Mandible Dislocation 

  • Author: Meher Chaudhry, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 19, 2012
 

Background

Mandible dislocation is the displacement of the mandibular condyle from the articular groove in the temporal bone. Different types of dislocations can result from traumatic and nontraumatic processes. Most dislocations are managed and reduced in the emergency department with elective follow-up. However, some situations require immediate consultation with an oromaxillofacial surgeon. This article focuses primarily on the diagnosis and management of mandible dislocations in adults.

Anatomy

The temporomandibular joint (TMJ) (see the image below) is the articular surface between the mandibular condyles and the temporal bone. Synovial membranes line the space between the two bones. The joint acts with a hinge as well as a gliding mechanism.[1]

The temporomandibular joint. The temporomandibular joint.

The temporomandibular ligament, sphenomandibular ligament, and capsular ligament support the joint. Blood supply is from the superficial temporal branch of the external carotid artery. Branches from the auriculotemporal and masseteric divisions of the mandibular nerve innervate the joint.

Closing of the mandible is performed by the masseter, temporalis, and medial pterygoid muscle. The jaw opens at the temporomandibular joint by traction on the mandibular neck by the lateral pterygoid muscle.

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Pathophysiology

The mandible can dislocate in the anterior, posterior, lateral, or superior position. Description of the dislocation is based on the location of the condyle in comparison to the temporal articular groove.[1]

Anterior dislocations are the most common and result in displacement of the condyle anterior to the articular eminence of the temporal bone. These dislocations are classified as acute, chronic recurrent, or chronic.

  • Acute dislocations can be seen after trauma or dystonic reactions, but they are usually a result of extreme mouth opening such as with yawning, general anesthesia, dental extraction, vomiting, or seizures. Anterior dislocations after endoscopic procedures have also been reported.[2]
  • Anterior dislocations are usually secondary to an interruption in the normal sequence of muscle action when the mouth closes from extreme opening. The masseter and temporalis muscles elevate the mandible before the lateral pterygoid muscle relaxes resulting in the mandibular condyle being pulled anterior to the bony eminence and out of the temporal fossa. Spasm of the masseter, temporalis, and pterygoid muscles causes trismus and keeps the condyle from returning into the temporal fossa. These dislocations can be both unilateral and bilateral.[3]
  • Acute chronic dislocations result from a similar mechanism in patients with risk factors such as congenitally shallow mandibular fossa, loss of joint capsule from previous mandible dislocations, or hypermobility syndromes.
  • Chronic dislocations result from untreated TMJ dislocations and the condyle remains displaced for an extended time period. Open reduction is often required.[4, 5, 6]

Posterior dislocations typically occur secondary to a direct blow to the chin. The mandibular condyle is pushed posteriorly toward the mastoid. Injury to the external auditory canal from the condylar head may occur from this type of injury.[1, 7]

Superior dislocations, also referred to as central dislocations, can occur from a direct blow to a partially opened mouth. The angle of the mandible in this position predisposes upward migration of the condylar head. This can result in fracture of the glenoid fossa with mandibular condyle dislocation into the middle skull base. Further injuries from this type of dislocation can range from facial nerve injury, to intracranial hematomas, cerebral contusion, leakage of cerebrospinal fluid, and damage to the eighth cranial nerve resulting in deafness.[8]

Lateral dislocations are usually associated with mandible fractures.[9, 1] The condylar head migrates laterally and superiorly and can often be palpated in the temporal space.[10]

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Epidemiology

Frequency

Mandibular dislocations are infrequent presentations to the emergency department. Lowery et al reported seeing 37 dislocations over a 7-year period in an emergency setting with approximately 100,000 annual visits.[3] Anterior mandible dislocations are most common and often result from nontraumatic causes.

Mortality/Morbidity

Significant morbidity associated with isolated mandible dislocations is rare. However, fractures of the mandible, maxillofacial, or orbital bones are often seen with traumatic TMJ dislocations.

Mandibular dislocations may be associated with chronic recurrent dislocations, ischemic necrosis of the condylar head, traumatic damage to the articular disk, and mandibular osteomyelitis. Chronic untreated dislocations can result in permanent malocclusion.[9, 11, 12]

Mortality in cases of mandibular dislocation is usually a result of concurrent serious traumatic injuries and not from the dislocation itself.

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Contributor Information and Disclosures
Author

Meher Chaudhry, MD  Clinical Instructor of Emergency Medicine, George Washington University Hospital Medical Faculty Associates

Meher Chaudhry, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD  Assistant Professor, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

James E Keany, MD, FACEP  Medical Director, TravelMDAssist; Staff Physician, Department of Emergency Services, Mission Hospital Regional Medical Center

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and California Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Edward J Newton, MD, and Christian D McClung, MD, to the development and writing of this article.

References

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The temporomandibular joint.
Classic reduction technique. The physician places gloved thumbs on the patient's inferior molars bilaterally, as far back as possible. The fingers of the physician are curved beneath the angle and body of the mandible.
Recumbent approach. The patient is placed recumbent, and the physician stands behind the head of the patient. The physician places his or her thumbs on the inferior molars and applies downward and backward pressure until the jaw pops back into place.
Wrist pivot method. The patient is placed in a sitting position, and the physician stands facing the patient. The physician grasps the mandible at the apex of the mentum with both thumbs. The fingers are placed on the inferior molars.
Ipsilateral approach - extraoral route. The patient is placed in a sitting position, and the physician stands behind the patient. The physician stabilizes the patient's head with his or her nondominant hand and uses the dominant hand to apply downward pressure on the displaced condyle that is palpated just inferior to the zygomatic arch.
 
 
 
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