Executive Editor: Marcelo Figari, Gregorio Sánchez Aniceto

General Editor: Daniel Buchbinder

Authors: Ricardo Cienfuegos, Carl-Peter Cornelius, Edward Ellis III, George Kushner

Mandible - Special considerations

Multiple fractures

1. General considerations

The mandible is similar in shape to a hoop and therefore multiple fracture sites are common. They can be grouped into the broad categories listed below:

  • Unilateral fractures (double or multiple unilateral)
  • Bilateral fractures
  • Fractures with contralateral condyle compromise
  • Bilateral condyle fractures with symphysis/anterior body compromise

Whenever one fracture of the mandible is identified, the surgeon must always suspect that one or more additional fractures are present. Careful clinical and x-ray examination will assist in establishing the correct diagnosis.

2. Unilateral fractures (double or multiple unilateral)

General considerations

This injury occurs when a large amount of force is applied to a specific area of the mandible.

Another example of a unilateral multiple fracture.

Treatment considerations

If the fractures are located unilaterally close to each other, the intermediate fragment is fixed with long spanning adaptation or more frequently reconstruction plates along the inferior border.

If the fracture lines are located further apart, the surgeon has additional options to treat the multiple fractures. One fracture is rigidly fixed while the other is commonly fixed with a less rigid osteosynthesis, eg, a single plate.

Fractures in the tooth-bearing area of the anterior mandible are generally treated first to establish the ideal occlusion. Fractures in the nontooth-bearing area (posterior body/angle/ramus/condyle) are usually treated secondarily.

Alternatively, the surgeon may choose to use rigid internal fixation at both fracture sites.

3. Bilateral fractures

General considerations

It is very common that bilateral mandibular fractures are identified in clinical practice. The most common combination of fractures is an angle combined with a contralateral fracture through the body or symphysis.

Treatment considerations

Fractures in the tooth-bearing area of the anterior mandible are generally treated first to establish the ideal occlusion. Fractures in the nontooth-bearing area (posterior body/angle/ramus/condyle) are usually treated secondarily.

Most commonly, the angle fracture is treated with one miniplate fixation (Champy) and the contralateral fracture through the body/symphysis is treated with more rigid fixation.

Various fixation schemes are available for the fracture of the body/symphysis eg, two miniplates, a large, or extra-large profile locking plate 2.0, or a reconstruction plate.

The surgeon has the option of treating both fractures with rigid internal fixation.

Simple right angle fracture fixed with a miniplate in the external oblique line and simple left body fracture fixed by means of a large profile locking plate 2.0.

Simple right angle fracture fixed with a miniplate in the external oblique line and a left body fracture fixed by means of reconstruction plate 2.4.

4. Fractures with contralateral condylar fractures

General considerations

This fracture is generally seen as a result of a direct blow to the ipsilateral mandibular body which fractures and also causes a mandibular condyle fracture on the contralateral side.

Treatment considerations

Fractures in the tooth-bearing area of the anterior mandible are generally treated first to establish the ideal occlusion. Fractures in the nontooth-bearing area (condyle) are usually treated secondarily.
Most commonly, the fracture through the body/symphysis is treated using stable fixation. This offers the choice of treating the condyle fracture closed or open.

One has the choice of various stable/rigid fixation schemes for the fracture of the body/symphysis. One can use two miniplates, a heavy locking plate 2.0, or a reconstruction plate.

If it is decided that the condylar fracture will be treated closed, postoperative arch bars and training elastics can be used. This will allow postoperative physical therapy to rehabilitate the condylar fracture.

Click here for a description of closed treatment of the condyle.

5. Bilateral condylar fractures with symphysis/anterior body fracture

General considerations

One of the most difficult fractures to manage is the bilateral condylar fracture with anterior body or symphyseal fracture.

Commonly, the condylar segments are displaced and the mandible is widened due to the “wishbone” effect of the three fractures together.

CT showing mandibular widening, resulting in a “U”-shaped mandible instead of the normal “V” shape.

Treatment considerations

Treatment of bilateral condyle and symphysis/anterior body fractures usually begins with the most anterior fracture component and ends with the most posterior one.

The reduction and stabilization of the anterior fracture is crucial for the restoration of the transverse dimension of the mandible. If the exact dimension is not restored, the transverse dimension of the subcondylar region could never be restored. Adequate reduction of the fracture in the lingual side before fixation is crucial. When the anterior osteosynthesis is performed with a strong plate, some overbending is required in order to close the lingual gap. Click here for a document also explaining the overbending procedure.

The fixation of the subcondylar fractures is usually performed secondarily. Alternatively, the condylar fractures could be treated closed.

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v1.0 2008-12-01