What is the management and treatment for a patient with a bilateral mandible fracture?

Management of Bilateral Mandible Fracture

Immediately secure the airway with tracheal intubation, as bilateral mandible fracture is an absolute indication for intubation due to risk of airway obstruction from loss of tongue support and creation of a "flail mandible." 1

Immediate Airway Management

• Bilateral mandible fractures mandate tracheal intubation according to the Association of Anaesthetists guidelines, listed explicitly as an indication for intubation in trauma patients 1
• The bilateral fracture creates a "flail mandible" with loss of support for tongue muscles, causing upper airway obstruction that can occur immediately or develop over days 2
• Use rapid sequence induction with manual in-line cervical spine stabilization, maintaining head-up tilt to prevent aspiration 1
• Employ high-dose fentanyl (3-5 µg/kg) or alfentanil (10-20 µg/kg), followed by induction agent maintaining MAP, and neuromuscular blockade with suxamethonium 1.5 mg/kg or rocuronium 1 mg/kg 1
• Maintain systolic BP >110 mmHg and MAP >90 mmHg during intubation 1

Diagnostic Imaging

Obtain CT maxillofacial with multiplanar reformations immediately—this is the gold standard with nearly 100% sensitivity for detecting mandibular fractures. 3, 4

• CT is superior to conventional radiography (which has only 86-92% sensitivity) and is essential for detecting subtle nondisplaced fractures, posterior mandibular fractures, and condylar fractures 1, 4
• Always search for a second fracture after identifying the first, as 67% of mandibular fractures involve two separate fracture sites due to the U-shaped ring configuration 1, 3, 4
• Common paired patterns include: mandibular angle or subcondylar fracture with contralateral parasymphyseal fracture, or bilateral subcondylar fractures with symphyseal fracture (flail mandible) 1, 3
• Request 3-D reconstructions for surgical planning, particularly for characterizing comminution and displacement 1, 4

Screen for Critical Associated Injuries

Obtain CT head in addition to maxillofacial CT, as 39% of mandibular fracture patients have coexisting intracranial injuries. 1, 3, 4

• Evaluate cervical spine (injured in approximately 11% of cases)—this is a commonly overlooked injury with devastating consequences if missed 3, 4
• Assess for inferior alveolar nerve damage by testing for anesthesia/paresthesia of lower lip, chin, anterior tongue, and mandibular teeth, which occurs when fractures extend through the mandibular canal 1, 4
• Approximately 20-40% of patients have additional injuries beyond the mandible 1, 3

Definitive Management

Arrange immediate oral and maxillofacial surgery consultation for definitive surgical management. 4

• Treatment depends on fracture displacement, comminution, and occlusion derangement 5, 6
• Bilateral cases with displaced fragments and dislocated condylar processes typically require open reduction with internal fixation 5
• Unilateral cases with deranged occlusion may be managed with closed reduction and maxillomandibular fixation 5
• Non-displaced fractures without occlusion derangement may be treated conservatively with medication for symptomatic relief 5

Critical Pitfalls to Avoid

• Never miss the second fracture—this is the most critical error given the 67% incidence of paired fractures; systematically examine the entire mandible on CT 3, 4
• Never rely on conventional radiography alone, which misses subtle fractures and has significantly lower sensitivity than CT 4
• Never overlook cervical spine injuries, present in 11% of cases 3, 4
• Never dismiss the possibility of intracranial injury, occurring in 39% of mandibular fracture patients 3, 4
• Never delay airway management—bilateral mandible fractures can cause airway obstruction immediately or develop over days post-trauma 2