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British Journal of Oral and Maxillofacial Surgery 46 (2008) 119–122

Glenotemporal osteotomy and bone grafting in the

management of chronic recurrent dislocation and
hypermobility of the temporomandibular joint
A.M. Medra a,∗ , A.M. Mahrous b,1
a Department of Cranio-Maxillo-facial, Oral and Plastic Surgery, Faculty of Dentistry, Alexandria University, Egypt
b Department of General Surgery, Maxillo-facial and Plastic Surgery Unit, Faculty of Medicine, El-Minia University, Egypt

Accepted 19 August 2007

Available online 1 November 2007

Abstract

Chronic recurrent dislocation of the temporomandibular joint (TMJ) is rare and has many causes. Although it is possible to start treating it
conservatively, these treatments are usually unsuccessful. Over the years, many operations have been done including operating on the muscles,
the articular capsule, the articular meniscus, and the condyle. At present, the most widely accepted techniques are those used on the articular
eminence. It may be reduced (eminectomy), favouring free movement of the condyles, or an obstacle may be interposed to prevent excessive
movement of the condyles. These later techniques include Norman’s (glenotemporal osteotomy with interpositional bone grafting). Other
techniques include Dauterey’s procedure, on which onlay bone grafts or bone substitutes are inserted in a subperiosteal pocket inferior to the
articular eminences.
We report a prospective study of 60 patients who had a bilaterally modified glenotemporal osteotomy, 40 who had chronic dislocations of
the temporomandibular joints and the other 20 who had severe hypermobility of the joints. Bone grafts, iliac or calvarial, were inserted at the
osteotomy between the zygomatic arch and the articular eminence, and fixed either by wires, mini-plates or microplates, and screws. Stable
results were obtained and retained during long-term follow up of 1–8 years.
© 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Chronic; Recurrent; Dislocation; Temporomandibular joint; Osteotomy

Introduction “long-standing” is applicable to those in whom it has lasted

Anterior mandibular dislocation may be classified as acute,
chronic, recurrent (habitual), and long-standing. Acute dis-
location of the temporomandibular joint (TMJ) is a condition
where the condyle moves suddenly ventral to the artic-
ular eminence and becomes locked in front of it. The
term “chronic”, “chronic recurrent”, or “habitual” should
be reserved for repeated episodic dislocations. The term
∗ Corresponding author at: 9 Khalil El-Masry Str., Roushdy, Alexandria,
Egypt. Tel.: +20 3 5466488; fax: +20 3 4868922.
E-mail address: prof ahmedmedra@hotmail.com (A.M. Medra).
1 Tel.: +20 122375099.
for longer than a month.1
Chronic recurrent dislocation (Fig. 1) of the jaw has vari-
ous causes that involve traumatic factors, hereditary, acquired
neurological illness, and ingestion of certain medicines.2–4
Incoordination of the neuromuscular activity of the chewing
muscles, and articular anatomical alterations such as a flat
eminence or abnormal condylar morphology, have an impor-
tant role.5 On other occasions, there is no obvious cause.
Certain factors such as a lack of teeth and articular laxity
could predispose.6
A radiograph will confirm the diagnosis and indicate the
position of the highest point of the displaced condyle ante-
rior and superior to the lowest point of the articular eminence

0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.08.004
120 A.M. Medra, A.M. Mahrous / British Journal of Oral and Maxillofacial Surgery 46 (2008) 119–122
Fig. 1. Recurrent dislocation of temporomandibular joint, class III malocclusion. The patient cannot close her mouth without assistance (published with the
patient’s permission).
Fig. 2. Panoramic radiograph showing the condyles displaced anteriorly to
the articular eminence.
(Fig. 2)1 (Norman JE. Glentemporal osteotomy and a mod-
ified dowel graft. Paper presented at European Association
for Maxillofacial Surgery; 1994).
We report our experience with a modified Norman’s pro-
cedure in patients with chronic recurrent dislocation and
hypermobility of the TMJ (Fig. 3).
Fig. 3. Patient with severe hypermobility. The mouth wide open, but the
patient cannot close it without assistance.
Patients and methods
This study included 60 patients: 40 with chronic recurrent
dislocation and 20 with hypermobility of the TMJ. There
were 40 women and 20 men, whose ages ranged between 18
and 36 years (mean 27). Forty patients had chronic recur-
rent dislocation, and on clinical examination they all had
had multiple episodes of dislocation of the joints bilater-
ally that had required admission to hospital on at least one
occasion for reduction of the dislocation by manipulation
under general anaesthesia or sedation. It was possible to
evaluate mouth opening in 36 patients but was not in the
other four because of pain and the fear of dislocation. The
mean mouth opening in the first group was 46 mm (range
46–55). In the 20 patients with hypermobility, mouth opening
ranged from 55 to 60 mm (mean 58). Clinical examina-
tion showed the usual signs and symptoms of dysfunction
of the TMJ including preauricular and facial pain, joint
noises during mandibular movements, and disturbance of
mandibular movements caused by abnormal muscular activ-
ity that caused excessive mouth opening with the condyles
in anterior relation to the eminence. Radiographic exami-
nation showed that the condyles were completely displaced
anterior to the articular eminences, but patients could close
their mouths without assistance: the condyles were sublux-
ated.
Surgical technique
All patients were operated on under general anaesthesia
with nasotracheal intubation. The operation started with a
preauricular incision with temporal extension. Dissection
continued until the deep temporal fascia was reached, then
the root of the zygomatic arch was identified, followed by
 A.M. Medra, A.M. Mahrous / British Journal of Oral and Maxillofacial Surgery 46 (2008) 119–122 121

subperiosteal exposure of the zygomatic arch to protect the

frontal branch of the facial nerve. The articular eminence was
also exposed keeping the soft tissues attached to its lower
portion.
A horizontal osteotomy separated the articular eminence
from the zygomatic arch using a micro-reciprocating saw or
fine fissure bur. The osteotomy should be at least 1.5 cm deep
in the articular eminence.
A fine osteotome was then used to separate the articular
eminence from the zygomatic arch.
The capsule was preserved in all cases; all the work was
extracapsular. The periosteum of the inner surface of the emi-
nence was also left intact to avoid resorption of the eminence.
The gap was about 3–5 mm wide.
A bone graft was harvested from either the iliac crest
(n = 40) or from the outer table of the skull (split calvarial)
(n = 20). When cranial bone was used, the incision extended
into the temporoparietal area.
The bone grafts were trimmed and then interposed in the
space created by the osteotomy and the bone was brought
together. In 10 patients, wire was used to stabilise the
osteotomy and the graft. An important step in the operation
is to leave adequate space in front of the condyle so that it
can move freely when the mouth is opened. The bone graft
should not impinge on the condyle.
Fig. 4. Same patient as in Fig. 1 six months after glenotemporal osteotomy
In 40 patients titanium miniplates were used for and split calvarial bone graft.
osteosynthesis,5 and in 10 a microplate and microscrews were
used.

Results
Patients were followed up from 1 to 8 years (mean 3). All
patients were satisfied with the results, had stable joints,
and could chew normally. One developed a recurrence as
a result of severe injury to the joint 6 months postoperatively,
which was corrected by reoperation. No other patient devel-
oped recurrent dislocation during follow up. All patients had
limited mouth opening during the immediate postoperative
period, ranging between 15 and 25 mm (mean 19) during the
first month. This gradually improved so that 3 months post-
operatively it ranged between 28 and 38 mm (mean 32). By
6 months postoperatively, it had increased from 35 to 42 mm
(mean 39) (Fig. 4). One year postoperatively, mouth opening
was in the range 38–45 mm (mean 42), and then stabilised.
Temporary paralysis of the frontal branch of the facial nerve
in five patients resulted from traction on the tissues, and had
resolved within 3 months. The articular pain and clicking that
had been present in all patients preoperatively disappeared,
and mandibular movement improved. Three patients had pain
during opening of the mouth because the wires used to fix the
bone graft were impinging on the condyles; the wires were
removed and the pain went. Postoperative radiographs imme-
diately after operation and then yearly showed the bone grafts
to have been well incorporated without reduction in vertical
Discussion
Many operations have been described for the treatment of
chronic recurrent dislocation of the jaw. Eminectomy may fail
to solve the underlying problem as the condyle may continue
to dislocate, and at the end cause serious articular damage
from repeated injury.6 Dautrey’s procedure 7 may be followed
by internal displacement of the mandibular condyle if it is
small because of the limited cross-section of the lateromedial
zygomatic arch, and it is not applicable in all age groups
because of the risk of fracture; elasticity decreases as age
increases. There is also the risk of relocation of fragments.
In his study on the role of midtemporal shortening for the
management of dislocation, Sherif (Sherif AE. Midtempo-
ral shortening for correction of chronic recurrent mandibular
dislocation: a retrospective study and addition of a new surgi-
cal modality. Paper presented at the 81st General Session of
the International Association for Dental Research 2003.) said
that all patients improved with no recurrences. Zeigler et al.8
reported 19 patients of 21 who improved after an injection of
Botulinum toxin into the lateral pterygoid muscle.
Glenotemporal osteotomy with interpositional bone graft
not only increases the height of the articular eminence but
also increases its width, and so avoids the medial escape of
the condyle. The operation is totally extracapsular. Karabouta
9 reported good results with the use of hydroxyapatite as an

height. interpositional biocompatible material, yet the patient’s own

122 A.M. Medra, A.M. Mahrous / British Journal of Oral and Maxillofacial Surgery 46 (2008) 119–122
bone may usefully be used as graft material. It can be obtained
at the same operation, and the iliac crest provides enough
bone with good osteoinductive capacity, although it does tend
to resorb. There is also the problem of morbidity of the donor
site in the form of postoperative discomfort.10 The current
fashion is to incorporate cranial bone11 from the temporopari-
etal area, so taking advantage of a single incision.12 Despite
the fact that this bone is usually thin, unlimited amounts may
be obtained, and there is no morbidity if the graft is taken
carefully. Published complications, such as scalp infection,
seroma, dural tear, arachnoid bleeding, and haematoma were
not encountered in the current series. The bone has the same
characteristics as the cut bone, with less tendency to resorb.
Osteosynthesis was good regardless of whether it has
wire or plate osteosynthesis. Problems such as intra-articular
infection, rejection, looseness of screws, or free moving for-
eign bodies within the joints, were not encountered. However,
some authors do not favour the introduction of foreign mate-
rials like screws or plates into the joint and prefer wire
osteosynthesis to avoid these problems.13 Costas Lopez et
al.6 mentioned that it is not always necessary to use any
osteosynthesis because of the tendency for the space left by
the osteotomy to be obliterated if the periosteum of the medial
part of the articular eminence is preserved.
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