damages of middle area of face: classification, clinic, diagnostics, temporal (transporting)...

Damages of middle area of face: classification, clinic, diagnostics, temporal (transporting) immobilization. Cranial-jaw-facial trauma, breaks of basis of skull. Permanent immobilization and osteosyntez at the damages of bones of face. Types of regeneration fracture of jaws. Late complications of battle damages of bones of fase and their consequences.

Uniqueness of the Uniqueness of the MandibleMandible U-shaped boneU-shaped bone Bilateral joint articulationsBilateral joint articulations Muscles of mastication and Muscles of mastication and

suprahyoid muscle groups can suprahyoid muscle groups can lead to instability and fracture lead to instability and fracture displacementdisplacement

Only mobile bone of the Only mobile bone of the facial/cranial regionfacial/cranial region

Uniqueness of the Uniqueness of the MandibleMandible Thick cortical bone with single Thick cortical bone with single

vessel for endosteal blood supplyvessel for endosteal blood supply– Varies with patient’s age and Varies with patient’s age and

amount of dentitionamount of dentition– With atrophic mandibles, endosteal With atrophic mandibles, endosteal

blood supply is decreased and blood supply is decreased and periosteal blood supply is the periosteal blood supply is the dominant dominant

Biomechanical Aspects Biomechanical Aspects of Mandible Fracturesof Mandible Fractures Multiple studies have shown that Multiple studies have shown that

greater than 75% of mandible greater than 75% of mandible fractures begin in areas of tensionfractures begin in areas of tension

Exception to this is comminuted Exception to this is comminuted intracapsular condylar fractures intracapsular condylar fractures which are totally compression in which are totally compression in originorigin– Evans et al. J Bone Joint Surg 33; 1951Evans et al. J Bone Joint Surg 33; 1951– Huelke et al. J Oral Surg 27;1969Huelke et al. J Oral Surg 27;1969– Huelke et al. J Dent Res 43; 1964Huelke et al. J Dent Res 43; 1964

Biomechanical Aspects Biomechanical Aspects of Mandible Fracturesof Mandible Fractures

Biomechanical Aspects Biomechanical Aspects of Mandible Fracturesof Mandible Fractures Once the mandible is loaded, the Once the mandible is loaded, the

forces are distributed across the forces are distributed across the entire length of the mandibleentire length of the mandible

However, due to irregularities of the However, due to irregularities of the mandibular arch (foramen, mandibular arch (foramen, concavities, convexities, ridges, and concavities, convexities, ridges, and cross sectional thickness cross sectional thickness differences) load is distributed differences) load is distributed differently in areasdifferently in areas

Biomechanical Aspects Biomechanical Aspects of Mandible Fracturesof Mandible Fractures Impacted third molars increases Impacted third molars increases

the risk of mandibular angle the risk of mandibular angle fractures and decrease the risk of fractures and decrease the risk of condylar fractures due to inherent condylar fractures due to inherent weakness in the angle area with weakness in the angle area with impacted teethimpacted teeth

EpidemiologyEpidemiology

Males>Females Males>Females Age: 16-30 yearsAge: 16-30 years Assault>MVA>Falls>Sports for most Assault>MVA>Falls>Sports for most

common cause of fracturecommon cause of fracture With concomitant facial injuries, 45% With concomitant facial injuries, 45%

included at least 1 mandible fractureincluded at least 1 mandible fracture Haug et al. An epidemiologic survey of facial Haug et al. An epidemiologic survey of facial

fractures and concomitant injuries. JOMS 1990;48.fractures and concomitant injuries. JOMS 1990;48. Ellis et al. Ten years of mandible fractures: An Ellis et al. Ten years of mandible fractures: An

analysis of 2,137 cases. Oral Surg Oral Med Oral analysis of 2,137 cases. Oral Surg Oral Med Oral Path 1985;59.Path 1985;59.


Mandible fractures in conjunction Mandible fractures in conjunction with other injuries:with other injuries:– Generally relevant to mode of injuryGenerally relevant to mode of injury

Assault- 90% mandible only (Ellis Oral Assault- 90% mandible only (Ellis Oral Surg Oral Path Oral Med 1985)Surg Oral Path Oral Med 1985)

MVA- 46% with other injuries (Olson MVA- 46% with other injuries (Olson JOMS 1982)JOMS 1982)

Spinal Cord injuries- varies according to Spinal Cord injuries- varies according to studiesstudies

– 3-49% 3-49%

Classification SchemesClassification Schemes

Multiple schemes exist to classify Multiple schemes exist to classify fracturesfractures

Relate fracture type, anatomic Relate fracture type, anatomic location, muscular relation, location, muscular relation, dentition relation, etc.dentition relation, etc.


Fracture types:Fracture types:– Simple/closed- not opened to the Simple/closed- not opened to the

external environmentexternal environment– Compound/opened- fracture extends Compound/opened- fracture extends

into external environmentinto external environment– Comminuted- splintered or crushedComminuted- splintered or crushed– Greenstick- only one cortex fracturedGreenstick- only one cortex fractured– Pathologic- pre-existing disease of Pathologic- pre-existing disease of

bone lead to fracturebone lead to fracture


Fracture types:Fracture types:– Multiple- two or more lines of Multiple- two or more lines of

fractures on the same bone that do fractures on the same bone that do not communicatenot communicate

– Impacted- fracture which is driven Impacted- fracture which is driven into another portion of boneinto another portion of bone

– Indirect- a fracture at a point distant Indirect- a fracture at a point distant from the site of injuryfrom the site of injury

– Complicated/complex- damage to Complicated/complex- damage to adjacent soft tissue, can be simple adjacent soft tissue, can be simple or compoundor compound


Anatomic Anatomic Classification: Classification: – Developed by Developed by

Dingman and Dingman and NatvigNatvig

SymphysisSymphysis ParasymphysealParasymphyseal BodyBody AngleAngle RamusRamus Condyle processCondyle process Coronoid processCoronoid process Alveolar processAlveolar process


Dentition Classification:Dentition Classification:– Developed by Kazanjian and Developed by Kazanjian and

ConverseConverse– Class I: teeth are present on both Class I: teeth are present on both

sides of the fracture linesides of the fracture line– Class II: Teeth present only on one Class II: Teeth present only on one

side of the fracture lineside of the fracture line– Class III: Patient is edentulous Class III: Patient is edentulous


Muscle Action Muscle Action Classification:Classification:– Vertically Favorable vs. Vertically Favorable vs.

Non FavorableNon Favorable Resistance to medial pullResistance to medial pull

– Horizontal Favorable vs. Horizontal Favorable vs. Non FavorableNon Favorable

Resistance to upward Resistance to upward movementmovement

Generally apply to angle Generally apply to angle and body fracturesand body fractures


Condylar fractures:Condylar fractures:– General classification:General classification:– In order from most inferior to In order from most inferior to

superiorsuperior SubcondylarSubcondylar Condylar neckCondylar neck IntracapsularIntracapsular

DiagnosisDiagnosis

Prior to examination, it is important Prior to examination, it is important to gain the following informationto gain the following information– Mechanism of injuryMechanism of injury– Previous facial fracturesPrevious facial fractures– Pre-existing TMJ disordersPre-existing TMJ disorders– Pre-existing occlusionPre-existing occlusion– Past medical history (epilepsy, Past medical history (epilepsy,

alcoholic, mental retardation, alcoholic, mental retardation, diabetes, psychiatric, immune status)diabetes, psychiatric, immune status)

DiagnosisDiagnosis

Physical exam:Physical exam:– Tenderness- generally non-descriptTenderness- generally non-descript– Malocclusion- Malocclusion-

Anterior open bite- bilateral condylar or Anterior open bite- bilateral condylar or angleangle

Unilateral open bite- ipsilateral angle and Unilateral open bite- ipsilateral angle and parasymphyseal fractureparasymphyseal fracture

Posterior cross bite- symphyseal and Posterior cross bite- symphyseal and condylar fractures with splaying of the condylar fractures with splaying of the posterior segmentsposterior segments

Prognathic bite- TMJ effusionsPrognathic bite- TMJ effusions Retrognathic bite- condylar or angle Retrognathic bite- condylar or angle

fracturesfractures

DiagnosisDiagnosis

Physical exam:Physical exam:– Loss of form- bony contour change, Loss of form- bony contour change,

soft tissue depressions, deformitiessoft tissue depressions, deformities– Loss of function- can be from Loss of function- can be from

guarding, pain, trismusguarding, pain, trismus Deviation on opening towards side of Deviation on opening towards side of

condylar fracturecondylar fracture Inability to open due to impingement of Inability to open due to impingement of

coronoid or ramus on the zygomatic archcoronoid or ramus on the zygomatic arch Premature contacts from alveolar, angle, Premature contacts from alveolar, angle,

ramus, or symphysis ramus, or symphysis

DiagnosisDiagnosis

Physical exam:Physical exam:– Edema- non descriptEdema- non descript– Abrasions/lacerations- potential for Abrasions/lacerations- potential for

compound fracturecompound fracture– Ecchymosis- especially floor of mouthEcchymosis- especially floor of mouth

Symphyseal or body fractureSymphyseal or body fracture

– Crepitus with manipulationCrepitus with manipulation– Altered sensation/parathesiaAltered sensation/parathesia– Dolor/Tumor/Rubor- signs of inflammationDolor/Tumor/Rubor- signs of inflammation

DiagnosisDiagnosis

DiagnosisDiagnosis

Radiographic EvaluationRadiographic Evaluation– Panoramic radiograph:Panoramic radiograph:

Most informative radiographic toolMost informative radiographic tool Shows entire mandible and direction of Shows entire mandible and direction of

fracture (horizontal favorable, fracture (horizontal favorable, unfavorable)unfavorable)

Disadvantages:Disadvantages:– Patient must sit up-rightPatient must sit up-right– Difficult to determine buccal/lingual bone and Difficult to determine buccal/lingual bone and

medial condylar displacementmedial condylar displacement– Some detail is lost/blurred in the symphysis, Some detail is lost/blurred in the symphysis,

TMJ and dentoalveolar regionsTMJ and dentoalveolar regions

DiagnosisDiagnosis

Radiographic Radiographic EvaluationEvaluation– Reverse Towne’s Reverse Towne’s

radiograph:radiograph: Ideal for showing Ideal for showing

lateral or medial lateral or medial condylar condylar displacementdisplacement

DiagnosisDiagnosis

Radiographic Radiographic EvaluationEvaluation– Lateral oblique Lateral oblique

radiograph:radiograph: Used to visualize Used to visualize

ramus, angle, and ramus, angle, and body fracturesbody fractures

Easy to doEasy to do Disadvantage:Disadvantage:

– Limited Limited visualization of the visualization of the condylar region, condylar region, symphysis, and symphysis, and body anterior to the body anterior to the premolarspremolars

DiagnosisDiagnosis

Radiographic Radiographic EvaluationEvaluation– Posteroanterior (PA) Posteroanterior (PA)

radiograph:radiograph: Shows displacement Shows displacement

of fractures in the of fractures in the ramus, angle, body, ramus, angle, body, and symphysis and symphysis regionregion

Disadvantage:Disadvantage:– Cannot visualize Cannot visualize

the condylar the condylar regionregion

DiagnosisDiagnosis

Radiographic EvaluationRadiographic Evaluation– Occlusal views:Occlusal views:

Used to visualize fractures in the body Used to visualize fractures in the body in regards to medial or lateral in regards to medial or lateral displacementdisplacement

Used to visualize symphyseal fractures Used to visualize symphyseal fractures for anterior and posterior displacementfor anterior and posterior displacement

DiagnosisDiagnosis

Radiographic EvaluationRadiographic Evaluation– Computed tomography CT:Computed tomography CT:

Excellent for showing intracapsular Excellent for showing intracapsular condyle fracturescondyle fractures

Can get axial and coronal views, 3-D Can get axial and coronal views, 3-D reconstructionsreconstructions

Disadvantage:Disadvantage:– ExpensiveExpensive– Larger dose of radiation exposure compared Larger dose of radiation exposure compared

to plain filmto plain film– Difficult to evaluate direction of fracture from Difficult to evaluate direction of fracture from

individual slices (reformatting to 3-D individual slices (reformatting to 3-D overcomes this)overcomes this)

DiagnosisDiagnosis

DiagnosisDiagnosis

Radiographic EvaluationRadiographic Evaluation– Ideally need 2 radiographic views of Ideally need 2 radiographic views of

the fracture that are oriented 90’ the fracture that are oriented 90’ from one another to properly work from one another to properly work up fracturesup fractures Panorex and Towne’sPanorex and Towne’s CT axial and coronal cutsCT axial and coronal cuts

– Single view can lead to misdiagnosis Single view can lead to misdiagnosis and complications with treatmentand complications with treatment

DiagnosisDiagnosis

This Towne’s view This Towne’s view show a body show a body fracture that is fracture that is displaced in a displaced in a medial to lateral medial to lateral direction and a direction and a subcondylar subcondylar fracture with fracture with lateral lateral displacementdisplacement

DiagnosisDiagnosis

However, Panorex clearly shows the However, Panorex clearly shows the superior displacement of the right superior displacement of the right body fracturebody fracture

General Principles in the General Principles in the Treatment of Mandible Treatment of Mandible FracturesFractures 1. Patient’s general physical status 1. Patient’s general physical status

should be evaluated and monitored should be evaluated and monitored prior to any consideration of prior to any consideration of treating mandible fracturetreating mandible fracture

2. Diagnosis and treatment of 2. Diagnosis and treatment of mandibular fractures should not be mandibular fractures should not be approached with an “emergency-approached with an “emergency-type” mentalitytype” mentality

General Principles in the General Principles in the Treatment of Mandible Treatment of Mandible FracturesFractures 3. Dental injuries should be 3. Dental injuries should be

evaluated and treated evaluated and treated concurrently with the treatment of concurrently with the treatment of mandibular fracturesmandibular fractures

4. Re-establishment of occlusion 4. Re-establishment of occlusion is the primary goal in the is the primary goal in the treatment of mandibular fracturestreatment of mandibular fractures

5. With multiple facial fractures, 5. With multiple facial fractures, mandibular fractures should be mandibular fractures should be treated firsttreated first

General Principles in the General Principles in the Treatment of Mandible Treatment of Mandible FracturesFractures 6. Intermaxillary fixation time 6. Intermaxillary fixation time

should vary according to the type, should vary according to the type, location, number, and severity of location, number, and severity of the mandibular fractures as well the mandibular fractures as well as the patient’s health and age, as the patient’s health and age, and the method used for and the method used for reduction and immobilizationreduction and immobilization

General Principles in the General Principles in the Treatment of Mandible Treatment of Mandible FracturesFractures 7. Prophylactic antibiotics should 7. Prophylactic antibiotics should

be used for mandibular fracturesbe used for mandibular fractures 8. Nutritional needs should be 8. Nutritional needs should be

monitored closely postoperativelymonitored closely postoperatively 9. Most mandibular fractures can 9. Most mandibular fractures can

be treated with closed reductionbe treated with closed reduction

Bone HealingBone Healing

Bone healing is altered by types Bone healing is altered by types of fixation and mobility of the of fixation and mobility of the fracture site in relation to functionfracture site in relation to function

Can be primary or secondary Can be primary or secondary bone healingbone healing


Primary bone healing:Primary bone healing:– No fracture callus formsNo fracture callus forms– Heals by a process of 1)haversian Heals by a process of 1)haversian

remodeling directly across the remodeling directly across the fracture site if no gap exists fracture site if no gap exists (Contact healing), or 2) deposition of (Contact healing), or 2) deposition of lamellar bone if small gaps exist lamellar bone if small gaps exist (Gap healing)(Gap healing)

– Requires absolute rigid fixation with Requires absolute rigid fixation with minimal gapsminimal gaps


Contact HealingContact Healing Gap HealingGap Healing


Secondary bone healing:Secondary bone healing:– Bony callus forms across fracture Bony callus forms across fracture

site to aid in stability and site to aid in stability and immobilizationimmobilization

– Occurs when there is mobility Occurs when there is mobility around the fracture sitearound the fracture site


Secondary bone healing involves Secondary bone healing involves the formation of a subperiosteal the formation of a subperiosteal hematoma, granulation tissue, then hematoma, granulation tissue, then a thin layer of bone forms by a thin layer of bone forms by membranous ossification. Hyaline membranous ossification. Hyaline cartilage is deposited, replaced by cartilage is deposited, replaced by woven bone and remodels into woven bone and remodels into mature lamellar bonemature lamellar bone

Closed ReductionClosed Reduction

Fracture reduction that involves Fracture reduction that involves techniques of not opening the techniques of not opening the skin or mucosa covering the skin or mucosa covering the fracture sitefracture site

Fracture site heals by secondary Fracture site heals by secondary bone healingbone healing

This is also a form of non-rigid This is also a form of non-rigid fixationfixation


Indications:Indications:– ““It is safe to say that the vast majority of It is safe to say that the vast majority of

fractures of the mandible may be treated fractures of the mandible may be treated satisfactorily by the method of closed satisfactorily by the method of closed reduction” reduction” Bernstein Acad Opthalmol Otolaryngol 74;1970Bernstein Acad Opthalmol Otolaryngol 74;1970

– ““If the principle of using the simplest If the principle of using the simplest method to achieve optimal results is to be method to achieve optimal results is to be followed, the use of closed reduction for followed, the use of closed reduction for mandibular fractures should be widely mandibular fractures should be widely used” used” Peterson’s Principle of Oral and Maxillofacial Surgery Peterson’s Principle of Oral and Maxillofacial Surgery 22ndnd edition edition


Indications:Indications:– Simply stated as all cases that open Simply stated as all cases that open

reduction is not indicated or is reduction is not indicated or is contraindicatedcontraindicated

– Comminuted fractures- especially Comminuted fractures- especially gunshot woundsgunshot wounds

– Lack of soft tissue covering for Lack of soft tissue covering for avulsive type injuriesavulsive type injuries


Indications:Indications:– Nondisplaced favorable fracturesNondisplaced favorable fractures– Mandibular fractures in children with Mandibular fractures in children with

developing dentitiondeveloping dentition– Condylar fracturesCondylar fractures– Edentulous fractures with use of Edentulous fractures with use of

prosthesis with circumandibular prosthesis with circumandibular wireswires


Contraindications:Contraindications:– Medical conditions that should avoid Medical conditions that should avoid

intermaxillary fixationintermaxillary fixation AlcoholicsAlcoholics Seizure disorderSeizure disorder Mental retardationMental retardation Nutritional concernsNutritional concerns Respiratory diseases (COPD)Respiratory diseases (COPD)

– Unfavorable fracturesUnfavorable fractures


Advantages:Advantages:– Low costLow cost– Short procedure timeShort procedure time– Can be done in clinical setting with Can be done in clinical setting with

local anesthesia or sedationlocal anesthesia or sedation– Easy procedureEasy procedure– No foreign body in patients No foreign body in patients


Disadvantages:Disadvantages:– Not absolute stability (secondary Not absolute stability (secondary

bone healing)bone healing)– Oral hygiene difficultOral hygiene difficult– Possible TMJ sequelaePossible TMJ sequelae

Muscular atrophy/stiffnessMuscular atrophy/stiffness MyofibrosisMyofibrosis Possible affect on TMJ cartilagePossible affect on TMJ cartilage Decrease range of motionDecrease range of motion

– Non-complianceNon-compliance


Techniques:Techniques:– Arch bars – Erich arch barsArch bars – Erich arch bars– Ivy loopsIvy loops– Essig WireEssig Wire– Intermaxillary fixation screwsIntermaxillary fixation screws– SplintsSplints– Bridal wiresBridal wires


Length of Intermaxillary fixation:Length of Intermaxillary fixation:– Based on multiple factorsBased on multiple factors

Type and pattern of fractureType and pattern of fracture Age of patientAge of patient Involvement of intracapsular fracturesInvolvement of intracapsular fractures

– Average adult: 3-4 weeksAverage adult: 3-4 weeks– Children 15 years or younger- 2-3 Children 15 years or younger- 2-3

weeksweeks– Elderly patients- 6-8 weeksElderly patients- 6-8 weeks– Condylar fractures- 2-4 weeksCondylar fractures- 2-4 weeks


Intermaxillary fixation:Intermaxillary fixation:– Multiple studies show clinical bone Multiple studies show clinical bone

union (no mobility, no pain, reduced on union (no mobility, no pain, reduced on films) in 4 weeks in adults and 2 weeks films) in 4 weeks in adults and 2 weeks in childrenin children

Juniper et al. J Oral Surg 1973;36Juniper et al. J Oral Surg 1973;36 Amaratunga NA. J Oral Maxillofac Surg 1987;45Amaratunga NA. J Oral Maxillofac Surg 1987;45

– Condylar process fractures tend to need Condylar process fractures tend to need only short periods of IMF to aid with only short periods of IMF to aid with pain and occlusion; usually 2 weekspain and occlusion; usually 2 weeks

Walker RV. J Oral Surg 1966;24Walker RV. J Oral Surg 1966;24

External Pin FixationExternal Pin Fixation

Technique of fracture repair by using Technique of fracture repair by using transcutaneous pins threaded into transcutaneous pins threaded into the lateral surface of the mandible. the lateral surface of the mandible. The pin segments are then The pin segments are then connected together with an acrylic connected together with an acrylic bar, metal framework, or graphite bar, metal framework, or graphite rods.rods.

Synonymous with the Joe Hall Morris Synonymous with the Joe Hall Morris applianceappliance


Indications:Indications:– Comminuted mandible fractures Comminuted mandible fractures

with/without displacementwith/without displacement– Avulsive gunshot woundsAvulsive gunshot wounds– Edentulous mandible fracturesEdentulous mandible fractures– Can be used on patients that are Can be used on patients that are

poor candidate for open reduction poor candidate for open reduction and closed reduction (may increase and closed reduction (may increase likelihood of follow-up)likelihood of follow-up)


Joe Hall Morris Joe Hall Morris appliance applied appliance applied to mandibular to mandibular defectdefect

Regional Dynamic Regional Dynamic ForcesForces Different portions of the mandible will Different portions of the mandible will

undergo different patterns of force in undergo different patterns of force in relation to loadingrelation to loading

Regional Dynamic Regional Dynamic ForcesForces Mandibular Angle Region:Mandibular Angle Region:

– Generally vertical pull due to Generally vertical pull due to masseter, medial pterygoid, and masseter, medial pterygoid, and temporalis muscletemporalis muscle

– Rarely is there any medial or lateral Rarely is there any medial or lateral rotational forcesrotational forces

– Therefore, fixation/stabilization is to Therefore, fixation/stabilization is to address the vertical componentaddress the vertical component

Regional Dynamic Regional Dynamic ForcesForces Mandibular Body Region:Mandibular Body Region:

– Transitional zoneTransitional zone– Contains both vertical and horizontal Contains both vertical and horizontal

movementsmovements– Fixation/stabilization is directed Fixation/stabilization is directed

towards countering both directionstowards countering both directions

Regional Dynamic Regional Dynamic ForcesForces Anterior Mandible:Anterior Mandible:

– Direction of forces tends to alter Direction of forces tends to alter with functionwith function

– Zones of compression and tension Zones of compression and tension may actually alter with functionmay actually alter with function

– Undergoes shearing and torsional Undergoes shearing and torsional forcesforces

Open ReductionOpen Reduction

Implies the opening of skin or Implies the opening of skin or mucosa to visualize the fracture mucosa to visualize the fracture and reduction of the fractureand reduction of the fracture

Can be used for manipulation of Can be used for manipulation of fracture onlyfracture only

Can be used for the non-rigid and Can be used for the non-rigid and rigid fixation of the fracturerigid fixation of the fracture


Indications:Indications:– Unfavorable/unstable mandibular Unfavorable/unstable mandibular

fractures fractures – Patients with multiple facial Patients with multiple facial

fractures that require a stable fractures that require a stable mandible for basing reconstructionmandible for basing reconstruction

– Fractures of an edentulous mandible Fractures of an edentulous mandible fracture with severe displacementfracture with severe displacement


Indications:Indications:– Edentulous maxillary arch with Edentulous maxillary arch with

opposing mandible fractureopposing mandible fracture– Delayed treatment with interposition Delayed treatment with interposition

of soft tissue that prevents closed of soft tissue that prevents closed reduction techniques to re-reduction techniques to re-approximate the fragmentsapproximate the fragments


Indications:Indications:– Medically compromised patientsMedically compromised patients

Gastrointestinal diseasesGastrointestinal diseases Seizure disordersSeizure disorders Compromised pulmonary healthCompromised pulmonary health Mental retardationMental retardation Nutritional disturbancesNutritional disturbances Substance abuse patientsSubstance abuse patients


Contraindications:Contraindications:– If a simpler method of repair is If a simpler method of repair is

available, may be better to proceed available, may be better to proceed with those optionswith those options

– Severely comminuted fracturesSeverely comminuted fractures– Patients with healing problems Patients with healing problems

(radiation, chronic steroid use, (radiation, chronic steroid use, transplant patients)transplant patients)

– Mandible fractures that are grossly Mandible fractures that are grossly infectedinfected

Open Reduction:Open Reduction:Rigid FixationRigid Fixation

Rigid fixation:Rigid fixation:– Any form of fixation that counters Any form of fixation that counters

any biomechanical forces that are any biomechanical forces that are acting upon the fracture siteacting upon the fracture site

– Prevents any inter-fragmentary Prevents any inter-fragmentary motion across that fracture sitemotion across that fracture site

– Heals with primary (contact or gap) Heals with primary (contact or gap) bone healing, produces no callus bone healing, produces no callus around fracture sitearound fracture site

Open Reduction:Open Reduction: Rigid FixationRigid Fixation

Lag screw technique:Lag screw technique:– Utilizes screws that create a Utilizes screws that create a

compression of the fracture compression of the fracture segments by only engaging the segments by only engaging the screw threads in the remote screw threads in the remote segment and screw head in the near segment and screw head in the near cortexcortex

– Should be used to gain rigid fixationShould be used to gain rigid fixation


Lag screw technique:Lag screw technique:– Advantages:Advantages:

Low cost, less equipment Low cost, less equipment Faster technique than platingFaster technique than plating Rigid fixationRigid fixation

– Disadvantages:Disadvantages: Screw must be placed perpendicular to Screw must be placed perpendicular to

fracturefracture Can be technique sensitive Can be technique sensitive


Lag screw technique:Lag screw technique:– Utilizes 2-3 screws to overcome Utilizes 2-3 screws to overcome

rotational forcesrotational forces– Must be placed at a divergent angle Must be placed at a divergent angle

of 7’ from one anotherof 7’ from one another– Smaller diameter drill used to for Smaller diameter drill used to for

portion of screw engaged in distant portion of screw engaged in distant segmentsegment

– A single lag screw can be placed in A single lag screw can be placed in the angle region to resist tensionthe angle region to resist tension


Compression plate technique:Compression plate technique:– Technique that creates rigid fixationTechnique that creates rigid fixation– When screws engage plate, they When screws engage plate, they

impart compression across the impart compression across the fracture segmentsfracture segments

– Results in the fragments being Results in the fragments being brought together with compression brought together with compression and interfragmentary frictionand interfragmentary friction


Compression plate technique:Compression plate technique:– Advantages:Advantages:

Rigid fixationRigid fixation Thicker hardwareThicker hardware

– Disadvantages:Disadvantages: Technique sensitive- plates must be Technique sensitive- plates must be

adapted properly or mal-alignment can adapted properly or mal-alignment can occuroccur

More expensive then miniplatesMore expensive then miniplates Bicortical screwsBicortical screws


Compression plate technique:Compression plate technique:– With regards to the regional dynamic forces of With regards to the regional dynamic forces of

the mandible, the ideal area to place the the mandible, the ideal area to place the compression plate would be the alveolus (due to compression plate would be the alveolus (due to tension). However, due to the presence of the tension). However, due to the presence of the dentition, bicortical screws cannot be placed. dentition, bicortical screws cannot be placed.


Compression plate technique:Compression plate technique:– Therefore, compression plates are placed at Therefore, compression plates are placed at

the inferior border of the mandible with the inferior border of the mandible with bicortical screws.bicortical screws.

– Must utilize a tension band at the superior Must utilize a tension band at the superior surface to counteract compressive spread of surface to counteract compressive spread of superior surface by the compression platesuperior surface by the compression plate

Arch barsArch bars Miniplates with monocortical screws (3 on each Miniplates with monocortical screws (3 on each

side ideal)side ideal)

– Tension band placed prior to compression Tension band placed prior to compression plateplate


Compression plate technique:Compression plate technique:– Two types of compression plates existTwo types of compression plates exist

Dynamic compression plates (DCP)- Dynamic compression plates (DCP)- require tension band, can be placed require tension band, can be placed intra-orallyintra-orally

Eccentric dynamic compression plate Eccentric dynamic compression plate (EDCP)- designed with the most lateral (EDCP)- designed with the most lateral holes angled in a superior/medial holes angled in a superior/medial direction to impact compression at the direction to impact compression at the superior region. Must be placed extra-superior region. Must be placed extra-orally. Avoids use of tension bandorally. Avoids use of tension band


Reconstruction plate:Reconstruction plate:– Rigid fixation techniqueRigid fixation technique– Large plates that are load-bearing (can Large plates that are load-bearing (can

bear entire load of region)bear entire load of region)– Consist of plates that utilize screws Consist of plates that utilize screws

greater than 2mm in diameter (2.3, 2.4, greater than 2mm in diameter (2.3, 2.4, 2.7, 3.0)2.7, 3.0)

– Can use non-locking and locking type Can use non-locking and locking type platesplates

– Must use 3 screws on each side of fracture Must use 3 screws on each side of fracture (maximum strength with 4)(maximum strength with 4)


Reconstruction plate:Reconstruction plate:– Advantages:Advantages:

Rigid fixation with load-bearing propertiesRigid fixation with load-bearing properties Low infection rates in the literature, especially Low infection rates in the literature, especially

in the mandibular angle regionin the mandibular angle region Can be used for edentulous and comminuted Can be used for edentulous and comminuted

fracturesfractures

– Disadvantages:Disadvantages: ExpensiveExpensive Requires larger surgical openingRequires larger surgical opening Can be palpated by patient if in body or Can be palpated by patient if in body or

symphysis regionsymphysis region


Rigid fixation:Rigid fixation:– Includes the use of:Includes the use of:

Reconstruction plate with 3 screws on Reconstruction plate with 3 screws on each side of the fractureeach side of the fracture

Large compression platesLarge compression plates 2 lag screws across fracture2 lag screws across fracture Use of 2 plates over fracture siteUse of 2 plates over fracture site 1 plate and 1 lag screw across fracture 1 plate and 1 lag screw across fracture

sitesite


Examples of rigid fixation Examples of rigid fixation schemes for the mandibular schemes for the mandibular body fracturebody fracture– 1 plate and 1 lag screw1 plate and 1 lag screw– 2 plates non compression mini 2 plates non compression mini

plates with inferior bicortical plates with inferior bicortical screwsscrews

– Compression plateCompression plate


Rigid fixation of mandibular angle Rigid fixation of mandibular angle fractures:fractures:– 2 non compression mini-plates with inferior 2 non compression mini-plates with inferior

plate with bicortical screwsplate with bicortical screws– Reconstruction plateReconstruction plate


Rigid fixation for symphyseal Rigid fixation for symphyseal fractures:fractures:– Compression plate with arch Compression plate with arch

barbar– 2 lag screws2 lag screws– 2 miniplates, inferior is 2 miniplates, inferior is

bicortical and may be bicortical and may be compression platecompression plate

Open Reduction:Open Reduction:Non-rigid Internal FixationNon-rigid Internal Fixation

Non rigid internal fixation:Non rigid internal fixation:– Bone fixation that is not strong Bone fixation that is not strong

enough to prevent interfragmentary enough to prevent interfragmentary motion across a fracture sitemotion across a fracture site

– Heals by secondary bone healing Heals by secondary bone healing with callus formationwith callus formation

– Consists of miniplate application Consists of miniplate application with functional stable fixation and with functional stable fixation and intraosseous wiringintraosseous wiring

Open Reduction:Open Reduction: Non-rigid Internal FixationNon-rigid Internal Fixation

Non rigid internal fixation:Non rigid internal fixation:– Functional stable fixation:Functional stable fixation:

Term used when there is enough Term used when there is enough fixation that allows skeletal fixation that allows skeletal mobility/function but still forms a bony mobility/function but still forms a bony callus and secondary bone healingcallus and secondary bone healing

Consists of miniplates opposing tension Consists of miniplates opposing tension or compressionor compression

Relies on the buttressing effects of the Relies on the buttressing effects of the bone (more bone height, more bone (more bone height, more buttressing) or the vertical distance of buttressing) or the vertical distance of placement of miniplates placement of miniplates


Non rigid fixation Non rigid fixation with functional with functional stable fixation:stable fixation:– 2 plates that are 2 plates that are

spread apart are spread apart are better able to better able to resist the loadresist the load


Non rigid fixation Non rigid fixation with functional with functional stable fixation:stable fixation:– Single plate placed Single plate placed

in a mandible with in a mandible with greater vertical greater vertical height will be more height will be more rigid due to rigid due to buttressing effects buttressing effects of the thicker boneof the thicker bone


Non rigid fixation with functional Non rigid fixation with functional stable fixation:stable fixation:– Technique pioneered by ChampeyTechnique pioneered by Champey– Developed mathematical models to Developed mathematical models to

determine forces on the mandible in determine forces on the mandible in relation to the inferior alveolar relation to the inferior alveolar canal, root apices, and bone canal, root apices, and bone thicknessthickness


Non rigid fixation with functional Non rigid fixation with functional stable fixation:stable fixation:– Developed guidelines for the use of Developed guidelines for the use of

plates in relation to the mental foramen plates in relation to the mental foramen in regards to ideal lines of in regards to ideal lines of osteosynthesisosteosynthesis

Posterior to mental foramen- 1 plate applied Posterior to mental foramen- 1 plate applied just below root apices/above IANjust below root apices/above IAN

Anterior to mental foramen- 2 platesAnterior to mental foramen- 2 plates Utilizes monocortical miniplates onlyUtilizes monocortical miniplates only


Non rigid fixation with functional stable Non rigid fixation with functional stable fixation:fixation:– This technique is recommend with early This technique is recommend with early

mandibular fracture treatment (within 1mandibular fracture treatment (within 1stst 24 hours) due to increase failure with 24 hours) due to increase failure with delaysdelays

– Intra-oral technique Intra-oral technique – Utilizes IMF for short periods of timeUtilizes IMF for short periods of time– Literature complication rates are Literature complication rates are

extremely variableextremely variable

Open Reduction:Open Reduction:Intraosseous WiresIntraosseous Wires

Non rigid fixation with intraosseous Non rigid fixation with intraosseous wiring:wiring:– Use of wire for direct skeletal fixationUse of wire for direct skeletal fixation– Keeps the fragments in an exact Keeps the fragments in an exact

anatomical alignment, but must rely on anatomical alignment, but must rely on other forms of fixation to maintain other forms of fixation to maintain stability (splints, IMF). stability (splints, IMF). Not Rigid to Not Rigid to allow functionallow function..

– Low cost, fast to perform, must rely on Low cost, fast to perform, must rely on patient compliance as does closed patient compliance as does closed reduction techniquesreduction techniques

Open Reduction:Open Reduction: Intraosseous WiresIntraosseous Wires

Non rigid fixation with intraosseous Non rigid fixation with intraosseous wiring:wiring:– Simple straight wire- direction of pull is Simple straight wire- direction of pull is

perpendicular to fractureperpendicular to fracture– Figure of eight wire- increased strength at Figure of eight wire- increased strength at

superior and inferior regions compared to superior and inferior regions compared to straight wirestraight wire

– Transosseous/circum-mandibular wire- Transosseous/circum-mandibular wire- used for oblique type fractures- passes used for oblique type fractures- passes wire from skin with the use of an awlwire from skin with the use of an awl


Non rigid fixation with Non rigid fixation with intraosseous wiring:intraosseous wiring:– Straight wireStraight wire– Figure of eightFigure of eight– Transosseous-circum-Transosseous-circum-

mandibular mandibular


Non rigid fixation with Non rigid fixation with intraosseous wiring:intraosseous wiring:– Mostly used in the Mostly used in the

mandibular angle as a mandibular angle as a superior border wire superior border wire with simultaneous with simultaneous removal of third molar removal of third molar from fracture sitefrom fracture site

– Can be used in the Can be used in the inferior border of inferior border of symphyseal and symphyseal and parasymphyseal parasymphyseal fracturesfractures

Edentulous FracturesEdentulous Fractures

Biomechanics differ for edentulous Biomechanics differ for edentulous fractures compared to othersfractures compared to others– Decrease bone height leads to Decrease bone height leads to

decreased buttressing affect (alters decreased buttressing affect (alters plate selection)plate selection)

– Significant bony resorption in the body Significant bony resorption in the body regionregion

– Significant effect of muscular pull, Significant effect of muscular pull, especially the digastric musclesespecially the digastric muscles


Incidence and Incidence and location of location of mandible mandible fractures in the fractures in the edentulous edentulous mandiblemandible– Highest percent Highest percent

in the bodyin the body– Atrophy creates Atrophy creates

saddle defect in saddle defect in bodybody


Biological differencesBiological differences– Decreased inferior alveolar artery Decreased inferior alveolar artery

(centrifugal) blood flow(centrifugal) blood flow– Dependent on periosteal Dependent on periosteal

(centripetal) blood flow(centripetal) blood flow– Medical conditions that delay Medical conditions that delay

healinghealing– Decreased ability to heal with ageDecreased ability to heal with age


Classification of the edentulous Classification of the edentulous mandible:mandible:– Relates to vertical height of thinnest Relates to vertical height of thinnest

portion of the mandibleportion of the mandible Class I- Class I- 16-20mm16-20mm Class II- Class II- 11-15mm11-15mm Class III- Class III- <10mm<10mm


Closed ReductionClosed Reduction– Use of Use of

circumandibular circumandibular wires fixated to the wires fixated to the pryriform rims and pryriform rims and circumzygomatic circumzygomatic wires with patient’s wires with patient’s denture or splintsdenture or splints

– Requires IMF- usually Requires IMF- usually longer periods of longer periods of timetime

– Generally used to Generally used to repair Class I type repair Class I type fractures or thickerfractures or thicker


External pin fixation:External pin fixation:– May be used for fixation with/without the May be used for fixation with/without the

use of IMFuse of IMF– Avoids periosteal strippingAvoids periosteal stripping– Used for comminuted edentulous fracturesUsed for comminuted edentulous fractures– Can be used in patients that an open Can be used in patients that an open

procedure is contraindicated procedure is contraindicated – Must use large diameter screws (4mm) for Must use large diameter screws (4mm) for

fixation, may be difficult in Class III fixation, may be difficult in Class III patientspatients


Open reduction techniques:Open reduction techniques:– Recommended for fractures that have Recommended for fractures that have

not healed from other treatments, IMF not healed from other treatments, IMF contraindicated, splints/dentures contraindicated, splints/dentures unavailable, or the mandible is too unavailable, or the mandible is too atrophic for success with closed atrophic for success with closed reductionreduction

– Utilizes rigid fixation techniquesUtilizes rigid fixation techniques– Can utilize simultaneous bone grafting Can utilize simultaneous bone grafting

with severely atrophic mandibles if with severely atrophic mandibles if there is the possibility of inadequate there is the possibility of inadequate bony contactbony contact


Open reduction techniques:Open reduction techniques:– Studies indicate that the lowest Studies indicate that the lowest

complication rates occur with extra-complication rates occur with extra-oral approaches with rigid fixation, oral approaches with rigid fixation, especially with class III atrophic especially with class III atrophic mandiblesmandibles

Bruce et al. J Oral Maxillofac Surg 1993;51Bruce et al. J Oral Maxillofac Surg 1993;51 Luhr et al. J Oral Maxillofac Surg 1996;54Luhr et al. J Oral Maxillofac Surg 1996;54

Pediatric Mandible Pediatric Mandible FracturesFractures Relatively uncommon type of injuryRelatively uncommon type of injury Incidence of fractures in children Incidence of fractures in children

under 15 years- 0.31/100,000under 15 years- 0.31/100,000 Usually represent less than 10% of Usually represent less than 10% of

all mandible fractures for children all mandible fractures for children 12 years or younger12 years or younger

Less than 5% of all mandible Less than 5% of all mandible fractures for children 6 years or fractures for children 6 years or youngeryounger

Pediatric Mandible Pediatric Mandible FracturesFractures Uniqueness of children:Uniqueness of children:

– Nonunion and fibrous union are rare Nonunion and fibrous union are rare due to osteogenic potential of due to osteogenic potential of children. children. They heal rapidly.They heal rapidly.

– Due to growth, imperfect fracture Due to growth, imperfect fracture reduction can be “compensated with reduction can be “compensated with growth”. Therefore, malocclusion growth”. Therefore, malocclusion and malunions usually resolve with and malunions usually resolve with timetime

Pediatric Mandible Pediatric Mandible FracturesFractures Uniqueness of children:Uniqueness of children:

– The mandible tends to be thinner The mandible tends to be thinner and has a less dense cortex (could and has a less dense cortex (could affect hardware placement)affect hardware placement)

– Presence of tooth buds in the lower Presence of tooth buds in the lower portions of the mandible (could portions of the mandible (could affect hardware placement)affect hardware placement)

– Short and less bulbous deciduous Short and less bulbous deciduous teeth make arch bar application teeth make arch bar application difficultdifficult

Pediatric Mandible Pediatric Mandible FracturesFractures Treatment modalities:Treatment modalities:

– Due to rapid healing, closed reduction Due to rapid healing, closed reduction techniques may be tolerated techniques may be tolerated

– Most fractures can be treated with follow-Most fractures can be treated with follow-ups and soft/non-functional diet or closed ups and soft/non-functional diet or closed reduction with arch bars or acrylic splintreduction with arch bars or acrylic splint

– Open reduction only advocated for severely Open reduction only advocated for severely displaced unfavorable fractures, in delayed displaced unfavorable fractures, in delayed treatment (>7days) due to soft tissue in-treatment (>7days) due to soft tissue in-growth, or patients with airway/medical growth, or patients with airway/medical issuesissues

Pediatric Mandible Pediatric Mandible FracturesFractures Treatment of condylar fractures:Treatment of condylar fractures:

– Treatment goals are to restore Treatment goals are to restore mandibular function, occlusion, mandibular function, occlusion, prevent growth disturbances, and prevent growth disturbances, and maintain symmetrymaintain symmetry

– Must avoid ankylosisMust avoid ankylosis– Use short periods of IMF (7-14 days), Use short periods of IMF (7-14 days),

then jaw opening exercises; in then jaw opening exercises; in children under 3 years, immediate children under 3 years, immediate function necessary to prevent function necessary to prevent ankylosisankylosis

Pediatric Mandible Pediatric Mandible FracturesFractures Most studies show minimal risk Most studies show minimal risk

for growth disturbances for for growth disturbances for fractures of the mandibular body, fractures of the mandibular body, angle, symphysis, or ramus.angle, symphysis, or ramus.

Most disturbances occur from Most disturbances occur from intracapsular condylar fracturesintracapsular condylar fractures

Low rate of malunion, nonunion, Low rate of malunion, nonunion, or infections for pediatric or infections for pediatric fracturesfractures

Condylar Process Condylar Process FracturesFractures Incidence:Incidence:

– Represent 25-35% Represent 25-35% of all mandible of all mandible fracturesfractures

– Location:Location: 14% intracapsular 14% intracapsular

(41% in children (41% in children <10)<10)

24% condylar neck 24% condylar neck (38% in adults >50)(38% in adults >50)

62% subcondylar 62% subcondylar 84% unilateral84% unilateral 16% bilateral16% bilateral

Condylar Process Condylar Process FracturesFractures Classifications:Classifications:

– Wassmund Scheme:Wassmund Scheme: I- minimal displacement of head (10-45’)I- minimal displacement of head (10-45’) II- fracture with tearing of medial joint II- fracture with tearing of medial joint

capsule (45-90’), bone still contactingcapsule (45-90’), bone still contacting III- bone fragments not contacting, III- bone fragments not contacting,

condylar head outside of capsule medially condylar head outside of capsule medially and anteriorly displacedand anteriorly displaced

IV- head is anterior to the articular IV- head is anterior to the articular eminenceeminence

V- vertical or oblique fractures through V- vertical or oblique fractures through condylar head condylar head


– Lindahl classification:Lindahl classification: I- nondisplacedI- nondisplaced II- simple angulation of displacement, no II- simple angulation of displacement, no

overlapoverlap III- displaced with medial overlapIII- displaced with medial overlap IV- displaced with lateral overlapIV- displaced with lateral overlap V- displaced with anterior or posterior V- displaced with anterior or posterior

overlapoverlap VI- no contacts between segmentsVI- no contacts between segments


– MacLennan classification:MacLennan classification: I- nondisplacedI- nondisplaced II- deviation of fractureII- deviation of fracture III- displacement but condyle still in III- displacement but condyle still in

fossafossa IV- dislocation outside of glenoid fossaIV- dislocation outside of glenoid fossa

Condylar Process Condylar Process FracturesFractures Goals of condylar fracture repair:Goals of condylar fracture repair:

– 1) Pain-free mouth opening with 1) Pain-free mouth opening with opening of 40mm or greateropening of 40mm or greater

– 2) Good mandibular motion of jaw in 2) Good mandibular motion of jaw in all excursionsall excursions

– 3) Restoration of preinjury occlusion3) Restoration of preinjury occlusion– 4) Stable TMJs4) Stable TMJs– 5) Good facial and jaw symmetry 5) Good facial and jaw symmetry

Condylar Process Condylar Process FracturesFractures Growth alteration from condylar Growth alteration from condylar

fractures:fractures:– Estimated that 5-20% of all severe Estimated that 5-20% of all severe

mandibular asymmetry is from mandibular asymmetry is from condylar traumacondylar trauma

– Believed to be from shortening of Believed to be from shortening of the ramus or alterations in muscle the ramus or alterations in muscle action leading to growth changesaction leading to growth changes

Condylar Process Condylar Process FracturesFractures Treatment alternatives:Treatment alternatives:

– Non-surgical- diet, observation and Non-surgical- diet, observation and physical therapyphysical therapy

– Closed reduction- utilizes a period of Closed reduction- utilizes a period of IMF the physical therapyIMF the physical therapy

– Open reductionOpen reduction

Condylar Process Condylar Process FracturesFractures Closed reduction:Closed reduction:

– Indications:Indications: Split condylar headSplit condylar head Intracapsular fractureIntracapsular fracture Small fragments from comminuted Small fragments from comminuted

condylecondyle Risk of devascularization of the condylar Risk of devascularization of the condylar

segment with ORIFsegment with ORIF

– Treated with short course of IMF Treated with short course of IMF with post-operative physical therapywith post-operative physical therapy

Condylar Process Condylar Process FracturesFractures Open reduction:Open reduction:

– Zide’s absolute indications:Zide’s absolute indications: 1) middle cranial fossa involvement with 1) middle cranial fossa involvement with

disabilitydisability 2) inability to achieve occlusion with 2) inability to achieve occlusion with

closed reductionclosed reduction 3) invasion of joint space by foreign 3) invasion of joint space by foreign

bodybody

Condylar Process Condylar Process FracturesFractures Open reduction:Open reduction:

– Zide’s relative indications:Zide’s relative indications: 1) bilateral condylar fractures where 1) bilateral condylar fractures where

the vertical facial height needs to be the vertical facial height needs to be restoredrestored

2) associated injuries that dictate early 2) associated injuries that dictate early or immediate functionor immediate function

3) medical conditions that indicate open 3) medical conditions that indicate open proceduresprocedures

4) delayed treatment with malalignment 4) delayed treatment with malalignment of segmentsof segments

Condylar Process Condylar Process FracturesFractures Open reduction Open reduction

techniques:techniques:– Multiple Multiple

approaches and approaches and fixation have fixation have been developed been developed and usedand used

Condylar Process Condylar Process FracturesFractures Studies have shown that closed Studies have shown that closed

reduction techniques rarely produce reduction techniques rarely produce pain, limit function, or produce growth pain, limit function, or produce growth disturbancesdisturbances

Open reductions techniques show an Open reductions techniques show an early return to normal function, but are early return to normal function, but are technique sensitive, time extensive, technique sensitive, time extensive, and can lead to facial nerve and can lead to facial nerve dysfunction depending upon surgical dysfunction depending upon surgical approachapproach

ComplicationsComplications Infection:Infection:

– Studies have looked at infection rates for Studies have looked at infection rates for different types of techniques: Highly variable in different types of techniques: Highly variable in literatureliterature

– Most early studies indicate a decrease in Most early studies indicate a decrease in infection rates with plating after time infection rates with plating after time (experience)(experience)

– Dodson et al. J Oral Maxillofac Surg 1990;48Dodson et al. J Oral Maxillofac Surg 1990;48 Closed reduction- 0%Closed reduction- 0% Wire osteosynthesis- 20%Wire osteosynthesis- 20% Rigid fixation- 6.3%Rigid fixation- 6.3%

– Assael J Oral Maxillofac Surg 1987;45Assael J Oral Maxillofac Surg 1987;45 Closed reduction- 8%Closed reduction- 8% Wire osteosynthesis- 24%Wire osteosynthesis- 24% Rigid fixation- 9%Rigid fixation- 9%

ComplicationsComplications

Infection:Infection:– Studies show variation of infection rates Studies show variation of infection rates

with rigid vs. non rigid fixation schemeswith rigid vs. non rigid fixation schemes– Most show that wire osteosynthesis Most show that wire osteosynthesis

techniques have the highest infection techniques have the highest infection rates due to the higher level of mobility at rates due to the higher level of mobility at fracture site, leading to vascular damage fracture site, leading to vascular damage and perculation of bacteria into facture and perculation of bacteria into facture site. Is this due to early mobilization of site. Is this due to early mobilization of patient?????patient?????


Due to dirty environment of oral Due to dirty environment of oral cavity, mandible fractures should be cavity, mandible fractures should be on antibiotics to decrease infections, on antibiotics to decrease infections, especially with fractures in the especially with fractures in the dento-alveolar portion.dento-alveolar portion.

Difficult to get a concensus of Difficult to get a concensus of infection rates due to wide range infection rates due to wide range and case report citings in the and case report citings in the literatureliterature


Malocclusion:Malocclusion:– More difficult to manage with rigid More difficult to manage with rigid

fixationfixation– Most studies have shown that Most studies have shown that

malocclusion occur more malocclusion occur more frequently with rigid fixationfrequently with rigid fixation

– May be due to plate mal-May be due to plate mal-positioning/iatrogenicpositioning/iatrogenic

– Low risk in pediatric fractures due Low risk in pediatric fractures due to growth and dentition repositionto growth and dentition reposition


Malunion and nonunion:Malunion and nonunion:– Most nonunions occur from infections Most nonunions occur from infections

of the fracture or teeth in the line of of the fracture or teeth in the line of fracturefracture

– Malunions are usually tolerated well by Malunions are usually tolerated well by the patient, most malunions of the the patient, most malunions of the body, symphysis, or angle can result in body, symphysis, or angle can result in malocclusions. This is harder for the malocclusions. This is harder for the patient to tolerate. More common with patient to tolerate. More common with improper use of fixation technique.improper use of fixation technique.

Teeth in the Fracture Teeth in the Fracture LineLine Should a tooth in the line of fracture be Should a tooth in the line of fracture be

removed?removed?– If the periodontium is reasonably intact, the If the periodontium is reasonably intact, the

tooth can be lefttooth can be left– If the tooth has not sustained major If the tooth has not sustained major

structural or pulpal injury, it can be leftstructural or pulpal injury, it can be left– If the tooth does not interfere with fracture If the tooth does not interfere with fracture

reduction, it can be leftreduction, it can be left– Patients with teeth in the line of fracture are Patients with teeth in the line of fracture are

considered to have open fractures and considered to have open fractures and should be placed on antibiotic coverageshould be placed on antibiotic coverage

– Removal of a tooth in the fracture line can Removal of a tooth in the fracture line can lead to displacement and difficulty in lead to displacement and difficulty in fracture reductionfracture reduction

ConclusionsConclusions

Simplest method is probably the Simplest method is probably the best methodbest method

Just because something can be Just because something can be done, should it?done, should it?

If the prognosis of a tooth is in If the prognosis of a tooth is in question, remove it.question, remove it.

ConclusionsConclusions

Closed reduction techniques are Closed reduction techniques are much better in pediatric and much better in pediatric and condylar fracturescondylar fractures

Antibiotics should be used in all Antibiotics should be used in all mandible fractures except mandible fractures except fractures only in the ramus, fractures only in the ramus, coronoid, or condylar region that coronoid, or condylar region that are closed.are closed.


Get the proper occlusion prior to Get the proper occlusion prior to plating. Malunions/malocclusions plating. Malunions/malocclusions poorly tolerated by patients.poorly tolerated by patients.

The literature is highly variable on The literature is highly variable on complication rates. The technique complication rates. The technique utilized is really up to the surgeon and utilized is really up to the surgeon and their perceived comfort. No true their perceived comfort. No true standard of care for mandible standard of care for mandible fractures.fractures.

damages of middle area of face: classification, clinic, diagnostics, temporal (transporting)...

Documents

years of mandible fractures

mandible fracturehaug

oral surg oral med oral

j oral surg

epidemiologymandible

lines of fractures

risk of condylar fractures

j bone joint surg