MANDIBULAR

SOYEBO O.A
FRACTURES

OUTLINE
INTRODUCTION
CLASSIFICATION
AETIOLOGY
EPIDEMIOLOGY
SIGNS & SYMPTOMS
INVESTIGATION
MANAGEMENT

INTRODUCTION
Fracture of the mandible occurs more frequently than that of any other
facial skeleton.
It is the one serious facial bone injury that the average practicing dental
surgeon may expect to encounter, albeit on rare occasions, at his
surgery.
It is also a facial fracture which he may have the misfortune to cause as
a complication of tooth extraction.
Broadly divided into:
1. Fractures with no gross communition of the bone and without
significant loss of hard and soft tissues
2. Fractures with gross communition of the bone and with extensive loss
of both hard and soft tissues.

ANATOMY
Lower jaw bone
U shaped body
2 vertically directed
rami
Condylar process
Coronoid process
Oblique line
Mental foramen

INTERNAL ANATOMY
Mandibular foramen
Lingula
Pterygoid fovea
Mylohyoid line
Fossae
Submandibular
Sublingual
Digastric
Mental spines
Genioglossus
Geniohyoid

MUSCULATURE:
jaw elevators
Masseter muscle: from
zygoma to angle and
ramus
Temporalis muscle: from
infratemporal fossa to
coronoid and ramus.
Medial pterygoid
muscle: medial pterygoid
plate and pyramidal
process into the lower
mandible.

MUSCULATURE:
jaw depressors
Lateral pterygoid muscle:
lateral pterygoid plate to
condylar neck and TMJ
capsule
Mylohyoid muscle:
Mylohyoid line to body of
hyoid
Digastric muscle: mastoid
notch to digastric fossa
Geniohyoid muscle: inferior
genial tubercle to anterior
hyoid bone

INNERVATION
CN3; mandibular nerve
through the foramen
ovale
Inferior alveolar nerve
through the mandibular
foramen
Inferior dental plexus
Mental nerve through
the mental foramen.

BLOOD SUPPLY

Internal maxillary
artery
Inferior alveolar
artery
Mental artery

CLASSIFICATION OF FRACTURES
Type of fracture
Site of fracture
Cause of fracture

TYPE OF FRACTURE
Simple
Includes a closed linear fractures of the condyle, coronoid,
ramus and edentulous body of the mandible.

Compound
Fractures of tooth bearing portions of the mandible, into d
mouth via the periodontal membrane and at times through
the overlying skin.

Communited
Usually compound fractures characterized by fragmentation of
bone

Pathological

COMPOUND
SIMPLE

COMMUNITED

SITE OF FRACTURE
Dentoalveolar
Condyle
Coronoid
Ramus
Angle
Body (molar
and premolar
areas)
Parasymphysis
Symphysis

SITE OF FRACTURE

A- CONDYLAR
B- CORONOID
C-RAMUS
D- ANGLE
E- BODY(MOLAR
PREMOLAR AREAS
F- PARASYMPHYSIS
G- SYMPHYSIS
H-DENTO-ALVEOLAR

CAUSE OF FRACTURE
Direct violence
Indirect violence
Excessive muscular contraction
Fracture of the coronoid process because of sudden reflex
contracture of the temporalis muscle.

PATTERN OF FRACTURE
Unilateral fracture
Bilateral fracture
Multiple fracture
Communited fracture

AETIOLOGY
Road traffic accidents
Interpersonal violence
Contact sports
Industrial trauma
Falls

EPIDEMIOLOGY
The mandible is one of the most commonly fractured
bones of the face and this is directly related to its
prominent and exposed position.
Oikarinen and Lindqvist (1975) studied 729 patients
with multiple injuries sustained in RTA. The most
common facial fractures were in the mandible.

Mandible (61%)
Maxilla (46%)
Zygoma(27%)
Nasal Bone (19%)

 Studies have shown that the incidence of mandible

fractures are influenced by various etiological factors
e.g.

Geography
Social trends
Road traffic legislations
Seasons

 Site of Fracture: Oikarinen and Malmstrom (1969)

analyzed 600 mandible fractures. On analysis the
following results were obtained:

Body of mandible (33.6%)

Sub- condylar area(33.4%)
Angle (17.4%)
Dentoalveolar (6.7%)
Ramus (5.4%)
Symphyseal 2.9%
Coronoid 1.3%

 Even though the body of the mandible has the highest

incidence when it comes to mandibular fracture, the
condyle remains the commonest site for mandibular
fracture

SIGNS AND SYMPTOMS

GENERAL
SPECIFIC

GENERAL SIGNS AND SYMPTOMS

Swelling
Pain
Drooling
Tenderness
Bony discontinuity
Lacerations

Limitation in mouth
opening
Ecchymosis
Fractured, subluxed,
luxated teeth.
Bleeding from the
mouth.

SPECIFIC SIGNS AND SYMPTOMS

DENTOALVEOLAR FRACTURES

Lip bruises and laceration

Step deformity
Bony discontinuity
Fracture, luxation or subluxation of teeth
Laceration of the gingivae

FRACTURE OF THE BODY

Swelling
pain
Tenderness
Step deformity
Anaesthesia or paraesthesia of the lip
Intra oral hemorrhage

SYMPHYSEAL/PARASYMPHYSEAL FRACTURES

Tenderness
Sublingual haematoma
Loss of tongue control
soft tissue injury to the chin and lower lip

 FRACTURE OF THE RAMUS

Swelling
Ecchymosis
Pain
Trismus

FRACTURE OF THE ANGLE

Swelling
Posterior gag
Deranged occlusion
Anaesthesia or paraesthesia of lower lip
Haematoma
Step deformity behind the last molar tooth
Tenderness

 CORONOID FRACTURE

Tenderness over the anterior part of the tragus

Haematoma
Painful limitation of movement
Protrusion of mandible may be present.

SYMPHYSEAL/PARASYMPHESEAL FRACTURES

Tenderness
pain
Step deformity
Sublingual haematoma
Loss of tongue control
May have soft tissue injury to the chin and lower lip

 CONDYLAR FRACTURE (unilateral/bilateral and

Intracapsular/extracapsular)
Unilateral condylar fractures

Swelling over the TMJ

Hemorrhage from ear on the affected side
Battles sign
Locked mandible
Hollow over the condylar region after edema has subsided
rarely, Paraesthesia of lower lip
Deviation to the affected side upon opening
Painful limitation of movement

 Bilateral condylar fractures

Same as above
Limitation in mouth opening
Restricted mandibular movement
Anterior open bite

INVESTIGATION
Treatment plan for mandibular fractures is very
dependent on precise radiological diagnosis
RADIOGRAPHS
Essential radiographs
Extra-oral radiographs
Intra-oral radiographs

Desirable radiographs

Essential Extra-oral
Radiographs
Oblique lateral
radiographs (left and
right)
Fracture of body proximal
to canine region
Fractures of angle, ramus
and condylar region

 Posterior-anterior
view
Shows displacement of
fractures in the ramus,
angle, body

Rotated posterioranterior view

Fractures between
Symphysis and canine
region

 Reverse Townes
view
Ideal for showing
lateral or medial
condylar
displacement

Essential Intra-oral Radiographs

Periapical radiographs:
Association of tooth to line of fracture
Existing pathology related to tooth in line of fracture
Fracture of tooth in line of mandibular fracture

Occlusal radiographs:
Association of root of tooth to line of fracture

Desirable Radiographs
Panoramic tomography
represents the best
single overall view of the
mandible especially the
condyles

Standard linear
tomography
Computed tomography
(CT)

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

BONE HEALING
Bone healing is altered by types of fixation and mobility
of the fracture site in relation to function
Primary bone healing
Secondary bone healing

Bone Healing
Primary bone healing:
No fracture callus forms
Heals by a process of
1. Haversian remodeling directly across the fracture site if no
gap exists (Contact healing), or
2. Deposition of lamellar bone if small gaps exist (Gap healing)
. Requires absolute rigid fixation with minimal gaps

Bone Healing

Contact Healing

Gap Healing

Bone Healing
Secondary bone healing:
Bony callus forms across fracture site to aid in stability and
immobilization
Occurs when there is mobility around the fracture site

Bone Healing
Secondary bone healing involves the
formation of a sub periosteal hematoma,
granulation tissue, then a thin layer of bone
forms by membranous ossification. Hyaline
cartilage is deposited, replaced by woven
bone and remodels into mature lamellar bone

Bone Healing

TEETH IN LINE OF FRACTURE

Teeth in line of fracture are a potential impediment to healing for the
following reasons
1. The fracture is compound into the mouth via the opened periodontal
membrane
2. The tooth may be damaged structurally or loose its blood supply as a result
of the trauma so that the pulp subsequently becomes necrotic
3. The tooth may be affected by some pre-existing pathological process
.Indications for removal
Absolute
Relative

Absolute indications
Longitudinal fracture involving the root
Dislocation or subluxation of tooth from socket
Presence of periapical infection
Infected fracture line
Acute pericoronitis

Relative indications
Functionless tooth which would eventually be removed
electively
Advanced caries
Advanced periodontal disease
Teeth involved in untreated fractures presenting more
than 3days after injury

Management of teeth retained in

fracture line
Good quality intra-oral periapical radiograph
Appropriate antibiotic therapy
Splinting of tooth if mobile
Endodontic therapy if pulp is exposed
Immediate extraction if fracture becomes infected

IMMOBILIZATION
The period of stable fixation required to ensure full
restoration of function varies according to:
1. Site of fracture
2. Presence of retained teeth in the line of fracture
3. Age of the patient
4. Presence or absence of infection

 A simple guide to time of immobilization for fractures of

the tooth bearing area of the mandible is as follows:
Young adult
with

Fracture of angle
Receiving

Early treatment
In which

Tooth removed from fracture line

3
week
s

 If:
a) Tooth retained in fracture line: add 1 week
b) Fracture at Symphysis: add 1 week
c) Age 40yrs and above: add 1 or 2 weeks
d) Children and adolescent: subtract 1 week

METHODS OF IMMOBILIZATION
Osteosynthesis without intermaxillary fixation
1. Non-compression small plates
2. Compression plates
3. Mini plates
4. Lag screws

 Intermaxillary fixation
1. Bonded brackets
2. Dental wiring
1. Direct
2. Eyelet

3. Arch bars
4. Cap splints

 Intermaxillary fixation with Osteosynthesis

1. Trans osseous wiring
2. Circumferential wiring
3. External pin fixation
4. Bone clamps
5. Transfixation with kirschner wires

CLOSED REDUCTION
Fracture reduction that involves techniques of not
opening the skin or mucosa covering the fracture site
Fracture site heals by secondary bone healing
This is also a form of non-rigid fixation

 If the principle of using the simplest method to achieve

optimal results is to be followed, the use of closed
reduction for mandibular fractures should be widely
used Petersons Principle of Oral and Maxillofacial Surgery 2nd edition
INDICATIONS
1. Nondisplaced favorable fractures
2. Mandibular fractures in children with developing
dentition
3. Condylar fractures

 CONTRAINDICATIONS:
1. Alcoholics
2. Seizure disorder
3. Mental retardation
4. Nutritional concerns
5. Respiratory diseases (COPD)
.Unfavorable fractures

 ADVANTAGES
1. Low cost
2. Short procedure time
3. Can be done in clinical setting with local anesthesia or
sedation
4. Easy procedure

 DISADVANTAGES
1. Not absolute stability (secondary bone healing)
2. Oral hygiene difficult
3. Possible TMJ sequelae
a) Muscular atrophy/stiffness
b) Decrease range of motion

 TECHNIQUES:
1. Arch bars Erich arch bars
2. Ivy loops
3. Essig Wire
4. Intermaxillary fixation screws
5. Splints
6. Bridal wires

OPEN REDUCTION
Implies the opening of skin or mucosa to visualize the fracture and
reduction of the fracture
Can be used for manipulation of fracture only
Can be used for the non-rigid and rigid fixation of the fracture
INDICATIONS
Unfavorable/unstable mandibular fractures
Fractures of an edentulous mandible fracture with severe
displacement
Delayed treatment with interposition of soft tissue that prevents
closed reduction techniques to re-approximate the fragments

Open reduction/rigid fixation

Open reduction/ non rigid

SPECIAL CONSIDERATIONS
Edentulous mandible
Mandible in children

Mandibular Fractures in children

Mandible is resilient at this period
Line between cortex and medulla is less well defined
High ratio of bone to teeth substance

Factors to consider in treating fractures in children

Interference with growth potential
Fixation in deciduous/mixed dentition
Unerupted teeth

Fracture of Edentulous mandible

Influencing factors:
1. Decreased inferior alveolar artery (centrifugal) blood
flow
2. Dependent on periosteal (centripetal) blood flow
3. Medical conditions that delay healing
4. Decreased ability to heal with age
5. Altered physical characteristics following tooth loss

 Methods of immobilization:
Direct Osteosynthesis
1. Bone plates
2. Transosseous wiring
3. Circumferential wiring
. Indirect skeletal fixation
1. Pin fixation
2. Bone clamps
. Intermaxillary fixation using gunning type splints
1. Used alone
2. Combined with other techniques

COMPLICATIONS
Misapplied fixation
Infection
TMJ ankylosis
Nerve damage
Displaced teeth
Gingival and periodontal complications

 Malunion
Delayed union/Non union
Inadequate immobilization, fracture alignment
Interposition of soft tissue or foreign body
Incorrect technique

Limitation in mouth opening

Scar formation

CONCLUSION
An adequate knowledge of the diagnosis and
management of various types of mandibular fracture is
needed so as to provide the desired treatment in order
to prevent unfavorable and adverse complications.