A patient who fell from a two‑wheeler and sustained impact to the mandible presents with mandibular swelling, tenderness, and trismus. What is the appropriate next step in evaluation and management?

Immediate Imaging with CT Maxillofacial

Obtain a CT maxillofacial (MDCT) with multiplanar reformations immediately—this is the gold standard for evaluating mandibular fractures and is nearly 100% sensitive for detecting fractures, comminution, and displacement that will determine your surgical management 1.

Why CT is Essential in This Case

The clinical presentation of mandibular swelling, tenderness, and trismus following direct trauma strongly suggests a mandibular fracture. CT is superior to all other imaging modalities because:

• Nearly 100% sensitivity for mandibular fractures with excellent interobserver agreement 1
• Critical for detecting posterior fractures (ramus, condyle, subcondylar) where displacement can be subtle—these are easily missed on plain films 1
• Identifies comminution and displacement, which directly change surgical management from closed to open reduction 1
• 3D reconstructions are essential for preoperative planning, particularly since 67% of mandibular fractures involve two separate sites due to the ring-like configuration of the mandible 1
• Faster acquisition and less dependent on patient positioning than radiography—important when trismus limits mouth opening 1

Why Not Plain Films?

While orthopantomogram (OPG) has 86-92% sensitivity for simple fractures 1, it has critical limitations:

• Misses condylar and subcondylar fractures with anterior displacement 1
• Misses nondisplaced/minimally displaced anterior fractures overlapping the cervical spine 1
• Can mistake complex fractures for isolated fractures 1
• Use of OPG has become less favorable in emergency/trauma settings 1

Given the mechanism (two-wheeler fall with direct mandibular impact) and presence of trismus, there is high clinical suspicion warranting CT, not plain films.

Critical Assessment Points During Evaluation

Look for the Second Fracture

67% of mandibular fractures have two separate fracture sites 1. Common patterns:

• Mandibular angle/subcondylar fracture with contralateral parasymphyseal fracture
• Flail mandible: bilateral subcondylar fractures with symphyseal fracture 1

Assess for Associated Injuries

• 39% have coexisting intracranial injuries 1
• 20-40% have other injuries beyond the mandible 1
• Consider head CT if any signs of head trauma, altered mental status, or loss of consciousness 1
• Consider cervical spine imaging—11% have cervical spine injuries with mandibular fractures 1

Evaluate for Nerve Injury

Check for inferior alveolar nerve damage (anesthesia of ipsilateral lower lip, chin, anterior tongue, mandibular teeth) if fracture extends through mandibular canal 1

Treatment Algorithm Based on CT Findings

Operative Management Indicated If:

• Displaced fractures
• Comminuted fractures
• Multiple fracture sites
• Malocclusion present
• Condylar fractures with significant displacement

Fixation Approach:

• Open reduction with internal fixation (ORIF) using miniplates is standard for most fractures requiring surgery 2, 3, 4
• Intraoral approach has equivalent infection rates to extraoral approach (5.9% vs 10%, no significant difference) 5
• Consider dual plating for optimal stability in symphysis, parasymphysis, and angle fractures 6

Closed Management May Be Appropriate If:

• Nondisplaced fractures
• Favorable fracture patterns
• Normal occlusion maintained
• Use intermaxillary fixation (IMF) when indicated 7

Common Pitfalls to Avoid

1. Missing the second fracture site—always complete the ring assessment 1
2. Relying on plain films alone—they miss posterior and minimally displaced fractures 1
3. Overlooking associated head/cervical spine injuries in high-energy mechanisms 1
4. Delaying imaging for "low suspicion"—this patient has clear clinical indicators (swelling, tenderness, trismus) warranting immediate CT 1