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ANATOMY AND FRACTURES OF THE MANDIBLE

ANATOMY
Mandible interfaces with skull base via the TMJ and is

held in position by the muscles of mastication

Anatomic units of the mandible

Muscles of the mandible Posterior group


Origin Insertion Innervation Action Masseter
Inferior 2/3 zygomatic bone & medial surface of zygomatic arch Limits of temporal fossa Lateral ramus and angle of mandible Masseteric branch of anterior division of mandibular nerve (V) Elevate and protrude mandible

Temporalis

Medial surface coronoid process, anterior surface of ramus down to occlusal plane Medial surface of ramus and angle of mandible

Two deep temporal branches of mandibular nerve (V), sometimes reinforced by middle temporal nerve Branch from main trunk of mandibular nerve

Elevates mandible, posterior fibres are the only muscle fibres to retract the mandible Pulls angle of mandible superiorly, anteriorly and medially Lateral movement, protrusion, important in active opening of the mouth

Medial pterygoid Lateral pterygoid

Pterygoid fossa, mainly medial surface of lateral pterygoid process Upper head from infratemporal surface of skull, lower head from lateral pterygoid plate

Upper head inserts into TMJ capsule, lower head into anterior surface of condylar neck

Branch of anterior division of mandibular nerve

Muscles of the mandible Anterior group


Origin Insertion Innervation Action Genioglossus
Superior part of mental spine of mandible Hypoglossal nerve (XII) Depresses tongue, posterior part protrudes tongue

Geniohyoid

Inferior part of mental spine of mandible

Body of hyoid bone

C1 through hypoglossal nerve (XII)

Pulls hyoid bone anterosuperiorly, shortens floor of mouth and widens pharynx Elevates hyoid bone, floor of mouth and tongue during swallowing and speaking Depresses mandible, raises hyoid bone and steadies it during swallowing and speaking

Mylohyoid

Mylohyoid line of mandible

Raphe and body of hyoid bone

Mylohyoid nerve, a branch of inferior alveolar nerve (V3)

Digastric

Anterior: Digastric fossa of mandible Posterior: Mastoid notch of temporal bone

Intermediate tendon to body and superior (greater) horn of hyoid bone

Anterior: Mylohyoid nerve (V3) Posterior: Facial nerve (VII)

Muscles of Mastication
OUTER SURFACE

Muscles of Mastication
INNER SURFACE

Muscles of Mastication
4 muscles of mastication
Masseter Temporalis

Medial pterygoid
Lateral pterygoid

Supplied by V3, testament to same embryologic

origin as the mandible from the 1st branchial arch

Masseter
Divided into 3 heads
Superficial:
largest head Arises anterior 2/3rds of the lower border of the zygomatic

arch
Wide insertion to angle, forwards along lower border and

upwards to lower part of ramus

Intermediate:
Middle 1/3 of the arch

Deep:
Deep surface of the arch

Action: elevator and drawing forward the angle

Masseter
Intermediate and deep fuse and pass vertically

downwards to fuse with ramus


Nerve and artery divide muscle incompletely into 3

parts
Masseteric nerve (Br of anterior division of V3) runs

between deep and intermediate


Br of superficial temporal and transverse facial runs

between superficial and intermediate

Temporalis
Arises temporal fossa between inferior temporal line

and infratemporal crest


Inserts at posterior border of the coronoid process

and ascending ramus


Upper and anterior fibres elevate the mandible Posterior fibres (horizontal) retract the mandible

(only muscles that do so)

Medial pterygoid
2 heads:
Deep:
Larger

Medial surface of the lateral pterygoid plate and the

fossa between 2 plates

Superficial :
Tuberosity of the maxilla and pyramidal process of

palatine bones

Insert lower and posterior part of angle (with

masseter)
Action: upwards and forwards and medially

Lateral pterygoid
2 heads:
Superior:
Infratemporal fossa

Inferior:
Lateral surface of the lateral pterygoid

Fuse into a short thick tendon that inserts into

pterygoid fovea
the upper fibres passing into articular disc and

anterior part of the capsule

Action: side-to-side plus only muscle to open

jaw

Temporomandibular Joint
Articulation
Synovial joint between the condyle of the mandible

and the mandibular fossa in the squamous part of the temporal bone
Both bone surfaces covered with layer of

fibrocartilage identical to the disc


No hyaline cartilage, therefore an atypical joint

Temporomandibular Joint
Unique feature of the TMJs is the articular

disc.
Composed of fibrocartilaganeous tissue
Divides each joint into 2:
Inferior compartment Superior compartment

Temporomandibular Joint
Inferior compartment
Allows for pure rotation of the condylar head, corresponds to the first 20 mm or so of the opening

of the mouth. (opening and closing movements)

Superior compartment

involved in translational movements sliding the lower jaw forward or side to side

Temporomandibular Joint

Temporomandibular Joint

Atypical synovial joint separated into upper and lower cavities by a fibrocartilaginous disc

No hyaline cartilage

Capsule attached high on neck of mandible around articular margin, then to transverse prominence or articular tubercle and as far posteriorly as squamotympanic fissure Fibrocartilage attached around periphery to capsule

Anteriorly near head of mandible, so mobile Posteriorly near temporal bone, so more fixed Thinner in middle than periphery, crinkled fibres to allow movement and contouring

Lateral TM ligament is a stout fibrous band passing from zygomatic arch to posterior border of neck and ramus, blending with capsule

Tightens with movements away from rest

Sphenomandibular ligament runs between sphenoid spine and lingula of mandible

Remains constant tension through range of motion as the lingula is the axis of rotation of the mandible

Sensation supplied by auriculotemporal nerve with some supply from nerve to masseter (Hiltons law)

TMJ Ligaments
3 ligaments associated with the TMJ:
1) Temporomandibular ligament (Major)

is really the thickened lateral portion of

the capsule, and it has two parts:


an outer oblique portion (OOP) and

an inner horizontal portion (IHP)


Lower border of zygomatic arch to posterior border of

the neck and ramus

TMJ Ligaments
2) stylomandibular ligament (minor)
separates the infratemporal region from the parotid

region
runs from the styloid process to the angle of the

mandible
3) Sphenomandibular ligament (minor)
runs from the spine of sphenoid to the lingula of the

mandible

TMJ Ligaments
The minor ligaments are important in that they

define the limits of movements,


ie the farthest extent of movements of the mandible. Not connected to joint

However, movements of the mandible made past

these extents functionally allowed by the muscular attachments BUT will result in painful stimuli

TMJ Ligaments

TMJ Ligaments

Mandibular Forces

Nerve Supply
Inferior alveolar nerve branch of the mandibular

division of Trigeminal (V) nerve, enters the mandibular foramen and runs forward in the mandibular canal, supplying sensation to the teeth.
At the mental foramen the nerve divides into two

terminal branches:
Incisive nerve: supplies the anterior teeth mental nerve: sensation to the lower lip

Evaluation - History
Always remember ABCs of life along with

secondary and tertiary survey


Mechanism of injury
MVA associated with multiple comminuted #
Fist often results in single, non - displaced # Anterior blow to chin - bilateral condylar # Angled blow to parasymphysis can lead to

contralateral condylar or angle #


Clenched teeth can lead to alveolar process #

Physical Exam Occlusion Change in occlusion - determine preinjury occlusion


bite is suggestive of bilateral condylar or angle fractures process or parasymphyseal fractures

Posterior premature dental contact or an anterior open Posterior open bite is common with anterior alveolar Unilateral open bite is suggestive of an ipsilateral angle

and parasymphyseal fracture


Retrognathic occlusion is seen with condylar or angle

fractures
Condylar neck # are assoc with open bite on opposite

side and deviation of chin towards the side of the fx.

Angles classification
Class I:
Normal Mesial buccal cusp of the upper 1st molar

occludes with mesial buccal groove of the mandibular molar

Class II:
Retrocclusion, mandibular deficiency

Class III:
Prognathic occlusion, maxillary deficiency,

mandibular excess

Dental classification of occlusion

Angles classification (1887)

Class I

Based on relationship of permanent 1st molars and to a lesser degree the permanent canines to each other

Molar relation

Canine relation

Mesiobuccal cusp of maxillary 1st molar is in line with buccal groove of mandibular 1st molar Buccal groove of mandibular 1st molar is distal to mesiobuccal cusp of maxillary 1st molar Buccal groove of mandibular 1st molar is mesial to mesiobuccal cusp of maxillary 1st

Maxillary permanent canine occludes with distal of mandibular canine and mesial half of mandibular 1st premolar Distal surface of mandibular canine is distal to mesial surface of maxillary canine by at least width of a premolar Distal surface of mandibular canine is mesial to mesial surface of the maxillary canine by at least the width of a

II
Div1 Overjet Div2 Lingual inclination

III

Malocclusion

Physical Exam
Anaesthesia of the lower lip
Abnormal mandibular movement
unable to open - coronoid fx

unable to close - # of alveolus, angle or ramus


trismus

Lacerations, Haematomas, Ecchymosis Loose teeth swelling

Physical Exam
Multiple fractures sites are common:
1 fracture: 50% 2 fractures: 40%

>2 fractures: 10%

Dual patterns:
Angle contralateral body Symphysis and bilateral condyles

15% another facial fracture

General Principles of treatment ABCs


Tetanus Nutrition Almost all can be considered open fractures as

they communicate with skin or oral cavity


Reduction and fixation Post-op monitoring for N/V, use of wire cutters Oral care - H2O2 , irrigations, soft toothbrush

Aims of Management
1) Achieve anatomical reduction and stabilisation
2) Re-establish pre-traumatic functional occlusion 3) Restore facial contour and symmetry 4) Balance facial height and projection

Fracture Frequency

Classification of Fractures Open vs Closed

Displaced vs non-displaced Complete vs greenstick Linear Vs comminuted Relationship to the teeth


Class I: teeth both sides of fracture Class II: teeth one side of fracture Class III: edentulous

Favourable vs unfavourable

Treatment options
No treatment
Soft diet Maxillomandibular fixation Open reduction - non-rigid fixation Open reduction - rigid fixation External pin fixation

IMF

IMF

Islet IMF

Open reduction nonrigid fixation

External Fixation

Principles of fixation
Usually one plate with 4

cortices of fixation are required for adequate immobilisation


Anterior to mental

foramen, 2 levels of fixation are required to overcome torsional forces


Unfavourable fractures

usually require 2 levels of fixation for stability


Fixation along Champys

line allows better fixation due to the strong buttress structure

Condylar fractures

Classification

Condylar

Intra- or extra-capsular

subcondylar

Watch for intracranial condylar head Condylar heads tend to dislocate anteromedially towards pterygoid plates due to pull from medial pterygoid Indications for open reduction are angulation > 30, fracture gap > 5mm, lateral override, bilateral fractures of head/neck

Risks avascular necrosis of condylar head, facial nerve injury, hypertrophic scarring (10%)

Alveolar fractures

3% total fractures, often in combination with other fractures


Can often be reduced and fixed with arch bars (can be acrylated) or Essig splints May require monocortical plate fixation

Teeth are often insensate and require orthodontic evaluation


Gross comminution or loss of blood supply increases the risk of infection and primary debridement of the devitalised segment with soft tissue coverage may be a better long term option Can have compression fractures of alveolus resulting in loosened teeth

Miller Grade 1 - < 1mm looseness Miller Grade 2 1-3mm looseness Miller Grade 3 - > 3mm looseness and loose superoinferiorly in socket

Teeth in fracture line


Important in fracture stability when using IMF Less important in fracture stability when plates used to fix fractures Reasons to extract the tooth Severe tooth loosening with chronic periodontal disease Fracture of the root of the tooth Extensive periodontal injury and broken alveolar walls Displacement of teeth from their alveolar socket Interference with bony reduction and reestablishing occlusion Third molars tend to cause the most controversy Third molars that are erupting normally need not be removed unless they are interfering with fracture reduction Impacted third molars can be removed as they are rarely a functional part of the occlusion Removal of third molars unnecessarily leads to increased conversion from closed reduction to open reduction

Edentulous mandible

No occlusal plane Lack of mandibular height due to atrophy Changed pattern of fracture body is more common as atrophy is greatest Changed position of inferior alveolar nerve and artery Changed pattern of blood supply more circumferential than radial Role of recon plates and bone grafting Role of dentures

Paediatric mandible
Often greenstick fractures that heal within 2-3 weeks
65% mandibular fractures in children < 10yo are in

condylar region, 40% in 11-15yo

Arch bars are common use to avoid damage to

secondary teeth, but primary teeth are conically shaped


and effective

Acrylic splint secured by circumferential wiring is safe Condyle is the major growth centre of the mandible and

has some ability to remodel, and poorly tolerates periosteal stripping

Crush of condylar head (esp. < 3y) can lead to altered

mandibular growth and TMJ ankylosis secondary to haemorrhage

Complications

Airway esp with IMF (wire cutters and pre-op education)


Infection Delayed and non-union

Inadequate immobilisation, fracture alignment Inteposition of soft tissue or foreign body Incorrect technique

Inferoir alveolar nerve damage

56%pre-treatment
19% post-treatment

Malocclusion TMJ ankylosis esp intracapsular condyle #