Professional Documents
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http://tajmeel.ta.ohost.de
Dr. Mohamed El Rouby محمد أحمد الروبي.د
Lecturer of Plastic Surgery مدرس جراحة التجميل
+20101556023 or +20126531265 or elroubyegypt@gmail.com
INTRODUCTION
Treatment goals are to restore function and premorbid occlusion. Mastication, speech, and
normal range of oral motion should be achieved. Contour defects must be corrected. Early
treatment curtails the possibility of infection.
The amount of force needed to fracture bones have been divided into those that require
high impact to fracture (> 50 times the force of gravity [g]) and those that require only low
impact to fracture (< 50 g).
• High impact
o Supraorbital rim - 200 g
o Symphysis of the mandible - 100 g
o Frontal-glabella - 100 g
o Angle of mandible - 70 g
• Low impact
o Zygoma - 50 g
o Nasal bone - 30 g
Aetiology:
• Vehicular accidents - 43%
• Assaults - 34%
• Work related - 7%
• Fall - 7%
• Sporting accidents - 4%
• Miscellaneous - %5
Pathophysiology:
Classification of mandibular fractures
• Simple or closed -
• Compound or open -
• Comminuted -
• Greenstick -
• Pathologic -
• Multiple - Variety in which two or more lines of fracture on the same bone are not
communicating with one another
• Impacted - Fracture in which one fragment is driven firmly into the other
• Atrophic - Fracture resulting from severe atrophy of the bone, as in edentulous
mandibles
• Indirect - Fracture at a point distant from the site of injury
• Complicated or complex - Fracture in which considerable injury to the adjacent soft
tissues or adjacent parts occurs; may be simple or compound
Classification by anatomic region
• Symphysis - Fracture in the region of the central incisors that runs from the alveolar
process through the inferior border of the mandible
• Parasymphyseal - Fractures occurring within the boundaries of vertical lines distal
to the canine teeth
• Body - From the distal symphysis to a line coinciding with the alveolar border of the
masseter muscle (usually including the third molar)
• Angle - Triangular region bounded by the anterior border of the masseter muscle to
the posterosuperior attachment of the masseter muscle (usually distal to the third
molar)
• Ramus - Bounded by the superior aspect of the angle to two lines forming an apex
at the sigmoid notch
• Condylar process - Area of the condylar process superior to the ramus region
• Coronoid process - Includes the coronoid process of the mandible superior to the
ramus region
• Alveolar process - Region that normally contains teeth
Muscles involved in opening the mouth include the anterior belly of the digastric muscle
and the mylohyoid, geniohyoid, and genioglossus muscles.
Oral closure is provided by the action of the temporalis, masseter, and the internal (or
medial) pterygoid muscles.
The only protrusion from the mandible is the external, or lateral, pterygoid muscle.
The muscles attached to the ramus (masseter, temporal, medial pterygoid) displace the
proximal segment upward and medially when the fractures are vertically and horizontally
unfavorable. Conversely, these same muscles tend to stabilize the bony fragments in
horizontally and vertically favorable fractures.
In bilateral fractures in the cuspid areas, the symphysis of the mandible is displaced
inferiorly and posteriorly by the pull of the digastric, geniohyoid, and genioglossus
muscles.
Angle classification:
is based on the relationship of the mesial-buccal cusp of the maxillary first molar to the
buccal groove of the mandibular first molar
(Mesial anterior in reference to the sagittal plane and distal is posterior to that same
plane.)
the relationship of the canine teeth to determine the occlusal class.
Class I occlusion refers to the mesial-buccal cusp of the maxillary first molar's contact with
the mandibular first molar's buccal groove. The mesial-buccal cusp lies in front of (or
mesial to) the groove in class II occlusion. In angle class III occlusion, the mesial-buccal
cusp of the maxillary first molar falls behind (or distal to) the groove.
N.B. Fractures that occur in the region of the teeth are considered to be compound
fractures prophylactically treated with antibiotics.
INDICATIONS
I- Observation
Historically, for minimally displaced fractures that were of a favorable type, a Barton-type
head bandage gave enough support for the fracture to heal. This was especially true in
children. A liquid or pureed diet was maintained for 4 weeks.
Factors affecting fragment displacement include:
1- direction and intensity of the traumatic force
2- direction and bevel of the fracture line
3- presence or absence of teeth in the fragments
4- direction of muscle pull
5- extent of soft-tissue injury
II- Maxillomandibular fixation and closed reduction
If external dressings are not sufficient, closed reduction can be accomplished with
maxillomandibular fixation (MMF),
The structure of the mandible is such that masticatory force trajectories are
transmitted to the skull base, but the jaw usually fractures prior to penetration of the
middle cranial fossa. This design permits great forces on the mandible to be
distributed along its frame.
The third division of the trigeminal nerve enters the mandible, at the lingula, as the
inferior alveolar nerve (IAN). The lingula is also the point of attachment for the
sphenomandibular ligament. The IAN gives off dental branches before exiting the
mental foramen, located between the first and second premolar teeth, in the lower
third of the mandible as the mental nerve. Knowledge of the path of the nerve and the
length of the teeth is important in planning the placement of titanium plates and
screws.
WORKUP
Lab Studies:
• Routine preoperative laboratory
Imaging Studies:
• CT scan.
• A panoramic radiograph (Panorex) affords an excellent 2-dimensional
representation of the mandible.
• Several types of plain films add to the evaluation of mandibular fractures.
o The dental periapical view gives fine detail to the teeth and their roots.
o The dental occlusal view helps determine whether the fracture is vertically
favorable or unfavorable.
o The Caldwell is a coronal view that shows displacement in the horizontal
plane.
o The oblique views highlight the ramus angle and posterior body.
o The reverse Towne view depicts the condylar/subcondylar region well.
• Obtain a chest radiograph when evidence of a broken denture or missing tooth is
present.
TREATMENT
Medical therapy:
Indications for closed reduction
• Nondisplaced favorable fractures
• Grossly comminuted fractures
• Severely atrophic edentulous mandibles
• Fractures in children involving the developing dentition
• Coronoid fractures:
• Treatment of condylar fractures
Surgical therapy:
Goals: anatomic reduction of fracture segments, restoration of premorbid occlusion, and
avoidance of complications.
Timing: treatment should be instituted within 7 days.
Options:
I- Closed reduction of dentate patients
A- Erich arch bars
B- Bridle wire
• Manually reduce the segments with the use of local anesthesia.
• Loop two teeth (if available) with 24-gauge wire anterior and posterior to the fracture
segment. The closest stable teeth can be used if the adjacent dentition is poor or
missing.
• Tighten the wire in a clockwise fashion while manually reducing the segments
C- Ivy loops
• Ivy loops are used for intermaxillary fixation when full dentition is present in good
condition and the fracture is displaced minimally.
D- A variety of wiring techniques (eg, Essig wire, continuous-loop [Stout]
wiring) besides those mentioned above has been used for closed reduction
and intermaxillary fixation.
Preoperative details:
Perioperative antibiotics are recommended
appropriate diagnostic studies
A dental evaluation helps to determine the condition of the teeth and allows
appropriate fabrication of a dental appliance when needed.
Intraoperative details: Occlusion is always set first MMF by Erich arch bars are
secured with Stainless steel wires (24-26 gauge) around available molar, premolar, or
canine teeth a mucosal or skin incision Fixation
N.B.
Anterior teeth should not be used for fixation because of their conical shape,
which will cause them to be distracted out of the socket by the wire.
if a subcondylar fracture is present, immobilization must not exceed 2 weeks +
physiotherapy to prevent ankylosis of the condyle.
the course of the marginal mandibular branch of cranial nerve VII is more at
risk from an external incision than percutaneous access.
To combat the distraction of the segments, place a tension band superiorly
along with an inferior plate.
If no teeth are found proximally, a small plate may be placed on the external
oblique ridge of the mandible to act as a tension band. This concept is
exemplified in Champy's technique.
Ellis has had great success with noncompression, monocortical plates,
fashioned in 2 planes at the external oblique ridge, for nondisplaced angle
fractures. The 2-dimensional bend counteracts forces in both horizontal and
vertical planes.
At present, the resorbable plates are being used in non–load-bearing areas,
such as the periocular area.
Postoperative details:
1- Patients left in MMF should have a nasal trumpet until fully awake. Wire cutters should
be taped to the head of the bed, and a tracheotomy tray should be in the room.
2- use a 60-cc syringe, with a 3-inch trimmed red rubber catheter for feeding.
3- Patients must practice strict oral hygiene.
Follow-up care:
• Children are kept in MMF for 4 weeks, adults for 6 weeks, and elderly patients for 8
weeks.
• Patients with condylar fractures must be taken out of MMF by 2 weeks, and
aggressive physiotherapy must be instituted to prevent ankylosis.
• Measure the oral opening. Normal interincisal distance is 40mm (=35 - 55 mm)
COMPLICATIONS
Acute complications are the result of trauma itself.
Intermediate complications are caused during MMF,
late ones occur after MMF.
N.B. The overall complication rate is 3 times as high if the fracture is treated more than 10
days after initial injury.
1. respiratory distress occurs with bilateral body, parasymphyseal, or condylar fractures.
2. infection delayed union, nonunion, osteomyelitis, and loss of teeth and bone structure.
3. Exposure of implanted hardware
4. Ankylosis : interincisal opening smaller than 5 mm. either fibrous or bony.
OUTCOME AND PROGNOSIS
With proper treatment planning and surgical technique, mandible fractures have a
favorable prognosis.
FUTURE AND CONTROVERSIES
resorbable plate
Relevant Anatomy:
- Subcondylar fractures
-- Closed reduction
Most practitioners agree that most subcondylar fractures can be treated in a closed
fashion.
-- Open treatment
Options:
1. Extraoral approaches include:
2. the preauricular
3. face-lift, retroauricular
4. retromandibular
5. submandibular incisions
6. often in combination.
CONCLUSION
Perhaps the collective experience of the many surgeons who treat these fractures can best be characterized
as follows:
• Intracapsular fractures are best treated closed.
• Fractures in children are best treated closed except when the fracture itself anatomically prohibits
jaw function.
• Most fractures in adults can be treated closed.
• Physical therapy that is goal-directed and specific to each patient is integral to good patient care and
is the primary factor influencing successful outcomes, whether the patient is treated open or closed.
• When open reduction is indicated, the procedure must be performed well, with an appreciation for
the patient's occlusal relationships, and it must be supported by an appropriate physical therapy and
follow-up regimen.