Case 3 Mandibular Fractures

Vinay Rao and Albert S. Woo

Case 3 Mandibular Fractures

Case 3 (a, c) A 21-year-old female presents to the emergency department complaining of facial pain after being shot in the face, with bullet entering from right cheek and exiting left jaw.

3.1 Description

  • Bullet hole in right cheek, exit site presumed to be IN left jaw

  • Displaced, comminuted body and angle fracture of the mandible with large butterfly fragment and malocclusion on examination

  • Unclear facial nerve function or evidence of parotid injury

3.2 Work-Up

3.2.1 Initial Assessment

  • ABCs: Attention to patency of the airway given multiple mandibular fractures. Intubation may be necessary if the patient cannot protect the airway.

  • Cervical spine precautions: This is mandatory in the setting of high energy injuries until the spine is cleared both clinically and radiographically.

  • Concomitant injuries: Manage any potentially life-threatening injuries first. The repair of mandibular fractures is not emergent and can be performed on an elective basis (generally within 14 days of injury).

3.2.2 History

  • Mechanism of injury, presence/location of pain, loss of sensation, presence of loose or missing teeth, use of dentures, assessment of occlusion

  • Relevant medical history (prior mandibular or facial fractures), surgical history (prior facial surgery), social history (alcohol, smoking, drug use)

3.2.3 Physical Examination

  • Palpate bony structures in a systematic fashion to identify areas of tenderness, deformity, step-off, and instability.

  • Assess mobility (ability to open/close mouth, deviation of mandible on movement) and occlusion (may be evaluated based on wear facets of teeth)

  • State of dentition: Edentulous mandibles will require more aggressive procedures to rigidly fixate bone segments due to decreased bone stock.

  • Evidence of intraoral lacerations (exposed bone), loose or absent teeth, identification and removal of prosthetics (dentures), sublingual hematoma, or foreign bodies

  • Neurologic examination: The mental/inferior alveolar nerve provides sensation to the lower lip. The marginal mandibular branch of the facial nerve innervates the depressors of the lower lip and is rarely injured.

  • In gunshot wounds, must consider all structures in path of bullet, including parotid, facial nerve, muscle, tongue, and other intraoral injuries.

  • Assess presence of concomitant midfacial fractures (may alter occlusion).

3.2.4 Pertinent Imaging or Diagnostic Studies

  • High-resolution maxillofacial computed tomography (CT): Gold standard for imaging. Three-dimensional reconstructions may assist in further evaluating injury.

  • When CT is unavailable, X-ray studies may be useful.

    • Option 1: Panorex. Visualization of entire mandible and dentition. Limited evaluation at symphysis and condyles. Additional Towne’s view improves evaluation of subcondylar regions.

    • Option 2: Mandible series (anteroposterior”. lateral, and bilateral oblique views)

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 3 Mandibular Fractures
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