Contemporary management of Mandibular Fractures contributions... · Classification of region of...

B E T H A N J O N E S

Management of MandibularFracture

Classification of fracture

Simple/Closed – does not produce wound to externalenvironment.

Compound/Open – external wound communicateswith the fracture.

Comminuted – bone is splintered/crushed Greenstick – one cortex of bone is fractures and the

other is bent. Pathologic – due to pre-existing bone disease Multiple – >2 fracture lines that do not communicate. Impacted – one fragment driven firmly into the other. Atrophic – due to severe atrophy e.g. edentulous. Indirect – distant from site of injury.

Classification of region of fracture

Symphysis – region of central incisors through toinferior border of mandible.

Parasymphyseal – vertical and distal to the canines. Body – from distal symphysis alveolar border of

masseter muscle. Angle – Triangular region bounded by masseter

muscle. Ramus – superior to the angle with apex at sigmoid

notch. Coronoid – fracture of coronoid process. Alveolar – region usually containing teeth. Condylar .

Incidence

Up to 70% of all maxillofacial fractures. Increased incidence in Males aged 21-30yrs 29% Body 26% Condylar 25% Angle 17% Symphysis 4% Ramus 1% Coronoid process

History & Examination

History of incident Lacerations/swelling/haematoma Palpation - step deformity/tenderness Paraesthesia/dysaesthesia/anaesthesia of IDN. TMJ examination - Condyle # ? Deviation/trismus Altered occlusion Sublingual hematoma

CASE C.D.

Hx – allegded assault – punch to R side of face. Lacerations – nil Swelling – R angle of mandible Haematoma – extraoral/sublingual – nil Palpation- No obvious step deformity, tender R angle

and L parasymphysis. Paraesthesia – nil TMJ – trismus – 2fingers Occlusion - altered

Investigation – PA Mandible

OPT

Management

Clerk patient for theatre – NBM Meds – IV antibiotics (co-amoxiclav) and strong

analgesics. Consent –

Procedure – ORIF +/- IMF +/- extractions Reason – to allow for function Risk – Pain, Swelling, Bleeding, Bruising, Infection , numbness

of lip/tongue, permanent/temporary.

Treatment

Conservative Treatment Fracture undisplaced.Analgesia, Antibiotics, Soft diet, OHI, follow up. Active TreatmentReduction open/closedFixation ImmobilisationRehabilitation

Closed reduction

Non-displaced favourable fractures Grossly comminuted fractures- reduce stripping of

periosteum Children in developing dentition Coronoid fractures unless impingement on zygoma Condylar fractures Indirect fixation - IMF.

IMF

Archbars –Prefabricated – requires adjustmentCustom made

Intraoral bone Screws – IMF screws(wire/elastic fixation)

High level of success – simple technique and reducedoperative time.

Schnieder et al 2000 – 100% accurate occlusion and adequatehealing post treatment.

Bissada et al 2011 – 97.25% Normal occlusion post treatment.

Complications – Root fracture/impingment Nerve injury Screw/wire loosening Screw lose Potential for infection

Open reduction with internal fixation.

Displaced unfavourable fractures Severely atrophic edentulous mandibles – ORIF with

rigid fixation +/- bone graft. Complex facial fractures Mandibular non-unions / malunions Condylar fractures.

Fixation

Direct Reconstruction plates Bone plates and screws

Load bearing osteosynthesis:

Locking reconstruction plate – bears 100% functional forceat fracture site.

Atrophic/edentulous/comminuted/defect fractures

Load sharing Osteosynthesis

Ideally bone assumes most functional loads Champy Miniplate fixation along lines of

ideal osteosynthesis.AKA functionallyadequate / semi rigid fixation

Works with principles ofbiomechanics ofmandible.

Favourable / Unfavourable

Effect of muscle pull on fracture fragments. Vertically/Horizontally Favourable/unfavourable Unfavourable – fragments more likely displaced Favourable – muscle pulls stabilises fracture.

Biomechanics of Mandible

Zones of tension and compression from functionalforces – location of bite force and insertion ofmuscles mastication.

Hunting bow – strongest at symphysis, weakest atcondyles.

Load sharing osteosynthesis:

Created by frictional resistance at bone ends – requiresadequate bony buttressing at fracture therefore cant be usedfor defect fractures.

Bone assumes most of functional force Lag technique – compression of fracture – screw must be

perpendicular to #, overdrill near cortex so that threadsengage only the far cortex = COMPRESSION

Not suitable for comminuted #

Compression plating : forces of masticationovercome by plate and bony buttressing.

Requires excellent bony buttressing Screws tightened down ramped hole- bringing

fracture segments together. Usually used in addition with miniplate to align

and stabilize fracture.

Extraction of teeth within the line of fracture

CONTROVERSIAL Neal et al 1978 – no statistical difference whether

teeth in line of fracture were extracted or retained. Amaratunga 1987 – concluded no significant

difference in between number of complications innon-infected teeth removed/ retained

Shetty and Freymiller 1989 – reviewed literature

Indications for extraction of teeth within fractureline

Tooth luxated from socket / interfering withreduction of fracture.

Tooth is fractured / mobile. Tooth pathology - decayed or has periodontal

disease, cyst, pericoronitis

Indications to leave tooth within fracture line

Tooth does not interfere with reduction/fixation. If removal compromises fracture site for fixation i.e

excess bone removal. Tooth in good condition and aids in establishing

occlusion. Conserve if possible

Post-op Radiographs

Post – op Radiographs

Post -op

Occlusion normal. Trismus, pain and swelling still present Instruction –

Soft ‘no-chew’ diet Avoid contact sports or heavy lifting ABX for 7days Analgesia

Rv 1 week – minimal swelling, trismus improving, nopain.

Further 2 week rv – discharge.

Summery

Examination and history Requires two radiographic veiws Antibiotics Adequate reduction to allow for function SOFT diet Review

REFERENCES

Mandibular Fractures -Donald R Laub Jr, MD, FACS Professor,Departments of Surgery and Pediatrics, University of Vermont College of Medicine;Interim Chief of Plastic and Reconstructive Surgery, Fletcher-Allen Health Care

http://www.scribd.com/doc/3670563/Management-of-Mandibular-Fracture Indications for open reduction of mandIbular condyle fractures, M Zide+ J Kent,

Journal of Oral and maxillofacial surgery, Vol 41, issue 2, 88-89 1983 Spiessl B, Schroll K. Gelenkfortsatz und gelenkkopfchenfracturen. In: Higst H,

editor. Spezielle frakture und luxationslehre. Stuttgart: Thieme; 1972 [BD. I/I]. Mandibular Reconstruction, Plating -Jesse E Smith, MD Consulting Staff,

Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head andNeck Surgery, John Peter Smith Hospital

Intermaxillary screw fixation in mandibular fracture repair. Bissada E,Abou-Chacra Z, Ahmarani C, Poirier J, Rahal AJ Otolaryngol Head Neck Surg.

http://www2.aofoundation.org http://emedicine.medscape.com/article

References

Neal DC, Wagner WF, Alpert B. Morbidity associatedwith teeth in the line of mandibular fractures. J OralSurg. Nov 1978;36(11):859-62

e Amaratunga NA. The effect of teeth in the line ofmandibular fractures on healing. J Oral MaxillofacSurg. Apr 1987;45(4):312-4.

Shetty V, Freymiller E. Teeth in the line of fracture: areview. J Oral Maxillofac Surg. Dec1989;47(12):1303-6

Mandibular Fractures laub et al –medscape.com