Mandibular fracture 2 / fixed orthodontic courses


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Mandibular fracture 2 / fixed orthodontic courses

  1. 1.
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  5. 5. FRACTURE : Definition : Fracture is defined as sudden violent solution in the continuity of the bone which may be complete or incomplete resulted from direct or indirect causes.
  6. 6. MANDIBULAR FRACTURES : Fractures of the mandible are common in patients, who sustain facial trauma. Study conducted by Hang et al in 1983, showed the ratio of 6: 2: 1 of mandibular , zygomatic , maxillary fractures incidence respectively. Approximately two thirds of all facial fractures are the mandibular fractures ( nearly 70 % ). SEX : Most mandibular fractures are seen to occur in male patients. Ratio is approximately 3 : 1 AGE : 35 % of mandibular fractures occur between the ages of 20 to 30 years.
  7. 7. AETIOLOGY OF MANDIBULAR FRACTURES       1.Vehicular accidents - 43%. 2.Altercation,assaults,interpersonnel violence - 34% 3.Fall - 7% 4.Sporting accidents - 4% 5.Industrial mishaps or work accidents - 10% 6.Pathological fractures or miscellaneous - 2%.
  8. 8. Location of mandibular fractures : As per Olson’s study in 1982, Condyle fractures Angle fractures Dento alveolar fractures Molar region Symphysis Body fractures Ramus fracture Coronoid fractures Mental region Cuspid - 29% 25% 3% 15% 16% 22% 4% 1% 14% 7%
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  10. 10. Number of fractures per mandible. The number of mandibular fractures per patient ranged from 1.5 to 1.8. 1. Unilateral , single 2. Bilateral , double 3. Multiple fractures - 53% 37% 10% Fifty percent have more than one fracture.
  11. 11. Classification of mandibular fractures : General classification II) Anatomical locations III) Relation of the fracture to site of injury IV) Completeness V) Depending on the mechanism VI) Number of fragments VII) Involvement of the integument VIII) The shape or area of the fracture IX) According to the direction of fracture and favourability for the treatment X) According to presence or absence of teeth XI) AO classification – relevant to internal fixation I)
  12. 12. I)Kruger’s general classification: 1)Simple or closed: A fracture that does not produce a wound open to the external environment , whether it be through the skin, mucosa or periodontal membrane. The linear fracture which does not have communication with the exterior. Eg: Fracture in the region of the condyle, coronoid process, ascending ramus etc.
  13. 13. 2) Compound or open: This fracture has communication with the external environment through skin, mucosa or periodontal membrane. All the fractures involving the tooth bearing area of the mandibular or where an external or intraoral wound is present involving the fracture line.
  14. 14. 3) Comminuted fracture: A fracture in which the bone is splintered or crushed into multiple pieces. These types are generally due to a greater degree of violence or high velocity impact. Gunshot wounds, where missiles are traveling at a high velocity can produce these fractures.
  15. 15. 4) Greenstick fracture: A fracture in which one cortex of the bone is broken with the other cortex being bent. It is an incomplete fracture seen in young children because of inherent resiliency of the growing bone.
  16. 16. 5)Pathologic fracture: Spontaneous fracture of the mandible occurring from mild injury or as a result of a normal degree of muscular contraction. This is because of weakness caused due to the pre-existing bone pathology.
  17. 17. Areas of structural weakness may result from the following: a) Generalized skeletal disease: i) Endocrinal disorders – Hyper parathyroidism, or postmenopausal osteoporosis. ii) Developmental disorders – Osteoporosis, osteogenesis imperfecta. iii) Systemic disorders – Reticuloendothelial diseases, Paget’s disease, osteomalacia & severe anemia. b) Localised skeletal disease: Various cysts, odontomes, tumours, osteomyelitis, osteoradionecrosis affect the local region.
  18. 18. 6) Multiple Fractures: A variety in which there are two or more lines of fracture on the same bone not communicating with one another. 7) Impacted: Rarely seen in mandibular fractures. More commonly seen in maxilla. This is a fracture in which one fragment is firmly driven into the other fragment and clinical movement is not appreciable. 8) Atrophic: A spontaneous fracture resulting from atrophy of the bone, as in edentulous mandible. 9) Indirect: A fracture at a point distant from the site of injury.
  19. 19. 10) Complicated or complex: Fractures associated with the damage to the important vital structures complicating the treatment as well as prognosis. Eg: Fractures with injury to the inferior alveolar vessels or nerve, facial nerve or its branches, facial vessels, condylar fractures with associated injuries to middle cranial fossa, etc.
  20. 20. II) Anatomical Location ROWE AND KILLEY’S CLASSIFICATION: A) Fractures not involving the basal bone-are termed as dentoalveolar fractures. B) Fractures involving the basal bone of the mandible. Subdivided into following: i) Single unilateral ii) Double unilateral iii) Bilateral iv) Multiple
  21. 21. DINGMAN AND NATWIG’S CLASSIFICATION OF ANATOMIC REGION: A )Symphysis Fracture (Midline) – Fractures between central incisors B) Parasymphyseal – Fractures occurring within the area of the symphysis. C) Canine region fracture D) Body – From the distal symphysis to a line coinciding with the alveolar border of the masseter muscle (usually including the third molar). E) Angle – Triangular region bounded by the anterior border of the masseter muscle to the posterosuperior attachment of the masseter muscle (Usually distal to third molar). F) Ramus – Bounded by superior aspect of the angle to two lines forming an apex at the sigmoid notch. G) Condylar process – Area of the condylar process superior to the ramus region H) I) Coronoid process – Includes the coronoid process of the mandible superior to ramus region. Alveolar process – The region that would normally contain teeth
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  23. 23. ANGLE FRACTURES may be classified as: )Vertically favorable or unfavorable ) Horizontal favorable on unfavorable.
  24. 24. In 1934, Wassmund described five types of condylar fractures: Type I: Defined as a fracture of the neck of the condyle with relatively slight displacement of the head. The angle between the head & axis of ramus varies from 10 to 45 degrees. Type II: Produce an angle from 45 to 900 resulting in tearing of medial portion of the joint capsule. Type III: The fragments are not in contact and head is displaced mesially and forwards owing to traction of lateral pterygoid muscle. Type IV: The fractures of condylar head articulate on, or in a forward position with regard to, the articular eminence. Type V: Consisted of vertical or oblique fractures through the head of condyle.
  25. 25. III) IV) V) Relation of the fracture to the site of injury: i) Direct fractures ii) Indirect fractures(Countercoup) Completeness - Complete and incomplete fractures Depending on the mechanism i) Avulsion fracture ii) Bending fracture iii) Burst fracture iv) Countercoup fracture v) Torsional fracture VI) Number of Fragments - Single, multiple, comminuted VII) Involvement of the integument -Closed/ open fractures -Grades/ severity I-V VIII) Shape or area of fracture: Transverse, oblique, butterfly, oblique surfaces
  26. 26. IX) According to the direction of fracture and favorability for treatment a. Horizontally favorable fracture b. Horizontally unfavorable fracture c. Vertically favorable fracture d. Vertically unfavorable fracture X. According to presence or absence of teeth in relation to fracture line
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  28. 28. KAZANJIAN’S AND CONVERSE CLASSIFICATION: Class I: When the teeth are present on both sides of the fracture line. a) An adequate number of teeth of suitable shape and stability. Wiring- direct, continuous /multiple loop or interdental eyelet type, use of prefabricated arch bars. b) An inadequate number of teeth, whose shape or stability is unsuitable. c) Lateral compression splint, arch bars or cast metal cap splints.
  29. 29. Class II – When the teeth are present only on one side of fracture line. a) Short edentulous posterior fragment i) If favorable, immobilization of main fragment by interdental wiring or arch bars. ii) If unfavorable – open reduction with direct fixation is a must. b) Long edentulous posterior fragment i) Without displacement – Conservative treatment ii) With vertical & medial displacement requires open surgical reduction & fixation.
  30. 30. Class III – When both the fragments on each side of the fracture line are edentulous. i) Simple or compound fracture without much displacement in the body region.Simple gunning type splints. ii) Simple fractures which are unfavorable. Open reduction & fixation. iii) Compound fractures. Surgical intervention
  31. 31. XI) AO CLASSIFICATION(RELEVANT TO INTERNAL FIXATION): 1) F: Number of fracture or fragments 2) L: Location (site) of fracture 3) O: Status of occlusion 4) S: Soft tissue involvement 5) A: Associated fractures of facial skeleton Grades of severity: I-V • Grade I and II are closed fractures • Grade III and IV are open fractures • Grade V open fracture with a bony defect (gunshot)
  32. 32. History: The patient’s health history may reveal of existing systemic bone disease, neoplasia with potential metastasis, arthritis & related collagen disorders, nutritional & metabolic disorders, & endocrine diseases that may cause or be directly related to the fractured jaw A history of temporomandibular joint dysfunction can have significant legal & post treatment ramifications. Fractures sustained in vehicular accidents are usually far different from those sustained in personnel altercations. An anterior blow directly to chin can result in bilateral condylar fractures & an angled blow to the parasymphysis may cause a contralateral condylar or angle fracture.
  33. 33. CLINICAL EXAMINATION: The signs and symptoms of mandibular fractures are as follows: 1. 2. 3. 4. 5. Change in occlusion: Anesthesia, paresthesia or Dysesthesia of the lower lip Abnormal mandibular movements: Change in facial contour and mandibular arch form: Lacerations, Haematoma & Ecchymosis: 6. 7. Loose teeth and crepitation on palpation: Dolor, Tumor, Rubor & Color :
  34. 34. Radiologic examination: 1) Panoramic radiograph 2) Lateral oblique radiograph 3) Posteroanterior radiograph 4) Occlusal view 5) Periapical view 6) Reverse Towne’s view 7) Temporomandibular joint, including tomograms. 8) Computed tomography (CT) scan.
  35. 35. General principles in treatment of mandiibular fractures. 1) The patient’s general physical status should be carefully evaluated & monitored prior to any consideration of treating mandibular fractures 2) Diagnosis & treatment of mandibular fractures should be approached methodically not as an “emergency type” mentality. 3) Dental injuries should be evaluated & treated concurrently with treatment of mandibular fractures. 4) Re establishment of occlusion is the primary goal in the treatment of mandibular fractures. 5) With multiple facial fractures, mandibular fractures should be treated first. 6) Intermaxillary fixation time should vary according to the type, location, number & severity of mandibular fractures as well as the patient’s age & health & the method used for reduction & immobilization. 7) Prophylactic antibiotics should be used for compound fractures. 8) Nutritional needs should be closely monitored postoperatively. 9) Most mandibular fractures can be treated by closed reduction.
  36. 36. Management of mandibular fractures: 1) Closed reduction It is often advocated because of its relative simplicity, low cost & non invasive nature of treatment. Indications: 1) Non displaced favourable fractures 2) Grossly comminuted fractures. 3) Severely atrophic edentulous mandible. 4) Fractures exposed by significant loss of overlying soft tissues. 5) Mandibular fractures in children with developing dentitions. 6) Coronoid process fractures 7) Condylar fractures.
  37. 37. TECHNIQUES FOR CLOSED REDUCTION AND FIXATION OF DENTULOUS MAXILLA AND MANDIBLE: 1) Bridle Wire A simple bridle wire placed around the adjacent teeth of a mandible fracture can temporarily stabilize a flailed mandible segment. It prevents soft tissue damage.  The first step in placement is measurement of arch bar. The bar is usually placed two teeth proximal from the fracture .  The bar is traditionally placed from a point distal to the first molar on the opposite side. • Wire is the next consideration & 24-gauge wire is recommended for the circumdental wires while 26 gauge wire is used for the box wires that provide the maxillomandibular fixation.
  38. 38. The first circumdental wires placed are usually on the second premolars. The measured arch bar is then placed in the loops of the wires & the wires loosely secured. Wiring then takes place from midline to posterior to avoid excess arch bar in the anterior of the arch. After placement of the circumdental wires and gross reduction of the fractured segments, tightening them takes place in the same fashion from midline to posterior. The box wires are then placed and occlusion is obtained. The circumdental wires are then tightened & the rosettes are formed. Box wires are then fully tightened and maxillomandibular fixation is achieved. Aids in protecting airway, helps alleviates pain from two segments moving against each other. Armamentarium: Local anesthetic, Needle driver or needle holder, 24 or 26 gauge stainless steel wire.
  39. 39. After adequate local anesthesia has been administered the two segments are manually reduced. The wire is passed around the necks of the teeth & the fracture loosely approximated. While manually stabilizing the fracture, the operator achieves further reduction by tightening the wire in a clockwise fashion. The box wires are then placed and occlusion is obtained. The circumdental wires are then tightened & the rosettes are formed. Box wires are then fully tightened and maxillomandibular fixation is achieved. Aids in protecting airway, helps alleviates pain from two segments moving against each other. Armamentarium: Local anesthetic, Needle driver or needle holder, 24 or 26 gauge stainless steel wire.
  40. 40. 2)Ivy loops: Ivy loops are a quick and easy way of obtaining maxillomandibular fashion.  The loop is constructed of 24 gauge wire and passed interproximal to two stable teeth. The ends of the wire are first brought around mesial & distal sides of the teeth.  The distal wire is then delivered under the loop & tightened to the mesial wire in an apical region direction.  Tightening of the loop is then accomplished to adapt it into the interproximal space
  41. 41. Treatment of partially edentulous mandible: If patient is partially edentulous, a pre-existing partial denture can to wired to either jaw using circum mandibular or circum zygomatic wiring technique. If no prosthesis is available, impression can be taken, & acrylic blocks can be fabricated, incorporated with an arch wire, & applied to remaining teeth Treatment of edentulous mandible: If patient is completely edentulous, dentures can be wired to the jaws with the use of circum mandibular or circum zygomatic wires, or in the case of a maxillary denture, palatal screw fixation can be done to hold the denture. If dentures are not available, impressions are taken of the jaws, & acrylic base plates are processed & used as denture. An arch bar can be processed into the dentures/holes can be placed into the flange of the denture for intermaxillary wires. Prosthetic incisor teeth can be removed for existing dentures, & space can be made in the acrylic to allow food intake. (Gunning splint)
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  44. 44. 2.Open reduction Advantage: 1) Reduction, fixation is done under direct vision. 2) Stable fixation is achieved by better approximation of fractured segments.
  45. 45. Indications for Open Reduction: 1)Displaced unfavorable fractures through the angle of the mandible 2) Displaced unfavorable fractures of the body or the parasymphyseal region of the mandible 3) Multiple fractures of facial bones 4) Midface fractures & displaced bilateral condylar fractures 5) Fractures of an edentulous mandible with severe displacement of fracture fragments. 6) Edentulous maxilla opposing a mandibular fracture. 7) Associated condylar fractures 8)When intermaxillary fixation is contraindicated or not possible 9) To preclude the need for IMF for patient comfort. 10) Malunion. 11) Delay of treatment & interposition of soft tissue b/w noncontacting displaced fracture fragments.
  46. 46. Contraindications: 1) GA or more prolonged procedure is not advisable 2) Severe comminution with loss of soft tissue 3) Gross infection at fracture site 4) Patient refusing open reduction.
  47. 47. Technique for open reduction & fixation Surgical approaches :  Factors used to establish the location of incision include fracture location, skin lines and nerve position a) Extraoral approaches Submandibular Risdon’s incision This incision is used to access the mandibular ramus, angle and posterior body. Patient is prepared & draped in routine surgical manner. Head of the patient is turned sideways. • The skin incisions is 4 to 5 cm in length, 2cm below the angle of the mandible to avoid damage to the marginal mandibular branch of the facial nerve. • Ideally the incision is placed in a relaxed skin tension line (the Langer’s line.)
  48. 48.  The skin and subcutaneous tissues are incised with a scalpel down to the level of the platysma and undermining of the skin to allow improved retraction is accomplished with scissors.  The platysma is then sharply divided exposing the superficial layer of the deep cervical fascia.  The plane of the dissection is carried out through this layer over the superior surface of the submandibular gland . • The facial artery and vein are identified.They are clamped, divided & ligated. •The dissection continues towards the mandible, exposing the pterygo massetric sling posteriorly . •Subperiosteal dissection is performed anteroposterior and the desired area of the mandibular body, angle or ramus is accessed. • The desired procedure is carried out. Closure is done in layers.
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  51. 51. 2) Retromandibular approach:  This approach was basically a variation of submandibular approach except the incision was about 3 cm above the sulmandibular incision.  The incision is made to encounter the parotid, massetric and deep cervical fascia.  The dissection is then extended anteriorly through the deep cervical fascia with surgeon using nerve stimulation. • The incision to bone through masseter muscle is b/w the marginal mandibular and buccal branches of facial nerve. • The muscle and periosteum are incised over the angle instead of the inferior border. • The soft tissues and the nerve fibres are then retracted superiorly. • This incision give superior access to the ramus and subcondylar region of mandible.
  52. 52.  The undersurface of this layer is where the superficial temporal vessels are found, as well as the auriculotemporal nerve and facial nerve.  All these layers should be retracted anteriorly with soft tissue flap.  The facial nerve has been described as crossing the zygomatic arch 0.8 to 3.5 cm (mean 2 cm) anterior to the concavity of the auditory canal.
  53. 53. 4) Endaural approach: Started in the skin crease between the anterior helical cartilage and the tissue extended downward in the cleft b/w tragus and helix and inward approximately 5 mm along the roof of auditory canal.   As incision deepens, it is carried anterior through the tragal cartilage
  54. 54. INTRA ORAL ACCESS: 1)Symphyis and Parasymphysis region: Termed as anterior, vestibular approach or deglowing incision. The lower lip is everted and an incision is created at the depth of the vestibule in the mucosa with a scalpel or electro cautery. Incision is curvilinear and extends anteriorly into the lip. •The mentalis muscle with be visible and fibres are divided in an oblique fashion, leaving a margin of the muscle attached to the bone for closure. •The periosteum is divided and a sub periosteal dissection is done to identify the mentalis muscle. •Closure is completed in layers. • A pressure dressing is secured to the area to prevent haematoma formation and maintain the position of mentalis muscle
  55. 55. 2.Intraoral (Body, Angle, Ramus region )
  56. 56. Transbuccal incision: Dissection in this region begins with a mucous incision that is stated with a scalpel or electrocautery 3 to 5 mm below the mucogingival junction. The incision is created in to the bone to avoid the mental nerve and it extends over the external oblique ridge. •The level of the incision at the external oblique ridge should not be carried superior to mandibular occlusal plane to avoid herniation of buccal fat pad. • The incision is carried through the periosteum & a subperiosteal dissection is performed. •Reduction,fixation is used to expose the lateral border of ramus. •Reduction, fixation is done. • Closure is completed in one layer.
  57. 57. Bone plating: Advantages: 1) Rigid or stable fixation 2) Eleviates the need for immobilization of the mandible . 3) Early return to home & work 4) Soft diet can be taken 5) Maintainence of oral hygiene
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  59. 59. Compression plates: These compression plates include at least two pear shaped holes.  The widest diameter of the hole lies near the fracture line. The screw is inserted in the narrow part of the hole & at final movement of tightening, its head comes to rest in the widest diameter of the hole, which is counter sunk to receive it. The compression holes in the plate may be positioned one on each side of fracture line.
  60. 60. Complications – Mental fatigue, fracture of plate, necrosis of bone ends, osteoporotic changes Complication of mandibular fracture management: 1) Infection 2) Nerve damage 3) Displaced teeth & foreign bodies 4) Pulpitis 5) Gingival or periodontal complications 6) Delayed healing and non union related to fixation techniques 7) Facial widening. 8) Malunion 9) Delayed union 10)Sequestration of bone.
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  63. 63. References: 1. Gustow .D. Kruger 1. Fonseca (Volume – 1)
  64. 64. Thank you Leader in continuing dental education