Mandible Fractures Jacques Peltier MD Matthew Ryan MD UTMB – Dept of Otolaryngology May 2004.

Mandible FracturesMandible Fractures

Jacques Peltier MDJacques Peltier MDMatthew Ryan MDMatthew Ryan MD

UTMB – Dept of OtolaryngologyUTMB – Dept of OtolaryngologyMay 2004May 2004

HistoryHistory

• Edwin Smith Papyrus 1650 described Edwin Smith Papyrus 1650 described Hx, Phy, Diagnosis. Often fatal Hx, Phy, Diagnosis. Often fatal diseasedisease

• Hippocrates – Described Hippocrates – Described monomaxillary dental fixation and monomaxillary dental fixation and bindingbinding

• Sulicetti – 1492 Described “tie teeth Sulicetti – 1492 Described “tie teeth of jaw to teeth of uninjured jaw”of jaw to teeth of uninjured jaw”

HistoryHistory

• Schede 1888 – Bone plate of steel Schede 1888 – Bone plate of steel secured with 4 screwssecured with 4 screws

• Luhr 1960 – Developed mandibular Luhr 1960 – Developed mandibular compression platescompression plates

• Michelet and Champy 1970’s – Michelet and Champy 1970’s – Placement of small bendable non-Placement of small bendable non-compression platescompression plates

EpidemiologyEpidemiology

• Mandible most common after nasal Mandible most common after nasal fractures fractures

• Mandible : Zygoma : Maxilla 6:2:1Mandible : Zygoma : Maxilla 6:2:1

• Ellis 4711 facial fractures, 45% with Ellis 4711 facial fractures, 45% with mandible fracturesmandible fractures

• Assault>MVA>Fall>SportsAssault>MVA>Fall>Sports


• Sites of weaknessSites of weakness– Third molar (esp. impacted)Third molar (esp. impacted)– Socket of canine toothSocket of canine tooth– Condylar neckCondylar neck


• Boole et al (laryngoscope) 5196 Boole et al (laryngoscope) 5196 fracturesfractures– Young military menYoung military men– Angle 35%, Symphysis 20%, Body 12%, Angle 35%, Symphysis 20%, Body 12%,

Condylar 9%, Subcondylar 4%, Ramus Condylar 9%, Subcondylar 4%, Ramus 4%, Alveolar 3%, Coronoid 1%4%, Alveolar 3%, Coronoid 1%

– 70% 1 fracture, 30% 2 fractures, .2% 70% 1 fracture, 30% 2 fractures, .2% more than 2 more than 2

– Facial lacs 30%, other facial fx. 16%, C-Facial lacs 30%, other facial fx. 16%, C-spine 0.8%spine 0.8%

Haug et alHaug et al

Fischer et alFischer et al

Favorable vs. UnfavorableFavorable vs. Unfavorable

• Masseter, Medial and Lateral Masseter, Medial and Lateral Pterygoid, and Temporalis tend to Pterygoid, and Temporalis tend to draw fractures medial and superiordraw fractures medial and superior

• Almost all fractures of angle Almost all fractures of angle unfavorableunfavorable

EvaluationEvaluation

• Stabilization via ATLS protocolStabilization via ATLS protocol

• Part of secondary surveyPart of secondary survey– Pain, malocclusion, trismus, V3 sensory Pain, malocclusion, trismus, V3 sensory

deficitdeficit– History of TMJ (earlier mobilization)History of TMJ (earlier mobilization)– Blow to face favors parasymphyseal Blow to face favors parasymphyseal

fracture and contralateral angle fracturefracture and contralateral angle fracture– Fall to chin (bilateral condylar fractures)Fall to chin (bilateral condylar fractures)


• Previous occlusion (Class I-III)Previous occlusion (Class I-III)

• Psychiatric, nutritional, Psychiatric, nutritional, gastrointestinal, seizure disordersgastrointestinal, seizure disorders

• Previous facial traumaPrevious facial trauma

• Other injuries (c-spine, intra-Other injuries (c-spine, intra-abdominal, likely prolonged abdominal, likely prolonged intubation)intubation)

Physical ExamPhysical Exam

• Complete Head and Neck examComplete Head and Neck exam– Palpable step offPalpable step off– Tenderness to palpationTenderness to palpation– MalocclusionMalocclusion– Trismus (35 mm or less)Trismus (35 mm or less)– FOM hematomaFOM hematoma– Altered sensation of V3Altered sensation of V3– CrepitusCrepitus


• Dental ExamDental Exam– Lost, fractured, or unstable teethLost, fractured, or unstable teeth– Dental HealthDental Health– Relation to fractureRelation to fracture– QuantityQuantity


• Unilateral fractures of CondyleUnilateral fractures of Condyle– Decreased translational movement, Decreased translational movement,

functional height of condylefunctional height of condyle– Deviation of chin away from fracture, Deviation of chin away from fracture,

open bite opposite side of fractureopen bite opposite side of fracture

Bilateral fractures of condyleBilateral fractures of condyle

- Anterior open bite- Anterior open bite

Picture of open bitesPicture of open bites


• Panorex, mandible series Panorex, mandible series

• CT scanCT scan– Not as diagnostic as plain films for Not as diagnostic as plain films for

nondisplaced fractures of mandible.nondisplaced fractures of mandible.– Most useful for coronoid and condylar Most useful for coronoid and condylar

fractures, associated midface fracturesfractures, associated midface fractures

PhysiologyPhysiology

• Primary HealingPrimary Healing– In rigid fixation techniquesIn rigid fixation techniques– Lag screws, compression plates, Recon Lag screws, compression plates, Recon

plate, external fixation, Wire fixation, plate, external fixation, Wire fixation, Miniplate fixationMiniplate fixation

– No callus formationNo callus formation– Question of bone resorptionQuestion of bone resorption

PhysiologyPhysiology

• Secondary bone healingSecondary bone healing– Callus formationCallus formation– Remodeling and strengtheningRemodeling and strengthening– MMF, Wire fixation, Miniplate fixationMMF, Wire fixation, Miniplate fixation

Closed ReductionClosed Reduction

• Favorable, non-displaced fracturesFavorable, non-displaced fractures

• Grossly comminuted fractures when Grossly comminuted fractures when adequate stabilization unlikelyadequate stabilization unlikely

• Severely atrophic edentulous Severely atrophic edentulous mandiblemandible

• Children with developing dentitionChildren with developing dentition


• Length of MMFLength of MMF– De Amaratuga – 75% of children under De Amaratuga – 75% of children under

15 healed by 2 weeks, 75% young 15 healed by 2 weeks, 75% young adults 4 wksadults 4 wks

– Juniper and Awty – 82% had healed at 4 Juniper and Awty – 82% had healed at 4 wkswks

– Longer period for edentulous fractures Longer period for edentulous fractures 6-10wks6-10wks


• Edentulous fracturesEdentulous fractures– Bradley found absent inferior alveolar Bradley found absent inferior alveolar

artery in 40% 60-80 yo’sartery in 40% 60-80 yo’s– Periosteal blood supply disturbed by Periosteal blood supply disturbed by

strippingstripping– Up to 20% non-union despite type of Up to 20% non-union despite type of

treatmenttreatment– May consider Gunning SplintsMay consider Gunning Splints

Open ReductionOpen Reduction

• Displaced unfavorable fracturesDisplaced unfavorable fractures

• Mandible fractures with associated Mandible fractures with associated midface fracturesmidface fractures

• When MMF contraindicated or not When MMF contraindicated or not possiblepossible

• Patient comfortPatient comfort

• Facilitate return to workFacilitate return to work


• ContraindicationsContraindications– General Anesthetic risk too highGeneral Anesthetic risk too high– Severe comminution and stabilization Severe comminution and stabilization

not possiblenot possible– No soft tissue to cover fracture siteNo soft tissue to cover fracture site– Bone at fracture site diffusely infected Bone at fracture site diffusely infected

(controversial)(controversial)


• Associated condylar fractureAssociated condylar fracture

• Associated Midface fracturesAssociated Midface fractures

• Psychiatric illnessPsychiatric illness

• GI disorders involving severe N/VGI disorders involving severe N/V

• Severe malnutritionSevere malnutrition

• To avoid tracheostomy in patients To avoid tracheostomy in patients who need postoperative intubationwho need postoperative intubation


• Intraosseous wiringIntraosseous wiring– Semirigid fixationSemirigid fixation– CheapCheap– Technically difficultTechnically difficult– Primary and Secondary bone healingPrimary and Secondary bone healing


• Lag ScrewsLag Screws– Rigid fixation (Compression)Rigid fixation (Compression)– Good for anterior mandible fractures, Good for anterior mandible fractures,

Oblique body fractures, mandible angle Oblique body fractures, mandible angle fracturesfractures

– CheapCheap– Technically difficultTechnically difficult– Injury to inferior alveolar neurovascular Injury to inferior alveolar neurovascular

bundlebundle

Open reductionOpen reduction

• Ellis 41 patients with anterior lag Ellis 41 patients with anterior lag screw techniquescrew technique

• 4.9% infection rate4.9% infection rate

• No malocclusionNo malocclusion

• No Non-unionNo Non-union

Lag Screw TechniqueLag Screw Technique

Rigid FixationRigid Fixation

• Compression platesCompression plates– Rigid fixationRigid fixation– Allow primary bone healingAllow primary bone healing– Difficult to bendDifficult to bend– Operator dependentOperator dependent– No need for MMFNo need for MMF


• MiniplatesMiniplates– Semi-rigid fixationSemi-rigid fixation– Allows primary and secondary bone Allows primary and secondary bone

healinghealing– Easily bendableEasily bendable– More forgivingMore forgiving– Short period MMF RecommendedShort period MMF Recommended


• Schierle et al studied experimental Schierle et al studied experimental model, then applied in patients.model, then applied in patients.– Model suggested two plates more stableModel suggested two plates more stable– Patients divided into two groups with Patients divided into two groups with

equal complication rates, equal equal complication rates, equal functional resultsfunctional results

Miniplates, Champy Miniplates, Champy techniquetechnique

http://gateway2.ovid.com/ovidweb.cgi?View+Image=00004911-199908000-00001%7CFF6&S=IDNJHKKKCHNLKM00D


• Reconstruction PlatesReconstruction Plates– Good for comminuted fracturesGood for comminuted fractures– Bulky, palpableBulky, palpable– Difficult to bendDifficult to bend– Locking plates more forgivingLocking plates more forgiving

External FixationExternal Fixation

• Alternative form of rigid fixationAlternative form of rigid fixation

• Grossly comminuted fractures, Grossly comminuted fractures, contaminated fractures, non-unioncontaminated fractures, non-union

• Often used when all else failsOften used when all else fails

Edentulous FracturesEdentulous Fractures

• Chalmers and Lyons 1976 – Chalmers and Lyons 1976 – Recommended closed reduction to Recommended closed reduction to preserve periosteal blood supplypreserve periosteal blood supply

• Chalmers and Lyons 1995Chalmers and Lyons 1995– 167 fractures in edentulous mandibles167 fractures in edentulous mandibles– ORIF 82%ORIF 82%– 15% complications15% complications– 12% Fibrous union12% Fibrous union

Edentulous FracturesEdentulous Fractures

• ORIFORIF– Inferior alveolar canal more superior in Inferior alveolar canal more superior in

locationlocation– Vertical height 20mm compatible with Vertical height 20mm compatible with

standard plating systemsstandard plating systems– Vertical height 10mm or less, likely need Vertical height 10mm or less, likely need

rib graftrib graft– Plate removal after fracture healing if Plate removal after fracture healing if

interferes with denture placementinterferes with denture placement

Teeth in line of fractureTeeth in line of fracture

• Keep teeth ifKeep teeth if– Previously healthyPreviously healthy– Peridontal plexus intactPeridontal plexus intact– No major structural injuryNo major structural injury– Tooth does not interfere with reduction Tooth does not interfere with reduction

of fractureof fracture


• Neal and associatesNeal and associates– 32% incidence of morbidity with teeth in 32% incidence of morbidity with teeth in

line of fractureline of fracture– No statistical difference if tooth was No statistical difference if tooth was

removedremoved


• AmaratungaAmaratunga– 16% complication rate in retained teeth16% complication rate in retained teeth– 13% in removed teeth13% in removed teeth– Retain teeth for 4-6 weeks if important Retain teeth for 4-6 weeks if important

for MMFfor MMF

Condylar and Subcondylar Condylar and Subcondylar

• Lindhal and HollenderLindhal and Hollender– Closed reduction in children, teens, Closed reduction in children, teens,

adultsadults– Intracapsular fracturesIntracapsular fractures– Higher incidence of postoperative Higher incidence of postoperative

sequelae in adultssequelae in adults– Children and Teens with less sequelae, Children and Teens with less sequelae,

more remodeling more remodeling

Condylar and SubcondylarCondylar and Subcondylar

• NorholtNorholt– Children 5-20 with intracapsular Children 5-20 with intracapsular

condylar fracturescondylar fractures– Increased dysfunction with increasing Increased dysfunction with increasing

ageage


• Closed reduction with arch bars MMF Closed reduction with arch bars MMF 2-3 weeks mainstay for youths2-3 weeks mainstay for youths– Ankylosis of TMJ and facial asymmetry Ankylosis of TMJ and facial asymmetry

most feared complicationmost feared complication– Less effective forLess effective for

• increasing ageincreasing age

• decreased ramus heightdecreased ramus height

• more displaced more displaced


• ORIF, Absolute indicationsORIF, Absolute indications– Displacement into middle cranial fossaDisplacement into middle cranial fossa– Inability to achieve occlusion with closed Inability to achieve occlusion with closed

reductionreduction– Foreign body in joint spaceForeign body in joint space


• Relative indicationsRelative indications– Bilateral condylar fractures to preserve Bilateral condylar fractures to preserve

vertical heightvertical height– Associated injuries that dictate earlier Associated injuries that dictate earlier

functionfunction•Soft tissue swelling causing airway Soft tissue swelling causing airway

compromise with MMFcompromise with MMF

• Intracapsular fracture on opposite side Intracapsular fracture on opposite side where early mobilization importantwhere early mobilization important

Immediate MobilizationImmediate Mobilization

• Kaplan et al. Kaplan et al. – Studied ORIF in two groups, one with Studied ORIF in two groups, one with

MMF for 2 weeks, one with immediate MMF for 2 weeks, one with immediate mobilizationmobilization

– No statistical difference in rates of No statistical difference in rates of complications, postoperative pain, complications, postoperative pain, dental health, nutritional statusdental health, nutritional status

Bioabsorbable Plates Bioabsorbable Plates

• Plating can relieve stress, no bone remodeling Plating can relieve stress, no bone remodeling

• Bulky plates, thermal sensitivity, palpableBulky plates, thermal sensitivity, palpable

• Absorbable plates expensiveAbsorbable plates expensive

• Better in children?Better in children?

• Use of poly-L-lactide in 69 fractures by Kim et Use of poly-L-lactide in 69 fractures by Kim et alal– 12% complication12% complication– 8% infection8% infection– No malunionNo malunion

Kim et al “Treatment of Mandible Fractures using Bioabsorbable plates”, Plastic and Reconstructive Surgery, vol 110, july 2002, 25-31

Bailey, Byron J. Head and Neck Surgery - OtolaryngologyThird Edition. Lippincott Williams and Wilkins, 2001. Ellis, E. “Treatment Methods for Fractures of the Mandibular Angle." Journal of Craniomaxillofacial Trauma, vol. 28. 1999: 243-252.

Ellis, E., et. al. “Lag Screw Fixation of Mandibular Angle Fractures.” Journal of Oral Maxillofacial Surgery, vol. 49. 1991: 234-243.

Kim et. al. "Treatment of Mandible Fractures Using Bioabsorable Plates." Journal of Plastic and Reconstructive Surgery, vol. 110. 2002: 25-31. Boole et. al. "5196 Mandible Fractures Among 4381 Active Duty Army Soldiers, 1980 to 1998." Laryngoscope, 111(10). Oct. 2001: 1691-6, Kaplan et al. "Immediate Mobilization Following Fixation of Mandible Fractures, A Prospective Randomized Study." Laryngoscope, vol. 111(9). Sept 2001: 1520-1524 Spina and Marciani. Mandibular Fractures, pages 85 - 105 Schierle et. al. "One or Two Plate Fixation of Mandible Fractures?" Journal of Cranio-Maxillofacial Surgery. Vol. 25, 1997: 162-168.

ReferencesReferences

Mandible Fractures Jacques Peltier MD Matthew Ryan MD UTMB – Dept of Otolaryngology May 2004.

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