A 19-year-old female patient reported with a history of frequent episodes of difficulty in closing the mouth after wide mouth opening, for the past 6 months. This was associated with joint sounds which were bilateral. Characteristically, the patient experienced severe pain, 5–10 min after forceful closing of mouth. During every episode, the pain originated on the right side of the TMJ and lasted for 2 h. The nature of the pain was dull and aching and radiating to the right side ear, forehead, neck, and shoulder. The pain was aggravated by excessive jaw movements and relieved by rest and nonsteroidal anti-inflammatory drugs.\nThe patient's medical history did not reveal anything relevant to the clinical symptoms such as trauma to the joint, medication, or parafunctional habits.\nExtraoral clinical examination revealed the following: the maximal mouth opening was 52 mm with a deviation of the mandible toward the left side. Bilateral preauricular hollowing was noted on wide opening. On palpation, mild tenderness was appreciated on the right side of TMJ along with clicking during the late opening and early closing of the mouth. Intraoral examination revealed Class 1 occlusion and the maxillary dental midline coinciding with the mandibular dental midline. Based on the clinical features, a provisional diagnosis of subluxation of the joint was made.\nOrthopantomogram (OPG) was taken in two views with the mouth open and closed: closed mouth view demonstrated a slender and small condyle with shallow articular eminence on both sides of the TMJ and open mouth view showed bilateral dislocation of condyle anterior to the eminence []. Assessment of cone-beam computed tomography (CT) demonstrated the length of condyle on the right and left as 16.1 mm and 18.5 mm, respectively. The mediolateral width of the right condyle was 12.5 mm and the left condyle was 13.4 mm. The vertical dimensions of the articular eminence on the right and left side were 29.4 mm and 22.9 mm, respectively. Based on all the above investigations, a definitive diagnosis of bilateral subluxation of TMJ was made and planned for surgical management.\nUnder general anesthesia, vestibular incision was placed extending from the 2nd molar till the ascending ramus of the mandible. The ramus and coronoid were exposed after dissection of soft tissues. Osteotomy cut was marked using the following reference points: Point A was marked on the ramus of the mandible from the lower occlusal plane and Point B was marked 16 mm above the first point which was planned preoperatively using stereolithography model []. Osteotomy cut was made from the Point B to the base of the sigmoid notch. The osteotomy of coronoid was completed using a mallet and chisel. A trough was created on the lateral surface of the ramus to position the osteotomized coronoid. The coronoid was positioned inferiorly in the trough and was fixed with a 2-holed, 2-mm plate using 6-mm screws through the transbuccal approach. The surgical wound was closed with 3-0 vicryl in layers. Extraoral stab incision was also sutured with 3-0 vicryl suture. The mouth opening of the patient on the 1st postoperative period was 25 mm. Postoperatively, the length and thickness of the right temporalis and lateral pterygoid on both sides were assessed using ultrasonography which revealed appreciable increase in both the dimensions []. Postoperatively, the position of coronoid was confirmed with OPG and three-dimensional CT [Figures and ].\nThe patient was followed up for 6 months, during which the patient's mouth opening was 40 mm consistently, with no incidence of open lock, TMJ pain, or difficulty in jaw movements.
NP was a 60-year-old housewife who\npresented with a three hour history of inability to close\nthe mouth after yawning. There was associated pain\nand discomfort in the preauricular area bilaterally. She\nhad a similar incident four (4) months earlier. No\nprevious history of trauma. She is a known\nhypertensive on moduretic. A diagnosis of bilateral\nanterior TMJ dislocation was made. She had a\nsuccessful treatment using the extra-oral technique after\nfailed Hippocrates manouvre attempts. She was\nsubsequently immobilized with the barrel bandage