Pediatric emergency medicine trisk 3250 3250

Mandibular dislocation occurs when the capsule and TMJ ligaments are
sufficiently stretched to allow the condyle to move to a point anterior to the
articular eminence during opening. Dislocation can be unilateral or bilateral and
often accompanies a history of extreme mouth opening (e.g., deep yawn) or
following a prolonged dental appointment. The muscles of mastication enter a
tonic contraction state, and the patient is unable to move the condyle back into the
glenoid fossa and close his or her mouth.
Clinical assessment. Local bleeding, gingival/mucosal tears, or sublingual
ecchymoses may be clues to underlying bony injury. Posterior tooth fractures, or
evidence of malocclusion may also alert the emergency physician to the
possibility of a jaw fracture. In some cases, depressed or mobile jaw fragments
may be identified. A unilateral condylar fracture should be suspected if the
mandible deviates toward the affected side on opening.
A panoramic radiograph or CT scan should be obtained when mandibular
fractures are suspected. A panoramic radiograph may not be possible in a young
or severely injured child, and may not be available in the emergency department
setting.
Management. The appropriate service (dentistry, oral and maxillofacial surgery,
or plastic surgery) should be consulted depending on availability. In cases where
the fracture is none/minimally displaced, there is no evidence of airway
obstruction, dehydration, or unremitting pain, a patient may be discharged on a
soft diet with close outpatient follow-up with specialty care. For unstable or
concerning fractures, specialty services are required to stabilize the fracture, using
either open or closed reduction.
For a dislocation, gentle downward and backward pressure should be applied
by the physician’s thumb (wrapped in gauze) on the occlusal surfaces of the
posterior teeth ( Fig. 105.6 ). The downward pressure moves the dislocated
condyle below the articular eminence; subsequent backward pressure on the
molars shifts the condyle posteriorly into the mandibular fossa. If this approach
fails, intravenous diazepam (0.2 mg/kg, maximum 10 mg) can be administered as
an adjunctive muscle relaxant before reattempting to relocate the condyles.

Figure 105.7 shows the anatomic landmarks and repositioning of the TMJ.