Hierarchy of management that covers different levels of management
mandibular fracture
1. Epidemiological Study of Mandibular
Fractures in Iraqi Sample
Graduation project
submitted to the department of oral and maxillofacial surgery
Prepared by
Tasneem Kareem
Ibrahim Ahmed
Supervised by
Assist. Lecturer Dr. Zainab Mahmood AL-Bahrani
B.D.S, Dip. In oral and maxillofacial surgery
M.Sc. In oral and maxillofacial radiology
2015
3. INTRODUCTION
Anatomy of mandible
The mandible (from Latin mandibula, "jawbone") or inferior maxillary bone is
the largest, strongest and lowest bone in the face. It forms the lower jaw and
holds the lower teeth in place.
The mandible is divided into eight regions. The symphysis is located in the
midline, joining the right and left halves of the mandible. The
parasymphyseal region is located on either side of the symphysis, and spans
from canine to canine. Moving posterolaterally, the body is the region from
the canine to the angle, which is the non-tooth bearing region between the
body and the ramus. The ramus is the vertical portion of the mandible that
extends from the angle toward the zygomatic arch, terminating at the
coronoid process and condyle.
4. Mandibular bone fracture
The mandibular bone consider as the unique facial bone having the
ability to be a mobile bone that play a major role in mastication,
speech, and deglutition. Mandibular fractures constitute a large
proportion of cases of maxillofacial trauma, so the purpose of this
study was to investigate the epidemiological pattern of mandibular
fractures.
5. CLASSIFICATION
Mandible fractures can be classified in several ways. Standard fracture
nomenclature for long bone fractures is the first classification
(simple, compound, comminuted, or greenstick). The second
method is by anatomic location. The third is by dentition status,
and the fourth is by stability of the fracture, i.e. favorable versus
unfavorable.
6. CLASSIFICATION
1- According to the fracture type
*In a simple fracture the oral mucosa and external skin are intact.
*In a compound or open fracture there is a laceration of the mucosa
or skin present, or the fracture passes through a tooth root.
*Comminuted fractures have multiple bone fragments.
*Greenstick fractures involve only one cortex of the bone and occur
most commonly in children.
7. CLASSIFICAION
2- According to the Location
This is the most useful classification, because both the signs and
symptoms, and also the treatment are dependent upon the
location of the fracture:
8. CLASSIFICATION
* Alveolar (Dento-alveolar)fracture
This type of fracture involves the alveolus (the alveolar process of the mandible).
* Condylar fracture
Condylar fractures are classified by location compared to the capsule of ligaments that
hold the temporomandibular joint (intracapsular or
extracapsular).
* Coronoid fracture
Because the coronoid process of the mandible lies deep to many structures, including
the zygomatic complex (ZMC), it is rare to be broken in isolation. It usually
occurs with other mandibular fractures or with fracture of the zygomatic complex
or arch.
9. CLASSIFICATION
* Ramus fracture
Ramus fractures are said to involve a region inferiorly bounded by an
oblique line extending from the lower third molar.
* Angle fracture
Angle fractures are defined as those that involve a triangular region
bounded by the anterior border of masseter muscle and an oblique
line extending from the lower third molar (wisdom tooth) region
to the posteroinferior attachment of the masseter muscle.
10. CLASSIFICATION
* Body fracture
defined as those that involve a region bounded anteriorly by the parasymphysis
(defined as a vertical line just distal to the canine tooth) and posteriorly by
the anterior border of the masseter muscle.
* Parasymphysis fracture
Parasymphyseal fractures are defined as mandibular fractures that involve a
region bounded bilaterally by vertical lines just distal to the canine tooth.
* Symphysis fracture
•Symphyseal fractures are linear fractures that run in the midline of the
mandible (the symphysis).
11. CLASSIFICATION
3- According to the Dentition Classification:
Developed by Kazanjian and Converse
* Class I: teeth are present on both sides of the fracture line
* Class II: Teeth present only on one side of the fracture line
* Class III: Patient is edentulous.
4- According to the stability
Fractures can be classified as favorable or unfavorable based on the stability (or lack
thereof) afforded by the pull of muscles on the fractured segments of bone.
12. ETIOLOGY
The Major etiologic factors of Mandible fracture are varying by the time period
and the region studied. In some countries, blunt force trauma (a punch) is
the leading cause of mandible fracture, where as in others, motor vehicle
collisions are now a leading cause. On battle grounds, it is more likely to be
high velocity injuries (bullets and shrapnel). Prior to the routine use of seat
belts, airbags and modern safety measures, motor vehicle collisions where a
leading cause of facial trauma.
•Mandibular fracture is a rare complication of third molar removal, and may
occur during or after the procedure. Children injuries are usually resulted
from fall accidents in addition to sporting accidents.
13. EXAMINATION
History
Pain and malocclusion after a blow to the lower face strongly suggest
mandibular fracture. Additional symptoms include anesthesia of the lower
lip and chin caused by trauma to the inferior alveolar nerve.
Unfortunately attempts to obtain history is often limited by the patient being
intubated, unconscious, confused, or intoxicated.
If the patient is awake and cooperative, he or she should be questioned about
the presence and location of pain, malocclusion, trismus, intraoral bleeding,
and loss of sensation, particularly in the mental nerve region.
14. EXAMINATION
Physical Examination
The physical examination of the patient means the general
appearance to be first assessed and any lacerations, ecchymosis,
edema, or areas of distortion are noted.
The entire mandible is palpated for tender areas, mobility, step-offs,
and crepitus. The occlusion should be checked bilaterally and note
made of any deviation of the mandible.
15. EXAMINATION
Radiographic Evaluation
Proper treatment of fractured mandible is dependent on proper
diagnosis. Panoramic radiography has become the standard of care
for the evaluation of mandibular fractures in many institutions.
Panoramic views with posteroanterior or reverse Towne's views are
likely to give a higher yield than the panoramic view alone. The
periapical view can be useful to identify specific dental trauma or
abscesses. Occlusal views are under utilized, and can be very useful
when used intra-operatively on patients with symphyseal and
parasymphyseal fractures.
16. EXAMINATION
Radiographic Evaluation
The use of computed tomography (CT) as a diagnostic tool has been
controversial in the past. Early studies comparing the sensitivity of
CT to other modalities of the radiographic workup suggested that
CT was not as sensitive. More recent studies performed with
improved, higher resolution CT suggest that CT is superior to
panoramic radiography, both in sensitivity and in offering the
surgeon a better understanding of the nature of the fractures.
Three-dimensional CT may have an important role in the future
for evaluating pre- and postreduction techniques
17. COMPLICATIONS
Complications may be related to the trauma of the mandible or related
to delay in fixing the fractured mandible that increases the risk of
complications, but neurological complications or other problems
such as airway compromise may make this inevitable.
If there is bilateral fracture of the body of mandible, parasymphyseal, or
condylar fractures, there is risk of impairment of airways.
Infection, malunion or non-union, ankylosis are considered major
complications which can result in poor ability to open the mouth.
The psychological implications of facial trauma are such that the risk
of post-traumatic stress disorder is increased in this condition.
18. MATERIAL AND METHOD
A retrospective cross sectional study on the medical data base records
of (30 patients) aged over (15 years) who had been diagnosed with
a Mandibular bone fracture referred to the hospital of Al- Shaheed
Ghazi Al Hariri in 2 years duration.
This study carried out on the recorded information of each patients
including age, gender, type and site of fractured mandible,
etiology, and the type of radiographic view
19. MATERIAL AND METHOD
Age was classified into 3 groups: 15 to 30 years old, 31 to 49 years old,
and >50 years old.
*The causes of the accidents were grouped into the following categories:
*Road traffic accidents (RTA)
*Interpersonal violence (IPV)
*Sports, falls, and occupational accidents
*Blast injury
*Pathological conditions
20. MATERIAL AND METHOD
The fracture area was recorded from different diagnostics radiographic views such as:
anteroposterior, lateral-oblique,orthopantomograms, and computed tomography.
According to radiographic findings, the fractured mandibles were classified according
to location into six anatomical sites including:
*Symphysis/parasymphysis
*Body
*Angle
*Ramus,
*Condyle
*Coronoid process.
All data were analyzed using descriptive statistical analysis.
25. RESULT
Out of 30 patients whom their data were reviewed and diagnosed with fractured
mandible, 22(73.3%) were males and 8(26.6%) were females with male to
female ratio of about(2.75:1).
Table (1): Frequency of gender distribution of the sample.
%NumberGender
26.6%8Female
73.3%22Male
100%30Total
26. RESULT
Table (2): Frequency distribution of the study sample by age.
The peak of incidence was in the age group (15-30) years followed by (31-49),
and (>50).
%NumberAge Group
(by years)
56.6%17(15-30)
33.3%10(31-49)
10%3>50
(15-54)Range
30.3Mean age (years)
10030Total
27. RESULT
The prevalence of fractures of one area of mandible (86.7%)
was more compared with multiple areas (13.3%)
•The type of requested x-ray in most cases were panoramic
radiography as in table (3), the recorded data of some
patients were with more than one x- ray view due to
overlapping.
28. RESULT
Table (3):Distribution of Mandibular fractures according to x-ray
Type.
%NumberX-ray
63.3%19Panoramic
13.3%4Postero-anterior
36.3%11C.T scan
20%6Others (True
lateral, Water’s
view, Sub-
mentovertex)
29. RESULT
Table (4): Frequency distribution of the study sample by cause of trauma.
%NumberCause of trauma
20%6Road traffic
accidents
13.3%4Interpersonal
violence
36.6%11Blast injury
16.6%5Falls, sports,
occupational
accident
13.3%4Pathological
condition
30. RESULT
FIG. (7) Pie chart shows distribution of the fractures according to the anatomical
site
1
2
3
4
5
body#
symphysial#
31. DISCUSSION
The rapid continuous developmental growth of society, industry and life
style resulted in high number of variant type of accidental injuries and
associated with fractures of any part of the body including Mandibular
bone fractures.
In this study the reviewing of patients with mandibular fracture shows
that the majority of patient with a mandibular fracture are males this
may be due to the fact that males are more presence in outdoor activity
also there is a strong relationship between blunt force trauma and
mandible fractures which explains why most of fractures occur in
males, this result was similar to the result of Sakr et al (2006),
Khorasani M. and Khorasani B. (2009)(,AndreasaZ. J. et al (2011)
32. DISCUSSION
Based on this study most patients were in the age group (15-
30) years this related to the etiological factors of a
mandibular fracture which was in agreement with several
studies that reported the this young adult age group as the
most common like Abbas et al. (2003) and Al-Ahmad et al.
(2004)
33. DISCUSSION
The etiology of mandibular fracture varies significantly between countries.
Almost all authors try to explain this variability by socioeconomic, cultural
and environmental factors, In the comparison of the socioeconomic status of
populations of different countries, the factor “income” , “education”,
“occupation” and “wealth” account for the socioeconomic status in addition
to traffic safety which responsible for road traffic accident, so the result of
this study according to causes of fracture differ from other studies since
most of referral cases to the hospital of Al- Shaheed Ghazi Al Hariri in were
marital injuries comparing with Khorasani M. and Khorasani B. (2009)Sakr
et al (2006)Abbas et al. (2003)(25)studies that reviles most cases were due to
motor vehicles accident, while In contrast to several studies, which report
very high rates of interpersonal violence Lee (2008) and Oikarinen et al
(2005)
34. DISCUSSION
Regarding the relationship of trauma mechanism and fracture site, our study
confirms previous findings of a correlation between etiology and fracture
pattern.
Body of the mandible shows the highest rate of fractures and this was agreed
with the result of Qudah et al (2005), Fnseca and Walker(1997), Fasola et al
(2001)
King et al.(2004)( study shows the prevalent fractures resulting from motor
vehicle collisions are in the parasymphseal and condylar region, The same
applies to falls, which are most commonly associated with condylar fracture
in Lee (2008).
35. DISCUSSION
As a conclusion the Mandibular fractures occur in people of all ages
and races, in a wide range of social settings. Their causes often
reflect shifts in trauma patterns over time.
It is hoped that a careful assessments such as detailed history,
radiographical and clinical examination will be valuable to
government agencies and health care professionals involved in
planning future programs of prevention and treatment.
