Mandible CPG

CLINICAL PRACTICE GUIDELINE
Philippine Journal Of Otolaryngology-Head And Neck Surgery Supplement Issue November 2021
José Florencio F. Lapeña Jr., MA, MD1,2*±, Joselito F. David,

BS, MD2,3*±, Ann Nuelli B. Acluba - Pauig, BS, MD2*, Jehan
Grace B. Maglaya, BS, MD2,4, Enrico Micael G. Donato, BS,
Management of Isolated Mandibular
MD2,5*, Francis V. Roasa, BS, MD3, Philip B. Fullante, BS,
MD1, Jose Rico A. Antonio, BS, MD6*, Ryan Neil C. Adan, Body Fractures in Adults
MD2, Arsenio L. Pascual III, BS, MD7*, Jennifer M. de Silva-
Leonardo, MD, MMHoA5, Mark Anthony T. Gomez, MD,
MPM2,8, Isaac Cesar S. De Guzman, BS, MD8,9, Veronica
Jane B. Yanga, RN, MD2, Irlan C. Altura, RMT, MD10, Dann
Joel C. Caro, RN, MD10, Karen Mae A. Ty, RN, MD8, and
the Guideline Development Group* (Elmo R. Lago Jr.,
MD, MClinAud4*, Joy Celyn G. Ignacio, BS, MD2*, Antonio ABSTRACT
Mario L. de Castro, BS, MD11*, Policarpio B. Joves Jr., BS,
MD12*, Alejandro V. Pineda Jr., BS, MD13*, Edgardo Jose B.
Tan, BS, MD14*, Tita Y. Cruz, MA, EdD15*, Eliezer B. Blanes,
DMD16*, Mario E. Esquillo, DMD17*, Emily Rose M. Dizon, Objective
BS, MD18*, Joman Q. Laxamana, BS, MD19*, Fernando T. The mandible is the most common fractured craniofacial bone of all craniofacial fractures
Aninang, BS, MD19*, Ma. Carmela Cecilia G. Lapeña, BA,
MA20*). in the Philippines, with the mandibular body as the most involved segment of all mandibular
*Guideline Development Group fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and
±Co-first Authorship; these authors contributed equally to the work. management of mandibular body fractures in particular. General guidelines include the American
1
Department of Otolaryngology-Head and Neck Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual
Surgery, University of the Philippines College of Medicine
and Philippine General Hospital; 2Department of
of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association
Otolaryngology – Head and Neck Surgery, East Avenue of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial
Medical Center; 3Department of Otolaryngology -
Head and Neck Surgery, University of Santo Tomas; Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic
4
Department of Otorhinolaryngology - Head and Neck Review on interventions for the management of mandibular fractures. On the other hand, a
Surgery, University of the East – Ramon Magsaysay
Memorial Medical Center Inc.; 5Department of very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture
Otolaryngology – Head and Neck Surgery, Manila
Central University - Filemon D. Tanchoco Medical of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the
Foundation Hospital; 6Department of Ear, Nose, prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and
Throat, Head and Neck Surgery, Rizal Medical Center;
7
Department of Otolaryngology - Head and Neck management, this clinical practice guideline focuses on the management of isolated mandibular
Surgery, Quezon City General Hospital; 8Department
of Otolaryngology-Head and Neck Surgery, Jose body fractures in adults.
R. Reyes Memorial Medical Center, 9Department
of Otolaryngology-Head and Neck Surgery, De La
Salle University Medical Center, 10Department of Purpose
Otolaryngology-Head and Neck Surgery, Ilocos
Training and Regional Medical Center,11Department of This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as
Orthopedic Surgery, Veterans Memorial Medical Center; well as primary care and specialist physicians, nurses and nurse practitioners, midwives and
12
Office of the Medical Director, Far Eastern University
– Nicanor Reyes Memorial Foundation Medical Center; community health workers, dentists, and emergency first-responders) who may provide care
13
Department of Family Medicine, University of Santo
Tomas Hospital; 14Department of Anesthesiology, to adults aged 18 years and above that may present with an acute history and physical and/
University of Santo Tomas Hospital; 15School of or laboratory examination findings that may lead to a diagnosis of isolated mandibular body
Nursing, Far Eastern University – Nicanor Reyes
Memorial Foundation Medical Center; 16Department fracture and its subsequent medical and surgical management, including health promotion and
of Dental Medicine, St. Jude Hospital and Medical
Center;17Department of Dental and Oral Medicine,
disease prevention.
De Los Santos – STI Medical Center;18Department of
Radiology, East Avenue Medical Center;19Motorcycle
Philippines Forum, East Avenue Medical Center Rider’s It is applicable in any setting (including urban and rural primary-care, community centers,
Club; 20Multimedia Arts Program, School of Design and treatment units, hospital emergency rooms, operating rooms) in which adults with isolated
Arts, De La Salle - College of St. Benilde.
mandibular body fractures would be identified, diagnosed, or managed.
Correspondence: Prof. Dr. José Florencio F. Lapeña, Jr.

Department of Otolaryngology - Head and Neck Surgery Outcomes are functional resolution of isolated mandibular body fractures; achieving
Ward 10, Philippine General Hospital premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing
Taft Avenue, Ermita, Manila 1000
Philippines use of ineffective interventions; avoiding co-morbid infections, conditions, complications and
Phone: (632) 8554 8467
Email: [email protected] , [email protected] adverse events; minimizing cost; maximizing health-related quality of life of individuals with
isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in
patients and occurrence in others.
Creative Commons (CC BY-NC-ND 4.0)
Attribution - NonCommercial - NoDerivatives 4.0 International c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Philippine Journal Of Otolaryngology-Head And Neck Surgery 1

Action Statements and unstable mandibular body fracture patients who cannot afford
The guideline development group made strong recommendations or avail of titanium plates; (12) open reduction with titanium plates -
for the following key action statements: (6) pain management- clinicians ORIF using titanium plates and screws should be performed in isolated
should routinely evaluate pain in patients with isolated mandibular displaced unfavorable and unstable mandibular body fracture; (13)
body fractures using a numerical rating scale (NRS) or visual analog maxillomandibular fixation - intraoperative MMF may not be routinely
scale (VAS); analgesics should be routinely offered to patients with a needed prior to reduction and internal fixation; and (15) promotion -
numerical rating pain scale score or VAS of at least 4/10 (paracetamol clinicians should play a positive role in the prevention of interpersonal
and a mild opioid with or without an adjuvant analgesic) until the and collective violence as well as the settings in which violence occurs in
numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- order to avoid injuries in general and mandibular fractures in particular.
prophylactic antibiotics should be given to adult patients with isolated
mandibular body fractures with concomitant mucosal or skin opening Keywords: Mandibular fractures; jaw fractures; maxillofacial
with or without direct visualization of bone fragments; penicillin is the fractures; classification; complications; history; diagnosis; diagnostic
drug of choice while clindamycin may be used as an alternative; and (14) imaging; therapy; diet therapy; drug therapy; prevention and control;
prevention- clinicians should advocate for compliance with road traffic rehabilitation; surgery.
safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for
the prevention of motor vehicle, cycling and pedestrian accidents and INTRODUCTION
maxillofacial injuries. The mandible is the most common fractured craniofacial bone,
involving 32.3 - 40% of all craniofacial fractures in the Philippines1,2 in
The guideline development group made recommendations for contrast to nasal bone fractures in international literature.3 The etiology
the following key action statements: (1) history, clinical presentation, and fracture patterns vary from country to country depending on
and diagnosis - clinicians should consider a presumptive diagnosis of various environmental and socioeconomic factors.4 A 2010-2017 survey
mandibular fracture in adults presenting with a history of traumatic of eight local otorhinolaryngology – head and neck surgery (ORL-HNS)
injury to the jaw plus a positive tongue blade test, and any of the training institutions (University of the Philippines - Philippine General
following: malocclusion, trismus, tenderness on jaw closure and broken Hospital, East Avenue Medical Center, Jose R. Reyes Memorial Medical
tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray Center, University of Santo Tomas Hospital, Baguio General Hospital
as the initial imaging tool in evaluating patients with a presumptive and Medical Center, Rizal Medical Center, and the University of the
clinical diagnosis; (3) radiographs - where panoramic radiography is not East – Ramon Magsaysay Memorial Medical Center Inc.) revealed the
available, clinicians may recommend plain mandibular radiography; mandibular body as the most commonly involved segment (29%) of all
(4) computed tomography - if available, non-contrast facial CT Scan mandibular fractures.1
may be obtained; (5) immobilization - fractures should be temporarily
immobilized/splinted with a figure-of-eight bandage until definitive However, to the best of our knowledge, there are no existing
surgical management can be performed or while initiating transport guidelines for the diagnosis and management of mandibular body
during emergency situations; (8) anesthesia - nasotracheal intubation is fractures in particular. General guidelines include the American
the preferred route of anesthesia; in the presence of contraindications, Academy of Otolaryngology – Head and Neck Surgery Foundation
submental intubation or tracheostomy may be performed; (9) (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck
observation - with a soft diet may serve as management for favorable chapter on Mandibular Trauma5 and the American Association of Oral
isolated nondisplaced and nonmobile mandibular body fractures with and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for
unchanged pre - traumatic occlusion; (10) closed reduction - with Oral and Maxillofacial Surgery section on the Mandibular Angle, Body,
immobilization by maxillomandibular fixation for 4-6 weeks may be and Ramus.6 Similarly, a 2013 Cochrane Intervention Review attempted
considered for minimally displaced favorable isolated mandibular to “provide reliable evidence of the effects of any interventions either
body fractures with stable dentition, good nutrition and willingness open (surgical) or closed (non- surgical) that can be used in the
to comply with post-procedure care that may affect oral hygiene, diet management of mandibular fractures, excluding the condyles, in adult
modifications, appearance, oral health and functional concerns (eating, patients”.7 On the other hand, a very specific Clinical Practice Guideline
swallowing and speech); (11) open reduction with transosseous on the Management of Unilateral Condylar Fracture of the Mandible
wiring - with MMF is an option for isolated displaced unfavorable was published by the Ministry of Health Malaysia.8
2 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Addressing the prevalence of mandibular body fractures, and

dearth of specific guidelines for its diagnosis and management, this
clinical practice guideline focuses on the management of isolated
mandibular body fractures in adults.
Definitions of Terms
In this guideline, the mandibular body is defined as the lateral bony

Figure 3. Diagram illustrating an isolated, or simple fracture of the mandible
region between the first premolar and after the second molar. (Figure 1) body.10 Reproduced with permission, from the Arbeitsgemeinschaft für
Osteosynthesefragen (AO) Surgery Reference Glossary. Online AO Surgery
Reference. [cited 2015 August 8, 2015]. Available from https://www2.
aofoundation.org/wps/portal/surgery?showPage=diagnosis&bone=CMF&segm
ent=Mandible)
Guideline Purpose
This guideline is meant for all clinicians in any setting who interact
with adults aged 18 years and above, who may present with an acute
Figure 1. The mandibular body, B, lies between the first premolar and the history and physical and/or laboratory examination findings that
second molar.9 Reproduced with permission, from Ehrenfeld M, Manson PN,
Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. may lead to a diagnosis of isolated mandibular body fracture and its
2012. London: Thieme.
subsequent medical and surgical management, including health
promotion and disease prevention.
The anterior and posterior transition zones, regions bounded The guideline does not apply to mandibular body fractures with
by vertical strips in the width of the crowns of the canine and third concomitant fractures elsewhere in the mandible, craniomaxillofacial,
molar, respectively, are not included in this guideline. (Figure 2) or cervical skeleton. It also does not apply to conditions associated with
pathologic bone lesions/disease (osteoradionecrosis, pericoronitis,
periodontal pockets, odontogenic cysts); gunshot injuries; iatrogenic
mandibular fractures (intraoperative fracture associated with tooth
removal); Langerhans cell histiocytosis and in patients who are
unconscious, obtunded or neurologically unstable.
Other modifying factors such as edentulous mandible; congenital,

developmental, structural, metabolic, infectious, neoplastic disorders /
conditions affecting the mandible; atrophic mandible; tooth injuries/
Figure 2. Anterior (pink) and posterior (blue) transition zones (numbered 1 periodontal trauma; alveolar fracture involvement; and bone loss/
and 2, respectively).9 Reproduced with permission, from Ehrenfeld M, Manson
PN, Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. defect fracture are not the primary focus of this guideline, but may be
2012. London: Thieme. discussed relative to their impact on management.
In particular, this guideline is for the use of providers of health

care to adults 18 years and older, including primary care and specialist
An isolated, or simple fracture is defined as a single fracture line
physicians, nurses and nurse practitioners, midwives and community
producing two fracture fragments (Figure 3) as opposed to a complex
health workers, dentists and emergency first-responders.
fracture with one or more intermediate fragment(s) in which there is
no contact between the main fragments after reduction or a fracture
It is applicable in any setting (including urban and rural primary-
with more than one fracture line so that there are three pieces or more.
care, community centers, treatment units, hospital emergency rooms,

operating rooms) in which adults with isolated mandibular body action statement profiles (ASP) of the proposed guideline. The GDG met
fractures would be identified, diagnosed, or managed. monthly from August 2015 to April 2016 to discuss, evaluate, critique,
revise, and agree on each KAS in the light of the ASP drafted by the
Although it was developed with input from other specialties and GWG on each chapter topic.
contains key action statements directed toward them, the intent is to
provide guidance specifically for otolaryngologists – head and neck The GDG initially brainstormed and listed topics they considered
surgeons. potentially relevant to the CPG, grouped into diagnosis, treatment,
and prevention. (Table 1) Each participant ranked all the generated
The primary outcome is to have a functional resolution of isolated topics from 1 to 41. The rank averages were computed, and the top and
mandibular body fractures. Additional outcomes include achieving bottom 10 interventions listed according to rank. Where no intervention
premorbid form; avoiding use of context-inappropriate diagnostics was top-ranked for a certain category (prevention), or an important
and therapeutics; minimizing use of ineffective interventions; avoiding intervention (antibiotics) was not top-ranked for a certain category
co-morbid infections, conditions, complications and adverse events; (treatment), these were added to the top-ranked interventions by
minimizing cost; maximizing health-related quality of life of individuals consensus.
with isolated mandibular body fracture; increasing patient satisfaction;
and preventing recurrence in patients and occurrence in others.
Table 1. Topics and issues considered in Mandibular Body Fractures guideline developmenta
METHODS Diagnosis Treatment Prevention

Directed History Stabilization Environmental Controls
This guideline was commissioned by the Philippine Society of Symptoms of Mandibular Immobilization Pedestrian Protection
Otolaryngology – Head and Neck Surgery (PSOHNS) and undertaken Fracture
by the Philippine Academy of Craniomaxillofacial Surgery (PACMFS). Physical Examination Splinting/Bandaging Motorist Education
This guideline was developed with an explicit and transparent a priori Malocclusion Analgesics Traffic Law Enforcement
protocol for creating actionable statements based on supporting Signs of Mandibular Steroids Airbags
Fracture
evidence and the associated balance of benefit and harm, as outlined
Bimanual Palpation Anesthetics – local, Seatbelts
in the third edition of the Clinical Practice Guideline Development topical
Manual: A Quality-Driven Approach for Translating Evidence into Action Bite Test Anesthetics – regional, Protective gear (helmets)
of the American Academy of Otolaryngology-Head and Neck Surgery general
Foundation (AAO-HNSF).11 Imaging Procedures Antibiotics Road signs and
international standards
CT Scans, X-Rays, Topical astringents, Safety barriers
A 19-member Guideline Development Group (GDG) was Panoramic xray antiseptics
constituted, consisting of a chair, co-chair/methodologist, staff lead, Blood tests, ancillary labs Appliances, other Alcohol and substance
content experts and stakeholders (2 maxillofacial surgeons, 2 dentists, Alternatives abuse/intoxication
an anesthesiologist, an orthopedic surgeon, a nurse practitioner, Dental Impression Closed/Open Reduction, Medications impairing
a radiologist, 2 family physicians, an ORL-HNS resident physician Internal Fixation ability to handle
Arch Bars and IDW / MMF machinery
representative, 2 motorcyclists, a bicyclist/commuter/pedestrian as
Strict implementation
consumer advocate, and 1 liaison each of the PSO-HNS and PACMFS). of driving license
(Appendix A) A Guideline Working Group (GWG) consisting of content requirement
experts (PACMFS consultants) and resident physicians of PSO-HNS Ernst Ligature Safety advancements in
Ivy loop the vehicles
training institutions was also convened. (Appendix B)
Interosseous Wires
The GWG, together with the GDG Chair, Co-Chair/Methodologist, Plates and Screws
and Staff Lead conducted twice-monthly meetings from March 2015 Absorbable plates
a
This list was created by the guideline development group to refine content and prioritize action statements; not all
to research, collect data, critically appraise evidence, review and grade items listed were ultimately included or discussed in the guideline.
literature, draft the scope, objectives, key action statements (KAS) and

Literature Searches 2015 to April 2016. Relevant evidence was reviewed and analyzed by
the GDG and integrated in the recommendations of this CPG. A sample
Literature searches were performed by the Guideline Working search for the first KAS is shown in Figure 4.
Group (GWG) from March through July 2015 using a validated filter
strategy to identify all published clinical practice guidelines, manuals,
systematic reviews, meta-analyses, randomized controlled trials, 56 articles identified in Cochrane, PubMed MEDLINE, NGC,
GIM and HERDIN
comparative studies and original research studies.
Search terms: mandible, mandibular, mandibular trauma, fracture,
The initial PubMed MEDLINE search using “facial fractures” or symptoms, signs, physical examination, physical finding, guideline,
meta-analysis, systematic
“maxillofacial fractures” or “mandibular fractures” or “jaw fractures”
in any field yielded 8752 potential articles. Original research studies
274 RCTs, comparative
were identified by limiting the MEDLINE search to articles on humans studies and original articles 278 articles excluded based
published in English until July 2015. The resulting data set of 1116 identified in PubMed on title and abstract non-
articles yielded 274 randomized controlled trials, 359 reviews, 58 MEDLINE, GIM, HERDIN English articles, not related
to mandibular fractures
systematic reviews, 1 guideline, and 424 studies that did not fall under and animal studies
the previous types.
52 articles selected
Search of the National Guideline Clearinghouse (NGC) for any topic
related to mandibular fractures yielded 3 systematic reviews. 50 articles excluded after
24 articles identified by obtaining the full text
manual crosschecking
Randomized controlled trials were identified by search of the of references and using
Cochrane Controlled Trials Register, which identified 472 trials with targeted searches
“mandibular fracture” or “jaw fracture” or “mandibular trauma” or

36 cross sectional, 1 cohort,
“maxillofacial fracture” in any field. Search of the Cochrane Library and 1 meta-analysis
identified one relevant title. After eliminating articles that did not have
mandibular fracture as the primary focus, only 1 systematic review met
quality criteria of having explicit criteria for conducting the literature
38 total articles used of KAS1
search and selecting source articles for inclusion or exclusion.
Figure 4. Search strategy for the first key action statement

Using the same search parameters in the Global Index Medicus
(GIM) yielded 21 case reports, 11 incidence studies, 6 prevalence
studies, 6 screening studies, 3 systematic reviews, 1 evaluation study In a series of meetings (held every 2 weeks), the working group
and 1 practice guideline. defined the scope and objectives of the proposed guideline. During
the 9 months devoted to guideline development ending in April
A search in HERDIN yielded 4 descriptive studies and 3 case reports. 2016, the development group met once every month to discuss key
action statements in the light of action statement profiles drafted by
The literature was further narrowed using the standard literature the GWG on each chapter topic. Consultants assigned to write each
review process including removal of topics without sufficient evidence; ASP reviewed the literature, met with their respective GWG resident
non original research; letters; commentaries; narrative reviews; non members to critically appraise the literature, grade levels of evidence (A,
clinical research; irrelevant case reports; or irrelevant case series. B, C, D), and refine each drafted KAS and ASP. All literature was classified
Articles that were hit in multiple search engines were counted as one. according to levels of evidence based on the Modified Evidence
Pyramid illustrated in Figure 5.12 They also submitted relevant articles
Search results were distributed to the GDG prior to each GDG via email and met with respective members of the development group
meeting. Materials were supplemented, as needed, with targeted prior to the monthly in-person GDG meetings.
searches to address gaps identified in writing the guideline from August

}
that did not meet the criteria of consensus or near consensus. For
Meta-Analysis purposes of emphasis, Strong Consensus was defined as a mean Likert
Based on ability Systematic Reviews 1
to control for score ≥8.00 with no outliers.9 The individual ratings and averages per
bias and to Randomized
Controlled Trials item are seen in Figure 6.
demonstrate 2
cause and effect Cohort Studies
in humans
Case Control Studies 3
Case Reports
4
Ideas, Editorials, Opinions 5

Animal Research
In vitro (text tube) Research
Figure 5. Levels of clinical evidence for therapy/prevention and etiology/harm. Modified Evidence
Pyramid used with permission granted by SUNY Downstate Medical Center, Medical Research Library
at Brooklyn, http://library.downstate.edu/EBM2/2100.htm.12
The GDG refined each drafted KAS and ASP, classifying each
evidence-based action statement (strong recommendation,
Figure 6. Individual ratings and average ratings per key action statement obtained from the Delphi
recommendation, option). The evidence profile for each statement process
was converted into an action statement profile, following each key
action statement. Statements about the aggregate evidence quality Financial Disclosure and Conflicts of Interest
(recommendation grade and level of evidence), benefit, risks, harms,
cost, benefit - harm assessment, value judgements, intentional A contract grid was accomplished by each Guideline Development
vagueness, role of patient preference, exceptions, policy level, and Group (GDG) and Guideline Working Group (GWG) member for the 1st
differences of opinion, were included in each ASP. The definitions conference meeting; copies of the Policy for Management of Financial
for evidence-based statements were based on guidelines from the Conflicts of Interest in the Development of ATS Clinical Practice
American Academy of Otolaryngology-Head and Neck Surgery.11 Guidelines, and Conflict of Interest Guidelines for Clinical Guidelines was
also provided per panelist to stress the importance of COI disclosures.
These included non-financial conflicts (intellectual passion, personal
All GDG panel members participated in a Delphi Process in April relationships, institutional and professional affiliations, political or
2016 to arrive at consensus on the final 15 key action statements and religious beliefs). After review and discussion of their disclosures,
their respective action statement profiles. A sample of the instrument panelists agreed to remind the panel of potential conflicts before
used is in Appendix C. Panelists individually rated their agreement any related discussion, and to recuse themselves from any discussion
with each key action statement on a 9-point Likert scale labeled at related to their potential conflict of interest if so requested. Panelists
intervals (1 - strongly disagree, 3 – disagree, 5 – neutral, 7 – agree, 9 – also agreed to maintain confidentiality about proceedings until the
strongly agree), and the mean scores were computed and projected for final CPG was publicized.
discussion.
Final Version of the Guideline
Accepted criteria for consensus9 were applied. Consensus meant
statements achieving a mean score of ≥7.00 and having no more than In the process of writing the final CPG, additional literature was
1 outlier (that is, any rating ≥2 Likert points from the mean in either retrieved and critically appraised by the GWG until September 2017,
direction); Near Consensus meant statements achieving a mean score and included in the references for action statement profiles. As none
≥6.50 and having no more than 2 outliers (any rating ≥2 Likert points of the additional evidence contradicted the key action statements and
from the mean in either direction); No Consensus meant statements action statement profiles, the full GDG was not reconvened to appraise

these statements. This final version was rewritten by the two co-first GUIDELINE KEY ACTION STATEMENTS
authors (JFL, JFD) with the assistance of a Head and Neck Microvascular
Reconstructive Surgery Fellow (MATG) and Craniomaxillofacial Surgery This guideline has fifteen (15) key action statements, grouped into
Fellows (ICSDG, ICA, VJBY, KMAT, DJCC), supported by an expanded GWG diagnosis (1-4), treatment (5-13) and disease prevention and health
(Appendix B), who re-checked all statements, citations, and references. promotion (14-15). Each evidence-based statement is organized
The publication of this version was delayed by the COVID-19 pandemic similarly: a key action statement in bold, followed by the strength of
that began in early 2020. the recommendation in italics and an action statement profile that
explicitly states the aggregate evidence quality, benefit, harms, risks,
The final key action statements and action statement profiles were costs, and benefit-harm assessment. In addition, there are statements
pilot-presented to local clinicians in a provincial setting (Maxillofacial of any value judgments, the role of patient (caregiver) preferences,
Seminar and Workshop on Mandibular and Midface Fractures, clarification of any intentional vagueness by the panel, exceptions to
Philippine Academy of Craniomaxillofacial Surgery and Bicol ENT- the statement, any differences of opinion, and a repeat statement of
HNS Chapter, Naga City, October 28, 2017), and before a national the strength of the recommendation. Supporting text subsequently
convention of otolaryngologists (PSO-HNS 61st Annual Convention and discusses the evidence base supporting the statement. A summary of
10th International Symposium on Recent Advances in Rhinosinusitis each key action statement in this guideline can be found in Table 4.
and Nasal Polyposis, The Manila Hotel, December 1, 2017). This CPG was
then presented at a national forum of family physicians and general Table 4. Summary of guideline key action statements
practitioners (Philippine Academy of Family Physicians 57th Anniversary Statement Action Strength
and Annual Convention, Philippine International Convention Center,
1. History, clinical Clinicians should consider Recommendation
March 2, 2018), and an international conference of otolaryngologists presentation and a presumptive diagnosis of
(10th International Academic Conference in Otology, Rhinology, and diagnosis mandibular fracture in adults
presenting with a history of
Laryngology, Fairmont Hotel, Makati City, March 2, 2018). It was also
traumatic injury to the jaw
presented during the PACMFS Maxillofacial Seminar and Workshop on plus a positive tongue blade
Mandibular and Midface Fractures at the Ilocos Training and Regional test, and any of the following
physical findings: malocclusion,
Medical Center, San Fernando, La Union on November 16, 2018; as part trismus, tenderness on jaw
of the Basic Facial Plastic and Maxillofacial Course, PSO-HNS, Philippine closure and broken tooth.
Academy of Facial Plastic and Reconstructive Surgery (PAFPRS), and 2. Panoramic xray Clinicians may request for Recommendation
panoramic x-ray as the initial
PACMFS at the Manila Doctors Hospital on April 26, 2019; the PACMFS imaging tool in evaluating
Maxillofacial Seminar and Workshop at the Jose B. Lingad Memorial patients with a presumptive
Regional Hospital in San Fernando, Pampanga, July 11, 2019; the clinical diagnosis of mandibular
fractures
PACMFS Maxillofacial Seminar and Workshop on Mandibulo-Maxillary
3. Radiographs In a setting where panoramic Recommendation
Fixation (MMF) and Mandibular and Midface Fractures at the Paulino radiography is not available,
J. Garcia Memorial Research and Medical Center in Cabanatuan clinicians may recommend
plain mandibular radiography
City, Nueva Ecija on February 7, 2020; and as a keynote lecture at among patients with
the Arbeitsgemeinschaft für Osteosynthesefragen CranioMaxilloFacial presumptive clinical diagnosis
(AOCMF) Asia Pacific Management of Facial Trauma course in Thiruvalla, of mandibular fracture.
Kerala, India on January 4, 2020. 4. Computed If available, non-contrast Facial Recommendation
Tomography CT Scan may be obtained for
the assessment of mandibular
The recommendations in this CPG are based on the best available fractures.
published data through September 2017. Where data were lacking, a 5. Immobilization Isolated mandibular body Recommendation
fractures should be temporarily
combination of clinical experience and expert consensus was used. A immobilized/splinted with a
scheduled review process will occur 5 years from publication of this CPG figure-of-eight bandage until
or sooner if new compelling evidence warrants earlier consideration. definitive surgical management
can be performed or while
initiating transport during
emergency situations.

Statement Action Strength Statement Action Strength

6. Pain Management Clinicians should routinely Strong 10. Closed Reduction Closed reduction with Recommendation
evaluate pain in patients with Recommendation immobilization by
isolated mandibular body maxillomandibular fixation for
fractures using a numerical 4-6 weeks may be considered
rating scale (NRS) or visual in patients with minimally
analog scale (VAS); analgesics displaced favorable isolated
should be routinely offered to mandibular body fracture with
patients with a numerical rating stable dentition, good nutrition
pain scale score or VAS of at and who are willing to comply
least 4/10.   with post-procedure care that
Patients may be initially may affect oral hygiene, diet
managed with paracetamol modifications, appearance,
and a mild opioid with or oral health and functional
without an adjuvant analgesic. concerns (eating, swallowing
Reassessment should be done and speech).
and adequate analgesia should 11. Open Reduction with In patients with isolated Recommendation
be given until the numerical transosseous wiring displaced unfavorable and
rating pain scale score or VAS is unstable mandibular body
3/10 at most. fracture who cannot afford
7. Antibiotics Prophylactic antibiotics should Strong or avail of titanium plates,
be given to adult patients with Recommendation transosseous wiring with
isolated mandibular body maxillomandibular fixation is
fractures with concomitant an option.
mucosal or skin opening with 12. Open Reduction with Open reduction and internal Recommendation
or without direct visualization titanium plates fixation using titanium
of bone fragments. plates and screws should be
In patients without mucosal performed in isolated displaced
or skin lacerations, prophylactic unfavorable and unstable
antibiotics can be given 1 hour mandibular body fracture.
prior to surgery and up to 24 13. Maxilllomandibular Intraoperative MMF may not Recommendation
hours post op. Fixation be routinely needed prior
Penicillin is the drug of to reduction and internal
choice while clindamycin may fixation of isolated displaced
be used as an alternative for unfavorable and unstable
patients in whom penicillin is mandibular body fracture.
contraindicated. 14. Prevention Clinicians should advocate for Strong
8. Anesthesia Nasotracheal intubation is the Recommendation compliance with road traffic Recommendation
preferred route of anesthesia safety laws (speed limit, anti-
in patients diagnosed with drunk driving, seatbelt and
isolated mandibular body helmet use) for the prevention
fracture. of motor vehicle, cycling and
In the presence of pedestrian accidents and
contraindications to maxillofacial injuries.
nasotracheal intubation, 15. Promotion Clinicians should play a positive Recommendation
submental intubation role in the prevention of
or tracheostomy may be interpersonal and collective
performed. violence as well as the settings
9. Observation Observation with a soft diet Recommendation in which violence occurs
may serve as management in order to avoid injuries
for patients diagnosed in general and mandibular
with favorable isolated fractures in particular.
nondisplaced and nonmobile
mandibular body fractures with
unchanged pre - traumatic
occlusion.

STATEMENT 1. HISTORY, CLINICAL PRESENTATION AND DIAGNOSIS: Level III. A cross sectional study performed among 11,728
Clinicians should consider a presumptive diagnosis of mandibular patients in Brazil revealed that “the most frequent cause of
fracture in adults presenting with a history of traumatic injury to maxillofacial injuries for both genders was traffic accidents
the jaw plus a positive tongue blade test, and any of the following (39.6%), followed by fights (21.6%). In women, the second
physical findings: malocclusion, trismus, tenderness on jaw closure most frequent cause was falls (22.4%).” 19
and broken tooth. Recommendation.
Level III. A cross sectional study done in Italy (UNITO)
Action Statement Profile for Statement 1 and the Netherlands (VUMC) between January 2001 and
l Aggregate evidence quality: Level II, Grade B December 2010 included 752 patients from Turin and 245
patients from Amsterdam. Assault was the main cause of
Level III. A cross sectional study of 449 patient records in fractures with “27% at VUMC, 29% at UNITO.” “A statistically
Nigeria showed most fractures were caused by road crashes significant association was found between male gender and
and involved the mandibular body (51%) followed by the the aetiology of ‘assault’ in both study populations’’. They also
angle (19%), with male preponderance (4.7 males:1 female).13 noted that “the most frequently observed sign in both study
populations was post-traumatic malocclusion, followed by
Level III. A cross sectional study of 314 patients from two facial lacerations in the chin region and inferior alveolar nerve
urban centers in Nigeria noted “the commonest site of paresthesia.” 20
fracture … was the body of the mandible followed by the
angle.” Road traffic crashes were the leading cause (67.5%), Level III. A cross sectional study that reviewed records of
followed by assault (18.8%). In contrast, assault was the 444 patients in the University Hospital of Freiburg, Germany
commonest cause of injury in developed countries.14 noted that “road traffic accidents and fights were the leading
causes of mandibular fractures, followed by falls. Bicycle
Level II. A retrospective cohort study by the University of accidents were the most common cause of all road traffic
Pittsburgh from 2001 to 2005 involving a total of 13,142 accidents”. It was hypothesized to be related to the fact that a
patients showed “assault was the predominant mechanism of small university with a young population was involved. “Falls
injury (42%), followed by motor vehicle accidents (31%);” with and sport accidents were also noted to be more common in
“male preponderance... similar to overall age distribution.”15 larger cities.” 21
Level III. A cross sectional study in the Quirino Memorial Level III. A cross sectional study in the Piracicaba Dental
Medical Center from 1996 to 1997 involving 29 patients School, Brazil from 1999 to 2004 included a total of 1,024
attributed the highest number of fractures to vehicular patients with 1,399 facial fractures. Results revealed that
accidents at 44.8% followed by assault at 24.1%.16 “traffic accidents were the most frequent etiological factor of
maxillofacial fractures irrespective of gender (46.2% for men
Level III. A cross sectional study involving 768 patients in and 40.3% for women)”. 22
Shiraz Chamran Emergency Hospital, Iran between 2004 and
2010 observed that “isolated mandibular fracture due to road Level III. A cross sectional study of 355 patient records from
traffic accident was the most common type of maxillofacial Brazil in 2010 revealed “interpersonal violence in 99 cases
injuries” and that the most common site of the mandible (27.9%, SD%=4.5) and car accidents in 59 cases (16.6%,
fractured was the body.17 SD%=5.2)”. Young male adults were the most prevalent
victims. 23
Level III. A cross sectional study of 532 patients in Turkey
noted that different causes were involved in young and adult Level III. A cross sectional study in Brazil from January 2000 to
patients. “The most common cause of injury in young patients December 2002 showed that 2,736 of the patients had facial
was falls (65%), while road traffic accidents predominated in fractures,1,023 (37.39%) of whom had mandibular fractures.
adult patients (88%).” 18 “The major cause of mandibular fractures in this study was

vehicle accidents, second most common was violence.” Level III. A cross sectional study in the United States evaluated
“Gunshot wounds and traffic accidents were more common records from 1,067 patients sustaining 1,515 mandibular
in males than in females. The opposite occurred with falls and fractures. The major causes of mandibular fracture were
violence.” 24 altercations (47.5%), automobile accidents (27.3%) and
motorcycle accidents (4.2%), accounting for approximately
Level III. A cross sectional study in South America showed one third of fractures. The causes of the remainder of
that 126 patients suffered a total of 201 mandibular fractures, mandibular fractures could be grouped into four major
associated or not with other maxillofacial fractures. The categories: falls (7.1%), sports-related incidents (5.4%) work-
etiology most frequently observed was traffic accidents in 59 related accidents (3.0%), and other causes (5.5%). 29
patients (47%). Symptoms of mandibular fractures include
pain in 114 (91%), changed dental occlusion in 98 (78%), Level III. A cross sectional study of records of 328 active
and mental nerve paresthesia in 35 (28%). Signs included military personnel and dependents treated for mandibular
facial swelling (74%), limitation of mouth opening (55%), and fractures at a tertiary military hospital in the Philippines
malocclusion (48%). 25 showed varied causes: vehicular accidents (not work-
related) in 190 (57.9%), combat-related (from gunshots) in
Level III. A cross sectional study 138 cases of mandibular 102 (31.1%), accidental falls in 17 (5.2%), violent assault in
fracture in different government hospitals in the Philippines 13 (4.0%) and sports-related injuries in 6 (1.8%). The most
(East Avenue Medical Center, Jose R. Reyes Memorial Hospital, commonly fractured site was the body (188 cases; 27.77%),
Philippine Orthopedic Hospital, and V. Luna Memorial followed by the parasymphysis (166 cases; 24.52%). The
Hospital) found the major cause of mandibular fracture was angle, symphysis, ramus and condyle had prevalence rates of
assault or mauling comprising 60 cases (43.5%) of the entire 17.58%, 11.23%, 7.68%, and 7.38%, respectively. 2
study. 26
Level III. A cross sectional study that reviewed records of 512
Level III. A cross sectional study in Scotland found that 4,711 patients at the Philippine General Hospital from January
patients had maxillofacial fractures of one or more facial 2004 to December 2007 noted maxillofacial fractures were
bones; of which 2,137 had at least one mandibular fracture most common among young adults aged 21 to 30 years old
(with a total of 3,462 mandibular fractures). The patients (34.8%), followed by adults aged 31 to 40 years old (22.1%).
were from a large industrialized area with high rates of Men were injured more than women with a 7:1 ratio (males =
unemployment. The mandible is one of the more common 87% females = 13%). The most common etiology was traffic-
targets in altercations and, as the majority of this sample of related accidents (63.7%) in contrast to physical assault in
patients sustained trauma during altercations, one could previous decades. Other causes were physical assault or
expect this finding. 27 mauling (14.5%), falls (11.5%), gunshot wounds (6.4%) and
hacking (3.1%). Mandibular fractures were the most common
Level III. A cross sectional study of 790 cases of oral– (168; 32.8%). 4
maxillofacial trauma in South America found that 140
individuals (17.7%) had injuries stemming from interpersonal Level III. A cross sectional study of 2,094 patients with facial
violence [(10.1%) due to urban violence and 42 (5.3%) due fractures from various accidents in a Tertiary Hospital in
to domestic violence]. For urban violence, the most common Korea revealed the most common age group was the third
types of injury were facial contusion and dental concussion decade of life (29%), involving males more than females
(70; 87.5%), facial laceration (46; 57.5%), and mandibular (3.98:1). The most common etiology was violent assault or
fracture (26; 32.5%). For domestic violence, the most frequent nonviolent traumatic injury (49.4%) and the most common
types of injury were facial contusion (n = 41; 97.6%), facial isolated fracture sites were nasal bone (37.7%), mandible
laceration (16; 38.1%), and mandible fracture (10; 23.8%). 28 (30%), orbital bones (7.6%), zygoma (5.7%), maxilla (1.3%)
and frontal bone (0.3%). 30

Level III. A cross sectional study of 134 patients with 225 with prevalence in summer (31%) and winter (28%) months.
mandibular fractures at a suburban trauma center in The most common location was the angle (36%), followed
Illinois, USA. Study showed violent crimes (assault, gunshot by the body (21%) and parasymphyseal region (17%), and
wounds) accounted for the majority cause (50%) vs. motor 52% had more than one fracture site. The evolving pattern
vehicle accidents (29%). Overall, parasymphyseal fractures of fractures in urban trauma centers showed an increasing
were most frequently involved (35%), followed by the body trend of association with illicit substances and interpersonal
and angle fractures (21% and 15%, respectively). There was a violence as a major causative factor. 34
statistically significant association of motor vehicle accidents
with parasymphyseal fractures (45%), and gunshot wounds Level III. A cross sectional study of 580 patients with
with body fractures (36%), whereas assault victims had a mandibular fractures at the University of Iowa Hospitals
higher than predicted frequency of angle fractures (27%) and and Clinics from 1972 to 1978 showed more fractures of the
fewer parasymphyseal fractures (19%). Patients aged 17 to condyle (29.1%) and angle (24.5%), with correspondingly
30 were more likely to suffer from gunshot wounds, whereas fewer parasymphysis/symphysis region (22%) and body
older adults (age 31–50) were more likely to be assault (16%) fractures, in comparison to other reported studies.
victims. Patients over age 50 suffered fractures from falls at a The site of fracture is related to the type of trauma involved.
higher than expected rate. 31 Altercations, in which most force is directed in a single
blow to the lateral aspect of the jaw, tend to result more
Level III. A cross sectional study on epidemiology and frequently in angle (37.3%) and body (19.4%) fractures.
patterns of injury in mandibular trauma based on the While automobile accidents, which more frequently involve
Parkland Memorial Hospital, Texas registry yielded 4,143 trauma to the anterior mandible, result in more fractures of
mandibular fractures in 2,828 patients between 1993-2010. the symphysis region (27.7%), alveolus (4.5%) and condyle
Average age was 38 years with 33% in the third decade, (30.9%). Motorcycle accidents produce many more alveolar
83.27% were male and most injuries occurred in summer fractures (9.1%), suggesting that the traumatic force in this
(July highest). Mechanisms of injury were predominantly kind of accident is often directed to the alveolus. 46.6% of
low-velocity blunt injuries (62%) vs. high-velocity blunt those individuals involved in motor vehicle accidents had the
injuries (31%). Anatomical distribution of fractures was: angle highest incidence of concomitant other injuries in addition to
(27%), symphysis (21.3%), condyle/subcondyle (18.4%), and the mandibular fractures.35
body (16.8%). 32
Level III. A cross sectional study of records and radiographs
Level III. A cross sectional study reviewed records of 119 in maxillofacial units of two universities in Jordan showed a
patients treated for mandibular fractures between 2006 and total of 703 patients with 892 mandibular fractures [502 (71%)
2011 in Brazil revealed mandibular fractures mostly affect male and 201 (29%) females]. There were 497 (71%) adults
Caucasian (72.2%) men (80.7%). Road traffic accidents (RTA) with 676 fractures, and 206 (29%) young patients with 216
caused the most fractures (49.5%), followed by physical fractures. In adults, the most common fracture site was the
violence, including gunshot wounds (21%). Motorcycle mandibular body (32%) often caused by road traffic accidents
accidents were the most common cause of RTA (76.2%). (47%), whereas in young patients, the condyle (38%) was the
And the most affected mandibular regions were the predominant fracture site and the most common etiology
parasymphysis (26.9%) and the mandible angle (25.1%). 33 was a fall (49%).36
Level III. A cross sectional study of 1,267 patients with clinical Level III. A cross sectional study of 266 patients with
and radiological diagnosis of mandibular fractures at an urban mandibular fractures in Sweden 1999-2008. The study
level I trauma center in Washington, DC showed that 86% revealed that 70% of fractures involve young men, aged 16
were male and 37% were in the 25 to 34-year-old age group. to 30 years old (50%). Interpersonal violence was the most
Use of an illicit substance at the time of trauma was seen in common etiology (24%) followed by falls (23%) that had the
55% of all cases. Interpersonal violence accounted for 79%, highest incidence during the summertime and weekends. 37

Level III. A cross sectional study of 509 patients treated at blade test, 2 patients proved to have fractures on radiograph.
the University Hospital in Alexandria, Egypt from the year The study concluded the tongue blade test had a sensitivity
1991 to 2000 reviewed a total of 755 mandibular fractures; of 95.7%, specificity of 63.5%, a positive predictive value of
79% were composed of men with a 3.6:1 male:female ratio. 66.2%, a negative predictive value of 95.2%, and an accuracy
Most fractures were sustained by men in the age group 21–30 of 77.3%.41
years (26%) and girls between 0 and 10 years (43%). 198 of
509 (39%) patients sustained fracture due to road crashes, Level III. A double blinded diagnostic cross sectional study
followed by falls (n=173, 43%) and assaults (n=83, 16%). of 57 subjects with facial trauma who were included over a
Fractures of the angle (22%) were the most common followed non-consecutive 4-month period from June 2013 to April
by the parasymphyseal region (21%) and the lowest was in 2014. The study aimed to assess the predictive value of
the coronoid region (1%). The largest monthly incidence was physical examination findings in detecting facial fractures in
in January (13%) and least in October (6%).38 trauma patients. Dental malocclusion (31.6%) and tenderness
(35.1%) showed the best diagnostic properties. And intraoral/
Level III. A cross sectional study of 213 patients with gingival laceration (19.3%) showed relatively poor positive
mandibular bone fracture in Amsterdam for a period of 10 predictive value and sensitivity. The study concluded that
years between January 2000 to January 2009 consisted of physical examination findings of mandibular fractures have
146 male and 67 female patients with a ratio of 2.2:1, with a a 100% sensitivity rate and negative predictive value on
mean age of 32.5 (SD, 15.2) years. For male patients, violence correlation to CT scan findings. However, the mandible has
(33.6%) was the main cause of injury while traffic accidents a low positive predictive value of 55.6% and specificity of
(50.7%) were the most common cause in female patients. 71.4%.42
Overall, the mandibular body (46.8%) was the main site
involved regardless of the etiology.39 Level III. A diagnostic cross sectional study using the
Manchester mandibular fracture decision rule to reduce the
Level III. A cross sectional review of records of mandibular need for radiographs in mandibular trauma conducted at
fractures in the United States and in Turkey between 1991 the city-centre emergency department between July 2000
and 2000, wherein 210 Turkish patients had 252 mandibular and December 2001 included 280 patients in the study with
fractures, whereas the 665 US patients had 1042 mandibular 65 cases of mandibular fracture based on radiographs. The
fractures. Majority of the patients were male, 84% in the US clinical predictors used in the decision rule for mandibular
versus 76% in Turkey. Assault (53.7%) was the most common fracture had the following sensitivity rates: malocclusion
cause of mandibular fractures in the US, whereas in Turkey the (88%), pain with mouth closed (77%), trismus (63%), broken
most common cause was motor vehicular accident (36.2%). teeth (14%), and step deformity (18%). The decision rule
The angle of the mandible (27.57%) was the most common showed 100% sensitivity and 37% specificity. The study
site of fracture in the US in contrast to Turkey, where the concluded the decision rule successfully predicted a fracture
body (28.97%) was the most common fracture site. The study in all 28 cases with clinical suspicion of fracture prior to the
concluded that socioeconomic, cultural and environmental x-ray and 83 radiographs were avoided without missing any
factors all play a part in determining the types of patients fracture.43
involved, sites of injury and the causes of the problem.40
Level I. A meta-analysis of 269 papers on the utility of the
Level III. A cross sectional study of 110 patients with tongue blade test for the diagnosis of mandibular fracture.
complaints or physical findings suggestive of undiagnosed Two diagnostic studies with best evidence reported high
mandibular fracture seen at the emergency department of sensitivity (95.7 and 95%) of the tongue blade test as a
Kern Medical Center from February 1992 to March 1994 where useful screening tool in evaluating patient with mandibular
53 patients had mandibular fractures; 41 of 53 patients had fractures.44
at least one mandibular fracture while 12 appeared normal
on x-ray. Among 42 patients scored negative on the tongue

Level III. A diagnostic cross-sectional study was conducted in l Benefit: Clinicians can presumptively rule out a diagnosis
an urban emergency department in Kansas City from January of mandibular fracture during the initial patient encounter;
1, 1993, to December 31, 1993, to evaluate the diagnostic potential savings from avoiding unnecessary radiographs,
accuracy of clinical signs and symptoms of mandibular medical treatment, and costly procedures for patients
fracture. A total of 119 subjects were included in the study without mandibular fractures
and 44 subjects were diagnosed with mandibular fracture. l Risks, harms, costs: None
Malocclusion (33 of 44 subjects) and facial asymmetry (21 of l Benefit-harm assessment: Preponderance of benefit over
44 subjects) were strong predictors of fracture. A negative harm
result on the tongue blade test (2 of 44 subjects) was a l Value judgements: Although the GDG recognized that
strong predictor of non-fracture. In conclusion, the tongue a conclusive diagnosis of mandibular fracture may be
blade test is a useful screening tool in evaluation of patients difficult without imaging, making a presumptive diagnosis
with mandibular trauma because of its high sensitivity and of mandibular fracture based on history and physical
negative predictive value.45 examination alone is reasonable. Patients with high suspicion
of mandibular fracture (based on clinical signs and positive
Level III. A cross sectional study from August 1, 2010 to April tongue blade test) can be referred early to specialists.
11, 2012 at a single urban academic emergency room to l Intentional vagueness: None
determine the sensitivity and specificity of the tongue blade l Role of patient preferences: Small; patients can refuse
test in comparison with CT scan in 190 patients. The tongue examination
blade test showed a sensitivity of 95% and specificity of 68%. l Exceptions: Airway compromise, loose dentition,
The test also demonstrated an accuracy rate of 82% in this uncooperative patients
study.46 l Policy level: Recommendation
l Differences of opinion: None
Level III. A cross sectional study to evaluate the utility of the
tongue blade bite test in predicting mandibular fracture Supporting Text
in Louisiana from year 2011 to 2014. A chart review of 86 There were 38 studies/articles included in our review: 36 cross
patients with facial trauma (with 12 pediatric patients) were sectional studies, 1 cohort study and 1 meta-analysis.
included in the study. All subjects had a bite test done and In several studies, motor vehicle accidents and interpersonal
underwent CT scan. Bite test revealed a sensitivity of 88.5%, violence were the major causes of trauma resulting in mandibular
specificity of 95%, positive predictive value of 88.5%, and fractures.2,4,13-38, 40 In the US, the body of the mandible was the 2nd or
negative predictive value of 95%. Among the pediatric group, 3rd most frequently fractured part of the mandible, after the angle
the sensitivity was 100%, specificity was 88.9%, positive and parasymphyseal areas.31-33, 40 However, in other countries, the body
predictive value was 75% and negative predictive value was of the mandible was the most frequently fractured region, whether
100%.47 caused by vehicular accidents, gunshot, falls, violent assaults or sports.
The mandibular body was also found to be the most common site of
Level III. A cross sectional study of 144 patients with blunt fracture, whether as a single fracture or one among multiple fractures.2,
trauma to the face were evaluated with tongue blade test 4, 13, 14, 17, 36, 39
Variations on the cause of injury were noted depending on
and CT scan or plain radiograph of the face to determine the age, sex, and socioeconomic conditions of the country or city as
the sensitivity and specificity of the tongue blade test on well as time of the year where the accident or assault occurred.13, 15, 18,
mandibular fracture and maxillary sinus fracture. 16 patients 20-21, 24, 30, 31, 34, 36-40
In Western Europe and the United States of America,
(11.1%) had mandibular fractures and positive tongue blade interpersonal violence or altercations are considered the leading cause
test. 37 patients (27.8%) had maxillary sinus or Lefort fractures of trauma to the head and jaw.15, 20, 29, 31, 32, 34, 37, 40 However, in Asia, Africa
and positive tongue blade tests. For mandibular fractures, and South America, motor vehicle accidents were the leading cause of
the sensitivity was 100% and specificity was 74.8%, while in mandibular fractures,2, 13, 14, 17-19, 22, 24, 25, 33, 36, 38, 40 although in a South Korean
maxillary sinus fractures, tongue blade test sensitivity was study as well as in a Brazilian study, violent assaults outnumber traffic
48.6% and specificity was 69.8%.48 accidents.23, 30 In the Philippines, the etiology of mandibular fractures

appears to be conflicting, with studies showing motor vehicle accidents Level III. A diagnostic cross sectional comparison of
overshadow assault or interpersonal violence as the common cause of panoramic tomography and mandibular series including
mandibular fractures, while another study reported assaults or mauling advantages and disadvantages of each modality in 88
a major cause.2, 4, 16, 26 patients with known fractures of the mandible treated at
A history of blunt or sharp force to the jaw suggests the possibility of the Medical College of Virginia Hospital from February 1981
mandibular fracture.15, 24, 27, 28, 31, 32, 40, 41 Patients with mandibular fractures through January 1985 concluded that the panoramic view is
complain of pain, change in occlusion and numbness, with or without superior to the standard mandibular series for the diagnosis
lacerations, in the chin area, and commonly present with facial swelling, of mandibular fractures. 81 of 88 (92%) of the fractures were
limitation of mouth opening, malocclusion and inferior alveolar nerve recognized in the panoramic view while only 58 of 88 (66%)
and/or mental nerve paresthesia.20, 25, 42 were detected in plain views.49
The absence of malocclusion, trismus, tenderness on jaw closure,
broken tooth, and step-deformity, and a negative tongue blade test Level III. A diagnostic cross sectional study conducted at an
may rule out mandibular fracture and avoid further radiographic urban university health sciences school diagnostic radiology
testing.41-46 With the high sensitivity and negative predictive values of department compared the accuracy of mandibular series,
clinical signs and the tongue blade test, the clinician can presumptively panoramic radiography, digitized mandibular series, and
rule out the diagnosis of mandibular fracture during the initial patient panoramic radiography plus anteroposterior radiograph in
encounter.41, 42, 44-46 A systematic review (short review in 2003 by Malhotra the detection of induced fractures in 25 cadaver mandibles
and Dunning of two diagnostic studies on the use of the tongue blade showed panoramic tomography is adequate for detection
test) showed the high sensitivity and high negative predictive value of fractures in the body of the mandible (88% sensitive, 94%
(computed during appraisal) of the tongue blade test in ruling out the specific).50
diagnosis of mandibular fracture.44 The studies reviewed compared the
tongue blade bite test to plain radiography which was the acceptable Level IV. The AOCMF training manual on a systematic
surrogate gold standard at that time.41, 45 Newer diagnostic studies have approach to evaluation and diagnosis in craniomaxillofacial
been published that compared the utility of the tongue blade test to trauma stated that panoramic tomography is a useful
the new gold standard, computed tomography (CT), in diagnosing screening tool in evaluating for mandibular fracture. It has
mandibular fractures. These studies affirm that the bite test or tongue similar or better sensitivity than standard mandibular series
blade test is highly sensitive and specific for predicting mandibular radiographs in detecting mandibular fracture especially the
fractures.46, 47 Another study corroborates their findings, however, only body region. It is also useful in evaluating the dentoalveolar
the study abstract was available at the time of this writing and thus region.51
could not be properly appraised.48
The clinical signs seen in patients with mandibular trauma have also Level III. A clinical trial study conducted at the University of
been found to be useful in ruling out mandibular fractures.42, 43, 45 One Texas Health Science Center on adult female cadavers to
study developed a “maximally sensitive” clinical decision tool (absence assess the age- and sex specific risks in adult female patients
of malocclusion, tenderness on jaw closure, broken tooth, trismus and from rotational panoramic radiography estimated risk by
step deformity) that will enable a clinician to rule out the diagnosis of using a computer algorithm for simulation of radiation
fracture and obviate the need to request for radiographic studies.43 transport through the human anatomy. The study showed
that radiation doses from panoramic radiography are less
STATEMENT 2. PANORAMIC X-RAY: Clinicians may request for than those from the 21-film full-mouth (FMX), but greater
panoramic x-ray as the initial imaging tool in evaluating patients than from a 4-film interproximal (BMX) examination.52
with a presumptive clinical diagnosis of mandibular fractures.
Recommendation. Level IV. A narrative review on radiation exposure from
panoramic radiography using the ‘As Low As Reasonably
Action Statement Profile for Statement 2 Achievable’ (ALARA) principle. Between 4.7 to 14.9 uSv
l Aggregate evidence quality: Level III, Grade C radiation doses per exposure was the calculated effective
dose from various panoramic units used.53

Level IV. In a literature review, Panoramic x-ray is considered be carried out. The modality should entail optimal preoperative and
as the most informative radiograph used in diagnosing intraoperative case management, minimizing treatment failures and
mandibular fractures. However, these are few of the complication rates.49, 50
disadvantages: 1) Technique requires patient to be in upright A standard panoramic radiograph is noted to show the most
position; 2) Difficult to appreciate the buccal lingual bone comprehensive view with a single film.50 Panoramic radiography
displacement due it produces 2-dimensional image; 3) Lack is also referred to as panographic view, pantomography and
of fine details in the symphysis region of the mandible due to orthopantomography. It is also useful in examining dentition, presence
thickness of the bone.54 of impacted teeth with respect to the fracture, alveolar process and
portion of the mandibular canal. It has 92% diagnostic accuracy over
l Benefit: Panoramic x-ray provides a single, comprehensive standard radiographs.49 Hence, it is the most suitable screening film
view of the mandible with less radiation exposure and faster for the radiographic examination of the mandible.49-52 Panoramic
results than mandibular series; easier interpretation due to x-ray provides less exposure to radiation 49 and presents faster results
decreased bone superimpositions with less missed fractures compared with other modalities. Effective Radiation doses ranged
including status of existing dentition.52 between 4.7-14.9 uSv for one exposure.53 Several disadvantages were
l Risks, harms, costs: Panoramic x-rays may fail to detect noted: 1) Patients are required to be positioned upright, which may
symphyseal, condylar, subcondylar, coronoid fractures be disadvantageous to patients with limited mobility. 2) The image
and fail to differentiate between inner and outer table produced is a 2-dimensional view, which results in a limited evaluation
fractures. Radiation doses range between 4.7-14.9uSv per of buccal and lingual displaced fractures. 3) Details may not be
exposure; Technique usually requires upright position unless appreciated in the symphyseal area.54
zonography is available: Direct cost of procedure (around PhP
500.00-1000.00). STATEMENT 3. RADIOGRAPHS: In a setting where panoramic
l Benefit - harm assessment: Preponderance of benefit over radiography is not available, clinicians may recommend plain
harm. mandibular radiography among patients with presumptive clinical
l Value judgements: Although the panel recognizes the diagnosis of mandibular fracture. Recommendation.
superior role of CT scans in imaging mandibular fractures,
superiority is not significantly better than Panoramic x-ray for Action Statement Profile for Statement 3
simple mandible body fractures. Panoramic x-rays are more l Aggregate evidence quality: Level III, Grade C
accessible, affordable, and entail less radiation exposure than
mandibular series and CT scan. However, use is limited to Level III. A cross sectional study comparing panoramic
patients who can stand or sit upright. In the Philippines, most and standard radiographs for the diagnosis of mandibular
trauma patients from middle to marginalized sectors are fracture involved 50 patients with known fractures of the
brought to government hospitals where plain radiographs mandible at the Medical College of Virginia Hospital from
and/or panoramic x-ray are readily available. February 1981 to January 1985. Both panoramic radiograph
l Intentional vagueness: None and mandibular series were performed for all the patients
l Role of patient preferences: Small within 12 hours of each other. Results of the radiograph were
l Exceptions: Unable to tolerate upright position evaluated by two senior residents in the Oral and Maxillofacial
l Policy level: Recommendation Surgery Department. 92% of the fractures were identified
l Differences of opinion: None from the Panoramic radiographs while 66% were detected
in the mandibular series. In the mandibular series, 21 out
Supporting Text of 29 fractures in the condylar region were better evaluated
Six studies were reviewed which consisted of 3 narrative reviews, 2 by using Towne’s view. All 6 cases of fracture located in the
cross sectional studies and 1 laboratory study. symphysis region were recognized using the posteroanterior
Meticulous clinical examination of the mandibular area is critical and Towne’s view while the lateral oblique view was best
when a mandibular fracture is suspected. When there is a presumptive used in identifying ramus, angle and body fractures.49
clinical diagnosis of a mandibular fracture, imaging studies should

Level III. A cross sectional study comparing the diagnostic Level I. An evidence-based guideline authored by the
efficacies of panographic radiographs, mandibular trauma SEDENTEXCT project stated that exposure to radiation is
series, and digitized radiographs in detection of mandibular higher in mandibular radiographs versus panoramic x ray (<6
fractures where 25 cadaveric specimens were subjected to mSv versus 2.7-24.3 mSv), but much lower than CT scan (280
blunt trauma. Each specimen underwent all three imaging mSv - 1410 mSv).57
modalities and six observers recorded their diagnosis using
a five-point confidence rating scale (1-fracture definitely Level III. A diagnostic cross sectional study on 21 subjects
absent; 2-fracture probably absent; 3-unsure whether with mandibular fractures managed by the plastic
fracture is present; 4-fracture probably present; and surgery service at a single institution in the United
5-fracture definitely present). The study stated that “location- States examined all patients with a standard mandibular
wise differences in diagnostic accuracy were noted and series (anteroposterior, right and left lateral oblique,
possibly could be explained by the fact that visualization Towne’s), panoramic tomography and axial and coronal
of the coronoid and condylar, with mean percentage of CT. Mandibular series x-ray ranked second in accuracy
65% on the mandibular series was relatively more difficult (93%) next to Coronal CT scan (97%), followed by panorex
due to projection geometry issues and superimposition by radiograph (90%) and axial CT (82%).58
overlying anatomy, compared with panoramic images where
these were minimal to nonexistent.”50 l Benefit: Plain mandibular series have comparable sensitivity

and specificity to panoramic x-rays in detection of mandibular
Level III. A diagnostic cross sectional study evaluated fractures.55 Also, they are widely available compared to other
54 patients presenting with acute mandibular injury imaging modalities.
examined at the urban university medical center emergency l Risks, harms, costs: Plain mandibular series may miss
department and compared pantomography (Panelipse fractures on every site of mandible excluding fractures on the
Panoramic XRay System #46181121G1) and mandibular ramus.49 Decrease in diagnostic accuracy of plain mandibular
series (postero-anterior, right and left oblique, and reverse films versus panoramic x-ray and CT due to superimposition
Towne projections) in the detection of mandibular fracture. of bony structures and confusing spatial relationships.50
The films were read in a randomized fashion by 2 board- Exposure to radiation is higher in mandibular radiographs
certified emergency physicians and a single staff radiologist versus panoramic x-ray (< 6 uSv vs. 2.7-24.3 uSv), but much
without access to clinical information or identifying patient lower than CT (280 - 1410 uSv) 57 Cost of standard mandibular
data. The sensitivity for fracture detection for each physician radiographs around PhP 400-600 in government hospitals
was 0.85, 0.77 and 0.89 with mandibular series and 0.79, 0.74, and around PhP 1,300-1,800 in private hospitals in the
and 0.83 with pantomography. The specificity for fracture Philippines; lower than panoramic x-ray.
detection for each physician was 0.88, 0.92, and 0.96 for l Benefit - harm assessment: Preponderance of benefit over
mandibular series and 0.96, 1.00 and 0.92 for pantomography. harm
The study showed that standard mandibular series has been l Value judgements: The group concurs that CT is the imaging
shown to have comparable sensitivity and specificity to gold standard for evaluating mandibular fractures. However,
pantomography in the detection of mandibular fractures.55 due to CT higher costs, panoramic x-ray is considered the
best initial imaging modality for evaluating mandibular body
Level IV. A narrative review discussing the different fractures. Because panoramic x-ray is not widely available,
imaging modalities in mandibular fracture stated that plain mandibular series are deemed sufficient based on
the plain mandibular series (which includes the postero- aggregate evidence and the ASP, which recommends it
anterior, Towne’s and lateral views) is still used as routine as the next best imaging modality after panoramic x-ray
screening tool in the detection of mandibular fracture in in the context of low- and middle-income patients. Plain
comparison to other imaging modalities. The Towne’s view mandibular series are widely available, affordable and have
was found particularly useful in assessing preoperative and comparable sensitivity with panoramic x-ray and CT Scan.
postoperative subcondylar fractures.56

l Intentional vagueness: none radiographic imaging for the mandible. Panorex is an

l Role of patient preferences: Large. Patients may opt for CT excellent screening evaluation for patients who can sit
Scan instead of plain mandibular series if they can afford its or stand upright without motion. CT Scan is generally
cost. preferred for multiple mandibular fractures and especially
l Exceptions: No absolute contraindication. Inability to position helpful in multiply traumatized requiring images and when
the head properly may constitute a relative contraindication. visualization is difficult especially for condylar head and high
l Policy level: Recommendation condylar neck.5
Level II. This clinical simulation study compares the diagnostic
Supporting Text accuracies of panoramic radiograph, mandibular series,
Six articles were reviewed for this statement: 4 cross sectional digitized mandibular series, and panoramic radiograph -
studies, 1 narrative review and 1 clinical guideline. anteroposterior view in detecting facial fractures inflicted
Plain mandibular series is a good screening examination among among 25 cadavers. Results showed that panoramic
patients with suspected mandibular fractures since it is accurate, radiographs are adequate in detecting mandibular fractures.
widely available and affordable compared to other modalities.55, Addition of anteroposterior view to panoramic radiographs
56
One disadvantage of mandibular series is that it is limited by its augment diagnostic accuracy.
2-dimensional view. It may miss fractures of different sites of the It was also mentioned that only in rare instances where
mandible, except the ramus, due to the superimposition of bony there is extreme displacement of the fracture segments is CT
structures and the confusing spatial relationships of one segment to indicated. An instance of such a condition is a high condylar
the other.50 The limitation, however, may be reduced by taking multiple fracture. Advanced imaging in such instances can provide
radiographic views (postero-anterior, lateral oblique, and reverse multiplanar and 3-D examinations with relatively high-
Towne’s).49, 50, 56 The combination and simultaneous correlation of these contrast images.
films may be used to confirm a possible fracture in the mandible. Furthermore, routine use of CT is not justified as standard of
In comparison with other imaging modalities such as panoramic care for mandibular fractures due to the high cost, increased
radiography and computed tomography, plain mandibular series ranks radiation burden of the examination, and potential for artifact
second after coronal computed tomography in terms of accuracy in generation of restorations within the oral cavity, in addition
the detection of fractures of the mandible, followed by panoramic to the patient’s having to remain motionless for the period of
radiography and axial computed tomography.58 image acquisition.50
STATEMENT 4. COMPUTED TOMOGRAPHY: If available, non- Level III. A diagnostic accuracy study of 164 patients with
contrast Facial CT scan may be obtained for the assessment of suspected mandibular trauma examined by 6 oral and
mandibular fractures. Recommendation. maxillofacial surgeons. Initial radiographic examination
comprised panoramic imaging (Orthophos XG Plus, Sirona,
Action Statement Profile for Statement 4 Bensheim, Germany) and a posteroanterior skull radiograph
(Siemens Multix Pro/Vertix/ Poly-doros, Siemens, Erlangen,
l Aggregate evidence quality: Level III, Grade C
Germany). In instances wherein there was inconclusive
radiologic data, CBCT (NewTom 3G MF12, NNT Viewer
Level IV. A narrative review discussing the differences
Software version 3.00, 12-in FOV) was done to confirm or
between cone beam CT and conventional CT including rule out the presence of mandibular fracture. Results showed
several applications of each method stated that CT studies that CBCT can identify an additional 17.75% of mandibular
are rarely used to evaluate isolated mandibular fractures. fractures and 14.72% in fractures and a change in treatment
However, they are of value in the evaluation of complex in 9.52% of all examined cases.59
mandibular fractures including condylar fractures.64
Level IV. A narrative review of different ER diagnostic imaging
Level IV. The AAO-HNS Resident’s Manual of Trauma to the protocols for maxillofacial trauma proposed a ‘mandibulo-
Face, Head, and Neck discussed the strengths of different facial series’ (PA, oblique, occipito-mental and panorex)

for isolated mandibular fracture and a CT scan for cases of Level IV. A narrative review discussing the management of
combined midface and mandibular fracture.61 mandibular fractures states that in patients with multiple
midface injuries, those wearing a cervical collar or unable
Level V. A case report of a patient who sustained multiple to undergo panoramic radiography, maxillofacial CT is
fractures including C-1 vertebra and mandibular body necessary. An algorithm showed that panorex plus low
determined that the positioning used for conventional films Towne’s view should be used for low suspicion of mandibular
to diagnose mandibular fracture could not be done due to fracture whereas CT scan with or without 3D reconstruction
risk for added injury, hence CT scan was used.62 is advised if there is high suspicion, with or without other
facial fractures.60
Level IV. A narrative review discussing the evolution of
imaging in maxillofacial trauma stated that although image Level III. A diagnostic accuracy study comparing CT and plain
resolution is less than conventional plain film imaging, initial radiographs’ ability to detect facial fractures indicated that
investigations demonstrated that CT provided superior 3D CT was statistically more significant (Z= 8.8, p<.001) in
diagnostic accuracy compared to radiography in the terms of fracture site detection compared to conventional
diagnosis of maxillofacial injury particularly with respect radiographs. Moreover, 3D CT was superior in displaying
to soft tissue diagnosis. One study reviewed showed that extent of fractures and comminution as well as displacement
coronal CT was the most accurate method for diagnosis of and it provided additional conceptual information compared
mandibular fractures, followed by mandibular series and to conventional radiographs in the majority of patients with
panoramic radiography.65 maxillofacial trauma.67
Level IV. A narrative review mentioned that the introduction Level III. A cross sectional study determining the clinical
of computed tomography (CT) has increased the sensitivity usefulness of 3D CT compared to 2D CT showed that in a
and accuracy with which craniofacial fractures can be majority of cases within each of the four clinical groups
detected, facilitating more detailed analysis and classification (including trauma), the clinicians believed that 2D or 3D
of facial fractures.72 reformatting of the CT images provided additional useful
information for patient management. In most of the cases, 3D
Level IV. This narrative review discussing the role of imaging imaging provided information in addition to that provided
in the evaluation of complex facial fractures including by the axial or 2D reformatted images.68
important considerations to look for depending on the site
of facial fracture stated that accurate maxillofacial fracture Level IV. This narrative review mentioned that the advent of
detection by CT is important for surgical treatment to avoid computed tomography (CT), thin-cut facial CT scans, and
undesirable functional and/or cosmetic sequelae.73 most recently three-dimensional CT reformations, have
improved diagnosis, and have shifted the primary diagnostic
Level IV. This narrative review presented a treatment protocol modality of facial fractures from the physical exam and plain
utilized by oral and maxillofacial surgery departments radiographs to CT.70
of various military hospitals (Wilford Hall USAF Medical
Center, the National Naval Medical Center–Bethesda, Walter Level IV. A narrative review which presented a comprehensive
Reed Army Medical Center, and the National Naval Medical classification of craniofacial fractures mentioned that the
Center– San Diego) for maxillofacial injuries. In this protocol, accurate analysis of thin axial CT slices with high-quality 2D
imaging and stereolithographic models are done following and 3D-reconstructions guaranteed a good practical imaging
stabilization and identification of patient injuries. A CT scan approach.71
should be the minimum information obtained before surgery
(although patients in this review suffered from extensive Level IV. A narrative review mentioned that the 3D extension
facial trauma secondary to combat injuries rather than simple of defects can be assessed accurately with CT. Important
and isolated mandibular fractures).75 information concerning the amount and direction of fracture

dislocation becomes clear and localization of important question for which imaging is required cannot be answered
structures can be determined accurately.74 adequately by lower dose conventional (traditional)
radiography.”57
Level III. A cross sectional study comparing the diagnostic l Benefit: Image enhancing tools, better imaging quality
sensitivity of mandibular series and axial CT in ruling out (identify number and anatomic location of mandibular
mandibular fractures showed that CT demonstrated higher fractures), provide more accurate details on the fracture
image quality scores (87%) compared to mandibular series (extent, severity and degree of displacement of fractured
(66%) based on reviewers’ subjective assessment of quality.76 segments), decreased interpretation error.
l Risks, harms, costs: Potential risk of unnecessary exposure
Level I. This systematic review evaluated the data available to ionizing radiation for patients undergoing CT Scanning.
regarding reliability and accuracy of skeletal CT landmark A maxillo-mandibular multislice CT (MSCT) (effective dose
identification and stated that “the more complex the surgery, 280-1,410 μSV) has higher radiation exposure vs. panoramic
the more critical it is to have accurate CT data to minimize x-ray (effective dose 2.7-24.3 μSV) Plain CT (PhP 3,500-5,000)
intraoperative risk and poor outcome. The acceptable degree is more expensive than plain radiographs (PhP 240-1600).
of error will depend on the type and complexity of the surgical l Benefit - harm assessment: Preponderance of benefit over
procedures being planned and the goals of the study”.66 harm
l Value judgements: Option for clinician to request CT scan
Level III. A retrospective case series discussed the indications because of higher sensitivity & accuracy in diagnosing
of intraoperative cone beam computed tomography (CT) as mandibular fractures; important to adequately identify
the gold standard in preoperative diagnostics of maxillofacial all fractures to preoperatively anticipate techniques that
fractures that is performed post-operatively as well as during may or may not be applicable for safe and optimal surgical
follow-up. Fluoroscopy based cone beam CT has also been
procedure. Affordability may be an issue for patients.
used for surgical navigation and intraoperative assessment of
l Intentional vagueness: Type of CT scan (multislice, CBCT) not
adequacy of reduction in complex mandibular fractures.72
specified; availability and affordability have to be considered.
l Role of patient preferences: Moderate; patients who cannot
Level IV. A narrative review discussing the advantages and
afford CT may request alternative imaging (room for
disadvantages of CT and CBCT said that CT provides good
negotiation).
resolution of soft and hard tissues but delivers the highest
l Exceptions: None
amount of radiation while CBCT is able to provide excellent
l Policy level: Recommendation
information of bony structures but is not able to effectively
assess the soft tissue components.63
Supporting Text
Level IV. A narrative review discussing the advances in head
Twenty-one (21) articles were reviewed, including 10 review articles,
and neck imaging in general stated the disadvantages of CT
in the head and neck. Chief among them is radiation risk. 5 cross-sectional studies, 2 prospective studies, 1 retrospective study, 1
Artifacts can also be an issue, especially in the head and neck, case series, 1 case report, and 1 practice guideline.
where the anatomy is complex and many different tissue The decision to use more advanced imaging modalities such as
types are in close proximity. Beam-hardening artifacts from Computed Tomography or Cone Beam Computed Tomography to
bone, hardware, or dental amalgam, can obscure images diagnose mandibular fractures should be decided after considering
of nearby soft tissues. Motion (eg, from swallowing or severity of the injury, structural superimposition, patient’s functional
phonation) can also cause artifacts, although this is less of an restrictions, cost, availability, soft-tissue imaging requirements and the
issue with the most current 64-slice scanners, which require need for 3-dimensional views.64
less scan time.69 CT is a better tool for a more definitive diagnosis and treatment
planning of complex maxillofacial structures than traditional
Level IV. Basic Principles of SEDENTEXCT Guideline for Cone radiographs. It can identify the number and anatomical location of
Beam CT states that “CBCT should only be used when the mandibular fractures, provide more accurate details on the extent of

the fracture, severity of comminution and degree of displacement of Action Statement Profile for Statement 5
the fragments. A CT scan is therefore reserved and more advantageous l Aggregate Evidence Quality: Level II, Grade B
for patients with complex mandibular injuries and other concomitant Level II. A quasi-experimental study compared the
injuries of the maxillofacial skeleton.5, 50, 59, 61,62, 64, 65, 72, 73, 75 effectiveness of simple splinting and traction splinting in
Three-dimensional reconstruction can be done in conjunction patients with femoral fracture on pain intensity measured in
as it provides better visualization of the position, displacement and visual analog scale immediately after the 1st hour, 6th hour
comminution of bone fragments.50, 60, 63, 67, 68, 70, 71, 73, 74, 76 “The more and 12th hour of splinting. The pain intensity decreased
complex the surgery, the more critical it is to have accurate CT data to significantly in both groups. The reduction in pain intensity
minimize intraoperative risk and poor outcome.”66 was far more superior in traction splints than simple
The disadvantages of CT include its cost, lack of accessibility, and splinting.77
immediate availability. It may also produce significant artifacts -- beam-
hardening artifacts (bone, hardware, or dental amalgam) and motion Level IV. Guidelines on casting and splinting mentioned that
artifacts (swallowing or phonation) that can obscure images. It also casting is the mainstay of treatment for most fractures and
subjects the patient to high radiation exposure. As radiation has a generally provide more effective immobilization.78
cumulative effect on the human body, any reduction in exposure to
radiation is considered beneficial.63, 66, 69 Level V. A case report of a 28-year-old man presenting with
One advanced imaging modality that may be used as an alternative a history of painful swollen wrist following a fall on both
to CT is CBCT. One of the basic principles of SEDENTEXCT Guidelines outstretched arms who was treated with a cast due to an
for Cone Beam CT stated “CBCT should only be used when the question undisplaced scaphoid wrist fracture and proximal pole
for which imaging is required cannot be answered adequately by lower fracture on the right and left. Conservative cast immobilization
dose conventional (traditional) radiography”.57 had a positive effect on early return to full activity.79
CBCT increases diagnostic certainty to 90.5% in patients with
suspected mandibular fracture. It provides additional fracture detection Level I. A systematic review on management of mandibular
and leads to a change in the treatment plan in 9.52% of sites compared condyle fractures compared conservative management
to plain radiographs. 59 It has reduced radiation exposure time and (closed reduction) and open reduction and fixation.
consequently reduced radiation exposure for patients. Another Conservative management in this study includes either soft
advantage is the different display modes unique to maxillofacial diet, analgesics, and antibiotics, with or without maxillary-
imaging, and smaller size and cost than conventional CT scan.66, 69 mandibular fixation. A total of 102 references were retrieved,
Although several studies have shown the diagnostic efficacy of however, none of these studies met the inclusion criteria.
CBCT in mandibular fractures, it has not yet been recommended as Therefore, this systematic review showed there is still lack of
the primary diagnostic tool to use in a person suspected with multiple, evidence regarding the indications for either surgical or non-
severe facial injuries due to its limitations in soft tissue contrast. Unlike surgical treatment of the mandibular condyle.80
CBCT, CT may show the relations of a bone fragment and the adjacent
muscle, bleeding, and existence of some foreign bodies in a traumatic Level IV. A US patent recorded on Sept. 18, 1973, invented
injury. CBCT may be recommended as an alternative to the CT scan by Joseph E. O’ Malley illustrates the precise immobilization
for ambulatory patients without loss of consciousness with suspected of mandible fractures using a one-piece device. It is made
mandibular fractures.76 of velcro connections that support the harness around
the chin to the occiput. A head strap on top also uses
STATEMENT 5. IMMOBILIZATION: Isolated mandibular body Velcro Connection. This invention was based on a splint for
fractures should be temporarily immobilized/splinted with a mandibular injuries, the Barton’s Bandage.81
figure-of-eight bandage until definitive surgical management
can be performed or while initiating transport during emergency Level IV. A simplified splint for precise immobilization of the
situations. Recommendation. mandible or lower jawbone in mandibular injuries having a
main or supporting harness of a single piece of material with
a chin support and an occiput engaging support connected

by curved portions passing over the ears on either side of the Action Statement Profile for Statement 6
patient’s head.82 l Aggregate Evidence Quality: Level I, Grade A
l Benefit: Reduction of pain and prevention of further Level IV. The Emergency Care Acute Pain Management
complication while waiting for definitive treatment. Manual formulated by the National Institute of Clinical
l Risks, Harm, Cost: Undue pressure may result on the forehead Studies of Australia states that pain is a subjective experience
and ears if the bandage is not properly applied. This may be and should be assessed using a validated pain scale. The
avoided with minimal traction. Numerical Rating Score may be used on adults, and is a ten-
l Benefit-Harm Assessment: There is preponderance of benefit point scale rated from 0 (no pain) to 10 (worst pain possible).
over harm. Moderate pain ranges from 4 to 6.83
l Value Judgements: In general, the initial treatment for
mandibular fractures is immobilization. This is necessary Level I. According to the health care protocol (acute pain
until definitive surgical management can be performed or assessment and opioid prescribing protocol) used in
while initiating transport during emergency situations. The Minnesota, while pain screening using a numeric pain scale
reduction of pain and the reduction of further complications increases the rate of pain assessments used, this does not
can improve the quality of life of patients with isolated affect the level of pain or treatment prescription.84
mandibular body fractures. In developing countries, patients
in low socioeconomic brackets who cannot undergo Level I. The WHO Cancer Pain Relief monograph states that
immediate surgical treatment may benefit from this type of in patients with mild pain, non-opioid drugs such as aspirin,
immobilization. paracetamol, or any of the non-steroidal anti-inflammatory
l Intentional Vagueness: None drugs will be adequate. In patients with moderately severe
l Role of patient preference: None pain, if non-opioids do not provide adequate relief when
l Exception: None given on a regular basis, codeine or an alternative weak
l Policy Level: Recommendation opioid should be prescribed.85
l Differences of Opinion: None
Level III. A cross sectional study of 101 Dutch Hospitals that
Supporting Text were requested to submit their protocols for post-operative
Six articles were included in this review, composed of 1 quasi- pain management, showed that 22 different analgesics were
experimental study, 1 practice guideline, 1 case report, 1 systematic used in 135 administration schemes. Paracetamol, diclofenac,
review, 2 patents. Immobilization has always been the mainstay of and morphine were mentioned in the majority of treatment
treatment for all types of fractures in general.77-82 Literature reviews schemes. All of the protocols mentioned the use of a visual
since the World War II era described the use of Barton’s Bandage as a analogue scale or numeric rating scale to assess pain. It also
means for immobilization of the mandible. They noted that the benefits found no specialized pain protocols for the treatment of post-
of immobilization in fractures included lessening of the pain and surgical fracture pain and that there was great variability in
prevention of further displacement of fractures.77-80 postoperative fracture pain; and highlights a need for the
improvement of protocols used for the management of
STATEMENT 6. PAIN MANAGEMENT: Clinicians should routinely postoperative pain, as many of the pain protocols for the
evaluate pain in patients with isolated mandibular body fractures management of post-surgical fracture pain were incomplete
using a numerical rating pain scale or visual pain analog scale. and inefficient, and non-specific to postoperative fracture
Analgesics should be routinely offered to patients with numerical pain, emphasizing the importance of developing an
rating pain scale score or VAS of at least 4/10. Patients may be evidence-based, clear, and specific protocol for the treatment
initially managed with paracetamol and a mild opioid with or of pain after surgical treatment of traumatic fractures.86
without an adjuvant analgesic. Reassessment should be given
until the numerical rating pain scale score or VAS is 3/10 at most. Level III. A cross sectional study was conducted at the
Strong Recommendation. Emergency Department (ED), Division of General Pediatrics,
The Children’s Hospital of Philadelphia (CHOP) and the

Department of Emergency Medicine, Medical College of that with a baseline VAS score in excess of 30 mm they would
Pennsylvania, Philadelphia (MCP) to see whether children probably have recorded at least moderate pain on a 4-point
received analgesic treatment similar to adults with the same categorical scale. The initial level of pain has historically been
acute, painful conditions. Charts of 112 pediatric patients measured with a standard categorical scale (none, mild,
from CHOP ED and 156 patients from the MCP ED were moderate or severe). However, visual analogue scales (VAS)
reviewed. The data suggest that physicians need additional are often used in the belief that the measurement continuum
education about management of acute pain.87 produces greater sensitivity than the discrete points of the
categorical scale.90
Level III. A cross sectional study used data from the Emergency
department component of the National Hospital Ambulatory Level III. A cross sectional review participated in by 14
Medical Care Survey directed by the Centers for Disease accident and emergency departments in England with
Control and Prevention National Center for Health Statistics 100 senior house officers as respondents found a large
for 1997 to 2000. Of 2,828 patients with isolated closed percentage of the respondents would use an inappropriate
fractures of the extremities or clavicle, 64% received any route of administration (intramuscular 50% rather than
analgesic and 42% received a narcotic analgesic. The scales intravenous 50%), some would use an inappropriate drug
used (e.g. Modified Infant Pain Scale; Face, Legs, Activity, Cry, and often wait too long (90min) before giving a further dose
Consolability pain rating scale; and the Wong-Baker Faces of analgesic. Results suggest that a) there is need for further
pain rating scale) have been validated in infants and young teaching on pain relief at medical schools, b) casualty
children. They also concluded that additional effort and officers need to be taught about analgesia when they start
resources are needed to address the issue of undertreatment working in accident and emergency departments, and (c) it
of pain in children and adults with fractures in the ED setting. may be beneficial for accident and emergency departments
Special attention should be given to analgesia in the very to have an analgesic policy.91
old and very young. Educating providers on nonverbal
options for measuring pain, especially in young children, may l Benefit: Reduction of pain
improve measurement and documentation of pain status l Risks, Harm, Cost: Patients with allergies to analgesics
and facilitate recognition and treatment of pain in these l Benefit-Harm Assessment: There is a preponderance of
vulnerable populations.88 benefit over harm
l Value Judgement: Patients who are adequately immobilized
Level III. A descriptive cross sectional study of consecutive usually do not present with pain. It is also dependent on a
patients admitted to four surgical wards of a major 550- patient’s pain threshold, so there is a need for a numerical
bed regional hospital in Denmark between November 2005 pain scale to better control pain or give comfort to the
and May 2006 measured pain by numerical rating scales, patient. Based on our literature review, it has been shown
and means and standard deviations were used to describe that most institutions do not have proper emergency room
data. To aid interpretation of data, ratings were categorized assessment of fracture pain, nor do patients receive adequate
into no pain (0), mild 1–3), moderate (4–7) and severe pain management.
(8–10). The study highlights that further work is required Based on the WHO analgesic ladder, paracetamol in
to develop better approaches for patient assessment of conjunction with tramadol or any other mild opioid may be
pain management needs, and to ensure that patients are used to manage pain initially while an adjunct analgesic may
recognized as having an important, mutually identified clear be given if pain management is inadequate.
role in their pain management to ensure their needs are While the panel recognizes that the parenteral and
met.89 intramuscular route may be more efficacious, we leave
the administration route to the discretion of the primary
Level I. A meta-analysis of 1,080 patients from 11 controlled healthcare provider.
double-blinded randomized trials that investigated the l Intentional Vagueness: The analgesic, dosage, duration and
analgesic effects of various drugs in postoperative pain found route are not specified.

l Role of patient preference: Moderate; especially patients with Level I. Clinical practice guidelines on Antibiotic Prophylaxis
allergies to analgesics. against Wound Infections for Oral Procedures published
l Exceptions: Patients with allergies to analgesics by the Ministry of Health Malaysia (2002) classified ORIF
l Policy Level: Recommendation of mandibular fractures with concomitant mucosal or
l Differences of Opinion: None skin laceration as Class III surgery requiring prophylactic
antibiotics. Penicillin alone has adequate coverage for the
Supporting Text bacterial flora causing surgical site and/or implant infection.93
There were 9 articles used in this section: 6 guidelines, 1 textbook
chapter, 1 prospective study and 1 individual patient meta-analysis. Level II. A prospective cohort study conducted a regional
The practice guidelines and emergency protocols included in the 2-stage prospective audit involving 5 different maxillofacial
formulation of this key action statement all state that a numerical units in the Yorkshire region of the UK to evaluate the
pain rating scale or visual analogue scale is imperative in the initial effectiveness of perioperative antimicrobial prophylaxis in
assessment of patients with pain.83, 84, 86, 88-91 They may not necessarily be the treatment of mandibular fractures. The first stage (145
specific to mandibular fractures, but they reiterate the need for proper patients) surveyed current practice concerning antimicrobial
management of pain at the emergency room. prophylaxis and found out the current infection rate after
Adequate analgesia for moderate pain, described as a numerical open reduction and internal fixation (ORIF) of mandibular
score of 4/10, is managed via the WHO analgesic ladder. This guideline fractures. The second stage (157 patients) implemented a
states that patients should be initially managed with paracetamol plus common antimicrobial protocol in all units and recorded
a mild opioid with or without an additional analgesic until adequate the infection rates using the new regimen. A systematic
analgesia is achieved.85 review by Andreasen et al. found a 3-fold reduction in
There is room for improvement in the management of pain as infection in groups given antibiotic prophylaxis. The
evinced by our literature review which shows that hospitals vary in the published infection rates for open reduction and internal
way pain is managed, and that pain is usually overlooked once patients fixation (ORIF) of mandibular fractures with antimicrobial
are seen at the emergency room.86-91 prophylaxis range from 2% to 14%. They recommend short
perioperative antimicrobial prophylaxis with a maximum of
STATEMENT 7. ANTIBIOTICS: Prophylactic antibiotics should be 2 postoperative doses after ORIF of mandibular fractures.94
given to adult patients with isolated mandibular body fractures
with concomitant mucosal or skin opening with or without direct Level I. A randomized controlled trial at the University
visualization of bone fragments. In patients without mucosal or of Miami Medical School randomized 90 patients with
skin lacerations, prophylactic antibiotics can be given 1 hour prior compound mandible fracture to two antibiotic regimens.
to surgery and up to 24 hours postoperatively. Penicillin is the The surgical procedures were performed by oral/
drug of choice while Clindamycin may be used as an alternative maxillofacial surgery. Standard treatment consisted of
for patients in whom Penicillin is contraindicated. Strong open reduction with either bone plates or wires with all
Recommendation. patients receiving 6 weeks of maxillomandibular fixation.
The patients were monitored at 2-week intervals for 8
Action Statement Profile for Statement 7 weeks by two of the authors, who were blinded to which
l Aggregate Evidence Quality: Level I, Grade A antibiotic regimen the patient was assigned. Two patients
Level I. This CPG states that in certain circumstances, in each group had postoperative infections within the first
oral antimicrobial rinses and systemic antibiotics may be 2 weeks of treatment. The infections resolved with local
indicated to lower the probability of infections related to wound care, removal of internal fixation devices, and oral
surgery. It also states that prophylaxis is recommended antibiotics. After resolution of the infection each patient
because endothelialization of prosthetic material occurs had a malunion, which was managed without additional
within 6 months after the procedure. Prophylaxis should also complications.95
be considered for patients with total joint replacement.92

Level I. A randomized double-blind clinical study in India as low as 10% with the use of prophylactic antibiotics. In this
involving 60 patients undergoing BSSO (premised on study, the rate of infection in both groups was comparable to
the basic purpose of antibiotic prophylaxis to provide an that of previous studies on the rate of infection in mandibular
adequate drug level in the tissues before, during, and for the fractures when perioperative antibiotics were used. This
shortest possible time after the procedure) randomly divided represents further evidence that the use of prophylactic
patients into two groups: group I, given a single injection of perioperative antibiotics has a benefit in reducing the rate of
amoxicillin 1.0 g administered preoperatively followed by postoperative infection in mandibular fractures.98
two postoperative doses of saline four hourly (single dose
group); and group II, given a single injection amoxicillin 1.0 g Level III. A cross sectional study of 79 patients with mandible
administered preoperatively followed by two postoperative fractures treated with ORIF at the Plastic Surgery Department
doses of amoxicillin 0.5 g four hourly. There was a statistical of the Brigham and Women’s Hospital, Boston, MA, from June
difference in the rates of infection between the two groups. 2007 to June 2012 revealed an overall infection rate with use
The findings indicate that a short postoperative course of of antibiotic prophylaxis of 7.59%, but patients treated with
antibiotics is more effective than a single preoperative dose clindamycin had an infection rate of 19.35%. The infection
for the prevention of infection following BSSO.96 rate when using ampicillin/sulbactam was significantly
lower than clindamycin. On the basis of this review, proper
Level I. A randomized, double-blind placebo-controlled antibiotic prophylaxis should cover both potential aerobes
pilot clinical study of 98 patients with zygomatic or Le Fort and anaerobes.99
fractures, who were treated by open reduction and internal
fixation at the Department of Cranio-Maxillofacial Surgery, Level I. A prospective randomized trial of 291 patients
University Hospital of Bern, Switzerland, from January 2008 presented for evaluation and treatment of open mandibular
to July 2011 corroborated the Surgical Infection Prevention fractures at Parkland Memorial Hospital, Dallas, TX from
Guideline Writers Work-group in the United States 2005 June 1999 to May 2003, where 181 patients of 291 patients
consensus paper that advised antimicrobial prophylaxis be met the inclusion criteria and were randomly divided into 2
given within 60 min before the incision is made, and then groups based on whether or not they received postoperative
discontinued within 24 h postoperatively, as prolonged use antibiotics. Both groups received preoperative antibiotics of
of prophylactic antimicrobial agents showed no additional various regimens as well as intraoperative antibiotics on the
benefit, and is associated with emergence of resistant day of surgery. The use of antibiotics in the preoperative period
bacterial strains.97 is standard practice in the treatment of mandibular fracture.
Given the fact that mandibular fractures involving the tooth-
Level I. A randomized, double-blind, and placebo-controlled bearing segments of the mandible are contaminated at the
clinical study in the Medical College of Virginia Hospital of time of the fracture, as well as at the time of surgery, the use
of preoperative/intraoperative or postoperative antibiotics
Virginia Commonwealth University from January 1, 1997
when dealing with these injuries is intended to prevent
to December 31, 1997 randomly assigned 30 patients with
infection in a contaminated wound.100
uncomplicated mandibular fractures into 2 groups: group
1 (14 patients) and group 2 (16 patients). According to the
Level I. A systematic review of 4 studies concerning the
classification of wounds based on their risk for infection, those
possible benefit of prophylactic antibiotics in the treatment
associated with fractures of the mandible involving the tooth-
of maxillofacial fractures combined the evidence from all
bearing region (angle and body fractures) could be classified
4 studies and concluded that there was a significant 3-fold
as Class III, contaminated wounds. If the patient presented
decrease in infection rate with administration of antibiotics.101
with evidence of infection of the fracture or the fracture was
Level I. A systematic literature review of 44 studies from
delayed in receiving treatment, the wound could be classified eight countries addressing antibiotics and facial fracture
as a Class IV (infected) wound. The risk of potential infection management was performed in June 2013 to identify
of these wounds without the use of prophylactic antibiotics published studies evaluating the use of antibiotics in
ranges from 22% to 50%. However, this risk can be reduced to craniofacial trauma including the upper, middle, and

lower thirds of the craniofacial skeleton. Prophylactic larynx, as well as in infected ears and sinuses, is contaminated.
antibiotic use was evaluated by higher level of evidence Surgical prophylaxis requires antibiotics active vs. anaerobes.
studies for mandible fractures: preoperative antibiotic use Primary prophylaxis used for oral and pharyngeal surgeries
in comminuted mandible fractures was supported, but are Ampicillin/Sulbactam OR oral Amoxicillin/clavulanate
postoperative antibiosis in mandible fractures was not.102 1-hour pre op. Alternatives include IV Clindamycin OR
Cefazolin + Metronidazole pre-anesthesia.106
Level I. A systematic review and meta-analysis of 4 RCT’s
with a total of 2063 implants and 1002 patients found that Level I. This guideline stated that for 50 years, the American
antibiotic use significantly lowered the implant failure rate (p Heart Association (AHA) has recommended a penicillin as
= .003), with an odds ratio of 0.331, implying that antibiotic the preferred choice for dental prophylaxis for infective
treatment reduced the odds of failure by 66.9%. Based on the endocarditis (IE). During these 50 years, the committee was
results of this meta-analysis, and pending further research unaware of any cases reported to the AHA of fatal anaphylaxis
in the field, it can be concluded that there is evidence in resulting from the administration of a penicillin recommended
favor of systematic antibiotic use in patients receiving dental in the AHA guidelines for IE prophylaxis. The Committee
implants, since such treatment significantly reduces implant believes that a single dose of amoxicillin or ampicillin is safe
failure. In contrast, antibiotic use does not exert a significant and is the preferred prophylactic agent for individuals who
preventive effect against postoperative infection.103 do not have a history of type I hypersensitivity reaction to
a penicillin, such as anaphylaxis, urticaria, or angioedema.
Level II. A retrospective (cohort) chart review of 150 patients Fatal anaphylaxis from cephalosporin is estimated to be less
treated operatively for both complicated and uncomplicated common than from penicillin, at approximately 1 case per 1
mandibular fractures at University of New Mexico Health million patients. Fatal reactions to a single dose of a macrolide
Sciences Center in Albuquerque, NM, between January 1, or clindamycin are extremely rare. There has been only 1 case
2000 and June 12, 2007 found that the use of postoperative report of documented Clostridium difficile colitis after a single
prophylactic antibiotics does not have a statistically dose of prophylactic clindamycin.107
significant effect on postoperative infection rates in surgical
management of complicated or uncomplicated mandibular l Benefit: Prophylactic antibiotics reduce the incidence of
fractures.104 surgical wound infection and therefore reduce the morbidity
to the patient.
Level II. A retrospective cohort study of 789 case histories l Risks, Harm, Cost: There is potential harm of having a reaction
regarding treatment results and nature of complications to the administration of Penicillin and Clindamycin.
developed at the Maxillofacial Department of the National l Benefit-Harm Assessment: Preponderance of benefit over
Medical University (Kyiv, Ukraine) from 1999 to 2003 found harm.
that the incidence of infection in patients with mandibular l Value Judgement: Prophylactic antibiotics should be given to
fractures located in tooth bearing areas was determined by patients with open mandibular body fractures. They have the
the following risk factors: social and organizational conditions benefit of reducing the incidence of surgical site and implant
of medical care, trauma pattern, pre-existing medical status infection. In the setting of underdeveloped and developing
and treatment tactics. The main contributory factors were countries where patients with mandibular fracture may have
delayed medical care, accompanying pathological disorders, poor oral hygiene, prophylactic antibiotics are beneficial.
angular location, multiple and comminuted fractures and the l Intentional vagueness: The dose, duration, and route of
type of antibiotic used.105 antibiotic administration are not specified in this guideline
for isolated mandibular body fractures with concomitant
Level IV. This guideline states that one milliliter of saliva mucosal or skin opening with or without direct visualization
typically contains over 100 million anaerobic microorganisms of bone fragments.
and 10 million aerobes. The implication is that virtually all l Role of patient preference: None
surgery in the pharynx, nasopharynx, hypopharynx, and l Exception: None

l Policy Level: Strong Recommendation Level IV. A narrative review stated that a nasotracheal tube
l Differences in Opinion: None may be preferred to an oral tube for better field of vision, but
may have significant failure rates when attempted blind.110
Supporting Text Level IV. A narrative review stated that nasal endotracheal
There were 16 studies/articles included in our review: 4 clinical tubes provide surgeons with good surgical access and of
practice guidelines, 3 systematic reviews, 5 observational studies, particular importance in maxillofacial trauma surgery was
and 4 randomized controlled trials. Antibiotic prophylaxis is indicated the usefulness of preformed north-facing tubes which can
in patients with mandibular trauma accompanied by extensive oral be secured to the forehead without obscuring the facial bony
laceration and/or skin laceration92-99 and even without visualized contour.111
mucosal lacerations or bone fragments, fractures in tooth-bearing
regions are considered contaminated.98-100 Prophylactic antibiotics Level IV. A narrative review emphasized that a simple
reduce the incidence of surgical wound infection and therefore reduce and straightforward approach for airway management is
morbidity of the patient. important during emergency situations. Various available
Antibiotics should be given immediately at the emergency room options include orotracheal intubation, nasotracheal
and extended up to 1 day after definitive management.93, 97, 100-105 In intubation or a surgical airway such as tracheostomy or
cases of closed mandibular fractures, prophylactic antibiotics may be cricothyroidotomy.112
given 1 hour prior to procedure and up to 24 hours post operatively.93-94
Penicillin is the drug of choice while Clindamycin can be given in Level IV. A case report from the Surgery and Integrated
cases where Penicillin is contraindicated.93, 106-107 In support of the use Clinic Department, Aracatuba Dental School, Sa˜o Paulo
of Clindamycin as an alternative to Penicillin, we included a guideline State University, Araraquara, Sa˜o Paulo, Brazil, described the
from the American Heart Association as infective endocarditis shares efficiency of submental intubation in management of a case
the same bacterial flora as the oral cavity.107 with panfacial fracture wherein dental occlusion and nasal
pyramid assessment was necessary.113
STATEMENT 8. ANESTHESIA: Nasotracheal intubation is the
preferred route of anesthesia in patients diagnosed with isolated Level III. A cross-sectional study in the division of Oral
mandibular body fracture. In the presence of contraindications to and Maxillofacial Surgery, Piracicaba Dental School, State
nasotracheal intubation, submental intubation or tracheostomy University of Campinas, UNICAMP, Piracicaba, SP, Brazil over
may be performed. Recommendation. a 10-year period from April 1999 to July 2009 found 3,149
patients with facial trauma; 2,090 of which had facial fractures
Action Statement Profile for Statement 8 with 674 subjected to general anesthesia. Fifteen patients
l Aggregate Evidence Quality: Level III, Grade C underwent submental intubation because of a combination
of fractures affecting the midface and dental occlusion. The
Level IV. A narrative review from the Department of study concluded that submental intubation is a simple,
Otolaryngology and Communication Sciences, State safe technique with low morbidity in operative airway
University of New York recommended nasotracheal management of maxillofacial trauma patients requiring
intubation followed by submental or retromolar intubation access to dental occlusion and the nasal pyramid.114
while avoiding tracheostomy to allow operative access for
patients undergoing ORIF wherein occlusion should be Level III. A cross-sectional study at the Oral and Maxillofacial
established.108 Surgery Unit, Al-Adam Hospital in Kuwait from January 1,
2004 to September 15, 2007 included a total of 356 patients
Level IV. A narrative review presented 2 advantages of admitted due to maxillofacial trauma, with 222 operated
nasotracheal intubation for procedures that would entail on under general anesthesia and 8 subjected to submental
access to oral cavity and face: improved patient tolerance and intubation. The study concluded that it is technically easier,
inability of the patient to bite the ETT.109 less time consuming and has lower morbidity compared to
tracheostomy.115

Level III. A cross-sectional study at the School of Dental l Benefit-Harm Assessment: Preponderance of benefit over
Sciences, Sharda University, Greater Noida between April 2006 harm.
and March 2014 on maxillofacial trauma patients showed l Value Judgement: The need for free manipulation of the
that the majority (449 patients) had nasotracheal intubation, mandible for adequate reduction and fixation can be best
204 had oral intubations, 6 had tracheostomies, and 15 had achieved if there is no oral obstruction; the airway is more
submental intubations. The study concluded that in instances secure when a nasotracheal route is used.
where the nasal route of intubation was contraindicated, An alternative means of airway access may be used in
submental intubation was a viable alternative.116 special cases such as when complex facial fractures are
present. Tracheostomy should be considered in patients with
Level III. A cross-sectional study at Al-Nahdha Hospital from massive craniofacial injury and in those who are expected to
July 2008 to December 2009 reviewed 177 facial trauma be intubated for more than 5 days.
patients and showed that in majority (57%) of patients, nasal l Intentional vagueness: The choice between submental
intubation was used and the main indication was evaluation intubation and tracheostomy as an alternative to nasotracheal
and establishment of occlusion.117 intubation is highly influenced by the operator’s skill and
training.
Level IV. A case series at the Rohilkhand Medical College and l Role of patient preference: Small
Hospital, Bareilly, Uttar Pradesh, India from November 2006 l Exceptions: None
to November 2009 described 25 out of 310 patients that were l Policy level: Recommendation
selected for submental intubation and operated on under the l Differences of Opinion: None
faciomaxillary surgery department. All of the patients selected
had midfacial fractures (Le Fort I and II) panfacial fractures Supporting Text
(midfacial and mandibular fractures) in which orotracheal There were 12 articles included in our review: 6 narrative review
and nasotracheal intubation were contraindicated. Results articles, 4 cross sectional studies, 1 case series, and 1 case report.
showed that submental tracheal intubation is an effective Nasotracheal intubation is widely used in maxillofacial surgery.108-112
and useful technique for airway control and is a reliable route Submental intubation is a safe alternative to tracheostomy for those
with no safety issues.118 not requiring prolonged ventilation.113-116, 119 The review of literature
recommends the use of nasotracheal intubation as the standard in
Level III. A narrative review with case series from the Division managing patients with facial trauma wherein manipulation of the jaw
of Plastic and Craniofacial Surgery, Children’s Mercy Hospital, and establishment of occlusion is necessary.108-115, 117-119
Kansas elaborated the advantages of submental intubation
when orotracheal and nasotracheal intubation is not feasible. STATEMENT 9. OBSERVATION: Observation with soft diet may serve
Of great importance to oral and maxillofacial surgeons as management for patients diagnosed with favorable isolated
was the ability to ensure dental occlusion throughout the nondisplaced and nonmobile mandibular body fractures with
procedure.119 unchanged pre - traumatic occlusion. Recommendation.
l Benefit: For adequate reduction, establishment of occlusion Action Statement Profile for Statement 9
and in aid of maxillomandibular fixation during surgery. l Aggregate Evidence Quality: Level II, Grade B
l Risks, Harm, Cost: There are risks in patients who have
undergone nasal surgery and those with skull base and Level III. A cross sectional study on mandibular fractures at
cervical fractures. Epistaxis may arise due to trauma. There the Oral and Maxillofacial Surgery Unit, Canniesburn Hospital,
is also the need for an experienced anesthesiologist and the Glasgow, Scotland from January 1, 1974 to December 31,
use of Magill forceps; an armored tube is necessary for those 1983 included a total of 3,462 mandibular fractures in
undergoing submental intubation, and tracheostomy tube 2,137 patients with complete records, wherein 687 patients
for those undergoing tracheostomy. (32.1% of the total sample of 2,137) did not undergo surgical
intervention and the fractures were observed for 4 to 6

weeks. Likewise, for 1,038 who sustained only 1 fracture, 485 which were simple, undisplaced fractures. These patients did
(46.7%) were kept under observation. In these cases treated not have the added stress of an operation.122
without surgical intervention, the patients obtained their pre-
trauma centric occlusion with minimal difficulty or functional l Benefit: Observation and conservative management has
limitation.27 been shown to achieve satisfactory healing and acceptable
quality of life; management through observation and soft
Level III. A cross sectional study in the University Hospital, diet may result in spontaneous and satisfactory healing of
Basel, Switzerland between January 1996 and January favorable isolated nondisplaced and nonmobile mandibular
2001 treated 28 patients (nine females, nineteen males) body fracture. Cost-effectiveness and avoidance of the
with 35 fractures by observation and soft diet only for 4 burden of unnecessary operation and surgical pain and stress
weeks. Patients were selected based on criteria of: a. non are the primary advantages of this management.
displaced fractures by clinical and radiographic examination; l Risks, Harm, Cost: Frequent clinical follow up and cost of
b. unchanged pretraumatic occlusion; c. willingness to serial radiographs.
participate in the study. Patients with isolated high condylar l Benefit-Harm Assessment: There is a preponderance of
neck fractures were not included. No treatment was given, benefit over harm.
but patients were instructed to reduce mouth opening and l Value Judgements: Non-surgical interventions including
maintain a soft diet for 4 weeks. Radiographic examinations observation and soft diet have been shown to be beneficial
obtained at 4, 8, and 12 weeks revealed spontaneous healing in non-displaced mandibular body fractures in terms
of all fractures.120 of morbidity and cost. Thus, they serve as an option for
uncomplicated cases. Observation accompanied by a soft
diet is an adequate management of a favorable isolated
Level II. A prospective cohort study on the non-surgical
nondisplaced and nonmobile mandibular body fracture. It is
management of mandibular fractures at the Maxillofacial
not costly and it avoids unnecessary surgical procedures.
Surgery Unit of Aminu Kano Teaching Hospital (AKTH) Kano,
l Intentional Vagueness: The duration of observation with soft
Nigeria from January to December 2012 had a total of 153
diet is not specified in this guideline. The basis for conversion
patients with mandibular fractures seen but only 10 patients
to other forms of management is not included either.
meeting inclusion criteria. The study evaluated the quality
l Role of patient preference: None
of life of patients using the General Oral Health Assessment
l Exception: None
Index (GOHAI) questionnaire, accomplished via interview
l Policy Level: Recommendation
on day 1, 6 weeks and 8 weeks post-trauma, and showed
l Differences of Opinion: None
that there was acceptable healing of all fractures with a
significantly improved mean quality of life outcome from
Supporting Text
41.42 at presentation to 59.90 at 8 weeks post op.121 There were 4 studies reviewed, 2 cross sectional studies and 2
prospective cohort studies, all showing that patients with favorable
Level II. A prospective cohort study at the Maxillofacial isolated nondisplaced nonmobile body of mandibular fractures
Surgery Unit of Aminu Kano Teaching Hospital (AKTH) managed with observation on a soft diet had spontaneous healing of
Kano, Nigeria from January to December 2012 on quality fractures and had no complications.27, 120-122
of life after treatment showed no significant differences in
the mean scores of those treated by closed reduction/MMF STATEMENT 10. CLOSED REDUCTION: Closed reduction with
and those treated by ORIF. There was, however, a significant immobilization by maxillomandibular fixation for 4-6 weeks may
difference in QoL between subjects treated conservatively be considered in patients with minimally displaced favorable
and those treated by either closed reduction/MMF or ORIF isolated mandibular body fracture with stable dentition, good
techniques (p = .000) at all the review times. The significant nutrition and who are willing to comply with post-procedure care
difference at 8 weeks in the QoL of subjects who were treated that may affect oral hygiene, diet modifications, appearance, oral
conservatively compared with those treated surgically may health and functional concerns (eating, swallowing and speech).
be related to the type of fractures managed conservatively, Recommendation.

Action Statement Profile for Statement 10 University, Nova Scotia, Canada on the management of
l Aggregate Evidence Quality: Level II, Grade B mandibular body and symphysis fractures mentioned
different treatment options and discussed the advantages
Level I. A Cochrane meta-analysis on interventions for and disadvantages of each. The review emphasized the
the management of mandibular fracture included 12 importance of a combination of correct diagnosis, proper
studies involving 689 participants (830 fractures). Different treatment plan, and appropriate intervention for a specific
interventions were examined and the included studies case and type of patient.54
involved a limited number of participants with low number
of events. The authors report inadequate evidence to support Level II. A retrospective cohort study at the Oral and
the effectiveness of a single approach in the management Maxillofacial Surgery Service of San Francisco General
of mandibular fractures without condylar involvement. Hospital included 85 patients treated for mandibular
Treatment decisions should be based on clinician experiences fractures from January 1 to December 31, 1993. The patients
and patient individual circumstances.7 were divided into 2 groups: 1) patients treated by closed
reduction with MMF; and 2) patients treated with open
Level II. A prospective cohort study of health-related quality reduction and internal fixation using plates and screws. The
of life (QoL) after treatment of mandibular fractures at treatment time, length of hospital stay, intraoperative time
Aminu Kano Teaching Hospital, Kano, Nigeria, from January and charge analysis showed that the use of closed reduction
to December 2012 illustrates a significant difference in QoL with MMF in the management of mandibular fractures
between subjects treated conservatively and those treated provided considerable savings over treatment by using ORIF.
by either closed reduction/MMF or ORIF techniques (p = The use of ORIF should be reserved for patients and fracture
.000) at all review times. Regarding the psychosocial, physical, types with specific indications.124
and pain domains - patients treated with ORIF reported
significantly more pain, while MMF patients scored higher Level IV. A textbook chapter on the Management of
in the psychosocial and physical domains. Patients managed Mandibular Fractures from the Textbook of Advanced Oral
conservatively recorded a significant improvement across and Maxillofacial Surgery further elaborated on advantages
all three domains. The authors concluded that treatment of of closed reduction such as simplicity, reduced operative
mandibular fracture with the use of a conservative approach time, cost-effectiveness and avoidance of damage to
in preference to ORIF to MMF, combined with adequate adjacent structures as well as disadvantages including
analgesia, showed an improved quality of life.122 inability to directly visualize the reduced fracture, the need to
keep the patient on a liquid diet and difficulties with speech
Level I. A randomized controlled trial at the Oral Surgery and respiration. Evidence-based studies cited in this chapter
Department, Faculty of Dentistry, Mansoura University, mentioned that 75-80% of mandibular fractures treated with
Egypt over the course of 2 years included 30 patients with open and closed reduction and maxillomandibular fixation
43 mandibular fractures, who had no other facial fractures. showed clinical union by 4 weeks.125
Patients were divided into 2 groups: 22 fractures in 15 patients
in group A treated with conventional MMF for 6 weeks, and Level I. An algorithm for treatment of non-condylar
21 fractures in 15 patients in group B treated with MMF for a mandibular fractures at the Department of Oral and
short period of 2 weeks followed by splinting the lower jaw Maxillofacial Surgery, University of Texas Health Science
with an arch bar. Results showed that there was no significant Center in San Antonio mentioned closed treatment for
difference between both patient groups with regards to mandibular fractures and stated that closed reduction
mean time for fracture healing, postoperative infection, or works very well when applied to appropriate fractures;
malocclusion.123 IMF/MMF application restores occlusion, aids in fracture
reduction and fixation and allows healing to progress.126
Level IV. A narrative review from the Department of Oral
and Maxillofacial Science, Faculty of Dentistry, Dalhousie

Level I. A randomized controlled trial by the Department multiple fractures. Results showed good healing in all patients
of Oral and Maxillofacial Surgery, Vidya Shikshan Prasarak as seen in the follow up orthopantomogram at 6 weeks post
Mandal Dental College and Research Centre, Nagpur, treatment and repeated after 3 months to determine the
Maharashtra, India included 50 patients with minimally progress of bone healing.129
displaced mandibular fractures from November 2009 to
October 2011. Patients were divided into 2 groups: 1) the l Benefit: Restores preoperative stable occlusion, good healing
study group, treated using intermaxillary fixation screw of fracture,7,54, 123 simpler, faster, cheaper, less painful than
technique; and 2) the control group, treated using eyelet open reduction techniques.54, 122, 124, 125
interdental wiring technique. Parameters such as time for l Risks, Harm, Cost: Medically unstable patients who cannot
placement and removal of both, postoperative occlusion, tolerate/comply with immobilization with MMF125; poor
stability of IMF wire, intraoperative pain, anesthesia, oral nutrition, unstable dentition near the fracture site.54, 125
hygiene status, glove perforation rate and complications l Benefit-Harm Assessment: There is a preponderance of
were evaluated. Results showed IMF screws were a viable benefit over harm.
alternative to eyelets and interdental wiring in terms of l Value Judgements: Although maxillomandibular fixation
significant reduction in operating time, negligible pain and is less invasive and is associated with lower pain and cost,
infection, trauma to marginal gingiva, and maintenance of patient nutrition and quality of life may be affected over the
oral hygiene. IMF screws were well tolerated both by patients duration of treatment.
and surgeons, and IMFS application is an uncomplicated and l Intentional Vagueness: higher level evidence is still needed
rapid technique, useful for intraoperative ORIF and long term to recommend whether to manage patients with closed
for closed reduction.127 reduction or open reduction.7
l Role of patient preference: Small
Level II. A prospective cohort study of 208 patients with 256 l Exception: Medically unstable patients who cannot tolerate/
mandibular fractures treated with MMF at the provincial comply with immobilization with MMF; poor nutrition54,125;
hospital in Kandy, Sri Lanka from January 1978 through unstable dentition near the fracture site.54, 125, 126
December 1983 assessed union of fractures once a week l Policy Level: Recommendation
and followed all patients for a period of 6 months after l Differences of Opinion: None
removal of fixation. The study revealed that a shorter period
of 3-4 weeks would suffice than what has been advocated in Supporting Text
standard texts, and age has an influence in terms of duration Based on our review of 10 articles: 1 meta-analysis, 2 randomized
of immobilization, observed to be shorter in children. This controlled trials, 3 prospective cohort studies, 1 narrative review article,
must be considered during planning of maxillomandibular 1 book chapter, and 1 algorithm; most cases of isolated minimally
fixation.128 displaced mandibular body fractures that underwent closed reduction
with maxillomandibular fixation achieved healing and union.7,54, 123-124,
Level II. A prospective cohort study at the Department of 126-129
And closed reduction with MMF is simpler, faster, cheaper and less
Plastic and Reconstructive Surgery, Pakistan Institute of painful than open reduction techniques.54, 122, 124-125
Medical Sciences (PIMS), Islamabad, Pakistan, over a three- Important prerequisites to achieve good occlusion and better
year period from September 1997 to October 2000 included healing include the presence of stable dentition and good nutrition.
270 patients with maxillofacial injuries. Two hundred twenty However, the level of evidence for studies supporting this statement
eight (228) had mandibular fractures with a total of 344 was grade B at most, and higher level evidence is still needed to
fractures (single and multiple fractures per patient) found recommend whether to manage patients with closed reduction or
through clinical evaluation, radiographs and CT scans. There open reduction.7
were 2 treatment modalities used in the study: 1) closed In comparison with open reduction techniques, closed reduction
reduction with MMF in isolated body and angle fractures; with maxillomandibular fixation seemed to be simpler, associated with
and 2) open reduction with internal fixation for symphyseal, lower pain and cost.54, 122,124-125 However, plaque occurrence, poor oral
parasymphyseal, displaced body and angle fractures, or hygiene, maintenance, worries in appearance and functionality were

some of the disadvantages associated with closed reduction with complications; perhaps the increased risk of infectious
MMF.127-129 complications results from treatment of compound
fractures older than 72 hours because medullary bone is
STATEMENT 11. OPEN REDUCTION WITH TRANSOSSEOUS WIRING: acutely infected and has potentially impaired blood supply
In patients with isolated displaced unfavorable and unstable (the incidence of technical complications was remarkably
mandibular body fracture who cannot afford or avail of titanium higher in patients repaired after 3 days).132
plates, transosseous wiring with Maxillomandibular Fixation is an
option. Recommendation. Level II. A cohort study of 148 patients with mandibular
fractures operated on using transosseous wiring from 1963 to
Action Statement Profile for Statement 11 1972 describes that a fifth of the fractures were operated on
l Aggregate Evidence Quality: Level II, Grade B more than 10 days after injury, and half of the complications
occurred in this group. Complication rates were about three
Level I. A randomized controlled trial of 40 patients who times higher than the group that had early treatment. The
sustained mandibular fractures selected from the outpatient study concluded that transosseous wiring technique is well
department of the dental college of Yamunanagar divided proven and at least as good as treatment with titanium
them into 3 groups: 20 were managed with intraosseous plates.133
wiring (group I) and 20 were managed with titanium plate
fixation; 10 with postoperative immobilization (group IIA) Level II. A cohort study involving 204 patients with
and 10 without postoperative immobilization (group IIB). The mandibular body fractures who were treated with internal
radiographic gap between fractured ends of those managed wire fixation from 1968 to 1976 in the Academic Hospital
with fixation with titanium plates was less than the gap in and Diakonessen Hospital, Groningen, Netherlands showed
patients managed with intraosseous wiring. The average gap uneventful bone healing in 197 patients. There was delayed
in group I patients was 16.1 sq.mm, in group IIA, 9.1sq.mm union in 4 patients and deep infection in 3 patients. The
and in group IIB, 7.6sq.mm. Differences in postoperative pain study concluded that internal wire fixation is suitable for
(p>.1) and occlusion (p>.05) between the two groups were treatment of mandibular body fractures.134
not statistically significant.130
l Benefit: Lower Cost; reduced days lost out of work; avoidance
Level II. An interventional quasi-experimental study of 60 or reduction of IMF duration postoperatively.
patients with mandibular fractures at the King Edward l Risks, Harm, Cost: Relatively increased morbidity in terms of
Medical College, Mayo Hospital, Lahore from 2004 to 2005 surgical malocclusion, delayed union, higher infection rates
studied three modalities of mandibular osteosynthesis with and mental nerve injury; wider fracture gap post-operatively;
20 patients in each group: MMF, transosseous wiring (TOW) delayed restoration of function.
and miniplates. Maxillomandibular fixation and transosseous l Benefit-Harm Assessment: There is preponderance of benefit
wiring are still commonly used methods today. The most over harm
common complication was infection, common in TOW and l Value Judgements: Transosseous wiring is another form of
mini-plating due to direct intraoral contamination. The maxillomandibular fixation in place of traditional plating
differences were not found to be statistically significant with methods. However, it is associated with higher infection
infection occurring in 5% of the MMF group, 15% of the TOW rates, postoperative malocclusion and mental nerve injury.
group and 10% of the plating group.131 While the panel recognizes the superiority of titanium plates,
the group also recognizes that not all patients can afford it.
Level III. A cross sectional study of 84 patients with The delays in the surgery in such cases may lead to surgical
mandibular fractures at the San Francisco General Hospital and technical difficulties, making early establishment of
found infectious complications in 3 of the 25 patients treatment using transosseous wires an option.
who were repaired after 7 or more days. Delayed repair of l Intentional Vagueness: The type of wire and wiring technique
mandibular fractures increases the incidence of infectious and duration of MMF are not specified.

l Role of patient preference: Moderate. postoperative pain (p>.1) and occlusion (p>.05) between the
l Exception: When medical illness or systemic injury add undue groups were not statistically significant.130
risk to an extended general anesthesia.
l Policy Level: Recommendation. Level II. An interventional quasi-experimental study of sixty
l Differences of Opinion: None patients with mandibular fractures at the King Edward
Medical College, Mayo Hospital, Lahore from 2004 to 2005
Supporting Text compared 3 modalities of mandibular osteosynthesis among
Based on our review of 5 articles, 1 randomized controlled trial, 20 patients in each group: MMF, transosseous wirings and
2 cohort studies, 1 quasi experimental study, and 1 cross sectional miniplates. Rigid internal fixation in the form of plates was
study, the use of transosseous wiring with maxillomandibular fixation advantageous as it allowed immediate or early mandibular
remains an option in the treatment of isolated displaced unfavorable mobility, with good functional and aesthetic results and a
and unstable mandibular body fracture in patients who are financially low rate of complications. The major operative morbidity
constrained. Although it provides less stable fixation as shown by proved to be infection followed by malocclusion. Miniplate
having a greater gap at the fractured ends at 3 months post-op, it osteosynthesis had reduced complication rates at 20%
is comparable to titanium fixation systems in terms of achieving compared to MMF at 30% and transosseous wiring at 50%.131
the correct post-operative occlusion, eventual fracture healing and
complication rate.130-131,133-134 Level II. A retrospective cohort study of 205 patients seen at
The purpose of this statement is to address the need for reasonable the Maxillofacial Unit of The Royal Melbourne Hospital from
treatment options for financially constrained patients with mandibular 1985 to 1990 assigned the data of the patients into 3 groups:
fractures. It has been observed that many of these patients have a delay 83 patients managed with miniplate fixation according
in the treatment of their condition and several days delay will lead to to Champy’s principles (Group I), 40 patients underwent
technical difficulties and a higher complication rate in terms of healing miniplate fixation ignoring Champy’s principles (Group II),
and achieving proper occlusion.132-133 and 82 had transosseous wiring (Group III). Patients managed
with transosseous wiring had a significantly longer hospital
STATEMENT 12. OPEN REDUCTION WITH TITANIUM PLATES: Open stay and IMF duration, increasing the cost of treatment and
reduction and internal fixation using Titanium plates and screws patient debility; 72% of those in group III had hospital stay
should be performed in isolated displaced unfavorable and more than 3 days while only 44% of those in group I and II
unstable mandibular body fractures. Recommendation. stayed over 3 days.135
Action Statement Profile for Statement 12 l Benefit: Better and more stable fixation; reduced days lost
l Aggregate Evidence Quality: Level II, Grade B out of work; 130 avoidance or reduction of IMF duration
postoperatively; 135 early restoration of normal function;
Level I. A randomized controlled trial selected 40 patients better approximation of fracture ends; lower overall cost
who sustained mandibular fractures from the outpatient compared to interosseous wiring in an ideal setting; shorter
department of the dental college of Yamunanagar and hospital stays in an ideal setting; avoidance or reduction of
divided them into 3 groups: 20 patients were managed IMF duration postoperatively.135
with intraosseous wiring (group I) and 20 patients were l Risks, Harm, Cost: Overall cost associated with ORIF.
managed with Titanium plate fixation, 10 with postoperative l Benefit-Harm Assessment: There is preponderance of benefit
immobilization (group IIA), and 10 without postoperative over harm.
immobilization (group IIB). Overall surgical morbidity of l Value Judgements: displaced, unfavorable and unstable
patients managed with titanium plate fixation was 60% with mandibular body fractures require stable fixation that only
post operative immobilization and 40% in patients without titanium plates are able to provide. This is also associated
postoperative immobilization compared to 65% in patients with lesser hospital stay, faster recovery and minimal
managed with intraosseous wiring. Group I patients had a gap affectation in daily living. The panel recognizes that internal
of 16.1 sq.mm; IIA, 9.1sq.mm and IIB, 7.6sq.mm. Differences in fixation with titanium plates is a superior method of fixation

over intraosseous wiring. The intraoral approach is preferred isolated mandibular fracture managed at the Maxillofacial
for ORIF of isolated displaced unfavorable and unstable Unit at Newcastle General Hospital over a 1-year period
mandibular body fracture; the use of Titanium plates allows from 1995 to 1996 included 115 patients who fulfilled the
more stable fixation and assures early restoration of normal criteria: 66 patients had their fractures reduced manually
form and function with lower overall cost for the patient. by anatomical reduction and 49 patients were reduced with
Although the initial cost of ORIF may seem more expensive pre-operative intermaxillary fixation. Results revealed no
than intraosseous wiring, the cost of managing complications difference in the final occlusion of the patients. The study
of intraosseous wiring may be more expensive in the long concluded that manual anatomical reduction was more
term. economical in time and cost, safer for the operator, and more
l Intentional Vagueness: The type of titanium plate is not comfortable for the patient.136
specified in this guideline; the intraoral approach is not
specified either, recognizing surgeon preference and the Level I. A randomized controlled trial conducted among 80
need for complete intraoral instrumentation. patients with isolated mandibular fractures managed by open
l Role of patient preference: None. reduction and internal fixation using two titanium miniplates
l Exception: When medical illness or systemic injury add undue in Zagazig, Egypt from 2008 to 2014 classified patients into
risk to an extended general anesthetic. two groups: a control group (40 patients) whose occlusion
l Policy Level: Recommendation. was reduced with intraoperative rigid maxillomandibular
l Differences of Opinion: None. fixation (MMF) with wires and archbars, and a study group
(40 patients) whose occlusion was reduced with temporary
Supporting Text intraoperative manual MMF until plate fixation. Mouth
Three studies reviewed, 1 randomized controlled trial, 1 quasi opening was normal in 26 patients (65%) and functional in
experimental study, and 1 retrospective cohort study showed that 14 patients (35%) in the study group, and it was normal in
the use of bone plates assures early restoration of normal form and 11 patients (27.5%) and functional in 29 patients (72.5%)
function, compared to intraosseous wiring which was associated with in the control group. The study concluded that temporary
extended periods of maxillomandibular immobilization.130-131 Overall manual MMF had the advantages of shorter operative time
cost and charges associated with treating mandibular fractures with and less risk of blood-transmitted diseases to the surgical
ORIF, such as operating room time and expenses, hardware charges, team and the patient in addition to the benefits of immediate
charges related to overall hospital length of stay and charges related to postoperative mandible mobilization.137
treatment complications, and loss of income due to absence from work
are significantly lower when titanium plates are used.131,135 Level I. A randomized controlled trial among 50 patients who
Patients who underwent ORIF with titanium plates and screws presented with isolated mandibular fractures in Queensland,
regained confidence faster by not being conscious of the awkward Australia, from 2009 to 2010 compared Intermaxillary fixation
looking dental wiring used for immobilization.131 Furthermore, (IMF) and manual reduction. Patients admitted on an even
maxillomandibular immobilization is not essential post-operatively date were managed with IMF, while patients admitted on
after internal fixation with titanium plates.130 an odd date were assigned to manual reduction. IMF was
associated with an increased duration of procedure (p <
STATEMENT 13. MAXILLOMANDIBULAR FIXATION: Intraoperative .001) and increased complication rate (p = .063), without
MMF may not be routinely needed prior to reduction and internal any observable benefit with regard to either radiographic
fixation of isolated displaced unfavorable and unstable mandibular outcome or occlusal outcome.138
body fracture. Recommendation.
l Benefits: Shorter operative time; comparable occlusal
Action Statement Profile for Statement 13 outcome; lower cost; less risk of blood borne diseases for
l Aggregate evidence quality: Level II, Grade B patients and surgeons.
l Risks, harms, costs: Malocclusion, dependent on skill of
Level II. A retrospective cohort study of all patients with surgeon.

l Benefit - harm assessment: Preponderance of benefit over the most common cause of RTA (76.2%). The most affected
harm. mandibular regions were the parasymphysis (26.9%) and
l Value judgements: The panel recognizes that in treatment the mandible angle (25.1%).33
of isolated displaced unfavorable and unstable mandibular
body fractures, establishment of proper occlusion is essential. Level III. This cross sectional study reviewed records of 444
The panel concedes that use of intra-operative MMF may not patients with mandibular fracture from the year 2000 to
be routinely done by a skilled surgeon, and intraoperative 2005 in the University Hospital of Freiburg, Germany. There
manual MMF may be performed instead prior to plate was a higher male:female ratio with regards to mandibular
fixation. fractures. Road traffic accidents caused 32% of injuries
l Intentional vagueness: The type of manual MMF is not followed by fights at 28%. The mandibular condyle was the
specified. most common fracture site, occurring 42% of the time.21
l Role of patient preferences: None
l Exceptions: When medical illness or systemic injury add Level III. A cross sectional study at the Royal Hobart Hospital,
undue risk to an extended general anesthesia Tasmania from 1993 to 1999 involving 251 patients revealed
l Policy level: Recommendation that assaults were the most common cause of fractures at
l Differences of opinion: None 55%, followed by motor vehicle accidents at 18.3%.139
Supporting Text Level III. A cross sectional review of records of 310 motorcycle
The purpose of this statement is to emphasize that restoration of crash victims admitted to the Trauma Division, Department
the premorbid occlusion is essential to the treatment of mandibular of Surgery, of the Philippine General Hospital from 2004
fracture. However, it also concedes that in skilled hands, maintenance to 2006 showed that the majority of victims were young
adults with a mean age of 27.7 and 83.8% were males, with
of proper occlusion can be achieved by manual reduction based
maxillofacial involvement in 78%, and helmet use in only
on 3 articles that we reviewed, 2 randomized controlled trials and 1
11 of 84 (13%) injured motorcyclists. Alcohol consumption
retrospective cohort study.136-138 This method of open reduction has
prior to the crash was documented in 88%.140
economic benefits: faster operation time and cheaper total cost.136-138 It
is also safer for both the patient and the surgical team due to decreased
Level III. A cross sectional study of 2,581 patients at
associated injuries and blood-borne disease transmission.136-138 For the
Christchurch Hospital, New Zealand over an 11-year-period
patient, manual reduction is associated with decreased discomfort and
from 1996 to 2006 comparing interpersonal violence and
has similar occlusal outcomes in the early postoperative period with
motor vehicle accidents in the etiology of maxillofacial
earlier return of function.136
fractures revealed that interpersonal violence was the main
etiology of maxillofacial fractures. Alcohol involvement
STATEMENT 14. PREVENTION: Clinicians should advocate for
occurred in 87% of fractures caused by interpersonal violence,
compliance with road traffic safety laws (speed limit, anti-drunk
and 58% with motor vehicular accidents.141
driving, seatbelt and helmet use) for the prevention of motor
vehicle, cycling and pedestrian accidents and maxillofacial injuries. Level III. A cross sectional review of alcohol involvement in
Strong Recommendation. cases of maxillofacial trauma among 94 patients at St. Anna
Action Statement Profile for Statement 14 Hospital during a 5-year period from 2005 to 2010 noted that
l Aggregate evidence quality: Level I, Grade A 47% of trauma referrals involved alcohol. The association rose
to 72% when considering assault cases alone.142
Level III. A cross sectional review of records of 119 patients
treated for mandibular fractures between 2006 and 2011 in Level II. A prospective cohort study of 83 fractures of the
Brazil revealed mandibular fractures mostly affect Caucasian mandible in 252 facial trauma cases at the Canberra Hospital,
(72.2%) men (80.7%). Road traffic accidents (RTA) caused Australia during a 16 month period concluded that mandible
the most fractures (49.5%), followed by physical violence, fractures caused by interpersonal violence are more severe
including gunshot wounds (21%). Motorcycle accidents were and more likely to require surgery, especially when alcohol

intoxication is involved. Alcohol involvement in mandible for the use of automotive safety devices and compliance by
fracture presentation for oral maxillofacial trauma review occupants.16
increased the relative risk of requiring surgical intervention
by 2.68 (CI 1.11–9.47).143 Level I. A systematic review on the effectiveness of road
traffic prevention in low- and middle-income countries which
Level III. A cross sectional study of records of 2,581 patients included 18 articles for the qualitative synthesis on road traffic
seen at the oral and maxillofacial Surgery Unit at Christchurch policies found that “legislation-based interventions had the
Hospital, New Zealand from 1996 to 2006 revealed that strongest evidence for road traffic crash, injury, and death
alcohol was the main contributing factor for facial fractures prevention.” Legislative measures implementing a single
associated with interpersonal violence and emphasized the road safety measure may also be effective; one study in Brazil
important role of medical professionals in the rehabilitation suggested that legislation decreasing the legal blood alcohol
process of patients and prevention programs.144 content (BAC) level from 0.06 g/L to 0.02 g/L was associated
with a significant (p<0.05) reduction in both traffic fatalities
Level III. A cross sectional study at Christ Church hospital, (7.2% to 16%) and injuries (1.8% to 2.3%). As expected, areas
New Zealand, over an 11-year period from 1996 to 2006 with higher levels of police enforcement demonstrated
examined data on demographics, fractures, mode of injuries, higher levels of effective legislation. Similarly, in 2010, Mexico
and treatment for maxillofacial trauma patients. A total of also implemented legislation to reduce the legal BAC to 0.05
1,264 patients were identified to have alcohol related facial g/L, with increasing penalties with increasing BAC.152
fractures; 90% were males and 66% were in the 15 to 29 year-
age group. Assault was the most common cause of injury Level III. A cross sectional study of 998 cases of maxillofacial
(73% in the first period and 83% in the second period). The trauma over a 6 month period from June 2007 in the
study also concluded that alcohol related injuries were the emergency department of Government Dental College,
main problem in young male adults.145 Calcutta, India reported that the total number of motorcycle
accident cases was 191 compared to 289 in the pre helmet law
Level III. A cross sectional study of 350 maxillofacial trauma period (34 % decrease in incidence of motorcycle accidents
patients secondary to road traffic accidents in India from from the prelaw to postlaw period). The study concluded
2011 to 2012 revealed that 95.75% of victims did not wear that helmets are effective in reducing severity of injuries
helmets and that the most common cause for accidents was from road traffic accidents, and that health and medical
not following traffic rules (24%). The study concluded that professionals are responsible for the safety of patients, while
“low utilization of safety devices and negligence of traffic public awareness campaigns can help improve issues on road
rules” are etiologic factors in facial trauma.146 traffic accidents.153
Level I. A Cochrane systematic review on the effects of Level III. A cross sectional study of 512 patients admitted
helmets for preventing injury in motorcycle riders included at the Philippine General Hospital for a 4-year period from
61 observational studies. From four higher quality studies 2004 to 2007 revealed that young adults aged 21 to 30 years
helmets were estimated to reduce the risk of death by 42% old were the most affected age group. The most common
(OR 0.58, 95% CI 0.50 to 0.68) and from six higher quality cause of facial fractures was road traffic accidents at 63.7%.
studies helmets were estimated to reduce the risk of head The study suggested that a prevention protocol must be
injury by 69% (OR 0.31, 95% CI 0.25 to 0.38).147 developed based on traffic–related injuries.4
Level III. A cross sectional study in the Quirino Memorial Level IV. A narrative review article from the Royal Colleges
Medical Center from 1996 to 1997 involving 29 patients of Surgeons of Edinburgh and Ireland studied the trends in
attributed the highest number of fractures to vehicular violence and emphasized the important role of physicians in
accidents at 44.8% followed by assault at 24.1%. The study patient care and violence prevention through data collection
suggested that the government should conduct campaigns and sharing. Physicians can also contribute through

community safety partnerships with the local government Helmet use was only found in a minority of injured motorcyclists,
and police.154 among whom maxillofacial involvement was seen in the majority.140
Preventive practices (i.e., mandatory use of seat belts and helmets)
l Benefit: Adherence to road traffic safety laws, use of helmets likewise reduces the risk for mortality and head and neck injuries
and seatbelts and driving without the influence of alcohol following vehicular accidents.146,147 The Land and Transportation Code
reduces risk of morbidity and mortality. Land Transportation (RA 4136)148, Motorcycle Helmet Act of 2009 (RA 10054)149, Seat Belts
and Traffic Code (RA 4136), Motorcycle Helmet Act of 2009 (RA Use Act of 1999 (RA 8750) 150 and Anti-Drunk and Drugged Driving Act
10054), Seat Belts Use Act of 1999 (RA 8750) and Anti-Drunk of 2013 (RA10586)151 are Philippine laws drafted to protect individual
and Drugged Driving Act of 2013 (RA10586) legislations that and public safety. Similar laws are also present in other countries
encourage abidance to speed regulation, increase use of and have been proven effective to decrease incidence and severity of
helmets, seatbelts and prevent driving under the influence maxillofacial injuries.16 The extremely low percentages of road traffic
of alcohol, decreasing incidence of road traffic accidents and accidents in most European countries could be associated with strict
preventing maxillofacial injuries. adherence to road traffic laws and implementation of preventive
l Risks, harms, costs: Advocating compliance with road traffic practices like mandatory use of seat belts, air bags and helmet, setting
safety laws requires clinicians to work beyond their role of speed limits, and strict policies against alcohol consumption and
in diagnosis and management, entailing time and cost of driving.152
educational materials. Health and medical professionals have an ethical responsibility
l Benefit - harm assessment: Preponderance of benefit over to educate and arrange for the safety of individuals.153 Efforts to
harm. educate and promote road safety especially among young adults are
l Value judgements: Several studies support the need for warranted.4 Efforts to protect those who are exposed to the risk of
increased public awareness regarding traffic laws, mandating road traffic accidents are also warranted. Collaboration with different
helmet/seatbelt use and avoidance of alcohol intake when sectors involved in collecting and reporting road traffic injury data
driving. Implementation of these policies significantly reduce should be encouraged.144,154
the incidence of road traffic accidents and violent crime
in general and consequently, the reduction of mandibular STATEMENT 15. PROMOTION: Clinicians should play a positive role
trauma. The socio-economic impact of CMF trauma on health in the prevention of interpersonal and collective violence as well
care systems and industry in terms of hospital costs, lost as the settings in which violence occurs in order to avoid injuries
workdays, decreased productivity and increased resource in general and mandibular fractures in particular. Recommendation.
utilization should be realized.
l Intentional vagueness: None. Action Statement Profile for Statement 15
l Role of patient preferences: None. l Aggregate evidence quality: Level III, Grade C
l Exceptions: None.
l Policy level: Strong Recommendation. Level III. A cross sectional study of 512 patients admitted
l Differences of opinion: None. at the Philippine General Hospital for a 4-year period from
2004 to 2007 revealed that young adults aged 21 to 30 years
Supporting Text old were the most affected age group. The most common
Based on the review of 16 articles, 2 systematic reviews, 1 cause of facial fractures was road traffic accidents at 63.7%.
prospective cohort, 12 cross sectional studies, and 1 narrative review The study suggested that “a prevention protocol must be
article, the data shows road traffic accidents and assaults are the most developed based on traffic–related injuries.”4
common causes of mandibular fractures.21, 33, 139
Several factors contribute to the prevalence of road traffic accidents, Level III. A cross sectional review of records of 310 motorcycle
particularly alcohol consumption. Motorists under the influence crash victims admitted to the Trauma Division, Department of
of alcohol have a higher likelihood of injury or are more likely to be Surgery, of the Philippine General Hospital from 2004 to 2006
involved in trauma. Alcohol intoxication is associated with interpersonal showed that the majority of victims were young adults with
violence and correlates with the severity of mandibular fractures.140-145 a mean age of 27.7 and 83.8% were males, with maxillofacial

involvement in 78%, and helmet use in only 11 of 84 (13%) Level III. A cross-sectional study of 200 trauma patients
injured motorcyclists. Alcohol consumption prior to the crash attended at the ENT department and trauma centre, Gajra
was documented in 88%.140 Raja Medical College and associated J.A. Group Hospitals,
Gwalior, India from 2014 to 2015 revealed that 64% of the
Level III. A cross sectional analysis of records of patients seen patients were males and that road traffic accidents (37%) were
at the Oral and Maxillofacial Surgery Unit at Christchurch the most common cause of injury followed by interpersonal
Hospital, New Zealand from 1996 to 2006 revealed violence (25%).156
that alcohol was the main contributing factor for facial
fractures associated with interpersonal violence. The study Level III. A cross sectional review of records involving 285
emphasized the important role of medical professionals patients seen at the University Hospital, Newark, New Jersey
in the rehabilitation process of patients and prevention (a level 1 trauma center) from 2000 to 2012 revealed that
programs.144 124 patients (43.5%) obtained fractures from interpersonal
violence. Mandibular fractures were the most common site
Level III. A cross sectional study at Christchurch Hospital, involved in fractures secondary to interpersonal violence.157
New Zealand over an 11-year period from 1996 to 2006
examined data on demographics, fractures, mode of injuries, l Benefit: Preventing violence and the settings in which it
and treatment for maxillofacial trauma patients; 90% of the occurs decreases injuries in general and maxillofacial injuries
patients were males and 66% were in the 15 to 29-year age in particular.
group. Assault was the most common cause of injury (73% l Risks, harms, costs: None
in the first period and 83% in the second period). The study l Benefit - harm assessment: Preponderance of benefit over
also concluded that “alcohol related injuries were the main harm
problem in young male adults”.145 l Value judgements: None
l Intentional vagueness: The manner by which clinicians play
Level IV. A narrative review article from the Royal Colleges their role in the prevention of interpersonal and collective
of Surgeons of Edinburgh and Ireland studied the trends in violence as well as the settings in which violence occurs is left
violence and emphasized the important role of physicians in to their discretion.
patient care and violence prevention through data collection l Role of patient preference: None
and sharing. Physicians can also contribute through l Exception: None
community safety partnerships with the local government l Policy level: Recommendation
and police.154
Level III. A cross sectional study involving 92 patients seen

Supporting Text
at the emergency department at the University Hospital,
The 8 articles reviewed were composed of cross sectional studies
University of Medicine and Dentistry of New Jersey from 1999
and 1 narrative review article.
to 2000 noted that 80% of the patients were males and that
Another main cause of maxillofacial fractures is interpersonal
assault (75%) was the most common cause of facial trauma
violence.155-156 “The World Health Organization has defined
followed by motor vehicle accidents (18.5%). “In response
interpersonal violence (IPV) as violence committed by an individual or
to the health promotion portion of the interview schedule,
a small group of individuals and includes physical and sexual assault,
82.6% (n = 76) of all participants expressed willingness
emotional and psychological abuse, and neglect.”144 Young male
to change behavior patterns that may be contributing to
adults were the most affected demographic group, with alcohol as a
facial trauma. Most respondents appeared to be in the
main contributing factor.4, 140, 145
contemplation or preparation stage of change.” The study
“Mandible fractures are common following interpersonal violence,
concluded that “patients experiencing recurrent trauma are
responsive to violence reduction programs.”155 often cited as one of the most common fractures following assault.”157
“The health professionals have an important role in community violence
prevention to increase public safety.”144,154 “Oral and maxillofacial

surgeons who typically treat the patients with facial injuries in the Injuries are preventable by changing the environment, individual
acute and convalescent phase are in a good position to institute the behavior, product, social norms, legislation and governmental and
necessary rehabilitation process, as well as preventive programs.”144 The institutional policies to reduce or eliminate risks and increase protective
majority of people consulting at the emergency department for facial factors. Violence-related facial fractures are a health hazard that
trauma due to interpersonal violence are in the contemplation or the deserves more public awareness and implementation of preventive
preparation stage of behavior change. Given these results, it may be programs. Health professionals need to be aware of their important
beneficial to develop violence reduction programs within emergency role in prevention, and preventive measures have to be disseminated
departments.155 effectively.144,154,155,157
REFERENCES
1. David JF, Laxamana JQ, Altura IC, Caro DJC, De Guzman ICS, Yanga VJB, et al. A survey of national trauma data bank. J Oral Maxillofac Surg. 2015 Dec;73(12):2361-6. DOI: 10.1016/j.
mandibular fracture location in Philippine ORL-HNS institutions from 2010-2017. (Unpublished). joms.2015.04.032. PubMed PMID: 26006752.
2. Galvan GNB. Evaluation of mandibular fractures in a tertiary military hospital: A 10- 16. Agbayani-De Jesus LE. Mandibular fractures: a 2-year retrospective study. Philipp J Otolaryngol
year retrospective study. Philipp J Otolaryngol Head Neck Surg. 2011 Jan-Jun;26(1):16-20. Head Neck Surg. Oct-Dec 1999;14(4):6–8. [cited 2017 Aug 27] Available from: https://www.
DOI:10.32412/pjohns.v26i1.595. herdin.ph/index.php/component/herdin/?view=research&cid=36088.
3. Chegar B, Tatum III S, Nasal Fractures. In: Flint PW, Haughey BH, Lund V, Niparko JK, Robbins 17. Arabion H, Tabrizi R, Aliabadi E, Gholami M, Zarei K. A retrospective analysis of maxillofacial
KT, Thomas JR, editors. Cummings Otolaryngology - Head and Neck Surgery 6th Edition. trauma in Shiraz, Iran: a 6-year- study of 768 patients (2004-2010). J Dent (Shiraz). 2014
Philadelphia: Elsevier; 2015. p. 493-505. Mar;15(1):15-21. PubMed PMID: 24738085. PubMed Central PMCID: PMC3986572.
4. Germar GG, Cruz MAY. A four-year study of the demographic distribution and treatment of 18. Atilgan S, Erol B, Yaman F, Yilmaz N, Ucan MC. Mandibular fractures: a comparative analysis
maxillofacial fractures admitted at the Philippine general hospital. Acta Medica Philippina. between young and adult patients in the southeast region of Turkey. J Appl Oral Sci. 2010 Feb;
2009 Sep 1;43(3):16–25. [cited 2017 Aug 27] Available from https://www.herdin.ph/index. 18(1):17-22. DOI: 10.1590/S1678-77572010000100005. PubMed PMID: 20379677. PubMed
php?view=research&cid=40858. Central PMCID: PMC5349041.
5. Eusterman V. Mandibular Trauma. In: Brennan J, Holt G, Connor M, Donald P, Eusterman V, 19. Somensi MA, Goncalves ADO, Navarro C, Hochuli-Vieira E. A six-year retrospective study of
Hayes D, editors. Resident Manual of Trauma to the Face, Head, and Neck First Edition. Virginia: maxillofacial fractures from radiographic findings in Brazil. Revista da Faculdade de Odontologia-
American Academy of Otolaryngology - Head and Neck Surgery Foundation; 2012. p. 100-139. UPF. 2013 Dec;18(1):49–54. DOI: 10.5335/rfo.v18i1.3007.
6. Lieblich SE, Dym H,Fenton D. Parameters of care: AAOMS clinical practice guidelines for oral 20. Boffano P, Kommers SC, Karagozoglu KH, Gallesio C, Forouzanfar T. Mandibular trauma:
and maxillofacial surgery (AAOMS ParCare) Sixth Edition 2017: Dentoalveolar Surgery. J Oral a two-centre study. Int J Oral Maxillofac Surg. 2015 Aug; 44(8):998-1004. DOI: 10.1016/j.
Maxillofac Surg. 2017;75(8):e50–73 DOI:10.1016/j.joms.2017.04.028. ijom.2015.02.022. PubMed PMID: 25813086.
7. Nasser M, Pandis N, Fleming PS, Fedorowicz Z, Ellis E, Ali K. Interventions for the management 21. Bormann K-H, Wild S, Gellrich N-C, Kokemüller H, Stühmer C, Schmelzeisen R, et al. Five-
of mandibular fractures. Cochrane Database Syst Rev. 2013 Jul 8;(7):CD006087. DOI: year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology,
10.1002/14651858.CD006087.pub3. PubMed PMID:23835608. treatment, and complications. J Oral Maxillofac Surg. 2009 Jun 67:1251-5. DOI: 10.1016/j.
8. Ministry of Health Malaysia, Oral Health Programme. Clinical Practice Guidelines: Management joms.2008.09.022. PubMed PMID: 19446212.
of Unilateral Condylar Fracture of the Mandible. Putrajaya, Malaysia; 2005. [cited 2015 August 22. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year
3] Available from: https://www.scribd.com/document/53319982/CPG-Management-of- prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Jul;102(1):28-34. DOI:
Unilateral-Condylar-Fracture-of-Mandible-1. 10.1016/j.tripleo.2005.07.023. PubMed PMID: 16831669.
9. Prein J, Ehrenfeld M, Introduction. In: Ehrenfeld M, Manson PN, Prein J., editors. Principles of 23. Carvalho TB, Cancian LR, Marques CG, Piatto VB, Maniglia JV, Molina FD. Six years of facial
Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AO trauma care: an epidemiological analysis of 355 cases. Braz J Otorhinolaryngol. 2010 Sep-
FOUNDATION. New York:Thieme. 2012. p. 3-14. Oct;76(5):565-74. PubMed PMID: 20963338.
10. Cienfuegos R, Cornelius CP, Ellis E III, Kushner G. AO Surgery Reference [Internet]. 1st edition. 24. Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN. 1,454 mandibular fractures: a 3-year study
AO FOUNDATION. [cited 2015 August 8, 2015]. Available from: https://surgeryreference. in a hospital in Belo Horizonte, Brazil. J Craniomaxillofac Surg. 2012 Feb;40(2):116-23. DOI:
aofoundation.org/cmf/trauma/mandible. 10.1016/j.jcms.2011.03.012. PubMed PMID: 21458284.
11. Rosenfeld RM, Shiffman RN, Robertson P. Clinical practice guideline development manual, third 25. de Matos FP, Arnez MF, Sverzut CE, Trivellato AE. A retrospective study of mandibular
edition: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck fracture in a 40-month period. Int J Oral Maxillofac Surg. 2010 Jan;39(1):10-5. DOI: 10.1016/j.
Surg. 2013 Jan;148(1):S1-55. DOI: 10.1177/0194599812467004. PubMed PMID: 23243141. ijom.2009.10.005. PubMed PMID: 19914802.
12. Levels of clinical evidence for therapy/prevention and etiology/harm. Modified evidence 26. Dugan MA, De Gracia MA, Villanueva SD, Uy HG. 138 cases of mandibular fractures in
pyramid [Internet]. Brooklyn (NY): SUNY downstate medical center, Medical research library; four government hospitals from July 1995 to July 1996. J Philipp Dent Assoc. 1998 Mar-
[updated 2019 Aug; cited 2021 Ju 17]. Available from: http://library.downstate.edu/EBM2/2100. May;49(4):56-70. PubMed PMID: 10202526.
htm. 27. Ellis E 3rd, Moos KF, el-Attar A. Ten years of mandibular fractures: an analysis of 2,137 cases. Oral
13. Adebayo ET, Ajike OS, Adekeye EO. Analysis of the pattern of maxillofacial fractures in Kaduna, Surg Oral Med Oral Pathol. 1985 Feb;59(2):120-9. DOI: 10.1016/0030-4220(85)90002-7. PubMed
Nigeria. Br J Oral Maxillofac Surg. 2003 Dec;41(6):396-400. DOI: 10.1016/s0266-4356(03)00165-7. PMID: 3856795.
PubMed PMID: 14614869. 28. Ferreira MC, Batista AM, Ferreira Fde O, Ramos-Jorge ML, Marques LS. Pattern of oral-
14. Adeyemo WL, Iwegbu IO, Bello SA, Okoturo E, Olaitan AA, Ladeinde AL, et al. Management of maxillofacial trauma stemming from interpersonal physical violence and determinant factors.
mandibular fractures in a developing country: a review of 314 cases from two urban centers in Dent Traumatol. 2014 Feb;30(1):15-21. DOI: 10.1111/edt.12047. PubMed PMID: 23675634.
Nigeria. World J Surg. 2008 Oct 8; 32:2631–5. DOI: 10.1007/s00268-008-9773-8. PubMed PMID: 29. Fridrich KL, Pena-Velasco G, Olson RA. Changing trends with mandibular fractures: a review of
18841410. 1,067 cases. J Oral Maxillofac Surg. 1992 Jun;50(6):586-9. DOI: 10.1016/0278-2391(92)90438-6.
15. Afrooz PN, Bykowski MR, James IB, Daniali LN, Clavijo-Alvarez JA. The epidemiology of PubMed PMID: 1593318.
mandibular fractures in the United States, Part 1: A review of 13,142 cases from the US

30. Hwang K, You SH. Analysis of facial bone fractures: an 11-year study of 2,094 patients. Indian J 57. SEDENTEXCT Project. Radiation protection N° 172: cone beam ct for dental and maxillofacial
Plast Surg. 2010 Jan;43(1):42-8. DOI: 10.4103/0970-0358.63959. PubMed PMID:20924449. radiology evidence-based guidelines. European Commission; 2012. p. 30-31.
31. King RE, Scianna JM, Petruzzelli GJ. Mandible fracture patterns: a suburban trauma center 58. Markowitz BL, Sinow JD, Kawamoto Jr HK, Shewmake, K, Khoumehr F. Prospective comparison
experience. Am J Otolaryngol. 2004 Sep-Oct;25(5):301-7. DOI: 10.1016/j.amjoto.2004.03.001. of axial computed tomography and standard and panoramic radiographs in the diagnosis of
PubMed PMID:15334392. mandibular fractures. Ann Plast Surg. 1999 Feb;42(2):163-9. DOI: 10.1097/00000637-199902000-
32. Morris C, Bebeau NP, Brockhoff H, Tandon R, Tiwana P. Mandibular fractures: an analysis 00010. PubMed PMID: 10029481.
of the epidemiology and patterns of injury in 4,143 fractures. J Oral Maxillofac Surg. 2015 59. Kaeppler G, Cornelius CP, Ehrenfeld M, Mast G. Diagnostic efficacy of cone-beam computed
May;73(5):951.e1-951.e12. DOI: 10.1016/j.joms.2015.01.001. PubMed PMID: 25883009. tomography for mandibular fractures. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013
33. Munante-Cardenas JL, Facchina Nunes PH, Passeri LA. Etiology, treatment, and Jul;116(1):98-104. DOI:10.1016/j.oooo.2013.04.004. PubMed PMID: 23768877.
complications of mandibular fractures. J Craniofac Surg. 2015 May;26(3):611-5. DOI: 10.1097/ 60. Stacey DH, Doyle JF, Mount DL, Snyder MC, Gutowski KA. Management of mandible fractures.
SCS.0000000000001273. PubMed PMID: 25643329. Plast Reconstr Surg. 2006 Mar;117(3):48e-60e. DOI: 10.1097/01.prs.0000209392.85221.0b.
34. Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma PubMed PMID: 16525255.
center. J Oral Maxillofac Surg. 2003 Jun;61(6):713-8. DOI: 10.1053/joms.2003.50118. PubMed 61. Mihailova H. Imaging modalities and algorithm in cases of mandibular trauma. Journal Of
PMID: 12796884. IMAB-annual Proceeding (Scientific Papers) 2008, Book 2.
35. Olson RA, Fonseca RJ, Zeitler DL, Osbon DB. Fractures of the mandible: a review of 580 cases. J 62. Tyndall DA, Matteson SR, Gregg JM. Computed tomography in diagnosis and treatment
Oral Maxillofac Surg. 1982 Jan;40(1):23-8. DOI: 10.1016/s0278-2391(82)80011-6. PubMed PMID: of mandibular fractures. Report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol. 1983
6950035. Dec;56(6):567-70. DOI: 10.1016/003-4220(83)90068-3. PubMed PMID: 6581452.
36. Qudah MA, Al-Khateeb T, Bataineh AB, Rawashdeh MA. Mandibular fractures in Jordanians: 63. Shintaku WH, Venturin JS, Azevedo B, Noujeim M. Applications of cone-beam computed
a comparative study between young and adult patients. J Craniomaxillofac Surg. 2005 tomography in fractures of the maxillofacial complex: Review article. Dent Traumatol 2009
Apr;33(2):103-6. DOI: 10.1016/j.jcms.2004.07.007. PubMed PMID: 15804588. Mar;25:358–66. DOI: 10.1111/j.1600-9657.2009.00795.x. PubMed PMID: 19515071.
37. Ramadhan A, Gavelin P, Hirsch JM, Sand LP. A retrospective study of patients with mandibular 64. Petersson A, Gröndahl HG, Suomalainen A. Computed tomography in oral and maxillofacial
fractures treated at a Swedish university hospital 1999-2008. Ann Maxillofac Surg. 2014 Jul- radiology. Nor Tannlegeforen Tid. 2009;119:86-93. [cited 2017 Aug 20] Available from: https://
Dec;4(2):178-81. DOI: 10.4103/2231-0746.147119. Pubmed PMID: 25593868. www.tannlegetidende.no/asset/2009/P09-02-86-93.pdf.
38. Sakr K, Farag IA, Zeitoun IM. Review of 509 mandibular fractures treated at the university 65. Scarfe WC. Imaging of maxillofacial trauma: Evolutions and emerging revolutions. Oral Surg
hospital, Alexandria, Egypt. Br J Oral Maxillofac Surg. 2006 Apr;44(2):107-11. DOI: 10.1016/j. Oral Med Oral Pathol Oral Radiol Endod. 2005;100(2):S75-96. DOI:10.1016/j.tripleo.2005.05.057.
bjoms.2005.03.014. PMID: 15896887. PubMed Central PMCID: PMC4293839. PubMed PMID: 16037795.
39. van den Bergh B, van Es C, Forouzanfar T. Analysis of mandibular fractures. J Craniofac Surg. 2011 66. Lou L, Lagravere MO, Compton S, Major PW, Flores-Mir C. Accuracy of measurements and
Sep;22(5):1631-4. DOI: 10.1097/SCS.0b013e31822e5f20. PubMed PMID: 21959402. reliability of landmark identification with computed tomography (CT) techniques in the
40. Simsek S, Simsek B, Abubaker AO, Laskin DM. A comparative study of mandibular fractures in maxillofacial area: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007
the United States and Turkey. Int J Oral Maxillofac Surg. 2007 May;36(5):395-7. DOI: 10.1016/j. Sep;104:402-11. DOI: 10.1016/j.tripleo.2006.07.015. PubMed PMID: 17709072.
ijom.2006.11.010. Pubmed PMID: 17391922. 67. Ansari K, Ahmed SS, Kumar R, Ekramullah. Diagnostic efficacy of 3D CT vs conventional
41. Alonso LL, Purcell TB. Accuracy of the tongue blade test in patients with suspected mandibular radiographs in maxillofacial trauma: a comparative study. Asian Pac. J. Health Sci. 2015;2(1):42-
fracture. J Emerg Med. 1995 May-Jun;13(3):297-304. DOI: 10.1016/0736-4679(95)00006-v. 50. DOI: 10.21276/apjhs.2015.2.1.7.
Pubmed PMID: 7673618. 68. Alder ME, Deahl ST, Matteson SR. Clinical usefulness of two-dimensional reformatted and
42. Timashpolsky A, Dagum AB, Sayeed SM, Romeiser JL, Rosenfeld EA, Conkling N. A prospective three-dimensionally rendered computerized tomographic images: literature review and a
analysis of physical examination findings in the diagnosis of facial fractures: determining survey of surgeons’ opinions. J Oral Maxillo Fac Surg. 1995 Apr;53(4):375-86. DOI: 10.1016/0278-
predictive value. Plast Surg (Oakv). 2016 Summer;24(2):73-9. DOI: 10.4172/plastic- 2391(95)90707-6. PubMed PMID: 7699491.
surgery.1000958. Pubmed PMID: 27441188; Pubmed Central PMCID: PMC4942239. 69. Ouyang T, Branstetter BF IV. Advances in head and neck imaging. Oral Maxillofac Surg Clin North
43. Charalambous C, Dunning J, Omorphos S, Cleanthous S, Begum P, Mackway-Jones K. A Am. 2010 Feb;22(1):107–15. DOI: 10.1016/j.coms.2009.10.002. PubMed PMID: 20159481.
maximally sensitive clinical decision rule to reduce the need for radiography in mandibular 70. Follmar KE, Baccarani A, Das RR, Erdmann D, Marcus JR, Mukundan S. A clinically applicable
trauma. Ann R Coll Surg Engl. 2005 Jul;87(4):259-63. DOI: 10.1308/1478708051810. PubMed reporting system for the diagnosis of facial fractures. Int. J. Oral Maxillofac Surg. 2007
PMID: 16053686. May;36(7):593–600. DOI: 10.1016/j.ijom.2007.03.010. PubMed PMID: 17507201.
44. Malhotra R, Dunning J. The utility of the tongue blade test for the diagnosis of mandibular 71. Buitrago-Téllez CH, Schilli W, Bohnert M, Alt K, Kimmig M. A comprehensive classification of
fracture. Emerg Med J. 2003 Nov;20(6):552-3. DOI: 10.1136/emj.20.6.552. PubMed PMID: craniofacial fractures: postmortem and clinical studies with two- and three-dimensional
14623851; PubMed Central PMCID: PMC1726238. computed tomography. Injury. 2002 Oct; 33: 651–68. DOI: 10.1016/s0020-1383(02)0019-5.
45. Schwab RA, Genners K, Robinson WA. Clinical predictors of mandibular fractures. Am J Emerg PubMed PMID: 12213415.
Med. 1998 May;16(3):304-5. DOI: 10.1016/s0735-6757(98)90108-5. PubMed PMID: 9596439. 72. Pohlenz P, Blessmann M, Blake F, Heinrich S, Schmelzle R, Heiland M. Clinical indications and
46. Caputo ND, Raja A, Shields C, Menke N. Re-evaluating the diagnostic accuracy of the tongue perspectives for intraoperative cone-beam computed tomography in oral and maxillofacial
blade test: still useful as a screening tool for mandibular fractures? J Emerg Med. 2013 Jul;45(1):8- surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Mar;103(3):412-17. DOI:10.1016/j.
12. DOI: 10.1016/j.jemermed.2012.11.078. PubMed PMID: 23490109. tripleo.2006.05.008. PubMed PMID: 17321455.
47. Neiner J, Free R, Caldito G, Moore-Medlin T, Nathan CA. Tongue blade bite test predicts mandible 73. Lo Casto A, Priolo GD, Garufi A, Purpura P, Salerno S, La Tona G, Coppolino F. Imaging evaluation
fractures. Craniomaxillofac Trauma Reconstr. 2016 Jun;9(2):121-4. DOI: 10.1055/s-0035-1567812. of facial complex strut fractures. Semin Ultrasound CT MR. 2012 Oct;33(5):396-409. DOI:
PubMed PMID: 27162567. PubMed Central PMCID: PMC4858423. 10.1053/j.sult.2012.06.003. PubMed PMID: 22964406.
48. Haydel MJ, Meyers R, Mills L. Use of the tongue-blade test to identify patients with 74. Santler G, Kärcher H, Ruda C. Indications and limitations of three-dimensional models in
mandible & maxillary sinus fractures. Ann Emerg Med. 2005 Sep 1;46(3):66. DOI: 10.1016/j. cranio-maxillofacial surgery. J Craniomaxillofac Surg. 1998 Feb;26(1):11-6. DOI: 10.1016/S1010-
annemergmed.2005.06.246. 5182(98)80029-2. Pubmed PMID: 9563589.
49. Chayra GA, Meador LR, Laskin DM. Comparison of panoramic and standard radiographs 75. Powers DB, Will MJ, Bourgeois SL Jr, Hatt HD. Maxillofacial trauma treatment protocol. Oral
for the diagnosis of mandibular fractures. J Oral Maxillofac Surg. 1986 Sep;44(9):677-9. DOI: Maxillofacial Surg Clin North Am. 2005 Aug;17(3):341-55. DOI: 10.1016/j.coms.2005.05.003.
10.1016/0278-2391(86)90034-0. PubMed PMID: 3462360. PubMed PMID: 18088790.
50. Nair MK, Nair UP. Imaging of mandibular trauma: roc analysis. Acad Emerg Med. 2001 Jul;8(7):689- 76. Creasman CN, Markowitz BL, Kawamoto HK Jr, Cohen S, Kioumehr F, Hanafee WN, Shaw WW.
95. DOI: 10.1111/j.1553-2712.2001.tb00186.x. PubMed PMID: 11435182. Computed tomography versus standard radiography in the assessment of fractures of the
51. Buitrago-Téllez CH, Cornelius CP, Prein J, Kunz C, di Ieva A, Audigé L. The comprehensive aocmf mandible. Ann Plast Surg. 1992 Aug;29(2):109-13. DOI: 10.1097/00000637-199208000-00002.
classification system: radiological issues and systematic approach. Craniomaxillofac Trauma PubMed PMID: 1530260.
Reconstr. 2014 Dec;7(1):S123-30. DOI: 10.1055/s-0034-1389565. PubMed PMID: 25489396. 77. Irajpour A, Kaji NS, Nazari F, Azizkhani R, Zadeh AH. A comparison between the effects of simple
PubMed Central PMCID: PMC4251726. and traction splints on pain intensity in patients with femur fractures. Iran J Nurs Midwifery Res.
52. Gibbs SJ, Pujol A, McDavid WD, Welander U, Tronje G. Patient risk from rotational panoramic 2012 Nov;17(7):530-3. PubMed PMID: 23922601. PubMed Central PMCID: PMC3730458.
radiography. Dentomaxillofac Radiol. 1988;17(1):25-32. DOI: 10.1259/dmfr.1988.0003. PubMed 78. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009
PMID: 3251793. Jan 1;79(1):16-22. PubMed PMID: 19145960.
53. Farman AG. Panoramic radiology: risk within reason. In: Farman AG. Editor. Panoramic 79. Yinusa W, Adetan O, Odatuwa-Omagbemi DO, Eyo MU. Bilateral simultaneous fracture of the
Radiology Seminars On Maxillofacial Imaging and Interpretation. Berlin:Springer; 2007. p25-32 carpal scaphoid successfully treated with conservative cast immobilisation: a case report.
DOI: 10.1007/978-3-540-46230-9_4. West Afr J Med. 2010 Nov-Dec;29(6):425-8. DOI: 10.4314/wajm.v29i6.68299. PubMed PMID:
54. Goodday RH. Management of fractures of the mandibular body and symphysis. Oral Maxillofac 21465453.
Surg Clin North Am. 2013 Nov;25(4):601-16. DOI: 10.1016/j.coms.2013.07.002. PubMed PMID: 80. Sharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, Oliver R. Interventions for
24021623., the treatment of fractures of the mandibular condyle. Cochrane Database Syst Rev. 2010 Apr
55. Guss DA, Clark RF, Peitz T, Taub M. Pantomography vs mandibular series for the detection of 14;(4):CD006538. DOI: 10.1002/14651858.CD006538.pub2.CD006538.pub2. PubMed PMID:
mandibular fractures. Acad Emerg Med. 2000 Feb;7(2):141-5. DOI: 10.1111/j.1553-2712.2000. 20393948.
tb00517.x. PubMed PMID: 10691072. 81. Baker JL Jr, O’Malley JE. Simplified splint for precise immobilization of the mandible. Plast
56. Schubert W. Radiographic diagnosis of mandibular fractures: mode and implication. Oper Tech Reconstr Surg. 1971 Dec;48(6):598-9. DOI: 10.1097/00006534-197112000-00020. PubMed PMID:
Otolayngol Head Neck Surg. 2002 Dec;13(4):246-53. DOI: 10.1016/s1043-1810(02)80054-9. 5141280.

82. O’Malley JE, inventor. Splint for immobilization of the mandible. United States patent interdisciplinary working group. Circulation. 2007 Oct;116(15):1736-54. DOI: 10.1161/
US3759256. 1973 Sept 18. CIRCULATIONAHA.106.183095. PubMed PMID: 17446442.
83. Doherty S, Acworth J, Taylor S, Bennetts S. Emergency care acute pain management manual. 108. Kellman RM, Losquadro WD. Comprehensive airway management of patients with maxillofacial
Canberra: National Health and Medical Research Council; 2011. p. 8-10. trauma. Craniomaxillofac Trauma Reconstr. 2008;1(1):39-47. DOI: 10.1055/s-0028-1098962.
84. Thorson D, Biewen P, Bonte B, Epstein H, Haake B, Hansen C, et al. Acute pain assessment and PubMed PMID: 22110788.
opioid prescribing protocol. Inst Clin Syst Improv. 2014 Jan. Available from: https://crh.arizona. 109. Daily WH. Nasotracheal intubation. In: Hagberg CA, Daily WH, Artime CA, editors. The Difficult
edu/sites/default/files/u35/Opioids.pdf. Airway: A Practical Guide. New York: Oxford University Press. 2013. p. 41-8. DOI: 10.1093/
85. World Health Organization. Cancer Pain Relief. Geneva; 1986. 18p. Available at: https://apps. med/9780199794416.001.0001.
who.int/iris/handle/10665/43944. 110. Watkins TA, Opie NJ, Norman A. Airway choices in maxillofacial trauma. Trends Anaesth Crit Care.
86. Ossendorp R, Forouzanfar T, Ashton-James CE, Bloemers F. Protocols for treating the 2011 Aug;1(4):179-90. DOI: 10.1016/j.tacc.2011.05.005.
postoperative pain of fractures in Dutch hospitals. J Pain Res. 2013 Aug 13;6:635-9. DOI: 111. Pavlakovic L, Lee G. Anaesthesia for maxillofacial surgery. Anaesth Intensive Care Med. 2014
10.2147/JPR.S43729. PubMed PMID: 23976863. PubMed Central PMCID: PMC3747026. Jun;15(8):379-84. DOI: 10.1016/j.mpaic.2014.04.016.
87. Selbst SM, Clark M. Analgesic use in the emergency department. Ann Emerg Med. 1990 112. Ray BR, Kumar D, Goswami D, Trikha A, Roychoudhury A, Bhutia O. Anaesthetic management
Sep;19(9):1010-3. DOI: 10.1016/s0196-0644(05)82565-x. PubMed PMID: 2393166. of maxillofacial trauma. Trends Anaesth Crit Care. 2013 Oct;3(5):231-37. DOI: 10.1016/j.
88. Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency department analgesia for tacc.2013.07.001.
fracture pain. Ann Emerg Med. 2003 Aug;42(2):197-205. DOI: 10.1067/mem.2003.275. PubMed 113. de Melo WM, Brêda MA Jr, Pereira-Santos D, Pereira CC, Sonoda CK, Araújo MM. Submental
PMID: 12883507. endotracheal intubation: a valuable resource for the management of panfacial fractures. J
89. Lorentzen V, Hermansen IL, Botti M. A prospective analysis of pain experience, beliefs and Craniofac Surg. 2012 Nov;23(6):1851-3. DOI: 10.1097/SCS.0b013e31826b8345. PubMed PMID:
attitudes, and pain management of a cohort of Danish surgical patients. Eur J Pain. 2012 23147327.
Feb;16(2):278-88. DOI: 10.1016/j.ejpain.2011.06.004. PubMed PMID: 22323380. 114. Lima SM Jr, Asprino L, Moreira RW, de Moraes M. A retrospective analysis of submental
90. Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate intubation in maxillofacial trauma patients. J Oral Maxillofac Surg. 2011 Jul;69(7):2001-5. DOI:
pain in millimetres?. Pain. 1997 Aug;72(1-2):95-7. DOI: 10.1016/s0304-3959(97)00005-5. 10.1016/j.joms.2010.10.017. PubMed PMID: 21367502.
PubMed PMID: 9272792. 115. Schütz P, Hamed HH. Submental intubation versus tracheostomy in maxillofacial trauma
91. Reichl M, Bodiwala GG. Use of analgesia in severe pain in the accident and emergency patients. J Oral Maxillofac Surg. 2008 Jul;66(7):1404-9. DOI: 10.1016/j.joms.2007.12.027. PubMed
department. Arch Emerg Med. 1987;4(1):25-31. DOI: 10.1136/emj.4.1.25 PubMed PMID: 3580071. PMID: 18571024.
92. Miloro M, DeLeeuw K, Ruggiero S. Parameters of care: clinical practice guidelines for oral and 116. Jin H, Patil PM. Midline submental intubation might be the preferred alternative to oral and nasal
maxillofacial surgery (AAOMS ParCare) 2012: patient assessment. J Oral Maxillofac Surg. 2012 intubation in elective oral and craniomaxillofacial surgery when indicated. J Oral Maxillofac
Nov;70(11):E12-30. DOI: 10.1016/j.joms.2012.07.029. Surg. 2015 Jan;73(1):39-46. DOI: 10.1016/j.joms.2014.08.018. PubMed PMID: 25511955.
93. Mustafa WM, Kanagaratnam SS Hamid AL, Chelvanayagam PI, Yaya EA, Wahab ZB, Tin MD, et 117. Raval CB. Rashiduddin M. Airway management in patients with maxillofacial trauma – a
al. Clinical practice guidelines: antibiotic prophylaxis against wound infection for oral surgical retrospective study of 177 cases. Saudi J Anaesth. 2011;5(1):9-15. DOI: 10.4103/1658-
procedure. Ministry of Health Malaysia; 2003. 354X.76476. PubMed PMID: 21655009.
94. Singh RP, Carter LM, Whitfield PH. Antimicrobial prophylaxis in open reduction and internal 118. Agrawal M, Kang LS. Midline submental orotracheal intubation in maxillofacial injuries : a
fixation of compound mandibular fractures: a collaborative regional audit of outcome. Br J substitute to tracheostomy where postoperative mechanical ventilation is not required. J
Oral Maxillofac Surg. 2013 Jul; 51(5):444-7. DOI: 10.1016/j.bjoms.2012.0819. PubMed PMID: Anaesth Clin Pharmacol. 2010;26(4):498-502. PubMed PMID: 21547178. PubMed Central PMCID:
23369782. PMC3087271.
95. Heit JM, Stevens MR, Jeffords K. Comparison of ceftriaxone with penicillin for antibiotic 119. Eisemann B, Eisemann M, Rizvi M, Lypka MA. Defining the role for submental intubation. J Clin
prophylaxis for compound mandible fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Anesth. 2014;26(3):238-42. DOI: 10.1016/j.jclinane.2013.09.009. PubMed PMID: 24813811.
1997 Apr;83(4):423-6. DOI: 10.1016/s1079-2104(97)90139-6. PubMed PMID: 9127371. 120. Ghazal G, Jaquiéry C, Hammer B. Non-surgical treatment of mandibular fractures-survey of 28
96. Wahab PU, Narayanan V, Nathan S, Madhulaxmi. Antibiotic prophylaxis for bilateral sagittal patients. Int J Oral Maxillofac Surg. 2004 Mar;33(2):141-5. DOI: 10.1054/ijom.2003.0458. PubMed
split osteotomies: a randomized, double-blind clinical study. Int J Oral Maxillofac Surg. 2013 PMID: 15050069.
Mar;42(3):352-5. DOI: 10.1016/j.ijom.2012.10.036. PubMed PMID: 23265757. 121. Omeje KU, Efunkoya AA, Adebola AR, Osunde OD. Oral health-related quality of life in non-
97. Soong PL, Schaller B, Zix J, Iizuka T, Mottini M, Lieger O. The role of postoperative prophylactic surgical treatment of mandibular fractures: a pilot study. Niger J Exp Clin Biosci. 2015 Jun;3(1):8-
antibiotics in the treatment of facial fractures: a randomised, double-blind, placebo-controlled 13. DOI: 10.4103/2348-0149.158144.
pilot clinical study. Part 3: Le fort and zygomatic fractures in 94 patients. Br J Oral Maxillofac 122. Omeje KU, Adebola AR, Efunkoya AA, Osunde OD, Bamgbose BO, Akhiwu BI, et al. Prospective
Surg. 2014 Apr;52(4):329-33. DOI: 10.1016/j.bjoms.2014.01.010. PubMed PMID: 24602602. study of the quality of life after treatment of mandibular fractures. Br J Oral Maxillofac Surg. 2015
98. Abubaker AO, Rollert MK. Postoperative antibiotic prophylaxis in mandibular fractures: a Apr;53(4):342-6. DOI: 10.1016/j.bjoms.2015.01.009. PubMed PMID: 25682422.
preliminary randomized, double-blind, and placebo-controlled clinical Study. J Oral Maxillofac 123. Al-Belasy FA. A short period of maxillomandibular fixation for treatment of fractures of the
Surg. 2001 Dec;59(12):1415-9. DOI: 10.1053/joms.2001.28272. PubMed PMID:11732026. mandibular tooth-bearing area. J Oral Maxillofac Surg. 2005 Jul;63(7):953-6. DOI: 10.1016/j.
99. Schaefer EH, Caterson EJ. Antibiotic selection for open reduction internal fixation of mandible joms.2005.02.008. PubMed PMID: 16003621.
fractures. J Craniofac Surg. 2013 Jan; 24(1):85-8. DOI: 10.1097/SCS.0b013e318275ef21. PubMed 124. Schmidt BL, Kearns G, Gordon N, Kaban LB. A financial analysis of maxillomandibular fixation
PMID: 23321876. versus rigid internal fixation for treatment of mandibular fractures. J Oral Maxillofac Surg. 2000
100. Miles BA, Potter JK, Ellis E 3rd. The efficacy of postoperative antibiotic regimens in the open Nov;58(11):1206-10;1210-1. DOI: 10.1053/joms.2000.16612. PubMed PMID: 11078130.
treatment of mandibular fractures: a prospective randomized trial. J Oral Maxillofac Surg. 2006 125. Bhagol A, Singh V, Singhal R. Management of mandibular fractures. In: Motamedi MHK, editor.
Apr;64(4):576-82. DOI: 10.1016/j.joms.2006.01.003. PubMed PMID: 16546635. A Textbook of Advanced Oral and Maxillofacial Surgery. Croatia:IntechOpen; 2013. p. 385-414.
101. Andreasen JO, Jensen SS, Schwartz O, Hillerup Y. A systematic review of prophylactic antibiotics 126. Ellis E 3rd. An algorithm for the treatment of non condylar mandibular fractures. J Oral Maxillofac
in surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg. 2006 Nov; 64(11):1664-8. Surg. 2014 May;72(5):939-49. DOI: 10.1016/j.joms.2013.11.026. PubMed PMID: 24480758.
DOI: 10.1016/j.joms.2006.02.032. PubMed PMID: 17052593. 127. Ingole PD, Garg A, Shenoi SR, Badjate SJ, Budhraja N. Comparison of intermaxillary fixation
102. Mundinger GS, Borsuk DE, Okhah Z, Christy MR, Bojovic B, Dorafshar AH, et al. Antibiotic screw versus eyelet interdental wiring for intermaxillary fixation in minimally displaced
and facial fractures: evidence-based recommendations compared with experienced-based mandibular fracture: a randomized clinical study. J Oral Maxillofac Surg. 2014 May;72(5):958.
practice. Craniomaxillofac Trauma Reconstr. 2015 Mar;8(1):64-78. DOI: 10.1055/s-0034-1378187. e1-7. DOI: 10.1016/j.joms.2014.01.005. PubMed PMID: 24642133.
PubMed PMID: PMC4329036. 128. Amaratunga NA. The relation of age to the immobilization period required for healing
103. Ata-Ali J, Ata-Ali F, Ata-Ali F. Do antibiotics decrease implant failure and postoperative of mandibular fractures. J Oral Maxillofac Surg. 1987 Feb;45(2):111-3. DOI: 10.1016/0278-
infections: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2014 Jan;43(1): 68- 2391(87)90400-9. PubMed PMID: 3468212.
74. DOI: 10.1016/j.ijom.2013.05.019. PubMed PMID: 23809986. 129. Ajmal S, Khan MA, Jadoon H, Malik SA. Management protocol of mandibular fractures at
104. Lovato C, Wagner JD. Infection rates following perioperative prophylactic antibiotics Pakistan Institute of Medical Sciences, Islamabad, Pakistan. J Ayub Med Coll Abbottabad. 2007
versus postoperative extended regimen prophylactic antibiotics in surgical management Jul-Sep;19(3):51-5. PubMed PMID: 18444592.
of mandibular fractures. J Oral Maxillofac Surg. 2009 Apr;64(4):827-32. DOI: 10.1016/j. 130. Jain S, Gupta S. Titanium miniplates versus intraosseous wires as methods of fixation of
joms.2008.06.093. PubMed PMID: 19304041. mandibular fractures: a clinical study. Indian J Stomatol. 2011;2(4):238-44. [cited 3 Aug 2017]
105. Malanchuk VO, Kopchak AV. Risk factors for development of infection in patients with Available from: https://www.researchgate.net/publication/328576775_Titanium_miniplates_
mandibular fractures located in the tooth-bearing area. J Craniomaxillofac Surg. 2007 versus_intraosseous_wires_as_methods_of_fixation_of_mandibular_fractures_A_clinical_
Jan;35(1):57-62. DOI: 10.1016/j.jcms.2006.07.865. PubMed PMID: 17298884. study.
106. Fairbanks DNF. Pocket Guide to Antimicrobioal Therapy on Otolaryngology-Head and Neck 131. Rahim AUR, Warraich RA. Mandibular fracture osteosynthesis: A comparison of three techniques.
Surgery. 13th ed. Virginia: American Academy of Otolaryngology-Head and Neck Surgery Pakistan Oral Dent J. 2009 Dec;29(2):201-6. Corpus ID:38059798. [cited 3 Aug 2017] Available
Foundation Inc.; 2007. from: https://www.semanticscholar.org/paper/MANDIBULAR-FRACTURE-OSTEOSYNTHESIS-
107. Wilson W, Taubert KA, Gewitz M, Lockhart P, Baddour LM, Levison M, et al. Prevention of %3A-A-COMPARISON-Rahim-Warraich/9eedcc99162acae53505fcbbdb37e49c34f446ffnot
infective endocarditis guidelines from the american heart association: a guideline from the available in Pubmed.
american heart association rheumatic fever, endocarditis, and kawasaki disease committee, 132. Biller JA, Pletcher SD, Goldberg AN, Murr AH. Complications and the time to repair of mandible
council on cardiovascular disease in the young, and the council on clinical cardiology, council fractures. Laryngoscope. 2005 May;115(5):769-72. DOI: 10.1097/01.MLG.0000157328.10583.A7.
on cardiovascular surgery and anesthesia, and the quality of care and outcomes research PubMed PMID: 15867637.

133. Freihofer HP Jr, Sailer H. Experiences with intraoral trans-osseous wiring of mandibular fractures.
J Maxillofac Surg. 1973 Dec;1(4):248-52. DOI: 10.1016/s0301-0503(73)80048-7. PubMed PMID:
4521498.
134. van Dijk L, Brons R, Bosker H. Treatment of mandibular fractures by means of stable internal
wire fixation. Int J Oral Surg. 1977 Jun;6(3):173-6. DOI: 10.1016/s0300-9785(77)80050-1.
PubMedPMID: 408286.
135. Renton TF, Wiesenfeld D. Mandibular fracture osteosynthesis: a comparison of three techniques.
Br J Oral Maxillofac Surg. 1996 Apr;34(2):166-73. DOI: 10.1016/s0266-4356(96)90372-1. PubMed
PMID: 8861293.
136. Fordyce AM, Lalani Z, Songra AK, Hildreth AJ, Carton AT, Hawkesford JE. Intermaxillary
fixation is not usually necessary to reduce mandibular fractures. Br J Oral Maxillofac Surg. 1999
Feb;37(1):52-7. DOI: 10.1054/bjom.1998.0372. PubMed PMID: 10203223.
137. El-Anwar MW, Sayed El-Ahl MA, Amer HS. Open reduction and internal fixation of mandibular
fracture without rigid maxillomandibular fixation. Int Arch Otorhinolaryngol. 2015
Oct;19(4):314-8. DOI: 10.1055/s-0035-1549154. PubMed PMID: 26491477; PubMed Central
PMCID: PMC4593909.
138. Hsu E, Crombie A, To P, Marquart L, Batstone MD. Manual reduction of mandibular fractures
before internal fixation leads to shorter operative duration and equivalent outcomes when
compared with reduction with intermaxillary fixation. J Oral Maxillofac Surg. 2012 Jul;70(7):1622-
6. DOI: 10.1016/j.joms.2012.03.012. PubMed PMID: 22698294.
139. Dongas P, Hall GM. Mandibular fracture patterns in Tasmania, Australia. Aust Dent J. 2002
Jun;47(2):131-7. DOI: 10.1111/j.1834-7819.2002.tb00316.x. PubMed PMID: 12139266.
140. Consunji RJ, Larona AJ, Jumangit A 3rd, Ameratunga S. Motorcycle-related trauma in the
Philippines resulting in hospital admission: the epidemiology of cases at the Philippine General
Hospital. Acta Medica Philippina. 2013; 47(3): 11-4 DOI: 10.47895/amp.v47i3.1279.
141. Lee KH, Snape L, Steenberg LJ, Worthington J. Comparison between interpersonal violence
and motor vehicle accidents in the aetiology of maxillofacial fractures. ANZ J Surg. 2007
Aug;77(8):695-8. DOI: 10.1111/j.1445-2197.2007.04189.x. PubMed PMID: 17635287.
142. Gagov L, Rubiev M, Deliverska E. The role of alcohol involvement in maxillofacial trauma. J of
IMAB. 2012;18(2):147-9. DOI: 10.5272/jimab.2012182.147.
143. O’Meara C, Witherspoon R, Hapangama N, Hyam DM. Mandible fracture severity may be
increased by alcohol and interpersonal violence. Aust Dent J. 2011 Jun;56(2):166-70. DOI:
10.1111/j.1834-7819.2011.01319.x. PubMed PMID: 21623808.
144. Lee KH. Interpersonal violence and facial fractures. J Oral Maxillofac Surg. 2009 Sep;67(9):1878-
83. DOI: 10.1016/j.joms.2009.04.117. PubMed PMID: 19686924.
145. Lee K. Trend of alcohol involvement in maxillofacial trauma. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2009 Apr;107(4):e9-13. DOI: 10.1016/j.tripleo.2008.12.020. PubMed PMID:
19201626.
146. Agnihotri A, Galfat D, Agnihotri D. Incidence and pattern of maxillofacial trauma due to road
traffic accidents: a prospective study. J Maxillofac Oral Surg. 2014;13(2):184-8. DOI: 10.1007/
s12663-013-0502-y. PubMed PMID: 24822011.
147. Liu BC, Ivers R, Norton R, Boufous S, Blows S, Lo SK. Helmets for preventing injury in motorcycle
riders. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004333. DOI: 10.1002/14651858.
CD004333.pub3. PubMed PMID: 18254047.
148. Public Law: An Act to Compile the Laws Relative to Land and Transportation and Traffic Rules, to
Create a Land Transportation Commission and for other Purposes. Republic Act No. 4136 (Date
of Approval: June 20, 1964).
149. Public Law: An Act Mandating All Motorcycle Riders To Wear Standard Protective Motorcycle
Helmets While Driving and Providing Penalties Therefore. Republic Act No. 10054 (Date of
Approval: March 23, 2010).
150. Public Law:An Act Requiring The Mandatory Compliance By Motorists of Private and Public
Vehicles To Use Seat Belt Devices, and Requiring Vehicla Manufacturers to Install Seat Belt
Devices in All Their Manufactured Vehicles. Republic Act No. 8750 (Date of Approval: August 5,
1999).
151. Public Law: An Act Penalizing Persons Driving Under the Influence of Alcohol, Dangerous Drugs,
and Similar Substances, and for Other Purposes. Republic Act No. 10586 (Date of Approval: May
27, 2013).
152. Staton C. Vissoci J. Gong E. Toomey N. Wafula R. Abdelgadir J. Hocker M. Road traffic injury
prevention initiatives: A systematic review and metasummary of effectiveness in low
and middle income countries. PLoS One. 2016 Jan;11(1): e0144971. DOI: 10.1371/journal.
pone.0144971. PubMed PMID: 26735918.
153. Usha M, Ravindran V, Soumithran CS, Ravindran Nair KS. The impact of mandatory helmet law
on the outcome of maxillofacial trauma: a comparative study in kerala. J Maxillofac Oral Surg.
2014 Jun;13(2):176-83. DOI: 10.1007/s12663-013-0496-5. PubMed PMID: 24822010; PubMed
Central PMCID: PMC4016405.
154. Shepherd J. Preventing violence-caring for victims. Surgeon. 2007 Apr;5(2):114-21. DOI:
10.1016/s1479-666x(07)80066-7. PubMed PMID: 17450696.
156. Laski R, Ziccardi VB, Broder HL, Janal M. Facial trauma: a recurrent disease? the potential
role of disease prevention. J Oral Maxillofac Surg. 2004 Jun;62(6):685-8. DOI: 10.1016/j.
joms.2003.12.008. PubMed PMID: 15170278.
157. Singhai J, Nigam R, Jain AK. The demographic study of otorhinolaryngological trauma among
patients with head and neck trauma and their management in a tertiary care centre. Indian J
Otolaryngol Head Neck Surg. 2018 Jun;70(2):249-55. DOI: 10.1007/s12070-017-1132-3. PubMed
PMID: 29977850. PMCID: PMC6015569.
158. Hoppe IC, Kordahi AM, Lee ES, Granick MS. Pediatric facial fractures: interpersonal
violence as a mechanism of Injury. J Craniofac Surg. 2015 Jul;26(5):1446-9. DOI: 10.1097/
SCS.0000000000001822. PubMed PMID: 26106996.

APPENDIX A: GUIDELINE DEVELOPMENT GROUP (GDG)
Chair: Dr. Joselito F. David

Co-Chair/Methodologist: Dr. Jose Florencio F. Lapeña Jr.
Liaison Officers: Dr. Elmo R. Lago Jr. (PSO-HNS)
Dr. Enrico Micael G. Donato (PACMFS)
Staff Lead: Dr. Ann Nuelli Acluba-Pauig
Resident Representative: Dr. Joy Celyn G. Ignacio
Maxillofacial Surgeons: Dr. Jose Rico A. Antonio
Dr. Arsenio L. Pascual III
Orthopedic Surgeon: Dr. Antonio Mario L. de Castro
Family Physicians/GPs: Dr. Policarpio B. Joves Jr.
Dr. Alejandro V. Pineda Jr.
Anesthesiologist: Dr. Edgardo Jose B. Tan
Nurse Practitioner: Dean Tita Y. Cruz
Dentists: Dr. Eliezer B. Blanes
Dr. Mario E. Esquillo
Radiologist: Dr Emily Rose M. Dizon
Motorcyclists: Dr. Joman Q. Laxamana
Dr. Fernando T. Aninang
Bicyclist/Commuter/Pedestrian: Ms. Carmela Cecilia G. Lapeña
APPENDIX B: GUIDELINE WORKING GROUP (GWG)

Consultants Residents
* Dr. Joselito F. David1,2 * Dr. Rene Rose A. Arciga8 * Dr. Fatima Angela C. Umali8
* Dr. Jose Florencio F. Lapeña Jr.1,3 * Dr. Anna Carlissa P. Arriola8 * Dr. Ma. Concepcion F. Vitamog8
* Dr. Francis V. Roasa2 * Dr. Mark Jansen D. G. Austria6 * Dr. Helena Michelle N. Casipit2
* Dr. Arsenio L. Pascual III4 * Dr. Vergil Leo Claude C. Esquivel4 * Dr. Marichu Florence Ciceron-Gloria2
* Dr. Enrico Micael G. Donato1,5 * Dr. Elaine Rose C. Ferrandiz4 * Dr. Harvey Hendrix G. Chu2
* Dr. Jose Rico A. Antonio6 * Dr. Soraya N. Joson1 * Dr. Giselle L. Gotamco2
* Dr. Jehan Grace B. Maglaya1,7 * Dr. Jaysonnel O. Notario3 * Dr. Mark Aldrin A. Alcid2
* Dr. Rene Louie C. Gutierrez1 * Dr. Almia A. Pazon4 * Dr. Veronica Marie M. Mendoza2
* Dr. Jennifer M. de Silva Leonardo5 * Dr. Shella May M. Promentilla1 * Dr. Anli Kael C. Tan2
* Dr. Ryan Neil C. Adan1 * Dr. Amihan Singson-Morales3 * Dr. Dann Joel C. Caro2
* Dr. Philip B. Fullante3 * Dr. Karen Adiel D. Rances4 * Dr. Jenina Rachel DJ Escalderon2
* Dr. Ann Nuelli B. Acluba-Pauig1 * Dr. Melanie Grace Y. Cruz1 * Dr. Christen-Zen I. Sison2
Dr. Jay Pee M. Amable7 * Dr. Jan Caezar B. Cordero1 * Dr. Therese Monique DG Gutierrez2
* Dr. Jemilyn C. Gammad8 * Dr. Alfred Peter Justine E. Dizon1
* Dr. Stephen Y. Lee8 * Dr. Patrick Jan T. Lim1
* Dr. Marion S. Bassig8 * Dr. Fatima M. Gansatao1
* Dr. Jose Carlo R. Villanueva7 Dr. Nicole Sacayan-Quitay3
* Dr. Dennis Andrew C. Remigio1 Dr. Tracy Joyce M. Zamora8
* Dr. Paula Sigma L. Javier1 Dr. Chantel Jacqueline R. Tirol3
* Dr. Joy Celyn G. Ignacio1 Dr. Louie Francis T. Akiat1
* Dr. Karina Vel E. Dizon1 Dr. Mark Gil A. Magboo1
Dr. Louie Aldwin D. Roque8 Dr. Fery Mai J. Rafanan1
Dr. Bianca Denise E. Edora8 Dr. Laurice Ann C. Canta1
Dr. Jesusa Santos-Perez8
*Original GWG; the rest contributed after 2017
1
East Avenue Medical Center, 2University of Santo Tomas Hospital, 3University of the Philippines – Philippine General Hospital, 4Quezon City General Hospital, 5Manila Central University – Filemon D. Tanchuco
Medical Foundation Hospital, 6Rizal Medical Center, 7Univsersity of the East Ramon Magsaysay Memorial Medical Center Inc. 8Jose R. Reyes Memorial Medical Center

APPENDIX C: DELPHI PROCESS INSTRUMENT C. Nasotracheal intubation is the preferred route of anesthesia in patients
diagnosed with isolated mandibular body fracture.
For each item, please encircle the whole number (between 1-9) that is closest to your In the presence of contraindications to nasotracheal intubation, submental
opinion. intubation or tracheostomy may be performed.
1. HISTORY, CLINICAL PRESENTATION AND DIAGNOSIS

Clinicians should consider a presumptive diagnosis of mandibular fracture in
adults presenting with a history of traumatic injury to the jaw plus a positive
tongue blade test, and any of the following physical findings: malocclusion,
trismus, tenderness on jaw closure, broken tooth and step deformity. 4. TREATMENT (SURGICAL)
A. Observation with a soft diet may serve as management for patients diagnosed
with favorable isolated nondisplaced and nonmobile mandibular body
fracture with unchanged pre - traumatic occlusion.
2. IMAGING
A. Clinicians may request for panoramic x-ray as the initial imaging tool in
evaluating patients with a presumptive clinical diagnosis of mandibular
fractures.
A. Closed reduction with immobilization by maxillomandibular fixation for 4-6
weeks may be considered in patients with minimally displaced favorable
isolated mandibular body fracture with stable dentition, good nutrition and
who are willing to comply with post-procedure care that may affect oral
A. In a setting where panoramic radiography is not available, clinicians may hygiene, diet modifications, appearance, oral health and functional concerns
recommend plain mandibular radiography among patients with presumptive (eating, swallowing and speech).
clinical diagnosis of mandibular fracture.
B. If available, non-contrast Facial CT Scan may be obtained for the assessment

B. a. Open reduction and internal fixation using Titanium plates and screws
of mandibular fractures.
should be performed in isolated displaced unfavorable and unstable
mandibular body fracture.
3. TREATMENT (MEDICAL)
A. Isolated mandibular body fractures should be temporarily immobilized/
splinted with a figure-of-eight bandage until definitive surgical management b. In patients with isolated displaced unfavorable and unstable mandibular
can be performed or while initiating transport during emergency situations. body fracture who cannot afford or avail of titanium plates, transosseous
wiring with maxillomandibular fixation is an option.
A. Clinicians should routinely evaluate pain in patients with isolated mandibular

body fractures using a numerical rating pain scale or visual pain analog scale; c. Intraoperative MMF may not be routinely needed prior to reduction and
analgesics should be routinely offered to patients with a numerical rating pain internal fixation of isolated displaced unfavorable and unstable mandibular
scale score or VAS of at least 4/10. body fracture.
Patients may be initially managed with Paracetamol and a mild opioid with or
without an adjuvant analgesic. Reassessment should be done and adequate
analgesia should be given until the numerical rating pain scale score or VAS is
3/10 at most.
5. PREVENTION AND PROMOTION
A. Clinicians should advocate for compliance with road traffic safety laws (speed
limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor
vehicle, cycling and pedestrian accidents and maxillofacial injuries.
B. Prophylactic antibiotics should be given to adult patients with isolated
mandibular body fractures with concomitant mucosal or skin opening with or
without direct visualization of bone fragments.
In patients without mucosal or skin lacerations, prophylactic antibiotics can
be given 1 hour prior to surgery and up to 24 hours post op. A. Clinicians should play a positive role in the prevention of interpersonal and
Penicillin is the drug of choice while Clindamycin may be used as an alternative collective violence as well as the settings in which violence occurs in order to
for patients in whom Penicillin is contraindicated. avoid injuries in general and mandibular fractures in particular.


Mandible CPG

Uploaded by

Copyright:

Available Formats

Mandible CPG

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Mandible CPG

Uploaded by

Copyright:

Available Formats

CLINICAL PRACTICE GUIDELINE

José Florencio F. Lapeña Jr., MA, MD1,2*±, Joselito F. David,

Correspondence: Prof. Dr. José Florencio F. Lapeña, Jr.

Philippine Journal Of Otolaryngology-Head And Neck Surgery 1

2 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Addressing the prevalence of mandibular body fractures, and

In this guideline, the mandibular body is defined as the lateral bony

Other modifying factors such as edentulous mandible; congenital,

In particular, this guideline is for the use of providers of health

Philippine Journal Of Otolaryngology-Head And Neck Surgery 3

METHODS Diagnosis Treatment Prevention

4 Philippine Journal Of Otolaryngology-Head And Neck Surgery

“mandibular fracture” or “jaw fracture” or “mandibular trauma” or

Figure 4. Search strategy for the first key action statement

Philippine Journal Of Otolaryngology-Head And Neck Surgery 5

Ideas, Editorials, Opinions 5

6 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 7

Statement Action Strength Statement Action Strength

8 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 9

10 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 11

12 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 13

14 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 15

16 Philippine Journal Of Otolaryngology-Head And Neck Surgery

l Intentional vagueness: none radiographic imaging for the mandible. Panorex is an

Philippine Journal Of Otolaryngology-Head And Neck Surgery 17

18 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 19

20 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 21

22 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 23

24 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 25

26 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 27

28 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 29

30 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 31

32 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 33

34 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 35

36 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Level III. A cross sectional study involving 92 patients seen

Philippine Journal Of Otolaryngology-Head And Neck Surgery 37

38 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 39

40 Philippine Journal Of Otolaryngology-Head And Neck Surgery

Philippine Journal Of Otolaryngology-Head And Neck Surgery 41

APPENDIX A: GUIDELINE DEVELOPMENT GROUP (GDG)

Chair: Dr. Joselito F. David

APPENDIX B: GUIDELINE WORKING GROUP (GWG)

42 Philippine Journal Of Otolaryngology-Head And Neck Surgery