Indications for open reduction

• Displaced unfavorable fractures through the angle of the mandible: Often, the proximal segment is displaced superiorly and medially and requires an open technique for proper reduction.
• Condylar fractures: Although strong evidence supporting open reduction of condylar fractures is lacking, a specific group of individuals benefit from surgical intervention. The classic article by Zide and Kent lists absolute and relative indications for open reduction of the fractured mandibular condyle. Careful evaluation of each case on an individual basis is crucial.
• Absolute indications
1. Displacement of the condyle into the middle cranial fossa
2. Inability to obtain adequate occlusion by closed techniques
3. Lateral extracapsular dislocation of the condyle
• Relative indications
1. Bilateral condylar fractures in an edentulous patient when splints are unavailable or impossible because of severe ridge atrophy.
2. Unilateral or bilateral condylar fractures when splinting is not recommended because of concomitant medical conditions or when physiotherapy is not possible
3. Bilateral fractures associated with comminuted midfacial fractures
• Medically compromised patients: These patients may require open reduction. This group of patients includes those with decreased pulmonary function, GI disorders, severe seizure disorders, and patients with psychiatric or neurologic problems.
• Complex facial fractures: Such fractures can be reconstructed best after open reduction and fixation of the mandibular segments to provide a stable base for restoration.
• Other fractures: Consider open reduction with primary bone grafting in fractures of a severely atrophic edentulous mandible with severe displacement of the fracture segments or a nonunion after closed reduction of a severely atrophic edentulous mandible fracture.
• Mandibular nonunions require open access for debridement and subsequent reduction.
• Malunions after improper reduction often require osteotomies through open surgical approaches to correct mandibular discrepancies.

Contraindications:

Contraindications to closed reduction:

• Patients with poorly controlled seizure history
• Patients with compromised pulmonary function (ie, moderate-to-severe asthma, chronic obstructive pulmonary disease)
• Patients with psychiatric or neurologic problems
• Patients with eating or GI disorders

These patients benefit from ORIF.

Imaging Studies:

• The following types of radiographs are helpful in diagnosis of mandibular fractures:

• Panoramic radiograph.

• Lateral oblique radiographs

• Posteroanterior (PA) mandibular view

• Reverse Towne view

• Mandibular occlusal view

• Periapical radiographs

• Temporomandibular joint views including tomography

• CT scan.

• Initial screening of patients is most effective with a panoramic radiograph, since it shows the entire mandible including the condyles.

• Standard mandibular series should consist of at least a panoramic radiograph, a PA view, and a reverse Towne view.

• Since an accurate panoramic radiograph requires that the patient is able to stand upright and without any motion, achieving good quality films with severely traumatized patients may be difficult. Traditional lateral oblique views of the mandible can be used when obtaining a panoramic radiograph is not possible.

• The reverse Towne view is the plain film of choice for excluding condylar and subcondylar fractures. Transcranial temporomandibular radiographs also may be helpful in detecting condylar fractures and anterior displacement of the condylar head. If visualization of the condylar head is difficult with plain films, obtain a CT scan. Although high cost and radiation exposure limit its use, CT scan is ideal for intracapsular and high neck condylar fractures.

• Occlusal views are helpful for accurate assessment of symphyseal fractures.

• Obtain periapical radiographs of the teeth on either side of a fracture to assess root fractures.

Diagnostic Procedures:

• For cases where the preinjury occlusion is difficult to determine, particularly in partially dentate and edentulous patients, the use of study models is very helpful. Model surgery on the study models can be performed and acrylic splints fabricated to the new arch form. These splints may include a lingual, palatal, or labial splint that will be secured in place during surgery. The splints may be secured with the use of circummandibular wires for the mandible or with circumzygomatic or piriform wires for the maxilla. A maxillary splint also may be secured with palatal screws.

• For fully edentulous patients, dentures can be secured to the maxilla and mandible and used for splints. If dentures are not available, impressions are taken of the jaws, and acrylic baseplates are processed and used as dentures. These are known as Gunning splints. An arch bar also can be processed into the dentures, or holes can be placed into the flange of the denture for intermaxillary wires. Prosthetic incisor teeth can be removed for existing dentures, and space can be made in the acrylic to allow food intake.

Surgical therapy: