Mandible Fractures

Nelligan
Dental wiring and fixation techniques
•
Mandible Fractures
• Fractures of the jaws invariably produce malocclusion. Knowledge of
the dentition is thus an absolute prerequisite for the proper
treatment of jaw fractures. Restoration of the occlusion usually
indicates anatomic reduction and proper positioning of the jaws and
facial bones.
• Mandibular fractures are classified according to location for
treatment, presence of compound injury through the skin or mucosa,
and anatomical fracture pattern.
Clinical Examination
• Pain and tenderness
• Fractures occurring along the course of the inferior alveolar may
produce numbness in the distribution of the nerve , ipsilateral lower
lip (mental nerve) and ipsilateral teeth.
• Foul-smelling odor (fetor oris),
• Trismus
• Excessive saliva (drooling).
• Small gingival or mucosal lacerations between teeth indicate the
possibility of a fracture.
Diagnosis
• Inspection : Swelling, hematoma, ecchymosis, intraoral laceration, deviation
• Palpation :
One hand should stabilize the ramus, while the other manipulates the
symphysis or the body area (Bimanual manipulation)
The mandible may be pulled forward with one hand while the other hand is
placed one finger in the ear canal and one finger over the condylar process
Tenderness/pain
• Function : Malocclusion.
Direction and angulation of the fracture line
• Kelsey Frye and colleagues described fractures as “favorable” or “unfavorable”
Directed downward and forward as the posterior group of muscles and the
anterior group of muscles pull in antagonistic directions, favoring stability at
the fracture site : horizontally favorable (HF)
From above, downward, and posteriorly : horizontally unfavorable (HU).
From posteriorly forward and medially, displacement would take place in a
medial direction because of the medial pull of the elevator muscles of
mastication : vertically unfavorable (VU).
From the lateral surface of the mandible posteriorly and medially as the
muscle-pull tends to prevent displacement : vertically favorable fracture (VF).
General principles of reduction and fixation
• Superior and inferior border stabilization
• Fixation involves arch-bar placement and the use of a superior border
unicortical noncompression miniplate. The inferior border is aligned
and approximated by a stabilization plate.
• In severely displaced fractures, provisional stabilization with an
inferior border wire assists the proper arch-bar application. The use
of the “locking plate” minimizes the requirement for precise plate
bending.
• Comminuted fractures require larger fixation plates, and are
conceptually fractures with “bone loss”, where the plate itself bears
the entire load of fixation
General principles of reduction and fixation
• Periosteal attachments should be retained where possible, as the
periosteal blood supply is often the only remaining circulation (the
medullary blood supply is generally injured by the fracture).
• “Free” bone fragments will generally survive if stabilization is
sufficient and if they are covered by well vascularized soft tissue.
• Mentalis muscle stump on the bone should always be preserved and
the muscle must be repaired during soft tissue closure
Fracture Class I
• There are teeth on each side of the fracture.
• Although many of these fractures can be managed by intermaxillary
fixation (4-6 weeks) , and internal fixation with miniplates may be
used for noncomminuted, nonbone gap fractures is also preferred.
This technique prevents displacement and permits light function.
Fracture Class II
• Teeth are present only one side of the fracture site and these
fractures must have an open reduction.
• The type and strength of plate needed to control the
nontoothbearing fragment and displacement of the fracture will vary
according to the direction and bevel of the fracture and the position
of the teeth and surrounding muscles. Generally, a larger inferior
border plate with a smaller superior border plate is preferred with
three screws placed in solid, nonfractured bone to each side of the
fracture.
Fracture Class III
• No teeth on either side of the fracture.
• Nondisplaced, immobile fractures conceptually may be treated by a
soft diet with close follow up. The majority of class III fractures
however, should be managed with rigid fixation with superior and
inferior border fixation.
Condylar and subcondylar fractures
• High condylar (intracapsular) fractures (head and upper neck) are
generally treated with closed reduction with a limited (2-week) period
of postoperative IMF, followed by early “controlled” mobilization
utilizing elastics for reestablishing occlusion in a rest position.
• Most neck and low subcondylar fractures with good alignment,
reasonable contact of the bone ends and preservation of ramus
vertical height without condylar head dislocation may be treated by
IMF for 4–6 weeks, with weekly or biweekly observation of the
occlusion for at least 4 additional weeks after release of fixation in
light function if fracture alignment is reasonable.
Edentulous mandible fracture
• Characterized by the loss of the alveolar ridge and the teeth.
• Closed fractures demonstrating minimal displacement : Soft diet and
avoidance of dentures observation.
• In practice, most fractures are better treated with a load-bearing
plate.
1. The bone atrophy may be minimal if there is sufficient height
(>20mm) of the mandibular body to ensure good bone healing.
2. Moderate atrophy, the height of the mandibular body ranges from
10–20 mm, and healing is usually satisfactory but not as certain if
the height were >20 mm.
3. Severe atrophy (the mandibular height is <10 mm, one can assume
that the patient has a disease of “poor bone healing”.
IMF
• This is a rapid method of immobilizing the teeth in occlusion, given
good dentition and uncomplicated fracture types. The number and
position of the IMF screws is based on the fracture type, fracture
location and surgeon preference. Screws must be positioned superior
to the maxillary tooth roots and inferior to the mandibular tooth
roots