Professional Documents
Culture Documents
22 Management of Mandibular Fractures
22 Management of Mandibular Fractures
22 Management of Mandibular Fractures
Principles of Management of
Mandibular Fractures
Guillermo E. Chacon, DDS
Peter E. Larsen, DDS
Management of trauma has always been masticate properly, to speak normally, and Fixation must be able to resist the dis-
one of the surgical subsets in which oral to allow for articular movements as ample placing forces acting on the mandible. It
and maxillofacial surgeons have excelled as before the trauma. In order to achieve can take one of two forms: direct or indi-
over the years. More particularly, our these goals, restoration of the normal rect. When direct fixation is used, the frac-
experience with dental anatomy, head and occlusion of the patient becomes para- ture site is opened, visualized, and reduced;
neck physiology, and occlusion provides mount for the treating surgeon. then stabilization is applied across the frac-
us with unparalleled skills for the manage- Basic principles of orthopedic surgery ture site. The rigidity of direct fixation can
ment of mandibular fractures. also apply to mandibular fractures includ- range from a simple osteosynthesis wire
The mandible is the second most ing reduction, fixation, immobilization, across the fracture (ie, nonrigid fixation) to
commonly fractured part of the maxillofa- and supportive therapies. It is well known a miniplate at the area of fracture tension
cial skeleton because of its position and that union of the fracture segments will (ie, semirigid fixation) or a compression
prominence.1,2 The location and pattern of only occur in the absence of excessive bone plate (ie, rigid fixation) to compres-
the fractures are determined by the mech- mobility. Stability of the fracture segments sion screws alone (lag screw technique).
anism of injury and the direction of the is key for proper hard and soft tissue heal- Indirect fixation is the stabilization of the
vector of the force. In addition to this, the ing in the injured area. Therefore, the frac- proximal and distal fragments of the bone
patient’s age, the presence of teeth, and the ture site must be stabilized by mechanical at a site distant from the fracture line. The
physical properties of the causing agent means in order to help guide the physio-
also have a direct effect on the characteris- logic process toward normal bony healing.
tics of the resulting injury.3 Reduction of the fracture can be
Bony instability of the involved achieved either with an open or closed
anatomic areas is usually easily recognized technique. In open reduction, as the name
during clinical examination. Dental mal- implies, the fracture site is exposed, allow-
occlusion, gingival lacerations, and ing direct visualization and confirmation
hematoma formation are some of the of the procedure. This is typically accom-
most common clinical manifestations. panied by the direct application of a fixa-
In the management of any bone frac- tion device at the fracture site (Figure 22-
ture, the goals of treatment are to restore 1). A closed reduction takes place when
proper function by ensuring union of the the fracture site is not surgically exposed
fractured segments and reestablishing but the reduction is deemed accurate by
preinjury strength; to restore any contour palpation of the bony fragments and by FIGURE 22-1 Open reduction with internal fix-
defect that might arise as a result of the restoration of the functioning segments, ation implies surgical exposure, visualization,
injury; and to prevent infection at the frac- for example, restoration of the dental and manipulation with the placement of a stabi-
lization device directly along the bone segments
ture site. Restoration of mandibular func- occlusion by wiring the teeth together,
involved in the fracture. A locking reconstruction
tion, in particular, as part of the stomatog- using splints, or employing external pins plate has been placed on this injury via a sub-
nathic system must include the ability to (Figure 22-2). mandibular approach.
402 Part 4: Maxillofacial Trauma
Biomechanical Considerations
Studies of the relationship between the
nature, severity, and direction of traumatic
force on the resultant mandibular injury
were made by Huelke and colleagues.14–19
Before this, few experimental studies had
been done with regard to the mechanism of
mandibular fracture. Most literature regard-
ing the mechanism of fracture was based on
clinical impressions and opinions.
Early investigators showed that linear
A
fractures in long bones were initiated by
FIGURE 22-3 Superior (A) and lateral (B) views of bone failure resulting from tensile strain
a mandibular external fixator. In this particular sys- rather than compressive strain.20 Huelke
tem, biphasic pins are applied transcutaneously and
are secured to one another using a universal joint and Harger applied forces of varying mag-
system and rigid metal rods. nitudes and direction to dried mandibles
and observed the resultant production of
tension and compression.17 They found
that > 75% of all experimentally produced
fractures of the mandible were in primary
areas of tensile strain, which supported a
B similar observation made earlier in long
Principles of Management of Mandibular Fractures 403
bones. A notable exception was that com- This produces a fracture that begins in the tension develops along the lateral aspect of
minuted condylar head injury that was lingual region and spreads toward the buc- the condylar neck and mandibular body
produced by a load parallel to the cal aspect.17 The mobile contralateral regions, as well as along the lingual aspect
mandibular ramus was primarily the condylar process moves in a direction of the symphysis. This leads to bilateral
result of compressive force. away from the impact point until it is lim- condylar fractures and a symphysis frac-
In response to loading, the mandible is ited by the bony fossa and associated soft ture (Figure 22-5).
similar to an arch because it distributes the tissue. At this point, tension develops Variation from these standard fracture
force of impact throughout its length (Fig- along the lateral aspect of the contralater- patterns occurs for two general reasons.
ure 22-4). However, unlike the arch, the al condylar neck, and a fracture occurs. If First, there is a wide range in the possible
mandible is not a smooth curve of uni- greater force is applied to the parasymph- magnitude and direction of the impact
form bone, but rather it has discontinu- ysis-body region, not only will tension and in the shape of the object delivering
ities such as foramina, sharp bends, ridges, develop along the contralateral condylar the impact. Second, the condition of the
and regions of reduced cross-sectional neck leading to fracture in this area, but dentition, position of the mandible, and
dimension like the subcondylar area. As a continued medial movement of the small- influence of associated soft tissues could
result, parts of the mandible develop er ipsilateral mandibular segment will lead not be controlled in these studies.
greater force per unit area, and conse- to bending and tension forces along the Early observers felt that the presence of
quently, tensile strain is concentrated in lateral aspect and subsequent fracture of posterior dentition tended to reduce the
these locations. the condylar process on the ipsilateral side. incidence of condylar injury.21–23 The
When a force is directed along the Force applied directly in the symphysis implication was that, as the mandible was
parasymphysis-body region of the region along an axial plane is distributed forced posteriorly and superiorly, the denti-
mandible, compressive strain develops along the arch of the mandible. Because tion would meet and absorb some of the
along the buccal aspect, whereas tensile the condylar heads are free to rotate with- force, thereby diminishing the force
strain develops along the lingual aspect. in the glenoid fossa to a certain degree, received at the condyle. This was supported
Force
Compression Compression
Compression
Tension
Compression Compression
Rotational movement
permitted
Tension Tension
FIGURE 22-4 The effect of a load on an arch where ends are free to rotate. Adapted from Larsen PE. Traumatic injuries
of the condyle. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM, editors. Principles of oral and maxillofacial
surgery. Vol 1. Philadelphia (PA): JB Lippincott Company; 1992. p. 444.
404 Part 4: Maxillofacial Trauma
Evaluation of Mandibular
Fractures
Traumatic craniofacial and skull base
Tension Compression Compression Tension
injuries require a multidisciplinary team
approach. Trauma physicians must evalu-
ate carefully, triage properly, and maintain
a high index of suspicion to improve sur-
vival and enhance functional recovery.
Frequently, craniofacial and skull base
injuries are overlooked while treating
more life-threatening injuries.27 Unno-
Tension ticed complex craniofacial and skull base
fractures, cerebrospinal fluid fistulas, and
cranial nerve injuries can result in blind-
ness, diplopia, deafness, facial paralysis, or
meningitis.
Following the principles of Advanced
Compression
Trauma Life Support, during the initial
assessment in the emergency department,
the first and most critical obligation is to
make sure that the airway is patent and
FIGURE 22-5 Force directed at the symphysis along an axial plane is distributed along the arch of the free of potential obstruction. The tongue,
mandible. Tension is dissipated along the mandible, and the fracture occurs bilaterally in the area of which may have a tendency to fall back,
least stability, the condylar neck. As in other fractures, a symphysis fracture may develop caused by
tension from the blow. Adapted from Larsen PE. Traumatic injuries of the condyle. In: Peterson LJ, must be controlled, and objects obstruct-
Indresano AT, Marciani RD, Roser SM, editors. Principles of oral and maxillofacial surgery. Vol 1. ing the airway must be removed. If an
Philadelphia (PA): JB Lippincott Company; 1992. p. 445. obstruction cannot be removed, a new air-
way must be established by endotracheal
intubation (remembering possible cervical
by the clinical observation that the posteri- molars are present, this area represented a spine injuries) or cricothyrotomy. After
or dentition was often fractured on the side region of inherent weakness and the inci- the airway has been secured and respira-
of the condylar fracture. However, more dence of condylar fractures decreases, tion is occurring, vital signs must be
recent findings do not support this theory whereas the incidence of mandibular angle assessed, including pulse rate and blood
and show that all types of fractures occur, fractures increases.25 pressure. Any significant blood loss is like-
irrespective of the occlusion, and that no Although unable to show that the ly to be coming from injuries apart from
correlation exists between the degree of dis- occlusion played any role in the type of those of the face. Other critical injuries
location, level of fracture, or type of frac- fracture produced, investigators have must be ruled out, including intracranial
ture with the presence of a distal occlu- found that the relative degree of mandibu- hemorrhages, cervical and other spinal
sion.24 Although the presence or absence of lar opening at the time of impact does play injuries, chest injuries, abdominal trauma,
a posterior dentition does not correlate an important role in the type of fracture and fractures of the long bones.
with the incidence of fracture, the presence that occurs.23,26 More recent studies have Local examination of the face and jaws
of specific teeth, particularly impacted third shown that not only is the incidence of should be conducted in a logical sequence.
molars, has been shown to markedly affect fracture higher when the mouth is open, The first objective is to obtain an accurate
the incidence of mandibular fractures. It but the level of fracture varies with degree history from the patient, or relative if the
was shown that, when impacted third of opening. When the mouth is opened, patient cannot cooperate. Pertinent to a
Principles of Management of Mandibular Fractures 405
occlusion, fracture of the dentition, and pain at a fracture site. In the case of sub-
decreased interincisal opening. condylar fractures, firm posterior pressure
Continuing with the systematic evalu- on the chin will cause pain in the pre-
ation of the patient, it is suggested that auricular region.
examination of the soft tissues be under-
taken next. The gingival tissue should be Radiographic Evaluation
inspected for tears or lacerations. With the To adequately screen for the presence of a
aid of a tongue blade, the floor of the mandibular fracture, at least two views at
mouth is examined; sublingual ecchymosis right angles to each other are necessary. A
is almost pathognomonic of a fracture of panoramic radiograph and a reverse
FIGURE 22-8 Significant midline deviation the mandible. Next the dentition is exam- Towne’s view (Figure 22-11) are adequate
toward the fracture side along with buccal cusp ined for evidence of broken teeth and for screening studies for this purpose. If only
tip fractures of both mandibular bicuspids and steps or irregularities in the dental arch. one view is used, fractures can easily be
first molar.
The patient is asked to lightly bite the teeth missed.28 In the multiple-trauma patient
together and to say whether the bite feels for whom panoramic radiographs are not
premature contact is present bilaterally on different from normal, following which the possible, lateral oblique views may be sub-
the posterior dentition with an anterior occlusion is inspected. Premature occlusal stituted. Other radiographic views that
open bite. The posterior dentition may be contacts are noted. The three causes of an may be useful depending on the circum-
fractured on both sides in these situations. altered occlusion in the trauma patient are stances are posteroanterior mandibular,
Often the patient with a fracture of the a displaced fracture, a dental injury such as mandibular occlusal, and periapical. Linear
condylar process also has a limited range a displaced tooth, and a temporomandibu- tomographies of the temporomandibular
of motion. This limitation, however, is pri- lar joint effusion or dislocation. joints can also be useful in the evaluation
marily caused by voluntary restriction as a If the patient is edentulous and has of fractures at the level of the condylar
result of pain. One has to keep in mind intact dentures with him, these can be process. However, intracapsular fractures
that any limitation of mandibular move- replaced in the mouth and the occlusion
ment may also be a result of reflex muscle inspected (Figure 22-9). The mandible
spasm, temporomandibular effusion, or should then be grasped on each side of any
mechanical obstruction to the coronoid suspected fracture and gently manipulated
process resulting from depression of the to assess mobility. If no fracture can be
zygomatic arch. Other less common find- found but clinical suspicion remains high,
ings include blood within the external the mandible may be compressed by
auditory canal and, in the case of fracture applying pressure over both angles (Figure
dislocation, development of a prominent 22-10). This nearly always gives rise to
preauricular depression. Careful otoscopic
evaluation of the external auditory canal is
of particular importance in patients sus-
pected to have suffered an injury at this
level. Occasionally a fracture of the condy-
lar process will produce a tear in the
epithelial lining of the anterior wall of the
canal, which produces bleeding from the
acoustic meatus. It is important to deter-
mine that this bleeding is not coming from
behind a ruptured tympanic membrane,
which may signify a basilar skull fracture.
A detailed intraoral examination FIGURE 22-9 The patient’s own dentures often
become very useful instruments in the assessment FIGURE 22-10 The application of gentle biman-
should be undertaken with good lighting
and management of mandibular fractures in the ual pressure over the angle regions can unmask a
and immediate availability of suction. The edentulous patient, if they are intact or can be minimally displaced fracture in the anterior
most common intraoral findings are mal- reasonably repaired. region of the mandible.
Principles of Management of Mandibular Fractures 407
characterize the nature and severity of and their counteracting forces also play a
the orofacial injury engenders variation primary role in the pattern and direction
in practice patterns.30 Probably the most of the fractures. It is the displacing forces
basic question one should ask at the ini- of the muscles of mastication that influ-
tial evaluation is whether the fractures ence favorableness (Figures 22-14 and
are displaced or nondisplaced. Depend- 22-15). The principle of favorableness is
ing on the amount of energy transmitted based on the direction of a fracture line
to the facial skeleton and the vector in as viewed on radiographs in the horizon-
which such force is directed, there will be tal or vertical plane. A horizontally favor- FIGURE 22-14 Diagram of horizontally unfa-
vorable (left) and favorable (right) fracture
more or less disruption of the normal able fracture line resists the upward dis- lines. Arrows indicate displacing forces. Adapted
anatomic structures. Muscle attachment placing forces, such as the pull of the from Luyk NH.88 p. 410.
Principles of Management of Mandibular Fractures 409
skin communicating with the fracture may be localized to the fracture site, Nonfracture Injuries of the
site, edentulous portions of the such as the result of a cyst or metasta- Articular Apparatus
mandible may be involved. tic tumor, or as part of a generalized
The most commonly documented result of
• Greenstick fracture: This type of frac- skeletal disorder, such as osteopetrosis.
trauma to the articular apparatus and
ture frequently occurs in children and • Displaced fracture: Fractures may be
mandibular condyle is fracture. Other
involves incomplete loss of continuity nondisplaced, deviated, or displaced.
injuries occur as well and must be considered
of the bone. Usually one cortex is frac- A nondisplaced fracture is a linear
in the differential diagnosis (Table 22-1).
tured and the other is bent, leading to fracture with the proximal fragment
Anterior dislocation occurs when the
distortion without complete section. retaining its usual anatomic relation-
condyle moves anterior to the articular
There is no mobility between the ship with the distal fragment. In a
eminence. This is by far the most common
proximal and distal fragments. deviated fracture, a simple angulation
situation and represents a pathologic for-
• Comminuted fractures: These are of the condylar process exists in rela-
ward extension of the normal translational
fractures that exhibit multiple frag- tion to the remaining mandibular
movement of the condylar head. Unlike
mentation of the bone at one fracture fragment, without development of a
subluxation, which is also a forward exten-
site. These are usually the result of gap or overlap between the two seg-
sion of the condyle, dislocation is not self-
greater forces than would normally be ments. Displacement is defined as
reducing. Dislocation may be caused by
encountered in simple fractures. movement of the condylar fragment
yawning, oral sex, phenothiazine use, and
• Complex or complicated fracture: This in relation to the mandibular segment
trauma. Traumatically induced anterior
type of injury implies damage to struc- with movement at the fracture site.
dislocation is most commonly bilateral,
tures adjacent to the bone such as major The fragment can be displaced in a lat-
but it may occur unilaterally (particularly
vessels, nerves, or joint structures. This eral, medial, or anteroposterior direc-
if associated with a concomitant fracture
usually implies damage to the inferior tion. In displaced fractures the articu-
elsewhere in the mandible). The diagnosis
alveolar artery, vein, and nerve in lar surface of the condyle remains
of an anteriorly dislocated mandible is
mandibular fractures proximal to the within the glenoid fossa and does not
made by the following clinical features: an
mental foramen and distal to the herniate through the joint capsule.
anterior open bite with the inability to
mandibular foramen. On rare occasions • Dislocated fracture: A dislocation
close the mouth; severe pain in the region
a peripheral branch of the facial nerve occurs when the head of the condyle
may be damaged or the inferior alveolar moves in such a way that it no longer
nerve injured in subcondylar fractures. articulates with the glenoid fossa.
Table 22-1 Injuries of the Articular
• Telescoped or impacted fracture: This When this is associated with a fracture Apparatus
type of injury is rarely seen in the of the condyle, it is termed a fracture
mandible, but it implies that one bony dislocation. Fracture dislocations are Effusion
fragment is forcibly driven into the discussed more completely later in this Hemorrhagic or serous
other. This type of injury must be dis- chapter. The mandibular condyle may Soft tissue injury
impacted before clinical movement also be dislocated as a result of trauma Disk
between the fragments is detectable. without an associated condylar frac- Capsule
• Indirect fracture: Direct fractures arise ture. Dislocations can occur anterior- Ligaments
immediately adjacent to the point of ly, posteriorly, laterally, and superiorly. Dislocation of the condyle from the fossa
contact of the trauma, whereas indi- • Special situations: Other types of frac- Without fracture
rect fractures arise at a point distant tures that do not readily fit the above With fracture other than condyle
With associated condylar fracture
from the site of the fracturing force. classification include grossly commin-
An example of this is a subcondylar uted fractures or fractures involving Fracture
fracture occurring in combination adjacent bony structures, such as the Nondisplaced
Deviated
with a symphysis fracture. glenoid fossa or tympanic plate; open
Displaced
• Pathologic fracture: A pathologic frac- or compound fractures; and fractures
Dislocated
ture is said to occur when a fracture in which a combination of several dif- Comminuted
results from normal function or mini- ferent types of fractures exist. Open Involving adjacent bony structures
mal trauma in a bone weakened by fractures of the condyle are usually
Combinations of the above
pathology. The pathology involved caused by missiles such as bullets.
Principles of Management of Mandibular Fractures 411
anterior to the ear; absence of the condyle these maneuvers. In refractory cases or in tion of the dislocation through manipula-
from the glenoid fossa with a visible and cases associated with mandibular body and tion of the dislocated segment by grasping
palpable preauricular depression; inability angle fractures in which the dislocated seg- it with a thumb on the dentition and with
to move the mandible except to open the ment is difficult to control by manipula- the fingers extraorally along the body of the
mouth slightly in a purely rotational man- tion, surgical intervention may be required. mandible. If the proximal segment size is
ner; difficulty in speaking; and a prognath- A percutaneous bone hook placed through inadequate for this maneuver, a percuta-
ic lower jaw. Finally, if unilateral disloca- the sigmoid notch or wires placed through neous towel clip through the angle or a
tion is present, the chin will be deviated to the angle of the mandible allow for addi- small incision with placement of a wire
the opposite side (Figure 22-17). Patients tional downward traction.38,39 Following through the angle (as described for anterior
with anterior dislocation of the mandibu- successful reduction, the patient should be dislocation) may be necessary. After reduc-
lar condyles without other mandibular instructed to refrain from opening his or tion of the dislocation, treatment of the
trauma should be approached using the her mouth widely and to support the jaw associated fracture is accomplished, prefer-
following treatment protocol: 2 cc of local with a hand under the chin when yawning ably with rigid internal fixation.
anesthetic solution should be deposited for a period of 3 weeks to allow for healing Superior dislocation into the middle
into the joint capsule followed by manual of the injured soft tissue in and around the cranial fossa without associated fracture of
reduction. If this is unsuccessful or the joint. IMF is not necessary for a first-time the mandibular condyle has been
patient is overly apprehensive, diazepam acute anterior dislocation of the jaw, described. The patient is predisposed to
should be carefully titrated intravenously unless it persistently dislocates after this type of dislocation when the condylar
followed by further attempts at manual reduction. In persistent, recurrent dislo- head is small and rounded.40 This injury is
reduction. If these measures fail, then gen- cation, contributing factors, such as phe- more common when the mouth is open at
eral anesthesia with the use of a muscle nothiazine use, should be identified. A the moment of impact.41 This type of
relaxant may be necessary.37 It is usually soft diet may also be recommended for injury usually occurs with concomitant
possible to reduce an acute dislocation with several days along with a nonsteroidal midface fractures that are telescoped,
anti-inflammatory analgesic. causing shortening of the vertical dimen-
When a blow to the mandible pro- sion of the face and allowing superior dis-
duces primarily a posterior vector of force location of the mandibular condyle. Supe-
and does not result in fracture of the rior dislocation of the mandibular condyle
condylar neck, the head of the condyle is associated with cerebral contusion and
may be forced into a posterior dislocation. basilar skull fracture with facial nerve
This injury is frequently associated with paralysis and deafness. These patients pre-
laceration and fracture of the external sent with severe restriction of interincisal
auditory canal leading to hemorrhage that opening, pain in the area of the temporo-
is visible at the external acoustic meatus.26 mandibular joint, bleeding from the exter-
In most cases maintenance of the patient’s nal auditory canal or hemotympanum,
occlusion and treatment of the associated and deviation of the jaw to the affected
ear injuries are the only management pro- side. A variety of treatment modalities are
cedures necessary. recommended, including observation,
Lateral dislocation of the condylar head condylotomy, elastic traction, condylecto-
is always associated with a concomitant my, and manual reduction.42 Neurosurgi-
fracture either of the condyle or elsewhere cal consultation is required.
within the mandible. The diagnosis of this Effusion and hemarthrosis of the
condition is straightforward. The condylar temporomandibular joint after trauma
head is palpable as a hard mass either in the occur similarly as in other joints.23 In
preauricular region or in the lower part of most cases this leads to a distention of
FIGURE 22-17 Prognathic appearance, chin the temporal space. This type of injury is the joint capsule with varying amounts
deviation, and a large amount of swelling on the associated with a marked crossbite, which is of discomfort. Frequently deviation of
right side of the face as a result of a right unilat- not attributable solely to the mandibular the mandible away from the affected side
eral condylar dislocation, which occurred as a
result of a blow to the chin during a motor ve- fracture but instead is secondary to the dis- occurs as a result of downward pressure
hicle crash. placed condyle. Treatment requires reduc- on the condyle from the production of
412 Part 4: Maxillofacial Trauma
fluid within the joint. This produces achieve a stable occlusion without manip- motor vehicle accident.2,48,51–53 Males are
facial asymmetry and malocclusion (Fig- ulation of the jaw, Ivy loop wiring or arch overwhelmingly reported to be affected
ure 22-18). bars should be placed and guiding elastics more frequently than females in a ratio rang-
The treatment of traumatically used to produce a stable occlusion. ing from 3:1 to 7:1 depending on the survey
induced effusions of the temporo- Arthrocentesis, arthroscopy, or both are and especially the country involved.48,54,55
mandibular joint is aimed at the restora- common therapies for hemarthrosis in Predictably, such studies reveal the most sus-
tion of preinjury occlusion with return to other joints and may also be considered.43 ceptible age group for both sexes is between
function and relief of pain. If the patient Regardless of the therapy chosen, care 21 and 30 years of age.54,56,57
presents with the subjective symptoms of a should be taken to avoid excessive IMF In most cases, mandibular fractures
joint effusion but has a stable and repro- because this may result in a long-term lim- are encountered in isolation from any
ducible occlusion, the condition may be itation of function. It has been suggested other facial fractures. But different studies
managed with close daily observation, that this limitation in function is a result have revealed that almost 20% of these
nonsteroidal anti-inflammatorv medica- of organization of the blood within the patients have concomitant fractures in
tions, and a soft diet. Frequently the con- joint space with development of fibrosis other anatomic structures of the facial
dition will resolve in a matter of days. If, and subsequent ankylosis. Many authors skeleton,58–60 with the most common one
however, the malocclusion is significant have emphasized the importance of this being the zygomaticomaxillary complex.61
enough that the patient is unable to proposed mechanism in the development Further injury away from the facial region
of ankylosis.44,45 Aspiration or arthroscop- may also be present, including multiple-
ic lavage may alleviate this. It is possible, system trauma. In the study by Ellis and
however, that the development of limited colleagues of 2,137 patients with mandibu-
function and ankylosis is more dependent lar fractures, 10.5% of subjects sustained
on the inability to maintain a full range of other injuries outside the maxillofacial
motion during the IMF period rather than region.48 Injury patterns are largely depen-
on the hemarthrosis. This theory is sup- dent on the mechanism of injury, with
ported by the failure of experimentally patients involved in motor vehicle acci-
induced hemarthroses to produce ankylo- dents sustaining a great percentage of other
sis,46 and by the absence of ankylosis and injuries. The distribution of principal frac-
limited function after iatrogenically ture sites has been reported as 33% involv-
induced hemarthroses during joint injec- ing the body, 29% in the condylar region,
tions or arthroscopy.47 Most likely, 23% the angle, and 8% in the symphysis
decreased range of motion after joint effu- region (Figure 22-19). It is not unusual to
sion is the result of intra-articular fibrosis sustain more than one fracture site in the
potentiated by prolonged IMF. mandible. Mandibular fractures are mul-
tiple in more than 50% of the cases.48,62,63
Treatment of Mandibular The left side is more commonly involved,
A
Fractures in particular the left angle, probably
Fractures of the mandible have been report- because most assailants are right-handed
ed to comprise between 40 and 62% of all and the left side of the jaw would be the
facial fractures,36, 48, 49 although these figures side most likely to be struck.57 Falls show a
may not represent the true incidence greater proportion of subcondylar frac-
because isolated nasal fractures are seldom tures, as high as 36.3% in one study.49
included in such surveys. If these injuries are When multiple fractures of the mandible
taken into account, the occurrence of are considered, the most common combi-
mandibular fractures decreases to anywhere nations are angle and opposite body, bilat-
between 10 and 25% of all facial fractures eral body, bilateral angle, and condyle and
B depending on the mechanism of injury.50 opposite body (Figure 22-20).36
The literature is consistent on the fact that The site of fracture is also determined
FIGURE 22-18 Significant facial asymmetry (A)
and malocclusion (B) resulting from a large left about one-half of all patients who suffer by the size, direction, and surface area of
temporomandibular joint hemarthrosis. mandibular fractures are involved in a the impacting blow. An impact to the chin
Principles of Management of Mandibular Fractures 413
and fracture outcomes from those of the choose the simplest and most effective
direct fracture; that is, the tensile strain surgical method available to reach them.
develops on the side opposite to the The goals to be achieved in treatment
29.3
4.8 impact. In the case of greenstick fractures, of fractures of the mandible are listed in
the fracture occurs on the tension side and Table 22-2. Maintenance of a stable occlu-
bending occurs on the compression side. sion is necessary for both functional and
esthetic reasons. Complete range of motion
23.1
1.4
General Approach and Goals of also allows normal mastication and pre-
Therapy vents the development of contralateral tem-
33.0
Deciding on the correct treatment is often poromandibular joint dysfunction. A nor-
8.4
more difficult than administering the mal range of motion is most dependent on
treatment itself. The dilemma concerning postoperative retraining of the muscles and
FIGURE 22-19 Percentage of mandibular fracture the appropriate management of fractures elimination of pain. Ideally, the disk-
site distribution. Adapted from Luyk NH.88 p. 411.
of the mandibular condyle is most exem- condylar relationship should remain intact
plary of this. Technically easy procedures without evidence of internal derangement.
with a line of force through the symphysis such as closed reduction have experienced Some clinical signs of internal derangement
and temporomandibular joints will pro- long-term successful results, whereas more such as joint noise can be tolerated if not
duce a single subcondylar fracture at complicated and technically demanding associated with pain or decreased range of
193 kg (425 lb.) and a bilateral subcondy- procedures of open reduction have con- motion. Growth disturbance can result
lar fracture at about 250 kg (550 lb.), tinually and cyclically been employed in from ankylosis or from injury to the carti-
whereas symphyseal fractures require an attempt to improve on the results laginous head of the condyle. A goal of
force between 250 and 408 kg (900 lb.).64 obtained with closed reduction. Although treatment should include early mobilization
An impact to the lateral aspect of the anatomic reduction with rigid internal to prevent ankylosis and close follow-up to
mandibular body using a 2.5 × 10 cm (1 × stabilization of the fracture segments may identify growth changes early in their devel-
4 in.) impact surface will produce a be desirable, it is essential that the surgeon opment. Attainment of an anatomic bony
mandibular fracture at 136 to 317 kg clearly define the goals of therapy and union is not a primary goal in treatment of
(300–700 lb.). When an impact force is
delivered to the mandible, the bone bends
inward, producing compressive forces on
the impacted (lateral) surface and tensile
forces on the lingual (medial) surfaces of
the bone opposite the impact site.18 Frac-
ture results when the tensile strain over-
comes the resistance of the bone, begin-
ning on the medial side of the mandible
and progressing through the bone toward
A B
the impact point.
Direct fracture may occur at the site of
impact, but additional indirect fractures
may result when higher forces are
involved. An example would be a blow to
the left angle, causing a direct fracture at
the left-angle region and an indirect frac-
ture in the right body. Occasionally, only
indirect fracture results, usually in the sub-
condylar area as, for example, when a blow C D
on the chin results in a fracture of either
FIGURE 22-20 Most common multiple mandibular fracture sites: A, angle and opposite body;
condylar neck. Indirect fractures demon- B, bilateral body; C, bilateral angle; and D, condyle and opposite angle. Adapted from Luyk NH.88
strate the opposite tensile strain patterns p. 413.
414 Part 4: Maxillofacial Trauma
Table 22-2 Goals of Therapy Therefore, the indications for closed strongly promote closed reduction for the
reduction may simply be stated as all cases management of fractures of the mandibu-
1. Obtain stable occlusion. in which an open reduction is either not lar condyle in both adults and chil-
2. Restore interincisal opening and
indicated or is contraindicated. Several dren.21,22,33,34,67–70 These uniformly excel-
mandibular excursive movements.
conditions deserve specific mention. lent results were obtained in all ages of
3. Establish a full range of mandibular
excursive movements.
Grossly comminuted fractures are, as a patients treated.71 Conclusions drawn by
4. Minimize deviation of the mandible. general rule, best treated by closed reduc- various authors are the following: no cor-
5. Produce a pain-free articular apparatus tion, because using open reduction tech- relation exists between the degree of radi-
at rest and during function. niques would jeopardize the blood supply ographic displacement and the severity of
6. Avoid internal derangement of the to the small bone fragments and lead to an clinical symptoms; no correlation exists
temporomandibular joint on the increased likelihood of infection. This cat- between the radiographic alignment of the
injured or the contralateral side. egory also includes gunshot wounds, fracture segments and postoperative func-
7. Avoid the long-term complication of which are particularly prone to infection. tion; growth complications and ankylosis
growth disturbance. Fractures in the severely atrophic are exceedingly rare; open reduction with
edentulous mandible represent a difficult internal fixation is fraught with complica-
clinical situation. On the one hand, there is tions; and evidence supports the choice of
condylar fractures, particularly if it must be limited osteogenic potential; the majority closed reduction as the primary treatment
done at the expense of other more impor- of the blood supply comes from the modality for condylar fractures regardless
tant goals. A malunion or fibrous union periosteum, so an open reduction further of the degree of displacement.
that functions normally without pain is disrupts the blood supply. On the other Although the majority of the large stud-
preferable to a radiographically excellent hand, a stable, nonmobile reduction and ies reviewed patients in all age groups, some
reduction that does not eliminate pain or fixation of these fractures is difficult with authors specifically studied children and
limits motion. closed reduction techniques. Open reduc- their response to conservative management
tion with limited dissection of the soft tis- of condylar fractures.72–78 All obtained
Treatment Options sue and rigid fixation may be the preferred
technique. Later in this chapter we review
Closed Reduction If the principle of in more detail the management of this
using the simplest method to achieve opti- group of patients.
mal results is to be followed, the use of In situations where there is a lack of
closed reduction for mandibular fractures soft tissue overlying the fracture site, soft
should be widely used. According to Bern- tissue flaps have to be transposed to cover
stein, “It is safe to say that the vast majori- a fracture site (particularly if a through-
ty of fractures of the mandible may be and-through communication exists
treated satisfactorily by the method of between the skin and oral cavity). The
closed reduction.”65 May and colleagues go presence of bone plates, screws, and wires
further66: “Many fractures are probably may increase the likelihood of infection
overtreated by open reduction. It is impor- under these circumstances.
tant to realize that the majority of frac- Fractures in children involving the
tures can be successfully managed by con- developing dentition are difficult to man-
servative means (closed reduction).” This age by open reduction because of the pos-
concept becomes critical when one con- sibility of damage to the tooth buds or
siders the economic significance of inflat- partially erupted teeth (Figure 22-21).
ed hospital, operating room material, and Closed reduction of fractures of the
personnel costs. Even more important, the mandible together with indirect fixation
need for general anesthesia is obviated. A can be achieved by either the application FIGURE 22-21 Posteroanterior mandibular
patient with a mandibular fracture man- of IMF or by applying a technique to the view of a 4-year-old child with a symphysis frac-
aged by closed technique can be success- mandible only. ture. Management of this injury through an
open reduction with internal fixation poses a sig-
fully treated as an outpatient with either The overwhelming majority of pub- nificant risk of damaging the developing perma-
local anesthesia or conscious sedation. lished clinical series over the past 50 years nent dentition.
Principles of Management of Mandibular Fractures 415
excellent results with minimal complica- 4 weeks, and in older patients in 6 to (Figure 22-23), continuous wire loop tech-
tions when fractures of the condyle in chil- 8 weeks. Several other factors should be nique (Stout’s method, Obwegeser’s
dren were treated with closed methods. taken into account when deciding on the method), cast cap splints, and IMF screws
The superiority of closed reduction of appropriate regime for a particular patient. (Figure 22-24).
condylar fractures is also supported by The following situations generally require Methods for dentate patients usually
numerous animal studies. Experimentally longer periods of IMF: comminuted frac- include 0.5 mm (25-gauge) soft stainless
induced fracture dislocation in rhesus mon- tures; fractures in alcoholics, particularly steel wires around the teeth. In general, the
keys has resulted in “a workable, usable those with nutritional problems; fractures wires should be handled in a similar fash-
mandibular articulation regardless of in patients with psychosocial handicaps; ion for all methods, following certain
whether the condyle was left remaining at fractures treated late; and fractures with principles:
right angle to the ramus, pushed medially or teeth removed in the line of the fracture.
1. Tighten the wires with a continuous
anteriorly, or reduced and maintained via
tension.
transosseous wire. There was little sacrifice Length of Fixation for Condylar Fractures
2. Direct the force apically when tighten-
of mandibular growth or symmetry.”79 Fur- Ideally, the period of IMF should allow for
ing the wires.
ther studies compared three methods of reestablishment of the preinjury occlusion
3. Tighten all wires in a clockwise direc-
treatment for fracture dislocations in rhesus and should not be longer. Increased length
tion.
monkeys.80, 81 No difference existed between of the time of fixation may result in limita-
4. At the end of tightening, turn only half
those treated with internal fixation using tion in function or ankylosis of the joint. In
a turn at a time.
wire ligature, those treated with maxillo- practice, a wide variety of opinions exists
5. Turn the end of the wire into the inter-
mandibular fixation, or those who received over the length of time that constitutes an
proximal embrasure.
no treatment. No incidents of nonunion adequate period of fixation. Differences
were reported with any closed technique. depend on the age of the patient, the type of These additional rules apply when
fracture, and the presence of other fractures. arch bars are used:
Length of Fixation Traditionally the Most clinicians agree that a shorter period is
1. Adapt the arch bar closely.
length of IMF used for adult mandibular needed in children, but they are no closer in
2. Use a cuspid wrap wire where indicated.
fractures has been 6 to 8 weeks. However, agreement over what this time should be.
3. Avoid placing the wire across the
this length of IMF is not without penalty. Animal studies have shown excellent occlu-
intermaxillary stabilization lugs.
Often patients continue to lose weight sion and postoperative function even in
4. Use circumferential wires when single
during this period, they may not be able to fracture dislocations when no IMF is
teeth stand alone, and intraosseous
return to work, and there is some evidence used.79–81 Some studies in humans also
suspension or circum-mandibular
of histologic changes in the temporo- agree with this. However, the inability to
wires in edentulous areas.
mandibular joint.82,83 Juniper and Awty occlude the teeth without pain is frequently
5. In the area of the fracture, reduction
were able to demonstrate that 80% of present in patients with condylar fractures
should be accomplished prior to stabi-
mandibular fractures treated by open or and does require some period of fixation.
lization of the arch bar on both sides
closed reduction and IMF were clinically Attempts to predetermine which fractures
of the fracture.
united in 4 weeks.84 They were also able to will need longer IMF than others have been
demonstrate a clear relationship between made.85 The length of time has been based
the age of the patient and the predictabili- on the presence or absence of teeth, the type
ty of early fracture union. These results of fracture, and the age of the patient. How-
were confirmed by Amaratunga.85 He ever, Walker has suggested that a relatively
found that 75% of mandibular fractures short period of intermaxillary fixation is
were clinically stable by 4 weeks, that required for all patients regardless of age,
almost all fractures in children healed in occlusion, and type of fracture.86,87
2 weeks, and that a significant number of
fractures in older patients took 8 weeks to Intermaxillary Techniques DENTATE
heal. It appears that each individual case PATIENTS Intermaxillary techniques in
must be judged on its merits but that most dentate patients include application of
uncomplicated fractures in children are arch bars (Figure 22-22), direct wiring, Ivy FIGURE22-22 Placement of Erich arch bars for
united in 2 to 3 weeks, in adults 3 to loop wiring (interdental eyelet wiring) noninvasive treatment of a mandibular fracture.
416 Part 4: Maxillofacial Trauma
A B
FIGURE 22-24 An option to obtain intermaxillary fixation in patients with a reliable occlusion is the FIGURE 22-25 For the fabrication of a lingual
use of intermaxillary fixation screws. In most cases two screws placed on each side is sufficient to splint, the cast must be carefully sectioned along
maintain the reduction. A, Right buccal view. B, Left buccal view. the areas where the fractures are located.
Principles of Management of Mandibular Fractures 417
Medically Compromised Patients Some essary, the maximal blood supply to the
patients with special medical conditions fracture site should be preserved.
are best treated without IMF. They may be If closed reduction is used for the
better treated with an open reduction. treatment of a condylar process fracture, it
This group of patients includes those with is best that intermaxillary fixation be dis-
decreased pulmonary function. Williams continued in all patients at approximately
and Cawood have demonstrated signifi- 10 to 14 days. If other mandibular frac-
cant decrease in pulmonary function asso- tures are associated with the fractured
ciated with IMF.90 Patients with gastroin- condyle, it is desirable to treat them with
testinal disorders who are on a liquid diet, some form of additional stabilization,
FIGURE 22-29 Intermaxillary fixation in an particularly one based on milk products, such as a lingual splint, external pins, or
edentulous patient using Gunning’s splints with may have difficulties. Those with severe rigid internal fixation. This allows for the
arch bars imbedded into the acrylic.
seizure disorders in which airway difficul- early release of IMF without compromis-
ties may arise with IMF and patients with ing the healing of these other fractures.
follow.89 If, in addition to a fracture in this psychiatric or neurologic problems may be
area, the patient also has a concomitant candidates for open reduction. Open Reduction of Condylar Fractures
angle or condylar fracture, the risk of lat- A variety of useful techniques for open
eral flaring of the mandibular angles is a Concurrent Condylar Fracture Associated reduction have been described.73,91–94 The
very real possibility. This negative result with Fractures Elsewhere in the Mandible reason for employing open reduction in
can be much worse in cases in which bilat- It is often advantageous to be able to mobi- each case was to avoid the complications
eral condylar fractures are present and in lize condylar fractures early to prevent pos- found in closed reduction. No data or
patients with associated midfacial frac- sible ankylosis. This is particularly true in follow-up of patients was presented to
tures, when the mandible is used as the cases of intracapsular fractures in which document this. Tanasen and Lamberg,
base for the reconstruction. immobilization is more likely to lead to Zide and Kent, and Raveh and colleagues
ankylosis. In this situation open reduction followed patients with open reduction for
Prolonged Delay in Treatment of the Frac- and fixation of angle, body, or symphyseal up to 37 months.95–97 Complication rates
ture with Interpositional Soft Tissue fractures will allow early mobilization of of 85, 50, and 10% were seen, respectively,
Occasionally when there has been an an associated condylar fracture. including facial nerve dysfunction and
excessive delay in treating a fractured There are certain contraindications to keloid formation. No comparison was
mandible, interpositional tissue between the use of open reduction of mandibular made with patients treated with closed
the two bone ends can prevent a satisfac- fractures. As a general principle, when a reduction during the same time period.
tory closed reduction. In this situation an simpler means of treating a fracture can be Chuong and Piper attempted to compare
open reduction is necessary to remove the used, it should be. This is often more cost- closed reduction with open reduction,
soft tissue between the fragments. effective for the community at large and including concomitant disk repair in their
often results in fewer complications. How- study.98 Eight of nine open reduction
Complex Facial Fractures The satisfacto- ever, each individual case must be judged patients who were studied for an average
ry reduction of complex facial fractures on its merits. of 11 months experienced complications
requires two stable reference points to The periosteal blood supply of multi- (89%). Six of 12 patients receiving closed
which the maxillary complex can be ple small fragments of bone can be jeopar- reduction were found to have malocclu-
reduced. These include a stable supraorbital dized when an open reduction is attempt- sion at the end of treatment (50%). It is
bar of bone and also a stable mandible. This ed for comminuted fractures. This can possible that the high incidence of maloc-
often necessitates open reduction and fixa- lead to an increased likelihood of infection clusion in the closed reduction group
tion of the mandibular fractures. Open and delayed healing. Gunshot wounds are might be a result of prolonged fixation,
reduction and fixation of a subcondylar best managed by closed reduction when- inadequate follow-up, and lack of super-
fracture are indicated when there are bilat- ever possible, because often the bone is vised postoperative rehabilitation.87
eral subcondylar fractures in the presence comminuted and there is a greater risk of There is a lack of any controlled clinical
of complex middle third fractures, so that a infection in these fractures. Atrophic data to indicate the superiority of open
stable vertical platform is provided on edentulous mandibles must be treated reduction techniques as a primary mode of
which the face can be reconstructed. with care. When an open reduction is nec- management of condylar fractures in
Principles of Management of Mandibular Fractures 419
children or adults. Although it is apparent formed or in those situations in which a nale for open condylar reduction in
that, in some situations, an unacceptable closed reduction is not possible. Limitation these situations is that it allows for the
incidence of complications results when of function may be caused by fracture with establishment of a horizontal and verti-
closed reduction is employed, it is inappro- dislocation of the proximal segment into cal dimension of the midface when this
priate to assume that an open technique the middle cranial fossa, by invasion of the cannot be achieved by other means. If
can avoid these complications until this is joint by a foreign body, by lateral extracap- rigid internal fixation of the midface is
borne out in controlled clinical trials. sular dislocation of the condylar head, or by possible, then open reduction of the
Despite the evidence in favor of closed the presence of any fracture dislocation that condyle may no longer be indicated.
reduction as the treatment of choice for produces a mechanical stop, preventing 2. Situations in which IMF is not feasible.
the majority of fractured condyles in both mandibular movement. Inability to per- Certain medical conditions, such as
children and adults, there are indications form a closed reduction may result when poorly controlled seizures, psychiatric
for the performance of open reduction the fracture is displaced so that it is impos- disorders, or severe mental retarda-
(Table 22-3). sible to manipulate the teeth into an appro- tion, make maxillomandibular fixation
In the past the indication for open priate occlusion. difficult and possibly dangerous. Also,
reduction of a condylar fracture was pri- patients with multiple trauma, partic-
marily a radiographic one. Essentially, it Possible or Relative Indications Possible ularly head injury or chest injury, are
was thought that the condyle behaved like or relative indications for open reduction at increased risk for complications if
other areas of the mandible or other also exist and should be assessed on the
placed in maxillomandibular fixation
bones in the body and that it would basis of benefit as opposed to risk:
unless tracheostomy is planned. In
respond better and heal with more satis-
1. Bilateral condylar fractures with com- addition, maxillomandibular fixation
factory function if an ideal anatomic
minuted midfacial fractures. The ratio- is extremely difficult in those patients
reduction were obtained.93,95,99,100 It has
been shown that there is little if any cor-
relation between the degree of displace- Table 22-3 Indications for Open Reduction of Fractures of the Mandibular Condyle
ment or dislocation of the fracture and 1. Absolute indications
the ability to obtain satisfactory function A. Limitation of function secondary to the following:
with a closed reduction. A more func- 1. Fracture into middle cranial fossa
tional approach in assessing the need for 2. Foreign body within the joint capsule
open reduction was taken by Zide and 3. Lateral extracapsular dislocation of condylar head
Kent.96,101 According to these investiga- 4. Other fracture dislocations in which a mechanical stop is present on opening,
tors, indications for open reduction of which is confirmed radiographically
condylar fractures should rely on the B. Inability to bring the teeth into occlusion for closed reduction
identification of specific clinical entities
2. Relative indications
that, when treated with closed reduction,
A. Bilateral condylar fractures with comminuted midface fractures in which rigid
would result in a high degree of failure.
internal fixation of the midface is not possible
They also take into account an objective B. Situations when intermaxillary fixation is not feasible as a result of the following:
evaluation of function at the time of the 1. Medical restrictions
planned reduction, the presence and con- a. Poorly controlled seizure disorder
dition of the patient’s dentition, the like- b. Psychiatric disorders
lihood of successfully performing a c. Severe mental retardation
closed reduction, and the presence of d. Concomitant injuries such as head injury or chest injury (unless
other modifying factors such as the tracheostomy is planned)
patient’s medical condition or the exis- 2. Displaced fractures where dentures or splints are not feasible because of severe
tence of other facial fractures. mandibular atrophy
C. Bilateral fractures in which it is impossible to determine what the proper occlusion is
as a result of loss of posterior teeth or the presence of a preinjury skeletal
Absolute Indications Absolute indica-
malocclusion
tions for open reduction are present in those
D. In fracture dislocation in adults to restore the position and function of the
situations in which limitation in function is
meniscus (controversial)
highly probable if a closed reduction is per-
420 Part 4: Maxillofacial Trauma
with displaced condylar fractures in that, in fracture dislocations in which may be easily approached from an intra-
whom dentures are not present and open reduction is indicated, an oral incision.103 In severe anteromedial
splints are not feasible because of attempt should be made to reposition fracture dislocations in which the condylar
severe mandibular atrophy. the disk at the time of the reduction. head is not retrievable despite the choice
3. Bilateral fractures in which it is However, inadequate data exist to of approach, a vertical ramus osteotomy,
impossible to determine the proper suggest that open reduction per- followed by removal of the osteotomized
occlusion. Occasionally, a patient with formed solely for the purpose of disk segment, has been recommended.104–106
bilateral fractures will have such an repositioning is valid. This allows for access to the proximal
ambiguous occlusion that, even with condylar head, which is located medially
the use of study models and careful Surgical Approach CONDYLAR FRACTURES and is also removed. Rigid fixation with
clinical examination, it is not possible A variety of surgical approaches to the frac- plates or screws is carried out between the
to determine the appropriate maxillo- tured condyle have been suggested, includ- ramus segment and condylar head. The
mandibular relation. This may lead to ing intraoral, submandibular, retro- unit is returned as a free autogenous bone
inappropriate placement of the mandibular, preauricular, and, more graft, and the osteotomy is plated. This
mandible into malocclusion or to recently, endoscopic. The most important technique is useful for high dislocated
placement of a preexisting malocclu- factor in determining the approach used is fractures and may be accomplished
sion into a normal relation, thereby the level at which the fracture has occurred. through a retromandibular approach.
predisposing the patient to nonunion Modifying factors such as the degree of dis- OTHER MANDIBULAR FRACTURES
or long-term functional disability. placement or dislocation and the planned Open reduction of mandibular fractures
4. Fracture dislocation in an adult method of fixation may also have a bearing prior to the advent of antibiotics was asso-
patient to restore position and func- on the approach selected. ciated with a high incidence of infection.
tion of the disk. Previous emphasis on Traditionally fractures in the condylar Following the introduction of antibiotics,
indications for open reduction have neck and above were best approached most clinicians used the extraoral
centered around the need for bony through a preauricular or endaural inci- approach to the fracture site. This tech-
reduction and fixation without con- sion.101 This approach also has the added nique, however, is time-consuming, results
sideration of disk position. The advantage of allowing for surgical manip- in a visible surgical scar, and can damage
unstated implication of most of the ulation of the soft tissues within the joint, adjacent structures, particularly the mar-
literature is that the position of the if desired. Subcondylar fractures and frac- ginal mandibular branch of the facial
dislocated disk is not critical for opti- tures extending into the upper ramus nerve. Transoral open reduction has been
mal functional results after condyle region are best approached using a retro- advocated as an excellent alternative.107–110
fracture.98 However, this is contradic- mandibular or Hinds approach.102 The The technique is claimed to be quicker to
tory, given the present emphasis on incision begins approximately 1 cm below perform, results in no extraoral scar, and
the importance of correct condylar the lobe of the ear and 1 cm posterior to does not damage the facial nerve. Less
disk alignment for management of the ramus of the mandible. The dissection postoperative wound care is required, and
those patients with internal derange- is carried down to the parotid gland, it is simple to perform the techniques
ment of the temporomandibular which is retracted anteriorly, providing under local anesthesia. Transoral open
joint. The disk is important in the access to the vertical fibers of the masseter reduction of mandibular fractures is use-
prevention of post-traumatic ankylo- muscle overlying the ramus. These fibers ful in tooth-bearing portions of the jaw
sis.47 An interesting concept has been are not stripped but instead are separated (ie, in symphyseal, body, and angle frac-
raised about the possible necessity for bluntly along their vertical course, allow- tures). Complications rates and infection
disk repositioning, especially in frac- ing access to the underlying ramus. Access rates appear to be similar between the two
ture dislocations, to allow for optimal can easily be gained to relatively high sub- techniques when large numbers of cases
temporomandibular joint function. condylar fractures through this approach, are studied.111,112
Some clinicians have suggested that and a variety of fixation techniques are Occasionally, a combination of ap-
“open reduction and internal fixation possible without additional percutaneous proaches is necessary, particularly in frac-
of condylar fractures in conjunction puncture, as may be needed if a sub- ture dislocations in which a preauricular
with disk repair is a biologically mandibular approach is used. Low sub- approach may be necessary to retrieve the
sound approach….”98 Based on their condylar fractures, especially those with- proximal segment, while fixation is per-
experience, it might be recommended out a significant degree of displacement, formed through another approach.113
Principles of Management of Mandibular Fractures 421
Throughout the past decade, surgeons fixation devices may be employed (Figure
have become interested in the concept of 22-31). In a given situation, any one of
minimally invasive surgical approaches to these techniques may have certain advan-
avoid potential patient morbidity from tages over the other. With the development
more traditional open surgical techniques. of sophisticated rigid internal fixation sys-
With the development of these techniques, tems and instrumentation for their place-
management of these injuries via an endo- ment, miniplate fixation of these fractures
scopic approach has gained great popular- will be the technique most readily
ity among surgeons. In 1994 Ma and Fang employed in most cases. Miniature bone
were the first ones to describe the use of an plates can be applied using any of the pre-
endoscope to access the mandibular angle viously discussed approaches. These plates
region.114 Later Jacobovicz and colleagues have the advantage of being available in a
modified this technique for the manage- wide variety of shapes and sizes; they are A
ment of condylar fractures.115 Recently, now readily available in most operating
more authors have also described their rooms; and they provide a more stable
experience with this approach.116–118 form of fixation than do wires or Kirschn-
The surgical approach, as described by er wires. Theoretically, bone plates have
Miloro,118 requires a 15 to 20 mm modified another advantage—they can be placed on
Risdon incision to gain access to the lateral a relatively small proximal fragment first,
ramus. A subperiosteal dissection is then allowing for the creation of a handle to
performed blindly to create an “optical cav- more effectively manipulate the proximal
ity” on the lateral aspect of the ramus on segment into an appropriate reduction.
the fracture side from the sigmoid notch to Should the incision selected not allow for
the inferior border and from the mandibu- total access to the fracture, currently avail-
lar notch anteriorly to the posterior border able bone-plating systems are equipped
of the ascending ramus posteriorly. A mod- with instrumentation for percutaneous B
ified Storz retractor with a curved end is placement of screws.
FIGURE 22-30 Endoscopic management of condylar
then placed through the incision and below WIRE Intraosteal wiring (wire fractures offers excellent reduction and fixation of the
the periosteum to engage the sigmoid osteosynthesis) can be placed either by an fracture segments, while reducing the morbidity of
notch. A 4 mm, 30˚ endoscope is used for intra- or extraoral route using one of three conventional open approaches to this site. A, Visual-
retraction and visualization of the surgical basic techniques: ization of the condylar neck fracture. B, Titanium
miniplate in place after reduction. (Photographs
site. Following irrigation and the use of a courtesy of Michael Miloro, DMD, MD)
suction elevator, the sigmoid notch, inferi- 1. A simple straight wire across the frac-
or border, mandibular notch, posterior ture site (Figure 22-32A). This should
border, and the fracture site can be clearly be placed so that the direction of pull of 3. Transosseous circum-mandibular
identified endoscopically. The fractured the wire is perpendicular to the fracture wiring (Obwegeser’s technique) (Fig-
segments are then repositioned and site. This technique can be either ure 22-32C). This is a useful wiring
reduced. Inferior traction on the angle of through both the buccal and lingual technique when the fracture runs
the mandible, although limited by IMF, can cortical plate or it may be used on the obliquely compared with the inferior
be helpful in the mobilization of the seg- buccal cortical plate only. This is useful border of the mandible. If the fracture
ments. Fixation is achieved with a 2.0 mm in the angle region, where a third molar line is too vertical the wire could
titanium miniplate and screws through a socket can be quickly and easily used become displaced into the fracture line.
preauricular stab incision and trocar (Fig- for a simple straight buccal cortex wire.
ure 22-30). Following reduction and stabi- 2. Figure-of-eight wire (Figure 22-32B). The wire used should be a pre-
lization, the IMF is released for evaluation This wiring technique has been stretched soft stainless steel, and the frac-
of the occlusion. shown to have increased strength ture should be held in a reduced position
compared with simple techniques at while the wire is being tightened so that
Methods of Fixation Once access to the both the inferior and superior borders the wire does not reduce the fracture and
fracture has been achieved, any number of in angle fractures.119 possibly lead to wire breakage.
422 Part 4: Maxillofacial Trauma
A B C
D E F
G H I
FIGURE 22-31 Previously reported techniques for direct stabilization of condyle fractures: A, Silverman (1925); B and C, Thoma (1945); D, Stephenson
(1952); E, Robinson (1960); F, Robinson (1962); G, Messer (1972); H, Kobert (1978); I, Petzel (1982). (CONITINUED ON NEXT PAGE)
Principles of Management of Mandibular Fractures 423
RIGID FIXATION Dissatisfaction with seek alternative methods of treatment, Edentulous Fractures The edentulous
the use of IMF as a means of treatment of including the use of rigid internal fixation. mandible in the trauma patient has several
mandibular fractures has resulted in the The principal disadvantages of the com- factors modifying its behavior that the den-
development of open reduction and fixa- pression plating systems for mandibular tate mandible does not. The loss of the teeth
tion techniques that do not require the teeth fractures are the use of an external approach, results in resorption of the alveolar bone,
to be wired together. Criticism of the disad- thus giving rise to facial scarring and the which weakens the mandible. The loss of
vantages of prolonged immobilization of potential for damage to the mandibular bone also means that there is less cross-
the jaws has included patient complaints of branch of the facial nerve, and the use of sectional area of bone in contact in fracture
panic, insomnia, social inconvenience, pho- very rigid plates, giving rise to “stress shield- patients and less periosteum and endos-
netic disturbance, loss of effective work ing,” although this has never been shown to teum to supply the osteogenic cells for frac-
time, physical discomfort, weight loss, histo- be a problem in mandibular fractures. Also, ture healing. Because of the aging process
logic changes in the condylar head, and dif- the position of the teeth and inferior alveolar the majority of the blood supply to the
ficulty recovering a normal range of jaw nerve and the use of bicortical screw fixation edentulous mandible is from the perios-
movement. This has led some clinicians to necessitate that the compression plates be teum rather than the inferior alveolar
424 Part 4: Maxillofacial Trauma
A B C
FIGURE 22-32 A, Simple wiring technique. B, Figure-of-eight wire. C, Transosseous circum-mandibular wire. Adapted from Luyk NH.88 p. 427.
artery.122 A larger percentage of fractures in therapy may be all that is necessary. More which may be mobile during the mixed den-
the edentulous patient are not compound definitive treatment will be necessary if the tition stage and whose shape has little in the
because of the lack of teeth. Minor displace- fragments are displaced or excessively way of undercut areas, which means that they
ment of the bones can be easily accommo- mobile. The bilateral body fracture do not retain wire as well as adult teeth. The
dated in the construction of new dentures. deserves special mention because the pull presence of tooth buds reduces the area avail-
The edentulous population also tends to of the suprahyoid muscles tends to displace able for interosteal fixation, and there exists a
have more health problems resulting from this fracture inferiorly. These usually occur greater potential for ankylosis and growth
conditions such as osteoporosis, diabetes in the pencil-thin atrophic mandible. A disturbances in the younger population.
mellitus, and steroid therapy, which may variety of treatment modalities have been Also, children do not tend to tolerate IMF as
directly affect bone healing. The site distrib- suggested to treat these difficult fractures well as adult patients. On the other hand,
ution of fractures tends to be different in the including open reduction with rigid inter- fractures tend to heal quicker in children and
edentulous patient, with a higher percent- nal fixation, closed reduction with and slight malocclusion problems can be com-
age of body fractures (43.5%) and lower without bone grafts, and external pin fixa- pensated for by growth of the patient.
percentages of angle (15.2%) and symphy- tion. When the edentulous mandible is Children make up about 5% of all
seal (4.3%) fractures (Figure 22-33).123 A comminuted again because of the poor mandibular fractures. These fractures are
20% incidence of nonunion has been blood supply to the bone fragments, those rare in children under 5 years of age because
reported in the treatment of edentulous fragments are best managed by closed of the greater elasticity of the bone and
fractures, particularly when nonrigid fixa- reduction. The use of semirigid fixation lighter weight of children, which lowers the
tion was applied in open reduction cases.111 systems without some form of IMF is not
Longer periods of immobilization have also indicated in this patient subset.
been shown to be necessary to achieve satis- External pin fixation by the biphasic
factory healing.124,125 technique is often used in edentulous frac-
The anatomic site influences treat- tures. It obviates the need for IMF, thus 37.0 0
ment. If the location of the fracture is pos- allowing early mobilization of the jaw and
terior to the denture-bearing area, then improving feeding in some patients. It can
either additional fixation (eg, external pin be used in comminuted fractures without
fixation) or open reduction and fixation jeopardizing blood supply to the fractures,
15.2
may be necessary to control the proximal and it can also bridge a bone loss gap
43.5
fragment. Muscle pull on the edentulous before bone grafting. 4.3
jaw is considerably weaker than in a den-
tate mandible and undisplaced fractures Fractures in Children As previously men-
are often closed injuries. Therefore, if the tioned, fractures in children are less common
FIGURE 22-33 Percentage of fracture sites in
fragments are undisplaced or minimally than in adults. Their management is compli- edentulous patients. Adapted from Luyk NH.88
displaced and not mobile, conservative cated by the presence of deciduous teeth, p. 429.
Principles of Management of Mandibular Fractures 425
forces of impact during falls. Condylar frac- communication with the mouth, no peri- tures whether closed reduction or open
tures appear to be common, affecting about coronitis exists, and reduction of the frac- reduction is contemplated. The antibiotic
46% of patients either alone or in combina- ture is achievable without removal. Shetty prophylaxis should begin preoperatively
tion with other fractures.126 and Freymiller reviewed the indications and be continued for not more than
Mandibular fractures in children can for removal of teeth in the line of the frac- 24 hours postreduction.
often be successfully managed by acrylic ture as follows137:
splint therapy of the mandible only or Complications
with eyelet wires and IMF.126,127 A short- 1. Teeth grossly loosened, showing evi-
ened period of IMF, 2 to 3 weeks, is all that dence of periapical pathology or sig- Delayed Union and Nonunion
is required. When an open reduction is nificant periodontal disease Nonunion is distinguished from delayed
required, it has been successfully accom- 2. Partially erupted third molars with union by the potential of the bone to heal.
plished by the extraoral route using inferi- pericoronitis or associated cyst Delayed union is a temporary condition in
or border wiring in order to avoid the 3. Teeth that prevent reduction of fractures which adequate reduction and immobiliza-
tooth buds.128,129 4. Teeth with fractured roots tion eventually produces bony union. On
If adequate bone height is available 5. Teeth with exposed root apices or the other hand, nonunion may persist
below the area where the tooth buds are entire root surface from the apex to indefinitely without evidence of bone heal-
located, the use of resorbable plates offers the gingival margin ing unless surgical treatment is undertaken
a great advantage to fixate these fractures 6. An excessive delay from the time of to repair the fracture. Nonunion is general-
(Figure 22-34). fracture to definite treatment ly characterized by pain and abnormal
Complications are rare in this group of mobility following treatment. Malocclusion
patients. Malunion, nonunion, and infec- Use of Antibiotics may be present in dentate cases and mobil-
tion tend to have a low incidence.67 Two Zallen and Curry demonstrated that with ity exists across the fracture line. Radi-
serious complications that can occur, how- compound mandibular fractures, an infec- ographs demonstrate no evidence of heal-
ever, are ankylosis and growth distur- tion rate of 50% can be expected in those ing and in later stages show rounding off of
bances. Both of these tend to be more com- patients who do not receive antibiotic ther- the bone ends. Delayed and nonunion
mon with intracapsular condylar fractures apy.138 A prospective trial was undertaken in occur in about 3% of fractures.140
and when the damage is of a crushing which only dentate compound mandibular There are several causes and contribut-
nature.130 The incidence and severity of fractures were evaluated. One-half of the ing factors. The most common reason is
these complications can be reduced by patients in this study received “prophylactic poor reduction and immobilization.141
shorter periods of IMF and close follow-up. antibiotics,” usually penicillin. It was not This is more likely in edentulous fractures.
stated for how long the antibiotic therapy Infection is often an underlying cause, and
Management of Teeth in the Line of Frac- was continued or when it started in relation any tooth in the line of the fracture must be
ture In the past, teeth in the line of the to the injury. One-half the patients who did carefully assessed for root fracture and
fracture were always removed.23,131,132 not receive antibiotics had infections at the vitality. A decreased blood supply can lead
Their removal was advocated because frac- fracture site as opposed to only 6% of those to delays in healing. Excessive stripping of
tures of the dentate portion of the jaws are who did receive antibiotics. It seemed to
compound via the periodontal ligament make little difference whether the fractures
and it was believed that this communica- were treated by open or closed reduction.
tion fostered infection, osteomyelitis, and All fractures in this study were treated within
nonunion. However, Neal and colleagues, 36 hours. Another study has confirmed these
Kahnberg and Ridell, Schneider and Stern, results in facial fractures and has suggested
and Amaratunga have all been able to that short-term prophylaxis as is used in elec-
show that the majority of teeth in the frac- tive surgery may be as effective as the more
ture line can be saved if appropriate usual 5-day course of antibiotics.139 This
antibiotic therapy and fixation techniques group also found little difference in the inci-
are used.133–136 The impacted mandibular dence of infection whether there was a delay
third molar tooth deserves special men- in treatment of mandibular fractures or not.
tion. Most authors have advocated leaving Penicillin should remain the antibiotic FIGURE 22-34 Use of a resorbable plate for fixa-
the tooth in situ if the tooth is not in direct of choice for compound mandibular frac- tion of a symphysis fracture in a 4-year-old child.
426 Part 4: Maxillofacial Trauma
the periosteum, especially in comminuted commonly.58 Treatment has already been clusion.145,146 Malocclusion can be cor-
and edentulous fractures, can lead to outlined as for delayed and nonunion of rected by further or prolonged IMF in the
delayed healing. Metabolic deficiencies and fractures. early stages of healing, and selective tooth
alcoholism are also significant contributors grinding, orthodontics, or osteotomies
to delayed healing. Cannell and Boyd Malunion after complete bony union.
showed a high incidence of delayed union Malunions can be defined as a bone union Malocclusion that does not result
and nonunion in a group of alcoholic of the fracture in which some displace- from growth alterations but from a mal-
patients.142 These patients were probably ment of the bones still exists. Not all union of the condyle fracture occurs infre-
also at increased likelihood to sustain a malunions of fractured mandibles are quently if an adequate follow-up regimen
mandibular fracture. Although the exact clinically significant. Often malunions in is followed. If malocclusion does persist,
reasons for delayed healing in this group of edentulous patients or those involving the its management is similar to the manage-
patients is not known, they are known to ramus and condylar area of the mandible ment of malocclusion from other causes.
have metabolic and vitamin deficiencies, result in no clinically detectable alteration Judicious use of equilibration, orthodon-
poor compliance particularly with IMF, in appearance or function. When, the tics, and orthognathic surgery allows for
poor bony quality, and impaired local dentate portion of the jaw is involved, restoration of a functional occlusion.
blood supply, all of which could be con- however, a malocclusion can result. The Before reconstructing the occlusion to this
tributing factors. These patients should be rates of malocclusion in patients treated new articulation, it is necessary to allow a
treated whenever possible with closed with IMF tend to be very low. In one period of 6 to 12 months for complete
reductions, because this treatment has a prospective trial between rigid internal healing and for any remodeling of the
lower incidence of complications in this fixation and standard techniques the rate articular apparatus to occur.
group of patients.142 of malocclusion with the rigid fixation
Treatment of delayed union and was three times higher. However, as the Nerve Injury
nonunion is aimed at eliminating the authors concede, they were initially inex- Traumatic injury to the inferior alveolar
underlying cause of the problem. When perienced with the technique and others nerve is common in displaced fractures of
infection is present it must be managed have reported a low incidence of maloc- the body and angle of the mandible. There
with débridement of sequestra, drainage,
and antibiotic therapy. Loose fixation such
as wires and plates must be removed, and
adequate fixation with IMF, extraoral pin
fixation, or even rigid plate fixation should
be applied across the fracture site.143 If
there is a gap between the bone ends, a
bone graft may be necessary.
Infection
Infection and osteomyelitis appear to be
the most common complications (Figure
22-35). In some studies, particularly with-
out antibiotics, it may occur in over 50%
of cases.144 Some of the underlying causes
have already been discussed. These can be
divided into systemic factors, such as alco-
holism and no antibiotic coverage, and
local factors, such as poor reduction and
fixation, fractured teeth in the line of frac-
ture, and comminuted fractures. A B
Most infections appear to be mixed in
FIGURE 22-35 A, Sinus tract from an infected anterior mandibular fracture after open reduction
nature, with α-hemolytic Streptococcus with internal fixation. B, After hardware removal and bony débridement, a large defect can be
and Bacteroides spp organisms found most observed in the left parasymphysis region.
Principles of Management of Mandibular Fractures 427
are few studies documenting recovery of theory. Frequently, complete regeneration Temporomandibular Joint
the nerve. Larsen and Nielsen reported a of the condyle occurs in young patients, Dysfunction
permanent disturbance in mental nerve with no residual deficit following frac-
A wide range of temporomandibular
function in 8% of 229 patients studied.147 ture, and better regeneration occurs in
joint problems may result from injuries
Return of nerve function depends on the actively growing patients, particularly
to the condylar apparatus. Internal
degree of initial trauma to the nerve and an those under the age of 12 years.148,149 This
derangement and ankylosis are perhaps
accurate reduction and adequate fixation clinical observation is supported by
the two most common.
of the mandibular fracture. Rarely other experimental studies,104 which found
branches of the mandibular division of the that, following surgically created fracture
Internal Derangement A correlation
trigeminal nerve can be affected. These dislocations in young monkeys, excellent
exists between previous condylar fracture
include the masseteric nerve, auriculotem- regeneration occurred with no growth
and the development of internal derange-
poral nerve (both with condylar fractures), disturbance in any of the animals. This
ment of the temporomandibular joint.
and the buccal and lingual nerves associat- ability for restitution of growth in chil-
There is a greater incidence of temporo-
ed with intraoral lacerations with body or dren under the age of 12 years appears to
mandibular joint pain, deviation on open-
angle fractures. Also rare is damage to the account for the lack of direct correlation
ing and joint noise in patients with previ-
marginal mandibular branch of the facial between the age of injury and the degree
ous condylar fractures.71 The resultant
nerve with fractures of the condyle, ramus, of growth disturbance—a correlation
internal derangement primarily occurs in
and angle of the mandible. It is more com- that would be expected if the sole deter-
adults and is of two broad types. The first
mon to see this nerve damage caused by a minant were the amount of growth left at
is internal derangement that occurs on the
laceration along its course. the time of injury.
side of the fracture and results from soft
Most fractures of the mandible heal The concept that the condylar carti-
tissue injury within the joint. Open reduc-
with relatively simple management. All lage acts as a growth center has been
tion with direct repair of the injured soft
clinicians must be wary of overtreatment replaced by the theory that the cartilage
of simple cases that can lead to an increase acts as a remodeling center.150 The resti-
in cost of treatment for both the patient tution of growth seen after condylar
and society and also an increase in compli- injury (which at times may actually lead
cation rates. to overgrowth of the affected condyle) is
a direct result of this remodeling center
Growth Alteration within the condylar cartilage reacting to a
Growth alterations as the result of traumatic episode. It is not unusual for a
condylar injury may occur as the result new condylar apparatus to develop, with
of two mechanisms. Over- or understim- resorption of the displaced or dislocated
ulation of normal growth may result condylar head. This compensatory
from direct injury to the condyle, or a growth seems to depend on the potential
restriction of normal growth may occur space created by the displacement of the
secondary to fibrosis or scarring of the stump of the condylar process.150 For this
surrounding tissue. reason, it is important to maintain the
It was once thought that fracture of mandible in its original occlusion, not
the condyle produced a growth deficit in only for a few weeks during healing, but
proportion to the age of the patient at the also for the next several months while
time of injury: the younger the child, the bony regeneration and compensatory
greater potential growth problem. 120 growth occur. Even when occlusion is
However, although it is true that children maintained and the patient is of the ideal
undergo several periods of rapid growth age, 25% of subjects experience a growth
during their development and that an disturbance.148,149,151 Because of this, ade-
injury during one of these growth peri- quate patient education and long-term
FIGURE 22-36 Significant mandibular hypopla-
ods may be associated with a higher inci- follow-up for several years is necessary in
sia in a 12-year-old boy, resulting from bilateral
dence of growth alteration,78 other fac- children with fractures of the condyle intracapsular condylar fractures suffered shortly
tors are involved that alter this simplistic (Figure 22-36). after birth.
428 Part 4: Maxillofacial Trauma
tissues has been advocated by some as a op ankylosis. The postinjury relation of the area of temporomandibular joint ankylo-
possible means of preventing this prob- condylar stump with the glenoid fossa is sis.48 Experimentally, ankylosis has been
lem.98,99 No long-term data have estab- also a factor. With fractures of the condylar created in a baboon by a combination of
lished that this is effective. The other form head, a greater likelihood exists that there bilateral fractures of the condyloid
of internal derangement occurs contralat- will be intimate contact between the prox- process, diskectomy, and prolonged
eral to the condylar injury. This derange- imal portion of the distal segment and the immobilization, while the same procedure
ment was described by Gerry as the glenoid fossa, predisposing the patient to without diskectomy did not produce
“condylar postfracture syndrome.”32 ankylosis.48 Failure to produce ankylosis ankylosis.48 Thus far, this discussion has
Patients who develop a unilateral hinge after experimentally induced condylar been limited to the development of true
type of joint after a fracture can rapidly fractures,81 coupled with the clinical obser- ankylosis with the formation of a bony or
develop overfunction of the contralateral vation that the incidence of intracapsular fibrous union within the joint itself. There
joint with hypermobility and, ultimately, fracture is much higher than that of anky- is also the potential for the development
anterior dislocation of the disk. losis, leads one to believe that other factors of pseudo ankylosis if soft tissue trauma
besides the site of fracture must be opera- surrounding the joint leads to fibrosis and
Ankylosis Ankylosis is a rare complica- tive in the production of ankylosis. scarring or (in the case of zygomatic arch
tion of mandibular fractures. It is more like- The condyle of a young child is more and coronoid fractures) a bony union
ly to occur in children and is associated with easily crushed than fractured,153,154 possibly develops between other fractured areas
intracapsular fractures and immobilization because the cortical bone of the child is rel- and not within the joint itself.
of the mandible. The most commonly atively thin and the condylar neck broad.155 In summary, it is likely that the follow-
accepted etiology is of intra-articular The immediate subarticular layer is also ing groups of patients will be at high risk for
hemorrhage, leading to abnormal fibrosis extensively vascularized. An impact leading development of ankylosis: patients under
and ultimately ankylosis.141 In children, if to a crush injury is more common in a child the age of 10 years at the time of injury;
left untreated, it results in disturbed because of these anatomic differences, and patients with intracapsular fractures and
growth and underdevelopment of the the resulting fragments of highly vascular- fracture dislocations with gross telescoping;
affected side. Prevention is easier than cure, ized osteogenic material that are dispersed
and the use of only short periods of IMF in throughout the joint space may be the
children can help reduce the occurrence of cause of ankylosis.155 This theory helps to
this complication. Management once the explain the clinical observation that there is
condition is established is surgical with a a greater predisposition for post-traumatic
temporomandibular joint arthroplasty, ankylosis in patients sustaining such
wide resection of the ankylotic portion of injuries before the age of 10 years.156
bone, coronoidectomy, and reconstruction It is widely accepted that the length of
with a costochondral rib graft, with active the maxillomandibular fixation may play
early and prolonged mobilization and a role in the development of ankylosis.
exercises.152 Markey was unable to produce ankylosis
Although development of internal after experimentally induced fracture
derangement seems to occur solely in with prolonged maxillomandibular fixa-
adult patients, ankylosis is much more tion.157 In studies performed by Beekler
common in children (Figure 22-37). and Walker, ankylosis occurred with pro-
Factors contributing to the develop- longed fixation, while no ankylosis could
ment of ankylosis have been outlined.35 be created in a moving jaw.81 This con-
They include the site and type of fracture, firms the observation that the duration of
the age of the patient at the time of injury, immobilization is contributory to the
the duration of IMF, and the extent of development of ankylosis, although it is
damage to the disk. not the primary determinant. The loca-
The site and type of fracture may play tion and condition of the disk may be
an important role in whether or not anky- another determinant in the occurrence of
FIGURE 22-37 Coronal computed tomography
losis occurs. It is widely accepted that intra- temporomandibular joint ankylosis scan of the patient in Figure 22-36 showing true
capsular fractures are more likely to devel- because one never finds the disk in the bony ankylosis of both temporomandibular joints.
Principles of Management of Mandibular Fractures 429
and patients with compound comminuted condylar segments.159,160 If aberrant rein- sion. Children of less than 12 years of age
fractures, particularly if the coronoid nervation occurs from this injury, the late rarely require more fixation, but patients
process and zygoma are also involved.35 complication of auriculotemporal syn- over the age of 12 years show extreme
Prevention of temporomandibular drome may result.160,161 variability, regardless of fracture type. If
joint ankylosis is accomplished by recog- the occlusion is stable and reproducible at
nition of those patients at risk, brief Postoperative Management the time of IMF release, then jaw-opening
immobilization periods, and aggressive Regardless of the technique employed for exercises are begun. If aggressive physio-
postoperative physiotherapy and long- treatment of the mandibular fractures, the therapy is initiated after release of IMF for
term follow-up. postoperative management of the patient treatment of a condylar process fracture,
is critical for long-term successful rehabil- the patient should be evaluated in
Other Complications Associated itation and return to function. 24 hours to confirm the presence of a
with Condylar Fractures In cases in which open reduction inter- stable occlusion. The arch bars are left in
When the condylar head is forced posteri- nal fixation is employed without the use of place and training elastics are used. The
orly in the process of fracture, some force postoperative IMF, follow-up visits should purpose of these elastics is to permit func-
is directed against the posterior and supe- be used as reinforcement sessions to remind tion, while maintaining the occlusion. An
rior walls of the glenoid fossa. Fracture of the patient about proper diet and progres- effective way to accomplish this is to grad-
the tympanic plate may occur. In addition, sive increase in function. It has been our ually reduce the use of elastics over a peri-
partial obstruction of the external audito- experience that in many respects this group od of time. Initially, elastics should be used
ry canal may result, causing a conductive of patients should be monitored more 24 hours a day. They should be placed
hearing loss because of the close proximi- closely than those treated with IMF to pre- lightly during the daytime to assist in
ty of the middle ear. Patients with a histo- vent possible postoperative complications guiding the mandible into occlusion, par-
ry of a condyle fracture should undergo a secondary to their injudicious or untimely ticularly if significant deviation is present,
careful otoscopic examination to evaluate return to normal diet and function. and applied more tightly at night. After
the condition of the anterior wall of the The proper length of maxillo- 1 week, it may be possible to completely
external auditory canal, as well as to mandibular fixation (if used), the dura- abandon daytime elastic fixation and con-
observe for signs of potential middle ear tion and frequency of evaluation by the tinue with relatively tight elastic fixation at
injury. Appropriate consultation must be surgeon, the early detection of potential night. After another 1 to 2 weeks of this
obtained if injuries of this nature are indi- complications, the judicious use of physio- therapy, assuming that continued mainte-
cated by clinical examination or history. therapy, and proper patient education are nance of a normal occlusion is present, the
Basilar skull fracture along the floor of the all necessary. In most cases some form of patient should be allowed to function
middle cranial fossa may also occur from a IMF will have been employed. The length without any guiding elastic fixation for
similar mechanism, resulting in cerebral of the fixation period, as previously dis- approximately 1 week. If, at that time,
contusion. The fracture may also spread cussed, varies between 2 to 8 weeks there continues to be a stable occlusion,
through the petrous portion of the tempo- depending on many factors. At the end of further evaluation should continue for
ral bone, resulting in injury of cranial this period, a systematic approach for other problems, such as limited mouth
nerves VII and VIII and a neurosensory removal of the fixation is desirable. A opening or pain, and the arch bars may be
hearing deficit (as opposed to a conduc- follow-up regimen similar to that described removed. If, on the removal of the IMF or
tion deficit), facial nerve paralysis, and by Walker must then be instituted.87,88 This at any time during the training period, the
possibly Battle’s sign. allows for wound healing monitoring, oral occlusion becomes unstable and nonre-
If either of the fracture segments hygiene reinforcement, and observation of producible, an additional period of tight
encroaches on the infratemporal fossa, adequate dietary intake. It also gives the intermaxillary fixation with wires or elas-
trauma to the nerves or vessels in this area clinician the opportunity to control the tics is indicated for 1 or 2 weeks. Clinical
may occur. Damage of a large vessel can occlusion in those patients who need fur- experience seems to indicate that a longer
result in hematoma formation or develop- ther stabilization, while encouraging early period of controlled elastic traction is often
ment of a false aneurysm.158 This expand- movement in those patients who have sta- needed in adults with displaced or dislo-
ing hematoma or false aneurysm may also ble occlusions. It is impossible to predict cated fractures, particularly if these are
cause injury to the seventh cranial nerve. on the basis of the type of fracture which bilateral. Even with judicious use of guid-
The third division of the cranial nerve V patients will need continued aggressive ing elastic fixation, patient education, and
may also be injured by the displaced elastic guidance to maintain their occlu- careful continued evaluation, malocclusion
430 Part 4: Maxillofacial Trauma
persists in some patients. In these cases one compression plate (DCP). Acta Orthop 25. Petzel JR, Bulles G. Experimental studies of the
must consider equilibration, orthodontics, Scand 1969;125:45–61. fracture behaviour of the mandibular condy-
9. Michelet F, Deymes J, Dessus B. Osteosynthesis lar process. J Maxillofac Surg 1981;9:211–5.
osteotomies, or a combination of these to with miniaturized screwed plates in maxillo- 26. Cope MR, Lawlor MG. An unusual mandibular
correct the malocclusion. facial surgery. J Maxillofac Surg 1973; dislocation. Br J Oral Maxillofac Surg
Throughout the post-IMF period, 1:79–84. 1985;23:112–7.
aggressive maintenance of range of 10. Champy M, Lodde JP, Schmitt R, et al. 27. Katzen JT, Jarrahy R, Eby JB, et al. Craniofacial
Mandibular osteosynthesis by miniature and skull base trauma. J Trauma 2003;
motion is necessary. In some patients this
screwed plates via a buccal approach. 54:1026–34.
may be as simple as instructing them to J Maxillofac Surg 1978;6:14–21. 28. Chacon GE, Dawson KH, Myall RW, Beirne
open their mouths as wide as possible in a 11. Rahn BA. Direct and indirect bone healing OR. A comparative study of 2 imaging tech-
symmetrical manner. Other patients may after operative fracture treatment. Oto- niques for the diagnosis of condylar frac-
initially require daily evaluations and laryngol Clin North Am 1987;20:425–40. tures in children. J Oral Maxillofac Surg
12. Worthington P, Champy M. Monocortical 2003;61:668–72.
forced opening by the surgeon. Manually 29. Chayra GA, Meador LR, Laskin DM. Compari-
miniplate osteosynthesis. Otolaryngol Clin
forcing the teeth apart, use of a ratchet, North Am 1987;20:607–20. son of panoramic and standard radiographs
mouth props, progressive wedging of 13. Davies BW, Cerdena JP, Guyuron B. Noncom- for the diagnosis of mandibular fractures.
tongue blades between the teeth, or other pression unicortical miniplate osteosynthe- J Oral Maxillofac Surg 1986;44:677–9.
sis of mandibular fractures. Ann Plast Surg 30. Shetty V, Atchison K, Belin TR, et al. Clinician
more sophisticated physiotherapy devices
1992;28:414–9. variability in characterizing mandible frac-
are all effective means of regaining pre- tures. J Oral Maxillofac Surg 2001;59:254–
14. Huelke DF. Mechanics in the production of
injury interincisal opening. mandibular fractures: a study with the 61; discussion 261–2.
The success or failure of any pro- “stresscoat” technique. I. Symphyseal 31. Gilhuus-Moe O. Fracture of the mandibular
condyle in the growth period. Acta Odontol
posed treatment for the fractured impacts. J Dent Res 1964;43: 437–46.
Scand 1971;29:53–63.
mandible, whether by open or closed 15. Huelke DF, Burdi AR, Eymen C. Mandibular
32. Gerry RG. Condylar fractures. Br J Oral Surg
fractures as related to site of trauma and state
reduction, will necessarily hinge on the 1965;3:114–22.
of dentition. J Dent Res 1961;40:1262–6.
careful adherence to sound physiologic 16. Huelke DF, Burdi AR, Eymen CE. Association
33. Blevins D, Gores RJ. Fractures of the mandibu-
and surgical principles and to close post- lar condyloid process: results of conserva-
between mandibular fractures and site of
tive treatment in 140 patients. J Oral Surg
operative follow-up. trauma, dentition and age. J Oral Surg
Anesth Hosp Dent 1961;19:329–33.
Anesth Hosp Dent 1962;20:478–81.
34. MacLennan WD. Consideration of 180 cases of
References 17. Huelke DF, Harger JH. Maxillofacial injuries:
typical fractures of the mandibular condy-
1. Ogundare BO, Bonnick A, Bayley N. Pattern of their nature and mechanisms of produc-
lar process. Br J Plast Surg 1952;5:122–7.
mandibular fractures in an urban major tion. J Oral Surg 1969;27:451–60.
35. Bradley P. Injuries of the condylar and coronoid
trauma center. J Oral Maxillofac Surg 2003; 18. Huelke DF, Harger JH. Mechanisms in the pro-
process. In: Rowe NL, Williams JL, editors.
61:713–8. duction of mandibular fractures: an exper-
Maxillofacial injuries. Volume 1. Edinburgh:
2. Thaller SR. Management of mandibular frac- imental study. J Oral Surg 1968;26:86–9. Churchill-Livingstone; 1985. p. 337–62.
tures. Arch Otolaryngol Head Neck Surg 19. Huelke DF, Patrick LM. Mechanics in the pro- 36. Kelly DE, Harrigan WF. A survey of facial frac-
1994;120:44–7. duction of mandibular fractures: strain- tures: Bellevue Hospital 1948-1974. J Oral
3. Fasola AO, Obiechina AE, Arotiba JT. Incidence gauge measurements of impacts to the chin. Surg 1975;33:146–9.
and pattern of maxillofacial fractures in the J Dent Res 1964;43:437–46. 37. Luyk NH, Larsen PE. The diagnosis and treat-
elderly. Int J Oral Maxillofac Surg 20. Evans FG, Pedersen HE, Lissner HR. The role ment of the dislocated mandible. Am J
2003;32:206–8. of tensile stress in the mechanism of Emerg Med 1989;7:329–35.
4. Hoffman WY, Barton RM, Price M, Mathes SJ. femoral fractures. J Bone Joint Surg 1951; 38. Lello GE. Treatment of long standing
Rigid internal fixation vs. traditional tech- 33:485–8. mandibular dislocation of the mandible.
niques for the treatment of mandible frac- 21. Kromer H. Closed and open reduction of condy- J Oral Maxillofac Surg 1987;45:893–6.
tures; J Trauma 1990;30:1032–6. lar fractures. Denl Rec 1953;73:569–71. 39. Hayward JR. Prolonged dislocation of the
5. Kellman RM. Recent advances in facial plating 22. Chalmers J. Lyons Club. Fractures involving mandible. J Oral Surg 1965;23:585–94.
techniques. Facial Plast Surg Clin North the mandibular condyle: a post-treatment 40. da Fonseca GD. Experimental study on frac-
Am 1995;3:227–39. survey of 120 cases. J Oral Surg 1974;9:233. tures of the mandibular condylar process
6. Dawson KH, Chigurupati R. Fixation of 23. Rowe NL, Killey HC. Fractures of the facial (mandibular condylar process fractures).
mandibular fractures: a tincture of science. skeleton. 2nd ed. Edinburgh: Churchill- Int J Oral Surg 1974;3:89–101.
Ann R Australas Coll Dent Surg Livingstone; 1968. 41. Ihalainen U, Tasanen A. Central dislocation of
2002;16:118–22. 24. Lindahl L. Condylar fractures of the mandible. the mandibular condyle into the middle
7. Cawood JI. Small plate osteosynthesis of I. Classification and relation to age, occlu- cranial fossa: a case report and review of the
mandibular fractures. Br J Oral Maxillofac sion and concomitant injuries of teeth and literature. Int J Oral Surg 1983;12:39–45.
Surg 1985;77–91. teeth supporting structures, and fractures 42. Musgrove BT. Dislocation of the mandibular
8. Allgower M, Ehrsam R, Ganz R, Matter P, Per- of the mandibular body. Int J Oral Surg condyle into the middle cranial fossa. Br J
ren SM. Clinical experience with a new 1977;6:12–21. Oral Maxillofac Surg 1986;24:22–7.
Principles of Management of Mandibular Fractures 431
43. Harilainen A, Myllynen P, Anhla H, Seitsalo S. 60. Luyk NH, Ferguson JW. The diagnosis and ini- 79. Walker RV. Traumatic mandibular condyle
The significance of arthroscopy and exami- tial management of the fractured mandible. fracture dislocations. Am J Surg 1960;
nation under anesthesia in the diagnosis of Am J Emerg Med 1991;9:352–9. 100:850–63.
fresh injury haemarthrosis of the knee 61. Motamedi MH. An assessment of maxillofacial 80. Beekler DM, Walker RV. Condyle fractures.
joint. Injury 1988;19:21–4. fractures: a 5-year study of 237 patients. J Oral Surg 1969;27:563–4.
44. Fieldhouse J. Bilateral temporomandibular joint J Oral Maxillofac Surg 2003;61:61–4. 81. Boyne PJ. Osseous repair and mandibular
ankylosis with associated micrognathia: 62. Kreutziger KL, Kreutziger KL. Comprehensive growth after subcondylar fractures. J Oral
report of a case. Br J Oral Surg 1974;11:213–6. surgical management of mandibular frac- Surg 1967;225:300–9.
45. Guralnick WC, Kaban LB. Surgical treatment tures. Southern Med J 1992;85:506–18. 82. Smets LM, Van Damme PA, Stoelinga. Non-
of mandibular hypomobility. J Oral Surg 63. Walker RV, Bertz JE. Facial and extracranial surgical treatment of condylar fractures in
1976;34:343–8. head injuries. Care of the trauma patient. adults: a retrospective analysis. J Cran-
46. Hoaglund FT. Experimental hemarthrosis. Shires GT, editor. New York: McGraw-Hill iomaxillofac Surg 2003;31:162–7.
83. Glineburg RW, Laskin DM, Blankstein DL. The
J Bone Joint Surg 1967;49:285–98. Book Co; 1966. p 478.
effect of immobilization on the primate
47. Laskin DM. Role of the meniscus in the etiolo- 64. Huelke DF, Compton CP. Facial injuries in
temporomandibular joint: a histologic and
gy of posttraumatic temporomandibular automobile crashes. J Oral Maxillofac Surg
histochemical study. J Oral Maxillofac Surg
joint ankylosis. Int J Oral Surg 1978; 1983;41:241–4.
1982;40:3–8.
7:340–5. 65. Bernstein L. Practical points in the manage-
84. Juniper RP, Awty MD. The immobilization
48. Ellis E, Moos KF, EI-Attar A. Ten years of ment of mandibular fractures. Trans Am
period for fractures of the mandibular
mandibular fractures: An analysis of 2,137 Acad Opthalmol Otolaryngol 1970;74: body. J Oral Surg 1973;36:157–63.
cases. Oral Surg 1985;59:120–9. 1068–73. 85. Amaratunga NA. The relation of age to the
49. Leathers R, Le AD, Black E, McQuirter JL. Orofa- 66. May M, Tucker HM, Ogura IH. Closed man- immobilization period required for healing
cial injury in underserved minority popula- agement of mandibular fractures. Arch of mandibular fractures. J Oral Maxillofac
tions. Dent Clin North Am 2003;47:127–39. Otolaryngol 1972;95:53–7. Surg 1987;45:111–3.
50. Calloway DM, Anton MA, Jacobs JS Changing 67. Cook RM, MacFarlane WI. Subcondylar frac- 86. Walker RV. The consultant: condylar fractures.
concepts and controversies in the manage- ture of the mandible. Oral Surg Oral Med J Oral Surg 1966;24:367–9.
ment of mandibular fractures. Clin Plast Oral Pathol 1969;27:297–304. 87. Walker RV. Open reduction of condylar frac-
Surg 1992;19:59–69. 68. MacGregor AB, Fordyce GL. The treatment of tures of the mandible in conjunction with
51. Edwards TJ, David DJ, Simpson DA, Abott AA. fracture of the neck of the mandibular repair of discal injury: discussion. J Oral
Patterns of mandibular fractures in Ade- condyle. Br Dent J 1957;106:351. Maxillofac Surg 1988;46:262–3.
laide, South Australia. Aust N Z J Surg 69. Leake D, Doykos J, Habal M, et al. Long-term 88. Luyk NH. Principles of management of frac-
1994;64:307–11. follow-up of fractures of the mandibular tures of the mandible. In:. Peterson LJ,
52. Fridrich KL, Pena-Velaso G, Olson AJ. Chang- condyle in children. Plast Reconstr Surg Indresano AT, Marciani RD, Roser SM edi-
ing trends with mandibular fractures: A 1971;47:127–31. tors. Principles of oral and maxillofacial
review of 1067 cases. J Oral Maxillofac Surg 70. Lindahl L. Condylar fractures of the mandible. surgery. Philadelphia, PA: Lippincott-
1992;50:586–9. IV. Function of the masticatory system. Int Raven; 1992. p. 381–434.
53. Iizuka T, Lindqvist C. Rigid internal fixation of J Oral Surg 1977;6:195–203. 89. Messer EJ, Keller JJ. A rational approach to the
mandibular fractures: an analysis of 270 71. De Riu G, Gamba U, Anghioni M, Sessena E. A mandibular parasymphyseal fracture.
fractures using the AO/ASIF method. Int J comparison of open and closed treatment of J Oral Surg 1976;34:808–10.
Oral Maxillofac Surg 1992;21:65–9. condylar fractures: a change in philosophy. 90. Williams JG, Cawood JI. Effect of intermaxil-
54. Hagan EH, Huelke DR. An analysis of 319 case Int J Oral Maxillofac Surg 2001;30:384–9. lary fixation on pulmonary function. Int J
reports of mandibular fractures. J Oral Surg 72. MacLennan WD, Simpson W. Treatment of the Oral Maxillofac Surg 1990;19:76–8.
91. Wood GD. Assessment of function following
1961;19:93–104. fractured mandibular condylar process in
fracture of the mandible. Br Dent J
55. Van Hoof RF, Merkx CA, Stekenlenburg EC. children. Br J Plast Surg 1965;18:423–7.
1980;149:137–41.
The different pattern of fractures of the 73. Thomson HG, Farmer AW, Lindsay WK. Condy-
92. Brown AE, Obeid G. A simplified method for
facial skeleton in four European countries. lar neck fractures of the mandible in chil-
the internal fixation of fractures of the
Int J Oral Surg 1977;6:3–11. dren. Plast Reconstr Surg 1964;34:452–63.
mandibular condyle. Br J Oral Maxillofac
56. El-Degwi A, Mathog RH: Mandible fractures— 74. Russell D, Nosti JC, Reavis C. Treatment of
Surg 1984;22:145–50.
medical and economic considerations. Oto- fractures of the mandibular condyle. 93. Wennogle CF, Delo RI. A pin-in-groove tech-
laryngol Head Neck Surg 1993;108:213–9. J Trauma 1972;12:704–7. nique for reduction of displaced subcondy-
57. Olson RA, Fonseca RJ, Zeitler DL, Osborn DB. 75. Hotz RP. Functional jaw orthopedics in the lar fractures of the mandible. J Oral Max-
Fractures of the mandible: a review of 580 treatment of condylar fractures. Am J illofac Surg 1985;43:659–65.
cases. J Oral Surg 1982;40:23–8. Orthod 1978;73:365–77. 94. Kitayama S. A new method of intraoral open
58. Salem JE, Lilly G, Cutcher JL, Steiner M. Analy- 76. Rowe NL. Fractures of the jaws in children. reduction using a screw applied through
sis of 523 mandibular fractures. Oral Surg J Oral Surg 1969;27:497–507. the mandibular crest of condylar fractures.
1968;26:390–5. 77. Waite DE. Pediatric fractures of the jaw and J Craniomaxillofac Surg 1989;17:16–23.
59. Haug RH, Prather J, Indresano AT. An epi- facial bones. Pediatrics 1973;51:551–9. 95. Tanasen A, Lamberg MA. Transosseous wiring
demiologic survey of facial fractures and 78. Rakower W, Protzell A, Rosencrans M. Treat- in the treatment of condylar fractures of the
concomitant injuries. J Oral Maxillofac ment of displaced condylar fractures in mandible. J Oral Maxillofac Surg 1976;
Surg 1990;48:926–32. children. J Oral Surg 1961;19:517–21. 4:200–6.
432 Part 4: Maxillofacial Trauma
96. Zide MF, Kent JN. Indications for open reduc- 114. Ma S, Fang RH. Endoscopic mandibular angle 133. Neal DC, Wagner W, Alpert B. Morbidity asso-
tion of mandibular condyle fractures. J Oral surgery: a swine model. Ann Plast Surg ciated with teeth in the line of mandibular
Maxillofac Surg 1983;41:89–98. 1994;33:473–5. fractures. J Oral Surg 1978;36:859–62.
97. Raveh J, Vuillemin T, Ladrach K. Open reduc- 115. Jacobovicz J, Lee C, Trabulsy PP. Endoscopic 134. Kahnberg KE, Ridell A. Prognosis of teeth
tion of the dislocated fractured condylar repair of mandibular subcondylar frac- involved in the line of mandibular frac-
process: indications and surgical procedures. tures. Plast Reconstr Surg 1998;101:437–41. tures. Int J Oral Surg 1979;8:163–72.
J Oral Maxillofac Surg 1989;47:120–7. 116. Troulis MJ, Kaban LB. Endoscopic approach to 135. Schneider SS, Stern M. Teeth in the line of
98. Chuong R, Piper MA. Open reduction of the ramus/condyle unit: Clinical applica- mandibular fractures. J Oral Surg 1971;
condylar fractures of the mandible in con- tions. J Oral Maxillofac Surg 2001;59;503–9. 29:107–9.
junction with repair of discal injury: a pre- 117. Sandler NA. Endoscopic-assisted reduction 136. de Amaratunga NA. The effect of teeth in the
liminary report. J Oral Maxillofac Surg and fixation of a mandibular subcondylar line of mandibular fractures on healing. J
1988;46:257–63. fracture: report of a case. J Oral Maxillofac Oral Maxillofac Surg 1987;45:312–4.
99. Lund K. Unusual fracture dislocation of the Surg 2001;59:1479–82. 137. Shetty V, Freymiller E. Teeth in the line of frac-
mandibular condyle in a six year old girl. 118. Miloro M. Endoscopic-assisted repair of sub- ture: a review. J Oral Maxillofac Surg
Int J Oral Surg 1972;1:53–60. condylar fractures. Oral Surg Oral Med 1989;47:1303–6.
100. Henny FA. A technique for open reduction of Oral Pathol Oral Radiol Endod 2003; 138. Zallen RD, Curry IT. A study of antibiotic
fractures of the mandibular condyle. J Oral 96:387–91. usage in compound mandibular fractures. J
Surg 1951;9:233–5. 119. Fisher IT, Cleaton-Jones PE, Lownie JF. Relative Oral Surg 1975;33:431–4.
101. Zide MF. Open reduction of mandibular efficiencies of various wiring configurations 139. Chole RA, Yee J. Antibiotic prophylaxis for
condyle fractures: indications and tech- commonly used in open reductions of frac- facial fractures. Arch Otolaryngol Head
nique. Clin Plast Surg 1989;16:69–76. tures of the angle of the mandible. Oral Surg Neck Surg 1987;113:1055–7.
102. Hinds EC, Girotti WJ. Vertical subcondylar Oral Med Oral Pathol 1990;70:10–7. 140. Chuong R, Donoff RB, Guralnick WC. A retro-
osteotomy: a reappraisal. J Oral Surg 120. Johansson B, Krekmanov L, Thomsson spective analysis of 327 mandibular frac-
1967;24:164–70. M.0Miniplate osteosynthesis of infected tures. J Oral Maxillofac Surg 1983;41:305–9.
mandibular fractures. J Craniomaxillofac
103. Jeter TS, Vansickels JE, Nishioka GJ. Intraoral 141. Mathog RH, Rosenberg Z. Complications in
Surg 1988;16:22–7.
open reduction with rigid internal fixation the treatment of facial fractures. Otolaryn-
121. Woo SL, Lothringer KS, Akeson WH, et al. Less
of mandibular subcondylar fractures. J Oral gol Clin North Am 1976;9:533–52.
rigid internal fixation plates: historical per-
Maxillofac Surg 1988;1113–6. 142. Cannell H, Boyd R. The management of max-
spectives and new concepts. J Orthop Res
104. Ellis E, Reynolds ST, Park HS. A method to illofacial injuries in vagrant alcoholics. J
1984;1:431–49.
rigidly fix high condylar fractures. Oral Maxillofac Surg 1985;13:121–4.
122. Bradley JC. Age changes in the vascular supply
Surg Oral Med Oral Pathol 1989;68:369–74. 143. Beckers HL. Treatment of initially infected
of the mandible. Br Dent J 1972;132:142–4.
105. Boyne PJ. Free grafting of traumatically dis- mandibular fractures with bone plates. J
123. Marciani RD. Invasive management of the
placed or resected mandibular condyles. J Oral Surg 1979;37:310–3.
fractured atrophic edentulous mandible.
Oral Maxillofac Surg 1989;47:228–32. 144. Abiose BO. Maxillofacial skeleton injuries in
J Oral Maxillofac Surg 2001;59:792–5.
106. Mikkonen P, Lindqvist C, Pihakari A, et al. the western states of Nigeria. Br J Oral Max-
124. Amaratunga NA. A comparative study of the
Osteotomy-osteosynthesis in displaced illofac Surg 1986;24:31–9.
clinical aspects of edentulous and dentu-
condylar fractures. Int J Oral Maxillofac lous mandibular fractures. J Oral Maxillo- 145. Dodson TB, Perrott DH, Kaban LB, Gordon
Surg 1989;18:267–70. fac Surg 1988;46:3–5. NC. Fixation of mandibular fractures: a
107. Hooley JR. Reduction of mandibular fractures 125. Bruce RA, Strachan DS. Fractures of the eden- comparative analysis of rigid internal fixa-
by intraoral inferior border wiring. J Oral tulous mandible: the Chalmers J. Lyons tion and standard fixation technique. J Oral
Surg 1969;27:87–91. Academy study. J Oral Surg 1976;34:973–9. Maxillofac Surg 1990;48:362–6.
108. Paul JK. Intraoral open reduction. J Oral Surg 126. Amaratunga NA. Mandibular fractures in chil- 146. Tu HK, Tenhulzen D. Compression osteosynthe-
1968;26:516–22. dren-A study of clinical aspects, treatment sis of mandibular fractures: a retrospective
109. Rontal E, Meyerhoff W, Hohmann A. The needs and complications. J Oral Maxillofac study. J Oral Maxillofac Surg 1985;43:585–9.
transoral reduction of mandibular frac- Surg 1988;46:637–40. 147. Larsen OD, Nielsen A. Mandibular fractures. 1.
tures. Arch Otolaryngol 1973;97:279–82. 127. MacLennan WD, Simpson W. Treatment of An analysis of their etiology and location in
110. Sazima HJ, Grafft ML, Fulcher CL. Transoral fractured mandibular condylar processes in 286 patients. Scand J Plast Reconstr Surg
reduction of mandibular fractures. J Oral children. Br J Plast Surg 1965;18:423–7. 1976;10:213–8.
Surg 1971;29:247–54. 128. Krausen AS, Samuel M. Pediatric jaw fractures: 148. Proffit WR, Vig KW, Turvey TA. Early fracture
111. van Dijk L, Brons R, Bosker H. Treatment of indications for open reduction. Otolaryn- of the mandibular condyles: frequently an
mandibular fractures by means of stable gol Head Neck Surg 1979;87:318–22. unsuspected cause of growth disturbances.
internal wire fixation. Int J Oral Surg 129. Khosla M, Boren W. Mandibular fractures in Am J Orthod 1980;78:1–24.
1977;6:173–6. children and their management. J Oral Surg 149. Gilhuus-Moe O. Fractures of the mandibular
112. Freihofer HP Jr, Sailer HF. Experience with 1971;24:116–21. condyle in the growth period. Histologic
intraoral trans-osseous wiring mandibular 130. Walker DG. Facial development. Ann R Coll and autoradiographic observations in the
fractures. J Maxillofac Surg 1973;1:248–52. Surg Engl. 1957 Aug;21:90–118. contralateral, nontraumatized condyle.
113. Takenoshita Y, Oka M, Tashiro H. Surgical 131. Kruger GO. Textbook of oral surgery. 3rd ed. St Acta Odontol Scand 1971; 29:53–63
treatment of fractures of the mandibular Louis (MO): C.V. Mosby; 1968. 150. Durkin JF, Heeley J, Irving JT. The cartilage of
condylar neck. J Craniomaxillofac Surg 132. Clark HB. Practical oral surgery. 2nd ed. the mandibular condyle. Oral Sci Rev
1989;17:119–24. Philadelphia (PA): Lea & Febiger; 1959. 1973;2:29–99.
Principles of Management of Mandibular Fractures 433
151. Lund K. Mandibular growth and remodeling in relation to some deformities. Br Dent J tial facial paralysis secondary to mandibu-
process after condylar fracture. A longitudi- 1944;76:57–63. lar fracture. J Oral Surg 1970;28:854–6.
nal roentgencephalometric study. Acta 155. Rowe NL. Ankylosis of the temporo- 159. Schmidseder R, Scheunemann H. Nerve
Odontol Scand Suppl. 1974;32:113–117. mandibular joint. J R Col Surg Edinb injuries in fractures of the condylar neck.
152. Munro IR, Chen YR, Park BY. Simultaneous 1982;27:67–79. J Maxillofac Surg 1977;5:186–90.
total correction of temporomandibular 156. Topazian RG. Etiology of ankylosis of the tem- 160. Laws IM. Two unusual complications of
ankylosis and facial asymmetry. Plast poromandibular joint: analysis of 44 cases. fractured condyles. Br J Oral Surg 1967;
Reconstr Surg 1986;77:517–29. J Oral Surg 1964;22:227–33. 5:51–9.
153. Dufuormental ML. Fractures of the mandible 157. Markey RG. Condylar trauma and facial asym- 161. Martis C, Athanassiades S. Auriculotemporal
in the region of the joint. Br Dent J 1929; metry: an experimental study [thesis]. syndrome (Freye’s syndrome) secondary to
50:620–2. Seattle: University of Washington; 1974. fracture of the mandibular condyle. Plast
154. Roushton MA. Growth of mandibular condyle 158. Kennedy JW, Kent JN. False aneurysm and par- Reconstr Surg 1969;44:603–4.