LIMITATION OF MOVEMENT OF MANDIBLE F O L L O W I N G TRAUMA

By JOHN POTTER, F.R.C.S.Ed., and F. E. HOPPER, B.D.S., F.D.S.R.C.S. From the Plastic and Jaw Unir, Shotley Bridge Hospital

As a result of trauma to the mandible there is not infrequently fracture of the neck of one or both condyles which, when treated, usually shows restoration of function without limitation of movement. Occasionally there may be limitation of movement of the jaw with deviation of the chin. The following patient gave no definite history of fracture, but excessive bone production in the region of the temporo-mandibular joint resulted in severe limitation of movement of the mandible.

CASE RECORD

The patient, R. T., aged 17 years, an agricultural worker, stated that three years previously he had fallen from his bicycle and injured his lower jaw, for which

A B FIG. I

Before operation.

he did not receive any treatment. Since that time he had noticed a hard swelling in front of his left ear, associated with difficulty in opening his mouth (Fig. I, A and B). On examination there was a smooth bony-hard swelling, approximately 2 cm. in diameter, in front of the tragus of the left ear and apparently continuous with the zygomatic arch. The overlying skin appeared normal, and there was a large firm non-tender lymph node in the upper left deep cervical chain and a similar enlarged lymph node in the right deep cervical chain. Movement of the mandible was limited to I2 mm. measured between the left upper canine tooth and the left lower second incisor, but there was no deviation from the midline on opening.

The following teeth were present : --

65432 / 34567 7654321 123457

the upper anterior teeth having been lost in the accident. The cranial nerves all appeared normal on clinical examination.

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116 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. 2

layers, and the patient was instructed from the day after operation.

Radiographic examination showed enlargement of both condyles of the mandible with apparent fusion between the left condyle and the zygomatic

arch (Fig. 2). Under endotracheal anmsthesia the

left zygomatic arch was exposed through a vertical pre-auricular incision and the bony

swel l ing of the zygomatic arch chiselled away. The macroscopic structure appeared to be similar to that of normal cancellous bone. When the excess bone had been removed it appeared that the temporo- mandibular joint had been partly obliter- ated, but on the medial aspect of the pos- terior part of the mass the joint appeared more or less normal and it was then possible to obtain movement of the man- dible. The bony mass had been encroach- ing on the joint space and interfering with the normal function of the temporo- mandibular joint, allowing practically no movement. The wound was closed in to begin active movement of the jaw as

A B C

FIG. 3 After operation.

One week after operation there was an opening, measured between the same points as before, of 21 mm. One week later this had increased to 28 mm., and after three months there was an opening of 3I mm. with excellent function and satisfactory appearance, without any deviation (Fig. 3, A, B, and c).

COMMENT

In the above case there was a history of trauma but no definite evidence of fracture of either the mandible or the zygomatic arch. The resultant bone production may have been due to an organised subperiosteal hmmatoma with subsequent laying down of new bone, but such a degree of bone production in this area is most unusual.