Mandible Fracture Treatment & Management

Updated: Oct 22, 2016
  • Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Prehospital Care

Airway, breathing, and circulation are the first priority. Hold 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 airway free of blood and debris.

Place 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.

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Emergency Department Care

Airway, breathing, and circulation

Frequently assess airway. Isolated mandible 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 projected course.

Before using paralytics in an intubation, carefully evaluate the ability to manage the airway with a bag and mask or laryngeal airway. If unable to manage the airway, do not paralyze the patient. Fiber optic guides or bronchoscopic-guided intubation may be an option. If in doubt, prepare for a cricothyrotomy before attempting 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 of ED care, though it should be kept in mind when evaluating the airway in the primary survey.

A Barton bandage can be placed if the patient has no airway compromise by wrapping a gauze roll over the crown of head and around the jaw to provide support. Wrap a second gauze roll around forehead and back of head to hold first bandage in place.

Open fractures require antibiotics. Penicillin or one of the cephalosporins are current DOC. Penicillin-allergic patients can be given clindamycin. [23]

The following procedure takes a fair amount of time and usually is performed by an ear, nose, and throat (ENT) or dental consultant.

Erich arch bar can be used to hold fractures that are stable by placing arch bar around the base of the teeth and bending ends around the posterior molar. Next, wire each tooth to the bar by wrapping a 26-gauge steel wire around base of tooth and then around arch wire and twisting it tight. If maxillary teeth are to be used as a splint, they are wired in the same manner. Then, use elastic bands to tie the 2 arch wires together. Remember, patient's mouth is now banded shut. Do not perform this procedure if the patient has a risk of vomiting or has problems with the airway.

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Consultations

Provide care for the multiple-injured patient in conjunction 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 in patients with facial injuries, and consultation with a psychiatrist should be considered. [7, 18]

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Medical Care

Place patient on a diet of soft or pureed food.

Instruct patient to return if any signs of infection are noted.

Medications such as NSAIDs, acetaminophen, and a short course of narcotics can be used for pain control.

Liquid preparations of medications are preferable.

If arch wires are in place, instruct patient on release of interwire bands and give proper tools. Inability to release 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 and 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 institution, some patients with stable fractures that require arch band fixation are treated and released from ED, while others are treated on an inpatient basis.

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Complications

Complication include the following:

  • Loss of airway
  • Aspiration of avulsed teeth
  • Infection
  • Nonunion
  • Malnutrition and weight loss if teeth are banded together
  • Injury to inferior alveolar or, more distally, mental nerve
  • Posttraumatic stress disorder [18]
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Prevention

Use of seat belts and airbags can reduce incidence of facial injuries in motor vehicle crashes.

Use of helmet with facial guards can reduce injury in motorcycle accidents and accidents in such sports as skiing, snowboarding, hockey, and football.

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