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)

Only gold members can continue reading. Log In or Register to continue

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