Imaging Studies

See the list below:

The following types of radiographs are helpful in diagnosis of mandibular fractures:
- Panoramic radiograph
  
  $Mandibular fracture. Postoperative pantomogram.$ Mandibular fracture. Postoperative pantomogram.
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  $Mandibular fracture. Close-up view of postoperativ$ Mandibular fracture. Close-up view of postoperative pantomogram.
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  $Mandibular fracture. Postoperative pantomogram.$ Mandibular fracture. Postoperative pantomogram.
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- Lateral oblique radiographs
  
  $Mandibular fracture. Lateral view.$ Mandibular fracture. Lateral view.
  View Media Gallery
- Posteroanterior (PA) mandibular view
  
  $Mandibular fracture. Infection treated with incisi$ Mandibular fracture. Infection treated with incision and drainage and intravenous antibiotics. Hardware was removed and site debrided. Postoperative posteroanterior cephalometric view demonstrating reconstruction plate in place.
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- Reverse Towne view
- Mandibular occlusal view
- Periapical radiographs
- Temporomandibular joint views including tomography
- CT scan
  
  $Axial CT scan demonstrating multiple fractures of$ Axial CT scan demonstrating multiple fractures of the mandible.
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  Axial CT scan demonstrating severe displacement.
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Initial screening of patients is most effective with a panoramic radiograph, since it shows the entire mandible, including the condyles.
Standard mandibular series should consist of at least a panoramic radiograph, a PA view, and a reverse Towne view.
Since an accurate panoramic radiograph requires that the patient is able to stand upright and without any motion, achieving good quality films with severely traumatized patients may be difficult. Traditional lateral oblique views of the mandible can be used when obtaining a panoramic radiograph is not possible.
The reverse Towne view is the plain film of choice for excluding condylar and subcondylar fractures. Transcranial temporomandibular radiographs also may be helpful in detecting condylar fractures and anterior displacement of the condylar head. If visualization of the condylar head is difficult with plain films, obtain a CT scan. Although high cost and radiation exposure limit its use, CT scan is ideal for intracapsular and high neck condylar fractures.
Occlusal views are helpful for accurate assessment of symphyseal fractures.
Obtain periapical radiographs of the teeth on either side of a fracture to assess root fractures.

Diagnostic Procedures

See the list below:

For cases where the preinjury occlusion is difficult to determine, particularly in partially dentate and edentulous patients, the use of study models is very helpful. Model surgery on the study models can be performed and acrylic splints fabricated to the new arch form.^[62]These splints may include a lingual, palatal, or labial splint that will be secured in place during surgery. The splints may be secured with the use of circummandibular wires for the mandible or with circumzygomatic or piriform wires for the maxilla. A maxillary splint also may be secured with palatal screws.
For fully edentulous patients, dentures can be secured to the maxilla and mandible and used for splints.^[49]If dentures are not available, impressions are taken of the jaws, and acrylic baseplates are processed and used as dentures. These are known as Gunning splints. An arch bar also can be processed into the dentures, or holes can be placed into the flange of the denture for intermaxillary wires. Prosthetic incisor teeth can be removed for existing dentures, and space can be made in the acrylic to allow food intake.

Other Tests

In the REDUCTION-I (REDucing Unnecessary Computed Tomography Imaging for MaxillOfacial INjury–I) study, Rozema et al developed a clinical decision aid for ruling out mandibular fractures in the emergency department. The aid employs the angular compression test, the axial chin pressure test, objective malocclusion, tooth mobility or avulsion, and the tongue blade bite test. The investigators stated that the decision aid has a sensitivity of 98.5 and a negative predictive value of 98.7.^[63]

In the REDUCTION-II study, Rozema et al developed a clinical decision aid for determining whether patients in the emergency department have mandibular fractures requiring treatment. The aid employs observations on mouth-opening limitation, jaw movement pain, objective malocclusion, and tooth mobility or avulsion. According to the investigators, the aid’s sensitivity and negative predictive value are both 100.0, with the specificity being 39.1.^[64]

Treatment & Management

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Media Gallery

The anatomic regions of the mandible.
The muscular forces acting upon the mandible.
A "favorable" body fracture with muscular force not tending to distract the fracture.
An "unfavorable" angle fracture with distracting muscular forces.
Right mandibular condylar fracture.
Retromandibular approach to right mandibular condylar fracture.
Intraoperative view. Fixation of right mandibular condyle fracture.
Mandibular fracture. Postoperative pantomogram.
Mandibular fracture. Close-up view of postoperative pantomogram.
Mandibular fracture. Coronal CT scan demonstrating bilateral high condylar fractures.
Mandibular fracture. Postoperative coronal image demonstrating open reduction internal fixation of the left condylar fracture to restore posterior vertical height.
Mandibular fracture. Postoperative pantomogram.
Mandibular fracture. Intraoperative view. Reconstruction plate used to span continuity defect of right mandibular body.
Mandibular fracture. Autologous bone harvested from the patient's anterior iliac crest placed into defect.
Mandibular sagittal symphysis fracture and dentoalveolar fracture.
Mandibular fracture treated with lag screw fixation and debridement of dentoalveolar segment.
Mandibular fracture. Patient lost to follow-up at local county jail presents with infected nonunion of mandibular symphysis.
Mandibular fracture. Infection treated with incision and drainage and intravenous antibiotics. Hardware was removed and site debrided. Postoperative posteroanterior cephalometric view demonstrating reconstruction plate in place.
Mandibular fracture. Lateral view.
Right mandibular parasymphysis fracture.
Mandibular fracture treated with 4-hole positional plate and maxillomandibular fixation.
Comminuted mandibular fracture.
Axial CT scan demonstrating multiple fractures of the mandible.
Axial CT scan demonstrating severe displacement.
Mandibular fracture. Intraoperative view demonstrating fixation of mandibular segments.
Mandibular fracture. Left lateral view.
Mandibular fracture. Right lateral view.
Mandibular fracture. Axial CT scan demonstrating status post fixation.
Right mandibular ramus and left mandibular parasymphysis fractures.
Mandibular fracture. Pantomogram status post fixation.
Mandibular fracture. Postoperative posteroanterior cephalometric view.
Right sagittal mandibular body fracture and left parasymphysis fracture.
Mandibular fracture. The right side was treated with 3 positional screws to engage buccal and lingual cortices of sagittal fracture. The right side is rigidly fixated with a 6-hole plate.
Right mandibular body fracture. Left mandibular angle fracture going through tooth #17.
Right mandibular body and left mandibular angle fractures status post fixation. Tooth #17 was extracted.
Mandibular fracture. Interarch elastics may be used for maxillomandibular fixation. They also may be used loosely for guidance during postoperative care.
Left mandibular angle fracture involving tooth #17. Right mandibular body fracture.
Tooth #17 was extracted. A superior border plate was placed at the left mandibular angle. An inferior border plate was placed for the right mandibular body fracture.
Mandibular fracture. Patient presents with occlusal step off between right mandibular central and lateral incisors.
Mandibular fracture. View of occlusal step off.
Mandibular fracture. Bridle wire used to decrease mobility and provide patient comfort.
Mandibular fracture. Barton bandage used to decrease fracture mobility and provide patient comfort until definitive treatment.
Left mandibular body fracture.
Mandibular fracture. Open reduction rigid internal fixation of left mandibular body fracture.
Mandibular fracture. Postoperative radiograph demonstrating reduction and fixation.
Mandibular fracture. Patient with poorly controlled type 1 diabetes with left open, complete, moderately displaced mandibular angle fracture between teeth #17 and #18.
Mandibular fracture. Treated initially with a superior border plate and an inferior border plate as well as extraction of tooth #17.
Mandibular fracture. Patient returns with infected nonunion of left mandibular angle and loose hardware. The superior border plate was removed. Tooth #18 was extracted. The patient was treated with intravenous and oral antibiotics.
Mandibular fracture. Rigid fixation with an 8-hole plate. Two holes in the center are used to span the fracture site.

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Author

Donald R Laub, Jr, MD, MS, FACS Surgeon, Four Seasons Dermatology

Donald R Laub, Jr, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Pediatric Plastic Surgeons, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Gold Humanism Honor Society, New England Hand Society, New England Society of Plastic and Reconstructive Surgeons, Vermont Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jaime R Garza, MD, DDS, FACS Consulting Staff, Private Practice

Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Received none from Allergan for speaking and teaching; Received none from LifeCell for consulting; Received grant/research funds from GID, Inc. for other.

Chief Editor

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, The Scientific Research Honor Society, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

James F Thornton, MD Associate Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Robert David Nesbit, MD; Adel R Tawfilis, DDS; David W Kim, MD; and Patrick Byrne, MD to the development and writing of this article.

Mandibular Fractures Workup

Imaging Studies

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