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Mandible Fractures

http://tajmeel.ta.ohost.de
Dr. Mohamed El Rouby ‫ محمد أحمد الروبي‬.‫د‬
Lecturer of Plastic Surgery ‫مدرس جراحة التجميل‬
+20101556023 or +20126531265 or elroubyegypt@gmail.com

INTRODUCTION
Treatment goals are to restore function and premorbid occlusion. Mastication, speech, and
normal range of oral motion should be achieved. Contour defects must be corrected. Early
treatment curtails the possibility of infection.

The amount of force needed to fracture bones have been divided into those that require
high impact to fracture (> 50 times the force of gravity [g]) and those that require only low
impact to fracture (< 50 g).
• High impact
o Supraorbital rim - 200 g
o Symphysis of the mandible - 100 g
o Frontal-glabella - 100 g
o Angle of mandible - 70 g
• Low impact
o Zygoma - 50 g
o Nasal bone - 30 g

Sex: Adult male-to-female ratio is 3:1.


Age: Male predominance is reduced to 3:2 in children.
Frequency: The areas of the mandible most commonly fractured include the condylar-
subcondylar region, body, and angle. Location of the fractures and associated frequency
are as follows:
• Condyle - 36 - 29%
• Angle - 20 - 24%
• Symphysis - 14 - 22%
• Body - 21 - 16%
• Ramus or alveolus - 3 - 1.7%
• Coronoid - 2 - 1.3%
• Midline < 1%

Aetiology:
• Vehicular accidents - 43%
• Assaults - 34%
• Work related - 7%
• Fall - 7%
• Sporting accidents - 4%
• Miscellaneous - %5
Pathophysiology:
Classification of mandibular fractures
• Simple or closed -
• Compound or open -
• Comminuted -
• Greenstick -
• Pathologic -
• Multiple - Variety in which two or more lines of fracture on the same bone are not
communicating with one another
• Impacted - Fracture in which one fragment is driven firmly into the other
• Atrophic - Fracture resulting from severe atrophy of the bone, as in edentulous
mandibles
• Indirect - Fracture at a point distant from the site of injury
• Complicated or complex - Fracture in which considerable injury to the adjacent soft
tissues or adjacent parts occurs; may be simple or compound
Classification by anatomic region
• Symphysis - Fracture in the region of the central incisors that runs from the alveolar
process through the inferior border of the mandible
• Parasymphyseal - Fractures occurring within the boundaries of vertical lines distal
to the canine teeth
• Body - From the distal symphysis to a line coinciding with the alveolar border of the
masseter muscle (usually including the third molar)
• Angle - Triangular region bounded by the anterior border of the masseter muscle to
the posterosuperior attachment of the masseter muscle (usually distal to the third
molar)
• Ramus - Bounded by the superior aspect of the angle to two lines forming an apex
at the sigmoid notch
• Condylar process - Area of the condylar process superior to the ramus region
• Coronoid process - Includes the coronoid process of the mandible superior to the
ramus region
• Alveolar process - Region that normally contains teeth

Angle fractures may be classified as:


(1) vertically favorable or unfavorable and
(2) horizontally favorable or unfavorable.

Muscles involved in opening the mouth include the anterior belly of the digastric muscle
and the mylohyoid, geniohyoid, and genioglossus muscles.
Oral closure is provided by the action of the temporalis, masseter, and the internal (or
medial) pterygoid muscles.
The only protrusion from the mandible is the external, or lateral, pterygoid muscle.
The muscles attached to the ramus (masseter, temporal, medial pterygoid) displace the
proximal segment upward and medially when the fractures are vertically and horizontally
unfavorable. Conversely, these same muscles tend to stabilize the bony fragments in
horizontally and vertically favorable fractures.
In bilateral fractures in the cuspid areas, the symphysis of the mandible is displaced
inferiorly and posteriorly by the pull of the digastric, geniohyoid, and genioglossus
muscles.

Favorable and unfavorable fractures.


Top: Horizontal reference. Bottom: Vertical reference.

Condylar fractures are classified as:


 Extracapsular
 Subcondylar
 Intracapsular
The lateral pterygoid tends to cause anterior and medial displacement of the condylar
head. Five types of condylar fractures are described in order of increasing severity:
• Type I is a fracture of the neck of the condyle with relatively slight displacement of
the head. The angle between the head and the axis of the ramus 10-45°.
• Type II fractures produce an angle from 45-90°  tearing of the medial portion of
the joint capsule.
• Type III fractures are those in which the fragments are not in contact, and the head
is displaced medially and forward. The fragments are confined within the area of the
glenoid fossa. The capsule is torn, and the head is outside the capsule.
• Type IV fractures of the condylar head articulate on or in a forward position with
regard to the articular eminence.
• Type V fractures consist of vertical or oblique fractures through the head of the
condyle.
Clinical:
1. History can help in the diagnosis.
2. Symptoms: pain, trismus, difficulty chewing, and anesthesia or paresthesia of the
lower lip and chin.
3. On examination: abnormal mandibular movements, malocclusion, change in facial
contour and mandibular arch form, tenderness, swelling, redness, lacerations,
hematoma, ecchymosis and trismus.
N.B. Loose and fractured teeth should be evaluated and counted. If teeth are missing,
consider a chest radiograph to rule out aspiration.
N.B. It must be remembered that not all patients have ideal occlusion:
(ie, only 74% of the population have an angle class I bite). The remainder has either
retrognathia (angle class II, 24%) or prognathia (angle class III, 1%).

Angle classification:
is based on the relationship of the mesial-buccal cusp of the maxillary first molar to the
buccal groove of the mandibular first molar
(Mesial  anterior in reference to the sagittal plane and distal is posterior to that same
plane.)
the relationship of the canine teeth to determine the occlusal class.
Class I occlusion refers to the mesial-buccal cusp of the maxillary first molar's contact with
the mandibular first molar's buccal groove. The mesial-buccal cusp lies in front of (or
mesial to) the groove in class II occlusion. In angle class III occlusion, the mesial-buccal
cusp of the maxillary first molar falls behind (or distal to) the groove.

Relation between 1st molar teeth, cuspid and incisior teeth


A= class I normal occlusion
B= class II retrooclusion, mandibular deficiency
C= class III prognathic occlusion, maxillary deficiency, mandibular access
Mesial= toward midline , distal= away from midline
Teeth spaces interproximal space
Mandibular  labial and buccal + lingual surface
Maxillary  labial , buccal and palatal + lingiual surface

N.B. Fractures that occur in the region of the teeth are considered to be compound
fractures  prophylactically treated with antibiotics.

INDICATIONS
I- Observation
Historically, for minimally displaced fractures that were of a favorable type, a Barton-type
head bandage gave enough support for the fracture to heal. This was especially true in
children. A liquid or pureed diet was maintained for 4 weeks.
Factors affecting fragment displacement include:
1- direction and intensity of the traumatic force
2- direction and bevel of the fracture line
3- presence or absence of teeth in the fragments
4- direction of muscle pull
5- extent of soft-tissue injury
II- Maxillomandibular fixation and closed reduction
If external dressings are not sufficient, closed reduction can be accomplished with
maxillomandibular fixation (MMF),

III- Open reduction


Open reduction is an excellent modality via either an intraoral or extraoral incision. To
maintain fixation, titanium plates and screws or stainless steel wire may be used. Even
with an incision, percutaneous access may be needed for the placement of plates, screws,
or wire.
RELEVANT ANATOMY AND CONTRAINDICATIONS
Relevant Anatomy:
 The mandible is derived from the first branchial arch (membranous bone). Ossification
is by direct mineral deposition into the organic matrix of mesenchyme or connective
tissue. Bone matrix is 35% organic and 65% inorganic, and 90% of the organic
component is type I collagen. Hydroxyapatite makes up most of the inorganic portion
of bone.
 The mandible is divided into the condylar, subcondylar, ramus, angle, body,
parasymphyseal, symphyseal, coronoid, and dental alveolar regions.

 The structure of the mandible is such that masticatory force trajectories are
transmitted to the skull base, but the jaw usually fractures prior to penetration of the
middle cranial fossa. This design permits great forces on the mandible to be
distributed along its frame.
 The third division of the trigeminal nerve enters the mandible, at the lingula, as the
inferior alveolar nerve (IAN). The lingula is also the point of attachment for the
sphenomandibular ligament. The IAN gives off dental branches before exiting the
mental foramen, located between the first and second premolar teeth, in the lower
third of the mandible as the mental nerve. Knowledge of the path of the nerve and the
length of the teeth is important in planning the placement of titanium plates and
screws.

 Contraindications: Reduction of fractures can be delayed until the patient is stable.


Ideally, fracture reduction should be performed within 7-10 days. After this period, the
risks of malunion, malocclusion, and facial asymmetry increase.
 Poor candidates for MMF include the following:
• Patients who are noncompliant
• Patients with alcoholism, seizure disorder, severe pulmonary dysfunction, mental
retardation, psychosis, or poor nutrition (e.g. patients with diabetes)
• Patients who are pregnant
• Patients with multiple injuries
• Patients who are unwilling to make the change in lifestyle that is needed for 4-6
weeks

WORKUP
Lab Studies:
• Routine preoperative laboratory
Imaging Studies:
• CT scan.
• A panoramic radiograph (Panorex) affords an excellent 2-dimensional
representation of the mandible.
• Several types of plain films add to the evaluation of mandibular fractures.
o The dental periapical view gives fine detail to the teeth and their roots.
o The dental occlusal view helps determine whether the fracture is vertically
favorable or unfavorable.
o The Caldwell is a coronal view that shows displacement in the horizontal
plane.
o The oblique views highlight the ramus angle and posterior body.
o The reverse Towne view depicts the condylar/subcondylar region well.
• Obtain a chest radiograph when evidence of a broken denture or missing tooth is
present.
TREATMENT
Medical therapy:
Indications for closed reduction
• Nondisplaced favorable fractures
• Grossly comminuted fractures
• Severely atrophic edentulous mandibles
• Fractures in children involving the developing dentition
• Coronoid fractures:
• Treatment of condylar fractures

Indications for open reduction


• Displaced unfavorable fractures through the angle of the mandible:
• Condylar fractures:
o Absolute indications
1. Displacement of the condyle into the middle cranial fossa
2. Inability to obtain adequate occlusion by closed techniques
3. Lateral extracapsular dislocation of the condyle
o Relative indications
1. Bilateral condylar fractures in an edentulous patient when splints are
unavailable or impossible because of severe ridge atrophy
2. Unilateral or bilateral condylar fractures when splinting is not
recommended because of concomitant medical conditions or when
physiotherapy is not possible
3. Bilateral fractures associated with comminuted midfacial fractures
• Medically compromised patients:
• Complex facial fractures:
• Other fractures: Consider open reduction with primary bone grafting in fractures of a
severely atrophic edentulous mandible with severe displacement
o Mandibular nonunions require open access for debridement and subsequent
reduction.
o Malunions after improper reduction often require osteotomies through open
surgical approaches to correct mandibular discrepancies.

Surgical therapy:
Goals: anatomic reduction of fracture segments, restoration of premorbid occlusion, and
avoidance of complications.
Timing: treatment should be instituted within 7 days.
Options:
I- Closed reduction of dentate patients
A- Erich arch bars
B- Bridle wire
• Manually reduce the segments with the use of local anesthesia.
• Loop two teeth (if available) with 24-gauge wire anterior and posterior to the fracture
segment. The closest stable teeth can be used if the adjacent dentition is poor or
missing.
• Tighten the wire in a clockwise fashion while manually reducing the segments
C- Ivy loops
• Ivy loops are used for intermaxillary fixation when full dentition is present in good
condition and the fracture is displaced minimally.
D- A variety of wiring techniques (eg, Essig wire, continuous-loop [Stout]
wiring) besides those mentioned above has been used for closed reduction
and intermaxillary fixation.

II- Closed reduction of partially edentulous patients


The partial dentures can be secured to either jaw using circummandibular or
circumzygomatic wiring techniques.
If the patient has no existing partial denture, acrylic blocks also can be fabricated with an
incorporated arch bar and secured with circummandibular or circumzygomatic wires.

III- Closed reduction of edentulous patients


• As before or
• Biphasic pin fixation (external pin fixation or Joe Hall Morris appliance) if:
1. In edentulous patients with a discontinuity defect because of either severe
trauma or resection
2. In severely comminuted fractures
3. When intermaxillary or rigid fixation cannot be used

IV- Open reduction


1. Wire osteosynthesis
2. Intraoral approach
3. Submandibular approach
4. Retromandibular approach
5. Preauricular approach

V- The Joe-Hall-Morris appliance is an example of an external-pin


fixation device.

VI- Oblique fractures, especially in the parasymphyseal region, are


amenable to lag screws or to the lag technique,

Preoperative details:
 Perioperative antibiotics are recommended
 appropriate diagnostic studies
 A dental evaluation helps to determine the condition of the teeth and allows
appropriate fabrication of a dental appliance when needed.
Intraoperative details: Occlusion is always set first  MMF by Erich arch bars are
secured with Stainless steel wires (24-26 gauge) around available molar, premolar, or
canine teeth  a mucosal or skin incision  Fixation

N.B.
 Anterior teeth should not be used for fixation because of their conical shape,
which will cause them to be distracted out of the socket by the wire.
 if a subcondylar fracture is present, immobilization must not exceed 2 weeks +
physiotherapy to prevent ankylosis of the condyle.
 the course of the marginal mandibular branch of cranial nerve VII is more at
risk from an external incision than percutaneous access.
 To combat the distraction of the segments, place a tension band superiorly
along with an inferior plate.
 If no teeth are found proximally, a small plate may be placed on the external
oblique ridge of the mandible to act as a tension band. This concept is
exemplified in Champy's technique.
 Ellis has had great success with noncompression, monocortical plates,
fashioned in 2 planes at the external oblique ridge, for nondisplaced angle
fractures. The 2-dimensional bend counteracts forces in both horizontal and
vertical planes.
 At present, the resorbable plates are being used in non–load-bearing areas,
such as the periocular area.
Postoperative details:
1- Patients left in MMF should have a nasal trumpet until fully awake. Wire cutters should
be taped to the head of the bed, and a tracheotomy tray should be in the room.
2- use a 60-cc syringe, with a 3-inch trimmed red rubber catheter for feeding.
3- Patients must practice strict oral hygiene.

Follow-up care:
• Children are kept in MMF for 4 weeks, adults for 6 weeks, and elderly patients for 8
weeks.
• Patients with condylar fractures must be taken out of MMF by 2 weeks, and
aggressive physiotherapy must be instituted to prevent ankylosis.
• Measure the oral opening. Normal interincisal distance is 40mm (=35 - 55 mm)

COMPLICATIONS
 Acute complications are the result of trauma itself.
 Intermediate complications are caused during MMF,
 late ones occur after MMF.
N.B. The overall complication rate is 3 times as high if the fracture is treated more than 10
days after initial injury.
1. respiratory distress occurs with bilateral body, parasymphyseal, or condylar fractures.
2. infection  delayed union, nonunion, osteomyelitis, and loss of teeth and bone structure.
3. Exposure of implanted hardware
4. Ankylosis : interincisal opening smaller than 5 mm. either fibrous or bony.
OUTCOME AND PROGNOSIS
With proper treatment planning and surgical technique, mandible fractures have a
favorable prognosis.
FUTURE AND CONTROVERSIES
resorbable plate

Mandible Fractures in Children


Mandible development
During the first years of life, the size and proportions of the facial skeleton change
markedly. The facial skeleton increases in relation to the rest of the head, and the sinuses
and dentition develop postnatally. The mandible is relatively small at birth and grows by
remodeling. The eruption of teeth and the development of the alveolar process also
contribute to vertical growth. Apposition of bone at other surfaces causes the bone to
develop a more adult shape. Thus, the mandible assumes a more forward position and a
longer shape. The condylar growth centers are crucial in mandibular development. Each
center consists of chondrogenic, cartilaginous, and osseous zones. A thin vascular layer
covers the chondrogenic zone. Bone is deposited at the posterior borders of the rami and
condyles. Trauma to the growth center just beneath the articular disk is cause for concern.
Delayed growth on the affected side can cause facial asymmetry, mandibular deviation,
and malocclusion.
A high tooth-to-bone ratio exists in the pediatric bone. Fractures frequently occur through
developing tooth crypts. Teeth in the line of fracture may develop with malformations.
Teeth begin to erupt at age 6 months, and the full complement of 20 primary teeth is
erupted completely at about age 2 years. These teeth are relatively stable until age 6
years when root resorption begins to occur, which causes the teeth to loosen. Permanent
dentition erupts, beginning with the first molars and central incisors, at ages 6-7 years. The
second molars erupt at age 12 years.
Because the young patient has a high ratio of cancellous to cortical bone and a thick layer
of soft tissue covering, greenstick fractures are common. Rapid healing occurs in pediatric
bone, and the best reduction is obtained within 5 days. However, if callus is already
formed, a slight discrepancy in primary occlusion is acceptable. Some degree of functional
remodeling can be anticipated.

Relevant Anatomy:

Distribution of mandibular fractures


most mandibular fractures occurred at the condyle (55%), followed by the parasymphyseal
region (27%), then the body (9%), and angle (8%).
As the age of the patient increases, the relative number of condylar fractures decreases,
while fractures in the body and angle increase. Patients aged 10 years and older are
similar to adults in cause and fracture pattern.

Fractures, Mandible, Condylar and Subcondylar


TREATMENT Section 6 of 11
- Isolated intracapsular fractures
should be treated solely with physical therapy.
In the early rehabilitative phase, controlling the occlusion (usually by means of arch bars
and elastics) while emphasizing return of normal range of motion is important.
- Patients with no dentition
Certainly, preexisting dentures or gunning splints may be wired in and adapted for
interarch elastics. In most cases, however, an equally good outcome can be obtained with
careful physical therapy that trains patients to open to a normal distance without deviation.

- Subcondylar fractures
-- Closed reduction
Most practitioners agree that most subcondylar fractures can be treated in a closed
fashion.
-- Open treatment
Options:
1. Extraoral approaches include:
2. the preauricular
3. face-lift, retroauricular
4. retromandibular
5. submandibular incisions
6. often in combination.

absolute indications for open treatment of subcondylar fractures are as follows:


• Dislocation into the middle cranial fossa or external auditory canal
• Lateral extracapsular displacement
• Inability to obtain adequate occlusion
• Open joint wound with foreign body or gross contamination
The relative indications listed by Kent and Zide are as follows:
• Bilateral subcondylar fractures + no dentition and where a splint is unavailable or
when splinting is impossible because of alveolar ridge atrophy
• Bilateral or unilateral subcondylar fractures when splinting is not recommended for
medical reasons or where adequate physiotherapy is impossible
• Bilateral condylar fractures associated with comminuted midfacial fractures
• Bilateral subcondylar fractures with associated gnathologic problems,
o 1) retrognathia or prognathism
o 2) open bite with periodontal problems or lack of posterior support
o 3) loss of multiple teeth and later need for elaborate reconstruction
o 4) bilateral condylar fractures with unstable occlusion due to orthodontics
o 5) unilateral condylar fracture with unstable fracture base

- Edentulous bilateral fractures


- Open reduction and internal fixation

- Bilateral condylar and midfacial fractures


Traditionally, such patients were reconstructed bottom up, inside out. With the advent of
rigid fixation, reconstructing from the outer facial frame as described by Gruss is also
possible. The surgeon thus takes into consideration the degree of comminution, the
associated injuries, and the state of the dentition when determining whether to open one or
both subcondylar fractures in such a patient.

 If the fracture segment is small enough, some surgeons advocate condylectomy +


The patient participates in extensive physical therapy.
 Wire fixation and intramedullary pins have also been used to stabilize these
fractures. Again, occlusal control and physiotherapy remain crucial to successful
outcomes.
 In some cases, external fixators (eg, Joe Hall Morris-type appliances) have been
used with good success but poor esthetics + occlusal control and physiotherapy.
 Finally, miniplates and screws are discussed.

CONCLUSION
Perhaps the collective experience of the many surgeons who treat these fractures can best be characterized
as follows:
• Intracapsular fractures are best treated closed.
• Fractures in children are best treated closed except when the fracture itself anatomically prohibits
jaw function.
• Most fractures in adults can be treated closed.
• Physical therapy that is goal-directed and specific to each patient is integral to good patient care and
is the primary factor influencing successful outcomes, whether the patient is treated open or closed.
• When open reduction is indicated, the procedure must be performed well, with an appreciation for
the patient's occlusal relationships, and it must be supported by an appropriate physical therapy and
follow-up regimen.