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MandibularFractures
Author:DonaldRLaub,Jr,MD,MS,FACSChiefEditor:DeepakNarayan,MD,FRCSmore...
Updated:Apr08,2014

Background
Mandiblefracturesareafrequentinjurybecauseofthemandible'sprominenceandrelativelackofsupport.Aswith
anyfacialfracture,considerationmustbegivenfortheneedofemergencytreatmenttosecuretheairwayorto
obtainhemostasisifnecessarybeforeinitiatingdefinitivetreatmentofthefracture.

HistoryoftheProcedure
Thefirstdescriptionofmandibularfracturewasasearlyas1650BC,whenanEgyptianpapyrusdescribedthe
examination,diagnosis,andtreatmentofmandiblefractures.Manypatientsreceivedeitherimpropertreatmentor
notreatmentand,subsequently,died.Hippocrateswasthefirsttodescribereapproximationandimmobilization
throughtheuseofcircumdentalwiresandexternalbandaging.Theimportanceofestablishingproperocclusionfirst
wasdescribedinatextbookwritteninSalerno,Italy,in1180.Maxillomandibularfixationwasfirstmentionedin
1492,inaneditionofthebookCirugiaprintedinLyons.ChopartandDesaultuseddentalprostheticdevicesto
immobilizefracturesegments. [1]
Mostfracturetreatment,however,involvedsomeformofexternalbandageorwrap,occasionallyusedinconjunction
withabridlewire,untilthe19thcentury,whenGilmerreformedthetreatmentoffracturesbyfixatedfullarchbars
onthemandibleandthemaxilla. [2]In1888,Schedewasthefirsttouseasolidsteelplateheldby4screwsfor
fixation. [3]
ThetechniqueofrigidinternalfixationwasdevelopedandpopularizedbyArbeitsgemeinschaftfur
Osteosynthesefragen/AssociationfortheStudyofInternalFixation(AO/ASIF)inEuropeinthe1970s.Thebasic
principlesoftheAO,outlinedbySpiessl,callforprimarybonehealingunderconditionsofabsolutestability. [4]Rigid
internalfixationmustneutralizeallforces(tension,compression,torsion,shearing)developedduringfunctional
loadingofthemandibletoallowforimmediatefunction.Thisisaccomplishedbyinterfragmentarycompression
plates.Useaninferiorborderplatetocountercompressionforcesandasuperiorborderplateorarchbarstocounter
tractionortensionforcesatthesuperiorborder. [5]
AOreconstructionplatesalsoimpactedthemanagementofcomminutedandinfectedmandibularfracturesEllis
reporteda7.5%infectionrateintreatmentofmandibularanglefractureswithanAOreconstructionplatewithout
intermaxillaryfixation(IMF). [6]
DuringthesametimethatSpiesslwasexpoundingtheAOdoctrine,ChampyetalinFranceweredevelopingthe
conceptofadaptiveosteosynthesis.Champyadvocatedtransoralplacementofsmall,thin,malleable,stainlesssteel
miniplateswithmonocorticalscrewsalonganidealosteosynthesislineofthemandible.Champybelievedthat
compressionplateswereunnecessarybecauseofmasticatoryforcesthatproduceanaturalstrainofcompression
alongtheinferiorborder. [7]
These2changesofAOrigidinternalfixationandtheChampymethodofmonocorticalminiplatesrevolutionizedthe
treatmentapproachtomandibularfractures.Manyfracturespreviouslytreatedwithclosedreductionoropen
reductionwithwireosteosynthesisarenowcommonlytreatedwithopenreductionwithplateandscrewfixation.An
exampleofthisevolutionisthetreatmentofcomminutedmandibularfractures.Thesewerethoughttobetreated
bestbyclosedreductiontominimizestrippingoftheperiosteumofsmallbonefragments.Althoughthistreatment
modalityisstillused,rigidfixationnowenablesthecliniciantoavoidclosedreductionwiththeuseofreconstruction
platesandgoodsofttissuecoverage. [8]

Epidemiology
Frequency
Numerousinvestigatorshavereportedstudiesonpopulationsonallcontinentsfracturesofthemandiblehavebeen
reportedtoaccountfor3670%ofallmaxillofacialfractures. [9,10,6,11]Allreportsapparentlyshowahigher
frequencyinmalesaged2130y. [12]Othercontributingfactors,suchassocioeconomicstatus,environment,alcohol
use,andmechanisms,showgreatervariability. [13,14]

Etiology
Majoretiologicfactorsvarybasedongeographiclocation.InvestigatorsincountriessuchasJordan, [15]Singapore,
[16]Nigeria, [17]],[ [18]NewZealand, [19]Denmark, [20]Greece, [21]andJapan[22]reportedmotorvehicleaccidentsto
bethemostcommoncauseinreportsfromothercountriessuchasGreenland, [23]Finland, [24]Scotland, [25]
Sweden, [26]Bulgaria, [27]andCanada[11]foundassaultstobethemostcommonetiology.
ResultsintheUnitedStateshavebeendivided.In1982,Olsonandassociatesdemonstratedthatvehicular
accidentscaused48%offractures. [28]In1985,Fridrichandassociatesdemonstratedthataltercationsaccountedfor
47%offracturesandautomobileaccidentsfor27%. [29]Alsoin1985,Ellisetalreportedthat43%werecausedby
vehicularaccidents,34%werecausedbyassaults,7%wereworkrelated,7%occurredastheresultofafall,4%
occurredinsportingaccidents,andtheremainderhadmiscellaneouscauses. [6]
VaillantandBenoistdescribed14casesofgunshotinjuriestothemandible2childrenhadinjuriesthatresulted
fromaccidents,andtheadults'fractureswerecausedbysuicideorassault. [30]

Locationofmandibularfractures
Fridrichandassociatesshowedthatmostfracturesoccurinthebody(29%),condyle(26%),andangle(25%)ofthe
mandible.Thesymphysesaccountfor17%ofmandibularfractures,whereasfracturesoftheramus(4%)and
coronoidprocess(1%)haveloweroccurrencerates.Inautomobileaccidents,thecondylarregionwasthemost
commonfracturedsite.Inmotorcycleaccidents,thesymphysiswasfracturedmostoften.Whenassaultwasthe
cause,theangledemonstratedthehighestincidenceoffracture. [29]

Associatedinjurieswithmandibularfractures

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Fridrichandassociatesreportedthatinpatientswithmandiblefractures,43%ofthepatientshadanassociated
injury.Ofthesepatients,headinjuriesoccurredin39%ofpatients,headandnecklacerationsin30%,midface
fracturesin28%,ocularinjuriesin16%,nasalfracturesin12%,andcervicalspinefracturesin11%.Otherinjuries
presentinthisgroupwereextremitytraumain51%,thoracictraumain29%,andabdominaltraumain14%.Ofthe
1067patientsstudied,12(2.6%)diedoftheirassociatedinjuriesbeforethemandiblefracturecouldbetreated. [29]

Numberoffracturespermandible
Inpatientswithmandiblefractures,53%ofpatientshadunilateralfractures,37%ofthepatientshad2fractures,
and9%had3ormorefractures. [28]

Pathophysiology
Classificationofmandibularfractures
Seethelistbelow:
SimpleorclosedFracturethatdoesnotproduceawoundopentotheexternalenvironment,whetheritbe
throughtheskin,mucosa,orperiodontalmembrane
CompoundoropenFractureinwhichanexternalwound,involvingskin,mucosa,orperiodontalmembrane,
communicateswiththebreakinthebone
ComminutedFractureinwhichtheboneissplinteredorcrushed

Comminutedmandibularfracture.

GreenstickFractureinwhichonecortexoftheboneisbrokenandtheothercortexisbent
PathologicFractureoccurringfrommildinjurybecauseofpreexistingbonedisease
MultipleVarietyinwhichtwoormorelinesoffractureonthesamebonearenotcommunicatingwithone
another
ImpactedFractureinwhichonefragmentisdrivenfirmlyintotheother
AtrophicFractureresultingfromsevereatrophyofthebone,asinedentulousmandibles
IndirectFractureatapointdistantfromthesiteofinjury
ComplicatedorcomplexFractureinwhichconsiderableinjurytotheadjacentsofttissuesoradjacentparts
occursmaybesimpleorcompound

Classificationbyanatomicregion

Theanatomicregionsofthemandible.

Seethelistbelow:
SymphysisFractureintheregionofthecentralincisorsthatrunsfromthealveolarprocessthroughthe
inferiorborderofthemandible
ParasymphysealFracturesoccurringwithintheboundariesofverticallinesdistaltothecanineteeth

Rightmandibularparasymphysisfracture.

BodyFromthedistalsymphysistoalinecoincidingwiththealveolarborderofthemassetermuscle(usually
includingthethirdmolar)

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Rightsagittalmandibularbodyfractureandleftparasymphysisfracture.

AngleTriangularregionboundedbytheanteriorborderofthemassetermuscletotheposterosuperior
attachmentofthemassetermuscle(usuallydistaltothethirdmolar)

Rightmandibularbodyfracture.Leftmandibularanglefracturegoingthroughtooth#17.

RamusBoundedbythesuperioraspectoftheangletotwolinesforminganapexatthesigmoidnotch

Rightmandibularramusandleftmandibularparasymphysisfractures.

CondylarprocessAreaofthecondylarprocesssuperiortotheramusregion

Rightmandibularcondylarfracture.

CoronoidprocessIncludesthecoronoidprocessofthemandiblesuperiortotheramusregion
AlveolarprocessRegionthatnormallycontainsteeth

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Mandibularsagittalsymphysisfractureanddentoalveolarfracture.

Theeffectofmuscleactiononthefracturefragmentsisimportantinclassificationofmandibularangleandbody
fractures.Anglefracturesmaybeclassifiedas(1)verticallyfavorableorunfavorableand(2)horizontallyfavorableor
unfavorable.Themusclesattachedtotheramus(masseter,temporal,medialpterygoid)pulltheproximalsegment
upwardandmediallyandthesymphysisofthemandibleisdisplacedinferiorlyandposteriorlybythepullofthe
digastric,geniohyoid,andgenioglossusmuscles.

Themuscularforcesactinguponthemandible.

Whenthefracturesareverticallyandhorizontallyunfavorable,thefragmentstendtobedisplaced.

An"unfavorable"anglefracturewithdistractingmuscularforces.

Conversely,thesesamemusclestendtostabilizethebonyfragmentsinhorizontallyandverticallyfavorable
fractures.

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A"favorable"bodyfracturewithmuscularforcenottendingtodistractthefracture.

Condylarfracturesareclassifiedasextracapsular,subcondylar,orintracapsular.Thelateralpterygoidtendstocause
anteriorandmedialdisplacementofthecondylarhead.Fivetypesofcondylarfracturesaredescribedinorderof
increasingseverity:
TypeIisafractureoftheneckofthecondylewithrelativelyslightdisplacementofthehead.Theangle
betweentheheadandtheaxisoftheramusvariesfrom1045.
TypeIIfracturesproduceananglefrom4590,resultingintearingofthemedialportionofthejointcapsule.
TypeIIIfracturesarethoseinwhichthefragmentsarenotincontact,andtheheadisdisplacedmediallyand
forward.Thefragmentsareconfinedwithintheareaoftheglenoidfossa.Thecapsuleistorn,andthehead
isoutsidethecapsule.
TypeIVfracturesofthecondylarheadarticulateonorinaforwardpositionwithregardtothearticular
eminence.
TypeVfracturesconsistofverticalorobliquefracturesthroughtheheadofthecondyle.

Presentation
History
Seethelistbelow:
Acompletemedicalandpsychiatrichistoryisimportantfordiagnosisandfuturetreatmentofmandible
fractures.
Thoroughlyexplorepossiblebleedingdisorders,endocrinedisorders,orbonyandcollagenousdisordersprior
tosurgery.
Historyofpreviousmandibulartraumacanhelppreventmisdiagnoses.
Anypretraumatictemporomandibularjointdysfunctionneedstobedocumentedindetailpriortotreatment.
Thesource,size,anddirectionoftraumaticforcearehelpfulindiagnosis.
Fracturessustainedbyafisttendtohavesingle,simple,ornondisplacedfractureswhereaspatients
involvedinmotorvehicleaccidentssustaincompoundcomminutedfractures.
Localizedtrauma(eg,pipe,stick,hammer)tendstocauseasinglecomminutedfracturesincethe
forceisconcentratedinasmallarea.
Traumadistributedtoalargersurfaceareamaycauseseveralfractures(eg,symphysis,condyle)
secondarytodistributionoftheforcethroughoutthemandible.
Directionoftheforcecanhelpinmakingthediagnosisofconcomitantfractures.Traumadirectedto
thechinoftenresultsinasymphysealfracturewithconcomitantunilateralorbilateralcondylar
fractures.

Clinicalexamination
Seethelistbelow:
Advancedtraumalifesupportprotocol
Notefaciallacerations,swellings,andhematomas.Acommonsiteforalacerationisunderthechin,
andthisshouldalertthecliniciantothepossibilityofanassociatedsubcondylarorsymphysisfracture.
Frombehindthesupineorseatedpatient,bimanuallypalpatetheinferiorborderofthemandiblefrom
thesymphysistotheangleoneachside.Noteareasofswelling,stepdeformity,ortenderness.
Noteareasofparesthesia,dysesthesia,oranesthesiaalongthedistributionoftheinferioralveolar
nerve.Numbnessinthisregionisalmostpathognomonicofafracturedistaltothemandibular
foramen.
Standinginfrontofthepatient,palpatethemovementofthecondylethroughtheexternalauditory
meatus.Painelicitedthroughpalpationofthepreauricularregionshouldalertthecliniciantoa
possiblecondylarfracture.
Observeanydeviationonopeningofthemouth.Classically,deviationonopeningistowardtheside
ofthemandibularcondylefracture.Noteanylimitedopeningandtrismusthatmaybearesultof
reflexmusclespasm,temporomandibulareffusion,ormechanicalobstructiontothecoronoidprocess
resultingfromdepressionofthezygomaticboneorarch.
Changesinocclusionarehighlysuggestiveofamandibularfracture.Achangeinocclusionmaybe
duetoadisplacedfracture,fracturedteethandalveolus,orinjurytothetemporomandibularjoint.
Lookforintraoralmucosalorgingivaltears.Floorofthemouthecchymosismayindicateamandibular
bodyorsymphysealfracture.
Ifafracturesitealongthemandibleissuggested,graspthemandibleoneachsideofthesuspected
siteandgentlymanipulateittoassessmobility.

Indications
Theindicationsforclosedversusopenreductionhavechangeddramaticallyoverthelastcentury.Theabilitytotreat
fractureswithopenreductionandrigidinternalfixation(ORIF)hasdramaticallyrevolutionizedtheapproachto
mandibularfractures. [31,32]
Traditionally,closedreduction(CR)andORIFwithwireosteosynthesishaverequiredanaverageof6weeksof

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immobilizationbymaxillomandibularfixation(MMF)forsatisfactoryhealing.Difficultiesassociatedwiththis
extendedperiodofimmobilizationincludeairwayproblems,poornutrition,weightloss,poorhygiene,phonation
difficulties,insomnia,socialinconvenience,patientdiscomfort,workloss,anddifficultyrecoveringnormalrangeof
jawfunction.Incontrast,rigidandsemirigidfixationofmandiblefracturesallowearlymobilizationandrestorationof
jawfunction,airwaycontrol,improvednutritionalstatus,improvedspeech,betteroralhygiene,patientcomfort,and
anearlierreturntotheworkplace. [33,34,12]
Schmidtetal[35]andShettyetal[36]performedfinancialanalysiscomparingpatientstreatedwithclosedreduction
andMMFwiththosetreatedwithORIF,andfound,atleastwithinthepatientpopulationatriskformandible
fractures,thattheclosedtreatmentwasmorecosteffective.

Indicationsforclosedreduction
Seethelistbelow:
Nondisplacedfavorablefractures:Openreductioncarriesanincreasedriskofmorbidity,thususethesimplest
methodtoreduceandfixatethefracture.
Grosslycomminutedfractures:Generally,thesearebesttreatedbyclosedreductiontominimizestrippingof
theperiosteumofsmallbonefragments.
Fracturesinchildreninvolvingthedevelopingdentition:Suchfracturesaredifficulttomanagebyopen
reductionbecauseofthepossibilityofdamagetothetoothbudsorpartiallyeruptedteeth. [37]Aspecial
concerninchildrenistraumatothemandibularcondyle. [38]Thecondyleisthegrowthcenterofthe
mandible,andtraumatothisareacanretardgrowthandcausefacialasymmetry.Earlymobilization(710d
ofintermaxillaryfixation)ofthecondyleisimportant. [39]Ifopenreductionisnecessarybecauseofsevere
displacementofthefracture,theuseofresorbablefixationorwiresalongthemostinferiorborderofthe
mandiblemaybeindicated.
Coronoidfractures:Thesefracturesusuallyrequirenotreatmentunlessimpingementonthezygomaticarch
ispresent.
Treatmentofcondylarfractures:Thisisoneofthemorecontroversialtopicsinmaxillofacialtrauma. [40]
Indicationsforopenreductionarediscussedbelow.Ifcondylarfracturesdonotfallwithinthiscriteria,they
canbetreatedwithclosedreductionforaperiodof23weekstoallowforinitialfibrousunionofthefracture
segments.Ifthecondylarfractureisinassociationwithanotherfractureofthemandible,treatthe
noncondylarfracturewithORIF,andtreatthecondylarfracturewithclosedreduction.

Indicationsforopenreduction
Seethelistbelow:
Displacedunfavorablefracturesthroughtheangleofthemandible:Often,theproximalsegmentisdisplaced
superiorlyandmediallyandrequiresanopentechniqueforproperreduction. [41]
Severelyatrophicedentulousmandibles:Thesehavelittlecancellousboneremainingandminimal
osteogenicpotential,andfracturehealingmaybedelayed.EllisandPriceadvocateanaggressiveprotocolof
ORIFwithrigidfixationandacutebonegrafts. [42]Theydemonstratednocomplicationswiththisapproach,
despitetheadvancedageandmedicalcomorbiditiesofthispatientpopulation. [42]
Complexfacialfractures:Suchfracturescanbereconstructedbestafteropenreductionandfixationofthe
mandibularsegmentstoprovideastablebaseforrestoration.
Condylarfractures:Althoughstrongevidencesupportingopenreductionofcondylarfracturesislacking,a
specificgroupofindividualsbenefitfromsurgicalintervention.TheclassicarticlebyZideandKentlists
absoluteandrelativeindicationsforopenreductionofthefracturedmandibularcondyle. [43]Palmierietal
[44]andDeRiuetal [45]demonstratedbetterlongtermrangeofmotionandocclusioninpatientswith
condylarfacturestreatedwithORIFversusclosedreductionandMMF.
Absoluteindications
1. Displacementofthecondyleintothemiddlecranialfossa
2. Inabilitytoobtainadequateocclusionbyclosedtechniques[46]
3. Lateralextracapsulardislocationofthecondyle
Relativeindications
1. Bilateralcondylarfracturesinanedentulouspatientwhensplintsareunavailableorimpossible
becauseofsevereridgeatrophy

Mandibularfracture.CoronalCTscandemonstratingbilateralhighcondylarfractures.

2. Unilateralorbilateralcondylarfractureswhensplintingisnotrecommendedbecauseof
concomitantmedicalconditionsorwhenphysiotherapyisnotpossible
3. Bilateralfracturesassociatedwithcomminutedmidfacialfractures
Mandibularnonunionsrequireopenaccessfordebridementandsubsequentreduction. [47]
Malunionsafterimproperreductionoftenrequireosteotomiesthroughopensurgicalapproachestocorrect
mandibulardiscrepancies. [48]

Timingofopenreduction
Traditionalteachinghasbeenthatmandiblefracturesshouldbereducedwithin24hoursofinjury. [7]Recentstudies
haveshownnoincreaseincomplicationswithadelayofrepairbeyond24hours. [49,50,51,52,53,54]Billeretal
showednoincreaseininfectionsinrepairsdelayedover72hours,buttherewasanincreasedincidenceoftechnical
complications. [52]Barkeretalshowednocorrelationofcomplicationsanddelayofrepairofover2weeks. [54]

RelevantAnatomy
ThemandibleisaUshapedbonethemiddleportionistermedthesymphysis.Thehorizontalbodyofthemandible
bearsthetoothbearingalveolarprocess.Distally,thehorizontalbodyofthemandiblejoinstheverticalramusatthe

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angle.Theramushasboththecoronoidandcondylarprocesses.Thecoronoidisthesiteofinsertionforthe
temporalismuscle,whilethecondylarprocessarticulateswiththemandibularfossaeofthetemporalbone.

Theanatomicregionsofthemandible.

Contraindications
Contraindicationstoclosedreductionincludethefollowing(thesepatientsbenefitfromopenreductionandrigid
internalfixation[ORIF]):
Patientswithpoorlycontrolledseizurehistory
Patientswithcompromisedpulmonaryfunction(ie,moderatetosevereasthma,chronicobstructive
pulmonarydisease)
Patientswithpsychiatricorneurologicproblems
PatientswitheatingorGIdisorders
Workup

ContributorInformationandDisclosures
Author
DonaldRLaub,Jr,MD,MS,FACSProfessor,DepartmentsofSurgeryandPediatrics,UniversityofVermont
CollegeofMedicineMedicalDirector,VermontStateCleftPalateCraniofacialCenterMedicalDirector,
Children'sUpperExtremityCenteratFletcherAllenHealthCare
DonaldRLaub,Jr,MD,MS,FACSisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAssociationforHandSurgery,AmericanCleftPalateCraniofacialAssociation,AmericanCollegeof
Surgeons,AmericanSocietyforSurgeryoftheHand,AmericanSocietyofMaxillofacialSurgeons,American
SocietyofPlasticSurgeons,AssociationforAcademicSurgery,VermontMedicalSociety,AOFoundation,
AmericanAssociationofPediatricPlasticSurgeons,NortheasternSocietyofPlasticSurgeons
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
JaimeRGarza,MD,DDS,FACSConsultingStaff,PrivatePractice
JaimeRGarza,MD,DDS,FACSisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofOtolaryngologyHeadandNeckSurgery,AmericanCollegeofSurgeons,AmericanSocietyfor
AestheticPlasticSurgery,AmericanSocietyofMaxillofacialSurgeons,TexasMedicalAssociation,Texas
SocietyofPlasticSurgeons
Disclosure:ReceivednonefromAllerganforspeakingandteachingReceivednonefromLifeCellforconsulting
Receivedgrant/researchfundsfromGID,Inc.forother.
ChiefEditor
DeepakNarayan,MD,FRCSAssociateProfessorofSurgery(Plastic),YaleUniversitySchoolofMedicineChief
ofPlasticSurgery,WestHavenVeteransAffairsMedicalCenter
DeepakNarayan,MD,FRCSisamemberofthefollowingmedicalsocieties:AmericanAssociationforthe
AdvancementofScience,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanSocietyof
MaxillofacialSurgeons,AmericanSocietyofPlasticSurgeons,PlasticSurgeryResearchCouncil,RoyalCollege
ofSurgeonsofEngland,RoyalCollegeofSurgeonsofEdinburgh,IndianMedicalAssociation
Disclosure:Nothingtodisclose.
AdditionalContributors
JamesFThornton,MDAssociateProfessor,DepartmentofPlasticSurgery,UniversityofTexasSouthwestern
MedicalCenter
Disclosure:Nothingtodisclose.
Acknowledgements
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofpreviousauthors
RobertDavidNesbit,MDAdelRTawfilis,DDSDavidWKim,MDandPatrickByrne,MDtothedevelopment
andwritingofthisarticle.

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