1. Management of mandibular #

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

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

4. TREATMENT 3 main principles of fracture management REDUCTION FIXATION
IMMOBLIZATION

5. 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

6. 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)

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

8. Closed Reduction with IMF

9. 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.

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

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

22. 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

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

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

25. 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

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

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

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

29. 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

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

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

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

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

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

38. miniplates

39. 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

40. Lag Screw Technique

41. Lag Screw Technique

42. Lag Screw Technique

43. Lag screw

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

45. Reconstruction plate Comminuted Body/Parasymph
2.4 Locking Reconstruction plate

46. 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

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

49. External skeletal fixation

50. 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

51. 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

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

53. 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

54. 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

55. 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.

60. 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

61. 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

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

63. 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

65. 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