Mandible Fracture


Article Author:
Ho-Wang Yuen


Article Editor:
Thomas Mazzoni


Editors In Chief:
Brian Downs
Ziad Katrib


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
10/30/2019 5:38:53 PM

Introduction

Any significant force applied to the mandible can cause fractures to this ring-like structure. Open fractures are common, including laceration of the gum overlying a fracture.[1]

Etiology

The mandible is the third most commonly fractured facial bone, following nasal and zygomatic fractures. Most frequently, fractures are a result of trauma, such as motor vehicle accidents, personal violence, industrial accidents, or contact sports.[1]

Epidemiology

Vehicular accidents and altercations are the primary causes of mandibular fractures in the United States and throughout the world. In urban trauma setting, altercations accounted for most fractures (50%), and motor vehicle accidents were less likely (29%).[1]

Mandibular fractures are uncommon in children under age of 6. When they occur, they are often greenstick fractures.

Pathophysiology

Because of its ring-like structure, multiple fractures are seen in more than 50% of cases. The most common fractured area is the body (29%), followed by the condyle (26%), angle (25%), and symphysis (17%). The ramus (4%) and coronoid process (1%) are rarely fractured. In automobile accidents, the condyle was the most common fracture site; whereas, the symphysis was most commonly fractured in motorcycle accidents. In assault cases, the angle is the most common fractured site.[2]

Mandible fractures can be classified by favorableness, based on the association between the direction of the fracture line and the way muscle distraction affects the fracture fragments. Mandibular fractures are favorable when muscles tend to draw the fracture fragments together and unfavorable when muscle forces displace fracture fragments. 

Depending on the fractured areas, the patient can present with trismus, dental malocclusion, swelling, and tenderness externally and intraorally. Damage to the inferior alveolar nerve may result in anesthesia to the lower lip.

Patients with mandibular fractures frequently have other associated injuries (43%). The most common associated injuries include head injuries (39%), head and neck laceration (30%), midface fractures (28%), ocular injuries (16%), nasal fractures (12%), and cervical spine fractures (11%).

The presence of lower wisdom teeth may increase the risk of fracture of the angle of the mandible. Patients with a mandibular fracture that have wisdom teeth also have a higher infection risk (16.6%) when compared with the ones without wisdom teeth (9.5%).

In the pediatric population, any fracture of the mandible may damage permanent teeth. Follow up with the oral and maxillofacial surgeon is indicated.

History and Physical

Patients will present with mandibular pain, facial asymmetry, deformity, and dysphagia. Malocclusion, a decreased range of movement of the temporomandibular joint, trismus, or lower lip numbness can also be present. Eliciting the mechanism of injury is important. In a vehicular motor accident, the patient usually suffers from multiple, compound, or communicated mandibular fractures. Mandibular fracture of a patient from an altercation is usually single, simple, and nondisplaced.

On physical examination, one should inspect the maxillofacial area for deformity, including ecchymosis and swelling. One should also look for any malocclusion, trismus, or facial asymmetry. A careful intraoral examination should be performed; sublingual hematoma is suggestive of an occult mandibular fracture.

The tongue-blade bite test is a quick and inexpensive diagnostic tool for predicting mandibular fractures. It has a sensitivity of 88.5% and a specificity of 95%. It can be performed by asking the patient to bite down strongly on a tongue depressor and keep the tongue depressor clenched between the teeth. The examiner should twist the tongue blade. If there is no fracture of the mandible, the examiner should be able to break the blade. In the presence of a mandibular fracture, the patient opens his or her mouth because they experience pain from the fracture, and the tongue depressor remains intact.[3]

Evaluation

Diagnosis of mandibular fractures requires radiographic imaging studies, including mandibular series, panorex, and CT scan. Mandibular series include anteroposterior view, bilateral oblique views, and Towne view. They are best for evaluating the condyles and neck of the mandible. Dental panoramic view, or panorex, is best for evaluating the symphysis and the body of the mandible. CT scan is indicated if associated facial fractures are suspected. A chest radiograph is necessary for an unconscious patient with missing teeth to rule out aspiration.

Laboratory studies are generally not indicated unless urgent or emergency surgery is anticipated. In those situations, basic screening labs should be obtained including complete blood count, complete or basic metabolic panel, type and screen, and prothrombin time or INR for patients who are on warfarin for anticoagulation.[4]

Treatment / Management

Patients with mandibular fractures frequently have associated injuries. Initial treatment should be directed toward immediate, potentially life-threatening injuries such as airway obstruction, major hemorrhage, cervical spine injury, and intracranial injury. If oral intubation cannot be performed, cricothyrotomy is indicated. Nasotracheal intubation should not be performed if midface or nasal fractures are suspected. Patients with mandibular fractures should also be placed on cervical spine immobilization.[5][6][7]

Mandibular fractures with mucosal, gingival, or tooth socket disruption are considered open fractures, and antibiotics with intraoral anaerobic pathogens coverage should be given to reduce the risk of infection. The appropriate antibiotic agent includes penicillin, ampicillin/sulbactam, and clindamycin for penicillin-allergic patients. Tetanus prophylaxis is also indicated in open fractures. Pain control should be achieved with acetaminophen, NSAID, or opioid.

Fractures of the body, angle, ramus, and symphysis will require splinting by placing arch bars to accomplish interdental fixation, also known as "wiring the jaw shut." Fixation limits fracture motion and decreases the patient's pain and discomfort. It normally takes 4 to 6 weeks to achieve satisfactory healing.

Patients with linear, nondisplaced, or greenstick fractures can be treated as an outpatient with a soft diet, analgesic, and urgent follow up with the oral and maxillofacial surgeon for elective operative repair that can be performed as an outpatient procedure in 3 to 5 days. Barton's bandage, an ace wrap over the top of the head and underneath the mandible, should be placed to stabilize the fracture and help relieve pain.

Hospital admission is indicated in patients with significantly displaced fracture. An oral and maxillofacial surgeon should be consulted for open fractures which require operative repair. Patients with airway compromise, patients who are unable to tolerate POs and secretions, and patients with inadequate pain control will also require hospital admission.[8][9]

Differential Diagnosis

Differential diagnosis includes mandibular contusion, mandibular dislocation, and isolated dental trauma. In a mandibular dislocation, if a single condyle is dislocated, the jaw will deviate away from the side of the dislocation. In mandibular fracture, the jaw will deviate toward the side of the fracture.

Enhancing Healthcare Team Outcomes

Mandibular fractures are often associated with significant associated traumatic injuries. In some instances, the airway may be compromised. Care of trauma patients is best achieved with an interdisciplinary team of clinicians and specialty trained emergency and trauma nurses. [Level V]


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Mandible Fracture - Questions

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A patient is punched in the face. X-rays reveal evidence of a mandibular fracture. The majority of mandibular fractures that are the result of an assault occur at what location?



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What is the most frequently fractured part of the mandible in pediatric patients?



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In planning for the reduction of a mandibular fracture, which of the following is the most reliable way to restore function?



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Conservative therapy can be used for mandible fractures in certain situations. In which of the following scenarios would a nonoperative treatment be recommended?



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What is the most common cause of mandible fractures in industrialized nations?



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Which of the following is NOT a general principle of open reduction in comminuted angular fractures of the mandible?



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Which of the following is NOT a general principle observed in mandible fracture treatment?



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Mandible Fracture - References

References

Tongue Blade Bite Test Predicts Mandible Fractures., Neiner J,Free R,Caldito G,Moore-Medlin T,Nathan CA,, Craniomaxillofacial trauma & reconstruction, 2016 Jun     [PubMed]
Assessment of patients with facial fractures., Ellis E 3rd,Scott K,, Emergency medicine clinics of North America, 2000 Aug     [PubMed]
Jin KS,Lee H,Sohn JB,Han YS,Jung DU,Sim HY,Kim HS, Fracture patterns and causes in the craniofacial region: an 8-year review of 2076 patients. Maxillofacial plastic and reconstructive surgery. 2018 Dec;     [PubMed]
Fridrich KL,Pena-Velasco G,Olson RA, Changing trends with mandibular fractures: a review of 1,067 cases. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 1992 Jun;     [PubMed]
Pickrell BB,Serebrakian AT,Maricevich RS, Mandible Fractures. Seminars in plastic surgery. 2017 May;     [PubMed]
Pickrell BB,Hollier LH Jr, Evidence-Based Medicine: Mandible Fractures. Plastic and reconstructive surgery. 2017 Jul;     [PubMed]
Beirne JC,Butler PE,Brady FA, Cervical spine injuries in patients with facial fractures: a 1-year prospective study. International journal of oral and maxillofacial surgery. 1995 Feb;     [PubMed]
Sinclair D,Schwartz M,Gruss J,McLellan B, A retrospective review of the relationship between facial fractures, head injuries, and cervical spine injuries. The Journal of emergency medicine. 1988 Mar-Apr;     [PubMed]
Haug RH,Wible RT,Likavec MJ,Conforti PJ, Cervical spine fractures and maxillofacial trauma. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 1991 Jul;     [PubMed]

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