Fractures of the Mandible

Fracture of Mandible is the most common occurrence in comparison to any other bone of the maxillofacial region. Various classifications are put forward which are helpful in diagnosing the mandible fracture. This chapter focuses on the general and clinical examination of the maxillofacial region which helps in clinical diagnosis, different radiographic techniques, various approaches, emergency as well as surgical management and outcome with various modalities of treatment.


Surgical Anatomy
The mandible is a horseshoe-shaped only mobile bone of the facial skeleton. It is the strongest bone with thick cortices. Symphysis is the most prominent part of mandible, and the condyles articulate with glenoid fossa of temporal bone. The inferior alveolar neurovascular bundle passes through the bone, and in the case of fracture, it may get traumatized and can lead to hematoma and neurological de cit.

Angle of the Mandible
By de nition, there are three types of angle as described below: 1. Clinical angle: It is the junction between the alveolar bone and ramus at the origin of internal oblique ridge. 2. Surgical angle: It is the junction between body of the mandible and ramus at the origin of the external oblique ridge. 3. Anatomical angle or (gonion): It is the junction where the lower border meets the posterior border of ramus.
Anatomically, mandibular angle is a weaker structure compared to other anatomic subsites.
• The ramus of the mandible is thin as compared to the body. Whenever a thick portion of the bone unites with the thin portion, it constitutes a line of weakness. • Further the third molars are located in the angle region, and when they are impacted, they occupy lot of space in the bone and undermine it. • In the case of mesio-angular impaction, the impacted third molar tooth acts as a wedge and predisposes the fracture of angle of mandible, if the direction of force is perpendicular to it. • The bone grains which are oriented vertically in the ramus change their course at the angle of mandible as they enter the body of mandible. This abrupt change in the course of the bone grains also makes the bone weak. All these factors make the mandible vulnerable for fracture at this site.

Canine Region of the Mandible
In the canine area, also the mandible is weaker as the canine has the longest and the strongest root, and it occupies lot of space in the bone and undermines and weakens it. Thus, the mandible has a tendency to fracture at this site.

Symphysis and Parasymphysis of Mandible
• The symphyseal area is most prominent and most vulnerable to trauma. There is a compression of the outer cortex and expansion of the inner cortex, and the fracture will result when the forces are beyond the limits of the capacity of the bone to withstand them. • There is a pair of genial tubercles on the lingual cortical plate in the midline, situated supero-inferiorly, which give origin to the genioglossus and geniohyoid muscles, respectively. Whenever there is a bilateral fracture at the parasymphysis area, the tongue tends to lose its anchorage on the bone, and the patient loses control and the tongue tends to fall back. It is especially true for the unconscious patient, where the tongue fall blocks the airway, and it could be fatal if not prevented.

Classi cation
The general classi cation of fractures of bone is described in

Classi cation of Mandibular Fracture According to the Impact
According to the impact on bone, fracture can be classi ed as direct fracture and indirect fracture. During an impact, the force on the cortex results in compression, and the other cortex undergoes tension. If the force of the impact is more than the compressive and tensile strength of the bone, the bone fractures.
In a similar fashion, when there is an impact, the point of application of force gets compressed, and the resultant vector travels along the bone and applies tensor force on the point intersected by this vector. The fracture at the site of impact is called direct fracture, and the fracture at the site of intersection with the vector is indirect fracture.
For instance, the force applied to the symphysis menti results in a direct fracture at the symphysis. The vector travels to the condylar necks bilaterally and induce indirect fractures This type of fracture is not exposed to the external environment as the overlying soft tissue cover is intact Compound fracture In such type of fractures, the fracture line is exposed to the external environment. All dentate fractures are compound fracture as they communicate with the oral cavity Comminuted fracture Comminuted fractures have multiple fracture lines and more than two bony fragments Simple comminuted fracture It is a comminuted fracture not exposed to the external environment Compound comminuted fracture This type of fracture is a comminuted one which is exposed to the external environment Complicated fracture This fracture involves vital structures like adjacent nerves, vessels, or joint, directly or indirectly Impacted fracture The fractured fragments inter-digitate to an extent that there is no appreciable clinical movement. Such a fracture is unusual in the mandible and is commonly seen in the maxilla Greenstick fracture It is an incomplete fracture presenting as cortical bending rather than breaking. It is commonly seen in children as their bones are more elastic in nature. This elasticity allows the bone to bend. This type of fracture is commonly seen in long bones and mandibular condyle of children Pathological fracture This fracture occurs readily with minimal trauma or sometimes even during normal physiological function as the bone is signi cantly weak due to existing undermining pathology A. Rai of subcondylar areas bilaterally, as the condylar necks are weak. This is called a "tripod fracture" (as the fracture is at 3 points) or "parade ground fracture" or "guardsman's fracture." The later terms are used because these fractures are commonly seen among soldiers who stand upright on the parade ground for a long time. When they faint, they fall on their chin resulting in symphysis and bilateral condylar neck fractures.

Combination of Fracture
The most common mandible fracture seen in the developed countries is angle fracture combined with contralateral body or symphysis of the mandible [3].

Classi cation of Mandibular Fracture According to Displacement
The fracture fragments are liable to displacement according to unfavorable muscle pull leading to dif culty in the management of these displaced fractures. Table 52.3 highlights various muscles attached to the mandible with their actions. According to the displacement of fracture fragments due to muscle pull, the fracture can be classi ed as: When viewed from superior aspect: 1. Vertically favorable: When the fracture line is passing from buccal cortical plate to the lingual cortical plate with the buccal end lying mesially and the lingual end of the line lying distally. In such situation the distal fragment will be drawn closer to the proximal fragment due to the pull of the medial pterygoid muscle, and the fracture segments will come closer rather than getting separated in buccolingual plane, and thus the fracture is called as vertically favorable (Fig. 52.5a). 2. Vertically unfavorable: In this case, the fracture line passes buccolingually with the buccal end lying mesially. The distal fragment in this case will be easily viewed from superior border. The distal fragment in this case will easily get drifted   lingually due to the pull of the medial pterygoid muscle; thus there will be separation of the fragments in the buccolingual plane due to the unfavorable muscle pull, and the fracture is said to be vertically unfavorable ( Fig. 52.5b).
When viewed from buccal aspect: 1. Horizontally favorable: The fracture line runs superoinferiorly with its superior end lying posteriorly than its inferior end. In this situation, the muscle pulls from the temporalis, masseter muscle will pull the distal segment superiorly, and the suprahyoid muscles will put the proximal segment inferiorly, thus drawing both the segments closer to each other. This type of fracture is called as horizontally favorable fracture ( Fig. 52.6a). 2. Horizontally unfavorable: The fracture line runs superoinferiorly with its superior end lying anteriorly and the inferior end lying posteriorly; thus, the muscle pull becomes unfavorable and drifts the proximal and distal fracture segments apart. This is described as a horizontally unfavorable fracture ( Fig. 52.6b).

Clinical Features
The clinical features of the fractures are described in

Bimanual Palpation
The abnormal mobility at the fracture site can be elicited by the bimanual palpation. The mandible is grasped on either side of the suspected fracture line in such a way that the index nger is on the occlusal surface of the teeth and the thumbs are on the inferior border. The proximal and distal segments are moved in supero-inferior and anteroposterior direction, to elicit abnormal mobility ( Fig. 52.15).

Compression Test
When there is a hairline, undisplaced fracture of the mandible especially at the symphysis or angle or in the subcondylar areas and it is not conspicuous clinically and radiologically, a compression of the mandible at the symphysis area and both the sides over the body, using both the palms by the operator, elicits tenderness which may suggest the fracture ( Fig. 52.16a, b).

Radiographic Examination
As a rule, in orthopedics, the X-ray must be taken in two planes perpendicular to each other, i.e., in the anteroposterior and mediolateral. The most common radiographs to detect fracture of the mandible are:      -Radiographs should not be advised unnecessary, and they should always be performed after clinical examination and after making provisional clinical diagnosis. -Surgeons should not depend on the radiologist's report for their diagnosis; radiographs should help in con rming the clinical diagnosis and for the medicolegal record-keeping purpose as much as possible.

Are Postoperative Radiographs Necessary?
The answer is no. The reasons behind this is: 1. More than 100-250 deaths occur worldwide from cancer due to unnecessary radiation from diagnostic radiology as suggested by Royal College of Radiologists [4] 2. If somehow retreatment is required for the patient, it generally depends most commonly on the clinical ndings rather than radiographic However, the postoperative radiographs are required in few cases of: -Mandibular fracture treated with closed reduction -In medicolegal cases to prevent judicial complications [5] -Patients who enrolled in the research activities Bergh van den et al. [6] also suggested that postoperative radiography is not necessary. The advantages of avoiding postoperative radiographs are: 1. Exposure reduction of patients to ionizing radiation 2. Reduced cost 3. More ef cient discharge

Emergency Management (refer Chap. 48 of this book)
Once the basic Airway, breathing, circulation (ABC) in the emergency management has been secured, the suturing of the extra-/intraoral wounds and initial stabilization and immobilization of the fracture fragments are important. Box 52.2 shows advantages of immobilization of fracture fragments. Initial stabilization and immobilization is done by:

Bridle wiring (refer Chap. 50 of this book)
It is a type of temporary stabilization and reduction of the fracture fragments of the dentate segment with the help of 24-or 26-gauge wires under local anesthesia.
The wire should be wrapped around two healthy teeth adjacent to the fracture line; if the tooth adjacent to the fracture are mobile, the wire should be wrapped around the second tooth adjacent to the fracture ( Fig. 52.22a, b).

Supportive bandage
These bandages are commonly used to temporarily stabilize the fracture of the lower jaw. Small crepe bandages can be used for mandible fracture.     (Table 52.5) (Table 52.6)

Clinical Tip
Wiring techniques required use of multiple wires. These wires cause inadvertent nger puncture to the operator's ngers and increases the risk of spread of blood-borne diseases like HIV and hepatitis. To avoid such complication, Rai [7] recommended the use of dynaplast adhesive tape over all ngertips before wearing sterile gloves while doing Maxillomandibular Fixation (MMF) ( Fig. 52.25). (Table 52.7) According to Dimitroulis [8] MMF is unnecessary in undisplaced angle fracture if there is a skilled assistant present to assist and help manually reduce the fracture fragments for plating. Author also believes that many undisplaced, single fracture of mandible can be xed without MMF when two skilled surgeons operate the case.

Symphysis and Parasymphysis
Fracture (Video 52.1) Various internal xation techniques were mentioned in the literature for both symphysis and parasymphysis fractures [9]. They are enumerated in Table 52.8. Note: Readers has to refer Chap. 51 on plating systems to know the principles of osteosynthesis, tension banding, zone of compression/tension, etc.
Fixation with two miniplates is widely used for the xation of symphysis and parasymphysis fractures (Fig. 52.31). Some authors preferred use of two lag screws ( Fig. 52.32a, b) for the xation of symphysis fractures, but their uses are less in comparison to two miniplates because they are technique sensitive. Three-dimensional plates require less manipulation and adaptation which indirectly reduce the operating time Prevention of postoperative complications 4.
Rehabilitation of Functions    Fig. 52.33), but use of it is questionable when fracture fragments are multiple even in isolated symphysis fractures.
Usually, an intraoral approach is preferred for management of symphysis and parasymphysis fractures. However, if an existing laceration or scar is present, it should be utilized for exposure of fractured segments and subsequent management ( Fig. 52.34).

Parasymphysis Fracture
1. Mental nerve: The anatomic challenge in ORIF. 2. Plating should be done after the blunt dissection and retraction of the neurovascular bundle.
3. One miniplate above and another below the mental nerve used for xation of parasymphysis fracture ( Fig. 52.35).

Mandibular Angle
The prevalence of angle fractures ranges from 16.5 to 37 % in the literature. Presence of third molar (3M) increases the chance of angle fracture by 3.27 times, and class II-B positions of 3M are the most favorable for angle fracture, while class I-A act as protective factors [10].

Impact of Presence or Absence of Impacted Mandibular Third Molar (IM3M) on Angle and Condylar Fracture
-Presence of IM3M generates a weak area in the mandibular angle and predisposes the angle region to fracture after injury; on the other hand, IM3M can decrease the occurrence of condylar fracture which is supposed to be the weakest area of mandible [11]. -Angle fracture is seen most commonly in patients having super cially impacted (vs deeply impacted ) third molars (M3s) [12]. The reason behind this is that the mandibular strength is derived from maintenance of cortical and not the medullary bone integrity; this cortical integrity of the external ridge is disrupted by the presence of super cial impacted M3s which produce the point of weakness in the mandible and make it more prone to fractures [13].

Open vs. Closed Reduction
Closed reduction is advisable for patients who are medically un t for surgery (due to any reasons) or those who did not give consent for open reduction internal xation (ORIF).
Sugar [15] concluded that the combined use of transbuccal and intraoral approach is safe and effective than the intraoral approach alone for ORIF. Author too prefers the same approach.

Advantages of Transbuccal
Approach [16] 1. Through a small stab incision, a blunt dissection is performed with dissecting scissors till the mandibular periosteum is torn and the trocar is placed through the dissected channel.   Reconstruction bone plates 2.
Segmental arch bar with single large and stronger bone plate  [19] in a meta-analysis showed that the incidence of wound infection, dehiscence, hardware failure, and overall complications were less in patients treated with one miniplate on external oblique ridge in comparison to two.
Ellis III [20] also advocated use of single miniplate on superior border because:  -If infection occurs, retrieval of single miniplate can be done under local anesthesia in a clinic, but two plates commonly required general anesthesia which indirectly increases the cost and prolonged the hospital stay.
Rai et al. [21] also conclude better results with two-plate xation. Second miniplate is supposed to increase stability and protects the fracture site against torsion and bending.    Levy et al. [22]advocated two-plate xation superior for ORIF of angle fracture. According to them two miniplates provide better stabilization and have reported lowest complication rate in comparison to any other plating technique.
Wusiman et al. [23] demonstrate that three-dimensional (3D) miniplates provide better xation than standard miniplates. It also provides simultaneous stabilization of tension and compression zones with lower incidence of postoperative complications and good results. According to Zix et al. [24] 1-mm-thick 3D plate is as stable as 2 mm miniplates, and it offers better bending stability and more resistant to out of plane movement or torque.
Ellis III and Ghali [25] used lag screws for treating mandibular angle fractures but reported very high incidence of postoperative infection and bone exposure. Also the xation of angle with lag screws is technique sensitive and requires expertise.
Kang and Zide used seven-hole angle plate when Champy technique is ineffective and more rigid or semirigid xation is required [26]. According to them seven-hole angle plate is xed through transfacial trocar and stabilized intraorally. On the other hand, Champy plate required bending, lacks rigidity, dif culty in screw hole drilling, inaccurate centric placement of screws.

Extraction vs. Retention of IM3M in Angle Fracture
The use of postoperative MMF and extraction versus retention of teeth in the line of fracture did not in uence any of the outcomes [27]. Increase rate of infection by extraction of a tooth was found in the study by Ellis and Walker in 1994 [28]. However, in another study published in 2002, Ellis [29] reported an increased incidence of infection if teeth were left in the line of fracture. Author advocates extraction of 3Ms at the time of ORIF for better results.

Body Fracture
A single four hole with gap miniplate (Fig. 52.41) below the root apex and the inferior alveolar canal is suf cient for xation of body fracture of mandible through the intraoral approach most of the times, except when a patient is having extraoral soft tissue injury/scar or having severely comminuted fracture fragments.

Ramus Fracture
Mandibular ramus (MR) fracture occurs rarely and ranked third least common fracture after alveolar and coronoid fracture [30]. MR fractures are very rare in isolation. It can be horizontal or vertical. Its incidence ranges from 0.9 to 5.5% [31]. Isolated ramus fracture can be managed by closed reduction, but ORIF is the treatment of choice when it is associated with other maxillofacial fractures. To correct the facial height when midface is also fractured, the vertical rami become the only determinant, and re-establishment of these buttresses is very important before repositioning the crushed midfacial bones [32] (Fig. 52.42a-c).

Management of Triangular Fragments (TF) at the Lower Border
Heslop et al. [33] advocated repositioning of TF if they are attached to the muscle or periosteum and remove them if they are very small or detached from the periosteum. According to Blinder et al. [34] to prevent infection and preserve vascularization, TF should be unexposed and unreduced. TF should be sandwiched between the two fracture lines by rigid xation without exposure, and preserving vascularization may be the treatment of choice TF of bone at the angle region were more often shown to get infected in comparison to body, symphysis, or parasymphysis because thick, better vascularized, and more cancellous bone presents in these areas as compared to angle region. It's better to remove small fragments in the angle region to avoid postoperative discomfort.

Coronoid Fracture
It generally occurs in combination with other fracture of the mandible (Fig. 52.43a), and with zygomatic complex fracture (commonly with arch) (Fig. 52.43b), rarely does it occur in isolation. It can be treated by extraoral or intraoral approaches. Later, having low incidence of facial nerve injury and no facial scar. Coronoid fracture ranges from 0.6 to 4.7% of all facial fractures and 1-2.9% of all mandibular fractures [35]. It manifests as [36,37]: Conservative management in the form of soft diet and mouth opening exercises to avoid bony adhesions to the surrounding structures [38]. If patients are treated with MMF and trismus occurs, it can be managed by removal of the coronoid process [39].

Bilateral Fracture of Mandible
Over half of the mandibular fractures are bilateral; in the case of angle fracture, most of the times, it occurs in combination of contralateral mandibular body and symphysis [40]. ORIF is the treatment of choice most of the times. Clinical Tip: An MMF screw can be effectively used for reduction of a bilateral mandibular fracture by placing the screw in the symphysis region. A wire is passed through the screw, and the fracture segment can be manipulated for reduction (Fig. 52.44).

Comminuted Mandible Fractures
Comminution is de ned as presence of multiple fracture lines in many small pieces within the same area of mandibular angle, body, ramus, and symphysis [41]. This type of fracture rarely occurs in the condyle region. In a comminuted fracture, bone is "crushed, broken, splintered" into number of pieces, creating multiple small fragments (at least two free segments of bone) (Fig. 52.45a, b).
To x small fragments, multiple options are mentioned in the literature like miniplate, microplate, screws, steel wires, and absorbable sutures. A fragment larger than 1 cm should be conserved, reduced, and xed [42].
Ellis et al. [43] advocated that more complications are associated with multiple fragment fractures in comparison to fractures having few segments. Therefore, comminuted fractures need load-bearing xation.
The bone fragments will not provide buttressing to help stabilize the fracture; therefore surgeons operating comminuted mandibular fractures having two or more free bone fragments and/or requiring bone fragment removal should opt for reconstruction plates. Miniplates can be used when comminuted mandibular fractures have only one free bone fragment. Combination of reconstruction and miniplates can be used when multiple small fragments are there in comminuted mandible fracture (Fig. 52.46). Implants used for xation of comminuted fractures are mentioned in Box 52.4.
Use of reconstruction plates required expertise and it is time-consuming. Sometimes contour is also not favorable ©Association of Oral and Maxillofacial Surgeons of India Dia et al. [44] used titanium mesh for the treatment of comminuted mandible fracture with successful results. According to them mesh required little soft tissue exposure, had low infection rate, and provides favorable mandibular morphology.

Inferior Alveolar Nerve (IAN) Injury in Mandible Fracture
According to the literature, the incidence of IAN injury was [45]: 1. 5.4-81.4% before treatment 2. 0.4-91.3% after intervention 3. 0-46.6% after 1 year The neurosensory testing was done both before and after the treatment of mandibular fracture in which nerve injury is suspected. Two-point discrimination and pinprick testing can be used to assess the level of IAN injury. Preoperative knowledge of the patient's IAN position (based on CT/CBCT) is very important in decision-making regarding xation position of the fracture fragments with miniplates. Plating should be done above or below the course of IAN. ORIF in the area of IAN takes longer duration to normalization of sensation, and it ranges from 1 week to 12 months. Postoperative CT/CBCT is mandatory if operating surgeon suspected the impingement of screw on the IAN or no relief of sensation after 6 weeks of ORIF for further management. Surgeons should not hesitate to redo the surgery in cases of IAN injury by miniplates and screws.

Geriatric Mandibular Fracture
With old age, the incidence rate of maxillofacial fracture increases, with mandibular fracture appearing with a greater frequency. As the age advances, the weakening of the mandible occurs due to: -Loss of teeth -Reduced vascularity or decreased blood ow in elderly -Loss of bone mass The most common mechanisms of injury in geriatric patients are [46]:

Fall 2. Assaults 3. Motor vehicle accidents
Fractures of the edentulous mandible pose unique challenges. Old age itself is a risk factor for poor outcomes following trauma. There are associated comorbidities like hypertension, diabetes mellitus, dementia, or stroke which limit the functional capacity of the patient to bear the stress of surgery and postoperative recovery. Also, the atrophic mandible has compromised blood supply with little osteo-   A. Rai genic potential resulting in delayed bone healing. Bilateral mandibular fracture (bucket handle fracture) occurs most commonly in elderly (Fig. 52.48).

Management
Controversy exists in the treatment of edentulous mandibular fracture. One school of thought advocated closed reduction, and another school is in favor of open reduction and internal xation. According to Bradley [47] the major blood supply to the mandible is "sub periosteal Plexus," and re ection of periosteum in ORIF may seriously impair vascular supply to the bone resulting in non-union.
Controversy again exists in the use of bone grafts in edentulous mandible. Are bone grafts necessary? Answer is not always. Reconstruction plates (load-bearing plates) can be used for comminuted fractures and with large defects. Bone morphogenic proteins and tricalcium phosphate can be used as alternative to autogenous grafts in patients whom multiple comorbidities may in uence local or systemic outcomes [48].
Few authors advocated extramucosal intraoral plating for the ORIF of the edentulous mandibular fracture. It preserves the blood supply to the mucosa and bone, at the same time provides adequate stability [49,50].
The techniques of edentulous atrophic mandible fracture management are:

Closed reduction (CR)
This technique is opted when the patient's systemic condition does not allow for an open surgery. CR can be accomplished if the mandibular height is at least 30 mm. It is dif cult to achieve CR if the mandibular height is <10 mm. CR can be accomplished using a preexisting denture. If there is no denture, gunning splint can be prepared. The denture/splint is used for immobilization and xed to the mandible with circum-mandibular wiring ( Fig. 52.49a, b).
Advantages: Periosteal supply to the bone is maintained. Disadvantages

Pediatric Mandibular Fractures
Among all the maxillofacial fractures, the incidence of pediatric facial fracture is 1-15%. After nasal bone fracture, the second most common fractures in children are mandibular fracture with an incidence of 5-50% [51]. In mandible, the condyle is the commonest site of fracture in pediatric patients followed by symphysis and parasymphysis. The most common mechanisms of injury in children are [52]: 1. Fall from height 2. Bicycle falls 3. Automobile and sports accidents 4. Violence In children, the developing tooth buds of canine approximate the lower border of mandible. This creates a stress point making the mandible susceptible to fracture in this location. Once the canine erupts, this weak point is reinforced with the bone and is not weaker than any other regions of the mandible. This is the reason probably why parasymphysis fracture is more common in children than adolescents.
With increasing age, the skull-to-face ratio decreases. The larger cranium shields the smaller middle and lower thirds of the face from injuries. This prevents mandibular fracture in small children; however, with increasing age the mandible becomes more prominent resulting in more injuries to this region.

Management
However the absence of teeth due to exfoliation and poor retention of wires on the deciduous teeth crowns makes the ligature wire and traditional use of arch bars dif cult or sometimes impossible [54]. In such cases splinting with acrylic splint retained with circum-mandibular wires remains a viable option in treatment of pediatric mandibular fractures.
Cap splints are secured to mandible by circum-mandibular wiring. Kelsey Fry bone awl is used for this purpose. A widebore needle can also be used for the same (Fig. 52.51a, b). Intravenous cannula stillete (IVCS) is also mentioned in the literature for performing circum-mandibular wiring. The 16-gauge IVCS was used instead of conventional awl [55].
However, management of pediatric mandibular fracture with ORIF is controversial as the xation of plates may hamper the growth and development of jaw. Titanium miniplates have been successfully used for ORIF, but the implants are to be removed within 3-to 12-month period [56].
Yerit et al. [57] proposed use of biodegradable plates for ORIF. These plates should be mechanically strong and must undergo resorption within a predictable time frame.
The management of pediatric mandibular fractures is different in comparison to adults due to [53]

Use of Bone Grafts in Mandible Fracture Treatment
Anterior iliac crest (cancellous or cortico-cancellous) and bula (free microvascular reconstruction) are the most commonly used sites from where the bone grafts are used for mandibular reconstruction. All the cases required bone grafting in cases of mandibular fracture treated with ORIF should be kept in MMF of 4 weeks postoperatively.  Rachmiel et al. [59] advocated two-stage reconstruction of mandibular bone defect after trauma by bone grafting followed by alveolar distraction osteogenesis (ADO). This modality helps in correction of intermaxillary vertical relationship and provides suf cient amount of bone for the placement of dental implants and prosthesis.

Postoperative Care
• Pressure dressing over the site to avoid postoperative hematoma in required cases. • Elastic traction for correction of minor discrepancies in occlusion (Fig. 52

Delayed
• Infection: Found to be the most common complication ( Fig. 52.52) •

Case Scenario 1
A male patient reported with a gunshot injury over right side of face. Patient's Glassgow coma scale (GCS) was 15/15 with stable vital signs, but the patient has dif culty in breathing. On maxillofacial examination, a gunshot wound was present over right side of face at the right mandibular angle region. Deviation of mandible was present on right side with cross bite on right side and open bite on left side. Tenderness was present over right mandibular angle region. On palpation, intersegmental mobility was present over right angle region. Provisional diagnosis: Right mandibular angle fracture following gunshot Investigation: Apart from blood investigation, a CT scan was performed, and a nal diagnosis of comminuted right mandibular ramus and angle fracture with bullet in situ was made ( Fig. 52.57a).
Management: Patient was subjected to emergency surgery under general anesthesia with a treatment plan of bullet retrieval, debridement, and open reduction and internal xation of fracture. After the anesthesia was induced, patient preparation was done; the fracture site was exposed through an extraoral approach. Thorough debridement was done, and bullet was retrieved in multiple pieces (Fig. 52.57b). The bone segments which were detached were removed, and the fracture segments were xed using a reconstruction plate following achieving occlusion (Fig. 52.57c). The use of bone graft was eliminated considering the risk of postoperative infection due to scattering of bullet particles. Moreover, the fracture site was a nondentate site; hence bone grafting was not mandatorily indicated for postoperative dental rehabilitation. Figure 52.57d shows postoperative OPG and xation of fracture with reconstruction plate (refer Chap. 59 on Gun shot injuries).

Case Scenario 2
A female patient reported with the chief complaint of difculty in chewing following operation to treat mandibular fracture. Patient gave a history of fall from height following which she was operated for ORIF elsewhere. The general condition of patient was good. On maxillofacial examination, mandible was deviated on right side with cross bite on right side and open bite with lingualized occlusion on left side ( Fig. 52.58a). Patient provided us with a pretreatment OPG which revealed right subcondylar with left side mandibular comminuted body and angle fracture (Fig. 52.58b). We subjected the patient to another OPG which revealed improper xation of left mandibular body fracture and no xation of left angle and right subcondylar fracture (Fig. 52.58c).
Diagnosis: Malunited left mandibular body, left angle fracture, and right subcondylar fracture Management: Patient was subjected to general anesthesia. Once the anesthesia was induced, patient preparation was done, and fracture site was exposed through extraoral incision for all the fractures. Existing implants were removed which resulted in removal of few small bone fragments. The fractured and carious teeth were extracted and reduction was done by MMF. Occlusion was achieved (Fig. 52.58d), and xation was performed using two miniplates at subcondylar site and load-bearing reconstruction plate at the body-angle unit. A postoperative OPG was done (Fig. 52.58e). Patient was discharged in stable condition. After 6 months, dental rehabilitation was performed for missing teeth by delivering dental bridge (Fig. 52.58f).