How to perform dislocation reduction of the temporomandibular joint

In this opportunity I will talk about a very important topic in the health area. In most cases in the area of shock trauma, or polytrauma, are often atypical injuries, but that every doctor during the exercise of his career should know and know how to handle.

We should start by mentioning that dislocation of the jaw or temporomandibular joint (TMJ), usually originates, when there are previous musculoskeletal problems in the jaw, such as joint laxity, congenital hypermobility syndrome or neuromuscular problems (dystonic reactions) that pull the jaw out of the joint spontaneously or by simple and easy movements. They are also the result of direct trauma to the jaw.

In general, every medical specialist must identify this type of dislocation and correct it easily, simply and directly.

^{Public domain Flickr}

Anatomy and physiopathology

The temporomandibular joint has a very particular presentation, since it is composed of two joints separated by a joint disc. The TMJ is located between the temporal bone and the jaw.

It is given the bicondile synovial joint termination, since it is made up of two joints separated by a joint disc, and that these comprise the joint tuber of the joint bone, the fossa and condyle of the jaw. This gives it the property of behaving like a hinge joint and of moving.

This joint together with several muscles, allows us to perform multiple functions such as mastication, opening and closing of the oral cavity, lateral movements, protrusion and retrusion.

^{Temporomandibular Joint. Public domainCC BY-SA 3.0}

The etiology as already mentioned can be the result of a basic pathology or by traumatic facial injuries, in relation to the first one this can be triggered by simple things like laughing, chewing, during vomiting, yawning, among others.

All of this is due to the fact that during these actions the mandibular condyle can slip in front of the eminent joint of the temporal bone and therefore the anchorage of the jaw muscles pulls the condyle over and forward of the eminent joint causing the jaw to be fixed in a dislocated position and rarely returning to its normal position.

^{Temporomandibular joint. By Anatomist90Public domain CC BY-SA 3.0}

Dislocations can occur in several ways, such as:

Anterior dislocations can manifest themselves spontaneously, in healthy individuals and occasionally return to their normal position.

TMJ dislocations are usually bilateral, but can also occur unilaterally.

Posterior, superior and lateral dislocations are less frequent and are associated with direct trauma to the jaw with or without a jaw fracture.

The diagnosis of these dislocations is simply clinical, and they are corroborated by X-ray studies or more complex studies such as tomography.

Pain is the cardinal symptom in this lesion, and it is presented when executing opening, protrusion and closing movements. A unilateral dislocation causes the jaw to protrude to the non-dislocated side and therefore a palpable depression is observed in the preauricular injured area.

We should try to reduce dislocations of dislocations of jaws that are closed and not accompanied by jaw bone fractures, as long as the patient is conscious, cooperative and under his consent.

When is reduction contraindicated?

All those cases of open dislocations, both superior, posterior and lateral, should be evaluated by surgeons or otolaryngologists.

If it is associated with mandibular bone fractures, they should be evaluated by specialists to determine whether or not reduction will be performed.

When it is associated with nerve endings or lesions of cranial pairs, it is necessary to be urgently evaluated by a specialist before the reduction if possible, or in its defect be taken to the operating room and resolve under general anesthesia.

^{3D mandible fracture. Public domain CC BY 3.0}

Initial assessment

Always every physician before performing a simple or complex medical procedure must explain it to the patient and/or his representative and thus obtain the signed consent.

Once the patient is completely examined and we proceed with the reduction, it is advisable to place the patient in a seated position, with a solid headboard, in order to support the head.

It is recommended that prior to the procedure, endovenous analgesia and the use of muscle relaxant type drugs be applied to facilitate the manipulation of this area and to bring the jaw into place in the simplest and least traumatic manner.

The use of these drugs (analgesia or sedation and intravenous muscle relaxants) is essential, especially if the jaw has been dislocated for more than 6 to 8 hours.

There is another alternative as is the case of direct analgesia in the TMJ, we proceed to locate us in the depression resulting from the dislocation about 2.5 cm in front of the ear swallow and just above the condyle (head) of the jaw.

After asepsis and antisepsis of the area, a needle is inserted perpendicularly to the skin and medially up to about 0.5 cm and the anaesthetic solution is administered approximately 1 CC.

How to correctly perform the jaw reduction?

The materials required for this procedure are very simple and straightforward, only requiring a pair of gloves and gauze.

We proceed to place the gloves and wrap several layers of gauze around each thumb, thus preventing any injury to the doctor during the reduction.

Once the patient is in the position already described, the doctor can sit or stand in front of the patient.

Place both thumbs inside the patient's mouth and over the back molars of the jaw bilaterally, place the index, middle, ring and little fingers around the jaw, placing the index fingers behind the jaw angle.

Gentle downward and backward force will be applied to allow the chewing muscles to relax, as the downward pressure releases the mandibular condyle from the articular eminence of the temporal bone.

The patient is asked to open the oral cavity completely, which encourages the impacted mandibular condyle to be released on the anterior articular surface of the TMJ eminence.

This, in conjunction with the procedure described, helps to put the TMJ back into place.

^{A medical illustration depicting a normal vs. dislocated mandible. Public domain CC BY-SA 4.0}

Check if the reduction was done correctly

The patient will be asked to be able to open and close his or her mouth, which will run smoothly and on its own.

It is not necessary to request post-reduction x-rays, unless a fracture is suspected during reduction or a fracture has already been observed prior to reduction, but of little significance that has not contraindicated reduction, and x-ray checks are requested to verify the post-reduction status.

Recommendations

Refer to your surgeon or an otolaryngologist within the first 24 to 48 hours of the event.

Or recurrent dislocations warrant surgical fixation and the patient should be advised to avoid excessive jaw opening (greater than 2cm), to avoid sticky, hard foods and to start a soft diet to avoid excessive work of the TMJ.

The patient to take certain measures during the yawning such as placing the hand on the jaw so that it is held to prevent the jaw from opening too much and dislocating.

The use of nonsteroidal anti-inflammatory drugs will provide an analgesic of choice in these cases.

Complications

Fractures during reduction. Fractures are rarely iatrogenic.

Intrusion of the mandibular condyle into the ear canal (more common in posterior dislocations).

Fractures at the base of the skull (upper dislocations).

Brain contusions.

Facial nerve injury or middle or inner ear injury with impaired hearing or balance.

Sometimes closed dislocations may not be successful and require sedation and general anesthesia. This occurs most often with chronic dislocations, dislocations longer than 12 hours, and recurrent dislocations.

Sources:

^{The Temporomandibular Joint Examination Roger A. Meyer. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition._link}

^{Temporomandibular disorders. Part 1: anatomy and examination/diagnosis Stephen M Shaffer, Jean-Michel Brismée, Phillip S Sizer, and Carol A Courtney_link}

^{Temporomandibular joint dislocation Naresh Kumar Sharma, Akhilesh Kumar Singh, Arun Pandey, Vishal Verma, and Shreya Singh_link}

^{The Treatment of Temporomandibular Joint Dislocation A Systematic Review Ulla Prechel, Peter Ottl, Prof. Dr. med. dent., Oliver M. Ahlers, PD Dr. med. dent., and Andreas Neff, Prof. Dr. med. Dr. med. dent._link}

^{Mandible Dislocation Jeffery Hillam; Blake Isom._link}

^{Reduction of superior-lateral intact mandibular condyle dislocation with bone traction hook Bong Chul Kim, Sara Rebeca Kang Samayoa, and Hyung Jun Kimcorresponding author_link}

^{Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department Antonio Pinto, Daniela Berritto, Anna Russo, Federica Riccitiello, Martina Caruso, Maria Paola Belfiore, Vito Roberto Papapietro, Marina Carotti, Fabio Pinto, Andrea Giovagnoni, Luigia Romano and Roberto Grassi_link}

^{Informed consent: Issues and challenges Lokesh P. Nijhawan, Manthan D. Janodia, B. S. Muddukrishna,2 K. M. Bhat, K. L. Bairy, N. Udupa,1 and Prashant B. Musmade_link}

^{Reduction of Mandibular Dislocation Technique Updated: Apr 17, 2019 Author: Erik D Schraga, MD; Chief Editor: Arlen D Meyers, MD, MBA_link}

^{Temporomandibular Disorders Updated: Feb 22, 2017 Author: Joseph Rios, MD; Chief Editor: Robert A Egan, MD_link}

^{Temporomandibular Joint Pathology and Its Indication in Clinical Orthodontics By Bakr M. Rabie, Jeremy Ho and Qianfeng Li_link}

^{The Temporomandibular Joint _link}

^{Joint Dislocations Authored by Dr Jacqueline Payne, Reviewed by Dr Adrian Bonsall | Last edited 14 Jun 2018 | Certified by The Information Standard_link}

^{Temporomandibular joint From Wikipedia, the free encyclopedia_link}

^{Temporomandibular Joint and Airway Disorders _link}

^{Sample records for painful temporomandibular joints _link}

^{Understanding Bone Fractures -- Diagnosis and Treatment _link}

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