Flail mandible

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A flail mandible is an uncommon type of comminuted fracture through the mandibular symphysis and bilateral condyles and/or rami which can result in posterior displacement and internal rotation of the mandibular bodies, eversion of the angles of the mandible, and glossoptosis. Together with concomitant sublingual hematomas, it can result in upper airway compromise ^1-4.

Clinical presentation

• dysphagia and odynophagia ²

• stridor ²

• retrognathia and facial widening ^1,6

• intraoral hemorrhage/laceration ⁴

Pathology

The body of the mandible is the attachment site of genioglossus and geniohyoid muscles responsible for tongue protrusion and swallowing respectively. In a flail mandible fracture, the mandibular body and tongue muscles are displaced posteriorly, pushing the root of the tongue against the posterior pharyngeal wall and narrowing the upper airway. Loss of geniohyoid muscle function impairs swallowing ¹.

Radiographic features

Although a flail mandible can be seen on plain radiography, as it is usually the result of high-energy trauma, CT is recommended to assess for associated injuries.

Plain radiograph

Occipitomental (OM) views show the flared mandible sign ⁵ characterized by eversion of angles of the mandible and bilateral condyle and/or rami fractures.

CT

• comminuted mandibular fracture

• glossoptosis resulting in apposition of the root of the tongue and posterior pharyngeal wall and upper airway compromise

• sublingual and submandibular space hematomas

Treatment and prognosis

In the emergency setting intubation is required to preserve airway patency. This often followed by open reduction and internal fixation of the fractured fragments.¹