YIJOM-3294; No of Pages 4

Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2015.10.022, available online at http://www.sciencedirect.com

Systematic Review Paper

TMJ Disorders

Stability of treatments for V. L. de Almeida1, N. de S. Vitorino2,

A. L. de O. Nascimento3,
D. C. da Silva Júnior3,
P. H. L. de Freitas1,3
recurrent temporomandibular 1
Department of Dentistry, Federal University
of Sergipe at Lagarto, Lagarto, Sergipe,
Brazil; 2Brazilian Army Health Corps, Armed

joint luxation: a systematic Forces Hospital, Brası́lia, Brazil; 3Graduate

Program of Applied Health Sciences, Federal
University of Sergipe at Lagarto, Lagarto,

review Sergipe, Brazil

V.L. de Almeida, N. de S. Vitorino, A.L. de O. Nascimento, D.C. da Silva Júnior,

P.H.L. de Freitas: Stability of treatments for recurrent temporomandibular joint
luxation: a systematic review. Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx.
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Abstract. Temporomandibular joint luxation (TMJ) is the excessive anterior

translation of the mandibular condyle out of its normal range of movement and
away from the glenoid fossa. Once dislocation occurs, the abnormal condylar
position generates reflex contractions of the masticatory muscles, which in turn
hinder movement of the condyle back to its resting position. Frequent luxation
episodes characterize a condition referred to as recurrent TMJ luxation. While there
are several surgical and conservative therapeutic options available for recurrent
TMJ luxation, a robust, evidence-based rationale for choosing one technique over
another is missing. Thus, a systematic review based on the PRISMA statement was
proposed in an attempt to determine which therapeutic option results in the longest
time to relapse. There is no good quality evidence on which treatment options
Key words: temporomandibular joint; tempor-
guarantee the long-term elimination of recurrent TMJ luxation. In cases of post- omandibular joint disorders; articular hypermo-
surgical relapse, eminectomy has often been used as a ‘rescue procedure’, which bility; dislocation; review.
may mean that surgeons empirically consider this treatment to be the ‘gold
standard’ for addressing recurrent TMJ luxation. Accepted for publication 30 October 2015

Temporomandibular joint (TMJ) luxation
is the excessive anterior translation of the
mandibular condyle out of its normal
range of movement and away from the
glenoid fossa. While anterior, posterior,
cranial, and caudal positioning of the con-
dyle are possible, clinical experience
shows that anteriorly dislocated condyles
are the most frequent. Once dislocation
occurs, the abnormal condylar position
generates reflex contractions of the masti-
catory muscles, which in turn hinder
movement of the condyle back to its rest-
ing position.1,2
Treatments for TMJ luxation may be
temporary or definitive. Manual reposi-
tioning of the condyle back into the gle-
noid fossa is mostly temporary if the
condition is recurrent. Definitive treat-
ments can be further divided into conser-
vative or surgical.3 Intermaxillary fixation
(IMF), muscular exercises, the injection of
sclerosing solutions and autologous blood
into the TMJ, and the administration of
botulinum toxin are some of the conserva-
tive treatments proposed, which unfortu-
nately have significant failure rates.1,4 The

0901-5027/000001+04 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: de VL, et al. Stability of treatments for recurrent temporomandibular joint luxation: a systematic
review, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.10.022
YIJOM-3294; No of Pages 4

2 de Almeida et al.

surgical management of recurrent TMJ

luxation can either restrain mandibular
movement (by creating an obstacle at
the articular eminence) or clear the path
of the condylar head by removing the
eminence. Some of the techniques used
to restrict mandibular movement include
the oblique osteotomy of the zygomatic
arch, also known as Dautrey’s procedure,5
miniplating of the articular eminence,6
myotomy of the lateral pterygoids,7
intraoral lateral pterygoid muscle tendon
scarification, and capsule plication.8 Al-
ternatively, eminectomy is the reference
procedure for the total release of condylar
translation.2
Considering the many surgical and con-
servative therapeutic options available and
contrasting this with the relative scarcity
of an evidence-based rationale for the
choice of one technique over another,
the present systematic review was per-
formed in an attempt to answer the fol-
lowing question: Among the treatments
available for recurrent TMJ luxation,
which therapeutic option results in the
longest time to relapse?
Fig. 1. Flow diagram of the study selection process for the systematic review based on the
Methods PRISMA statement.9

This systematic review was performed
from July to December 2014 and followed
the recommendations given in the PRISMA
Statement.9 First, an electronic search was
conducted in the PubMed and Scopus data-
bases to obtain articles related to prospec-
tive or retrospective cohort studies that
included patients who underwent conser-
vative or surgical treatment for recurrent
TMJ luxation. The therapeutic options
included eminectomy, miniplating of the
articular eminence, zygomatic arch down-
fracture, glenotemporal osteotomy of the
zygomatic arch, autologous blood injec-
tion, botulinum toxin injection, sclerosing
solution injection, and myotomy of the
lateral pterygoids.
Study identification
Key words and Boolean operators used
were: #eminectomy, #miniplate emino-
plasty, #Dautrey Procedure, #Glenotem-
poral Osteotomy, #Temporomandibular
Joint AND Autologous Blood Injection,
#Temporomandibular Joint AND Botu-
linum Toxin, #Recurrent Mandibular Dis-
location AND Sclerosing Solutions,
#Temporomandibular Joint AND Lateral
Pterygoid Myotomy.
Titles and abstracts identified were
screened without time restrictions, resulting
in a number of seemingly relevant studies
for the systematic review. Subsequently,
the full texts were retrieved, read, and
checked against the following inclusion
criteria: (1) the article, written in English,
should represent a prospective or retrospec-
tive observational study that included
patients suffering from recurrent TMJ lux-
ation, either unilateral or bilateral; (2) the
patient sample (total or partial) should have
been followed up for at least 3 years post-
operatively. A flow diagram of the study
selection process is given in Fig. 1.
In addition, two independent reviewers
(V.L.A. and N.S.V.) assessed the studies
included through a list of questions based
on the Critical Appraisal Skills Pro-
gramme (CASP) for cohort studies.10 A
third examiner (P.H.L.F.) resolved any
inconsistencies between reviewers. The
following questions were used to assess
the quality of the studies included: Did the
study address a clearly focused issue? Was
the cohort or sample recruited in an ac-
ceptable way? Was the outcome accurate-
ly measured to minimize bias? Was the
follow-up of subjects complete enough?
How precise are the results?
Results
Description of the studies included
All studies included assessed the recur-
rence of TMJ luxation.11–22 Not all studies
followed their entire cohort up to the third
postoperative year, therefore only those
patients who were followed up for 3 years
or more were considered in the analysis
presented here. Since the statistical data
presented in the studies varied and were
mostly descriptive, it was decided not to
perform a meta-analysis. Details of all the
studies, including the authors, patient sam-
ple, type of intervention, and follow-up
data, are presented in Table 1.
Quality of the studies included
All studies included focused on a specific
issue, had recruited their cohorts in an
acceptable manner, and had presented
their results clearly. In all samples, there
was at least one patient who was followed
up for the period defined in the inclusion
criteria. However, none of the studies was
considered to be entirely free of bias.
Discussion
Consensus regarding the most effective
treatment for recurrent TMJ luxation is
yet to be reached. While several studies
have addressed the issue, the majority
have been case reports and literature
reviews. Highly relevant studies such as
randomized controlled trials were not
identified and only a few prospective
and retrospective cohort studies were
available up to the end of this review.

Please cite this article in press as: de VL, et al. Stability of treatments for recurrent temporomandibular joint luxation: a systematic
review, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.10.022
YIJOM-3294; No of Pages 4

Treatments for recurrent TMJ luxation 3

Table 1. Details of the studies included in the review.

Follow-up Number of patients Recurrence
(range in with follow-up (follow-up
Author Sample Surgical intervention months) 3 years (% of sample) 3 years)
Vasconcelos et al. (2009)19 10 Eminectomy 2–63 6 (60%) None
Wahab and Warraich (2008)20 15 Eminectomy 8–60 4 (27%) None
Vasconcelos et al. (2009)18 8 Miniplating of articular eminence 48–69 8 (100%) 1
Shibata et al. (2002)22 9 Miniplating of articular eminence 4–49 1 (11%) None
Buckley and Terry (1988)11 2 Miniplating of articular eminence 72 1 (50%) None
Costas Lopez et al. (1996)21 10 Glenotemporal osteotomy of the 5–51 1 (10%) None
zygomatic arch
Kuttenberger and Hardt (2003)16 20 Miniplating of articular eminence 24–85 18 (90%) None
Iizuka et al. (1988)14 12 Down-fracture of the zygomatic arch 6–63 6 (50%) None
Kobayashi et al. (2000)15 12 Down-fracture of the zygomatic arch 18–96 8 (67%) None
Gadre et al. (2010)12 20 Down-fracture of the zygomatic arch 14–60 9 (45%) None
Srivastava et al. (1994)17 12 Down-fracture of the zygomatic arch 36–62 12 (100%) 1
Guven (2008)13 12 Glenotemporal osteotomy of the 24–72 11 (92%) None
zygomatic arch
7 Eminectomy 12–144 4 (57%) None

Furthermore, the bulk of these studies had
patient samples that were followed up for
no longer than 30 months postoperatively.
Effective treatments for TMJ luxation
must promote a balance among factors such
as ligament and muscular actions and bone
morphology.23 Therapy is usually directed
towards the modification of some form of
joint mechanics. Following any surgical
procedure on the TMJ, the stomatognathic
system needs time to regain its balance.
While there is no evidence on this specific
aspect, clinical experience suggests that the
absence of recurrence during the 3 years
postoperative may represent more stable
surgical results.
Only some of the studies included had
their entire patient sample followed up for
longer than 3 years. To meet the inclusion
criteria, methodological adjustments had
to be made in order to consider only those
patients who were followed up for 3 years
or longer. Table 1 shows the total patient
sample for each study, the number of
patients followed up for 3 years or longer,
and the presence or absence of relapse in
the subsample. Interestingly, only articles
related to surgical treatments contemplat-
ed the inclusion criteria.
Three studies addressed eminectomy as
a therapeutic option for recurrent mandib-
ular luxation. In a study by Vasconcelos
et al., six out of 10 patients were followed
up for 3 years or longer.19 The samples of
Wahab and Warraich20 and Guven et al.13
had four out of 15 and four out of seven
participants, respectively, meeting the in-
clusion criteria.
The remaining studies addressed the fol-
lowing therapeutic alternatives: miniplat-
ing of the articular eminence, down-
fracture of the zygomatic arch, and gleno-
temporal osteotomy of the zygomatic arch.
Relapse was reported in two cases from two
different studies, one in which the miniplate
fractured, which led to post-surgical epi-
sodes of luxation,18 and the other in a
patient who had undergone unilateral sur-
gery and began to experience dislocations
of the non-operated side.17 Hardware frac-
ture appeared as a relatively frequent com-
plication (25%) requiring reoperation after
initial miniplating of the articular emi-
nence.18 Guven et al. reported postopera-
tive pain in three patients who had screws
placed in the articular eminence to prevent
recurrent TMJ luxation.13 Since postopera-
tive jaw excursions were painful, a second
procedure combining screw removal and
eminectomy had to be performed.
After applying a simplified version of
the CASP quality assessment question-
naire for cohort studies, the impression
was that, due to the small study sample,
short follow-up periods, and absence of
statistical analysis (except for the study by
Kuttenberger and Hardt16), it would be
difficult to define the accuracy of the
results of the studies included.
Therefore, with regard to the literature
available up to the date of completion of
this review, it was not possible to deter-
mine which treatment options guarantee
the long-term elimination of recurrent
TMJ luxation. When complications were
encountered, however, eminectomy was
often used as a ‘rescue procedure’. Thus,
it appears that surgeons empirically con-
sider eminectomy to be the ‘gold standard’
for the treatment of recurrent TMJ luxa-
tion. Multicenter clinical trials comparing
surgical or conservative techniques
against eminectomy may help to provide
good evidence to determine the most ef-
fective treatment for this condition. The
authors consider that a follow-up period of
3 years or longer provides a general idea of
the stability of the surgical results.
Funding
None.
Competing interests
No competing interest to disclose.
Ethical approval
Not required.
Patient consent
Not required.
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Address:
Paulo Henrique Luiz de Freitas
Department of Dentistry
Federal University of Sergipe at Lagarto
Rua Padre Alvares Pitangueira
No. 248
Centro
49.400-000 Lagarto
SE
Brazil
Tel: +55 79 2105 6550
E-mail: paulo@bucomaxiloaracaju.com.br