DEPARTMENT OF ORAL MEDICINE

AND RADIOLOGY

Seminar on
MANDIBULAR
FRACTURES
Presented by
SYED NABI AHMED
C.R.I.
 Anatomy: Bony Landmarks
 Condylar Process
 Coronoid Process
 Symphysis/parasymphysis
 Ramus
 Angle
 Body
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
Mandibular Fracture
Innervation
 The mandibular nerve, through the foramen
ovale
 Inferior alveolar nerve through the mandibular
foramen
 Inferior dental plexus
 Mental nerve 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
Classification of Mandibular
Fracture

 According to Generic Terms

 Simple or Closed Fracture : Fracture that
does not communicate with external
environment.
 Compound or Open Fracture : Fracture that
communicate with external environment
through skin, mucosa or periodontal ligament.
 Commiuted Fracture : Fracture in which a
single anatomic region of a bone is broken into
pieces.
 Greenstick Fracture : A fracture in
which one side of the bone is broken
and the other side is bent
 Pathologic Fracture : A fracture
occurring at a site weakened by pre-
existing disease.
 Complicated Fracture : A fracture
with significant injury to adjacent soft
tissues or structures.
 Dislocation Fracture : Fracture of a
bone near an articulation with concomitant
dislocation from that articulation
 Direct Fracture : Fracture that occurs at
the point of impact
 Indirect Fracture : Fracture that occurs at
a point distant from the site of impact
 Impacted Fracture : Fracture in which
one fragment is driven into the other
fragment.
 Incomplete Fracture : Fracture in which
the line of fracture does not include the
entire bone.
 Multiple Fracture : Two or more lines of
fractures exist on a bone and do not
communicate with each other
 Unstable Fracture : Fracture with
intrinsic tendency to slip out of place
after reduction
 According to Anatomic Region Involved
 Condylar Process
 Coronoid
 Ramus
 Angle
 Body
 Symphysis/Parasymphysis
 Alveolar
 According to Radiographic Direction
 Horizontal
 Vertical
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
Physical Examination
 Change in occlusion is highly diagnostic
 Anterior open bite suggestive bilateral
condylar or angle fractures
 Posterior open bite common with alveolar
process or parasymphyseal fractures
 Unilateral open bite with ipsilateral angle
or parasymphyseal fracture
 Retrognathic (Angle III) seen with condylar
or angle fractures
 Prognathic (Angle II) seen with TMJ
effusion
 Anesthesia of lower lip is “pathognomonic”
of a fracture distal to the mandibular
foramen
 The converse is not true: not all fractures
distal to the mandibular foramen have
mental n. anesthesia
 Trismus of less than 35mm also highly
suggestive of mandibular fracture
 Inability to open the mandible suggests
impingement of the coronoid process on the
zygomatic arch
 Inability to close the mandible suggests a
fracture of the alveolar process, angle, ramus
or symphysis
Signs and Symptoms
 Anesthesia of the lower lip
 Abnormal mandibular movement
 unable to open - coronoid fx
 unable to close - fx of alveolus, angle or ramus
 trismus
 Lacerations, Hematomas, Ecchymosis
 Loose teeth
 Swelling
 Pain
 Malocclusion
Radiographic Examination
 Panorex shows the entire mandible, but
requires the patient to be upright. It also has
particularly poor detail of the TMJ and medial
displacement of the condyles
 AP - ramus and condyle
 Submental - symphysis
 CT - condylar fractures
General Principles of
Treatment
 The general physical status should be
thoroughly evaluated.
 Tetanus
 Nutrition
 40% associated with significant injury,
10% of which are lethal
 Cerebral contusion is common
 Dental injuries should be treated
concurrently
 Reestablishment of occlusion is the
primary goal
 Fractured teeth may jeopardize occlusion
 Mandibular cuspids are cornerstone of
treatment
 Prophylactic antibiotics.
 With multiple facial fractures, mandibular
fractures are treated first
 Almost all can be considered open fixation 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

 Biweekly examination - hardware, occlusion,

weight
Treatment Options
 Soft diet
 Maxillomandibular fixation
 Open reduction - non-rigid fixation
 Open reduction - rigid fixation
 External pin fixation
 Lag screw, DCP
Closed Reduction
 Grossly comminuted fractures
 Significant tissue loss
 Edentulous mandibles
 Fractures in children
 Condylar fractures
Open Reduction
 Displaced, unfavorable fractures of angle
 Displaced unfavorable fractures of the body
or parasymphysis, as these tend to open at
the inferior border, leading to malocclusion
 Multiple fractures of facial bones
 Displaced, bilateral condylar fractures
Open Reduction - Nonrigid Fixation
Open Reduction - Rigid Fixation
Closed Reduction of the
Dentulous Patient
 Erich Arch Bars. Can lead to periodontal
infalmmation.

 Avoid fixating incisors, as these teeth are

moved by the wires
 Ivy loops
Ivy Loops
Erich Arch Bars
Closed Reduction of the
Partially Edentulous Patient
 Partials and circum wires or screws
 Acrylic partials with incorporated arch bar
wires
Closed Reduction of the
Edentulous Patient
 Dentures with circum wires and screws
 Fabricated acrylic plates (Gunning Splints)
 In fractures of both the mandible and maxilla,
circumzygomatic and circum-mandibular
wires should be tied together to prevent
telescoping of maxilla
Open Reduction and
Osteosynthesis
 Simpler than rigid fixation
 MMF still required
 Useful in angle, parasymphyseal fractures
Open Reduction Internal Fixation
 Performed with compression plates and lag
screws
 MMF generally not required
 Eccentrically placed holes and screws placed
at angles “compress” the bone
Complications
 Socioeconomic groups
 Infection (James, et. al.)
 Delayed healing and malunion. Most
commonly caused by infection and
noncompliance
 Nerve paresthesias in less than 2%
 TMJ problems
Conclusion
 With multiple techniques available, there is
still controversy over the best treatment for
each type of mandible fracture
 The decision is a clinical one based on patient
factors, the type of mandible fracture, the skill of
the surgeon, and the available hardware
 Further studies are in progress