This is a protocol for the management of mandibular fractures

1. MANDIBULAR FRACTURES
PRESENTED BY: GROUP B
FACILITATOR: DR WAKULOBA

2. Contents.
• Surgical anatomy
• Epidemiology.
• Classification systems
• General Clinical features and diagnosis
• Radiographic features
• Management Principles

3. Surgical anatomy
• Strongest facial bone
• Parabola shaped bone
• Angle of curvature is 110-140°
• Mandible is the 2nd bone to ossify
• Energy of 44.6-74.4 kg/m required to fracture the
mandible.

5. 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.

6. Age changes of mandible.
• Mental foramena.
child – near inferior border.
old age – near alveolar ridge.
• Ramus angle.
child & old – obtuse
• Alveolar ridge
• Blood supply

7. Champy’s principles
• Forces of mastication produce tensional forces
on upper border & forces of compression on
lower border.
• Champy put forward the lines where plates &
screws have to be placed - “ideal osteosynthesis
lines”
• It corresponds to course of a line of tension at
base of the alveolar process.
• Only in symphysis region, 2 plates are placed to
neutralize torsional forces.

8. Blood supply.
• Helps in the healing of
fractured bone.
• Endosteal blood supply via
inferior dental artery & veins.
• Peripheral blood supply -
Periosteum

9. Nerve supply.
• Inferior alveolar nerve
• Damage - angle & body #
• Anesthesia or parasthesia of the
nerve
• Recovery / regeneration - 3 to 12
months

10. Epidemiology.
• Etiology:

11. • Site

12. CAR ACCIDENTS
ASSAULTS
BIKE ACCIDENTS

13. Classification
• General
• Anatomical
• Completeness
• Mechanism of injury
• Number of fragments
• Shape of fracture
• Direction & favorability of treatment
• Presence or absence of teeth
• AO classification.

14. Kruger's Classification
SIMPLE ( CLOSED) Linear fracture lines which do not communicate
with the exterior
COMPOUND
( OPEN)
The fracture is communicating intraorally or
extraorally.
COMMUNITED Shattering of bone into multiple pieces

15. COMPLEX
COMPLICATED
There is adjunct injury to the adjacent nerves or
major blood vessels , joints.
IMPACTED One fragment is firmly driven within the other fragment and
clinical movement not appreciated
GREENSTICK Only one cortex broken. Common in children
PATHOLOGICAL Spontaneous fracture as a result of normal muscle contraction or
trauma due to increased weakness of underlying bone .
Impacted fracture

16. Dingman and Natvigs Classification
• Symphysis fracture
• Canine region fracture
• Body of the mandible
fracture
• Angle fracture
• Ramus fracture
• Coronoid fracture
• Condylar fracture
• Dentoalveolar fracture

17. 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

18. 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

19. Presence or absence of teeth
Kazanjian V.H. & Converse J.M.
CLASS 1 TEETH ON BOTH
SIDES OF FRACTURE LINE
MONOMAXILLARY
CLASS II TEETH ONLY ON ONE SIDE
OF THE FRACTURE LINE
INTERMAXILLARY
FIXATION
CLASS III EDENTULOUS PATIENT OPEN REDUCTION
/ PROSTHESIS

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

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

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

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

24. A: Associated fracture
A 0 None
A 1 Dentoalveolar fracture
A 2 Nasal bone fracture
A 3 Zygoma fracture
A 4 Lefort I
A 5 Lefort II
A 6 Lefort III

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

26. Clinical features.
• Extensive edema
• Tenderness.
• step deformity
• bone crepitus
• Facial asymmetry

27. Deviation of jaw Restriction of mouth opening

28. Extensive soft tissue and bony defect

29. 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

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

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

32. Displacement of fracture
• Direction and intensity of the traumatic force.
• Site of fracture.
• Direction of fracture line.
• Muscle pull exerted on fractured fragments.
• Presence or absence of teeth.
• Extent of soft tissue wound.

33. Radiographic Investigations
 OPG
 PA View
 PNS View(Paranasal sinuses )
 Lateral oblique Radiograph
 Occlusal view
 CT scan.

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

35. PA view.
• Medial / lateral displacement.

36. lateral view, occipital frontal (OF)
view and finally the occipital
mental (OM) view
Indicated for
Visualizing Medial
Displacement
Of Condylar Neck
The 4th & 5th
MacGregor Line
coincides with Mandible
PNS view

37. 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

38. CT scan.
• Condylar fracture.
• Cervical spine injury.

39. Principles of Management of
mandibular fractures

40. Principles of management
• Aim of intervention- restore the fracture segments to their pre-fracture
position and rigidly hold the segments together long enough for them to
unite. This is known as reduction and fixation.
• The principle of management- adequate reduction and fixation of the
reduced segments to allow for primary healing or formation and
stabilization of the bone callus at the fracture site followed by
rehabilitation.
• Basic principles:
 Reduction
 Fixation
 Immobilization

41. Definition
• Reduction refers to the repositioning of the fractured bony
segments into the preinjury normal anatomical position.
• The reduction can be achieved by withot exposure of the fracture
site; closed reduction(CR) or by direct exposure and
approximation of the fractured segments; open reduction(OR).
• The reduced fracture segments can be fixed internally by either;
 Rigid fixation
 Semi-rigid fixation
• Or fixed externally by either;
 Extraoral methods as in frames
 Intraoral as in MMF or splints

42. 1.Conservative management.
Criteria:
1. Where there is a linear un-displaced fracture.
2. Occlusion not affected by the fracture.
3. No infection evident in the fracture site.
4. Compliant pt willing to be on prescribed soft diet for atleast 4
weeks.
5. Coronoid fractures that do not cause restriction of mouth opening
or closure.
• Pain management and prophylactic antibiotics
• Instructions on how to maintain good OH.

43. Closed reduction
• Refers to external fixation devices and maxillomandibular fixation(MMF),
also referred to as intermaxillary fixation(IMF).
• Based on the principle that when the teeth on fractured segments are in
correct occlusion with the opposing maxillary teeth, then the bone
fragments to which they are attached will also be satisfactorily aligned.
• Healing of the bone occurs by secondary intention with callus formation and
takes 4-6 weeks
• The presence of teeth provides an accurate guide for reduction.
• Teeth may on occasion be brought into contact during reduction, yet be
occluding incorrectly owing to lingual inclination of the fractured fragments.
• Whenever the occlusion is used as an index of accurate reduction, it is
important to recognize any pre-existing occlusal abnormalities, such as
anterior open bite, etc.
• Wear facets on the teeth, can provide valuable clues to previous contact
areas

44. Indications for CR of a mandibular fracture
1. Non-displaced favorable fracture.
2. Grossly comminuted fractures with small bone fragments where
stripping of the periosteum from the small fragments may lead to necrosis.
3. Severely atrophic edentulous mandible.
4. Lack of soft tissue overlying the fracture site.
5. Fractures in children with developing teeth buds.
6. Coronoid process fractures
7. Pts deemed as high risk for treatment under GA.
8. Pts who cannot afford ORIF.
Contraindications of CR
• Pts with poorly controlled seizure history like epilepsy
• Compromised pulmonary function( moderate to severe asthma, COPD)
• GIT disorders(GERDS)

45. Techniques and materials used to
achieve MMF:
 Archbars
 Interdental wires(eyelets or ivy loops)
 Reduction by use of elastic traction;
 Severely displaced fractures maybe difficult to reduce into
occlusion, hence rubber elastics may be used between the hooks
on the lower and upper arch bars instead of tie wires. These are
used for 3-7 days as a temporary measure to gradually guide the
fractured segments into occlusion.

49. Disadvantages of MMF
• Requires an extended period of immobilization
• May pose a problem to the airway.
• Poor nutrition and weight loss
• Poor OH
• Phonation and speech difficulties
• May lead to difficulty in recovering normal range of jaw mvmt.
• Ankylosis in children
• Requires the presence of a sound dentition
• Social inconvenience and discomfort.
• Subsequent muscle disuse atrophy.

50. Open reduction and internal fixation(ORIF)
• Open techniques involves surgical exposure of the fracture site and
direct fixation at the fracture site once reduction is achieved.
• Fracture segments are brought too their correct position before
fixation which can be attained by MMF in pts with adequate
dentition or by manipulation using reduction forceps in edentulous
or compromised dentition status.
• Can be intraoral or extraoral depending on the location and severity
or complexity of the fracture.
• Extraoral approach, through a submandibular incision(>4 cm below
the inferior margin of the mandible to minimize the risk of the
marginal mandibular nerve injury).

51. • ORIF can be achieved by either semi-rigid fixation or rigid fixation.
1. SEMI-RIGID FIXATION
 Also, direct wire osteosynthesis(DWO)
 A form of fixation using 0.35mm-0.6mm SS wire to secure the
fractured segments.
 A small amount of movement of the proximal and distal segments
occurs causing healing with periosteal callus formation.
 Requires superior and inferior border wiring and must remain
reinforced with MMF for atleast 4 weeks.
 Useful in angle and parasymphyseal fractures in centers where
reconstruction plates are not available or affordable.
2.Rigid fixation
 Involves the use of plates of varying sizes and shapes that are
selected based on the fracture site and severity.
 Once acceptable reduction is achieved, the selected plate is bent
appropriately and adapted to the bone.
 The plates are then secured in place using screws that are measured
to match the thickness of the mandible at that point.

52. Methods of fixation after open reduction
1. Direct wire osteosynthesis
2. Circum-mandibular wire.
3. Mini-plates and monocortical screws
4. Rigid plates and bi-cortical screws
5. Rigid compression plates and screws
6. Lag screws(in parasymphyseal region)

53. (1)Preoperative X-ray
showing fracture line,
(2)Extraoral open reduction,
(3)Compression bone plate
adaptation and fixation after
reduction,
(4) Compression bone plate
fixed with bicortical screws,
(5) Postoperative X-ray
showing rigid fixation

54. Indications for open reduction
1. Displaced unfavourable fractures through the angle of the mandible
2. Pts with concurrent displaced mid-face fractures(panfacial) where a
rigid mandible is necessary
3. Fractures of a severely atrophic mandible that requires primary bone
grafting.
4. Multiple fractures.
5. Malunion
6. Non-union
7. Pathologic fractures
8. Some condylar fractures
9. Pts with conditions in which CR is contraindicated.

55. Contraindications for open reduction
1. Pts who are high GA risks.
2. Atrophic edentulous mandible where periosteal stripping may
lead to necrosis.
3. Comminuted fractures with tiny bone fragments.
4. Children at risk of damage to the unerupted permanent
dentition.
5. Some condylar fractures
6. Inadequate facility and lack of a skilled surgeon

56. Absolute and relative indications of OR by Zide and Kent
Absolute indications
• To restore vertical and anteroposterior facial dimension.
• When stability of occlusion is limited
• When rigid internal fixation is used to address other facial fractures affecting the occlusion
• When manipulation and closed treatment cannot re-establish the pre-traumatic occlusion.
• Invasion of foreign body.
• Post pubertal pts
• Dislocation of the condyle into middle cranial fossa.
Relative indications
• Edentulous jaws
• Uncontrolled seizure disorders
• Status asthmaticus
• Psychologic compromise

57. Advantages of ORIF
1. Immediate loading of the mandible is possible within 1-2
weeks.
2. No prolonged period of immobilization.
3. Good OH practice possible.
4. Pt is able to take normal oral medication.
5. Speech is not interfered with.
6. Where CR has failed.

58. Disadvantages of ORIF
1. GA related risks.
2. Expensive(reconstruction plate and theatre)
3. Implant may cause foreign body reaction.
4. 2nd operation to remove the implant may be necessary.
5. Risk of damage to nerves.
6. scarring(keloids and hypertrophic scars)
7. Not compatible with MRI if steel based
8. Damage to deciduous dentition in children.
9. Risky in pts with bleeding disorders
10. Atrophic edentulous mandible may undergo necrosis due to peristeal
stripping.

59. UNDISA EURO
BDS/10/18

60. Coronoid fracture
• Rare fracture-Isolated fractures of the coronoid process caused
by direct trauma are rare, as it is anatomically protected by the
complex zygomatic arch/ temporo-zygomatic bone and their
associated muscles. (2.9% of the mandibular fractures)
Aetiology
• Most fractures here are caused by strokes (contusion or
penetrating injuries)
• Caused by reflex contraction of temporalis or direct trauma to
ramus.
• Fragment pulled upward into the infratemporal fossa

61. Clinical features
• Tenderness over the anterior ramus
• Painful limitations of extrusive and lateral excursive movement.
• Slight to moderate swelling over the region of the zygomatic arch.
• Malocclusion
• Conservative management is first recommended for fractures of the
coronoid process with minimal displacement or restriction of mouth
opening.
• For patients with significant fracture displacement and limited mouth
opening, or with concomitant fractures of the zygoma, zygomatic arch, or
mandibular ramus, ORIF via the modified retromandibular approach
through the anterior border of the parotid gland is an alternative treatment
method.

63. Angle fractures
• The angle of the mandible is an anatomically weak and an area
susceptible to fracture. The presence of an impacted or
partially erupted third molar tooth further weakens it.
• Angle of mandible is the most common site for fracture (23-42%
of mandibular fractures) however, bilateral angle fracture is
very rare and uncommon.
• Causes-motor vehicle accident, assault
• Classification depends on the direction of the fracture line and
the effect of muscle action
• Hence fractures are
• Vertically favourable or unfavourable
• Horizontally favourable or unfavourable

65. • Muscles attached to the ramus
–the masseter, temporalis and
medial pterygoid displace
proximal segment upward and
medially when the fractures
are unfavourable.
• The muscles also impact the
bone minimizing displacement
in horizontal and vertical
favourable fractures

66. Inspection
• Swelling at the angle with obvious deformity
• Step deformity behind the last molar
• Haematoma adjacent to the angle on either the buccal and lingual side
• Anaesthesia or paresthesia of lower lip
• Derangement of occlusion.(anterior open bite, retro gnathic occlusion)
Palpation
• Tenderness at the angle externally
• Movements/crepitus at the site
• Step deformity
• Painful movement /trismus
• Loose teeth

67. Management
1.Closed reduction and intermaxillary fixation for 4-6 weeks with arch
bars,screws.Indicated in simple fractures without any significant
displacement
2.Open reduction
Indicated in unfavourable fractures with significant displacement.
Two fracture lines at the base
Periodontally compromised teeth
Edentulous patients
 Open reduction and non-rigid fixation with wire
Open reduction and rigid external fixation with plates and lag screws.

68. Open reduction with upper border
wiring and MMF
Advantages
• Minimally invasive
• Requires less skill
• Economic
Disadvantages
• Non rigid
• Has to be removed
• Possibility of lingual nerve injury

69. Open reduction with rigid fixation
• Rigid fixation is associated with rapid bone healing,excellent
stabilization at fracture site and excellent post –operative
stability.
Disadvantages of rigid fixation
• Bicortical screws used cause sensory disturbance along the
path of the inferior alveolar nerve
• Post-operative malocclusion rates are high due to difficulties in
bending the rigid plate.
• Extra oral scar due to incisions made in the extra oral
approach.

72. • Upper border plate/tension plate on the external oblique ridge
• Indicated for vertical and horizontal favourable fractures
Upper and lower plate
• Considered the best line of treatment
• Used in all types of fractures.
• Plate size and rigidity depend on the direction of the force

73. • Open reduction with 3 dimension plates
• Acts as double plating
• Prevents torsion movement
• Plate placed at the mandibular angle
2.0mm titanium plate

74. • Reconstruction plate with other methods of fixation.
• Best used in comminuted fracture

75. Surgical approaches
• Intraoral approach incision on external oblique ridge
• Submandibular incision
• Incision through the laceration

76. Body fracture-Molar and premolar
region
Aetiology- fracture of the body of the mandible accounts for almost 11% to 36%, with
personal violence as the principal factor.
Epidemiology
• In children, condylar and body fractures have been demonstrated to be the most
prevalent maxillofacial fractures.
• Body fractures are more prevalent among males than females.
• Mandibular body fractures usually occur between the distal aspect of the canine
and a hypothetical line that corresponds to the region of anterior attachment of
the masseter muscle.
• They may be classified based on the anatomic location, the direction of the
fracture line, position of teeth relative to the fracture, and favourability.
• Based on the fracture line direction and the effect of muscle distraction on the
fracture fragments, the body fractures can classify into two types (favorable and
unfavorable).

77. • In favorable fractures, the bony fragments are drawn together by the
muscle distraction, whereas in unfavorable fractures, the bony segments
become displaced by the muscle forces.
• These forces that render the fracture unfavorable are exerted by various
muscles such as masseter, temporalis, and medial pterygoid muscle. These
muscles distract the proximal bony segment in the superomedial direction.
• Moreover, two additional muscles (mylohyoid and anterior belly of
digastrics) may also play a role in displacing the segments in the posterior
and inferior direction.

79. Physical examination
• Intraorally, a change in occlusion may be apparent on physical examination.
• There may be anaesthesia, paraesthesia, or dysesthesia of the lower lip. This
change in lower lip sensation generally occurs in displaced body fractures that
are distal to the mandibular foramen (along with the distribution of the
inferior alveolar nerve) and not seen in nondisplaced mandible fractures.
• Laceration in the gingiva,
• Step defect in the occlusion,
• Ecchymosis in the mouth floor is a pathognomonic sign of a mandibular body
fracture.
• The examiner should note the mobility in the fracture. To do so, use both
hands to manipulate the mandible by placing the thumb on the occlusal
surface of the teeth and fingers on the inferior border of the mandible. Then
slowly and carefully, pressure should be placed between the two hands.

80. • Extraorally, there may be a change in facial contour due to
loss of external mandibular form and skin abrasion.
• flattened appearance of the lateral aspect of the face. On
palpation of there is a loss of the mandibular body. An
unfavorable fracture should be suspected.
• The anterior face may get displaced in the forward
direction, resulting in elongation. In such cases, the
anterior mandible becomes displaced in the downward
direction.

81. Evaluation
• Evaluation of the body fracture is via radiographs using plain
radiography (panoramic, lateral-oblique, posteroanterior, occlusal, and
peri apical views) and CT scan.
• The lateral-oblique view helps to diagnose posterior body fractures.
• Mandibular occlusal view and Caldwell posteroanterior view
demonstrate the presence of medial or lateral displacement of body
fractures.
• Among all the radiographs, the most informative is the panoramic
radiograph.
• CBCT can be useful as it is highly sensitive in identifying fractures. Also, it
provides better imaging quality and decreases the chances of
interpretation error

82. • There are two methods to treat mandibular body fractures, i.e., non-
surgical conservative management and surgical management. Whether to
treat the fracture using surgical or non-surgical means depends on the
type, severity, and consequences of fracture.
Indications for closed reduction include:
• Non-displaced favorable fractures
• Presence of healthy dentition with sufficient teeth to obtain a stable
occlusion
• Grossly comminuted fractures
• Edentulous fractures
• Fractures in children with developing dentition
• Presence of adequate occlusion
• Good facial esthetics and adequate open mouth

83. Open reduction and internal rigid fixation (ORIF)
• Surgical management can take place using an intraoral or extraoral approach, the
choice of which depends mainly on the site and type of body fracture.
• Simple and fractures in the anterior segment with no or only slight dislocation
should preferably have treatment using an intraoral approach. This approach
provides excellent access to the fracture site and allows observing the occlusion to
reduce fracture and application of rigid fixation.
• The incision is placed in the vestibular region approximately 5 to 7 mm below the
mucogingival junction to facilitate closure. This location also aids in the prevention
of wound dehiscence. During an intraoral approach, care is necessary to avoid
injuring the mental nerve.
On the other hand, the clinician can treat comminuted and fractures in the posterior
segment with a high degree of dislocation using an extraoral approach as placing
longer and stronger plates is difficult using the intraoral approach.
An extraoral surgical approach is also a possibility with fractures that lie between
the mandibular body's inferior and lingual aspects. Care is necessary to avoid
injuring the marginal mandibular nerve

84. Prognosis
• Both closed and open reductions of mandibular body fractures lead to
favorable results in terms of bony union.
• The treatment of dental injuries should be done concurrently with the
fracture as the fractured teeth may become infected and jeopardize
bone union.
• Hence, they require removal.
• As mandibular canines help to determine the occlusion, the clinician
should preserve them, if possible.
• The management and prognosis of edentulous body fractures are
often challenging due to advanced age and multiple comorbidities.

85. Symphysis and parasymphysis fractures
• Symphyseal/parasymphyseal fracture is defined as fracture line in mandibular
bone between the canine teeth.
• The symphysis of the mandible is defined as the region between the roots of
the central incisors, and the parasym- physis as the region between the lateral
roots of the canines and the central incisors.
• Mandibular symphyseal fracture accounts for 15.6 to 29.3% of mandibular
fractures
• Commonly associated with fractures of one or both condyles.
• Aetiology
Trauma from interpersonal violence or motor vehicle accidents. Falls, industrial
accidents, and sports injuries are lesser etiologies.
Most trauma is blunt, but penetrating trauma is common with interpersonal
violence and war injury.

86. Pathophysiology
• Blunt trauma can injure any part of
the mandible.
• A sharp blow applied anteriorly
often fractures the
symphyseal/parasymphyseal
region and the condyle region or
regions.
• Blunt force applied broadly across
the body of the mandible may also
result in a fracture of the
symphyseal/parasymphyseal
region.

87. Clinical features of symphyseal and
parasymphyseal fractures
• Tenderness at fracture site.
• Lingual haematoma(Cole’s sign)
• Inability to control salivary secretion.
• In oblique fractures,there is overriding of the segments with lingual
inversion of the occlusion.
• Soft tissue injury of the lip and chin.
• Detachment of the genioglossus muscle-Loss of tongue support and
obstruction of the airway.
• Not usually associated with anaesthesia of the Mental region
• Possible condylar fracture

88. Management of symphyseal and parasymphyseal
fractures
• Closed reduction
• Open reduction with inernal fixation using cortical plates in displaced
fractures

89. Fractures of the edentulous mandible
• Fractures of the edentulous mandible pose unique challenges. The
atrophic mandible has little osteogenic potential and a reduced
healing capacity .
• In the past, MMF was used by wiring the edentulous mandible to
dentures or splints. However, because these patients are often
elderly with comorbidities, it created additional complications such
as infection and pulmonary issues
• Rigid, internal fixation is frequently performed in these patients . This
has led to reduced convalescence time and a more manageable
healing process.
• Primary bone grafting is commonly done because of the atrophic
nature of the mandible.

90. • Options for ORIF include the use of miniplates or larger locking
reconstruction types .
• Miniplates are small in size, which allows for smaller incision sites.
• The screws are also small, which allows these plates to be placed in areas of
thin bone fragments, such as in the edentulous mandible.
• Both single and double miniplates can help with load sharing in mandibular
fractures.
• For larger fractures, heavier, load-bearing locking plates can be used. This
helps with flexion in the mandible that occurs with opening and closing the
mouth, which especially affects the edentulous mandible.

93. Mandibular fractures in children
• Mandibular fractures in children most commonly occur in condylar
region, followed by para-symphysis and angle.
• The fractures tend to be minimally displaced and in majority of cases
can be treated conservatively.
• Young bone possesses unique physical properties that coupled with
space occupying developing dentition give rise to patterns of fracture
not seen in adults.
• Bone fragments in children may become partially united as early as 4
days and fractures become difficult to reduce by seventh day.5
• This results in need for different forms of fixation as early as possible
for comparatively shorter duration of time.

94. • Non-union or fibrous union rarely occurs in children and excellent remodelling
occurs under the influence of masticatory stresses even when there is imperfect
apposition of bone surfaces.
• The management of mandibular fractures in children differs somewhat from that
of adults mainly because of concern for possible disruption of growth
• Growth abnormalities may occur as result of fracture dislocation of condyle due to
elimination of ‘functional matrix’ of lateral pterygoid function, trismus or ankylosis.
• Methods of dentoalveolar stabilization also require some reforms. Between 2-4
years sufficient number of fully formed deciduous teeth are present facilitating
application of arch bars or eyelet wires.
• 5 to 8 years age old group may present with some difficulty owing to loss or
loosening of deciduous teeth.
• The shape and shortness of deciduous crowns may make the placement of
circumdental wires and arch bar slightly more difficult in children.
• However the narrow cervix of tooth in relation to crown and roots provides better
retention of wires as in Ivy loops or stout wires.
• Mandibular cortex is thinner in children so care must be taken to avoid pulling a
wire through the mandible when placing circummandibular wiring for splints

95. • While doing open reduction and fixation presence of tooth buds throughout
the body of mandible must be a consideration as trauma to developing
tooth buds may result in failure of eruption of permanent teeth and hence
narrow alveolar ridge.
• The emergency management of facial trauma in paediatric population also
needs extra-consideration.
• Clinical signs of shock may occur with even insignificant amounts of rapid
blood loss due to small blood volume.
• Because of small size of airway laryngeal edema or retroposition of base of
tongue may produce sudden obstruction.
• Tracheostomy if required should be done using vertical incision avoiding first
tracheal ring and high lying left innominate vein.

97. When the arch bars cannot be placed
due to traumatized or otherwise
inadequate dentition, the fracture
site can be immobilized with a lingual
splint.
The Risdon cable. A twisted 24-gauge
wire is adapted to the cervical margins
of the teeth across the dental arches
and secured using interdental wires.
This is a suitable alternative to arch bar
placement in children and adolescents
because its low profile is easier to adapt
to the pediatric dentition.

98. Management of teeth in the fracture line
• They are important in fracture stability when using IMF
• They are less important in fracture stability when plates are used to fix the fractures.
Reasons to extract the tooth
• Severe tooth loosening with chronic periodontal disease and peri apical pathology
• Partially erupted third molars with pericoronitis or cystic areas
• Excessive delay from the time of fracture to the time of definitive treatment.
• Fracture of the root of the tooth
• Extensive periodontal injury and broken alveolar walls.
• Displacement of teeth from their alveolar socket
• Interference with bony reduction and reestablishing occlusion
• Acute recurring abscess in the line of fracture despite antibiotic therapy

100. CONDYLAR FRACTURES
BDS/07/18

101. ETIOLOGY
• Whenever a blow is received on the lateral side of face, the zygomatic arch protects the
condyle and coronoid process.
• Under these circumstances, the arch may fracture and may be associated with fracture
or dislocation of the condyle
• When a blow is given on the face resulting in fracture of the mandibular condyle, the
position of the fractured condyle in relation to the remainder of the ramal stump will
depend on certain factors:
1. The direction and degree of force.
2. The precise point of application of force.
3. Whether the teeth were in occlusion at the time of injury.
4. Whether the patient is partially or fully edentulous

102. MECHANISM OF INJURY
Trauma Causing Condylar Injury, Lindahl 1977
 Kinetic Energy imparted by moving object on static individual:
 Assault(fist)
 Industrial accidents
 Kinetic Energy derived from movement of individual and expended on a static object:
 Parade Ground Fracture - Fall of victim without attempt to shield face due to sudden loss of
consciousness
 Fall during epileptic attack
 Kinetic energy summation of forces from combination of the above which produces
more severe injury:
 RTA

103. Mechanism of injury to the condyles:
(1) Blow,
(2) Ground fall,
(3) Dashboard RTA injury

104. CLASSIFICATION
1. Unilateral or Bilateral Fracture
2. Intracapsular(High Condylar) or Extracapsular (Low Condylar) fractures
 Intracapsular: Fractures involving articular surfaces, condylar neck just below articular surface
 Extracapsular: Fractures running deepest concavity of sigmoid notch to posterior direction

105. Anatomical Classification

106. Other Classifications
• Wassmund’s classification (1934)
• MacLennan System (1952) - based on relationship of the proximal and distal
fracture segments to each other
• Spiessl and Scholl - based on displacement severity
• Lindahl’s classification - considered comprehensive
 Requires radiograph taken in two planes at right angles to each other

107. LINDAHL CLASSIFICATION, 1977
1. ANATOMICAL LOCATION OF FRACTURE
 Condylar Head
 Condylar Neck
 Subcondylar
2. Relationship of the Condylar Fragment to the mandible
 Nondisplaced
 Deviated
 Displacement with medial or lateral overlap
 Displacement with anterior or lateral overlap
 No contact between fractured segments
3. Relationship of Condylar Head and Fossa
 Nondisplaced
 Deviated
 Dislocation

108. (A) Relationship of condylar fragment to mandible (B) Relationship of
condylar fragment to glenoid fossa
Anatomic Location of Fracture

109. • Fracture with little or no displacement occurs when adequate natural or artificial molar
support exists and the teeth are in occlusion at the time of impact.
• A variable degree of displacement will take place , if the teeth are separated or the force is
received from a lateral direction.
• Full force of impact will be transmitted to the condyles, resulting in a variable degree of
fracture dislocation, if the mouth is widely open or there is inadequate molar support at the
time of injury
• When the blow is received in the center of the chin, the distribution of force is equal to both
the condyles,
-resulting in a bilateral indirect fracture through the necks, accompanied by a direct fracture
at the symphysis (countercoup type of fractures).
• This type more often is seen in an epileptic patients or soldiers who fall on the face during
parade.

110. DIAGNOSIS
1. Evidence of facial trauma, especially in the area of the mandible and symphysis.
2. Localized pain and swelling in the region of the TMJ.
3. Limitation in mouth opening.
4. Deviation, upon opening, toward the involved side.
5. Posterior open bite on the contralateral side.
6. Shift of occlusion toward the ipsilateral side with possible cross bite.
• Occlusion: Unilateral posterior crossbite or contralateral open bite
(gagging of the occlusion on the ipsilateral molar teeth) and
retrognathic occlusion may also be associated. Displacement of the
condyle from the fossa or overriding of the fractured condylar neck
shortens the ramus on that side producing the malocclusion.

111. 7. Blood in the external auditory canal. It is important to distinguish bleeding originating in the
external auditory canal from the middle ear haemorrhage. The latter signifies a fracture of the
petrous temporal bone
8. Pain on palpation over the fracture site
9. Lack of condylar movement upon palpation
• If the condylar head is dislocated medially, a characteristic hollow over the region of the
condylar head may occur
10. Difficulty in lateral excursions as well as protrusion
11. Persistent cerebrospinal fluid leak through the ear is indicative of an associated fracture of
the middle cranial fossa (otorrhoea)

112. Bilateral Condylar Fracture
1. Signs and symptoms of unilateral condylar fractures present on both sides
2. Swelling over both fracture sites
3. Overall mandibular movement more restricted than in unilateral
4. Anterior open bite present if there is displacement of the condyles from glenoid fossa, or
overriding of the fracture ends with posterior gagging of occlusion
5. Elongated face appearance
6. Pain and limitation on opening and restricted protrusion and lateral excursions
7. Frequent association with fracture of the symphysis or parasymphysis

113. Significant midline
deviation towards the
fracture side

114. Anterior Open Bite
present in a bilateral
condyle fracture
Anterior and right lateral open bite
associated with left mandibular
condyle fracture

115. • Clinically, it will be noted that there is asymmetry of the face on the
involved side due to, shifting of the mandible posteriorly and laterally
towards the affected side (deviation of the mandible).
• Premature occlusion on the involved side is caused by upward pull of
the elevator muscles of the mandible.
• An open bite deformity anteriorly and on the opposite side of the
mandible is noted. In case of bilateral fracture condyles, the patient
will have anterior open bite deformity with premature contact only
on the posterior teeth.
• This is caused by upward displacement of ramus and telescoping of
the fractured fragments, due to contractions of the lateral pterygoid
muscles

116. • In bilateral condylar fracture, which occurs below the attachment of the lateral
pterygoid muscles, the patient is unable to protrude the mandible
• In unilateral fractures at the same level, the patient is unable to perform lateral
movements to the opposite side, as the lateral pterygoid muscle is out of function
on the affected side
• Fractures above the level of the lateral pterygoid muscle insertion do not exhibit
displacement, as there is absence of contracting muscle attached to the proximal
segment.
• The patient may complain of severe pain in the TM joint and it will be noted that the
teeth are separated and do not come into the occlusion on the affected side,
because of the haemarthrosis in the joint, which forces the condyles downwards.
• It may be few weeks before the teeth come into their normal occlusal relationship.
• In this type of fractures, especially in children, active early mobilization of the joint is
a must, the parents should be warned about the possibility of the development of
ankylosis of the TMJ, if proper treatment is not initiated.

117. Radiology and Imaging
• OPG-shows empty fossa and increase in joint space.
• Reverse Towne’s view-showing elongated condylar fracture
• PA mandible
• CT scan(coronal)-important in sagittal fracture of the condyle.

119. Reverse Towne’s View

121. Goals of therapy
1. To get stable occlusion
2. Restoration of interincisal opening
3. Restore Full range of mandibular excursive movement
4. Decrease deviation
5. Eliminate pain
6. Avoid internal derangement
7. Avoid growth disturbance

122. TREATMENT OF CONDYLAR FRACTURES
 The management of condylar fractures is divided into:
(a) Non-surgical -
 Conservative -Immobilization by Intermaxillary fixation
 Functional - Active movement
(b) Surgical
 The decision will vary depending on the age of the patient, the
type of fracture, concomitant injuries and associated
anatomical findings.

123. Treatment of condylar fractures in
infants and young children
Unique anatomical features of infants condyle
1. Short thick necks with a less pronounced head.
2. Thin cortical bone with large marrow rich in undifferentiated
pluripotent cells.
3. Trauma often leads to intra-capsular fractures.
4. Release of marrow and blood into the joint space readily predispose
to ankylosis.
Unless severely displaced, the fractures are treated by closed reduction
with a short period of fixation not exceeding 10 days followed by mouth
opening exercises to minimize the risk of ankylosis.

124. Treatment Protocol
0-2 years - Encouragement of active jaw function + analgesics
3-12years - Functional Treatment for both unilateral and bilateral condylar
fractures. IMF for 7-10 days in case of extreme pain
 With significant displacement and ST injury, myofunctional interocclusal
appliances may be used.
13-18years -Relatively decreased remodelling capacity. May result in
abnormally shaped condylar head, shortened ramus heights. IMF for 2-3
weeks. Can be considered for surgery based on severity

125. In Adults:
Unilateral Intracapsular Fracture
 Does not cause much deformity
 Conservative treatment (usual IMF for 7-10days)
 IMF for 2-3 weeks incase of malocclusion
Bilateral Intracapsular Fracture
 IMF for 3-4weeks
 Physiotherapy afterwards to prevent restriction in mouth opening
Unilateral Extracapsular Fracture
 No displacement, no disturbance to occlusion - no effective treatment
 Displacement or severe malocclusion - Open reduction
Bilateral Extracapsular Fracture
 Results in instability and gross displacement of mandible
 Open reduction of at least one side is recommended to establish normal height
 If there is association with gross midfacial fractures, open reduction of both sides
should be done

126. Nonsurgical Management of Condylar
Fractures
• Most cases of the condylar fractures are best managed through
nonsurgical means. The obvious advantage is the avoidance of
morbidity and complications associated with surgery.
• Conservative method varies from no fixation to employing various
devices.
1. Condylar fractures without displacement or with minimum
displacement, without much occlusal disturbance and functional range
of
motion do not require any active treatment.
• Patient is asked to restrict the movements and semisolid soft diet
intake for 10 to 15 days followed by active movements.

127. 2. In case of deviation on mouth opening without much occlusal
discrepancy, a simple muscle training in front of a mirror is adequate.
On the involved side, class II elastic traction and on the normal side,
vertical elastic forces may be beneficial.
3. In cases, where condylar fragment overriding is seen with
alteration in ramus height, producing malocclusion, initially elastic
traction is given to
correct the malocclusion, followed by IMF for 2 to 3 weeks.
• Early mobilization is advocated in cases of young
children to avoid ankylosis of TMJ.

128. Surgical Correction of Condylar Fractures
• Many a times, ankylosis, malocclusion, continued pain, dysfunction are
examples of residual difficulties associated with the conservative management
with condylar fractures
Absolute Indications for Open Surgery
1. Fracture dislocations in the auditory canal or middle cranial fossa (rare)
2. Anterior dislocation with restricted mandibular movements
3. Bilateral condylar fractures associated with a comminuted LeFort III type with
craniofacial
dysjunction.

129. Zide and Kent indications for open
reduction of condylar fractures
Absolute indications:
1. Displacement of the condyle into the middle cranial fossa.
2. Inability to obtain adequate occlusion by closed techniques
3. Lateral extra-capsular dislocation of the condyle
4. Invasion by foreign body in the joint capsule

130. Relative Indications
1. Subcondylar fractures with overriding of the fragments with
anterior open bite.
2. Anterior and medial displacement of the condylar fragment.
3. In case of delayed treatment, where there is pain and dysfunction
associated with malunited fracture.
4. Unilateral or bilateral fractures with loss of the posterior teeth, in
either upper jaw or both the jaws.
5. Cases in which position of the condylar fragment interferes with
normal function of the jaws.

131. Surgical Approaches to the Condyle
• Preauricular approach
• Retromandibular approach
• Submandibular approach
• Intraoral approach
• Bicoronal (bilateral condylar fracture along with frontal bone
fracture)

133. Surgical Approach to the Condyle
• The preauricular approach historically has had a relatively high
incidence of facial nerve involvement.
• Modifications of this approach include an approach to the joint
region through a subtemporal fascial-periosteal envelope.
Such an approach allows avoidance of the facial nerve
branches by staying first posterior and then deep to the nerve.
• Postramal approach is better for subcondylar fractures.

134. Methods of Fixation of the Condyle
• Transosseous wiring
• Kirschner wire
• Intramedullary screw
• Bone pins
• Bone plating

135. Preparation of the patient
• The temporal region is shaved preferably the day before surgery.
• The skin of the preauricular region and the ear are prepared in the usual
manner.
• The patient should be placed on the table so that the sagittal plane of the head
is parallel with the table.
• This often requires that the shoulder be raised with a flat sandbag. Sandbags
are also used to maintain the head in the correct position.

136. Operative Procedure
• Operative procedure Access to the TMJ is done for high condylar fracture via
modified preauricular incision and for subcondylar through postramal
approach.
• Blunt retractors are inserted and the zygomatic arch is located. The depression
in the inferior border of the arch denotes the location of the mandibular joint.
• The mandible at this point may be moved by the assistant, which may produce
movement of the fragments and so helps in locating them.
• As one proceeds, the transverse facial artery and vein may be encountered, cut
and tied. Inverted L-shaped incision is taken from
• the lower border of the zygomatic arch to the outer surface of the ramus.

137. • The procedure from here, depends on whether the condyle is displaced
laterally or medially, which is already determined from the radiographs.
• If the condyle is laterally displaced, then the periosteum of the neck of the
condyle is stripped off with a periosteal elevator.
• The condylar retractor is now inserted from the posterior border going
medially to protect the vital structures. The hole is drilled through the outer
cortex till the inner cortex.
• The 26 gauge double wire is passed through the hole and grasped with the
haemostat from the medial aspect

138. • The mandibular fragment is located next, since the fragment is under the
condyle. If submandibular or postramal approach is taken, then small hole is
made at the angle at the inferior border of the mandible, through which
double wire is passed and grasped with a haemostat
• This wire is pulled downward, so that there is better access for grasping the
condylar fragment as well as ramus.
• By using periosteal elevator and special condylar retractor, another hole is
drilled in the ramal fragment. The wire, previously placed in the condylar
fragment is now drawn through from the fracture surface by inserting a
looped wire in the hole from the outer surface of the ramus.

139. • The fracture is then reduced under direct vision and temporary IMF is done
intraorally by the assistant.
• After that the wire ends are twisted together and cut off and the ends are
bent over close to the bone. In cases, where condyles are medially displaced,
the procedure is reversed.
• First the mandibular fragment is located by manipulation and same
procedure can be repeated as described. After fixation by the wires, the
wound is closed in layers and dressing is given.
• At the end of the operation, temporary IMF should be removed to facilitate
extubation and it should be replaced next day.
• Immobilization is kept for 15 to 20 days.

140. • Minibone plating can also be done instead of intraosseous wiring
• Here, the fracture should be reduced as described and then the small four hole
or two hole bone plate should be adapted to the external cortex and fixed with
monocortical selftapping screws.
• If the high condylar fractured fragment is displaced too anteromedially, then it
should be located by depressing the ramal fragment and catching it with the
haemostat.
• Then if it can be fixed back as a free graft to the ramal stump, the attempt
should be done. But many times condylectomy is recommended, because
replantation is not possible.

143. Complications of condylar fractures
1. Permanent TMJ derangement e.g., osteoarthritis or internal
joint derangement due to injury to the meniscus.
2. Facial asymmetry esp. in children due to growth
interference. This may require osteotomy,bone grafting or
distraction osteogenesis to correct the deformity.
3. Trismus
4. Ankylosis esp. following intra-capsular fracture in children.
Shown in the radiograph as a mushrooming head of the
affected condyle, also a prominent antegonion notch.
5. Lateral open bite.

144. Early/concurrent complications
1. Fracture of the tympanic plate
2. Fracture of the glenoid fossa with or without displacement
of the condylar segment into the middle cranial fossa.
3. Damage to the trigeminal and facial nerves
4. Vascular injury
5. infection

145. Late complications
• Delayed union
• Non-union
• Malunion
• Malocclusion
• Growth disturbances
• Tmj dysfunction
• Ankylosis
• Scars

146. References.
• Oral & maxillofacial trauma- Fonseca,vol 1
• Maxillofacial Injuries- Rowe & Williams
• Textbook of oral & maxillofacial surgery by SM Balaji
• Textbook of oral & maxillofacial surgery by Peter Ward Booth.
• Textbook of oral & maxillofacial surgery by Neelima malik.
• Killeys - fractures of the mandible

147. THE END!!