Management of Non-Displaced Mandibular Ramus Fractures
Non-displaced mandibular ramus fractures should be managed conservatively with closed reduction and brief maxillomandibular fixation (MMF), as the surrounding pterygomasseteric sling provides inherent stability that maintains anatomic alignment without surgical intervention.
Initial Diagnostic Approach
CT maxillofacial with multiplanar reformations is the primary diagnostic modality, offering nearly 100% sensitivity for detecting mandibular fractures, including subtle non-displaced ramus fractures that conventional radiography frequently misses 1, 2.
Conventional radiography has only 86-92% sensitivity and should not be relied upon alone, particularly for posterior mandibular and ramus fractures where displacement assessment is critical 1, 2.
Search for a second fracture after identifying the first one—67% of mandibular fractures occur in pairs due to the U-shaped configuration of the mandible 1, 2.
Assessment for Associated Injuries
Obtain CT head in addition to maxillofacial CT, as 39% of patients with mandibular fractures have coexisting intracranial injuries 1.
Evaluate for cervical spine injury, which occurs in approximately 11% of mandibular fracture patients—this is a commonly overlooked associated injury with potentially devastating consequences 1, 2.
Assess for inferior alveolar nerve damage by testing for anesthesia or paresthesia of the lower lip, chin, anterior tongue, and mandibular teeth 1.
Treatment Selection for Non-Displaced Ramus Fractures
Closed reduction with brief MMF (3-5 days) is the preferred treatment for non-displaced ramus fractures, as the medial pterygoid, masseter, and pterygomasseteric sling provide inherent stability 3, 4.
The average MMF duration after closed treatment is approximately 21 days, though some protocols use shorter durations of 3-5 days with excellent outcomes 3, 5.
Non-displaced ramus fractures are inherently stable due to the surrounding musculature (medial pterygoid medially, masseter laterally, and pterygomasseteric sling inferiorly), making surgical intervention unnecessary in most cases 4.
When to Consider Open Reduction
Open reduction and internal fixation (ORIF) should be reserved for displaced ramus fractures or when closed reduction fails to maintain adequate occlusion 3, 6, 5.
ORIF facilitates early return of function with MMF periods of only 3-5 days, but carries risks including reduced mouth opening requiring physiotherapy and muscle relaxants 3, 5.
The extraoral approach is typically used for ORIF when surgical intervention is necessary, though this adds morbidity compared to conservative management 6.
Expected Outcomes
All patients treated with closed reduction for non-displaced ramus fractures demonstrate improvement in occlusion post-treatment with minimal complications 3, 5.
Closed treatment avoids surgical morbidity while achieving adequate functional and anatomic reduction in non-displaced fractures 3, 5.
Critical Pitfalls to Avoid
Failing to identify paired fractures—the most critical error given the 67% incidence of multiple mandibular fractures 1, 2.
Relying on conventional radiography alone, which will miss subtle non-displaced fractures with significantly lower sensitivity than CT 1, 2.
Overlooking cervical spine injuries (present in 11% of cases) and intracranial injuries (present in 39% of cases) 1, 2.
Unnecessarily pursuing surgical intervention for stable, non-displaced ramus fractures when the surrounding musculature provides adequate stability 3, 4.