Vol.18, No.
5 May 1996
Continuing Education Article
FOCAL POINT
★ Each of the approaches to
the management of canine
mandibular fractures has
advantages and disadvantages;
the technique to be used will vary
from case to case.
KEY FACTS
■ Vehicular trauma—usually,
being hit by a car—is the most
common cause of canine
mandibular fractures.
■ Mandibular fractures constitute a
small percentage of all fractures
in dogs (1.5% to 2.5%).
■ The endotracheal tube is ideally
placed through a pharyngostomy
opening in order to enable
optimum assessment of dental
occlusion.
■ Dental bonding, which is a
relatively new technique, has
been successfully used to
manage various fractures in
several regions of the mandible.
Managing Mandibular
Fractures in Dogs
Rapperswil, Switzerland Noah’s Ark Pet Hospital
Rensselaer, Indiana
Ulrich A. Goeggerle, DrMedVet
Greg A. Inskeep, DVM
Purdue University
James P. Toombs, DVM, MS
I n dogs, the incidence of mandibular fractures is 1.5% to 2.5% of all frac-
tures.1 The most common causes of these fractures in dogs are vehicular
trauma, fights, unknown trauma, iatrogenic trauma, and gunshots. The
most frequently affected areas are the premolar, molar, and symphyseal regions
and the vertical ramus. The canines, the incisors, and the condylar and coro-
noid regions are less commonly affected (Figure 1). Nearly 50% of dogs that
sustain mandibular fractures are younger than 1 year of age1 (see the box). This
article reviews the common types of mandibular fractures in dogs and discusses
several management techniques.
ANATOMY AND BIOMECHANICAL PRINCIPLES
Appropriate management of fractures of the mandible depends on a knowledge of
the exact anatomy and the biomechanical principles of this dynamic structure (Fig-
ure 2). The mandibular canal is a very important structure that contains the alveolar
artery, vein, and nerve. It marks the border between the upper two thirds and the
lower third of the mandibular body. Proper decision-making in fracture repair de-
pends on an appreciation of the tension side of the bone and the various forces that
act on it. The tension side of the mandible is on the alveolar margin (Figure 3).
MANAGEMENT
Anesthesia in Fracture Repair
Because dental occlusion is used as a guide in fixation of most mandibular
fractures, normal placement of an endotracheal tube interferes with proper surgi-
cal technique. Placement of the tube through a pharyngostomy opening is rec-
ommended in all cases in which dental occlusion is used to assess functional posi-
tive or negative anatomic reduction of mandibular fractures.2 A recommended
technique for translocation of the endotracheal tube3 is illustrated in Figure 4.
Repair Techniques
Tape Muzzle
A tape muzzle is indicated for fractures with healthy soft tissue and high
Small Animal The Compendium May 1996

first, passed caudal to the ears, brought back to

the opposite side, and again attached to the
first piece. A third piece is placed to exactly
cover the second piece, this time sticky side
down. The same is done with the last piece of
tape, which covers the first piece3 (Figure 5).
The tape muzzle technique is inexpensive,
easy to perform, and noninvasive. It is usually
well tolerated by dogs and provides maximum
Figure 1—Distribution of mandibular fractures in dogs. (From Evans preservation of the existing blood supply in the
HE, Umphlet RC: Miller’s Anatomy of the Dog, ed 3. Ithaca, NY, Cor- fractured region. Development of contact der-
nell University Press, 1993. Reprinted with permission.) matitis is a common complication3; this can be
minimized by keeping
the region under the
muzzle clean and well Data Concerning
ventilated. Aspiration Mandibular
pneumonia is rare but Fractures1
can occur if the pa-
tient vomits.5,6
■ Frequency:
Loop Cerclage with 1.5%–2.5% of all
Stainless Steel fractures in dogs
Symphyseal frac-
tures are the main ■ Age of affected dogs:
indication for loop Approximately 43%
cerclage, especially if
younger than 1 year
incisors are loose or
Figure 2—Anatomy of the canine mandible. (From Evans HE, Umphlet old
incomplete and inter-
RC: Miller’s Anatomy of the Dog, ed 3. Ithaca, NY, Cornell University
Press, 1993. Reprinted with permission.) dental wiring cannot
be performed. When ■ Causes:
one or two lower ca- —Vehicular trauma
nine teeth are missing, (52.3%)
healing potential (e.g., in young animals)3 that involve loop cerclage is contraindicat-
—Fights (19.1%)
minimal or no displacement, such as midbody unilater- ed.7–9 In some cases, sedation
3,4
combined with local anesthe- —Unknown trauma
al fractures. Further indications are vertical ramus
fractures4 and comminuted fractures, if they are unilat- sia is sufficient for the proce- (12.4%)
eral and good occlusion can be achieved.4 Use of a tape dure. In areas that are more —Iatrogenic trauma
muzzle is a helpful adjunctive treatment with other difficult to approach and in (11.4%)
techniques (e.g., internal reduction or dental bonding). nervous dogs, a short-duration —Gunshots (4.8%)
Tape muzzles are not effective in brachycephalic injectable anesthetic or gas
breeds.3 They are also contraindicated in fractures of anesthesia is recommended.
The technique is illustrated in ■ Affected regions:
the rostral mandibular region.3
General anesthesia is seldom required for tape muzzle Figure 6. Modified versions —Premolars (31%)
application. In most cases, sedation is sufficient. A 0.5- have been described.8 —Molars (18%)
to 2-inch wide nonelastic tape is used. The first piece of Loop cerclage is an inex- —Symphysis (15%)
tape is placed (sticky side up) around the caudal part of pensive and easy procedure; —Vertical ramus
the muzzle. A gap of 0.5 to 1.5 centimeters is left be- in many cases, it can be per-
(12%)
tween the upper and lower incisors to allow vomiting formed via sedation. If the cer-
clage is tightened too much, —Canines (9%)
and sufficient movement of the tongue for alimenta-
tion. This gap can be maintained by inserting a pencil bone necrosis can occur. —Incisors
or pen between the upper and lower incisor teeth while —Condyle (5%)
the initial portion of the muzzle is applied. A second Interdental Wiring —Coronoid process
piece of tape (again, sticky side up) is attached to the Indications for interdental

VERTICAL RAMUS FRACTURES ■ TAPE MUZZLE TECHNIQUE

The Compendium May 1996 Small Animal

Figure 3— External tary wiring include simple transverse fractures,3 short

forces (medium arrows) oblique fractures,3 comminuted fractures,2 and bilateral
and internal forces rostral body fractures.9 Significant comminution and
(large arrows) that act bone loss3 are contraindications. General anesthesia is
on the mandible. The
necessary. The mandibular body is approached from a
result is a continuum
of tensile and compres- ventral direction.2 If fractures are in the condylar re-
sive stresses from one gion, the approach is lateral. The fractured area is ex-
side of the bone to the posed, and the direction of displacement of the fracture
other (small arrows). parts is determined. A Kirschner wire is used to make a
In an intact mandible hole in the two fracture fragments to enable placement
(A) and in a fractured of a hemicerclage wire. The mandibular canal and the
mandible (B), the only tooth roots should be avoided. One or preferably two
area of compressive 18- to 20-gauge wires are placed perpendicular to the
stresses is the point of fracture line. One wire should be placed as close as pos-
fragment contact (C). sible to the tension side of the mandible. After reduc-
P = pterygoid muscle,
tion of the fracture, the ends of the wires are twisted,
T = temporalis muscle,
M = masseter muscle, cut, and bent down (Figure 8).
D = digastric muscle. Advantages of this technique are that the implants
(From Rudy RL, Boudrieau RJ: Maxillofacial and mandibu- are small and few in number and that no special equip-
lar fractures. Semin Vet Med Surg Small Anim 7(1):20, 1992. ment is required for their application. The major disad-
Reprinted with permission.) vantage is that slight inaccuracy leads to displacement
and instability.9

Interarcade Wiring
wiring are symphyseal fractures (if the incisors are in- Interarcade wiring can be used for simple, nondis-
tact and firm7) and simple transverse mandibular body placed fractures of the mandibular body and ramus10
fractures.3 Oblique and complicated fractures of the and even for severely comminuted fractures that
body of the mandible are contraindications. The tech- involve the vertical ramus. Other indications include
nique should be avoided if teeth next to the fracture those described for the tape muzzle technique. Signifi-
line are loose or broken. Short-duration injectable anes- cantly displaced fractures and fractures with bone loss
thetics (e.g., propofol) or gas anesthesia are appropriate are contraindications for interarcade wiring.
for this procedure. The wire is General anesthesia is necessary
tightened on the buccal side just to perform the technique. The
enough to maintain reduction3 last upper premolar (P4) and the
(Figure 7). If the wire is tight- first lower molar (M1) are iden-
ened too much, distraction of tified bilaterally. The gingiva
the ventral part of the fracture around these teeth is elevated
can result. If this occurs, addi- A subperiosteally on the lingual
tional interfragmentary wiring and buccal surfaces and retracted
will be necessary.9 so that the adjacent bone be-
The major advantage of this comes visible. Holes are drilled
technique is that there are no in the maxilla and mandible, in a
implants in the fractured region. D buccal-to-lingual direction, be-
In addition, the technique is in- Figure 4— Placement of an endotracheal tube tween the roots immediately ad-
expensive and easy to perform. through a pharyngostomy opening. (A) Palpation jacent to the body of the tooth.
Indications for this technique are of the piriform fossa through the mouth. (B) Skin The holes are drilled perpendic-
limited. It should only be used if incision over the piriform fossa. (C) Guiding ular to the tooth axis. Placement
the teeth next to the fracture line the endotracheal tube from the pharynx through of the wire is depicted in Figure
are firm and intact and if the re- the incision. (D) The endotracheal tube placed 9. The ends of the wire are
gion is easily accessible. through the pharyngostomy opening. (From Slat- twisted next to the hole in the
ter DJ: Textbook of Small Animal Surgery, ed 2. mandible. Normal occlusion is
Interfragmentary Wiring Philadelphia, WB Saunders Co, 1993, p 1921. obtained by holding the jaws
Reprinted with permission.)
Indications for interfragmen- manually together, and the final

TRANSVERSE MANDIBULAR BODY FRACTURES ■ SEVERELY COMMINUTED FRACTURES

Small Animal The Compendium May 1996

is probably the only advantage of this technique. Major

disadvantages are that damage of tooth roots, vascula-
ture, and nerves in the mandibular canal is likely9 (Fig-
ure 10) and that exact positioning of the pin is diffi-
cult.11 It is also difficult to determine the best size of
pin. Such complica-
tions as malocclusion
and nonunion 3 are
common.

Plate Fixation
Plate fixation is
Figure 5—Tape muzzle applied to a dog with a mandibular indicated in manag-
fracture. ing complex and bilat-
eral fractures of the
mandibular body 7
tightening of the wire is done. The twisted end is short- and fractures of the
ened and placed in the space between the two rows of ramus. Contraindica-
upper and lower teeth10 (Figure 9). If the wire is placed tions are infected Figure 7—Interdental wiring. (A)
correctly, direct pressure is applied only to the teeth; fractures and fractures Correct application of wire. (B)
bone necrosis thus is minimal. 10
with bone loss. Gen- Distraction of the ventral part of
the fracture line caused by exces-
The procedure is inexpensive, easy to maintain, and eral anesthesia is re-
10 sive wire tension. (From Slatter
well tolerated. Aspiration of ingesta is rare but may quired. For fractures DJ: Textbook of Small Animal
occur if the animal vomits. This is the major potential of the mandibular Surgery, ed 2. Philadelphia, WB
disadvantage of the technique. Stretching and breaking body, a ventral ap- Saunders Co, 1993, p 1915. Re-
of the wire 10 and sub- proach is performed.2 printed with permission.)
sequent loss of fracture For fractures in the
reduction is another po- region of the ramus, a
tential complication. lateral approach is preferred. Ideally, the plate is placed
next to the alveolar border of the mandibular body, which
Intramedullary is the tension side of this bone; however, plates are often
Pinning placed near the ventral border of the mandibular body to
Unilateral and bilateral avoid tooth roots and the mandibular canal. After reduc-
transverse or oblique tion of the fracture, the plate is contoured to the bone (the
fractures of the mandibu- most important step in this procedure). Placement of the
lar body (especially in the plate follows the general principles of plate fixation in oth-
area from PM2 to M111) er bones3,5 (Figure 11).
can be managed via in- An advantage of plate fixation is that the technique
tramedullary pinning. provides good rigidity,7 allowing unrestricted use of the
Contraindications are mandible immediately after surgery.7 Disadvantages are
comminuted fractures that the procedure is expensive and difficult to per-
and fractures with bone form. Direct contact of the implant with the fracture
Figure 6— Loop cerclage with
loss as well as fractures stainless steel. After placement of disturbs circulation to the healing bone. Because of the
rostral to the second pre- two hypodermic needles (1 and anatomy of the mandible, it is hard to place a bone
molar and caudal to the 2), a stainless-steel wire is inserted plate at the location that is biomechanically ideal.
first molar. General anes- using the needles as a guide. The
thesia is necessary to per- wire is twisted outside the skin. External Skeletal Fixation
form the procedure. The (From Brinker WO, Piermattei Indications for external skeletal fixation include
technique has been de- DL, Flo GS: Handbook of Small mandibular fractures that are complex,3 highly com-
scribed in the literature.11 Animal Orthopedics and Fracture minuted,3 or open3 and those that involve bone loss.12
The fact that intra- Treatment. Philadelphia, WB Generalized bone disease is a contraindication for this
medullary pinning is Saunders Co, 1990. Reprinted technique.13,14 Dogs with mandibular fractures have
with permission.)
relatively inexpensive been successfully treated via several external fixation

FRACTURES WITH BONE LOSS ■ PRINCIPLES OF PLATE FIXATION

Small Animal
systems, including the biphase
mandibular splint (designed for
humans), the Kirschner–Ehmer
splint (with small or medium-
sized clamps), and the acrylic
and pin splint. Patient size, and
thus mandible size, dictates
which system can be used in a
given case.
The biphase mandibular
splint is contraindicated in dogs
that weigh less than 10 kilo-
grams; the mandibular fixation
screws are too large to enable
safe placement in dogs that have
small mandibles. The Kirsch-
ner–Ehmer splint can be used
in small patients; the acrylic and
pin splint is less bulky and is
probably the external fixation
technique that is best suited to
treating mandibular fractures in
very small patients. General
anesthesia is necessary for fixator
application regardless of the
technique used.
The biphase mandibular
splint uses special cobalt-
chromium transfixation screws
and dental acrylic to form the
primary splint. Swivel clamps,
screw-holding blocks, and metal
rods are used as a temporary
mechanical splint to maintain
reduction of the fracture until
the acrylic splint hardens (Fig-
ure 12). Teeth with exposed
roots in the fracture gap may
interfere with bony union and
BIPHASE MANDIBULAR SPLINT ■ TRANSFIXATION SCREWS
The Compendium May 1996
Figure 8—Interfragmentary wiring. should be removed before the technique is
(A through C) Use of interfragmen- applied.15
tary wires in fractures of various re- Postoperative care includes daily cleaning
gions. (D) Supplementation of inter- of screw–skin junctions and feeding of a soft
fragmentary wire with pin. (E and F) diet until healing is complete. To remove the
Combination of interfragmentary splint, the central portion of the bar is cut
wires and interdental wires in a sim-
and the stability of the fracture site is as-
ple rostral bilateral fracture. (From
Brinker WO, Piermattei DL, Flo sessed. If instability is evident, the bar is re-
GS: Handbook of Small Animal Or- paired with an acrylic patch. Sedation is usu-
thopedics and Fracture Treatment. ally sufficient to remove the splint.15
Philadelphia, WB Saunders Co, For the acrylic and pin (or Kirschner-wire)
1990. Reprinted with permission.) fixation technique, the same principle is used
as in the biphase splint technique. The for-
mer technique is less expensive
and can be used in smaller dogs.
Stiff, threaded pins or Kirschner
wires are used instead of the
cobalt-chromium screws. The
Kirschner–Ehmer splint is not de-
scribed here because its indica-
tions are limited and it has no
major advantages when compared
with the biphase external fixation
splint or the acrylic and pin
splint.
Figure 9—Interarcade wiring. The ends of the wire
Advantages of external fixation
are passed, in a buccal-to-lingual direction, through
for treatment of mandibular frac-
predrilled holes. One end (a) is passed, in a lingual-
to-buccal direction, through the hole in the man- tures include exclusion of im-
12
dible. The other end (b) is bent over the posterior plants in the healing area and
notch of the crown of the first lower molar. (From avoidance of surgical dissection at
12,16
Lantz GC: Interarcade wiring as a method of fixa- the fracture site. Good an-
tion for selected mandibular injuries. JAAHA chorage in the bone is provided
17:599, 1981. Reprinted with permission.) by screws or threaded pins. 12,16
The biphase mandibular splint
and the acrylic and pin splint are
lightweight 16 and formable. 14
Possible loosening of the screws14
and the high cost (because of the
special equipment required14) are
disadvantages of the biphase
splint. The convincing advan-
tages of acrylic and pin fixation
make this technique our first
choice.
Figure 10—Intramedullary pinning of a mandibu- Partial Mandibulectomy
lar fracture. An intramedullary pin that is large Partial mandibulectomy is in-
enough for stable fixation often damages tooth dicated (1) if chronic mandibular
roots or the neurovascular structures in the man- osteomyelitis is present and (2) in
dibular canal. (From Chambers JN: Principles of all cases in which primary fixa-
management of mandibular fractures in the dog tion is impossible. 17 General
and cat. J Vet Orthop 2(2):26, 1981. Reprinted anesthesia is required. The tech-
with permission.)
nique is detailed in the liter-
Small Animal The Compendium May 1996

ature. 17 If a combined ventral General anesthesia is required.

and oral approach is performed,
enough gingival and buccal tis-
sue must be preserved to guaran-
tee closure without tension. Skin
closure is accomplished via non-
absorbable suture material in a
simple interrupted pattern. For
intraoral soft tissue closure,
polyglactin 910 or polydiox-
anone is recommended.17 Exci-
sion of the infected area allows
primary healing of the chronical-
ly inflamed region; this healing
is the main goal of the proce-
dure.
Wound dehiscence is the
most common complication. 17
Figure 12A
Figure 12—Biphase external fixation splinting of a mandibular fracture. (A) Ventrodor-
sal radiograph demonstrating placement of cobalt-chromium screws. (B) The patient
after placement of the splint.
Figure 11—Bone plate fixation of a mandibular
fracture. The plate is placed in the lower half
of the mandible to avoid tooth roots and the
mandibular canal. To avoid damaging the roots,
screws must be placed at an angle. (From Cham-
bers JN: Principles of management of mandib-
ular fractures in the dog and cat. J Vet Orthop
2(2):26, 1981. Reprinted with permission.)
Figure 12B
A tape muzzle can be applied
as an additional support for the
dental bonding, especially in
large dogs. After complete heal-
ing of the fracture, the dental
composite is removed with den-
tal burrs. General anesthesia is
usually necessary. Physiologic in-
ability to open the jaw is caused
by muscle contracture and the
development of fibrous tissue
near the fracture site. To break
down part of this fibrous tissue,
the mouth is opened with gentle
force during anesthesia. Muscle
contracture should resolve as
soon as the patient is eating nor-
mally again.6
Major advantages of this
technique are that it does not
damage the blood supply or the
teeth, it can be used in brachy-
cephalic breeds, and it allows
maintenance of peroral alimenta-
tion.6 Because injuries in which
more then two canine teeth are
missing are rare, the disadvantage
of requiring two intact canine
teeth is minimal. The possibility
of overheating (related to dis-
turbed thermoregulation) in a
warm environment can be mini-
mized by thorough instruction of
the owners concerning patient
care.6 Another possible complica-
tion, aspiration pneumonia if the

Partial mandibulectomy is a salvage procedure and Figure 13—Dental bond-

should only be considered if other fixation tech- ing. Frontal view of the
niques have failed or severe chronic osteomyelitis is mouth of a dog with
dental acrylic in place
present.
(crosshatched area), con-
necting the upper and
Dental Bonding the lower canine teeth.
Dental bonding involves the use of dental composite (From Wallace BJ, Kap-
to connect opposing canine teeth of the maxilla and atkin AS, Manfra Maret-
mandible (Figure 13). The goals are to neutralize inter- ta S: Dental composite
nal and external forces that act on the mandible and to for the fixation of man-
stabilize mandibular fractures in three dimensions. Sin- dibular fractures and lux-
gle or multiple fractures in any region of the mandible ations in 11 cats and 6
can be managed by dental bonding.6 Dental bonding is dogs. Vet Surg 23:190,
contraindicated if more than two canines are unstable 1994. Reprinted with
permission.)
or missing6 or if bilateral rostral fractures are present.

INTRAORAL SOFT TISSUE CLOSURE ■ DENTAL COMPOSITE

Small Animal
dog vomits, can also be avoided by good instruction of
owners.6
SUMMARY
Each of the techniques described here has advantages
and disadvantages, and each has distinct indications.
The decision of which technique to use should be made
on a case-by-case basis. Intramedullary pinning in
mandibular fractures has numerous disadvantages and
thus cannot be recommended. Dental bonding is a rel-
atively new technique that has been successfully used
to manage various fractures in several regions of the
mandible. We recommend this technique as a fairly easy
to perform, inexpensive, and effective method for man-
aging mandibular fractures. With the exception of the
tape muzzle (a basic and commonly used technique),
this article has not described the procedures in detail.
About the Authors
Dr. Goeggerle is in private practice in a small animal clinic
in Rapperswil, Switzerland. Dr. Inskeep is affiliated with
Noah’s Ark Pet Hospital in Rensselaer, Indiana. Dr.
Toombs, who is a Diplomate of the American College of
Veterinary Surgeons, is affiliated with the Department of
Clinical Sciences, School of Veterinary Medicine, Purdue
University, West Lafayette, Indiana.
REFERENCES
1. Umphlet RC, Johnson AL: Mandibular fractures in the dog.
A retrospective study. Vet Surg 19(4):272–275, 1990.
2. Rudy RL, Boudrieau RJ: Maxillofacial and mandibular frac-
tures. Semin Vet Med Surg Small Anim 7(1):3–20, 1992.
3. Egger EL: Skull and mandibular fractures, in Slatter DJ:
The Compendium May 1996
Textbook of Small Animal Surgery, ed 2. Philadelphia, WB
Saunders Co, 1993, pp 1910–1921.
4. Withrow SJ: Taping of the mandible in treatment of man-
dibular fractures. JAAHA 11:27–31, 1981.
5. Taylor RA: Mandibular fractures, in Bojrab MJ (ed): Cur-
rent Techniques in Small Animal Surgery, ed 3. Philadelphia,
Lea & Febiger, 1990, pp 890–894.
6. Wallace BJ, Kapatkin AS, Manfra Maretta S: Dental com-
posite for the fixation of mandibular fractures and luxations
in 11 cats and 6 dogs. Vet Surg 23:190–194, 1994.
7. Brinker WO, Piermattei DL, Flo GS: Fractures and disloca-
tions of the upper and lower jaw, in Handbook of Small Ani-
mal Orthopedics and Fracture Treatment. Philadelphia, WB
Saunders Co, 1990, pp 230–243.
8. Hinko PJ: A method for reduction and fixation of symphy-
seal fractures of the mandible. JAAHA 12:98–100, 1976.
9. Chambers JN: Principles of management of mandibular
fractures in the dog and cat. J Vet Orthop 2(2):26–36, 1981.
10. Lantz GC: Interarcade wiring as a method of fixation for se-
lected mandibular injuries. JAAHA 17:599–603, 1981.
11. Cechner PE: Malocclusion in the dog caused by intra-
medullary pin fixation of mandibular fractures: Two case re-
ports. JAAHA 16:79–85, 1980.
12. Greenwood KM, Creagh JR: Bi-phase external skeletal splint
fixation of mandibular fractures in dogs. J Am Coll Vet Surg
9:128–134, 1980.
13. Stampley AR, Lawrence D: Acrylic external fixation in the
treatment of complex mandibular fractures. Canine Pract
18(6):15–19, 1993.
14. Weigl JP, Dorn AS, Chase DC, Jaffrey B: The use of the
biphase external fixation splint for repair of canine mandibu-
lar fractures. JAAHA 17:547–554, 1981.
15. Toombs JP: Treatment of mandibular fractures with the
bi-phase external fixation splint. Proc 16th Annu Vet Surg
Forum:257–258, 1988.
16. Davidson JR, Bauer MS: Fractures of the mandible and the
maxilla. Vet Clin North Am Small Anim Pract 22(1):109–
119, 1992.
17. Lantz GC, Salisbury SK: Partial mandibulectomy for treat-
ment of mandibular fractures in dogs: Eight cases (1981–
1984). JAVMA 191(2):243–245, 1987.