Mandible Dislocation Treatment & Management

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Medication Summary
Sedation and analgesia are indicated if reduction is attempted. The medications traditionally used for this purpose are diazepam and morphine. Other conscious sedation protocols can be used providing the patient maintains an adequate gag reflex. Deep conscious sedation is not desirable because the patient should remain seated during relocation. Certain medications that can cause masseter spasm (eg, methohexital, chlordiazepoxide, phenothiazines) should be avoided because this complication would prevent relocation of the mandible.

Analgesics
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.

Morphine (Astramorph, Duramorph)
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Various IV doses are used; commonly titrated until desired effect obtained.

Fentanyl citrate (Duragesic, Sublimaze)
Potent narcotic analgesic with much shorter half-life than morphine sulfate. With short duration (30-60 min) and easy titration, an excellent choice for pain management and sedation. Easily and quickly reversed by naloxone.

Anxiolytics
Class Summary
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.

Diazepam (Valium)
Individualize dosage and increase cautiously to avoid adverse effects.

Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent medication for patients requiring sedation for >24h. Monitor BP after administering dose and adjust as necessary.

        

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Further Inpatient Care
In the rare cases of mandible dislocation that cannot be reduced by the methods described in Emergency Department Care, closed reduction under general anesthesia or open reduction may be required.
Dislocations associated with fractures of the mandible are best reduced by oral maxillofacial surgeons or otolaryngologists.

Further Outpatient Care
Successfully relocated mandible dislocations do not require any specific ongoing treatment, although the patient should be cautioned against opening the mouth wide, which could easily cause a recurrence.
A soft collar may be considered for support of the TMJ after reduction.
All patients with reduced mandible dislocations should be monitored by an appropriate specialist because of the possibility of jaw instability, ligamentous damage, and chronic TMJ pain.

        

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Complications from mandibular dislocation and reduction are rare.

Complications of dislocation
Chronic recurrent anterior dislocations can result in injury to the joint capsule and degenerative disease of the joint space.
Injury to the external carotid and facial nerve can result.
Posterior dislocations can injure the external auditory canal.
Deafness can result from damage to the auditory canals and surrounding structures.
Superior dislocations have been associated with cerebral contusion, CNS deficits, and seventh and eighth cranial nerve injury.

Complications of reduction
Iatrogenic fracture of the mandibular condyle may occur as it passes under the articular eminence.
The physician’s thumbs may be injured as a consequence of rapid jaw closure with reduction.

Prognosis
The prognosis for most isolated mandibular dislocations is good but varies based on the type of dislocation.

Acute anterior mandibular dislocations carry an excellent prognosis with few cases that progress to chronic recurrent dislocation.
Lateral dislocations are often associated with fractures and require open reduction.
Posttraumatic ankylosis is possible for dislocations with displaced condylar fractures.
Posterior dislocations occasionally require fixation of the external auditory canal and may result in hearing deficits.
Superior dislocations and those unreducible by a closed technique require emergent consultation by an oromaxillofacial surgeon and should be assessed for damage to the surrounding cranial nerves and cerebral structures.
Slight facial asymmetry and lack of development of the mandibular ramus have been reported in long-term follow-up of a case of pediatric superior mandible dislocation.

Patient Education
Patients should be instructed to avoid opening their mouths widely to prevent recurrent dislocation.

        

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