management of mandibular fractures
TRANSCRIPT
Management of Mandibular Fracture
DR. TSHEWANG GYELTSHEN_ 49DDCH_2017
What is a Fracture?
Fracture is defined as a break in structural and natural continuity of bone
Mandibular Fracture:- Is that when fracture is involved in the mandible.
Etiology Vehicular Accidents involving (RTA) – 43 % Interpersonal violence, Assaults – 34% Falls – 7% Contact sports 4 % Industrial /work related – 10% Pathological Fracture – unconfirmed Studies have shown that the incidence of mandible fractures are
influenced by various etiological factors e.g. Geography Social trends Road traffic legislations Seasons
4Diagnosis of mandibular fractures
History Clinical examinationRadiological examination
Clinical examinationMouth openingOcclusion Lacerations Coleman’s signStep deformity (shoulder defect)
Inspection
Tenderness CrepitationMobility of the teethForeign bodies
Palpation
Radiographic examination Plain radiograph
OPG Lateral oblique PA mandible Lower occlusal
CT scan 3-D CT MRI
6
Emergencies Involving Mandibular Fracture
With rare exception, mandible fractures are not surgical emergencies.
Emergencies involving Mandibular fracture happens with unfavorable fractures involving bilateral Para-symphysis fracture pulling the anterior part backward and compromising the airway.
Paralysis of tongue and consequently airway compromisation
Types of Mandibular Fracture Simple - Includes a closed linear fractures Compound or open Comminuted Greenstick Pathologic Multiple Impacted Atrophic Complicated or complex
9Classification by anatomic region
Dingman and Natvig Condylar process Coronoid Ramus Angle Body Symphysis Parasymphysis Alveolar process
Treatment Protocol ATLS protocol
Primary Survey – A-- Airway Maintenance and Cervical Spine Protection B– Maintenance of Breathing and Ventilation C– Circulation and Hemorrhage Control D– Disability/Neurological Examination – AVPU E– Exposure under proper environment
Secondary Survey – head-to-toe evaluation, including a complete history and physical examination and reassessment of all vital signs.
Tertiary Survey -- In Hospital Care
Definitive In-Hospital Treatment Reduction
Restoration of a functional alignment of the bone fragments Use of occlusion1. Open reduction2. Closed reduction
Fixation Immobilization
To allow bone healing Through fixation of fracture line1. Rigid2. Non-rigid
12Closed reductionIndications a) Nondisplaced favorable fracturesb) Grossly comminuted fracturesc) Significant loss of overlying soft tissued) Edentulous mandibular fracturese) Mandibular fractures in childrenf) Coronoid process fracturesg) Condylar fractures
13Open reduction Displaced unfavourable fractures Multiple fractures of the
facial bones Midface fractures and displaced bilateral condylar fracture Fractures of an edentulous mandible with severe
displacement of fracture segment Edentulous maxilla opposing a mandibular fracture Delay of treatment and interposition of soft tissue between
noncontacting displaced fractures fragments Malunion Conditions contraindicating Intermaxillary fixation
Removal of a tooth from the fracture line
ABSOLUTE INDICATION RELATIVE INDICATION Vertical fracture Dislocation or
subluxation Periapical infection Infected fracture line Acute pericoronitis
Functionless Advanced caries Advanced periodontal
disease Doubtful teeth Teeth involved in untreated
fractures presenting more than 3 days after injury
Methods of immobilization Intermaxillary fixation with Osteosynthesis Intermaxillary fixation:-
Bonded Brackets Dental Wiring :-
a). Direct wiring b). Eyelet wiring
Arch Bars Cap Splints IMF Screws
Osteosynthesis without Intermaxillary fixation
16Methods of immobilization
INTERMAXILLARY FIXATION WITH OSTEOSYNTHESIS
Trans-osseous wiring Circumferential wiring External pin fixation Bone clamps Transfixation with Kirschner wire
17Methods of immobilization
INTERMAXILLARY FIXATION WITHOUT OSTEOSYNTHESIS Compression plates Miniplates Lag screws
18Period of immobilizationYoung adult withFracture of the angle receivingEarly treatment in which Tooth removed from fracture line
ifa) Tooth retained in fracture line : add 1wkb) Fracture at the Symphysis: add 1 wkc) Age 40yrs and over : add 1or 2 wksd) Children and adolescents : subtract 1 wk
3 weeks
19Various dental wiring techniques
ESig's wiring- (single –double wiring) (Charles J. Essig ) Gilmer’s wiring Risdon’s wiring – (Twisted labial wire) (E.Fulton Risdon)
Ivy eyelet wiring (Robert H.Ivy ) Clovehitch wiring Col . Stout’s multiloop wiring (R.A.Stout) Button wiring (Varaztad Hovhannes Kazanjian )
Management of Coronoid Process and Ramus Fracture
Most ramus fractures can be treated with MMF x 6 weeks Challenges– Difficult intra-oral plating External approach for plating is similar to that of angle fractures Coronoid Fracture is uncommon and if it occurs it is usually associated
with a ZMC fracture
Management of Condylar Fracture Most condyle fractures can be treated with MMF x 2-4
weeks If the head is involved, MMF is limited to 2 weeks to
prevent TMJ ankyloses Frequent scenario is a condyle fracture with contralateral
parasymphyseal, body, or angle fracture—treat contralateral fracture with ORIF and condyle fracture with MMF x 2-4 weeks
When plating is required, an external approach is preferred External approach is similar to the angle approach but with
the superior end of the incision brought to about 2 cm from the earlobe.
Mx. Of Condylar Fracture: literature Review
Controversial Treatment Options between closed or open reduction Treatment aim – to recover normal TMJ function Treatment choice depends on fracture level, amount of
displacement, adequacy of the occlusion and age.
Advantagesearly mobilization of the mandible, better occlusal results, better function, maintenance of posterior ramal height, avoidance of facial asymmetries
Disadvantages
Risk of damage to facial nerve branchChance of Cutaneous Scar
Open Reduction
Closed Reduction includes MMF with Elastics Degree of displacement of the condylar fracture has been used in deciding between
open or closed treatment Mikkonen et al. recommended open reduction if the condylar displacement was
greater than 45 degrees in a sagittal or coronal plane Widmark et al. recommended opening such fractures if the displacement was
greater than 30 degrees. Zide and Kent described the absolute and relative indications for open reduction of
condyle fractures
1. displacement of the condylar head into the middle cranial fossa;
2. Impossibility of obtaining adequate occlusion by closed reduction; 3. lateral extracapsular displacement of the
condyle; and 44. Invasion by a foreign body (e.g. gunshot wound.
1. bilateral condyle fractures in an edentulous patient;
2. unilateral or bilateral condyle fractures when splinting is not recommended for medical reasons;
3. . bilateral condyle fractures associated with comminuted midface fractures; and
4. bilateral condyle fractures and associated anthological problems (e.g. lack of posterior occlusal support)
Absolute Indications Relative Indications
Management of Mandibular Angle Fracture
One of the most common fracture sites. Non-displaced fractures can be treated with MMF x 6 weeks
Reasons cited: Presence of impacted third molarsThinner cross-sectional area in the angle region. Biomechanical lever arm.
Although maintenance of the absolute rigidity on treatment of angle fractures has been major principle, In 1973, Michelet et al, described the use of small, malleable bone plates for treatment of angle fractures.
This led to a change from the previous belief that rigid fixation was necessary for bone healing. Later, Champy et al. validated the technique by performing several clinical investigations.
They determined the most stable location where bone plates should be placed based on the ‘‘Champy’s ideal lines of osteosynthesis’’
Disadvantage:- Unable to achieve absolute immobilization
A prospective study performed by Amrish Bhagol et al looked at eight methods for treating mandibular angle fractures: 1. closed reduction 2. extraoral ORIF with a large reconstruction plate 3. intraoral ORIF using a single lag screw 4. intraoral ORIF using two 2.0-mm minidynamic compression plates 5. intraoral ORIF using two 2.4-mm mandibular compression plate 6. intraoral ORIF using two noncompression miniplates 7. intraoral ORIF using a single noncompression miniplate; and 8. intraoral ORIF using a single malleable noncompression miniplate
In the study, they found out that, extraoral ORIF with a reconstruction plate and intraoral ORIF using a single miniplate had least complications (7.5% and 2.5%, respectively).
Thus they concluded that these two methods were best for angular fracture management.
Management of Fracture of the Body of Mandible
Simple fractures involving the body of the mandible can be effectively treated with one miniplate along the Champy line of osteosynthesis.
Dissection should be done avoiding the damage to mental nerve which supplies the lower lips.
Champy popularized the treatment of mandible fractures with miniplate fixation along the ideal lines of osteosynthesis. This is a form of load-sharing osteosynthesis to be applied in simple fracture patterns having an acceptable amount of bone stock.
Intraoral approach best Arch bars placed and MMF wires secured prior to incision 5 cm incision made in the gingivobuccal sulcus over the fracture,
leaving a 1 cm cuff of tissue from the mucogingival junction for closure Dissection carried to bone Mental nerves identified and preserved Fracture line debrided, reduced, and MMF tightened Four hole tension band secured between the tooth roots and mental
foramen with monocortical screws Larger 2.3 to 2.7 mm system titanium plate is secured anteriorly
through the intraoral incision with 2-3 screws. MMF wires cut and occlusion checked; if satisfactory, incision is closed.
Management of the Fracture of the Parasymphysis and Symphysis Parasymphyseal fractures:- Fracture lines in the canine region.
Symphysis fracture:- Any fracture line between the canine to canine.
Several authors have shown that miniplate fixation in symphysis and parasymphysis is very effective way to fix this fractures.
The most common approach – transoral gingivolabial and gingivobuccal incision.
Larger comminuted fractures, an external approach may be necessary to accurately and rigidly fixate the mandible.
Simple symphysis fractures can be treated with two miniplates fixation.
Single Miniplates not given – displaces on torsional forces during functions
One miniplate is placed at the inferior border and a second plate is placed superiorly. Several authors have shown that miniplate fixation along these lines is a very effective
way to fixate these fractures. More rigid fixation should be considered for comminuted fractures Lag Screw :- used in reduction of the lingual border of the fracture and re-establish the
appropriate intergonial distance by squeezing the mandibular angles together. For optimal strength, two lag screws are placed.
Baby John et al described a case of 4.5 years old boy having been treated with acrylic aplints.
Under sedation, upper and lower arch alginate impressions were taken and stone casts were poured. An open occlusal acrylic splint was fabricated and under GA, the mandibular fracture was immobilized and fixed with acrylic splint and then retained by circummandibular wiring. Patient was reviewed weekly and on the third postoperative week was removed with LA. Patient achieved perfect occlusion and good masticatory efficiency.
Treatment principles of mandibular fractures in children differ from that of adults due to concerns regarding mandibular growth and development of dentition
Geriatric Patient with Mandible Fracture
Fractures of the edentulous mandible most commonly involve the body region
Can be treated by either open or closed reduction methods.
Closed reduction with the use of prosthetics (existing dentures or Gunning splints)
The current accepted concept in geriatric mandible fracture is to go for open reduction and internal fixation
Coleman’s Sign" There is one sign which is almost pathognomonic of fracture of the body of the mandible, and that is an effusion of blood into the (tissues of the) floor of the mouth, raising its mucous membrane and producing a characteristic bluish, tense swelling under the tongue”. – Frank Coleman, 1912
Recent Developments in Mandibular Fracture Management
Use of 3D Navigation System in Mandibular Fracture Treatment as described by Matthias Feichtinger et al, 2001
Use of Digital Volume Tomography (DVT) in mandibular Fracture as described by CM Ziegler et al
The panoramic radiograph is poorly positioned due to patient’s multiple trauma. It shows fractures at the right mandibular angle and the left canine and premolar region 3D reconstruction confirm the fractures at the
right mandibular angle and demonstrates clearly the parasymphyseal fracture in the left canine region. This 3D image also shows a displaced fragment at the inferior cortex.
Axial DVT view
Recently endoscopic subcondylar fracture repair has been described with encouraging results.
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