THE MANDIBLE

The human mandible has no one design for life. Rather, it adapts and
remodels through the seven stages of life, from the slim arbiter of things to
come in the infant, through a powerful dentate machine and even weapon in
the full flesh of maturity, to the pencil-thin, porcelain-like problem that we
struggle to repair in the adversity of old age.
D.E. Poswillo 1988
The cartilages and bones of the mandibular skeleton form from
embryonic neural crest cells that originated in the mid and hindbrain regions
of the neural folds. These cells migrate ventrally to form the mandibular
(and maxillary) facial prominences, where they differentiate into bones and
connective tissues.
The first structure to develop in the region of the lower jaw is the
mandibular

division

of

the

trigeminal

nerve

that

precedes

the

ectomesencymal condensation forming the first (mandibular) branchial arch.

The prior presence of the nerve has been postulated as requisite for inducing
osteogenesis by the production of neurotrophic factors. The mandible is
derived from ossification of an osteogenic membrane formed from
ectomesencymal condensation at 36-38 days of development. This
mandibular ectomesenchyme must interact initially with the epithelium of
the mandibular arch, before primary ossification can occur; the resulting
intramembranous bone lies lateral to Meckels cartilage of the first
(mandibular) branchial arch. A single ossification center for each half of the
mandible arises in the 6th week i.u. (The mandible and the clavicle are the

first bones to begin to ossify) in the region of the bifurcation of the inferior
alveolar nerve and artery into mental and incisive branches. The ossifying
membrane is lateral to Meckels cartilage and its accompanying
neurovascular bundle. Ossification spreads from the primary centre below
and around the inferior alveolar nerve and its incisive branch, and upwards
to form a trough for the developing teeth. Spread of the intramembranous
ossification dorsally and ventrally forms the body and ramus of the
mandible. Meckels cartilage becomes surrounded and invaded by bone.
Ossification stops dorsally at the site that will become the mandibular
lingula, from where Meckels cartilage continues into the middle ear. The
prior presence of the neurovascular bundle ensures formation of the
mandibular foramen and canal and the mental foramen.
The first branchial arch core of Meckels cartilage almost meets its
fellow of the opposite side ventrally. It diverges dorsally to end in the
tympanic cavity of each middle ear, which is derived from the first
pharyngeal pouch, and is surrounded by the forming petrous portion of the
temporal bone. The dorsal end of Meckels cartilage ossifies to form the
basis of two of the auditory ossicles, viz. the malleus and incus. The third
ossicle, the stapes, is derived primarily from the cartilage of the second
branchial arch.
Almost all of Meckels cartilage disappears (Meckels cartilage lacks
the enzyme phosphatase found in ossifying cartilages, thus precluding its
ossification, and disappears by the 24th week i.u.). Parts transform into the
sphenomandibular and anterior malleolar ligaments. A small part of its
ventral end (from the mental foramen ventrally to the symphysis) forms
accessory endochondral ossicles that are incorporated into the chin region of
the mandible. Meckels cartilage dorsal to the mental foramen undergoes

resorption on its lateral surface at the same time, as intramembranous bony

trabeculae are forming immediately lateral to the resorbing cartilage. Thus,
the cartilage from the mental foramen to the lingula is not incorporated into
ossification of the mandible.
The initial woven bone formed along Meckels cartilage is soon
replaced by lamellar bone, and typical haversian systems are already present
at the 5th month i.u. This earlier remodeling than other bones is attributed as
a response to the early intense sucking and swallowing which stress the
mandible.
Secondary accessory cartilages appear between the 10th and 14th
weeks of i.u to form the head of the condyle, part of the coronoid process,
and the mental protuberance. The appearance of these secondary mandibular
cartilages is dissociated from the primary branchial (Meckels) and
chondrocranial cartilages. The secondary cartilage of the coronoid process
develops within the temporalis muscle as its predecessor. The coronoid
accessory

cartilage

becomes

incorporated

into

the

expanding

intramembranous bone of the ramus and disappears before birth. In the

mental region, on either side of the symphysis, one or two small cartilages
appear and ossify in the 7th month i.u. to form a variable number of mental
ossicles in the fibrous tissue of the symphysis. The ossicles become
incorporated into the intramembranous bone when the symphysis menti is
converted from a syndesmosis into a synostosis during the first postnatal
year.
The condylar secondary cartilage appears during the 10th week i.u. as
a cone shaped structure in the ramal region. This condylar cartilage is the
primordium of the future condyle. Cartilage cells differentiate from its
centre, and the cartilage condylar head increases by interstitial and

appositional growth. By the 14th week, the first evidence of endochondral

bone appears in the condyle region. The condylar cartilage serves as an
important centre of growth (The nature of this growth, as primary (an initial
source of morphogenesis) or secondary (compensating for functional
stimulation), is controversial, but experimental evidence indicates the need
for mechanical stimuli for normal growth) for the ramus and body of the
mandible. Much of the cone shaped cartilage is replaced with bone by the
middle of fetal life; but its upper end persists into adulthood, acting as both a
growth cartilage and an articular cartilage. Changes in mandibular position
and form are related to the direction and amount of condylar growth. The
condylar growth rate increases at puberty, peaks between 12 1/2 and 14 years
of age, and normally ceases at about 20 years. However, the continuing
presence of the cartilage provides a potential for continued growth, which is
realized in conditions of abnormal growth such as acromegaly.
The shape and size of the diminutive fetal mandible undergo
considerable transformation during its growth and development. The
ascending ramus of the neonatal mandible is low and wide; the coronoid
process is relatively large and projects well above the condyle; the body is
merely an open shell containing the buds and partial crowns of the
deciduous teeth; the mandibular canal runs low in the body. The initial
separation of the right and left bodies of the mandible at the midline
symphysis menti is gradually eliminated between the 4th and 12th months
postnatally, when ossification converts the syndesmosis into a synostosis,
uniting the two halves.
Although the mandible appears in the adult as a single bone, it is
developmentally and functionally divisible into several skeletal subunits.
The basal bone of the body forms one unit, to which are attached the

alveolar, coronoid, angular and condylar processes and the chin. Each of
these skeletal subunits is influenced in its growth pattern by a functional
matrix that acts upon the bone: the teeth act as a functional matrix for the
alveolar unit; the action of the temporalis muscles influences the coronoid
process; the masseter and medial pterygoid muscles act upon the angle and
ramus of the mandible; and the lateral pterygoid has some influence on the
condylar process. The functioning of the related tongue and perioral
muscles, and the expansion of the oral and pharyngeal cavities, provide
stimuli for mandibular growth to reach its full potential. Of the facial bones,
the mandible undergoes the most growth postnatally and evidences the
greatest variation in morphology.
Limited growth takes place at the symphysis menti until fusion
occurs. The main sites of postnatal mandibular growth are at the condylar
cartilages, the posterior borders of the rami, and the alveolar ridges. These
areas of bone deposition account grossly for increases in the height, length
and width of the mandible. However, superimposed upon this basic
incremental growth are numerous regional remodeling changes, subjected to
the local functional influences that involve selective resorption and
displacement of individual mandibular elements.
The condylar cartilage of the mandible serves the uniquely dual roles
of an articular cartilage in the temporomandibular joint, characterized by a
fibro cartilage surface layer, and as a growth cartilage analogous to the
epiphyseal plate in a long bone, characterized by a deeper hypertrophying
cartilage layer. The subarticular appositional proliferation of cartilage within
the condylar head provides the basis for growth of a medullary core of
endochondral bone, on whose outer surface a cortex of intramembranous
bone is laid. The growth cartilage may act as a functional matrix to stretch

the

periosteum,

inducing

the

lengthened

periosteum

to

form

intramembranous bone beneath it. The diverse histological origins of the

medulla and cortex are effaced by their fusion. The formation of bone within
the condylar heads causes the mandibular rami to grow upward and
backward, displacing the entire mandible in an opposite downward, forward
direction. Bone resorption subjacent to the condylar head accounts for the
narrowed condylar neck. The attachment of the lateral pterygoid muscle to
this neck, and the growth and action of the tongue and masticatory muscles,
are functional forces implicated in this phase of mandibular growth.
Any damage to the condylar cartilages restricts the growth potential
and normal downward and forward displacement of the mandible,
unilaterally or bilaterally, according to the side(s) damaged. Lateral
deviations of the mandible, and varying degrees of micrognathia and
accompanying malocclusion result.
In the infant, the condyles of the mandible are inclined almost
horizontally, so that condylar growth leads to an increase in the length of the
mandible, rather than increase in height. Due to the posterior divergence of
the two halves of the body of the mandible (in a V shape), growth at the
condylar heads of the increasingly more widely displaced rami results in
overall widening of the mandibular body, which, with remodeling, keeps
pace with the widening cranial base. No interstitial widening of the mandible
can take place at the fused symphysis menti after the first year, apart from
some widening by surface apposition.
Bone deposition occurs on the posterior border of the ramus, while
concomitant resorption on the anterior border maintains the proportions of
the ramus, and in effect, moves it backwards in relation to the body of the
mandible. This deposition resorption extends up to the coronoid process,

involving the mandibular notch, and progressively repositions the

mandibular foramen posteriorly, accounting for the anterior overlying plate
of the lingula. The attachment of the elevating muscles of mastication to the
buccal and lingual aspects of the ramus, and to the mandibular angle and
coronoid process influences the ultimate size and proportions of these
mandibular elements.
The posterior displacement of the ramus converts former ramal bone
into the posterior part of the body of the mandible. In this manner, the body
of the mandible lengthens, the posterior molar region relocating anteriorly
into the premolar and canine regions. This is one means by which additional
space is provided for eruption of the molar teeth, all three of which originate
in the ramus body junction. Their forward migration and posterior ramal
displacement lengthen the molar region of the mandible.
The forward shift of the growing mandibular body changes the
direction of the mental foramen during infancy and childhood. The mental
neurovascular bundle emanates from the mandible at right angles or even a
slightly forward direction at birth. In adulthood the mental foramen (and its
neurovascular content) is characteristically directed backward. This change
may be ascribed to forward growth in the body of the mandible, while the
neurovascular bundle drags along. A contributory factor may be the
differential rates of bone and periosteal growth. The latter, by its firm
attachment to the condyle and comparatively loose attachment to the
mandibular body, grows more slowly than the body, which slides forward
beneath the periosteum. The changing direction of the foramen has clinical
implications in the administration of local anaesthetic to the mental nerve: in
infancy and childhood, the syringe needle may be applied at right angles to

the body of the mandible to enter the mental foramen, whereas in the adult
the needle has to be applied obliquely from behind to achieve entry.
The location of the mental foramen also alters its vertical relationship
within the body of the mandible from infancy to old age. When teeth are
present the mental foramen is located midway between the upper and lower
borders of the mandible. In the edentulous mandible, lacking an alveolar
ridge, the mental foramen appears near the upper margin of the thinned
mandible.
The alveolar process develops as a protective trough in response to the
tooth buds, and becomes superimposed upon the basal bone of the
mandibular body. It adds to the height and thickness of the body of the
mandible, and is particularly manifest as a ledge extending lingually to the
ramus to accommodate the third molars. The alveolar bone fails to develop if
teeth are absent, and resorbs in responses to tooth extraction. The
orthodontic movement of teeth takes place in the labile alveolar bone, of
both maxilla and mandible, and fails to involve the underlying basal bone.
The chin, formed in part of the mental ossicles from accessory
cartilages and the ventral end of Meckels cartilage, is very poorly developed
in the infant. It develops almost as an independent subunit of the mandible,
influenced by sexual as well as specific genetic factors. Sex differences in
the symphyseal region of the mandible are not significant until other
secondary sex characteristics develop. Thus, the chin becomes significant
only at adolescence from development of the mental Protuberance and
tubercles. Whereas small chins are found in adults of both sexes, very large
chins are characteristically masculine. The skeletal unit of the chin may be
an expression of the functional forces exerted by the lateral pterygoid

muscles that, in pulling the mandible forward, indirectly stress the mental
symphyseal region by their concomitant inward pull. Bone buttressing to
resist muscle stressing, which is more powerful in the male, is expressed in
the more prominent male chin. The protrusive chin is a uniquely human trait,
lacking in all other primates and hominid ancestors.
The mental protuberance forms by osseous deposition during
childhood. Its prominences are accentuated by bone resorption in the
alveolar region above it, creating the supramental concavity known as Point
B in orthodontic terminology. Underdevelopment of the chin is known as
microgenia.
A genetically determined exostosis on the lingual aspect of the body
of the mandible, the torus mandibularis, develops, usually bilaterally, in the
canine premolar region. These tori are unrelated to any muscle attachments
or known functional matrices.
During fetal life the relative sizes of the maxilla and mandible vary
widely. Initially, the mandible is considerably larger than the maxilla, a
predominance lessened later by the relatively greater development of the
maxilla; by about 8 weeks i.u. the maxilla overlaps the mandible. The
subsequent relatively greater growth of the mandible results in
approximately equal size of the upper and lower jaws by the 11th week.
Mandibular growth lags behind maxillary between the 13th and 20th weeks
i.u., due to a change over from Meckels cartilage to condylar secondary
cartilage as the main growth determinant of the lower jaw. At birth, the
mandible tends to be retrognathic to the maxilla, although the two jaws may
be of equal size. This retrognathic condition is normally corrected early in
postnatal life by rapid mandibular growth and forward displacement to
establish orthognathia, or an Angle Class I maxillomandibular relationship.

Inadequate mandibular growth results in an Angle Class II relation, and

overgrowth of the mandible produces a Class III relation. The mandible can
grow for much longer than the maxilla.

Anomalies of development:
The mandible may be grossly deficient or absent in the condition of
agnathia which reflects a deficiency of neutral crest tissue in the lower part
of the face. Aplasia of the mandible and hyoid bone (first and second arch
syndrome) is a rare lethal condition with multiple defects of the orbit and
maxilla. Well developed, albeit low set, ears and auditory ossicles in this
syndrome suggest ischaemic necrosis of the mandible and hyoid bone occurs
after formation of the ear.
Micrognathia, a diminutive mandible is characteristic of several
syndromes, including Pierre Robins and the cat-cry (Cri du chat) syndromes,
mandibulofacial dysostosis (Treacher Collins syndrome), progeria Downs
syndrome (trisomy 21), oculomandibulodyscephaly (the Hallerman-Streiff
syndrome) and Turners syndrome (XO sex-chromosome complement).
A central dysmorphogenic mechanism of defective neural crest
production, migration, or destruction may be responsible for the hypo plastic
mandible common to these conditions. Absent or deficient neural crest tissue
around the optic cup causes a vacuum so that the developing otic pit,
normally adjacent to the second branchial arch, moves cranially into first
arch territory and the ear becomes located over the angle of the mandible.
Derivatives of the deficient ectomesenchyme, specifically the zygomatic,
maxillary and mandibular bones, are hypoplastic, accounting for the typical
facies common to these syndromes.

In Pierre Robins syndrome, the underdeveloped mandible usually

demonstrates catch-up growth in the child; in mandibulofacial dysostosis,
deficiency of the mandible is maintained throughout growth; in unilateral
agenesis of the mandibular ramus, the deformity increases with age. Hemi
facial microsomia (Goldenhars syndrome) also becomes more severe with
retarded growth.
Variations in condylar form may occur, among them the rare bifid or
double condyle that results from the persistence of septa dividing the fetal
condylar cartilage.
Macrognathia, producing prognathism, is usually an inherited
condition, but abnormal growth phenomena such as hyperpituitarism may
produce mandibular overgrowth of increasing severity with age. Congenital
hemifacial hypertrophy, evident at birth, tends to accentuate at puberty.
Unilateral enlargement of the mandible, the mandibular fossa, and the teeth
is of obscure etiology. More common is isolated unilateral condylar
hyperplasia.

ANATOMY
The mandible the largest, strongest and lowest bone in the face, has a
horizontally curved body, convex forward, and two broad rami, ascending
posteriorly.
The mandibular body, somewhat U-shaped, has external and internal
surfaces, separated by upper and lower borders. Anteriorly, the upper
external surface shows a faint median ridge, often absent, indicating fusion
of the halves of the fetal bone (symphysis menti); inferiorly this ridge
divides to enclose a triangular mental protuberance, its base centrally
depressed but raised on each side as mental tubercle. Below the interval

between two premolar teeth, or the second premolar, is the mental foramen,
from which emerge the mental nerve and vessels; its posterior border is
smooth accommodating the dorsolaterally emerging nerve (Warwick 1950).
A faint oblique line ascends backwards from each mental tubercle, sweeps
below the foramen, and then becomes more marked as it continues into the
anterior border of the ramus.
The bodys lower border, the base, extends posterolaterally from the
symphysis in to that of the ramus behind the third molar tooth. Near the
midline, on each side, is a rough digastric fossa, behind which the base is
thick, rounded, with a slight anteroposterior convexity. As the ramus is
approached, this changes to a gentle concavity; thus, in profile, the whole
base is sinuous.
The upper border, the alveolar part, contains 16 alveoli for roots of
teeth, varying in size and depth, some being multiple.
The internal surface is divided by an oblique mylohyoid line, sharp
and distinct near the molars, faint in front and extending from behind the
third molar, a centimeter from the upper border, to the mental symphysis
between the digastric fossae. Below this line is the slightly concave
submandibular fossa; the area above it widens anteriorly into a triangular
sublingual fossa. Above the latter and extending back to the third molar, the
bone is covered by oral mucosa. Above the anterior ends of the mylohyoid
lines, the posterior symphyseal aspect has a small elevation, often divided
into upper and lower parts, the mental spines (genial tubercles). Posteriorly
the mylohyoid groove extends down and forwards from the ramus below the
mylohyoid lines posterior part. Superior to the mental spines most mandibles
display a median pit opening into a canal. As yet its development and
contents are uncertain but it is a useful radiological landmark the name

genial foramen has been proposed. Above the mylohyoid line, medial to the
molar roots, a rounded torus mandibularis sometimes appears.
The mandibular ramus is quadrilateral, with two surfaces, four borders
and two processes. The flat lateral surface has oblique ridges in its lower
part; the medial presents a little above centre, an irregular mandibular
foramen, leading into the mandibular canal, curving down and forwards into
the body to its mental foramen. Anteromedially the foramen is overlapped
by a thin, triangular lingula. The mylohyoid groove descends forwards from
behind the lingula; short ridges mark the surface behind it. The inferior
border, continuous with mandibular base, meets the posterior border at the
angle. This is typically everted, but in females frequently incurved. The thin
upper border bounds the mandibular incisure surmounted in front by the
somewhat triangular, flat, coronoid process, behind by a strong condylar
process. The posterior border thick and rounded extends from condyle to
angle, being gently convex backwards above, and concave below; it is in
contact with the parotid gland. The anterior border is thin above and
continuous with that of the coronoid process, and thicker below and
continuous with the oblique line.
The coronoid process projects up and slightly forward. Its posterior
border bounds the mandibular incisure, its anterior continues into that of the
ramus. Its margins and medial surface are attachments for most of the
temporalis.
The condylar process is apically enlarged as a head of condyle,
covered by fibrocartilage. It articulates with the temporal bones mandibular
fossa, with an articular disc between. It is convex in all directions, its
transverse dimension greater. Its lateral aspect is a blunt projection, palpable
in front of the auricular tragus. As the mouth opens the condyle descends

forwards, admitting a finger tip towards its vacated fossa. Below the head is
the narrower neck, slightly flattened from before backwards, its anterior
aspect overlapped laterally by the mandibular incisures, margin medial to
which the necks anterior surface bears a rough pterygoid fovea.
The mandibular canal descends obliquely forwards in the ramus from
the mandibular foramen, then horizontally forwards in the body below the
alveoli, with which it communicates by small canals. It contains the inferior
alveolar nerve and vessels from which branches enter dental roots,
periodontal sockets and septa. Between the roots of the first and second
premolars, or below the second, the canal divides into mental and incisive
parts the mental canal swerves up, back and laterally to the mental foramen;
the incisive canal continues below the incisor teeth.
The mandibular body bears a small shallow incisive fossa below the
incisors, an attachment for mentalis and part of orbicularis oris. To the
anterior ends of the oblique lines are attached depressor labii inferioris and
anguli oris, and platysma to bone below and backwards beyond them.
Adjoining the alveolar border bone is covered by oral mucosa and, below
this in the molar region, the buccinator has a linear attachment extending
medially behind the last molar to the pterygomandibular raphe.
To the mylohyoid line is attached the mylohyoid muscle and, above its
posterior end the superior pharyngeal constrictor, some retro molar fascicles
of the buccinator, and the pterygomandibular raphe behind the third molar.
Although usually described separately, here the constrictor, buccinator and
the raphe are blended and jointly attach to the mandibular periosteum. The
lingual nerve reaches the tongue above the mylohyoid line, closely related to
bone near its posterior end often the nerve is accommodated in a shallow,
curved groove. To the superior mental spines are attached the genioglossi, to

the

inferior

the

geniohyoids.

The

submandibular

fossa

adjoins

submandibular lymph nodes as well as the salivary gland; the facial artery
usually descends here to curl round the base of the mandible, sometimes
making a shallow groove. The digastric fossa is for attachment of the muscle
anterior belly.
The mandibular ramus and its processes provide attachment for
muscles of mastication, much of its lateral surface to masseter, except
posterosuperiorly, where it is covered by the parotid gland; the medial
surface receives the medial pterygoid on the roughened area postero-inferior
to the mylohyoid groove. To the lingula the sphenomandibular ligament is
attached, posterior to which the mylohyoid nerve and vessels enter the
mylohyoid groove, reaching the mandibular body below the mylohyoid
groove, reaching the mandibular body below the mylohyoid line; they then
pass superficial to mylohyoid. Below the lingula, but above the roughened
attachment mentioned above, the medial surface of the ramus is related to
the medial pterygoid, the lingula nerve being between muscle and bone. The
lowest attachment of temporalis descends beyond the coronoid process to
the anterior ramal border and particularly its adjoining medial surface. To
the area posterosuperior to the mandibular foramen the maxillary artery and
its inferior alveolar branch are related, and lateral pterygoid to the area near
the mandibular incisure. The mandibular incisure transmits the masseteric
nerve and vessels form the infratemporal fossa.
The coronoid process is covered laterally by the anterior part of
master descending to its attachment on the ramus. Its anterior border is
palpable below the zygoma; this is most evident during mouth opening. The
condylar process projects more at its medial pole.

Its articular surface

descends only a little on its anterior surface, covers the whole of its superior

aspect and descents 5 mm posteriorly. Its projecting lateral part is separated

from the cartilaginous external acoustic meatus by the parotid. Laterally on
its neck the joints lateral ligament is attached, covered by parotid glad. The
pterygoid fovea, anterior on the neck, receives the lateral pterygoid. The
necks medial surface is related to the Auriculotemporal nerve above and
maxillary artery below.
The parotid gland is below the external acoustic meatus and lies
between the ramus and mastoid process, with the styloid process medial; but
it extends forwards lateral to the temporomandibular joint and to the exposed
ramus behind the masseter. It also curls round the posterior border to the
medial aspect of the ramus above the attachment of the medial pterygoid.
Accessory foramina of the mandible are usually unnamed and
infrequently described. Yet a study of 300 mandibles yielded a count of
2449 accessory foramina. Since many transmit auxiliary nerves to teeth
(from facial, buccal, transverse cutaneous & others), their occurrence is
significant in dental blocking techniques.

Further mandibular variants

include lingual depressions, molar or canine, variable position of mental

foramen, multiple mental foramina, lingual fenestrations of molar sockets,
retromolar foramina and condylar defects.
Aspects of mandibular structure.

In addition to variable mandibular

canals, numerous analyses have been made of the structure of surface tables
and buttresses of compact bone and the geometry of trabeculation in
attempts to relate these to habitual functional stresses.

Holographic

interferometry has been used to study surface strains induced by orthodontic

forces.

Age Changes in the Mandible

At birth the two halves of the mandible are united by a fibrous
symphysis menti. Anterior ends of both rudiments are covered by cartilage,
separated only by a symphysis. Until fusion occurs new cells are added to
each cartilage from symphyseal fibrous tissue, ossification on its mandibular
side proceeding towards the midline; when the later process overtakes the
former, extending into median fibrous tissue, the symphysis fuses but details
are uncertain. At this stage the body is a mere shell, enclosing imperfectly
separated sockets of deciduous teeth. The mandibular canal is near the
lower border, the mental foramen opens below the first deciduous molar and
is directed forwards. The coronoid process projects above the condyle.
In the first to third postnatal years the two halves join at their
symphysis from below upwards; separation near the alveolar margin may
persist into the second year. The body elongates, especially behind the
mental foramen, providing space for three additional teeth. During the first
and second years, as a chin develops, the mental foramen alters direction
from anterior to posterosuperior, and then almost horizontally posterior, as
the adults, accommodating a changing direction of the emerging mental
nerve. The proximal zone of the conical condylar cartilage persists as an
epiphyseal plate. Its proliferation contributes to persist as an epiphyseal
plate. Its proliferation contributes to vertical increase in the ramus and to
general mandibular growth, which is essentially downwards and forwards.
With its antimere it also adapts the intercondylar distance to the widening
cranial base. The condylar cartilage is covered on its articular aspect by
self-perpetuating fibrous tissue, deep, to which a proliferating intermediate
zone is responsible for ramal growth.
chondrocytes and then bone.

Beneath this are hypertrophic

As depth of the body increases, alveolar

growth makes room for roots of teeth, the subalveolar region becoming
thicker and deeper. After eruption of permanent teeth the mandibular canal
is a little above the mylohyoid line, and the mental foramen occupies its
adult position. As the mandible increases in size, bone is added at posterior
borders of ramus and coronoid process, absorption occurring at their anterior
borders. This remodeling is continuous until adult size is reached, allowing
alveolar parts to accommodate permanent molar teeth.
In adults alveolar and subalveolar regions are about equal in depth, the
mental foramen midway between upper and lower borders; the mandibular
canal nearly parallels the mylohyoid line. The angle between the lower
border of body and a plane touching the posterior surface of condyle above,
and ramus below, diminishes as ramal height increases with age; but X-ray
photographs at different ages show that its contour remains unaltered.
In old age the bone is reduced in size, as teeth are lost and the alveolar
region absorbed; the mandibular canal and mental foramen are nearer the
superior border. Both may even disappear, exposing the inferior alveolar
nerve. The ramus becomes oblique, the angle about 140o, and the neck
inclined backwards. Absorption affects chiefly the thinner alveolar wall and,
after completion, a linear alveolar ridge is left at the superior border of the
mandible. In the mandible the labial wall is thinner in incisor and canine
regions, the lingual wall in the molar. The mandibular alveolar ridge hence
is within the line of teeth in the former but outside it in molar regions,
forming a curve wider posteriorly than that of the line of the teeth, but
intersecting it near the premolars. In the maxilla, however, the labial wall is
ridge entirely within the line of teeth.

BLOOD SUPPLY
Blood supply to the mandibular cortex is a decisive factor of bone
growth & bone repair. Disturbances of Vascularization of mandible hare
been suggested as being responsible for severe complications in fracture
healing such as posttraumatic resorption of the condyle or those following
osteotomies.
It is know that the blood supply of mandible is mainly periosteal i
deriving from perimandibular branches maxillary, facial & external carotid
arteries. The inferior alveolar artery is the only endosteal artery of mandible
known to supply to the part of the ramus & the body of the lower jaw. Three
different anatomical parts of mandible are distinguished:
a. Zone I: the body of the mandible, beginning in the symphysis & ending
in the connecting line between retromolar area & angle of the mandible.
b. Zone II: the caudal part of the mandibular ramus, located dorsally &
cranially to Zone I, It extends to the base of the condyle.
c. Zone III: the condyle, i.e. the condylar process with the mandibular head,
located cranially to zone II.
Endosteal blood supply
Zone I: Inferior alveolar artery & branch of lingual artery entering the
mentum.
Zone II: One branch of Inferior alveolar artery & one branch of masseteric
artery.

Zone III: One or two branches of masseteric artery & one or two branches
of Transverse facial artery.
End- & periosteal blood supply
Zone I: Inferior alveolar & mental arteries
Zone II: Transverse facial & Massetric arteries
Zone III: Transverse facial & Massetric arteries
Periosteal blood supply
Zone I: Mental, submental & Lingual arteries
Zone II: Transverse facial & Deep temporal arteries
Zone III: Superficial temporal, Deep temporal & facial arteries.

SURGICAL ANATOMY OF THE MANDIBLE

INTRODUCTION:
The mandible is basically long bone, which is bent into a blunt Vshape. As with all tubular bones, strength resides in its dense cortical plates.
The cortical bone is thicker anteriorly and at the lower border of the
mandible, while posteriorly the lower border is relatively thin. The central
cancellous bone of the body forms a loose network with frequent large bonefree spaces.
Thus the mandible is strongest anteriorly in the midline with
progressively less strength towards the condyles.

The basic V-shape is

modified by their functional processes-namely, the angles, to which are

attached the masseter and medial, pterygoid muscles, the coronoid processes
for the temporalis muscles, the alveolar bone which forms around the

developing teeth and then supports their roots after eruption. The form of
the alveolar process is entirely dependent upon the presence (or absence) of
the teeth and the functional forces transmitted through them.
The mandible differs from all other long bones in two important
respects:
1. Any movement inevitably causes both condyles to move with respect to
the skull bases.
2. Although anatomically the condyles are the articular surfaces of the
mandible, functionally the occlusal surface of the mandibular teeth sub
serves this role. In a functional sense then, the oral cavity is analogous to a
joint space.
The mandible is subcutaneous or submucosal in most of its extent, the
only part inaccessible to palpation being the upper and posterior portion of
the ascending ramus. The anterior edge of the ascending ramus may be
readily palpated intra-orally, but the fibres of the temporalis muscle clothe
its upper half.
THE TEETH
The presence of the teeth in the mandible and maxilla is the most important
anatomical factor, which makes fractures of these bones entirely different
from, fractures elsewhere.

The occlusion of the teeth is a delicately

balanced mechanism and any disturbance resulting from malunion of a

fracture leads to a reduction in masticatory efficiency and comfort, and so
restoration of the occlusion is the prime aim in the treatment of fractures of
the mandible. Conversely, the presence of the teeth is extremely helpful in
the reduction and fixation of mandibular fractures; the teeth may be regarded
as a row of bone-pins offering direct control of attached fragments of bone

without any of the problems associated with surgically introduced metal

pins. During reduction of mandibular fractures it is imperative to determine
the original occlusion of the teeth and to restore it. This will obviously
reposition the tooth-bearing fragments of the mandible to their original
relationship with the maxilla.
Complete fractures of the body of the dentate mandible must of
necessary involve the roots or periodontal membrane of adjacent teeth, only
very rarely passing through interradicular bone. The root of an involved
tooth may be fracture, but this is unusual. The most important point to note
in such fractures is that the alveolar process is invested over about half its
tears in all cases directly over the fracture both buccally and lingually. Such
fractures are thus open (compound) into the oral cavity and exposed to
possible infection. The tooth contained in the socket through which the
fracture passes may also undergo pulpal necrosis as a result of damage to the
apical blood supply, which leaves the pulp chamber of the tooth filled with
necrotic tissue and ultimately tissue fluid. This is a potential nidus for
infection since it is beyond the reaches of the defensive mechanisms of the
body. The mucoperiosteum of the edentulous mandible is, by contrast, an
intact sleeve and is less frequently ruptured in association with underlying
fractures. In consequence these remain closed and the mucoperiosteum
limits their displacement.
The mandible is commonly fractured because of its prominent
position. Forward falls in the unconscious patient will result in the point of
the chin striking the ground and the chin and body of the mandible form an
inviting landmark in fights.

THE STRENGTH OF THE MANDIBLE

There have been numerous investigations into the resistance of the
mandible to applied forces with particularly valuable contributions by
Huelke (1961) and Hodgson (1967). The major points to note are that bones
fracture at sites of tensile strain, since their resistance to compressive forces
is greater.
Huelke (1961) has shown that the isolated mandible is liable to
particular patterns of distribution of tensile strain when forces are applied to
it. Anterior forces applied to the symphysis menti, over one mental foramen
or over the mandibular body, lead to strain at the condylar necks and along
the lingual plates in the opposite molar region.
Slightly different strain patterns result from important variables,
including whether the condyles are fixed or mobile, but to quote:
In its response to loading the mandible is quite similar to an
architectural arch in that it distributes the applied force along its length.
The mandible, however, is not a smooth curve of uniform cross-section... as
a result there are parts of the mandible which develop greater force per unit
area parts and consequently, tensile strain is concentrated in these locations.
There is a marked correlation between these sites of tensile strain and
the results of experimental fractures, which occur in 74% of cases at sites of
high stress. The mandible is a strong bone, the energy required to fracture it
being of the order of 44.6-74.4 kg/m, which is about the same as the zygoma
and about half that for the frontal bone.
SOFT TISSUE FACTORS
The periosteum of the mandible appears to play little part in
influencing the site of mandibular fractures or subsequent displacement,

except in the edentulous patient. The muscles attached to the mandible exert
considerable influence over the displacement of fragments after fracture;
they probably play a significant but poorly defined role in the actual
localization of fracture lines both directly and indirectly, and will be
discussed in connection with injuries at particular sites.
THE INFERIOR DENTAL NEUROVASCULAR BUNDLE
The inferior dental bundle is obviously at risk in fractures of the mandible
between the mental foramen and the mandibular foramen.

The fibrous

sheath provides considerable support for the contained vessels and nerve,
which accounts for the surprisingly low incidence of permanent nerve
damage after fracture.

Even markedly displaced fractures may,

unexpectedly, not be associated with transient neuropraxia.

Vascular

damage to the inferior dental artery and veins may be presumed to be more
common than nerve damage but is clinically unimportant, provided that total
transection of the vessel has occurred thus allowing retraction and
spontaneous arrest of hemorrhage to take place.
Many surveys have been conducted to know the disposition of
mandibular fracture lines. Only one, however, has detailed the site of the
injuring force (Hagan & Huelke 1961). Clean-cut patterns emerge from
these surveys, namely:
1. The condylar region is most commonly fractured.
2. The angle is the second most common site, but if only one fracture occurs
it is more commonly at the angle than the condyle.
3. Multiple fractures are more common than single in a ratio of about 2:1.
4. 80% of the patients are dentate.

THE CONDYLAR REGION

1. Localization
The zygomatic arch gives some measure of protection to the condyle from
direct trauma, so that the impact, which causes condylar injuries, is usually
an indirect one, through the body of the mandible, with the exception of
penetrating injuries.
An impact transmitted through the neck of the condyle may fail to
cause a fracture but may contuse the capsular ligaments, causing a capsulitis.
This results in an effusion of inflammatory exudate into the joint cavity itself
or bleeding into the give a haemarthrosis. The lateral side of the capsule is
thickened to form the temporomandibular ligament so that, if rupture of the
capsule occurs, it is more likely to be on the weaker medial aspect,
encouraging displacement to this side. The capsule is less well developed in
children than in adults, making rupture more likely.
Normally the eminentia limits the extent of forward translatory
movement of the condyle. On some individuals, with a lax capsule allowing
hypermobility, subluxation or dislocation over the eminentia occurs quite
frequently. Whether this excessive range of movement is due primarily to
the synovial laxity or whether it is the causal factor which leads to
subsequent dislocation is uncertain. It seems that the latter is more likely,
since such individuals frequently demonstrate hypermobility in other joints.
After dislocation, spasm in the lateral pterygoid, with its insertion into the
neck of the condyle, may make reduction difficult and this factor also affects
the temporalis muscle.
The usual site for a fracture of this region is not through the
anatomical neck but obliquely downwards and backwards from the sigmoid
notch to a point somewhat above the middle of the posterior border of the

ascending ramus. This fracture is extracapsular and is commonly referred to

as a subcondylar fracture. Fracture may occur through the anatomical neck
of the condyle or, quite exceptionally, the head is fractured within the joint
cavity (intracapsular) and may often be comminuted.
The subcondylar fracture is invariably produced indirectly as a result
of violence to the mental prominence or contra lateral body of the mandible.
Most authorities agree that it occurs with the teeth apart and the elevator
muscles relaxed. The line of fracture, very significantly, lies just above the
posterosuperior insertion of the masseter muscle. As mentioned previously,
the condylar neck is a site of maximum tensile strain with anterior and
anterolateral applied forces.

The fact that the fracture occurs precisely

where it does may be related to the muscular response to injury, which, with
posterolateral condylar displacement along the axis of the lateral pterygoid
muscle, would initiate a stretch reflex in that muscle. Fractionally later,
contraction of the masseter and medial pterygoid muscles would impose an
area of maximum strain just above the masseteric insertion. This active
type of fracture would not occur in unconscious patients.
The importance of the meniscus is becoming increasingly recognized
in temporomandibular joint injury. Loss if this structure leads to eventual
degenerative changes in the condylar articulation tearing or displacement of
the meniscus may be important requirement for ankylosis after condylar
fracture.
In co-ordination of translatory movement of the condyle and meniscus
under the influence of the lateral pterygoid muscle can result in clicking, or
locking in the temporomandibular joint pain/dysfunction syndrome, Trauma
may initiate such symptoms, particularly if a tear is created in the mensical
attachments to the capsule.

The nerve supply to the joint is principally from the articular branches
of the Auriculotemporal nerve (Tjilander 1961), which run medial to the
condylar neck, with additional possible innervation from branches of the
nerve to the masseter and deep aspect of the temporalis muscles.
Stimulation of these nerves, for example by trauma, may cause reflex
changes in the muscles of mastication accounting for the spasm and
restricted mobility seen after injury. The condyle is in close relationship to a
number of other nerves, particularly the facial and long buccal, so that it is
understandable that trauma to these could occur after injury with resultant
motor or sensory loss, although neurological loss in these circumstances is
comparatively uncommon.
Paraesthesia of the mental nerve may, rarely, occur following fracture
dislocation of the condyle in an anteromedial direction as the result of
trauma to or compression of the mandibular nerve as it emerges from the
foramen ovale.
Displacement
The word displacement always refers to the disturbed relationship
between the fractured bone ends and in the case of condylar fractures this is
usually slight.

The important abnormality here relates to the position

assumed by the condylar head. The bone ends may be deviated due to
anteromedial displacement of the condylar head, which is still contained by
the joint capsule, or alternatively the capsule may rupture, leading to
separation of the articulating surfaces thus, by definition, being dislocated.
There is no doubt that this anteromedial displacement or dislocation is
produced by violent contraction of the lateral pterygoid muscle at, or
immediately after, the moment of fracture. An anterior capsular tear,

associated with rupture of the fibres of the lateral pterygoid muscle inserted
into the disc, would have the potential for causing periodic inability to close
the jaw fully, due to the disc being displaced posteriorly, while a posterior
tear without rupture of these muscle fibres could result in episodes
interference with opening due to anterior displacement of the disc.
A patient with a unilateral subcondylar fracture may present without
the typical disturbance of occlusion, but during function all demonstrate a
common characteristic. This is deviation of the mandible to the side of the
injury on opening. This is due to the insertion of the lateral pterygoid no
longer influencing the main fragment of the mandible. Thus only rotary
movements (at the fracture site) occur on the side of injury with no anterior
translation of the condylar head on opening. The net effect is that the centre
of rotation of the injured side is moved from its normal position upwards
and backwards into the fracture line.
The thin tympanic plate constitutes part of the posterior non-articular
portion on the glenoid cavity. The cushioning effect of the postcondylar soft
tissues tends to protect this area, as does the restraining effect of the
temporomandibular ligament, but this plate may be fractured, with distortion
of the bony wall. This may, very rarely, occur without condylar fracture,
whereas a fracture generally absorbs most of the impact.
Central dislocation of the condyle into the middle cranial fossa is a
well-recognized although a very rare entity when the mandible receives a
blow in the mental region with the mouth open, the medial and lateral poles
of its condyles are impacted against the medial and lateral elevated margins
of the glenoid fossa, thus preventing the dislocation of the condyles into the
cranial cavity through the thin roof of the fossa. Only a small rounded

condyle would be likely to impinge on the centre of the fossa with a

possibility of penetration.

This type of condylar configuration is

uncommon, accounting for about 2.8% of all existing condylar shapes. It is,
indeed, fortunate that the neck of the condyle breaks so readily, since it
limits the force applied to the cranial base, thus reducing the likelihood of
displacement of the head of the condyle through the thin roof of the glenoid
fossa into the middle cranial fossa.
RAMUS AND CORONOID PROCESS
There is usually only minimal displacement of the coronoid process,
since the fragment is splinted by the tendinous insertion of the temporalis
muscle. Occasionally, as the result of considerable violence, this insertion is
ruptured and elevation of the tip of the coronoid process occurs. Such
injuries are probably caused when there is a combination of forces in
opposite directions arising from an impact on the chin depressing the
mandible, which simultaneously invokes a powerful contraction of the
temporalis muscle, elevating the mandible as an associated component of the
physiological jaw reflexes. In rare cases the fracture may extend from the
sigmoid notch downwards and forwards to the retro molar fossa.
THE ANGLE OF THE MANDIBLE
After the condylar neck, the angle region is the commonest site of
mandibular fracture. It is important to distinguish between:
The clinical angle, which is the junction between the alveolar bone
and the ramus at the origin of the internal oblique line.
The surgical angle, which is the junction between the body of the
mandible and the ramus at the origin of the external oblique line.

The anatomical angle or gonion where the lower border meets the
posterior border of the ramus.
Fractures in this region have, in common, involvement of the junction
of the posterior end of the alveolar process and body of the mandible with
the ascending ramus. From this point on the upper border they extend
downwards, but only rarely do they involve the anatomical angle.
In most cases the fracture line extends from the surgical angle
downwards and backwards, terminating at the lower border anterior to the
masseter muscle. When a third molar tooth is present the fracture commonly
extends through its crypt or socket, but occasionally it passes in front of or
behind the wisdom tooth. The fracture usually results from a blow over the
same side of the mandible between the canine and second molar regions, but
may result from violence to the chin point on the opposite side.

It is

probable that this occurs, in common with body fractures, when a force is
applied with the teeth clenched but there is no direct evidence to support this
theory.
1. Localization
As mentioned earlier, the lingual surface of the mandible in the region
of the second and third molars is one site of maximum tensile strain
resulting from anterolateral application of force on the same side. The
weakness of the angle is produced by the abrupt change in direction between
the body and ascending ramus in two planes. In the vertical plane a change
of direction is almost 200, while in the horizontal plane it is about 70 0 at the
upper border. This due to the lack of conformity between the curve of the
alveolar process, which is U-shaped, and the rami of the mandible, which

diverge.

In addition to the shape of the bone, two other factors are

important.
a) A partly erupted or unerupted wisdom tooth occupies a space, which
would otherwise contribute materially to the strength of the mandible and
thus weakens it. The strength of the mandibular body in this region lies in
the upper border as evidenced by the thickness of the cortical plate.
b). The insertions of the masseter and medial pterygoid muscles comprise a
great source strength to the ascending ramus, and the anterior limit of their
insertion lies just behind the third molar. The common disposition of the
fracture is through the anterior root socket of the third molar and associated
buccal plate, but on the lingual side it extends backwards, leaving the distal
surface of the distal root socket and then passing through the lingual plate.
The whole fracture line inclines downwards from the wisdom tooth to the
lower border.

2. Displacement
A fracture at the angle prevents the elevator muscles attached to the
ascending ramus (the proximal or posterior fragment) from having any direct
effect on the remainder of the mandible (the tooth bearing fragment). There
is thus a tendency for the posterior fragment to ride upwards, forwards and
inwards since the medial pterygoid muscle exerts its action medially at about
300 to the vertical axis.

Clinical evidence indicates that the bulk of the

displacement occurs at the time of injury and is probably due to activation of

the stretch reflexes in the pterygomasseteric sling by the injuring force. The

posterior fragment is held in its displaced position by the reflex spasm

imposed upon in the muscles by pain. The tooth-bearing fragment is thus
secondarily displaced in an anterior and contralateral direction.

Favourable and unfavourable fractures

These traditional but not very practical terms relate to the line of
fractures at the angle as observed along the vertical and horizontal planes.
The terms are defined, from the viewpoint of the observer, as vertical or
horizontal, and with respect to the potential for displacement exhibited by
the posterior fragment; favourable if the displacement is limited by the
disposition of the fracture line and unfavourable if otherwise.

Thus a

vertically favourable fracture runs from the buccal plate anteriorly and
backwards through the lingual plate posteriorly while a vertically
unfavourable fracture runs from the lingual plate anteriorly.

Likewise,

horizontally unfavourable fractures extend from the upper border

downwards and backwards whereas horizontally favourable fractures extend
from the upper border downwards and forwards.
Displacement of the posterior fragment is only marked if the fracture
line is unfavourable in both planes or if there is comminution, which
automatically reduces the stability of the posterior fragment.
These fractures involve the tooth bearing area and so are normally
open (compound) into the oral cavity. If, however, the wisdom tooth is
unerupted the laxity of the mucoperiosteum in this region frequently means
that the fracture remains closed (simple).

FRACTURES OF THE BODY OF THE MANDIBLE

1. Localization
Most fractures in this area result from direct violence and tend to be
concentrated in the first molar or canine regions, in the molar region because
it is the site of receipt of the blow and the canine region because it is a site of
high strain resulting from applied forces, together with a point of maximum
weakness associated with the length of the canine root.
2. Displacement
The further forward the site of fracture, the more is the upward
displacement of the elevators counteracted by the downward pull of the
mylohyoid muscle attached to the mylohyoid ridge on the lingual aspect of
the mandible. At the same time, the medial or lingual displacement tends to
be increased, whilst the factors previously mentioned with regard to the
favourability or otherwise of the lines of fracture remain unaltered. Because
the lesser and greater fragments bear teeth which are partially controlled by
their maxillary opponents, displacement is limited and the occlusion may be
minimally disturbed.
These fractures must of necessary cause a tear of the overlying
attached mucoperiosteum and be open into the mouth. Fractures in the
lower incisor region are frequently oblique, with the fragment from which
the genial muscles arise displaced lingually. The two fragments tend to
rotate medially due to the medial pull of the mylohyoid muscles, and the
incisor teeth adjacent to the fracture overlap. It is, in fact, rare for the
fracture line to pass through the anatomical symphysis, which is the thickest
and strongest area of the mandible. In clinical practice it will be found that

the fracture passes through the parasymphyseal region, to one side or the
other of the genial tubercles.

Multiple fractures of the mandible

1. Fracture of the body and opposite angle or condyle. These are common
combinations, since a blow directed anterolaterally to the mandible may
result in a direct fracture at the site of injury and an indirect fracture of the
condylar or angle region on the opposite side. Conversely, a blow may
result in ipsilateral angle fracture and contralateral fracture of the body
through the canine or premolar region.

In general the second fracture

implies a greater force and thus the likelihood of increased displacement.

However, the presence of occluding teeth will minimize this effect, whereas
the absence of teeth, constituting an edentulous posterior fragment, increases
the degree of displacement.
2. Bilateral subcondylar fractures are common and usually due to an impact
on the point of the chin with the teeth apart. If the teeth are in occlusion at
the moment of impact much of the force will be absorbed, usually resulting
in fracture of the teeth, and the condyle may escape injury. However, with a
greater degree of force, a condylar fracture will occur, Gross anteromedial
deviation or dislocation of the condyles is usual and the tooth bearing
fragment is subject to marked rotation in the vertical plane about the last
standing teeth with the production of a gross anterior open bite.
3. Bilateral angle fractures are not common but result in gross displacement
of all three fragments. The two posterior fragments are drawn upwards and
forwards and the anterior tooth-bearing fragment is rotated downwards by
the inframandibular musculature.

4. Bilateral body fractures are also infrequent. The anterior fragment is

driven downwards and backwards and the position is maintained by the
unopposed traction of the genial and inframandibular muscles. The two
posterior fragments are prevented from medial displacement by the anterior
fragment and from upward displacement by occlusal contact and thus retain
a relatively normal position. In the edentulous case the lack of occlusal
contact results in serve displacement of the fragments.
5. Three or more fractures. Mandibular fractures at more than two sites are
not uncommon and the permutation of combinations is large.
APPLIED ANATOMY OF THE SURROUNDING SOFT TISSUES
THE CONDYLAR REGION
The mandibular condyle and its capsule are covered by the parotid
gland, which, in this region, is termed the glenoid lobe. This lobe lies within
the parotid fascia, glenoid lobe. This lobe lies within the parotid fascia,
which is derived from the divergent and upward extension of the deep
cervical fascia, and encloses the superficial temporal artery and vein with the
temporal and zygomatic branches of the facial nerve. The fascia fuses with
the perichondrium and periosteum of the external auditory meatus, and also
the temporal fascia behind the joint capsule at the root of the zygomatic
arch. dissection to expose the joint, therefore, is carried out in close contact
with, and following the direction of, the perichondrium and periosteum
covering the anterior wall of the external and auditory meatus. A surgical
cleft is thus created along an almost avascular plane which leads naturally to
the posterior aspect of the joint capsule behind and beneath the glenoid lobe
of the parotid gland and its contained arteries, veins and nerves. The general
direction of the meatus is downwards, forwards and inwards and dissection

must proceed in the manner. Failure to appreciate this fact, leading to an

injudicious attempt to deepen the incision at right angles to the surface, will
result in transection of the cartilaginous anterior wall of the meatus and,
possibly, injury to the tympanum.
The temporal fascia is attached to the upper border of the zygomatic
arch and blends with the periosteum overlying that structure. The branches
of the facial nerve crossing the arch on their way to supply the frontalis and
orbicularis occuli muscles lie immediately superficial to the periosteum.
Any dissection in a forward direction in this area must proceed superficially
to the bone and deep to the periosteum if injury to the nerves is to be
avoided. The maxillary artery will be close to medial proximity to the
condylar neck.

This relationship is particularly important in cases of

ankylosis characterized by massive bone formation in cases of relation to the

medial pole of the condyles. The medial pole of the condyle is situated
within approximately 0.5 cm of the pharyngotympanic tube from which it is
separated by the down tuned edge of the tegmen tympani. It also lies a
similar distance from the carotid canal lying poster medially, which is,
however, separated by the tympanic plate of the temporal bone.
THE ANGLE AND BODY
As well as providing an ideal approach to the angle of the mandible,
the natural skin creases of the neck run in the correct direction for avoiding
the important underlying anatomical structures. An incision made in one of
these will immediately expose the underlying platysma. Careful dissection
through the platysma prevents damage to any of the important underlying
structures, although care should be taken to avoid the external jugular vein
running from the angle of the mandible downwards and posteriorly.

Immediately beneath the platysma the deep cervical fascia invests the
muscles of the neck. It consists of fine fibroareolar tissue, which occupies
all the intervals, which would otherwise exist between the muscles and the
vessels of the neck. In certain situations the fascia assumes the form of a
thin fibrous sheet or layer, but elsewhere the tissue is loosely arranged and is
easily broken down. It becomes condensed around the blood vessels,
providing them with fibrous sheaths, which here, as elsewhere in the body,
bind the arteries and their accompanying vessels closely together.
Along the posterior border of the sternomastoid it divides to enclose
the muscle, and at the anterior margin again forms a single lamella, which
covers the anterior triangle of the neck and reaches forwards to the median
plane, where it is continuous with the corresponding lamella from the
opposite side. In the median plane the fascial is fixed to the symphysis
menti and the body of the hyoid bone. Superiorly, from its attachment to the
superior nuchal line of the occipital bone and the mastoid process of the
temporal bone, the fascia extends forwards and downwards to the attached to
the whole length of the base of the mandible. Posterior to the angle of the
mandible it is very strong and binds the anterior edge of the sternomastoid
firmly to that bone, ensheaths the parotid gland.
The loose areolar portion of the deep cervical fascia immediately
anterior to the sternomastoid muscle forms an easy plane of dissection,
which is avascular. After division of the overlying platysma, this plane is
sought and a dissection commenced which may, if necessary, be extended
upwards or downwards as required. Immediately anterior to this plane, the
denser layer of fascia investing the submandibular gland forms an important
landmark. Division of this investing layer achieves approach to the lower
border of the mandible.

Immediately below lie the branches of the facial nerve. Dingman &
Grabb (1962) investigated the distribution of the mandibular branches of the
facial nerve in relationship to the angle of the mandible and the overlying
deep cervical fascia.
Following the dissection of the mandibular branch of the facial nerve in 100
cases, the principal conclusions were as follows.
1. In 8% of cases the nerve, posterior or proximal to the point where the
facial artery crossed the mandible, passed above the inferior border.
2. In the remaining 19% the nerve described a downward arc, the lower
point of which was I cm below the inferior border.
3. Anterior or distal to the where the facial artery crossed the mandible,
100% of the branches of the facial nerve which innervated the depressors of
the lower lip pass above the inferior border.
4. All branches anterior or distal to the facial artery, which were situated
below the mandible, were innervating the platysma and not the depressors of
the lower lip. However, since the anterior fibres of the platysma were
frequently in continuity with the lower fibres of the quadratus labii
inferioris, these muscles contracted as one unit so that a false interpretation
of the precise innervation might be made.
5. In 98% of cases the mandibular branch passed over the superficial surface
of the posterior facial vein and could readily be identified at this site.
100%of cases showed that the nerve passed superficial to the anterior facial
vein.

The nerve lay superficial to the facial artery, being situated

immediately anterior or posterior to the vessel, and not infrequently upon the
artery. The submandibular lymph node lay immediately posterior to the
artery, was constant in position and was a useful landmark.
6. The mandibular and buccal branches anastomosed in only 5% of cases.

7. The mandibular ramus consisted of two branches in 67% of specimens; a

single branch in 21%; a triple branch in 8% and four or more in 3% of the
dissections performed.
The facial artery lies immediately beneath the deep cervical fascia and
can be observed pulsating beneath this layer. In approximately 20% of cases
the mandibular branch of the facial nerve turns upwards and accompanies
the vessel at this point and should if possible be dissected away and
retracted. Frequently the anterior branch of the posterior facial vein may
also be seen traversing this particular area and may require isolation,
division and ligation.

BIOMECHANICAL CONSIDERATIONS
The outer cortex of the body of Mandible has an average thickness of
3.3mm is particularly strong & offers a good anchorage for the
osteosynthesis screws. The cortical bone is thicker in the chin region & is
reinforced laterally by the oblique line, which runs from the coronoid
process to the molar region. In the symphysis region, cross sections of the
mandible show the thickest cortex to be at the lower border; behind the third
molar, it is stronger at the upper border.
Near the alveolar process the thickness of the bone is variable; the
anatomy of the tooth roots & the structure of the bone do not allow screw
fixation in this region. To avoid damaging the root apices it is safe to place
the screws away from the occlusal plane by a distance of at least three times
the length of the crown of the tooth.
The inferior alveolar nerve runs in the mandibular canal, from the
lingula to the mental foramen, on a concave course. Measurements show
that, from back to front, it runs even closer to the outer cortex and to the

lower border. At its lowest point it is 8 to 10mm away from the basilar
border of mandible. Although the average thickness of the cortex in that
region is 5mm, it may be less than 3mm in some cases.
About 1 cm before the mental foramen the canal turns upwards &
forwards. The foramen lies approximately at the middle of the distance
between the alveolar crest & lower border of mandible on a vertical line
corresponding to the Ist or 2nd premolar. It is important to remember that
the mental foramen sometimes lies higher than the canine apex. Therefore
osteosynthesis in this region involves a certain risk of apical injury.
In most cases the mandibular canal surrounds the neurovascular
bundle as a bony tunnel, but sometimes its bony structure is poorly
developed. Repeated tests in freshly prepared mandibles have shown that
the intrusion of a screw into canal does not usually cause nerve injury,
because the nerve moves away from the instrument (GERBER, 1975).
Drilling the holes appears to be more dangerous to the nerve than inserting
screws.
It should be noted that, with ageing, the alveolar bone atrophies & the
structure of the mandible is reduced to 2 cortical layers. In Edentulous
patients the flat upper border of mandible is composed of sclerous bone,
giving poor anchorage for the screws.
During the first year of life, the blood, supply of the mandible depends
on the inferior dental artery. Later periosteal Vascularization increasingly
takes over. In the adult subject, as demonstrated by Bradley (1975) the
blood supply relies Entirely on the periosteum of the basillar process. This
area should therefore be treated with care. Extensive periosteal stripping

should be avoided to preserve the blood supply.

For this reason or

transmucosal approach is preferred than a Trans-cutaneous approach.

Knowledge of Masticatory stresses Exerted on the mandible is
fundamental because these stresses determine the rational design &
positioning of osteosynthesis plates. By means of strain gauges connected to
a wheatstone bridge, maximal biting forces in young men with healthy teeth
were measured. The following values were obtained:
Incisor region: 290 N
Canine region: 300 N
Premolar region: 480 N
Molar region: 660 N
It is important to understand the distribution of strains created within
the

mandible

as

PHYSIOLOGICALLY

result

of

these

CO-ORDINATED

MASTICATORY
MUSCLE

FORCES.

FUNCTION

PRODUCES TENSION FORCES AT THE UPPER BORDER and

COMPRESSIVE FORCES AT THE LOWER BORDER OF MANDIBLE.
TORSION FORCES are produced ANTERIOR TO CANINE.
In every mandibular fracture these forces cause distraction at the
alveolar crest region, accentuated by the degree of Trauma & by contraction
of the muscles of the floor of the mouth, which can lead to displacement of
the fragments. The compressive force at the lower border is a dynamic &
physiologic force, which is exerted permanently on the fractured fragments
along their basillar border. This compression is due to muscular tonus &
increases during masticatory function.

DEFINITION OF IDEAL OSTEOSYNTHESIS LINE OF MANDIBLE

It corresponds to the course of a Tension line at the base of the
alveolar process inferior to the root apices. In that region a plate can be
fixed with monocortical screws, as follows:
Behind the mental foramen the plate is applied immediately below the
dental roots & above the Inferior alveolar nerve.
At the angle of the jaw the plate is placed ideally on the inner broad
surface of the External oblique line; if it has been destroyed, the plate
is fixed on the external cortex as high as possible.
In the anterior region, between the mental foramina in addition to the
sub apical plate, another plate near the lower border is necessary to
neutralize Torsion forces.
The result of such a monocortical Tension-banding osteosynthesis is the
neutralization of the distraction & Torsion band strains Exerted on the
fracture site, while physiological self-compression strains are restored.
In the edentulous mandible the correct position of the plate is on the outer
cortex of the mandible where the biting forces produce Tension forces at the
upper border of mandible. The plate should never be fixed on the upper flat
surface where the bone is sclerous.

SURGICAL APPROACHES TO MANDIBLE

1. MANDIBLE INTRA-ORAL VESTIBULAR APPROACH
Depending on the fracture line an incision is made following the oblique
line & is continued forward, 4 to 5mm below the attachment of the mucosa
& gingiva. The incision is only carried three the mucosa. The following,
second incisions is made it right angles to the underlying bone & carried

down through the submucosa, muscles & periosteum. Care must be taken to
avoid injury to the mental nerve. The nerve has to be identified during
subperiosteal dissection.

After dissection of the neurovascular bundle

mandible can be exposed. The dissection should be carried out Inferiorly

enough to allow adequate application of the fixation system.

The

periosteum should be handled with care & should not be Elevated

Excessively. Wound is closed in layers or in single Layer.
2. MANDIBLE INTRORAL MARGINAL RIM INCISION
For exposure of the alveolar crest or Treatment of Traumatized teeth, then
protection of lacerated mucosa is preferred. This can be achieved by using
the marginal rim incision, which allows direct Elevation of the underlying
periosteum without involving incisions into the overlying mucosa,
submucosa, muscle & periosteal layers. Wound healing is Excellent without
visible scarring (KERSCHER, KREUSICH 1993).
3. MANDIBULAR COMBINED INTRAORAL AND TRANSBUCCAL
APPROACH
This approach is needed in case of fixation of screws or plates at the
angle of mandible by an intra-oral Transbuccal approach. First the mandible
is exposed by an intraoral approach. For Transbuccal drilling, tapping &
screw insertion a stab incision is made three the skin overlying the plate.
The incision should follow the relaxed skin tension lines.

Next the

Transbuccal trocar is inserted & a transbuccal tunnel is established. The

Trocar is removed a check retractor inserted.

4. MANDIBLE EXTRA-ORAL SUBMANDIBULAR APPROACH

(RISDONS)
The incision should be made in a natural skin crease at a level
approximately 2-finger breadths below the inferior border of mandible.
Skin & subcutaneous tissues is incised to the level of platysma muscle,
which is incised at right angle to the muscle fibers.

The marginal

mandibular branch of facial nerve is closely related & must be identified

immediately beneath the platysma muscle.
Alternatively the dissection can be developed through the deep cervical
fascia at the level of submandibular gland. The capsule of the gland is
identified 7 the overlying facial vein & artery are ligated. The marginal
branch of facial nerves lies superior to these vessels & is therefore not
endangered by this approach.
ECKELT (1991) developed technique for lag screw osteosynthesis of
condylar fractures. A skin incision is made 1cm superior to the inferior
border of mandible & Extended to the level of platysma muscle. Then the
facial nerve is identified using nerve stimulation. The masseter is incised
superior to the facial nerve & reflected inferiorly, which avoids risk of
damage to the facial nerve.