Shahaf Givony1
1 Lithuanian University of Health Sciences. Academy of Medicine. Faculty of Odonthology.
ABSTRACT
Mandibular fractures usually happen among young males at the age of 16-30 years old. The mandible which has been rated as the second facial bone with the highest rate of injuries, tends to break much more often compared to any other bone of the cranium and represent up to 70% of the cases. This tendency to fracture may be explained by the protruded position, mobility and particular shape of it. The tendency for a mandibular fracture may also be explained by the common risk factors such as vehicle accidents and physical violence that are part of our daily life. There are many other risk factors according to the literature which differ between individuals due to the different socio-economic status, culture, technology and environment. Before the clinical examination of the fracture, it is obligatory to make sure that a clear airway path presents with no other fatal injuries. The examination may be supported by imaging methods which together will approve the diagnosis and method of treatment. Patients with a fracture of the mandible may suffer from post-operative complications which may occur after a short or long duration of the treatment. Those complications may be malocclusion, infections, trismus, damaged teeth and soft tissue, esthetic disfiguration, functional problems, pain and many more. In addition, those complications may be expressed as an unfavorable effect to the quality of life due to an unstable emotional state, an unpleasant feeling such as awkwardness to smile or laugh and difficulty to make social interactions.
Keywords: Mandibular fracture, Fracture imaging techniques, Facial fracture treatment, Facial fracture classification, Post-operative complications.
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45
Medical Sciences 2020 Vol. 8 (13), p. 45-52
Mandibular fractures, diagnostics, postoperative complications
Shahaf Givony
1
1
Lithuanian University of Health Sciences. Academy of Medicine. Faculty of Odonthology.
ABSTRACT
Mandibular fractures usually happen among young males at the age of 16-30 years old. The mandible which has
been rated as the second facial bone with the highest rate of injuries, tends to break much more often compared
to any other bone of the cranium and represent up to 70% of the cases. This tendency to fracture may be explained
by the protruded position, mobility and particular shape of it. The tendency for a mandibular fracture may also be
explained by the common risk factors such as vehicle accidents and physical violence that are part of our daily
life. There are many other risk factors according to the literature which differ between individuals due to the
different socio-economic status, culture, technology and environment. Before the clinical examination of the
fracture, it is obligatory to make sure that a clear airway path presents with no other fatal injuries. The examination
may be supported by imaging methods which together will approve the diagnosis and method of treatment.
Patients with a fracture of the mandible may suffer from post-operative complications which may occur after a
short or long duration of the treatment. Those complications may be malocclusion, infections, trismus, damaged
teeth and soft tissue, esthetic disfiguration, functional problems, pain and many more. In addition, those
complications may be expressed as an unfavorable effect to the quality of life due to an unstable emotional state,
an unpleasant feeling such as awkwardness to smile or laugh and difficulty to make social interactions.
Keywords: Mandibular fracture, Fracture imaging techniques, Facial fracture treatment, Facial fracture
classification, Post-operative complications.
Abbrevations
Temporomandibular joint (TMJ), United States of America (USA), Orthopantomogram (OPG), Multidetector
computed tomography (MDCT), Computed tomography (CT), Posteroanterior (PA), Ultrasonography (USG),
Magnetic resonance imaging (MRI), Intermaxillary fixation (IMF), Open reduction with internal fixation (ORIF)
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Introduction
The facial bones are immensely prone sites for
injuries. The mandible specifically, has a higher
tendency for maxillofacial injury compared to any
other bone of the cranium. This tendency can be
explained by the protruded position, mobility and
particular shape of the mandible which eventually
may lead to the loss of function and unreversed
damage [4, 6]. The U-shape of the mandible has an
important feature known as the ‘ring bone rule’,
which states that in case of a fracture in one location,
another fracture or displacement will most likely to
appear over the opposite side [1].
The mandible considered as responsible for 15.5%-
59% of the facial bones fractures and has been rated
as the 2
nd
facial bone with the highest rate of injuries.
Recent reports have shown that the usage of a
seatbelt and automatic airbags within the vehicle
have drastically reduces the chance for the
passengers to suffer from fracture during a car
accident. Due to a better and safer technologies in
the last few years, the incidence and patterns of
facial bones fractures among passengers in their
vehicles have reduced [3].
Possible complications of a mandibular fracture may
be a result of the surgery itself which in that case,
they must be treated as soon as possible. The
complications may occur directly after mandibular
fracture such as airway obstruction, bleeding,
broken teeth or bones. The complications may occur
after a much longer duration such as nonunion,
malunion, damage to the nerve, infections,
temporomandibular joint (TMJ) dislocations and
tearing [10]. Patients with a fracture of the mandible
may also present symptoms such as, trismus, step
deformity pain, esthetic disfiguration and may be
having a functional problem to chew and talk [1, 4].
The aim of this article is to present the available
literature regarding fractures of the mandible with a
focus on the possible complications of treated or
untreated cases.
Epidemiology
In 2007, out of 400,000 visits to the emergency
departments in the United States of America (USA)
as a result of fractures of to the facial bones, 23% of
them were related to the mandible [9]. Mandibular
fractures usually happen among young males at the
age of 16-30 years old. The mandible, unlike other
bones of the facial skeleton, tends to break much
more and represent up to 70% of the cases [1].
The mandible may have fractures at different
locations, in which the literature presents different
statistics for each one of them. The most common
location is the parasymphysis with 35-50%, body of
the mandible with 21-36%, condyle with 20-26%
and the angle of the mandible with 15-26% while the
least common location is the ramus with 2-4% and
the coronoid process with 1-2% [1]. A study which
was conducted in Taiwan among 6013 patients has
shown that the mandible is the 2
nd
most common site
for a fracture with 24.7%, followed by fracture of
the nasal bones with 22.8% but still remains less
than the maxillary and malar bones with 48%.
Another study which was conducted by the authors
Christopher et al, has shown that the most common
site for a fracture is the angle with 27%, followed by
the symphysis with 21.3%, condyle 18.4% and the
body of the mandible with 16.8%. A different study
which was conducted by the authors Fridrich et al.,
has shown that the most common site for a fracture
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47
is the angle with 28.5%, followed by the symphysis
[5]. In addition, a group of studies which had
investigate the fractures of the mandible have shown
that the parasymphysis is the most common site
whereas the least common was the coronoid process
[2].
Risk factors
Maxillofacial injuries depend on numbers of causes
which determined by the geographic areas, socio-
economic status, culture, demography, technology
and environment of the individuals. The fractures of
the mandible do not have a specific etiological factor
in the literature [6, 7]. Epidemiological researches
from the past have suggested that each risk factor is
a bit more common for a specific age group. For
instant, in countries at the region of North-America,
North Europe, Australia and New Zealand the
number one cause for fractures of the mandible is
violence between people. In countries with new
industry and less development like Nigeria and
Jordan, the number one cause for fractures of the
mandible is vehicle accidents [7]. Most of the
mandibular fractures in the USA are caused by
violence between men at the age 18-24 years old. A
study which was conducted between 13,142 patients
have shown that men have a 4 times higher chance
to suffer from fractures of the mandible. This study
has also shown that more than 50% of the fractures
related to men are from violence, compare to women
which most of their fractures are a result of vehicle
accidents and falls [3].
At the present days in contrast with the past, the
main cause of fractures to the mandible is vehicle
accidents. That cause may be explained by the
constant growing number of vehicles and the lack of
speed limitations which have led to a higher number
of high-speed traumas. The 2
nd
cause by its rating is
the physical violence, which was the leading cause
30 years ago when the number of vehicles were
much smaller. In addition, fractures of a mandible
are more common in societies with a low
socioeconomic status due to their frequent use of
alcohol and tendency for a loud and violent
arguments [1].
Classification
In the broad field of facial trauma, the specific
fracture of a mandible should not be included in the
classification because of the protruded and fragile
position of the mandible compare to the rest of the
facial skeleton [1]. The classification that will be use
clinically to evaluate the fractures must be easy and
convenient. It must contain few specific
characteristics, such as the anatomical position and
displacement level of the fracture [15].
Fractures of the mandible may be classified
according to the anatomy, dentition, severity and
action of the muscles. The fractures may also be
open, close, displaced, pathological and
comminuted. Kazanjian and Converse have
classified the fractures of the mandible according to
3 types of dentition and their proximity to the
fracture line. In class 1, teeth located on each side of
the fracture line. In class 2, teeth located only on one
side of the fracture line. In class 3, there are no teeth
on either side of the fracture line. This classification
is relevant for cases which may require the teeth to
be used for fragmental reduction and attachment by
wires or other means to keep the alignment.
Classification by the action of the muscle, can by
apply for the angle and body of the mandible.
Fractures of those anatomical areas may be held in a
position which may improve or worsen the healing
process due to the surrounding muscles and their
directions of action. The position of the fracture may
be improved and considered as favorable, in
situations which include opposite directions
between the bone fragments and the direction of the
muscle’s actions. The position of the fracture may
be worsened and considered as unfavorable, in
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situations which include the same directions
between the bone fragments and the direction of
action of the muscle which eventually leads to a
bigger displacement. Fractures of the mandible may
also be classified according to their severity. The F-
F4 system grades the severity as F - not visible
fracture line, F1 – single fracture line at the alveolar
area, F2- single and continuous line which separate
the bone completely, F3- two continuous lines
which separate the bone completely, F4- more than
three continuous lines which separate the bone
completely. As the grade of the classification is
higher, the risk is higher for inferior alveolar nerve
impairment and complications after the surgery [1].
Fractures may be also classified into 3 classes
according to their diagnostic imaging methods, such
as towne's view and orthopantomogram (OPG).
Class 1 represents fracture with a reduction of the
ramus height which is smaller than 2mm or fracture
which have been displaced less than 10 degrees.
Class 2 represents fracture with a reduction of the
ramus height which is between 2-15mm or fracture
which have been displaced between 10-35 degrees.
Class 3 represents fracture with a reduction of the
ramus height which is bigger than 15mm or fracture
which have been displaced more than 10-35 degrees.
Treatment by open reduction should be apply for
classes 2 and 3 while close reduction for class 1 [10].
Examination
The first tasks to do before the assessment of a facial
bone fracture is to make sure that there is a clear
airway path and no other injuries which may
jeopardize the life of the patient [1]. The occlusion
state of the patient is one of the most important
diagnostic characteristics for proper evaluation of
mandibular fractures. In cases which have recently
occur, it provides a lot of information to ask the
patient if his bite is balanced and normal. Any
complain from the patient side such as
malocclusion, must be properly evaluated and
recorded in written or in any other form and must be
compared to the occlusion state prior to the trauma.
If the patient is incapable to provide the needed
information due to medical situation such as
sedation, intubation or any other reason, the
information should be taken from previous dental
records. During the clinical evaluation, the
practitioner will have to palpate the exact location of
the fracture from both sides while looking for any
mobility. No mobility at all will suggest that
conservative treatment will be very responsive due
to the high stability and proper occlusal alignment
of the fracture. Any intraoral tearing of soft tissues
and hematomas with proximity to the fracture must
be recorded due to the higher risk for infection. A
very clear sign for fracture of the mandible is a big
ecchymosis at the floor of the mouth. In addition,
clinical evaluation of the dentition must be done
during the primary evaluation and in case of any
mobile, carious, broken teeth especially near the
fracture line, it should be recorded as well and to
take into an account of a possible extraction.
Extraction would be advised in case the tooth is
severely broken, prevent proper reduction of the
segments, displaced out of the socket, has a deep
caries with possibility for future abscess, very
mobile with widespread periodontal disease and has
certain pathologies such as cyst or pericoronitis [3].
Inability to identify the specific size, structure and
severity of a certain fracture may result an
insufficient surgical treatment. Therefore, an
increasing number of treatment management
considerations are based on the accurate and
informative Multidetector computed tomography
(MDCT). MDCT has become the primal tool of
diagnostic for orbital and facial structures. There is
an antagonism for primary examination of doubtful
mandibular fractures with MDCT, due to the fact
that mandibular fractures frequency is much higher
than midface fractures and the total cost as a result
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will be higher. On the other hand, the popularity of
regular dental radiography and OPG have drastically
reduced in the emergency care as the availability of
the MDCT has increased [9].
Diagnostic methods
The use of imaging methods would be advised in
case of a suspicious fracture of the mandible. Early
identification of a mandibular fracture is highly
important in order to prevent harmful consequences
such as malunion, nonunion and delayed union.
Fracture of the mandible usually presents certain
clinical characteristics such as malocclusion, spasm
of the jaw muscles, constant pain, damaged teeth
and step deformity. In case of any of these facial
characteristics, the patient would be advised to
undergo radiographic imaging [1].
Fractures of the mandible may be evaluated by a
number of radiographic imaging from 3 different
positions, such as the lateral, oblique and the
posteroanterior (PA). The PA and the oblique
positions may provide a comprehensive view of the
ramus, angle and body of the mandible. The lateral
position is especially beneficial for the evaluation of
the TMJ and possible dislocations. Different
positions of radiographic imaging are necessary in
order to recognize the lines of the fracture and
displacement [1].
In order to achieve an adequate treatment for a
fracture of the mandible, the diagnosis must be
accurate. An extensive and accurate diagnosis may
be achieved by the use of an OPG, which may
clearly present the different areas of the mandible
[10].
Nowadays, computed tomography (CT) can
presents the most extensive and particularized
information regarding the facial bones [10]. There
are a few indications which advise the use of a CT
for the mandible. The first indication is in case of an
unsteady patient with conjecture for a present
fracture of the mandible. The second indication is in
case of a concern of a fracture which is not
illustrated in the radiographic imaging. The 3
rd
indication would be advised if the radiographic
evaluation of a mandibular fracture would help to
prepare a treatment plan for cases which may require
an open or close reduction and the improved
information given by the CT might assist [1].
Known as Ultrasonography (USG), has been proven
as beneficial imaging technique for the
identification of fractures of the mandible. The USG
is beneficial due to the non-ionizing radiation
emission, cheap technique and fast imaging. On the
other hand, the USG is unable to present the specific
severity of the mandibular fracture due to the lack of
spatial information which is provided from different
angles, as possible in other imaging technique. This
technique would be recommended in cases which
include patients that are not able to undergo CT as a
result of a certain trauma, pregnancy and would
prefer to reduce the level of ionizing radiation [1].
Magnetic resonance imaging (MRI) holds the
advantage of not applying ionizing radiation to the
patient, but in case that a very informative and fast
imaging under 24 hours is required, the preferable
imaging technique would be CT. This specific
technique would be advised in case of a suspicion
for trauma to the soft tissues. For instant, in case of
a condylar fracture, the disc of the TMJ would
require evaluation for a dislocation or any capsular
rupture [1].
Management
The expertise of the oral and maxillofacial surgeons
regarding the anatomical, functional and occlusal
aspects of the mandible is obligatory for an accurate
initial diagnosis, therapeutic planning and
accomplishment of a positive outcome for the
patient [9]. The predilection of the surgeon to a
certain type of treatment for the mandibular fracture
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may be depend on the features of the fracture itself
[8] such as the location [3]. Treatment may include
soft diet, close reduction with intermaxillary fixation
(IMF) and open reduction with internal fixation
(ORIF) [8]. As most of the mandibular fractures
demands a certain type of fixation for a better
healing process in order to restore the position of the
jaws before the trauma, a minor percentage of the
mandibular fractures do not present any occlusal
alterations, such as displacement, and do not require
surgical treatment [3].
The specific treatment of a fracture will be
depending on the specific location. In case of an
isolated fracture at the body of the mandible which
is not or barely displaced and have an adequate
number of surrounding teeth, the most proper way
of treatment will be to use an IMF. ORIF would be
more suitable for older patients, in order to prevent
the inconvenience and obstruction of the long-term
use of IMF. In case of fracture at the symphysis and
or the parasymphysis, the most common way of
treatment is ORIF. Close reduction would be advice
for those with a fracture which is not dislodge. In
case of fracture at the angle, the most common way
of treatment is ORIF as a result of the strong
inclination toward displacement. In case of fracture
at the condyle, the consensus is to reconstruct the
range of motion soon as possible in order to restore
the activity of the TMJ. Those patients usually suffer
from a pain near the ear, malocclusion and deviated
chin during movements of the mandible [3].
After the reduction of the separated segments, the
teeth at the area may act as an anchor one to the other
with the reinforcement of a wire. The teeth near the
fracture site are a significant anatomical promoter
which does not present anywhere else in the body
[14]. The result of the various treatments should be
a healed fracture with correct occlusion and without
any malocclusion such as nonunion, malunion
and/or delayed union [1].
Complications
The outcomes of trauma to the face may be
expressed as an unfavorable effect to the quality of
life due to an unstable emotional state, an unpleasant
feeling such as awkwardness to smile or laugh and
difficulty to make social interactions [2]. Many of
the patients who suffer from a certain trauma, will
likely to present with a facial injury that may be
specific to the face or combined with other bony
fractures in different locations over the body. Those
injuries demand a fast diagnosis and treatment in
order to prevent any aesthetic and functional
complications later on [11].
The mandible undergoes almost twice as much
repairs compared to any other bone of the face as a
result of fractures. The initial purposes in the
management of mandibular fractures should be to
reform the original shape and function of the
traumatized bone and surrounding structures in
order to obtain a bony union of the separated
segments [16]. A study by Girotto in 2001, have
investigated the consequences of injury to the face
from the functional point of view and have claimed
that those cases cannot be forsaken and have to be
managed as soon as possible, due to the relation
between the gravity of the injury to the physical
limitations such as malocclusion, difficulty to chew,
sense any odor and feel physical stimulation [11].
There are many complications which may happen
after a surgery of maxillofacial area. Those
complications may be related to soft tissues, TMJ,
various nerves, bones, osteonecrosis, malocclusions,
malunion or nonunion and infections. Those
complications may be related to teeth such as
necrosis to the pulp, broken teeth, teeth
displacement which may occur during the surgery or
postoperative [10]. The rates of postoperative
complications as a result of mandibular fractures are
between 7-29%. Those rates are influenced by the
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51
severity, location and the number of involved areas
of the fracture. Patients who smokes, have a
systemic disease or expose to any physical
mistreatment behavior will present with higher rates
of the complications [3]. The most prevalent
complications are infection of the site, technical
equipment failure, osteomyelitis, lack of a proper
healing such as nonunion or malunion and the most
common of all is malocclusion which most likely to
occur as a result of wrong placement of the fixation
[3].
Another possible postoperative complication is a
symmetrical face, which may occur due to an
incorrect reduction of the mandible at the necessary
time of healing. The incorrect reduction of the
mandible and as a result an incorrect position of the
condyle, has a direct effect on the TMJ which in the
long term would lead to TMJ disorders [13].
The most common complication of mandibular
fractures, particularly at the angle of the mandible is
infection. After the treatment of a mandibular
fracture, the area is more subjected to infection and
other circumstances which may reduce the blood
flow to the area and eventually lead to nonunion and/
or malunion. The prevalence of nonunion and/ or
malunion in the literature is approximately 1-2%
[12]. The mouth provides a shelter for a substantial
number of microscopic organisms which may
postpone the regular healing process of wounds and
might lead to infections in the area of the surgery. A
recent research has suggested that proper mouth
health care prior to the surgery, may decrease the
possibility for infection and its important value to
minimize the chance for complications after the
surgery. Proper mouth health care after the surgery
is recommended for patients who are having a
trouble to keep a satisfying level of oral hygiene as
a result of a damage to the surgical site, such as
microflora habitat which have been filled with
pathogens. Complications after the surgery
frequently leads to sustained hospitalization and
decreased quality of life among the involved patients
[17].
Complications after surgery cannot be avoided from
happening but can definitely be reduced by taking
into account the specific causing factor while
making a treatment plan. For instant, the first
treatment of choice for complications such as TMJ
disorders and malocclusion which occurred due to
malunion is to do a surgery again [13].
Conclusion
In conclusion, the high prevalence and tendency of
the specific mandibular fractures will always open a
door to the post-operative complications. Those
complications cannot be completely avoided from
happening but can definitely be reduced by an
earlier and more accurate identification which will
assist to select the proper method of treatment and
will minimize the harmful consequences.
In conclusion, the fractures of the mandible may
differ from one geographical region to the other due
to variant risk factors and individual’s
circumstances.
In conclusion, fractures of the mandible may differ
from one geographical region to the other due to
variant risk factors and individual’s circumstances
but the high prevalence and tendency remains high
worldwide. The amount of mandibular fractures
cannot be completely avoided from happening but
can definitely be reduced by an earlier identification
which will assist to select the proper method of
treatment and will minimize the harmful
consequences.
Acknowledgements
None.
Conflicts of interest
The authors have no conflicts of interest to declare.
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