Mandibular fracture: clinical guidelines

List of Abbreviations

BP – blood pressure

HIV – human immunodeficiency virus

TMJ – Temporomandibular joint

DII — dicrotic index

DCI — dicrotic coefficient

GI – gastrointestinal tract

PT – physical therapy

PAP – perioperative antibiotic prophylaxis

RVR — rheovasoneurography

MFR – maxillofacial region

TBI – traumatic brain injury

ENMG – electroneuromyography

EPT – electric pulp testing

UHF EF — ultra-high-frequency electric field

Terms and Definitions

Anterograde amnesia — loss of memory for current events, experiences, and facts occurring during the period following the acute stage of the illness, often against the background of persisting consciousness disturbances from the acute stage.

Congrade amnesia — complete or partial loss of memory for events of the acute stage of the illness (period of impaired consciousness).

Retrograde amnesia — loss of memory for impressions and events preceding the acute period of the illness or injury.

Anisocoria – a condition characterized by unequal pupil sizes, and possible slight pupillary deformity.

Intraoral approach — a type of surgical approach performed by sequential dissection of the oral mucosa, periosteum, and sometimes deeper layers of soft tissues to visualize jaw fragments.

Oral hygiene – a set of measures aimed at reducing the amount of dental deposits.

Gaze divergence — divergence of the visual axes of the right and left eyes.

Closed mandibular fracture — a type of fracture in which there is no communication between the fracture line and the external environment through a skin wound, a wound (rupture) of the oral mucosa, or through the periodontal ligament of the tooth.

Fracture line — a planar representation of the fracture plane on a radiograph.

External approach — a type of surgical approach performed by sequential dissection of the skin, subcutaneous adipose tissue, and deeper layers of soft tissues to visualize jaw fragments.

Osteosynthesis – surgical fixation of bone fragments.

Extra focal osteosynthesis — osteosynthesis in which the fixation device is located outside the fracture line.

Closed osteosynthesis — osteosynthesis without soft tissue dissection in the fracture area.

Open osteosynthesis — osteosynthesis with soft tissue incision in the fracture area.

Focal osteosynthesis — osteosynthesis in which the fixation device crosses the fracture line.

Open mandibular fracture — a type of fracture in which communication occurs between the fracture line and the external environment through a skin wound, a wound (rupture) of the oral mucosa, or through the periodontal ligament of the tooth.

Lumbar puncture — puncture of the subarachnoid space of the spinal cord at the level of LII-LIV vertebrae to obtain cerebrospinal fluid.

Fragment reduction – a procedure aimed at repositioning and aligning bone fragments.

Positive load sign — the appearance of sharp pain in the fracture area due to the displacement of fragments and irritation of the damaged periosteum when pressure is applied to a knowingly intact area of the jaw.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

A fracture is defined as an injury to the mandible with a disruption of its integrity.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

In peacetime, the causes of mandibular fractures are most often impacts and contusions sustained from falls, crushing, etc. Gunshot fractures are relatively rare. Currently, the frequency of traffic and domestic trauma has increased [1, 2, 3].

A mandibular fracture usually occurs as a result of a force exceeding the physical capacity of the bone tissue. Such a fracture is called traumatic [4].

Four mechanisms of mandibular fracture are distinguished: bending, shear, compression, avulsion.

The mandible is arch-shaped. In the region of the angles, mental foramen, and canine, in the region of the base and neck of the condylar process, i.e., in the thinnest or curved areas, the mandible experiences the greatest stress and breaks due to bending. Several variants of mandibular fracture due to bending are possible.

The shearing mechanism occurs when a force is applied to a bone area lacking support, and it shears relative to the supported bone area. This is how a longitudinal fracture of the mandibular ramus occurs if a force directed from bottom to top is applied to the base of the mandible anterior to its angle in a narrow area (in the projection of the coronoid process). The anterior section of the ramus shifts upward relative to the posterior section, which is supported in the glenoid fossa. The shearing mechanism is also possible in fractures of the mandibular body. If a force is applied to the base of the mandible from bottom to top in an edentulous area, it may shift upward relative to the dentate area without having support.

The compression mechanism manifests when the acting and counteracting forces are directed toward each other. When an impact is delivered from bottom to top to the base of the body in the angle region over a wide area, the mandibular ramus undergoes compression and breaks transversely.

The avulsion mechanism manifests when an impact is directed from top to bottom on the chin area with tightly clenched teeth. A reflexive contraction of the masticatory muscles occurs, and the temporalis muscle, attached to the thin coronoid process, avulses it from the ramus.

In addition to traumatic fractures, pathological fractures are distinguished, which occur without a traumatic factor in areas with reduced strength due to bone destruction by pathological processes (odontogenic cyst, osteoblastoclastoma, chronic osteomyelitis with extensive sequestration, etc.) [6, 7].

1.3 Epidemiology of the Disease or Condition

Mandibular fractures are the most common among all facial skeleton bone fractures [7, 8]. According to various authors [5, 9, 10, 11, 12], the proportion of patients with mandibular fractures ranges from 75% to 95% among all maxillofacial patients.

According to various authors, the ratio of facial injuries in men and women is characterized by a significant predominance of male trauma, amounting to 8:1 [13]. The predominance of male trauma over female is also noted by other authors [14, 15, 16].

According to most authors, the highest number of fractures occurs between the ages of 20 and 30 years. Thus, the following data are found in the literature: patients aged 20–29 years account for 36.6%, and those aged 30–39 years account for 25.9%. People over 60 years old make up 2.8% of the injured, and children under 15 years old make up 4% [17, 18].

1.4 Features of Coding the Disease or Condition

S02.6 – Fracture of mandible

1.5 Classification of the disease or condition

A. By localization:

I. Fractures of the body of the jaw:

a) with the presence of a tooth in the fracture line;

b) in the absence of a tooth in the fracture line.

II. Fractures of the ramus of the jaw:

a) of the ramus proper;

b) of the coronoid process;

c) of the condylar process: base, neck, head.

B. By the nature of the fracture:

1. Without displacement of fragments, with displacement of fragments.

2. Linear, comminuted.

1.6 Clinical presentation of the disease or condition

Patients complain of pain in the area of the mandible where the fracture occurred. Pain intensifies with jaw movement, biting, and chewing food, especially hard food. Numbness of the chin and lower lip skin on the affected side, the oral mucosa, the alveolar part of the mandible, and teeth in the jaw area located mesial to the fracture line is often noted, which is associated with traumatic damage to the inferior alveolar nerve.

Soft tissues in the area of jaw damage are typically edematous, non-tense, and facial configuration is disrupted.

Palpation of the mandible reveals pathological mobility of bone fragments, bone crepitus, and a positive "indirect load" sign. Signs of fragment displacement include malocclusion and palpation of a bony "step" along the lower border of the jaw.

Tears and hematomas are often determined on the mucosa of the alveolar part of the mandible in the area of damage. A characteristic sign of a mandibular fracture is the location of the hematoma — on the vestibular and lingual sides of the alveolar part. The localization of the hematoma corresponds to the fracture site and coincides with the localization of the hematoma in the perimaxillary soft tissues. Visualization of bone fragments in the oral cavity is often possible.

The bite change depends on the nature of fragment displacement, which is associated with the fracture localization. The large fragment is displaced downward, and the small one upward. For this reason, the teeth of the small fragment contact the antagonists, whereas contact with antagonists is absent on the large fragment, except for the molars, leading to an open bite.

In fractures of the condylar process, asymmetry of the range of motion in the temporomandibular joint on the right and left is determined. When opening the mouth, the chin shifts toward the fracture side; lateral movements of the mandible are painful, and the range of motion is reduced.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for diagnosis establishment:

The diagnosis of mandibular fracture is established based on complaints, anamnestic data, physical, and instrumental examinations.

2.1 Complaints and Anamnesis

Patients complain of pain in the lower jaw that worsens when opening and closing the mouth, chewing, soft tissue swelling, impaired speech and chewing function, malocclusion, numbness of the skin in the chin and lower lip area, and bleeding from the mouth [21, 22, 23]. In the presence of a concussion, dizziness, headache, nausea, and vomiting may occur [5, 24, 25].

2.2 Physical Examination

The general condition of the patient is assessed based on clinical signs (preservation or absence of consciousness, patient's contact responsiveness, character of breathing and pulse, blood pressure level, muscular defense or pain upon abdominal palpation). Damage to other anatomical regions must be ruled out [5, 21, 26].

Comments: When moving the fingers along the posterior border of the ramus and the base of the mandibular body, one can identify a bone prominence, bone defect, or painful point.

Next, the load test is checked. It is used to identify a painful bone area corresponding to the site of the suspected fracture. During the examination, the physician presses on a knowingly intact area of the patient's lower jaw, and sharp pain arises in the fracture area due to the displacement of fragments and periosteal irritation.

The presence of the axial load symptom can be identified in various ways.

· Place the index and thumb of the right hand on the patient's chin and apply pressure from front to back, right to left, and left to right.

Pain occurs in fractures of the ramus (angle, condylar process) and body of the mandible [5, 27, 28].

· Place the fingers on the external surface of the mandibular angles on the left and right and apply pressure toward the midline.

Pain occurs in fractures of the chin and body of the mandible [5, 25, 28].

· Press with the thumbs from bottom to top onto the base of the mandible in the angle region on both sides. Pain occurs in a fracture of the mandibular ramus [5, 29, 30].

Comments: In a condylar process fracture, the range of motion will be smaller than on the healthy side, and movement of the damaged condylar head may be absent [5, 29, 32].

Next, the oral cavity is examined. The range of mandibular motion is determined, a reduction of which may indicate a fracture. A deviation of the chin toward the fracture side when opening the mouth may be noted. Attention is paid to the bite, which is most often disturbed in a fracture. Dental percussion is performed – percussion of the teeth between which the fracture line passes may be painful.

In a fracture of the mandibular body, a hematoma is often detected in the oral vestibule and on the lingual side of the alveolar part, which is a diagnostic sign, since with soft tissue contusion, a hematoma occurs only on the vestibular side.

Sometimes a laceration of the alveolar mucosa extending into the interdental space can be found in the oral cavity, indicating the location of the fracture line.

A reliable sign of a fracture is the symptom of fragment mobility.

Comments: This method is used to determine a fracture within the dental arch. There is an increase in the interdental space or the mucosal laceration of the alveolar part due to the displacement of fragments and a change in the height of adjacent teeth [5, 18, 33].

Comments: This method is used when the fracture line is localized in the mandibular angle region [5, 18, 33].

2.3 Laboratory Diagnostics

• laboratory diagnostic tests are recommended for all patients with mandibular fractures prior to surgical intervention [18].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: All mandibular fractures within the dental arch are infected with pathogenic microflora of the oral cavity, predominantly staphylococci and streptococci.

2.4 Instrumental Diagnostics

Instrumental research methods are used to clarify the clinical diagnosis, evaluate treatment efficacy, and assess rehabilitation [35, 36, 37]. The most widely used and one of the most informative examination methods for jaw fractures is radiography. The fracture line is identified on the radiograph [19, 20].

More modern diagnostic methods include orthopantomography and computed tomography of the facial skull.

Comments: During radiography of the facial skeleton bones (in anteroposterior and lateral projections), the entire lower jaw is visualized, superimposed by the image of the cervical spine; the bones of the cranial vault, temporal bone pyramids, upper jaw, orbital opening, nasal cavity walls, and lower sections of the maxillary sinuses are visible. On the radiograph of the lower jaw in an oblique projection, the mandibular angle and ramus with processes, as well as lower molars, are determined. Sometimes the zygomatic arch of the adjacent side is projected into the mandibular notch [38, 40, 41].

Comments: Using this method, mandibular fractures in the condylar process, ramus, body, and chin regions can be diagnosed quite accurately. Of particular value is the clear visualization of the fracture line in the mental region, which is poorly detected on standard radiographs [38, 40, 41, 42, 43].

Comments: Software of modern computed tomography scanners makes it possible to determine both linear and angular parameters of the skull. This technique provides a 1:1 scale image of the skull, which has high diagnostic value [15, 44, 45, 46].

2.5 Other Procedures

2.5.1. Internal organ injury

2.5.2. Traumatic brain injury

Comments: Cerebral concussion is characterized by a loss of consciousness (from a few seconds to 20 minutes). Congrade, retrograde, or anterograde amnesia may occur occasionally. Nausea or a single episode of vomiting may be present. Patients report headache, dizziness, weakness, tinnitus, diaphoresis, facial flushing, and sleep disturbances. Pain with eye movement and reading, ocular divergence, and vestibular hyperesthesia may occur. In mild concussion, miosis is observed, whereas severe concussion presents with mydriasis. Anisocoria occurs occasionally [5, 18]. Cerebral contusion, depending on the severity, is characterized by loss of consciousness (from a few minutes to hours and weeks), headache, nausea, vomiting (including repetitive vomiting), con-, retro-, and anterograde amnesia, bradycardia or tachycardia, elevated blood pressure, and tachypnea [5, 18, 19, 118].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. Orthopedic Treatment

Temporary methods of orthopedic immobilization and therapeutic (permanent) methods are distinguished. Therapeutic methods are subdivided into extra-laboratory prefabricated splints (individual metal or other material dental splints, standard dental splints) and laboratory-fabricated splints (Weber simple or inclined-plane tooth-gum splint, Vankevich and Vankevich-Stepanov splints, various dental cap appliances, Port gingival splint).

The most common individual dental splints are the wire splints with intermaxillary fixation loops by S.S. Tigerstedt. Several designs have been proposed: smooth arch bar, splint with a spacer bend, splint with loops, and splint with an inclined plane [108].

Comments: The smooth arch bar is used for the treatment of patients with linear mandibular fractures within the dental arch without fragment displacement or with easily repositionable fragments, and with fractures of the alveolar part of the mandible, provided that there are at least 4 stable teeth on the larger fragment and at least 2 stable teeth on the smaller fragment.

The splint with a spacer bend is used for mandibular fractures without displacement or with easily repositionable fragments if the fracture line passes through an edentulous part of the alveolar process, as well as for fragment fixation in fractures within the dental arch with a bone tissue defect of no more than 2–4 cm. The splint with a spacer bend can be used if there are at least 2 stable teeth on the smaller fragment and 4 on the larger fragment. The spacer bend prevents lateral displacement of the fragments [7, 18].

In the treatment of patients with mandibular fractures outside the dental arch; fractures with difficult-to-reduce fragments requiring traction; and bilateral, double, and multiple mandibular fractures, two-jaw custom wire splints with loops are used. In addition, loop splints are used for fragment fixation in fractures within the dental arch when there are at least 4 stable teeth on the larger fragment and at least 2 stable teeth on the smaller fragment [109, 110, 111, 112].

Standard splints manufactured industrially that do not require bending of loops—specifically, ribbon arch bars according to Erich and Vasiliev—are also used for permanent fixation [108].

For unilateral fractures, splint immobilization is carried out for 4–5 weeks, and for bilateral fractures, up to 6 weeks [7].

3.2. Surgical treatment

Indications:

1. Inability to reposition displaced bone fragments by orthopedic methods.

2. Insufficient number of stable teeth for stable fixation of bone fragments using orthopedic methods.

3. Interposition of soft tissues in the fracture gap.

4. Fracture-dislocation of the condylar process [18].

Contraindications:

1. Severe general somatic pathology in the stage of decompensation.

2. Acute moderate or severe traumatic brain injury [18].

Comments: There are a number of conditions in which surgical methods of bone fragment fixation have no alternative. These conditions include: jaw fracture outside the dental arch; fracture within the dental arch with an insufficient number of stable teeth on the fragments; significant fragment displacement; pathological fracture resulting from an inflammatory or neoplastic bone disease; comminuted fractures of the body and ramus of the mandible; defects of the body and ramus of the mandible; and the need for osteoplasty and reconstructive surgery [68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79].

Comments: Theoretical calculations using mathematical modeling [70, 89, 90] have demonstrated that treatment of mandibular fractures using internal fixation with bone plates corresponds most closely to the principles of absolute stability [70, 89, 90, 91, 92, 93, 94, 95, 96, 97].

Comments: The use of an intraoral approach makes the surgical procedure less traumatic. The volume of traumatized tissue is minimized. The risk of bleeding and injury to the facial nerve is sharply reduced, and the duration of the surgery—and consequently anesthesia time—is shortened. The patient's rehabilitation period is reduced. If the plate needs to be removed in the late postoperative period, it is significantly easier to do so via the intraoral approach. The intraoral approach is most commonly used for fragment fixation in the mandibular body region. A disadvantage of the technique is considered to be the increased risk of postoperative infection of the fracture gap in case of poor oral hygiene [98, 99, 100, 102, 103].

3.3. Prevention of Surgical Site Infections

Comments: The choice of regimen and protocol for antimicrobial prophylaxis is based on national and international guidelines for the prevention of SSIs [63,64,65,122,123,124,125].

• It is recommended, in most cases, to administer a single dose of the antibiotic; if prolonged prophylaxis is necessary, the drug should be discontinued no later than 24 hours after surgery in patients with mandibular fractures, even in the presence of a drain, for the purpose of antimicrobial prophylaxis [63,64,65,122,123,124,125].
• Level of recommendation C (evidence level - 5).
• Comments: In case of a high risk of complications, extending antibiotic prophylaxis for 24–48 hours in the postoperative period is permitted [63,122, 127,128]. Prolonging antibiotic prophylaxis after the end of surgery does not increase its efficacy, but elevates the risk of selecting antibiotic-resistant strains and complications, notably C. difficile-associated diarrhea

For type IV wounds—"infected wound" in cases of old trauma, prior infection, presence of purulent discharge, or non-viable tissues—antibiotic therapy is recommended [63,122, 125,126,127,128].

GCR ALEL 3Grade of Recommendation A (Level of Evidence - 3).

Comments: Type IV wounds include old traumatic wounds with non-viable tissues, as well as postoperative wounds in areas where infection was already present. This implies that microorganisms capable of causing surgical site infections (SSIs) were present in the surgical site prior to the operation!

Table 1. Antibacterial drugs for AMP in patients with mandibular fractures

¹ penicillin allergy, high risk of MRSA.

² for patient body weight less than 80 kg - Cefazolin** dose is 1 g, for weight from 80 kg to 130 kg - 2 g, for body weight over 130 kg - 3 g.

³ — 120 minutes before incision.

⁴- gentamicin dose is calculated based on ideal body weight.

3.4. Pain Management

Mandible reposition and osteosynthesis procedures are usually performed under general balanced endotracheal anesthesia with nasotracheal intubation or combined anesthesia.

Comments: In cases of severe comorbid pathology that increase the operative and anesthesiologic risk, surgeries can be performed under local anesthesia with premedication.

3.5 Other treatments

3.5.1. Diet Therapy

A patient with a jaw fracture is unable to consume food of normal consistency and chew it. This hinders the normal course of bone tissue reparative processes due to an insufficient intake of proteins, fats, carbohydrates, micronutrients, and vitamins, and also disrupts the activity of the gastrointestinal tract. Thus, organizing adequate nutrition for patients with mandible fractures is one of the main tasks, upon the correct solution of which the outcome of treatment depends.

Comments: The first jaw diet has the consistency of cream. The daily energy value of the first jaw diet is 3000-4000 calories. The rubber tube of the drinking bowl can be inserted through a defect in the dental arch at the site of a missing tooth. If all teeth are present, the tube is inserted into the retromolar space behind the wisdom tooth. Food from the drinking bowl, warmed to 45-50⁰ C, is administered repeatedly in small portions until the patient feels full. If the entire volume of food is not consumed, it must be fed to the patient after a short break.

Gastric tube feeding is performed by physicians or nursing staff. The tube is inserted into the stomach through the lower nasal passage. The remaining external part must be of sufficient length for fixation to the patient's head. Food is administered in small portions through the tube using a syringe or funnel at least 4 times a day: at 9:00, 13:00, 14:00, 18:00, and 1 hour before sleep. At the same time, its amount is distributed as follows: 30% of the daily food volume for breakfast, 40% for lunch, 20-25% for dinner, and 5-8% for the second dinner. Feeding via a gastric tube is usually carried out for 10-14 days, rarely 3-4 weeks. This depends on the patient's condition and the severity of injuries. After removing the tube, they switch to feeding from a drinking bowl [10, 32].

Comments: If parenteral nutrition of the victim is necessary, amino acid mixtures for parenteral nutrition are used for intravenous administration [7, 12, 13, 18, 35, 61, 62, 70, 112]. The daily volume of nutrient mixtures averages 1.0-1.5 liters. They are administered 2-3 times a day by drip infusion, very slowly (20-25 drops per minute). Rapid administration (30-50 drops per minute) often leads to severe chills, nausea, and vomiting [18].

Comments: The second jaw diet has the consistency of thick sour cream. This diet acts as a transitional diet to the regular table. Food is consumed by the patient independently using ordinary cutlery [10, 18, 108, 113].

3.5.2. Physiotherapy

Comments: On the third day, exposure to an ultra-high-frequency electric field (UHF EF) on the postoperative area is prescribed. UHF EF therapy improves blood circulation in the postoperative zone, increases lymph outflow, promotes rapid resorption of hematoma, reduction of edema, and decrease in the intensity of postoperative pain. Exposure to UHF EF with a power of 20-30 W for 10 minutes, 5-7 procedures, is prescribed. To reduce pain and affect the traumatized inferior alveolar nerve, impulse current electrophoresis, combined exposure to impulse currents and phonophoresis of medicinal substances using anesthetics, and darsonvalization are used. For infected open fractures, exposure to a alternating magnetic field (AMF) with a frequency of 50 Hz in combination with antibiotics is used. Under the influence of the magnetic field, which has an anti-inflammatory effect, post-traumatic edema is reduced, tissue trophism is restored, and the bactericidal effect of antibiotics is increased. The treatment course consists of 10 procedures of 20 minutes each [18, 113, 114].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

5. Prevention and Dispensary Observation

Comments: Teeth with an exposed root slow down the process of bone fragment consolidation, since bone trabeculae grow only from one fragment into another and do not fuse with the tooth root [67, 115, 116].

Comments: Teeth with periapical chronic foci are always potentially dangerous in terms of the development of inflammatory complications. This category also includes teeth in cases of root fracture, mobility, wide exposure of root cementum, and dislocation of the tooth from the socket [67, 115, 117].

6. Organization of Medical Care

Indications for emergency hospitalization in the maxillofacial surgery department:

1) presence of a mandible fracture with displacement of fragments.

2) presence of a mandible fracture without displacement of fragments for up to 2 weeks.

3) presence of a mandible fracture without displacement of fragments for more than 2 weeks with complications in the ENT organs and/or the organ of vision, central or peripheral nervous system.

Indications for planned hospitalization in the Department of Maxillofacial Surgery:

No indications.

Comment: since a mandible fracture is an emergency condition, all patients with this disease are recommended to be hospitalized on emergency indications.

If more than 28 days have elapsed since the injury, this condition does not belong to this disease group and is coded according to ICD-10 as T90.2 – Sequelae of skull and facial bone fracture.

7. Additional Information

Factors negatively affecting treatment outcomes:

• Development of infectious complications.
• Non-compliance with the regimen of local contact hypothermia.
• Poor oral hygiene.
• Non-compliance by the patient with the diet and masticatory activity restrictions.
• Non-compliance with exercise therapy recommendations in the postoperative period.
• Participation in contact sports within 3 months.
• Failure to attend follow-up examinations.
• Non-compliance with other recommendations of the attending physician.

7.1. Temporary immobilization

Comments: Contraindications to intermaxillary fragment fixation in cases of brain injury are associated with the risk of aspiration asphyxia if the victim vomits. When using the Oliver-Ivy method, in order to open the patient's mouth in an emergency and prevent vomiting aspiration, it is sufficient to cut the 2 vertical wire ligatures passed through the loops. To restore intermaxillary fixation, it is sufficient to re-insert the wire ligatures into the loops and twist their ends [108, 119, 120].

Comments: From a practical standpoint, TBI combined with facial bone fractures is divided into four groups (Gelman Yu.E., 1977).

1) Group 1 – severe TBI (moderate to severe brain contusion, intracranial hematomas) and severe facial bone fractures (maxillary fracture Le Fort I and II, simultaneous fracture of the maxilla and mandible). Half of such patients develop traumatic shock. Temporary immobilization in Group 1 patients is possible immediately after they emerge from shock. Therapeutic immobilization using orthopedic methods is permitted on days 2–5 after trauma and emergence from shock; osteosynthesis is performed no earlier than day seven. 2) Group 2 – severe TBI and non-severe facial bone trauma (maxillary fracture Le Fort III, unilateral fractures of the maxilla and mandible, zygomatic bones, etc.). Therapeutic immobilization in Group 2 patients can be performed after 1–3 days. 3) Group 3 – non-severe TBI (concussion, mild brain contusion) and severe facial bone injuries. The severity of the patient's condition is mainly due to facial skeleton trauma. Therapeutic immobilization, including osteosynthesis, is possible as early as the first day after injury. 4) Group 4 – non-severe TBI and non-severe facial skeleton injuries. Fragment immobilization can be performed within the first hours after trauma. Early specialized treatment not only does not worsen the patient's condition but also reduces the risk of intracranial inflammatory complications [18, 121, 122].

7.2. Oral Hygiene

Comments: Medical toilet of the oral cavity consists of thorough cleaning of splints and teeth from food debris by irrigating and rinsing the oral vestibule with antiseptic solutions. Rinsing is performed by irrigating with an antiseptic jet from a syringe. After rinsing, splints are cleaned from food debris stuck between the splint, teeth, gums, ligatures, and rubber rings. During dressings, it is necessary to check the position of the splint, traction loops, and the state of wire ligatures. If there are pressure sores from the loops on the mucosa of the lips, gums, or cheeks, they must be adjusted to the appropriate position. Loose ligatures are tightened and bent toward the teeth.

Comments: The patient should rinse the mouth with antiseptics not only after every meal, but also between meals and before bedtime. The patient should brush their teeth with a brush and toothpaste, and use a toothpick to remove leftover food remaining after brushing [18, 58, 108].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.
2. Drobyshev A.Yu. – MD, PhD, Professor, Vice-President of the Association of Maxillofacial Surgeons.
3. Yaremenko A.I. – MD, PhD, Professor, Vice-President of the Association of Maxillofacial Surgeons.
4. Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".
5. Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.
6. Belchenko V. A. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.
7. Braylovskaya, T. V. – MD, Associate Professor, Executive Secretary of the Association of Maxillofacial Surgery Specialists LLC.
8. Durnovo, E. A. – MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.
9. Ivanov, S. Yu. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.
10. Epifanov, S. A. – MD, Associate Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.
11. Lepilin A. V. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.
12. Nerobeev A.I. – MD, PhD, Professor, Honorary President of the Association of Maxillofacial Surgeons.
13. Roginsky, V. V. – MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.
14. Savelyev A.L. – PhD, Assistant Professor, Department of Maxillofacial Surgery and Dentistry, Samara State Medical University.
15. Stolyarenko, P.Yu. – PhD in Medical Sciences, Associate Professor, Member of the LLC "Association of Specialists in Maxillofacial Surgery".
16. Sysolyatin P.G. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.
17. Tarasenko, S.V. – MD, PhD, Professor, Member of the LLC "Association of Maxillofacial Surgeons".
18. Topolnitsky, O. Z. – MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.

All members of the working group are members of the All-Russian Public Organization "Association of Specialists in Maxillofacial Surgery". There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Dentists
2. Maxillofacial surgeons
3. Trauma and orthopedic surgeons
4. Neurosurgeons
5. Mid-level medical personnel
6. Healthcare organizers
7. Medical insurance experts (including conducting medical and economic expertise)
8. Medical students, residents, postgraduate students

Table 1. Scale for evaluating levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

• Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care".
• Article 37 of Federal Law No. 323-FZ dated November 21, 2011, "On the Fundamentals of Public Health Protection in the Russian Federation".

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

A fracture is defined as a disruption of the anatomical integrity of the mandible. In peacetime, mandibular fractures are most commonly caused by impacts and blunt force trauma sustained during falls, compression, physical altercations, etc. Mandibular fractures are the most prevalent among all facial bone fractures.

There are several signs that allow for the suspicion of a mandibular fracture. These include soft tissue swelling around the jaws, mandibular pain that intensifies when opening and closing the mouth, and malocclusion. Biting and chewing food is extremely painful or impossible. Numbness of the skin in the chin and lower lip area and bleeding from the mouth frequently occur. Furthermore, mandibular fractures are quite often accompanied by a traumatic brain injury. This may present with dizziness, headache, nausea, and vomiting, and the victim may partially or fully forget the circumstances of the injury.

If one or more of these signs appear, immediate medical assistance must be sought by calling an ambulance. The sooner specialized medical care is provided for a mandibular fracture, the lower the probability of complications, including very severe ones. Such complications include osteomyelitis, phlegmon, neuritis, neuralgia, malunion of fragments, pseudoarthrosis (false joint), etc. Resulting complications often lead to severe health consequences and require prolonged treatment with repeated surgical interventions.

Treatment of patients with mandibular fractures is carried out in a specialized inpatient medical facility. The essence of treatment consists of reducing the fragments and stably fixing them in the correct position for the period required for bone callus formation (approximately four weeks). The accuracy of fragment reduction is monitored using control radiography. There are surgical and orthopedic (conservative) methods of treatment, each of which has certain advantages and disadvantages. Most orthopedic techniques boil down to applying splinting structures to the upper and lower dental arches, which are fastened together, securing the mandibular fragments to the immobile maxilla. The advantage of orthopedic (conservative) methods is low invasiveness and the absence of the risk of surgical complications (damage to major blood vessels and nerve trunks during surgery). Significant disadvantages include the forced immobility of the mandible throughout the entire fixation period, poor oral hygiene (which can result in inflammatory complications), and trauma to the periodontal ligament apparatus of the teeth. Moreover, stable fixation of fragments using splinting is far from possible in all clinical situations. Currently, as a rule, orthopedic treatment methods are used for mandibular fractures within the dental arch without significant fragment displacement.

Currently, the "gold standard" of surgical treatment methods is the fixation of fragments using extraosseous titanium miniplates. This technique allows for the most accurate reduction and stable fixation of bone fragments. In the postoperative period, the patient is usually able to open the mouth immediately, oral care is simplified, and early application of therapeutic exercises is possible, which prevents the development of scarring changes in the masticatory muscles and shortens the rehabilitation period.

In addition to fragment fixation and prescription drug therapy, the use of various physiotherapeutic treatment methods and therapeutic exercises is essential. The timely application of these methods helps to optimize the bone-healing process and prevent the development of complications such as muscle contracture, pseudoarthrosis, delayed union, and osteomyelitis.

Inpatient treatment is carried out for 1 to 2 weeks, after which the patient is discharged for outpatient follow-up with an oral and maxillofacial surgeon at their place of residence. When orthopedic treatment methods are used, the outpatient physician adjusts the splints, fixing ligatures, and elastic traction as necessary. Sutures are removed on days 7–10. Four weeks from the start of treatment, the external fixation structures are removed in an outpatient setting, after which, in the absence of complications, the patient is able to fully resume their professional duties, provided they are not associated with heavy physical labor. Heavy physical exertion should be avoided for another 2–3 weeks.

It is important to remember that the success of the treatment depends not least on the patient themselves, and on how conscientiously they follow the doctor's recommendations. Thus, a crucial condition for successful treatment is meticulous adherence to oral hygiene, especially when orthopedic treatment methods are chosen. Dental splints, wire fixation ligatures, and the lack of mandibular movement cause impaired self-cleansing of the oral cavity and teeth by saliva and solid food. Food debris gets trapped on the splints and ligatures, serving as a fertile environment for the proliferation of aggressive microorganisms that cause a variety of complications, ranging from periodontal disease of the supporting teeth to the development of phlegmon and osteomyelitis.

It is necessary to rinse the oral cavity with antiseptic solutions not only after every meal, but also between meals and before bedtime. Oral irrigation can be performed, for example, using a rubber bulb syringe. In addition, it is mandatory to brush teeth with toothpaste and a toothbrush, use a toothpick to remove food debris, and massage the gums with the index finger several times a day.

An essential component of treatment is adequate nutrition. However, solid food intake is impossible for patients with mandibular fractures. A special diet has been developed for such patients—the jaw diet, which varies in consistency and components depending on the severity of the victim's general condition and the method of fragment fixation. The first jaw diet has the consistency of cream. It is prescribed for orthopedic fragment fixation for the entire duration of treatment. The second jaw diet (consistency of thick sour cream) is prescribed more frequently to patients after surgical treatment, as well as after the removal of elastic traction and in the first two days after splint removal. This diet serves as a transition to the general diet. In a hospital setting, the diet is prescribed by a physician, and the hospital cafeteria features a special menu and daily ration schedules.

Under outpatient observation, after discharge from the hospital, the patient must take care of preparing appropriate food themselves. It should be kept in mind that the food must be liquid and high-calorie, including proteins, fats, carbohydrates, and vitamins. Three liquids can be recommended to dilute (thin out) any food: milk, vegetable broth, or meat broth. They are used to dilute boiled strained vegetables (potatoes, carrots, beets are mandatory, greens, tomatoes, sweet peppers, etc.), strained pasta, and well-boiled grains (buckwheat and oatmeal flakes are especially useful), cottage cheese, and other products. To obtain a sufficient amount of protein, boiled meat passed through a meat grinder twice—and sometimes additionally strained through a sieve—is diluted in meat broth.

In addition, ready-to-eat products can be used: sour cream, cream, milk, kefir, juices, fruit and vegetable purees (preferably from fresh fruits and vegetables).

The use of vegetable oil in all dishes is mandatory, as it contains many unsaturated fatty acids, which have a beneficial effect on bone tissue regeneration.

Food is taken warm 5–6 times a day. If the dental arches are in tight contact (maxillomandibular splints), food is introduced using a feeding cup with a rubber tube into the gap behind the last tooth. If there is a dental arch defect (a tooth or several teeth are missing), it is used to introduce food through the feeding cup tube or using a spoon. In surgical treatment methods, when the mandible is not fixed to the maxilla, it is possible to eat using a regular spoon.

Medications in the form of tablets or dragees are crushed to a powdery state and dissolved in a tablespoon of warm water, after which they are administered using a feeding cup or spoon.

Alcohol intake is strictly prohibited during the treatment period; with such a meager diet, it is rapidly absorbed and causes severe intoxication up to the point of poisoning. Alcohol can provoke vomiting, which is life-threatening during maxillomandibular fragment fixation, as the patient, unable to open their mouth independently, may choke on their vomit.