What is the workup for temporomandibular joint (TMJ) dislocation?

From the Guidelines

The initial workup for jaw dislocation should prioritize a thorough history and physical examination, followed by radiographic imaging with panoramic radiographs (Panorex) as the first-line study to confirm the diagnosis and rule out fractures. When evaluating a patient with a suspected jaw dislocation, it is crucial to inquire about trauma, previous dislocations, and symptoms such as pain, malocclusion, and difficulty speaking or eating 1. The physical examination should include an assessment for facial asymmetry, an open bite, and the inability to close the mouth, as well as palpation of the temporomandibular joints to evaluate for displacement.

Key Components of the Workup

• A focused history to identify potential causes and contributing factors
• A thorough physical examination to assess the extent of the dislocation and rule out other injuries
• Radiographic imaging, starting with panoramic radiographs, to confirm the diagnosis and assess for any fractures or other complications
• Consideration of computed tomography (CT) for complex cases or when fractures are suspected

Management Approach

The management of jaw dislocation should be guided by the principles outlined in recent clinical practice guidelines, which emphasize the importance of conservative approaches as the first line of treatment 1. This includes measures such as reassurance, jaw rest, avoidance of irritating behaviors, heat, NSAIDs, oral appliances in the presence of bruxism, physiotherapy, and pharmacotherapy. Surgery should only be considered after non-response to conservative therapy, and options may include arthrocentesis, arthroscopy, or open surgery of the temporomandibular joint.

Post-Reduction Care

After prompt reduction of the dislocation using techniques such as the Hippocratic method or the wrist pivot method, patients should be advised to follow a soft diet for 1-2 weeks and use NSAIDs for pain management, such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily. It is also important for patients to avoid wide mouth opening for several weeks to allow for proper healing. Follow-up should be arranged within 1-2 weeks to assess healing and function, and recurrent dislocations may necessitate referral to an oral-maxillofacial surgeon for consideration of surgical intervention.

From the Research

Jaw Dislocation Workup

• Jaw dislocation, also known as mandibular dislocation, can occur after activities that hyperextend the mandible or open the mouth widely, such as yawning, laughing, or taking a large bite 2.
• The most common type of dislocation is anterior dislocation, where the condylar head of the mandible dislocates out of the glenoid fossa anterior to the articular eminence of the temporal bone 2.
• Reduction of jaw dislocation can be achieved through various methods, including:
  • Closed reduction methods, such as the classic approach, recumbent, posterior, and ipsilateral approaches, as well as the wrist pivot method, alternative manual technique, and gag reflex induction 2.
  • The "syringe" technique, a hands-free approach that uses a syringe to guide the anteriorly displaced condyle back into its normal anatomical position 3.
  • The Hippocratic Method, an ancient Greek procedure that involves a bimanual intraoral technique performed by two medical personnel 4.
  • An extraoral route method, which applies steady pressure over the prominent part of the coronoid process and anterior border of the ramus to reduce the dislocated mandible 5.
  • The use of intraoral local anaesthetic to aid reduction of acute temporomandibular joint dislocation, reducing the need for conscious sedation, muscle relaxants, or general anaesthetic 6.

Reduction Techniques

• The choice of reduction technique depends on the individual case and the clinician's preference.
• Some techniques, such as the "syringe" technique, do not require procedural sedation or intravenous analgesia 3.
• Other techniques, such as the Hippocratic Method, may require sedation 4.
• The use of intraoral local anaesthetic can aid reduction and reduce the need for sedation or other forms of anaesthesia 6.