Mandibuar fracture anatomy, incidence and protocols to manage mandibular fractures and the recent protocols eplained in detail

1. MANDIBULAR
FRACTURES
Dr.ABHISHEK P.T.
Resident
Department Of Oral and maxillofacial Surgery
K.V.G.D.C.H Sullia

2. Contents.
 Introduction.
 History.
 Surgical anatomy
 Epidemiology.
 Classification systems
 Clinical examination
 Radiographic features and diagnosis
 Treatment planning
 Special considerations
 Conclusion
 References

3. Introduction.
 Strongest at the same
time most frequent
fractured facial bone!
 Mandibular fractures
occurs twice as often as
mid-facial fractures
 For better management
of this scenario an OMFS
surgeon should be
exposed to the minute
details of the anatomy
and different surgical
considerations.

4. History.
 Egyptian Papyrus (1650 BC) –
Examination, diagnosis &
treatment.
 Hippocrates – Approximation of #
segments.
 Salerno, Italy (1180) – Proper
occlusion.
 1492, the book Cyrurgia by
Guglielmo Salicetti – use of IMF.
 John Barton - Barton Bandage

5. 1860 GILMER GILMERS WIRING & FULL ARCH BARS
1900 MAHE PLATING KIT SIMILAR TO MODERN
SYSTEMS
1920 F. RISDON RISDONS WIRING
1961 LUHR DYNAMIC COMPRESSION PLATES
1970 BRONS & BOERING LAG SCREWS
1973 MICHELET MINIPLATES FOR MAND
OSTEOSYNTHESIS
1978 CHAMPY MINIPLATE OSTEOSYNTHESIS
PRINCIPALS

6. Surgical anatomy
 Strongest facial bone
 Parabola shaped bone
 Angle of curvature is 110-140°
 Mandible is the 2nd bone to ossify
 Composed of dense cortical bone encloses
medullary bone.

8. Weak areas of mandible
 Junction of the ramus and the body ( angle of the
mandible) are fractured commonly.
 Symphysis region - junction of two individual bones.
 Junction between alveolar bone & basal mandibular
bone.
 Parasymphyseal region - lateral to the mental
prominence, incisive fossa and mental foramen.
 Presence of impacted tooth, canine with long roots
further weakens the mandible.

9. Age changes of mandible.
 Mental foramina.
child – near inferior border.
old age – near alveolar ridge.
 Ramus angle.
child & old – obtuse
 Alveolar ridge
 Blood supply

10. Safe distance in mandible.
Average thickness of
Cortex in symphysis &
parasymphisis
region is 2.5 mm
Average thickness of
Cortex in premolar &
Body region is 3.5 mm

11. Distance between I.A.
Canal & cortex
 At bicuspid - 4.0 mm
 Molar region - 5.9 mm
Anteriorly distance
Between adjacent
Root apices is 3.7 mm
Posteriorly distance
Between adjacent
Root apices is 6.3 mm

12. Muscle attachments
Muscles of mastication
1. Temporalis (1)
2. Masseteer(14)
3. Medial pterygoid
4. Lateral pterygoid
Muscles on lingual aspecct
of mandible
1. Geniohyoid
2. Genioglossus
3. Mylohyoid
4. Ant belly of digastric

14. Blood supply.
• Helps in the healing of
fractured bone.
• Endosteal blood supply via
inferior dental artery & veins.
• Peripheral blood supply -
Periosteum

15. Nerve supply.
• Inferior alveolar nerve

16. Champy’s principles
 Forces of mastication produce
tensional forces on upper border &
forces of compression on lower
border.
 Champy put forward the lines
where plates & screws have to be
placed - “ideal osteosynthesis
lines”.
 It corresponds to course of a line of
tension at base of the alveolar
process.
 Only in symphysis region, 2 plates

17. Epidemiology
 Etiology:

18.  Age
 Sex

19. Classification
1. Dictionary classification
2. Kruger’s classification
3. Anatomical location ( Row & killey, Dingman and
Natwig)
4. Kazanjian's classification
5. AO classification
6. On mechanism of action
7. According to direction and favorability of muscle

20. Dictionary classification( Dorlands)
 Simple/ closed
 Compound /open
 Communited
 Greenstick
 Pathologic
 Multiple
 Impacted
 Atrophic
 Indirect
 Complicated/ complex
Impacted #

21. Kruger's Classification
SIMPLE ( CLOSED) Linear fracture lines which do not communicate
with the exterior
COMPOUND
( OPEN)
The fracture is communicating intraorally or
extraorally.
COMMUNITED Shattering of bone into multiple pieces
COMPLEX
COMPLICATED
They is adjunct injury to the adjacent nerves or
major blood vessels , joints.
GREENSTICK Only one cortex broken. Common in children
PATHOLOGICAL Spontaneous fracture as a result of normal muscle
contraction or
trauma due to increased weakness of underlying bone .

23. BASED ON ANTOMY
Rowe and Killey Dingman and Natwig

24. Rowe and Killey classification
 Involving basal bone
1. Single
2. Unilateral
3. Bilateral
4. Multiple
 Not involving basal bone( dento alveolar)

25. Dingman & Natvig classification
 Symphysis fracture
 Canine region
fracture
 Body of the mandible
fracture
 Angle fracture
 Ramus fracture
 Coronoid fracture
 Condylar fracture
 Dentoalveolar fracture

26. Direction & favorability of treatment
 Favourable : Muscle pull is restricting the fracture
line from displacement is considered favorable
fractures.
 Unfavourable: when the muscle pull is displacing the
fracture line from each other
 Elevator group of muscles exert an upward forward
and medial pull
 Depresor group of muscle exerts –downward and
backward pull.

27. Horizontally Favourable
Fracture line runs
downward & forward so
upward displacement
avoided
Horizontally
Unfavourable
Fracture line runs Down
Wards and Back Wards
so
upward Displacement
Unrestricted

28. VERTICALLY FAVORABLE VERTICALLY UNFAVORABLE
FRACTURE LINE RUNS FROM THE
OUTER BUCCAL PLATE OBLIQUELY
BACKWARDS AND LINGUALLY , MEDIAL
MOVEMENT RESTRICTED
FRACTURE LINE RUNS FROM THE
INNER LINGUAL PLATE OBLIQUELY
BACKWARDS AND BUCCALLY , MEDIAL
MOVEMENT UNRESTRICTED( A point more
antriorly from lingual side to point posterior on
buccal side)

30. Presence or absence of teeth
Kazanjian V.H. & Converse J.M.
CLASS 1 TEETH ON BOTH
SIDES OF FRACTURE LINE
CLASS II TEETH ONLY ON ONE SIDE
OF THE FRACTURE LINE
CLASS III EDENTULOUS PATIENT

31. AO Classification
F NO. OF FRACTURE OR FRAGMENTS
L LOCATION OF THE FRACTURE
O STATUS OF OCCLUSION
S SOFT TISSUE INVOLVEMENT
A ASSOCIATED FRACTURES

32. F: NO. OF FRACTURES
F0 Incomplete fractures
F1 Single fractures
F2 Multiple fractures
F3 Comminuted fractures
F4 Fracture with bone defect

33. L: Location of fracture
L1 Pre-canine
L2 Canine
L3 Post-canine
L4 Angle
L5 Supra-angular
L6 Condyle
L7 Coronoid
L8 Alveolar process

34. O: Status of occlusion
O 0 No malocclusion
O 1 Malocclusion
O 2 Edentulous mandible

35. A: Associated fracture
A 0 None
A 1 Dentoalveolar fracture
A 2 Nasal bone fracture
A 3 Zygoma fracture
A 4 Lefort I
A 5 Lefort II
A 6 Lefort III
F0-L2-O0-A 1:
Incomplete fracture ,canine region, No malocclusion with associated dento alveolar
fracture

36. Clinical examination.
 History
 Mechanism of injury
 Inspection/ Palpation [Extraoral / Intraoral]

37. History
 Chief complaint
 History of presenting illness
 Loss of consciousness, vomiting, amnesia
 Systemic examination

38. Mechanism of injury
1. Type of traumatic force
Vehicle accidents usually gives multiple compound
fracture
A broad blunt objet blow will cause usually a
communited injury as the force distribute
throughout the bone.
2. Direction of the force
Eg : An injury on chin causing symphyseal fracture is
having a high chance of associated unilateral or
bilateral condylar fracture.
3. Any pre-traumatic temporomandibular joint
dysfunction needs to be noted.

39. Clinical Examination :INSPECTION
1. Extra oral
 Change in the contour of a face and swelling in the
region of mandible.
 Swelling associated with ecchymosis is suggestive
hematoma with fracture.
 A lacerataion on the chin
2. Intra oral
Mucosal and gingival tear
Echymosis
Occlusal changes

40. Deviation of jaw Restriction of mouth
opening

41. Extensive soft tissue and bony defect

42. Collapsed arch and
Interfragmentary mobility
Open bite due bilateral posterior
Gagging of occlusion
Open bite and cross bite due to
Unilateral gagging of occlusion
Occlusal step with
Unilateral cross bite

43. Mandibular fracture has to be differentiated from extensive
Soft tissue injury and dentoalveolar trauma
UNILATERAL OPEN BITE

44. Multiple fragmentation
With complete loss of occlusion
Sublingual
Unfavorable fracture line
Causing displacement of tooth

45. Palpation: Extra oral
Extensive edema
• Tenderness.
• Step deformity
• Bone crepitus

46. Radiographic features
 OPG
 PA View
 PNS View
 Lateral oblique Radiograph
 Occlusal view
 CT scan.
Whenever one fracture of the mandible is identified, the surgeon must always
suspect that one or more additional fractures are present.
Careful clinical and x-ray examination will assist in establishing the correct
diagnosis.

47. Advantages
-Entire mandible is visualized.
Disadvantages
OPG view

48. PA view.
 Medial / lateral
displacement.

49. Indicated for
Visualizing Medial
Displacement
Of Condylar Neck
The 4th & 5th
MacGregor Line
coincides with Mandible
PNS view

50. Because of distortion in
Symphysis Region in
an OPG , an Occlusal
View is indicated in
Symphysial fractures
Also shows Vertical
Favorability of Body
Fractures
Occlusal view

51. Peri apical
 Most of the fine details with the nondisplaced linear
fracture is also visible

52. CT scan.
 Condylar fracture.
 Cervical spine injury.

53. MANAGEMENT
 KEEP IN MIND
- Force great enough to cause fracture to the strongest
maxillofacial bone can also cause injury to the organ systems
as well.
-Consider methodically. NOT AN EMERGENCY.
-PRIME GOAL IN TREATMENT OF MANDIBULAR FRACTURE-
-THE OLD ADAGE –Inside Out and Bottom to Top

54. We are surgeons not superheroes...
ALWAYS KEEP IN MIND THAT CLOSED
REDUCTION ALSO IS A SUCCESSFULLY
PRACTICED OPTION IN
TREATING MANDIBULAR FRACTURE
SINCE YEARS….

55.  Open reduction give functional stabilisation but 25%
incidences of Facial nerve injuries are aproblem.
 Endoscopic technique should be refined and refined
iinstrumentation.

56. INDICATION FOR OPEN REDUCTION
 Displaced unfavourable fracture
 Multiple fractures of facial bone
 Bilateral condylar fracture
 Edentulous maxilla

57. INDICATION OF CLOSED REDUCTION
 Non-displaced fracture
 Grossly communited
 Edentulous mandible
 Coronoid process fractures

58. Also indicated where open reduction is
contra indicated
 Not advisable under GA
 Gross infections
 Pt. refusing open reduction

59. Closed reduction and Fixation
 Bridle wire
 Ivy loops
 Arch bars
 Risdon wiring
 IMF screws
 Special considerations
1. Edentulous patients
2. Partially edentulous patients
3. Pediatric patients

60. Bridle wire
For temporary reduction and
stabilization.
Old technique.
Wire (25 or 26 gauge) is
wrapped around two teeth on
either side of the fracture.

61. Ivy loops
 A 24 gauge wire is
used.
 Quick easy way to
achieve maxilla-
mandibular fixation.

62. Arch Bars
Risdon’s Arch Bar
Winter’s Arch bar
Jelenko Arch Bar
Erich’s Arch Bar
Hamilton Arch Bar

63. Risdon Wiring
 Can be
advantageous in
treating primary
and early mixed
dentition.
 24- 26 gauge
wire is used.

64. IMF screws
 Used in minimally
displaced fractures.
 In serologically positive
patients, where the
surgeon is at a high
risk of skin puncture
with arch bar
placement.

65. OPEN REDUCTION
 EXTRA ORAL SURGICALAPPROACHES TO THE
MANDIBLE.

66. SUBMENTAL APPROACH
The submental approach is used to treat fractures of the anterior mandibular body and
symphysis. These fractures can usually be approached and treated intraorally.
However, depending on the difficulty or severity of the fracture, and/or the presence of
a laceration suitable, an extraoral approach via the submental route may be indicated.
An advantage to this approach is that the surgeon can easily inspect the lingual surface
of the mandible to assure optimal reduction of the fracture in this region.

67. SUBMANDIBULAR APPROACH
If using skin creases for the incision, the orientation of the scalpel
blade is parallel to the relaxed skin tension lines (RSTL).

68. Advantages:
Allows optimal manipulation of the fragments
Good control of the lingual cortex and inferior border
Variations:
The incision can either be parallel to the inferior border of the
mandible (A) or be placed in an existing skin crease (B) for
maximum cosmetic benefit.
MOST USEFUL FOR:
BODY Fracture
ANGLE Fracture
Communited
Atrophic mandible

69. RETROMANDIBULAR APPROACH
-A vertical incision through skin and
subcutaneous tissue is made,
extending from just below the ear
lobe towards the mandibular angle.
-It should parallel the posterior
border of the mandible.

70. Most useful for:
Ramus fracture
Posterior Angle
fracture
Sub-condylar
fracture

71. PREAURICULAR APPROACH
Incision is made in the pre-auricular skin crease.

72. Most useful for:
High condylar fractures/
Zygomatic arch
fractures
Useful for low ramus #

73. EXISTING LACERATION APPROACH
The surgeon may elect to extend the
laceration to provide adequate access
to the fractured area, following the
relaxed skin tension lines (RSTL).
Bacterial contamination is not a
contraindication for the use of existing
lacerations for surgical approach.

74. INTRA ORAL SURGICAL APPROACHES TO
MANDIBLE
Skeletonization:
Mental nerve to be taken care of
during fixation.

75. Vestibular incision Vestibular plus
envelope incision
Where there is no third molar present, or
where one is present but is to be left in
place, a purely vestibular incision
approximately 5 mm away from the
attached gingiva is made.
When an erupted third molar is to be
removed, the incision must incorporate
the attached gingiva around the buccal
side of the tooth.

77. Open Reduction options
 Lag screws

78.  A large variety of plates are available for application
to the mandible. Types of plates include:
 Mandible plates 2.0
 Locking plates 2.0
 (Locking) reconstruction plates
 Dynamic compression plates
 Universal fracture plates

79. Mandible plate 2.0
Plate thickness of 1.3 mm or less. Therefore, small and medium profile
locking plates 2.0 and mandible plates 2.0 are considered miniplates.

80. Locking plate 2.0
-Locking plates 2.0 available are:
-Small profile locking plate 2.0
-Medium profile locking plate
2.0
-Large profile locking plate 2.0
-Extra-large profile locking plate
2.0

81. Advantages of locking plate
 Conventional plate/screw systems require precise
adaptation of the plate to the underlying bone.
 normal plate system compress the bone to the screw and
get maximum fixation
 Locking plate as the screws are tightened get locked with
the plate and attaining stability.

82. (Locking) reconstruction plates
Used for load bearing osteosynthesis in mandible

83. Reconstruction plates
The comminuted zone can then be simplified to reduce the smaller fragments into one
large fragment by using miniplates.
This is best done by starting at the superior border (alveolar process).

84. After a framework has been created at the superior border, the
simplification process is continued at the inferior border.
Reduction of the fragments is done manually or with the use of
elevators, bone clamps, or bone hooks.

85. Dynamic compression plates
 This illustration shows dynamic compression plates
2.4. Screws inserted bicortically are needed when
using 2.4 plates

86. Compression is obtained by tightening screws down a ramped
hole design. This is the spherical gliding principle.
The compression holes are drilled eccentrically to allow for
compression.

87. The plate must be overbent slightly to close the lingual cortex.

88. A miniplate with screws inserted
monocortically is used to avoid
damage to the tooth roots.
Heavier compression plates (at
least 4-hole) is placed at the
inferior border (compression
zone).

89. Universal fracture plate
Universal fracture plates offer more biomechanical stability than DCP 2.4 plates

90.  Plate contouring

91. Symphysis & Parasymphysis # management
1. CLOSED REDUCTION
2. OPEN REDUCTION
• Two lag screw fixation
• Lag screw fixation
• One plate and arch bar
• Two plates
1.CLOSED REDUCTION
2.OPEN REDUCTION
• Two plates
• Reconstruction plate
SIMPLE FRACTURES COMPLEX FRACTURES

92. One plate and arch bar
 Indication : less vertical height of symphysis region
 relatively inexpensive.
2.0 mm screw, 6 mm in length a 6-hole locking plate 2.0

93. Two plate fixation
2.0 mm screw, 6 mm in length
- In cases where an arch bar
is not possible because of
missing teeth, loose teeth, or
the objection to using an arch
bar.
-The advantage of using two
miniplates is that they are
easy to contour and to secure
to the mandible using
monocortical screws.
-Are readily available in most
operating rooms.
They can be applied very
rapidly and provide stable
fixation when two are applied.

94. Plating for symphysis and para symphysis
fracture
 After plating according to
surgeons choice confirmation
of reduction is important
 There must be no gap at the
lingual aspect. Such a gap
would lead to occlusal
disturbance and mandibular
widening.

95. Because the mandibular symphysis undergoes twisting during
function, two mini-plates can prevent such motion from
occurring.

96. SYMPHYSIS PARA SYMPHYSIS COMPLEX
FRACTURES
 TWO PLATE (BASAL TRIANGLE)
 RECONSTRUCTION (PLATE BASAL TRIANGLE)
 COMMINUTED (BASAL TRIANGLE)

97. TWO PLATE (BASAL TRIANGLE
Can be done by using one reconstruction plate or two
plates
Plates along the inferior border being a heavy locking plate
2.0 of large or extra-large profile
- Sequence of plate insertion
The superior plate is inserted first.

98. Plate selection
Superior border
• 4- or 6-hole mandible plate 2.0 with or without
center space
• 4- or 6-hole small profile locking plate 2.0 with or
without center space
Inferior border
• 6- or 8-hole large profile locking plates 2.0
• 6- or 8-hole extra-large locking plates 2.0

99. Comminuted basal triangle
-It should be a load bearing plating
-A locking reconstruction plate
2.4 should be used.
-The plate must be long
enough there can be a
minimum of three or preferably
four screws on each side of the
fracture.
-The screws adjacent to the
fracture should be at least 7
mm away from the fracture
line.
-Most commonly there will be

101. MANDIBULAR BODY FRACTURES
SIMPLE FRACTURES COMPLEX FRACTURES
1. CLOSED REDUCTION
2. OPEN REDUCTION
-One miniplate
-Two plates
-One large plate
OPEN REDUCTION
Two plates
Reconstruction plate

102. One miniplate
 The following screws and plates can be used
 4- or 6-hole mandible plate 2.0 with or without center
space
 4- or 6-hole small profile locking plates 2.0
 4- or 6-hole medium profile locking plates 2.0
Indication
All teeth in place
Single fracture line
Minimal displacement

103. Two plate
Sequence of plate insertion
The superior plate is inserted first in order to
achieve preliminary fixation
• 4- or 6-hole mandible plate 2.0 with or
without center space
• 4- or 6-hole small profile locking plate 2.0
with or without center spaceSuperior
border
• 4- or 6-hole mandible plate 2.0 with or
without center space
• 4- or 6-hole small profile locking plate 2.0
• 4- or 6-hole medium profile locking plate
2.0
• 4- or 6-hole large profile locking plate 2.0
(straight or curved)
Inferior
border
This option offers additional stability compared with a single miniplate fixation
Specially indicated in transitional areas like ramus and angle

104. One large plate
Reconstruction plates are commonly used if the
fracture is associated with additional factors: eg,
delayed fracture treatment, infection.
One of these plate can be chosen for inferior border
 6- to 8- hole large profile locking plate 2.0
 6- to 8- hole extra-large profile locking plate 2.0
 6- to 8- hole locking reconstruction plate 2.4.

105. COMPLEX BODY FRACTURE
TWO PLATE
• A two plate osteosynthesis is performed in
body fractures with a basal triangle.
RECONSTRUCTION
PLATE
• A load-bearing fixation is indicated for the
open surgical treatment in all types of
comminuted fractures in the mandibular body.

106. TWO PLATE
• 4- or 6-hole mandible plate 2.0
with or without center space
• 4- or 6-hole small profile
locking plate 2.0 with or
without center space
Superior
border
• 6- to 8-hole large profile
locking plates 2.0
• 6- to 8-hole extra large profile
locking plates 2.0
Inferior
border

107. Reconstruction plate
Indicated in complex comminuted fracture
Lower border is lated with locking 2.4
Insert a 2.4 mm locking head screw of
appropriate length

108. MANDIBULAR ANGLE AND RAMUS
FRACTURE
SIMPLE FRACTURES COMPLEX FRACTURES
1. CLOSED REDUCTION
2. OPEN REDUCTION
-Wire
- Miniplate at the external-
oblique ridge
- Two miniplates
- Reconstruction plate
1. CLOSED
REDUCTION
2. OPEN REDUCTION
-Two plates
-Reconstruction plate

109. Single miniplate
INDICATION : Isolated undisplaced fracture of angle
-Plating an be done accoding to surgeons choice from 4 hole and 6 hole
miniplates.
-If adequate bone is not there then 6 hole is opted
-minimum size of mandibula miniplate is 2.0. Here surgeon chose
for more rigid fixation that is 2.0 locking and goes on

111. Two miniplate
 Indications
-When there are bilateral angle fractures
-When there is an associated maxillary fracture

112.  Choice of plate
• The surgeon must choose whether to
use a 4- or 6-hole miniplate along the
oblique ridge in the angle region
Upper
border
• 4- or 6-hole mandibular plate 2.0 with or
without center space
• 4- or 6-hole locking small profile plate 2.0
• 4- or 6-hole locking medium profile plate
2.0
• 4- or 6-hole locking large profile plate 2.0
Lower
border

113. Reconstruction plate
 Indications
-Simple fractures that have been infected for several
days or weeks
-Fractures that extend through an angle where the
height of the bone is much diminished

114. For load-bearing fixation, a reconstruction
plate 2.4

115. COMPLEX RAMUS/ANGLE
 Two plate (basal triangle)
 Reconstruction plate(basal triangle)
 Reconstruction plate (comminuted fracture)

116. Indication
 Control of top of the basal triangle is required
 Two plate is easier than reconstruction plate fixation

117. • A 2.0 miniplate
Superior
border
• 6- to 8-hole medium profile
locking plate 2.0
• 6- to 8-hole large profile locking
plate 2.0 (straight or prebent)
• 6- to 8-hole extra large profile
locking plate 2.0
Inferior
border

118. 2mm screw of appropriate length

119. Reconstruction plate(basal triangle)
 Indication
Basal fracture needs load bearing fixation
2.4 reconstruction plate is used

120. Comminuted basal fracture

121. SPECIAL CONSIDERATIONS

122. UNILATERAL FRACTURES

123. If the fractures are located unilaterally close to each other, the intermediate
fragment is fixed with long spanning adaptation or more frequently reconstruction
plates along the inferior border.

124. If the fracture lines are located further apart,
One fracture is rigidly fixed while the other is commonly fixed with a less rigid
osteosynthesis, eg, a single plate.
Fractures in the tooth-bearing area of the anterior mandible are
generally treated first to establish the ideal occlusion. Fractures in the nontooth-
bearing area (posterior body/angle/ramus/condyle) are usually treated secondarily.

125. BILATERAL FRACTURES
The most common
combination of
fractures is an angle
combined with a
contralateral fracture
through the body or
symphysis.

126. Simple right angle fracture fixed with a miniplate in the external
oblique line and simple left body fracture fixed either with two
plate or single plate on lower border

127. Teeth In The Line Of Fracture
Commonly, there are impacted wisdom teeth associated with mandibular
angle fractures..
The surgeon can either remove the offending tooth or leave it in place if it
is thought not to compromise the result of fracture treatment.
Indications to leave teeth in the line
of fracture
•Tooth not interfering with
reduction and fixation of
fracture.
•If tooth removal requires
removal of excessive amount of
bone
•Tooth that is in good condition
and assists in establishing
occlusion and reducing the
fracture.

128. Indications for removal of teeth in the line of fracture
•Tooth luxated from its socket and/or interfering with reduction of the fracture.
•Tooth that is fractured .
•Tooth with advanced dental caries carrying a significant risk of abscess during
treatment.
•Tooth with advanced periodontal disease with mobility which would not contribute to
establishment of stable occlusion.
•Tooth with existing pathology such as cyst formation or pericoronitis.

129. Involvement of alveolar area
 Routine diagnosis of alveolar fractures should
include an OPG. Periapical and occlusal dental x-
rays can be beneficial.
 OPG showing a right body mandibular fracture with
an associated alveolar component.

130. Alveolar process fractures can
usually be treated by reduction
and fixation with an arch bar
that must be maintained for
approximately 6 weeks to provide
time for the fracture to heal.
As an alternative, open
reduction and internal
fixation may be used in
selected isolated alveolar
fractures and mostly in
those associated with more
severe mandibular
fractures.

131. Alveolar fragment treated using a miniplate
plate fixed with monocortically inserted
screws located adjacent to the tooth apices
The mandibular fracture was treated
with a large profile locking plate 2.0
to give enough stability along the
inferior mandibular border.

132. Infected Fractures
Open fractures can generally be regarded as contaminated
Chronic cases exhibit the typical signs of osteomyelitis.

133. pseudarthrosis must be a safe
procedure. Under these conditions,
high rigidity (absolute immobility)
is mandatory. Therefore the locking
reconstruction system 2.4 is
recommended.
Under these conditions, high rigidity
(absolute immobility) is mandatory

134. Therefore the locking reconstruction system 2.4 is
recommended.
It is important not to place any screws into the
infected bone area
The reconstruction plate functions as a bridging
device.
The extent of the exposure
must anticipate the
application of a large
reconstruction plate
allowing for the placement
of at least three screws on
either side away from the
defect.

135. The remaining dead space is filled with cancellous chips which are further used to
augment the area

136. COMPLICATIONS
 Delayed treatment
 Complications arising during the primary treatment
 Late complications

137. Complications during the primary treatment
 Displaced teeth and foreign body
 Misapplied fixation
care is needed to avoid damage to inferior dental
canal (Compression plates and screws need
sufficient length to impinge the inner cortex)
 Rigid semi rigid fixation can cause the distortion to
anatomical alignment.
 Incidence of infection is more at the angle of
mandible with the fracture involved third molars.

138. Late complications
 Mandible has an impressive capacity to heal by itslef
providing some bone contact is present.
 The use of IMF can mask the minor occlusal
derrangement after the fixation.
 Inadequate reduction can cause gross derangement
in occlusion and later malunion of the bone.
Malunion is common . Not nonunion

139. Delayed and non union
 DELAYED UNION : If the time taken to heal the
mandibular fracture healing is protracted unduly then
it is referred as delayed union.
 Healing process is disturbed due to infection or
general factors like osteoporosis and nutritional
defficiency.

140. NON UNION
 Fracture is not only not united but will not unite on its
own.
 RADIOGRAPH : shows rounding off and sclerosing
of bone ends.
 PREVENTABLE CAUSES OF NON UNION :
1. Infection of the fracture site.
2. Inadequate immobilization.
3. Unsatisfactory apposition of bone ends with soft
tissue interposition.

141.  CAUSES WHICH IS IMPOSSIBLE OR VERY
DIFFICULT TO OVERCOME
1. Ultra thin edentulous mandible in an elderly debiliated
patient.
2. Loss of bone and soft tissue as a result of severe trauma
eg. Missile injury
3. Inadequate blood supply to fracture site,
eg. Post radiotherapy

142. RECENT ADVANCES :TROCAR

143.  Transbuccal instrumentation extends the
versatility of transoral approaches.
 the posterior divisions of the mandible are
pierced from externally. Via this transbuccal
route a special instrumentation is inserted:
 Control and guidance of the procedure is done
simultaneously from the external side and the
internal approach. In the clinical situation
(contrasting in contrast to this illustration) the
soft tissues are less retracted.

146. ENDOSCOPIC APPROACHES
-Transoral approach : 7 years supplimentary study to evalate the outcome of transoral
endoscopic approach in condylar fractures
-Between 2005 and 2012, 50 patients with condylar fractures underwent endoscope-
assisted reduction surgery.
-There was no facial nerve damage or transitory hypoesthesia, and there were no visible
scars after the surgery.
-Transoral endoscope-assisted treatment is a challenging but reliable method with lower
morbidity and a rapid recovery.
It should be emphasized that endoscopy augments, rather than replaces, the
'time tested' principles of adequate skeletal exposure, accurate fracture reduction,
and appropriate internal fixation.

147. CONCLUSION
 Has already been stressed throught the seminar
mandibular fractures are common occurring. As a
omf surgeon we need to update ourselves regarding
the various treament options and choose the one
that is most suitable for for patients.
 For better management of this scenario an OMF
surgeon should be exposed to the minute details of
the anatomy and different surgical considerations.

148. References.
 Oral & maxillofacial trauma- Fonseca,vol 1
 Maxillofacial Injuries- Rowe & Williams
 Fractures of he facial skelton - Peter Banks
 Textbook of oral & maxillofacial surgery by Peter Ward
Booth.
 Textbook of oral & maxillofacial surgery by Neelima
malik.
 Killeys - fractures of the mandible
 Fgd

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