Modifications to Norman's procedure for hypermobility of the TMJ

Abstract

Background: Norman's procedure is a well known surgical technique for the hypermobility of temporomandibular joint. In this procedure after performing glenotemporal osteotomy the augmentation of the zygomatic root of the temporal bone is done by placing a bone graft from the iliac crest to prevent forward movement of the condyle beyond the eminence. This paper describes the clinical outcome of two modifications added to Norman's procedure. In addition to the conventional procedure inferiorly based pedicled flap from the temporal fascia was sutured to the antero-lateral aspect of the capsule. Intraorally pterygoid disjunction was carried out only in those case in which hypermobility was associated with painful temporomandibular joint disorder.

Methods: Modified Norman's procedure was performed in 10 patients (4 females & 6 males), 7 of them were bilateral and 3 cases were unilateral under general anesthesia.

Results: After one year follow up in none of the cases graft failed or rejected though recurrence along with TMJ pain was noticed in 2 cases.

Conclusion: This technique is versatile but long-term follow up on a larger number of patients is necessary to be able to draw definitive conclusions.

Keywords: Dislocation; Norman's procedure; Pterygoid disjunction; Subluxation; Temporofascial flap.

Fig. 1

Increased preoperative mouth opening.

Fig. 2

Hypermobility of TMJ on TMJ open mouth view.

Fig. 3

Osteotomy cuts for glenotemporal osteotomy.

Fig. 4

Glenotemporal osteotomy.

Fig. 5

Interpositioning of Iliac crest graft.

Fig. 6

Harvesting pedicled temporofascial flap.

Fig. 7

Suturing temporofascial flap over the antero-lateral aspect of TMJ capsule.

Fig. 8

Axial section showing pterygoid disjunction.

Fig. 9

Postoperative mouth opening.

Fig. 10

Restricted translation of condyle post surgery.