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Mandible Dislocation Treatment & Management

  • Author: Meher Chaudhry, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Apr 08, 2016
 

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).

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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.[22] A short-acting benzodiazepine, such as intravenous midazolam, can be used for muscle relaxation. In patients deemed high risk for procedural sedation, masseteric and deep temporal nerve block along with local analgesic infiltration of lidocaine into the TMJ joint can be considered to aid reduction. This technique has been reported to reduce both masseter and temporalis muscle spams and pain, resulting in successful reduction of the anterior jaw dislocation.[23]

Several methods have been proposed and successfully used for reduction of anterior jaw displacement. Several case reports also suggest that eliciting a gag reflex may help spontaneously reduce anterior jaw dislocations.[24] Also, see Joint Reduction, Mandibular Dislocation.

Classic reduction technique

The patient is placed in a sitting position, and the physician stands facing the patient (as shown in the image below).

Classic reduction technique. The physician places 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.[5]

Recumbent approach

The patient is placed recumbent, and the physician stands behind the head of the patient (as shown in the image below).

Recumbent approach. The patient is placed recumben 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.

The physician places his or her thumbs on the inferior molars and applies downward and backward pressure until the jaw pops back into place.[25]

Wrist pivot method

The patient is placed in a sitting position, and the physician stands facing the patient (as shown in the image below).

Wrist pivot method. The patient is placed in a sit 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.[7]

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 (as shown in the image below). 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. The external approach has been reported to be successful in approximately 55% of cases of acute anterior mandible dislocation.[25, 26]

Ipsilateral approach - extraoral route. The patien 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.[25]

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.

Several methods have been successfully used in outpatient follow up to prevent recurrent dislocations. These include surgical alteration of the ligaments, muscles, and bones of the jaw, as well as immobilization of the mandible by maxillomandibular fixation.[27] Intramuscular botulin injections to weaken the lateral pterygoid muscles have also been used to prevent recurrent dislocations.[28]

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.

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.

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.

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

Patients should refrain from wide jaw opening for 1-2 weeks after reduction. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to alleviate initial discomfort.[11]

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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.

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Complications

Complications from mandibular dislocation and reduction are rare.

Complications of dislocation include the following:

  • 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, CNS deficits, and seventh and eighth cranial nerve injury.

Complications of reduction include the following

  • Iatrogenic fracture of the mandibular condyle may occur as it passes under the articular eminence. [5]
  • The physician's thumbs may be injured as a consequence of rapid jaw closure with reduction.
  • In geriatric patients, the ridges of the mandible become atrophic with time, and the use of any method of reduction that exerts force on the mandible increases the risk of fracture of the mandible. [29]
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Contributor Information and Disclosures
Author

Meher Chaudhry, MD Emergency Medicine, Team Health, University of Tennessee Medical Center

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

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Society for Academic Emergency Medicine

Disclosure: Received salary from WebMD for employment.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children's Hospital of Orange County at Mission

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

Disclosure: Nothing to disclose.

Acknowledgements

Christian D McClung, MD, MPhil(Cantab) Staff Physician, Department of Emergency Medicine, Los Angeles County/University of California Medical Center

Disclosure: Nothing to disclose.

Edward J Newton, MD, FACEP, FRCPC Professor of Clinical Emergency Medicine, Chairman, Department of Emergency Medicine, University of Southern California Keck School of Medicine

Disclosure: Nothing to disclose.

Tom Scaletta, MD President, Smart-ER (http://smart-er.net); 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.

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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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