champy.pdf

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Face!Mouth!&!Jaw!Surgery:!International!Trainee!Journal!of!Oral!&!Maxillofacial!Surgery.!2012;!2(1):12B21!

!!Introduction!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!!!!Fractures! of! the! mandible! are! common! and!most! patients! will! present! to! the! maxillofacial!team! by! referral! from! the! emergency!department.!!The!aetiology!of!the!injury!usually!falls!under!the!broad!category!of!trauma!and!as!such!other!injuries!are!common!and!need!to!be!excluded;! cervical! spine! fractures! can! be!present! in! as! many! as! 20%! of! cases.1! ! The!advanced! trauma! life! support! (ATLS)!framework!provides! a! concise! approach! to! the!management! of! these! patients! on! initial!presentation.! !Once!other! injuries!are!excluded!or!dealt!with!and!the!patient!is!stable,!attention!can!be!turned!to!any!mandibular!fractures.!!!

!Examining! the! aetiology! of! the! injuries! more!closely,! one! finds! that! the! most! common!mechanism! of! injury! in! the! UK! is! assault,!followed! by! traffic! accidents,! falls! and! sports!injury.2! Males! are! six! times! more! likely! to!present! with! a! mandibular! fracture! than!females.3! As! ever,! detailed! medical! notes! with!diagrams!are!invaluable!as!part!of!good!medical!record! keeping! and! given! that! interpersonal!violence! is! the! most! common! mechanism! of!injury,! they!may! be! needed! by! the! court! later.!!Do!bear! in!mind!though!that! fractures!can!also!be!pathological!and!iatrogenic.!!This! article! will! discuss! and! explain! general!principles! and! should! be! used! as! a! means! of!

Nabeela&Ahmeda,*&

Katherine&Georgeb&

aKing’s!College!Hospital,!London!bGuy’s!Hospital,!London!!*Correspondence:!Oral!and!Maxillofacial!Department,!King’s!College!Hospital,!!Denmark!Hill,!London,!SE5!9RS!!Email:[email protected] !

!How!to!Manage!Fractures!of!the!Mandible!–!a!Simple!Guide!

Fractures!of!the!mandible!are!common!reason!for!

maxillofacial!referrals!by!Emergency!

Departments.!Irrespective!of!the!mechanism!of!

injury,!correct!and!appropriate!diagnosis!are!

essential.!

This!review!article!looks!at!the!aetiology,!

presentation,!diagnosis!and!subsequent!

management!of!mandibular!fractures,!including!

those!of!the!condyle.!

!Face!Mouth!Jaw!Surg!2012;!2!(1):!12B21!

Abstract!

FMJS%

!!!!EDUCATIONAL!!REVIEW!

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Ahmed!!!!! How!to!Manage!Fractures!of!the!Mandible!–!A!Simple!Guide!

revisiting!methods! of! fracture! fixation! and! the!arguments! for! and! against! the! different!methods!of!management.!!!How!do!you!classify!mandibular!fractures?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!I!!The! classification! of! mandibular! fractures! is!similar! to! any!other!broken!bone.! !The! type!of!fracture,! location! and! the! degree! of!displacement!should!be!described!(Figure!1!and!2).! This! simplistic! approach! aids!communication! between! surgeons! and!facilitates! treatment! decisions! as! to! whether!surgery! is! required! and! the! urgency! of! such!intervention!.!!!!

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Figure!2:!Anatomy!of!the!mandible!

!

The! mechanism! of! injury,! prominence! of! the!mandible! and! inherent! areas! of! weakness!influence! fracture! sites.!Concurrent! dental!trauma! may! also! be! present! and! should! be!considered! in! order! to! account! for! missing!tooth! fragments! in! a! patient! who! may! be!unconscious.! A! good! history! can! help! you!predict! where! the! suspected! fracture! may!indeed!be!present.!!

The! commonest! fracture! site! is! the! body! and!the! least! fractured! part! the! coronoid! of! the!mandible.2!A!2%!deformity!in!bone!is!sufficient!to!trigger!a!fracture!process.5!!Mandible!Location! %!of!total!fractures!Body! 33.6%!SubBcondylar!area! 33.4%!Angle! 17.4%!Alveolar! 6.7%!Ramus! 5.4%!Symphyseal! 2.9%!Coronoid! 1.3%!!Displacement! of! fractured! segments! is!affected!by!what!factors?!1)!Force!of!blow.!2)!Integrity!of!periostium.!3)!Degree!of!interdigitation!of!fracture!ends.!4)!Direction!of!fracture!line.!5)!Pull!of!muscles!inserted!into!the!mandible.!

Figure!1:!Fracture!description!based!on!!type!and!anatomical!site!

Type!Greenstick!Simple!

Compound!Comminuted!Pathological!

!Anatomical/Site!of!fracture!

Dentoalveolar!Condylar!Coronoid!Ramus!Angle!Body!

Parasymphysis!Symphysis!

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Management!Principles!!!!!!!!!!!!!!!!!i!!As!with!all!trauma,!the!priority!of!management!should!be!as!follows:!!1)!Control!of!life!threatening!injuries!!2)!Diagnosis!and!treatment!of!other!serious!injuries!as!needed!!3)! Diagnosis! and! management! of!maxillofacial!injuries!!!History!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!Ask! about! the! circumstances! of! injury,! which!may!give!an!indication!as!to!the!force!used!and!aid! in! prediction! of! the! fracture! pattern.! Being!punched! once! will! give! you! a! different!predicted!injury!to!someone!who!has!fallen!and!landed!on!their!chin.!!Ask!about!their!complaints!and!what!they!think!is! wrong.! Ask! questions! about! their! pain,! any!perceived! numbness! and! any! problems! with!opening! or! closing! their!mouth.! These! injuries!can! present! in! delayed! fashion! because! of!problems!or!pain!eating.!Ask!the!patient!if!their!bite! feels! normal,! any! subjective! change! in!occlusion! may! be! the! result! of! swelling! but!could!also!indicate!a!displaced!fracture.!!!

Examination!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!ExtraQoral!Look!for!any!obvious!asymmetry,!swelling,!and!bruising.! Document! the! presence! of! any!lacerations.!Palpate! the! mandibular! border! bilaterally! for!any!step!deformity.!Note!the!nature!of!swelling!and!mobility.! ! Record! tenderness! and! function!in!terms!of!jaw!movement.!!

Cranial! nerve! assessment! is! mandatory!(especially!for!ID!nerve!function).!!IntraQoral!Assess! the! occlusion! and! note! any!derangement.! Look! for! bruising! or! lacerations!of!the!soft!tissues!and!gingival!tears.!Palpate!the!alveolar!processes!and!document!any!fractured!or!missing!teeth.!Document! the! maximum! interBincisal! distance!on!mouth!opening.!!!

What! Radiographs! should! be!taken! to! identify! possible!mandibular!fractures?!!!!!!!!!!!!!!!!!!!i!!!Patients! referred! from! the! emergency!department! with! an! isolated! mandibular!fracture! should! have! undergone! radiographic!examination!by!way!of!two!plain!radiographs!at!different! angles! to! each! other.! ! These! will!usually! include! a! posteroanterior! view! of! the!mandible! and! a! dental! panoramic! tomogram!(DPT)! or! lateral! oblique! views.! ! Other! views!such! a! lower! standard! occlusal,! periapicals,! an!anteroposterior! mandible! or! occipital! mental!views!may!also!be!helpful! in!certain!situations.!!!In! the!multi! trauma! setting,! assessment!with! a!CT!scan!is!performed.!!!Figure!3:!DPT!of!a!right!parasymphyseal!fracture!of! the! mandible.! The! unerupted! teeth! have!influenced!fracture!line!propagation!

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What! broad! treatment! options!are!available?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!1.!Non!Operative!Management!This! can! be! indicated! if! it! is! a! single,! stable,!undisplaced!fracture!of!the!mandible.!However!you!need!a!good!stable!occlusion!and!a! patient! who! can! tolerate! a! soft! diet! and!maintain! good! oral! hygiene.! They! will! also!require! pain! relief! with! oral! analgesics! and! a!course! of! antibiotics! may! be! indicated.! If!considering!this,!early!review!is!mandatory!and!the! patient! warned! any! change! in! occlusion!would! warrant! intervention.! Any! associated!gingival!or!soft!tissue!laceration!adjacent!to!the!fracture!would!exclude!this!potential!method!of!management.!!2.!Operative!management!This! is! where! the! fracture/s! are! unstable! or!open!and!would!require!reduction!and! fixation!using!the!following!methods:!!a)!Closed!reduction!Bwith!intermaxillary!fixation!(IMF)!using:!!

• arch! bars,! Leonard! buttons! or! eyelet!wiring!if!dentate!

• Gunning! splints! or! dentures! if!edentulous! held! by! trans! palatal! and!circumferential!wiring!

Bwith!external!fixation!!IMF!is!limited!by:!

1. Inadequate!teeth!for!stabilisation.!2. Unstable!initial!occlusion.!3. Muscle!pull!may!misalign!fragments!

even!if!the!occlusion!is!correct.!4. Not! useable! if! associated! with!

midface! (zygomatic,! ethmoidal)!fractures.!

5. Aspiration! risk! especially! if! the!patient! vomits! or! has! significant!swelling.!

6. Risk!of!weight! loss/!presence!of!coBexisting!respiratory!disease.!

7. Patient!acceptance.!!If! you! are! going! to! use! IMF,! the! interdental!wiring! is! usually! perfrmed! with! 0.4mm!stainless!steel!wire.!!b)!Open!reduction!!This! is! indicated! for! displaced! unfavorable!fractures! of! the! mandible! and! allows! early!mobilization! and! return! of! jaw! function.!!Surgical!access!to!the!mandible!is!usually!via!an!intraoral! approach.! ! However,! an! extra! oral!approach! may! be! chosen! in! situations! where!load!bearing!reconstruction!plates!are!required!for! adequate! fixation! or! where! soft! tissue!lacerations! are! appropriately! positioned! for!access.!!Remember,! the! distance! between! ID! canal! and!cortex! is! approximately! 4mm! in! the! premolar!and!5.9!mm!in!the!second!molar!region,!so!this!should!be!borne!in!mind!when!deciding!on!your!screw! length.! The! mental! nerve! and! foramen!also! need! to! be! accommodated!when! planning!fixation.!In!general!terms,!any!fracture!anterior!to! the! mental! foramen! requires! two! plates!based! on! Champy’s! principles! and!will! lead! to!reduced!postoperative!morbidity.6!!!Consenting! a! patient! for! a!fractured!mandible!!!!!!!!!!!!!!!!!!!!!!!!!i!!Clearly!the!benefits!are!a!restoration!of!function!and! improved! healing.! However,! patients!should!be!counselled!about!the!following:!

• Planned! access! (intra! or! extra! oral! and!transbuccal!approaches)!

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• The! plates! are! left! in! situ! and! not!removed! (and! do! not! set! off! metal!detectors).!

• Your! proposed! use! of! arch! bars! and!whether! these! will! be! left! in! situ!postoperatively! (and! think! about! any!disruption!to!crowns/fillings)!

• Post! operative! pain,! swelling,! bleeding,!bruising.!

• The!risk!of!infection!(early/late).!• Possible! need! for! plate! removal! B! this!

occurs! in!5B20%!of!cases!and! is!usually!due! to! either! wound! breakdown! or!infection.7!

• Poor!fracture!healing.!• Warn! them!about!paraesthesia!of! ID!or!

mental! nerve! (permanent! vs!temporary)!

• Injury!to!marginal!mandibular!branch!of!facial! nerve! (if! transbuccal! approach!discussed)!

• Loss! of! teeth! (requiring! extraction! if!impairing!reduction!of!fracture)!

• Malocclusion! (perceived! and! actually!post!operatively)!

• Loss! of! vitality! of! teeth! adjacent! to!fracture!line!

• Presence! of! a! scar! (if!transbuccal/extraoral!approach)!

• TMJDS.!!!PreBoperative!management!!!!!!!!!i!!Antibiotics! are! required! for! all! compound!fractures! and! dentoalveolar! fractures! (make!sure! you! are! familiar! with! local! antibiotic!prophylaxis! recommendations)! as! essentially!these!are!open!fractures.!!PreBop! fasting! must! be! strictly! adhered! to! as!these! patients! often! have! limited! mouth!

opening! and! may! require! awake! fibreBoptic!intubation.!!Remind! the! anaesthetist! you! will! require! a!nasal! tube,! unless! there! is! an! edentulous! area!the! tube!can!be! secured! through!or! the!plan! is!to! place! a! tracheostomy! or! convert! to! a!submental!intubation!if!an!oral!tube!is!placed!!!PostBoperative!management!!!!!!!i!!IMF!is!usually!released!before!the!patient!wakes!up!and!then!replaced!using!orthodontic!elastics!once!the!patient! is! fully!conscious.! ! If!wire!IMF!remains! in! situ! post! operatively,! the!anaesthetist! will! wait! until! the! patient! is!conscious! prior! to! extubation! and!wire! cutters!must!accompany!them!at!all!times.!!It!is!considered!good!surgical!practice!to!remain!in! theatre! with! your! patient! until! they! have!been!extubated.!It!is!also!a!good!opportunity!to!recheck! occlusion! and! ensure! no! TMJ!dislocation!has!occurred!during!the!final!stages!of!the!anaesthetic!procedure!and!extubation.!!Intermediate!postQop!

• close!supervision!• head!elevated!30!degrees!• suction!at!bedside!• prescribe! medications! such! as!

antiemetics,!analgesia!and!antibiotics.!• prescribe! hot! salt! water! and!

chlorhexidine!mouthwashes!!!Pre!Discharge!Advice!!!!!!!!!!!!!!!!!!!!!i!!Advise!patients!to!not!smoke.!No!contact!sports!for!at!least!6!weeks.!It’s! important!to!reinforce!that!their!diet!needs!to! be! soft! and! ensure! a! preBop! weight! is!

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recorded! (if! patients! are! in! IMF!or!have!a!preBop! low! BMI! consider! dietician! input! if!available).! Weekly! weights! are! helpful! if! they!remain! in! IMF! and! help! guide! nutritional!support.!!Consider! postBoperative! radiographs! before!discharge!(although!this!is!a!controversial!issue.!Some!argue!that!clinical!reduction!is!sufficient).!However,!postoperative!radiographs!are!useful!in!patient!education,!analysing!injuries!in!those!who! represent! with! problems! and! in! the!assessment! of! patients! with! an! ongoing!malocclusion!complaint!post!surgery.!!Arrange!a!postBoperative!review!approximately!a!week!later.!Post!Treatment!Review!in!Outpatients!

• Document! any! complaints! or! patient!concerns!

• Check!their!occlusion!• Document! any! residual/onBgoing!

paraesthesia!• Review! any! other! soft! tissue! injuries!

and!remove!sutures!• Review!medications!• Patient! reinstructed! of! importance! of!

good!oral!hygiene!and!nutrition!• Avoid!contact!sports!• Consider!need!for!onBgoing!IMF!• Planned!mobilisation!• Remember! dental! rehabilitation! via!

GDP!if!any!associated!dental!injuries!!!!What! are! the! common!complications! of! mandibular!fractures?!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!1)!Bone:!delayed!union,!nonBunion,!malBunion,!osteomyelitis!

2)!Teeth:!malocclusion,!loss,!infection!3)Nerves:! sensory! loss! anaesthesia/!hypoaesthesia/!dysaesthesia!4)!Joint:!dysfunction,!fibrous/bony!ankylosis!5)!Aesthetic:!deformity!!!Specific!fracture!sites!!!!!!!!!!!!!!!!!!!!!i!!Coronoid!Fractures!These!rarely!require!fixation,!although!this!may!be! indicated! if! there! is! impingement! on! the!zygomatic!arch.8!!Ramus!Fractures!This! is! an! unusual! fracture! which,! if! present,!usually!shows!little!displacement.!Closed! reduction! and! fixation! is! the! usual!treatment! of! choice! and! can! be! achieved! with!no! operative! intervention! if! a! malocclusion! is!not! present.! If! there! is! a! malocclusion! or!another! fracture! present,! then! use! arch! bars!and!arrange!fixation!of!the!other!fracture.!!Angle!Fractures!and!Body!Fractures!Can! be! managed! with! IMF,! monocortical!miniplate! osteosynthesis,! wire! osteosynthesis,!screw!fixation!or!a!combination!of!all.!These!fractures!can!be!accessed!via!an!intraoral!approach,! but! more! commonly! a! transbuccal!approach! is! adopted! for! the! final! fixation! to!facilitate! the! placement! of! the! screws!perpendicular! to! the! bone.! As! such! patients!need! additional! warning! on! the! consent! form!regarding! neuropraxic! injury! to! the! marginal!mandibular! branch! of! the! facial! nerve! and! the!presence!of!a!small!scar.!!Symphysis!and!parasymphysis!fractures!Open!reduction!and!internal!fixation!is!required!as! displacement! is! often! present! because! of!muscle! forces! exerted! in! this! area.! They! often!coexist!with!condylar!fractures,!so!check!the!xB

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rays! carefully! and! if! need! be! go! back! and!examine! the! patient.! This! is! why! a! thorough!history!at!initial!clerking!is!helpful!in!suggesting!where!the!injuries!may!be!present.!!!Condylar!fractures!!!!!!!!!!!!!!!!!!!!!!!!!!i!!Condylar! fractures!are!an! interesting!subgroup!of! mandibular! fracture,! presenting! their! own!challenges! in! terms! of! assessment! and!management.! They! are! common,! occurring! in!30B50%! of! mandibular! fractures! and! they!usually!occur!unilaterally.!!As!a!general!rule,!fractures!with!a!displacement!of! more! than! 10! degrees! and! overlap! of! more!than!2mm!should!be!treated!with!ORIF.9!There!are! several! classification! systems! devoted! to!condylar! fractures,! focusing! on! the! anatomical!location! and! the! displacement! of! the! condylar!segment.! ! The! subclassification! proposed! by!Loukota! at! al.! focuses! on! the! anatomical!location! of! the! fracture! and! has! been! adopted!by! the! Strasbourg! Osteosynthesis! Research!Group.10! It! is! simple! to! use! and! easy! to!remember! and!when! combined!with! the! angle!of! displacement! and! the! amount! of! overlap! of!the!condylar!segment,!provides!clinicians!with!a!useful! framework! on! which! to! help! guide!treatment!decisions!(Figure!4).!!!!Figure! 4:! SORG! classification:! (1)! high/condylar!neck! fracture;! (2)! low/condylar! base! fracture;!(3)! diacapitular! fracture! (with! permission! from!Loukota,!journal!permission!pending)!

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The!management!principles!are!similar!to!those!for!mandibular!fractures!in!general,!in!terms!of!history! and! examination.! ! However,! on!examination,! one! should! suspect! a! fractured!condyle! if! there! is! pain! on! palpation! of! the!temporomandibular! joint,! laceration! or!bleeding!noted!at!the!external!acoustic!meatus,!injury!to!the!chin,!deviation!of!the!mandible!on!opening! and! a! lateral! open! bite! on! the!contralateral!side!to!the!fracture.!Investigations!for! the! ambulant! patient! would! normally!include!2!radiographic! images!of!the!mandible;!a!postero!anterior!(PA)!mandible!and!a!DPT,!as!for!other!mandibular!fractures.!!CT!scans!can!be!useful! in! the! assessment! of! intracapsular!fractures! of! the! condyle!which! can! not! always!be! seen! on! plain! radiographs;! and! again,! may!also! be! the! imaging! modality! of! choice! in! the!multi!trauma!patient.!!In!general!terms,!treatment!options!comprise:!1.! Functional! (soft! diet/analgesia/activity!modification)!2.! Indirect! immobilization! (arch! bars! and!elastics/wires)!3.!Open!reduction!and!fixation!using!plates!!The! decision!will! depend! upon! patient! factors,!the! occlusal! discrepancy! and! the! classification!of! the! fracture! as! previously! discussed.!Where!there! is! no! occlusal! discrepancy! then! no!surgical! intervention! is! required! and! patients!can!be!managed!with!a!soft!diet!and!warned!to!refrain! from! contact! sports.! ! ! The! choice!between! a! closed! reduction! or! open! reduction!and!internal!fixation!is!more!fluid.!!!!Closed!reduction!is!advocated!for!high!condylar!neck! or! dicapitular! fractures,! in! minimally!displaced! fractures! and! in! the! management! of!condylar!fractures!in!children.! ! In!this!group!of!patients! the! results! of! closed! treatment! are!good.! ! It!must! be! remembered! that! although! a!closed!approach,!it!should!not!be!thought!of!as!a!

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conservative!approach!as! intermaxillary!elastic!fixation!is!required!and!this!is!associated!with!a!degree! of! morbidity.! ! A! general! anaesthetic! is!usually!required! in!order! to!place!the!archbars!and! these! are! worn! for! a! period! of! 6! weeks.!!Elastic! intermaxillary! fixation! to! correct! the!malocclusion!is!usually!worn!for!up!to!2!weeks,!followed! by! the! use! of! guiding! elastics! and!postoperative!physiotherapy!in!order!to!get!the!joint!moving.!!!!Open! reduction! and! internal! fixation! of!fractured! condyles! is!becoming!more! common,!due! in! part! to! an! improvement! in! the!technology! available! and! also! to! several! trials!which!have!supported!the!technique.! !Absolute!and!relative!indications!were!initially!proposed!in! 1983,! although! these! have! been! modified!over!time!and!are!as!follows:11!!Absolute!Indications!

• Displacement! of! the! condyle! into! the!middle!cranial!fossa!

• Impossibility! of! obtaining! adequate!occlusion!by!closed!reduction!

• Lateral!extracapsular!displacement!• Invasion!by!foreign!body!

!Relative!Indications!

• Bilateral! fractures! in! an! edentulous!patient!without!a!splint!

• Unilateral! or! bilateral! condylar! fractures!where! splinting! cannot! be! accomplished!for! medical! reasons! or! because!physiotherapy!is!impossible!

• Bilateral! condylar! fractures! with!comminuted! midfacial! fractures,!prognathia!or!retrognathia!

• Periodontal!problems,!loss!of!teeth!• Unilateral!condylar!fracture!with!unstable!base!

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Surgical!Approaches!to!the!Condyle!There!are!several!surgical!access!approaches!to!the!fractured!condyle!and!the!choice!is!based!on!the! position! of! the! fracture! and! surgical!preference.!!The!more!common!approaches!are!listed:!!

• Retromandibular!• Submandibular!• Transmeatal!• PreBauricular!• Endoscopic!

!The!most!common!risks!of!an!open!approach!to!the! fractured! condyle! are! pain,! bleeding,! scar!formation! and! the! risk! of! infection.! ! Of! more!concern! to! the! majority! of! surgeons! and!patients! is! the! risk! to! the! facial! nerve! and! the!possibility! of! temporary! or! permanent!weakness!following!surgery.!!However,!the!risk!of! facial!nerve!weakness!has!been!shown!to!be!very! low! in! the! published! literature! with!temporary!weakness! ranging! between!0%!and!30%! and! permanent! weakness! of! 1%! when! a!retromandibular!approach!was!employed.12,13!If!the! condyle! is! approached! by! a! transparotid!route,!there!is!also!a!risk!of!sialocele!formation!or!a!salivary!fistula.! !Again,!the!risks!of!this!are!low.!!Treatment! of! condylar! fractures! remains!controversial.! However,! the! risks! of! a! surgical!approach! should! be! considered! as! there! are!benefits!to!closed!treatment!as!well.!!!Benefits! of! open! reduction! and! internal!fixation!1. Anatomical!reduction!2. Occlusal!stability!3. Rapid!recovery!of!function!4. Maintenance!of!vertical!ramus!height!5. Reduced!deviation!on!opening!

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6. No! airway! compromise! (short! and! long!term! because! of! potential! reduction! in!movement)!

7. Potential! reduction! in! complaints! of! TMJ!dysfunction.!

!!Benefits!of!closed!treatment!1. Reduced!overall!morbidity!2. Avoids!risks!of!an!open!approach,!such!as!a!

scar,! sialocele,! and! risk! of! facial! nerve!injury!

3. Technically! much! simpler! (arch! bars! vs.!retromandibular!approach)!

4. Less!risk!of!ankylosis!of!the!joint!5. Less!risk!of!avascular!necrosis!!As! a! general! rule! of! thumb,! discuss! cases! of! a!condylar!fracture!with!a!senior!in!the!presence!of! a! malocclusion.! Any! patients! who! are! sent!home! with! a! unilateral! undisplaced/minimally!displaced! condyle!must! be! reviewed! early! and!warned! surgical! intervention!may!be! indicated!in!the!occlusion!drifts.!It! is!essential!to!instruct!them!on! the!necessity! for! following!a! soft!diet,!analgesia!and!avoidance!of!any!further!trauma.!!!!Special!Circumstances!!!!!!!!!!!!!!!!!!!i!!What!do!you!do!for!children!under!10?!If!there!is!a!malocclusion!present,!this!can!often!be!disregarded,! as! spontaneous! correction!will!take!place!as!the!dentition!develops.!If!there!is!a!displaced!condylar!neck,!fractures!will!undergo!full!functional!restitution!in!most!cases,14!and!in!children! unilateral! and! bilateral! condylar!fractures! are! treated! in! the! same! way.!!Treatment! should!be!entirely! functional!where!possible.!If! intervention!is!required!in!the!form!of! IMF! (indicated! for! control! of! pain)! this!should! be! released! after! 7B10! days! to! avoid!ankylosis.! !Where!an!intracapsular!fracture!has!been! diagnosed,! careful! followBup! and!

monitoring!of!growth!is!required,!so!that!if!any!associated! facial! asymmetry!develops! it! can!be!appropriately!managed.!!What!do!you!do!for!adolescents!aged!10Q17?!Same! principles! apply! as! for! adults!with! some!modifications! (and! will! be! dependent! upon!their!stage!of!dental!development).!If! malocclusion! is! present! capacity! for!spontaneous! correction! is! less,! so! will! require!intervention! and! this! will! usually! constitute! a!brief!period!of!IMF,!not!longer!than!2B3!weeks.!!!Summary!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!Appropriate!assessment,!a!good!clinical!examination!along!with!knowledge!gained!from!radiological!investigations!allows!sufficient!information!to!be!attained!in!order!to!plan!the!management!of!a!patient!with!a!mandibular!fracture!but,!as!this!article!shows,!each!case!much!be!reviewed!with!individual!merit!to!plan!the!best!outcome!for!the!patient.!!!References!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!i!!

1. Williams! J,! Jehle! D,! Cottington! E,!Shufflebarger! C.! Head,! facial,! and!clavicular! trauma! as! a! predictor! of!cervicalBspine! injury.! Ann! Emerg! Med!1992;21(6):719B22.!

2. Coulthard! P,! Yong! SL,! Adamson! L,!Warburton!A,!Worthington!HV,!Esposito!M,! et! al.! Domestic! violence! screening!and!intervention!programmes!for!adults!with! dental! or! facial! injury.! Cochrane!Database!Syst!Rev!2010(12):CD004486.!

3. Bochlogyros!PN.!A! retrospective! study!of!1,521! mandibular! fractures.! J! Oral!Maxillofac!Surg!1985;43(8):597B9.!

4. Oikarinen! VJ,! Malmstrom! M.! Jaw!

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fractures.! Suom! Hammaslaak! Toim!1969;65(1):95B111.!

5. Prein.! Internal! fixation!of! the!craniofacial!skeleton.!1st!Edition!ed:!Springer.!

6. Renton! TF,! Wiesenfeld! D.! Mandibular!fracture! osteosynthesis:! a! comparison!of! three!techniques.!Br!J!Oral!Maxillofac!Surg!1996;34(2):166B73.!

7. Chaushu!G,!Manor!Y,!Shoshani!Y,!Taicher!S.! Risk! factors! contributing! to!symptomatic! plate! removal! in!maxillofacial! trauma! patients.! Plast!Reconstr!Surg!2000;105(2):521B5.!

8. Yaremchuk!MJ.!Rigid!internal!fixation!of!a!displaced!mandibular!coronoid!fracture.!J!Craniofac!Surg!1992;3(4):226B9.!

9. Schneider! M,! Erasmus! F,! Gerlach! KL,!Kuhlisch! E,! Loukota! RA,! Rasse!M,! et! al.!Open! reduction! and! internal! fixation!versus! closed! treatment! and!mandibulomaxillary! fixation! of!fractures! of! the! mandibular! condylar!process:! a! randomized,! prospective,!multicenter! study! with! special!evaluation! of! fracture! level.! J! Oral!Maxillofac!Surg!2008;66(12):2537B44.!

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10. Loukota!RA,! Eckelt!U,!De!Bont! L,!Rasse!M.! Subclassification! of! fractures! of! the!condylar! process! of! the! mandible.! Br! J!Oral!Maxillofac!Surg!2005;43(1):72B3.!

11. Zide! MF,! Kent! JN.! Indications! for! open!reduction! of! mandibular! condyle!fractures.! J! Oral! Maxillofac! Surg!1983;41(2):89B98.!

12. Manisali! M,! Amin! M,! Aghabeigi! B,!Newman! L.! Retromandibular! approach!to! the! mandibular! condyle:! a! clinical!and! cadaveric! study.! Int! J! Oral!Maxillofac!Surg!2003;32(3):253B6.!

13. Ellis! E,! 3rd,! McFadden! D,! Simon! P,!Throckmorton!G.!Surgical!complications!with! open! treatment! of! mandibular!condylar! process! fractures.! J! Oral!Maxillofac!Surg!2000;58(9):950B8.!

14. Walker! RV.! Traumatic! mandibular!condylar!fracture!dislocations.!Effect!on!growth! in! the! Macaca! rhesus! monkey.!Am!J!Surg!1960;100:850B63.

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