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As the mandible is a hoop of bone articulating with the skull at its proximal
ends by two joints and since the chin is a prominent feature of face, the mandible is
prone to fracture.
The mandible has been compared to an archery bow, which is the strongest at its
center and weakest at its end, where it breaks often. Hence, the fracture occurring
in any part of mandible refers to as mandibular fracture.
• INCIDENCE:
Mandibular fracture is more common than middle third injury. The most
common facial fractures are-
Mandible : 61%
Maxilla : 46%
Zygoma : 27%
Nasal bone : 19.5%
• AETIOLOGY:
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Sports injury, gun shot injury, industrial injury
War
Violence
Blow
Faulty tooth extraction
• Pathological:
Osteolytic lesion-
Osteo fibroma
Fibrous Dysplasia
Other pathologies-
Osteomyelitis
Osteoporosis
Osteogenic imperfecta
Osteonecrosis
Large cyst
• CLASSIFICATION:
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1. Angle of the mandible-31% of all mandibular fracture
2. Body of the mandible-36%
Molar region -----------15%
Mental region-----------14%
Cuspid area--------------7%
3. Simple Fracture:
When there is a break in continuity of bone without break in mucosa or skin that is
the fracture fragments not exposed to the external environment.
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Fig: Simple fracture
2. Compound Fracture:
When the fracture ends of the bone are associate with the break in continuity of
skin or mucous membrane there by communicating with external environment
3. Communited fracture:
communication
Compound communited fracture-when there is external
communication
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Fig: Communited fracture
4. Greenstick Fracture:
It occurs mainly in children. The bone in the children is soft and elastic so a crack
in the bone in which one cortex of the bone is fractured where as other cortex is
bent only as in case of green stick of a tree.
5. Pathological Fracture:
The fracture occurs from mild injury or as a result of normal degree of muscular
contraction due to weakness caused by pre-existing bone pathology.
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Fig: Pathological fracture
1. Direct fracture:
2. Indirect Fracture:
If the fracture occurs away from the site of impact, it is referred to as indirect
fracture.
Sudden musculature contracture may also causes some fracture such as fracture of
the Coronoid process because of the sudden reflex contracture of the Temporalis
muscles & also fracture of the Condylar neck.
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Fig: Direct and indirect fracture
1. Favorable fracture:
A fracture is said to be favorable if the muscular pull resists the displacement of the
fracture—
a. Horizontally favorable fracture
b. Vertically favorable fracture
A B
2. Unfavorable Fracture:
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A fracture is said to be unfavorable if the muscular pull does not resists the
displacement of the fracture—
a. Horizontally unfavorable Fracture
b. Vertically unfavorable Fracture
A B
1. Unilateral Fracture:
o Unilateral Fracture of the body of the mandible
2. Bilateral fracture:
o Angle of the mandible
o Canine region
o Condylar neck
3. Multiple Fracture
The most common multiple fracture is caused by a fall on the mid point of the chin
resulting in fracture of the Symphysis & both condyles.
It is usually seen in epileptics, elderly patients and occasionally in soldiers. So it is
called –Guardsman fracture.
4. Comminuted fracture:
o Symphysis & parasymphyseal region (most common)
o War missiles injuries
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F. Based on the presence or absence of teeth:
1. Class –I: When teeth are present on both side of the fractured line.
2. Class-II: When teeth are present on one side of the fractured line.
3. Class-III: When both the fragments of each side of the fractured line are
edentulous.
A B
C
Fig: A) Class-I B) Class-II C) Class-III
• ROLES OF MUSCLE DISPLACEMENT OF MANDIBULAR
FRACTURE:
They do not play any important role in the displacement of fracture of mandible, as
the origin of these muscles from bone & insertion into the skin. To displace the
bone the muscle should originate and insert into the bone only.
2. Muscle of mastication:
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o Lateral pterygoid muscle helps in displace the neck of condyle anterio-
medially.
Fig: Diagram showing muscular pull in mandible; A) lateral view B) medial side
C) Horizontal views
History of injury.
Acute continuous pain with swelling of lower part of face.
Discoloration of skin.
Soft tissue laceration.
Bleeding from the mouth.
Break in the continuity of bone with the deformity of the facial
symmetry.
Break in the continuity of mucosa with swelling in the floor of the
mouth.
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Break in the continuity of dental arch and loss mastication with
abnormal mobility.
Difficulty in chewing and swallowing.
Inability to open the mouth and difficulty in closing of mouth
leading to loss of function.
Foul odour and excessive salivation as the patient can not clean the
oral cavity.
Abnormal occlusion.
Anterior open bite and lateral cross bite.
Deviation of mandible during movement mainly seen in the
unilateral fracture.
On palpation-a crepitus sound may be felt.
A step deformity may be in the lower border of the mandible,
occlusal surface and upper border of the mandible.
Trismus mainly in the fracture of ramus
Neurological defect.
A. Airway maintenance:
1. Clear the mouth and throat of blood clot, tenacious salivary secretion, and
foreign bodies like denture or luxated tooth with the help to powerful suction
and wet swab.
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passing a stay suture through the tongue that can be stabilizing with the shire
of the patient.
5. Airway tube.
6. Cricothyroidotomy
7. Tracheostomy
B. Bleeding control:
C. Control of circulation:
A. History Taking:
1. Accurate detail and proper history of patient should be taken as per clinical
or medico logical point of view.
2. If the patient is unable to give statement then the same should be recorded
from accompanying person, relative, friends or police officers.
3. It will reveal about how the injury occured, the type of injury & the severity
of the injury.
B. General examination:
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1. It should be carried out to look for any serious injury elsewhere in the body
so that the appropriate specialist could be consulted.
2. Inspection & palpation of head for any soft tissue as well as bone injury.
3. Inspection & palpation of chest & abdomen for any injury.
C. Regional examination:
1. Extra oral:
-Inspection
-Palpation
2. Intra oral:
- Inspection
- Palpation
D. Radiological examination:
I. Extra-oral radiograph:
a. P/A view of mandible in open mouth.
b. Right and left lateral oblique view.
c. X-ray for TMJ in both opened and closed mouth position.
4. OPG.
Fig: OPG shows fracture of the body of the mandible and right condylar region
3. Definitive treatment:
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1. Conservative treatment:
When fracture line seen but no displacement then conservative treatment is
done-
a) Control of pain-
A patient of fracture of mandible experiences extreme degree of pain
and may go into shock because of severe pain so IV-Diazepam can be
given in the dose of 10 mg combined with 20 mg Pentazocine as
analgesic.
b) Control of Infection-
Prevention of infection in case of fracture or control of already
established infection is of outmost importance so, Antibiotic should
prescribe
d) Soft diets
e) Oral Hygiene instruction
f) Advice to the patient to shouldn’t move the jaw vigorously
g) Follow-up.
2. Active treatment:
If displacement occurs then active treatment is done. The treatment follows
some principles.
Types of reduction:
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It is usually done in simple fracture-
A
A B
2. Open Reduction:
a) If widely displacement occurs the open reduction must be
anatomically precise when teeth are involved which were previously
in good occlusion.
b) Open reduction and immobilization is best effected under General
Anesthesia- when severe compound fracture.
c) Sometimes open reduction done under local anesthesia- when
fracture is not so severe.
B) Fixation:
C) Immobilization:
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The reduced and fixed fragments of the bone are immobilized for
certain period for healing.
Healing of fracture:
• Clotting of blood
• Organization of haematoma
• Formation of fibrous callus
• Formation of primary callus
o Uniting callus
o Bridging callus
o Anchoring callus
o Sealing callus
D) Rehabilitation
Return to normal function and appearance is the goal of all clinical
examination.
Young adult with fracture of the angle receiving early treatment in which tooth
removed from fracture line – 3 weeks
If:
1. If tooth retained in the fracture line, add 1 week
2. Fracture in the Symphysis, add 1 week
3. Age 40 years or over, add 1 to 2 weeks
4. Children or adolescents, subtract 1 week.
Applying this guideline is follows that a fracture of the Symphysis in 40 years old
patient when the tooth in the fracture line is retained requires 6 weeks
immobilization.
(Basic 3 weeks +1 week for less favorable site+ 1 week allowed for age+1 week
for tooth retained in the fractured line)
• METHODS OF IMMOBILIZATION:
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A) Intermaxillary fixation:
1. Dental wiring:
Direct wiring or glimmers direct method of wiring
Eyelet wiring or Ivy Eyelet wiring or Interdental wiring.
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Figure ‘8’ wiring Two hole and four hole system
Fig: Intraosseous or transosseous wiring
A B
Fig: After reduction fixation with A) mini bone plate B) compression bone plate
Methods of immobilization:
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Bone plate
Trans fixation with Krischner’s wire- when body of the
mandible is less than 10 mm in depth
Cortico-cancellous bone grafting.
3. Indirect skeletal fixation
External pin fixation
Bone clamps
• POSTOPERATIVE CARE:
General supervision:
Correction of unacceptable reduction
Occlusion should be checked as early as possible
Inspection of fixation
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Should lie on the lateral posture
Sedation: With Diazepam (Dose is adjusted according to the
patient’s response to 5 mg increment)
Prevention of infection- with prophylactic antibiotic.
Oral Hygiene: Mouthwash with 0.2% chlorohexidine gluconate.
The lips tends to stick together so the lips and mouth should be
cleaned with moist saline swabs at regular intervals and the lips
regularly lubricated with steroid containing ointment or
petroleum jelly.
Feeding- Liquid/soft diet/ (2000-2500) cal/day.
- Fluid balance by daily intake about 3 L water.
• COMPLICATIONS:
Infections:
1. Abscess resulting in necrosis and Osteomyelitis
2. Fracture with chronic facial fistula due to chronic infection
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Ankylosis of temporomandibular Joint
Sequestration of bone
Incomplete closure of mouth due to fracture of Coronoid.
Facial asymmetry and step defect
Premature contact of tooth.
Disturbance in occlusion
Scars.
• CONDYLAR FRACTURE:
• CLASSIFICATION:
1. Extra-capsular fracture
Unilateral
Bilateral
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2. Intra capsular Fracture:
Unilateral
Bilateral
3. According to displacement:
No displacement
Forward displacement
Medial displacement
Lateral displacement
A) In case of children:
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B
A
B) In Case of adult:
1. Unilateral:
If occlusion is OK then IMF
If painful joint then IMF for 2 weeks
2. Bilateral:
Intermittent IMF
IMF for 2 weeks
IMF only at nights for 4 weeks
1. Unilateral:
IMF for 4 weeks
Open reduction if necessary
2. Bilateral:
IMF for 4-6 weeks
Open reduction if necessary
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• POST OPERATIVE MANAGEMENT & INSTRUCTION:
Based on Lectures of
Asst. Professor Dr. Kazi Sazzad Hossain
Department of Oral Surgery and Anaesthesiology
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• BIBLIOGRAPHY:
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