fracture mandible

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MANDIBULAR FRACTURE:

MANDIBULAR FRACTURE

Contents:

Contents Introduction Applied anatomy of mandible History Etiology & Incidence Classification Clinical examination Signs & Symptoms Imaging

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Management - Closed method - Open method Edentulous mandible fracture Post operative care Complications Recent Advances References

Introduction:

Introduction Fracture of the mandible occurs more frequently than any other fracture of the facial skeleton. It may broadly be divided into two main groups: Fractures with no gross comminution of the bone and without significant loss of hard or soft tissue. Fractures with gross communition of the bone and with extensive loss of both hard and soft tissue.

Applied Anatomy:

Applied Anatomy The mandible is the largest, heaviest and strongest bone of the face. Mandible is horseshoe or parabola in shape. Two rami project upward from the posterior aspect of the body. The condylar processes of these rami articulate with the temporal bone to form the TM joints.

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The mandible has been compared to an archery bow, which is strongest at its center and weakest at its ends, where it often breaks. It carries alveolar process and the teeth. The mandible is composed of a compact outer and inner plate of cortical bone and a central portion of medullary bone ( spongiosa) whose trabeculae are distributed along the lines of maximum stress.

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The lower portion of the body is heavy and thick and consists of dense cortical bone with little spongiosa and changes very little during adult life. The alveolar process has got lingual and buccal plate of compact but thin bone. The body of the mandible is naturally strengthened by a strong system of buttresses which extend into the region of the rami.

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On lateral surface, the strong external oblique ridge extends from the body obliquely upward to the anterior border of the ramus. Medial surface is thinner than the lateral surface. Here the mylohyoid line extends from the area of the socket of the third molar diagonally downward and forward toward the genial tubercles at the midline.

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Bony chin is the most vulnerable endangered targeted area, but it is naturally strengthened by the mental protuberances. The ramus consists essentially of two thin plates of compact bone, separated by a narrow portion of cancellous bone. The posterior border of the ramus is strong and rounded.

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Muscle attachments and displacement of fractures: The periosteum is a most important structure in determining the stability or otherwise of a mandibular fracture. The periosteum of the mandible is stout and unyielding and gross displacement of fragments cannot occur if it remains attached to the bone.

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Periosteum may be stripped from the bone ends by the extremity of the force applied, but frequently it yields to the accumulation of the blood seeping from the ruptured cancellous bone . Once the periosteal splint has been removed displacement of the bone ends is free to occur under the influence of the attached muscles.

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Fracture at the Symphysis and Parasymphysis: The mylohyoid muscle constitutes a diaphragm between the hyoid bone and the mylohyoid ridge on the inner aspect of the mandible. In transverse midline fractures of the symphysis the mylohyoid and geniohyoid muscles act as a stabilizing force. An oblique fracture in this region will tend to overlap under the influence of the geniohyoid / mylohyoid diaphragm.

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When a bilateral parasymphyseal fracture occurs it usually results from considerable force which disrupts the periosteum over a wide area. Such a fracture is readily displaced posteriorly under the influence of the genioglossus muscle and to a lesser extent the geniohyoid.

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Fractures at the angle of the mandible: Influenced by the medial pterygoid- masseter ‘sling’ of which the medial pterygoid is the stonger component. Fractures of the condylar process: When a fracture of the condylar neck occurs the condylar head is frequently displaced and sometimes dislocates from the articular fossa. The most frequent direction of displacement is medially and forward under the influence of lateral pterygoid muscle.

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Fractures of the coronoid process: This is a rare fracture which is said to be brought about by reflex muscular contraction of the strong temporalis muscle which then displaces the fragment upwards towards the infratemporal fossa.

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MEDIAL PTERYGOID TEMORALIS MYLOHYOID ANT. BELLY OF DIGASTRIC GENIOHYOID GENIOGLOSSUS

History:

History Historical insight improves understanding of current techniques and provides the basis for the development of new methods. From the time of Hippocrates, physicians have described many different techniques for treating mandibular fractures, the principle of which has always been repositioning and immobilisation of the bony fragments.

The Pre-Christian era:

The Pre-Christian era The first description of mandibular fractures dates to the 17 th century BC in the ‘Edwin Smith Papyrus’, bought by Smith in Luxor in 1862 and later translated by Breasted. Simple fractures of the jaw were treated by bandages, obtained from the embalmer, and soaked in honey and white of egg, while wounds were treated by the application of fresh meat on the first day, a method which may well have introduced tissue enzymes and thromboplastins. R. Mukerji , G. Mukerji , M. McGurka: Mandibular fractures: Historical Perspective. British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228

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Hippocrates not only devised the technique of reducing a dislocated mandible but also taught methods of immobilising a fractured mandible. The ends of the fracture were reduced by hand and the fracture site was immobilised by gold or linen threads tied around the adjacent teeth. In addition to this intraoral immobilisation, he recommended extraoral fixation by strips of Carthaginian leather glued to the skin, the ends of which were tied over the skull.

The Early Medieval Period:

The Early Medieval Period During the period of the Roman Empire (23 BC–410 AD) few advances were made in the treatment of mandibular injuries, and reliance was placed upon the traditional Hippocratic methods. Aulus Cornelius Celsus collected Greek and Roman medical & adhered to the treatment advocated by the Corpus Hippocraticum : “The fragments are repositioned using two fingers, then tie together with horsehair the two adjacent teeth, or if these are loose, tie them to teeth further away.”

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Celsus advocated a ligature for fixation of the fracture. Postoperative treatment included rubbing the injury with wine, oil, or flour. About 500 AD, the Indian surgeon Sushruta wrote a treatise on operations. He recommended treating fractured jaws by using complicated bandaging and bamboo splints covered with a mixture of flour and glue that were applied under the chin to immobilise the fractures.

The 17th and 18th Centuries:

The 17th and 18th Centuries During this period, the barber surgeons used the classical treatment of fractures. After manually resetting the fractured jaw, ensuring that the normal occlusion was maintained and the teeth adjacent to the fracture line were joined by ligatures, the mandible was immobilised by bandages. Various modifications of bandages were used to immobilise the lower jaw by binding it to the upper jaw by a bandage that passed under the chin and over the head. It was prevented from slipping by another bandage carried over and around the occiput.

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Bandages to immobilise the lower jaw: Garretson’s (left) and Hamilton’s (right)

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In 1779, Chopart and Desault described a simple dental splint, essentially a shallow trough of iron laid over the lower occlusal table which was clamped down to the lower border of the mandible by an external screw device. Apparatus to immobilise a fracture mandible according to Chopart and Desault (1779)

The 19th and 20th centuries:

The 19th and 20th centuries At the turn of the 19th century, there was gradual shift in the management of fractures of the jaw away from general surgeons to dental surgeons, because the management of fractures depended on manipulating the dentition. External fixation often caused infection and the risk of malocclusion. In 1826, Rodgers did one of the first open reductions.

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Baudens is credited with being the pioneer of wiring mandibular fractures, and as early as 1840 he used circumferential wires to immobilise an oblique fracture. Up to this time, all fractures of the jaw were reduced manually, without the aid of anaesthesia as an outpatient procedure. The introduction of anaesthesia by Dr. Horace Wells in 1844 revolutionised the practice of surgery.

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In 1855, Hamilton introduced the gutta-percha splint that was prepared in the patient’s mouth after reduction of the fracture. This splint enjoyed wide application, particularly during the American Civil War. Kingsley devised a splint, “Kingsley’s apparatus” with attached bars by which the splint and the jaw could be bound firmly together with an outside bandage passing from one bar to the other underneath the chin. In 1858, Hayward developed a metal splint for severely dislocated fractures, the splint being adjusted to the individual needs on the basis of a plaster model of the jaws.

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Kingsley’s splint (top) and applied (bottom)

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Thomas Gunning(1866) designed the ‘Gunning splint’. Gurnell Hammond(1871) developed a wire ligature splint for immobilisation of the mandible. Thomas L. Gilmer(1887) reintroduced intermaxillary fixation and the use of arch bars for mandibular fractures. Robert H. Ivy (1922) modified the technique of intermaxillary fixation by creating a loop (eyelet) in the wire ligature, which later became popular and was known as the ‘Ivy loop’.

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The Gunning splint (1866)

Development of osteosynthesis:

Development of osteosynthesis The first osteosynthesis plate was used by the British surgeon Sir William Lane. Bigelow(1943) described screws and bars made of vitallium—an alloy of cobalt, chrome, and molybdenum—for use in the management of mandibular fractures. In the late 1960s Luhr and Perren et al. developed plates with cone-shaped or spherical screw heads and compression holes that were congruent in shape.

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Pauwels reported that the most favourable site of internal fixation of a fractured bone was where the muscular tensile forces were at their greatest. Champy and Lodde in the early 1970s applied this ‘tension band principle’ (also referred to as Champy’s principle) to the mandible in mathematical, biomechanical and clinical studies. Miniplate osteosynthesis was first introduced by Michelet et al. in 1973 and further developed by Champy and Lodde in 1975.

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Osteosynthesis plate introduced by Hans Luhr Miniplates developed by Champy and Lodde

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Lag Screw Fixation (LSF) for mandibular fracture treatment was introduced in 1970 by Brons & Boering. Spiessl introduced the lag-screw technique of osteosynthesis in1974. In the recent times, Ellis has done extensive work on non-compression, monocortical plates for mandibular fractures, particularly those of the condyle and angle.

Etiology:

Etiology

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Blow Fall R.T.A

Location of Mandibular Fractures:

Location of Mandibular Fractures

Classification:

Classification Kruger’s General classification: Simple or closed Compound or open Comminuted Complicated or complex Impacted Greenstick Pathological

Classification:

Classification Anatomical Location: Row and Killey’s classification Fractures not involving the basal bone – are termed as dentoalveolar fractures. Fractures involving the basal bone of the mandible. Subdivided into following: Unilateral. Bilateral. Multiple.

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Dingman and Natvig’s classification by anatomic region: Symphysis fracture (midline fracture). Parasymphysis (Canine region fracture). Body of the mandible between canine and angle. Angle region- Triangular region bounded by the anterior border of the masseter and an oblique line extending from the third molar region to the posterosuperior attachment of the masseter. Ramus region – bounded by the superior aspect of the angle to two lines forming an apex at the sigmoid notch. Coronoid region. Condylar fractures. Dentoalveolar region.

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Relation of the Fracture to the site of injury -Direct fractures. -Indirect (countercoup) fractures. Completeness - Complete - Incomplete fractures

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Number of Fragments: Single Multiple Comminuted Shape or area of the Fracture: Transverse Oblique Butterfly shape

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According to Etiology:

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According to the Direction of Fracture and Favourability for treatment ( Angle fracture): Horizontally favourable fracture. Horizontally unfavourable fracture. Vertically favourable fracture. Vertically unfavourable fracture.

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Horizontally favourable fracture Horizontally unfavourable fracture Vertically favourable fracture Vertically unfavourable fracture .

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Kazanjian and Converse classification: According to Presence or Absence of Teeth in Relation to the Fracture line : Class I when the teeth are present on both sides of the fracture line. Class II When the teeth are present only on one side of the fracture line. Class III When both the fragments on each side of the fracture line are edentulous.

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AO Classification: F: Number of fracture or fragments. L: Location (site) of the fracture. O: Status of occlusion. S: Soft tissue involvement. A: Associated fractures of the facial skeleton

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F0-F4 L1-L8 O0-O2 S0-S4 A0-A6

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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

CLINICAL EXAMINATION:

CLINICAL EXAMINATION Examination of a patient with mandibular fracture is done in 3 stages: Immediate assessment and treatment of life threatening conditions if any. General clinical examination. Local examination of the mandibular fracture.

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Case history Source/size/direction of traumatic force helpful in diagnosis Observe any deviation on opening of mouth. Note any limited opening / trismus.

Local Examination:

Local Examination Preparation for examination: The face must be gently cleaned in order that an accurate evaluation of any soft tissue injury can be made. The mouth should be examined for loose or broken teeth or dentures and any congealed blood removed with swabs held in non-toothed forceps.

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Extraoral examination: Swelling and ecchymosis Deformity in the bony contour of the mandible If considerable displacement has occurred the patient is unable to close the anterior tooth together and the mouth hangs open. Blood stained saliva is frequently observed dribbling from the corners of the mouth, particularly if the fracture is recent.

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Palpation should begin bilaterally in the condylar region and then continue downwards and along the lower border of the mandible. Bone tenderness is almost pathognomic of a fracture, even an undisplaced crack, but if there is more displacement it may be possible to palpate deformity or elicit bony crepitus.

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Fractures of the body of the mandible are often associated with injury to the inferior dental nerve in which case there will be reduced or absent sensation on one or both sides of the lower lip.

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Intraoral examination: A good light is essential. The buccal and lingual sulci are examined for ecchymosis. Submucosal extravasation of blood is often indicative of underlying fracture, particularly on the lingual side. On the lingual side the mucosa of the floor of the mouth overlies the periosteum of the mandible which, if breached following a fracture, will invariably be the cause of any leakage of blood into the sublingual mucosa.

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The occlusion plane of the teeth is next examined, or if the patient is edentulous, the alveolar ridge. Step defects in the occlusion or alveolus are noted along with any obvious lacerations of the overlying mucosa. All the individual teeth are examined and any luxation or subluxation along with fractured teeth, missing crowns, bridges or fillings to be noted.

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If a fracture site along the mandible is suggested, grasp the mandible on each side of suspected site and gently manipulate it to assess mobility.

Signs and Symptoms :

Signs and Symptoms Change in occlusion: This is highly suggestive of a mandibular fracture, and the bite will feel different. This may occur due to fractured teeth, alveolus mandible, or trauma to TMJ and muscles of mastication. Anterior open bite may occur due to bilateral angle or condylar fractures or from maxillary fractures with inferior displacement of the posterior maxilla. Posterior open bite can occur with fractures of the anterior alveolar process or parasymphyseal fractures. Unilateral openbite – ipsilateral angle and parasymphyseal fractures.

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Posterior crossbite-midline symphyseal or condylar fractures with splaying of the posterior mandibular segments. Retrognathic occlusion – condylar/angle fractures and forwardly displaced maxillary fractures. Prognathic occlusion – effusion of TMJ, protective forward positioning of the mandible, retropositioning of the maxilla.

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Anesthesia, Paresthesia or dysesthesia of the lower lip: Most pathognomonic sign of a fracture distal to the mandibular foramen, causing damage to the inferior alveolar nerve. Conversely, most non displaced fractures of the body angle and symphysis are not characterized by anesthesia, so this is not a sole diagnostic feature in diagnosis.

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Abnormal mandibular movements: Usually limited opening and trismus due to guarding of muscles of mastication are seen, but certain predictable abnormal movement are seen in certain cases, e.g. deviation to the same side on opening seen in condylar fractures, therefore lateral pterygoid of normal side is not counteracted by that of the fractured side.

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Inability to open the jaw may be due to impingement of the coronoid on the zygomatic arch, either from fractures of the ramus and coronoid process, or from a depressed zygomatic arch fracture. Inability to close the jaw due to fracture of alveolar process, angle, ramus, or symphysis causing premature dental contact. Lateral mandibular movements may be inhibited by bilateral condylar fractures, and fracture ramus with bone displacement.

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Change in facial contour and mandibular arch form: May be masked by swelling. Flattened appearance of lateral aspect of face may be due to fracture body, angle or ramus. Deficient mandibular angle - unfavourable angle fractures where proximal fragment rotates superiorly.

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Retruded chin – bilateral parasymphyseal fractures. Elongated facial appearance – bilateral subcondylar, angle or body fractures, which allows the anterior mandible to be displaced downwards. Facial asymmetry. Change in arch form.

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Lacerations, haematoma and ecchymosis: Trauma significant enough to cause loss of skin or mucosal continuity or subcutaneous / submucosal bleeding certainly can cause trauma to the underlying mandible. Ecchymosis in the floor of the mouth indicates mandibular body or symphyseal fracture.

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Ecchymosis in the floor of the mouth

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Loose teeth and crepitation on palpation. Multiple fractured teeth that are firm indicate that the jaws were clenched during the traumatic insult, thus lessening the effect on the supporting bone. Crepitation will be felt in a fracture on palpation. The signs of inflammation are excellent primary signs of trauma and can greatly increase the index of suspicion for mandibular fractures.

Imaging Studies:

Imaging Studies The single most informative radiologic study used in diagnosing mandibular fractures is the panoramic radiograph. Panorex provides the ability to view the entire mandible in one radiograph. Panorex requires an upright patient, and it lacks fine detail in the TMJ, symphysis, and dental/alveolar process regions.

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Parasympysis OPG

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Plain films, including lateral-oblique, occlusal, posteroanterior, and periapical views, may be helpful. The lateral-oblique view helps in diagnosing ramus, angle, or posterior body fractures. The condyle, bicuspid, and symphysis regions often are unclear. Mandibular occlusal views show discrepancies in the medial and lateral position of the body fractures. Caldwell posteroanterior views demonstrate any medial or lateral displacement of ramus, angle, body, or symphysis fractures.

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SYMPHYSIS # P.A. MANDIBLE

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CT scanning may also be helpful. CT scanning allows physicians to survey for facial fractures in other areas, including the frontal bone, naso-ethmoid-orbital complex, orbits, and the entire craniofacial horizontal and vertical buttress systems. Reconstruction of the facial skeleton is often helpful to conceptualize the injury. CT scanning is also ideal for condylar fractures, which are difficult to visualize.

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Three-dimensional reconstructions of mildly displaced left angle and right parasymphysial mandibular fractures

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Two-dimensional axial image and three-dimensional reconstructions of a displaced left parasymphysial fracture. PARASYMPHYSIS # PARASYMPHYSIS # Axial section CT Scan 3D reconsruction

Mandibular Fracture Management:

Mandibular Fracture Management Restoring form and function is the ultimate goal of facial fracture repair. Principles of mandibular fracture repair include reduction, fixation, stabilization and prevention of infection. Adhering to the principles of fracture repair result in an adequate treatment outcome, as measured by the patient’s return to form and function.

General principles:

General principles The patient’s general physical status should be carefully evaluated and monitored before any consideration of treating mandibular fractures. Diagnosis and treatment of mandibular fractures should be approached methodically, not with an “emergency type” mentality.

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Dental injuries should be evaluated and treated concurrently with treatment of mandibular fractures. Reestablishment of occlusion is the primary goal in the treatment of mandibular fractures. With multiple facial fractures, mandibular fractures should be treated first.

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Intermaxillary fixation time should vary accordingly to the type, location, number and severity of the mandibular fractures; the patient’s age and health; and the method used for reduction and immobilization. Prophylactic antibiotics should be used for compound fractures. Nutritional needs should be closely monitored postoperatively.

Preliminary Treatment:

Preliminary Treatment Airway Hemorrhage Soft tissue lacerations Support of the broken fragments Control of pain Control of infection Food and fluid

Closed Reduction:

Closed Reduction Implies fracture reduction without opening skin or mucosa. It is a blind procedure relying on the fragments locking together. This is most likely if the periosteum is intact. E.g. I.M.F or M.M.F. The reduction normally occurs without direct visualization of the fragments in final positions. The commonest method of closed reduction relies on correct positioning of teeth to control the reduction. The teeth are used to assist the reduction, check alignment of the fragments and assist in immobilization.

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Luyk proposed, “ if the principle of using the simplest method to achieve optimal results is to be followed, the use of closed reduction for mandibular fractures should be widely used. He also proposed, “ the indications for closed reduction may simply be stated as all cases in which an open reduction is either not indicated or is contraindicated.”

Indications:

Indications Grossly comminuted fractures Fractures of the severly atrophic edentulous mandible Lack of soft tissue overlying the fracture site Fractures in children involving the developing dentition. Infected fractures of lower jaw.

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OPG of a patient with a comminuted right mandibular body fracture that was minimally displaced. Patient was treated closed with 5 weeks of MMF and the fracture healed uneventfully ( Postoperative OPG)

Contraindications :

Contraindications Poorly controlled seizure history Compromise pulmonary function Psychiatric / neurologic problem Eating / GIT disorder

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Closed reduction and indirect skeletal fixation: Direct interdental wiring. Indirect interdental wiring (eyelet). Continuous or multiple loop wiring. Arch bars. Cap splints. Pin fixation.

Arch bar Fixation:

Arch bar Fixation

Direct Interdental wiring:

Direct Interdental wiring

Continuous / multiple loop wiring:

Continuous / multiple loop wiring

Advantages:

Advantages Inexpensive. Only stainless steel wires needed (usually arch bars also). Easy availability, convenient. Short procedure, stable. Gives occlusion some “leeway” to adjust itself. Generally easy, no great operator skill needed. Conservative, no need for surgical tissue damage. No foreign object or material left in the body. No operating room needed in most cases, outpatient treatment. Callus formation (secondary bone healing) allows bridging of small bony gaps.

Disadvantages :

Disadvantages Cannot obtain absolute stability (contributing to nonunion and infection). Non compliance from patient due to long period in IMF. Difficult (liquid) nutrition. Complete oral hygiene impossible. Muscular atrophy and stiffness. Denervation of muscles alteration in fibre types.

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Myofibrosis. Changes in temporomandibular joint cartilage. Weight loss. Irreversible loss of bite force. Decrease range of motion of mandible. Risks of wounds to operators manipulating wires.

Open reduction:

Open reduction Open reduction involves exposure of the fracture through either the skin or mucosa and fracture segments are visualized and reduced.

Biomechanics of the mandible:

Biomechanics of the mandible In every mandibular fractures, the forces of mastication produce tension forces at the upper border and compression forces at the lower border. Therefore distraction of the fractured fragments will be seen at the alveolar crest region. In the canine region, there are overlapping tensile and compressive loads in both directions. Besides this torsional forces are also significant.

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Throughout the body of the mandible biting forces produces tension at the upper border and compression forces at the lower border. The neutral axis is approximately at the level of the inferior alveolar canal.

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The mandible is a strong bone, the energy required to fracture is being of the order of 44.6-74.4 kg/m, which is about the same as the zygoma and about half that for the frontal bone. ( Swearingen 1965, Hodgson 1967, Nahum 1975)

CHAMPY’S IDEAL OSTEOSYNTHESIS LINE ON MANDIBLE:

CHAMPY’S IDEAL OSTEOSYNTHESIS LINE ON MANDIBLE It corresponds to the course of a line of tension at the base of the alveolar process. In this region a plate can be fixed with monocortical self tapping screws. Behind the mental foramen, a plate can be applied immediately below the dental roots and above the inferior alveolar nerve.

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At the angle of the jaw, the plate is most favourably placed on the broad surface of the external oblique line as high as possible. In the anterior region between the mental foramina, in addition to the subapical plate, another plate near the lower border of the mandible is necessary in order to neutralize torsional forces. Second plate is applied parallel to the first plate with a gap of 4.5 mm between them.

Indications :

Indications Displaced unfavourable fractures through the angle of mandible. When proximal fragment is displaced superiorly, medially and cannot be maintained without intraosseous wires, screws or plating. Displaced unfavourable fractures of the body or the parasymphyseal region of the mandible. When treated with closed reduction parasymphyseal fracture tend to open at the inferior border with the superior aspect of the mandibular segments rotating medially at the point of fixation.

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Multiple fracture of the facial bones. In multiple fracture of the facial bones, open fixation of the mandibular segments provide a stable base for restoration.

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Midface fractures and displaced bilateral condylar fractures. With midface frace and displaced bilateral condylar fracture, one of the condylar fractures should be opened to establish the vertical dimension of the face. Fractures of an edentulous mandible with severe displacement of the fracture segments. Open reduction should be considered to reestablish continuity of the mandible.

Contraindications:

Contraindications A General Anesthetic or a more prolonged procedure is not advisable. Severe comminution is present and the creation of stable units with rigid fixation is not possible. Bone at the fracture site is diffusely involved with infection. Patients refuse a more complex treatment approach.

Advantages :

Advantages Early return to normal jaw function. Normal nutrition. Normal oral hygiene after a few days. Avoidance of airway problem. Can get absolute stability, promotes primary bone healing. Bone fragments re-approximated exactly by visualization. Avoids IMF for patient with occupational benefits in avoiding mandible fixation.

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Helpful in special nutrition requirements (diabetics, alcoholics, psychiatric disorders, pregnancy). Easy oral access (for example in intensive care unit patients). Decreased patient discomfort, greater patient satisfaction. Less myoatrophy. Decreased hospital time. Substantial savings in overall cost of treatment. Lower risk of major complications. Lower infection rates, improved overall results. Lower rate of malunion/nonunion

Disadvantages:

Disadvantages Significant operating room time. Prolonged anaesthesia. Expensive hardware. Some risk to neuromuscular structure and teeth. “Unforgiving procedure”, the rigidity of the plate means no manipulation is permissible. Need much operator skill, meticulous technique needed. Higher frequency malocclusion. Higher frequency facial nerve palsy. Scarring (extraoral and intraoral). No bridging of small bone defect (absence of callus)

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Treatment by open reduction and dental skeletal fixation: Transosseous wiring (osteosynthesis). Plating. Intramedullary pinning. Titanium mesh. Circumferential straps. Bone clamps. Bone screws

Methods of open reduction:

Methods of open reduction Intraoral approach Extra oral approach Factors used to establish the location of incision includes, Fracture locaton Skin lines Nerve position

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Extraoral Approaches

Submandibular approach:

Submandibular approach Described by Risdon in 1934.

Modifications of submandibular approach:

Modifications of submandibular approach For increased ipsilateral exposure, the submandibular incision can be extended posteriorly toward the mastoid region, and anteriorly in an acting manner toward the submental region. The incision leaves the resting skin tension lines anteriorly.

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Extension of the submandibular incision posteriorly toward the mastoid region and anteriorly toward the submental region in a “stepped” manner.

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Submandibular incisions connected in the midline for complete bilateral exposure of the mandible.

Retromandibular approach:

Retromandibular approach Described by Hinds & Girotti in 1967.

Preauricular approach:

Preauricular approach Described by Thoma(1945) & Rowe (1972).

Endaural approach:

Endaural approach

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Preauricular Endaural

Intraoral approach:

Intraoral approach Anterior vestibular approach or ‘Degloving incision’ ( Symphysis and Parasymphysis region) Transbuccal incision ( Body, Angle, Ramus region)

Mandibular fracture of edentulous mandible:

Mandibular fracture of edentulous mandible The physical characteristics of the body of the mandible are altered considerably following the loss of teeth. Following resorption of the alveolar process, the vertical depth of the subsequent denture bearing- area is reduced by approximately one half and in some cases by considerably more.

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The resistance of the bone to trauma is further reduced by changes in the structure of the bone associated with the process of ageing. The ageing process is also associated with significant changes in the vascular architecture. The endosteal blood supply from the inferior dental vessels begins to disappear and the bone becomes increasingly dependent on the periosteal network of vessels. Cohen L. Further studies into the vascular architecture of the mandible J. Dent. Res. 1960 ;39: 260. Bradley, J.C. A radiological investigation into the age changes of the inferior dental artery. Br. J. Oral Surg. 1975; 13:85.

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The denture – bearing area of the edentulous mandible is therefore not only more easily fractured, but also less well disposed to rapid and ueventful healing. The smaller cross- sectional area of bone at the fracture site and the absence of the stabilizing influence of teeth means that the bone ends are more easily displaced, and even after reduction the area of contact between them may be insufficient for healing to occur easily.

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Advantages: Fractures are much less frequently compound into the mouth than when teeth are present. As a result whenever closed reduction is possible the risk of subsequent infection of the fracture is negligible. Amaratunga et al. A comparative study of the clinical aspects edentulous and dentulous mandibular fractures. J. Oral Maxillofac. Surg. 1988; 46:3 The absence of teeth means that precise reduction is not necessary as any inaccuracy is easily compensated by adjustment of dentures.

MANAGEMENT:

MANAGEMENT Direct osteosynthesis: Bone plates Transosseous wiring Circumferential wiring or straps Transfixation with Kirschner wires Fixation using cortico- cancellous bone graft

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Indirect skeletal fixation: Pin fixation Bone clamps Intermaxillary fixation using Gunning –type splints

Postoperative care :

Postoperative care Immediate postoperative phase: When the patient is recovering from G.A. Intermediate postoperative care: It includes, -Posture -Control of pain -Prevention of infection -Oral hygiene maintenance -Feeding

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Late postoperative care: - Testing of union and removal of fixation - Adjustment of occlusion - Teeth and supporting tissues.

Complications:

Complications Arising during primary treatment: - Infection - Nerve Injury - Pulpitis - Gingival & Periodontal complications Late complications: - Malunion - Delayed union - Nonunion - Limitation of opening - Scars

Complications: :

Complications: Infection: The overall post operative infection rate has been reported to be between 3% and 27%. The most common cause is mobility of fracture segments. Inadvertent placement of screws in the line of fracture Poor plate adaptation and inadequate cooling of bone during screw hole preparation increase the risk of post operative infection. Fractures in the proximal part of the mandibular body or in the angle region have a higher propensity for infection because of decreased cross sectional surface area of bone.

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The other factors implicated in an increased rate of infection include extraction of molar teeth from the line of fracture. The extraction of teeth is indicated when there is periapical pathology, fractured, or severely displaced or those that prevent fracture reduction.

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Nerve Injury: Iatrogenic injury to the sensory branches of the trigeminal nerve is known to occur following open reduction. The nerve injury is often the result of over retraction and also occurs following the application of rigid fixation. Injury to branches of facial nerve occasionally occurs during repair of mandibular fracture, in case of submandibular incision and approach to condyle the marginal mandibular nerve and temporal branches are damaged respectively.

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Malunion: Mal union is the healing of bone segments in a non physiologic position secondary to either non treatment or inadequate treatment of a displaced fractures malunion may occur as a result of plate bending, plate fracture, loosening of screw or poor intraoperative reduction. In dentate portion of maxilla and mandible this leads to a malocclusion.

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Delayed union: The time taken for a mandibular fracture to unite is unduly protracted it is referred to as a case of delayed union. If union is delayed beyond the expected time for that particular fracture it must be assumed that the healing process has been disturbed. This is the result of local factor such as infection or general factors such as osteoporosis or nutritional deficiency.

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Nonunion: Means that the fracture is not only not united but will not unite on its own. Causes: Infection Inadequate immobilization Unsatisfactory opposition of bone ends with interposition of soft tissue. Inadequate blood supply General disease, e.g. Osteoporosis, nutritional deficiencies.

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Scar: Mandibular fractures have associated soft tissue injuries which leads to scar formation. Injury to tooth roots: There is always the possibility of trauma to the dental structures when placing screws in the dentate region of maxilla and mandible.

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Limitation of opening: Prolonged immobilization of the mandible in intermaxillary fixation will result in weakening of the muscles of mastication. Excess haemorrhage within the muscles, considerable amount of organizing haematoma and early scar tissue may be present when fixation is released. All these factors combine to cause limitation of opening and restricted mandibular excursion.

Recent Advances:

Recent Advances Gui-Youn Cho Lee, Francisco J. Rodríguez Campo , Raúl González García , Mario F. Muñoz Guerra , Jesús Sastre Pérez , Luis Naval Gías . Endoscopically-assisted transoral approach for the treatment of subcondylar fractures of the mandible. Med Oral Patol Oral Cir Bucal. 2008 Aug 1;13(8):511-5. Objective of the study to introduce the endoscopically-assisted transoral approach for the treatment of subcondylar fractures. Endoscopic treatment by transoral approach combines the positive aspects of both conventional techniques: closed and open reduction; allowing anatomic reduction and a stable fixation leaving no visible facial scars and with a minimum risk of injury to the facial nerve.

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Endoscopic image of the left subcondylar fracture, displaced and high.

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General requirements for endoscopic surgery include the following: The ability to surgically obtain and maintain an optical cavity The ability to insert a fiberoptic endoscope The ability to maintain adequate hemostasis The ability to apply instrumentation

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Advantages of endoscopic repair include the following: More accurate fracture visualization Small external incisions Reduced soft tissue dissection The potential for visualization around corners The possibility of reduced duration of hospital stays Improved teaching opportunities (since the procedure can be visualized on a television monitor)

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Disadvantages of endoscopic repair include the following: A current lack of dedicated instrumentation A moderate learning curve for the techniques A narrow field of view A limited ability for bimanual instrumentation without an assistant

References:

References Maxillofacial Surgery- Peter Ward Booth . Surgical management of mandibular Fractures Vol.1. Oral & Maxillofacial Trauma. FONSECA . Walker, Betts, Barber, Powers. Mandibular Fractures. Vol.1. Maxillofacial Injuries. N.L. Rowe and J.L. Williams . Mandibular fractures.

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Oral & Maxillofacial Surgery- Trauma. FONSECA . Marciani, Hendler. Vol.3. Killey’s fractures of the mandible . Peter banks. 4 th edition. Textbook of oral & maxillofacial surgery. Neelima Anil Malik. R. Mukerji , G. Mukerji , M. McGurka: Mandibular fractures: Historical Perspective. British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228

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Gui-Youn Cho Lee, Francisco J. Rodríguez Campo , Raúl González García , Mario F. Muñoz Guerra , Jesús Sastre Pérez , Luis Naval Gías . Endoscopically-assisted transoral approach for the treatment of subcondylar fractures of the mandible. Med Oral Patol Oral Cir Bucal. 2008 Aug 1;13(8):511-5. Cohen L. Further studies into the vascular architecture of the mandible J. Dent. Res. 1960 ;39: 260. Bradley, J.C. A radiological investigation into the age changes of the inferior dental artery. Br. J. Oral Surg. 1975; 13:85.

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