Mandibular fractures

Mandibular Fractures
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 HISTORY
 INTRODUCTION
 ANATOMY
 CLASSIFICATION
 EXAMINATION AND DIAGNOSIS
 TREATMENT
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 The pre-Christian era
 The first description of mandibular fractures dates to the 17th Century
BC in the ‘Edwin Smith papyrus’,
 Hippocrates – direct reapproximation of # segments with the use of
circum dental wires
 1180, Textbook written in Salerno, Italy – importance of establishing a
proper occlusion.
 1492, the book Cyrurgia by Guglielmo Salicetti – first mention of the use
of maxillomandibular fixation in treatment of mandibular #.

History
 1887, Gilmer reintroduced MMF in United States.
 Buck & Kinlock- first to do ORIF using wires.
 1888 Schede- First to use stainless steel plate & screws.
 1960, Luhr- first to use Vitallium compression plate
 1970, Spiessl through AO/ASIF introduced principles of rigid internal fixation.
 1970, Michelet- introduced small bendable, non compression plates- these were
further modified by Champy.
 1987 – M.S. Leonard first to report use of lag screws
 Late 1990s – introduction of use of bioresorbable plates

• A tubular long bone, which is bent into a blunt V-shape.
• Mandible is strongest anteriorly in midline with
progressively less strength towards condyle .
• dentition
• Muscle attachments.
• Mandible is one of the strongest bones, the energy
required to # it being of the order of 44.6 –74.4 Kg /
M(425Lb), which is about same as zygoma and about ½
that of frontal bone
Mandible is embryologically a membrane bent bone although, resembles
physically long bone .

27-04-2016 Mandibular Fractures 11

 Zones of compression and tension within the mandible are determined by the
muscles inserting and the forces exerted by these muscles.
 Smaller arrows show direction of muscular forces
 Larger arrows show the load placed during function.
 This gives a zone of compression along the lower border and a zone of tension
along the superior border
 Neutral axis about the level of the canal.

FRACTURE :
Definition :
Fracture is defined as break in the continuity of the
bone.
Mandibular fractures :
Fractures of the mandible are common in patients, who
sustain facial trauma.
SEX :
Most mandibular fractures are seen to occur in male patients.
Ratio is approximately 4.5 : 1
AGE :
35 % of mandibular fractures occur between the ages of
20 to 30 years.

ETIOLOGY OF MANDIBULAR FRACTURES
 Vehicular accidents
 Altercation,assaults,
interpersonel violence
 Fall
 Sporting accidents
 Industrial mishaps or work
accidents
 Pathological fractures or
miscellaneous

Factors influencing displacement
of fracture
 Degree of force
 Resistance to the force offered by the facial bones
 Direction of force
 Point of application of force
 Cross-sectional area of the agent or object struck
 Attached muscles

# SYMPHYSIS AND PARASYMPHYSIS:-
Mylohyoid constitues a diaphragm b/w hyoid bone &
mylohyoid ridge on inner aspect of mandible
• Oblique # in this region tends to overlaps -- genio &
mylohyoid diaphragm

Bucket handle displacement
•B/L # of parasymphysis results from
force which disrupts the periosteum.
• displaced posteriorly under the
influence of genioglossus /
geniohyoid muscle
•Often removes attachment of tongue
& allows
TONGUE FALL BACK

Classification of mandibular fractures :
I. General classification
II. Anatomical locations
III. Relation of the fracture to site of injury
IV. Completeness
V. Depending on the mechanism
VI. Number of fragment
VII. Involvement of the integument
VIII.The shape or area of the fracture
IX. According to the direction of fracture and favourability for the
treatment
X. According to presence or absence of teeth
XI. AO classification – relevant to internal fixation

1. Kruger's general classification
• Simple or Closed Fracture
• Compound or Open
• Comminuted
• Complicated or complex
• Impacted
• Greenstick fracture
• Pathological

2. Rowe & Killey classification
• Fractures not involving basal bone
• Fractures involving basal bone of the mandible. Subdivided into following:
 Single Unilateral
 Double unilateral
 Bilateral
 Multiple
3. Dingman & Natvig classification
• Midline
• Parasymphyseal
• Symphysis
• Body
• Angle
• Ramus
• Condylar process
• Coronoid process
• Alveolar process 27-04-2016Mandibular Fractures 20

4. Kruger & Schilli classification
I. Relation to the external environment
• Simple Or closed
• Compound or open
II. Types of fracture
• Incomplete
• Greenstick
• Complete
• Comminuted
III. Dentition of the jaw with reference to the use of splint
• Sufficiently dentulous patient
• Edentulous or insufficiently dentulous patient
• Primary and Mixed dentition
IV. Localization
• Fractures of the symphysis region between canines
• Fractures of the canine region
• Fractures of the body of the mandible
• Fractures of the angle
• Fractures of the mandibular ramus
• Fractures of the coronoid process
• Fractures of the condyle

5. Kazanjian classification
Class – III : Patient is edentulolus
Class – I : teeth are present on both sides of
the fracture line
Class – II : Teeth are present on only one side of
fracture line

6. According to direction of the fracture and favorability for treatment ( Fry et al)

7. Relation of the fracture to the site of injury
 Direct fracture
 Indirect fracture

8. AO Classification(relevant to internal fixation):
1) F: Number of fracture or fragments
2) L: Location (site) of fracture
3) O: Status of occlusion
4) S: Soft tissue involvement
5) A: Associated fractures of facial skeleton

9. Grades of severity: I-V
Grade I and II are closed fractures
Grade III and IV are open fractures
Grade V open fracture with a bony defect
(gunshot)

10. AO-analogue classification system of mandibular fractures
 Each compartment is classified independently, describing the degree of
displacement and the presence of multifragmentation or osseous defects.
 Each fracture is classified:
- type A, nondisplaced fractures
- type B, displaced fractures
- type C, multifragmentary/defect fractures
 Each fracture is divided into 3 groups, specific to the mandibular unit.

Vertical unit

Horizontal unit

Central horizontal unit

 History
 Clinical Examination
 Radiological Examination
 Panoramic radiograph
 Lateral oblique Radiograph
 Posteroanterior Radiograph
 Occlusal view
 reverse towne’s view
 CT scan

History
Focussed questioning should reveal following:
 Mechanism of injury
 Previous facial fracture
 H/O TMJ disorders
 Preinjury occlusion

Clinical examination
Examination of pt with # of mandible takes place in 3
stages:
A. Immediate assessment and treatment of any
condition constituting a threat to life.
B. General clinical examination of pt.
C. Local examination of mandibular #.

• Change in occlusion
• Anesthesia, Paresthesia or Dysesthesia of
lower lip
• Abnormal mandibular movements
• Change in facial contour and mandibular arch
form
• Laceration, Hematoma and Ecchymosis
• Loose teeth and crepitation on palpation
Clinical Examination

Clinical examination

Test for sensation

Signs and
symptoms Tenderness +ve
 Occlusion changes - # teeth
- # alveolar process
- # mandible at any location
- # condyle
 Anterior open bite - B/L condylar #
 Posterior open bite - parasymphysis #
 Unilateral open bite - # ipsilateral angle
- # parasymphysis
 Posterior cross bite - midline symphysis #
- condylar #

Radiological examination
Ideally need 2 radiographic views of the fracture that are
oriented 90’ from one another to properly work up
fractures
 Single view can lead to misdiagnosis and complications
with treatment

 OPG
 Most informative
 Shows entire mandible and direction of fracture (horizontal favorable,
unfavorable)
Disadvantages:
 – Patient must sit up up-right
 – Difficult to determine buccal/lingual bone and medial condylar
displacement
 – Some detail is lost/blurred in the symphysis, TMJ and dentoalveolar
regions

Posteroanterior (pa) radiograph:
Shows displacement of fractures in the ramus, angle, body,
and symphysis region
Disadvantage:
 Cannot visualize the condylar
region

Lateral oblique
 Used to visualize ramus, angle, and body fractures
Disadvantage:
 Limited visualization of the condylar region, symphysis, and
body anterior to the premolar

Occlusal radiograph
 Used to visualize fractures in the body in regards to
medial or lateral displacement
Used to visualize symphyseal fractures for anterior and
posterior displacement

Computed tomography ct:
 Excellent for showing intracapsular condyle
fractures
 axial and coronal views,
 3-D reconstructions
Disadvantage:
 – Expensive
 – Larger dose of radiation exposure
compared to plain film
 – Difficult to evaluate direction of fracture
from individual slices (reformatting to 3-D
overcomes this)

1. The patient’s general physical status
2. Diagnosis and treatment of mandibular fractures should be
approached methodically not with an “emergency-type” mentality
3. Dental injuries should be evaluated and treated concurrently with
treatment of mandibular fractures
4. Re-establishment of occlusion is the primary goal in the treatment of
mandibular fracture.
5. With multiple facial fracture mandibular fracture should be treated
first.
6. Intermaxillary fixation time should vary according to the type,
location, number severity of the mandibular fracture as well as the
patient’s age and health.
7. Prophylactic antibiotics should be used for compound fractures.
General principles in the treatment of
mandibular fracture

Basic principles for Rx of Fracture
Reduction
 Closed
 Direct interdental
wiring Indirect
interdental wiring
(eyelet or Ivy loop)
 Continuous or
multiple loop
wiring
 Arch bars
 Cap splints
 'Gunning-type'
splints
 Pin fixation 27-04-2016Mandibular Fractures 46
 Open
 Transosseous
wiring
(osteosynthesis)
 Plating
 Intramedullary
pinning
 Titanium mesh
 Circumferential
straps
 Bone clamps
 Bone staples
 Bone screws
Fixation
 Direct
 Indirect

Immobilization
 Methods of immobilization
 (a) Osteosynthesis without intermaxillary fixation
 (i) Non-compression small plates
 (ii) Compression plates
 (iii) Mini-plates
 (iv) Lag screws
 (b) Intermaxillary fixation
 (i) Bonded brackets
 (ii) Dental wiring
 Direct
 Eyelet
 (iii) Arch bars
 (iv) Cap splints
 (v) MMF screws
 (c) Intermaxillary fixation with osteosynthesis
 (i) Transosseous wiring
 (ii) Circumferential wiring
 (iii) External pin fixation
 (iv) Bone clamps
 (v) Transfixation with Kirschner wires

CLOSED REDUCTION

1. Non-displaced favorable fractures
2. Grossly comminuted fractures
3. Fractures exposed by significant loss of overlying soft
tissue.
4. Mandibular fractures in children with developing dentition
5. Coronoid process fracture
6. Condylar fractures
Indication for Closed Reduction of Fractures

ADVANTAGES & DISADVANTAGES
OF CLOSED REDUCTION
Advantages
 Inexpensive
 Only stainless steel wire
needed
 Convenient
 Gives occlusion
 Conservative
 O.T not required
 Generally easy ,no great
operator skill needed
Disadvantages
•Cannot obtain absolute
stability
•Difficulty nutrition
•Oral hygiene impossible
•Long period of IMF
•Changes in TMJ cartilage
•Weight loss
•Decrease range of motion of
mandible
•Risk of wounds to operator

CLOSED REDUCTION
 HISTORY
 William Saliceto(1210-1277) Tied the teeth (MMF)
 Thomas Gilmer(1849-1931) Reviewed the tech, introduced Arch
Bars in 1907.
 Barton bandage by JOHN BARTON
 Lingual-Labial occlusal splint.
 Vacuum formed acrylic splint
 Royal Berkshire Halo Frame

Direct interdental wiring
 Gilmer's wiring
 simple & rapid method of
immobilization jaw
 first aid method
 temporary immobilization of
# fragment
Disadvantage
- complete removal of wires
- extrusion of teeth

IVY LOOP METHOD
 Quick and easy way of
obtaining maxillo-
mandibular fashion.
 24 gauge wire
 simple and effective for
reduction and
immobilization of #

WILLIAM’S MODIFICATION

Clove hitch
 Incase of single tooth

Button Wiring
 Leonard (1977) considers that eyelet
wires have several drawbacks.
 He described the use of titanium buttons
of 8mm diameter, inclusive of a 1mm
rim, and 2mm deep.

Col. Stout wiring

Risdon’s wiring

Arch bars
 For temporary fragment stabilization in emergency cases before definitive
treatment
 As a tension band in combination with rigid internal fixation
 For long-term fixation in conservative treatment
 For fixation of avulsed teeth and alveolar crest fractures

 Different types of Arch bar
 Winters
 Jelenkos
 Dautrys Arch bar
 Berns titinium arch bars
 Burmachs arch bar
 Custom made

Screws
 Screws are quick to place
 Reduce the chance of needlestick injury from wires
 Can be used with heavily restored teeth
 Can be placed and removed rapidly
 Well tolerated by patient
 Allow oral hygiene to be easily maintained
 IMF screws are machine manufactured and are
available in the self-drilling and traditional drilling
styles

 Monocortical in nature
 Once a screw loosens, it must be removed and replaced, or an
alternative method of reduction of the fracture should be
considered
 Do not allow for any dynamic movement, and occlusal
discrepancies may not be adjusted as with arch bars and
elastics.
Disadvantage

Cap Splints :
 Indications
 Advanced periodontal disease
 #s of tooth bearing segments & condylar neck
 Portion of body of mandible missing
 Impression technique
 Fitting the splint
 Reduction of fracture

Biphasic pin fixation
 Closed technique uses external fixation (Morris
appliance & Roger anderson appliance) for
management of communited mandibular #.
 screws placed - two on either side of the fracture
through stab incisions & holes drilled in the mandible.

 Once external pins are in position,
the fracture segments are manipulated to
achieve reduction.
 Then the pins are locked in reduced position by applying of an
acrylic mix that is placed over the ends of the pins that are protruding
out of the skin.
 The acrylic is allowed to harden while mandible is held in reduced
position.
 Steinmann pins or Kirshner wires can also be used as external pins

Indications
 Edentulous fractures
 If IMF is not feasible
 Comminuted fractures
 Bone graft requirements
 With a head frame
Contraindications
 Irradiated tissues
 Grossly contaminated tissue
 Osteoporosis
 Osteosclerosis
 Atrophy

Advantages
 Control of the edentulous
fragments without involving
the fracture lines.
 under LA.
 avoidance of the need for
surgery at the fracture site,
 minimum operative time
 Simple surgical technique.
Disadvantages
 Conspicuous uncomfortable
 uncooperative or cerebrally
irritated patient.
 Difficulty with washing and
shaving
 scars caused- pinholes
 risk of infection.

• Used in edentulous jaw fractures
• Acrylic splints take the form of modified dentures with bite
block in place of molar teeth & space in the incisor area to
facilitate feeding
Gunning splints

INDICATION
 unilateral / bilateral # edentulous mandible
CONTRAINDICATIONS
 unfavorable displaced #s lying out side denture
bearing areas
 severe posterior displacement of #s of the anterior
part of mandible

Immobilization
Maxilla -Peralveolar wiring
- Circum zygomatic wiring
- With help of bone screws
Mandible - Circum mandibular wiring

OPEN REDUCTION

1. Displaced unfavorable fracture through angle of the mandible
2. Displaced unfavorable fractures of the body or pasymphyseal region
3. Multiple fractures of the facial bones
4. Midface fractures and displaced Bilateral condylar fractures
5. Fractures of the edentulous mandible with severe displacement of
fragments
6. Edentulous maxilla opposing a mandibular fracture
7. Delay of treatment and interposition of soft tissue between noncontacting
displaced fracture fragments.
8. Malunion
9. Special systemic conditions contraindicating intermaxillary fixation
Indications for open Reduction

Contraindications
• G.A / more prolonged procedure is not
advisable
• Gross infections at the # site
• Severe comminution with loss of soft tissue
• Patients with difficult to control seizures

Advantages of open reduction.
 Accurate reduction & fixation of
fractures by direct visualization.
 Better bone healing.
 Early return to normal jaw
function.
 Normal nutrition, no weight loss.
 Patient can maintain oral
hygiene.
 Early return to work.
Disadvantages of open reduction.
• Requires surgical exposure.
• May Require general anesthesia.
• Expensive.
• Compared to IMF technique is
difficult and risky
• Foreign body left in the tissues.
• Scarring.

Surgical approaches to the mandible
 Intraoral symphysis and
parasymphysis
Intraoral body, angle
and ramus –
Transbuccal approach

Degloving incision

Extraoral approaches
Submental Submandibular Retromandibular

Transalveolar / upper border wiring
Sir Williams Kelsey Fry
 To control the posterior fragment
 Use – vertically and horizontally unfavorable #
 Horizontal mattress wiring

Transosseous / lower border wiring
Hayton Williams 1958
 # fragments expose extraorally
 posterior fragment hole higher level then anterior
fragment
 both wires passes simultaneously through same hole
1973 Obwegeser :-
 Combined direct and figure of ‘8’ wiring with single
stand of wire

Transosseous or lower border wiring

Bone plate osteosynthesis
 Non compression plate with monocortical screw
 Compression plates with bicortical screw
 - DCP - EDCP
 Bio degradable plates and screws
 Three dimensional plates
 Titanium miniplates

Compression plates
•Axial compression b/w fractured bone ends
•Rigid fixation with intra-fragmentry compression
•Bone ends correctly opposed and maintained
•IMF is not needed post operatively
•Primary bone healing occurs by direct osteoblastic activity
within #
•AO/ASIF dynamic compression plates
Compression plate approach Eccentric dynamic compression plate

Principle of compression plate
osteosynthesis
 The holes for the screws should
be prepared at the far ends of the
plate holes.
 When tightening the screws the
fracture ends are approximated
by the effect of the spherically
shaped holes

DCP EDCP
 The plate design is based on a screw head that,
when tightened, slides down an inclined plane
within the plate.
 Screw behaves as compression screw or the
static screw
 Compression is not achieved at the upper
border so tension band is required
 The EDCP is similar to the DCP in that the inner
holes are designed to produce compression
across the fracture site
 Two oblique outer eccentric compression holes
aligned at an angle oblique to the long axis of
the plate. The activation of these outer holes
produces a rotational movement of the fracture
segments with the inner screws acting as the axis
of rotation
 Brings compression at the upper border so
tension band is not required

Mini plate Osteosynthesis :-
1973 MICHELET
1975 CHAMPY MODIFIED
- Under physiological strain, forces of tension along the alveolar border &
forces of compression along the lower border of the mandible.
- With in the body of the mandible these forces produce, predominantly,
moments of flexion – angle strong & weak in PM region.
- with in the symphysis – torsional moments
- Champy et al analysed these moments using a mathematical model of the
mandible – ideal line of osteosynthesis.
# symphysis 2 plates
# angle 1 plate
Monocortical screws 2 mm diameter and 5 to 10 mm length
Plate 2cm long, 0.9mm thick and 6mm wide

Champy’s line of
osteosynthesis

Advantages of monocortical
miniplate osteosynthesis over
bicortical compression plates.
Monocortical
 Requires minimal dissection.
 Less technique sensitive
 Less chances of complications
Bicortical
 Extra oral approach
 Nerve injury
 Difficult to adapt

Compression plate Miniplates
 Bicortical plates
 Bulky and difficult to use
 Applied extraorally
 Cannot be used at the upper border of
the mandible
 Provides rigid fixation
 No interfragmentary movement
allowed
 Monocortical plates
 Easy to use
 Applied intraorally, small incision , less
soft tissue dissection , less likely to be
palpable
 Can be used without any associated
complication
 Provides functionally stable fixation
 Little interfragmentary movement
present, torsional movement seen under
functional loading

Locking vs Standard mini plates

3-D plate ostesynthesis
 Titanium 3-D plating system was developed by Farmand to meet
the requirements of semi-rigid fixation with lesser complications.
 The 3-D miniplate is a misnomer as the plates are not three
dimensional, but hold the fracture fragments rigidly by resisting
the forces in three dimensions, namely, shearing, bending, and
torsional forces.
 The basic concept of 3-D fixation as explained by Farmand
is that a geometrically closed quadrangular plate secured with bone
screws creates stability in three dimensions. The stability is gained
over a defined surface area and is achieved by its configuration
and not by its thickness or length.

 ADVANTAGES
 The large free areas between the plate arms and minimal
dissection permit good blood supply to the bone.
 The 3-D plating system uses fewer plates and screws as
compared to the conventional miniplates, to stabilize the bone
fragments. Thus, it uses lesser foreign material, and reduces
the operation time and overall cost of the treatment
 The 3-D plating system has a compact design and is easy to
use. The 1.0-mm-thick 3-D plate is as stable as the much
thicker 2.0 mm miniplate.
 This offers better bending stability and more resistance to out-
of plane movement or torque.

Three dimensional plate

Bioabsorbable Plates
Bioresorbable materials used for rigid fixation
 Polydioxanone
 Polyglycolic acid
 Polylactic acid
Strength inadequate to provide clinically acceptable rigid fixation.
 Use of poly-L-lactide (PLLA) in 69 fractures by Kim et al
 12% complication
 8% infection
 No malunion

Bioresorbable plates & screws
Advantages:
 Provides the proper strength
when necessary and then
harmlessly degrades over
time.
 No need for an additional
removal operation.
 Reduce the total treatment &
rehabilitation time of the
patient.
 No bending pliers are
necessary. 27-04-2016Mandibular Fractures 96

Lag screw
Compress fracture fragments without the use of bone plate
Two sound bony cortices are required -- Shares the loads with the bone
Uses:
 absolute rigid fixation
 Less hardware
 More cost effective
 Rigid method of internal fixation
 Insertion -quicker and easier
 Reduction more accurate

Lag screws
 Placed in direction that is perpendicular to the line of
fracture to prevent overriding & displacement during
tightening of the screws.
INDICATIONS
• #s in edentulous parts
• Concomittant #s of body & condyle
• IMF contraindicated
• Saggital/oblique fractures
• Non/malunion

Reconstruction
plates
 For communited mandibular fractures
 Decreased post op morbidity
 Stabilization of entire communited complex
 2.0 mm plate with bicortical screw used in
conjunction with lag screws or miniplates

Protocol for treatment of mandibular fractures
 Simple fractures of the condylar process and ramus -
closed reduction. MMF for 48 to72 hours - training
elastics and close observation
 No MMF is required for coronoid fractures; archbars
and training elastics are used only if a malocclusion is
present.
 Simple or compound fractures with a time delay from
injury to immobilization of < 72 hours are treated by a
closed reduction (CR) or, if indicated, open reduction
with rigid fixation (ORIF).

 Compound fractures - delay from injury to immobilization
of >72 hours - MMF and IV antibiotics .
 If the closed reduction is adequate, the patient is continued
on oral antibiotics for an additional 10 to 14days and
maintained in MMF and on a blenderized diet for 5 to 6
weeks from the time of closed reduction.
 If not, ORIF is performed, and MMF is maintained for 10 to
14 additional days.
 Edentulous patients are treated with rigid fixation, no MMF,
and a blenderized diet for 4 to 5 weeks.
 Teeth in the line of fracture are judged individually.

Young adult with Fracture
of the angle receiving Early
treatment in which Tooth
removed from fracture line
3 weeks
Guide for time of immobilization
(a) Tooth retained in fracture line: add 1 week
(b) Fracture at the symphysis: add 1 week
(c) Age 40 years and over: add 1 or 2 weeks
(d) Children and adolescents: subtract 1 week
IF

The goal of AO/ASIF is rigid internal fixation with primary
bone healing, under functional loading
Basic principles
 Reduction of bony fragments
 Stable fixation of the fragments
 Preservation of the adjacent blood supply
 Early functional mobilization

Teeth in the line of fracture
 Potential impediment to healing
 Fracture is compound
 Tooth maybe damaged structurally subsequently become
necrotic
 Pre existing pathology – apical granuloma

Absolute
 Longitudinal #
 Dislocation/subluxation of tooth
 Periapical Infection
 Infection of the fracture line
 Acute pericoronitis
Relative
 Functionless tooth
 Advanced caries
 Periodontal disease
 Doubtful teeth
 Untreated # > 3 days
Indications for removal

Management of teeth retained in fracture line
 Intra-oral periapical radiograph
 Systemic antibiotic therapy
 Splinting of tooth if mobile
 Endodontic therapy if pulp exposed
 Immediate extraction if fracture becomes infected
 Follow-up for 1 yr with endodontic therapy if there is demonstrable loss of
vitality.

Complications
Complications during primary treatment
 Misapplied fixation
 Infection
 Nerve damage
 Displaced teeth and foreign bodies
 Pulpitis
 Gingival and periodontal complications
 Drug reactions

Late complications
 Malunion
 Delayed union
 Non-union
 Derangement of the temporomandibular joint
 Late problems with transosseous wires and plates
 Sequestration of bone
 Trismus
 Scars

Management of Infections

Reference
 Maxillofacial injuries – N.L. Rowe, J Williams, Vol 1
Ied.
 Oral & maxillofacial trauma – Raymond J Fonseca 4th
ed
 Journal of Cranio-Maxillofacial Surgery 2008; 36: e251 -
e259
 Subodh et al, Clinical Study An Epidemiological Study on
Pattern and Incidence of Mandibular Fractures, Hindawi
Publishing Corporation Plastic Surgery International,
Volume 2012, Article ID 834364,7pages

 A comprehensive classification of mandibular fractures: a
preliminary agreement validation studyC. H. Buitrago-Tellez, L.
Audige, B. Strong, P. Gawelin, J. Hirsch Int. J. Oral Maxillofac.
Surg. 2008; 37: 1080–1088.
 A. H. Kamboozia, A. Punnia-Moorthy: The fate of teeth in
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 Atlas Oral Maxillofacial Surg Clin N Am 17 (2009) 81–
91,Fractures of the Growing Mandible;George M. Kushner, Paul
S. Tiwana.
 Protocol for treatment of mandibular fractures
Philip L. Maloney,J Oral Maxillofac Surg,59:879-884, 2001.

 3-D plate osteosynthesis; Dental Research Journal /Mar 2012 /Vol 9 /
Issue 2
 R. Mukerji , G. Mukerji , M. McGurk Mandibular fractures: Historical
perspective British Journal of Oral and Maxillofacial Surgery 44 (2006)
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 Bioresorbable plates & screws[Robert M. Laughlin JOMS
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 Killey & kay textbook of mandibular fractures.

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