[ ISSN : 2576-5442 ]
TMJ; Dislocation; Botulinum toxin; Haemorrhagic stroke
Temporomandibular joint (TMJ) dislocations, which occur as a result of an excess of muscle activity/ spasticity in the protractor masticatory muscles, were defined as neurogenic dislocations of the TMJ. We report a case of a 36-year-old woman with sequelae of haemorrhagic stroke, which developed recurrent episodes of TMJ dislocation, interfering with the rehabilitation program and her well-being/quality of life. Conservative measures were implemented but 2 months later, TMJ dislocation episodes continued (2-3 daily). Then, type A botulinum toxin (BTX-A) injections were applied to both lateral pterygoid muscles, and these episodes ceased to happen for more than seven months. While conservative treatment is often not sufficient, surgical procedures are invasive and involve more risk, BTX-A injections, were an effective treatment option during for a longer than expected period of time.
Temporomandibular joint (TMJ) dislocations occurring as a result of muscle over activity in the protractor masticatory muscles were recently defined as neurogenic dislocations of the TMJ [1].
Some neurologic disorders, such as multiple sclerosis, Parkinson’s disease, traumatic brain injury, cerebral palsy and stroke, mostly those occurring with spasticity oromandibular dystonia, are accompanied by repeated TMJ dislocation [2].
Dislocation of the TMJ is generally of unknown origin. In addition to neurogenic muscular hyperactivity, it is known that there is a genetic predisposition, including disorders of collagen metabolism, such as ligamentous hyperlaxity and Ehler-Danlos syndrome, and risk factors, like extreme mouth opening during yawning, trauma, dental and ENT treatments, and a side effect of some medications used in psychiatric conditions [3]. Recurrent dislocation of the mandibular condyle places a hard problem for patients. It produces pain, anxiety and eating difficulties. Dislocations become more frequent and more difficult to control or prevent [4].
Since 1995, botulinum BTX-A injections have been used in the treatment of recurrent dislocation of TMJ, being the Lateral Pterygoid (LP) the most commonly injected muscle [1]. This muscle is mainly active in horizontal movements of the condoyle and generates contra lateral and protrusive force. It also stabilizes the disc-condoyle complex [4]. The superior and medial fibres of the upper head of the LP muscle insert into the medial half of the capsule and the meniscus [5].
The excess muscle activity in muscle bundles of the upper head and the superior part of the lower head of the LP could lead to unstable movements and disc/meniscus damage [4]. 63% of the patients with degenerative changes on the TMJ are related with over activity of the LP and its action in the anterior displacement of the auricular meniscus [6]. The injection of BTX-A in LP, produces a dose dependent temporary decrease of muscle activity, without systemic effects, interrupting the cascade of events.The severity influences the doses needed/used. The dose of BTX-A (Botox®) used per LP, per side, ranges between50Uand 100U - the 50U doses were given as repeated injections and the 100U were used only in severe cases, with several dislocations per week [7]. The LP is usually scarce of major side effects compared to other muscles, involved in jaw opening (mylohyoid, anterior belly of the dygastric, genihyoid), for which dysphagia, dysarthria, or aspiration may be an issue, due to the possible diffusion of the toxin into the masticatory muscles [3].
The most serious adverse event is transient dysphagia, occurring in8% of the treated patients. Other adverse events, in rare cases, are nasal speech (1.2% of patients), painful chewing (0.5%), nasal regurgitation (0.5%) and dysarthria (0.5%) [8]. All adverse events usually subside within 2-4 weeks [9]. Therapy with BTX- A is contraindicated in diseases affecting neuromuscular transmission, like myasthenia gravis or the Lambert Eaton syndrome, when amino glycoside antibiotics.
Although targeting accuracy and procedure safety are higher when a guided injection technique is used, the treatment can be performed simply and safely without electromyography, electrical stimulation or imaging control, by an experienced specialist, who masters the anatomy of the region [10]. Before the injection with BTX-A, conservative measures should be applied. However, these measures are sometimes insufficient to prevent further neurogenic dislocations of the TMJ [7].
A 36 years-old female, admitted at a rehabilitation centre, 2 months post-haemorrhagic stroke (right intra parenchymal haemorrhage) that led to quadriparesis (left side no visible contraction; right side whit active movement, full range of motion with gravity eliminated), moderate cognitive deficit, dysarthria and incontinence. The patient was treated with sertraline for emotional lability. The sertraline dose was increased due to a clinical worsening. Therefore, oro mandibular dystonia episodes were observed, leading to a painful and disabling recurrent TMJ dislocation.
These episodes required frequent use of diazepam to facilitate TMJ replacement manoeuvres and it interfered with the rehabilitation program and the patient’s quality of life. We discontinued sertraline administration at that time and after this no other oromandibular dystonia episodes were observed. Inter maxillary fixation screws were placed for mandibular block and conservative measures were implemented.
An orthosis for chin restraint was custom designed and produced for immobilization. The patient remained asymptomatic for 3 months, during this period she was submitted to a reconstruction cranioplasty, returning to the rehabilitation centre 2 months later. During the second inpatient stay, at the rehabilitation centre, she started to present repeated dislocations at an increased frequency. Maxillofacial surgeons refuted surgery as an option, because it would carry major risks.
During one month, TMJ dislocation episodes increased to a number of 2-3 times per day. In order to treat the patient, BTX-A injection was applied to both lateral pterygoid muscles, with a dose of 100U of on a botulinum toxin (Botox®) per side. The injection was made via an intraoral route without anaesthesia, and using anatomical references only. Following chemical neuro-muscular block of the pterygoid muscles, no further dislocations occurred until the date of writing this paper (7 months). There were no adverse events. On the positive side, there was a significant improvement of the patient’s speech quality, head posture, mastication, mood and motivation to participate in the rehabilitation program.
The bilateral neuromuscular block of the LP muscle restricts the angle of mouth opening, thus helping to prevent dislocation. A limitation of movement in the medial-lateral direction may reduce the corresponding tractional forces produced during jaw function and perhaps favour regenerative processes [4].
The effects of the BTX-A treatment are typically seen within 3 to 10 days after the injection, and they generally last 3 to 6 months. The muscle recovers over several months as the nerve terminal regains function [3]. However, the precise mechanisms behind the favourable treatment outcomes are unclear to date. Intramuscular injections of BTX-A are safe and reliable as a treatment with minimal side effects for recurrent neurogenic TMJ dislocations [9]. Due to BTX-A treatment, our patient became more capable to participate in the overall rehabilitation program. Intramuscular injections with BTX-A represent an effective and safe therapeutic option for recurrent TMJ dislocation, especially when other conservative measures fail and for patients to whom surgery would carry major risks [7]. This procedure could be an alternative to surgery and maybe considered as an initial approach in moderate to severe cases [3].
3. Martínez-Pérez, Pedro García Ruiz-Espiga. Recurrent temporomandibular joint dislocation treated with botulinum toxin: Report of 3 cases. Dolores J Oral MaxillofacSurg. 2004; 62: 244-255.
5. Naidoo L C. A lateral pterygoid muscle and its relationship to the meniscus of the temporomandibular joint. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontics. 1996; 82: 4-9.
Falcão C, Amorim I, Proença S and Jacinto J. Neurogenic Temporomandibular Joint Dislocations treated with Botulinum Toxin Injections: Case Report. SM Musculoskelet Disord. 2017; 2(2): 1014.
Occlusion is biologically defined as the coordinated functional interaction between the various cell populations forming the masticatory system as they differentiate, model, remodel, fail and repair
Talia Becker*
Achilles tendon is a common site of foot and ankle discomfort but its rupture is not frequent. It’s a superficial tendon and this lends it to excellent evaluation by sonography instead of magnetic resonance imaging. Recently ultrasonography has been widely used in musculoskeletal practice. We present a case of Achilles tendon ruptures diagnosed based on fundamental sonographic findings.
Arash Babaei-Ghazani¹,², Safoora Ebadi¹,², Bijan Forogh¹,³, and Bina Eftekharsadat⁴*
Osteoarthritis (OA), one of the most common skeletal disorders characterized by cartilage degradation and osteophyte formation in joints, is induced by accumulated mechanical stress; however, little is known about the underlying molecular mechanism. Several experimental OA models in mice by producing instability in the knee joints have been developed to apply approaches from mouse genetics. Although proteinases like matrix metalloproteases and aggrecanases have now been proven to be the principal initiators of OA progression, clinical trials of proteinase inhibitors have not been successful for the treatment, turning the interest of researchers to the upstream signals of proteinase induction. These signals include under graded and fragmented matrix proteins like type II collagen or fibronection that affects chondrocytes through distinct receptors. Another signal is pro inflammatory factors that are produced by chondrocytes and synovial cells; however, recent studies that used mouse OA models in knockout mice did not support that these factors have a role in the central contribution to OA development. Our mouse genetic approaches found that the induction of a transcriptional activator Runx2 in chondrocytes under mechanical stress contributes to the pathogenesis of OA through chondrocyte hypertrophy. In addition, chondrocyte apoptosis has recently been identified as being involved in OA progression. We hereby propose that these endochondral ossification signals may be important for the OA progression, suggesting that the related molecules can clinically be therapeutic targets of this disease.
Hiroshi Kawaguchi
Estimating the Knee Functional Axis (KFA) is crucial to both correctly implanting the prosthesis and accessing the joint kinematics. Researchers have mainly reported KFA by manual management of flexion extension movements, which are passively performed without any voluntary movements. Active touch and movement refers to what is ordinarily called as touching, which is defined as variations in skin stimulation caused by variations in a person’s motor activity.
The difference is very important for the individual. However, it has not been emphasized in the biomechanical literatures. This study aims to confirm the distinction between touching and being touched. We are particularly interested in measuring the Instantaneous Axes of the Knee (IAK) during locomotion. This geometrical “pattern” of the IAK is altered along with the touch pattern by the mechanical necessities of terrestrial movement.
Wangdo Kim¹, Young Choi², and Hong-Gi Lee³*
Although fractures of the epiphyseal cartilage injuries are common in childhood, epiphyseal fractures involving the proximal tibia entities are very rare and are usually caused by high-energy trauma, with an incidence ranging between 0.5 and 3.1% of patients; peak incidence between the ages 12-14 years in male patients. The aim of this report is describe a case of fracture of the epiphyseal cartilage of a 13 year old boy, a victim of sports trauma showing lateral tibial plateau fracture and epiphyseal cartilage fracture at the same side, not compatible with the classifications of fractures in children.
Omar Ferreira Miguel
In the last few years, clinical applications of regenerative medicine have been increasing their way in medical practice.
Valerio Di Nicola¹,² and Mauro Di Pietrantonio³*
The twentieth century epidemic of low back pain has continued unabated into the 21st century. Up to 20% of the Australian population will experience low back pain at some stage of their lives
J Saunders¹, M Cusi¹,³ and H Van der Wall¹,²*
Music is the most essential ingredient of any entertainment. In order to create successful entertaining event musicians plays an imperative role. Musicians are wizards who spread the fragrance of joy by absorbing woes, in the form of Playing Related Musculoskeletal Disorders (PRMDs), for themselves. Like other occupations, musicians also suffer from work related musculoskeletal disorders which are often disabling
Wricha Mishra
Dupuytren’s Contracture (DC) is a fibro-proliferative tumor according to ICD 10 - fascial fibromatosis of unknown etiology (M 720), accompanied by a stable bending contracture of fingers. In CD in the postoperative period extremely high rate of surgical complications is observed: intraoperative (injury of blood vessels, nerves, tendons), general postoperative (hematoma, necrosis, odema, stiffness, etc.), late postoperative (recurrence, spread, progression). In the last case according to the data of different authors, complications frequency is depend upon the degree (from partial up to the total) and the accuracy of excision of the affected aponeurosis ?almaris. One of the problems in choosing the type of operation and technology is the complexity of the cutoff determination boundaries of the affected CD. Up to now there is no suitable for use in the practical CD surgery algorithm of the affected aponeurosis ?almaris spread non invasive visualization in a particular patient. The most appropriate method for the solution of this problem is a method of MRI. The technology of identifying the boundaries of surgery of the affected aponeurosis palmaris in Dupuytren’s contracture by means of MRI has been elaborated. It has been shown that MRI is a highly informative method in the assessment of topographic anatomy of aponeurosis palmaris in normal and CD states. PD, T1, T2 - weighed images allow objectively to visualize the border areas of the affected aponeurosis in I - III stages of CD. PD fsat (fat tissues signal saturation) MRI mode is not recommended for use.
Baikeev RF¹, Mikusev GI², Osmonaliyev IZh², Zakirov RH² and Afletonov EN²*
Metallosis is an aseptic fibrosis, local necrosis, inflammation, or loosening of an implant device secondary to metallic corrosion and release of wear debris. The condition has been highlighted recent years due to the clinical complications caused by metal-on-metal (MoM) hip replacement. Although some major types of MoM hip prostheses have been recalled from the market, metallosis is far from over as not only there are still a million implanted MoM hip prosthetic cases worldwide, but also it has been found in non-MoM hip prostheses and other metal implants. This mini review aims to provide recent findings of implants related metallosisin skeletal tissue.
Zhidao Xia