Mandibular Fracture.ppt

Mandibular Fracture

1. MANDIBULAR
FRACTURES
Prof. Dr.Shivaraj.S.Wagdargi
Oral and maxillofacial Surgery

2. –Introduction
–Classification
–Diagnosis of mandibular fracture
–Radiologic examination
–General principles
–Treatment of mandibular fractures
–Complication associated with mandibular
fractures
–Conclusion
–References
CONTENTS

3. INTRODUCTION
•Mandible forms the lower third of the face and is
responsible for esthetics , mastication and speech
•Given the unique geometry of the mandible and TMJ’s,
these fractures can result in marked pain, dysfunction, and
deformity if not recognized and treated appropriately .
•Understanding of the anatomy and physiology of the
masticatory system is therefore essential in treating fractures
of the mandible.

4. –Simple or closed
–Compound or open
–Comminuted
–Greenstick
–Pathologic
–Multiple
–Impacted
–Atrophic
–Indirect
–Complicated or complex
Dorland’s Illustrated Medical Dictionary:

5. DINGMAN & NATVIG’S
CLASSIFICATION
(based on anatomic region -1964)
–SYMPHYSIS #
–PARASYMPHYSEAL #
–BODY #
–ANGLE #
–RAMUS REGION #
–CORONOID #
–CONDYLE #
–DENTOALVEOLAR #

6. Kazanjian and Converse
1974
Class I: Teeth are present on both
sides of the fracture line.
Class II: Teeth are present on only one
side of the fracture line.
Class III: The patient is edentulous.

7. Kruger and Schilli-1982
1. Relation to the external environment
A. Simple or closed
B. Compound or open
2. Types of fractures
A. Incomplete
B. Greenstick
C. Complete
D. Comminuted
3. Dentition of the jaw with reference to the use of splints
4. Localization

8. Vertically favorable fracture
Angle fractures may be classified as (direction of # line & muscle action)
(1) Vertically favorable or unfavorable and
(2) Horizontally favorable or unfavorable

9. Vertically unfavorable fracture

10. Horizontally favorable fracture
Horizontally unfavorable fracture

11. Bilateral fractures in the canine area

12. DIAGNOSIS OF MANDIBULAR
FRACTURES

13. CLINICAL EXAMINATION
Three stages
1.Immediate assessment and treatment of any condition constituting a threat
to life
2.General clinical examination of the patient
3.Local examination of the mandibular fracture
The mere fact that a patient is ambulant and apparently unaffected by the
Injury doesn't necessarily preclude the presence of more serious underlying
damage (Killey)

14. Signs and symptoms
–Change in Occlusion
(Unilateral open bite, Retrognathicor prognathicocclusion etc.)
–Paresthesiaof the Lower Lip
–Abnormal Mandibular Movements (trismusor deviations)
–Change in Facial Contour and Mandibular Arch Form
(flattened, deficient mandible angle, retrudedchin, elongated face)
–Lacerations, Hematoma, and Ecchymoses
–Loose Teeth and Crepitationson Palpation (jaw clenched)
–Dolor, Tumor, Rubor, and Calor

15. DENTOALVEOLAR FRACTURES
–Avulsion, subluxation or fracture with alveolar component
–Occur alone or in combination with other fractures
–Full thickness wound of the lower lip or ragged laceration on the
inner aspect –impact of anteriors
–Bruising of the lips with foreign bodies within.
–Laceration of the gingiva, deformity of the alveolus
–Alveolar # -with /without associated injury to teeth

16. CORONOID FRACTURES
–Rare fracture –reflex contraction of the temporalis or
direct trauma to the ramus
–Fragment pulled upwards into infratemporal fossa
–Tenderness over the anterior ramus
–Painful limitation of protrusive & lateral excursions
movement

17. Signs and symptoms influenced by the degree of displacement
Inspection:
–Swelling E/O at the angle with
obvious deformity
–I/O –step deformity behind the
last molar
–Haematomaadjacent to the
angle on either buccalor lingual
side or both
–Anesthesia / parasthesiaof the
lower lip
–Derangement of occlusion
Palpation:
–Tenderness at the angle
externally
–Movement / Crepitus at the
site
–Step deformity
–Painful movements / trismus
ANGLE FRACTURES

18. BODY FRACTURES (MOLAR & PREMOLAR REGIONS)
–Similar features as angle # -swelling & tenderness
–Derangement of occlusion
–Premature contact on the distal fragment
–Vertical fracture of teeth in the fracture line

19. MULTIPLE & COMMINUTED FRACTURES
–More severe soft tissue injury
–Impossible to determine the pattern clinically
–Not associated with gross displacement

20. PARASYMPHYSIS AND SYMPHYSIS FRACTURES
–Commonly associated with fracture of one or both condyles
–Tenderness at the # site
–Lingual haematoma (Cole’s sign)
–Oblique # -over-riding of the fragments with lingual inversion of
the occlusion
–Soft tissue injury of the lip & chin
–Detachment of the genioglossus –loss of tongue control &
obstruction of the airway
–Not usually associated with anesthesia of the mental region

21. CLINICAL EXAMINATION SUMMARY
Clinical signs to look for and to rule out –Fonseca
1. Evidence of trauma –facial contusions, abrasions, laceration of the
chin, and /or ecchymosis or hematoma in the TMJ region
2. Bleeding from the external auditory canal
3. A noticeable or palpable swelling over the TMJ
4. Facial asymmetry as a result of edema or ramalshortening
5. Pain and tenderness
6. Crepitation
7. Malocclusion
8. Deviation of the mandible
9. Muscle spasm with associated pain and limited mouth opening
10.Dentoalveolar injuries

22. 1. Panoramic radiograph
2. Lateral oblique radiograph
3. Posteroanteriorradiograph
4. Occlusal view
5. Periapicalview
6. Computed tomography (CT) scan
RADIOLOGIC EXAMINATION

23. Panoramic radiograph
Shows the entire mandible , simple technique
Requires the patient to be upright (difficult in traumatized patient)
Poor detail in the TMJ & symphysisregion.

24. Posteroanterior radiograph
Demonstrates medial / lateral displacement of
fractures in the ramus, angle,body,and symphysis
region
Cannot visualize thecondylar region

25. Lateral oblique radiograph
Used to visualize ramus,
angle, and body fractures
Limited visualization of the
condylar region, symphysis,

26. Occlusal view
Used to visualize fractures in the body in regardsto medial or lateraldisplacement
Used to visualize symphysealfractures for anteriorand posteriordisplacement

27. Computed tomography
(CT) scan
Ideal -condyle fractures axial and coronal views, 3-D
reconstructions
Disadvantage:
–Expensive
–Larger dose of radiation exposure compared to plain film
–Difficult to evaluate direction of fracture from individual
slices (reformatting to 3-D overcomes this)

28. SPECIFIC TREATMENT OF MANDIBULAR
FRACTURE
–REDUCTION –CLOSED REDUCTION
OPEN REDUCTION
–FIXATION –RIGID FIXATION
SEMI RIGID FIXATION
–IMMOBILIZATION

29. REDUCTION
–Restoration of a functional alignment of the
bone fragments
–Must be anatomically precise
–Partial edentulous or opposing teeth missing
-less precise reduction acceptable
–Recognize any pre-existing occlusal
abnormalities
–Wear facets –valuable clues to previous
contact area

30. - NondisplacedFavorable Fractures (simplest method)
- Grossly Comminuted Fractures (Rich blood supply)
- Fractures Exposed by Significant Loss of Overlying Soft Tissue
- Edentulous Mandibular Fractures
- Mandibular Fractures in Children with Developing Dentitions
- Coronoid Process Fractures
- Condylar Fractures
INDICATIONSCLOSED REDUCTION

31. −Displaced Unfavorable Fractures of the Body, angle or the Parasymphyseal
Region of the Mandible
−Multiple Fractures of the Facial Bones
−Midface Fractures and Displaced Bilateral Condylar Fractures
−Fractures of an Edentulous Mandible with Severe Displacement of the
Fracture Fragments
−Edentulous Maxilla Opposing a Mandibular Fracture
INDICATIONS FOR OPEN REDUCTION

32. TEETH IN THE FRACTURE LINE
–Tooth may be damaged structurally or loose blood supply
–necrosis of pulp
–Tooth may be affected by some pre-existing pathology
–Fracture line may be infected –prolongs healing
–Pre-antibiotic days –such teeth extracted
–Tooth which is structurally undamaged, potentially
functional and not subluxed –retained
–Controversy regarding 3rd molar –removal or not?

33. Absolute indications for removal:
–Longitudinal fracture involving the root
–Dislocation or subluxation of the tooth from socket
–Presence of periapicalinfection
–Infected fracture line
–Acute pericoronitis
Relative indications:
–Functionless tooth -eventually be removed
–Advanced caries
–Advanced periodontal disease
–Doubtful teeth –could be added to existing denture

34. Management of teeth retained in fracture line:
–Good quality intra-oral periapical radiograph
–Appropriate antibiotic therapy
–Splinting of tooth if mobile
–Endodontic therapy if pulp is exposed
–Immediate extraction if fracture becomes infected
–Follow up for 1 year with endodontic therapy if there is
demonstrable loss of vitality

35. CLOSED REDUCTION & INDIRECT SKELETAL
FIXATION
–Direct interdental wiring
–Indirect interdental wiring ( eyelet / ivy )
–Continuous or multiple loop (COL .STOUTS)
–Arch bars
–Cap splints
–Gunning type splints

36. DIRECT INTERDENTAL WIRING (GILMER’S)
–SIMPLE AND RAPID IMMOBILIZATION
OF JAWS
TECHNIQUE
–15cm length of pre-stretched wire
0.35mm diameter passed around the
tooth emerging through interdental
spaces
–Twist produce 3cm tail
–After gross reduction twist the tail
together obtaining cross bracing
effect

37. INTERDENTAL EYELET WIRING (IVY LOOP METHOD)
15 cm prestrechedwires
0.35mm diameter
Eyelets are made by twisting
the middle of each length of
wire around the shaft of rod
around 3mm diameter.

38. CONTINIOUS OR MULTIPLE LOOP WIRING
–Stout’s 1943
–Permits blocks of teeth in either jaw to be wired in a such a manner that
elastic traction can be used to reduce the fracture.

39. ARCH BARS Baker(1986) describes a precast arch bar for greater accuracy of
Occlusal reduction
Erich arch bar
Jelenko pattern
Krupp's pattern German silver

40. The chosen arch bar is bent to confirm to the buccaland labial gingival margins of
teeth in displaced fractures to provide temporary reduction and stabilization wire is
passed around the teeth on either side of the fracture line, the ends of which are
twisted tightly together

41. INTERMAXILLARY FIXATION
SCREWS
Karlis et al.-use of cortical bone screw
fixation
the application of arch bars and
insertion of the wire in the interdental
space increase the chance of accidental
skin puncture, hence the chances of HIV
and viral hepatitis
ADVANTAGES -Ease of application,
Decreased operating time hence
diminished overall cost, Decreased risk
of disease of transmission
DISADVANTAGES: Interference with plate

42. CAP SPLINTS
Cap splints are of greater assistance with
fracture where standing teeth are
present on or all of the separate
fragments

43. GUNNING TYPE SPLINTS
Indication
•Pathological fractures
•Gunshot injuries
•Osteomyelitis at an edentulous
fracture site.
•Fracture associated with extreme
atrophy of the edentulous jaw.
•Fracture of the mandible
associated with fracture of the
middle third of the facial skeleton

44. –Patient existing denture
–Impressions from the patient mouth
–Model cast from the fitting surface of the patients
denture
–prefabricated gunning splints
Contraindication:
•Unfavorably displaced fractures laying outside the denture bearing
areas
•Severe posterior displacement of fracture of the anterior part of the
mandible which will probably require additional fixation

45. OPEN REDUCTION & DIRECT
SKELETAL FIXATION

46. SURGICAL APPROACHES TO THE
MANDIBLE

47. INTRAORAL SYMPHYSIS AND
PARASYMPHYSIS
•Anterior vestibular approach / Genioplasty
incision.
•Fast and simple way to gain access to the
anterior mandible without creating an extraoral
scar.
•The incision region is infiltrated with local
anestheticand vasoconstrictors.
•The lip retracted -a curvilinear incision is made
perpendicular to the mucosal surface (leaving at
least 1cm of mucosa attached to the gingiva).

48. •The mentalismuscle-incised
perpendicular to bone, leaving a
flap of muscle attached to bone
for closure.
•Subperiosteallydissection -
identify the mental neurovascular
bundle
•The fracture site is then identified
and reduced. The surgical site is
then closed in layers

49. SUBMENTAL INCISION:
•The visualization of the lingual cortex is possible
•The incision is marked in the submental crease and it
should not cross the inferior border of the mandible
•Incision should follow curve of mandible
•Subcutaneous tissue dissection –expose inferior
border of the mandible.
•Periosteum is incised to allow a subperiosteal
dissection.
•The mental nerves are identified and protected from
injury
•Closure is completed in three layers periosteum,
subcutaneous tissue and skin.

50. 78
Retromandibular approach or hind’s approach
•Exposes the entire ramus from behind the
posterior border.
•ADVANTAGES: close proximity to the
condylar area
•DISADVANTAGES: passing through the
parotid gland tissue, thus increasing the
risk of facial nerve injury and salivary
fistulae

51. •Main landmarks should be
visible –ear, lower lip and
corner of mouth
INCISION
•Begins 0.5cm below the ear
lobe
•Continues inferiorly 3.5 cm
Just behind the posterior
border of mandible

52. Sharp dissection through the thin
platysmamuscle, SMAS, and
parotid capsule after undermining
with a hemostat.

53. Blunt hemostat dissection through the parotid
gland, spreading in the direction of the fibers of
VII

54. Incision through the pterygomasseteric
sling along the posterior border of the
mandible. The inferior division of VII is
being retracted superiorly.
Subperiostealdissection of the masseter
muscle.
The periosteal elevator is used to strip the
muscle fibers from the top to the bottom
of the ramus.

55. Exposure of the posterior ramus.
The sigmoid notch retractor is placed into the
sigmoid notch, elevating the masseter, parotid,
and superficial tissues.

56. Approximating pterygomassetericsling
Closure of parotidcapsule

57. SUBMANDIBULAR APPROACH
–(Risdon 1934) -exposing the body, angle and ramus
•Incision : 1-2 cm below the inferior border
within a skin crease to avoid damage to
marginal mandibular nerve.
•Infiltration with local hemostatic is done
and 4-5 long incision made using a #15
blade through skin, subcutanoustissue and
platysma.

58. –The dissection to the bone is carried out
through the deep cervical fascia.
–The nerve fibres are retracted superiorly and
blunt dissection used to expose the pterygo-
masseteric sling.
–The capsule of the submandibular gland below
and lower pole of parotid gland above may be
encountered.

59. –Subperiosteal dissection -to expose the angle, body
and ramus and thus, the fracture site
–If facial vessels cannot be retracted successfully, they
may be ligated and cut
–Exposure can be increased and closure enhanced by
dissecting the medial pterygoid and stylomandibular
ligament from the inferior and posterior border

60. –The ends of the fracture segments are then
curetted to remove fibrous/granulation tissue
–Closure is done in multiple layers

61. METHODS OF FIXATION

62. TRANSOSSEOUS WIRING
–used either as a means of controlling a
fracture or an additional method to cap
and gunning type splints
–Indications:
•The edentulous mandibular fractures
•Grossly communicated mandibular
fractures

63. CIRCUMFERENTIAL WIRING
INDICATIONS
-oblique fractures of body of mandible
-children with mixed dentition
-in gunning type of splints in edentulous
mandible
•The wire is passed through upper border
of the fractured fragment over the
acrylic template which then passes
through the lower border of mandible
circumferentially

64. TRANSFIXATION BY KIRSHNER’S WIRES (K. WIRE)
–It is used to provide temporary stabilization of the
fractured mandible
–The fracture is held in reduced position and one or
more k wires are drilled through the fragments so that
part of the wire passes through undamaged bone on
each side of the bone

65. METHODS OF IMMOBILIZATION
–Non-compression plates
–Compression plates
–Mini-plates
–Lag screws

66. CHOICE OF METHOD
–Fracture pattern
–Skill of the operator & resources available
–General medical condition of the patient
–Presence of other injuries
–Degree of local contamination and infection
–Associated soft tissue injury or loss

67. COMPRESSION PLATING SYSTEMS
•Goal –‘Absolute stability’
•Maximum compressive forces –upto
300 kPa/cm
2
•Effect is stabilization of fracture,
minimizing inter osseous gap and
reduced chance of infection/nonunion

68. –Ideal location is at region of max tension –superior
border –but due to presence of tooth root and inf
alvbundle, this is not possible
–Thus the plate is inserted at the lower border, but
this fails to control the superior border fanning –
tension banding req
–Disadvantages –bulky, more chance of plate
exposure, palpable -patient dissatisfaction

69. CHAMPY ET AL 1976,1978
Champy.et.al 1976,78 analyzed the ideal line of osteosynthesis to neutralize the displacing forces
using mathematical model of the mandible
The Champy’s lines run from either sides of the external oblique ridge forwards, above the level of
the mandibular canal to just below and ahead of the mental foramen, where it splits, going above at
the subapical level and below just above the inferior border

70. MONOCORTICAL MINIPLATE OSTEOSYNTHESIS
–Basic principle is to fix
plates along the
Champy’s lines of
osteosynthesis
–Plating along these lines
will eliminate torsional
forces which tend to
open up the fracture
sites at the superior
border

71. Advantages:
•Reduced size –smaller incision & minimal soft tissue
dissection
•Easily to place
•Less likely to be palpable
•Uses monocorticalscrews –less likely to damage adjacent
structures
•Can be easily contoured in 3 dimensions
Disadvantages
•Smaller size –less rigid –plate fracture
•Limited use in communitedfractures
•Required longer period of reduced masticatory function
post operatively (soft diet)

72. Clinical applications:
•Symphysis# -2 plates at subapicaland
inferior border
•Parasymphysis# -single plate at subapical
region
•Angle # -single plate at external oblique
ridge

73. LARGE RECONSTRUCTION PLATE
•Temporary load bearing plates
•Communited #, defect #, infected #
•Most proximal screw -1cm away from fragment end
•4 screws in each end provide maximum resistance -Fonseca

74. Mini-Locking-System (plate thickness 1.0 mm,
screw outer diameter 2.0 mm).
Plate comes with threads
MINI PLATE LOCKING SYSTEM
LOCKING PRINCIPLE
-prevents stripping of screws
-prevents loosening and movements of
screws

75. –Conventional plating systems can lead to secondary dislocation as soon as the
pressure between plate and bone is no longer guaranteed. Plate fixation with
locking screws can avoid this kind of secondary dislocation.
–screw loosening and subsequent loss of reduction –avoided
–Advantages:
•Simplifies bending of plates
•Reduce dislocation following osteosynthesis
•Increases primary stability
•Prevents interference with vascular supply

76. COMPRESSION OSTEOSYNTHESIS USING LAG
SCREW
–In the treatment of oblique fractures

77. 1.True lag screws have threads only on the terminal end
of the screw.
Therefore, when inserted across a fracture, the threads
of the tip of the screw engage the far cortex and the
head of the screw engages the near cortex, causing
compression of the fracture fragments upon tightening.
2. If the near cortex is not overdrilled, the threads of the
screw will engage both near and far cortices preventing
compression of the fracture fragments.
3. Drill the near cortex to the external diameter of screw
4. Contraindication -comminutedfractures

78. BIODEGRADABLE PLATES AND SCREWS
Metallic plate
–Loosening, corrosion, avascular entrapment, infection,
intereferencewith fit of prosthesis, palpable
Polyglycolic acid Polydioxonone Poly-L-lacticide

79. ADVANTAGE
•Biocompatible,
•Absorbable material
•Appropriate load bearing properties
•Sufficient degradation rate to obviate the
necessity to remove plate and screws.
DISADVANTAGES
•Dimensions of the plate and screws
•During degradation marked
collection of the fluid occurs at the
site, resulting in an unacceptable
clinical swelling

80. COMPLICATIONS
•Infection–delay in treatment, patient non compliance
–(antibiotic therapy, plate removal if req)
•Facial widening –incorrect choice of rigid fixation device –
symphysealwith condylar # -lateral flaring of mandibular
angle (Ellis -provide medial direction to gonialangles)

81. •Malunion–complex injury, non compliant patient, violation of
principles of reduction ( correction –mandibular osteotomies to
correct occlusion)
•Delayed union/Nonunion-Inadequate immobilization, fracture
alignment, Interposition ofsoft tissue or foreign body, Incorrect
technique, high velocity injuries (re-operate and fix with locking
reconstruction plate)
•Scarformation–incisions in natural skin crease

82. CONCLUSION
•GiventheuniquegeometryofthemandibleandTMJ’s,these
fracturescanresultinmarkedpain,dysfunction,anddeformity
ifnotrecognizedandtreatedappropriately.
•Understanding of the anatomy and physiology of the
masticatory system is therefore essential to provide the desired
treatment in order to prevent unfavorable and adverse
complications.

83. –Oralandmaxillofacialtrauma3
rd
Edition2005VolumeI&II
–RoweandWilliams’MaxillofacialInjuries2
nd
Edition
VolumeI
–FonsecaOralandMaxillofacialsurgeryVolume3Trauma
–Mandibularfractures-KilleyandKay
REFERENCES