Temporomandibular Joint Reduction
Most commonly, reduction of a temporomandibular joint (TMJ) dislocation is performed via the intraoral route. [10] To prevent trauma, the practitioner’s fingers should be gloved with thick gauze taped securely on both thumbs. To ensure adequate leverage, the patient should be positioned so that so that the mandible is below the level of the practicitioner's elbows.
Place your thumbs upon the lower molars or on the ridge of the mandible intraorally, posterior to the molars, with your fingers wrapped externally around the mandibles. Apply firm, slow, and steady pressure in a downward and posterior direction. If bilateral reduction is not possible, reduction may be done one side at a time. (See the images below.) Reduction attempts that require excessive force should be aborted because they may cause iatrogenic fracture of the mandibular condyles. [11]
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.
After reduction has been successfully completed, plain radiographs may be obtained to exclude iatrogenic mandibular condylar fracture. However, this may not be necessary if reduction resolves the pain.
The patient may wear a soft neck brace, and warm compresses may be placed on the TMJs for comfort. The patient should be instructed to avoid extreme opening of the mouth, such as may occur during yawning, laughing, or dental procedures. Pain relief may be achieved with nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, or mild opiates.
Patients with chronic dislocations may benefit from the use of a Barton bandage, an elastic bandage that is wrapped around the bottom of the mandible and over the top of the head to prevent excessive jaw opening.
An oral-maxillofacial surgeon or otolaryngologist should be consulted for dislocations that are irreducible, associated with fracture, or immediately recurrent.
Outpatient observation should be arranged to evaluate for possible chronic TMJ pain and ligamentous damage or instability.
Gorchynski et al described a hands-free "syringe" technique for TMJ reduction that does not require procedural sedation or intravenous analgesia. [12] Of 31 patients with acute nontraumatic TMJ dislocations studied by the investigators at two university centers, 30 (97%) had a successful reduction with this technique, and most of the dislocations (77%) were reduced in less than 1 minute. At 3-day follow-up, there were no recurrent dislocations.
Complications
Potential complications of reduction of a TMJ dislocation include the following:
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Injury to the practitioner - This may occur during reduction as the jaw closes on the thumbs
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Damage to dental hardware or oral prostheses
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Fracture of the mandibular condyle
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Complications of procedural sedation (eg, hypotension, respiratory compromise or apnea, aspiration, dysrhythmia, or allergy)
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Injury to the facial nerve or external carotid artery (rare)
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Delay in reduction - This may result in fibro-osseous ankylosis, which may produce limited TMJ mobility
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The temporomandibular joint.
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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.
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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.
