Like all fractures, consideration has to be given to other illnesses that might jeopardize the patient, then to reduction and fixation of the fracture itself. Except in avulsive type injuries, or those where there might be airway compromise, a several day delay in the treatment of mandible fractures seems to have little impact on the outcome or complication rates. General considerations Since mandible fractures are usually the result of blunt force trauma to the head and face, other injuries need to be considered before the mandible fracture. First and foremost is compromise of the airway. While rare, bilateral mandible fractures that are unstable can cause the tongue to fall back and block the airway. Fractures such as a symphyseal or bilateral parasymphyseal may lead to mobility of the central portion of the mandible where genioglossus attaches, and allow the tongue to fall backwards and block the airway. In larger fractures, or those from high velocity injuries, soft tissue swelling can block the airway. In addition to the potential for airway compromise, the force delivered to break the jaw can be great enough to either fracture the cervical spine or cause intra-cranial injury (head injury). It is common for both to be assessed with facial fractures. Finally, vascular injury can result (with particular attention to the internal carotid and jugular) from high velocity injuries or severely displaced mandible fractures. Loss of consciousness combined with aspiration of tooth fragments, blood and possibly dentures mean that the airway may be threatened. Reduction Reduction refers to approximating the ends of the bones edges that are broken. This is done with either an open technique, where an incision is made, the fracture is found and is physically manipulated into place, or closed technique where no incision is made. The mouth is unique, in that the teeth are well secured to the bone ends but come through epithelium (mucosa). A leg or wrist, for instance, has no such structure to help with a closed reduction. In addition, when the fracture happens to be in a tooth bearing area of the jaws, aligning the teeth well usually results in alignment of the fracture segments. To align the teeth, circumdental wiring is often used where wire strands (typically 24 gauge or 26 gauge) are wrapped around each tooth then attached to a stainless steel arch bar. When the maxillary (top) and<unk>  (bottom) teeth are aligned together, this brings the fracture segments into place. Higher tech solutions are also available, to help reduce the segments with arch bars using bonding technology. Fixation Simple fractures are usually treated with closed reduction and indirect skeletal fixation, more commonly referred to as maxillo-mandibular fixation (MMF). The closed reduction is explained above. The indirect skeletal fixation is accomplished by placing an arch bar, secured to the teeth on the maxillary and<unk>  dentition, then securing the top and bottom arch bars with wire loops. Many alternatives exist to secure the maxillary and<unk>  dentition including resin bonded arch bars, Ivy loops (small eyelets of wires), orthodontic bands and MMF bone screws where titanium screws with holes in the head of them are screwed into the basal bone of the jaws then secured with wire. Closed reduction with direct skeletal fixation follows the same premise as MMF except that wires are passed through the skin and around the bottom jaw in the mandibule and through the piriform rim or zygomatic buttresses of the maxilla then joined together to secure the jaws. The option is sometimes used when a patient is edentulous (has no teeth) and rigid internal fixation cannot be used. Open reduction with direct skeletal fixation allows the bones to be directly<unk> ed through an incision so that the fractured ends meet, then they can be secured together either rigidly (with screws or plates and screws) or non-rigidly (with transosseous wires). There are a multitude of various plate and screw combinations including compression plates, non-compression plates, lag-screws, mini-plates and biodegradable plates. External fixation, which can be used with either open or closed reduction uses a pin system, where long screws are passed through the skin and into either side of a fracture segment (typically 2 pins per side) then secured in place using an external fixator. This is a more common approach when the bone is heavily comminuted (shattered into small pieces, for instance in a bullet wound) and when the bone is infected (osteomyelitis). Regardless of the method of fixation, the bone need to remain relatively stable for a period of 3–6 weeks. On average, the bone gains 80% of its strength by 3 weeks and 90% of it by 4 weeks. There is great variation depending on the severity of injury, health of the wound, and age of the patient. File:Maxillomandibularfixation.Maxillomandibular fixation with circumdental wires, archbars and elastics for a condyle fracture File:Rigid Internal fixation mandible.Rigid internal fixation of parasymphysis fracture of the mandible. White arrow marks fracture, black arrow marks arch bar on lower teeth File:Rigid Internal fixation mandible condyle.Rigid internal fixation of right condyle fracture with mini-plate on the neck of the condyle. Black arrow marks right earlobe, white arrow marks head of the condyle File:External fixation mandible.External fixation of left mandible fracture Current clinical evidence A 2013 Cochrane review assessed clinical studies on surgical (open reduction) and non-surgical (closed reduction) management of mandible fractures that do not involve the condyle. The review found insufficient evidence to recommend the effectiveness of any single intervention. Special considerations Condyle The best treatment for condylar fractures is controversial. There are two main options, namely closed reduction or open reduction and fixation. Closed reduction may involve intermaxillary fixation, where the jaws are splinted together in the correct position for a period of weeks. Open reduction involves surgical exposure of the fracture site, which can be carried out via incisions within the mouth or incisions outside the mouth over the area of the condyle. Open reduction is sometimes combined with use of an endoscope to aid visualization of fracture site. Although closed reduction carries a risk of the bone healing out of position, with consequent alteration of the bite or the creation of facial asymmetry, it does not risk temporary damage to the facial nerve or result in any facial scar that accompanies open reduction. A systematic review was unable to find sufficient evidence of the superiority of one method over another in the management of condylar fractures. Paediatric condylar fractures are especially problematic, owing to the remaining growth potential and possibility of ankylosis of the joint. Early mobilization is often recommended as in the Walker protocol. Edentulous mandible A broken jaw that has no teeth in it faces two additional issues. First, the lack of teeth makes reduction and fixation using MMF difficult. Instead of placing circumdental wires around the teeth, existing dentures can be left in (or Gunning splints, a type of temporary denture) and the mandible fixated to the maxilla using skeletal fixation (circummandibular and circumzygomatic wires) or using MMF bone screws. More commonly, open reduction and rigid internal fixation is placed. When the width of the mandible is less than 1 cm, the jaw loses its endosteal blood supply. Instead, the blood supply comes largely from the periosteum. Open reduction (which normally strips the periosteum during the dissection) can lead to avascular necrosis. In these cases, oral surgeons sometimes opt for external fixation, closed reduction, supraperiosteal dissection or other techniques to maintain the periosteal blood flow. High velocity injuries In high velocity injuries, the soft tissue can be severely damaged far from the bullet wound itself due to hydrostatic shock. Because of this the airway must be carefully managed and vessels well examined. Because the jaw can be highly comminuted, MMF and rigid internal fixation can be difficult. Instead, external fixation is often used,. Pathologic fracture Fractures where large cysts or tumours are in the area (and weaken the jaw), where there is an area of osteomyelitis or where osteonecrosis exist cause special challenges to fixation and healing. Cysts and tumours can limit effective bone to bone contact and osteomyelitis or osteonecrosis compromise blood supply to the bone. In all of the situations, healing will be delayed and sometimes, resection is the only alternative to treatment.
Mandibular fracture
Nasal fracture
Skull fracture
Cervical fracture
Glossoptosis
Le Fort fracture of skull
Zygoma fracture
Zygomaticomaxillary complex fracture