Prehospital Care
Airway, breathing, and circulation are the first priority. Hold the airway open by jaw thrust or airway adjuncts, including endotracheal intubation.
Treat hypoventilation with intubation and bag ventilation. Nasotracheal intubation is considered a relative contraindication with severe maxillofacial trauma because of concern for intracranial placement of endotracheal tubes.
Suction usually is needed to keep the airway free of blood and debris.
Place the patient on a backboard with a collar if cervical spine injury is a possibility.
Control actively bleeding wounds by applying direct pressure with a bandage.
Emergency Department Care
Airway, breathing, and circulation (primary survey)
Frequently assess the airway. Isolated mandibular fracture from a blunt mechanism usually does not require intubation, but frequent suctioning is mandatory.
Early intubation before swelling occurs makes airway control much easier, rather than waiting until a problem arises from obstruction. This is usually a clinical decision based on the projected course.
Before using paralytics in an intubation, carefully evaluate ability to manage the airway with a bag and mask or a laryngeal airway. If unable to manage the airway, do not paralyze the patient. Fiberoptic guides or bronchoscopically guided intubation may be an option. If in doubt, prepare for a cricothyroidotomy before attempting to manage the airway with either sedation or paralytics.
Do not focus on obvious deformity, thereby forgetting to perform a complete primary survey. Rapidly diagnose other life threats, and undertake appropriate resuscitation.
Secondary survey
Diagnosis of mandibular fracture is part of the secondary survey in ED care, although it should also be kept in mind when the airway is evaluated in the primary survey.
If the patient has no airway compromise, place a Barton bandage by wrapping a gauze roll over the crown of the head and around the jaw to provide support. Wrap a second gauze roll around the forehead and the back of the head to hold the first bandage in place.
Open fractures require antibiotics. Penicillin or one of the cephalosporins is the current drug of choice. Penicillin-allergic patients can be given clindamycin. [14]
The following procedure takes a fair amount of time and usually is performed by an ear, nose, and throat (ENT) or dental consultant:
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Use the Erich arch bar to hold fractures that are stable by placing the arch bar around the base of the teeth and bending the ends around the posterior molar.
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Next, wire each tooth to the bar by wrapping a 26-gauge steel wire around the base of the tooth and then around the arch wire and twisting it tightly. If maxillary teeth are to be used as a splint, they are wired in the same manner.
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Then, use elastic bands to tie the 2 arch wires together. Remember, the patient's mouth is now banded shut. Do not perform this procedure if the patient is at risk of vomiting or has problems with the airway.
Consultations
Provide care for the patient with multiple injuries in collaboration with a surgeon who has experience in trauma care.
Definitive treatment of mandibular fractures is performed by an oral-maxillofacial surgeon or an ENT specialist.
The incidence of posttraumatic stress disorder is high among patients with facial injuries; consultation with a psychiatrist should be considered. [8, 32]
Complications
Choosing appropriate surgical management can prevent complications such as malocclusion, pain, and revision procedures. Depending on type and location of fractures, various open and closed surgical reduction techniques can be utilized. [15]
Airway compromise is a life-threatening complication in maxillofacial fracture. However, the occurrence of airway compromise following mandibular fracture was little known. Maxillofacial fractures that occurred from 2017 to 2020 were investigated retrospectively. A total of 154 patients with maxillofacial fractures were identified; mandibular fractures accounted for 93% of maxillofacial fractures. Of these, 3 cases (1.9%) required airway management at the time of initial treatment. [33]
Complications include the following:
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Loss of airway
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Aspiration of avulsed teeth
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Infection
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Nonunion
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Malnutrition and weight loss if teeth are banded together
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Injury to inferior alveolar or, more distally, mental nerve
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Posttraumatic stress disorder [32]
Medical Care
Place the patient on a diet of soft or pureed food.
Instruct the patient to return if any signs of infection are noted.
Use medications such as NSAIDs, acetaminophen, or a short course of narcotics for pain control.
Liquid preparations of medications are preferable.
If arch wires are in place, instruct the patient on release of interwire bands and provide the proper tools. Inability to release the bands can be fatal if the patient vomits or has an airway problem.
Fractures of the body of the mandible running from anterior to posterior in a downward direction (unfavorable) usually are displaced and can be stabilized with wire bar fixation of upper and lower teeth. Unstable fractures may require open reduction internal fixation if they are not reduced by wire fixation, or if they are markedly unstable.
An edentulous mandible usually is unfavorable because the patient has no teeth to stabilize the fracture. A stable nondisplaced fracture in an edentulous patient may be splinted with his or her denture, and the patient restricted to a diet of soft food. An unstable fracture usually requires internal fixation to maintain reduction.
All open fractures and unstable fractures require admission. Depending on the institution, some patients with stable fractures that require arch band fixation are treated and released from the ED; others are treated on an inpatient basis.
Prevention
Use of seat belts and airbags can reduce the incidence of facial injuries in motor vehicle crashes.
Use of a helmet with facial guards can reduce injury in motorcycle accidents and in accidents in sports such as skiing, snowboarding, hockey, and football.
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Anatomy of the mandible.
