2. SOME FACTS
2
Mandibular fracture > middle third fracture (anatomical factor)
Minor mandibular fracture may be associated with head injury owing to the
cranio-mandibular articulation
Mandibular fracture may compromise the patency of the airway in particular
with loss of consciousness----BILATERAL PARASYMPHYSIS FRACTURE
Fracture of mandible occurred with frontal impact force as low as 425 lb
(190 Kg) {Condylar fracture}
3. 3
Fracture of condyle regarded as a safety mechanism to the patient
Frontal force of 800-900 lb (350-400 Kg) is required to cause
symphysial fracture
Mandible was more sensitive to lateral impact than frontal one----
ANGLE FRACTURE > CONDYLAR FRACTURE
Long canine tooth and partially erupted wisdoms represent line of
relatively weakness
6. 6
Blood supply
Endosteal supply via the ID artery and vein
Periosteal supply, important in aging due to diminishes and
disappearance of alveolar artery
(Supra Periosteal Fixation)
Bradley 1972
Nerve
Damage of inferior dental nerve
Facial palsy by direct trauma to ramus
Damage to mandibular division of facial nerve
7. Etiology of mandibular fractures
7
Vehicular accidents 43%
Assaults,interpersonal
violence,etc
34%
Fall 7%
Sports 4%
Industries mishaps or work
accidents
10%
Pathological fractures or
miscellaneous
2%
8. Classification of mandibular fractures
8
Simple or closed
Compound or open
Comminuted
Greenstick
Pathologic
Multiple
Impacted
Atrophic
Indirect
Complicated or complex
9. SIMPLE FRACTURE
Linear fracture which are
not in communication with
the exterior – Rowe &
Killeys
Kruger – is one in which
the overlying integument is
intact.
10. COMPOUND FRACTURE
A fracture in which an
external wound involving
the skin, mucosa, or
periodontal membrane
communicates with the
break in the bone.
17. INDIRECT FRACTURE
A fracture at a point distant from the site of
injury
COMPLICATED/COMPLEX –
A fracture in which there is considerable injury
to the adjacent soft tissue or adjacent parts;
may be simple or compound
18. Classification by anatomic region
18
Dingman and Natvig
Condylar process
Coronoid
Ramus
Angle
Body
Symphysis
Parasymphysis
Alveolar process
20. HORIZONTALLY UNFAVOURABLE FRACTURES
The masseter ,temporalis and medial pterygoid cause upward and
medial pterygoid cause upward and medial displacement of the
proximal segment
VERTICALLY UNFAVOURABLE FRACTURES
Medial and lateral pterygoids result in medial displacement of the
proximal segment
20
32. Closed reduction
32
Indications
a) Nondisplaced favorable fractures
b) Grossly comminuted fractures
c) Significant loss of overlying soft tissue
d) Edentulous mandibular fractures
e) Mandibular fractures in children
f) Coronoid process fractures
g) Condylar fractures
33. CLOSED REDUCTION
Advantages
• Inexpensive
• Simple procedure
• Gives occlusion some
“leeway "to adjust
itself
• No foreign body left in
the body
Disadvantages
• Cannot obtain absolute
stability
• Long period of IMF
• PossibleTMJ sequelae
• Decrease range of
motion of mandible
• Impaired pulmonary
function
34. Open reduction
34
Displaced unfavourable fractures Multiple fractures of the
facial bones
Midface fractures and displaced bilateral condylar fracture
Fractures of an edentulous mandible with severe
displacement of fracture segment
Edentulous maxilla opposing a mandibular fracture
Delay of treatment and interposition of soft tissue between
noncontacting displaced fractures fragments
Malunion
Conditions contraindicating Intermaxillary fixation
35. OPEN REDUCTION
Advantages
• Early return to normal jaw
function
• Avoidance of airway problems
• Absolute stability
• Bone fragments re-
approximated exactly by
visualization
• Low rate of malunion
/nonunion
• Lower infection rate
• Avoids IMF
Disadvantages
• Morbidity of surgical
procedure
• Significant operating time
• Expensive hardware
• Secondary procedure for
removal of hardware
36. Removal of a tooth from the fracture
line
ABSOLUTE INDICATION RELATIVE INDICATION
Vertical fracture
Dislocation or subluxation
Periapical infection
Infected fracture line
Acute pericoronitis
Functionless
Advanced caries
Advanced periodontal
disease
Doubtful teeth
Teeth involved in untreated
fractures presenting more
than 3 days after injury
37. Methods of immobilization
Osteosynthesis without Intermaxillary fixation
Intermaxillary fixation
Intermaxillary fixation with Osteosynthesis
40. Methods of immobilization
40
INTERMAXILLARY FIXATIONWITH OSTEOSYNTHESIS
Transosseous wiring
Circumferential wiring
External pin fixation
Bone clamps
Transfixation with Kirschner wire
41. Period of immobilization
41
Young adult
with
Fracture of the angle
receiving
Early treatment
in which
Tooth removed from fracture line
If
a) Tooth retained in fracture line : add 1wk
b) Fracture at the Symphysis: add 1 wk
c) Age 40yrs and over : add 1or 2 wks
d) Children and adolescents : subtract 1 wk
3 weeks
44. Indications of Rigid Osteosynthesis
44
Fractures in an edentulous part of the body of the mandible
Concomitant fractures of the body and condyle
Patients in whom IMF is contraindicated
Fractures associated with closed head injury
Continuity defects
Fractures in which nonunion or malunion has occurred
45. Limitations and drawbacks
Procedure is technically demanding, requires precise plate
adaptation
Danger of gap appearing in lingual border &alveolar region
causing malocclusion
All systems developed for this purpose require additional
modification such as eccentric DCP or tension band in upper
alveolus
46. .Load-Bearing versus
Load-Sharing Fixation
LOAD-BEARING FIXATION
is a device that is of sufficient
strength and rigidity that it can bear the
entire load applied to the mandible during
functional activities
comminuted fractures of the mandible
those fractures where there is very little bony interface because of
atrophy,
those injuries that have resulted in a loss of a portion of the
mandible (defect fractures)
47. Load sharing devices
Load-sharing fixation is any form of
internal fixation that is of insufficient stability
to bear all of the functional loads applied across the fracture by the
masticatory system.
requires solid bony fragments on each side of the fracture that can
bear some of the functional load
Fractures that can be stabilized adequately with load-sharing
fixation devices are simple linear fractures,and constitute the
majority of mandibular
fractures
Eg;-2.0 mm miniplating systems
Lag screw techniques
48. Complications of rigid internal fixation
48
Infection
Minor - not necessitating the plate removal
Major - necessitating the plate removal
Sensory
Inferior alveolar nerve
Mental nerve
Motor
Marginal mandibular nerve
49. Complications of rigid internal fixation
49
Malunion or nonunion malocclusion
Restriction of craniofacial growth
Hypertrophic scar formation
Joint pain
Injury to tooth roots
Metal allergy
51. Fixation of miniplates for mandibular
fractures
51
Angle fracture - superior aspect of the mandible extending
on to the broad surface of the external oblique ridge
Region between two mental foramina – 2 plates are
recommended
1. Subapical region of the Symphysis
2. Inferior border of the mandible
Body of the mandible - one plate recommended just below
the apices of the teeth but above the inferior alveolar nerve
canal
52.
53.
54.
55.
56. Advantages of the Monocortical
miniplate Osteosynthesis
56
Less soft tissue dissection.
Less likely to palpable.
No necessity for subsequent removal.
Decrease the degree of stress shielding.
Minimal risk of dental injury.
Can also be performed under L.A .
Decrease in surgical morbidity.
57. Limitations and potential complications
57
Not rigid
Torsional movements resulting in infection or nonunion, or both
Longer plates required to span communited fractures
