eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Dislocation, Mandible

Meher Chaudhry, MD, Chief Resident, Department of Emergency Medicine, Detroit Receiving Hospital, University Health Center
Adam J Rosh, MD, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital

Updated: Jan 14, 2009

Introduction

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 Media file 1) 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 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.

The temporomandibular joint.

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 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 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 and can result in facial nerve palsy, cerebral contusion, or deafness. 
• Lateral dislocations are usually associated with mandible fractures.^8,1 The condylar head migrates laterally and superiorly and can often be palpated in the temporal space.⁹

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.^8,10,11  
 
Mortality in cases of mandibular dislocation is usually a result of concurrent serious traumatic injuries and not from the dislocation itself. 

Clinical

History

• Most patients present with jaw pain and trismus after extreme mouth opening or after a direct blow to the jaw. In addition, patients describe difficulty with speaking or swallowing, and malocclusion.^7,12
• A history of previous dislocations, hypermobility syndromes, or injury to the TMJ joint should be elicited from patients.  
• In rare cases of multisystem trauma, head injuries, intoxication, or other causes of altered mental status, the patient may not be able to give a history suggestive of mandible dislocation. 
• Malocclusion is not unique to mandible fractures or dislocations, and maxillary fractures should be considered in the differential diagnosis in patients with malocclusion and pain.⁹

Physical

A thorough examination of the head, neck, and nervous system should be performed in patients with suspected mandible dislocation. Usually pain and difficulty with jaw movement is present in all patients with mandible injury.   

• Inspect the oral cavity for gingival lacerations, which may signal an open fracture. 
• A "tongue blade test" can be performed in subtle cases of jaw injury. A tongue blade is placed between the molars, and the patient is asked to bite down. If the patient can stabilize the tongue blade sufficiently for the examiner to twist it until it breaks, a mandibular fracture is unlikely.^13,9  Alonso et al and Schwab et al reported that the tongue blade test is 95% sensitive. It should be performed on both sides.
• Anterior mandible dislocations usually result in a visible and palpable periauricular depression from displacement of the condyle. 
  • Unilateral dislocations result in a deviation of the jaw away from the dislocation. 
  • When both mandibular condyles are dislocated anteriorly, the patient appears to have an underbite, or prognathia, with pain over both TMJ areas.¹²  
• A thorough examination of the central nervous system, especially cranial nerves V and VII, should be performed in all patients with suspected jaw dislocations. This is vital, especially in cases of superior jaw dislocation. 
• External auditory canal should be inspected, and hearing should be assessed in patients with suspected posterior mandible dislocation. 
• The condylar head can sometimes be felt in the temporal space in cases of lateral dislocation.

Causes

Risk factors

• Shallow mandibular fossa
• Previous TMJ trauma or dislocation that disrupted the joint capsule
• Dystonic reactions
• Seizures
• Hypermobility syndromes, such as Marfan syndrome or Ehlers-Danlos syndrome, which predisposes the TMJ to dislocation due to increased laxity of surrounding connective tissue^14,9,15

Differential Diagnoses

Workup

Laboratory Studies

• No initial laboratory workup is necessary in a healthy patient with an isolated jaw injury and an otherwise normal examination and vital signs.
• A pregnancy test may be indicated in women of childbearing age prior to imaging studies.
• In patients with associated injuries, other comorbid illnesses, or those requiring open reduction, laboratory workup may be useful.

Imaging Studies

Imaging studies should be obtained prior to reduction to identify any fractures. In rare cases of chronic dislocations, imaging studies can be avoided based on the discretion of the treating physician. 

• Fractures associated with nontraumatic anterior mandibular dislocations are rare. However, traumatic dislocations are often associated with mandibular fractures. Isolated trauma to the mandible can be evaluated by using an orthopanoramic radiograph and a mandible posteroanterior (PA) view with maximal mouth opening. This is an acceptable option for patients with chronic recurrent dislocations and a nontraumatic mechanism. However, certain fractures, such as nondisplaced mental fractures, may not be recognized on panoramic and PA radiographs because of the overlapping spine obscuring the image. In addition, restricted mouth opening can result in inadequate projection of the condylar process on the PA view, resulting in missed fracture of the mandibular ramus. 
• The use of CT scanning for mandible injuries is increasing because CT scan provides greater sensitivity in diagnosing mandibular abnormalities. The use of CT in traumatic mandible injuries is increasing.¹⁶  The ability to obtain reconstructed images along the sagittal and coronal plane and along the alveolar ridge to create panoramiclike images further contributes to improved visualization of the fractures and acceptability of CT as the initial imaging modality in stable patients with traumatic mandible injury. 
• Although MRI is not the first-line imaging modality in patients with mandible dislocations, it is useful in assessing the integrity of the TMJ joint, articular disks, and associated structures. MRI is also informative in patients with chronic recurrent dislocations while planning further long-term management. MRI is highly sensitive in detecting complications of mandibular injuries, such as pseudoarthrosis from fragment nonunion of traumatic fractures, ischemic necrosis of the condylar head, and traumatic damage to the articular disk. Both CT and MRI can be used to assess for posttraumatic osteomyelitis.¹⁶

Treatment

Prehospital Care

No specific treatment of mandibular dislocation is indicated in the field. The decision regarding self-transport versus paramedic transport is based upon factors other than the mandibular dislocation (eg, presence of multiple trauma, patient's level of pain and distress).

Emergency Department Care

A thorough assessment of the patient’s airway, breathing, and circulation (ABCs) should be performed at presentation. If a complete history, physical assessment, and appropriate imaging study reveal an isolated mandibular dislocation, a decision is to be made if closed reduction in the emergency department is appropriate. 
 
Oral maxillofacial surgery consultation is indicated for patients with dislocations associated with fractures and for chronic dislocations. Based on the degree and displacement of the fracture and damage to associated structures, many of these patients require open reduction in the operating room.

Providing analgesia and muscle relaxation prior to reduction is important. Several options are available including procedural sedation using a combination of intravenous sedatives and analgesics. Local anesthetics (eg, lidocaine) can be injected directly in the TMJ space at the site of the preauricular depression.¹⁷ A short-acting benzodiazepine, such as intravenous midazolam, can be used for muscle relaxation. Several methods have been proposed and successfully used for reduction of anterior jaw displacement. Also see Joint Reduction, Mandibular Dislocation.

Classic reduction technique

The patient is placed in a sitting position, and the physician stands facing the patient (see Media file 2).

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.

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.

The physician applies downward and backward pressure on the mandible using his or her thumbs while slightly opening the mouth. This helps disengage the condyle from the anterior eminence and reposition it back into the mandibular fossa. 

There is a risk of injury to the thumbs of the physician as the mouth snaps closed with successful reduction. Therefore, it is recommended that the physician wrap both thumbs with gauze.¹

Recumbent approach

The patient is placed recumbent, and the physician stands behind the head of the patient (see Media file 3).

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 till the jaw pops back into place.

The physician places his or her thumbs on the inferior molars and applies downward and backward pressure till the jaw pops back into place.¹⁸

Wrist pivot method

The patient is placed in a sitting position, and the physician stands facing the patient (see Media file 4). 

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.

The physician grasps the mandible at the apex of the mentum with both thumbs. The fingers are placed on the inferior molars. The physician applies cephalad force on the thumbs and caudad pressure with fingers. The wrist is then pivoted to reduce the dislocated mandibular condyle back into place.³

Ipsilateral approach

This approach is composed of 3 maneuvers: external, intraoral, and then combined route.

The extraoral route is attempted first. The patient is placed in a sitting position, and the physician stands behind the patient (see Media file 5). 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.

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.

If this method fails, the physician stands facing the patient and applies downward pressure intraorally on the ipsilateral lower molar teeth. A combined approach is then used if the first two approaches are unsuccessful. Intraoral downward force is applied on the molars as the other hand is used to apply extraoral downward pressure on the displaced condyle.¹⁸

Diet

A soft diet should be recommended for the first few days after reduction.

Activity

Patients should refrain from opening their mouth more than 2 cm for 2 weeks after reduction. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to alleviate initial discomfort.⁷

Consultations

• Superior dislocations, chronic old dislocations, open dislocations, dislocations associated with cranial nerve injury or fractures, or acute dislocations unreducible by a closed technique require emergent consultation with an oral maxillofacial surgeon.
• Elective follow-up with an oral maxillofacial surgery is recommended for all dislocations managed and reduced in the emergency department. 

Medication

Sedation and analgesia are indicated if reduction is attempted. The medications traditionally used for this purpose are diazepam and morphine. Other conscious sedation protocols can be used providing the patient maintains an adequate gag reflex. Deep conscious sedation is not desirable because the patient should remain seated during relocation. Certain medications that can cause masseter spasm (eg, methohexital, chlordiazepoxide, phenothiazines) should be avoided because this complication would prevent relocation of the mandible.

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.

Morphine (Astramorph, Duramorph)

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose

Pediatric

Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Fentanyl citrate (Duragesic, Sublimaze)

Potent narcotic analgesic with much shorter half-life than morphine sulfate. With short duration (30-60 min) and easy titration, an excellent choice for pain management and sedation. Easily and quickly reversed by naloxone.

Dosing

Adult

0.5-1 mcg/kg/dose IV/IM q30-60min

Pediatric

<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min
>12 years: Administer as in adults

Interactions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation

Anxiolytics

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.

Diazepam (Valium)

Individualize dosage and increase cautiously to avoid adverse effects.

Dosing

Adult

5 mg IV/IM q2-4h prn

Pediatric

0.1-0.3 mg/kg IV q4-8h

Interactions

Phenothiazines, barbiturates, alcohols, and MAOIs may increase CNS toxicity

Contraindications

Documented hypersensitivity; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent medication for patients requiring sedation for >24h. Monitor BP after administering dose and adjust as necessary.

Dosing

Adult

1-10 mg/d IV/IM divided bid/tid; not to exceed 4 mg/dose

Pediatric

0.05-0.1 mg/kg IV slowly over 2-5 min; may repeat a dose of 0.05 mg/kg IV slowly

Interactions

Alcohol, phenothiazines, barbiturates, and MAOIs may increase CNS toxicity

Contraindications

Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease

Follow-up

Further Inpatient Care

• In the rare cases of mandible dislocation that cannot be reduced by the methods described in Emergency Department Care, closed reduction under general anesthesia or open reduction may be required.
• Dislocations associated with fractures of the mandible are best reduced by oral maxillofacial surgeons or otolaryngologists.

Further Outpatient Care

• Successfully relocated mandible dislocations do not require any specific ongoing treatment, although the patient should be cautioned against opening the mouth wide, which could easily cause a recurrence.
• A soft collar may be considered for support of the TMJ after reduction.
• All patients with reduced mandible dislocations should be monitored by an appropriate specialist because of the possibility of jaw instability, ligamentous damage, and chronic TMJ pain.

Transfer

• Patients with dislocation of the mandible can be transferred providing no severe associated injuries are present, vital signs are stable, and the airway is patent.
• In many cases, relocation is simple to perform at the initial ED visit, and the patient can be referred for ongoing care at another facility, precluding the need for transfer.

Complications

Complications from mandibular dislocation and reduction are rare. 

• Complications of dislocation
  • Chronic recurrent anterior dislocations can result in injury to the joint capsule and degenerative disease of the joint space. 
  • Injury to the external carotid and facial nerve can result.
  • Posterior dislocations can injure the external auditory canal.
  • Deafness can result from damage to the auditory canals and surrounding structures. 
  • Superior dislocations have been associated with cerebral contusion and CNS deficits.   
• Complications of reduction
  • Iatrogenic fracture of the mandibular condyle may occur as it passes under the articular eminence.¹  
  • The physician’s thumbs may be injured as a consequence of rapid jaw closure with reduction.

Prognosis

The prognosis for most isolated mandibular dislocations is good but varies based on the type of dislocation.

• Acute anterior mandibular dislocations carry an excellent prognosis with few cases that progress to chronic recurrent dislocation.
• Lateral dislocations are often associated with fractures and require open reduction.
• Posttraumatic ankylosis is possible for dislocations with displaced condylar fractures.
• Posterior dislocations occasionally require fixation of the external auditory canal and may result in hearing deficits. 
• Superior dislocations and those unreducible by a closed technique require emergent consultation by an oromaxillofacial surgeon and should be assessed for damage to the surrounding cranial nerves and cerebral structures.

Patient Education

• Patients should be instructed to avoid opening their mouths widely to prevent recurrent dislocation.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center, Breaks, Fractures, and Dislocations Center, and Teeth and Mouth Center. Also, see eMedicine's patient education articles Temporomandibular Joint (TMJ) Syndrome, Broken Jaw, and Broken or Knocked-out Teeth.

Multimedia

Media file 1: The temporomandibular joint.

Media file 2: 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.

Media file 3: 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 till the jaw pops back into place.

Media file 4: 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.

Media file 5: 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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Keywords

jaw dislocation, mandible dislocation, temporomandibular joint dislocation, TMJ syndrome, temporomandibular joint syndrome, TMJ joint, traumatic mandible injury, TMJ dislocation, mandible dislocation types, mandibular dislocation, Marfan syndrome, Ehlers-Danlos syndrome

Contributor Information and Disclosures

Author

Meher Chaudhry, MD, Chief Resident, Department of Emergency Medicine, Detroit Receiving Hospital, University Health Center
Disclosure: Nothing to disclose.

Coauthor(s)

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

Medical Editor

James E Keany, MD, FACEP, Medical Director, JetWest International Air Ambulance; Consulting Staff, Department of Emergency Services, Mission Hospital Regional Medical Center; Host of Healthbuzz at Jim.MD
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, 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 and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

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, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

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

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