Mandibular Body Fractures Treatment & Management
- Author: Jose E Barrera, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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.
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. 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.
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.
Reduce and approximate fragments with lag screws or 1.5/2.0 miniplates. Bridge fragments with reconstruction plates.
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.
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; 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. These fractures were treated through an extraoral approach with rigid internal fixation. Immediate bone grafts were used in 23 of the 32 patients.
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.
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.
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. The plate fracture was most common in angle-type plates because of constriction on the internal side of the plate.
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.
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.
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.
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. 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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