4. management of mandibular

Dr Simon Rock
12/28/2020Dr.Simon Rock

 Primary Healing
 In rigid fixation techniques
 Lag screws, compression plates, Reconstruction plate, external
fixation
 No callus formation
 Question of bone resorption
 Secondary bone healing
 Callus formation
 In non & semi-rigid fixation techniques
 Remodeling and strengthening
 MMF, Wire fixation, Miniplate fixation

3 main principles of fracture management
 REDUCTION
 FIXATION
 IMMOBLIZATION
Eradication of infection

• Definison; Restoration of a functional
alignment of the bone fragments.
-dentate mandible
-edentulous mandible
Teeth are used
to assist the reduction,
to check alignment of the fragments
to assist in the immobilization

• 1-CLOSED REDUCTION:-
-by means of manipulation of teeth
-gradual reduction of fracture by elstic traction
-immobilization with intermaxillary fixation(IMF)
• 2-OPEN REDUCTION
-operative open exploration
- open reduction & internal fixation(ORIF)
-with or without (IMF)

Indications
 Favorable, non-displaced fractures
 Severely atrophic edentulous mandible
 Children with developing dentition
 Grossly comminuted fractures when adequate stabilization
unlikely

Indication
 Displaced unfavorable fractures
 Mandible fractures with associated midface fractures
 Associated condylar fracture
 When MMF contraindicated or not possible
 Patient comfort, now days becomes the standard treatment
 Contraindications
 General Anesthetic risk too high
 Severe comminution and stabilization not possible
 No soft tissue to cover fracture site
 Bone at fracture site diffusely infected (controversial)

 Absolute indication for removal of a tooth from a
mandibular fracture line:
1. Longitudinal #
2. Dislocation of teeth
3. Periapical infection
4. Infected # line
5. Acute pericoronitis

 Relative indication for removal of a tooth from a
mandibular fracture line:
1. Functionless teeth
2. Advanced caries
3. Advanced periodontal disease
4. Doubtfuf teeth which can be added to denture
5. # presented 3 days later

• Management of teeth retained in # line
1. Good-quality intra-oral radiograph
2. Systematic antibiotics therapy
3. Splinting of tooth if mobile
4. Endodontic therapy if pulp is exposed
5. Extration if fracture becomes infected
6. Follow up

 Definition: stabilization of displaced parts to prevent
movement during healing
 May be used as the main method of treatment (IMF) in non
displaced #
 Or adjunctive to internal fixation

• Simple guide;
young adult
+
fracture of angle
+ 4 weeks
early treatment
+
tooth removed from # line

• Add one week if
toot retained in # line
# at symphysis
age 40 years or more
• Substract one week for
childern & adolescents
• Retain attachment to teeth for one week

 Methods of immobilization
intermaxillary fixation(IMF)
a-dental wiring
*direct
*eyelet (Ivy loops)
*Eren wiring

METHODS OF
IMMOBILIZATION
b- Arch bar
Erich
Jelenko
German silver bar
c -Cap splint
d- bonded brackets
d-Gunning type splint

Erich
 More malleable
Jelenko
 Stiffer/less malleable
12/28/2020 Dr.Simon Rock

Disadvatages of (IMF)
talking
diet
wieght loss
oral hygiene
 GA
 Contraindication of (IMF)
 Psychiatric illness
 GI disorders involving severe N/V
 Severe malnutrition
 To avoid tracheostomy in patients who need postoperative intubation

 Def. ligation of the displaced part to adjacent non-
fractured structures
 Proper occlusion established before reduction
stabilization and fixation of the bony segment
A) Non rigid fixation (need IMF)
-transosseous wiring
-bone clamp
-transfixation using Kirschner wires
 - Circummandibular wiring (edentulous p’t
 Intraosseous wiring
 Semirigid fixation
 Cheap
 Technically easy
 Secondary bone healing
 Need (IMF)
 Exellent occ. 12/28/2020Dr.Simon Rock

B) Rigid fixation
-bone plating
compression plates
small plates
miniplates
resorbable plates
reconstruction Plates
-lag screws
-external pin fixation
Advantages of rigid fixation
1. IMF is eliminated or reduced
2. Improved postoperative nutrition
3. Improved postoperative hygiene

 Compression plates
 Rigid fixation
 Allow primary bone healing
 Difficult to bend
 Operator dependent
 No need for MMF
 Grossly displaed #
 Miniplates
 Semi-rigid fixation
 Allows primary and secondary bone healing
 Easily bendable
 More forgiving
 Short period MMF Recommended

 miniplates

 Lag Screws
 Rigid fixation (Compression)
 Good for anterior mandible fractures, Oblique body fractures,
mandible angle fractures
 Cheap
 Technically difficult
 Injury to inferior alveolar neurovascular bundle

 Reconstruction Plates
 Good for comminuted fractures
 Bulky, palpable
 Difficult to bend
 Locking plates more forgiving
Bioabsorbable Plates
• Bulky plates, palpable
• Absorbable plates expensive
• Better in children?
• Use of poly-L-lactide in 69 fractures by Kim et al
• 12% complication
• 8% infection
• No malunion 12/28/2020Dr.Simon Rock

RECONSTRUCTION PLATE
Comminuted Body/Parasymph 2.4 Locking Reconstruction plate
12/28/2020 Dr.Simon Rock

 Alternative form of rigid fixation
 Grossly comminuted fractures, contaminated fractures, non-
union
 Often used when all else fails

 Rapid bony union -2week
 Accurate reduction is less important
 Growth center
 The most feared complication of a pedi mandible # is ankylosing of the TMJ
with impact on jaw growth that causes severe facial deformity- prevent with
weekly mobilization
 Treatment
 Children
 Most need CR + immobilization
 Conical shape makes arch bars less useful
 Rigid techniques can harm the tooth bud.
 Indications for ORIF
 Unstable fractures
 Not amenable to CR
 Bilateral fractures with gross instability
 Use unicortical plates
 Remove 6-8 weeks later

SPECIAL CONSIDERATIONS
EDENTULOUS FRACTURES
 Bradley found absent inferior alveolar artery in 40% 60-80 yo’s
 Periosteal blood supply disturbed by stripping
 Up to 20% non-union despite type of treatment
 Recommended closed reduction to preserve periosteal blood supply
 Inferior alveolar canal more superior in location
 Vertical height 20mm compatible with standard plating systems
 Vertical height 10mm or less, likely need rib graft
 Plate removal after fracture healing if interferes with denture placement

 (A) Used alone
 (B) Combined with other methods.
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.
2. INDIRECT SKELETAL FIXATION
(i) Pin Fixation
(ii) Bone Clamps
3. INTERMAXILLARY FIXATION USING GUNNING TYPE
SPLINTS.

SPECIAL
CONSIDERATIONS
CONDYLAR AND
SUBCONDYLAR Lindhal and Hollender
 Closed reduction in children, teens, adult in cases of intracapsular
fractures may leads to ankylosis
 Functional treatment for intracapsular fractures
 Higher incidence of postoperative sequelae, like mal-occlusion, in
adults
 Children and Teens with less sequelae, due to more remodeling
 For extracapsular # closed reduction with arch bars & IMF for 2-3
weeks is the treatment of choice for youths
 Less effective for
 increasing age
 decreased ramus height
 more displaced

 ORIF, Absolute indications
 Displacement into middle cranial fossa
 Inability to achieve occlusion with closed reduction
 Foreign body in joint space
 Relative indications
 Bilateral condylar fractures to preserve vertical height
 Associated injuries that dictate earlier function
 Soft tissue swelling causing airway compromise with MMF
 Intracapsular fracture on opposite side where early mobilization important

 Kaplan et al.
 Studied ORIF in two groups, one with MMF for 2 weeks, one with
immediate mobilization
 No statistical difference in rates of complications, postoperative
pain, dental health, nutritional status

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