Mandibular dislocation occurs when the capsule and TMJ ligaments are sufficiently stretched to allow the condyle to move to a point anterior to the articular eminence during opening Dislocation can be unilateral or bilateral and often accompanies a history of extreme mouth opening (e.g., deep yawn) or following a prolonged dental appointment The muscles of mastication enter a tonic contraction state, and the patient is unable to move the condyle back into the glenoid fossa and close his or her mouth Clinical assessment Local bleeding, gingival/mucosal tears, or sublingual ecchymoses may be clues to underlying bony injury Posterior tooth fractures, or evidence of malocclusion may also alert the emergency physician to the possibility of a jaw fracture In some cases, depressed or mobile jaw fragments may be identified A unilateral condylar fracture should be suspected if the mandible deviates toward the affected side on opening A panoramic radiograph or CT scan should be obtained when mandibular fractures are suspected A panoramic radiograph may not be possible in a young or severely injured child, and may not be available in the emergency department setting Management The appropriate service (dentistry, oral and maxillofacial surgery, or plastic surgery) should be consulted depending on availability In cases where the fracture is none/minimally displaced, there is no evidence of airway obstruction, dehydration, or unremitting pain, a patient may be discharged on a soft diet with close outpatient follow-up with specialty care For unstable or concerning fractures, specialty services are required to stabilize the fracture, using either open or closed reduction For a dislocation, gentle downward and backward pressure should be applied by the physician’s thumb (wrapped in gauze) on the occlusal surfaces of the posterior teeth ( Fig 105.6 ) The downward pressure moves the dislocated condyle below the articular eminence; subsequent backward pressure on the molars shifts the condyle posteriorly into the mandibular fossa If this approach fails, intravenous diazepam (0.2 mg/kg, maximum 10 mg) can be administered as an adjunctive muscle relaxant before reattempting to relocate the condyles Figure 105.7 shows the anatomic landmarks and repositioning of the TMJ