Mandible Fractures

Mandible Fractures
Dr. ERNESTO CARMONA

MAXILLOFACIAL SPECIALIST
Epidemiology
• Mandible most common after nasal

fractures
• Mandible : Zygoma : Maxilla 6:2:1
• Ellis 4711 facial fractures, 45% with
mandible fractures
• Assault>MVA>Fall>Sports
Epidemiology
• Sites of weakness
– Third molar (esp. impacted)
– Socket of canine tooth
– Condylar neck
Epidemiology
• Boole et al (laryngoscope) 5196 fractures

– Young military men
– Angle 35%, Symphysis 20%, Body 12%,
Condylar 9%, Subcondylar 4%, Ramus 4%,
Alveolar 3%, Coronoid 1%
– 70% 1 fracture, 30% 2 fractures, .2% more
than 2
– Facial lacs 30%, other facial fx. 16%, C-spine
0.8%
Haug et al
Fischer et al
Favorable vs. Unfavorable
• Masseter, Medial and Lateral Pterygoid,

and Temporalis tend to draw fractures
medial and superior
• Almost all fractures of angle unfavorable
Evaluation
• Stabilization via ATLS protocol

• Part of secondary survey
– Pain, malocclusion, trismus, V3 sensory deficit
– History of TMJ (earlier mobilization)
– Blow to face favors parasymphyseal fracture
and contralateral angle fracture
– Fall to chin (bilateral condylar fractures)
Evaluation
• Previous occlusion (Class I-III)

• Psychiatric, nutritional, gastrointestinal,
seizure disorders
• Previous facial trauma
• Other injuries (c-spine, intra-abdominal,
likely prolonged intubation)
Physical Exam
• Complete Head and Neck exam

– Palpable step off
– Tenderness to palpation
– Malocclusion
– Trismus (35 mm or less)
– FOM hematoma
– Altered sensation of V3
– Crepitus
Physical Exam
• Dental Exam
– Lost, fractured, or unstable teeth
– Dental Health
– Relation to fracture
– Quantity
Physical Exam
• Unilateral fractures of Condyle

– Decreased translational movement, functional
height of condyle
– Deviation of chin away from fracture, open
bite opposite side of fracture
Bilateral fractures of condyle
- Anterior open bite
Picture of open bites
Evaluation
• Panorex, mandible series

• CT scan
– Not as diagnostic as plain films for
nondisplaced fractures of mandible.
– Most useful for coronoid and condylar
fractures, associated midface fractures
Physiology
• Primary Healing
– In rigid fixation techniques
– Lag screws, compression plates, Recon plate,
external fixation, Wire fixation, Miniplate
fixation
– No callus formation
– Question of bone resorption
Physiology
• Secondary bone healing

– Callus formation
– Remodeling and strengthening
– MMF, Wire fixation, Miniplate fixation
Closed Reduction
• Favorable, non-displaced fractures

• Grossly comminuted fractures when
adequate stabilization unlikely
• Severely atrophic edentulous mandible
• Children with developing dentition
Closed Reduction
• Length of MMF
– De Amaratuga – 75% of children under 15
healed by 2 weeks, 75% young adults 4 wks
– Juniper and Awty – 82% had healed at 4 wks
– Longer period for edentulous fractures 6-
10wks
Closed Reduction
• Edentulous fractures
– Bradley found absent inferior alveolar artery
in 40% 60-80 yo’s
– Periosteal blood supply disturbed by stripping
– Up to 20% non-union despite type of
treatment
– May consider Gunning Splints
Open Reduction
• Displaced unfavorable fractures

• Mandible fractures with associated
midface fractures
• When MMF contraindicated or not possible
• Patient comfort
• Facilitate return to work
Open Reduction
• Contraindications
– General Anesthetic risk too high
– Severe comminution and stabilization not
possible
– No soft tissue to cover fracture site
– Bone at fracture site diffusely infected
(controversial)
Open Reduction
• Associated condylar fracture

• Associated Midface fractures
• Psychiatric illness
• GI disorders involving severe N/V
• Severe malnutrition
• To avoid tracheostomy in patients who
need postoperative intubation
Open Reduction
• Intraosseous wiring
– Semirigid fixation
– Cheap
– Technically difficult
– Primary and Secondary bone healing
Open Reduction
• Lag Screws
– Rigid fixation (Compression)
– Good for anterior mandible fractures, Oblique
body fractures, mandible angle fractures
– Cheap
– Technically difficult
– Injury to inferior alveolar neurovascular
bundle
Open reduction
• Ellis 41 patients with anterior lag screw

technique
• 4.9% infection rate
• No malocclusion
• No Non-union
Lag Screw Technique
Lag Screw Technique
Lag Screw Technique
Rigid Fixation
• Compression plates
– Rigid fixation
– Allow primary bone healing
– Difficult to bend
– Operator dependent
– No need for MMF
Rigid Fixation
• Miniplates
– Semi-rigid fixation
– Allows primary and secondary bone healing
– Easily bendable
– More forgiving
– Short period MMF Recommended
Rigid Fixation
• Schierle et al studied experimental model,

then applied in patients.
– Model suggested two plates more stable
– Patients divided into two groups with equal
complication rates, equal functional results
Miniplates, Champy technique
Rigid Fixation
• Reconstruction Plates
– Good for comminuted fractures
– Bulky, palpable
– Difficult to bend
– Locking plates more forgiving
External Fixation
• Alternative form of rigid fixation

• Grossly comminuted fractures,
contaminated fractures, non-union
• Often used when all else fails
Edentulous Fractures
• Chalmers and Lyons 1976 –

Recommended closed reduction to
preserve periosteal blood supply
• Chalmers and Lyons 1995
– 167 fractures in edentulous mandibles
– ORIF 82%
– 15% complications
– 12% Fibrous union
Edentulous Fractures
• ORIF
– Inferior alveolar canal more superior in
location
– Vertical height 20mm compatible with
standard plating systems
– Vertical height 10mm or less, likely need rib
graft
– Plate removal after fracture healing if
interferes with denture placement
Teeth in line of fracture
• Keep teeth if
– Previously healthy
– Peridontal plexus intact
– No major structural injury
– Tooth does not interfere with reduction of
fracture
• Neal and associates

– 32% incidence of morbidity with teeth in line
of fracture
– No statistical difference if tooth was removed
• Amaratunga
– 16% complication rate in retained teeth
– 13% in removed teeth
– Retain teeth for 4-6 weeks if important for
MMF
Condylar and Subcondylar
• Lindhal and Hollender

– Closed reduction in children, teens, adults
– Intracapsular fractures
– Higher incidence of postoperative sequelae in
adults
– Children and Teens with less sequelae, more
remodeling
• Norholt
– Children 5-20 with intracapsular condylar
fractures
– Increased dysfunction with increasing age
• Closed reduction with arch bars MMF 2-3

weeks mainstay for youths
– Ankylosis of TMJ and facial asymmetry most
feared complication
– Less effective for
• increasing age
• decreased ramus height
• more displaced
• ORIF, Absolute indications

– Displacement into middle cranial fossa
– Inability to achieve occlusion with closed
reduction
– Foreign body in joint space
• Relative indications
– Bilateral condylar fractures to preserve
vertical height
– Associated injuries that dictate earlier function
• Soft tissue swelling causing airway compromise
with MMF
• Intracapsular fracture on opposite side where early
mobilization important
Immediate Mobilization
• Kaplan et al.
– Studied ORIF in two groups, one with MMF for
2 weeks, one with immediate mobilization
– No statistical difference in rates of
complications, postoperative pain, dental
health, nutritional status
Bioabsorbable Plates
• Plating can relieve stress, no bone remodeling

• Bulky plates, thermal sensitivity, palpable
• Absorbable plates expensive
• Better in children?
• Use of poly-L-lactide in 69 fractures by Kim et al
– 12% complication
– 8% infection
– No malunion
References
Kim et al “Treatment of Mandible Fractures using Bioabsorbable plates”, Plastic and Reconstructive Surgery, vol 110, july
2002, 25-31
Bailey, Byron J. Head and Neck Surgery - OtolaryngologyThird Edition. Lippincott Williams and Wilkins, 2001.
Ellis, E. “Treatment Methods for Fractures of the Mandibular Angle." Journal of Craniomaxillofacial Trauma, vol. 28. 1999:
243-252.
Ellis, E., et. al. “Lag Screw Fixation of Mandibular Angle Fractures.” Journal of Oral Maxillofacial Surgery , vol. 49. 1991:
234-243.
Kim et. al. "Treatment of Mandible Fractures Using Bioabsorable Plates." Journal of Plastic and Reconstructive Surgery , vol.
110. 2002: 25-31.
Boole et. al. "5196 Mandible Fractures Among 4381 Active Duty Army Soldiers, 1980 to 1998." Laryngoscope, 111(10). Oct.
2001: 1691-6,
Kaplan et al. "Immediate Mobilization Following Fixation of Mandible Fractures, A Prospective Randomized Study."
Laryngoscope, vol. 111(9). Sept 2001: 1520-1524
Spina and Marciani. Mandibular Fractures, pages 85 - 105
Schierle et. al. "One or Two Plate Fixation of Mandible Fractures?" Journal of Cranio-Maxillofacial Surgery . Vol. 25, 1997:
162-168.

Mandible Fractures

Uploaded by

Copyright:

Available Formats

Mandible Fractures

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Mandible Fractures

Uploaded by

Copyright:

Available Formats

Mandible Fractures

Dr. ERNESTO CARMONA

• Mandible most common after nasal

• Boole et al (laryngoscope) 5196 fractures

• Masseter, Medial and Lateral Pterygoid,

• Stabilization via ATLS protocol

• Previous occlusion (Class I-III)

• Complete Head and Neck exam

• Unilateral fractures of Condyle

• Panorex, mandible series

• Secondary bone healing

• Favorable, non-displaced fractures

• Displaced unfavorable fractures

• Associated condylar fracture

• Ellis 41 patients with anterior lag screw

• Schierle et al studied experimental model,

• Alternative form of rigid fixation

• Chalmers and Lyons 1976 –

• Neal and associates

• Lindhal and Hollender

• Closed reduction with arch bars MMF 2-3

• ORIF, Absolute indications

• Plating can relieve stress, no bone remodeling

Spina and Marciani. Mandibular Fractures, pages 85 - 105

You might also like