Malocclusion with left-sided anterior open bite.
Displaced oblique right subcondylar fracture extending through sigmoid notch.
Displaced, comminuted fracture of left posterior body of mandible, with possible involvement of mandibular third molar (tooth No. 17).
History and physical examination
ABCs (airway, breathing, circulation): Attention to stability of the airway, given multiple mandible fractures. Rarely, intubation may be necessary if the patient cannot protect the airway.
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).
Palpate/manipulate the mandible for step-offs and instability.
Assess mobility (ability to open and close mouth, deviation of mandible on movement) and occlusion (may evaluate based on wear facets of teeth).
State of dentition: Patients with edentulous mandibles will require more aggressive procedures to rigidly fix bone segments because of decreased bone stock.
Neurologic examination: The mental/inferior alveolar nerve provides sensation to the lower lip and frequently sustains neurapraxic injury with blunt trauma. The marginal mandibular branch of the facial nerve innervates the depressors of the lower lip and is rarely injured.
Assess for concomitant midfacial fractures (may alter occlusion).
Pertinent imaging or diagnostic studies
High-resolution maxillofacial computed tomography (CT): This is the gold standard for imaging. Three-dimensional reconstructions may assist in further evaluating injury.
When CT is unavailable, other studies may be useful.
Panorex: Allows visualization of the entire mandible and dentition. Limited evaluation at symphysis and condyles. Additional Towne view improves visualization of subcondylar regions.
Mandible series (anteroposterior, lateral, oblique, open-mouth reverse Towne view).
Initial management (in the emergency department)
Oral chlorhexidine rinse: Decreases oral flora/bacterial count.
Bridle wire (optional): Stainless steel wire typically placed two teeth away on either side of a fracture line to help with temporary stability. May be useful to increase patient comfort in the setting of unstable fractures.