eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Mandible: Treatment & Medication
Updated: Jan 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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.
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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.
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
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
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.
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
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
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.
Adult
5 mg IV/IM q2-4h prn
Pediatric
0.1-0.3 mg/kg IV q4-8h
Phenothiazines, barbiturates, alcohols, and MAOIs may increase CNS toxicity
Documented hypersensitivity; narrow-angle glaucoma
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.
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
Alcohol, phenothiazines, barbiturates, and MAOIs may increase CNS toxicity
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
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
More on Dislocation, Mandible |
| Overview: Dislocation, Mandible |
| Differential Diagnoses & Workup: Dislocation, Mandible |
 Treatment & Medication: Dislocation, Mandible |
| Follow-up: Dislocation, Mandible |
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| References |
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References
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Further Reading
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
