Case of mandibular parasymphysis and angle fracture
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Dr. Bhavik Miyani, Resident Doctor in Department of Oral & Maxillofacial Surgery, NPDCH, Visnagar.
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Case of mandibular parasymphysis and angle fracture
- 1. A CASE OF TRAUMA PRESENTED BY, DR. BHAVIK MIYANI. IInd YEAR PG OMFS. GUIDED BY, DR. ANIL MANAGUTTI, HOD. DR. SHAILESH MENAT, PROFESSOR. DR. RUSHIT PATEL, READER. Department of OMFS, NPDCH 1
- 2. CONTENTS Case Report Discussion Conclusion References Department of OMFS, NPDCH 2
- 3. NAME :- Priyansh Patel AGE/SEX :- 29 Years/ Male OCCUPATION :- Bussinessman ADDRESS :- Surat CONTACT NO :- 9825654223 OPD NO. :- CASE REPORT Department of OMFS, NPDCH 3
- 4. CHIEF COMPLAIN Patient complain of pain in lower right back and lower front jaw region since 2 hours. Department of OMFS, NPDCH 4
- 5. HISTORY OF PRESENT ILLNESS • Patient was relatively asymptomatic before 2 hours. • Then he met an accident while he was driving a bike a monkey came across to the road and fallen down on the road on front side. Department of OMFS, NPDCH 5
- 6. • Then he visited civil hospital, visnagar from there he referred to our department. • No H/O – Epistaxis, Bleeding from ear, Vomiting. • No H/O – Unconsciousness. Department of OMFS, NPDCH 6
- 7. PAST MEDICAL HISTORY :- - No H/O previous hospitalization - No H/O any systemic diseases like Hypertension, Diabetes Mellitus, Hepatitis PAST DENTAL HISTORY :- - No relevant past dental history DRUG HISTORY :- - No relevant drug allergy FAMILY HISTORY :- - No relevant family history Department of OMFS, NPDCH 7
- 8. PERSONAL HISTORY :- - Habits :- No harmful habits - Diet :- Vegetarian - Marital status :- Married - Brushing :- Once a day with toothbrush Department of OMFS, NPDCH 8
- 9. • Conscious • Cooperative • Well Oriented to time, place and person • Built :-Well built • Nourishment :- Well nourished • Gait :- Normal Vital signs :- • Temperature: Afebrile • Blood pressure: 130/84 mmhg • Pulse rate: 88 beats/min • Respiratory rate: 14 cycles/min GENERAL EXAMINATION Department of OMFS, NPDCH 9
- 10. LOCAL EXAMINATION 1. EXTRA- ORAL EXAMINATION :- • Face :- Facial asymmetry due to swelling present over right zygoma region. • Skin and soft tissue :- Laceration over right zygoma and left cheek region. • Lips :- Competent • Jaw movement :- Reduced due to pain • TMJ :- No clicking or crepitus while opening or closing mouth • Mouth Opening :- 38 mm • Tenderness on palpation on left parasymphysis region and right angle region of mandible. Department of OMFS, NPDCH 10
- 11. EXTRA- ORAL EXAMINATION Department of OMFS, NPDCH 11
- 12. 2. INTRA-ORAL EXAMINATION :- - Hard Tissue Examination - - Present teeth- 11-18,21-28,31-37,41-47 - Occlusion is disturbed bilaterally. - Step deformity is palpated on left parasymphysis region. - Vertically fractured tooth i.r.t. 47 - Root stump i.r.t. 26 - Soft Tissue Examination - - Buccal Mucosa – NAD - Labial Mucosa - NAD - Palate - NAD - Gingiva – Laceration is present i.r.t. 33-34 region 12
- 13. INTRA- ORAL EXAMINATION Department of OMFS, NPDCH 13Department of OMFS, NPDCH
- 14. PROVISIONAL DIAGNOSIS 1. Left Mandibular Parasymphysis Fracture 2. Right Mandibular Angle Fracture Department of OMFS, NPDCH 14
- 15. INVESTIGATIONS (1) Pre- operative blood profile (2) ECG (3) Chest X-Ray (4) PNS View (5) OPG Department of OMFS, NPDCH 15
- 16. PRE-OPERATIVE PROFILE Department of OMFS, NPDCH 16
- 17. X- RAY Department of OMFS, NPDCH 17
- 18. PNS VIEW Department of OMFS, NPDCH 18
- 19. OPG OPG is showing fracture line starting from crest of alveolar ridge between 33 and 34 tooth and passing inferior and backward direction involving inferior border of mandible suggestive of parasymphysis fracture. There is also presence of fracture line passing from 48 inferior and backward direction involving basal bone suggestive of simple fracture.
- 20. FINAL DIAGNOSIS 1. Favorable Left Mandibular Parasymphysis Fracture 2. Horizontal Unfavorable Simple Right Mandibular Angle Fracture Department of OMFS, NPDCH 20
- 21. 1. Intermaxillary Fixation 2. Open Reduction Internal Fixation. TREATMENT PLAN Department of OMFS, NPDCH 21
- 22. INTERMAXILLARY FIXATION Department of OMFS, NPDCH 22
- 23. ARMAMENTERIUM 23
- 24. TREATMENT DONE
- 25. 25
- 26. MANDIBULAR FRACTURE Department of OMFS, NPDCH 26
- 27. CONTENTS - INTRODUCTION - ANATOMY OF THE MANDIBLE - BIOMECHANICAL CONSIDERATION - CLASSIFICATIONS - GENERAL PRINCIPLES OF TREATMENT OF MANDIBULAR FRACTURE - SURGICAL APPROACHES - CORONOID FRACTURE - CONCLUSION - REFERENCES Department of OMFS, NPDCH 27
- 28. FRACTURE “Fracture is defined as a sudden, violent discontinuity of bone and may be complete or incomplete in character.” Department of OMFS, NPDCH 28 INTODUCTION
- 30. AREAS OF WEAKNESS OF MANDIBLE • Symphysis, which is the region of bony union of the 2 halves during 1st year of life • Parasymphysis region due to presence of mental foramen and canine root • Junction of the stronger body of the mandible and the weaker ramus – angle • Areas where investing bone volume is reduced due to presence of long roots or impacted teeth – parasymphysis and angle • Edentate regions of the mandible leads to atrophy of the bone • Slender neck of the Condyle. Department of OMFS, NPDCH 30
- 31. MUSCLE ACTION 31
- 32. CLASSIFICATION Department of OMFS, NPDCH 32
- 33. • Simple • Compound • Comminuted • Green stick • Pathological PATTERN OF FRACTURE (KRUGER’S GENERAL CLASSIFICATION): • Multiple • Impacted • Atrophic • Indirect/countercoup fractures • Complicated or complex
- 34. BASED ON THE ANATOMIC REGION BY DINGMAN AND NATVIG
- 35. BASED ON THE PRESENCE OR ABSENCE OF TEETH- KAZANJIAN AND CONVERSE. • Class I - Teeth present on either side of fracture fragment • Class II- Teeth present on only one side of fracture fragment • Class III- The patient is edentulous.
- 36. Favourable FRY ET AL Unfavourable HORIZONTAL VERTICAL
- 37. GENERAL PRINCIPLES IN THE TREATMENT OF MANDIBULAR FRACTURES
- 38. • Patient’s general physical status • Methodical approach -not with an “emergency-type” mentality. • Dental injuries -evaluated & treated concurrently with T/t of mandibular fractures. • Re-establishment of occlusion -primary goal • With multiple facial #, mandibular # should be treated first.
- 39. • IMF time. • Prophylactic antibiotics– compound # • Nutritional needs closely monitored postoperatively. • Most mand. # can be treated by closed reduction.
- 41. INDICATIONS FOR CLOSED REDUCTION • Nondisplaced favorable fracture • Grossly comminuted fractures • Fractures exposed by significant loss of overlying soft tissues • Edentulous mandibular fractures • Mandibular fractures in children with developing dentitions • Coronoid process fractures • Condylar fractures
- 42. INDICATIONS FOR OPEN REDUCTION • Displaced unfavorable fractures through the angle • Displaced unfavorable fractures of the body or parasymphysis • Multiple fractures of facial bones • Midface fractures with displaced and bilateral condylar fractures • Fracture of edentulous mand. with severe displacement. • Treatment delay and interposition of soft tissue • Systemic conditions contraindicating IMF • Malunion - perform osteotomies
- 43. ADVANTAGES OF OPEN REDUCTION. • Accurate reduction & fixation of fractures by direct visualization. • Better bone healing. • Early return to normal jaw function. • Normal nutrition, no weight loss. • Patient can maintain oral hygiene. • Early return to work.
- 44. DISADVANTAGES OF OPEN REDUCTION. • Requires surgical exposure. • Requires general anesthesia. • Expensive. • Compared to IMF technique is difficult and risky. • Foreign body is left in the tissues. • Scarring.
- 46. • CLOSED REDUCTION AND INDIRECT SKELETAL FIXATION : – Direct interdental wiring (Gilmer) – Indirect interdental wiring (eyelet or Ivy loop) – Continuous or multiple loop wiring – Arch bars – Cap splints – Gunning type splints – Pin fixation
- 47. BRIDLE WIRE
- 48. DIRECT INTERDENTAL WIRING INTERDENTAL EYELET WIRING CLOVE HITCH CONTINUOUS OR MULTIPLE LOOP WIRING [
- 49. BUTTON WIRING IMF SCREWS
- 50. ARCH BARS • INDICATIONS FOR USE Insufficient teeth Efficient intermaxillary fixation is otherwise impossible. Simple dento-alveolar fractures, multiple tooth bearing fragments Fracture involving middle third of face …suspension wiring Lab. Facilities inadequate…
- 51. CAP SPLINTS • INDICATIONS Advanced periodontal disease Fractures of tooth bearing segments & condylar neck Portion of body of mandible missing
- 53. OPEN REDUCTION AND DIRECT SKELETAL FIXATION : OSTEOSYNTHESIS WITHOUT IMF Non – compression small plates Compression plates Mini- plates Lag screws • OSTEOSYNTHESIS WITH IMF Transosseous wiring Circumferential wiring External pin fixation Bone clamps K - wires
- 57. EXTRA ORAL APPROACHES. SUBMANDIBULAR APPROACH RISDON'S (1934)
- 58. Retro mandibular approach Hinds and Girotti (1967)
- 62. • Screws – almost all are self tapping self drilling( some) • Bicortical screws can be used at the inferior border • A minimum of two screws should be placed in each osseous segment. • Angle of mandible – superior aspect of mandible onto broad surface of external oblique ridge • Between mental foramina – two plates • Body –one plate used ,below apices but above canal
- 63. • OSTEOSYNTHESIS WITH IMF Transosseous wiring Circumferential wiring External pin fixation Bone clamps K - wires
- 67. INTRA-MEDULLARY PINNING • Major (1938) – McDowell – use in maxillofacial fractures • 2mm K-Wires are used • Useful in emergency, immediate stabilization of a fractured mandible • Versatile, can be applied in any part of the mandible • However, stability provided is not adequate for Fixation/immobilization
- 69. Young adult With Fracture of the angle receiving Early treatment in which Tooth removed from fracture line • If : – Tooth retained in fracture line : add 1 week – Fracture at the symphysis : add 1 week – Age 40 years and over : add 1or 2 weeks – Children and adolescents : subtract 1 week 3 WEEKS PERIOD OF IMMOBILISATION
- 70. FRACTURES OF CORONOID PROCESS • Incidence – 0.6 to 4.7 % • AETIOLOGY Injuries due to direct trauma Injury due to indirect trauma Injury of iatrogenic origin
- 71. • Clinical features: Ecchymosis Evidence of depressed fracture of zygoma Trismus & lateral cross bite • Radiographic diagnosis • Treatment
- 72. COMPLICATIONS • Complications during primary treatment Misapplied fixation Infection- 3% - 27% Nerve damage Displaced teeth and foreign bodies Pulpitis Gingival and periodontal complications Drug reactions
- 73. Malunion Non-union Delayed union LATE COMPLICATIONS
- 74. Derangement of the temporomandibular joint Late problems with transosseous wires and plates Sequestration of bone Limitation of opening Scars
- 75. • A study was conducted to compare the complication rate with different types of mandibular fracture. • “It was concluded that the occurrence of postoperative complications in the treatment of mandibular fractures is fundamentally related to the severity of the fracture rather than to the type of treatment used.” J Oral Maxillofac Surg :58 ;273-280, 2000
- 76. Review of literature…… • If the initial treatment is delayed for more than 3 days, any infection at the compound fracture site(s) should first be resolved by MMF and intravenous antibiotics before performing an open reduction. This is done to ensure adequate perfusion of blood at the fracture site when the open reduction is performed.. J Oral Maxillofac Surg 59:879-884, 2001
- 77. • Treatment outcomes between rigid extraoral fixation and semi rigid intraoral fixation for the management of isolated mandibular angle fractures were compared and concluded that Isolated mandibular angle fractures can be effectively treated with either intraoral monocortical fixation or extraoral bicortical fixation techniques. Use of a standard protocol involving early surgical management with limited periosteal reflection, concomitant removal of third molars, and short-term maxillo mandibular fixation ensures predictable success with a low incidence of complications. J Oral Maxillofac Surg. 2008 Nov;66(11):2254-60.
- 78. 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 hardwares.
- 79. REFERENCES • MAXILLOFACIAL INJURIES - ROWE & WILLIAMS. VOL- 1 • ORAL MAXILLORFACIAL TRAUMA- RAYMOND-J.FONSECA. VOL-1 • MANDIBULAR FRACTURES - KILLEY & KAY. • PETERSON'S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERY Second Edition
Editor's Notes
- Basically a tubular long bone which is bent into a blunt V shape Strength resides in its dense cortical plates. Cortical bone is thicker anteriorly and lower border of mandible while posteriorly the lower border in rel. thin Central cancellous bone of the body forms loose network with frequent large bone free spaces. Mandible is stronger anteriorly in midline with progressively less strength towards the condyle. Four process: 1. angular process---attachment to masseter and medial pterygoid 2. coronoid process--- temporalis muscle 3. condylar process--- lateral pterygoid 4. alveolar process---- forms around dev. Tooth and supports their roots after eruption. Mandible is subcutaneous/submucosal in most of its extent only part inaccessibel to palpation being the upper and posterior portion of ascending ramus.
- Mylohyoid, Geniohyoid, Genioglossus & Anterior belly of omohyoid – postero-medial & inferior displacement of # fragment. Pterygomassetric sling – Supero-medial & anterior displacement of fractured lesser fragment. Lateral Pterygoid muscle- Antero-medial displacement of fractured condyle. Temporalis – postero-superior displacement of fractured coronoid process.
- Simple fracture: A simple fracture consists of a single fracture line that does not communicate with the exterior Compound fracture: These fractures have a communication with the external environment, usually by the periodontal ligament of a tooth, and involve all fractures of the tooth-bearing portions of the jaws. In addition, if there is a breach of the mucosa leading to an intraoral communication or a laceration of the skin communicating with the fracture site, edentulous portions of the mandible may be involved Comminuted fractures: These are fractures that exhibit multiple fragmentation of the bone at one fracture site. These are usually the result of greater forces than would normally be encountered in simple fractures. Greenstick fracture: This type of fracture frequently occurs in children and involves incomplete loss of continuity of the bone. Usually one cortex is fractured and the other is bent, leading to distortion without complete section. There is no mobility between the proximal and distal fragments. Pathologic fracture: A pathologic fracture is said to occur when a fracture results from normal function or minimal trauma in a bone weakened by pathology. Multiple #: 2 or more lines of # on same bone not communicating with one another. Telescoped or impacted fracture: This type of injury is rarely seen in the mandible, but it implies that one bony fragment is forcibly driven into the other. This type of injury must be disimpacted before clinical movement between the fragments is detectable Direct fractures arise immediately adjacent to the point of contact of the trauma, whereas indirect fractures arise at a point distant from the site of the fracturing force. An example of this is a subcondylar fracture occurring in combination with a symphysis fracture. Complex or complicated fracture: This type of injury implies damage to structures adjacent to the bone such as major vessels, nerves, or joint structures.
- . Condylar Process Fracture: runs from the mandibular notch to the posterior border of the ramus of the mandible. 2. Ascending Ramus Fracture: extends horizontally through both the anterior and posterior borders of the ramus or vertically from the mandibular notch to the inferior border of the mandible. 3. Angle Fracture: Any fracture distal to the second molar, extending from any point on the curve formed by the junction of the body and ramus in the retromolar area to any point on the curve formed by the inferior border of the body and posterior border of the ramus of the mandible. 4. Body Fracture: occurs between the mesial portion of the canine and the distal portion of the second molar and extends from the alveolar process through the inferior border. 5. Symphysis Fracture: Any fracture in the region of the incisors that runs from the alveolar process through the inferior border of the mandible. 6. Dentoalveolar Fracture: Fracture of the tooth-bearing portion of the jaw not extending to the inferior border.
- The principle of favorableness is based on the direction of a fracture line as viewed on radiographs in the horizontal or vertical plane. These terms are described from viewpoint of the observer. A horizontally favorable fracture line resists the upward displacing forces, such as the pull of the masseter and temporalis muscles on the proximal fragment when viewed in the horizontal plane. # line extend from upper border downwards and forward whereas in unfav. # line runs from upper border downwards and backwards. A vertically favorable fracture line resists the medial pull of the medial pterygoid on the proximal fragment when viewed in the vertical plane.# line runs from buccal plate anteriorly and backwards thru the lingual plate posteriorly whereas in unfavorable # line runs from lingual plate anteriorly backwards thru the buccal plate posteriorly.
- 1.Patients general physical status should be carefully evaluated and monitored before any consideration of treating mandibular #. It must be emphasized that any force great enough to cause a mandible # is capable of injuring any other organ system of the body. The downward spiral to disaster begins if this principle is not followed. 2.Diagnosis and treatment of mandibular # should be approached methodically and not with emergency type mentality. Patient rarely die of mandible # so clinician has time to carefully and thoroughly evaluate the nature of injury based on history, local physical and radiological examination and treatment should be instituted in a controlled environment and fashion. 3. # teeth can become infected and may jeopardize bone union, however intact tooth in line of # that is maintaining bone fragments can be protected by antibiotic coverage. 4. It is said that facial esthetics will not be adversely affected by slight fragment displacement, however function can be severely compromised when improper treatment results in malocclusion, Impressive appearing radiographic bone adaption should not be the primary treatment goal. 5. The principle of “inside out and from bottom to top” should be applied so to build the foundation on which facial bones can be laid
- 1.should vary acc. to type, location, number, severity of mand. #, pt. age & health and method used for reduction and immobilization 2. Despite numerous new antibiotics penicillin remains the agent of choice. 3. Excellent reduction and fixation technique may fail in patient who has undergone notable weight loss and has a catabolic nutritional status. 4.Because closed reduction tech. has long history of success.
- 1. Open reduction can carry increased risk of morbidity. 2. Because of excellent blood supply of face small bone fragments can coalesce and heal if ass. Periosteum is not disturbed. 3. Because wires, screws, and plates may decrease the chances of bone union by further disrupting the soft tissue.
- 2.-when treated with closed reduction, these fractures tend to open at the inferior border, leading to malocclusion the mandible is fixed first, providing a stable and accurate base for restoration ; One of the condyles should be opened to provide an accurate vertical dimension of the face
- Hippocrates was first to advocate the use of wires in reduction of mand. # A simple bridle wire placed around the adjacent teeth of a mand # can temp. stabilize the # fragments. it helps to prevent further soft tissue damage, aid in protecting airway, helps alleviate pain and assist in preventing muscle cramping that is ass. With instable segments.
- CONTINUOUS OR MULTIPLE LOOP WIRING [COL. STOUT WIRING]
- Leonard (1977) considers that eyelet wires have several drawbacks. Drawn into interdental space Elastic traction ..difficult He described the use of titanium buttons of 8mm diameter, inclusive of a 1mm rim, and 2mm deep.
- Indications Pathological # or Gunshot inj. Atrophic edentulous fractures Osteomyelitis at an edentulous fracture site Bone graft requirements With a head frame Contraindications Irradiated tissues Grossly contaminated tissue Osteoporosis Osteosclerosis
- Champy was able to define the areas for miniplate fixation along the so called ideal osteosynthesis line. This line corresponds to the line of tension along the mandibular body. From parasymphysis to parasymphysis, two miniplates are required to overcome the torsional forces affecting this area. Posteriorly, a single miniplate along the oblique line or below it was thought to be effective; however, Kroon has shown that the forces in this area vary from positive to negative during function, necessitating the use of a second plate inferior to the first if dependable stabilization and healing are to be achieved. Whether to use one or two miniplates when repairing a fracture at the mandibular angle remains controversial.
- Holes are drilled in the bone ends 6mm distant on either side of the fracture line Then, 0.45 mm D soft stainless steel wire is passed through the holes and across the fracture line After accurate reduction, the free ends of the wire are twisted together tightly, cut off short and the cut end tucked into the nearest drill hole
- Long curved awl is placed externally in the desired position inferior to lower border of mandible.(care taken to avoid facial vessels and area of mental foramen). Operators middle or index finger of the other hand should be placed in the lingual sulcus where it protects the Submandibular duct and lingual nerve. Awl is pushed thru the skin until it reaches the lower border of the mandible, with the point remaining in contact with the bone throughout the procedure, the awl is advanced so that in emerges in the lingual sulcus, where the wire is threaded into the eyelet of the awl. Once this is done the awl is slowly withdrawn so that the point can traverse the lower border and pushed into buccal sulcus where the end of wire is retrieved and detached The wire ends secured by the artery forceps and pulled to and fro so that no soft tissue remain b/w wire and the bone
- With introduction of more accurate methods of direct fixation there has been decline in the indications for the use of this rather inaccurate method of immobilisation
- Treatment is usually instituted only if occlusion is compromised or if # coronoid impinges on the zygomatic arch inhibiting mandibular movements
- Infection and osteomyelitis appear to be the most common complications. underlying causes : divided into systemic factors, such as alcoholism and no antibiotic coverage, and local factors, such as poor reduction and fixation, fractured teeth in the line of fracture, and comminuted fractures Most infections appear to be mixed in nature, with α-hemolytic Streptococcus and Bacteroides spp organisms found most commonly Traumatic injury to the inferior alveolar nerve is common in displaced fractures of the body and angle of the mandible. Return of nerve function depends on the degree of initial trauma to the nerve and an accurate reduction and adequate fixation of the mandibular fracture.
- Nonunion is distinguished from delayed union by the potential of the bone to heal. Delayed union is a temporary condition , adequate reduction and immobilization eventually produces bony union. On the other hand, nonunion may persist indefinitely without evidence of bone healing unless surgical treatment is undertaken to repair the fracture. Nonunion is generally characterized by pain and abnormal mobility following treatment, Malocclusion may be present, mobility exists across the fracture line. Radiographs demonstrate no evidence of healing and in later stages show rounding off of the bone ends. The most common reason is poor reduction and immobilization , infection, decreased blood supply, excessive stripping of periosteum and metabolic defiecinces. Treatment 1.Eliminate underlying cause 2.If infection present---debridement of sequestrate, drainage and antibiotic therapy. 3.Loose fixation must be removed 4. Adequate rigid fixation must be done 5. If gap present bone graft may be necessary Malunion is defined as bone union of the #in which some displacement of bone exists. Not all malocclusion are clinically significant In edentulous pat. Or those involving ramus or condyle result in no clinically alterations. If malocclusion present Use of further/prolonged IMF in early stages of bone healing Selective tooth grinding Orthodontics/ostetomies after complete bony union Before reconstructing occlusion to new articulation it is necessary to allow a period of 6-12 months of complete healing.
- Internal fixation of mandibular angle fractures: a comparison of 2 techniques.