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Mandibular fractures


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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.

Published in: Education, Health & Medicine
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Mandibular fractures

  2. 2. ANCIENT GREECE: HIPPOCRATESHIPPOCRATES The son of a physician-priest Written in 460 BC Describes MMF . . . !
  3. 3. HIPPOCRATES “Displaced but incomplete fractures of the mandible where continuity of the bone is preserved should be reduced by pressing the lingual surface with the fingers while counterpressure is applied from the outside. Following the reduction, teeth adjacent to the fracture are fastened to one another using gold wire.”
  4. 4. THE EDWIN SMITH TREATISE  “If thou examinst a man having a fracture in his mandible, thou shouldst place thy hand upon it…and find that fracture crepitating under they 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.”  The cause of death was believed to be sepsis
  5. 5. OBJECTIVES  Anatomy  Fracture distraction  Principles of rigid internal fixation  AO method  Rapid IMF  ORIF vs. MMF
  6. 6. OVERVIEW  Accounts for over 50% of the prehospital trauma deaths encountered by prehospital provider  Even when not fatal, head injuries are devastating to the survivor and family  Victims of significant head injury seldom recover to the same physical and emotional state of pre-injury  Many victims suffer irreversible personality changes
  7. 7. MAXILLO-FACIAL TRAUMA  Causes -  MVA, home accidents, athletic injuries, animal bites, violence, industrial accidents  Soft tissue -  lacerations, abrasions, avulsions  vascular area supplied by internal and external carotids  Management -  Seldom life-threatening unless in the airway  consider spinal precautions  have suction available and in control of conscious patients  control bleeding
  8. 8. FACIAL FRACTURES  Fx to the mandible, maxilla, nasal bones, zygoma & rarely the frontal bone  S/S -  pain, swelling, malocclusion, deep lacerations, limited ocular movement, asymmetry, crepitus, deviated nasal septum, bleeding from orifice  Mandibular Fx -  malocclusion, numbness, inability to open or close the mouth, excessive salivation  Anterior dislocation extensive dental work, yawning  Condylar heads move forward and muscles spasm
  10. 10. ANATOMY: BONY LANDMARKS Condylar Process Coronoid Process Ramus Angle Body Symphysis/ parasymphysis
  11. 11. CAUSES OF JAW FRACTURES  Falling onto face from a significant height  Gun shot wounds to the face  Motor vehicular accidents  Blow to the face  Weakening of the jaw caused by  Severe gum disease (periodontal disease) erosion of the jaw bone  All meat diet  Supplementation with improper ratio of calcium and phosphorus  Chronic kidney disease  Osteogenesis imperfecta - congenital disease  Cancer of the jaw bone
  12. 12. PATHOPHYSIOLOGY Optimal mandible function requires maintenance of normal anatomic shapeshape and stiffnessand stiffness (ie, resistance to deformation underload).
  13. 13. PATHOPHYSIOLOGY  Fractures result secondary to mechanical overload. Torque results in spiral fractures avulsion, in transverse fractures bending, in short oblique fractures compression, in impaction and comminution.
  14. 14. PATHOPHYSIOLOGY:  Degree of fragmentation depends upon energy transfer as a result of overload.  Therefore, wedge and multifragmentary fractures are associated with higher energy release.
  15. 15. PATHOPHYSIOLOGY: An evidence based study involving 3002 patients with mandibular fractures… the presence of a lower third molar may double the risk of an angle fracture of the mandible.
  16. 16. PATHOPHYSIOLOGY: Another study compared fractures with wisdom teeth to those without. Showed increased infectious risk (16.6%) in fractures with wisdom teeth compared with 9.5% risk in fractures without wisdom teeth.
  17. 17. CLASSIFICATION OF FRACTURES  Simple Fracture.  A simple fracture is a break in the bone that does not produce an open wound in the skin.  complete or incomplete.  Tissue adjacent to the fracture may or may not suffer considerable injury.  Also known as closed fracture
  18. 18. CLASSIFICATION OF FRACTURES Multiple - two or more fracture lines that are not connected to each other. Indirect - The fracture site is distant from the site of injury. Complex - there are considerable Soft Tissue Injuries; this may be simple or compound fracture
  19. 19. CLASSIFICATION OF FRACTURES Comminuted - involves splintered or crushed bone. Greenstick - also called incomplete fracture. one cortex of the bone is broken and the other cortex is bent Atrophic - fracture resulting from severe atrophy of the bone.
  20. 20. CLASSIFICATION OF FRACTURES  Compound Fracture / Open fracture  with an external wound extending to the bone.  Communication is an invitation for contamination.  Fracture communicates with the external wound, involving skin, mucosa, or periodontal membrane  Comminuted Fracture.  bone is splintered into three or more fragments or is crushed.  NOTE: A compound-comminuted fracture is one with both a splintering of the bone and a break in the bone with an opening to the covering surface.
  21. 21. CLASSIFICATION OF FRACTURES  Depressed Fracture. fractured part is driven below the normal level of the bone, as in a skull fracture.  Impacted Fracture. hard cortical bone of one fragment is driven into the softer cancellous bone of another fragment.  Pathologic (Spontaneous) Fracture. break without external violence at an area of the bone that has been weakened by a local disease.
  22. 22. CLASSIFICATION OF FRACTURES Multiple Fracture. two or more fractures occur in the same or different bones.  Favorable Fracture. line of the fracture occurs in a direction that does not allow the pull of the muscles on the segments to displace the segments.  Unfavorable Fracture. fracture with displacement or separation of the fractured segments due to muscle pull on the segments.
  23. 23. Mandibular fractures can occur..
  24. 24. THE ANGLE CLASSIFICATION  Based upon the relationship of the first mandibular and maxillary molars Class I: normal occlusion Class II: an “underbite” Class III: an “overbite”  Observe wear facets
  26. 26.  Class I: (normal) Mesiobuccal cusp rests in the mesiobuccal groove  Class II (retrognathic) Mesiobuccal cusp is mesial or anterior to the mesiobuccal groove.  Class III (prognathic) Mesiobuccal cusp is distal or posterior to the buccal groove.
  27. 27. OCCLUSION  Normal occlusion can be defined when the mesiolabial cusp of the maxillary first molar approximates the buccal groove of the mandibular first molar.
  28. 28. OCCLUSION  Angle’s Classification  Position of the maxillary and mandibular first molars Class I: (normal)  Mesiobuccal cusp rests in the mesiobuccal groove
  29. 29. OCCLUSION  Angle’s Classification  Position of the maxillary and mandibular first molars Class II (retrognathic)  Mesiobuccal cusp is mesial or anterior to the mesiobuccal groove.
  30. 30. OCCLUSION  Angle’s Classification  Position of the maxillary and mandibular first molars Class III (prognathic)  Mesiobuccal cusp is distal or posterior to the buccal groove.
  31. 31. COMMON SITES OF FRACTURE  Weak areas include 3rd molar and canine fossa
  32. 32. Fracture Type Prevalence Body 30 - 40 % Angle 25 - 31 % Condyle 15 - 17 % Symphysis 7 - 15 % Ramus 3 - 9 % Alveolar 2 - 4 % Coronoid process 1 - 2 %
  34. 34. ANATOMY mandible - lower jaw bone there is a left and a right mandible have joints - allow the mouth to open and close have a hollow canal - nerves and blood vessels are housed
  35. 35. ANATOMY  U – shaped body  Vertically directed rami  Coronoid  Condyle  Oblique line  Mental foramen
  36. 36. INTERNAL ANATOMY  Mandibular foramen  Lingula  Pterygoid fovea  Mylohyoid line  Fossae  Submandibular  Sublingual  digastric  Mental spines  Genioglossus  Geniohyoid
  37. 37. ANATOMY  Body - From the distal symphysis to a line coinciding with the alveolar border of the masseter muscle (usually including the third molar) (30-40%)  Angle - Triangular region bounded by the anterior border of the masseter muscle to the posterosuperior attachment of the masseter muscle (usually distal to the third molar) (25 - 31%)  Condyle - Area above the ramus region (15 - 17%)
  38. 38. ANATOMY  Symphysis - Region of the central incisors that runs from the alveolar process through the inferior border of the mandible (7 - 15%)  Ramus - Part of the mandible that is bounded by the superior aspect of the angle (3-9%)  Alveolar process - Region of the mandible that carries the teeth (2 - 4%)  Coronoid process - Includes the coronoid process of the mandible superior to the ramus region (1 - 2%)
  39. 39. INNERVATION  CNV3, the mandibular n., through the foramen ovale  Inferior alveolar n. through the mandibular foramen  Inferior dental plexus  Mental n. through the mental foramen
  40. 40. INNERVATION  CNV3, the mandibular n., through the foramen ovale  Inferior alveolar n. through the mandibular foramen  Inferior dental plexus  Mental n. through the mental foramen
  41. 41. ARTERIAL SUPPLY  Internal maxillary artery  Inferior alveolar artery  Mental artery
  42. 42. MUSCULATURE:JAW ELEVATORS  Masseter: Arises from zygoma and inserts into the angle and ramus  Temporalis: Arises from the infratemporal fossa and inserts onto the coronoid and ramus  Medial pterygoid: Arises from medial pterygoid plate and pyramidal process and inserts into lower mandible
  43. 43. MUSCULATURE: JAW DEPRESSORS  Lateral pterygoid: lateral pterygoid plate to condylar neck and TMJ capsule  Mylohyoid: mylohyoid line to body of hyoid  Digastric: mastoid notch to the digastric fossa  Geniohyoid: inferior genial tubercle to anterior hyoid bone
  44. 44. FAVORABLE FRACTURES  Those fractures where the muscles tend to draw fragments together  Ramus fractures are almost always favorable as the jaw elevators tend to splint the fractured bones in place
  46. 46. UNFAVORABLE FRACTURES  Fractures where the muscles tend to draw fragments apart  Most angle fractures are horizontally unfavorable  Most symphyseal/parasymphyseal fractures are vertically unfavorable
  47. 47. ANATOMY  back part of the jaw is covered with muscles that are used to open and close the mouth  teeth of the mandibles and maxilla usually interdigitate or have good occlusion  teeth are rooted in sockets in the mandible and maxilla
  48. 48. MUSCLE SLING
  49. 49. MUSCLE SLING  Vertical rami totally embedded within sling  Masseter  Pterygoids
  50. 50. MUSCLE SLING Angle and condylar neck not entirely protected by sling Bony trabecular crests, ridges, lines
  51. 51. MUSCLE SLING Trabeculae resist normal tension, compression, and rotation of mastication Little resistance to lateral stress from blunt trauma
  55. 55. DIAGNOSIS  ROS: bone disease, neoplasia, arthritis, CVD, nutrition and metabolic disorders, endocrine d/o  TMJ and ankylosis  MVA >> compound, comminuted fractures  Fists >> often single, non displaced fractures  An angled blow to the parasymphysis >> contralateral condylar fractures  An anterior blow to the chin >> bilateral condylar fractures
  56. 56. PHYSICAL EXAM  Change in occlusion is highly diagnostic  Anterior open bite suggestive bilateral condylar or angle fractures  Posterior open bite common with alveolar process or parasymphyseal fractures  Unilateral open bite with ipsilateral angle or parasymphyseal fracture  Retrognathic (Angle III) seen with condylar or angle fractures  Prognathic (Angle II) seen with TMJ effusion
  57. 57. PHYSICAL EXAM Anesthesia of lower lip :“pathognomonic” of a fracture distal to the mandibular foramen The converse is not true: not all fractures distal to the mandibular foramen have mental n. anesthesia Trismus of less than 35mm also highly suggestive of mandibular fracture
  58. 58. PHYSICAL EXAM Inability to open the mandible suggests impingement of the coronoid process on the zygomatic arch Inability to close the mandible suggests a fracture of the alveolar process, angle, ramus or symphysis
  60. 60. PHYSICAL EXAMINATION Pertinent physical findings are limited to the injury site. Change in occlusion may be evident on physical examination. highly suggestive of mandibular fracture. Ask patient to compare postinjury and preinjury occlusion.
  63. 63. LACERATIONS AND ECCHYMOSIS Mandibular fractures can often be directly visualized beneath facial lacerations. Lacerations should be closed after definitive therapy of the fracture Ecchymosis is diagnostic of symphyseal fractures
  65. 65. PHYSICAL EXAMINATION Lacerations, hematoma, and ecchymosis may be associated with mandibular fractures.
  67. 67. PALPATION The mandible should be palpated with both hands, with the thumb on the teeth and the fingers on the lower border of the mandible. Slowly and carefully place pressure, noting the characteristic crepitation of a fracture
  69. 69. PHYSICAL EXAMINATION Posttraumatic premature posterior dental contact (anterior open bite) and retrognathic occlusion may result from a mandibular angle fracture. Unilateral open bite deformity is associated with a unilateral angle fracture. Anesthesia, paresthesia, or dysesthesia of the lower lip may be evident.
  70. 70. PHYSICAL EXAMINATION Most nondisplaced mandible fractures are not associated with changes in lower lip sensation; Displaced fractures distal to the mandibular foramen (in the distribution of the inferior alveolar nerve) may exhibit these findings.
  71. 71. PHYSICAL EXAMINATION Loss of the mandibular angle on palpation may be because of an unfavorable angle fracture in which the proximal segment rotates superiorly. The anterior face may be displaced forward, causing elongation.
  72. 72. PHYSICAL EXAMINATION Do not close facial lacerations before treating underlying fractures except in the case of life-threatening hemorrhage. Pain, swelling, redness, and localized calor are signs of inflammation evident in primary trauma.
  73. 73. PHYSICAL EXAMINATION Change in facial contour loss of external mandibular form may indicate mandibular fracture. An angle fracture may cause the lateral aspect of the face to appear flattened.
  75. 75. RADIOGRAPHIC EXAM Panorex shows the entire mandible, but requires the patient to be upright.  It also has particularly poor detail of the TMJ and medial displacement of the condyles  AP - ramus and condyle  Submental - symphysis  CT - condylar fractures
  76. 76. Panoramic radiograph 12 weeks after cancellous iliac crest bone graft with reconstruction plate showing bony union
  77. 77. IMAGING STUDIES:  The single most informative radiologic study used in diagnosing mandibular fractures is the panoramic radiograph.  Panorex provides the ability to view the entire mandible in one radiograph.  Panorex requires an upright patient, and it lacks fine detail in the TMJ, symphysis, and dental/alveolar process regions.  Plain films, including lateral-oblique, occlusal, posteroanterior, and periapical views, may be helpful.  The lateral-oblique view helps in diagnosing ramus, angle, or posterior body fractures. The condyle, bicuspid, and symphysis regions often are unclear.  Mandibular occlusal views show discrepancies in the medial and lateral position of the body fractures.  Caldwell posteroanterior views demonstrate any medial or lateral displacement of ramus, angle, body, or symphysis fractures.  CT scanning may also be helpful.  CT scanning allows physicians to survey for facial fractures in other areas, including the frontal bone, naso-ethmoid-orbital complex, orbits, and the entire craniofacial horizontal and vertical buttress systems.  Reconstruction of the facial skeleton is often helpful to conceptualize the injury.  CT scanning is also ideal for condylar fractures, which are difficult to visualize.
  78. 78. COMPLICATIONS Socioeconomic groups Infection (James, et. al.) Delayed healing and malunion. Most commonly caused by infection and noncompliance Nerve paresthesias in less than 2%
  79. 79. STUDY BY JAMES, ET. AL.  Prospective study of 422 pts  Infection rate 7%  50% of infections associated with fractured or carious teeth  ORIF led to 12% infection rate  Staph, strep, bacteroides  Prophylaxis, tooth extraction
  80. 80. BONE HEALING  Reactive Phase Fracture Formation of granulation tissue  Reparative phase Replacement of granulation tissue by callus  Connective tissue + cartilage Replacement of callus by lamellar bone  Remodeling phase Remodeling of bone to normal contour The amount of callus formation is indirectly proportional to the degree of immobilization
  81. 81. GENERAL PRINCIPLES OF TREATMENT  The general physical status should be thoroughly evaluated.  40% associated with significant injury, 10% of which are lethal  Cerebral contusion is common  ABC’s!  Almost never emergent
  82. 82. GENERAL PRINCIPLES Dental injuries should be treated concurrently Reestablishment of occlusion is the primary goal Fractured teeth may jeopardize occlusion Mandibular cuspids are cornerstone of Tx Prophylactic antibiotics
  83. 83. GENERAL PRINCIPLES With multiple facial fractures, mandibular fractures are treated first
  84. 84. MANDIBULAR FRACTURES  Dentoalveolar injuries  Cautious use of intermaxillary fixation  Pattern of injuries with condyle most frequently injured  Possible growth disturbance  High osteogenic potential  Rare complications
  85. 85. PRINCIPLES OF JAW FRACTURE REPAIR  Alignment of the jaw - teeth line up in normal position is critical for healing of the fracture  Remove all loose teeth or teeth that have periodontal disease at the level of the fracture
  86. 86. PRINCIPLES OF JAW FRACTURE REPAIR If the tooth root has been involved a root canal procedure may be required Careful suturing of gums
  87. 87. MANDIBULAR FRACTURES  Physical Exam  Observance of mandibular range of motion and malocclusion  Radiographic assessment  Greenstick common  Types of condylar fractures  *especially for kids
  88. 88. CLOSED REDUCTION  Grossly comminuted fractures  Significant tissue loss  Edentulous mandibles  Fractures in children  Condylar fractures  Contraindicated in SzDo, psych, and compromised pulmonary function
  89. 89. OPEN REDUCTION  Displaced, unfavorable fractures of angle  Displaced unfavorable fractures of the body or parasymphysis, as these tend to open at the inferior border, leading to malocclusion  Multiple fractures of facial bones  Displaced, bilateral condylar fractures
  90. 90. CLOSED REDUCTION : DENTULOUS PATIENT Erich Arch Bars. Can lead to periodontal infalmmation. Avoid fixating incisors, as these teeth are moved by the wires Ivey loops
  91. 91. CLOSED REDUCTION : PARTIALLY EDENTULOUS PATIENT  Partials and circum wires or screws  Acrylic partials with incorporated arch bar wires
  92. 92. CLOSED REDUCTION : EDENTULOUS PATIENT  Dentures with circum wires and screws  Fabricated acrylic plates (Gunning Splints)  In fractures of both the mandible and maxilla, circumzygomatic and circum-mandibular wires should be tied together to prevent telescoping of maxilla
  93. 93. OPEN REDUCTION AND OSTEOSYNTHESIS  Simpler than rigid fixation  MMF still required  Useful in angle, parasymphyseal fractures
  94. 94. ORIF  Performed with compression plates and lag screws  MMF generally not required  Eccentrically placed holes and screws placed at angles “compress” the bone
  96. 96. When double fractures occur, they are usually on contralateral sides of the symphysis. Common combinations include the angle plus the contralateral body or condyle. Triple fractures occasionally occur, - most common type is fracture of both condyles plus the symphysis.
  97. 97.  The mandible may also be dislocated without fracture, sometimes spontaneously during a large yawn.  patient usually presents with considerable pain.  Spasm in the masseter and pterygoid muscles tend to force the condyles up the anterior slope of the articular eminence and prevent normal mouth closure.
  98. 98. AO/ASIFAO/ASIF  “Arbeitsgemeinschaft fur Osteosynthesefragen”  The Association for the Study of Internal Fixation  Davos, Switzerland  Foundation providing clinical and scientific research relevant to trauma care for injuries of the musculoskeletal system  Purpose: Rigid internal fixation with resultant primary bone healing, even under conditions of full functional loading
  99. 99. INTERNAL RIGID FIXATION Advantages Early active pain-free functional movement Avoidance of intermaxillary fixation Safe, secured airway without tracheotomy Earlier return to work
  100. 100. INTERNAL RIGID FIXATION Interfragmentary compression Increased friction between fragments Increased surface area of direct contact Primary bone healing No evidence of pressure necrosis Loose hardware acts only as foreign body
  101. 101. CHAMPY’S IDEAL LINES OF OSTEOSYNTHESIS  Masticatory muscles produce tension at upper border and compression at lower border  Torsional forces produced anterior to the canines
  102. 102. CHAMPYCHAMPY  Monocortical “tension banding” osteosynthesis neutralizes distraction and torsion during physiologic stress, while normal basilar compression is restored
  103. 103. DYNAMIC COMPRESSION Compression resulting in preload and friction  Preload prevents distraction  Friction resists torsional forces  Closure results only underneath plate  Gap on opposite side  Allows for primary healing  Contraindicated in comminution
  104. 104. REDUCTION – GENERAL REMARKS  Restoration of occlusion with IMF  Selection of access  Fracture type and location  General anesthesia  Nasal vs. tracheotomy  Tension bands  Bicortical screws  Monocortical to avoid tooth roots and mandibular nerve  Compression and reconstruction plates  Inferior margin  Bicortical screws
  106. 106. SYMPHYSIS AND PARASYMPHYSEAL  Transverse fracture without dislocation
  108. 108. SYMPHYSIS AND PARASYMPHYSEAL  Transverse fracture with dislocation
  109. 109. SYMPHYSIS AND PARASYMPHYSEAL  Basal triangle or comminuted
  110. 110. BODY •Without dislocation •With dislocation
  111. 111. BODY
  112. 112. BODY  Comminuted
  113. 113. ANGLE  Without dislocation
  114. 114. ANGLE
  115. 115. ANGLE  With/without dislocation
  116. 116. ANGLE  Comminuted
  117. 117. ASCENDING RAMUS  Comminuted
  119. 119. CONDYLE PROCESS  Classified according to Kohler (1951)  Condylar fracture line runs inside capsule of TMJ Not fixed with plates or screws  Subcondylar situated below the capsule Classified into high and low  Condylar base fractures are at level of the sigmoid notch (incisura semilunaris)
  122. 122. RAPID IMF  Advantages:  Easy insertion, OR time ≈ 10 minutes  Removal without anesthesia  Minimal danger to surgeon  Decreased damage to dental papillae and oral mucosa  Easier to maintain dental hygiene  Compatible with all rigid plating systems
  123. 123. RAPID IMF  Disadvantages  Dental root injury  Loss of tension band directional traction
  124. 124. RAPID IMF  Roccia, Fasolis et al.  An Audit of Mandibular Fractures Treated by IMF Using Intraoral Cortical Bone Screws  Journal of Crani-maxillofacial Surgery  Turin, Italy 2005
  125. 125. RAPID IMF  ORIF 44 patients  CR 18 patients  Occlusion 2-3 weeks  Screws removed under local only  Minimum 6 month f/u Oral mucosa covering screw 5% Lost screws 2% Dental root injury 11% Infection 1% Malocclusion < 1%
  126. 126. RAPID IMF CONCLUSIONS • Recommended: – Single or double fractures with minimal displacement – Compound condylar fractures – Edentulous patients if proper dentures available • Contraindicated: – Multiple comminuted fractures – Alveolar bone fractures – Pediatric patients with unerupted teeth – Severe osteoporosis
  127. 127. POSTOPERATIVE ANTIBIOTICS  Abubaker et al.  Medical College of Virginia  J Oral Maxillofac Surg. 2001  Prospective, randomized, double-blind, placebo-controlled study  30 patients, 2 arms, 6 week post-op f/u ** No significant statistical difference between groups
  128. 128. ORIF VS. MMF TMJ FUNCTION ANALYSIS  Gorgu, Erdogan et al.  Scand J Plast Reconstr Surg Hand Surg 2002  Ankara, Turkey  Prospective Comparative Study of the Range of Movement of TMJ After Mandibular Fractures: Rigid or Non-rigid Fixation
  129. 129. GORGU, ERDOGAN ET AL.  Prospective, randomized, controlled study  147 patients in 3 groups (1993-1998)  MMF= 54  4 weeks immobilization  Titanium miniplate ORIF= 49  No movement restriction  Control= 44  Randomly selected with no hx of mandible injury  Mean follow-up 2.2 yrs (1-3)  Exclusion criteria  Condylar frx, multiple frx, comminution or significant displacement, malocclusion, edentulous
  130. 130. GORGU, ERDOGAN ET AL. MMF * (n=54) ORIF ** (n=49) Controls (n=44) Max jaw opening (mm) 30.9 (6.0) 45.1 (5.9) 50 (5.4) Max displacement to left (mm) 8.0 (2.9) 9.9 (2.4) 11 (2.5) Max displacement to right (mm) 6.8 (3.3) 9.6 (2.3) 10 (2.6) Protrusion (mm) 3.4 (1.5) 9.3 (0.8) 10 (1.0) * p < 0.001 compared with control ** p < 0.001 compared with control and MMF group
  131. 131. GORGU, ERDOGAN ET AL.  Trauma is major factor leading to TMJ dysfunction  MMF increased the incidence and severity of TMJ dysfunction MMF * (n=54) ORIF ** (n=49) Controls (n=44) Click 38 (70%) 20 (41%) 11 (25%) Crepitus 36 (67%) 11 (22%) 5 (11%) * p < 0.003 compared with control ** p < 0.005 compared with control and MMF group
  132. 132. ORIF VS. MMF COMPLICATION ANALYSIS  Moreno et al.  J Oral Maxillofac Surg 2000  Madrid, Spain  Complication Rates Associated with Different Treatments for Mandibular Fractures
  133. 133. MORENO ET AL. Retrospective study  245 patients with 386 fractures (1993-1996)  Isolated condylar process fractures excluded  Treatment methods:  MMF (n=136)  Exclusive, 40 days occlusion  2-mm miniplates (n=45)  Post-op MMF 0 – 15 days  AO 2.4 mm system (n=19)  Immediate mobility  AO 2.7 mm system (n=32)  Immediate mobility  Severity scale, multiple variables analyzed
  134. 134. MORENO ET AL  Rate of postoperative infection for each type of treatment, separated by severity of fractures 0 25 50 75 100 MMF 2 mm AO 2.4 AO 2.7 1 2 3 4 Severity *p < 0.001 between infection rate and fracture severity only
  135. 135. MORENO ET AL  Rate of postoperative malocclusion for each type of treatment, separated by severity of fractures 0 25 50 75 100 MMF 2 mm AO 2.4 AO 2.7 1 2 3 4 *p < 0.05 between malocclusion rate and fracture severity only Severity
  136. 136. MORENO ET AL  Overall complication rate for each type of treatment, separated under severity of the fractures 0 25 50 75 100 MMF 2 mm AO 2.4 AO 2.7 1 2 3 4 *p < 0.001 between overall rate and fracture severity only Severity
  137. 137. ORIF POST-OP MMF VS. IMMEDIATE MOBILIZATION  B Kaplan, S Park et al.  Laryngoscope 2001  Univ of Virginia Medical Center  Immediate Mobilization Following Fixation of Mandible Fractures
  138. 138. PARK ET AL.  Prospective, randomized, single-blinded study  ORIF 2.0 mm titanium plates  Inclusion: displaced fractures between angles only  29 patients in 2 groups (1997 – 2000)  Immediate function (n=16)  2 weeks post-op MMF (n=13)  Follow-up intervals: 3 wks, 3 mos, 6 mos  Variables assessed by surgeon blinded to the history of immobilization  Pain, non-union, malunion, occlusion, trismus, infection, weight loss, dental hygiene
  139. 139. PARK ET AL.  No statistical difference between measured variables  The assumed beneficial effects from transient TMJ rest and no fracture stresses was not realized Wt loss in pounds Objective trismus in cm
  140. 140. ORIF VS. MMF COST ANALYSIS  B Schmidt, L Kaban et al.  J Oral Maxillofac Surg 2000  University of California San Francisco  A Financial Analysis of MMF vs. Rigid Internal Fixation for Treatment of Mandibular Fractures
  141. 141. KABAN ET AL.  Retrospective study  85 patients in two groups  CRF (n=38)  ORIF (n=47) (external and transoral approaches)  Outcome variables:  Length of hospital stay  Duration of anesthesia  Surgery time  Patient fee for primary treatment without complications  Estimated average patient fee to manage a major post-op infection
  142. 142. KABAN ET AL. CRF ORIF Preop hospital days 1.79 1.98 Postop hospital days 1.95 2.56 *Anesthesia time (min) 141 309 *Surgical time (min) 106 267 *p < 0.0001
  143. 143. KABAN ET AL.  Did not evaluate savings from earlier return to work in ORIF patients Charge for primary treatment Charge for complication* Total charg e CRF $10,099 ± 5,489 $26,671 ± 2,310 $10,9 26 ORIF $28,361 ± 14,731 $39,212 ± 38,694 $34,6 35 P- value < 0.001 < 0.0652 < 0.001 * Incidence of post-op infx was 16% (ORIF) and 3%(MMF)
  144. 144. CLOSED TECHNIQUES  Nondisplaced favorable fractures  Grossly comminuted fractures  Edentulous fractures (using a mandibular prosthesis)  Fractures in children with developing dentition  Coronoid and condylar fractures
  145. 145. INDICATIONS FOR OPEN REDUCTION  Displaced unfavorable angle, body, or parasymphyseal fractures  Multiple facial fractures  Bilateral displaced condylar fractures  Fractures of an edentulous mandible (with severe displacement of fracture fragments in an effort to reestablish mandible continuity)
  146. 146. Grafted right mandibular body nonunion with cancellous iliac crest bone graft, packed into polyglactin mesh tube.
  147. 147. Grafted left mandibular body nonunion with cancellous iliac crest bone graft packed into polyglactin mesh tube.
  148. 148. CONCLUSIONS  AO does not mean “always operate” or “always open”  AO standards provide sound techniques resulting in a consistently high success rate in most hands  Occlusion must be 100% prior to rigid internal fixation  Main indications for RIF include:  Compound fractures with defects  Edentulous mandibles or those with few teeth  Fracture dislocation ± condylar neck fracture  Panfacial trauma  Electively
  149. 149. WISE SAYINGS ABOUT MANDIBULAR FRACTURES  Remember the ring bone rule.  Symphyseal fractures can be diabolically hard to see, even on a well- exposed AP film  Remember the Panorex view -- this can usually only be taken by a special machine in the oral surgery department, but it provides the best single view of the mandible and will show you fractures that cannot be seen by any other method short of CT.  Look carefully along the cortical margin of the whole mandible for discontinuities. This may be the only sign of a fracture that you will see.
  150. 150. WISE SAYINGS ABOUT MANDIBULAR FRACTURES  Also carefully examine the mandibular canal for discontinuities.  A fracture line entering the root of a tooth is considered an open fracture by definition.  Pathologic fractures can occur in the mandible. Look carefully for evidence of a periapical abscess or a mandibular tumor, especially if there doesn't seem to be enough trauma to match the injury.
  151. 151. OBJECTIVES  Anatomy  Fracture distraction  Principles of rigid internal fixation  AO method  Rapid IMF  ORIF vs. MMF