The Journal of Emergency Medicine, Vol. 27, No. 2, pp.

167170, 2004
Copyright 2004 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/04 $see front matter

doi:10.1016/j.jemermed.2004.03.007

Techniques and
Procedures

THE WRIST PIVOT METHOD, A NOVEL TECHNIQUE FOR

TEMPOROMANDIBULAR JOINT REDUCTION
Lori E. Lowery,

MD,*,

Michael S. Beeson,

MD, MBA,*,

and Kevin K. Lum,

MD*,

*Northeastern Ohio University College of Medicine, Akron, Ohio and Summa Health System, Akron, Ohio
Reprint Address: Michael S. Beeson, MD, MBA, FACEP, 41 Arch St., Suite 521, Akron, OH 44304

e AbstractTemporomandibular joint (TMJ) dislocation

is an infrequent dislocation of the mandible. The usual
technique of reduction, recommended by most Emergency
Medicine textbooks, consists of downward forces applied to
the mandible. In the authors experience this is often painful and requires significant sedation. We present a patient
in whom the usual manner of TMJ dislocation reduction
was difficult. We describe a novel technique for TMJ dislocation reduction that uses the intrinsic biomechanical
properties of the mandible. 2004 Elsevier Inc.

CASE REPORT
A 53-year-old man with a remote history of bilateral
TMJ dislocation presented to the Emergency Department
(ED) with the chief complaint of locked jaw. The
patient stated that while laying back in a recliner and
yawning he felt sudden pain in his lower face and was
unable to close his mouth. This episode was similar to a
prior TMJ dislocation 30 years ago. The patient was
experiencing such pain with any attempted jaw motion
that he was writing all answers. The patient denied any
recent trauma, surgery or other illness.
Physical examination revealed a middle-aged man in
significant discomfort with his mouth in the open position. He was unable to speak due to pain. The posterior
molars were approximated but anterior teeth were gaping. A palpable preauricular depression consistent with
condyle dislocation from the glenoid fossa was present
bilaterally. The patients history and physical examination were consistent with a nontraumatic bilateral TMJ
dislocation.
The patient was prepared for reduction. An intravenous line, oxygen via nasal cannula, and continuous
pulse oximetery were appropriately placed on the patient.
Three milligrams (mg) of midazolam and 50 g of
sublimaze were administered intravenously. The patient
became sleepy but arousable to verbal stimuli. Conventional reduction technique was attempted in which the

e Keywordstemporomandibular joint; TMJ; TMJ dislocation; ED procedure

INTRODUCTION
An infrequently used but necessary technique emergency
physicians (EPs) must have in their arsenal is reduction
of a mandibular dislocation at the temporomandibular
joint (TMJ). Although most textbooks describe a
straightforward approach to reduction, it has been the
authors experience that conscious sedation and significant force is required to achieve reduction. In this article,
a novel approach to reduction is described, along with a
discussion of the biomechanics of mandibular dislocation affecting reduction techniques. Our approach is
based on using the intrinsic biomechanical properties of
the mandible.

Techniques and Procedures is coordinated by George Sternbach, MD, of Stanford University Medical Center, Stanford,
California

RECEIVED: 28 February 2003; FINAL

ACCEPTED: 30 March 2004

SUBMISSION RECEIVED:

21 February 2004;
167

168

L. E. Lowery et al.

Figure 1. Conventional reduction technique for TMJ dislocation reduction.

physicians gloved thumbs are placed on the occlusal

surface of the patients inferior molars bilaterally (Figure
1). Firm inferior, posterior pressure was then applied as
described in various references (13). The initial attempt
was unsuccessful, with great distress to the patient. The
patient received additional sedation, 4 mg of midazolam
and 50 g of sublimaze, and a second conventional
reduction attempt was again unsuccessful. After discussion between the authors, a third attempt with a new
technique was tried. The authors desired to benefit from
both the muscular forces at work, as well as the shape of
the mandible. Without further sedation, a third attempt

Figure 2. The wrist pivot method for TMJ dislocation reduction.

using this new technique was performed successfully.

The patients most recent sedation had been 20 min
earlier. While facing the patient, the mandible was
grasped with the physicians thumbs at the apex of the
mentum and fingers on the surface of the occlusal surface
of the inferior molars (Figure 2). By applying cephalad
force with the thumbs and caudad pressure with the
fingers, then pivoting at the wrists, the dislocated
mandible was reduced with minimal difficulty. The
patient immediately resumed normal movement of his
jaw. The patient was subsequently discharged in good
condition.

Novel Technique of TMJ Reduction

169

DISCUSSION
Mandibular dislocation at the TMJ is an infrequent presentation to the ED. At our institution, consisting of two
EDs with approximately 100,000 combined annual visits, 37 TMJ dislocations have presented over a 7-year
period, 19952002. Although infrequent, reduction of
TMJ dislocation is a technique EPs must have in their
repertoire.
The TMJ is a ginglymoarthrodial joint, combining
gliding and hinge motions. Dislocation can occur anteriorly, posteriorly, laterally or superiorly. Discussion
here will be limited to anterior dislocation as occurred to
our patient, as it is by far the most common type and the
only to occur without a fracture (4). TMJ dislocation
occurs when there is an interruption in the normal sequence of muscle action during closure from maximal
opening. Interruption allows elevation of the mandible
before retraction. This occurs when the protracting lateral pterygoid muscles fail to relax before the masseter
and temporalis muscles elevate the mandible (5). The
condyle travels anteriorly along the eminence and becomes locked in the anterior superior aspect of the eminence (Figure 3). The masseter, pterygoid, and temporalis muscles go into spasm attempting to close the
mandible. Trismus results and the condyle cannot return
to the temporal fossa (3). Muscle spasm and edema result
in significant pain to the patient.
Potential causes of TMJ dislocation include any action that may involve the mouth being maximally open.
Common causes include yawning and trying to chew a
large food bolus. The literature has noted TMJ dislocation as a complication of anesthetic induction, intravenous sedation, Ehlers-Danlos Syndrome, trauma and
even tetanus (4,6 10). The complications of TMJ dislocation include recurrent subluxation/dislocation from injury to the articulating cartilage, as well as fracture (11).
The prognosis is usually excellent, although recurrent
TMJ subluxation/dislocation may require surgical treatment (12,13).
Diagnosis may be made clinically if the following
features are present. The patient will present with inability to close the mouth, severe pain anterior to the ears,
absence of the condyle from the glenoid fossa resulting
in a visible, palpable preauricular depression and a prominent-appearing lower jaw (14). If dislocation is unilateral, the jaw deviates away from the involved side (15).
If trauma is involved, radiographic analysis is needed for
the evaluation of possible fracture.
Conventional techniques as described by standard
Emergency Medicine textbooks describe the EP placing
his protected thumbs on the occlusal surface of the patients molars, wrapping his fingers laterally around the
mandible and then applying a constant inferior and pos-

Figure 3. Anatomic description of TMJ dislocation.

terior force, gliding the mandibular condyles back into

the glenoid fossa. The conventional reduction technique
requires the physician to manually overcome the substantial force created by the pterygoid, masseter and
temporalis muscles to achieve reduction (Figure 1).
In the novel technique we describe, these forces are
utilized to assist with reduction. The physicians thumbs
are placed at the mentum of the mandible to apply an
upward force and the fingers are wrapped laterally
around the mandible. The angle of the mandible is then
used as a fulcrum with the pterygoid, masseter and
temporalis muscles exerting a force parallel to the EPs.
Simultaneous pivoting action of the physicians wrists
with the thumb (anterior portion of the fulcrum) pushing
superiorly and the operators fingers on the mandibular
body pushing inferiorly allows the condyles to rotate
back into the glenoid fossa (Figure 2). It is important to
note that these forces must be applied bilaterally to
prevent mandibular fracture. The muscles of mastication
provide assistance rather than impedance with this new

170

L. E. Lowery et al.

technique as they promote rotation and reduction. Rather

than attempting to lengthen the muscles that are in spasm
to clear the condylar ridge, this technique pivots the
mandibular condyle, easing the reduction into the fossa.
The muscles of mastication provide a force-oriented superior and posterior. As the angle of the mandible rotates, these forces help bring reduction into the condyle.
To protect the operators fingers during reduction, it is
suggested that a bite block be used. This will prevent a
human bite to the operator in the event of sudden closure
of the mandible due to spasm, reduction, etc. Although
not used in this particular patient, a bite block could
prevent operator injury regardless of technique used.
CONCLUSION
In conclusion, we describe a novel technique, the wristpivot technique, for mandibular dislocation, which has
not been previously described in the literature. It utilizes
the muscles of mastication in conjunction with the forces
applied by the physician for a smoother, more comfortable reduction of the mandible for the patient and the
physician.
REFERENCES
1. Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, ed. Emergency medicine: a comprehensive study guide, 5th edn. New York:
McGraw-Hill; 2000:1668.

2. Amsterdam JT. Emergency dental procedures. In: Roberts JR,

Hedges JR, eds. Clinical procedures in emergency medicine, 3rd
edn. Philadelphia: W.B. Saunders Co.; 1998:1164 9.
3. Cantrill SV. Facial trauma. In: Rosen P, Barkin R, eds. Emergency
medicine concepts and clinical practice, 4th edn. St. Louis, MO:
Mosby; 1998:459.
4. Moore CA, Ellis B. Dislocation of the mandible during the course
of cataract surgery. Ophthalmic Surg Lasers 1998;29:2512.
5. Thompson WR. Dislocation (luxation) of the temporomandibular
joint. Appl Ther 1966;8:686 7.
6. Gambling D, Ross P. Temporomandibular joint subluxation on
induction of anesthesia. Anesth Analg 1988;67:912.
7. Lacy P, Lee J, OMorain C. Temporomandibular joint dislocation:
an unusual complication of upper gastrointestinal endoscopy. Am J
Gastroenterol 2000;95:3653 4.
8. Goodman R, Allison M. Chronic temporomandibular joint subluxation in Ehlers-Danlos syndrome: report of case. J Oral Surg
1969;27:659 61.
9. Walker R, Connor P. Unilateral mandible fracture with bilateral
TMJ dislocation. Tenn Med 2000;93:19 20.
10. Thachil R, Philip B, Sridhar C. Temporomandibular dislocation: a
complication of tetanus. J Trop Med Hyg 1993;96:60 1.
11. Pynn B, Clarke H. Parasymphyseal fracture with an associated
temporomandibular joint dislocation: case report. J Trauma 1992;
32:256 8.
12. Westwood R, Fox G, Tilson H. Eminectomy for the treatment of
recurrent temporomandibular joint dislocation. J Oral Surg 1975;
33:774 9.
13. Segami N, Kaneyama K, Tsurusako S, Suzuki T. Arthroscopic
eminoplasty for habitual dislocation of the temporomandibular
joint: preliminary study. J Craniomaxillofac Surg 1999;27:
390 7.
14. Luyk NH, Lansen PE. The diagnosis and treatment of the dislocated mandible. Am J Emerg Med 1989;7:329 35.
15. Colucciello SA. The treacherous and complex spectrum of maxillofacial trauma: etiologies, evaluation and emergency stabilization.
Emerg Med Rep 1995;16:59 70.