Mandibular fractres

1. 11
Maxillofacial TraumaMaxillofacial Trauma
Mandibular FracturesMandibular Fractures
Mandible is embryologically a membrane bent bone although,
resembles physically long bone it has two articular cartilages
with two nutrient arteries

2. 22
Mandible in traumaMandible in trauma
Mandibular fracture is more common than middleMandibular fracture is more common than middle
third fracturethird fracture (anatomical factor)(anatomical factor)
It could be observed either alone or in combinationIt could be observed either alone or in combination
with other facial fractureswith other facial fractures
Minor mandibular fracture may be associated withMinor mandibular fracture may be associated with
head injury owing to the cranio-mandibularhead injury owing to the cranio-mandibular
articulationarticulation
Mandibular fracture may compromise the patency ofMandibular fracture may compromise the patency of
the airway in particular with loss of consciousnessthe airway in particular with loss of consciousness
Fracture of mandible occurred with frontal impactFracture of mandible occurred with frontal impact
force as low as 425 lb (190 Kg)force as low as 425 lb (190 Kg) {Condylar fracture}{Condylar fracture}

3. 33
Fracture of condyle regarded as a safety mechanismFracture of condyle regarded as a safety mechanism
to the patientto the patient
Frontal force of 800-900 lb (350-400 Kg) is requiredFrontal force of 800-900 lb (350-400 Kg) is required
to cause symphesial fractureto cause symphesial fracture
Mandible was more sensitive to lateral impact thanMandible was more sensitive to lateral impact than
frontal onefrontal one
Frontal impact is substantially cushioned by openingFrontal impact is substantially cushioned by opening
and retrusion of the jawand retrusion of the jaw
(Nahum 1975(Nahum 1975))
Long canine tooth and partially erupted wisdomsLong canine tooth and partially erupted wisdoms
represent line of relatively weaknessrepresent line of relatively weakness

4. 44
Anatomical considerationsAnatomical considerations
Attached muscles:Attached muscles:
MasseterMasseter
TemporalisTemporalis
Medial and lateralMedial and lateral
pterygoidpterygoid
MylohyoidMylohyoid
Geniohyoid andGeniohyoid and
genioglosusgenioglosus
anterior belly ofanterior belly of
digastricsdigastrics

5. 55
Blood supplyBlood supply
Endosteal supply via the ID artery and veinEndosteal supply via the ID artery and vein
Periosteal supply, important in aging due toPeriosteal supply, important in aging due to
diminishes and disappearance of alveolardiminishes and disappearance of alveolar
arteryartery
Bradley 1972Bradley 1972
NerveNerve
Damage of inferior dental nerveDamage of inferior dental nerve
Facial palsy by direct trauma to ramusFacial palsy by direct trauma to ramus
Damage of facial nerve in temporal boneDamage of facial nerve in temporal bone
fracturefracture
Goin 1980Goin 1980
Damage to mandibular division of facialDamage to mandibular division of facial
nervenerve

6. 66
Factors influenced site of fractureFactors influenced site of fracture
and displacementand displacement
Anatomy of theAnatomy of the
mandible and attachedmandible and attached
muscle (canine &muscle (canine &
wisdoms)wisdoms)
Weakening areas ofWeakening areas of
mandible (resorptionmandible (resorption
and pathologyl)and pathologyl)
Direction of force of theDirection of force of the
blowblow
Age of the patientAge of the patient

7. 77
Types of fractureTypes of fracture
SimpleSimple
Greenstick fracture (rare, exclusively in children)Greenstick fracture (rare, exclusively in children)
Fracture with no displacement (Linear)Fracture with no displacement (Linear)
Fracture with minimal displacementFracture with minimal displacement
Displaced fractureDisplaced fracture
Comminuted fractureComminuted fracture
Extensive breakage with possible bone and soft tissueExtensive breakage with possible bone and soft tissue
lossloss
Compound fractureCompound fracture
Severe and tooth bearing area fracturesSevere and tooth bearing area fractures
Pathological fracturePathological fracture
(osteomyelities, neoplasm and generalized skeletal(osteomyelities, neoplasm and generalized skeletal
disease)disease)

8. 88
Sites of fracturesSites of fractures
Condyle fractureCondyle fracture
– Intracapsular fractureIntracapsular fracture
– Extracapsular fractureExtracapsular fracture
High condyle neck fractureHigh condyle neck fracture
Low condylar fractureLow condylar fracture
Angle/ ramus fractureAngle/ ramus fracture (body(body
fracture)fracture)
Canine regionCanine region (parasymphesial(parasymphesial
fracture)fracture)
Midline fractureMidline fracture (symphesis(symphesis
fracture)fracture)
Coronoid fractureCoronoid fracture (rare)(rare)

9. 99
Incidence of mandibular fracturesIncidence of mandibular fractures
Body fractures 33.6%Body fractures 33.6%
Subcondylar fracture 33.4%Subcondylar fracture 33.4%
Fractures at the angle 17.4%Fractures at the angle 17.4%
Alveolar fractures 6.7%Alveolar fractures 6.7%
Ramus fractures 5.4%Ramus fractures 5.4%
Midline fractures 2.9%Midline fractures 2.9%
Fracture of coronoid process 1.3%Fracture of coronoid process 1.3%
Oikarinen & Malmstrom 1969Oikarinen & Malmstrom 1969

10. 1010
Favourable orFavourable or unfavourableunfavourable
They can be vertically or horizontally inThey can be vertically or horizontally in
directiondirection
They are influenced by the medial pterygoid-They are influenced by the medial pterygoid-
masseter “sling”masseter “sling”
If the vertical direction of the fracture favours theIf the vertical direction of the fracture favours the
unopposed action of medial pterygoid muscle, theunopposed action of medial pterygoid muscle, the
posterior fragment will be pulled linguallyposterior fragment will be pulled lingually
If the horizontal direction of the fracture favours theIf the horizontal direction of the fracture favours the
unopposed action of messeter and pterygoid muscles inunopposed action of messeter and pterygoid muscles in
upward direction, the posterior fragment will be pulledupward direction, the posterior fragment will be pulled
linguallylingually
Favourable fracture line makes the reducedFavourable fracture line makes the reduced
fragment easier to stabilizefragment easier to stabilize

11. 1111
Effects of muscles on displacementEffects of muscles on displacement
Transverse midline fracture (symphesial)Transverse midline fracture (symphesial)
stabilizes by the action of mylohyoid andstabilizes by the action of mylohyoid and
geniohyoidgeniohyoid
Oblique fracture (parasymphesial) tends toOblique fracture (parasymphesial) tends to
overlap under the influence of muscles actionoverlap under the influence of muscles action
Bilateral parasymphesial fracture results inBilateral parasymphesial fracture results in
backward displacement associated with loss ofbackward displacement associated with loss of
tongue control when the level of consciousnesstongue control when the level of consciousness
is depressedis depressed

12. 1212
Condylar fracturesCondylar fractures
The most common mandibular fractureThe most common mandibular fracture
Unilateral or bilateralUnilateral or bilateral
Intracapsular or extracapsularIntracapsular or extracapsular
Antero-medial displacement isAntero-medial displacement is
common but it may remaincommon but it may remain
angulated with the ramusangulated with the ramus
Dislocation of the glenoid fossa andDislocation of the glenoid fossa and
fracture of petrous temporal bonefracture of petrous temporal bone
which is very rarewhich is very rare

13. 1313
Sign and symptomsSign and symptoms
Swelling, pain, tenderness and restriction of movementSwelling, pain, tenderness and restriction of movement
Deviation of mandible towards the side of fractureDeviation of mandible towards the side of fracture
Gagging of occlussion (premature contact on the posteriorGagging of occlussion (premature contact on the posterior
teeth) with bilateral condylar displaced or over-riding fracturesteeth) with bilateral condylar displaced or over-riding fractures
Displacement of mandible toward the affected sideDisplacement of mandible toward the affected side
Anterior open bite on opposite side of fractureAnterior open bite on opposite side of fracture
Laceration of EAM****Laceration of EAM****
Retroauricular ecchymosis****Retroauricular ecchymosis****
Cerebrospinal leak and otorrhea in association with skull baseCerebrospinal leak and otorrhea in association with skull base
fracturefracture
Condylar fracturesCondylar fractures

14. 1414
Sequlae of TMJ injurySequlae of TMJ injury
Artheritic changesArtheritic changes
Haemartherosis, fibrosis and aknylosisHaemartherosis, fibrosis and aknylosis
Meniscal damage and detachmentMeniscal damage and detachment
TMDTMD
Staph infectionStaph infection with condylar backwardwith condylar backward
displacement and external auditory meatus injurydisplacement and external auditory meatus injury
MeningitisMeningitis with petrous temporal bone fracture andwith petrous temporal bone fracture and
intracranial involvementintracranial involvement
Condylar fracturesCondylar fractures

15. 1515
Coronoid process fracture:Coronoid process fracture:
Rare fracture caused by direct trauma toRare fracture caused by direct trauma to
ramus and results from reflux contraction oframus and results from reflux contraction of
temporalistemporalis
Can be seen following operation of largeCan be seen following operation of large
ramus cystramus cyst
Elicit tenderness over the anterior part ofElicit tenderness over the anterior part of
ramusramus
Development of tell-tale haematomaDevelopment of tell-tale haematoma

16. 1616
Fracture of the ramus:Fracture of the ramus:
Type I Single fractureType I Single fracture
Mimics low condylar fracture that runsMimics low condylar fracture that runs
below the sigmoid notchbelow the sigmoid notch
Type II comminuted fractureType II comminuted fracture
Common in missile injuries and appears toCommon in missile injuries and appears to
be with little displacement due to effects ofbe with little displacement due to effects of
messeter and medial pterygoid musclesmesseter and medial pterygoid muscles

17. 1717
Fracture of the angle and bodyFracture of the angle and body
Pain, tenderness and trismusPain, tenderness and trismus
Extra-oral swelling at the angle with obviousExtra-oral swelling at the angle with obvious
deformitydeformity
Step deformity behind the molar teethStep deformity behind the molar teeth
Movement and crepitus at the fracture siteMovement and crepitus at the fracture site
Derangement of occlussionDerangement of occlussion
Intra-oral buccal and lingula heamatomaIntra-oral buccal and lingula heamatoma
Involvement of IDNInvolvement of IDN
Gingival tear if fracture in dentated areaGingival tear if fracture in dentated area
Tooth involvement and possible longitudinalTooth involvement and possible longitudinal
split fracturesplit fracture

18. 1818
Midline fractureMidline fracture
The most common missed fracture (alwaysThe most common missed fracture (always
fine crack)fine crack)
Can be symphesial or parasymphesialCan be symphesial or parasymphesial
fracturefracture
Commonly associated with one or bothCommonly associated with one or both
condyles fracturecondyles fracture
Unilateral fracture leads to over-riding ofUnilateral fracture leads to over-riding of
the fragments and bilateral may contributethe fragments and bilateral may contribute
in loss of voluntery tongue controlin loss of voluntery tongue control
Long canine tooth represent a weak areaLong canine tooth represent a weak area
and contributes to parasymphesial fractureand contributes to parasymphesial fracture
Rarely runs across mental foramenRarely runs across mental foramen

19. 1919
Signs and symptomsSigns and symptoms
Pain and tendernessPain and tenderness
Swelling and odemeaSwelling and odemea
Development of step deformityDevelopment of step deformity
Mental anesthesiaMental anesthesia
Heamatoma in the floor of mouth and buccal mucosaHeamatoma in the floor of mouth and buccal mucosa
Soft tissue injury of the chin and lower lipSoft tissue injury of the chin and lower lip
If associated with condylar fracturesIf associated with condylar fractures
Absence of condyle movement on the contrlateral sideAbsence of condyle movement on the contrlateral side
Deviation of mandibleDeviation of mandible
Anterior open biteAnterior open bite
Gagging of oclussionGagging of oclussion
Limitation of mouth openingLimitation of mouth opening
Midline fracture

20. 2020
Clinical assessment and diagnosisClinical assessment and diagnosis
History of traumaHistory of trauma
(traumatized patients with possible head injury) and facial(traumatized patients with possible head injury) and facial
injuriesinjuries
Clinical ExaminationClinical Examination
▶▶ ExtroralExtroral
Inspection (assessment of asymmetery, swelling, ecchymosis, lacerationInspection (assessment of asymmetery, swelling, ecchymosis, laceration
and cut wounds)and cut wounds)
Palpation for eliction of tenderness, pain, step deformity and malfunctionPalpation for eliction of tenderness, pain, step deformity and malfunction
▶▶ Intra- and paraoralIntra- and paraoral
bleeding, heamatoma, gingival tear, gagging of occlussionbleeding, heamatoma, gingival tear, gagging of occlussion
and step deformity and sensory and motor deficiencyand step deformity and sensory and motor deficiency
RadiographsRadiographs

21. 2121
RadiographsRadiographs
Plain radiographPlain radiograph
OPGOPG
Lateral obliqueLateral oblique
PA mandiblePA mandible
AP mandible (reverseAP mandible (reverse
Townes)Townes)
Lower occlusalLower occlusal
CT scanCT scan
3-D CT imaging3-D CT imaging
MRIMRI

22. 2222
Principles of treatmentPrinciples of treatment
similar to elsewhere fractures in the bodysimilar to elsewhere fractures in the body
Reduction of fragments in good positionReduction of fragments in good position
Immobilization until bony union occursImmobilization until bony union occurs
These are achieved by:These are achieved by:
Close reduction and immobilizationClose reduction and immobilization
Open reduction and rigid fixationOpen reduction and rigid fixation
Other objective of mandible fracture treatment:Other objective of mandible fracture treatment:
Control of bleedingControl of bleeding
Control of infectionControl of infection

23. 2323
Definitive treatmentDefinitive treatment
Soft tissue repairSoft tissue repair
DebridmentDebridment
Irrigation with saline and antibioticsIrrigation with saline and antibiotics
Closure in layersClosure in layers
DressingDressing
Reduction and fixation of the jawReduction and fixation of the jaw
▶▶ Close reduction and IMF (traditional method by means ofClose reduction and IMF (traditional method by means of
manipulation)manipulation)
▶▶ Open reduction and semi-rigid fixation (using inter-ossousOpen reduction and semi-rigid fixation (using inter-ossous
wirings)wirings)
▶▶ Open reduction and rigid fixation (using bone palatesOpen reduction and rigid fixation (using bone palates
osteosynthesis)osteosynthesis)
Objective:Objective:
Restoration of functional alignment of the bone fragments inRestoration of functional alignment of the bone fragments in
anatomically precise position utilizing the present teeth foranatomically precise position utilizing the present teeth for
guidanceguidance

24. 2424
Close reductionClose reduction
Arch barsArch bars
– JelenkoJelenko
– Erich patternErich pattern
– German silver notchedGerman silver notched
Cap splintsCap splints
▶▶ IMF prior to rigid fixationIMF prior to rigid fixation
▶▶ For the purpose of closeFor the purpose of close
reductionreduction

25. 2525
Close reductionClose reduction
Bonded bracketsBonded brackets
IMF screwsIMF screws
Dental wiring:Dental wiring:
Direct wiringDirect wiring
Eyelet wiringEyelet wiring
Local anesthesia orLocal anesthesia or
sedationsedation
Minimal displacementMinimal displacement
IMF for 6 weeksIMF for 6 weeks
Treatment can be performedTreatment can be performed
under GA or LA and whenunder GA or LA and when
surgery is contraindicatedsurgery is contraindicated

26. 2626
Fracture mandible in childrenFracture mandible in children
Close reductionClose reduction
Open reduction andOpen reduction and
fixationfixation
Plating at the inferiorPlating at the inferior
borderborder
Resorpable platesResorpable plates

27. 2727
Gunning’s splintGunning’s splint
Old modalityOld modality
Edentulous patientEdentulous patient
Rigid fixation is notRigid fixation is not
possiblepossible
To establish theTo establish the
occlusionocclusion

28. 2828
Open reduction and fixationOpen reduction and fixation
Intraoral approachIntraoral approach
Extraoral approachExtraoral approach
▶▶ SubmandibularSubmandibular
approachapproach

29. 2929
Rigid fixationRigid fixation
Intraossous wiringIntraossous wiring
Plates and screwsPlates and screws
Kirchener wireKirchener wire
Lag screwsLag screws

30. 3030
Reconstruction palateReconstruction palate
Severe trauma
Loss of part of the bone

31. 3131
Condylar fracturesCondylar fractures
Intraoral approachIntraoral approach
Ramus incisionRamus incision
Extraoral approachExtraoral approach
Preauricular approachPreauricular approach
Retromandibular approachRetromandibular approach

32. 3232
IMFIMF
Transosseous wiringTransosseous wiring
Circumferential wiringCircumferential wiring
External pin fixationExternal pin fixation
Bone clampsBone clamps
Trans-fixation with Kirschner wiresTrans-fixation with Kirschner wires

33. 3333
OsteosynthesisOsteosynthesis
Non-compression small platesNon-compression small plates
Compression platesCompression plates
MiniplatesMiniplates
Lag screwsLag screws
Resorbable plates and screwsResorbable plates and screws

34. 3434
Teeth in the fracture lineTeeth in the fracture line
The fracture is compound into the mouthThe fracture is compound into the mouth
The tooth may be damaged or lose itsThe tooth may be damaged or lose its
blood supplyblood supply
The tooth may be affected by someThe tooth may be affected by some
preexisting pathologypreexisting pathology

35. 3535
Management of teeth retained in fractureManagement of teeth retained in fracture
lineline
Good quality intra-oral periapical radiographGood quality intra-oral periapical radiograph
Insinuation of appropriate systemic antibioticInsinuation of appropriate systemic antibiotic
therapytherapy
Splinting of tooth if mobileSplinting of tooth if mobile
Endodontic therapy if pulp is exposedEndodontic therapy if pulp is exposed
Immediate extraction if fracture becomesImmediate extraction if fracture becomes
infectedinfected
Follow up for 1 year and endodontic therapy ifFollow up for 1 year and endodontic therapy if
there is a loss of vitalitythere is a loss of vitality

36. 3636
Absolute indicationsAbsolute indications
Longitudinal fractureLongitudinal fracture
Dislocation or subluxation from socketDislocation or subluxation from socket
Presence of periapical infectionPresence of periapical infection
Infected fracture lineInfected fracture line
Acute pericoronitisAcute pericoronitis
Relative indicationsRelative indications
Functional tooth that would be removedFunctional tooth that would be removed
Advanced caries or periodontal diseasesAdvanced caries or periodontal diseases
Doubtful tooth which would be added to existingDoubtful tooth which would be added to existing
denturedenture
Tooth in untreated fracture presenting more than 3Tooth in untreated fracture presenting more than 3
days after injurydays after injury

37. 3737