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1. 1
Maxillofacial Trauma
Management of Mandibular Fractures
Mandible is embryologically a membrane bent bone although,
resembles physically long bone it has two articular cartilages
with two nutrient arteries

2. 2
Mandible in trauma
Mandibular fracture is more common than middle
third fracture (anatomical factor)
It could be observed either alone or in combination
with other facial fractures
Minor mandibular fracture may be associated with
head injury owing to the cranio-mandibular
articulation
Mandibular fracture may compromise the patency of
the airway in particular with loss of consciousness
Fracture of mandible occurred with frontal impact
force as low as 425 lb (190 Kg) {Condylar fracture}

3. 3
Fracture of condyle regarded as a safety mechanism
to the patient
Frontal force of 800-900 lb (350-400 Kg) is required
to cause symphesial fracture
Mandible was more sensitive to lateral impact than
frontal one
Frontal impact is substantially cushioned by opening
and retrusion of the jaw
(Nahum 1975)
Long canine tooth and partially erupted wisdoms
represent line of relatively weakness

4. 4
Anatomical considerations
Attached muscles:
Masseter
Temporalis
Medial and lateral
pterygoid
Mylohyoid
Geniohyoid and
genioglosus
anterior belly of
digastrics

5. 5
Blood supply
Endosteal supply via the ID artery
and vein
Periosteal supply, important in
aging due to diminishes and
disappearance of alveolar artery
Bradley 1972
Nerve
Damage of inferior dental nerve
Facial palsy by direct trauma to
ramus
Damage of facial nerve in temporal
bone fracture
Goin 1980
Damage to mandibular division of
facial nerve

6. 6
Factors influenced site of fracture
and displacement
Anatomy of the
mandible and attached
muscle (canine &
wisdoms)
Weakening areas of
mandible (resorption
and pathologyl)
Direction of force of the
blow
Age of the patient

7. 7
Types of fracture
Simple
Greenstick fracture (rare,
exclusively in children)
Fracture with no displacement
(Linear)
Fracture with minimal
displacement
Displaced fracture
Comminuted fracture
Extensive breakage with possible bone
and soft tissue loss
Compound fracture
Severe and tooth bearing area fractures
Pathological fracture
(osteomyelities, neoplasm and
generalized skeletal disease)

8. 8
Sites of fractures
Condyle fracture
– Intracapsular fracture
– Extracapsular fracture
High condyle neck fracture
Low condylar fracture
Angle/ ramus fracture (body
fracture)
Canine region (parasymphesial
fracture)
Midline fracture (symphesis
fracture)
Coronoid fracture (rare)

9. Mandible Fracture Frequency
Condyle 30%
Ramus 3%
Angle 25%
Body 25% Parasymphyseal /
Mental 15%
Coronoid process 2%

10. 10
Favourable or unfavourable
They can be vertically or horizontally in
direction
They are influenced by the medial pterygoid-
masseter “sling”
If the vertical direction of the fracture favours the
unopposed action of medial pterygoid muscle, the
posterior fragment will be pulled lingually
If the horizontal direction of the fracture favours the
unopposed action of messeter and pterygoid muscles in
upward direction, the posterior fragment will be pulled
lingually
Favourable fracture line makes the reduced
fragment easier to stabilize

11. 11
Effects of muscles on displacement
Transverse midline fracture (symphesial)
stabilizes by the action of mylohyoid and
geniohyoid
Oblique fracture (parasymphesial) tends to
overlap under the influence of muscles action
Bilateral parasymphesial fracture results in
backward displacement associated with loss of
tongue control when the level of consciousness
is depressed

12. 12
Condylar fractures
The most common mandibular fracture
Unilateral or bilateral
Intracapsular or extracapsular
Antero-medial displacement is
common but it may remain
angulated with the ramus
Dislocation of the glenoid fossa and
fracture of petrous temporal bone
which is very rare

13. 13
Sign and symptoms
Swelling, pain, tenderness and restriction of movement
Deviation of mandible towards the side of fracture
Gagging of occlussion (premature contact on the posterior
teeth) with bilateral condylar displaced or over-riding fractures
Displacement of mandible toward the affected side
Anterior open bite on opposite side of fracture
Laceration of EAM****
Retroauricular ecchymosis****
Cerebrospinal leak and otorrhea in association with skull base
fracture
Condylar fractures

14. 14
Sequlae of TMJ injury
Artheritic changes
Haemartherosis, fibrosis and aknylosis
Meniscal damage and detachment
TMD
Staph infection with condylar backward
displacement and external auditory meatus injury
Meningitis with petrous temporal bone fracture and
intracranial involvement
Condylar fractures

15. 15
Coronoid process fracture:
Rare fracture caused by direct trauma to
ramus and results from reflux contraction of
temporalis
Can be seen following operation of large
ramus cyst
Elicit tenderness over the anterior part of
ramus
Development of tell-tale haematoma

16. 16
Fracture of the ramus:
Type I Single fracture
Mimics low condylar fracture that runs
below the sigmoid notch
Type II comminuted fracture
Common in missile injuries and appears to
be with little displacement due to effects of
messeter and medial pterygoid muscles

17. 17
Fracture of the angle and body
Pain, tenderness and trismus
Extra-oral swelling at the angle with obvious
deformity
Step deformity behind the molar teeth
Movement and crepitus at the fracture site
Derangement of occlussion
Intra-oral buccal and lingula heamatoma
Involvement of IDN
Gingival tear if fracture in dentated area
Tooth involvement and possible longitudinal
split fracture

18. 18
Midline fracture
The most common missed fracture (always
fine crack)
Can be symphesial or parasymphesial
fracture
Commonly associated with one or both
condyles fracture
Unilateral fracture leads to over-riding of
the fragments and bilateral may contribute
in loss of voluntery tongue control
Long canine tooth represent a weak area
and contributes to parasymphesial fracture
Rarely runs across mental foramen

19. 19
Signs and symptoms
Pain and tenderness
Swelling and odemea
Development of step deformity
Mental anesthesia
Heamatoma in the floor of mouth and buccal mucosa
Soft tissue injury of the chin and lower lip
If associated with condylar fractures
Absence of condyle movement on the contrlateral side
Deviation of mandible
Anterior open bite
Gagging of oclussion
Limitation of mouth opening
Midline fracture

20. 20
Clinical assessment and diagnosis
History of trauma
(traumatized patients with possible head injury) and facial
injuries
Clinical Examination
▶ Extroral
Inspection (assessment of asymmetery, swelling, ecchymosis, laceration
and cut wounds)
Palpation for eliction of tenderness, pain, step deformity and malfunction
▶ Intra- and paraoral
bleeding, heamatoma, gingival tear, gagging of occlussion
and step deformity and sensory and motor deficiency
Radiographs

21. 21
Radiographs
Plain radiograph
OPG
Lateral oblique
PA mandible
AP mandible (reverse
Townes)
Lower occlusal
CT scan
3-D CT imaging
MRI

22. 22
Principles of treatment
similar to elsewhere fractures in the body
Reduction of fragments in good position
Immobilization until bony union occurs
These are achieved by:
Close reduction and immobilization
Open reduction and rigid fixation
Other objective of mandible fracture treatment:
Control of bleeding
Control of infection

23. 23
Definitive treatment
Soft tissue repair
Debridment
Irrigation with saline and antibiotics
Closure in layers
Dressing
Reduction and fixation of the jaw
▶ Close reduction and IMF (traditional method by means of
manipulation)
▶ Open reduction and semi-rigid fixation (using inter-ossous
wirings)
▶ Open reduction and rigid fixation (using bone palates
osteosynthesis)
Objective:
Restoration of functional alignment of the bone fragments in
anatomically precise position utilizing the present teeth for
guidance

24. 24
Close reduction
Arch bars
– Jelenko
– Erich pattern
– German silver notched
Cap splints
MMF Screw
▶ IMF/MMF prior to rigid
fixation
▶ For the purpose of close
reduction

25. 25
Close reduction
Bonded brackets
IMF/MMF screws (Quick-Fix)
Dental wiring:
Direct wiring
Eyelet wiring
Local anesthesia or sedation
Minimal displacement
IMF/MMF (Quick-Fix) for 6 weeks
Treatment can be performed under GA or LA and
when surgery is contraindicated

26. Archbar vs MMF Screw (Quick-Fix)
Archbar
 Less Convenience
Patients
Require teeth for fixation
Damage teeth and periodontal
tissue
Uncomfortable during the fixation
period
Difficult daily maintenance of oral
hygiene
Operator
Risk of blood-transmitted diseases
Need longer time to use
MMF Screw (Quick-Fix)
The Easy Alternative to
Arch Bars
Patented Auto-Drive self drilling
screws
Dramatically reduces application
time of MMF (only 5 minutes)
Simple
Minimizes risk of wire puncture
wound
Better oral hygiene maintenance
Ideal for edentulous or partially
edentulous

27. 27
Fracture mandible in children
Close reduction
Open reduction and
fixation
Plating at the inferior
border
Biodegradable plate
and screw

28. 28
Open Reduction and Fixation System
Intraoral approach
Extraoral approach
▶ Submandibular
approach

29. 29
Rigid Fixation System
Intraossous wiring
Plates and screws
2.0mm and 2.4mm
– Standard plate and
screw
– Locking plate and
screw
Kirchener wire
Lag screws

30. Plate 2.0mm and 2.4mm
30

31. 31
Reconstruction palate
Severe trauma
Loss of part of the bone

32. Recon: TCA
Temporary Condyle Attachment (TCA)
– Oncology/Ablation cases only
– Maximum implantation of 1 year
– Only OsteoMed Medically Tracked Device
3 Forms
– No Left/Right
– Unique Anatomical Shape
– Adjustable

33. Reconstruction Locking Plate

34. Recon: Instruments
Instrumentation
– Lag screw cannula and
depth gauge
Tip of gauge will
point to drill exit
point
Length of screw
needed to engage
both cortices
The measurement
directly above the
drill entry point will
state needed length

35. Recon: Instrumentation

36. Recon: Instrumentation
Instrumentation
– Fx plate bending pliers
– Roller benders
Used for major contours
Bends in the saggital and lateral
plane
– Reconstruction bending pliers
For intermediate bending
– Bending irons
Bending slot in the tip
Finishing bends
Unusual or tight bends

37. Rigid Fixation System
Instrumentation
– Fracture plate benders

38. Rigid Fixation System
Instrumentation
– Taperlocktm
screwdriver body
– Modular for all the
drivers stems, taps
and countersinks

39. Rigid Fixation System
Instrumentation
– Calibrated plate
benders
– Calibrated “tick” marks
to estimate step range
for “L” and Zed plates

40. Rigid Fixation System
Instrumentation
– 3 prong plate benders
Used with 10 and 16
hole plates to bend in
the saggital plane

41. Rigid Fixation System
Instrumentation
– Right angle plate
benders
Places 90 degree angle
bends in plates
Used with “L” and Zed
plates for LeFort 1
osteotomies

42. Rigid Fixation System
Cannula/Trocar
– Trocar is used to
penetrate soft tissue

43. Rigid Fixation System
Cannula/Cheek
retractor
Cannula/Drill guide

44. Rigid Fixation System
Instrumentation
– Cheek Retractor “U”
Shape
– Cheek Retractor
– Cannula
– Neutral Drill Guide

45. Rigid Fixation System
Instrumentation
– Cannula/Depth gauge
Determines what size
screw needs to be used

46. 46
Condylar fractures
Intraoral approach
Ramus incision
Extraoral approach
Preauricular approach
Retromandibular approach

47. 47
IMF/MMF
Transosseous wiring
Circumferential wiring
External pin fixation
Bone clamps
Trans-fixation with Kirschner wires
Maxillo Mandibular Fixation Screw (Quick-Fix)

48. 48
Osteosynthesis
Non-compression small plates
Compression plates
Mini plates (2.0mm and 2.4mm)
Lag screws
Biodegradable plates and screws

49. 49
Teeth in the fracture line
The fracture is compound into the mouth
The tooth may be damaged or lose its
blood supply
The tooth may be affected by some
preexisting pathology

50. 50
Management of teeth retained in fracture
line
Good quality intra-oral periapical radiograph
Insinuation of appropriate systemic antibiotic
therapy
Splinting of tooth if mobile
Endodontic therapy if pulp is exposed
Immediate extraction if fracture becomes
infected
Follow up for 1 year and endodontic therapy if
there is a loss of vitality

51. 51
Absolute indications
Longitudinal fracture
Dislocation or subluxation from socket
Presence of periapical infection
Infected fracture line
Acute pericoronitis
Relative indications
Functional tooth that would be removed
Advanced caries or periodontal diseases
Doubtful tooth which would be added to existing
denture
Tooth in untreated fracture presenting more than 3
days after injury

52. Complications
Airway esp with IMF (wire cutters and pre-op education)
Infection
Delayed and non-union
– Inadequate immobilisation, fracture alignment
– Inteposition of soft tissue or foreign body
– Incorrect technique
Inferoir alveolar nerve damage
– 56%pre-treatment
– 19% post-treatment
Malocclusion
TMJ ankylosis esp intracapsular condyle #
52

53. 53