Chin trauma: A clue to associated

mandibular and cervical spine injury

Charles N. Bertolami, D.D.S., D.Med.Sc.,* and Leonard B. Kaban, D.M.D., M.D.,**
Farmington, Conn., and Boston, Mass.

Chin trauma, mandibular fracture, and cervical spine injury are often progressive components of a single
injury pattern. Knowledge of a commonly occurring sequence of damage in patients who have sustained
minor head trauma helps to minimize diagnostic omissions and provides a rational basis for deciding
how extensive the patient’s evaluation should be. Chin laceration associated with underlying skeletal
damage has been described previously, but its diagnostic significance seldom has been appreciated.
This report describes representative patients with fractures of the cervical spine and of the mandible
secondary to chin trauma and suggests a protocol for efficient diagnosis.

B lunt trauma to the chin may result in a spectrum
of injuries, ranging from minor lacerations to com-
pound fractures. The extent of soft-tissue and skele-
tal damage is related to the force and direction of
impact; a relatively large force seemsto be required
to produce a mandibular symphysis fracture,*
whereas lesser impacts generally result only in
soft-tissue lacerations. Cervical spine fracture is the
most serious component in the sequence of injury
and may be overlooked during early evaluation.
This report reviews the relationship between chin
trauma, mandibular fracture, and cervical spine
injury to aid in identifying frequently occurring
patterns of damage.
Case 1
A 20-year-old woman sustained multiple injuries in a
motor vehicle accident and was taken to a local hospital.
She had a 3 cm. chin laceration without malocclusion or
significant limitation of mandibular movement. The
remainder of the physical and laboratory examination
findings were within normal limits. Mandibular and
cervical spine radiographs were ordered, and the chin
laceration was sutured. After 8 hours, the radiographs
were reviewed and showed a nondisplaced fracture of the
right angle of the mandible through an impacted third
molar socketand a fracture of the second cervical vertebra
(Fig. 1).
*Department of Oral and Maxillofacial Surgery, School of
Dental Medicine, University of Connecticut.
**Department of Oral and Maxillofacial Surgery, Harvard
School of Dental Medicine, Children’s Hospital Medical Center,
Brigham and Women’s Hospital.
122
The patient was transferred to Brigham and Women’s
Hospital, and the mandibular fracture was treated by
closed reduction and immobilization. The neck was stabi-
lized with a cervical collar, and all fractures healed
without complications.
Case 2
A comatose3-year-old girl was admitted to the hospital
after a high-speed motor vehicle accident. She had a
depressedskull fracture, chin lacerations, a mobile mandib-
ular symphysis fracture, an open-bite, and retrognathism.
The lateral skull radiograph confirmed these findings and
also showed a fracture of the odontoid process(Fig. 2). A
tracheostomy was performed, the skull fracture was
reduced, and the patient was placed in cervical traction.
When her condition stabilized, the mandibular fractures
were treated by closed reduction and immobilization. After
lengthy hospitalization the central nervous system status
improved and patient made a full recovery.
Case 3
An unconscious 23-year-old white woman was found
in the rear seat of an automobile which had been involved
in a head-on collision. Originally she had been in the front
seat but was projected to the rear seat at the time of
impact. Examination revealed a massive degloving wound
of the scalp, fixed, dilated pupils, agonal respirations,
flaccid extremities, absence of deep tendon reflexes, a
nonresponsive sensory examination, chin laceration, and
a fractured mandibular right central incisor. Cervical
spine radiographs showed a fracture of the odontoid
process, a transverse fracture of the second cervical
vertebral body, and a fracture of the transverse process of
the tirst cervical vertebra (Fig, 3). An incidental finding
on the anteroposterior cervical spine film was a right
mandibular parasymphysis fracture (Fig. 4).
0030-4220/82/020122 + 05$00.50/0@ 1982 The C. V. Mosby Co.
Volume 53 Chitr frauma 123
Number 2

Fig. 1. Lateral spine radiograph demonstrating nondisplaced fracture of the right mandibular angle as
well as a fracture of the second cervical vertebra. Inset: Tomographic appearance of axis fracture.

Fig. 2. Odontoid fracture in a 3-year-old patient with a depressed skull fracture, mandibular symphysis
fracture, open-bite, and retrognathism.

DISCUSSION
Recognition of a predictable pattern of injury
associated with chin trauma enhances accurate
determination of the extent of damage. The cases
reported here exemplify a common relationship
between chin trauma and fractures of the man 3ible
and cervical spine.
The chin laceration has been described as a clue
to underlying skeletal damage.? Depending Ilpon
the direction and magnitude of the impact force:, the
124 Bertolami and Kaban
Fig. 3. Fracture of the odontoid process, transverse frac-
ture of the second cervical vertebral body, and fracture of
the transverse process of the first cervical vertebra.
spectrum of injuries includes disruption of the
symphyseal soft tissue, fractures of the mandibular
condyles, angles, symphysis, or parasymphysis, and
fracture of the cervical spine.
Mandibular symphysis fractures can be identified
by clinical examination. Important diagnostic crite-
ria include evidence of chin trauma, irregularity of
the occlusal plane, mobility of mandibular frag-
ments, crepitus, and mucosal laceration. The most
important clue may be the patient’s perception that
the “bite is off.” Coexistent fractures of the mandi-
bular angles or condyles may be less apparent.
Estimates of the frequency of secondary fractures
have ranged from 51 to 72 percent”. ‘. 9 with 20
percent involving the mandibular condyle and 52
percent involving the angle.3 Two commonly
observed patterns of injury include symphysis frac-
ture with unilateral or bilateral condylar fractures”
or a parasymphysis fracture with contralateral angle
fracture.”
Since cervical spine injury can occur in all types
of head and facial trauma,2, 6 it is not surprising that
concomitant mandibular fractures have been
described.7-10The management of such patients has
been specifically addressed,Ybut the cervical spine
fracture has generally been regarded as a separate
entity rather than as part of a single injury pattern
produced by one impact force.
The exact mechanisms of cervical spine injury
vary, but hyperextension and/or hyperflexion of the
0l-d SW’?&
February, I982
Fig. 4. Incidental finding of mandibular parasymphysis
fracture in anteroposterior cervical spine film.
neck are important factors.‘, I’ ly The probability of
combined mandibular and cervical spine injury is
greater in cases in which chin impact is known to
have produced hyperextension. The first and second
cervical vertebrae are particularly susceptible to
traumatic injury, with dorsal dislocation and odon-
toid (dens) fracture being produced by the displaced
anterior arch of the atlas during hyperextension.”
Although cervical spine injuries involving the odon-
toid process are rarely associated with injury else-
where in the spine,‘:’ unrecognized fracture can be
fatal because of compression of the cephalad spinal
cord. The large diameter of the cervical spinal canal
permits relatively severe compression before onset
of symptoms. Neither of the first two cases pre-
sented here exhibited symptoms of cervical spinal
cord compression; however, the patient presented in
Case 1 was at substantial risk because of an 8-hour
delay in identifying the cervical spine fracture. This
case emphasizes the importance of immediate
examination of radiographs despite minor superfi-
cial injury and lack of overt symptoms. In a retros-
pective study of thirty-seven multiple-injury pa-
tients, Chan and associate9 reported a failure to
Volume 53 Chin trauma 125
Number 2

diagnose more than 5 percent of all spinal fractures

at the time of initial clinical and radiographic
evaluation. Byrne and Woodward” described a
patient with mandibular fractures in whom an
odontoid process fracture was not recognized, and
Fein and colleagues”’ reported a patient with a
cornminuted mandibular fracture who experienced
late onset of neurologic symptoms secondary to
hemorrhage into the C6-7 disk space. Chin lacera-
tions associated with underlying injury have often
been described,“. x !’ but their diagnostic significance
has seldom been appreciated’ (Fig. 5).
In Case 1, avulsion of the vertebral arch of the
axis occurred, with possible displacement of the axis
(Fig. 1). Such fractures have been well docu-
mented’ i. li and represent hyperextension injuries.
Momentum imparted to the mandible during
impact was presumably followed by rebound cervi-
cal hyperextension and cervical spine fracture. The
presence of a chin laceration and right jaw pain
warranted a high index of suspicion for a hyperex-
tension pattern of injury and justified radiographic
examination of both the mandible and the cervical
spine.
The second case may be less typical because the
anterior fracture dislocation of the odontoid is
suggestive of a true flexion injury; hyperflexion of
the neck during deceleration results in cervical Fig. 5. Typical appearance of chin laceration associated
injury which is followed by impact and subsequent with underlying skeletal damage.
mandibular fracture. The situation described in
Case 3 is quite common; emergency room personnel when a history of hyperextensive impact force is
are generally attuned to the possibility of cervical given and clinical evidence of chin laceration, man-
spine damage in severely traumatized patients but dibular fracture, and/or neck pain exists, cervical
commonly overlook significant mandibular injury. spine radiographs are mandatory. The cervical spine
Awareness of common patterns of damage pro- films should be obtained and interpreted prior to
vides a basis for deciding how extensive a diagnostic additional radiographs or further manipulation.
assessment should be. Efficient diagnosis requires Such procedures should provide efficient and com-
identification of all injuries with minimal expendi- plete identification of all injuries while assuring
ture of resources; consequently, radiographs and rapid recognition of potentially life-threatening
other procedures should be confined to those which skeletal damage.
yield essential information. Prediction of a specific
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126 Bertolami and Kaban Oral Surg.
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Reprint requests to:
Dr. C. N. Bertolami
Department of Oral and Maxillofacial Surgery
University of Connecticut Health Center
Farmington. Conn. 06032