mandibular fracture and close reduction

1. MANDIBULAR FRACTURE
–CLOSED REDUCTION
PREPARED BY : DR. AKSHAY SHAH
GUIDED BY :DR. NEHA VYAS

2. CONTENT
• INTRODUCTION
• ANATOMY
• AETIOLOGY
• EPIDEMIOLOGY
• CLASSIFICATION
• SIGNS & SYMPTOMS
• INVESTIGATION
• MANAGEMENT

3. INTRODUCTION
The mandible is largest, heaviest, strongest and the only movable
bone of the facial skeleton with the incidence of injury and fracture
being most common of all facial bones

4. ANATOMY
EXTERNAL ANATOMY
• U shaped body
• 2 vertically directed rami
• Condylar process
• Coronoid process
• Oblique line
• Mental foramen

5. INTERNALANATOMY
• Mandibular foramen
• Lingula
• Mylohyoid line
• Fossae
• Submandibular
• Sublingual
• Digastric
• Mental spines
• Genioglossus
• Geniohyoid

6. MUSCULATURE:
jaw elevators
• Masseter muscle: from
zygoma to angle and ramus
• Temporalis muscle: from
infratemporal fossa to coronoid
and ramus.
• Medial pterygoid muscle: medial
pterygoid plate and pyramidal
process into the lower mandible.

7. MUSCULATURE:
jaw depressors
• Lateral pterygoid muscle:
lateral pterygoid plate to
condylar neck and TMJ
capsule
• Mylohyoid muscle:
Mylohyoid line to body of hyoid
• Digastric muscle: mastoid notch
to digastric fossa
• Geniohyoid muscle: inferior
genial tubercle to anterior hyoid
bone

8. INNERVATION
• CN3; mandibular nerve through
the foramen ovale
• Inferior alveolar nerve through
the mandibular foramen
• Inferior dental plexus
• Mental nerve through the mental
foramen.

9. BLOOD SUPPLY
• Internal maxillary artery
• Inferior alveolar artery
• Mental artery

10. AETIOLOGY
• Road traffic Accidents
• Interpersonal violence
• sports
• trauma
• Fall down

11. EPIDEMIOLOGY
• The mandible is one of the most commonly fractured bones of
the face and this is directly related to its prominent and exposed
position.
• The most common facial fractures are in the mandible.
• Mandible (61%)
• Maxilla (46%)
• Zygoma(27%)
• Nasal Bone (19%)

12. • Studies have shown that the incidence of mandible fractures are influenced
by various etiological factors e.g.
• Geography
• Road traffic laws
• Seasons
• Even though the body of the mandible has the highest incidence when it
comes to mandibular fracture, the condyle remains the commonest site
for mandibular fracture
• Energy required to fracture the mandible it ranging from 44.6 to 74.4 kg/m.

13. CLASSIFICATIONS
By Rowe & Killey (1968)
• Not involving basal bone
Alveolar process fractures
• Involving basal bone:
• Single Unilateral
• Double Unilateral
• Bilateral
• Multiple

14. •According to Anatomical region by Dingman and Natvig (1969)
• Midline
• Parasymphyseal
• Symphysis [17%]
• Body [29%]
• Angle [25%]
• Ramus [4%]
• Condylar process [26%]
• Coronoid process [1%]
• Alveolar process

15. •According to Presence/Absence of Servicable Teeth in Relation to the Line of
Fracture by Kazanjian and Converse(1978)
• Class I
• Class II
• Class III
•Class I : teeth present on both side of fracture line
•Class II : teeth present on only one side of fracture line
•Class III : patient is an edentulous.

16. Kruger and Schilli – Developed Four
categories (1986)
• Relation to the External Environment
• Simple or Closed
• Compound or Open
• Type of Fracture
• Incomplete
• Greenstick
• Complete
• Comminuted
• Dentition of the Jaw with ref. to the use of Splints
• Sufficiently dentulous jaw
• Edentulous or Inufficiently dentulous
• Primary or Mixed dentition
• Localization

17. According to Dorland illustrated medical dictionary (2003):
• Simple
• Compound
• Comminuted
• Greenstick
• Pathologic
• Multiple
• Impacted/Telescoping
• Atrophic

18. Direction & favorability of treatment
Horizontally Favourable
Fracture line runs
downward & forward so
upward displacement
avoided
Horizontally
Unfavourable
Fracture line runs Down
Wards and Back Wards
so
upward Displacement
Unrestricted

19. 27-04-2016Mandibular Fractures 23
6.According to direction of the fracture and favorability for treatment ( Fry etal)

20. VERTICALLY FAVORABLE VERTICALLY UNFAVORABLE
FRACTURE LINE RUNS FROM THE
OUTER BUCCAL PLATE OBLIQUELY
BACKWARDS AND LINGUALLY , MEDIAL
MOVEMENT RESTRICTED
FRACTURE LINE RUNS FROM THE
INNER LINGUAL PLATE OBLIQUELY
BACKWARDS AND BUCCALLY , MEDIAL
MOVEMENT UNRESTRICTED

21. AO Classification (2007)
F NO. OF FRACTURE OR FRAGMENTS
L LOCATION OF THE FRACTURE
O STATUS OF OCCLUSION
S SOFT TISSUE INVOLVEMENT
A ASSOCIATED FRACTURES

22. F: NO. OF FRACTURES
F0 Incomplete fractures
F1 Single fractures
F2 Multiple fractures
F3 Comminuted fractures
F4 Fracture with bone defect

23. L: Location of fracture
L1 Pre-canine
L2 Canine
L3 Post-canine
L4 Angle
L5 Supra-angular
L6 Condyle
L7 Coronoid
L8 Alveolar process

24. O: Status of occlusion
O 0 No malocclusion
O 1 Malocclusion
O 2 Edentulous mandible

25. S:Soft tissue involvement
S 0 Closed
S 1 Open intraoral
S 2 Open extraoral
S 3 Open intraoral / extraoral
S 4 avulsion

26. A: Associated fracture
A0 None
A1 Dentoalveolar fracture
A2 Nasal bone fracture
A3 Zygoma fracture
A4 Lefort I
A5 Lefort II
A6 Lefort III

27. Shetty et all. combined six significant injury criteria to create
the acronym FLOSID (2007)
which essentially allowed for ease of assessment and defined fracture
characteristics
They assessed mandibular fractures using the taxonomy described and added
weighting factors to address severity (mandible injury severity score)
1. Fracture type (F) a. Incomplete b. Simple c. Comminuted d. Bone defect

28. 2. Location of fracture (L)
a. Left from midline (L1) to condylar head (L8)
b. Right from midline (R1) to condylar head (R8)

29. 3. Nature of occlusion (0)
a. Normal
b. Malocclusion
c. Edentulous

30. 4. Extent of soft tissue damage (S)
a. Closed
b. Open intaorally
c. Open extraorally
d. Open intro and extraorally
e. Soft tissue defect

31. 5. Presence of infection (I)
a. Yes
b. No
6. Radiographic analysis of interfragmentary displacement (D)
a. Mild
b. Moderate
c. Severe

32. Clinical examination.
• History
• Mechanism of injury
• Extraoral / Intraoral

33. SIGNS AND SYMPTOMS
• GENERAL
• SPECIFIC

34. GENERAL SIGNS ANDSYMPTOMS
• Swelling
• Pain
• Drooling of saliva
• Tenderness
• Bony discontinuity
• Lacerations
• Limitation in mouth
opening
• Ecchymosis
• Fractured,mobile teeth.
• Avulsion
• Bleeding .

35. Deviation of jaw
opening
Restriction of mouth

36. Extensive soft tissue and bony defect

37. Collapsed arch and
Interfragmentary mobility
Open bite due bilateral poster
Gagging of occlusion
Open bite and cross bite due to
Unilateral gagging of occlusion
Occlusal step with
Unilateral cross bite

38. Mandibular fracture has to be differentiated from extensive
Soft tissue injury and dentoalveolar trauma
UNILATERAL CROSS BITE UNILATERAL OPEN BITE

39. Multiple fragmentation
With complete loss of occlusion
Sublingual
Unfavorable fracture line
Causing displacement

40. SPECIFIC SIGNS AND SYMPTOMS
• DENTOALVEOLAR FRACTURES
• Lip bruises and laceration
• Step deformity
• Bony discontinuity
• Fracture, luxation or subluxation of teeth
• Laceration of the gingivae
• SYMPHYSEAL/PARASYMPHESEAL FRACTURES
• Tenderness
• pain
• Step deformity

41. • FRACTURE OF THE RAMUS
• Swelling
• Ecchymosis
• Pain
• Trismus
• FRACTURE OF THE ANGLE
• Swelling
• Posterior gag
• Deranged occlusion
• Anaesthesia or paraesthesia of lower lip
• Haematoma
• Step deformity behind the last molar tooth
• Tenderness

42. • FRACTURE OF THE BODY
• Swelling
• pain
• Tenderness
• Step deformity
• Anaesthesia or paraesthesia of the lip
• Intra oral hemorrhage
• CORONOID FRACTURE
• Tenderness over the anterior part of the tragus
• Haematoma
• Painful limitation of movement
• Protrusion of mandible may be present.

43. • CONDYLAR FRACTURE (unilateral/bilateral and
Intracapsular/extracapsular)
• Unilateral condylar fractures
• Swelling over the TMJ
• Hemorrhage from ear on the affected side
• Battle’ssign
• Locked mandible
• Depression over the condylar region after edema has subsided
• rarely, Paraesthesia of lower lip
• Deviation to the affected side upon opening
• Painful limitation of movement

44. • Bilateral condylar fractures
• Same as above
• Limitation in mouth opening
• Restricted mandibular movement
• Anterior open bite

45. Radiographic features
• OPG
• PA View
• PNS View
• Lateral oblique Radiograph
• Occlusal view
• CT scan.

46. - Commonly used.
- Entire mandible is visualized.
OPG view

47. PAview.
• Medial / lateral
displacement.

48. Indicated for
Visualizing Medial
Displacement
Of Condylar Neck
The 4th & 5th
MacGregor Line
coincides with Mandible
PNS view

49. Because of distortion in
Symphysis Region in
an OPG , an Occlusal
View is indicated in
Symphysial fractures
Also shows Vertical
Favorability of Body
Fractures
Occlusal view

50. CT SCAN

51. Management – General Principles
General physical examination to rule out associated injuries
Decision to preserve or extract fractured or involved teeth
PRIMARY GOAL – Re-establishment of OCCLUSION
Fracture Union
Function
Aesthetics
In Multiple facial fracture ,treat mandibular fractures 1st (INSIDE OUT AND BOTTOM TO UP)
All intraoral surgeries to be done first before any extraoral open reductions/suturing of
facial lacerations

52. Prophylactic antibiotics should be used for compound fractures
Nutritional needs should be closely monitored post-operatively
Most mandibular fractures can be treated by closed and open reduction

53. CLOSED REDUCTION
What is close reduction?
Restoration and alignment of the fractured fragments to their original
anatomical position without visualization of the fracture line is known as close
reduction.

54. •Indications - CLOSED REDUCTION
•Non-dispalced favourable fractures
• Simplest possible means should be employed
•Grossly comminuted fractures
• Bag of bones [periosteum acts like a bag]
•Fractures exposed by significant loss of overlying soft tissue
• Secondary granulation
• Rotational flaps
• Microvascular grafts

55. • Edentulous mandibular fractures
• Compromised endosteal bl. Supply
• Diminished endosteal cells available for repair
• Stripping during OR further compromises blood supply
• In children with developing dentition
• Coronoid process fractures
• only in cases of
• Compromised occlusion
• Impingement of #fragment over zygomatic arch
• Condylar fractures
• most condylar fracture are treated by closed reduction if occlusion is not compromised.

56. ADVANTAGES:
Inexpensive
Conservative
No operating room needed in most cases

57. DISADVANTAGE:
Cannot obtain absolute stability (contributing to nonunion & infection)
Noncompliance from patient due to long period of IMF
Difficult nutrition
Weight loss

58. Methods used to achieve close reduction
Reduction by manipulation
Reduction by traction
Intraoral traction method
Extraoral traction method

59. Reduction by manipulation
• Reduction by manipulation is done when the fractured fragments
are adequately mobile without much overriding or impaction
and the patient comes for treatment immediately after trauma.
Then the digital or hand manipulation for reduction can be used
• Specially designed instruments for grasping the fragments are
available like disimpaction forceps, bone holding forceps.

60. MANDIBULAR FRACTURES
BARREL BANDAGE BARTON BANDAGE

61. Role of Bandage
•Temporary immobilization of fractured jaw
• ↓PAIN – by reducing the amount of friction between fragmnets
• #→swelling→sagging of soft tissues→↑distraction of #fragments
• Decreased MICROMOVEMENT of #fragments – decreased irritation of
surrounding soft tissues – decreases inflammatory response
• Mobilization of #fragments – Ingress of saliva and microbes – increased amount
of contamination of #site
MANDIBULAR FRACTURES

62. Reduction By Manipulation

63. Close reduction by traction
• Intraoral traction method :
• In this method prefabricated arch bars are attached to
maxillary and mandibular dental arches by means of
interdental wiring .The fracture fragments are subjected to
gradual elastic traction by placing the elastics, from upper to
lower arch bars in a definite manner & direction depending
on the fracture line.

64. Intraoral traction method
The fracture
fragments are
subjected to gradual
elastic traction by
placing the elastics,
from upper to lower
arch bars in a
definite manner &
direction depending
on the fracture line.

65. External pin fixation
• Closed technique uses external fixation (Morris appliance
& Roger anderson appliance) for management of
communited mandibular #.
• screws placed - two on either side of the fracture through stab
incisions & holes drilled in the mandible.

66. • Once external pins are in position,
• the fracture segments are manipulated toachieve reduction.
• Then the pins are locked in reduced position by applying of an
acrylic mix that is placed over the ends of the pins that are
protruding out of the skin.
• The acrylic is allowed to harden while mandible is held in
reduced position.
• Steinmann pins or Kirshner wires can also be used as external
pins

67. • Indications
• Edentulous fractures
• If IMF is not feasible
• Comminuted fractures
• Bone graft requirements
With a head frame
Contraindications
• Irradiated tissues
• Grossly contaminated tissue
• Osteoporosis
• Osteosclerosis
• Atrophy

68. Advantages
• Control of the edentulous
fragments without involving
the fracture lines.
• under LA.
• avoidance of the need for
surgery at the fracture site,
Disadvantages
• Conspicuous uncomfortable
• uncooperative or cerebrally
irritated patient.
• Difficulty with washing and
shaving
• scars caused- pinholes
• minimum operative time
• risk of infection.
• Simple surgical technique.

69. Closed Reduction Techniques
•Bridle Wire
• First advocated by Hippocrates
• A simple bridle wire is placed around the adjacent teeth of a mandible
fracture temporarily stabillizes a flailed mandibular segment
• This helps in
• Preventing further soft tissue damage
• Aids in protecting airway
• Alleviates pain
• Assists in preventing muscle cramping associated with unstable fragments

71. • IVY EYELET WIRING
• The Ivy loop embraces the two adjacent teeth.one or two Ivy
eyelets should be placed in each quadrant.
• A 26guage stainless steel wires cut in 20cm lengths areused.
• A loop is formed in center of wire around the beak of a towel clip
or shank of dental bur and twisted thrice with two tail ends. Such
Ivy loops can be preformed and stored in cold sterilizing solution
for emergency use.
• The two tail ends of the eyelet are passed through the
interdental space of the selected two teeth from buccal to
lingual side.
• One end of the wire is passed around the distal tooth lingually and
brought out from the distal interdental space over the buccal side
and threaded through the previously formed loop.

73. • The other wire tail end is carried around the lingual surface of the mesial tooth and
brought out on the buccal surface from the mesial interdental space, where it meets
the first tail endwire.
• The two wires are crossed and twisted together and the loop is adjusted and bend
towards gingiva.
• The mandibular wire eyelets can be secured tomaxillary eyelets by joining wires.
• Advantage is that bridging wires can be removed wheneverrequired without
disturbing the mainwiring.
• Even when there is breakage of wire during fixation only thateyelet can be removed and
replaced.

74. WILLIAM MODIFICATION ( 1968 )

75. CLOVE HITCH METHOD

76. STOUT’S MULTI LOOP WIRING
• The posterior part of four quadrants are used forwiring.
• 4 pieces of 26guage 20cm long wires are required and piece of
solder is used for making loops.
• The piece of solder wire is adapted to buccal surface ofteeth.
• The 20cm long pre stretched wire is folded into two parts, one
part acts as the stationary wire and the other end is brought
distal to the second molar and taken around it on lingual side.

78. • This working end is threaded through the mesial side of second
• molar to the buccal side under the solder wire.
• It is then looped around the stationary wire and solder wire and
back into the interdental space from buccal to lingual. The same
procedure is repeated for each tooth up tomidline.
• The solder wire is removed after the loops are formed and theloops
• are twisted to form eyelets.
• Finally the stationary and working ends of the wiresare
twisted together.

79. GILMER’S WIRING
• It is used for IMF.
• Most common and simple method.
• Few firm teeth in the mandible as well as in maxilla arechosen.
• At least one firm teeth must be chosen anterior and posterior to the fracture line.
• A pre stretched 20cm long 26guage wire is taken and passed around the neck of the
chosen tooth.
• Both the ends of the wire are brought out on the buccal side and twisted.

81. • The same procedure is carried out for all the chosen teeth in
the individual arches.
• Then the mandibular wires are twisted tightly withthe
corresponding maxillary wires.The ends are cutshort and sharp
ends are tucked in.
• The main disadvantage of this wiring is that there may be
extrusion of the teeth as excess load is applied.
• Another disadvantage is of requiring complete removal of the
wires to open the mouth in emergencysituations.

82. • RISDON’S WIRING
• It is commonly used method of horizontal wire fixation.
• This can be a substitute technique for archbar.
• In this method second molars are usually chosen for anchorageon
• either side.
• A 25cm long 26guage wire is passed around the neck of second
molar on each side and both the ends are brought in buccalside.

84. • The ends are twisted for entire length thus forming a strongbase
• wire that comes towards the midline from each secondmolars.
• Two base wires are grasped and twisted at mid line and adapted
to the necks of the teeth on the buccal side.
• Thisbase wire is secured to individual teeth by using additional
interdental wires.
• This type of horizontal wiring offers strong fixation.

85. Arch Bars
Frequently used method
Erich arch bar most commonly used
Steps in placement
Direction of wire tightening
24-guage wires used for circumdental wiring
26-guage wires used for MMF

86. Various varieties of commercially
produced arch bars

88. Intermaxillary Fixation Screws
• Use of cortical bone screw fixation in the treatment of mandibular fractures –
First advocated by Karlis et al
• Advantages
• Ease of application
• Decreased operating time
• Decreased risk of disease transmission
• Decreased cost
• Disadvantages
• lack of tension band effect
• Interference with internal fixation plates

90. • OBWEGESER’S PROCEDURE
• It is used for fixation of lateral compression splint to the mandibular bone.
• Lower border of mandible is palpated in the canine region and the skin is pierced beneath
the lower border of the mandible by Kelsey-Fry bone awl and it emerges through the floor
ofmouth.
• A 26 or 28 guage wire is inserted through the eye of the awl and the awl is withdrawn till
the lower border and directed upward along the buccal surface of mandible to pierce
through the buccal sulcus.
• The two ends of the wire are adjusted and the splint is adjusted and the lingual and buccal
wires are held together and twisted in the region of canine grooves, cut and finished inward.
CIRCUMMANDIBULAR WIRING

92. • Gunning splint was initially fabricated by Thomas brain gunning for the
immobilization of edentulous ridges.
• Used in edentulous jaw fractures
• In edentulous patient due to the absence of teeth it is difficult to reduce and
immobilize the fracture.
• Acrylic splints take the form of modified dentures with bite block in place of molar
teeth & space in the incisor area to facilitate feeding
Gunning splints

93. • A gunning splint resembles a mono block consists of two bite block fixed to the
maxilla by per alveolar wiring and to the mandible by circumferential wiring.
• Then interconnecting the both with wire loop and elastics
• Existing denture can also be used as splint

94. • INDICATION
• unilateral / bilateral fracture of edentulous
mandible
• CONTRAINDICATIONS
• unfavorable displaced #s lying out side denture bearing
areas
• severe posterior displacement of #s of the anterior part of
mandible

95. Time of Immobilization
• Young adult with Fracture of the Angle receiving Early Treatment in which
Tooth removed from the # line – 3 weeks
• If :
• Tooth retained in fracture line : +1wk
• Fracture symphysis : +1wk
• Age: 40 above :+1/2wks
• Children and Adolescents :1wk

96. References.
• Oral & maxillofacial trauma- Fonseca,vol 1
• Maxillofacial Injuries- Rowe & Williams
• Killeys and key - fractures of the mandible
• Mandible Fixation- AO Foundation
• Textbook of oral & maxillofacial surgery by S.M Balaji.