MANDIBULAR FRACTURES
1. INTRODUCTION:
Mandible fractures occupy an important place in our daily practice due to their frequency.
The low and projected position of the facial skeleton makes it play the role of a real bumper.
Mandibular fractures have varying degrees of impact on facial functions and aesthetics, depending on their location.
Treatment aims to restore these two elements as much as possible.
2. DEFINITIONS:
Fracture: it is a sudden and accidental break in the continuity of a bone.
Open fracture: a fracture is said to be open when there is a mucosal or cutaneous breach, putting the fracture site in communication with the external environment (fractures of the toothed sectors are considered open fractures).
Closed fracture: a fracture is said to be closed when this break does not exist.
Total fracture: affects the entire thickness of the bone body.
Partial fracture: only affects part of the body of the bone.
Unifocal fracture. Single focus
Multifocal fracture: with multiple foci.
3. ETIOLOGIES:
Several etiologies are implicated in facial fractures:
- Traumatic:
- AVP
- Work or sports accident
- Violence (fights – assault)
- The falls.
- Iatrogenic:
- Extraction of DDS, or impacted canine
- Excision of large cyst
- Predisposing causes:
- Pathological factors: osteitis, malignant tumor, large cyst, irradiation, osteopathy.
- Areas of weakness: neck of the condyle, angle across the axis of the DDS, axis of the canine, presence of dental germs.
5-Etiopathogenesis:
- The mandibular bone can fracture under the influence of:
From a direct shock: the fracture occurs at the point of impact of the trauma.
From an indirect shock: the fracture occurs at a distance from the point of impact, generally at the level of the areas of least resistance.
MANDIBULAR FRACTURES
Fracture displacements depend on:
*shock energy
*the direction of the shock
*number and direction of fracture lines
*the action of the masticatory muscles
*the absence or presence of teeth
There are different types of movement:
- Offset (vertical plane): in stair tread,
- Overlapping or separation (horizontal plane) results in a shortening of the mandibular arch, with deviation of the inter-incisal point on the fractured side.
- Angulation (frontal plane): results in a plication of the mandibular arch at the level of the fracture focus.
- Torsion (frontal plane):
“In fact, clinically it is the combination of all three types of displacement.”
6- DIAGNOSTIC APPROACH:
1. Lift the emergency:
assess vital functions in order to prevent and treat emergencies that could compromise the patient’s life.
-clear the upper aerodigestive tract of anything that may be obstructing it
(blood, food debris, dental or prosthetic)
-place the injured person in the lateral safety position (PLS) while maintaining cervical rigidity if there is any doubt about a cervical injury.
-If necessary use:
- Mayo or Guédel cannula;
- traction on the tongue;
- oro- or nasotracheal intubation;
- tracheotomy if necessary;
-stop bleeding (fracture reduction, vascular ligation, wound suture, nasal packing);
“These actions undertaken at the scene of the accident must be continued during medical transport (SAMU) and then the emergency department of the hospital takes over under the responsibility of a surgeon and an anesthesiologist-resuscitator.”
2. Clinical examination proper:
It is based on an exobuccal and endobuccal examination but begins, like any clinical examination, with the anamnesis.
In the event of a clinical diagnosis or suspected fracture, the clinical examination is systematically supplemented by a radiological assessment.
2.1. Questioning:
– specify the circumstances of the accident: time, point of impact, etc.
-age, general condition, treatments
-notion of loss of consciousness
-functional signs: pain, difficulty closing the mouth, respiratory discomfort, eye problems, etc.
2.2 inspection:
Often made difficult by edema and pain. The presence of a fracture can already be suspected by the sight of:
-bruise or skin wound
-gap
-facial asymmetry
-dental articulation disorders
-mucous membrane wounds or dental lesions
2.3 Palpation:
looking for a painful point or a bony irregularity
Direct signs of fracture:
*like bone displacements,
*mobilities of fragments,
*elective painful points at the support point or at a distance
*discontinuity of a bony edge with the perception of a “stair step”.
– search for craniofacial disjunction, with abnormal mobility of the upper jaw in relation to the cheekbones or forehead.
– The integrity, mobility, and vitality of each tooth must be systematically sought and noted.
2.3. Regional review:
Eye examination.
ENT examination.
Neurological examination.
This clinical assessment must be supplemented by a radiological assessment.
3. Radiological examinations:
Essential and complementary, they confirm or refute the clinical assessment.
They look for other possible associated injuries that may have been missed during the initial injury assessment.
Firstly we ask:
A panoramic X-ray:
This is a reference image in the lesion assessment of the mandible. The image obtained allows the analysis of the mandibular bone architecture and the toothed portions.
Standard shots:
-strict profile
-Blondeau incidence
-Hirtz incidence
-possibly retroalveolar images
or occlusal shots
Computed tomography:
Computed tomography currently occupies a prominent place in the assessment of dento-maxillofacial and craniofacial trauma.
It is indicated as a first-line treatment in the context of multiple trauma, allowing, with a single examination, a complete injury assessment to be carried out in a patient who cannot be easily mobilized.
Currently, CT allows very rapid image acquisition with multiplanar reconstructions. The quality of the radiological assessment in CT scan makes it possible to obtain images that are faithful to reality even in three-dimensional reconstructions.
Taking photographs and dental impressions:
*Taking pre- and post-operative photographs with different incidences, from the front, profile, top view, three-quarter view, open mouth and closed mouth, complete the data from the clinical examination and provide useful reference data for therapeutic and medico-legal management.
*The making of plaster study models of the dental arches at different times during treatment. However, taking impressions may be difficult in patients with facial trauma due to the extent of the lesions and the pain they cause, and the possible presence of edema and trismus.
7. CLINICAL STUDY:
A- partial fractures
A.1- Fractures of the alveolar rim:
Often it is a child who has had a fall. The patient presents with a wound on the lower lip causing hemorrhage
The intraoral examination reveals:
-fracture with displacement
– the incisor or incisor-canine group is generally projected inwards
-gum sores
-we can have hemorrhages
-it is mainly palpation which allows the limits of the fracture to be confirmed and the diagnosis to be made (fractured region taken between the thumb and index finger) + X-ray
A. 2- Fracture of the coronoid process:
The fracture line is usually located at the base of the coronet.
Often due to lateral trauma
The clinic is marked by:
*pain when opening and closing
*mild trismus
*lateral deviation
*the index finger introduced into the oral cavity at the bottom of the vestibule triggers pain at the level of the coronary artery
This fracture is often associated with subcondylar or zygomatic arch fractures.
B – Total fractures:
B.1. Unifocal total fractures:
a- Fractures of the dentate region:
a.1- Symphyseal and parasymphyseal fractures:
usually due to a direct violent impact on the chin, sometimes it is a side impact.
By definition, they are located between the distal faces of the canines. The fracture line is variable, median, paramedian, oblique or vertical, with a preferential location along a dental root and more specifically along the canine, due to the rarefaction of the bone at this level.
The fracture line can be vertical, oblique or lambda
– The movement:
In the case of a median line: in general the displacement is not very significant, or even zero, due to the balance of muscular forces.
In the case of a paramedian trait: generally there is a shift and lingoversion of one fragment in relation to the other.
-Clinic:
Without displacement: clinical diagnosis is difficult, there may be a tear in the gingival mucosa, the functional signs are discreet.
With displacement: functional signs are important.
Palpation reveals an irregularity of the basilar edge.
MANDIBULAR FRACTURES
a.2. Fractures of the horizontal branch:
Caused by a direct impact at the point of application, they are located between the mesial face of the first premolar and the distal face of the second molar.
The stability of the fracture is conditioned by the orientation of the fracture line:
- Clinical:
-incisor gap
-lateral deviation of the inter-incisal point on the fractured side
-2-stage occlusion with premature molar contact on the fractured side
– frequent Vincent sign
-on palpation: painful jump of the basilar edge at the point of fracture.
a.3. Fractures of the mandibular angle:
The region is limited posteriorly by the horizontal line of the retromolar trigone and anteriorly by the distal face of the second molar. The presence of an impacted wisdom tooth is a factor favoring the occurrence of this type of fracture.
The stroke tends to take an oblique downward and backward direction and most often results from a direct or indirect impact on the chin.
The displacement is minimal, when it exists it is less clear than in the previous fractures.
Clinic:
- without displacement: facial deformation due to angle edema, pain and trismus attract attention.
– with displacement generally manifests itself by a shift of the interincisal point on the fractured side and a contralateral posterior gap.
Injury to the inferior dental nerve is common.
b- Fractures of the non-dentate region:
b.1. Fractures of the ascending branch:
They concern the region extending from the mandibular angle to the processes of the condyle and the coronal.
– Shift :
- horizontal line: there is no major displacement if it exists, sometimes there is a shortening of the rising branch by overlapping of the 2 fragments (upper and lower)
- – vertical line: from the sigmoid notch to the angle, the displacement is generally minimal.
b.2. Fractures of the condyle:
They mainly originate from indirect shocks, on the chin or the contralateral side of the mandible.
We distinguish:
- intra-articular fractures. 3-2
- extra-articular fractures.1
*Extra-articular fractures: basicervical fractures (low subcondylar).
This is the most common condylar fracture, due to a direct or indirect impact on the chin.
The fracture line is oblique from front to back in profile.
The move:
Results in overlapping with tilting of the fragment forward and outward, or dislocation of the condylar head, while the lower fragment is drawn backward and upward under the combined action of the masseter and the internal pterygoid.
*Intra-articular fractures:
High subcondylar fractures. Corresponds to fractures of the neck of the anatomical condyle.
Under the action of the muscle fibers of the medial pterygoid, the head of the condyle tilts forward and inward.
Capital fractures. They concern the head of the condyle. We have several types
1- Partial fracture:
2- complete fracture or decapitation: .
3- bursting of the condyle: the head of the condyle bursts, giving a fracture with several lines.
– without movement: the clinical signs are discreet:
- Pain located in front of the ear, occurring when opening and closing the mouth, when chewing, also caused by anteroposterior pressure on the chin, and when palpating the condylar region.
- A limitation of mouth opening, with slight lateral deviation at mouth opening.
– with displacement:
- Pretragal pain with emptiness of the glenoid cavity, and condylar movement not perceived on palpation.
- Trismus and laterodeviation.
- Shift of the inter-incisor line with premature molar contact on the fractured side and a contralateral open bite.
- In capital fractures otorrhagia with CAE injury is possible.
B.2. Bifocal fractures:
- Symmetrical fractures:
1. Biparasymphyseal fractures:
Common in motorcyclists who fall on their chin.
These forms cause a downward and backward displacement of the symphyseal region, with a risk of posterior drop of the tongue which can thus cause respiratory distress.
2. Biangular fractures:
There is a setback of the toothed part, a gap affecting the entire arch which only makes contact at the back with the maxillary tuberosity or the last tooth.
3. Bicondylar fractures:
Bilateral forms are often high condylar fractures, the mandible tends to move backwards, there is molar contact and incisor gaping.
- asymmetric fractures:
These forms, the three fragments of which are solicited by unequal muscular actions, escape an overall description; the most frequent forms are:
Parasymphyseal or horizontal branch fractures, associated with contralateral angle or condyle fractures.
Angle fractures associated with contralateral condyle fractures.
B.3. Trifocal fractures:
The most common trifocal fractures involve involvement of the symphysis and both condyles or both angles.
This results in a widening and retraction of the mandibular arch.
B.4. Specific fractures:
1. Communicative fractures:
These are multi-fragmentary fractures which may involve loss of substance or even the disappearance of a bone segment.
They are quite typical of ballistic trauma from firearms or major trauma encountered during traffic accidents or falls from great heights.
2. Fractures in children:
Three periods are distinguished:
• from birth to the first year: the plasticity of the bone is such that trauma is reduced to a minimum.
• between 1 and 6 years: the development of motor skills means that the child is more exposed to jaw trauma.
The condylar region is very fragile and does not withstand shocks or falls on the chin very well.
The presence of temporary tooth germs also contributes to weakening the bone structure.
At this age we often have incomplete fractures.
• between 6 and 12 years old: the child has mixed dentition. Alveolar dental trauma is frequent and is encouraged by the presence of immature teeth on the arch.
The maxillary incisor sector is particularly affected.
3. Fractures in the edentulous:
Loss of teeth results in loss of alveolar bone.
The mandible is therefore weakened by the loss of this bone capital
The absence of teeth facilitates movement .
MANDIBULAR FRACTURES
4. Pathological fractures:
They are defined as fractures occurring in bone tissue weakened by the development of an osteolytic pathological process.
The etiologies are numerous. They can be benign tumors of odontogenic or non-odontogenic origin (mandibular cysts, ameloblastomas, etc.), malignant tumors (sarcomas, etc.), general pathologies with mandibular repercussions (osteoporosis), infectious or post-radiation pathologies (chronic osteitis, osteoradionecrosis).
These pathologies generally complicate therapeutic management and are sources of delayed consolidation.
MANDIBULAR FRACTURES
8-treatment
Emergency treatment is essential before any therapy because there is a life-threatening prognosis.
Emergency actions: must maintain or restore vital functions (respiratory and hemodynamic): A B C
A: airway :
– Clear the VADS
– Place the injured person in PLS while maintaining cervical rigidity.
B: breathing :
– Maintain air flow and freedom of AVs
* mayo or Guédel cannula;
*pulling of the tongue;
* oro or nasotracheal intubation;
*tracheotomy if necessary;
– Perform artificial ventilation if the neurological or thoracic condition requires it.
MANDIBULAR FRACTURES
C: circulation :
– Stop bleeding (fracture reduction, vascular ligation, wound sutures, nasal packing);
– Treat shock (central venous route)
1- medical treatment:
antibiotics
Nonsteroidal anti-inflammatory drugs or corticosteroids
Painkillers
Tetanus vaccination
Oral hygiene
Liquid or semi-solid food.
2- dental treatment:
Teeth are classified into 3 categories:
*useful teeth serving as a wedge or guide for occlusion
*harmful teeth: decayed, fractured or hindering reduction: to be extracted
*indifferent teeth: included or without antagonists
Teeth close to the fracture line: monitor their vitality.
3- treatment of the fracture:
*goals
The purposes of the processing are:
-restore bone continuity
-respecting the anatomy
-in order to preserve aesthetics and/or function
For this, three therapeutic rules of traumatology:
Reduction-containment-immobilization-rehabilitation
*means:
- functional processes:
-food
-careful mobilization of the mandible with clinical and radiological monitoring
-mechanotherapy and Delaire method ++
- orthopedic procedures
– fracture reduction: it can be
*manual
*orthopedic: by sectioned arches which are then joined together
For the reduction we will use anatomical landmarks: bone harmony but also and above all dental landmarks, hence the importance of the presence of teeth.
The contention comes after the reduction allows the stable maintenance of the fragments in the reduction position. It is ensured by ligatures, metal arches, gutters with chin sling or by surgical procedures.
– immobilization aims to avoid movements induced at the fracture site by muscular forces provided essentially by bimaxillary blocking (BBM)
- surgical procedures:
This is osteosynthesis which can be done by wire or by screwed plates.
*therapeutic indications
Fr. symphysaire:
-BBM in closed mouth from 4 to 6 weeks
or osteosynthesis
Fr of the horizontal branch:
-BBM for 45 days
Angular Fr
-without travel: BBM
-with displacement: osteosynthesis
Fr of Ramus:
-Without travel: abstention
-with travel: reduction followed by BBM of 45 days
Fr condyle:
*orthopedic method
-with displacement: reduction by placing a molar wedge on the fractured side with anterior elastic traction (open-mouth BBM) for 24 to 72 hours followed by closed-mouth BBM
-without movement: BBM in closed mouth of
21 days with mechanotherapy
functional method (Delaire):
early mobilization in propulsion (elastic tractions from upper canine to lower molar)
Fr of the corona:
Therapeutic abstention
In case of functional impairment: surgical treatment (coronoidectomy)
8. Complications:
1/ Immediate complications:
Asphyxia: by glossoptosis – obstruction of the VADS.
Hemorrhage.
Loss of consciousness : temporary, or lasting several days, thus delaying treatment (multiple trauma)
Nerve damage.
2/ secondary complications:
Infectious complications:
Soft tissue infections: cellulitis.
Osteitis.
These infections are due to poor oral hygiene, but also the presence of latent dental infection, or post-traumatic dental mortification.
Delay and failure to consolidate:
It is observed when the fracture site is painful and mobile beyond 2 months.
Pseudarthrosis is the definitive absence of consolidation beyond 6 months. X-rays show decalcification of the bone ends or osteocondensation around the focus.
MANDIBULAR FRACTURES
Vicious callus:
This is a consolidation in a bad position .
Joint complications:
-post-traumatic osteoarthritis
– dysfunction of the masticatory system
-temporomandibular ankylosis : the complications of which can be serious in children
Temporomandibular ankylosis causes permanent constriction of the jaws, complicated in children by mandibular atrophy due to damage to condylar growth, a source of facial asymmetry or retromandibulia (bird profile).
MANDIBULAR FRACTURES
Conclusion :
Early diagnosis of mandibular fractures, particularly those involving the condylar region, through targeted questioning and good interpretation of radiological examinations, is the only guarantee of adequate management in order to avoid serious complications with unfortunate consequences.
MANDIBULAR FRACTURES
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.