management of mandibular fractures.ppt

$: Management of Mandibular fractures.ppt$
7/18/2019 Management of Mandibular fractures.ppt

http://slidepdf.com/reader/full/management-of-mandibular-fracturesppt 1/53

11

Maxillofacial TraumaMaxillofacial Trauma

Management of Mandibular FracturesManagement of Mandibular Fractures

Mandible is embryologically a membrane bent bone although,

resembles physically long bone it has two articular cartilages

with two nutrient arteries



22

Mandible in traumaMandible in traumaMandibular fracture is more common than middleMandibular fracture is more common than middlethird fracturethird fracture (anatomical factor)(anatomical factor)

It could be observed either alone or in combinationIt could be observed either alone or in combinationwith other facial fractureswith other facial fractures

Minor mandibular fracture may be associated withMinor mandibular fracture may be associated withhead injury owing to the cranio-mandibularhead injury owing to the cranio-mandibulararticulationarticulation

Mandibular fracture may compromise the patency ofMandibular fracture may compromise the patency ofthe airway in particular with loss of consciousnessthe airway in particular with loss of consciousness

Fracture of mandible occurred with frontal impactFracture of mandible occurred with frontal impactforce as low as 425 lb (!" #g$force as low as 425 lb (!" #g$ {Condylar fracture}{Condylar fracture}



33

Fracture of condyle regarded as a safety mechanismFracture of condyle regarded as a safety mechanismto the patientto the patient

Frontal force of %""-!"" lb (&5"-4"" #g$ is re'uiredFrontal force of %""-!"" lb (&5"-4"" #g$ is re'uiredto cause symphesial fractureto cause symphesial fracture

Mandible was more sensitive to lateral impact thanMandible was more sensitive to lateral impact thanfrontal onefrontal one

Frontal impact is substantially cushioned by openingFrontal impact is substantially cushioned by openingand retrusion of the jawand retrusion of the jaw

(Nahum 19! (Nahum 19! ) )

ong canine tooth and partially erupted wisdomsong canine tooth and partially erupted wisdomsrepresent line of relatively wea)nessrepresent line of relatively wea)ness



44

Anatomical considerations Anatomical considerations

Attached muscles: Attached muscles:

Masseter Masseter

TemporalisTemporalis

Medial and lateralMedial and lateralpterygoidpterygoid

MylohyoidMylohyoid

Geniohyoid andGeniohyoid andgenioglosusgenioglosus

anterior belly ofanterior belly ofdigastricsdigastrics



*lood supply*lood supply

+ndosteal supply via the I, artery and+ndosteal supply via the I, artery andveinvein

eriosteal supply. important in agingeriosteal supply. important in agingdue to diminishes and disappearancedue to diminishes and disappearanceof alveolar arteryof alveolar artery

"radley 19# "radley 19#

/erve/erve

,amage of inferior dental nerve,amage of inferior dental nerve

Facial palsy by direct trauma to ramusFacial palsy by direct trauma to ramus

,amage of facial nerve in temporal,amage of facial nerve in temporalbone fracturebone fracture

$oin 19%& $oin 19%& ,amage to mandibular division of,amage to mandibular division offacial nervefacial nerve



!!

Factors influenced site of fractureFactors influenced site of fracture

and displacementand displacement

0natomy of the0natomy of themandible and attachedmandible and attachedmuscle (canine 1muscle (canine 1wisdoms$wisdoms$

ea)ening areas ofea)ening areas ofmandible (resorptionmandible (resorptionand pathologyl$and pathologyl$

,irection of force of the,irection of force of theblowblow

0ge of the patient0ge of the patient



""

Types of fractureTypes of fracture

3imple3imple

reenstic) fracture (rare.reenstic) fracture (rare.eclusively in children$eclusively in children$

Fracture with no displacementFracture with no displacement(inear$(inear$

Fracture with minimalFracture with minimaldisplacementdisplacement

,isplaced fracture,isplaced fracture

6omminuted fracture6omminuted fracture'tensie brea*age with possible bone'tensie brea*age with possible bone

and soft tissue lossand soft tissue loss

6ompound fracture6ompound fracture+eere and tooth bearing area fractures+eere and tooth bearing area fractures

athological fractureathological fracture(osteomyelities, neoplasm and(osteomyelities, neoplasm and

generalied s*eletal disease)generalied s*eletal disease)



##

$ites of fractures$ites of fractures6ondyle fracture6ondyle fracture

% Intracapsular fractureIntracapsular fracture

% +tracapsular fracture+tracapsular fracture

&igh condyle nec' fracture&igh condyle nec' fracture

(o) condylar fracture(o) condylar fracture

0ngle7 ramus fracture0ngle7 ramus fracture *body*bodyfracture+fracture+

6anine region6anine region *parasymphesial*parasymphesial

fracture+fracture+

Midline fractureMidline fracture *symphesis*symphesis

fracture+fracture+

6oronoid fracture6oronoid fracture *rare+*rare+



Mandible FractureFrequency

Condyle30%

Ramus3%

Angle 25%

Body 25% Parasympyseal ! Mental

"5%

Coronoid process2%



1,1,

Fa-ourable orFa-ourable or unfa-ourableunfa-ourable

8hey can be vertically or hori9ontally in8hey can be vertically or hori9ontally in

directiondirection

8hey are influenced by the medial pterygoid-8hey are influenced by the medial pterygoid-masseter :sling;masseter :sling;

If the vertical direction of the fracture favours theIf the vertical direction of the fracture favours theunopposed action of medial pterygoid muscle. theunopposed action of medial pterygoid muscle. theposterior fragment will be pulled linguallyposterior fragment will be pulled lingually

If the hori9ontal direction of the fracture favours theIf the hori9ontal direction of the fracture favours theunopposed action of messeter and pterygoid muscles inunopposed action of messeter and pterygoid muscles inupward direction. the posterior fragment will be pulledupward direction. the posterior fragment will be pulledlinguallylingually

Favourable fracture line ma)es the reducedFavourable fracture line ma)es the reduced

fragment easier to stabili9efragment easier to stabili9e



1111

.ffects of muscles on displacement.ffects of muscles on displacement

Trans-erse midline fracture *symphesial+Trans-erse midline fracture *symphesial+

stabili/es by the action of mylohyoid andstabili/es by the action of mylohyoid and

geniohyoidgeniohyoid

0bliue fracture *parasymphesial+ tends to0bliue fracture *parasymphesial+ tends too-erlap under the influence of muscles actiono-erlap under the influence of muscles action

ilateral parasymphesial fracture results inilateral parasymphesial fracture results inbac')ard displacement associated )ith loss ofbac')ard displacement associated )ith loss of

tongue control )hen the le-el of consciousnesstongue control )hen the le-el of consciousness

is depressedis depressed



1212

ondylar fracturesondylar fractures

The most common mandibular fractureThe most common mandibular fracture<nilateral or bilateral<nilateral or bilateral

Intracapsular or etracapsular Intracapsular or etracapsular

Anteromedial displacement is Anteromedial displacement is

common but it may remaincommon but it may remain

angulated )ith the ramusangulated )ith the ramus

5islocation of the glenoid fossa and5islocation of the glenoid fossa andfracture of petrous temporal bonefracture of petrous temporal bone

)hich is -ery rare)hich is -ery rare



1313

$ign and symptoms$ign and symptoms

3welling. pain. tenderness and restriction of movement3welling. pain. tenderness and restriction of movement

,eviation of mandible towards the side of fracture,eviation of mandible towards the side of fracture

agging of occlussion (premature contact on the posterioragging of occlussion (premature contact on the posteriorteeth$ with bilateral condylar displaced or over-riding fracturesteeth$ with bilateral condylar displaced or over-riding fractures

,isplacement of mandible toward the affected side,isplacement of mandible toward the affected side

0nterior open bite on opposite side of fracture0nterior open bite on opposite side of fracture

aceration of +0M====aceration of +0M====

>etroauricular ecchymosis====>etroauricular ecchymosis====

6erebrospinal lea) and otorrhea in association with s)ull base6erebrospinal lea) and otorrhea in association with s)ull basefracturefracture

6ondylar fractures6ondylar fractures



1414

3e'ulae of 8M? injury3e'ulae of 8M? injury

0rtheritic changes0rtheritic changes

@aemartherosis. fibrosis and a)nylosis@aemartherosis. fibrosis and a)nylosis

Meniscal damage and detachmentMeniscal damage and detachment

8M,8M,

+taph infection+taph infection with condylar bac)wardwith condylar bac)warddisplacement and eternal auditory meatus injurydisplacement and eternal auditory meatus injury

MeningitisMeningitis with petrous temporal bone fracture andwith petrous temporal bone fracture andintracranial involvementintracranial involvement

6ondylar fractures6ondylar fractures



11

6oronoid process fractureA6oronoid process fractureA

>are fracture caused by direct trauma to>are fracture caused by direct trauma toramus and results from reflu contraction oframus and results from reflu contraction oftemporalistemporalis

6an be seen following operation of large6an be seen following operation of largeramus cystramus cyst

+licit tenderness over the anterior part of+licit tenderness over the anterior part oframusramus

,evelopment of tell-tale haematoma,evelopment of tell-tale haematoma



1!1!

Fracture of the ramusAFracture of the ramusA

Type 6 $ingle fractureType 6 $ingle fracture Mimics low condylar fracture that runsMimics low condylar fracture that runs

below the sigmoid notchbelow the sigmoid notch

Type 66 comminuted fractureType 66 comminuted fracture

Common in missile injuries and appears toCommon in missile injuries and appears to

be with little displacement due to effects ofbe with little displacement due to effects of

messeter and medial pterygoid musclesmesseter and medial pterygoid muscles



1"1"

Fracture of the angle and bodyFracture of the angle and bodyain. tenderness and trismusain. tenderness and trismus

+tra-oral swelling at the angle with obvious+tra-oral swelling at the angle with obviousdeformitydeformity

3tep deformity behind the molar teeth3tep deformity behind the molar teeth

Movement and crepitus at the fracture siteMovement and crepitus at the fracture site

,erangement of occlussion,erangement of occlussion

Intra-oral buccal and lingula heamatomaIntra-oral buccal and lingula heamatoma

Involvement of I,/Involvement of I,/

ingival tear if fracture in dentated areaingival tear if fracture in dentated area

8ooth involvement and possible longitudinal split8ooth involvement and possible longitudinal split

fracturefracture



1#1#

Midline fractureMidline fracture

8he most common missed fracture (always8he most common missed fracture (always

fine crac)$fine crac)$

6an be symphesial or parasymphesial6an be symphesial or parasymphesialfracturefracture

6ommonly associated with one or both6ommonly associated with one or bothcondyles fracturecondyles fracture

<nilateral fracture leads to over-riding of<nilateral fracture leads to over-riding ofthe fragments and bilateral may contributethe fragments and bilateral may contribute

in loss of voluntery tongue controlin loss of voluntery tongue control

ong canine tooth represent a wea) areaong canine tooth represent a wea) areaand contributes to parasymphesial fractureand contributes to parasymphesial fracture

>arely runs across mental foramen>arely runs across mental foramen

Midli f t



1717

$igns and symptoms$igns and symptoms

ain and tendernessain and tenderness

3welling and odemea3welling and odemea

,evelopment of step deformity,evelopment of step deformity

Mental anesthesiaMental anesthesia

@eamatoma in the floor of mouth and buccal mucosa@eamatoma in the floor of mouth and buccal mucosa

3oft tissue injury of the chin and lower lip3oft tissue injury of the chin and lower lip

If associated with condylar fracturesIf associated with condylar fractures

0bsence of condyle movement on the contrlateral side0bsence of condyle movement on the contrlateral side

,eviation of mandible,eviation of mandible

0nterior open bite0nterior open bite

agging of oclussionagging of oclussion

imitation of mouth openingimitation of mouth opening

Midline fracture



2,2,

linical assessment and diagnosislinical assessment and diagnosis

@istory of trauma@istory of trauma (traumati9ed patients with possible head injury$ and facial(traumati9ed patients with possible head injury$ and facial

injuriesinjuries

6linical +amination6linical +amination +troral+troral

Inspection (assessment of asymmetery. swelling. ecchymosis. lacerationInspection (assessment of asymmetery. swelling. ecchymosis. lacerationand cut wounds$and cut wounds$

alpation for eliction of tenderness. pain. step deformity and malfunctionalpation for eliction of tenderness. pain. step deformity and malfunction

Intra- and paraoralIntra- and paraoral

bleeding. heamatoma. gingival tear. gagging of occlussionbleeding. heamatoma. gingival tear. gagging of occlussionand step deformity and sensory and motor deficiencyand step deformity and sensory and motor deficiency

>adiographs>adiographs



2121

8adiographs8adiographs

9lain radiograph9lain radiograph09G09G

(ateral obliue(ateral obliue

9A mandible9A mandible

A9 mandible *re-erse A9 mandible *re-erse

To)nes+To)nes+

(o)er occlusal(o)er occlusal

T scanT scan

35 T imaging35 T imaging

M86M86

http://www.srt-psc.com/jfmand2.jpg






5 fi iti t t t5 fi iti t t t



2323

5efiniti-e treatment5efiniti-e treatment

3oft tissue repair 3oft tissue repair 5ebridment5ebridment

6rrigation )ith saline and antibiotics6rrigation )ith saline and antibioticslosure in layerslosure in layers

5ressing5ressing

>eduction and fiation of the jaw>eduction and fiation of the jaw

▶▶ 6lose reduction and IMF (traditional method by means of6lose reduction and IMF (traditional method by means ofmanipulation$manipulation$

▶▶ Bpen reduction and semi-rigid fiation (using inter-ossousBpen reduction and semi-rigid fiation (using inter-ossouswirings$wirings$

▶▶ Bpen reduction and rigid fiation (using bone palatesBpen reduction and rigid fiation (using bone palatesosteosynthesis$osteosynthesis$

BbjectiveABbjectiveA

-estoration of functional alignment of the bone fragments in-estoration of functional alignment of the bone fragments inanatomically precise position utiliing the present teeth foranatomically precise position utiliing the present teeth for

guidanceguidance



2424

lose reductionlose reduction

Arch bars Arch bars % ?elen)o?elen)o

% +rich pattern+rich pattern

% erman silver notchederman silver notched

ap splintsap splints

MMF $cre)MMF $cre)

▶ ▶ .M/0MM/ prior to rigid fiation.M/0MM/ prior to rigid fiation

▶ ▶ /or the purpose of close/or the purpose of close

reductionreduction



22

lose reductionlose reductiononded brac'etsonded brac'ets

6MFMMF scre)s *;uic'Fix+6MFMMF scre)s *;uic'Fix+

5ental )iring:5ental )iring:,irect wiring,irect wiring

+yelet wiring+yelet wiring

ocal anesthesia or ocal anesthesia or sedationsedation

Minimal displacementMinimal displacement

6MFMMF *;uic'Fix+ for ! )ee's6MFMMF *;uic'Fix+ for ! )ee's reatment can be performed under $2 or 32 andreatment can be performed under $2 or 32 and

when surgery is contraindicated when surgery is contraindicated



Archbar -s MMF $cre) *;uic'Fix+ Archbar -s MMF $cre) *;uic'Fix+

Archbar Archbar

(ess on-enience(ess on-enience9atients9atients

8euire teeth for fixation8euire teeth for fixation

5amage teeth and periodontal5amage teeth and periodontal

tissuetissue

<ncomfortable during the fixation<ncomfortable during the fixation

periodperiod

5ifficult daily maintenance of oral5ifficult daily maintenance of oral

hygienehygiene

0perator 0perator

8is' of bloodtransmitted diseases8is' of bloodtransmitted diseases

=eed longer time to use=eed longer time to use

MMF $cre) *;uic'Fix+MMF $cre) *;uic'Fix+

The .asy Alternati-e toThe .asy Alternati-e to

Arch ars Arch ars

9atented Auto5ri-e self drilling9atented Auto5ri-e self drillingscre)sscre)s

5ramatically reduces application5ramatically reduces application

time of MMFtime of MMF (only 5 minutes)(only 5 minutes)

$imple$imple

Minimi/es ris' of )ire punctureMinimi/es ris' of )ire puncture

)ound)ound

etter oral hygiene maintenanceetter oral hygiene maintenance

6deal for edentulous or partially6deal for edentulous or partially

edentulousedentulous



2"2"

Fracture mandible in childrenFracture mandible in children

lose reductionlose reduction0pen reduction and0pen reduction and

fixationfixation

9lating at the inferior9lating at the inferiorborder border

iodegradable plateiodegradable plate

and scre)and scre)

http://www.srt-psc.com/ca2.jpg

http://www.srt-psc.com/ca3.jpg



2#2#

0pen 8eduction and Fixation $ystem0pen 8eduction and Fixation $ystem

6ntraoral approach6ntraoral approach

.xtraoral approach.xtraoral approach

▶▶ $ubmandibular$ubmandibular

approachapproach



2727

8igid Fixation $ystem8igid Fixation $ystem

6ntraossous )iring6ntraossous )iring

9lates and scre)s9lates and scre)s

2>,mm and 2>4mm2>,mm and 2>4mm

% $tandard plate and$tandard plate andscre)scre)

% (oc'ing plate and(oc'ing plate and

scre)scre)

?irchener )ire?irchener )ire

(ag scre)s(ag scre)s



9late 2>,mm and 2>4mm9late 2>,mm and 2>4mm

3,3,



3131

8econstruction palate8econstruction palate

3evere trauma

oss of part of the bone



8econ: TA8econ: TA

Temporary ondyle Attachment *TA+Temporary ondyle Attachment *TA+

% 0ncologyAblation cases only0ncologyAblation cases only

% Maximum implantation of 1 year Maximum implantation of 1 year

% 0nly 0steoMed Medically Trac'ed 5e-ice0nly 0steoMed Medically Trac'ed 5e-ice

3 Forms3 Forms

% =o (eft8ight=o (eft8ight

% <niue Anatomical $hape<niue Anatomical $hape

% Ad@ustable Ad@ustable



8econstruction (oc'ing 9late8econstruction (oc'ing 9late



Recon: InstrumentsRecon: Instruments

InstrumentationInstrumentation

– Lag screw cannulaLag screw cannula

and depth gaugeand depth gauge

Tip of gauge )ill

point to drill exit

point

(ength of scre)

needed to engage

both cortices

The measurement

directly abo-e the

drill entry point )ill

state needed length



8econ: 6nstrumentation8econ: 6nstrumentation



Recon: InstrumentationRecon: Instrumentation

InstrumentationInstrumentation– Fx plate bending pliersFx plate bending pliers

– Roller bendersRoller bendersUsed for major contoursUsed for major contours

Bends in the saggital andBends in the saggital andlateral planelateral plane

– Reconstruction bendingReconstruction bendingplierspliers

For intermediate bendingFor intermediate bending

– Bending ironsBending ironsBending slot in the tipBending slot in the tip

Finishing bendsFinishing bends

Unusual or tight bendsUnusual or tight bends




6nstrumentation6nstrumentation

% Fracture plate bendersFracture plate benders





% Taperloc'Taperloc' tmtm scre)dri-erscre)dri-er

bodybody

% Modular for all theModular for all thedri-ers stems tapsdri-ers stems taps

and countersin'sand countersin's





% alibrated platealibrated plate

bendersbenders

% alibrated Btic'C mar'salibrated Btic'C mar'sto estimate step rangeto estimate step range

for B(C and Ded platesfor B(C and Ded plates





% 3 prong plate benders3 prong plate benders

<sed )ith 1, and 1!<sed )ith 1, and 1!

hole plates to bend inhole plates to bend in

the saggital planethe saggital plane





% 8ight angle plate8ight angle plate

bendersbenders

9laces 7, degree angle9laces 7, degree angle

bends in platesbends in plates

<sed )ith B(C and Ded<sed )ith B(C and Ded

plates for (eFort 1plates for (eFort 1

osteotomiesosteotomies




annulaTrocar annulaTrocar

% Trocar is used toTrocar is used topenetrate soft tissuepenetrate soft tissue




annulahee'annulahee'

retractor retractor

annula5rill guideannula5rill guide





% hee' 8etractor B<Chee' 8etractor B<C$hape$hape

% hee' 8etractor hee' 8etractor

% annulaannula

% =eutral 5rill Guide=eutral 5rill Guide





% annula5epth gaugeannula5epth gauge

5etermines )hat si/e5etermines )hat si/e

scre) needs to be usedscre) needs to be used



4!4!

ondylar fracturesondylar fractures

6ntraoral approach6ntraoral approach

8amus incision8amus incision

.xtraoral approach.xtraoral approach4reauricular approach4reauricular approach

-etromandibular approach-etromandibular approach



4"4"

6MFMMF6MFMMF

Transosseous )iringTransosseous )iring

ircumferential )iringircumferential )iring

.xternal pin fixation.xternal pin fixation

one clampsone clamps

Transfixation )ith ?irschner )iresTransfixation )ith ?irschner )ires

Maxillo Mandibular Fixation $cre) *;uic'Fix+Maxillo Mandibular Fixation $cre) *;uic'Fix+



4#4#

0steosynthesis0steosynthesis

=oncompression small plates=oncompression small plates

ompression platesompression plates

Mini plates *2>,mm and 2>4mm+Mini plates *2>,mm and 2>4mm+

(ag scre)s(ag scre)s

iodegradable plates and scre)siodegradable plates and scre)s



4747

Teeth in the fracture lineTeeth in the fracture line

The fracture is compound into the mouthThe fracture is compound into the mouth

The tooth may be damaged or lose itsThe tooth may be damaged or lose itsblood supplyblood supply

The tooth may be affected by someThe tooth may be affected by somepreexisting pathologypreexisting pathology

Management of teeth retained in fractureManagement of teeth retained in fracture



,,

Management of teeth retained in fractureManagement of teeth retained in fracture

lineline

Good uality intraoral periapical radiographGood uality intraoral periapical radiograph

6nsinuation of appropriate systemic antibiotic6nsinuation of appropriate systemic antibiotic

therapytherapy

$plinting of tooth if mobile$plinting of tooth if mobile

.ndodontic therapy if pulp is exposed.ndodontic therapy if pulp is exposed

6mmediate extraction if fracture becomes6mmediate extraction if fracture becomes

infectedinfectedFollo) up for 1 year and endodontic therapy ifFollo) up for 1 year and endodontic therapy if

there is a loss of -italitythere is a loss of -itality



11

0bsolute indications0bsolute indicationsongitudinal fractureongitudinal fracture

,islocation or subluation from soc)et,islocation or subluation from soc)et

resence of periapical infectionresence of periapical infection

Infected fracture lineInfected fracture line

0cute pericoronitis0cute pericoronitis

>elative indications>elative indicationsFunctional tooth that would be removedFunctional tooth that would be removed

0dvanced caries or periodontal diseases0dvanced caries or periodontal diseases

,oubtful tooth which would be added to eisting,oubtful tooth which would be added to eistingdenturedenture

8ooth in untreated fracture presenting more than &8ooth in untreated fracture presenting more than &days after injurydays after injury



omplicationsomplications Air)ay esp )ith 6MF *)ire cutters and preop education+ Air)ay esp )ith 6MF *)ire cutters and preop education+

6nfection6nfection

5elayed and nonunion5elayed and nonunion

% 6nadeuate immobilisation fracture alignment6nadeuate immobilisation fracture alignment

% 6nteposition of soft tissue or foreign body6nteposition of soft tissue or foreign body

% 6ncorrect techniue6ncorrect techniue

6nferoir al-eolar ner-e damage6nferoir al-eolar ner-e damage

%!Epretreatment!Epretreatment

% 17E posttreatment17E posttreatment

MalocclusionMalocclusion

TM an'ylosis esp intracapsular condyle TM an'ylosis esp intracapsular condyle 22

management of mandibular fractures.ppt

Documents