Fractures of the Mandible PDF

‫ حسنين احمد‬.‫د‬/‫جامعة بغداد‬/ ‫كلية طب االسنان‬/ ‫المرحلة الخامسة‬ Fractures of the Mandible A fracture is defined as a break in the continuity of the bone which happens either as a result of violence or because the bone is unhealthy and unable to withstand normal st...

‫ حسنين احمد‬.‫د‬/‫جامعة بغداد‬/ ‫كلية طب االسنان‬/ ‫المرحلة الخامسة‬ Fractures of the Mandible A fracture is defined as a break in the continuity of the bone which happens either as a result of violence or because the bone is unhealthy and unable to withstand normal stresses. The mandible is the second most commonly fractured part of the maxillofacial skeleton because of its position and prominence and blows to the mandible are transmitted directly to the base of the skull through the temporomandibular articulation, this means that relatively minor mandibular fractures may be associated with a surprising degree of closed head injury. The impact forces that are required to produce mandibular fracture are higher than those of the maxilla. When the force is applied to the bone, the buccal cortex at the site of application of the force undergoes compression and the other cortex (lingual cortex) of the bone undergoes tension. If the force is greater than the compressive and the tensile strength of the bone a fracture occurs. The teeth are important in determining where fractures occur. The long canine tooth and the partially erupted or un-erupted wisdom tooth both represent lines of relative weakness. Restoration of mandibular function, in particular, as part of the stomatognathic system must include the ability to masticate properly, to speak normally, and to allow for articular movements as ample as before the trauma. In order to achieve these goals, restoration of the normal occlusion of the patient becomes paramount for the treating surgeon. The alveolar resorption that follows tooth loss also weakens the mandible and fractures of the edentulous body often result from much smaller impact forces. Classification of mandibular fractures According to the type of fracture, mandibular fractures can be classified into: Simple/closed: A type of single fracture that does not have communication with the external environment. Compound/opened: A type of fracture that extends into external environment through skin, mucosa, or periodontal membrane. Comminuted: When the bone is fragmented into multiple pieces. This usually requires considerably more energy than does a simple fracture. Greenstick: When only one cortex of the bone is broken with the other cortex being bent, it is found exclusively in children. Pathologic: Caused by pre-existing pathological condition of bone (such as osteomyelitis, neoplasms or generalized skeletal disease) that leads to fracture from minimal trauma. Complicated/complex: Fractures associated with the damage to the important vital structures complicating the treatment, as well as prognosis, including the severely atrophied mandible. Single: Only one fracture line in the same bone. Multiple: Two or more lines of fractures on the same bone that do not communicate. Fractures of the mandible can also be classified according to the anatomic site into: Dentoalveolar Condylar Coronoid Ramus Angle Body (molar/premolar area) Symphysis/Para-symphysis Mandibular fractures classified according to their tendency to displace as a result of the pull of the attached muscles into: 2 The principle of favorableness is based on the direction of a fracture line as viewed on radiographs in the horizontal or vertical plane. A horizontally favorable fracture line resists the upward displacing forces, such as the pull of the masseter and temporalis muscles on the proximal fragment when viewed in the horizontal plane. A vertically favorable fracture line resists the medial pull of the medial pterygoid on the proximal fragment when viewed in the vertical plane. Although this principle can be applied to any fracture of the mandible where there are muscles attached, it is most commonly used with angle fractures. Direct and indirect fractures When the force is applied to the mandible, the point of application of the force is compressed causing direct fracture and the resultant vector travels along the bone and applies tensile force on the point intersected By this vector causing indirect fracture. Whenever a direct fracture is seen at the site of primary impact, one must examine the corresponding indirect fracture site and rule out the indirect fracture. Common combinations of direct and indirect fractures are: Symphyseal (direct) fracture combined with bilateral subcondylar (indirect) fractures also called parade ground fracture or guardsman's fracture. Parasymphyseal (direct) fracture combined with contralateral subcondylar or angle (indirect) fracture. Body (direct) fracture combined with contralateral angle or subcondylar (indirect) fracture. Clinical features The main clinical features of mandibular fractures include: 1. Pain especially on talking and swallowing leading to drooling of saliva. 2. Swelling due to edema and hematoma causing facial asymmetry. 3. The teeth near the fracture site may become loosened, displaced or avulsed with laceration of the gingiva. 4. Bleeding from the fracture site. 5. Trismus and difficulty in moving the jaw. 6. Bone tenderness over fracture site. 7. Mobility of fractured segment. 3  8. Step deformity palpable at the site due to the displacement of the fracture segments. 9. Numbness of the lower lip due to injury to the inferior alveolar nerve in the bony canal during the fracture. 10. Altered occlusion due to displacement of the fracture segments. 11. Sublingual hematoma which is regarded as a pathognomonic sign of fracture. 12. In some cases of bilateral subcondylar fractures with condylar displacement and shortening of the ramus leads to premature contact of the posterior teeth and anterior open bite. 13. Bilateral parasymphyseal fracture may be readily displaced posteriorly under the influence of the genioglossus muscle and to a lesser extent, the geniohyoid allowing the tongue to fall back and obstruct the oropharynx which constitutes a threat to the airway especially in patients with depressed level of consciousness. 14. In some cases of condylar fractures bleeding from the ear may result from laceration of the anterior wall of the external auditory meatus, caused by violent movement of the condylar head against the skin in this region. It is important to distinguish bleeding originating in the external auditory canal from the more serious middle ear hemorrhage while signifies a fracture of the petrous temporal bone and may be accompanied by cerebrospinal otorrhea. In all cases of suspected condylar fracture the ear should be examined carefully with an otoscope. Imaging The clinical diagnosis of the fracture is essential but radiographs confirm the diagnosis of the fracture and are mandatory. The principle in trauma radiology is to obtain at least two views, each taken at right angles to the other, in order to assess the degree of displacement and angulation of the fragments A panoramic radiograph (OPG) represents the best single overall view of the mandible including the condyles. The combination of a posteroanterior (PA) view of the mandible and OPG usually provide a complete view of the mandible and obviate the need for further radiographs in most patients and significantly reduces the overall radiation dose to the patient. 4 If OPG is not available, PA mandible with left and right oblique lateral views can be taken. In PA mandible view the condylar head may be obscured by superimposition of the skull base and mastoid process, for this reason, the 30° anteroposterior Townes projection is sometimes used. This view demonstrates the condylar region very well, along with the posterior fossa of the skull. A reverse Townes projection may be used to achieve the same effect. In both projections, the central ray is angled at 30° to the horizontal base line, which shows the image of the condylar head and subcondylar region clear of the dense bony structures of the base of the skull. Occlusal Views are valuable for demonstrating midline fractures of the mandible with minimal displacement. CT scan is not normally undertaken for isolated mandibular fractures unless there are complicating factors such as significant comminution, it is also useful in the assessment of displaced and comminuted fractures of the condylar region where it will demonstrate considerable detail that would otherwise not be clear on standard radiographs, such as an un-displaced vertical fracture of the condylar head: Treatment The aim of treatment is primarily to restore function, namely to restore both the occlusion and pain-free normal movements of both TMJs. For these goals to be reached, precise anatomical reduction is not essential in every case, although it is clearly desirable. Factors affecting treatment of mandibular fractures 1.The fracture pattern 2. The skill of the operator. 3. The resources available. 4. The general medical condition of the patient. 5. The presence of other injuries. 6. The degree of local contamination and infection. 7. Associated soft-tissue injury or loss. 5 The principles of treatment of fractures are: Debridement Reduction; it is the restoration of functional alignment of the fractured bone fragments. Fixation. Immobilization. Rehabilitation. Treatment of mandibular fractures can be closed or open Closed treatment It consists of closed reduction with indirect fixation and immobilization with intermaxillary fixation (IMF) [also called mandibulomaxillary fixation (MMF)]. It is the traditional conservative treatment of mandibular fractures. Closed reduction is achieved without surgical exposure of the fracture site by manipulation or elastic traction and indirect fixation utilizes the standing teeth to place the teeth in normal occlusion and immobilize them in that position thus indirectly reduce the bone fragments. This method can be used as a definitive treatment of mandibular fractures or as temporary fragment stabilization in emergency cases before definitive open treatment. Methods of immobilization After proper reduction and achievement of good occlusal relationship, the upper and the lower jaws are immobilized by fixing them together in occlusal relationship by IMF, this can be achieved by: Bonded orthodontic brackets: By bonding a ·number of modified orthodontic brackets onto the teeth and applying light wires or intermaxillary elastic bands. Interdental wiring: This method is only applicable when the patient has a complete, or almost complete, number of suitably shaped teeth, 0.5 mm soft stainless wire is 6 usually. used. Many different techniques for wire fixation exist; direct interdentaI wiring, eyelet or Ivy loops, and Ernst ligatures, in addition to other techniques. After applying the fixation wires, tie wires are applied to immobilize the mandible. Arch bars: They are tooth-borne devices used in IMF of dentate patients. They are the most versatile form of IMF. They are also used in temporary stabilization of mandibular fractures and for fixation of avulsed teeth and dentoalveolar fractures. Arch bars are indicated where the patient has an insufficient number of suitably shaped teeth or when a direct linkage across the fracture is required. Different types of arch bars are in use. They come as custom made or commercially manufactured available in aluminum, stainless steel, and nowadays titanium, as well as various alloys. Many patterns or designs of arch bars are present; Erich, Schuchardt, Jelenko, Krupps and Dautreys patterns. Recently hybrid arch bar systems that use bone support have been developed. IMF screws These screws are self-drilling and self-tapping. The screw head is elongated and contains holes for wire placement. They are inserted through small incisions in the labial vestibule avoiding injury to the apices of the nearby teeth, it is regarded as a rapid method to achieve IMF. Cap splints They are fabricated by making an impression of the fractured jaw and preparation of the cast on which a cap splint made of acrylic or metal can be fabricated and used for fixation of the fracture. The acrylic splint is secured to the mandible by circummandibular wiring, using a bone awl. Dentures or Gunning type splints in edentulous jaw fractures, complete denture can be used as a splint and if the patient is not denture wearer Gunning-type splints can be fabricated, they take the form of modified dentures with bite blocks in place of the molar teeth and a space in the incisor area to facilitate feeding. They are fixed to the jaws by circummandibular and maxillary peralveolar wires or screws, and IMF is achieved by connecting the two splints with wire loops or elastic bands. External pin fixation · This method is seldom used nowadays, it is indicated in special conditions, such as infected fractures, fractures caused by gunshot injuries or pathological fractures. 7 Ideally, at least two self-tapping screw pins are placed either side of the fracture or defect. The fracture is then reduced and the pins linked by an external bar framework. Period of immobilization With early uncomplicated treatment in a healthy young adult union can on average be achieved after 3 weeks, at which time the fixation can be released. As an empirical guide a further 1-2 weeks should be added for each and any of the following circumstances: 1. Where a tooth is retained in the fracture line. 2. Patients aged 40 years and over. 3. Patients who are smokers. 4. Mobile or comminuted fractures. 5. Fractures in alcoholics, particularly those with nutritional problems Rules such as these are designed for guidance only, and it must be emphasized that the IMF should be released and the fracture tested clinically before the fixation is finally removed. The relative indications of closed treatment are: Non-displaced favorable fractures. Limited resources and facilities for open treatment. Medically compromised patients where conservative line of treatment is required. Grossly infected fractures. Pediatric fractures with mixed dentition phase. Edentulous fractures Advantages of closed treatment Non-invasive, simple, easy to master. Can be performed under local anesthesia. Less expensive. 8 Disadvantages of closed treatment The closed treatment relies on positioning the occluding teeth in a correct way, based on the assumption that this will result in precise reduction of the attached bony fragments, but in fact closed treatment provides only a limited control over the final repositioning of the fractured bone fragment and it does not ensure anatomical reduction of the fracture. In certain cases, closed treatment may be difficult especially in cases of malocclusion, missing, diseased, or damaged teeth. The immobilization may not be adequate which delays the healing. The treatment induces morbidity to the patient due to the IMF affecting eating and speech. Closed treatment is contraindicated in some conditions, e.g., epilepsy, chronic respiratory diseases, incompliant patient, or chronic alcohol or drug abuse. Open treatment It consists of open reduction and internal fixation (ORIF) or direct skeletal fixation. In open reduction, the fracture site is surgically exposed and the fracture is reduced under direct vision and the fractured fragments are immobilized by different internal direct fixation methods. ORIF is now considered the main method of treatment of mandibular fractures. The main indications for open treatment: 1. Displaced unfavorable fractures. 2. Multiple fractures of the facial bones 3. Fractures of an edentulous mandible with severe displacement. 4. Delay of treatment and interposition of soft tissue between non-contacting displaced fracture fragments. 5. Special systemic conditions contraindicating IMF. Depending on the planned method of internal fixation and the site of the fracture, three different surgical approaches to the mandibular body, with slight modifications, are possible: intraoral, extraoral, or combined access. 9 Methods of internal fixation (osteosynthesis) Interosseous or Trans-osseous wiring It is the direct skeletal fixation of two or more bone fragments with the aid of wire ligatures pulled through previously drilled holes, it is considered a non-rigid fixation method. It can be applied on the upper or lower border following reduction, but additional fixation of the fractured mandible with IMF is required to maintain stability. Wiring can be in the form of simple ligature, combination of simple ligature and figure-of-eight wiring or in the form of double ligature. The advent of plating techniques has superseded interosseous wiring in most situations especially in developed countries. Miniplates (miniaturized plates) These are the most common form of internal fixation used in the management of mandibular fractures. They provide semi-rigid or load sharing fixation and were developed in 1970s and were originally fabricated in stainless steel but titanium is now the metal of choice. The miniplate principle involves placing the miniplates along the tension and torsion lines across the fracture, the plate can be anchored using only the outer cortical bone with so-called "monocortical" screws which are 2 mm in diameter. As a result, plates and monocortical screws can be placed safely in anatomically correct position where they are biomechanically desirable. Three-dimensional titanium miniplates They are based on the principle of the quadrangle as a geometrically stable configuration for support. The plates are adapted to the bone and are secured with monocortical self-cutting screws. Non-compression rigid plates These plates provide rigid or load bearing fixation, they are mainly used in the management of infected, severely comminuted fractures, in fractures where there are continuity defects, and in fractures in which delayed union or non-union has occurred. 10 Adaptation of the plates is technically more demanding and they often require an extra-oral approach for accurate placement. They require bicortical screws and are fixed in place at or near the lower border of the mandible in order to avoid damage to the inferior alveolar nerve and the dental roots. Some modern designs of plates employ locking screws that lock into the plate at the completion of insertion in order to avoid any micro-movement between the plate and the screw. Compression plates These plates provide rigid fixation, the principle of compression plating is by transforming the downward force of screw insertion into a longitudinally directed compressive force. This action displaces the screw and the fractured fragment in the direction of the opposite fragment, resulting in compression between the bone ends. Studies have shown that this type of plates does not offer any advantage to the patient in the treatment. Lag screws In oblique fractures compression lag screws can be applied without plates, they are placed perpendicularly across the fracture line in order to avoid displacing the fragments. To produce compression, the proximal bone hole is oversized so that only the distal fragment is engaged by the screw. Tightening applies sufficient compression and consequently fixation of the fracture site. It is an effective method, which can be employed transorally in a number of cases. This technique appears to be ideal for parasymphyseal and symphyseal fractures, but it becomes technically more difficult in body or angle fractures because the risk of damage to the alveolar inferior nerve increases Bioabsorbable plates and screws These are made from materials that undergo degradation, so they do not have to be removed after fracture healing. They are mainly indicated in pediatric fractures. Teeth in the line of fracture Teeth in the fracture line may cause infection of the 11 fracture site either from the oral cavity via the disrupted periodontium or directly from an infected pulp or chronic apical infection. Infection of the fracture site will result in protracted healing or even non-union. Absolute indications for removal of a tooth from the fracture line: 1. Longitudinal fracture involving the root. 2. Dislocation or subluxation of the tooth from its socket. 3. Presence of periapical infection. 4. Advanced periodontal disease. 5. Already infected fracture line. 6. Acute pericoronitis. 7. Where a displaced tooth prevents reduction of the fracture. Relative indications for removal of a tooth from the fracture line: 1. Functionless tooth that would probably eventually be removed. 2. Advanced caries. 3. Doubtful teeth that could be added to existing dentures. Otherwise teeth that are structurally undamaged and potentially functional should be retained and antibiotics administered. Teeth in line of fracture should be followed up for 1 year and should be endodontically treated if there is demonstrable loss of vitality. If fracture becomes infected, immediate extraction should be performed. Complications of mandibular fractures Intraoperative and early postoperative complications: Misplaced fixation Damage caused by misplaced fixation devices like transosseous wires or plates, the risk of damage to structures within the body of the mandible like the inferior alveolar canal and root apices is less when using monocortical screws. Circumandibular wires should be carefully located in order to prevent a wire close to a fracture line from being inadvertently drawn up in to the fracture giving rise to displacement of the bone fragments and damage to the inferior alveolar bundle. Infection of the fracture site 12 The main contributing factors are: Compound fractures with gross contamination. Inadequate stabilization of the fracture. Loose fixation devices. Immunocompromised patients, e.g., diabetics and alcoholism. Most infections are usually mild, with intraoral swelling and discomfort. However these can progress to cellulitis, abscess formation, fistula, osteomyelitis, and, rarely, necrotizing fasciitis. The infection should be prevented by good antibiotic prophylaxis, maintenance of wound hygiene, adequate immobilization, effective management of the teeth involved in the fracture line and ensuring that the fixation devices are not loose. The infection will invariably interfere with the healing of the fracture. The principles of management are: control the infection (incision and drainage, and antibiotics) Remove any focus of infection (teeth, sequestra, or plates and screws) Optimize the healing environment (patient's health, oral health) Immobilize the fracture. Nerve damage Anesthesia or paresthesia of the lower lip as a result of injury to the inferior dental nerve is the most common complication of fracture of the body of the mandible. The degree of deficit often depends on the amount of fracture displacement at the moment of impact and the type of nerve injury. Damage to the inferior alveolar nerve can also be iatrogenic in origin that results from treatment which is most commonly associated with open treatment. Facial nerve damage may complicate some fractures of the ramus and condyle, either.as a result of a penetrating injury severing branches of the nerve, or blunt trauma causing a neuropraxia. Late complications 13 Malunion The healing of the fracture is an abnormal or non-anatomical position. It can occur as a result of inadequate reduction, inadequate immobilization or if no treatment is done. It may result in occlusal discrepancies, compromising the patient's ability to bite and chew. It can also result in poor esthetics. However, some cases do not result in any clinical difficulties and these minor discrepancies are usually accepted by both patients and clinicians. If malalignment is noticed early in the postoperative phase it may be corrected by returning the patient to the operating room for repeated reduction. Minor malunions do not usually cause major clinical problems, because the dentition often readjusts to a new bite. Alternatively, judicious selective grinding can balance the new occlusion satisfactorily. However, significant malunions of the mandible can produce gross occlusal derangement and facial deformity which can be resolved by operative reconstruction usually in the form of re-fracture or planned osteotomy or ostectomy with rigid fixation, bone graft may be required in some cases. Delayed union It occurs when the union of the fractured segments is delayed beyond the expected time for that particular fracture, taking the site and the patient's age into consideration. It results from disturbance of the healing process by local factors such as infection, or general factors such as osteoporosis or nutritional deficiency. The delay in union is managed by prolonging the period of immobilization. Non-union It is failure of the fracture to unite on its own. Non-union can be caused by local or general factors: 1. Infection of the fracture site. 2. Inadequate immobilization and excessive mobility of fractured fragments 14  3. Unsatisfactory apposition of bone ends with interposition of soft tissue. 4. The ultra-thin edentulous mandible in an elderly debilitated patient. 5. Loss of bone and soft tissue as a result of severe trauma, e.g. missile injury. 6. Inadequate blood supply to fracture site, e.g. after radiotherapy. 7. The presence of bone pathology, e.g. a malignant neoplasm. 8. General disease, e.g. osteoporosis, severe nutritional deficiency, disorders of calcium metabolism. In nonunion, the fragments are united by fibrous tissue rather than the bone and pseudo arthrosis (false joint) results. The bone ends become rounded off arid sclerosed (eburnation). Treatment is surgical exploration of the fracture site and any obvious impediment to healing such as a sequestrum or devitalized tooth removed. The bone ends are then freshened and the jaw is immobilized using rigid fixation. If there is any doubt concerning the health or apposition of the bone ends autogenous cancellous bone chips should be obtained from the iliac crest and packed around the fracture site. Complications associated with condylar fracture 1. Malocclusion. 2. Limitation of range of movement. 3. Displacement of the disc (reducible or irreducible). 4. Chronic pain associated with dysfunctional movement or with osteoarthritis. 5. Fibrous or bony ankylosis. 6. Disturbance of further growth in children. Complications associated with internal fixation These may include exposure of the plates especially when placed near the oral mucosa. Plates may also become infected after healing of the fracture, in such case removal of the plate resolves the problem. 15 The upper border may cause symptoms, particularly if covered by a denture,' also lower border wires sometimes give rise to pain and Discomfort if the overlying skin is thin. In these circumstances they should be removed. Sequestration of bone Comminuted fractures of the mandible, particularly those caused by missile injuries, may be complicated by the formation of bone sequestra. A sequestrum may be a cause of delayed union or act as a potential source of infection. In some cases a sequestrum may extrude spontaneously into the mouth with quite minimal symptoms, but otherwise a localized abscess forms and surgical removal of the dead bone becomes necessary. Mandibular fractures that require special considerations Pediatric fractures Fractures of the mandible are uncommon in children and some modifications to the principles of treatment are necessary when the fracture occurs in a child. The main Characteristics of mandibular fractures in children are: Bone in young children is resilient and greenstick fracture is more likely to occur and there is a greater risk of damage to developing teeth. Mandibular fractures in young children heal very rapidly and some fractures are stable within a week, and firmly united within 3 weeks. Treatment of mandibular fractures in children is generally of a conservative nature because of the rapidity of healing and the adaptive potential of the bone and dentition. Mandibular fractures may disturb the growth of the mandible if un-erupted permanent teeth or teeth germs are lost. Damage to the growth potential will be more severe in the event of infection of the fracture site. Fractures of the condyle require special consideration. When fixation is needed in very young with un-erupted or very few deciduous teeth a Gunning-type splint for the lower jaw alone may be used. This is constructed as a simple acrylic and retained by two light circumandibular wires. 16  When sufficient firm erupted deciduous and permanent teeth are present; eyelet wires or arch bars can be used. When there is significant displacement of fragments, open reduction may be necessary. In this situation any plate or wire fixation must be strictly confined to the lower border to avoid damage to developing tee.th: Slight imperfection in reduction can be accepted when a fracture is treated, because continuing growth and eruption of teeth will compensate in most cases for the imperfect alignment the fragments. Prolonged follow-up is required following most fractures of the mandible in children in order to be sure that there are no long-term effects on both mandibular growth and the normal development of the permanent dentition. Fractures of the condyle Fractures involving the mandibular condyle are the only facial bone fractures that involve a synovial joint. Many classification systems have been proposed for fractures of the condylar region. Classification of condylar fracture 1. Fracture through the head of the condyle (diacapitular fracture): the fracture line starts in the articular surface and may extend outside the TMJ capsule. 2. Fracture of the condylar neck: The fracture line starts somewhere above line A (the perpendicular line through the sigmoid notch to the tangent of the ramus) in more than half of its length, it runs above the line A in the lateral view. 3. Fracture of the condylar base: The fracture line runs behind the mandibular foramen and, in more than half of its length, below line A. Minimal displacement: displacement of less than 10° or overlap of the bone edges by less than 2 mm, or both. Fractures of the condylar region involve the TMJ either directly or indirectly and may lead to disturbance of function of the TMJ. Fractures that involve the subcondylar area 17 in children can occasionally lead to significant disturbance of growth. Fractures into the joint space can result in fibrous or bony ankylosis. Treatment of condylar fractures All intra capsular fractures and all fractures in growing children should be treated conservatively Immediate or early mobilization should be encouraged. However, if the occlusion is disturbed IMF is applied and maintained until stable union can be expected to be present, the period of immobilization should not exceed 10-21 days. ORIF of condylar fractures Absolute Indications: A. Limitation of function secondary to the following: Displacement of condyle into middle cranial fossa Impossibility of restoring occlusion with closed treatment. Lateral extra-capsular displacement of condylar head Invasion by foreign body within the joint capsule (e.g. missile) B. Inability to bring the teeth into occlusion for closed reduction Relative indications: Bilateral fracture with associated mid-face fracture (particularly where one condylar fracture is dislocated or angulated) Bilateral fracture with severe open bite deformity Unilateral fracture with dislocation, overlap or significant angulation of the condylar head When IMF is contraindicated for medical reasons Surgical approaches for ORIF Submandibular approach to expose the fracture, combined with a classical pre- auricular approach to the TMJ if needed. Retromandibular or trans-parotid approaches also gives good access for plate fixation. Other approaches include; modified Blair incision approach, rhytidectomy approach and retroauricular approach 18 Intraoral approach has the advantage of avoiding facial scarring and risk of injury to the facial nerve but the major disadvantage is limited access , which makes fragment control difficult and the procedure surgically more challenging. Minimally invasive endoscopic repair of condylar fractures offers less morbidity and operating time, as well as quick patient recovery. The main advantages are reduced risks to the facial nerve and minimal scarring, compared with standard percutaneous approaches. Fixation methods in ORIF Among the fixation methods that have been used are; transosseous wire, Kirschner wire (K-wire), miniplates, lag screws, bioresorbable Plates and Pins and more-recently ultrasound activated resorbable plates and pins. Major complications Ankylosis of the TMJ Ankylosis of the TMJ can occur following trauma. Fractures that involve the joint space, particularly in young patients, seem most prone to result in this complication. Predisposing factors include: 1. Age: the major incidence is below the age of 10 years. 2. Type of injury: intracapsular trauma with crushing of the condyle. 3. Damage to the disc: disruption of the disc is likely to occur in two particular types of fracture: a severe intracapsular compression injury or a fracture dislocation. Disturbance of growth When the fracture involves the condylar cartilage and the articular surface, subsequent disturbance of growth may occur. In some cases, fibrous or bony ankylosis of the TMJ is an additional complication which reduces the normal functional movement of the jaw that further inhibits growth. The effect of damage is failure of development of the condylar process and a smaller mandible on the affected side. Fractures of the edentulous mandible The physical characteristics of the mandible are altered considerably following the loss of the teeth: The alveolar process undergoes resorption and the mandible becomes atrophic 19  and thin. The resistance of the bone to trauma is further reduced by changes in the structure of the bone associated with the process of ageing. The blood supply of the edentulous mandible is more periosteal due to the diminished endosteal blood supply of the mandible. The healing potential of the bone is reduced and the healing of the fracture is slow process and the complications such as nonunion are more likely to occur. Smaller cross-sectional area of bone at the fracture site and the absence of the stabilizing influence of teeth mean that the bone ends are more easily displaced and even after reduction the area of contact between them may be insufficient for healing to occur easily. Fracture are much less frequently compound into the mouth than when teeth are present. As a result, if treatment is by closed reduction the risk of subsequent infection is much reduced. The absence of teeth means that precise anatomical reduction is not necessary as any inaccuracy is easily compensated by adjustment of dentures. Treatment Un-displaced fractures require no active treatment. The edentulous mandibular fractures can be treated by closed reduction using the Gunning type splints or if the patient is a denture wearer, the dentures can be modified to allow IMF, which can be used as splint. Fractures of the ramus, angle and the condylar region cannot be effectively managed with the Gunning splints as the proximal fragment cannot be controlled, especially in case of unfavorable fractures. When ORIF is required, reduction should be made with minimum exposure of the fracture site to minimize interference with the periosteal blood supply. Fixation methods include; transosseous wiring and bone plates. Very thin mandible may not unite satisfactorily with conventional methods of reduction and fixation and in these cases autogenous bone grafting should be used to stabilize and augment the fracture where the patient's general condition permits. 20 It must be remembered that accurate anatomical reduction is not required as any inaccuracy is easily compensated by adjustment of dentures and that in very thin mandible stable fibrous union may be an acceptable result in the very old or infirm patient. Comminuted mandibular fractures Comminuted mandibular fractures result from high energy injuries such as missile injuries, these injuries are associated with soft tissue damage and many of these fractures are open (compound) and contaminated. The bone fragments are often difficult to manipulate and secure, while maintaining their soft tissue attachments and are therefore at risk of becoming loose or devitalized later on. Successful management seeks to combine adequate immobilization and vascularization of the fragments while preventing subsequent infection. The traditional method of treatment of these fractures used closed techniques, thereby avoiding periosteal stripping and further devitalizing the bone. However, these techniques do not guarantee adequate immobilization of all the fragments, although clinically they work well in selected cases. Recently ORIF has been advocated to provide a load bearing fixation and stability- across the fracture In severe injuries after airway and hemorrhage control, temporary IMF or external fixation can be used until definitive ORIF. 21