mandibular fractures

Osteomyelitis of jaws

Mandibular Fractures

03/06/15Mandibular Fractures 1/116

HISTORYINTRODUCTIONANATOMYCLASSIFICATIONEXAMINATION AND DIAGNOSISTREATMENT

03/06/15Mandibular Fractures 2 Contents:

The pre-Christian eraThe first description of mandibular fractures dates to the 17th Century BC in the Edwin Smith papyrus,

Hippocrates direct reapproximation of # segments with the use of circum dental wires

1180, Textbook written in Salerno, Italy importance of establishing a proper occlusion.

1492, the book Cyrurgia by Guglielmo Salicetti first mention of the use of maxillomandibular fixation in treatment of mandibular #.

03/06/15Mandibular Fractures 3 History:

History1887, Gilmer reintroduced MMF in United States.Buck & Kinlock- first to do ORIF using wires.1888 Schede- First to use stainless steel plate & screws.1960, Luhr- first to use Vitallium compression plate1970, Spiessl through AO/ASIF introduced principles of rigid internal fixation.1970, Michelet- introduced small bendable, non compression plates- these were further modified by Champy.1987 M.S. Leonard first to report use of lag screwsLate 1990s introduction of use of bioresorbable plates

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A tubular long bone, which is bent into a blunt V-shape.Mandible is strongest anteriorly in midline with progressively less strength towards condyle .dentitionMuscle attachments.Mandible is one of the strongest bones, the energy required to # it being of the order of 44.6 74.4 Kg / M(425Lb), which is about same as zygoma and about that of frontal bone 03/06/15Mandibular Fractures 5Introduction: Mandible is embryologically a membrane bent bone although, resembles physically long bone .

[Swearingen 1965, Hodgson 1967, Nahum 1975a, Luce et al 1979]

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03/06/15Mandibular Fractures 6 Anatomy:


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Mylohyoid, Geniohyoid, Genioglossus & Anterior belly of omohyoid postero-medial & inferior displacement of # fracture fragment.Pterygomassetric sling Supero-medial & anterior displacement of fractured lesser fragment.Lateral Pterygoid muscle- Antero-medial displacement of fractured condyle.Temporalis postero-superior displacement of fractured coronoid process.

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Zones of compression and tension within the mandible are determined by the muscles inserting and the forces exerted by these muscles.Smaller arrows show direction of muscular forcesLarger arrows show the load placed during function.This gives a zone of compression along the lower border and a zone of tension along the superior borderNeutral axis about the level of the canal.


FRACTURE :Definition :Fracture is defined as break in the continuity of the bone.Mandibular fractures :Fractures of the mandible are common in patients, who sustain facial trauma. SEX :Most mandibular fractures are seen to occur in male patients. Ratio is approximately 4.5 : 1AGE :35 % of mandibular fractures occur between the ages of 20 to 30 years.


ETIOLOGY OF MANDIBULAR FRACTURESVehicular accidents Altercation,assaults, interpersonel violence Fall Sporting accidents Industrial mishaps or work accidents Pathological fractures or miscellaneous 03/06/15Mandibular Fractures 14

Factors influencing displacement of fractureDegree of forceResistance to the force offered by the facial bonesDirection of force Point of application of force Cross-sectional area of the agent or object struckAttached muscles 03/06/15Mandibular Fractures 15

# SYMPHYSIS AND PARASYMPHYSIS:- Mylohyoid constitues a diaphragm b/w hyoid bone & mylohyoid ridge on inner aspect of mandibleOblique # in this region tends to overlaps -- genio & mylohyoid diaphragm


Bucket handle displacement03/06/15Mandibular Fractures 17B/L # of parasymphysis results from force which disrupts the periosteum.

displaced posteriorly under the influence of genioglossus / geniohyoid muscleOften removes attachment of tongue & allows TONGUE FALL BACK

Classification of mandibular fractures :

General classificationAnatomical locationsRelation of the fracture to site of injury CompletenessDepending on the mechanismNumber of fragmentInvolvement of the integumentThe shape or area of the fractureAccording to the direction of fracture and favourability for the treatmentAccording to presence or absence of teethAO classification relevant to internal fixation


Kruger's general classification Simple or Closed Fracture Compound or Open Comminuted Complicated or complex Impacted Greenstick fracture Pathological

Classification: 03/06/15Mandibular Fractures 19

Rowe & Killey classification Fractures not involving basal bone Fractures involving basal bone of the mandible. Subdivided into following: Single Unilateral Double unilateral Bilateral MultipleDingman & Natvig classification Midline Parasymphyseal Symphysis Body Angle Ramus Condylar process Coronoid process Alveolar process


Kruger & Schilli classificationRelation to the external environmentSimple Or closedCompound or openTypes of fractureIncompleteGreenstickCompleteComminutedDentition of the jaw with reference to the use of splintSufficiently dentulous patientEdentulous or insufficiently dentulous patientPrimary and Mixed dentition LocalizationFractures of the symphysis region between caninesFractures of the canine regionFractures of the body of the mandibleFractures of the angleFractures of the mandibular ramusFractures of the coronoid processFractures of the condyle03/06/15Mandibular Fractures 21

Kazanjian classificationClass III : Patient is edentulolus

Class I : teeth are present on both sides of the fracture lineClass II : Teeth are present on only one side of fracture line



6. According to direction of the fracture and favorability for treatment ( Fry et al)

7. Relation of the fracture to the site of injuryDirect fracture Indirect fracture


8. AO Classification(relevant to internal fixation): 1) F: Number of fracture or fragments 2) L: Location (site) of fracture 3) O: Status of occlusion 4) S: Soft tissue involvement 5) A: Associated fractures of facial skeleton


9. Grades of severity: I-V

Grade I and II are closed fractures

Grade III and IV are open fractures

Grade V open fracture with a bony defect (gunshot)


10. AO-analogue classification system of mandibular fracturesEach compartment is classified independently, describing the degree of displacement and the presence of multifragmentation or osseous defects. Each fracture is classified: - type A, nondisplaced fractures - type B, displaced fractures - type C, multifragmentary/defect fracturesEach fracture is divided into 3 groups, specific to the mandibular unit.


Panoramic view showing the vertical mandibular units (green), the lateral horizontal units (orange) and the central mandibular unit (red)27

Vertical unit 03/06/15Mandibular Fractures 28


Horizontal unit03/06/15Mandibular Fractures 30

Central horizontal unit03/06/15Mandibular Fractures 31

History Clinical Examination Radiological Examination Panoramic radiograph Lateral oblique Radiograph Posteroanterior Radiograph Occlusal view reverse townes view CT scanDiagnosis of Mandibular fracture: 03/06/15Mandibular Fractures 32

HistoryFocussed questioning should reveal following:Mechanism of injuryPrevious facial fractureH/O TMJ disordersPreinjury occlusion


Clinical examinationExamination of pt with # of mandible takes place in 3 stages:A.Immediate assessment and treatment of any condition constituting a threat to life.B.General clinical examination of pt.C.Local examination of mandibular #.03/06/15Mandibular Fractures 34

Change in occlusionAnesthesia, Paresthesia or Dysesthesia of lower lipAbnormal mandibular movementsChange in facial contour and mandibular arch formLaceration, Hematoma and EcchymosisLoose teeth and crepitation on palpationClinical Examination03/06/15Mandibular Fractures 35

Clinical examination



Test for sensation

Signs and symptomsTenderness +veOcclusion changes - # teeth - # alveolar process - # mandible at any location- # condyle

Anterior open bite - B/L condylar #

Posterior open bite- parasymphysis #

Unilateral open bite - # ipsilateral angle - # parasymphysis

Posterior cross bite - midline symphysis #- condylar #03/06/15Mandibular Fractures 38

Radiological examination

Ideally need 2 radiographic views of the fracture that are oriented 90 from one another to properly work up fractures Single view can lead to misdiagnosis and complications with treatment03/06/15Mandibular Fractures 39

OPGMost informative Shows entire mandible and direction of fracture (horizontal favorable, unfavorable)Disadvantages: Patient must sit up up-right Difficult to determine buccal/lingual bone and medial condylar displacement Some detail is lost/blurred in the symphysis, TMJ and dentoalveolar regions03/06/15Mandibular Fractures 40

Posteroanterior (pa) radiograph: Shows displacement of fractures in the ramus, angle, body, and symphysis region

Disadvantage: Cannot visualize the condylar region 03/06/15Mandibular Fractures 41

Lateral oblique Used to visualize ramus, angle, and body fracturesDisadvantage: Limited visualization of the condylar region, symphysis, and body anterior to the premolar


Occlusal radiographUsed to visualize fractures in the body in regards to medial or lateral displacement

Used to visualize symphyseal fractures for anterior and posterior displacement


Computed tomography ct:Excellent for showing intracapsular condyle fractures axial and coronal views, 3-D reconstructionsDisadvantage: Expensive Larger dose of radiation exposure compared to plain film Difficult to evaluate direction of fracture from individual slices (reformatting to 3-D overcomes this)03/06/15Mandibular Fractures 44

The patients general physical status Diagnosis and treatment of mandibular fractures should be approached methodically not with an emergency-type mentalityDental injuries should be evaluated and treated concurrently with treatment of mandibular fracturesRe-establishment of occlusion is the primary goal in the treatment of mandibular fracture.With multiple facial fracture mandibular fracture should be treated first.Intermaxillary fixation time should vary according to the type, location, number severity of the mandibular fracture as well as the patients age and health.Prophylactic antibiotics should be used for compound fractures.General principles in the treatment of mandibular fracture03/06/15Mandibular Fractures 45

should be carefully evaluated and monitored prior to any consideration of treating mandibular fracture.

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Basic principles for Rx of FractureReductionClosed Direct interdental wiring Indirect interdental wiring (eyelet or Ivy loop)Continuous or multiple loop wiringArch barsCap splints'Gunning-type' splintsPin fixation03/06/15Mandibular Fractures 46OpenTransosseous wiring (osteosynthesis) PlatingIntramedullary pinningTitanium meshCircumferential strapsBone clampsBone staplesBone screws

FixationDirectIndirect

ImmobilizationMethods of immobilization(a) Osteosynthesis without intermaxillary fixation(i) Non-compression small plates(ii) Compression plates(iii) Mini-plates(iv) Lag screws(b) Intermaxillary fixation(i) Bonded brackets(ii) Dental wiringDirectEyelet(iii) Arch bars(iv) Cap splints(v) MMF screws(c) Intermaxillary fixation with osteosynthesis(i) Transosseous wiring(ii) Circumferential wiring(iii) External pin fixation(iv) Bone clamps(v) Transfixation with Kirschner wires03/06/15Mandibular Fractures 47

03/06/15Mandibular Fractures 48CLOSED REDUCTION

Non-displaced favorable fracturesGrossly comminuted fracturesFractures exposed by significant loss of overlying soft tissue.Mandibular fractures in children with developing dentitionCoronoid process fractureCondylar fracturesIndication for Closed Reduction of Fractures03/06/15Mandibular Fractures 49

ADVANTAGES & DISADVANTAGES OF CLOSED REDUCTION

Advantages Inexpensive Only stainless steel wire needed ConvenientGives occlusion Conservative O.T not requiredGenerally easy ,no great operator skill needed

Disadvantages

03/06/15Mandibular Fractures 50Cannot obtain absolute stability Difficulty nutrition Oral hygiene impossibleLong period of IMFChanges in TMJ cartilageWeight loss Decrease range of motion of mandible Risk of wounds to operator

CLOSED REDUCTIONHISTORY William Saliceto(1210-1277) Tied the teeth (MMF) Thomas Gilmer(1849-1931) Reviewed the tech, introduced Arch Bars in 1907. Barton bandage by JOHN BARTONLingual-Labial occlusal splint. Vacuum formed acrylic splint Royal Berkshire Halo Frame 03/06/15Mandibular Fractures 51

Direct interdental wiring

Gilmer's wiringsimple & rapid method of immobilization jaw first aid method temporary immobilization of # fragment

Disadvantage - complete removal of wires- extrusion of teeth


IVY LOOP METHOD

Quick and easy way of obtaining maxillo-mandibular fashion.24 gauge wiresimple and effective for reduction and immobilization of #


A 24-gauge wire, approximately 4 to 6 in long, is twisted into a 2- to 3-mm loop directly in the middle of the wire.53

WILLIAMS MODIFICATION


Clove hitchIncase of single tooth03/06/15Mandibular Fractures 55

Button WiringLeonard (1977) considers that eyelet wires have several drawbacks.He described the use of titanium buttons of 8mm diameter, inclusive of a 1mm rim, and 2mm deep.03/06/15Mandibular Fractures 56

Col. Stout wiring


3mm diameter 5 cm length57

Risdons wiring


Arch barsFor temporary fragment stabilization in emergency cases before definitive treatment As a tension band in combination with rigid internal fixation For long-term fixation in conservative treatment For fixation of avulsed teeth and alveolar crest fractures


Different types of Arch barWinters JelenkosDautrys Arch barBerns titinium arch barsBurmachs arch barCustom made


Screws Screws are quick to placeReduce the chance of needlestick injury from wiresCan be used with heavily restored teethCan be placed and removed rapidlyWell tolerated by patientAllow oral hygiene to be easily maintainedIMF screws are machine manufactured and are available in the self-drilling and traditional drilling styles03/06/15Mandibular Fractures 61

A small 2-mm incision can be made in the mucosa and down through periosteum61

Monocortical in natureOnce a screw loosens, it must be removed and replaced, or an alternative method of reduction of the fracture should be consideredDo not allow for any dynamic movement, and occlusal discrepancies may not be adjusted as with arch bars and elastics.03/06/15Mandibular Fractures 62Disadvantage

Cap Splints : Indications Advanced periodontal disease#s of tooth bearing segments & condylar neckPortion of body of mandible missing

Impression techniqueFitting the splintReduction of fracture 03/06/15Mandibular Fractures 63

Biphasic pin fixation

Closed technique uses external fixation (Morris appliance & Roger anderson appliance) for management of communited mandibular #.screws placed - two on either side of the fracture through stab incisions & holes drilled in the mandible.


Once external pins are in position, the fracture segments are manipulated to achieve reduction.

Then the pins are locked in reduced position by applying of an acrylic mix that is placed over the ends of the pins that are protruding out of the skin.

The acrylic is allowed to harden while mandible is held in reduced position.Steinmann pins or Kirshner wires can also be used as external pins


IndicationsEdentulous fracturesIf IMF is not feasibleComminuted fracturesBone graft requirementsWith a head frame

ContraindicationsIrradiated tissuesGrossly contaminated tissueOsteoporosisOsteosclerosisAtrophy 03/06/15Mandibular Fractures 66

AdvantagesControl of the edentulous fragments without involving the fracture lines. under LA.avoidance of the need for surgery at the fracture site,minimum operative timeSimple surgical technique.DisadvantagesConspicuous uncomfortableuncooperative or cerebrally irritated patient.Difficulty with washing and shaving scars caused- pinholes risk of infection. 03/06/15Mandibular Fractures 67

Used in edentulous jaw fracturesAcrylic splints take the form of modified dentures with bite block in place of molar teeth & space in the incisor area to facilitate feedingGunning splints


INDICATIONunilateral / bilateral # edentulous mandible

CONTRAINDICATIONSunfavorable displaced #s lying out side denture bearing areassevere posterior displacement of #s of the anterior part of mandible


Immobilization Maxilla -Peralveolar wiring - Circum zygomatic wiring - With help of bone screws Mandible - Circum mandibular wiring


03/06/15Mandibular Fractures 71OPEN REDUCTION

Displaced unfavorable fracture through angle of the mandibleDisplaced unfavorable fractures of the body or pasymphyseal regionMultiple fractures of the facial bonesMidface fractures and displaced Bilateral condylar fracturesFractures of the edentulous mandible with severe displacement of fragmentsEdentulous maxilla opposing a mandibular fractureDelay of treatment and interposition of soft tissue between noncontacting displaced fracture fragments.MalunionSpecial systemic conditions contraindicating intermaxillary fixation

Indications for open Reduction03/06/15Mandibular Fractures 72

Contraindications

G.A / more prolonged procedure is not advisable Gross infections at the # site Severe comminution with loss of soft tissue Patients with difficult to control seizures 03/06/15Mandibular Fractures 73

Advantages of open reduction. Accurate reduction & fixation of fractures by direct visualization.Better bone healing.Early return to normal jaw function.Normal nutrition, no weight loss.Patient can maintain oral hygiene.Early return to work.

03/06/15Mandibular Fractures 74Disadvantages of open reduction.

Requires surgical exposure.

May Require general anesthesia.

Expensive.

Compared to IMF technique is difficult and risky

Foreign body left in the tissues.

Scarring.

Surgical approaches to the mandibleIntraoral symphysis and parasymphysis03/06/15Mandibular Fractures 75Intraoral body, angle and ramus

Transbuccal approach

Degloving incision03/06/15Mandibular Fractures 76

Extraoral approaches03/06/15Mandibular Fractures 77

SubmentalSubmandibularRetromandibular

Transalveolar / upper border wiringSir Williams Kelsey Fry To control the posterior fragmentUse vertically and horizontally unfavorable #Horizontal mattress wiring03/06/15Mandibular Fractures 78

Transosseous / lower border wiring

Hayton Williams 1958 # fragments expose extraorallyposterior fragment hole higher level then anterior fragmentboth wires passes simultaneously through same hole

1973 Obwegeser :- Combined direct and figure of 8 wiring with single stand of wire


Transosseous or lower border wiring


Bone plate osteosynthesis

Non compression plate with monocortical screwCompression plates with bicortical screw- DCP- EDCPBio degradable plates and screwsThree dimensional platesTitanium miniplates03/06/15Mandibular Fractures 81

Compression platesAxial compression b/w fractured bone endsRigid fixation with intra-fragmentry compressionBone ends correctly opposed and maintained IMF is not needed post operatively Primary bone healing occurs by direct osteoblastic activity within #AO/ASIF dynamic compression plates

Compression plate approach

Eccentric dynamic compression plate 03/06/15Mandibular Fractures 82

Principle of compression plate osteosynthesis

The holes for the screws should be prepared at the far ends of the plate holes.When tightening the screws the fracture ends are approximated by the effect of the spherically shaped holes03/06/15Mandibular Fractures 83

DCP EDCPThe plate design is based on a screw head that, when tightened, slides down an inclined plane within the plate.Screw behaves as compression screw or the static screwCompression is not achieved at the upper border so tension band is required

The EDCP is similar to the DCP in that the inner holes are designed to produce compression across the fracture siteTwo oblique outer eccentric compression holes aligned at an angle oblique to the long axis of the plate. The activation of these outer holes produces a rotational movement of the fracture segments with the inner screws acting as the axis of rotationBrings compression at the upper border so tension band is not required


Mini plate Osteosynthesis :- 1973 MICHELET1975 CHAMPY MODIFIED

- Under physiological strain, forces of tension along the alveolar border & forces of compression along the lower border of the mandible. - With in the body of the mandible these forces produce, predominantly, moments of flexion angle strong & weak in PM region. - with in the symphysis torsional moments - Champy et al analysed these moments using a mathematical model of the mandible ideal line of osteosynthesis.# symphysis 2 plates# angle 1 plate

Monocortical screws 2 mm diameter and 5 to 10 mm length Plate2cm long, 0.9mm thick and 6mm wide03/06/15Mandibular Fractures 85

Champys line of osteosynthesis03/06/15Mandibular Fractures 86

Advantages of monocortical miniplate osteosynthesis over bicortical compression plates.Monocortical Requires minimal dissection.Less technique sensitiveLess chances of complications

BicorticalExtra oral approachNerve injuryDifficult to adapt03/06/15Mandibular Fractures 87

Compression plate Miniplates Bicortical plates

Bulky and difficult to use Applied extraorally

Cannot be used at the upper border of the mandible Provides rigid fixation No interfragmentary movement allowed

Monocortical plates

Easy to use Applied intraorally, small incision , less soft tissue dissection , less likely to be palpable Can be used without any associated complication Provides functionally stable fixation Little interfragmentary movement present, torsional movement seen under functional loading


Locking vs Standard mini plates



3-D plate ostesynthesis

Titanium 3-D plating system was developed by Farmand to meet the requirements of semi-rigid fixation with lesser complications.The 3-D miniplate is a misnomer as the plates are not three dimensional, but hold the fracture fragments rigidly by resisting the forces in three dimensions, namely, shearing, bending, and torsional forces.The basic concept of 3-D fixation as explained by Farmandis that a geometrically closed quadrangular plate secured with bone screws creates stability in three dimensions. The stability is gained over a defined surface area and is achieved by its configuration and not by its thickness or length.


ADVANTAGESThe large free areas between the plate arms and minimal dissection permit good blood supply to the bone.The 3-D plating system uses fewer plates and screws as compared to the conventional miniplates, to stabilize the bone fragments. Thus, it uses lesser foreign material, and reduces the operation time and overall cost of the treatmentThe 3-D plating system has a compact design and is easy to use. The 1.0-mm-thick 3-D plate is as stable as the much thicker 2.0 mm miniplate. This offers better bending stability and more resistance to out-of plane movement or torque.


Three dimensional plate



Bioabsorbable PlatesBioresorbable materials used for rigid fixation PolydioxanonePolyglycolic acidPolylactic acid Strength inadequate to provide clinically acceptable rigid fixation.Use of poly-L-lactide (PLLA) in 69 fractures by Kim et al12% complication8% infectionNo malunion


poly(L-lactide) (PLLA)Biodegradable materials usually degrade in vivo through a two-phase process.During phase 1, water molecules hydrolytically attack the chemical bonds, cutting long polymer chains to many short chainsPhase 2 involves the cellular response whereby macrophages and giant cells metabolize the products of phase 1 degrada- tion into substances, such as water and carbon dioxide

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Bioresorbable plates & screws

Advantages:Provides the proper strength when necessary and then harmlessly degrades over time.No need for an additional removal operation.Reduce the total treatment & rehabilitation time of the patient.No bending pliers are necessary.03/06/15Mandibular Fractures 96

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Lag screwCompress fracture fragments without the use of bone plateTwo sound bony cortices are required -- Shares the loads with the bone Uses: absolute rigid fixationLess hardware More cost effectiveRigid method of internal fixation Insertion -quicker and easierReduction more accurate


In contrast, a true lag screw has threads only at its termi- nal end. When used, the threads engage the distant cortex and the head sits against the proximal cortex, resulting in compression and mechanical resthe Eckelt technique for treatment of condylar neckThe Krenkel technique for treatment of condylar neck fractures.97

Lag screwsPlaced in direction that is perpendicular to the line of fracture to prevent overriding & displacement during tightening of the screws.INDICATIONS#s in edentulous partsConcomittant #s of body & condyleIMF contraindicatedSaggital/oblique fracturesNon/malunion



Reconstruction plates03/06/15Mandibular Fractures 100

For communited mandibular fracturesDecreased post op morbidityStabilization of entire communited complex2.0 mm plate with bicortical screw used in conjunction with lag screws or miniplates

Protocol for treatment of mandibular fractures

Simple fractures of the condylar process and ramus - closed reduction. MMF for 48 to72 hours - training elastics and close observation No MMF is required for coronoid fractures; archbars and training elastics are used only if a malocclusion is present. Simple or compound fractures with a time delay from injury to immobilization of < 72 hours are treated by a closed reduction (CR) or, if indicated, open reduction with rigid fixation (ORIF).


Compound fractures - delay from injury to immobilization of >72 hours - MMF and IV antibiotics .If the closed reduction is adequate, the patient is continued on oral antibiotics for an additional 10 to 14days and maintained in MMF and on a blenderized diet for 5 to 6 weeks from the time of closed reduction. If not, ORIF is performed, and MMF is maintained for 10 to 14 additional days.

Edentulous patients are treated with rigid fixation, no MMF, and a blenderized diet for 4 to 5 weeks.

Teeth in the line of fracture are judged individually. 03/06/15Mandibular Fractures 102

Young adult with Fracture of the angle receiving Early treatment in which Tooth removed from fracture line

3 weeks

Guide for time of immobilization03/06/15Mandibular Fractures 103(a) Tooth retained in fracture line: add 1 week(b) Fracture at the symphysis: add 1 week(c) Age 40 years and over: add 1 or 2 weeks(d) Children and adolescents: subtract 1 week

IF


The goal of AO/ASIF is rigid internal fixation with primary bone healing, under functional loadingBasic principlesReduction of bony fragments Stable fixation of the fragments Preservation of the adjacent blood supply Early functional mobilization 03/06/15Mandibular Fractures 105

Teeth in the line of fracturePotential impediment to healing Fracture is compound Tooth maybe damaged structurally subsequently become necroticPre existing pathology apical granuloma


Absolute Longitudinal #Dislocation/subluxation of toothPeriapical InfectionInfection of the fracture lineAcute pericoronitisRelativeFunctionless toothAdvanced cariesPeriodontal diseaseDoubtful teethUntreated # > 3 days

03/06/15Mandibular Fractures 107Indications for removal

Management of teeth retained in fracture lineIntra-oral periapical radiographSystemic antibiotic therapySplinting of tooth if mobileEndodontic therapy if pulp exposedImmediate extraction if fracture becomes infectedFollow-up for 1 yr with endodontic therapy if there is demonstrable loss of vitality.03/06/15Mandibular Fractures 108

ComplicationsComplications during primary treatmentMisapplied fixationInfection Nerve damage Displaced teeth and foreign bodies Pulpitis Gingival and periodontal complications Drug reactions


Late complicationsMalunion Delayed union Non-union Derangement of the temporomandibular joint Late problems with transosseous wires and plates Sequestration of bone TrismusScars 03/06/15Mandibular Fractures 110

Management of Infections


ReferenceMaxillofacial injuries N.L. Rowe, J Williams, Vol 1 Ied.Oral & maxillofacial trauma Raymond J Fonseca 4th edJournal of Cranio-Maxillofacial Surgery 2008; 36: e251 - e259Subodh et al, Clinical Study An Epidemiological Study on Pattern and Incidence of Mandibular Fractures, Hindawi Publishing Corporation Plastic Surgery International, Volume 2012, Article ID 834364,7pages


A comprehensive classification of mandibular fractures: a preliminary agreement validation studyC. H. Buitrago-Tellez, L. Audige, B. Strong, P. Gawelin, J. Hirsch Int. J. Oral Maxillofac. Surg. 2008; 37: 10801088.A. H. Kamboozia, A. Punnia-Moorthy: The fate of teeth in mandibular fracture lines. A clinical and radiographic follow-up study. Int. J. Oral Maxillofac. Surg 1993; 22. 9~101.Atlas Oral Maxillofacial Surg Clin N Am 17 (2009) 8191,Fractures of the Growing Mandible;George M. Kushner, Paul S. Tiwana.Protocol for treatment of mandibular fracturesPhilip L. Maloney,J Oral Maxillofac Surg,59:879-884, 2001.03/06/15Mandibular Fractures 113

3-D plate osteosynthesis; Dental Research Journal /Mar 2012 /Vol 9 / Issue 2R. Mukerji , G. Mukerji , M. McGurk Mandibular fractures: Historical perspective British Journal of Oral and Maxillofacial Surgery 44 (2006) 222228Bioresorbable plates & screws[Robert M. Laughlin JOMS 2007;65:89-96]Killey & kay textbook of mandibular fractures.


Thank you03/06/15Mandibular Fractures 115

mandibular fractures

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