MANDIBLE FRACTURE

Surgical Specialist Education Program

Sebelas Maret University School of Medicine
RSUD Dr. Moewardi
 
Created by:
dr. Randi
 Anatomy

Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures: epidemiology, patterns, treatments, and outcomes. 
J Oral Maxillofac Surg. 2016;74(9):1792-9.
 Anatomy

Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures: epidemiology, patterns, treatments, and outcomes. 
J Oral Maxillofac Surg. 2016;74(9):1792-9.
Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures: epidemiology, patterns, treatments, and outcomes. 
J Oral Maxillofac Surg. 2016;74(9):1792-9.
 Definition

Mandibular fracture is the loss of mandibular bone

discontinuity
Loss of continuity in the lower jaw (mandible), which
results from trauma to the face or pathological
conditions, which can be fatal if not treated properly

Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures: epidemiology, patterns, treatments, and outcomes. 
J Oral Maxillofac Surg. 2016;74(9):1792-9.
 Etiology

– Trauma
– Pathological processes: benign or malignant tumors in the
lower jaw, osteogenesis imperfecta, osteomyelitis,
osteomalacia, overall bone atrophy or osteoporosis
necrosis or metabolic bone disease

Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures: epidemiology, patterns, treatments, and outcomes. 
J Oral Maxillofac Surg. 2016;74(9):1792-9.
 CLASSIFICATION

– Based on the anatomical

region

Michael Ehrenfeld, Paul N Manson, Joachim Prein. 2012. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and
Orthognathic Surgery. Switzerland. pp 12-13
 – Based on the presence or absence of teeth
– Class 1 Fracture :
– there are teeth on 2 sides of the fracture, treatment
in class 1 fractures can be through interdental wiring
– Class 2 Fracture :
– The teeth is only in one fracture
– Class 3 Fracture :
– there are no teeth on either side of the fracture, in
this case it is done through an open reduction, then
a plate and screw is installed, or it can be by
intermaxillary fixation

Michael Ehrenfeld, Paul N Manson, Joachim Prein. 2012. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and
Orthognathic Surgery. Switzerland. pp 12-13
 Classification

Fig Third generation AOCMF

classification.
a Level 1: Mandible, midface, skull
base, and cranial vault.
b Level 2: Classification proposal:
skull frontal view. Differentiation of
anatomical regions: zygoma (Z),
upper central midface (U),
intermediate central midface (I),
lower central midface (L), frontal
(F), parietal (P), sphenoidal (S),
temporal (T).
Michael Ehrenfeld, Paul N Manson, Joachim Prein. 2012. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and
Orthognathic Surgery. Switzerland. pp 12-13
 Classification

3rd level AOCMF 3rd generation classification description:

mandibular panoramic photo
Body Region = 1 (anterior transition zone)
Ramus Region = 2 (posterior transition zone)
proc. condylar (P), coronoid (C), angle / ramus (A), body (B), symphysis / parasymphysis (S)
Michael Ehrenfeld, Paul N Manson, Joachim Prein. 2012. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and
 Diagnosis

 History taking
HISTORY  In cases of trauma, examine patients with suspected
TAKING
mandibular fractures
 In trauma patients with mandibular fractures,
attention should be given to the possibility of airway
PHYSICAL obstruction
EXAMINATION

ADDITIONAL
EXAMINATION

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral

Maxillofac Surg Clin North Am. 2013;25(4):591-600
Diagnosis

– Physical Examination
– Inspection
– Inspection starts from extraoral then intraoral, paying
attention to deformity
– Preauricular swelling often indicates condyle fracture
– Also see whether there are missing teeth.
– Also pay attention to whether there are malocclusions
– Palpation
– Patients are asked to open and close the mouth, assessing
the presence or absence of pain, deformity or dislocation

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral

Maxillofac Surg Clin North Am. 2013;25(4):591-600
Tragus examination

TMJ examination can be done by:

– the patient is instructed to open and close the mouth
– The operator will palpate on the front of the tragus during this
situation or can also by inserting the little finger into the external
auditory canal, checking whether there is clicking or the patient feels
pain
– It also must evaluate the maximum size of the patient's mouth
opening, presence / absence of lateral deviation when opening and
closing the mouth, and mastication of muscle tone

Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures: epidemiology, patterns,
treatments, and outcomes. J Oral Maxillofac Surg. 2016;74(9):1792-9.
Diagnosis

Additional Examination
– X-ray examination is used to determine the pattern of
fractures that occur
– CT scan is used to identify complex condyle fractures
 Management

– The principle of handling mandibular fractures in the initial step is emergency

– such as the airway (airway), breathing (breathing), blood circulation including shock
treatment (circulation),
– treatment of soft tissue injuries and transient immobilization and evaluation of
possible brain injuries
– the second is definitive treatment of fractures
– close reduction / repositioning of fracture fragments (close reduction)
– openly (open reduction)

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
  Close repotition
 The indications for closed repositioning include :
 Mild to moderate degree of displacement or open fracture
 Condyle fracture
 Fracture in children
 Severe communicative fractures or fractures where the blood supply decreases.
 Mandibular odontulous fracture
 Mandibular fractures that are associated with panfacial fractures

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
 – The technique used in the treatment of mandible
fractures is closed reduction
– Intermaxillary fixation
– This fixation is maintained for 3-4 weeks on the fracture of
the condylus area
– 4-6 weeks in other areas of the mandible

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
 – Fixation technique
– Ivy loop
– Ivy loop placement uses a 24-gauge wire between 2 stable teeth, with the use of smaller wires to provide
maxillomandibular fixation (MMF)

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
 – Arch barr technique
– Indications for arch arch
insertion include
inadequate / inadequate
teeth for other methods,
accompanied by maxillary
fracture
– A dentoalveolar fragment
is obtained at one end of
the jaw that needs to be
reduced according to the
jaw arch before being
intermaxillary fixation
mounted

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
 – Wiring (wire)
– The wire is made like an eye, then the eye is placed
around two teeth or upper or lower molars
– A fracture of lower jaw is fixed to the upper jaw through
the eyes in the upper and lower wires
– If necessary this wire bonding is installed in various
places to obtain strong fixation

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
 – Open reposition
– Indications of open
repositioning include :
– Open or displaced
fracture of moderate to
severe degree
– An irreducible fracture
with closed repositioning

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
 – Plating
– Plate placement aims to provide resistance
to the fracture area, so that it can unite the
fracture portion with the superior alveoli

Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600
 Complication

– The most common complication in mandible fractures is infection or

osteomyelitis, which can lead to various other possible complications

Seemann R, Schicho K, Wutzl A, Koinig G, Poeschl WP, Krennmair G, et al. Complication rates in the operative
treatment of mandibular angle fractures: a 10-year retrospective. J Oral Maxillofac Surg. 2010;68(3):647-50.
 REFERENCES
1. Al-Moraissi EÀ, El-Sharkawy TM, El-Ghareeb TI, Chrcanovic BR. Three-dimensional versus standard miniplate fixation in the management of mandibular
angle fractures: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2014;43(6):708-16.
2. Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600.
3. Ellis E 3rd. Open reduction and internal fixation of combined angle and body/symphysis fractures of the mandible: how much fixation is enough? J Oral
Maxillofac Surg. 2013;71(4):726-33.
4. Malanchuk VO, Kopchak AV. Risk Al-Moraissi EA. One miniplate compared with two in the fixation of isolated fractures of the mandibular angle. Br J Oral
Maxillofac Surg. 2015;53(8):690-8.
5. Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures: epidemiology, patterns, treatments, and outcomes. J Oral Maxillofac Surg. 
2016;74(9):1792-9.
6. Ramakrishnan J, Shingleton A, Reeves D, Key JM, Vural E. The effects of molar tooth involvement in mandibular angle fractures treated with rigid fixation. 
Otolaryngol Head Neck Surg. 2009;140(6):845-8.
7. Seemann R, Schicho K, Wutzl A, Koinig G, Poeschl WP, Krennmair G, et al. Complication rates in the operative treatment of mandibular angle fractures: a 10-
year retrospective. J Oral Maxillofac Surg. 2010;68(3):647-50.
8. Subodh et al, Clinical Study An Epidemiological Study on Pattern and Incidence of Mandibular Fractures, Hindawi Publishing Corporation Plastic Surgery
International, Volume 2012, Article ID 834364,7pages
9. Vineeth K, Lalitha RM, Prasad K, Ranganath K, Shwetha V, Singh J. "A comparative evaluation between single noncompression titanium miniplate and three
dimensional titanium miniplate in treatment of mandibular angle fracture" — a randomized prospective study. J Craniomaxillofac Surg. 2013;41(2):103-9.
10. Zanakis S, Tasoulas J, Angelidis I, Dendrinos C. Tooth in the line of angle fractures: the impact in the healing process. A retrospective study of 112 patients. J 
Craniomaxillofac Surg. 2015;43(1):113-6.
THANKYOU