Pearls of mandibular trauma management

Abstract

Mandibular trauma is a common problem seen by plastic surgeons. When fractures occur, they have the ability to affect the patient's occlusion significantly, cause infection, and lead to considerable pain. Interventions to prevent these sequelae require either closed or open forms of reduction and fixation. Physicians determining how to manage these injuries should take into consideration the nature of the injury, background information regarding the patient's health, and the patient's comorbidities. Whereas general principles guide the management of the majority of injuries, special consideration must be paid to the edentulous patient, complex and comminuted fractures, and pediatric patients. These topics are discussed in this article, with a special emphasis on pearls of mandibular trauma management.

Keywords: IMF; MMF; Mandible; closed reduction; facial trauma; lag screws; maxillofacial; occlusion; plating.

Figure 1

Regions of the mandible include symphysis, parasymphysis, body, angle, subcondylar and condylar regions, and alveolar ridge.

Figure 2

The mandibular condyle can be divided into the condylar (intracapsular) and subcondylar (extracapsular) regions.

Figure 3

Evaluation of the occlusion requires looking at several aspects.

Figure 4

Intraoral soft tissue injuries and lacerations need to be evaluated for and addressed preoperatively, if possible.

Figure 5

The Gilmer method of IMF/MMF can be used along with Erich arch bars to provide additional stability, alignment, and control to the occlusion and fracture segments.

Figure 6

(A–D) Four-point screw fixation can also be used to stabilize the occlusion and maintain IMF/MMF.

Figure 7

Champy's lines of tension correspond with biomechanically favorable regions of the mandible where less stability would be required to allow for fracture healing.

Figure 8

(A–E) A young female patient suffered an oblique fracture through the symphysis/parasymphysis. This was subsequently treated with lag screws that were placed perpendicular to the fracture site. Postoperative reduction films demonstrate nearly perfect reduction.

Figure 9

(A, B) An additional method to manage symphyseal/parasymphyseal fractures is through superior border monocortical and inferior border bicortical plating.

Figure 10

(A, B) Body fractures can also be plated in accordance with Champy's lines of tension, with superior border monocortical plating and inferior border bicortical plating.

Figure 11

(A–D) Strut plates (Stryker, Kalamazoo, MI) can be used for treating mandibular fractures when requiring more stability than that provided by a single plate along the oblique ridge.

Figure 12

Intracapsular condylar fractures are usually managed with a conservative approach with IMF/MMF and an early return to function to reduce the risk of subsequent TMJ ankylosis.

Figure 13

(A–E) Subcondylar fracture and accompanying parasymphyseal fracture that were treated with IMF/MMF and superior and inferior border plating of the parasymphyseal fracture. Treating subcondylar fractures with a closed approach is often the best approach.

Figure 14

Panorex demonstrating ORIF of a subcondylar fracture. The open approach requires a significantly greater degree of expertise, is technically more challenging, and carries a significant risk of a facial nerve traction injury.

Figure 15

Algorithm for management of subcondylar fractures based on the stability of the maxilla, the status of the occlusion, and the laterality of the injury.

Figure 16

(A–F) This is a complex and significantly comminuted mandibular fracture that was subsequently treated with external fixation to avoid significant soft tissue and vascularity disruption that would have occurred if internal fixation was attempted.

Figure 17

Osteomyelitis associated with a mandibular angle fracture instability secondary to not receiving treatment.

Figure 18

(A, B) Osteomyelitis of the mandibular body associated with fracture instability secondary to poor plate adaptation.