MANDIBULAR FRACTURES

DR E.A. ADELUSI
BDS, MDS, FWACS,
 INTRODUCTION

• The mandible is essentially a long bone bent into a blunt U-

shape. bilaterally with the temporal bones through the
temporomandibular joints (TMJs).
• During function of the intact mandible, both TMJs have to
move.
• When the mandible is fractured, the muscles acting on the
mandible are able to displace the fragments in a horizontal and
vertical plane.
• The forces generated give rise to areas of tension and
compression as described by Champy
Anatomy
Anatomy (contd)
Age changes in the mandible
 Surgical anatomy CONTD
• This basic configuration is modified by sites of muscle
attachments, notably masseter and medial pterygoid around
the angle, and temporalis around the coronoid process.
• The presence of teeth, particularly those with long roots
such as the canines, or unerupted teeth, produces lines of
weakness in the mandible.
• The mandible is strongest anteriorly in the midline and is
progressively weaker posteriorly towards the condylar
processes.
• The mandible has great resistance to compressive forces, but
fractures at sites of tensile strain.
Surgical anatomy cont
Surgical anatomy cont
 Surgical anatomy CONTD
• The mandible is liable to particular patterns of distribution
of tensile strain when forces are applied to it.
• Anterior forces applied to the mental symphysis, or over the
body of the mandible, lead to strain at the condylar necks
and also along the lingual cortical plates on the contralateral
side in the molar region.
• In order of frequency, fractures occur most commonly at the
neck of the condyle, the angle, the parasymphyseal region
and the body of the mandible.
• Most often the mandible fractures occur at two of these
sites: isolated fractures are relatively unusual.
 Surgical anatomy CONTD
• Fractures at the ramus exhibit very little
displacement due to the splinting activity of medial
pterygoid medially and masseter laterally.
• These two bulky muscles are widely attached to the
ramus and their attachments extend across the
fracture lines.
• Similarly the coronoid process is rarely significantly
displaced because it is splinted by the tendinous
insertion of temporalis.
 Surgical anatomy CONTD

• The condyle is protected from direct injury by the zygomatic

arches.
• Fractures occur usually by the transmission of force following
a blow to the front of the mandible or to the contralateral
body.
• Except in children most condylar fractures are not
intracapsular, and occur in the neck.
• They typically run obliquely downwards and backwards from
the mandibular notch.
• The condyle is usually displaced anteromedially (because of
the attachment of lateral pterygoid to the temporomandibular
joint disc, capsule and anterior border of the neck of the
condyle).
SURGICAL ANATOMY CONTD
• The majority of fractures at the angle of the mandible run
vertically downwards and backwards from the alveolar bone to
the angle.
• When a third molar tooth is present the fracture line will pass
through its socket.
• The presence of the tooth results in a line of weakness.
• A fracture at the angle prevents the powerful elevator muscles
(masseter, medial pterygoid and temporalis) from having any
direct effect on the tooth-bearing part of the jaw.
• Thus, the posterior fragment is typically displaced upwards,
forwards and inwards as a result of the unopposed pull of these
powerful muscles.
 Surgical anatomy CONTD
• Most fractures of the body of the mandible occur as the
result of direct trauma and tend to be concentrated in the
first molar or canine region.
• The further forward the site of the fracture, the more the
upward displacement of the elevators is counter-acted by the
downward pull of geniohyoid and the anterior belly of
digastric.
• When teeth are present displacement is limited by the dental
occlusion, since further displacement is resisted by the lower
and upper teeth.
• Displacement may be considerable in the edentulous patient.
Bucket handle fracture
 Surgical anatomy CONTD

• Mandible receives endosteal supply via the inferior alveolar

artery and vein
• Periosteal supply is from adjacent vessels – facial, lingual
• The periosteal supply becomes more important as age
increases
• The inferior alveolar nerve is frequently damaged in
fractures of the body and angle of the mandible producing
anesthesia and paraesthesia within the distribution of the
mental nerve on the side of the injury
 Aetiology of facial fractures
• Road traffic accidents
• Falls
• Interpersonal violence
• Sport injuries
• Industrial injuries
• War
A. Dento-alveolar B. Symphyseal C. Para-symphyseal
D. Body E. Angle F. Ramus
G. Coronoid H. Condyle I. Subcondylar
 Classification schemes – Fracture
type
• Simple/closed- not opened to the external
environment
• Compound/opened- fracture extends into
external environment
• Comminuted- splintered or crushed
• Greenstick- only one cortex fractured
• Pathologic- pre-existing disease of bone lead to
fracture
 Classification schemes – pattern
• Unilateral – usually only one line of fracture but may be more
• Bilateral – fracture line on both sides of the mandible
• Multiple- two or more lines of fractures on the same bone that do not
communicate (Guardman’s fracture)
• Communited – multiple fracture lines rendering the mandible into
small fragments usually due to excesive force
• Impacted- fracture which is driven into another portion of bone
• Indirect (Contre- coup)- a fracture at a point distant from the site of
impact/ soft tissue injury
• Complicated/complex- damage to adjacent soft tissue, can be simple or
compound
• Fracture due to excessive contraction - coronoid
Classification schemes – Dentition
• Developed by Kazanjian and Converse
• Class I: teeth are present on both sides
of the fracture line
• Class II: Teeth present only on one
side of the fracture line
• Class III: Patient is edentulous
 Classification schemes – Muscle Action/Favourability

• Generally apply to angle and body fractures

with distruption of the periosteum
• Vertically Favorable vs. Non Favorable -
Resistance to medial pull
• Horizontal Favorable vs. Non Favorable -
Resistance to upward movement
 Classification schemes – Muscle Action

Vertically Favorable vs. Horizontally Favorable

Non Favorable vs. Non Favorable
Horizontally favorable fracture vs
Horizontally unfavorable fracture

Horizontally Horizontally
favorable fracture unfavorable fracture
 Vertically favorable fracture
vs Vertically unfavorable fracture

Vertically favorable fracture Vertically unfavorable fracture

 Displacement of fractures

• The periosteum helps in holding the

fracture segments together
• When the periosteum is stripped off the
bone, displacement results depending on
• 1. State of the periosteum
• 2. Muscles acting around the fracture line
• 3. Direction of the force
 Clinical assessment: Prior to examination
• It is important to gain the following
information
• Mechanism of injury
• Previous facial fractures
• Pre-existing TMJ disorders
• Pre-existing occlusion
• Past medical history (epilepsy, alcoholism,
mental retardation, diabetes, psychiatric
disorder, immune status)
 Clinical assessment: Dento-alveolar fracture
• Fracture of the alveolus occurring in association with
avulsion, subluxation or fracture of the teeth
• Importance of dental trauma is that it frequently requires
immediate treatment both to relieve pain and often to
preserve the dentition
• Meticulous dental examination is essential and any missing
fragment of crown on fillings noted
• Chest x ray if a segment could not be accounted for.
• Alveolar fracture in the mandible are frequently associated
with complete fractures of the tooth bearing segment.
 Clinical assessment: fracture of the
symphisis and parasymphisis

• Commonly associated with condylar fractures

• Usually associated with minimal displacement because of
the thickness of the bone in this region
• Gross distortion results in loss of tongue control and
obstruction of the airway in an unconscious patient
• Displacement is also associated with deranged occlusion
in the anterior region
 Clinical assessment: fracture of the
symphisis and parasymphisis

• Usually not associated with mental nerve injury

• Pain during function
• Swelling in the anterior mandible
• Bleeding into the sublingual mucosa
• Step deformity
• Laceration of the chin (Tell-tale sign)
 Clinical assessment: fracture of the body

• Inferior alveolar nerve anaesthesia

• Derangement of occulsion
• Gagging of occlusion
• Step deformity
• Intra- -oral buccal and sublingual hematoma
• Extra oral swelling
• Pain
• Bleeding
• Involvement of tooth along the fracture line – Fracture, subluxation or avulsion
• Limitation in mouth opening
• Crepitation may be elicited (very painful for the patient)
Clinical assessment: fracture of the angle
• Similar to findings in the fractures of the body
• Muscular activity is more marked and fracture could be
favourable or non-favourable

Clinical assessment: fracture of the ramus

• Rare but can occur as a component of condylar fracture or other
mandibular fracture
• Tenderness around the fracture line
• Trismus
• Hematoma formation
• Usually undisplaced due to presence of periosteum
Clinical assessment: fracture of the coronoid
• May be due to reflex contraction of the temporalis or following
comminution of the ramus/ condylar region
• May be pathologic (large cyst)
Clinical assessment: fracture of the condyle
• May be unilateral, bilateral, intracapsular or extracapsular
• Intracapsular is usually undisplaced
• Unilateral condylar fracture
• Severe pain on movement
• Swelling around the TMJ
• Bleeding from the external auditory meatus
• Battle sign – ecchymosis of skin just below the mastiod process on the same side
• Painful limitation of protrusion and lateral excursion of the mandible
• Deviation of the mandible to the side of the fracture
 Clinical assessment: fracture of the condyle

• Bilateral condylar fracture

• Similar findings as in unilateral occurring bilaterally
• Tenderness of the TMJ bilaterally
• Bleeding from both ears
• Bilateral swelling around the TMJ
• Severe limitation of mouth opening
• Anterior open bite due to premature contact of the
posterior teeth on both sides
Altered occlusion observed in a fracture of the condyle of the mandible
Anterior open bite due to shortening of the
ramus in bilateral condylar fracture
 Diagnostic imaging
• Plain radiograph still provides the foundation of imaging
• To adequately screen for the presence of a mandibular
fracture, at least two views at right angles to each other are
necessary
• The mandibular views include
• Intraoral periapical view: to determine the involvement of the
teeth. Could be used to assess soft tissue impaction of tooth
segment
• Occlusal view: to assess the symphyseal and parasymphyseal
region due to distortion seen on postero-anterior view
Occlusal view
 Diagnostic imaging cont

• Orthopanthomogram
 Diagnostic imaging cont
Extraoral views
Postero-anterior projection shows mediolateral
displacement of fracture of the body, angle,
ramus or condylar regions
• Right and left lateral oblique of the mandible: the two sides are
taken for comparison, useful for the body, angle, ramus and condyle
• Rotated PA: the ray is centred away from the cervical spine. Useful
for symphyseal and parasymphyseal with no associated cervical
spine injury
Postero-anterior projection
Rotated PA view
Postero-anterior projection
Postero-anterior projection
Postero-anterior projection
Postero-anterior projection
Postero-anterior projection
Oblique lateral view
Unerupted third molar
 Diagnostic imaging cont

• Towne’s view: useful for assessing condylar fracture, it is

an AP view.
• Reverse Townes is a PA view and more frequently
requested by the Maxillofacial surgeon
Reversed Towne’s
 Advanced diagnostic modalities
• Computed tomography scan: when there is
intracapsular condylar fracture or complex
maxillofacial fracture
• Magnetic resonance imaging: when there is extensive
soft tissue involvement especially in the region of the
TMJ or when there is persistent leakage of CSF
• Endoscopy and barium meal if patient swallowed
fracture segment
• Angiography if there is major arterial involvement
Computed tomography scan: Axial and coronal
Condylar fracture
Angle fracture on PA jaws and axial CT cut
3D- Computed tomography scan
Fracture of the body of the mandible PA jaws
and 3D-CT
3D- Computed tomography scan
3D- Computed tomography scan
Treatment of mandibular fracture
There are as many opinions as
there are people: Each has his
own correct way.
• Terence (circa 190–159 BC):
Phormio
 Goals of mandibular fracture repair
• To re-establish a stable occlusion
• To re-establish an adequate range of motion
• To restore facial and mandibular arch form
• To restore pain-free function
• To avoid internal derangement of the temporomandibular
joint
• To avoid growth disturbances of the mandible
 Treatment of mandibular fracture

• The basic treatment is reduction and

immobilization and could be done under
local anaesthesia (with sedation) or
general anaesthesia.
• These are achieved by:
• Close reduction and immobilization
• Open reduction and internal fixation
 Reduction
• Reduction is the restoration of anatomical (functional and
aesthetic) alignment of the bone fragments.
• In the dentate mandible this means anatomical alignment
when teeth that were previously in good occlusion are
involved.
• Achieving occlusion is a guide to good reduction. However,
preexisting occlusal abnormalities must be recognized.
• Gradual reduction may be achieved by small elastic bands.
• Teeth could also assist in immobilization e.g. MMF
Indications for closed reduction techniques of mandibular
fractures.
• Non-displaced mandibular fracture
• Grossly comminuted mandibular fracture
• Atrophic edentulous mandibular fracture
• Loss of soft tissue coverage over a fracture
• Mandibular fractures in children
• Condylar fracture in children
 Advantages of closed reduction
• Low cost,
• Shorter length of procedure,
• Ability to achieve preinjury occlusion with
some dynamic adjustment
• Most techniques are relatively easy to learn
and maintain in the surgeon’s repertoire.
• Does not require opening of tissues with
incisions or dissection and placement of
foreign body materials.
 Indications for open reduction techniques of mandibular fractures.

• Systemic disorders
• Displaced unfavorable fractures
• Multiple facial and/or mandibular fractures
• Bilateral condylar fractures and midface fractures
• Delayed treatment with soft tissue in between the
fracture
• Malunion/non-union
 Teeth in the fracture line

• Commonly seen in fracture of the symphysis, parasymphysis, body

and angle in a dentate patient.
• Serves as a potential impediment to healing by
• Fracture is compound to the mouth via the opened periodontal membrane
• Tooth may be structurally damaged or lose its blood supply as a result of the
impact and the pulp becomes necrotic
• There may be preexisting pathology such as periapical granuloma
• The fracture may therefore become infected.
• Infection of fracture line results in protracted healing or even nonunion
• In pre-antibiotics days all teeth along the fracture line were routinely extracted
• Today, there are absolute and relative indications to removal of a tooth in the
fracture line
 Absolute indication for removal of a tooth along the fracture line
• Longitudinal fracture involving the root
• Dislocation or subluxation of a tooth from the socket
• Presence of periapical infection
• Infected fracture line
• Acute pericoronitis

Relative indication for removal of a tooth along the fracture line

• Functionless tooth which would eventually be removed
• Advanced caries
• Advanced periodontal disease
• Doubtful teeth which should be added to existing dentures
• Teeth involved in untreated fractures presenting more than 3 days
after injury
 Management of teeth retained in fracture line

• Good quality intra-oral periapical radiograph

• Institution of appropriate systemic antibiotic therapy
• Splinting of tooth if mobile
• Endodontic therapy if pulp is exposed
• Immediate extraction if fracture line becomes infected
• Follow up for 1 year and endodontic therapy if there is
demonstrable loss of vitality
 Immobilization

• Immobilization is keeping the reduced fracture

segments stable for a period of time to allow for
healing to occur.
• This should follow accurate reduction
• Methods of immobilization are categorized into 3
groups
• Osteosynthesis without MMF
• MMF
• Osteosynthesis with MMF
 Factors that determine the immobilization used
• Pattern of fracture
• Presence or absence of teeth
• Availability of facilities and resources
• Age and medical conditions
• Skill and experience of the operator
• Presence of concomitant fracture
• Financial constraints
 Methods of immobilization I
• Osteosynthesis without maxillomandibular fixation
1. Non-compression small plates
2. Compression plates
3. Miniplates
4. Lag screws
5. Resorbable plates and screws
 Methods of immobilization I (cont)
Non-Compression plates
• Historical
• Larger than the present plate design and therefore more
bulky
• May be palpable under the skin
 Methods of immobilization I (cont)
Compression plate
• Compression osteosynthesis is based on the biological principles
established for the treatment of fractures of weight bearing long bones
• All compression plates include at least 2 pear shaped holes, which may
be positioned on one on either sides or both on the same side.
• The widest diameter of the holes lies nearest to the fracture line
• The screw is inserted into the narrowest part of the hole and at the final
moment of tightening its head sinks into the wider diameter.
• No longer popular, because anatomical reduction is difficult with
compression plates
• Plate is applied to the convex surface of the mandible at its lower border,
however as the plate is tighten, there is tendency of the upper border and
the lingual plate to open.
• It is important to attach a tension band at the level of the alveolus before
tightening
 Methods of immobilization I (cont)
Compression plate
Disadvantages
1. Lengthy operative approach
2. Require considerable expertise
3. Difficult to apply in oblique fractures
4. Difficult to apply in comminuted fractures
5. Bulky necessitating later removal in most patients
Diagrammatic representation of a small compression plate to illustrate
which the principle by which compression of the bone interface is achieved.
The eccentric pear shaped hole in the plate cause inward movement of
the screw at the final stage of tightening when the head of the screw
localizes in the wider part of the hole
 Diagram illustrating the chief problem with a
compression plate

• A. Compression near the lower border opens up the fracture at the alveolar margin
• B. A tension band previously applied to the teeth prevents the distorting effect of the
lower border compression plate
• C. A similar effect is achieved by prior application of a small cortical non-
compression plate above the level of the inferior alveolar canal
 Methods of immobilization I (cont)
Mini plates
• Introduced by Roberts in 1964
• Length is 2.5cm and uses a screw 7mm long and 2mm in
diameter
• Screw only engages the outer cortex
• It is not bulky and may not necessitate removal
• The applied force is minimal and does not result in gapping
of the upper border
 Methods of immobilization I (cont)
Mini plates – indication for application

• May be used in all cases of mandibular fractures but it is

particularly benefit if
1. Fractures in an edentulous part of the body of the mandible
2. Concomitant fractures of the body and condyle when early
mobilization is indicated
3. When there are associated fractures of the other parts of the
facial skeleton
4. Patients in whom MMF is contraindicated
5. Fractures associated with closed head injury
6. Fractures in which there is continuity defect
7. Fracture in which non-union or mal-union has occurred
Mini plates
Miniplates of various sizes and shapes
Placement of miniplates
Placement of miniplates: Intraoral approach
 Methods of immobilization I (cont)
Lag screws
• Suitable for management of oblique fractures
• The hole drilled in the outer cortex is made to a slightly larger
diameter than the threaded part of the screw, therefore the
thread only engages the inner plate
• When tightening the head of the screws engages the outer
plate ant the oblique fracture is compressed
 Methods of immobilization I (cont)
Lag screws

• A. Note that the screw is 900 to the fracture line

• B. compression is only possible only if the proximal hole
is enlarged, so that the screw does not engage
 Methods of immobilization I (cont)
Resorbable plates and screws
• Based on co polymer of 70/30 poly(L/DL-lactide)
• Advantages include
• Strength is comparable to titanium plating system
• A convenient hex-drive break away delivery system simplifies
screw placement
• Eliminates growth restriction and implant migration in paediatric
patients
• Resorbs completely and eliminates the need for a second surgery
• Does not induce late stage inflammatory reaction
 Methods of immobilization II

• Maxillo-mandibular fixation
a) Bonded bracket
b) Dental wires
i. Direct
ii. Eyelet
c) Arch bars
d)Cap splints
e) MMF screws
 Methods of immobilization II (Cont)
Orthodontic brackets
• Custom made or fabricated in the laboratory
• Used for minimally displaced fractures
• Ensure proper application by avoiding moisture when attaching brackets
• May apply wires or elastic to achieve MMF
 Methods of immobilization II (Cont)
Dental wiring
• Has sufficient good shaped teeth in either the upper and
lower jaws are present.
• The wire used is 0.45mm soft stainless and it is stretched by
10%, this is to prevent it from being loose.
• It should not be overstretched to prevent it from becoming
brittle
 Methods of immobilization II (Cont)
Direct wires
• The fixation device is applied directly to the tooth
• About 15cm of soft stainless steel wire is used after stretch and the two
end held together with wire twister
• The wire is introduced into the interdental space from buccal to lingual.
• The upper and lower jaws were then joined.
 Methods of immobilization II (Cont)
Eyelet wires
• Made from 0.45mm soft stainless steel wires
• Twist 15cm length around a 3mm rod to get a eye
• Place the 2 ends of the wire into the interdental space
• Let the ends go around the adjacent teeth, then place one
of the ends into the eyelet and twist with the other ends.
• Tuck the end interdentally
• Use a straight wire to tie the upper and lower teeth
Methods of immobilization II (Cont)
Eyelet wire placement procedure

• (A) Initial step in eyelet

placement.
• (B) Free ends pass
around adjacent teeth at
cervical level and below
height of contour. Note
that loop placement
remains facial.
• (C) Distal wire is passed
through loop anteriorly
on facial aspect of tooth
surface.
• (D) eyelet in place.
• (E) MMF using eyelet
wire technique.
Proper and improper tie of wire
 Methods of immobilization II (Cont)
Arch bars
• Has different shapes and sizes,
• Types: Jelenko, Erich’s, Winter, German silver bar and other less popular
ones e.g. Schuchardt,
• Arch bars are used when there are insufficient number of teeth and you
want to maintain a direct fixation across a fracture
• It must conform to the shape of the arch
VARIOUS TYPES OF
ARCH BARS

a and b: Jelenko arch bars

c: Erich arch bar
d and e: German silver
arch bar
 Placement of Erich arch bar

• (A) After the arch bar material is cut to the length of each dental arch, the bar is placed along the buccal surface of the
dental arch, hooks oriented apically. An 0.45mm soft stainless steel wire is passed interdentally around each tooth,
such that one end of the wire is positioned occlusal and the other apical of the arch bar. (B) Each wire is twisted
clockwise, thus tightening it around the tooth, apical to the crown. (C) The twisted ends are then trimmed and then
tucked down toward the gingival, also in a clockwise direction. (D) The patient should be placed into occlusion, and
the 2 arch bars secured to each other, either with a wire loops or rubber bands. (E) Arch bars completed.
Erich Arch bar in place
MMF using Erich arch bar and tie wires
MMF using Erich arch bar and elastics
Jelenko arch bar on a model
 Methods of immobilization II (Cont)
Cap splint
• Mainly historical
• Time consuming and other techniques give better result
• Indications
• Temporary retention of some teeth which are weak (periodontally
involved)
• When there is fracture of dentulous mandible along with condylar
fractures and an early immobilization of the jaws is required
• When there is mandibular fracture with appreciable loss of
mandibular bone and soft tissue defects.
 Procedure

• An impression of the teeth and alveolar bone should be

taken.
• Cast the impression
• Fabricate the cap splint incorporation hooks
• Cement the splints to the teeth with ZnPO4
• Disadvantage is that reduction may not be achieved as the
splint is placed on the occlusion
 Methods of immobilization II (Cont)
MMF Screws

• A technique for closed reduction

• The benefits of this particular technique include its ease of
placement with little risk for wire injury and decreased
amount of time for placement.
• They are easy to remove at the end of the healing period
and can be removed in minutes with minimal local
anesthesia
• Placement of screws should be in areas that avoid the
apices of the dentition and all vital structures
Methods of immobilization II (Cont)
MMF Screws
MMF Screws
 Determinants of length of period of Immobilization
• When MMF is the main means of immobilization, period of
immobilization depends on :
• the age of the patient,
• Presence or Absence of a tooth along the fracture line
• site of the fracture,
• Time of presentation - early or late.
 Fracture mathematics

• Juniper and Awty (1973) showed that in favourable

circumstance, stable clinical union can be achieved after 3
weeks.
• A simple guide is : a young adult with fracture in the angle
receiving early treatment in which the tooth along the
fracture line has been removed. Then immobilization
should be for 3 weeks.
• If
• The tooth along the fracture line is retained, add 1 week
• The fracture is at the symphysis, add 1 week
• The patient is 40 and above, add 1 weeks
• The patient presents late, add 1 weeks
• Children and adolescent: subtract 1 week
 Disadvantages of MMF

• The airway is partially compromised and is at increased

risk in the event of postoperative swelling, regurgitation or
vomiting. Opioid analgesia and other central nervous
system depressants should be avoided to minimise
respiratory depression and nausea.
• There is reduced tidal volume.
• Patients are unable to take solid diet. Patients should
receive 3 litres of fluid and 2500 calories each day, and
some encouragement will be required initially to achieve
this when a patient is in IMF.
 Disadvantages of MMF cont
• It is difficult to maintain good oral hygiene. Tooth brushing
of the lingual aspects of teeth is not possible; therefore,
patients must compensate with warm saline mouth
wash/copious mouthrinsing and the use of a chlorhexidine
rinse.
• There is poor patient tolerance of MMF.
• Wire trauma to oral soft tissue
• Post-treatment stiffness of the temporomandibular joint can
occur and there is a risk of ankylosis.
• It interferes with speech
 Disadvantages of MMF cont
• Inhalers for asthma therapy are difficult to use.
• For surgeons, the looming risk of wire
penetration injuries to fingers and hands must be
considered.
• Though the teeth may appear to be in good
occlusion, displacement of the basal bone may
still be present
• When there is concomitant fracture of the
maxillae and mandible, neither jaw is capable of
correctly orientating and stabilizing the other
• There may not be enough teeth to provide
 Methods of immobilization III
• Osteosynthesis with Maxillo-mandibular fixation
1. Transosseous wiring
2. Circumferential wiring
3. External pin fixation
4. Bone clamps
5. Transfixation with kirschner wires
Methods of immobilization III (Cont) Transosseous wiring
• Passing wire across the fracture site
• Another form of mandibular fixation not expensive and
with minimal or moderate skill
• Wire is 0.45mm soft stainless wire
• Transosseous wiring can be in 2 forms
• Upper border
• Lower border
• Middle border
• Procedure: open up, drill, make a hole, introduce wire
• Fix the segments by twisting the wires
• Repair the soft tissue
Methods of immobilization III (Cont)
Transosseous wires

• Types of ligature
styles
• 1. Simple
• 2. Combined
simple and figure
of eight
• 3. Brons wiring
• 4. Double ligature
Methods of immobilization III (Cont)
Transosseous wires

• Upper border wiring

 Methods of immobilization III (Cont)
Pin fixation
• Popular in the old, commonest is Toller’s pin and Moule’s pin
• Involves the use of bone pins about 3mm in diameter
• Indication
• When you want to maintain continuity of bone in cases of infected
fracture
• When a patient has panfacial fracture
• When there is loss of bony tissue and the relative position of the teeth
is to be maintained
• Disadvantages
• electronic activity
• Aesthetically unpleasing
 Pin fixation

• Superior and lateral views of a mandibular external fixator.

In this particular system, biphasic pins are applied
transcutaneously and are secured to one another using a
universal joint system and rigid metal rods.
 Methods of immobilization III (Cont)
Circumferential wiring
• It is a simple method 0.45mm soft stainless steel wire used in
oblique fracture of the mandible
• Procedure
• Insert a length of wire lateral to the bone and manipulate to go around
the mandible
• Tie together after it has gone round
• Cut wire and tuck in into the bone
• Bone awl is an instrument used for passing the wire
 Methods of immobilization III (Cont)
Circumferential wiring

• Steps for placement of circum-mandibular wires using awl technique.

Circumferential wiring
Methods of immoblization III (Cont)
Kirschener’s wire
• Used commonly in orthopaedics
• It is passed into the medullary bone on either side of the
fracture
• It is quick and inexpensive
 Paediatric mandibular fracture
• Mandibular fracture in children is modified by peculiar
anatomical variations present in the pediatric age group.
• This variation includes
• Children possesses resilient bone that requires considerable force to
fracture
• There is poor cortico-medulary diffrentiation
• There is high ratio of bone to tooth substance
• Good blood supply so rate of healing is faster
• Majority of the fracture in children is incomplete
• The are limited number of teeth that are adaptable for maxillo-
mandibular fixation
• Condylar fracture are usually intracapsular due to the poorly
developed condylar neck
 The aim of treatment of
mandibular fracture in children
• To obtain bony union,
• To normalize the occlusion,
• To restore normal form and function,
• To avoid impediments to normal growth.
 Challenges in management of mandibular fracture in children

• Interference with growth potential:

normal growth of the mandible will be disrupted if unerupted
permanent teeth or tooth germs are lost because the alvelolus
will not develop in affected areas.
• The capacity for preferential growth in the subcondylar
region will also be compromised by high condylar fracture
particularly if function is restricted
 Challenges in management of
mandibular fracture in children (cont)
• Fixation in the deciduous and mixed dentition: if
the severity and displacement of the fracture warrant
immobilization of the mandible . Then the following
modification is essential
• Fixation devices independent of the teeth
• Gunning type splint
• Circumferential wire
• Plate and wire fixation confined to the lower border
• Simple elastic bandage chin support
• Lingual splint
• Fixation utilizing teeth when adequate
number of firm erupted deciduous and
permanent teeth are available
• Eyelet wires using 0.35mm soft stainless steel
wires,
• Risdon cable
• Arch bar using light German silver or Jelenko
• Orthodontic brackets bonded directly to the teeth
• Cap splints
Lingual splint
 Risdon cable

• 0.35mm soft stainless steel wire is braided and acts as

archbar. Each tooth ligated to the braided arch bar in the
standard fashion. Note low profile of Risdon cable.
Challenges in management of mandibular
fracture in children (cont)

• Unerupted teeth: it is unsafe to transosseous

wire or bone pins and plates in children below age 10years
due to the fact that the mandible is congested with
developing teeth
• In exceptional cases, lower border should be wired with
caution or a small plate with monocortical plate may be
applied
• Resorbable plates has also been employed for this cases
Challenges in management of mandibular
fracture in children (cont)
• Healing and remodelling
• Mandibular fractures in children heals very rapidly and
some fractures are stable within a week and firmly
united in 3 weeks
• Some slight imperfection in reduction is acceptable as
continuous growth and eruption will compensate in
most cases
• Follow-up is important to be sure that there is no long
term effect on mandibular growth
 Synopsis of paediatric mandibular
fracture
• Modification of the principle of treatment is necessary to take account of;
• Capacity for rapid bony union-fractures are stable at between 1 and 3
weeks
• The mixed dentition and multiple buried developing teeth
• Potential interference with subsequent growth
• Accurate reduction is less important as further growth will often
compensate for occlusal discrepancies
• Direct osteosynthesis should be avoided. Wiring or plating the lower border
may occasionally be indicated
• MMF can be applied to deciduous teeth but finer diameter wire should be
used
• Fracture of the condyle require special consideration
• Prolonged period of follow-up is important
 Mandibular fracture in the elderly

• The physical characteristics of the body of the mandible are altered

considerably following the loss of the teeth. This changes include
• Resorption of the alveolar process and the vertical depth of the subsequent
denture-bearing area is reduced by approximately one-half or more in some
cases
• Decreased resistance to fracture
• Periosteal blood supply becomes more significant
• Decreased bone cross section with associated increased likelihood of
fracture displacement
• Alveolar nerve lies closer to the surface so there is increased likelihood of
injury to the nerve
• Commoner occurrence of non-union due to poor blood supply and reduced
cross-sectional area
• Fracture are usually not compound into the mouth due to loss of periodontal
communication
Reduction of fractured edentulous mandible
• Precise anatomical reduction is not necessary
• The objective of reduction is to achieve
sufficient bone contact and alignment with
the minimal direct operative interference at
the fracture site.
• The blood supply is mainly periosteal so
there should be minimal disruption of the
periosteum
 Immobilizing the fractured edentulous mandible
• Direct osteosynthesis – (it is important to maintain minimal
periosteal stripping)
• Bone plates
• Transosseous wiring
• Circumferential wiring or straps
• Transfixation with Kirschner wires
• Fixation using cortico-cancellous bone graft
• Indirect skeletal fixation
• Pin fixation
• Bone clamps
• Maxillo-mandibular fixation using Gunning-type splints
• Used alone
• Combined with other methods
 Gunning’s type splint (GTS)

• Can be used with MMF

• Could be upper or lower or both
• It is a modified monoblock consisting of 2 bite blocks with a
space in the incisor area to facilitate feeding
• The upper plate is attached to the maxilla by peralveolars wire and
the lower splint to the mandibular body by circumferential wires.
• MMF can be effected by connecting the 2 splints with wire loops
or elastic bands
• The GTS should hold the jaws in a slightly overclosed
relationship to ensure a more effective reduction. The edges
should also be slightly overextended around the sulcus in order to
minimize food entry under the fitting surface.
Gunning’s type splint
 Gunning’s type splint
Disadvantages

• The splint becomes foul smelling during the 6 weeks of

fixation as a result of food stagnation between the poorly
fitting surface of the splint and the oral mucosa
• Candida induced stomatitis may occur
• The wire track within the tissue may become infected
• The splint are inefficient as a method of immobilization and
provide poor control of mobile fractures
 Primary bone grafting
• Extreme atrophy of the mandible can occur to
such an extent that the mandibular
neurovascular bundle may come to lie above
the bone covered only by soft tissue
• If the depth of the thinnest part of the
mandible is less than 1cm then the mandible
is ultra-thin and will require bone grafting.
• Rib graft and iliac crest graft are the most
popular for grafting
 Synopsis of fracture of the edentulous mandible
• In the edentulous mandible, reduction and fixation is mainly
required for fracture of the angle and body with a view of
restoring an adequate denture bearing area and avoiding facial
deformity
• Reduction should be achieved with minimal exposure because of
the reduced blood supply
• Gunning type splint may be used but other techniques are
preferred
• In fit patient open reduction and fixation using mini plates are
preferred.
• When the mandibular depth is less than 1cm then non union and
fibrous union is more likely
• Ultra thin mandible may require grafting
 Condylar fracture
• The only maxillofacial fracture
involving a synovial joint
• Advent of CT and MRI has shown that
incidence is higher than previously
reported
• Multiple classification schemes
 Trauma to the condylar region
• Contusion: injury to the capsular ligaments may be associated
with synovial effusion, haemathrosis, meniscus tearing.
Require advance imaging for diagnosis. May predispose to
degenerative changes in the TMJ
• Dislocation: irreducible displacement of the condyle from the
glenoid fossa. Usually anterior or medial.
• Fracture: any fracture above the level of the sigmoid notch.
May be intracapsular or extracapsular
 Condylar fracture in children

• In the youngest age group (0-2 year olds) the condylar neck
is short and thick and engages a shallow glenoid fossa.
• Extensive vascular channels are found in the condylar head which is
covered by cartilage making it extremely vulnerable to a crushing
injury.
• The bone itself has a very high osteogenic potential and is
characterized by thick medullary space and thin bony cortices
resulting in a greater likelihood of greenstick fracture.
• Unlike older age groups, the short stocky nature of the condylar
neck makes it relatively resistant to fracture.
 Condylar fracture in children (cont)

• In the median age group (3-10 year olds) a more adult like
configuration of the condylar process and glenoid fossa
develops, although unlike adults, there still remains an
enormous potential for regeneration and remodelling in this
age group.
• For the older age group (10-17 year olds) one finds that
although the capacity for extensive new bone formation is
equivalent to that of children, teenagers lack the
corresponding capacity for condylar remodelling that is
found in the younger age groups
 Treatment of condylar fracture

• Conservative –
• Observation
• Soft diet (non-chewing)
• Analgesics
• Intermaxillary fixation
• Wires
• Elastics
• Surgery
• Open reduction and internal fixation
Absolute indications for conservative therapy

• Intracapsular fractures
• Fractures in small
children
• Fractures without
dislocation/ displacement
 Indication for the treatment of condylar fractures

• Absolute indication for open reduction

• Impossibility of achieving occlusion by conservative technique
• Lateral extracapsular displacement
• Displacement of the condyle into the middle crania fossa
• Invasion of the TMJ by foreign bodies eg (missile injury.
• Relative indication for open reduction
• When MMF is contraindicated for medical reasons eg epilepsy,
COPD
• Bilateral fracture with associated midfacial fracture
• Bilateral fracture with severe anterior open bite
Criteria for choice of treatment modality

• 1. Age of the patient • 3. Anatomical site

• <10 years • Extracapsular
• 10-17 years • Intracapsular
• >17 years • High condylar
• Low condylar
• 2. Side of the fracture • 4. Occlusion
• Unilateral • Disturbed
• Bilateral • Not disturbed
 Management of condylar fracture
(children less than 10 years old)

• Fractures are rare and minimal because of the resilience of the

bone
• Same protocol for intra or extracapsular fracture
• If occlusion is minimally disturbed then treatment is
conservative as mandibular growth and development allows
for spontaneous correction
• Ensure long term close monitoring
• If pain is severe in the immediate post trauma period,
immobilize for not more than 10days to minimize pain and
reduce the risk of ankylosis
Management of condylar fracture
(10 – 17 years old)

• Less risk of ankylosis

• Less chance of spontaneous correction of occlusion
• Immobilize for 2-3weeks
• Treatment usually non-operative
• Ensure long term follow up
 Management of condylar fracture
(Adults – unilateral intracapsular)

• Occlusion is usually undisturbed

• Treatment is conservative
• If occlusion is disturbed then put patient in MMF for 2-3
weeks
 Management of condylar fracture
(Adults – unilateral extracapsular)

• Occlusion is disturbed if fracture segment is displaced

resulting in shortening of the ramus
• Immobilize for 3-4 weeks
• Risk of ankylosis is high
• High condylar neck fracture poses greater risk of facial nerve
damage if open reduction is done. So consider close reduction
• If the fracture is low condylar, then risk of facial nerve injury
is low so consider open reduction.
 Management of condylar fracture
(Adults – bilateral intracapsular)

• Occlusion is usually undisturbed because of the

splinting action of the 2 capsules
• Immobilize for 3-4weeks
• Commence physiotherapy immediately after removing
the fixation device
• Long tem jaw exercise
 Management of condylar fracture
(Adults – bilateral extracapsular)

• Difficulty in management is due to shortening of the ramus,

gaging of occlusion and anterior open bite
• Immobilize for 4-6weeks using MMF
• MMF may be achieved using arch bars/ cap splints with
hooks and elastics
• Open reduction and internal fixation on one side only and
monitor closely
• Open reduction and internal fixation on both sides
 Management of condylar fracture
(Adults – bilateral extracapsular)

• Complications of open reduction

• Facial nerve paralysis (lower motor neuron)
• Frey’s syndrome
• Ankylosis if active jaw exercise is not instituted early
• Parotid fistula formation
• Incisions for open reduction
• Pre auricular Intraoral
• Post auricular Retromandibular
• Submandibular Temporal
• Endural
 Post operative care

• Important in patients who had surgical manipulation of

structures in and around the airway especially under general
anaesthesia
• Post operative management could be divided into 3
• Immediate – when patient is recovering from anaethesia
• Intermediate – before clinical bony union is achieved
• Late – involves the removal of the fixation devices, bite
rehabilitation and mobilization of the TMJ
 Post operative care - immediate

• Patient is transferred to the ICU or HDU where an

experienced nurse monitors the BP, pulse rate,
respiratory rate and urinary output every 15 mins until
patient is stable
• Ensure efficient suction machine to toilet the oral cavity
• Adequate lightening
• Wire cutters and scissors must be kept at the patient
bedside this to remove tie wires and elastic bands in
case of respiratory distress
• Tongue stitch is reserved for unconscious patient.
 Post operative care – intermediate (cont)
• General supervision – patient should be reviewed twice daily
(morning and evening), check vital signs, urinary output and
occlusion
• Posture of the patient – patient should be encouraged to sit
up unless there is an associated vertebrae injury.
Unconscious patient should be placed in the left lateral
position to allow for drainage of oral secretion
• Sedation – mild analgesia should be used post operatively.
Use of narcotics should be discouraged because of
respiratory and cough reflex depression
 Post operative care – intermediate (cont)

• Control of infection – important to give antibiotics

prophylactically in cases of compound fracture or missile
injury
• Feeding - conscious patient should start with semi solid food,
2000-2500calories per day rich in protein, vitamins and iron.
Straw feeing should be encouraged
• In the unconscious patient – nurse feeding will be required, NG tube
and PEG may be indicated
• Oral hygiene – warm saline mouth wash 10times daily,
normal oral hygiene measures as tolerated. 0.2%
chlorhexidine gluconate mouth wash to reduce bacterial load
• Petroleum jelly should be applied on the lip to prevent drying
 Post operative care - late
• Testing of clinical union and removal of fixation devices:
remove tie wires after period of immobilization, compare
immediate post op radiograph with recent radiograph to
assess extent of bone deposition
• Removal of plate is only necessary if there is infection,
plate become exposed, plate becomes palpable under the
mucosa or patient’s preference,
• Occlusal adjustment may be necessary especially if cap
splint was used.
• Mobilization of the TMJ: to rehabilitate the joint and
muscles
 Complications of mandibular fracture
management
• At initial management • Late complications
• Infection • Malunion
• Nerve damage • Nonunion
• Malocclusion
• Delayed union
• Trismus
• Osteomyelitis
• Cosmetic comprom
• Unacceptable scar
• Avulsed, displaced and mobile
teeth • TMJ derangement
• Periodontal and gingival
complications
• Foreign body reaction
• Pulpal necrosis
 References

• Banks P & Brown A. (2002): Fractures of the facial skeleton.

• Bagheri SC et al. (2012): Current therapy in Oral and Maxillofacial
Surgery.
• Blitz M & Notarnicola K. (2009): Closed Reduction of the Mandibular
Fracture. Atlas Oral Maxillofacial Surg Clin N Am, 17 (1), pp.1–13.
• Booth PW et al. (2007): Maxillofacial Surgery.
• Glazer M et al. (2010): Mandibular fractures in children: Analysis of
61 cases and review of the literature. Int J Ped Otorhinolaryngol, 75
(1), pp.8–10.
• Kushner GM & Tiwana PS. (2009): Fractures of the Growing
Mandible. Atlas Oral Maxillofacial Surg Clin N Am, 17 (1), pp.81–91.
• Lars Andersson et al. (2010): Oral and Maxillofacial Surgery
• Miloro M. (2006): Peterson's Principles of Oral and Maxillofacial
Surgery 2nd ed.
• Neelima A M. (2008): Textbook of Oral and Maxillofacial