Surgical Management of Recurrent Temporomandibular Joint Dislocation - Systematic Literature Review and Development of a Treatment Protocol

Recurrent TMJ dislocation is a rare entity, clinically distinct from acute or chronic dislocation. It is associated with significant morbidity and deterioration to quality of life for affected patients. Recurrent temporomandibular joint (TMJ) dislocation can be challenging to treat and current understanding regarding aetiology and management of this condition is limited. The aim of this thesis was twofold. The first was to conduct a systematic review regarding the current understanding of managing recurrent TMJ dislocation. The second aim was to review the surgical management and long-term outcomes of patients with recurrent TMJ dislocation who presented to a single Hospital Department over a period of six years so as to formulate a practical treatment algorithm. A retrospective review of cases surgically managed for recurrent TMJ dislocation was undertaken with respect to patient demographics, clinical features, surgery provided, and long term follow up. A literature review was conducted using PRISMA guidelines to identify papers published between 2006 and 2016. The resultant papers were analysed. A total of 33 papers were found relevant to the study. Minimally invasive techniques described included autologous blood injection, which was associated with an overall success of 80% at 12 months. Other modalities investigated included OK-432 sclerotherapy, laser capsulorrhaphy, botulinum toxin of the lateral pterygoid muscle or modified dextrose. These publications show promising success rates. Surgical techniques described included disc plication, eminoplasty and eminectomy. These modalities had a similar success rate, although numbers were limited. For the second part of this thesis, a total of 14 patients were identified who were managed for recurrent TMJ dislocation over a 6-year period from 2010 to 2016. The cases were followed up for a minimum of 12 months and a maximum of seven years. Results showed effective long-term resolution of symptoms using a combination of eminectomy, disc plication (meniscopexy) and where clinically indicated, lateral pterygoid myotomy. This thesis found that the true incidence of recurrent TMJ dislocation is unknown and aetiology is limited to expert opinion. The current understanding of management for recurrent TMJ dislocation is limited to case series and case reports. This thesis compiles the current understanding of management of recurrent TMJ dislocation. A decision making algorithm, with a personalised, step-wise approach to treatment is presented. The retrospective review portion of the thesis has shown that a combination of eminectomy and disc plication (meniscopexy) is effective in providing long term positive outcomes in the surgical management of recurrent TMJ dislocation. Those cases of recurrent TMJ dislocation resulting from dystonia of the lateral pterygoid muscle also benefitted from additional lateral pterygoid myotomy.