Note carefully Zetterberg’s “OH CRAP” face.

 

As facial injuries go, the kind you’re likely to get while playing hockey is generally on the cringeworthy side of things. They bleed a lot, they bruise in a truly spectacular way, and they’re about as obvious as an injury can get. Luckily, they’re frequently quickly repaired with little to no time lost. Split lip? Stitched. Bloody nose? Packed. Tooth knocked out? Whatever.

Jaw fractures are an exception to the rule – they often don’t look like much, but they can be a difficult fix, and come with a long, annoying recovery. Detroit’s Patrick Eaves is finding all of this out the hard way after blocking a shot with his face in Saturday’s game against Nashville.

Eaves was hit by the puck near his right ear, and something you may have noticed while staring at yourself in the mirror (That’s normal, right? Everyone does that?) is that the ear is awfully close to the jaw. Something you may not have noticed is that your lower jaw – the mandible – is a pretty complicated piece of equipment. Not only does it hold your bottom teeth, it holds all of their nerves and blood supply, the nerve that provides sensation to your lower lip, and is the attachment point for some pretty important muscles, like the masseter (the one you chew with). It’s also worth noting that the fancy medical term for things relating to the chin area is ‘mental’, which is absolutely hilarious at 3am when you’re on hour 12 in the anatomy lab at medical school.

 

The red bits? Muscles go there.

 

The problems with breaking your jaw are for the most part obvious. You can’t chew or talk without ridiculous amounts of pain, your mouth won’t close properly, and it hurts like a bitch. The less obvious problems are the scary ones – if you interrupt the blood supply or nerves to your bottom teeth you’re going to end up with a mouth full of dead teeth. If you mess up the nerves you could also end up with lower lip that’s permanently numb.

Mandibular fractures are usually the result of a car accident or assault, and are most commonly through the body of the bone. If you’re really unlucky you can end up with a bilateral fracture (where the front of your mandible becomes essentially free-floating). The good news is mandibular fractures are usually unilateral. The bad news is they’re usually a surgical fix, and they’re a pain in the butt to heal.

 

Unilateral mandibular fracture

 

Treatment

Assuming the patient is stable (ie. not choking on their own teeth or blood), the first step in most (arguably any) mandibular fracture is to start them on antibiotics. The human mouth is a filthy, filthy place, and the last thing you want is mouth bacteria getting into an open wound. The repair of the mandible may be surgical or not, depending on the type and location of the fracture.

Closed reduction (non-surgical): MMF (mandibulomaxillary fixation) is basically having your jaw wired shut. This is a miserable existence. You can’t eat, you can’t keep your teeth clean, it’s hard to breathe, hard to sleep, and after four to six weeks of not being able to move your jaw, you’re looking at some pretty uncomfortable physical therapy. Not to mention living on Ensure shakes and puréed food sucks, and you’re going to end up losing weight. This is the treatment of choice for a few specific fracture situations, like non-displaced favourable fractures (fancy talk for a crack that hasn’t shifted the bone, and where the ends of the fracture aren’t being pulled apart by tension from the surrounding muscles). It’s also the treatment of choice for kids who are still growing, and for severely comminuted fractures (where the bone is essentially shattered so there’s not enough left to hold together with plates and screws).

There are multiple wiring methods to keep the jaw shut, the most common being arch bars (shown). These are metal bars that follow the regular contour of the jaw, held on by wires anchored to the teeth. Closure of the jaw is accomplished with more wires, or with elastic bands. The use of elastic bands allows for quick release in the event of choking or vomiting, but doesn’t provide as strong a closure.

 

If you look closely (which I wouldn’t do if I were you), you can see how nasty the teeth have gotten.

 

Open reduction: This is our old friend ORIF (open reduction/internal fixation), which is to say cutting your face open and putting it back together with plates and screws. This is often the preferred treatment method, as it’s a very stable repair and allows for a shorter amount of time spent with your jaw wired shut. The procedure begins with MMF to establish the correct occlusion (the way your teeth fit together). An incision is made either inside the mouth (which can actually be done under a local anesthetic), under the jaw, or near the ear, and the fracture is plated or screwed back together. The assumption is that you’ll be stuck in MMF less than four to six weeks, but of course everyone heals differently so that’s not always the case.

Internal fixation plates can range in size depending on how much weight or stress they have to bear, and more serious breaks may require multiple plates to achieve a good result (shown).

 

Post-repair x-ray showing the repair plate and MMF hardware

 

Incredibly lucky people: In rare cases a fracture may be mild enough to allow for neither MMF nor ORIF. In some cases you may just be on a soft diet and strict instructions not to use your mouth too much (I’m not going to make the obvious joke here, and neither should you).

In any mandibular fracture, teeth that are in the fracture line are removed unless they’re needed for the attachment of the apparatus to keep your jaw closed. In that case they’ll be used as anchors for the wires, then removed after the MMF is over. The point is that cracked teeth are better out than in – there’s no reason to add anything else to the mix that would provide a home for infection. Along those same lines, any badly rotted or previously damaged teeth should be removed at the time of repair. The importance of all this dental housekeeping is that mandibular fractures which haven’t healed properly are usually due to problems with infection (from lack of antibiotics or funky teeth).

 

Now what?

Eaves had his repair surgery on Monday, and the Red Wings have estimated he’ll be out for six to eight weeks. Why so long? You can count on weight loss when all you can take in is liquids. The other issue is that it’s all but impossible to work out with a mouth that won’t open. Backhand Shelf editor Justin Bourne is a veteran of the mandibular fracture, and noted that with his jaw wired shut he couldn’t even make it up the stairs to his third-story apartment without feeling suffocated.

Athletes in this situation are limited to very light workouts, like slow stationary biking, walking or very light weightlifting – nothing strenuous that would get the heart or respiratory rate up. Incredibly, despite the physical and diet restrictions (and the inevitable weight loss and deconditioning), Detroit’s Brad Stuart broke his jaw in early January, and was back on the ice in February sporting some stylish protective equipment.

 

Brad Stuart doesn’t want you touching his jaw.

 

With any sort of luck, Eaves can hope to bounce back as quickly as Stuart (likely with an equally attractive mask). In the meanwhile he has weeks of soup, suffocation, pity and misery ahead of him. Mandiblar fractures really stink. They stink almost as bad as Eaves’ mouth will after several weeks of being wired shut.