Thangarajah et al. Journal of Medical Case Reports 2010, 4:263 http://www.jmedicalcasereports.com/content/4/1/263 Postoperative radiographs indicated that his mandibular condyles had been restored to their correct position within his glenoid fossae. He was discharged from hos- pital the following day with no further follow up as per institutional policy. Advice regarding the possibility of further dislocation and instability were given to him prior to discharge. Discussion A dislocation of the TMJ is defined as the excessive forward movement of the mandibular condyle beyond the articular eminence with complete separation of the articular surfaces and fixation in that position [3]. Several morphological variants exist based on the posi- tion of the condyle in relation to the articular emi- nence; these are termed anterior, posterior, superior, and lateral [1]. However, the anterior subtype is most common [4]. Several precipitants have been identified for dislocation and can be classified as either traumatic or non-traumatic. Non-traumatic precipitants are more common and include laughing, taking a large bite of something, convulsions, and yawning [1,5]. In addition to these, predisposing factors to dislocation have also been recognized. These include poor joint capsule integrity, weak articular eminence morphology, and muscle hypotonicity [5]. The diagnosis of TMJ dislocation is often clinically based in the first instance. Typical signs and symptoms seen in patients with TMJ dislocation include mandibu- lar pain, an inability to occlude the teeth, pre-auricular depressions, and a prominent mandibular head ante- riorly (anterior variant) [6]. The recognition of any of the aforementioned features should prompt an immedi- ate radiograph to confirm the diagnosis. The treatment of a patient with TMJ dislocation entails reduction of the deformity, which can be accom- plished in either a ward or the emergency department setting. It is imperative that this procedure is performed with little delay because complications such as fracture become increasingly apparent if time is wasted. Further- more, spasms of both the masseter and pterygoid mus- cles worsens as time elapses, therefore making the reduction procedure more difficult [2]. To achieve reduction of an anterior dislocation, down- ward pressure should be applied on the patient’s lower molar teeth while elevating the angle of the mandible with the fingers and pushing the entire mandible poster- iorly. To prevent the patient from biting down on the examiners’ hands, swabs can be applied over the patient’s lower molars. The two major inhibiting factors for reduction are elevator muscular spasm and pain both in and around the joint capsule. These both increase if dislocation is prolonged and thus various methods to counter them have been proposed [7]. Page 2 of 3 One commonly employed technique to counter the inhibiting factors for reduction is to ask the patient to open his or her mouth widely or against resistance. This reduces the tone of the patient’s elevator muscles, thereby permitting reduction. Sedatives are also routinely used but when given intravenously require cardio- respiratory monitoring of the patient. Muscle relaxants have also been utilized; however, if given orally they may take up to one hour to take effect and there can be diffi- culty encountered in the patient swallowing the tablet. Some more novel techniques to relax the facial muscles include the infiltration of local anesthesia around the joint capsule and use of specific nerve blocks. Although use of local anesthetic is recognized to reduce pain, it does not have the same effect on muscle spasm. The use of nerve blocks has been extensively described in the lit- erature with varying outcomes. Specific nerves that have been targeted include the mandibular, deep temporal and masseteric nerves. For example, mandibular nerve blocks have been traditionally used during a number of dental procedures and have more recently been used to provide analgesia for patients undergoing surgery in the vicinity of the mandibular region. In conjunction with sedation, it has been found to be a safe alternative to general anesthesia for patients undergoing closed reduction of TMJ dislocation [1,2,4,7]. Despite the success of such conservative measures, there remain a proportion of patients that require closed reduction under general anesthesia. However, when this fails other more invasive procedures such as temporal myotomy or sagittal split mandibular osteotomy may be used [7]. The post-reduction care typically involves diet- ary control, use of anti-inflammatory medications, immobilisation of the mandible and mouth-opening training [1]. After a short period of immobilisation, it is imperative that limited movement of the patient’s jaw is commenced. For those patients who subsequently undergo recurrent dislocations, operative intervention is usually required [1]. In the current case several attempts were made to reduce the TMJ. In hindsight, however, it is clear that insufficient quantities of both analgesia and sedation were used given the patients’ large build. This made reduction extremely difficult and deterred him from accepting alternative methods of anesthesia, such as a nerve block or local anesthetic infiltration. It is for this reason that general anesthesia of this patient was used. Conclusions TMJ dislocation is easily managed and completely treata- ble. To achieve a satisfactory outcome both adequate analgesia and muscle relaxation should be ensured. The patients’ weight should be considered because insufficient doses of analgesia may render the reduction unsuccessful.