Mandible fracture

Professor
Lika Karalashvili
 factors influencing displacement of a mandibular fracture

1. Direction and intensity of the traumatic force.

2. Site of fracture.

3. Direction of the fracture line.

4. Muscle pull exerted on the fractured fragments.

5. Presence or absence of teeth.

6. Extent of soft tissue wounds

 factors influencing displacement of a mandibular fracture

1- . If the strong force is directed at particular site, it can result first into direct fracture and also
into another indirect fracture on the opposite side. Depending on the direction of the fracture
line and muscle pull exerting on the fragments, the resultant displacement will be brought
about due to extensive tear of the ligaments as well as supporting soft tissues.

2. The body of the mandible is only lightly covered by the muscles which offer very little
protection. The ramus, however, is well-splinted by the masseter and medial pterygoid muscles.
Therefore, an extensive comminuted fracture in this region shows minimum displacement.

3. Presence or absence of teeth on the proximal segment of a fracture line can have influence
on the total amount of displacement of proximal segment. Teeth which are present on the
proximal segment may prevent displacement by occlusal contact with the maxillary teeth.

4. Extent of supporting soft tissue wound is also an important factor. Severe tear of the
musculature and overlying soft tissues permit wider displacement.
 classification
According by anatomical location

Rowe and Killey’s classification

A. Fractures not involving the basal bone—

are termed as dentoalveolar fractures.

B. Fractures involving the basal bone of the

mandible. Subdivided into following:
oSingle unilateral
o Double unilateral
o Bilateral
oMultiple
 classification
Dingman and Natvig classification by anatomic region
A. Symphysis fracture (midline fracture).
B. Canine region fracture.
C. Body of the mandible between canine and angle.
D. Angle region—triangular region bounded
by the anterior border of the masseter to the
posterosuperior attachment of the masseter.
E. Ramus region—bounded by the superior
aspect of the angle to two lines forming an
apex at the sigmoid notch.
F. Coronoid region.
G. Condylar fractures.
H. Dentoalveolar region.
 classification
Relation of the Fracture to the Site of Injury
Direct fractures.
 Indirect (countrecoup) fractures.
Completeness
•Complete and incomplete fractures.
Depending on the Mechanism
Avulsion fracture
 Bending fracture
 Burst fracture
 Countrecoup fracture
 Torsional fracture.
Number of Fragments
Single, multiple, comminuted, etc.
Involvement of the Integument
 Closed or open fractures.
 Grades of severity I to V.
Shape or Area of the Fracture
Transverse,
 oblique,
butterfly,
oblique surfaced
Diagnosis
The diagnosis of mandibular fractures must begin with a careful history and clinical
examination. Immediate attention must always be given to problems associated with
airway compromise and bleeding which may endanger the patient's life. Once the airway,
breathing and circulation have been adequately assessed, a quick neurologic function
evaluation should be performed. While taking history, information about the mode of
injury will often suggest a specific fracture pattern and may provide the surgeon with
valuable insight regarding the potential for concomitant injuries. Patients who sustain
fractures involving the mandible will often report a paresthesia or change in their
occlusion noted immediately after the traumatic event. The patient's past medical and
surgical history, medication use and known drug allergies should also be reviewed.
Temporomandibular joint dysfunction and any previous non-surgical or surgical treatment
should be carefully documented. When a mandibular fracture is suspected, meticulous
clinical examination of the maxillofacial region is critical and should be carried out prior to
the ordering of radiographic imaging studies.
Clinical examination
Without question, a change in occlusion is the most common physical finding in patients with
fractures of the mandible. When examining the occlusion, it is important to consider that the
patient may have had an abnormal dental or skeletal occlusal relationship (Class II or Class III)
prior to the injury. Changes in occlusion will likely accompany fractures of the mandible, but
may also be present in soft tissue trauma of the TMJ, fractures of the alveolus, dental
fractures or fractures of the maxilla. When the fracture traverses a region of the mandible
that includes the inferior alveolar nerve, some level of neurosensory disturbance involving
this nerve will result. Abnormalities in the mandibular range of motion or deviation of the
mandible are also indicative of fracture, as can be an inability to close completely. These
restrictions may also be the result of internal TMJ injury or hematoma. Sublingual ecchymosis
is highly suggestive of a fracture involving the mandibular arch. Another indication of fracture
is a bony step which is most easily recognized by careful palpation along the inferior border of
the mandible.

Symptoms of Mandibular Fractures

Pain, swelling, redness, and increased heat in the jaw or ear area.
Difficulties speaking, chewing, and breathing.
Numbness or bruising of your face and neck.
Loose teeth or change in teeth alignment.
Bleeding from the mouth.
 Treatment

Conservative therapy: Conservative Treatment with Splints

Supervised spontaneous healing: In crack Lateral compression splints: These are
fractures or greenstick fractures with no prepared and fixed to the mandibular
malocclusion, there is no need for fixation. body with circummandibular wiring
Closed reduction is simple and an attractive (for the children with complete
solution for them. Patient is advised to take lot deciduous dentition or with mixed
of fluids and soft food for 10 to 14 days. dentition).
 Treatment

Closed Reduction

Most of the mandibular fractures can be treated by closed reduction. It is often advocated,
because of its relative simplicity, low cost and noninvasive nature of treatment

Indications
1. Nondisplaced favorable fracture.
2. Grossly comminuted fractures.
3. Severely atrophic edentulous mandible.
4. Lack of soft tissue overlying the fracture site.
5. Fractures in children with developing teeth buds.
6. Coronoid process fractures.
 Treatment

Closed Reduction

In closed reduction procedure, either dental wiring or arch bars are applied to individual
dental arches and satisfactory occlusion is gained after reduction and IMF is carried out.
The recommended immobilization period for mandibular fractures correlates with the
bony callus stage of secondary bone healing. The average recommended immobilization
period for mandibular fractures is 6 weeks.
 Treatment

Open Reduction
Open reduction is not usually necessary. But, in multiple displaced fractures especially, at
the angle and parasymphysis region, open reduction may be needed. Intraosseous wiring
or bone plating should be done at the lower border of the mandible without damaging
the developing teeth buds.

Advantages of Open Reduction and Direct Fixation

1. Reduction and fixation is done under direct vision.
2. Stable fixation is achieved by better approximation of fractured fragments.
 Indications for Open Reduction
Open reduction of mandibular fractures previously was reserved for displaced fractures in
the angle and nontooth bearing regions of horizontal mandible. But with the advent of
antibiotic era and improved fixation methods, a new paradigm has emerged. Open
reduction and rigid or stable fixation may be indicated as the procedure of first choice,
when one or all of the following conditions are present:
1. Displaced unfavorable fractures.
2. Multiple fractures.
3. Associated midface fractures.
4. Associated condylar fractures.
5. When intermaxillary fixation (IMF) is contraindicated or not possible.
6. To preclude the need for IMF for patient comfort.
7. To facilitate the patient’s early return to work.
Contraindications for Open Reduction
Open reduction may be contraindicated, when:
1. GA or a more prolonged procedure is not advisable.
2. Severe comminution with loss of soft tissue.
3. Gross infection at the fracture site.
4. Patient refusing open reduction.
Intraoral Approach—Symphysis and Parasymphysis Region
Termed as anterior, vestibular approach or ‘degloving incision’. The lower lip is everted and
an incision is created at the depth of the vestibule in the mucosa with a scalpel or
electrocautery. Incision is curvilinear and extends anteriorly into the lip. The mentalis
muscle will be visible and the fibers are divided in an oblique fashion, leaving a margin of
the muscle attached to the bone for closure. The periosteum is divided and a subperiosteal
dissection is done to identify the mental nerves. Reduction and bone plate fixation is done.
Closure is completed in layers. A pressure dressing is secured to the area to prevent
hematoma formation and maintain the position of the mentalis muscle.
 Intraoral (Body, Angle, Ramus Region): Transbuccal Incision
Dissection in this region begins with a mucosal incision, that is started with a scalpel or
electrocautery, 3 to 5 mm below the mucogingival junction. The incision is created
perpendicular to the bone to avoid the mental nerve and it extends over the external
oblique ridge. The level of the incision at the external oblique ridge should not be carried
superior to the mandibular occlusal plane to avoid herniation of the buccal fat pad. The
incision is carried through the periosteum and a subperiosteal dissection is performed.
Periosteal elevator is used to expose the lateral border of the ramus. L-shaped retractors can
be used during the procedure. To protect the facial nerve, facial artery and vein, the
dissection should not violate the periosteal envelope. Reduction and fixation is done.
Closure is completed in one layer.
 Rigid fixation
Rigid fixation in the mandible refers to a form of treatment that consists of applying
fixation to adequately reduce the fracture and also permit active use of the mandible
during the healing process. The four AO/ASIF principles are;

anatomical reduction

functionally stable fixation

atraumatic surgical technique

immediate active function.

Although many osteosynthesis

systems are currently available to treat
mandibular fractures, the principles of
plate application are similar
 Rigid fixation

Compression plates
Compression plates cause compression at the fracture site making primary bone healing
more likely.

Reconstruction plates
Reconstruction plates are recommended for comminuted fractures and also for bridging
continuity gaps. These plates are rigid and have corresponding screws with a diameter of
2.3–3.0 mm. Reconstruction plates can be adapted to the underlying bone and contoured
in three dimensions.

A problem that may be associated

with conventional reconstruction
plates is loosening of the screws
during the healing process leading
to instability of the fracture.
 Rigid fixation

Locking reconstruction plates

introduced the titanium hollow-screw osteointegrated reconstruction plate . This system
achieves stability between the screw and plate by insertion of an expansion screw into the
head of the bone screw. This causes expansion of the screw flanges and locks them against
the wall of the hole in the bone plate.
These plates function as internal fixators by achieving stability by locking the screw to the
plate and allow greater stability as compared to conventional plates.
 Lag screw fixation
Lag screws can provide osteosynthesis of mandibular fractures . They work well in oblique
fractures and require a minimum of two screws. The lag screw engages the opposite cortex
while fitting passively in the cortex of the outer bone segment. This can be accomplished by
using a true lag screw or by overdrilling the proximal cortex. This causes compression of the
osseous segments and provides the greatest rigidity of all fixation techniques. The proximal
cortex should be countersunk to distribute the compressive forces over a broader area and
avoid microfractures. The anatomy of the symphyseal region of the mandible lends itself to
use of lag screws in a different technique
 Miniplates
Miniplates typically refer to small plates
with a screw diameter of 2.0 mm. These
plates have been shown to be effective in
treating mandibular fractures. Typically a
superior and inferior plate is required for
adequate fixation. An exception to this is in
the mandibular angle region where a
superior border plate placed at the point of
maximal tension is sufficient.
Bioresorbable plates
Bioresorbable plates are manufactured from varying
amounts of materials including polydioxanone (PDS),
polyglycolic acid, and polylactic acid. It has been
shown that the breakage of a poly-L-lactic acid
(PLLA) plate occurred at 50% of the yield strength
required to break a miniplate.
The common complication which we encountered
during their use was screw head fracture during
tightening. Consideration may be given for use in
pediatric patients with the understanding of the
possible complications.