Mandible Fractures and medical management

Management of mandible fractures

1. Mandible Fractures: The complex Bone Peter D Waite MPH DDS MD Professor and McCallum Chair KLS Martin Lecture

2. History of Mandible fractures Egypt papyrus writing 1650BC described non-treatable fatal mandible fractures Hippocrates first described reduction and stabilization Italy, 1180 importance of occlusion Guglielmo Salicetti 1492 described MMF but was lost until Gilmer (US) 1887 Kinlock, Buck used Open Reduction and Silver wire

3. History cont. Schede 1888 first Steel bone plate Luhr, 1960 vitalium plate Spiessl 1970 AO Champy, Michelet develop noncompression

4. The Edwin Smith Surgical Papyrus Ed. Henry Breasted, 1930 Imhotep Egypt's great architect-physician 3000 BC

5. Epidemiology Males, ages 16-40 Mandible to maxilla 6:1

6. 834 trauma patients 68% 18 – 40 yrs old 73% male 63% blunt trauma 40% weekends 7days ICU 9% fatal

7. Facial fractures 3% MVA 90% assaults Mandible most often Left> nasal> right Shepherd ‘88

8. Fracture concepts Bone fractures by tensile strain, since resistance to compression force is greater. Bone is pulled apart, not broken

9. Seat Belt legislation MVA 33% decrease to 22% Front seat 20% decrease to 5% Assaults 28% increase to 44%

10. Alcohol and violence Most drinkers are not violent Higher assoc. with urban, unemployment, male groups

11. Mortality in facial trauma 84 cases 20 died of asphyxia due to aspiration of blood, airway obstruction

12. classification Simple or closed Compound or open Comminuted Greenstick Pathologic Complicated dislocation Direct /Indirect Impacted Incomplete Multiple Unstable Favorable /unfavorable

13. Diagnosis History: Pain, malocclusion, trismus, difficulty chewing, altered sensation Mechanism of injury Previous facial trauma TMJ Pre Injury occlusion

14. Diagnosis Physical Exam Tenderness to palpation Malocclusion Loss of normal form, asymmetry Loss of function, Altered sensation Edema, Bleeding, Ecchymosis, Hematoma Abrasions, lacerations Crepitation, Emphysema

15. Principles of Fx Healing Primary healing Without callus Haversions remodeling, 50-80micm/day Gap healing (OJD) 0.8-1.0mm 2-4 weeks

16. Principles of Fx Healing Secondary bone healing Unstable, fibrous callus Inflammatory stage 1 – Mast cells Cartilaginous stage 2 – callus Bony stage 3 – osteocytes Remodeling stage 4 - woven bone

17. Principles of Rigid Fixation Mandible is a class 3 lever Stabilization by splinting i.e. Atrophic mandible Stabilization by compression i.e.. Large contact bone fixed with miniplates

18. Hardware design Plates and screws

19. MMF: Arch bars American arch bar 1 st place finalist 1983 First place in single and double competition in European games 1985 Blue ribbon victory of 1 st Asian Arch Bar game in Korea 1995 International faculty/resident competition world record 12min application 10point finish, 2000

20. Open reduction indications Treatment of choice Displaced unstable Assoc. mid face fx Assoc, condyle fx MMF contra-indicated or precluded for comfort Facilitate patient

21. Surgical approach to mandible Anterior vestibule Intraoral body, angle, ramus Submandibular, risdon Submental

22. Alveolar atrophy results in decrease vertical dimension.

23. Problem of atrophy The unique systemic physiology of patients with mandibular atrophy, and their anatomy; 3D bone, with or without teeth, specific muscle pull, and function, presents a very complex challenge for fracture fixation and healing.

24. External pin fixation Rarely indicated today, with internal fixation technology.

25. implants, 3-01-01

26. Big Jim

27. A good rep is Obedient, kind, honest, helpful, punctual, polite, accurate, informative, optimistic Always takes the blame after a brief professional berating. Never, talks too much about how other surgeons “do it “ Never “bad mouths” Knows the limits on “sucking up too much”

28. Dr. James KLS Koehler MD DDS

29. Thank you