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MANDIBULAR FRACTURESMANDIBULAR FRACTURES
Frederick Mars Untalan, MD
ANCIENT GREECE:
HIPPOCRATESHIPPOCRATES
The son of a
physician-priest
Written in 460 BC
Describes MMF . . . !
HIPPOCRATES
“Displaced but incomplete
fractures of the mandible
where continuity of the bone is preserved
should be reduced by pressing the lingual
surface with the fingers
while counterpressure is applied from the
outside. Following the reduction,
teeth adjacent to the fracture are fastened to
one another using gold wire.”
THE EDWIN SMITH TREATISE
 “If thou examinst a man having a fracture in his
mandible, thou shouldst place thy hand upon it…and
find that fracture crepitating under they 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.”
 The cause of death was believed to be sepsis
OBJECTIVES
 Anatomy
 Fracture distraction
 Principles of rigid internal fixation
 AO method
 Rapid IMF
 ORIF vs. MMF
OVERVIEW
 Accounts for over 50% of the
prehospital trauma deaths
encountered by prehospital
provider
 Even when not fatal, head
injuries are devastating to
the survivor and family
 Victims of significant head
injury seldom recover to the
same physical and emotional
state of pre-injury
 Many victims suffer
irreversible personality
changes
MAXILLO-FACIAL TRAUMA
 Causes -
 MVA, home accidents,
athletic injuries, animal
bites, violence, industrial
accidents
 Soft tissue -
 lacerations, abrasions,
avulsions
 vascular area supplied by
internal and external
carotids
 Management -
 Seldom life-threatening
unless in the airway
 consider spinal
precautions
 have suction available
and in control of
conscious patients
 control bleeding
Mandibular fractures
FACIAL FRACTURES
 Fx to the mandible,
maxilla, nasal bones,
zygoma & rarely the
frontal bone
 S/S -
 pain, swelling,
malocclusion, deep
lacerations, limited
ocular movement,
asymmetry, crepitus,
deviated nasal septum,
bleeding from orifice
 Mandibular Fx -
 malocclusion,
numbness, inability to
open or close the mouth,
excessive salivation
 Anterior dislocation
extensive dental work,
yawning
 Condylar heads move
forward and muscles
spasm
Mandibular fractures
SPORTING TRAUMA
ANATOMY: BONY LANDMARKS
Condylar Process
Coronoid Process
Ramus
Angle
Body
Symphysis/
parasymphysis
CAUSES OF JAW
FRACTURES
 Falling onto face from a significant height
 Gun shot wounds to the face
 Motor vehicular accidents
 Blow to the face
 Weakening of the jaw caused by
 Severe gum disease (periodontal disease) erosion of the jaw
bone
 All meat diet
 Supplementation with improper ratio of calcium and
phosphorus
 Chronic kidney disease
 Osteogenesis imperfecta - congenital disease
 Cancer of the jaw bone
PATHOPHYSIOLOGY
Optimal mandible function requires
maintenance of normal anatomic shapeshape
and stiffnessand stiffness (ie, resistance to
deformation underload).
PATHOPHYSIOLOGY
 Fractures result secondary to mechanical
overload.
Torque results in spiral fractures
avulsion, in transverse fractures
bending, in short oblique fractures
compression, in impaction and comminution.
PATHOPHYSIOLOGY:
 Degree of fragmentation depends upon energy transfer
as a result of overload.
 Therefore, wedge and multifragmentary fractures are
associated with higher energy release.
PATHOPHYSIOLOGY:
An evidence based study involving 3002 patients with
mandibular fractures…
the presence of a lower third molar may double the
risk of an angle fracture of the mandible.
PATHOPHYSIOLOGY:
Another study
compared fractures with wisdom teeth to those without.
Showed increased infectious risk (16.6%) in fractures
with wisdom teeth compared with 9.5% risk in
fractures without wisdom teeth.
Mandibular fractures
CLASSIFICATION OF
FRACTURES
 Simple Fracture.
 A simple fracture is a break in the bone that does not
produce an open wound in the skin.
 complete or incomplete.
 Tissue adjacent to the fracture may or may not suffer
considerable injury.
 Also known as closed fracture
CLASSIFICATION OF
FRACTURES
Multiple - two or more fracture lines that are not
connected to each other.
Indirect - The fracture site is distant from the site of
injury.
Complex - there are considerable
Soft Tissue Injuries; this may be simple or
compound fracture
CLASSIFICATION OF
FRACTURES
Comminuted - involves splintered or crushed
bone.
Greenstick - also called incomplete fracture.
one cortex of the bone is broken
and the other cortex is bent
Atrophic - fracture resulting from severe
atrophy of the bone.
CLASSIFICATION OF
FRACTURES
 Compound Fracture / Open fracture
 with an external wound extending to the bone.
 Communication is an invitation for contamination.
 Fracture communicates with the external wound,
involving skin, mucosa, or periodontal membrane
 Comminuted Fracture.
 bone is splintered into three or more fragments or is
crushed.
 NOTE: A compound-comminuted fracture is one
with both a splintering of the bone and a break in
the bone with an opening to the covering surface.
CLASSIFICATION OF
FRACTURES
 Depressed Fracture.
fractured part is driven below the normal level of
the bone, as in a skull fracture.
 Impacted Fracture.
hard cortical bone of one fragment is driven into
the softer cancellous bone of another fragment.
 Pathologic (Spontaneous) Fracture.
break without external violence at an area of the
bone that has been weakened by a local disease.
CLASSIFICATION OF
FRACTURES
Multiple Fracture.
two or more fractures occur in the same or
different bones.
 Favorable Fracture.
line of the fracture occurs in a direction that does
not allow the pull of the muscles on the segments
to displace the segments.
 Unfavorable Fracture.
fracture with displacement or separation of the
fractured segments due to muscle pull on the
segments.
Mandibular fractures
Mandibular fractures can occur..
THE ANGLE
CLASSIFICATION
 Based upon the relationship of the first mandibular
and maxillary molars
Class I: normal occlusion
Class II: an “underbite”
Class III: an “overbite”
 Observe wear facets
Mandibular fractures
MALOCCLUSION
 Class I: (normal)
Mesiobuccal cusp rests in the mesiobuccal groove
 Class II (retrognathic)
Mesiobuccal cusp is mesial or anterior to the mesiobuccal groove.
 Class III (prognathic)
Mesiobuccal cusp is distal or posterior to the buccal groove.
OCCLUSION
 Normal occlusion can be
defined when the
mesiolabial cusp of the
maxillary first molar
approximates the
buccal groove of the
mandibular first molar.
OCCLUSION
 Angle’s Classification
 Position of the maxillary
and mandibular first molars
Class I: (normal)
 Mesiobuccal cusp rests in
the mesiobuccal groove
OCCLUSION
 Angle’s Classification
 Position of the maxillary
and mandibular first molars
Class II (retrognathic)
 Mesiobuccal cusp is mesial
or anterior to the
mesiobuccal groove.
OCCLUSION
 Angle’s Classification
 Position of the maxillary
and mandibular first molars
Class III (prognathic)
 Mesiobuccal cusp is distal or
posterior to the buccal
groove.
COMMON SITES OF
FRACTURE
 Weak areas include 3rd
molar and canine fossa
Fracture Type Prevalence
Body 30 - 40 %
Angle 25 - 31 %
Condyle 15 - 17 %
Symphysis 7 - 15 %
Ramus 3 - 9 %
Alveolar 2 - 4 %
Coronoid process
1 - 2 %
EMOTIONAL AGRESSION
ANATOMY
mandible - lower jaw bone
there is a left and a right mandible
have joints - allow the mouth to
open and close
have a hollow canal - nerves and
blood vessels are housed
ANATOMY
 U – shaped body
 Vertically directed
rami
 Coronoid
 Condyle
 Oblique line
 Mental foramen
INTERNAL ANATOMY
 Mandibular foramen
 Lingula
 Pterygoid fovea
 Mylohyoid line
 Fossae
 Submandibular
 Sublingual
 digastric
 Mental spines
 Genioglossus
 Geniohyoid
ANATOMY
 Body - From the distal symphysis to a line
coinciding with the alveolar border of the
masseter muscle (usually including the third
molar) (30-40%)
 Angle - Triangular region bounded by the
anterior border of the masseter muscle to the
posterosuperior attachment of the masseter
muscle (usually distal to the third molar) (25 -
31%)
 Condyle - Area above the ramus region (15 -
17%)
ANATOMY
 Symphysis - Region of the central incisors that runs
from the alveolar process through the inferior border
of the mandible (7 - 15%)
 Ramus - Part of the mandible that is bounded by the
superior aspect of the angle (3-9%)
 Alveolar process - Region of the mandible that
carries the teeth (2 - 4%)
 Coronoid process - Includes the coronoid process of
the mandible superior to the ramus region (1 - 2%)
INNERVATION
 CNV3, the
mandibular n.,
through the foramen
ovale
 Inferior alveolar n.
through the
mandibular foramen
 Inferior dental plexus
 Mental n. through the
mental foramen
INNERVATION
 CNV3, the
mandibular n.,
through the foramen
ovale
 Inferior alveolar n.
through the
mandibular foramen
 Inferior dental plexus
 Mental n. through the
mental foramen
ARTERIAL SUPPLY
 Internal maxillary artery
 Inferior alveolar artery
 Mental artery
MUSCULATURE:JAW ELEVATORS
 Masseter: Arises from
zygoma and inserts into
the angle and ramus
 Temporalis: Arises
from the infratemporal
fossa and inserts onto the
coronoid and ramus
 Medial pterygoid:
Arises from medial
pterygoid plate and
pyramidal process and
inserts into lower
mandible
MUSCULATURE: JAW DEPRESSORS
 Lateral pterygoid:
lateral pterygoid plate to
condylar neck and TMJ
capsule
 Mylohyoid: mylohyoid
line to body of
hyoid
 Digastric: mastoid notch
to the
digastric fossa
 Geniohyoid: inferior
genial tubercle to
anterior hyoid bone
Mandibular fractures
FAVORABLE FRACTURES
 Those fractures where
the muscles tend to
draw fragments
together
 Ramus fractures are
almost always
favorable as the jaw
elevators tend to
splint the fractured
bones in place
SURGICAL TECHNIQUES
 BSSO
UNFAVORABLE FRACTURES
 Fractures where the muscles tend to draw
fragments apart
 Most angle fractures are horizontally unfavorable
 Most symphyseal/parasymphyseal fractures are
vertically unfavorable
Mandibular fractures
ANATOMY
 back part of the jaw is
covered with muscles that
are used to open and close
the mouth
 teeth of the mandibles and
maxilla usually
interdigitate or have good
occlusion
 teeth are rooted in sockets
in the mandible and
maxilla
MUSCLE SLING
MUSCLE SLING
 Vertical rami totally
embedded within sling
 Masseter
 Pterygoids
MUSCLE SLING
Angle and
condylar neck
not entirely
protected by
sling
Bony trabecular
crests, ridges,
lines
MUSCLE SLING
Trabeculae resist
normal tension,
compression,
and rotation of
mastication
Little resistance
to lateral stress
from blunt
trauma
FRACTURE DISTRACTION AND
FAVORABILITY
FRACTURE DISTRACTION AND
FAVORABILITY
STOMPS TO THE FACE
DIAGNOSIS
 ROS: bone disease, neoplasia, arthritis, CVD,
nutrition and metabolic disorders, endocrine d/o
 TMJ and ankylosis
 MVA >> compound, comminuted fractures
 Fists >> often single, non displaced fractures
 An angled blow to the parasymphysis >>
contralateral condylar fractures
 An anterior blow to the chin >> bilateral condylar
fractures
PHYSICAL EXAM
 Change in occlusion is highly diagnostic
 Anterior open bite suggestive bilateral condylar or angle
fractures
 Posterior open bite common with alveolar process or
parasymphyseal fractures
 Unilateral open bite with ipsilateral angle or
parasymphyseal fracture
 Retrognathic (Angle III) seen with condylar or angle
fractures
 Prognathic (Angle II) seen with TMJ effusion
PHYSICAL EXAM
Anesthesia of lower
lip :“pathognomonic” of a fracture
distal to the mandibular foramen
The converse is not true: not all
fractures distal to the mandibular
foramen have mental n. anesthesia
Trismus of less than 35mm also
highly suggestive of mandibular
fracture
PHYSICAL EXAM
Inability to open the mandible
suggests impingement of the
coronoid process on the
zygomatic arch
Inability to close the mandible
suggests a fracture of the
alveolar process, angle, ramus
or symphysis
MANDIBULAR FRACTURE
PHYSICAL EXAMINATION
Pertinent physical findings are
limited to the injury site.
Change in occlusion may be evident
on physical examination.
highly suggestive of mandibular
fracture.
Ask patient to compare postinjury
and preinjury occlusion.
MAXILLARY ADVANCEMENT WITH LE
FORT III FOR CORRECTION OF
MAXILLARY DEFICIENCY
MANDIBULAR SETBACK FOR WITH
CORRECTION OF PROGNATHISM
AND ASYMMETRY
LACERATIONS AND ECCHYMOSIS
Mandibular fractures can often be
directly visualized beneath facial
lacerations.
Lacerations should be closed after
definitive therapy of the fracture
Ecchymosis is diagnostic of
symphyseal fractures
LACERATED LIPS
PHYSICAL EXAMINATION
Lacerations, hematoma, and ecchymosis may be
associated with mandibular fractures.
SEVERE MAXILLO-FACIAL
TRAUMA
PALPATION
The mandible should be palpated
with both hands, with the thumb
on the teeth and the fingers on the
lower border of the mandible.
Slowly and carefully place
pressure, noting the characteristic
crepitation of a fracture
INTRA-ORAL HARD TISSUE
INJURIES
PHYSICAL EXAMINATION
Posttraumatic premature posterior dental contact
(anterior open bite) and retrognathic occlusion may
result from a mandibular angle fracture.
Unilateral open bite deformity is associated with a
unilateral angle fracture.
Anesthesia, paresthesia, or dysesthesia of the lower lip
may be evident.
PHYSICAL EXAMINATION
Most nondisplaced mandible
fractures are not associated with
changes in lower lip sensation;
Displaced fractures distal to the
mandibular foramen (in the
distribution of the inferior
alveolar nerve) may exhibit these
findings.
PHYSICAL EXAMINATION
Loss of the mandibular angle on palpation may be
because of an unfavorable angle fracture in which the
proximal segment rotates superiorly.
The anterior face may be displaced forward, causing
elongation.
PHYSICAL EXAMINATION
Do not close facial lacerations before treating underlying
fractures except in the case of life-threatening
hemorrhage.
Pain, swelling, redness, and localized calor are signs of
inflammation evident in primary trauma.
PHYSICAL EXAMINATION
Change in facial contour
loss of external mandibular form
may indicate mandibular fracture.
An angle fracture may cause the
lateral aspect of the face to appear
flattened.
SPORTING TRAUMA
RADIOGRAPHIC EXAM
Panorex shows the entire mandible, but requires the
patient to be upright.
 It also has particularly poor detail of the TMJ and medial
displacement of the condyles
 AP - ramus and condyle
 Submental - symphysis
 CT - condylar fractures
Mandibular fractures
Panoramic radiograph 12 weeks after cancellous iliac crest bone graft with
reconstruction plate showing bony union
IMAGING STUDIES:
 The single most informative radiologic study used in diagnosing mandibular
fractures is the panoramic radiograph.
 Panorex provides the ability to view the entire mandible in one radiograph.
 Panorex requires an upright patient, and it lacks fine detail in the TMJ,
symphysis, and dental/alveolar process regions.
 Plain films, including lateral-oblique, occlusal, posteroanterior, and
periapical views, may be helpful.
 The lateral-oblique view helps in diagnosing ramus, angle, or posterior body
fractures. The condyle, bicuspid, and symphysis regions often are unclear.
 Mandibular occlusal views show discrepancies in the medial and lateral position of
the body fractures.
 Caldwell posteroanterior views demonstrate any medial or lateral displacement of
ramus, angle, body, or symphysis fractures.
 CT scanning may also be helpful.
 CT scanning allows physicians to survey for facial fractures in other areas,
including the frontal bone, naso-ethmoid-orbital complex, orbits, and the entire
craniofacial horizontal and vertical buttress systems.
 Reconstruction of the facial skeleton is often helpful to conceptualize the injury.
 CT scanning is also ideal for condylar fractures, which are difficult to visualize.
Mandibular fractures
Mandibular fractures
Mandibular fractures
Mandibular fractures
Mandibular fractures
COMPLICATIONS
Socioeconomic groups
Infection (James, et. al.)
Delayed healing and malunion.
Most commonly caused by
infection and noncompliance
Nerve paresthesias in less than
2%
STUDY BY JAMES, ET. AL.
 Prospective study of 422 pts
 Infection rate 7%
 50% of infections associated with fractured or
carious teeth
 ORIF led to 12% infection rate
 Staph, strep, bacteroides
 Prophylaxis, tooth extraction
BONE HEALING
 Reactive Phase
Fracture
Formation of granulation
tissue
 Reparative phase
Replacement of granulation
tissue by callus
 Connective tissue + cartilage
Replacement of callus by
lamellar bone
 Remodeling phase
Remodeling of bone to
normal contour
The amount of callus formation is
indirectly proportional to the degree
of immobilization
GENERAL
PRINCIPLES OF
TREATMENT
 The general physical
status should be
thoroughly evaluated.
 40% associated with
significant injury, 10%
of which are lethal
 Cerebral contusion is
common
 ABC’s!
 Almost never
emergent
GENERAL PRINCIPLES
Dental injuries should be treated
concurrently
Reestablishment of occlusion is the
primary goal
Fractured teeth may jeopardize
occlusion
Mandibular cuspids are cornerstone
of Tx
Prophylactic antibiotics
GENERAL PRINCIPLES
With multiple facial
fractures,
mandibular
fractures are
treated first
MANDIBULAR FRACTURES
 Dentoalveolar injuries
 Cautious use of intermaxillary fixation
 Pattern of injuries with condyle most frequently
injured
 Possible growth disturbance
 High osteogenic potential
 Rare complications
PRINCIPLES OF JAW FRACTURE
REPAIR
 Alignment of the jaw - teeth line up in normal position
is critical for healing of the fracture
 Remove all loose teeth or teeth that have periodontal
disease at the level of the fracture
PRINCIPLES OF JAW FRACTURE
REPAIR
If the tooth root has been involved a
root canal procedure may be required
Careful suturing of gums
MANDIBULAR FRACTURES
 Physical Exam
 Observance of mandibular range of motion
and malocclusion
 Radiographic assessment
 Greenstick common
 Types of condylar fractures
 *especially for kids
CLOSED REDUCTION
 Grossly comminuted fractures
 Significant tissue loss
 Edentulous mandibles
 Fractures in children
 Condylar fractures
 Contraindicated in SzDo, psych, and
compromised pulmonary function
OPEN REDUCTION
 Displaced, unfavorable fractures of angle
 Displaced unfavorable fractures of the body or
parasymphysis, as these tend to open at the
inferior border, leading to malocclusion
 Multiple fractures of facial bones
 Displaced, bilateral condylar fractures
CLOSED REDUCTION : DENTULOUS
PATIENT
Erich Arch Bars. Can lead to
periodontal infalmmation.
Avoid fixating incisors, as these
teeth are moved by the wires
Ivey loops
CLOSED REDUCTION :
PARTIALLY EDENTULOUS
PATIENT
 Partials and circum wires or screws
 Acrylic partials with incorporated arch bar
wires
CLOSED REDUCTION :
EDENTULOUS PATIENT
 Dentures with circum wires and screws
 Fabricated acrylic plates (Gunning Splints)
 In fractures of both the mandible and maxilla,
circumzygomatic and circum-mandibular wires
should be tied together to prevent telescoping of
maxilla
OPEN REDUCTION AND
OSTEOSYNTHESIS
 Simpler than rigid fixation
 MMF still required
 Useful in angle, parasymphyseal fractures
ORIF
 Performed with compression plates and lag
screws
 MMF generally not required
 Eccentrically placed holes and screws placed at
angles “compress” the bone
DEGLOVING INJURY
When double fractures occur, they are
usually on contralateral sides of the
symphysis.
Common combinations include the angle
plus the contralateral body or condyle.
Triple fractures occasionally occur, - most
common type is fracture of both condyles
plus the symphysis.
 The mandible may also be
dislocated without fracture,
sometimes spontaneously
during a large yawn.
 patient usually presents with
considerable pain.
 Spasm in the masseter and
pterygoid muscles tend to force
the condyles up the anterior
slope of the articular eminence
and prevent normal mouth
closure.
AO/ASIFAO/ASIF
 “Arbeitsgemeinschaft fur Osteosynthesefragen”
 The Association for the Study of Internal
Fixation
 Davos, Switzerland
 Foundation providing clinical and scientific
research relevant to trauma care for injuries of
the musculoskeletal system
 Purpose: Rigid internal fixation with resultant primary bone
healing, even under conditions of full functional loading
INTERNAL RIGID FIXATION
Advantages
Early active pain-free functional
movement
Avoidance of intermaxillary fixation
Safe, secured airway without
tracheotomy
Earlier return to work
INTERNAL RIGID FIXATION
Interfragmentary compression
Increased friction between fragments
Increased surface area of direct contact
Primary bone healing
No evidence of pressure necrosis
Loose hardware acts only as foreign
body
CHAMPY’S IDEAL LINES OF
OSTEOSYNTHESIS
 Masticatory muscles produce tension at upper
border and compression at lower border
 Torsional forces produced anterior to the
canines
CHAMPYCHAMPY
 Monocortical “tension banding” osteosynthesis
neutralizes distraction and torsion during physiologic
stress, while normal basilar compression is restored
DYNAMIC COMPRESSION Compression resulting in
preload and friction
 Preload prevents
distraction
 Friction resists torsional
forces
 Closure results only
underneath plate
 Gap on opposite side
 Allows for primary
healing
 Contraindicated in
comminution
REDUCTION – GENERAL REMARKS
 Restoration of occlusion with IMF
 Selection of access
 Fracture type and location
 General anesthesia
 Nasal vs. tracheotomy
 Tension bands
 Bicortical screws
 Monocortical to avoid tooth roots and mandibular
nerve
 Compression and reconstruction plates
 Inferior margin
 Bicortical screws
AO METHODAO METHOD
SYMPHYSIS AND PARASYMPHYSEAL
 Transverse fracture without dislocation
SYMPHYSIS AND PARASYMPHYSEAL
SYMPHYSIS AND PARASYMPHYSEAL
 Transverse fracture with dislocation
SYMPHYSIS AND PARASYMPHYSEAL
 Basal triangle or comminuted
BODY
•Without dislocation
•With dislocation
BODY
BODY
 Comminuted
ANGLE
 Without dislocation
ANGLE
ANGLE
 With/without dislocation
ANGLE
 Comminuted
ASCENDING RAMUS
 Comminuted
ASCENDING RAMUS
CONDYLE PROCESS
 Classified according to Kohler
(1951)
 Condylar fracture line runs
inside capsule of TMJ
Not fixed with plates or screws
 Subcondylar situated below the
capsule
Classified into high and low
 Condylar base fractures are at
level of the sigmoid notch
(incisura semilunaris)
LOW SUBCONDYLAR AND
CONDYLAR BASE
BILATERAL CONDYLAR BASE
RAPID IMF
 Advantages:
 Easy insertion, OR time ≈ 10
minutes
 Removal without anesthesia
 Minimal danger to surgeon
 Decreased damage to dental
papillae and oral mucosa
 Easier to maintain dental
hygiene
 Compatible with all rigid
plating systems
RAPID IMF
 Disadvantages
 Dental root injury
 Loss of tension band
directional traction
RAPID IMF
 Roccia, Fasolis et al.
 An Audit of Mandibular Fractures Treated by
IMF Using Intraoral Cortical Bone Screws
 Journal of Crani-maxillofacial Surgery
 Turin, Italy 2005
RAPID IMF
 ORIF 44 patients
 CR 18 patients
 Occlusion 2-3 weeks
 Screws removed under local only
 Minimum 6 month f/u
Oral mucosa
covering screw
5%
Lost screws 2%
Dental root
injury
11%
Infection 1%
Malocclusion < 1%
RAPID IMF CONCLUSIONS
• Recommended:
– Single or double fractures with minimal displacement
– Compound condylar fractures
– Edentulous patients if proper dentures available
• Contraindicated:
– Multiple comminuted fractures
– Alveolar bone fractures
– Pediatric patients with unerupted teeth
– Severe osteoporosis
POSTOPERATIVE ANTIBIOTICS
 Abubaker et al.
 Medical College of Virginia
 J Oral Maxillofac Surg. 2001
 Prospective, randomized, double-blind,
placebo-controlled study
 30 patients, 2 arms, 6 week post-op f/u
** No significant statistical difference between groups
ORIF VS. MMF
TMJ FUNCTION ANALYSIS
 Gorgu, Erdogan et al.
 Scand J Plast Reconstr Surg Hand Surg 2002
 Ankara, Turkey
 Prospective Comparative Study of the Range of
Movement of TMJ After Mandibular Fractures:
Rigid or Non-rigid Fixation
GORGU, ERDOGAN ET AL.
 Prospective, randomized, controlled study
 147 patients in 3 groups (1993-1998)
 MMF= 54
 4 weeks immobilization
 Titanium miniplate ORIF= 49
 No movement restriction
 Control= 44
 Randomly selected with no hx of mandible injury
 Mean follow-up 2.2 yrs (1-3)
 Exclusion criteria
 Condylar frx, multiple frx, comminution or
significant displacement, malocclusion, edentulous
GORGU, ERDOGAN ET AL.
MMF *
(n=54)
ORIF **
(n=49)
Controls
(n=44)
Max jaw opening (mm) 30.9 (6.0) 45.1 (5.9) 50 (5.4)
Max displacement to
left (mm)
8.0 (2.9) 9.9 (2.4) 11 (2.5)
Max displacement to
right (mm)
6.8 (3.3) 9.6 (2.3) 10 (2.6)
Protrusion (mm) 3.4 (1.5) 9.3 (0.8) 10 (1.0)
* p < 0.001 compared with control
** p < 0.001 compared with control and MMF group
GORGU, ERDOGAN ET AL.
 Trauma is major factor leading to TMJ dysfunction
 MMF increased the incidence and severity of TMJ dysfunction
MMF *
(n=54)
ORIF **
(n=49)
Controls
(n=44)
Click 38 (70%) 20 (41%) 11 (25%)
Crepitus 36 (67%) 11 (22%) 5 (11%)
* p < 0.003 compared with control
** p < 0.005 compared with control and MMF group
ORIF VS. MMF
COMPLICATION ANALYSIS
 Moreno et al.
 J Oral Maxillofac Surg 2000
 Madrid, Spain
 Complication Rates Associated with
Different Treatments for Mandibular
Fractures
MORENO ET AL. Retrospective study
 245 patients with 386 fractures (1993-1996)
 Isolated condylar process fractures excluded
 Treatment methods:
 MMF (n=136)
 Exclusive, 40 days occlusion
 2-mm miniplates (n=45)
 Post-op MMF 0 – 15 days
 AO 2.4 mm system (n=19)
 Immediate mobility
 AO 2.7 mm system (n=32)
 Immediate mobility
 Severity scale, multiple variables analyzed
MORENO ET AL
 Rate of postoperative infection for each type of
treatment, separated by severity of fractures
0
25
50
75
100
MMF 2 mm AO 2.4 AO 2.7
1
2
3
4
Severity
*p < 0.001 between infection rate and fracture severity only
MORENO ET AL
 Rate of postoperative malocclusion for each type of
treatment, separated by severity of fractures
0
25
50
75
100
MMF 2 mm AO 2.4 AO 2.7
1
2
3
4
*p < 0.05 between malocclusion rate and fracture severity only
Severity
MORENO ET AL
 Overall complication rate for each type of treatment,
separated under severity of the fractures
0
25
50
75
100
MMF 2 mm AO 2.4 AO 2.7
1
2
3
4
*p < 0.001 between overall rate and fracture severity only
Severity
ORIF
POST-OP MMF VS. IMMEDIATE
MOBILIZATION
 B Kaplan, S Park et al.
 Laryngoscope 2001
 Univ of Virginia Medical Center
 Immediate Mobilization Following Fixation
of Mandible Fractures
PARK ET AL.
 Prospective, randomized, single-blinded study
 ORIF 2.0 mm titanium plates
 Inclusion: displaced fractures between angles only
 29 patients in 2 groups (1997 – 2000)
 Immediate function (n=16)
 2 weeks post-op MMF (n=13)
 Follow-up intervals: 3 wks, 3 mos, 6 mos
 Variables assessed by surgeon blinded to the
history of immobilization
 Pain, non-union, malunion, occlusion, trismus,
infection, weight loss, dental hygiene
PARK ET AL.
 No statistical difference between measured variables
 The assumed beneficial effects from transient TMJ rest
and no fracture stresses was not realized
Wt loss in pounds
Objective trismus in cm
ORIF VS. MMF
COST ANALYSIS
 B Schmidt, L Kaban et al.
 J Oral Maxillofac Surg 2000
 University of California San Francisco
 A Financial Analysis of MMF vs. Rigid
Internal Fixation for Treatment of
Mandibular Fractures
KABAN ET AL.
 Retrospective study
 85 patients in two groups
 CRF (n=38)
 ORIF (n=47) (external and transoral approaches)
 Outcome variables:
 Length of hospital stay
 Duration of anesthesia
 Surgery time
 Patient fee for primary treatment without
complications
 Estimated average patient fee to manage a major
post-op infection
KABAN ET AL.
CRF ORIF
Preop hospital days 1.79 1.98
Postop hospital days 1.95 2.56
*Anesthesia time
(min)
141 309
*Surgical time
(min)
106 267
*p < 0.0001
KABAN ET AL.
 Did not evaluate savings from earlier return to
work in ORIF patients
Charge for
primary
treatment
Charge for
complication*
Total
charg
e
CRF $10,099 ±
5,489
$26,671 ± 2,310 $10,9
26
ORIF $28,361 ±
14,731
$39,212 ±
38,694
$34,6
35
P-
value
< 0.001 < 0.0652 < 0.001
* Incidence of post-op infx was 16% (ORIF) and 3%(MMF)
CLOSED TECHNIQUES
 Nondisplaced favorable fractures
 Grossly comminuted fractures
 Edentulous fractures (using a mandibular
prosthesis)
 Fractures in children with developing dentition
 Coronoid and condylar fractures
INDICATIONS FOR OPEN
REDUCTION
 Displaced unfavorable angle, body, or
parasymphyseal fractures
 Multiple facial fractures
 Bilateral displaced condylar fractures
 Fractures of an edentulous mandible (with severe
displacement of fracture fragments in an effort to
reestablish mandible continuity)
Mandibular fractures
Grafted right mandibular body nonunion
with cancellous iliac crest bone graft,
packed into polyglactin mesh tube.
Grafted left mandibular body nonunion
with cancellous iliac crest bone graft
packed into polyglactin mesh tube.
CONCLUSIONS
 AO does not mean “always operate” or “always
open”
 AO standards provide sound techniques resulting
in a consistently high success rate in most hands
 Occlusion must be 100% prior to rigid internal
fixation
 Main indications for RIF include:
 Compound fractures with defects
 Edentulous mandibles or those with few teeth
 Fracture dislocation ± condylar neck fracture
 Panfacial trauma
 Electively
WISE SAYINGS ABOUT
MANDIBULAR FRACTURES
 Remember the ring bone rule.
 Symphyseal fractures can be diabolically hard to see, even on a well-
exposed AP film
 Remember the Panorex view -- this can usually only be taken by a special
machine in the oral surgery department, but it provides the best single view
of the mandible and will show you fractures that cannot be seen by any
other method short of CT.
 Look carefully along the cortical margin of the whole mandible for
discontinuities. This may be the only sign of a fracture that you will see.
WISE SAYINGS ABOUT
MANDIBULAR FRACTURES
 Also carefully examine the mandibular canal for
discontinuities.
 A fracture line entering the root of a tooth is considered an
open fracture by definition.
 Pathologic fractures can occur in the mandible. Look carefully
for evidence of a periapical abscess or a mandibular tumor,
especially if there doesn't seem to be enough trauma to match
the injury.
Mandibular fractures
OBJECTIVES
 Anatomy
 Fracture distraction
 Principles of rigid internal fixation
 AO method
 Rapid IMF
 ORIF vs. MMF
MANDIBULAR FRACTURESMANDIBULAR FRACTURES
Frederick Mars Untalan, MD

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Mandibular fractures

  • 2. ANCIENT GREECE: HIPPOCRATESHIPPOCRATES The son of a physician-priest Written in 460 BC Describes MMF . . . !
  • 3. HIPPOCRATES “Displaced but incomplete fractures of the mandible where continuity of the bone is preserved should be reduced by pressing the lingual surface with the fingers while counterpressure is applied from the outside. Following the reduction, teeth adjacent to the fracture are fastened to one another using gold wire.”
  • 4. THE EDWIN SMITH TREATISE  “If thou examinst a man having a fracture in his mandible, thou shouldst place thy hand upon it…and find that fracture crepitating under they 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.”  The cause of death was believed to be sepsis
  • 5. OBJECTIVES  Anatomy  Fracture distraction  Principles of rigid internal fixation  AO method  Rapid IMF  ORIF vs. MMF
  • 6. OVERVIEW  Accounts for over 50% of the prehospital trauma deaths encountered by prehospital provider  Even when not fatal, head injuries are devastating to the survivor and family  Victims of significant head injury seldom recover to the same physical and emotional state of pre-injury  Many victims suffer irreversible personality changes
  • 7. MAXILLO-FACIAL TRAUMA  Causes -  MVA, home accidents, athletic injuries, animal bites, violence, industrial accidents  Soft tissue -  lacerations, abrasions, avulsions  vascular area supplied by internal and external carotids  Management -  Seldom life-threatening unless in the airway  consider spinal precautions  have suction available and in control of conscious patients  control bleeding
  • 9. FACIAL FRACTURES  Fx to the mandible, maxilla, nasal bones, zygoma & rarely the frontal bone  S/S -  pain, swelling, malocclusion, deep lacerations, limited ocular movement, asymmetry, crepitus, deviated nasal septum, bleeding from orifice  Mandibular Fx -  malocclusion, numbness, inability to open or close the mouth, excessive salivation  Anterior dislocation extensive dental work, yawning  Condylar heads move forward and muscles spasm
  • 12. ANATOMY: BONY LANDMARKS Condylar Process Coronoid Process Ramus Angle Body Symphysis/ parasymphysis
  • 13. CAUSES OF JAW FRACTURES  Falling onto face from a significant height  Gun shot wounds to the face  Motor vehicular accidents  Blow to the face  Weakening of the jaw caused by  Severe gum disease (periodontal disease) erosion of the jaw bone  All meat diet  Supplementation with improper ratio of calcium and phosphorus  Chronic kidney disease  Osteogenesis imperfecta - congenital disease  Cancer of the jaw bone
  • 14. PATHOPHYSIOLOGY Optimal mandible function requires maintenance of normal anatomic shapeshape and stiffnessand stiffness (ie, resistance to deformation underload).
  • 15. PATHOPHYSIOLOGY  Fractures result secondary to mechanical overload. Torque results in spiral fractures avulsion, in transverse fractures bending, in short oblique fractures compression, in impaction and comminution.
  • 16. PATHOPHYSIOLOGY:  Degree of fragmentation depends upon energy transfer as a result of overload.  Therefore, wedge and multifragmentary fractures are associated with higher energy release.
  • 17. PATHOPHYSIOLOGY: An evidence based study involving 3002 patients with mandibular fractures… the presence of a lower third molar may double the risk of an angle fracture of the mandible.
  • 18. PATHOPHYSIOLOGY: Another study compared fractures with wisdom teeth to those without. Showed increased infectious risk (16.6%) in fractures with wisdom teeth compared with 9.5% risk in fractures without wisdom teeth.
  • 20. CLASSIFICATION OF FRACTURES  Simple Fracture.  A simple fracture is a break in the bone that does not produce an open wound in the skin.  complete or incomplete.  Tissue adjacent to the fracture may or may not suffer considerable injury.  Also known as closed fracture
  • 21. CLASSIFICATION OF FRACTURES Multiple - two or more fracture lines that are not connected to each other. Indirect - The fracture site is distant from the site of injury. Complex - there are considerable Soft Tissue Injuries; this may be simple or compound fracture
  • 22. CLASSIFICATION OF FRACTURES Comminuted - involves splintered or crushed bone. Greenstick - also called incomplete fracture. one cortex of the bone is broken and the other cortex is bent Atrophic - fracture resulting from severe atrophy of the bone.
  • 23. CLASSIFICATION OF FRACTURES  Compound Fracture / Open fracture  with an external wound extending to the bone.  Communication is an invitation for contamination.  Fracture communicates with the external wound, involving skin, mucosa, or periodontal membrane  Comminuted Fracture.  bone is splintered into three or more fragments or is crushed.  NOTE: A compound-comminuted fracture is one with both a splintering of the bone and a break in the bone with an opening to the covering surface.
  • 24. CLASSIFICATION OF FRACTURES  Depressed Fracture. fractured part is driven below the normal level of the bone, as in a skull fracture.  Impacted Fracture. hard cortical bone of one fragment is driven into the softer cancellous bone of another fragment.  Pathologic (Spontaneous) Fracture. break without external violence at an area of the bone that has been weakened by a local disease.
  • 25. CLASSIFICATION OF FRACTURES Multiple Fracture. two or more fractures occur in the same or different bones.  Favorable Fracture. line of the fracture occurs in a direction that does not allow the pull of the muscles on the segments to displace the segments.  Unfavorable Fracture. fracture with displacement or separation of the fractured segments due to muscle pull on the segments.
  • 28. THE ANGLE CLASSIFICATION  Based upon the relationship of the first mandibular and maxillary molars Class I: normal occlusion Class II: an “underbite” Class III: an “overbite”  Observe wear facets
  • 31.  Class I: (normal) Mesiobuccal cusp rests in the mesiobuccal groove  Class II (retrognathic) Mesiobuccal cusp is mesial or anterior to the mesiobuccal groove.  Class III (prognathic) Mesiobuccal cusp is distal or posterior to the buccal groove.
  • 32. OCCLUSION  Normal occlusion can be defined when the mesiolabial cusp of the maxillary first molar approximates the buccal groove of the mandibular first molar.
  • 33. OCCLUSION  Angle’s Classification  Position of the maxillary and mandibular first molars Class I: (normal)  Mesiobuccal cusp rests in the mesiobuccal groove
  • 34. OCCLUSION  Angle’s Classification  Position of the maxillary and mandibular first molars Class II (retrognathic)  Mesiobuccal cusp is mesial or anterior to the mesiobuccal groove.
  • 35. OCCLUSION  Angle’s Classification  Position of the maxillary and mandibular first molars Class III (prognathic)  Mesiobuccal cusp is distal or posterior to the buccal groove.
  • 36. COMMON SITES OF FRACTURE  Weak areas include 3rd molar and canine fossa
  • 37. Fracture Type Prevalence Body 30 - 40 % Angle 25 - 31 % Condyle 15 - 17 % Symphysis 7 - 15 % Ramus 3 - 9 % Alveolar 2 - 4 % Coronoid process 1 - 2 %
  • 39. ANATOMY mandible - lower jaw bone there is a left and a right mandible have joints - allow the mouth to open and close have a hollow canal - nerves and blood vessels are housed
  • 40. ANATOMY  U – shaped body  Vertically directed rami  Coronoid  Condyle  Oblique line  Mental foramen
  • 41. INTERNAL ANATOMY  Mandibular foramen  Lingula  Pterygoid fovea  Mylohyoid line  Fossae  Submandibular  Sublingual  digastric  Mental spines  Genioglossus  Geniohyoid
  • 42. ANATOMY  Body - From the distal symphysis to a line coinciding with the alveolar border of the masseter muscle (usually including the third molar) (30-40%)  Angle - Triangular region bounded by the anterior border of the masseter muscle to the posterosuperior attachment of the masseter muscle (usually distal to the third molar) (25 - 31%)  Condyle - Area above the ramus region (15 - 17%)
  • 43. ANATOMY  Symphysis - Region of the central incisors that runs from the alveolar process through the inferior border of the mandible (7 - 15%)  Ramus - Part of the mandible that is bounded by the superior aspect of the angle (3-9%)  Alveolar process - Region of the mandible that carries the teeth (2 - 4%)  Coronoid process - Includes the coronoid process of the mandible superior to the ramus region (1 - 2%)
  • 44. INNERVATION  CNV3, the mandibular n., through the foramen ovale  Inferior alveolar n. through the mandibular foramen  Inferior dental plexus  Mental n. through the mental foramen
  • 45. INNERVATION  CNV3, the mandibular n., through the foramen ovale  Inferior alveolar n. through the mandibular foramen  Inferior dental plexus  Mental n. through the mental foramen
  • 46. ARTERIAL SUPPLY  Internal maxillary artery  Inferior alveolar artery  Mental artery
  • 47. MUSCULATURE:JAW ELEVATORS  Masseter: Arises from zygoma and inserts into the angle and ramus  Temporalis: Arises from the infratemporal fossa and inserts onto the coronoid and ramus  Medial pterygoid: Arises from medial pterygoid plate and pyramidal process and inserts into lower mandible
  • 48. MUSCULATURE: JAW DEPRESSORS  Lateral pterygoid: lateral pterygoid plate to condylar neck and TMJ capsule  Mylohyoid: mylohyoid line to body of hyoid  Digastric: mastoid notch to the digastric fossa  Geniohyoid: inferior genial tubercle to anterior hyoid bone
  • 50. FAVORABLE FRACTURES  Those fractures where the muscles tend to draw fragments together  Ramus fractures are almost always favorable as the jaw elevators tend to splint the fractured bones in place
  • 52. UNFAVORABLE FRACTURES  Fractures where the muscles tend to draw fragments apart  Most angle fractures are horizontally unfavorable  Most symphyseal/parasymphyseal fractures are vertically unfavorable
  • 54. ANATOMY  back part of the jaw is covered with muscles that are used to open and close the mouth  teeth of the mandibles and maxilla usually interdigitate or have good occlusion  teeth are rooted in sockets in the mandible and maxilla
  • 56. MUSCLE SLING  Vertical rami totally embedded within sling  Masseter  Pterygoids
  • 57. MUSCLE SLING Angle and condylar neck not entirely protected by sling Bony trabecular crests, ridges, lines
  • 58. MUSCLE SLING Trabeculae resist normal tension, compression, and rotation of mastication Little resistance to lateral stress from blunt trauma
  • 62. DIAGNOSIS  ROS: bone disease, neoplasia, arthritis, CVD, nutrition and metabolic disorders, endocrine d/o  TMJ and ankylosis  MVA >> compound, comminuted fractures  Fists >> often single, non displaced fractures  An angled blow to the parasymphysis >> contralateral condylar fractures  An anterior blow to the chin >> bilateral condylar fractures
  • 63. PHYSICAL EXAM  Change in occlusion is highly diagnostic  Anterior open bite suggestive bilateral condylar or angle fractures  Posterior open bite common with alveolar process or parasymphyseal fractures  Unilateral open bite with ipsilateral angle or parasymphyseal fracture  Retrognathic (Angle III) seen with condylar or angle fractures  Prognathic (Angle II) seen with TMJ effusion
  • 64. PHYSICAL EXAM Anesthesia of lower lip :“pathognomonic” of a fracture distal to the mandibular foramen The converse is not true: not all fractures distal to the mandibular foramen have mental n. anesthesia Trismus of less than 35mm also highly suggestive of mandibular fracture
  • 65. PHYSICAL EXAM Inability to open the mandible suggests impingement of the coronoid process on the zygomatic arch Inability to close the mandible suggests a fracture of the alveolar process, angle, ramus or symphysis
  • 67. PHYSICAL EXAMINATION Pertinent physical findings are limited to the injury site. Change in occlusion may be evident on physical examination. highly suggestive of mandibular fracture. Ask patient to compare postinjury and preinjury occlusion.
  • 68. MAXILLARY ADVANCEMENT WITH LE FORT III FOR CORRECTION OF MAXILLARY DEFICIENCY
  • 69. MANDIBULAR SETBACK FOR WITH CORRECTION OF PROGNATHISM AND ASYMMETRY
  • 70. LACERATIONS AND ECCHYMOSIS Mandibular fractures can often be directly visualized beneath facial lacerations. Lacerations should be closed after definitive therapy of the fracture Ecchymosis is diagnostic of symphyseal fractures
  • 72. PHYSICAL EXAMINATION Lacerations, hematoma, and ecchymosis may be associated with mandibular fractures.
  • 74. PALPATION The mandible should be palpated with both hands, with the thumb on the teeth and the fingers on the lower border of the mandible. Slowly and carefully place pressure, noting the characteristic crepitation of a fracture
  • 76. PHYSICAL EXAMINATION Posttraumatic premature posterior dental contact (anterior open bite) and retrognathic occlusion may result from a mandibular angle fracture. Unilateral open bite deformity is associated with a unilateral angle fracture. Anesthesia, paresthesia, or dysesthesia of the lower lip may be evident.
  • 77. PHYSICAL EXAMINATION Most nondisplaced mandible fractures are not associated with changes in lower lip sensation; Displaced fractures distal to the mandibular foramen (in the distribution of the inferior alveolar nerve) may exhibit these findings.
  • 78. PHYSICAL EXAMINATION Loss of the mandibular angle on palpation may be because of an unfavorable angle fracture in which the proximal segment rotates superiorly. The anterior face may be displaced forward, causing elongation.
  • 79. PHYSICAL EXAMINATION Do not close facial lacerations before treating underlying fractures except in the case of life-threatening hemorrhage. Pain, swelling, redness, and localized calor are signs of inflammation evident in primary trauma.
  • 80. PHYSICAL EXAMINATION Change in facial contour loss of external mandibular form may indicate mandibular fracture. An angle fracture may cause the lateral aspect of the face to appear flattened.
  • 82. RADIOGRAPHIC EXAM Panorex shows the entire mandible, but requires the patient to be upright.  It also has particularly poor detail of the TMJ and medial displacement of the condyles  AP - ramus and condyle  Submental - symphysis  CT - condylar fractures
  • 84. Panoramic radiograph 12 weeks after cancellous iliac crest bone graft with reconstruction plate showing bony union
  • 85. IMAGING STUDIES:  The single most informative radiologic study used in diagnosing mandibular fractures is the panoramic radiograph.  Panorex provides the ability to view the entire mandible in one radiograph.  Panorex requires an upright patient, and it lacks fine detail in the TMJ, symphysis, and dental/alveolar process regions.  Plain films, including lateral-oblique, occlusal, posteroanterior, and periapical views, may be helpful.  The lateral-oblique view helps in diagnosing ramus, angle, or posterior body fractures. The condyle, bicuspid, and symphysis regions often are unclear.  Mandibular occlusal views show discrepancies in the medial and lateral position of the body fractures.  Caldwell posteroanterior views demonstrate any medial or lateral displacement of ramus, angle, body, or symphysis fractures.  CT scanning may also be helpful.  CT scanning allows physicians to survey for facial fractures in other areas, including the frontal bone, naso-ethmoid-orbital complex, orbits, and the entire craniofacial horizontal and vertical buttress systems.  Reconstruction of the facial skeleton is often helpful to conceptualize the injury.  CT scanning is also ideal for condylar fractures, which are difficult to visualize.
  • 91. COMPLICATIONS Socioeconomic groups Infection (James, et. al.) Delayed healing and malunion. Most commonly caused by infection and noncompliance Nerve paresthesias in less than 2%
  • 92. STUDY BY JAMES, ET. AL.  Prospective study of 422 pts  Infection rate 7%  50% of infections associated with fractured or carious teeth  ORIF led to 12% infection rate  Staph, strep, bacteroides  Prophylaxis, tooth extraction
  • 93. BONE HEALING  Reactive Phase Fracture Formation of granulation tissue  Reparative phase Replacement of granulation tissue by callus  Connective tissue + cartilage Replacement of callus by lamellar bone  Remodeling phase Remodeling of bone to normal contour The amount of callus formation is indirectly proportional to the degree of immobilization
  • 94. GENERAL PRINCIPLES OF TREATMENT  The general physical status should be thoroughly evaluated.  40% associated with significant injury, 10% of which are lethal  Cerebral contusion is common  ABC’s!  Almost never emergent
  • 95. GENERAL PRINCIPLES Dental injuries should be treated concurrently Reestablishment of occlusion is the primary goal Fractured teeth may jeopardize occlusion Mandibular cuspids are cornerstone of Tx Prophylactic antibiotics
  • 96. GENERAL PRINCIPLES With multiple facial fractures, mandibular fractures are treated first
  • 97. MANDIBULAR FRACTURES  Dentoalveolar injuries  Cautious use of intermaxillary fixation  Pattern of injuries with condyle most frequently injured  Possible growth disturbance  High osteogenic potential  Rare complications
  • 98. PRINCIPLES OF JAW FRACTURE REPAIR  Alignment of the jaw - teeth line up in normal position is critical for healing of the fracture  Remove all loose teeth or teeth that have periodontal disease at the level of the fracture
  • 99. PRINCIPLES OF JAW FRACTURE REPAIR If the tooth root has been involved a root canal procedure may be required Careful suturing of gums
  • 100. MANDIBULAR FRACTURES  Physical Exam  Observance of mandibular range of motion and malocclusion  Radiographic assessment  Greenstick common  Types of condylar fractures  *especially for kids
  • 101. CLOSED REDUCTION  Grossly comminuted fractures  Significant tissue loss  Edentulous mandibles  Fractures in children  Condylar fractures  Contraindicated in SzDo, psych, and compromised pulmonary function
  • 102. OPEN REDUCTION  Displaced, unfavorable fractures of angle  Displaced unfavorable fractures of the body or parasymphysis, as these tend to open at the inferior border, leading to malocclusion  Multiple fractures of facial bones  Displaced, bilateral condylar fractures
  • 103. CLOSED REDUCTION : DENTULOUS PATIENT Erich Arch Bars. Can lead to periodontal infalmmation. Avoid fixating incisors, as these teeth are moved by the wires Ivey loops
  • 104. CLOSED REDUCTION : PARTIALLY EDENTULOUS PATIENT  Partials and circum wires or screws  Acrylic partials with incorporated arch bar wires
  • 105. CLOSED REDUCTION : EDENTULOUS PATIENT  Dentures with circum wires and screws  Fabricated acrylic plates (Gunning Splints)  In fractures of both the mandible and maxilla, circumzygomatic and circum-mandibular wires should be tied together to prevent telescoping of maxilla
  • 106. OPEN REDUCTION AND OSTEOSYNTHESIS  Simpler than rigid fixation  MMF still required  Useful in angle, parasymphyseal fractures
  • 107. ORIF  Performed with compression plates and lag screws  MMF generally not required  Eccentrically placed holes and screws placed at angles “compress” the bone
  • 109. When double fractures occur, they are usually on contralateral sides of the symphysis. Common combinations include the angle plus the contralateral body or condyle. Triple fractures occasionally occur, - most common type is fracture of both condyles plus the symphysis.
  • 110.  The mandible may also be dislocated without fracture, sometimes spontaneously during a large yawn.  patient usually presents with considerable pain.  Spasm in the masseter and pterygoid muscles tend to force the condyles up the anterior slope of the articular eminence and prevent normal mouth closure.
  • 111. AO/ASIFAO/ASIF  “Arbeitsgemeinschaft fur Osteosynthesefragen”  The Association for the Study of Internal Fixation  Davos, Switzerland  Foundation providing clinical and scientific research relevant to trauma care for injuries of the musculoskeletal system  Purpose: Rigid internal fixation with resultant primary bone healing, even under conditions of full functional loading
  • 112. INTERNAL RIGID FIXATION Advantages Early active pain-free functional movement Avoidance of intermaxillary fixation Safe, secured airway without tracheotomy Earlier return to work
  • 113. INTERNAL RIGID FIXATION Interfragmentary compression Increased friction between fragments Increased surface area of direct contact Primary bone healing No evidence of pressure necrosis Loose hardware acts only as foreign body
  • 114. CHAMPY’S IDEAL LINES OF OSTEOSYNTHESIS  Masticatory muscles produce tension at upper border and compression at lower border  Torsional forces produced anterior to the canines
  • 115. CHAMPYCHAMPY  Monocortical “tension banding” osteosynthesis neutralizes distraction and torsion during physiologic stress, while normal basilar compression is restored
  • 116. DYNAMIC COMPRESSION Compression resulting in preload and friction  Preload prevents distraction  Friction resists torsional forces  Closure results only underneath plate  Gap on opposite side  Allows for primary healing  Contraindicated in comminution
  • 117. REDUCTION – GENERAL REMARKS  Restoration of occlusion with IMF  Selection of access  Fracture type and location  General anesthesia  Nasal vs. tracheotomy  Tension bands  Bicortical screws  Monocortical to avoid tooth roots and mandibular nerve  Compression and reconstruction plates  Inferior margin  Bicortical screws
  • 119. SYMPHYSIS AND PARASYMPHYSEAL  Transverse fracture without dislocation
  • 121. SYMPHYSIS AND PARASYMPHYSEAL  Transverse fracture with dislocation
  • 122. SYMPHYSIS AND PARASYMPHYSEAL  Basal triangle or comminuted
  • 124. BODY
  • 127. ANGLE
  • 132. CONDYLE PROCESS  Classified according to Kohler (1951)  Condylar fracture line runs inside capsule of TMJ Not fixed with plates or screws  Subcondylar situated below the capsule Classified into high and low  Condylar base fractures are at level of the sigmoid notch (incisura semilunaris)
  • 135. RAPID IMF  Advantages:  Easy insertion, OR time ≈ 10 minutes  Removal without anesthesia  Minimal danger to surgeon  Decreased damage to dental papillae and oral mucosa  Easier to maintain dental hygiene  Compatible with all rigid plating systems
  • 136. RAPID IMF  Disadvantages  Dental root injury  Loss of tension band directional traction
  • 137. RAPID IMF  Roccia, Fasolis et al.  An Audit of Mandibular Fractures Treated by IMF Using Intraoral Cortical Bone Screws  Journal of Crani-maxillofacial Surgery  Turin, Italy 2005
  • 138. RAPID IMF  ORIF 44 patients  CR 18 patients  Occlusion 2-3 weeks  Screws removed under local only  Minimum 6 month f/u Oral mucosa covering screw 5% Lost screws 2% Dental root injury 11% Infection 1% Malocclusion < 1%
  • 139. RAPID IMF CONCLUSIONS • Recommended: – Single or double fractures with minimal displacement – Compound condylar fractures – Edentulous patients if proper dentures available • Contraindicated: – Multiple comminuted fractures – Alveolar bone fractures – Pediatric patients with unerupted teeth – Severe osteoporosis
  • 140. POSTOPERATIVE ANTIBIOTICS  Abubaker et al.  Medical College of Virginia  J Oral Maxillofac Surg. 2001  Prospective, randomized, double-blind, placebo-controlled study  30 patients, 2 arms, 6 week post-op f/u ** No significant statistical difference between groups
  • 141. ORIF VS. MMF TMJ FUNCTION ANALYSIS  Gorgu, Erdogan et al.  Scand J Plast Reconstr Surg Hand Surg 2002  Ankara, Turkey  Prospective Comparative Study of the Range of Movement of TMJ After Mandibular Fractures: Rigid or Non-rigid Fixation
  • 142. GORGU, ERDOGAN ET AL.  Prospective, randomized, controlled study  147 patients in 3 groups (1993-1998)  MMF= 54  4 weeks immobilization  Titanium miniplate ORIF= 49  No movement restriction  Control= 44  Randomly selected with no hx of mandible injury  Mean follow-up 2.2 yrs (1-3)  Exclusion criteria  Condylar frx, multiple frx, comminution or significant displacement, malocclusion, edentulous
  • 143. GORGU, ERDOGAN ET AL. MMF * (n=54) ORIF ** (n=49) Controls (n=44) Max jaw opening (mm) 30.9 (6.0) 45.1 (5.9) 50 (5.4) Max displacement to left (mm) 8.0 (2.9) 9.9 (2.4) 11 (2.5) Max displacement to right (mm) 6.8 (3.3) 9.6 (2.3) 10 (2.6) Protrusion (mm) 3.4 (1.5) 9.3 (0.8) 10 (1.0) * p < 0.001 compared with control ** p < 0.001 compared with control and MMF group
  • 144. GORGU, ERDOGAN ET AL.  Trauma is major factor leading to TMJ dysfunction  MMF increased the incidence and severity of TMJ dysfunction MMF * (n=54) ORIF ** (n=49) Controls (n=44) Click 38 (70%) 20 (41%) 11 (25%) Crepitus 36 (67%) 11 (22%) 5 (11%) * p < 0.003 compared with control ** p < 0.005 compared with control and MMF group
  • 145. ORIF VS. MMF COMPLICATION ANALYSIS  Moreno et al.  J Oral Maxillofac Surg 2000  Madrid, Spain  Complication Rates Associated with Different Treatments for Mandibular Fractures
  • 146. MORENO ET AL. Retrospective study  245 patients with 386 fractures (1993-1996)  Isolated condylar process fractures excluded  Treatment methods:  MMF (n=136)  Exclusive, 40 days occlusion  2-mm miniplates (n=45)  Post-op MMF 0 – 15 days  AO 2.4 mm system (n=19)  Immediate mobility  AO 2.7 mm system (n=32)  Immediate mobility  Severity scale, multiple variables analyzed
  • 147. MORENO ET AL  Rate of postoperative infection for each type of treatment, separated by severity of fractures 0 25 50 75 100 MMF 2 mm AO 2.4 AO 2.7 1 2 3 4 Severity *p < 0.001 between infection rate and fracture severity only
  • 148. MORENO ET AL  Rate of postoperative malocclusion for each type of treatment, separated by severity of fractures 0 25 50 75 100 MMF 2 mm AO 2.4 AO 2.7 1 2 3 4 *p < 0.05 between malocclusion rate and fracture severity only Severity
  • 149. MORENO ET AL  Overall complication rate for each type of treatment, separated under severity of the fractures 0 25 50 75 100 MMF 2 mm AO 2.4 AO 2.7 1 2 3 4 *p < 0.001 between overall rate and fracture severity only Severity
  • 150. ORIF POST-OP MMF VS. IMMEDIATE MOBILIZATION  B Kaplan, S Park et al.  Laryngoscope 2001  Univ of Virginia Medical Center  Immediate Mobilization Following Fixation of Mandible Fractures
  • 151. PARK ET AL.  Prospective, randomized, single-blinded study  ORIF 2.0 mm titanium plates  Inclusion: displaced fractures between angles only  29 patients in 2 groups (1997 – 2000)  Immediate function (n=16)  2 weeks post-op MMF (n=13)  Follow-up intervals: 3 wks, 3 mos, 6 mos  Variables assessed by surgeon blinded to the history of immobilization  Pain, non-union, malunion, occlusion, trismus, infection, weight loss, dental hygiene
  • 152. PARK ET AL.  No statistical difference between measured variables  The assumed beneficial effects from transient TMJ rest and no fracture stresses was not realized Wt loss in pounds Objective trismus in cm
  • 153. ORIF VS. MMF COST ANALYSIS  B Schmidt, L Kaban et al.  J Oral Maxillofac Surg 2000  University of California San Francisco  A Financial Analysis of MMF vs. Rigid Internal Fixation for Treatment of Mandibular Fractures
  • 154. KABAN ET AL.  Retrospective study  85 patients in two groups  CRF (n=38)  ORIF (n=47) (external and transoral approaches)  Outcome variables:  Length of hospital stay  Duration of anesthesia  Surgery time  Patient fee for primary treatment without complications  Estimated average patient fee to manage a major post-op infection
  • 155. KABAN ET AL. CRF ORIF Preop hospital days 1.79 1.98 Postop hospital days 1.95 2.56 *Anesthesia time (min) 141 309 *Surgical time (min) 106 267 *p < 0.0001
  • 156. KABAN ET AL.  Did not evaluate savings from earlier return to work in ORIF patients Charge for primary treatment Charge for complication* Total charg e CRF $10,099 ± 5,489 $26,671 ± 2,310 $10,9 26 ORIF $28,361 ± 14,731 $39,212 ± 38,694 $34,6 35 P- value < 0.001 < 0.0652 < 0.001 * Incidence of post-op infx was 16% (ORIF) and 3%(MMF)
  • 157. CLOSED TECHNIQUES  Nondisplaced favorable fractures  Grossly comminuted fractures  Edentulous fractures (using a mandibular prosthesis)  Fractures in children with developing dentition  Coronoid and condylar fractures
  • 158. INDICATIONS FOR OPEN REDUCTION  Displaced unfavorable angle, body, or parasymphyseal fractures  Multiple facial fractures  Bilateral displaced condylar fractures  Fractures of an edentulous mandible (with severe displacement of fracture fragments in an effort to reestablish mandible continuity)
  • 160. Grafted right mandibular body nonunion with cancellous iliac crest bone graft, packed into polyglactin mesh tube.
  • 161. Grafted left mandibular body nonunion with cancellous iliac crest bone graft packed into polyglactin mesh tube.
  • 162. CONCLUSIONS  AO does not mean “always operate” or “always open”  AO standards provide sound techniques resulting in a consistently high success rate in most hands  Occlusion must be 100% prior to rigid internal fixation  Main indications for RIF include:  Compound fractures with defects  Edentulous mandibles or those with few teeth  Fracture dislocation ± condylar neck fracture  Panfacial trauma  Electively
  • 163. WISE SAYINGS ABOUT MANDIBULAR FRACTURES  Remember the ring bone rule.  Symphyseal fractures can be diabolically hard to see, even on a well- exposed AP film  Remember the Panorex view -- this can usually only be taken by a special machine in the oral surgery department, but it provides the best single view of the mandible and will show you fractures that cannot be seen by any other method short of CT.  Look carefully along the cortical margin of the whole mandible for discontinuities. This may be the only sign of a fracture that you will see.
  • 164. WISE SAYINGS ABOUT MANDIBULAR FRACTURES  Also carefully examine the mandibular canal for discontinuities.  A fracture line entering the root of a tooth is considered an open fracture by definition.  Pathologic fractures can occur in the mandible. Look carefully for evidence of a periapical abscess or a mandibular tumor, especially if there doesn't seem to be enough trauma to match the injury.
  • 166. OBJECTIVES  Anatomy  Fracture distraction  Principles of rigid internal fixation  AO method  Rapid IMF  ORIF vs. MMF