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Face!Mouth!&!Jaw!Surgery:!International!Trainee!Journal!of!Oral!&!Maxillofacial!Surgery.!2012;!2(1):12B21!
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EDUCATIONAL!!
REVIEW!

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How!to!Manage!Fractures!of!the!
Mandible!!a!Simple!Guide!
Nabeela&Ahmeda,*&
Katherine&Georgeb&
aKings!College!Hospital,!London!

Abstract!
Fractures!of!the!mandible!are!common!reason!for!
maxillofacial!referrals!by!Emergency!

bGuys!Hospital,!London!

Departments.!Irrespective!of!the!mechanism!of!

injury,!correct!and!appropriate!diagnosis!are!

*Correspondence:!Oral!and!Maxillofacial!
Department,!Kings!College!Hospital,!!Denmark!
Hill,!London,!SE5!9RS!
!
Email:!nabeela@doctors.net.uk

essential.!
This!review!article!looks!at!the!aetiology,!
presentation,!diagnosis!and!subsequent!
management!of!mandibular!fractures,!including!
those!of!the!condyle.!

!
Introduction!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!!!
!
Fractures! of! the! mandible! are! common! and!
most! patients! will! present! to! the! maxillofacial!
team! by! referral! from! the! emergency!
department.!!The!aetiology!of!the!injury!usually!
falls!under!the!broad!category!of!trauma!and!as!
such!other!injuries!are!common!and!need!to!be!
excluded;! cervical! spine! fractures! can! be!
present! in! as! many! as! 20%! of! cases.1! ! The!
advanced! trauma! life! support! (ATLS)!
framework! provides! a! concise! approach! to! the!
management! of! these! patients! on! initial!
presentation.! ! Once! other! injuries! are! excluded!
or!dealt!with!and!the!patient!is!stable,!attention!
can!be!turned!to!any!mandibular!fractures.!
!
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Face!Mouth!Jaw!Surg!2012;!2!(1):!12B21!
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Examining! the! aetiology! of! the! injuries! more!
closely,! one! finds! that! the! most! common!
mechanism! of! injury! in! the! UK! is! assault,!
followed! by! traffic! accidents,! falls! and! sports!
injury.2! Males! are! six! times! more! likely! to!
present! with! a! mandibular! fracture! than!
females.3! As! ever,! detailed! medical! notes! with!
diagrams!are!invaluable!as!part!of!good!medical!
record! keeping! and! given! that! interpersonal!
violence! is! the! most! common! mechanism! of!
injury,! they! may! be! needed! by! the! court! later.!!
Do!bear!in!mind!though!that!fractures! can! also!
be!pathological!and!iatrogenic.!
!
This! article! will! discuss! and! explain! general!
principles! and! should! be! used! as! a! means! of!

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How!to!Manage!Fractures!of!the!Mandible!!A!Simple!Guide!

revisiting! methods! of! fracture! fixation! and! the!

arguments! for! and! against! the! different!
methods!of!management.!
!
!

Figure!2:!Anatomy!of!the!mandible!

How! do! you! classify! mandibular!

fractures?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!I!
!
The! classification! of! mandibular! fractures! is!
similar! to! any! other! broken! bone.! ! The! type! of!
fracture,! location! and! the! degree! of!
displacement!should!be!described!(Figure!1!and!
2).!
This!
simplistic!
approach!
aids!
communication! between! surgeons! and!
facilitates! treatment! decisions! as! to! whether!
surgery! is! required! and! the! urgency! of! such!
intervention!.!
!
!
!
Figure!1:!Fracture!description!based!on!!
type!and!anatomical!site!
Type!
Greenstick!
Simple!
Compound!
Comminuted!
Pathological!
!
Anatomical/Site!of!fracture!
Dentoalveolar!
Condylar!
Coronoid!
Ramus!
Angle!
Body!
Parasymphysis!
Symphysis!

!
!
!
!
!

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The! mechanism! of! injury,! prominence! of! the!
mandible! and! inherent! areas! of! weakness!
influence! fracture! sites.!Concurrent! dental!
trauma! may! also! be! present! and! should! be!
considered! in! order! to! account! for! missing!
tooth! fragments! in! a! patient! who! may! be!
unconscious.! A! good! history! can! help! you!
predict! where! the! suspected! fracture! may!
indeed!be!present.!!
The! commonest! fracture! site! is! the! body! and!
the! least! fractured! part! the! coronoid! of! the!
mandible.2!A!2%!deformity!in!bone!is!sufficient!
to!trigger!a!fracture!process.5!
!

Mandible!Location!
Body!
SubBcondylar!area!
Angle!
Alveolar!
Ramus!
Symphyseal!
Coronoid!

%!of!total!fractures!
33.6%!
33.4%!
17.4%!
6.7%!
5.4%!
2.9%!
1.3%!

!
Displacement! of! fractured! segments! is!
affected!by!what!factors?!
1)!Force!of!blow.!
2)!Integrity!of!periostium.!
3)!Degree!of!interdigitation!of!fracture!ends.!
4)!Direction!of!fracture!line.!
5)!Pull!of!muscles!inserted!into!the!mandible.!

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Management!Principles!!!!!!!!!!!!!!!!!i!
!
As!with!all!trauma,!the!priority!of!management!
should!be!as!follows:!
!
1)!Control!of!life!threatening!injuries!!
2)!Diagnosis!and!treatment!of!other!serious!
injuries!as!needed!!
3)! Diagnosis! and! management! of!
maxillofacial!injuries!
!
!

History!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!
!
Ask! about! the! circumstances! of! injury,! which!
may!give!an!indication!as!to!the!force!used!and!
aid! in! prediction! of! the! fracture! pattern.! Being!
punched! once! will! give! you! a! different!
predicted!injury!to!someone!who!has!fallen!and!
landed!on!their!chin.!
!
Ask!about!their!complaints!and!what!they!think!
is! wrong.! Ask! questions! about! their! pain,! any!
perceived! numbness! and! any! problems! with!
opening! or! closing! their! mouth.! These! injuries!
can! present! in! delayed! fashion! because! of!
problems!or!pain!eating.!Ask!the!patient!if!their!
bite! feels! normal,! any! subjective! change! in!
occlusion! may! be! the! result! of! swelling! but!
could!also!indicate!a!displaced!fracture.!
!
!

Examination!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!
!
ExtraQoral!
Look!for!any!obvious!asymmetry,!swelling,!and!
bruising.! Document! the! presence! of! any!
lacerations.!
Palpate! the! mandibular! border! bilaterally! for!
any!step!deformity.!Note!the!nature!of!swelling!
and! mobility.! ! Record! tenderness! and! function!
in!terms!of!jaw!movement.!!

Cranial! nerve! assessment! is! mandatory!

(especially!for!ID!nerve!function).!
!
IntraQoral!
Assess! the! occlusion! and! note! any!
derangement.! Look! for! bruising! or! lacerations!
of!the!soft!tissues!and!gingival!tears.!Palpate!the!
alveolar!processes!and!document!any!fractured!
or!missing!teeth.!
Document! the! maximum! interBincisal! distance!
on!mouth!opening.!
!
!

What! Radiographs! should! be!

taken! to! identify! possible!
mandibular!fractures?!!!!!!!!!!!!!!!!!!!i!!
!
Patients! referred! from! the! emergency!
department! with! an! isolated! mandibular!
fracture! should! have! undergone! radiographic!
examination!by!way!of!two!plain!radiographs!at!
different! angles! to! each! other.! ! These! will!
usually! include! a! posteroanterior! view! of! the!
mandible! and! a! dental! panoramic! tomogram!
(DPT)! or! lateral! oblique! views.! ! Other! views!
such! a! lower! standard! occlusal,! periapicals,! an!
anteroposterior! mandible! or! occipital! mental!
views! may! also! be! helpful! in! certain! situations.!!!
In! the! multi! trauma! setting,! assessment! with! a!
CT!scan!is!performed.!
!
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Figure!3:!DPT!of!a!right!parasymphyseal!fracture!
of! the! mandible.! The! unerupted! teeth! have!
influenced!fracture!line!propagation!

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How!to!Manage!Fractures!of!the!Mandible!!A!Simple!Guide!

What! broad! treatment! options!

are!available?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!
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1.!Non!Operative!Management!
This! can! be! indicated! if! it! is! a! single,! stable,!
undisplaced!fracture!of!the!mandible.!
However!you!need!a!good!stable!occlusion!and!
a! patient! who! can! tolerate! a! soft! diet! and!
maintain! good! oral! hygiene.! They! will! also!
require! pain! relief! with! oral! analgesics! and! a!
course! of! antibiotics! may! be! indicated.! If!
considering!this,!early!review!is!mandatory!and!
the! patient! warned! any! change! in! occlusion!
would! warrant! intervention.! Any! associated!
gingival!or!soft!tissue!laceration!adjacent!to!the!
fracture!would!exclude!this!potential!method!of!
management.!
!
2.!Operative!management!
This! is! where! the! fracture/s! are! unstable! or!
open! and! would! require! reduction! and! fixation!
using!the!following!methods:!
!
a)!Closed!reduction!
Bwith!intermaxillary!fixation!(IMF)!using:!!
arch! bars,! Leonard! buttons! or! eyelet!
wiring!if!dentate!
Gunning! splints! or! dentures! if!
edentulous! held! by! trans! palatal! and!
circumferential!wiring!
Bwith!external!fixation!
!
IMF!is!limited!by:!
1.
Inadequate!teeth!for!stabilisation.!
2.
Unstable!initial!occlusion.!
3.
Muscle!pull!may!misalign!fragments!
even!if!the!occlusion!is!correct.!
4.
Not! useable! if! associated! with!
midface! (zygomatic,! ethmoidal)!
fractures.!
5.
Aspiration! risk! especially! if! the!
patient! vomits! or! has! significant!
swelling.!

6.
7.

Risk!of!weight!loss/!presence!of!coB
existing!respiratory!disease.!
Patient!acceptance.!

!
If! you! are! going! to! use! IMF,! the! interdental!
wiring! is! usually! perfrmed! with! 0.4mm!
stainless!steel!wire.!
!
b)!Open!reduction!!
This! is! indicated! for! displaced! unfavorable!
fractures! of! the! mandible! and! allows! early!
mobilization! and! return! of! jaw! function.!!
Surgical!access!to!the!mandible!is!usually!via!an!
intraoral! approach.! ! However,! an! extra! oral!
approach! may! be! chosen! in! situations! where!
load!bearing!reconstruction!plates!are!required!
for! adequate! fixation! or! where! soft! tissue!
lacerations! are! appropriately! positioned! for!
access.!
!
Remember,! the! distance! between! ID! canal! and!
cortex! is! approximately! 4mm! in! the! premolar!
and!5.9!mm!in!the!second!molar!region,!so!this!
should!be!borne!in!mind!when!deciding!on!your!
screw! length.! The! mental! nerve! and! foramen!
also! need! to! be! accommodated! when! planning!
fixation.!In!general!terms,!any!fracture!anterior!
to! the! mental! foramen! requires! two! plates!
based! on! Champys! principles! and! will! lead! to!
reduced!postoperative!morbidity.6!
!
!

Consenting! a! patient! for! a!

fractured!mandible!!!!!!!!!!!!!!!!!!!!!!!!!i!
!
Clearly!the!benefits!are!a!restoration!of!function!
and! improved! healing.! However,! patients!
should!be!counselled!about!the!following:!
Planned! access! (intra! or! extra! oral! and!
transbuccal!approaches)!

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The! plates! are! left! in! situ! and! not!

removed! (and! do! not! set! off! metal!
detectors).!
Your! proposed! use! of! arch! bars! and!
whether! these! will! be! left! in! situ!
postoperatively! (and! think! about! any!
disruption!to!crowns/fillings)!
Post! operative! pain,! swelling,! bleeding,!
bruising.!
The!risk!of!infection!(early/late).!
Possible! need! for! plate! removal! B! this!
occurs! in! 5B20%! of! cases! and! is! usually!
due! to! either! wound! breakdown! or!
infection.7!
Poor!fracture!healing.!
Warn! them! about! paraesthesia! of! ID! or!
mental!
nerve!
(permanent!
vs!
temporary)!
Injury!to!marginal!mandibular!branch!of!
facial! nerve! (if! transbuccal! approach!
discussed)!
Loss! of! teeth! (requiring! extraction! if!
impairing!reduction!of!fracture)!
Malocclusion! (perceived! and! actually!
post!operatively)!
Loss! of! vitality! of! teeth! adjacent! to!
fracture!line!
Presence!
of!
a!
scar!
(if!
transbuccal/extraoral!approach)!
TMJDS.!

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PreBoperative!management!!!!!!!!!i!
!
Antibiotics! are! required! for! all! compound!
fractures! and! dentoalveolar! fractures! (make!
sure! you! are! familiar! with! local! antibiotic!
prophylaxis! recommendations)! as! essentially!
these!are!open!fractures.!
!
PreBop! fasting! must! be! strictly! adhered! to! as!
these! patients! often! have! limited! mouth!

opening! and! may! require! awake! fibreBoptic!

intubation.!
!
Remind! the! anaesthetist! you! will! require! a!
nasal! tube,! unless! there! is! an! edentulous! area!
the! tube! can! be! secured! through! or! the! plan! is!
to! place! a! tracheostomy! or! convert! to! a!
submental!intubation!if!an!oral!tube!is!placed!
!
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PostBoperative!management!!!!!!!i!
!
IMF!is!usually!released!before!the!patient!wakes!
up!and!then!replaced!using!orthodontic!elastics!
once!the!patient!is!fully!conscious.!!If!wire!IMF!
remains! in! situ! post! operatively,! the!
anaesthetist! will! wait! until! the! patient! is!
conscious! prior! to! extubation! and! wire! cutters!
must!accompany!them!at!all!times.!
!
It!is!considered!good!surgical!practice!to!remain!
in! theatre! with! your! patient! until! they! have!
been!extubated.!It!is!also!a!good!opportunity!to!
recheck! occlusion! and! ensure! no! TMJ!
dislocation!has!occurred!during!the!final!stages!
of!the!anaesthetic!procedure!and!extubation.!
!
Intermediate!postQop!
close!supervision!
head!elevated!30!degrees!
suction!at!bedside!
prescribe!
medications!
such!
as!
antiemetics,!analgesia!and!antibiotics.!
prescribe! hot! salt! water! and!
chlorhexidine!mouthwashes!
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Pre!Discharge!Advice!!!!!!!!!!!!!!!!!!!!!i!
!
Advise!patients!to!not!smoke.!
No!contact!sports!for!at!least!6!weeks.!
Its!important!to!reinforce!that!their!diet!needs!
to! be! soft! and! ensure! a! preBop! weight! is!

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How!to!Manage!Fractures!of!the!Mandible!!A!Simple!Guide!

recorded! (if! patients! are! in! IMF! or! have! a! preB

op! low! BMI! consider! dietician! input! if!
available).! Weekly! weights! are! helpful! if! they!
remain! in! IMF! and! help! guide! nutritional!
support.!
!
Consider! postBoperative! radiographs! before!
discharge!(although!this!is!a!controversial!issue.!
Some!argue!that!clinical!reduction!is!sufficient).!
However,! postoperative! radiographs! are! useful!
in!patient!education,!analysing!injuries!in!those!
who! represent! with! problems! and! in! the!
assessment! of! patients! with! an! ongoing!
malocclusion!complaint!post!surgery.!
!
Arrange!a!postBoperative!review!approximately!
a!week!later.!
Post!Treatment!Review!in!Outpatients!
Document! any! complaints! or! patient!
concerns!
Check!their!occlusion!
Document!
any!
residual/onBgoing!
paraesthesia!
Review! any! other! soft! tissue! injuries!
and!remove!sutures!
Review!medications!
Patient! reinstructed! of! importance! of!
good!oral!hygiene!and!nutrition!
Avoid!contact!sports!
Consider!need!for!onBgoing!IMF!
Planned!mobilisation!
Remember! dental! rehabilitation! via!
GDP!if!any!associated!dental!injuries!
!!
!

What!
are!
the!
common!
complications! of! mandibular!
fractures?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!
!
1)! Bone:!delayed!union,!nonBunion,!malBunion,!
osteomyelitis!

2)!Teeth:!malocclusion,!loss,!infection!
3)Nerves:!
sensory!
loss!
anaesthesia/!
hypoaesthesia/!dysaesthesia!
4)!Joint:!dysfunction,!fibrous/bony!ankylosis!
5)!Aesthetic:!deformity!
!

Specific!fracture!sites!!!!!!!!!!!!!!!!!!!!!i!
!
Coronoid!Fractures!
These!rarely!require!fixation,!although!this!may!
be! indicated! if! there! is! impingement! on! the!
zygomatic!arch.8!
!
Ramus!Fractures!
This! is! an! unusual! fracture! which,! if! present,!
usually!shows!little!displacement.!
Closed! reduction! and! fixation! is! the! usual!
treatment! of! choice! and! can! be! achieved! with!
no! operative! intervention! if! a! malocclusion! is!
not! present.! If! there! is! a! malocclusion! or!
another! fracture! present,! then! use! arch! bars!
and!arrange!fixation!of!the!other!fracture.!
!
Angle!Fractures!and!Body!Fractures!
Can! be! managed! with! IMF,! monocortical!
miniplate! osteosynthesis,! wire! osteosynthesis,!
screw!fixation!or!a!combination!of!all.!
These!fractures!can!be!accessed!via!an!intraoral!
approach,! but! more! commonly! a! transbuccal!
approach! is! adopted! for! the! final! fixation! to!
facilitate! the! placement! of! the! screws!
perpendicular! to! the! bone.! As! such! patients!
need! additional! warning! on! the! consent! form!
regarding! neuropraxic! injury! to! the! marginal!
mandibular! branch! of! the! facial! nerve! and! the!
presence!of!a!small!scar.!
!
Symphysis!and!parasymphysis!fractures!
Open!reduction!and!internal!fixation!is!required!
as! displacement! is! often! present! because! of!
muscle! forces! exerted! in! this! area.! They! often!
coexist!with!condylar!fractures,!so!check!the!xB

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rays! carefully! and! if! need! be! go! back! and!
examine! the! patient.! This! is! why! a! thorough!
history!at!initial!clerking!is!helpful!in!suggesting!
where!the!injuries!may!be!present.!
!
!

Condylar!fractures!!!!!!!!!!!!!!!!!!!!!!!!!!i!
!
Condylar! fractures! are! an! interesting! subgroup!
of! mandibular! fracture,! presenting! their! own!
challenges! in! terms! of! assessment! and!
management.! They! are! common,! occurring! in!
30B50%! of! mandibular! fractures! and! they!
usually!occur!unilaterally.!
!
As!a!general!rule,!fractures!with!a!displacement!
of! more! than! 10! degrees! and! overlap! of! more!
than!2mm!should!be!treated!with!ORIF.9!There!
are! several! classification! systems! devoted! to!
condylar! fractures,! focusing! on! the! anatomical!
location! and! the! displacement! of! the! condylar!
segment.! ! The! subclassification! proposed! by!
Loukota! at! al.! focuses! on! the! anatomical!
location! of! the! fracture! and! has! been! adopted!
by! the! Strasbourg! Osteosynthesis! Research!
Group.10! It! is! simple! to! use! and! easy! to!
remember! and! when! combined! with! the! angle!
of! displacement! and! the! amount! of! overlap! of!
the!condylar!segment,!provides!clinicians!with!a!
useful! framework! on! which! to! help! guide!
treatment!decisions!(Figure!4).!
!
!
!
Figure! 4:! SORG! classification:! (1)! high/condylar!
neck! fracture;! (2)! low/condylar! base! fracture;!
(3)! diacapitular! fracture! (with! permission! from!
Loukota,!journal!permission!pending)!

The!management!principles!are!similar!to!those!
for!mandibular!fractures!in!general,!in!terms!of!
history! and! examination.! ! However,! on!
examination,! one! should! suspect! a! fractured!
condyle! if! there! is! pain! on! palpation! of! the!
temporomandibular! joint,! laceration! or!
bleeding!noted!at!the!external!acoustic!meatus,!
injury!to!the!chin,!deviation!of!the!mandible!on!
opening! and! a! lateral! open! bite! on! the!
contralateral!side!to!the!fracture.!Investigations!
for! the! ambulant! patient! would! normally!
include!2!radiographic!images!of!the!mandible;!
a!postero!anterior!(PA)!mandible!and!a!DPT,!as!
for!other!mandibular!fractures.!!CT!scans!can!be!
useful! in! the! assessment! of! intracapsular!
fractures! of! the! condyle! which! can! not! always!
be! seen! on! plain! radiographs;! and! again,! may!
also! be! the! imaging! modality! of! choice! in! the!
multi!trauma!patient.!
!
In!general!terms,!treatment!options!comprise:!
1.! Functional! (soft! diet/analgesia/activity!
modification)!
2.! Indirect! immobilization! (arch! bars! and!
elastics/wires)!
3.!Open!reduction!and!fixation!using!plates!
!
The! decision! will! depend! upon! patient! factors,!
the! occlusal! discrepancy! and! the! classification!
of! the! fracture! as! previously! discussed.! Where!
there! is! no! occlusal! discrepancy! then! no!
surgical! intervention! is! required! and! patients!
can!be!managed!with!a!soft!diet!and!warned!to!
refrain! from! contact! sports.! ! ! The! choice!
between! a! closed! reduction! or! open! reduction!
and!internal!fixation!is!more!fluid.!!!
!
Closed!reduction!is!advocated!for!high!condylar!
neck! or! dicapitular! fractures,! in! minimally!
displaced! fractures! and! in! the! management! of!
condylar!fractures!in!children.!!In!this!group!of!
patients! the! results! of! closed! treatment! are!
good.! ! It! must! be! remembered! that! although! a!
closed!approach,!it!should!not!be!thought!of!as!a!

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conservative! approach! as! intermaxillary! elastic!

fixation!is!required!and!this!is!associated!with!a!
degree! of! morbidity.! ! A! general! anaesthetic! is!
usually! required! in! order! to! place! the! archbars!
and! these! are! worn! for! a! period! of! 6! weeks.!!
Elastic! intermaxillary! fixation! to! correct! the!
malocclusion!is!usually!worn!for!up!to!2!weeks,!
followed! by! the! use! of! guiding! elastics! and!
postoperative!physiotherapy!in!order!to!get!the!
joint!moving.!!!
!
Open! reduction! and! internal! fixation! of!
fractured! condyles! is! becoming! more! common,!
due! in! part! to! an! improvement! in! the!
technology! available! and! also! to! several! trials!
which!have!supported!the!technique.!!Absolute!
and!relative!indications!were!initially!proposed!
in! 1983,! although! these! have! been! modified!
over!time!and!are!as!follows:11!
!
Absolute!Indications!
Displacement! of! the! condyle! into! the!
middle!cranial!fossa!
Impossibility! of! obtaining! adequate!
occlusion!by!closed!reduction!
Lateral!extracapsular!displacement!
Invasion!by!foreign!body!
!
Relative!Indications!
Bilateral! fractures! in! an! edentulous!
patient!without!a!splint!
Unilateral! or! bilateral! condylar! fractures!
where! splinting! cannot! be! accomplished!
for! medical! reasons! or! because!
physiotherapy!is!impossible!
Bilateral! condylar! fractures! with!
comminuted!
midfacial!
fractures,!
prognathia!or!retrognathia!
Periodontal!problems,!loss!of!teeth!
Unilateral!condylar!fracture!with!unstable!
base!
!
!

Surgical!Approaches!to!the!Condyle!
There!are!several!surgical!access!approaches!to!
the!fractured!condyle!and!the!choice!is!based!on!
the! position! of! the! fracture! and! surgical!
preference.!!The!more!common!approaches!are!
listed:!
!
Retromandibular!
Submandibular!
Transmeatal!
PreBauricular!
Endoscopic!
!
The!most!common!risks!of!an!open!approach!to!
the! fractured! condyle! are! pain,! bleeding,! scar!
formation! and! the! risk! of! infection.! ! Of! more!
concern! to! the! majority! of! surgeons! and!
patients! is! the! risk! to! the! facial! nerve! and! the!
possibility! of! temporary! or! permanent!
weakness!following!surgery.!!However,!the!risk!
of!facial!nerve!weakness!has!been!shown!to!be!
very! low! in! the! published! literature! with!
temporary! weakness! ranging! between! 0%! and!
30%! and! permanent! weakness! of! 1%! when! a!
retromandibular!approach!was!employed.12,13!If!
the! condyle! is! approached! by! a! transparotid!
route,!there!is!also!a!risk!of!sialocele!formation!
or!a!salivary!fistula.!!Again,!the!risks!of!this!are!
low.!
!
Treatment! of! condylar! fractures! remains!
controversial.! However,! the! risks! of! a! surgical!
approach! should! be! considered! as! there! are!
benefits!to!closed!treatment!as!well.!
!
!
Benefits! of! open! reduction! and! internal!
fixation!
1. Anatomical!reduction!
2. Occlusal!stability!
3. Rapid!recovery!of!function!
4. Maintenance!of!vertical!ramus!height!
5. Reduced!deviation!on!opening!

!!
!
!
!

19!

Face!Mouth!&!Jaw!Surgery:!International!Trainee!Journal!of!Oral!&!Maxillofacial!Surgery.!2012;!2(1):12B21!

!
!
!
6. No! airway! compromise! (short! and! long!
term! because! of! potential! reduction! in!
movement)!
7. Potential! reduction! in! complaints! of! TMJ!
dysfunction.!
!
!
Benefits!of!closed!treatment!
1. Reduced!overall!morbidity!
2. Avoids!risks!of!an!open!approach,!such!as!a!
scar,! sialocele,! and! risk! of! facial! nerve!
injury!
3. Technically! much! simpler! (arch! bars! vs.!
retromandibular!approach)!
4. Less!risk!of!ankylosis!of!the!joint!
5. Less!risk!of!avascular!necrosis!
!
As! a! general! rule! of! thumb,! discuss! cases! of! a!
condylar!fracture!with!a!senior!in!the!presence!
of! a! malocclusion.! Any! patients! who! are! sent!
home! with! a! unilateral! undisplaced/minimally!
displaced! condyle! must! be! reviewed! early! and!
warned! surgical! intervention! may! be! indicated!
in!the!occlusion!drifts.!It!is!essential!to!instruct!
them! on! the! necessity! for! following! a! soft! diet,!
analgesia!and!avoidance!of!any!further!trauma.!!
!
!

Special!Circumstances!!!!!!!!!!!!!!!!!!!i!
!
What!do!you!do!for!children!under!10?!
If!there!is!a!malocclusion!present,!this!can!often!
be! disregarded,! as! spontaneous! correction! will!
take!place!as!the!dentition!develops.!If!there!is!a!
displaced!condylar!neck,!fractures!will!undergo!
full!functional!restitution!in!most!cases,14!and!in!
children! unilateral! and! bilateral! condylar!
fractures! are! treated! in! the! same! way.!!
Treatment! should! be! entirely! functional! where!
possible.!If!intervention!is!required!in!the!form!
of! IMF! (indicated! for! control! of! pain)! this!
should! be! released! after! 7B10! days! to! avoid!
ankylosis.!!Where!an!intracapsular!fracture!has!
been! diagnosed,! careful! followBup! and!

monitoring!of!growth!is!required,!so!that!if!any!
associated! facial! asymmetry! develops! it! can! be!
appropriately!managed.!
!
What!do!you!do!for!adolescents!aged!10Q17?!
Same! principles! apply! as! for! adults! with! some!
modifications! (and! will! be! dependent! upon!
their!stage!of!dental!development).!
If! malocclusion! is! present! capacity! for!
spontaneous! correction! is! less,! so! will! require!
intervention! and! this! will! usually! constitute! a!
brief!period!of!IMF,!not!longer!than!2B3!weeks.!
!
!

Summary!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!
!
Appropriate!assessment,!a!good!clinical!
examination!along!with!knowledge!gained!from!
radiological!investigations!allows!sufficient!
information!to!be!attained!in!order!to!plan!the!
management!of!a!patient!with!a!mandibular!
fracture!but,!as!this!article!shows,!each!case!
much!be!reviewed!with!individual!merit!to!plan!
the!best!outcome!for!the!patient.!
!
!

References!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!
!
1. Williams! J,! Jehle! D,! Cottington! E,!
Shufflebarger! C.! Head,! facial,! and!
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1992;21(6):719B22.!
2. Coulthard! P,! Yong! SL,! Adamson! L,!
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M,! et! al.! Domestic! violence! screening!
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3. Bochlogyros! PN.! A! retrospective! study! of!
1,521! mandibular! fractures.! J! Oral!
Maxillofac!Surg!1985;43(8):597B9.!
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Ahmed!!!!!

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How!to!Manage!Fractures!of!the!Mandible!!A!Simple!Guide!

fractures.! Suom! Hammaslaak! Toim!

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Open! reduction! and! internal! fixation!
versus!
closed!
treatment!
and!
mandibulomaxillary!
fixation!
of!
fractures! of! the! mandibular! condylar!
process:! a! randomized,! prospective,!
multicenter! study! with! special!
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10. Loukota! RA,! Eckelt! U,! De! Bont! L,! Rasse!

M.! Subclassification! of! fractures! of! the!
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