Interesting Case - Dislocated Temporomandibular Joint

The case that I'd like to review today is a trauma case that I came across recently. This person came into the emergency room and from a personal altercation, sustained a nasal bone fracture and had this radiographic finding of his left temporomandibular joint that was very strange. The report from the emergency room physician was that the left temporomandibular joint was dislocated. I kind of scratched my head on this one. I wasn't quite sure. I asked a few questions and it didn't quite add up. I wasn't sure what to make of this. If you go to www.dentistbraincandy.com and go to the show notes for this, you will see the CT scan that shows cross section of the joints. You'll see a coronal and a sagittal view of the joint. You'll see that the condyle appears to be on the crest of the articular eminence with a very large gap and increased joint space.

Looking at the scan only or not seeing the patient, it was pretty obvious, first of all, that there's a significant nasal bone and nasal-septal fracture. This jaw joint was a bit of an interesting puzzle. My differential diagnosis was, maybe there's a fracture there. When you go through the scans, there's no evidence of any condylar, subcondylar, or jaw fracture. I thought, maybe, it could be a hemarthrosis. There could be bleeding within that joint space and with enough pressure, you could imagine the glenoid fossa filling up with blood and the condylar head being displaced inferiorly and eventually, even somewhat anteriorly as it fall down that articular slope. Again, there seem a bit of a stretch but maybe it's a possibility.

Usually, with dislocations of the jaws, you'll see the condyle move anteriorly and actually go beyond the articular eminence and be caught outside of the glenoid fossa and the patient is therefore, locked open and unable to spontaneously reduce their dislocation. When the patient came in, I started with my physical exam and I noted that the patient was able to easily close down into their normal occlusion. They have no gap, they had no pain. They had no pain in their joint on the left side. There was significant swelling and ecchymosis in and around the nasal bridge and the eye. This was from the nasal bones and the nasal-septal fracture. In further conversation and acquiring a history, I notice that this patient postured his jaw. With further discussion with his escort, it was discovered that this fellow just has a habit of posturing his jaw and during his scan, kept his jaw in this unique posture or position which led to this really abnormal scan.

To make a long story short, this patient did not have a hemarthrosis. They did not have a dislocation. They simply had a nasal bone fracture and a nasal-septal fracture. The patient was taken to the operating room and had a close reduction of the nasal septum done and a close reduction of the nasal bones. You can see the pre-operative films and the post-operative films if you go to www.dentistbraincandy.com. Thank you for tuning in to this week's episode of Dentist Brain Candy. Please feel free to e-mail me at [email protected] or find us on Facebook at Bryan McLelland, DDS. There are some upcoming events that I'd like to inform you about. In February of 2016, we have an OSHA update, a CPR renewal class for those that need it. In the afternoon, I am going to present with an excellent laboratory technician, Nick Grishan, restoring hybrids and adding this as a restorative option and the treatment option in your dental practice. It's an open invitation for those who would like to come. Please e-mail me at [email protected] for an official invite.

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