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MANDIBLE
FRACTURE
MANDIBLE
Rajesh R Yadav MS (ENT) DORL FCPS
Assistant Professor
Rajawadi Hospital
Formerly Registrar
Shri Harilal Bhagwati Hospital
Mumbai, Maharashtra, India
Chris De Souza
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Fracture Mandible
First Edition : 2012
ISBN 978-93-5025-801-9
Printed in
Dedicated to
Dinesh Yadav
In memory of my brother Dinesh Yadav, who is still
there with me and in me. His sweet memory always
keeps him alive. I miss him in every step of my life.
Rajesh R Yadav
Foreword
I am pleased and honored to write the foreword of this book on the Fracture
Mandible. My initial reaction was one of amazement when I saw how well the
book was written. When I finished reading it, I did feel that it was so well
written that it was definitely worth publishing and that all of us should possess
a copy of it and learn from it. It is lucid, well organized and extremely well
illustrated. It is also an unusual book dealing with a problem that so far was in
the realm of facial plastic surgery. The book is full of authors passion in
dealing with this problem and this passion is full of enthusiasm and deep insight.
I have long felt that otolaryngologists need to expand their expertise and deal
with facial plastic surgery in an in-depth way. As victims of high velocity
trauma find their way to emergency rooms all over globe we will definitely find
that this book become extremely relevant.
I look forward to seeing this book go into several editions and I wish to
see its scope and purpose expand.
I have no doubt that these talented enthusiastic surgeons and authors with
their passion and vision accomplish all of this.
Chris de Souza MS DORL DNB FACS
Honorary ENT and Skull Base Surgeon
Tata Memorial Hospital, Mumbai, Maharashtra, India
Consultant Otolaryngologist and Head Neck Surgeon
Lilavati Hospital and Holy Family Hospital
Mumbai, Maharashtra, India
Preface
In the modern era of rapid life, vehicular accidents and violence are a
common occurrence. Fractures of the mandible are gaining attention due to
the upward trend of accidents of two wheelers and other motor vehicles.
Before making an attempt of reducing the fracture, it is of utmost
importance to learn not only the relevant anatomy but also the development,
the dentition, the mechanisms of mandibular injuries and the different muscle
forces acting on different fragments of mandible.
Although management of mandibular fractures is routinely included in
the realm of plastic and reconstructive surgery or maxillofacial surgery, it
may not be possible to avail of such expertise all at times and in every region
of even a city like Mumbai, let alone managing such cases in more peripheral
hospitals. When faced with such situations, we ventured to learn the art of same
and, after managing more than two hundred cases of fracture mandible, we
thought of putting our experience on a paper so that others can benefit from our
work.
We do not claim that this is the best way, but we hope it can be of great
help to our friends working at different levels especially those with smaller,
private setups where, we will be happy to fill in the gaps in the required expertise.
We present here, to you, an overview of different methods of fixation,
anesthesia, anatomy and overall treatment. With our own experience, we felt
that even ENT Surgeons can deal with fractures of the mandible confidently.
The purpose of this book is to motivate more and more ENT Surgeons to do so.
We have avoided some of the techniques that are not often used now to fix
the mandible (e.g. external fixation techniques, nonrigid fixation techniques,
etc.) in order to stay abreast with the current trends in management.
We are grateful to our teachers, paramedical staff and patients who had
shown confidence in us.
We request the readers to point out any shortcomings in our present effort
to share our experience as it is a learning process and learning never stops.
Rajesh R Yadav
Akancha R Yadav
Prakash V Dhond
Acknowledgments
First and foremost, I would like to thank god for giving me the opportunity and
skill to do this work. I am thankful to my parents for always showering their
blessings on us. I am most grateful for the continued motivation and contribution
bestowed upon me by my co-editor that includes my mentor Dr Prakash V
Dhond and Dr Akancha R Yadav. The greater part of my experience comes from
Shri Harilal Bhagwati Municipal General Hospital, Mumbai, Maharashtra, India,
which for me is more than a temple. Here I had the good fortune of also having
the expert guidance of Dr Lalit Seth. My sincerest thanks go out to my patients
who have put their faith in my endeavors. I would like to thank the administrators,
particularly Dr Mahendra Wadiwala, Dr Dinesh Shetty, Dr Bhatt, Anesthetist,
Dr Bhavana Wadiwala and others, who trusted me and allowed me to manage
such cases here. I am thankful to my brother Sunil Yadav who helped me in
writing this book. I am grateful to Dr Ajay Haryani (Plastic Surgeon) from
whom I learnt the procedure.
I am grateful to Dr Deepak More and Dr Girish Surlikar, my buddies, my
friends, and everything who I trust will be always there for me in need.
Rajesh R Yadav
Contents
1. Dentition.................................................................................. 1
2. Fracture Healing and Biomechanics of Mandible ................ 6
3. Anatomy of Mandible........................................................... 12
4. Classification of Mandible Fractures .................................. 18
5. History and Clinical Examination........................................ 28
6. Radiology .............................................................................. 38
7. Preliminary Treatment .......................................................... 39
8. General Treatment of Fracture Mandible ............................ 42
9. Anesthesia for Fracture Mandible ....................................... 63
10. Specific Treatment of Fracture Mandible ........................... 74
11. Surgical Approaches ............................................................ 83
12. Fracture of Mandible in Children ....................................... 98
13. Postoperative Care ............................................................. 100
14. Complications ..................................................................... 104
Dentition / 1
Dentition
6 months
7 months
16 months
12 months
20 months
2 / Fracture Mandible
First premolar
Second premolar
First molar
Second molar
1011 years
1012 years
67 years
1213 years
Mandibular
Central incisor
Lateral incisor
Cuspid
First premolar
Second premolar
First molar
Second molar
67 years
79 years
90 years
1012 years
1112 years
67 years
1113 years
Dentition / 3
relationship to the jaws) and the relationships of the cuspid and the first
molar teeth on each side serve as a principle guides to the establishment
of proper occlusion. By the study of models, the wear-facet pre-existing
occlusion can often easily be recognized. Where the teeth have habitually come
together are indicated by wear-facets. A patient who had a class III oclussion
relationship (skeletal malocclusion) before injury would be impossible to treat
by attempting to force a teeth into a neutral occlusal relationship. A class I
(neutral) occlusion is one of which the mesial buccal cusp of the upper
first molar occludes with the mesial buccal groove of the mandibular
first molar. The protruding or jetting type of jaw is known as class III
malocclusion (mesial occlusion), and the retrusive or undeveloped jaw is termed
class II malocclusion (distocclusion). Other abnormalities of occlusal
relationship in the lateral direction, referred to as crossbite. Openbite or absence
of occlusal contact in any area should be noted. This may occur laterally,
anteriorly or anterolaterally and may be unilateral or bilateral. In the injured
patient in whom teeth or segment of bone are missing, it may be difficult to
determine what the normal occlusal relationship should be.
4 / Fracture Mandible
Dentition / 5
teeth brought into the best possible occlusal relationship so that adequate chewing
surface and joint function occur after the reduction, fixation, and consolidation
of jaw fractures.
SUMMARY
6 / Fracture Mandible
Two types of bone found in the bodycortical and trabecular. Cortical bone
is dense and compact. It forms the outer layer of the bone. Trabecular bone
makes up the inner layer of the bone and has a spongy, honeycomb-like
structure. Throughout life, bone is constantly renewed through a two-part
process called remodeling. This process consists of resorption and formation.
During resorption, special cells called osteoclasts break down and remove
old bone tissue. During bone formation, new bone tissue is laid down to
replace the old. Several hormones including calcitonin, parathyroid hormone,
vitamin D, estrogen (in women), and testosterone (in men), among others,
regulate osteoclast and osteoblast function. In the process of fracture healing,
several phases of recovery facilitate the proliferation and protection of the
areas surrounding fractures and dislocations. The length of the process depends
on the extent of the injury.
The process of the entire regeneration of the bone can depend on the
angle or dislocation of fracture. While the bone formation usually spans the
entire duration of the healing process.
While immobilization and surgery may facilitate healing, a fracture
ultimately heals through physiological processes. The healing process is
mainly determined by the periosteum (the connective tissue membrane
covering the bone). The periosteum is one source of precursor cells which
develop into chondroblasts and osteoblasts that are essential to the healing of
bone. The bone marrow (when present), endosteum, small blood vessels,
andfibroblastsare other sources of precursor cells.
2. Reparative phase
iii. Cartilage callus formation
iv. Lamellar bone deposition
3. Remodeling phase
v. Remodeling to original bone contour
Reactive
Afterfracture, the first change seen by light and electron microscopy is the
presence of blood cells within the tissues which are adjacent to the injury
site. Soon after fracture, the blood vessels constrict, stopping any further
bleeding.Within a few hours after fracture, the extravascular blood cells
form a blood clot, known as a hematoma. All of the cells within the blood
clot degenerate and die. Some of the cells outside of the blood clot, but
adjacent to the injury site, also degenerate and die. Within this same area,
thefibroblastssurvive and replicate. They form a loose aggregate of cells,
interspersed with small blood vessels, known as granulation tissue.
Reparative
Days after fracture, the cells of the periosteum replicate and transform. The
periosteal cells proximal to the fracture gap develop into chondroblasts which
formhyalinecartilage.Theperiostealcellsdistaltothefracturegapdevelop
intoosteoblastswhichformwovenbone.Thefibroblastswithinthegranulation
tissue develop into chondroblasts which also form hyaline cartilage. These
two new tissues grow in size until they unite with their counterparts from
8 / Fracture Mandible
Remodeling
The remodeling process substitutes the trabecular bone with compact bone.
The trabecular bone is first resorbed by osteoclasts, creating a shallow
resorption pit known as a Howships lacuna. Then osteoblasts deposit
compact bone within the resorption pit. Eventually, the fracture callus is
remodelled into a new shape which closely duplicates the bones original
Gap Healing
When small gaps occur between bone segments, within a few days after fracture,
gap healing begins at these points. Blood vessels from periosteum, endosteum
or haversian canals invade the gaps, bringing mesenchymal osteoblastic
precursors. Bone is deposited directly on the surfaces of the fractured segments
without resorption and without intermediate cartilage formation.
Contact Healing
It occurs through the formation of a bone metabolizing unit (BMU) a bone
remodelling unit (BRU) or a bone repair unit (BRU) which are all synonyms
for the newly forming (or regenerating) osteon. Advancing group of osteoclasts
followed by vessels and cells differentiated into osteoblasts and form new
bone.
Osteoclasts begin to cut away cores on either sides of fracture, progressing
towards the fracture side, through necrotizing bone and into opposing bone
10 / Fracture Mandible
General
Biomechanics of Mandible
This biomechanics of the mandible is a complex topic, there are various
forces which are applied on the mandible, e.g. biting force or muscle force. The
masticatory function of mandible is governed by influence of jaw opening
muscle inserted on the lingual aspect of the anterior part and the jaw closing
muscle on the posterior part of the mandible. The anatomical form of mandibular
body and the influence of muscular pull create characteristic stress within the
bone.
This forces applied on a mandible causes varying zones of tension and
compression force. Normally, on the superior portion of the mandible, tension
zone is applied and its maximum at the angle of mandible. On the inferior
border of mandible compression force is applied. A torsional force also exists
between the canines which increase its strength in midline. Osteosynthesis
plates are applied in such a way to combat this compression and tension force.
Additional osteosynthesis plate is applied at midline to combat the torsional
force.
SUMMARY
12 / Fracture Mandible
Anatomy of Mandible
Anatomy of Mandible / 13
The mandible is a strong bone but has several areas of weakness that are
prone to fracture. The body of the mandible is composed principally of dense
cortical bone with a small substantial spongiosa through which blood vessels,
lymphatic vessels and nerves pass.
Areas of Weakness
Presence of Teeth
Body of the mandible has two components that is alveolar component which
carries the teeth and basal bones. The presence of teeth make the bony structure
weak, resulting alveolar fracture can occur independent of the basal bone. Teeth
which have long roots or that are embedded in the bone also weaken the structure,
external root of canine is the longest amongst all mandibular teeth, presence of
impacted or unerupted third molar also make the structure weak.
Presence of Foramina
Weaken the structure but this point is contested by many workers as presence
of foramina add to the compactness of the bone. The fracture of the
14 / Fracture Mandible
Mandibular Muscles
The various muscles attached to the mandible can be grouped as:
1. Muscles of facial expression
2. Muscles of mastication
3. Accessory muscles of mastication.
Muscles of Mastication
Masseter, medial pterygoid, temporalis and external pterygoid are strong
muscles that help in closing and opening movements of the jaw. These
muscles play a major role in the fracture displacement especially of the angle
and condyle region. These muscles have strong tendonous attachment at the
site of origin and insertion.
The masseter and medial pterygoid muscles that form the sling of the
mandible displace the ramal fragment upward. They are aided in their action
Anatomy of Mandible / 15
16 / Fracture Mandible
Anatomy of Mandible / 17
Blood Vessels
Apart from hemorrhage from the inferior dental vessels which has been
mentioned, injury to major blood vessels is unusual in association with
mandibular fractures. A large sublingual hematoma may result from rupture of
dorsal lingual veins medial to an angle fracture. The facial vessels are vulnerable
to direct trauma where they cross the lower border of the mandible anterior to
the angle.
Temporomandibular Joint
Traumatic arthritis can occur without a fracture of the condyle, from indirect
transmitted violence. A synovial effusion occurs with widing of the joint
space on radiographs. Such a joint is extremely painful and mandibular
movement very restricted. When an intracapsular fracture of the condylar
head occur there may be direct involvement of the temporomandibular joint
with hemorthrosis. If this occurs in a young child it can lead to fibrous or bony
ankylosis of the temporomandibular articulation and destruction of the growth
potential of the condyle. Not infrequently a fractured condylar head is driven
backwards with sufficient force to tear, the adjacent external auditory
meatus and cause bleeding from the external ear. Such bleeding must be
carefully distinguished from the middle ear bleeding which signifies a fracture
of the base of the skull. Very rarely, the glenoid fossa is fractured as the
mandibular condyle is driven against this thin part of the temporal bone but
usually a fracture of the condylar neck prevents the other more serious injury
occurring.
SUMMARY
Trivial trauma can cause major injuries so all trauma should be taken
seriously.
Area of weakness are:
Presence of third molar (impacted)
Neck of condyle
Symphysis of mandible
Presence of foramina
Angle of mandible.
18 / Fracture Mandible
Classification of
Mandibular Fractures
Etiology of Fractures
Vehicular accidents and assaults are the primary causes of mandibular facial
fractures throughout the world. The other chief causes for these fractures are
Work related falls, sporting injuries and industrial trauma.
Vehicular accidents
Assaults
Falls
Sporting accidents
Miscellaneous causes
Thus the causes for maxillofacial fractures can be classified into:
a. Intrinsic causes
b. Extrinsic causes
Bending force
Torsional force
Neoplasia
Bony cysts
Osteoporotic bone
Osteoradionecrosis
Extrinsic Causes
20 / Fracture Mandible
The mandible is involved in 70% of patients with facial fractures. The number
of mandible fractures per patient ranges from 1.5 to 1.8. Mandible fracture
patterns of a suburban trauma centre found that violent crimes such as assault
and gunshot wounds accounted for a majority of the fractures (50%), while
motor vehicle accidents were less likely (29%).
The fractures of mandible area are classified based on the following
criteria:
a. Anatomical locations
b. Site of injury
c. Condition of the bone fragments at the fracture site
d. According to the direction of the fracture and favourability for treatment
e. According to severity of fracture
f. Presence or absence of teeth in the jaws
g. Clinical and radiological findings
1.
A.
B.
C.
D.
E.
F.
G.
H.
b. Indirect fracture
An indirect fracture is the one that occurs away from the site of injury.
A trauma on side of the mandible can cause a direct fracture at the canine
region on the same side and an indirect fracture of the angle of the mandible
or neck of the condyle on contralateral side.
3. Classification based on the condition of the bone fragments at the site
of the fracture
This classification denotes the condition of the bone fragments at the fracture
site and hints at the severity of trauma and damage to the soft tissues.
a. Simple fracture
When there is break in
continuity of the bone without
any break in mucosa or skin
membrane thereby the fracture
fragments are not exposed to
the external environment such
a fracture is said to be simple
fracture.
22 / Fracture Mandible
b. Compound fracture
When the fractured ends of the bone
are associated with the break in
continuity of skin or mucous
membrane thereby communicating
with the external environment
through the wound then it is called
as compound fracture. As a rule,
Fig. 4.4: Compound fracture
fractures involving the tooth bearing
area are always compound fractures because they communicate with the oral
environment through gingival sulcus and periodontal ligament.
c. Comminuted fracture
When the bone is splintered into
more than two fragments, it is
called as comminuted fracture.
These are high impact injuries on
account of major trauma.
d. Greenstick fracture
The bone in children is soft elastic
and there occurs an incomplete
type of fractures at times.
These appear as a crack in the
bone in which only one cortex of
the bone is fractured whereas other
cortex is bent only as in the case
of a green stick of a tree.
24 / Fracture Mandible
5. Classification according to
presence or absence of teeth
Teeth may have important role to play in the management of the fracture since
occlusion is considered to be a guide in reduction. When a teeth are not present,
alternative method of treatment to simple wiring procedures are compelled to
be considered.
a. Class I When teeth are present on both sides of the fracture line.
b. Class II When teeth are present only on one side of the fracture line.
c. Class III When both the fragments on each side of the fracture line are
edentulous.
26 / Fracture Mandible
Fracture Displacement
The pull of the muscles are described above and the direction of the line of the
fracture along with the intensity of the force hitting, the jaw are responsible for
the displacement of the mandibular fragments are described as under.
Fracture Condyle
There is no dislocation of the condyle if only a crack in a neck appears without
any tear in the capsule of the joint and periosteum of the bone but if there is
a fracture causing tear, anterior or medial dislocation of the condyle due to the
attachment of lateral pterygoid muscle will take place.
If the fracture lines are running towards each other, i.e. converging lines
from labial to lingual table of the mandible as well as from superior to inferior
border, no displacement is expected. However, if the lines are unfavorable ie.
If the fracture lines are running divergently from labial to lingual table of the
mandible as well as superior to inferior border, the central fractured fragment
is pulled downward and backward by the mylohyoid, geniohyoid, digastrics and
genioglossus muscles. It is further complicated by the collapse of the fragment
on the lateral side, medially towards each other making a closed reduction very
difficult.
Fracture of Symphysis
A vertical midline fracture normally exhibits no displacement but if the fracture
line runs an oblique course, the balance of the muscles is disturbed causing
displacement of the fragments backwards and downwards.
28 / Fracture Mandible
History
History is very much informative in case of fracture mandible.
Elicit regarding shape and size of the object causing injury, blow from
a broad, blunt object can cause several fractures while smaller well
defined object may cause single comminuted fractures. Since, impact of
force is concentrated in small area
Try to elicit the direction of impact. Anterior blow on a chin can cause
parasymphysis or bilateral condyle fracture.
The examination of a patient with the fracture of the mandible takes place
in three stages:
1. Instant and rapid assessment
2. General clinical examination of the patient
3. Local examination of the mandibular fracture
General Examination
Fractures of the mandible are, of course, caused by trauma of varying degrees
of severity and is reasonable to consider the possibility that this degree of
trauma may also have caused injury elsewhere in the body. This is especially
true if the patient has been involved in a accident such as road traffic
accident or a fall from a considerable height. However, a simple blow on the
lower jaw as a result of a fight or during the course of some game may result
in force being transmitted to the cranium which results in serious injury or
even death of the patient.
It is unusual for a patient with a mandibular fracture to be shocked and
if this condition is present some more serious injury should be suspected.
Extraoral Examination
Inspection
a. Swelling
Many of the physical signs of a fractured bone result from the
extravasation of blood from the damaged bone ends. This results in
very rapid early swelling from the accumulation of blood within the
tissues and later increase in the swelling resulting from increased
capillary permibiality and oedema. Swelling and ecchymosis indicate
the site of any mandibular fracture.
b. Deformity
There may be obvious deformity in the bony contour of the mandible.
c. Gait of patient
If considerable displacement has occurred the patient is unable to
close the anterior teeth together and the mouth hangs open. A conscious
patient may seek to support the lower jaw with his hand.
30 / Fracture Mandible
Palpation
Palpation should begin bilaterally in the condylar region and then continue
downwards and along the lower border of the mandible. If there is more
displacement it may be possible to palpate deformity or elicty bony crepitus.
Fractures of the body of the mandible are associated with injury to the
inferior dental nerve in which case there will be reduced or absent sensation on
one or both side of the lower lip.
Intraoral Examination
Dentoalveolar Fractures
Dentoalveolar injuries are defined as those in which avulsion, subluxation
or the fracture of the teeth occurs in association with the fractures of the
alveolus.
They may occur alone or in combination with some other type of mandibular
fractures.
Fractures of the roots of the teeth may be present which are difficult to
diagnose clinically. Exclusively mobile teeth which do not appear to be
subluxed are suspect and should be earmarked for later periapical
radiographs.
Individual teeth may be missing and/or recent extraction wound suggest that
the tooth concerned has been knocked out.
32 / Fracture Mandible
Condylar Fractures
These are the most common overall fractures of the mandible and are once
most commonly missed on clinical examination. Condylar fracture may be
unilateral or bilateral, and they may either involve the joint compartment as
intracapsular fractures or the condylar neck when they are regarded as
extracapsular. The extarcapsular fracture may exist with or without dislocation
of the condylar head, and the upper fragment may either remain angulated on
the lower portion of the ramus or be displaced medially or laterally.
There is often swelling over the temporomandibular joint area and there
may be hemorrhage from the ear on that side. Bleeding from the ear results
from laceration of the anterior wall of the external auditory meatus, caused
by a violent movement of the condylar head against the skin in this region.
It is important to distinguish bleeding originating in the external auditory
canal from the more serious hemorrhage.
The haematoma surrounding a fractured condyle may track downwards
and backwards below the external auditor canal. This give rise to
ecchymosis of the skin just below the mastoid process on the same side.
This particular physical sign also occur with fractures of the base of the
skull when it is known as battles sign.
In the recently injured patient there is invariably tenderness over the
condylar area.
When post-traumatic edema is present it is difficult to palpate the condylar
head.
The mandible deviates on opening towards the side of the fracture, and there
is usually painful limitations of protusion and lateral excursion to the opposite
side.
In all cases of bilateral fracture there is a pain and limitation of opening and
restricted protusion and lateral excursions.
Single Fracture
This is in effect a low condylar fracture with both the coronoid and condylar
process on the upper fragment.
Comminuted Fracture
Such a fracture always result from direct violence to the side of the face.
There is tenderness over the ramus and movements produced pain over
the same area.
34 / Fracture Mandible
When there is a gross displacement, the inferior dental artery may be torn
and this can give rise to severe intraoral hemorrhage.
Crepitation on palpation.
36 / Fracture Mandible
6
A
of
a.
b.
c.
d.
e.
Radiology
Essential Radiographs
a. Left and right oblique lateral view of mandible
This view are used to demonstrate fracture of mandible ramus, body of
mandible and symphysis region.
b. Posteroanterior
This view demonstrates fracture of body and angle with the type of
displacements. An undisplaced fracture of condyle head is difficult to see
in this view as it is obscured by superimposition of mastoid process.
c. Reverse Townes projection
This projection is used to demonstrate fracture of condyle region. As this
avoid superimposition of mastoid bone.
d. Intraoral
1. Periapical films are required to demonstrate a relationship of teeth to
the line of fractures and any damage to the teeth itself.
Radiology / 37
2. Occlusal films can help us to evaluate the relationship of tooth root to the
fracture.
Desirable Radiographs
Panoramic Films
Panoramic films are useful in defining location and displacement of mandible
fracture. It has a accuracy rate of 92% for diagnosis of fracture. This films
give a best single overall view of mandible and are specially valuable for
demonstrating fracture in condyle region. The combination of posterioranterior view and a pantomogram obviates the need for further radiographs.
The sites in which mandible fractures are most commonly under diagnose
on this view are condylar angle and symphysis area especially if there is
some blurring by the patients movement or hardware.
Advantages
Simplicity of technique
Good details
Can visualize mandible and maxilla with root of teeth in one radiograph.
Disadvantages
The accuracy rate of ct scan is around 92%. This offers a very little
advantage as a diagnostic tool in lower third of a face and are not justified
for isolated mandibular fractures on either clinical or economic ground. It
demonstrates detail of TM joint injury.
38 / Fracture Mandible
Three-dimensional CT Scan
It can be obtained to compare symmetry and volume of two side of bone of
face.
SUMMARY
Preliminary Treatment / 39
Preliminary Treatment
Most of the fractures of the mandible encountered are associated with fracture
in other part of body or other injuries in body. It is not common for such
patients to suffer from shock and evidence of acute circulatory collapse in
itself is indicative of damage to other important structures. Trauma to the
mandible does, however, frequently cause concussions from transmitted violence
to the base of the skull.
Airway Maintenance
Relatively minor injuries which cause intraoral bleeding and fracture of teeth
or dentures can lead to airway obstruction in an unconscious or semi-conscious
patient. The essential first aid required consists of careful examination of the
mouth and the removal of all fragments of teeth, broken fillings and dentures.
If suction is available blood clots and the saliva should be evacuated and the
patient positioned so that further bleeding and secretions can escape from the
oral cavity. If the symphysis region is fractured and particularly if it is
comminuted there is some danger of the tongue falling back and obstructing
the airway in a patient who has lost voluntary control of the intrinsic
musculature. Occasionally a suture passed through the dorsum of the tongue
may assist in controlling its position. The most satisfactory posture for an
unconscious patient is lying on his side in the position used routinely during
recovery from a general anesthetic. This position should be opted for
transportation of a patient to an accident unit or another treatment center.
Blood Loss
Serious blood loss is not common in mandibular fractures. Considerable blood
loss can however occur, when there are extensive associated soft tissue
lacerations, obvious bleeding points such as the facial vessel should be
secured with artery forceps and a temporary dressing applied. Occasionally
brisk and persistent hemorrhage originates from a grossly displaced fracture of
40 / Fracture Mandible
the body of the mandible. This can only be controlled by manual reduction of
the fracture and temporary partial immobilization by means of a suture or wire
ligature passed around teeth on each side of the fracture line.
Pain Control
The majority of the patients with mandibular fractures do not appear to suffer
much a pain, perhaps owing to the frequently associated neuropraxia of the
inferior dental nerve. Some mobile fractures of the body of the mandible are,
however, extremely uncomfortable and a potent cause of restlessness in a
cerebrally irritated patient. This situation is one of the rare indications for
giving priority to the immobilization of the mandible in the presence of other
serious injury.
It should be remembered that use of the powerful analgesics such as
morphine is contraindicated as they depress the cough reflex and respiratory
Preliminary Treatment / 41
center and also mask pain which can be diagnostically important (e.g. from a
ruptured spleen).
Control of Infection
All fractures of body of mandible involving teeth are compound fractures as
they are potential source of infection. Immediately injection augmentin should
be given every 12 hourly for first 2 to 3 days. There are also chances of
anaerobic infection. So injection metronidazole or oral metronidazole should
be administered.
SUMMARY
42 / Fracture Mandible
General Treatment of
Fracture Mandible
Principles
a. Fracture reduction and fixation to restore anatomical relationships;
b. Fracture fixation providing absolute or relative stability as the personality
of the fracture, the patient, and the injury requires;
c. Preservation of the blood supply to soft tissues and bone by gentle reduction
techniques and careful handling;
d. Early and safe mobilization and rehabilitation of the injured part and the
patient.
Reduction
Reduction of fracture means restoration of functional alignment of the bone
fragment. In the dentate mandible reduction must be anatomically precise
when teeth are involved and previously in a good occlusion. Less precise
reduction may be accepted if part of the body of mandible is edentulous or
there are no opposing teeth.
The presence of teeth provides an accurate guide in most cases by which the
fracture segment can be aligned. The teeth are used to access the reduction,
check alignment of the fragment and assist immobilization. However the occlusion
is used as a index for accurate reduction it is important to recognise any preexisting occlusion abnormality like anterior or lateral open bite were facets on
individual teeth can provide valuable clues to previous contact areas. The teeth
may on occasion be brought into contact during reduction and yet be occluding
incorrectly owing to lingual inclination of fractured segment.
Close reduction can be achieved in a case of mild displaced fracture. While
widely displaced, multiple or extensive comminuted fractures will require a
open reduction.
Immobilization
Following accurate reduction of fragment, the fracture side need to be
immobilized to allow the bone healing to occur. The period of the
immobilization depends upon the sites of fractures, the presence of teeth, age
of a patient and absence and presence of a patient.
Period of Mobilization
A simple guide for a period of immobilization for fracture of mandible of a
tooth bearing area are as follows
Normally a 3 weeks of immobilization is required in a case of young
adult with fracture of angle receiving early treatment in which teeth are
removed from the fracture line.
If
a. Tooth retained in fracture lineadd 1 week
b. Fracture at the symphysisadd 1 week
c. Age 40 years and overadd 1 or 2 week
d. Childrens and adolescentssubtract 1 week
44 / Fracture Mandible
Intermaxillary Fixation
Arch Bars
Arch bars are preferred:
General Considerations
There are important points to consider before starting.
The occlusion must be checked. In the case of jaw malformations, such
as a deep bite deformity, it may be impossible to use arch bars.
One pitfall when using arch bars is the risk of contamination of
bloodborne infection from patients. Passing the wires to secure the arch bar
can result in a puncture or tear in the surgeons glove and the possibility
of disease transmission to the surgeon.
D
E
Fig. 8.3: Fitting an arch bar. A Selection of appropriate length and contouring of
Erich arch bar. B Arch bar to be placed on a teeth for a proper measurement.
Extra length of the arch bar need to be trimmed and the posterior edge of the bar
need to be bend to prevent soft tissue injury. C and D Wire is passed above and
below the arch bar and tightened so as not to obstruct the lug. It is important to
make sure that this wires have been tightly applied by checking whether any
vertical movement of arch bar is possible. The wire used are of normally of 26
gauge. E Intermaxillary fixation can be established by either wires or by elastic
46 / Fracture Mandible
Wiring Techniques
Gilmer Method
This is the simplest way to establish
intermaxillary fixation by gilmer
method. This technique is simple and
effective but has a disadvantage that
mouth cannot be opened for
inspection of the fracture side
without removal of wire fixation. The
method consists of passing wire
ligatures around neck of available
teeth and twisting them in a clockwise
direction until the wire is tightened
around its tooth. After adequate
Fig. 8.4: Gilmers method of fixation
number of wire has been placed in
upper and lower teeth are brought into the occlusion and the wire are twisted
one upper to one lower wire. A stainless steel 24 gauge or 26 gauge wire are
usually applied.
Eyelet Method
This method of fixation has the
advantage that jaws may be open for
inspection by removal of only the
intermaxillary ligatures. This method
consists of twisting a 20 cm length
of 24 gauge or 26 gauge wire around
a instrument to establish a loop. Both
end of the wire are passed through
the interproximal space from the
Fig. 8.5: Eyelet method of fixation
outer surface. One end of the wire is
passed around the anterior tooth the other around the posterior tooth. One end
of the wire may pass through the loop. The eyelet should project in upper jaw
above and in lower jaw below the horizontal twist to prevent ends from impinging
on each other. After establishment of sufficient number of eyelets the teeth are
brought into occlusion and ligature are passed in loop fashion between one
upper and one lower eyelet. The interjaw wires are twisted tightly to provide
intermaxillary fixation.
Acrylic Splints
These are useful in maintenance of intermaxillary fixation and in establishing
the continuity of maxillary and mandibular dental arches in particular segment
of missing teeth can be compensated with suitable design splint. These are
useful in maintenance of intermaxillary fixation and in establishing the continuity
of maxillary and mandibular dental arches in particular segment of missing
teeth can be compensated with suitable design splint. Appliance of this types
are effective but requires detailed dental knowledge and skeletal models of
splint construction. The splints are fabricated by specially educated physician
with dental training, dental professional or dental laboratory.
48 / Fracture Mandible
Nonrigid Osteosynthesis
Transosseous wiring
Circumferential wiring
External pin fixation
Bone clamps
Trans fixation with kirschner wires (K wires)
These fixation been non rigids require intermaxillary fixation.
Semirigid Osteosynthesis
Mandibular plate
Dynamic compression plate
Lag screw plate
Rigid Osteosynthesis
Reconstruction plate
Locking plate
Three-dimensional sturd
Miniplates
Mini plates are available in various shapes and lengths but can only be used with
non-locking screws. For mandible 2.5 mm or 2 mm plate are usually used. They
are most commonly used for fracture mandible.
Indications
Simple fractures mandible with excellent bony buttressing, are preffered for
dynamic plate compression plate.
Contraindications
Compression plating is contraindicated when there is not good bony buttressing
at the fracture site, as is seen in atrophic edentulous mandible fractures,
defect fractures, comminuted fractures, and other complex mandibular
fractures.
Defect fractures
Communited fractures
Compression Plating
Principle
As the eccentrically placed compression screws are tightened, the head moves
down the ramp and the bone is compressed together.
Diagrams showing two eccentrically screw inserted but not fully tightened
screws.
50 / Fracture Mandible
Overbending
The plate must be overbend slightly
to close the lingual cortex. As
compression screws are tightened,
the slightly overbent plate closes
the lingual gap. If the plate is not
slightly overbent, the buccal cortex
will be well aligned but a gap
remains at the lingual cortex
There are two drill guides used with compression plating. The yellow drill
guide is used for eccentric hole placement. The green drill guide is used for
neutral hole placement.
To drill eccentrically, the arrow on the yellow end of the drill guide must
point towards the fracture. The number close to the arrow shows the maximal
possible amount of bone movement upon screw insertion.
To place an eccentric hole, the proper gold drill guide must be used and the
arrow must point toward the fracture.
Once both the eccentrically placed screws are tightened, the fracture is
compressed. There is no need to compress the fracture additionally so the
remaining screws are placed in a neutral position. The appropriate green drill
guide is used to place the neutral screws
Screws used for the compression plate are bicortical in nature.
Indication
In parasymphysis/symphayis oblique fracture.
52 / Fracture Mandible
ContraindicationComminuted Fractures
Because lag screw technique compresses the fracture fragments together, the
use of this technique is contraindicated in comminuted fractures.
Lag Technique
The first step is to determine that
the drill is aligned perpendicular to
the bevel of the fracture. The near
cortex is perforated using a drill that
is the same diameter as the external
diameter of the screw. The gliding
hole is taken to the fracture site or
slightly beyond.
Fig. 8.13: Drill the near cortex to the
external diameter of screw
For example, when using a plating
system 2.4, the external diameter of
the screw is 2.4 mm. The drill used
to drill the near cortex is therefore
2.4 mm.
It may be difficult for the surgeon
to determine when the fracture site
has been reached with the gliding
hole. It may be advantageous to drill
past the fracture site rather than stay
short of the fracture site. If the
gliding hole is short of the fracture,
Fig. 8.14
compression of this fracture will not
be obtained with lag screw technique.
When drilling obliquely to the
surface of the bone, the point of the
drill can easily slide along the bone.
It is helpful to first orient the drill
perpendicular to the near cortex to
create an initial hole before
reorienting the drill perpendicular to
the bevel of the fracture.
A special drill guide is used to
Fig. 8.15
drill through the far cortex. This drill
Figs 8.14 and 8.15: Drill the far cortex to
guide has an extension on its tip that the inner diameter of the screw using
is the same diameter as the external centering drill guide
Screw Insertion
The proper length screw is inserted
and tightened. One should observe
the near cortex as the screw is
tightened to assure that cracking or
crazing does not occur from overtightening.
54 / Fracture Mandible
Locking Plates
Locking plates are available in a variety of plate thicknesses (referred to as
profile). All locking plates can hold either locking head screws or standard
(nonlocking) screws.
Locking plates available are:
There is only one thickness of the locking reconstruction plate. However, there
are multiple plate configurations to meet a variety of clinical applications. The
threaded head of the 2.4 mm locking head screws is cylindrical. Therefore, a
threaded drill guide is mandatory to assure the correct perpendicular insertion
of 2.4 mm locking head screws. Angulation is not possible.
Reconstruction plates are used for load bearing osteosynthesis of mandibular
fractures
56 / Fracture Mandible
Unlocking plates
Rigid fixation
During insertion the locking head screw engages and locks into the threaded
plate hole.
Conventional Screws
If necessary the threaded plate hole also accepts nonlocking screws, which
permit greater angulation.
Biomechanics
Conventional Screws
With the conventional technique,
the tightening of the screws
presses the plate against the bone.
This pressure generates friction,
which contributes significantly to
primary stability.
Loading forces are transmitted from the bone to the plate,
across the fracture and back into
the bone. Friction between plate
and bone is necessary for stability
using conventional screws.
58 / Fracture Mandible
Loading forces are transmitted directly from the bone to the screws, then
onto the plate, across the fracture and again through the screws into the bone.
Friction between plate and bone is not necessary for stability.
The plate and screws provide
adequate rigidity and do not depend
on the underlying bone (load
bearing osteosynthesis) when using
a locking reconstruction plate 2.4.
On each side of the fracture, the Fig. 8.27: Loading force transmitting directly
from bone-to-screw then to plate and then
screws are locked into the plate as screw-to-bone
well as into the bone. The result is
a rigid frame construct with high mechanical stability (internal external fixator).
Load-Baring Osteosynthesis
(stabilization by splinting)
The plate bears the forces of function
at the fracture site. This is accomplished with a locking reconstruction
plate. Clinical uses are the management
of atrophic edentulous fractures,
comminuted fractures, defect fractures,
and other complex mandibular
fractures.
Load-Sharing Osteosynthesis
60 / Fracture Mandible
General Consideration
Stability at the fracture site is created by
the frictional resistance between the bone
ends and the hardware used for fixation.
This requires adequate bony buttressing
at the fracture site. Examples of loadsharing osteosynthesis include lag screw
fixation technique and compression
plating. Load-sharing osteosynthesis
cannot be used with defect fractures or
comminuted fractures, due to the lack
of bony buttressing at the fracture site.
Another form of load-sharing
osteosynthesis is the miniplate fixation
technique popularized by Champy. This
is also known as functionally adequate
fixation or semirigid fixation.
Load-Bearing
In load-bearing fixation the plate assumes
100% of the functional loads.
This is an example of load-bearing
osteosynthesis for the treatment of a defect
fracture in the angular region. The osteosynthesis assumes all the masticatory loads
while the bone graft matures and consolidates in a protected environment.
SUMMARY
62 / Fracture Mandible
Anesthesia for
Fracture Mandible
All closed reduction of fracture mandible can be done under local anesthesia.
While open reduction is preferably done under general anesthesia. Young
cooperative patient with simple, undisplaced fracture open reduction can be
tried under local anesthesia. We prefer to apply arch bar under local anesthesia
and in case of open reduction patient is then further given general anesthesia.
Application of arch bar is better done in local anesthesia. As this require
cooperation of the patient in terms of mouth opening and moving the tongue in
an appropriate direction, thus this prevents excess retraction and a pressure on
a tongue which is required if IMF is done in general anesthesia. Thus this cause
decrease edema of tongue and cheek.
General Anesthesia
The anesthesia is same as all routine procedures but few special precautions
need to be taken.
Procedure
- Reduction and fixation of fracture mandible
Time
- 2 to 3 hours depending upon the severity
Postoperative pain
- ++
Position
- Supine with head up tilt with head ring, in case of
extraoral approach a shoulder should be kept
Blood loss
- Variable
Intubation technique - Nasal tube (blind or guided) and IPPV
Fibreoptic intubation may be required.
Preoperative
64 / Fracture Mandible
Check for evidence of basal skull fracture and CSF leak, which make nasal
intubation contraindicated
In a case of severe trismus and where postoperative edema may be
anticipated, tracheostomy should be considered
Submantle intubation should be considered in a case of pan facial trauma
Perioperative
Postoperative
Observe the patient for sometime in a recovery before sending it to the ward
Start humidified oxygen
Always keep a wire cutter and a suction machine beside the patients bed
(to cut the wires in a case of emergency)
Shift the patient with nasopharyngeal airway to the ward.
Local Anesthesia
Two percent lignocaine with adrenaline is used for local anesthesia. In case of
hypertension and other contraindication a plain lignocaine can be used. In case
long duration of anesthesia is required long acting local anesthesia (bupivacaine,
ropivacaine, and tetracaine can be used). But 2% lignocaine with adrenalin gives
enough duration of anesthesia for arch bar application, so long acting is not
usually required.
Dosage
The permission level of plain lignocaine is 4 mg/kg body weight and for 2%
lignocaine with adrenalin is 7 mg/kg body weight and for bupivacaine is 2 mg/
kg body weight.
Area of Infiltration
For upper jaw anesthesia we need:
1. Posterosuperior alveolar nerve block
2. Middle superior alveolar nerve block
3. Anterosuperior alveolar nerve block (infraorbital nerve)
4. Greater palatine nerve block
5. Incisive foramen nerve block
66 / Fracture Mandible
Goal
Goal is to deposit local anesthesia close to the PSA nerve located posterior
superior and medial to the maxillary tuberosity.
Nerve anesthetized
1. Anterosuperior alveolar
2. Middle superior alveolar
3. Infraorbital nerve
Technique
Procedure
The bone immediately inferior to the notch is convex, this represents the
lower border of orbit and a roof of infraorbital foramen
As your finger continous inferiorly a concavity is felt, this is infraorbital
foramen
Maintain your finger on the foramen or mark the skin at the site
Retract the lips, pull the tissue in muccobuccal fold
Insert the needle into the height of muccobuccal fold over the first premolar
with the bevel facing bone
Reach to your required site
68 / Fracture Mandible
Fig. 9.3
Part of insertionadvance the syring from the opposite side of the mouth
at the right angle to the target area.
Procedure
Feel for depression of greater palatine foramen with the help of cotton
swab and a finger
The foramen is located distal to second molar but it may be either anterior
or posterior to its usual position
Inject in the foramen area around few drops.
70 / Fracture Mandible
Fig. 9.5
Procedure
Landmark
72 / Fracture Mandible
Procedure
Landmark
Mandibular premolars
Muccobuccal fold
Procedure
74 / Fracture Mandible
10
Specific Treatment of
Fracture Mandible
Closed Reduction
Intermaxillary fixation application with arch bar:
Simple technique
Miniplate Osteosynthesis
Advantages
a.
b.
c.
d.
e.
Behind the mental foramen only one plate should be applied, immediately
below the dental root and above the inferior alveolar nerve.
Between the two canines and in front of mental foramen another plate
near the lower border of mandible is applied in addition to the upper
plate.
Technique
This miniplates are around 0.9 mm thick and 6 mm wide. The difference between
holes are standardized. The screws available are from 5 to 15 mm in length. The
diameter of the screws is 2 mm. Screw of 6 or 8 mm in length are usually used
in mandible. The screws are self-tapping.
76 / Fracture Mandible
B
A
D
C
E
Fig. 10.4
78 / Fracture Mandible
Treatment
The aim of treatment of condylar fracture is to reestablish the anatomical
relationship for providing good function and growth on long term basis.
a. Fracture of head of condyle
The intracapsular fracture of head of a condyle is rare and should be treated
conservatively by intermaxillary fixation for a period of 2 to 4 weeks followed
by restoration of function. Severe comminuted fractures of the condyle are
treated by condylectomy especially in unilateral cases. In case of children,
costochondral grafts should be given to replace the lost condyle.
Subcondylar fractures
These are the fractures below the neck of the condyle. These fractures are
classified as:
Fig. 10.8
80 / Fracture Mandible
Fig. 10.9
Open Reduction
In grossly displaced condyle fracture where reduction cannot be achieved by
conventional method there is a fear of future dearrangement or ankylosis, an
open reduction is indicated.
The indications are:
Mistakes
Common mistakes observed in treatment of rigid fixation:
Tips
82 / Fracture Mandible
Due to drilling heat is generated, this heat can cause bone necrosis and
early screw loosening so cooling by putting saline over the drill bit.
Avoid damage to mental nerve, tooth root, inferior alveolar canal.
Proper bending of a plate should be done.
A space of about 5 mm should be kept between two plates.
SUMMARY
Surgical Approaches / 83
11
Surgical Approaches
Surgical Approaches
1. Extraoral
2. Intraoral
3. The use of existing lacerations
Extraoral Approach
Submental Approach
The submental approach is used to treat fractures of the anterior mandibular
body and symphysis. These fractures can usually be approached and treated
intraorally. However, depending on the difficulty or severity of the fracture,
and/or the presence of a laceration suitable, an extraoral approach via the
submental route may be indicated.
Advantages
84 / Fracture Mandible
Dissection
Carry the incision through the skin and subcutaneous tissues to the platysma
muscle.
Submandibular Approach
In 1934risdon describe this technique.
Surgical Approaches / 85
Principles
This approach is selected for fractures of the mandibular body and angle regions
unsuitable for intraoral treatment.
This applies to more difficult fracture patterns such as comminuted, atrophic,
and defect fractures in order to allow optimal manipulation of the fragments,
good control of the lingual cortex and inferior border, and the application of
the selected hardware.
Variations
The incision can either be parallel to the inferior border of the mandible atleast
2 cm below the angle of the mandible (A) or be placed in an existing skin
crease (B) for maximum cosmetic benefit.
If using skin creases for the incision, the orientation of the scalpel blade is
parallel to the skin creases.
Subplatysma flap elevated.
Neurovascular structures
The main neural structure is the marginal mandibular branch of the facial nerve
(CN VII). The facial artery and vein are also encountered during this dissection.
They are commonly located 1 cm below the angle of the mandible.
This neurovascular structure are identified by Holder Martins method in
which facial vessels are identified and they are retracted so that they are safe
in the flap.
The dissection is carried out through the deep cervical fascia.
The muscle, periosteum and other soft tissues are retracted superiorly to
expose the body, angle and the ramus of the mandible.
Then the fracture line is identified.
Retromandibular Approaches
In 1967, Hinds and Girrotti first described
this approach.
Skin incision
Incision is made 3 cm above the submandibular incision
The incision is carried curving behind
the angle of mandible
Use of normal saline for infilteration is
employed for maintenance of the plane and
in a cases where nerve stimulator has to be
used.
86 / Fracture Mandible
the
the
the
the
the
the
Surgical Approaches / 87
cutaneous tissue is made, extending from just below the ear lobe towards the
mandibular angle. It should parallel the posterior border of the mandible.
Dissection
The subcutaneous tissue is undermined, exposing the superficial musculoaponeurotic system (SMAS).
A vertical incision is made through the SMAS into the parotid gland.
Blunt dissection of the parotid gland
Bluntly dissect the parotid gland parallel to the direction of the facial nerve
branches and towards the posterior border of the mandible. The dissection
should be anterior to the retromandibular vein.
Branches of the facial nerve may be found during the dissection. A nerve
stimulator may be helpful to identify them. They should be mobilized and
protected.
Once the posterior border of the mandible has been reached, an incision
is made through the pterygomasseteric sling.
Subperiosteal dissection of the mandibular ramus
A periosteal elevator is used to strip the masseter muscle from the ramus.
Further dissection superiorly along the posterior border exposes the condylar
process.
Transparotid approach: Wound closure
The wound is reapproximated in layers for anatomic realignment and avoidance
of dead space. The parotid gland capsule must be closed tightly to prevent
salivary fistula. The SMAS is resuspended.
Alternative: Retroparotid approach
Principles
A frequently used alternative to the
retromandibular transparotid approach
described above is one in which the
parotid gland is lifted rather than
dissected through. This requires the
incision to be placed more posteriorly
which means that exposure of the
mandible is more limited. Rather than
approaching the mandible from directly
over the ramus, it is approached more
posteriorly.
88 / Fracture Mandible
Skin incision
An oblique incision through skin and subcutaneous tissue is made, extending
from the mastoid process to a point just below the angle of the mandible.
Dissection
The subcutaneous tissue is undermined, exposing the superficial
musculoaponeurotic system (SMAS).
An oblique incision is made through the SMAS. The posterior aspect of
the parotid gland is identified and dissection continues behind the gland.
The gland is lifted off the masseter muscle and retracted anteriorly.
Once the posterior border of the mandible has been reached, an incision is
made through the pterygomasseteric sling.
Subperiosteal dissection of the mandibular ramus
A periosteal elevator is used to strip the masseter muscle from the ramus.
Further dissection superiorly along the posterior border exposes the condylar
process.
Wound closure
The wound is reapproximated in layers for anatomic realignment and
avoidance of dead space.
The SMAS is resuspended.
A suction drain may be placed.
Preauricular Approach
Principles
The preauricular approach can be used to access and treat fractures in the
mandibular condylar head and neck region. Many surgeons perform temporal
mandibular joint (TMJ) surgery and routinely use this incision to access the
superior portion of the mandibular condylar process.
Neurovascular structures
Branches of the facial nerve may be involved in this incision and dissection.
The superficial temporal artery and vein are commonly encountered in this
surgical approach. The vessels should be conserved if possible.
Facelift incision
Skin incision
Make the incision in a preauricular skin crease.
Dissection
Locating temporalis fascia.
Surgical Approaches / 89
90 / Fracture Mandible
Gives easy access and better stability and facilitated exposure of arch
along with the condylar arc.
c. Alkayat-Bramley preauricular incision
So rarely used.
1. Intraoral approach
Surgical Approaches / 91
Mucosal Incision
Unless contraindicated, infiltrate the area with a local anesthetic containing
a vasoconstrictor.
Make an incision through the mucosa in the vestibule. Between the
canines the incision is made 1015 mm away from the attached gingiva in
a curvilinear fashion. Posterior to the canine the incision is only 5 mm away
from the attached gingiva, staying superior to the mental nerve.
Neurovascular Structures
The mental nerve is a branch of the fifth cranial nerve (trigeminal nerve).
This nerve provides sensation to the anterior mandibular vestibule, lip and
chin.
When the incision is extended posterior to the canine teeth, the mental
nerve can be damaged. Keep the incision superior to the mental nerve in the
body region.
Particularly in the extended intraoral approach, care must be taken to
protect the mental nerve in the anterior body region.
92 / Fracture Mandible
Wound Closure
After thoroughly irrigating the wound and checking for hemostasis the incision
is closed. Anteriorly, the mentalis muscle is reapproximated to prevent
drooping of the chin tissues. The mucosa is closed with interrupted or
running resorbable sutures.
An elastic pressure dressing on the chin region helps support the soft
tissues and prevent hematoma formation
Principles
Vestibular incisions
The intraoral approach is used for the majority of simple angle fractures.
Depending on whether or not a third molar is to be extracted, there are two
Surgical Approaches / 93
94 / Fracture Mandible
Surgical Approaches / 95
Buccinator Muscle
The lateral mucogingival vestibular incision transsects the lower attachment
of the buccinator muscle. Stripping the mucoperiosteal flap laterally dislocates
the lower border of the muscle. To reattach the muscle, the sutures for
wound closure in the lateral vestibular should not only be superficial. The
suture should catch all layers (mucosa and muscle) as a safeguard for muscle
reattachment.
Reminder: The buccinator muscle belongs to the mimic muscle system and
has a unique functional structure allowing for a movement comparable to a
peristaltic motion. The deep fibers run in parallel bundles from the modiolus
to the pterygomandibular raphe at the level of the occlusal plane (intercalar
region) and account for the buccinator mechanism building up a ridge towards
the occlusal plane. Its detachment can result in an impaired bolus transport
out of the buccal space which is troublesome for the patient. The buccinator
is innervated by the motor buccal branch of the facial nerve.
Incision
Unless contraindicated, infiltrate the area with a local anesthetic containing
a vasoconstrictor.
Make an incision through the mucosa in the vestibule approximately 5
mm away from the attached gingiva (in the mucogingival junction), extending
up the external oblique ridge.
Exposure of Fracture
The lateral surface of the ramus and condylar process is exposed in a
subperiosteal plane to visualize the fracture. Right-angled retractors and
fiberoptic lighting would facilitate this procedure. The fracture must be
reduced adequately before fixation is applied. The fixation can be done
either by transbuccal or right-angled instrumentation.
96 / Fracture Mandible
The surgeon has the option of treating the fracture through the intraoral
approach under direct vision or may opt for endoscopic assistance.
The incision is very similar to the standard incision used to approach the
ramus and condyle unit. Surgeon preference for a smaller incision is
acceptable.
A specific instrumentation is recommended in order to facilitate the
endoscopically assisted condylar fracture treatment.
Create the optical cavity for the endoscope by elevating the periosteum
of the ascending ramus towards the condylar region. Stop the dissection once
you have reached the fracture line. Dissection beyond the fracture line will
be completed after introduction of the endoscope.
Fig. 11.10
Wound closure
Closure of the intraoral incision
After thoroughly irrigating the wound and checking for hemostasis the incision
is closed using interrupted or running resorbable sutures.
Surgical Approaches / 97
Surgical dressing
An elastic pressure dressing covering the ramus/condylar process region
helps support the soft tissues and prevent hematoma formation.
Periosteum
Mimic muscles
Platysma/SMAS
Subcutaneous tissues
Damaged facial and trigeminal nerve branches injured Stensens duct are
repaired as meticulously as possible. A drain may be used if necessary.
SUMMARY
98 / Fracture Mandible
12
Fracture of Mandible in
Children
Fracture of mandible is not very common in children this is because the bones
are resilient at this age and considerable forces are required to cause a fracture.
In children the line of demarcation between medulla and cortex is not well
defined as in adult. There are more chances of green-stick fractures occurring
in children. There is greater risk of damage to the developing teeth than the
later years.
The treatment of mandible fracture in children before puberty are of
conservative management. This is because of rapid healing of bones and
adaptive potential of bone and its contain dentition.
Some special factors need to be considered during the management of
fractured mandible in children.
b. When some occlusions are present with caries and loose deciduous tooth
in mandible can be suspended on each side with circumferential wires on
each side linked to circumzygomatic wires from above.
c. A simple elasticated bandage chin support can be given in case of
minimally displaced fractures where jaw movements are not that painful.
Simple arch bar and eyelet wiring can be done. This arch bar is to be fixed
to the teeth with more thinner, flexible, soft Stainless steel of 0.35 mm
diameter.
Light arch bar of german silver can be used for irregular dentition as they
are more easily adaptable. This should be attached to the tooth by similar 0.35
mm diameter wire.
Unerupted Tooth
Patient below age of 910 years the body of mandible is conjusted with
developing teeths so its unsafe to apply transosseous wires or to insert bone pains
or plate in them. In cases of gross displacement of fractures the lower border should
be wired with caution. The bones pins and plates are contraindicated.
Follow-up
The healing in children is very rapid. Some fractures are stable within a week
and get firmly united in three weeks time. Fracture did not need to be reduced
perfectly. Imperfection in reduction can be accepted rather than refracturing
the mandible with possible damage to the developing teeth. In case of above
circumstances continuing growth and eruption of teeth will compensate for the
imperfect alignment of fragment.
A prolonged follow-up is required in order to be sure that there is no longterm effect on both mandibular growth and normal development of permanent
dentition. Close cooperation with paedodontist, orthodontist and dentist is of
vital importance.
SUMMARY
13
Postoperative Care
The postoperative care is also very important as the intraoperative care. With
the advent of this direct osteosynthesis technique postoperative care has simpler
and safer. The postoperative care is divided into three phases:
1. Immediate postoperative phasethis is the phase when is recovering from
the general anesthesia.
2. Intermediate phasethis is a phase before the clinical bony unions has
been established.
3. The late postoperative phasethis includes removal of fixation biterehabilitation, physiotherapy and long-term observation of dentition.
Prevention of Infection
Cases of fractures of tooth bearing areas injection augmentin + injection
mertrogyl should be given for 5 days. If healing goes well antibiotic can be
discontinued after 5 days. Simple closed fractures of condyle neck do not
require any prophylactic antibiotic.
Oral Hygiene
This play an important role in the prevention of infection in a fracture line.
Hot normal saline mouth washes are given after every meal for conscious
patients in a case of immobilization by any of wiring techniques. Patient is
asked to do a toothbrush in a visual manner. The size of the tooth brush
should be of a smaller size. Betadin gargle or 0.2% chlorhexidine gluconate
mouth wash significantly reduce the bacterial count and improves a plaque
control in patient with intermaxillary fixation.
Patient who does not cooperate, mouth must be cleaned by a nursing staff
after every meal using normal saline solution with the help of hugginson and
syringe. Care must be taken not to direct the stream of fluid down the side
of nay compounded fractures, so introducing infection. Caps splints can be
cleaned with 14% sodium bicarbonate solution. Rubber band if soiled with
food should be changed. The lip should be kept lubricated with petroleum
jelly to prevent drying and sticking of the lips. If the lips are excoriated and
sore 1% hydrocotisone ointment can be applied.
Feeding
The problem of providing a patient suffering from maxofacial injury with
adequate nutrition varies according to whether the patient is conscious and
cooperative or is uncooperative.
Adjustment of Occlusion
Little adjustment of occlusion is required if wiring technique is employed as
the cusps are placed in a correct position under a direct vision at the time
of immobilization. In case of caps splint, however, accurate the splint may be
14
Complications
Early Complication
Hemorrhage
There can be hemorrhage in a soft tissue which may require drainage if its
localized. Some symphysis and parasymphysis fractures can be accompanied
with tear in a soft tissue which extends along the floor of mouth as far as
pharynx. This tear opens the deep spaces of a neck to blood and saliva thus
permitting infecting to the deep spaces of neck which can track into the
thorax. If such tears are present tissue in a floor of mouth should be closed
in layer with drain in a dependant portion of the wound with antibiotic
coverage.
Carotid Injury
Severe mandibular dislocations may damage the carotid artery, resulting in
aneurysm formation or thrombosis with stroke. The condyle is frequently
driven into the auricular canal, because it is adjacent to it, lacerating the
canal and resulting in bleeding.
Infection
By achieving adequate stability of bone fragment in a fracture area reduce
the possibility of infection. More chances of infection in cases of periosteal
stripping which decreases the blood supply.
Complications / 105
Swelling
Erythema
Trismus
Pain
Purulent discharge.
Infection occurring in fractures usually results from one or more of the
following etiology:
Microorganisms
Fracture instability
Systemic antibiotics
Restabilization of fracture
Treatment
a. Early reduction of fracture with immobilization
b. Drainage of absess if any otherwise osteitis can progress into osteomyelitis
True osteomyelitis in mandible is relatively uncommon. Localized osteitis
occur but this condition rarely progress into true osteomyelitis. The use of
antibiotic, the prompt drainage of area prevent this occurance of osteomyelitis.
If osteomyelitis occurs it should be easily demonstrated radiographically as
increased fluffiness and varying opacity of the bone.
Treatment
a.
b.
c.
d.
e.
Late Complication
Nonunion
A nonunion occurs when the mandible does not heal in an appropriate time
frame. Healing at the side of mandible fracture is completed within 48
weeks. Remodelling and bone healing continue histologically for 26 weeks.
The result is mobility of the fracture segments present after an adequate healing
phase. Patients may also demonstrate malocclusion and infection at the site of
fracture.
Etiology
Nonunions are usually the result of one or more of the following factors:
a. Fracture instability (mobility)
b. Infection
c. Inaccurate reduction
d. No contact between fragments
e. Decrease blood supply to the bone
f. Poor nutritional condition of the patient
g. Old edentulous patient
h. Lack of water tight intraoral closure, bathes the fracture in bacteria thus
leading to nonunion
Treatment
Treatment will consist of:
Controlling infection
Complications / 107
Malunion/Malocclusion
Etiology
Malunions occur for at least one of several reasons:
Treatment
The treatment of a malunion must involve:
Ankylosis
Ankylosis is a process where the mandibular condyle fuses to the glenoid
fossa. This generally occurs after prolonged immobilization (MMF) of a
condylar fracture.
Patient demonstrating their maximum interincisal opening after treatment
of multiple mandibular fractures and prolonged period of MMF.
The treatment of ankylosis in this case is additional surgery in the form
of a gap arthroplasty or total alloplastic joint replacement.
Fixation Failure
Implant failure includes plate fracture and screw head fracture. Fixation
failure results in fracture mobility that can subsequently lead to infection,
nonunion and/or malunion.
Fixation fails by a number of mechanisms which include:
Treatment
a. Physiotheraphy may accelerate the recovery period
b. Simple jaw excercise should be employed
c. Occasionally manipulation of mandible under anesthesia may assist the
breakdown of scar tissue within muscle.
Fibrodysplasia Ossifficans
This involve the main muscle of mastication and it is a very rare combination
of fracture mandible. The hematoma which occurs in muscle get organized and
eventually become ossified, this view is supported by finding of trabecular
bone within the muscle mass.
Treatment
a. Excision of ectopic bone
b. There is a high chance of recurrence.
Scar
Etiology
a.
b.
c.
d.
Complications / 109
Treatment
a.
b.
c.
d.
e.
f.
Wait and watch for 1st year as they may soften and fed away
Massage of the scar
Pressure bandage
Application of lanoline
Infilteration of injection kenacort and hylinese
Surgical revision if possible
SUMMARY
Index / 111
Index
Page numbers followed by f refer to figure
A
Accessory muscles of mastication 16
Acrylic splints 47
Airway maintenance 39
Alkayat-Bramley preauricular incision 90
Angle of mandible 13
Ankylosis 107
Anterosuperior alveolar nerve block 66
AO classification of mandibular fractures 24
Arch bars 44
Avascular necrosis 105
B
Basal triangle fracture of parasymphysis
area 78f
Bilateral condylar fractures 32
Biomechanics of mandible 10, 11f
Blood
loss 39
vessels 17
Blunt dissection of parotid gland 87
Bonded modified orthodontic brackets 47
Buccal nerve block 71
Buccinator muscle 93, 95
C
Carotid injury 104
Categories of
associated fractures 25
fractures 25
occlusion 25
soft tissue involvement 25
Champys line 74f
of osteosynthesis 74
Closed reduction 74
Combination with transbuccal technique 94
Comminuted fracture 22, 22f, 33, 52
of angle and body 78f
of parasymphysis 77f
Complex symphysis 77
Complication after insufficient amount of
fixation 108f
D
Dental terminology 4f
Dentoalveolar fractures 31
Determine screw length 53, 53f
Different levels of force distribution 60
Dissect over condylar fragment 96
Dissection 84, 87, 88
of joint capsule 89
Dynamic compression plate 48, 50f
E
Eccentric drilling for compression 50
Eyelet method 46
of fixation 46f
F
Face lift incision 88, 89f
Facial nerve injury 104
Factors affecting bone healing 10
Feeding 101
Fibrodysplasia ossifficans 108
Fixation
failure 107
in deciduous and mixed dentition period
98
independent of teeth 98
utilizing teeth 99
G
Gap healing 9
Gilmer method 46
of fixation 46f
Grades of severity 25
Greater palatine
block 69
nerve block 68
Greenstick fracture 22, 22f
Insertion of
endoscope 96
optical retractor 96
Insufficient amount of fixation 107
Intermaxillary fixation 44
screw technique 47, 47f
Intermediate load-sharing situation 61
Intraoral incison for symphysis and body
fracture 91f
L
Lag
screw 51
principle 51f
and technique 51
technique 51, 52
Limitation of opening of mouth 108
Load-bearing osteosynthesis 59, 61f, 78f
Load-sharing osteosynthesis 59, 78f
Local
anesthesia 64
examination of mandibular fracture 29
Location of mental foramen 72
Locking
head screws 57
plate 54
system 58, 59
reconstruction plate 55, 56f
Lower jaw infiltration 70
H
Head entering medullary space 54f
Healing of fracture 7f, 8f
bone 9
Hemorrhage 104
Hindrance in growth potential 98
Horizontally
favorable fractures 23, 23f
unfavorable fractures 23, 23f
I
Ideal
lines of osteosynthesis 60
load-sharing situation 61
Incising temporalis fascia 89
Inferior alveolar nerve block 70
Infra-alveolar nerve block 70
Infraorbital
block 68
nerve block 66, 68
M
Malreduction of fracture 60f
Mandibular
condyle fracture 79
muscles 14
Mental nerve block 72
Mentalis muscle dissection 92
Middle superior alveolar nerve block 66,
67
Minihole plate 75f
Miniplate
at external oblique line 78f
osteosynthesis 74
Mobilization of temporomandibular joint
103
Mucosal incision 91
for angle fracture 92f
for condyle and ramus fracture 94f
Multiple and comminuted fractures 34
Index / 113
Muscles of
facial expression 14
mastication 14
N
Neck of condyle 13
Nerves 16
Neurovascular structures 85, 88, 91
Nonrigid osteosynthesis 48
O
Off-angle drilling 51f
Open reduction 81
Option for off-angle drilling 51
Osteitis 105
Osteomyelitis 105
P
Parasymphysis fracture 76, 77
Pathological fractures 18
Period of mobilization 43
Phases of fracture healing 6
Posterosuperior alveolar nerve block 65, 66
Prevention of infection 101
Primary
bone healing 9
loss of reduction 58
R
Removal of fixation 102
Rigid osteosynthesis 48
Rowe modification 90
S
Screw
driver and screw 75f
insertion 53f, 54
Secondary loss of reduction 59
Semirigid osteosynthesis 48
Sensory buccal nerve 93, 95
Sign and symptoms of mandibular
fractures 31
Simple fracture 21, 21f
Single fracture 33
Skin incision 85, 88
T
Temporomandibular joint 17
Threaded plate hole and threaded screw
head 57f
Three-dimensional CT scan 38
Tranparotid approach skin incision 86f
Treatment of infected fractures 105
Triangular base fracture at angle of
mandible 78f
Type of fixation 43f
U
Unerupted tooth 99
Unilateral condylar fractures 32
Universal fracture plate 59
Use of existing lacerations 97
V
Variations in incision 83f
Various
site of fracture 20f
submandibular incisions 84f
Vascular supply of mandible 16
Vertically
favorable fractures 23, 23f
unfavorable fracture 24, 24f
Vestibular incision 91-93
W
Wiring techniques 46
Wound closure 84, 88, 89, 92, 96, 97
of vestibular incision 94
using envelope flap 94