Nondisplaced fracture of the mandible Plain film radiography Traditionally, plain films of the mandible would be exposed but had lower sensitivity and specificity owing to overlap of structures. Views included AP (for parasymphsis), lateral oblique (body, ramus, angle, coronoid process) and Towne's (condyle) views. Condylar fractures can be especially difficult to identify, depending on the direction of condylar displacement or dislocation so multiple views of it are usually examined with two views at perpendicular angles. Panoramic radiography Panoramic radiographs are tomograms where the mandible is in the focal trough and show a flat image of the mandible. Because the curve of the mandible appears in a 2-dimensional image, fractures are easier to spot leading to an accuracy similar to CT except in the condyle region. In addition, broken, missing or malaligned teeth can often be appreciated on a panoramic image which is frequently lost in plain films. Medial/lateral displacement of the fracture segments and especially the condyle are difficult to gauge so the view is sometimes augmented with plain film radiography or computed tomography for more complex mandible fractures. Computed tomography Computed tomography is the most sensitive and specific of the imaging techniques. The facial bones can be visualized as slices through the skeletal in either the axial, coronal or sagittal planes. Images can be reconstructed into a 3-dimensional view, to give a better sense of the displacement of various fragments. 3D reconstruction, however, can mask smaller fractures owing to volume averaging, scatter artifact and surrounding structures simply blocking the view of underlying areas. Research has shown that panoramic radiography is similar to computed tomography in its diagnostic accuracy for mandible fractures and both are more accurate than plain film radiograph. The indications to use CT for mandible fracture vary by region, but it does not seem to add to diagnosis or treatment planning except for comminuted or avulsive type fractures, although, there is better clinician agreement on the location and absence of fractures with CT compared to panoramic radiography. File:Simple mandible fracture.Panoramic radiograph of a simple mandible fracture of the right<unk>  body, minimally displaced. Note that the teeth to the left of the fracture do not touch Image:Fracturef mandible.lateral oblique image demonstrating a fractured mandible. File:Townes view bilateral condyle fracture.Towne's view of a bilateral condyle fracture. White arrow is a fracture on the neck of the condyle. Black arrow shows the condyle pulled to the medial. The same injury can be seen on the opposite side File:3D CT mandible fracture.3D CT reconstruction of mandible fracture, white arrow marks fracture, red arrow marks moderate displacement and open bite File:Occlusal view symphsis fracture.occlusal radiograph of a<unk>  parasymphysis fracture Classification There are various classification systems of<unk> s in use. Location The most frequent locations of a<unk> . This is the most useful classification, because both the signs and symptoms, and also the treatment are dependent upon the location of the fracture. The mandible is usually divided into the following zones for the purpose of describing the location of a fracture (see diagram): condylar, coronoid process, ramus, angle of mandible, body (molar and premolar areas), parasymphysis and symphysis. Alveolar This type of fracture involves the alveolus, also termed the alveolar process of the mandible. Condylar Condylar fractures are classified by location compared to the capsule of ligaments that hold the temporomandibular joint (intracapsular or extracapsular), dislocation (whether or not the condylar head has come out of the socket (glenoid fossa) as the muscles (lateral pterygoid) tend to pull the condyle anterior and medial) and neck of the condyle fractures. E.g. extracapsular, non-displaced, neck fracture. Pediatric condylar fractures have special protocols for management. Coronoid Because the coronoid process of the mandible lies deep to many structures, including the zygomatic complex (ZMC), it is rare to be broken in isolation. It usually occurs with other<unk> s or with fracture of the zygomatic complex or arch. Isolated fractures of the coronoid process should be viewed with suspicion and fracture of the ZMC should be ruled out. Ramus Ramus fractures are said to involve a region inferiorly bounded by an oblique line extending from the lower third molar (wisdom tooth) region to the posteroinferior attachment of the masseter muscle, and which could not be better classified as either condylar or coronoid fractures. Angle The angle of the mandible refers to the angle created by the arrangement of the body of the mandible and the ramus. Angle fractures are defined as those that involve a triangular region bounded by the anterior border of masseter muscle and an oblique line extending from the lower third molar (wisdom tooth) region to the posteroinferior attachment of the masseter muscle. Body Fractures of the<unk>  body are defined as those that involve a region bounded anteriorly by the parasymphysis (defined as a vertical line just distal to the canine tooth) and posteriorly by the anterior border of the masseter muscle. Parasymphysis Parasymphyseal fractures are defined as<unk> s that involve a region bounded bilaterally by vertical lines just distal to the canine tooth. Symphysis Symphyseal fractures are a linear fractures that run in the midline of the mandible (the symphysis). Fracture type<unk> s are also classified according to categories that describe the condition of the bone fragments at the fracture site and also the presence of communication with the external environment. Greenstick Greenstick fractures are incomplete fractures of flexible bone, and for this reason typically occur only in children. This type of fracture generally has limited mobility. Simple A simple fracture describes a complete transection of the bone with minimal fragmentation at the fracture site. Comminuted The opposite of a simple fracture is a comminuted fracture, where the bone has been shattered into fragments, or there are secondary fractures along the main fracture lines. High velocity injuries (e.g. those caused by bullets, improvised explosive devices, etc...) will frequently cause comminuted fractures. Compound A compound fracture is one that communicates with the external environment. In the case of<unk> s, communication may occur through the skin of the face or with the oral cavity.<unk> s that involve the tooth-bearing portion of the jaw are by definition compound fractures, because there is at least a communication via the periodontal ligament with the oral cavity and with more displaced fractures there may be frank tearing of the gingival and alveolar mucosa. Involvement of teeth When a fracture occurs in the tooth bearing portion of the mandible, whether or not it is dentate or edentulous will affect treatment. Wiring of the teeth helps stabilize the fracture (either during placement of osteosynthesis or as a treatment by itself), so the lack of teeth will guide treatment. When an edentulous mandible (no teeth) is less than 1 cm in height (as measured on panoramic radiograph or CT scan) additional risks apply because the blood flow from the marrow (endosseous) is minimal and the healing bone must rely on blood supply from the periosteum surrounding the bone. If a fracture occurs in a child with mixed dentition different treatment protocols are needed. Other fractures of the body, are classified as open or closed. Because fractures that involve the teeth, by definition, communicate with the mouth this distinction is largely lost in mandible fractures. Condylar, ramus, and coronoid process fractures are generally closed whereas angle, body and parasymphsis fractures are generally open. multiple mandible fractures of a patient in the right condyle (extracapsular/neck/not dislocated), right body (vertically unfavourable) and left coronoid process Displacement The degree to which the segments are separated. The larger the separation, the more difficult it is to bring them back together (approximate the segments) Favourability For angle and posterior body fractures, when the angle of the fracture line is angled back (more posterior at the top of the jaw and more anterior at the bottom of the jaw) the muscles tend to bring the fracture segments together. This is called favorable. When the angle of the fractures is pointing to the front, it is unfavorable. Age of the fracture While mandible fractures have similar complication rates whether treated immediately or days later, older fractures are believed to have higher non-union and infection rates although the data on this makes it difficult to draw firm conclusions.
Mandibular fracture
Nasal fracture
Skull fracture
Cervical fracture
Glossoptosis
Le Fort fracture of skull
Zygoma fracture
Zygomaticomaxillary complex fracture