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The Open Otorhinolaryngology Journal, 2013, 7, 1-4 1

1874-4281/13 2013 Bentham Open
Open Access
Management of Mandibular Fractures from Penetrating Trauma
Elizabeth Hoddeson
1
, Eric Berg
2
and Charles Moore
*,1

1
Department of Otolaryngology, Emory University Hospital, 1365 Clifton Road, Atlanta, GA 30322, USA
2
Department of Otolaryngology, Childrens Hospital of Philadelphia, 34
th
Street & Civic Center Blvd., Philadelphia, PA
19104, USA
Abstract: Gunshot wound injuries to the face result in a varied scope of traumatic injuries. Mandible fractures may occur
through this mechanism of injury, however when caused by firearms, the patterns of fracture and overall composite
defects resulting are unique. The velocity of the weapon and the distance from which the injury occurred often determines
the extent of injury produced from the penetrating force. A review of the management of mandibular fractures from
penetrating trauma is presented. Operative and reconstructive options including advantages and disadvantages are
discussed for consideration to produce the optimal result for rehabilitation of the injured patient.
Keywords: Mandibular Fractures, Penetrating Trauma, firearms, velocity of the weapon.
INTRODUCTION
Penetrating injuries are defined as those that violate
mucosal or skin barriers to enter the body, and can be caused
by knives, bullets, shrapnel, or other objects. The type of
injury is often determined by the velocity of the weapon and
the distance from which the injury occurred [1]. The true
incidence of gunshot wound injuries to the face is unknown;
one retrospective study over a 4 year period showed that the
face was injured in 6% of all gunshot wound victims at one
trauma center [2].
Gunshot wound injuries to the face result in a varied
scope of traumatic injuries including soft tissue, vascular,
skeletal, orbital, cervical spine, thoracic, and intracranial.
Overall, mandible fractures are very common, however when
caused by firearms, the patterns of fracture and overall
composite defects resulting are unique. Among mandible
fractures, condylar fractures are common, between 17.5% -
52% of all mandible fractures [3]. Condylar fractures are
classified in two ways: by anatomic level as condylar head
(intracapsular), condylar neck (extracapsular), and
subcondylar, and also as undisplaced, deviated, displaced
(with medial or lateral overlap or complete separation), and
dislocated (outside the glenoid fossa) [3].
Condylar fracture reconstruction can be approached with
a variety of materials including free bone grafts, metal
prosthesis, and pediculate bone cancellous marrow grafts.
The choice of reconstruction material is often dependent on
the specific nature of the fracture and coincidental bone
defect as well as the overall rehabilitative potential of the


*Address correspondence to this author at the Department of
Otolaryngology, Emory University Hospital, 1365 Clifton Road, Ste. 2300,
Atlanta, GA 30322, USA; Tel: 404-778-3381; Fax: 404-616-8202;
E-mail: [email protected]
patient for mastication, occlusion, and function. Presence of
a large bone defect limits traditional reconstructive options.
Here we present a unique approach to the repair of such a
defect.
CASE PRESENTATION
A 27 year old otherwise healthy male presented to Grady
Memorial Hospital in May, 2009 subsequent to suffering a
gunshot wound to the left face one inch anterior to the
tragus. The list of injuries incurred included vertebral artery
thrombus, external carotid artery thrombus, left C1 spine
fracture, left facial nerve paralysis, left external auditory
canal lacerations, and multiple facial fractures including
subluxed left condylar fracture and completely disrupted and
fragmented left ramus fracture. He was intubated in the
operating room emergently, a heparin drip was initiated, and
local wound care with iodoform packing was initiated for the
gunshot wound. Definitive surgical repair of mandible defect
was deferred until the patients clinical status was stabilized
and coexisting injuries were managed, about six weeks in
total. This time was utilized for operative planning.
Following his initial trauma the patient was placed in a
cervical collar for six weeks; on the completion of this
period antero-posterior flexion extension radiographs were
obtained by the orthopedic spine physicians. The patient had
no evidence of instability or fractures on imaging and no
clinical pain or paresthesias with bending the neck. The
cervical collar was removed and the patient cleared for
normal mobility prior to operative intervention on the
mandible. The patient was admitted to the hospital pre-
operatively in order to bridge his anticoagulation, which is
prescribed by the trauma surgeons indefinitely, with heparin.
Further review of the radiographic images demonstrated
a comminuted defect of the left mandible extending from the
mid-body through the condylar neck (Fig. 1). The native

2 The Open Otorhinolaryngology Journal, 2013, Volume 7 Hoddeson et al.

Fig. (1). Three-dimensional reconstruction of computed
tomography of mandible demonstrating comminuted defect.
condyle was displaced medially and the remaining fragments
were not usable due to their extensive fragmentation. A
custom prosthesis was designed based on a three-
dimensional model of the patients skeletal defects utilizing
Medical Modelling Software. The prosethesis was
produced by Biomet, and the total cost of design and
production was $9500.00 (Figs. 2, 3). Bone support from an
iliac crest bone graft was considered during the
reconstruction planning stages.

Fig. (2). Custom-designed mandibular prosthesis.
The patient was taken to the operating room where an
external approach to the mandible to the level of the glenoid
fossa was utilized. The patient had extensive scarring, which
made identification of normal tissue planes and anatomic
landmarks difficult (Fig. 4). The inferior division of the
facial nerve was absent, however the superior division was
identified and protected. The native condylar head was
located and removed from its dislocated position medial to
the glenoid fossa. Multiple small bone fragments were
removed from the region of the ramus, but a moderately
large piece of inferior ramus was found to have formed a

bony union with the body of the mandible. Using a
reciprocating saw, this fragment was shaved in order to fit
within the tray of the prosthesis. This precluded the need for
cadaveric or autologous bone grafting. The patient was
placed into maxillary-mandibular fixation to ensure proper
occlusion. At this point, the implant was positioned with the
condylar prosthesis securely inside the glenoid fossa and the
tray flush with native mandible body and parasymphysis
anteriorly (Fig. 5). It was secured in place using multiple
locking bone screws. An unsupported portion of the
prosthesis at the angle of the mandible was bridged using
bone matrix protein and crushed bone fragments. The wound
was irrigated and closed in a standard fashion with a
Jackson-Pratt drain in place.

Fig. (3). Custom-designed mandibular prosthesis in position on
three-dimensional model.

Fig. (4). Dissection bed after removal of bone fragments. Suction
tip points to glenoid fossa with superior division of facial nerve
lying laterally.
The patient had an uneventful hospital post-operative
course and was discharged home with maxillary-mandibular
fixation wires remaining intact. The wires and screws
securing maxillary-mandibular fixation were removed six
weeks post-operatively as the patient was in normal dental
occlusion and a panorex film demonstrated that the
prosthetic condyle was in proper position within the glenoid
fossa. The patient had improvement in his trismus as
compared to pre-operative measurements immediately after

Management of Mandibular Fractures from Penetrating Trauma The Open Otorhinolaryngology Journal, 2013, Volume 7 3

Fig. (5). Prosthesis positioned in glenoid fossa, secured to native
mandible anteriorly.
the wires were removed with 1.2 cm opening between the
central incisors. He was fitted with a Dyna splint and over
the subsequent nine months improved to 4 cm of opening.
He continued to work with a physical therapist specializing
in temperomandibular joint disorders throughout the first
two years following surgery. A CT face obtained three years
following surgery demonstrates displacement of the condylar
prosthesis anteriorly and inferiorly from the glenoid fossa, a
finding which had been present since the first post-operative
CT obtained at six months post-operatively, and resorption
of the bone chips and graft material placed during surgery.
The patient has normal eye closure but persistent paralysis of
the lower division of the facial nerve following the trauma.
He is satisfied with the cosmetic outcome of the mandibular
contour, but does suffer from chronic pain in his left face,
back, and shoulder following this traumatic event. His pain
is managed by a pain physician.
DISCUSSION
There are multiple operative approaches to management
of mandible fractures well-described in the literature.
Traumatic or iatrogenic mandible defects present a more
difficult challenge, often requiring a creative approach by the
surgical team. This becomes substantially more complex
when there is involvement of the condyle. Regardless of the
nature of the defect, the ideals for mandible reconstruction
remain constant: to provide an anatomical reconstruction
with sufficient height and adequate native muscle attachment
to allow for normal function.
Approaches described have been utilized in the past both
alone and in combination. In certain circumstances patients
with small mandible defects, particularly in the case of
malignancy can be left to swing and have satisfactory
functional outcomes. This is often desirable when radiation
therapy has already been delivered or is anticipated, as it
significantly impairs wound healing and increases post-
operative graft failure and infection rates.
Perhaps the most simple technique involves application
of a reconstruction plate. These plates depend upon bone
support from cadaveric, autologous, or native sources.
Locking screws are utilized to minimize compression of
underlying bone and to optimize vascularity surrounding the
graft as to permit stabilization without precise alignment of
the plate against the bone [4]. With a small defect, less than
one centimeter, a plate can be used without a bone graft.
Advantages of this technique include decreased operative
time and a viable alternative for patients where poor ability
to perfuse and heal microvascular anastamoses is anticipated.
Disadvantages include risk of wound dehiscence with plate
exposure which increases in the setting of radiation therapy
to 20-48%, infection resulting most often from loosening or
breakage of screws, plate breakage, and imaging difficulties.
Pediculate bone cancellous marrow grafts are based upon
the Axhausen theory of osteogenesis in which surviving
transplanted cells proliferate and form random new osteoid
dependent upon the spatial orientation of the grafted tissue
and the resorb and remodel into mature osteons with an
organized structure [4].

Advantages of this technique include
a high rate of osteogenesis, low rate of surgical
complications, early resumption of function. Disadvantages
resemble those of reconstruction plates with wound
dehiscence, tray exposure, infection, and interference with
implant rehabilitation requiring ultimate removal of the tray
once mature bone has formed.
Larger defects are better served using vascularized bone
flaps [4, 5]. Autologous bone sources include free bone
grafts, pedicled bone grafts, and microvascular free flaps.
This becomes more complicated and technically difficult
when the defect involves the condyle, although rib grafts
shaped to from a neo-condyle have been described. Free
bone grafts are effective for defects less than 5 centimeters in
width with surrounding soft tissue uncompromised. Success
is highly dependent on revascularization at the recipient site
and any micro-movement from non-rigid fixation of the graft
jeapordizes viability. There is very low morbidity at the
donor site for free bone grafts, most frequently harvested
from the ipsilateral iliac crest. Pedicled bone grafts have
essentially been replaced by microvascular free flaps. The
major disadvantages of this approach that are overcome by
the free flap include the very thin width of grafted bone
which is insufficient to support prostheses, a bone longer
than 5 centimeters is not always available or sufficiently
vascularized to be viable, and very poor asthetic results. The
major microvascular free flaps described and regularly used
for mandible reconstruction include the radial, scapula, iliac
crest, and fibular. The major advantages of this approach are
repair of soft tissue and bone defects simultaneously from
one donor site with very high success rates even in the
setting of radiation therapy, and satisfactory functional
outcomes. Disadvantages include prolonged operative time,
varying rates of donor site morbidity, and the fact that
outcome success is based largely upon hospital infrastructure
able to support both the high demands intra- and post-
operatively for these patients.
More recently transport disc distraction osteogenesis is
described in the literature as an application for mandible
reconstruction after many years of use in long bones [4, 6].
In this technique new bone formation is induced by an
opening created by a distraction device between two bony
surfaces. Advantages include the fact that regenerated bone
has similar dimensions to preexisting mandible, including
the ability for the inferior alveolar canal to reccanulate, there
is no donor site, and facilitates use of dental implants.
4 The Open Otorhinolaryngology Journal, 2013, Volume 7 Hoddeson et al.
Disadvantages include difficulty in regenerating complicated
curves in symphyseal and condylar defects, expensive, and
difficult patient compliance issues.
Tissue engineered transplants are described in the
literature. There are several ongoing studies surrounding this
technique and several successful case reports described
utilizing this technology. They are not utilized in general
practice at this point in time.
Modern imaging and 3-dimensional modeling techniques
to create a custom prosthesis have facilitated a new approach
to large mandible defects involving multiple subsites of the
mandible. An exact model of the mandible with the present
defect can be manufactured based on a three dimensional
reconstruction of the patients computerized tomography
scan. The surgeon can use this model to bend a
reconstruction plate pre-operatively in order to decrease
operating time and enhance precision of the plate contour.
Alternatively, this technology can facilitate creation of a
custom plate with or without an included prosthetic condyle
with prearranged dimensions for creating osteotomies in
grafted bone to facilitate an exact fit. Advantages to such a
technique are multiple and include decreased operating time,
improved asthetic result, more accurate alignment of native
and grafted bone segments presumably improving
vascularization and viability, and decreased surgeon fatigue
intraoperatively. The major disadvantages are cost and
preoperative time requirement in order to create the model
and custom plate. Our case demonstrates the success of such
an approach.
CONFLICT OF INTEREST
The authors confirm that this article content has no
conflict of interest.
ACKNOWLEDGEMENTS
Declared none.
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Received: February 16, 2013 Revised: March 16, 2013 Accepted: March 16, 2013

Hoddeson et al.; Licensee Bentham Open.
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