mandibular fractures

$: mandibular fractures$
Mandible FracturesMandible Fractures

Dr. Sumer YadavDr. Sumer YadavMch plastic surgeryMch plastic surgery

dr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery, [email protected]@gmail.com

HistoryHistoryEdwin Smith Papyrus 1650 described Hx, Edwin Smith Papyrus 1650 described Hx,

Phy, Diagnosis. Often fatal diseasePhy, Diagnosis. Often fatal diseaseHippocrates – Described monomaxillary Hippocrates – Described monomaxillary

dental fixation and bindingdental fixation and bindingSulicetti – 1492 Described “tie teeth of jaw Sulicetti – 1492 Described “tie teeth of jaw

to teeth of uninjured jaw”to teeth of uninjured jaw”


AnatomyAnatomyMandible interfaces with skull base via the Mandible interfaces with skull base via the

TMJ and is held in position by the muscles TMJ and is held in position by the muscles of masticationof mastication

Divided into components with weakest Divided into components with weakest sites being the third molar area, socket of sites being the third molar area, socket of the canine tooth, and the condyle.the canine tooth, and the condyle.


Anatomic units of the Anatomic units of the mandiblemandible


Symphysis Symphysis - Fracture in the region of the central incisors - Fracture in the region of the central incisors that runs from the alveolar process through the inferior that runs from the alveolar process through the inferior border of the mandible border of the mandible

ParasymphysealParasymphyseal - Fractures occurring within the - Fractures occurring within the boundaries of vertical lines distal to the canine teeth boundaries of vertical lines distal to the canine teeth

BodyBody - From the distal symphysis to a line coinciding - From the distal symphysis to a line coinciding with the alveolar border of the masseter muscle (usually with the alveolar border of the masseter muscle (usually including the third molar) including the third molar)

AngleAngle - Triangular region bounded by the anterior border - Triangular region bounded by the anterior border of the masseter muscle to the posterosuperior of the masseter muscle to the posterosuperior attachment of the masseter muscle (usually distal to the attachment of the masseter muscle (usually distal to the third molar)third molar)

RamusRamus - Bounded by the superior aspect of the angle to - Bounded by the superior aspect of the angle to two lines forming an apex at the sigmoid notch two lines forming an apex at the sigmoid notch

Condylar processCondylar process - Area of the condylar process - Area of the condylar process superior to the ramus region superior to the ramus region

Coronoid processCoronoid process - Includes the coronoid process of the - Includes the coronoid process of the mandible superior to the ramus region mandible superior to the ramus region

Alveolar processAlveolar process - Region that normally contains teeth - Region that normally contains teeth dr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery, [email protected]@gmail.com

InnervationInnervationMandibular nerve through the foramen Mandibular nerve through the foramen

ovaleovale Inferior alveolar nerve through the Inferior alveolar nerve through the

mandibular foramenmandibular foramen Inferior dental plexusInferior dental plexusMental nerve through the mental foramenMental nerve through the mental foramen


Anatomy - Mental foramenAnatomy - Mental foramen

Neck of mandible

Oblique line of mandible

Incisive foramen

Mental foramen

Mental tubercle


Anatomy - Mandibular foramenAnatomy - Mandibular foramen

Mandibularforamen

Mental groove

Mental ridge

Genial tubercle

Socket third molar


Deep Masseter

Superficial Masseterdr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery,

[email protected]@gmail.com

EpidemiologyEpidemiology

Mandible most common after nasal Mandible most common after nasal fractures fractures

Mandible : Zygoma : Maxilla 6:2:1Mandible : Zygoma : Maxilla 6:2:1MVA>Assault>Fall>SportsMVA>Assault>Fall>Sports


Arterial supplyArterial supply Internal maxillary artery from the external Internal maxillary artery from the external

carotidcarotid Inferior alveolar artery through the Inferior alveolar artery through the

mandibular foramenmandibular foramenMental artery through the mental foramenMental artery through the mental foramen


Temporomandibular jointTemporomandibular joint• Ginglymoarthrodial jointGinglymoarthrodial joint• Articular surfaceArticular surface• Articular discArticular disc• Ligament Ligament 1.Fibrous capsule1.Fibrous capsule 2.Lateral ligament2.Lateral ligament 3.Sphenomandibular ligament3.Sphenomandibular ligament 4.Stylomandibular ligament4.Stylomandibular ligament


TMJTMJ

Articular disc Articular disc separates the joint separates the joint into 2 spaceinto 2 space

Inferior/Inferior/GinglymusGinglymus Hinge movement Hinge movement

Superior/Superior/ArthrodialArthrodial


Fractures of mandibleFractures of mandibleAccording to anatomic location fracture ofAccording to anatomic location fracture ofmandible divided into seven main types:mandible divided into seven main types:

1.1. Condylar- intra capsular/extra capsularCondylar- intra capsular/extra capsular2.2. CoronoidCoronoid3.3. RamusRamus4.4. AngleAngle5.5. BodyBody6.6. Symphysis and parasymphysisSymphysis and parasymphysis7.7. Comminuted fractures-multipleComminuted fractures-multiple


Fracture FrequencyFracture Frequency


Mandibular # classified as locationMandibular # classified as location(Dingmen & Natvig 1964)(Dingmen & Natvig 1964)

1. Parasymphyseal & symphyseal1. Parasymphyseal & symphyseal 2. Canine2. Canine 3. Body3. Body 4. Angle 4. Angle 5. Ramus5. Ramus 6. Coronoid process6. Coronoid process 7. Condyloid process7. Condyloid process 8. Alveolar process & multiple #8. Alveolar process & multiple #


Type of fracturesType of fractures

Simple/linearSimple/linearGreen stickGreen stickCompound- through skin/ mouthCompound- through skin/ mouthComminutedComminutedPathological-osteomyelitis/neoplasmPathological-osteomyelitis/neoplasmUnilateral/bilateralUnilateral/bilateral


Favorable vs. UnfavorableFavorable vs. Unfavorable

Masseter, Medial and Lateral Masseter, Medial and Lateral Pterygoid, and Temporalis tend to Pterygoid, and Temporalis tend to draw fractures medial and superiordraw fractures medial and superior

Almost all fractures of angle Almost all fractures of angle unfavorableunfavorable


Mandibular ForcesMandibular Forces


Vertically & Horizontally unfavorable #


Factor affecting displacement of Factor affecting displacement of # segment# segment

1. Direction & angulation of # line1. Direction & angulation of # line 2. Presence & absence of teeth in # 2. Presence & absence of teeth in # segmentsegment 3. Soft tissue at site of #3. Soft tissue at site of # 4. Direction & intensity of traumatic 4. Direction & intensity of traumatic forceforce 5. # of alveolar structure & damage 5. # of alveolar structure & damage to teethto teeth


Picture of open bitesPicture of open bites


Classification of malocclusion: Classification of malocclusion: Angles (1899)Angles (1899)

Class 1-Neutro Class 1-Neutro occlusion-occlusion-

The mesio buccal The mesio buccal

cusp of maxillary cusp of maxillary first molar aligned first molar aligned axially with axially with mesiobuccal groove mesiobuccal groove of mandibular first of mandibular first molar. molar.


Class 2 or Dist Class 2 or Dist occlusion:occlusion:

Buccal groove of Buccal groove of

lower first molar is lower first molar is distal ( post ) to distal ( post ) to mesiobuccal cusp of mesiobuccal cusp of upper first molar upper first molar


Classification of malocclusion: Classification of malocclusion: Angles (1899)Angles (1899)

Class 3: Mesio- occlusion:Class 3: Mesio- occlusion: Buccal groove of lower Buccal groove of lower

first molar is mesial (or first molar is mesial (or ant) to mesiobuccal cusp ant) to mesiobuccal cusp of ant first molarof ant first molar

The mandibular teeth The mandibular teeth are in ant relationship are in ant relationship with corresponding with corresponding maxillary teeth. maxillary teeth.


Evaluation - HistoryEvaluation - History

Mechanism of injury Mechanism of injury MVA associated with multiple comminuted fxMVA associated with multiple comminuted fxFist often results in single, non - displaced fxFist often results in single, non - displaced fxAnterior blow to chin - bilateral condylar fxAnterior blow to chin - bilateral condylar fxAngled blow to parasymphysis can lead to Angled blow to parasymphysis can lead to

contralateral condylar or angle fxcontralateral condylar or angle fxClenched teeth can lead to alveolar process Clenched teeth can lead to alveolar process

fxfx


Past Medical HistoryPast Medical History

bone diseasebone diseaseneoplasianeoplasiaarthritis, tmj (risk for ankylosis)arthritis, tmj (risk for ankylosis)collagen vascular disease, endocrine d/ocollagen vascular disease, endocrine d/onutrition and metabolic disorders, including nutrition and metabolic disorders, including

alchohol abusealchohol abuseseizure seizure


EvaluationEvaluationStabilization via ATLS protocolStabilization via ATLS protocolPart of secondary surveyPart of secondary survey

Pain, malocclusion, trismus, V3 sensory Pain, malocclusion, trismus, V3 sensory deficitdeficit

History of TMJ (earlier mobilization)History of TMJ (earlier mobilization)Blow to face favors parasymphyseal fracture Blow to face favors parasymphyseal fracture

and contralateral angle fractureand contralateral angle fractureFall to chin (bilateral condylar fractures)Fall to chin (bilateral condylar fractures)


EvaluationEvaluationPrevious occlusion (Class I-III)Previous occlusion (Class I-III)Psychiatric, nutritional, gastrointestinal, Psychiatric, nutritional, gastrointestinal,

seizure disordersseizure disordersPrevious facial traumaPrevious facial traumaOther injuries (c-spine, intra-abdominal, Other injuries (c-spine, intra-abdominal,

likely prolonged intubation)likely prolonged intubation)


Fischer et alFischer et al


Cervical spine injuryCervical spine injury


Signs and symptoms:Signs and symptoms:Pain at site of #Pain at site of #Swelling and ecchymosis at # site Swelling and ecchymosis at # site Step deformity at # siteStep deformity at # siteLoss of teeth. Gingival lacerationsLoss of teeth. Gingival lacerationsMal occlusion/open bite./ cross biteMal occlusion/open bite./ cross biteAnaesthesia in mental region.Anaesthesia in mental region.Bleeding at fracture site.Bleeding at fracture site.Mucosal lacerations at fracture siteMucosal lacerations at fracture site


Physical ExamPhysical ExamDental ExamDental Exam

Lost, fractured, or unstable teethLost, fractured, or unstable teethDental HealthDental HealthRelation to fractureRelation to fractureQuantityQuantity


Physical Exam - OcclusionPhysical Exam - Occlusion Change in occlusion - determine preinjury occlusionChange in occlusion - determine preinjury occlusion Posterior premature dental contact or an anterior open Posterior premature dental contact or an anterior open

bite is suggestive of bilateral condylar or angle fracturesbite is suggestive of bilateral condylar or angle fractures Posterior open bite is common with anterior alveolar Posterior open bite is common with anterior alveolar

process or parasymphyseal fracturesprocess or parasymphyseal fractures Unilateral open bite is suggestive of an ipsilateral angle Unilateral open bite is suggestive of an ipsilateral angle

and parasymphyseal fractureand parasymphyseal fracture Retrognathic occlusion is seen with condylar or angle Retrognathic occlusion is seen with condylar or angle

fractures fractures Condylar neck fx are assoc with open bite on opposite Condylar neck fx are assoc with open bite on opposite

side and deviation of chin towards the side of the fx.side and deviation of chin towards the side of the fx.dr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery,


MalocclusionMalocclusion


Mal occlusionMal occlusion

Open biteOpen bitedr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery,


Physical ExamPhysical Exam

Unilateral fractures of CondyleUnilateral fractures of CondyleDecreased translational movement, functional Decreased translational movement, functional

height of condyleheight of condyleDeviation of chin away from fracture, open Deviation of chin away from fracture, open

bite opposite side of fracturebite opposite side of fracture

Bilateral fractures of condyleBilateral fractures of condyle- Anterior open bite- Anterior open bite


Diagnostic ImagingDiagnostic Imaging X- raysX- rays1.1. post ant projection (PA)post ant projection (PA)2.2. Oblique lat projectionOblique lat projection3.3. Occlusal; view of mandible.Occlusal; view of mandible. Ortho- pan tomogramOrtho- pan tomogram C-T ScanC-T Scan1.1. Two dimentional; axial, coronal. Two dimentional; axial, coronal. 2.2. Three dimentionalThree dimentional MRIMRI


Posterior anterior view10*Posterior anterior view10*


Posterior lateral obliquePosterior lateral oblique


Mandible seriesMandible series


Evaluation - Mandible filmsEvaluation - Mandible films


Posterior anterior view10*Posterior anterior view10*


Lateral obliqueLateral oblique


PanorexPanorex


Tomography scanner Tomography scanner


Ortho-pan tomogram Ortho-pan tomogram


CT ScanCT Scan


CT Scan -three dimensionalCT Scan -three dimensional


Treatment HistoryTreatment History

Schede 1888 – Bone plate of steel Schede 1888 – Bone plate of steel secured with 4 screwssecured with 4 screws

Luhr 1960 – Developed mandibular Luhr 1960 – Developed mandibular compression platescompression plates

Michelet and Champy 1970’s – Placement Michelet and Champy 1970’s – Placement of small bendable non-compression platesof small bendable non-compression plates


PhysiologyPhysiologyPrimary HealingPrimary Healing

In rigid fixation techniquesIn rigid fixation techniquesLag screws, compression plates, Recon plate, Lag screws, compression plates, Recon plate,

external fixation, Mini plate fixationexternal fixation, Mini plate fixationNo callus formationNo callus formationQuestion of bone resorptionQuestion of bone resorption


PhysiologyPhysiologySecondary bone healingSecondary bone healing

Callus formationCallus formationRemodeling and strengtheningRemodeling and strengtheningMMF, Wire fixation, Mini plate fixationMMF, Wire fixation, Mini plate fixation


General Principles of General Principles of treatmenttreatment

TetanusTetanus NutritionNutrition Almost all can be considered open fx as they Almost all can be considered open fx as they

communicate with skin or oral cavitycommunicate with skin or oral cavity Reduction and fixationReduction and fixation Post-op monitoring for N/V, use of wire cuttersPost-op monitoring for N/V, use of wire cutters Oral care - H2O2 , irrigations, soft toothbrushOral care - H2O2 , irrigations, soft toothbrush Biweekly exam - hardware, occlusion, weightBiweekly exam - hardware, occlusion, weight


Principle of treatment of Principle of treatment of mandibular #mandibular #

1. Restoration of normal occlusion 1. Restoration of normal occlusion with adequate union of # segmentwith adequate union of # segment

2. Avoidance of infection2. Avoidance of infection

3. Maintenance of facial symmetry &3. Maintenance of facial symmetry & balancebalance


Treatment optionsTreatment optionsNo treatmentNo treatmentSoft dietSoft dietMaxillomandibular fixationMaxillomandibular fixationOpen reduction - non-rigid fixationOpen reduction - non-rigid fixationOpen reduction - rigid fixationOpen reduction - rigid fixationExternal pin fixationExternal pin fixation


Treatment options for dentate Treatment options for dentate patientspatients


Closed ReductionClosed Reduction

Favorable, non-displaced fracturesFavorable, non-displaced fracturesGrossly comminuted fractures when Grossly comminuted fractures when

adequate stabilization unlikelyadequate stabilization unlikelySeverely atrophic edentulous mandibleSeverely atrophic edentulous mandibleChildren with developing dentitionChildren with developing dentition


TechniquesTechniques Gilmer method [outdated]Gilmer method [outdated] Eyelet methodEyelet method Arch bar fixation – the best whenever Arch bar fixation – the best whenever possible possible

-Single root and conical shape teeth require -Single root and conical shape teeth require special wiring techniques special wiring techniques -Rubber bands or wires -Rubber bands or wires Orthodontic bands Orthodontic bands Acrylic splints Acrylic splints Intermaxillary fixation screw techniqueIntermaxillary fixation screw technique pin fixationpin fixation

Closed ReductionClosed Reduction


Gilmer wiresGilmer wires


Maxillomandibular fixationMaxillomandibular fixation


Alternative - Ivy loopsAlternative - Ivy loops


Clove hitchClove hitch


Leonard’s Leonard’s buttons for buttons for maxillo-maxillo-mandibular mandibular fixation.fixation.


Four screw fixation techniqueFour screw fixation technique


Maxillomandibular fixationMaxillomandibular fixationarch bar & rubber bandsarch bar & rubber bands


Inter maxillary fixationInter maxillary fixation arch bar & secondary wires. arch bar & secondary wires.


Four screw fixationFour screw fixation


Post op protocolPost op protocol

- Dental hygiene - Dental hygiene

- occlusion for all fractures (4-6 weeks)- occlusion for all fractures (4-6 weeks) -Condylar and subcondylar - 3 weeks with Condylar and subcondylar - 3 weeks with intermittent application of rubber bands intermittent application of rubber bands

- Coronoid process-2 weeks restCoronoid process-2 weeks rest

- Liquid high protein dietLiquid high protein diet


Open ReductionOpen ReductionDisplaced unfavorable fracturesDisplaced unfavorable fracturesMandible fractures with associated Mandible fractures with associated

midface fracturesmidface fracturesWhen MMF contraindicated or not When MMF contraindicated or not

possiblepossiblePatient comfortPatient comfortFacilitate return to workFacilitate return to work


Open ReductionOpen Reduction

Associated Midface fracturesAssociated Midface fracturesPsychiatric illnessPsychiatric illnessGI disorders involving severe N/VGI disorders involving severe N/VSevere malnutritionSevere malnutritionTo avoid tracheostomy in patients who To avoid tracheostomy in patients who

need postoperative intubationneed postoperative intubation


Open ReductionOpen ReductionContraindicationsContraindications

General Anesthetic risk too highGeneral Anesthetic risk too highSevere comminution and stabilization not Severe comminution and stabilization not

possiblepossibleNo soft tissue to cover fracture siteNo soft tissue to cover fracture siteBone at fracture site diffusely infected Bone at fracture site diffusely infected

(controversial)(controversial)


Facial incisionsFacial incisions


Open ReductionOpen Reductionsemi-rigid fixationsemi-rigid fixation

Inter-osseous wiringInter-osseous wiringSemirigid fixationSemirigid fixationCheapCheapTechnically difficultTechnically difficultPrimary and Secondary bone healingPrimary and Secondary bone healing


Transosseous wiring or Transosseous wiring or osteosynthesis or direct wiringosteosynthesis or direct wiring

• Tran alveolar or upper border wiringTran alveolar or upper border wiring ( William Kelsey fry )( William Kelsey fry ) a. horizontal mattressa. horizontal mattress b. simple wire loopb. simple wire loop• Transosseos or lower border wiringTransosseos or lower border wiring a. Extra oral approacha. Extra oral approach b. Intra oral approachb. Intra oral approach


Open reduction - nonrigid Open reduction - nonrigid fixationfixation


Types of inter-osseous wiringTypes of inter-osseous wiring


Rigid FixationRigid Fixation Developed and popularized by AO/ASIF Developed and popularized by AO/ASIF

(Association for the Study of Internal Fixation) in (Association for the Study of Internal Fixation) in Europe in the 1970s. Europe in the 1970s.

The basic principles of the AO, outlined by The basic principles of the AO, outlined by SpiesslSpiessl, call for primary bone healing under , call for primary bone healing under conditions of absolute stability. conditions of absolute stability.

Must neutralize all forces - tension, Must neutralize all forces - tension, compression, torsion, and shearing - allow for compression, torsion, and shearing - allow for immediate function. immediate function.

Inferior border plate compression forces. Inferior border plate compression forces. superior border plate /arch bars traction or superior border plate /arch bars traction or tension forcestension forces


Rigid FixationRigid FixationCompression platesCompression plates

Rigid fixationRigid fixationAllow primary bone healingAllow primary bone healingDifficult to bendDifficult to bendOperator dependentOperator dependentNo need for MMFNo need for MMF


Compression platingCompression plating

• Exert axial compressionExert axial compression• Titanium or vitallium plateTitanium or vitallium plate• 4 hole plate 31mm,35,40,50mm long4 hole plate 31mm,35,40,50mm long or 5- 6 hole plateor 5- 6 hole plate• Retention half – 2 holeRetention half – 2 hole• Compression half – 2 holeCompression half – 2 hole• Compression screw 8- 20 mm longCompression screw 8- 20 mm long


Compression plateCompression plate


Dynamic compression plates-Dynamic compression plates-locking / non-lockinglocking / non-locking

Spherical gliding principle Spherical gliding principle


Open reduction - Rigid Open reduction - Rigid fixationfixation


Bending and over bending Bending and over bending techniquestechniques


Non compression platingNon compression plating• Reconstruction, miniplates. Reconstruction, miniplates. • Indication Indication - head injury & epileptic patient- head injury & epileptic patient - class 1 class 2 # - class 1 class 2 # - associated #- associated # - badly displaced # & comminuted#- badly displaced # & comminuted#• Stainless steel, titanium plate 4 hole, Stainless steel, titanium plate 4 hole,

vitallium metacarpal plate, screw 6- 7 mmvitallium metacarpal plate, screw 6- 7 mm


Rigid FixationRigid Fixation

Reconstruction PlatesReconstruction PlatesGood for comminuted fracturesGood for comminuted fracturesBulky, palpableBulky, palpableDifficult to bendDifficult to bendLocking plates availableLocking plates available


Reconstruction PlateReconstruction Plate


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Monocortical miniplates.Monocortical miniplates.Champy et al in France Champy et al in France Advocated transoral placement of small, Advocated transoral placement of small,

thin, malleable stainless steel miniplates thin, malleable stainless steel miniplates with monocortical screws along an ideal with monocortical screws along an ideal osteosynthesis line of the mandible.osteosynthesis line of the mandible.

Believed that compression plates were Believed that compression plates were unnecessary. Masticatory forces unnecessary. Masticatory forces natural strain of compression along the natural strain of compression along the inferior border. inferior border.


Rigid FixationRigid Fixation

MiniplatesMiniplatesSemi-rigid fixationSemi-rigid fixationAllows primary and secondary bone healingAllows primary and secondary bone healingEasily bendableEasily bendableMore forgivingMore forgivingShort period MMF RecommendedShort period MMF Recommended


Evaluation - PanorexEvaluation - Panorex


Double layer mini-platesDouble layer mini-plates


Miniplates, Champy techniqueMiniplates, Champy technique


http://gateway2.ovid.com/ovidweb.cgi?View+Image=00004911-199908000-00001%7CFF6&S=IDNJHKKKCHNLKM00D

Open ReductionOpen ReductionLag ScrewsLag Screws

Rigid fixation (Compression)Rigid fixation (Compression)Good for anterior mandible fractures, Oblique Good for anterior mandible fractures, Oblique

body fractures, mandible angle fracturesbody fractures, mandible angle fracturesCheapCheapTechnically difficultTechnically difficult Injury to inferior alveolar neurovascular Injury to inferior alveolar neurovascular

bundlebundle


Lag screwLag screw


Lag Screw TechniqueLag Screw Technique


Metallic mesh implantMetallic mesh implant

• Stain less steel mesh or titanium mesh Stain less steel mesh or titanium mesh with screwwith screw

• Firm stabilizationFirm stabilization• Bend J or U shapeBend J or U shape• In edentulous patientIn edentulous patient• Malunion or non unionMalunion or non union


Mesh implantMesh implant


Nylon circumferential strapNylon circumferential strap• In edentulous patientIn edentulous patient• PartsParts - self locking device- self locking device - series of blocks- series of blocks - nylon 66- nylon 66• Intraoral / extraoral approachIntraoral / extraoral approach• 4mm & 6mm size4mm & 6mm size• Instrument Instrument - introducer - introducer - tightening device- tightening device• Long oblique & spiral #Long oblique & spiral #


Nylon strapNylon strap


External FixationExternal Fixation

Alternative form of rigid fixationAlternative form of rigid fixationGrossly comminuted fractures, Grossly comminuted fractures,

contaminated fractures, non-unioncontaminated fractures, non-unionOften used when all else failsOften used when all else fails


External FixationExternal Fixation


ComplicationsComplications EarlyEarlyHeamorrhageHeamorrhageCarotid injuryCarotid injuryFacial nerve injuryFacial nerve injuryInfectionInfectionAvascular necrosis osteitisAvascular necrosis osteitis

Late complicationsLate complicationsTMJ ankylosisTMJ ankylosisNon union Non union Malunion Malunion MalocclusionMalocclusionIncreased facial width and rotation Increased facial width and rotation Implant failureImplant failuredr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery,


Symphyseal and Para- symphyseal Symphyseal and Para- symphyseal fracturesfractures

Best is intra oral approachBest is intra oral approach Protection of mental nerve-both while stripping Protection of mental nerve-both while stripping the periosteum for exposure and while the periosteum for exposure and while insertion of screwsinsertion of screws Atleast three screw outside the # area in good Atleast three screw outside the # area in good bonebone Two plates –preferably unicortical on the top Two plates –preferably unicortical on the top and bicortical on the inferior marginand bicortical on the inferior margin


Symphyseal and Para- symphyseal Symphyseal and Para- symphyseal fracturesfractures

Reinsertion of mentalis insertion while Reinsertion of mentalis insertion while suturing suturing

Water tight closure following repairWater tight closure following repairCompression plating for non-comminuted Compression plating for non-comminuted

non-bone gap fracturesnon-bone gap fracturesLag screws application possible size at Lag screws application possible size at

least 35mm- 45mm, two in numberleast 35mm- 45mm, two in number


Body fracturesBody fractures Two plates upper border uni-cortical Two plates upper border uni-cortical tension band plate and compression plates tension band plate and compression plates for lower borderfor lower border Angle fracturesAngle fractures To remove or not to remove the 3To remove or not to remove the 3rdrd molar molar Two plates –upper tension band and lower Two plates –upper tension band and lower non compression or compression platesnon compression or compression plates Complicated comminuted fractures –Complicated comminuted fractures –reconstruction platesreconstruction plates

dr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery,


Coronoid fracturesCoronoid fractures

Usually undisplaced Usually undisplaced Observation with liquid diet or IMF for two Observation with liquid diet or IMF for two

weeks weeks When associated with other fractures When associated with other fractures

internal fixation is preferredinternal fixation is preferred


Condylar #Condylar #• 25- 35% 25- 35% • Indirect blowIndirect blow• General nature of injuryGeneral nature of injury - contusion- contusion - dislocation- dislocation - fracturefracture• Mechanism of injury- Lindahl 1977Mechanism of injury- Lindahl 1977 1. KE 1 2. KE 2 3. KE 1&21. KE 1 2. KE 2 3. KE 1&2


Mechanism of condylar #Mechanism of condylar #


Condylar #Condylar #classificationclassification

1.1. Dislocation Dislocation 2.2. FractureFracture a. comprehensive classificationa. comprehensive classification b. clinical classificationb. clinical classification - no displacement- no displacement - # deviation- # deviation - # dislocation- # dislocation - # displacement- # displacement


Comprehensive classificationComprehensive classification


Clinical classificationClinical classification


Clinical classificationClinical classification Type IType I fracture of the neck, slight displacement, (the fracture of the neck, slight displacement, (the

head and the axis of the ramus varies from 10-45°.)head and the axis of the ramus varies from 10-45°.)

Type IIType II angle from 45-90°, resulting in tearing of the angle from 45-90°, resulting in tearing of the medial portion of the joint capsule.medial portion of the joint capsule.

Type IIIType III fragments are not in contact, and the head is fragments are not in contact, and the head is

displaced medially and forward. The fragments are displaced medially and forward. The fragments are within the glenoid fossa. The capsule is torn, and the within the glenoid fossa. The capsule is torn, and the head is outside the capsule.head is outside the capsule.

Type IVType IV fractures of the condylar head articulate on or in fractures of the condylar head articulate on or in

a forward position with regard to the articular eminence.a forward position with regard to the articular eminence. Type VType V fractures consist of vertical or oblique fractures fractures consist of vertical or oblique fractures

through the head of the condyle.through the head of the condyle.dr sumer yadav, mch plastic surgery, dr sumer yadav, mch plastic surgery, [email protected]@gmail.com

TreatmentTreatment High condylarHigh condylar – 2 weeks IMF with – 2 weeks IMF with

intermittent early controlled intermittent early controlled mobilisationmobilisation

Low condylarLow condylar 1.1. With good alignment of fractures-IMFWith good alignment of fractures-IMF2.2. Angulation >30degrees or bone gap>4-Angulation >30degrees or bone gap>4-

5mm then ORIF.5mm then ORIF.3.3. Care taken to protect the facial nerve Care taken to protect the facial nerve


Condylar and SubcondylarCondylar and Subcondylar

ORIF, Absolute indicationsORIF, Absolute indicationsDisplacement into middle cranial fossaDisplacement into middle cranial fossaLateral extra- capsular displacement of Lateral extra- capsular displacement of

condylecondyle Inability to achieve occlusion with closed Inability to achieve occlusion with closed

reductionreductionForeign body in joint spaceForeign body in joint space


Condylar and SubcondylarCondylar and Subcondylar

Relative indicationsRelative indications1.1. Bilateral condylar fractures to preserve vertical Bilateral condylar fractures to preserve vertical

heightheight2.2. Associated injuries that dictate earlier functionAssociated injuries that dictate earlier function3.3. Soft tissue swelling causing airway compromise Soft tissue swelling causing airway compromise

with MMFwith MMF4.4. Intracapsular fracture on opposite side where early Intracapsular fracture on opposite side where early

mobilization importantmobilization important5.5. Bilateral condylar fractures with comminuted Bilateral condylar fractures with comminuted

midface fractures. midface fractures.


Treatment of fractureTreatment of fracture 1. surgical 1. surgical - preauricular approach- preauricular approach - submandibular- submandibular - intraoral- intraoral - fixation by - fixation by . Introsseous wiring. Introsseous wiring . bone pin. bone pin . Plate screw. Plate screw . Gut suture. Gut suture . K wire. K wire . Modified K wire. Modified K wire


Condylar fractures fixationsCondylar fractures fixations


Risdon approachRisdon approach


Dealing with teethDealing with teeth


Teeth in line of fractureTeeth in line of fractureKeep teeth ifKeep teeth if

Previously healthyPreviously healthyPeridontal plexus intactPeridontal plexus intactNo major structural injuryNo major structural injuryTooth does not interfere with reduction of Tooth does not interfere with reduction of

fracturefracture


Injury to teethInjury to teethFractured teeth can become infected and Fractured teeth can become infected and

cause malunion. cause malunion. Extraction necessary if root of tooth is Extraction necessary if root of tooth is

fracturedfracturedA tooth that is intact but in the line of the A tooth that is intact but in the line of the

fracture can be left in place and protected fracture can be left in place and protected by antibiotics, may need extraction laterby antibiotics, may need extraction later


Alveolar fractureAlveolar fracture


Alveolar fractureAlveolar fracture Class IClass I : This involves a fracture of the edentulous : This involves a fracture of the edentulous

segment.segment.

Class IIClass II : The fracture involves dentulous segment with : The fracture involves dentulous segment with little, if any, displacement. little, if any, displacement.

Class IIIClass III : The fracture involves dentulous segment with : The fracture involves dentulous segment with moderate-to-severe displacement. moderate-to-severe displacement.

Class IVClass IV : The alveolar process fracture shares one or : The alveolar process fracture shares one or more fracture lines with other fractures of the tooth-more fracture lines with other fractures of the tooth-bearing facial skeleton.bearing facial skeleton.


CLASS I

CLASS III CLASS IV

CLASS II


Dento- alveolar fracturesDento- alveolar fractures

Avulsion, subluxation or fracture of teeth Avulsion, subluxation or fracture of teeth with fracture of alveolus.with fracture of alveolus.

Early treatment if pulp exposed-relieve Early treatment if pulp exposed-relieve pain and may save teeth.pain and may save teeth.

Fractured and extruded teeth are removedFractured and extruded teeth are removedLess displaced teeth-if not causing Less displaced teeth-if not causing

occlusal interference left like that.occlusal interference left like that.


Alveolar Alveolar fracture fracture fixation.fixation.


Dento- alveolar fracturesDento- alveolar fractures

Crown #- pulp exposed- calcium Crown #- pulp exposed- calcium hydroxide cement dressinghydroxide cement dressing

Root #- vertical split- extract Root #- vertical split- extract transverse fracture- splint 8wkstransverse fracture- splint 8wks

Avulsion- immediate replantation and Avulsion- immediate replantation and splintsplint

Alveolar #- reduction and fixationAlveolar #- reduction and fixation


Pediatric dentitionPediatric dentition


Post natal growth of MandiblePost natal growth of MandibleMost frequently involved in post-traumatic Most frequently involved in post-traumatic

developmental malformationsdevelopmental malformationsGrows by bone deposition & alveolar Grows by bone deposition & alveolar

process development process development Elongation of mandible is by bony addition Elongation of mandible is by bony addition

at condyles & ramus on it's posterior at condyles & ramus on it's posterior borderborder

Growth of condyles is the result of Growth of condyles is the result of enchondral ossification in epiphysisenchondral ossification in epiphysis


Special considerations Special considerations


Special considerations Special considerations Deciduous teeth vs. permanentDeciduous teeth vs. permanent

Fractures with deciduous dentition can be Fractures with deciduous dentition can be treated with MMF for 2-3 weeks. Rigid treated with MMF for 2-3 weeks. Rigid techniques can harm the tooth bud.techniques can harm the tooth bud.

Growth center Growth center The most feared complication of a pediatric The most feared complication of a pediatric

mandible fx is ankylosis of the TMJ with impact mandible fx is ankylosis of the TMJ with impact on jaw growth that causes severe facial on jaw growth that causes severe facial deformity- prevent with early mobilizationdeformity- prevent with early mobilization


Special considerations Special considerations


Mandibular fractures (pediatrics)Mandibular fractures (pediatrics)

Between 5 to 9 yr (a period of mixed dentition) Between 5 to 9 yr (a period of mixed dentition) difficult to use dentition for fixation (absence of difficult to use dentition for fixation (absence of teeth & poor retentive shape)teeth & poor retentive shape)

IMF is obtained by circumferential wiring around IMF is obtained by circumferential wiring around the body of mandible. the body of mandible.

Wire is further passed into floor of nose & Wire is further passed into floor of nose & downward through the palate , (without downward through the palate , (without interfering with tooth buds of sec. dentition) interfering with tooth buds of sec. dentition)


Mandibular fractures(contd)Mandibular fractures(contd)

Older childOlder child IMF dental fixation is adequate, IMF dental fixation is adequate, sometimes band & arch application is usefulsometimes band & arch application is useful

InfantsInfants acrylic splint is fabricated & placed over acrylic splint is fabricated & placed over mandibular arch after realignment of fragments, mandibular arch after realignment of fragments, lined with softened dental compound & lined with softened dental compound & circumferential wiring is donecircumferential wiring is done

# mandible should be treated within 3-4 days # mandible should be treated within 3-4 days because of rapid fixationbecause of rapid fixation


Mandibular fractures(contd)Mandibular fractures(contd)

Minor degrees of malunion & malocclusion Minor degrees of malunion & malocclusion is corrected by adjustments taking place in is corrected by adjustments taking place in erupting teeth under normal masticatory erupting teeth under normal masticatory stresses ( Converse & Dingman) stresses ( Converse & Dingman)

Injuries to articular surface of TM joint Injuries to articular surface of TM joint results in hemarthrosis ,cicatricial results in hemarthrosis ,cicatricial organization & subsequent bony ankylosisorganization & subsequent bony ankylosis


Edentulous mandible fracturesEdentulous mandible fractures Body fractures most commonBody fractures most common Plating most preferable methodsPlating most preferable methods Encircling over their own dentures is also Encircling over their own dentures is also possible possible Strong reconstruction plates to be usedStrong reconstruction plates to be used If bone height >20mm healing is goodIf bone height >20mm healing is good

<10mm healing is poor<10mm healing is poor Protect Inferior alveolar n. which lies very Protect Inferior alveolar n. which lies very superficial superficial


Classification of edentulous Classification of edentulous atrophic mandibleatrophic mandible


Closed ReductionClosed ReductionEdentulous fracturesEdentulous fractures

Absent inferior alveolar artery in 40% 60-80 Absent inferior alveolar artery in 40% 60-80 yrs.yrs.

Periosteal blood supply disturbed by strippingPeriosteal blood supply disturbed by strippingUp to 20% non-union despite type of Up to 20% non-union despite type of

treatmenttreatmentMay consider Gunning SplintsMay consider Gunning Splints


Gunning splintGunning splint

• Use in edentulous mandibleUse in edentulous mandible• Reconstructed fromReconstructed from - patient denture- patient denture - dental impression- dental impression - model cast- model cast - prefabricated gunning splint- prefabricated gunning splint• Fixation to mandible & maxillaFixation to mandible & maxilla


Denture preparationDenture preparation


Obwegeser’s circummandibular Obwegeser’s circummandibular wiringwiring


Application of splintsApplication of splints


Edentulous FracturesEdentulous FracturesORIFORIF

Inferior alveolar canal more superior in Inferior alveolar canal more superior in locationlocation

Vertical height 20mm compatible with Vertical height 20mm compatible with standard plating systemsstandard plating systems

Vertical height 10mm or less, likely need rib Vertical height 10mm or less, likely need rib graftgraft

Plate removal after fracture healing if Plate removal after fracture healing if interferes with denture placementinterferes with denture placement


Biphasic Biphasic pins.pins.


Endoscopic surgeryEndoscopic surgery


IndicationsIndications

Compliant adult patient with acute Compliant adult patient with acute condylar fractures.condylar fractures.

With significant radiological displacement.With significant radiological displacement.Persistent malocclusion with closed Persistent malocclusion with closed

reduction & MMF.reduction & MMF.


Contraindications Contraindications

Intercondylar fracturesIntercondylar fracturesFracture neck of condyle, with small Fracture neck of condyle, with small

proximal segment - will not accommodate proximal segment - will not accommodate at least 2 screws of microplate.at least 2 screws of microplate.

Condition of patient doesn’t allow for long Condition of patient doesn’t allow for long surgeries.surgeries.


ADVANTAGESADVANTAGES

No external scar.No external scar.No risk of neuro-vascular damage.No risk of neuro-vascular damage.Less dissection- less fibrosis.Less dissection- less fibrosis.


Biodegradable platesBiodegradable plates Made of a blend of rigid and elastic polymers Made of a blend of rigid and elastic polymers

selected for their strength, malleability and selected for their strength, malleability and degradation properties. degradation properties.

- L-lactide- D,L-lactide (not in CPS Baby)- Glycolide (only in CPS Baby)- Trimethylene carbonate


DegradationDegradation

The implants CoThe implants Co22 + H + H22oo

Degradation by hydrolysis and over a period of time are metabolized through natural processes in the body into carbon dioxide.

Host tissue i.e. bone or soft tissue, grows into

the space occupied by the implant as it degrades.


Secured plateSecured plate


Bioabsorbable Plates Bioabsorbable Plates

Bulky plates, Bulky plates, thermal sensitivity, thermal sensitivity, palpablepalpableAbsorbable plates expensiveAbsorbable plates expensiveBetter in childrenBetter in children


Advantages Advantages Do not interfere with bone growth No risk of metal allergies being caused by metal

implants. Metal implants have the potential to cause

stress shielding Safe when post operative MRI or radiations are

required. Rare instances of metal accumulation in the

tissues or migration of the metal.


mandibular fractures

Health & Medicine