Signs and Symptoms
- Mand ibular pain
- Facial asymmetry, deformity, and dysphagia
- Malocclusion, decreased range of motion of the temporomand ibular 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 mand ible
- Protrusion or lateral excursion of the jaw
- Interference with normal mand ibular function, including decreased range of motion or deviation of the mand ible with opening:
- The examiner should be able to insert three fingers between the mand ible 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 mand ibular condyles when palpated through the external ear canals suggests mand ible fracture
- Tenderness of the condyle at the TMJ
Essential Workup
- Diagnosis of mand ibular fractures requires radiographs - mand ibular series or panorex
- Panorex superior for evaluation of all of the mand ible except condyles
- Low threshold for obtaining facial bone CT if associated injuries are suspected
Diagnostic Tests & Interpretation
Lab
Only indicated if immediate operative intervention is indicated, or for evaluation of other injuries
Imaging
- Dental panoramic views or plain films should be obtained
- Plain films including an anteroposterior (AP), bilateral obliques, and Towne view should be obtained:
- Mand ibular views are best for evaluating the condyles and neck of mand ible
- Dental panoramic view may be obtained:
- Panorex best evaluates the symphysis and body
- 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 mand ate a chest radiograph to rule out aspiration
- Obtain cervical spine imaging if the neck cannot be cleared clinically
- Obtain facial bone CT if other injuries of the face suspected
Differential Diagnosis
- Contusions
- Dislocation of the mand ible:
- 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
Prehospital
- Cautions:
- Protect the airway
- Protect the cervical spine
- Preserve any avulsed teeth
Initial Stabilization/Therapy
- 20-40% of patients with mand ibular 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 mand ibular 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 are still generally recommended to cover intraoral anaerobic pathogens although some experts and studies doubt their efficiency
- Tetanus prophylaxis for open fractures
- Analgesia such as acetaminophen, ibuprofen, or narcotic medications
- Temporary pain relief in a patient with a stable airway can be afforded with a Barton band age, which is a 4 in (typically) ace wrap around the jaw and top of the head which stabilizes the jaw
- 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 mand ible dislocation is present, while the jaw is open apply bilateral downward pressure on the occlusal surface of the posterior lower teeth while grasping the mand ible:
- 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 examiner's fingers should be wrapped in gauze to prevent injury
Medication
- Acetaminophen: 500 mg (peds: 10-15 mg/kg, do not exceed 5 doses/24 hr) PO q4-6h, do not exceed 4 g/24 hr
- Amoxicillin/clavulanate: 500/125-875/125 mg PO b.i.d (peds: 40 mg/kg/d of amoxicillin PO b.i.d)
- Amoxicillin: 500 mg PO t.i.d (peds: 40 mg/kg PO div t.i.d)
- 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 q.i.d (peds: 10-20 mg/kg/24 hr)
- Diazepam: 5-10 mg (peds: 0.1-0.2 mg/kg) IV
- Ibuprofen: 600-800 mg (peds: 20-40 mg/kg/24 hr) PO t.i.d-q.i.d
- 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/24 hr) PO q.i.d
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
Follow-up Recommendations
Oral or maxillofacial surgeon within 2-3 d for uncomplicated fractures
See Also (Topic, Algorithm, Electronic Media Element)