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358
CHAPTER12 The lower jaw andface
• Damaged, loose, missing teeth (see E Chapter 13)
• Occlusal derangement, or steps in the occlusalplane.
Sublingual haematoma (submucosal blood under the tongue) is highly
suggestive of a fracture involving the lingual plate of the mandible. If
present, the air way should be reviewed regular ly in any patient tak ing
antiplatelet agents or anticoagulants (notably aspirin and warfarin), since
continued bleeding may put the airway atrisk.
Testing any suspected fracture sites can be done by gra sping the mandible on each side of the suspected site and gently manipulating it to
assess mobility. Check the patient’s occlusion and look for loose teeth.
A normal bite will have an even and almost simultaneous contact of
all the teeth. Derangement can be assessed by asking the patient to
slowly bite together. Look for premature cont acts and any teeth that
do not come into contact. Also look for any obvious bony or soft tissue
swellings.
Following injury, any missing teeth must be accounted for. If their whereabouts are unknown, request a chest and sof t tissue X- ray of the neck.
Similarly, if associated with a lip laceration, a soft tissue radiograph of the
lips is essential.
Examination of the lower jaw for non- traumatic problems follows the same
sequence. Although fractures are less likely, keep pathological fractures in
mind. These can present without an obvious history of trauma.
Approximately half of patients with a mandibular fracture will have multiple fractures present. In about 10% , three or more sites will be involved.
Therefore, if you identify one fracture, look for another (cf. pelvic fractures).
Useful investigations
Laboratory investigations
• FBC:this is usually required in all cases of suspected infec tion and
following signicant blood loss. Araised WCC is a useful guide to
severity of infection.
• Glucose:screen for diabetes (associated with spreading sepsis).
• ES R/ CRP:this is also a useful guide to severity of infection.
• Microbiology:for any pus/ discharge.
Plainlms
Preliminary investigations commonly include an orthopantomograph
(OPT), posteroanterior (PA) mandible lm, and lateral obliquelms.
Indications for performing these images are as follows:
Patients presenting witha history oftrauma and clinical suspicion ofa
fractured mandible
• Two images should be taken at 90 degrees to eachother.
• An OPT requires the patient to sit or stand upright. If this is not
possible, a lateral oblique lm can betaken.
• If a fracture of the condylar neck is suspected, a rever se Townes view
can be helpful.
• It is important that all images include the mandible in its entirety.
INJU RIE S TO THE LOWERJ AW
Pain inthejaw
• If trauma is involved, then an OPT and PA mandible are required.
• If a dentoalveolar infection is suspected, the patient needs an OPT to
examine the teeth and bone morphology.
• If the patient has had recent surgery, an OPT is indicated.
Swelling ofthejaw
An OPT should be taken to assess the dentition and underlyingbone.
Limitation ofmouth movement
• If trauma to the TMJ is suspec ted, an OPT and PA mandible should
beused.
• If dislocation is suspected, an OP T must image both the condyle and
glenoidfossa.
Altered sensation ofthe lowerlip
OP T.
Fistula/ sinus ofthesk in
OPT is required to image the teeth and underlyingbone.
CT/ M RI
Not all patients require a C T of their mandible. Indications are generally
as follows:
• Imaging complex fractures including the condylar region. With
isolated condylar fractures, this may be done as an outpatient .
• Imaging the mandible and soft tissues to identify the source and
extent of severe cer vicofacial infections (see E Chapter 5).
• Imaging the TMJ for patients with suspec ted joint ar thropathy (usually
as an outpatient).
• Imaging bone when osteomyelitis, ORN, or large cystic pathology
has been identied on plainlms.
• Imaging of suspected tumours (CT orMRI)
Ultrasound
This has a limited role in lower jaw conditions. It is useful in assessing soft
tissue swellings surrounding the lower jaw. This would be primarily to
dierentiate bet ween solid or uid lled swellings. Ultra sound also has a
role in dierentiating salivary gland swellings from lymphnodes.
359
cInjuries tothe lowerjaw
The commonest cause of patients presenting with lower jaw symptoms
will be from an injury.
Clinical features
Most patients will give a histor y of blunt injury to the face, the most common mechanism being interpersonal violence. Spor ts, falls, and accident s
are other common causes. Common symptoms include:
• Pain
• Swelling
• Alteredbite
360
CHAPTER12 The lower jaw andface
• Numbness of the lowerlip
• Diculty in opening and closing of thejaw.
The hallmark of a mandible fracture is a change in the bite (occlusion); however, a normal occlusion does not rule out a mandible fracture.
Other features include:
• Loosened/ missingteeth
• Facial deformity
• Mobility across the fracture
• Bleeding from a tear of the overlying gingivaltissue
• Sublingual haematoma (Figure12.1)
• Tris m u s .
Initial assessment
(See also E Chapter 2.) Isolated lower jaw trauma can occasionally present
as an emergency.
Airway
Obstruction can be caused by displaced or broken dentures/ teeth or
severely displaced fractures. The commonest cause is bleeding and/ or
saliva, especially if the patient is intoxicated or supine. If the patient is
supine, quickly decide if he/ she can sit up (this is possible in most isolated low- velocity injuries— see E Chapter 4), or if they need full spi-
nal protection. Sitting up will cer tainly help the airway. Saliva and blood
should be cleared by suction. Displaced fractures should be manually
reduced if possible and supported. This usually slows the bleeding.
Major bleeding is rare, but if ongoing the air way should be protected
with a denitive airway.
Bilateral anterior (‘bucket handle’) or comminuted mandibular frac-
tures can displace allowing the base of the tongue to fall back. This is
Figure12.1 Sublingual haematoma.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Man dibu lar Fra ctures’, 2014, Fi gure6 .5d, e ds M. Per ry and S. Ho lmes , Copyr ight © 2014,
Spri nger- Verl ag Lond on. Wit h permiss ion of Sp ring er Nat ure.
Parasymphyseal/
Mental 15%
INJU RIE S TO THE LOWERJ AW
much more likely when patients are supine with a reduced conscious level.
Any obstruction can be initially dealt with by gently pulling the fractured
bones forward. This provides only temporar y relief and a denitive airway will probably be required. But it may also cause fur ther bleeding.
Bleeding
Bleeding from mandibular fractures although common is not usually lifethreatening. If the patient is in shock, look for another cause. Actively
consider facial bleeding, in awake supine patients— they may be swallowing
blood. If bleeding is obvious and signicant , it must be controlled during
the primary survey. Bleeding from overlying lacerations can be controlled
either by pressure or by rapid placement of tacking sutures. These are
placed to stem bleeding and are not intended as denitive closure.
cCommon fracture patterns
The periosteum is an important structure in maint aining the stability of a
mandibular fracture. In young patients it is generally a strong unyielding
membrane. Gross displacement of the fractures only occurs after heavy
impacts. However, once the periosteum has been torn, displacement of
the bones can occur under the inuence of the attached muscles. Highenergy mandibular fractures therefore tend to be unstable.
Common fracture patterns include those shown in Figure12.2.
cAngle fractures
Fractures of the angle (wisdom tooth area) can be displaced by the
medial pter ygoid and ma sseteric muscles, depending on the frac ture
orientation (termed ‘favourable’ or ‘unfavourable’). These may pull
the posterior fragment lingually, or in an upward direction. This is only
impor tant when the periosteum has been torn allowing displacement to
occur. See Figures 12.3 and12.4.
361
Coronoid
process 2%
f
e
a
b
Body 25%
c
d
Angle 25%
Condyle 30%
g
Ramus 3%
h
Figure12.2 Com mon fr actures of the lowerjaw.
Repro duced with p ermi ssion from O’C onno r I. F. and Urd ang M., Handbook for Surgical CrossCover, Figur e9.7, p.367, Copyrigh t © 2008 with p ermissio n from Oxfor d Univers ityPr ess.
a Symphysis
b Para symphysis
c Body
d Angle
e Ramus
f Coronoid process
g Low condylar
h High condylar
362
CHAPTER12 The lower jaw andface
Figure12.3 OPT showing angle fracture.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Man dibu lar Fra ctures’, 2014, Fi gure6 .32a , eds M. Pe rry and S. H olme s, Copy righ t © 2014,
Spri nger- Verl ag Lond on. Wit h permiss ion of Sp ring er Nat ure.
Figure12.4 PA mandible showing angle fracture.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Man dibu lar Fra ctures’, 2014, Fi gure6 .32b, ed s M. Perry a nd S. Ho lmes, C opyright © 20 14,
Spri nger- Verl ag Lond on. Wit h permiss ion of Sp ring er Nat ure.
INJU RIE S TO THE LOWERJ AW
cFractures atthe symphysis and parasymphysis
The mylohyoid muscle passes between the hyoid bone and the inner
aspect of the mandible. With midline frac tures of the symphysis, the
mylohyoid and geniohyoid mus cles can act a s a stabilizing force. However,
oblique fractures will tend to overlap due to the pull of these muscles.
With bilateral parasymphyseal fractures (which result from considerable
force), the periosteum is often torn and the fragments can displace under
the inuence of the genioglossus, so- called bucket handle fractures.
cCondylar fractures
This is a common site of fracture and often occurs in association with
fractures elsewhere in the jaw. The classical history is a blow or fall onto
the point of the chin, where one or both condyles are fractured, of ten
associated with a symphyseal or parasymphyseal fracture (so- called
guardsman’s fracture). Beware the laceration over the chin following a fall—
check the condyles carefully. On mouth opening, the jaw deviates towards
the site of injur y.
Condylar fr actures in adults tend to occur outside the joint space,
although the joint can still be damaged with long- term problems. Eusion
or bleeding into the joint space can occur in the absence of a fracture,
the space is distended and the patient complains of an abnormal bite.
Intracapsular fractures in children are more common and can result in
growth disturbances in the condyle later on. See Figure12.5.
cRamus fractures
These are uncommon and usually follow a direct blow to the side of the
face. Check for other fractures (notably the z ygomatic arch). Since the
ramus is heavily enveloped in muscle the fracture does not displace too
much. Treatment is based on the patients bite, not the X- ray appearances.
363
Figure12.5 OPG showing bilateral fracture dislocations of the condyle.
Repro duced from At las of Operat ive Maxi llofaci al Trauma Su rger y:Pri mary Re pair of F acial In jurie s,
‘Man dibu lar Fra ctures’, 2014, Fi gure6 .83, ed s M. Per ry an d S. Hol mes, Co pyright © 2014 ,
Spri nger- Verl ag Lond on. Wit h permiss ion of Sp ring er Nat ure.
364
CHAPTER12 The lower jaw andface
Management
• ABCs.
• Pain relief is a pr iority and may be simply achieved by inltration of
local anaesthesia or, if possible, by an inferior dental ner veblock.
• Minimize movement across the fracture site. This reduces pain,
bleeding, and contamination of the fracture from oral bacteria:
•
Asimple method is to apply a soft neck collar but this should only
be done after the cervical spine has been formally cleared.
•
If possible, place a br idal wire across the fracture site. This is a loop
of wire encircling the teeth either side of the fracture. Care must
be taken not to avulse the teeth by over- tightening thewire.
• Any loose dentoalveolar fractures should be splinted.
Non- surgical management
This is possible if the patient is cooperative andhas:
• Aminimally displaced fracture on imaging
• With no mobility across the fractureline
• No change in occlusion
• No evidence of bleeding or infection.
Treatment involves oral analgesia , antibiotics for 1 week, and a liquid/
very soft diet for 4 weeks until a stable callus has formed. Patients still
need urgent follow- up but do not need admission.
For painful or more displaced fractures, intermaxillar y xation (IMF)
may be applied. The upper and lower teeth are xed together using wires
or elastics. This uses the upper (uninjured) teeth for support and as a
guide, to re- establish the bite and immobilize the fracture during healing.
Various devices are available to achieve this. Relative contraindications
include respiratory disease, the possibility of convulsions, a head injury
(GCS score of ≤8), and poor patient cooperation. If the patient has no
teeth (edentulous patients), modied dentures (Gunning splints) can be
ligated to the jaws to achieve a similar goal. This may be possible in the
emergency department, but usually patients need admission or transfer
to the appropriate specialty’s depar tment for this to bedone.
Surgicalrepair
This is required in displaced or mobile fractures where IMF is not suit able
or cannot be undertaken. Sur gical exposure of the fracture and anatomical reduction is carried out . The fracture is accurately reduced and xed
using titanium ‘mini’ plates or screws. This is now the preferred approach
to most mandibular fractures, resulting in faster recovery and rehabilit ation. However, there is potentially more mor bidity, especially injury to
the inferior alveolar nerve and tooth roots. The patient still requires a
soft diet for the same period of time. Keep the patient fasted and refer to
maxillofacial (or appropriate specialty).
TEMPOROMANDIBULAR JOINT DISLOCATION
cTemporomandibular joint dislocation
TMJ dislocation occurs when the condyle is displaced anterior ly out of
its socket, the glenoid fossa, and is prevented from returning to the correct position. It becomes trapped anterior to ar ticular eminence. See
Figure12.6.
Spasm of the powerful masticator y muscles then prevents its reloca-
tion. It usually occurs with an audible pop at times of ma ximal mouth
opening, i.e. yawning, or following an injury to the jaw when the mouth is
open. Radiographs are not normally required unless there is a history of
trauma— to make sure it is not a fracture/ dislocation.
The patient will attend with a mouth that is propped open, they cannot
close or move the jaw and this will be associated with drooling.
Management
There are many ways to relocate a dislocated jaw. The trick is muscle
and patient relaxation (analgesia and sedation). The TMJ is an intrinsically unstable joint and it is the spasm in the powerful masticator y muscles that prevents relocation in many cases. Relocation therefore of ten
requires analgesia and a parenteral short- acting muscle rela xant (e.g.
midazolam). Entonox is also a very good drug to use. Local anaesthesia
injected directly into the muscles of mastication (both sides) is also very
helpful. Whatever you use, give this plent y of time to take eect.
The patient is then sat with their back and head resting against a wall.
Stand in front and place your thumb(s) inside the patient’s mouth, just
posterior to the last st anding mandibular teeth. Apply downward and
365
Figure12.6 TMJ dislocation.
366
CHAPTER12 The lower jaw andface
posterior pressure from your thumb(s) and at the same time push up
with your ngers on the under sur face of the chin. If fully relaxed, the
joint(s) should pop back into position and the mouth can fullyclose.
Be mindful to wrap gauze around your thumbs to avoid trauma when
the patient bites down. Once reduced, place a barrel bandage around
the patient’s head for 30 minutes and monitor closely if parenteral sedative or a muscle relaxant wasgiven.
If this does not work or the jaw immediately dislocates again, refer to
maxillofacial for advice.
Patients with dislocation cannot close their wide open mouths. This is a
common cause of confusion. If the patient cannot open their mouth or it is
only slightly open it is not a dislocation.
cInfective swellings aroundthe
lower jaw andface
General considerations
Acute swellings around the lower jaw are usually due to bacterial infections in the adjacent fascial spaces. These may be localized at rst but
they can quickly become widespread. Most often they arise from an under-
lying dental infection. However, there are other causes (such as infections
of bone cysts, skin lesions, or the salivary glands). Infections localized
only to the skin (cellulitis) may also occur. Untreated, some infections
can rapidly progress and become life- threatening. Spread of infection
depends on the local anatomy, particularly the point of origin of the
infec tion (i.e. which tooth). Virulence of the organism and host resistance
are also important factors.
Fascial spaces related tothe mandible
The mylohyoid muscle divides the oor of the mouth into t wo large
spaces— the sublingual space above the muscle and the submental and
submandibular spaces belowit.
Sublingualspace
This is a horseshoe - shaped space passing from one side of the oor of
the mouth to the other. The superior limit of this space is the tongue
and the inferior limit is the mylohyoid. It contains the sublingual glands
and the deep lobes of the submandibular glands. It communicates posteriorly with the submandibular spaces. Swelling here is potentially very
serious because of the threat to the airway. The tissues are delicate and can
easily distend, pushing the tongue up and back. Usually infections here
are associated with swelling in one or both submandibular spaces. They
are almost always due to dental infections. When signicant swelling is
present, urgent decompression is required.
Submandibularspace
This is triangular in shape, bounded above by the mylohyoid muscle
(medially) and mandible (laterally), and below by the deep cervical fascia.
It contains lymph nodes, the supercial lobe of the submandibular gland,
and blood vessels. It communicates with the sublingual space above,
the supercial facial space laterally, and the deep pter ygoid space and
INFECTIVE SWELLINGS AROUND THE LOWE R JAW ANDFACE
paraphar yngeal spaces posteriorly. Surgical access can be made 2– 3cm
below the lower border of the mandible. Skin and subcutaneous tissues
are incised and sinus forceps are used to penetr ate the deep cervical
fascia towards the lingual side of the mandible.
Submentalspace
This is contained by the two anter ior bellies of the digastric muscles.
Above is the mylohyoid muscle and below is the deep cervical fascia,
covered by platysma and skin. It contains submental lymph nodes and
communicates with the submandibular space. Surgical access is obtained
behind the chin prominence in theneck.
Buccalspace
This is a commonly aected space and often presents to casualty as a ‘fat
face’. Infections can spread into it from both mandibular and maxillary
teeth. It is bounded by the buccinator muscle anteromedially, and the masseter muscle posteromedially. Later ally is the deep fascia from the parotid
capsule and the overlying platysma. The inferior boundar y is the insertion
of the deep fascia into the mandible, and its superior boundar y the z ygomatic arch. It s contents are the buccal fat pad. Posteriorly it is continuous
with the pterygoid space. Surgical access is usually obtained from within
the mouth. If the abscess points onto the skin, an incision can be made
externally, but a scar will result.
Masticatorspace
This is bounded laterally by the temporalis facia, zygomatic arch, and
masseter muscle, and medially by the medial and lateral pterygoid muscles. The temporalis muscle and mandibular ramus further divide this
space into supercial and deep compar tments. The super cial compartment contains the submasseteric space below and the supercial
temporal space above. The deep compar tment contains the supercial
pter ygoid space (or pterygomandibular space) below and the deep temporal space above. The supercial pterygoid space communicates with
the deep pterygoid space. The super cial and deep temporal spaces
together are also known as the infratemporal fossaspace.
eLudwig’sangina
This is a rapidly spreading, tense cellulitis of the submandibular, sublingual, and subment al spaces bilaterally. When advanced it is an obvious
diagnosis, with gross swelling both in the neck and the mouth. Earlier
infections still need to be treated seriously and need urgent referral.
Ludwig’s angina is a potential airway emergency which if not diagnosed and
treated quickly has a mortality rate of around 75% within the rst 12– 24
hours. With aggressive surgical intervention, good airway control, and
antibiotics this r ate has now droppedto5%.
Usually the cause is a submandibular space infection secondar y to an
infected wisdom tooth. Other causes include tonsillitis, infected mandibular fractures, and submandibular sialadenitis. From the submandibular
space, the infection spreads to the sublingual space around the deep lobe
of the submandibular gland. It then passes to the contralateral sublingual space and thence to the other submandibular space. The submental
space is also aected by lymphatic spread. Infection can also originate in
the sublingual space and spread laterally to both sides. Left untreated,
367