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MANAGEMENT OF MANDIBULAR FRACTURES

Ghiffar Oka Prihardian

18700062

FAKULTAS KEDOKTERAN
UNIVERSITAS WIJAYA KUSUMA SURABAYA
TH. 2022 / 2023

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I. INTRODUCTION
Facial trauma often involves face-shaping bones, including mandibles. The
fracture of the mandible ranks second from the fracture of the facial area, since it is a
protruding bone located at the edge and its position in the lower third of the face so
that it is often subjected to forced ruda. Besides that, it is a place of attachment of the
masticatory muscles so that they have an active movement. 1 Diagnosis of mandibular
fracture can be indicated by the presence of pain, swelling, tenderness, maloclusion,
tooth fracture, the presence of gaps, unevenness of the teeth, asymmetrical arcus
dentalis, the presence of intra-oral lacerations, loose teeth and crepitation. 1,2,3
In particular the treatment of mandibular fractures and maxillofacial bones began
to be introduced by Hipocrates in 460-375 BC using occlusion guidance or the ideal
relationship between the lower teeth and the maxillary teeth as a rationale and
diagnosis of mandibular fractures. 1,2,4
The purpose of mandibular fracture
management is to obtain anatomreduction i from the fracture line, regain occlusion
before injury, immobilize the mandible in a certain period for healing, maintain
adequate nutrition, prevent infection, malunion and nonunion. Management of a
technique often used is wheezingwith arch bars and elastic bands for intermaxillary
fixation for stable fractures. It can also be used with a combination of open reduction
and interosseus wire or plate that is rigid in unstable or unfavorable fractures. 2,3,4

Pada subsequent development by clinicians using occlusion as a basic concept of


handling mandibular fractures and maxillofacial bones especially in their diagnostics
and management. In principle there are two ways of management

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mandibular fracture is a closed method or also called conservative treatment and an
open way that is taken surgically. On a closed technique immobilization and fracture
reduction can be achieved with maxillomandibular fixation apparatus. In open
proceedings,the fractured part is surgically opened and the fracture segment is
reduced and fixed directly using a wire or plate called wire or plate osteosynthesis.
These two techniques are not always performedalone but are sometimes applied
together or called a combination procedure. In the management of mandibular
fractures, dental and orthopedic principles are always observed so that the area
experiencing the fracture will return to or approach the actual anatomical contents
post and good mastication function. 3.4 pm

I. BIBLIOGRAPHY REVIEW
2.1 Anatomy of the mandibles
The mandible is the largest and most powerful bone in the facial area. It is
formed by two symmetrical bones that hold fusion within the first year of life. This
bone consists of a corpus, which is an arch of a horseshoe and a pair of flat and wide
ramus pointingupwards at the back of the corpus. At the end of each ramus two
protrusions are obtained called processus condiloideus processus koronoideus. The
condyloideus processus consists of kaput and column. The outer surface of the
mandibular co-rpus on the median line is a fine bone protrusion called the mentum
symphysis which is the embryological meeting place of the two bones. 3
The mandibular corpus part forms a protrusion called the alveolaris processus
which has 16 holes for the tooth holder. The lower part of the mandibular corpus has
curved and smooth edges. In the middle of the mandibular corpus approximately 1 cm
from the symphysis is obtained the mentalist foramen passed by the vasa and nervus
mentalis. The inner surface of the mandibular corpus is concave and obtained linea
milohioidea which is a milohioid musculus origo. Angulus mandible

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is the confluence between the back edge of the mandibular ramus and the lower edge
of the mandibular corpus. The mandibular angulus is located subcutaneously and is
easily palpable on 2-3 fingers under the auricular lobule. Overall this mandibular
bone is in the form of a horseshoe widening behind, pinning and rising on the right
and left ramus so that it forms a pillar, the ramus forming a 120⁰ angle to thecorpus
in adults. In the younger ones the angle is greater and the ramus appears more
divergent. 3.4 pm
From the aspect of its function, it is a combination of L-shaped bones working to
chew with the strongest part in the temporalis musculus that inserts on the medial side
at the end of the choronoideus process and the maseter musculus which inserts on the
lateral side of the angulus and the mandibular ramus. The medial pterigoideus
musculus inserts on the lower medial side of the ramus and angulus mandible. The
musculus maseter together with the musk ulustemporalis is the power to move the
mandibles in the process of closing the mouth. The lateral pterigoideus musculus
inserts on the front of the capsule of the temporo-mandibular joint, the articular disc
plays a role in opening the mandible. The function of the pte rigoid musculusis of
great importance in the healing process in intracapsular fractures. 3.4 pm
The mandible gets nutrients from the inferior alveolaris artery which is the first
branch of the maxillary artery that enters through the mandibular foramen along with
the veins and the inferior laris alveo nervusruns in the alveolary canal. The inferior
alveolaris artery nourishes the lower teeth as well as the surrounding gums, then in
the foramen mentalis comes out as the mentalist artery. Before exiting the foramen
the mentalist branched off towards the vus incisionand walked anterior forward inside
the bone. The mentalist artery beranastomosis with the fascial artery, the submentalis
artery and the inferior labii artery. The submentalis artery and the inferior labii artery
are branches of the fascial artery. The menta lysis arterynourishes the chin. Reverse
blood flow from the mandible through the inferior alveolaris vein to the posterior
fascoral vein. The chin region drains blood to the submentalist vein, which further
drains the blood to the vein

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anterior fascialist. Theanterior fascial v ena and the posterior fascist vein merge into
the communist fascist vein that drains blood to the internal jugular vein. 3

Figure 1. Anatomy of the mandibles3

2.2. Epidemiology of mandibular fractures


Fractures in the midface often occur as a result of motor vehicle
accidents, falls, violence and other blunt force trauma. Based on a study
conducted by Rowe da Killey in 1995, the ratio between mandibular and
maxillary fractures exceeds 4:1. 5
From the retrospective research data of Sunarto Reksoprawiro in 2001-
2005 in patients treated at SMF Surgical Sciences RSU DR. Soetomo,
Surabaya showed that patients with maxillofacial fractures due to traffic
accidents in motorcyclists were more commonlyfound in men of productive
age, namely the age of 21-30 years, around 64.38%. The incidence of
mandibular and maxillary fractures ranks highest at 29.85%, followed by
Zigoma fractures at 27.64% and nasal fractures at 12.66%. Meanwhile,
according to the results of research by Ajike et al, it was found that
maxillofacial fractures due to traffic accidents in cyclists

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motors are more commonly found in males than females with a ratio of 3.7:1.
The most incidence ismandibular fracture by 75%, fracture of the middle third
of the face by 25% and maxillofacial combination fracture by 12%. 5

2.2. Mandular Biomechanics


The mandible has a lot of mobility and force, so in handling mandibular
fractures, you must really pay attention to the biomechanics that occur. The
mandibular movement is influenced by four pairs of musculus called
themuscles of the h musculus namely: the maceteral musculus, temporalis,
pterigoideus lateralis and medialis. 3
At the time of opening the mouth, what contracts is the inferior part of the
pterigoideus pterigoideus lateralis, followed by the superior part of the
pterigoideus lateralis musculus when opening the mouthlebi h wide.
Meanwhile, those that play a role in closing the mouth are the temporalis
musculus and the maseter is strengthened again by the pterigoideus medialis
musculus. 3.4 pm

2.3. Mandibular fracture


Fracture is defined as a linear deformity or the occurrence of bone
discontinuities caused by forced ruda. Fractures can occur as a result of
trauma or due to pathological processes. A mandibular fracture is a break in
the continuity of the mandibular bone. 3,4,6
The mandible is a strong bone, but
in some places there is a weak part of it. The area of the mandibular corpus
consists mainly of dense cortical bones with a small amount of spongiosa
substance as a place of passage of blood vessels and lymph vessels. The thin
areas of the mandible are the angulus and subcondyle so this part belongs to
the weak part of the mandible. In addition, weak points are also found in the
mental foramen, mandibular angulus where the molar teeth III especially the
eruption are few, the condyle colum

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mandibles especially when the trauma from the front of the langsung hits the
chin then the force will be passed towards the back. 3.4 pm
Fracture lines in the mandibles are common in weak areas of the
mandibles depending on the mechanism of the trauma that occurs. The
subcondilar fracture line is generally below the neck of the condyloideus
processusakib at fight and is almost vertical in shape. However, in traffic
accidents, the fracture line occurs close to the kaput condilus, the fracture line
that occurs is oblic. 7 In the angulus region the fracture line is generally below
or behind the iii molar region towards the mandibular angulus. In fractures of
the corpus mandibles the fracture line is not always parallel to the axis of the
tooth, often the fracture line is oblic. The fracture line begins in the alveolar
region of the canine and the incisor runs oblic towards the midline. 7.8
In a
mandibular fracture, the fractured fragment is displaced due to the pull of the
mastication muscles, therefore the reduction and fixation in the mandibular
fracture must use splinting to counteract the pull of the mastication muscles.
Some of the factors thataffect the displacement of mandibular fractures
include: the direction and strength of the trauma, the direction and angle of the
fracture line, the presence or absence of teeth in the fragments, the direction of
muscle detachment and the extent of soft tissue damage. In the area of ramus
mandibles rarely occurs fraktur, because this area is fixed by the musculus
maseter on the lateral and medial parts by the musculus pterigoideus medialis.
Likewise in the chonoideus processus fixed by the macetic musculus. 3,7,8
Several kinds of classification of mandibular fractures can be classified
by:
1. Incidence of mandibular fractures according to their anatomical location;
condyloideous processus (29.1%), mandibular angulus (24%), mandibular
symphysis (22%), mandibular corpus (16%), alveolus (3.1%), ramus
(1.7%), koronoideus processus (1.3%). 4

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Fig.2 Mandibular region and mandibular fracture frequency based on
region4

2. Based on the presence or absence of teeth on the left and right fracture
lines; class I: teeth are on both parts of the fracture line, k elas II: teeth are
only present on one part of the fracture line, class III: there are no teeth on
both fragments, perhaps the previous tooth is already absent (edentulous)
or the tooth is lost when trauma occurs. 3.4 pm

Figure 3. The relationship of the presence or absence of teeth


in the fracture garis 3

3. Based on the direction of the fracture and the ease of repositioning are
distinguished:

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horizontal and vertical are divided into favourable and unfavourable. The
favourable and unfavourable criteria are based on the direction of one
fracture line against the musculus force acting on the fragment. It is called
favourable when the direction of the fragment makes it easier to reduce
bone repositioning time, while unfavourable when the fracture line makes
it difficult to reposition. 3.7

A B

C D
Figure 4. A. Horizontal favourable fracture, B. Horizontal unfavourable
fracture, C. Vertical favourable fracture, D. Vertical unfavourable fracture3

4. Based on the severity of the fracture degree, it is divided into simple or


closed fractures, that is, there is no connection with the outside world and
there are no discontinuities of the tissue around the fracture. Compound
or open fracture

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i.e. an outside-related fracture involving the skin, mucosa or periodontal
membrane.
5. Based on the type of fracture is divided into greenstick or incomplete
fracture; an imperfect fracture where on one side of the bone has a
fracture while on the other side the bone is still bound. Greenstick
fractures are usually obtained in children due to thick periosteum. Single
fracture; fracture on only one tempat only. Multiple fractures; Fractures
that occur in two or more places, generally bilateral. Comminuted
fracture; There are small fragments that can be simple or compound
fractures. In addition there are also pathological fractures; fractures that
occur as a result of the process of metastasis to the bone, impacted
fractures; fracture with one of the fracture fragments inside the other
fracture fragment. Atrophic fracture; is a spontaneous fracture that occurs
in an atrophic bone as in a toothless jaw. Indirect fracture; fractures that
occur far from the site of the trauma. 3,4,7

Figure 5. Mandibular fracture type. A. Greenstick B. Simple


C. Comminuted D. Compound5

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2.4. Biomechanics of Mandibular Fracture

The concept of biomechanics in mandibular fracture treatment needs to be


understood because static and dynamic states can affect the fracture healing
process. The goal of all fracture therapy is to restore shape and function as it
was. This can be achieved by immobilizing using internal and external
fixation. 3,4,8
The lower jaw has a unique anatomical shape, based on bone architecture,
the shape and attachment of the mandibular muscles can be described as a
structure that converts the pressure it receives into a form of tension and
compression. Compression forces are generated along the basal region of the
mandible, while tension forces are present along the alveolar region. The
imaginary tranversal axis located approximately along the length of the
mandibular canal separates the alveolaris process which is a stress region or
called the tension area from the mandibular basal region which is a
compression area or called a compression area. When the mandible has a
fracture, the principle of treatment is carried out taking into account the forces
on the sides of the imaginary axis, so that the two opposing voltage forces
must be neutralized to obtaina stable reduction. 4,8,9

2.4. Etiology of mandibular fractures


A hard impact on the face can cause a fracture of the mandible. The
tolerance of the mandible to impact is higher than that of the other bones of
the face. Mandibular fractures are more common than other facial bone
fractures because ofthe protruding shape of the mand ibula making it sensitive
to impact. In general, mandibular fractures are caused by direct trauma. 1,3,10
Mandibular fractures can be caused by trauma as well as pathological
processes. According to Kruger, 69% of mandibular fractures are causedby

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physical hardness, 27% accidents, 2% due to exercise and 4% pathological
factors, while pathological fractures can be caused by cysts, bone tumors,
osteogenesis imperfectta, osteomyelitis, osteoporosis, atrophy or bone
necrosis. 7.11

2.5. Diagnosis of mandibular fracture


In establishing the diagnosis of mandibular fracture includes anamnesis, if
it is a trauma case, it must be known about the mechanism of the trauma or
the mode of injury, physical examination and supporting examination. 3,4,7
In the case of trauma, the examination of patients with suspicion of
mandibular fracture must follow the rules of ATLS (Advandce Trauma Live
Suport), which consists of an initial examination or primary survey that
coversthe examination of airway, breathing, circulation and disability. In
patients with trauma with mandibular fractures, it should be noted that there is
a possibility of airway obstruction that can be caused by the mandibular
fracture itself or due to intraoral bleeding that causes blood aspiration. 4
After a primary survey is carried out and the patient's condition is stable,
it can be continued with a secondary survey examination including: 1.
Anamnesis, in anamnesis subjective complaints related to mandibular
fractures are suspected of the presence of pain, abnormal occlusion swelling,
numbness of the mentalist nerve distribution, swelling, bruising, bleeding
from the tooth socket, fractured teeth tours or dates, trismus, chewing
incompetence. In addition, complaints are usually accompanied by a history
of trauma such as traffic accidents, violence, falls, sports accidents or a
history of pathological diseases.
2. Clinical examination includes; A.clinical assessment of patients in general:
in general maxillofacial trauma can be known its presence in

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initial examination or primary survey or secondary examination or
secondary survey. 4
Examination of the airways is importantbecause trauma can cause airway
disorders. Blockage can be caused by the tongue falling back towards the
back, it can also be due to the closure of the airways due to the presence of
mucus, blood, vomit and foreign bodies. B. examiner n local fracture of the
mandible, between; a. extraoral clinical examination, appearing above the
place where the fracture occurs, usually ecimosis and swelling. There are also
frequent soft tissue lacerations and there can be clearly visible deformations of
the mandibular contours that arereinforced. In the event of a displacement of
the premises from the fragments the patient can not close the anterior tingle
and the mouth hangs sagging and open. Patients are often seen supporting the
lower jaw by hand. It is also possible that saliva mixed with blood drips from
the corners of the patient's mouth. Gentle palpation with the fingertips is
performed against the condyle area on both sides, then passed along the lower
border of the mandible. Softened parts should be found in the fracture areas,
as well as changes in bone contours and crepitations. b. intraoral clinical
examination, any fragments of a broken tooth must be removed from the
mouth. The buccal sulcus is examined for the presence of ecimosis and then
the lingual sulcus. Hematomas in the lingual sulcus due to the trauma of the
lower jaw are almost always pathognomonic mandibular fractures. 4.7
3.
Supporting checks; In the fracture of the mandible, supporting examinations
can be carried out, including; 1. X-ray photo to find out the pattern of
fractures that occur. Each radiological examination is expected to produce
image quality that covers the observed area i.e. the pathological region along
with the surrounding normal area. 2. Eisler's photo, this photo was made for
the imaging of the mandibles of the ramus and corpus, made right or left side
as needed. 3. Town's view ; made to see projections of maxilla, zygoma and
mandibular bones. 4. Reverse Town′s view;

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It is done to see the presence of fractures of the neck condilus mandible,
especially those displaced to the medial and can also be to see the lateral
walls of the maxilla. 5. Panoramic Photo; also called pantomography or
rotational radiography is made to determine the condition of the mandibles
ranging from the right condyle to the left condyle and its tickling position
includingocclusion of the maxillary teeth. The advantages of panoramic are;
wide anatomical coverage, low radiation dose, quite convenient examination,
can be done in people with trismus. The disadvantage cannot show a clear
anatomical picture of the periapical daerah as intraoral photographs produce.
6. Temporomandibular Joint; in patients with direct trauma to the chin area,
the condition on the chin is often good, but there is a fracture in the
mandibular condyle area so that the patient complains of TMJ area pain when
opening the mouth, trismus sometimes a little malocclusion. In making
standard TMJ photos, there is usually an open mouth lateral projection or
Parma and a regular or Schuller shut-up lateral projection. 7.Orbitocondylar
view; performed to see the TMJ at the time of opening the mouth wide,
indicating the condition of the structure and contours of the condyle kaput
visible from the front. 8.CT Scan; This examination carried out in emergency
cases is still not a standard examination. CT Scan is mainly for very complex
maxillofacial fractures . 8.10

Figure 4. CT Scan of coronal fracture


bilateral condylar 8

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2.6. Management of mandibular fractures
The principles of handling mandibular fractures in the initial step are
emergency such as airway or airway, breathing or breathing, blood
circulation including shock or circulation management, soft tissue wound
management and temporary immobilization as well asan evaluation of
possible brain injury. The second stage is the definitive handling of fractures.
The management of mandibular fractures is generally divided into two
methods, namely closed and open repositioning. In closed or conservative
repositioning , reduction fraktur and immobilization of the mandibles is
achieved by placing maxillomandibular fixation apparatus. Open
repositioning of the fractured part is opened surgically, the segment is reduced
and fixed directly by means of a wire or plate called wire or plate
osteosynthesis. Open and closed techniques are not always performed
separately, but sometimes combined. The third approach is a modification of
the open technique that is the external skeletal fixation method. In the
management of mandibular fractures, dental and orthopedic principles are
always observed so that the fractured area will return or approach the actual
anatomical position and good mastication function. 3,4,7
Closed reduction of lower jaw fractures is conservative treatment by
repositioning without direct surgery on the fracture line and immobilizing
with interdental wiring or external pin fixation. Indications for closed
reduction include: a. fracture of the if unit as long as the periosteum is intact
so that bone recovery can be expected, b. fracture with heavy soft tissue
damage where soft tissue reconstruction can be used rotation flap and free flap
if the wound is not too large. c. Edentulous mandible, d. fracture in children,
e. condylus fracture. The technique used in mandibular fracture therapy in
closed reduction is intermaxillary fixation. This fixation is maintained 3-4
weeks at fractures of the condylus region and 4-6 weeks on a

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other areas of the mandible. The advantages of closed repositioning are that it
is more efficient, the complication rate is lower and the operation time is
shorter. This technique can be done at the polyclinical level. The
disadvantages include prolonged fixation, nutrcontents, the risk of TMJ
ankylosis or temporomandibular joints and airway problems. 4,9,12
Some
intermaxillary fixation techniques include; a. eyelet or ivy loop technique, the
placement of ivy loops using a 24-gauge wire between two stable teeth by
usingn smaller wires to provide maxillomandibular fixation (MMF) between
ivy loops. The advantage of this technique, the material is easy to obtain and
slightly inflicts less damage to periodontal tissue and the jaw can be opened
by simply lifting the best-selling intermaxis bond. Disadvantages of easily
broken wire time used for intermaxillary fixation,9,11

Picture. Eyelet or ivy loop9 technique

b. arch bar technique, the indication of arch bar installation is that the teeth
are lacking or insufficient for the installation of other means, accompanied by
a maxillary fracture and obtained dentoalveolar fragments at one end of the
jaw that need to be reduced according to the curvature of the jaw before
installing the intermaxillary fixation. Theuse of arch bars is easy to get, low
cost, easy to adapt and application. The disadvantage is that it causes
inflammation of the ginggiva and periodontal tissue, it cannot be used in
patients with extensive edentulous. 9.11

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Picture. Maxillomandibular fixation9

Open repositioning (open reduction); surgical procedure to correct


malocclusion deformities that occur in lower jaw fractures by fixing directly
using wire (wire osteosynthesis) or plate (osteosynthesis plate). Indications for
open repositioning: a. Displaced unfavourable fracture through the angulus,
b. Displaced unfavourable fractures of the corpus or parasymphysis, c.
multiple fractures of the facial bones, d. midface fractures accompanied by
displaced bilateral condylus fractures. Open reduction surgery technique is a
type of contamination clean operation, requiring general anesthesia. The
advantages of open reduction include: early mobilization and better
reaproximation of bone fragments. The disadvantage is that it costs more and
an operating room and anesthesia are required for its
action. 4,8,9

Picture. Open reduction operation technique3

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Follow-up after surgery is to give analgetics as well as give broad-
spectrum antibiotics to open fracture patients and evaluated nutritional needs,
monitor intermaxilla fixation for 4-6 weeks. Tighten the cable every 2
minggu. Once the wire is opened, evaluate it with a panoramic photo to make
sure the fracture has been unfolded. 9.12

2.7. Complications
Complications after repairs to mandibular fractures are generally rare.
The most common complication that occurs in mandibula fractures is
infection or osteomyelitis which can later lead to various other complications.
The mandibular bone is the area that most often experiences fracture healing
disorders, be it malunion or nonunion. Complaints can be in the form of
prolonged pain and discomfort in the jaw joint or temporo mandibular joint
due to changes in position and instability between the left and right jaw joints.
This not only impacts the joints but the masticatory musclesand muscles
around the face can also provide a pain response. 9.10
There are several risk factors that are specifically related to mandibular
fractures and have the potential to cause malunion or nonunion. The biggest
risk factors are infection, then poor position, lack of immobilization of the
fracture segment, thepresence of foreign bodies, unfavorable muscle pull in
the fracture segment. Severe malunion in the mandibles will result in
asymmetrical facial and may also be accompanied by impaired function.
These abnormalities can be corrected by performing precise osteotomy
planning to reconstruct the shape of the mandibular arch. 9

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2.8. Care after fixation or immobilization
After carrying out the treatment of mandibular fractures by repositioning,
fixation and immobilization are continued with the treatment; general health
maintenance includes; a. administration of antibiotics, analgetics, roborantia
and nutritious food, b. organizing hygiene mouth, c. maintenance of fization
tools,
d. organizing physiotherapy. 4,9,11
The follow-up after surgery is to give analgetics as well as give broad-
spectrum antibiotics to open fracture patients and evaluate the needs of the
nurisi, monitor intermaxilla fixation for 4-6 weeks. Tighten the cable every 2
weeks. Once the wire is opened, evaluate it with a panoramic photo to make
sure the fracture has been unfolded. 4,8,9

II. DISCUSSION
The mandible is a part of the facial bone that is often injured due to its
protruding position and easy to receive impact, thus allowing the mandibular
fracture to rank second in the fracture of the facial area. Trauma that occurs in
the mandibles causes fractures that can interfere with the function of the
chewer. The main causes of mandibular fractures are traffic accidents and
violence. According to Kruger, 69% of mandibular fractures are caused by
physical violence, 27% accidents, 2% due to exercise and 4% pathological
factors, while pathological fractures can be caused oleh cysts, bone tumors,
osteogenesis imperfectta, osteomyelitis, osteoporosis, atrophy or bone
necrosis.
Since mandibular fractures are common, early diagnosis is essential to
establish the appropriate type of treatment. X-ray examination of mandibular
fractures is very helpful to support clinical diagnosis. The results of the
examination will provide clues regarding the localization, type and extent of
the fracture. Thus it will make it easier to establish the type of its treatment.

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The first treatment of a mandibular fracture is the treatment of
concomitant complications. Treatment is aimed at shock, respiratory
obstruction, bleeding, damage to soft tissues and neurological abnormalities.
Treatment against complications accompanying mandibular fractures is
classified in emergency care, which include; maintains respiration function
and circulatory function.

III. CONCLUSION
The fracture of the mandible ranks second in the facial area due to its
prominent position and is located in thelower third of the face. The purpose of
mandibular fracture treatment is primarily to restore chewing and speech
functions. This can be achieved by the selection of the right modality, the
correct surgical techniques especially in the achievement of mandibular
occlusion, serta treatment after surgery and rehabilitation. In the management
of mandibular fractures, it is necessary to understand the biomechanics of the
mandibles so that the correct fixation location can be estimated and
satisfactory results are obtained .

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