Basics
Description
- Typically due to a direct force
- The most common area fractured is the angle, followed by the condyle, molar, and mental regions.
- Because of its thickness, the mandibular symphysis is rarely fractured.
- Multiple fractures are seen in >50% of cases owing to the ring-like structure of the mandible.
- Bilateral mandibular fractures most commonly result from motor vehicle accidents (MVAs).
- Open fractures are common, including lacerations of the gum overlying a fracture.
Etiology
- The mandible is the 3rd most common facial fracture following nasal and zygomatic fractures.
- MVAs, personal violence, contact sports, or industrial accidents
- Patients are often intoxicated and unable to give a clear history of events.
- Facial and head lacerations and facial fractures are the most commonly associated injuries.
- Mandibular fractures are uncommon in children <6 yr of age; when they do occur, they are often greenstick fractures and can be managed with soft diet alone.
- Inform parents that because any fracture of the mandible may damage permanent teeth, follow-up with a specialty consultant is advisable.
- Refer pediatric patients to a specialist with experience in children due to issues with growth plates and permanent teeth.
Diagnosis
Signs and Symptoms
- Mandibular pain
- Facial asymmetry, deformity, and dysphagia
- Malocclusion, decreased range of motion of the temporomandibular joint (TMJ), trismus, or a grating sound conducted to the ear
- Gum laceration, subungual or gum hematoma
History
- Mechanism of injury
- Malocclusion, dental pain, associated injuries
Physical Exam
- Inspect maxillofacial area for deformity, including ecchymosis or swelling.
- Malocclusion, trismus, or facial asymmetry
- Loose, fractured, or missing teeth; gross malalignment of teeth; separation of tooth interspaces, bleeding at the base of teeth; gum lacerations between teeth; and ecchymosis or hematoma of the floor of the mouth
- Step-off, bony disruption, or point tenderness with palpation along the entire length of the mandible
- Protrusion or lateral excursion of the jaw
- Interference with normal mandibular function, including decreased range of motion or deviation of the mandible with opening:
- The examiner should be able to insert three fingers between the mandible and the maxilla.
- Inability of the patient to hold a tongue depressor laterally between the teeth when pulled by the examiner, or attempted to be broken by twisting (positive tongue blade test)
- Paresthesia of the lower lip or gums indicates secondary damage to the inferior alveolar nerve.
- Inability to note motion of the mandibular condyles when palpated through the external ear canals suggests mandible fracture.
- Tenderness of the condyle at the TMJ
Essential Workup
- Diagnosis of mandibular fractures requires radiographs " mandibular series or panorex.
- Panorex superior for evaluation of all of the mandible except condyles
- Low index for obtaining facial bone CT if associated injuries are suspected
Diagnosis Tests & Interpretation
Lab
Only indicated if immediate operative intervention is indicated, or for evaluation of other injuries
Imaging
- Plain films or dental panoramic views should be obtained.
- Plain films including an anteroposterior (AP), bilateral obliques, and Towne view should be obtained:
- Mandibular views are best for evaluating the condyles and neck of mandible (most common site of fracture).
- Dental panoramic view may be obtained:
- Panorex best evaluates the symphysis and body (less common fracture site).
- If condylar fracture is still suspected and not noted on initial radiographs, obtain CT of the condyles in the coronal plane.
- Missing teeth that cannot be found mandate a chest radiograph to rule out aspiration.
- Obtain cervical spine films if the neck cannot be cleared clinically
- Obtain facial bone CT if other injuries of the face suspected.
Differential Diagnosis
- Contusions
- Dislocation of the mandible:
- If a single condyle is dislocated, the jaw will deviate away from the side of the dislocation.
- If fractured, the jaw will deviate toward the fractured side.
- Isolated dental trauma
Treatment
Pre-Hospital
- Cautions:
- Protect the airway.
- Protect the cervical spine.
- Preserve any avulsed teeth.
Initial Stabilization/Therapy
- 20 " 40% of patients with mandibular fractures have associated injuries:
- Treatment is directed toward immediate, potentially lethal injuries such as airway obstruction, aspiration, major hemorrhage, cervical spine injury, and intracranial injury.
- Airway must be protected.
- Cervical spine precautions
- If oral intubation cannot be performed, nasotracheal intubation should be performed unless associated facial injuries are present, in which case cricothyrotomy may be indicated.
Ed Treatment/Procedures
- With the exception of condylar fractures, many mandibular fractures are associated with mucosal, gingival, or tooth socket disruption and should be considered open fractures:
- Antibiotics such as penicillin, clindamycin, amoxicillin, amoxicillin/clavulanate or azithromycin to cover intraoral anaerobic pathogens
- Tetanus prophylaxis for open fractures
- Analgesia such as acetaminophen, ibuprofen, or narcotic medications
- Definitive care usually consists of reduction and fixation by wiring upper and lower teeth in occlusion for 4 " 6 wk or by ORIF:
- Linear, nondisplaced, or greenstick fractures may be treated with soft diet without wiring.
- If mandible dislocation is present, while the jaw is open apply bilateral downward pressure on the occlusal surface of the posterior lower teeth while grasping the mandible:
- The goal is to free the condyle from its anterior position to the eminence.
- Reduction is facilitated by muscle relaxants (diazepam or midazolam) or anesthetic injection of mastication muscles.
- A bite block should be used, or the examiners fingers should be wrapped in gauze to prevent injury.
Medication
- Acetaminophen: 500 mg (peds: 10 " 15 mg/kg, do not exceed 5 doses/24h) PO q4 " 6h, do not exceed 4 g/24h
- Amoxicillin/clavulanate: 500/125 " 875/125 mg PO BID (peds: 40 mg/kg/d of amoxicillin PO BID
- Amoxicillin: 500 mg PO TID (peds: 40 mg/kg PO div. TID)
- Azithromycin: 500 mg PO day 1 followed by 250 mg day 2 " 4 (peds: 10 mg/kg day 1 followed by 5 mg/kg day 2 " 4)
- Clindamycin: 150 " 450 mg PO QID (peds: 10 " 20 mg/kg/24h)
- Diazepam: 5 " 10 mg (peds: 0.1 " 0.2 mg/kg) IV
- Ibuprofen: 600 " 800 mg (peds: 20 " 40 mg/kg/24h) PO TID " QID
- Midazolam: 2 " 5 mg (peds: 0.02 " 0.05 mg/kg/dose, max. dose 0.4 mg/kg total and not >10 mg) IV over 2 " 3 min
- Penicillin VK: 250 " 500 mg (peds: 25 " 50 mg/kg/24h) PO QID
Follow-Up
Disposition
Admission Criteria
- Significant displacement or associated dental trauma " open fractures require urgent specialty consultation for possible admission.
- The severity of associated trauma may indicate admission.
- Any patient with the potential for airway compromise should be admitted.
- An unreliable patient with nondisplaced fractures should be admitted for definitive fixation.
- In the pediatric population, if the mechanism of injury is not appropriate to the injuries seen, pediatric or child protective services consultation should be obtained.
Discharge Criteria
Patients with nondisplaced, closed fractures may be discharged on analgesics and a soft diet.
Followup Recommendations
Oral or maxillofacial surgeon within 2 " 3 days for uncomplicated fractures
Pearls and Pitfalls
- The most sensitive sign of a mandibular fracture is malocclusion.
- Failure to recognize that a gum laceration overlying a mandibular fracture represents an open fracture which requires antibiotics.
- Missing mandibular condyle fractures when only a panorex film is obtained " if there is condyle tenderness or malocclusion, obtain plain films or CT.
- Missing teeth must be accounted for, if not found, obtain a chest x-ray to rule out aspiration.
- A nonfractured mandible should be able to hold a tongue blade between the molars tightly enough to break it off. There should be no pain in attempting to rotate the tongue blade between the molars.
Additional Reading
- Alpert B, Tiwana PS, Kushner GM. Management of comminuted fractures of the mandible. Oral Maxillofac Surg Clin North Am. 2009;21(2):185 " 192.
- Ellis E 3rd. Management of fractures through the angle of the mandible. Oral Maxillofac Surg Clin North Am. 2009;21(2):163 " 174.
- Koshy JC, Feldman EM, Chike-Obi CJ, et al. Pearls of mandibular trauma management. Semin Plast Surg. 2010;24(4):357 " 374.
- Myall RW. Management of mandibular fractures in children. Oral Maxillofac Surg Clin North Am. 2009;21(2):197 " 201.
- Perez R, Oeltjen JC, Thaller SR. A review of mandibular angle fractures. Craniomaxillofac Trauma Reconstr. 2011;4(2):69 " 72.
See Also (Topic, Algorithm, Electronic Media Element)
- Dental Trauma
- Facial Fractures
Codes
ICD9
- 802.20 Closed fracture of mandible, unspecified site
- 802.21 Closed fracture of mandible, condylar process
- 802.25 Closed fracture of mandible, angle of jaw
- 802.28 Closed fracture of mandible, body, other and unspecified
- 802.22 Closed fracture of mandible, subcondylar
- 802.23 Closed fracture of mandible, coronoid process
- 802.24 Closed fracture of mandible, ramus, unspecified
- 802.26 Closed fracture of mandible, symphysis of body
- 802.27 Closed fracture of mandible, alveolar border of body
- 802.29 Closed fracture of mandible, multiple sites
- 802.2 Closed fracture of mandible
ICD10
- S02.61XA Fracture of condylar process of mandible, init for clos fx
- S02.65XA Fracture of angle of mandible, init for clos fx
- S02.609A Fracture of mandible, unsp, init encntr for closed fracture
- S02.69XA Fracture of mandible of oth site, init for clos fx
- S02.62XA Fracture of subcondylar process of mandible, init
- S02.63XA Fracture of coronoid process of mandible, init for clos fx
- S02.64XA Fracture of ramus of mandible, init for clos fx
- S02.66XA Fracture of symphysis of mandible, init for clos fx
- S02.67XA Fracture of alveolus of mandible, init for clos fx
SNOMED
- 263172003 Fracture of mandible
- 207759004 Closed fracture of mandible, angle of jaw (disorder)
- 207755005 Closed fracture of condylar process of mandible (disorder)
- 66517001 Closed fracture of body of mandible (disorder)
- 207757002 Closed fracture of coronoid process of mandible (disorder)
- 86559007 Closed fracture of ramus of mandible (disorder)