CME

Management of Mandible Fractures

D. Heath Stacey, M.D.
John F. Doyle, D.D.S.
Delora L. Mount, M.D.
Mary C. Snyder, M.D.
Karol A. Gutowski, M.D.
Madison, Wis.

Learning Objectives: After studying this article, the participant should be able
to: 1. Review the incidence and etiology of mandible fractures. 2. Discuss
indications and techniques for closed and open treatment of mandible fractures.
3. Review complications of mandible fractures.
Background: Mandible fractures are among the most common types of facial
fractures treated by plastic surgeons. They must be managed carefully to maintain the function of the mandible, reestablish proper occlusion, and minimize
secondary complications.
Methods: Current methods of management include combinations of soft diet,
intermaxillary fixation, open reduction with plate fixation, and, rarely, external
fixation.
Results: Decision-making depends on the age of the patient, type of fracture
identified, and concomitant medical conditions or injuries.
Conclusion: The authors review the diagnosis and current trends in management of mandible fractures. (Plast. Reconstr. Surg. 117: 48e, 2006.)

ANATOMY

he mandible is a U-shaped bone containing

thick buccal and lingual cortices and a thin
medullary cavity. This bone actually consists of two hemimandibles that unite at the midline symphysis. Each side consists of the perpendicular body and the horizontal ramus, which
unite at the angle. The upper border of the
ramus is capped by the coronoid anteriorly and
the condyle posteriorly, separated by the sigmoid notch. The condyle articulates with the
glenoid fossa to form the temporomandibular
joint, a diarthrodial joint with two motions: rotation around the horizontal axis of the condylar
head and forward translation. The joint capsule
contains a mobile cartilaginous disc that can be
injured or displaced with condylar fractures. The
alveolar ridge is the tooth-bearing region of the
mandibular body and consists of compact cortical bone.
The blood supply of the mandible is from the
inferior alveolar artery and the direct muscular
attachments. The inferior alveolar nerve enters
the medial mandible at the mandibular foramen
with the artery, traverses the medullary cavity
near the lingual cortex below the level of the
From the Division of Plastic and Reconstructive Surgery,
Department of Surgery, University of Wisconsin Medical
School.
Received for publication December 9, 2004; revised May 23,
2005.
Copyright 2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000209392.85221.0b

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tooth roots, and then rises to exit the mental

foramen at about the second premolar. This
nerve provides sensation to the mandibular
teeth and the skin and mucosa of the lower lip.
Two main groups of muscles insert and act
upon the mandible: the muscles of mastication
and the suprahyoid muscles. There are four
chief muscles of mastication, innervated by the
mandibular branch of the trigeminal nerve. The
masseter is a thick, rectangular muscle, originating from the zygomatic arch and inserting on the
lower lateral border of the ramus. The temporalis originates from the temporal fossa and inserts
on the coronoid and anterior border of the ramus. The medial pterygoid originates on the
medial portion of the lateral pterygoid plate and
inserts along the medial border of the angle.
These three muscles exhibit a strong upward
pull on the posterior mandible and act to close
the mouth. The temporalis also retracts the mandible. The lateral pterygoid muscle originates
from the lateral aspect of the lateral pterygoid
plate and the greater wing of the sphenoid and
inserts on the neck of the condyle and the capsule of the temporomandibular joint. This muscle protrudes the mandible and assists in opening the mouth. Alternating actions of the
internal and external pterygoid muscles result in
side-to-side movement of the mandible.
The suprahyoid muscle group includes the
digastric, stylohyoid, mylohyoid, and geniohyoid
muscles. The digastric muscle has two bellies
joined by a central tendon. The posterior belly,

www.plasreconsurg.org

Volume 117, Number 3 Mandible Fractures

innervated by the facial nerve, originates from the
mastoid and extends anteriorly and inferiorly. The
anterior belly, innervated by the mylohyoid branch
of the inferior alveolar nerve, originates on the
lingual surface of the parasymphysis and extends
inferiorly and posteriorly. The two muscles insert
into a common tendon, which perforates the stylohyoid muscle, and into the greater cornu of the
hyoid. The stylohyoid originates from the styloid
process and inserts into the body of the hyoid. It is
innervated by the facial nerve. The mylohyoid is a
broad, flat muscle originating from the mylohyoid
line on the lingual surface of the mandible, extending from the symphysis to the third molar. It
insets into the body of the hyoid and is innervated
by the mylohyoid branch of the inferior alveolar
nerve. The geniohyoid originates from the lingual
surface of the mandible superior to the mylohyoid
and inserts into the body of the hyoid bone. The
hypoglossal nerve innervates this muscle. The suprahyoid musculature elevates the hyoid and the
base of tongue during swallowing and depresses
the mandible, which opens the mouth.1
Displacement of fracture segments commonly
occurs as a result of the differing forces of these
muscles acting upon the mandible. In general,
the muscles of mastication tend to displace posterior segments superiorly, while the suprahyoid
muscles pull the anterior segments inferiorly. In
addition, the lateral pterygoid muscles tend to
pull the condylar head medially with high condyle fractures.

INCIDENCE
A recent review of the pattern of mandibular
fracture presentation at an urban trauma center
found that mandible fractures overwhelmingly

occur in males and are most often caused by interpersonal altercations.2 More than one-third of
fractures occur in the 25- to 34-year-old age group,
and 55 percent of cases involve illicit drug use.3
The mandible is the site of injury in approximately
40 percent of pediatric facial trauma cases, which
are most commonly a result of motor vehicle
accidents.4,5 Fracture location by site includes condylar (36 percent), body (21 percent), angle (20
percent), symphysis (14 percent), alveolar ridge
(3 percent), ramus (3 percent), and coronoid fractures (2 percent) (Fig. 1). Patients with mandible
fractures often have other serious injuries that
warrant additional attention, including cervical
spine injuries or other facial fractures.

DIAGNOSIS
The mechanism of injury can provide valuable
information in the examination and treatment of
patients with mandibular trauma. Interpersonal
altercations tend to result in a higher incidence of
angle fractures, whereas motor vehicle accidents
are associated with parasymphyseal fractures. Pediatric patients with jaw pain after a fall need to be
evaluated carefully for condylar fractures, which
may be bilateral.
Past medical history should be assessed, because seizure disorders, alcohol abuse, temporomandibular joint problems, and nutritional or
metabolic derangements can influence treatment
and outcomes. It is important to have an idea of
the preinjury dental occlusion, because it will be
abnormal in many patients. Dental impressions, if
present, can be extremely helpful and should be
requested from the patients dentist.
A complete head and neck examination is indicated in the evaluation of the patient with sus-

Fig. 1. Regions of the mandible and the correlating percentage of fractures occurring in each region. Reprinted with
permission from Dingman, R. O., and Natvig, P. Surgery of Facial Fractures.

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Plastic and Reconstructive Surgery March 2006

pected mandibular trauma. In addition, the temporomandibular joint is examined in the
cooperative patient by placing a finger in the external auditory canal. The condylar head will
translate anteriorly without significant pain if the
joint is not injured. Physical examination findings
in mandibular fractures are summarized in Table
1. Both subjective and objective malocclusions are
very common. Unilateral condylar fractures commonly present with a contralateral open bite and
deviation to the ipsilateral side upon opening.
Bilateral condylar fractures may present with anterior open bite and premature posterior contact.
Concomitant injuries must be ruled out, especially after motor vehicle accidents or gunshot
wounds, and the principles of ATLS should be
followed. Bilateral body or angle fractures can result in airway distress. In cases of mandible fractures secondary to interpersonal conflict, loss of
consciousness occurs in 20 percent, and the possibility of closed head injury should be
considered.6

RADIOLOGY
An algorithm is presented in Figure 2 that may
guide the clinician in radiographic evaluation of
the patient with a suspected mandibular fracture.
Plain radiographs, such as the low Townes view
and a Panorex, are usually the first radiographs
ordered (Figs. 3 and 4). A low Townes view will
clearly show the condylar processes of the mandible and is helpful in identifying fractures in the
sagittal plane. In one study, the Panorex was
shown to diagnose 92 percent of mandible
fractures.7 It is also useful as a postreduction radiograph. A maxillofacial computed tomography
scan may be useful if the patient has multiple
midface injuries, is in a cervical collar, or cannot
otherwise undergo panoramic radiography. The
three-dimensional reconstructions may be useful
in planning treatment or if the axial cuts appear
confusing (Figs. 5 and 6).
Wilson et al.8 found that a helical computed
tomography scan was 100 percent sensitive in diTable 1. Physical Examination Findings
Malocclusion
Buccal or lingual ecchymosis
Mucosal lacerations indicating an open fracture
Palpable bony step-offs
Pain
Numbness
Trismus
Edema
Excess salivation
Tongue lacerations

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agnosing fractures of the mandible compared with

a Panorex, which was 86 percent sensitive. Of the
fractures missed by the Panorex, six out of seven
were located in the posterior mandible. However,
this study also suggests that a dental root fracture
may be better visualized using a Panorex, especially when the fracture is located in the angle.
Cervical spine fractures may be present in 2.6 percent of patients with mandible fractures, and they
must be ruled out before proceeding with any
operative management.9 14

CLASSIFICATION OF FRACTURES
Mandibular fractures are most often described
by anatomic location (Fig. 1) in the mandible and
whether they are displaced, comminuted, or
greensticked. They may also be classified as either favorable or unfavorable, based on location
and configuration. Favorable fractures are those
that are nondisplaced by muscular pull and include most ramus fractures. Angle fractures that
extend posteriorly and downward are horizontally
unfavorable and tend to be displaced by the muscles of mastication. Symphyseal and parasymphyseal fractures tend to be vertically unfavorable and
are displaced by the downward pull of the suprahyoid musculature. High condylar fractures are
considered unfavorable and are often displaced
medially by the lateral pterygoid muscle.

MANAGEMENT OF MANDIBULAR
FRACTURES
An algorithm for treatment of mandible fractures is presented in Figure 7.
Timing
Definitive repair of a mandibular fracture is
not a surgical emergency, and treatment is often
delayed in the multiply injured patient. A recent
study comparing patients undergoing repair
within 3 days of injury to those repaired after 3
days found no increase in complication rates.15 We
currently attempt to manage these patients within
24 to 36 hours of injury, to minimize patient discomfort and expedite hospital discharge, as well as
to avoid maximal soft-tissue edema and fibrinous
deposition within the fracture.
In cases of treatment delay, we occasionally use
a Barton bandage to obtain dental occlusion and
decrease pain.16 This bandage is formed by wrapping a - to 12-inch gauze bandage underneath
the jaw and then alternating around the top of the
head and back of the neck. The gauze is then
secured with an elastic wrap. The bandage should

Volume 117, Number 3 Mandible Fractures

Fig. 2. Diagnostic algorithm.

Fig. 3. A low Townes view in a postoperative patient after plating of left angle fracture and right parasymphyseal fracture.

Antibiotics
Mandibular fractures are essentially open fractures that should be considered contaminated,
because of the oral flora, and many surgeons utilize prophylactic antibiotics. Controversial indications for perioperative antibiotics include heavily
contaminated fractures, severely comminuted
fractures, severely lacerated soft tissues, difficult
fractures requiring a long operative time, and delayed fracture treatment.17 However, a recent randomized prospective study showed no difference
in rates of wound infection in patients with an
uncomplicated mandible fracture who received
postoperative antibiotics versus those who received placebo.18 Currently, we give either penicillin with metronidazole or clindamycin alone to
patients with complicated mandible and/or multiple facial fractures. Prophylaxis should also be
considered in uncomplicated fractures occurring
in patients with valvular heart disease or prosthetic
implants.

supply a force that maintains occlusion. Patients

may find long-term use of the bandage uncomfortable, and definitive treatment should be
sought as soon as feasible.

Teeth in the Line of Fracture

Special consideration should be given to teeth
in the line of fracture. A loose tooth is not necessarily an indication for extraction. Chidyllo and

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Plastic and Reconstructive Surgery March 2006

Fig. 4. Preoperative Panorex view of the same patient shown in

Figure 2. Note the severely displaced parasymphyseal fracture on
the right and the left angle fracture.

nondisplaced or grossly comminuted fractures,

fractures in the presence of mixed dentition or in
the atrophic mandible, and fractures of the coronoid or condyle. External fixation and intraoral
appliances were once widely used for closed
reduction23 but have now been largely replaced by
other methods. Splints and dentures are occasionally used in children with mixed dentition or in
edentulous patients. The splints or dentures are
fixed to the mandible and maxilla by palatal screws
or circumferential wires. Occlusion is then established and maintained by wiring the upper and
lower appliances together.
Closed reduction is commonly achieved by intermaxillary fixation using arch bars, Ivy loops, or
suspension screws. Arch bars are applied to the
upper and lower jaws with circumdental wires.
Occlusion can be maintained with either wires or
elastics. We prefer to use elastics to provide a constant tension and to guide the teeth into occlusion.
Ivy loops are useful in patients with mixed dentition or poor dentition and in patients who are
unable to tolerate the application of arch bars, but
they are largely of historical interest. Another
method of intermaxillary fixation involves placement of anterior suspension screws and wiring.
Two screws are placed near the lateral pyriform
aperture in the maxilla and two are placed medial
to the mental foramen in the mandible, with sus-

Fig. 5. Maxillofacial computed tomography three-dimensional

reconstruction of a patient with a posttraumatic fracture of the
left ramus and right parasymphyseal region (courtesy of Lindell
Gentry, M.D.).

Marschall19 recommend tooth extraction if a comminuted or displaced fracture contains a tooth, if

the tooth root is fractured, if there is periodontal
disease or an abscess near the fracture line, or if
the tooth is functionless because of lack of opposing teeth. Fuselier et al.20 recently found no significant increase in complication rates when a
tooth in the line of fracture was retained. In addition, the presence of an impacted third molar in
the mandible increases the chance of an angle
fracture at least two-fold.21,22
Closed Reduction
Indications for closed reduction of mandibular fractures remain controversial but may include

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Fig. 6. Maxillofacial computed tomography three-dimensional

reconstruction of a patient with a comminuted right parasymphyseal fracture and a left ramus linear fracture (courtesy of Lindell Gentry, M.D.). Note also the bilateral Le Fort I, II, and III fractures.

Volume 117, Number 3 Mandible Fractures

Fig. 7. Treatment algorithm. MMF, mandibulomaxillary fixation; ORIF, open reduction and internal fixation.

pension wiring to bring the teeth into occlusion.

Table 2 summarizes posttreatment care for closed
and open treatment.
A recent study noted a lower complication rate
with closed treatment of fractures of the mandibular body, angle, and parasymphyseal regions.2
However, Ellis et al.24 found lower complication
rates in patients with comminuted mandibular
fractures who underwent open reduction and fixation than in those who were treated with closed
reduction. Closed reduction of mandibular fractures cost significantly less than open reduction
(mean charges, $10,927 versus $34,636), according to a recent report by Schmidt et al.25
Open Reduction and Internal Fixation
Indications for open reduction and internal
fixation of mandible fractures include most symphyseal and parasymphyseal fractures, displaced
body and angle fractures, and certain condylar
Table 2. Posttreatment Care
Nutrition consult for jaw-wire diet
Physical therapy consult
Occupational therapy consult
Give patient wire cutters and instruct on use
Patient compliance with mandibulomaxillary fixation may
be a problem
Stress oral hygiene

fractures. Specific indications for opening of condyle fractures are reviewed below.
Adequate exposure is a key component of
proper open reduction of mandible fractures. An
intraoral buccal sulcus incision is commonly used
for parasymphyseal and body fractures, with care
taken to avoid injury to the mental nerve and its
branches. Either an external or an intraoral approach can be used for access to angle and ramus
fractures. The external approach can provide better visualization and access to the inferior border,
but the marginal mandibular nerve may be placed
at risk. Most plating companies offer specialized
cheek retractors that aid in the intraoral approach
to the posterior mandible (Fig. 8). The fracture
site should be adequately debrided of all fibrin
and hematoma to allow tight approximation of the
bone edges.
Reduction can often be achieved with application of intermaxillary fixation. Additional reduction may be achieved with the use of a lower
border wiring technique26,27 or bone pliers to approximate two fracture fragments. This lower border wire can then be removed once a plate has
been placed across the fracture line. There continues to be debate over whether to maintain intermaxillary fixation after open reduction and internal fixation of the mandible. Indications for use
of intermaxillary fixation after open reduction

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Plastic and Reconstructive Surgery March 2006

Fig. 8. A transbuccal approach for placement of screws into

plates to repair a mandible body or angle fracture. A cheek retractor is placed, and then the transbuccal instrument is placed
through a stab incision. The photograph is from the surgeons
perspective.

and internal fixation include the presence of a

concomitant subcondylar fracture, if a single plate
is used without a tension band or when the stability
of the internal fixation is in question, such as in
comminuted fractures. Lazow28 had good results
with a 2- to 3-week period of mandibulomaxillary
fixation after performing open reduction and internal fixation, with a complication rate of only 3.4
percent.
A recent review provided by Alpert et al.29 describes the three basic types of rigid fixation: stabilization by compression, stabilization by splinting, and semirigid fixation. The indications for the
use of compression plates remain controversial, as
the plates are technically difficult to use and may
cause malocclusion and there are no studies showing their superiority versus other fixation methods. Compression plating of mandibular fractures
may result in higher rates of complications, especially infections.
Lag screws may be used for compression if the
fracture line is favorable and if the fracture is
noncomminuted. Usually, two lag screws at least
20 mm in length are sufficient for stabilization.
When treating a parasymphyseal fracture, two
long lag screws can be criss-crossed across the vertical fracture line (Fig. 9).17,30 The superior screw
must be placed in the buccal cortex to avoid damage to the tooth roots. Lag screws may also be used
to repair oblique fractures of the horizontal ramus.
A tension band plate is sometimes placed on
the superior border of the fracture line to closely
approximate this area, because it tends to sepa-

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rate. This is referred to as the Champy technique.

The tension band plate can also be used in the
wider section of the vertical mandible. This is
sometimes used in body and angle fractures. Care
must be taken to avoid the dental roots. The tension band can be used in combination with a
larger bicortical fracture plate or may be used
alone, with reliance on the muscles of mastication
for fixation.
A locking reconstructing plate can be used
when the fragments are small and comminuted
and compression is not needed.29 This method has
become more popular over the past few years.
Internal fixation is achieved by locking the screw
to the plate rather than compressing each fragment of bone to the plate. We usually place a
minimum of four screws in the plate, two on each
side of the fracture line. A locking plate may also
be used in combination with a dental splint to add
additional fixation if the comminution involves
alveolar bone. Proponents of the locking plate
point out that the placement of screws should not
alter the reduction, but this has not been proven.
Also, the screw should not loosen secondary to
inflammation, infection, or placement in a fracture gap, since it is locked to the plate. It is unproven whether adequate alignment of the fractured mandible can be obtained with an unbent
locking plate when treating comminuted mandible fractures or combined parasymphyseal and
condylar fractures. These complex fractures make

Fig. 9. Parasymphyseal fracture treated with two horizontal lag

screws.

Volume 117, Number 3 Mandible Fractures

it difficult to obtain adequate arch form when
plating them. For instance, if the plate is not contoured to the curve of the mandible when plating
a parasymphyseal fracture, then a concomitant
subcondylar fracture will be displaced. The treatment of comminuted fractures using AO/ASIF
reconstruction plates was reported to have a low
complication rate of 3 percent in at least one
study.31
Semirigid fixation can be performed using a
small plate with 1.5- to 2.0-mm unicortical screws.
The advantages are the limited periosteal stripping of the fracture site needed. This technique
relies on the forces of the strong jaw muscles to
hold the fracture in place. The minor complication rate is higher and includes plate/screw extrusion and fracture, but the major complication
rate is low.29

TREATMENT OF CONDYLE FRACTURES

There are a few absolute indications for performing open reduction and internal fixation on
condylar fractures: displacement into the middle
cranial fossa, impossibility of obtaining dental occlusion by closed reduction, lateral extracapsular
displacement of the condyle, presence of a foreign
body, or open fracture with potential for fibrosis.32
Relative indications include bilateral or unilateral
condylar fractures with a midface fractures, comminuted symphysis and condyle fracture with
tooth loss, displaced fracture resulting in open
bite or retrusion in mentally retarded or medically
compromised adults who would not tolerate intermaxillary fixation, and displaced condylar fractures in the edentulous or partially dentate mandible with posterior bite collapse. Haug and
Assael33 reported that their absolute indications
for open reduction and internal fixation of condylar fractures include patient preference (when
no contraindication exists), failure of closed treatment to reestablish preinjury occlusion, rigid fixation of another facial fracture affecting occlusion, or limited stability of occlusion (e.g., less
than three teeth per quadrant, gross periodontal
disease, or skeletal deformity.) Their absolute contraindications to open reduction and internal fixation of condylar fractures are fractures at or
above the ligamentous attachment (single fragment, comminuted, or medial pole) or when
other injury or illness precludes extended general
anesthetic risk.
Lindahl34 presented a manageable classification system of mandible condyle fractures
(Table 3) based on a prospective study of 138
mandible fractures. His system defines the frac-

Table 3. Lindahl Classification System for Mandible

Condyle Fractures
Fracture level
Condylar head: at or above the ligamentous attachment
Condylar neck: thin, constricted region below head of
condyle
Subcondylar: from the sigmoid notch to the posterior
mandible just below the neck of the condyle
Dislocation at fracture level of condylar neck, subcondylar
Angulation with medial override
Angulation with lateral override
Angulation without override
Fissure
Position of condylar head to articular fossa
No displacement
Slight displacement
Moderate displacement
Dislocation

ture level, degree of dislocation, and position of

the condylar head with respect to the articular
fossa.
Brandt and Haug35 pointed out that the current classification schemes regarding choice of
open reduction and internal fixation versus closed
management focus on signs and symptoms and
not on the location of the condylar fracture. Their
conclusions from the studies reviewed were that if
a patient has good range of motion, good occlusion, and minimal pain, then observation or
closed reduction and mandibulomaxillary fixation is preferred, regardless of the level of fracture.
A condylar head fracture should be managed in
the same fashion. They advocate that open reduction and internal fixation is indicated for displaced or unstable low condylar neck or subcondylar fractures.
We manage condylar fractures without indications for open treatment by placing arch bars
and guided elastics, with early physical therapy
within 1 to 2 weeks to restore mobility. Others have
advocated functional therapy without a period of
mandibulomaxillary fixation. It is important to
emphasize that the occlusal status of the patient
with a condyle fracture should be assessed, and if
there is no malocclusion, then conservative management, especially in children, is advocated.
There may be a higher patient perception of pain
associated with closed treatment.
Brandt and Haug35 reviewed several studies of
outcomes of condyle fractures treated by closed
reduction and mandibulomaxillary fixation versus
open reduction and internal fixation. The closed
treatment group showed a higher percentage of
anatomic displacement when compared with the
open reduction/internal fixation group in one

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Plastic and Reconstructive Surgery March 2006

study.36 Worsaae and Thorn37 cited a 39 percent
complication rate in the closed treatment group,
which included asymmetry, malocclusion, reduced maximum intercisal opening, headaches,
and pain. The open reduction/internal fixation
group had a 4 percent complication rate, which
included malocclusion, impaired mastication, and
pain. Ellis and Throckmorton38 reviewed occlusal
results of 142 patients with unilateral neck or subcondylar fractures and found a higher percentage
of malocclusion (22.6 percent to 28.6 percent versus 0 percent) in the closed treatment group versus the open treatment group. Another review of
146 patients (81 with closed treatment and 65 with
open treatment) focused on the comparison of
postoperative mandible and facial morphology.38
The results were that patients treated with closed
methods had a higher incidence of shorter posterior facial height on the side of injury and more
tilting of the occlusal and bigonial planes toward
the fractured side. Throckmorton and Ellis39 followed 62 patients treated by open reduction and
internal fixation and 74 treated by closed reduction and found that patients treated with open
reduction achieved postoperative mandible mobility quicker postoperatively than patients treated
by closed methods, as measured by a jaw-tracking
device. They also concluded that, regardless of
treatment, patients with unilateral condylar fractures had maximum excursion with return to normal values within 3 years.
A study of 65 patients treated with a closed
approach showed a difference in condyle position
between the initial examination and after placement of arch bars, but not after 6 weeks.40 This
difference was noted in the coronal plane but not
in the sagittal plane, as evaluated by a low Townes
and Panorex radiograph. Ellis et al.41 also looked
at how well a fractured condylar process was reduced after fixation by prospectively studying 61
patients treated by open reduction and internal
fixation for unilateral condyle fractures using low
Townes and panoramic radiographs. The fractured condyle was compared with the normal contralateral condyle preoperatively, immediately
postoperatively, and at 6 weeks and 6 months.
Postoperatively, the difference in position was less
than 2 degrees, but 10 to 20 percent of the condyles subsequently had a postsurgical change in
position of more than 10 degrees.
Another study demonstrated no difference between open reduction and internal fixation versus
closed reduction and mandibulomaxillary fixation with regard to maximum achievable bite
forces. The authors note that it is probable that

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asymmetries in condylar support are of little performance for generating occlusal force, since
there is a lack of correlation between the amount
of condylar displacement and maximal bite forces.
Ellis et al.42 reviewed their complications in
178 patients with unilateral condylar fractures (85
were treated with closed reduction and 93 were
treated with open reduction). At 6 weeks postoperatively, 17.2 percent of the open group had facial nerve weakness; all cases were resolved by 6
months. Hypertrophic or wide scars were noted in
7.5 percent of the open treatment group. They
used a transparotid, retromandibular approach to
the condyle and only treated the condyle fracture
after other mandible fractures, if present, were
exposed and fixated. Three cases of parotid fistula
occurred in the open treatment group. It should
be noted that all of the open procedures were
performed by a single surgeon, which added an
average of 40 minutes to the operating room time
when compared with the closed treatment group.
Brandt and Haug35 reviewed some of the options for internal fixation of condylar fractures.
Their conclusions are that the literature supports
that the adaptation plate is the least favorable and
the minidynamic compression plate is the most
favorable of the available options for internal fixation of condylar fractures.
Assael43 reviewed many of the same articles as
Brandt and Haug35 did and offered alternative
conclusions from the evidence. Assael43 cites MacLennans44 series of 180 patients, of whom 61 percent had a radiographic deformity and only 6 percent had a clinical deformity after closed
treatment for condylar fractures. He argues that
complications should be measured by looking at
whether the patient has pain, decreased function,
and a bad clinical appearance, rather than at radiographic criteria. It should be noted that patients with condylar fractures treated with closed
reduction rarely complain of a posttraumatic deformity. The avoidance of visible scars with closed
treatment should also be considered, since patients generally find these scars to be unfavorable.
Assael43 minimizes the difference that Ellis and
Throckmorton38 found in facial symmetry and ramus height in the closed and open treatment
groups, because clinical examination was not used
as an outcome indicator. In addition, the decrease
in ramus height in the closed group was 2 to 5 mm,
and this was not shown to be clinically significant.
Silvennoinen et al.45 noted a 13 percent rate of
malocclusion in their series of patients with condylar fractures treated by closed treatment. They
concluded that a subset of patients exist who have

Volume 117, Number 3 Mandible Fractures

a functional reduction of ramus height and these
patients will benefit from open treatment. Shortened ramus height can be determined clinically by
noting ipsilateral molar occlusal disruption, inability to maintain maximum intercuspation, and
superior displacement of the gonion on radiographs. This subset is probably about 10 percent
of patients who present with condylar fractures,
and they can be identified before treatment.
A good assessment of the variables affecting
whether a condyle fracture should be treated open
or closed is offered by Assael.43 A patients age, sex,
systemic diseases, and compliance should be considered. Children up to age 11 undergo more
adaptation and remodeling than do teenagers and
adults.34 Females may have more functional impairment after a condyle fracture regardless of
treatment. The presence of diabetes mellitus, osteoporosis, renal failure, tobacco, alcohol, and
drug abuse, and many other diseases influences
the choice of treatment.
In addition, there is a small risk of infection
with open treatment that is increased if there is
delayed treatment or multiple injuries. The risk of
nerve injury to the facial nerve or trigeminal nerve
with open treatment is a concern. Scarring also is
a concern with open treatment. Both nerve injury
and scarring may be addressed by newer endoscopic techniques, which are discussed below. The
presence of comminution of the condylar head or
neck may persuade the surgeon to avoid open
treatment, because of higher rates of treatment
failure, ankylosis, and infection. Hemarthrosis can
displace the condyle and lead to fibroankylosis.
Chuong and Piper46 reported using arthroscopic
lavage when performing open reduction.
Associated fractures of the midface or symphysis probably are relative indications for open treatment of the condylar fractures to restore anatomic
and functional alignment. The surgeon must also
consider whether the patient has enough dentition to maintain ramus height. If not, then open
treatment may be a better choice. Also, if the patient is categorized as Angel class II, closed treatment may cause greater retrognathia and an open
bite. Dentition should also be assessed to determine whether there are worn occlusal surfaces of
the teeth, which can make maintenance of occlusion difficult when closed treatment is chosen.
Other factors noted by Assael43 include patient
expectations, surgeon ability, the technology of
the health care environment, and institutional resources.
Endoscopic open reduction and internal fixation of the condylar region has been used with

some success.4750 The benefits of this approach

include less chance of facial nerve injury and improved aesthetic outcome because of smaller
scars. Most surgeons report that endoscopic techniques take the same amount of time or longer
than other open treatment methods. Endoscopically assisted open treatment is difficult to master,
and there is a steep learning curve. The transoral
approach to the condyle leads to difficulty in visualization, which partially is improved with use of
an angled scope. Comminuted, dislocated, and
subcondylar fractures should probably be approached extraorally, according to Schon and
Schmelzeisen.50 Drawbacks to the endoscopic approach include a higher rate of hardware loosening, leading to reoperation in at least one study,47
and a possible higher rate of nonunion,
refracture,48 and possibly malocclusion. Schon et
al.51 reported their experience with transoral, endoscopically assisted open treatment with
miniplate fixation of displaced condyle fractures
in eight adults. At 18-month follow-up, there were
no facial nerve palsies, no visible scars, and good
temporomandibular joint function.

THE EDENTULOUS MANDIBLE

Controversy exists over the management of
mandibular fractures in the edentulous patient.
The severely atrophic mandible, with a height of
less than 20 mm, is especially problematic.
Barber52 advocates a conservative approach, using
the patients dentures or Gunning splints to provide closed reduction and intermaxillary fixation.
External fixation may also be considered in comminuted fractures. Barber reported low rates of
nonunion and good functional outcomes with
both of these methods. He also pointed out that
these patients are often elderly and have comorbidities that give them a higher risk of adverse
outcome with general anesthesia; therefore, techniques that are less invasive may be more suitable.
Marciani53 advocates open reduction of mandibular fractures in the edentulous patient if there is
a high likelihood that closed management will
result in complications or functional oral impairment. If open reduction is indicated, the fixation
device selected should provide immediate function and long-term stability (e.g., a titanium mesh
crib with immediate bone grafting). Luhr et al.54
reported a less than 4 percent complication rate
in a series of 84 patients with fractured atrophic
mandibles (20 mm in height or less) treated by
compression plating without mandibulomaxillary fixation.

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Plastic and Reconstructive Surgery March 2006

MANDIBLE FRACTURES IN CHILDREN
There are several differences in the treatment
of mandible fractures in children. The bone of a
child is more elastic and fractures tend to greenstick or minimally displace. There are also many
unerupted teeth, which tend to weaken the bone.
The mandible of a child is still growing, and any
open reduction of fractures can disrupt growth
centers, especially of the condyle. Most clinicians
advocate treating nondisplaced fractures of the
condyle in children by closed reduction combined
with some sort of fixation with mandibulomaxillary fixation and guided elastics. Guided elastics
and early mobility help prevent ankylosis at the
temporomandibular joint. Rigid mandibulomaxillary fixation should not last for more than 7 to 10
days in a child. If the child has no evidence of
malocclusion, we often prescribe a soft diet and
analgesics.
Nondisplaced angle, body, and parasymphyseal fractures may be treated with closed treatment
methods. Displaced mandibular fractures in children are treated in a manner similar to that used
for adults, with open reduction and internal fixation as indicated, but absorbable plates should be
considered. Yerit et al.55 recently reported their
series of 22 adult patients with mandible fractures
treated by open reduction/internal fixation using
poly-L-lactate absorbable plates and screws. There
were two cases of mucosal dehiscence, with one
requiring reoperation and placement of a titanium plate. The role of absorbable plates in the
treatment of mandible fractures continues to
evolve and has implications in the treatment of the
childs growing mandible.

COMPLICATIONS
In the literature, one may find mandible complication rates ranging from 7 to 29 percent.56,57
The complication rate has been correlated to the
severity of the fracture. Lois et al.58 found no difference in the complication rate of fractures
treated by mandibulomaxillary fixation versus
open reduction and internal fixation (4.3 percent
and 5.45 percent, respectively). Their total complication rate was 9.5 percent. They concluded
that in fractures with displacement in the range of
2 to 4 mm, there is no difference between mandibulomaxillary fixation and open reduction/internal fixation.
Collins et al.59 looked retrospectively at their
experience with different types of mandible fractures and found that complication rates were as
follows: angle fractures, 9.4 percent; body frac-

58e

tures, 8 percent; and parasymphyseal fractures, 3.3

percent. There was no statistical difference between complication rates in the body and the angle. The most commonly fractured site in this
study was the parasymphyseal region.
Alpert et al.29 described four types of complications: (1) those arising in the course of proper
treatment; (2) those caused by inadequate/inappropriate treatment; (3) those due to surgical failure; and (4) those that result from no treatment.
They went on to give examples of each, such as
infection from open reduction/internal fixation,
malocclusion from improper treatment, injury to
the marginal mandibular nerve due to technical
mistakes, and malocclusion from no treatment.
Wound infection is the most common complication in all types of mandible fractures. Some
studies have found that the rate of wound infection is higher in fractures treated by open reduction and internal fixation.2 Maloney et al.60 noted
a 3.3 percent bone infection rate in patients
treated with open reduction/internal fixation. Angle fractures were the most common in their
series.60 Other complications that occur less often
include malocclusion, nonunion, malunion,
tooth loss, trismus, ankylosis, deviation, unsightly
scars, and paresthesias.
Normal bony union of the mandible takes
place over 4 to 8 weeks, depending on the age of
the patient.61 A nonunion occurs when bony
union has not occurred within this time period.
The radiographic appearance is one of sclerotic
bony margins and a gap where bone has not
bridged the fracture site. Many of these fibrous
nonunions will eventually convert to a bony union.
Mathog and Boies62 cited inadequate mobilization, incomplete reduction, infection, poor blood
supply, and nutritional/metabolic alterations as
the most frequent causes of nonunion in mandible fractures. In their series of 577 mandible fractures, the incidence of nonunion was 2.4 percent.
Eight of the 14 nonunions were treated with debridement, antibiotics, and fixation, which suggests that improvements in technique and longer
fixation periods are factors in achieving bony
union. Six patients required bone grafts to maintain proper occlusal relationships. We have also
found that sex, age, and the cause of fracture give
no predictive information for a nonunion.

CONCLUSIONS
Fractures of the mandible are frequently encountered by the plastic surgeon. Investigation
into the mechanism of trauma, along with careful
physical examination, will often identify the loca-

Volume 117, Number 3 Mandible Fractures

tion of the fracture, which can then be verified
radiographically. After concomitant injuries and
comorbid conditions are evaluated, treatment
planning can begin. The algorithms presented in
this article will guide the surgeon in proper management of all types of mandible fractures.
D. Heath Stacey, M.D.
University of Wisconsin
3334 Bradbury Road
Madison, Wis. 53719
dheathstacey@gmail.com

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