Fraktur Mandibula

Anatomy: Bony Landmarks

• Condylar Process
• Coronoid Process
• Ramus
• Angle
• Body
• Symphysis/parasymphysis
Occlusion: The Angle Classification

• Based upon the relationship of the first mandibular and maxillary

molars
• Class I: normal occlusion
• Class II: an “underbite”
• Class III: an “overbite”
• Observe wear facets
Common Sites of Fracture

• Condyle 36%
• Body 21%
• Angle 20%
• Parasymphysis 14%
• Coronoid, ramus, alveolus, symphysis 3%
• Weak areas include 3rd molar and canine fossa
Innervation

• CNV3, the mandibular n., through the foramen ovale

• Inferior alveolar n. through the mandibular foramen
• Inferior dental plexus
• Mental n. through the mental foramen
Arterial Supply

• Internal maxillary artery

• Inferior alveolar artery
• Mental artery
Musculature: Jaw Elevators

• Masseter: Arises from zygoma and inserts into the angle and ramus
• Temporalis: Arises from the infratemporal fossa and inserts onto the
coronoid and ramus
• Medial pterygoid: Arises from medial pterygoid plate and pyramidal
process and inserts into lower mandible
Musculature: Jaw Depressors

• Lateral pterygoid: lateral pterygoid plate to condylar neck and TMJ

capsule
• Mylohyoid: mylohyoid line to body of hyoid
• Digastric: mastoid notch to the digastric fossa
• Geniohyoid: inferior genial tubercle to anterior hyoid bone
Favorable Fractures

• Those fractures where the muscles tend to draw fragments together

• Ramus fractures are almost always favorable as the jaw elevators
tend to splint the fractured bones in place
Unfavorable Fractures

• Fractures where the muscles tend to draw fragments apart

• Most angle fractures are horizontally unfavorable
• Most symphyseal/parasymphyseal fractures are vertically
unfavorable
Midline fracture

Signs and symptoms

• Pain and tenderness

• Swelling and odemea
• Development of step deformity
• Mental anesthesia
• Heamatoma in the floor of mouth and buccal mucosa
• Soft tissue injury of the chin and lower lip

If associated with condylar fractures

• Absence of condyle movement on the contrlateral side

• Deviation of mandible
• Anterior open bite
• Gagging of oclussion
• Limitation of mouth opening

12
Clinical assessment and diagnosis
• History of trauma
(traumatized patients with possible head injury) and facial injuries

• Clinical Examination
▶ Extroral
Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut
wounds)
Palpation for eliction of tenderness, pain, step deformity and malfunction

▶ Intra- and paraoral

bleeding, heamatoma, gingival tear, gagging of occlussion and step
deformity and sensory and motor deficiency

• Radiographs

13
Radiographs

• Plain radiograph
• OPG
• Lateral oblique
• PA mandible
• AP mandible (reverse
Townes)
• Lower occlusal
• CT scan
• 3-D CT imaging
• MRI

14
Close reduction

• Arch bars
• Jelenko
• Erich pattern
• German silver notched
• Cap splints

▶ IMF prior to rigid fixation

▶ For the purpose of close
reduction

15
Close reduction

Bonded brackets
IMF screws
Dental wiring:
• Direct wiring
• Eyelet wiring
• Local anesthesia or sedation
• Minimal displacement
• IMF for 6 weeks
Treatment can be performed under GA
or LA and when surgery is
contraindicated

16
Fracture mandible in children

• Close reduction
• Open reduction and
fixation
• Plating at the inferior
border
• Resorpable plates

17
Gunning’s splint

• Old modality
• Edentulous patient
• Rigid fixation is not
possible
• To establish the occlusion

18
Open reduction and fixation

• Intraoral approach

• Extraoral approach
▶ Submandibular
approach

19
Rigid fixation

• Intraossous wiring
• Plates and screws
• Kirchener wire
• Lag screws

20
Reconstruction palate

Severe trauma
Loss of part of the bone

21
Condylar fractures

• Intraoral approach
Ramus incision

• Extraoral approach
Preauricular approach
Retromandibular approach

22
IMF

• Transosseous wiring

• Circumferential wiring

• External pin fixation

• Bone clamps

• Trans-fixation with Kirschner wires

23
Osteosynthesis

• Non-compression small plates

• Compression plates

• Miniplates

• Lag screws

• Resorbable plates and screws

24
Teeth in the fracture line

• The fracture is compound into the mouth

• The tooth may be damaged or lose its blood supply

• The tooth may be affected by some preexisting pathology

25
Management of teeth retained in fracture line

• Good quality intra-oral periapical radiograph

• Insinuation of appropriate systemic antibiotic
therapy
• Splinting of tooth if mobile
• Endodontic therapy if pulp is exposed
• Immediate extraction if fracture becomes infected
• Follow up for 1 year and endodontic therapy if
there is a loss of vitality

26
Absolute indications
• Longitudinal fracture
• Dislocation or subluxation from socket
• Presence of periapical infection
• Infected fracture line
• Acute pericoronitis

Relative indications
• Functional tooth that would be removed
• Advanced caries or periodontal diseases
• Doubtful tooth which would be added to existing denture
• Tooth in untreated fracture presenting more than 3 days after
injury

27