›Acetaminophen (paracetamol)
›Acetaminophen 1000 mg orally or IV every 6 hours
›Maximum 4000 mg/day; maximum 3000 mg/day if elderly, low body weight, chronic alcohol use, or hepatic impairment
›Diazepam
›Diazepam 5 to 10 mg IV given slowly for masseter and temporalis spasm
›May repeat 5 mg once after 10 minutes
›Reduce to 2 to 5 mg in the elderly or frail and watch for respiratory depression
›Expect additive respiratory depression if procedural sedation is added later; titrate the subsequent agent down
›Midazolam
›Midazolam 1 to 2 mg IV as an alternative anxiolytic, titrated 1 mg every 2 to 3 minutes
›Start at 0.5 mg increments and a lower total dose in the elderly
›Nitrous oxide
›Nitrous oxide 50% with oxygen 50% by demand valve for anxiolysis and analgesia in a cooperative patient
›Often sufficient for a recent habitual dislocation; avoid if there is a pneumothorax, bowel obstruction, or recent middle-ear surgery
›Intra-articular and regional local anesthesia
›Lidocaine 1% or 2%, 1 to 2 mL injected into the superior joint space just anterior to the tragus and below the zygomatic arch, aimed at the empty fossa
›Can achieve reduction without systemic sedation; ultrasound guidance improves accuracy
›Maximum lidocaine 4.5 mg/kg plain, not to exceed 300 mg; 7 mg/kg with epinephrine, not to exceed 500 mg
›Auriculotemporal nerve block or a masseteric motor block with 2 to 3 mL of lidocaine 1% to 2% to relax the elevators
›Bupivacaine 0.5% (maximum 2 mg/kg, not to exceed 175 mg without epinephrine) if a longer-acting block is wanted for an anticipated difficult reduction
›Dexamethasone
›Dexamethasone 8 mg IV or orally as a single optional dose for periarticular inflammation after a prolonged or traumatic dislocation
›Not routinely required and not a substitute for reduction
›Use procedural sedation when analgesia and local anesthesia fail or the patient cannot tolerate manipulation
›Confirm fasting status and perform an airway assessment
›Weigh aspiration risk (locked-open mouth, pooled saliva) against the benefit of muscle relaxation, and prefer the shortest effective plan
›Maintain SpO2 at 94% or above with supplemental oxygen
›Accept a baseline of 88 to 92% in known chronic obstructive pulmonary disease or chronic hypoxemia and titrate to the patient's usual saturation
›Propofol
›Propofol 0.5 to 1 mg/kg IV bolus, then 0.5 mg/kg every 1 to 3 minutes titrated to masseter relaxation
›Reduce the initial dose by 20 to 50% in the elderly, frail, or hypovolemic
›Omit or halve the bolus and start at 0.25 to 0.5 mg/kg if systolic blood pressure is below 100 mmHg; have a fluid bolus and a vasopressor ready
›Once masseter tone softens, stop dosing and let the level lighten before the next increment to avoid apnea and overshoot
›Ketamine
›Ketamine 0.5 to 1 mg/kg IV over 1 to 2 minutes, or 4 mg/kg IM, for dissociation with preserved airway tone
›Useful when hypotension or apnea are the main concerns
›Increases salivation; have glycopyrrolate 0.2 mg IV available and keep suction ready because the patient is already drooling
›Expect a transient rise in heart rate and blood pressure; avoid as sole agent with uncontrolled hypertension or if the jaw pain could be ischemic
›Ketofol
›Propofol 0.5 mg/kg with ketamine 0.5 mg/kg IV as a combined push to limit the dose and hemodynamic effect of either agent
›Titrate small additional aliquots of propofol 0.25 mg/kg as needed
›Opioid-benzodiazepine alternative
›Fentanyl 1 mcg/kg IV (usually 50 to 100 mcg), titrated 25 to 50 mcg every 3 to 5 minutes
›Combined with midazolam 1 mg increments when propofol is unavailable
›Reduce both agents and lengthen the interval in the elderly; monitor for delayed respiratory depression
›Monitoring cadence and reversal
›Pulse oximetry and waveform capnography breath to breath, cardiac rhythm continuously, blood pressure every 3 minutes during titration
›Blood pressure every 5 minutes in recovery until the patient returns to baseline mentation and protective reflexes
›Naloxone 0.04 to 0.4 mg IV titrated for opioid-induced apnea
›Flumazenil 0.2 mg IV only if benzodiazepine reversal is truly needed and the patient is not benzodiazepine-dependent or seizure-prone
Manual intraoral reduction
›The classic maneuver distracts the condyle downward below the eminence, then guides it posteriorly and superiorly into the fossa
›Wrap both thumbs in gauze or use external bite blocks; place them on the occlusal surfaces of the mandibular molars, or on the external oblique ridges and retromolar pads if edentulous
›Curl the fingers under the chin and along the inferior mandibular border
›Apply steady, increasing downward pressure with the thumbs while the fingers lift the chin, disengaging the condyle from in front of the articular eminence
›Completing the reduction
›Once the condyle drops below the eminence, guide the mandible posteriorly and then upward
›An audible or palpable clunk with immediate restoration of normal occlusion signals success
›Reduce one side at a time in bilateral dislocation if simultaneous reduction fails, starting with the more symptomatic or longer-dislocated side
›Keep the thumbs lateral and slide them off the occlusal surface as the jaw snaps closed to avoid a bite injury
›Post-maneuver check
›Recheck occlusion, full mouth closure, pain-free gentle opening, and condylar translation in the fossa
›If several firm attempts over 5 to 10 minutes fail despite adequate relaxation, switch technique or escalate rather than applying uncontrolled force
Alternative and rescue reduction techniques
›Alternatives reduce operator bite risk, need less force, or succeed when the classic method fails
›Syringe technique: place a 5 or 10 mL syringe between the posterior upper and lower molars on the affected side and ask the patient to gently bite and roll it back and forth
›The rolling motion eases the condyle back over the eminence; effective for a cooperative patient with a recent atraumatic dislocation and needs no sedation
›Extraoral (Gorchynski) technique: palpate the coronoid processes through the cheeks, place the thumbs over the coronoids and the index fingers over the mastoid tips, and apply anterior-to-posterior and inferior pressure on the coronoids while stabilising at the mastoid
›Additional maneuvers
›Wrist-pivot method: thumbs on the chin, fingers on the occlusal surface of the lower molars; push up on the chin with the thumbs and down on the molars with the fingers by pivoting the wrists
›Ipsilateral (posterior) approach: downward pressure over the ipsilateral mandibular molars with one hand while the other supports the contralateral mandibular body
›Posterior pharyngeal (gag) stimulation can trigger reflex jaw relaxation as an adjunct in a lightly sedated or unsedated patient
›Recumbent positioning with the operator standing behind the head is an option if the seated approach fails
When reduction fails — escalation to OMFS
›Persistent failure means inadequate muscle relaxation or a mechanical barrier; identify which before escalating
›Reassess muscle relaxation: add or repeat a benzodiazepine, add an intra-articular or auriculotemporal block, or deepen procedural sedation one level
›Reassess analgesia and patient guarding; an anxious, under-medicated patient cannot relax the elevators
›Reconsider an unrecognised condylar or fossa fracture, a superior, posterior, or lateral pattern, or a chronic dislocation with periarticular fibrosis
›Obtain CT if it has not already been done
›Technique and operator
›Confirm operator position and patient seating; try a different technique and a different, often more experienced, operator
›Limit closed attempts: after roughly three well-executed attempts with adequate sedation and local anesthesia, stop and consult oral and maxillofacial surgery
›Definitive options
›Reduction under general anesthesia with neuromuscular blockade
›Open reduction for long-standing or irreducible dislocation
›Do not leave a patient in an unreduced dislocation overnight without a definitive plan; delay converts a bedside procedure into an operative one and risks chronicity
Post-reduction care and immobilization
›The immediate goal is to prevent re-dislocation while the capsule and muscles recover
›Apply a Barton (barrel) bandage or an elastic wrap around the mandible and cranium to limit opening for 24 hours or more
›Ensure it can be released quickly if the patient vomits
›Instruct the patient to support the chin with a hand and keep the tongue behind the teeth when yawning, and to avoid wide opening for 2 to 3 weeks
›Symptomatic care
›Soft or liquid diet for 1 to 2 weeks; food cut into small pieces; no gum and no hard or chewy foods
›Ibuprofen 400 to 600 mg every 6 to 8 hours (maximum 2400 mg/day) or acetaminophen 1000 mg every 6 hours (maximum 4000 mg/day) for 3 to 5 days
›Intermittent warm compresses to the joint for 15 to 20 minutes several times a day
›Confirm and document restored occlusion, symmetrical pain-free opening to about 40 mm, and condylar translation before discharge
›Follow-up and imaging
›Post-reduction imaging (panoramic film or CT) only if the reduction was difficult, a fracture is suspected, or symptoms persist
›Arrange oral and maxillofacial or maxillofacial follow-up within 1 to 2 weeks; sooner for a recurrent or traumatic case
›Warn explicitly about recurrence and give written return precautions
Medication cautions, antiemetics, and iatrogenic harm review
›Several routine emergency interventions specifically worsen this condition; review each before ordering
›The dominant iatrogenic risk is aspiration and apnea during procedural sedation in a patient who cannot close the mouth or clear secretions
›Suction, capnography, and a fasting assessment are mandatory; consider a local-anesthetic-only reduction instead
›Aggressive laryngoscopy and maximal mouth opening can themselves dislocate the temporomandibular joint
›Support the mandible during intubation and recognise a post-extubation open lock; if intubation is otherwise required, reduce the dislocation once the airway is secured
›Metoclopramide
›Metoclopramide 10 mg IV can cause an acute dystonic reaction that produces or reproduces the dislocation
›Avoid in this setting; if inadvertently given and dystonia follows, treat with an anticholinergic
›Prochlorperazine
›Prochlorperazine 10 mg IV or 25 mg rectally carries the same dystonia risk
›Avoid; do not use as the antiemetic of convenience here
›Promethazine
›Promethazine 12.5 to 25 mg IV or IM causes dystonia and severe tissue injury on extravasation
›Avoid
›Droperidol
›Droperidol 0.625 to 1.25 mg IV prolongs the QT interval and can cause dystonia
›Avoid; if used for another indication, obtain a baseline electrocardiogram and correct potassium and magnesium first
›Ondansetron
›Ondansetron 4 mg IV or 4 to 8 mg orally every 8 hours is the preferred antiemetic (maximum single IV dose 16 mg)
›Obtain an electrocardiogram first if there are QT risk factors or concurrent QT-prolonging drugs
›Other interventions walked explicitly
›Opioids: use the lowest effective dose; opioid-induced vomiting can re-dislocate a freshly reduced joint and raises aspiration risk; pair with ondansetron, not a dopamine antagonist
›Fluid loading and vasopressors: not part of temporomandibular joint management; use only to support sedation-induced hypotension
›Mechanical circulatory support and intra-aortic balloon pump: not applicable
›Anticoagulation and antiplatelet agents: no direct role; expect more periarticular bruising from injections, check coagulation status before operative reduction, and note that anticoagulation worsens hemorrhage in a superior or traumatic dislocation with intracranial extension
›Fibrinolysis: no role; do not give fibrinolytics for "jaw pain" without a completed cardiac evaluation, and do not dismiss ischemic jaw pain as temporomandibular joint pain
›Analgesia: nonsteroidal anti-inflammatory drugs and acetaminophen are first-line; ketamine and nitrous oxide are useful adjuncts that avoid dopamine antagonism and heavy respiratory depression
›Benzodiazepines for spasm: titrate down when combined with opioids or propofol; reduce doses in the elderly to avoid oversedation and falls
Recurrent, chronic, and dystonia-related dislocation
›Repeated, long-standing, and drug-induced dislocation each need a specific pathway beyond acute reduction
›Recurrent (habitual) dislocation: teach jaw-opening limitation and a home self-reduction technique, refer to oral and maxillofacial surgery, and consider a period of intermaxillary elastic guidance
›Chronic or long-standing dislocation (present beyond several weeks, generally more than a month): closed reduction usually fails because of fibrosis; refer for open reduction, with condylectomy reserved for the most protracted cases
›Botulinum toxin type A
›Botulinum toxin type A injected into each lateral pterygoid, specialist-administered, typically 25 to 50 units per muscle
›Reduces the forward pull of the muscle; effect lasts about 3 to 4 months and often needs repeating
›Watch for transient dysphagia and a change in chewing; avoid in a generalised neuromuscular disorder such as myasthenia gravis
›Autologous blood injection
›Autologous blood injection about 2 to 3 mL into the superior joint space with 1 mL pericapsular, performed by oral and maxillofacial surgery for recurrent dislocation
›Minimally invasive sclerosing option; may be repeated
›Surgical options for refractory recurrent dislocation
›Eminectomy, Dautrey eminence augmentation, and capsular plication or capsulorrhaphy
›Condylotomy or lateral pterygoid myotomy are used less commonly
›Dystonia-related dislocation
›Diphenhydramine 25 to 50 mg IV or IM, then oral diphenhydramine 25 to 50 mg every 6 hours for 48 to 72 hours
›Benztropine 1 to 2 mg IV or IM as an alternative, then 1 to 2 mg orally twice daily for 48 to 72 hours (maximum 6 mg/day); avoid in children under 3 years
›Identify and stop the offending dopamine antagonist; the dislocation will keep recurring until the dystonia is controlled
›For tardive oromandibular dystonia, involve neurology; anticholinergics are less effective and botulinum toxin may be needed