Jaw dislocation or fracture

Jaw dislocation is a displacement of the temporomandibular joint. 

Jaw fracture is a break in one or both of the two maxillae (upper jawbones) or the mandible (lower jawbone). Treatment can usually restore jaw alignment and function.

Causes
Simple fractures or dislocations are usually caused by a manual blow along the jawline; more serious compound fractures, from car accidents and penetration injuries.

Signs and symptoms
Malocclusion is the most obvious sign of dislocation or fracture. Other signs and symptoms include mandibular pain, swelling, ecchymosis, loss of function, and asymmetry. In addition, mandibular fractures that damage the alveolar nerve produce paresthesia or anesthesia of the chin and lower lip. Maxillary fractures produce infraorbital paresthesia and commonly accompany fractures of the nasal and orbital complex.

Diagnosis
Abnormal maxillary or mandibular mobility during physical examination and a history of trauma suggest fracture or dislocation. X-rays can confirm diagnosis, but a computed tomography scan is usually necessary for accurate diagnosis and repair.

Treatment
As in all traumatic injuries, check first for a patent airway, adequate ventilation, and pulses; then control hemorrhage and check for other injuries. As necessary, maintain a patent airway with an oropharyngeal airway, nasotracheal intubation, or a tracheotomy. Administer an analgesic for pain as needed.
After the patient’s condition stabilizes, surgical reduction and fixation by wiring restores mandibular and maxillary alignment. Maxillary fractures may also require reconstruction and repair of soft-tissue injuries.
Teeth and bones are never removed during surgery unless unavoidable. If the patient has lost teeth from trauma, the surgeon will decide whether they can be reimplanted. If they can, he’ll reimplant them within 6 hours, while they’re still viable. Viability is increased if the tooth is placed in milk. Dislocations are usually reduced manually under anesthesia.

Special considerations

After reconstructive surgery:

• Position the patient on his side, with his head slightly elevated. A nasogastric tube is usually in place, with low suction to remove gastric contents and prevent nausea, vomiting, and aspiration of vomitus.
• As necessary, suction the nasopharynx through the nose, or pull the cheek away from the teeth and insert a small suction catheter through any natural gap between teeth.
• If the patient isn’t intubated, provide nourishment through a straw. If he has a natural gap between his teeth, insert the straw there—if not, one or two teeth may have to be extracted.
• Start the diet with clear liquids; after the patient can tolerate fluids, offer milk shakes, broth, juices, pureed foods, and nutritional supplements.
• If the patient is unable to tolerate oral fluids, I.V. therapy can maintain hydration postoperatively.
• Administer an antiemetic, as needed, to minimize nausea and prevent aspiration of vomitus (a real danger in a patient whose jaw is wired). Keep a pair of wire cutters at the bedside to snip the wires in case the patient vomits. A dental water-pulsator may be used for mouth care while the wires are intact.
• Because the patient will have difficulty talking while his jaw is wired, provide a Magic Slate or pencil and paper, and suggest appropriate diversions.