I.

History
A. General Data
E.D.R., 59 years old, female, married, Roman Catholic, presently residing at Sta. Ana Manila
came in our institution for ER consult for several times.
B. Chief Complaint: Lockjaw
C. History of Present Pregnancy
5 months PTC, patient had her first episode of lock jaw. This was described by locking of the
jaw open which is impossible for patient to close her mouth. This was associated with pain in the infra-
auricular area. No crepitus, no grinding, no tinnitus or other hearing problem noted. Consult was done
in our institution where she was diagnosed to have Tempomandibular joint dislocation and was given
Eperisone 50mg OD for 5 days which provided temporary relief. Patient underwent close reduction of
TMJ then Bartons bandage was applied. She was referred to a dentist for further management but
failed to comply. Since then patient had been brought several times in different institutions due to her
recurrent lock jaw attacks.
Few hours prior to consult, patient was resting on her bed when she had a locked jaw. Patient
was then rushed in our ER department for management.

D. Past Medical History

At the 2010, patient had a stroke and was diagnosed to be hypertensive with unrecalled
medication. She is non-diabetic and no history of pulmonary tuberculosis, asthma, cancer,
cardiovascular disease and kidney disease. She had no previous history of surgery. She had no history
of allergy to any medications or any food.
E. Family History
There were no history of hypertension, diabetes mellitus, asthma, cardiovascular disease,
malignancies and kidney disease in her family.
F. Obstetrical History: Gravida 2 Para 2 (2002)
G. Menstrual and Gynecological History
The patient had her menarche at the age of 13 occurring at regular intervals of 28 days lasting
for 3-4 days consuming 3 moderately soaked napkins per day and not associated with dysmenorrhea.
Patient had her menopause at the age of 46 years old. No pap smear done and no history of
contraceptive use.
H. Sexual History
Patient had her first contact at the age 19 years old and had 2 sexual partners. She denies any
history of dyspareunia, postcoital bleeding, leukorrhea and exposure to sexually transmitted infection.
I. Personal and Social History
Patient is non-smoker, non-alcohol beverage drinker and denies illicit drug use. She is a
college undergraduate and a housewife. She is living with her husband and 2 children. Garbage is
collected once a week. Water source is from NAWASA.

II. Review of Systems

General: (-) chills night sweats, fever, change in weight
Skin: (-) scars, lesions, rashes, ulcerations, excoriations
HEENT:
Head: (-) Headache, masses, bruises
Eyes: (-) eye pain, red eyes, eye itchiness, eye discharge
Ears: (-) tinnitus, ear discharge, ear pain, deafness
Nose: (-) colds, nasal discharge, epistaxis, trauma
Neck: (-) neck pain, goiter, cervical lymphadenopathy
Remelou G. Alfelor ENT Case Report Page 1 of 9
 Throat: (-) throat pain, dysphagia
Respiratory: (-) difficulty of breathing dyspnea, hemoptysis, cough, colds
Heart: (-) cyanosis, edema, heart murmurs, chest pain, palpitations
Gastrointestinal: (-) nausea and vomiting, loss of appetite, abdominal pain, diarrhea, jaundice
Genitourinary: (-) dysuria, frequency, urgency, nocturia, enuresis, hematuria, vaginal discharge and
itchiness
Extremities: (-) swelling bilateral extremities , warmth/erythema, joint pain, muscle pain, cramps
Neurologic/Psychiatric: (-) mental status changes, agitation, disorientation, mood change, weakness

III. Physical Examination

A. General Survey: In general, the patient looks thin, small-framed woman, dressed and groomed
appropriated for her age. She is alert, awake, and responsive to the examiner. She is sitting on her
wheelchair while holding her jaw, slightly in pain but not in respiratory distress.
B. Vital Signs and Anthropometrics
Result
Weight = 50 kg
BMI = 21.6 kg/m2 (normal)
Height = 152 cm
BP = 130/90 mmHg Normotensive
PR = 85 bpm, regular rhythm Normal
RR = 16 breath/min Normal
Temperature = 36.9 Celsius (axillary) Afebrile

C. Skin and Appendages: The patients skin is fair, warm to touch and she has good skin turgor. No
raches, no edema, erythema, cyanosis, pallor, masses or lesions noted. The nail beds were not pale and
no clubbing or koilonychias were observed.
D. HEENT:
The patient has medium length, black hair with evenly distributed volume, pattern and
texture. Her head is symmetrical and normocephalic without lesions, masses, scars and tenderness. The
scalp has no lesions, non-edematous, no parasites nor scales.
Upon inspection, her eyes are symmetrical and not protruding. There were no ptosis or
strabismus noted. The eyebrows are also symmetrical and with equal hair distribution, eyelids were
non-edematous. Lacrimal glands were not swollen or tender. She has pink palpebral conjunctiva with
no inflammation, masses nor ulcerations noted. She has anicteric sclera with no corneal ulcers or
opacities. Her pupils are equally reactive to light, accommodation with consensual reflex. No visible
lesions, masses, ulcerations or serous drainage in the ears.
Her auricles are symmetrical. Tympanic membrane is intact on both ears without retained
cerumen. There was no tragal tenderness noted on both ears.
Her nose is symmetrical and nasal septum is in midline. External nares are equal in size
and shape. Vestibule and nasal cavity has no masses, no serous/purulent/blood-tinged drainage. Both
nostrils are patent without watery/mucoid discharge. No nasal flaring was noted.
The lips are symmetrical, no masses or ulcerations. Gums and buccal areas are pinkish
free of lesions, masses or ulcerations. The tongue is pinkish and mobile, free of masses or ulcerations.
The palate is smooth and free of lesions. The floor of mouth is free of masses or ulcers. Upon

Remelou G. Alfelor ENT Case Report Page 2 of 9

 inspection of mandibular area, there were no swelling but a deformity is noted at the Tempomandibular
joint area. No active movement of the jaw noted.
Neck has no limitation of motion and any nuchal spasm or rigidity. There was no
lymphadenopathy, no enlargement of parotid and submandibular glands and cervical lymph nodes
noted. Thyroid gland moves with swallowing and trachea is in midline position.
E. Chest and Lungs: Upon inspection, chest is symmetrical; no chest retractions and use of accessory
muscles; no masses, lesions, discolorations or deformities; symmetrical chest expansion. On palpation,
there was no cervical lymphadenopathy. Resonant on all lung fields, no dullness and chest lag noted.
Upon auscultation, vesicular on all lung fields and clear breath sounds. No wheezes, crackles, rales and
rhonchi noted.
F. Cardiovascular System: On inspection, no precordial bulging noted. PMI is at 5th ICS LMCL. Upon
palpation, no thrills and no heaves noted. Apex beat at 5th ICS LMCL. Patient had normal rate and
rhythm with no murmurs. At apex, S2>S1 while at the base S1>S2.
G. Breast: Breasts are symmetrical and non-tender.
H. Abdomen: Upon inspection, abdomen is flabby with inverted umbilicus. No engorged or dilated veins,
visible pulsations noted. On auscultation, normoactive bowel sound, no boborygmi noted. There was
no tenderness on light and deep palpation in all quadrants.
I. Extremities: (-) for clubbing, cyanosis, venous engorgement, hemorrhages, contusion; (+) strong
central and peripheral pulses; (+) rapid capillary refill, (-) bipedal edema

IV. Diagnosis: Tempomandibular Joint Dislocation

V. Plan and Management

Soft diet and increase oral fluid intake
For Bartons Bandaging and maintain for 5 days
Avoid excessive opening of mouth
Advise dental consult
Take home medications:
1) Paracetamol 500mg/tab, one tablet q6 prn for pain

VI. Discussion

The temporomandibular joint (TMJ) is formed by

the articulation of the mandible and the temporal bone of the
cranium. It allows opening, closing, and a side to side movement of
the mouth. The TMJ is found anteriorly to the tragus of the ear, on
the lateral aspects of the face.

Bony Surfaces
The temporomandibular joint consists of articulations between three surfaces; the mandibular
fossa and articular tubercle (from the squamous part of the temporal bone), and the head of mandible. This joint has
a unique mechanism; the articular surfaces of the bones never come into contact with each other, they are separated

Remelou G. Alfelor ENT Case Report Page 3 of 9

by an articular disk. The presence of such a disk splits the joint into two synovial joint cavities, each lined by a
synovial membrane. The articular surfaces of the bones are covered by fibrocartilage, not hyaline cartilage.

Structure
There are six main components of the TMJ:
Mandibular condyles
Articular surface of the temporal bone
Capsule
Articular disc
Ligaments
Lateral pterygoid
Capsule and articular disc

Articular disk of the temporomandibular joint

The capsule is a dense fibrous membrane that surrounds the joint and
incorporates the articular eminence. It attaches to the articular eminence, the articular disc and
the neck of the mandibular condyle. The unique feature of the TMJs is the articular disc. The disc is composed of
dense fibrous connective tissue that is positioned between the two bones that form the joint. The TMJs are one of the
few synovial joints in the human body with an articular disc, another being the sternoclavicular joint. The disc
divides each joint into two. These two compartments are synovial cavities, which consists of an upper and a lower
synovial cavity. The synovial membrane lining the joint capsule produces the synovial fluid that fills these cavities.
The central area of the disc is avascular and lacks innervation, and, in contrast, the peripheral region has both blood
vessels and nerves. Few cells are present, but fibroblasts and white blood cells are among these. The central area is
also thinner but of denser consistency than the peripheral region, which is thicker but has a more cushioned
consistency. The synovial fluid in the synovial cavities provides the nutrition for the avascular central area of the
disc. With age, the entire disc thins and may undergo addition of cartilage in the central part, changes that may lead
to impaired movement of the joint. The lower joint compartment formed by the mandible and the articular disc is
involved in rotational movementthis is the initial movement of the jaw when the mouth opens. The upper joint
compartment formed by the articular disc and the temporal bone is involved in translational movementthis is the
secondary gliding motion of the jaw as it is opened widely. The part of the mandible which mates to the under-
surface of the disc is the condyle and the part of the temporal bone which mates to the upper surface of the disk is
the articular fossa or glenoid fossa or mandibular fossa. The articular disc is a fibrous extension of the capsule in
between the two bones of the joint. The disc functions as articular surfaces against both the temporal bone and the
condyles and divides the joint into two sections, as already described. It is biconcave in structure and attaches to the
condyle medially and laterally. The anterior portion of the disc splits in the vertical dimension, coincident with the
insertion of the superior head of the lateral pterygoid. The posterior portion also splits in the vertical dimension, and
the area between the split continues posteriorly and is referred to as the retrodiscal tissue. Unlike the disc itself, this
piece of connective tissue is vascular and innervated, and in some cases of anterior disc displacement, the pain felt

Remelou G. Alfelor ENT Case Report Page 4 of 9

during movement of the mandible is due to the condyle compressing this area against the articular surface of the
temporal bone.

Ligaments
There are three ligaments associated with the
TMJ: one major and two minor ligaments. These ligaments are
important in that they define the border movements, or in other
words, the farthest extents of movements, of the mandible.
Movements of the mandible made past the extents functionally
allowed by the muscular attachments will result in painful
stimuli, and thus, movements past these more limited borders
are rarely achieved in normal function. The major ligament, the
temporomandibular ligament, is actually the thickened lateral
portion of the capsule, and it has two parts: an outer oblique portion (OOP) and an inner horizontal portion (IHP).
The base of this triangular ligament is attached to the zygomatic process of the temporal bone and the articular
tubercle; its apex is fixed to the lateral side of the neck of the mandible. This ligament prevents the excessive
retraction or moving backward of the mandible, a situation that might lead to problems with the TMJ. The two
minor ligaments, the stylomandibular and sphenomandibular ligaments are accessory and are not directly attached to
any part of the joint.
The stylomandibular ligament separates the infratemporal region (anterior) from the parotid region
(posterior), and runs from the styloid process to the angle of the mandible; it separates the parotid and
submandibular salivary glands. It also becomes taut when the mandible is protruded. The sphenomandibular
ligament runs from the spine of the sphenoid bone to the lingula of mandible. The inferior alveolar nerve descends
between the sphenomandibular ligament and the ramus of the mandible to gain access to the mandibular foramen.
The sphenomandibular ligament, because of its attachment to the lingula, overlaps the opening of the foramen. It is a
vestige of the embryonic lower jaw, Meckel cartilage. The ligament becomes accentuated and taut when the
mandible is protruded. Other ligaments, called "oto-mandibular ligaments", connect middle ear (malleus) with
temporomandibular joint:
Discomallear (Or Disco-Malleolar) Ligament
Malleomandibular (Or Malleolar-Mandibular) Ligament

Innervation
Sensory innervation of the temporomandibular joint is derived from the auriculotemporal and
masseteric branches of V3 or mandibular branch of the trigeminal nerve. These are only sensory innervation. Recall
that motor is to the muscles. The specific mechanics of proprioception in the temporomandibular joint involve four
receptors. Ruffini endings function as static mechanoreceptors which position the mandible. Pacinian corpuscles are
dynamic mechanoreceptors which accelerate movement during reflexes. Golgi tendon organs function as static

Remelou G. Alfelor ENT Case Report Page 5 of 9

mechanoreceptors for protection of ligaments around the temporomandibular joint. Free nerve endings are the pain
receptors for protection of the temporomandibular joint itself.

Blood supply
Its arterial blood supply is provided by branches of the external carotid artery, predominately the
superficial temporal branch. Other branches of the external carotid artery namely: the deep auricular artery, anterior
tympanic artery, ascending pharyngeal artery, and maxillary artery- may also contribute to the arterial blood supply
of the joint.

Dislocation of the Temporomandibular Joint

Dislocation of the temporomandibular joint is a painful condition that occurs when the mandibular
condyle becomes fixed in the antero-superior aspect of the articular eminence. TMJ dislocation is due to either
trauma or, more commonly, excessive opening of the mandible. Other mechanisms include passionate kissing,
eating, yelling, singing, endoscopy, and intubation. Spasm of the masseter, temporalis, and internal pterygoid
muscles results in trismus, preventing return of the condyle to the temporal fossa. More commonly, dislocation
occurs bilaterally, resulting in a mandible that is fixed in a symmetrically open position so that only the most
posterior teeth may be contacting. Infrequently, unilateral dislocation occurs with resultant deviation of the jaw to
the unaffected side. With dislocation, the mandibular condyles may be palpated anterior to the articular eminence.
The diagnosis should be obvious through history and physical examination, and radiographs should not be necessary
for confirmation. However, in the setting of trauma, radiographs should be obtained to exclude concomitant fracture.
Patients who have experienced previous dislocation are more prone to recurrence. Additionally, patients with
weakness of the joint capsule, anatomic aberration of the joint, or injury to the associated ligaments are at greater
risk of dislocation.

Risk factors for mandible dislocation include the following:

Shallow mandibular fossa
Previous TMJ trauma or dislocation that disrupted the joint capsule
Dystonic reactions
Seizures
Hypermobility syndromes, such as Marfan syndrome or Ehlers-Danlos syndrome, which predisposes the TMJ
to dislocation due to increased laxity of surrounding connective tissue

Management
1. Close Reduction
Indications for reduction of a TMJ dislocation include the following:
Acute dislocation of the TMJ, either unilaterally or bilaterally; acute episodes are most easily managed with
manual reduction
Chronic recurrent dislocations and chronic persistent dislocations; manual reduction may be attempted, but
chronic dislocations are likely to necessitate surgical treatment

Remelou G. Alfelor ENT Case Report Page 6 of 9

 Contraindications for reduction of a TMJ dislocation include the following:
Mandibular fracture
Extensive facial trauma
Multiple prior unsuccessful attempts
Anesthesia
The typically intense spasm that occurs with temporomandibular joint (TMJ) dislocation often
necessitates the use of substantial analgesia and procedural sedation prior to attempts at reduction.
Local anesthesia may be used as an adjunctive measure with 1-2 mL of 1% intra-articular lidocaine but
is unlikely to provide adequate pain relief when used alone.

Equipment employed in reduction of a TMJ dislocation includes the following:

Gauze bandages
Tape
Gloves
Lidocaine, 1%
Syringe, 3-5 mL
Needle, 27 gauge
Monitoring and airway equipment (for procedural sedation)

Positioning
The patient should be seated in an upright position and facing forward, with his or her back and
head braced posteriorly. Either a chair with a firm backrest or a low stool placed against a wall may be used.
Alternatively, the patient may be positioned with his or her back turned to the practitioner performing the
procedure and with the posterior portion of his or her head braced firmly against the practitioners body.

Technique
Most commonly, reduction of a temporomandibular joint (TMJ) dislocation is performed via the
intraoral route. To prevent trauma, the practitioners fingers should be gloved with thick gauze taped securely on
both thumbs. Place your thumbs upon the lower molars or on the ridge of the mandible intraorally, posterior to
the molars, with your fingers wrapped externally around the mandibles. With the patient positioned so that the
mandible is below the level of your elbows, apply firm, slow, and steady pressure in a downward and posterior
direction. If bilateral reduction is not possible, reduction may be done one side at a time.

Classic Reduction Technique

The physician places gloved thumbs on the patient's
inferior molars bilaterally, as far back as possible. The
fingers of the physician are curved beneath the angle and
body of the mandible.

Remelou G. Alfelor ENT Case Report Page 7 of 9

 Recumbent Approach
The patient is placed recumbent, and the physician stands behind
the head of the patient. The physician places his or her thumbs on
the inferior molars and applies downward and backward pressure
until the jaw pops back into place.

After reduction has been successfully completed, plain radiographs may be obtained to exclude
iatrogenic fracture of the mandibular condyles. However, this may not be necessary if reduction resolves the
pain. The patient may wear a soft neck brace, and warm compresses may be placed on the TMJs for comfort.
The patient should be instructed to avoid extreme opening of the mouth, such as may occur during yawning,
laughing, or dental procedures. Pain relief may be achieved with nonsteroidal anti-inflammatory drugs
(NSAIDs), benzodiazepines, or mild opiates. Patients with chronic dislocations may benefit from the use of a
Barton bandage, an elastic bandage that is wrapped around the bottom of the mandible and over the top of the
head to prevent excessive jaw opening. An oral-maxillofacial surgeon or otolaryngologist should be consulted
for dislocations that are irreducible, associated with fracture, or immediately recurrent. Outpatient observation
should be arranged to evaluate for possible chronic TMJ pain and ligamentous damage or instability.
Without adequate sedation, reduction is unlikely to be successful. Agents of choice include
midazolam, propofol, and other medications with muscle-relaxant properties. To prevent injury to the
practitioner, the thumbs should be adequately wrapped. Adequate leverage may be maintained by keeping the
mandible below the level of the practitioner's elbows. Reduction attempts that require excessive force should be
aborted because iatrogenic fracture of the mandibular condyles may occur.

Potential complications of reduction of a TMJ dislocation include the following:

Injury to the practitioner (this may occur during reduction as the jaw closes on the thumbs)
Damage to dental hardware or oral prostheses
Fracture of the mandibular condyle
Complications of procedural sedation (e.g., hypotension, respiratory compromise or apnea, aspiration,
dysrhythmia, or allergy)
Injury to the facial nerve or external carotid artery (rare)
Delay in reduction (this may result in fibro-osseous ankylosis, which may produce limited TMJ mobility)

2. Bartons Bandaging
A Barton bandage (Barton bandage.) may be needed for 2 or 3 days. Most importantly, the patient
must avoid opening the mouth wide for at least 6 wk. When anticipating a yawn, the patient should place a fist
under the chin to prevent wide opening. Food must be cut into small pieces. If the patient suffers from chronic
dislocations and more conservative treatment modalities have been exhausted, an oral and maxillofacial surgeon
may be consulted. As last-resort treatments, the ligaments around the TMJ can be surgically tightened
(shortened) in an attempt to stabilize the joint or the articular eminence can be reduced (Eminectomy).

Remelou G. Alfelor
This figure 8 bandage is wrapped Page 8 of 9
ENT Case Report
around the head and jaw to provide
support below and anterior to the lower
jaw.
Source:
1. http://teachmeanatomy.info/head/joints/temporomandibular/
2. Grays Anatomy 3rd Edition
3. Medscape. Tempomandibular Joint Dislocation

Remelou G. Alfelor ENT Case Report Page 9 of 9