mandible fracture

1. Mandibular Fractures

2. • INTRODUCTION
• SURGICAL ANATOMY
• EPIDEMIOLOGY
• CLASSIFICATION
• SIGNS & SYMPTOMS
• INVESTIGATION
• MANAGEMENT
• CONCLUSION

3. INTRODUCTION
• Only mobile bone of the facial/cranial region
• Bilateral joint articulations
• Strongest facial bone
• Parabola shaped bone
• Once the mandible is loaded, the forces are distributed
across the entire length of the mandible.

4. Weak areas of Mandible
• Junction between alveolar bone & basal mandibular bone.
• Symphysis region - junction of two individual bones.
• Parasymphyseal region - lateral to the mental prominence,
incisive fossa and mental foramen.
• Junction of the ramus and the body are fractured
commonly.
• Presence of impacted tooth, canine with long roots.

5. Anatomy

7. Nerve supply
• CN3; mandibular nerve
through the foramen
ovale
• Inferior alveolar nerve
through the mandibular
foramen
• Inferior dental plexus
• Mental nerve through
the mental foramen.

8. Blood supply
• Internal maxillary artery
• Inferior alveolar artery
• Mental artery

9. Epidemiology
• Males>Females
• Age: 16-30 years
• RTA>Assault>Falls>Sports for most common
cause of common fracture
• 45% Mandible fractures occur in conjunction
with other injuries, 10% lethal.

10. CLASSIFICATION

11. Fracture Pattern(Kruger’s Classification)

12. Anatomic Classification:
Developed by Dingman and Natvig

13. 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

14. Muscle Action Classification:
Generally apply to angle and body fractures
Based on direction of muscle pull
Anterior group – Downward, Backward & Medial pull
Posterior group – Upward, Forward & Medial pull
• Vertically Favorable vs. Non Favorable
Resistance to medial pull
• Horizontal Favorable vs. Non Favorable
Resistance to upward pull

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

17. GENERAL SIGNS AND SYMPTOMS
• Swelling
• Pain
• Drooling saliva
• Tenderness
• Bony discontinuity
• Lacerations
• Limitation in mouth opening
• Ecchymosis
• Fractured, subluxed, luxated teeth.
• Bleeding from the mouth.

18. SPECIFIC SIGNS AND SYMPTOMS
• DENTOALVEOLAR FRACTURES
– Lip bruises and laceration
– Step deformity
– Bony discontinuity
– Fracture, luxation or subluxation of teeth
– Laceration of the gingivae
• FRACTURE OF THE BODY
– Swelling
– pain
– Tenderness
– Step deformity
– Anaesthesia or paraesthesia of the lip
– Intra oral hemorrhage
• SYMPHYSEAL/PARASYMPHYSEAL FRACTURES
– Tenderness
– Sublingual haematoma
– Loss of tongue control
– soft tissue injury to the chin and lower lip.

19. • 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.

20. • CORONOID FRACTURE
– Tenderness over the anterior part of the tragus
– Haematoma
– Painful limitation of movement
– Protrusion of mandible may be present.

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

23. Radiological Evaluation
• X-rays
• OPG
• Lateral Oblique views
• PNS view
• CT scan with 3D recon.
Posteroanterior (PA) view
• Shows displacement of fractures
in the ramus, angle, body, and
symphysis region
Disadvantage:
• Cannot visualize the condylar
region

24. OPG
Most informative
radiographic tool for
condyle & dentition
status assessment
Shows entire mandible
and direction of
fracture (horizontal
favorable, unfavorable)

25. Lateral oblique radiograph:
• Used to visualize ramus,
angle, and body fractures
• Easy to do
Disadvantage:
• Limited visualization of the
condylar region, symphysis,
and body anterior to the
premolars

26. Computed
tomography CT:
• Excellent for showing
fractures
• Can get axial and
coronal views with 3-D
reconstructions

27. General Principles in the Treatment of Mandible
Fractures
1.Patient’s general physical status should be evaluated
and monitored prior to any consideration of treating
mandible fracture
3.Dental injuries should be evaluated and treated
concurrently with the treatment of mandibular
fracture

28. 4.Re-establishment of occlusion is the primary goal in
the treatment of mandibular fractures
5.Intermaxillary fixation time should vary according to
the type, location, number, and severity of the
mandibular fractures as well as the patient’s health
and age, and the method used for reduction and
immobilization

29. 6. Prophylactic antibiotics should be used for
mandibular fractures
7. Nutritional needs should be monitored closely
postoperatively
8. Most mandibular fractures can be treated with
closed reduction

30. Treatment Options
• Conservative Treatment
Undisplaced fractures.
Analgesia, Antibiotics, Soft diet.
• Active Treatment
Open/closed reduction & fixation
Immobilisation with IMF
• Rehabilitation

31. Closed reduction and fixation
Indications:
All cases where open reduction is not indicated or is
contraindicated
-Badly comminuted fractures - especially gunshot wounds
-Undisplaced favourable fractures
-Mandibular fractures in children with developing
dentition
-Most of the condylar fractures
-Edentulous fractures with use of prosthesis with
circummandibular wires.

32. Contraindications:
• Medical conditions that should avoid intermaxillary
fixation :
Alcoholics
Seizure disorder
Mental retardation
Nutritional concerns
Respiratory diseases (COPD)
• Unfavorable fractures

33. Advantages:
• Low cost
• Short procedure time
• Can be done in clinical
setting with local
aneasthesia or sedation
• Easy procedure
• No foreign body in
patients
Disadvantages:
• Not absolute stability
(secondary bone healing)
• Oral hygiene difficult
• Possible TMJ sequelae
• Muscular stiffness /
Myofibrosis
• Decrease range of motion
• Non-compliance.

34. Closed Reduction & fixation Techniques:
• Gilmer method
• Ivy loops/ eyelet method
• Arch bars – Erich arch bars
• Intermaxillary fixation screws
• Acrylic Splints

35. Gilmer method

36. Ivy loops/ eyelet method

37. Arch bars – Erich arch bars

38. Arch bar for Incisors

39. Intermaxillary fixation screws

40. Length of Intermaxillary fixation:
– Based on multiple factors
• Type and pattern of fracture
• Age of patient
• Involvement of intracapsular fractures
– Average adult: 3-4 weeks
– Children 15 years or younger- 2-3 weeks
– Elderly patients - 6-8 weeks
– Condylar fractures - 2-4 weeks

41. External Pin Fixation
• Technique of fracture repair
by using transcutaneous
pins threaded into the
lateral surface of the
mandible.
• The pin segments are then
connected together with an
acrylic bar, metal
framework, or graphite
rods.
• Synonymous with the Joe
Hall Morris appliance

42. Indications:
• Comminuted mandible fractures with/without
displacement
• Avulsive gunshot wounds
• Edentulous mandible fractures
• Can be used on patients that are poor
candidate for open reduction and closed
reduction (may increase likelihood of follow-
up)

43. Open Reduction
• Implies the opening of skin or mucosa to
visualize the fracture and reduction of the
fracture
• Can be used for manipulation of fracture only
• Can be either rigid or non-rigid fixation of the
fracture

44. Indications:
• Unfavourable / unstable mandibular fractures
• Fractures of an edentulous mandible fracture with
severe displacement
• Delayed treatment with interposition of soft tissue
that prevents closed reduction techniques to re-
approximate the fragments

45. Open Reduction & Rigid Fixation
– Any form of fixation that counters any biomechanical
forces that are acting upon the fracture site
– Prevents any inter-fragmentary motion across that fracture
site
– Heals with primary (contact or gap) bone healing,
produces no callus around fracture site
Eg. Lag screws ,
Compression plates (DCP / EDCP) ,
Reconstruction plates with screws.

47. Compression plate
technique:
• Rigid fixation
• When screws engage
plate, they impart
compression across the
fracture segments
• Results in the fragments
being brought together
with compression and
interfragmentary friction

48. Two types of compression plates exist
• Dynamic compression plates (DCP) –
require tension band, can be placed intra intra-orally
• Eccentric dynamic compression plate (EDCP) –
Avoids use of tension band
designed with the most lateral holes angled in
a superior/medial direction to impact
compression at the superior region.
Must be placed extra-orally.

49. Reconstruction plate:
– Rigid fixation technique
– Large plates that are load-bearing (can bear entire
load of region)
– Consist of plates that utilize screws greater than
2mm in diameter (2.3, 2.4, 2.7, 3.0)
– Must use 3 screws on each side of fracture
(maximum strength with 4)

51. Rigid fixation of mandibular angle
fractures:
• – 2 non compression
mini mini-plates;
inferior plate with
• bicortical screws
• – Reconstruction plate

52. Rigid fixation for symphyseal
fractures:
Compression plate with arch bar
2 lag screws
2 miniplates - inferior is bicortical and
may be compression plate

53. Mini Plate Fixation
– Technique pioneered by Champy
– Developed mathematical models to determine
forces on the mandible in relation to the inferior
alveolar canal, root apices, and bone thickness

54. Developed guidelines for the use of plates in relation to
the mental foramen in regards to ideal lines of
osteosynthesis
- Posterior to mental foramen- 1 plate applied just
below root apices
-Anterior to mental foramen- 2 plates
-Utilizes monocortical miniplates only

55. Non rigid fixation with
intraosseous wiring:
– Straight wire
– Figure of eight wire
– Transosseous circum-
mandibular wire

56. Indications for extraction of teeth within fracture
line
Tooth luxated from socket / interfering with reduction
of fracture.
Tooth is fractured / mobile.
Tooth pathology - decayed or has periodontal
disease, cyst, pericoronitis

57. Indications to leave tooth within fracture line
Tooth does not interfere with reduction/fixation.
If removal compromises fracture site for fixation i.e
excess bone removal.
Tooth in good condition and aids in establishing
occlusion.

58. Fractures in Edentulous Mandible
Decrease bone height leads to decreased buttressing
affect (alters plate selection)
Dependent on periosteal (centripetal) blood flow
Decreased ability to heal with age
Co-morbid medical conditions that delay healing

59. Treatment :
Closed Reduction as well as open reduction can be done
– Use of circumandibular wires fixated to the pryriform
rims and circumzygomatic wires with patient’s denture
or splints
– Requires IMF – usually longer periods of time(6-8 wks)

60. Paediatric Mandible Fractures
• Relatively uncommon type of injury
• Incidence of fractures in children under 15
under years- 0.31/100,000
• Usually represent less than 10% of all
mandible fractures for children 12 years or
younger

61. Uniqueness of children:
• Nonunion and fibrous union are rare due to
osteogenic potential of children.
• They heal rapidly.
• Due to growth, imperfect fracture reduction can
be “compensated with growth”.
Therefore, malocclusion and malunions usually
resolve with time

62. • The mandible tends to be thinner and has a less
dense cortex (could affect hardware placement)
• Presence of tooth buds in the lower portions of
the mandible (could affect hardware placement)
• Short and less bulbous deciduous teeth make
arch bar application difficult

63. Treatment modalities:
• Due to rapid healing, closed reduction techniques may be
tolerated
• Most fractures can be treated with follow-ups and
soft/non-chew diet or closed reduction
with arch bars or acrylic splint
• Open reduction only advocated for
- severely displaced unfavorable fractures
- delayed treatment (>7days) due to soft tissue in-growth,
- patients with airway/medical issues

64. Complications
The literature is highly variable on complication rates.
• Infection
• Delayed healing(3%) and nonunion(1%)
– most common cause is infection
– second most common cause is noncompliance
– inadequate reduction, metabolic or nutritional
deficiency can play a role
• Nerve paresthesias (Inf. Alveolar nerve) occur in 2%
• Malocclusion and malunion (rare in childrens)
• TMJ problems

65. Conclusion
• Simplest method is probably the best method
• Closed reduction techniques are much better in
paediatric.
• With multiple techniques available, there is still
controversy over the best treatment for each type
of mandible fracture
– The decision is a clinical one based on patient factors,
the type of mandible fracture, the skill of the surgeon,
and the available hardware

66. THANK YOU