I hadn’t realised that I was using a different technique until I saw a patient in the emergency department with a dislocated jaw, explained what I was going to do, and then reduced her jaw in a few seconds. She had previously had a number of painful distressing experiences with her jaw and insisted that I teach other doctors what I had just done to her. So, here is the technique that I use, based on the anatomy of the jaw in dislocation, and using positioning, leverage, and minimal force to reduce the joint.
Click below for a how-to video
The patient usually presents with the jaw locked in the open position, following excessive mouth opening (yawning laughing etc). The dislocation can be unilateral or bilateral. Any impact to the jaw should raise concern of a concurrent fracture.
The clinical picture used here is with the kind permission of Shanti Landon
Arrow pointing down is the mandibular condyle, the arrow pointing up denotes the articular tubercle. There is an articular disc that sits between the two. Normally the condyle lies in the fossa when mouth closed and moves forwards slightly when open. The anatomy in dislocation changes - excessive opening can result in more anterior movement of the condyle which then slips forwards over the tubercle and becomes wedged in position. The pain caused by stretching of the articular capsule causes spasming of the internal pterygoid, masseter and temporalis, which pull the condyle superiorly, further wedging it anterior to the tubercle. Attempting to overcome these spasming muscles with force will result in pain, using force to overcome the obstructing tubercle may result in further injury to the structures.
stand in front of seated patient
- double gloved thumbs placed firmly but gently behind lower molars.
- “hold.” This steady gentle pressure is maintained throughout to act as a fulcrum holding the condyle against the articular tubercle during reduction movement (and absolutely not to pull against or attempt to overcome muscular spasm).
- little fingers of both hands placed under the mental process of the chin which is slowly lifted in order to allow the articular surface of the mandibular condyle to roll over the disc overlying the articular tubercle.
- once the chin is lifted to an appropriate angle the condyle will slide posteriorly back into the mandibular fossa.
- stand in front of seated patient
- thumbs placed firmly but gently behind molars
- steady gentle pressure maintained throughout
- little fingers of both hands placed under chin which is slowly lifted
One of my registrars discovered that her hands were too small to allow her little fingers to lift the chin, easily solved by me doing that part for her, lifting the chin with my index finger. If you discover that issue while positioning your patient, grab an assistant.
A couple of years ago I was at the ACEM conference in Queenstown, New Zealand and was introduced to a guy called Rich who used my shoulder technique (badly as the photo proves!) When I told him I also used a jaw technique he made me promise to put it online so this one's for you, Rich. We were in an ice bar at the time and bring to explain where your thumbs go while wearing massive gloves and drinking cocktails is not easy. You can check out Rich at @airwaycam or better still, get onto one of his great airway courses.