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08.03.2016
Management of mandibular fractures has continued to evolve since on of the earliest descriptions in Egyptian literature. It was not until the advent of the Hippocratic concept for reapproximation and immobilization that management of mandibular fractures was revolutionized.
FIGURE 14-1 Chopart and Desault (1795) used viselike devices to treat mandibular fractures.
Various techniques were advocated however, most were variations of bandages and external appliances, extraoral and intraoral appliances, monomaxillary wiring, including bars, monomaxillary splints, and intermaxillary wiring and splints, guides or glides, and internal fixation, including wires, plates, and screws. Bandages, first mentioned by Hippocrates,3 gained notoriety and acceptance as a standard of care when John Rhea Barton described his Barton bandage15 (Fig. A primitive approach combined a rigid splint on the occlusal surface of the teeth and one on the undersurface of the mandible. FIGURE 14-3 Thomas Brian Gunning (1840-1889) was the first to use vulcanite in a custom-fitted splint to immobilize mandibular fragments. Originally advocated by Hippocrates,3 and then later supported in the writings of numerous authors,30–33 monomaxillary wiring was popular in the treatment of mandibular fractures. Splints became popular in the middle of the nineteenth century and were usually cast of metal and custom-fitted for the patient.
Guglielmo Salicetti (William of Saliceto)44 has been credited with being the first to use intermaxillary fixation.
Orthodontic bands and arches were used in patients with loose, fractured, or missing teeth.
Historically, mandibular body, ramus, or angle fractures were treated with closed reduction and intermaxillary fixation (IMF).
In the middle of the nineteenth century, Buck and Kinlock have described the use of wire ligature for the immobilization of mandibular fractures.17,49 Using this method, one would drill a hole on both sides of the fracture site and then pass a wire. FIGURE 14-4 The Thomas principle (1869) presented a technique of intraoral open reduction with silver wire osteosynthesis. In 1881, Gilmer36 described a method of mandibular fracture fixation that used two heavy rods placed on either side of the fracture and wired together. In 1915, Ivy52 attempted the use of Sherman’s steel plates but abandoned the method because of infection and necrosis.
Internal rigid fixation of the facial skeleton is a reliable method for obtaining osteosynthesis.
Resorbable plating systems or biodegradable fixation devices have been used in orthopedics and craniomaxillofacial fields for over 25 years.60 These materials not only reduce the risk of complications and mitigate the need for implant removal, but add the benefit of rigid fixation with biodegradation. Treatment of the fractured edentulous jaw began with a report by Baudens73 (1844), who used circumferential wiring to reduce and fix the bone. Another technique, described by Partridge41 in 1976, involves the use of a nylon circumferential strap wrapped around the body of the mandible and tightened. The causes of maxillofacial fractures have changed over the past decades and will continue. The main causes of mandibular fractures worldwide include motor vehicle accidents (MVAs), interpersonal violence (IPV), falls, and sports-related injuries. Despite the many variables associated with the causes of mandibular fractures, MVAs and assaults are undoubtedly the primary causes of mandibular fractures throughout the world. Dental implants have revolutionized the restorative treatment of edentulous patients over the last decade. The first described case in 1650 BC, discussed the examination, diagnosis, and treatment of mandibular fractures and other surgical complications.
Hippocrates described direct reapproximation of the fracture segments with the use of circumdental wiress, similar to today’s bridle wire. Emphasis remained on some form of external bandage or wrap occasionally used in conjunction with a bridle wire.
This viselike device was then used to apply pressure to the two splints, theoretically immobilizing and fixating the fractured segments. He used the splint in conjunction with an external head appliance, and these splints could also be applied to the maxilla and mandible, resulting in IMF (Fig. It was similar in concept to today’s bridle wire and the Risdon wire of the early 1920s, and monomaxillary wiring afforded some element of reduction, but without supplemental fixation, fractures were inadequately immobilized. Gilmer,45 also credited with being the first to use this technique, passed wires around individual teeth of both arches and then ligated these opposing wires. The famous American orthodontist Angle46 described many methods of IMF that used bands and other orthodontic techniques. However, it was Gilmer48 who took this idea a step further and fixated full arch bars on both the mandible and maxilla, revolutionizing the treatment of fractures. The wire, which was iron or silver, was then tightened periodically by creating pigtails on each end of it (Fig. The spiral springlike termination was tightened intermittently “until union was secured.” A, Proximal segment. The rods were pushed through skin, mucous membranes, and bone and were wired on both the mouth and skin sides. In 1917, Cole53 used silver plates and screws on each side of the fracture and then silver wires attached to the plates to immobilize the fracture. Historically, metallic plates and screws have been used to allow for early passive and active function. Before the 1960s, the biomechanical knowledge of internal rigid fixation for the facial skeleton was adapted from the orthopedic literature. These were also called load-bearing plates because of their rigidity and application over complex comminuted fractures.


Gunning used splints, as described earlier.27–29 In 1851, Robert74 used silver wire passed circumferentially around the mandible with a needle and tied the wire around a piece of lead that had been molded to the edentulous mandible.
Past data from industrialized or developed nations with large numbers of vehicles indicated that multiple mandibular fractures were occurring with severe concomitant facial fractures and associated nonmaxillofacial injuries, situations that required extensive treatment.
He advocated wiring of the adjacent teeth with external bandaging to immobilize the fracture.3,4 Hippocrates had the insight to realize that reapproximation and immobilization are paramount in the treatment of mandibular fractures. Attention was being directed toward the development and improvement of intraoral and extraoral devices. Dorrance and Bransfield26 wrote about the multiple disadvantages of this method, however, including the inability to gain proper occlusion, its inapplicability for fractures of the posterior mandible and for bilateral fractures, its promotion of drooling, and the lack of immobilization necessary for proper union.
Some were cemented to the teeth and others involved sophisticated clamps that would tie buccal and lingual segments together.17,34–43 The use of monomaxillary wiring, bars, arches, and splints is limited to fractures containing stable teeth on both sides of the fracture. A recent study by Cousin revisited this methodology and noted success using nonwire fixation for IMF.
Dorrance and Bransfield stated that the earliest reference to the use of true bone plates was that of Schede, who, around 1888, used a solid steel plate held by four screws.26 During World War I, Kazanjian50 used wire sutures through bone fragments and tied the wire to an arch bar for fixation. These materials have less strength, which would limit their use in loaded and functional bone, such as the mandible. In the mid-1960s, Luhr65 pursued research in rigid fixation for the facial skeleton and developed the Vitallium mandibular compression plate using glide screw principles. Gilmer36 (1881) described a gutta-percha or vulcanite splint used by Black that was maintained by circumferential wires of silver or platinum.
This method can be applied only to fractures that have extreme obliquity, but the amount of periosteal stripping involved may outweigh any potential benefit. Varying socioeconomic conditions combined with behavioral differences, however, make the aggregate comparison of mandibular fractures difficult. In contrast, assaults and falls have become the predominant mechanism for facial injuries.99–101 Statistics from smaller developing countries have indicated that MVAs remain the most frequent cause. Reports have shown that on average, more than 75% of mandibular fractures are caused by MVAs and IPV, whereas 7% are work-related, 7% occur as the result of a fall, 4% occur in sports-related accidents, and the remainder have miscellaneous causes.
As implantation procedures have become the norm, fractures of the mandible and other maxillofacial bones are more common. An anterior space was provided for nourishment.27–29 This basic principle, of using splints for intermaxillary fixation, although modified, is still used routinely in the treatment of edentulous and partially edentulous mandibular fractures. In 1900, Mahe51 used multiple plates to secure multiple mandibular fragments after applying a monomaxillary splint. Others have reported that metallic alloys containing nickel, cobalt, and chromium may sensitize the patient and lead to allergic reactions. Throughout the 1960s, Luhr continued research on rigid fixation and also contributed the self-threading screw.
Pickerill75 (1913) passed screws into the bone on either side of the fracture and maintained them with a connecting steel bar. Obtaining analysis data from various regions can increase the understanding of facial trauma and allow for optimization of treatment.76,77 Demographic information on maxillofacial injuries has changed with the onset of motor vehicle seat belt and airbag laws, reduced speed limits, and increasing urban violence.
The amount of osseous resorption secondary to long-term use of a prosthesis and the higher incidence of metabolic abnormalities in older adults result in a lower grade of recipient bone.
Physicians must take backscatter into consideration in patients in whom reconstruction with metallic implants has been performed following tumor resection and who will require radiation therapy.
In 1973, Michelet et al72 placed bendable monocortical miniplates to treat mandibular fractures. Therefore, patient selection is paramount, and adhering to good osseointegration principles allow for better results.
They found that adaptation of a compression plate on the lateral cortex, at the inferior border of the mandible, gave excellent compression and adaptation at the inferior border but the superior border (tension zone) splayed. The advantages of miniplates were their thinness and the fact that they could be placed through intraoral incisions.
It is important to note, however, that local laws and socioeconomic conditions in developed versus developing countries create mixed results for case by case studies. Many investigators thought that a second tension zone plate would be necessary, whereas others believed that arch bars in tooth-bearing areas were sufficient to limit tension zone splaying.
Also known as load-sharing plates, miniplates transferred the path of static compression to one of dynamic compression. Of these, 81% affected the teeth or alveolar process and 11% were fractures of the mandible and the middle third of the face. Civilian injuries were not as life-threatening when compared with their high-velocity combat counterparts. In 1973, Schmocker and Speissl68 developed the eccentric dynamic compression plate, which provided compression at the tension and compression zones of the mandible. Fixation to the alveolar ridge allows tensile stress placed on the miniplate to cause an increase in dynamic compression and stability. When the screws closest to the fracture were tightened, the fracture line would be placed under compression. Their surgical approach involved fabrication of an occlusal splint, IMF, aggressive debridement of hard and soft tissues, and immediate reconstruction with a titanium plate, which they believed could restore the appropriate function and contour of the patient.



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