alone
was not successful to keep the reduced left condyle within the glenoid fossa.
Intermaxillary fixation was needed to improve the treatment outcome.
Non-steroidal anti-inflammatory drug was prescribed for myofacial pain.
The management of this case was challenging contributed to the nature of
clinical presentations.
regions. The pain developed after he sustained a blunt
trauma; that is hit by a metal rod, to his lower right jaw.
He, however, only presented to our clinic 11 days after
the incident.
The pain was dull and throbbing in nature. The
intensity of pain was almost constant throughout the
day only to aggravate by mandible movement. He had
difficulty in chewing food and noted that his bite was
not the same since the incident.
Clinical examination
Clinical examination demonstrated asymmetrical
face with the chin point deviated to the right. The
mandible was deviated to right on opening. Mouth
opening was not restricted and he was able to
perform lateral excursion of mandible. Left TMJ
and muscles of mastication were also tender to
palpation.
Intraoral examination demonstrated localised
calculus deposition of the cervical region of upper
first permanent molars. Occlusion was deranged with
the lower midline shifted to the right (Figure 1). The
35
Unilateral dislocation of TMJ Mohd Razi et al.

Figure 2 Dental panoramic tomogram showing the left condyle was out
(A) from glenoid fossa. Crowns fracture involving the 41, 42 and 43 with no
pulpal involvement.

Diagnosis
Diagnosis of long-standing unilateral dislocation of left
condyle, myofacial pain and uncomplicated crown
fracture of 41, 42 and 43 were made.

Treatment
Manual reduction of left condyle was carried out suc-
(B) cessfully; the dislocation however, relapsed almost
immediately. The procedure was repeated and IMF was
placed (Figure 4). Non-steroidal anti-inflammatory
drug (NSAID) that is Ibuprufen 400 mg at 8 hourly was
prescribed for 2 weeks to address myofacial pain. After
2 weeks, IMF was removed. The occlusion was stable
and myofacial pain has resolved. In addition, the frac-
tured lower incisors and canine were restored with
composite and localised scaling was carried out.

(C)
Figure 1 Occlusion at rst presentation, (A) anterior view (B) right pos-
terior occlusion (C) left posterior occlusion. The lower midline was shifted
to right and the posterior teeth were not in intercuspation.
crown of 41, 42 and 43 were fractured with no pulpal
involvement.
Radiographic examination
Dental panoramic tomogram (DPT) revealed the left
condyle was displaced and out of the glenoid fossa
(Figure 2). Cone beam volume tomography (CBVT) of
both condyles further confirmed dislocation of left
condyle (Figure 3).
Follow-up
Follow-up appointments has been carried out at 1 and
3 months post-treatment. He had an uneventful
recovery, therefore discharged from our care.
Discussion
TMJ dislocation occurs when the condyles move
forward, slip underneath the articular eminence and
are completely displaced out of the glenoid fossa. Most
frequently this event occurs as a result of extreme
mouth opening1,58 or trauma4,6. In addition, previous
reports have also documented anaesthetics pro-
cedures9,10, drugs11,12 and connective tissue disorder13
resulted in TMJ dislocation.
Long-standing TMJ dislocation of the condyle
causes muscle spasm, fibrotic changes of soft tissue and
soft tissue in-growth into the glenoid fossa making
reduction difficult14. Although manual reduction of

36 Oral Surgery 9 (2016) 35--39.

2015 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Mohd Razi et al.
Figure 3 Coronal views of CVCT of (A) right
TMJ and (B) left TMJ. The position of the left
condyle was displaced from glenoid fossa
compared to the right condyle which was in (A)
normal position.
long-standing dislocated TMJ is still primary choice of
treatment, this approach alone frequently fails
and fixation is necessary to prevent recurrence3. In
the literature, other available treatment options have
been described and can be categorised into non-
surgical (e.g. injection of sclerozing agents, autologous
blood15,16 and botulinum toxin17) and surgical therapies
(e.g. myotomy, eminectomy, and augmentation of the
articular eminence with a bone graft1820).
In this article we presented a case of long-standing
unilateral TMJ dislocation resulted from direct trauma
to the mandible. The patient presented late to our clinic
with deranged occlusion, spasm and tenderness of the
muscles of mastication. Manual reduction was carried
out without anaesthesia or sedation as patient was
willing to endure the procedure. The manual reduction
was successful with patient was able to achieved good
intercuspation of the posterior teeth. The dislocation,
however, was immediately relapsed with evidence of
deviated chin point and deranged occlusion. The
relapse suggested the muscles spasms exerted forces to
the condyle resulting in dislocation3.
In order to keep the left condyle in glenoid fossa, and
to allow muscles of mastication to relax, the patient
was put under IMF. This was achieved with four eyelets
placed in each quadrant and a soft wire (0.3 mm in
diameter) on each side of the jaws as intermaxillary
Oral Surgery 9 (2016) 35--39.
2015 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Unilateral dislocation of TMJ
(B)
fixator. The rationale of using soft wire was to reduce
the likelihood of ankylosis of the TMJ. We are opting
for eyelets and tie wire rather than upper and lower
archbars with orthodontic elastic or tie wire in view of
easy and less traumatic placement.
Examination of muscle of mastication revealed ten-
derness on palpation suggesting spasm of the muscles.
Therefore, pain relief and muscle relaxation form a
major part of treatment. NSAIDs have been suggested
to be taken on regular basis rather than as needed
basis to maximise their anti-inflammatory effect21. In
this case we only prescribed the medication for 2 weeks
rather than the suggested period21 with resolved
symptoms at review appointment. In our opinion the
immobilisation of TMJ with IMF not only maintains
the condyle in glenoid fossa but also allowed relaxation
of muscle of mastication thus significantly reduces the
duration of symptoms.
Conclusion
Unilateral TMJ dislocation is a rare occurrence. An
immediate manual reduction of TMJ in acute episode is
the best treatment approach. In this case, due to the
nature of long-standing dislocation, manual reduction
alone was not successful to keep the condyle in glenoid
fossa. IMF was required to prevent the relapsed.
37
Unilateral dislocation of TMJ
(A)
(B)
Figure 4 (A) Right posterior occlusion (B) left posterior occlusion after
manual reduction of left condyle with the intermaxillary xation (eyelets) in
situ. The intercuspation of the posterior teeth were improved compared to
initial presentation.
Acknowledgements
We wish to thank the Director General of Health,
Malaysia for granting permission to publish this case
report. Our thanks also go to the Sarawak State Deputy
Director of Oral Health services and the Principal
Director of Oral Health Division, Ministry of Health
Malaysia for their continual support.
Conflict of interest
The authors confirm that they have no conflict of
interest.
38
Mohd Razi et al.
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