Mandibular and Maxillary Fractures

1. MANDIBULAR AND
MAXILLARY
FRACTURES
DR. HADI MUNIB
ORAL AND MAXILLOFACIAL SURGERY RESIDENT

2. OUTLINE
• Evaluation of trauma patients
• Types of Mandibular Fractures
• Types of Maxillary Fractures
• Management of Facial Fractures
• References

3. EVALUATION OF TRAUMA
PATIENTS
• Multidisciplinary team approach
• ATLS
• ABC
• Examination

4. FRACTURES OF THE MANDIBLE HAVE BEEN REPORTED
TO COMPRISE BETWEEN 40 AND 62% OF ALL FACIAL
FRACTURES, ALTHOUGH THESE FIGURES MAY NOT
REPRESENT THE TRUE INCIDENCE BECAUSE ISOLATED
NASAL FRACTURES ARE SELDOM INCLUDED IN SUCH
SURVEYS.

5. CLASSIFICATION OF MANDIBULAR
FRACTURES
• Favourable vs. Unfavourable
• Anatomic site
• Pattern of fracture

8. CLASSIFICATION OF MANDIBULAR
FRACTURES
• Displaced fracture: Fractures may be nondisplaced, deviated, or displaced. Displacement
is defined as movement of the condylar fragment in relation to the mandibular segment
with movement at the fracture site.
• Dislocated fracture: A dislocation occurs when the head of the condyle moves in such a
way that it no longer articulates with the glenoid fossa.
• Special situations: Grossly comminuted fractures or fractures involving adjacent bony
structures, such as the glenoid fossa or tympanic plate; open or compound fractures; and
fractures in which a combination of several different types of fractures exist.

9. CLASSIFICATION OF MAXILLARY
FRACTURES
• Le Fort System

10. LE FORT
CLASSIFICATION
• Le Fort I: traverse the lateral antral wall, the lateral nasal wall, and the lower third
of the septum, and they separate at the pterygoid plates.
• Le Fort II: Involves most of the nasal bones, the maxillary bones, the palatine bones,
the lower two-thirds of the nasal septum, the dentoalveolus and the pterygoid plates.
• Le Fort III: Involves the nasal bones, the zygomas, the maxillae, the palatine bones,
and the pterygoid plates.
• ALL LE FORT FRACTURES INVOLVE PTERYGOID PLATES.

11. MANAGEMENT OF FACIAL FRACTURES
• No Treatment
• Closed Reduction
• Open Reduction

12. NO TREATMENT

13. CLOSED REDUCTION
• The fracture without opening direct flap on the fracture site
• IMF (inter-maxillary fixation)
• Establish a proper occlusal relationship by wiring teeth together and there
are several techniques with the most common one is arch bar.
• Arch bar with elastics
• IMF screws with elastics

15. OPEN REDUCTION AND INTERNAL FIXATION
(ORIF)
• A direct flap is created on the fracture site and internal fixation is done
• Non-Rigid Fixation
• Compression Plates (Rigid Fixation)
• Lag screws
• Reconstruction Plates
• Miniplates

16. INTERNAL FIXATION

17. INTERNAL FIXATION
• Internal fixation simply implies the placement of wires, screws, plates,
rods, pins, and other hardware directly to the bones to help stabilize a
fracture.
• Can be rigid or non-rigid depending on the nature of the fracture, and the
type, strength, size, and location of the hardware placed.

18. RIGID FIXATION
• “Any form of fixation applied directly to the bones which is strong enough to
prevent inter-fragmentary motion across the fracture when actively using the
skeletal structure.”
• Examples of rigid fixation in the mandible are:
1. The use of two lag screws or bone plates across a fracture
2. The use of a reconstruction bone plate with at least three screws on each side
of the fracture
3. The use of a large compression plate across a fracture.

20. COMPRESSION PLATES
• Extra-Oral Approach
• Scar

21. LAG SCREWS
• 2 screws in a horizontal way
• Rigid Fixation
• Sympheseal region

22. RECONSTRUCTION PLATES
• Load-Bearing
• Comminuted Fractures

23. MINIPLATES
• 2 mm thickness
• Titanium
• Intra-Oral Approach
• Bendable

24. LOAD-BEARING VS. LOAD-SHARING
• Load-bearing fixation is a device that is of sufficient strength and rigidity that it
can bear the entire load applied to the mandible during functional activities.
• Injuries that require load-bearing fixation are comminuted fractures of the
mandible.
• Load-Sharing fixation is any form of internal fixation that is of insufficient stability
to bear all of the functional loads applied across the fracture by the masticatory
system.
• Fractures that can be stabilized adequately with load-sharing fixation devices are
simple linear fractures.
• Fixation devices that are considered load-sharing include the variety of 2.0 mm
miniplating systems that are available from a number of manufacturers

25. CHAMPY PRINCIPLE
• Consists of a 2.0 mm mini-plate applied with monocortical screws along the
superior border and another at the
• Because metallic plates have high tensile strength, even thin plates work
adequately at the angle to prevent the tendency for a gap to form at the superior
border under function.
• Anterior to the mental foramen there is a so called the line of compression and at
the upper border there is something called line of tension

27. PRIMARY BONE HEALING IN RIGID
FIXATION
• New bone is laid down by the osteoblasts, forming osteons which cross the
gap and impart microscopic points of bony union to the fracture.
• A remodeling phase then converts the entire area to morphologically
normal bone.
• This Bone healing is called primary or direct bone union.
• It requires absolute immobilization between the osseous fragments, that is,
rigid fixation, and minimal distance (gap) between them.

29. CONDYLAR FRACTURES
• Often untreated
• OCCLUSION
• Guardsman Fracture
• Closed Reduction
• Open Reduction

30. CLOSED REDUCTION
• Best if inter-maxillary fixation be discontinued in all patients at
approximately 10 to 14 days.
• If other mandibular fractures are associated with the fractured condyle, it
is desirable to treat them with some form of additional stabilization.

31. OPEN REDUCTION
• Facial nerve
• Frey’s Syndrome
• Scar

32. CHILDREN
• Prolonged MMF may result in Ankyloses
• Surgery and Plates may result in growth restriction
• Functional Occlusion
• Splints
• Resorbable plates

33. MAXILLARY FRACTURES MANAGEMENT
• Reduction
• Fixation
• ORIF
- Buttresses

34. COMPLICATIONS

35. REFERENCES
• Chapter 20: Rigid vs. Non-Rigid Fixation
• Chapter 22: Principles of Management of Mandibular Fractures
• Chapter 23: Management of Maxillary Fractures

36. THANK YOU