mandibular fractures

Mandible FracturesMandible Fractures
Dr. Sumer YadavDr. Sumer Yadav
Mch plastic surgeryMch plastic surgery
dr sumer yadav, mch plastic surgery,dr sumer yadav, mch plastic surgery,
sumeryadav2004@gmail.comsumeryadav2004@gmail.com

HistoryHistory
 Edwin Smith Papyrus 1650 described Hx,Edwin Smith Papyrus 1650 described Hx,
Phy, Diagnosis. Often fatal diseasePhy, Diagnosis. Often fatal disease
 Hippocrates – Described monomaxillaryHippocrates – Described monomaxillary
dental fixation and bindingdental fixation and binding
 Sulicetti – 1492 Described “tie teeth of jawSulicetti – 1492 Described “tie teeth of jaw
to teeth of uninjured jaw”to teeth of uninjured jaw”

AnatomyAnatomy
 Mandible interfaces with skull base via theMandible interfaces with skull base via the
TMJ and is held in position by the musclesTMJ and is held in position by the muscles
of masticationof mastication
 Divided into components with weakestDivided into components with weakest
sites being the third molar area, socket ofsites being the third molar area, socket of
the canine tooth, and the condyle.the canine tooth, and the condyle.

Anatomic units of theAnatomic units of the
mandiblemandible

 SymphysisSymphysis - Fracture in the region of the central incisors- Fracture in the region of the central incisors
that runs from the alveolar process through the inferiorthat runs from the alveolar process through the inferior
border of the mandibleborder of the mandible
 ParasymphysealParasymphyseal - Fractures occurring within the- Fractures occurring within the
boundaries of vertical lines distal to the canine teethboundaries 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 (usuallywith 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 posterosuperiorof the masseter muscle to the posterosuperior
attachment of the masseter muscle (usually distal to theattachment 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 notchtwo 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 regionsuperior to the ramus region
 Coronoid processCoronoid process - Includes the coronoid process of the- Includes the coronoid process of the
mandible superior to the ramus regionmandible superior to the ramus region
 Alveolar processAlveolar process - Region that normally contains teeth- Region that normally contains teethdr sumer yadav, mch plastic surgery,dr sumer yadav, mch plastic surgery,

InnervationInnervation
 Mandibular nerve through the foramenMandibular nerve through the foramen
ovaleovale
 Inferior alveolar nerve through theInferior alveolar nerve through the
mandibular foramenmandibular foramen
 Inferior dental plexusInferior dental plexus
 Mental 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
Mandibular
foramen
Mental groove
Mental ridge
Genial tubercle
Socket third
molar

Deep Masseter
Superficial Masseter

EpidemiologyEpidemiology
 Mandible most common after nasalMandible most common after nasal
fracturesfractures
 Mandible : Zygoma : Maxilla 6:2:1Mandible : Zygoma : Maxilla 6:2:1
 MVA>Assault>Fall>SportsMVA>Assault>Fall>Sports

Arterial supplyArterial supply
 Internal maxillary artery from the externalInternal maxillary artery from the external
carotidcarotid
 Inferior alveolar artery through theInferior alveolar artery through the
mandibular foramenmandibular foramen
 Mental artery through the mental foramenMental artery through the mental foramen

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

TMJTMJ
 Articular discArticular disc
separates the jointseparates the joint
into 2 spaceinto 2 space
 Inferior/Inferior/GinglymusGinglymus
Hinge movementHinge movement
 Superior/Superior/ArthrodialArthrodial

Fractures of mandibleFractures of mandible
According to anatomic location fracture ofAccording to anatomic location fracture of
mandible divided into seven main types:mandible divided into seven main types:
1.1. Condylar- intra capsular/extra capsularCondylar- intra capsular/extra capsular
2.2. CoronoidCoronoid
3.3. RamusRamus
4.4. AngleAngle
5.5. BodyBody
6.6. Symphysis and parasymphysisSymphysis and parasymphysis
7.7. 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. Angle4. 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/linear
Green stickGreen stick
Compound- through skin/ mouthCompound- through skin/ mouth
ComminutedComminuted
Pathological-osteomyelitis/neoplasmPathological-osteomyelitis/neoplasm
Unilateral/bilateralUnilateral/bilateral

Favorable vs. UnfavorableFavorable vs. Unfavorable
 Masseter, Medial and LateralMasseter, Medial and Lateral
Pterygoid, and Temporalis tend toPterygoid, and Temporalis tend to
draw fractures medial and superiordraw fractures medial and superior
 Almost all fractures of angleAlmost all fractures of angle
unfavorableunfavorable

Mandibular ForcesMandibular Forces

Vertically & Horizontally unfavorable #

Factor affecting displacement ofFactor 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 traumatic4. Direction & intensity of traumatic
forceforce
5. # of alveolar structure & damage5. # 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-NeutroClass 1-Neutro
occlusion-occlusion-
The mesio buccalThe mesio buccal
cusp of maxillarycusp of maxillary
first molar alignedfirst molar aligned
axially withaxially with
mesiobuccal groovemesiobuccal groove
of mandibular firstof mandibular first
molar.molar.

Class 2 or DistClass 2 or Dist
occlusion:occlusion:
Buccal groove ofBuccal groove of
lower first molar islower first molar is
distal ( post ) todistal ( post ) to
mesiobuccal cusp ofmesiobuccal cusp of
upper first molarupper first molar

Classification of malocclusion:Classification of malocclusion:
Angles (1899)Angles (1899)
Class 3: Mesio- occlusion:Class 3: Mesio- occlusion:
 Buccal groove of lowerBuccal groove of lower
first molar is mesial (orfirst molar is mesial (or
ant) to mesiobuccal cuspant) to mesiobuccal cusp
of ant first molarof ant first molar
 The mandibular teethThe mandibular teeth
are in ant relationshipare in ant relationship
with correspondingwith corresponding
maxillary teeth.maxillary teeth.

Evaluation - HistoryEvaluation - History
Mechanism of injuryMechanism of injury
MVA associated with multiple comminuted fxMVA associated with multiple comminuted fx
Fist often results in single, non - displaced fxFist often results in single, non - displaced fx
Anterior blow to chin - bilateral condylar fxAnterior blow to chin - bilateral condylar fx
Angled blow to parasymphysis can lead toAngled blow to parasymphysis can lead to
contralateral condylar or angle fxcontralateral condylar or angle fx
Clenched teeth can lead to alveolar processClenched teeth can lead to alveolar process
fxfx

Past Medical HistoryPast Medical History
bone diseasebone disease
neoplasianeoplasia
arthritis, tmj (risk for ankylosis)arthritis, tmj (risk for ankylosis)
collagen vascular disease, endocrine d/ocollagen vascular disease, endocrine d/o
nutrition and metabolic disorders, includingnutrition and metabolic disorders, including
alchohol abusealchohol abuse
seizureseizure

EvaluationEvaluation
 Stabilization via ATLS protocolStabilization via ATLS protocol
 Part of secondary surveyPart of secondary survey
Pain, malocclusion, trismus, V3 sensoryPain, malocclusion, trismus, V3 sensory
deficitdeficit
History of TMJ (earlier mobilization)History of TMJ (earlier mobilization)
Blow to face favors parasymphyseal fractureBlow to face favors parasymphyseal fracture
and contralateral angle fractureand contralateral angle fracture
Fall to chin (bilateral condylar fractures)Fall to chin (bilateral condylar fractures)

EvaluationEvaluation
 Previous occlusion (Class I-III)Previous occlusion (Class I-III)
 Psychiatric, nutritional, gastrointestinal,Psychiatric, nutritional, gastrointestinal,
seizure disordersseizure disorders
 Previous facial traumaPrevious facial trauma
 Other 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 # siteSwelling and ecchymosis at # site
 Step deformity at # siteStep deformity at # site
 Loss of teeth. Gingival lacerationsLoss of teeth. Gingival lacerations
 Mal occlusion/open bite./ cross biteMal occlusion/open bite./ cross bite
 Anaesthesia 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 Exam
 Dental ExamDental Exam
Lost, fractured, or unstable teethLost, fractured, or unstable teeth
Dental HealthDental Health
Relation to fractureRelation to fracture
QuantityQuantity

Physical Exam - OcclusionPhysical Exam - Occlusion
 Change in occlusion - determine preinjury occlusionChange in occlusion - determine preinjury occlusion
 Posterior premature dental contact or an anterior openPosterior 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 alveolarPosterior open bite is common with anterior alveolar
process or parasymphyseal fracturesprocess or parasymphyseal fractures
 Unilateral open bite is suggestive of an ipsilateral angleUnilateral open bite is suggestive of an ipsilateral angle
and parasymphyseal fractureand parasymphyseal fracture
 Retrognathic occlusion is seen with condylar or angleRetrognathic occlusion is seen with condylar or angle
fracturesfractures
 Condylar neck fx are assoc with open bite on oppositeCondylar 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.

MalocclusionMalocclusion

Mal occlusionMal occlusion
Open biteOpen bite

Physical ExamPhysical Exam
Unilateral fractures of CondyleUnilateral fractures of Condyle
Decreased translational movement, functionalDecreased translational movement, functional
height of condyleheight of condyle
Deviation of chin away from fracture, openDeviation 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- rays
1.1. post ant projection (PA)post ant projection (PA)
2.2. Oblique lat projectionOblique lat projection
3.3. Occlusal; view of mandible.Occlusal; view of mandible.
Ortho- pan tomogramOrtho- pan tomogram
C-T ScanC-T Scan
1.1. 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

Lateral obliqueLateral oblique

PanorexPanorex

Tomography scannerTomography scanner

Ortho-pan tomogramOrtho-pan tomogram

CT ScanCT Scan

CT Scan -three dimensionalCT Scan -three dimensional

Treatment HistoryTreatment History
 Schede 1888 – Bone plate of steelSchede 1888 – Bone plate of steel
secured with 4 screwssecured with 4 screws
 Luhr 1960 – Developed mandibularLuhr 1960 – Developed mandibular
compression platescompression plates
 Michelet and Champy 1970’s – PlacementMichelet and Champy 1970’s – Placement
of small bendable non-compression platesof small bendable non-compression plates

PhysiologyPhysiology
 Primary HealingPrimary Healing
In rigid fixation techniquesIn rigid fixation techniques
Lag screws, compression plates, Recon plate,Lag screws, compression plates, Recon plate,
external fixation, Mini plate fixationexternal fixation, Mini plate fixation
No callus formationNo callus formation
Question of bone resorptionQuestion of bone resorption

PhysiologyPhysiology
 Secondary bone healingSecondary bone healing
Callus formationCallus formation
Remodeling and strengtheningRemodeling and strengthening
MMF, Wire fixation, Mini plate fixationMMF, Wire fixation, Mini plate fixation

General Principles ofGeneral Principles of
treatmenttreatment
 TetanusTetanus
 NutritionNutrition
 Almost all can be considered open fx as theyAlmost 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 ofPrinciple of treatment of
mandibular #mandibular #
1. Restoration of normal occlusion1. 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 options
 No treatmentNo treatment
 Soft dietSoft diet
 Maxillomandibular fixationMaxillomandibular fixation
 Open reduction - non-rigid fixationOpen reduction - non-rigid fixation
 Open reduction - rigid fixationOpen reduction - rigid fixation
 External pin fixationExternal pin fixation

Treatment options for dentateTreatment options for dentate
patientspatients

Closed ReductionClosed Reduction
 Favorable, non-displaced fracturesFavorable, non-displaced fractures
 Grossly comminuted fractures whenGrossly comminuted fractures when
adequate stabilization unlikelyadequate stabilization unlikely
 Severely atrophic edentulous mandibleSeverely atrophic edentulous mandible
 Children with developing dentitionChildren with developing dentition

TechniquesTechniques
 Gilmer method [outdated]Gilmer method [outdated]
 Eyelet methodEyelet method
 Arch bar fixation – the best wheneverArch bar fixation – the best whenever
possiblepossible
-Single root and conical shape teeth require-Single root and conical shape teeth require
special wiring techniquesspecial wiring techniques
-Rubber bands or wires-Rubber bands or wires
 Orthodontic bandsOrthodontic bands
 Acrylic splintsAcrylic splints
 Intermaxillary fixation screw techniqueIntermaxillary fixation screw technique
 pin fixationpin fixation

Gilmer wiresGilmer wires

Maxillomandibular fixationMaxillomandibular fixation

Alternative - Ivy loopsAlternative - Ivy loops

Clove hitchClove hitch

Leonard’sLeonard’s
buttons forbuttons for
maxillo-maxillo-
mandibularmandibular
fixation.fixation.

Four screw fixation techniqueFour screw fixation technique

Maxillomandibular fixationMaxillomandibular fixation
arch 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 withCondylar and subcondylar - 3 weeks with
intermittent application of rubber bandsintermittent application of rubber bands
- Coronoid process-2 weeks restCoronoid process-2 weeks rest
- Liquid high protein dietLiquid high protein diet

Open ReductionOpen Reduction
 Displaced unfavorable fracturesDisplaced unfavorable fractures
 Mandible fractures with associatedMandible fractures with associated
midface fracturesmidface fractures
 When MMF contraindicated or notWhen MMF contraindicated or not
possiblepossible
 Patient comfortPatient comfort
 Facilitate return to workFacilitate return to work

 Associated Midface fracturesAssociated Midface fractures
 Psychiatric illnessPsychiatric illness
 GI disorders involving severe N/VGI disorders involving severe N/V
 Severe malnutritionSevere malnutrition
 To avoid tracheostomy in patients whoTo avoid tracheostomy in patients who
need postoperative intubationneed postoperative intubation

 ContraindicationsContraindications
General Anesthetic risk too highGeneral Anesthetic risk too high
Severe comminution and stabilization notSevere comminution and stabilization not
possiblepossible
No soft tissue to cover fracture siteNo soft tissue to cover fracture site
Bone at fracture site diffusely infectedBone at fracture site diffusely infected
(controversial)(controversial)

Facial incisionsFacial incisions

semi-rigid fixationsemi-rigid fixation
 Inter-osseous wiringInter-osseous wiring
Semirigid fixationSemirigid fixation
CheapCheap
Technically difficultTechnically difficult
Primary and Secondary bone healingPrimary and Secondary bone healing

Transosseous wiring orTransosseous 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 - nonrigidOpen reduction - nonrigid
fixationfixation

Types of inter-osseous wiringTypes of inter-osseous wiring

Rigid FixationRigid Fixation
 Developed and popularized by AO/ASIFDeveloped 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 byThe 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 forcompression, 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 orsuperior border plate /arch bars traction or
tension forcestension forces

 Compression platesCompression plates
Rigid fixationRigid fixation
Allow primary bone healingAllow primary bone healing
Difficult to bendDifficult to bend
Operator dependentOperator dependent
No 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 principleSpherical gliding principle

Open reduction - RigidOpen reduction - Rigid
fixationfixation

Bending and over bendingBending and over bending
techniquestechniques

Non compression platingNon compression plating
• Reconstruction, miniplates.Reconstruction, miniplates.
• IndicationIndication
- 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

 Reconstruction PlatesReconstruction Plates
Good for comminuted fracturesGood for comminuted fractures
Bulky, palpableBulky, palpable
Difficult to bendDifficult to bend
Locking plates availableLocking plates available

Reconstruction PlateReconstruction Plate

Monocortical miniplates.Monocortical miniplates.
 Champy et al in FranceChampy et al in France
 Advocated transoral placement of small,Advocated transoral placement of small,
thin, malleable stainless steel miniplatesthin, malleable stainless steel miniplates
with monocortical screws along an idealwith monocortical screws along an ideal
osteosynthesis line of the mandible.osteosynthesis line of the mandible.
 Believed that compression plates wereBelieved that compression plates were
unnecessary. Masticatory forcesunnecessary. Masticatory forces
natural strain of compression along thenatural strain of compression along the
inferior border.inferior border.

 MiniplatesMiniplates
Semi-rigid fixationSemi-rigid fixation
Allows primary and secondary bone healingAllows primary and secondary bone healing
Easily bendableEasily bendable
More forgivingMore forgiving
Short period MMF RecommendedShort period MMF Recommended

Evaluation - PanorexEvaluation - Panorex

Double layer mini-platesDouble layer mini-plates

Miniplates, Champy techniqueMiniplates, Champy technique

 Lag ScrewsLag Screws
Rigid fixation (Compression)Rigid fixation (Compression)
Good for anterior mandible fractures, ObliqueGood for anterior mandible fractures, Oblique
body fractures, mandible angle fracturesbody fractures, mandible angle fractures
CheapCheap
Technically difficultTechnically difficult
Injury to inferior alveolar neurovascularInjury to inferior alveolar neurovascular
bundlebundle

Lag screwLag screw

Lag Screw TechniqueLag Screw Technique

Metallic mesh implantMetallic mesh implant
• Stain less steel mesh or titanium meshStain 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
• InstrumentInstrument
- 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 fixation
 Grossly comminuted fractures,Grossly comminuted fractures,
contaminated fractures, non-unioncontaminated fractures, non-union
 Often used when all else failsOften used when all else fails

External FixationExternal Fixation

ComplicationsComplications
EarlyEarly
HeamorrhageHeamorrhage
Carotid injuryCarotid injury
Facial nerve injuryFacial nerve injury
InfectionInfection
Avascular necrosis osteitisAvascular necrosis osteitis
Late complicationsLate complications
TMJ ankylosisTMJ ankylosis
Non unionNon union
MalunionMalunion
MalocclusionMalocclusion
Increased facial width and rotationIncreased facial width and rotation
Implant failureImplant failuredr sumer yadav, mch plastic surgery,dr sumer yadav, mch plastic surgery,

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

Symphyseal and Para- symphysealSymphyseal and Para- symphyseal
fracturesfractures
 Reinsertion of mentalis insertion whileReinsertion of mentalis insertion while
suturingsuturing
 Water tight closure following repairWater tight closure following repair
 Compression plating for non-comminutedCompression plating for non-comminuted
non-bone gap fracturesnon-bone gap fractures
 Lag screws application possible size atLag screws application possible size at
least 35mm- 45mm, two in numberleast 35mm- 45mm, two in number

Body fracturesBody fractures
 Two plates upper border uni-corticalTwo plates upper border uni-cortical
tension band plate and compression platestension 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
molarmolar
 Two plates –upper tension band andTwo plates –upper tension band and
lower non compression or compressionlower non compression or compression
platesplates
 Complicated comminuted fractures –Complicated comminuted fractures –
reconstruction platesreconstruction plates

Coronoid fracturesCoronoid fractures
 Usually undisplacedUsually undisplaced
 Observation with liquid diet or IMF for twoObservation with liquid diet or IMF for two
weeksweeks
 When associated with other fracturesWhen 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
- dislocationdislocation
- 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. DislocationDislocation
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, (thefracture 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 theangle 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 isfragments are not in contact, and the head is
displaced medially and forward. The fragments aredisplaced medially and forward. The fragments are
within the glenoid fossa. The capsule is torn, and thewithin 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 infractures 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 fracturesfractures 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,

TreatmentTreatment
 High condylarHigh condylar – 2 weeks IMF with– 2 weeks IMF with
intermittent early controlledintermittent early controlled
mobilisationmobilisation
 Low condylarLow condylar
1.1. With good alignment of fractures-IMFWith good alignment of fractures-IMF
2.2. 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 nerveCare taken to protect the facial nerve

Condylar and SubcondylarCondylar and Subcondylar
ORIF, Absolute indicationsORIF, Absolute indications
Displacement into middle cranial fossaDisplacement into middle cranial fossa
Lateral extra- capsular displacement ofLateral extra- capsular displacement of
condylecondyle
Inability to achieve occlusion with closedInability to achieve occlusion with closed
reductionreduction
Foreign body in joint spaceForeign body in joint space

Condylar and SubcondylarCondylar and Subcondylar
Relative indicationsRelative indications
1.1. Bilateral condylar fractures to preserve verticalBilateral condylar fractures to preserve vertical
heightheight
2.2. Associated injuries that dictate earlier functionAssociated injuries that dictate earlier function
3.3. Soft tissue swelling causing airway compromiseSoft tissue swelling causing airway compromise
with MMFwith MMF
4.4. Intracapsular fracture on opposite side where earlyIntracapsular fracture on opposite side where early
mobilization importantmobilization important
5.5. Bilateral condylar fractures with comminutedBilateral condylar fractures with comminuted
midface fractures.midface fractures.

Treatment of fractureTreatment of fracture
1. surgical1. 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 fracture
 Keep teeth ifKeep teeth if
Previously healthyPreviously healthy
Peridontal plexus intactPeridontal plexus intact
No major structural injuryNo major structural injury
Tooth does not interfere with reduction ofTooth does not interfere with reduction of
fracturefracture

Injury to teethInjury to teeth
 Fractured teeth can become infected andFractured teeth can become infected and
cause malunion.cause malunion.
 Extraction necessary if root of tooth isExtraction necessary if root of tooth is
fracturedfractured
 A tooth that is intact but in the line of theA tooth that is intact but in the line of the
fracture can be left in place and protectedfracture 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 teethAvulsion, subluxation or fracture of teeth
with fracture of alveolus.with fracture of alveolus.
 Early treatment if pulp exposed-relieveEarly 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 removed
 Less displaced teeth-if not causingLess displaced teeth-if not causing
occlusal interference left like that.occlusal interference left like that.

AlveolarAlveolar
fracturefracture
fixation.fixation.

Dento- alveolar fracturesDento- alveolar fractures
 Crown #- pulp exposed- calciumCrown #- pulp exposed- calcium
hydroxide cement dressinghydroxide cement dressing
 Root #- vertical split- extractRoot #- vertical split- extract
transverse fracture- splint 8wkstransverse fracture- splint 8wks
 Avulsion- immediate replantation andAvulsion- immediate replantation and
splintsplint
 Alveolar #- reduction and fixationAlveolar #- reduction and fixation

Pediatric dentitionPediatric dentition

Post natal growth of MandiblePost natal growth of Mandible
 Most frequently involved in post-traumaticMost frequently involved in post-traumatic
developmental malformationsdevelopmental malformations
 Grows by bone deposition & alveolarGrows by bone deposition & alveolar
process developmentprocess development
 Elongation of mandible is by bony additionElongation of mandible is by bony addition
at condyles & ramus on it's posteriorat condyles & ramus on it's posterior
borderborder
 Growth of condyles is the result ofGrowth of condyles is the result of
enchondral ossification in epiphysisenchondral ossification in epiphysis

Special considerationsSpecial considerations

Special considerationsSpecial considerations
 Deciduous teeth vs. permanentDeciduous teeth vs. permanent
Fractures with deciduous dentition can beFractures with deciduous dentition can be
treated with MMF for 2-3 weeks. Rigidtreated with MMF for 2-3 weeks. Rigid
techniques can harm the tooth bud.techniques can harm the tooth bud.
 Growth centerGrowth center
The most feared complication of a pediatricThe most feared complication of a pediatric
mandible fx is ankylosis of the TMJ withmandible fx is ankylosis of the TMJ with
impact on jaw growth that causes severeimpact on jaw growth that causes severe
facial deformity- prevent with earlyfacial deformity- prevent with early
mobilizationmobilization

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 ofdifficult to use dentition for fixation (absence of
teeth & poor retentive shape)teeth & poor retentive shape)
 IMF is obtained by circumferential wiring aroundIMF 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 , (withoutdownward 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 overacrylic 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 & malocclusionMinor degrees of malunion & malocclusion
is corrected by adjustments taking place inis corrected by adjustments taking place in
erupting teeth under normal masticatoryerupting teeth under normal masticatory
stresses ( Converse & Dingman)stresses ( Converse & Dingman)
 Injuries to articular surface of TM jointInjuries to articular surface of TM joint
results in hemarthrosis ,cicatricialresults 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 alsoEncircling over their own dentures is also
possiblepossible
 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 veryProtect Inferior alveolar n. which lies very
superficialsuperficial

Classification of edentulousClassification of edentulous
atrophic mandibleatrophic mandible

 Edentulous fracturesEdentulous fractures
Absent inferior alveolar artery in 40% 60-80Absent inferior alveolar artery in 40% 60-80
yrs.yrs.
Periosteal blood supply disturbed by strippingPeriosteal blood supply disturbed by stripping
Up to 20% non-union despite type ofUp to 20% non-union despite type of
treatmenttreatment
May 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 circummandibularObwegeser’s circummandibular
wiringwiring

Application of splintsApplication of splints

Edentulous FracturesEdentulous Fractures
 ORIFORIF
Inferior alveolar canal more superior inInferior alveolar canal more superior in
locationlocation
Vertical height 20mm compatible withVertical height 20mm compatible with
standard plating systemsstandard plating systems
Vertical height 10mm or less, likely need ribVertical height 10mm or less, likely need rib
graftgraft
Plate removal after fracture healing ifPlate removal after fracture healing if
interferes with denture placementinterferes with denture placement

BiphasicBiphasic
pins.pins.

Endoscopic surgeryEndoscopic surgery

IndicationsIndications
 Compliant adult patient with acuteCompliant adult patient with acute
condylar fractures.condylar fractures.
 With significant radiological displacement.With significant radiological displacement.
 Persistent malocclusion with closedPersistent malocclusion with closed
reduction & MMF.reduction & MMF.

ContraindicationsContraindications
 Intercondylar fracturesIntercondylar fractures
 Fracture neck of condyle, with smallFracture neck of condyle, with small
proximal segment - will not accommodateproximal segment - will not accommodate
at least 2 screws of microplate.at least 2 screws of microplate.
 Condition of patient doesn’t allow for longCondition 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 polymersMade of a blend of rigid and elastic polymers
selected for their strength, malleability andselected 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 PlatesBioabsorbable Plates
 Bulky plates,Bulky plates,
 thermal sensitivity,thermal sensitivity,
 palpablepalpable
 Absorbable plates expensiveAbsorbable plates expensive
 Better in childrenBetter in children

AdvantagesAdvantages
 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

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