Maxillofacial Trauma

Management of Mandibular 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 trauma
Mandibular fracture is more common than middle
third fracture (anatomical factor)
It could be observed either alone or in combination
with other facial fractures
Minor mandibular fracture may be associated with
head injury owing to the cranio-mandibular
articulation
Mandibular fracture may compromise the patency of
the airway in particular with loss of consciousness
Fracture of mandible occurred with frontal impact
force as low as 425 lb (190 Kg) {Condylar fracture}
2

Fracture of condyle regarded as a safety mechanism

to the patient
Frontal force of 800-900 lb (350-400 Kg) is required
to cause symphesial fracture
Mandible was more sensitive to lateral impact than
frontal one
Frontal impact is substantially cushioned by opening
and retrusion of the jaw
(Nahum 1975)
Long canine tooth and partially erupted wisdoms
represent line of relatively weakness
3

Anatomical considerations
Attached muscles:
Masseter
Temporalis
Medial and lateral
pterygoid
Mylohyoid
Geniohyoid and
genioglosus
anterior belly of
digastrics
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Blood supply
Endosteal supply via the ID artery and
vein
Periosteal supply, important in aging
due to diminishes and disappearance
of alveolar artery
Bradley 1972

Nerve
Damage of inferior dental nerve
Facial palsy by direct trauma to ramus
Damage of facial nerve in temporal
bone fracture
Goin 1980

Damage to mandibular division of

facial nerve

Factors influenced site of fracture

and displacement
Anatomy of the
mandible and attached
muscle (canine &
wisdoms)
Weakening areas of
mandible (resorption
and pathologyl)
Direction of force of the
blow
Age of the patient
6

Types of fracture
Simple
Greenstick fracture (rare,
exclusively in children)
Fracture with no displacement
(Linear)
Fracture with minimal
displacement

Displaced fracture
Comminuted fracture
Extensive breakage with possible bone
and soft tissue loss

Compound fracture
Severe and tooth bearing area fractures

Pathological fracture
(osteomyelities, neoplasm and
generalized skeletal disease)
7

Sites of fractures

Condyle fracture

Intracapsular fracture
Extracapsular fracture
High condyle neck fracture
Low condylar fracture

Angle/ ramus fracture (body

fracture)
Canine region (parasymphesial
fracture)
Midline fracture (symphesis
fracture)
Coronoid fracture (rare)

Mandible Fracture
Frequency
Coronoid process
2%
Condyle
30%
Ramus
3%

Angle 25%
Body 25%

Parasymphyse
al / Mental
15%

Favourable or unfavourable
They can be vertically or horizontally in
direction
They are influenced by the medial pterygoidmasseter sling
If the vertical direction of the fracture favours the
unopposed action of medial pterygoid muscle, the
posterior fragment will be pulled lingually
If the horizontal direction of the fracture favours the
unopposed action of messeter and pterygoid muscles in
upward direction, the posterior fragment will be pulled
lingually

Favourable fracture line makes the reduced

fragment easier to stabilize

10

Effects of muscles on displacement

Transverse midline fracture (symphesial)
stabilizes by the action of mylohyoid and
geniohyoid
Oblique fracture (parasymphesial) tends to
overlap under the influence of muscles action
Bilateral parasymphesial fracture results in
backward displacement associated with loss of
tongue control when the level of consciousness
is depressed
11

Condylar fractures
The most common mandibular fracture
Unilateral or bilateral
Intracapsular or extracapsular

Antero-medial displacement is
common but it may remain
angulated with the ramus
Dislocation of the glenoid fossa and
fracture of petrous temporal bone
which is very rare
12

Condylar fractures

Sign and symptoms

Swelling, pain, tenderness and restriction of movement
Deviation of mandible towards the side of fracture
Gagging of occlussion (premature contact on the posterior
teeth) with bilateral condylar displaced or over-riding fractures
Displacement of mandible toward the affected side
Anterior open bite on opposite side of fracture
Laceration of EAM****
Retroauricular ecchymosis****
Cerebrospinal leak and otorrhea in association with skull base
fracture
13

Condylar fractures

Sequlae of TMJ injury

Artheritic changes
Haemartherosis, fibrosis and aknylosis
Meniscal damage and detachment
TMD
Staph infection with condylar backward
displacement and external auditory meatus injury
Meningitis with petrous temporal bone fracture and
intracranial involvement
14

Coronoid process fracture:

Rare fracture caused by direct trauma to
ramus and results from reflux contraction of
temporalis
Can be seen following operation of large
ramus cyst
Elicit tenderness over the anterior part of
ramus
Development of tell-tale haematoma
15

Fracture of the ramus:

Type I Single fracture
Mimics low condylar fracture that runs
below the sigmoid notch

Type II comminuted fracture

Common in missile injuries and appears to
be with little displacement due to effects of
messeter and medial pterygoid muscles
16

Fracture of the angle and body

Pain, tenderness and trismus
Extra-oral swelling at the angle with obvious
deformity
Step deformity behind the molar teeth
Movement and crepitus at the fracture site
Derangement of occlussion
Intra-oral buccal and lingula heamatoma
Involvement of IDN
Gingival tear if fracture in dentated area
Tooth involvement and possible longitudinal split
fracture

17

Midline fracture
The most common missed fracture (always
fine crack)
Can be symphesial or parasymphesial
fracture
Commonly associated with one or both
condyles fracture
Unilateral fracture leads to over-riding of
the fragments and bilateral may contribute
in loss of voluntery tongue control
Long canine tooth represent a weak area
and contributes to parasymphesial fracture
Rarely runs across mental foramen
18

Midline fracture

Signs and symptoms

Pain and tenderness
Swelling and odemea
Development of step deformity
Mental anesthesia
Heamatoma in the floor of mouth and buccal mucosa
Soft tissue injury of the chin and lower lip

If associated with condylar fractures

Absence of condyle movement on the contrlateral side
Deviation of mandible
Anterior open bite
Gagging of oclussion
Limitation of mouth opening
19

Clinical assessment and diagnosis

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

Clinical Examination
Extroral
Inspection (assessment of asymmetery, swelling, ecchymosis, laceration
and cut wounds)
Palpation for eliction of tenderness, pain, step deformity and malfunction

Intra- and paraoral

bleeding, heamatoma, gingival tear, gagging of occlussion
and step deformity and sensory and motor deficiency

Radiographs
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Radiographs
Plain radiograph
OPG
Lateral oblique
PA mandible
AP mandible (reverse
Townes)
Lower occlusal

CT scan
3-D CT imaging
MRI
21

Principles of treatment
similar to elsewhere fractures in the body
Reduction of fragments in good position
Immobilization until bony union occurs

These are achieved by:

Close reduction and immobilization
Open reduction and rigid fixation

Other objective of mandible fracture treatment:

Control of bleeding
Control of infection
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Definitive treatment
Soft tissue repair
Debridment
Irrigation with saline and antibiotics
Closure in layers
Dressing

Reduction and fixation of the jaw

Close reduction and IMF (traditional method by means of
manipulation)
Open reduction and semi-rigid fixation (using inter-ossous
wirings)
Open reduction and rigid fixation (using bone palates
osteosynthesis)
Objective:
Restoration of functional alignment of the bone fragments in
anatomically precise position utilizing the present teeth for
guidance
23

Close reduction
Arch bars

Jelenko
Erich pattern
German silver notched

Cap splints
MMF Screw

IMF/MMF prior to rigid fixation

For the purpose of close
reduction

24

Close reduction
Bonded brackets
IMF/MMF screws (Quick-Fix)
Dental wiring:
Direct wiring
Eyelet wiring
Local anesthesia or sedation

Minimal displacement
IMF/MMF (Quick-Fix) for 6 weeks
Treatment can be performed under GA or LA and
when surgery is contraindicated

25

Archbar vs MMF Screw (Quick-Fix)

Archbar
Less Convenience
Patients
Require teeth for fixation
Damage teeth and periodontal
tissue
Uncomfortable during the fixation
period
Difficult daily maintenance of oral
hygiene
Operator
Risk of blood-transmitted diseases
Need longer time to use

MMF Screw (Quick-Fix)

The Easy Alternative to
Arch Bars
Patented Auto-Drive self drilling

screws
Dramatically reduces application
time of MMF (only 5 minutes)
Simple
Minimizes risk of wire puncture
wound
Better oral hygiene maintenance
Ideal for edentulous or partially
edentulous

Fracture mandible in children

Close reduction
Open reduction and
fixation
Plating at the inferior
border
Biodegradable plate
and screw

27

Open Reduction and Fixation System

Intraoral approach

Extraoral approach
Submandibular
approach

28

Rigid Fixation System

Intraossous wiring
Plates and screws
2.0mm and 2.4mm
Standard plate and
screw
Locking plate and
screw

Kirchener wire
Lag screws
29

Plate 2.0mm and 2.4mm

30

Reconstruction palate
Severe trauma
Loss of part of the bone

31

Recon: TCA
Temporary Condyle Attachment (TCA)
Oncology/Ablation cases only
Maximum implantation of 1 year
Only OsteoMed Medically Tracked Device
3 Forms

No Left/Right
Unique Anatomical Shape
Adjustable

Reconstruction Locking Plate

Recon: Instruments
Instrumentation

Tip of gauge will

point to drill exit
point

Lag screw cannula

and depth gauge

The measurement
directly above the
drill entry point will
state needed length

Length of screw
needed to engage
both cortices

Recon: Instrumentation

Recon: Instrumentation
Instrumentation
Fx plate bending pliers
Roller benders
Used for major contours
Bends in the saggital and
lateral plane

Reconstruction bending
pliers
For intermediate bending

Bending irons
Bending slot in the tip
Finishing bends
Unusual or tight bends

Rigid Fixation System

Instrumentation
Fracture plate benders

Rigid Fixation System

Instrumentation
Taperlocktm screwdriver
body
Modular for all the
drivers stems, taps
and countersinks

Rigid Fixation System

Instrumentation
Calibrated plate
benders
Calibrated tick marks
to estimate step range
for L and Zed plates

Rigid Fixation System

Instrumentation
3 prong plate benders
Used with 10 and 16
hole plates to bend in
the saggital plane

Rigid Fixation System

Instrumentation
Right angle plate
benders
Places 90 degree angle
bends in plates
Used with L and Zed
plates for LeFort 1
osteotomies

Rigid Fixation System

Cannula/Trocar
Trocar is used to
penetrate soft tissue

Rigid Fixation System

Cannula/Cheek
retractor

Cannula/Drill guide

Rigid Fixation System

Instrumentation
Cheek Retractor U
Shape
Cheek Retractor
Cannula
Neutral Drill Guide

Rigid Fixation System

Instrumentation
Cannula/Depth gauge
Determines what size
screw needs to be used

Condylar fractures
Intraoral approach
Ramus incision
Extraoral approach
Preauricular approach
Retromandibular approach

46

IMF/MMF
Transosseous wiring
Circumferential wiring
External pin fixation
Bone clamps
Trans-fixation with Kirschner wires
Maxillo Mandibular Fixation Screw (Quick-Fix)

47

Osteosynthesis
Non-compression small plates
Compression plates
Mini plates (2.0mm and 2.4mm)
Lag screws
Biodegradable plates and screws
48

Teeth in the fracture line

The fracture is compound into the mouth
The tooth may be damaged or lose its
blood supply
The tooth may be affected by some
preexisting pathology
49

Management of teeth retained in fracture

line
Good quality intra-oral periapical radiograph
Insinuation of appropriate systemic antibiotic
therapy
Splinting of tooth if mobile
Endodontic therapy if pulp is exposed
Immediate extraction if fracture becomes
infected
Follow up for 1 year and endodontic therapy if
there is a loss of vitality
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Absolute indications
Longitudinal fracture
Dislocation or subluxation from socket
Presence of periapical infection
Infected fracture line
Acute pericoronitis

Relative indications
Functional tooth that would be removed
Advanced caries or periodontal diseases
Doubtful tooth which would be added to existing
denture
Tooth in untreated fracture presenting more than 3
days after injury
51

Complications
Airway esp with IMF (wire cutters and pre-op education)
Infection
Delayed and non-union
Inadequate immobilisation, fracture alignment
Inteposition of soft tissue or foreign body
Incorrect technique

Inferoir alveolar nerve damage

56%pre-treatment
19% post-treatment

Malocclusion
TMJ ankylosis esp intracapsular condyle #
52

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