Dentist in pune. (BDS. MDS) - Dr. Amit T. Suryawanshi. Seminar-Canine Impaction. Email ID- amitsuryawanshi999@gmail.com Contact -Ph no.-9405622455 Subscribe our channel on youtube - https://www.youtube.com/channel/UC_gylEXTrjmEbbOTSXjuZ4Q/videos?view_as=public Follow us on slideshare

1. Dr. Amit T. Suryawanshi
Dentist, Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2.  MANAGEMENT of mandibular fracture depends on
knowlege with dental anatomy, head and neck
physiology and occlusion
 The mandible is the second most commonly fractured
bone in maxillofacial skeleton because of its position
of prominence.
 The location and pattern of the fracture are
determined by the mechanism of injury, and the
direction of the vector of the force.
 Advancement related to management- Rigid internal
fixation.

3.  U – shaped body
 Vertically directed
rami
Coronoid
Condyle
 Oblique line
 Mental foramen

4. • Mandibular foramen
• Lingula
• Pterygoid fovea
• Mylohyoid line
• Fossae
– Submandibular
– Sublingual
– digastric
• Mental spines
– Genioglossus
– Geniohyoid

5. Muscle Sling
• Vertical rami totally
embedded within sling
– Masseter
– Pterygoids
• Angle and condylar neck
not entirely protected by
sling
– Bony trabecular crests,
ridges, lines
• Trabeculae resist normal
tension, compression,
and rotation of
mastication
– Little resistance to lateral
stress from blunt trauma

6. Fracture Distraction and
Favorability

7. Innervation
• Mandibular nerve through the foramen ovale
• Inferior alveolar nerve through the mandibular
foramen
• Inferior dental plexus
• Mental nerve through the mental foramen

8. Arterial supply
• Internal maxillary artery from the external carotid
• Inferior alveolar artery through the mandibular
foramen
• Mental artery through the mental foramen

9. • 1650 BC –Edwin smith surgical papyrus
• Hippocrates- cicumferential dental
• 1275 - Salicetti-IMF
• Gilmer- To apply correctly
• 20 th century –MM fixation or Gunning type splints for the
edentulous.
• 1968 - Luhr& Spiessl -idea of using miniature bone plates

10. 1976 – Spissel in german speaking countries
Concept-based on orthopedic principles and
trying to fit orthopedic material to the
complex and very different structure of facial
skeleton.
Absolute interfragmentory immobilization is
achieved with no resorption of fracture ends,
no callous formation, and intracortical
remodelling across the fracture site whereby
the fractured bone cortex is gradually
replaced by new Haversian systems .
“C a l l o u s f o r m a t i o n c o n s i d e r e d a failure”

11. • Plates are bulky, very large to use, and always
required large skin incision. Neck scar
undesirable
• Nerve damage –both inferior alveolar and Facial
• Infection of the plates
• Resurgery to remove plates always necessary.
Biomechanically in a wrong position

12.  1973- Michelet introduced a new technique,
using smaller Miniplates in intraoral
approach.
 Principle- like a suspension bridge to define
tension in a fracture.
 Champy et al – refined and researched

13.  Bone tensile failure results from tensile
strain rather than compressive strain
 Similar to arch-distributes the force of
impact throughout its length.
 Foramina, sharp bends, ridges and reduced
cross sectional dimension – tensile strain
concentration

14.  WIDE RANGE of magnitude and direction of
impacts
 Condition of the dentition, position of the
mandible at the time of impact and influence
of associated soft tissues.
Relation with Dentition
 Presence of posterior teeth - reduce condylar
fracture
 Impacted third molar-area of internal
weakness

17.  Assault
 Road traffic accidents
 Sports injuries
 Industrial or work place accidents
 Falls, which may be a trip or a medical
syncope .

18.  At least two films at right angles
 Standard-OPG & reverse townes
 # parasymphysis-occlusal film
 CT-cost sensitive
- concomitant midface fractures
- communited fractures
- condylar fractures -3D reconstruction
- cervical spine injury
- very young patients- under sedation

19.  Change in occlusion
 Paresthesia, anesthesia
 Localized pain
 Altered range of motion or deviation of the
mandible.
 Changes in facial contour ,symmetry and dental
arch form
 Lacerations, hematoma, sub lingual echymosis
 Mobility of the tooth
 Crepitus or mobility of bone segments
 Palpable bony steps.

21.  Simple :no external contamination
 Compound: communication with external environment.
 Comminuted: multiple segments of bone that have been
splintered or crushed.
 Green stick: one cortex is compromised ,but the other is
intact.
 Pathologic: pre existing disease or lesion associated with a
fracture site.
 Multiple: two or more lines of fracture on the same
bone ,but not communicating with one another.
 Impacted: one segments is telescoped within the adjacent
fragment.
 Atropic: decreased bony mass
 Indirect: fracture is present at the site distant from the
point of impact
 Complex: associated soft tissue injury

23. ANATOMIC
Symphysis
Body
Angle
Ramus
Coronoid
Condylar process
Dentulous
Partially edentulous
Dentulous
Primary or mixed dentition
BIOMECHANICAL
FAVORABLE : muscle pull will tent to keep the fracture reduced.
UNFAVORABLE: muscle pull will tent to distract the segments.

25.  Krugers classification
 Simple/closed
 Compound/open
 Comminuted
 Complicated
 Impacted
 Greenstick
 Pathological

26. Rowe & Killeys classification
-Single unilateral
-Double unilateral
-Bilateral
-Multiple
Kazanjian & converse classification
-Class 1
-Class 2
-Class 3

27.  Symphysis region, which is formed by the
bony union of 2 halves in the centre at the
first year of life.
 Parasymphysis region, which lies lateral to
the mental prominence.
 The angle of the mandible
 The neck of the mandibular candyle.

28. G. Acc. To presence or absence of teeth in
relation to # line.
Kazanjian Classification:
Class 1: When teeth are present on both sides
of the fracture line.
Class 2 : When teeth are present only on one
side of the fracture line.
Class 3: When both fragments on each side of
fracture line are edentulous.

29.  Clinical Examination:
1. Immediate assessment : Pts with
maxillar injuries may have sustained
other bodily injury which may be a
threat to life therefore they should be
considered first.
2. General Clinical Examination : # of the
mandible are caused by trauma & the
patient may also suffer from injury
elsewhere in the body.A thorough
general assessment of the patient should
be carried out.

30. 3. Local examination of the fracture
 Extra oral examination:
Most of the physical signs of a fractured
bone result from the extravasation of
blood from the damaged bone ends.
Swelling and ecchymosis indicate the site of
any mandibular fracture.
There may be obvious deformity in the bony
control and if considerable displacement
has occurred, the pt’s mouth hangs
open.

31.  Intraoral Examination:
The buccal and lingual sulci are examined
for ecchymosis
Occlusal plane is next examined
Individual teeth along with luxation and
subluxation are noted.
Mobility is checked of the possible fracture
sites.
Signs and symptoms of mandibular
fractures at various fracture sites:

32. 1. Dentoalveolar : Those in which avulsion,
subluxation or fracture of the teeth occur
in association with the alveolus.
2. Fracture of the coronoid process: It is
usually considered to result from reflex
contracture of the powerful ant fibres of
temporalis muscle. It is diff to diagnose
clinically. There may be tenderness over
the area, painful limitation of movement,
esp protrusion of the mandible.

33. 3.Fracture of the ramus : Swelling and
ecchymosis is seen extraorally and
intraorally. Tenderness, severe trismus is
usually present.
4.Fracture of the angle : Swelling at the angle
externally and there may be obvious
deformity. Hematoma, derangement of
occlusion. On palpation, tenderness and
crepitus is elicited, movements are painful.
5. Fracture of the body: Similar to fracture
of the angle.Even slight displacement causes
derangement of occlusion.

34. Fracture Frequency

35. Evaluation
– Pain, malocclusion, trismus, V3 sensory
deficit
– History of TMJ (earlier mobilization)
– Blow to face favors parasymphyseal fracture
and contralateral angle fracture
– Fall to chin (bilateral condylar fractures)

36. Evaluation
• Previous occlusion (Class I-III)
• Psychiatric, nutritional, gastrointestinal, seizure disorders
• Previous facial trauma
• Other injuries (c-spine, intra-abdominal, likely prolonged intubation)

37. Evaluation - History
• Mechanism of injury
_ multiple comminuted fx
– Fist often results in single, non - displaced
fx
– Anterior blow to chin - bilateral condylar fx
– Angled blow to parasymphysis can lead to
contralateral condylar or angle fx
– Clenched teeth can lead to alveolar
process fx

38. Physical Exam - Occlusion
• Change in occlusion - determine preinjury occlusion
• Posterior premature dental contact or an anterior
open bite is suggestive of bilateral condylar or angle
fractures
• Posterior open bite is common with anterior alveolar
process or parasymphyseal fractures
• Unilateral open bite is suggestive of an ipsilateral
angle and parasymphyseal fracture
• Retrognathic occlusion is seen with condylar or angle
fractures
• Condylar neck fx are assoc with open bite on
opposite side and deviation of chin towards the side
of the fx.

39. Physical Exam
• Anesthesia of the lower lip
• Abnormal mandibular movement
– unable to open - coronoid fx
– unable to close - fx of alveolus, angle or
ramus
– trismus
• Lacerations, Hematomas, Ecchymosis
• Loose teeth
• Palpation

40. Physical Exam
• Dental Exam
– Lost, fractured, or unstable teeth
– Dental Health
– Relation to fracture
– Quantity

41. Malocclusion

42. Physical Exam, Cont
• 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

43. 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

44. Palpation
• The mandible should be palpated with both hadns, 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

46. Techniques for mandibular
fractures with closed reduction
Direct interdental wiring [Gilmer]
1.First aid method for temporary immobilization.
2.5cm of .35mm wire used.
3.ADVANTAGE: Simple technique.
4.DISADVANTAGE: A loose or broken wire cannot
be replaced without removing and replacing others

47. GILMER WIRING

48. Button wiring
Leonard 1977
This technique tided tthhee pprroobblleemmss aassssoocciiaatteedd
wwiitthh eeyyeelleett wwiirriinngg..
11..EEyyeelleett ffrreeqquueennttllyy ddrraawwnn iinnttoo tthhee
iinntteerrddeennttaall ssppaaccee..
22..EEllaassttiicc ttrraaccttiioonn uussiinngg eeyyeelleettss iiss ttiimmee
ccoonnssuummiinngg..
33..IInn ccaassee ooff GGAA rreemmoovvaall ooff tthhrrooaatt ppaacckk mmuusstt
pprreecceeddee wwiirree ttiigghhtteenniinngg dduurriinngg wwhhiicchh bblloooodd&&
ssaalliivvaa mmaayy ppooooll iinnttoo tthhee oorroopphhaarryynnxx..

49. 1.Titanium buttons 88mmmm ddiiaammeetteerr,,22mmmm ddeeeepp..
22..BBuuttttoonn lliiggaatteedd oonn tteeeetthh lliikkee eeyyeelleettss..
Disadvantages
CCaannnnoott bbee uusseedd iinn……..
11..PPoosstteerriioorr ccrroossss bbiittee..
22..AAnntteerriioorr oovveerrbbiittee..
DDuuee ttoo llaacckk ooff ssppaaccee ffoorr
bbuuttttoonnss..
33..LLoonnee ssttaannddiinngg tteeeetthh..

50. TThhee cclloovvee hhiittcchh
MMooddiiffiiccaattiioonn wwhheenn ffeeww tteeeetthh aarree aabbsseenntt

51. CCoonnttiinnuuoouuss oorr mmuullttiippllee lloooopp
wwiirriinngg {{SSttoouutt 11994433}}

52. OObbwweeggeesseerr’’ss mmeetthhoodd

53. AArrcchh bbaarrss
IInnddiiccaattiioonnss
11..IInnssuuffffiicciieenntt nnuummbbeerr ooff tteeeetthh..
22.. UUnnffaavvoorraabbllee tteeeetthh ddiissttrriibbuuttiioonn..
33..SSiimmppllee oorr mmuullttiippllee ddeennttooaallvveeoollaarr ffrraaccttuurreess..
44..AAss aann iinntteeggrraall ppaarrtt ooff sskkeelleettaall ffiixxaattiioonn..
55..IInnaaddeeqquuaattee llaabb ffaacciilliittiieess..
66..TToo rreedduuccee pprreeooppeerraattiivvee ttiimmee

54. TTyyppeess ooff aarrcchh bbaarrss
11..aa::PPrreeffaabbrriiccaatteedd
bb::Custom made
2.a:Erich
b:Jelenco
c:Krupps

55. AArrcchh bbaarrss
JJeelleennccoo CCuussttoomm mmaaddee
JJeelleennccoo wwiitthh mmooddiiffiieedd uuppppeerr ddeennttuurree

56. AAccrryyllaatteedd aarrcchhbbaarrss
SScchhuucchhaarrdd’’ss mmooddiiffiiccaattiioonn 11995566
1.Aluminium-brass alloy wire 2mm in
diameter used.
2. 6 pieces of 1.4mm wire soldered to the
main wire
3.Advantages:
a.Does not compress on gingival tissue.
b.Reduced chances of pressure necrosis and
stagnation.
c.Enhanced patient comfort.

57. Stanhope’s modification
1.Extraoral construction
2.Acrylic at the interdental spaces secures the arch
bar in position

58. Directly bonded archbars
1.Orthodontic mesh welded on to the back
of archbar.
2.Made in sections.
3.Bonded by composite or acrylic.
4.Not popular due to the difficulty in
maintaining dryness.

59. CCaapp sspplliinnttss
11..MMeettaalllliicc &&aaccrryylliicc ttyyppeess uusseedd..
22..OOcccclluussaall rreelliieeff ggiivveenn..
33..UUsseedd ccoommmmoonnllyy iinn cchhiillddrreenn..
44..SStteeppss iinn ffaabbrriiccaattiioonn::
IImmpprreessssiioonn mmooddeell SSpplliinntt ffaabbrriiccaattiioonn
cceemmeennttaattiioonn IIMMFF

60. CCaappsspplliinnttss
55..BBllaacckk ccooppppeerr cceemmeenntt pprreeffeerrrreedd dduuee ttoo……
AAddeeqqaattee bboonnddiinngg,,aannttiiccaarriiooggeenniicciittyy..
66..DDiissaaddvvaannttaaggeess::rreedduucceedd wwoorrkkiinngg
ttiimmee,,ssttaaiinnss rreessttoorraattiioonnss,,ssttiicckkyy..
77..PPoollyyccaarrbboonnaattee cceemmeenntt::cclleeaanneerr ffiieelldd bbuutt
rreedduucceedd bboonnddiinngg..
88..AAccrryylliicc ccaappsspplliinnttss hhaavvee nnoo cceemmeenntt ttooootthh
iinntteerrffaaccee,,ssoo ffoooodd eenntteerrss tthhee iinntteerrffaaccee &&tthhiiss
lleeaaddss ttoo ffeettoorr oorriiss

61. MMeettaalllliicc ccaappsspplliinntt

62. AAlltteerrnnaattiivvee tteecchhnniiqquueess ffoorr tthhee
eeddeennttuulloouuss mmaannddiibbllee
GGuunnnniinngg ttyyppee sspplliinnttss::
IINNDDIICCAATTIIOONN::UUssuuaallllyy uusseedd ffoorr uunniillaatteerraall oorr
bbiillaatteerraall ffrraaccttuurreess wwhheerree tthhee aarreeaass llyyiinngg
pprrooxxiimmaall ttoo tthhee ffrraaccttuurree ccaann bbee ffiixxeedd bbyy IIMMFF..
CCOONNTTRRAAIINNDDIICCAATTIIOONNSS::
11..UUnnffaavvoorraabbllyy ddiissppllaacceedd ffrraaccttuurreess llyyiinngg
oouuttssiiddee tthhee ddeennttuurree bbeeaarriinngg aarreeaa..
22..PPrroojjeeccttiillee iinnjjuurriieess iinnvvoollvviinngg sseevveerree bboonnee
lloossss..

63. 3.Extreme aattrroopphhyy ooff tthhee jjaaww bboonneess..
TTyyppeess::
11..PPrree--eexxiissttiinngg ddeennttuurreess..
22..ccuussttoomm mmaaddee..
33..PPrreeffaabbrriiccaatteedd..
44..DDiissppoossaabbllee eeddeennttuulloouuss
ttrraayyss wwiitthhoouutt tthheeiirr
hhaannddlleess..

64. LLiimmiittaattiioonnss ooff IIMMFF
11..PPrreeeexxiissttiinngg mmaalloocccclluussiioonnss aarree ddiiffffiiccuulltt ttoo
rreeddeeffiinnee..
22..QQuuaalliittyy aanndd qquuaannttiittyy ooff tteeeetthh..
33..DDiissppllaacceemmeenntt dduuee ttoo mmuussccllee aattttaacchhmmeennttss..
44..DDiiffffiiccuulltt ttoo ttrreeaatt ccoommbbiinneedd ddoouubbllee jjaaww
ffrraaccttuurreess..
55..VVoommiittiinngg,,sswweelllliinngg dduurriinngg iimmmmeeddiiaattee ppoosstt--
oopp..
66..RReessppiirraattoorryy pprroobblleemmss lliikkee aasstthhmmaa..
77..PPaattiieennttss ddiisslliikkee iitt..

65. AAlltteerrnnaattiivvee tteecchhnniiqquueess ffoorr
mmaannddiibbllee--ooppeenn rreedduuccttiioonn
TTrraannssoosssseeoouuss wwiirriinngg::
IINNDDIICCAATTIIOONNSS::
11..CCoonnttrrooll ooff eeddeennttuulloouuss ppoosstteerriioorr ffrraaggmmeenntt..
22..EEddeennttuulloouuss mmaannddiibbuullaarr ffrraaccttuurreess..
33..GGrroossssllyy ccoommmmiinnuutteedd ffrraaccttuurreess..
44..CCoonnttrrooll ooff lloowweerr bboorrddeerr wwhheenn uuppppeerr
bboorrddeerr hhaass bbeeeenn ffiixxeedd bbyy ccoovveennttiioonnaall
mmeetthhooddss..

66. UUppppeerr bboorrddeerr wwiirriinngg

67. LLoowweerr bboorrddeerr
wwiirriinngg

68. Open Reduction
• Lag Screws
– Rigid fixation (Compression)
– Good for anterior mandible fractures, Oblique
body fractures, mandible angle fractures
– Cheap
– Technically difficult
– Injury to inferior alveolar neurovascular
bundle

69. Lag Screw Technique

70. Lag Screw Technique

71. Lag Screw Technique

72. Rigid Fixation
• Compression plates
– Rigid fixation
– Allow primary bone healing
– Difficult to bend
– Operator dependent
– No need for MMF

73. Rigid Fixation
• Miniplates
– Semi-rigid fixation
– Allows primary and secondary bone healing
– Easily bendable
– More forgiving
– Short period MMF Recommended

74. Rigid Fixation
• Reconstruction Plates
– Good for comminuted fractures
– Bulky, palpable
– Difficult to bend
– Locking plates more forgiving

75. External Fixation
• Alternative form of rigid fixation
• Grossly comminuted fractures, contaminated fractures, non-union
• Often used when all else fails

76. External Fixation

77. Teeth in line of fracture
• Keep teeth if
– Previously healthy
– Peridontal plexus intact
– No major structural injury
– Tooth does not interfere with reduction of
fracture

78. Bioabsorbable Plates
• Plating can relieve stress, no bone remodeling
• Bulky plates, thermal sensitivity, palpable
• Absorbable plates expensive
• Better in children?
• Use of poly-L-lactide in 69 fractures by Kim et al
– 12% complication
– 8% infection
– No malunion

79. • Cases in which mandible appears stable
• Favorable fracture pattern
• No displacement of bony segments
• No change in occlusion
• Motivated patient
• Management
- Careful observation
- Liquid diet, limited physical activity
Remain prepared to intervene

80.  Some type of external stabilization
 Common-eyelet wiring, Erich arch bars, ivy
loops, stout wiring, Ernst and Gilmer
ligatures
 Bonded arch bars
 modified bone screws
 Massive communition of mandible with
significant tissue loss-external
pin stabilization

81.  Nondisplaced ,stable fractures
 Grossly communited fractures-periosteal
stripping may devitalize small bone fragments
 Gunshot wounds
 Compromised soft tissue matrix
-Result of pre existingcondition(radiotheraphy)
-Avulsive loss of tissue
 Pediatric fractures

82.  Open approach gives best
visuvalization,anatomical reduction
 Trans oral apporach-5to 7mm from
mucogingival junction
 Percutaneous trocar
 Skin incisins-reserved for condylar
neck,grossly communited factures,severly
atrophic mandible(<10mm height)
 Heavy training elastics-neuromuscular
training

84.  Screw itself has a threaded head which
engages the plate
 Plate does not have to be ideally adopted
 Heavier stronger design
 Elimination of bone resorption
 Role in
gross communition
continuity defects prior to formal
reconstruction

85.  Excellent alternative in selected cases of
anterior mandible #
 Posterior mandible and ramus-technically
difficult
 Trocar may necessary

87. Technically difficult to repair, associated
complications are frequent.
REASONS
(1)Force is necessary to create this type of
injury carries with a higher degree of
surrounding tissue injury
(2)Increase difficulty with reduction and
stabilization of multiple fragments.
(3)High risk for ischemic
compromised fragments
to necrosis.

88.  Reduced vascularity to the mandible due to the
decrease in flow from inferior alveolar artery.
 Blood supply is mainly periosteal
 Dense sclerotic bone and decreased osteoblastic
activity
 Less bone area contact
 Systemic compromise
 Most edentulous fractures –at body or condyle
Mid body or saddle –weakest point

89.  Closed reduction with the use of
prosthetics(existing dentures or Gunning splints.)
 External fixation
 Wire fixation
 Open reduction with internal fixation:
1. Reconstruction plates (2.3 , 2.7 mm
diameter screws)
2. Mandible fixation plates (2.0, 2.4 mm
diameter screws)
- Dynamic compression plates
- Plates at both inferior and superior
borders
3. Bone grafting and miniplate fixation.

91.  MALUNION NONUNION
It is a site with high incidence of altered fracture healing .
Infection it is the main contributor.
OTHER CAUSES
-poor apposition
-poor immobilization
-presence of foreign bodies
-unfavorable muscle pull on fracture segments
-aseptic necrosis of bone fragments
-soft tissue interposition
-malnutrition by debilitation.
Most common cause for nonunion is residual mobility
across fracture.

92.  Rigid internal fixation with a reconstruction
plate
 External fixation
 Particulate bone grafting or Cortical bone
grafting to the defect.
 Polyglycolic or polylactate mesh as a carrier
for cancellous bone graft.
 Composite free flap reconstruction.

93.  Most common complication of surgical
interaction.
 Risk factor-
-Communited fracture
-Active substances abuse.
-Noncompliance with post operative regimens.
-Significant delayed treatment
MANIFESTATIONS
Cellulitis, abscess formation, fistula,
osteomyelitis and rarely necrotizing fascitis

94. 1. The development of adequate drainage
2. Removal of the source
3. Appropriate antibiotic coverage
Clinical examination &plain radiographic assess
the status of fracture segments and hardware.
Specimen for bacterial culture & sensitivity
CT and MRI – if adjacent soft tissues are
involved.
Antibiotic of choice PG / clindamycin

95.  No improvement in the level of sensation
,after 6-8 weeks –baseline neurologic
function.
 Surgical repair is considered after 6 months.

96.  APPROPRIATE DIAGNOSIS
 ANATOMIC REDUCTION
 STABILIZATION OF THE FRACTURED SEGMENTS
USING OCCLUSION AS A GUIDE.
 STABLE INTERNAL FIXATION

97. Interdental eyelet wiring
iivvyy lloooopp mmeetthhoodd
11..PPrreesseennccee ooff ssuuiittaabbllee nnuummbbeerr,,qquuaalliittyy aanndd
sshhaappee ooff tteeeetthh..
22..FFaavvoorraabbllee ffrraaccttuurree lliinneess wwiitthh mmiinniimmaall
ddiissppllaacceemmeenntt..
33..NNoott ssaattiissffaaccttoorryy ffoorr ffrraaccttuurreess ooff aasscceennddiinngg
rraammuuss aanndd ccoonnddyyllee
44..OOcccclluussiioonn iiss tthhee kkeeyy..

98. Complications
• Socioeconomic groups
• Infection (James, et. al.)
• Delayed healing and malunion. Most commonly caused by infection
and noncompliance
• Nerve paresthesias in less than 2%

99. Conclusions
• With multiple techniques available, there is still controversy over the
best treatment for each type of mandible fracture
– The decision is a clinical one based on
patient factors, the type of mandible
fracture, the skill of the surgeon, and the
available hardware
– Further studies are in progress

100. Reduction: Reduction of a fracture means
the restoration of functional alignment of
the bone fragments.
• In the dentate mandible reduction must
be anatomically precise.
• The teeth are used to assist the
reduction, check alignment of the
fragments and assist in the immobilization.

101. • Whenever the occlusion is used as an
index of accurate reduction, it is
important to recognize any pre- existing
occlusal abnormalities such as an anterior
or lateral open bite.
• Widely displaced, multiple or extensively
comminuted fractures may be impossible
to reduce by means of manipulation of the
teeth alone, in which case open operative
exploration becomes necessary.
• Gradual reduction of fractures can also be
carried out by elastic traction.

103. Following accurate reduction of the
fragments, the fracture site must be
immobilized to allow bone healing to
occur.
Period of Immobilization:
The period of stable fixation required to
ensure full restoration of function varies
according to the site of fracture, the
presence of otherwise of retained teeth in
the line of fracture, the age of the patient
and the presence or absence of infection.

104. A Simple guide to the time of immobilization
for fractures of the tooth bearing area of
the lower jaw is as follows:
Young adult
With
Fracture of the angle
Receiving
Early treatment 3 weeks
In which
Tooth removed from fracture line.

105. If :
Tooth retained in fracture line : add 1 week.
Fracture at the symphysis : add 1 week
Age 40 years and over : add 1 or 2 weeks
Children and adolescents : subtract 1 week.

106. a. Osteosynthesis without intermaxillary
fixation:
i. Non – compression small plates
ii. Compression plates:
iii. Mini – plates
iv. Lag screws

107. b. Intermaxillary fixation:
i.Bonded brackets
ii. Dental wiring:
Direct :
Eyelet:
iii. Arch bars
iv. Cap splints

108. c. Intermaxillary fixation with osteosynthesis:
i. Transosseous wiring
ii. Circumferential wiring
iii. External pin fixation
iv. Bone clamps;
v. Transfixation with Kirschner wires.

109. Osteosynthesis without intermaxillary
fixation:
Non Compression small plates:
Made of stainless steel or Titanium.
They are available in various sizes and
shapes.
These plates are however, larger than the
more recently designed mini – plates,which
is used to incorporate compression across
the fracture.

110. Compression Plates:
•Bony union is achieved by firm
approximation of the fragments under
pressure.
•They are of 2 types – Dynamic compression
plate(DCP) & Eccentric dynamic compression
plate (EDCP)
•It is necessary to apply these plates to the
convex surface of the mandible at its lower
border.
•There is a tendency for the upper border &
the lingual plate to open with the final
tightening of the screws.leading to distortion
of occlusion & opening of the fracture line.

111. • In order to overcome these problems
various designs of compression plate have
been devised.
• It is necessary to apply a tension band at
the level of the alveolus before tightening
the screws.
•This can be in the form of an arch bar
ligatured to the teeth or as a separate plate
with screws penetrating the outer cortex
only.
•Disadvantages :The procedure tends to be
lengthy & needs expertise. The fixation
plate is bulky.

114. Mini – plates:
•Champy et al. (1978) introduced a mini-plate
system customised for use in
mandibular fractures.
• Originally fashioned in stainless steel,
they are now widely available in titanium.
• Non-compression mini-plates with screw
fixation confined to the outer cortex allow
the operator to place plates both
immediately sub-apically as well as at the
lower border.

115. •All plates can be inserted by an intra-oral
approach without the need for
intermaxillary fixation.
•Mini –plate osteosynthesis can be used in
virtually all types of mandibular body
fracture.
• Plates can be inserted via an intra – oral
approach using special cheek retractors and
protective sleeves passed through the soft
tissues of the cheek. It is only necessary to
reflect periosteum from the outer plate of
bone.
•The plates can usually be left in
permanently without causing trouble.

118. Lag screws
•A few oblique fractures of the mandible can
be rigidly immobilized by inserting two or
more screws whose thread engages only the
inner plate of bone.
•The hole drilled in the outer cortex is made
to a slightly larger diameter than the
threaded part of the screw.
•When tightened the head of the screw
engages in the outer plate and the oblique
fracture is compressed. At least two such
lag screws are necessary to achieve rigid
immobilization.

120. Intermaxillary fixation:
Bonded modified orthodontic brackets
Fractures with minimal displacement in patients
with good oral hygiene can be immobilized by
bonding a number of modified orthodontic
brackets onto the teeth and applying
intermaxillary elastic bands.

121. Dental wiring is used when the patient has a
complete or almost complete set of suitably
shaped teeth.
0.45nim soft stainless steel wire has been
found effective.

122. Direct Wiring
•The middle portion of a 6 inc (15cm) length
of wire is twisted round a suitable tooth and
then the free ends are twisted together.
•Similar wires are attached to other teeth
elsewhere in the upper and lower jaws and
then after reduction of the fracture the
plaited ends of wires in the upper and lower
jaws are in turn twisted together.

123. Interdental eyelet wiring :
• Eyelets are constructed.
• These eyelets are fitted between two teeth.
• About five eyelets are applied in the upper
and five in the lower jaw and then the eyelets
are connected with tie wires passing through
the eyelets from the upper to the lower jaw.

125. Arch Bars
• Useful when the patient has an insufficient
number of suitably shaped teeth to enable
effective interdental eyelet wiring.
• Many varieties of prefabricated arch bar are
available and the Winter, jelenko and Erich type
bars have all proved effective.

127. • Arch bars should be cut to the required
length and bent to the correct shape before
starting the operation.
• As the mandibular fragments are displaced
owing to the fracture the bar is bent so that it
fits around the upper arch.
• The arch bar is wired to successive teeth
on each side working backwards to each third
molar area.

128. • It is important to retighten each wire before
the twisted portion is cut and trucked into a
position where it will not irritate the tissues.
Cap Splints:
Silver cap splints were for many years the
method of choice for the immobilization of all
jaw fractures.

129. Indications for the use of cap splints are as
follows:
1. Patients with extensive and advanced
periodontal disease when a temporary
retention of the dentition is required during
the period of fracture healing.
2. To provide prolonged fixation on the
mandibular teeth in a patient with fractures
of the tooth – bearing segment and bilateral
displaced fractures of the condylar neck.

130. Intermaxillary Fixation with osteosynthesis:
Although some simple fractures of the tooth –
bearing portion of the mandible can be
accurately and adequately treated by
intermaxillary fixation alone, in practice that
fixation is frequently reinforced by open
reduction of the fracture and some type of
non – rigid osteosynthesis

131. Transosseous Wiring:
• In principle holes are drilled in the bone
ends on either side of the fracture line
after which a length of 0.45mm soft
stainless steel wire is passed through the
holes and across the fracture.
• After accurate reduction of the fracture
the free ends of the wire are twisted
tightly,cut off short and the twisted ends
tucked into the nearest drill hole.

132. Circumferential wiring:
A few oblique fractures of the body of the
mandible can be reinforced by passing a
length of 0.45mm soft stainless steel wire
circumferentially.
External pin fixation:
The technique consists of inserting into
each major bone fragment a pair of 1/8 inch
(3mm) titanium or stainless steel pins which
diverge from each other, but are connected
by a cross bar which is attached to each pin
by means of universal joints.

133. The main indications for the use of pin
fixation for mandibular fractures may be
summarized as follows:
1. To provide fixation across an infected
fracture line
2. To maintain the relative position of
major fragments in extensively
comminuted fractures.
3. In the treatment of bimaxillary fractures
when a ‘box frame’ form of fixation is
employed.

134. Fractures of the edentulous
mandible
•The physical characteristics of the body of
the mandible are altered considerably
following the loss of the teeth.
• Vertical depth of the subsequent denture –
bearing area is reduced.
•The endosteal blood supply from the
inferior dental vessels begins to disappear.

135. Reduction
• For the reasons already stated, precise
anatomical reduction is not necessary.
• The reduced cross- section of bone fractures
of thin mandibles means that displacement
occurs more readily and in this situation open
reduction may be only way to restore adequate
bone contact.

136. Methods of immobilization
There is no uniformly accepted method.
The methods of treatment currently in
common uses are:
1. Direct osteosynthesis:
a. Bone plates
b. Transosseous wiring.
c. Circumferential wiring or straps
d. Transfixation with Kirschner wires
e. Fixation using cortico – cancellous bone
graft.

137. 2. Indirect skeletal fixation:
a. Pin fixation
b. Bone clamps
3. Intermaxillary fixation using gunning –
typesplints:
a. Used alone
b. Combined with other methods.

138. Direct osteosynthesis
Bone plates:
Bone plates are particularly useful for
displaced fractures of the edentulous
mandible, particularly those at the angle.
The reduced depth of bone in the
edentulous mandible favours the use of non –
compression mini-plates.

140. Transosseous Wiring
Many simple edentulous fractures can be
satisfactorily immobilized by direct
transosseous wires.
Transosseous wires do not provide rigid
osteosynthesis and supplementary fixation
may be necessary.
Circumferential wiring or straps:
Oblique fractures of the edentulous
mandible can be most effectively and simply
immobilized by circumferential wires.

141.  Primary Bone Grafting:
• A 5 cm length of rib is obtained as an
autogenous graft.
• The rib is split and the two pieces are
placed one on each side of the fractures
site in the manner of a first –aid splint
applied to a limb.
• The rib halves are lashed together by a
series of circumferential wires sandwiching
the fractured bone ends between them.

142.  Indirect skeletal fixation:
• A system of bone pins joined together by rods
and universal joints, can be used in
edentulous mandibular fractures.
• The method is occasionally of practical use
when there has been extensive comminution
of a long segment particularly if this involves
the symphysis.

143.  Intermaxillary fixation using gunning –
type splints:
• The dental splint described originally by
Gunning in 1866.
• If the patient is completely edentulous
immobilization is carried out by attaching
the upper splint to the maxilla by
peralveolar wires and the lower splint to
the mandibular body by circumferential
wires.
• Intermaxillary fixation can then be
effected by connecting the two splints
with wire loops or elastic bands.

144. Steps in construction:
1. Upper and lower impressions are taken
2. Plaster casts are made
3. Upper and lower base plates adapted
4. Bite blocks prepared in posterior region
only
5. Upper and lower plates with bite blocks
are constructed using heat cure acrylic
leaving the anterior region open for
feeding.

145. 6. Hooks are
incorporated in buccal
side of the bite
blocks.
7. Grooves must be
made in both gunning
splint, in the canine
region to prevent the
peralveolar and
circumferential wires
from slipping.

146.  Infection
 Nerve damage
 Malunion
 Foreign bodies
 Delayed union
 Non union

147. HHoorriizzoonnttaallllyy ffaavvoorraabbllee
HHoorriizzoonnttaallllyy uunnffaavvoorraabbllee
VVeerrttiiccaallllyy ffaavvoorraabbllee
VVeerrttiiccaallllyy uunnffaavvoorraabbllee

148.  Direct fracture
 Indirect fracture

149.  Typical Causes
 Direct violence
 Indirect violence
 Crush injuries
 Road traffic incident
 Aero plane crashes
 Mining accident
 Predisposing causes
 Presence of cysts, tumors, osteomyelitis, 3rd molars
 Systemic diseases affecting the formation of
structure of bone

150. OOPPGG
LLAATTEERRAALL OOBBLLIIQQUUEE VVIIEEWW
PPAA VVIIEEWW
OOCCCCLLUUSSAALL
CCTT SSCCAANNSS
IIOOPPAA

151. 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
 OOppeenn
 Transosseous
wiring
(osteosynthesis)
 Plating
 Intramedullary
pinning
 Titanium mesh
 Circumferential
straps
 Bone clamps
 Bone staples
 Bone screws
FFiixxaattiioonn
DDiirreecctt
IInnddiirreecctt

152.  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
(c) Intermaxillary fixation with osteosynthesis
 (i) Transosseous wiring
 (ii) Circumferential wiring
 (iii) External pin fixation
 (iv) Bone clamps
 (v) Transfixation with Kirschner wires

153. Young adult with
Fracture of the angle
receiving Early
treatment in which
Tooth removed from
fracture line
33 wweeeekkss
IF
((aa)) TTooootthh rreettaaiinneedd iinn ffrraaccttuurree lliinnee:: aadddd 11 wweeeekk
((bb)) FFrraaccttuurree aatt tthhee ssyymmpphhyyssiiss:: aadddd 11 wweeeekk
((cc)) AAggee 4400 yyeeaarrss aanndd oovveerr:: aadddd 11 oorr 22 wweeeekkss
((dd)) CChhiillddrreenn aanndd aaddoolleesscceennttss:: ssuubbttrraacctt 11 wweeeekk

154.  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

156. IVY LOOP METHOD

159. IN CASE OF SINGLE TOOTH

160.  Continous or Multiple
loop wiring

161.  Twisted Labial Wire

162. 
Continous Multiple Loop Wiring


163. RRIISSDDOONN AARRCCHH BBAARR
JJEELLEENNKKOO AARRCCHH BBAARR
EERRIICCHH AARRCCHH BBAARR
KKRRUUPPPPAA AARRCCHH BBAARR
EERRIICCHH AARRCCHH BBAARR
HHAAMMIILLTTOONN ((11996677))

164. BARKER(1986)

165. AACCRRYYLLAATTEEDD AARRCCHH BBAARRSS
sscchhuucchhaarrddtt((11995566))
sscchhuucchhaarrddtt&&mmeettzz((11996666))
ssttaannhhooppee((11996699))
ccllaarrkkee((11997777))

166. DIRECTLY BONDED ARCH BARS
Baurmash et al(1988)
Wall(1986)

167. CAP SPLINTS
1. Cast silvercap splints
2.Acrylic splints
ROBTERTSON(1965)

168.  GUNNING TYPE
SPLINTS
THOMAS BRYAN
GUNNING-(1885)

169. TTRREEAATTMMEENNTT MMOODDAALLIITTIIEESS FFOORR
EEDDEENNTTUULLOOUUSS MMAANNDDIIBBLLEE
PERALVEOLAR WIRING

170. TThhee OObbwweeggeesseerr
tteecchhnniiqquuee ffoorr
cciirrccuummffeerreennttiiaall wwiirriinngg
CCIIRRCCUUMMMMAANNDDIIBBUULLAARR
WWIIRRIINNGG ((BBrraaddlleeyy--11997755))

171.  INTER OSSEOS WIRING
 EXTRA ORAL PIN FIXATION
ROGER ANDERSON APPLIANCE
 PRIMARY RIB GRAFTING
- OBWEGER& SAILER (1973)

172.  HISTORY
1. Gorden Buck(1807-1877)
2. Hansmann(1886)
3. Christiansen(1954)
4. Luhr(1968)
5. Spiessel(1970 & 1974)
6. Schmoker & Niederdellmann & Schilli(1973)
7. Michelet & Champy(1978)
8. Marciani & Gonty(1993)
9. Ellis(1993 & 1996)

173. Intraoral symphysis aanndd ppaaaarraassyymmpphhyyssiiss
IInnttrraaoorraall bbooddyy,, aannggllee
aanndd rraammuuss

174. SSuubbmmeennttaall
SSuubbmmaannddiibbuullaarr

190.  Non-Union
 Malunion
 Fibrous Union
 Paresthesia
 Anesthesia
 Infection

191.  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

192.  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

193.  With multiple facial fractures, mandibular
fractures are treated first

194.  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

195.  Prospective, 8 year study at Parkland
involving angle fractures
 Nonrigid fixation had 17% complication rate
 AO Recon plate had 8% complication rate
 DCP had 13% complication rate
 Non compression plate 3% complication rate
1st
Qtr
2 n
d
Qt r
3r d
Qtr
4th
Qtr
90
80
70
60
50
40
30
20
10
0
Ea st
West
N orth

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