MANDIBULAR ANGLE FRACTURES

Dr. Amit T. SuryawanshiOral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.comMobile No - 9405622455

INTRODUCTION

LARGEST SINGLE FRACTURE

CLINICAL CHALLENGE TO TREAT

HIGHEST POST SURGICAL COMPLICATIONS

WHY ?

PRESENCE OF THIRD MOLAR

THINNER CROSS SECTION AREA

“LEVER AREA”

“ Ellis et al 1999 JOMFS”

ANGLE FRACTURE

HISTORY

HIPPOCRARUS-MONOMAXILLARY DENTAL FIXATION AND BINDING

SULICETTI-1492”THE TEETH OF JAW TO TEETH OF UNINJURED JAW

LUHR 1960

MICHELET AND CHAMPY 1970’S

EDWARD ELLIS 1990’S

SURGICAL ANATOMY

ANATOMIC ANGLE

CLINICAL ANGLE

SURGICAL ANGLE

ROLE OF MUSCLES

MUSCLES OF MASTICATION

MUSCLES OF FACIAL EXPRESSION

ACCESSORY MUSCLES OF MASTICATION

BIOMECHANICS OF THE MANDIBLE

BLOOD SUPPLY

CENTRALLY

PERIPHERALLYPERIOSTEAL VESSELSMUSCLE ATTACHMENTS

ETIOLOGY

ALTERCATIONS

BLOW FROM LATERAL PORTION OF THE MANDIBLE

INDIRECT FRATURE

PRESENCE OF THIRD MOLAR

“David Halmos ,Ellis JOMFS 2004”

INCIDENCE

CLASSIFICATIONS

RELATION TO EXTERNAL ENVIRONMENT

1.SIMPLE/CLOSED

2.COMPOUND/OPEN

CLASSIFICATIONS(CONTD)

TYPES OF FRACTURE

1.INCOMPLETE

2.COMPLETE

3.GREENSTICK

4.COMMINUTED

CLASSIFICATIONS(CONTD)

WITH REFERENCE TO DENTITION

1.SUFFICIENTLY DENTULOUS JAW

2.EDENTULOUS /INSUFFICIENTLY DENTULOUS JAW

3.PRIMARY/MIXED DENTITION

CLASSIFICATIONS(CONTD)

DIRECTION OF FRACTURE LINE AND THE EFFECT OF MUSCLE ACTION ON THE FRACTURE FRAGMENTS

1.VERTICALLY FAVORABLE/UNFAVORABLE

2.HORIZONTALLY FAVORABLE/UNFAVORABLE

HORIZONTALLY FAVORABLE/UNFAVORABLE

VERTICALLYFAVORABLE/UNFAVORABLE

DIAGNOSIS

HISTORY:PREEXISTING BONE DISEASE,NEOPLASIA,COLLAGEN DISORDERS, METABOLIC DISORDERS,ENDOCRINE DISORDERS,PSYCHIATRIC PROBLEMS. “PATHOLOGIC FRACTURE”

HISTORY

VEHICLE ACCIDENT VS PERSONAL VIOLANCE

BLUNT OBJECT VS SMALL WELL DEFINED OBJECT

DIRECTION OF FORCE

ANTERIOR BLOW TO THE CHIN

AN ANGLED BLOW FROM LATERAL DIRECTION

FRACTURE MECHANISMS

Angle and Opposite Body

Bilateral Angle

Condyle and Opposite Angle

Isolated angle

Impacted fracture

CLINICAL FEATURES

CHANGE IN FACIAL CONTOURFLATTENED APPEARANCEA DEFICIENT MANDIBULAR ANGLEAPPEARANCE OF ELONGATED FACE

CHANGE IN OCCLUSSIONPREMATURE POSTERIOR DENTAL CONTACTANTERIOR OPEN BITEUNILATERAL OPEN BITERETROGNATHIC OCCLUSSION

CLINICAL FEATURES

ANESTHESIA,PARESTHESIA/DYESTHESIAABNORMAL MANDIBULAR MOVEMENTS-INABILITY TO CLOSE THE JAW/TRISMUSLACERATIONS,HAMATOMA,ECCHYMOSISCREPITATIONS

METHOD OF PALPATION

CLOSED REDUCTION

GROSSELY COMMINUTED FRACTURE

FRACTURE OF ATROPHIC MANDIBLE

FRACTURE OF CHILDREN INVOLVING DEVELOPING DENTITION

NONDISPLACED FAVORABLE FRACTURE

Closed reduction options

LENGTH OF IMF

TRADITIONALLY 6 WEEKSAMARTANGA ET AL.MOST UNCOMPLICATED FRACTURE UNITED IN CHILDREN 2-3 WEEKS ,ADULTS 3-4 WEEKS,ELDER 6-8 WEEKSCOMMINUTED FRACTURE, NUTRITIONAL PROBLEMS,PSYCHOLOGICAL HANDICAPS,LATE TREATMENT,TEETH IN LINE OF FRACTURE REQUIRES LONGER PERIOD OF IMMOBILIZATION.

OPEN REDUCTION

WHEN CLOSED REDUCTION WILL NOT WORK.ANGLE FRACTURE DISPLACED AT THE TIME OF INJURY.HORIZONTALLY/VERTICALLY UNFAVORABLE FRACTURE.PROLONGED DELAY IN TREATMENTINTERPOSITIONAL SOFT TISSUECOMPLEX FACIAL FRACTUREMEDICALLY COMPROMISED PATIENTSCONCURRENT CONDYLAR FRACTURE

SURGICAL APPROACHES

SUBMANDIBULAR APPOACH

RETROMANDIBULAR APPROACH

INTRAORAL ACCESS

FIXATION

METHODS OF HISTORICAL INTEREST

ROBINSON AND YOON PLATE

MENON PLATE

WIRE OSTEOSYNHTESIS

RIGID FIXATION

TRANSOSSEOUS WIRESSIMPLE WIRING TECHNIQUE

FIGURE OF 8 WIRES

TRANSOSTEAL CIRCUMMANDIBULAR WIRING(OBWEGESSOR TECHNIQUE)

RIGID INTERNAL FIXATION

COMPRESSION OSTEOSYNTHESISDYNAMIC COMPRESSION PLATESECCENTRIC DYNAMIC COMPRESSION PLATESRECONSTRUCTION PLATESTHSOMONOCORTICAL MINIPLATESMICROPLATESLAG SCREW OSTEOSYNTHESISBIORESORBABLE PLATES

COMPRESSION PLATES

EDC

AO/ASIF PRINCIPLE

ANATOMIC REDUCTIONRIGID FIXATIONATRAUMATIC SURGICAL TECHNIQUEIMMEDIATE ACTIVE FUNCTIONIN 1994 FUNCTIONALLY STABLE OCCLUSION

“EDWARD ELLISS INT.J.MFS1999”

MINIPLATES

SEMIRIGID FIXATION

ALOOWS PRIMARY AND SECONDARY HEALING

SHORT PERIOD OF IMF

Some controversy

THE NEED FOR POST SURGICAL MMF

TIME BETWEEN THE FRACTURE AND SURGERY.

USE OF MINIPLATES IN INFECTED FRACTURES

“NAKAMURA S ET AL. COMPLICATIONS OF MINI PLATE . J ORAL MAXILLOFAC SURG 52:233,1994”

LAG SCREWES

LAG SCREWES

RECONSTRUCTION PLATES

EXTERNAL FIXATION

BIORESORBABLE PLATES

ANGLE FRACTURE IN CHILDREN

“KABAN-PAEDIATRIC ORAL MAXILLOFACIAL SURGERY”

ANGLE FRACTURE IN EDENTULOUS MANDIBLE

TREATMENT OF MALUNITED ANGLE FRACTURE

Soft tissue interposition

Titanium mesh/Vitallium mesh

Autogenous bone graft

Bloomquist (1982)

“Thomas Schug et al J. CRAN. MFS 2000”

REVIEW OF LITERATURES TREATMENT REFERENCES SAMPLE COMPLICATIONS

No rigid fixation Passeri et l1993 99 17%

AO reconstruction plate Ellis et al 1993 52 7.5%

Lag screw Ellis et al 1991 88 13%

Two minidynamic compression plates (2.omm)

Ellis et al 1992 30 29%

Two dynamic compression plates (2.4mm)

Ellis et al 1993 65 32%

Two non- compression miniplates

Ellis et al 1994 67 23%

One non- compression miniplates

Ellis et al 1996 81 16%

One malleable non- compression

miniplates

Potter et al 1999 51 15.2%

CONCLUSION

REFERENCES

1. Fonseca-0ral and maxillofacial surgery. Vol.3” 2. Row and Williams – Trauma3. Fonseca- Trauma4. KABAN-PAEDIATRIC ORAL MAXILLOFACIAL SURGERY5. JOURNAL OF MAXILOFACIAL SURGERY6. Passeri et l 1993 7. Ellis et al 1993 8. Ellis AND Ghali et al 19919. Ellis and Karas et al 199210. Ellis and Sinn et al 199311. Ellis and Walker et al 199412. Ellis and Walker et al 199613. Potter and Ellis et al 199914. George Dimitroulis 200215. David Halmos ,Ellis 2004

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