Emergency Medicine

TRAUMATIC CONDITIONS OF THE FACE AND MOUTH

430 Maxillofacial and Dental Emergencies

Fractured mandible

DIAGNOSIS

1 This is due to a blow on the jaw causing a unilateral or frequently bilateral

fracture. Occasionally, the temporomandibular joint may be dislocated or

the condylar process driven up into the temporal bone, causing bleeding and

deformity of the external auditory canal.

2 Look for localized pain, particularly on attempted jaw movement, and

malocclusion.

3 Examine inside the mouth for bruising or bleeding of the gum and disconti-

nuity of the teeth, if there is a displaced fracture.

(i) Assess for numbness of the lower lip if the inferior dental nerve

has been damaged in its course through the mandible.

4 Request X-rays including an anteroposterior view, with a panoramic ortho-

pantomogram (OPG) or lateral views of the mandible.

MANAGEMENT

1 Clear the airway of any clots or debris, and ensure that the tongue or a

portion of the mandible does not slip back and occlude the pharynx.

2 Refer any unstable or grossly displaced injuries immediately to the maxillo-

facial surgery team.

3 Otherwise, give the patient tetanus prophylaxis and antibiotics for an un-

displaced fracture, as many fractures are compound into the mouth.

(i) Give amoxycillin 875 mg and clavulanic acid 125 mg one tablet

orally b.d. for 5 days.

4 Refer the patient to the next maxillofacial surgery clinic.

Dislocated mandible

DIAGNOSIS

1 Dislocation may occur spontaneously after yawning or it may follow a blow

to the jaw. It may be unilateral or more commonly bilateral and may become

recurrent.

2 The mouth is stuck open and is painful.

3 Consider and exclude drug-induced dystonia to metoclopramide or pheno-

thiazines on direct questioning, as this may mimic or even predispose to

dislocation.

(i) Give benztropine (benzatropine) 1–2 mg i.v. followed by 2 mg

orally once daily for up to 3 days if this is a dystonic reaction (see

p. 327).

4 Request an AP and lateral X-ray of the temporomandibular joints to exclude

an associated fracture, unless the dislocation was spontaneous or recurrent.