The traditional intraoral manual reduction
of temporomandibular joint (TMJ) dislocations is
time consuming, difficult, and at times
ineffective, and commonly requires conscious
sedation.
Objectives: the authors describe a novel
technique for the reduction of acute
nontraumatic TMJ dislocations in the emergency
department (ED).
Methods: This study was a prospective
convenience sample population during a 3-year
period at two university teaching-hospital EDs
where acute nontraumatic TMJ dislocations were
reduced utilizing our syringe technique.
Demographics, mechanism, duration of
dislocation, and reduction time were
collected.
Briefly, the ''syringe'' technique is a
hands-free technique that requires a syringe to
be placed between the posterior molars as they
slide over the syringe to glide the anteriorly
displaced condyle back into its normal
anatomical position.
Procedural sedation or intravenous analgesia
is not required.
Results: Of the 31 patients, the mean age
was 38 years. Thirty patients had a successful
reduction (97%). The majority of dislocations
were reduced in <1 min (77%). The two most
common mechanisms for acuteTMJ dislocations were
due to chewing (n = 19; 61%) and yawning (n = 8;
29%).There were no recurrent dislocations at
3-day followup.
Conclusion:We describe a novel technique for
the reduction of the acutely nontraumatic TMJ
dislocation in the ED. It is simple, fast, safe,
and effective
Intoduction
Acute nontraumatic temporomandibular joint
(TMJ) dislocations are usually the consequence
of excessive mouth opening, for example, tooth
extraction, laughing, yawning, or taking a large
bite of food. Anterior TMJ dislocations are the
most common form in nontraumatic dislocations of
the jaw. The emergency physician (EP) routinely
relies on the traditional method of intraoral
reduction of the TMJ, which commonly requires
procedural sedation or substantial intravenous
analgesia. The literature reports two
alternative methods for the reduction of TMJ
dislocations. In 2004, Lori et al. describe a
variation of the intraoral approach, and in
2007, Chen et al. describe an extraoral or
external approach. Both of these methods require
the physician to manually manipulate the
mandible.
New Technique
The technique we propose is effective and
may be rapidly performed. The only piece of
equipment utilized in our technique is a 5-mL or
10-mL syringe. With the patient in a sitting
position, the physician places the syringe
between the posterior upper and lower molars or
gums on the affected side. The patient is asked
to gently bite down and grasp the syringe as the
patient is instructed to roll the syringe back
and forth, resulting in the reduction of the
dislocated TMJ. Selection of the syringe size
varies with each patient. The size depends upon
the distance between the upper and lower molars
or gums and the patient's ability to open the
mouth on the affected side to accommodate the
syringe size. The mechanics of our technique
utilize the syringe as a rolling fulcrum upon
which the mandible and maxilla apply slight
downward pressure as the syringe is grasped
between the teeth or gums. As the molars or gums
roll over the syringe, it produces a gliding
motion as the mandible slides posteriorly. The
condyle that is displaced anterior to the
articular eminence of the temporal bone moves
posteriorly to allow the condyle to slip gently
back into its normal anatomical position. The
masseter, pterygoid, and temporalis muscles work
in concordance to allow relocation of the
condyle and reduction of the TMJ. If the
dislocation is bilateral, by reducing one side,
the other side reduces spontaneously.
Discussion
To our knowledge, our technique is the first
described in the medical literature that does
not require intraoral or external manual
manipulation of the mandible for the reduction
of acute nontraumatic TMJ dislocations in the
ED. It is simple, safe, fast, and effective, and
does not require procedural sedation. Most
medical textbooks describe the traditional
intraoral reduction method for TMJ dislocations.
This technique requires a significant amount of
force, especially in patients who have strong
mastication musculatures for TMJ reduction. The
traditional intraoral technique requires
physicians to place their two thumbs on the
molars of the mandible, and then push the
mandible in an inferior and posterior direction
to reposition the condyle back into the glenoid
fossa. The intraoral approach has numerous
disadvantages. First, there is a high risk of
bite injuries, which might lead to transmittable
diseases such as human immunodeficiency virus
infection and hepatitis. Second, procedural
sedation is typically required for this type of
reduction because the physician applying
additional force to manually manipulate the
mandible causes pain for the patient. Third,
during the reduction, repeated attempts may be
necessary before successfully achieving the
reduction. It is not always effective, and
inadvertent mandibular or condylar fractures may
occur. Lori et al. introduced a wrist-pivot
method that utilizes the intrinsic biomechanical
properties of the mandible. This technique,
however, also requires the placement of the
physicians' hands inside the patients' mouth .
If the physician does not apply equal intraoral
forces bilaterally, a mandibular or condylar
fracture may result. The authors report that
their technique requires intravenous procedural
sedation. Chen et al. introduced an extraoral or
external approach, where the thumb is positioned
just above the anteriorly displaced coronoid
process and the fingers are positioned behind
the mastoid process. Simultaneously on the
opposite side, the fingers hold and rotate the
mandible angle anteriorly and the thumb is
placed over the malar eminence as a fulcrum.
Scamahorn reported the ''corkscrew'' technique
in the Reader's Forum of Postgraduate Medicine.
In this technique, a cork is placed bilaterally
between the teeth as the physician externally
manipulates the mandible for reduction.
Nontraumatic TMJ dislocations are infrequent to
the ED. We had a high number of subjects in this
study, just fewer than the 37 subjects reported
by Lowery et al. in 2004.
Limitations
All the dislocations in this study
population were anteriorly displaced; we cannot
confirm the usefulness of the technique for the
less common posterior or lateral dislocations.
Traumatic TMJ dislocations may involve posterior
and lateral dislocations as well as an
associated fracture, making the reduction more
difficult. Further studies involving acute
traumatic TMJ dislocations utilizing our
technique or in combination with external
manipulation and intravenous analgesia, may
demonstrate its value.
Conclusion
Our described technique is a novel
hands-free maneuver that is quick, simple, safe,
and effective. EPs should consider this method
as a useful technique in the management of acute
nontraumatic TMJ dislocations in the ED.
