Preventing complications is the best way to avoid them. Adequate imaging, planning and stable osteosynthesis techniques will help avoid complications.
The mandible is the only facial bone that is movable. The results of mandibular fracture treatments are easily measurable. Unfortunately, there is a relatively high complication rate when dealing with mandible fractures.
A nonunion occurs when the mandible does not heal in an appropriate time
frame. The result is mobility of the fracture segments present after an
adequate healing phase. Patients may also demonstrate malocclusion and
infection at the site of fracture.
Note: no bony union is visible in fracture gap.
Clinical photograph reveals lack of bone at the fracture site.
Nonunions are usually the result of one or more of the following
- Fracture instability (mobility)
- Inaccurate reduction
- No contact between fragments
Treatment will consist of:
- Identifying the cause
- Controlling infection
- Surgical reconstruction: removing the existing hardware, debridement of
devital bone and/or soft tissues, decortication of bone fragments at the
fracture ends, reestablishing occlusion, stabilizing segments using a locking
reconstruction plate 2.4, and autogenous bone graft to this area.
Panoramic x-ray 6 weeks after treatment of left angle fracture with single
miniplate. The fracture is grossly mobile, infected, and the plate has become
The fracture was debrided, the plate removed, the infection drained, and the
patient placed on antibiotics to control infection.
Once infection has subsided, the patient was taken to surgery and the
fracture exposed through a submandibular approach. The fibrous tissue between
the fragments was debrided and the fragments decorticated.
Postoperative panoramic and ...
... PA x-rays showing relationship of bone fragments and internal fixation
The occlusion was reestablished with MMF and a miniplate placed along the
superior border to maintain the position of the proximal segment after pushing
it posteriorly and superiorly to see the condyle. A reconstruction plate was
then adapted and secured to provide load-bearing fixation across the fracture
gap. Once the occlusion was verified by releasing MMF, the miniplate was
Particulate autogenous bone was placed into the fracture gap and the
incision closed in layers.
Photograph taken 10 months later showing reestablishment of normal occlusal
Panoramic x-ray taken 10 months postoperatively showing bone filling
Malunions occur for at least one of several reasons:
- Inadequate occlusal reduction during surgery
- Inadequate osseous reduction during surgery
- No osseous reduction (eg, condyle fractures)
- Imprecise application of internal fixation devices
- Inadequate stability (lack of rigidity)
The treatment of a malunion must involve:
- Identification of the cause
- Orthodontic/orthopedic treatment if possible
- Osteotomies as necessary (re-fracture, standard osteotomies,
Frontal photograph of a patient who sustained right angle and left symphysis
fractures but was never treated. Note a deviation of his chin to the left.
Intraoral photograph showing significant malocclusion resulting from
malunion of fractures.
Panoramic x-ray showing malunion of right angle and left parasymphyseal
Photograph of dental models mounted on an articulator.
... of obtainable occlusion.
Interocclusal splint fabricated to be used during surgery to help position
Intraoperative photograph showing malunion of right angle fracture.
Intraoperative photograph showing malunion of left parasymphyseal
Intraoperative photograph taken after right angle osteotomy and fixation
with two miniplates.
Intraoperative photograph taken after left parasymphyseal osteotomy and
fixation with a reconstruction plate.
Postoperative panoramic x-ray shows osteotomies and fixation devices.
Postoperative photograph showing that the facial asymmetry has been
Postoperative occlusion showing elimination of the malocclusion.
Infected fractures will usually demonstrate one or more of the following
- Purulent discharge
Infection occurring in fractures usually results from one or more of the
- Fracture instability
- Devital tissues (teeth, bone, etc)
The treatment of infected fractures involves:
- Incision and drainage of abscesses,
- Irrigations of the wounds as necessary
- Systemic antibiotics
- Removal of devital teeth/bone
- Removal of any loose internal fixation devices
- Re-stabilization of fracture
ORIF of posterior body and condyle fractures of the right mandible.
Note the consolidation at the body fracture and signs of bone resorption at
the condylar fracture site.
Obvious infection of surgical site with wound dehiscence and purulent
The patient was taken to surgery and the internal fixation devices were
removed along with loose bony fragments. The right mandibular condyle was found
to be avascular and was therefore removed.
Panoramic x-ray showing removal of right mandibular condyle and mandibular
body plates to treat infection of this surgical site. Good consolidation of the
right mandibular body is evident.
The infection subsequently subsided and the soft tissues healed.
Patient will require secondary reconstruction of right mandibular
Ankylosis is a process where the mandibular condyle fuses to the glenoid
fossa. This generally occurs after prolonged immobilization (MMF) of a condylar
Patient demonstrating their maximum interincisal opening after treatment of
multiple mandibular fractures and prolonged period of MMF.
Panoramic x-ray showing bilateral condyle fractures and a symphyseal
Note: lack of joint space in bilateral TMJ region.
CT scan showing bilateral TMJ ankylosis with bony fusion of mandibular
condyle to the glenoid fossa on the left side.
The only option to remedy ankylosis in this case is additional surgery in
the form of a gap arthroplasty or total alloplastic joint replacement.
Fixation failure results in fracture mobility that can subsequently lead to
infection, nonunion and/or malunion.
Fixation fails by a number of mechanisms which include:
- Insufficient amount of fixation
- Fracture of the plate
- Loosening of the screws
- Devitalization of bone around screws
Insufficient amount of fixation
Left mandibular angle fracture was treated using a malleable miniplate 2.0
at the inferior border of the mandible. This is insufficient fixation for this
Illustration demonstrating biomechanics of an angle fracture. A small plate
applied at the inferior border provides insufficient stability in such a
fracture. It cannot prevent a gap from opening at the superior surface of the
mandible under function.
The patient developed infection of left angle fracture site 2 weeks later.
They were taken back to the operation room and stable fixation was applied.
Subsequently, the fracture healed.
Fracture of the plate
X-ray shows a superior border miniplate.
It is obvious, that this clinical situation (edentulous mandible at fracture
site, impacted third molar) is biomechanically demanding and not suitable for
one miniplate osteosynthesis.
X-ray shows plate fractured. Segments were mobile which required treatment
consisting of ORIF with locking reconstruction plate 2.4.
Loosening of screws
Four weeks after two miniplate fixation of a right angle fracture, the
patient presents with a draining sinus tract through the skin.
X-ray shows at least one loose screw and loss of fixation.
The patient was taken back to surgery where a reconstruction plate was
Devitalization of bone around screws
6 weeks after treatment of right angle fracture and left body fracture with
two compression plates, the patient presents with swelling. Panoramic x-ray
shows loose hardware in the right side.
The fracture was opened and the hardware was found to be still attached to
portions of the buccal cortex which had become devitalized and sequestered.
Fortunately, the lingual cortex had healed and the occlusion was normal.
Thus, no further treatment was necessary.