Management of Mandibular Fractures - Presented as a aprt of weekly Presentation in OMFS Department, Dhaka Dental College; Dhaka; Bangladesh

1. Management of
Mandibular Fracture
DR. TSHEWANG GYELTSHEN_ 49DDCH_2017

2. What is a Fracture?
 Fracture is defined as a break in structural and natural
continuity of bone
 Mandibular Fracture:- Is that when fracture is
involved in the mandible.

3. Etiology
 Vehicular Accidents involving (RTA) – 43 %
 Interpersonal violence, Assaults – 34%
 Falls – 7%
 Contact sports 4 %
 Industrial /work related – 10%
 Pathological Fracture – unconfirmed
 Studies have shown that the incidence of mandible fractures are influenced by
various etiological factors e.g.
 Geography
 Social trends
 Road traffic legislations
 Seasons

4. Diagnosis of mandibular fractures 4
History
Clinical examination
Radiological examination

5. Clinical examination
Mouth opening
Occlusion
Lacerations
Coleman’s sign
Step deformity
(shoulder defect)
Inspection
Tenderness
Crepitation
Mobility of the teeth
Foreign bodies
Palpation

6. Radiographic examination
 Plain radiograph
 OPG
 Lateral oblique
 PA mandible
 Lower occlusal
 CT scan
 3-D CT
 MRI
6

7. Emergencies Involving Mandibular
Fracture
 With rare exception, mandible fractures are not surgical emergencies.
 Emergencies involving Mandibular fracture happens with unfavorable
fractures involving bilateral Para-symphysis fracture pulling the anterior
part backward and compromising the airway.
 Paralysis of tongue and consequently airway compromisation

8. Types of Mandibular Fracture
 Simple - Includes a closed linear fractures
 Compound or open
 Comminuted
 Greenstick
 Pathologic
 Multiple
 Impacted
 Atrophic
 Complicated or complex

9. Classification by anatomic region 9
Dingman and Natvig
 Condylar process
 Coronoid
 Ramus
 Angle
 Body
 Symphysis
 Parasymphysis
 Alveolar process

10. Treatment Protocol
 ATLS protocol
 Primary Survey –
 A-- Airway Maintenance and Cervical Spine Protection
 B– Maintenance of Breathing and Ventilation
 C– Circulation and Hemorrhage Control
 D– Disability/Neurological Examination – AVPU
 E– Exposure under proper environment
 Secondary Survey – head-to-toe evaluation, including a complete
history and physical examination and reassessment of all vital signs.
 Tertiary Survey -- In Hospital Care

11. Definitive In-Hospital Treatment
 Reduction
 Restoration of a functional alignment of the bone fragments
 Use of occlusion
1. Open reduction
2. Closed reduction
 Fixation
 Immobilization
 To allow bone healing
 Through fixation of fracture line
1. Rigid
2. Non-rigid

12. Closed reduction 12
Indications
a) Nondisplaced favorable fractures
b) Grossly comminuted fractures
c) Significant loss of overlying soft tissue
d) Edentulous mandibular fractures
e) Mandibular fractures in children
f) Coronoid process fractures
g) Condylar fractures

13. Open reduction 13
 Displaced unfavourable fractures Multiple fractures of the facial bones
 Midface fractures and displaced bilateral condylar fracture
 Fractures of an edentulous mandible with severe displacement of
fracture segment
 Edentulous maxilla opposing a mandibular fracture
 Delay of treatment and interposition of soft tissue between
noncontacting displaced fractures fragments
 Malunion
 Conditions contraindicating Intermaxillary fixation

14. Removal of a tooth from the fracture
line
ABSOLUTE INDICATION RELATIVE INDICATION
 Vertical fracture
 Dislocation or subluxation
 Periapical infection
 Infected fracture line
 Acute pericoronitis
 Functionless
 Advanced caries
 Advanced periodontal disease
 Doubtful teeth
 Teeth involved in untreated
fractures presenting more than 3
days after injury

15. Methods of immobilization
 Intermaxillary fixation with Osteosynthesis
 Intermaxillary fixation:-
 Bonded Brackets
 Dental Wiring :-
 a). Direct wiring
 b). Eyelet wiring
 Arch Bars
 Cap Splints
 IMF Screws
 Osteosynthesis without Intermaxillary fixation

16. Methods of immobilization 16
INTERMAXILLARY FIXATION WITH OSTEOSYNTHESIS
 Trans-osseous wiring
 Circumferential wiring
 External pin fixation
 Bone clamps
 Transfixation with Kirschner wire

17. Methods of immobilization 17
INTERMAXILLARY FIXATION WITHOUT OSTEOSYNTHESIS
 Compression plates
 Miniplates
 Lag screws

18. Period of immobilization 18
Young adult
with
Fracture of the angle
receiving
Early treatment
in which
Tooth removed from fracture line
if
a) Tooth retained in fracture line : add 1wk
b) Fracture at the Symphysis: add 1 wk
c) Age 40yrs and over : add 1or 2 wks
d) Children and adolescents : subtract 1 wk
3 weeks

19. Various dental wiring techniques 19
 ESig's wiring- (single –double wiring) (Charles J. Essig )
 Gilmer’s wiring
 Risdon’s wiring – (Twisted labial wire) (E.Fulton Risdon)
 Ivy eyelet wiring (Robert H.Ivy )
 Clovehitch wiring
 Col . Stout’s multiloop wiring (R.A.Stout)
 Button wiring (Varaztad Hovhannes Kazanjian )

20. Management of Coronoid Process and
Ramus Fracture
 Most ramus fractures can be treated with MMF x 6 weeks
 Challenges– Difficult intra-oral plating
 External approach for plating is similar to that of angle fractures
 Coronoid Fracture is uncommon and if it occurs it is usually associated with a
ZMC fracture

21. Management of Condylar Fracture
 Most condyle fractures can be treated with MMF x 2-4 weeks
 If the head is involved, MMF is limited to 2 weeks to prevent TMJ
ankyloses
 Frequent scenario is a condyle fracture with contralateral
parasymphyseal, body, or angle fracture—treat contralateral
fracture with ORIF and condyle fracture with MMF x 2-4 weeks
 When plating is required, an external approach is preferred
 External approach is similar to the angle approach but with the
superior end of the incision brought to about 2 cm from the
earlobe.

22. Mx. Of Condylar Fracture: literature
Review
 Controversial Treatment Options between closed or open reduction
 Treatment aim – to recover normal TMJ function
 Treatment choice depends on fracture level, amount of displacement,
adequacy of the occlusion and age.
Advantages
early mobilization of the mandible,
better occlusal results,
better function,
maintenance of posterior ramal
height,
avoidance of facial asymmetries
Disadvantages
Risk of damage to facial nerve branch
Chance of Cutaneous Scar
Open Reduction

23.  Closed Reduction includes MMF with Elastics
 Degree of displacement of the condylar fracture has been used in deciding between open or
closed treatment
 Mikkonen et al. recommended open reduction if the condylar displacement was greater than 45
degrees in a sagittal or coronal plane
 Widmark et al. recommended opening such fractures if the displacement was greater than 30
degrees.
 Zide and Kent described the absolute and relative indications for open reduction of condyle
fractures
1. displacement of the condylar head into the
middle cranial fossa;
2. Impossibility of obtaining adequate occlusion by
closed reduction;
3. lateral extracapsular displacement of the condyle;
and 4
4. Invasion by a foreign body (e.g. gunshot wound.
1. bilateral condyle fractures in an edentulous
patient;
2. unilateral or bilateral condyle fractures when
splinting is not recommended for medical
reasons;
3. . bilateral condyle fractures associated with
comminuted midface fractures; and
4. bilateral condyle fractures and associated
anthological problems (e.g. lack of posterior
occlusal support)
Absolute Indications
Relative Indications

24. Management of Mandibular Angle
Fracture
 One of the most common fracture sites.
 Non-displaced fractures can be treated with MMF x 6 weeks
Reasons cited:
Presence of impacted third molars
Thinner cross-sectional area in the angle
region.
Biomechanical lever arm.

25.  Although maintenance of the absolute rigidity on treatment of angle fractures
has been major principle, In 1973, Michelet et al, described the use of small,
malleable bone plates for treatment of angle fractures.
 This led to a change from the previous belief that rigid fixation was necessary
for bone healing. Later, Champy et al. validated the technique by performing
several clinical investigations.
 They determined the most stable location where bone plates should be placed
based on the ‘‘Champy’s ideal lines of osteosynthesis’’
 Disadvantage:- Unable to achieve absolute immobilization

26.  A prospective study performed by Amrish Bhagol et al looked at eight methods for
treating mandibular angle fractures:
 1. closed reduction
 2. extraoral ORIF with a large reconstruction plate
 3. intraoral ORIF using a single lag screw
 4. intraoral ORIF using two 2.0-mm minidynamic compression plates
 5. intraoral ORIF using two 2.4-mm mandibular compression plate
 6. intraoral ORIF using two noncompression miniplates
 7. intraoral ORIF using a single noncompression miniplate; and
 8. intraoral ORIF using a single malleable noncompression miniplate
 In the study, they found out that, extraoral ORIF with a reconstruction plate and
intraoral ORIF using a single miniplate had least complications (7.5% and 2.5%,
respectively).
 Thus they concluded that these two methods were best for angular fracture
management.

27. Management of Fracture of the Body
of Mandible
 Simple fractures involving the body of the mandible can be effectively treated with one
miniplate along the Champy line of osteosynthesis.
 Dissection should be done avoiding the damage to mental nerve which supplies the lower
lips.
Champy popularized the treatment of mandible
fractures with miniplate fixation along the ideal
lines of osteosynthesis. This is a form of load-
sharing osteosynthesis to be applied in simple
fracture patterns having an acceptable amount of
bone stock.

28.  Intraoral approach best
 Arch bars placed and MMF wires secured prior to incision
 5 cm incision made in the gingivobuccal sulcus over the fracture, leaving a 1 cm
cuff of tissue from the mucogingival junction for closure
 Dissection carried to bone
 Mental nerves identified and preserved
 Fracture line debrided, reduced, and MMF tightened
 Four hole tension band secured between the tooth roots and mental foramen
with monocortical screws
 Larger 2.3 to 2.7 mm system titanium plate is secured anteriorly through the
intraoral incision with 2-3 screws.
 MMF wires cut and occlusion checked; if satisfactory, incision is closed.

29. Management of the Fracture of the
Parasymphysis and Symphysis
 Parasymphyseal fractures:- Fracture lines in the canine region.
 Symphysis fracture:- Any fracture line between the canine to canine.

30.  Several authors have shown that miniplate fixation in symphysis
and parasymphysis is very effective way to fix this fractures.
 The most common approach – transoral gingivolabial and
gingivobuccal incision.
 Larger comminuted fractures, an external approach may be
necessary to accurately and rigidly fixate the mandible.
 Simple symphysis fractures can be treated with two miniplates
fixation.
 Single Miniplates not given – displaces on torsional forces
during functions

31.  One miniplate is placed at the inferior border and a second plate is placed superiorly.
 Several authors have shown that miniplate fixation along these lines is a very effective way to fixate
these fractures.
 More rigid fixation should be considered for comminuted fractures
 Lag Screw :- used in reduction of the lingual border of the fracture and re-establish the appropriate
intergonial distance by squeezing the mandibular angles together. For optimal strength, two lag
screws are placed.

32.  Baby John et al described a case of
4.5 years old boy having been
treated with acrylic aplints.
 Under sedation, upper and lower
arch alginate impressions were
taken and stone casts were poured.
An open occlusal acrylic splint was
fabricated and under GA, the
mandibular fracture was
immobilized and fixed with acrylic
splint and then retained by
circummandibular wiring. Patient
was reviewed weekly and on the
third postoperative week was
removed with LA. Patient achieved
perfect occlusion and good
masticatory efficiency.
Treatment principles of mandibular fractures in children differ from that of adults due to concerns
regarding mandibular growth and development of dentition

33. Geriatric Patient with Mandible
Fracture
 Fractures of the edentulous mandible most commonly involve
the body region
 Can be treated by either open or closed reduction methods.
 Closed reduction with the use of prosthetics (existing dentures
or Gunning splints)
 The current accepted concept in geriatric mandible fracture is
to go for open reduction and internal fixation

34. Coleman’s Sign
" There is one sign which is almost pathognomonic of
fracture of the body of the mandible, and that is an
effusion of blood into the (tissues of the) floor of the
mouth, raising its mucous membrane and producing a
characteristic bluish, tense swelling under the tongue”.
– Frank Coleman, 1912

35. Recent Developments in Mandibular
Fracture Management
 Use of 3D Navigation System in Mandibular Fracture Treatment as
described by Matthias Feichtinger et al, 2001

37.  Use of Digital Volume Tomography (DVT) in mandibular Fracture as described by
CM Ziegler et al
The panoramic radiograph is poorly positioned due
to patient’s multiple trauma. It shows fractures at the
right mandibular angle and the left canine and
premolar region 3D reconstruction confirm the fractures at the right
mandibular angle and demonstrates clearly the
parasymphyseal fracture in the left canine region. This
3D image also shows a displaced fragment at the
inferior cortex.
Axial
DVT view
 Recently endoscopic subcondylar fracture repair
has been described with encouraging results.

38. THANKING YOU