The temporomandibular joint (TMJ) or TMJ is a type of ginglymoarthrodial joint and its articulation involves both sliding and hinge type movements. Dislocation of this joint is a very painful condition and needs acute emergency care. Most of these acute dislocations can be managed by emergency physicians. However, chronic dislocations can be managed with the conservative approach. TMJ disorders are the rare complications in those patients, which are under antiretroviral therapy and until now, there are only few cases reports in the literature. We report three cases of TMJ dislocations that were managed successfully in an emergency room. No conclusive cause-effect relationship has been found linking the TMJ disorders to the human immunodeficiency virus-antiviral treatment

Anandhi, D

Raju, K N J Prakash

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 82
Case Series
Management of temporomandibular joint dislocations in the emergency 
department - a case series
D Anandhi, K N J Prakash Raju
From Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 
Tamil Nadu, India
Correspondence to: Dr. D Anandhi, Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical 
Education and Research, Puducherry - 605 006, Tamil Nadu, India. Phone: +91-9626064984. E-mail: anandhideva1@gmail.com
Received - 25 February 2018 Initial Review - 07 March 2018 Published Online - 18 April 2018
The temporomandibular joint (TMJ) is a specialized joint between the mandible and the temporal bone of the skull. The condyle of the mandible articulates in a 
concavity known as the glenoid fossa or the mandibular fossa [1]. 
The articulation of TMJ involves both sliding and hinge type 
movements, and dislocation of this joint is a very painful condition 
and needs acute emergency care. During dislocation, the condyle 
moves in front of the articular eminence and unable to recede 
back to its normal position. It can be partial (subluxation) or 
complete (dislocation), bilateral or unilateral, and acute or chronic 
(protracted or recurrent). The most common type is the anterior 
dislocation [1]. TMJ dislocation mostly occurs in the second and 
third decades of life, children and elderly may also be affected [2]. 
Females are more likely to develop TMJ dislocation as compare 
to males, but the reason for this is not yet fully understood [3,4].
CASE REPORT
Case 1
A 23-year-old male patient reached the emergency ward and 
reported with a chief complaints of pain in the jaw, inability to 
open jaw (following yawning), and inability to speak. He had 
a similar episode for the past 3 months which had resolved 
spontaneously.
On examination, his vital signs were stable; the mouth was 
wide open, locked, and significant drooling of saliva. There 
was a depression in his preauricular area with tenderness on 
the right side, and chin was deviated to the left side. The right 
TMJ dislocation was diagnosed based on the history and clinical 
findings. The treatment involved procedural sedation using 3 mg 
intravenous midazolam and 50 mg intravenous tramadol. The 
manual reduction was performed by placing both the gloved 
thumbs over the occlusal surface of lower molar teeth (with 
simultaneous chin elevation with fingers), and entire mandible 
was pushed down and posteriorly. As the initial attempt failed, we 
tried the same procedure keeping gauze pieces over the teeth and 
considerable success was achieved. Postprocedure, the patient 
was comfortable, able to speak, and eat. On 4th week follow-up, 
he was doing fine and there was no recurrence (Fig. 1).
Case 2
A 42-year-old female patient with the history of retropositive 
(human immunodeficiency virus [HIV] on antiretroviral therapy) 
came to the emergency department and complaints of inability to 
speak, pain over the jaw, drooling of saliva from the mouth, and 
difficulty in eating for 4 days. On examination, she was anxious. 
Her vital signs were normal, the mouth was wide open, and there 
were white plaques over the tongue and mucosal membranes, 
which was suggestive of oral candidiasis. Palpation over the right 
preauricular region suggested emptiness in the joint space. Based 
on the history of the patient and clinical examination, a diagnosis 
of the right TMJ dislocation was made.
ABSTRACT
The temporomandibular joint (TMJ) or TMJ is a type of ginglymoarthrodial joint and its articulation involves both sliding and 
hinge type movements. Dislocation of this joint is a very painful condition and needs acute emergency care. Most of these acute 
dislocations can be managed by emergency physicians. However, chronic dislocations can be managed with the conservative 
approach. TMJ disorders are the rare complications in those patients, which are under antiretroviral therapy and until now, there are 
only few cases reports in the literature. We report three cases of TMJ dislocations that were managed successfully in an emergency 
room. No conclusive cause-effect relationship has been found linking the TMJ disorders to the human immunodeficiency virus-
antiviral treatment.
Key words: Antiviral therapy, Emergency department, Emergency procedures, Temporomandibular joint dislocation, 
Temporomandibular joint
Anandhi and Raju Temporomandibular joint dislocations - emergency department experience
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 83
The manual reduction was tried after giving analgesics 
and sedation, but initial three attempts failed. Then, the 
oromaxillofacial duty team was contacted, the patient was 
counseled once again about the procedure, and adequate sedation 
was given and dislocation was reduced using the wrist pivot 
method [5]. Postreduction, she was able to speak and the pain was 
relieved. She was advised to have soft diet, use of a bandage to 
cover head and jaw, and to keep hand below jaw during yawning. 
On 6th week follow-up, the patient was well and there was no 
recurrence (Fig. 2).
Case 3
A 65-year-old female patient with seizure disorder presented 
with a reduced mouth opening during an episode of seizure. 
On examination, TMJ dislocation was confirmed, the reduction 
was performed by keeping the patient in a supine position, the 
physician on the head-end side, both thumbs were placed over 
the lower molars, and the downward pressure was applied. 
Postreduction, she was able to close mouth and perform routine 
activities. We advised soft diet and to avoid wide opening of the 
mouth. After 2 months, she had recurrent TMJ dislocation during 
a seizure episode, which was reduced successfully and advised 
to wear a soft cervical collar to prevent recurrence, and a dose of 
antiepileptics was increased to prevent seizures (Fig. 3).
DISCUSSION
A TMJ dislocation is defined as an excessive forward movement 
of the condyle of mandible beyond the articular eminence with 
complete separation of the articular surfaces and fixation in that 
position [6]. Morphological variants exist based on the position 
of the condyle in relation to the articular eminence; these are 
described as anterior, posterior, superior, and lateral [6]. However, 
the anterior subtype is the most common. In all our cases, there 
was anterior dislocation of the TMJ.
By the clinical-radiological evaluation, Akinbami [7] 
classified TMJ dislocation into the following three types:
•	 Type	I	-	The	head	of	the	condyle	is	directly	below	the	tip	of	
the eminence
•	 Type	II	-	The	head	of	the	condyle	is	in	front	of	the	tip	of	the	
eminence
•	 Type	III	-	The	head	of	the	condyle	is	high-up	in	front	of	the	
base of the eminence.
The TMJ dislocations may be further subdivided into acute 
or chronic conditions as follows: chronic recurrent if it appears 
repeatedly over a short period and chronic persistent dislocations 
if it persists over a long period [7,8]. Chronic persistent 
dislocation can be defined as an acute dislocation left untreated 
or inadequately treated for 72 h or more, and there is a consensus 
that if the situation persists for more than a month and it is labeled 
as long-standing or protracted TMJ dislocation [9]. This last 
condition is the most challenging and difficult to treat of the three.
Majority of the cases, irrespective of the clinical subtype 
were due to yawning [10]. In a Nigerian study of 96 patients with 
TMJ dislocations, excessive mouth opening while yawning was 
the most common cause of dislocation, followed by road traffic 
accidents and underlying systemic disease, and the most common 
cause of epilepsy [10]. Research has shown that the presence of 
underlying illness such as connective tissue disorders, Ehlers–
Danlos syndrome, psychogenic, and neurological disorders, 
and the use of drugs containing amphetamine-like substances, 
contributes substantially to the etiopathogenesis of condylar 
dislocation [10].
Figure 1: In Case 1, a young boy with temporomandibular joint 
dislocation
Figure 3: In Case 3, elderly lady with temporomandibular joint 
dislocation
Figure 2: In Case 2, human immunodeficiency virus patient with 
temporomandibular joint dislocation and on antiretroviral therapy. 
(a) Lateral view, (b) anterior view
a b
Anandhi and Raju Temporomandibular joint dislocations - emergency department experience
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 84
HIV-infected patients often report chronic pain and pathology 
that targets at body joints during retroviral therapy. Although both 
conditions may share similar secondary disorders, no conclusive 
cause-effect relationship has been found linking the TM disorders 
to the HIV-antiviral treatment [11]. Our second patient was 
infected with HIV and was on antiviral therapy.
A European survey of 878 people with HIV infection on 
antiretroviral treatment suggested that protease inhibitors caused 
arthralgia. Among several cases reported of rheumatological 
pathology (TM dysfunction, frozen shoulder, Dupuytren’s 
disease, and tendinitis), most were probably related to the intake 
of indinavir in HIV-positive patients [12]. Florence et al. have 
reported that the TMJ complaints disappeared completely when 
the protease inhibitor (indinavir) was replaced with nevirapine, a 
nonnucleoside analog [13].
Generally, the management of TMJ dislocation depends on 
whether it presents as an acute, chronic, or recurrent lesion, but 
all the available treatment options in the literature have been 
categorized as either conservative or surgical. Manual reduction 
with or without anesthesia/analgesia remains the preferred method 
Figure 4: Protocol for managing TM joint dislocation in Emergency Department
Anandhi and Raju Temporomandibular joint dislocations - emergency department experience
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 85
of treatment for acute dislocations. Different methods available to 
reduce the TMJ dislocation are the conventional method, wrist 
pivot method, extraoral reduction technique, hands-off syringe 
technique, and gag reflex method.
Conventional Method
In this method, the patient is placed in seated position (anterior 
approach) or supine (posterior approach). The physician, by 
applying bimanual intraoral force on the mandibular molars of 
the patient in an inferior and then posterior direction, will reduce 
the dislocated condyle back into the glenoid fossa [14].
Wrist Pivot Method
The patient is placed in seated position. While facing the patient, 
the physician grasps the mandible with thumbs at the apex of 
the mentum and fingers on the occlusal surface of the inferior 
molars. The reduction is done by applying cephalad force with 
the thumbs and caudal pressure with the fingers and wrist acting 
as a pivot [5].
Hands-off Syringe Technique
In this technique, the patient bites with their posterior molar 
teeth on a 5–10 cc syringe on the side of the dislocation. The 
syringe is rotated back and forth, so that it pushes the molar teeth 
posteriorly. The direction of rotation is clockwise for a right side 
dislocation or counterclockwise to the left [15].
Gag Reflex Method
In 1987, Awang described induction of the gag reflex by probing 
the soft palate creates a reflex neuromuscular action that resulted 
in the reduction [16].
There is no risk of biting associated with the extraoral method 
of reduction, and also there is no significant difference in success 
rate between this and the conventional method. Hence, the 
extraoral method could be considered as the appropriate first-line 
treatment where there is a risk of patient biting the surgeon’s hand 
during reduction. Given the overall benefits of the wrist pivot 
method, this method could be considered as the first-line and gold 
standard treatment modality in all other cases [14].
In case of chronic protracted dislocation, elastic rubber 
traction with arch bars and ligature wires/intermaxillary fixation 
with elastic bands are used to achieve the reduction [8]. However, 
chronic (prolonged) cases are more difficult to manage, possibly 
due to the development of fibrosis within the joint cavities, 
myospasm, bony union, or a combination of these. The surgical 
techniques adopted for prolonged cases were condylectomy, 
inverted L-shaped osteotomy, oblique ramus osteotomy, and 
vertical subsigmoid osteotomy [10].
Usually, after reduction of dislocated TMJ, the patient is 
provided with a bandage around the face and jaw and is asked 
not to open his/her mouth wide. However, the patient finds 
difficulty in eating and drinking due to the bandage, which further 
deteriorates the general health of the patient. Thus, the addition 
of a cervical collar to the geriatric population not only helps 
in the management of cervical spondylosis but also decreases 
recurrent mandibular dislocation by acting as a restrainer [17]. 
Each emergency department should have a protocol to manage 
TMJ dislocation. The flowchart shown below is our ED protocol 
for TMJ dislocation.
Protocol for managing TM joint dislocation in Emergency 
Department [Fig. 4]
After confirming TMJ dislocation, the duration of dislocation 
should be considered. If its Acute, trauma related fracture of the 
mandible should be ruled out, if TMJ dislocation is associated with 
fracture, reduction attempt should not be attempted.  Instead Oro-
maxillosurgeon should be involved. In case of Chronic recurrent 
and Acute dislocation with out fracture, manual reduction should 
attempted after explaining the procedure, adequate analgesics 
and muscle relaxants should be considered. In case of Chronic 
Persistent cases anticipate difficult reduction and involve Oro-
maxillo surgeon. Post reduction care should be given in all 
patients.
CONCLUSION
The manual reduction is sufficient in cases of acute TM 
dislocation. The physicians should be familiar with different 
methods of manual reduction of an acute dislocated TMJ. A soft 
cervical collar can be advised to seizure disorder patients with 
TMJ dislocation to prevent recurrence. Chronic protracted and 
chronic recurrent dislocations are the most difficult to treat but 
can be managed conservatively with the help of experienced 
persons. Hence, the most important point to keep in mind is to 
identify the cause and treat them accordingly.
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Anandhi D, Raju KNJP. Management of 
temporomandibular joint dislocations in emergency department - a case 
series. Indian J Case Reports. 2018;4(2):82-86.


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