Maxillofacial Trauma

Mandibular Fractures

Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages with two nutrient arteries
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Mandible in trauma
Mandibular fracture is more common than middle third fracture (anatomical factor)

It could be observed either alone or in combination with other facial fractures
Minor mandibular fracture may be associated with head injury owing to the cranio-mandibular articulation Mandibular fracture may compromise the patency of the airway in particular with loss of consciousness Fracture of mandible occurred with frontal impact force as low as 425 lb (190 Kg) {Condylar fracture}
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Fracture of condyle regarded as a safety mechanism to the patient
Frontal force of 800-900 lb (350-400 Kg) is required to cause symphesial fracture Mandible was more sensitive to lateral impact than frontal one Frontal impact is substantially cushioned by opening and retrusion of the jaw (Nahum 1975) Long canine tooth and partially erupted wisdoms represent line of relatively weakness
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Anatomical considerations
Attached muscles: Masseter Temporalis Medial and lateral pterygoid Mylohyoid Geniohyoid and genioglosus anterior belly of digastrics
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Blood supply
Endosteal supply via the ID artery and vein Periosteal supply, important in aging due to diminishes and disappearance of alveolar artery
Bradley 1972

Nerve
Damage of inferior dental nerve Facial palsy by direct trauma to ramus Damage of facial nerve in temporal bone fracture
Goin 1980

Damage to mandibular division of facial nerve
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Factors influenced site of fracture and displacement
Anatomy of the mandible and attached muscle (canine & wisdoms)

Weakening areas of mandible (resorption and pathologyl) Direction of force of the blow
Age of the patient
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Types of fracture
Simple
Greenstick fracture (rare, exclusively in children) Fracture with no displacement (Linear) Fracture with minimal displacement

Displaced fracture

Comminuted fracture
Extensive breakage with possible bone and soft tissue loss

Compound fracture
Severe and tooth bearing area fractures

Pathological fracture
(osteomyelities, neoplasm and generalized skeletal disease)
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Sites of fractures
Condyle fracture
– Intracapsular fracture – Extracapsular fracture
High condyle neck fracture Low condylar fracture

Angle/ ramus fracture (body fracture) Canine region (parasymphesial fracture) Midline fracture (symphesis fracture) Coronoid fracture (rare)

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Incidence of mandibular fractures
Body fractures 33.6% Subcondylar fracture 33.4% Fractures at the angle 17.4% Alveolar fractures 6.7% Ramus fractures 5.4% Midline fractures 2.9% Fracture of coronoid process 1.3%
Oikarinen & Malmstrom 1969
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Favourable or unfavourable
They can be vertically or horizontally in direction They are influenced by the medial pterygoidmasseter “sling”
If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled lingually If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled lingually

Favourable fracture line makes the reduced fragment easier to stabilize
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Effects of muscles on displacement
Transverse midline fracture (symphesial) stabilizes by the action of mylohyoid and geniohyoid Oblique fracture (parasymphesial) tends to overlap under the influence of muscles action Bilateral parasymphesial fracture results in backward displacement associated with loss of tongue control when the level of consciousness is depressed
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Condylar fractures
The most common mandibular fracture
Unilateral or bilateral Intracapsular or extracapsular

Antero-medial displacement is common but it may remain angulated with the ramus Dislocation of the glenoid fossa and fracture of petrous temporal bone which is very rare
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Condylar fractures

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

Sequlae of TMJ injury
Artheritic changes

Haemartherosis, fibrosis and aknylosis
Meniscal damage and detachment

TMD
Staph infection with condylar backward displacement and external auditory meatus injury Meningitis with petrous temporal bone fracture and intracranial involvement
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Coronoid process fracture:
Rare fracture caused by direct trauma to ramus and results from reflux contraction of temporalis Can be seen following operation of large ramus cyst Elicit tenderness over the anterior part of ramus Development of tell-tale haematoma
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Fracture of the ramus:
Type I Single fracture Mimics low condylar fracture that runs below the sigmoid notch

Type II comminuted fracture Common in missile injuries and appears to be with little displacement due to effects of messeter and medial pterygoid muscles
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Fracture of the angle and body
Pain, tenderness and trismus Extra-oral swelling at the angle with obvious deformity Step deformity behind the molar teeth Movement and crepitus at the fracture site Derangement of occlussion Intra-oral buccal and lingula heamatoma

Involvement of IDN
Gingival tear if fracture in dentated area Tooth involvement and possible longitudinal split fracture

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Midline fracture
The most common missed fracture (always fine crack)

Can be symphesial or parasymphesial fracture
Commonly associated with one or both condyles fracture Unilateral fracture leads to over-riding of the fragments and bilateral may contribute in loss of voluntery tongue control Long canine tooth represent a weak area and contributes to parasymphesial fracture Rarely runs across mental foramen
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Midline fracture

Signs and symptoms
Pain and tenderness Swelling and odemea Development of step deformity Mental anesthesia Heamatoma in the floor of mouth and buccal mucosa Soft tissue injury of the chin and lower lip

If associated with condylar fractures
Absence of condyle movement on the contrlateral side Deviation of mandible Anterior open bite Gagging of oclussion Limitation of mouth opening
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Clinical assessment and diagnosis
History of trauma
(traumatized patients with possible head injury) and facial injuries

Clinical Examination
▶ Extroral
Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut wounds) Palpation for eliction of tenderness, pain, step deformity and malfunction

▶ Intra- and paraoral bleeding, heamatoma, gingival tear, gagging of occlussion and step deformity and sensory and motor deficiency

Radiographs
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Radiographs
Plain radiograph
OPG Lateral oblique PA mandible AP mandible (reverse Townes) Lower occlusal

CT scan 3-D CT imaging MRI
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Principles of treatment
similar to elsewhere fractures in the body
Reduction of fragments in good position Immobilization until bony union occurs

These are achieved by:
Close reduction and immobilization Open reduction and rigid fixation

Other objective of mandible fracture treatment:
Control of bleeding Control of infection
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Definitive treatment
Soft tissue repair
Debridment Irrigation with saline and antibiotics Closure in layers Dressing

Reduction and fixation of the jaw
▶ Close reduction and IMF (traditional method by means of manipulation) ▶ Open reduction and semi-rigid fixation (using inter-ossous wirings) ▶ Open reduction and rigid fixation (using bone palates osteosynthesis)

Objective:
Restoration of functional alignment of the bone fragments in anatomically precise position utilizing the present teeth for guidance
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Close reduction
Arch bars
– Jelenko – Erich pattern – German silver notched

Cap splints

▶ IMF prior to rigid fixation ▶ For the purpose of close
reduction
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Close reduction
Bonded brackets IMF screws Dental wiring:
Direct wiring Eyelet wiring Local anesthesia or sedation

Minimal displacement IMF for 6 weeks
Treatment can be performed under GA or LA and when surgery is contraindicated
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Fracture mandible in children
Close reduction Open reduction and fixation Plating at the inferior border Resorpable plates

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Gunning’s splint
Old modality Edentulous patient Rigid fixation is not possible To establish the occlusion

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Open reduction and fixation
Intraoral approach

Extraoral approach ▶ Submandibular approach

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Rigid fixation
Intraossous wiring Plates and screws Kirchener wire Lag screws

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Reconstruction palate
Severe trauma Loss of part of the bone

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Condylar fractures
Intraoral approach Ramus incision Extraoral approach
Preauricular approach Retromandibular approach

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IMF
Transosseous wiring Circumferential wiring

External pin fixation
Bone clamps Trans-fixation with Kirschner wires
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Osteosynthesis
Non-compression small plates Compression plates

Miniplates
Lag screws Resorbable plates and screws
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Teeth in the fracture line
The fracture is compound into the mouth The tooth may be damaged or lose its blood supply The tooth may be affected by some preexisting pathology

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Management of teeth retained in fracture line
Good quality intra-oral periapical radiograph Insinuation of appropriate systemic antibiotic therapy Splinting of tooth if mobile Endodontic therapy if pulp is exposed Immediate extraction if fracture becomes infected Follow up for 1 year and endodontic therapy if there is a loss of vitality
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Absolute indications
Longitudinal fracture Dislocation or subluxation from socket Presence of periapical infection Infected fracture line Acute pericoronitis

Relative indications
Functional tooth that would be removed Advanced caries or periodontal diseases Doubtful tooth which would be added to existing denture Tooth in untreated fracture presenting more than 3 days after injury
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