Fracture, Jaw (Mandible and Maxilla)

Risk: Individuals between the ages of 20 and 29 years are the most frequently affected group, and men are approximately 3 times more likely than women to sustain a broken jaw (Keim).

History: Individuals who suffer facial trauma severe enough to fracture the maxilla or mandible may be unconscious or unable to speak. A clear description of the events leading up to the trauma should be obtained from the individual or witnesses. The mechanism of injury, including the magnitude, location, and direction of impact, is especially important. Since injuries associated with severe facial trauma can be life-threatening, resuscitation, evaluation of all injuries, and stabilization of the individual take priority. When a history can be obtained, it is important to determine if there was loss of consciousness or any changes in mental status, vision, hearing, or the way the teeth come together (occlusion). A complete medical history may be obtained, including medical conditions (especially any underlying bone disease, neoplasia, arthritis, or temporomandibular joint dysfunction), medications, allergies, and occupation.

The most common symptom is jaw pain. Individuals may report a feeling that the teeth do not fit together correctly (malocclusion), may be unable to open the jaw fully, have problems speaking, or have swelling of the jaw. Biting down may cause pain. Movement of the jaw may cause muscle spasm or produce a grinding sound. There may be areas of numbness or tingling on the face, chin, or lower lip due to nerve damage. Individuals may bleed from the nose or the mouth, or may note clear fluid running from the nose or ears. There may be associated wounds of the face or mouth or dental injuries. There may also be bruising under the tongue or a cut in the ear canal due to the backward movement of the broken jawbone.

During the evaluation, the physician should always assess the potential of physical abuse having caused the injury.

Physical exam: This discussion is limited to findings specific to the maxilla and mandible.

Again, a thorough physical examination to rule out concomitant injuries is important. Physical examination begins with inspection of the face from all angles for asymmetry, open wounds, and foreign bodies. The entire mandible (including the condyle near the ear) is examined gently with the fingers (palpated) for any areas of tenderness, swelling, or discontinuity (“step-off”). The mouth is inspected for bleeding, edema, or ecchymosis. Teeth are checked for stability, bleeding at the gumline, and malocclusion. Loose and fractured teeth should be evaluated and counted. If teeth are missing, a chest radiograph may be taken to rule out aspiration. The nasal cavity is examined carefully for any fresh or old blood as well as clear cerebrospinal fluid. The eyes are examined for visual acuity (near and far vision), extraocular motion (ability of the eyes to move in all directions), integrity of the bony orbits, and bruising.

For maxillary (Le Fort) fractures, physical examination findings may include facial distortion in the form of an elongated face, a mobile maxilla, or midface instability and malocclusion. Maxillary fractures are classified by location: Le Fort I is a transverse fracture of the maxilla just above the teeth; Le Fort II is a pyramid fracture of the maxilla, the apex of which is above the bridge of the nose and extends laterally and inferiorly through the infraorbital rims; and Le Fort III is complete craniofacial disruption with fractures of the zygoma, infraorbital rims, and maxilla. Le Fort III fractures are most common with massive trauma, as in high speed motor vehicle accidents. This injury requires significant force and, therefore, is relatively uncommon in athletes. However, it may be observed with an injury from a hockey puck, baseball pitch, or baseball bat. Athletes with this injury may report double vision (diplopia), malocclusion, or numbness.

Tests: If the fracture is an isolated injury, laboratory tests may be requested before surgery. If there has been major trauma, laboratory tests will be performed as part of the standard trauma protocol in the Emergency Department.

If an isolated mandibular fracture is suspected, a panoramic radiograph (Panorex) is preferred because this view shows the entire mandible in one plane. Since the specialized equipment for this view is not always available, routine films of the mandible are often done. If the results indicate a need for additional information, a CT scan is performed. Computerized tomography images in both the axial and coronal planes, along with a panoramic radiograph, afford an excellent representation of the mandible.

Plain radiographs are less helpful for maxillary and facial injuries but are important in ruling out injuries to the cervical spine. A CT scan is extremely useful in maxillofacial trauma. CT can depict all portions of the mandible in three planes, given sagittal and coronal reconstructions, but direct coronal views are most helpful. Besides identifying the fracture, determining the degree of fragment displacement is easier with CT than with plain radiography.

Finally, if a broken tooth or dentures are incidentally detected, chest radiography should be performed to rule out the aspiration of teeth or other dental hardware.

For simple, isolated fractures of the jaw, a special rehabilitation protocol is rarely indicated. The rehabilitation depends on the location, severity and type of stabilization (operative, nonoperative). The literature supports early mobilization once the fracture is stable, without the use of postoperative jaw wiring (Kaplan).

If indicated, an occupational therapist can provide assistive devices for drinking and eating. Depending on the severity and etiology of the fracture, a gentle general conditioning program may be beneficial.

Additional information may provide insight into the rehabilitation needs of these individuals (Dimitroulis).