Symphysis & Angle MANDIBULAR FRACTURES

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IBU

LAR

FR

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Condylar

Coronoid

Ramus

Symphysis

Body

Angle

Dentoalveolar

MANDIBULAR FRACTURES

Name : Faisal Moteq Al-Qahtani

ID.N : 431803127

Dentoalveolar 6.7 %

Problem

• Fractures that occur in the midline of the mandible are classified as

present, the fracture line passes between the mandibular central incisors.

• Fractures occurring in the area of the mandible from cuspid to cuspid, but not in the midline, are

classified as parasymphyseal

• The etiology of symphyseal and parasymphyseal fractures is largely from trauma from

interpersonal violence or motor

• Falls, industrial accidents, and sports injuries are lesser etiologies.

• Most trauma is blunt, but penetrating trauma is common with interpersonal violence and war

injury.

Mandibular Parasymphyseal Fractures

The broad red line indicates t

The pink area between the cuspid teeth, excepting the symphysis,

indicates the parasymphyseal area

Etiology

Fractures that occur in the midline of the mandible are classified as


Fractures occurring in the area of the mandible from cuspid to cuspid, but not in the midline, are

.

The etiology of symphyseal and parasymphyseal fractures is largely from trauma from

interpersonal violence or motor vehicle accidents.

Falls, industrial accidents, and sports injuries are lesser etiologies.

Most trauma is blunt, but penetrating trauma is common with interpersonal violence and war

Mandibular Parasymphyseal Fractures " Symphysis "

The broad red line indicates the symphyseal area. The pink area between the cuspid teeth, excepting the symphysis,

parasymphyseal area.

Fall

Fractures that occur in the midline of the mandible are classified as symphyseal. When teeth are


Fractures occurring in the area of the mandible from cuspid to cuspid, but not in the midline, are

The etiology of symphyseal and parasymphyseal fractures is largely from trauma from

Most trauma is blunt, but penetrating trauma is common with interpersonal violence and war

" Symphysis "

The pink area between the cuspid teeth, excepting the symphysis,

• The patient has a history of trauma. Pain and tenderness are present about the anterior

mandible, and the patient reports malocclusion. False motion of the mandible is usually evident.

• Preoperative examinations are often impaired by tenderness and masticatory muscle spasm;

therefore, a thorough reexamination of the face and oral cavity is performed prior to definitive

therapy.

• The entire mandible is carefully inspected and palpated. All teeth are inspected and evaluated

for injury and mobility.

• A survey of the dental arches is completed to detect any sockets missing teeth. The maxilla is

examined to detect any previously missed injuries.

• Fractures of the symphysis/parasymphysis are inherently unstable.

• Muscles of mastication insert into posterior portions of the mandible with a net effect of

superior rotation about the axis of the temporomandibular joint.

• The suprahyoid muscles of the neck act directly on the anterior mandible, with a net effect of

inferior rotation around the axis of the temporomandibular joint and scissoring motion around a

vertical axis through the symphysis. The later action is from the mylohyoid muscles.

• Fractures of the anterior mandible lack 2 of the stabilizing factors provided to fractures of the

posterior tooth-bearing mandible: the splinting effects of the masseter and internal pterygoid

muscles, which form a natural sling, and the interlocking cusps and fossae of bicuspid and molar

teeth.

• Presence of a symphyseal/parasymphyseal fracture is the indication for treatment.

• Mode of treatment varies among patients.

Diagnosis

R. Anatomy

Indications

• The only absolute contraindication to managing these fractures exists if the patient is not stable

enough to undergo the needed treatment.

• A specific contraindication for maxillomandibular fixation (MMF) is poorly controlled seizures.

• Patients with uncleared cervical spines present limitations regarding which treatment for facial

fractures is safe.

• 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.

• Occasionally, fractures on the anterior mandible are nondisplaced and stable.

• 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.

• A medically stable patient with a mandible fracture should receive definitive care as soon as is

practical.

• A stable patient, evaluation by the anesthetist, and informed consent, The anesthesia team

needs to know that nasal intubation is required.

Contraindication

Medical therapy

Surgical Therapy

Preoperative

• The patient is placed in the supine position and nasally intubated by the anesthesia team.

Usually, headlights offer the best illumination.

• The fracture site may be approached via an intraoral incision, extraoral incision, or laceration.

• Prior to exposing the fracture line

reduction of the fracture, places the posterior teeth into occlusion, and produces some stability

at the alveolar margin.

• After adequate exposure of the fracture lines, anatomic reduction is achieved

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

inferior margin and the other at the alveolar level as seen in the image below.

� When using the titanium craniofacial system techniques

level is required as seen in the image below, to avoid distraction at the lingual surface of

the mandible, dynamic compression plates should be overcontoured by 3

Intraoperative

Two miniplates are required for the symphysis/parasymphysis region because

it is subjected to torsio

miniplate.

Tension banding is required to prevent splaying of the fracture line at the

superior surface of the mandible when using a dynamic compression plate. A

mandibular arch bar can accompli

d in the supine position and nasally intubated by the anesthesia team.

Usually, headlights offer the best illumination.

The fracture site may be approached via an intraoral incision, extraoral incision, or laceration.

Prior to exposing the fracture line, the patient is placed in MMF, this accomplishes a gross


After adequate exposure of the fracture lines, anatomic reduction is achieved


reduction has been accomplished.

Rigid hardware is then placed with attention to the technique appropriate for the system

Champy miniplate system, two plates are required,


titanium craniofacial system techniques , tension banding at the alveolar


mandible, dynamic compression plates should be overcontoured by 3

are required for the symphysis/parasymphysis region because

torsional forces, which would be poorly resisted by one

is required to prevent splaying of the fracture line at the


mandibular arch bar can accomplish this. In this example, a miniplate is used.

d in the supine position and nasally intubated by the anesthesia team.

The fracture site may be approached via an intraoral incision, extraoral incision, or laceration.

his accomplishes a gross


After adequate exposure of the fracture lines, anatomic reduction is achieved. Inspection of the


Rigid hardware is then placed with attention to the technique appropriate for the system

e required, first plate at the


tension banding at the alveolar


mandible, dynamic compression plates should be overcontoured by 3-5°.

are required for the symphysis/parasymphysis region because

, which would be poorly resisted by one

is required to prevent splaying of the fracture line at the


sh this. In this example, a miniplate is used.

� 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

roots. This is not a method for the inexperienced surgeon, and it requires careful planning

and exacting technique.

additional stability.

• After placement of rigid internal fixation, most surgeons remove the patient from MMF.

• If interosseus wiring is used, MMF is required for 4

• Analgesics and antibiotics are indicated postoperatively. Analgesics are usually required for

several days. An?bio?cs for 7

• If MMF is used, precautions to help prevent and/or deal with nausea and vomiting are

paramount.

• If the MMF technique includes having wires hold the teeth in occlusion, a wire

should be with the patient for the first day.

Opposing lag screws have been used to treat a symphyseal fracture. This procedure

requires precise technique and is not for the occasional operator.

Postoperative

When the fracture is midline, an alternative to plate fixation is the use of opposing lag


drilling the holes. In choosing the locations for the screws, care is taken to avoid tooth


and exacting technique. When using this techniques , consider using a lingual splint for

After placement of rigid internal fixation, most surgeons remove the patient from MMF.

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

Analgesics and antibiotics are indicated postoperatively. Analgesics are usually required for

several days. An?bio?cs for 7-10 days postopera?vely should provide good infec?on

If MMF is used, precautions to help prevent and/or deal with nausea and vomiting are

If the MMF technique includes having wires hold the teeth in occlusion, a wire

should be with the patient for the first day.

have been used to treat a symphyseal fracture. This procedure

requires precise technique and is not for the occasional operator.

When the fracture is midline, an alternative to plate fixation is the use of opposing lag


the locations for the screws, care is taken to avoid tooth


When using this techniques , consider using a lingual splint for

After placement of rigid internal fixation, most surgeons remove the patient from MMF.

Analgesics and antibiotics are indicated postoperatively. Analgesics are usually required for

10 days postopera?vely should provide good infec?on prevention.

If MMF is used, precautions to help prevent and/or deal with nausea and vomiting are

If the MMF technique includes having wires hold the teeth in occlusion, a wire-cutting device

have been used to treat a symphyseal fracture. This procedure

• 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.

• 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.

• A united fracture with normal dental occlusion is the expected outcome. Once this result is

obtained, the prognosis for the future is excellent.

Follow-up

Complications

Prognosis

• Mandible fractures are also described by the relationship between the direction of the fracture

line and the effect of muscle distraction on fracture fragments.

• Mandible fractures are favorable when muscles tend to draw bony fragments together and

unfavorable when bony fragments are displaced by muscle forces.

• Vertically unfavorable fractures allow distraction of fracture segments in a horizontal direction.

• These fractures tend to occur in the body or symphysis

• Horizontally unfavorable fractures allow displacement of segments in the vertical plane.

Mandibular

Background

A: Horizontally unfavorable.

C: Vertically unfavorable.

Mandible fractures are also described by the relationship between the direction of the fracture

line and the effect of muscle distraction on fracture fragments.

Mandible fractures are favorable when muscles tend to draw bony fragments together and

unfavorable when bony fragments are displaced by muscle forces.

Vertically unfavorable fractures allow distraction of fracture segments in a horizontal direction.

These fractures tend to occur in the body or symphysis-parasymphysis area.

Horizontally unfavorable fractures allow displacement of segments in the vertical plane.

Mandibular angle Fractures

A: Horizontally unfavorable. B: Ho

C: Vertically unfavorable. D: Vertically favorable.

Mandible fractures are also described by the relationship between the direction of the fracture

Mandible fractures are favorable when muscles tend to draw bony fragments together and

Vertically unfavorable fractures allow distraction of fracture segments in a horizontal direction.

parasymphysis area.

Horizontally unfavorable fractures allow displacement of segments in the vertical plane.

B: Horizontally favorable.

D: Vertically favorable.

• The angle of the mandible is the triangular region bounded by the anterior border of the

masseter muscle to the posterior and superior attachment of the masseter muscle (usu

to the third molar), this area is fracture .

• Vehicular accidents and assaults are the primary causes of mandibular fractures throughout the

world.

• Assault most often causes mandible angle fractures.

Problem

Etiology

Data from industrialized nations suggest that mandible fractures have various causes as follows:

The angle of the mandible is the triangular region bounded by the anterior border of the

masseter muscle to the posterior and superior attachment of the masseter muscle (usu

to the third molar), this area is fracture .

Vehicular accidents and assaults are the primary causes of mandibular fractures throughout the

Assault most often causes mandible angle fractures.


The angle of the mandible is the triangular region bounded by the anterior border of the

masseter muscle to the posterior and superior attachment of the masseter muscle (usually distal

Vehicular accidents and assaults are the primary causes of mandibular fractures throughout the


History

• Obtain a thorough history specific to preexisting systemic bone disease, neoplasia, arthritis,

collagen vascular disorders, and temporomandibular joint (TMJ) dysfunction.

• Knowledge of the type and direction of the causative traumatic force helps determine the nature

of injury, also assists the clinician in suspecting and diagnosing additional fractures.

Physical examination

• Change in occlusion may be evident on physical examination. Any change is highly suggestive of

mandibular fracture. Ask the patient to compare postinjury and preinjury occlusion.

• Posttraumatic premature posterior dental contact (anterior open bite) and retrognathic

occlusion may result from a mandibular angle fracture. Unilateral open bite deformity is

associated with a unilateral angle fracture.

• Change in facial contour or loss of external mandibular form may indicate mandibular fracture,

an angle fracture may cause the lateral aspect of the face to appear flattened. Loss of the

mandibular angle on palpation may be because of an unfavorable angle fracture in which the

proximal segment rotates superiorly. The anterior face may be displaced forward, causing

elongation.

• Lacerations, hematoma, and ecchymosis may be associated with mandibular fractures. Their

presence should alert the clinician that thorough investigation is necessary to exclude fracture.

• Use the simplest means possible to reduce and fixate a mandibular fracture. Because open

reduction can carry an increased morbidity risk.

• Use closed techniques for Nondisplaced favorable fractures

• Indications for open reduction include Displaced unfavorable angle, body, or parasymphyseal

fractures.

Diagnosis

Indications

• Evaluate and monitor the patient's general physical condition prior to treating mandibular

fractures.any force capable of causing a mandibular fracture may also injure other organ

systems.

• Bilateral cervical subcutaneous emphysema, pneumothorax, pneumomediastinum, and spleen

lacerations have also been associated with mandible fractures after trauma, patients should not

undergo surgical reduction of mandible fractures until these issues are addressed.

Multiple approaches for open reduction and internal fixation (ORIF) exist. Consider fracture location,

nerve position, and skin-crease lines when choosing the appropriate approach.

Intraoral approach

• The intraoral approach is usually used in fractures that are nondisplaced or only slightly

displaced. The mandible base may require additional stab incisions to place screws for plate

fixation. Intraoral lacerations may be used for access in fixation of mandible fractures.

• Local anesthesia may be sufficient for simple or nondislocated fractures when 1-plate fixation is

required.

Extraoral approach

• External incisions are usually necessary with fractures that have a high degree of dislocation or

with comminuted fractures, since placing longer and stronger plates is difficult via the intraoral

approach.

• General anesthesia is indicated in the extraoral approach, give careful attention to the marginal

mandibular branch of the facial nerve.

Contraindications

Surgical Therapy

Transverse fracture line without displacement

• Semirigid fixation using miniplates and monocortical screws may be used in a transverse fracture

line with limited exposure.

• This fracture is better managed using two

first in the area of the oblique line and the second at the inferior border. Fixation is also possible

using a single lag screw in the anteroposterior

Transverse fracture and its fixation are seen in the image below.

e line without displacement

Semirigid fixation using miniplates and monocortical screws may be used in a transverse fracture

is better managed using two miniplates (4-6 holes, 2-3 screws on each side), the

n the area of the oblique line and the second at the inferior border. Fixation is also possible

using a single lag screw in the anteroposterior-oblique approach in nonosteoporotic bones.

Transverse fracture and its fixation are seen in the image below.

Semirigid fixation using miniplates and monocortical screws may be used in a transverse fracture

3 screws on each side), the

n the area of the oblique line and the second at the inferior border. Fixation is also possible

oblique approach in nonosteoporotic bones.

Transverse fracture line with displacement

• With dislocation, the medial pterygoid and masseter muscles cause vertically and horizontally

unfavorable vector forces, which make reduction more difficult.

• For a minimally displaced fracture, achieve reduction

to the proximal fragment on the medial aspect of the anterior border of the ramus using 2

screws. Reduce the fracture using the plate as a handle to complete IMF. Bend the free end of

the plate to conform to the distal oblique ridge and fix with monocortical screws.

• A widely displaced fracture may require stabilization by using a reconstruction plate.

Angular fractures with basal triangle

• As with displaced fractures, use an angulated 2.4 reconstruc?on plate wi

of the mandible aHer IMF. The triangle can be fixed to the plate, or lag screws (2.0, 2.4) can be

placed. Use a 2.0 miniplate along the oblique line.

Comminuted angular fractures

• These often occur in association with other mandibu

• After temporary IMF, reduction and fixation of fragments within simpler fractures can be

accomplished using 1.5 or 2.0 miniplates and lag screws and then bridging with a 2.4

reconstruction plate. Miniplates are often used to re

angular fracture.

a: Transverse and longitudinal fractures.

b: A lag screw and reconstruction plate used to provide fixation.

Transverse fracture line with displacement

With dislocation, the medial pterygoid and masseter muscles cause vertically and horizontally

unfavorable vector forces, which make reduction more difficult.

For a minimally displaced fracture, achieve reduction by fixing a 2.0 miniplate of suitable length

to the proximal fragment on the medial aspect of the anterior border of the ramus using 2


he distal oblique ridge and fix with monocortical screws.

A widely displaced fracture may require stabilization by using a reconstruction plate.

Angular fractures with basal triangle

As with displaced fractures, use an angulated 2.4 reconstruc?on plate wi


placed. Use a 2.0 miniplate along the oblique line.

These often occur in association with other mandibular and maxillary fractures.

After temporary IMF, reduction and fixation of fragments within simpler fractures can be


reconstruction plate. Miniplates are often used to reduce large fragments of a comminuted

: Transverse and longitudinal fractures.

: A lag screw and reconstruction plate used to provide fixation.

With dislocation, the medial pterygoid and masseter muscles cause vertically and horizontally

by fixing a 2.0 miniplate of suitable length

to the proximal fragment on the medial aspect of the anterior border of the ramus using 2-3


he distal oblique ridge and fix with monocortical screws.

A widely displaced fracture may require stabilization by using a reconstruction plate.

As with displaced fractures, use an angulated 2.4 reconstruc?on plate with 6-8 holes at the base


lar and maxillary fractures.

After temporary IMF, reduction and fixation of fragments within simpler fractures can be


duce large fragments of a comminuted

: A lag screw and reconstruction plate used to provide fixation.

Comminuted fractures of the ascending mandibular ramus

• In the case of concurrent fractures of the ascending ramus, a combined submandibular and

preauricular approach may be warranted.

• Simplify the fracture using 2.0 miniplates and subsequent bridging and then stabilize it with a 2.4

universal fracture plate or reconstruction plate. Com

mandibular ramus and its reduction is seen in the image below.

a : A comminuted fracture of the left ascending ramus.

b : Reduction using miniplates of the superior aspect of the ascending ramus.

c : Bridging of the comminuted area using a reconstruction plate.

Comminuted fractures of the ascending mandibular ramus

fractures of the ascending ramus, a combined submandibular and

preauricular approach may be warranted.

Simplify the fracture using 2.0 miniplates and subsequent bridging and then stabilize it with a 2.4

universal fracture plate or reconstruction plate. Comminuted fracture of the ascending

mandibular ramus and its reduction is seen in the image below.

: A comminuted fracture of the left ascending ramus.

: Reduction using miniplates of the superior aspect of the ascending ramus.

the comminuted area using a reconstruction plate.

fractures of the ascending ramus, a combined submandibular and

Simplify the fracture using 2.0 miniplates and subsequent bridging and then stabilize it with a 2.4

minuted fracture of the ascending

: Reduction using miniplates of the superior aspect of the ascending ramus.

• Approach mandibular fractures methodically. Patients rarely die solely from mandibular

fractures. Diagnose and treat in an efficient manner.

• As with all trauma patients, strictly adhere to advanced trauma life support (ATLS) protocols.

Particular attention to the airway is of critical importance to any patient with craniofacial

trauma.

• Use prophylactic antibiotics for compound fractures. Penicillin remains the antibiotic of choice.

Evaluate nutritional needs.

• The goal of treatment is to reestablish occlusion. Function is compromised with malunion.

• The three separate techniques for rigid fixation of the mandible that have been developed are

(1) the bicor?cal Luhr system, using vitallium plates, (2) system of stainless steel compression or

reconstruc?on plates with bicor?cal screws, and (3) the Champy miniplate technique placed

along the line of ideal osteosynthesis, using monocortical screws.

• Perform intraoral surgery prior to an extraoral approach. IMF time varies according to type,

location, number, and severity of fracture(s).

• 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 in consultation with a dentist. Mandibular

cuspids help determine occlusion and should be preserved if possible.

• Administer analgesic medications in the postoperative period. Administer antibiotic therapy

covering gram-positive organisms to patients with open fractures.

• Keep wire cutters at the bedside in case of emesis. Reevaluate nutritional needs.

Preoperative

Intraoperative

Postoperative

• Maintain IMF for 4-6 weeks. Tighten wires every 2 weeks.

• After wires are removed, a Panoramic radiograph is usually taken to ensure complete fracture

union.

• The most common complication is infection or osteomyelitis.

• Malunion and nonunion of the mandible occur because of failure to observe treatment goals as

previously outlined.

• Contributing factors include oral sepsis, teeth in the fracture line, alcohol abuse and chronic

disease, prolonged time prior to treatment, poor patient compliance, and displacement of

fracture fragments.

• In addition, plate fracture has been identified as a complication.

• Both closed and open reductions of mandibular fractures cause favorable results for bony union.

• In a study of 922 mandibular body and angle fractures that were repaired using an intraoral

approach without IMF, solid bony union was achieved in more than 99% of pa?ents.

Follow-up

Complications

Prognosis

SIGNS AND SYMPTOMS

General Specific

General

Swelling

Pain

Drooling

Tendernes

Bony

discontinuity

Lacerations Bleeding

from the

mouth

Ecchymosis

Fractured,

subluxe ,

luxated

teeth

Limitation in

mouth

opening

Specific

DENTO-

ALVEOLAR

THE

BODY

THE

RAMUS

SYMPHYSEAL

CONDYLAR CORONOID

THE ANGLE

Bilateral Unilateral

� DENTOALVEOLAR FRACTURES SIGNS AND SYMPTOMS

• Lip bruises and laceration

• Step deformity

• Bony discontinuity

• Fracture, luxation or subluxation of teeth

• Laceration of the gingivae

� FRACTURE OF THE BODY SIGNS AND SYMPTOMS

• Swelling

• pain

• Tenderness

• Step deformity

• Anaesthesia or paraesthesia of the lip

• Intra oral hemorrhage

� SYMPHYSEAL/PARASYMPHYSEAL FRACTURES SIGNS AND SYMPTOMS

• Tenderness

• Sublingual haematoma

• Loss of tongue control

• soft tissue injury to the chin and lower lip

� FRACTURE OF THE RAMUS SIGNS AND SYMPTOMS

• Swelling • Ecchymosis • Pain • Trismus

� FRACTURE OF THE ANGLE SIGNS AND SYMPTOMS

• Swelling

• Posterior gag

• Deranged occlusion

• Anaesthesia or paraesthesia of lower lip

• Haematoma

• Step deformity behind the last molar tooth

• Tenderness

� CORONOID FRACTURE SIGNS AND SYMPTOMS

• Tenderness over the anterior part of the tragus

• Haematoma

• Painful limitation of movement

• Protrusion of mandible may be present.

� UNILATERAL CONDYLAR FRACTURES SIGNS AND SYMPTOMS

• Swelling over the TMJ

• Hemorrhage from ear on the affected side

• Battle’s sign

• Locked mandible

• Hollow over the condylar region after edema has subsided

• rarely, Paraesthesia of lower lip

• Deviation to the affected side upon opening

• Painful limitation of movement

� BILATERAL CONDYLAR FRACTURES SIGNS AND SYMPTOMS

• Same as above

• Limitation in mouth opening

• Restricted mandibular movement

• Anterior open bite

The End Good luck

Symphysis & Angle MANDIBULAR FRACTURES

Health & Medicine