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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

Lateral ramus and


angle of mandible

Masseteric branch of
anterior division of
mandibular nerve (V)

Elevate and protrude


mandible

Temporalis

Limits of temporal
fossa

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

Two deep temporal


branches of
mandibular nerve
(V), sometimes
reinforced by middle
temporal nerve

Elevates mandible,
posterior fibres are
the only muscle
fibres to retract the
mandible

Medial
pterygoid

Pterygoid fossa,
mainly medial
surface of lateral
pterygoid process

Medial surface of
ramus and angle of
mandible

Branch from main


trunk of mandibular
nerve

Pulls angle of
mandible superiorly,
anteriorly and
medially

Lateral
pterygoid

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

Lateral movement,
protrusion, important
in active opening of
the mouth

Muscles of the mandible


Anterior group
Origin

Insertion

Innervation

Action

Hypoglossal nerve
(XII)

Depresses tongue,
posterior part
protrudes tongue

Genioglossus

Superior part of
mental spine of
mandible

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

Mylohyoid

Mylohyoid line of
mandible

Raphe and body of


hyoid bone

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

Elevates hyoid bone,


floor of mouth and
tongue during
swallowing and
speaking

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)

Depresses mandible,
raises hyoid bone
and steadies it during
swallowing and
speaking

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

Sphenomandibular ligament runs between sphenoid spine and


lingula of mandible

Tightens with movements away from rest

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


Posterior premature dental contact or an anterior open

bite is suggestive of bilateral condylar or angle


fractures

Posterior open bite is common with anterior alveolar

process or parasymphyseal fractures

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 1 st 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)

Based on relationship of permanent 1st molars and to


a lesser degree the permanent canines to each other

Class

Molar
relation

Canine relation

Mesiobuccal cusp of
maxillary 1st molar is in
line with buccal groove
of mandibular 1st molar

Maxillary permanent canine


occludes with distal of
mandibular canine and mesial
half of mandibular 1st premolar

II

Buccal groove of
mandibular 1st molar is
distal to mesiobuccal
cusp of maxillary 1st
molar

Distal surface of mandibular


canine is distal to mesial surface
of maxillary canine by at least
width of a premolar

Buccal groove of
mandibular 1st molar is
mesial to mesiobuccal
cusp of maxillary 1st
molar

Distal surface of mandibular


canine is mesial to mesial
surface of the maxillary canine
by at least the width of a
premolar

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

Acrylic splint secured by circumferential wiring is

safe and effective

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 #