Mandibular fractres

Mandibular fractres - Maxillofacial Trauma Mandibular...

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Unformatted text preview: Maxillofacial Trauma Mandibular Fractures Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages with two nutrient arteries 1 Mandible in trauma Mandibular fracture is more common than middle Mandibular third fracture (anatomical factor) (anatomical It could be observed either alone or in combination It with other facial fractures with Minor mandibular fracture may be associated with head injury owing to the cranio-mandibular articulation articulation Mandibular fracture may compromise the patency of Mandibular the airway in particular with loss of consciousness the Fracture of mandible occurred with frontal impact Fracture force as low as 425 lb (190 Kg) {Condylar fracture} {Condylar 2 Fracture of condyle regarded as a safety mechanism Fracture to the patient to Frontal force of 800-900 lb (350-400 Kg) is required Frontal to cause symphesial fracture to Mandible was more sensitive to lateral impact than Mandible frontal one frontal Frontal impact is substantially cushioned by opening Frontal and retrusion of the jaw and (Nahum 1975) Long canine tooth and partially erupted wisdoms Long represent line of relatively weakness represent 3 Anatomical considerations Attached muscles: Masseter Temporalis Medial and lateral Medial pterygoid pterygoid Mylohyoid Geniohyoid and Geniohyoid genioglosus genioglosus anterior belly of anterior digastrics digastrics 4 Blood supply Endosteal supply via the ID artery and vein Periosteal supply, important in aging due to Periosteal diminishes and disappearance of alveolar artery artery Bradley 1972 Nerve Nerve Damage of inferior dental nerve Damage Facial palsy by direct trauma to ramus Damage of facial nerve in temporal bone Damage fracture fracture Goin 1980 Damage to mandibular division of facial Damage nerve nerve 5 Factors influenced site of fracture Factors and displacement and Anatomy of the Anatomy mandible and attached muscle (canine & wisdoms) wisdoms) Weakening areas of Weakening mandible (resorption and pathologyl) and Direction of force of the Direction blow blow Age of the patient 6 Types of fracture Simple Greenstick fracture (rare, exclusively in children) Greenstick Fracture with no displacement (Linear) Fracture with minimal displacement Displaced fracture Comminuted fracture Extensive breakage with possible bone and soft tissue Extensive loss loss Compound fracture Severe and tooth bearing area fractures Pathological fracture (osteomyelities, neoplasm and generalized skeletal (osteomyelities, disease) disease) 7 Sites of fractures Condyle fracture – Intracapsular fracture – Extracapsular fracture High condyle neck fracture Low condylar fracture Angle/ ramus fracture (body fracture) fracture) Canine region (parasymphesial fracture) fracture) Midline fracture (symphesis fracture) fracture) Coronoid fracture (rare) 8 Incidence of mandibular fractures Body fractures 33.6% Subcondylar fracture 33.4% Fractures at the angle 17.4% Alveolar fractures 6.7% Ramus fractures 5.4% Midline fractures 2.9% Fracture of coronoid process 1.3% Oikarinen & Malmstrom 1969 9 Favourable or unfavourable Favourable unfavourable They can be vertically or horizontally in They direction direction They are influenced by the medial pterygoidmasseter “sling” If the vertical direction of the fracture favours the If unopposed action of medial pterygoid muscle, the posterior fragment will be pulled lingually posterior If the horizontal direction of the fracture favours the If unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled lingually lingually Favourable fracture line makes the reduced Favourable fragment easier to stabilize fragment 10 10 Effects of muscles on displacement Transverse midline fracture (symphesial) Transverse stabilizes by the action of mylohyoid and geniohyoid geniohyoid Oblique fracture (parasymphesial) tends to Oblique overlap under the influence of muscles action overlap Bilateral parasymphesial fracture results in Bilateral backward displacement associated with loss of tongue control when the level of consciousness is depressed is 11 11 Condylar fractures The most common mandibular fracture The Unilateral or bilateral Unilateral Intracapsular or extracapsular Antero-medial displacement is Antero-medial common but it may remain angulated with the ramus angulated Dislocation of the glenoid fossa and Dislocation fracture of petrous temporal bone which is very rare which 12 12 Condylar fractures Sign and symptoms Swelling, pain, tenderness and restriction of movement Deviation of mandible towards the side of fracture Gagging of occlussion (premature contact on the posterior Gagging teeth) with bilateral condylar displaced or over-riding fractures teeth) Displacement of mandible toward the affected side Anterior open bite on opposite side of fracture Laceration of EAM**** Retroauricular ecchymosis**** Cerebrospinal leak and otorrhea in association with skull base Cerebrospinal fracture fracture 13 13 Condylar fractures Sequlae of TMJ injury Artheritic changes Haemartherosis, fibrosis and aknylosis Meniscal damage and detachment TMD Staph infection with condylar backward displacement and external auditory meatus injury displacement Meningitis with petrous temporal bone fracture and intracranial involvement intracranial 14 14 Coronoid process fracture: Rare fracture caused by direct trauma to Rare ramus and results from reflux contraction of temporalis temporalis Can be seen following operation of large Can ramus cyst ramus Elicit tenderness over the anterior part of Elicit ramus ramus Development of tell-tale haematoma 15 15 Fracture of the ramus: Type I Single fracture Mimics low condylar fracture that runs below the sigmoid notch below Type II comminuted fracture Common in missile injuries and appears to be with little displacement due to effects of messeter and medial pterygoid muscles messeter 16 16 Fracture of the angle and body Pain, tenderness and trismus Extra-oral swelling at the angle with obvious Extra-oral deformity deformity Step deformity behind the molar teeth Movement and crepitus at the fracture site Derangement of occlussion Intra-oral buccal and lingula heamatoma Involvement of IDN Gingival tear if fracture in dentated area Tooth involvement and possible longitudinal Tooth split fracture split 17 17 Midline fracture The most common missed fracture (always The fine crack) fine Can be symphesial or parasymphesial Can fracture fracture Commonly associated with one or both Commonly condyles fracture condyles Unilateral fracture leads to over-riding of Unilateral the fragments and bilateral may contribute in loss of voluntery tongue control in Long canine tooth represent a weak area Long and contributes to parasymphesial fracture Rarely runs across mental foramen Rarely 18 18 Midline fracture Signs and symptoms Pain and tenderness Swelling and odemea Development of step deformity Mental anesthesia Heamatoma in the floor of mouth and buccal mucosa Heamatoma Soft tissue injury of the chin and lower lip Soft If associated with condylar fractures Absence of condyle movement on the contrlateral side Deviation of mandible Anterior open bite Gagging of oclussion Limitation of mouth opening 19 19 Clinical assessment and diagnosis Clinical History of trauma History (traumatized patients with possible head injury) and facial injuries injuries Clinical Examination ▶ Extroral Extroral Inspection (assessment of asymmetery, swelling, ecchymosis, laceration Inspection and cut wounds) and Palpation for eliction of tenderness, pain, step deformity and malfunction ▶ Intra- and paraoral Intrableeding, heamatoma, gingival tear, gagging of occlussion and step deformity and sensory and motor deficiency and Radiographs 20 20 Radiographs Radiographs Plain radiograph Plain OPG Lateral oblique PA mandible AP mandible (reverse AP Townes) Townes) Lower occlusal CT scan 3-D CT imaging MRI 21 21 Principles of treatment similar to elsewhere fractures in the body Reduction of fragments in good position Immobilization until bony union occurs These are achieved by: Close reduction and immobilization Open reduction and rigid fixation Other objective of mandible fracture treatment: Control of bleeding Control of infection 22 22 Definitive treatment Definitive Soft tissue repair Soft Debridment Irrigation with saline and antibiotics Closure in layers Dressing Dressing Reduction and fixation of the jaw Reduction ▶ Close reduction and IMF (traditional method by means of manipulation) manipulation) ▶ Open reduction and semi-rigid fixation (using interOpen ossous wirings) ▶ Open reduction and rigid fixation (using bone palates osteosynthesis) osteosynthesis) Objective: Restoration of functional alignment of the bone fragments in anatomically precise position utilizing the present teeth for guidance guidance 23 23 Close reduction Arch bars – – – Jelenko Erich pattern German silver notched Cap splints ▶ IMF prior to rigid fixation IMF ▶ For the purpose of close reduction reduction 24 24 Close reduction Bonded brackets IMF screws Dental wiring: Direct wiring Eyelet wiring Local anesthesia or sedation sedation Minimal displacement IMF for 6 weeks Treatment can be performed under GA or LA and when surgery is contraindicated surgery 25 25 Fracture mandible in children Close reduction Open reduction and Open fixation fixation Plating at the inferior Plating border border Resorpable plates 26 26 Gunning’s splint Old modality Edentulous patient Rigid fixation is not Rigid possible possible To establish the To occlusion occlusion 27 27 Open reduction and fixation Intraoral approach Extraoral approach ▶ Submandibular approach approach 28 28 Rigid fixation Intraossous wiring Plates and screws Kirchener wire Lag screws 29 29 Reconstruction palate Severe trauma Loss of part of the bone 30 30 Condylar fractures Intraoral approach Ramus incision Extraoral approach Preauricular approach Retromandibular approach 31 31 IMF Transosseous wiring Circumferential wiring External pin fixation Bone clamps Trans-fixation with Kirschner wires 32 32 Osteosynthesis Non-compression small plates Compression plates Miniplates Lag screws Resorbable plates and screws 33 33 Teeth in the fracture line The fracture is compound into the mouth The tooth may be damaged or lose its The blood supply blood The tooth may be affected by some The preexisting pathology preexisting 34 34 Management of teeth retained in fracture Management line line Good quality intra-oral periapical radiograph Insinuation of appropriate systemic antibiotic Insinuation therapy therapy Splinting of tooth if mobile Endodontic therapy if pulp is exposed Immediate extraction if fracture becomes Immediate infected infected Follow up for 1 year and endodontic therapy if Follow there is a loss of vitality there 35 35 Absolute indications Longitudinal fracture Dislocation or subluxation from socket Presence of periapical infection Infected fracture line Acute pericoronitis Relative indications Functional tooth that would be removed Advanced caries or periodontal diseases Advanced Doubtful tooth which would be added to existing denture denture Tooth in untreated fracture presenting more than 3 Tooth days after injury days 36 36 37 37 ...
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