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Mandible Fracture 01 31 08


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Mandible Fracture 01 31 08

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