A Topic from Subject of Maxillofacial Trauma written in my Final Year of Dentistry. This Chapter is Clinical Based Review of Mandible Fracture, one of the most common fractures of Face during Road Traffic Accident.

1. Every effort has been made to keep this
topic as short as possible without removing
the actual or clinically important points.
MANDIBLE
FRACTURE
Short Notes for Rapid Review
Sarang Suresh Hotchandani

2. ~ 1 ~
INTRODUCTION
 Occurs more frequently than any other fracture of
facial skeleton
 Sometimes can be complication of tooth
extraction
 Fracture of the mandible may be broadly divided
into two main groups;
o Fractures with no gross comminution of
the bone and without significant loss of
hard or soft tissues.
 Most Common type
o Fractures with gross comminution of the
bone and with extensive loss of both hard
& soft tissues
 May result from;
 Missile injuries in war
 Industrial injuries
 Major road accidents
 Management of these both types is different.
AETIOLOGY
 Road traffic accident (RTA)
 Interpersonal violence
 Falls
 Sporting injuries
 Industrial trauma
 Tooth extraction
INCIDENCE
 The most common facial fractures are in the
mandible, followed by the maxilla, the Zygoma &
then in last nasal bones.
 Fracture of mandibular CONDYLE IS THE
COMMONEST SITE
 Fracture of mandibular ANGLE IS THE FREQUENT
SITE
CLASSIFICATION
01) Based on TYPE OF FRACTURE
02) Based on SITE OF FRACTURE
03) Based on CAUSE OF FRACTURE
TYPE OF FRACTURE
Simple Fracture
 Closed linear fracture of mandible
 Greenstick is variant of simple fracture found in
children.
 Minimal fragmentation of bone
 Non-external communication
Compound Fracture
 Aka OPEN FRACTURES
 In this, communication of margin of fractured bone
occurs with external environment;
o Fracture of tooth bearing portion of
mandible are always compound into the
mouth via periodontal membrane
o Some compound fractures of mandible
open through overlying skin.
Comminuted
 In this, fractured bone is compound and is in
multiple segments with other hard and soft tissue
loss.
 Usually caused by;
o Penetrating sharp objects
o Missiles
Pathological Fracture
 When fracture of jaws occurs with minimal trauma
because of already weakened by any pathological
condition, they are said tobe pathological fracture.
 Example of Conditions;
o Osteomyelitis
o Neoplasms
o Generalized skeletal disease
o Severe alveolar resorption
SITE OF FRACTURE
Treatment and signs & symptoms are different for
different locations of fracture of mandible.

3. ~ 2 ~
FAVORABLE vs UNFAVORABLE
FRACTURES
 It depends on ANGULATION OF FRACTURE LINE &
FORCE OF THE MUSCLE PULL proximal or distal to
the fracture line.
 In favorable fracture, fracture line and muscle pull
resist displacement of the fracture.
 In unfavorable fracture, muscle pull results in
displacement of fractured segments.
BASED ON CAUSES OF
FRACTURE
 Direction and type of force determines the pattern
of mandibular fracture.
DIRECT & INDIRECT VIOLENCE
Due to shape of mandible, any direct violence to one
area may produce indirect force/violence of lesser
severity in another usually opposite part of mandible
which can produce multiple fracture. So keeping this
concept in mind,direct & indirect violence is again divided
into;
01) Unilateral fracture mandible
02) Bilateral fracture mandible
03) Multiple fracture mandible
04) Comminuted fracture mandible
Unilateral fracture mandible
 Single or multiple fracture on one side of mandible.
 Frequently caused by direct violence, but
sometimes;
o can be caused by indirect violence in which
site at which direct violence has occurred
remain intact.
Bilateral fracture mandible
 more frequently caused by combination of direct &
indirect violence.
o Direct force on angle may also fracture
condylar neck of opposite side OR
o Direct force on canine of one side may
fracture angle of mandible of other side.
Multiple fracture mandible
 More than two fractures of mandible
 Caused by combination of direct & indirect force.
o Force on chin may fracture both condyles
along with chin.
 Usually occur in;
o Epileptics
o Elderly patients
o Soldiers
 GUARDSMAN fracture; soldiers
who faint on parade from which
fracture combination derives its
name.
Comminuted Fracture mandible
 Always result from direct violence
FRACTURE DUE TO EXCESSIVE
MUSCULAR CONTRACTION
 Fracture of condylar neck or coronoid process due
to sudden contraction of temporalis muscle.
SURGICAL ANATOMY OF
MANDIBLE
 Mandible is strongest and most rigid component of
facial skeleton. However, it is more commonly
fractured due to;
o Its prominent & exposed situation

4. ~ 3 ~
 Mid facial skeleton is match – box like and provide
cushion effect to underlying structure. WHILE
o Forces applied to mandible are transmitted
directly to base of skull through TMJ
 Fracture of mandible may constitute a threat to
airway due to its association with head injury.
Cause of airway obstruction in mandibular fracture
are;
o Depressed consciousness due to head injury
o Broken teeth and displaced dentures
obstructing airway.
o Bleeding into floor of mouth and base of
tongue causes swelling which obstructs the
oro – pharynx.
Mandibular fracture sites
 The minimum force which cause fracture of
mandible as observed from Nahum’s Cadaver
experiment was found to be;
o 425 pounds for mandible when applied from
front.
 Fracture of neck of the condyle is regarded as
safety mechanism which protects the patient from
damage to middle cranial fossa.
 Nahum also observed that a frontal force of 800 –
900 pounds was required to produce fracture of the
symphysis & both condylar necks.
 Mandible is much more SENSITIVE TO LATERAL
FORCES than frontal forces.
 Alveolar resorption weakens the mandible &
fracture of edentulous of body of mandible results
from much smaller force.
The Teeth
 Produce line of weakness in mandible
o Teeth determines where fracture will
occur.
o long canine tooth, partially erupted wisdom
tooth & impacted 2nd
premolars represent
the line of weakness in mandible.
 Source of infection in fracture
Muscle attachments and
displacement of fractures
 The periosteum of the mandible is thick & inflexible
in structure.
o However, it may become flexible due to
accumulation of blood from rupture
cancellous bone.
 Displacement of bone during mandible fracture
does not occur if the periosteum is attached to
underlying bone.
o It means for displacement of bone
fragments during fracture, the periosteum
must be stripped out.
FRACTURE AT ANGLE OF MANDIBLE
AND DISPLACEMENT
 Fracture at angle of mandible are influenced by
both medial pterygoid & masseter muscles.
o But, medial pterygoid is strong
component involved in displacement.
 Fracture in this region have been classified as;
(figure 2.6 &2.7 in Killey)
o Vertically favorable
o Vertically unfavorable
o Horizontally favorable
o Horizontally unfavorable
FRACTURE & DISPLACEMENT AT
SYMPHYSIS & PARASYMPHYSIS
 In this area, following muscles play the role;
o Mylohyoid muscle
o Genio – hyoid muscle
o Genio – glossus muscle
 In transverse midline fracture of mandible, Genio –
hyoid and mylohyoid muscles act as stabilizing
force and prevent the displacement.
 But, if the fracture occurs lateral to the midline in
the incisor area, the fragment which contains
genial tubercles will be displaced lingually by the
pull of geniohyoid & mylohyoid muscles
 When bilateral parasymphyseal fracture occurs the
anterior fragment is displaced backward by the pull
of genioglossus muscles (figure 2.10 in Killey)
o Threat to airway in this condition occur
only when voluntary tongue control is lost
during loss of consciousness of patient. For
explanation read passage on page # 18 in
Killey.
FRACTURE & DISPLACEMENT OF
CONDYLAR PROCESS
 When condylar neck is fractured, condylar head is
displaced and dislocates from the articular fossa.
o Displacement of condylar head occurs in
forward & medial direction due to pull from
lateral pterygoid muscles.
FRACTURE & DISPLACEMENT OF
CORONOID PROCESS
 It is rare caused by reflex muscular contraction of
temporalis muscles, which displaces the coronoid
process upward into infra – temporal fossa.

5. ~ 4 ~
COMMINUTED FRACTURES &
DISPLACEMENTS
 The amount of displacement in comminuted
fractures is very little.
o It is because of fragmentation at the site of
muscle attachments which pulls the small
fragments leaving the bulk of bone un-
displaced.
FRACTURE & DISPLACEMENT OF
EDENTULOUS MANDIBLE
 Bucket handle displacement
o In this anterior part of mandible is
displaced backwards due to pull of
digastric and mylohyoid muscles, which
can compromise airway.
BLOOD SUPPLY OF THE
MANDIBLE
 The mandible receives an endosteal supply via the
inferior dental artery.
 The other blood supply which mandible receive is
from the periosteum
 Inferior dental artery slowly diminishes and
disappear with aging, so that’s why blood supply
from periosteum is important
o So, that’s why open reduction with
elevation of periosteum is not a best
treatment approach in older patients.
 Other vessels which can be damaged during
fracture of mandible are;
o Dorsal lingual veins causing sub lingual
hematoma
o Facial vessels which cross the lower border
of mandible anterior to angle.
OTHER IMPORTANT
RELATED ANATOMICAL
STRUCTURES
Nerves
 Inferior dental nerve is frequently damages in
fractures of the body & angle of the mandible
 Sometime, facial nerve can be damaged by direct
trauma over mandibular ramus.
o Facial palsy of the lower moto neuron type
results.
 sometimes, mandibular division of facial nerve is
damaged in isolation in association with a fracture
of the body or angle.
Temporomandibular joint
 Traumatic arthritis can occur without fracture of
the condyle from indirect transmitted force.
 Intra – capsular fracture of condylar head when
occur during young age lead to haem – arthrosis
and resulting fibrous or bony ankyloses and
reduction in growth potential of condyle.
 Rupture of meniscus along with haem - arthrosis
predisposes to fibrous or bony ankyloses.
 Rarely, fractured condylar head damages external
auditory meatus and cause bleeding from the
external ear.
o Bleeding from middle ear shows damage to
middle cranial fossa.
CLINICAL EXAMINATION
 Clinical examination of patient with mandibular
fracture occurs in three steps;
o Initially immediate assessment &
treatment of any condition constituting a
threat to life is performed.
o Then, general clinical examination of
patient is done
o Finally, Local examination of the
mandibular fracture is performed.
General clinical examination
Usually fracture of mandible is associated with
injury elsewhere in the body.
So, for this before treating mandibular fracture we
should be clear that no concurrent injury has
happened or if happened it is treated before or
along with treatment of mandibular fracture.
Local Examination of the
mandibular fracture
PREPARATION OF THE PATIENT FOR
EXAMINATION
 The face must be gently cleaned with warm water
or swabs to removed clotted blood, road dirt, etc.
so that accurate evaluation of any soft tissue injury
can be done.
 The oral cavity is also cleaned with swabs held in
non – toothed forceps.
 Loose or broken teeth or dentures should be
examined and broken dentures are assembled
extra orally to make sure that all parts are present,
if missing check whether they have been
swallowed or fall anywhere else.

6. ~ 5 ~
 During this cleaning, craniumand cervical spine are
inspected and palpated for signs for injury
 After these, go for detailed examination of
mandibular fracture.
EXTRA – ORAL EXAMINATION OR
EXTRA – ORAL CLINICAL FEATURES OF
MANDIBULAR FRACTURE
 Swelling and ecchymosis indicate the site of any
mandibular fracture
o Initially, swelling occurs because of
accumulation of blood within tissues, while,
later swelling is caused by increased
capillary permeability and edema.
o Ecchymosis; subcutaneous spots of
bleeding with diameter larger than 1
centimeter.
 Extra – orally we can also see, deformity in bony
contour of the mandible.
o Sometimes, patient is unable to close
anterior teeth and mouth hangs open.
 Blood stained saliva dribbling from the corners of
mouth.
 Bone tenderness on palpation is pathognomic of
a fracture
o if there is displacement of bone, there may
be bone crepitus
 Reduced or absent sensation on one or both
sides of lower lip
o Usually occur in fracture of body of
mandible.
INTRA – ORAL EXAMINATION OR
INTRA – ORAL CLINICAL FEATURES OF
MANDIBULAR FRACTURE
 Clean oral cavity with mouth wash or saline and
remove clotted blood, fractured teeth or denture.
 Examine buccal or lingual sulcus for ecchymosis
o Ecchymosis in buccal sulcus usuallydoes not
indicated any fracture. while,
o Ecchymosis in the floor of mouth or lingual
sulcus indicates the fracture near to it.
o Small linear hematomas in the 3rd
molar
region indicate fracture in the adjacent
bone.
 Examine the occlusal plane indentate patient while
examine alveolar ridge if patient is edentulous.
o Note any step deformity in the occlusion or
alveolus
 Examine all individual teeth and note;
o Luxation or subluxation
o Missing crowns, bridges or fillings
o Fracture involvement of dentine or pulp
o Loose filling, cracks or splits in tooth
 If they are missing, go for chest radiograph.
 Examine the mobility of fracture site by placing
finger & thumb on each side of fracture.
 Check pain or limitation of mandibular movement
if patient is co – operative.
SIGNS AND SYMPTOMS OF
MANDIBULAR FRACTURES AT
VARIOUS SITES OF MANDIBLE
Dento – alveolar fracture
Soft – tissue injuries
 Full thickness or ragged laceration on inner aspect
of lower lip.
o Caused by impaction against the lower
teeth during trauma.
 Bruising of lips and portion of tooth or foreign body
embedded in soft tissues.
 Laceration of gingiva
 De – gloving injury on chin
 Horizontal tear in buccal sulcus at the junction of
attached and free gingiva.
Damage to Teeth during dento – alveolar
fracture.
 Fracture of crown from direct trauma or forcible
impaction against opposing tooth.
 Pulp chamber may or may not be exposed
 Fracture crowns or fillings may be embedded in
soft tissues or inhaled.
 Excessively mobile teeth due to luxation or
subluxation
 Root fracture
Alveolar fracture
 Teeth within alveolar fractures are always assumed
to be devitalized.

7. ~ 6 ~
Condylar fracture
 They may be unilateral or bilateral
 They may involve the joint compartment; in this
case they are called as intra – capsular condylar
fracture.
o While, when condylar neck is fracture, it is
calledas extra –capsular condylar fracture.
 This type of fracture is more
common than intra – capsular
 The extra – capsular fracture may
exist with or without dislocation
of condylar head.
 The commonest condylar
head displacement is
“antero – medial
displacement” due to pull
from lateral pterygoid
muscles which is attached
to antero – medial aspect
of condylar head and to
meniscus of TMJ.
 Swelling over TMJ area & hemorrhage from ear
on the damaged side
o Bleeding result from laceration of anterior
wall of external auditory meatus.
o Bleeding from middle ear represent
fracture of petrous part of temporal bone,
which also can be accompanied by
cerebrospinal otorrhoea.
 Battle’s sign
o It is the sign in which ecchymosis of skin
occurs below the mastoid process of
affected side.
o The hematoma of condylar fracture moves
downward and backward below the
external auditory canal.
 Locked mandible and middle ear bleeding
o It occurs when condylar head is impacted in
glenoid fossa
 Depression on the region of condylar head
o It occurs when condylar head is dislocated
medially and all edema has been subsided.
But this usually does not happen.
 Tenderness over condylar region
o It is possible to determine whether the
condylar head is displaced from glenoid
fossa by palpation within external auditory
meatus.
 Paresthesia of lower lip is rare in condylar fracture
 Shortening of ramus ondisplaced side of condyle
 Deviation of mandible on opening inthe affected
side
 Painful limitation of protrusion and lateral
excursion to opposite side
 Bilateral intra – capsular fracture rarely decreases
the ramus height and also, occlusion is normal in
bilateral condylar fracture.
 If both condyles are displaced during bilateral
condylar fracture, anterior open bite will result.
 Bilateral condylar fracture is sometimes associated
with fracture of symphysis or Para symphysis
fracture
Fracture of coronoid process
 Difficult to diagnose clinically
 Tenderness over the anterior part of the ramus
 Tell – tale hematoma
 Limitation in protrusion of mandible
Fracture of Ramus
 There may be single fracture or comminuted
fracture
 Swelling and ecchymosis both extra – orally &
intra – orally
 Tenderness over the ramus
 Pain on movement
 Sever trismus
Fracture of angle of mandible
 Swelling & deformity at angle extra – orally
 Step deformity behind the last molar intra –
orally
 Un – displaced fractures are revealed by presence
of hematoma adjacent to angle on lingual or
buccal side or both.
 Anesthesia or paresthesia of lower lip
 Deranged occlusion
 Bone tenderness at angle
 Crepitus at fracture site during palpation
 Painful movement & trismus
Fracture of the body of mandible (molar &
pre – molar region)
 Swelling & bone tenderness similar to those
fracture of angle
 Derangement of occlusion due to displacement
of fractured parts
 Gingival tears due to displacement
 Inferior dental artery may be damaged due to
displacement
 Molar teeth may split longitudinally in the
fracture line and cause discomfort
Fracture of para – symphysis & symphysis
region
 Commonly associated with fractures of both
condyles

8. ~ 7 ~
 Sublingual hematoma & bone tenderness
 Lingual inversion of occlusion on each side
 Soft tissue injury of chin & lower lip
 Sometimes associated with severe concussion &
detachment of genioglossus muscles cause loss
of tongue control resulting obstruction of
airway.
 A fracture of symphysis is not accompanied by
anesthesia of skin of the mental region unless
mental nerve is damaged.
Multiple & Comminuted fractures
The physical signs & symptoms of comminuted
fractures depends on the site and number of the
fractures.
RADIOLOGY FOR
MANDIBULAR FRACTURE
 Radiographs for mandibular fracture are taken for
following reasons;
o Treatment planning
o To know the exact relation of teeth to a
fracture line
o To know whether condylar fracture involves
joint space or not
o To determine the presence of comminution.
 Radiographs of mandible fracture are divided into;
o Essential
 Left & right oblique lateral with
tubeangledat 30 degrees towards
lower jaw
 Postero – anterior view
 Rotated Postero – anterior view
 Intra oral radiographs
 Periapical films
 occlusal films
o Desirable radiographs
 Panoramic radiography
 Standard linear tomography
 Computed tomography
 MRI
Left & right oblique lateral
radiographs
 Tube is angled at 0
degrees & it shows
 fracture of body
proximal to canine
region
 fracture of angle
 fracture of ramus & condylar region
Postero – anterior
View
 This view, shows the posterior part of mandible
 shows, fracture of body & angle together with
type of displacement
 un – displaced condylar head is difficult to be
visualized because it is obscured by
superimposition from mastoid process.
REVERSE TOWNE’S (PA PROJECTION)
VIEW
This view showed condylar head & necks and was
indicated in following problems;
 High fracture of condylar necks
 Intra – capsular fracture of TMJ

9. ~ 8 ~
Rotated Postero – anterior view
 This projection is needed to show fractures b/w
symphysis & canine region.
 To demonstrate this area, head must be rotated
from PA position until the suspected fracture line is
parallel to line of vertical beam.
Intra – oral
radiographs
PERIAPICAL
FILMS
 Demonstrate
the relationship
of teeth to the
line of fracture
 Damage to
teeth
themselves
OCCLUSAL FILMS
 Help to evaluate the relationship of tooth root to
the fracture
 Demonstrate midline fracture of body of mandible
with minimal displacement
Panoramic Tomography
 Demonstrate fracture of condylar region
 The combination of PA view & OPG prevent the
need for further radiographs in mandibular fracture
and also decreases the dose of radiation to patient.
Standard Linear Tomography
 Demonstrates
o Mandibular movements

10. ~ 9 ~
o Presence of intra – articular synovial
effusion
Computed Tomography (CT
Scan)
 Most valuable in the assessment of complex facial
trauma, especially that of upper mid –facial region.
 Offer very little advantage as a diagnostic tool in
the lower third of the face and also are not
indicated for isolated fracture of mandible.
o However, they can show detail of TMJ injury
such as vertical fracture of condylar head.
MRI
 Demonstrate meniscus within TMJ and measures
any displacement or injury to meniscus.
PRELIMINARY TREATMENT
IN PATIENT OF MANDIBLE
FRACTURE
 Normally in civilian practice, we do not encounter
patients with mandible fracture having serious
damage to other parts of body.
 However, trauma to mandible usually cause
concussion from transmitted violence to base of
skull.
o Concussion; it is traumatic brain injury that
alters the way your brain function for short
time.
Management of Airway
 Intra oral bleeding, fractures of teeth or denture
can cause airway obstruction in unconscious or
semi-conscious patient.
o Management;
 Examine the mouth
 Remove fragments of teeth,
filling, dentures.
 If suction available, use it to
remove saliva and blood clot.
 Position the patient, lying on his
side so that further bleeding &
secretions can flow from oral
cavity.
 If symphysis region is broken, there are many
chance that tongue may fall back, in this condition,
tie the tongue with suture passing from dorsum
and hold it to prevent it from falling back.
 The position for unconscious patient is lying on his
side.
o This position is also used during recovery
from GA and during transporting the
patient.
Management of Hemorrhage
 Serious hemorrhage is unusual in mandibular
fracture
 Obvious bleeding points such as facial vessels
should be secured with artery forceps and a
temporary dressing.
 Sometime, brisk & persistent hemorrhage
originates from displaced fracture of body of the
mandible.
o This can be managed by;
 Manual reduction of fracture and
temporary partial immobilization.
 Temporary partial immobilization
occur by means of suture or wire
ligature passed around teeth on
each side of fracture line.
Management of Soft – Tissue
Lacerations.
 Soft tissue wounds should be closed within 24
hours.
 If soft tissue repair along with definitive treatment
of fracture is possible, it is advantageous.
Otherwise, soft tissue must be closed ASAP.
 Before closure, they must be cleaned to remove
foreign material and gently scrubbed with mild
antiseptic cleaner such as 15 Cetavlon.
Management of the Bone
Fragments
 It is best to carry out definitive standard fixation
technique such as arch bar for immobilization bone
fragments.
 Do not waste time with ineffective temporary
fixations with;
o Barrel bandage
o Webbing head cap with chin support
o Elasto Plast chin strap

11. ~ 10 ~
Control of Pain
 In majority of patient,
pain does not occur due
to Neuropraxia of
inferior dental nerve.
o Neuropraxia;
disorder of PNS
in which there
is temporary
loss of motor &
sensory function due to blockage of nerve
conduction.
 However, sometimes mobile fracture of mandible
causes severe restlessness in a patient.
o This is one rare condition in which mandible
fracture is treated first than other injuries.
 Powerful analgesics such as morphine is
contraindicated because they depress cough reflex
and respiratory center which may cause death of
patient.
o It also masks the pain which can be
diagnostically important (e.g. from a
ruptured spleen).
Control of Infection
 Following measures should be taken;
o Benzyl – penicillin
 1 mega unit IM every 6 hours for 2 –
3 days. After this Oral penicillin for
1 week.
o Metronidazole (PO or IV)
 400 – 800 mg b.d.
Food and fluid
 It should be withheld if an immediate operation
under GA is going to be done.
 Otherwise, fluid diet must be taken for few days.
MANAGEMENT OF
FRACTURES OF DENTULOUS
OR TOOTH BEARING AREA
OF MANDIBLE
 General principle of management;
o Reduction (realignment) of fragments of
bone followed by immobilization until bony
union occurs.
 Traditionally immobilization has been done by a
procedure called inter – maxillary fixation. (IMF)
o In this, mandible is temporarily linked with
opposing jaw by help of wires or sutures
etc.
 Although there are many disadvantages to IMF as
mentioned below, this procedure is still used
because very large number of mandible fractures
encountered and limitation of resource such O.T
time etc.
o Prevent normal jaw function during
immobilization.
o Restriction of diet to liquid or semi – liquid
which result in weight loss.
o Oral hygiene is difficult to maintain.
o Recovery is prolonged
o 30% reduction of Ventilatory volume.
 So, alternatives to IMF were developed which are
being used in current period such as;
o Rigid osteosynthesis by means of bone
plates.
Reduction
 It is defined as “restoration of functional alignment
of bone fragments”.
 In dentate mandible, reduction must be
anatomically correct and also in occlusion.
o Less precise reduction may be accepted if
the part ofbody is edentulousor there are no
opposing teeth.
 Presence of teeth provide;
 Assist in reduction
 Alignment of fragments
 Assist in immobilization.
o If reduction is based on occlusion, it is
important to recognize previous occlusal
abnormalities such as;
 Anterior or lateral open bite
o Contact areas can be identified by
examining wear faces of teeth.
 Widely displaced, multiple or extensively
comminuted fractures are reduced by open
operative exploration.
 Reduction should be done in GA or LA based on
circumstances.
 If due to compromised general medical condition
of patient, fracture cannot be reduced with GA.
Then, in them fracture can be reduced by;
o Elastic traction; in this elastic bands are
applied tocap splints or wire fitted toteeth
on individual mandibular fragments and
then attached to maxilla.

12. ~ 11 ~
TEETH IN FRACTURE LINE
 Teeth in the fracture line are a potential hindrance
to healing of bone due to infection of fracture.
 Retention of healthy tooth will delay the clinical
union fracture by a short period of 3 – 4 days.
 Absolute Indications for removal of tooth from
the fracture line;
o Longitudinal fracture of root
o Dislocation or subluxation of tooth
o Presence of periapical infection
o Infected fracture line
o Acute pericoronitis.
 Relative indications for removal of tooth
o Functionless tooth which would eventually
be removed electively;
 3rd
molar
o Advanced caries
o Advanced periodontal disease
o Doubtful teeth which could be added to
existing dentures
o Teeth involved in untreated fractures
presenting more than 3 days after injury.
Management of teeth retained in fracture
line, STEP WISE.
01) IOPA radiograph
02) Antibiotic therapy
03) Splitting of tooth if mobile.
04) Endodontic therapy if pulp exposed.
05) Extraction if fracture become infected
06) Follow up 1 for 1 year with endodontic therapy.
IMMOBILIZATION
 Fracture site is immobilized to allow bone healing
to occur.
 It can be achieved by;
o Osteosynthesis without Inter – maxillary
Fixation.
 Non – compression small plates
 Compression plates
 Mini – plates
 Large screws
o Inter – maxillary fixation
 Bonded brackets
 Dental wiring
 Direct
 Eyelet
 Arch bar
 Cap splints
o Inter – maxillary fixation with
osteosynthesis
 Trans – osseous wiring
 Circumferential wiring
 External pin fixation
 Bone clamps
 Trans – fixation with Krischner
wires.
 Osteosynthesis can be achieved by
o Rigid Fixation
o Semi rigid fixation
 Osteosynthesis; is the reduction and internal fixation
of a bone fracture with implantable devices that are
usually made of metal. It is a surgical procedure with
an open or per cutaneous approach to the fractured
bone.
o Internal fixation is
an operation in orthopedics that involves
the surgical implementation of implants for
the purpose of repairing a bone.
 Rigid fixation;
o By means of non-compressing or
compressing plates, pins etc.
o Non-compressing heals with secondary
intention.
 Callus formation occur
o Compressing, heals with primary intention.
 No callus formation
o More rapid stabilization of fracture site
than semi - rigid fixation.
 Semi – rigid fixation
o By means of wires.
o Heal by secondary intention with callus
formation
Period of Immobilization
 Period of immobilization depends on following
factors;
o Site of fracture
o Presence of retained teeth in fracture line
o Presence or absence of infection
 Fracture of mandibleusually heal within 3 weeks on
average in favorable circumstances.
 A simple guide to the time of immobilization of
fracture mandible;
 Young Adult + Fracture of Angle + Early Treatment
+ Tooth Removed from Fracture
3 weeks
 If…
o Tooth is retained in fracture line; add 1 week
in above mentioned basic 3 weeks.

13. ~ 12 ~
o Fracture is at the symphysis: add 1 week in
above mentioned basic 3 weeks.
 They require much time because poor
endosteal blood supply at symphysis
region.
o Age 40 years or above; add 1 or 2 weeks in
above mentioned basic 3 weeks.
o Children and adolescent; subtract 1 week
from above mentioned basic 3 weeks.
 Because they heal rapidly due to
rich blood supply and high
osteoblastic activity at that stage.
 Example; fracture of symphysis in 40 – year old
patient with retained tooth in fracture line. It will
require 6 weeks of immobilization.
o Basic week 3
o Symphysis 1
o Retained tooth 1
o Age 1
o TOTAL 6 weeks
OSTEOSYNTHESIS
WITHOUT INTER –
MAXILLARY FIXATION OR
RIGID OSTEO – SYNTHESIS
 This type of osteosynthesis can be achieved by use
of bone plates.
 Currently there are 3 systems of bone plates are
available;
o Compression Plates
 Swiss AO system
(Arbeitsgemeinschaft fur
Osteosynthese)
 ASIF techniques (Association for
the study of Internal Fixation)
o Non – compression plates AKA semi – rigid
ADVANTAGES;
o Prevent the need for IMF
o Patient can enjoy relatively normal diet
o Rapid restoration of function
o Maintain oral hygiene more easily
 Rigid fixation with plates is carried out from intra
oral approach.
 Bone plates however do not achieve the
fundamental objective of correct occlusion in
repair of mandible fracture. This can be overcome
by skillful hands of surgeon.
o So that’s why sometime, patients are still
treated with IMF for short period of time
along with plating.
 The incidence of post-operative infection of bone
plates is decreasing but still many plates have tobe
removed after treatment (DISADVANTAGE).
 Plates are currently made of titanium.
o Other material is stainless steel, chrome –
cobalt alloys.
INDICATIONS OF RIGID FIXATION;
 Fracture in an edentulous part of the body of
mandible.
 Concomitant fractures of the body and condyle
when early mobilization is indicated.
 Patient in whom IMF is contraindicated;
o Elder patients
o Mentally disturbed patients
 Fracture associated with closed head injury
 Continuity defects
 Fractures in which non – union or mal union has
occurred.
Non – Compression Small
Plates
 In these small conventional orthopedic plates are
used.
 They are not used currently.
 These plates are contoured according to bone
surface.
Compression Plates
 They are applied to the convex surface of mandible
at its lower border using screws which engage the
inner cortical plate.
 These plate contain at least minimum of 2 pear
shaped holes.
o Widest diameter of hole should lie towards
the fracture line.
Screw is inserted in the narrow part and after tightening,
head will rest in wider part of hole.

14. ~ 13 ~
 Chief problem with compression plates;
o Compression near the lower border open up
the fracture at the alveolar margin.
This problem can be
overcome by following
two methods;
01) Arch bar ligature to
the teeth
02) Separate plate
with screws
Disadvantages
of
Compression
Plates
 Post –
operative
removal due
to bulkiness
of the plate.
 Opening & distortion of fracture at alveolar
margins.
 Stress shielding effect
o reduction in bone density (osteopenia) as a
result of removal of typical stress from the
bone by an implant
Mini Plates
 was introduced by Champy et al. (1978)
 These are non-
compression mini
plates with screw
fixation.
 Can be placed anywhere
 These plates can be inserted intraorally below
periosteum with or without IMF.
 These plates can be left permanently, but
theoretically should be removed.
Lag Screws
 They are used for oblique
fractures.
 Thread of screw engages
only on the inner plate of bone.
 Hole drilled in outer cortex is made to a slightly
larger diameter than the threaded part.
 Minimum 2 screws are needed
INTERMAXILLARY FIXATION
– [IMF]
 Done when sufficient numbers of teeth are
present.
 Clinical union in approx. 4 weeks in nearly all cases.
 Can be done without general anesthesia.
 Different methods of IMF have been described in
following headings.
Bonded
Modified
Orthodontic
Brackets
 In this method, we apply the modified orthodontic
brackets on to the teeth of maxilla & mandible,
each containing hooks.
o After application of brackets, inter –
maxillary elastic bands are applied on the
bracket to immobilize the mandible.
 Usually performed in;
o Fractures with minimal displacement &
o Patients with good oral hygiene
Dental Wiring
 Is used when the patient has a complete or almost
complete set suitable shaped teeth.
 0.45 mm stainless steel wire is used.
o This wire requires stretching before use to
prevent loosing of wire after applying on
teeth.

15. ~ 14 ~
 There are two types of dental wiring for IMF
o Direct Wiring
o Interdental Eyelet wiring
DIRECT WIRING (GILMER WIRING)
 Most simple rapid technique.
 In this technique, 6 inch (15cm) wire is taken and the
middle portion of wire is twisted around a suitable
tooth and then the free ends are twisted together to
produce a 3 – 4 inch (7.5 – 10 cm) length of plaited
wire (choti wangur)
 It can be applied as “clove hitch” form for great
stability and when few teeth are absent.
o CLOVE HITCH; a knot by which a rope is
secured by passing it twice round a spar or
another rope that it crosses at right angles
in such a way that both ends pass under the
loop of rope at
the front.
DISADVANTAGE OF DIRECT WIRING: A loose or
broken wire cannot be replaced without removing and
replacing others.
INTERDENTAL EYELET
WIRING
Eyelets are constructed by holding a 6
inch (15cm) length of wire by a pair of
artery forceps at either end and giving the
middle of the wire two turns around a
piece of round bar 1/8 inch or 3mm in
diameter which is fixed in upright
position.
01) These eyelets are passed b/w two
teeth from buccal to lingual/palatal.
02) The two arms passed back to buccal side through
the adjacent distal and mesial interdental spaces
03) The distal arm is inserted through the loop.
04) Then two ends of
the wires are
twisted together.
05) Upper and lower
jaw are connected
by “Tie wire”
passing through
eyelets from upper
and
lower
jaw.
06) Before tightening the tie wire, extraction should be
done if needed and everything is cleared from
mouth because after tightening of tie wire, mouth
will remain closed for some weeks.
 Minimum 5 eyelets are placed in maxilla and 5
eyelets in mandible.
 Evaluate normal pre-fracture occlusion before
tightening, because some patients have
abnormality of their occlusion and an attempt to
achieve theoretically correct occlusion in such
cases result in gross derangement of bony
fragments.

16. ~ 15 ~
 Tie wires should be tightened in molar area, first on
one side and then on other, so working and moving
round to incisor area.
o If wires are tightened on one side first, cross
bite will develop.
o If anterior wire is tightened first, posterior
open bite will develop.
 Wiresare twisted tightly on multi-rooted teeth, but
care must be taken on anterior teeth, because
tightening can result in extraction of anterior teeth.
 After wiring is completed, finger is moved around
mouth to check if there is any projection is left
which can ulcerate the tissue.
 ADVANTAGES
o Tie wire can be removed without
disturbing eyelet.
o If one eyelet is broken it can be replaced
easily without removing other eyelets.
ARCH BARS
 It is most versatile form of mandibular fixation.
 Used, when;
o Patients with insufficient number of teeth
o Direct link across the fracture is required.
 Technique Overview;
o The fracture is reduced, and then teeth are
tied to a metal bar which has been bent to
adapt to the dental arch.
 Types of
prefabricated
Arch bars;
o Winter
o Jelenko
o Enrich
 These bars are
tied to teeth with;
o 6-inch length of either 0.45 mm or 0.35 mm
stainless steel wire.
Technique for Arch Bar.
01) Check occlusion
a. Before
inserting
the arch
bars, check
the
occlusion.
There
should be full interdigitating of the teeth
with regular contacts.
b. Determine if the patient has a normal
occlusion or a preexisting malocclusion
before taking the patient to the operating
room.
02) Adjust the shape of arch bar according to jaw;
a. The prefabricated arch bar must be adjusted
in shape and length according to the
individual situation. The arch bar should not
damage the gingiva.
b. Firstly, the bar is adapted closely to the
dental arch. The bar should be placed
between the dental equator and the
gingiva.
c. Methods to obtain length and curvature of
arch;
i. Comparing with maxillary arch
ii. From plaster model of similar size
03) Trimming the bar
The bar should be
trimmed to allow
ligation to as many
teeth as possible. The
bar should not extend
past the most distal
tooth or protrude into
the gingiva as this will
be an irritation to the
patient.
“thehooksmustbepositioned symmetricallyinthe
upper and lower jaw. This symmetry is essential for
functional training with elastics.”
04) Ligature Preparation
a. Insert wire in
similar manner
to direct wiring
method, but do
not tie it.
05) Attaching the bar to teeth with wire
a. Position the arch bar and fix it using the wire
twister.
b. Start from midline and successively proceed
to backwards till last tooth.

17. ~ 16 ~
c. One end of the wire should be above the
arch bar and the other end below it.
06) Cut the wire with
the cutter and
turn the ends
away from the
gingiva to
prevent damage.
a. Make sure
the wire rosettes do not protrude away from
the arch bar as this will be an irritation to the
patient.
07) Joining of maxilla and mandible IMF;
a. Can be done by either elastics or wires.
CAP SPLINTS
 These appliances are used less frequently now a
days and are indicated in few cases as mentioned
below;
o Patients with extensive and advanced
periodontal disease.
 In current practice, surgeons
usually extract these teeth and
apply bone plates.
o To provide prolong fixation on the
mandibular teeth in a patient with fractures
of tooth – bearing segment and bilateral
displaced condylar neck fracture
o When a portion of body of the mandible is
missing together with soft tissue loss.
o Orthognathic surgery
o Mid facial fractures along with mandible
fracture.
 It is constructed in laboratory and is time
consuming.
 Completely formed splint is tried first before
cementation.
 Cementation of splints can be achieved by;
o Black copper cement
o Cold – cure acrylic
 Gingival inflammation is major
disadvantage.
Impression technique for cap splints
 Only teeth and small amount of alveolar margin is
recorded in the impression.
 Use mandibular tray for both jaws.
o Overcome the problem of limited mouth
opening in fracture.
 Mouth and teeth must be cleaned.
 Alginate is reliable material for inexperienced
doctors.
Inter-maxillary fixation wiring techniques. A, Arch bar
inter-maxillary fixation. B, Ivy loop wiring technique. C,
Continuous loop wiring technique.
Inter – maxillary fixation with
osteosynthesis
In this mandible fractures are treated by combination
of IMF & trans osseous wiring.
TRANS OSSEOUS WIRING
 In this method, direct wiring across the fracture is
used to immobilize the fracture of mandible.
o Holes are drilled in the bone ends on either
side of the fracture line after which stainless
steel wire of 0.45 mm is passed through
holes & across the fracture & after
reduction, free ends of the wire are twisted
together & cut off.
 Upper border wires are applied via an intra – oral
approach and this approach is used for;
o Aligning edentulous posterior fragment
o Stabilizing fracture at the angle.
 Lower border wires are applied via intra – oral or
extra – oral approach for;
o Grosslydisplaced fracturesof body or angle.
o Fractures at symphysis region
 Wiring can be done by intro oral
incision in anterior buccal sulcus.

18. ~ 17 ~
 If single wire is to be applied on lower border, it
should be applied in “figure 8” pattern.
 If the line of fracture is very oblique in the vertical
plain. In this condition, pass two wires separately
directly through outer and inner cortical plate and
twist the ends
together
under lower
the lower
border.
Advantages
of trans
osseous
wiring
 Minimal specialized equipment
CIRCUMFERENTIAL WIRING
 It is used in oblique fractures in which wire of same
dimension as trans osseous wire is passed
circumferentially around fracture.
EXTERNAL PIN FIXATION
 It is mostly used in comminuted fractures.
 In this method, a pair of 1/8 inch (3mm) titanium or
stainless steel pin is inserted into each bone
fragmentswhich are connected to eachby a cross bar
attached with universal joints.
 This type of fixation is not rigid and so that’s why
IMF is required.

19. ~ 18 ~
 Another method of reinforcing the extra oral
fixation is by self-curing acrylic resin in” bi phasic
appliance”
An alternative to themodular technique is thebiphasic pin fixation
(also known as Joe Hall Morris fixation).
Subsequent to thefirst phasewherefracture alignment is achieved
with adjustable connecting rods between the pin pairs (not shown
in the illustration), is the second phase when the aligned pins are
covered with a silicon tube, e.g. endotracheal tube, injected with
methyl methacrylate resin. Alternatively, the pins can be
connected with a moldable plastic shield that hardens after
application.
Indications of External Pin Fixation
 Missile injuries of mandible
 Infected fracture line
 Extensively comminuted fractures
 Bi-maxillary fracture (box frame fixation)
BONE CLAMPS
 It is external fixation
 Example of appliance; Brent Hurst appliance
 In this method clamps
are attached to
fragments of
fractured bone which
is then joined with
external rods similar
to external pin
fixation.
TRANSFIXATION
WITH KIRSCHNER
WIRES (K – WIRES)
 Most commonly used in orthopedic.
 They provide temporary stabilization in
comminuted fractures.
o The fracture is reduced; holes are drilled on
both side of fracture parts in which wire is
passed.
 It can be applied as single rod or horseshoe shaped
for whole mandible.
Choice of Method of
Immobilization.
 The fracture pattern
 Skill of operator
 Resources available
 General medical condition of patient
 Presence of other injuries
 Degree of comminution
 Soft tissue injury or loss.

20. ~ 19 ~
FRACTURE OF EDENTULOUS
MANDIBLE
Effects of edentulous mandible
 Loss of vertical depth
 Decreased resistance of bone to trauma
 Diminishing of endosteal bone supply of IAA
o Increase demand from periosteal blood
supply.
 Easily fractured
 Slow healing with complications
 Increased chances of displacement of bone
fragments
 Non union
ADVANTAGES OF EDENTULOUS
MANDIBLE
 Less chances of compound fracture in the mouth
because of absence of teeth.
o That’s why risk of fracture line infection is
reduced
 Precise reduction of fractured parts not necessary.
o Inaccuracy of jaw is compensated by
dentures.
Reduction
 Precise anatomic reduction is not necessary as
mentioned above.
 Reduction and fixation become more difficult as
the mandible atrophies.
Methods of Immobilization
 Traditional method for immobilization of
edentulous mandible was inter maxillary fixation
with Gunning Splints, however they are now
replaced with other methods as mentioned in
below.
 In older patients inter maxillary fixation is less
desirable because of following reasons;
o Difficulty in nutrition
o Oral candidiasis
o Etc.
 The methods of immobilization currently available
for edentulous jaws.
o Direct osteosynthesis
 Bone plates
 Trans osseous wiring
 Circumferential wiring or straps
 Trans fixation with Krischner
wires
 Fixation using cortico cancellous
bone graft
o Indirect Skeletal Fixation
 Pin fixation
 Bone clamps
o Inter maxillary fixation using Gunning Type
Splints
 Used alone
 Combine with other methods.
DIRECT OSTEO SYNTHESIS
Bone Plates
 Currently preferred method of fixation for the
majority of edentulous mandible body fracture.
 Allow the fracture to be stabilized without
immobilizing the whole jaw.
o The patient is comfortable.
 Cannot be used with very thing mandible.
o They require extensive stripping of
periosteum which can damage the blood
supply and prevent the healing.
Trans Osseous Wiring
 It is simple and reliable alternative to bone plates.
 Does not provide rigid osteosynthesis and
supplementary fixation may be necessary
 Easier to apply from intra oral approach
 Less periosteal stripping is required; advantage in
thin mandible.
Circumferential Wiring or Straps
 Effective in oblique fracture of edentulous
mandible.
Trans fixation with Kirschner Wire
 Used where sufficient amount of bone is present in
edentulous mandible
 Contraindicated in ultra-thin mandible
Primary Bone Grafting
 It is a method of stabilizing and augmenting the
fracture of the body of the ultra – thin edentulous
mandible.
 A 5 cm length of rib is obtained as autogenous
graft, the rib is split and placed at fracture site
which is again covered with circumferential wiring.
o Iliac bone can be taken as bone graft.
 Postoperative morbidity at donor site is reduced by
controlled infusion of bupivacaine through epidural
catheter.

21. ~ 20 ~
INDIRECT SKELETAL FIXATION OR
OSTEOSYNTHESIS
Same as mentioned for dentate mandible.
INTER MAXILLARY FIXATION USING
GUNNING TYPE SPLINTS
 They are vulcanite overlay of the edentulous
mandible, consists of bite blocks in place of molar
teeth and a space in the incisor area to facilitate
feeding.
 They can be used if edentulous space is in one or
both jaws.
o If both jaws are edentulous, immobilization
is carried out by attaching the maxillary
splint by pre alveolar wires & mandibular
splints with circumferential wires in the
jaws. In them, inter maxillary fixation occur
by connecting the both splints with wire
loops and elastic bands.
o If one jaw is edentulous & other is not, then
that one gunning splint is attached with
whatever type of splint present in the
opposite jaw.
 These gunning splints should hold the jaws in
slightly over close relationship.
 The edges of these splints should be overextended
to prevent entrapment of food.
o Overextension does not cause ulceration of
mucosa in immobilized jaw.
 Gunning splints are constructed on models from
impression of patients’ mouth.
o The degree of overextension can be
obtained by using impression compound as
impression material.
 The splints are constructed in acrylic resin and
fitting surface is lined with black Gutta Percha.
o Hooks are incorporated into each splint for
IMF
 If the OMFS laboratory is not available, gunning
splint can be prepared from patient’s denture by;
o Grinding the fitting surface and filling the
black Gutta Percha, & then removing the
anterior teeth for feeding. Hooks applied
with self – cure material.
 If maxillarysplint is not retaining, it can be attached
to maxilla by help of awl wire of 0.45 mm passing
through the alveolus high up in the canine area on
each side and then through an appropriately
positioned hole in the palatal portion of the splint,
the two free ends on each side are twisted together
over the splint, cut short and bent in one of the
hooks or clefts.
 The lower splint is attached with help of
circumferential wire.
 They are still widely used for fixation of fractures of
edentulous mandible.
 Method is useful for simple fractures treated by
minor surgeons.
 Splint become foul during 4 – 6 weeks due to
stagnation of food.
 Candida induced stomatitis & infection of wire are
common.
 They are however inefficient as a method of
immobilization and provide poor control of mobile
fractures, particularly with thin mandible.
Selection of Method of Fixation
in Edentulous Mandible
 Reduction should be accomplished with minimal
exposure because of risk of non – union due to
interference with periosteal blood supply
 In fit patients, open reduction & direct
osteosynthesis is the method of choice. Inter –
maxillary fixation should be avoided whenever
possible.
 The most effective form of osteosynthesis in
edentulous mandible is by non-compression mini
plates.
 The ultra-thin mandible should be treated with
autogenous bone grafts if the patient’s medical
condition permits.

22. ~ 21 ~
FRACTURE OF CONDYLAR
REGION
 They are the only facial bone fracture which involve
a synovial joint.
 Trauma to this region is divided into 3 main types.
o Contusion
 CHARACTERIZED BY;
 Damage to capsular ligaments
 Synovial effusion
 Haemarthosis
 Tearing of meniscus
o Dislocation
 Anterior & Medial common
 Lateral, Posterior & Central rare.
o Fracture
Management of Condylar
Fracture
1) Conservative Management of Condylar Fracture
2) Open Reduction of Condylar Fracture
CONSERVATIVE MANAGEMNT OF
CONDYLAR FRACTURE
 IMF
 Functional therapy
o Passive mandibular movement exercise
o Mouth opening exercise
Advantages of Conservative Treatment
 Safe treatment
 No injury to nerves & vessels
 No post-operative complications
Disadvantages of Conservative Tx.
 IMF cause injury to PDL & Buccal Mucosa
 Poor oral hygiene
 Pronunciation disorder
 Imbalanced nutrition
 Mouth opening disorder
 Respiration disorder
 Growth disorder
 Mandibular deviation
 Facial asymmetry
OPEN REDUCTION OF CONDYLAR
FRACTURE
Indications of Open Reduction
 Condylar displacement into middle cranial fossa
 Impossibility of restoring occlusion
 Lateral extra capsular displacement of condyle
 Invasion by foreign body. E.g. Missile
 Patients in whom IMF is contraindicated
 Bilateral fracture along with mid face fracture
 Bilateral fracture with sever open bite
Advantages of Open Reduction
 Reduction of displaced bony fragments tothe most
ideal anatomical site by direct approach to fracture
site.
 Prevent complications such as;
o Respiratory disorder
o Pronunciation disorder
o Sever nutritional imbalance
Disadvantages of Open Reduction
 Invasive treatment
 Injury of nerves & vessels
 Post-operative infection
 Permanent scar
Major Complications
ANKYLOSIS OF T.M.J
 Most frequent causes or factors
o Fractures in children below age 10
o Intra capsular crushing of condyle
o Damage to meniscus
DISTURBANCE IN GROWTH
Failure of development of condylar process and a
smaller mandible on the affected side.
Treatment of Condylar Fracture
Classification of Condylar Fractures
1) Age of patient
a. Under 10 years
b. 10 – 17 years
c. Adults
2) Surgical Anatomy
a. Intra capsular
b. Extra capsular
i. High condylar neck
ii. Low condylar neck
3) Site
a. Unilateral
b. Bilateral
4) Occlusion
a. Disturbed
b. Undisturbed.
Children Under 10 years of Age
 More chances of growth disturbances and
limitations of movement in this group.

23. ~ 22 ~
 Malocclusion if caused by condylar fracture will
resolve spontaneously in this age group.
 Use only conservative approach in this age group.
o Careful follow-up and monitoring of growth
is required and mandibular development is
reduced, it can be treated with
myofunctional appliances.
Adolescents 10 – 17 years’ age
 Capacity of spontaneous correction of
malocclusion is less than above mentioned
younger group.
 Also conservative treatment is given only.
ADULTS
Unilateral intra capsular fracture
 If occlusion is not disturbed, go for conservative
treatment without mandible immobilization.
 If malocclusion is present, go for IMF with eyelets
for 2 -3 weeks.
Unilateral condylar neck fracture
 If fracture is un-displaced and occlusion is normal –
no treatment.
 If fracture is displaced with malocclusion & there is
low condylar neck fracture – open reduction is
treatment.
 If, there is high neck fracture, displacement &
malocclusion – IMF for 3 – 4 wks.
Bilateral Intra capsular fracture
 Immobilization of mandible for 3 – 4 weeks
followed by jaw physiotherapy for prevention of
limited movement.
Bilateral Condylar neck fracture
 Functional treatment is contraindicated.
 IMF for up to 6 weeks
 Open intervention
 Treatment is beyond our scope.
FRACTURES OF MANDIBLE
IN CHILDREN
 They are uncommon in children because of strong
mandible at this stage which require a large
amount of force to fracture it.
 Greenstick fracture is more frequent.
 Greater risk of damage to teeth;
o Disturbed formation
o Pulp necrosis
 The treatment of mandibular fracture in children
before puberty is generally of a conservative nature
because of rapidly healing and adaptive potential
of the bone and its contained dentition.
 The normal growth of mandible will not occur if
unerupted permanent teeth or teeth germs are lost
because the alveolus will not develop at that site.
Fixation in the Deciduous &
Mixed dentition Period
FIXATION INDEPENDENT OF THE
TEETH
 In the very young with unerupted or very few
deciduous teeth – gunning splint is used for lower
jaw alone.
 When there iswidespread caries or loosedeciduous
teeth, the mandible may be suspended by
circumferential wires on each side linked to
circumzygomatic wires from above. fixation
utilizing the teeth
 Cap splints in partially erupted teeth.
 Eye lit wire or arch bar in sufficient firm deciduous
& permanent teeth.
o Use thin wire 0.35 stainless steel
o Arch bar without hooks
 Orthodontic brackets in simple fractures.
Healing & Remodeling
Mandibular fractures in children heal very rapidly and
some fractures are stable within a week and firmly
united within 3 weeks.
POST OPERATIVE CARE
01) The immediate post – operative phase
a. When pt. is recovering from the G.A
02) The intermediate post – operative phase
a. Before clinical bony union established
03) The late post – operative phase
IMMEDIATE POST –
OPERATIVE PHASE
 Good nursing care in ICU or in ward till recovery
from G.A
 Naso pharyngeal airway should be left in situ after
operation till patient gain consciousness.
 Physical control of tongue in an unconscious with
the suture in patients with;
o Extensive soft tissue injury to oropharynx
o Expected to remain cerebrally irritated after
recovery.

24. ~ 23 ~
 Patients should be lying on their sides during
recovery to enable saliva or blood to escape from
mouth.
 Post – operative vomiting should be avoided and
should not occur.
INTERMEDIATE POST –
OPERATIVE CARE
GENERAL SUPERVISION
 Occlusion should be checked;
o Direct osteosynthesis carries with it a
greater risk of malalignment.
o Unacceptable reduction should be corrected
as early as possible.
 Inspection of IMF
o P.O reduction is maintained or not
o Looseness of fixation
 Post – operative radiographs
o Confirmation of satisfactory reduction and
fixation.
 Pain, swelling or infection if visible, should be
corrected ASAP
o Good reduced & immobilized fracture is
painless & post – operative edema has been
subsided.
POSTURE
 Conscious patient with mandible fracture should
be nursed with sitting position with the chin
forward.
o This position is contra indicated in those
patient in whom fracture vertebrae is
present.
 Unconscious patient shouldbenursed lyingon the
side.
SEDATION
 Adequately treated mandible fracture patient will
experience very little pain & P.O analgesics are
rarely indicated and should not be given routinely.
 Morphine & its derivatives are contraindicated in
patients with maxillofacial injuries because they;
o Depress respiratory center & cough reflex.
o Mask the declining level of consciousness.
o Obscure the pupillary changes which are
indicative or rise in intra cranial pressure;
 Coz of constriction of pupil
o Suppression of signs of injuries of injuries of
other areas.
 Intra – abdominal bleeding
 Patients who are cerebrally irritated;
o Sedate them with IV diazepam
Restless in semi – conscious patient is due
to airway difficulty or distended bladder.
PREVENTION OF INFECTION
 Penicillin is the drug of choice along with
metronidazole to the regime.
ORAL HYEGINE
 Conscious Patient
o If mouth can be opened – hot normal saline
mouthwashes OR 0.2% chlorhexidine
gluconate mouthwash
o If mouth closed during embolization – clean
the wires with TOOTHBRUSH is usual
manner.
 Unconscious Patient
o Cleaning of mouth by nursing staff with
normal saline solution after every meal by
using “Higginson Syringe”
o Cap splints can be cleaned with 1 – 4%
sodium bicarbonate solution by cotton
swabs held in forceps or tweezers.
 Contaminated rubber bands are changed
frequently.
 The lips and mouth should be cleaned with moist
saline swabs at regular intervals and lips regularly
lubricated with steroid – containing ointment (1%
hydrocortisone ointment) or petroleum jelly.
Feeding
 The conscious cooperative pt.
o These patients can be fed by mouth a semi –
solid or liquid diet with the help of feeder,
feeding cup or straw.
 The unconscious or uncooperative patient
o There are two routes of feeding in these
patients;
 Enteral Route
 Trans – nasal gastric tube
 Naso – gastric tube
 Parenteral Route
 IV Drip (fluid overloading is
greatest risk in this
method)
Late Post – Operative Care
TESTING OF UNION AND REMOVAL OF
FIXATION
 All plates & trans osseous wires should not be
removed unless they cause trouble.

25. ~ 24 ~
 Indication for their removal;
o Infection
o Exposure to mouth
o Close & prominent proximity to skin
o Interference with denture.
 When IMF is used, it is left there until clinical union
occurs.
o Little movement at the time of removal or
wires is acceptable.
o The mouth should be cleaned with 1%
chlorhexidine gluconate solution before
removal of wires.
 Cap splints are removed with Upper Reid forceps.
ADJUSTMENT OF OCCLUSION
 Little or none adjustment of occlusion is required
with direct or eyelet wiring.
 Adjustment of occlusion is always required in cap
splints.
 Slight derangement of occlusion can be corrected
by allowing the patient to masticate normally.
 More gross abnormalities of occlusion are treated
by grinding the cusps.
 Edentulous patients will require new denture after
healing, because old ones are not going to fit.
MOBILIZATION OF TMJ
 Function of TMJ is adversely affected in condyle
fractures.
 Other fracturesalsoreduce the overall mobility and
closing force of mandible.
ANESTHESIA & PARESTHESIA OF LIP
 If IAN is involved in fracture, the damage may take
following form & recovery depend on nature &
degree of damage;
o Neuropraxia OR
 It is a disorder of the peripheral nervous
system in which there is a temporary
loss of motor and sensory function due
to blockage of nerve conduction.
 Take 6 – 8 weeks for recovery.
o Neurotmesis
 (in Greek tmesis signifies "to cut") It is
the most serious nerve injury in the
scheme. In this type of injury, both
the nerve and the nerve sheath are
disrupted. While partial recovery may
occur, complete recovery is impossible.
 May take 18 months.
 Area of lower lip which is supplied by IAN also has
accessory sensory supply from the mylohyoid nerve.
 Damage to lingual nerve cause loss of sensation in
the anterior 2/3rd
of tongue.
TEETH AND SUPPORTING TISSUES
 Fixation methods which involve attachments to
teeth need to distribute the load so as to avoid
excessive traction on individual segments of the
dentition, otherwise irreversible damage to PDL
may occur.
 Teeth retained in the fracture line – need
periodontal treatment.
 Lost teeth – prosthetic treatment.
COMPLICATIONS OF
MANDIBLE FRACTURE
Complication Arising During
Primary Treatment
 Misapplied Fixation
o Bone plates – damage to roots or inferior
dental canal, distortion of anatomical
alignment & occlusion.
o Trans osseous wires –displacement of bone
fragments, damage to inferior alveolar
nerve, inadequate retention of cap splint.
o External pins –impingeonnerves,vesselsor
teeth, split the bone fragments, may
become loos if not inserted properly.
 Infection
o Results in necrosis or osteomyelitis
o Mostly occur in patient with;
 Diminished local resistance to
bacterial invasion
 Debilitated patients, diabetics,
patients on steroid therapy
 Injudicious surgical interference
 Nerve Damage
o Inferior alveolar nerve damage
 Anesthesia of Lower Lip as A Result
of Damage to Inferior Alveolar
Nerve Is the Most Common
Complication of Fracture of
Mandible.
o Facial nerve damage.
 Displaced teeth and foreign bodies embedded in
tissue may result in abscess
 Pulpitis
 Gingival and periodontal complications
o Local gingivitis always occurs in interdental
wires & cap splints
o Partial extrusion or loss of teeth from
applying too much interdental force
 Drug Reaction
o if drug reaction is suspected, discontinue all
drugs and prescribe antihistamine.

26. ~ 25 ~
Later Complications
 Mal – Union
o Minor mal – union is more common in cap
splints and usually results from;
 Uneven cementing of splints
 Variation in thickness of metal
casting.
o If fixation is removed during clinical union
when the callus is still soft, minor
discrepancies in the occlusion will often
correct themselves as the patient starts to
use the jaws again or by occlusal grinding.
o CAUSES OF GROSS DERANGEMENT OF
OCCLSUION & DEFORMITY OF FACE;
 Untreated fracture
 They will require operative or
surgical reconstruction.
 Delayed Union
o Causes
 Infection
 osteoporosis
 nutritional deficiency.
 Sequestered bone
 Devitalized tooth
o Treatment
 Moderate delay – prolong the
immobilization.
 Removal of sequestered bone &
tooth
 Autogenous cancellous bone
chips from iliac crest in the
fracture line inserted.
 Non – Union
o Radiographs shows rounding off and
sclerosis of bone ends – eburnation.
o CAUSES OF NON – UNION
o Infection of fracture site
o Inadequate mobilization
o Unsatisfactory apposition of bone ends
with interposition of soft tissues.
o The ultra – thin mandible in elderly
debilitated patient
o Loss of bone and soft tissue as a result of
severe trauma
o Inadequate blood supply to the fracture
site – after radiotherapy
o Bone pathology – neoplasm
o General diseases;
 Osteoporosis
 Nutritional deficiency
 Disorder of calcium metabolism
o TREATMENT OF NON – UNION
 Bone graft
 Derangement of Temporomandibular Joint
 Late Problems with Tran osseous wires
o Trans osseous wire at the upper border
cause symptoms if covered by denture.
o Bone plates should not be placed near the
mucosa to prevent their rupture
o Lower border wires cause pain and
discomfort in thin skins
o Infection of bone plates
 Sequestration of Bone
o Mostly in comminuted fractures
o Act as source of infection
 Limitation of opening
o CAUSES
 Prolonged immobilization - result
in weakening of muscles of
mastication.
 Hemorrhage within muscles –
form scar
 Fibrodyplasia ossificans – rare
condition in which hematoma
ossifies.
o TREATMENT
 Spontaneous recovery
 Physiotherapy
 Manual manipulation under
anesthesia to break the scar
 Excision in Fibrodyplasia
ossificans.
 Scars
Summary of Complications
Early Complication Later Complications
 Misapplied Fixation
 Infection
 Nerve Damage
 Displaced Teeth &
Foreign bodies
 Pulpitis
 Gingival & Perio
Complications
 Drug Reaction
 Mal – union
 Delayed union
 Non – union
 Derangement of TMJ
 Bone Sequestration
 Trismus
 Scars
FRACTURES WITH GROSS
COMMINUTION OF BONE &
LOSS OF HARD AND SOFT
TISSUES
 Caused by;
o Industrial injuries or fast moving projectiles
o Missile injury (most common cause)

27. ~ 26 ~
 These fractures are usually extensively
comminuted, compound & contaminated by
foreign matter & bacteria
 This kind of damage is due to release of Kinetic
energy from fast moving object;
o Kinetic energy is directly proportional to
velocity of object
There are FOUR phases of management of these
fractures;
01) Immediate pre – operative phase
02) Primary surgery
03) Immediate post – operative phase
04) Reconstructive phase
Immediate Pre – Operative
Phase
Mentioned in Preliminary Treatment above.
Primary Surgery
Performed only after tracheostomy.
01) Wound Toilet
a. it is cleaning of wound
02) Debridement
a. it is removal of devitalized tissues
03) Management of Involved Teeth
a. Extensively damaged & subluxed teeth
should be removed
04) Reduction & Fixation
a. Arch wire is best method alongwith minimal
number of trans osseous wires
05) Closure of mucosa & skin
a. oral mucosa is closed first after reduction
and it must be water tight and then jaws are
immobilized and after that skin wound is
sutured.
b. The rich blood supply of face makes it easy
to raise flap from other areas of face.
06) Drainage
a. Drains are applied to prevent & control the
infection of sequestrate bone.
Immediate Post – Operative
Phase
 Sympathetic nursing to boost their confidence
regarding the future facial deformity.
 Special feeding devices and saliva shield is given to
prevent the escape of oral secretions.
 Active oral hygiene with mouth irrigation
 Nursing care of wounds.
Reconstructive Phase
 Bone grafting
 Skin grafting
 Dentures
 Etc.
THE END
AUTHOR
SARANG SURESH HOTCHANDANI
Final Year BDS, Batch – 01
Bibi Aseefa Dental College
SMBBMU Larkana, Sindh, PAKISTAN
hotchandanisarang@gmail.com
Mob: 03154044802 - 03463361966
www.twitter.com/fetusdentista