Zygoma: Strong buttress of lateral midface lying between zygomatic process of frontal bone and maxilla.
The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.
Zygoma: Strong buttress of lateral midface lying between zygomatic process of frontal bone and maxilla.
The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
Fractures of The Body of The Mandible In Maxillofacial SurgeryShahdHIbrahim
Fractures of the body of the mandible:
Introduction
Classification
History
Presentation
Examination
Radiography
Management
Complications
Post-operative Care
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
Fractures of The Body of The Mandible In Maxillofacial SurgeryShahdHIbrahim
Fractures of the body of the mandible:
Introduction
Classification
History
Presentation
Examination
Radiography
Management
Complications
Post-operative Care
Condylar fractures 2 /certified fixed orthodontic courses by Indian dental a...Indian dental academy
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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Mandibular fractures
Dr. Ahmed M. Adawy
Professor Emeritus, Dept. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University
Fractures of the mandible are a common form of facial injury in adults and occur most frequently in males during the third decade of life. The main causes of mandibular fractures are road traffic accidents, interpersonal violence, falls and sport injuries. Mandibular fractures are classified according to various criteria. The three main factors to consider are the cause of the fracture, the type of fracture and the site of the fracture. Clinical diagnosis as well as radiographic examinations are presented. Treatment modalities are discussed. Moreover, treatment-related complications are given.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Condylar fractures represent one of the most controversial issues in maxillofacial traumatology regarding classification, diagnoses and therapeutic management. Classification systems of condylar fracture is discussed. Diagnosis is usually based on history clinical examination and radiographic finding. Treatment ranges from observation, jaw exercises to closed or opened interventions. For years closed reduction was thought to be essentially complication-free. Several serious complications however have been reported including temporomandibular joint ankyloses, malocclusion, mandibular deviation and the generative joint pathology. The absolute and relative indications for open reduction is given. The debate between supporters of open or closed reduction is still continuing and the issue has not been resolved. However, the final choice treatment modality should takes into account the location of the fracture, age of the patient, presence or absence of other associated injuries, cosmetic impact of the surgery and presence of other systemic medical conditions.
Maxillofacial trauma mandible /certified fixed orthodontic courses by Indian ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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The lower jaw frequently breaks due to accidents, assaults or sometimes due to underlying disease. Just as with other bones in the body, there are a various methods for repairing the mandible.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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2. HISTORY
ANATOMY
INTRODUCTION
CLASSIFICATION
EXAMINATION AND DIAGNOSIS
TREATMENT
CONDYLAR FRACTURES
3. • The pre-Christian era
The first description of mandibular fractures dates to the 17th Century BC in
the ‘Edwin Smith papyrus’,
The Egyptians’ attitude to mandibular fractures was rather pessimistic:
“If thou examinest a man having a fracture in his mandible,
thou shouldst place thy hand upon it...and find that fracture
crepitating under thy fingers, thou shouldst say concerning
him: One having a fracture in his mandible, over which a
wound has been inflicted, thou will a fever gain from it. An
ailment not to be treated. Death usually followed, presumably
caused by infection”.
• Hippocrates – direct reapproximation of # segments with the use of
circum dental wires
• 1180, Textbook written in Salerno, Italy – importance of establishing a
proper occlusion.
• 1492, the book Cyrurgia by Guglielmo Salicetti – first mention of the use
of maxillomandibular fixation in treatment of mandibular #.
R. Mukerji et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228
4. History
• 1887, Gilmer reintroduced MMF in United States.
• Buck & Kinlock- first to do ORIF using wires.
• 1888 Schede- First to use stainless steel plate & screws.
• 1960, Luhr- first to use Vitallium compression plate
• 1970, Spiessl through AO/ASIF introduced principles of
rigid internal fixation.
• 1970, Michelet- introduced small bendable, non
compression plates- these were further modified by
Champy.
• 1987 – M.S. Leonard first to report use of lag screws
• Late 1990s – introduction of use of bioresorbable plates
5.
6.
7. Area of weakness
• Junction of Alveolar bone & Basal mandibular bone.
• Symphysis.
• Teeth
• Foramen
• Angle
• Condyle
10. • Zones of compression and tension
within the mandible are determined by
the muscles inserting and the forces
exerted by these muscles.
• Smaller arrows show direction of
muscular forces
• Larger arrows show the load placed
during function.
• This gives a zone of compression
along the lower border and a zone of
compression along the superior border
• Neutral axis about the level of the
canal.
11. Factors influencing displacement of
fracture
• Degree of force
• Resistance to the force offered by the facial bones
• Direction of force
• Point of application of force
• Cross-sectional area of the agent or object struck
• Attached muscles
12. # SYMPHYSIS AND PARASYMPHYSIS:-
Mylohyoid constitues a diaphragm b/w hyoid bone & mylohyoid ridge on
inner aspect of mandible
• Mylohyoid & geniohyoid -- stabilizing force symphysis transverse #
• Oblique # in this region tends to overlaps -- genio & mylohyoid diaphragm
13. Bucket handle
displacement
•B/L # of parasymphysis results from
force which disrupts the periosteum.
• displaced posteriorly under the
influence of genioglossus /
geniohyoid muscle
•Often removes attachment of tongue
& allows
TONGUE FALL BACK
14. ANGLE # :-
• medial pterygoid stronger component
• Vertical direction # favors the unopposed
action of the medial
pterygoid muscle,, post fragment pulled lingually
• Horizontal direction # line favors the unopposed
action of masseter and medial pterygoid muscle,,
post fragment displaced upwards
16. Nerves
• The inferior dental nerve is frequently damaged in #
of body and angle
• The fibrous sheath provides considerable support for
contained vessels and nerves which accounts for
surprisingly low incidence of permanent nerve
damage after #
• Condyle may impact with such force against the
temporal bone and # which results in facial nerve
damage within follapian canal [Goin. 1980].
• Injury to facial nerve due to external trauma.
17. • Angle 110-140*
• Angle decreases with growth- changes in condylar process
,shape and size
Age Changes
18. Blood vessels
• Vascular damage to inferior dental artery and vein
• A large sublingual haematoma may result from
rupture of dorsal lingual veins medial to an angle.
• Hemorrhage from torn periosteum.
• The facial vessels are vulnerable to direct trauma
where they cross the lower border of the mandible at
anteroinferior margin of Masseter muscle.
19. • A tubular long bone, which is bent into a blunt V-shape.
• Mandible is strongest anteriorly in midline with
progressively less strength towards condyle .
• dentition
• Muscle attachments.
• Mandible is one of the strongest bones, the energy
required to # it being of the order of 44.6 –74.4 Kg /
M(425Lb) approximately 350- 400 kg (800-900lb),
which is about same as zygoma and about ½ that of
frontal bone
[Swearingen 1965, Hodgson 1967, Nahum 1975a, Luce et al 1979]
Mandible is embryologically a membrane bent bone although, resembles
physically long bone it has two articular cartilages with two nutrient
arteries.
20. 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.
Mandibular fractures :
Fractures of the mandible are common in patients, who
sustain facial trauma.
SEX :
Most mandibular fractures are seen to occur in male patients.
Ratio is approximately 4.5 : 1
AGE :
35 % of mandibular fractures occur between the ages of
20 to 30 years.
Subodh et al, Clinical Study An Epidemiological Study on Pattern and Incidence of Mandibular
Fractures, Hindawi Publishing Corporation Plastic Surgery International, Volume 2012, Article ID
834364,7pages
22. Number of fractures per mandible.
The number of mandibular fractures per patient ranged from 1.5 to 1.8.
1. Unilateral , single - 53%
2. Bilateral , double - 37%
3. Multiple fractures - 10%
Fifty percent have more than one fracture.
Subodh et al, Clinical Study An Epidemiological Study on Pattern and Incidence of Mandibular
Fractures, Hindawi Publishing Corporation Plastic Surgery International, Volume 2012, Article ID
834364,7pages
23. Classification of mandibular fractures :
I. General classification
II. Anatomical locations
III. Relation of the fracture to site of injury
IV. Completeness
V. Depending on the mechanism
VI. Number of fragment
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
24. 1. Kruger's general classification
• Simple or Closed Fracture
• Compound or Open
• Comminuted
• Complicated or complex
• Impacted
• Greenstick fracture
• Pathological
Simple fracture Compound Fracture
Comminuted fracture
Impacted fracture
Greenstick fracture
25. 2. Rowe & Killey classification
• Fractures not involving basal bone
• Fractures involving basal bone of the mandible. Subdivided into following:
Single Unilateral
Double unilateral
Bilateral
Multiple
3. Dingman & Natvig classification
• Midline
• Parasymphyseal
• Symphysis
• Body
• Angle
• Ramus
• Condylar process
• Coronoid process
• Alveolar process
26. 4. Kruger & Schilli classification
I. Relation to the external environment
• Simple Or closed
• Compound or open
II. Types of fracture
• Incomplete
• Greenstick
• Complete
• Comminuted
III. Dentition of the jaw with reference to the use of splint
• Sufficiently dentulous patient
• Edentulous or insufficiently dentulous patient
• Primary and Mixed dentition
IV. Localization
• Fractures of the symphysis region between canines
• Fractures of the canine region
• Fractures of the body of the mandible
• Fractures of the angle
• Fractures of the mandibular ramus
• Fractures of the coronoid process
• Fractures of the condyle
27. 5. Kazanjian classification
Class – III : Patient is edentulolus
Class – I : teeth are present on both sides of
the fracture line
Class – II : Teeth are present on only one side of
fracture line
28. 6. According to direction of the fracture and favorability for
treatment ( Fry et al)
Horizontally favorable
Horizontally unfavorable
Vertically favorable
Vertically unfavorable
29. 7. Relation of the fracture to the site of injury
• Direct fracture
• Indirect fracture
30. 8. 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
31. 9. 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. 10. AO-analogue classification system of mandibular fractures
• Each compartment is classified independently, describing the
degree of displacement and the presence of multifragmentation
or osseous defects.
• Each fracture is classified:
- type A, nondisplaced fractures
- type B, displaced fractures
- type C, multifragmentary/defect fractures
• Each fracture is divided into 3 groups,
specific to the mandibular unit.
Int.J.Oral Maxillofac.Surg.2008;37:1080-1088
39. History
• Focussed questioning should reveal following:
• Mechanism of injury
• Previous facial fracture
• H/O TMJ disorders
• Preinjury occlusion
40. Clinical examination
Examination of pt with # of mandible takes place in 3
stages:
A. Immediate assessment and treatment of any
condition constituting a threat to life.
B. General clinical examination of pt.
C. Local examination of mandibular #.
41. • Change in occlusion
• Anesthesia, Paresthesia or Dysesthesia of
lower lip
• Abnormal mandibular movements
• Change in facial contour and mandibular arch
form
• Laceration, Hematoma and Ecchymosis
• Loose teeth and crepitation on palpation
Clinical Examination
44. Signs and symptoms
• Tenderness +ve
• Occlusion changes - # teeth
- # alveolar process
- # mandible at any location
- # condyle
• Anterior open bite - B/L condylar #
• Posterior open bite - parasymphysis #
• Unilateral open bite - # ipsilateral angle
- # parasymphysis
• Posterior cross bite - midline symphysis #
- condylar #
45. Radiological examination
Ideally need 2 radiographic views of the fracture that are
oriented 90’ from one another to properly work up
fractures
• Single view can lead to misdiagnosis and
• complications with treatment
46. • Most informative
• Shows entire mandible and
direction of fracture (horizontal favorable, unfavorable)
Disadvantages:
• – Patient must sit up up-right
• – Difficult to determine buccal/lingual bone and
• medial condylar displacement
• – Some detail is lost/blurred in the symphysis, TMJ
and dentoalveolar regions
47. Posteroanterior (pa) radiograph:
Shows displacement of fractures in the ramus, angle, body, and
symphysis region
Disadvantage:
• Cannot visualize the condylar
region
48. Lateral oblique
• Used to visualize ramus, angle, and
body fractures
Disadvantage:
• Limited visualization of the condylar
region, symphysis, and body anterior to
the premolar
49. Occlusal radiograph
• Used to visualize fractures in the body in regards to medial or
lateral displacement
Used to visualize symphyseal fractures for anterior and posterior
displacement
50. Computed tomography ct:
Excellent for showing
intracapsular condyle fractures
axial and coronal views,
3-D reconstructions
Disadvantage:
• – Expensive
• – Larger dose of radiation
exposure compared to plain
film
• – Difficult to evaluate direction of
fracture from individual slices
(reformatting to 3-D overcomes
this)
51. 1. The patient’s general physical status should be carefully evaluated
and monitored prior to any consideration of treating mandibular
fracture.
2. Diagnosis and treatment of mandibular fractures should be
approached methodically not with an “emergency-type” mentality
3. Dental injuries should be evaluated and treated concurrently with
treatment of mandibular fractures
4. Re-establishment of occlusion is the primary goal in the treatment of
mandibular fracture.
5. With multiple facial fracture mandibular fracture should be treated
first.
6. Intermaxillary fixation time should vary according to the type,
location, number severity of the mandibular fracture as well as the
patient’s age and health.
7. Prophylactic antibiotics should be used for compound fractures.
General principles in the treatment of
mandibular fracture
52. Basic principles for Rx of Fracture
Reduction
• Closed
• Direct interdental
wiring Indirect
interdental wiring
(eyelet or Ivy loop)
• Continuous or multiple
loop wiring
• Arch bars
• Cap splints
• 'Gunning-type' splints
• Pin fixation
Open
Transosseous
wiring
(osteosynthesis)
Plating
Intramedullary
pinning
Titanium mesh
Circumferential
straps
Bone clamps
Bone staples
Bone screws
Fixation
Direct
Indirect
53. Immobilization
• Methods of immobilization
• (a) Osteosynthesis without intermaxillary fixation
• (i) Non-compression small plates
• (ii) Compression plates
• (iii) Mini-plates
• (iv) Lag screws
• (b) Intermaxillary fixation
• (i) Bonded brackets
• (ii) Dental wiring
• Direct
• Eyelet
• (iii) Arch bars
• (iv) Cap splints
• (v) MMF screws
• (c) Intermaxillary fixation with osteosynthesis
• (i) Transosseous wiring
• (ii) Circumferential wiring
• (iii) External pin fixation
• (iv) Bone clamps
• (v) Transfixation with Kirschner wires
54. 1. Non-displaced favorable fractures
2. Grossly comminuted fractures
3. Fractures exposed by significant loss of overlying soft
tissue.
4. Mandibular fractures in children with developing dentition
5. Coronoid process fracture
6. Condylar fractures
IndicationforClosedReductionof Fractures
55. ADVANTAGES& DISADVANTAGESOF
CLOSEDREDUCTION
Advantages
• Inexpensive
• Only stainless steel wire
needed
• Convenient
• Gives occlusion
• Conservative
• O.T not required
• Generally easy ,no great
operator skill needed
Disadvantages
•Cannot obtain absolute
stability
•Difficulty nutrition
•Oral hygiene impossible
•Long period of IMF
•Changes in TMJ cartilage
•Weight loss
•Decrease range of motion of
mandible
•Risk of wounds to operator
56. CLOSED REDUCTION
• HISTORY
• William Saliceto(1210-1277) Tied the teeth (MMF)
• Thomas Gilmer(1849-1931) Reveiwed the tech,
introduced Arch Bars in 1907.
• Barton bandage by JOHN BARTON
• Lingual-Labial occlusal splint.
• Vaccum formed acrylic splint
• Royal Berkshire Haio Frame
57. Direct interdental wiring
• Gilmer's wiring
• simple & rapid method of
immobilization jaw
• first aid method
• temporary immobilization
of # fragment
Disadvantage
- complete removal of wires
- extrusion of teeth
58. IVLOOPMETHOD
IVY-LOOP METHOD
• quick and easy way of
obtaining maxillo-
mandibular fashion.
• 24 gauge wire
• simple and effective for
reduction and
immobilization of #
61. Button Wiring
• Leonard (1977)
considers that eyelet
wires have several
drawbacks.
• He described the use
of titanium buttons
of 8mm diameter,
inclusive of a 1mm rim,
and 2mm deep.
64. Arch bars
• For temporary fragment stabilization in emergency cases
before definitive treatment
• As a tension band in combination with rigid internal fixation
• For long-term fixation in conservative treatment
• For fixation of avulsed teeth and alveolar crest fractures
65. • Different types of Arch bar
• Winters
• Jelenkos
• Dautrys Arch bar
• Berns titinium arch bars
• Burmachs arch bar
• Custom made
66. Screws
• Screws are quick to place
• Reduce the chance of needlestick injury from wires
• Can be used with heavily restored teeth
• Can be placed and removed rapidly
• Well tolerated by patient
• Allow oral hygiene to be easily maintained
67. Pre drilled Drill free
• When drilling the screw
holes, saline irrigation
assists bone debris removal
and cooling of tissues.
• There is a risk of the drill
damaging the roots of
adjacent teeth, especially in
inexperienced hands
• Cannot be used
• No irrigation required
• Less chance of damage
to adjacent teeth
• Drill free screws may
be used in comminuted
fractures
68. Cap Splints :
• Indications
Advanced periodontal
disease
#s of tooth bearing
segments & condylar neck
Portion of body of
mandible missing
• Impression technique
• Fitting the splint
• Reduction of fracture
69. Biphasic pin fixation
• Closed technique uses external fixation (Morris
appliance & Roger anderson appliance) for
management of communited mandibular #.
• screws placed - two on either side of the fracture
through stab incisions & holes drilled in the
mandible.
70. • Once external pins are in position,
the fracture segments are manipulated to
achieve reduction.
• Then the pins are locked in reduced position by applying
of an acrylic mix that is placed over the ends of the pins
that are protruding out of the skin.
• The acrylic is allowed to harden while mandible is held in
reduced position.
• Steinmann pins or Kirshner wires can also be used as
external pins
71. Indications
• Edentulous fractures
• If IMF is not feasible
• Comminuted fractures
• Bone graft
requirements
• With a head frame
Contraindications
• Irradiated tissues
• Grossly contaminated
tissue
• Osteoporosis
• Osteosclerosis
• Atrophy
72. Advantages
• Control of the edentulous
fragments without
involving the fracture lines.
• under LA.
• avoidance of the need for
surgery at the fracture site,
• minimum operative time
• Simple surgical technique.
Disadvantages
• Conspicuous
uncomfortable
• uncooperative or cerebrally
irritated patient.
• Difficulty with washing
and shaving
• scars caused- pinholes
• risk of infection.
73. Acrylic splints take the form of
modified dentures with bite block in place of molar teeth &
space in the incisor area to facilitate feeding
Used in edentulous jaw fractures
Gunning splints
74. INDICATION
• - unilateral / bilateral # edentulous mandible
CONTRAINDICATIONS
• - unfavorable displaced #s lying out side denture
bearing areas
• - severe posterior displacement of #s of the anterior
part of mandible
75. •Preparation of cast/ mock surgery
•Preparation of acrylic block in centric
relation
•Acrylic bite block in molar region
•Space in anterior region
•Stainless steel hooks in molar region
Fabrication
78. Houpert’s procedure
The operator should drill transfixion holes (in a
vestibulo‐lingual direction) with a tiny round burr in the crown
of the deciduous teeth away from the pulp and a safe distance
from the occlusal surface.
A 0.2‐mm stainless steel wire impregnated in silver nitrate is
introduced through the holes. Depending on the number of
teeth used, either bimaxillary or monomaxillary fixation can be
applied. Each hole should be filled with amalgam.
A variation of this technique (Ginestet) allows placing an
eyelet through each hole to fix both a vestibular and a
lingual/palatal hard, 0.5‐mm stainless steel wire, with the
possibility of a double splint device both in the vestibular and
at the lingual/palatal aspect of the dental arcade.
79. 1. Displaced unfavorable fracture through angle of the mandible
2. Displaced unfavorable fractures of the body or pasymphyseal region
3. Multiple fractures of the facial bones
4. Midface fractures and displaced Bilateral condyler fractures
5. Fractures of the edentulous mandible with severe displacement of
fragments
6. Edentulous maxilla opposing a mandibular fracture
7. Delay of treatment and interposition of soft tissue between noncontacting
displaced fracture fragments.
8. Malunion
9. Special systemic conditions contraindicating intermaxillaryfixation
Indications for open Reduction
80. Contraindications
• G.A / more prolonged procedure is not
advisable
• Gross infections at the # site
• Sever comminution with loss of soft
tissue
• Patients with difficult to control
seizures
84. Transalveolar / upper border wiring
Sir Williams Kelsey Fry
• To control the posterior fragment
• Use – vertically and horizontally unfavorable #
• Horizontal mattress wiring
85. Transosseous / lower border wiring
Hayton Williams 1958
• # fragments expose extraorally
• posterior fragment hole higher level then anterior
fragment
• both wires passes simultaneously through same hole
1973 Obwegeser :-
• Combined direct and figure of ‘8’ wiring with single stand
of wire
87. Bone plate osteosynthesis
• Non compression plate with monocortical screw
• Compression plates with bicortical screw
- DCP - EDCP
• Bio degradable plates and screws
• Three dimensional plates
• Titanium miniplates
88. Principle of compressionplate osteosynthesis
• The holes for the screws
should be prepared at
the far ends of the plate
holes.
• When tightening the
screws the fracture ends
are approximated by the
effect of the spherically
shaped holes
Journal of Cranio-Maxillofacial Surgery 2008; 36: e251 - e259
89. Compression plates
•Axial compression b/w fractured bone ends
•Rigid fixation with intra-fragmentry compression
•Bone ends correctly opposed and maintained
•IMF is not needed post operatively
•Primary bone healing occurs by direct osteoblastic activity
within #
•AO/ASIF dynamic compression plates
Compression plate approach Eccentric dynamic compression plate
90. DCP EDCP
• The plate design is based on a screw head
that, when tightened, slides down an
inclined plane within the plate.
• Screw behaves as compression screw or the
static screw
• Compression is not achieved at the upper
border so tension band is required
• The EDCP is similar to the DCP in that
the inner holes are designed to produce
compression across the fracture site
• Two oblique outer eccentric compression
holes aligned at an angle oblique to the
long axis of the plate. The activation of
these outer holes produces a rotational
movement of the fracture segments with
the inner screws acting as the axis of
rotation
• Brings compression at the upper border
so tension band is not required
91. Mini plate Osteosynthesis :-
1973 MICHELET
1975 CHAMPY MODIFIED
- Under physiological strain, forces of tension along the
alveolar border & forces of compression along the lower
border of the mandible.
- With in the body of the mandible these forces produce,
predominantly, moments of flexion – angle strong & weak in
PM region.
- with in the symphysis – torsional moments
- Champy et al analysed these moments using a mathematical
model of the mandible – ideal line of osteosynthesis.
# symphysis 2 plates
# angle 1 plate
Monocortical screws 2 mm diameter and 5 to 10 mm length
Plate 2cm long, 0.9mm thick and 6mm wide
92. Advantages of monocortical miniplate
osteosynthesis over bicortical
compression plates.
Monocortical
• Requires minimal
dissection.
• Less technique
sensitive
• Less chances of
complications
Bicortical
• Extra oral approach
• Nerve injury
• Difficult to adapt
93. Compression plate Miniplates
• Bicortical plates
• Bulky and difficult to use
• Applied extraorally
• Cannot be used at the upper
border of the mandible
• Provides rigid fixation
• No interfragmentary
movement allowed
• Monocortical plates
• Easy to use
• Applied intraorally, small
incision , less soft tissue
dissection , less likely to be
palpable
• Can be used without any
associated complication
• Provides functionally stable
fixation
• Little interfragmentary
movement present, torsional
movement seen under
functional loading
97. 3-D plate ostesynthesis
DentalResearchJournal/Mar2012/Vol9/Issue2
• Titanium 3-D plating system was developed by Farmand to
meet the requirements of semi-rigid fixation with lesser
complications.
• The 3-D miniplate is a misnomer as the plates are not three
dimensional, but hold the fracture fragments rigidly by
resisting the forces in three dimensions, namely, shearing,
bending, and torsional forces.
• The basic concept of 3-D fixation as explained by
Farmand
is that a geometrically closed quadrangular plate secured with
bone screws creates stability in three dimensions. The stability is
gained over a defined surface area and is achieved by its
configuration and not by its thickness or length.
98. • The large free areas between the plate arms and minimal
dissection permit good blood supply to the bone.
• The newly introduced 3-D plating system provides definite
advantages over the conventional miniplates.
• The 3-D plating system uses fewer plates and screws as
compared to the conventional miniplates, to stabilize the bone
fragments. Thus, it uses lesser foreign material, and reduces
the operation time and overall cost of the treatment
• The 3-D plating system has a compact design and is
• easy to use. The 1.0-mm-thick 3-D plate is as stable
• as the much thicker 2.0 mm miniplate. This offers
• better bending stability and more resistance to out-ofplane
movement or torque.
101. Advantages: -
• Improved handling characteristics,
• Increased stability,
• Shorter surgical time,
• Preservation of bony
perfusion,
• Decreased bone necrosis,
• Increased bony healing and regeneration.
102. Bioabsorbable Plates
Bioresorbable materials used for rigid fixation
• Polydioxanone
• Polyglycolic acid
• Polylactic acid
Strength inadequate to provide clinically acceptable
rigid fixation.
• Use of poly-L-lactide in 69 fractures by Kim et al
• 12% complication
• 8% infection
• No malunion
Plastic and Reconstructive Surgery, vol 110, july 2002, 25-31
103. Bioresorbable plates & screws
[RobertM. LaughlinJOMS2007;65:89-96]
Advantages:
• Provides the proper strength
when necessary and then
harmlessly degrades over
time.
• No need for an additional
removal operation.
• Reduce the total treatment
& rehabilitation time of the
patient.
• No bending pliers are
necessary.
104. Lag screw
Compress fracture fragments without the use of bone plate
Two sound bony cortices are required -- Shares the loads with
the bone
Uses:
• absolute rigid fixation
• Less hardware
• More cost effective
• Rigid method of internal fixation
• Insertion -quicker and easier
• Reduction more accurate
105. Lag screws
Placed indirection that is perpendicular
to the line of fracture to prevent
overriding
& displacement during
tightening of the screws.
INDICATIONS
• #s in edentulous parts
• Concomittant #s of body & condyle
• IMF contraindicated
• Saggital/oblique fractures
• Non/mal union
108. Anchor lag screwvs conventional lag
screw
Journaloforalbiologyandcraniofacialresearch3(2013)15e19
Loosening of screw, damage to bone, mobility of fragments, incidence of pain,
infection presence
109. Reconstruction plates
• For communited mandibular fractures
• Decreased post op morbidity
• Stabilization of entire communited complex
• Defect fractures can be treated
• 2.0 mm plate with bicortical screw used in conjuction with lag
screws or miniplates
110. Advantages of open
reduction.
• Accurate reduction &
fixation of fractures by
direct visualization.
• Better bone healing.
• Early return to normal
jaw function.
• Normal nutrition, no
weight loss.
• Patient can maintain
oral hygiene.
• Early return to work.
Disadvantages of
open reduction.
• Requires surgical
exposure.
• Requires general
anesthesia.
• Expensive.
• Compared to IMF
technique is difficult
and risky.
• Foreign body is left
in the tissues.
• Scarring.
111. Protocolfor treatmentof mandibular
fractures
(PhilipL.Maloney,JOralMaxillofacSurg,59:879-884,2001)
• Simple fractures of the condylar process and ramus -
closed reduction. MMF for 48 to72 hours - training
elastics and close observation
• No MMF is required for coronoid fractures; archbars and
training elastics are used only if a malocclusion is
present.
• Simple or compound fractures with a time delay from
injury to immobilization of < 72 hours are treated by a
closed reduction (CR) or, if indicated, open reduction
with rigid fixation (ORIF).
112. • Compound fractures - delay from injury to
immobilization of >72 hours - MMF and IV antibiotics .
• If the closed reduction is adequate, the patient is
continued on oral antibiotics for an additional 10 to
14days and maintained in MMF and on a blenderized
diet for 5 to 6 weeks from the time of closed reduction.
• If not, ORIF is performed, and MMF is maintained for
10 to 14 additional days.
• Edentulous patients are treated with rigid fixation, no
MMF, and a blenderized diet for 4 to 5 weeks.
• Teeth in the line of fracture are judged individually.
113. The goal of AO/ASIF is rigid internal fixation with
primary bone healing, under functional loading
Basic principals
• Reduction of bony fragments
• Stable fixation of the fragments
• Preservation of the adjacent blood supply
• Early functional mobilization
114. Bone healing
• Histomorphologic changes during fracture healing
Post fracture time Histology
Immediate Extravasation of blood
24 hrs Aseptic inflamm – clot
48 hrs Org of clot
4 days Intramemb bone formation
Subperiosteal bone formatn
5 to 10 days Hyaline cartilage
116. Generalprinciples in the treatmentof
mandibularfractures
• Patient’s general physical status
• Methodical approach -not “emergency-type” mentality.
• Dental injuries - evaluated & treated concurrently
with T/t of mandibular fractures.
• Re-establishment of occlusion -primary goal
• With multiple facial fractures, mandibular fractures
should be treated first.
117. • IMF time should vary
• Type
• Location
• Number
• Severity of mandibular fractures
• As well as the patient’s age & health
the method used for reduction & immobilization.
• Prophylactic antibiotics should be used for compound
fractures.
• Nutritional needs should be closely monitored
postoperatively.
118.
119. Young adult with Fracture
of the angle receiving Early
treatment in which Tooth
removed from fracture line
3 weeks
Guide for time of immobilization
(a) Tooth retained in fracture line: add 1 week
(b) Fracture at the symphysis: add 1 week
(c) Age 40 years and over: add 1 or 2 weeks
(d) Children and adolescents: subtract 1 week
IF
120. Teeth in the line of fracture
• Potential impediment to healing
• Fracture is compound
• Tooth maybe damaged structurally subsequently become
necrotic
• Pre existing pathology – apical granuloma
121. Teeth in line of fracture
Indications for
removal
Absolute
• Longitudinal #
• Dislocation/subluxation of
tooth
• Periapical Infection
• Infection of the fracture line
• Acute pericoronitis
Relative
• Functionless tooth
• Advanced caries
• Periodontal disease
• Doubtful teeth
• Untreated # > 3
days
122. Managementof teethretainedin fracture
line
• Intra-oral periapical radiograph
• Systemic antibiotic therapy
• Splinting of tooth if mobile
• Endodontic therapy if pulp exposed
• Immediate extraction if fracture becomes infected
• Follow-up for 1 yr with endodontic therapy if there is
demonstrable loss of vitality.
123. Fracture healing
• With RIF the strain on the
bone is reduced
• Bone heals by direct
approximation
• Gap healing – minimal
callus
• healing – satisfactory
immobilisation
• Inflammatory stage
• Cartilagenous stage
• Bony callous stage
• Remodelling
124. Complications
Complications during primary treatment
Misapplied fixation
Infection
Nerve damage
Displaced teeth and foreign bodies
Pulpitis
Gingival and periodontal complications
Drug reactions