Surgical Science, 2013, 4, 500-505
Published Online November 2013 (
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Clinical Outcome of Conservative Tr eatment of Displaced
Mandibular Fracture in Adults
Lipa Bodner1*, Sigal Amitay1, Ben Zion Joshua2
1Department of Oral and Maxillofacial Surgery, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University
of the Negev, Beer-Sheva, Israel
2Department of Otolaryngology Head and Neck S urgery, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion
University of the Negev, Beer-Sheva, Israel
Email: *
Received September 3, 2013; revised October 1, 2013; accepted October 9, 2013
Copyright © 2013 Lipa Bodner et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The article evaluates 12 cases of conservative treatment of displaced mandibular fractures in adults. Twelve cases of
displaced mandibular fractures treated surgically, either by closed reduction (IMF) or open reduction internal fixation
(ORIF) served as controls. Occlusion, maximal mouth opening, lateral jaw movements, neurological dysfunction
(=sensory deficit), and bone remodeling were evaluated and scored in both groups, and results were compared. No sig-
nificant differences were found between the two groups in all the evaluated parameters. It is concluded that in certain
cases, with displacement of 2 - 4 mm, where a surgical approach is not feasible, reasonable spontaneous reduction and
bone remodeling can occur. Meticulous follow-up is mandatory.
Keywords: Mandible; Jaw Bone; Trauma; Displaced Fracture; Conservative Management
1. Introduction
Fractures of the mandible are generally treated by closed
or open reduction [1]. The aim of the treatment is to re-
duce the displaced fracture and restore proper occlusion
and facial contour. The closed reduction methods involve
intermaxillary fixation (IMF) using splints, arch bars, or
maxillomandibular fixation screws [2,3]. There are seve ral
disadvantages with IMF, including: compromised airway,
poor oral hygiene, speech difficulties, impaired nu tritional
intake with weight loss, and disusing atrophy of the mas-
ticatory muscles. Open reduction and internal fixation
(ORIF) using wires, pins, screws, or plates are among the
common methods [4].
In recent years, ORIF, by allowing immediate mobi-
lization of the mandible, has won increasing acceptance
as the method for treatment of mandibular fractures [5].
Conservative management as a treatment modality is
well accepted in mandibular condylar fractures [6]. Con-
servative treatment in cases of mandibular body fractures
has been reported in children in early childhood age,
[7-12] and in adults with atrophic edentulous mandible
[13-15]. In some reports, closed reduction with IMF was
considered as conservative treatment [16-18].
We are unaware of reports describing conservative
treatment for displaced mandibular fracture in adults.
The purpose of the present report is to follow the cli-
nical outcome of 12 patients with displaced mandibular
fracture treated conservatively in terms of restoration of
mandibul a r f un c t i on.
2. Material and Methods
Twenty-four cases of mandibular fracture were included
in the present study. The control group (n = 12) was
treated surgically by either closed reduction (IMF) or
open reduction (ORIF).
The experimental group (n = 12) was also advised to
undergo surgery, either closed or open reduction. How-
ever, due to personal or medical reasons, they were not
operated on.
The first patient, who was the trigger for the present
study, was a 34-year-old psychiatric female patient with
a displaced fracture of the mandible, who “refused” to
stay at the hospital for surgery. The case was evaluated
by the risk management committee of the hospital, and
the advice was that as the surgery she needed was not a
*Corresponding a uthor.
life-saving procedure, it was illegal to hospitalize her
against her will and/or force her toward surgery. Her
parents were involved in the entire process; however, as
she was an adult, they were not eligible to make a legal
decision on her behalf.
For some other participants in the experimental group,
there were medical contra-indications for general anes-
thesia due to comorbid conditions, the legal guardians
were not available, or they refused general anesthesia for
some personal or religious reasons.
Clinical examination of the functional state of the
mandible was performed by one of the authors (LB) as
part of the standardized procedure followed for all jaw
trauma patients at the hospital. The examination included:
occlusion, maximal mouth opening, lateral jaw move-
ments, neurological dysfunction (=sensory deficit), and
bone remodeling. Data were classified according to a
numerical scale, based on the clinical dysfunction index
of Helkimo [19] with modification [20]. The patients
were classified as clinically symptom-free (SF), having
mild symptoms (MS), or having severe symptoms (SS).
The analytical description of the scale system and the
indices used are presented in Table 1. Patients in both
groups were followed routinely in a similar manner. The
follow-up evaluation was done for an average of 12 months
post-treatment. Patients in both groups were asked to
self-estimate the treatment outcome, and score it as either
poor, good, or excellent. A paired t-test was used to
detect significant changes between the experimental and
control gr oups.
Table 1. The index system used for evaluation of mandibular
Normal = 0
Mostly normal = 1 a) Occlusion
Abnormal = 5
>40 mm = 0
30 - 39 mm = 1
b) Maximal mouth
opening <30 mm = 5
>7 mm = 0
4 - 6 mm = 1
c) Lateral jaw
movement <3 mm = 5
Normal sensation of l o w e r lip and gum = 0
Abnormal sensation of lower lip or gum = 1
d) Neurological
dysfunction Abnormal sensation of lower lip and gum = 5
Normal bony union = 0
Incomplete bony union = 1 e) Bone regeneration
Non-union = 5
0 = Symptom free (SF)
1 - 5 = Score 1 = Mild symptoms (MS)
Sum of A + B + C
+ D + E:
6 - 25 = Score 5 = Severe symptoms (SS)
3. Results
The patients’ characteristics and their self-estimation of
treatment outcome are presented in Tables 2 and 3 and
Figures 1-4. The prevalence of mandibular function fol-
lowing surgical and conservative treatment is presented
in Table 4. Evaluation of the function indices showed
Figure 1. Fracture of Lt. angle of a dentate mandible, with 3
mm displacement, treated conservatively (Table 2, case 1).
Figure 2. Outcome of the conservative treatment one year
post trauma. Complete bony regeneration can be seen.
Figure 3. Fracture of the Rt. body of an edentulous man-
dible, with 4 mm displacement, conservative treatment (Ta-
ble 2, case 12).
Figure 4. Outcome of the conservative treatment, one year
ost trauma. Good bony regeneration can be seen. p
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Table 2. Characteristics of patients with displaced mandibular fracture in the experimental (conservative treatment) group.
Age Sex Location of fracture Displacement
Vertical/horizontal Dentate (D)
Edentulous (E)Reason for no
treatment Self-estimation of outcome
1 34 F Lt. angle 3 mm Vertical D Psychiatric
ti t
2 43 M Rt. Body 2 mm Horizontal E MCI Excellent
3 71 F Rt. Body 3 mm Vertical E MCI Good
4 62 M Lt. Angle 2 mm Vertical D LSU Excellent
5 26 M Rt. Angle 2 mm Vertical D PsychEt
Ls 2
Lt. isis 2
iatric patient xcellen
6 41 M Lt. Angle 2 mm Vertical D LSU Excellent
7 81 M Rt. Body 4 mm Vertical E MCI Poor-good
8 15 M t. Symphisi mm HorizontalD ALG Excellent
9 83 M Parasymph mm HorizontalE MCI Good
10 21 M Rt. Body 2 mm Horizontal D LSU Excellent
11 64 M Rt. Ramus 2 mm Horizontal D MCI Good
12 79 F Rt. Body 4 mm Vertical E MCI Good
le 3araristics of pith displacedacture in the control (operative treatment) gn = 12). Tab. Chcteatients w mandibular frroup (
Age Sex Location of
fracture Displacement
Vertical/horizontal Dentate (D)
Edentulous (E) Type of treatment
IMF/ORIF Self-est imation of outcom e
1 30 F Lt. Angle 3 mm Vertical D IMF Excellent
2 43 M Lt. Body 2 mm Horizontal E ORIF Excellent
3 71 F Rt. Body 3 mm Vertical E ORIF Good
4 62 F Rt. Angle 2 mm Vertical D IMF Gont
Ls 2
Lt. Pisis 2
5 26 M Rt. Angle 2 mm Vertical D IMF xcellen
6 41 M Lt. Angle 2 mm Vertical D IMF Excellent
7 81 M Lt. Body 4 mm Vertical E ORIF Good
8 15 F t. Symphysi mm HorizontalD IMF Excellent
9 83 M arasymph mm HorizontalE ORIF Good
10 21 M Lt. Body 4 mm Horizontal D IMF Excellent
11 64 M Rt. Ramus 2 mm Horizontal D IMF Good
12 79 F Rt. Body 4 mm Vertical E ORIF Good
Tab. The p of mation followi surgical and vative treatmen
imental) n (%)
le 4revalencendibular funcngconsert.
Score No. Surgical (control) n (%) Conservative (exper
Occlusion 3 0 = SF 11, 92 10, 8
1 = MS
5 = SS 1, 8
0 2, 17
N 2, 1
al mouth op0
12, 100
12, 100
Lateral jaw m o vement 0
12, 100
12, 100
eurological dysfunction0
10, 83
11, 92
, 8
Bone regeneration 0
11, 92
1, 8
10, 83
2, 17
that gecant differences we found be-
een the control and experimental groups (p > 0.05).
(range 15 - 83), respectively. The M:F ratio was 3.0 and
2.0 in the rimental and control groively.
The mean displacement was 2.50 and 2.66 mm in the
lent in 7 (58%) patients, good in 4 (33.3%) patients, and
nerally no signifire
The mean age of the patients in the control group and
experimental group was 52.8 (range 18 - 83) and 51.6 experimental and control groups. The self-estimation of
treatment outcome in the experimental group was excel-
poor-good in 1 (8%) patient. The self-estimation of
treatment outcome in the control group was excellent in 6
(50%) patients, good-excellent in 1 (8%) patient, and
good in 5 (42%) patients. The differences were not sig-
nificant (p > 0.06).
The occlusion score was 92% SF and 8% MS com-
pared to 83% SF and 17% MS in control and experi-
mental groups, respectively. The scores for maximal
mouth opening and lateral jaw movement were SF
(100%) in both groups. The neurological dysfunction
score was 83% SF and 17% MS compared to 92% SF
literature on complication rates of
res revealed that it ranges from 7 to 29
fixation and open reduction and
infection from ORIF, malo-
ion is discussed with the
ucosa at the fracture area. Only
surgery for
r treatment of clavicle fractures, where mini-
where no other treatment modality
d 8% MS in control and experimental groups, res-
pectively. Bone regeneration score was 92% SF and 8%
MS compared to 83% SF and 17% MS in control and
experimental groups, respectively. The differences be-
tween the control and experimental groups were not sig-
nificant (p > 0.06).
4. Discussion
The study was undertaken to determine if conservative
treatment of patients with displaced mandibular fracture
results in normal jaw function or with increased risk of
possible dysfu nct i on
Reviewing the
mandibular fractu
per cent [21]. The complication rate has been correlated
more to the severity of fracture and less to the type of
treatment. No difference in complication rate was found
between intermaxillary
ternal fixation [22]. It was concluded that in fractures
with displacement of 2 to 4 mm, there is no difference
between closed reduction and open reduction. Our in-
terest was to look at a group of patients with displa-
cement of 2 - 4 mm, treated conservatively, and follow
the rate of complications.
Alpert et al. [23] described four types of complications:
1) those arising in the course of proper treatment, 2)
those arising due to inappropriate treatment, 3) those due
to surgical failure, and 4) those that result from no treat-
ment. They also gave examples for each type of com-
plication, such as wound
lusion from improper treatment, injury to the marginal
mandibular nerve due to technical mistakes, and malo-
cclusion from no treatment.
In the present series, 12 patients were treated con-
servatively. The results are more than satisfactory, as
they are very similar to the results of patients treated by
closed (IMF) or open reduction (ORIF). It has to be
emphasized that conservative treatment does not mean
“no treatment”. The situat
tient and/or with his family that under the specific
circumstances, the conservative treatment is in fact the
treatment of choice. The patients were routinely followed
once a day, once a week, and later once a month, and the
progress or no prog ress w as evaluated p er each visit. Th e
option of chang ing treatment modality toward ORIF was
always on the table.
Among the dentate patients, normal occlusion is the
key factor that is evaluated during each follow-up visit.
Also, the need to be on a liquid/soft diet is emphasized
each visit. The edentulous patients were instructed not to
use their dentures for several months, in order to prevent
pressure-sores of the m
ter 12 - 16 weeks and radiographic evidence of bony
union of the mandible, was the denture relined with a
soft-liner and put back in place. Complete bony union
and remodeling of the displaced fracture is an age-de-
pendent process. Among the younger patients the process
was faster, lasting 3 - 6 months compared to the older
patients where it lasted one year or more until they were
able to masticate normally with their natural teeth or
dentures. Each of the patients was a unique professional
challenge that was followed very carefully.
Conservative or non-surgical treatment, consisting of
observation and soft diet only, has been reported as a
treatment option in greenstick or non-displaced mandi-
bular fractures with normal occlusion [24,25]. In the
report by Ellis et al., [24] 687 patients, 32% of the total
sample of 2137 patients, did not undergo
rrection of their mandibular fracture and were
observed for 4 - 6 weeks. Ghazal et al. [25] reported on
28 cases of mandibular fractures that were managed by
observation and soft diet only. This conservative appr oac h
resulted in spontaneous healing of the fractures. The
hypothesis is that with greenstick and non-displaced frac-
ture, the periosteum is intact, and therefore may maintain
sufficient stability for interfragmentary motion not to
exceed the level tolerated by bone, thereby permitting
ossification. However, in displaced fracture the perios-
teum is probably damaged, the gap and motion between
fragments are larger, which may interfere with ossifica-
tion. Therefore, the common approach is closed or open
In our series, the displacement was 2 - 4 mm, which is
considered a mild displacement. It is hypothesized that in
cases with displacement larger than 4 mm, where the risk
of non-union is much greater, the conservative approach
might be more risky. Similar clinical thoughts have been
reported fo
ally displaced or non-displaced fractures can be treated
non-surgically, whereas displaced fracture has to be
treated by ORIF [26].
5. Conclusion
Conservative treatment of displaced fracture of the
mandible carries higher risk of complications compared
to IMF or ORIF. However, in certain cases, with dis-
placement of 2 - 4 mm,
Open Access SS
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