History
Because maxillofacial fractures are the result of trauma, primary survey and attention to airway, breathing, and circulation take priority. [7, 28, 29]
Causes of fracture of the mandible include motor vehicle accidents, as an occupant or as a pedestrian struck by a vehicle; violence, by being struck with fists, feet, or objects, including bullets in penetrating injuries; and falls, either from a height or in a case of syncope.
Focus the primary evaluation on patency of the airway, control of the cervical spine, breathing and circulatory impairment, and loss of consciousness, if the patient is experiencing neurologic impairment.
Once life threats have been addressed, obtain a thorough (AMPLE) history:
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Allergies
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Medications
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Past medical history
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Last meal
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Events leading to injury
Next, ask the patient specific questions regarding the facial injury, such as these:
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Do you have epistaxis or clear fluid running from the nares or ears?
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Did you lose consciousness? If so, for how long?
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Have you had any visual problems, such as double or blurred vision?
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Have you had any hearing problems, such as decreased hearing or tinnitus?
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Do you have any malocclusion (crooked teeth or a poor bite)? Can you bite down without pain?
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Does moving your jaw cause pain or spasm?
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When the jaw moves, does this produce a grinding sound?
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Do you have areas of numbness or tingling on your face?
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(For women) Was your injury caused by a partner? Do you feel threatened by anyone?
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(For children) Ask questions to determine whether child abuse is an issue.
Physical
Complete examination of the face is necessary because multiple injuries can easily occur. [17] Portions of the examination specific to the mandible are marked with an asterisk (*).
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Inspect face for asymmetry, performed while looking down from the head of the bed.
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Inspect open wounds for foreign bodies, and palpate for bony injury.
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Palpate bony structures of the supraorbital ridge and the frontal bone for step-off fracture.
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Thoroughly examine eyes for injury, abnormal ocular movements, and visual acuity. [30]
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Inspect nares for telecanthus and widening of the nasal bridge, then palpate for tenderness and crepitus.
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Inspect nasal septum for septal hematoma and clear rhinorrhea, which may suggest cerebrospinal fluid (CSF) leak.
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Palpate zygoma along its arch, as well as along its articulations with the frontal bone, temporal bone, and maxillae.
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Check facial stability by grasping the teeth and hard palate and gently pushing back and forth and up and down, while feeling for movement or instability of the midface. [17]
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*Test teeth for stability and inspect for bleeding at the gumline—a sign of fracture through the alveolar bone.
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*Check teeth for malocclusion and step-off.
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*Palpate mandible for tenderness, swelling, and step-off along its symphysis, body, angle, and coronoid process anterior to the ear canal.
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*Check for localized edema or ecchymosis in the floor of the mouth.
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Evaluate distributions of the supraorbital, infraorbital, *inferior alveolar, and *mental nerves for anesthesia.
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*If teeth are missing, account for them to ensure that they have not been aspirated.
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*Inspect the area just anterior to the meatus of the ear for ecchymosis, and palpate for tenderness. This is the condyle of the mandible and is the site of often-missed fracture. Plain radiographs are not good for visualizing the condyle; maintain a high level of suspicion if the physical exam is suggestive.
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*Mandibular fracture is suggested by inability to open the mouth, trismus, malocclusion of the teeth, or palpable step-offs of bone along symphysis, angles, or body. Gingival bleeding at the base of a tooth suggests fracture, especially if the teeth are malaligned. Edema or ecchymosis may be present in the floor of the mouth. Neurologic findings may include hypesthesia in the distribution of inferior alveolar or mental nerves.
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Anatomy of the mandible.
