JAW FRACTURES

Patients who have no recollection of tetanus booster within

past 5-10 days should be reffered to their general physician
for one. For better evaluation and treatment of multiple
severe injuries efforts of trauma team (general surgeons,
cardiothoracic surgeons, neurosurgeon anaesthesiologist,
ophthalmologist, otolaryngologists, urologists and oral-
maxillo facial surgeons.)
During clinical examination:-
Extraorally-note lacerations, which have involved vital
structures like parotid duct, facial nerve, labial artery.
Intraorally- fractured jaw bones or alveolar process, there will
be bleeding to the floor of mouth, or bleeding into the labial
vestibule., Note the depth of the fracture, note mobility of
teeth and process the teeth
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• Longer periods of imf/mmf in children (2-3
months) leads to bony ankylosis or fibrosis
and severe limited mouth opening
• Intra-oral approach of open reduction is
possible for symphysis is anterior
mandible.while extraoral approach is possible
for posterior ramus, condylar fractures. And
posterior body as angle fractures are
approached with combinations of extra-oral
and intra-oral approach

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1 FRACTURE OF THE MANDIBLE.
Mandible is U-shaped bone with 2 processes,
symphysis and has chin ranging between the two
mental foramen. Mandible has certain weak areas
and it’s only the free bone in the skull. Muscles
opening the mandible are lateral pteryoid and
poster fibers of temporalis.
Mandible is more liable to fracture because it’s
mandibular fracture are more frequent. The
commonest area is in condylar region and least is
the coronoid process because of not being along
the line of transmission of forces.
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• Classification of mandibular Fractures.
1. Simple fracture-does not communication with outside seen in
ramus, Condyle and coronoid.
2.Compound fracture-communication with outside
3.Communited fracture involves various bones
4.Anatomical mandibular fracture
• # condyle-29.1%
• # coronoid process 1.3%
• # Ramus-1.7%
• # Body-16%
• # Mental region 22%
• # Of angle 24.5%
• # Alveolar ridge is 3.1%
When describing the fracture, say compound # body mandible or
communicated #,# line takes any direction.
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Clinical features of fracture mandible.
• Pain
• Malocclusion-The upper teeth do not meet
the lower teeth.
• Palpate for step-Deformity by bimanual
palpation and check for tenderness.
• Crackling sound due to air or any foreign body
within the fracture line.
• There is loss of function.
• Obvious bleeding

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• Any presence of ecchymosis, oedema, swelling,
haematoma, in lower part of face suggest #
mandible.
• # in the mental region-the # passes in either side
of symphysis so there will be pull of muscles
making the tongue to fall back wards causing
airway obstruction, so need for tracheostomy
and clinical manifestation depends on where the
# line is found. When examining patient.
• See where the # is intra-orally, detect # area
bimanually.

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• 2 FRACTURE OF THE CONDYLES
The mandible is mobile hence when the patient falls
on the chin or dash board injury (person is yelling)
hence this force is extended on the condylar fossa.
So the joint of TMJ receives the momentum and
causes the condylar fracture or simple fracture
which goes below to involve the neck. A fall on the
chin results in to bilateral fracture of condyle with
displacement of fracture segments. This fracture are
associated with an open bite when patient is
opening the mouth there is deviation to one side.
Segment perforates the external meatus (middle
ear) so there is bleeding from the ear.
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• On palpation- Normally there is movement of the head of
the condyle that is not recorded. If bilaterally there is no
movement but if unilateral then there is movement on one
side.
Management:
It’s a small joint in a very sensitive area so we normally use
open Reduction that requires 2-3 hours looking for the
fragments.
Immobilize the occlusion (Jaws) using intermaxillary wires, give
it a shorter time (check for pseudo union) so immobilize for
2-3 weeks.
Open Reduction-make a para-auricular incision then use
intraosseous wiring, drill pins and put wires or use a plating
system or use intramedullary pins, k-wires or stainman pins.

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 3 Coronoid fracture-
it is very rare, it does not cause much effects,
coronoid fracture alone does not cause much
deformity. Unless the mouth opening is
affected then that is when there is a problem
because it forms much of a free bone.

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 4 ALVEOLAR FRACTURES

Alveolar fractures may occur independently/ or with

segment of bone containing at least one tooth or
many teeth and sometimes with concomitant
injuries like crown fractures, root fractures and soft
tissue injuries.
Teeth with root apices exposed within a dento-
alveolar fracture should first have a root canal
therapy done if not they get inflammatory root
resorption and infection and dento- osseous healing.
Stabilized with (1) arch bars (2) acid etched arch
wire, (3) cold-cured acrylic splint.
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• Type of dento-alveolar injuries
Duration of immobilization
• Mobile teeth 7-10 days
• Tooth displacement 2-3 weeks
• Root fracture 2-4 months
• Replanted tooth (mature) 7-10 days
• Replanted tooth (immature) 3-4 weeks

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Treatment of fracture mandible
1.Take x-rays-Lateral oblique, PA Jaws.
2.Reduction-open and closed reduction.
3.Immobilize
4. Fixation
5.Supportive management

• Diet
• Oral Hygiene
• Medication

Closed Reduction – Manipulate fracture sites while wound is closed

to bring the # edge into close apposition.
Open reduction - involves raising the flap and surgically exposing the
fracture sites and bringing the segment into proper alignment.
Probably use of the wound to access the # site is very important.
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Methods of immobilization.
Can be extra-osseous method e.g
• Inter maxillary fixation IMF OR MMF used for fixing
jaws #s. using eyelets wires tied up and down jaws
then they are connected with a wire loop.
• Use Arch bars-These are fabricated bars used to
hold teeth together.
• Use splints e.g cap splints, acrylic splints or gunning
splints these are connected by tieing wires to keep
#s in normal position.
• Intra-osseous method e.g use stainless steel wire;
use a plating system or inter-medullary pins.
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Post operative care for mandibular # patients
• Improve oral hygiene by giving antiseptic to rinse after every
meal.
• Immediately after immobilization, monitor vital signs because
it can compromise their functions e.g BP, temperature, pulse.
• Diet-let them be on soft diet.
• Fight infection by giving antibiotics.
• Control pain-give analgesic.
• Take post operative X-ray to check whether segments are in
proper aligment.
• Monitor the nerve function.
• Let the patients come back for assessment
• Tell patients to do exercises to relax the muscles.

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Complications of mandibular # management

1. infections-osteomyelitis, ludwigs Angina, cellulitis.

2.Malocclusion
3.Mal-union
4.Disturbance of temporomandibular joint.
5.Non vital teeth especially if infection sets in especially in the #
line.

5 MIDFACE INJURIES/MAXILLARY FRACTURES.

The following bones are involved-Zygomatic bone, the maxillary
process and frontal process, Maxilla, palatine bone with palatine
sutures, incisive canal, greater palatine and minor palatine canal,
pterygoid plates-lateral and medial structures associated with
pterygoid plates are sphenoid bone and pterygopalatine cavity
(fossa), Nasal bone, vomer and lacrimal plates. 15
Clinical features/common features are;
• Lengthening of the face.
• Obstruction of airway because of involvement
of nose or palate, which forms part of the
airway. The soft palate moves downwards and
sites on sheath of tongue so it obstructs
airway.
• There is anterior open bite
• You find a dish face deformity.

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CLASSIFICATION ON MIDFACE FRACTURES
Common classification is in relation to maxilla
1. Rene le fort classification for maxilla le fort I, II and III
2. Rowe and Williams classifications of zygoma
MAXILLARY FRACTURES
Le fort 1 #, Guerin#/ lower fracture.
This detaches the tooth bearing portion of the top jaw and detaches
it in the line along the margin of anterior nasal spine aperture. The
line goes to tuberosity (pterygiod plates) and doesn’t give a lot of
bleeding. There is less oedema and lengthening of face.
On palpation-there is movement of segments while holding maxilla
with fingers, so one gets sinking and movement of segments.
Treatment-plating system to plate the fracture after reduction or use
of circumferential wires

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Le fort II #/ pyramidal#/ subzygomatic#.
So fracture line passes below the zygoma, from nose (bridge) follows
the anterior part then enters the antero-mesial part of orbit, follows
maxilla, zygomatic suture and continues up to pterygoid plate 1/3 of
fractures detaches maxillary bone, part of septum and orbit is intact
to the cranium so called reserved zygomatic #.
Le fort III/ high level #.
Here the mid fracture detaches the entire facial skeleton from the
cranial base. Fracture line passes through base of nose, inferior
orbital canal or goes through optic and pteygoid plate.
The fracture then runs towards the sphenopalatine suture through
ethymoid and the whole portion hangs from cranial base. It is a very
severe # involving olfactory nerves and dura that connect the bridge
of Ethymoid is close to dura hence le fort III injury causes CSF
(cerebrospinal fluid) leaking (Foramen spinosus and ovale are
demaged so there is frequent infections so one gets meningitis.

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Clinical features le fort fractures.

Le fort I- mild, severe clinical condition.

Le fort I and II There is characteristic massive swelling because it lacks fascia
and there is bilateral sub conjuctival ecchymosis.

• There is reddening/bleeding from sub conjuntival region

• Frequent lengthening of face:- portion of face falls downwards and
backwards.
• Abnormal mobility of face (rock the segment they play)
• Pain all over the nose
• Sutures open
• Malocclusion with anterior open bite
• Diplopia (double vision).
• Anaethesia (because it affects most nerves).
• Bleeding /CSF flows from the nasal portion especially if the septum is
traumatized.

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Surgical treatment of mid face fracture

Follow ABCD management of trauma, emergency treatment comes

first, resuscitate your patient. Definitive treatment comes 2-3 days,
later so allow for improved medical condition of the patient.
Stabilize, the procedures is done starting with dental alveolar
injuries and mandibular fractures are managed first. Then reduce
the fracture of maxilla last.

Various methods of immobilizing mid face fractures

1.Internal methods
2.External methods
Both internal and external methods of fixation or immobilization can
be done using suspension wires or suspension

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Common areas for incision
1. Pre existing areas/ accessory area with a wound.
2. Make a coronal incision-were circumferental incision is
made along hair line of head then pull the bones or use
midline coronal incision. E.g intraosseous plating system.
3. Blephsoraplasty-make incision around the eye or use a low
infra orbital incisions. In case of zygoma-maxillary fracture or
make degraviding incision of nose were the strip around the
nose is done when there’s high level fracture of nasal base.
4. Medial canthus incision-it’s done around were the lacrimal
gland sits.
5. Intra-oral vestibular/sulcus incision is done especially during
maxillectomy.

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 ZYGOMATIC FRACTURES

• Its connected to the maxilla, orbit , skull and

it’s a strong bone. Masetter attaches to lower
border of the arch and body. It contains eye
globe and helps transmit masticatory forces to
the cranial base.

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 Classification of zygomatic fractures
• Type i un displaced fracture
• Type ii fracture of the arch
• Type iii fracture of malar bone or body of
zygoma but frontal zygomatic sutures remain
intact
• Type iv fracture body with sutures open
• Type v the whole zygoma has pure blown out
• Type vi orbital rim fracture
• Type vii communited fracture like crashed
zygomatic bone in to multiple pieces 23
 Clinical features of zygomatic fractures
• There is bruishing, swelling over the cheeks
• There is depression of cheek prominence . the
cheeks it looks flat or depressed
• There is trismus or spasms of masticatory
muscles especially if there is bilateral fractures
• There is restricted lateral mandibular
movements
• NB if you palpate the infraorbital margins there
is usually a step deformity and also diplopia
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• One gets exopthalmos this pushes globe outwards
• There is peri orbital ecchymosis and sub
conjuctival heamorrhage.the eye is red takes a
long time to disappear completely because the
eye has a delicate membrane so gets direct fusion
of oxygen from external
• One gets aneasthesia or paraesthesia of lips or
cheeks
• Epitaxis from the nose when the zygomatico
maxillary sutures opens
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 treatment options
• if no displacement then use a non surgical means
let patient be on soft diet and avoid hard foods
• ORIF done surgically
• Expose zygoma using various approaches eg
infratemporal fossa approach,intra oral
approach., circumferential wiring ,coronal
incision and temporal region approach
• Commonly we use intra oral approach by incising
around the premolar and molar region 2-3cm
and use zygomatic reducer
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Complications of zygomatic fractures
• Facial deformity
• Paraesthesia
• Persistence trismus
• Eye pushed out because the zygoma goes
downwards and backwards .so diplopia
persists

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 PREVENTION
• measures to reduce facial traumas include laws
to enforce seat belts and public education to
increase awareness on importance of helmets
and seat belts.
• Efforts to reduce drink drunk driving. Changing
societal attitudes towards the activity
• Information obtained from biomechanic studies
should be used to design automobiles

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• Material in the mouth that threatens the airway can be
removed manually or using a suction tool for that purpose
and supplemental oxygen provided.
• Facial structures that threaten to interfere with the airway
can be reduced by moving the bones back into place.
Both reduce bleeding and moves the bone out of the way
of the airway
• Intubation may be difficult or impossible due to swelling.
Nasal intubation inserting an end tracheal tube through
the nose may be contra-indicated in the presence of facial
trauma because if there is undiscovered fracture at the
base of the skull, the tube could be forced through it and
into the brain. If facial injuries prevent oral tracheal or
naso tracheal intubation, a surgical airway can be placed
to provide an adequate airway.
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• Although cricothyrotomy and tracheotomy can secure an
airway when other methods fail, they are used only as a last
resort because of potential complications and difficulty of
the procedures
• A dressing can be placed to keep the wound clean to
facilitate healing or antibiotic given to fight infection
• lacerated wounds stitched
• People with contaminated wounds. They are immunized
with tetanus toxic vaccine
And finally nasal pack put to control nose bleeds or if
hematoma formed on septum of nose then it must be
drained

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