Fractures of Mandible

Assistant prof. Dr. Omed Ikram

• The mandible is the largest, heaviest
and strongest bone of the face.
• The normal mandible provides a
normal airway and proper facial
contour.
• A solid movable mandible allows
normal chewing, swallowing and
speech.
• It is prone to injury, because of its
prominent position in the facial
skeleton.
• It is a common site of election for
receiving intentional or unintentional
violence.
 Areas of Weakness (Vulnerable for
Fracture)
• 1. The junction of the alveolar bone and basal
mandibular bone creates a line of weakness.
Dentoalveolar fractures can be seen
independently with or without the fracture of
basal bone.
2. Symphysis region is formed by the
bony union of two halves in the
center at first year of life. Symphysis
fracture is seen at this line of
weakness.
3. Parasymphysis region lateral to the mental
prominence is a naturally weak area
susceptible for parasymphyseal fracture. This
is because of the presence of the incisive fossa
and mental foramen.
4. The body of the mandible is considerably
thicker than the ramus and the junction of
these two portions constitutes a line of
structural weakness. Angle fractures are
commonly seen due to the curvature of
trajectories in this region.
5. Strength of the lower jaw also varies with the
presence or absence of teeth. The presence of
impacted lower third molars or excessive long
roots of canines make the area more
vulnerable for fracture.
6. The slender neck of the mandibular condyle
renders it particularly liable to fracture as a
result of direct violence applied to the chin.
This anatomical weakness actually acts as a
safety mechanism, as a fracture of the neck of
the condyle prevents injury to the middle
cranial fossa. Direct blow to the chin region
can lead toward fracture of one or both
condyles. Sideways blow can bring about
fracture of the opposite condylar neck along
with parasymphysis fracture at the same side
of the blow.
• Blood Supply
1. Central blood supply through the inferior alveolar
artery.
2. Peripheral blood supply through the periosteum.
• When a fracture of the mandible occurs, blood
vessels involved in the line of fracture are torn. The
resultant effusion of blood into surrounding tissues
produces ecchymosis and haematoma. If the
periosteum on the lingual side is torn, it can lead
to sublingual haematoma. The intact periosteum
maintains the collateral blood supply
• Before the antibiotic era, the
teeth in the fracture line were
extracted prophylactically to
prevent infection (which is no
more required).
• In the severely atrophic mandible, there is
greater dependence on periosteal blood
supply than the central supply. Therefore, if
open reduction is planned, stripping of the
periosteum in such cases should be kept to a
minimum.
• Nerve Supply
Damage to the inferior alveolar nerve after
fracture, results in the paraesthesia or
anaesthesia of the lower lip on the affected
side. If the nerve is completely severed, then
recovery by regeneration takes 3 to 12
months, usually preceded by ‘tingling’
sensation, paraesthesia and hyperaesthesia of
the area.
Muscle Action
1. The muscles of facial expression, which are
attached on the outer aspect of the anterior
part of the mandible and which are inserted
into the skin, exert no effect on the
displacement of the fragments following
mandibular fracture.
2. The muscles originating from the inner aspect
of the mandible, the mylohyoid, geniohyoid,
genioglossus and anterior belly of digastric
exert their effect in centripetal manner. The
fractured fragments, therefore, tend to
collapse posteriorly or medially.
3. The lateral pterygoid muscle is inserted into
the medial fossa on the anterior aspect of the
condyle. Therefore, in condylar fractures, the
head is displaced anteriorly and medially and
may also undergo lateral rotation due to the
spasm of the muscle.
Symphysis Fracture
• If the fracture line passes from the labial to the
lingual surface in a straight line (rare), the
fracture is fairly stable to the influence of the
muscles which are attached to the genial
tubercle.
• If, the fracture line runs obliquely, then varying
degree of displacement or overlap will be seen.
Medial displacement will be due to the action of
the mylohyoid muscle and also due to imbalance
of the muscles attached to the genial tubercles
on either side.
Canine Region Fracture
• Common site of fracture, partly due to the
length of the canine root weakening the bone
and also due to the maximum convexity of the
curvature at this site.
• If the fracture is bilateral, then the total
displacement will be much more and can be
hazardous, because of the tongue fall and
obstruction of the airway.
Fractures of the Edentulous Mandible
• Following extreme alveolar atrophy in the molar
regions of the edentulous mandible, these areas
are prone to fracture.
• The bilateral fractures of the body of the
edentulous mandible can occur near the posterior
attachment of the mylohyoid diaphragm. The
mylohyoid muscle level appears to be higher up in
this situation, because of extreme atrophy and loss
of vertical height of the body of mandible. There is
a downward and backward angulation of the
anterior part of the mandible seen due to the
influence of the digastric and the mylohyoid
muscles.
Aetiology of mandibular fractures
i. Vehicular accidents
ii. Altercation, assaults
interpersonal violence
iii. Fall
iv. Sports injuries
v. Industrial mishaps or work accidents
vi. Pathological fractures or miscellaneous
 Classifications
Kruger’s General Classification
• Simple or closed
The linear fracture which does not have
communication with the exterior or the interior.
Such a fracture does not produce a wound open
to the external environment either through the
skin, mucosa or periodontal membrane. It may or
may not be displaced.
Examples Fractures in the region of the condyle,
coronoid process, ascending ramus
• Compound or open
This fracture has communication with the
external environment through skin or with the
internal environment through mucosa or
periodontal membrane.
Comminuted
A fracture in which the bone is splintered or
crushed into multiple pieces. These types are
generally due to a greater degree of violence
or high velocity impact. Gunshot wounds,
where missiles are travelling at a high velocity
can produce these fractures.
Complicated or complex
Fractures associated with the damage to the
important vital structures complicating the
treatment as well as prognosis.
• Example Fractures with injury to the inferior
alveolar vessels or nerve, facial nerve or its
branches, facial vessels, condylar fractures
with associated injuries to middle cranial
fossa, etc.
Impacted Rarely seen in mandibular fractures.
More commonly seen in maxilla. This is a
fracture in which one fragment is firmly driven
into the other fragment and clinical
movement is not appreciable.
• Greenstick A fracture in which one cortex of
the bone is broken with the other cortex being
bent. It is an incomplete fracture seen in
young children because of inherent resilience
of the growing bone.
Pathological Spontaneous fracture of the
mandible occurring from mild injury or as a
result of a normal degree of muscular
contraction. This is because of weakness
caused due to the pre-existing bone
pathological processes.
 Anatomical Location
Rowe and Killey’s classification
A. Fractures not involving the basal bone—are
termed as dentoalveolar fractures.
B. Fractures involving the basal bone of the
mandible. Subdivided into following:
i. Single unilateral
ii. Double unilateral
iii. Bilateral
iv. Multiple
Dingman and Natvig’s classification of mandibular
fractures by anatomic region (1) Coronoid process,
(2) Condylar process, (3) Ramus region, (4) Angle region,
(5) Body region, (6) Alveolar process, (7) Symphysis region
Relation of the Fracture to the Site of Injury
• i. Direct fractures.
• ii. Indirect (countercoup) fractures.
• According to the Direction of Fracture and
Favourability for Treatment
a. Horizontally favourable fracture.
b. Horizontally unfavourable fracture.
c. Vertically favourable fracture.
d. Vertically unfavourable fracture.
Horizontally favourable line of fracture at the
angle of the mandible, (2) Horizontally
unfavourable line of fracture at the angle of
the mandible
(1) Vertically favourable line of fracture
through the right angle of the mandible,
(2) Vertically unfavourable line of fracture
through the right angle of the mandible
Signs and symptoms of mandibular fractures.
•Occlusal changes
•Deviation on opening
•Altered range of motion
•Localized pain
•Lacerations, ecchymosis, or hematoma
•Neurosensory deficits of the inferior alveolar nerve
•Changes in facial contour or mandibular arch form
•Blood in external auditory canal
•Mobility of bone segments
•Step deformity
Indications for removal of teeth in the line of
fracture
•Grossly mobile teeth with periapical pathology or
significant periodontal disease
•Partially erupted third molars with pericoronitis or
an associated cyst
•Teeth that prevent adequate reduction of the
fracture
•Teeth with fractured roots
•Teeth with exposed root surface from the apex to
gingival margin
 Radiographic examination
A panoramic radiograph is the single most
comprehensive image and usually allows for
satisfactory visualization of all regions of the
mandible (condyle, ramus, body, and
symphysis). It is also useful for examining
the existing dentition
•lateral skull
• posterioanterior
view
• lateral oblique
views
• reverse Townes
view
•CBCT
Towne’s view
is especially useful
in ruling out
subcondylar
fractures
PA view
Computed tomography (CT)
scans offer the most detailed
and comprehensive view of
the facial skeleton. Current
protocols allow for axial,
coronal, sagittal, and even
reconstructed
threedimensional
(3D) images to be formatted
Axial CT scan depicting comminuted symphysis
fractures.
Coronal CT scans

Sagittal CT scan depicting an anteriorly

displaced condylar fracture
General MANAGEMENT
• Airway
• Tongue falling back
• Blood clots
• Fractured teeth segments
• Broken fillings
• Dentures
• Hemorrhage
• Soft tissue lacerations
• Support of bone fragments
• Pain control
• Infection control e.g. compound fractures
• Food and Fluid
DEFINITIVE TREATMENT
• Reduction
Restoration of a functional alignment of the bone
fragments
• Use of occlusion
1. Open reduction
2. Closed reduction
• Immobilization
To allow bone healing Through fixation of fracture line
1. Rigid
2. Non-rigid
Goals of mandibular fracture repair

•Re-establish a stable occlusion

•Re-establish an adequate range of motion
•Restore facial and mandibular arch form
•Restore pain-free function
•Avoid internal derangement of the
temporomandibular joint
•Avoid growth disturbances of the mandible
 Closed reduction
Indications
1. Nondisplaced favourable fracture.
2. Grossly comminuted fractures.
3. Severely atrophic edentulous mandible.
4. Lack of soft tissue overlying the fracture site.
5. Fractures in children with developing teeth
buds.
6. Coronoid process fractures.
Intermaxillary fixation
1. Bonded brackets
2. Dental wiring
a. Direct
b. Eyelet
c. Arch bars
d. Cap splints
Erich arch bars and interdental stainless steel
wires.
Intermaxillary fixation (IMF) bone screws and
maxillomandibular fixation wires
Open reduction and rigid or stable fixation
1. Displaced unfavourable fractures.
2. Multiple fractures.
3. Associated midface fractures.
4. Associated condylar fractures.
5. When IMF is contraindicated or not possible.
6. To preclude the need for IMF for patient comfort.
7. To facilitate the patient’s early return to work.
METHODS OF IMMOBILIZATION
• Osteosynthesis without intermaxillary fixation
1. Non-compression small plates
2. Compression plates
3. Mini plates
4. Lag screws
Bone Plating Advantages
i. Rigid or stable fixation.
ii. Obviates the need for immobilization of the
mandible.
iii. Early return to home and work.
iv. Soft diet can be taken.
v. Maintenance of oral hygiene.
vi. Useful in mentally challenged, physically
handicapped patients.
vii. Maintenance of airway in multiple fractures.
 Classification of Condylar Fractures
1. Unilateral or bilateral condylar fractures
2. Rowe and Killey’s classification
a. Simple fractures of condyle
b. Compound fractures of condyle
c. Comminuted fracture associated with
zygomatic arch fractures
3. Rowe and Killey’s classification
a. Intracapsular fractures or high condylar
Fractures
i. Fractures involving the articular surface
(rare).
ii. Fractures above or through the anatomical
neck, which do not involve the articular
surfaces
b. Extracapsular or low condylar or subcondylar
fractures:
Here the fracture runs from the lowest
point of curvature of the sigmoid notch,
obliquely downward and backward below the
surgical neck of the condyle to the posterior
aspect of the upper part of the ramus.
Diagnostic Findings of Condylar Fractures
1. Evidence of facial trauma, symphysis.
2. Localized pain and swelling in the region of the TMJ.
3. Limitation in mouth opening.
4. Deviation, upon opening, toward the involved side.
5. Posterior open bite on the contralateral side.
6. Shift of occlusion
7. Blood in the external auditory canal.
8. Pain on palpation over the fracture site.
9. Lack of condylar movement upon palpation.
10. Difficulty in lateral excursions as well as
protrusion.
11. The occurrence of anterior open bite with
bilateral subcondylar fractures.
Signs of injury to the temporomandibular joint (1) Effusion–
h–haemarthrosis, a–midline shift to contralateral side,
b–unilateral posterior open bite
(2) Unilateral fracture dislocation, c–telescoping, d–posterior
premature contact, e–midline to
ipsilateral side,
(3) Bilateral fracture dislocation with anterior open bite
(4) Bilateral dislocation of the condyles without fracture.
Note the total inability to occlude
Nonsurgical Management of Condylar
Fractures
Condylar fractures without displacement or with
minimum displacement, without much occlusal
disturbance and functional range of motion do not
require any active treatment. Patient is asked to
restrict the movements and semisolid soft diet
intake for 10 to 15 days followed by active
movements.
Early mobilization is advocated in cases of young
children to avoid ankylosis of TMJ
Absolute Indications for Open Surgery
1. Fracture dislocations in the auditory canal or middle cranial fossa
2. Anterior dislocation with restricted mandibular
movements
3. Bilateral condylar fractures associated with a comminuted LeFort III
type with craniofacial dysjunction.

Relative Indications
1. Anterior and medial displacement of the condylar
fragment.
2. Unilateral or bilateral fractures with loss of the
posterior teeth
3. Cases in which position of the condylar fragment
interferes with normal function of the jaws.
Dentoalveolar fracture
Type I: Fractures within enamel
Type II: Fractures involving enamel
and dentin
Type III: Fractures involving pulp
Type IV: Root fractures

Ellis classification of dentoalveolar fractures

 Andreasen Classification
Injuries to Dental Tissues and Pulp
Crown infraction (craze lines without loss of tooth
substance)
Complicated crown fracture producing a pulp
exposure
Uncomplicated crown-root fracture without
pulpal exposure
Complicated crown-root fracture with pulpal
exposure
Root fractures (can be cervical, middle, or apical
thirds and oblique root fractures)
Injuries to Periodontal Tissues
Concussion: Percussion sensitive without loosening
of teeth
Subluxation: Tooth is loosened but not displaced
Luxation (lateral, intrusive, and extrusive luxations):
Tooth is displaced without any fractures or
comminution of the alveolar socket
Avulsion: Loss of teeth with or without supporting
bone
Injuries to the Supporting Bone
•Fracture of a single wall of an
alveolus
•Comminution of the alveolar
housing, seen with intrusive or
lateral luxation
•En bloc fracture of the alveolar
process, the fracture line not
necessarily extending through a
tooth socket
•Fracture involving the main body
of the mandible or maxilla
Injuries to the periodontal
tissues. (a) Concussion. (b)
Subluxation. (c) Extrusive
luxation. (d) Lateral luxation.
(e) Intrusive
luxation.
Cone-beam CT picture of a central incisor
showing a lateral luxation with fracture of the
labial bone plate.
Injuries to Gingiva
or Mucosal Regions
Abrasion
Contusion
Laceration
 Recommended Treatment for
Dentoalveolar Injuries
Enamel fractures Smoothen round edges; serial pulp
testing
Uncomplicated crown fracture Indirect pulp capping
involving calcium hydroxide base, glass ionomer, dentin
bonding agent, and composite cement
Complicated crown fracture
Small pulpal exposures treated by direct pulp capping,
larger exposures greater than 24 h treated by
calcium hydroxide pulpotomy, followed by conventional
root canal therapy at completion of root
development
Crown-root fracture Most of these fractures will require
extractions and socket preservation; however,
conservative treatment in form of orthodontic extrusions
and crown lengthening can be used in select cases

Root fractures Apical and middle third fractures if mobile

needs rigid splint; cervical fractures poor prognosis,
recommend extractions
Concussion Relieve occlusion; soft diet

Subluxation Similar to concussion; may

need nonrigid splint if teeth mobile

Intrusion Open apex: allow teeth to erupt;

closed apex: reposition, stabilize, and root
canal treat because of
the high incidence of pulpal necrosis
Extrusion Reposition, semirigid splint for 2 to 3
weeks, RCT
Lateral luxation If coexisting alveolar process
fractures, rigid splint for 2 to 8 weeks
Avulsions (< 2 h) Open apex: transport in Hank’s
balanced salt solution or milk, transfer to 1 mg/20
mL doxycycline bath, replant semirigid splint for 2
weeks; calcium hydroxide apexification if pathosis
occurs
Closed apex: same as above and endodontically
treat at the time of splint removal
Alveolar fractures Rigid splints for about a 6-week
duration to achieve bony union
Acid etch composite splint technique for
management of dentoalveolar injuries.
Reduction and arch bar fixation of posterior
segmental maxillary alveolar fractures.
Treatment of root fracture by repositioning
the coronal fragment and splinting.
Treatment principle for lateral luxation:
repositioning and splinting
Due to the presence of splints or arch bars
stabilizing the dentoalveolar segment,
optimal oral hygiene is essential for a
successful outcome. Meticulous tooth
brushing, chlorhexidine mouth rinses
are strongly recommended.
 Facial soft tissue injuries
Traumatic laceration remains one of the most common
problems treated in the emergency room

Contusions and abrasions top the list of injuries

treated, hematoma, puncture and foreign body
wounds, occur most frequently to the head or neck

Causes of these soft tissue injuries were most frequently

traffic accidents followed by sports and violence,
followed by play
 Management

Assessment
The mechanism of injury and time of occurrence, as
well as witnessed accounts should be recorded.
Mechanism of injury will provide
information about any potential foreign
bodies that need to be removed or
contaminants that may affect wound
healing.
Physical examination includes inspection
of the area noting the location, size, and
shape of the wound. Limitation of function
and involvement of nerves, vessels, muscles.
Presence of foreign bodies, contamination,
associated fractures or hematomas.
 Timing of repair

•Immediate primary closure of clean wounds.

•Delayed primary closure is a method of
management of dirty or infected traumatic
wounds or wounds that have gone unrepaired
for a considerable amount of time. These
wounds are converted to fresh wounds
through debridement and removal of tissue
edges and then covered loosely for several
days.
 Tetanus prophylaxis

the tetanus immune status of the patient

should be established. It should be
determined whether or not the patient has
had an initial tetanus immunization
 Tissue handling
•Gentle handling of all tissue
• proper use of retractors, tissue forceps
•sutures promote faster healing. Sutures tied too
tightly around the edges of the wound increase the
risk of infection.
• The presence of dirt, glass, or other foreign
material increases the risk of infection.
•Bleeding control.
•Another principle in wound handling is elimination
of wound dead space prior to closure.
 Instrumentation
•Absorbable sutures
Due to the difficulty in removing sutures in a young patient
and need for an additional visit to the provider, absorbable
sutures have become an alternative to the nylon
sutures traditionally used in repair of facial lacerations.

Tissue adhesive
Cyanoacrylate-based tissue adhesives have been
used for laceration repair
 Postoperative care
Postoperative wound care should
include verbal and written instructions
and information about the dressing
management, cleansing of the wound,
activity limitations, pain management,
expectations of the appearance of the
wound during the healing course, and
follow-up appointment.
 Dressing management
Repaired lacerations of the face can generally
be left uncovered. Due to the high vascularity
of facial skin, these wounds usually heal well
and have a low risk of infection. The use of
white petrolatum ointment may be just as
effective at preventing crusting around the
wound encouraging epithelialization to occur
rapidly and allowing easy removal of sutures
 Abrasion
Abrasions are typically characterized as
superficial injuries that denude the surface
epithelium; however, involvement of deeper
cutaneous layers must be ruled out. Serve as
massive portals of entry for microbes, much
like burn injuries. proper management is
required to prevent poor outcomes such as
infection, scarring, or contamination tattooing.
Abrasions require thorough lavage with irrigant
along with careful inspection and removal of any
solid remnants and necrotic epithelium. Remaining
irritants may be the source of prolonged
inflammation, infection, and eventual discoloration
of the wound following healing.
Abrasions are generally more painful than
lacerations or puncture wounds and more
aggressive forms of pain management should be
considered.
Abrasive wounds should be dressed with
antibiotic ointment and covered with
sterile gauze if necessary to maintain
wound moisture until re-epithelialization
is complete and final resolution of
the wound takes place.
 Laceration
Laceration is the most common type of facial injury
requiring surgical intervention. Assessment
of the depth of injury and reapproximation of
transected tissues is undertaken prior to closure of
the skin. Irregular edges and devitalized tissues
should be excised to provide sharp edges for easier
reapproximation when cosmetically possible.
Closure should be undertaken in
multiple layers with absorbable
sutures used for deep layers, and the
skin closed with monofilament
sutures which should be removed
after 3–5 days.
Contusions and haematomas
Bruising injury resulting from trauma is often
associated with tissue oedema. These injuries are
often associated with haematoma, which, if small, is
resorbed by the body. A moist, heated compress may
aid in reabsorption. Larger haematomas may be
selectively incised and drained to prevent
subcutaneous scarring.
Avulsion
When small areas of tissue are lost due
to trauma, undermining the adjacent skin
will allow the margins to be directly
approximated and closed. Larger defects,
however, will require skin grafts or flaps
for coverage.
Mucosa
In general, lacerations, abrasions, and
burns of the mucosa heal quickly with
little intervention needed; however, if
large or gaping, intraoral wounds
benefit from approximation and suture
closure
Bites
Human and animal bites result in
extensively contaminated wounds.
Copious irrigation and sharp
debridement of devitalized tissue is
essential in preventing wound infection.
This may result in sacrifice of vital soft
tissue components in aesthetically
sensitive areas, but cannot be avoided.
Quiz