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11
Maxillofacial TraumaMaxillofacial Trauma
Mandibular FracturesMandibular Fractures
Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages
with two nutrient arteries
22
Mandible in traumaMandible in traumaMandibular fracture is more common than middle Mandibular fracture is more common than middle third fracture third fracture (anatomical factor)(anatomical factor)
It could be observed either alone or in combination It could be observed either alone or in combination with other facial fractureswith other facial fractures
Minor mandibular fracture may be associated with Minor mandibular fracture may be associated with head injury owing to the cranio-mandibular head injury owing to the cranio-mandibular articulationarticulation
Mandibular fracture may compromise the patency of Mandibular fracture may compromise the patency of the airway in particular with loss of consciousnessthe airway in particular with loss of consciousness
Fracture of mandible occurred with frontal impact Fracture of mandible occurred with frontal impact force as low as 425 lb (190 Kg) force as low as 425 lb (190 Kg) {Condylar fracture}{Condylar fracture}
33
Fracture of condyle regarded as a safety mechanism Fracture of condyle regarded as a safety mechanism to the patientto the patient
Frontal force of 800-900 lb (350-400 Kg) is required Frontal force of 800-900 lb (350-400 Kg) is required to cause symphesial fractureto cause symphesial fracture
Mandible was more sensitive to lateral impact than Mandible was more sensitive to lateral impact than frontal onefrontal one
Frontal impact is substantially cushioned by Frontal impact is substantially cushioned by opening and retrusion of the jawopening and retrusion of the jaw
(Nahum 1975(Nahum 1975))
Long canine tooth and partially erupted wisdoms Long canine tooth and partially erupted wisdoms represent line of relatively weaknessrepresent line of relatively weakness
44
Anatomical considerationsAnatomical considerations
Attached muscles:Attached muscles:MasseterMasseterTemporalisTemporalisMedial and lateral Medial and lateral pterygoidpterygoidMylohyoidMylohyoidGeniohyoid and Geniohyoid and genioglosusgenioglosusanterior belly of anterior belly of digastricsdigastrics
55
Blood supplyBlood supplyEndosteal supply via the ID artery and veinEndosteal supply via the ID artery and veinPeriosteal supply, important in aging due to Periosteal supply, important in aging due to diminishes and disappearance of alveolar diminishes and disappearance of alveolar arteryartery
Bradley 1972Bradley 1972
Nerve Nerve Damage of inferior dental nerveDamage of inferior dental nerveFacial palsy by direct trauma to ramusFacial palsy by direct trauma to ramusDamage of facial nerve in temporal bone Damage of facial nerve in temporal bone fracturefracture
Goin 1980Goin 1980
Damage to mandibular division of facial Damage to mandibular division of facial nervenerve
66
Factors influenced site of fracture Factors influenced site of fracture and displacementand displacement
Anatomy of the Anatomy of the mandible and attached mandible and attached muscle (canine & muscle (canine & wisdoms)wisdoms)
Weakening areas of Weakening areas of mandible (resorption mandible (resorption and pathologyl)and pathologyl)
Direction of force of the Direction of force of the blowblow
Age of the patientAge of the patient
77
Types of fractureTypes of fractureSimpleSimple
Greenstick fracture (rare, exclusively in children)Greenstick fracture (rare, exclusively in children)Fracture with no displacement (Linear)Fracture with no displacement (Linear)Fracture with minimal displacementFracture with minimal displacement
Displaced fractureDisplaced fracture
Comminuted fractureComminuted fractureExtensive breakage with possible bone and soft tissue Extensive breakage with possible bone and soft tissue
lossloss
Compound fractureCompound fractureSevere and tooth bearing area fracturesSevere and tooth bearing area fractures
Pathological fracturePathological fracture(osteomyelities, neoplasm and generalized skeletal (osteomyelities, neoplasm and generalized skeletal
disease)disease)
88
Sites of fracturesSites of fracturesCondyle fractureCondyle fracture– Intracapsular fractureIntracapsular fracture– Extracapsular fractureExtracapsular fracture
High condyle neck fractureHigh condyle neck fracture
Low condylar fractureLow condylar fracture
Angle/ ramus fractureAngle/ ramus fracture (body (body fracture)fracture)
Canine regionCanine region (parasymphesial (parasymphesial fracture)fracture)
Midline fractureMidline fracture (symphesis (symphesis fracture)fracture)
Coronoid fractureCoronoid fracture (rare) (rare)
99
Incidence of mandibular fracturesIncidence of mandibular fracturesBody fractures 33.6%Body fractures 33.6%
Subcondylar fracture 33.4%Subcondylar fracture 33.4%
Fractures at the angle 17.4%Fractures at the angle 17.4%
Alveolar fractures 6.7%Alveolar fractures 6.7%
Ramus fractures 5.4%Ramus fractures 5.4%
Midline fractures 2.9%Midline fractures 2.9%
Fracture of coronoid process 1.3%Fracture of coronoid process 1.3%Oikarinen & Malmstrom 1969Oikarinen & Malmstrom 1969
1010
Favourable or Favourable or unfavourableunfavourableThey can be vertically or horizontally in They can be vertically or horizontally in directiondirection
They are influenced by the medial pterygoid-They are influenced by the medial pterygoid-masseter “sling”masseter “sling”
If the vertical direction of the fracture favours the If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled linguallyposterior fragment will be pulled linguallyIf the horizontal direction of the fracture favours the If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled upward direction, the posterior fragment will be pulled linguallylingually
Favourable fracture line makes the reduced Favourable fracture line makes the reduced fragment easier to stabilizefragment easier to stabilize
1111
Effects of muscles on displacementEffects of muscles on displacement
Transverse midline fracture (symphesial) Transverse midline fracture (symphesial) stabilizes by the action of mylohyoid and stabilizes by the action of mylohyoid and geniohyoidgeniohyoid
Oblique fracture (parasymphesial) tends to Oblique fracture (parasymphesial) tends to overlap under the influence of muscles actionoverlap under the influence of muscles action
Bilateral parasymphesial fracture results in Bilateral parasymphesial fracture results in backward displacement associated with loss of backward displacement associated with loss of tongue control when the level of consciousness tongue control when the level of consciousness is depressedis depressed
1212
Condylar fracturesCondylar fracturesThe most common mandibular fracture The most common mandibular fracture
Unilateral or bilateralUnilateral or bilateral
Intracapsular or extracapsularIntracapsular or extracapsular
Antero-medial displacement is Antero-medial displacement is common but it may remain common but it may remain
angulated with the ramusangulated with the ramus
Dislocation of the glenoid fossa and Dislocation of the glenoid fossa and fracture of petrous temporal bone fracture of petrous temporal bone which is very rarewhich is very rare
1313
Sign and symptomsSign and symptoms
Swelling, pain, tenderness and restriction of movementSwelling, pain, tenderness and restriction of movement
Deviation of mandible towards the side of fractureDeviation of mandible towards the side of fracture
Gagging of occlussion (premature contact on the posterior Gagging of occlussion (premature contact on the posterior teeth) with bilateral condylar displaced or over-riding fracturesteeth) with bilateral condylar displaced or over-riding fractures
Displacement of mandible toward the affected sideDisplacement of mandible toward the affected side
Anterior open bite on opposite side of fractureAnterior open bite on opposite side of fracture
Laceration of EAM****Laceration of EAM****
Retroauricular ecchymosis****Retroauricular ecchymosis****
Cerebrospinal leak and otorrhea in association with skull base Cerebrospinal leak and otorrhea in association with skull base fracturefracture
Condylar fracturesCondylar fractures
1414
Sequlae of TMJ injurySequlae of TMJ injury
Artheritic changesArtheritic changes
Haemartherosis, fibrosis and aknylosisHaemartherosis, fibrosis and aknylosis
Meniscal damage and detachmentMeniscal damage and detachment
TMDTMD
Staph infectionStaph infection with condylar backward with condylar backward displacement and external auditory meatus injurydisplacement and external auditory meatus injury
MeningitisMeningitis with petrous temporal bone fracture and with petrous temporal bone fracture and intracranial involvementintracranial involvement
Condylar fracturesCondylar fractures
1515
Coronoid process fracture:Coronoid process fracture:
Rare fracture caused by direct trauma to Rare fracture caused by direct trauma to ramus and results from reflux contraction of ramus and results from reflux contraction of temporalistemporalis
Can be seen following operation of large Can be seen following operation of large ramus cystramus cyst
Elicit tenderness over the anterior part of Elicit tenderness over the anterior part of ramusramus
Development of tell-tale haematomaDevelopment of tell-tale haematoma
1616
Fracture of the ramus:Fracture of the ramus:Type I Single fractureType I Single fracture
Mimics low condylar fracture that runs Mimics low condylar fracture that runs below the sigmoid notchbelow the sigmoid notch
Type II comminuted fractureType II comminuted fracture
Common in missile injuries and appears to Common in missile injuries and appears to be with little displacement due to effects of be with little displacement due to effects of messeter and medial pterygoid musclesmesseter and medial pterygoid muscles
1717
Fracture of the angle and bodyFracture of the angle and bodyPain, tenderness and trismusPain, tenderness and trismus
Extra-oral swelling at the angle with obvious Extra-oral swelling at the angle with obvious deformitydeformity
Step deformity behind the molar teethStep deformity behind the molar teeth
Movement and crepitus at the fracture siteMovement and crepitus at the fracture site
Derangement of occlussionDerangement of occlussion
Intra-oral buccal and lingula heamatomaIntra-oral buccal and lingula heamatoma
Involvement of IDNInvolvement of IDN
Gingival tear if fracture in dentated areaGingival tear if fracture in dentated area
Tooth involvement and possible longitudinal Tooth involvement and possible longitudinal split fracturesplit fracture
1818
Midline fractureMidline fractureThe most common missed fracture (always The most common missed fracture (always fine crack)fine crack)
Can be symphesial or parasymphesial Can be symphesial or parasymphesial fracturefracture
Commonly associated with one or both Commonly associated with one or both condyles fracturecondyles fracture
Unilateral fracture leads to over-riding of Unilateral fracture leads to over-riding of the fragments and bilateral may contribute the fragments and bilateral may contribute in loss of voluntery tongue controlin loss of voluntery tongue control
Long canine tooth represent a weak area Long canine tooth represent a weak area and contributes to parasymphesial fracture and contributes to parasymphesial fracture
Rarely runs across mental foramenRarely runs across mental foramen
1919
Signs and symptomsSigns and symptoms
Pain and tendernessPain and tendernessSwelling and odemeaSwelling and odemeaDevelopment of step deformityDevelopment of step deformityMental anesthesiaMental anesthesiaHeamatoma in the floor of mouth and buccal mucosa Heamatoma in the floor of mouth and buccal mucosa Soft tissue injury of the chin and lower lipSoft tissue injury of the chin and lower lip
If associated with condylar fracturesIf associated with condylar fractures
Absence of condyle movement on the contrlateral sideAbsence of condyle movement on the contrlateral sideDeviation of mandibleDeviation of mandibleAnterior open biteAnterior open biteGagging of oclussionGagging of oclussionLimitation of mouth openingLimitation of mouth opening
Midline fracture
2020
Clinical assessment and diagnosis Clinical assessment and diagnosis
History of traumaHistory of trauma (traumatized patients with possible head injury) and facial (traumatized patients with possible head injury) and facial
injuriesinjuries
Clinical ExaminationClinical Examination▶▶ ExtroralExtroral
Inspection (assessment of asymmetery, swelling, ecchymosis, laceration Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut wounds)and cut wounds)
Palpation for eliction of tenderness, pain, step deformity and malfunctionPalpation for eliction of tenderness, pain, step deformity and malfunction
▶▶ Intra- and paraoralIntra- and paraoral bleeding, heamatoma, gingival tear, gagging of occlussion bleeding, heamatoma, gingival tear, gagging of occlussion
and step deformity and sensory and motor deficiencyand step deformity and sensory and motor deficiency
RadiographsRadiographs
2121
Radiographs Radiographs
Plain radiographPlain radiographOPGOPG
Lateral obliqueLateral oblique
PA mandiblePA mandible
AP mandible (reverse AP mandible (reverse Townes)Townes)
Lower occlusalLower occlusal
CT scanCT scan
3-D CT imaging3-D CT imaging
MRIMRI
2222
Principles of treatmentPrinciples of treatmentsimilar to elsewhere fractures in the bodysimilar to elsewhere fractures in the body
Reduction of fragments in good positionReduction of fragments in good position
Immobilization until bony union occursImmobilization until bony union occurs
These are achieved by:These are achieved by:Close reduction and immobilizationClose reduction and immobilizationOpen reduction and rigid fixationOpen reduction and rigid fixation
Other objective of mandible fracture treatment:Other objective of mandible fracture treatment:Control of bleedingControl of bleeding
Control of infectionControl of infection
2323
Definitive treatment Definitive treatment Soft tissue repairSoft tissue repair
DebridmentDebridmentIrrigation with saline and antibioticsIrrigation with saline and antibioticsClosure in layersClosure in layersDressing Dressing
Reduction and fixation of the jawReduction and fixation of the jaw▶▶ Close reduction and IMF (traditional method by means of Close reduction and IMF (traditional method by means of
manipulation)manipulation)▶▶ Open reduction and semi-rigid fixation (using inter-ossous Open reduction and semi-rigid fixation (using inter-ossous
wirings)wirings)▶▶ Open reduction and rigid fixation (using bone palates Open reduction and rigid fixation (using bone palates
osteosynthesis)osteosynthesis)
Objective:Objective: Restoration of functional alignment of the bone fragments in Restoration of functional alignment of the bone fragments in
anatomically precise position utilizing the present teeth for anatomically precise position utilizing the present teeth for guidanceguidance
2424
Close reductionClose reduction
Arch barsArch bars– JelenkoJelenko
– Erich patternErich pattern
– German silver notchedGerman silver notched
Cap splintsCap splints
▶▶ IMF prior to rigid fixationIMF prior to rigid fixation
▶▶ For the purpose of close For the purpose of close reductionreduction
2525
Close reductionClose reduction
Bonded bracketsBonded brackets
IMF screwsIMF screws
Dental wiring:Dental wiring:Direct wiringDirect wiring
Eyelet wiringEyelet wiring
Local anesthesia orLocal anesthesia or sedationsedation
Minimal displacementMinimal displacement
IMF for 6 weeksIMF for 6 weeks Treatment can be performed Treatment can be performed
under GA or LA and when under GA or LA and when surgery is contraindicatedsurgery is contraindicated
2626
Fracture mandible in childrenFracture mandible in children
Close reductionClose reduction
Open reduction and Open reduction and fixationfixation
Plating at the inferior Plating at the inferior borderborder
Resorpable platesResorpable plates
2727
Gunning’s splintGunning’s splint
Old modalityOld modality
Edentulous patientEdentulous patient
Rigid fixation is not Rigid fixation is not possiblepossible
To establish the To establish the occlusionocclusion
2828
Open reduction and fixationOpen reduction and fixation
Intraoral approachIntraoral approach
Extraoral approachExtraoral approach
▶▶ Submandibular Submandibular approachapproach
2929
Rigid fixationRigid fixation
Intraossous wiringIntraossous wiring
Plates and screwsPlates and screws
Kirchener wireKirchener wire
Lag screwsLag screws
3030
Reconstruction palateReconstruction palate
Severe trauma
Loss of part of the bone
3131
Condylar fracturesCondylar fractures
Intraoral approachIntraoral approach
Ramus incisionRamus incision
Extraoral approachExtraoral approachPreauricular approachPreauricular approach
Retromandibular approachRetromandibular approach
3232
IMFIMF
Transosseous wiringTransosseous wiring
Circumferential wiringCircumferential wiring
External pin fixationExternal pin fixation
Bone clampsBone clamps
Trans-fixation with Kirschner wiresTrans-fixation with Kirschner wires
3333
OsteosynthesisOsteosynthesis
Non-compression small platesNon-compression small plates
Compression platesCompression plates
MiniplatesMiniplates
Lag screwsLag screws
Resorbable plates and screwsResorbable plates and screws
3434
Teeth in the fracture lineTeeth in the fracture line
The fracture is compound into the mouthThe fracture is compound into the mouth
The tooth may be damaged or lose its The tooth may be damaged or lose its blood supplyblood supply
The tooth may be affected by some The tooth may be affected by some preexisting pathologypreexisting pathology
3535
Management of teeth retained in fracture Management of teeth retained in fracture lineline
Good quality intra-oral periapical radiographGood quality intra-oral periapical radiograph
Insinuation of appropriate systemic antibiotic Insinuation of appropriate systemic antibiotic therapytherapy
Splinting of tooth if mobileSplinting of tooth if mobile
Endodontic therapy if pulp is exposedEndodontic therapy if pulp is exposed
Immediate extraction if fracture becomes Immediate extraction if fracture becomes infectedinfected
Follow up for 1 year and endodontic therapy if Follow up for 1 year and endodontic therapy if there is a loss of vitalitythere is a loss of vitality
3636
Absolute indicationsAbsolute indicationsLongitudinal fractureLongitudinal fractureDislocation or subluxation from socketDislocation or subluxation from socketPresence of periapical infectionPresence of periapical infectionInfected fracture lineInfected fracture lineAcute pericoronitisAcute pericoronitis
Relative indicationsRelative indicationsFunctional tooth that would be removedFunctional tooth that would be removedAdvanced caries or periodontal diseases Advanced caries or periodontal diseases Doubtful tooth which would be added to existing Doubtful tooth which would be added to existing denturedentureTooth in untreated fracture presenting more than 3 Tooth in untreated fracture presenting more than 3 days after injurydays after injury
3737