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. 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 (as shown in the image below).
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.
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 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.
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 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.
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.
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.
Diet
A soft diet should be recommended for the first few days after reduction.
Activity
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.
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