Mandibular Fracture

• OUTLINE
• • INTRODUCTION
• • CLASSIFICATION
• • AETIOLOGY
• • EPIDEMIOLOGY
• • SIGNS & SYMPTOMS
• • INVESTIGATION
• • MANAGEMENT
 INTRODUCTION
• Fracture of the mandible occurs more frequently than that
of any otherfacial skeleton.
• It is the one serious facial bone injury that the average
practicing dental surgeon may expect to encounter, albeit
on rare occasions, at his surgery.
• It is also a facial fracture which he may have the
misfortune to cause as a complication of tooth extraction.
• Broadly divided into:
1. Fractures with no gross communition of the bone and
without significant loss of hard and soft tissues
2. Fractures with gross communition of the bone and with
extensive loss of both hard and soft tissues.
ANATOMY
•Lower jaw bone
• U shaped body
• 2 vertically directed rami
• Condylar process
• Coronoid process
• Oblique line
• Mental foramen
INTERNAL
ANATOMY
• Mandibular foramen
• Lingula
• Pterygoid fovea
• Mylohyoid line
• Fossae
Submandibular
Sublingual
Digastric
• Mental spines
Genioglossus
Geniohyoid
MUSCULATURE:
jaw elevators
• Masseter muscle: from
zygoma to angle and
ramus
• Temporalis muscle: from
infratemporal fossa to
coronoid and ramus.
• Medial pterygoid muscle:
medial pterygoid plate and
pyramidal process into the
lower mandible.
MUSCULATURE:
jaw depressors
• Lateral pterygoid muscle:
lateral pterygoid plate to
condylar neck and TMJ
capsule
• Mylohyoid muscle:
Mylohyoid line to body of
hyoid
• Digastric muscle: mastoid
notch to digastric fossa
• Geniohyoid muscle: inferior
genial tubercle to anterior
hyoid bone
INNERVATION
• CN3; mandibular nerve
through the foramen ovale
• Inferior alveolar nerve
through the mandibular
foramen
• Inferior dental plexus
• Mental nerve through
the
mental foramen.
BLOOD SUPPLY
• Internal maxillary
artery
• Inferior alveolar
artery
• Mental artery
 CLASSIFICATION OF FRACTURES
• Type of fracture
• Site of fracture
• Cause of fracture
 TYPE OF FRACTURE
• Simple
• Includes a closed linear fractures of the condyle, coronoid, ramus
and edentulous body of the mandible.
• Compound
• Fractures of tooth bearing portions of the mandible, into d mouth
via the periodontal membrane and at times through the overlying
skin.
• Communited
• Usually compound fractures characterized by fragmentation of
bone
• Pathological
• Results from an already weakened mandible by pathological
conditions.
SITE OF FRACTURE
• Dentoalveolar
• Condyle
• Coronoid
• Ramus
• Angle
• Body (molar and
premolar areas)
• Parasymphysis
• Symphysis
 CAUSE OF FRACTURE
• Direct violence
• Indirect violence
• Excessive muscular contraction
• Fracture of the coronoid process because of
sudden reflex contracture of the temporalis
muscle.
 PATTERN OF FRACTURE
• Unilateral fracture
• Bilateral fracture
• Multiple fracture
• Communited fracture
 AETIOLOGY
• Road traffic accidents
• Interpersonal violence
• Contact sports
• Industrial trauma
• Falls
 EPIDEMIOLOGY
• • The mandible is one of the most commonly fractured
bones of the face and this is directly related to its
prominent and exposed position.
• Oikarinen and Lindqvist (1975) studied 729 patients
with multiple injuries sustained in RTA. The most
common facial fractures were in the mandible.
• Mandible (61%)
• Maxilla (46%)
• Zygoma(27%)
• Nasal Bone (19%)
 Cont..
• Studies have shown that the incidence of
mandible fractures are influenced by various
etiological factors e.g.
• Geography
• Social trends
• Road traffic legislations
• Seasons
 Cont..
• Site of Fracture: Oikarinen and Malmstrom (1969)
analyzed 600 mandible fractures. On analysis the
following results were obtained:
• Body of mandible (33.6%)
• Sub- condylar area(33.4%)
• Angle (17.4%)
• Dentoalveolar (6.7%)
• Ramus (5.4%)
• Symphyseal 2.9%
• Coronoid 1.3%
• Even though the body of the mandible has the
highest incidence when it comes to
mandibular fracture, the condyle remains the
commonest site for mandibular fracture
 SIGNS AND SYMPTOMS
• GENERAL
• SPECIFIC
 GENERAL SIGNS AND SYMPTOMS
• Swelling
• Pain
• Drooling
• Tenderness
• Bony discontinuity
• Lacerations
• Limitation in mouth opening
• Ecchymosis
• Fractured, subluxed, luxatedteeth.
• Bleeding from the mouth
 SPECIFIC SIGNS AND SYMPTOMS
• SPECIFIC SIGNS AND SYMPTOMS
• DENTOALVEOLAR FRACTURES
• Lip bruises and laceration
• Step deformity
• Fracture, luxation or subluxation of teeth
• Laceration of the gingivae
• FRACTURE OF THE BODY
• Swelling
• pain
• Tenderness
• Step deformity
• Anaesthesia or paraesthesia of the lip
• Intra oral hemorrhage
• SYMPHYSEAL/PARASYMPHYSEAL FRACTURES
• Tenderness
• Sublingual haematoma
• Loss of tongue control
• soft tissue injury to the chin and lower lip
• FRACTURE OF THE RAMUS
• Swelling
• Ecchymosis
• Pain
• Trismus
• FRACTURE OF THE ANGLE
• Swelling
• Posterior gag
• Deranged occlusion
• Anaesthesia or paraesthesia of lower lip
• Haematoma
• Step deformity behind the last molar tooth
• Tenderness
• CORONOID FRACTURE
• Tenderness over the anterior part of the tragus=
• Haematoma
• Painful limitation of movement
• Protrusion of mandible may be present.
• SYMPHYSEAL/PARASYMPHESEAL FRACTURES
• Tenderness
• pain
• Step deformity
• Sublingual haematoma
• Loss of tongue control
• May have soft tissue injury to the chin and lower lip
• CONDYLAR FRACTURE (unilateral/bilateral and
Intracapsular/extracapsular
• • Unilateral condylar fractures
• Swelling over the TMJ
• Hemorrhage from ear on the affected side
• Battle’s sign
• Locked mandible
• Hollow over the condylar region after edema has
subsided
• rarely, Paraesthesia of lower lip
• Deviation to the affected side upon opening
• Painful limitation of movement
• • Bilateral condylar fractures
• Same as above
• Limitation in mouth opening
• Restricted mandibular movement
• Anterior open bite
 INVESTIGATION
• Treatment plan for mandibular fractures is
very dependent on precise radiological
diagnosis
• • RADIOGRAPHS
• Essential radiographs
• • Extra-oral radiographs
• • Intra-oral radiographs
• • Desirable radiographs
 Essential Extra-oral Radiographs
• • Oblique lateral
radiographs
(left and right)
• Fracture of body
proximal to canine
region
=• Fractures of angle,
ramus and condylar
region
• • Posterior-anterior
view
• Shows displacement of
fractures in the
ramus,angle, body
• Rotated posterior-
anterior view
• Fractures between
Symphysis and canine
region
• • Reverse Towne’s view
• Ideal for showing
lateral or medial
condylar displacement
 Essential Intra-oral Radiographs
• Periapical radiographs:
• Association of tooth to line of fracture
• Existing pathology related to tooth in line of
fracture
• Fracture of tooth in line of mandibular fracture
• Occlusal radiographs:
• Association of root of tooth to line of fracture
 Desirable Radiographs
• Panoramic tomography
• represents the best
single overall view of
the mandible especially
the condyles
• Standard linear
tomography
• Computed tomography
(CT)
 MANAGEMENT
• Airway
• Tongue falling back
• Blood clots
• Fractured teeth segments
• Broken fillings
• Denture
• Hemorrhage
• Soft tissue lacerations
• Support of bone fragments
• Pain control
• Infection control e.g. compound fractures
• Food and Fluid
 DEFINITIVE TREATMENT
• Reduction
• Restoration of a functional alignment of the bone
fragments
• Use of occlusion
• 1. Open reduction
• 2. Closed reduction
• Immobilization
• To allow bone healing
• Through fixation of fracture line
• 1. Rigid
• 2. Non-rigid
 BONE HEALING
• Bone healing is altered by types of fixation and
mobility of the fracture site in relation to
function
• Primary bone healing
• Secondary bone healing
 Bone Healing
• Primary bone healing:
• No fracture callus forms
• Heals by a process of
1. Haversian remodeling directly across the fracture
site if no gap exists(Contact healing), or
2. Deposition of lamellar bone if small gaps exist
(Gap healing)
• Requires absolute rigid fixation with minimal gaps
 Bone Healing
• Secondary bone healing:
• Bony callus forms across fracture site to aid in
stability and immobilization
• Occurs when there is mobility around the
fracture site
 Bone Healing
• • Secondary bone healing involves the
formation of a subperiosteal hematoma,
granulation tissue, then a thin layer of bone
forms by membranous ossification. Hyaline
cartilage is deposited, replaced by woven
bone and remodels into mature lamellar bone
 TEETH IN LINE OF FRACTURE
• • Teeth in line of fracture are a potential impediment to healing for
the
• following reasons
1. The fracture is compound into the mouth via the opened
periodontal membrane
2. The tooth may be damaged structurally or loose its blood supply
as a result of the trauma so that the pulp subsequently becomes
necrotic
3. The tooth may be affected by some pre-existing pathological
process
• Indications for removal
• Absolute
• Relative
 Absolute indications
Longitudinal fracture involving the root
• Dislocation or subluxation of tooth from
socket
• Presence of periapical infection
• Infected fracture line
• Acute pericoronitis
 Relative indications
• Functionless tooth which would eventually be
removed electively
• Advanced caries
• Advanced periodontal disease
• Teeth involved in untreated fractures
presenting more than 3days after injury
 Management of teeth retained in
fracture
line
• • Good quality intra-oral periapical radiograph
• • Appropriate antibiotic therapy
• • Splinting of tooth if mobile
• • Endodontic therapy if pulp is exposed
• • Immediate extraction if fracture becomes
infected
 IMMOBILIZATION
• The period of stable fixation required to
ensure full restoration of function varies
according to:
1. Site of fracture
2. Presence of retained teeth in the line of
fracture
3. Age of the patient
4. Presence or absence of infection
• • A simple guide to time of immobilization for
fractures of the tooth bearing area of the
mandible is as follows:
• Young adult
• With Fracture of angle
• ReceivingEarly treatment In which
• Tooth removed from fracture line
• 3weeks
• • If:
• a) Tooth retained in fracture line: add 1 week
• b) Fracture at Symphysis: add 1 week
• c) Age 40yrs and above: add 1 or 2 weeks
• d) Children and adolescent: subtract 1 week
 CLOSED REDUCTION
• Fracture reduction that involves techniques of
not opening the skin ormucosa covering the
fracture site
=• Fracture site heals by secondary bone healing
• This is also a form of non-rigid fixation
• “If the principle of using the simplest method to
achieve optimal results is to be followed, the use
of closed reduction for mandibular fractures
should be widely used” Peterson’s Principle of
Oral and Maxillofacial Surgery 2ndedition
• INDICATIONS
1. Nondisplaced favorable fractures
2. Mandibular fractures in children with developing
dentition
3. Condylar fractures
• • CONTRAINDICATIONS:
1. Alcoholics
2. Seizure disorder
3. Mental retardation
4. Nutritional concerns
5. Respiratory diseases (COPD)
• Unfavorable fractures
• ADVANTAGES
1. Low cost
2. Short procedure time
3. Can be done in clinical setting with local anesthesia or
sedation
4. Easy procedure
• • DISADVANTAGES
1. Not absolute stability (secondary bone
healing)
2. Oral hygiene difficult
3. Possible TMJ sequelae
• a) Muscular atrophy/stiffness
• b) Decrease range of motion
 OPEN REDUCTION
• Implies the opening of skin or mucosa to visualize the
fracture and reduction of the fracture
Can be used for manipulation of fracture only
Can be used for the non-rigid and rigid fixation of the
fracture
• INDICATIONS
Unfavorable/unstable mandibular fractures
Fractures of an edentulous mandible fracture with severe
displacement
Delayed treatment with interposition of soft tissue that
prevents closed reduction techniques to re-approximate
the fragments
Open reduction/rigid fixation
 COMPLICATIONS

• Misapplied fixation
• Infection
• TMJ ankylosis
• Nerve damage
• Displaced teeth
• Gingival and periodontal complications
 CONCLUSION
• • An adequate knowledge of the diagnosis
and management of various types of
mandibular fracture is needed so as to provide
the desired treatment in order to prevent
unfavorable and adverse complications
 Reference
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