Dr. Amit T. SuryawanshiDentist, Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.comMobile No - 9405622455

MANAGEMENT of mandibular fracture depends on knowlege with dental anatomy, head and neck physiology and occlusion

The mandible is the second most commonly fractured bone in maxillofacial skeleton because of its position of prominence.

The location and pattern of the fracture are determined by the mechanism of injury, and the direction of the vector of the force.

Advancement related to management- Rigid internal fixation.

U – shaped body Vertically directed

ramiCoronoidCondyle

Oblique line Mental foramen

• Mandibular foramen• Lingula• Pterygoid fovea• Mylohyoid line• Fossae

– Submandibular– Sublingual– digastric

• Mental spines– Genioglossus– Geniohyoid

Muscle Sling• Vertical rami totally

embedded within sling– Masseter– Pterygoids

• Angle and condylar neck not entirely protected by sling– Bony trabecular crests,

ridges, lines

• Trabeculae resist normal tension, compression, and rotation of mastication– Little resistance to lateral

stress from blunt trauma

Fracture Distraction and Favorability

Innervation

• Mandibular nerve through the foramen ovale

• Inferior alveolar nerve through the mandibular foramen

• Inferior dental plexus• Mental nerve through the mental foramen

Arterial supply

• Internal maxillary artery from the external carotid

• Inferior alveolar artery through the mandibular foramen

• Mental artery through the mental foramen

• 1650 BC –Edwin smith surgical papyrus

• Hippocrates- cicumferential dental

• 1275 - Salicetti-IMF

• Gilmer- To apply correctly

• 20 th century –MM fixation or Gunning type splints for the edentulous.

• 1968 - Luhr& Spiessl -idea of using miniature bone plates

1976 – Spissel in german speaking countries

Concept-based on orthopedic principles and trying to fit orthopedic material to the complex and very different structure of facial skeleton.

Absolute interfragmentory immobilization is achieved with no resorption of fracture ends, no callous formation, and intracortical remodelling across the fracture site whereby the fractured bone cortex is gradually replaced by new Haversian systems .

“Callous formation considered a failure”

• Plates are bulky, very large to use, and always required large skin incision. Neck scar undesirable

• Nerve damage –both inferior alveolar and Facial• Infection of the plates • Resurgery to remove plates always necessary.

Biomechanically in a wrong position

1973- Michelet introduced a new technique, using smaller Miniplates in intraoral approach.

Principle- like a suspension bridge to define tension in a fracture.

Champy et al – refined and researched

Bone tensile failure results from tensile strain rather than compressive strain

Similar to arch-distributes the force of impact throughout its length.

Foramina, sharp bends, ridges and reduced cross sectional dimension – tensile strain concentration

WIDE RANGE of magnitude and direction of impacts

Condition of the dentition, position of the mandible at the time of impact and influence of associated soft tissues.

Relation with Dentition Presence of posterior teeth - reduce condylar

fracture Impacted third molar-area of internal

weakness

Assault Road traffic accidents Sports injuries Industrial or work place accidents Falls, which may be a trip or a medical

syncope .

At least two films at right angles Standard-OPG & reverse townes # parasymphysis-occlusal film CT-cost sensitive - concomitant midface fractures - communited fractures - condylar fractures -3D reconstruction - cervical spine injury - very young patients- under sedation

Change in occlusion Paresthesia, anesthesia Localized pain Altered range of motion or deviation of the

mandible. Changes in facial contour ,symmetry and dental

arch form Lacerations, hematoma, sub lingual echymosis Mobility of the tooth Crepitus or mobility of bone segments Palpable bony steps.

Simple :no external contamination Compound: communication with external environment. Comminuted: multiple segments of bone that have been

splintered or crushed. Green stick: one cortex is compromised ,but the other is

intact. Pathologic: pre existing disease or lesion associated with a

fracture site. Multiple: two or more lines of fracture on the same

bone ,but not communicating with one another. Impacted: one segments is telescoped within the adjacent

fragment. Atropic: decreased bony mass Indirect: fracture is present at the site distant from the

point of impact Complex: associated soft tissue injury

ANATOMICSymphysisBodyAngleRamusCoronoidCondylar processDentulousPartially edentulousDentulousPrimary or mixed dentition

BIOMECHANICALFAVORABLE : muscle pull will tent to keep the fracture reduced.UNFAVORABLE: muscle pull will tent to distract the segments.

Krugers classification Simple/closed Compound/open Comminuted Complicated Impacted Greenstick Pathological

Rowe & Killeys classification-Single unilateral-Double unilateral-Bilateral-Multiple

Kazanjian & converse classification-Class 1-Class 2-Class 3

Symphysis region, which is formed by the bony union of 2 halves in the centre at the first year of life.

Parasymphysis region, which lies lateral to the mental prominence.

The angle of the mandible The neck of the mandibular candyle.

G. Acc. To presence or absence of teeth in relation to # line.

Kazanjian Classification:Class 1: When teeth are present on both sides

of the fracture line.Class 2 : When teeth are present only on one

side of the fracture line.Class 3: When both fragments on each side of

fracture line are edentulous.

Clinical Examination:1. Immediate assessment : Pts with

maxillar injuries may have sustained other bodily injury which may be a threat to life therefore they should be considered first.

2. General Clinical Examination : # of the mandible are caused by trauma & the patient may also suffer from injury elsewhere in the body.A thorough general assessment of the patient should be carried out.

3. Local examination of the fracture Extra oral examination:Most of the physical signs of a fractured

bone result from the extravasation of blood from the damaged bone ends.

Swelling and ecchymosis indicate the site of any mandibular fracture.

There may be obvious deformity in the bony control and if considerable displacement has occurred, the pt’s mouth hangs open.

Intraoral Examination:The buccal and lingual sulci are examined

for ecchymosisOcclusal plane is next examined Individual teeth along with luxation and

subluxation are noted.Mobility is checked of the possible fracture

sites.

Signs and symptoms of mandibular fractures at various fracture sites:

1. Dentoalveolar : Those in which avulsion, subluxation or fracture of the teeth occur in association with the alveolus.

2. Fracture of the coronoid process: It is usually considered to result from reflex contracture of the powerful ant fibres of temporalis muscle. It is diff to diagnose clinically. There may be tenderness over the area, painful limitation of movement, esp protrusion of the mandible.

3.Fracture of the ramus : Swelling and ecchymosis is seen extraorally and intraorally. Tenderness, severe trismus is usually present.

4.Fracture of the angle : Swelling at the angle externally and there may be obvious deformity. Hematoma, derangement of occlusion. On palpation, tenderness and crepitus is elicited, movements are painful.

5. Fracture of the body: Similar to fracture of the angle.Even slight displacement causes derangement of occlusion.

Fracture Frequency

Evaluation

– Pain, malocclusion, trismus, V3 sensory deficit

– History of TMJ (earlier mobilization)– Blow to face favors parasymphyseal fracture

and contralateral angle fracture– Fall to chin (bilateral condylar fractures)

Evaluation

• Previous occlusion (Class I-III)• Psychiatric, nutritional, gastrointestinal, seizure disorders• Previous facial trauma• Other injuries (c-spine, intra-abdominal, likely prolonged intubation)

Evaluation - History

• Mechanism of injury

_ multiple comminuted fx– Fist often results in single, non - displaced

fx– Anterior blow to chin - bilateral condylar fx– Angled blow to parasymphysis can lead to

contralateral condylar or angle fx– Clenched teeth can lead to alveolar

process fx

Physical Exam - Occlusion

• Change in occlusion - determine preinjury occlusion• Posterior premature dental contact or an anterior

open bite is suggestive of bilateral condylar or angle fractures

• Posterior open bite is common with anterior alveolar process or parasymphyseal fractures

• Unilateral open bite is suggestive of an ipsilateral angle and parasymphyseal fracture

• Retrognathic occlusion is seen with condylar or angle fractures

• Condylar neck fx are assoc with open bite on opposite side and deviation of chin towards the side of the fx.

Physical Exam

• Anesthesia of the lower lip• Abnormal mandibular movement

– unable to open - coronoid fx– unable to close - fx of alveolus, angle or

ramus– trismus

• Lacerations, Hematomas, Ecchymosis• Loose teeth

• Palpation

Physical Exam

• Dental Exam

– Lost, fractured, or unstable teeth– Dental Health– Relation to fracture– Quantity

Malocclusion

Physical Exam, Cont

• Inability to open the mandible suggests impingement of the coronoid process on the zygomatic arch

• Inability to close the mandible suggests a fracture of the alveolar process, angle, ramus or symphysis

Lacerations and Ecchymosis

• Mandibular fractures can often be directly visualized beneath facial lacerations.

• Lacerations should be closed after definitive therapy of the fracture• Ecchymosis is diagnostic of symphyseal fractures

Palpation

• The mandible should be palpated with both hadns, with the thumb on the teeth and the fingers on the lower border of the mandible. Slowly and carefully place pressure, noting the characteristic crepitation of a fracture

Techniques for mandibular fractures with closed reduction

Direct interdental wiring [Gilmer]1.First aid method for temporary immobilization.

2.5cm of .35mm wire used.

3.ADVANTAGE: Simple technique.

4.DISADVANTAGE: A loose or broken wire cannot be replaced without removing and replacing others

GILMER WIRING

Button wiringLeonard 1977

This technique tided the problems associated This technique tided the problems associated with eyelet wiring.with eyelet wiring.

1.Eyelet frequently drawn into the 1.Eyelet frequently drawn into the interdental space.interdental space.

2.Elastic traction using eyelets is time 2.Elastic traction using eyelets is time consuming.consuming.

3.In case of GA removal of throat pack must 3.In case of GA removal of throat pack must precede wire tightening during which blood& precede wire tightening during which blood& saliva may pool into the oropharynx.saliva may pool into the oropharynx.

1.Titanium buttons 8mm diameter,2mm deep. 1.Titanium buttons 8mm diameter,2mm deep.

2.Button ligated on teeth like eyelets.2.Button ligated on teeth like eyelets.

Disadvantages

Cannot be used in….Cannot be used in….

1.Posterior cross bite.1.Posterior cross bite.

2.Anterior overbite.2.Anterior overbite.

Due to lack of space for Due to lack of space for buttons.buttons.

3.Lone standing teeth.3.Lone standing teeth.

The clove hitchThe clove hitch

Modification when few teeth are absentModification when few teeth are absent

Continuous or multiple loop Continuous or multiple loop wiring {wiring {Stout 1943}Stout 1943}

Obwegeser’s methodObwegeser’s method

Arch barsArch bars

IndicationsIndications

1.Insufficient number of teeth.1.Insufficient number of teeth.

2. Unfavorable teeth distribution.2. Unfavorable teeth distribution.

3.Simple or multiple dentoalveolar fractures.3.Simple or multiple dentoalveolar fractures.

4.As an integral part of skeletal fixation.4.As an integral part of skeletal fixation.

5.Inadequate lab facilities.5.Inadequate lab facilities.

6.To reduce preoperative time6.To reduce preoperative time

Types of arch barsTypes of arch bars

1.a:1.a:Prefabricated Prefabricated

b:b:Custom made

2.a:Erich

b:Jelenco

c:Krupps

Arch barsArch bars

JelencoJelenco Custom madeCustom made

Jelenco with modified upper dentureJelenco with modified upper denture

Acrylated archbarsAcrylated archbarsSchuchard’s modification 1956Schuchard’s modification 1956

1.Aluminium-brass alloy wire 2mm in diameter used.

2. 6 pieces of 1.4mm wire soldered to the main wire

3.Advantages:

a.Does not compress on gingival tissue.

b.Reduced chances of pressure necrosis and stagnation.

c.Enhanced patient comfort.

Stanhope’s modification

1.Extraoral construction

2.Acrylic at the interdental spaces secures the arch bar in position

Directly bonded archbars

1.Orthodontic mesh welded on to the back of archbar.

2.Made in sections.

3.Bonded by composite or acrylic.

4.Not popular due to the difficulty in maintaining dryness.

Cap splintsCap splints

1.Metallic &acrylic types used.1.Metallic &acrylic types used.

2.Occlusal relief given.2.Occlusal relief given.

3.Used commonly in children.3.Used commonly in children.

4.4.Steps in fabrication:Steps in fabrication:

ImpressionImpression modelmodel Splint fabricationSplint fabrication

cementationcementation IMFIMF

CapsplintsCapsplints

5.Black copper cement preferred due to…5.Black copper cement preferred due to…

Adeqate bonding,anticariogenicity.Adeqate bonding,anticariogenicity.

6.Disadvantages:reduced working 6.Disadvantages:reduced working time,stains restorations,sticky.time,stains restorations,sticky.

7.Polycarbonate cement:cleaner field but 7.Polycarbonate cement:cleaner field but reduced bonding.reduced bonding.

8.Acrylic capsplints have no cement tooth 8.Acrylic capsplints have no cement tooth interface,so food enters the interface &this interface,so food enters the interface &this leads to fetor orisleads to fetor oris

Metallic capsplintMetallic capsplint

Alternative techniques for the Alternative techniques for the edentulous mandibleedentulous mandible

INDICATION:Usually used for unilateral or INDICATION:Usually used for unilateral or bilateral fractures where the areas lying bilateral fractures where the areas lying proximal to the fracture can be fixed by IMF.proximal to the fracture can be fixed by IMF.

CONTRAINDICATIONS:CONTRAINDICATIONS:

1.Unfavorably displaced fractures lying 1.Unfavorably displaced fractures lying outside the denture bearing area.outside the denture bearing area.

2.Projectile injuries involving severe bone 2.Projectile injuries involving severe bone loss.loss.

Gunning type splints:Gunning type splints:

3.Extreme atrophy of the jaw bones.3.Extreme atrophy of the jaw bones.

Types:Types:

1.Pre-existing dentures.1.Pre-existing dentures.

2.custom made.2.custom made.

3.Prefabricated.3.Prefabricated.

4.Disposable edentulous 4.Disposable edentulous trays without their trays without their handles.handles.

Limitations of IMFLimitations of IMF

1.Preexisting malocclusions are difficult to 1.Preexisting malocclusions are difficult to redefine.redefine.

2.Quality and quantity of teeth.2.Quality and quantity of teeth.

3.Displacement due to muscle attachments.3.Displacement due to muscle attachments.

4.Difficult to treat combined double jaw 4.Difficult to treat combined double jaw fractures.fractures.

5.Vomiting,swelling during immediate post-5.Vomiting,swelling during immediate post-op.op.

6.Respiratory problems like asthma.6.Respiratory problems like asthma.

7.Patients dislike it.7.Patients dislike it.

Alternative techniques for Alternative techniques for mandible-open reductionmandible-open reduction

Transosseous wiring:Transosseous wiring:

INDICATIONS:INDICATIONS:

1.Control of edentulous posterior fragment.1.Control of edentulous posterior fragment.

2.Edentulous mandibular fractures.2.Edentulous mandibular fractures.

3.Grossly comminuted fractures.3.Grossly comminuted fractures.

4.Control of lower border when upper 4.Control of lower border when upper border has been fixed by coventional border has been fixed by coventional methods.methods.

Upper border wiringUpper border wiring

Lower border Lower border wiringwiring

Open Reduction

• 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

Rigid Fixation

• Compression plates

– Rigid fixation– Allow primary bone healing– Difficult to bend– Operator dependent– No need for MMF

Rigid Fixation

• Miniplates

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

Rigid Fixation

• Reconstruction Plates

– Good for comminuted fractures– Bulky, palpable– Difficult to bend– Locking plates more forgiving

External Fixation

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

External Fixation

Teeth in line of fracture

• Keep teeth if

– Previously healthy– Peridontal plexus intact– No major structural injury– Tooth does not interfere with reduction of

fracture

Bioabsorbable Plates

• Plating can relieve stress, no bone remodeling • Bulky plates, thermal sensitivity, 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

• Cases in which mandible appears stable• Favorable fracture pattern• No displacement of bony segments• No change in occlusion• Motivated patient• Management - Careful observation - Liquid diet, limited physical activity

Remain prepared to intervene

Some type of external stabilization Common-eyelet wiring, Erich arch bars, ivy

loops, stout wiring, Ernst and Gilmer ligatures

Bonded arch bars modified bone screws Massive communition of mandible with

significant tissue loss- external pin stabilization

Nondisplaced ,stable fractures Grossly communited fractures-periosteal

stripping may devitalize small bone fragments Gunshot wounds Compromised soft tissue matrix

-Result of pre existingcondition(radiotheraphy)-Avulsive loss of tissue

Pediatric fractures

Open approach gives best visuvalization,anatomical reduction

Trans oral apporach-5to 7mm from mucogingival junction

Percutaneous trocar Skin incisins-reserved for condylar

neck,grossly communited factures,severly atrophic mandible(<10mm height)

Heavy training elastics-neuromuscular training

Screw itself has a threaded head which engages the plate

Plate does not have to be ideally adopted Heavier stronger design Elimination of bone resorption Role in gross communition continuity defects prior to formal

reconstruction

Excellent alternative in selected cases of anterior mandible #

Posterior mandible and ramus-technically difficult

Trocar may necessary

Technically difficult to repair, associated complications are frequent.

REASONS (1)Force is necessary to create this type of

injury carries with a higher degree of surrounding tissue injury

(2)Increase difficulty with reduction and stabilization of multiple fragments.

(3)High risk for ischemic compromised fragments to necrosis.

Reduced vascularity to the mandible due to the decrease in flow from inferior alveolar artery.

Blood supply is mainly periosteal Dense sclerotic bone and decreased osteoblastic

activity Less bone area contact Systemic compromise Most edentulous fractures –at body or condyle Mid body or saddle –weakest point

Closed reduction with the use of prosthetics(existing dentures or Gunning splints.)

External fixation Wire fixation Open reduction with internal fixation: 1. Reconstruction plates (2.3 , 2.7 mm

diameter screws) 2. Mandible fixation plates (2.0, 2.4 mm

diameter screws) - Dynamic compression plates - Plates at both inferior and superior

borders 3. Bone grafting and miniplate fixation.

MALUNION NONUNION

It is a site with high incidence of altered fracture healing .

Infection it is the main contributor.

OTHER CAUSES

-poor apposition

-poor immobilization

-presence of foreign bodies

-unfavorable muscle pull on fracture segments

-aseptic necrosis of bone fragments

-soft tissue interposition

-malnutrition by debilitation.

Most common cause for nonunion is residual mobility across fracture.

Rigid internal fixation with a reconstruction plate

External fixation Particulate bone grafting or Cortical bone

grafting to the defect. Polyglycolic or polylactate mesh as a carrier

for cancellous bone graft. Composite free flap reconstruction.

Most common complication of surgical interaction.

Risk factor- -Communited fracture-Active substances abuse.-Noncompliance with post operative regimens.-Significant delayed treatment

MANIFESTATIONS Cellulitis, abscess formation, fistula,

osteomyelitis and rarely necrotizing fascitis

1. The development of adequate drainage2. Removal of the source3. Appropriate antibiotic coverage

Clinical examination &plain radiographic assess the status of fracture segments and hardware.

Specimen for bacterial culture & sensitivity CT and MRI – if adjacent soft tissues are

involved. Antibiotic of choice PG / clindamycin

No improvement in the level of sensation ,after 6-8 weeks –baseline neurologic function.

Surgical repair is considered after 6 months.

APPROPRIATE DIAGNOSIS ANATOMIC REDUCTION STABILIZATION OF THE FRACTURED SEGMENTS

USING OCCLUSION AS A GUIDE. STABLE INTERNAL FIXATION

Interdental eyelet wiring ivy loop methodivy loop method

1.Presence of suitable number,quality and 1.Presence of suitable number,quality and shape of teeth.shape of teeth.

2.Favorable fracture lines with minimal 2.Favorable fracture lines with minimal displacement.displacement.

3.Not satisfactory for fractures of ascending 3.Not satisfactory for fractures of ascending ramus and condyleramus and condyle

4.Occlusion is the key.4.Occlusion is the key.

Complications

• Socioeconomic groups• Infection (James, et. al.)• Delayed healing and malunion. Most commonly caused by infection

and noncompliance• Nerve paresthesias in less than 2%

Conclusions

• With multiple techniques available, there is still controversy over the best treatment for each type of mandible fracture

– The decision is a clinical one based on patient factors, the type of mandible fracture, the skill of the surgeon, and the available hardware

– Further studies are in progress

Reduction: Reduction of a fracture means the restoration of functional alignment of the bone fragments. • In the dentate mandible reduction must be anatomically precise.• The teeth are used to assist the reduction, check alignment of the fragments and assist in the immobilization.

• Whenever the occlusion is used as an index of accurate reduction, it is important to recognize any pre- existing occlusal abnormalities such as an anterior or lateral open bite.

• Widely displaced, multiple or extensively comminuted fractures may be impossible to reduce by means of manipulation of the teeth alone, in which case open operative exploration becomes necessary.

• Gradual reduction of fractures can also be carried out by elastic traction.

Following accurate reduction of the fragments, the fracture site must be immobilized to allow bone healing to occur.

Period of Immobilization:The period of stable fixation required to ensure full restoration of function varies according to the site of fracture, the presence of otherwise of retained teeth in the line of fracture, the age of the patient and the presence or absence of infection.

A Simple guide to the time of immobilization for fractures of the tooth bearing area of the lower jaw is as follows:

Young adultWithFracture of the angleReceivingEarly treatment 3 weeksIn whichTooth removed from fracture line.

If :Tooth retained in fracture line : add 1 week.Fracture at the symphysis : add 1 weekAge 40 years and over : add 1 or 2 weeksChildren and adolescents : subtract 1 week.

a. Osteosynthesis without intermaxillary fixation:

i. Non – compression small platesii. Compression plates:iii. Mini – platesiv. Lag screws

b. Intermaxillary fixation:i.Bonded bracketsii. Dental wiring:Direct :Eyelet:

iii. Arch barsiv. Cap splints

c. Intermaxillary fixation with osteosynthesis:i. Transosseous wiringii. Circumferential wiringiii. External pin fixation iv. Bone clamps;v. Transfixation with Kirschner wires.

Osteosynthesis without intermaxillary fixation:Non Compression small plates: Made of stainless steel or Titanium. They are available in various sizes and shapes. These plates are however, larger than the more recently designed mini – plates,which is used to incorporate compression across the fracture.

Compression Plates:•Bony union is achieved by firm approximation of the fragments under pressure.•They are of 2 types – Dynamic compression plate(DCP) & Eccentric dynamic compression plate (EDCP)•It is necessary to apply these plates to the convex surface of the mandible at its lower border.•There is a tendency for the upper border & the lingual plate to open with the final tightening of the screws.leading to distortion of occlusion & opening of the fracture line.

• In order to overcome these problems various designs of compression plate have been devised. • It is necessary to apply a tension band at the level of the alveolus before tightening the screws. •This can be in the form of an arch bar ligatured to the teeth or as a separate plate with screws penetrating the outer cortex only.•Disadvantages :The procedure tends to be lengthy & needs expertise. The fixation plate is bulky.

Mini – plates:•Champy et al. (1978) introduced a mini-plate system customised for use in mandibular fractures.

• Originally fashioned in stainless steel, they are now widely available in titanium.

• Non-compression mini-plates with screw fixation confined to the outer cortex allow the operator to place plates both immediately sub-apically as well as at the lower border.

•All plates can be inserted by an intra-oral approach without the need for intermaxillary fixation.•Mini –plate osteosynthesis can be used in virtually all types of mandibular body fracture. • Plates can be inserted via an intra – oral approach using special cheek retractors and protective sleeves passed through the soft tissues of the cheek. It is only necessary to reflect periosteum from the outer plate of bone.•The plates can usually be left in permanently without causing trouble.

Lag screws•A few oblique fractures of the mandible can be rigidly immobilized by inserting two or more screws whose thread engages only the inner plate of bone.•The hole drilled in the outer cortex is made to a slightly larger diameter than the threaded part of the screw.•When tightened the head of the screw engages in the outer plate and the oblique fracture is compressed. At least two such lag screws are necessary to achieve rigid immobilization.

Intermaxillary fixation:Bonded modified orthodontic bracketsFractures with minimal displacement in patients with good oral hygiene can be immobilized by bonding a number of modified orthodontic brackets onto the teeth and applying intermaxillary elastic bands.

Dental wiring is used when the patient has a complete or almost complete set of suitably shaped teeth.0.45nim soft stainless steel wire has been found effective.

Direct Wiring

•The middle portion of a 6 inc (15cm) length of wire is twisted round a suitable tooth and then the free ends are twisted together.•Similar wires are attached to other teeth elsewhere in the upper and lower jaws and then after reduction of the fracture the plaited ends of wires in the upper and lower jaws are in turn twisted together.

Interdental eyelet wiring : • Eyelets are constructed.• These eyelets are fitted between two teeth.• About five eyelets are applied in the upper and five in the lower jaw and then the eyelets are connected with tie wires passing through the eyelets from the upper to the lower jaw.

Arch Bars• Useful when the patient has an insufficient number of suitably shaped teeth to enable effective interdental eyelet wiring.• Many varieties of prefabricated arch bar are available and the Winter, jelenko and Erich type bars have all proved effective.

• Arch bars should be cut to the required length and bent to the correct shape before starting the operation.

• As the mandibular fragments are displaced owing to the fracture the bar is bent so that it fits around the upper arch.

• The arch bar is wired to successive teeth on each side working backwards to each third molar area.

• It is important to retighten each wire before the twisted portion is cut and trucked into a position where it will not irritate the tissues.

Cap Splints:Silver cap splints were for many years the

method of choice for the immobilization of all jaw fractures.

Indications for the use of cap splints are as follows:

1. Patients with extensive and advanced periodontal disease when a temporary retention of the dentition is required during the period of fracture healing.

2. To provide prolonged fixation on the mandibular teeth in a patient with fractures of the tooth – bearing segment and bilateral displaced fractures of the condylar neck.

Intermaxillary Fixation with osteosynthesis: Although some simple fractures of the tooth –

bearing portion of the mandible can be accurately and adequately treated by intermaxillary fixation alone, in practice that fixation is frequently reinforced by open reduction of the fracture and some type of non – rigid osteosynthesis

Transosseous Wiring: • In principle holes are drilled in the bone ends on either side of the fracture line after which a length of 0.45mm soft stainless steel wire is passed through the holes and across the fracture.

• After accurate reduction of the fracture the free ends of the wire are twisted tightly,cut off short and the twisted ends tucked into the nearest drill hole.

Circumferential wiring:A few oblique fractures of the body of the mandible can be reinforced by passing a length of 0.45mm soft stainless steel wire circumferentially.External pin fixation:

The technique consists of inserting into each major bone fragment a pair of 1/8 inch (3mm) titanium or stainless steel pins which diverge from each other, but are connected by a cross bar which is attached to each pin by means of universal joints.

The main indications for the use of pin fixation for mandibular fractures may be summarized as follows:

1. To provide fixation across an infected fracture line

2. To maintain the relative position of major fragments in extensively comminuted fractures.

3. In the treatment of bimaxillary fractures when a ‘box frame’ form of fixation is employed.

Fractures of the edentulous mandible•The physical characteristics of the body of the mandible are altered considerably following the loss of the teeth.

• Vertical depth of the subsequent denture – bearing area is reduced.

•The endosteal blood supply from the inferior dental vessels begins to disappear.

Reduction• For the reasons already stated, precise anatomical reduction is not necessary.• The reduced cross- section of bone fractures of thin mandibles means that displacement occurs more readily and in this situation open reduction may be only way to restore adequate bone contact.

Methods of immobilizationThere is no uniformly accepted method.The methods of treatment currently in

common uses are:1. Direct osteosynthesis:a. Bone platesb. Transosseous wiring.c. Circumferential wiring or strapsd. Transfixation with Kirschner wirese. Fixation using cortico – cancellous bone

graft.

2. Indirect skeletal fixation:a. Pin fixationb. Bone clamps3. Intermaxillary fixation using gunning –

typesplints:a. Used aloneb. Combined with other methods.

Direct osteosynthesis

Bone plates:Bone plates are particularly useful for

displaced fractures of the edentulous mandible, particularly those at the angle.

The reduced depth of bone in the edentulous mandible favours the use of non – compression mini-plates.

Transosseous Wiring

Many simple edentulous fractures can be satisfactorily immobilized by direct transosseous wires.

Transosseous wires do not provide rigid osteosynthesis and supplementary fixation may be necessary.Circumferential wiring or straps:

Oblique fractures of the edentulous mandible can be most effectively and simply immobilized by circumferential wires.

Primary Bone Grafting:• A 5 cm length of rib is obtained as an

autogenous graft. • The rib is split and the two pieces are

placed one on each side of the fractures site in the manner of a first –aid splint applied to a limb.

• The rib halves are lashed together by a series of circumferential wires sandwiching the fractured bone ends between them.

Indirect skeletal fixation:

• A system of bone pins joined together by rods and universal joints, can be used in edentulous mandibular fractures.

• The method is occasionally of practical use when there has been extensive comminution of a long segment particularly if this involves the symphysis.

Intermaxillary fixation using gunning – type splints:

• The dental splint described originally by Gunning in 1866.

• If the patient is completely edentulous immobilization is carried out by attaching the upper splint to the maxilla by peralveolar wires and the lower splint to the mandibular body by circumferential wires.

• Intermaxillary fixation can then be effected by connecting the two splints with wire loops or elastic bands.

Steps in construction:

1. Upper and lower impressions are taken2. Plaster casts are made3. Upper and lower base plates adapted4. Bite blocks prepared in posterior region

only5. Upper and lower plates with bite blocks

are constructed using heat cure acrylic leaving the anterior region open for feeding.

6. Hooks are incorporated in buccal side of the bite blocks.

7. Grooves must be made in both gunning splint, in the canine region to prevent the peralveolar and circumferential wires from slipping.

Infection Nerve damage Malunion Foreign bodies Delayed union Non union

Horizontally favorableHorizontally favorable

Vertically unfavorableVertically unfavorable

Vertically favorableVertically favorable

Horizontally unfavorableHorizontally unfavorable

Direct fracture Indirect fracture

Typical Causes Direct violence Indirect violence

Crush injuries Road traffic incident Aero plane crashes Mining accident

Predisposing causes Presence of cysts, tumors, osteomyelitis, 3rd molars Systemic diseases affecting the formation of

structure of bone

OPGOPG

LATERAL OBLIQUE VIEWLATERAL OBLIQUE VIEW

PA VIEWPA VIEW OCCLUSAL OCCLUSAL

CT SCANSCT SCANS

IOPAIOPA

ReductionClosed

Direct interdental wiring Indirect interdental wiring (eyelet or Ivy loop)

Continuous or multiple loop wiring

Arch bars Cap splints 'Gunning-type' splints Pin fixation

OpenOpen Transosseous

wiring (osteosynthesis)

Plating Intramedullary

pinning Titanium mesh Circumferential

straps Bone clamps Bone staples Bone screws

FixationFixationDirectDirect IndirectIndirect

Methods of immobilization (a) Osteosynthesis without intermaxillary fixation

(i) Non-compression small plates (ii) Compression plates (iii) Mini-plates (iv) Lag screws

(b) Intermaxillary fixation (i) Bonded brackets (ii) Dental wiring

Direct Eyelet

(iii) Arch bars (iv) Cap splints

(c) Intermaxillary fixation with osteosynthesis (i) Transosseous wiring (ii) Circumferential wiring (iii) External pin fixation (iv) Bone clamps (v) Transfixation with Kirschner wires

Young adult with Fracture of the angle receiving Early treatment in which Tooth removed from fracture line

3 weeks3 weeks

(a) Tooth retained in fracture line: add 1 week(a) Tooth retained in fracture line: add 1 week(b) Fracture at the symphysis: add 1 week(b) Fracture at the symphysis: add 1 week(c) Age 40 years and over: add 1 or 2 weeks(c) Age 40 years and over: add 1 or 2 weeks(d) Children and adolescents: subtract 1 week(d) Children and adolescents: subtract 1 week

IF

HISTORY William Saliceto(1210-1277) Tied the teeth (MMF) Thomas Gilmer(1849-1931) Reveiwed the tech, introduced

Arch Bars in 1907. Barton bandage by JOHN BARTON

Lingual-Labial occlusal splint. Vaccum formed acrylic splint Royal Berkshire Haio Frame

IVY LOOP METHOD

IN CASE OF SINGLE TOOTH

Continous or Multiple loop wiring

Twisted Labial Wire

Continous Multiple Loop Wiring

RISDON ARCH BARRISDON ARCH BARJELENKO ARCH BARJELENKO ARCH BARERICH ARCH BARERICH ARCH BARKRUPPA ARCH BARKRUPPA ARCH BARERICH ARCH BARERICH ARCH BARHAMILTON (1967) HAMILTON (1967)

BARKER(1986)

ACRYLATED ARCH BARSACRYLATED ARCH BARS

schuchardt(1956) schuchardt(1956) schuchardt&metz(1966)schuchardt&metz(1966)stanhope(1969)stanhope(1969)clarke(1977)clarke(1977)

DIRECTLY BONDED ARCH BARSBaurmash et al(1988)

Wall(1986)

CAP SPLINTS 1. Cast silvercap splints 2.Acrylic splints

ROBTERTSON(1965)

GUNNING TYPE SPLINTS

THOMAS BRYAN GUNNING-(1885)

PERALVEOLAR WIRING

TREATMENT MODALITIES FOR TREATMENT MODALITIES FOR EDENTULOUS MANDIBLEEDENTULOUS MANDIBLE

The Obwegeser The Obwegeser technique for technique for circumferential wiringcircumferential wiring

CIRCUMMANDIBULAR CIRCUMMANDIBULAR WIRING (Bradley-1975)WIRING (Bradley-1975)

INTER OSSEOS WIRING EXTRA ORAL PIN FIXATION ROGER ANDERSON APPLIANCE PRIMARY RIB GRAFTING - OBWEGER& SAILER (1973)

HISTORY1. Gorden Buck(1807-1877)2. Hansmann(1886)3. Christiansen(1954)4. Luhr(1968)5. Spiessel(1970 & 1974)6. Schmoker & Niederdellmann & Schilli(1973)7. Michelet & Champy(1978)8. Marciani & Gonty(1993)9. Ellis(1993 & 1996)

Intraoral symphysis and paarasymphysisIntraoral symphysis and paarasymphysis

Intraoral body, angle Intraoral body, angle and ramusand ramus

SubmentalSubmental

SubmandibularSubmandibular

Non-Union Malunion Fibrous Union Paresthesia Anesthesia Infection

The general physical status should be thoroughly evaluated.

40% associated with significant injury, 10% of which are lethal

Cerebral contusion is common ABC’s! Almost never emergent

Dental injuries should be treated concurrently

Reestablishment of occlusion is the primary goal

Fractured teeth may jeopardize occlusion Mandibular cuspids are cornerstone of Tx Prophylactic antibiotics

With multiple facial fractures, mandibular fractures are treated first

Prospective study of 422 pts Infection rate 7% 50% of infections associated with fractured

or carious teeth ORIF led to 12% infection rate Staph, strep, bacteroides Prophylaxis, tooth extraction

Prospective, 8 year study at Parkland involving angle fractures

Nonrigid fixation had 17% complication rate AO Recon plate had 8% complication rate DCP had 13% complication rate Non compression plate 3% complication rate

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WestN orth

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