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FRACTURE

MANDIBLE

FRACTURE
MANDIBLE
Rajesh R Yadav MS (ENT) DORL FCPS
Assistant Professor
Rajawadi Hospital
Formerly Registrar
Shri Harilal Bhagwati Hospital
Mumbai, Maharashtra, India

Akancha R Yadav BDS


Dental Consultant
Mumbai, Maharashtra, India

Prakash V Dhond MS (ENT) DORL


Honorary ENT Consultant
Shri Harilal Bhagwati Hospital
Mumbai, Maharashtra, India
Foreword

Chris De Souza

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Fracture Mandible
First Edition : 2012
ISBN 978-93-5025-801-9
Printed in

Dedicated to

Dinesh Yadav
In memory of my brother Dinesh Yadav, who is still
there with me and in me. His sweet memory always
keeps him alive. I miss him in every step of my life.
Rajesh R Yadav

Foreword
I am pleased and honored to write the foreword of this book on the Fracture
Mandible. My initial reaction was one of amazement when I saw how well the
book was written. When I finished reading it, I did feel that it was so well
written that it was definitely worth publishing and that all of us should possess
a copy of it and learn from it. It is lucid, well organized and extremely well
illustrated. It is also an unusual book dealing with a problem that so far was in
the realm of facial plastic surgery. The book is full of authors passion in
dealing with this problem and this passion is full of enthusiasm and deep insight.
I have long felt that otolaryngologists need to expand their expertise and deal
with facial plastic surgery in an in-depth way. As victims of high velocity
trauma find their way to emergency rooms all over globe we will definitely find
that this book become extremely relevant.
I look forward to seeing this book go into several editions and I wish to
see its scope and purpose expand.
I have no doubt that these talented enthusiastic surgeons and authors with
their passion and vision accomplish all of this.
Chris de Souza MS DORL DNB FACS
Honorary ENT and Skull Base Surgeon
Tata Memorial Hospital, Mumbai, Maharashtra, India
Consultant Otolaryngologist and Head Neck Surgeon
Lilavati Hospital and Holy Family Hospital
Mumbai, Maharashtra, India

Preface
In the modern era of rapid life, vehicular accidents and violence are a
common occurrence. Fractures of the mandible are gaining attention due to
the upward trend of accidents of two wheelers and other motor vehicles.
Before making an attempt of reducing the fracture, it is of utmost
importance to learn not only the relevant anatomy but also the development,
the dentition, the mechanisms of mandibular injuries and the different muscle
forces acting on different fragments of mandible.
Although management of mandibular fractures is routinely included in
the realm of plastic and reconstructive surgery or maxillofacial surgery, it
may not be possible to avail of such expertise all at times and in every region
of even a city like Mumbai, let alone managing such cases in more peripheral
hospitals. When faced with such situations, we ventured to learn the art of same
and, after managing more than two hundred cases of fracture mandible, we
thought of putting our experience on a paper so that others can benefit from our
work.
We do not claim that this is the best way, but we hope it can be of great
help to our friends working at different levels especially those with smaller,
private setups where, we will be happy to fill in the gaps in the required expertise.
We present here, to you, an overview of different methods of fixation,
anesthesia, anatomy and overall treatment. With our own experience, we felt
that even ENT Surgeons can deal with fractures of the mandible confidently.
The purpose of this book is to motivate more and more ENT Surgeons to do so.
We have avoided some of the techniques that are not often used now to fix
the mandible (e.g. external fixation techniques, nonrigid fixation techniques,
etc.) in order to stay abreast with the current trends in management.
We are grateful to our teachers, paramedical staff and patients who had
shown confidence in us.
We request the readers to point out any shortcomings in our present effort
to share our experience as it is a learning process and learning never stops.

Rajesh R Yadav
Akancha R Yadav
Prakash V Dhond

Acknowledgments
First and foremost, I would like to thank god for giving me the opportunity and
skill to do this work. I am thankful to my parents for always showering their
blessings on us. I am most grateful for the continued motivation and contribution
bestowed upon me by my co-editor that includes my mentor Dr Prakash V
Dhond and Dr Akancha R Yadav. The greater part of my experience comes from
Shri Harilal Bhagwati Municipal General Hospital, Mumbai, Maharashtra, India,
which for me is more than a temple. Here I had the good fortune of also having
the expert guidance of Dr Lalit Seth. My sincerest thanks go out to my patients
who have put their faith in my endeavors. I would like to thank the administrators,
particularly Dr Mahendra Wadiwala, Dr Dinesh Shetty, Dr Bhatt, Anesthetist,
Dr Bhavana Wadiwala and others, who trusted me and allowed me to manage
such cases here. I am thankful to my brother Sunil Yadav who helped me in
writing this book. I am grateful to Dr Ajay Haryani (Plastic Surgeon) from
whom I learnt the procedure.
I am grateful to Dr Deepak More and Dr Girish Surlikar, my buddies, my
friends, and everything who I trust will be always there for me in need.
Rajesh R Yadav

Contents
1. Dentition.................................................................................. 1
2. Fracture Healing and Biomechanics of Mandible ................ 6
3. Anatomy of Mandible........................................................... 12
4. Classification of Mandible Fractures .................................. 18
5. History and Clinical Examination........................................ 28
6. Radiology .............................................................................. 38
7. Preliminary Treatment .......................................................... 39
8. General Treatment of Fracture Mandible ............................ 42
9. Anesthesia for Fracture Mandible ....................................... 63
10. Specific Treatment of Fracture Mandible ........................... 74
11. Surgical Approaches ............................................................ 83
12. Fracture of Mandible in Children ....................................... 98
13. Postoperative Care ............................................................. 100
14. Complications ..................................................................... 104

Index ......................................................................................................... 111

Dentition / 1

Dentition

By 5 to 6 months of age the deciduous (temporary) teeth begins to erupt. The


lower central incisors are first teeth to erupt, the child has a total of 20
teeth, 10 in upper and 10 in lower dental arch by the age of 20 to 24
months. Deciduous teeth consists of incisors, the cuspid teeth, the deciduous
molars. The first permanent molar erupt behind the second deciduous molar
by the age of 6 years, at the age of 6 years permanent incisors erupt, at
the age of 9 years the permanent lateral incisors have erupted. At the age
of 10 to 11 years the deciduous molar teeth are replaced by the permanent
premolar teeth. At the age of 12 to 13 years the second permanent molar
teeth and permanent canine teeth have erupted. All permanent teeth have
erupted by the age of 14 years. When all the permanent teeth have erupted,
the adult has 32 permanent teeth, 8 in each quadrant.
Human primary or deciduous teeth eruption sequence
Maxillary
Central incisor
7 months
Lateral incisor
9 months
Cuspid
18 months
First molar
14 months
Second molar
24 months
Mandibular
Central incisor
Lateral incisor
Cuspid
First molar
Second molar

6 months
7 months
16 months
12 months
20 months

Human permanent teeth eruption sequence


Maxillary
Central incisor
78 years
Lateral incisor
89 years
Cuspid
1112 years

2 / Fracture Mandible

First premolar
Second premolar
First molar
Second molar

1011 years
1012 years
67 years
1213 years

Mandibular
Central incisor
Lateral incisor
Cuspid
First premolar
Second premolar
First molar
Second molar

67 years
79 years
90 years
1012 years
1112 years
67 years
1113 years

Fig. 1.1: Diagram illustrates various dental and oral terminologies

The Angles classification of malocclusion describes the skeletal relationship


between the teeth of maxilla and the mandible. The first step in identifying
abnormal occlusal patterns is to count the teeth, identifying those that are
missing and those that are present. Missing teeth in the partially dentulous
patients can produce changes in dental relationships. The relationships between
the central incisors of the mandible and the maxilla (the midline

Dentition / 3

relationship to the jaws) and the relationships of the cuspid and the first
molar teeth on each side serve as a principle guides to the establishment
of proper occlusion. By the study of models, the wear-facet pre-existing
occlusion can often easily be recognized. Where the teeth have habitually come
together are indicated by wear-facets. A patient who had a class III oclussion
relationship (skeletal malocclusion) before injury would be impossible to treat
by attempting to force a teeth into a neutral occlusal relationship. A class I
(neutral) occlusion is one of which the mesial buccal cusp of the upper
first molar occludes with the mesial buccal groove of the mandibular
first molar. The protruding or jetting type of jaw is known as class III
malocclusion (mesial occlusion), and the retrusive or undeveloped jaw is termed
class II malocclusion (distocclusion). Other abnormalities of occlusal
relationship in the lateral direction, referred to as crossbite. Openbite or absence
of occlusal contact in any area should be noted. This may occur laterally,
anteriorly or anterolaterally and may be unilateral or bilateral. In the injured
patient in whom teeth or segment of bone are missing, it may be difficult to
determine what the normal occlusal relationship should be.

Fig. 1.2: The occlusal relationships between the first molar


and cuspid teeth are indicated

4 / Fracture Mandible

Normally patient is helpful in advising the physician about the pre-exisiting


occlusal pattern and can comment on whether the teeth are coming together
properly. The perception of the patients is one of the most sensitive indicators
of proper allignment after jaw fracture treatment.

Fig. 1.3: Dental terminology

In head injury patients, when cooperation is not possible study models


become more important. Information may also be obtained from the patients
family, from old photographs that demonstrates the dentition or from dentist
or orthodontists who may have treated the patient previously or perhaps have
taken radiographs or have models. In older patients wear-facets on the teeth
give clues to pre-existing relationships. A patient in neutro-occlusion, for
instance, often shows more wear surfaces on the outer (labial) edges of the
lower anterior and on the under (lingual) surfaces of the maxillary anterior
teeth. The wear-facets shows that the teeth previously occluded in a normal
relationship. The patient with a severe retruded jaw usually has no wearfacets on the incisor edges of the lower anterior teeth. The patient who has
a protuding lower jaw may have worn surfaces on the outer anterior edge
of the maxillary teeth. Dental consultation may be helpful when the apparent
occlusion does not fit a precise, pre-existing pattern. It is important TO
RESTORE THE OCCLUSION IN FRACTURE OF THE JAWS TO
THE PREEXISTING DENTAL RELATIONSHIPS. Alternatively (and
less desirably) the occlusion should be brought into a range where it can
easily be corrected with orthodontic manipulation. It is necessary that the

Dentition / 5

teeth brought into the best possible occlusal relationship so that adequate chewing
surface and joint function occur after the reduction, fixation, and consolidation
of jaw fractures.
SUMMARY

Try to restore occlusion in fracture mandible to pre-existing dental


relationship.
Three types of occlusion
Class I: Normal occlusion
Class II: Disto-occlusion
Class III: Mesio-occlusion
Try to have knowledge of occlusion of pre-existing dental relationship before
operating fracture mandible.
Normal occlusion (pre-existing occlusion) is desired final result of the
treatment of fracture mandible.

6 / Fracture Mandible

Fracture Healing and


Biomechanics of
Mandible

Two types of bone found in the bodycortical and trabecular. Cortical bone
is dense and compact. It forms the outer layer of the bone. Trabecular bone
makes up the inner layer of the bone and has a spongy, honeycomb-like
structure. Throughout life, bone is constantly renewed through a two-part
process called remodeling. This process consists of resorption and formation.
During resorption, special cells called osteoclasts break down and remove
old bone tissue. During bone formation, new bone tissue is laid down to
replace the old. Several hormones including calcitonin, parathyroid hormone,
vitamin D, estrogen (in women), and testosterone (in men), among others,
regulate osteoclast and osteoblast function. In the process of fracture healing,
several phases of recovery facilitate the proliferation and protection of the
areas surrounding fractures and dislocations. The length of the process depends
on the extent of the injury.
The process of the entire regeneration of the bone can depend on the
angle or dislocation of fracture. While the bone formation usually spans the
entire duration of the healing process.
While immobilization and surgery may facilitate healing, a fracture
ultimately heals through physiological processes. The healing process is
mainly determined by the periosteum (the connective tissue membrane
covering the bone). The periosteum is one source of precursor cells which
develop into chondroblasts and osteoblasts that are essential to the healing of
bone. The bone marrow (when present), endosteum, small blood vessels,
andfibroblastsare other sources of precursor cells.

Phases of Fracture Healing


There are three major phases of fracture healing, two of which can be further
sub-divided to make a total of five phases;
1. Reactive phase
i. Fracture and inflammatory phase
ii. Granulation tissue formation

Fracture Healing and Biomechanics of Mandible / 7

2. Reparative phase
iii. Cartilage callus formation
iv. Lamellar bone deposition
3. Remodeling phase
v. Remodeling to original bone contour

Reactive
Afterfracture, the first change seen by light and electron microscopy is the
presence of blood cells within the tissues which are adjacent to the injury
site. Soon after fracture, the blood vessels constrict, stopping any further
bleeding.Within a few hours after fracture, the extravascular blood cells
form a blood clot, known as a hematoma. All of the cells within the blood
clot degenerate and die. Some of the cells outside of the blood clot, but
adjacent to the injury site, also degenerate and die. Within this same area,
thefibroblastssurvive and replicate. They form a loose aggregate of cells,
interspersed with small blood vessels, known as granulation tissue.

Reparative
Days after fracture, the cells of the periosteum replicate and transform. The
periosteal cells proximal to the fracture gap develop into chondroblasts which
formhyalinecartilage.Theperiostealcellsdistaltothefracturegapdevelop
intoosteoblastswhichformwovenbone.Thefibroblastswithinthegranulation
tissue develop into chondroblasts which also form hyaline cartilage. These
two new tissues grow in size until they unite with their counterparts from

Fig. 2.1: Healing of fracture (stage 1)

8 / Fracture Mandible

other parts of the fracture. These processes culminate in a new mass of


heterogenous tissue which is known as the fracture callus. Eventually, the
fracture gap is bridged by the hyaline cartilage and woven bone, restoring
some of its original strength.
The next phase is the replacement of the hyaline cartilage and woven
bone with lamellar bone. The replacement process is known as endochondral
ossificationwith respect to the hyaline cartilage and bony substitutionwith
respect to the woven bone. Substitution of the woven bone with lamellar
bone precedes the substitution of the hyaline cartilage with lamellar bone.
The lamellar bone begins forming soon after the collagen matrix of either
tissue becomes mineralized. At this point, the mineralized matrix is penetrated
by channels, each containing a microvessel and numerous osteoblasts. The
osteoblasts form new lamellar bone upon the recently exposed surface of the
mineralized matrix. This new lamellar bone is in the form of trabecular
bone.Eventually,allofthewovenboneandcartilageoftheoriginalfracture
callus is replaced by trabecular bone, restoring most of the bones original
strength.

Fig. 2.2: Healing of fracture (stage 2)

Fig. 2.3: Healing of fracture (stage 3)

Remodeling
The remodeling process substitutes the trabecular bone with compact bone.
The trabecular bone is first resorbed by osteoclasts, creating a shallow
resorption pit known as a Howships lacuna. Then osteoblasts deposit
compact bone within the resorption pit. Eventually, the fracture callus is
remodelled into a new shape which closely duplicates the bones original

Fracture Healing and Biomechanics of Mandible / 9

shape and strength. The remodeling phase takes 3 to 5 years depending on


factors such as age or general condition.
Healing of fracture bone is divided into two types:
a. Primary bone healing (Direct bone healing)
Gap healing
Contact healing
b. Secondary bone healing (Indirect bone healing)when semirigid
fixation, nonrigid fixation is done or patient fracture site is not surgically
treated.

Primary Bone Healing


It occurs when rigidity and anatomic reduction exists. It also takes place
in cancellous bone without rigid stabilization if no gross mobility is present.
Osteogenic cells and capillaries proliferate in the medullary bone on both
sides of fracture, forming new bone along the fracture site.
Primary bone healing is of two types:

Gap Healing
When small gaps occur between bone segments, within a few days after fracture,
gap healing begins at these points. Blood vessels from periosteum, endosteum
or haversian canals invade the gaps, bringing mesenchymal osteoblastic
precursors. Bone is deposited directly on the surfaces of the fractured segments
without resorption and without intermediate cartilage formation.

Gap < 0.3 mmlamellar bone forms directly

Gap between 0.3 to 1 mmwoven bone forms first followed by lamellar


bone.
Formation of lamellar bone occurs over a period of six weeks. Lamellar
bundles are oriented at right angles to the longitudinal axis of remaining
bone.

Contact Healing
It occurs through the formation of a bone metabolizing unit (BMU) a bone
remodelling unit (BRU) or a bone repair unit (BRU) which are all synonyms
for the newly forming (or regenerating) osteon. Advancing group of osteoclasts
followed by vessels and cells differentiated into osteoblasts and form new
bone.
Osteoclasts begin to cut away cores on either sides of fracture, progressing
towards the fracture side, through necrotizing bone and into opposing bone

10 / Fracture Mandible

ends proceding at a rate of 50 to 80 m/day. The result in bone provides a


pathway for vessels in growth and osteoblastic proliferation with formation of
newbone.Osteonformsatarateof1to2m/day.
Complete reconstruction of cortex takes place within six months. Gap
healing begins almost immediately in areas where a space of up to 1 mm exist
between fracture ends. Gaps are filled by appositional bone formation
remodeling then restores the architecture.
In areas of contact healing consolidation is achieved through a haversian
remodeling alone. Osteoclasts produce pathways between fracture fragments,
which are then bridged by newly formed regenerating osteons.

Factors Affecting Bone Healing


Local

Soft tissue trauma


Adequate reduction
Early fixation
Infection
Loss of tissue
Restoration of function

General

Ageyounger patients healing is faster


Nutrition
Medically compromised patientdiabetes melitis, HIV

Biomechanics of Mandible
This biomechanics of the mandible is a complex topic, there are various
forces which are applied on the mandible, e.g. biting force or muscle force. The
masticatory function of mandible is governed by influence of jaw opening
muscle inserted on the lingual aspect of the anterior part and the jaw closing
muscle on the posterior part of the mandible. The anatomical form of mandibular
body and the influence of muscular pull create characteristic stress within the
bone.
This forces applied on a mandible causes varying zones of tension and
compression force. Normally, on the superior portion of the mandible, tension
zone is applied and its maximum at the angle of mandible. On the inferior
border of mandible compression force is applied. A torsional force also exists
between the canines which increase its strength in midline. Osteosynthesis

Fracture Healing and Biomechanics of Mandible / 11

Fig. 2.4: Biomechanics of mandible

plates are applied in such a way to combat this compression and tension force.
Additional osteosynthesis plate is applied at midline to combat the torsional
force.
SUMMARY

Three phases of bone healing


1. Reactive phase
i. Fracture and inflammatory phase
ii. Granulation tissue formation
2. Reparative phase
iii. Cartilage Callus formation
iv. Lamellar bone deposition
3. Remodeling phase
v. Remodeling to original bone contour.
Primary aim of treatment of fracture mandible is to heal fracture mandible
by direct method (primary intension), i.e. gap healing or by contact
healing.
Proper reduction and maintenance of blood supply fasten bone healing.
Compression force are at lower border of mandible.
Tension force are at upper border of mandible.
Torsional force are at between canines and is maximum at midline.

12 / Fracture Mandible

Anatomy of Mandible

The mandible is a movable, predominantly U-shaped bone consisting of horizontal


and vertical segments, the horizontal segment consists of the body on each side
and the symphysis area centrally. The vertical segments consist of the angles
and the rami, which articulate with the skull through the condyles and the
temporomandibular joints. The mandible is attached to other facial bones by a
complex system of muscles and ligaments. The mandible articulates with the
maxilla through the occlusion of the teeth.
Though the prominence, position and anatomic configuration of the
mandible are such that it is one of the most frequently injured facial bones.

Fig. 3.1: Impact of trauma to various site

Trauma to maxillary area (B) absorbed direct trauma transmitting to skull


thus decrease impact to skull (cushion effect). Trauma to mandible (C) are
transmitted directly to the base of the skull through the temporomandibular
articulation. This in turn means that relatively minor mandibular fractures
may be associated with a surprising degree of head injury.

Anatomy of Mandible / 13

The mandible is a strong bone but has several areas of weakness that are
prone to fracture. The body of the mandible is composed principally of dense
cortical bone with a small substantial spongiosa through which blood vessels,
lymphatic vessels and nerves pass.

Areas of Weakness
Presence of Teeth
Body of the mandible has two components that is alveolar component which
carries the teeth and basal bones. The presence of teeth make the bony structure
weak, resulting alveolar fracture can occur independent of the basal bone. Teeth
which have long roots or that are embedded in the bone also weaken the structure,
external root of canine is the longest amongst all mandibular teeth, presence of
impacted or unerupted third molar also make the structure weak.

Neck of the Condyle


A thin neck of the mandibular condyle is an area of anatomical weakness and
get easily fractured in response to any direct or indirect trauma to the mandible.
Therefore, the mandibular condyle acts as a shock absorber in preventing the
intracranial injuries.

Symphysis of the Mandible


It is an area of fusion of two halfs of the mandible. The complete bony union
takes place at the end of the first year of life but this line of fusion remains
relatively weak point in the structure.

Angle of the Mandible


The trajectories of the mandible change their direction where the body and
ramus meet. The angle of mandible is anatomically as well as physiologically
weak structure. It is further weakened by the presence of an impacted tooth.
The attachment of the muscles on the mandible anterior to the angle pull it
downwards and backwards whereas the muscles attached posterior to the
angle pull upwards and forwards. This is a significant observation in reference
to the displacement of the fractured fragments.

Presence of Foramina
Weaken the structure but this point is contested by many workers as presence
of foramina add to the compactness of the bone. The fracture of the

14 / Fracture Mandible

mandible in the-tooth bearing area normally compound into the oral


cavity, and tooth in the line of fracture poses danger of being a source of
infection.

Mandibular Muscles
The various muscles attached to the mandible can be grouped as:
1. Muscles of facial expression
2. Muscles of mastication
3. Accessory muscles of mastication.

Muscles of Facial Expression


The muscle of facial expression have their origin from the bone and insertion
into the skin. These muscles play no role in the displacement of the fractured
mandible because to displace the bone muscle should have attachment on
fixed ends, i.e. a bone only.

Muscles of Mastication
Masseter, medial pterygoid, temporalis and external pterygoid are strong
muscles that help in closing and opening movements of the jaw. These
muscles play a major role in the fracture displacement especially of the angle
and condyle region. These muscles have strong tendonous attachment at the
site of origin and insertion.
The masseter and medial pterygoid muscles that form the sling of the
mandible displace the ramal fragment upward. They are aided in their action

Fig. 3.2A: Muscle attachment from lateral side

Anatomy of Mandible / 15

Fig. 3.2B: Muscle attachment from medial side

Fig. 3.2C: Muscle attachment (horizontal view)

by temporalis muscle as well. This fragment is usually displaced medially because


of the larger functional directional pull of the medical pterygoid muscle. The
medial pterygoid is more medially placed in comparison to the masseter muscle
that runs a rather vertical course.
The lateral pterygoid muscle that is attached to the neck of the condyle
and meniscus runs an anteromedial course up to the pterygoid plate and scaphoid
fossa thereby displacing the fractured condyle medially.

16 / Fracture Mandible

Accessory Muscles of Mastication


Muscles like mylohyoid, geniohyoid and digastrics have their origin from the
bone as well as insertion into another bone. These are also strong muscles
that pull the body of the mandible downward and medially. Symphysis is
pulled downward and backward by suprahyoid group of muscles.
Displacement of symphysis is also important because it leads to fall of
tongue and respiratory distress on account of the attachment of the tongue
to the mandible through genioglossus muscle.

Vascular Supply of Mandible


An effective blood supply is very much important factor in healing of a
fractured mandible bone. A mandible receives an endosteal supply via the
inferior dental artery and vein and these vessels are important in young
patients. Occasionally, a fracture of the body of the mandible will cause a
complete rupture of the inferior dental artery. Whereas this vessel usually
goes into spasm with spontaneous arrest of hemorrhage, this is not always the
case and prolific bleeding can occur which is difficult to control. In this rare
emergencies, the mandible fracture needs to be reduced immediately by
manipulation and the bone ends held in rough alignment by a wire ligature
around adjacent teeth. The other and more important blood supply to the
mandible derives from the periosteum. The periosteal supply becomes
increasingly important with ageing as the inferior dental artery slowly
diminishes in size and eventually disappears. This fact has considerable
significance for the healing of fractures in the elderly. Open reduction of
fractures in this age group involves elevation of periosteum from the bones
and further deprivation of blood supply to the fracture side with resultant
delayed or non-union.

Other Important Structure


Nerves
The inferior dental nerve is frequently damaged in fractures of the body and
angle of the mandible producing anesthesia or paresthesia within the distribution
of the mental nerve on the side of the injury. There are numerous reported
cases where the facial nerve has been damaged by direct trauma over the
mandibular ramus. Occassionaly, the mandibular division of the facial nerve is
damaged in isolation in association with a fracture of the body or angle.

Anatomy of Mandible / 17

Blood Vessels
Apart from hemorrhage from the inferior dental vessels which has been
mentioned, injury to major blood vessels is unusual in association with
mandibular fractures. A large sublingual hematoma may result from rupture of
dorsal lingual veins medial to an angle fracture. The facial vessels are vulnerable
to direct trauma where they cross the lower border of the mandible anterior to
the angle.

Temporomandibular Joint
Traumatic arthritis can occur without a fracture of the condyle, from indirect
transmitted violence. A synovial effusion occurs with widing of the joint
space on radiographs. Such a joint is extremely painful and mandibular
movement very restricted. When an intracapsular fracture of the condylar
head occur there may be direct involvement of the temporomandibular joint
with hemorthrosis. If this occurs in a young child it can lead to fibrous or bony
ankylosis of the temporomandibular articulation and destruction of the growth
potential of the condyle. Not infrequently a fractured condylar head is driven
backwards with sufficient force to tear, the adjacent external auditory
meatus and cause bleeding from the external ear. Such bleeding must be
carefully distinguished from the middle ear bleeding which signifies a fracture
of the base of the skull. Very rarely, the glenoid fossa is fractured as the
mandibular condyle is driven against this thin part of the temporal bone but
usually a fracture of the condylar neck prevents the other more serious injury
occurring.
SUMMARY

Trivial trauma can cause major injuries so all trauma should be taken
seriously.
Area of weakness are:
Presence of third molar (impacted)
Neck of condyle
Symphysis of mandible
Presence of foramina
Angle of mandible.

18 / Fracture Mandible

Classification of
Mandibular Fractures

Etiology of Fractures
Vehicular accidents and assaults are the primary causes of mandibular facial
fractures throughout the world. The other chief causes for these fractures are
Work related falls, sporting injuries and industrial trauma.

Vehicular accidents

Assaults

Work related causes

Falls

Sporting accidents

Miscellaneous causes
Thus the causes for maxillofacial fractures can be classified into:
a. Intrinsic causes
b. Extrinsic causes

Intrinsic Causes (Pathological Fractures)


Fractures that occur due to intrinsic weakness of the bone and not due to
force of impact. Pathological fractures occur because of underlying bony or
systemic disease that causes one, many, or all bones of the skeletal system
to be abnormal and thus more susceptible to fracture.
Pathological fractures may occur from any type of trauma.

Bending force

Torsional force

Compressive force or shearing force


Often the only force necessary to cause fracture is the persons weight,
especially in the mandible it may be chewing force, thus spontaneous fracture
occurs without overt trauma.
Pathological fracture may occur through any of the following types of
bony pathology.

Neoplasia

Bony cysts

Classification of Mandibular Fractures / 19

Osteoporotic bone

Osteoradionecrosis

Caused by secondary nutritional hyperparathyroidism

Localized bone infection (osteomylelitis)

Osteoporotic bone due to disuse following prolong external fixation or


removal of a rigid internal device.
Unfortunately, fracture may occur even as a sequela of improper implant
placement due to the tensile forces acting on the bone during mandibular
function.

Extrinsic Causes

Direct violence (fracture at the side of impact)


Indirect violence (fracture caused due to transmission of impact)
Bending forces
Torsional forces
Compression forces
Shearing forces

Factors affecting displacement of the fracture:

Muscular pull on the fractured segment

Force of the impact

Site and direction of the fracture line

Muscular teardamage of muscle attachment might lead to the displacement


of certain fracture (coronoid)

Presence of teeth in the posterior segmentpresence of posterior teeth


may prevent displacement due to contact with the occlusal surface of the
maxillary teeth.

Frequency of the Fracture


In general, incident of fractures of the mandibular body, condyle and angle are
relatively similar, while fractures of the ramus and coronoid process are rare.
The literature may suggest that following mean frequency percentages based on
location.
Condyle
- 29%
Angle
- 26%
Body
- 25%
Symphysis
- 15%
Ramus
- 4%
Coronoid process
- 1%

20 / Fracture Mandible

Fig. 4.1: Various site of fracture

The mandible is involved in 70% of patients with facial fractures. The number
of mandible fractures per patient ranges from 1.5 to 1.8. Mandible fracture
patterns of a suburban trauma centre found that violent crimes such as assault
and gunshot wounds accounted for a majority of the fractures (50%), while
motor vehicle accidents were less likely (29%).
The fractures of mandible area are classified based on the following
criteria:
a. Anatomical locations
b. Site of injury
c. Condition of the bone fragments at the fracture site
d. According to the direction of the fracture and favourability for treatment
e. According to severity of fracture
f. Presence or absence of teeth in the jaws
g. Clinical and radiological findings
1.
A.
B.
C.
D.
E.
F.
G.
H.

Classification based on anatomical location of the fractures


Fracture of the symphysis
Fracture of the canine region
Fracture of the body of the mandible
Fracture of the angle of the mandible
Fracture of the ramus
Fracture of the condyle
Fracture of the coronoid process
Fracture of the dentoalveolar

Classification of Mandibular Fractures / 21

2. Classification based on site of injury


a. Direct fracture
If the fracture occurs at the site of impact, it is labelled as direct fracture.

Fig. 4.2: Classification according to site of injury

b. Indirect fracture
An indirect fracture is the one that occurs away from the site of injury.
A trauma on side of the mandible can cause a direct fracture at the canine
region on the same side and an indirect fracture of the angle of the mandible
or neck of the condyle on contralateral side.
3. Classification based on the condition of the bone fragments at the site
of the fracture
This classification denotes the condition of the bone fragments at the fracture
site and hints at the severity of trauma and damage to the soft tissues.

a. Simple fracture
When there is break in
continuity of the bone without
any break in mucosa or skin
membrane thereby the fracture
fragments are not exposed to
the external environment such
a fracture is said to be simple
fracture.

Fig. 4.3: Simple fracture

22 / Fracture Mandible

b. Compound fracture
When the fractured ends of the bone
are associated with the break in
continuity of skin or mucous
membrane thereby communicating
with the external environment
through the wound then it is called
as compound fracture. As a rule,
Fig. 4.4: Compound fracture
fractures involving the tooth bearing
area are always compound fractures because they communicate with the oral
environment through gingival sulcus and periodontal ligament.

c. Comminuted fracture
When the bone is splintered into
more than two fragments, it is
called as comminuted fracture.
These are high impact injuries on
account of major trauma.

Fig. 4.5: Comminuted fracture

d. Greenstick fracture
The bone in children is soft elastic
and there occurs an incomplete
type of fractures at times.
These appear as a crack in the
bone in which only one cortex of
the bone is fractured whereas other
cortex is bent only as in the case
of a green stick of a tree.

Fig. 4.6: Greenstick fracture

4. Classification according to the direction of fracture line and


favorability for treatment
This classification is basically restricted to the fractures of the angle of the
mandible. The line of fracture is considered to determine the type of fixation
required. A fractured line is considered favorable if the muscular pull resists
the displacement of the fracture and in case the muscular pull distracts the
fractured fragment away from the line of fracture favouring displacement, it is

Classification of Mandibular Fractures / 23

labelled as unfavorable fracture. Fractures of the angle of the mandible are


influenced by the pull of the medial pterygoid, masseter and temporalis muscles
that tend to displace the ramus in an upward and medial direction. However, the
displacement of the fractured fragment is also influenced by the direction of
the force, magnitude of the impact, site of fracture, presence or absence of
teeth on each side of the fractured line.
These fractures can be classified as follows:
a. Horizontally favorable fractures
When viewed from the side of the fracture
line runs from the lower border of the
mandible extending upward and backward
to meet the upper border. The upward
displacement of the posterior fragment is
prevented by the anterior fragment.
Fig. 4.7: Horizontally favorable
fractures

b. Horizontally unfavorable fractures


When the fracture line runs from the lower
border of the mandible in an upward and
forward direction to meet the alveolar crest,
the upward movement of the posterior
fragment is called as horizontally
unfavorable fractures.

Fig. 4.8: Horizontally


unfavorable fractures

c. Vertically favorable fractures


When a fracture is viewed from above or
occlusal surface, the fracture line that runs
from buccal plate obliquely backwards
toward the lingual plate, it will resist the
medial displacement of the posterior
segment. Such a fracture is called as
vertically favorable fracture.
Fig. 4.9: Vertically favorable
fractures

24 / Fracture Mandible

d. Vertically unfavorable fracture


When a fracture line viewed from above,
extends from the buccal cortical plate
coming forward to join the lingual
cortical plate, it is labelled as vertically
unfavorable fracture because the posterior segment can easily get displaced
medially without any hindrance.
Fig. 4.10: Vertically unfavorable
fractures

5. Classification according to
presence or absence of teeth
Teeth may have important role to play in the management of the fracture since
occlusion is considered to be a guide in reduction. When a teeth are not present,
alternative method of treatment to simple wiring procedures are compelled to
be considered.
a. Class I When teeth are present on both sides of the fracture line.
b. Class II When teeth are present only on one side of the fracture line.
c. Class III When both the fragments on each side of the fracture line are
edentulous.

Fig. 4.11: Classification according to presence or absence of teeth

6. AO classification of mandibular fractures


This classification is based on clinical and radiological findings and describes
mandibular fractures along with soft tissue involvement. It has five components
depending on the types of fractures and other associated findings:
F
Number of fractures
L
Localization (site)
O
Occlusion
S
Soft tissue involvement
A
Associated fractures

Classification of Mandibular Fractures / 25

These components are described further as under:


Categories of fractures (F)
F0
Incomplete fractures
F1
Single fractures
F2
Multiple fractures
F3
Comminuted fractures
F4
Fracture with bone defect
Categories of localization (L)
L1
Precanine
L2
Canine
L3
Postcanine
L4
Angular
L5
Supra-angular
L6
Processus anticularis
L7
Processus muscularis
L8
Alveolar process
Categories of occlusion (O)
O0
No malocclusion
O1
Malocclusion
O2
Edentulous mandible
Categories of soft tissue involvement (S)
S0
Closed
S1
Open intraorally
S2
Open extraorally
S3
Open intra-extraorally
S4
Soft tissue defect
Categories of associated fractures (A)
A0
None
A2
Fracture and/ or loss of tooth
A3
Nasal bone
A4
Zygoma
A5
Le Fort I
A6
Le Fort II
A7
Le Fort III
Grades of severity (I-V)
Grade I and Grade II: These are closed fractures.

26 / Fracture Mandible

Grade III and Grade IV: These are open fractures


Grade V: This includes open fracture with a bone defect and fractures due to
gunshot.

Fracture Displacement
The pull of the muscles are described above and the direction of the line of the
fracture along with the intensity of the force hitting, the jaw are responsible for
the displacement of the mandibular fragments are described as under.

Fracture Condyle
There is no dislocation of the condyle if only a crack in a neck appears without
any tear in the capsule of the joint and periosteum of the bone but if there is
a fracture causing tear, anterior or medial dislocation of the condyle due to the
attachment of lateral pterygoid muscle will take place.

Fracture Angle of the Mandible


As explained earlier the unfavorable lines of the fracture from the treatment
point of view in the angle region favor superior and medial displacement of the
posterior segment. If the lines are favorable both horizontally and vertically,
there are minimal chances of displacement.

Fracture of Body of the Mandible


Both the elevators and depressor muscles play a role in displacement. The
mylohyoid muscles displaces the fragments medially and inferiorly. If the
fracture line is favorable, no displacement is seen unless there is some extreme
degree of violence. In unfavorable line of fracture both in horizontal and vertical
direction, i.e. if the fracture line is running from the lingual to buccal table in
an anterior direction and from lower to upper border again in an anterior
direction, the larger fragment of bone bearing the dental arch will be displaced
inferiorly and medially.

Fracture in the Canine Region


Bone is weakened in this region due to the long root of the canine hence,
fracture is more common in this region. The role of causing displacement is
played by depressor group of muscles of the jaw. Bilateral fractures cause a lot
of displacement depending upon the line of the fracture.

Classification of Mandibular Fractures / 27

If the fracture lines are running towards each other, i.e. converging lines
from labial to lingual table of the mandible as well as from superior to inferior
border, no displacement is expected. However, if the lines are unfavorable ie.
If the fracture lines are running divergently from labial to lingual table of the
mandible as well as superior to inferior border, the central fractured fragment
is pulled downward and backward by the mylohyoid, geniohyoid, digastrics and
genioglossus muscles. It is further complicated by the collapse of the fragment
on the lateral side, medially towards each other making a closed reduction very
difficult.

Fracture of Symphysis
A vertical midline fracture normally exhibits no displacement but if the fracture
line runs an oblique course, the balance of the muscles is disturbed causing
displacement of the fragments backwards and downwards.

Fracture of Ramus of the Mandible


The sling of the mandible formed by the masseter and medial pterygoid muscle
forms a thick protective case around the ramus and gives it a splinting action.
Generally talking, there is no dislocation of the fractured fragments of the
ramus but in injuries like gunshot wounds, there may be shattering of bone.

Fracture of Coronoid Process


Fractures of the coronoid process of the mandible are not commonly seen. In
cases there is a fracture with a tear in the periosteum, the tendonous attachment
of the temporalis muscle will pull the fractured coronoid process upwards.
SUMMARY

Vehicular accidents and assault are main cause of fractures.


Condyle and angle are the most common site of the angle
Any break in mucosa or a skin with fracture mandible is compound
fracture.
Favorable fractures are those fractures in which because of muscle pull
fractured fragments are brought together.
Unfavorable fractures are those fractures in which because of muscle pull
fractured fragments are pulled away from each other.

28 / Fracture Mandible

History and Clinical


Examination

History
History is very much informative in case of fracture mandible.

A detailed history of patient should be taken

Any pre-existing disease should be enquired like:


a. Systemic disease like diabetes and hypertension
b. Psyschiatric illness
c. Alcoholic withdrawal symptom
d. Epilepsy
e. Other endocrine, collagen diseases
In such patient like psyschiatric, alcoholic withdrawn, epilespsy, intermaxillary fixation should be avoided.

History regarding etiology of fracture should be elicited. In cases of high


velocity (RTA) suspect other fracture also in a body

Elicit regarding shape and size of the object causing injury, blow from
a broad, blunt object can cause several fractures while smaller well
defined object may cause single comminuted fractures. Since, impact of
force is concentrated in small area

Try to elicit the direction of impact. Anterior blow on a chin can cause
parasymphysis or bilateral condyle fracture.
The examination of a patient with the fracture of the mandible takes place
in three stages:
1. Instant and rapid assessment
2. General clinical examination of the patient
3. Local examination of the mandibular fracture

Instant and Rapid Assessment


Vehicular accident or assault patient who has a fracture mandible may sustain
injury on another part of the body which may constitute actual threat to a
life. This should be given a first priority than the facial trauma. It is always
necessary to make a rapid assessment and start the resuscitation of patient
first and then a detailed examination to be done.

History and Clinical Examination / 29

General Examination
Fractures of the mandible are, of course, caused by trauma of varying degrees
of severity and is reasonable to consider the possibility that this degree of
trauma may also have caused injury elsewhere in the body. This is especially
true if the patient has been involved in a accident such as road traffic
accident or a fall from a considerable height. However, a simple blow on the
lower jaw as a result of a fight or during the course of some game may result
in force being transmitted to the cranium which results in serious injury or
even death of the patient.
It is unusual for a patient with a mandibular fracture to be shocked and
if this condition is present some more serious injury should be suspected.

Local Examination of the Mandibular Fracture


Preparation for Examination
Before any detailed examination of the mandible, the face must be gently cleaned
with swabs to remove blood clot, road dirt, etc. inorder that an accurate evaluation
of any soft tissue injury can be made. The mouth similarly should be examined
for loose or broken teeth or dentures, and any congealed blood removed with
swabs held in nontoothed forces. During this gentle cleaning of face, the cranium
and cervical spine are carefully inspected and then palpated for signs of injury.
Finally, the mandibular fracture is examined in detail.

Extraoral Examination
Inspection
a. Swelling
Many of the physical signs of a fractured bone result from the
extravasation of blood from the damaged bone ends. This results in
very rapid early swelling from the accumulation of blood within the
tissues and later increase in the swelling resulting from increased
capillary permibiality and oedema. Swelling and ecchymosis indicate
the site of any mandibular fracture.
b. Deformity
There may be obvious deformity in the bony contour of the mandible.
c. Gait of patient
If considerable displacement has occurred the patient is unable to
close the anterior teeth together and the mouth hangs open. A conscious
patient may seek to support the lower jaw with his hand.

30 / Fracture Mandible

Palpation
Palpation should begin bilaterally in the condylar region and then continue
downwards and along the lower border of the mandible. If there is more
displacement it may be possible to palpate deformity or elicty bony crepitus.
Fractures of the body of the mandible are associated with injury to the
inferior dental nerve in which case there will be reduced or absent sensation on
one or both side of the lower lip.

Intraoral Examination

It is impossible to assist intraoral damage if the parts are obscured by


blood.
The buccal and lingual sulci are examined for ecchymosis. Submucosal
extravasation of blood is often indicative of underlying fracture, particularly
on the lingual side (Colemans sign).
Ecchymosis in the buccal sulcus is not necessarily the result of the
fracture as there is considerable soft tissue overlying the bone in this area
and extensive brusing may follow a blow over the lower jaw insufficient
to cause a fracture.
However, on the lingual side the mucosa of the floor of the mouth
overlies periosteum of the mandible which, if breached following a
fracture, will invariably be the cause of any leakage of blood into the
lingual submucuosa.
The occlusal plane of the teeth is next examined, or if the patient is
edentulous, the alveolar ridge.
It is important to examine all the individual teeth and to note any
luxation or subluxation along with missing crowns, bridges and/or fillings.
Individually fractured teeth must be assessed for involvement of the dentine
or pulp.
Possible fracture sites are gently tested for mobility by placing a finger and
thumb on each side and using pressure to elicit unnatural mobility. If the
patient can cooperate, he is asked to carry out a full range of mandibular
movements and any pain or limitation of movement recorded. Occasionally,
this detailed examination fails to confirm.
A mandibular fracture which is thought to be present from the history
and presence of hematoma. In such cases, the flat of both hands should
be placed over the two angle of the mandible and gentle pressure exerted.
This maneuver will always elicit pain when even a crack fracture is
present.

History and Clinical Examination / 31

Sign and Symptoms of Mandibular Fractures


Fracture of the mandible can be divided according to their anatomical location
into eight main types, these are:
1. Dentoalveolar
2. Condylar
3. Coronoid
4. Ramus
5. Angle
6. Body (molar and premolar areas)
7. Symphysis and parasymphysis
8. Multiple and comminuted fractures.

Dentoalveolar Fractures
Dentoalveolar injuries are defined as those in which avulsion, subluxation
or the fracture of the teeth occurs in association with the fractures of the
alveolus.

They may occur alone or in combination with some other type of mandibular
fractures.

Fracture of the crown of individual teeth may occur as a direct result of


trauma or by forcible impaction against the opposing dentition.

Meticulous dental examination is essential and any missing fragments of


crown or missing fillings noted. These may be invaded within the soft
tissues or more rarely swallowed or inhaled.

Fractures of the roots of the teeth may be present which are difficult to
diagnose clinically. Exclusively mobile teeth which do not appear to be
subluxed are suspect and should be earmarked for later periapical
radiographs.

Individual teeth may be missing and/or recent extraction wound suggest that
the tooth concerned has been knocked out.

Occasionally, molar and premolar teeth appear superficially normal but


close inspection reveals either a vertical split or a horizontal fracture just
below the gingival margin resulting from indirect trauma against the
opposing dentition or violent impact by a small hard object such as
missile.

Fracture of the alveolus may be present with or without associated injury


to the teeth.

32 / Fracture Mandible

Condylar Fractures
These are the most common overall fractures of the mandible and are once
most commonly missed on clinical examination. Condylar fracture may be
unilateral or bilateral, and they may either involve the joint compartment as
intracapsular fractures or the condylar neck when they are regarded as
extracapsular. The extarcapsular fracture may exist with or without dislocation
of the condylar head, and the upper fragment may either remain angulated on
the lower portion of the ramus or be displaced medially or laterally.

Unilateral Condylar Fractures

There is often swelling over the temporomandibular joint area and there
may be hemorrhage from the ear on that side. Bleeding from the ear results
from laceration of the anterior wall of the external auditory meatus, caused
by a violent movement of the condylar head against the skin in this region.
It is important to distinguish bleeding originating in the external auditory
canal from the more serious hemorrhage.
The haematoma surrounding a fractured condyle may track downwards
and backwards below the external auditor canal. This give rise to
ecchymosis of the skin just below the mastoid process on the same side.
This particular physical sign also occur with fractures of the base of the
skull when it is known as battles sign.
In the recently injured patient there is invariably tenderness over the
condylar area.
When post-traumatic edema is present it is difficult to palpate the condylar
head.
The mandible deviates on opening towards the side of the fracture, and there
is usually painful limitations of protusion and lateral excursion to the opposite
side.

Bilateral Condylar Fractures

As with the unilateral fracture overall mandibular movement is usually more


restricted extraorally then is the case with a unilateral fracture. As with the
unilateral fracture derangement of the occlusion will be found only if the
condyle is displaced on one or the other side causing shortening of the
ramus.
If both fractures have resulted in displacement of the condyles from the
glenoid fossa or overriding of the fractured bone ends, an anterior openbite
is found to be present.

History and Clinical Examination / 33

In all cases of bilateral fracture there is a pain and limitation of opening and
restricted protusion and lateral excursions.

Fracture of the Coronoid Process

This is a rare fracture.


The fracture can be caused by direct trauma to the ramus but is rarely
in isolation in the circumstances.
If the tip of the coronoid process is detached, the fragment is pulled
upward towards the infratemporal fossa by the temporalis muscle.
This is difficult fracture to diagnose clinically.
There may be tenderness over the anterior part of the ramus and hematoma.
Painful limitation of movement, especially protrusion of the mandible may
be found.

Fracture of the Ramus


The fractures of the ramus are not common and there are two main types.

Single Fracture
This is in effect a low condylar fracture with both the coronoid and condylar
process on the upper fragment.

Comminuted Fracture
Such a fracture always result from direct violence to the side of the face.

Swelling and ecchymosis is usually noted both extra and intraorally.

There is tenderness over the ramus and movements produced pain over
the same area.

Severe trismus is usually present.

Inability to close and open mouth.

Fracture of the Angle

There is usually swelling at the angle externally .


There may be obvious deformity. Within a mouth a step deformity behind
the last molar tooth may be visible which is more apparent if no teeth
are present in the molar region.
Anterior open bite in bilateral angle fracture.
Ipsilateral open bite in unilateral angle fracture.
Retrognathic or flattened appearance of lateral aspect.
Inability to close jaw causing premature dental contact.

34 / Fracture Mandible

Fracture of the Body (Molar and Premolar Regions)


The physical signs and symptoms are similar to those of fractures of the angle
as far as swelling and bone tenderness are concerned.

Inability to open or close mouth.

Ecchymosis, swelling, bone tenderness are similar to fracture of angle.

Dentate mandible even slight displacement of the fracture causes


derangement of the occlusion.

Premature contact occurs on the distal fragment because of displacing


action of the muscles attached to the ramus.

When there is a gross displacement, the inferior dental artery may be torn
and this can give rise to severe intraoral hemorrhage.

Crepitation on palpation.

Flattened appearance of lateral aspect of face.

Fracture of the Symphysis and Parasymphysis

These fractures are commonly associated with fractures of one or both


condyles.
Ecchymosis on floor of mouth.
The thickness of the anterior mandible between the canine regions often
ensures that these fractures are fine cracks which are little displaced and
may be missed if the occlusion is undisturbed locally.
The presence of bone tenderness and a small lingual hematoma may be only
physical signs. The fracture line is often oblique which allows overriding of
the fragments with lingual inversion of the occlusion on each side. As such
fractures are always the result of direct violence there is frequently associated
soft tissue injury of the chin and lower lip.
Posterior crossbite in symphysis fracture.
Posterior open bite or unilateral open bite in parasymphysis fracture.
Chances of paresthesia of lower lip as injury of mental nerve after emergence
from foramina.
Chances of airway compression in case of bilateral parasymphysis fracture
with loss of tongue and loss of consciousness.

Multiple and Comminuted Fractures


The physical signs of the multiple and comminuted fractures depend on the site
and number of fractures. Multiple and comminuted fractures result from extreme
direct violence and are usually associated with more severe soft tissue injury.
In general comminuted fractures of the ramus, angle and molar regions are not

History and Clinical Examination / 35

associated with gross displacement of the fragments. However, comminution


of the symphysis allows the lateral segments to collapse and presents a much
more serious problem of management.
SUMMARY

See the patient as whole


a. Resuscitate the patient first.
b. Mandible treatment can wait.
Detailed examination can give rough idea of site of fracture.
Swelling and ecchymosis suggest underlying fracture mandible.
Deviation from normal occlusion, open bite, crossbite suggest fracture
mandible.
Deformity, inability to close and open mouth suggestive of fracture mandible.
Look for inferior alveolar nerve or mental nerve paresthesia.

36 / Fracture Mandible

6
A
of
a.
b.
c.
d.
e.

Radiology

precise radiological diagnosis is very much important for treatment plan


fracture mandible. It depicts:
A exact relationship of teeth in fracture line
A type of fracture, simple or communited
Number of fractures
Area of fractures
Degree of displacements.

Radiographs of mandible is divided into:


a. Essential view
It is available in all departments of radiology and can be done easily on all
patients.
b. Desirable view
The equipments for the same view are not available in routine radiology
department. The equipments are of specialized nature and cannot be done on
severely injured patients.

Essential Radiographs
a. Left and right oblique lateral view of mandible
This view are used to demonstrate fracture of mandible ramus, body of
mandible and symphysis region.
b. Posteroanterior
This view demonstrates fracture of body and angle with the type of
displacements. An undisplaced fracture of condyle head is difficult to see
in this view as it is obscured by superimposition of mastoid process.
c. Reverse Townes projection
This projection is used to demonstrate fracture of condyle region. As this
avoid superimposition of mastoid bone.
d. Intraoral
1. Periapical films are required to demonstrate a relationship of teeth to
the line of fractures and any damage to the teeth itself.

Radiology / 37

2. Occlusal films can help us to evaluate the relationship of tooth root to the
fracture.

Desirable Radiographs
Panoramic Films
Panoramic films are useful in defining location and displacement of mandible
fracture. It has a accuracy rate of 92% for diagnosis of fracture. This films
give a best single overall view of mandible and are specially valuable for
demonstrating fracture in condyle region. The combination of posterioranterior view and a pantomogram obviates the need for further radiographs.
The sites in which mandible fractures are most commonly under diagnose
on this view are condylar angle and symphysis area especially if there is
some blurring by the patients movement or hardware.

Advantages

Simplicity of technique
Good details
Can visualize mandible and maxilla with root of teeth in one radiograph.

Disadvantages

Impractical for severely traumatic patients


Cannot be done in all hospital set ups
TMJ area, symphysis, dental and alveolar process region areas of which
fine details cannot be appreciated
Difficult to appreciate buccal and lingual bone displacement.

Computed Tomographic Scan


Indications
1.
2.
3.
4.
5.

In cases of multiple facial injuries


Cases of communated fractures
Cases of missile injuries
Cases of infected, malunion, nonunion fracture mandible
In cases of vertical split fractures

The accuracy rate of ct scan is around 92%. This offers a very little
advantage as a diagnostic tool in lower third of a face and are not justified
for isolated mandibular fractures on either clinical or economic ground. It
demonstrates detail of TM joint injury.

38 / Fracture Mandible

Three-dimensional CT Scan
It can be obtained to compare symmetry and volume of two side of bone of
face.
SUMMARY

Posteroanterior view and a pantogram is all what needed in a simple


case of fracture mandible.
Reverse townes view can be used for condyle fractures.
CT Scan indicated in complicated comminuted infected fracture mandible
and associated with facial injuries.

Preliminary Treatment / 39

Preliminary Treatment

Most of the fractures of the mandible encountered are associated with fracture
in other part of body or other injuries in body. It is not common for such
patients to suffer from shock and evidence of acute circulatory collapse in
itself is indicative of damage to other important structures. Trauma to the
mandible does, however, frequently cause concussions from transmitted violence
to the base of the skull.

Airway Maintenance
Relatively minor injuries which cause intraoral bleeding and fracture of teeth
or dentures can lead to airway obstruction in an unconscious or semi-conscious
patient. The essential first aid required consists of careful examination of the
mouth and the removal of all fragments of teeth, broken fillings and dentures.
If suction is available blood clots and the saliva should be evacuated and the
patient positioned so that further bleeding and secretions can escape from the
oral cavity. If the symphysis region is fractured and particularly if it is
comminuted there is some danger of the tongue falling back and obstructing
the airway in a patient who has lost voluntary control of the intrinsic
musculature. Occasionally a suture passed through the dorsum of the tongue
may assist in controlling its position. The most satisfactory posture for an
unconscious patient is lying on his side in the position used routinely during
recovery from a general anesthetic. This position should be opted for
transportation of a patient to an accident unit or another treatment center.

Blood Loss
Serious blood loss is not common in mandibular fractures. Considerable blood
loss can however occur, when there are extensive associated soft tissue
lacerations, obvious bleeding points such as the facial vessel should be
secured with artery forceps and a temporary dressing applied. Occasionally
brisk and persistent hemorrhage originates from a grossly displaced fracture of

40 / Fracture Mandible

the body of the mandible. This can only be controlled by manual reduction of
the fracture and temporary partial immobilization by means of a suture or wire
ligature passed around teeth on each side of the fracture line.

Soft Tissue Lacerations


It is desirable to close a soft-tissue wound within 24 hours of injury, as it is
often possible to gain access and to stabilize bone fragments through overlying
wounds, it is therefore advantageous, where possible, to combine soft tissue
repair with definitive treatment of the fracture. If this is not possible because
of the patients general condition the soft tissue must be dealt with separately
under local analgesia as soon as possible after injury. Before closing wounds
they must be cleaned to remove foreign material and so avoid subsequent
unsightly tattooing of the scar. Wounds should be gently scrubbed if necessary
with a mild antiseptic cleanser such as 1% cetavlon.

Support of the Bone Fragments


In most of the cases temporary splinting of the fragments is unnecessary and
such devices as the barrel bandage, webbing head cap with chin support, and
Elastoplast chin strap are not only superfluous but may in some instances may
cause the patient additional discomfort. If this type of first aid is applied it is
salutary to observe how often the patient experiences relief when it is removed.
Usually if any urgent immobilization of the fragment is required it is best to
carry out a definitive standard fixation technique such as an arch bar and not to
waste time with an ineffective temporary fixation.

Pain Control
The majority of the patients with mandibular fractures do not appear to suffer
much a pain, perhaps owing to the frequently associated neuropraxia of the
inferior dental nerve. Some mobile fractures of the body of the mandible are,
however, extremely uncomfortable and a potent cause of restlessness in a
cerebrally irritated patient. This situation is one of the rare indications for
giving priority to the immobilization of the mandible in the presence of other
serious injury.
It should be remembered that use of the powerful analgesics such as
morphine is contraindicated as they depress the cough reflex and respiratory

Preliminary Treatment / 41

center and also mask pain which can be diagnostically important (e.g. from a
ruptured spleen).

Control of Infection
All fractures of body of mandible involving teeth are compound fractures as
they are potential source of infection. Immediately injection augmentin should
be given every 12 hourly for first 2 to 3 days. There are also chances of
anaerobic infection. So injection metronidazole or oral metronidazole should
be administered.
SUMMARY

Treat the life-threatening condition first.


Treatment of fracture mandible can wait.

42 / Fracture Mandible

General Treatment of
Fracture Mandible

Principal of fracture treatment of the mandible do not differ from fracture


elsewhere in the body.

Principles
a. Fracture reduction and fixation to restore anatomical relationships;
b. Fracture fixation providing absolute or relative stability as the personality
of the fracture, the patient, and the injury requires;
c. Preservation of the blood supply to soft tissues and bone by gentle reduction
techniques and careful handling;
d. Early and safe mobilization and rehabilitation of the injured part and the
patient.

Reduction
Reduction of fracture means restoration of functional alignment of the bone
fragment. In the dentate mandible reduction must be anatomically precise
when teeth are involved and previously in a good occlusion. Less precise
reduction may be accepted if part of the body of mandible is edentulous or
there are no opposing teeth.
The presence of teeth provides an accurate guide in most cases by which the
fracture segment can be aligned. The teeth are used to access the reduction,
check alignment of the fragment and assist immobilization. However the occlusion
is used as a index for accurate reduction it is important to recognise any preexisting occlusion abnormality like anterior or lateral open bite were facets on
individual teeth can provide valuable clues to previous contact areas. The teeth
may on occasion be brought into contact during reduction and yet be occluding
incorrectly owing to lingual inclination of fractured segment.
Close reduction can be achieved in a case of mild displaced fracture. While
widely displaced, multiple or extensive comminuted fractures will require a
open reduction.

General Treatment of Fracture Mandible / 43

Immobilization
Following accurate reduction of fragment, the fracture side need to be
immobilized to allow the bone healing to occur. The period of the
immobilization depends upon the sites of fractures, the presence of teeth, age
of a patient and absence and presence of a patient.

Period of Mobilization
A simple guide for a period of immobilization for fracture of mandible of a
tooth bearing area are as follows
Normally a 3 weeks of immobilization is required in a case of young
adult with fracture of angle receiving early treatment in which teeth are
removed from the fracture line.
If
a. Tooth retained in fracture lineadd 1 week
b. Fracture at the symphysisadd 1 week
c. Age 40 years and overadd 1 or 2 week
d. Childrens and adolescentssubtract 1 week

Fig. 8.1: Type of fixation

Thus if there is a fracture in a symphysis in a 40-year-old patient with tooth


in a fracture line is retained then a 6 week immobilization is required (basic 3
weeks + 1 week for unfavourable site + 1 week for the age + 1 week for the
teeth retained in a line of fracture).
This rule is for guidance only. However, the fracture segments need to be
tested clinically before this immobilization is removed or released.

44 / Fracture Mandible

Intermaxillary Fixation
Arch Bars
Arch bars are preferred:

For temporary fragment stabilization in emergency cases before definitive


treatment

As a tension band in combination with rigid internal fixation

For long-term fixation in conservative treatment

For fixation of avulsed teeth and alveolar crest fractures

General Considerations
There are important points to consider before starting.
The occlusion must be checked. In the case of jaw malformations, such
as a deep bite deformity, it may be impossible to use arch bars.
One pitfall when using arch bars is the risk of contamination of
bloodborne infection from patients. Passing the wires to secure the arch bar
can result in a puncture or tear in the surgeons glove and the possibility
of disease transmission to the surgeon.

Fig. 8.2: Another way of arch bar application

General Treatment of Fracture Mandible / 45

D
E

Fig. 8.3: Fitting an arch bar. A Selection of appropriate length and contouring of
Erich arch bar. B Arch bar to be placed on a teeth for a proper measurement.
Extra length of the arch bar need to be trimmed and the posterior edge of the bar
need to be bend to prevent soft tissue injury. C and D Wire is passed above and
below the arch bar and tightened so as not to obstruct the lug. It is important to
make sure that this wires have been tightly applied by checking whether any
vertical movement of arch bar is possible. The wire used are of normally of 26
gauge. E Intermaxillary fixation can be established by either wires or by elastic

46 / Fracture Mandible

Wiring Techniques
Gilmer Method
This is the simplest way to establish
intermaxillary fixation by gilmer
method. This technique is simple and
effective but has a disadvantage that
mouth cannot be opened for
inspection of the fracture side
without removal of wire fixation. The
method consists of passing wire
ligatures around neck of available
teeth and twisting them in a clockwise
direction until the wire is tightened
around its tooth. After adequate
Fig. 8.4: Gilmers method of fixation
number of wire has been placed in
upper and lower teeth are brought into the occlusion and the wire are twisted
one upper to one lower wire. A stainless steel 24 gauge or 26 gauge wire are
usually applied.

Eyelet Method
This method of fixation has the
advantage that jaws may be open for
inspection by removal of only the
intermaxillary ligatures. This method
consists of twisting a 20 cm length
of 24 gauge or 26 gauge wire around
a instrument to establish a loop. Both
end of the wire are passed through
the interproximal space from the
Fig. 8.5: Eyelet method of fixation
outer surface. One end of the wire is
passed around the anterior tooth the other around the posterior tooth. One end
of the wire may pass through the loop. The eyelet should project in upper jaw
above and in lower jaw below the horizontal twist to prevent ends from impinging
on each other. After establishment of sufficient number of eyelets the teeth are
brought into occlusion and ligature are passed in loop fashion between one
upper and one lower eyelet. The interjaw wires are twisted tightly to provide
intermaxillary fixation.

General Treatment of Fracture Mandible / 47

Intermaxillary Fixation Screw Technique


Intermaxillary fixation screws has been introduced as labour saving device.
Intermaxillary fixation screws provide a rapid method of immobilization of
teeth in a good dentician in uncomplicated fracture types. The number and
position of this screws to be inserted is based on fracture types, the location
of fracture and the surgeon preference. Screw must be position superior to the
maxillary tooth roots and inferior to the mandible tooth root.

Fig. 8.6: Intermaxillary fixation screw technique

Disadvantages are minimal and a focused point of force application to


maintain good intermaxillary fixation. The focus point of force applied may
result in malocclusion by leaving the posterior dentician in an open bite.

Acrylic Splints
These are useful in maintenance of intermaxillary fixation and in establishing
the continuity of maxillary and mandibular dental arches in particular segment
of missing teeth can be compensated with suitable design splint. These are
useful in maintenance of intermaxillary fixation and in establishing the continuity
of maxillary and mandibular dental arches in particular segment of missing
teeth can be compensated with suitable design splint. Appliance of this types
are effective but requires detailed dental knowledge and skeletal models of
splint construction. The splints are fabricated by specially educated physician
with dental training, dental professional or dental laboratory.

Bonded Modified Orthodontic Brackets


This method is used in patient with minimal displaced fractures patient with
good oral hygiene. This require a help of orthodontic brackets which are
applied on a teeth then applying intermaxillary elastic bends. The orthodontic
brackets are prepared in maxofacial laboratory. This technique requires
complete elimination of moisture, this is not applicable in cases where there
is intraoral bleeding.

48 / Fracture Mandible

Nonrigid Osteosynthesis

Transosseous wiring
Circumferential wiring
External pin fixation
Bone clamps
Trans fixation with kirschner wires (K wires)
These fixation been non rigids require intermaxillary fixation.

Semirigid Osteosynthesis

Mandibular plate
Dynamic compression plate
Lag screw plate

Rigid Osteosynthesis

Reconstruction plate
Locking plate
Three-dimensional sturd

Miniplates
Mini plates are available in various shapes and lengths but can only be used with
non-locking screws. For mandible 2.5 mm or 2 mm plate are usually used. They
are most commonly used for fracture mandible.

Dynamic Compression Plates


Screws are need to be inserted bicortically when using plates.

Indications
Simple fractures mandible with excellent bony buttressing, are preffered for
dynamic plate compression plate.

Contraindications
Compression plating is contraindicated when there is not good bony buttressing
at the fracture site, as is seen in atrophic edentulous mandible fractures,
defect fractures, comminuted fractures, and other complex mandibular
fractures.

General Treatment of Fracture Mandible / 49

It is also contraindicated in:

Simple fractures with an extreme oblique pattern (sagittal fractures)

Fracture mandible with no good bony buttress

Atropic mandibular fracture

Edentulous fracture mandible

Defect fractures

Communited fractures

Other complex fractures

Compression Plating
Principle
As the eccentrically placed compression screws are tightened, the head moves
down the ramp and the bone is compressed together.
Diagrams showing two eccentrically screw inserted but not fully tightened
screws.

Fig. 8.7: The left screw is fully tightened


and thereby narrowing the gap

Fig. 8.8: Tightening the right screw


finally compresses the fracture
toward each other these compression screws are bicortical in nature

50 / Fracture Mandible

Compression Plating Technique


The compression plate is adapted by slightly over bending and eccentric hole
is drilled on either side of the fracture.

Fig. 8.9: Dynamic compression plate

Overbending
The plate must be overbend slightly
to close the lingual cortex. As
compression screws are tightened,
the slightly overbent plate closes
the lingual gap. If the plate is not
slightly overbent, the buccal cortex
will be well aligned but a gap
remains at the lingual cortex

Eccentric Drilling for


Compression

Fig. 8.10: Gap at lingual cortex if plate


not overbend

There are two drill guides used with compression plating. The yellow drill
guide is used for eccentric hole placement. The green drill guide is used for
neutral hole placement.
To drill eccentrically, the arrow on the yellow end of the drill guide must
point towards the fracture. The number close to the arrow shows the maximal
possible amount of bone movement upon screw insertion.
To place an eccentric hole, the proper gold drill guide must be used and the
arrow must point toward the fracture.
Once both the eccentrically placed screws are tightened, the fracture is
compressed. There is no need to compress the fracture additionally so the
remaining screws are placed in a neutral position. The appropriate green drill
guide is used to place the neutral screws
Screws used for the compression plate are bicortical in nature.

General Treatment of Fracture Mandible / 51

Option for Off-Angle Drilling


There are times when off-angle drilling
is necessary to avoid anatomic
structures such as tooth roots.
Although the hole does not have to
be drilled at 90 to the bone it should
not enter the fracture, and it should not
be angled in such a way that it interferes
with the adjacent screws.

Fig. 8.11: Off-Angle drilling

Lag Screws and Technique


Principles
This technique, advocated by niederdellmann et al is not commonly practice
because it is difficult to excecute and
it is easy to achieve in adequate fixation.

Fig. 8.12: Lag screw principle

Lag Screw Versus Lag Technique


Lag screws and the lag technique compress the fracture fragments together.
There are two methods by which to achieve this.
True lag screws (as illustrated here) have threads only on the terminal end
of the screw. Therefore, when inserted across a fracture, the threads of the tip
of the screw engage the far cortex and the head of the screw engages the near
cortex, causing compression of the fracture fragments upon tightening.
True lag screws are not available. Instead, a lag technique is used. The lag
technique involves overdrilling the near cortex to the size of the external
diameter of the screw. When the screw is inserted, it glides through this
overdrilled hole and the threads only engage the far cortex. As the screw is
tightened the head of the screw engages the near cortex and the fracture fragments
are compressed together.
If the near cortex is not overdrilled, the threads of the screw will engage
both near and far cortices preventing compression of the fracture fragments.

Indication
In parasymphysis/symphayis oblique fracture.

52 / Fracture Mandible

ContraindicationComminuted Fractures
Because lag screw technique compresses the fracture fragments together, the
use of this technique is contraindicated in comminuted fractures.

Lag Technique
The first step is to determine that
the drill is aligned perpendicular to
the bevel of the fracture. The near
cortex is perforated using a drill that
is the same diameter as the external
diameter of the screw. The gliding
hole is taken to the fracture site or
slightly beyond.
Fig. 8.13: Drill the near cortex to the
external diameter of screw
For example, when using a plating
system 2.4, the external diameter of
the screw is 2.4 mm. The drill used
to drill the near cortex is therefore
2.4 mm.
It may be difficult for the surgeon
to determine when the fracture site
has been reached with the gliding
hole. It may be advantageous to drill
past the fracture site rather than stay
short of the fracture site. If the
gliding hole is short of the fracture,
Fig. 8.14
compression of this fracture will not
be obtained with lag screw technique.
When drilling obliquely to the
surface of the bone, the point of the
drill can easily slide along the bone.
It is helpful to first orient the drill
perpendicular to the near cortex to
create an initial hole before
reorienting the drill perpendicular to
the bevel of the fracture.
A special drill guide is used to
Fig. 8.15
drill through the far cortex. This drill
Figs 8.14 and 8.15: Drill the far cortex to
guide has an extension on its tip that the inner diameter of the screw using
is the same diameter as the external centering drill guide

General Treatment of Fracture Mandible / 53

diameter of the screw. The drill


guide snugly fits into the hole
previously drilled through the near
cortex.
It is imperative that the fracture
fragments be properly reduced prior
to drilling through the far cortex..
The drill guide centers the drill
that will be used to drill the far
cortex with the hole through the near
Fig. 8.16: Special drill guide used to drill
cortex. This drill has the diameter
for far cortex
that is similar to the inner diameter
of the screw. For instance, when using a 2.4 mm screw, a 1.8 mm drill is used
to drill the far cortex.
When drilling, it is difficult to irrigate the tip of the drill. Therefore, it is
imperative that the drill be repeatedly withdrawn so that the irrigant effectively
cools the tip of the drill and washes away bony debris.

Determine the Screw Length


A depth gauge is used to determine
the screw length. It is important to
assure that the tip of the screw
completely engages the far cortex.
Because self-tapping screws have a
point on their tips, it is important
that the tip of the screw completely
exits the far cortex so that the screw
Fig. 8.17: Determine screw length
threads engage completely. Therefore, it is always better to select a
screw that is slightly longer than the measurement recorded with the depth
gauge.

Screw Insertion
The proper length screw is inserted
and tightened. One should observe
the near cortex as the screw is
tightened to assure that cracking or
crazing does not occur from overtightening.

Fig. 8.18: Screw insertion

54 / Fracture Mandible

Countersink Near Cortex


A countersinking tool is used to create a platform in the near cortex, these
countersinking should be done by hand instrumentation. Use of power
instruments can easily penetrate the outer cortex.
The hole created by the
countersinking tool provides a
platform into which the undersurface of the head of the screw
will intimately contact when the
screw is tightened.
Failure to perform proper
countersinking causes an
Fig. 8.19: Improper countersinking
eccentric force which can displace the fracture fragments upon
tightening the screws.
The medullary bone offers no
resistance to the head of the
screw. Therefore, it is imperative
that countersinking does not
remove all of the cortical bone
around the circumference of the
head of the screw. Otherwise, as
Fig. 8.20: Head entering the medullary space
the screw is tightened its head
will enter the medullary space and provide no compression of the fracture
fragments
Properly applied lag screw resulting in interfragmentary compression.

Locking Plates
Locking plates are available in a variety of plate thicknesses (referred to as
profile). All locking plates can hold either locking head screws or standard
(nonlocking) screws.
Locking plates available are:

Small profile locking plate

Medium profile locking plate

Large profile locking plate

Extra-large profile locking plate


They are also available in multiple shapes to meet a variety of clinical
applications.

General Treatment of Fracture Mandible / 55

The threaded head of the 2.0 mm locking head screws is conical. It is


therefore possible to insert locking head screws at small angles. A threaded
drill guide is not necessary.

Locking Reconstruction Plates

Fig. 8.21: Locking reconstruction plate

There is only one thickness of the locking reconstruction plate. However, there
are multiple plate configurations to meet a variety of clinical applications. The
threaded head of the 2.4 mm locking head screws is cylindrical. Therefore, a
threaded drill guide is mandatory to assure the correct perpendicular insertion
of 2.4 mm locking head screws. Angulation is not possible.
Reconstruction plates are used for load bearing osteosynthesis of mandibular
fractures

Locking Versus Nonlocking PlatesAdvantages to a


Locking Plate/Screw System
There are several advantages to a locking plate/screw system:
Locking plate and screw systems have advantages over the conventional screw
systems. Conventional plate/screw systems require precise adaptation of the
plate to the underlying bone. Without this intimate contact, tightening of the
screws will draw the bone segments toward the plate, resulting in alterations in
the position of the osseous segments and the occlusal relationship. Locking
plate/screw systems offer certain advantages over other plates in this regard.
The most significant advantage may be that it becomes unnecessary for the
plate to intimately contact the underlying bone in all areas. As the screws are
tightened, they lock to the plate, thus stabilizing the segments without the
need to compress the bone to the plate. This makes it impossible for the screw
insertion to alter the reduction.

56 / Fracture Mandible

Another potential advantage in locking plate/screw systems is that they do


not disrupt the underlying cortical bone perfusion as much as conventional
plates, which compress the undersurface of the plate to the cortical bone.
A third advantage to the use of locking plate/screw systems is that the
screws are unlikely to loosen from the plate. This means that even if a screw
is inserted into a fracture gap, loosening of the screw will not occur. Similarly,
if a bone graft is screwed to the plate, a locking screw will not loosen during
the phase of graft incorporation and healing. The possible advantage to this
property of a locking plate/screw system is a decreased incidence of
inflammatory complications from loosening of the hardware. It is known that
loose hardware propagates an inflammatory response and promotes infection.
For the hardware or a locking plate/screw system to loosen, loosening of a
screw from the plate or loosening of all of the screws from their bony insertions
would have to occur.
Locking plate/screw systems have been shown to provide more stable
fixation than conventional nonlocking plate/screw systems.
Locking plates

Unlocking plates

Rigid fixation

Semi rigid fixation

Does not require precise adaptation

Requires precise adaptation

Do not disturb the underlying bone


perfusion

It do disturb the underlying bone


perfusion

Decrease incident of complication like


loosening of screw and infection

Increase incident of complication


like loosening of srews and infection

More stable fixation

Less stable fixation

Screw insertion does not affect the


reduction of the segment

Screw insertion does affect the


reduction of the segment

Locking Head Screws


The locking plate has a corresponding threaded plate hole.

Fig. 8.22: Threaded plate hole and threaded screw head

General Treatment of Fracture Mandible / 57

During insertion the locking head screw engages and locks into the threaded
plate hole.

Fig. 8.23: Screw should be perpendicular to the plate

Conventional Screws
If necessary the threaded plate hole also accepts nonlocking screws, which
permit greater angulation.

Biomechanics
Conventional Screws
With the conventional technique,
the tightening of the screws
presses the plate against the bone.
This pressure generates friction,
which contributes significantly to
primary stability.
Loading forces are transmitted from the bone to the plate,
across the fracture and back into
the bone. Friction between plate
and bone is necessary for stability
using conventional screws.

Fig. 8.24: Friction between bone and plate

Fig. 8.25: Loading force transmitted from


bone-to-plate and then plate-to-bone

Locking Head Screws


However, with the locking head
screws engaged in the plate, the
plate is not pressed onto the bone.
This reduces interference to the
blood supply to the bone underlying the plate.

Fig. 8.26: No pressure on bone-locking


system

58 / Fracture Mandible

Loading forces are transmitted directly from the bone to the screws, then
onto the plate, across the fracture and again through the screws into the bone.
Friction between plate and bone is not necessary for stability.
The plate and screws provide
adequate rigidity and do not depend
on the underlying bone (load
bearing osteosynthesis) when using
a locking reconstruction plate 2.4.
On each side of the fracture, the Fig. 8.27: Loading force transmitting directly
from bone-to-screw then to plate and then
screws are locked into the plate as screw-to-bone
well as into the bone. The result is
a rigid frame construct with high mechanical stability (internal external fixator).

Primary Loss of Reduction


Conventional Plate System
When using conventional plates
and screws it is essential to contour
the plate precisely to the bone
surface.
When using conventional plate
and screws the plate must be
precisely adapted to the bone,
otherwise the tightening of the
screws will lead to a primary loss
of reduction in (Fig. 8.28) the plate
is not well adapted to the outer
cortex in lower diagram (Fig. 8.29)
shows that when the screws are
inserted, the bone will be pulled to
the plate, causing malreduction of
the fracture.

Fig. 8.28: Precise adaptation of plate

Fig. 8.29: Imperfect adaptation leads to


malreduction of fracture

Locking Plate System


When using a locking plate/screw system, the plate does not have to be precisely
adapted to the bone. When tightening a locking head screw, the screw will not
cause a primary loss of reduction as it tightens into the threaded plate hole and
will not draw the bone fragments to the plate.

General Treatment of Fracture Mandible / 59

Secondary Loss of Reduction


Conventional Plate System
In conventional plate systems, screw loosening may lead to loss of reduction.

Locking Plate System


In a locking system, screw loosening rarely occurs because the screw head is
locked to the plate.

Universal Fracture Plate 2.4


They are designed to be used with bicortical screws. Universal fracture plates
offer more biomechanical stability than DCP 2.4 plates

Load-Baring Osteosynthesis
(stabilization by splinting)
The plate bears the forces of function
at the fracture site. This is accomplished with a locking reconstruction
plate. Clinical uses are the management
of atrophic edentulous fractures,
comminuted fractures, defect fractures,
and other complex mandibular
fractures.

Load-Sharing Osteosynthesis

Fig. 8.30: Load-bearing


osteosynthesis

Fig. 8.31: Lag screw load-sharing osteosynthesis

60 / Fracture Mandible

General Consideration
Stability at the fracture site is created by
the frictional resistance between the bone
ends and the hardware used for fixation.
This requires adequate bony buttressing
at the fracture site. Examples of loadsharing osteosynthesis include lag screw
fixation technique and compression
plating. Load-sharing osteosynthesis
cannot be used with defect fractures or
comminuted fractures, due to the lack
of bony buttressing at the fracture site.
Another form of load-sharing
osteosynthesis is the miniplate fixation
technique popularized by Champy. This
is also known as functionally adequate
fixation or semirigid fixation.

Fig. 8.32: Minihole plate load


sharing osteosynthesis

Ideal Lines of Osteosynthesis


Champy popularized the treatment of
Fig. 8.33: Champys line
mandible fractures with miniplate fixation
along the ideal lines of osteosynthesis. This is a form of load-sharing
osteosynthesis to be applied in simple fracture patterns having an acceptable
amount of bone stock.

Different Levels of Force Distribution


In the load-bearing situation the plate assumes all the forces, in the loadsharing situation there are different levels of force distribution between the
plate(s) and the bone.

Load-Bearing
In load-bearing fixation the plate assumes
100% of the functional loads.
This is an example of load-bearing
osteosynthesis for the treatment of a defect
fracture in the angular region. The osteosynthesis assumes all the masticatory loads
while the bone graft matures and consolidates in a protected environment.

Fig. 8.34: Load-bearing


osteosynthesis

General Treatment of Fracture Mandible / 61

Intermediate Load-Sharing Situation


Intermediate load-sharing situation
where the osteosynthesis and the bone
share the functional loads almost
equally.
This is an example of load-sharing
osteosynthesis for the treatment of a
simple angular fracture. The two
miniplates share the loads with the
bone in an anatomical region where
the bone stock and force distribution
are not ideal.

Fig. 8.35: Intermediate load-sharing


osteosynthesis

Ideal Load-Sharing Situation


Ideal load-sharing situation where the bone assumes most of the functional
loads.
In this example, a simple mandibular body fracture was considered suitable
for a single miniplate osteosynthesis in the neutral zone because of the good
bone stock and optimal force distribution.

SUMMARY

Aim of treatment of fracture mandible is to reduce the fracture segment


and fix it so that normal anatomical relationship can be maintained.
Atmost precaution to be taken to preserve the blood supply of the bone
and the soft tissue by careful handling and reduction technique.
Attempt should be made for early and safe mobilization and rehabilitation
of the patient.
There are many methods of closed reduction but arch bar application is
more commonly used.
Period of immobilization 34 weeks for young adult with angle fracture
+ 1 week if teeth is in a fracture line
+ 1 week for fracture of parasymphysis
+ 1 or 2 week for age 40 years and above
1 week for childrens and adolsent
Dynamic compression plates and lag screws are not commonly used in
fracture mandible.
Reconstruction plate, miniplate are most commonly used.
Rigid osteosynthesis are:
Reconstruction plate
Locking plates
Three-dimensional sturd.

62 / Fracture Mandible

Semirigid osteosynthesis are:


Mandibular plate
Dynamic compression plate
Lag screw plate
Nonrigid osteosynthesis are:
Transosseous wiring
Circumferential wiring
External pin fixation
Bone clamps
Transfixation with K wire
Load sharing osteosynthesis are:
Lag screw
Dynamic compression plate
Miniplates
Load-bearing osteosynthesis are:
Reconstruction plate
Locking plates
Locking plates are better than unlocking plates.

Anesthesia for Fracture Mandible / 63

Anesthesia for
Fracture Mandible

All closed reduction of fracture mandible can be done under local anesthesia.
While open reduction is preferably done under general anesthesia. Young
cooperative patient with simple, undisplaced fracture open reduction can be
tried under local anesthesia. We prefer to apply arch bar under local anesthesia
and in case of open reduction patient is then further given general anesthesia.
Application of arch bar is better done in local anesthesia. As this require
cooperation of the patient in terms of mouth opening and moving the tongue in
an appropriate direction, thus this prevents excess retraction and a pressure on
a tongue which is required if IMF is done in general anesthesia. Thus this cause
decrease edema of tongue and cheek.

General Anesthesia
The anesthesia is same as all routine procedures but few special precautions
need to be taken.
Procedure
- Reduction and fixation of fracture mandible
Time
- 2 to 3 hours depending upon the severity
Postoperative pain
- ++
Position
- Supine with head up tilt with head ring, in case of
extraoral approach a shoulder should be kept
Blood loss
- Variable
Intubation technique - Nasal tube (blind or guided) and IPPV
Fibreoptic intubation may be required.

Preoperative

It is same as all routine anesthesia


Careful assessment for associate injury should be done
Make a meticulous assessment of airway, there may be several trismus
and soft tissue swelling
Explain the patient about postoperative events like mouth closure in a brief
Assess nostril patency

64 / Fracture Mandible

Check for evidence of basal skull fracture and CSF leak, which make nasal
intubation contraindicated
In a case of severe trismus and where postoperative edema may be
anticipated, tracheostomy should be considered
Submantle intubation should be considered in a case of pan facial trauma

Perioperative

Trismus make intubation look potentially difficult preoperatively as the


mouth opening is markedly limited due to the muscle spasm, hematoma,
pain, but this tend to relax following induction
Nose should be packed with 4% lignocaine with adrenaline or otrivin
nasal drop should be used
Bilateral mandible fractures can cause increase anterior jaw displacement
after induction but airway maintenance by face mask may not always be
easy due to increase jaw movement, swelling
A rapid sequence induction with suxa-methonium is appropriate
A marked swelling may make intubation difficult and awake fibreoptic
intubation may be required
Gas induction is often difficult due to pain while applying the face mask
Make sure that the patient when comes out from anesthesia should not be
sedated and should be completely awake from the anesthesia
If throat pack is placed around the tube should be removed before the
application of wires.

Postoperative

Observe the patient for sometime in a recovery before sending it to the ward
Start humidified oxygen
Always keep a wire cutter and a suction machine beside the patients bed
(to cut the wires in a case of emergency)
Shift the patient with nasopharyngeal airway to the ward.

Local Anesthesia
Two percent lignocaine with adrenaline is used for local anesthesia. In case of
hypertension and other contraindication a plain lignocaine can be used. In case
long duration of anesthesia is required long acting local anesthesia (bupivacaine,
ropivacaine, and tetracaine can be used). But 2% lignocaine with adrenalin gives
enough duration of anesthesia for arch bar application, so long acting is not
usually required.

Anesthesia for Fracture Mandible / 65

Dosage
The permission level of plain lignocaine is 4 mg/kg body weight and for 2%
lignocaine with adrenalin is 7 mg/kg body weight and for bupivacaine is 2 mg/
kg body weight.

Area of Infiltration
For upper jaw anesthesia we need:
1. Posterosuperior alveolar nerve block
2. Middle superior alveolar nerve block
3. Anterosuperior alveolar nerve block (infraorbital nerve)
4. Greater palatine nerve block
5. Incisive foramen nerve block

A: Area anaesthetized by posterosuperior alveolar nerve block

B: Area where local anesthesia is deposited C: Area from where anesthesia is


for superior alveolar nerve block
injected
Fig. 9.1

66 / Fracture Mandible

Posterosuperior Alveolar Nerve Block

26 number short needle is used


Orient the bevel of the needle towards bone
Partially open the patients mouth, pulling the mandible to the side of
injection
Retract the patients cheek with your finger
Insert the needle into a height of mucobuccal fold over second molar
Advance the needle slowly in upward, inward and backward direction
Slowly advance to the soft tissue
No resistance is filled, if resistance is felt withdraw the needle slightly
and change the direction and re-advance again.

Goal
Goal is to deposit local anesthesia close to the PSA nerve located posterior
superior and medial to the maxillary tuberosity.

Middle Superior Alveolar Nerve Block

26 number short needle used


Area of insertion, height of muccobuccal fold above the second premolar
buccal fold
Aspirate and if no blood then deposit 0.91 ml solution.

Anterosuperior Alveolar Nerve Block


(Infraorbital Nerve Block)

Nerve anesthetized
1. Anterosuperior alveolar
2. Middle superior alveolar
3. Infraorbital nerve

Technique

Target areainfraorbital foramen (below the infraorbital notch)


Landmarkmuccobuccal fold, infraorbital notch, infraorbital foramen
Area of insertionheight of muccobuccal fold directly over first premolar.

Procedure

Feel for infraorbital notch


Move your fingers downward from the notch applying gentle pressure to
the tissue

Anesthesia for Fracture Mandible / 67

A: Area where local anesthesia is


deposited for middle superior alveolar
nerve block

B: Area from where anesthesia is


injected

C: Area anaesthetized by middle superior alveolar nerve block


Fig. 9.2

The bone immediately inferior to the notch is convex, this represents the
lower border of orbit and a roof of infraorbital foramen
As your finger continous inferiorly a concavity is felt, this is infraorbital
foramen
Maintain your finger on the foramen or mark the skin at the site
Retract the lips, pull the tissue in muccobuccal fold
Insert the needle into the height of muccobuccal fold over the first premolar
with the bevel facing bone
Reach to your required site

68 / Fracture Mandible

A: Area which is anaesthetized by infraorbital nerve block

B: Area where local anesthesia is


injected for infraorbital block

C: Area where local ansethesia is


deposited

Fig. 9.3

Aspirate and if no blood slowly deposit 1 ml in a target area


One can feel that solution is deposited beneath the fingers if needle is
in a right plane.

Greater Palatine Nerve Block

Target areagreater palatine nerve as it passes anteriorly between the soft


tissue and bone of the heart palate
Landmarka greater palatine foramen and junction of maxillary alveolar
process and palatine bone

Anesthesia for Fracture Mandible / 69

A: Area where greater palatine foramen is located

B: Area which is blocked by greater palatine block


Fig. 9.4

Part of insertionadvance the syring from the opposite side of the mouth
at the right angle to the target area.

Procedure

Feel for depression of greater palatine foramen with the help of cotton
swab and a finger
The foramen is located distal to second molar but it may be either anterior
or posterior to its usual position
Inject in the foramen area around few drops.

70 / Fracture Mandible

Lower Jaw Infiltration


1. Inferior alveolar nerve block
2. Buccal nerve
3. Mental nerve

Inferior Alveolar Nerve Block

Landmarkcoronoid notch (greater concavity of anterior border of ramus)


Ptrygomandibular raphe
Occlusion plane of mandibular posterior teeth

A: Area anesthetized by infra-alveolar nerve block

B: Area from which anesthesia is given

C: Area where infra-alveolar nerve is


located

Fig. 9.5

Anesthesia for Fracture Mandible / 71

Procedure

A finger tip is kept in a coronoid notch


An imaginary line extended posterior from the finger tip in a coronoid
notch to the deepest part of the pterygomandibular raphe
This imaginary line should be parallel with the occlusal plane of the
mandibular molar teeth
The needle inserted anteroposterior distance from the coronoid notch back
to the deepest part of the pterygomandibular raphe
The finger on the coronoid notch is used to pull the tissue laterally,
stretching them over the injection side making them taut and for better
visibility and to be less traumatic.

Buccal Nerve Block

Landmark

External oblique ridge


Muccobuccal fold

A: Area anesthetized by buccal nerve block

B: Area where local anesthesia is deposited


Fig. 9.6

72 / Fracture Mandible

Procedure

A 25 gauge 1 inch long needle is inserted either in retromolar triangle area


or buccalmuccosa just distal to mandibular third molar area
0.5 ml of local anesthesia is injected

Mental Nerve Block

Landmark

Mandibular premolars
Muccobuccal fold

A: Location of mental foramen

B: Area in which local anesthesia is


injected for mental nerve block

C: Area anesthetized by mental nerve block


Fig. 9.7

Anesthesia for Fracture Mandible / 73

Procedure

A 24 gauge needle with 1 inch length is inserted in muccolabial fold in


between two premolar directing downward and anteriorly after retracting
the cheek
It contacts the bone at the level of apex at the second premolar anterior to
it
After aspiration, 0.5 ml is slowly injected.
SUMMARY

Do intermaxillary fixation under local if patient is co-operative.


All fracture mandible which require open reduction better to operative in
general anaesthesia.

74 / Fracture Mandible

10

Specific Treatment of
Fracture Mandible

Although many methods of osteosynthesis has been described but most


practised, easy, reliable method of osteosynthesis is miniplate osteosynthesis.
Dynamic compression plate osteosynthesis and lag screw osteosynthesis is not
widely practised. Nonrigid fixation is seldomly done.

Closed Reduction
Intermaxillary fixation application with arch bar:

Simple technique

Indicate for simple undisplaced fracture.

Miniplate Osteosynthesis
Advantages
a.
b.
c.
d.
e.

Not bulky and thick like dynamic compression plate


Not perfect adaptation required
Insertion of screw are easier
Gives good stability to the fracture line
Available in titanium as well as stainless steel material.

Champys Lines of Osteosynthesis


Champys and co-worker after careful
considering the biomechanics of
mandible have described Osteosynthesis
line for placing the miniplate in the
mandible.
A line drawn at the base of the
alveolar process corresponds to the line
of tension and a miniplate and a screw
can be fixed along this line. In parasymphysis region another line is drawn
to neutralize the tension force.

Fig. 10.1: Champys line

Specific Treatment of Fracture Mandible / 75

Behind the mental foramen only one plate should be applied, immediately
below the dental root and above the inferior alveolar nerve.
Between the two canines and in front of mental foramen another plate
near the lower border of mandible is applied in addition to the upper
plate.

Fig. 10.2: Minihole plate

Technique
This miniplates are around 0.9 mm thick and 6 mm wide. The difference between
holes are standardized. The screws available are from 5 to 15 mm in length. The
diameter of the screws is 2 mm. Screw of 6 or 8 mm in length are usually used
in mandible. The screws are self-tapping.

Fig. 10.3: Screw driver and screw

The plate is bended first so that they can be adapted to bone.


1.5 mm drillbit is used to create a hole almost perpendicular to the plate.
Eccentric drilling or repeated insertion of drill produce unfavorable hole
thus diminishing the grip of the screw.
During drilling continues liquid cooling is necessary to avoid thermal
necrosis.
A giveway indicates penetration of drill in a cortical bone.
Then screw is inserted near the fracture side and gradually tightened.
This same procedure is carried out for insertion of screw in all the plates.
The inferior alveolar nerve region is considered as the neutral zone of
the mandible. Avoid plate and screw fixation in this area that would
damage the nerve.

76 / Fracture Mandible

Basic treatment of any simple fracture mandible is application of load


sharing osteosynthesis plates (mini plate most commonly used along the
Champys line).
a. Symphysis fracture and parasymphysis fracture
Various options are:
A. Symphysis fracture
B. Parsymphysis fracture
C. Mini plate + dynamic plate osteosynthesis (load-sharing osteosynthesis)
D. Two miniplate osteosynthesis (most preferred and practised load-sharing
osteosynthesis)
E. Lag screw osteosynthesis (load-sharing osteosynthesis).

B
A

D
C

E
Fig. 10.4

Specific Treatment of Fracture Mandible / 77

b. Fracture of angle and ramus

A single monocotical miniplates applied on the external oblique line is


enough for simple angle fracture

Fracture between canine and angle (body) can be stabilized by superior


border plating along the champy line.

Fig. 10.5: Fracture at angle, plate at external oblique ridge

Basic treatment of any complex fractures (comminuted fractures, infected


fractures, loss of bone fractures) is application of larger plates (load-bearing
osteosynthesis).
A. Complex symphysis and parasymphysis fracture

Fig. 10.6A: Comminuted fracture of


parasymphysis

Fig. 10.6B: Reconstruction plate (loadbearing osteosynthesis) at the inferior


border to neutralize the tension and the
compression force + a arch bar
(Torsional bend) is used to neutralize
the rotational force

78 / Fracture Mandible

Fig. 10.6C: Basal triangle fracture of


parasymphysis area

Fig. 10.6D: Reconstruction plate (loadbearing osteosynthesis) at a inferior


border + miniplate (load-sharing
osteosynthesis) at the superior border

Fig. 10.7A: A triangular base fracture


at the angle of mandible

Fig . 10.7B: Miniplate (load-sharing


osteosynthesis) at the external oblique
line + reconstruction plate (load-bearing
osteosynthesis) at the inferior border

Fig. 10.7C: Comminuted fracture of


angle and body

Fig. 10.7D: Reconstruction plate (loadbearing osteosynthesis) at the inferior


border + miniplate (load-sharing osteosynthesis) at external oblique line and at
the body

Specific Treatment of Fracture Mandible / 79

Mandibular Condyle Fracture


Classification of condyle fractures
a. Fracture of head of condylesimple or comminuted fracture
b. Fracture of neck of condylesimple or incomplete fracture without any
displacement and complete fracture of neck of condyle with displacement
c. Subcondylar fracturelow and high
d. Malunited fracture.
The management of mandibular condyle fracture is very much important
especially in children because this can laed to disturbance of mandibular
growth pattern or even ankylosis of temporomandibular joint. This is the
most overlooked and least diagnosed side of fracture.

Treatment
The aim of treatment of condylar fracture is to reestablish the anatomical
relationship for providing good function and growth on long term basis.
a. Fracture of head of condyle
The intracapsular fracture of head of a condyle is rare and should be treated
conservatively by intermaxillary fixation for a period of 2 to 4 weeks followed
by restoration of function. Severe comminuted fractures of the condyle are
treated by condylectomy especially in unilateral cases. In case of children,
costochondral grafts should be given to replace the lost condyle.
Subcondylar fractures
These are the fractures below the neck of the condyle. These fractures are
classified as:

High condylar fracture

Low condylar fractures

Fig. 10.8

80 / Fracture Mandible

Fig. 10.9

These can be treated either by conservative approach or surgically depending


upon the amount of displacement.
Conservative approach is advocated in condylar fractures without any
displacement, condylar fracture with little displacement and slight overriding in
young children or subcondylar fracture, which are slightly displaced.

Fracture of Neck of Condyle


Undisplaced fracture should be treated conservatively, however, grossly displaced
fracture open reduction may be required.

Specific Treatment of Fracture Mandible / 81

Open Reduction
In grossly displaced condyle fracture where reduction cannot be achieved by
conventional method there is a fear of future dearrangement or ankylosis, an
open reduction is indicated.
The indications are:

Cases of condyle fracture with vertical overriding

Cases in which normal occlusion by manipulation or traction cannot be


achieved

Cases of gross displacement especially bilateral condyle fracture

Cases in which condyle fracture interfere with jaw movement

Cases in which condyle are partially fused in a wrong position


The condyle is surgically approached by preauricular approach or by
submandibular, retromandibular approach. The fracture is reduced and is
fixed by either by interosseous wiring or by monocotical miniplates.

Fracture of Coronoid Process


This account for 1% of fracture, most of the coronoid fractures do not require
any treatment. Cases in which coronoid hinders with opening of mouth, treatment
is advised. This coronoid fragment is fixed by interosseous wiring or by mini
plate. If reduction is not possible and function is impaired then coronoid process
is removed.

Mistakes
Common mistakes observed in treatment of rigid fixation:

Poor reduction of fractures

Interposition of tissue between the fracture line

Poor alignment of fractured segment

Insufficient screw placement

Poor plate bending

Poor or lose application of intermaxillary fixation.

Tips

Soft tissue in between the fracture line should be removed as proper


allignment cannot be attended. Nonhealing can occur if soft tissue is placed
between fractured fragment.
Use of drill sleeve provide protection to soft tissue.
Drill bit used should be 0.5 mm less than screw size. For example, if 2 mm
screw or plate is used 1.5 mm drill bit is used to make hole.

82 / Fracture Mandible

Due to drilling heat is generated, this heat can cause bone necrosis and
early screw loosening so cooling by putting saline over the drill bit.
Avoid damage to mental nerve, tooth root, inferior alveolar canal.
Proper bending of a plate should be done.
A space of about 5 mm should be kept between two plates.
SUMMARY

In case of simple, undisplaced fracture and no expertise available or


condition of patient does not allow general anesthesia; close reduction of
fracture mandible most preferably by arch bar method (IMF) is suitable.
In cases of parasymphysis and symphysis fracture in addition to lower
border miniplate application a superior border miniplate is also applied
to combat torsional force.
A miniplate with two hole on either side of fracture mandible is ideally
fixed.
Champys line of osteosynthesis give idea of sight of application of plates
in various areas.
In simple undisplaced fracture load sharing plate (mini plate) to be used.
In grossly displaced, infected, loss of segment fracture mandible
reconstruction plate should be ideally used.
All cases of undisplaced condyle fracture can be treated by closed
reduction.
Open reduction in a condyle fracture is indicated in cases where by
manipulation or traction the fracture segment is not reduced or cannot be
brought into normal occlusion.

Surgical Approaches / 83

11

Surgical Approaches

Surgical Approaches
1. Extraoral
2. Intraoral
3. The use of existing lacerations

Extraoral Approach
Submental Approach
The submental approach is used to treat fractures of the anterior mandibular
body and symphysis. These fractures can usually be approached and treated
intraorally. However, depending on the difficulty or severity of the fracture,
and/or the presence of a laceration suitable, an extraoral approach via the
submental route may be indicated.
Advantages

Lingual surface of the mandible can be easily inspected to assure optimum


reduction of fracture in this segment.

There is no major neurovascular structure in this area.

Scar is not that visible

Fig. 11.1: Variations in incision: (A) Following curvature of


anterior mandible, (B) Hidden in submental skin crease

84 / Fracture Mandible

Dissection

Carry the incision through the skin and subcutaneous tissues to the platysma
muscle.

The platysma muscle must be divided.

There may be a natural separation of the muscle in the midline region.


Additionally the platysma muscle can become very thin in this region.

Dissection is carried out to the inferior border of the mandible. The


periosteum is incised sharply and the flap is elevated to expose the
anterior surface of the symphysis.
Wound closure

The wound is closed in layers to realign the anatomic structures and to


eliminate dead space.

The periosteum and platysma muscle should be closed in different layers.

Option: bilateral extension


Submental extension
The submental incision can be extended laterally to encompass both the right
and left mandible by degloving the entire lateral surface of the mandible in
the same way as in the submandibular approach.
This may be necessary in complex fractures such as comminuted, atrophic,
and severe bilateral fractures.
To approach complex mandibular fractures the surgeon essentially
combines a right and left submandibular incision with a submental one.
The inferior border of the mandible is marked along with the planned
skin incision.

Submandibular Approach
In 1934risdon describe this technique.

Fig. 11.2: Various submandibular incisions

Surgical Approaches / 85

Principles
This approach is selected for fractures of the mandibular body and angle regions
unsuitable for intraoral treatment.
This applies to more difficult fracture patterns such as comminuted, atrophic,
and defect fractures in order to allow optimal manipulation of the fragments,
good control of the lingual cortex and inferior border, and the application of
the selected hardware.
Variations
The incision can either be parallel to the inferior border of the mandible atleast
2 cm below the angle of the mandible (A) or be placed in an existing skin
crease (B) for maximum cosmetic benefit.
If using skin creases for the incision, the orientation of the scalpel blade is
parallel to the skin creases.
Subplatysma flap elevated.
Neurovascular structures
The main neural structure is the marginal mandibular branch of the facial nerve
(CN VII). The facial artery and vein are also encountered during this dissection.
They are commonly located 1 cm below the angle of the mandible.
This neurovascular structure are identified by Holder Martins method in
which facial vessels are identified and they are retracted so that they are safe
in the flap.
The dissection is carried out through the deep cervical fascia.
The muscle, periosteum and other soft tissues are retracted superiorly to
expose the body, angle and the ramus of the mandible.
Then the fracture line is identified.

Retromandibular Approaches
In 1967, Hinds and Girrotti first described
this approach.
Skin incision
Incision is made 3 cm above the submandibular incision
The incision is carried curving behind
the angle of mandible
Use of normal saline for infilteration is
employed for maintenance of the plane and
in a cases where nerve stimulator has to be
used.

Fig. 11.3: Retromandibular


approach

86 / Fracture Mandible

Use of 2% lignocaine with adrenalin can be used for vasoconstrictor


effect.
Use of 2% local anesthetic may impair the function of the marginal
mandibular nerve and prevent the use of a nerve stimulator during the surgical
procedure.
Subplatysma flap elevated
Superior subplatysmal dissection would expose the underlying marginal
mandibular branch of the facial nerve (CN VII).
By ligating and dividing the facial artery and vein and then retracting the
vessels superiorly, the marginal mandibular branch of the facial nerve remains
included in the superior flap and is thus protected.
Divide the pterygomasseteric sling and incise the periosteum at the inferior
border to expose the fracture site.
This expose the body and angle region.
For wound closure, the pterygomasseteric sling is closed.
The wound is closed in layers to realign the anatomic structures and
eliminate dead space. The platysma muscle is closed. A drain may be used
if necessary.
Principles
The retromandibular approaches expose the entire ramus from behind
posterior border. They therefore may be useful for procedures involving
area on or near the condylar process/head, or the ramus itself.
There are two varieties of retromandibular approach used to access
posterior mandible. They differ in the placement of the incision and
anatomic dissection to the mandible.
The transparotid approach has the advantage of close proximity of
skin incision to the area of interest. The retroparotid approach has
advantage of not dissecting through the
parotid gland.
The facelift (rhytidectomy) approach can
be considered as an alternative to retromandibular approaches.
The main anatomic structures in this
approach are the main trunk and branches of
the facial nerve (CN VII) and the retromandibular vein.
Transparotid approach: Skin incision
A vertical incision through skin and sub-

the
the
the
the
the
the

Fig. 11.4: Tranparotid approach


skin incision

Surgical Approaches / 87

cutaneous tissue is made, extending from just below the ear lobe towards the
mandibular angle. It should parallel the posterior border of the mandible.
Dissection
The subcutaneous tissue is undermined, exposing the superficial musculoaponeurotic system (SMAS).
A vertical incision is made through the SMAS into the parotid gland.
Blunt dissection of the parotid gland
Bluntly dissect the parotid gland parallel to the direction of the facial nerve
branches and towards the posterior border of the mandible. The dissection
should be anterior to the retromandibular vein.
Branches of the facial nerve may be found during the dissection. A nerve
stimulator may be helpful to identify them. They should be mobilized and
protected.
Once the posterior border of the mandible has been reached, an incision
is made through the pterygomasseteric sling.
Subperiosteal dissection of the mandibular ramus
A periosteal elevator is used to strip the masseter muscle from the ramus.
Further dissection superiorly along the posterior border exposes the condylar
process.
Transparotid approach: Wound closure
The wound is reapproximated in layers for anatomic realignment and avoidance
of dead space. The parotid gland capsule must be closed tightly to prevent
salivary fistula. The SMAS is resuspended.
Alternative: Retroparotid approach
Principles
A frequently used alternative to the
retromandibular transparotid approach
described above is one in which the
parotid gland is lifted rather than
dissected through. This requires the
incision to be placed more posteriorly
which means that exposure of the
mandible is more limited. Rather than
approaching the mandible from directly
over the ramus, it is approached more
posteriorly.

Fig. 11.5: Retroparotid approach

88 / Fracture Mandible

Skin incision
An oblique incision through skin and subcutaneous tissue is made, extending
from the mastoid process to a point just below the angle of the mandible.
Dissection
The subcutaneous tissue is undermined, exposing the superficial
musculoaponeurotic system (SMAS).
An oblique incision is made through the SMAS. The posterior aspect of
the parotid gland is identified and dissection continues behind the gland.
The gland is lifted off the masseter muscle and retracted anteriorly.
Once the posterior border of the mandible has been reached, an incision is
made through the pterygomasseteric sling.
Subperiosteal dissection of the mandibular ramus
A periosteal elevator is used to strip the masseter muscle from the ramus.
Further dissection superiorly along the posterior border exposes the condylar
process.
Wound closure
The wound is reapproximated in layers for anatomic realignment and
avoidance of dead space.
The SMAS is resuspended.
A suction drain may be placed.

Preauricular Approach
Principles
The preauricular approach can be used to access and treat fractures in the
mandibular condylar head and neck region. Many surgeons perform temporal
mandibular joint (TMJ) surgery and routinely use this incision to access the
superior portion of the mandibular condylar process.
Neurovascular structures
Branches of the facial nerve may be involved in this incision and dissection.
The superficial temporal artery and vein are commonly encountered in this
surgical approach. The vessels should be conserved if possible.
Facelift incision
Skin incision
Make the incision in a preauricular skin crease.
Dissection
Locating temporalis fascia.

Surgical Approaches / 89

Carry the incision through the


skin and subcutaneous tissues to the
depth of the temporalis fascia. The
temporalis fascia is a glistening white
tissue layer that is best appreciated
in the superior portion of the
incision.
The superficial temporal vessels
may be retracted anteriorly with the
skin flap (sectioning some posterior
and superior branches) or left in
place (sectioning frontal branches).
Fig. 11.6: Facelift incision
The zygomatic arch can easily be
palpated at this point of the dissection. The lateral pole of the mandibular condyle can also be palpated. This
can be facilitated by having a surgical assistant manipulate the jaw.
Incising temporalis fascia
Make an oblique incision parallel to the frontal branch of the facial nerve,
through the superficial layer of the temporalis fascia above the zygomatic arch.
Dissection of the joint capsule
Insert the periosteal elevator beneath the superficial layer of the temporalis
fascia and strip the periosteum off the lateral zygomatic arch.
Dissection will be carried inferiorly to expose the capsule of the TMJ.
The frontal branch of the facial nerve is protected within the superficial
layer of the deep temporalis fascia.
Dissection can be carried inferiorly in a subperiosteal plane to reach the
neck of the mandibularcondyle.
A disadvantage of this approach is that the surgeon can reach only a limited
portion of the condylar neck region.
Wound closure
If the TMJ capsule has been incised to access the condylar head it must be
closed as the first step.
The temporalis fascia is closed as the next step.
Skin and subcutaneous sutures are placed.
A pressure dressing may be placed over this wound according to surgeons
preference.

90 / Fracture Mandible

The various modification of preauricular incision.


a. Rowe modification

Preauricular with temporal extension.

An incision is angled from the point of the attachment of helix upwards


and forward at 45 degree lying within the hair bearing area over the
temporal region.

This incision allows an extensive flap to be raised and avoid traction


injury to upper branches of facial nerve.

Reverse sigmoid shaped incision gives the most satisfactory result by


helping to disguise the final scars.
b. Blair and ivy

Preauricular incision with an inverted hockey stick incision over the


zygomatic arch.

Gives easy access and better stability and facilitated exposure of arch
along with the condylar arc.
c. Alkayat-Bramley preauricular incision

Alkayat-Bramley preauricular incision along with a (question marked shape)


curved temporal extension is advocated mainly for TMJ ankylosis as it
gives a wide area of exposure and also facilitates elevation of temporal flap
for reconstructive purpose.
d. Endaural approach

This approach gives good scar but poor access.

So rarely used.
1. Intraoral approach

Symphysis and body.

Condylar process and ramus


In practise intraoral approach is more commonly used.
Advantages

Intraoral approach is more rapid than extraoral approach

Avoid external scar

More visualization for horizontal mandible anteriorly


Disadvantages

Only labial cortex is visualized

Thus there is a chances of significant gap remaining in the lingual cortex

Surgical Approaches / 91

Intraoral Approach to the Symphysis and Body


Vestibular Incisions
The intraoral approach is the usual access
for simple fractures of the body,
symphysis, and angular regions.
The approach can be extended
posteriorly (dashed line) for better access
to the body, angle and ramus regions.
In complex fractures including
Fig. 11.7: Intraoral incison for
comminuted, edentulous, and avulsive
symphysis and body fracture
fractures requiring the placement of loadbearing reconstruction plates, a extraoral approach may provide better access.
Oral contamination is not a contraindication for an intraoral incision.

Mucosal Incision
Unless contraindicated, infiltrate the area with a local anesthetic containing
a vasoconstrictor.
Make an incision through the mucosa in the vestibule. Between the
canines the incision is made 1015 mm away from the attached gingiva in
a curvilinear fashion. Posterior to the canine the incision is only 5 mm away
from the attached gingiva, staying superior to the mental nerve.

Neurovascular Structures
The mental nerve is a branch of the fifth cranial nerve (trigeminal nerve).
This nerve provides sensation to the anterior mandibular vestibule, lip and
chin.
When the incision is extended posterior to the canine teeth, the mental
nerve can be damaged. Keep the incision superior to the mental nerve in the
body region.
Particularly in the extended intraoral approach, care must be taken to
protect the mental nerve in the anterior body region.

Surgical Flap Dissection


Dissect a mucosal flap that retracts or is lifted (as shown) to expose the
surface of the mentalis muscle. The branches of the mental nerve are located
just underneath the mucosal flap and must be respected.

92 / Fracture Mandible

Mentalis muscle dissection


The mentalis muscle is incised near the alveolar bone ridge thus creating a
stepwise approach which protects the mental nerve. Later, during wound
closure the mentalis muscle should be properly reattached.

Fracture Site Exposure


Elevate a mucoperiosteal flap to expose the fracture.
Extension of Approach
Lateral/posterior vestibular incision.
The approach can be extended laterally and posteriorly to provide access
to the body, angle and ramus regions of the mandible.
Right-angled retractors are helpful in this approach.

Wound Closure
After thoroughly irrigating the wound and checking for hemostasis the incision
is closed. Anteriorly, the mentalis muscle is reapproximated to prevent
drooping of the chin tissues. The mucosa is closed with interrupted or
running resorbable sutures.
An elastic pressure dressing on the chin region helps support the soft
tissues and prevent hematoma formation

Intraoral Approach to the Angle

Fig. 11.8: Mucosal incision for angle fracture

Principles
Vestibular incisions
The intraoral approach is used for the majority of simple angle fractures.
Depending on whether or not a third molar is to be extracted, there are two

Surgical Approaches / 93

surgical approaches. Where there is no third molar present, or where one is


present but is to be left in place, a purely vestibular incision approximately 5
mm away from the attached gingiva is made (A). When an erupted third molar
is to be removed, the incision must incorporate the attached gingiva around the
buccal side of the tooth (B, combination of vestibular and envelope incisions).
Oral contamination is not a contraindication for an intraoral incision.
Restricted access and contamination
In complex fractures including comminuted, edentulous, and avulsive
fractures that will require the placement of load-bearing reconstruction plates,
a transfacial/extraoral approach can provide better access to treat the injury.
Tips

Avoid injury to the sensory buccal nerve

Reattach the buccinators muscle to its original position as far as possible


Sensory buccal nerve
The sensory buccal nerve crosses the upper anterior rim of the mandibular
ascending ramus in the region of the coronoid notch. It is usually below the
mucosa running above the temporalis muscle fibers. When the posterior
vestibular incision is carried sharply along the bony rim, the buccal nerve
is at risk of transsection, followed by numbness in the buccal mucosal
region. Therefore, to protect the nerve, the posterior dissection is to be
extended bluntly as soon as the lower coronoid notch is reached.
The photograph shows the sensory buccal nerve.
Buccinator muscle
The lateral mucogingival vestibular incision transsects the lower attachment
of the buccinator muscle. Stripping the mucoperiosteal flap laterally dislocates
the lower border of the muscle. To reattach the muscle, the sutures for
wound closure in the lateral vestibular should not only be superficial. The
suture should catch all layers (mucosa and muscle) as a safeguard for muscle
reattachment.
Vestibular incision
Unless contraindicated, infiltrate the area with a local anesthetic containing
a vasoconstrictor.
Make an incision through the mucosa in the vestibule approximately
5 mm away from the attached gingiva (in the mucogingival junction),
extending up the external oblique ridge.
The fracture must be reduced adequately before fixation is applied. The
fixation can be either by transbuccal or right-angled instrumentation.

94 / Fracture Mandible

Combination with the transbuccal technique


The transbuccal trocar may also assist the surgeon in positioning posterior and
inferior screws, sometimes avoiding the need for an extraoral approach.
Wound closure of the vestibular incision
After thoroughly irrigating the wound and checking for hemostasis the surgeon
can close the incision.
An elastic pressure dressing covering the angle region helps support the
soft tissues and prevent hematoma formation.
Wound closure using envelope flap
The envelope portion of the flap is undermined with scissors to facilitate
tension-free advancement over extraction site. Generally, resorbable sutures
are used for this closure.
The flap is advanced and closed over the extraction site.

Intraoral Approach to the Condylar Process and Ramus


Principles
The vestibular incision can be
used for standard fracture fixation
techniques or in conjunction with
endoscopically assisted surgical
techniques.
The ramus and condyle region can
be exposed via an intraoral
approach by extending the
standard vestibular incision in a
superior direction up the
Fig. 11.9: Mucosal incision for condyle
ascending ramus. The incision can
and ramus fracture
be altered depending on the area
of the ramus/condylar process that needs exposure and treatment.
Oral contamination is not a contraindication for an intraoral incision.
In complex fractures including comminuted and avulsive fractures that
require the placement of load-bearing reconstruction plates, a transfacial/
extraoral approach can provide better access to treat the injury.
Tips

Avoid injury to the sensory buccal nerve

Reattach the buccinators muscle to its original position as far as possible

Surgical Approaches / 95

Sensory Buccal Nerve


The sensory buccal nerve crosses the upper anterior rim of the mandibular
ascending ramus in the region of the coronoid notch. It is usually below the
mucosa running above the temporalis muscle fibers. When the posterior
vestibular incision is carried sharply along the bony rim, the buccal nerve
is at risk of transsection resulting in numbness in the buccal mucosal region.
Therefore, to protect the nerve, the posterior incision is to be extended
bluntly as soon as the lower coronoid notch is reached.

Buccinator Muscle
The lateral mucogingival vestibular incision transsects the lower attachment
of the buccinator muscle. Stripping the mucoperiosteal flap laterally dislocates
the lower border of the muscle. To reattach the muscle, the sutures for
wound closure in the lateral vestibular should not only be superficial. The
suture should catch all layers (mucosa and muscle) as a safeguard for muscle
reattachment.
Reminder: The buccinator muscle belongs to the mimic muscle system and
has a unique functional structure allowing for a movement comparable to a
peristaltic motion. The deep fibers run in parallel bundles from the modiolus
to the pterygomandibular raphe at the level of the occlusal plane (intercalar
region) and account for the buccinator mechanism building up a ridge towards
the occlusal plane. Its detachment can result in an impaired bolus transport
out of the buccal space which is troublesome for the patient. The buccinator
is innervated by the motor buccal branch of the facial nerve.

Incision
Unless contraindicated, infiltrate the area with a local anesthetic containing
a vasoconstrictor.
Make an incision through the mucosa in the vestibule approximately 5
mm away from the attached gingiva (in the mucogingival junction), extending
up the external oblique ridge.

Exposure of Fracture
The lateral surface of the ramus and condylar process is exposed in a
subperiosteal plane to visualize the fracture. Right-angled retractors and
fiberoptic lighting would facilitate this procedure. The fracture must be
reduced adequately before fixation is applied. The fixation can be done
either by transbuccal or right-angled instrumentation.

96 / Fracture Mandible

The surgeon has the option of treating the fracture through the intraoral
approach under direct vision or may opt for endoscopic assistance.
The incision is very similar to the standard incision used to approach the
ramus and condyle unit. Surgeon preference for a smaller incision is
acceptable.
A specific instrumentation is recommended in order to facilitate the
endoscopically assisted condylar fracture treatment.
Create the optical cavity for the endoscope by elevating the periosteum
of the ascending ramus towards the condylar region. Stop the dissection once
you have reached the fracture line. Dissection beyond the fracture line will
be completed after introduction of the endoscope.

Insertion of the Optical Retractor


After assembly of the optical retractor to its handle, insert and place it around
the posterior border of the ramus.

Insertion of the Endoscope


Insert the endoscope through the optical retractor up to the fracture line.

Dissect over the Condylar Fragment


Using the periosteal elevator
dissect under endoscopic
visualization over the condylar
fragment. Care should be taken
near the inferior border of the
capsule so as not to violate the
joint space.
If the condylar fracture
fragment is initially medially
displaced, the surgeon must
bring the fragment into a lateral
position in order to complete the
dissection for the osteosynthesis.
This may be a highly demanding procedure.

Fig. 11.10

Wound closure
Closure of the intraoral incision
After thoroughly irrigating the wound and checking for hemostasis the incision
is closed using interrupted or running resorbable sutures.

Surgical Approaches / 97

Surgical dressing
An elastic pressure dressing covering the ramus/condylar process region
helps support the soft tissues and prevent hematoma formation.

The Use of Existing Lacerations


Frequently, patients with facial fractures also have lacerations. Very often,
these existing soft-tissue injuries can be used to directly access the facial
bones for management of the fractures.
The surgeon may elect to extend the laceration to provide adequate
access to the fractured area, following the relaxed natural skin creases.
Bacterial contamination is not a contraindication for the use of existing
lacerations for surgical approach.
Wound closure
Wound closure for this incision is primary closure of the laceration. Proper
cleansing, debridement, and hemostasis should be accomplished prior to
closure.
The laceration is closed in layers with resorbable interrupted sutures,
realigning the anatomic structures and eliminating dead space:

Periosteum

Mimic muscles

Platysma/SMAS

Subcutaneous tissues

Damaged facial and trigeminal nerve branches injured Stensens duct are
repaired as meticulously as possible. A drain may be used if necessary.
SUMMARY

Vestibular incision is best for simple fracture(symphysis, angle, body)


Preserve mental nerve
Close wound in two layers muscle and mucosa
Extraoral incision for
Complex, difficult, grossly displaced fracture
Preserve the facial nerve
Close the wound in layers
Try to give good scar
Mandibular condyle repair can be done endoscopically.

98 / Fracture Mandible

12

Fracture of Mandible in
Children

Fracture of mandible is not very common in children this is because the bones
are resilient at this age and considerable forces are required to cause a fracture.
In children the line of demarcation between medulla and cortex is not well
defined as in adult. There are more chances of green-stick fractures occurring
in children. There is greater risk of damage to the developing teeth than the
later years.
The treatment of mandible fracture in children before puberty are of
conservative management. This is because of rapid healing of bones and
adaptive potential of bone and its contain dentition.
Some special factors need to be considered during the management of
fractured mandible in children.

Hindrance in Growth Potential


Children have tooth germs and unerupted permanent teeths. If these are disturbed
the normal growth of mandible is disturbed. Development of alveolus will be
affeceted in those areas. This damage in a growth potential will be more severe
in case of infection in a fracture side. The growth in sub condylar regions can
be seriously compromised if there is high condylar fracture leading to restriction
of function as a result of fibrous or bony ankylosis of the temporomandiular
joint.

Fixation in the Deciduous and Mixed Dentition Period


In case of severe displaced fracture which requires immobilization of mandible.
Some modification of technique are required because of presence of
uninterrupted and partially erupted teeth of permanent dentition and deciduous
teeth variable mobility.

Fixation Independent of Teeth


a. In very young with unerupted or very few deciduous teeth gunning type
splint of lower jaw can be used which can be constructed by trough lined
with black gutta percha and retained by two circumferential wires.

Fracture of Mandible in Children / 99

b. When some occlusions are present with caries and loose deciduous tooth
in mandible can be suspended on each side with circumferential wires on
each side linked to circumzygomatic wires from above.
c. A simple elasticated bandage chin support can be given in case of
minimally displaced fractures where jaw movements are not that painful.

Fixation Utilizing the Teeth


Patient with erupted deciduous and permanent teeth:

Simple arch bar and eyelet wiring can be done. This arch bar is to be fixed
to the teeth with more thinner, flexible, soft Stainless steel of 0.35 mm
diameter.

Light arch bar of german silver can be used for irregular dentition as they
are more easily adaptable. This should be attached to the tooth by similar 0.35
mm diameter wire.

Orthodontic brackets can be bonded directly on a tooth in case of simple


fracture.

Unerupted Tooth
Patient below age of 910 years the body of mandible is conjusted with
developing teeths so its unsafe to apply transosseous wires or to insert bone pains
or plate in them. In cases of gross displacement of fractures the lower border should
be wired with caution. The bones pins and plates are contraindicated.

Follow-up
The healing in children is very rapid. Some fractures are stable within a week
and get firmly united in three weeks time. Fracture did not need to be reduced
perfectly. Imperfection in reduction can be accepted rather than refracturing
the mandible with possible damage to the developing teeth. In case of above
circumstances continuing growth and eruption of teeth will compensate for the
imperfect alignment of fragment.
A prolonged follow-up is required in order to be sure that there is no longterm effect on both mandibular growth and normal development of permanent
dentition. Close cooperation with paedodontist, orthodontist and dentist is of
vital importance.
SUMMARY

Growth of the bones are rapid.


Interference with growth potential should be kept in mind.
Conservative management to be done for fracture mandible in children.
Perfect reduction not required.
Prolonged follow-up is required.

100 / Fracture Mandible

13

Postoperative Care

The postoperative care is also very important as the intraoperative care. With
the advent of this direct osteosynthesis technique postoperative care has simpler
and safer. The postoperative care is divided into three phases:
1. Immediate postoperative phasethis is the phase when is recovering from
the general anesthesia.
2. Intermediate phasethis is a phase before the clinical bony unions has
been established.
3. The late postoperative phasethis includes removal of fixation biterehabilitation, physiotherapy and long-term observation of dentition.

Immediate Postoperative Phase


This is a phase in which we are highly dependent on intensive care unit
staff. In case of absence of such facilities an experienced nurse should remain
with the patient till the recovery is complete. An intermaxillary fixation is
carried out instruments like cutters, screw drivers and scissor should be easily
available near the bed side so that in a case of emergency this fixation can be
removed immediately. Patient should be return from the theatre with
nasopharyngeal airway in position and this should be left in situ until the patient
recovers unconsciousness. In case of patient being unconscious or a patient
sedated postoperatively or associated extensive soft tissue injury to the
oropharynx. A tongue suture should be taken which should pass transversely
across the dorsum of the tongue as an additional safeguard.
A suction machine should be kept beside patient to suck any saliva or
oozing blood from the mouth.
In case of vomiting with patients consciousness down there may be
chances of aspiration. In such cases immediately the intermaxillary fixation
should be removed and accordingly patient need to be intubated.

Postoperative Care / 101

Intermediate Postoperative Phase


General Supervision
Once a patient gains consciousness tongue suture if taken should be removed.
Patients occlusion need to be checked as early as possible. Any unacceptable
reduction need to be corrected in an early stage. Intermaxillary fixation should
be inspected for its loosening of wire or removal of wire. A postoperative
edema should be kept in a mind and should be informed to the patient and
the relatives about it before the operation. Any increase in a swelling with
sign of infection require immediate attention.

Prevention of Infection
Cases of fractures of tooth bearing areas injection augmentin + injection
mertrogyl should be given for 5 days. If healing goes well antibiotic can be
discontinued after 5 days. Simple closed fractures of condyle neck do not
require any prophylactic antibiotic.

Oral Hygiene
This play an important role in the prevention of infection in a fracture line.
Hot normal saline mouth washes are given after every meal for conscious
patients in a case of immobilization by any of wiring techniques. Patient is
asked to do a toothbrush in a visual manner. The size of the tooth brush
should be of a smaller size. Betadin gargle or 0.2% chlorhexidine gluconate
mouth wash significantly reduce the bacterial count and improves a plaque
control in patient with intermaxillary fixation.
Patient who does not cooperate, mouth must be cleaned by a nursing staff
after every meal using normal saline solution with the help of hugginson and
syringe. Care must be taken not to direct the stream of fluid down the side
of nay compounded fractures, so introducing infection. Caps splints can be
cleaned with 14% sodium bicarbonate solution. Rubber band if soiled with
food should be changed. The lip should be kept lubricated with petroleum
jelly to prevent drying and sticking of the lips. If the lips are excoriated and
sore 1% hydrocotisone ointment can be applied.

Feeding
The problem of providing a patient suffering from maxofacial injury with
adequate nutrition varies according to whether the patient is conscious and
cooperative or is uncooperative.

102 / Fracture Mandible

Conscious Cooperative Patient


Depending upon a size of the gap between the fixation of the patients can have
a semi solid or a liquid diet. A diet of 20002500 calories is adequate for
most patients nutritional requirement. Liquid or a semi solid diet should be
given in consultation with dietitian. Milk and milk products are encouraged for
regular daily consumptions. Diet should be supplemented with vitamins iron
preparation and high calorie protein preparation such as complain. Use of
flavouring agents should be used and liking of patients should be considered to
maintain the patients interest in a diet. A big diameter straw can be used for
sucking liquids.

Unconscious and Uncooperative Patient


Patients fluid and electrolyte should be maintained. A help of a physician,
surgeon, and dietitian is required to maintain the nutrition and metabolism of
patients. Rhyles tube should be inserted to feed the patient and if Rhyles tube
feeding is not adequate parental fluid therapy should be started with consultation
of the physician.

Late Postoperative Care


Removal of Fixation
The intermaxillary fixation in terms of wire technique can be removed after
the period of immobilization of the specific area fracture. Wire ligatures and
eyelets should be unwound a few turn to loosen them and the wire cuts in
such a way that there are no residual obstruction in smooth withdrawal of
the wire. Nevertheless the process is uncomfortable for the patient. After
removal, the mouth should be cleaned with antiseptic solutions, antibiotic is
given for 35 days as a prophylaxis to the infection with betadin or 1%
chlorhexidine solution for a mouth wash. In a cases of rigid osteosynthesis as
it produce stable union not much care is required. Patient should be kept on a
soft diet for first two weeks and carefully monitored for any wound infection.
There is no need to remove this fixation unless there is an infection or an
exposure in the mouth or extrusion from the skin.

Adjustment of Occlusion
Little adjustment of occlusion is required if wiring technique is employed as
the cusps are placed in a correct position under a direct vision at the time
of immobilization. In case of caps splint, however, accurate the splint may be

Postoperative Care / 103

a slight adjustment of occlusion is always required. Slight dearrangement of


occlusion can often be overcome by allowing the patient to masticate normally
as there is sufficient elasticity in recently healed fracture to allow occlusion
to correct itself. Patient with fracture of edentulous mandible can seldom wear
their original lower dentures and a new one is required when a fracture is
healing.

Mobilization of Temporomandibular Joint


After removal of wires there may be a slight pain in the temporomandibular
joint in initial period. Patient need to be encouraged for the movement of
temporomandibular joint. Patient is asked to open and close mouth frequently
to break the muscles spasm initially, after that there should be no difficulty
in moving their temporomandibular joint.
SUMMARY

Patients nutrition should be maintained.


Oral hygiene should be taken special care.
In compound fractures infection should be prevented.
Wire cutters, suction machine should be kept at the bed side.
A dental reference to be done after removal of wires done for the wiring
technique.
Implants need not require to be removed unless and until it is exposed,
infected or extruded.

104 / Fracture Mandible

14

Complications

Serious complication arising as a result of fracture mandible are rare as


fractures are treated competently nowadays. Minor complication are commoner
than the major one. The complications are divided into early complication
and late complication.

Early Complication
Hemorrhage
There can be hemorrhage in a soft tissue which may require drainage if its
localized. Some symphysis and parasymphysis fractures can be accompanied
with tear in a soft tissue which extends along the floor of mouth as far as
pharynx. This tear opens the deep spaces of a neck to blood and saliva thus
permitting infecting to the deep spaces of neck which can track into the
thorax. If such tears are present tissue in a floor of mouth should be closed
in layer with drain in a dependant portion of the wound with antibiotic
coverage.

Carotid Injury
Severe mandibular dislocations may damage the carotid artery, resulting in
aneurysm formation or thrombosis with stroke. The condyle is frequently
driven into the auricular canal, because it is adjacent to it, lacerating the
canal and resulting in bleeding.

Facial Nerve Injury


Contusion and laceration of facial nerve can occur leading to palsy or paralysis.

Infection
By achieving adequate stability of bone fragment in a fracture area reduce
the possibility of infection. More chances of infection in cases of periosteal
stripping which decreases the blood supply.

Complications / 105

Infected fractures will usually demonstrate one or more of the following


signs/symptoms:

Swelling

Erythema

Trismus

Pain

Purulent discharge.
Infection occurring in fractures usually results from one or more of the
following etiology:

Microorganisms

Fracture instability

Devital tissues (teeth, bone, etc).


The treatment of infected fractures involves:

Incision and drainage of abscesses,

Irrigations of the wounds as necessary

Systemic antibiotics

Removal of devital teeth/bone

Removal of any loose internal fixation devices

Restabilization of fracture

Stronger and longer plates need to be applied

Function should be permitted after the infection is cleared

Bone grafting should be considered in a case of big gap in a fracture.

Avascular Necrosis, Osteitis, and Osteomyelitis


This is more common in a older patient with edentulous mandible, in old
patient the inferior alveolar artery and vein get smaller in size thus decrease
blood supply to the mandible leading to potential of avascular necrosis. This
can be further increased by periosteal stripping.

Treatment
a. Early reduction of fracture with immobilization
b. Drainage of absess if any otherwise osteitis can progress into osteomyelitis
True osteomyelitis in mandible is relatively uncommon. Localized osteitis
occur but this condition rarely progress into true osteomyelitis. The use of
antibiotic, the prompt drainage of area prevent this occurance of osteomyelitis.
If osteomyelitis occurs it should be easily demonstrated radiographically as
increased fluffiness and varying opacity of the bone.

106 / Fracture Mandible

Treatment
a.
b.
c.
d.
e.

All sequestra and devitalized bone should be removed


Any internal fixation should be removed
Higher antibiotic should be started
Appropriate drainage if required should be done
Bone should be stabilized with external fixation

Late Complication
Nonunion
A nonunion occurs when the mandible does not heal in an appropriate time
frame. Healing at the side of mandible fracture is completed within 48
weeks. Remodelling and bone healing continue histologically for 26 weeks.
The result is mobility of the fracture segments present after an adequate healing
phase. Patients may also demonstrate malocclusion and infection at the site of
fracture.

Etiology
Nonunions are usually the result of one or more of the following factors:
a. Fracture instability (mobility)
b. Infection
c. Inaccurate reduction
d. No contact between fragments
e. Decrease blood supply to the bone
f. Poor nutritional condition of the patient
g. Old edentulous patient
h. Lack of water tight intraoral closure, bathes the fracture in bacteria thus
leading to nonunion

Treatment
Treatment will consist of:

Identifying the cause

Controlling infection

Surgical reconstruction: Removing the existing hardware, debridement of


devital bone and/or soft tissues, decortication of bone fragments at the
fracture ends, re-establishing occlusion, stabilizing segments using a locking
reconstruction plate 2.4, and autogenous bone graft to this area.

Complications / 107

Malunion/Malocclusion
Etiology
Malunions occur for at least one of several reasons:

Inadequate occlusal reduction during surgery

Inadequate osseous reduction during surgery

No osseous reduction (e.g. condyle fractures)

Imprecise application of internal fixation devices

Inadequate stability (lack of rigidity)

Treatment
The treatment of a malunion must involve:

Identification of the cause

Orthodontic/orthopedic treatment if possible

Osteotomies as necessary (refracture, standard osteotomies, combinations)

Ankylosis
Ankylosis is a process where the mandibular condyle fuses to the glenoid
fossa. This generally occurs after prolonged immobilization (MMF) of a
condylar fracture.
Patient demonstrating their maximum interincisal opening after treatment
of multiple mandibular fractures and prolonged period of MMF.
The treatment of ankylosis in this case is additional surgery in the form
of a gap arthroplasty or total alloplastic joint replacement.

Fixation Failure
Implant failure includes plate fracture and screw head fracture. Fixation
failure results in fracture mobility that can subsequently lead to infection,
nonunion and/or malunion.
Fixation fails by a number of mechanisms which include:

Insufficient amount of fixation

Fracture of the plate

Loosening of the screws

Devitalization of bone around screws

Insufficient Amount of Fixation


Left mandibular angle fracture was treated using a malleable miniplate 2.0 at
the inferior border of the mandible. This is insufficient fixation for this fracture.

108 / Fracture Mandible

Illustration demonstrating biomechanics of an angle fracture. A small


plate applied at the inferior border
provides insufficient stability in such a
fracture. It cannot prevent a gap from
opening at the superior surface of the
mandible under function.

Limitation of Opening of Mouth


Fig. 14.1: Complication after
Prolong immobilization of mandible and
insufficient amount of fixation
intermaxillary fixation can result in
weakening of muscle mastication.
With substantial hemorrhage within muscle can occur leading to organized
hemotoma with early scar tissue formation. All this leads to decrease mouth
opening.

Treatment
a. Physiotheraphy may accelerate the recovery period
b. Simple jaw excercise should be employed
c. Occasionally manipulation of mandible under anesthesia may assist the
breakdown of scar tissue within muscle.

Fibrodysplasia Ossifficans
This involve the main muscle of mastication and it is a very rare combination
of fracture mandible. The hematoma which occurs in muscle get organized and
eventually become ossified, this view is supported by finding of trabecular
bone within the muscle mass.

Treatment
a. Excision of ectopic bone
b. There is a high chance of recurrence.

Scar
Etiology
a.
b.
c.
d.

Contamination of wound with dirt specially tar products


Improper technique of suturing
Associated infection
Tendency of patient

Complications / 109

Treatment
a.
b.
c.
d.
e.
f.

Wait and watch for 1st year as they may soften and fed away
Massage of the scar
Pressure bandage
Application of lanoline
Infilteration of injection kenacort and hylinese
Surgical revision if possible
SUMMARY

Proper reduction, stable and appropriate fixation with prevention of infection


can prevent most of the complication of fracture mandible.
In cases of edentulous patient, grossly contaminated fractures, poor
nutritional condition of the patient, complication like malunion, nonunion should be kept in mind.
All devitalized structures, infected tissue, loose plates and srews should be
removed and replaced by appropriate ones.

Index / 111

Index
Page numbers followed by f refer to figure

A
Accessory muscles of mastication 16
Acrylic splints 47
Airway maintenance 39
Alkayat-Bramley preauricular incision 90
Angle of mandible 13
Ankylosis 107
Anterosuperior alveolar nerve block 66
AO classification of mandibular fractures 24
Arch bars 44
Avascular necrosis 105

B
Basal triangle fracture of parasymphysis
area 78f
Bilateral condylar fractures 32
Biomechanics of mandible 10, 11f
Blood
loss 39
vessels 17
Blunt dissection of parotid gland 87
Bonded modified orthodontic brackets 47
Buccal nerve block 71
Buccinator muscle 93, 95

C
Carotid injury 104
Categories of
associated fractures 25
fractures 25
occlusion 25
soft tissue involvement 25
Champys line 74f
of osteosynthesis 74
Closed reduction 74
Combination with transbuccal technique 94
Comminuted fracture 22, 22f, 33, 52
of angle and body 78f
of parasymphysis 77f
Complex symphysis 77
Complication after insufficient amount of
fixation 108f

Compound fracture 22, 22f


Compression plating 49
technique 50
Computed tomographic scan 37
Condylar fractures 32
Conscious cooperative patient 102
Contact healing 9
Control of infection 41
Conventional
plate system 58, 59
screws 57
Countersink near cortex 54

D
Dental terminology 4f
Dentoalveolar fractures 31
Determine screw length 53, 53f
Different levels of force distribution 60
Dissect over condylar fragment 96
Dissection 84, 87, 88
of joint capsule 89
Dynamic compression plate 48, 50f

E
Eccentric drilling for compression 50
Eyelet method 46
of fixation 46f

F
Face lift incision 88, 89f
Facial nerve injury 104
Factors affecting bone healing 10
Feeding 101
Fibrodysplasia ossifficans 108
Fixation
failure 107
in deciduous and mixed dentition period
98
independent of teeth 98
utilizing teeth 99

112 / Fracture Mandible


Fracture 18
angle of mandible 26
condyle 26
displacement 26
in canine region 26
of angle 33
and ramus 77
of body 34
of mandible 26
of coronoid process 27, 33, 81
of head of condyle 79, 80
of mandible 20
of ramus 33
of mandible 27
of symphysis 27
and parasymphysis 34
site exposure 92
Frequency of fracture 19

G
Gap healing 9
Gilmer method 46
of fixation 46f
Grades of severity 25
Greater palatine
block 69
nerve block 68
Greenstick fracture 22, 22f

Insertion of
endoscope 96
optical retractor 96
Insufficient amount of fixation 107
Intermaxillary fixation 44
screw technique 47, 47f
Intermediate load-sharing situation 61
Intraoral incison for symphysis and body
fracture 91f

L
Lag
screw 51
principle 51f
and technique 51
technique 51, 52
Limitation of opening of mouth 108
Load-bearing osteosynthesis 59, 61f, 78f
Load-sharing osteosynthesis 59, 78f
Local
anesthesia 64
examination of mandibular fracture 29
Location of mental foramen 72
Locking
head screws 57
plate 54
system 58, 59
reconstruction plate 55, 56f
Lower jaw infiltration 70

H
Head entering medullary space 54f
Healing of fracture 7f, 8f
bone 9
Hemorrhage 104
Hindrance in growth potential 98
Horizontally
favorable fractures 23, 23f
unfavorable fractures 23, 23f

I
Ideal
lines of osteosynthesis 60
load-sharing situation 61
Incising temporalis fascia 89
Inferior alveolar nerve block 70
Infra-alveolar nerve block 70
Infraorbital
block 68
nerve block 66, 68

M
Malreduction of fracture 60f
Mandibular
condyle fracture 79
muscles 14
Mental nerve block 72
Mentalis muscle dissection 92
Middle superior alveolar nerve block 66,
67
Minihole plate 75f
Miniplate
at external oblique line 78f
osteosynthesis 74
Mobilization of temporomandibular joint
103
Mucosal incision 91
for angle fracture 92f
for condyle and ramus fracture 94f
Multiple and comminuted fractures 34

Index / 113
Muscles of
facial expression 14
mastication 14

N
Neck of condyle 13
Nerves 16
Neurovascular structures 85, 88, 91
Nonrigid osteosynthesis 48

O
Off-angle drilling 51f
Open reduction 81
Option for off-angle drilling 51
Osteitis 105
Osteomyelitis 105

P
Parasymphysis fracture 76, 77
Pathological fractures 18
Period of mobilization 43
Phases of fracture healing 6
Posterosuperior alveolar nerve block 65, 66
Prevention of infection 101
Primary
bone healing 9
loss of reduction 58

R
Removal of fixation 102
Rigid osteosynthesis 48
Rowe modification 90

S
Screw
driver and screw 75f
insertion 53f, 54
Secondary loss of reduction 59
Semirigid osteosynthesis 48
Sensory buccal nerve 93, 95
Sign and symptoms of mandibular
fractures 31
Simple fracture 21, 21f
Single fracture 33
Skin incision 85, 88

Soft tissue lacerations 40


Subcondylar fractures 79
Submental extension 84
Subperiosteal dissection of mandibular
ramus 87, 88
Support of bone fragments 40
Surgical
dressing 97
flap dissection 91
Symphysis
fracture 76
of mandible 13

T
Temporomandibular joint 17
Threaded plate hole and threaded screw
head 57f
Three-dimensional CT scan 38
Tranparotid approach skin incision 86f
Treatment of infected fractures 105
Triangular base fracture at angle of
mandible 78f
Type of fixation 43f

U
Unerupted tooth 99
Unilateral condylar fractures 32
Universal fracture plate 59
Use of existing lacerations 97

V
Variations in incision 83f
Various
site of fracture 20f
submandibular incisions 84f
Vascular supply of mandible 16
Vertically
favorable fractures 23, 23f
unfavorable fracture 24, 24f
Vestibular incision 91-93

W
Wiring techniques 46
Wound closure 84, 88, 89, 92, 96, 97
of vestibular incision 94
using envelope flap 94