Mandibular fractures are common and may need emergency treatment, especially if there is any compromise of the airway. Dislocation of the temporomandibular joint can occur as a result of direct trauma but more often occurs as a result of excessive opening of the mandible, such as when yawning or during dental procedures.
When a blow to the mandible causes a fracture there are often other fractures too and these must be sought:
- Trauma to one side often produces an ipsilateral body fracture and a contralateral subcondylar fracture.
- A heavy blow to the symphysis produces a symphyseal fracture and bilateral subcondylar fractures.
- It is also important to exclude damage to the cervical spine and to ascertain that the airway is not compromised.
- Fractures of the mandible are common.The most commonly fractured sites are the body of the mandible, condyle, angle, symphysis, ramus and the coronoid process.
- The cause of the injury may be road traffic accidents, assault, falls, industrial injuries or sports injuries but the relative number of each varies considerably between countries and areas.
- Under the age of 25, dental trauma accounts for more lost teeth than caries or gum disease.
- In terms of violence, young males are most at risk with alcohol an aggravating factor.
- Women and children are much less at risk but can be from domestic violence.
The history may indicate the site and direction of force, the possible presence of other injuries (especially to the neck) and other relevant features such as loss of consciousness and head injury.
- Note any abnormality in facial contour and shape of the mandible as well as tenderness, swelling, redness, lacerations or haematoma.
- Check movements of the mandible and malocclusion.
- Loose and fractured teeth should be evaluated and counted.
- If teeth are missing and unaccounted for, consider CXR in case of inhalation.
If the mucosa is intact, clinical findings may be limited to bruising. If the mandibular branch of the trigeminal nerve (the inferior alveolar or mental nerve) has been injured, there will be paraesthesia or anaesthesia of the chin. Documenting this and any damage to the marginal mandibular nerve branch of the facial nerve is important before surgery.
Spasm of the muscles of mastication can produce trismus that impairs a proper oral examination. The pull of muscles may reduce or distract a fracture. Facial oedema, erythema, and pain may also occur.
Some fractures can result in the posterior displacement of the tongue and lead to airway compromise. The airway obstruction requires immediate attention.
- There are a number of views of plain X-rays that give a good picture of the mandible, teeth and their roots. A panoramic view is especially useful.
- CXR may also be required if teeth are unaccounted for.
- CT scanning gives excellent detail and is very helpful in planning management.
A patient with teeth that may be loose or knocked out requires immediate referral to a dentist if other injuries do not override that consideration.
Fractures in the region of the teeth must be considered as compound fractures, as there is a risk of infection from the oral cavity. An open laceration may overlie a compound fracture.
Treatment is usually surgical but a conservative approach may be acceptable for children with a greenstick fracture or the elderly edentulous patient with minimal displacement. Support to the jaw may relieve discomfort. Chewing should be minimised or avoided with a liquid or puréed diet.
A surgical approach is often advocated nowadays where a conservative line may have been acceptable before.
- Pre-operative and peri-operative antibiotics are used to reduce the risk of infection.
- Closed reduction may be achieved or open reduction permits direct inspection and mechanisms to stabilise the fracture.
- Wire tends to be reserved for children and titanium plates and screw fixation are often used in adults.
- Mandibulo-maxillary fixation (MMF) may be required:
- Children have MMF for four weeks, adults for six weeks; however, the elderly may require eight weeks.
- Patients with condylar fractures must have MMF removed by two weeks, and aggressive physiotherapy is required to prevent ankylosis.
- MMF requires tube feeding of a liquid or puréed diet and attention to oral hygiene.
- Implants may be used to correct deformity.Teeth on the fracture line rarely need removal.
Pre-operative antibiotics reduce the frequency of infection considerably.
Complications may be related to the trauma to the mandible or related trauma.
- Delay in fixing the fractured mandible increases the risk of complications but neurological complications or other problems such as airway compromise may make this inevitable.
- If there is bilateral fracture of the body of mandible, parasymphyseal, or condylar fractures, there is risk of impairment of airways, as the muscular action pulls the distal mandibular segment backwards, allowing the tongue to obstruct the oropharynx.
- There may also be nerve damage:
- In neuropraxia, function takes 4-6 weeks to return; however, in neurotmesis, function takes around 18 months to return, if it returns.
- Infection increases complications including malunion or non-union.
- Ankylosis can result in poor ability to open the mouth.
- The psychological implications of facial trauma are such that the risk of post-traumatic stress disorder is increased in this condition.[5, 6]
- Mouth guards in sport reduce the incidence of trauma to the mandible.[7, 8]
- They do not have an adverse effect on aerobic performance.
- The mouthguard needs to be appropriate to the individual and to the sport.[10, 11]
The condyle becomes locked when it has extended too far forward (in relation to the eminence) and spasm of the pterygoid and masseter muscles prevent it from moving back.
Associated spasm and oedema produce extreme discomfort and anxiety for a patient who can't speak because they are unable to close their mouth.
- Shallow mandibular fossa in the temporal bone.
- Weak or torn temporomandibular joint (TMJ) ligaments.
- Underdeveloped condyle of the mandible.
- Connective tissue diseases - eg, Marfan's syndrome or Ehlers-Danlos syndrome.
- Neuroleptic use (orofacial spasm).
- Anatomical abnormality of the fossa/interior articular eminence.
- Dislocation can occur bilaterally, or unilaterally, with jaw locked open symmetrically or deviating to one side (opposite to dislocation).
- Palpation shows TMJ anterior to the articular eminence.
- Usually occurs during maximum opening of mouth - eg, during yawning, laughing, prolonged dental work or an epileptic seizure.
- May also be secondary to trauma.
X-ray of the jaw to exclude fracture in addition to the dislocation.
Relief of pain and muscle spasm - eg, using intravenous benzodiazepine with or without an opioid or by using an injection of local anaesthetic into the condylar area.
For reduction of the dislocation:
- Face the patient with your thumbs on the lower molars or on the ridge of the mandible behind the molars, and your fingers placed externally around the inferior border of each side of the mandible (near the angles).
- Your thumbs should be protected with thick wrapping of gauze or tongue depressors wrapped in gauze.
- Apply firm, steady pressure in a downward and posterior direction.
- Reduction can be performed one side at a time if bilateral reduction is not possible.
- X-rays should be obtained to exclude fracture of the mandibular condyles caused by the reduction.
- Patients should eat a soft diet for one week.
- Avoid wide opening of mouth; place fist under chin when yawning.
- Prescribe analgesics and muscle relaxants. Local heat may offer relief.
- Refer to oral or maxillofacial surgeon for follow-up.
Chronic and recurrent dislocation
- The management is divided into two stages, initially conservative with surgical options used if conservative methods are unsuccessful.
- The conservative method includes the use of various sclerosing agents like alcohol, sodium tetradecyl sulfate, sodium psylliate, morrhuate sodium, and platelet-rich plasma injected into the joint space.
- The use of autologous blood in recurrent dislocation is very popular. It is based on the principle to restrict mandibular movements by inducing fibrosis in the upper joint space, the pericapsular tissues, or both.
- In the case of chronic protracted dislocation, elastic rubber traction with arch bars and ligature wires/intermaxillary fixation with elastic bands are useful to achieve the reduction.
- In recurrent cases, surgical options include either eminectomy or siting a mini-plate on the articular eminence.[13, 14]
Further reading and references
Caminiti MF, Weinberg S; Chronic Mandibular Dislocation: The Role Of Non-Surgical and Surgical Treatment
Nasser M, Pandis N, Fleming PS, et al; Interventions for the management of mandibular fractures. Cochrane Database Syst Rev. 2013 Jul 87:CD006087. doi: 10.1002/14651858.CD006087.pub3.
Gassner R, Tuli T, Hachl O, et al; Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg. 2003 Feb31(1):51-61.
Hoenig JF; Sliding osteotomy genioplasty for facial aesthetic balance: 10 years of experience. Aesthetic Plast Surg. 2007 Jul-Aug31(4):384-91.
Cranio-Maxillary-Facial Injuries; Wheeless' Textbook of Orthopaedics
Glynn SM, Asarnow JR, Asarnow R, et al; The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. 2003 Jul61(7):785-92.
Glynn SM, Shetty V, Elliot-Brown K, et al; Chronic posttraumatic stress disorder after facial injury: a 1-year prospective cohort study. J Trauma. 2007 Feb62(2):410-8
Patrick DG, van Noort R, Found MS; Scale of protection and the various types of sports mouthguard. Br J Sports Med. 2005 May39(5):278-81.
Knapik JJ, Marshall SW, Lee RB, et al; Mouthguards in sport activities : history, physical properties and injury prevention effectiveness. Sports Med. 200737(2):117-44.
Kececi AD, Cetin C, Eroglu E, et al; Do custom-made mouth guards have negative effects on aerobic performance capacity of athletes? Dent Traumatol. 2005 Oct21(5):276-80.
Choy MM; Children, sports injuries & mouthguards. Hawaii Dent J. 2006 Sep-Oct37(5):11-3.
Lieger O, von Arx T; Orofacial/cerebral injuries and the use of mouthguards by professional athletes in Switzerland. Dent Traumatol. 2006 Feb22(1):1-6.
Sharma NK, Singh AK, Pandey A, et al; Temporomandibular joint dislocation. Natl J Maxillofac Surg. 2015 Jan-Jun6(1):16-20. doi: 10.4103/0975-5950.168212.
de Almeida VL, de S Vitorino N, de O Nascimento AL, et al; Stability of treatments for recurrent temporomandibular joint luxation: a systematic review. Int J Oral Maxillofac Surg. 2016 Mar45(3):304-7. doi: 10.1016/j.ijom.2015.10.022. Epub 2015 Nov 23.
Cardoso AB, Vasconcelos BC, Oliveira DM; Comparative study of eminectomy and use of bone miniplate in the articular eminence for the treatment of recurrent temporomandibular joint dislocation. Rev Bras Otorrinolaringol (Engl Ed). 2005 Jan-Feb71(1):32-7. Epub 2006