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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 27  |  Issue : 1  |  Page : 119-122

Mandibular symphysis fracture associated with the displacement of a fractured genial segment: An unusual case report with review


1 Department of Oral Medicine and Radiology, KLR's Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India
2 Department of Oral Surgery, KLR's Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India
3 Department of Oral Surgery, Peoples College of Dental Sciences and Research Center, Bhopal, Madhya Pradesh, India
4 Department of Conservative Dentistry, Government Dental College and Hospital, Vijayawada, Andhra Pradesh, India

Date of Submission21-Aug-2014
Date of Acceptance24-Jun-2015
Date of Web Publication12-Oct-2015

Correspondence Address:
Krishnaveni Buduru
Department of Oral Medicine and Radiology, KLR's Lenora Institute of Dental Sciences, Rajanagaram, Rajahmundry - 533 294, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.167130

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   Abstract 

Fractures and displacement of fragments involving the genial tubercles due to trauma are rarely seen in patients with a full complement of teeth although spontaneous fractures of the genial tubercles in edentulous atrophic mandible are not uncommon. These are usually displaced and may be missed during routine clinical and radiographic examinations owing to superimposition of the features of a fractured mandible. Very few cases have been reported till date. Their implications lie in functional alterations that occur as a consequence of loss of attachment of the geniohyoid and genioglossus muscles. There is no universal opinion on the treatment of fractures involving the genial tubercles. Possible treatments include no surgical intervention, excision of the avulsed bone fragments, and muscular repositioning. We present a case of mandibular fracture associated with the fracture and displacement of a fragment involving the genial tubercles in a dentate patient where in the finding was incidental and a review of literature.

Keywords: Fractures, genial tubercle, mandible, unusual fracture


How to cite this article:
Buduru K, Vankudoth D, Bhargava D, Thota MM. Mandibular symphysis fracture associated with the displacement of a fractured genial segment: An unusual case report with review. J Indian Acad Oral Med Radiol 2015;27:119-22

How to cite this URL:
Buduru K, Vankudoth D, Bhargava D, Thota MM. Mandibular symphysis fracture associated with the displacement of a fractured genial segment: An unusual case report with review. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2022 Oct 6];27:119-22. Available from: https://www.jiaomr.in/text.asp?2015/27/1/119/167130


   Introduction Top


Fractures and displacement of fragments involving the genial tubercles due to trauma are rarely seen in patients with a full complement of teeth although spontaneous fractures of the genial tubercles in edentulous atrophic mandible are not uncommon. These are usually displaced and may be missed during routine clinical and radiographic examinations owing to superimposition of the features of a fractured mandible. Very few cases have been reported till date. We present a case of mandibular fracture associated with the fracture and displacement of a fragment involving the genial tubercles in a dentate patient where in the finding was incidental and a review of literature.


   Case Report Top


A 52-year-old male patient reported to the Department of Oral Medicine and Radiology with a chief complaint of severe pain and difficulty in opening his lower jaw since 3 days due to trauma from a road traffic accident. He had a history of bleeding from the mouth immediately after the injury, but did not experience vomiting, loss of consciousness, and bleeding from the nose and ear, which ruled out the possibility of a head injury. Past medical, dental and family history were insignificant. On examination, a diffuse extraoral swelling, ecchymosis and step deformity were present in the chin region. The swelling was tender to palpation. Intraoral findings included a deranged occlusion, step deformity in the midline and hematoma of floor of the mouth [Figure 1]. All the teeth, except the third molars, were clinically present. The patient had no other associated injuries elsewhere in the body. Based on the history and clinical features, a provisional diagnosis of mandibular fracture involving the symphysis was made.
Figure 1: Sublingual hematoma/Coleman's sign

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Following immobilization, for confirmation of the provisional diagnosis, an occlusal view of the mandible was advised. The radiograph showed a well-defined, homogenous radio-opaque object, triangular in shape suspended in the soft tissues of the floor of mouth [Figure 2] resembling an entrapped foreign body. But on correlating with the type of injury and the extraoral clinical findings, the presence of a foreign body was ruled out. On careful examination of the radiograph, a triangular radiolucent defect in the region of the genial tubercles was seen, following which, a bimanual palpation revealed a hard, mobile, irregular mass within the tissues. On the basis of the clinical and radiographical examination, we arrived at a final diagnosis of fractured and displaced fragment involving the genial tubercles which was unusual. Patient had normal functioning tongue even after the detachment of the fragment of the mandible involving the genial tubercles to which the geniohyoid and genioglossus muscles are inserted. All hematological laboratory investigations were within normal limits.
Figure 2: Occlusal radiograph showing free genial fragment in floor of the mouth

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The diagnosis of the displaced fragment was confirmed on surgical exposure of the mandibular symphysis fracture for open reduction and internal fixation using lag screws via an intraoral vestibular incision [Figure 3]. After achieving satisfactory anatomic reduction of the symphysis fracture and restoration of occlusion, the free fragment involving the genial tubercles in the floor of the mouth was left without any active intervention as it was not causing any inconvenience to the patient. The tongue functions were not altered as was presumed. The patient was followed up for a period of 3 months and the fracture healing was uneventful. Tongue movements and functions were normal during this period. The patient, however, did not report for a follow-up after 3 months.
Figure 3: Open reduction with lag screws in situ

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   Discussion Top


Mandibular fractures involving the genial tubercles is a rare pathology, more commonly seen in edentulous patients with severe mandibular atrophy. Majority of cases described and reported in the literature refer to spontaneous fractures in elderly patients with atrophic edentulous mandibles. [1],[2],[3],[4],[5] Only one such fracture case involving the genial tubercles in a patient with full complement of teeth, due to blunt trauma has been reported by Ryan et al. [2] They included a total number of 14 fracture cases involving the genial tubercles related to edentulous mandibles in the review of literature. This article represents a very rare type of fracture and displacement of the genial segment in a male patient with almost full complement of teeth.

The geniohyoid and genioglossus insert at the mandibular genial tubercles. The buccal phase of deglutition involves the passage of the bolus to the pharynx following the protrusion and raising of the tip of the tongue enabled by the genioglossus muscle. The pharyngeal phase of deglutition involves the passage of the food bolus through the pharynx enabled by the Winslow's geniopharyngeous muscle. The hyoideus is raised by the geniohyoid muscle which lowers the epiglottis resulting in laryngeal closure. [5] The resultant pull on the mandibular genial segment due to genioglossus and geniohyoid muscles is medial and inwards towards the floor of the mouth [Figure 4]. Similar displacement of the fractured genial segment in the direction of the resultant vector of the genial muscular pull has been presented in this case.
Figure 4: Muscle attachments of the genial tubercles

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As stated by Huelke and Harger, fracture occurs in the primary area of tensile strain. So any force directed along the parasymphysis region of the mandible, get distributed throughout its length resulting in compressive strain along the buccal aspect and a tensile strain along the lingual aspect. However, the mandible is not a smooth curve of uniform bone, but has discontinuities like foramina, ridges, tubercles, etc., where greater force per unit area and consequently tensile strain is concentrated, resulting in a fracture [6] [Figure 5].
Figure 5: Schematic representation of the distribution of forces in the mandible after impact on the symphysis region of the mandible

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The management of fractures involving the genial tubercles is controversial. This includes no surgical intervention, excision of the avulsed bone fragments and muscular repositioning. [3],[4],[5] However, a chronic irritant effect on the floor of the mouth can be produced, which can cause an inflammatory phenomena from where a malignant neoplasm may originate. [7]


   Conclusion Top


Based on the reviews and our experience, the fracture of a displaced genial segment without any functional disturbances may be managed conservatively and intervention may be done in selective cases of concern to the patients. All patients with fractured mandibular symphysis and para-symphyseal region should be given extra care during clinical and radiological examination to rule out such unusual and rare type of fractures and to avoid unexpected difficulties during reduction and fixation of fracture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gallego L, Junquera L, Villarreal P, de Vicente JC. Spontaneous fracture of the mandibular genial tubercles. A case report. Med Oral Patol Oral Cir Bucal 2007;12:E599-601.  Back to cited text no. 1
    
2.
Ryan JM, Ross D, Obeid G. Genial tubercle fracture: A case report and review of the literature. J Oral Maxillofac Surg 2010;68:2338-41.  Back to cited text no. 2
    
3.
Goebel WM. Fractured genial tubercles. J Prosthet Dent 1978;39:603-4.  Back to cited text no. 3
[PUBMED]    
4.
Maw RB, Lindsay JS. Conservative management of genial tubercle fractures. Oral Surg Oral Med Oral Pathol 1970;30:445-9.  Back to cited text no. 4
[PUBMED]    
5.
Shohat I, Shoshani Y, Taicher S. Fracture of the genial tubercles associated with a mandibular denture: A clinical report. J Prosthet Dent 2003;89:232-3.  Back to cited text no. 5
    
6.
Chacon GE, Larsen PE. Principles of management of mandibular fractures. In: Miloro M, Ghali GE, Larsen PE, Waite PD, editors. Peterson's Principles of Oral and Maxillofacial Surgery. 2 nd ed. Hamilton, Ontario: BC Decker Inc; 2004. p. 401-33.  Back to cited text no. 6
    
7.
Smyd S. Fracture of the genial tubercles. J Am Dent Assoc 1957;55:136-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


This article has been cited by
1 Transoral Approach to Open Reduction of a Traumatic Avulsion Fracture of the Genial Tubercle Associated With a Mandibular Symphysis Fracture: A Case Report and Literature Review
Danyon O. Graham, Edward Nguyen, Muammar Abu Serriah
Craniomaxillofacial Trauma & Reconstruction Open. 2020; 5: 2472751220
[Pubmed] | [DOI]



 

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