Facial Fract II PDF

Facial Fractures II: Lower Third
James F Thornton MD and Larry H Hollier MD
MAXILLARY FRACTURES Today most authors subscribe to the following

principles of craniomaxillofacial fracture manage-
ment:25,26
HISTORY • Early one-stage repair
The maxilla is the central keystone of the face, • Wide exposure of all fracture fragments
linking the cranial base superiorly with the occlusal • Precise anatomic reduction
plane of the lower jaw inferiorly. Multiple methods
• Rigid fixation
of management of maxillary fractures have evolved
through the ages, beginning with the now-obsolete • Immediate autogenous bone grafting
external methods of fixation, which prevailed before • Simultaneous definitive soft-tissue management
the advent of antibiotics,1-9 to modern craniofacial
surgical techniques.
SURGICAL ANATOMY
Ipsen10 first proposed internal K wire fixation of
facial fractures in 1933, and later Brown and Le Fort’s27,28 studies of patterns of fracture in
McDowell11,12 introduced it to the United States. the face are landmarks in the literature of cranio-
In 1939 Dingman13 popularized rubber band trac- maxillofacial surgery. Le Fort identified three great
tion to immobilize difficult fractures of the midface, lines of weakness in the facial skeleton that cor-
and 3 years later Adams14 used direct internal wir- respond to the most common sites of fracture29
ing and suspension techniques. Dingman2,15 sub- (Fig 1).
sequently emphasized sequential suspension of the Le Fort I fractures result in a floating palate. Le
reduced fragments to the nearest superior stable Fort II fractures produce separation and mobility of
buttress. the midface extending through the orbits and
In the early 1970s Ferraro and Berggren16 sug- nasoethmoid region. Le Fort III fractures discon-
gested rigid internal fixation with immediate bone nect the face from the cranium, producing a cran-
grafting for the repair of complex facial fractures, iofacial dysjunction. Several variations of the clas-
and since that time the practice has become wide- sic patterns exist, with fracture lines extending to
spread.17-23 involve the maxillary alveolus or to split the hard
palate. The simple Le Fort classification system is
The European experience with osteosynthe- often inadequate to describe the pattern and extent
sis and craniofacial techniques in the treatment of fracture in complex facial injuries. The majority
of fractures of the midface has been most favor- of complex facial injuries are not pure Le Fort frac-
able, and these methods have become the stan- tures but combinations of several types.
dard of care in maxillary fractures. As Wolfe24
Manson, Hoopes, and Su30 studied the skeletal
states,
anatomy of the midface as it relates to the frontal
The methods of treatment that were recom- cranium and cranial base. The authors identified
mended . . . in the mid-70s—small incisions, limited
three vertical pillars of the maxilla: the nasomaxillary
exposure, use of the halo head frame, packing the
maxillary antra for orbital fractures, prolonged (nasofrontal); the zygomaticomaxillary; and the
periods of intermaxillary fixation, canthal buttons, pterygomaxillary buttress30 (Fig 2). According to
and putting off “reconstruction” until later—have the authors, these buttresses “protect the maxilla
been relegated to the scrap heap of antiquated primarily against vertically directed forces. Shear
surgical methods. forces directed perpendicularly to the pillars pro-
Wolfe (1991) duce dysjunctions of the maxilla.”30,31
SRPS Volume 9, Number 27
Fig 2. Division of midface reconstruction into upper and lower

units and their relation to cranial base and frontal cranial
attachment. (VDO = vertical distance of occlusion.) (Reprinted
wtih permission from Manson PN, Hoopes JE, Su CT: Structural
pillars of the facial skeleton: An approach to the management
of Le Fort fractures. Plast Reconstr Surg 66:54, 1980.)
Fig 1. Common patterns of midface fractures. (Reprinted with

permission from Fonseca RJ, Walker RV, eds: Oral and Maxillo-
facial Trauma, 2nd ed. Philadelphia, Saunders, 1997.)
Manson and colleagues31,32 also described hori-

Fig 3. Horizontal pillars of the face. (Reprinted with permission
zontal buttresses of the face: the frontal bar, in-
from Markowitz BL, Manson PN: Panfacial fractures: Organiza-
fraorbital rims, zygomatic arch, and mandibular body tion of treatment. Clin Plast Surg 16(1):105, 1989.)
(Fig 3). Together with the nasoorbitoethmoid com-
plex and the maxillary arch and palate, they deter-
mine the midfacial width and projection. attempts at reconstruction.” It is important to dis-
The horizontal buttresses are of two types, coro- tinguish between vertical and horizontal buttresses
nal and sagittal (Fig 4).32 “The midface lacks sagittal in the midface to carry out reconstruction follow-
buttresses, particularly in the central segments . . . ing the anatomic subunit principle, as described by
[and] one sees flattening with severe injury despite Manson et al.32
2
as isolated injuries or in association with other Le

Fort fractures.35
ASSOCIATED INJURIES
Steidler and colleagues41 found various degrees
of head (51%), chest (12%), and abdominal injury
(5%) concomitant with midfacial fractures. Over
one third of their patients had other skeletal inju-
ries, and 9% were blind.
A retrospective review of 661 patients with facial
fracture admitted to a level I trauma center 42
revealed that 84% of patients who died of neuro-
logic injury had a facial fracture pattern that included
Fig 4. Buttressing of the Le Fort I (lower midfacial) segment in the midface. The dead (63/661, 9.5%) were more
comminuted fracture depends more on the mandible than on likely to have isolated midfacial fractures (n=23) or
the midface. Similarly, the frontal bone should buttress the
midfacial fractures in combination with upper or
upper midface. (Left) The midface lacks good sagittal but-
tresses except for the zygomatic arch. Good sagittal buttresses, lower facial third injuries (n=29). Isolated mandibu-
however, are available in the frontal bone and in the mandible. lar fractures had an extremely low incidence of
(Right) The central midface (dotted area) is weak in sagittal associated fatal neurologic injury (1/661).
buttress support and is inherently prone to deficient projection, In a large epidemiologic study from Taiwan of
expecially in the presence of nasoethmoid orbital fracture. 1025 patients with facial fractures, the most com-
(Reprinted with permission from Manson PN, Clark N, Robertson
B, et al: Subunit principles in midface fractures: the importance
mon life-threatening injury was cerebral trauma (21/
of sagittal buttresses, soft-tissue reductions, and sequencing 64), followed by hemorrhagic shock (19/64) and
treatment of segmental fractures. Plast Reconstr Surg 103:1287, airway compromise (17/64). The vast majority of
1999.) these patients had isolated fractures of the
midface.43
Unlike the mandible, which is strong and readily A report from Australia lists the incidence and
reconstructed, the bony buttresses in the region of nature of associated injuries in 839 patients with
the maxillary and ethmoid sinuses, orbital floor and facial fractures.44 Ninety-five patients (11%) sustained
pterygoid plate are fragile and easily disrupted. This significant injuries in addition to those in the facial
observation has led to the practice of reducing and skeleton: 45 neurologic, 33 ocular, 8 spinal, 16 to
stabilizing the mandible first to provide an occlusal the torso, and 62 to the extremities. Most neurosur-
gical injuries were the result of focal impact, while
basis on which to stabilize the maxilla.30-32
ocular injury was likely when the fracture involved
the orbit. Injuries to the spine, torso, and limbs were
EPIDEMIOLOGY seen mainly after vehicular accidents.
A high incidence of ocular injuries associated
Personal altercations and motor vehicle accidents
with midfacial fractures is also reported by Poon
account for over two thirds of facial fractures.
and colleagues,45 who note nearly 55% ocular or
Approximately 40% involve the middle third of the
orbital injuries associated with midfacial trauma in
face excluding the nose, which by itself is fractured their series.
in one third of cases.30,34-40 The frequency of cervical spine injury in associa-
Large series of midfacial fractures consistently tion with maxillofacial fractures is said to be 12% to
show a relative frequency of Le Fort II > Le Fort I > 18%.46 These injuries are mostly secondary to
Le Fort III patterns of fracture.30,33,34 Manson30 hyperflexion of the spine. In the presence of sig-
reports this ratio to be 42:30:28, whereas Morgan nificant facial trauma, cervical spine x-rays should
et al34 report an exaggerated ratio of 67:25:8. Sag- be obtained before commencing treatment. 47
ittal fractures of the alveolar ridge or palate account When indicated, the neck should be immobilized
for approximately 15% of maxillary fractures, either to prevent further damage.48
3
BIOMECHANICS The clinical signs of Le Fort II and III fracture are

Nahum studied the vulnerability of facial bones
49 1) bilateral circumorbital and subconjunctival
to impact forces and made the following generali- ecchymosis; 2) gross bilateral edema of the middle
zations: third of the face; 3) lengthening of the face; and 4)
malocclusion. The combined deformities produce
• Women have consistently lower impact toler- the so-called “panda facies”.54
ance levels than men. When examining a patient with suspected frac-
• The overlying soft tissue helps to absorb the ture of the midface, the clinician should hold one
energy of the impact and to reduce the magni- hand on the anterior maxilla and the other on the
tude of the injury. nasal root, otherwise scalp movement may falsely
• The nasal bones have the lowest level of impact suggest upper facial motion. In general Le Fort I
tolerance. fractures show movement of the lower maxilla but
none at the nasal root, whereas both Le Fort II and
• The zygomatic arch is the second most fragile
III fractures display motion at the nasal root. A step
area.
deformity at the infraorbital rim can be felt in Le
• The maxilla is very sensitive to localized hori- Fort II fractures. Le Fort III fractures show move-
zontal impacts. ment at the lateral orbital rim.
• The mandible is much more vulnerable to lat- The stability of the palate should be checked
eral impacts than to frontal blows. when a fracture of the midface is suspected. Inde-
pendent mobility of the right or left side of the
Low energy fractures typically involve the nasal palate indicates a sagittal fracture of the maxilla and
bones, nasoethmmoid area, frontal sinus, and palate that requires unique treatment strategies.35
zygoma. High energy fractures are common in
facial bones that have a high resistance to impact,
Radiographic Examination
such as the anterior mandible, maxilla, and supraor-
bital frontal bone.50 Luce, Tubb, and Moore51 note High-resolution CT scans are needed to thor-
an increased frequency of associated major injury oughly delineate the extent of injury in suspected
with high energy fractures, reflecting the greater midfacial fractures and after any complex maxillofa-
force required to elicit a fracture in these areas. cial trauma.55-57 An initial CT scan is now recom-
Nevertheless, a 30-mph collision generates an mended on the basis of cost effectiveness and sen-
impact force that exceeds the tolerance limits of sitivity in patients with a high index of suspicion for
most facial bones.52 a fracture.
Rudderman and Mullen53 analyzed the patterns With proven fractures, axial and coronal fine-cut
of stress distribution in the midface that can be views will provide the necessary information. Three-
used to advantage in stabilizing and restoring the dimensional CT reconstructions are useful in plan-
normal, pretraumatic load paths to assist in fracture ning a procedure, but are not indicated for the
healing. In the midface, the pattern of force flow is routine diagnosis of facial fractures. Several stud-
primarily vertical, which “in the least requires some ies confirm the superiority of CT scan over con-
attempt at reconstruction of the major support struc- ventional radiography in the evaluation of midfacial
tures (buttresses).”53 fractures.58-61 An additional advantage of axial CT is
in identifying fractures in the cribriform plate in cases
of a suspected CSF leak.
DIAGNOSIS
Physical Examination MANAGEMENT

Le Fort I fractures do not involve the orbit or
infraorbital nerve. On clinical evaluation, patients Objectives
show no ecchymosis around the eye, less pro- The priorities of care in fractures of the maxilla
nounced edema of the midfacial third than with other are the same as for any other facial fracture, namely:
fracture patterns, and no anesthesia of the cheek. 1) preservation of life; 2) maintenance of function;
4
and 3) restoration of form. The treatment of any different motions, three translational and three ro-
serious concurrent injuries takes precedence over tational, along the x, y, and z axes.53 “To prevent
the facial fractures and should include maintenance rotation in all three directions, three separate points
of the airway. After the patient is stabilized, the that are not on the same line must be fixed. The
overriding goal of treatment of maxillary fractures smaller the plate, the less mechanical advantage in
is to restore the pretraumatic functional occlusion preventing rotation. . . . When fractures are stabi-
and mastication, facial appearance, and communi- lized with the use of plating systems, the plates
cation capacity. become the path for much of the load distribu-
tion”53 (Fig 5).
Incisions
Lower maxillary fractures are best exposed
through an upper gingivobuccal sulcus incision.
This approach gives access to all four anterior but-
tresses as well as to the inferior orbital rim.62 Frac-
ture lines at the infraorbital rim can be exposed
through a subciliary, 63 subtarsal, 64 or trans-
conjunctival incision with or without extended lat-
eral canthotomy.65 The choice of incision rests on
the surgeon’s preference; each eyelid incision has
its own peculiar set of risks and benefits. The
subciliary incision has been linked with frequent
lower lid retraction and ectropion, and Wolfe64
believes it should never be used as a surgical
approach to the infraorbital rim and orbital floor.
Fractures in the nasoethmoid area are typically
exposed through a coronal incision.64 A direct
“open sky” approach has been described, or the
fracture can be reached through the traumatic skin
laceration. Fractures at the zygomaticofrontal
suture line can be exposed through an extended Fig 5. Plates for fracture fixation should be placed along areas
of force flow to better absorb the load and withstand deforming
lateral canthotomy incision66 or a lateral extension forces. (Reprinted with permission from Rudderman RH, and
of the upper blepharoplasty incision. If a coronal Mullen RL: Biomechanics of the facial skeleton. Clin Plast Surg
incision is needed to expose the nasoethmoid area, 19(1):11, Jan 1992.)
the zygomaticofrontal suture line can be approached
through the same incision. Compression of the bone ends is not required
for healing of fractures of the midface, and small
bone gaps (<5 mm) may be acceptable to pre-
Fixation serve occlusion and contour.47 As long as the
For decades the mainstay of midfacial fracture fragments are firmly fixed and there is no move-
management consisted of maxillomandibular fixa- ment about the fracture, the bone will heal by di-
tion (MMF) and craniofacial suspension.14 With rect bony union with no fibrous component and
the introduction of rigid stabilization in fracture fixa- minimal resorption of the fractured bone ends.69
tion, there is now little clinical role for craniofacial Ideally at least two screws should be placed across
suspension. either side of the fracture, and any comminuted
The benefits of rigid stabilization in fracture fixa- buttress fracture should be bone grafted to elimi-
tion and for promoting primary bone healing are nate gaps.70 Eppley and Prevel71 report adequate
well established and have been discussed in previ- fixation and acceptable complications with the use
ous issues of Selected Readings in Plastic Surgery.67,68 of resorbable plates and screws in the manage-
Plates used to stabilize a fracture must prevent six ment of midfacial fractures.
5
Manson30-32 believes that the mandible is the prin- orly oriented and have large individual segments
cipal structural pillar of the lower midface, upon and no comminution. If fractures could not be
which Le Fort fractures can be reduced and stabi- adequately reduced and aligned rigidly, they were
lized. Midfacial retrusion can be averted by placing managed with palatal splints. In their words, “splints
the maxilla in proper occlusion with the mandible are necessary for all complex fractures and for some
using MMF and then stabilizing the midfacial but- large segment fractures to provide further occlusal
tresses with plates. The importance of reestablish- alignment. . . . In comminuuted fractures, the use of
ing the preinjury occlusion cannot be overstated. a splint is not only indicated but is the easiest method
of providing vault stabilization.”72
FRACTURES OF THE PALATE Care must be taken not to devascularize the
buccal, gingival, or palatal mucosa during exposure
Fractures of the midface are seldom symmetri- of the fracture72 (Fig 7).
cal, and segmental fractures of the alveolus and Full open reduction must include reduction and
palate are common. Several classification schemes stabilization of the palatal vault, the dental arch (al-
have been suggested for palatal fractures.32,72,73 veolus or piriform aperture), and the four anterior
Hendrickson72 describes six types of palatal frac-
vertical buttresses of the maxilla (Fig 8).
ture (Fig 6):
Following rigid internal fixation, increased stabil-
Type I anterior and posterolateral alveolar
ity was often obtained such that the palatal splint
Type II sagittal
could be eliminated.
Type III parasagittal
Type IV paraalveolar Park and Auk73 also developed a classification
Type V complex scheme for palatal fractures that is based on ana-
Type VI transverse tomic location of the fracture line and related treat-
ment plans (Table 1).
The authors feel that fractures selected for inter- The authors find that closed reduction and
nal fixation should generally be anteriorly-posteri- immobilization for 4 to 6 weeks is often adequate
Fig 6. Above left, Type I posterolateral alveolar fracture. Above center, Midline sagittal palatal fracture; artist’s illustration in a child.
Above right, Paramedian-sagittal palatal fracture. Below left, Para-alveolar sagittal fracture. Below center, Palatal fracture of complex
pattern. Below right, Transverse palatal fracture. (Reprinted with permission from Hendrickson M, Clark N, Manson PN, et al: Palatal
fractures: classification, patterns, and treatment with rigid internal fixation. Plast Reconstr Surg 101:319, 1998.)
6
Fig 7. Above, Incisions for palatal fracture treatment must Fig 8. Above, The plan for fixation of the maxillary alveolus
be carefully designed. In some cases, the traditional trans- involves palatal vault and pyriform aperture or alveolar plating
verse vestibular maxillary incision (dotted line) should be plus buttress reconstruction. Below, The buttresses of the
reoriented vertically (dashed line) to prevent devascular- fractured maxilla and palate include a transverse (circumferen-
ization of the inferior gingival mucosa. Below, In the tial) buttress across the palatal vault, a circumferential buttress
absence of a vault laceration, incisions in the palatal vault across the alveolar ridge, and the six vertical buttresses of the
should be longitudinal and avoid the area of the greater maxilla. In traditional maxillary fracture open reduction tech-
palatine artery, which travels anteroposteriorly just above niques, only the four anterior buttresses (solid vertical lines) (the
the palatal mucoperiosteum. The dotted area represents naso-maxillary and zygomatico-maxillary) are stabilized. The
the safe region. (Reprinted with permission from Hendrickson posterior buttress (dotted vertical lines) (the pterygo-maxillary)
M, Clark N, Manson PN, et al: Palatal fractures: classification, is not routinely stabilized. (Reprinted with permission from
patterns, and treatment with rigid internal fixation. Plast Hendrickson M, Clark N, Manson PN, et al: Palatal fractures:
Reconstr Surg 101:319, 1998.) classification, patterns, and treatment wit rigid internal fixation.
Plast Reconstr Surg 101:319, 1998.)
Table 1
Classification of Palatal Fracture and Suggested Treatment
(Reprinted with permssion from Park S, Ock JJ: A new classification of palatal fracture and an algorithm to establish a treatment plan.
Plast Reconstr Surg 107:1669, 2001.)
7
treatment for alveolar fractures.73 All other frac- absorbing part of the traumatic forces.”74 On the
tures of the palate are treated with open reduction other hand, the midfacial bones of edentulous
and rigid internal fixation followed by intermaxillary patients are less resistant to fracture due to atro-
fixation for 2 to 6 weeks. They used an acrylic phy, and edentulous patients are more likely to be
palatal splint only to check occlusion before and elderly and to have brittle bones.
after rigid fixation. While the benefits of treatment of midfacial frac-
Intraoral splints can be useful adjuncts to midfacial tures are obvious for most patients—ie, improved
fracture reduction and immobilization. They range appearance and chewing ability—in elderly edentu-
from the simple type that helps stabilize an isolated lous patients the indications for open reduction
alveolar ridge fracture, to sophisticated palatal and and internal fixation are less clear-cut. Farmand
Gunning splints used in complex or comminuted and Baumann74 discuss the management of these
fractures of the maxilla.35 Unfortunately, in the acute cases and summarize their recommendations in
trauma setting it may be difficult to compensate for Fig 10.
the fracture lines on the dental model, with a result-
ing ill-fitting splint (Fig 9).
Fig. 10. Algorithm for management of the fractured edentulous

maxilla. (Adapted from Farmand M, Baumann A: The treatment
of the fractured edentulous maxilla. J Craniomaxillofac Surg
20:341, 1992.)
When properly applied, rigid internal fixation is

Fig 9. Acrylic splint helps stabilize fractured palate after usually sufficient to stabilize maxillary fractures in
reduction and fixation with intermaxillary elastics. A small wire edentulous patients. Neither the patient’s denture
coapts the segments at posterior margin of bony palate. (Re-
printed with permission from Manson PN et al: Sagittal fractures
nor an acrylic splint is necessary unless there is
of the maxilla and palate. Plast Reconstr Surg 72:484, 1983.) persistent instability from comminution of frag-
ments.
The trend in palatal fracture management, as
voiced by both Manson and Park, is toward wide
COMPLEX FRACTURES
exposure with open reduction and internal fixa-
tion, using splints only when needed to supple- Complex facial injuries are typically produced by
ment the fixation. high-velocity impact such as from motor vehicle
accident or gunshot wound to the face, producing
multiple fractures at several levels of the facial skel-
THE EDENTULOUS MAXILLA eton. The majority of these fractures, particularly in
Teeth communicate fracturing forces directly to the midface, are often unstable and have many
the alveolar bone. When teeth are absent, the small segments.75
maxilla is less likely to fracture. In addition, “den- Treatment begins with the traditional ABCs: air-
tures provide some protection against fracture by way, breathing, and circulation. The airway is kept
8
clear with an endotracheal tube, although occa- frequently result in injuries to the nasoethmoid com-
sionally a tracheostomy may be needed to facili- plex with subsequent telecanthus.
tate fracture repair or if prolonged ventilatory sup- Markowitz and colleagues78 recount their expe-
port is anticipated.54 After the patient is stabilized rience with six cases of traumatic telecanthus in a
and any concurrent life or limb threatening injuries large urban trauma center. Management of the
are addressed, early definitive treatment of the facial neurosurgical and ophthalmic emergencies takes
fractures is indicated. precedence over the facial fractures. The skeletal
A low Glasgow Coma Scale score should not anatomy is restored through extended open
preclude attempts at restoring facial integrity unless reduction of the NOE fractures with reattachment
the prognosis is grave. Head injury patients can of the medial canthal tendon, rigid fixation, and
undergo prolonged anesthesia without increased immediate bone grafting.
risk of complications so long as the intracranial pres- In contrast to Manson and his colleagues, who
sure is maintained below 25 mmHg.47 An intracranial begin at the NOE region and proceed laterally,
pressure monitor may be useful in these situations.
Gruss22,79-81 believes the zygomatic arch is the key
Benzil et al76 evaluated the benefits of early repair
element in midfacial fracture reduction and should
of craniomaxillofacial injuries in light of possible
be reduced and stabilized first, to reestablish the
increased morbidity and mortality. They looked at
pretraumatic facial width and to prevent further lat-
13 patients aged 3 to 53 years with Glasgow Coma
eral spread.
Scale scores of 10 to 15 who had single-stage repair
of their complex facial fractures within 24 hours of In high velocity injuries of the face, the impact
injury. The authors concluded that treatment can frequently shatters the midfacial buttresses, tele-
be performed safely with an acceptable rate of scoping the fragments and dislocating the maxilla
complications. posteriorly and superiorly. The impaction is
Successful treatment of patients with complex released with disimpaction forceps using the tech-
craniofacial injuries depends on the surgeon’s nique described by Dingman and Natvig2 and Rowe
appreciation of associated injuries, precise clinical and Williams.54
and diagnostic imaging to establish a 3-dimensional Pollock and Gruss82 recommend the following
configuration of the fracture(s), and application of protocol for the operative management of com-
well established principles of facial fracture repair. plex fractures of the midface.
Marciani and Gonty77 summarize the factors that 1. The mandible is manipulated in proper relation
contribute to a good outcome in surgery for cran- to the cranial base and stabilized first. Any frac-
iofacial trauma as follows: ture of the mandible is reduced and held there
• Early definitive treatment by rigid fixation.
• Anatomic and functional repair of nasoorbito- 2. The maxilla is placed in proper occlusion with
ethmoid injuries the mandible and stabilized with maxillary and
mandibular arch bars. Alveolar and vertical max-
• Wide exposure of fracture segments
illary fractures are reduced and intraoral lacera-
• Anatomic repositioning and stable fixation in all tions are repaired.
planes 3. Fragments of a fractured zygoma may interfere
with reduction of the maxillary components and
Complex midfacial fractures are reached through must be dealth with first. Zygomatic fractures
mainly three incisions: a coronal incision to expose are reduced and stabilized with miniplates.
the cranium, zygomatic arch, orbit, and nasoethmoid
4. The maxillary buttresses are reconstructed and
area; a subciliary or transconjunctival incision to
stabilized by rigid fixation.
expose the infraorbital rim, anterior zygoma, and
maxilla; and an upper buccal sulcus incision to 5. Orbital fractures are reduced by the open
expose the inferior maxilla. approach. If necessary, the orbit is reconstructed
Multiple complex fractures of the face resulting with calvarial bone grafts.
from high-energy impacts typically involve a combi- 6. The NOE complex is reconstituted and the
nation of Le Fort III and II fracture patterns. These medial canthal tendon is reattached.
9
7. All nasal fractures are reduced and any nasofrontal ing in direct communication between the ante-
separation is corrected. rior cranial fossa and orbit. Prevention: recon-
8. The frontal bone and sinus are attended to. struction of the orbital roof to separate the cavi-
9. All facial lacerations are sutured and soft-tissue ties.
avulsions are repaired. • Excessive use of bone grafts in the orbital roof
or supraorbital rim, causing asymmetry, exoph-
Forrest and Antonyshyn62 offer their algorithm thalmos, and vertical dystopia. Prevention: care-
for the repair of complex fractures of the midface ful reconstruction to avoid overcorrection.
(Fig 11). • Orbital dystopia. Prevention: adequate expo-
Gruss22 recommends long, contoured miniplates sure and reconstruction of the zygomatic arch
with screws placed in each fragment to maintain and lateral orbital rim and wall.
the normal bony curvature of the frontal bone in • Bone destruction in the glabella and nasofrontal
comminuted Le Fort II and III fractures. He identi- region. Prevention: reconstruction with bone
fies six potential pitfalls in the surgical reduction of grafts and reattachment of the nasal bones to
complex midfacial fractures and offers suggestions this rebuilt bony base.
for their prevention, as follows:79
• Comminution in the frontal and frontoorbital
• Inadequate reconstruction of the supraorbital region. This makes it difficult to stabilize the
ridge, which may produce flatness in the area. fragments while maintaining the appropriate con-
Prevention: full-thickness rib graft or stacking vex contour of the forehead. Prevention: use
of bone grafts in layers. of long miniplates or microplates molded to the
• Injury to the orbital roof with concomitant loss shape of the skull and affixed with specifically
of the posterior wall of the frontal sinus, result- designed 3-4 mm miniscrews.
Fig 11. Sequence of midface fracture repair. (Reprinted with permission from Forrest CR, Antonyshyn OM: Acute management of
complex midface fractures. Oper Tech Plast Reconstr Surg 5(3):188, 1998.)
10
In Manson’s series of 240 patients with midfacial limited bony and soft-tissue destruction. They ad-
fractures, 74 had primary bone grafting. Despite vocate this relatively conservative protocol for the
substantial graft resorption, Manson felt that “the management of most handgun wounds to the face.
grafts stabilize the reduction . . . [during] fracture Gruss 23 believes that early restoration of a
healing, . . . [and] scar contracture and initial bone midfacial scaffold decreases facial edema, pro-
union occur in the anatomic position desired.”18 motes bony union, prevents abnormal soft-tissue
Gruss’s22,79-81 experience with immediate bone contracture, and lessens the need for revision pro-
grafting in complex facial fractures has also been cedures later. He believes gunshot wounds of
favorable. In his words, “of the 167 patients with the face should be managed by immediate frac-
craniofacial injury, significant complications were ture reduction with rigid internal fixation and early
exceedingly few.”22 definitive bony and soft-tissue reconstruction. In
Since the advent of metal plating systems, cases of severe bony disruption but minimal soft-
maxillomandibular occlusal fixation is often released tissue injury, immediate definitive bone and soft-
after completion of the repair. This simplifies air- tissue repair can be accomplished. In severe inju-
way management, reduces the need for tracheo- ries with extensive bone and soft-tissue loss, the
stomy, improves oral hygiene, and facilitates food debridement and temporary soft-tissue repair to
intake. When mechanical stability of bony frag- cover exposed bone is followed by further debri-
ments is impossible to obtain, such as in the event dement as needed. External coverage is carried
of complex panfacial fractures with significant com- out 7 to 10 days later, and can involve a combina-
minution, maxillomandibular fixation may be tion of regional and distant flaps. The omentum is
retained postoperatively. used extensively to fill in dead space and to wrap
bone grafts and osteosynthesis plates, not for con-
tour or bulk.
GUNSHOT WOUNDS
The management priorities in gunshot wounds
FRACTURES IN CHILDREN
to the face are always to secure the airway, control
bleeding, manage hypovolemic shock, and treat Up to school age, children are relatively pro-
coexisting life-threatening injuries. Traditionally tected from facial fractures because their activities
bony restoration has been delayed until the soft are closely supervised.88 Children under 5 years of
tissue reconstruction was complete and the swell- age account for <1% of all facial trauma.89 After
ing had subsided.83-86 In 1972 Broadbent and age 5 or so, the frequency of facial trauma increases
Woolf83 advocated limited debridement of gunshot as the child enters school. Low velocity injuries
wounds to the face, skeletal stabilization, and elec- predominate in early childhood, while in older chil-
tive autogenous bone grafting, followed by soft- dren the proportion of high velocity trauma from
tissue coverage with local flaps when possible. motor vehicle accidents and urban violence is
Since then, many authors have confirmed the value higher.89 High Le Fort fractures are very rare in the
of conservative debridement of devitalized bone pediatric population. Blows severe enough to dis-
and soft-tissues. Only small pieces of bone that are rupt the cartilaginous suture lines frequently result
devoid of periosteum should be removed. in dural tears, extensive brain damage, and death.
Williams et al87 illustrate excellent functional and In 1968 Rowe90 summarized the literature of
cosmetic results in 35 patients with gunshot wounds facial fractures and found that 1% of all injuries
to the lower face treated by conservative debride- occur in children under 6 and 5% occur in children
ment of all devitalized tissue, fracture reduction under 12. McCoy and colleagues91 note that 6%
and stabilization, and soft-tissue repair by primary of facial fractures occur in children younger than
closure or local flap. No distant flaps were used 14. Güven92 reports a 2:1 male:female ratio and a
primarily. Large bony gaps were filled with autog- preponderance of mandibular fractures (86% vs
enous bone grafts at a second stage. The authors 14% maxillary fractures), particularly of the condyle.
review the principles of gunshot ballistics and relate A report from Athens 93 describes a 1.4:1
their success to the low-velocity missiles respon- male:female ratio and a similar prevalence of man-
sible for the injuries, which cause comparatively dibular fractures.
11
The anatomic distribution of facial fractures in ments, and recommend removal of the hardware
children and adults is different, and only partly after the fracture has healed. No fixation devices
explained by environmental factors. According to are placed near tooth buds to prevent damage to
Parker and Lehman,88 the differences are primarily the developing dentition. MMF is accomplished
a function of their respective developmental anato- with a combination of acrylic splints and piriform
mies, namely aperture or circummandibular wires. The authors
• in newborns the bony volume of the face with note good results even with some distraction of
respect to the cranium is 1:8, in adults it is 1:2 fracture fragments because of the capacity for
• the cranial sutures in young children are not remodeling of the child’s skeleton.
fused, and the growing bone is immature and Posnick and colleagues96 review the treatment
pliable of facial fractures in Toronto’s Hospital for Sick
Children. Closed reduction techniques with MMF
• children between 6 and 12 years of age have
were frequently chosen for mandibular condyle
mixed temporary and permanent dentition
fractures and open reduction techniques for other
• the midface of children is foreshortened, with regions of the facial skeleton. When open reduc-
abbreviated midfacial buttresses and minuscule tion was indicated, plate and screw fixation was the
sinuses that progressively increase in size until preferred method of stabilization. The authors rec-
the permanent teeth erupt94 ommend removal of the hardware in the growing
patient once fracture healing is complete, although
Fractures of the nose and lower jaw are therefore no sequelae ensued from rigid internal fixation of
relatively common in children, while fractures of mandibular and midfacial fractures.
the midface are rare.89,92-96
Kaban95 generally agrees with Posnick’s proto-
The early management of facial fractures in chil-
col. Bartlett and DeLozier101 stress the following
dren is also different from that of adults.97,98 Main-
points:
tenance of the airway can be precarious in chil-
dren, who are also prone to gastric distention, vom- • use CT scans routinely even when the injuries
iting, aspiration, and concurrent intracranial injury appear trivial
with CNS damage. Blood loss in excess of 20% of • consider observation for minimally displaced frac-
total blood volume in infants leads to profound tures
shock.91 Most children have to be sedated, at times
• be conservative and attempt the least invasive
with a general anesthetic,98 before they can be
properly evaluated and treated. Plain films are of surgical procedure first
little use in pediatric facial fractures, and CT scan is • use microplates whenever possible
nearly always indicated for adequate assessment.89 • avoid alloplasts and use bone grafts sparingly
In selected cases such as minimally displaced or
• always respect dental alveoli
greenstick fractures in young children, conserva-
tive treatment is appropriate. However, significantly • follow patients serially using photographs and
displaced fractures demand the same standards of cephalometric techniques
treatment regarding reduction and fixation as adult
fractures.89 Because children’s bones heal faster,
COMPLICATIONS
earlier reduction and stabilization of their fractures
is mandatory. And because of the absence of Nerve injury. Injury to the infraorbital nerve
retentive teeth, MMF that relies on attachment only (CN V2) manifesting as paresthesia of the upper
to the teeth will be tenuous.98 cheek is the most common persistent neural prob-
Some clinicians prefer to use wire, splints, and lem associated with facial trauma—17% in Steidler’s
other nonrigid systems in the repair of facial frac- series of 240 patients.102
tures in children because of the risk of damage to
the tooth buds.99 Thaller and Huang100 caution Ocular problems. The incidence of ocular com-
against the use of rigid fixation with miniplates and plications associated with midfacial trauma ranges
screws except in significantly displaced fracture seg- from 17% to 55%.45,102,103 Complications include
12
blindness, diplopia, enophthalmos, epiphora, available was found to be positive for HIV, repre-
blurred vision, telecanthus, and lacrimal drainage senting a 2.2% incidence. Another study of 100
problems. facial fracture patients from the United Kingdom
A survey of the literature reveals an incidence of found that none was seropositive for HIV, although
blindness associated with midfacial fractures of 1%.36 9 patients had one or more risk factors for HIV.102
A thorough screening ocular examination is indi-
cated for all midfacial fractures, and a definitive for- Prominence or exposure of plates and screws.
mal ophthalmologic exam should be obtained prior Complications of rigid fixation in the management
to any surgical fracture fixation lest developing ocu- of craniomaxillofacial trauma include prominence,
lar complications be attributed to the surgery.103,104 infection, exposure, and migration of the osteosyn-
thesis appliances. A retrospective analysis of 507
Brain damage. The most common acute life patients treated with plate and screw fixation for
threatening injury in facial fracture patients is cere- 1112 facial fractures revealed a 12% incidence of
bral trauma.43 Brain damage may be the result of complications necessitating hardware removal.108
mechanical injury or cerebral ischemia. Early treat- The frequency of infection and exposure may be
ment with steroids may improve the prognosis. decreased with antiseptic irrigation, correct place-
Factors associated with an unfavorable outcome ment of plates, attention to proper mucosal closure,
are patient age >40, Glasgow Coma Scale score and mucosal-saving techniques.
<10, systolic pressure <90 mmHg, abnormal CT A study of 44 patients with maxillofacial trauma
scan, and abnormal posturing.47 treated by open reduction and internal fixation using
1.0- and 1.5-mm microplates for fixation revealed
CSF rhinorrhea. Morgan34 found a 35% inci- a perioperative complication rate of 1.2% for the
dence of cerebrospinal fluid rhinorrhea in 300 cases 1.0-mm screws, primarily malposition. No compli-
of severe facial fracture. The flow ceased sponta- cations were observed with the 1.5-mm system and
neously by the fifth day in 66% of patients and there was no instance of exposed hardware.109
lasted more than 10 days in 13%. Steidler102 notes
a 37% incidence of CSF rhinorrhea in 80 cases of Occlusal abnormalities. Disturbances of dental
Le Fort fracture, of which 60% resolved spontane- occlusion are subtle but serious sequelae of midfacial
ously within 3 days. Dural repair should be consid- fractures. Analysis of a series of 100 consecutive
ered only when the drainage is significant, persists maxillary fractures from the UK show 8% had re-
beyond 2 weeks, and is resistant to placement of a sidual occlusal abnormalities after treatment.110
lumbar drain. Meticulous attention to occlusal relationships and
their restoration prior to rigid fixation is essential to
Infection. When patients are given appropriate prevent this serious complication.
antibiotics, the risk of meningitis associated with a
facial fracture is very slight (1/240 patients in Diabetes insipidus. Diabetes insipidus is an
Steidler’s series102). Sinusitis developed in 1.7% of infrequent complication of facial fracture. Symp-
Steidler’s patients.102 toms include polyuria, low specific gravity of urine,
A survey from Madrid105 showed a higher inci- and elevated plasma electrolyte levels.
dence of HIV-positive sera among patients with
mandibular fractures (19.8%) than among those Disturbances of smell and taste. Van Damme
with fractures of the midface (7.8%). Personal vio- and Freihofer111 report an impaired ability to smell
lence was the primary cause of fracture. HIV infec- and taste after high central midface fractures of
tion predisposes to greater morbidity during treat- 38% and 23% respectively. Disturbances of smell
ment. Intermaxillary fixation seemed to increase are most common after frontomaxillary and
the infection rate in HIV-positive patients. frontonasal fractures and increase in frequency with
A prospective study from Toronto106 was designed severity of the injury (80% prevalence in Le Fort III
to ascertain the HIV status of facial fracture patients fractures). Whether the smell disturbance is caused
treated at a large metropolitan hospital in 1993. by the fracture itself or by proximal brain trauma
Only 1 of 46 patients whose HIV test results were associated with the injury is unclear.
13
Nasal septal deviation. The incidence of nasal deformities after facial fracture. From these records
septal deviation after treatment of a midfacial frac- they selected 25 patients who were noted to have
ture ranges from 4.6% to 20%.34,102 severe posttraumatic sequelae of complex facial
injuries (Le Fort I, II, or III, zygomatic, NOE,
frontobasilar, or mandibular fracture). The authors
RESIDUAL DEFORMITIES
identified the following causes of residual defor-
Deformities of maxillary height and projection mity: 1) delayed initial treatment secondary to other
are not uncommon after facial fracture treatment. life-threatening injury; 2) inadequate initial fracture
Except for the orbicularis oculi muscle, which occa- reduction and fixation; and 3) severity of initial injury
sionally destabilizes reduced NOE and nasomaxillary with soft-tissue loss. The number of operations for
fractures, the muscles of facial expression play no correction averaged 3.76. There were 20 compli-
part in the displacement of fracture segments.54 In cations in 13 patients (52%), most frequently infec-
contrast, the muscles of mastication with origins in tion (11/20). The authors conclude that skeletal
the pterygoid plates may pull the maxilla posteri- abnormalities in these cases can generally be cor-
orly and inferiorly, and can contribute to an open rected with current craniofacial techniques, but the
bite deformity. status of the surrounding soft tissues limits the qual-
The initial traumatic force may also displace the ity of the final result.
maxilla posteriorly and inferiorly and produce an
open bite deformity. Overlapping of fragments
above and below an improperly reduced or inad- MANDIBULAR FRACTURES
equately stabilized Le Fort fracture can shorten the
midface. Malunion of maxillary fractures results in
midfacial retrusion (Le Fort I) or a “dishpan face” INTRODUCTION
(Le Fort II and III). Fractures of the mandible are common injuries,
Correction depends on the occlusal status: when and correct treatment to avoid long-term morbidity
occlusion is adequate, onlay bone grafts that allow is essential. Before rigid internal fixation became
for a certain amount of resorption may be suffi- commonplace, treatment of mandibular fractures
cient. When there is malocclusion, a midfacial was limited to closed techniques or open tech-
osteotomy and repositioning is indicated for cor- niques with wire osteosynthesis. With the intro-
rection. duction of rigid internal fixation (bone plating), the
Hardesty and Coffey112 focus on the manage- tendency is to perform open reduction to avoid
ment of bony deficits (nonunion) and misalign- maxillomandibular fixation. Studies of the biome-
ments (malunion) following treatment of facial frac- chanics and bone healing of the mandible have
tures. Skeletal reconstruction consists of one or contributed to this modern trend. We will review
more of the following: 1) direct reduction of concepts in mandibular fracture management, their
nonunited malaligned segments; 2) osteotomies implications, and specific patient populations includ-
along malunited fracture lines and reduction; or 3) ing children and edentulous patients. We will also
camouflage procedures using bone grafts or discuss specific complications and their manage-
alloplasts. Relative indications for these various ment.
approaches in long-standing secondary deformi-
ties are discussed. Functional rehabilitation may
require several operative stages and a surgical SURGICAL ANATOMY
sequence that provides for dental preparation, The mandible is a long bone shaped like a U and
alteration of the bony framework, and a well-vascu- consisting of tooth-bearing and non-tooth-bearing
larized soft-tissue cover. portions. The tooth-bearing portion of the man-
Cohen and Kawamoto113 analyzed the hospital dible is made up of a thick, compact anterior bor-
charts of 125 patients who were treated by der supporting a superiorly located alveolar pro-
Kawamoto during a 12-year period for residual cess. The ascending ramus terminates in the coro-
14
noid process and mandibular condyle. The man- the course of the inferior alveolar artery within the
dibular angle, ramus, coronoid process, and condyle bone, both exiting through the mental foramen.
are points of attachment for the muscles of masti- The Angle classification of dental occlusion refers
cation (Fig 12). specifically to the relationship of the mesial buccal
The condyle articulates with the cranium to cusp of the maxillary first molar to the mesial buc-
form the temporomandibular joint (TMJ). The cal groove of the mandibular first molar (Fig 13).
TMJ is a compressed fibrous disc interposed Abnormal occlusal relationships can be caused by
between the mandibular condyle and the articu- skeletal deformities or malalignment of the teeth
lar fossa. or a combination of the two.
The blood supply to the mandible comes from
two primary sources, the inferior alveolar artery BIOMECHANICS
and the muscular attachments. The inferior al-
veolar artery arises from the mandibular portion For the mandible to develop normally and attain
its proper form, it must have an adequate envelop-
of the maxillary artery. The artery descends be-
ing soft-tissue matrix and undergo appropriate func-
tween the sphenomandibular ligament and the
tional loading. Mandibular deformation occurs
ramus of the mandible. The inferior alveolar ar-
when functional and dynamic forces—such as
tery enters the mandibular foramen just below
muscle contractions and chewing—place an unbal-
the lingula on the medial aspect of the ramus and
anced load on the mandible.114 Generally, tensile
courses inferiorly and laterally, traversing the body
forces predominate along the alveolus and sup-
of the mandible to exit through the mental fora- erior border of the mandible, while compressive
men. The inferior alveolar nerve accompanies forces act on the inferior border of the mandible.
the artery, lying anterior to its course. At the Proximal to the canine teeth in the area of the
mandibular canal, the inferior alveolar artery mandibular symphysis, the prevailing force varies
sends numerous apical and peridontal branches. with type of occlusal loading, producing a torsion
The major muscle groups of the lower face sup- effect at the alveolus and inferior border (Fig 14).
ply blood to the mandible through the perforat- The alveolus and inferior border in this area of the
ing periosteal arterioles. mandible may be under compression or tensile
The inferior alveolar nerve innervates the man- forces at different times during the masticatory cycle,
dible and mandibular teeth. The nerve parallels thus producing an overall torsion effect.
Fig 13. Angle classification of occlusal status. Class I—

Fig 12. Anatomic regions of the mandible. normal. Class II—mesial. Class III—distal.
15
the alveolar bone will resorb. An edentulous man-

dible will atrophy at the alveolar ridge, with conse-
quent decrease in vertical dimension of the tooth-
bearing portion of the mandible.115
BONE HEALING
The pattern of bone healing that takes place in
the mandible is very similar to that which occurs in
long bones, and depends largely on the amount of
Fig 14. Natural forces acting on the mandible from pull of the
bone contact at the fracture site and the degree of
masseter, medial and lateral pterygoids, and temporalis muscles movement.
(tension) and geniohyoid, genioglossus, mylohyoid, and digas- Primary healing consists of direct bone forma-
tric muscles (compression). (Adapted from Niederdellmann H, tion without multistage differentiation of connec-
Shetty V: Solitary lag screw osteosynthesis in the treatment of
fractures of the angle of the mandible: A retrospective study. Plast
tive tissue and cartilage.116 Fibroblasts form along
Reconstr Surg 80:68, 1987.) the long axis of the fractured bone and are fol-
lowed closely by osteoblasts, which eventually pro-
The TMJ functions both by hinge movement duce new osteons. There is no callus formation as
and translation. Rotational movement about the there is in secondary healing and no surface
center of the condyle occurs early during jaw open- resorption of the fracture ends; rather, direct union
ing, whereas sliding translational motion occurs later of touching fragments is accomplished through
during wider opening as the condyle moves anteri- remodeling of the haversian canals. This type of
orly and inferiorly along the articular eminence of contact healing occurs only with absolute stability
the temporal fossa. of the fracture site such as seen after placement of
The overall shape of the mandible is also affected rigid bone plates and screws (Fig 15A).
by the presence of absence of teeth. If tooth erup- A form of primary bone healing called gap heal-
tion does not take place, the alveolar bone will not ing occurs in closely adapted and compressed frac-
develop. If the teeth are lost later in life, the func- tures in which not all bone surfaces are touching
tional stimuli provided by the teeth are lacking and (Fig 15B). Lamellar bone is deposited perpendicu-
Fig 15. Types of bone healing.

A, Primary bone healing by
direct contact of the fractured
ends. B, Primary healing in
which lamellar bone bridges
the gap between the segments.
C, Secondary bone healing in-
volving callus formation and
remodeling.
16
lar to the long axis of the fractured bone and subse- ably because of the lack of support by major muscle
quently must be remodeled. Final healing is thus groups in the direction of muscle pull in these
achieved in two stages. regions.
Secondary healing proceeds along well-
defined phases.117 Disruption of the haversian
systems results in bone death and resorption of EPIDEMIOLOGY
the fractured ends. A callus is formed to stabilize Because of the thick cortical bone at its infe-
the fractured segments, and initially consists of rior border, the mandible is an efficient stress-
clot, fibrous tissue, and osteogenic cells of both absorbing structure, yet its prominent position
periosteal and endosteal origins. The osteogenic as well as its mobility predisposes it to injury
cells differentiate into osteoblasts and form new from trauma directed at the lower facial third.
trabecula or chondroblasts, which in turn form More than half of all mandibular fractures are
cartilage. Remodeling of the callus takes place, caused by personal assault. The second most
and the cartilage is ultimately replaced with bone common cause of mandibular fracture is motor
(Fig 15C). The role of periosteal circulation in vehicle collisions.120
the healing process is documented in the litera- The relative frequency of mandibular fractures
ture. 118 by anatomic site is difficult to determine. Most
Secondary healing occurs where there is rela- fractures seem to occur in the body of the man-
tive instability of the reduced fracture and mobility dible closely followed by the angle and the
of the bone ends, such as after isolated maxillo- condyle.121-125 Fractures in the mandibular ramus
mandibular fixation or maxillomandibular fixation and symphysis are thought to be less common.
with internal wire fixation. Anatomic reduction and Fractures of the alveolar process are even more
fixation of the mandibular fracture results in a stable unusual, and the coronoid process is rarely frac-
union. Despite the intermediate stages of tissue tured.126
differentiation associated with secondary healing, Likely the site of fracture is directly related to the
secondary bone healing is no slower than primary type of trauma involved. Personal assault, which
bone healing. usually involves a laterally directed simple impact,
will produce frequent body and angle fractures and
less frequently condylar, symphysis, and alveolar
CLASSIFICATION
fractures. Conversely, motor vehicle collisions,
Mandibular fractures are classified as closed or which involve posteriorly directed forces along the
open, displaced or nondisplaced, complete or in- anterior mandible, will produce fractures in the sym-
complete, linear or comminuted.119 The angula- physis region as well as the alveolus and condyle.127
tion of the fracture line, whether favorable or unfa- Multiple mandibular fractures occurred in 24.5%
vorable, is of little clinical significance. Closed frac- of patients in one series.128
tures do not communicate with either the intraoral
or external environment. A fracture is considered
open if it communicates with the external environ- DIAGNOSIS
ment through a tear in the mucosa or skin or if it
communicates with a tooth socket as documented Physical Examination
on radiographic examination. Palpation of the mandible elicits tenderness and
Nondisplaced fractures of the mandible are may define fracture edges or cause movement of
often seen in the condyle, coronoid process, and the segments. Pain, malocclusion, trismus, swell-
ramus. Large muscle masses in these areas serve ing, anesthesia, paresthesia, hemorrhage, and
to stabilize the fractures. Displaced fractures are ecchymosis are frequent findings associated with
the direct result of the trauma sustained or may mandibular fractures. If the injury is several days
be secondary to muscle contraction and subse- old, the pain and swelling may be secondary to an
quent distraction of the fractured segments. The inflammatory process and the ecchymotic areas
most common site of displaced fractures in the may have migrated away from the fracture along
mandible are the body, symphysis, and angle, prob- the fascial planes.
17
Ecchymosis in the floor of the mouth is often can render parasymphyseal and symphyseal frac-
indicative of a fracture. Mandibular function is tures difficult to interpret. However, properly per-
assessed by measuring the incisal opening as well formed and interpreted panoramic series have a
as right and left lateral excursion. Protrusion and sensitivity of 90% and remain a cost effective imag-
deviation of the jaw on opening denotes limited ing technique for suspected mandibular fractures.130
translation of the ipsilateral condyle and indicates a Perhaps the best combination of plain films is a
possible condylar fracture. The TMJ is palpated panorex and an anteroposterior radiograph.
indirectly via the external auditory canal and directly Helical CT of the mandible is now a cost effec-
in the preauricular area. A positive tongue blade tive, sensitive, and complete imaging technique for
test (TBT), defined as the patient’s ability to grasp suspected mandibular fractures. The demonstrated
and hold a tongue blade against attempts to remove sensitivity for all anatomic portions of the mandible
it, is useful in excluding mandibular fracture (95% is close to 100%, yet a CT scan will not provide the
negative predictive value).129 detailed information on dental occlusal relation that
Any avulsed, loose, or fractured teeth found on a panorex examination will.131,132
intraoral examination should be documented. Patients with mandibular fractures should be sus-
Multiple crowded, rotated, or missing teeth make pected of having concomitant cervical spine inju-
fracture reduction more difficult. Malocclusion ries until proven otherwise. An often asked ques-
should be recorded and compared to the preinjury tion involves the necessity of routine cervical spine
occlusal status, keeping in mind that malocclusion films in the initial assessment of these patients.
is often present in the general population and is Andrew and coworkers133 analyzed the course of
not necessarily the result of a fracture. The preinjury mandibular fractures and related cervical spine injury
occlusion is ascertained by matching the wear fac- over a 3-year period. The authors concluded that
ets on the cusps of the mandibular teeth with the as a general rule one should use liberal guidelines
opposing wear facets on the maxillary teeth. Rarely for obtaining cervical spine radiographs in any
are dental models needed to determine the origi- patient who has cervical tenderness, neurologic
nal occlusal status. deficit, multisystem injury, or unconsciousness. Con-
versely, routine cervical spine films (those taken in
the absence of any suspicion of concomitant cervi-
Radiographic Evaluation cal spine injury) are costly and unnecessary.
Currently there are three imaging techniques to
evaluate suspected mandibular fractures: 1) a man-
MANAGEMENT
dibular series; 2) panoramic radiographs; 3) CT
scans. Regardless of specific circumstances, the goals
A mandibular series consists of facial radiographs of management of mandibular fractures are as fol-
in the anterior, posterior, right and left lateral, ob- lows:
lique, and Towne’s projections. The condylar and • to achieve anatomic reduction and stabilization
subcondylar areas are frequently obscured by • to reestablish pretraumatic functional dental
superimposed structures in the Towne’s view, but
occlusion
careful interpretation should disclose any fractures
in the region. A properly performed and inter- • to restore facial contour and symmetry
preted mandibular series has a sensitivity approach- • to balance facial height and projection
ing 90%.
A panoramic radiograph (panorex) is the best
diagnostic tool in suspected mandibular fractures. Nonsurgical
It not only allows easy identification of condylar Conservative treatment may be indicated when
and ramus fractures, but also shows the relation of the mandibular fracture demonstrates the follow-
the fracture line to the mandibular teeth. The qual- ing three basic characteristics: 1) radiographic evi-
ity of panoramic tomography is technique-depen- dence of minimal or no displacement; 2) pre-
dent, and blurring in the midline from superimposed traumatic dental occlusion; and 3) normal mandibu-
midline structures (such as the vertebral column) lar range of motion. The treatment regimen includes
18
a soft-food or liquid-only diet for at least 30 days displacement or comminution, open reduction with
after trauma, restricting mouth opening, and main- internal fixation is indicated.
taining good oral hygiene.134 Patients must be fol- The fracture is usually approached through an
lowed closely to ensure that the pretraumatic intraoral incision. After reduction and intermaxil-
occlusion is preserved until the fracture is com- lary fixation, a plate is applied along the inferior
pletely healed. border. Although not usually necessary, an extraoral
approach via a Risdon incision (Fig 16) also gives
access to the fracture.29 Either an arch bar at the
Surgical
alveolar process or a second monocortical plate at
The fundamental principles of mandibular frac- the superior border is indicated as a tension band.137
ture management are constant regardless of the
specific anatomic site of injury. The goal of surgery
should always be to restore the patient’s pretraumatic
occlusion. The location and condition of the frac-
ture dictate the type of reduction appropriate for
any given case. Most fractures of the mandible
require some type of reduction and immobilization.
Closed reduction is used when the fracture is
either nondisplaced or minimally displaced. Arch
bars and wires are applied to the teeth, followed by
maxillomandibular wires or elastics for 2 to 6 weeks
to ensure a stable reduction.124,135 Displaced frac-
tures usually require open reduction with or with-
out internal fixation by plating.
TIMING OF REDUCTION
Fig 16. Risdon incision. (Reprinted with permission from
Mandibular fractures should be reduced as soon Fonseca RJ, Walker RV, eds: Oral and Maxillofacial Trauma, 2nd
as possible to minimize pain, prevent progression of ed. Philadelphia, Saunders, 1997.)
the soft-tissue injury, and reduce the risk of infection.
If treatment must be delayed, the fracture should be Traditionally, severely comminuted mandibular
stabilized temporarily with bridle wires around the fractures have been treated by closed reduction to
teeth adjacent to the fracture. Edentulous patients avert periosteal stripping. In 1993 Smith and
can be temporarily stabilized with external dressings Johnson138 retrospectively evaluated the success
such as a Barton bandage or cervical spine collar. rate of rigid fixation in the management of 16 com-
Open fractures should be immobilized within 72 minuted fractures of the mandible, 10 of which
hours of injury.136 If definitive treatment is delayed involved the mandibular body or symphysis region.
by more than 3 days, any infection at the fracture The fractures were reduced and stabilized extraorally
site should be treated by MMF and intravenous anti- in 75% of cases using multiple titanium 2.0 mm
biotics prior to open reduction. Good oral hygiene miniplates. All patients healed to bony union with-
should be maintained in the interim until reduction. out grafting and all had satisfactory facial form and
function postoperatively.138
TREATMENT BY FRACTURE SITE

Mandibular Angle
Mandibular Body Mandibular angle fractures are often the result of
Many mandibular body fractures can be man- personal assault. A single lateral blow to the side of
aged by closed techniques, particularly if the frac- the face can produce a mandibular angle fracture,
ture is isolated, reducible, and the teeth are intact. commonly associated with a fracture of the con-
If multiple teeth are missing or if there is significant tralateral mandible.122 The angle of the mandible is
19
prone to fracture for a number of reasons, includ- mandibular dynamic compression plates; 6) intraoral
ing 1) the presence of third molars, which decrease open reduction and internal fixation using two
osseous support and weaken the mandible; 2) a noncompression miniplates; 7) intraoral open
thinner cross-sectional area in this section; and 3) reduction and internal fixation using a single
biomechanical effect from the angle, which serves noncompression miniplate; and 8) intraoral open
as a lever. The presence of third molars has a reduction and internal fixation using a single mal-
definite weakening effect on the angle. Clinical leable noncompression miniplate. The results from
studies have shown that patients with third molars this large clinical series demonstrate a high compli-
sustain a higher percentage of angle fractures than cation rate (17%) with closed reduction and non-
those without.139 rigid fixation. Cases treated with two-plate fixation,
The management of third molars at the site of a most of which were done through an extraoral
mandibular angle fracture is the source of a great approach, also exhibited significant complications.
deal of controversy. Clearly those teeth that are Outcome analysis favored the use of a single,
damaged by the fracture, those that are severely noncompression, 2.0 miniplate placed through an
diseased, and those that prevent fracture reduction intraoral approach, which yielded the smallest even-
should be extracted. For those teeth that do not tual complication rate.
meet these criteria, consideration should be given Ellis believes that, within limits, the complications
to maintaining the molar, as it may contribute sig- from fractures of the mandibular angle are inversely
nificantly to strength and stability of the angle region. proportional to the rigidity of the fixation applied.
Mandibular angle fractures carry the highest sur- The following observations emerged from analysis
gical complication rate of all mandibular fracures, of this series:139
and their treatment has undergone a significant • Much higher complications are seen with two
change over the last 10 years.139 Most mandibular points of fixation, ie, the use of two plates ver-
angle fractures are best managed with open reduc- sus single point fixation.
tion and internal fixation because of their tendency • Single miniplate fixation required a more limited
for displacement of the proximal segment. The
dissection than absolutely rigid two-plate fixa-
intraoral approach leaves no external scar and less-
tion.
ens the risk of marginal mandibular nerve injury.
The incision is made in the buccal vestibule and the • Absolute rigidity may not be required for man-
fracture is exposed. After adequate reduction a dibular angle fracture healing.
bone plate is applied, using a transcutaneous tro- • Complications arising from single miniplate fixa-
car if necessary. tion were more easily managed and often did
There has been a gradual evolution in fixation not require readmission or reoperation.
methods of mandibular angle fractures, from an
absolutely rigid fixation using 2.4 mm or larger plates The use of a solitary lag screw has been
along the inferior border, to the use of smaller, described in the treatment of mandibular angle frac-
double 2.0-mm noncompression plates, to the tures.145 Although lag screws provide a highly sat-
application of a single, malleable, noncompression isfactory fracture reduction with a low complica-
miniplate for bony fixation.139-144 tion rate, their application is sensitive to operative
Ellis139 describes a 10-year study of angle frac- technique.
tures treated and followed at the same institution. Comminuted fractures of the mandibular angle
Treatment methods included 1) closed reduction are rare, but when multiple fragments are present,
or intraoral open reduction and nonrigid fixation an external Risdon incision improves access to the
(MMF); 2) extraoral open reduction and internal fracture for better control of the reduction and
fixation with a rigid AO/ASIF reconstruction bone stabilization of the fragments.
plate; 3) intraoral open reduction and internal fixa-
tion using solitary lag screws; 4) intraoral open
reduction with internal fixation using two 2.0-mm Symphysis
dynamic compression plates; 5) intraoral open Stable fractures of the mandibular symphysis in
reduction with internal fixation using two 2.4-mm patients with normal occlusion can be treated by
20
closed means. True midline fractures are rare, how- fixation, either rigid or with elastics, and the fixa-
ever. Parasymphyseal fractures tend to be much tion released in 2 weeks, at which time the patient
more common. Open reduction is appropriate for is started on a regimen of intraoral elastics. A
many of these fractures and is usually accomplished postfixation physiotherapy program is essential to
via an intraoral incision. Reduction forceps are the eventual success of this treatment protocol.
useful to anatomically align the bone fragments Stretching exercises consisting of active incisor
and the jaws are placed in pretraumatic occlusion opening and lateral excursions eventually progress
while the fracture is immobilized with plates or lag to active and digitally assisted levering of the jaw.
screws.147 Open versus closed reduction of subcondylar
Stabilization typically requires two 2.0 miniplates, and condylar neck fractures remains a contentious
a single 2.4- or 2.7-mm plate, or an inferior border point. Several studies support a conservative
miniplate and an ach bar. During plate application approach (closed reduction) of these fractures. In
considerable care must be taken while applying 1947, a report from the Chalmers J Lyons Club
the plate(s) not to stretch or avulse the mental presented data on 120 cases of condylar fractures
nerves exiting the mental foramen. that favored closed reduction.152 More recently, a
The use of lag screws is an elegant and mini- study from Austria153 compared 229 consecutive
mally invasive technique well suited for reduction patients with subcondylar and condylar neck frac-
of symphyseal and parasymphyseal fractures. Lag tures, of which 161 were treated with MMF and
screw fixation with biodegradable polylactide screws the remainder were treated with open reduction
has also been described, with good success.148 and fixation using a variety of fixation techniques.
There was no described difference in mobility, joint
problems, or occlusion.
Mandibular Ramus and Coronoid An epidemiologic study from theU.K. examined
Fractures of the ramus are seldom displaced, 348 patients with condylar fracture for patterns of
probably because of the splinting effect of the mas- distribution and causes of fracture.154 A follow-up
seter, temporalis, and medial pterygoid muscles. report155 examined the results of conservative treat-
Both vertical and horizontal fractures of the ramus ment in these patients. The occlusal and functional
are usually treated by closed reduction and occlusal results in this cohort were similar to the results in
fixation. Similarly, fractures of the coronoid pro- patients treated with open reduction and internal
cess seldom require operative treatment and are fixation. The authors’ conclusion supported a con-
managed conservatively. servative, nonoperative treatment of condylar frac-
tures.155
Joos and Kleinheinz157 list absolute indications
Mandibular Condyle
for nonsurgical treatment of condylar fractures, to
Fractures of the condyle can be grouped into include
those involving the condylar head, the neck, and • condylar neck fractures in children
the subcondylar region. The condylar neck is sub-
ject to fracture because of its relatively small diam-
• high condylar neck fractures without disloca-
eter. Following blunt impact to the mandible, kinetic tion
energy is transferred along the length of the jaw to • intracapsular condylar fractures
the condylar neck, where the force of the blow
frequently exceeds the compressive strength of Conversely, proponents of open reduction are
the bone.149-151 critical of the conservative treatment approach, and
In contrast, a condylar head fracture is an believe that temporomandibular joint dysfunction
intracapsular injury. These fractures have a procliv- has been underreported and that there may be a
ity for ankylosis. If there is no malocclusion gener- higher incidence of traumatic arthritis, decreased
ated by the fracture, these injuries can be treated range of motion, and malocclusion than previously
without maxillomandibular fixation and the patient suspected in closed reduction series.156-158
placed on a soft diet. If malocclusion is present, Ellis has contributed perhaps the greatest body
the patient should be placed in maxillomandibular of information regarding open versus closed treat-
21
ment of mandibular condylar process fractures. The

author has looked at a 10-year experience with The presence of a midfacial fracture can be an
nearly 200 patients treated with both open and additional indication for open treatment of man-
closed techniques.159-165 His conclusions can be dibular condyle fractures.
summarized as follows: Zide and Kent151 list four absolute indications for
• More consistent occlusal results can be open reduction of condylar neck fracture:
expected in fractures of the mandibular condy- • Displacement of the condyle into the middle
lar process treated by open reduction. cranial fossa.
• Greater postoperative condylar mobility is • Difficulty obtaining adequate occlusion by closed
expected in patients treated by open reduction. reduction.
• More consistent facial symmetry with open • Lateral extracapsular displacement of the
reduction techniques. condyle.
• Presence of a foreign body (eg, a gunshot
A reasonable conclusion can be made that the wound) in the condyle.
degree of fracture displacement and dislocation of
the condyle determines the method of treatment167 Bilateral subcondylar fractures associated with
(Fig 17). midfacial fractures are traditionally managed with
• Displacement of the proximal fragment of 30 open reduction and internal fixation of the condy-
degrees or more from the axis of the ascending lar neck, at least unilaterally, to reestablish the verti-
ramus. cal dimension of the face. A recent clinical evalua-
• Shortening of the ascending ramus with tele- tion of the long-term outcome of patients treated
scoping of the fragments with concomitant open for bilateral fractures of the mandibular condyles
bite. supports the use of open reduction and internal
fixation.168
• Dislocation of the condylar head from the tem- A consensus paper stemming from an interna-
poromandibular fossa. tional conference in the Netherlands in 1998158
• Inability to obtain adequate occlusion with closed found “little scientific evidence that a period of rigid
reduction. IMF has any benefit, and it may adversely affect
Fig 17. Algorithm for treatment of condylar

neck fractures in the adult dentulous man-
dible. (Reprinted with permission from Klotch
DW, Lundy LB: Condylar neck fractures of the
mandible. Otolaryngol Clin North Am
24(1):181, 1991.)
22
future joint function. . . . Closed treatment will nor- Maxillomandibular Fixation

mally consist of a delay while swelling and spasm Problems associated with the use of maxillo-
settle, followed by MMF with elastic guidance, not mandibular fixation include feeding difficulties and
rigid, for 1-6 weeks.158 subsequent nutritional insufficiency, airway com-
Endoscopically assisted fixation of fractures of promise, social and communication difficulties, and
the mandibular condyle has been reported now by poor oral hygiene. In an otherwise healthy patient
numerous authors.169-172 Proponents of this tech- these are not serious consequences, but in the
nique say they provide the benefits of direct frac- elderly and in otherwise compromised patients,
ture reduction with better visualization and precise maxillomandibular fixation can be problematic.181
anatomic alignment of the bony segments while The duration of fixation is still
avoiding the facial scars and facial nerve injuries debated.119,123,124,182,183 Chuong et al184 showed clini-
associated with open techniques. cal union by 4 weeks in 79% of mandibular frac-
Analysis of surgical complications associated with tures and by 5 weeks in over 90%. They recom-
open treatment of mandibular condylar process mended checking for union every week by palpa-
fractures indicates that the most common compli- tion and manipulation of the fracture site; in most
cation is a transient weakness of the facial nerve.166 cases release of fixation may be possible by the
Another common complication is hypertrophic scar- third or fourth week, but this is clearly dependent
on the specifics of the fracture.
ring, which in Ellis’s series averaged 7.5%.
Ellis’s review of complications of mandibular
condyle fracture173 focuses on malocclusion, man- Rigid Internal Fixation
dibular hypomobility, asymmetry, and dysfunction/ Since its introduction in the early 1970s, rigid
degeneration. The clinical and surgical factors pre- internal fixation for the management of mandibular
disposing to their development are examined in fractures (Spiessl185 and Schilli186) has undergone
the article. many modifications. New plating systems as well
as new applications for rigid fixation have been
proposed. In the last few years the American litera-
FIXATION DEVICES
ture has been flooded with reports of indications
and contraindications, techniques and complications
External Appliances
of screws and plates. In general, the experience of
External skeletal fixation of mandibular fractures American surgeons with plating systems has been
(as with a Joe Hall Morris biphasic appliance) was positive, and rigid stabilization is now an accepted
widely practiced at one time.135,174-180 Although form of treatment for mandibular fractures in the
now largely replaced by internal fixation techniques United States.
in the management of mandibular fractures, exter- The current trend of mandibular fracture man-
nal fixation may still play a part in stabilizing large, agement is toward the use of rigid internal fixation
comminuted mandibular defects resulting from gun- techniques with an accompanying trend toward
shot wounds or severe mandibular infections with smaller and smaller hardware to achieve fixation.
osteomyelitis. The period of maxillomandibular fixation is kept to
a minimum.
Splints An understanding of the biomechanical principles
of jaw function and the forces acting on the man-
The basic indication for splinting is a lack of dibular bone is fundamental to the success of these
adequate dentition to place arch bars for maxillo- techniques. Masticatory movements of the jaw
mandibular fixation, such as in children who are at result in tension along the alveolus in the mandibu-
the mixed dentition stage or in adults who are miss- lar body and angle and in compression along the
ing teeth. See below under Fractures in Children inferior border in the same areas. In addition, as
and the Edentulous Patient for a more complete previously noted, the parasymphyseal area is an
discussion. area of torsion which produces both compression
23
and tensile forces at the alveolus and at the inferior successfully repair oblique fractures of the body,
border of the mandible. The osseous plate(s) used symphysis, and angle (Fig 18).
for fixation must be applied in such a way so as to
counteract these deforming forces.
Two treatment philosophies are currently popu-
lar. One espouses rigid fixation and is often attrib-
uted to the AO/ASIF school. The other advocates
less rigid but functionally stable fixation (Champy).
Proponents of the Champy school feel that strate-
gic placement of plates along natural lines of force
in the mandible stabilizes fractures sufficiently to
achieve union and avoids the disadvantages inher-
ent in the use of larger plates—eg, difficulty in plate
contouring, wide exposure, malocclusion.187-189 This
is perhaps best exemplified by the use of a single
miniplate along the oblique ridge of the mandible
to stabilize angle fractures.190-192
Comparative outcome studies of these two dif-
ferent treatment philosophies show largely similar Fig 18. A lag screw is inserted through a drill hole of the same
results. Davies192 exercised the principles set forth diameter as the screw threads. In the inner cortex of the bone,
by Champy in the treatment of 42 consecutive the drill bore should match the inside diameter of the screw.
(Adapted from Spiessl B: Principles of Rigid Internal Fixation in
patients with 64 displaced mandibular fractures. In- Fractures of the Lower Jaw. In Spiessl B (ed), New Concepts of
termaxillary fixation was not used postoperatively. Maxillofacial Bone Surgery. New York, Springer-Verlag, 1976.)
His results compare favorably with other forms of
treatment; specifically, there was no evidence of Shetty and Caputo201 evaluated the solitary lag
postoperative malocclusion and the overall com- screw technique in the management of mandibular
plication rate was 3%. angle fractures from a biomechanical standpoint.
Chuong and Donoff193 and Dierks194 review their Their results validated the clinical impressions of
experiences with the transoral approach to plating other investigators that the solitary lag screw, as a
in fractures of the mandible. Szabo and cowork- tension band, provides sufficient compression and
ers195 describe the technique of internal fixation of stability to withstand functional mandibular loading.
mandibular fractures using Champy plates. Niederdellman202,203 popularized the use of a 20-
Souyris 196 and Nishioka 197 detail the intraoral to 40-mm lag screw in the mandibular angle. The
approach to miniplate insertion. fracture is reduced through an intraoral incision
Regardless of the technique used, the main and a single lag screw is inserted transbuccally.
advantage of plates and screws in mandibular frac- Leonard204 discusses the many uses of lag screws
tures is that they eliminate the need for intermax- in mandibular fractures.
illary fixation. In the majority of plated fractures,
postoperative intermaxillary fixation is unneces-
sary unless concomitant fractures (subcondylar) FRACTURES IN CHILDREN
dictate the need for jaw immobilization. Com- Mandibular fractures account for 5% to 50%+
pared with MMF, plating dramatically shortens the of pediatric facial fractures.205 The most common
time to normal jaw function and helps maintain cause of mandibular fracture in children is a motor
body weight.198-200 vehicle collision.205
Yet another technique for internal fixation is the In early childhood the mandible is weakened by
use of lag screws. Ellis145-147 reviews the technique numerous unerupted and developing permanent
of lag screw fixation and confirms that a properly teeth, which limit the amount of bone and create
placed lag screw of the right length and design regions susceptible to fracture206 (Fig 19). Never-
creates sufficient bony compression and stability to theless, mandibular fractures in the young tend to
24
be incomplete and minimally displaced because of ened. As such, intermaxillary fixation is best
the relative lack of thick cortical bone and elasticity achieved using a circummandibular wire anteriorly
of the tissues, which allows the bones to bend connected to a wire passed through a drill hole in
rather than break.207 the piriform aperture.
For parasymphyseal and body fractures, stabili-
zation can also be achieved using lingual splints.
These are fashioned from dental impressions and,
in the case of displaced fractures, the models cut at
the fracture site and repositioned to establish the
preinjury occlusion. A splint is then made of acrylic
to fit just the lingual surface of the mandibular den-
tition. The splint is then secured in position with
circummandibular wires.
A subset of fractures that deserves special atten-
tion in children are those involving the condylar
head, particularly because of the risk they present
for growth disturbance.214-221 The mandibular
condyle of children is highly vascular. When sub-
jected to a compressive traumatic blow, the condyle
may fragment, resulting in a hemarthrosis with a
high risk of subsequent ankylosis. The emphasis in
treatment of these injuries should be early mobili-
Fig 19. Location of developing permanent tooth buds in the zation to prevent ankylosis. If IMF is felt to be
pediatric maxillofacial skeleton must be kept in mind when necessary due to a change in the occlusion, it should
applying rigid plate fixation. (Reprinted with permission from
Winzenburg SM, Imola MJ: Internal fixation in pediatric max- be maintained no longer than approximately 7 days,
illofacial fractures. Facial Plast Surg 14(1):45, 1998..) and then motion encouraged. These patients must
be followed closely over the years to detect pos-
Two-thirds of mandibular fractures in children sible growth disturbances.
younger than 10 years of age occur in the condy- For fractures of the condylar neck or subcondylar
lar region.208-212 The proportion drops to about region, treatment in the pediatric population aims
40% in children 11 to 15 years of age. at preserving the height of the ramus and TMJ
The treatment of mandibular fractures in chil- function. Closed reduction is usually sufficient, with
dren is different from that in adults because of the lingual splints used to bridge other associated frac-
presence of deciduous and unerupted teeth.213 tures. Immobilization should be limited and should
Other factors influencing the management options be followed by active exercises.205-210
are the capability for rapid healing in children and Numerous long term studies of the outcome of
the risk of treatment interfering with future man- conservative management in pediatric condylar frac-
dibular growth. Most fractures are best managed tures support this approach.222-227 Norholt and col-
by closed reduction, as will be discussed below. leagues220 analyzed the long term outcome of 55
Open reduction with internal fixation is often diffi- patients aged 5 to 20 years with fractures of the
cult, as the developing tooth buds leave little room mandibular condyle that were treated conserva-
for placement of fixation devices.213-215 tively. At an average 10 years after surgery, the
With respect to closed reduction, stabilization is functional and esthetic results were found to be
most frequently achieved with either intermaxillary satisfactory for patients who were in their early
fixation or lingual splints. The use of arch bars in teens or younger at the time of fracture. For patients
children less than about 9 years of age is frequently who were 18 to 20 years of age, however, the
problematic, as it is difficult to maintain wires around outcome of conservative treatment was judged to
the bases of the deciduous dentition due to absence be unsatisfactory, and the authors suggest opera-
of a distinct cingulum and the fact that these teeth tive treatment of mandibular condyle fractures in
are prone to extrusion when the wires are tight- older adolescents.
25
Posnick and coworkers228 review 318 facial frac- or fibrous union) occurred in 12.6% of patients
tures in a pediatric population, and note 34% treated with open reduction and internal fixation
involved the mandible. The authors advocate con- using bone plates and in 25% of patients treated by
servative treatment of most condylar process inju- conventional closed methods. The authors rec-
ries and nondisplaced simple body and angle frac- ommend rigid internal fixation with bone plates or
tures in this age group. Comminuted or displaced screws for the treatment of mandibular fractures in
mandibular fractures are treated by open reduc- edentulous patients because it eliminates the need
tion and internal fixation. Their results appear for splints and is associated with decreased mor-
excellent. bidity, improved healing, shorter disability time, and
The consensus is that conservative treatment of better jaw function and esthetics. The plates should
condylar fractures in children, when followed by generally be large (≥2.4 mm) and the screws pref-
early restoration of function and diligent physio- erably locking.
therapy, can be expected to produce good heal- A point of debate in rigid fixation of mandibular
ing, normal growth of the jaw, and little or no inter- fractures in edentulous patients concerns place-
ference with movement of the temporomandibu- ment of the bone plate subperiosteally. Bradley
lar joint. demonstrated that the main blood supply to the
edentulous mandible is via a subperiosteal plexus
fed by the overlying soft tissues.230 This finding
THE EDENTULOUS PATIENT would indicate that elevation of the periosteum to
Mandibular fractures in edentulous patients are apply a bone plate may well compromise the blood
very difficult to treat because of 1) the lack of teeth supply to the bone and interfere with healing. Con-
on which to anchor maxillomandibular fixation; 2) sequently, Bradley recommends supraperiosteal
the alveolar ridge is often atrophic and the man- application of the stabilization hardware.231 How-
dibular cross-section is small, so that muscle pull ever, treatment failures are usually secondary to
easily displaces the fragments; 3) the fractured bone mobility of the fragments from inadequate stabiliza-
is primarily cortical, with little capacity for repair; 4) tion, rather than a compromised blood supply.141
fixation with skeletal wires attached to maxillary Luhr and coworkers232 reported 84 edentulous
and mandibular dentures is frequently inadequate mandibular fractures treated with compression
because of the presence of mobile tissue on the plates without postoperative MMF. Primary bone
edentulous ridge—ie, the denture cannot be seated grafting was used in 6 cases. The authors propose
firmly enough on the alveolus to stabilize the a classification system for mandibular atrophy that
underlying bony fragments without eliciting soft- is based on vertical bone height measured at mid-
tissue necrosis; and 5) edentulous patients tend to point on the mandibular body, as follows:
be older and to have systemic disease(s). The Class I 16-20 mm
anesthetic risk and postoperative morbidity in these Class II 11-15 mm
patients should be considered when formulating Class III <10 mm
the treatment plan. They correlate the results of treatment with the
Closed management of fractures in the edentu- degree of atrophy, and recommend supraperiosteal
lous mandible involves the use of existing dentures placement of plates along with primary bone graft-
or Gunning splints to stabilize the fracture or the ing when the height of the alveolus is significantly
use of external fixation devices such as the Morris reduced.
appliance. Those who advocate closed treatment Several authors review the literature of man-
of these fractures do so primarily to avoid stripping dibular fracture treatment in the edentulous
the periosteum of the mandible, given that the bone patient. 233-236
is usually atrophic and has reduced healing poten-
tial.
However, Bruce and Ellis229 reviewed the out- TEETH IN THE LINE OF FRACTURE
come of 104 edentulous mandibular fractures and In the past surgeons routinely removed teeth
found the results to be worse after closed treat- that were in the line of fracture, regardless of their
ment. Problems with bone healing (delayed union status.237-240 With increasing understanding of the
26
biomechanics of jaw function, the current practice Teeth that are completely avulsed should be
is to retain teeth whenever possible and to remove replanted as quickly as possible after careful reposi-
them only when they are nonrestorable or severely tioning of the alveolar fragment and stabilization
broken. 241-244 Even then teeth are sometimes with an interdental wire or arch bar. This recom-
retained for purposes of stabilization and carefully mendation applies to teeth associated with isolated
extracted only after release of MMF. alveolar fractures. If the alveolar fracture is part of
Shetty and Freymiller243 offer the following guide- a larger mandibular fracture, then the teeth should
lines for the management of teeth in the line of not be replanted.
fracture: A fracture line that invades the periodontal liga-
• Intact teeth in the fracture line should be left in mentous space or that runs along the root surfaces
situ if they show no evidence of severe loosen- frequently causes devitalization of teeth and sec-
ing or inflammatory change. ondary infection.240 The infection usually manifests
• Impacted molars, especially complete bony im- weeks after the injury, at which time the involved
pactions, should be left in place to provide a tooth must be extracted and the fracture site
larger repositioning surface and for the applica- debrided. It is important to distinguish this clinical
tion of tension bands. The exceptions are par- situation from the more serious infection associ-
tially erupted molars with pericoronitis or asso- ated with avascular necrosis and sequestrum for-
ciated with a follicular cyst. mation at a malunited fracture site, which requires
thorough exploration and debridement.
• Teeth that prevent reduction of fractures should
be removed.
• Teeth with crown fractures may be retained pro- POSTOPERATIVE CARE
vided that emergency endodontic therapy is car- The primary concern in patients with mandibular
ried out. All teeth with fractured roots must be fractures who have been treated with MMF is the
removed. airway. A nasogastric tube should be positioned
• Teeth with exposed root apices or where the during surgery and left in place until the patient is
fracture line follows the root surface from api- ready for extubation to facilitate the removal of
cal region to gingival margin tend to develop gastric contents and prevent aspiration. With MMF,
healing complications. Hemisection should be it is essential that the patient not be extubated until
considered as an alternative to extraction. he or she is fully awake.
• Teeth that appear nonvital should be treated Prophylactic antibiotics are recommended in the
conservatively, keeping in mind their potential management of all open facial wounds, such as
for recovery and their importance in simplifying compound mandibular fractures. In Zallen and
fracture treatment and subsequent prosthodontic Curry’s246 series the infection rate was 50% when
rehabilitation. the patients received no antibiotics. Although all
• Primary extraction is preferred when there is the fractures occurred in the tooth-bearing areas
extensive periodontal damage with broken al- of the mandible, there was no correlation between
veolar walls and a deep pocket. the development of infection and removal or
Tooth fractures range in severity from cracks in retention of teeth.
the enamel to complete breaks of the crown. A It is important for the patient to maintain ad-
partial fracture of the crown in a tooth that is other- equate nutrition. Feeding should progress from a
wise intact with a stable root should be considered clear liquid diet to a high-protein, full liquid diet to
an indication for restorative dentistry.203,243-245 Res- blended fractured-jaw diet.247
toration is extremely difficult if there is complete
avulsion of the crown, however, in which case root
COMPLICATIONS
extraction and prosthetic reconstruction are indi-
cated. Likewise a tooth whose root has been The potential complications of mandibular frac-
transected by the fracture is doomed and should ture include infection, malocclusion, malunion, non-
be removed. union, plate exposure, and nerve injury.
27
Some common causes of nonunion of mandibu- hol and drug abuse, surgeon inexperience, and pa-
lar fractures include inadequate fracture immobili- tient noncompliance.
zation, inadequate fracture alignment, interposition Another complication after reduction of man-
of tissue or foreign body between fracture frag- dibular fractures is inferior alveolar nerve sensory
ments, infection at the fracture site, segmental bone abnormalities.252-254 Marchena and coauthors252
loss, and incorrect application of bone plates.248 examined 150 fractures occurring between the
Moulton-Barrett et al249 review the outcome of 308 mandibular and mental foramina with at least 1-
patients with mandibular fracture treated at Jackson year of follow-up. Pretreatment alveolar nerve dis-
Memorial Hospital in Miami. They report an over- turbance was documented in 56% (84/150), and it
all complication rate of 14% with infection account- became permanent in 16 (19%).
ing for approximately half of these and malunion Malocclusion is a particularly troublesome com-
and malocclusion the remainder. plication, if for no other reason that it is essentially
The incidence of nonunion following mandibu- entirely preventable. The most common cause is
lar fracture is reported to be 3.2%. The mandibular maladaption of the plate used for fixation, with
body has the highest incidence of nonunion of all resulting malreduction of the bone and movement
mandibular sites. Haug and Schwimmer 250 of the dentition. This should be recognized at the
attempted to identify risk factors that would be pre- termination of surgery when the MMF is released
dictive of nonunion, and found that inadequate and the occlusion assessed. Any discrepancy in
immobilization, anatomic location (body), teeth in the occlusion should prompt the surgeon to
the line of fracture, and the occurrence of late remove the fixation, reestablish MMF, and reapply
postsurgical infections correlated well with the the bone plates. Postoperative malocclusion sec-
development of fibrous union. Patients with self- ondary to internal fixation requires repeat opera-
abusive habits such as alcohol and drug use and tion in the vast majority of cases. The surgeon
noncompliant patients were also at high risk for should not rely on elastics or MMF to correct the
nonunion. Conversely, age, race, sex, mechanism problem.
of injury, and failure to use antibiotics were not risk Joos and colleagues255 looked at 76 patients over
factors. The treatment of nonunion generally con- a 2-year period and developed a mandibular frac-
sists of removing any infected teeth, debridement ture score which related to the complication rate.
of fracture, and reapplication of rigid internal fixa- Their fracture score considered both the anatomic
tion with or without bone grafting.250 location and amount of displacement as well as
Mathog and coworkers251 analyzed a series of interoperative management of the mandibular frac-
906 patients with 1432 mandibular fractures for tures. Not surprisingly, the complication rate
factors that might contribute to nonunion. They increased with severity of the fracture score. Treat-
found that multiple fractures were associated with ment of low score fractures with less rigid plating
nonunion, and the mandibular body was often systems had better results than treatment with larger
involved. Osteomyelitis was a frequent finding. plates. More severely comminuted fractures
Other factors were failure to provide antibiotics, showed fewer complications when treated with
delay in treatment, teeth in the fracture line, alco- more rigid plate systems.
28
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35

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Facial Fractures II: Lower Third

James F Thornton MD and Larry H Hollier MD

MAXILLARY FRACTURES Today most authors subscribe to the following

Fig 2. Division of midface reconstruction into upper and lower

Fig 1. Common patterns of midface fractures. (Reprinted with

Manson and colleagues31,32 also described hori-

as isolated injuries or in association with other Le

BIOMECHANICS The clinical signs of Le Fort II and III fracture are

Physical Examination MANAGEMENT

Fig. 10. Algorithm for management of the fractured edentulous

When properly applied, rigid internal fixation is

Fig 13. Angle classification of occlusal status. Class I—

the alveolar bone will resorb. An edentulous man-

Fig 15. Types of bone healing.

TREATMENT BY FRACTURE SITE

ment of mandibular condylar process fractures. The

Fig 17. Algorithm for treatment of condylar

future joint function. . . . Closed treatment will nor- Maxillomandibular Fixation

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