Management of

mandibular fractures
Advanced traumatic life support ATLS

 Primary survey
To stabilize the vitals
A . Airway and cervical spine injury
B. Breathing and ventilation
C. Circulation and hemoraghe control
D. Diisability
E. External enviroment
ATLS
 Secondary Survey
For definative diagnosis
Head to toe examination
 AMPLE History
 Thismnemonic device can be used for obtaining a
quick, focused history:
 Allergy
 Medications
 Previous medical history or illness/pregnancy
 Last Meal
 Events/environment related to injury
 Physical Examination.
 Vital Signs.
 Head and Face Examination.
 Neck Examination.
 Examination of the Chest.
 Examination of the Abdomen.
 Examination of the Extremities.
Basic principles of treatment of a
fracture

 1. Reduction
 2. Fixation
 3. Immobilization
Reduction
Reduction: Restoration of the fractured fragments
to their original anatomical position
 Closed reduction
(Alignment without visualization of the fracture line)
i. Reduction by manipulation.
ii. Reduction by traction.
No surgical intervention is needed in closed reduction. Alignment of
fractured fragments can be done without surgery. Occlusion of the teeth
is used as
a guiding factor.
Indications
1. Nondisplaced favorable fracture
2. Grossly comminuted fractures.
3. Severely atrophic edentulous mandible
4. Lack of soft tissue overlying the fracture site.
5. Fractures in children with developing teeth buds.
6. Coronoid fractures
Reduction by manipulation

when the fractured fragments are adequately mobile without much

overriding or impaction and the patient comes for treatment
immediately after trauma (fresh fractures), then the digital or hand
manipulation for reduction can be used. Specially designed
instruments for grasping the fragments are available (Disimpaction
forceps, bone holding forceps). It can be done under LA with sedation
or under GA depending on the need of
Reduction by manipulation
Reduction by traction

1.Intraoral traction method

prefabricated arch bars are attached to maxillary and mandibular dental arches by
means of interdental wiring. Here, the fractured fragments are subjected to gradual
elastic traction by placing the elastics, from upper to lower arch bars in a definite
manner and direction depending on the fracture line
Intraoral traction
Reduction by traction
 Extraoral traction

anchorage is taken usually from the intact skull of the patient and different types of head gears are use0d
for various attachments, coming down over the face and connected to the arch bars by elastics and wires.
Whenever the traction method is used, patient is encouraged to open and close the mouth slowly, so that
the elastic traction starts functioning. Patient should be kept on analgesics for pain control, so that the
elastic traction can be smooth. Once the proper occlusion is achieved, then the elastics are replaced by
wires to carry out intermaxillary fixation or intermaxillay ligation (IMF or IML).After the elastic traction
is given, then the patient should be observed for a period of 12 to 24 hours. At the end of 48 hours, if
satisfactory occlusion is not achieved, then open reduction is done
Open reduction

surgical reduction allows visuai identification of fractured fragments)

Indications
1. Displaced unfavorable fractures.
2. Multiple fractures.
3. Associated midface fractures.
4. Associated condylar fractures.
5. When IMF is contraindicated or not possible.
6. To preclude the need for IMF for patient comfort.
7. To facilitate the patient’s early return to work.
Contradictions

 1. GA or a more prolonged procedure is not advisable.

 2. Severe comminution with loss of soft tissue.
 3. Gross infection at the fracture site.
 4. Patient refusing open reduction.
Advantages

 Early return to normal jaw function

 • Normal nutrition
 • Normal oral hygiene after a few days
 • Avoidance of airway problem
 • Can get absolute stability, promotes primary bone healing
 • Bone fragments re-approximated exactly by visualization
 • Avoids detrimental effects to muscles of mastication
 Permits the physical therapy early postsurgically
 • Avoids IMF for patient with occupational benefits in avoiding mandible
 • Helpful in special nutritional requirement
 • Easy oral access
 • Decreased patient discomfort, greater patient satisfaction
 • Less myoatrophy
 • Decreased hospital time
 • Substantial savings in overall cost of treatment
 • Lower risk of major complications
 • Lower infection rates, improved overall results
 • Lower rate of malunion/nonunion
Disadvantages

 need for an open surgical procedure

 • Significant operating room time
 • Prolonged anesthesia
 • Expensive hardware
 • Some risk to neuromuscular structures and teeth
 • Need for secondary procedure to remove hardware
 • Needs much operator skill, meticulous technique needed
 • Directly compared to maxillomandibular fixation
 • Higher frequency of malocclusion
 • Higher frequency of facial nerve palsy
 • Scarring (extraoral and intraoral)
 • Needs sophisticated materi
Fixation

In this phase the fractured fragments (after reduction) are fixed, in their normal
anatomical relationship to prevent displacment and achieve Proper aproximation
Direct skeletal fixation
 External fixation
where the device is outside the
tissues, but inserted into the bone percutaneously
 Direct internal skeletal fixation
by devices which are totally enclosed within the tissues and uniting the bone ends by direct
approximation. In direct external fixation, bone clamps or pin fixation can be used, while direct internal
skeletal fixation is carried out with transosseous or intraosseous wiring or using bone plating system
Indirect fixation

the control of fragments is done via the denture bearing area. By means of arch bars
and IML or Gunning splint, if the patient is edentulous. It can be extraoral or intraoral
Immoblization
During this phase, the fixation
device is retained to stabilize the reduced fragments into their normal anatomical
position, until clinicalbony union takes place. The fixation device is utilized for a
particular period to immobilize the fractured Fragments. Immobilization period will
depend on the type of fracture and the bone involved. For maxillary fractures 3 to 4
weeks of immobilization period is sufficient, while for mandibular fracture it can
vary from 4 to 6 weeks. In condylar fracture the recommended immobilization
period is 2 to 3 weeks only, for prevention of ankylosis of Tmj
Next steps are prevention of infection and gradual
rehabilitation of function.