Mandibular Symphyseal and Parasymphyseal Fractures Treatment & Management

Essentially all symphyseal and parasymphyseal fractures are open to the mouth and, thus, are grossly contaminated. Antibiotic coverage is essential through the time of initial treatment and early healing. Penicillin is the drug of choice.

Analgesics of mild-to-moderate strength may be prescribed as required, taking care to consider any associated injuries that may contraindicate their use or limit their dose. Acetaminophen in liquid or tablet form may be sufficient. Requests for stronger analgesia should prompt the treating surgeon to consider that the patient may have unrecognized injuries, complications, or substance abuse.

Occasionally, fractures on the anterior mandible are nondisplaced and stable. In this instance, MMF for 6 weeks suffices as treatment. Most fractures are displaced and unstable, requiring a more aggressive approach to therapy.

Before rigid internal fixation became popular, symphyseal and parasymphyseal fractures were usually treated with open reduction with interosseus wiring combined with MMF. In some patients, a lingual splint was required to affect the desired degree of stability. In recent years, open reduction with plate or lag screw synthesis has become popular.

A medically stable patient with a mandible fracture should receive definitive care as soon as is practical. Numerous studies have demonstrated that delays in treatment increase the complication rate and reduce the chance of obtaining the best surgical result. The prerequisites for definitive care of these patients are imaging studies sufficient to evaluate their injuries (see Imaging Studies), a stable patient, evaluation by the anesthetist, and informed consent. The anesthesia team needs to know that nasal intubation is required.

The patient is placed in the supine position and nasally intubated by the anesthesia team. Usually, headlights offer the best illumination. Surgical treatment of mandibular fractures often includes the use of sharp objects (eg, wire, screws, arch bars). Therefore, attention to detail is required to minimize the risk of glove puncture.

True sterile preparation of the operative site for repair of mandible fractures is not possible. The extent of preparation to create a clean and disinfected field is controversial. Some clean the teeth, gingivae, and alveolar mucosae with a toothbrush and 3% hydrogen peroxide. The face is painted with povidone iodine solution. If a skin incision is necessary for an open reduction of another fracture, a typical povidone iodine soap scrub preparation is performed.

Prior to exposing the fracture line, the patient is placed in MMF. This accomplishes a gross reduction of the fracture, places the posterior teeth into occlusion, and produces some stability at the alveolar margin. The fracture site may be approached via an intraoral incision, extraoral incision, or laceration. After adequate exposure of the fracture lines, anatomic reduction is achieved. Inspection of the occlusion and alignment of teeth on either side of fracture lines should confirm that proper reduction has been accomplished.

Rigid hardware is then placed with attention to the technique appropriate for the system chosen. When using the Champy miniplate system, 2 plates are required: 1 at the inferior margin and the other at the alveolar level as seen in the image below.

When using the titanium craniofacial system techniques established by the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF), tension banding at the alveolar level is required as seen in the image below. This may be in the form of an alveolar miniplate, dental appliance, or the mandibular arch bar. To avoid distraction at the lingual surface of the mandible, dynamic compression plates should be overcontoured by 3-5°.

When the fracture is midline, an alternative to plate fixation is the use of opposing lag screws as seen in the image below. The fracture must be anatomically reduced prior to drilling the holes. In choosing the locations for the screws, care is taken to avoid tooth roots. Drill holes are made to accommodate the chosen screw size, and the hole on the side to receive the screw head is enlarged to the next larger size. Beveling of this side may also be desirable to receive the screw head. The enlargement of the screw-head side prevents the screw from purchasing bone in that fragment. This results in one hemimandible being pulled tightly against the other. This is not a method for the inexperienced surgeon, and it requires careful planning and exacting technique.

Interosseus wiring is an alternative to rigid fixation and is used when rigid devices and their support systems are not available or when the surgeon prefers this technique. A 2-hole figure-8 wire is the standard, with drill holes placed about 1 cm from the fracture line and 1 cm from the inferior border of the mandible. When using nonrigid techniques such as this, consider using a lingual splint for additional stability.

After placement of rigid internal fixation, most surgeons remove the patient from MMF. An exception exists when additional fractures requiring MMF are present. The most common site for such a fracture is the condylar area. These fractures are often treated by MMF only and are often associated with symphyseal/parasymphyseal fractures.

If interosseus wiring is used, MMF is required for 4-6 weeks.

Analgesics and antibiotics are indicated postoperatively. Analgesics are usually required for several days. Antibiotics for 7-10 days postoperatively should provide good infection prevention.

If MMF is used, precautions to help prevent and/or deal with nausea and vomiting are paramount. The nursing staff needs specific instructions on measures to take with nausea and/or impending vomiting. Prophylactic use of antiemetics is a strategy used by some. Others order antiemetics be given at the first hint of nausea. If the MMF technique includes having wires hold the teeth in occlusion, a wire-cutting device should be with the patient for the first day. Many place the wire cutters on a tracheostomy tape around the patient's neck.

After discharge from the hospital, the patient should be seen weekly and as needed. Nutritional status, wound healing, oral hygiene, maintenance of secure occlusion, and signs of infection should be assessed during weekly examinations.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Teeth and Mouth Center. Also, see eMedicine's patient education articles Broken Jaw and Broken or Knocked-out Teeth.

Malunion/malocclusion is the most common major complication and results from inadequate reduction and/or loss of reduction during the healing process.

Infection is usually localized and usually responds to antibiotics. Collections of pus should be drained, and hardware, if any, may require removal.

Exposure of implanted hardware requires removal of hardware.

Nonunion is an uncommon complication. It requires that the fracture lines be exposed and freshened with reapplication of fixation and may require bone graft in extreme cases.

A united fracture with normal dental occlusion is the expected outcome. Once this result is obtained, the prognosis for the future is excellent.

The choice of specific internal fixation systems for mandibular fractures is controversial. Some systems use dynamic compression with bicortical plates while others use noncompressing monocortical plates. Some experienced clinicians feel that interosseus wiring with MMF yields equal results without the disadvantages of open reduction with plate osteosynthesis.

The best route to the mandible for internal fixation is also debated, with some favoring an intraoral approach while others advocate an extraoral incision. Most favor the intraoral approach because an increased infection rate does not seem to be associated with this route.

The future will undoubtedly bring the evolution of newer and better plating systems. Use of stereolithography to aid in planning complex cases may become routine.