Management of mandibular #

Physiology Primary Healing In rigid fixation techniques Lag screws, compression plates, Reconstrution plate, external fixation No callus formation Question of bone resorption

Physiology Secondary bone healing Callus formation In non & semi-rigid fixation techniques Remodeling and strengthening MMF, Wire fixation, Miniplate fixation

TREATMENT 3 main principles of fracture management REDUCTION FIXATION IMMOBLIZATION

REDUCTION Definison; Restoration of a functional alignment of the bone fragments. -dentate mandible -edentulous mandible Teeth are used to assist the reduction, to check alignment of the fragments to assist in the immobilization

Types of reduction 1-CLOSED REDUCTION:- -by means of manipulation of teeth -gradual reduction of fracture by elstic traction -immobilization with intermaxillary fixation(IMF) 2-OPEN REDUCTION -operative open exploration - open reduction & internal fixation(ORIF) -with or without (IMF)

Closed Reduction Indications Favorable, non-displaced fractures Severely atrophic edentulous mandible Children with developing dentition Grossly comminuted fractures when adequate stabilization unlikely

Closed Reduction with IMF

Elastic traction MMF IN A PATIENT, CAN USES WIRE OR ELASTICS IN DOING THIS YOU WANT TO AVOID FIXING THE INCISORS AS THESE CAN BE ORTHODONTICALLY MOVED BY THE WIRES.

Open Reduction Indication Displaced unfavorable fractures Mandible fractures with associated midface fractures Associated condylar fracture When MMF contraindicated or not possible Patient comfort, nowdays becomes the standard treatment

Open Reduction Contraindications General Anesthetic risk too high Severe comminution and stabilization not possible No soft tissue to cover fracture site Bone at fracture site diffusely infected (controversial)

Teeth in line of fracture Amaratunga 16% complication rate in retained teeth 13% in removed teeth Retain teeth for 4-6 weeks if important for MMF

Teeth in # line Absolute indication for removal of a tooth from a mandibular fracture line: Longitudinal # Dislocation of teeth Periapical infection Infected # line Acute pericoronitis

Teeth in # line Relative indication for removal of a tooth from a mandibular fracture line: Functionless teeth Advanced caries Advanced periodontal disease Doubtfuf teeth which can be added to denture # presented 3 days later

Teeth in # line Management of teeth retained in # line Good-quality intra-oral radiograph Systematic antibiotics therapy Splinting of tooth if mobile Endodontic therapy if pulp is exposed Extration if fracture becomes infected Follow up

IMMOBILIZATION Definition: stabilization of displaced parts to prevent movement during healing May be used as the main method of treatment (IMF) in non displaced # Or adjunctive to internal fixation

Period of immobilization Simple guide; young adult + fracture of angle + 3 weeks early treatment tooth removed from # line

Add one week if toot retained in # line # at symphysis age 40 years or more Substract one week for childern & adolescents Retain attachment to teeth for one week

Methods of immobilization intermaxillary fixation(IMF) a-dental wiring *direct *eyelet (Ivy loops) *Eren wiring

Eyelet - Ivy loops IVY LOOPS - NOT AS STRONG AS THE ARCH BAR, USEFUL IN SELECTIVELY BRINGIN OCCLUSAL PAIRS OF TEETH TOGHETHER. APPLICATION IN KIDS WITH M IXED DENTITION, IN PARTIALLY EDENTULOUS PTS WHO WILL HAVE ADDITIONAL FORMS OF FIXATION, AND PTS WHO NEED TEMPORARY OCCLUSION WHILE OTHER METHODS ARE BEING APPLIED (PLATES OR EXT-FIX) TO MAKE; 26 GUAGE WIRE IS CUT TO 16 CM. SMALL LOOP IS FORMED HEMOSTAT. THE ENDS ARE INSERTED BETWEEN TWO SUITABLE TEETH. THE MESIAL END IS PASSE D THROUGH THE LOOP AND THEN TIGHTENED 28 GUAGE WIRES GO THROUGH THE EYE LITS FOR FIXATION

Methods of immobilization b- Arch bar Erich Jelenko German silver bar c -Cap splint d- bonded brackets d-Gunning type splint

Types of Arch Bars Erich More malleable Jelenko Stiffer/less malleable

Arch bar CLASSICAL INDICATIONS FOR CLOSED REDUCTION: GROSSLY COMMINUTED FX - HEAL BETTER IF PERIOSTEUM INTACT BUT MAY NEED EXT. FIX OR RECON. BAR FX WITH SIGNIFICANT LOSS OF SOFT TISSUE EDENTULOUS MANDIBLES - CLOSED REDUCTION WITH A GUNNING SPLINT FX IN KIDS- OPEN REDUCTION CAN DAMAGE DEVELOPING TEETH CONDYLAR FX - EARLY JAW MOBILIZATION IS REQUIRED TO AVOID ANKYLOSIS OF THE TMJ. KIDS - WEEKLY, ADULTS BIWEEKLY

Maxillomandibular fixation CANDY CANE WIRES WEAR FACETS REMEMBER, MMF CONTRAINDICATED IN EPILEPTICS, ALCHOLICS, PSHYCHIATRIC ANDFRAIL PTS WHO CANNOT TOLERATED. ALSO DIABETICS

Disadvatages of (IMF) talking diet wieght loss oral hygiene GA

Contraindication of (IMF) Psychiatric illness GI disorders involving severe N/V Severe malnutrition To avoid tracheostomy in patients who need postoperative intubation

FIXATION Def. ligation of the displaced part to adjacent non-fractured structures Proper occlusion established before reduction stabilization and fixation of the bony segment A) Non rigid fixation (need IMF) -transosseous wiring -bone clamp -transfixation using Kirschner wires - Circummandibular wiring (edentulous p’t

Intraosseous wiring Semirigid fixation Cheap Technically easy Secondary bone healing Need (IMF) Exellent occ.

B) Rigid fixation -bone plating compression plates small plates miniplates resorbable plates reconstruction Plates -lag screws -external pin fixation

Advantages of rigid fixation IMF is eliminated or reduced Improved postoperative nutrition Improved postoperative hygiene

Rigid Fixation Compression plates Rigid fixation Allow primary bone healing Difficult to bend Operator dependent No need for MMF Grossly displaed #

Rigid Fixation Miniplates Semi-rigid fixation Allows primary and secondary bone healing Easily bendable More forgiving Short period MMF Recommended

miniplates

Lag Screws Rigid fixation (Compression) Good for anterior mandible fractures, Oblique body fractures, mandible angle fractures Cheap Technically difficult Injury to inferior alveolar neurovascular bundle

Lag Screw Technique

Lag Screw Technique

Lag Screw Technique

Lag screw

Rigid Fixation Reconstruction Plates Good for comminuted fractures Bulky, palpable Difficult to bend Locking plates more forgiving

Reconstruction plate Comminuted Body/Parasymph 2.4 Locking Reconstruction plate

Bioabsorbable Plates Bulky plates, palpable Absorbable plates expensive Better in children? Use of poly-L-lactide in 69 fractures by Kim et al 12% complication 8% infection No malunion

External Fixation Alternative form of rigid fixation Grossly comminuted fractures, contaminated fractures, non-union Often used when all else fails

External skeletal fixation

Special considerations - Pediatric Rapid bony union -2week Accurate reduction is less important Growth center The most feared complication of a pedi mandible # is ankylosing of the TMJ with impact on jaw growth that causes severe facial deformity- prevent with weekly mobilization

Special considerations - Pediatric Treatment Children Most need CR + immobilization Conical shape makes arch bars less useful Rigid techniques can harm the tooth bud. Indications for ORIF Unstable fractures Not amenable to CR Bilateral fractures with gross instability Use unicortical plates Remove 6-8 weeks later

Special considerations \Edentulous fractures Bradley found absent inferior alveolar artery in 40% 60-80 yo’s Periosteal blood supply disturbed by stripping Up to 20% non-union despite type of treatment

Edentulous Fractures Chalmers and Lyons 1976 – Recommended closed reduction to preserve periosteal blood supply Chalmers and Lyons 1995 167 fractures in edentulous mandibles ORIF 82% 15% complications 12% Fibrous union

Edentulous Fractures Inferior alveolar canal more superior in location Vertical height 20mm compatible with standard plating systems Vertical height 10mm or less, likely need rib graft Plate removal after fracture healing if interferes with denture placement

METHODS OF IMMOBILIZATION 1. DIRECT OSTEOSYNTHESIS Bone Plates. Transosseous wiring. Circumferential wiring or straps. Transfixation with Kirschner wires. Fixation using cortico- cancellous bone graft. 2. INDIRECT SKELETAL FIXATION (i) Pin Fixation (ii) Bone Clamps 3. INTERMAXILLARY FIXATION USING GUNNING TYPE SPLINTS. (A) Used alone (B) Combined with other methods.

Special considerations Condylar and Subcondylar Lindhal and Hollender Closed reduction in children, teens, adult in cases of intracapsular fractures may leads to ankylosis Functional treatment for intracapsular fractures Higher incidence of postoperative sequelae, like mal-occlusion, in adults Children and Teens with less sequelae, due to more remodeling

Condylar and Subcondylar For extracapsular # closed reduction with arch bars & IMF for 2-3 weeks is the treatment of choice for youths Less effective for increasing age decreased ramus height more displaced

Condylar and Subcondylar ORIF, Absolute indications Displacement into middle cranial fossa Inability to achieve occlusion with closed reduction Foreign body in joint space

Condylar and Subcondylar Relative indications Bilateral condylar fractures to preserve vertical height Associated injuries that dictate earlier function Soft tissue swelling causing airway compromise with MMF Intracapsular fracture on opposite side where early mobilization important

Immediate Mobilization Kaplan et al. Studied ORIF in two groups, one with MMF for 2 weeks, one with immediate mobilization No statistical difference in rates of complications, postoperative pain, dental health, nutritional status