MANDIBULAR FRACTURE.pptx

FRACTURES

1. MANDIBULAR FRACTURE DR DAVIS NADAKKAVUKARAN READER MALABAR DENTAL COLLEGE

2. CONTENT Introduction Anatomy of mandible Etiology Location Classification of mandibular fracture Diagnosis Management

3. INTRODUCTION Most prominent jaw bone in the lower third of the face Fracture occur more frequently when compared to other bones For the management , proper anatomy and attachment of muscle of this jaw

4. ANATOMY OF MANDIBLE Largest , strongest bone in face Horse shoe or parabola shape Angle of curvature is 110 -140 Inferior border of the mandible is made of dense cortical bone only no medullary Cortical bone is thickest at lower border Gradually thins down as it goes posterioly . Composed of symphysis region which is the region where the two sides of developing mandible fuse during formation Horizontal aspect –body Vertical aspect –rami At end two process – coronoid and condylar aspect

5. MUSCLE ATTACHMENT Muscles of mastication Muscles on lingual side of mandible Geniohyoid Genioglossus Mylohyoid Anterior belly of digastric

6. ETIOLOGY External violence Vehicle accidents Industrial accidents Assaults Gunshots Sports trauma Contact sports such as boxing Fall froma height Sports Due to pathologies in the mandible Due to surgical procedures in the mandible

7. LOCATION Body region(29%) Condyle (26%) Symphysis (17%) Ramus (4%) Coronoid process fracture (1%)

8. CLASSIFICATION

9. Anatomical location

10. According to the direction of fracture and favorability for treatment

11. Horizontally unfavorable

12. Presence or absence of teeth

13. AO CLASSIFICATION

14. HISTORY Cause Protective helmet/ seatbuilt Direction of force Teeth clenched at the time of injury Flow from broad or sharp object Medical history

15. CLINICAL FEATURES

16. DIAGNOSIS Panoramic radiograph Lateral oblique radiograph Posterior anterior mandibular view Reverse towne view Mandibular occlusal view Periapical radiograph CT scan

17. MANAGEMENT PRINCIPLES IN TREATMENT Pt. physical and general status should be evaluated and monitored prior to any consideration Diagnosis and treatment of mandibular fracture should be approached methodologically Dental injuries should be evaluated Reestablishment of occlusion is primary goal With multiple fracture mandibular fracture should be trated firtst Prophylatic antibiotic treatment should be used for compound fracture

18. MODALITIES OF MANAGEMENT

19. Intermaxillary fixation with osteosynthesis Transosseous wiring Circumferential wiring External in fixation Bone clamps Transfixation with kirschner wires Intermaxillary fixation Dental arch wires Arch bars

20. Methods of immobilization Osteosynthesis without intermaxillary fixation Non compression small plates Compression plates Mini plates Lag screws

21. REDUCTION

22. CLOSED REDUCTION TECHNIQUES Arch bar fixation Bridle wiring Figure of eight wiring Gilmer’s direct interdental wiring Eyelet wiring Essig’s wiring Stout’s continuous loop wiring Risdon s wiring

23. ARCH BAR FIXATION Most common type –Erich’s arch bar Technique Prefabricated arch bar with hooks are incoorperated on the outer surface with flat malleable stainless steel metal strip. Should be cut accuarately to the length of the dental arch Each arch bar is fixed to upper and lower jaw On upper jaw hooks are arranged in upward direction and lower jaw with downward direction Adapted to buccal surface according to arch form Fixed to each tooth by 26 gauge stainless steel wire from mesial surface to lingual side and buccal to distal Twisting done in clock wise manner Advantages Less trauma Replaced easily Flat hook Donot irritate the tissue

24. 2.BRIDLE WIRE For temporary stabilization of fractured segment Techniques Fracture reduced under LA and held in position Wire looped around teeth either side of fracture and tightened on buccal side 3.FIGURE OF EIGHT WIRING Used to stabilize the dentoalveolar fracture Teeth on either side of fracture are used for this 26 guage prestreched stainless steel wire is used

25. 4.GILMERS DIRECT WIRING Simple method Techniques Prestreched 26 gauge stainless steel wire Wire passed around single tooth in upper arch till it is tightened Similiarly wire passed around corresponding tooth in lower arch Teeth are brought in occlusion and twisted wires are held together tightened Done in fast immobilization is required 5 .RISDON WIRING Substitute for arch bars Second premolars on either sides are chosen for anchorage

26. 6.EYELET WIRING Make eyelet from prestreched 24 gauge stainless steel wire15 cm long pieces is twisted around probe and make a loop in centre and twist half around it Loose end of the eyelet wire are passed interproximally between 2 stable teeth from buccal side Ends grasped on the lingual side other end is to mesial side and one side on to distal side then both ends to buccal sides Then it passed to the loop of eyelet and then tightened in apical direction Advantages Firm and stable If any one break , it can be replaced

27. 7.ESSIG S WIRING When many teeth adjacent to the fracture line are not much strong to stabilize the fracture Luxated teeth should be pushed back into their sockets and stabilization area choosen should be at leat 3 teeth away from fracture line 8.STOUT S CONTINOUES LOOP WIRING Posterior quadrent are used for wiring A piece of solder wire is dapted to the buccal side in first quardrent from where wiring is started

28. OTHER METHODS External pin fixation Splints Circum mandibular wiring

29. OPEN REDUCTION Indication Unfavorable displaced fracture Panfacial fracture Nonunited fracture Malunited fracture If occlusion is not achieved by closed reduction Contra indication Medically unfit patient Advantage Anatomic reduction Fixation in desired position Return of function eralier No airway compramise Disadvanatges Surgical procedure Complication of sugery

30. SURGICAL APPROACHES TO THE MANDIBLE Symhysis , parasymphysis and body regions of the mandible- intraoral incision in labial mucosa - extraoral incision

31. RIGID FIXATION Plates andscrew osteosynthesis are used Popularised by AO/ASIF Variuos types are Dynamic compression plates Eccentric dynamic compression plates Self compression plates Advanatges No MMF Airway safty Return of jaw function faster Patient nutrition is not compramised Disadvanatages Require surgical skill and training Fixation plates are bulky Stress shielding effect

32. DYNAMIC COMPRESSION PLATE(DCP) It xreates a compression on both side of fracture line Unique design –whole on the plates Two types 1–compression hole 2-static or passive hole compression hole-Widest diameter hole placed near fracture line and screw inserted in narrow part of the hole Both the screw are tightened fracture end gets compressed against each other Passive whole round , not create compression between bone fragment

33. ECCENTRIC DYNAMIC COMPRESSION PLATES(EDCP) DCP causes the problems of gaping of the superior border of mandible EDCP used Design Two compression plates on weither side of the fracture line Addition obliquely placed two compression holes two passive holes are present

34. SEMI RIGID FIXATION Champy introduced , in which material used was able to resist these unfavorable masticatory forces Designs of the plates Miniplates are mono cortical 1mm thick and 6mm wide They have a standard distance between the holes Screws are self tapping Technique of placement Fracture is exposed and reduced using manual manipulatio n or bone holding forceps Bones are held in the position and plates are applied on it Placed along the osteosynthesis lines Hole is placed away from the fracture line nad drilled perpendicular to the plates surface First screw is inserted and tightened Next screw is placed near to fracture line

35. Lag screws By brons and boering If fracture with bicortical section Bioresorbable plates Made up of polydioxanone,polyglycolic acid, polylactic acid Once a plates are placed , over a period o0f time, the material gets resorbed as the glycolic acid by citric acid cycle Eliminated as CO2 Disadvanatges Foreign body reaction Inflammatory reaction Osteolytic changes Plate may not be rigid to support the fracture

36. SPECIAL CONSIDERATION Fracture in edentulous patient; use of gunning splint

37. TEETH PRESENT IN THE LINE OF FRACTURE If the tooth present in the line of fracture, Indication for extraction Excessive mobility Fracture of the root Teeth that prevent reduction of fracture must be moved Indication for preservation Tooth with crown fracture Tooth that appears non –vital time of fracture Completely impacted teeth should be retained to provide additional bone for plating