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Maxillofacial TraumaMaxillofacial Trauma
Mandibular FracturesMandibular Fractures
Mandible is embryologically a membran...
22
Mandible in traumaMandible in trauma
Mandibular fracture is more common than middleMandibular fracture is more common t...
33
Fracture of condyle regarded as a safety mechanismFracture of condyle regarded as a safety mechanism
to the patientto t...
44
Anatomical considerationsAnatomical considerations
Attached muscles:Attached muscles:
MasseterMasseter
TemporalisTempor...
55
Blood supplyBlood supply
Endosteal supply via the ID artery and veinEndosteal supply via the ID artery and vein
Periost...
66
Factors influenced site of fractureFactors influenced site of fracture
and displacementand displacement
Anatomy of theA...
77
Types of fractureTypes of fracture
SimpleSimple
Greenstick fracture (rare, exclusively in children)Greenstick fracture ...
88
Sites of fracturesSites of fractures
Condyle fractureCondyle fracture
– Intracapsular fractureIntracapsular fracture
– ...
99
Incidence of mandibular fracturesIncidence of mandibular fractures
Body fractures 33.6%Body fractures 33.6%
Subcondylar...
1010
Favourable orFavourable or unfavourableunfavourable
They can be vertically or horizontally inThey can be vertically o...
1111
Effects of muscles on displacementEffects of muscles on displacement
Transverse midline fracture (symphesial)Transver...
1212
Condylar fracturesCondylar fractures
The most common mandibular fractureThe most common mandibular fracture
Unilatera...
1313
Sign and symptomsSign and symptoms
Swelling, pain, tenderness and restriction of movementSwelling, pain, tenderness a...
1414
Sequlae of TMJ injurySequlae of TMJ injury
Artheritic changesArtheritic changes
Haemartherosis, fibrosis and aknylosi...
1515
Coronoid process fracture:Coronoid process fracture:
Rare fracture caused by direct trauma toRare fracture caused by ...
1616
Fracture of the ramus:Fracture of the ramus:
Type I Single fractureType I Single fracture
Mimics low condylar fractur...
1717
Fracture of the angle and bodyFracture of the angle and body
Pain, tenderness and trismusPain, tenderness and trismus...
1818
Midline fractureMidline fracture
The most common missed fracture (alwaysThe most common missed fracture (always
fine ...
1919
Signs and symptomsSigns and symptoms
Pain and tendernessPain and tenderness
Swelling and odemeaSwelling and odemea
De...
2020
Clinical assessment and diagnosisClinical assessment and diagnosis
History of traumaHistory of trauma
(traumatized pa...
2121
RadiographsRadiographs
Plain radiographPlain radiograph
OPGOPG
Lateral obliqueLateral oblique
PA mandiblePA mandible
...
2222
Principles of treatmentPrinciples of treatment
similar to elsewhere fractures in the bodysimilar to elsewhere fractur...
2323
Definitive treatmentDefinitive treatment
Soft tissue repairSoft tissue repair
DebridmentDebridment
Irrigation with sa...
2424
Close reductionClose reduction
Arch barsArch bars
– JelenkoJelenko
– Erich patternErich pattern
– German silver notch...
2525
Close reductionClose reduction
Bonded bracketsBonded brackets
IMF screwsIMF screws
Dental wiring:Dental wiring:
Direc...
2626
Fracture mandible in childrenFracture mandible in children
Close reductionClose reduction
Open reduction andOpen redu...
2727
Gunning’s splintGunning’s splint
Old modalityOld modality
Edentulous patientEdentulous patient
Rigid fixation is notR...
2828
Open reduction and fixationOpen reduction and fixation
Intraoral approachIntraoral approach
Extraoral approachExtraor...
2929
Rigid fixationRigid fixation
Intraossous wiringIntraossous wiring
Plates and screwsPlates and screws
Kirchener wireKi...
3030
Reconstruction palateReconstruction palate
Severe trauma
Loss of part of the bone
3131
Condylar fracturesCondylar fractures
Intraoral approachIntraoral approach
Ramus incisionRamus incision
Extraoral appr...
3232
IMFIMF
Transosseous wiringTransosseous wiring
Circumferential wiringCircumferential wiring
External pin fixationExter...
3333
OsteosynthesisOsteosynthesis
Non-compression small platesNon-compression small plates
Compression platesCompression p...
3434
Teeth in the fracture lineTeeth in the fracture line
The fracture is compound into the mouthThe fracture is compound ...
3535
Management of teeth retained in fractureManagement of teeth retained in fracture
lineline
Good quality intra-oral per...
3636
Absolute indicationsAbsolute indications
Longitudinal fractureLongitudinal fracture
Dislocation or subluxation from s...
3737
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Mandibular fractres

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Mandibular fractres

  1. 1. 11 Maxillofacial TraumaMaxillofacial Trauma Mandibular FracturesMandibular Fractures Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages with two nutrient arteries
  2. 2. 22 Mandible in traumaMandible in trauma Mandibular fracture is more common than middleMandibular fracture is more common than middle third fracturethird fracture (anatomical factor)(anatomical factor) It could be observed either alone or in combinationIt could be observed either alone or in combination with other facial fractureswith other facial fractures Minor mandibular fracture may be associated withMinor mandibular fracture may be associated with head injury owing to the cranio-mandibularhead injury owing to the cranio-mandibular articulationarticulation Mandibular fracture may compromise the patency ofMandibular fracture may compromise the patency of the airway in particular with loss of consciousnessthe airway in particular with loss of consciousness Fracture of mandible occurred with frontal impactFracture of mandible occurred with frontal impact force as low as 425 lb (190 Kg)force as low as 425 lb (190 Kg) {Condylar fracture}{Condylar fracture}
  3. 3. 33 Fracture of condyle regarded as a safety mechanismFracture of condyle regarded as a safety mechanism to the patientto the patient Frontal force of 800-900 lb (350-400 Kg) is requiredFrontal force of 800-900 lb (350-400 Kg) is required to cause symphesial fractureto cause symphesial fracture Mandible was more sensitive to lateral impact thanMandible was more sensitive to lateral impact than frontal onefrontal one Frontal impact is substantially cushioned by openingFrontal impact is substantially cushioned by opening and retrusion of the jawand retrusion of the jaw (Nahum 1975(Nahum 1975)) Long canine tooth and partially erupted wisdomsLong canine tooth and partially erupted wisdoms represent line of relatively weaknessrepresent line of relatively weakness
  4. 4. 44 Anatomical considerationsAnatomical considerations Attached muscles:Attached muscles: MasseterMasseter TemporalisTemporalis Medial and lateralMedial and lateral pterygoidpterygoid MylohyoidMylohyoid Geniohyoid andGeniohyoid and genioglosusgenioglosus anterior belly ofanterior belly of digastricsdigastrics
  5. 5. 55 Blood supplyBlood supply Endosteal supply via the ID artery and veinEndosteal supply via the ID artery and vein Periosteal supply, important in aging due toPeriosteal supply, important in aging due to diminishes and disappearance of alveolardiminishes and disappearance of alveolar arteryartery Bradley 1972Bradley 1972 NerveNerve Damage of inferior dental nerveDamage of inferior dental nerve Facial palsy by direct trauma to ramusFacial palsy by direct trauma to ramus Damage of facial nerve in temporal boneDamage of facial nerve in temporal bone fracturefracture Goin 1980Goin 1980 Damage to mandibular division of facialDamage to mandibular division of facial nervenerve
  6. 6. 66 Factors influenced site of fractureFactors influenced site of fracture and displacementand displacement Anatomy of theAnatomy of the mandible and attachedmandible and attached muscle (canine &muscle (canine & wisdoms)wisdoms) Weakening areas ofWeakening areas of mandible (resorptionmandible (resorption and pathologyl)and pathologyl) Direction of force of theDirection of force of the blowblow Age of the patientAge of the patient
  7. 7. 77 Types of fractureTypes of fracture SimpleSimple Greenstick fracture (rare, exclusively in children)Greenstick fracture (rare, exclusively in children) Fracture with no displacement (Linear)Fracture with no displacement (Linear) Fracture with minimal displacementFracture with minimal displacement Displaced fractureDisplaced fracture Comminuted fractureComminuted fracture Extensive breakage with possible bone and soft tissueExtensive breakage with possible bone and soft tissue lossloss Compound fractureCompound fracture Severe and tooth bearing area fracturesSevere and tooth bearing area fractures Pathological fracturePathological fracture (osteomyelities, neoplasm and generalized skeletal(osteomyelities, neoplasm and generalized skeletal disease)disease)
  8. 8. 88 Sites of fracturesSites of fractures Condyle fractureCondyle fracture – Intracapsular fractureIntracapsular fracture – Extracapsular fractureExtracapsular fracture High condyle neck fractureHigh condyle neck fracture Low condylar fractureLow condylar fracture Angle/ ramus fractureAngle/ ramus fracture (body(body fracture)fracture) Canine regionCanine region (parasymphesial(parasymphesial fracture)fracture) Midline fractureMidline fracture (symphesis(symphesis fracture)fracture) Coronoid fractureCoronoid fracture (rare)(rare)
  9. 9. 99 Incidence of mandibular fracturesIncidence of mandibular fractures Body fractures 33.6%Body fractures 33.6% Subcondylar fracture 33.4%Subcondylar fracture 33.4% Fractures at the angle 17.4%Fractures at the angle 17.4% Alveolar fractures 6.7%Alveolar fractures 6.7% Ramus fractures 5.4%Ramus fractures 5.4% Midline fractures 2.9%Midline fractures 2.9% Fracture of coronoid process 1.3%Fracture of coronoid process 1.3% Oikarinen & Malmstrom 1969Oikarinen & Malmstrom 1969
  10. 10. 1010 Favourable orFavourable or unfavourableunfavourable They can be vertically or horizontally inThey can be vertically or horizontally in directiondirection They are influenced by the medial pterygoid-They are influenced by the medial pterygoid- masseter “sling”masseter “sling” If the vertical direction of the fracture favours theIf the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, theunopposed action of medial pterygoid muscle, the posterior fragment will be pulled linguallyposterior fragment will be pulled lingually If the horizontal direction of the fracture favours theIf the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles inunopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulledupward direction, the posterior fragment will be pulled linguallylingually Favourable fracture line makes the reducedFavourable fracture line makes the reduced fragment easier to stabilizefragment easier to stabilize
  11. 11. 1111 Effects of muscles on displacementEffects of muscles on displacement Transverse midline fracture (symphesial)Transverse midline fracture (symphesial) stabilizes by the action of mylohyoid andstabilizes by the action of mylohyoid and geniohyoidgeniohyoid Oblique fracture (parasymphesial) tends toOblique fracture (parasymphesial) tends to overlap under the influence of muscles actionoverlap under the influence of muscles action Bilateral parasymphesial fracture results inBilateral parasymphesial fracture results in backward displacement associated with loss ofbackward displacement associated with loss of tongue control when the level of consciousnesstongue control when the level of consciousness is depressedis depressed
  12. 12. 1212 Condylar fracturesCondylar fractures The most common mandibular fractureThe most common mandibular fracture Unilateral or bilateralUnilateral or bilateral Intracapsular or extracapsularIntracapsular or extracapsular Antero-medial displacement isAntero-medial displacement is common but it may remaincommon but it may remain angulated with the ramusangulated with the ramus Dislocation of the glenoid fossa andDislocation of the glenoid fossa and fracture of petrous temporal bonefracture of petrous temporal bone which is very rarewhich is very rare
  13. 13. 1313 Sign and symptomsSign and symptoms Swelling, pain, tenderness and restriction of movementSwelling, pain, tenderness and restriction of movement Deviation of mandible towards the side of fractureDeviation of mandible towards the side of fracture Gagging of occlussion (premature contact on the posteriorGagging of occlussion (premature contact on the posterior teeth) with bilateral condylar displaced or over-riding fracturesteeth) with bilateral condylar displaced or over-riding fractures Displacement of mandible toward the affected sideDisplacement of mandible toward the affected side Anterior open bite on opposite side of fractureAnterior open bite on opposite side of fracture Laceration of EAM****Laceration of EAM**** Retroauricular ecchymosis****Retroauricular ecchymosis**** Cerebrospinal leak and otorrhea in association with skull baseCerebrospinal leak and otorrhea in association with skull base fracturefracture Condylar fracturesCondylar fractures
  14. 14. 1414 Sequlae of TMJ injurySequlae of TMJ injury Artheritic changesArtheritic changes Haemartherosis, fibrosis and aknylosisHaemartherosis, fibrosis and aknylosis Meniscal damage and detachmentMeniscal damage and detachment TMDTMD Staph infectionStaph infection with condylar backwardwith condylar backward displacement and external auditory meatus injurydisplacement and external auditory meatus injury MeningitisMeningitis with petrous temporal bone fracture andwith petrous temporal bone fracture and intracranial involvementintracranial involvement Condylar fracturesCondylar fractures
  15. 15. 1515 Coronoid process fracture:Coronoid process fracture: Rare fracture caused by direct trauma toRare fracture caused by direct trauma to ramus and results from reflux contraction oframus and results from reflux contraction of temporalistemporalis Can be seen following operation of largeCan be seen following operation of large ramus cystramus cyst Elicit tenderness over the anterior part ofElicit tenderness over the anterior part of ramusramus Development of tell-tale haematomaDevelopment of tell-tale haematoma
  16. 16. 1616 Fracture of the ramus:Fracture of the ramus: Type I Single fractureType I Single fracture Mimics low condylar fracture that runsMimics low condylar fracture that runs below the sigmoid notchbelow the sigmoid notch Type II comminuted fractureType II comminuted fracture Common in missile injuries and appears toCommon in missile injuries and appears to be with little displacement due to effects ofbe with little displacement due to effects of messeter and medial pterygoid musclesmesseter and medial pterygoid muscles
  17. 17. 1717 Fracture of the angle and bodyFracture of the angle and body Pain, tenderness and trismusPain, tenderness and trismus Extra-oral swelling at the angle with obviousExtra-oral swelling at the angle with obvious deformitydeformity Step deformity behind the molar teethStep deformity behind the molar teeth Movement and crepitus at the fracture siteMovement and crepitus at the fracture site Derangement of occlussionDerangement of occlussion Intra-oral buccal and lingula heamatomaIntra-oral buccal and lingula heamatoma Involvement of IDNInvolvement of IDN Gingival tear if fracture in dentated areaGingival tear if fracture in dentated area Tooth involvement and possible longitudinalTooth involvement and possible longitudinal split fracturesplit fracture
  18. 18. 1818 Midline fractureMidline fracture The most common missed fracture (alwaysThe most common missed fracture (always fine crack)fine crack) Can be symphesial or parasymphesialCan be symphesial or parasymphesial fracturefracture Commonly associated with one or bothCommonly associated with one or both condyles fracturecondyles fracture Unilateral fracture leads to over-riding ofUnilateral fracture leads to over-riding of the fragments and bilateral may contributethe fragments and bilateral may contribute in loss of voluntery tongue controlin loss of voluntery tongue control Long canine tooth represent a weak areaLong canine tooth represent a weak area and contributes to parasymphesial fractureand contributes to parasymphesial fracture Rarely runs across mental foramenRarely runs across mental foramen
  19. 19. 1919 Signs and symptomsSigns and symptoms Pain and tendernessPain and tenderness Swelling and odemeaSwelling and odemea Development of step deformityDevelopment of step deformity Mental anesthesiaMental anesthesia Heamatoma in the floor of mouth and buccal mucosaHeamatoma in the floor of mouth and buccal mucosa Soft tissue injury of the chin and lower lipSoft tissue injury of the chin and lower lip If associated with condylar fracturesIf associated with condylar fractures Absence of condyle movement on the contrlateral sideAbsence of condyle movement on the contrlateral side Deviation of mandibleDeviation of mandible Anterior open biteAnterior open bite Gagging of oclussionGagging of oclussion Limitation of mouth openingLimitation of mouth opening Midline fracture
  20. 20. 2020 Clinical assessment and diagnosisClinical assessment and diagnosis History of traumaHistory of trauma (traumatized patients with possible head injury) and facial(traumatized patients with possible head injury) and facial injuriesinjuries Clinical ExaminationClinical Examination ▶▶ ExtroralExtroral Inspection (assessment of asymmetery, swelling, ecchymosis, lacerationInspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut wounds)and cut wounds) Palpation for eliction of tenderness, pain, step deformity and malfunctionPalpation for eliction of tenderness, pain, step deformity and malfunction ▶▶ Intra- and paraoralIntra- and paraoral bleeding, heamatoma, gingival tear, gagging of occlussionbleeding, heamatoma, gingival tear, gagging of occlussion and step deformity and sensory and motor deficiencyand step deformity and sensory and motor deficiency RadiographsRadiographs
  21. 21. 2121 RadiographsRadiographs Plain radiographPlain radiograph OPGOPG Lateral obliqueLateral oblique PA mandiblePA mandible AP mandible (reverseAP mandible (reverse Townes)Townes) Lower occlusalLower occlusal CT scanCT scan 3-D CT imaging3-D CT imaging MRIMRI
  22. 22. 2222 Principles of treatmentPrinciples of treatment similar to elsewhere fractures in the bodysimilar to elsewhere fractures in the body Reduction of fragments in good positionReduction of fragments in good position Immobilization until bony union occursImmobilization until bony union occurs These are achieved by:These are achieved by: Close reduction and immobilizationClose reduction and immobilization Open reduction and rigid fixationOpen reduction and rigid fixation Other objective of mandible fracture treatment:Other objective of mandible fracture treatment: Control of bleedingControl of bleeding Control of infectionControl of infection
  23. 23. 2323 Definitive treatmentDefinitive treatment Soft tissue repairSoft tissue repair DebridmentDebridment Irrigation with saline and antibioticsIrrigation with saline and antibiotics Closure in layersClosure in layers DressingDressing Reduction and fixation of the jawReduction and fixation of the jaw ▶▶ Close reduction and IMF (traditional method by means ofClose reduction and IMF (traditional method by means of manipulation)manipulation) ▶▶ Open reduction and semi-rigid fixation (using inter-ossousOpen reduction and semi-rigid fixation (using inter-ossous wirings)wirings) ▶▶ Open reduction and rigid fixation (using bone palatesOpen reduction and rigid fixation (using bone palates osteosynthesis)osteosynthesis) Objective:Objective: Restoration of functional alignment of the bone fragments inRestoration of functional alignment of the bone fragments in anatomically precise position utilizing the present teeth foranatomically precise position utilizing the present teeth for guidanceguidance
  24. 24. 2424 Close reductionClose reduction Arch barsArch bars – JelenkoJelenko – Erich patternErich pattern – German silver notchedGerman silver notched Cap splintsCap splints ▶▶ IMF prior to rigid fixationIMF prior to rigid fixation ▶▶ For the purpose of closeFor the purpose of close reductionreduction
  25. 25. 2525 Close reductionClose reduction Bonded bracketsBonded brackets IMF screwsIMF screws Dental wiring:Dental wiring: Direct wiringDirect wiring Eyelet wiringEyelet wiring Local anesthesia orLocal anesthesia or sedationsedation Minimal displacementMinimal displacement IMF for 6 weeksIMF for 6 weeks Treatment can be performedTreatment can be performed under GA or LA and whenunder GA or LA and when surgery is contraindicatedsurgery is contraindicated
  26. 26. 2626 Fracture mandible in childrenFracture mandible in children Close reductionClose reduction Open reduction andOpen reduction and fixationfixation Plating at the inferiorPlating at the inferior borderborder Resorpable platesResorpable plates
  27. 27. 2727 Gunning’s splintGunning’s splint Old modalityOld modality Edentulous patientEdentulous patient Rigid fixation is notRigid fixation is not possiblepossible To establish theTo establish the occlusionocclusion
  28. 28. 2828 Open reduction and fixationOpen reduction and fixation Intraoral approachIntraoral approach Extraoral approachExtraoral approach ▶▶ SubmandibularSubmandibular approachapproach
  29. 29. 2929 Rigid fixationRigid fixation Intraossous wiringIntraossous wiring Plates and screwsPlates and screws Kirchener wireKirchener wire Lag screwsLag screws
  30. 30. 3030 Reconstruction palateReconstruction palate Severe trauma Loss of part of the bone
  31. 31. 3131 Condylar fracturesCondylar fractures Intraoral approachIntraoral approach Ramus incisionRamus incision Extraoral approachExtraoral approach Preauricular approachPreauricular approach Retromandibular approachRetromandibular approach
  32. 32. 3232 IMFIMF Transosseous wiringTransosseous wiring Circumferential wiringCircumferential wiring External pin fixationExternal pin fixation Bone clampsBone clamps Trans-fixation with Kirschner wiresTrans-fixation with Kirschner wires
  33. 33. 3333 OsteosynthesisOsteosynthesis Non-compression small platesNon-compression small plates Compression platesCompression plates MiniplatesMiniplates Lag screwsLag screws Resorbable plates and screwsResorbable plates and screws
  34. 34. 3434 Teeth in the fracture lineTeeth in the fracture line The fracture is compound into the mouthThe fracture is compound into the mouth The tooth may be damaged or lose itsThe tooth may be damaged or lose its blood supplyblood supply The tooth may be affected by someThe tooth may be affected by some preexisting pathologypreexisting pathology
  35. 35. 3535 Management of teeth retained in fractureManagement of teeth retained in fracture lineline Good quality intra-oral periapical radiographGood quality intra-oral periapical radiograph Insinuation of appropriate systemic antibioticInsinuation of appropriate systemic antibiotic therapytherapy Splinting of tooth if mobileSplinting of tooth if mobile Endodontic therapy if pulp is exposedEndodontic therapy if pulp is exposed Immediate extraction if fracture becomesImmediate extraction if fracture becomes infectedinfected Follow up for 1 year and endodontic therapy ifFollow up for 1 year and endodontic therapy if there is a loss of vitalitythere is a loss of vitality
  36. 36. 3636 Absolute indicationsAbsolute indications Longitudinal fractureLongitudinal fracture Dislocation or subluxation from socketDislocation or subluxation from socket Presence of periapical infectionPresence of periapical infection Infected fracture lineInfected fracture line Acute pericoronitisAcute pericoronitis Relative indicationsRelative indications Functional tooth that would be removedFunctional tooth that would be removed Advanced caries or periodontal diseasesAdvanced caries or periodontal diseases Doubtful tooth which would be added to existingDoubtful tooth which would be added to existing denturedenture Tooth in untreated fracture presenting more than 3Tooth in untreated fracture presenting more than 3 days after injurydays after injury
  37. 37. 3737
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Mandibular fractres

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