Fractures of mandible and detailed discussion

Its a great powerpoint about various fractures of mandible

1. FRACTURE OF THE MANDIBLE

2. Fracture of the mandible Submitted by: Nadiya Sultana soheli : 25 Anika Antara : 26 Zahirul Islam : 27     Submitted To: Dr. Mohammad Emranul Islam Sir Professor and Head of Department of Oral and Maxillofacial Surgery City Dental College, Dhaka .

3. OUTLINE: INTRODUCTION ANATOMY HISTORY CLASSIFICATION AETIOLOGY EPIDEMIOLOGY SIGNS & SYMPTOMS INVESTIGATION MANAGEMENT

4. Introduction The mandible is the largest, heaviest and strongest monostatic bone of the face. The mandible forms the lower jaw and is the only movable bone of skull, articulating with the temporal bone at the Synovial temporo -mandibular joint. It is consisting of ‘U’ shaped or parabola shaped body and 2 broad and oblong rami projecting upward. Viewed from side each half of the bone is ‘L’ shaped. Fracture of mandible occurs more frequently than that of any other facial skeleton. Fracture of the mandible

5. Anatomy of mandible:

6. MUSCLE ATTACHMENT OF MANDIBLE Muscle attachment of inner surface Muscle attachment of outer surface

7. The weakest site of dentulous mandible is the condyle region and edentulous mandible is the molar region. Presence of teeth Neck of the condyle Symphysis of the mandible Angle of the mandible Presence of foramina Areas of Weakness (Vulnerable for Fracture)

8. NERVE SUPPLY OF THE MANDIBLE Mandible is supplied by inferior alveolar nerve. Mandibular nerve through foramen ovale and inferior alveolar nerve through the mandibular foramen. Inferior dental plexus supplying to the teeth and mental nerve through the mental foramen

9. Blood supply of the mandible Central blood supply through the inferior alveolar artery. Peripheral blood supply through the periosteum (periosteal vessels).

10. YEAR INVENTOR TREATMENT 1880 GILMER GILMERS WIRING AND FULL ARCH BARS 1900 MAHE PLATING KIT SIMILAR TO MORDERN SYSTEMS 1920 F. RISDON RISDONS WIRING 1961 LUHR DYNAMIC COMPRESSION PLATES 1970 BONES & BORING LAG SCREWS 1973 MICHELET MINIPLATES FOR MAND OSTEOSYNTHESIS 1978 CHAMPY MINIPLATES OSTEOSYNTHESIS PRINCIPALS HISTORY OF MANDIBLE FRACTURE The first description of the treatment of jaw fractures however, has to be credited to the Father of Medicine: ‘Hippocrates’. He made use of bandages and single jaw fixation, to manually reduce fractures of the jaws.

11. CLASSIFICATION OF MANDIBLE FRACTURE Kruger’s General Classification Depending on Type of Fracture Simple or closed fracture Compound or open fracture Comminuted fracture Complicated or complex Greenstick Pathological Figs: A to E: (A) Simple fracture; (B) Greenstick fracture. Straight line fractured cortex. Dotted line bent cortex (C) Compound comminuted fracture; (D) Compound fracture. Arrow-exposed bone; (E) Simple comminuted fracture

12. CLASSIFICATION OF MANDIBLE FRACTURE Dingman and Natvig anatomical classification of mandible fracture Symphysis fracture (midline fracture) :- 7-15% Body :- 30-40% Angle region :- 25-30% Ramus region :- 3-9% Coronoid region :-1-2% Condylar fractures :- 15-25% Dentoalveolar region :- 2-4% Fig: Dingman and Natvig anatomical classification

13. CLASSIFICATION OF MANDIBLE FRACTURE According to the Direction of Fracture and Favorability for Treatment Horizontally favorable fracture. Horizontally unfavorable fracture. Vertically favorable fracture. Vertically unfavorable fracture Figs: (A) Horizontally favourable line of fracture at the angle of the mandible. (B) Horizontally unfavourable line of fracture at the angle of the mandible. (C) Vertically favorable line of fracture through the right angle of the mandible. (D) Vertically unfavorable line of fracture through the right angle of the mandible

14. CLASSIFICATION OF MANDIBLE FRACTURE Kazanjian and Converse Classification Class I: When the teeth are present on both sides of the fracture line. Class II: When the teeth are present only on one side of the fracture line. Class III: When both the fragments on each side of the fracture line are edentulous Fig: Kazanjian and converse classification

15. The Dynamic Fracture (Blow) The Stationary factor (Jaw) Pathological cause THE DYNAMIC FRACTURE Direct Violence Fight (fist, metal rods, bricks) Fall Road traffic accidents Occupational hazards (Athletic Injury, industrial mishaps) Iatrogenic (during extraction, or any treatment) Indirect Violence Fall from height Due to excessive muscle contraction (fracture of coronoid process Aetiology of Fracture of Mandible

16. THE STATIONARY FACTOR: Depends on physiological age Child can have no fracture or green stick fracture in impact on bone, whereas old aged can have heavily fractured bone in mild impact also PATHOLOGICAL CAUSE: Osteomyelitis Tumours:- benign, malignant, metastatic Cystic lesion Aetiology of Fracture of Mandible

17. EPIDEMIOLOGY Chart: Fracture according to aetiology

18. EPIDEMIOLOGY Chart: Fracture according to site

19. Sign and symptoms General Specific CLINICAL FEATURE OF MANDIBLE FRACTURE

20. General: Swelling Lacerations Pain Tenderness Fracture, subluxed , luxated teeth Ecchymosis Bleeding from the mouth Drooling Limitation of mouth opening Bony CLINICAL FEATURE OF MANDIBLE FRACTURE

21. SPECIFIC SIGNS AND SYMPTOMS DENTOALVEOLAR FRACTURE: Lip bruises and laceration Step deformity Bony discontinuity Fracture, luxation or subluxation of teeth Laceration of gingiva Avulsion of dentoalveolar fragment Bony discontinuity Intraoral bleeding CLINICAL FEATURE OF MANDIBLE FRACTURE

22. FRACTURE OF THE BODY OF THE MANDIBLE Swelling: Intraoral and extra oral as per the line of fracture Pain Tenderness Step deformity Anaesthesia paraesthesia of lip Intraoral bleeding/ecchymosis/ sublingual hematoma Loss of tongue control in bilateral parasymphysis fracture CLINICAL FEATURES OF MANDIBLE FRACTURE

23. SYMPHYSIS OR PARASYMPHYSIS FRACTURE Tenderness Pain Step deformity Sublingual haematoma loss of tongue control Soft tissue injury to the chin and lower lip CLINICAL FEATURES OF MANDIBLE FRACTURE

24. FRACTURE OF THE RAMUS Swelling Pain Ecchymosis Trismus CORONOID FRACTURE Fenderness over the anterior part of the tragus Haematoma Painful limitation of movement Protrusion of mandible maybe present CLINICAL FEATURE OF MANDIBLE FRACTURE

25. FRACTURE OF THE ANGLE Swelling Posterior gag Haematoma Deranged occlusion Anaesthesia or paraesthesia of lower lip Step deformity behind the last molar teeth Tenderness CLINICAL FEATURE OF MANDIBLE FRACTURE

26. CONDYLAR FRACTURE (UNILATRAL, BILATARAL, INTRACAPSULAR, EXTRACAPSULAR) Unilateral condylar fracture : Swelling over the TMJ Haemorrhage from ear on the affected side Battle‘s sign Locked mandible Hollow over the condylar region after oedema has subside Rarely paraesthesia of lower lip Deviation to the affected side Painful limitation of movement CLINICAL FEATURE OF MANDIBLE FRACTURE

27. CONDYLAR FRACTURE (UNILATRAL, BILATARAL, INTRACAPSULAR, EXTRACAPSULAR) Bilateral condylar fracture Swelling over the TMJ Haemorrhage from ear on the affected side Battle‘s sign Locked mandible Hollow over the condylar region after oedema has subside Rarely paraesthesia of lower lip Deviation to the affected side Painful limitation of movement Restriction mandible movement Anterior open bite CLINICAL FEATURE OF MANDIBLE FRACTURE

28. Preliminary treatment History: Particulars of the patient Chief complaints History of the present illness Past medical history Drug history Family history Personal history Socioeconomic history Immunization history Allergy history MANAGEMENT

29. General examination Clinical examination : Extra-oral examination Intraoral examination MANAGEMENT

30. Investigation For Diagnosis Orthopantomogram Lateral Oblique View of Ramus , Angle P/A view X rayOcclusal View x ray CT Scan For Assessment Complete Blood Count - RBC , WBC, Platelet, Hb % Random Blood Sugar SGPT /ALT Serum Creatinine Ultra sonogram of full Abdomen HBsAg Rapid Antigen Test for Covid-19 MANAGEMENT

31. Radiology Radiographs of mandible can be divided into two categories . Essential Desirable radiographs Essential radiographs left and right oblique lateral with the tube angled at 30° towards the lower jaw Posterior- anterior Rotated PA view Intraoral- Periapical Desirable radiographs Orthopantomograph Computed Tomography 3D CT Scan MANAGEMENT

32. MANAGEMENT In case of SYMPHYSIS and PARASYMPHYSIS fracture , the fracture line travels to upper border of mandible to lower border of mandible. If lower border is involved then step deformity can be occurred in the respective site.

33. MANAGEMENT In case of ANGLE fracture , fracture line seen behind the 3rd molars teeth region descending down to the antigonial notch .

34. MANAGEMENT In case of RAMUS fracture , fracture line is seen with in the ramus of mandible in radiograph extending either anterior border to posteriorly or vice versa involving either of the borders.

35. MANAGEMENT CONDYLER fracture is most commonly seen in neck of condyle region. So, radiology shows defect on that region.

36. Objectives of treatment of patient is done for Preservation of life Maintenance of Functions Restoration of appearance Basic principles to be followed for preservation of life of the injured patient A- Airway patency is maintained B- Control of Bleeding C- Maintenance of Circulation Advance Trauma Life support is done to an injured patient at the accident site A - Airway Maintenance with Cervical spine protection B- Breathing Maintenance with Ventilation C- Circulation Maintenance with Haemorrhage Control D- Disability Assessment (Neurologic Evaluation) E- Exposure and Environment MANAGEMENT

37. Basic Principles to manage any fracture are Reduction Closed Reduction Fragments are aligned without visualization by two methods Reduction by manipulation Reduction by Traction II. Open Reduction Fixation Direct skeletal fixation- external, internal Indirect skeletal fixation- arch bar wiring, gunning splint Immobilization Condyle 2-3 weeks Mandible 4-6 weeks Maxilla 3-4weeks Rehabilitation MANAGEMENT

38. Reduction Close reduction Indications for Closed Reduction Non displaced favourable fracture Grossly comminuted fractures Severely atrophic edentulous mandible . Lack of soft tissue overlying the fracture sites Fractures in children with developing teeth buds Coronoid process fractures MANAGEMENT

39. Reduction Close reduction Contraindications for Closed Reduction Respiratory problems: Severe asthma, COPD, etc. Alcoholic patients Seizure disorders Mental retardation Nutritional concerns Unfavourable/displaced fractures . MANAGEMENT

40. Advantages of close reduction Inexpensive. Only stainless-steel wires needed. Short procedure, stable. Generally easy, no great operator skill needed. Conservative, no need for surgical tissue damage. No foreign object or material left in the body. No operating room needed in most case, outpatient treatment. Disadvantages of close reduction Cannot obtain absolute stability (contributing to non-union & infection). Non-compliance from patient due to long period of IMF. Difficult (liquid) nutrition. 4. Muscular atrophy & stiffness. Charges in temporomandibular joint cartilage. MANAGEMENT

41. Reduction Open Reduction Surgical way of fracture management Intraoral or extra oral incision is done for the open reduction . MANAGEMENT

42. Reduction Open Reduction Indications of open reduction Displaced unfavourable/ unstable fractures. Multiple fractures, associated with midface fractures Associated condylar fractures he When IMF is contraindicated or not possible To preclude the need for IMF for patient comfort To facilitate the patient's desire for early return to work Edentulous atrophic mandibular fractures with displacement. Delayed treatment with soft tissue entrapment at the fracture site MANAGEMENT

43. Reduction Open Reduction Contraindications for Open Reduction: GA or a more prolonged procedure is not advisable. Severe comminution with loss of soft tissue. Gross infection at the fracture site. Patient refusing open reduction MANAGEMENT

44. Advantages of open reduction Reduction, fixation is done under direct vision. Early return to normal jaw function. Can get absolute stability promotes primary bone healing. Normal nutrition. Easy oral access (for examples, in intensive care unit patients) Bone fragments re-approximated exactly by visualization. Disadvantages of open reduction Expensive hardware. Some risk to neuromuscular structures & teeth. Prolong anaesthesia. Significant operating room time. Metal rejection. Need skill operator. MANAGEMENT

45. Fixation Non Surgically: Indirect skeletal fixation is done by arch bars or interdental wiring Surgically: Direct skeletal fixation is done using intraosseous wiring or miniplate or bicortical screw system. MANAGEMENT

46. Miniplate Osteosynthesis The metal plates are attached on the external cortex of the bone with the help of screws. A plate bending pliers and a plate bending lever us needed for its adaptation to the bone margin and surfaces. Types of miniplates According to materials Stainless steel Titanium Titanium coated Stainless steel Absorbable MANAGEMENT

47. MANAGEMENT Different types of plates are available, as like: 4 holes, 6 holes, 8-16 holes. The thickness of plate is 0.9mm and diameter of hole 2.1mm with bevel of 30°. Self-tapping conical screw of length 5-15mm and diameter of 2mm are available. Diameter of screw head is 2.8mm counter sinking of the head of corresponding to the 30°beveled drill hole in the plate

48. The important anatomical issues with monocortical miniplate osteosynthesis are: The location of the dense cortical bone. The location and course of the mandibular canal. Displacing forces acting on the mandible MANAGEMENT

49. MANAGEMENT Champy’s Ideal Osteosynthesis Lines Champy’s principle: Forces of mastication produce tension forces on upper border and compression forces on the lower border. Torsional forces are produced additionally anterior to canine teeth. Champy suggested and popularised biomechanically favorable lines the ideal osteosynthesis lines‖ along which, on the buccal cortex, these miniplates are to be secured with monocortical screws.

50. MANAGEMENT Immobilization There is no need to use Intermaxillary Fixation (IMF) where fixation is done by miniplates . And IMF is used where closed reduction is done. Immobilization is done for 4-6 weeks with IMF. And for condylar fracture the period if 2-3 weeks. IMF - is simply the wires or Elastics bands that are attached to both mandibular arch and maxillary arch for the stabilization

51. MANAGEMENT For Edentulous Jaw Gunning splint is used for the stabilization . A gunning splint for the edentulous mandible consists of a type of monoblock resembling two bite blocks joint together . Circumferential wiring is used to fix the splint to the mandibular bone and upper denture or splint is fixed to the maxillary by means of prealveolar wiring.

52. Rehabilitation IMF is released and mandibular movement is checked. If ankylosis , then aggressive physiotherapy is provided to mobilize the joint. If necessary miniplate in removed and in case of children miniplate removal is must because continuous pain will develop during the jaw development. Curettage surgery is done in bone. MANAGEMENT

53. The Treatment Protocols for Mandibular Fractures in Children Conservative Treatment with Splints Lateral compression splints : These are prepared and fixed to the mandibular body with circummandibular wiring (complete deciduous dentition or with mixed dentition) Alternative methods used for fixation of mandibular fractures in children : Orthodontic resin can be used for fixation. Orthodontic rubber elastics in combination with fixed orthodontic brackets. Open Reduction Open reduction is not usually necessary. But, in multiple displaced fractures especially, at the angle and parasymphysis region, open reduction may be needed MANAGEMENT OF MANDIBULAR FRACTURE IN CHILDREN

54. Complications of Mandibular Fractures Complications during Primary Treatment. Late complications Complications During Primary Treatment: Misapplied Fixation Infection Nerve Damage Displaced Teeth and Foreign Bodies Pulpitis Gingival and Periodontal Complications Drug Reactions MANAGEMENT

55. Complications of Mandibular Fractures Late complications: Malunion - Non union - delayed union Delayed Union and Non-Union Sequestration of bone Traumatic Myositis Ossificans Limitation of Opening Scar MANAGEMENT

56. CASE REPORT

57. CONCLUSION Mandibular fractures are the most common fractures of facial region due to their prominent position. Treatment options depend upon the type of fracture of mandible according to the anatomic variations. Proper correction if bony defect/ fractures are very essential along with the proper correction of teeth in their occlusion. the improper treatment may lead the patient to have problem of occlusion, function of mandible aesthetics of teeth, and extra stretching forces to the muscles of mastication which may lead to psychological problem to the patient in long term