Management of Mandibular Fractures

Management of Mandibular Fractures - Presented as a aprt of weekly Presentation in OMFS Department, Dhaka Dental College; Dhaka; Bangladesh

1. Management of Mandibular Fracture Dr. Tshewang Gyeltshen_ 49DDCH_2017

2. What is a Fracture? Fracture is defined as a break in structural and natural continuity of bone Mandibular Fracture:- Is that when fracture is involved in the mandible.

3. Etiology Vehicular Accidents involving (RTA) – 43 % Interpersonal violence, Assaults – 34% Falls – 7% Contact sports 4 % Industrial /work related – 10% Pathological Fracture – unconfirmed Studies have shown that the incidence of mandible fractures are influenced by various etiological factors e.g. Geography Social trends Road traffic legislations Seasons

4. Diagnosis of mandibular fractures 4 History Clinical examination Radiological examination

5. Clinical examination

6. Radiographic examination Plain radiograph OPG Lateral oblique PA mandible Lower occlusal CT scan 3-D CT MRI 6

7. Emergencies Involving Mandibular Fracture With rare exception, mandible fractures are not surgical emergencies. Emergencies involving Mandibular fracture happens with unfavorable fractures involving bilateral Para-symphysis fracture pulling the anterior part backward and compromising the airway. Paralysis of tongue and consequently airway compromisation

8. Types of Mandibular Fracture Simple - Includes a closed linear fractures Compound or open Comminuted Greenstick Pathologic Multiple Impacted Atrophic Complicated or complex

9. Classification by anatomic region 9 Dingman and Natvig Condylar process Coronoid Ramus Angle Body Symphysis Parasymphysis Alveolar process

10. Treatment Protocol ATLS protocol Primary Survey – A-- Airway Maintenance and Cervical Spine Protection B– Maintenance of Breathing and Ventilation C– Circulation and Hemorrhage Control D– Disability/Neurological Examination – AVPU E– Exposure under proper environment Secondary Survey – head-to-toe evaluation, including a complete history  and physical examination and reassessment of all vital signs. Tertiary Survey -- In Hospital Care

11. Definitive In-Hospital Treatment Reduction Restoration of a functional alignment of the bone fragments Use of occlusion Open reduction Closed reduction Fixation Immobilization To allow bone healing Through fixation of fracture line Rigid Non-rigid

12. Closed reduction 12 Indications Nondisplaced favorable fractures Grossly comminuted fractures Significant loss of overlying soft tissue Edentulous mandibular fractures Mandibular fractures in children Coronoid process fractures Condylar fractures

13. Open reduction 13 Displaced unfavourable fractures Multiple fractures of the facial bones Midface fractures and displaced bilateral condylar fracture Fractures of an edentulous mandible with severe displacement of fracture segment Edentulous maxilla opposing a mandibular fracture Delay of treatment and interposition of soft tissue between noncontacting displaced fractures fragments Malunion Conditions contraindicating Intermaxillary fixation

14. Removal of a tooth from the fracture line ABSOLUTE INDICATION RELATIVE INDICATION Vertical fracture Dislocation or subluxation Periapical infection Infected fracture line Acute pericoronitis Functionless Advanced caries Advanced periodontal disease Doubtful teeth Teeth involved in untreated fractures presenting more than 3 days after injury

15. Methods of immobilization Intermaxillary fixation with Osteosynthesis Intermaxillary fixation:- Bonded Brackets Dental Wiring :- a). Direct wiring b). Eyelet wiring Arch Bars Cap Splints IMF Screws Osteosynthesis without Intermaxillary fixation

16. Methods of immobilization 16 INTERMAXILLARY FIXATION WITH OSTEOSYNTHESIS Trans-osseous wiring Circumferential wiring External pin fixation Bone clamps Transfixation with Kirschner wire

17. Methods of immobilization 17 INTERMAXILLARY FIXATION WITHOUT OSTEOSYNTHESIS Compression plates Miniplates Lag screws

18. Period of immobilization 18 Young adult with Fracture of the angle receiving Early treatment in which Tooth removed from fracture line if Tooth retained in fracture line : add 1wk Fracture at the Symphysis: add 1 wk Age 40yrs and over : add 1or 2 wks Children and adolescents : subtract 1 wk 3 weeks

19. Various dental wiring techniques 19 ESig's wiring- (single –double wiring) (Charles J. Essig ) Gilmer’s wiring Risdon’s wiring – (Twisted labial wire) (E.Fulton Risdon) Ivy eyelet wiring (Robert H.Ivy ) Clovehitch wiring Col . Stout’s multiloop wiring (R.A.Stout) Button wiring (Varaztad Hovhannes Kazanjian )

20. Management of Coronoid Process and Ramus Fracture Most ramus fractures can be treated with MMF x 6 weeks Challenges– Difficult intra-oral plating External approach for plating is similar to that of angle fractures Coronoid Fracture is uncommon and if it occurs it is usually associated with a ZMC fracture

21. Management of Condylar Fracture Most condyle fractures can be treated with MMF x 2-4 weeks If the head is involved, MMF is limited to 2 weeks to prevent TMJ ankyloses Frequent scenario is a condyle fracture with contralateral parasymphyseal, body, or angle fracture—treat contralateral fracture with ORIF and condyle fracture with MMF x 2-4 weeks When plating is required, an external approach is preferred External approach is similar to the angle approach but with the superior end of the incision brought to about 2 cm from the earlobe.

22. Mx . Of Condylar Fracture: literature Review Controversial Treatment Options between closed or open reduction Treatment aim – to recover normal TMJ function Treatment choice depends on fracture level, amount of displacement, adequacy of the occlusion and age. Advantages early mobilization of the mandible , better occlusal results, better function, maintenance of posterior ramal height, avoidance of facial asymmetries Disadvantages Risk of damage to facial nerve branch Chance of Cutaneous Scar Open Reduction

23. Closed Reduction includes MMF with Elastics D egree of displacement of the condylar fracture has been used in deciding between open or closed treatment Mikkonen et al. recommended open reduction if the condylar displacement was greater than 45 degrees in a sagittal or coronal plane Widmark et al. recommended opening such fractures if the displacement was greater than 30 degrees. Zide and Kent described the absolute and relative indications for open reduction of condyle fractures displacement of the condylar head into the middle cranial fossa; 2. I mpossibility of obtaining adequate occlusion by closed reduction; lateral extracapsular displacement of the condyle; and 4 4. Invasion by a foreign body ( e.g. gunshot wound. bilateral condyle fractures in an edentulous patient; unilateral or bilateral condyle fractures when splinting is not recommended for medical reasons ; . bilateral condyle fractures associated with comminuted midface fractures; and 4. bilateral condyle fractures and associated anthological problems (e.g. lack of posterior occlusal support) Absolute Indications Relative Indications

24. Management of Mandibular Angle Fracture One of the most common fracture sites. Non-displaced fractures can be treated with MMF x 6 weeks Reasons cited: Presence of impacted third molars Thinner cross-sectional area in the angle region. B iomechanical lever arm.

25. Although maintenance of the absolute rigidity on treatment of angle fractures has been major principle, In 1973, Michelet et al, described the use of small, malleable bone plates for treatment of angle fractures. This led to a change from the previous belief that rigid fixation was necessary for bone healing. Later, Champy et al. validated the technique by performing several clinical investigations. They determined the most stable location where bone plates should be placed based on the ‘‘ Champy’s ideal lines of osteosynthesis ’’ Disadvantage:- Unable to achieve absolute immobilization

26. A prospective study performed by Amrish Bhagol et al looked at eight methods for treating mandibular angle fractures: 1. closed reduction 2. extraoral ORIF with a large reconstruction plate 3. intraoral ORIF using a single lag screw 4. intraoral ORIF using two 2.0-mm minidynamic compression plates 5. intraoral ORIF using two 2.4-mm mandibular compression plate 6. intraoral ORIF using two noncompression miniplates 7. intraoral ORIF using a single noncompression miniplate; and 8. intraoral ORIF using a single malleable noncompression miniplate In the study, they found out that , extraoral ORIF with a reconstruction plate and intraoral ORIF using a single miniplate had least complications (7.5 % and 2.5%, respectively). Thus they concluded that these two methods were best for angular fracture management.

27. Management of Fracture of the Body of Mandible Simple fractures involving the body of the mandible can be effectively treated with one miniplate along the Champy line of osteosynthesis. Dissection should be done avoiding the damage to mental nerve which supplies the lower lips. Champy popularized the treatment of mandible fractures with miniplate fixation along the ideal lines of osteosynthesis. This is a form of load-sharing osteosynthesis to be applied in simple fracture patterns having an acceptable amount of bone stock.

28. Intraoral approach best Arch bars placed and MMF wires secured prior to incision 5 cm incision made in the gingivobuccal sulcus over the fracture, leaving a 1 cm cuff of tissue from the mucogingival junction for closure Dissection carried to bone Mental nerves identified and preserved Fracture line debrided, reduced, and MMF tightened Four hole tension band secured between the tooth roots and mental foramen with monocortical screws Larger 2.3 to 2.7 mm system titanium plate is secured anteriorly through the intraoral incision with 2-3 screws. MMF wires cut and occlusion checked; if satisfactory, incision is closed.

29. Management of the Fracture of the Parasymphysis and Symphysis Parasymphyseal fractures:- Fracture lines in the canine region. Symphysis fracture:- Any fracture line between the canine to canine.

30. Several authors have shown that miniplate fixation in symphysis and parasymphysis is very effective way to fix this fractures. The most common approach – transoral gingivolabial and gingivobuccal incision. Larger comminuted fractures, an external approach may be necessary to accurately and rigidly fixate the mandible. Simple symphysis fractures can be treated with two miniplates fixation. Single Miniplates not given – displaces on torsional forces during functions

31. One miniplate is placed at the inferior border and a second plate is placed superiorly. Several authors have shown that miniplate fixation along these lines is a very effective way to fixate these fractures. More rigid fixation should be considered for comminuted fractures Lag Screw :- used in reduction of the lingual border of the fracture and re-establish the appropriate intergonial distance by squeezing the mandibular angles together. For optimal strength, two lag screws are placed.

32. Baby John et al described a case of 4.5 years old boy having been treated with acrylic aplints. Under sedation, upper and lower arch alginate impressions were taken and stone casts were poured. An open occlusal acrylic splint was fabricated and under GA, the mandibular fracture was immobilized and fixed with acrylic splint and then retained by circummandibular wiring. Patient was reviewed weekly and on the third postoperative week was removed with LA. Patient achieved perfect occlusion and good masticatory efficiency. Treatment principles of mandibular fractures in children differ from that of adults due to concerns regarding mandibular growth and development of dentition

33. Geriatric Patient with Mandible Fracture Fractures of the edentulous mandible most commonly involve the body region Can be treated by either open or closed reduction methods. Closed reduction with the use of prosthetics (existing dentures or Gunning splints) The current accepted concept in geriatric mandible fracture is to go for open reduction and internal fixation

34. Coleman’s Sign " There is one sign which is almost pathognomonic of fracture of the body of the mandible, and that is an effusion of blood into the (tissues of the) floor of the mouth, raising its mucous membrane and producing a characteristic bluish, tense swelling under the tongue”. – Frank Coleman, 1912

35. Recent Developments in Mandibular Fracture Management Use of 3D Navigation System in Mandibular Fracture Treatment as described by Matthias Feichtinger et al, 2001

36. Use of Digital Volume Tomography (DVT) in mandibular Fracture as described by CM Ziegler et al The panoramic radiograph is poorly positioned due to patient’s multiple trauma. It shows fractures at the right mandibular angle and the left canine and premolar region 3D reconstruction confirm the fractures at the right mandibular angle and demonstrates clearly the parasymphyseal fracture in the left canine region. This 3D image also shows a displaced fragment at the inferior cortex. Axial DVT view Recently endoscopic subcondylar fracture repair has been described with encouraging results.

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