Surgical therapy of mandibular fractures in adults (excluding the condylar process)

Fractures of the mandibular body, even if minimally displaced, are nowadays usually treated by open reduction and osteosynthesis (ORIF). According to AO (level 2) they are classified into the regions symphysis, body, and mandibular angle (adjacent to ramus and coronoid process). Three-dimensional imaging (computed tomography [CT], cone-beam CT) has largely replaced conventional x-ray diagnostics, with orthopantomogram (OPG) and Clementschitsch projection now mostly employed in non or minimally displaced cases and/or for initial diagnostics. Although fractures involving the teeth and/or the periodontal ligaments have traditionally been defined as open fractures with risk of bony infection, nowadays, with antibiotics and efficient immobilization methods (such as IMF screws) at hand, emergency operations are now generally reserved for complex trauma cases. Equally, the traditional paradigm to remove teeth if crossing or adjacent to fracture gaps or if partially retained is no longer valid today. However, in case of removal, a more rigid osteosynthesis may be indicated, e.g., grid and/or trauma plates due to loss of stability in the area of the tension lines. Even minimally displaced fractures of the edentulous mandible should undergo ORIF, with highly atrophic mandibles to be treated preferentially via an extraoral approach. In case of multiple fragments, major fragmentation, or comminution, a step-by-step reduction using mini- or miniaturized plates can be recommended to decrease complexity of the fracture. After restoring geometry, if required, the ancillary plates can be replaced by a more rigid osteosynthesis. This is nowadays usually possible via intraoral access, as diverse grid plate and linear plate systems are available. In case of exposure of osteosynthesis material, if possible, infected plates and screws should not be removed until bony consolidation unless loose or causing major osteolysis.