, AR J

n, M

kron, OACEP, 4

eistecMethefulinwa

locpro

eloc

INTRODUCTION

Anphofjoistrau

can

a n

distiobathe

ATM(Epayaun

priex

tharec

sigtion. He was unable to speak due to pain. The posteriormolars were approximated but anterior teeth were gap-

REAC

The Journal of Emergency Medicine, Vol. 27, No. 2, pp. 167170, 2004Copyright 2004 Elsevier Inc.

Printed in the USA. All rights reservedinfrequently used but necessary technique emergencyysicians (EPs) must have in their arsenal is reductiona mandibular dislocation at the temporomandibularnt (TMJ). Although most textbooks describe aaightforward approach to reduction, it has been thethors experience that conscious sedation and signifi-t force is required to achieve reduction. In this article,ovel approach to reduction is described, along with acussion of the biomechanics of mandibular disloca-n affecting reduction techniques. Our approach issed on using the intrinsic biomechanical properties of

mandible.

ing. A palpable preauricular depression consistent withcondyle dislocation from the glenoid fossa was presentbilaterally. The patients history and physical examina-tion were consistent with a nontraumatic bilateral TMJdislocation.

The patient was prepared for reduction. An intrave-nous line, oxygen via nasal cannula, and continuouspulse oximetery were appropriately placed on the patient.Three milligrams (mg) of midazolam and 50 g ofsublimaze were administered intravenously. The patientbecame sleepy but arousable to verbal stimuli. Conven-tional reduction technique was attempted in which the

Techniques and Procedures is coordinated by George Sternbach, MD, of Stanford University Medical Center, Stanford,Californiadoi:10.1016/j.jem

Techniques andProcedures

THE WRIST PIVOT METHODTEMPOROMANDIBULA

Lori E. Lowery, MD,*, Michael S. Beeso

*Northeastern Ohio University College of Medicine, AReprint Address: Michael S. Beeson, MD, MBA, F

AbstractTemporomandibular joint (TMJ) dislocationan infrequent dislocation of the mandible. The usualhnique of reduction, recommended by most Emergencydicine textbooks, consists of downward forces applied tomandible. In the authors experience this is often pain-and requires significant sedation. We present a patient

whom the usual manner of TMJ dislocation reductions difficult. We describe a novel technique for TMJ dis-ation reduction that uses the intrinsic biomechanicalperties of the mandible. 2004 Elsevier Inc.

Keywordstemporomandibular joint; TMJ; TMJ dis-ation; ED procedureCEIVED: 28 February 2003; FINAL SUBMISSION RECEIVED: 21 FebCEPTED: 30 March 2004

167.2004.03.007

NOVEL TECHNIQUE FOROINT REDUCTION

D, MBA,*, and Kevin K. Lum, MD*,

hio and Summa Health System, Akron, Ohio1 Arch St., Suite 521, Akron, OH 44304

CASE REPORT

53-year-old man with a remote history of bilateralJ dislocation presented to the Emergency Department

D) with the chief complaint of locked jaw. Thetient stated that while laying back in a recliner andwning he felt sudden pain in his lower face and wasable to close his mouth. This episode was similar to aor TMJ dislocation 30 years ago. The patient wasperiencing such pain with any attempted jaw motiont he was writing all answers. The patient denied anyent trauma, surgery or other illness.Physical examination revealed a middle-aged man innificant discomfort with his mouth in the open posi-

0736-4679/04 $see front matterermedruary 2004;

phsur

1).dewa

paan

redsiotecbothe

usiThear

grame

offorfinma

pajawco

Fig n redu

Fig

168 L. E. Lowery et al.ysicians gloved thumbs are placed on the occlusalface of the patients inferior molars bilaterally (FigureFirm inferior, posterior pressure was then applied as

scribed in various references (13). The initial attempts unsuccessful, with great distress to the patient. Thetient received additional sedation, 4 mg of midazolamd 50 g of sublimaze, and a second conventionaluction attempt was again unsuccessful. After discus-n between the authors, a third attempt with a newhnique was tried. The authors desired to benefit fromth the muscular forces at work, as well as the shape of

mandible. Without further sedation, a third attempt

ure 1. Conventional reduction technique for TMJ dislocatioure 2. The wrist pivot method for TMJ dislocation reduction.ng this new technique was performed successfully.e patients most recent sedation had been 20 minlier. While facing the patient, the mandible wassped with the physicians thumbs at the apex of thentum and fingers on the surface of the occlusal surfacethe inferior molars (Figure 2). By applying cephaladce with the thumbs and caudad pressure with thegers, then pivoting at the wrists, the dislocatedndible was reduced with minimal difficulty. The

tient immediately resumed normal movement of his. The patient was subsequently discharged in good

ndition.

ction.

Masen

EDitspeTMrep

glirioheou

on

oc

quopbeera

an

co

co

ineralma

toin

tioColartiono

ev

catjurThTMme

feaityabinineera

If tthe

Emhistiema

terthereqstatem

utiare

uparo

use

temSimwisupbobano

pre

Fig

Novel Technique of TMJ Reduction 169DISCUSSION

ndibular dislocation at the TMJ is an infrequent pre-tation to the ED. At our institution, consisting of twos with approximately 100,000 combined annual vis-

, 37 TMJ dislocations have presented over a 7-yearriod, 19952002. Although infrequent, reduction of

J dislocation is a technique EPs must have in theirertoire.The TMJ is a ginglymoarthrodial joint, combiningding and hinge motions. Dislocation can occur ante-rly, posteriorly, laterally or superiorly. Discussionre will be limited to anterior dislocation as occurred tor patient, as it is by far the most common type and thely to occur without a fracture (4). TMJ dislocationcurs when there is an interruption in the normal se-ence of muscle action during closure from maximalening. Interruption allows elevation of the mandiblefore retraction. This occurs when the protracting lat-l pterygoid muscles fail to relax before the masseter

d temporalis muscles elevate the mandible (5). Thendyle travels anteriorly along the eminence and be-mes locked in the anterior superior aspect of the em-nce (Figure 3). The masseter, pterygoid, and tempo-is muscles go into spasm attempting to close thendible. Trismus results and the condyle cannot returnthe temporal fossa (3). Muscle spasm and edema resultsignificant pain to the patient.Potential causes of TMJ dislocation include any ac-n that may involve the mouth being maximally open.mmon causes include yawning and trying to chew age food bolus. The literature has noted TMJ disloca-n as a complication of anesthetic induction, intrave-us sedation, Ehlers-Danlos Syndrome, trauma anden tetanus (4,610). The complications of TMJ dislo-ion include recurrent subluxation/dislocation from in-y to the articulating cartilage, as well as fracture (11).e prognosis is usually excellent, although recurrentJ subluxation/dislocation may require surgical treat-

nt (12,13).Diagnosis may be made clinically if the followingtures are present. The patient will present with inabil-to close the mouth, severe pain anterior to the ears,

sence of the condyle from the glenoid fossa resultinga visible, palpable preauricular depression and a prom-nt-appearing lower jaw (14). If dislocation is unilat-l, the jaw deviates away from the involved side (15).rauma is involved, radiographic analysis is needed forevaluation of possible fracture.

Conventional techniques as described by standardergency Medicine textbooks describe the EP placingprotected thumbs on the occlusal surface of the pa-

nts molars, wrapping his fingers laterally around the

ndible and then applying a constant inferior and pos- proior force, gliding the mandibular condyles back intoglenoid fossa. The conventional reduction technique

uires the physician to manually overcome the sub-ntial force created by the pterygoid, masseter andporalis muscles to achieve reduction (Figure 1).

In the novel technique we describe, these forces arelized to assist with reduction. The physicians thumbs

placed at the mentum of the mandible to apply anward force and the fingers are wrapped laterallyund the mandible. The angle of the mandible is thend as a fulcrum with the pterygoid, masseter andporalis muscles exerting a force parallel to the EPs.ultaneous pivoting action of the physicians wrists

th the thumb (anterior portion of the fulcrum) pushingeriorly and the operators fingers on the mandibular

dy pushing inferiorly allows the condyles to rotateck into the glenoid fossa (Figure 2). It is important tote that these forces must be applied bilaterally tovent mandibular fracture. The muscles of mastication

ure 3. Anatomic description of TMJ dislocation.vide assistance rather than impedance with this new

technique as they promote rotation and reduction. Ratherthan attempting to lengthen the muscles that are in spasmto clear the condylar ridge, this technique pivots themandibular condyle, easing the reduction into the fossa.The muscles of mastication provide a force-oriented su-perior and posterior. As the angle of the mandible ro-tates, these forces help bring reduction into the condyle.

To protect the operators fingers during reduction, it issuggested that a bite block be used. This will prevent ahuman bite to the operator in the event of sudden closureof the mandible due to spasm, reduction, etc. Althoughnot used in this particular patient, a bite block couldprevent operator injury regardless of technique used.

CONCLUSION

In conclusion, we describe a novel technique, the wrist-pivot technique, for mandibular dislocation, which hasnot been previously described in the literature. It utilizesthe muscles of mastication in conjunction with the forcesapplied by the physician for a smoother, more comfort-able reduction of the mandible for the patient and thephysician.

REFERENCES

1.

2. Amsterdam JT. Emergency dental procedures. In: Roberts JR,Hedges JR, eds. Clinical procedures in emergency medicine, 3rdedn. Philadelphia: W.B. Saunders Co.; 1998:11649.

3. Cantrill SV. Facial trauma. In: Rosen P, Barkin R, eds. Emergencymedicine concepts and clinical practice, 4th edn. St. Louis, MO:Mosby; 1998:459.

4. Moore CA, Ellis B. Dislocation of the mandible during the courseof cataract surgery. Ophthalmic Surg Lasers 1998;29:2512.

5. Thompson WR. Dislocation (luxation) of the temporomandibularjoint. Appl Ther 1966;8:6867.

6. Gambling D, Ross P. Temporomandibular joint subluxation oninduction of anesthesia. Anesth Analg 1988;67:912.

7. Lacy P, Lee J, OMorain C. Temporomandibular joint dislocation:an unusual complication of upper gastrointestinal endoscopy. Am JGastroenterol 2000;95:36534.

8. Goodman R, Allison M. Chronic temporomandibular joint sublux-ation in Ehlers-Danlos syndrome: report of case. J Oral Surg1969;27:65961.

9. Walker R, Connor P. Unilateral mandible fracture with bilateralTMJ dislocation. Tenn Med 2000;93:1920.

10. Thachil R, Philip B, Sridhar C. Temporomandibular dislocation: acomplication of tetanus. J Trop Med Hyg 1993;96:601.

11. Pynn B, Clarke H. Parasymphyseal fracture with an associatedtemporomandibular joint dislocation: case report. J Trauma 1992;32:2568.

12. Westwood R, Fox G, Tilson H. Eminectomy for the treatment ofrecurrent temporomandibular joint dislocation. J Oral Surg 1975;33:7749.

13. Segami N, Kaneyama K, Tsurusako S, Suzuki T. Arthroscopiceminoplasty for habitual dislocation of the temporomandibularjoint: preliminary study. J Craniomaxillofac Surg 1999;27:390 7.

14. Luyk NH, Lansen PE. The diagnosis and treatment of the dislo-

15.

170 L. E. Lowery et al.Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, ed. Emer-gency medicine: a comprehensive study guide, 5th edn. New York:McGraw-Hill; 2000:1668.cated mandible. Am J Emerg Med 1989;7:32935.Colucciello SA. The treacherous and complex spectrum of maxil-lofacial trauma: etiologies, evaluation and emergency stabilization.Emerg Med Rep 1995;16:5970.

THE WRIST PIVOT METHOD, A NOVEL TECHNIQUE FOR TEMPOROMANDIBULAR JOINT REDUCTIONINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONREFERENCES