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Mandibular Body Fractures Treatment & Management

  • Author: Jose E Barrera, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Sep 28, 2015
 

Medical Therapy

Patients with isolated nondisplaced or minimally displaced condylar fractures may be treated with analgesics, soft diet, and close observation. Patients with coronoid process fractures may be treated similarly. Additionally, these patients may require mandibular exercises to prevent trismus. If the fractured coronoid restricts mandible movement, medical therapy is contraindicated. Use prophylactic antibiotics for compound fractures. Penicillin remains the antibiotic of choice.

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Surgical Therapy

Techniques for closed reduction and fixation of the dentulous mandible vary.

Closed reduction and fixation

Placement of Ivy loops using 24-gauge wire between 2 stable teeth, with use of a smaller-gauge wire to provide maxillomandibular fixation (MMF) between Ivy loops, has been successful. Arch bars with 24- and 26-gauge wires are versatile and frequently are used. In an edentulous mandible, dentures can be wired to the jaw with circummandibular wires. The maxillary denture can be screwed to the palate. Arch bars can be placed and intermaxillary fixation (IMF) achieved. Gunning splints also have been used in this scenario.

Open reduction and internal fixation

Multiple approaches to open reduction and internal fixation (ORIF) exist. Consider fracture location, nerve position, and skin crease lines when choosing the appropriate approach.

Intraoral versus extraoral approach to body fractures

The intraoral approach may be used in fractures with no or only slight dislocation. This approach allows sufficient exposure in the anterior part of the horizontal ramus. The molar area may require additional stab incisions to place screws for plate fixation. With an intraoral approach, exercise caution to avoid injuring the mental nerve.

The extraoral approach is necessary with fractures that have a high degree of dislocation or comminution because placing longer and stronger plates is difficult via the intraoral approach. Extraoral approach is also undertaken with fractures lying between the inferior and lingual aspects of the body. Give special attention to the marginal mandibular nerve. General anesthesia is indicated in both intraoral and extraoral approaches.

Transverse fracture line without displacement

Two 4-hole miniplates (2.0) may be used. Use monocortical screws for the superior plate. Place bicortical screws for the inferior mandibular border. Placing a superior plate helps neutralize tensile forces. In addition, a dental splint may be placed just underneath the tooth root apices. The splint must span at least 3 teeth on either side of the fracture. Recently, the treatment of mandibular fractures (symphysis, parasymphysis, and angle) with 3-dimensional plates provided 3-dimensional stability and carried low morbidity and infection rates.[5] The only probable limitations of 3-dimensional plates were excessive implant material due to the extra vertical bars incorporated for countering the torque forces.

Transverse fracture line with displacement

In this type of fracture, undertake wider surgical exposure. Reduction in the superior aspect of the placement may be secured with a tension-band splint or a 2.0 miniplate in the alveolar crest or tensile area.

Fix the inferior border with a 2.4 compression plate as seen in the image below. Stronger male patients may require a reconstruction plate with bicortical screws at this site.

Oblique fracture lines, which have wider surface area, may be fixed with 3 lag screws or a combination of lag screws and plates as seen in the image below.

(A) An oblique fracture of the body fixed with 1 l (A) An oblique fracture of the body fixed with 1 lag screw, in combination with a compression plate at the inferior border and a dental splint for tension. (B) A fracture of the mandible body with a basal triangle. (C) Open reduction and adequate fixation using a miniplate at the superior border and a reconstruction plate at the inferior border. (D) Postoperative radiograph demonstrating fixation. An open hole in the reconstruction plate lies between the triangle and the corpus.

Fractures of the basal triangle

The basal triangle may be reduced and fixed with a reconstruction plate at the mandible base. Lag screws may be used to fix comminuted segments to the plate or adjacent bone. Reduce the tensile aspect of the fracture with a 2.0 miniplate and monocortical screws or a tension-band splint as seen in the image above.

Comminuted fractures

Reduce and approximate fragments with lag screws or 1.5/2.0 miniplates. Bridge fragments with reconstruction plates.

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Preoperative Details

Approach mandibular fractures methodically. Patients rarely die from mandibular fractures. Perform diagnosis and treatment in an orderly and efficient manner. Use prophylactic antibiotics for compound fractures. Evaluate nutritional needs.

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Intraoperative Details

The primary goal of treatment is to reestablish occlusion. Function is compromised with malunion. Most mandibular fractures can be treated by closed reduction. Nondisplaced favorable fractures can be managed by closing with IMF alone. Arch bars or Ernst ligatures may be placed and supplemented with autopolymerizing resin.

Three separate techniques for rigid fixation of the mandible have been developed: (1) the bicortical Luhr system, using vitallium plates; (2) the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) system of stainless steel compression or reconstruction plates with bicortical screws;[6] and (3) the Champy miniplate technique placed along the "line of ideal osteosynthesis," using monocortical screws.

A prospective randomized clinical trial comparing 2.0-mm locking plates with 2.0-mm standard plates in the treatment of mandible fractures found the statistically significant difference between the plates. In addition, mandible fractures treated with 2.0-mm locking plates and 2.0-mm standard plates have similar short-term complication rates.

With multiple facial fractures, treat mandibular fractures first because the mandible is the foundation on which facial bones can be laid. Perform intraoral surgery prior to an extraoral approach. IMF time varies according to type, location, number, and severity of fracture. Generally, 6 weeks of IMF are prescribed, although this is only an empiric approximation.

Treat dental injuries concurrently with the fracture. Fractured teeth may become infected or jeopardize bone union and should be removed. Mandibular cuspids help determine occlusion and should be preserved, if possible.

The management of edentulous body fractures is challenging. Patients are typically advanced in age and present with multiple comorbidities. The tendency to do less should be avoided. Ellis et al reported on a 17-year experience of treating 32 atrophic mandibles and found that a more aggressive approach for managing fractures produced healing in all patients and, in the end, may be more "conservative" than a less aggressive approach.[7] These fractures were treated through an extraoral approach with rigid internal fixation. Immediate bone grafts were used in 23 of the 32 patients.

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Postoperative Details

Administer analgesic medications in the postoperative period. With open fractures, use antibiotic therapy covering gram-positive organisms. Keep wire cutters at the bedside in case of vomiting. Reevaluate nutritional needs.

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Follow-up

Maintain IMF for 4-6 weeks, tightening wires every 2 weeks. After wires are removed, a Panorex radiograph is usually obtained to ensure fracture union.

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Complications

Complications following mandibular fracture repair are rare. The most common complication is infection or osteomyelitis. Contributing factors include (1) oral sepsis, (2) teeth in the fracture line, (3) alcohol abuse and chronic disease, (4) prolonged time prior to treatment, (5) poor patient compliance, (6) displacement of fracture fragments, and (7) fracture of the plate.Material analysis of AO plates used in mandible fractures revealed titanium plate fracture in 4 out of 110 mandibular reconstructions.[8] The plate fracture was most common in angle-type plates because of constriction on the internal side of the plate.

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Outcome and Prognosis

Both closed and open reductions of mandibular fractures cause favorable results for bony union. In a study of 922 mandibular body and angle fractures treated with an intraoral approach without IMF, solid bony union was achieved in more than 99% of patients.[9]

Rarely does a second fracture following additional assault or vehicular accident occur. However, when it does happen, the cause for the second fracture is usually an assault, with 90% related to alcohol intake. Angle, body, and parasymphysis regions of the mandible were the most common sites to be involved in the first occasion.

In a study with 10 cases, an internal rigid fixation procedure was performed for the treatment of a secondary fracture. In the recurrent injuries, none of the fractures occurred at exactly the same anatomical site. Fractures were either in the neighboring side or in the contralateral side of the previously healed area of the mandible. On the second occasion, angle fractures were common, but body and subcondylar fracture rates increased. At second presentation, the complication rate increased from 23.1% to 53.8% and most commonly involved malocclusion.

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Future and Controversies

Controversy exists over open versus closed reduction for angle fractures. Traditionally, MMF has been the mainstay of treatment. Plating techniques have revolutionized open reduction as a treatment modality.

Advantages of closed reduction include proven efficacy, low complication rate, and short operating time. This technique may be performed as an office procedure. Disadvantages include long fixation (ie, 3-6 wk), poor nutrition associated with MMF, risk of TMJ ankylosis, and airway problems.

Advantages to ORIF include earlier mobilization and nearly exact bone fragment reapproximation. Disadvantages include increased treatment cost and need for operating room time.

Another controversy involves disposition of teeth located in the fracture line. In the postantibiotic era, infection of involved teeth is less troublesome. Many teeth may be retained, and they can be useful in reduction and stabilization of fractured segments. Extract teeth if they prevent proper reduction and fracture stability or if they have significant periodontal disease or caries.[10]

The use of miniplates for treatment of mandibular fractures has been controversial. A recent study using 0.55 mm-thick miniplates with 1.2 mm monocortical miniscrews showed that 2-point fixation with microplates is appropriate for the internal fixation of simple, isolated mandibular fractures.[11] Its advantages include a high adaptability to the fracture site, occlusal self-adjustment, a minimal mass effect, and a relatively strong holding power of 2-point fixation. In 54 patients, 8 complications were found, including 7 patients with a double fracture, including mild malocclusion (n = 3), paresthesia (n = 3), asymptomatic delayed union (n = 1), and asymptomatic plate fracture (n = 1).

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Contributor Information and Disclosures
Author

Jose E Barrera, MD Medical Director, Texas Facial Plastic Surgery and ENT; Associate Professor, Uniformed Services University of the Health Sciences; Clinical Associate Professor, University of Texas Health Science Center at San Antonio School of Medicine

Jose E Barrera, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine

Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society

Disclosure: Nothing to disclose.

References
  1. Pektas ZO, Bayram B, Balcik C, Develi T, Uckan S. Effects of different mandibular fracture patterns on the stability of miniplate screw fixation in angle mandibular fractures. Int J Oral Maxillofac Surg. 2012 Mar. 41(3):339-43. [Medline].

  2. Boffano P, Roccia F, Zavattero E, et al. European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015 May. 119 (5):499-504. [Medline].

  3. Siwani R, Tombers NM, Rieck KL, Cofer SA. Comparative analysis of fracture characteristics of the developing mandible: the Mayo Clinic experience. Int J Pediatr Otorhinolaryngol. 2014 Jul. 78 (7):1066-70. [Medline].

  4. Dodson TB. Third molars may double the risk of an angle fracture of the mandible. Evid Based Dent. 2004. 5(3):78. [Medline].

  5. Sadhwani BS, Anchlia S. Conventional 2.0 mm miniplates versus 3-D plates in mandibular fractures. Ann Maxillofac Surg. 2013 Jul. 3(2):154-9. [Medline]. [Full Text].

  6. Kuriakose MA, Fardy M, Sirikumara M, et al. A comparative review of 266 mandibular fractures with internal fixation using rigid (AO/ASIF) plates or mini-plates. Br J Oral Maxillofac Surg. 1996 Aug. 34(4):315-21. [Medline].

  7. Ellis E 3rd, Price C. Treatment protocol for fractures of the atrophic mandible. J Oral Maxillofac Surg. 2008 Mar. 66(3):421-35. [Medline].

  8. Katakura A, Shibahara T, Noma H, et al. Material analysis of AO plate fracture cases. J Oral Maxillofac Surg. 2004 Mar. 62(3):348-52. [Medline].

  9. Luhr HG, Hausmann DF. [Results of compression osteosynthesis with intraoral approach in 922 mandibular fractures]. Fortschr Kiefer Gesichtschir. 1996. 41:77-80. [Medline].

  10. Orabona GD, Abbate V, D'Amato S, Romano A, Iaconetta G. Surgical sequence of reduction in double mandibular fractures treatment. Ann Ital Chir. 2014 May-Jun. 85 (3):207-13. [Medline].

  11. Burm JS, Hansen JE. The use of microplates for internal fixation of mandibular fractures. Plast Reconstr Surg. 2010 May. 125(5):1485-92. [Medline].

  12. Alpert B, Engelstad M, Kushner GM. Invited review: small versus large plate fixation of mandibular fractures. J Craniomaxillofac Trauma. 1999 Fall. 5(3):33-9; discussion 40. [Medline].

  13. Barber HD, Woodbury SC, Silverstein KE. Mandibular fractures. Oral and Maxillofacial Trauma. Philadelphia, Pa: WB Saunders Co; 1991. 473-526.

  14. Collins CP, Pirinjian-Leonard G, Tolas A, et al. A prospective randomized clinical trial comparing 2.0-mm locking plates to 2.0-mm standard plates in treatment of mandible fractures. J Oral Maxillofac Surg. 2004 Nov. 62(11):1392-5. [Medline].

  15. Gardner KE, Aragon SB. The mandibular fracture. ENT Secrets. Philadelphia, Pa: Hanley & Belfus; 1996. 302-309.

  16. King RE, Scianna JM, Petruzzelli GJ. Mandible fracture patterns: a suburban trauma center experience. Am J Otolaryngol. 2004 Sep-Oct. 25(5):301-7. [Medline].

  17. Lazow SK. The mandible fracture: a treatment protocol. J Craniomaxillofac Trauma. 1996 Summer. 2(2):24-30. [Medline].

  18. Schilli W, Stoll P, Bahr W. Mandibular fractures. Manual of Internal Fixation. New York, NY: Springer-Verlag; 1990. 65-80.

  19. Spiessel B. The stability principle. Internal Fixation of the Mandible: A Manual of AO/ASIF Principle. New York, NY: Springer-Verlag; 1989. 30-45.

 
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A mandible body fracture with displacement. (A) Transverse fracture of the right mandible. (B) Fixation achieved using miniplates at the superior and inferior borders. (C) Postoperative radiograph demonstrating fixation.
Forces acting on the mandible and demonstration of the relationship between muscle pulls and fracture angulation. (A) Horizontally unfavorable. (B) Horizontally favorable. (C) Vertically unfavorable. (D) Vertically favorable.
(A) An oblique fracture of the body fixed with 1 lag screw, in combination with a compression plate at the inferior border and a dental splint for tension. (B) A fracture of the mandible body with a basal triangle. (C) Open reduction and adequate fixation using a miniplate at the superior border and a reconstruction plate at the inferior border. (D) Postoperative radiograph demonstrating fixation. An open hole in the reconstruction plate lies between the triangle and the corpus.
 
 
 
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