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Mandibular fracture Deepak Kumar Gupta
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Mandibular fractureDeepak Kumar Gupta
Applied Anatomy
• Body▫ Mental foramen lies on the anterior part of lateral
surface.▫ External oblique ridge – lateral side▫ Medial surface has mylohyoid line.▫ Mylohyoid line helps divide a sublingual from a
submandibular fossa▫ Posterior border of the mylohyoid line provides for
attachment of the pterygomandibular raphe▫ At the midline on the medial side are the superior
and inferior genial tubercles, as well as the digastric fossa
Applied Anatomy
• Ramus▫ Meets the body of the mandible at the angle of the
mandible on each side.▫ Masseter m. attaches to the lateral side▫ Medial pterygoid m. And sphenomandibular
lig. attach to the medial side▫ Mandibular foramen is located on the medial side
of the ramus▫ Superior part divides into a coronoid process
anteriorly and a condylar process posteriorly, separated by a mandibular notch
Applied Anatomy
• Coronoid process
▫ The anteriormost superior extension of each ramus
▫ Attatchment of Temporalis m.
• Condylar process Articulates with the temporal bone in the
temporomandibular joint
Has a neck that forms a condyle superiorly
Lateral pterygoid muscle attaches to pterygoidfovea on the neck
Alveolar Process
• Extends superiorly from the body
• Created by a thick buccal and a thin lingual plate of bone
• The part of the mandible that supports the mandibular teeth
• Each side of the mandible contains 5 primary and 8 permanent teeth
• Alveolar bone is resorbed when a tooth is lost
Nerve supply to [email protected]
Dingman and Natwig Classification• Midline
• Symphysis
• Parasymphysis
• Body
• Angle
• Ramus
• Condyle
• Coronoid process
• Dentoalveolarprocess
Kazanian and Converse classification
• Class I: teeth present on both side of fracture line
• Class II: teeth present on either side of fracture line
• Class III: edentulous patient
Class I
Kruger and Schilli Classification• Relation to external Environment
▫ Simple or compound
▫ Compound or open
• Types of fracture▫ incomplete fracture
▫ Greenstick fracture
▫ Complete
▫ Comminuted
Kruger and Schilli Classification
• Dentition of jaw with the use of splints▫ Sufficiently dentulous jaw▫ Edentulous or insufficiently jaw▫ Primary or mixed dentition
• Localisation▫ precanine▫ canine▫ postcanine▫ angle▫ supra-angular▫ condylar process▫ coronoid process▫ alveolar process
SPIESSEL CLASSIFICATION• Number of fragments –
F▫ F0: incomplete fracture▫ F1: single fracture▫ F2: multiple fracture▫ F3: comminuted fracture▫ F4: fracture with bone defect
• Location of fracture – L▫ L1: precanine▫ L2: canine▫ L3: postcanine▫ L4: angle▫ L5: supra-angular▫ L6: condylar process▫ L7: coronoid process▫ L8: alveolar process
SPIESSEL CLASSIFICATION• Status of occlusion – O
▫ O0: no malocclusion▫ O1: Malocclusion▫ O3: non-existent occlusion
• Soft tissue involvement – S▫ S0: closed▫ S1: open intraorally▫ S2:open extraorally▫ S3: open intra & extraorally▫ S4: soft tissue defect
• Associated fracture – A▫ A0: none▫ A1: fracture or loss of tooth▫ A2: nasal bone▫ A3: zygoma▫ A4: Le-fort – I▫ A5: Le-fort – II▫ A6: le fort – III
Direction of fracture line and effect of
muscle action
• Favourable
▫ Vertically favourable
▫ Horizontal favourable
• Unfavourable fractures Vertically
unfavourable
Horizontally unfavourable
Extra-oral findings
▫ Indirect sign Swelling
Ecchymosis
Erythema
Abrasion
Laceration
▫ Facial deformity▫ Paraesthesia or anaesthesia on
one or both side of mandibel –inferior alveolar nerve injury
▫ Step deformity, crepitus, bone tenderness
▫ Inablity to occlude teeth
Intra-oral findings
• Coleman’s sign: lingual haemotoma
• Buccal and lingual sulci –echymosis
• Step defect in occlusion or alveolus are noted –laceration of overlying mucos and gingival tear.
• Change of occlusion• Mobility• Pain, tenderness or
limitation while mandibular movement are indicative of fracture.
Area specific clinical feature
• Fracture at angle
▫ Step deformity at last molar tooth
▫ Premature dental contact – inablity to close mouth – anterior open bite
Unilateral – bilateral angle fracture
Ipsilateral – unilateral angle fracture
▫ Trsimus
▫ Retrognathic occlusion and flattened appearance on both surface
Fracture of Body
• Slight displacement – dearrangement of occlusion
• Premature contact on distal fragments -displacing action of muscles atatched to the ramus
• Coleman sign
• Flattened appearance on lateral side
• Impingement of airways – mylohyoid, digastricor omohyoid full the fragments posteriorarly.
Fracture of symphysis and
parasymphysis• Missed – when occlusion is not disturbed
• Only lingual haematoma (coleman sign) and bone tenderness is the sign
• Posterior openbite /unilateral openibite
• Posterior crossbite – midline symphysis fracture
• Retruded chin
• Severe concussion, loss of tongue control and obstruction of airway
• Fracture of coronoid process
▫ Caused by reflex contracture of powerful anterior fibers of temporalis
▫ Difficult to diagnose
▫ Painfull movement especially during protrusion movement
• Fracture of ramus
▫ Uncommon
▫ Flattened appearance of lateral aspect
▫ Severe trismus
Radiographic examination
• Periapical view
▫ Non-displaced linear fracture of body
▫ Alveolar process
▫ Dental trauma
• Occlusal view Medial and lateral position of body fracture
Anterior posterior displacement of symphysis
Panoromic radiographs
• Most informative radilogical studies for mandible fracture
• Advantage
▫ Visualize entire mandible in one radiograph
▫ Low dose of radiation
▫ Patient education is easy
▫ Short time(3-4 min) and can be taken closed mouth.
Panoromic radiographs
• Disadvantage
▫ Patient to be upright – impractical for severilytraumatized patient
▫ Difficult to appreciate: Buucolingual bone displacement or medial condylar displacement
▫ Final details are lacking
Radiographic examinationReverse Towne’s
radiographIdeal for showing lateral or
medial condylardisplacement
• Lateral oblique view▫ Fracture of ramus▫ Angle and posterior
body
Radiographic examination
• Posterior-anterior view Medial or lateral
displacement of fracture of ramus, angle, condyle, body and symphysis.
Midline or symphysealfracture well visualised
• CBCT/CT scan 3d reconstruction helps
understanding degree of diplacement as well as reveal fractures not evident in OPG
Diagnosis
• Radiographic Evaluation
▫ Ideally need 2 radiographic views of the fracture that are oriented 90’ from one another to properly work up fractures
Panorex and Towne’s
CT axial and coronal cuts
▫ Single view can lead to misdiagnosis and complications with treatment
• This Towne’s view show a body fracture that is displaced in a medial to lateral direction and a subcondylarfracture with lateral displacement
• However, Panorex clearly shows the superior displacement of the right body fracture
• Mandibular bilateral neck and mandibular body fractures;44-year-old female with trauma to chin 3 weeks previously, but still some problems with dental occlusion (only tooth fractures diagnosed by clinical and intraoral radiographic examinations). A Panoramic view shows fracture of mandibular body (arrow), and suggests possible fractures of condyles
Management
• Reduction and fixation
▫ Closed reduction
▫ Open Reduction
• Immobilization
• Mobilization
Closed reduction: indication• Favourable fracture• Grossly comminuted fracture : if opened it may
jeopardise the vascular supply of bony fragments• Severely atrophic mandible : open reduction
require stripping of bone which is not possible in already atrophied mandible. Reduced blood supply.
• Lack of soft tissue overlying fracture site: bone plates or screws would disrupt the soft tissue covering
• Children – developing dentition• Infected fracture: life threatening surgical risk
and delayed healing• Condylar fracture: no displaced fracture
Open reduction: indication
• Complex facial fracture
• Unfavourable fracture: symphysis, body or angle
• Displaced bilateral condylar fracture
• Delayed presentation
• Malunited mandibular fractures
• Mandible fracture opposing edentulous maxilla
• Edentulous mandibular fracture with severe displacement
• Medically compromised patient – severe seizure disorder, psychiatric or neurologic problem
Immobilization
• Allow bone healing.
• Factors considered for period of immobilization
▫ Type, location, number and severity of fracture
▫ General health condition
▫ Method employed for reduction and stability
• Average immobilization period is 6 weeks.
▫ Edentulous patient requires more time for healing
Killey and Kay guide for immobilization
• Young adult with fracture of angle receiving early treatment in which tooth is removed from fracture line - 3 weeks, if
▫ Tooth retained in fracture line – add 1 week
▫ Fracture at symphysis: add 1 week
▫ Age 4o years and above : add 1 week
▫ Children and adolescent: substract 1 week.
Approaches for Open reduction
Sypmhysis and parasymphysis: intra-oral vestibular approach
• A. Stepwise incision through the mucosa first, followed by the incision through the muscles and the periosteum.
• B. Two-layer wound closure for muscle and mucosa.
Extra-oral submandibular – Risdon
incision
For body and angle fracture of mandible. Also known as Transcervicalaccess of the submandibularstandard approach
Extra-oral sub mandibular –
Risdon incision
a Sharp dissection stepwise
through skin (red line
cranial), platysma, and
superficial cervical
fascia (dotted line caudal).
b Ligation of the facial vein
and/or artery is often
indicated. The bone surface
is reached in a
layer underneath the superior
cervical fascia.
1 Preauricular approach
2 Transparotid approach
3 Retromandibular approach
4 Submandibular approach
5 Retroauricular approach
Condylar Process Fractures
• Incidence:▫ Represent 25-35% of
all mandible fractures
▫ Location: 14% intracapsular (41% in
children <10)
24% condylar neck (38% in adults >50)
62% subcondylar
84% unilateral
16% bilateral
Condylar Process Fractures• Classifications:
▫ Wassmund Scheme:
I- minimal displacement of head (10-45’)
II- fracture with tearing of medial joint capsule (45-90’), bone still contacting
III- bone fragments not contacting, condylar head outside of capsule medially and anteriorly displaced
IV- head is anterior to the articular eminence
V- vertical or oblique fractures through condylar head
Condylar Process Fractures
• Classifications:
▫ Lindahl classification:
I- nondisplaced
II- simple angulation of displacement, no overlap
III- displaced with medial overlap
IV- displaced with lateral overlap
V- displaced with anterior or posterior overlap
VI- no contacts between segments
Condylar Process Fractures
• Classifications:
▫ MacLennan classification:
I- nondisplaced
II- deviation of fracture
III- displacement but condyle still in fossa
IV- dislocation outside of glenoid fossa
Condylar Process Fractures
• Goals of condylar fracture repair:
▫ 1) Pain-free mouth opening with opening of 40mm or greater
▫ 2) Good mandibular motion of jaw in all excursions
▫ 3) Restoration of preinjury occlusion
▫ 4) Stable TMJs
▫ 5) Good facial and jaw symmetry
Condylar Process Fractures
• Growth alteration from condylar fractures:
▫ Estimated that 5-20% of all severe mandibular asymmetry is from condylar trauma
▫ Believed to be from shortening of the ramus or alterations in muscle action leading to growth changes
Condylar Process Fractures
• Treatment alternatives:
▫ Non-surgical- diet, observation and physical therapy
▫ Closed reduction- utilizes a period of IMF the physical therapy
▫ Open reduction
Condylar Process Fractures
• Closed reduction:▫ Indications: Split condylar head Intracapsular fracture Small fragments from comminuted condyle Risk of devascularization of the condylar segment
with ORIF
▫ Treated with short course of IMF with post-operative physical therapy
Condylar Process Fractures• Open reduction:
▫ Zide’s absolute indications:
1) middle cranial fossa involvement with disability
2) inability to achieve occlusion with closed reduction
3) invasion of joint space by foreign body
Condylar Process Fractures
• Open reduction:▫ Zide’s relative indications: 1) bilateral condylar fractures where the vertical
facial height needs to be restored 2) associated injuries that dictate early or immediate
function 3) medical conditions that indicate open procedures 4) delayed treatment with malalignment of segments
Condylar Process Fractures
• Open reduction techniques:▫ Multiple approaches
and fixation have been developed and used
Condylar Process Fractures• closed reduction techniques rarely produce
pain, limit function, or produce growth disturbances
• Open reductions techniques show an early return to normal function, but are technique sensitive, time extensive, and can lead to facial nerve dysfunction depending upon surgical approach
Complications
• Infection:▫ Dodson et al. J Oral Maxillofac Surg 1990;48 Closed reduction- 0%
Wire osteosynthesis- 20%
Rigid fixation- 6.3%
▫ Assael J Oral Maxillofac Surg 1987;45 Closed reduction- 8%
Wire osteosynthesis- 24%
Rigid fixation- 9%
Complications
• Infection:▫ variation of infection rates with rigid vs. non rigid
fixation schemes
▫ Most show that wire osteosynthesis techniques have the highest infection rates due to the higher level of mobility at fracture site, leading to vascular damage and perculation of bacteria into facture site
Complications• Malocclusion:
▫ More difficult to manage with rigid fixation▫ Most studies have shown that malocclusion
occur more frequently with rigid fixation▫ May be due to plate mal-
positioning/iatrogenic▫ Low risk in pediatric fractures due to
growth and dentition reposition
Complications• Malunion and nonunion:
▫ Most nonunions occur from infections of the fracture or teeth in the line of fracture
▫ Malunions are usually tolerated well by the patient, most malunions of the body, symphysis, or angle can result in malocclusions. This is harder for the patient to tolerate. More common with improper use of fixation technique.
Conclusions
• Closed reduction techniques are much better in pediatric and condylar fractures
• Antibiotics should be used in all mandible fractures except fractures only in the ramus, coronoid, or condylar region that are closed.
Refrences• www.aofoundation.org• Textbook OF Oral And MF Surgery - S.M Balagi – 2007• Text book of oral and maxillofacial surgery 3rd
edition_Neelima Mallik• Principles_of_Internal_Fixation_of_the_Craniomaxillary
- AOCMF• Petersonâ Principles of Oral and MF Surgery -2nd ed• Oral Cavity Reconstruction• Advanced Trauma Life Support Student Manual, 8th edn . American
College of Surgeons . Chicago, IL• Facial trauma_Seth R. Thaller• Facial Plastic and reconstruction surgery 2nd edition Ira D.
Paper• FONSECA - Oral and MF Surgery(1)• Craniofacial Biology and Craniofacial Surgery• Contemporary oral and maxillofacial surgery _hupp_ellis_tucker• Complications in Head and Neck Surgery 2nd, D. Eisele• Clinical handbook of oral and maxillofacial surgery_lashkins• Pubmed.com, Google.com, • Textbook of Pathology 6th Edition, Harshmohan
THANKS……Feedback if any : [email protected]
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