Mandible Fracture 01 31 08
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Mandible Fracture 01 31 08 Presentation Transcript

  • 1.
    • Thursday Morning Conference
    • 01/31/2008
    • Paul K. Holden, MD
    UC Irvine Otolaryngology-Head & Neck Surgery
  • 2. Case Presentation
    • You are called to assess a patient in the trauma bay s/p fall from motorcycle onto his face.
  • 3. Exam Findings
    • ABC – talking, slurred speech, hemodynamically stable.
    • Extensive degloving chin laceration communicates with oral cavity. Some dental step-off, obvious malocclusion.
    • No neck swelling or soft tissue injury.
  • 4. Additional Concerns?
    • Intoxication? Head Injury?
    • C-spine
    • “Open” fracture
    • Missing teeth? WHERE ARE THEY?
  • 5. Rest of Exam
    • PERRL/EOMi, no raccoon eyes
    • Midface Stable, no septal hematoma, no step-offs in midface
    • Fresh blood occluding EACs bilaterally
    • Malocclusion, 1.5 cm MICD due to pain
    • Ecchymosis under tongue with minimal retrodisplacement. FOL – airway clear.
  • 6. Studies Done
    • CT Head w/o contrast (very limited view)
    • CT Face Axial/Coronal w/ 3-d recons
    • Prefer preoperative mandible series with panorex…why?
  • 7.  
  • 8.  
  • 9.  
  • 10.  
  • 11.  
  • 12. Mandible Fracture
    • Very often more than one fracture present
    • May result in airway compromise (acute or delayed)
    • Elevated risk of c-spine injury
    • Almost always considered contaminated
  • 13. Immediate Management
    • Rule out other significant injury including brain and c-spine
    • Monitor for airway issues – repeat exam (may include FOL), monitored bed
    • Start antibiotics immediately (what type?)
    • Pain management
    • Document CN function (esp inf alveolar)
  • 14. Considerations In Mandible Fx
    • Much of the morbidity of these injuries is attributed to improper management.
    • Infection risk increases with passage of time, substantially higher after 72h.
    • Risks of nonunion, malunion, malocclusion, plate fracture, plate extrusion, TMJ fixation, jaw restriction, poor cosmetic outcome
  • 15. Steps to Avoid Problems
    • Proper diagnosis
    • Consider Co-morbid Conditions
    • Consider Patient Personality/Occupation
    • Proper management plan for the circumstances
    • Proper technique (MMF, bending, drilling, screw placement, nerves, tooth roots)
    • When in doubt, use a LARGER plate.
  • 16. Concepts in Reduction
    • Patient’s baseline occlusion is first priority.
    • Class I, II, III … Crossbite?
    • Observe wear facets
    • Do not force class I if it doesn’t line up with wear facets.
    • Verify occlusion at beginning, mid, end of case. Remove MMF to verify if necessary.
  • 17. Plate Types
    • What is…
      • A tension band?
      • A compression plate?
      • A lag screw?
      • A recon (UF) plate?
      • A locking plate?
      • Load sharing vs. load bearing plate?
  • 18. Know Champy Lines
  • 19. Fracture Types
    • Condylar / Subcondylar
    • Ramus
    • Angle
    • Body
    • Parasymphaseal
    • Symphaseal
    • Alveolar Ridge
  • 20. Type and Management Symphaseal 2.0 L Compression + TB Lag Screws
  • 21. Type and Management Comminuted Symphaseal 2.4 Locking Recon Plate + TB Left Subcondylar
  • 22. Type and Management Parasymphaseal Two Miniplates?
  • 23. Type and Management Comminuted Parasymphaseal 2.4 Locking Recon Plate with TB
  • 24. Type and Management Comminuted Body/Parasymph 2.4 Locking Recon Plate with MPs
  • 25. Type and Management Symphaseal and Angle, 3 rd Molar Single Champy MP at Angle
  • 26. Type and Management Disloc Angle w/ Basal Triangle 2.4 Locking Recon Plate with 2.0 MP
  • 27. Special Case Edentulous Body Fracture 2.4 Locking Recon Plate, 4 screws
  • 28. Another Special Case Infected Angle Fracture 2.4 Locking Recon Plate
  • 29. Other Special Cases
    • Bilateral Parasymphaseal – Geniohyoid origin lost, tongue prolapses into airway.
    • Bilateral subcondylar – prone to TMD, loss of height, retrusion and increased width of mandible.
    • Pediatric Fractures – remove plates or use absorbable, minimize MMF.
    • Loss of Bone – from infection, severe trauma or nonunion.
  • 30. Controversies/Difficulties
    • When to perform ORIF on subcondylar
    • Tooth in the fracture line
    • Stops for unilateral subcondylar
    • Missing Teeth (but not edentulous)
    • When to go extra-oral route
    • How long to continue abx postop (Ali?)
  • 31. Back to Our Patient
  • 32. Back to Our Patient
    • Comminuted Symphaseal
    • High right subcondylar fracture/dislocation
    • Non-displaced left subcondylar fracture
  • 33.  
  • 34. No Mas!