Fracture of the Mandible

Fracture of Mandible, 2003
Copyright by Department of Oral & Maxillofacial Surgery
University of Dental Medicine, Myanmar
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1. FRACTURE OF THE MANDIBLEFRACTURE OF THE MANDIBLE
Htay Htay YiHtay Htay Yi
UDM ( Mandalay)UDM ( Mandalay)

2. AetiologyAetiology

3. Road traffic Road traffic
accidents(RTA)accidents(RTA)
car , motor car , motor
cycle , cycle ,
bicycle , bicycle ,
trishaw , carttrishaw , cart
head on , head on ,
turned over , turned over ,
colloidcolloid

4. Pedestrian – road crossing , plat formPedestrian – road crossing , plat form

6. Interpersonal violence(assault) Interpersonal violence(assault)
fist blow , hit with something – brick , stickfist blow , hit with something – brick , stick

9. domestic , abusedomestic , abuse

10. FallFall
slip on floor, fall from height (?ft) – slip on floor, fall from height (?ft) –
tree , tree ,

11. Sporting injuries Sporting injuries
Not a contact sportNot a contact sport

12. especially contact sportsespecially contact sports
injury timeinjury time

15. Cliff climbing – sport / fallCliff climbing – sport / fall

16. Industrial trauma Industrial trauma
machinemachine

17. War injury War injury
gun shot wound(GSW) , gun shot wound(GSW) ,
missile missile

19. influenced by – geography , social trends, road traffic influenced by – geography , social trends, road traffic
legislation & seasonslegislation & seasons

22. Why is it necessary to know the Why is it necessary to know the
cause of trauma ?cause of trauma ?
History of trauma – to exclude the fractureHistory of trauma – to exclude the fracture
Impact of forceImpact of force
Possible associated injuryPossible associated injury

23. Types of fractureTypes of fracture
Depend on the condition of bone fragments at the fracture site and Depend on the condition of bone fragments at the fracture site and
possible communication with the external environment ; possible communication with the external environment ;
General ;General ;
SimpleSimple
overlying integument is intactoverlying integument is intact
bone is not exposed to airbone is not exposed to air
neither intraorally nor extraorallyneither intraorally nor extraorally
condyle, coronoid, ramus and edentulous body of the mandiblecondyle, coronoid, ramus and edentulous body of the mandible

24. CompoundCompound
Fractures of the tooth-Fractures of the tooth-
bearing portions of the bearing portions of the
mandible are nearly mandible are nearly
always compound always compound into into
the mouththe mouth via the via the
periodontal membrane periodontal membrane
and some severe injuries and some severe injuries
are compound are compound through through
the overlying skinthe overlying skin

25. Compound Compound into the mouthinto the mouth via the periodontal membrane via the periodontal membrane
Gingival lacerationGingival laceration

26. compound through the overlying skin , saliva drooling compound through the overlying skin , saliva drooling
through the wound indicates that the wound is through and through the wound indicates that the wound is through and
throughthrough

27. GreenstickGreenstick fracture is fracture is
a rare variant of the a rare variant of the
simple fracture and is simple fracture and is
found exclusively in found exclusively in
children (condyle). It is children (condyle). It is
in which one side of in which one side of
the bone is broken, the the bone is broken, the
other being bent other being bent

28. ComminutedComminuted
fractured bone is in fractured bone is in
multiple segmentsmultiple segments
may be simple or may be simple or
compounded compounded
direct violence to the direct violence to the
mandible from penetrating mandible from penetrating
sharp objects and missile sharp objects and missile
injuries , gun shot wound injuries , gun shot wound
(GSW )(GSW )
may cause limited or may cause limited or
extensive comminutionextensive comminution
such fractures are usually such fractures are usually
compound compound
further complicated by further complicated by
bone and soft-tissue loss.bone and soft-tissue loss.

30. PathologicalPathological
result from minimal trauma to a mandible already result from minimal trauma to a mandible already
weakened by a pathological conditionsweakened by a pathological conditions
Local conditions - chronic osteomyelitis, large cyst, Local conditions - chronic osteomyelitis, large cyst,
large tumour, fibrous dysplasialarge tumour, fibrous dysplasia
Systemic conditions– hormonal disturbances- Systemic conditions– hormonal disturbances-
osteoporosis, hyperparathyroidismosteoporosis, hyperparathyroidism(bones(bones-pain -pain
,,stones-stones- renal, renal, moansmoans- abdominal- pancreatitis, peptic - abdominal- pancreatitis, peptic
ulcerulcer, groans, groans- weakness, - weakness, overtoneovertones- psychic s- psychic
depression) osteomalacia (Vit D def. in adult), bone depression) osteomalacia (Vit D def. in adult), bone
diseases (osteopetrosis, Paget, osteogenesis diseases (osteopetrosis, Paget, osteogenesis
imperfecta)imperfecta)

31. Extensive Ch. osteomyelitisExtensive Ch. osteomyelitis

32. Large cystLarge cyst

33. Large tumourLarge tumour

34. According to the siteAccording to the site
Fractures of the mandible occur at the following sitesFractures of the mandible occur at the following sites
Anatomical location Anatomical location
CondyleCondyle 29.1% 29.1%
AngleAngle 24.5% 24.5%
SymphysisSymphysis 22%22%
BodyBody 16%16%
DentoalveolarDentoalveolar3.1%3.1%
RamusRamus 1.7%1.7%
CoronoidCoronoid 1.3%1.3%

35.  condylar neck – long & selender condylar neck – long & selender

36. Angle o0f the mandibleAngle o0f the mandible
a - partially erupted impacted tooth a - partially erupted impacted tooth
b - bone grain of different directionb - bone grain of different direction
(b)
(a)

37. According to the force ;According to the force ;
Direct fracture due to direct forceDirect fracture due to direct force
Indirect fracture due to indirect force (contre-coup) Indirect fracture due to indirect force (contre-coup)
because of the shape of the mandible ( horse shoe ) any direct because of the shape of the mandible ( horse shoe ) any direct
violence to one area produces an indirect force of lesser violence to one area produces an indirect force of lesser
dimension in another usually opposite part of the bonedimension in another usually opposite part of the bone
sufficient to cause a second or third fracture as a result.sufficient to cause a second or third fracture as a result.
Excessive muscular contractionExcessive muscular contraction
Occasionally fracture of the coronoid process occurs because of Occasionally fracture of the coronoid process occurs because of
sudden reflex contracture of the temporalis musclesudden reflex contracture of the temporalis muscle

38. According to the side ; According to the side ;
Unilateral fracture – one side onlyUnilateral fracture – one side only
usually singleusually single
but occasionally more than one fracture may but occasionally more than one fracture may
be present on one side of the mandiblebe present on one side of the mandible
BilateralBilateral fracture – both sides fracture – both sides
frequently occur from a combination of direct frequently occur from a combination of direct
and indirect violence(contre-coup)and indirect violence(contre-coup)

39. Common bilateral fractures Common bilateral fractures
resulting from such a resulting from such a
mechanism are ;mechanism are ;
the angle and opposite the angle and opposite
condylar neckcondylar neck
the canine region and the canine region and
opposite angleopposite angle
bilateral condylar fracturebilateral condylar fracture

40. Less common are bilateral Less common are bilateral
angle and bilateral body angle and bilateral body

43. According to the number ;According to the number ;
Single fractureSingle fracture
one fracture lineone fracture line
Double fractureDouble fracture
two fracture linestwo fracture lines
Multiple fractureMultiple fracture
direct with indirect violence may give rise to direct with indirect violence may give rise to
multiple fractures in which number of fracture multiple fractures in which number of fracture
line is more than oneline is more than one

44. Favourable and unfavourable fractureFavourable and unfavourable fracture
direction of fracture line direction of fracture line
direction of attached muscle pull direction of attached muscle pull
impact of forcesimpact of forces
In a In a favorablefavorable fracture, the fracture line and the fracture, the fracture line and the
muscle pull muscle pull resist displacement resist displacement of the fractureof the fracture
In an In an unfavorableunfavorable fracture, the muscle pull fracture, the muscle pull
results in displacementresults in displacement of fractured segments. of fractured segments.

45. Fractures at the angle of the mandible ;Fractures at the angle of the mandible ;
by the medial pterygoid-masseter 'sling' of by the medial pterygoid-masseter 'sling' of
which the medial pterygoid is the stronger which the medial pterygoid is the stronger
componentcomponent
principle of favourability is based on the principle of favourability is based on the
direction of fracture line as viewed on direction of fracture line as viewed on
radiographs in the horizontal or vertical planeradiographs in the horizontal or vertical plane

50. HorizontalHorizontal
If the horizontal direction of the fracture line favours the unopposed If the horizontal direction of the fracture line favours the unopposed
action of the masseter and medial pterygoid muscle in an upward action of the masseter and medial pterygoid muscle in an upward
direction, the posterior fragment will be displaced upwards.direction, the posterior fragment will be displaced upwards.

51. Unfavourable fracture with marked displacement

52. VerticalVertical
If the vertical direction of the fracture line favours the unopposed If the vertical direction of the fracture line favours the unopposed
action of the medial pterygoid muscle, the posterior fragment will action of the medial pterygoid muscle, the posterior fragment will
be pulled lingually be pulled lingually

54. In the symphysis region muscle attachments are also importantIn the symphysis region muscle attachments are also important
The mylohyoid muscle constitutes a diaphragm between the hyoid bone and The mylohyoid muscle constitutes a diaphragm between the hyoid bone and
the mylohyoid ridge on the inner aspect of the mandiblethe mylohyoid ridge on the inner aspect of the mandible
In transverse midline fractures of the symphysis the mylohyoid and In transverse midline fractures of the symphysis the mylohyoid and
geniohyoid muscles act as a stabilizing forcegeniohyoid muscles act as a stabilizing force
 An oblique fracture in this region will tend to overlap under the An oblique fracture in this region will tend to overlap under the
influence of the geniohyoid / mylohyoid diaphragminfluence of the geniohyoid / mylohyoid diaphragm

55. Bilateral fracture of the body of the mandibleBilateral fracture of the body of the mandible
the anterior fragment is displaced backwards by the pull of the muscles attached to the the anterior fragment is displaced backwards by the pull of the muscles attached to the
genial tuberclesgenial tubercles
Favourable when inferior breadth of segment is narrower than superior breadth Favourable when inferior breadth of segment is narrower than superior breadth
Unfavourable when superior breadth of segment is narrower than inferior breadth Unfavourable when superior breadth of segment is narrower than inferior breadth
Voluntary tongue control is lost only when the patient's level of consciousness is depressedVoluntary tongue control is lost only when the patient's level of consciousness is depressed

56. Midline comminuted fracture of the mandible involving the genial tubercles , the Midline comminuted fracture of the mandible involving the genial tubercles , the
tongue has been deprived of it’s anterior skeletal attachmenttongue has been deprived of it’s anterior skeletal attachment

58. Bucket handle fractureBucket handle fracture

59. Clinical examinationClinical examination
Immediate assessmentImmediate assessment
Patients with maxillofacial injuries may have Patients with maxillofacial injuries may have
sustained other bodily injury which may constitute an sustained other bodily injury which may constitute an
actual threat to life or be of higher priority than the actual threat to life or be of higher priority than the
facial traumafacial trauma
Primary assessment according to ABCDEPrimary assessment according to ABCDE

60. Site of accidentSite of accident
HospitalHospital
Accident & Emergency Department ( A & E ) Accident & Emergency Department ( A & E )
Emergency , Resuscitation Clinic ( ERC )
A – airway
B – breathing
C – circulation
D - degree of consciousness
E - expose & examine

61. A - Air way A - Air way
Apnae for half minute - Oxygen saturation reduces to
85%
Management - to clear the air entry
Foreign body in the air
foreign body - prosthesis, tongue, teeth, secretion, blood, gastric
content

64. No F.B. in the airway
Concious case - chin lift - head tilt , jaw trust - cevical injury
no tube because it may cause vomiting & vocal cord spasm
Jaw trust
Chin lift – Head tilt

65. Poor gag reflex – Oropharyngeal – Gueidel’s airway , nasopharyngeal airway
No F.B. in the airway

66. B - BreathingB - Breathing
unconcious case - respiratory arrest unconcious case - respiratory arrest
mouth to mouth
AMBU 95-100% O2 (air mouth bag unit)
Barotrauma
air into stomach – gastric distention , diaphragm
movement impair , regurgitation
Endotracheal tube (ET - 8-8.5mm, thumb nail ), cuff

68. C- Circulation C- Circulation
Assessment – Hypovolaemia
Management - to maintain blood vol & flow
Peripheral vein - easy to access , percutaneous
2 short (5cm)14 G needle - twice the flow 16,18G
 withdraw blood for investigation
 resuscitative fluid - crystalloid , R/L , blood ( > 1lit
loss)

69. Basic CPR ( Cardiopulmonary resuscitation)Basic CPR ( Cardiopulmonary resuscitation)
-to produce blood flow-to produce blood flow
xiphoid-sternum junction, depth should be 4-5cm one
rescuer- 15 chest compression / 2 ventilations (80/min)
two rescuer- 5 chest compression / 1 ventilation
(60/min)
rib/sternum #, marrow & fat emboli, damage intra-
abdominal organ
check by carotid , femoral pulse every 2 mins
don’t stop

70. D - DisabilityD - Disability
Assessment - AVPU (American
college of surgeons )
A – alert
V - respond to vocal
P - respond to pain
U - unresponsive
GCS - Glasgow Coma scale -
level of consciousness - score-15
to point 3

71. E - ExposureE - Exposure
undress the patient completely
for examination
Other injuries
intracranial
intrathoracic
intra-abdominal - liver is
the second most frequently
injured
bone# - esp. cervical ,
pelvic, rib , femur ect.

72. General clinical examinationGeneral clinical examination
degree of trauma may also have caused injury elsewhere in the degree of trauma may also have caused injury elsewhere in the
bodybody
it is it is imperative, therefore, that all traumatic cases should have a , therefore, that all traumatic cases should have a
careful physical examinationcareful physical examination
Inform to specialty while life threatening conditions are overcome Inform to specialty while life threatening conditions are overcome
by immediate life saving measuresby immediate life saving measures
Then only , refer to specialty as soon as possible
No urgent definitive treatment for facial injury is necessary in
emergency
Bleeding control and airway maintenance are done at ERC
Definitive treatment can be done only when patient’s condition is
stable

73. Local examination of the mandibular fractureLocal examination of the mandibular fracture
Preparation for examinationPreparation for examination
face must be face must be gently cleanedgently cleaned with warm water or swabs to remove with warm water or swabs to remove
caked blood, road dirt, etc. in order that an accurate evaluation of caked blood, road dirt, etc. in order that an accurate evaluation of
any soft-tissue injury can be madeany soft-tissue injury can be made
the mouth, similarly, should be examined for the mouth, similarly, should be examined for loose or broken teeth loose or broken teeth
or dentures, and any congealed bloodor dentures, and any congealed blood removed with swabs held in removed with swabs held in
non-toothed forcepsnon-toothed forceps
during this gently cleaning of the face, the cranium and cervical during this gently cleaning of the face, the cranium and cervical
spine are carefully inspected and then palpated for signs of injuryspine are carefully inspected and then palpated for signs of injury
If a denture is fractured, the fragments should be assembled to If a denture is fractured, the fragments should be assembled to
make sure that no portion is missing – possibly displaced down the make sure that no portion is missing – possibly displaced down the
throatthroat
only after careful cleaning has been carried out both extra- and only after careful cleaning has been carried out both extra- and
intra-orally is it possible to evaluate the full extent of the injuryintra-orally is it possible to evaluate the full extent of the injury
finally the mandibular fracture is examined in detailfinally the mandibular fracture is examined in detail

74. Extra-oral examinationExtra-oral examination
painpain
early swellingearly swelling
ecchymosis ecchymosis
a conscious patient may support the lower jaw with the handsa conscious patient may support the lower jaw with the hands
limitation to range of mandibular movementlimitation to range of mandibular movement
blood stained saliva , dribbling from the corners of the mouthblood stained saliva , dribbling from the corners of the mouth
reduced or absent sensationreduced or absent sensation
Palpation should begin bilaterally in the condylar region and then Palpation should begin bilaterally in the condylar region and then
continue downwards and along the lower border of the mandiblecontinue downwards and along the lower border of the mandible
obvious step deformity in the bony contour of the mandible , check obvious step deformity in the bony contour of the mandible , check
whether the step is coincide with the step of the occlusal plane whether the step is coincide with the step of the occlusal plane
bone tenderness isbone tenderness is almost pathognomic of a fracture almost pathognomic of a fracture
bony crepitus by Bimanual palpationbony crepitus by Bimanual palpation

75. Abrasion of the left cheek Abrasion of the left cheek
and left shoulderand left shoulder
? Associated fracture of ? Associated fracture of
clavicle , scapula , clavicle , scapula ,
humerushumerus

76. Intra-oral examinationIntra-oral examination
gently cleaning - rinsing , with moistened swabs , suction if gently cleaning - rinsing , with moistened swabs , suction if
availableavailable
good light is essentialgood light is essential
Ecchymosis / haematomaEcchymosis / haematoma
ecchymosis in the buccal sulcus is not necessarily the result of a ecchymosis in the buccal sulcus is not necessarily the result of a
fracturefracture
the periosteum of the mandible which, if breached following a the periosteum of the mandible which, if breached following a
fracture, will invariably be the cause of any leakage of blood into fracture, will invariably be the cause of any leakage of blood into
the lingual submucosathe lingual submucosa
small linear haematomas, particularly in the third molar regionsmall linear haematomas, particularly in the third molar region
unable to occlude the teeth together ( Derangement of occlusion ) unable to occlude the teeth together ( Derangement of occlusion )
Derangement of alignmentDerangement of alignment
occlusal plane(step)of the teeth is next examined or, if the patient is occlusal plane(step)of the teeth is next examined or, if the patient is
edentulous, check the alveolar ridgeedentulous, check the alveolar ridge
lacerations of the overlying mucosa – gingival lacerationlacerations of the overlying mucosa – gingival laceration
tested for mobility by placing a finger and thumb on each side and tested for mobility by placing a finger and thumb on each side and
using pressure to elicit unnatural mobilityusing pressure to elicit unnatural mobility
occasionally, even this detailed examination fails to confirm a occasionally, even this detailed examination fails to confirm a
mandibular fracturemandibular fracture

77. Derangement of the occlusion – absent of intercuspal positionDerangement of the occlusion – absent of intercuspal position
Original occlusion ( pretraumatic occlusion ) cannot be achievedOriginal occlusion ( pretraumatic occlusion ) cannot be achieved

78. Gingival lacerationGingival laceration

79. Step formation ( occlusal plane )Step formation ( occlusal plane )

80. Fracture between lower central incisorsFracture between lower central incisors
Gingival soft tissue lacerationGingival soft tissue laceration
Sublingual haematomaSublingual haematoma

81. Check for motor and sensory functionCheck for motor and sensory function
Marginal branch injury - over –riding of the lower lip Marginal branch injury - over –riding of the lower lip
( post trauma condition/ pre- operative , post-operative ( post trauma condition/ pre- operative , post-operative
condition )condition )
IAN injury -paresthesia of the lower lip IAN injury -paresthesia of the lower lip

82. Radiological assessmentRadiological assessment
Why? Why?
site , number , type , direction of fracture line , site , number , type , direction of fracture line ,
displacement of fracture, tooth in line of fracturedisplacement of fracture, tooth in line of fracture
medicolegal medicolegal
foreign body (FB)foreign body (FB)
When?When?
 Pre-op ; diagnosisPre-op ; diagnosis
 Immediate post –op ; accuracy of reduction, fixationImmediate post –op ; accuracy of reduction, fixation
 late post-op ; any complicationslate post-op ; any complications

83. How ?How ?
Essential view Essential view
Posterio-anterior view of the Posterio-anterior view of the
mandible and Lateral oblique mandible and Lateral oblique
view of Rt & Lt side of the view of Rt & Lt side of the
mandiblemandible
(or)(or)
Orthopantomograph Orthopantomograph
(Panoramic X ray)(Panoramic X ray)

84. Special viewSpecial view
90 degree occlusal of mandible90 degree occlusal of mandible
TMJ view , Anterioposterior view of the TMJ view , Anterioposterior view of the
mandible mandible etc.etc.

85. What ?What ?
Radiographic signs of the fracturesRadiographic signs of the fractures
disruption in a continuity of the normal bony contourdisruption in a continuity of the normal bony contour
a demonstrable radiolucent fracture linea demonstrable radiolucent fracture line
displacement of the bone fracturedisplacement of the bone fracture
increased density due to overlap of the adjacent increased density due to overlap of the adjacent
fragmentfragment
the edges of the older fracture are typically rounded the edges of the older fracture are typically rounded
where as the edges of the recent fracture are sharpwhere as the edges of the recent fracture are sharp

86. Any breach in continuity – Any breach in continuity –
fracture fracture

87. disruption in a continuity of the normal bony disruption in a continuity of the normal bony
contourcontour
a demonstrable radiolucent fracture linea demonstrable radiolucent fracture line

88. radiolucent fracture lineradiolucent fracture line
break / breach in continuitybreak / breach in continuity

89. Orthopantomograph – one XrayOrthopantomograph – one Xray
disruption in a continuity of the normal bony contourdisruption in a continuity of the normal bony contour
a demonstrable radiolucent fracture linea demonstrable radiolucent fracture line
displacement of the bone fracturedisplacement of the bone fracture
increased density due to overlap of the adjacent fragmentincreased density due to overlap of the adjacent fragment

90. displacement of the displacement of the
bone fracturebone fracture

91. all signsall signs
increased density due to overlap of the increased density due to overlap of the
adjacent fragmentadjacent fragment

92. lateral cortex lateral cortex
superimpose exactly superimpose exactly
the two fractured the two fractured
cortical plates may be cortical plates may be
interpreted mistakenly interpreted mistakenly
as two fractures as two fractures
through the body of through the body of
the bonethe bone
site that can be site that can be
missed - mid palatal missed - mid palatal
fracture , coronoid fracture , coronoid
fracture fracture


93. General Principles of TreatmentGeneral Principles of Treatment
do not differ essentially from the treatment of do not differ essentially from the treatment of
fracture elsewhere in the bodyfracture elsewhere in the body
Oral and Maxillofacial surgeons are important Oral and Maxillofacial surgeons are important
for;for;
first aidfirst aid
final treatment ( reduction , fixation, final treatment ( reduction , fixation,
immobilization, rehabilitation)immobilization, rehabilitation)
management of late complicationsmanagement of late complications

94. ReductionReduction
the restoration of a functional alignment of the bone the restoration of a functional alignment of the bone
fragmentsfragments
presence of teeth provides an accurate guide in most cases presence of teeth provides an accurate guide in most cases
under general anesthesia, but occasionally it is possible to employ local analgesia under general anesthesia, but occasionally it is possible to employ local analgesia
supplemented if necessary by sedationsupplemented if necessary by sedation
when multiple fractures occurwhen multiple fractures occur
 the rule is 'bottom up and inside out' to establish a mandible as a baseline ( Small E. W. the rule is 'bottom up and inside out' to establish a mandible as a baseline ( Small E. W.
1971) 1971)
by Gruss & Mackinnon 1986 is in panfacial fractures first reconstructing the so called ' outer by Gruss & Mackinnon 1986 is in panfacial fractures first reconstructing the so called ' outer
facial frame' , should start in the area that gives certain anatomical reduction eg. mandible facial frame' , should start in the area that gives certain anatomical reduction eg. mandible
and zygomaand zygoma
Closed reductionClosed reduction – by manipulation to restore original – by manipulation to restore original
occlusion and fractured end are not under visionocclusion and fractured end are not under vision
minimally displaced fracturesminimally displaced fractures
Open reductionOpen reduction – by surgical intervention and fractured – by surgical intervention and fractured
end are reduced under vision to achieve original end are reduced under vision to achieve original
occlusionocclusion

95. Openreduction - OROpenreduction - OR
Intraoral and extraoral approachIntraoral and extraoral approach

96. FixationFixation
Following accurate reduction of the fragments, the Following accurate reduction of the fragments, the
fractured sitefractured site must be fixed must be fixed
Methods of fixation Methods of fixation ; ;
Direct Direct - Osteosynthesis – surgical fastening of the ends of fractured - Osteosynthesis – surgical fastening of the ends of fractured
bonebone
Direct fixation materials Direct fixation materials ;;
rigid rigid
compression plates , lag screw ( tight approximation / stability in three compression plates , lag screw ( tight approximation / stability in three
dimension- direct /primary bone healing , without the formation of any dimension- direct /primary bone healing , without the formation of any
intermediate callus )intermediate callus )
semi rigidsemi rigid
noncompression , miniplates , (small gap between the bone ends exists noncompression , miniplates , (small gap between the bone ends exists
resulting a limited amount of primary callus / secondary bone healing)resulting a limited amount of primary callus / secondary bone healing)
nonrigid nonrigid
external pin , bone clamp , transosseous , circumferential , K wire external pin , bone clamp , transosseous , circumferential , K wire
(indirect / secondary bone healing / callus formation)(indirect / secondary bone healing / callus formation)

97. ImmobilizationImmobilization
Immobilized Immobilized fractured partfractured part to allow bone healing to allow bone healing
to occurto occur
Methods of immobilization Methods of immobilization
MMFMMF ( Maxillomandibular fixation ) = IMF ( Maxillomandibular fixation ) = IMF
( Intermaxillary fixation ) ( Intermaxillary fixation )
ID (interdental ) , Arch bars , Cap splints , brackets ID (interdental ) , Arch bars , Cap splints , brackets
Osteosynthesis without MMFOsteosynthesis without MMF
 direct fixation with Compression plate , Lag screw direct fixation with Compression plate , Lag screw
Non-compression plate , Mini plateNon-compression plate , Mini plate
MMF with osteosynthesisMMF with osteosynthesis
direct fixation with External pin fixation , Bone clamp , direct fixation with External pin fixation , Bone clamp ,
Transosseous wiring , circumferential wiring , Transosseous wiring , circumferential wiring ,
Transfixation with Kirshner wireTransfixation with Kirshner wire

98. Compression plate and screwCompression plate and screw

99. Spherical surface againSpherical surface againsstt the the
incline planeincline plane
 Horizontal displacement Horizontal displacement
 Compression force Compression force

100. Lag screwLag screw
Monocortical and bicorticalMonocortical and bicortical

101. Lagging ------> coverLagging ------> cover
Screw thread engage bone near tip of screwScrew thread engage bone near tip of screw

102. MiniplateMiniplate
MicroplateMicroplate
Smaller than miniplateSmaller than miniplate
More malleableMore malleable
Primary fixation of midface and craniumPrimary fixation of midface and cranium

103. Bioresorable (polymer) plate and Bioresorable (polymer) plate and
screwscrew

105. External pin fixation

106. Kirschner pinKirschner pin

111. One straight and one figure of eight wiring at the lower border of the One straight and one figure of eight wiring at the lower border of the
fractured mandiblefractured mandible

112. OR & IOOR & IO

113. Figure of eight wiring at the lower border of the mandibleFigure of eight wiring at the lower border of the mandible

114. OR , IO - two straight wiring at the lower border of the mandibleOR , IO - two straight wiring at the lower border of the mandible

115. Why open reduction is necessary ?Why open reduction is necessary ?
Although the occlusion is restored back the bony alignment is not at it’s Although the occlusion is restored back the bony alignment is not at it’s
original positionoriginal position

116. Closed ReductionClosed Reduction
+ +
MMF MMF
CR, ID&IMF/MMFCR, ID&IMF/MMF
Open ReductionOpen Reduction
+ +
Direct Fixation ( rigid, semi rigid , nonrigid)Direct Fixation ( rigid, semi rigid , nonrigid)
+ +
MMFMMF
OR, IF &MMFOR, IF &MMF

124. Interdental and maxillomandibular fixationInterdental and maxillomandibular fixation

125. ID & MMFID & MMF

126. Arch barArch bar

129. Cast cap splintCast cap splint

134. Acrylic splint ( Stout splint)Acrylic splint ( Stout splint)

137. Different methods of immobilization

138. MMFMMF
Intraoperative MMF technique is used to Intraoperative MMF technique is used to
keep the mandible in the desired reduction keep the mandible in the desired reduction
position while the plates are being fixedposition while the plates are being fixed
MMF for postsurgical stabilization of the MMF for postsurgical stabilization of the
skeletal segmentsskeletal segments

139. Period of immobilizationPeriod of immobilization
In favourable circumstances , stable clinical union can on In favourable circumstances , stable clinical union can on
average regularly be achieved after 3 weeksaverage regularly be achieved after 3 weeks
Young adultYoung adult withwith fracture of the angle fracture of the angle of the mandible of the mandible
having having early treatmentearly treatment – – 3 weeks3 weeks
 if age 40 yrs and over - add 1 or 2 weeks ( dense bone if age 40 yrs and over - add 1 or 2 weeks ( dense bone
with poor blood supply )with poor blood supply )
 if children and adolescents - subtract 1 weekif children and adolescents - subtract 1 week
 if fracture at the symphysis ( poor blood supply ) - add if fracture at the symphysis ( poor blood supply ) - add
1week1week
If late treatment – more than 72 hours If late treatment – more than 72 hours
if tooth retain in fracture line - add 1 week ( infection )if tooth retain in fracture line - add 1 week ( infection )
if more than one fracture line – add 1 week if more than one fracture line – add 1 week
Rules such as these are designed for Rules such as these are designed for guidance onlyguidance only and and
it must be emphasized that the fracture must always be it must be emphasized that the fracture must always be
tested before the mandible is finally releasedtested before the mandible is finally released

140. Bilateral fracture of the Bilateral fracture of the
mandible at left angle and mandible at left angle and
right parasymphysisright parasymphysis
OR , IO , ID & IMOR , IO , ID & IM
Open reduction , inter-Open reduction , inter-
osseous wiring , interdental osseous wiring , interdental
and intermandibular fixationand intermandibular fixation
Figure of eight wiring at Figure of eight wiring at
the anglethe angle
Two straight wiring at the Two straight wiring at the
parasymphysisparasymphysis

142. OR , IO , MMFOR , IO , MMF
Open reduction , inter-osseous Open reduction , inter-osseous
wiring , maxillomandibular wiring , maxillomandibular
fixationfixation
Figure of eight wiring Figure of eight wiring
MMF by Arch barMMF by Arch bar

143. OR , IF , MMFOR , IF , MMF
Open reduction , internal Open reduction , internal
fixation and maxillomandibular fixation and maxillomandibular
fixationfixation
Figure of eight wiring at the Figure of eight wiring at the
angle fracture angle fracture
Miniplate at the Miniplate at the
parasymphysis fractureparasymphysis fracture

144. OR , IF , MMFOR , IF , MMF
Open reduction , Open reduction ,
internal fixation and internal fixation and
maxillomandibular maxillomandibular
fixationfixation
Two straight wire at Two straight wire at
Lt side of the Lt side of the
parasymphysis parasymphysis
Four holes Four holes
miniplate at Rt side miniplate at Rt side
of the body of the of the body of the
mandibular fracturemandibular fracture

145. Postoperative carePostoperative care
three phases; three phases;
Imediate phaseImediate phase – when patient is recovering from GA – when patient is recovering from GA
kept under skilled nursing supervision kept under skilled nursing supervision
until they are fully recover from the anesthetic and fit to transfer until they are fully recover from the anesthetic and fit to transfer
back to the wardback to the ward
prudent to have available at patient's bedside instruments such as prudent to have available at patient's bedside instruments such as
scissors, wire cutter, screwdrivers etc., so that fixation can be scissors, wire cutter, screwdrivers etc., so that fixation can be
removed in an emergencyremoved in an emergency
patients should be nursed lying on their sides during recovery patients should be nursed lying on their sides during recovery
enable any saliva or oozing of blood to escape from the mouthenable any saliva or oozing of blood to escape from the mouth
an efficient suction apparatus must be at the patient's bedside and an efficient suction apparatus must be at the patient's bedside and
to the sucker nozzle a length of 1/8 inch (#mm) rubber or polythene to the sucker nozzle a length of 1/8 inch (#mm) rubber or polythene
tubing is attached. tubing is attached.

146. Intermediate phaseIntermediate phase – before clinical bony union has become – before clinical bony union has become
established.established.
Prevention of infection -antibiotics can be discontinued 5 days after Prevention of infection -antibiotics can be discontinued 5 days after
immobilization of fracture. immobilization of fracture.
Oral hygieneOral hygiene
effective oral hygiene also plays an important part in prevention of effective oral hygiene also plays an important part in prevention of
infection of the fracture line. Tooth brushing – by toothbrush in usual infection of the fracture line. Tooth brushing – by toothbrush in usual
mannermanner
Mouth wash – 0.2% chlorhexadine , salineMouth wash – 0.2% chlorhexadine , saline
Feeding Feeding
the majority of the patients with fractured mandible can be fed (liquid) by the majority of the patients with fractured mandible can be fed (liquid) by
mouth even though their jaws are immobilizedmouth even though their jaws are immobilized
a diet of 2000 – 2500 calories is adequate for most of the patient's a diet of 2000 – 2500 calories is adequate for most of the patient's
nutritional requirementnutritional requirement
patient should be encouraged to eat a little and oftenpatient should be encouraged to eat a little and often
Ryle's tube (Enteral feeding - Nasogastric tube) feeding for a week to Ryle's tube (Enteral feeding - Nasogastric tube) feeding for a week to
those who has been undergone open reductionthose who has been undergone open reduction

147. Late postoperative care – Late postoperative care – which includes removal of which includes removal of
fixation, bite rehabilitation, physiotherapy and long term fixation, bite rehabilitation, physiotherapy and long term
observation of the dentition in particularobservation of the dentition in particular
Patients should be kept on a soft diet for the first 2 Patients should be kept on a soft diet for the first 2
weeksweeks
In some treatment centers plates are routinely remove In some treatment centers plates are routinely remove
after 6 months whereas in other they are left as after 6 months whereas in other they are left as
permanent implant until they become exposed or permanent implant until they become exposed or
infected infected
Adjustment of occlusion – slight derangement can often Adjustment of occlusion – slight derangement can often
be overcome but more gross abnormalities of occlusion be overcome but more gross abnormalities of occlusion
are treated by selective grinding. are treated by selective grinding.

148. ComplicationsComplications
Arising during primary treatment ;Arising during primary treatment ;
misapplied fixation - avoid IDC , and roots of the teeth, misapplied fixation - avoid IDC , and roots of the teeth,
vesselvessel
infection – injudicious surgical interference i.e. infection – injudicious surgical interference i.e.
transosseous wiring of a fracture already infected. FB – transosseous wiring of a fracture already infected. FB –
fragment of teeth or glass fragment of teeth or glass
nerve damage – neuroprexia , neurotmesis of IDCnerve damage – neuroprexia , neurotmesis of IDC
pulpitispulpitis
gingival and periodontal problemgingival and periodontal problem

149. Late complication ; Late complication ;
malunionmalunion – unacceptable malposition of fragment , gross – unacceptable malposition of fragment , gross
derangement of occlusionderangement of occlusion
delayed uniondelayed union –if the time taken for a fracture to unite is unduly –if the time taken for a fracture to unite is unduly
protracted . If union is delayed beyond the expected time for that protracted . If union is delayed beyond the expected time for that
particular fracture. particular fracture.
nonunionnonunion – it includes the condition of fibrous union. It is due to – it includes the condition of fibrous union. It is due to
number of circumstances – infection , inadequate immobilization , number of circumstances – infection , inadequate immobilization ,
unsatisfactory appositionunsatisfactory apposition
wire and plate exposure , pain , discomfort .Surgical removal these wire and plate exposure , pain , discomfort .Surgical removal these
will lead to rapid resolution of the problem. will lead to rapid resolution of the problem.
sequestration of bone – comminuted fracture . Antibiotics and dead sequestration of bone – comminuted fracture . Antibiotics and dead
bone allowed to extrude spontaneously without surgical interventionbone allowed to extrude spontaneously without surgical intervention
limitation of mouth opening – prolonged immobilization of MMF will limitation of mouth opening – prolonged immobilization of MMF will
result in weakening of the muscles of mastication. Early mobilization result in weakening of the muscles of mastication. Early mobilization
or mouth opening exercise immediate after MMF released is the or mouth opening exercise immediate after MMF released is the
solution to it. solution to it.
scars – hypertrophic and keloid occurs producing an ugly deformity. scars – hypertrophic and keloid occurs producing an ugly deformity.

150. Condylar fractureCondylar fracture

151. Surgical anatomySurgical anatomy
Young age( below 10yrs) Young age( below 10yrs)
thin cortex thin cortex
periosteum in active osteogenic periosteum in active osteogenic
phasephase
very vascular bone – very vascular bone –
haemarthrosishaemarthrosis
relative short & broad neck - relative short & broad neck -
intracapsular fractureintracapsular fracture
ankylosed and disturbance of ankylosed and disturbance of
mandibular growthmandibular growth
AdultAdult
thick cortex thick cortex
periosteum in latent osteogenic periosteum in latent osteogenic
phasephase
long & slender neck – long & slender neck –
extracapsular fractureextracapsular fracture

156. Classify asccording to surgical anatomy ;Classify asccording to surgical anatomy ;
Intracapsular / Extracapsular Intracapsular / Extracapsular
high and lowhigh and low
unilateral/ bilateralunilateral/ bilateral

161. History of traumaHistory of trauma
Contrecoup – direct force at angle and body will result in Contrecoup – direct force at angle and body will result in indirect indirect
fracturefracture at condylar neck at condylar neck
may or may not be direct fracture at the site of impactmay or may not be direct fracture at the site of impact
Tell tale scar with history of fall on chin is the another cause of Tell tale scar with history of fall on chin is the another cause of
fracture of condyle fracture of condyle
Guardman's fracture multiple fracture caused by fall on the chin Guardman's fracture multiple fracture caused by fall on the chin
resulting in fracture of the symphysis and both condyles , resulting in fracture of the symphysis and both condyles ,
commonly seen inepileptics , elderly and soldierscommonly seen inepileptics , elderly and soldiers
Unilateral condylar fracture when only one side of the condyle is Unilateral condylar fracture when only one side of the condyle is
occurred and bilateral where both sides are involvedoccurred and bilateral where both sides are involved
almost all fractures of condyle are closed and indirectalmost all fractures of condyle are closed and indirect
open and direct fracture in case of direct injury due to GSW , Dah open and direct fracture in case of direct injury due to GSW , Dah
cut etc.cut etc.

162. Direct fracture at the parasymphysis and indirect fracture ( contrecoup ) of Direct fracture at the parasymphysis and indirect fracture ( contrecoup ) of
the opposite subcondylethe opposite subcondyle

171. Clinical featuresClinical features
mid line of upper not in coincide with of lower – midline not coincide mid line of upper not in coincide with of lower – midline not coincide
in some original in some original
occlusion – undisturbed or derange occlusion – undisturbed or derange
deviation of jaw towards affected side while opening of mouthdeviation of jaw towards affected side while opening of mouth
anterior open bite in bilateral condylar fracture is due to premature anterior open bite in bilateral condylar fracture is due to premature
posterior teeth contactposterior teeth contact
contralateral open bite in case of unilateral condylar fracturecontralateral open bite in case of unilateral condylar fracture
limitation of opening of the mouthlimitation of opening of the mouth
pain, tenderness and crepitation at the fracture sitepain, tenderness and crepitation at the fracture site
absent of condylar movement at affected side ( preaurical palpation absent of condylar movement at affected side ( preaurical palpation
during jaw opening and closing)during jaw opening and closing)
reduce vertical height of the face, facial asymmetryreduce vertical height of the face, facial asymmetry
bleeding from external auditory canalbleeding from external auditory canal
preauricular depression in fracture, dislocation of condylepreauricular depression in fracture, dislocation of condyle

172. Radiological assessmentRadiological assessment
Orthopantomogram (Panoramic view)Orthopantomogram (Panoramic view)
TMJ Rt and Lt side + open and closeTMJ Rt and Lt side + open and close
Troller's transpharengeal viewTroller's transpharengeal view
Modified Towne's viewModified Towne's view

173. TreartmentTreartment
Principals - early reduction and early mobilizationPrincipals - early reduction and early mobilization
ReductionReduction
Conservative – closed reductionConservative – closed reduction
Surgery – open reduction ; plate, intraosseous wiring, K wire, Surgery – open reduction ; plate, intraosseous wiring, K wire,
pin etc.pin etc.
(absolute)(absolute)
displacement of condyle into middle cranial fossadisplacement of condyle into middle cranial fossa
impossibility of restoring occlusionimpossibility of restoring occlusion
lateral extracapsular displacementlateral extracapsular displacement
present of FB (missile)present of FB (missile)
(relative)(relative)
MMF is contraindicated for medical reasonMMF is contraindicated for medical reason
bilaterally with mid face fracturebilaterally with mid face fracture
bilaterally with severe open bite deformitybilaterally with severe open bite deformity
Fixation MMF/IMFFixation MMF/IMF
Immobilization - for 2-3wks in fracture condyle onlyImmobilization - for 2-3wks in fracture condyle only

174. Condylar fracture in Condylar fracture in
association with other part association with other part
of the mandibular fractureof the mandibular fracture
CR to the subcondylar CR to the subcondylar
fracture , OR & IO wiring fracture , OR & IO wiring
to the parasymphysis to the parasymphysis
MMF is released after 2 MMF is released after 2
weeksweeks
During that visit mouth During that visit mouth
opening exercise is done opening exercise is done
MMF is kept again for MMF is kept again for
another additioinal weeks another additioinal weeks
as requiredas required

176. Fracture of edentulous mandibleFracture of edentulous mandible

177. Fractures of edentulous mandibleFractures of edentulous mandible
Special considerationSpecial consideration
resorption of alveolar process- vertical height reduced to half or resorption of alveolar process- vertical height reduced to half or
moremore
resistance to trauma reduced – more easily fractureresistance to trauma reduced – more easily fracture
aging – bone dependent on periosteal network of vessels , less aging – bone dependent on periosteal network of vessels , less
uneventful healinguneventful healing
less cross sectional area - more easily displacedless cross sectional area - more easily displaced
less frequently compound – risk of infection is negligibleless frequently compound – risk of infection is negligible
precise reduction to restore occlusion is un-necessaryprecise reduction to restore occlusion is un-necessary
MMF is less desirable than in younger age groupMMF is less desirable than in younger age group
nutrition, candidiasisnutrition, candidiasis

178. Obj;Obj;
sufficient bone contact and alignment with minimum direct operative sufficient bone contact and alignment with minimum direct operative
interference at the fracture siteinterference at the fracture site
many undisplaced fractures require no active treatment many undisplaced fractures require no active treatment
Gunning type splints (Gunning – 1886) – bite block , modification of Gunning type splints (Gunning – 1886) – bite block , modification of
patient's denturepatient's denture
Osteosynthesis; plates, wire, pin, bone clamp etc. , fixation using Osteosynthesis; plates, wire, pin, bone clamp etc. , fixation using
cortico cancellous bone graftcortico cancellous bone graft

186. Bone awl is used for circumferential wiringBone awl is used for circumferential wiring

190. Fractures of mandible in childrenFractures of mandible in children
Special considerationSpecial consideration
bone resilient , less common to be fracturedbone resilient , less common to be fractured
presence of unerupted or partially erupted teeth of permanent presence of unerupted or partially erupted teeth of permanent
dentition and deciduous teeth of variable mobilitydentition and deciduous teeth of variable mobility
normal growth of mandible will be disturbed if unerupted teeth or normal growth of mandible will be disturbed if unerupted teeth or
tooth germs are lost – prolonged follow up is necessorytooth germs are lost – prolonged follow up is necessory

191. TreatmentTreatment
ConservativeConservative
simple elasticated bandage chin support in minimal displaced simple elasticated bandage chin support in minimal displaced
fracturefracture
cast cap splint, Gunning splint , acrylic stout splintcast cap splint, Gunning splint , acrylic stout splint
bone plates an pins are contraindicated – injury to teeth , unerupted bone plates an pins are contraindicated – injury to teeth , unerupted
teeth and tooth germsteeth and tooth germs
in exceptional such as gross displacement – lower border wire with in exceptional such as gross displacement – lower border wire with
cautioncaution

193. Classification of traumatic injuries to the teethClassification of traumatic injuries to the teeth
(modification – Sanders, Brandy, and Johnson)(modification – Sanders, Brandy, and Johnson)
A - Crown craze or crackA - Crown craze or crack
B - Crown fracture – confined to enamel, enamel and dentine B - Crown fracture – confined to enamel, enamel and dentine
involved, enamel, dentine and pulp exposure involvedinvolved, enamel, dentine and pulp exposure involved
C - Crown and root fracture – no pulp involvement, pulp involvementC - Crown and root fracture – no pulp involvement, pulp involvement
D - Horizontal root fracture – involving apical , middle, cervical thirdD - Horizontal root fracture – involving apical , middle, cervical third
E - Sensitivity(concussion)E - Sensitivity(concussion)
F - Mobility(subluxation or looseness but without tooth F - Mobility(subluxation or looseness but without tooth
displacement)displacement)
G - Tooth displacement – intrusion(into socket), extrusion(out of G - Tooth displacement – intrusion(into socket), extrusion(out of
socket), labial, lingual, lateral (mesial or distal) displacementsocket), labial, lingual, lateral (mesial or distal) displacement
H - Avulsion (complete displacement from socket) , missing tooth H - Avulsion (complete displacement from socket) , missing tooth
with bleeding socket - ? tooth embedded within soft tissue, with bleeding socket - ? tooth embedded within soft tissue,
swallowed, inhaledswallowed, inhaled
I - Alveolar process fracture ; when force is applied to any single I - Alveolar process fracture ; when force is applied to any single
tooth at that segment , a group of teeth including at the segment will tooth at that segment , a group of teeth including at the segment will
be mobilized alsobe mobilized also
recently damaged ? – infected , medicolegalrecently damaged ? – infected , medicolegal

194. Treatment options ;Treatment options ;
Crown craze – no treatment , periodic follow upCrown craze – no treatment , periodic follow up
Crown fracture – depth of the tissue involve- smoothing off sharp edges, restoration, Crown fracture – depth of the tissue involve- smoothing off sharp edges, restoration,
pulpotomy, periodic follow uppulpotomy, periodic follow up
Crown and root fracture – depend upon apical extent of fracture – restorable, Crown and root fracture – depend upon apical extent of fracture – restorable,
endodontic, extractionendodontic, extraction
Horizontal root fracture – fracture in relation to gingival crevice , middle & apical third Horizontal root fracture – fracture in relation to gingival crevice , middle & apical third
have good prognosis – exo, endo, immobilization( 2-4mths)have good prognosis – exo, endo, immobilization( 2-4mths)
Sensivity – no acute treatment, relieve occlusal contact, periodic follow upSensivity – no acute treatment, relieve occlusal contact, periodic follow up
Mobility – occlusal relieve, stabilize(3-4 wks), periodic observationMobility – occlusal relieve, stabilize(3-4 wks), periodic observation
Displacement – intrusion – less frequent than lateral , worst prognosis, controversy – Displacement – intrusion – less frequent than lateral , worst prognosis, controversy –
left alone and let erupt, reposition and splint (3-4wks), endo, if deciduous tooth – left alone and let erupt, reposition and splint (3-4wks), endo, if deciduous tooth –
remove it atraumaticallyremove it atraumatically
extrusion – seated back and splint, endo if requireextrusion – seated back and splint, endo if require
lateral – manual repositioning and splint , follow uplateral – manual repositioning and splint , follow up
Avulsion- most grave situation ,stabilizationAvulsion- most grave situation ,stabilization
replanted mature tooth(7-10 days)replanted mature tooth(7-10 days)
immature tooth(3-4wksimmature tooth(3-4wks))

195. Dentoalveolar injuryDentoalveolar injury

196. Splinting method Splinting method
Arch barArch bar
Acid etched composite & rigid wireAcid etched composite & rigid wire
Orthodontic bracket and Ortho wireOrthodontic bracket and Ortho wire
Continuous wiring – Essig , loopContinuous wiring – Essig , loop
Stout splintStout splint

197. Loop wiringLoop wiring

198. Essig wiringEssig wiring

199. Healing of the boneHealing of the bone
Primary ( direct or osteonal ) bony healingPrimary ( direct or osteonal ) bony healing
Secondary ( Indirect or callus ) bone unionSecondary ( Indirect or callus ) bone union

200. Primary ( direct or Primary ( direct or
osteonal ) bony healingosteonal ) bony healing
in the event of in the event of
anatomical reduction anatomical reduction
and rigid internal and rigid internal
fixation fixation
with very limited motion with very limited motion
between the fractured between the fractured
ends ends
no intermediate no intermediate
cartilage appears at the cartilage appears at the
union of the fragment union of the fragment
healing takes place by healing takes place by
bony tissue bony tissue

201. Secondary ( Indirect Secondary ( Indirect
or callus ) bone unionor callus ) bone union
is the normal process is the normal process
of fracture healingof fracture healing
when the mandibular when the mandibular
fracture is treated with fracture is treated with
closed reduction and closed reduction and
intermaxillary fixation .intermaxillary fixation .

202. Primary callus in different categories ;Primary callus in different categories ;
Anchoring callus ( develops on the outside surface of the bone near Anchoring callus ( develops on the outside surface of the bone near
the periosteum )the periosteum )
Sealing callus ( develops on the inside surface of the bone across Sealing callus ( develops on the inside surface of the bone across
the fractured end ) the fractured end )
Bridging callus ( develops on the outside surface of the anchoring Bridging callus ( develops on the outside surface of the anchoring
callus on the two fractured ends )callus on the two fractured ends )
Uniting callus (develops between the ends of bones and between Uniting callus (develops between the ends of bones and between
the areas of the other primary calluses that have been formed) .the areas of the other primary calluses that have been formed) .

203. Three overlapping phasesThree overlapping phases
Organization ; occurs during the first 10 days. Clot Organization ; occurs during the first 10 days. Clot
organization and proliferation of the blood vesselsorganization and proliferation of the blood vessels
Callus formation ; a rough ‘ woven bone ‘ or primary Callus formation ; a rough ‘ woven bone ‘ or primary
callus is formed in the next 10 to 20 days . The callus is formed in the next 10 to 20 days . The
secondary callus in which haversian system form in 20-secondary callus in which haversian system form in 20-
60 days ( fixation can be removed by that time ) . 60 days ( fixation can be removed by that time ) .
Functional reconstruction of the bone ; Haversian system Functional reconstruction of the bone ; Haversian system
are lined up according to the stress lines . Excess bone are lined up according to the stress lines . Excess bone
is removed . The shape of the bone is moulded to is removed . The shape of the bone is moulded to
conform with functional usage . conform with functional usage .

204. ReferencesReferences
Principles of management of maxillofacial trauma , 1Principles of management of maxillofacial trauma , 1
stst
ed. ed.
1992 , JB Lippincott Company , Larry J Peterson1992 , JB Lippincott Company , Larry J Peterson
Text book of Oral and Maxillofacial Surgery , 5Text book of Oral and Maxillofacial Surgery , 5
thth
ed. , ed. ,
Gustav O KrugerGustav O Kruger
Contemporary Oral and Maxillofacial Surgery, 4Contemporary Oral and Maxillofacial Surgery, 4
thth
ed. ed.
Larry J PetersonLarry J Peterson
Fractures of the facial skeleton , Peter banks , Andrew Fractures of the facial skeleton , Peter banks , Andrew
BrownBrown
Text book of General and Oral surgery , 2003 , David Text book of General and Oral surgery , 2003 , David
Wray et al . Wray et al .
Killey’s fractures of the mandible , 4Killey’s fractures of the mandible , 4
thth
ed. , Peter Banks ed. , Peter Banks
HHY