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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
Foreword
Chris De Souza
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Fracture Mandible
ISBN 978-93-5025-801-9
Printed in
Dedicated to
Dinesh Yadav
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.
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
3. Anatomy of Mandible........................................................... 12
6. Radiology .............................................................................. 38
1 Dentition
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.
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
Try to restore occlusion in fracture mandible to pre-existing dental
relationship.
Three types of occlusion Class I: Normal occlusion
Class II: Disto-occlusion
Class III: Mesio-occlusion
Try to have knowledge of occlusion of pre-existing dental relationship before
operating fracture mandible.
Normal occlusion (pre-existing occlusion) is desired final result of the
treatment of fracture mandible.
6 / Fracture Mandible
2 Biomechanics of
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
Fig. 2.2: Healing of fracture (stage 2) Fig. 2.3: Healing of fracture (stage 3)
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
Fracture Healing and Biomechanics of Mandible / 9
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
Ageyounger patients healing is faster
Nutrition
Medically compromised patientdiabetes melitis, HIV
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
Fracture Healing and Biomechanics of Mandible / 11
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
Three phases of bone healing
1. Reactive phase
i. Fracture and inflammatory phase
ii. Granulation tissue formation
2. Reparative phase
iii. Cartilage Callus formation
iv. Lamellar bone deposition
3. Remodeling phase
v. Remodeling to original bone contour.
Primary aim of treatment of fracture mandible is to heal fracture mandible
by direct method (primary intension), i.e. gap healing or by contact
healing.
Proper reduction and maintenance of blood supply fasten bone healing.
Compression force are at lower border of mandible.
Tension force are at upper border of mandible.
Torsional force are at between canines and is maximum at midline.
12 / Fracture Mandible
3 Anatomy of Mandible
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
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
4 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
Work related causes
Falls
Sporting accidents
Miscellaneous causes
Thus the causes for maxillofacial fractures can be classified into:
a. Intrinsic causes
b. Extrinsic causes
Osteoporotic bone
Osteoradionecrosis
Caused by secondary nutritional hyperparathyroidism
Localized bone infection (osteomylelitis)
Osteoporotic bone due to disuse following prolong external fixation or
removal of a rigid internal device.
Unfortunately, fracture may occur even as a sequela of improper implant
placement due to the tensile forces acting on the bone during mandibular
function.
Extrinsic Causes
Direct violence (fracture at the side of impact)
Indirect violence (fracture caused due to transmission of impact)
Bending forces
Torsional forces
Compression forces
Shearing forces
Factors affecting displacement of the fracture:
Muscular pull on the fractured segment
Force of the impact
Site and direction of the fracture line
Muscular teardamage of muscle attachment might lead to the displacement
of certain fracture (coronoid)
Presence of teeth in the posterior segmentpresence of posterior teeth
may prevent displacement due to contact with the occlusal surface of the
maxillary teeth.
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. Classification based on anatomical location of the fractures
A. Fracture of the symphysis
B. Fracture of the canine region
C. Fracture of the body of the mandible
D. Fracture of the angle of the mandible
E. Fracture of the ramus
F. Fracture of the condyle
G. Fracture of the coronoid process
H. Fracture of the dentoalveolar
Classification of Mandibular Fractures / 21
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. Fig. 4.3: 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
Fig. 4.6: Greenstick fracture
of a green stick of a tree.
4. Classification according to the direction of fracture line and
favorability for treatment
This classification is basically restricted to the fractures of the angle of the
mandible. The line of fracture is considered to determine the type of fixation
required. A fractured line is considered favorable if the muscular pull resists
the displacement of the fracture and in case the muscular pull distracts the
fractured fragment away from the line of fracture favouring displacement, it is
Classification of Mandibular Fractures / 23
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.
SUMMARY
Vehicular accidents and assault are main cause of fractures.
Condyle and angle are the most common site of the angle
Any break in mucosa or a skin with fracture mandible is compound
fracture.
Favorable fractures are those fractures in which because of muscle pull
fractured fragments are brought together.
Unfavorable fractures are those fractures in which because of muscle pull
fractured fragments are pulled away from each other.
28 / Fracture Mandible
History
History is very much informative in case of fracture mandible.
A detailed history of patient should be taken
Any pre-existing disease should be enquired like:
a. Systemic disease like diabetes and hypertension
b. Psyschiatric illness
c. Alcoholic withdrawal symptom
d. Epilepsy
e. Other endocrine, collagen diseases
In such patient like psyschiatric, alcoholic withdrawn, epilespsy, inter-
maxillary fixation should be avoided.
History regarding etiology of fracture should be elicited. In cases of high
velocity (RTA) suspect other fracture also in a body
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
It is impossible to assist intraoral damage if the parts are obscured by
blood.
The buccal and lingual sulci are examined for ecchymosis. Submucosal
extravasation of blood is often indicative of underlying fracture, particularly
on the lingual side (Colemans sign).
Ecchymosis in the buccal sulcus is not necessarily the result of the
fracture as there is considerable soft tissue overlying the bone in this area
and extensive brusing may follow a blow over the lower jaw insufficient
to cause a fracture.
However, on the lingual side the mucosa of the floor of the mouth
overlies periosteum of the mandible which, if breached following a
fracture, will invariably be the cause of any leakage of blood into the
lingual submucuosa.
The occlusal plane of the teeth is next examined, or if the patient is
edentulous, the alveolar ridge.
It is important to examine all the individual teeth and to note any
luxation or subluxation along with missing crowns, bridges and/or fillings.
Individually fractured teeth must be assessed for involvement of the dentine
or pulp.
Possible fracture sites are gently tested for mobility by placing a finger and
thumb on each side and using pressure to elicit unnatural mobility. If the
patient can cooperate, he is asked to carry out a full range of mandibular
movements and any pain or limitation of movement recorded. Occasionally,
this detailed examination fails to confirm.
A mandibular fracture which is thought to be present from the history
and presence of hematoma. In such cases, the flat of both hands should
be placed over the two angle of the mandible and gentle pressure exerted.
This maneuver will always elicit pain when even a crack fracture is
present.
History and Clinical Examination / 31
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.
Fracture of the crown of individual teeth may occur as a direct result of
trauma or by forcible impaction against the opposing dentition.
Meticulous dental examination is essential and any missing fragments of
crown or missing fillings noted. These may be invaded within the soft
tissues or more rarely swallowed or inhaled.
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.
Occasionally, molar and premolar teeth appear superficially normal but
close inspection reveals either a vertical split or a horizontal fracture just
below the gingival margin resulting from indirect trauma against the
opposing dentition or violent impact by a small hard object such as
missile.
Fracture of the alveolus may be present with or without associated injury
to the teeth.
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.
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.
Swelling and ecchymosis is usually noted both extra and intraorally.
There is tenderness over the ramus and movements produced pain over
the same area.
Severe trismus is usually present.
Inability to close and open mouth.
SUMMARY
See the patient as whole
a. Resuscitate the patient first.
b. Mandible treatment can wait.
Detailed examination can give rough idea of site of fracture.
Swelling and ecchymosis suggest underlying fracture mandible.
Deviation from normal occlusion, open bite, crossbite suggest fracture
mandible.
Deformity, inability to close and open mouth suggestive of fracture mandible.
Look for inferior alveolar nerve or mental nerve paresthesia.
36 / Fracture Mandible
6 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 posterior-
anterior 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
Impractical for severely traumatic patients
Cannot be done in all hospital set ups
TMJ area, symphysis, dental and alveolar process region areas of which
fine details cannot be appreciated
Difficult to appreciate buccal and lingual bone displacement.
Three-dimensional CT Scan
It can be obtained to compare symmetry and volume of two side of bone of
face.
SUMMARY
7 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
8 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 pre-
existing 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.
General Treatment of Fracture Mandible / 43
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
Intermaxillary Fixation
Arch Bars
Arch bars are preferred:
For temporary fragment stabilization in emergency cases before definitive
treatment
As a tension band in combination with rigid internal fixation
For long-term fixation in conservative treatment
For fixation of avulsed teeth and alveolar crest fractures
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.
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
outer surface. One end of the wire is Fig. 8.5: Eyelet method of fixation
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.
General Treatment of Fracture Mandible / 47
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.
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.
General Treatment of Fracture Mandible / 49
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.
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
Fig. 8.10: Gap at lingual cortex if plate
Eccentric Drilling for not overbend
Compression
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.
General Treatment of Fracture Mandible / 51
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
For example, when using a plating external diameter of screw
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
General Treatment of Fracture Mandible / 53
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 over-
tightening. Fig. 8.18: Screw insertion
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:
Small profile locking plate
Medium profile locking plate
Large profile locking plate
Extra-large profile locking plate
They are also available in multiple shapes to meet a variety of clinical
applications.
General Treatment of Fracture Mandible / 55
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
Screw insertion does not affect the Screw insertion does affect the
reduction of the segment reduction of the segment
During insertion the locking head screw engages and locks into the threaded
plate hole.
Biomechanics
Conventional Screws
With the conventional technique,
the tightening of the screws
presses the plate against the bone.
Fig. 8.24: Friction between bone and plate
This pressure generates friction,
which contributes significantly to
primary stability.
Loading forces are trans-
mitted from the bone to the plate,
across the fracture and back into
the bone. Friction between plate
and bone is necessary for stability
Fig. 8.25: Loading force transmitted from
using conventional screws. bone-to-plate and then plate-to-bone
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 accomp-
lished with a locking reconstruction
plate. Clinical uses are the management
of atrophic edentulous fractures,
comminuted fractures, defect fractures,
and other complex mandibular
fractures.
Fig. 8.30: Load-bearing
Load-Sharing Osteosynthesis osteosynthesis
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 load-
sharing osteosynthesis include lag screw
fixation technique and compression
plating. Load-sharing osteosynthesis
cannot be used with defect fractures or Fig. 8.32: Minihole plate load
comminuted fractures, due to the lack sharing osteosynthesis
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 osteo-
synthesis assumes all the masticatory loads
while the bone graft matures and conso- Fig. 8.34: Load-bearing
lidates in a protected environment. osteosynthesis
General Treatment of Fracture Mandible / 61
SUMMARY
Aim of treatment of fracture mandible is to reduce the fracture segment
and fix it so that normal anatomical relationship can be maintained.
Atmost precaution to be taken to preserve the blood supply of the bone
and the soft tissue by careful handling and reduction technique.
Attempt should be made for early and safe mobilization and rehabilitation
of the patient.
There are many methods of closed reduction but arch bar application is
more commonly used.
Period of immobilization 34 weeks for young adult with angle fracture
+ 1 week if teeth is in a fracture line
+ 1 week for fracture of parasymphysis
+ 1 or 2 week for age 40 years and above
1 week for childrens and adolsent
Dynamic compression plates and lag screws are not commonly used in
fracture mandible.
Reconstruction plate, miniplate are most commonly used.
Rigid osteosynthesis are:
Reconstruction plate
Locking plates
Three-dimensional sturd.
62 / Fracture Mandible
9 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
It is same as all routine anesthesia
Careful assessment for associate injury should be done
Make a meticulous assessment of airway, there may be several trismus
and soft tissue swelling
Explain the patient about postoperative events like mouth closure in a brief
Assess nostril patency
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
Trismus make intubation look potentially difficult preoperatively as the
mouth opening is markedly limited due to the muscle spasm, hematoma,
pain, but this tend to relax following induction
Nose should be packed with 4% lignocaine with adrenaline or otrivin
nasal drop should be used
Bilateral mandible fractures can cause increase anterior jaw displacement
after induction but airway maintenance by face mask may not always be
easy due to increase jaw movement, swelling
A rapid sequence induction with suxa-methonium is appropriate
A marked swelling may make intubation difficult and awake fibreoptic
intubation may be required
Gas induction is often difficult due to pain while applying the face mask
Make sure that the patient when comes out from anesthesia should not be
sedated and should be completely awake from the anesthesia
If throat pack is placed around the tube should be removed before the
application of wires.
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.
Anesthesia for Fracture Mandible / 65
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
Fig. 9.1
66 / Fracture Mandible
Goal
Goal is to deposit local anesthesia close to the PSA nerve located posterior
superior and medial to the maxillary tuberosity.
Technique
Target areainfraorbital foramen (below the infraorbital notch)
Landmarkmuccobuccal fold, infraorbital notch, infraorbital foramen
Area of insertionheight of muccobuccal fold directly over first premolar.
Procedure
Feel for infraorbital notch
Move your fingers downward from the notch applying gentle pressure to
the tissue
Anesthesia for Fracture Mandible / 67
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
Fig. 9.4
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
Procedure
A finger tip is kept in a coronoid notch
An imaginary line extended posterior from the finger tip in a coronoid
notch to the deepest part of the pterygomandibular raphe
This imaginary line should be parallel with the occlusal plane of the
mandibular molar teeth
The needle inserted anteroposterior distance from the coronoid notch back
to the deepest part of the pterygomandibular raphe
The finger on the coronoid notch is used to pull the tissue laterally,
stretching them over the injection side making them taut and for better
visibility and to be less traumatic.
Procedure
A 25 gauge 1 inch long needle is inserted either in retromolar triangle area
or buccalmuccosa just distal to mandibular third molar area
0.5 ml of local anesthesia is injected
Fig. 9.7
Anesthesia for Fracture Mandible / 73
Procedure
A 24 gauge needle with 1 inch length is inserted in muccolabial fold in
between two premolar directing downward and anteriorly after retracting
the cheek
It contacts the bone at the level of apex at the second premolar anterior to
it
After aspiration, 0.5 ml is slowly injected.
SUMMARY
Do intermaxillary fixation under local if patient is co-operative.
All fracture mandible which require open reduction better to operative in
general anaesthesia.
74 / Fracture Mandible
10 Specific Treatment of
Fracture Mandible
Closed Reduction
Intermaxillary fixation application with arch bar:
Simple technique
Indicate for simple undisplaced fracture.
Miniplate Osteosynthesis
Advantages
a. Not bulky and thick like dynamic compression plate
b. Not perfect adaptation required
c. Insertion of screw are easier
d. Gives good stability to the fracture line
e. Available in titanium as well as stainless steel material.
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.
B
A
D
C
E
Fig. 10.4
Specific Treatment of Fracture Mandible / 77
Fig. 10.6C: Basal triangle fracture of Fig. 10.6D: Reconstruction plate (load-
parasymphysis area bearing osteosynthesis) at a inferior
border + miniplate (load-sharing
osteosynthesis) at the superior border
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:
High condylar fracture
Low condylar fractures
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:
Cases of condyle fracture with vertical overriding
Cases in which normal occlusion by manipulation or traction cannot be
achieved
Cases of gross displacement especially bilateral condyle fracture
Cases in which condyle fracture interfere with jaw movement
Cases in which condyle are partially fused in a wrong position
The condyle is surgically approached by preauricular approach or by
submandibular, retromandibular approach. The fracture is reduced and is
fixed by either by interosseous wiring or by monocotical miniplates.
Mistakes
Common mistakes observed in treatment of rigid fixation:
Poor reduction of fractures
Interposition of tissue between the fracture line
Poor alignment of fractured segment
Insufficient screw placement
Poor plate bending
Poor or lose application of intermaxillary fixation.
Tips
Soft tissue in between the fracture line should be removed as proper
allignment cannot be attended. Nonhealing can occur if soft tissue is placed
between fractured fragment.
Use of drill sleeve provide protection to soft tissue.
Drill bit used should be 0.5 mm less than screw size. For example, if 2 mm
screw or plate is used 1.5 mm drill bit is used to make hole.
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
In case of simple, undisplaced fracture and no expertise available or
condition of patient does not allow general anesthesia; close reduction of
fracture mandible most preferably by arch bar method (IMF) is suitable.
In cases of parasymphysis and symphysis fracture in addition to lower
border miniplate application a superior border miniplate is also applied
to combat torsional force.
A miniplate with two hole on either side of fracture mandible is ideally
fixed.
Champys line of osteosynthesis give idea of sight of application of plates
in various areas.
In simple undisplaced fracture load sharing plate (mini plate) to be used.
In grossly displaced, infected, loss of segment fracture mandible
reconstruction plate should be ideally used.
All cases of undisplaced condyle fracture can be treated by closed
reduction.
Open reduction in a condyle fracture is indicated in cases where by
manipulation or traction the fracture segment is not reduced or cannot be
brought into normal occlusion.
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
Lingual surface of the mandible can be easily inspected to assure optimum
reduction of fracture in this segment.
There is no major neurovascular structure in this area.
Scar is not that visible
Dissection
Carry the incision through the skin and subcutaneous tissues to the platysma
muscle.
The platysma muscle must be divided.
There may be a natural separation of the muscle in the midline region.
Additionally the platysma muscle can become very thin in this region.
Dissection is carried out to the inferior border of the mandible. The
periosteum is incised sharply and the flap is elevated to expose the
anterior surface of the symphysis.
Wound closure
The wound is closed in layers to realign the anatomic structures and to
eliminate dead space.
The periosteum and platysma muscle should be closed in different layers.
Option: bilateral extension
Submental extension
The submental incision can be extended laterally to encompass both the right
and left mandible by degloving the entire lateral surface of the mandible in
the same way as in the submandibular approach.
This may be necessary in complex fractures such as comminuted, atrophic,
and severe bilateral fractures.
To approach complex mandibular fractures the surgeon essentially
combines a right and left submandibular incision with a submental one.
The inferior border of the mandible is marked along with the planned
skin incision.
Submandibular Approach
In 1934risdon describe this technique.
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 submandi-
bular 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 Fig. 11.3: Retromandibular
used. approach
86 / Fracture Mandible
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 musculo-
aponeurotic 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. Fig. 11.5: Retroparotid approach
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
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.
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
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.
Surgical dressing
An elastic pressure dressing covering the ramus/condylar process region
helps support the soft tissues and prevent hematoma formation.
SUMMARY
Vestibular incision is best for simple fracture(symphysis, angle, body)
Preserve mental nerve
Close wound in two layers muscle and mucosa
Extraoral incision for
Complex, difficult, grossly displaced fracture
Preserve the facial nerve
Close the wound in layers
Try to give good scar
Mandibular condyle repair can be done endoscopically.
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.
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 long-
term effect on both mandibular growth and normal development of permanent
dentition. Close cooperation with paedodontist, orthodontist and dentist is of
vital importance.
SUMMARY
Growth of the bones are rapid.
Interference with growth potential should be kept in mind.
Conservative management to be done for fracture mandible in children.
Perfect reduction not required.
Prolonged follow-up is required.
100 / Fracture Mandible
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 bite-
rehabilitation, 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.
102 / Fracture Mandible
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
Postoperative Care / 103
SUMMARY
Patients nutrition should be maintained.
Oral hygiene should be taken special care.
In compound fractures infection should be prevented.
Wire cutters, suction machine should be kept at the bed side.
A dental reference to be done after removal of wires done for the wiring
technique.
Implants need not require to be removed unless and until it is exposed,
infected or extruded.
104 / Fracture Mandible
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
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.
106 / Fracture Mandible
Treatment
a. All sequestra and devitalized bone should be removed
b. Any internal fixation should be removed
c. Higher antibiotic should be started
d. Appropriate drainage if required should be done
e. Bone should be stabilized with external fixation
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:
Identifying the cause
Controlling infection
Surgical reconstruction: Removing the existing hardware, debridement of
devital bone and/or soft tissues, decortication of bone fragments at the
fracture ends, re-establishing occlusion, stabilizing segments using a locking
reconstruction plate 2.4, and autogenous bone graft to this area.
Complications / 107
Malunion/Malocclusion
Etiology
Malunions occur for at least one of several reasons:
Inadequate occlusal reduction during surgery
Inadequate osseous reduction during surgery
No osseous reduction (e.g. condyle fractures)
Imprecise application of internal fixation devices
Inadequate stability (lack of rigidity)
Treatment
The treatment of a malunion must involve:
Identification of the cause
Orthodontic/orthopedic treatment if possible
Osteotomies as necessary (refracture, standard osteotomies, combinations)
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:
Insufficient amount of fixation
Fracture of the plate
Loosening of the screws
Devitalization of bone around screws
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. Contamination of wound with dirt specially tar products
b. Improper technique of suturing
c. Associated infection
d. Tendency of patient
Complications / 109
Treatment
a. Wait and watch for 1st year as they may soften and fed away
b. Massage of the scar
c. Pressure bandage
d. Application of lanoline
e. Infilteration of injection kenacort and hylinese
f. Surgical revision if possible
SUMMARY
Proper reduction, stable and appropriate fixation with prevention of infection
can prevent most of the complication of fracture mandible.
In cases of edentulous patient, grossly contaminated fractures, poor
nutritional condition of the patient, complication like malunion, non-
union should be kept in mind.
All devitalized structures, infected tissue, loose plates and srews should be
removed and replaced by appropriate ones.
Index / 111
Index
Page numbers followed by f refer to figure
B D
Basal triangle fracture of parasymphysis
area 78f Dental terminology 4f
Bilateral condylar fractures 32 Dentoalveolar fractures 31
Biomechanics of mandible 10, 11f Determine screw length 53, 53f
Blood Different levels of force distribution 60
loss 39 Dissect over condylar fragment 96
vessels 17 Dissection 84, 87, 88
Blunt dissection of parotid gland 87 of joint capsule 89
Bonded modified orthodontic brackets 47 Dynamic compression plate 48, 50f
Buccal nerve block 71
Buccinator muscle 93, 95 E
C Eccentric drilling for compression 50
Eyelet method 46
Carotid injury 104 of fixation 46f
Categories of
associated fractures 25
fractures 25 F
occlusion 25
soft tissue involvement 25 Face lift incision 88, 89f
Champys line 74f Facial nerve injury 104
of osteosynthesis 74 Factors affecting bone healing 10
Closed reduction 74 Feeding 101
Combination with transbuccal technique 94 Fibrodysplasia ossifficans 108
Comminuted fracture 22, 22f, 33, 52 Fixation
of angle and body 78f failure 107
of parasymphysis 77f in deciduous and mixed dentition period
Complex symphysis 77 98
Complication after insufficient amount of independent of teeth 98
fixation 108f utilizing teeth 99
112 / Fracture Mandible
Fracture 18 Insertion of
angle of mandible 26 endoscope 96
condyle 26 optical retractor 96
displacement 26 Insufficient amount of fixation 107
in canine region 26 Intermaxillary fixation 44
of angle 33 screw technique 47, 47f
and ramus 77 Intermediate load-sharing situation 61
of body 34 Intraoral incison for symphysis and body
of mandible 26 fracture 91f
of coronoid process 27, 33, 81
of head of condyle 79, 80 L
of mandible 20
of ramus 33 Lag
of mandible 27 screw 51
of symphysis 27 principle 51f
and parasymphysis 34 and technique 51
site exposure 92 technique 51, 52
Frequency of fracture 19 Limitation of opening of mouth 108
Load-bearing osteosynthesis 59, 61f, 78f
G Load-sharing osteosynthesis 59, 78f
Local
Gap healing 9 anesthesia 64
Gilmer method 46 examination of mandibular fracture 29
of fixation 46f Location of mental foramen 72
Grades of severity 25 Locking
Greater palatine head screws 57
block 69 plate 54
nerve block 68 system 58, 59
Greenstick fracture 22, 22f reconstruction plate 55, 56f
Lower jaw infiltration 70
H
Head entering medullary space 54f M
Healing of fracture 7f, 8f Malreduction of fracture 60f
bone 9 Mandibular
Hemorrhage 104 condyle fracture 79
Hindrance in growth potential 98 muscles 14
Horizontally Mental nerve block 72
favorable fractures 23, 23f Mentalis muscle dissection 92
unfavorable fractures 23, 23f Middle superior alveolar nerve block 66,
67
I Minihole plate 75f
Ideal Miniplate
lines of osteosynthesis 60 at external oblique line 78f
load-sharing situation 61 osteosynthesis 74
Incising temporalis fascia 89 Mobilization of temporomandibular joint
Inferior alveolar nerve block 70 103
Infra-alveolar nerve block 70 Mucosal incision 91
Infraorbital for angle fracture 92f
block 68 for condyle and ramus fracture 94f
nerve block 66, 68 Multiple and comminuted fractures 34
Index / 113