Mandible dislocation: Difference between revisions
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== Background == | ==Background== | ||
{| class="wikitable" | |||
|- | |||
**Mandibular condyle | ! Dislocation Type | ||
** | ! Frequency | ||
** | ! Associated with trauma? | ||
! Mechanism | |||
! Additional Comments | |||
! Associated with fracture? | |||
*Lateral | ! Image | ||
**Often associated | |- | ||
*Superior | | '''Anterior''' | ||
**Occur from blow to the partially opened mouth | | | ||
**Associated | *Most common | ||
| | |||
*No | |||
| | |||
*Spontaneously while patient is yawning, "popping" ears, or laughing | |||
*Risk factors: | |||
**Prior dislocation | |||
**Weakness or laxity of capsule | |||
**Ligamentous injury | |||
| | |||
*Mandibular condyle forced in front of the articular eminence | |||
*May happen bilaterally or unilaterally | |||
| | |||
*No | |||
| | |||
[[File:Anterior Dislocation.jpeg|100px]] | |||
|- | |||
| '''Posterior''' | |||
| | |||
*Rare | |||
| | |||
*Yes | |||
| | |||
*Follows a blow to the mandible that may or may not break the condylar neck | |||
| | |||
*Condylar head may prolapse into the external auditory canal | |||
| | |||
*Possible | |||
| | |||
[[File:Posterior Dislocation.jpeg|100px]] | |||
|- | |||
| '''Lateral''' | |||
| | |||
*Rare | |||
| | |||
*Yes | |||
| | |||
*Lateral trauma to mandible | |||
| | |||
*Often associated with mandibular fracture | |||
| | |||
*Yes | |||
| | |||
[[File:Lateral Dislocation.jpeg|100px]] | |||
|- | |||
| '''Superior''' | |||
| | |||
*Rare | |||
| | |||
*Yes | |||
| | |||
*Occur from blow to the partially opened mouth | |||
| | |||
*Can result in a fracture of the glenoid fossa and displacement of the condyle into the middle cranial fossa, potentially injuring the facial and vestibulocochlear nerves and the temporal lobe. | |||
*Associated with cerebral contusions, facial nerve palsy, deafness | |||
| | |||
*Yes | |||
| | |||
[[File:Superior Dislocation.jpeg|100px]] | |||
|} | |||
[[File:Gray311.png|thumb|Sagittal section of the articulation of the mandible.]] | |||
== Clinical Features== | ==Clinical Features== | ||
* | *Inability to close mouth | ||
*Difficulty speaking or swallowing | |||
*Malocclusion | |||
*Pain localized anterior to the tragus | |||
*Prominent-appearing lower jaw | |||
*Preauricular depression | |||
*Condylar head palpable in the temporal space (in lateral dislocation) | |||
== | ===Posterior Dislocation=== | ||
* | *Must examine the external auditory canal | ||
== | ==Differential Diagnosis== | ||
{{Jaw spasms DDX}} | |||
==Evaluation== | |||
## | *Generally a clinical diagnosis | ||
# | *For traumatic etiology, obtain CT face to evaluate for fracture | ||
**Also obtain CT IAC if concern for posterior dislocation | |||
*Examine external auditory canal, especially in posterior dislocation | |||
### | *Evaluate the cranial nerves to rule out concomitant injury | ||
### | |||
==Management== | |||
# | *If no concern for fracture, perform closed reduction in the emergency department (see techniques below) | ||
**Often easiest to reduce one side at a time | |||
*Provide [[analgesia|pain control]] and anxiolysis as needed | |||
*Consider [[procedural sedation]], especially if the mandible has been dislocated for an extended period | |||
**[[Local anesthetics]] may also be effective when injected into the preauricular depression just anterior to the tragus | |||
===Syringe Reduction Technique=== | |||
#Have the patient place an empty 5 or 10 mL syringe between the upper and lower molars on one side of the mouth | |||
#Direct the patient to roll the syringe back and forth until reduction is achieved | |||
#If the opposite side does not spontaneously (it generally will), may repeat same technique on the opposite side | |||
===Extra-oral Reduction Technique<ref>http://sjrhem.ca/rcp-save-thumbs-extra-oral-reduction-anterior-mandibular-dislocations/</ref>=== | |||
#Place the patient in seated position | |||
#Place one thumb on the one zygomatic arch, and the fingers of the same hand behind the mandible | |||
#On the opposite side, place thumb on the coronoid process of the mandible | |||
#Use the fingers of the first hand to pull the mandible forward while using the zygomatic arch to brace | |||
#At the same time, apply firm and consistent pressure on the coronoid process with the second hand | |||
#Once the first side is reduced, reverse hand positions and repeat the process on the second side | |||
===Intra-oral Reduction Techniques=== | |||
====Wrist Pivot Method<ref>Lowery LE, Beeson MS, Lum KK. The wrist pivot method, a novel technique for temporomandibular joint reduction. J Emerg Med. 2004 Aug;27(2):167-70. http://www.ncbi.nlm.nih.gov/pubmed/15261360</ref>==== | |||
[[File:wrist-pivot-method.jpg|thumbnail]] | |||
#Place patient in seated position | |||
#Face the patient and grasp the mandible with your thumbs at the apex of the mentum | |||
#Place well-wrapped and gloved fingers on the occlusal surface of the inferior molars | |||
#Apply cephalad force with the thumbs and caudal pressure with the fingers | |||
#Pivot your wrists to reduce joint | |||
====Traditional Technique==== | |||
[[File:Mandible dislocation.jpg|thumb|Posterior position]] | [[File:Mandible dislocation.jpg|thumb|Posterior position]] | ||
#Place patient in seated position (anterior approach) or supine (posterior approach) | |||
#Place well-wrapped and gloved thumbs over occlusal surface of inferior molars or lateral to molars in the buccal fold | |||
#Apply caudal and posterior pressure to reduce joint | |||
== Disposition == | ==Disposition== | ||
*Admit: | *Generally may be discharged if uncomplicated and successfully reduced | ||
**Instruct patient to use soft diet, not to open mouth wider than 2cm for 2 weeks, and to support mouth when yawning | |||
*Admit for: | |||
**Open dislocation | **Open dislocation | ||
**Superior dislocation | **Superior dislocation | ||
** | **Fracture | ||
**Nerve injury | **Nerve injury | ||
**Inability to reduce | **Inability to reduce | ||
== | ==See Also== | ||
* | |||
==External Links== | |||
*[http://brownemblog.com/blog-1/2019/11/9/brown-em-whit-ticisms-mandible-reduction Extra-oral reduction technique video ] | |||
==References== | |||
<references/> | |||
[[Category:ENT]] | [[Category:ENT]] | ||
[[Category:Orthopedics]] | |||
[[category:Trauma]] |
Latest revision as of 20:43, 17 December 2019
Background
Dislocation Type | Frequency | Associated with trauma? | Mechanism | Additional Comments | Associated with fracture? | Image |
---|---|---|---|---|---|---|
Anterior |
|
|
|
|
|
|
Posterior |
|
|
|
|
|
|
Lateral |
|
|
|
|
|
|
Superior |
|
|
|
|
|
Clinical Features
- Inability to close mouth
- Difficulty speaking or swallowing
- Malocclusion
- Pain localized anterior to the tragus
- Prominent-appearing lower jaw
- Preauricular depression
- Condylar head palpable in the temporal space (in lateral dislocation)
Posterior Dislocation
- Must examine the external auditory canal
Differential Diagnosis
Jaw Spasms
- Acute tetanus
- Akathisia
- Conversion disorder
- Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
- Dystonic reaction
- Electrolyte abnormality
- Hypocalcemic tetany
- Magnesium
- Mandible dislocation
- Meningitis
- Peritonsillar abscess
- Rabies
- Seizure
- Strychnine poisoning
- Stroke
- Temporomandibular disorder
- Torticollis
Evaluation
- Generally a clinical diagnosis
- For traumatic etiology, obtain CT face to evaluate for fracture
- Also obtain CT IAC if concern for posterior dislocation
- Examine external auditory canal, especially in posterior dislocation
- Evaluate the cranial nerves to rule out concomitant injury
Management
- If no concern for fracture, perform closed reduction in the emergency department (see techniques below)
- Often easiest to reduce one side at a time
- Provide pain control and anxiolysis as needed
- Consider procedural sedation, especially if the mandible has been dislocated for an extended period
- Local anesthetics may also be effective when injected into the preauricular depression just anterior to the tragus
Syringe Reduction Technique
- Have the patient place an empty 5 or 10 mL syringe between the upper and lower molars on one side of the mouth
- Direct the patient to roll the syringe back and forth until reduction is achieved
- If the opposite side does not spontaneously (it generally will), may repeat same technique on the opposite side
Extra-oral Reduction Technique[1]
- Place the patient in seated position
- Place one thumb on the one zygomatic arch, and the fingers of the same hand behind the mandible
- On the opposite side, place thumb on the coronoid process of the mandible
- Use the fingers of the first hand to pull the mandible forward while using the zygomatic arch to brace
- At the same time, apply firm and consistent pressure on the coronoid process with the second hand
- Once the first side is reduced, reverse hand positions and repeat the process on the second side
Intra-oral Reduction Techniques
Wrist Pivot Method[2]
- Place patient in seated position
- Face the patient and grasp the mandible with your thumbs at the apex of the mentum
- Place well-wrapped and gloved fingers on the occlusal surface of the inferior molars
- Apply cephalad force with the thumbs and caudal pressure with the fingers
- Pivot your wrists to reduce joint
Traditional Technique
- Place patient in seated position (anterior approach) or supine (posterior approach)
- Place well-wrapped and gloved thumbs over occlusal surface of inferior molars or lateral to molars in the buccal fold
- Apply caudal and posterior pressure to reduce joint
Disposition
- Generally may be discharged if uncomplicated and successfully reduced
- Instruct patient to use soft diet, not to open mouth wider than 2cm for 2 weeks, and to support mouth when yawning
- Admit for:
- Open dislocation
- Superior dislocation
- Fracture
- Nerve injury
- Inability to reduce
See Also
External Links
References
- ↑ http://sjrhem.ca/rcp-save-thumbs-extra-oral-reduction-anterior-mandibular-dislocations/
- ↑ Lowery LE, Beeson MS, Lum KK. The wrist pivot method, a novel technique for temporomandibular joint reduction. J Emerg Med. 2004 Aug;27(2):167-70. http://www.ncbi.nlm.nih.gov/pubmed/15261360