Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Mandibular fracture

Mandible Fracture

  • Login to see the comments

Mandibular fracture

  1. 1. Mandibular fracture Deepak Kumar Gupta
  2. 2. Applied Anatomy • Body ▫ Mental foramen lies on the anterior part of lateral surface. ▫ External oblique ridge – lateral side ▫ Medial surface has mylohyoid line. ▫ Mylohyoid line helps divide a sublingual from a submandibular fossa ▫ Posterior border of the mylohyoid line provides for attachment of the pterygomandibular raphe ▫ At the midline on the medial side are the superior and inferior genial tubercles, as well as the digastric fossa dr.dkg07@gmail.com
  3. 3. dr.dkg07@gmail.com
  4. 4. Applied Anatomy • Ramus ▫ Meets the body of the mandible at the angle of the mandible on each side. ▫ Masseter m. attaches to the lateral side ▫ Medial pterygoid m. And sphenomandibular lig. attach to the medial side ▫ Mandibular foramen is located on the medial side of the ramus ▫ Superior part divides into a coronoid process anteriorly and a condylar process posteriorly, separated by a mandibular notch dr.dkg07@gmail.com
  5. 5. Applied Anatomy • Coronoid process ▫ The anteriormost superior extension of each ramus ▫ Attatchment of Temporalis m. • Condylar process  Articulates with the temporal bone in the temporomandibular joint  Has a neck that forms a condyle superiorly  Lateral pterygoid muscle attaches to pterygoid fovea on the neck dr.dkg07@gmail.com
  6. 6. Alveolar Process • Extends superiorly from the body • Created by a thick buccal and a thin lingual plate of bone • The part of the mandible that supports the mandibular teeth • Each side of the mandible contains 5 primary and 8 permanent teeth • Alveolar bone is resorbed when a tooth is lost dr.dkg07@gmail.com
  7. 7. dr.dkg07@gmail.com
  8. 8. Nerve supply to Mandible dr.dkg07@gmail.com
  9. 9. Dingman and Natwig Classification • Midline • Symphysis • Parasymphysis • Body • Angle • Ramus • Condyle • Coronoid process • Dentoalveolar process dr.dkg07@gmail.com
  10. 10. Kazanian and Converse classification • Class I: teeth present on both side of fracture line • Class II: teeth present on either side of fracture line • Class III: edentulous patient Class I dr.dkg07@gmail.com
  11. 11. Kruger and Schilli Classification • Relation to external Environment ▫ Simple or compound ▫ Compound or open • Types of fracture ▫ incomplete fracture ▫ Greenstick fracture ▫ Complete ▫ Comminuted dr.dkg07@gmail.com
  12. 12. Kruger and Schilli Classification • Dentition of jaw with the use of splints ▫ Sufficiently dentulous jaw ▫ Edentulous or insufficiently jaw ▫ Primary or mixed dentition • Localisation ▫ precanine ▫ canine ▫ postcanine ▫ angle ▫ supra-angular ▫ condylar process ▫ coronoid process ▫ alveolar process dr.dkg07@gmail.com
  13. 13. SPIESSEL CLASSIFICATION • Number of fragments – F ▫ F0: incomplete fracture ▫ F1: single fracture ▫ F2: multiple fracture ▫ F3: comminuted fracture ▫ F4: fracture with bone defect • Location of fracture – L ▫ L1: precanine ▫ L2: canine ▫ L3: postcanine ▫ L4: angle ▫ L5: supra-angular ▫ L6: condylar process ▫ L7: coronoid process ▫ L8: alveolar process dr.dkg07@gmail.com
  14. 14. SPIESSEL CLASSIFICATION • Status of occlusion – O ▫ O0: no malocclusion ▫ O1: Malocclusion ▫ O3: non-existent occlusion • Soft tissue involvement – S ▫ S0: closed ▫ S1: open intraorally ▫ S2:open extraorally ▫ S3: open intra & extraorally ▫ S4: soft tissue defect • Associated fracture – A ▫ A0: none ▫ A1: fracture or loss of tooth ▫ A2: nasal bone ▫ A3: zygoma ▫ A4: Le-fort – I ▫ A5: Le-fort – II ▫ A6: le fort – III dr.dkg07@gmail.com
  15. 15. Direction of fracture line and effect of muscle action • Favourable ▫ Vertically favourable ▫ Horizontal favourable • Unfavourable fractures  Vertically unfavourable  Horizontally unfavourable dr.dkg07@gmail.com
  16. 16. Extra-oral findings ▫ Indirect sign  Swelling  Ecchymosis  Erythema  Abrasion  Laceration ▫ Facial deformity ▫ Paraesthesia or anaesthesia on one or both side of mandibel – inferior alveolar nerve injury ▫ Step deformity, crepitus, bone tenderness ▫ Inablity to occlude teeth dr.dkg07@gmail.com
  17. 17. dr.dkg07@gmail.com
  18. 18. Intra-oral findings • Coleman’s sign: lingual haemotoma • Buccal and lingual sulci – echymosis • Step defect in occlusion or alveolus are noted – laceration of overlying mucos and gingival tear. • Change of occlusion • Mobility • Pain, tenderness or limitation while mandibular movement are indicative of fracture. dr.dkg07@gmail.com
  19. 19. Area specific clinical feature • Fracture at angle ▫ Step deformity at last molar tooth ▫ Premature dental contact – inablity to close mouth – anterior open bite  Unilateral – bilateral angle fracture  Ipsilateral – unilateral angle fracture ▫ Trsimus ▫ Retrognathic occlusion and flattened appearance on both surface dr.dkg07@gmail.com
  20. 20. Fracture of Body • Slight displacement – dearrangement of occlusion • Premature contact on distal fragments - displacing action of muscles atatched to the ramus • Coleman sign • Flattened appearance on lateral side • Impingement of airways – mylohyoid, digastric or omohyoid full the fragments posteriorarly. dr.dkg07@gmail.com
  21. 21. Fracture of symphysis and parasymphysis • Missed – when occlusion is not disturbed • Only lingual haematoma (coleman sign) and bone tenderness is the sign • Posterior openbite /unilateral openibite • Posterior crossbite – midline symphysis fracture • Retruded chin • Severe concussion, loss of tongue control and obstruction of airway dr.dkg07@gmail.com
  22. 22. • Fracture of coronoid process ▫ Caused by reflex contracture of powerful anterior fibers of temporalis ▫ Difficult to diagnose ▫ Painfull movement especially during protrusion movement • Fracture of ramus ▫ Uncommon ▫ Flattened appearance of lateral aspect ▫ Severe trismus dr.dkg07@gmail.com
  23. 23. Radiographic examination • Periapical view ▫ Non-displaced linear fracture of body ▫ Alveolar process ▫ Dental trauma • Occlusal view  Medial and lateral position of body fracture  Anterior posterior displacement of symphysis dr.dkg07@gmail.com
  24. 24. Panoromic radiographs • Most informative radilogical studies for mandible fracture • Advantage ▫ Visualize entire mandible in one radiograph ▫ Low dose of radiation ▫ Patient education is easy ▫ Short time(3-4 min) and can be taken closed mouth. dr.dkg07@gmail.com
  25. 25. Panoromic radiographs • Disadvantage ▫ Patient to be upright – impractical for severily traumatized patient ▫ Difficult to appreciate: Buucolingual bone displacement or medial condylar displacement ▫ Final details are lacking dr.dkg07@gmail.com
  26. 26. Radiographic examination Reverse Towne’s radiograph Ideal for showing lateral or medial condylar displacement • Lateral oblique view ▫ Fracture of ramus ▫ Angle and posterior body dr.dkg07@gmail.com
  27. 27. Radiographic examination • Posterior-anterior view  Medial or lateral displacement of fracture of ramus, angle, condyle, body and symphysis.  Midline or symphyseal fracture well visualised • CBCT/CT scan  3d reconstruction helps understanding degree of diplacement as well as reveal fractures not evident in OPG dr.dkg07@gmail.com
  28. 28. dr.dkg07@gmail.com
  29. 29. dr.dkg07@gmail.com
  30. 30. Diagnosis • Radiographic Evaluation ▫ Ideally need 2 radiographic views of the fracture that are oriented 90’ from one another to properly work up fractures  Panorex and Towne’s  CT axial and coronal cuts ▫ Single view can lead to misdiagnosis and complications with treatment dr.dkg07@gmail.com
  31. 31. • This Towne’s view show a body fracture that is displaced in a medial to lateral direction and a subcondylar fracture with lateral displacement dr.dkg07@gmail.com
  32. 32. • However, Panorex clearly shows the superior displacement of the right body fracture dr.dkg07@gmail.com
  33. 33. • Mandibular bilateral neck and mandibular body fractures;44-year-old female with trauma to chin 3 weeks previously, but still some problems with dental occlusion (only tooth fractures diagnosed by clinical and intraoral radiographic examinations). A Panoramic view shows fracture of mandibular body (arrow), and suggests possible fractures of condyles dr.dkg07@gmail.com
  34. 34. • Axial CT image • shows mandibular body fracture without dislocation • (arrows). dr.dkg07@gmail.com
  35. 35. Management • Reduction and fixation ▫ Closed reduction ▫ Open Reduction • Immobilization • Mobilization dr.dkg07@gmail.com
  36. 36. Closed reduction: indication • Favourable fracture • Grossly comminuted fracture : if opened it may jeopardise the vascular supply of bony fragments • Severely atrophic mandible : open reduction require stripping of bone which is not possible in already atrophied mandible. Reduced blood supply. • Lack of soft tissue overlying fracture site: bone plates or screws would disrupt the soft tissue covering • Children – developing dentition • Infected fracture: life threatening surgical risk and delayed healing • Condylar fracture: no displaced fracture dr.dkg07@gmail.com
  37. 37. Open reduction: indication • Complex facial fracture • Unfavourable fracture: symphysis, body or angle • Displaced bilateral condylar fracture • Delayed presentation • Malunited mandibular fractures • Mandible fracture opposing edentulous maxilla • Edentulous mandibular fracture with severe displacement • Medically compromised patient – severe seizure disorder, psychiatric or neurologic problem dr.dkg07@gmail.com
  38. 38. Fixation • Direct • Indirect technique dr.dkg07@gmail.com
  39. 39. Immobilization • Allow bone healing. • Factors considered for period of immobilization ▫ Type, location, number and severity of fracture ▫ General health condition ▫ Method employed for reduction and stability • Average immobilization period is 6 weeks. ▫ Edentulous patient requires more time for healing dr.dkg07@gmail.com
  40. 40. Killey and Kay guide for immobilization • Young adult with fracture of angle receiving early treatment in which tooth is removed from fracture line - 3 weeks, if ▫ Tooth retained in fracture line – add 1 week ▫ Fracture at symphysis: add 1 week ▫ Age 4o years and above : add 1 week ▫ Children and adolescent: substract 1 week. dr.dkg07@gmail.com
  41. 41. Approaches for Open reduction Sypmhysis and parasymphysis: intra-oral vestibular approach dr.dkg07@gmail.com
  42. 42. • A. Stepwise incision through the mucosa first, followed by the incision through the muscles and the periosteum. • B. Two-layer wound closure for muscle and mucosa. dr.dkg07@gmail.com
  43. 43. Intra-oral-transbuccal incision For body and angle fracture of mandible dr.dkg07@gmail.com
  44. 44. Extra-oral submandibular – Risdon incision For body and angle fracture of mandible. Also known as Transcervical access of the submandibular standard approach dr.dkg07@gmail.com
  45. 45. Extra-oral sub mandibular – Risdon incision a Sharp dissection stepwise through skin (red line cranial), platysma, and superficial cervical fascia (dotted line caudal). b Ligation of the facial vein and/or artery is often indicated. The bone surface is reached in a layer underneath the superior cervical fascia. dr.dkg07@gmail.com
  46. 46. 1 Preauricular approach 2 Transparotid approach 3 Retromandibular approach 4 Submandibular approach dr.dkg07@gmail.com
  47. 47. Condylar Process Fractures • Incidence: ▫ Represent 25-35% of all mandible fractures ▫ Location:  14% intracapsular (41% in children <10)  24% condylar neck (38% in adults >50)  62% subcondylar  84% unilateral  16% bilateral dr.dkg07@gmail.com
  48. 48. Condylar Process Fractures • Classifications: ▫ Wassmund Scheme:  I- minimal displacement of head (10-45’)  II- fracture with tearing of medial joint capsule (45-90’), bone still contacting  III- bone fragments not contacting, condylar head outside of capsule medially and anteriorly displaced  IV- head is anterior to the articular eminence  V- vertical or oblique fractures through condylar head dr.dkg07@gmail.com
  49. 49. Condylar Process Fractures • Classifications: ▫ Lindahl classification:  I- nondisplaced  II- simple angulation of displacement, no overlap  III- displaced with medial overlap  IV- displaced with lateral overlap  V- displaced with anterior or posterior overlap  VI- no contacts between segments dr.dkg07@gmail.com
  50. 50. Condylar Process Fractures • Classifications: ▫ MacLennan classification:  I- nondisplaced  II- deviation of fracture  III- displacement but condyle still in fossa  IV- dislocation outside of glenoid fossa dr.dkg07@gmail.com
  51. 51. Condylar Process Fractures • Goals of condylar fracture repair: ▫ 1) Pain-free mouth opening with opening of 40mm or greater ▫ 2) Good mandibular motion of jaw in all excursions ▫ 3) Restoration of preinjury occlusion ▫ 4) Stable TMJs ▫ 5) Good facial and jaw symmetry dr.dkg07@gmail.com
  52. 52. Condylar Process Fractures • Growth alteration from condylar fractures: ▫ Estimated that 5-20% of all severe mandibular asymmetry is from condylar trauma ▫ Believed to be from shortening of the ramus or alterations in muscle action leading to growth changes dr.dkg07@gmail.com
  53. 53. Condylar Process Fractures • Treatment alternatives: ▫ Non-surgical- diet, observation and physical therapy ▫ Closed reduction- utilizes a period of IMF the physical therapy ▫ Open reduction dr.dkg07@gmail.com
  54. 54. Condylar Process Fractures • Closed reduction: ▫ Indications:  Split condylar head  Intracapsular fracture  Small fragments from comminuted condyle  Risk of devascularization of the condylar segment with ORIF ▫ Treated with short course of IMF with post- operative physical therapy dr.dkg07@gmail.com
  55. 55. Condylar Process Fractures • Open reduction: ▫ Zide’s absolute indications:  1) middle cranial fossa involvement with disability  2) inability to achieve occlusion with closed reduction  3) invasion of joint space by foreign body dr.dkg07@gmail.com
  56. 56. Condylar Process Fractures • Open reduction: ▫ Zide’s relative indications:  1) bilateral condylar fractures where the vertical facial height needs to be restored  2) associated injuries that dictate early or immediate function  3) medical conditions that indicate open procedures  4) delayed treatment with malalignment of segments dr.dkg07@gmail.com
  57. 57. Condylar Process Fractures • Open reduction techniques: ▫ Multiple approaches and fixation have been developed and used dr.dkg07@gmail.com
  58. 58. Condylar Process Fractures • closed reduction techniques rarely produce pain, limit function, or produce growth disturbances • Open reductions techniques show an early return to normal function, but are technique sensitive, time extensive, and can lead to facial nerve dysfunction depending upon surgical approach dr.dkg07@gmail.com
  59. 59. Complications • Infection: ▫ Dodson et al. J Oral Maxillofac Surg 1990;48  Closed reduction- 0%  Wire osteosynthesis- 20%  Rigid fixation- 6.3% ▫ Assael J Oral Maxillofac Surg 1987;45  Closed reduction- 8%  Wire osteosynthesis- 24%  Rigid fixation- 9% dr.dkg07@gmail.com
  60. 60. Complications • Infection: ▫ variation of infection rates with rigid vs. non rigid fixation schemes ▫ Most show that wire osteosynthesis techniques have the highest infection rates due to the higher level of mobility at fracture site, leading to vascular damage and perculation of bacteria into facture site dr.dkg07@gmail.com
  61. 61. Complications • Malocclusion: ▫ More difficult to manage with rigid fixation ▫ Most studies have shown that malocclusion occur more frequently with rigid fixation ▫ May be due to plate mal- positioning/iatrogenic ▫ Low risk in pediatric fractures due to growth and dentition reposition dr.dkg07@gmail.com
  62. 62. Complications • Malunion and nonunion: ▫ Most nonunions occur from infections of the fracture or teeth in the line of fracture ▫ Malunions are usually tolerated well by the patient, most malunions of the body, symphysis, or angle can result in malocclusions. This is harder for the patient to tolerate. More common with improper use of fixation technique. dr.dkg07@gmail.com
  63. 63. Conclusions • Closed reduction techniques are much better in pediatric and condylar fractures • Antibiotics should be used in all mandible fractures except fractures only in the ramus, coronoid, or condylar region that are closed. dr.dkg07@gmail.com
  64. 64. Refrences • www.aofoundation.org • Textbook OF Oral And MF Surgery - S.M Balagi – 2007 • Text book of oral and maxillofacial surgery 3rd edition_Neelima Mallik • Principles_of_Internal_Fixation_of_the_Craniomaxillary - AOCMF • Petersonâ Principles of Oral and MF Surgery -2nd ed • Oral Cavity Reconstruction • Advanced Trauma Life Support Student Manual, 8th edn . American College of Surgeons . Chicago, IL • Facial trauma_Seth R. Thaller • Facial Plastic and reconstruction surgery 2nd edition Ira D. Paper • FONSECA - Oral and MF Surgery(1) • Craniofacial Biology and Craniofacial Surgery • Contemporary oral and maxillofacial surgery _hupp_ellis_tucker • Complications in Head and Neck Surgery 2nd, D. Eisele • Clinical handbook of oral and maxillofacial surgery_lashkins • Pubmed.com, Google.com, • Textbook of Pathology 6th Edition, Harshmohan
  65. 65. THANKS…… Feedback if any : dr.dkg07@gmail.com Like, share and comment on https://www.facebook.com/notesdental facebook.com/notesdent al

×