Mandibular trauma

Mandibular Trauma

1. Mandibular Fractures Presented by Dr. Mohammed haneef

2. HISTORY ANATOMY INTRODUCTION CLASSIFICATION EXAMINATION AND DIAGNOSIS TREATMENT CONDYLAR FRACTURES Contents:

3. The pre-Christian era The first description of mandibular fractures dates to the 17 th Century BC in the ‘Edwin Smith papyrus ’, The Egyptians’ attitude to mandibular fractures was rather pessimistic: “ If thou examinest a man having a fracture in his mandible, thou shouldst place thy hand upon it...and find that fracture crepitating under thy fingers, thou shouldst say concerning him: One having a fracture in his mandible, over which a wound has been inflicted, thou will a fever gain from it. An ailment not to be treated. Death usually followed, presumably caused by infection ”. 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 #. History: R. Mukerji et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228

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

5. Anatomy:

6. Area of weakness Junction of Alveolar bone & Basal mandibular bone. Symphysis . Teeth Foramen Angle Condyle

7. Muscle Action Mylohyoid , Geniohyoid , Genioglossus & Anterior belly of omohyoid – postero -medial & inferior displacement of # fracture fragment. Pterygomassetric sling – Supero -medial & anterior displacement of fractured lesser fragment. Lateral Pterygoid muscle- Antero-medial displacement of fractured condyle. Temporalis – postero -superior displacement of fractured coronoid process.

8. 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 compression along the superior border Neutral axis about the level of the canal.

9. 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

10. # SYMPHYSIS AND PARASYMPHYSIS:- Mylohyoid constitues a diaphragm b/w hyoid bone & mylohyoid ridge on inner aspect of mandible Mylohyoid & geniohyoid -- stabilizing force symphysis transverse # Oblique # in this region tends to overlaps -- genio & mylohyoid diaphragm

11. Bucket handle displacement 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

12. ANGLE # :- medial pterygoid stronger component Vertical direction # favors the unopposed action of the medial pterygoid muscle,, post fragment pulled lingually Horizontal direction # line favors the unopposed action of masseter and medial pterygoid muscle ,, post fragment displaced upwards

13. 15

14. Nerves The inferior dental nerve is frequently damaged in # of body and angle The fibrous sheath provides considerable support for contained vessels and nerves which accounts for surprisingly low incidence of permanent nerve damage after # Condyle may impact with such force against the temporal bone and # which results in facial nerve damage within follapian canal [ Goin . 1980]. Injury to facial nerve due to external trauma.

15. Angle 110-140* Angle decreases with growth- changes in condylar process ,shape and size Age Changes

16. Blood vessels Vascular damage to inferior dental artery and vein A large sublingual haematoma may result from rupture of dorsal lingual veins medial to an angle. Hemorrhage from torn periosteum . The facial vessels are vulnerable to direct trauma where they cross the lower border of the mandible at anteroinferior margin of Masseter muscle.

17. 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) approximately 350- 400 kg (800-900lb), which is about same as zygoma and about ½ that of frontal bone [ Swearingen 1965, Hodgson 1967, Nahum 1975a, Luce et al 1979] Introduction: Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages with two nutrient arteries.

18. FRACTURE : Definition : Fracture is defined as sudden violent solution in the continuity of the bone which may be complete or incomplete resulted from direct or indirect causes . 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. 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

19. AETIOLOGY OF MANDIBULAR F RACTURES 1.Vehicular accidents 2.Altercation,assaults,interpersonnel violence 3.Fall 4.Sporting accidents 5.Industrial mishaps or work accidents 6.Pathological fractures or miscellaneous

20. Number of fractures per mandible. The number of mandibular fractures per patient ranged from 1.5 to 1.8. 1. Unilateral , single - 53% 2. Bilateral , double - 37% 3. Multiple fractures - 10% Fifty percent have more than one fracture. 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

21. 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

22. Kruger's general classification Simple or Closed Fracture Compound or Open Comminuted Complicated or complex Impacted Greenstick fracture Pathological Simple fracture Compound Fracture Comminuted fracture Impacted fracture Greenstick fracture Classification:

23. 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

24. 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

25. 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

26. 6. According to direction of the fracture and favorability for treatment ( Fry et al) Horizontally favorable Horizontally unfavorable Vertically favorable Vertically unfavorable

27. 7. Relation of the fracture to the site of injury Direct fracture Indirect fracture

28. 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

29. 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)

30. 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, multifragmenta ry /defect fractures Each fracture is divided into 3 groups, specific to the mandibular unit. Int.J.Oral Maxillofac.Surg.2008;37:1080-1088

31. Vertical unit

32. Horizontal unit

33. Central horizontal unit

34. Direct violence Indirect violence Excessive muscular contraction . Pathological fractures Iatrogenic R.T.A’s Falls Fights Sport Injuries Industrial mishaps Etiology:

35. History Clinical Examination Radiological Examination Panoramic radiograph Lateral oblique Radiograph Posteroanterior Radiograph Occlusal view reverse towne’s view CT scan Diagnosis of Mandibular fracture:

36. History Focussed questioning should reveal following: Mechanism of injury Previous facial fracture H/O TMJ disorders Preinjury occlusion

37. 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 #.

38. 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

39. Clinical examination

40. Test for sensation

41. 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 #

42. 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

43. 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

44. Posteroanterior (pa) radiograph: Shows displacement of fractures in the ramus, angle, body, and symphysis region Disadvantage: Cannot visualize the condylar region

45. Lateral oblique Used to visualize ramus, angle, and body fractures Disadvantage: Limited visualization of the condylar region, symphysis, and body anterior to the premolar

46. 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

47. 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)

48. The patient’s general physical status should be carefully evaluated and monitored prior to any consideration of treating mandibular fracture. 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

49. 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 Open Transosseous wiring ( osteosynthesis ) Plating Intramedullary pinning Titanium mesh Circumferential straps Bone clamps Bone staples Bone screws Fixation Direct Indirect

50. 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

51. 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

52. 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 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

53. CLOSED REDUCTION HISTORY William Saliceto (1210-1277) Tied the teeth (MMF) Thomas Gilmer(1849-1931) Reveiwed the tech, introduced Arch Bars in 1907. Barton bandage by JOHN BARTON Lingual-Labial occlusal splint. Vaccum formed acrylic splint Royal Berkshire Haio Frame

54. 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

55. IV LOOP METHOD IVY-LOOP METHOD quick and easy way of obtaining maxillo -mandibular fashion. 24 gauge wire simple and effective for reduction and immobilization of #

56. WILLIAM’S MODIFICATION

57. Clove hitch Incase of single tooth

58. 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.

59. Col. Stout wiring

60. Risdon’s wiring

61. 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

62. D ifferent types of Arch bar Winters Jelenkos Dautrys Arch bar Berns titinium arch bars Burmachs arch bar Custom made

63. 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

64. Pre drilled Drill free When drilling the screw holes, saline irrigation assists bone debris removal and cooling of tissues. There is a risk of the drill damaging the roots of adjacent teeth, especially in inexperienced hands  Cannot be used No irrigation required       Less chance of damage to adjacent teeth     Drill free screws may be used in comminuted fractures

65. 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

66. 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 .

67. 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

68. 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

69. 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 .

70. Acrylic splints take the form of modified dentures with bite block in place of molar teeth & space in the incisor area to facilitate feeding Used in edentulous jaw fractures Gunning splints

71. 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

72. Preparation of cast/ mock surgery Preparation of acrylic block in centric relation Acrylic bite block in molar region Space in anterior region Stainless steel hooks in molar region Fabrication

73. Immobilization Maxilla - Peralveolar wiring - Circum zygomatic wiring - With help of bone screws Mandible - Circum mandibular wiring Followed by IMF

74. Early General supervision Infection control Pain control Oral hygiene maintenance Feeding Post operative care Late Testing union & removal of fixation Jaw physiotherapy

75. Houpert’s procedure The operator should drill transfixion holes (in a vestibulo ‐lingual direction) with a tiny round burr in the crown of the deciduous teeth away from the pulp and a safe distance from the occlusal surface . A 0.2‐mm stainless steel wire impregnated in silver nitrate is introduced through the holes. Depending on the number of teeth used, either bimaxillary or monomaxillary fixation can be applied. Each hole should be filled with amalgam. A variation of this technique ( Ginestet ) allows placing an eyelet through each hole to fix both a vestibular and a lingual/palatal hard, 0.5‐mm stainless steel wire, with the possibility of a double splint device both in the vestibular and at the lingual/palatal aspect of the dental arcade.

76. 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 condyler 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 intermaxillaryfixation Indications for open Reduction

77. Contraindications G.A / more prolonged procedure is not advisable Gross infections at the # site Sever comminution with loss of soft tissue Patients with difficult to control seizures

78. Surgical approaches to the mandible Intraoral symphysis and parasymphysis Intraoral body, angle and ramus – Transbuccal approach

79. Degloving incision

80. Extraoral approaches Submental Submandibular Retromandibular

81. Transalveolar / upper border wiring Sir Williams Kelsey Fry To control the posterior fragment Use – vertically and horizontally unfavorable # Horizontal mattress wiring

82. 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

83. Transosseous or lower border wiring

84. 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

85. 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 Journal of Cranio -Maxillofacial Surgery 2008; 36: e251 - e259

86. 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

87. 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

88. 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

89. 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

90. 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

91. Champy’s line of osteosynthesis

92. Locking vs Standard mini plates

93. 3-D plate ostesynthesis Dental Research Journal /Mar 2012 / Vol 9 / Issue 2 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 .

94. The large free areas between the plate arms and minimal dissection permit good blood supply to the bone . The newly introduced 3-D plating system provides definite advantages over the conventional miniplates . 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- ofplane movement or torque .

95. Three dimensional plate

96. Advantages: - Improved handling characteristics, Increased stability, Shorter surgical time, Preservation of bony perfusion, Decreased bone necrosis, Increased bony healing and regeneration.

97. 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 in 69 fractures by Kim et al 12% complication 8% infection No malunion Plastic and Reconstructive Surgery, vol 110, july 2002, 25-31

98. Bioresorbable plates & screws [Robert M. Laughlin JOMS 2007;65:89-96] 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.

99. 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

100. Lag screws Placed indirection 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/mal union

101. Lag Screw fixation.

102. Lag Screw technique 107

103. Anchor lag screw vs conventional lag screw Journal of oral biology and craniofacial research 3 (2013) 15e19 Loosening of screw, damage to bone, mobility of fragments, incidence of pain, infection presence

104. Reconstruction plates For communited mandibular fractures Decreased post op morbidity Stabilization of entire communited complex Defect fractures can be treated 2.0 mm plate with bicortical screw used in conjuction with lag screws or miniplates

105. 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. Disadvantages of open reduction. Requires surgical exposure. Requires general anesthesia. Expensive. Compared to IMF technique is difficult and risky. Foreign body is left in the tissues. Scarring.

106. Protocol for treatment of mandibular fractures ( Philip L. Maloney,J Oral Maxillofac Surg,59:879-884, 2001) 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).

107. 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.

108. The goal of AO/ASIF is rigid internal fixation with primary bone healing, under functional loading Basic principals Reduction of bony fragments Stable fixation of the fragments Preservation of the adjacent blood supply Early functional mobilization

109. Bone healing Histomorphologic changes during fracture healing Post fracture time Histology Immediate Extravasation of blood 24 hrs Aseptic inflamm – clot 48 hrs Org of clot 4 days Intramemb bone formation Subperiosteal bone formatn 5 to 10 days Hyaline cartilage

110. Fibrocartilage + calcification 30 days until of Trabecular bone formation healing Cortical bone formation

111. General principles in the treatment of mandibular fractures Patient’s general physical status Methodical approach -not “ emergency-type ” mentality. Dental injuries - evaluated & treated concurrently with T/t of mandibular fractures. Re-establishment of occlusion - primary goal With multiple facial fractures, mandibular fractures should be treated first.

112. IMF time should vary Type L ocation N umber S everity of mandibular fractures A s well as the patient’s age & health the method used for reduction & immobilization. Prophylactic antibiotics should be used for compound fractures. Nutritional needs should be closely monitored postoperatively.

113. Young adult with Fracture of the angle receiving Early treatment in which Tooth removed from fracture line 3 weeks Guide for time of immobilization (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

114. 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

115. Teeth in line of fracture Indications for removal 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

116. 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.

117. Fracture healing With RIF the strain on the bone is reduced Bone heals by direct approximation Gap healing – minimal callus healing – satisfactory immobilisation Inflammatory stage Cartilagenous stage Bony callous stage Remodelling

118. Complications Complications during primary treatment Misapplied fixation Infection Nerve damage Displaced teeth and foreign bodies Pulpitis Gingival and periodontal complications Drug reactions

119. 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

120. Management of Infections

121. Intra oral ORIF

122. Management of TMJ complications

123. Thank you