Mandibular fracture 2 / fixed orthodontic courses

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CONTENTS :
FRACTURE
Definition
INTRODUCTION
ETIOLOGY
LOCATION
CLASSIFICATION OF MANDIBULAR
FRACTURES
DIAGNOSIS
CLINICAL EXAMINATION
Signs & symptoms
RADIOLOGIC EXAMINATION
GENERAL PRINCIPLES IN THE TREATMENT OF
MANDIBULAR FRACTURES.

•

MANAGEMENT OF MANDIBULAR FRACTURES
 TREATMENT OF PARTIALLY EDENTULOUS
MANDIBLE


TREATMENT OF EDENTULOUS MANDIBLE



COMPLICATIONS OF MANDIBULAR FRACTURE
MANAGEMENT
CONCLUSION




FRACTURE :
Definition :

Fracture is defined as sudden
violent solution in the continuity of the
bone which may be complete or
incomplete resulted from direct or
indirect causes.


MANDIBULAR FRACTURES :
Fractures of the mandible are common in patients, who
sustain facial trauma.
Study conducted by Hang et al in 1983, showed the ratio
of 6: 2: 1 of mandibular , zygomatic , maxillary fractures
incidence respectively.
Approximately two thirds of all facial
fractures are the mandibular fractures ( nearly 70 % ).
SEX :
Most mandibular fractures are seen to occur in male
patients. Ratio is approximately 3 : 1
AGE :
35 % of mandibular fractures occur between the ages of
20 to 30 years.

AETIOLOGY OF MANDIBULAR FRACTURES







1.Vehicular accidents
- 43%.
2.Altercation,assaults,interpersonnel
violence
- 34%
3.Fall
- 7%
4.Sporting accidents
- 4%
5.Industrial mishaps or work accidents
- 10%
6.Pathological fractures or miscellaneous
- 2%.

Location of mandibular fractures :
As per Olson’s study in 1982,
Condyle fractures
Angle fractures
Dento alveolar fractures
Molar region
Symphysis
Body fractures
Ramus fracture
Coronoid fractures
Mental region
Cuspid

-


29%
25%
3%
15%
16%
22%
4%
1%
14%
7%

Number of fractures per mandible.
The number of mandibular fractures per
patient ranged from 1.5 to 1.8.
1. Unilateral , single
2. Bilateral , double
3. Multiple fractures

-

53%
37%
10%

Fifty percent have more than one fracture.


Classification of mandibular fractures :
General classification
II)
Anatomical locations
III)
Relation of the fracture to site of injury
IV)
Completeness
V)
Depending on the mechanism
VI)
Number of fragments
VII)
Involvement of the integument
VIII) The shape or area of the fracture
IX)
According to the direction of fracture and
favourability for the treatment
X)
According to presence or absence of teeth
XI)
AO classification – relevant to internal fixation
I)


I)Kruger’s general classification:
1)Simple or closed: A fracture that does
not produce a wound open to the external
environment , whether it be through the skin,
mucosa or periodontal membrane.
The linear fracture which does not have
communication with the exterior.
Eg: Fracture in the region of the condyle,
coronoid process, ascending ramus etc.

2) Compound or open:
This fracture has communication
with the external environment through
skin, mucosa or periodontal membrane.
All the fractures involving the tooth
bearing area of the mandibular or where
an external or intraoral wound is present
involving the fracture line.

3) Comminuted fracture:
A fracture in which the bone is
splintered or crushed into multiple
pieces. These types are generally due to
a greater degree of violence or high
velocity impact. Gunshot wounds, where
missiles are traveling at a high velocity
can produce these fractures.

4) Greenstick fracture:
A fracture in which one cortex
of the bone is broken with the other
cortex being bent. It is an incomplete
fracture seen in young children because
of inherent resiliency of the growing
bone.


5)Pathologic fracture:
Spontaneous
fracture
of
the
mandible occurring from mild injury or as
a result of a normal degree of muscular
contraction. This is because of weakness
caused due to the pre-existing bone
pathology.


Areas of structural weakness may result from the
following:

a) Generalized skeletal disease:
i) Endocrinal disorders –
Hyper parathyroidism, or postmenopausal osteoporosis.
ii) Developmental disorders – Osteoporosis, osteogenesis
imperfecta.
iii) Systemic disorders – Reticuloendothelial diseases, Paget’s
disease, osteomalacia & severe anemia.
b) Localised skeletal disease:
Various cysts, odontomes, tumours, osteomyelitis,
osteoradionecrosis affect the local region.

6) Multiple Fractures:
A variety in which there are two or more
lines of fracture on the same bone not communicating
with one another.
7) Impacted:
Rarely seen in mandibular fractures. More
commonly seen in maxilla. This is a fracture in which
one fragment is firmly driven into the other fragment and
clinical movement is not appreciable.
8) Atrophic: A spontaneous fracture resulting from
atrophy of the bone, as in edentulous mandible.
9) Indirect: A fracture at a point distant from the site of
injury.

10)
Complicated
or
complex: Fractures
associated with the damage to the important vital
structures complicating the treatment as well as
prognosis.
Eg: Fractures with injury to the inferior alveolar
vessels or nerve, facial nerve or its branches, facial
vessels, condylar fractures with associated injuries to
middle cranial fossa, etc.


II) Anatomical Location
ROWE AND KILLEY’S CLASSIFICATION:
A) Fractures not involving the basal bone-are termed as
dentoalveolar fractures.
B) Fractures involving the basal bone of the mandible.
Subdivided into following:
i) Single unilateral
ii) Double unilateral
iii) Bilateral
iv) Multiple

DINGMAN AND NATWIG’S CLASSIFICATION OF
ANATOMIC REGION:
A

)Symphysis Fracture (Midline) – Fractures between central incisors

B) Parasymphyseal – Fractures occurring within the area of the symphysis.
C) Canine region fracture
D) Body – From the distal symphysis to a line coinciding with the alveolar border of the
masseter muscle (usually including the third molar).
E) Angle – Triangular region bounded by the anterior border of the masseter muscle to
the posterosuperior attachment of the masseter muscle (Usually distal to third molar).
F) Ramus – Bounded by superior aspect of the angle to two lines forming an apex at the
sigmoid notch.
G) Condylar process – Area of the condylar process superior to the ramus region
H)
I)

Coronoid process – Includes the coronoid process of the mandible superior to ramus
region.
Alveolar process – The region that would normally contain teeth

ANGLE FRACTURES may be classified as:

)Vertically favorable or unfavorable

) Horizontal favorable on unfavorable.


In 1934, Wassmund described five types of condylar fractures:
Type I: Defined as a fracture of the neck of the condyle with
relatively slight displacement of the head. The angle between the
head & axis of ramus varies from 10 to 45 degrees.
Type II: Produce an angle from 45 to 900 resulting in tearing of
medial portion of the joint capsule.
Type III: The fragments are not in contact and head is displaced
mesially and forwards owing to traction of lateral pterygoid muscle.
Type IV: The fractures of condylar head articulate on, or in a
forward position with regard to, the articular eminence.
Type V: Consisted of vertical or oblique fractures through the head
of condyle.

III)
IV)
V)

Relation of the fracture to the site of injury:
i) Direct fractures
ii) Indirect fractures(Countercoup)
Completeness
- Complete and incomplete fractures
Depending on the mechanism
i) Avulsion fracture
ii) Bending fracture
iii) Burst fracture
iv) Countercoup fracture
v) Torsional fracture

VI) Number of Fragments
- Single, multiple, comminuted
VII)

Involvement of the integument
-Closed/ open fractures
-Grades/ severity I-V

VIII)

Shape or area of fracture:
Transverse, oblique, butterfly, oblique surfaces

IX) According to the direction of fracture and
favorability for treatment
a. Horizontally favorable fracture
b. Horizontally unfavorable fracture
c. Vertically favorable fracture
d. Vertically unfavorable fracture
X. According to presence or absence of teeth in relation
to fracture line


KAZANJIAN’S AND CONVERSE
CLASSIFICATION:
Class I: When the teeth are present on both sides of the
fracture line.
a) An adequate number of teeth of suitable shape and
stability. Wiring- direct, continuous /multiple loop or
interdental eyelet type, use of prefabricated arch bars.
b) An inadequate number of teeth, whose shape or stability
is unsuitable.
c) Lateral compression splint, arch bars or cast metal cap
splints.

Class II – When the teeth are present only on one side of
fracture line.
a) Short edentulous posterior fragment
i) If favorable, immobilization of main fragment by interdental
wiring or arch bars.
ii) If unfavorable – open reduction with direct fixation is a
must.
b) Long edentulous posterior fragment
i) Without displacement – Conservative treatment
ii) With vertical & medial displacement requires open surgical
reduction & fixation.

Class III – When both the fragments on each side of the
fracture line are edentulous.

i) Simple or compound fracture without much displacement
in the body region.Simple gunning type splints.
ii) Simple fractures which are unfavorable. Open reduction &
fixation.
iii) Compound fractures. Surgical intervention


XI) AO CLASSIFICATION(RELEVANT TO
INTERNAL FIXATION):
1) F: Number of fracture or fragments
2) L: Location (site) of fracture
3) O: Status of occlusion
4) S: Soft tissue involvement
5) A: Associated fractures of facial skeleton
Grades of severity: I-V
•

Grade I and II are closed fractures

•

Grade III and IV are open fractures

•

Grade V open fracture with a bony defect (gunshot)

History:
The patient’s health history may reveal of existing systemic
bone disease, neoplasia with potential metastasis, arthritis
& related collagen disorders, nutritional & metabolic
disorders, & endocrine diseases that may cause or be
directly related to the fractured jaw
A history of temporomandibular joint dysfunction can have
significant legal & post treatment ramifications.
Fractures sustained in vehicular accidents are usually far
different from those sustained in personnel altercations.
An anterior blow directly to chin can result in bilateral
condylar fractures & an angled blow to the parasymphysis
may cause a contralateral condylar or angle fracture.

CLINICAL EXAMINATION:
The signs and symptoms of mandibular fractures are as
follows:
1.
2.
3.
4.
5.

Change in occlusion:
Anesthesia, paresthesia or Dysesthesia of the lower
lip
Abnormal mandibular movements:
Change in facial contour and mandibular arch form:
Lacerations, Haematoma & Ecchymosis:

6.
7.

Loose teeth and crepitation on palpation:
Dolor, Tumor, Rubor & Color :

Radiologic examination:
1) Panoramic radiograph
2)
Lateral oblique radiograph
3)
Posteroanterior radiograph
4)
Occlusal view
5)
Periapical view
6)
Reverse Towne’s view
7)
Temporomandibular joint, including
tomograms.
8) Computed tomography (CT) scan.

General principles in treatment of mandiibular
fractures.

1) The patient’s general physical status should be carefully evaluated
& monitored prior to any consideration of treating mandibular
fractures
2) Diagnosis & treatment of mandibular fractures should be
approached methodically not as an “emergency type” mentality.
3) Dental injuries should be evaluated & treated concurrently with
treatment of mandibular fractures.
4) Re establishment of occlusion is the primary goal in the treatment
of mandibular fractures.
5) With multiple facial fractures, mandibular fractures should be
treated first.
6) Intermaxillary fixation time should vary according to the type,
location, number & severity of mandibular fractures as well as the
patient’s age & health & the method used for reduction &
immobilization.
7) Prophylactic antibiotics should be used for compound fractures.
8) Nutritional needs should be closely monitored postoperatively.
9) Most mandibular fractures can be treated by closed reduction.

Management of mandibular fractures:
1) Closed reduction

It is often advocated because of its relative
simplicity, low cost & non invasive nature of treatment.
Indications:
1) Non displaced favourable fractures
2) Grossly comminuted fractures.
3) Severely atrophic edentulous mandible.
4) Fractures exposed by significant loss of overlying soft
tissues.
5) Mandibular fractures in children with developing
dentitions.
6) Coronoid process fractures
7) Condylar fractures.

TECHNIQUES FOR CLOSED REDUCTION AND
FIXATION OF DENTULOUS MAXILLA AND
MANDIBLE:
1) Bridle Wire
A simple bridle wire placed around the adjacent teeth of a
mandible fracture can temporarily stabilize a flailed
mandible segment. It prevents soft tissue damage.
 The first step in placement is measurement of arch bar.
The bar is usually placed two teeth proximal from the
fracture .
 The bar is traditionally placed from a point distal to the
first molar on the opposite side.
• Wire is the next consideration & 24-gauge wire is
recommended for the circumdental wires while 26
gauge wire is used for the box wires that provide the
maxillomandibular fixation.

The first circumdental wires placed are usually on the second
premolars.
The measured arch bar is then placed in the loops of the wires &
the wires loosely secured.
Wiring then takes place from midline to posterior to avoid excess
arch bar in the anterior of the arch.
After placement of the circumdental wires and gross reduction of the
fractured segments, tightening them takes place in the same fashion
from midline to posterior.
The box wires are then placed and occlusion is obtained.
The circumdental wires are then tightened & the rosettes are formed.
Box wires are then fully tightened and maxillomandibular fixation is
achieved.
Aids in protecting airway, helps alleviates pain from two segments
moving against each other.
Armamentarium: Local anesthetic, Needle driver or needle holder,
24 or 26 gauge stainless steel wire.

After adequate local anesthesia has been administered the two
segments are manually reduced.
The wire is passed around the necks of the teeth & the fracture
loosely approximated.
While manually stabilizing the fracture, the operator achieves
further reduction by tightening the wire in a clockwise fashion.
The box wires are then placed and occlusion is obtained.
The circumdental wires are then tightened & the rosettes are
formed.
Box wires are then fully tightened and maxillomandibular fixation
is achieved.
Aids in protecting airway, helps alleviates pain from two segments
moving against each other.
Armamentarium: Local anesthetic, Needle driver or needle
holder, 24 or 26 gauge stainless steel wire.

2)Ivy loops:
Ivy loops are a quick and easy way of obtaining
maxillomandibular fashion.
 The loop is constructed of 24 gauge wire and passed
interproximal to two stable teeth.
The ends of the wire are first brought around mesial &
distal sides of the teeth.
 The distal wire is then delivered under the loop &
tightened to the mesial wire in an apical region direction.
 Tightening of the loop is then accomplished to adapt it
into the interproximal space

Treatment of partially edentulous mandible:
If patient is partially edentulous, a pre-existing partial denture can
to wired to either jaw using circum mandibular or circum
zygomatic wiring technique.
If no prosthesis is available, impression can be taken, & acrylic
blocks can be fabricated, incorporated with an arch wire, &
applied to remaining teeth
Treatment of edentulous mandible:
If patient is completely edentulous, dentures can be wired to
the jaws with the use of circum mandibular or circum zygomatic
wires, or in the case of a maxillary denture, palatal screw fixation
can be done to hold the denture.
If dentures are not available, impressions are taken of the jaws, &
acrylic base plates are processed & used as denture.
An arch bar can be processed into the dentures/holes can be
placed into the flange of the denture for intermaxillary wires.
Prosthetic incisor teeth can be removed for existing dentures, &
space can be made in the acrylic to allow food intake. (Gunning
splint)

2.Open reduction
Advantage:
1) Reduction, fixation is done under direct
vision.
2) Stable fixation is achieved by better
approximation of fractured segments.


Indications for Open Reduction:
1)Displaced unfavorable fractures through the angle of the
mandible
2) Displaced unfavorable fractures of the body or the
parasymphyseal region of the mandible
3) Multiple fractures of facial bones
4) Midface fractures & displaced bilateral condylar fractures
5) Fractures of an edentulous mandible with severe
displacement of fracture fragments.
6) Edentulous maxilla opposing a mandibular fracture.
7) Associated condylar fractures
8)When intermaxillary fixation is contraindicated or not possible
9) To preclude the need for IMF for patient comfort.
10) Malunion.
11) Delay of treatment & interposition of soft tissue b/w noncontacting displaced fracture fragments.

Contraindications:
1)

GA or more prolonged procedure is
not advisable
2) Severe comminution with loss of
soft tissue
3) Gross infection at fracture site
4) Patient refusing open reduction.


Technique for open reduction & fixation
Surgical approaches :
 Factors used to establish the location of incision include fracture
location, skin lines and nerve position
a) Extraoral approaches

Submandibular Risdon’s incision
This incision is used to access the mandibular ramus, angle and
posterior body.
Patient is prepared & draped in routine surgical manner. Head of the
patient is turned sideways.
• The skin incisions is 4 to 5 cm in length, 2cm below the angle of
the mandible to avoid damage to the marginal mandibular branch
of the facial nerve.
• Ideally the incision is placed in a relaxed skin tension line (the
Langer’s line.)

 The skin and subcutaneous tissues are incised with a
scalpel down to the level of the platysma and undermining
of the skin to allow improved retraction is accomplished with
scissors.
 The platysma is then sharply divided exposing the
superficial layer of the deep cervical fascia.
 The plane of the dissection is carried out through this layer
over the superior surface of the submandibular gland .
• The facial artery and vein are identified.They are clamped,
divided & ligated.
•The dissection continues towards the mandible, exposing
the pterygo massetric sling posteriorly .
•Subperiosteal dissection is performed anteroposterior and
the desired area of the mandibular body, angle or ramus is
accessed.
• The desired procedure is carried out. Closure is done in
layers.

2) Retromandibular approach:
 This approach was basically a variation of submandibular
approach except the incision was about 3 cm above the
sulmandibular incision.
 The incision is made to encounter the parotid, massetric and
deep cervical fascia.
 The dissection is then extended anteriorly through the deep
cervical fascia with surgeon using nerve stimulation.
• The incision to bone through masseter muscle is b/w the
marginal mandibular and buccal branches of facial nerve.
• The muscle and periosteum are incised over the angle
instead of the inferior border.
• The soft tissues and the nerve fibres are then retracted
superiorly.
• This incision give superior access to the ramus and
subcondylar region of mandible.


The undersurface of this layer is where
the superficial temporal vessels are found, as
well as the auriculotemporal nerve and facial
nerve.

All these layers should be retracted
anteriorly with soft tissue flap.

The facial nerve has been described as
crossing the zygomatic arch 0.8 to 3.5 cm
(mean 2 cm) anterior to the concavity of the
auditory canal.

4) Endaural approach:
Started in the skin crease between the
anterior helical cartilage and the tissue
extended downward in the cleft b/w
tragus and helix and inward approximately
5 mm along the roof of auditory canal.





As incision deepens, it is carried anterior
through the tragal cartilage

INTRA ORAL ACCESS:
1)Symphyis and Parasymphysis region:
Termed as anterior, vestibular approach or deglowing
incision.
The lower lip is everted and an incision is created at the depth
of the vestibule in the mucosa with a scalpel or electro cautery.
Incision is curvilinear and extends anteriorly into the lip.
•The mentalis muscle with be visible and fibres are divided in
an oblique fashion, leaving a margin of the muscle attached to
the bone for closure.
•The periosteum is divided and a sub periosteal dissection is
done to identify the mentalis muscle.
•Closure is completed in layers.
• A pressure dressing is secured to the area to prevent
haematoma formation and maintain the position of mentalis
muscle

2.Intraoral (Body, Angle, Ramus region )


Transbuccal incision:
Dissection in this region begins with a mucous incision that
is stated with a scalpel or electrocautery 3 to 5 mm below the
mucogingival junction.
The incision is created in to the bone to avoid the mental
nerve and it extends over the external oblique ridge.
•The level of the incision at the external oblique ridge should
not be carried superior to mandibular occlusal plane to avoid
herniation of buccal fat pad.
• The incision is carried through the periosteum & a
subperiosteal dissection is performed.
•Reduction,fixation is used to expose the lateral border of
ramus.
•Reduction, fixation is done.
• Closure is completed in one layer.

Bone plating:
Advantages:
1) Rigid or stable fixation
2) Eleviates the need for immobilization of
the mandible .
3) Early return to home & work
4) Soft diet can be taken
5) Maintainence of oral hygiene


Compression plates:
These compression plates include at least two pear
shaped holes.
 The widest diameter of the hole lies near the fracture
line.
The screw is inserted in the narrow part of the hole &
at final movement of tightening, its head comes to rest
in the widest diameter of the hole, which is counter
sunk to receive it.
The compression holes in the plate may be
positioned one on each side of fracture line.

Complications – Mental fatigue, fracture of plate,
necrosis of bone ends, osteoporotic changes
Complication of mandibular fracture
management:
1) Infection
2) Nerve damage
3) Displaced teeth & foreign bodies
4) Pulpitis
5) Gingival or periodontal complications
6) Delayed healing and non union related
to fixation techniques
7) Facial widening.
8) Malunion
9) Delayed union
10)Sequestration of bone.

References:
1.

Gustow .D. Kruger

1.

Fonseca (Volume – 1)


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