Mandibular fractures

mandibular fractures

1. Mandibular Fractures 03/06/15 Mandibular Fractures 1 /116

2. HISTORY INTRODUCTION ANATOMY CLASSIFICATION EXAMINATION AND DIAGNOSIS TREATMENT 03/06/15 Mandibular Fractures 2 Contents:

3. The pre-Christian era The first description of mandibular fractures dates to the 17 th Century BC in the ‘Edwin Smith papyrus ’, Hippocrates – direct reapproximation of # segments with the use of circum dental wires 1180, Textbook written in Salerno, It aly – importance of establishing a proper occlusion. 1492, the book Cyrurgia by Guglielmo Salicetti – first mention of the use of maxillomandibular fixation in treatment of mandibular #. 03/06/15 Mandibular Fractures 3 History:

4. History 1887, Gilmer reintroduced MMF in United States. Buck & Kinlock - first to do ORIF using wires. 1888 Schede - First to use stainless steel plate & screws. 1960, Luhr - first to use Vitallium compression plate 1970, Spiessl through AO/ASIF introduced principles of rigid internal fixation. 1970, Michelet- introduced small bendable, non compression plates- these were further modified by Champy . 1987 – M.S. Leonard first to report use of lag screws Late 1990s – introduction of use of bioresorbable plates 03/06/15 Mandibular Fractures 4

5. A tubular long bone, which is bent into a blunt V-shape . Mandible is strongest anteriorly in midline with progressively less strength towards condyle . dentition Muscle attachments. Mandible is one of the strongest bones, the energy required to # it being of the order of 44.6 –74.4 Kg / M(425Lb), which is about same as zygoma and about ½ that of frontal bone 03/06/15 Mandibular Fractures 5 Introduction: Mandible is embryologically a membrane bent bone although, resembles physically long bone .

6. 03/06/15 Mandibular Fractures 6 Anatomy:

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12. Zones of compression and tension within the mandible are determined by the muscles inserting and the forces exerted by these muscles. S maller arrows show direction of muscular forces Larger arrows show the load placed during function. This gives a zone of compression along the lower border and a zone of tension along the superior border Neutral axis about the level of the canal. 03/06/15 Mandibular Fractures 12

13. FRACTURE : Definition : Fracture is defined as break in the continuity of the bone. Mandibular fractures : Fractures of the mandible are common in patients, who sustain facial trauma. SEX : Most mandibular fractures are seen to occur in male patients. Ratio is approximately 4.5 : 1 AGE : 35 % of mandibular fractures occur between the ages of 20 to 30 years. 03/06/15 Mandibular Fractures 13

14. ETIOLOGY OF MANDIBULAR FRACTURES Vehicular accidents Altercation ,assaults , interpersonel violence Fall Sporting accidents Industrial mishaps or work accidents Pathological fractures or miscellaneous 03/06/15 Mandibular Fractures 14

15. Factors influencing displacement of fracture Degree of force Resistance to the force offered by the facial bones Direction of force Point of application of force Cross-sectional area of the agent or object struck Attached muscles 03/06/15 Mandibular Fractures 15

16. # SYMPHYSIS AND PARASYMPHYSIS:- Mylohyoid constitues a diaphragm b/w hyoid bone & mylohyoid ridge on inner aspect of mandible Oblique # in this region tends to overlaps -- genio & mylohyoid diaphragm 03/06/15 Mandibular Fractures 16

17. Bucket handle displacement 03/06/15 Mandibular Fractures 17 B/L # of parasymphysis results from force which disrupts the periosteum . displaced posteriorly under the influence of genioglossus / geniohyoid muscle Often removes attachment of tongue & allows TONGUE FALL BACK

18. Classification of mandibular fractures : General classification Anatomical locations Relation of the fracture to site of injury Completeness Depending on the mechanism Number of fragment Involvement of the integument The shape or area of the fracture According to the direction of fracture and favourability for the treatment According to presence or absence of teeth AO classification – relevant to internal fixation 03/06/15 Mandibular Fractures 18

19. Kruger's general classification Simple or Closed Fracture Compound or Open Comminuted Complicated or complex Impacted Greenstick fracture Pathological Classification: 03/06/15 Mandibular Fractures 19

20. Rowe & Killey classification Fractures not involving basal bone Fractures involving basal bone of the mandible. Subdivided into following : Single Unilateral Double unilateral Bilateral Multiple Dingman & Natvig classification Midline Parasymphyseal Symphysis Body Angle Ramus Condylar process Coronoid process Alveolar process 03/06/15 Mandibular Fractures 20

21. Kruger & Schilli classification Relation to the external environment Simple Or closed Compound or open Types of fracture Incomplete Greenstick Complete Comminuted Dentition of the jaw with reference to the use of splint Sufficiently dentulous patient Edentulous or insufficiently dentulous patient Primary and Mixed dentition Localization Fractures of the symphysis region between canines Fractures of the canine region Fractures of the body of the mandible Fractures of the angle Fractures of the mandibular ramus Fractures of the coronoid process Fractures of the condyle 03/06/15 Mandibular Fractures 21

22. Kazanjian classification Class – III : Patient is edentulolus Class – I : teeth are present on both sides of the fracture line Class – II : Teeth are present on only one side of fracture line 03/06/15 Mandibular Fractures 22

23. 03/06/15 Mandibular Fractures 23 6. According to direction of the fracture and favorability for treatment ( Fry et al)

24. 7. Relation of the fracture to the site of injury Direct fracture Indirect fracture 03/06/15 Mandibular Fractures 24

25. 8. AO Classification(relevant to internal fixation): 1) F: Number of fracture or fragments 2) L: Location (site) of fracture 3) O: Status of occlusion 4) S: Soft tissue involvement 5) A: Associated fractures of facial skeleton 03/06/15 Mandibular Fractures 25

26. 9. Grades of severity: I-V Grade I and II are closed fractures Grade III and IV are open fractures Grade V open fracture with a bony defect (gunshot) 03/06/15 Mandibular Fractures 26

27. 10. AO-analogue classification system of mandibular fractures Each compartment is classified independently, describing the degree of displacement and the presence of multifragmentation or osseous defects. Each fracture is classified: - type A, nondisplaced fractures - type B, displaced fractures - type C, multifragmentary /defect fractures Each fracture is divided into 3 groups, specific to the mandibular unit. 03/06/15 Mandibular Fractures 27

28. Vertical unit 03/06/15 Mandibular Fractures 28

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30. Horizontal unit 03/06/15 Mandibular Fractures 30

31. Central horizontal unit 03/06/15 Mandibular Fractures 31

32. History Clinical Examination Radiological Examination Panoramic radiograph Lateral oblique Radiograph Posteroanterior Radiograph Occlusal view reverse towne’s view CT scan Diagnosis of Mandibular fracture: 03/06/15 Mandibular Fractures 32

33. History Focussed questioning should reveal following: Mechanism of injury Previous facial fracture H/O TMJ disorders Preinjury occlusion 03/06/15 Mandibular Fractures 33

34. Clinical examination Examination of pt with # of mandible takes place in 3 stages: A. Immediate assessment and treatment of any condition constituting a threat to life. B.  General clinical examination of pt. C.  Local examination of mandibular #. 03/06/15 Mandibular Fractures 34

35. Change in occlusion Anesthesia , Paresthesia or Dysesthesia of lower lip Abnormal mandibular movements Change in facial contour and mandibular arch form Laceration , Hematoma and Ecchymosis Loose teeth and crepitation on palpation Clinical Examination 03/06/15 Mandibular Fractures 35

36. Clinical examination 03/06/15 Mandibular Fractures 36

37. 03/06/15 Mandibular Fractures 37 Test for sensation

38. Signs and symptoms Tenderness + ve Occlusion changes - # teeth - # alveolar process - # mandible at any location - # condyle Anterior open bite - B/L condylar # Posterior open bite - parasymphysis # Unilateral open bite - # ipsilateral angle - # parasymphysis Posterior cross bite - midline symphysis # - condylar # 03/06/15 Mandibular Fractures 38

39. Radiological examination Ideally need 2 radiographic views of the fracture that are oriented 90’ from one another to properly work up fractures Single view can lead to misdiagnosis and complications with treatment 03/06/15 Mandibular Fractures 39

40. OPG Most informative Shows entire mandible and direction of fracture (horizontal favorable, unfavorable) Disadvantages: – Patient must sit up up -right – Difficult to determine buccal/lingual bone and medial condylar displacement – Some detail is lost/blurred in the symphysis, TMJ and dentoalveolar regions 03/06/15 Mandibular Fractures 40

41. Posteroanterior (pa) radiograph: Shows displacement of fractures in the ramus, angle, body, and symphysis region Disadvantage: Cannot visualize the condylar region 03/06/15 Mandibular Fractures 41

42. Lateral oblique Used to visualize ramus, angle, and body fractures Disadvantage: Limited visualization of the condylar region, symphysis, and body anterior to the premolar 03/06/15 Mandibular Fractures 42

43. Occlusal radiograph Used to visualize fractures in the body in regards to medial or lateral displacement Used to visualize symphyseal fractures for anterior and posterior displacement 03/06/15 Mandibular Fractures 43

44. Computed tomography ct : Excellent for showing intracapsular 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) 03/06/15 Mandibular Fractures 44

45. The patient’s general physical status Diagnosis and treatment of mandibular fractures should be approached methodically not with an “emergency-type” mentality Dental injuries should be evaluated and treated concurrently with treatment of mandibular fractures Re-establishment of occlusion is the primary goal in the treatment of mandibular fracture. With multiple facial fracture mandibular fracture should be treated first. Intermaxillary fixation time should vary according to the type, location, number severity of the mandibular fracture as well as the patient’s age and health. Prophylactic antibiotics should be used for compound fractures. General principles in the treatment of mandibular fracture 03/06/15 Mandibular Fractures 45

46. Basic principles for Rx of Fracture Reduction Closed Direct interdental wiring Indirect interdental wiring (eyelet or Ivy loop) Continuous or multiple loop wiring Arch bars Cap splints 'Gunning-type' splints Pin fixation 03/06/15 Mandibular Fractures 46 Open Transosseous wiring ( osteosynthesis ) Plating Intramedullary pinning Titanium mesh Circumferential straps Bone clamps Bone staples Bone screws Fixation Direct Indirect

47. Immobilization Methods of immobilization (a) Osteosynthesis without intermaxillary fixation (i) Non-compression small plates (ii) Compression plates (iii) Mini-plates (iv) Lag screws (b) Intermaxillary fixation (i) Bonded brackets (ii) Dental wiring Direct Eyelet (iii) Arch bars (iv) Cap splints (v) MMF screws (c) Intermaxillary fixation with osteosynthesis (i) Transosseous wiring (ii) Circumferential wiring (iii) External pin fixation (iv) Bone clamps (v) Transfixation with Kirschner wires 03/06/15 Mandibular Fractures 47

48. 03/06/15 Mandibular Fractures 48 CLOSED REDUCTION

49. Non-displaced favorable fractures Grossly comminuted fractures Fractures exposed by significant loss of overlying soft tissue. Mandibular fractures in children with developing dentition Coronoid process fracture Condylar fractures Indication for Closed Reduction of Fractures 03/06/15 Mandibular Fractures 49

50. ADVANTAGES & DISADVANTAGES OF CLOSED REDUCTION Advantages Inexpensive Only stainless steel wire needed Convenient Gives occlusion Conservative O.T not required Generally easy ,no great operator skill needed Disadvantages 03/06/15 Mandibular Fractures 50 Cannot obtain absolute stability Difficulty nutrition Oral hygiene impossible Long period of IMF Changes in TMJ cartilage Weight loss Decrease range of motion of mandible Risk of wounds to operator

51. CLOSED REDUCTION HISTORY William Saliceto ( 1210-1277) Tied the teeth (MMF) Thomas Gilmer(1849-1931) Reviewed the tech, introduced Arch Bars in 1907. Barton bandage by JOHN BARTON Lingual-Labial occlusal splint. Vacuum formed acrylic splint Royal Berkshire Halo Frame 03/06/15 Mandibular Fractures 51

52. Direct interdental wiring Gilmer's wiring simple & rapid method of immobilization jaw first aid method temporary immobilization of # fragment Disadvantage - complete removal of wires - extrusion of teeth 03/06/15 Mandibular Fractures 52

53. IVY LOOP METHOD Q uick and easy way of obtaining maxillo -mandibular fashion. 24 gauge wire simple and effective for reduction and immobilization of # 03/06/15 Mandibular Fractures 53

54. WILLIAM’S MODIFICATION 03/06/15 Mandibular Fractures 54

55. Clove hitch Incase of single tooth 03/06/15 Mandibular Fractures 55

56. Button Wiring Leonard (1977) considers that eyelet wires have several drawbacks. He described the use of titanium buttons of 8mm diameter, inclusive of a 1mm rim, and 2mm deep. 03/06/15 Mandibular Fractures 56

57. Col. Stout wiring 03/06/15 Mandibular Fractures 57

58. Risdon’s wiring 03/06/15 Mandibular Fractures 58

59. Arch bars For temporary fragment stabilization in emergency cases before definitive treatment As a tension band in combination with rigid internal fixation For long-term fixation in conservative treatment For fixation of avulsed teeth and alveolar crest fractures 03/06/15 Mandibular Fractures 59

60. D ifferent types of Arch bar Winters Jelenkos Dautrys Arch bar Berns titinium arch bars Burmachs arch bar Custom made 03/06/15 Mandibular Fractures 60

61. Screws Screws are quick to place Reduce the chance of needlestick injury from wires Can be used with heavily restored teeth Can be placed and removed rapidly Well tolerated by patient Allow oral hygiene to be easily maintained IMF screws are machine manufactured and are available in the self-drilling and traditional drilling styles 03/06/15 Mandibular Fractures 61

62. Monocortical in nature Once a screw loosens, it must be removed and replaced, or an alternative method of reduction of the fracture should be considered D o not allow for any dynamic movement, and occlusal discrepancies may not be adjusted as with arch bars and elastics. 03/06/15 Mandibular Fractures 62 Disadvantage

63. Cap Splints : Indications Advanced periodontal disease #s of tooth bearing segments & condylar neck Portion of body of mandible missing Impression technique Fitting the splint Reduction of fracture 03/06/15 Mandibular Fractures 63

64. Biphasic pin fixation Closed technique uses external fixation (Morris appliance & Roger anderson appliance) for management of communited mandibular #. screws placed - two on either side of the fracture through stab incisions & holes drilled in the mandible . 03/06/15 Mandibular Fractures 64

65. Once external pins are in position , the fracture segments are manipulated to achieve reduction. Then the pins are locked in reduced position by applying of an acrylic mix that is placed over the ends of the pins that are protruding out of the skin. The acrylic is allowed to harden while mandible is held in reduced position. Steinmann pins or Kirshner wires can also be used as external pins 03/06/15 Mandibular Fractures 65

66. Indications Edentulous fractures If IMF is not feasible Comminuted fractures Bone graft requirements With a head frame Contraindications Irradiated tissues Grossly contaminated tissue Osteoporosis Osteosclerosis Atrophy 03/06/15 Mandibular Fractures 66

67. Advantages Control of the edentulous fragments without involving the fracture lines. under LA. avoidance of the need for surgery at the fracture site, minimum operative time Simple surgical technique. Disadvantages Conspicuous uncomfortable uncooperative or cerebrally irritated patient. Difficulty with washing and shaving scars caused- pinholes risk of infection . 03/06/15 Mandibular Fractures 67

68. Used in edentulous jaw fractures Acrylic splints take the form of modified dentures with bite block in place of molar teeth & space in the incisor area to facilitate feeding Gunning splints 03/06/15 Mandibular Fractures 68

69. INDICATION unilateral / bilateral # edentulous mandible CONTRAINDICATIONS unfavorable displaced #s lying out side denture bearing areas severe posterior displacement of #s of the anterior part of mandible 03/06/15 Mandibular Fractures 69

70. Immobilization Maxilla - Peralveolar wiring - Circum zygomatic wiring - With help of bone screws Mandible - Circum mandibular wiring 03/06/15 Mandibular Fractures 70

71. 03/06/15 Mandibular Fractures 71 OPEN REDUCTION

72. Displaced unfavorable fracture through angle of the mandible Displaced unfavorable fractures of the body or pasymphyseal region Multiple fractures of the facial bones Midface fractures and displaced Bilateral condylar fractures Fractures of the edentulous mandible with severe displacement of fragments Edentulous maxilla opposing a mandibular fracture Delay of treatment and interposition of soft tissue between noncontacting displaced fracture fragments. Malunion Special systemic conditions contraindicating intermaxillary fixation Indications for open Reduction 03/06/15 Mandibular Fractures 72

73. Contraindications G.A / more prolonged procedure is not advisable Gross infections at the # site Severe comminution with loss of soft tissue Patients with difficult to control seizures 03/06/15 Mandibular Fractures 73

74. Advantages of open reduction. Accurate reduction & fixation of fractures by direct visualization. Better bone healing. Early return to normal jaw function. Normal nutrition, no weight loss. Patient can maintain oral hygiene. Early return to work. 03/06/15 Mandibular Fractures 74 Disadvantages of open reduction. Requires surgical exposure. May Require general anesthesia. Expensive. Compared to IMF technique is difficult and risky Foreign body left in the tissues. Scarring.

75. Surgical approaches to the mandible Intraoral symphysis and parasymphysis 03/06/15 Mandibular Fractures 75 Intraoral body, angle and ramus – Transbuccal approach

76. Degloving incision 03/06/15 Mandibular Fractures 76

77. Extraoral approaches 03/06/15 Mandibular Fractures 77 Submental Submandibular Retromandibular

78. Transalveolar / upper border wiring Sir Williams Kelsey Fry To control the posterior fragment Use – vertically and horizontally unfavorable # Horizontal mattress wiring 03/06/15 Mandibular Fractures 78

79. Transosseous / lower border wiring Hayton Williams 1958 # fragments expose extraorally posterior fragment hole higher level then anterior fragment both wires passes simultaneously through same hole 1973 Obwegeser :- Combined direct and figure of ‘8’ wiring with single stand of wire 03/06/15 Mandibular Fractures 79

80. Transosseous or lower border wiring 03/06/15 Mandibular Fractures 80

81. Bone plate osteosynthesis Non compression plate with monocortical screw Compression plates with bicortical screw - DCP - EDCP Bio degradable plates and screws Three dimensional plates Titanium miniplates 03/06/15 Mandibular Fractures 81

82. Compression plates Axial compression b/w fractured bone ends Rigid fixation with intra- fragmentry compression Bone ends correctly opposed and maintained IMF is not needed post operatively Primary bone healing occurs by direct osteoblastic activity within # AO/ASIF dynamic compression plates Compression plate approach Eccentric dynamic compression plate 03/06/15 Mandibular Fractures 82

83. Principle of compression plate osteosynthesis The holes for the screws should be prepared at the far ends of the plate holes. When tightening the screws the fracture ends are approximated by the effect of the spherically shaped holes 03/06/15 Mandibular Fractures 83

84. DCP EDCP The plate design is based on a screw head that, when tightened, slides down an inclined plane within the plate . Screw behaves as compression screw or the static screw Compression is not achieved at the upper border so tension band is required The EDCP is similar to the DCP in that the inner holes are designed to produce compression across the fracture site Two oblique outer eccentric compression holes aligned at an angle oblique to the long axis of the plate. The activation of these outer holes produces a rotational movement of the fracture segments with the inner screws acting as the axis of rotation Brings compression at the upper border so tension band is not required 03/06/15 Mandibular Fractures 84

85. Mini plate O steosynthesis :- 1973 MICHELET 1975 CHAMPY MODIFIED - Under physiological strain, forces of tension along the alveolar border & forces of compression along the lower border of the mandible. - With in the body of the mandible these forces produce, predominantly, moments of flexion – angle strong & weak in PM region. - with in the symphysis – torsional moments - Champy et al analysed these moments using a mathematical model of the mandible – ideal line of osteosynthesis . # symphysis 2 plates # angle 1 plate Monocortical screws 2 mm diameter and 5 to 10 mm length Plate 2cm long, 0.9mm thick and 6mm wide 03/06/15 Mandibular Fractures 85

86. Champy’s line of osteosynthesis 03/06/15 Mandibular Fractures 86

87. Advantages of monocortical miniplate osteosynthesis over bicortical compression plates. Monocortical Requires minimal dissection. Less technique sensitive Less chances of complications Bicortical Extra oral approach Nerve injury Difficult to adapt 03/06/15 Mandibular Fractures 87

88. Compression plate Miniplates Bicortical plates Bulky and difficult to use Applied extraorally Cannot be used at the upper border of the mandible Provides rigid fixation No interfragmentary movement allowed Monocortical plates Easy to use Applied intraorally , small incision , less soft tissue dissection , less likely to be palpable Can be used without any associated complication Provides functionally stable fixation Little interfragmentary movement present, torsional movement seen under functional loading 03/06/15 Mandibular Fractures 88

89. Locking vs Standard mini plates 03/06/15 Mandibular Fractures 89

90. 03/06/15 Mandibular Fractures 90

91. 3-D plate ostesynthesis T itanium 3-D plating system was developed by Farmand to meet the requirements of semi-rigid fixation with lesser complications. The 3-D miniplate is a misnomer as the plates are not three dimensional, but hold the fracture fragments rigidly by resisting the forces in three dimensions, namely , shearing, bending, and torsional forces . The basic concept of 3-D fixation as explained by Farmand is that a geometrically closed quadrangular plate secured with bone screws creates stability in three dimensions. The stability is gained over a defined surface area and is achieved by its configuration and not by its thickness or length . 03/06/15 Mandibular Fractures 91

92. ADVANTAGES The large free areas between the plate arms and minimal dissection permit good blood supply to the bone . The 3-D plating system uses fewer plates and screws as compared to the conventional miniplates , to stabilize the bone fragments. Thus, it uses lesser foreign material, and reduces the operation time and overall cost of the treatment The 3-D plating system has a compact design and is easy to use. The 1.0-mm-thick 3-D plate is as stable as the much thicker 2.0 mm miniplate. This offers better bending stability and more resistance to out- of plane movement or torque . 03/06/15 Mandibular Fractures 92

93. Three dimensional plate 03/06/15 Mandibular Fractures 93

94. 03/06/15 Mandibular Fractures 94

95. Bioabsorbable Plates Bioresorbable materials used for rigid fixation Polydioxanone Polyglycolic acid Polylactic acid Strength inadequate to provide clinically acceptable rigid fixation . Use of poly-L- lactide (PLLA) in 69 fractures by Kim et al 12% complication 8% infection No malunion 03/06/15 Mandibular Fractures 95

96. Bioresorbable plates & screws Advantages : Provides the proper strength when necessary and then harmlessly degrades over time. No need for an additional removal operation. Reduce the total treatment & rehabilitation time of the patient. No bending pliers are necessary. 03/06/15 Mandibular Fractures 96

97. Lag screw Compress fracture fragments without the use of bone plate Two sound bony cortices are required -- Shares the loads with the bone Uses: absolute rigid fixation Less hardware More cost effective Rigid method of internal fixation Insertion -quicker and easier Reduction more accurate 03/06/15 Mandibular Fractures 97

98. Lag screws Placed in direction that is perpendicular to the line of fracture to prevent overriding & displacement during tightening of the screws. INDICATIONS # s in edentulous parts Concomittant #s of body & condyle IMF contraindicated Saggital /oblique fractures Non/ malunion 03/06/15 Mandibular Fractures 98

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100. Reconstruction plates 03/06/15 Mandibular Fractures 100 For communited mandibular fractures Decreased post op morbidity Stabilization of entire communited complex 2.0 mm plate with bicortical screw used in conjunction with lag screws or miniplates

101. Protocol for treatment of mandibular fractures Simple fractures of the condylar process and ramus - closed reduction. MMF for 48 to72 hours - training elastics and close observation No MMF is required for coronoid fractures; archbars and training elastics are used only if a malocclusion is present . Simple or compound fractures with a time delay from injury to immobilization of < 72 hours are treated by a closed reduction (CR) or, if indicated, open reduction with rigid fixation (ORIF). 03/06/15 Mandibular Fractures 101

102. Compound fractures - delay from injury to immobilization of >72 hours - MMF and IV antibiotics . If the closed reduction is adequate, the patient is continued on oral antibiotics for an additional 10 to 14days and maintained in MMF and on a blenderized diet for 5 to 6 weeks from the time of closed reduction. If not, ORIF is performed, and MMF is maintained for 10 to 14 additional days. Edentulous patients are treated with rigid fixation, no MMF, and a blenderized diet for 4 to 5 weeks. Teeth in the line of fracture are judged individually. 03/06/15 Mandibular Fractures 102

103. Young adult with Fracture of the angle receiving Early treatment in which Tooth removed from fracture line 3 weeks Guide for time of immobilization 03/06/15 Mandibular Fractures 103 (a) Tooth retained in fracture line: add 1 week (b) Fracture at the symphysis: add 1 week (c) Age 40 years and over: add 1 or 2 weeks (d) Children and adolescents: subtract 1 week IF

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105. The goal of AO/ASIF is rigid internal fixation with primary bone healing, under functional loading Basic principles Reduction of bony fragments Stable fixation of the fragments Preservation of the adjacent blood supply Early functional mobilization 03/06/15 Mandibular Fractures 105

106. Teeth in the line of fracture Potential impediment to healing Fracture is compound Tooth maybe damaged structurally subsequently become necrotic Pre existing pathology – apical granuloma 03/06/15 Mandibular Fractures 106

107. Absolute Longitudinal # Dislocation/ subluxation of tooth Periapical Infection Infection of the fracture line Acute pericoronitis Relative F unctionless tooth Advanced caries Periodontal disease Doubtful teeth Untreated # > 3 days 03/06/15 Mandibular Fractures 107 Indications for removal

108. Management of teeth retained in fracture line Intra-oral periapical radiograph Systemic antibiotic therapy Splinting of tooth if mobile Endodontic therapy if pulp exposed Immediate extraction if fracture becomes infected Follow-up for 1 yr with endodontic therapy if there is demonstrable loss of vitality. 03/06/15 Mandibular Fractures 108

109. Complications Complications during primary treatment Misapplied fixation Infection Nerve damage Displaced teeth and foreign bodies Pulpitis Gingival and periodontal complications Drug reactions 03/06/15 Mandibular Fractures 109

110. Late complications Malunion Delayed union Non-union Derangement of the temporomandibular joint Late problems with transosseous wires and plates Sequestration of bone T rismus Scars 03/06/15 Mandibular Fractures 110

111. Management of Infections 03/06/15 Mandibular Fractures 111

112. Reference Maxillofacial injuries – N.L. Rowe, J Williams, Vol 1 Ied . Oral & maxillofacial trauma – Raymond J Fonseca 4 th ed Journal of Cranio -Maxillofacial Surgery 2008; 36: e251 - e259 Subodh et al, Clinical Study An Epidemiological Study on Pattern and Incidence of Mandibular Fractures, Hindawi Publishing Corporation Plastic Surgery International, Volume 2012, Article ID 834364,7pages 03/06/15 Mandibular Fractures 112

113. A comprehensive classification of mandibular fractures: a preliminary agreement validation study C . H. Buitrago - Tellez , L. Audige , B. Strong, P. Gawelin , J. Hirsch Int. J. Oral Maxillofac. Surg. 2008; 37: 1080– 1088. A. H. Kamboozia , A. Punnia-Moorthy : The fate of teeth in mandibular fracture lines. A clinical and radiographic follow-up study. Int. J. Oral Maxillofac . Surg 1993; 22. 9~101 . Atlas Oral Maxillofacial Surg Clin N Am 17 (2009) 81– 91,Fractures of the Growing Mandible;George M. Kushner, Paul S. Tiwana . Protocol for treatment of mandibular fractures Philip L. Maloney,J Oral Maxillofac Surg,59:879-884, 2001 . 03/06/15 Mandibular Fractures 113

114. 3-D plate osteosynthesis; Dental Research Journal /Mar 2012 / Vol 9 / Issue 2 R . Mukerji , G. Mukerji , M. McGurk Mandibular fractures: Historical perspective British Journal of Oral and Maxillofacial Surgery 44 (2006) 222– 228 Bioresorbable plates & screws[ Robert M. Laughlin JOMS 2007;65:89-96 ] Killey & kay textbook of mandibular fractures. 03/06/15 Mandibular Fractures 114

115. Thank you 03/06/15 Mandibular Fractures 115