|Year : 2011 | Volume
| Issue : 6 | Page : 104-106
Recurrent bilateral TMJ dislocation in a 20-month-old child: A rare case presentation
S Chhabra, N Chhabra
DAV (C) Dental College and Hospital, Yamuna Nagar, Haryana, India
|Date of Web Publication||12-Dec-2011|
DAV Dental College, Department of OMFS, Yamuna Nagar, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Temporomandibular joint dislocations are extremely rare in children and only four such cases have been reported in the literature so far. However, a case of recurrent bilateral mandibular dislocation is even rare to occur and a report of one such case is presented in this article.
Keywords: Bilateral, dislocation, infant, recurrent, temporomandibular joint
|How to cite this article:|
Chhabra S, Chhabra N. Recurrent bilateral TMJ dislocation in a 20-month-old child: A rare case presentation. J Indian Soc Pedod Prev Dent 2011;29, Suppl S1:104-6
|How to cite this URL:|
Chhabra S, Chhabra N. Recurrent bilateral TMJ dislocation in a 20-month-old child: A rare case presentation. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2019 Dec 15];29, Suppl S1:104-6. Available from: http://www.jisppd.com/text.asp?2011/29/6/104/90758
| Introduction|| |
Temporomandibular joint (TMJ) dislocations are rare in children, and a case of recurrent bilateral TMJ dislocation with signs, symptoms, diagnosis and management is reported in this article.
| Case Report|| |
A 20-month-old child was referred to the Department of Oral and Maxillofacial Surgery, DAV (C) Dental College and Hospital, Yamuna Nagar, Haryana, India, with a 20-hour history of inability to close mouth. Detailed history revealed that the patient had suffered from trauma in the chin region due to a fall on the ground leading to inability to close mouth.
On clinical examination, the patient revealed an inability to occlude teeth, protruding lower jaw, an anterior open bite and drooling saliva. The patient was unable to speak, drink or eat properly [Figure 1]. To confirm the clinical examination and to rule out mandibular fractures, a radiographic examination was carried out. As the child was uncooperative, an orthopantomogram could not be obtained and a GE HISPEED CT scan was done in which serial thin 1/1 mm sections were taken from the base of the skull to the lower border of mandible. The scan revealed that the mandibular fossae were empty bilaterally as the condylar heads were displaced anteriorly [Figure 2]. No evidence of mandibular fracture was seen [Figure 3].
|Figure 1: Episode I: Inability to close mouth due to dislocated TMJ after trauma over the chin|
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|Figure 3: Prominent articular eminence especially on the right side and no mandibular fracture seen in CT|
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The child was immediately admitted under pediatric consultation. The dislocations were manually reduced under mild sedation by application of gentle pressure downward in the lower posterior alveolus and upward on the chin. Satisfactory reduction was confirmed clinically by the return of child's normal occlusion and mobility of the lower jaw. A bandage was wrapped around the infant's chin and vertex to restrict wide jaw opening [Figure 4]. The patient was advised soft diet and restricted mouth opening and discharged. Regular examination of the child was done for 1 month and the child was normal.
|Figure 4: Bandage wrapped around head after reduction to restrict mandibular movements|
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After 3 months, the patient again reported to our department with the same problem of inability to close mouth which occurred due to wide mouth opening for examination of oral ulcers by a local practitioner [Figure 5]. The dislocation was again reduced manually under sedation. For the comfort of the child, a cervical collar was applied for 2 weeks [Figure 6]. The patient is under regular observation since past 1 year and no further episode has been reported.
| Discussion|| |
Dislocation refers to the displacement of the condyle outside the glenoid fossa, i.e. when the condyle moves into a position anterior to the articulation eminence (open lock) from which it cannot be voluntarily reduced.  It may be recurrent, longstanding or chronic. Recurrent dislocation is identified by episodes of open lock that last for a short duration before reduction, whereas longstanding dislocation occurs when the condyles remain lodged anterior to the articular eminence for a period of more than 3 weeks. Chronic and habitual dislocation refers to recurrent dislocation and reduction, which is normally the expression of a centrally mediated motor disturbance like orofacial dyskinesis.
The incidence of dislocation is highest in young women in the age group 21-30 years, but is extremely rare in infants. Acute dislocation may be initiated by overextension injuries like during wide mouth opening as in dental extractions or treatments, intubation with general anaesthesia, extrinsic trauma,  etc.
The presentation of a case of acute dislocation includes anterior open bite, protruded mandible, drooling saliva and difficulty in talking and eating. ,
Radiographic assessment may rarely be necessary for evaluation of hypermobility as preauricular hollowness and typical signs and symptoms may lead to the diagnosis. But in cases of extrinsic trauma, a radiograph or CT scan should always be done to rule out any facial bone fractures, as was done in our case.
Acute dislocation is most frequently caused by a combination of TMJ overextension and dyssynchronous muscle function. Joint overextension may be caused by yawning, vomiting, screaming, laughing or during an epileptic seizure. Dyssynchronous muscle contraction results from an alteration of the normal contraction sequence of the protractor and elevator muscles of the mandible. Once established, the dislocation is perpetuated by painful spasm of masticatory muscles,  maintained by neural reflexes. If the condylar head slips over the articular eminence and comes to lie anterior to the eminence, it means that the articular eminence is of sufficient size to maintain the dislocation. However, in case of infants, the articular eminences are underdeveloped and the glenoid fossa is almost flat, hence diminishing the chances of dislocation.  But in the case presented here, the articular eminences are well formed due to which dislocation occurred for the first time because of extrinsic trauma due to fall and recurred on wide mouth opening after 3 months. Thus, it should always be kept in mind that recurrent dislocation can also occur in infants, though any such case has not been reported in the literature so far. Serial examination of radiographs of 10 patients of the same age group further showed that the articular eminences of our patient were more well formed ,thus not only aiding the maintenance of dislocation but also a second episode of dislocation after 3 months.
The management is aimed at reduction of the condyles back to their normal position.  For this manual reduction, mild sedation and muscle relaxation are sufficient. The latter is done so as to relieve the muscle spasm. The patient is made to sit comfortably in a dental chair with the operator in front. The mandible is held in both the hands while applying downward pressure on the molar teeth with covered thumbs and an upward pressure on the chin with fingers to disengage the mandible. Following reduction, for restricting the mandibular movement, a bandage is wrapped around the head or maxillomandibular fixation can be done. For the comfort of infants, a cervical collar can also be given.  In our case, the parents of the patient had been given proper instructions to limit the mouth opening of the child and avoid wide opening till at least 12-13 years of age as the TMJ gradually assumes its adult appearance by this age.  The patient is being kept under regular follow-up, and if the problem persists, surgical correction may be required at a later stage when the TMJs have attained their complete form and function.
| Conclusion|| |
This case has been reported to emphasize that recurrent dislocation of TMJ is also a possibility in case of infants, although it is rare.
| References|| |
|1.||Peterson L. Contemporary Oral and Maxillofacial Surgery. St. Louis: Mosby; 1998. |
|2.||Atherton GJ, Peckitt NS. Bilateral dislocation of the temporomandibular joints in a 2-year-old child. Report of a case. J Oral Maxillofac Surg 1997;55:646-7. |
|3.||Cascarini L, Cameron MG. Bilateral TMJ dislocation in a 23-month-old infant: A case report. Dental Update 2009. |
|4.||Cascarini L, Cameron MG. Bilateral dislocation of temperomandibular joints in a child: easily missed with the dummy in. Postgrad Med J 2005;81:82. |
|5.||Whiteman PJ, Pradel EC. Bilateral temporomandibular joint dislocation in a 10-month-old infant after vomiting. Pediatr Emerg Care 2000;16:418-9. |
|6.||Merril RG. Mandibular dislocation. In: Keith DA, editor. Surgery of the Temporomandibular Joint. Boston, MA: Black-well Scientific Publications; 1992. p. 154-79. |
|7.||Moore RN. Morphology, growth and maturation. In: Saunders B, editor. Pediatric Oral and Maxillofacial Surgery, St. Louis: CV Mosby; 1979. p. 8-10. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]