DISLOCATION OF THE

MANDIBLE AS AN
EMERGENCY CASE

masykur rahmat
Dislocation :
a derangement between the articulating components
of a joint that is not self-reducing.

Subluxation :
A self-reducing or partial dislocation of a joint.

(Sarnat, 1992).
Dislocation of the mandible (TMJ) :
Displacement of condylar head completely out of
glenoid fossa, cannot be reduced by patient.

Dislocation of the mandible is a relatively common

seen in the Emergency Department and may occur in
up to 50% of the population during their lifetime
Aetiology.
Dislocation of the TMJ may occur as a result of :
1. External trauma, especially when the mouth is open.
2. Sudden wide opening, yawning or epileptic seizure
3. Prolonged wide opening of the mouth.
4. Extreme capsular laxity.
5. Muscular discoordination from drugs.
Sicher :
“The temporomandibular articulation is the only
Joint of the human body which can be dislocated
without the action of an external force”.
Classification.
A. Rapidity of onset and pattern of reccurence.

Dislocation Acute

Chronic

Chronic
recurrent
B. Directions.

Posterior Anterior

Medial

Superior Lateral
 Lateral
Type 1 = lateral subluxation

Type 2 = complete dislocation

C. Affected Side

Bilateral
Unilateral
 Diagno
sis

History Examination.:

Factors causing Prognathism

occlussal disharmony. Hollow ant to tragus
Palpable CH ant to AE
Open bite
Limited mouth opening
Pain in or around TMJ
Radiographic Examination :
Plain Radiographs TMJ views :
1. Transcraniooblique, Reverse Towne’s, PA.
R&L Oblique laterals, Schuller.
2. Orthopantomogram
3. Computerized tomograms-3D CT scans.
4. MRI.
MANAGEMENT :
I. Acute.
Acute dislocations should be reduced as soon as
possible before there is severe muscle spasm.
The key to reduction is directing the mandibular
condyle out of its displaced location anterior
to articular eminence of temporal bone.
Equipment :
1. Dental chair.
2. Gloves
3. Gause
4. Bite block
5. Other items to protect the operator’s fingers
6. Procedural sedation if needed.
PROCEDURE
1. Classic reduction Technique.
(Repotitio secundum Hypocrates)
Any dentures should be removed and a bite
block should be placed in the oral cavity.
The operator should stand facing the patient
sitting in the chair,and places his thumbs on
the patient’s lower molar teeth and constant
downward pressure directing the mandible
body and angle inferiorly and posteriorly
2. Recumbent approach (Gottlieb
method,1952)
The operator can stand behind the
head of the patient,placing the operator
tumbs on the patient’s molar teeth and
applying downward and backward
pressure for reduction .
3. Wrist pivot method (2004)
The patient’s is placed sitting position,and the operator
stands facing the patient
The operator grasps the mandible at the apex of
mentum with both thumbs.The fingers are placed on
the inferior molars
The operator applies cephalad force on the thumbs
and caudad pressure with fingers.The wrist is the
pivoted to reduce the dislocated mandibular condyle
back into place
4. Ipsilateral approach
This approach is composed of 3 maneuvers: Extraoral,
intraoral,and then combined route
The extraoral route: the operator stand behind the patient
and stabilizes patient’s head with his nondominant hand
and uses the dominant hand to apply downward
pressure on the displaced condyle(to be successful in
55%)
If this method fails,the operator stand facing the patient
and applies downward pressure intraorally on the
ipsilateral lower molar teeth and the other hand is used to
apply extraoral downward pressure on the displaced
condyle
5. Johnson’s method (W.Basil johnson 1958)
Johnson reported a method for reduction of acute
dislocations of the TMJ with injection 1,8cc lidocaine
HCl into the subcutaneous tissue of the depression of
the glenoid fossa
Even though the dislocation bilateral,it is only
necessary to inject the local anesthetic unilaterale
6. Gag reflex method (Awang,1987)
The gag reflex is a complex reflex action. As such,
induction of the gags reflex by stimulation of the soft
palate has been described as a successful method to
reduce anterior mandibular dislocations.
This method is easy to perform,relatively safe for
patient and operator,and requires little time.
Complication
II. Chronic
Non Surgical methods
1. Chronic dislocation of mandible (long-standing
mandibular dislocation) should be treated in the
hospital under general anesthesia
Although generally unsuccessful, manual reduction of
the dislocation should be attempted
2. Slow elastic traction with Erich arch bars & post bite
plane rest jaw for 2-3 week
Surgical methods:
1. Downward traction on the mandible via wires placed
at the angels of the mandible
2. Bilateral temporalis myotomy should be performed.
3. Subcondylar osteotomy or a condylectomy can be
performed
4. Eminectomy should be attempted if another method
was fails
III. Chronic reccurrent
Non Surgical methods:
1. Chemical capsulorraphy using Na psylliate (Schultz 1949)
0.5% 1ml soln of Na tetradecyl sulphate (STD) 3x 2-6 wk
interval causes pericapsular fibrosis which limit CH
excursion
2. Injection of autologous blood into the joint
Two milimeters autologous blood were injected into the
Upper Joint Space and 1 ml was injected round the capsul

3. Injection of botulinum toxin type A

Surgical methods :
1.Restitution of ligament & plication of capsule
(surgical capsulorrhaphy)
2. Limitation of forward movement by ligation of
condyle.
3. Limitation of forward movement by augmentation of
AE using bone graft from zygomatic arch,etc
4. Allow graft L-Shaped, vitallium mesh, titallium
miniplate,down fracturing of zygomatic arch
5.Eminectomy
 Complications
 Relapse / Recurrence
 Facial nerve palsy
 Limited mouth opening
 Infection
 Pseudoarthrosis
 Scar formation
Activity and Diet Post
Reduction
A soft diet should be recommended for the first few
days after reduction (3-6 days)
Patients should refrain from wide jaw opening for 1-2
weeks after reduction.
Chronic dislocation barton bandage or head-chin
strap
Nonsteroid anti-inflammatory drugs (NSAIDs) may be
used to alleviate initial discomfort
Terapi Inflamasi & Nyeri Akut
Diperlukan
anti inflamasi kuat,
analgesik yang poten,
dan bekerja cepat …...

Obat yang tersedia :

 Analgesik.
 Anti inflamasi.
 Anti inflamasi + Analgesik
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 Thank You
For your Attention