mandibular fractres

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Maxillofacial TraumaMaxillofacial Trauma

Mandibular FracturesMandibular Fractures

Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages

with two nutrient arteries

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Mandible in traumaMandible in traumaMandibular fracture is more common than middle Mandibular fracture is more common than middle third fracture third fracture (anatomical factor)(anatomical factor)

It could be observed either alone or in combination It could be observed either alone or in combination with other facial fractureswith other facial fractures

Minor mandibular fracture may be associated with Minor mandibular fracture may be associated with head injury owing to the cranio-mandibular head injury owing to the cranio-mandibular articulationarticulation

Mandibular fracture may compromise the patency of Mandibular fracture may compromise the patency of the airway in particular with loss of consciousnessthe airway in particular with loss of consciousness

Fracture of mandible occurred with frontal impact Fracture of mandible occurred with frontal impact force as low as 425 lb (190 Kg) force as low as 425 lb (190 Kg) {Condylar fracture}{Condylar fracture}

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Fracture of condyle regarded as a safety mechanism Fracture of condyle regarded as a safety mechanism to the patientto the patient

Frontal force of 800-900 lb (350-400 Kg) is required Frontal force of 800-900 lb (350-400 Kg) is required to cause symphesial fractureto cause symphesial fracture

Mandible was more sensitive to lateral impact than Mandible was more sensitive to lateral impact than frontal onefrontal one

Frontal impact is substantially cushioned by Frontal impact is substantially cushioned by opening and retrusion of the jawopening and retrusion of the jaw

(Nahum 1975(Nahum 1975))

Long canine tooth and partially erupted wisdoms Long canine tooth and partially erupted wisdoms represent line of relatively weaknessrepresent line of relatively weakness

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Anatomical considerationsAnatomical considerations

Attached muscles:Attached muscles:MasseterMasseterTemporalisTemporalisMedial and lateral Medial and lateral pterygoidpterygoidMylohyoidMylohyoidGeniohyoid and Geniohyoid and genioglosusgenioglosusanterior belly of anterior belly of digastricsdigastrics

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Blood supplyBlood supplyEndosteal supply via the ID artery and veinEndosteal supply via the ID artery and veinPeriosteal supply, important in aging due to Periosteal supply, important in aging due to diminishes and disappearance of alveolar diminishes and disappearance of alveolar arteryartery

Bradley 1972Bradley 1972

Nerve Nerve Damage of inferior dental nerveDamage of inferior dental nerveFacial palsy by direct trauma to ramusFacial palsy by direct trauma to ramusDamage of facial nerve in temporal bone Damage of facial nerve in temporal bone fracturefracture

Goin 1980Goin 1980

Damage to mandibular division of facial Damage to mandibular division of facial nervenerve

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Factors influenced site of fracture Factors influenced site of fracture and displacementand displacement

Anatomy of the Anatomy of the mandible and attached mandible and attached muscle (canine & muscle (canine & wisdoms)wisdoms)

Weakening areas of Weakening areas of mandible (resorption mandible (resorption and pathologyl)and pathologyl)

Direction of force of the Direction of force of the blowblow

Age of the patientAge of the patient

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Types of fractureTypes of fractureSimpleSimple

Greenstick fracture (rare, exclusively in children)Greenstick fracture (rare, exclusively in children)Fracture with no displacement (Linear)Fracture with no displacement (Linear)Fracture with minimal displacementFracture with minimal displacement

Displaced fractureDisplaced fracture

Comminuted fractureComminuted fractureExtensive breakage with possible bone and soft tissue Extensive breakage with possible bone and soft tissue

lossloss

Compound fractureCompound fractureSevere and tooth bearing area fracturesSevere and tooth bearing area fractures

Pathological fracturePathological fracture(osteomyelities, neoplasm and generalized skeletal (osteomyelities, neoplasm and generalized skeletal

disease)disease)

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Sites of fracturesSites of fracturesCondyle fractureCondyle fracture– Intracapsular fractureIntracapsular fracture– Extracapsular fractureExtracapsular fracture

High condyle neck fractureHigh condyle neck fracture

Low condylar fractureLow condylar fracture

Angle/ ramus fractureAngle/ ramus fracture (body (body fracture)fracture)

Canine regionCanine region (parasymphesial (parasymphesial fracture)fracture)

Midline fractureMidline fracture (symphesis (symphesis fracture)fracture)

Coronoid fractureCoronoid fracture (rare) (rare)

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Incidence of mandibular fracturesIncidence of mandibular fracturesBody fractures 33.6%Body fractures 33.6%

Subcondylar fracture 33.4%Subcondylar fracture 33.4%

Fractures at the angle 17.4%Fractures at the angle 17.4%

Alveolar fractures 6.7%Alveolar fractures 6.7%

Ramus fractures 5.4%Ramus fractures 5.4%

Midline fractures 2.9%Midline fractures 2.9%

Fracture of coronoid process 1.3%Fracture of coronoid process 1.3%Oikarinen & Malmstrom 1969Oikarinen & Malmstrom 1969

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Favourable or Favourable or unfavourableunfavourableThey can be vertically or horizontally in They can be vertically or horizontally in directiondirection

They are influenced by the medial pterygoid-They are influenced by the medial pterygoid-masseter “sling”masseter “sling”

If the vertical direction of the fracture favours the If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled linguallyposterior fragment will be pulled linguallyIf the horizontal direction of the fracture favours the If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled upward direction, the posterior fragment will be pulled linguallylingually

Favourable fracture line makes the reduced Favourable fracture line makes the reduced fragment easier to stabilizefragment easier to stabilize

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Effects of muscles on displacementEffects of muscles on displacement

Transverse midline fracture (symphesial) Transverse midline fracture (symphesial) stabilizes by the action of mylohyoid and stabilizes by the action of mylohyoid and geniohyoidgeniohyoid

Oblique fracture (parasymphesial) tends to Oblique fracture (parasymphesial) tends to overlap under the influence of muscles actionoverlap under the influence of muscles action

Bilateral parasymphesial fracture results in Bilateral parasymphesial fracture results in backward displacement associated with loss of backward displacement associated with loss of tongue control when the level of consciousness tongue control when the level of consciousness is depressedis depressed

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Condylar fracturesCondylar fracturesThe most common mandibular fracture The most common mandibular fracture

Unilateral or bilateralUnilateral or bilateral

Intracapsular or extracapsularIntracapsular or extracapsular

Antero-medial displacement is Antero-medial displacement is common but it may remain common but it may remain

angulated with the ramusangulated with the ramus

Dislocation of the glenoid fossa and Dislocation of the glenoid fossa and fracture of petrous temporal bone fracture of petrous temporal bone which is very rarewhich is very rare

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Sign and symptomsSign and symptoms

Swelling, pain, tenderness and restriction of movementSwelling, pain, tenderness and restriction of movement

Deviation of mandible towards the side of fractureDeviation of mandible towards the side of fracture

Gagging of occlussion (premature contact on the posterior Gagging of occlussion (premature contact on the posterior teeth) with bilateral condylar displaced or over-riding fracturesteeth) with bilateral condylar displaced or over-riding fractures

Displacement of mandible toward the affected sideDisplacement of mandible toward the affected side

Anterior open bite on opposite side of fractureAnterior open bite on opposite side of fracture

Laceration of EAM****Laceration of EAM****

Retroauricular ecchymosis****Retroauricular ecchymosis****

Cerebrospinal leak and otorrhea in association with skull base Cerebrospinal leak and otorrhea in association with skull base fracturefracture

Condylar fracturesCondylar fractures

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Sequlae of TMJ injurySequlae of TMJ injury

Artheritic changesArtheritic changes

Haemartherosis, fibrosis and aknylosisHaemartherosis, fibrosis and aknylosis

Meniscal damage and detachmentMeniscal damage and detachment

TMDTMD

Staph infectionStaph infection with condylar backward with condylar backward displacement and external auditory meatus injurydisplacement and external auditory meatus injury

MeningitisMeningitis with petrous temporal bone fracture and with petrous temporal bone fracture and intracranial involvementintracranial involvement


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Coronoid process fracture:Coronoid process fracture:

Rare fracture caused by direct trauma to Rare fracture caused by direct trauma to ramus and results from reflux contraction of ramus and results from reflux contraction of temporalistemporalis

Can be seen following operation of large Can be seen following operation of large ramus cystramus cyst

Elicit tenderness over the anterior part of Elicit tenderness over the anterior part of ramusramus

Development of tell-tale haematomaDevelopment of tell-tale haematoma

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Fracture of the ramus:Fracture of the ramus:Type I Single fractureType I Single fracture

Mimics low condylar fracture that runs Mimics low condylar fracture that runs below the sigmoid notchbelow the sigmoid notch

Type II comminuted fractureType II comminuted fracture

Common in missile injuries and appears to Common in missile injuries and appears to be with little displacement due to effects of be with little displacement due to effects of messeter and medial pterygoid musclesmesseter and medial pterygoid muscles

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Fracture of the angle and bodyFracture of the angle and bodyPain, tenderness and trismusPain, tenderness and trismus

Extra-oral swelling at the angle with obvious Extra-oral swelling at the angle with obvious deformitydeformity

Step deformity behind the molar teethStep deformity behind the molar teeth

Movement and crepitus at the fracture siteMovement and crepitus at the fracture site

Derangement of occlussionDerangement of occlussion

Intra-oral buccal and lingula heamatomaIntra-oral buccal and lingula heamatoma

Involvement of IDNInvolvement of IDN

Gingival tear if fracture in dentated areaGingival tear if fracture in dentated area

Tooth involvement and possible longitudinal Tooth involvement and possible longitudinal split fracturesplit fracture

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Midline fractureMidline fractureThe most common missed fracture (always The most common missed fracture (always fine crack)fine crack)

Can be symphesial or parasymphesial Can be symphesial or parasymphesial fracturefracture

Commonly associated with one or both Commonly associated with one or both condyles fracturecondyles fracture

Unilateral fracture leads to over-riding of Unilateral fracture leads to over-riding of the fragments and bilateral may contribute the fragments and bilateral may contribute in loss of voluntery tongue controlin loss of voluntery tongue control

Long canine tooth represent a weak area Long canine tooth represent a weak area and contributes to parasymphesial fracture and contributes to parasymphesial fracture

Rarely runs across mental foramenRarely runs across mental foramen

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Signs and symptomsSigns and symptoms

Pain and tendernessPain and tendernessSwelling and odemeaSwelling and odemeaDevelopment of step deformityDevelopment of step deformityMental anesthesiaMental anesthesiaHeamatoma in the floor of mouth and buccal mucosa Heamatoma in the floor of mouth and buccal mucosa Soft tissue injury of the chin and lower lipSoft tissue injury of the chin and lower lip

If associated with condylar fracturesIf associated with condylar fractures

Absence of condyle movement on the contrlateral sideAbsence of condyle movement on the contrlateral sideDeviation of mandibleDeviation of mandibleAnterior open biteAnterior open biteGagging of oclussionGagging of oclussionLimitation of mouth openingLimitation of mouth opening

Midline fracture

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Clinical assessment and diagnosis Clinical assessment and diagnosis

History of traumaHistory of trauma (traumatized patients with possible head injury) and facial (traumatized patients with possible head injury) and facial

injuriesinjuries

Clinical ExaminationClinical Examination▶▶ ExtroralExtroral

Inspection (assessment of asymmetery, swelling, ecchymosis, laceration Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut wounds)and cut wounds)

Palpation for eliction of tenderness, pain, step deformity and malfunctionPalpation for eliction of tenderness, pain, step deformity and malfunction

▶▶ Intra- and paraoralIntra- and paraoral bleeding, heamatoma, gingival tear, gagging of occlussion bleeding, heamatoma, gingival tear, gagging of occlussion

and step deformity and sensory and motor deficiencyand step deformity and sensory and motor deficiency

RadiographsRadiographs

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Radiographs Radiographs

Plain radiographPlain radiographOPGOPG

Lateral obliqueLateral oblique

PA mandiblePA mandible

AP mandible (reverse AP mandible (reverse Townes)Townes)

Lower occlusalLower occlusal

CT scanCT scan

3-D CT imaging3-D CT imaging

MRIMRI

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Principles of treatmentPrinciples of treatmentsimilar to elsewhere fractures in the bodysimilar to elsewhere fractures in the body

Reduction of fragments in good positionReduction of fragments in good position

Immobilization until bony union occursImmobilization until bony union occurs

These are achieved by:These are achieved by:Close reduction and immobilizationClose reduction and immobilizationOpen reduction and rigid fixationOpen reduction and rigid fixation

Other objective of mandible fracture treatment:Other objective of mandible fracture treatment:Control of bleedingControl of bleeding

Control of infectionControl of infection

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Definitive treatment Definitive treatment Soft tissue repairSoft tissue repair

DebridmentDebridmentIrrigation with saline and antibioticsIrrigation with saline and antibioticsClosure in layersClosure in layersDressing Dressing

Reduction and fixation of the jawReduction and fixation of the jaw▶▶ Close reduction and IMF (traditional method by means of Close reduction and IMF (traditional method by means of

manipulation)manipulation)▶▶ Open reduction and semi-rigid fixation (using inter-ossous Open reduction and semi-rigid fixation (using inter-ossous

wirings)wirings)▶▶ Open reduction and rigid fixation (using bone palates Open reduction and rigid fixation (using bone palates

osteosynthesis)osteosynthesis)

Objective:Objective: Restoration of functional alignment of the bone fragments in Restoration of functional alignment of the bone fragments in

anatomically precise position utilizing the present teeth for anatomically precise position utilizing the present teeth for guidanceguidance

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Close reductionClose reduction

Arch barsArch bars– JelenkoJelenko

– Erich patternErich pattern

– German silver notchedGerman silver notched

Cap splintsCap splints

▶▶ IMF prior to rigid fixationIMF prior to rigid fixation

▶▶ For the purpose of close For the purpose of close reductionreduction

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Bonded bracketsBonded brackets

IMF screwsIMF screws

Dental wiring:Dental wiring:Direct wiringDirect wiring

Eyelet wiringEyelet wiring

Local anesthesia orLocal anesthesia or sedationsedation

Minimal displacementMinimal displacement

IMF for 6 weeksIMF for 6 weeks Treatment can be performed Treatment can be performed

under GA or LA and when under GA or LA and when surgery is contraindicatedsurgery is contraindicated

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Fracture mandible in childrenFracture mandible in children


Open reduction and Open reduction and fixationfixation

Plating at the inferior Plating at the inferior borderborder

Resorpable platesResorpable plates

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Gunning’s splintGunning’s splint

Old modalityOld modality

Edentulous patientEdentulous patient

Rigid fixation is not Rigid fixation is not possiblepossible

To establish the To establish the occlusionocclusion

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Open reduction and fixationOpen reduction and fixation

Intraoral approachIntraoral approach

Extraoral approachExtraoral approach

▶▶ Submandibular Submandibular approachapproach

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Rigid fixationRigid fixation

Intraossous wiringIntraossous wiring

Plates and screwsPlates and screws

Kirchener wireKirchener wire

Lag screwsLag screws

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Reconstruction palateReconstruction palate

Severe trauma

Loss of part of the bone

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Intraoral approachIntraoral approach

Ramus incisionRamus incision

Extraoral approachExtraoral approachPreauricular approachPreauricular approach

Retromandibular approachRetromandibular approach

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IMFIMF

Transosseous wiringTransosseous wiring

Circumferential wiringCircumferential wiring

External pin fixationExternal pin fixation

Bone clampsBone clamps

Trans-fixation with Kirschner wiresTrans-fixation with Kirschner wires

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OsteosynthesisOsteosynthesis

Non-compression small platesNon-compression small plates

Compression platesCompression plates

MiniplatesMiniplates

Lag screwsLag screws

Resorbable plates and screwsResorbable plates and screws

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Teeth in the fracture lineTeeth in the fracture line

The fracture is compound into the mouthThe fracture is compound into the mouth

The tooth may be damaged or lose its The tooth may be damaged or lose its blood supplyblood supply

The tooth may be affected by some The tooth may be affected by some preexisting pathologypreexisting pathology

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Management of teeth retained in fracture Management of teeth retained in fracture lineline

Good quality intra-oral periapical radiographGood quality intra-oral periapical radiograph

Insinuation of appropriate systemic antibiotic Insinuation of appropriate systemic antibiotic therapytherapy

Splinting of tooth if mobileSplinting of tooth if mobile

Endodontic therapy if pulp is exposedEndodontic therapy if pulp is exposed

Immediate extraction if fracture becomes Immediate extraction if fracture becomes infectedinfected

Follow up for 1 year and endodontic therapy if Follow up for 1 year and endodontic therapy if there is a loss of vitalitythere is a loss of vitality

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Absolute indicationsAbsolute indicationsLongitudinal fractureLongitudinal fractureDislocation or subluxation from socketDislocation or subluxation from socketPresence of periapical infectionPresence of periapical infectionInfected fracture lineInfected fracture lineAcute pericoronitisAcute pericoronitis

Relative indicationsRelative indicationsFunctional tooth that would be removedFunctional tooth that would be removedAdvanced caries or periodontal diseases Advanced caries or periodontal diseases Doubtful tooth which would be added to existing Doubtful tooth which would be added to existing denturedentureTooth in untreated fracture presenting more than 3 Tooth in untreated fracture presenting more than 3 days after injurydays after injury

mandibular fractres

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