The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.11.107
Visual Diagnosis in Emergency Medicine
NEW FACIAL ASYMMETRY: A CASE OF UNILATERAL TEMPOROMANDIBULAR JOINT DISLOCATION Lindsay Cohen, MDCM* and Daniel J. Kim, MD*† *Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada and †Department of Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada Reprint Address: Daniel J. Kim, MD, Department of Emergency Medicine, Vancouver General Hospital, 855 12th Ave. W, Vancouver, BC V5Z 1M9, Canada
tional movement. TMJ dislocation occurs when the condyles move forward, slip underneath the articular eminence, and are completely displaced out of the
CASE REPORT A 78-year-old woman was transferred to the Emergency Department from a gastroenterology clinic after it was noted that she had new facial asymmetry (Figure 1) after an endoscopic procedure. Her past medical history was significant for atrial fibrillation, hypertension, and hypothyroidism. Her only complaint was of left jaw pain. Her neurologic examination revealed a normal cranial nerve examination and no focal neurologic deficits. She had full mouth opening without trismus. Plain x-ray studies of the left temporomandibular joint (TMJ) demonstrated displacement of the left mandibular condyle anterior to the articular eminence of the temporal bone in both the open- and closed-mouth positions (Figures 2, 3). Computed tomography of the facial bones confirmed the diagnosis of unilateral TMJ dislocation (Figure 4). Under procedural sedation, the patient’s dislocation was successfully reduced using a classic anterior approach. DISCUSSION Normally, the mandibular condyles should sit in the glenoid fossa of the temporal bone when the mouth is in a closed position. With mouth opening, the condyles slide forward along the glenoid fossa in combination with rota-
Figure 1. Facial asymmetry with the mandible deviated to the patient’s right.
RECEIVED: 19 August 2013; FINAL SUBMISSION RECEIVED: 9 November 2013; ACCEPTED: 17 November 2013 1
2
Figure 2. Closed-mouth plain x-ray image of the left temporomandibular joint. The mandibular condyle (arrow) is displaced anterior to the articular eminence of the temporal bone (arrowhead), whereas the glenoid fossa (asterisk) is empty.
glenoid fossa. TMJ dislocation most frequently occurs as a result of extreme mouth opening (i.e. eating, yawning, laughing) or trauma. Bilateral anterior dislocations are
Figure 3. Open-mouth plain x-ray study of the left temporomandibular joint. The mandibular condyle (arrow) is displaced anterior to the articular eminence of the temporal bone (arrowhead), and the glenoid fossa (asterisk) is empty.
L. Cohen and D. J. Kim
Figure 4. Sagittal computed tomography scan of the facial bones demonstrates that the left mandibular condyle (arrow) is displaced anterior to the articular eminence of the temporal bone (arrowhead).
most common, whereas unilateral TMJ dislocations are rare (1). A recent systematic review found that only 4 of 425 published cases of TMJ dislocation were unilateral (2). Cases of unilateral TMJ dislocation have been described as a result of seizure, prolonged mouth opening for procedures, and direct mandibular trauma (3–5). Clinically, patients with unilateral TMJ dislocation present with mandible deviation away from the side of the dislocation. Reduction is achieved in a manner similar to that used to reduce bilateral dislocations. The classic reduction maneuver is performed with the patient in a seated position, head firmly pressed against a headrest. The thumbs should be wrapped in gauze for protection and are positioned on the occlusive surfaces of the patient’s lower molars. The operator then exerts steady downward and posterior pressure on the affected side until reduction is achieved. Alternative methods include recumbent and posterior approaches. The recumbent approach is similar to the classic technique, except that the patient lies recumbent while the clinician applies caudal and posterior force on the mandible while standing in front of the patient. The posterior approach places the patient in a seated position. The operator stands behind the patient, places the thumbs posterior to the last molar, and applies downward force. This technique takes advantage of the levering effect that naturally occurs from this position (1).
Unilateral Temporomandibular Joint Dislocation
REFERENCES 1. Chan TC, Harrigan RA, Ufberg J, et al. Mandibular reduction. J Emerg Med 2008;34:435–40. 2. Akinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med 2011;7:10.
3 3. Behere PB, Marmarde A, Singam A. Dislocation of the unilateral temporomandibular joint a very rare presentation of epilepsy. Indian J Psychol Med 2010;32:59–60. 4. Satake H, Yamada T, Kitamura N, et al. Post-surgical unilateral temporomandibular joint dislocation treated by open reduction followed by orthodontic treatment. Int J Oral Maxillofac Surg 2011; 403:335–8. 5. Avrahami E, Rabin A, Mejdan M. Unilateral medial dislocation of the temporomandibular joint. Neuroradiology 1997;39:602–4.
http://dx.doi.org/10.1016/j.jemermed.2013.11.107
Visual Diagnosis in Emergency Medicine
NEW FACIAL ASYMMETRY: A CASE OF UNILATERAL TEMPOROMANDIBULAR JOINT DISLOCATION Lindsay Cohen, MDCM* and Daniel J. Kim, MD*† *Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada and †Department of Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada Reprint Address: Daniel J. Kim, MD, Department of Emergency Medicine, Vancouver General Hospital, 855 12th Ave. W, Vancouver, BC V5Z 1M9, Canada
tional movement. TMJ dislocation occurs when the condyles move forward, slip underneath the articular eminence, and are completely displaced out of the
CASE REPORT A 78-year-old woman was transferred to the Emergency Department from a gastroenterology clinic after it was noted that she had new facial asymmetry (Figure 1) after an endoscopic procedure. Her past medical history was significant for atrial fibrillation, hypertension, and hypothyroidism. Her only complaint was of left jaw pain. Her neurologic examination revealed a normal cranial nerve examination and no focal neurologic deficits. She had full mouth opening without trismus. Plain x-ray studies of the left temporomandibular joint (TMJ) demonstrated displacement of the left mandibular condyle anterior to the articular eminence of the temporal bone in both the open- and closed-mouth positions (Figures 2, 3). Computed tomography of the facial bones confirmed the diagnosis of unilateral TMJ dislocation (Figure 4). Under procedural sedation, the patient’s dislocation was successfully reduced using a classic anterior approach. DISCUSSION Normally, the mandibular condyles should sit in the glenoid fossa of the temporal bone when the mouth is in a closed position. With mouth opening, the condyles slide forward along the glenoid fossa in combination with rota-
Figure 1. Facial asymmetry with the mandible deviated to the patient’s right.
RECEIVED: 19 August 2013; FINAL SUBMISSION RECEIVED: 9 November 2013; ACCEPTED: 17 November 2013 1
2
Figure 2. Closed-mouth plain x-ray image of the left temporomandibular joint. The mandibular condyle (arrow) is displaced anterior to the articular eminence of the temporal bone (arrowhead), whereas the glenoid fossa (asterisk) is empty.
glenoid fossa. TMJ dislocation most frequently occurs as a result of extreme mouth opening (i.e. eating, yawning, laughing) or trauma. Bilateral anterior dislocations are
Figure 3. Open-mouth plain x-ray study of the left temporomandibular joint. The mandibular condyle (arrow) is displaced anterior to the articular eminence of the temporal bone (arrowhead), and the glenoid fossa (asterisk) is empty.
L. Cohen and D. J. Kim
Figure 4. Sagittal computed tomography scan of the facial bones demonstrates that the left mandibular condyle (arrow) is displaced anterior to the articular eminence of the temporal bone (arrowhead).
most common, whereas unilateral TMJ dislocations are rare (1). A recent systematic review found that only 4 of 425 published cases of TMJ dislocation were unilateral (2). Cases of unilateral TMJ dislocation have been described as a result of seizure, prolonged mouth opening for procedures, and direct mandibular trauma (3–5). Clinically, patients with unilateral TMJ dislocation present with mandible deviation away from the side of the dislocation. Reduction is achieved in a manner similar to that used to reduce bilateral dislocations. The classic reduction maneuver is performed with the patient in a seated position, head firmly pressed against a headrest. The thumbs should be wrapped in gauze for protection and are positioned on the occlusive surfaces of the patient’s lower molars. The operator then exerts steady downward and posterior pressure on the affected side until reduction is achieved. Alternative methods include recumbent and posterior approaches. The recumbent approach is similar to the classic technique, except that the patient lies recumbent while the clinician applies caudal and posterior force on the mandible while standing in front of the patient. The posterior approach places the patient in a seated position. The operator stands behind the patient, places the thumbs posterior to the last molar, and applies downward force. This technique takes advantage of the levering effect that naturally occurs from this position (1).
Unilateral Temporomandibular Joint Dislocation
REFERENCES 1. Chan TC, Harrigan RA, Ufberg J, et al. Mandibular reduction. J Emerg Med 2008;34:435–40. 2. Akinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med 2011;7:10.
3 3. Behere PB, Marmarde A, Singam A. Dislocation of the unilateral temporomandibular joint a very rare presentation of epilepsy. Indian J Psychol Med 2010;32:59–60. 4. Satake H, Yamada T, Kitamura N, et al. Post-surgical unilateral temporomandibular joint dislocation treated by open reduction followed by orthodontic treatment. Int J Oral Maxillofac Surg 2011; 403:335–8. 5. Avrahami E, Rabin A, Mejdan M. Unilateral medial dislocation of the temporomandibular joint. Neuroradiology 1997;39:602–4.
