mandible fracture - management -...
TRANSCRIPT
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Mandible fracture - Management
Dr Dinesh Kumar Verma
OMFS
SDCRI, SGNR
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MANAGEMENT
OPEN ! CLOSE !
DIRECT ! INDIRECT !
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IMMEDIATE (PRIMARY)
1. ABC
2. Temporary stabilization
3. Tetanus prophylaxis
4. Antibiotics
5. Analgesics
6. Nutrition (oral / parenteral)
DEFINITIVE
1. Conservative management
2. Reduction
a. Close
b. Open
2. Fixation
a. Indirect
b. Direct
3. Rehabilitation
Physiotherapy
Reduction – bringing the bone back to its anatomic position
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Conservative management
• Some #s are stable and occlusion is not deranged. Such #s may be treated by
1. soft and liquid diet
2. preventing wide mouth opening
3. preventing more trauma to the site (avoid crowded places)
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Closed reduction & Indirect Fixation Indications
• Undisplaced favorable fractures
• Grossly communited fractures
• Significant soft tissue loss
• Edentulous mandibular fractures of
severely atrophic ridges
• Paediatric fractures with developing
dentitions.
• Coronoid process fractures
• Condylar fractures with minimal occlusal
disturbance
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Closed reduction
• Fracture is reduced by manipulating the bone without exposing the fracture site
By manipulation
By traction using elastics
• Primary aim is to get good occlusion
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ADVANTAGES: 1. No need for GA 2. Can be used in comminuted fractures 3. Can be used in continuity defects DISADVANTAGES: 1. May not always be accurate 2. Long period of IMF 3. Inadequate reduction
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Indirect Fixation
• Mandible is stabilized against maxilla or cranium
• This indirect fixation is kept for 4-6 weeks
Methods:
1. Dental wiring with IMF
2. Cap splint
3. Gunning splint
4. Circumandibular wiring
5. External fixation with head caps, halo frames, pin fixation
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DENTAL WIRING:
1. 26 gauge stainless steel wire + wire holders + wire cutter + LA \ GA
2. Scaling and polishing before wiring
3. Different types of wiring in different clinical situations
4. Wiring can be used to :
a. splint mobile teeth
b. stabilize fractures
5. Splinting upper and lower jaws after dental wiring is called as IMF (inter-maxillary fixation)
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ESSIG,S WIRING
Gilmer direct
dental wiring
Risdon,s wiring Erich,s arch bar
Different types of Dental Wiring
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IVY EYELET WIRING
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CAP SPLINTS: • Two types: 1. metallic 2. acrylic • Indications: 1. when teeth cannot provide
adequate support for wiring (mixed dentition period) 2. when jaws cannot be put in IMF
(Asthama, children etc.) • Steps 1. impression and cast 2. cast is cut at # site and brought
into occlusion with maxillary teeth 3. cast mounted on articulator 4. splint fabricated (metallic or
acrylic) 5. # reduced and splint attached to
teeth (with cement)
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GUNNING SPLINTS: Indications : edentulous jaw # where open
reduction and fixation cannot be done
Steps in making splint 1. impression of the upper and lower
jaws 2. cast is made 3. cast is cut at # site and realignment
done 4. upper and lower base plates with
acrylic 5. posterior bite blocks made with
hooks on buccal side 6. heat curing done 7. upper and lower splints attached to
jaws with PERALVEOLAR wiring (maxilla) and
circumandibular (mandible) 8. hooks of upper and lower splints tied
together
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Circumandibular wiring
Awl
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HALO FRAME
EXTERNAL PIN FIXATION
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Biphasic pin fixation
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Open reduction and direct fixation • Access to the fracture site through wound or incision
• Reduction performed under direct vision
• Direct Fixation of the fracture fragments
• Suturing
INDICATIONS:
1. Displaced/ undisplaced favourable/unfavourable #
2. When IMF is contraindicated
3. Multiple #s of mandible
4. Associated #s of midface
ADVANTAGES
1. Accurate reduction and fixation
2. Direct visibility of the fracture
3. Faster functional rehabilitation
DISADVANTAGES
1. Surgical approach and associated complications
2. expensive
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SURGICAL APPROACH TO MANDIBLE
1. EXTRAORAL
a. Through lacerations
b. Submandibular incision (Risdon,s)
c. Modified Risdon,s
d. Retromandibular incision (Hind’s)
e. Submental incision
2. INTRAORAL
a. Through lacerations
b. Vestibular incisions
c. Anterior border of ramus incision
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Risdon’s Submandibular approach
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HINDS RETROMANDIBULAR APPROACH
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Vestibular incision
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Anterior border of ramus incision
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DIRECT FIXATION
• Transosseous wiring
• Miniplate & Microplates
• Reconstruction plates
• Compression plates (Dynamic & Eccentric dynamic)
• Locking plates
• Biodegradable plates
• Titanium mesh
• Lag screw osteosynthesis
• Intramedullary k-wire fixation
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TRANSOSSEOUS WIRING
First developed by Sir William
Kelsey fry
Indications
• Mostly used for reduction of posterior
edentulous mandibular fragment with
significant displacement
• For immobilisation of major fragments
when soft tissue or muscle trapped in
between the fragments.
Contraindications
• Not used for compound fractures
LOWER BORDER WIRING
UPPER BORDER TRANOSSEOUS WIRING
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Indications : 1. all dentulous and edentulous #s Special consideration: 1. in children plating should be
done at lower border to prevent damage to tooth bud
2. in infected #s compression plating is preferred because it gives more rigid fixation
Advantages: 1. plates are thin. No need to take
them out 2. easy to adapt to the bone 3. intraoral approach 4. less chance of damage to inferior
alveolar vessels and nerve
CHAMPY’S LINES OF
IDEAL OSTEOSYNTHESIS
Forces on the Fractured Mandible
Miniplate & Microplates (0.5 to 0.9mm)
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RECONSTRUCTION PLATES (2.7mm)
Indications:
Severely oblique fractures ,
communited fractures and
fractures with bone loss
(compression plating will
cause undesirable overlapping
and collapse of the bony
segments. Miniplates will be
instable and will not provide
adequate stability)
A MINIMUM OF THREE SCREWS SHOULD BE PLACED ON EITHER SIDE
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LOCKING PLATES
These plate have threaded holes through which when specially
Designed screws pass they get locked into them independent of
The bone . the screws are anchored seperately to the plate and
bone .
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COMPRESSION PLATING SYSTEM (1.5 -2.7mm)
• Two types:
1. dynamic compression plate (DCP)
2. eccentric dynamic compression plate
(EDCP)
• Principle:
the holes in the plate are bevelled at 30-
45deg. Because of this the screw first enters the bony cortex (bicortical) and then moves the bone towards the depth of bevel
• These plates are bulky and give a rigid fixation.
• Most of the time they require extra oral incision
•
Now not used frequently
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TENSION BAND PRINCIPAL
When a DCP is tightened
Tension forces on superior
Border increases
By 10-65 %
Applying a T.B. To the superior
Surface of the fractured
Mandible , axial compression
Occurs across the full width
Of the mandible, preventing
Distraction at the occlusal border
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ECCENTRIC DYNAMIC COMPRESSION PLATES
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Lag screw osteosynthesis • Main indication : in oblique #s • Any screw that has uniform
diameter along its length can be used as a lag screw
• The threads of the screw engage only one fracture fragment (the fragment away from the screw head)
• The hole in the other fragment serves as GLIDING hole (diameter larger than screw)
• The cortex near the screw head has counter sink for the screw head
• The final tightening of the screw compresses the two fragments together tightly
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INTRAMEDULLARY KIRSHNER
WIRE
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BIODEGRADABLE PLATES
POLYMERS OF PDS , POLYGLYCOLIC ACID , POLYLACTIC ACID . NEWER ONES
INCLUDE SELF REINFORCED PGA / PLA
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Fracture of edentulous mandible • Bilateral molar regions prone to # due to atrophy • The mylohyoid and digastric muscles pull the
anterior part down (BUCKET HANDLE #) • This extreme displacement may cause respiratory
obstruction Difficulties : 1. Healing is delayed 2. periosteal blood supply in old age – raising
periosteal flap for plating may compromise blood supply
Management: 1. closed reduction with gunning splint 2. Open reduction and miniplate fixation 3. comminuted #s – open reduction and fixation 4. severely atrophic mandible – open reduction with bone grafting
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Mandibular #s in children
Applied anatomy :
• the bone is elastic and soft so green stick # is more common
• The neck of condyle is thick so # of articulating surface is common – risk of TMJ ankylosis
• Because of change from deciduous to permanent dentition the occlusion can adapt to minor discrepancies.
• Faster healing
Management :
1. Green stick #s with no occlusal discrepancies – no fixation
2. Closed reduction with cap splint is preferred
3. Long duration IMF is not applied due to chance of TMJ ankylosis
4. Open reduction is used only in multiple displaced #s. Plate is fixed at lower border to prevent damage to teeth buds
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Fracture of condyle Clinical features:
1. posterior gagging of occlusion (early contact of molars)
2. deviation of mandible towards the side of # (on mouth opening)
3. anterior open bite
4. trismus
5. condylar movements not felt
6. bleeding from ear
7. preauricular tenderness
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MANAGEMENT:
1. Children – avoid IMF. Sometimes IMF is applied for pain control for 5-7 days. Functional therapy
2. Adults unilateral – IMF for 3-4 weeks followed by functional therapy. Or
open reduction and fixation. Required in displaced and dislocated #s
3. Adults bilateral – at least one side should be done by open reduction and fixation with IMF for 3-4 weeks. Or
open reduction and fixation for both sides
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COMPLICATIONS
1. Delayed union – when the # healing takes more than 6 weeks. Due to infection, inadequate fixation, diseases affecting bone vascularity and healing (diabetes, osteopetrosis), smoking
2. Malunion – when the reduction is not accurate the bone heals at that inaccurate site
3. Non-union – when there is no union. Due to infection, inadequate fixation, diseases affecting bone healing, soft tissue between # fragments
4. Infection and osteomyelitis 5. Trismus 6. Nerve injury 7. Malocclusion
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TITANIUM HOLLOW SCREW OSSEOINTEGRATED
RECONSTRUCTION PLATE
The thorpe system is a two Stage screw
system. The first screw is a hollow
Plasma coated screw which Passively
anchors the plate To the bone . then
the Conical expansion screw is Placed
in the head of the Anchor screw to fix
the Screw to the plate
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TEETH IN THE LINE OF #
Indications for removal
1. Vertical # involving crown and root
2. Complete subluxation of tooth
3. Teeth with large periapical pathology
4. Grossly infected # line
5. Bad periodontal condition with grade III mobility
6. Advanced caries
7. Root stumps