Temporomandibular Joint Subluxation Research Articles

Open-mouth jaw locking in a 5-year-old Persian cat: a case report.

Open-mouth jaw locking is an uncommon condition in feline patients. A 5-year-old neutered male Persian cat was evaluated for an acute inability to close its mouth and ptyalism. The general physical examination was unremarkable. A complete oral examination revealed a reduced vertical range of motion, as well as an asymmetric malocclusion with severe displacement of the mandibles to the left. Advanced diagnostic imaging included computed tomography (CT), which revealed a typical brachycephalic conformation, skeletal malocclusion and a bilateral temporomandibular joint (TMJ) subluxation, with the left coronoid process of the mandible abnormally positioned ventrolateral to the zygomatic arch. The open-mouth jaw locking was manually reduced and resolved. Once the coronoid process was repositioned, a second CT scan was performed and confirmed complete reduction of the TMJ subluxation. Supportive treatment with meloxicam was administered and a loose-fitting tape muzzle and Elizabethan collar were applied for two weeks. There was no recurrence of open-mouth jaw locking at long-term follow-up. This case report highlights the relevance of CT imaging and 3-dimensional reconstruction in the diagnosis of this unusual condition.

The effect of prolotherapy on TMJ: a literature review

This paper reviewed prolotherapy as an approach to treating temporomandibular joint disorders (TMD), focusing on temporomandibular joint subluxation and hypermobility. Prolotherapy, commonly used in orthopedics, involves injecting substances like dextrose or lidocaine to promote healing in musculoskeletal conditions. Clinical studies in which this prolotherapy was used for TMD were reviewed. Total 13 papers involving 372 patients (Male 90, Female 282) were examined, considering factors such as dextrose concentration (10%~50%), injection frequency (one to four times), injection period (one to four weeks) and injection sites. The assessment primarily focused on pain reduction and changes in maximum mouth opening after prolotherapy. In all papers, a consistent trend of pain reduction after prolotherapy was observed. Regarding maximum mouth opening, there were 6 cases of decreased range and 7 cases of increased range. With prolotherapy's rec-ognition as a new medical technology for TMD, it emerges as a potential alternative treatment, highlighting its significance in the field.

Recent Advances in Temporomandibular Joint Surgery.

Temporomandibular disorders (TMDs) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant cases. Several recent advancements in TMD and temporomandibular joint (TMJ) surgery have elevated understanding and the ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, the treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements in TMJ disorders and their surgical management.

A Comparative Preliminary Randomized Clinical Study to Evaluate HeavyBupivacaineDextrose Prolotherapy (HDP) and Autologous Blood Injection (ABI) for Symptomatic Temporomandibular Joint Hypermobility Disorder.

Temporomandibular joint (TMJ) sub-luxation can have a significant psycho-social impact on a patients' well-being. Several treatment modalities have been described in the literature for the same. The present study was undertaken to investigate the efficacy of heavy bupivacaine-dextrose prolotherapy (HDP) for the peri-articular tissues, superior joint space and the retro-discal area in the patients with symptomatic chronic sub-luxation. A preliminary clinical study was conducted among 60 patients diagnosed with chronic painful sub-luxation of the TMJ. Patients were divided into control group(CG), n = 30, where autologous blood was injected in the superior joint space, peri-capsular tissues and retro-discal area bilaterally as per the predetermined protocol; and the study group (SG), n = 30 patients were administered heavy bupivacaine-dextrose injection bilaterally in the peri-articular tissues, superior joint space and retro-discal area. The efficacy of the treatment was evaluated by assessing pain, maximum inter-incisal opening (MIO), changes in computed tomography scan, magnetic resonance imaging study, number and need for subsequent injections in both the groups. Among the 60 patients, majority of the patients exhibited successful outcome after both the interventions, ABI and HDP. There was statistically significant reduction in recorded pain score with reduced MIO post-treatment. No morphological changes were noted in the condyle in both the groups. No complications were recorded among the study population. HDP is a safe and simple modality for treating symptomatic sub-luxation with predictable clinical outcome. Heavy bupivacaine-dextrose can be considered as a prolotherapeutic agent for symptomatic chronic temporomandibular joint sub-luxation with the pharmacological benefit of local anaesthesia and proliferent delivery through the same injection.

Clinical investigation and research on Axis Ⅱ evaluation of patients with temporomandibular disorders

Objective: To screen the physical, psychological and behavioral factors related to patients with temporomandibular disorders (TMD) by using Axis Ⅱ assessment instruments of diagnostic criteria for TMD(DC/TMD). And to provide a reference to establish personalized diagnosis and treatment plans for TMD patients so as to prevent TMD and reduce predisposing factors. Methods: A total of 141 TMD patients, who were admitted in the Department of Oral and Maxillofacial Surgery in School and Hospital of Stomatology, Wuhan University from October 2018 to February 2021 were selected. There were 121 females and 20 males, with an average age of 30 years. A total of 90 healthy people were included as controls. A full-time psychologist conducted relevant questionnaire surveys. The questionnaires include general clinical survey forms and TMD symptom questionnaire. In addition, Axis Ⅱ assessment instruments include graded chronic pain scale, jaw functional limitation scale, oral behaviors checklist, patient health questionnaire-9 (depression), generalized anxiety disorder scale, patient health questionnaire-15 (physical symptoms), etc. The main observational indicators include: pain level, pain impact rates, overall classification of chronic pain, limited chewing function score, limited motor function score, limited communication function score, total jaw function restricted score, depression score, anxiety score, somatic symptom score and oral behavior score.The survey data were imported into SPSS 22.0 software for statistical analysis. Results: In the TMD group 60.3% (85/141) patients had various degrees of pain, 24.1% (34/141) of those with pain effect grades from 1 to 3 and 61.0% (86/141) showed chronic pain overall grades from Ⅰ to Ⅳ. The chewing function restricted score was 2.67(1.17, 4.25), motor function restricted score was 4.25(1.75, 6.12), communication function restricted score was 1.13(1.00, 2.25) and total jaw function restricted score was 2.56(1.47, 4.15) respectively. Patients with mild depression or above accounted for 59.6%(84/141), patients with mild anxiety or above accounted for 56.7%(80/141), 46.1%(65/141) patients had somatization symptoms. Statistical differences (P<0.05) were determined between TMD group and control group in various scores of jaw function, oral behavior grading, depression, anxiety, and physical symptoms. Physical symptoms had significantly statistical difference between different diagnostic classification(P<0.05). Meanwhile, among the different chronic pain levels in the TMD group, there were statistical differences in the various scales of mandibular dysfunction, depression, anxiety, and somatization. In the TMD group, other significant differences were noticed between males and females in terms of the average score of mouth opening, verbal and facial communication, the total score of mandibular dysfunction as well as physical symptoms (P<0.05). Conclusions: Compared with the healthy people, patients with TMD had more abnormal oral behaviors, different restriction of the mandibular functional activities. At the same time, depression, anxiety, and somatization were more serious. Patients with osteoarthritis and subluxation of temporomandibular joint were more likely to suffer physical symptoms. TMD patients suffering from pain had more severe mandibular dysfunction and symptoms of depression, anxiety, and somatization.

Arthrocentesis Followed by Autologous Blood Injection in the Treatment of Chronic Symptomatic Subluxation of Temporomandibular Joint.

Temporomandibular joint subluxation is defined as self-reducing partial dislocation of the TMJ during which the condyle passes anterior to the articular eminence. The study consisted of 30 patients, 19 females and 11 males with 14 unilateral and 16 bilateral cases of chronic symptomatic subluxation. Treatment consisted of arthrocentesis followed by 2ml of autologous blood injection into upper joint space and 1ml into pericapsular tissues using an autoclaved soldered double needle with single puncture technique. Parameters evaluated were pain, maximum mouth opening, excursive jaw movements, deviation on mouth opening and quality of life, hard and soft tissue changes on X-ray TMJ view and MRI. At 12month follow-up, average reduction in maximum interincisal opening, deviation on mouth opening, range of excursive movements on right and left sides and VAS scores were 20.54%, 32.84%, 29.59%, 27.37% and 74.53%, respectively. Out of 93.3% who responded to therapy, 66.7%, 20% and 6.7% responded after 1st, 2nd and 3rd AC + ABI, respectively. Remaining 6.7% patients had persistent painful subluxation and underwent open joint surgery. 93.3% patients responded to therapy, 80% were relieved of painful subluxation, 13.3% had painless subluxation and kept on follow-up. X-ray TMJ and MRI did not show any hard and soft tissue changes. A soldered double needle, single puncture, AC + ABI are a simple, safe, cost-effective, repeatable and minimally invasive nonsurgical therapy for treatment of CSS without any permanent radiographically evident soft or hard tissue changes.

Strategies to manage anterior disc displacement without reduction of temporomandibular joint: a case report

Introduction Articular disc displacement is the most common temporomandibular joint (TMJ) arthropathy [1]. Disc displacement without reduction (DDwoR) is an intracapsular biomechanical disorder involving the condyle-disc complex [1] and can cause TMJ pain, limited mouth opening [2] and a change in the opening pattern of the patient. At first, the treatment for DDwoR should be reversible and conservative and include drugs, interocclusal devices and physiotherapy (PT) [3]. Moreover, minimally invasive techniques such as viscosupplementation (VS) seems to reduce pain and symptoms associated with internal derangement and improve quality of life [4]. The aim of this study is to report the efficacy of a combined protocol (PT and VS) in the control of signs and symptoms of a patient with temporomandibular disorder (TMD). Materials and methods Female patient, 38 years, with signs and symptoms of TMD presents a clinical diagnosis of right TMJ DDwoR and left TMJ subluxation, according with the Diagnostic Criteria for Temporomandibular Disorders protocol (DC/TMD). The initial pain free opening (PFO) was 31 mm with an uncorrected deviation to the right side in terms of opening pattern. Interdisciplinary team composed by two dentists and two physiotherapists decided the following strategy: assessment of PFO and opening pattern (DC/TMD examination form) before and after any intervention. After the initial assessment we had the first session of PT to prepare for the VS composed of behavioural and cognitive therapy, manual therapy, motor control exercises and prescription of home exercises. One week after we performed the first session of VS with 1 ml of high molecular weight hyaluronic acid bilaterally in the TMJ followed by another session of PT. Two sessions were performed, once a week, in two consecutive weeks. All the assumptions of the Helsinki Declaration have been fulfilled and an informed consent for clinical case of Clínica Dentária Egas Moniz approved by the ethic commission of Instituto Universitário Egas Moniz. Results Data was collected before and after any intervention. In first session of PT, PFO measurements increased from 31 mm to 38 mm and opening pattern remained a right uncorrected deviation. After the VS and second PT session the PFO increased from 35 mm at the beginning of the intervention to 45 mm at the end and the opening pattern changed to a straight opening pattern. Discussion and conclusions VS has been proven to be effective for knee and other large joints [4]. Studies suggest that adding VS to PT and therapeutic exercise may increase functionality [5]. No significant differences between non-invasive conservative interventions and minimally invasive or invasive surgical interventions for TMJ DDwoR [2] so primary treatment should consist of conservative strategies [6] carried out by a multidisciplinary team in order to improve range of motion, restore biomechanics, dynamic lubrification and function. This case report suggest the effectiveness of the combined protocol (PT and VS) in the control of signs and symptoms of TMD reinforcing the role of the interdisciplinary team. However, further studies should be done with an increased sample.

Acute Temporomandibular Joint Dislocation during General Anesthesia Using LMA Supreme

Temporomandibular joint (TMJ) dislocation has been described in literature as a rare complication of LMA use. In this report, we describe the case of acute TMJ dislocation that occurred after LMA Supreme use in a 29 year old lady who underwent diagnostic hysterolaparoscopy under general anesthesia. The patient had an unremarkable airway and no history of TMJ subluxation or dislocation in the past. After induction of anesthesia, a size 3 LMA Supreme was successfully inserted in a single attempt after giving jaw thrust. After an uneventful surgical procedure the patient was reversed and the LMA Supreme was removed. After LMA removal, the patient was unable to close her mouth. The bony swelling palpable in the region anterior to bilateral TMJ confirmed the diagnosis of TMJ dislocation. A dental surgeon performed manual reduction of the same and the reduced position was secured using a bandage.

Perioperative Care in Patients with Ehlers Danlos Syndromes

Background: There is an increasing recognition of patients with Ehlers Danlos Syndromes. The laxity of the ligaments and the weakness of the connective tissue has resulted in increasing number of patients requiring surgical intervention. Ehlers Danlos Syndromes are not about hypermobile joints only, they are associated with multiple co-existing conditions such as Chiari malformation, Tethered Cord Syndrome, spinal instability, abdominal pain, Dysautonomia and Mast Cell Activation Syndrome. The combined incidence of Ehlers Danlos Syndromes is 1 in 5000 people. Most experts believe that the actual incidence is much higher. Many of these cases are under-diagnosed. Nevertheless, patients with Ehlers Danlos Syndromes, diagnosed or undiagnosed often require surgical intervention. This review article has been written to shed light on the need for special consideration during anesthesia. Objectives: Our objective was to conduct a review of anesthetic considerations in patients with Ehlers Danlos Syndromes. Study Design: We used a narrative review design. Methods: This review was done using searches of PubMed, MEDLINE/OVID, SCOPUS, and manual searches of the bibliographies of known primary and review articles from inception to 2019. Other data sources included hand searches of publications driven by manuscript authors. Search terms included concepts of “Ehlers Danlos Syndrome”, “EDS”, “pain”, “anesthesia”, “surgery” and combination of terms. Search method was not restricted to any one language. Results: Articles were screened by title, abstract, and full article review. They were then analyzed by specific clinical indications and appropriate data was presented based on critical analysis of those articles. Limitations: More studies about the effect of anesthetic techniques and Ehlers Danlos Syndromes are required. Conclusions: Patients with Ehlers Danlos Syndromes may present with an array of coexisting medical conditions such as Dysautonomia, Mast Cell Activation Syndrome, Chiari Malformation, Tethered Cord Syndrome, Craniocervical instability, Gastroparesis, altered sensitivity to local anesthetics. Anesthetic techniques need to be modified according to the presentation. Preoperatively, a note should be made of the joints that sublux most often, craniocervical instability. They are prone to temporomandibular joint subluxation, obstructive sleep apnea and tracheomalacia, spontaneous pneumothorax, POTS, MCAS, insensitivity to local anesthetics and coagulation disorders. Intraoperative considerations should include fiberoptic intubation, IV fluid loading for POTS, avoid drugs that release histamine, unpredictable response to opioids, precautions for gastroparesis. Patient should be positioned to avoid joint subluxation and over stretching nerves. Postoperative considerations include maintaining hemodynamic stability, avoid exacerbation of symptoms of MCAS, high suspicion of occult bleeding, high risk of post dural puncture headache in patients undergoing spinal procedure or neuroaxial block.

Zygomatic abscess complicating coalescent air cell infection and acute otitis media in a pediatric patient with facial swelling and temporomandibular joint subluxation

Acute otitis media is a localized infection. Advanced cases demonstrate local spread and abscess formation in the mastoid, temporomandibular joint, and zygomatic root if anatomy allows. We present a case of acute otitis media complicated by an abscess of a pneumatized zygomatic root extending into the temporomandibular joint treated by incision and drainage.

Assessment of the Temporomandibular Joint Function in Young Adults without Complaints from the Masticatory System.

Objective of the study was to evaluate the clinical status of the masticatory system in young adults with full permanent dentition and no stomatognathic system complaints. The study involved 186 randomly selected people with full dental arches with normal occlusal conditions corresponding to Angle's Class I aged 18 - 21 years with an average age of 19 years. Subjects were clinically examined and temporomandibular joint (TMJ) vibrations were recorded during open-wide and close movements using BioJVA. Then, patients were categorized into groups according to Piper's classification system. The TMJs of the subjects were categorized according to the values of the vibration energy and the Piper protocol. This detected 33.4% of the joints with loosened ligaments, subluxation in 8.28%, initial signs of disc dysfunction in 5.08% and disc displacement without locking in 1.6 %. Median frequency differed significantly (p < 0.05) between the group of subjects with initial signs of TMJ dysfunction and other groups. Peak Frequency differed significantly (p < 0.05) between the healthy joints and those with TMJ subluxation. In this group of young healthy people, the majority of study joints generated small vibrations. However, a subset of people manifested higher vibrations that may indicate an early stage of TMJ dysfunction. Median Frequency was an important parameter for detecting initial symptoms of TMJ dysfunction. Peak Frequency was an important characteristic parameter for detecting TMJ subluxation.

Chronic Recurrent Temporomandibular Joint Dislocation: A Comparison of Various Surgical Treatment Options, and Demonstration of the Versatility and Efficacy of the Dautrey's Procedure.

There has been a changing trend of treating temporomandibular joint subluxation, which range from conservative non-surgical measures to various soft and hard tissue surgical procedures aimed at either augmenting or restricting the condylar path. This study was aimed at comparing the efficacy of three major surgical treatment modalities: condylar obstruction creation, obstruction removal and anti-translatory procedures. Also, the location, anatomy and morphology of the TMJs pre- and post-surgery were evaluated and compared using radiographs, sagittal and 3-D Computed Tomographic scans. A 6-year study was carried out on seventy-five patients of various age groups. Twenty-five were operated by the Dautrey's procedure, 25 by articular eminectomy alone and the remaining 25 by eminectomy followed by meniscal plication and tethering. The distribution of patients in the three groups was random. Effectiveness of the surgical procedure and incidence of complications including recurrence were carefully compiled and compared between the three groups. Dautrey's procedure yielded more gratifying and stable results, leading to a successful and permanent correction of chronic recurrent dislocation of the TMJs, with practically nil complications, thus demonstrating it to be an extremely safe, effective and versatile technique, making the joints function normally and securing sufficient volume of mouth opening. There was observed an average increase in articular tubercle height by 3.65mm and a mean anterior shift of its lowest point by 4.5mm following the Dautrey's procedure, which were statistically significant findings. The upper age limit to carry out the Dautrey's procedure can be safely taken up to 45years.

Difficulty in Closing Mouth in Patient with Disc Displacement: A Case Report

Clinicians are familiar with limitation of opening mouth caused by temporomandibular disorders. Sometimes, patients also complain of difficulty in closing mouth. Difficulty in closing mouth can be caused by anterior, posterior disc displacement, and subluxation of temporomandibular joint (TMJ). In this report, we presented a patient who had a difficulty in both opening and closing mouth. The patient complained of TMJ noises and intermittent limitation of opening mouth, and inability to get teeth back into maximal intercuspal position. Magnetic resonance images revealed that the left TMJ had an anterior disc displacement with relative posterior disc displacement. We reviewed the possible causes, signs and symptoms, and treatment for difficulty in closing mouth with related literatures.

Buccal Mucosa Elasticity Influences Surgical Margin Determination in Buccal Carcinoma Resection

Little is known about whether buccal mucosa elasticity influences the determination of surgical margins for buccal carcinomas. This study investigated whether there is a difference in elasticity of the buccal mucosa in patients with buccal carcinoma compared with controls without the disease. A case-and-control study comprised of patients with buccal carcinoma and controls without the disease was conducted. In each patient, 2 gutta-percha points were attached to the buccal mucosa horizontally and examined twice by lateral cephalometry, once with the mouth closed and once during maximal mouth opening (MMO). Changes in distance between the gutta-percha points were used as a measurement of buccal elasticity. Information on age, alcohol consumption, betel nut chewing, smoking habits, oral submucosa fibrosis (OSF), temporomandibular joint (TMJ) subluxation, and interincisal distance at MMO (IDMMO) was collected. The results were analyzed using independent-sample and paired-sample t tests. Ten patients with buccal carcinoma and another 11 patients without buccal carcinoma were enrolled in this study. There was a significant increase in magnification percentage in patients with carcinoma (32.35%; P < .001) during MMO. Magnification of the comparison group during MMO measured 51.55%, also a significant increase (P < .001). Betel nut chewing significantly decreased mucosa elasticity; magnification was 29.20% (P= .013). Magnification was significantly higher in patients with TMJ subluxation (54.50%; P= .041) than in the controls. Age, alcohol consumption, smoking, OSF, and IDMMO did not affect buccal mucosa elasticity. Buccal mucosa elasticity increased considerably at MMO in patients with buccal carcinoma. This elasticity should be taken into account when calculating adequate surgical margins for transoral resection of buccal carcinoma.

Glenotemporal osteotomy with autogenous symphysis interpositional bone graft for temporomandibular joint subluxation

Chronic recurrent subluxation of the temporomandibular joint (TMJ) is known to have repeated episodes of joint dislocation, which are self-reducible in nature. Subluxation of TMJ accounts to multifactorial etiology. Accordingly, various treatment modalities have been postulated and performed to achieve functional outcomes for the patient. Conservative, surgical, and various treatment options have been discussed in the literature to correct the same. Glenotemporal osteotomy has been one such treatment modality to treat recurrent subluxation or dislocation of the jaws. This is a case report on a recurrent subluxating condyle treated by glenotemporal osteotomy with interpositional bone graft from the symphysis region.

Unmasking of incipient amyotrophic lateral sclerosis by botulinum toxin therapy

A 65 year old female was treated with Onyx embolisation of a superior cerebellar aneurysm for subarachnoid haemorrhage, resulting in mild residual left leg spasticity, but independent mobility. Eight years later, her left ankle started to turn inwards, and gradually the foot became inverted, ultimately becoming fixed due to tendon shortening from spasticity. There was no fluctuation in the position of the foot and it could not be easily corrected with passive stretching, as might be expected in dystonia. Examination revealed weakness of left ankle dorsiflexion, with normal sensation, reflexes and a flexor plantar response. MRI/MRA of the brain showed a treated aneurysm with no evidence of recurrence. Her weakness continued to progress and over the next 6 months she went on to develop brisk left knee and ankle jerks and a left extensor plantar response. Though there was no clinical evidence of wasting or fasciculation, an EMG of the left lower limb showed active denervation. A diagnosis of ALS was suspected, but with changes only confined to one limb there was insufficient evidence for an unequivocal diagnosis. In an attempt to alleviate severe pain associated with fixed flexion deformity, she was treated with 1,000 units of botulinum toxin A (Dysport) into the left plantar flexor muscles. Four days later, she rapidly deteriorated, developing generalised limb weakness with loss of ambulation, dysphagia and dysarthria. Her clinical course over the next year was entirely consistent with ALS, involving progressive weakness of all four limbs and respiratory failure, and ultimately requiring hospice care. In ALS a pre-clinical phase of motor neuron degeneration is likely to occur before motor symptoms develop. Botulinum toxin prevents acetylcholine-containing vesicles from binding to the pre-synaptic membrane. In its use in the treatment of sialorrhoea in ALS, there are no published reports of generalised exacerbation of limb muscle weakness. Anecdotal side effects include bilateral temporomandibular joint subluxation [1] and facial weakness [2]. In one case a woman with ALS who received botulinum toxin for sialorrhoea became anarthric and aphagic [3]. Botulinum toxin injection has also unmasked Lambert– Eaton myasthenic syndrome [4] and caused clinical deterioration in myasthenis gravis [5] and mitochondrial cytopathies [6]. The fact that symptoms were remote to the treatment site suggests a systemic effect of the toxin, a well-recognised phenomenon that has been demonstrated electrophysiologically in patients without clinical weakness [7]. Denervation and incomplete re-innervation in ALS may predispose to decompensation of the neuromuscular junction even with small amounts of toxin. It is perhaps surprising that more frequent side effects have not been reported in ALS, and the clinical course in this case may relate to the fact that this patient was treated for spasticity with a much larger dose than that generally used for sialorrhoea [8]. Clinicians should be aware of this potentially serious complication of the use of high-dose botulinum toxin in ALS. L. Kent P. Davies R. Kennett S. Wimalaratna R. Kerr M. R. Turner K. Talbot (&) Department of Neurology, John Radcliffe Hospital, Oxford, UK e-mail: Kevin.talbot@ndcn.ox.ac.uk

Unilateral synostosis of the zygomaticotemporal suture associated with mandibular coronoid process impingement in a dog

A 13-month-old dog was investigated for the complaint of open-mouth locked jaw. There were not any previous episodes of trauma witnessed. Computed tomographic evaluation revealed unilateral zygomatico-temporal synostosis and associated craniofacial asymmetry, with impingement of the mandibular coronoid process resulting in unilateral temporomandibular joint subluxation. Closed reduction of the subluxation was not maintained. Partial zygomatico-temporal suturectomy resulted in resolution of the clinical signs. To the author's knowledge, isolated zygomaticotemporal syno-stosis with associated temporomandibular subluxation has not been reported in the dog.

Munchausen Syndrome: A Case Report of Suspected Self-Induced Temporomandibular Joint Subluxation

As early as the 19th century, there have been gripping reports of patients who have intentionally contrived, embellished, simulated or self-induced an injury or illness to assume the sick role. It was not until 1951 that Asher classified this as a distinct psychiatric disorder known as Munchausen syndrome (MS).1 In this article we report a case of a 27-year-old female with suspected Munchausen syndrome, presenting with temporomandibular joint subluxation.

Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis

Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0–5 mm (mean 2.3 mm). The intraoperative mouth opening was 12–20 mm (mean 16 mm) after submucous release, and 32–42 mm (mean 35.5 mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8–9 cm in length and 2–2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18–38 mm (mean 28.2 mm) after a mean of 21 months’ follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.

Botulinum toxin injections for the treatment of oromandibular dystonia

Oromandibular dystonia is a neurologic disorder that manifests as involuntary repetitive spasms of the masticatory, lingual, and pharyngeal musculature, resulting in uncontrolled jaw and tongue movements. As with most dystonias, these actions are typically action induced and may cause considerable social distress to affected persons. In some cases, progressive disease may lead to significant dysphagia and/or dysarthria. Before the introduction of botulinum toxin injection, oral pharmacological agents provided limited treatment. This article reviews the assessment of oromandibular dystonia, techniques for intramuscular botulinum toxin injection, and possible posttreatment complications. Dystonia is a neurological phenomenon characterized by repetitive involuntary sustained (tonic) or spasmodic (clonic) muscle contractions that cause abnormal body posturing. 1 The dystonic movements are typically action induced; therefore, the involved body part may appear normal at rest. Dystonia can be categorized as focal, involving one particular small group of muscles; as segmental, involving neighboring groups of muscles; or as generalized, with widespread muscle involvement. However, the craniocervical region is more likely to be affected. 2 The etiologies of dystonia are varied, with the principal cause being idiopathic. Dystonia may also be the result of trauma, tardive syndromes, neurologic insult, neurodegenerative disease, or inherited disorders. Because the etiologies of dystonia may be diverse, consultation with a neurologist is prudent before rendering treatment. Cranial‐ cervical dystonia involves the musculature of the face, periorbita, masticatory complex, tongue, larynx, pharynx, and neck. 3 In this section we will focus on a subset of cranial‐ cervical dystonia known as oromandibular dystonia (OMD). OMD consists of involuntary spasms of masticatory, lingual, perioral, and pharyngeal muscles and may be classified as jaw opening, jaw closing, jaw deviation, and/or tongue protrusion type. When these symptoms are found in conjunction with blepharospasm, the condition is referred to as Meige’s syndrome. These involuntary postures of the tongue and jaw may lead to dysphagia, dysarthria, bruxism, and/or temporomandibular joint subluxation and damage. 4 In addition to physical impairment, the involuntary facial contortions may result in significant social impairment. 5