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FRACTURES OF THE
MANDIBLE
ANATOMY
Mandible interfaces with skull base via the TMJ
Insertion
Innervation
Action
Masseter
Masseteric branch of
anterior division of
mandibular nerve (V)
Temporalis
Limits of temporal
fossa
Medial surface
coronoid process,
anterior surface of
ramus down to
occlusal plane
Elevates mandible,
posterior fibres are
the only muscle
fibres to retract the
mandible
Medial
pterygoid
Pterygoid fossa,
mainly medial
surface of lateral
pterygoid process
Medial surface of
ramus and angle of
mandible
Pulls angle of
mandible superiorly,
anteriorly and
medially
Lateral
pterygoid
Branch of anterior
division of
mandibular nerve
Lateral movement,
protrusion, important
in active opening of
the mouth
Insertion
Innervation
Action
Hypoglossal nerve
(XII)
Depresses tongue,
posterior part
protrudes tongue
Genioglossus
Superior part of
mental spine of
mandible
Geniohyoid
C1 through
hypoglossal nerve
(XII)
Mylohyoid
Mylohyoid line of
mandible
Mylohyoid nerve, a
branch of inferior
alveolar nerve (V3)
Digastric
Anterior: Digastric
fossa of mandible
Posterior: Mastoid
notch of temporal
bone
Intermediate tendon
to body and superior
(greater) horn of
hyoid bone
Anterior: Mylohyoid
nerve (V3)
Posterior: Facial
nerve (VII)
Depresses mandible,
raises hyoid bone
and steadies it during
swallowing and
speaking
Muscles of
Mastication
OUTER SURFACE
Muscles of
Mastication
INNER SURFACE
Muscles of
Mastication
4 muscles of mastication
Masseter
Temporalis
Medial pterygoid
Lateral pterygoid
Masseter
Divided into 3 heads
Superficial:
largest head
Arises anterior 2/3rds of the lower border of the
zygomatic arch
Intermediate:
Middle 1/3 of the arch
Deep:
Deep surface of the arch
Masseter
Intermediate and deep fuse and pass
into 3 parts
Temporalis
Arises temporal fossa between inferior
mandible
Posterior fibres (horizontal) retract the
Medial pterygoid
2 heads:
Deep:
Larger
Medial surface of the lateral pterygoid plate and
Superficial :
Tuberosity of the maxilla and pyramidal process
of palatine bones
(with masseter)
Lateral pterygoid
2 heads:
Superior:
Infratemporal fossa
Inferior:
Lateral surface of the lateral pterygoid
pterygoid fovea
open jaw
Temporomandibular
Joint
Articulation
Synovial joint between the condyle of the
Temporomandibular
Joint
Unique feature of the TMJs is the
articular disc.
Composed of fibrocartilaganeous tissue
Divides each joint into 2:
Inferior compartment
Superior compartment
Temporomandibular
Joint
Inferior compartment
Allows for pure rotation of the condylar head,
corresponds to the first 20 mm or so of the
Superior compartment
Temporomandibular
Joint
Temporomandibular
Joint
No hyaline cartilage
TMJ Ligaments
3 ligaments associated with the TMJ:
1) Temporomandibular ligament (Major)
TMJ Ligaments
2) stylomandibular ligament (minor)
separates the infratemporal region from the
parotid region
runs from the styloid process to the angle of
the mandible
3) Sphenomandibular ligament (minor)
runs from the spine of sphenoid to the lingula
of the mandible
TMJ Ligaments
The minor ligaments are important in that
mandible.
TMJ Ligaments
TMJ Ligaments
Mandibular Forces
Nerve Supply
Inferior alveolar nerve branch of the
terminal branches:
Incisive nerve: supplies the anterior teeth
mental nerve: sensation to the lower lip
Evaluation - History
Always remember ABCs of life along with
Mechanism of injury
MVA associated with multiple comminuted #
Fist often results in single, non - displaced #
Anterior blow to chin - bilateral condylar #
Angled blow to parasymphysis can lead to
fractures
Angles classification
Class I:
Normal
Mesial buccal cusp of the upper 1 st molar
Class II:
Retrocclusion, mandibular deficiency
Class III:
Prognathic occlusion, maxillary deficiency,
mandibular excess
Dental classification of
occlusion
Angles classification (1887)
Class
Molar
relation
Canine relation
Mesiobuccal cusp of
maxillary 1st molar is in
line with buccal groove
of mandibular 1st molar
II
Buccal groove of
mandibular 1st molar is
distal to mesiobuccal
cusp of maxillary 1st
molar
Buccal groove of
mandibular 1st molar is
mesial to mesiobuccal
cusp of maxillary 1st
molar
Div1 Overjet
Div2 Lingual
inclination
III
Malocclusion
Physical Exam
Anaesthesia of the lower lip
Abnormal mandibular movement
unable to open - coronoid fx
unable to close - # of alveolus, angle or ramus
trismus
Physical Exam
Multiple fractures sites are common:
1 fracture: 50%
2 fractures: 40%
>2 fractures: 10%
Dual patterns:
Angle contralateral body
Symphysis and bilateral condyles
General Principles of
treatment
ABCs
Tetanus
Nutrition
Almost all can be considered open fractures
cutters
Aims of Management
1) Achieve anatomical reduction and
stabilisation
2) Re-establish pre-traumatic functional
occlusion
3) Restore facial contour and symmetry
4) Balance facial height and projection
Fracture Frequency
Classification of
Fractures
Open vs Closed
Displaced vs non-displaced
Complete vs greenstick
Linear Vs comminuted
Relationship to the teeth
Favourable vs unfavourable
Treatment options
No treatment
Soft diet
Maxillomandibular fixation
Open reduction - non-rigid fixation
Open reduction - rigid fixation
External pin fixation
IMF
IMF
Islet IMF
External Fixation
Principles of fixation
Usually one plate with 4
Anterior to mental
foramen, 2 levels of
fixation are required to
overcome torsional
forces
Unfavourable fractures
Condylar fractures
Classification
Condylar
Intra- or extra-capsular
subcondylar
Alveolar fractures
Can often be reduced and fixed with arch bars (can be acrylated)
or Essig splints
Edentulous mandible
No occlusal plane
Role of dentures
Paediatric mandible
Often greenstick fractures that heal within 2-3
weeks
Complications
Infection
Incorrect technique
56%pre-treatment
19% post-treatment
Malocclusion