Mandibular fractures ih

Mandibular Fractures
Presenter : Dr. Itrat Hussain

 The mandible is largest, heaviest, strongest and the only
movable bone of the facial skeleton with the incidence of
injury and fracture being most common of all facial bones
[61%] by virtue of its position and prominence followed by
maxilla [46%], zygoma [27%] and nasal bone [19.5%]
 Experimental cadaveric studies have shown that
mandibular fractures are twice as common as the
maxillary and four times higher force is required for #of
the mandible versus the maxilla
Oikarinen, Lindqvist. 1975; 729patients with mutiple injuries after RTA’s;
Heulke JOMS 1964 22;396 Mandibular Fractures

 Tubular long bone bent into a blunt V-shape
 Like an archery bow which is strongest at its centre
and weakest at its ends where it often breaks
 This is because like all tubular bones its strength
resides in its dense cortical plates which is thicker
anteriorly and at the lower border as compared to
the posterior part
 Basic V-shape is modified by functional processes at
the –
 Angle
 Alveolar process
 Coronoid

 Parabola/ Horse-shoe/ U-shaped in its
morphological form - is important in that direct
trauma at one site causes an indirect force on the
contralateral side thus leading to subsequent injury
at both the ends
 Lowest tolerable frontal impact – 425 lb
 800-900 lb; force required for bilateral subcondylar
and symphysis #
 More sensitive to lateral impacts
 Mandible differs from other long bones in that –
 Any movement causes both condyles to move
 Anatomically articulating surfaces – Condyles;
Functionally – Occlusal surfaces of lower teeth
Nahum et al

 Elevators
 Depressors

 Commonest site after condyle
 Anatomical, Clinical and Surgical Angle
 More commonly involved clinical and surgical
angle
 # occur because of Direct or Indirect trauma

 Bony architecture, Shape, Muscular
attachments of the mandible permit it to be
conceptualized as a structure that converts
imposed stresses into either tension or
compression
 Compressive forces – Along Basal aspect
 Tension forces – Alveolar aspect

 Several schemes have been proposed
 Simple
 Compound
 Comminuted
 Greenstick
 Pathologic
 Multiple
 Impacted/Telescoping
 Atrophic
 Indirect
 Complex/ Complicated
Dorland’s Medical Dictionary, Rowe and Killey

 Dingman and Natvig
 Midline
 Parasymphyseal
 Symphysis [17%]
 Body [29%]
 Angle [25%]
 Ramus [4%]
 Condylar process [26%]
 Coronoid process [1%]
 Alveolar process
% on basis of mean after evaluation of various literature

 Rowe & Killey
 Not involving
 Alveolar process fractures
 Involving
 Single Unilateral
 Double Unilateral
 Bilateral
 Multiple

 Relation to the External Environment
 Simple or Closed
 Compound or Open
 Type of Fracture
 Incomplete
 Greenstick
 Complete
 Comminuted
 Dentition of the Jaw with ref. to the use of Splints
 Sufficiently dentulous jaw
 Edentulous or Inufficiently dentulous
 Primary or Mixed dentition
 Localization

 Inspection
 Swelling [Tumor]
 Rubor
 Ecchymosis/ Bleeding
 Haematoma [Sublingual]
 Lacerations [Mucosal/Skin]
 Facial asymmetry
 Fracture lines/Step deformity
 Decreased interincisal distance
 Change in occlusal plane
 Empty socket/s or #/loose teeth
MandibularFractures

 Bimanual
 Tenderness
 Interfragmentary mobility
 Deranged Occlusion
 Crepitation on palpation
 Abnormal Mandibular Movements
 Teeth
 IAN
MandibularFractures

 OPG – single most important and informative
study in diagnosing mandibular fractures
including condyles
 Simple technique
 Complete mandibular visualization
 Good detail
 Disadvantages
 Upright patient posture is necessary
 Finer details of TMJ and symphyseal region not seen
 Bucco-lingual bone and medial displacement of
condyle cannot be appreciated
MandibularFractures

 Lateral oblique view –
 PA view
 Occlusal view
 Reverse Towne’s view
 Transcranial TMJ view
 Periapical view
 Computed Tomographic scan

 General physical examination to rule out associated
injuries
 Methodical approach; since not a life-threatening
condition
 Decision to preserve or extract fractured or involved
teeth
 PRIMARY GOAL – Re-establishment of OCCLUSION
 Fracture Union
 Function
 Aesthetics
 Impressive appearing radiographic bone adaptation –
ILLUSIVE – should not be the primary goal
 Multiple facial # ; treat mandibular fractures 1st
MandibularFractures

 Inside out and from bottom to top
 To build a foundation on which the facial
bones can be laid
 With the use of RIGID FIXATION deviation
from this principle can be allowed
 All intraoral surgeries to be done first before
any extraoral open reductions/suturing of
facial lacerations

 Non-dispalced favourable fractures
 Simplest possible means should be employed
 Grossly comminuted fractures
 Bag of bones [periosteum acts like a bag]
 Fractures exposed by significant loss of
overlying soft tissue
 Secondary granulation
 Rotational flaps
 Microvascular grafts

 Edentulous mandibular fractures
 Compromised endosteal bl. Supply
 Diminished endosteal cells available for repair
 Stripping during OR further compromises blood
supply
 #in children with developing dentition
 Coronoid process fractures
 OR only in cases of
 Compromised occlusion
 Impingement of #fragment over zygomatic arch
 Condylar fractures [controversial]

 Displaced unfavorable fractures through the angle
 Superior/Medial displacement of the proximal fragment
 Displaced unfavorable fractures of the body or the
parasymphysis region of the mandible
 Efffects of muscular pull
 Medial rotation at the superior border – Arch constriction
 Multiple fractures of the facial bones
 Midface fractures and displaced bilateral
condylar#
 Any one side condyle should be opened to restore VD

 #of the edentulous mandible with severe
displacement of the #fragments
 Nonatrophic edentulous mandibles
 Edentulous maxilla opposing a mandibular #
 Delayed treatment with soft tissue
interposition in between displaced
noncontacting fractured fragemnts
 Malunion
 Special systemic conditions contraindicating
MMF [Seizure disorders]
 Patients with – Head injury, Cervical spine
injury, Mutiple system injuries
 Patients with reduced post-op compliance

 General principles
 ABCDE
 Primary care in the emergency room
 Initial reduction and stabilization
 Barrel bandage
 Role of Bridle Wire

 Clean, debride and suture as per requirement
the soft tissue lacerations
 Temporary splinting of the #fragments by
means of a stay wire
 Extraoral temporary immobilization by means
of a barrel bandage

BARREL BANDAGE BARTON BANDAGE

 Temporary immobilization of fractured jaw
 ↓PAIN – by reducing the amount of friction between
fragmnets
 #→swelling→sagging of soft tissues→↑distraction of
#fragments
 Decreased MICROMOVEMENT of #fragments –
decreased irritation of surrounding soft tissues –
decreases inflammatory response
 Mobilization of #fragments – Ingress of saliva and
microbes – increased amount of contamination of
#site

 History
 Bandages and External appliances
 First – HIPPOCRATUS
 Gained acceptance after – JOHN RHEA BARTON –
Barton bandage – provided posterior directional forces
to # mandible resulting in “bird face deformity” and
malunion
Mandibular Fractures – history of t/t
Dorrance, Bransfield

 Extraoral and Intraoral appliances
 Worked by placing a rigid splint on the occlusal
surface of teeth and on the undersurface of mandible
and a viselike device was then used to apply
pressure to the two splints theoretically
immobilizing and fixating the fractured fragments
 Disadvantages –
 Inability to gain occlusion
 Inability to reduce # of the posterior mandible and
bilat. #
 Lack of immobilization
 Promotion of drooling

 Monomaxillary wiring, Bars, Arches and Splints –
originally by HIPPOCRATES, later on by many authors
 Affords some element of reduction without fixation
 Use - Limited to fractures containing stable teeth on
both the sides of the fracture
 Intermaxillary wiring –
 Gugliemo Salcetti –credited with the first use of IMF
 Gilmer –Contributed by first using direct interdental
wiring and also revolutionizing the closed reduction
techniques by use of arch bars

 Sutures –
 Buck and Kinlock – Use of iron or silver wire
ligatures for immobilization
 Discarded due to high incidence of infection
 Kazanjian – World

 Bone Plates -
 Gilmer -1881 – Fixation by use of two heavy rods placed on
either side of fracture and wired together
 Schede – 1888 –Earliest reference to the use of solid steel
bone plates held by 4 screws
 Mahe – 1900 – Used multiple plates to secure multiple
mandibular fragments after applying a monomaxillary splint
 Ivy – 1915 – Use of Sherman’s steel plates, abandoned –
infection and neccrosis
 Cole – 1917 – Silver plates and screws on each side of #, with
silver wires attached to the plates to immobilize the #
 Vorschutz – 1934 – Long screws through skin and bone to
reduce the # and the screws held in position by the use of
POP bandage – similar to Joe Hall Morris appliance of today
Mandibular Fractures –history of t/t

 Bridle Wire
 First advocated by Hippocrates
 A simple bridle wire is placed around the adjacent
teeth of a mandible fracture temporarily stabillizes a
flailed mandibular segment
 This helps in
 Preventing further soft tissue damage
 Aids in protecting airway
 Alleviates pain
 Assists in preventing muscle cramping associated with
unstable fragments

 Good method for temporary MMF especially
when placement of arch bars is difficult

 Frequently used method
 Erich arch bar most commonly used
 Steps in placement
 Direction of wire tightening
 24-guage wires used for circumdental wiring
 26-guage wires used for MMF

 Use of cortical bone screw fixation in the
treatment of mandibular fractures – First
advocated by Karlis et al
 Advantages
 Ease of application
 Decreased operating time
 Decreased risk of disease transmission
 Decreased cost
 Disadvantages
 lack of tension band effect
 Interference with internal fixation plates

 Used in cases of edentulous patients
 Closed reduction is achieved

 Most commonly done with
 Arch Bars
 Eyelet [Ivy] loops
 Continous loop [Stout]
 Less commonly used methods
 Risdon wiring
 IMF screws

 Young adult with Fracture of the Angle receiving
Early Treatment in which Tooth removed from
the # line – 3 weeks
 If :
 Tooth retained in # line - +1wk
 # symphysis - +1wk
 Age, 40+ - +1/2wks
 Children and Adolescents - -1wk
Juniper, Awty 1973

 Factors used to establish the location of incision
 Location of fracture
 Skin lines
 Nerve position
 Surgeon should include the angle of the mouth
in the operating field for
 Monitoring facial nerve activity
 Ensuring that the anesthetist has not paralysed the
patient for a prolonged duration

 First described [1934] – Risdon
 Skin incision is 4-5cm in length, 2cm below the angle of the
mandible
 Optimally placed within the skin crease
 Caution – Look for MARGINAL MANDIBULAR NERVE
 Surgical field – Extend upto atleast corner of mouth and
lower lip anteriorly and ear or ear lobule posteriorly
 In cases with shortening of the vertical ramal height incision
should be 2 cm below the anticipated position of the inferior
border after reduction
 Indication – Angle/Body fractures, Subcondylar #
Dingmann, Grabb; Ziarah, Atkinson – MMN maximum 1.2cm below the lower border; recommended incision to be atleast 1.5cm
below Mandibular Fractures

 First described – Hinds and Girotti [1967]
 Variation of submandibular approach
 Incision is about 3cm above the submandibular
incision
 Incision to bone through the masseter muscle is
usually between the marginal mandibular and
buccal branches of the facial nerve
 Indication – Superior access to ramus and
subcondylar region of the mandible

 For Symphysis and Parasmphysis – Curvilinear
incision made perpendicular to the mucosal
surface, carry the incision towards the lip
leaving atleast 1cm of mucosa attached to the
gingiva, mentalis muscle is now incised
perpendicular to the bone, leaving a flap of
muscle attached to bone for closure

 Body, Angle, Ramus – Mucosa is incised ~5mm
from the mucobuccal fold to the bone with the
blade positioned perpendicular to the bone to
avoid the mental nerve

 A surgical procedure that stabilizes and joins
the ends of fractured (broken) bones by
mechanical devices such as metal plates, pins,
rods, wires or screws
 Osteosynthesis refers particularly to
internal fixation of a fracture by such means, as
opposed to external fixation of a fracture by a
splint or cast
Webster’s New World Medical Dictionary

 Disadvantages –
 Lack Rigidity
 Directional Control
 Surface to bone-surface contact area to maintain rigidity
under function, hence post-op IMF is necessary
 Used most commonly for angle fractures inserted at
superior border through an intraoral approach
 Can also be used for symphyseal and
parasymphyseal especially in cases of fractures
perpendicular to the buccal surface of the mandible
in a figure of eight fashion

 Simple straight –
 Wire to placed so that the direction of pull of the
wire is perpendicular to the # site
 Can be either through either of the cortex or both
 m/c –angle region- buccal cortex of third molar
socket
 Figure-of-eight
 More strength
 Transosseous circum-mandibular wiring
[Obwegeser’s technique]

 Primary Goal – To restore pre-injury anatomy
 Has evolved from Orthopaedics based on three
goals –
 Anatomic Reduction – Promotes primary bone
repair, resulting in direct bone formation without
cartilaginous phase
 Fracture Compression - Promotes healing by close
approximation of bone fragments
 Rigid Immobilization – Allows osteogenesis to occur
in an ideal environment without the negative
influence of mobility at the fracture site

 As advocated by AO-ASIF research group, for
achieving early active pain-free healing with
primary [Direct] bone healing under conditions of
full functional loading without the need for
post-op MMF rigid fixation of the # fragments
by interfragmentary compression is necessary.

 In order to achieve this the stability provided
after fixation must be enough to neutralize all
bending, torsional and shearing forces to which
mandible is subjected particularly during
function

 Interfragmentary compression increases
friction between the fragments, also increasing
the surface area of the fragments that are in
contact
 Does it cause pressure necrosis of the bone ? ?
PERREN et al
 The lack of motion between the fragment ends results
in no interfragmentary strain thus allowing direct
bone formation

 R. Danis was the first to advocate the use of
compression for stabilization of bone fractures
 The stability in the # site is dependant on the
stiffness of the plate or screw and friction
between the fragment ends in the absence of
compression
 Compression preloads the contact surfaces and
keeps them motionless
 As long as preload [compression] is greater than the
external force that results in tension, the contacting
surface remains motionless resulting in 0 strain
conditions which is necessary direct bone formation

0 STRAIN CONDITION
FRICTION PREVENTING
MOVEMENT WHEN SHEARING
FORCES ARE APPLIED

 The dynamic compression plate generates
interfragmentary compression by SPHERICAL
GLIDING principle converting vertical force
into horizontal one, causing compression of the
# fragments closing the gap

DEMONSTRATION OF THE
ACTION OF DCP Mandibular Fractures
EFFECT OF PREBENDING AND
OVERCONTOURING

ARCH BAR ACTS AS A
TENSION BAND IN
DENTULOUS AREA
SMALL non-CP ACTS AS A TENSION
PLATE IN EDENTULOUS AREA #

 Used alone or in combination with tension band
 The compression at the alveolar border is
achieved with two oblique compression holes, as
the screws in the outer oblique hole are tightened,
the fragments are rotated about the screws
nearest to the # which function as axes of rotation
and the fragments are consequently compressed
at the alveolar border

 In contrast to the DCP the EDCP consists of
two distant holes directed in the vertical
plane[at 45˚] as opposed all holes in the
horizontal plane in cases of DCP
 This causes an effect like that of a tension band
thus obliterating the need for a separate plate
or band

 Complex curvature of the mandible – Difficult
to provide straight line compression
 Presence of teeth and IAN allows placement of
CP in areas already under compression
 Technique sensitive
 Mostly require extraoral incision for adequate
exposure
 ↑ chances of DAMAGE to MMN
 Scarring

 MALOCCLUSION
 Too much compression
 Inadequate compression at alveolar border
 Straightening of normal mandibular curvature
 Excessive contact and pressure from long, wide
plates – Compromised periosteal blood supply
especially in cases of
 Older adults
 Atrophic mandibles
 Extremely rigid plates – Stress Shielding –
DELAYED HEALING ? ? ! !

 Use-
 Comminuted #
 Continuity defects
 Avulsion injuries
 Provide strength
 No compression

 Not a special screw
 It is a technique of screw insertion especially used
in cases of oblique # line
 Results in compression between two # fragments
 Proximal fragment – Drilled using a drill bit
having the external diameter same as that of the
screw to be inserted – GLIDING HOLE
 Distal fragment – Drilled with a drill bit slightly
larger than the core diameter of the screw
 Tightening of the screw results in compression
between bone fragments

 Should always be placed perpendicularly
across the fracture line to PREVENT
OVERRIDING AND DISPLACEMENT
DURING TIGHTENING
 Ideal for parasymphyseal and symphyseal
fractures
 Technically difficult in body, angle areas – Risk
of damage to the nerve

 No use of plates - Less hardware - Cost-
effective
 Extremely effective method
 Can be employed transorally
 Very rigid method when applied properly
 Quicker, Easier method [since no plate is to be
bent] with a more accurate reduction than bone
plates

 First by Michelet et al in the year 1967
 Compression is not necessary for the healing o fCompression is not necessary for the healing o f
mandibular fracturesmandibular fractures
 To what extent the compression is desirable ? ?To what extent the compression is desirable ? ?
 There is no universal agreement that compressionThere is no universal agreement that compression
stimulates osteogenesisstimulates osteogenesis
 Not logical to apply compression where physiologicNot logical to apply compression where physiologic
stimulation of bone already existsstimulation of bone already exists
 Ideally, fracture fixation should counteract theIdeally, fracture fixation should counteract the
distracting forces that will serve to distract thedistracting forces that will serve to distract the
fragments at a fracture sitefragments at a fracture site

 Less technique sensitive
 Decreased operative time
 Decreased bulk of plates
 Allow osteosynthesis to occur under conditions of
physiologic stress and compression thus
minimizing the stress shielding effect
 Can be easily performed with intraoral access
especially in anterior mandible
 Decreased cost
 Plate removal not always necessary, decreased
incidence of second surgery

 Decreased resistance to torsional movements
especially in anterior mandibular region
 Rotation or dispalcement of #fragments under
masticatory stress + muscle pull

 Luhr – first to use compression plates on
#mandible
 The system works on the same principle as that
of DCP and EDCP
 Difference-Vitallium [Co-Ch-Mo alloy] is used

 L-lactic acid
 L-lactic + D-lactic acid
 L-lactic acid + glycolic acid
 Resorb
 Initially by HYDROLYSIS
 Later by PHAGOCYTOSIS
 Manufacturers claim – Resorb within 1yr
 Clinical evidence of existence upto 3yrs found
 Decrease ratio of l-lactic:glycolic acid –
Decreases resorption time

 Bone clamps
 Brethrust splint
 Advocated initially to avoid problems produced by
electrolytic activity produced by biologically
incompatible alloys which were used in EPF
 Transfixation with K-wires
 Vero, 1968
 Shuker, 1985

 Greenstick/Undisplaced #, cannot tolerate
MMF
 Clinico-radiologic observation
 Soft, Nonchewy diet
 Minimally displaced # who wishes to avoid
surgery and can tolerate MMF for 4-6 wks
 Closed reduction with MMF
 ORIF – vestibular incision+DCP;2.4mm bicort.
screws/2.0mm locking miniplate/2.4mm lag
screws
Mandibular FracturesLaskin - Decision making

 Grossly displaced, comminuted and/or
infected # - transcutaneous approach, Recon
plate with 2.4mm bicort. Screws
 1wk IMF req. with miniplates and lag screws –
acts like a tension band, stabilizes occlusion
and allows soft tissue reattachment
 All hardware to be placed below tooth apices
and parallel to the inferior border

 Anatomic challenge – Mental nerve
 Intraoral ORIF – blunt dissection and retraction
of the neurovascular bundle

 Transoral ORIF – Technical challenge
 Course of IAN
 Length of premolar and molar roots
 Medial flare of the inferior border

 Splinting by masseter and medial pterygoid –
No significant displacement
 Coronoid process # - Generally require no T/t
 Associated # - t/t to require obtain adequate
stabilization

Mandibular FracturesLaskin - Decision making in OMFS

 Grossly loosened showing evidence of periapical
pathology or significant periodontal disease
 Partially erupted third molars with pericoronitis or
associated cyst
 Preventing reduction of #
 Teeth with # roots
 Teeth with exposed root apices or entire root
surface
 An excessive delay from the time of fracture to
definitive t/t
Shetty, Freymiller – JOMS’89

 Edentulous jaw
 Atrophic jaw
 Osteoporosis
 Reduced vascularity
 Healing potential diminished
 Chances of avascular necrosis if periosteum is
stripped

 Direct osteosynthesis
 Bone plates
 Transosseous wiring
 Circumferential wiring or Straps
 Transfixation with K-wires
 Indirect Skeletal fixation
 Pin fixation
 Bone clamps
 IMF using gunning type splints –
 Used alone
 Combined with other methods
Killey and Kay

 Thomas Brian Gunning – first to use custom-
fitted intraoral dental splint for immobilization
 Used in conjunction with an extraoral head
appliance
 Could also be applied simultaneously to the
maxilla folllowed by MMF

 Why is treatment required ? ?
 Mainly required for # of angle and body
 To restore an adequate denture-bearing area
 Avoid facial deformity
 Choice of treatment
 Gunning type splints – Used most commonly – inherent
disadvantages
 OR,DO – method of choice in fit patients
 Most-effective form of osteosynthesis – non-compression
mini plates
 <10mm in length – Fibrous union more acceptable
than Non-union
 Ultra-thin mandible - ABG

 Condyle, Subcondylar and Angle account for
80% of the mandibular #
 Symphysis and parasymphysis – 15%-20%
 Body # - Rare

 Management differs in –
 Anatomic Variation
 Rapidity of healing
 Degree of patient co-operation
 Potential for changes in mandibular growth
 Condylar cartilage
 Posterior border of the ramus
 Alveolar ridge

 Thin cortex with ↓density – Take care to avoid
wire pull-through
 Presence of developing tooth buds
 Shape and Shortness of deciduous crowns –
Make placement of circumdental wires and
arch bars difficult
 Provide better retention for IVY LOOPS
 # fragments become partially united as early as
4days
 Difficult to reduce on day 7

 Body and Symphsis
 Majority – Undisplaced
 Elasticity of bone
 Embedded tooth buds – Hold fragments together like a
GLUE
 Slight occlusal discrepancies – Resolve
spontaneously as permanent teeth erupt

 Nondisplaced without malocclusion –
 Close observation -1/2 times/week
 Blenderized diet
 Avoidance of physical activities
 Displaced
 Closed reduction and immobilization
 > 2 yrs – Gunning splint
 2-6 yrs – Circumdental Wires over molars, place arch
bar IMF with elastics if possible

 Angle

 Infection – Found to be the most common
complication
 Predisposing factors –
 Preoperative oral sepsis
 Teeth in the line of fracture
 Alcoholic or Metabolic disturbances
 Prolonged time before treatment
 Poor patient compliance
 Iatrogenic causes – such as open fixation procedures
 Osteomyelitis – second most common
complication
Edwards et al – Strong relationship between severity of # and complication rate

 Complications are the most common in the
vehicular accident victim who has sustained
multiple injuries
 The patient who sustains only mandibular
fracture with/without facial laceration, seldom
experiences complication
 James and Olson et al – healthy teeth in the line
of fracture do not increase the incidence of
infection and aid in stabilization of # fragments
which outweighs their prophylactic removal to
decrease the possibility of infection

 More common in Symphyseal # associated with
condylar fractures
 Results due to the muscle pull from tongue and
suprahyoids which causes lateral flaring of the
mandibular angle and lingual tipping of the
buccal segment
 Flaring is also caused by tightening of
maxillomandibular fixation wires.
 T/t- Ellis suggested to provide pressure in
medial direction to the gonial angles during
reduction and fixation .

 Inferior alveolar nerve- most common
 Mandibular branch of facial nerve- Rare,
Results in motor dysfunction of the
musculature of face or lips (due to trauma in
the condylar region, ramus, angle)

 Immediate- Pain, Swelling
 Delayed-
 Malunion
 Nonunion
 Delayed union

 Implies that union time will ultimately occur
but over a long period of time than usual (6-8
weeks).
 Also termed as PSEUDOARTHROSIS, as the
bone defect allows unnatural and perpetual
mobility.
 Fragments are relatively fixed by
interfragmentary tissue that permits varying
degrees of motion.

 Effect of alcohol-
 Accumulation of hepatic fat may lead to diffusion of
fatty emboli capable of impairing local blood supply
 Secondary osteoporosis, osteomalacia and vitamin
deficiency in the undernourished alcoholics
 Postulated reasons for ↑incidence -
 Poor compliance to MMF
 Poor bone quality
 Impaired local blood supply
 t/t – Closed reduction whenever possible
Cannel, Boyd - ↑incidence of delayed and nonunion in alcoholics

 Complete suspension of process at some point
of osseous bridging of the defect.
 Implies a failure of the fracture hematoma to
become transformed into an osteogenic matrix
so that it is ultimately converted into
nonosteogenic fibrous tissue.

 Identified by –
 Mobility in all planes after an interval of time (10
weeks)
 R/G , no evidence of progressive decrease in
radioluscency at the # site
 rounding off of the bone ends in later stages
 Absence of histologically identifiable osteogenic
tissue.

 Extensive gap- due to
 Loss of bone substance at the time of fracture
 Wide displacement of fragments
 Improperly applied device for distraction
 Damage to surrounding muscles
 Abnormal biomechanics, Shearing, Torsional and
bending stresses
 Inadequate Reduction- Results in marked distraction
of # margins due to excess traction from insertion of
muscles on to the fractures or may be secondary to
interposition of soft tissue between the bone ends.

 Inadequate fixation
 Infection
 Compromised Vascularity – Excessive
periosteal stripping
 Mechanical overloading of bone

 Indicates that a fracture has healed, but in less than
an optimal position.
 May result in a bone being shorter than normal,
twisted or rotated in a bad position, or bent.
 Can also occur where a fracture has displaced the
surface of joint and the cartilage in the joint is no
longer smooth.
 May cause –
- Pain, joint degeneration
- Post traumatic arthritis or “Catching/ Giving
way “ episodes resulting from instability or
incongruency.

 Role of endoscopes –
 Ma and Fung 1994 – 1st
to use it for angle #
 Later, Jacobovicz et al – Modified it for
accessing condylar region
 Role of 3 D planning and CAS ? ?

 Fonseca, Trauma
 Rowe and Williams
 Kruger and Schilli
 Yaremchuk
 Kaban and Troulis
 PeterWardbooth
 Peterson
 Killey and Kay
 Daniel Laskin
 Otolaryngologic Clinics of NA
 JOMS
 OOO

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Mandibular fractures ih

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