CASE REPORT

DISLOCATIO TMJ

dr. D Mahdalena Bama

IDENTITAS
Minggu, 9 Juli 2017 pkl 23.45 WIB

• Ny.Mry
• 63 tahun
• Wonokusumo Lor IV/49
• BPJS
Subjectif

Tidak dapat menutup mulut setelah menguap ± 20 menit SMRS.

Nyeri pada rahang kanan, pasien baru pertama kali mengalami
hal ini. Riwayat demam sebelumnya disangkal. Nyeri pada lutut
kiri sejak ± 3 tahun, bengkak terkadang pada lutut kiri dan terka-
dang sulit untuk digerakkan.

RPD : DM tidak terkontrol, brusism disangkal

Riw sosial : Pemakaian gigi palsu disangkal
Objectif
KU : Gelisah GDA : 123 mg/dl
TD : 130/90 mmHg RR : 20 x/menit
N : 80 x/menit S : 36,2 ° C

K/L : A-/I-/C-/D-, Mulut terbuka, hipersalivasi (+)

Thorax : BND vesikuler , Bj1=Bj2, Rh -/-, Wh -/-
Abdomen : Suepel, H/L dbn, BU +
Eks : Akral HKM
Objectif
Status Lokalis
Reg Temporo Mandibular Joint dextra
L : Swealling (+), Open mouth (+), asimetris
F : Krepitasi (-)
M : Kikling (+), open lock (+)

Reg Genu (S)

L : Swealling (+)
F : Hiperemis (-)
M : ROM terbatas karena nyeri
LAB
ECG

Irama sinus 90 x/mnt

Ro
MAE
MAE

TMJ

TMJ
Assesment

• Dislocatio TMJ Dx
• OA reg Genu Sin
•DM
Planning
Inj Ketorolac 30 mg (iv)
Reposisi manual  evaluasi
Reg TMJ (DX)
L : Closed mouth (+), asimetris (+), interinsisi gap (+)
F : Kikling (-)

Konsul dr Erwin,spOT :
Acc MRS pro closed reduction pukul 08.00 dengan GA
Konsul dr Moriska, spAn
Konsul dr Pria, spPD  acc operasi, cek GDA post tindakan
Planning 11/7/2017
Post Closed reduction
Acc KRS
Kie terhadap pasien
untuk tidak membuka mulut terlalu lebar, dan menguap lebar
P oral Asam Mefenamat 3x 500 mg
Kontrol poli 1 minggu lagi
DEFINITION
What is the temporomandibular joint?
The temporomandibular joint (TMJ) is the jaw joint.

It is the hinge joint that connects the lower jaw

(mandible) to the temporal bone of the skull.

The joints move smoothly up and down and side to side,

which allows you to talk, chew, and yawn.

Muscles attached to and surrounding the jaw joint

control its position and how it moves
ANATOMY
The temporomandibular joint consists of articulations
between three surfaces :
• the mandibular fossa
• articular tubercle (from the squamous part of the temporal
bone)
• and the head of mandible.

This joint has a unique mechanism; the articular surfaces of

the bones never come into contact with each other –
they are separated by an articular disk.

The presence of such a disk splits the joint into two synovial
joint cavities, each lined by a synovial membrane. The articu
lar surface of the bones are covered by fibrocartilage, not
hyaline cartilage
ANATOMY
ANATOMY
There are three extracapsular ligaments.
Lateral ligament – It runs from the beginning of the articular tubule to the mandibular neck.
It is a thickening of the joint capsule, and acts to prevent posterior dislocation of the joint.
Sphenomandibular ligament – Originates from the sphenoid spine, and attaches to the mandible.
Stylomandibular ligament – A thickening of the fascia of the parotid gland.
Along with the facial muscles, it supports the weight of the jaw.
ANATOMY
ANATOMY
Anatomy

•Jaw opening : this action is assisted by the suprahyoid , sternohyoid,

and geniohyoid muscles

•Jaw Closure it is accompished by the simultaneous contraction of the

masseter, medial pterigoid muscle
 EPIDEMIOLOGY
Dislocation of the TMJ is due to either imbalance in the neuromuscular function or structural
deficit.

• Alteration in the neuromuscular function occurs due to laxity of the articular disc and the cap
sular ligament, long-standing internal derangement, and spasm of the lateral pterygoid
•muscles.

• Structural deficit involves arthritic changes in the condyle, i.e., flattening or narrowing, decre
ase in the height of the articular eminence, morphological changes of the glenoid fossa, zygo
matic arch, and squamotympanic fissure

• Other causes include over function , forceful wide opening of the mouth while yawning, laug
hing, vomiting, or seizures, dental treatments like third molar extractions or root canal
treatments, or oendotracheal intubation, laryngoscopy
EPIDEMIOLOGY
Anterior dislocations are most common mechanism

– Atraumatic (most common) from extreme mouth opening (yawning, eating,

dental procedure, etc).
– Traumatic: superior and posterior dislocations more common in trauma
– TMJ dislocations typically occur bilaterally.
CLINICAL FEATURES

• The most common clinical symptom

 inability to close the oral cavity, i.e., “open lock,”
difficulty in speech
 drooling of saliva
 and lip incompetency.

•In acute dislocation, pain in the pre auricular region is present

• chronic recurrent dislocation is rarely associated with it.
•Usually bilateral and at times unilateral dislocation may lead to deviation of t
he chin to the contralateral side.
• Palpation over the preauricular region may suggest emptiness in the joint s
pace.
•The patient may look anxious.
DISLOCATIO TMJ
CLINICAL EXAMINATION
A. INSPECTION

 Interincisal distance on mouth opening

Facial asymmetry
Deviation of mouth on opening or closing
Preauricular Swelling
Malocclusion
Improper dental restoration or
prosthesis
 CLINICAL EXAMINATION
B. Occlusal Evaluation

•Angle”s Classification ( class I,II,III)

• It provides information about occlusal relationship,

freeway space, overjet and overbite, the evidance for
brixism or other oral habits ( attritation and wear facets),
or oral structure

•No of missing teeth , loss of posterior occlusal contact p

redispose the TMJ the degenerative joint diseasea
CLINICAL EXAMINATION
c. Range of Mandibular Movements

• The distance between the incisal edges of upper and lower teeth is measure
d together with overjet and overbite normally 35- 50 mm
• Lateral motion 7-10 mm to both right and left
• Normal protusive range is 7-10 mm
• Subluxation or reccurent dislocation of one or both condyles can be determin
ed by abnormal palpation during movement
CLINICAL EXAMINATION
c. Palpation
• Tenderness suggests the presence of
- Fracture
- Synovitis
- Capsulitis of the joint

• Palpated the evidanve of enlargement ( muscle , mandibule) & movement of disc (

hypermobility)

• Overlying skin is checked for temperature and consistency in case of inflammator

y condition
CLINICAL EXAMINATION
D. Auscultation

• Noise is assessed by stethoscope and classified as either click ( closed click or open click)
• Or crepitus though it may be difficult to determine whether a noise is from one joint or both
Planning
A. DRUGS

•Antiinflamatory Agents
•Muscle relaxants
•Antidepressants  Myofasial Pain Disorders Syndrom
•Analgetic
 Planning
Management

Atraumatic TMJ dislocations are typically managed non-operatively with ED reduction

Supportive Care
– Provide analgesia as needed
– Local anesthestic (2-3cc) can be injected into the TMJ space or directly into the
lateral pterygoid muscle
– Consider procedural sedation as muscle spasm often limits success of reductio
n techniques

ttps://coreem.net/core/tmj-dislocation/
 Planning
Management

– Gag Technique
• Elicit a gag reflex using a tongue depressor
• This reflex inhibits the muscles of mouth closure, thereby
potentially allowing the condyle to move downward past t
he anterior lip of the mandibular fossa and relocating post
eriorly

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 Planning
Management (intraoral)

– Traditional
• Place the patient in an upright seated position
• While facing the patient, place bilateral thumbs (wrapped in gauze)
on the inferior molars and the remainder of fingers around the outsi
de of the jaw
• Apply downward and backward pressure to facilitate the condyles f
rom the anterior aspect of the articular eminence
• Have another person hold the patient’s head to prevent movement
• This can also be done while standing behind and above the patient
. You can use your abdomen brace the patient’s head

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 Planning
Management Intraoral

– Wrist pivot
• While facing the patient, grasp the mandible with both thumbs
under the chin and place fingers on the occlusal surfaces of
the lower molars
• Apply upward force with the thumbs and downward pressure
with the fingers while pivoting the wrist forward
• Force must be equally applied to all sites to prevent fracture.

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 Planning
Management Extraoral

• With one hand, grab the mandibular angle with fingers and place the
thumb over the malar eminence of the maxilla
• With the other hand, place the thumb just over the displaced
coronoid process and fingers behind the mastoid
• Simultaneously pull the mandibular angle forward on one side while
pushing the coronoid process on the other causing one if not both
TMJs to relocate back in the appropriate position

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 Post-reduction Care
https://coreem.net/core/tmj-dislocation/

– Advise patient to avoid extreme mouth opening and to eat soft

foods for 1 week
– Follow-up with oral surgery as needed
– Chronic dislocations may require surgical fixation

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