Beruflich Dokumente
Kultur Dokumente
Keywords Abstract
Temporomandibular joint; bilateral anterior
dislocation.
Nonreduced bilateral anterior dislocation of the temporomandibular joint (TMJ) is an
extremely rare condition, and its prosthodontic rehabilitation is a clinical challenge,
Correspondence
especially in patients who refuse to or cannot undergo surgery. There are no previous
Faleh Tamimi, Room M/64, Faculty of clinical reports of successful or standardized prosthetic rehabilitation approaches for
Dentistry, McGill University, 3640 University patients with this condition. This clinical report describes the successful prosthodontic
St., Montreal, Quebec H3A 0C7, Canada. management of an edentulous patient with nonreduced bilateral anterior dislocation
E-mail: faleh.tamimimarino@mcgill.ca of the TMJ.
∗
Both authors contributed equally.
doi: 10.1111/jopr.12318
Typically, at rest, the condyle of the mandible is positioned mised, and edentulous patients,3 with few clinical reports in the
in the most superior-posterior region of the glenoid fossa, and literature.4-6
at maximum opening opening, the 12 o’clock position of the The management approach of TMJ dislocations varies ac-
condyle is at the most inferior aspect of articular eminence cording to type of dislocation and its underlying cause. Vari-
on the zygomatic process of the temporal bone. Dislocation ous conservative and surgical methods have been described for
of the temporomandibular joint (TMJ) can be defined as the managing TMJ dislocations.1 The most conservative and first
displacement of the head of the condyle from its normal posi- treatment option, especially in acute dislocations, is the manual
tion, and it can be partial (subluxation) or complete (luxation).1 reduction of the dislocated TMJ. Manual reduction can be done
Subluxation is common and occurs mostly in patients with under local or general anesthesia, or analgesic control with or
hypermobile joints. It may never cause any problems to the pa- without sedation.1 However, manual reduction frequently fails
tients, and the joint always gets self-reduced back to its normal in patients with chronic dislocations who end up requiring al-
position by the patient upon closing the mouth. On the other ternative nonsurgical or surgical treatment modalities.2,7
hand, anterior dislocation occurs when the condyle is displaced Alternative nonsurgical techniques include intramuscular
anteriorly to the articular eminence and cannot be reduced by injection of botulinum toxin type A into the muscles of
the patient.2 Bilateral anterior dislocation of the TMJ is a rare mastication to reduce muscular activity,8,9 or intracapsular
condition most likely to occur in elderly, medically compro- injection of a sclerosing agent (i.e., alcohol, rivanol, 5% sodium
Prosthodontic management
A review of the literature was conducted to search for any pre-
vious prosthodontic clinical reports involving the treatment of
edentulous patients with nonreducible bilateral anterior condy-
lar dislocation. No previous reports were found; however, there
are many successful reports of prosthetic rehabilitation of pa-
tients lacking condylar guidance, such as patients who went
through mandibulectomy after radiotherapy.18 In these cases,
patients adapted to the new occlusal scheme by gradually ap-
plying modifications to the treatment dentures at specific time
intervals. We hypothesized that the prosthetic rehabilitation
of patients with nonreducible bilateral anterior TMJ disloca-
tion could be successful using techniques used to treat patients
lacking condylar guidance. These techniques depend on apply-
ing gradual modifications to treatment dentures at specific time Figure 2 Clinical photographs of the treatment denture with acrylic oc-
intervals.18 clusal rims for the maxilla and the mandible without teeth (top left), the
Prosthodontic rehabilitation of edentulous patients suffering maxillary and the mandibular acrylic occlusal rims with the added anterior
teeth (top right), the maxillary denture with a complete set of teeth, and
from TMJ dislocations usually commences after managing the
the mandibular denture with anterior teeth (bottom left), the maxillary
dislocation, but in this clinical situation after the failed attempts
and mandibular dentures with complete set of teeth in occlusion in the
to reduce the joint to its correct position, it was decided to start
patient’s mouth (bottom right).
the prosthodontic rehabilitation as a palliative approach. The
findings and management plan were discussed with the patient.
A clinical protocol was approved, and the patient’s informed postoperative instructions that included: (1) wear the treatment
consent was obtained to proceed with the prosthodontic re- dentures as much as possible; (2) take the dentures out at night
habilitation without reducing the TMJ. Preliminary and final and clean them; (3) insert food on both sides of the mandible and
impressions were made, and record bases with wax occlusal chew in hinge movements on both sides; (4) maintain a soft diet
rims were fabricated. The maxillary wax rim was modified ac- and avoid eating hard or sticky food; and (5) avoid voluntary
cording to esthetics and phonetics,19 and the Fox plane plate extreme opening of the jaw and prevent involuntary open-
was used to adjust the denture occlusal plane by following ings (e.g., yawning) by pushing the chin upwards with the hand.
the inter-pupillary and Camper’s lines.20 The mandibular wax
rim was modified following the maxillary wax rim to obtain
Gradual addition of teeth to the treatment
the compensating curves (curve of Spee and curve of Wilson),
dentures
since the mandible is in an atypical position. Due to the atypical
condylar position, the patient was repeatedly asked to swallow The patient did not report any further complaints after 3 weeks
and relax, and the most consistent measurements were con- of treatment denture delivery. Semi-anatomical artificial teeth
sidered for vertical relations. The bite registration records were were gradually added to the occlusal rims of the same treat-
taken with the dislocated joints and were found to be repeatable. ment dentures based on neutral zone measurements, esthetics,
After bite registration, the record bases with the wax rims were and bite registration. The whole set of artificial teeth were added
mounted on a semi-adjustable articulator to verify the occlusal in four subsequent appointments 2 weeks apart (Fig 2). In the
relationship and the occlusal vertical dimension. first appointment, the six maxillary anterior teeth were placed in
the acrylic rim. In the second appointment, the mandibular an-
Treatment denture without teeth terior teeth were added. In the third appointment, the maxillary
posterior teeth were added, so the patient had a maxillary com-
The next stage of treatment was the gradual adaptation of plete set of teeth with the mandibular anterior teeth only. In the
the neuromuscular system to the new occlusal scheme with fourth appointment mandibular posterior teeth were added, so
atypical joint position. Accordingly, acrylic denture bases the patient finally had her complete dentures with the complete
with acrylic occlusal rims (without teeth) were constructed set of teeth (Fig 2).
(treatment denture) (Fig 2) and delivered to the patient. She
was asked to wear the treatment dentures and to come back
Denture delivery and postinsertion follow-up
after 24 hours for occlusal adjustments; the occlusal rims were
adjusted until a satisfactory balanced occlusion was achieved. The finalized complete denture was delivered, and the patient’s
This was achieved by the following steps: (1) performing a progress was monitored for 1 year on regular monthly recall
pre-occlusal/pre-centric record check, (2) remounting the treat- appointments. After 1 month of wearing the dentures, the extent
ment dentures on the semi-adjustable articulator and removing of mouth opening increased and stabilized at 27 mm. This
any interferences during the simulation of the mandibular is probably due to the resolution of the TMJ inflammation
movements (centric, eccentric, and protrusive movements), that restricted its movement. After 1 year, the patient remained
and (3) reinsertion of the treatment dentures inside the patient’s satisfied with her dentures and was able to wear them at all times
mouth and checking for any interferences during mandibular and eat a wider range of foods efficiently without complaining
movements. After that, the patient was given appropriate of any pain or other complications.
Discussion References
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