Martha

 Doctor Friess we have a patient that is here to see you.  Immediately one can notice her pursing her lips stretching to gain competence over the front teeth as if she was puckering her mouth after eating a tart fruit. 

"What has happened? "I asked.

"I have been like this ever since I had my tooth removed in Northern Kenya," Martha said.

"How long has that been?" I asked.

"I think almost 2 months, and it is not getting any better. It hurts constantly" Martha replied.

Martha relaxed her lips and showed this uncomfortable position.  She is not smiling, eating, or intentionally opening her mouth.  This is how she is locked.  

Matha's mandible would not rotate up or down.  It was completely fixed in its current location. It was determined that the Temporal Mandibular Joint was dislocated during her unfortunate extraction.  After nearly 2 months in this position scar tissue had likely formed within the glennoid fossa interfering with the desired location of the capsule and coronoid process.  She could not close, open, or shift her jaw laterally even a few millimeters.

Typically for patients the TMJ will reduce on its own within hours but she had been less fortunate.   I offered to Martha that we could attempt to reduce her mandible manually in the dental clinic.  I began to press gently on her teeth and she winced in pain.  The muscles were inflamed and much to tender.  

I gave her bilateral dental blocks of the mandible.  I tried again several times to reduce her locked mandible, but got no movement.  We stopped after many attempts with Martha in tears of frustration as she indicated she could not take the pain of the pushing even one more time.   

 

The next option was take Martha to Theatre for Sedation in hopes that the muscle relaxation induced by the anesthetic would give some mobility to her TMJ and allow her teeth to close.   

Reduction of the mandible involves putting bilateral pressure with the  thumbs on the patients lower molars and pressing with lots of force downward and then backward.  The TMJ is a joint that both rotates and slides.  It has to be reduced over the eminence and so it can slide back into it's natural fossa where it can rotate up and down.  

Well I tried this procedure of pushing at least 20 different times in different directions and with differing forces unsuccessfully.  I couldn't leave Martha like this..that is no way to live unable to properly eat, enunciate words, and in constant pain.  I was unaware what of if a type of surgical coronoidplasty or condylarplasty might be an option? 

I offered a simple prayer of last resort as I had no other option.  Soon thereafter repeated attempts of reduction and direct pressure on her dislocated coronoid and condylar process her teeth came together.  

We quickly wrapped Martha's head in an Ace Bandage securing her teeth in a occluded position.  

Martha was certainly pleased when she awoke.  Strict instructions of no yawning, no eating hard foods, and no opening her mouth wide for several months were given.  I hope not to see Martha again in her previous condition.