The 'Syringe' Technique

A Hands-Free Approach for the Reduction of Acute Nontraumatic Temporomandibular Dislocations in the Emergency Department

Julie Gorchynski, MD; Eddie Karabidian, MSC; Michael Sanchez, MD

Disclosures

J Emerg Med. 2014;47(6):676-681. 

In This Article

Discussion

To our knowledge, our technique is the first described in the medical literature that does not require intraoral or external manual manipulation of the mandible for the reduction of acute nontraumatic TMJ dislocations in the ED. It is simple, safe, fast, and effective, and does not require procedural sedation. Most medical textbooks describe the traditional intraoral reduction method for TMJ dislocations. This technique requires a significant amount of force, especially in patients who have strong mastication musculatures for TMJ reduction.[3,4,8,9] The traditional intraoral technique requires physicians to place their two thumbs on the molars of the mandible, and then push the mandible in an inferior and posterior direction to reposition the condyle back into the glenoid fossa.[3,8–10] The intraoral approach has numerous disadvantages. First, there is a high risk of bite injuries, which might lead to transmittable diseases such as human immunodeficiency virus infection and hepatitis.[1,2,5] Second, procedural sedation is typically required for this type of reduction because the physician applying additional force to manually manipulate the mandible causes pain for the patient. Third, during the reduction, repeated attempts may be necessary before successfully achieving the reduction. It is not always effective, and inadvertent mandibular or condylar fractures may occur.[5,6] Lori et al. introduced a wrist-pivot method that utilizes the intrinsic biomechanical properties of the mandible. This technique, however, also requires the placement of the physicians' hands inside the patients' mouth.[2] If the physician does not apply equal intraoral forces bilaterally, a mandibular or condylar fracture may result.[5,6] The authors report that their technique requires intravenous procedural sedation.[2] Chen et al. introduced an extraoral or external approach, where the thumb is positioned just above the anteriorly displaced coronoid process and the fingers are positioned behind the mastoid process. Simultaneously on the opposite side, the fingers hold and rotate the mandible angle anteriorly and the thumb is placed over the malar eminence as a fulcrum.[1] Scamahorn reported the "corkscrew" technique in the Reader's Forum of Postgraduate Medicine.[11] In this technique, a cork is placed bilaterally between the teeth as the physician externally manipulates the mandible for reduction.[11] Nontraumatic TMJ dislocations are infrequent to the ED. We had a high number of subjects in this study, just fewer than the 37 subjects reported by Lowery et al. in 2004.[2]

Limitations

All the dislocations in this study population were anteriorly displaced; we cannot confirm the usefulness of the technique for the less common posterior or lateral dislocations. Traumatic TMJ dislocations may involve posterior and lateral dislocations as well as an associated fracture, making the reduction more difficult. Further studies involving acute traumatic TMJ dislocations utilizing our technique or in combination with external manipulation and intravenous analgesia, may demonstrate its value.

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