MANAGEMENT OF MANDIBULAR FRACTURE

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MANAGEMENT OF MANDIBULAR FRACTURE: 

MANAGEMENT OF MANDIBULAR FRACTURE Syeda Tooba Zaidi Deptt of oral surgery

ANATOMIC UNITS OF MANDIBLE: 

ANATOMIC UNITS OF MANDIBLE

Slide 3: 

fractures are systematized in several categories: A. According to the severity of the fracture: simple /closed/ and compound /towards the oral cavity or the skin/ B. According to the type of fracture : greenstick fracture, complex fracture, comminuted fracture, impacted fracture and depressed fracture C. According to the presence or absence of the teet h in the jaws / dentulous , partially edentulous, edentulous/. D . According to the location : 1. Region of symphysis 2. Canine region 3. Region of body 4. Region of angle 5. Region of ramus 6. Region of condylar process 7. Region of coronoid process CLASSIFICATION

AETIOLOGY: 

AETIOLOGY road injuries. Interpersonal violence. Falls. Sports injuries. Industrial trauma. Missile injuries. Gunshot wounds. Pathological fractures

TYPE OF FRACTURE: 

TYPE OF FRACTURE

SITE OF FRACTURE: 

SITE OF FRACTURE

Direction of fracture: 

Direction of fracture

Site of fracture: 

Site of fracture

INNERVATION: 

INNERVATION Mandibular nerve through the foramen ovale Inferior alveolar nerve through the mandibular foramen Inferior dental plexus Mental nerve through the mental foramen

ARTERIAL SUPPLY: 

ARTERIAL SUPPLY Internal maxillary artery from the external carotid Inferior alveolar artery through the mandibular foramen Mental artery through the mental foramen

ANGEL’S CLASSIFICATION: 

ANGEL’S CLASSIFICATION

Classified by the presence or absence of teeth: 

Classified by the presence or absence of teeth Class I : Teeth on both side of the fx line dentelous . Class II : Teeth on one side of the fx. Line partially edentulous. Class III : no teeth edentulous.

Mandibular forces: 

Mandibular forces

MUSCLE ATTECHMENT AND DISPLACEMENT OF FRACTURE: 

MUSCLE ATTECHMENT AND DISPLACEMENT OF FRACTURE

PAST MEDICAL HISTORY: 

PAST MEDICAL HISTORY bone disease neoplasia arthritis, tmj (risk for ankylosis ) collagen vascular disease, endocrine d/o nutrition and metabolic disorders, including alchohol abuse Seizure.

CLINICAL EXAMINATION: 

CLINICAL EXAMINATION Examination of a pt with mandible takes place in three stages. 1) immediate assessment and treatment of any condition constituting a threat of life. 2) general clinical examination of the pt. 3) local examination of the mandibular fracture

RADIOLOGICAL DIAGNOSIS: 

RADIOLOGICAL DIAGNOSIS Panoramic radigraphs . Lateral oblique radiographs. Posteroanterior (pa) mandibular view. Reverse towne view. Periapical radiographs Mandibular occlusal view. Temporomandibular joint views including tomography. Ct scan

Preliminary treatment: 

Preliminary treatment Airway Haemorrhage Soft tissue lacerations Support of bone fragments. Control of pain. Control of infection. Food and fluid.

FRACTURE OF THE TOOTH BEARING SECTION OF THE MANDIBLE.: 

FRACTURE OF THE TOOTH BEARING SECTION OF THE MANDIBLE. A simple guide to the time of immbolization for fractures of the tooth bearing area. Young adult with fracture of the angle receiving early treatment in which tooth removed from fracture line. 3 week If tooth retained in fracture line : 4 week Fracture at the symphysis : 4 week. Age 40 yrs and over: 4 to 5 weeks. Children and adolescent : 2 week

INDICATIONS: 

INDICATIONS Absolute indications for removal of a tooth from the fracture line: 1 longitudinal fracture involving the root. 2 dislocation or subluxation of the tooth from the socket. 3 presence of periapical infection. 4 infected fracture line. 5 acute pericoronitis . Relative indication for removal of a tooth the fracture line. 1 functionless tooth which would eventually be removed electively. 2 advanced caries. 3 advanced periodontal disease. Doubtful teeth which could be added to existing dentures.

Slide 22: 

Managment of the retained fracture line. 1 good quality intra oral periapical radiograph. 2 institution of appropriate systemic antibiotic therapy. 3 splinting of tooth if mobile. 4 endodontic therapy if pulp is exposed. 5 immediate extraction if fracture become infected.

METHODS OF IMMBOILIZATION: 

METHODS OF IMMBOILIZATION A) OSTEOSYNTHESIS without INTERMAXILLARY fixation. 1 non- compression small plates. 2 compression plates. 3 mini plates. 4 lag screws. B) INTERMAXILLARY FIXATION. 1 bonded brackets. 2 dental wirig direct; eyelet; 3 arch bars; 4 cap splints.

Slide 24: 

C) INTERMAXILLARY FIXATION WITH OSTEOSYNTHESIS. 1 tranosseous wiring. 2 cicumferential wiring. 3 External pin fixation. 4 bone clamps. 5 transfixation with krischner wires.

MAXILLOMANDIBULAR FIXTATION: 

MAXILLOMANDIBULAR FIXTATION MMF CONTRAINDICATED IN EPILEPTICS, ALCHOLICS, PSHYCHIATRIC AND DIABETICS

IVY LOOPS: 

IVY LOOPS

OPEN REDUCTION… NON RIGID FIXATION: 

OPEN REDUCTION… NON RIGID FIXATION

Slide 28: 

CLASSICAL INDICATION FOR OPEN REDUCTION MALOCCLUSION DESPITE MMF DISPLACED UNFAVORABLE FX THROUGH THE ANGLE DISPLACED, UNFAVORABLE FX OF THE BODY OR THE PARASYMPHYSIS MULTIPLE FX OF THE FACIAL BONES - MANDIBLE IS FIXED FIRST PROVIDING A STABLE BASE FOR RESTORATION - NON RIGID FIXATION MORE FORGIVING, EASIER TO PLACE. STILL REQUIRES MMT, USEFUL IN ANGLE AND PARASYMPHYSEAL FX.

Open reduction - Rigid fixation: 

Open reduction - Rigid fixation

EXTERNAL FIXATION: 

EXTERNAL FIXATION USUALLY NECESSARY IN COMMUNUTED FX. THOSE WHO CANNOT TOLERATE MMF OR GSW

Lag screw: 

Lag screw

Injury to teeth: 

Injury to teeth Fractured teeth can become infected and cause malunion . Extraction necessary if root of tooth is fractured A tooth that is intact but in the line of the fracture can be left in place and protected by antibiotics may need extraction later

FRACTURE OF THE EDENTULOUS MANDIBLE: 

FRACTURE OF THE EDENTULOUS MANDIBLE METHODS OF IMMOBILIZATION. 1 direct osteosynthesis : A) bone plates B) transosseous wiring. C) circumferential wiring or straps. D) transfixation with kirschner wires. E) fixation using cortico - cancellous bone graft.

Slide 34: 

INDIRECT SKELETAL FIXATION A) pin fixation. B) bone clamps INTERMAXILLARY FIXATION USING GUNNING- TYPE SPLINTS. A) used alone B) combined with other methods.

Treatment option for dentate patient: 

Treatment option for dentate patient CONDYLAR FRACURES MOST OFTEN TX WITH MMF ONLY – NONDISPLACED FOR 3 WKS, FOLLOWED BY ELASTICS X 2 WEEKS DISPLACED - 6 WEEKS OF IMF MAY NEED NOTHING OR MAY NEED ORIF TO AVOID ANKYLOSING THE TMJ NEED TO MOBILIZE EVERY 2 WEEKS IF ADULT. RAMUS FX ARE NATURALLY SPLINTED BY THE PTERYGOMASSETERIC MUSCLE SLING AND USUALLY GET MMF WITH SAME TIMEFRAME AS CONDYLAR. SYMP-PARA B/C NO OCCLUSAL STOPS. IF CLOSED REDUCTION MAY NEED LINGUAL SPLINT

Special considerations - Edentulous patients: 

Special considerations - Edentulous patients Dentures Splint Cirumzygomatic and circumandibular fixation

Splint fabrication: 

Splint fabrication

Slide 38: 

NEXT MAKE A CAST FROM THE IMPRESSION - USUALLY PLASTER OR STONE OF COMBO

Slide 39: 

NEXT ACRYLIC SPLINTS ARE MADE - GUNNING SPLINTS NOTE HOLES FOR WIRING AND GROOVES FOR CIRUMANDIBULAR WIRE

Application of splints: 

Application of splints FIXED WITH CIRCUMZYGOMATIC AND CIRCUMANDIBULAR WIRES

Slide 41: 

THIS SLIDE SHOWS THE CIRCUZYGO AND MANDIBLE WIRES AND THE COMPLETED FIXATION

Denture preparation: 

Denture preparation DENTURES WITH A CHANNEL FOR THE ARCH BAR AND CIRCUMANDIB. FIXATION

complication: 

complication Delayed healing(3%) and nonunion(1%) most common cause in infection second most common cause is noncompliance inadequate reduction, metabolic or nutritional deficiency can play a role Nerve paresthesia’s (Inf. Alveolar nerve) occur in 2% Malocclusion and malunion TMJ problems

Complication : 

Complication A study out of UCSF showed no statistically significant difference in complication rate between pts treated with miniplates versus MMF and wire fixation. Another study based on a group of patients with angle fx all treated at Parkland with nonrigid fixation or lag screw or miniplate showed the lowest complication rate.

FRACTURE OF THE CONDYLAR REGION: 

FRACTURE OF THE CONDYLAR REGION CLASSIFICATION OF CONDYLAR FRACTURE. INTRACAPSULAR EXTRACAPSULAR Luxation / sublaxation subcondylar neck Condylar head condylar neck hair line high condylar communited low condylar

TREATMENT OF CONDYLAR FRACTURES: 

TREATMENT OF CONDYLAR FRACTURES 3 TREATMENT OPTION. 1 functional. 2 indirect immobilization. 3 osteosynthesis . CONDYLAR FRACTURE SHOULD BE CLASSIFIED ACC TO: AGE. SURGICAL ANATOMY: Involving joint surface- intracapsular . Not involving joint surface- extracapsular . SITE; unilateral bilateral. OCCLUSION: undisturbed. malocclusion .

FRACTURE OF THE MANDIBLE IN CHILDREN: 

FRACTURE OF THE MANDIBLE IN CHILDREN The treatment before puberty is generally of a conservative nature because of rapid healing and the adaptive potential of the bone and its contained dentition. INTERFERNCE WITH GROWTH POTENTIAL The normal growth of the mandible will be disturbed if unerupted permanent teeth or teeth germs are lost, because the alveolus will not develop normally in the areas affected.

FIXATION IN THE DECIDUOUS AND MIXED DENTITION PERIOD: 

FIXATION IN THE DECIDUOUS AND MIXED DENTITION PERIOD FIXATION INDEPENDENT OF THE TEETH. In a very young with unerupted or very few deciduous teeth---------- use gunning type splint for the lower jaw alone and retained by two circumferential wires. Where some occlusion present bur there is wide spread of caries or deciduous teeth------use circumferential wires on each side with cicumzygomatic wires. Minimal jaw movement----------- use simple elastic bandage for chin support.

Slide 49: 

FIXATION UTILIZING THE TEETH. Mixed dentition with inadequate retension ----------use cap splints with cement bond and circumferential wire on each side. Sufficient firm erupted deciduous and permanent teeth------eyelets and arch bars UNERUPTED TEETH. Transosseous wires. Bone plates CONTRAINDICATED Pins

Special consideration for children: 

Special consideration for children Deciduous teeth vs. permanent Fractures with deciduous dentition can be treated with MMF for 2-3 weeks. Rigid techniques can harm the tooth bud. Growth center The most feared complication of a Pedi mandible fx is ankylosing of the TMJ with impact on jaw growth that causes severe facial deformity- prevent with weekly mobilization

Slide 51: 

IT IS HARDER TO PERIDONTAL WIRE LIGATURES AROUND DECIDOUS TEETH BECAUSE THE TOOTH IS CLOSER TO THE GINGIVAL MARGIN THAN THE CROWN OF THE PERMANENT TOOTH SO IT MAY BE NECESSARY TO SECURE THE WIRES TO THE PIRIFORM RIM AND MANDIBLE BY CIRCUMANDIBULAR WIRES

POST OPERATIVE CARE: 

POST OPERATIVE CARE THREE PHASES. 1) the immediate post operative phase when the pt is recovering from the general anesthesia. 2) the intermediate phase before clinical bony union has become established. 3) the late postoperative phase which includes removal of fixation, bite rehabilation , physiotherapy and long term observation of the dentition in particular.

Slide 54: 

THANK YOU