MANDIBULAR ANGLE FRACTURES
Dr. Amit T. SuryawanshiOral and Maxillofacial Surgeon
Pune, India
Contact details :Email ID - [email protected] 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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