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Every effort has been made to keep this topic as short as possible without removing the actual or clinically important points. MANDIBLE FRACTURE Short Notes for Rapid Review Sarang Suresh Hotchandani

Mandible Fracture

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Page 1: Mandible Fracture

Every effort has been made to keep this

topic as short as possible without removing

the actual or clinically important points.

MANDIBLE FRACTURE Short Notes for Rapid Review

Sarang Suresh Hotchandani

Page 2: Mandible Fracture

~ 1 ~

INTRODUCTION Occurs more frequently than any other fracture of

facial skeleton Sometimes can be complication of tooth

extraction Fracture of the mandible may be broadly divided

into two main groups; o Fractures with no gross comminution of

the bone and without significant loss of hard or soft tissues. Most Common type

o Fractures with gross comminution of the bone and with extensive loss of both hard & soft tissues May result from;

Missile injuries in war

Industrial injuries

Major road accidents Management of these both types is different.

AETIOLOGY Road traffic accident (RTA)

Interpersonal violence

Falls

Sporting injuries

Industrial trauma

Tooth extraction

INCIDENCE The most common facial fractures are in the

mandible, followed by the maxilla, the Zygoma & then in last nasal bones.

Fracture of mandibular CONDYLE IS THE COMMONEST SITE

Fracture of mandibular ANGLE IS THE FREQUENT SITE

CLASSIFICATION 01) Based on TYPE OF FRACTURE 02) Based on SITE OF FRACTURE 03) Based on CAUSE OF FRACTURE

TYPE OF FRACTURE Simple Fracture Closed linear fracture of mandible Greenstick is variant of simple fracture found in

children. Minimal fragmentation of bone Non-external communication

Compound Fracture Aka OPEN FRACTURES In this, communication of margin of fractured bone

occurs with external environment; o Fracture of tooth bearing portion of

mandible are always compound into the mouth via periodontal membrane

o Some compound fractures of mandible open through overlying skin.

Comminuted In this, fractured bone is compound and is in

multiple segments with other hard and soft tissue loss.

Usually caused by; o Penetrating sharp objects o Missiles

Pathological Fracture When fracture of jaws occurs with minimal trauma

because of already weakened by any pathological condition, they are said to be pathological fracture.

Example of Conditions; o Osteomyelitis o Neoplasms o Generalized skeletal disease o Severe alveolar resorption

SITE OF FRACTURE Treatment and signs & symptoms are different for different locations of fracture of mandible.

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FAVORABLE vs UNFAVORABLE FRACTURES It depends on ANGULATION OF FRACTURE LINE &

FORCE OF THE MUSCLE PULL proximal or distal to the fracture line.

In favorable fracture, fracture line and muscle pull resist displacement of the fracture.

In unfavorable fracture, muscle pull results in displacement of fractured segments.

BASED ON CAUSES OF FRACTURE Direction and type of force determines the pattern

of mandibular fracture.

DIRECT & INDIRECT VIOLENCE Due to shape of mandible, any direct violence to one area may produce indirect force/violence of lesser severity in another usually opposite part of mandible which can produce multiple fracture. So keeping this

concept in mind, direct & indirect violence is again divided into;

01) Unilateral fracture mandible 02) Bilateral fracture mandible 03) Multiple fracture mandible 04) Comminuted fracture mandible

Unilateral fracture mandible Single or multiple fracture on one side of mandible. Frequently caused by direct violence, but

sometimes; o can be caused by indirect violence in which

site at which direct violence has occurred remain intact.

Bilateral fracture mandible more frequently caused by combination of direct &

indirect violence. o Direct force on angle may also fracture

condylar neck of opposite side OR o Direct force on canine of one side may

fracture angle of mandible of other side.

Multiple fracture mandible More than two fractures of mandible Caused by combination of direct & indirect force.

o Force on chin may fracture both condyles along with chin.

Usually occur in; o Epileptics o Elderly patients o Soldiers

GUARDSMAN fracture; soldiers who faint on parade from which fracture combination derives its name.

Comminuted Fracture mandible Always result from direct violence

FRACTURE DUE TO EXCESSIVE MUSCULAR CONTRACTION Fracture of condylar neck or coronoid process due

to sudden contraction of temporalis muscle.

SURGICAL ANATOMY OF MANDIBLE Mandible is strongest and most rigid component of

facial skeleton. However, it is more commonly fractured due to;

o Its prominent & exposed situation

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Mid facial skeleton is match – box like and provide cushion effect to underlying structure. WHILE

o Forces applied to mandible are transmitted directly to base of skull through TMJ

Fracture of mandible may constitute a threat to airway due to its association with head injury. Cause of airway obstruction in mandibular fracture are;

o Depressed consciousness due to head injury o Broken teeth and displaced dentures

obstructing airway. o Bleeding into floor of mouth and base of

tongue causes swelling which obstructs the oro – pharynx.

Mandibular fracture sites The minimum force which cause fracture of

mandible as observed from Nahum’s Cadaver experiment was found to be;

o 425 pounds for mandible when applied from front.

Fracture of neck of the condyle is regarded as safety mechanism which protects the patient from damage to middle cranial fossa.

Nahum also observed that a frontal force of 800 – 900 pounds was required to produce fracture of the symphysis & both condylar necks.

Mandible is much more SENSITIVE TO LATERAL FORCES than frontal forces.

Alveolar resorption weakens the mandible & fracture of edentulous of body of mandible results from much smaller force.

The Teeth Produce line of weakness in mandible

o Teeth determines where fracture will occur.

o long canine tooth, partially erupted wisdom tooth & impacted 2nd premolars represent the line of weakness in mandible.

Source of infection in fracture

Muscle attachments and displacement of fractures The periosteum of the mandible is thick & inflexible

in structure. o However, it may become flexible due to

accumulation of blood from rupture cancellous bone.

Displacement of bone during mandible fracture does not occur if the periosteum is attached to underlying bone.

o It means for displacement of bone fragments during fracture, the periosteum must be stripped out.

FRACTURE AT ANGLE OF MANDIBLE AND DISPLACEMENT Fracture at angle of mandible are influenced by

both medial pterygoid & masseter muscles. o But, medial pterygoid is strong

component involved in displacement. Fracture in this region have been classified as;

(figure 2.6 &2.7 in Killey) o Vertically favorable o Vertically unfavorable o Horizontally favorable o Horizontally unfavorable

FRACTURE & DISPLACEMENT AT SYMPHYSIS & PARASYMPHYSIS In this area, following muscles play the role;

o Mylohyoid muscle o Genio – hyoid muscle o Genio – glossus muscle

In transverse midline fracture of mandible, Genio – hyoid and mylohyoid muscles act as stabilizing force and prevent the displacement.

But, if the fracture occurs lateral to the midline in the incisor area, the fragment which contains genial tubercles will be displaced lingually by the pull of geniohyoid & mylohyoid muscles

When bilateral parasymphyseal fracture occurs the anterior fragment is displaced backward by the pull of genioglossus muscles (figure 2.10 in Killey)

o Threat to airway in this condition occur only when voluntary tongue control is lost during loss of consciousness of patient. For explanation read passage on page # 18 in Killey.

FRACTURE & DISPLACEMENT OF CONDYLAR PROCESS When condylar neck is fractured, condylar head is

displaced and dislocates from the articular fossa. o Displacement of condylar head occurs in

forward & medial direction due to pull from lateral pterygoid muscles.

FRACTURE & DISPLACEMENT OF CORONOID PROCESS It is rare caused by reflex muscular contraction of

temporalis muscles, which displaces the coronoid process upward into infra – temporal fossa.

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COMMINUTED FRACTURES & DISPLACEMENTS The amount of displacement in comminuted

fractures is very little. o It is because of fragmentation at the site of

muscle attachments which pulls the small fragments leaving the bulk of bone un-displaced.

FRACTURE & DISPLACEMENT OF EDENTULOUS MANDIBLE Bucket handle displacement

o In this anterior part of mandible is displaced backwards due to pull of digastric and mylohyoid muscles, which can compromise airway.

BLOOD SUPPLY OF THE MANDIBLE The mandible receives an endosteal supply via the

inferior dental artery. The other blood supply which mandible receive is

from the periosteum Inferior dental artery slowly diminishes and

disappear with aging, so that’s why blood supply from periosteum is important

o So, that’s why open reduction with elevation of periosteum is not a best treatment approach in older patients.

Other vessels which can be damaged during fracture of mandible are;

o Dorsal lingual veins causing sub lingual hematoma

o Facial vessels which cross the lower border of mandible anterior to angle.

OTHER IMPORTANT RELATED ANATOMICAL STRUCTURES

Nerves Inferior dental nerve is frequently damages in

fractures of the body & angle of the mandible Sometime, facial nerve can be damaged by direct

trauma over mandibular ramus. o Facial palsy of the lower moto neuron type

results. sometimes, mandibular division of facial nerve is

damaged in isolation in association with a fracture of the body or angle.

Temporomandibular joint Traumatic arthritis can occur without fracture of

the condyle from indirect transmitted force. Intra – capsular fracture of condylar head when

occur during young age lead to haem – arthrosis and resulting fibrous or bony ankyloses and reduction in growth potential of condyle.

Rupture of meniscus along with haem - arthrosis predisposes to fibrous or bony ankyloses.

Rarely, fractured condylar head damages external auditory meatus and cause bleeding from the external ear.

o Bleeding from middle ear shows damage to middle cranial fossa.

CLINICAL EXAMINATION Clinical examination of patient with mandibular

fracture occurs in three steps; o Initially immediate assessment &

treatment of any condition constituting a threat to life is performed.

o Then, general clinical examination of patient is done

o Finally, Local examination of the mandibular fracture is performed.

General clinical examination Usually fracture of mandible is associated with

injury elsewhere in the body. So, for this before treating mandibular fracture we

should be clear that no concurrent injury has happened or if happened it is treated before or along with treatment of mandibular fracture.

Local Examination of the mandibular fracture PREPARATION OF THE PATIENT FOR EXAMINATION The face must be gently cleaned with warm water

or swabs to removed clotted blood, road dirt, etc. so that accurate evaluation of any soft tissue injury can be done.

The oral cavity is also cleaned with swabs held in non – toothed forceps.

Loose or broken teeth or dentures should be examined and broken dentures are assembled extra orally to make sure that all parts are present, if missing check whether they have been swallowed or fall anywhere else.

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During this cleaning, cranium and cervical spine are inspected and palpated for signs for injury

After these, go for detailed examination of mandibular fracture.

EXTRA – ORAL EXAMINATION OR EXTRA – ORAL CLINICAL FEATURES OF MANDIBULAR FRACTURE Swelling and ecchymosis indicate the site of any

mandibular fracture o Initially, swelling occurs because of

accumulation of blood within tissues, while, later swelling is caused by increased capillary permeability and edema.

o Ecchymosis; subcutaneous spots of bleeding with diameter larger than 1 centimeter.

Extra – orally we can also see, deformity in bony contour of the mandible.

o Sometimes, patient is unable to close anterior teeth and mouth hangs open.

Blood stained saliva dribbling from the corners of mouth.

Bone tenderness on palpation is pathognomic of a fracture

o if there is displacement of bone, there may be bone crepitus

Reduced or absent sensation on one or both sides of lower lip

o Usually occur in fracture of body of mandible.

INTRA – ORAL EXAMINATION OR INTRA – ORAL CLINICAL FEATURES OF MANDIBULAR FRACTURE Clean oral cavity with mouth wash or saline and

remove clotted blood, fractured teeth or denture.

Examine buccal or lingual sulcus for ecchymosis o Ecchymosis in buccal sulcus usually does not

indicated any fracture. while, o Ecchymosis in the floor of mouth or lingual

sulcus indicates the fracture near to it. o Small linear hematomas in the 3rd molar

region indicate fracture in the adjacent bone.

Examine the occlusal plane in dentate patient while examine alveolar ridge if patient is edentulous.

o Note any step deformity in the occlusion or alveolus

Examine all individual teeth and note; o Luxation or subluxation o Missing crowns, bridges or fillings o Fracture involvement of dentine or pulp o Loose filling, cracks or splits in tooth

If they are missing, go for chest radiograph. Examine the mobility of fracture site by placing

finger & thumb on each side of fracture. Check pain or limitation of mandibular movement

if patient is co – operative.

SIGNS AND SYMPTOMS OF MANDIBULAR FRACTURES AT VARIOUS SITES OF MANDIBLE

Dento – alveolar fracture

Soft – tissue injuries Full thickness or ragged laceration on inner aspect

of lower lip. o Caused by impaction against the lower

teeth during trauma. Bruising of lips and portion of tooth or foreign body

embedded in soft tissues. Laceration of gingiva De – gloving injury on chin Horizontal tear in buccal sulcus at the junction of

attached and free gingiva.

Damage to Teeth during dento – alveolar fracture. Fracture of crown from direct trauma or forcible

impaction against opposing tooth. Pulp chamber may or may not be exposed Fracture crowns or fillings may be embedded in

soft tissues or inhaled. Excessively mobile teeth due to luxation or

subluxation Root fracture

Alveolar fracture Teeth within alveolar fractures are always assumed

to be devitalized.

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Condylar fracture They may be unilateral or bilateral They may involve the joint compartment; in this

case they are called as intra – capsular condylar fracture.

o While, when condylar neck is fracture, it is called as extra – capsular condylar fracture. This type of fracture is more

common than intra – capsular The extra – capsular fracture may

exist with or without dislocation of condylar head.

The commonest condylar head displacement is “antero – medial displacement” due to pull from lateral pterygoid muscles which is attached to antero – medial aspect of condylar head and to meniscus of TMJ.

Swelling over TMJ area & hemorrhage from ear on the damaged side

o Bleeding result from laceration of anterior wall of external auditory meatus.

o Bleeding from middle ear represent fracture of petrous part of temporal bone, which also can be accompanied by cerebrospinal otorrhoea.

Battle’s sign o It is the sign in which ecchymosis of skin

occurs below the mastoid process of affected side.

o The hematoma of condylar fracture moves downward and backward below the external auditory canal.

Locked mandible and middle ear bleeding o It occurs when condylar head is impacted in

glenoid fossa Depression on the region of condylar head

o It occurs when condylar head is dislocated medially and all edema has been subsided. But this usually does not happen.

Tenderness over condylar region o It is possible to determine whether the

condylar head is displaced from glenoid fossa by palpation within external auditory meatus.

Paresthesia of lower lip is rare in condylar fracture Shortening of ramus on displaced side of condyle Deviation of mandible on opening in the affected

side Painful limitation of protrusion and lateral

excursion to opposite side

Bilateral intra – capsular fracture rarely decreases the ramus height and also, occlusion is normal in bilateral condylar fracture.

If both condyles are displaced during bilateral condylar fracture, anterior open bite will result.

Bilateral condylar fracture is sometimes associated with fracture of symphysis or Para symphysis fracture

Fracture of coronoid process Difficult to diagnose clinically Tenderness over the anterior part of the ramus Tell – tale hematoma Limitation in protrusion of mandible

Fracture of Ramus There may be single fracture or comminuted

fracture Swelling and ecchymosis both extra – orally &

intra – orally Tenderness over the ramus Pain on movement Sever trismus

Fracture of angle of mandible Swelling & deformity at angle extra – orally Step deformity behind the last molar intra –

orally Un – displaced fractures are revealed by presence

of hematoma adjacent to angle on lingual or buccal side or both.

Anesthesia or paresthesia of lower lip Deranged occlusion Bone tenderness at angle Crepitus at fracture site during palpation Painful movement & trismus

Fracture of the body of mandible (molar & pre – molar region) Swelling & bone tenderness similar to those

fracture of angle Derangement of occlusion due to displacement

of fractured parts Gingival tears due to displacement Inferior dental artery may be damaged due to

displacement Molar teeth may split longitudinally in the

fracture line and cause discomfort

Fracture of para – symphysis & symphysis region Commonly associated with fractures of both

condyles

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Sublingual hematoma & bone tenderness Lingual inversion of occlusion on each side Soft tissue injury of chin & lower lip Sometimes associated with severe concussion &

detachment of genioglossus muscles cause loss of tongue control resulting obstruction of airway.

A fracture of symphysis is not accompanied by anesthesia of skin of the mental region unless mental nerve is damaged.

Multiple & Comminuted fractures The physical signs & symptoms of comminuted fractures depends on the site and number of the fractures.

RADIOLOGY FOR MANDIBULAR FRACTURE Radiographs for mandibular fracture are taken for

following reasons; o Treatment planning o To know the exact relation of teeth to a

fracture line o To know whether condylar fracture involves

joint space or not o To determine the presence of comminution.

Radiographs of mandible fracture are divided into; o Essential

Left & right oblique lateral with tube angled at 30 degrees towards lower jaw

Postero – anterior view Rotated Postero – anterior view Intra oral radiographs

Periapical films

occlusal films o Desirable radiographs

Panoramic radiography Standard linear tomography Computed tomography MRI

Left & right oblique lateral radiographs Tube is angled at 0

degrees & it shows fracture of body

proximal to canine region

fracture of angle

fracture of ramus & condylar region

Postero – anterior View This view, shows the posterior part of mandible

shows, fracture of body & angle together with type of displacement

un – displaced condylar head is difficult to be visualized because it is obscured by superimposition from mastoid process.

REVERSE TOWNE’S (PA PROJECTION) VIEW This view showed condylar head & necks and was indicated in following problems;

High fracture of condylar necks Intra – capsular fracture of TMJ

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Rotated Postero – anterior view This projection is needed to show fractures b/w

symphysis & canine region. To demonstrate this area, head must be rotated

from PA position until the suspected fracture line is parallel to line of vertical beam.

Intra – oral radiographs PERIAPICAL FILMS Demonstrate

the relationship of teeth to the line of fracture

Damage to teeth themselves

OCCLUSAL FILMS Help to evaluate the relationship of tooth root to

the fracture Demonstrate midline fracture of body of mandible

with minimal displacement

Panoramic Tomography Demonstrate fracture of condylar region The combination of PA view & OPG prevent the

need for further radiographs in mandibular fracture and also decreases the dose of radiation to patient.

Standard Linear Tomography Demonstrates

o Mandibular movements

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o Presence of intra – articular synovial effusion

Computed Tomography (CT Scan) Most valuable in the assessment of complex facial

trauma, especially that of upper mid – facial region. Offer very little advantage as a diagnostic tool in

the lower third of the face and also are not indicated for isolated fracture of mandible.

o However, they can show detail of TMJ injury such as vertical fracture of condylar head.

MRI Demonstrate meniscus within TMJ and measures

any displacement or injury to meniscus.

PRELIMINARY TREATMENT IN PATIENT OF MANDIBLE FRACTURE Normally in civilian practice, we do not encounter

patients with mandible fracture having serious damage to other parts of body.

However, trauma to mandible usually cause concussion from transmitted violence to base of skull.

o Concussion; it is traumatic brain injury that alters the way your brain function for short time.

Management of Airway Intra oral bleeding, fractures of teeth or denture

can cause airway obstruction in unconscious or semi-conscious patient.

o Management; Examine the mouth Remove fragments of teeth,

filling, dentures. If suction available, use it to

remove saliva and blood clot. Position the patient, lying on his

side so that further bleeding & secretions can flow from oral cavity.

If symphysis region is broken, there are many chance that tongue may fall back, in this condition, tie the tongue with suture passing from dorsum and hold it to prevent it from falling back.

The position for unconscious patient is lying on his side.

o This position is also used during recovery from GA and during transporting the patient.

Management of Hemorrhage Serious hemorrhage is unusual in mandibular

fracture Obvious bleeding points such as facial vessels

should be secured with artery forceps and a temporary dressing.

Sometime, brisk & persistent hemorrhage originates from displaced fracture of body of the mandible.

o This can be managed by; Manual reduction of fracture and

temporary partial immobilization. Temporary partial immobilization

occur by means of suture or wire ligature passed around teeth on each side of fracture line.

Management of Soft – Tissue Lacerations. Soft tissue wounds should be closed within 24

hours. If soft tissue repair along with definitive treatment

of fracture is possible, it is advantageous. Otherwise, soft tissue must be closed ASAP.

Before closure, they must be cleaned to remove foreign material and gently scrubbed with mild antiseptic cleaner such as 15 Cetavlon.

Management of the Bone Fragments It is best to carry out definitive standard fixation

technique such as arch bar for immobilization bone fragments.

Do not waste time with ineffective temporary fixations with;

o Barrel bandage o Webbing head cap with chin support o Elasto Plast chin strap

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Control of Pain In majority of patient,

pain does not occur due to Neuropraxia of inferior dental nerve.

o Neuropraxia; disorder of PNS in which there is temporary loss of motor & sensory function due to blockage of nerve conduction.

However, sometimes mobile fracture of mandible causes severe restlessness in a patient.

o This is one rare condition in which mandible fracture is treated first than other injuries.

Powerful analgesics such as morphine is contraindicated because they depress cough reflex and respiratory center which may cause death of patient.

o It also masks the pain which can be diagnostically important (e.g. from a ruptured spleen).

Control of Infection Following measures should be taken;

o Benzyl – penicillin 1 mega unit IM every 6 hours for 2 –

3 days. After this Oral penicillin for 1 week.

o Metronidazole (PO or IV) 400 – 800 mg b.d.

Food and fluid It should be withheld if an immediate operation

under GA is going to be done. Otherwise, fluid diet must be taken for few days.

MANAGEMENT OF FRACTURES OF DENTULOUS OR TOOTH BEARING AREA OF MANDIBLE General principle of management;

o Reduction (realignment) of fragments of bone followed by immobilization until bony union occurs.

Traditionally immobilization has been done by a procedure called inter – maxillary fixation. (IMF)

o In this, mandible is temporarily linked with opposing jaw by help of wires or sutures etc.

Although there are many disadvantages to IMF as mentioned below, this procedure is still used because very large number of mandible fractures encountered and limitation of resource such O.T time etc.

o Prevent normal jaw function during immobilization.

o Restriction of diet to liquid or semi – liquid which result in weight loss.

o Oral hygiene is difficult to maintain. o Recovery is prolonged o 30% reduction of Ventilatory volume.

So, alternatives to IMF were developed which are being used in current period such as;

o Rigid osteosynthesis by means of bone plates.

Reduction It is defined as “restoration of functional alignment

of bone fragments”. In dentate mandible, reduction must be

anatomically correct and also in occlusion. o Less precise reduction may be accepted if

the part of body is edentulous or there are no opposing teeth.

Presence of teeth provide; Assist in reduction Alignment of fragments Assist in immobilization.

o If reduction is based on occlusion, it is important to recognize previous occlusal abnormalities such as; Anterior or lateral open bite

o Contact areas can be identified by examining wear faces of teeth.

Widely displaced, multiple or extensively comminuted fractures are reduced by open operative exploration.

Reduction should be done in GA or LA based on circumstances.

If due to compromised general medical condition of patient, fracture cannot be reduced with GA. Then, in them fracture can be reduced by;

o Elastic traction; in this elastic bands are applied to cap splints or wire fitted to teeth on individual mandibular fragments and then attached to maxilla.

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TEETH IN FRACTURE LINE Teeth in the fracture line are a potential hindrance

to healing of bone due to infection of fracture. Retention of healthy tooth will delay the clinical

union fracture by a short period of 3 – 4 days. Absolute Indications for removal of tooth from

the fracture line; o Longitudinal fracture of root o Dislocation or subluxation of tooth o Presence of periapical infection o Infected fracture line o Acute pericoronitis.

Relative indications for removal of tooth o Functionless tooth which would eventually

be removed electively; 3rd molar

o Advanced caries o Advanced periodontal disease o Doubtful teeth which could be added to

existing dentures o Teeth involved in untreated fractures

presenting more than 3 days after injury.

Management of teeth retained in fracture line, STEP WISE. 01) IOPA radiograph 02) Antibiotic therapy 03) Splitting of tooth if mobile. 04) Endodontic therapy if pulp exposed. 05) Extraction if fracture become infected 06) Follow up 1 for 1 year with endodontic therapy.

IMMOBILIZATION Fracture site is immobilized to allow bone healing

to occur. It can be achieved by;

o Osteosynthesis without Inter – maxillary Fixation. Non – compression small plates Compression plates Mini – plates Large screws

o Inter – maxillary fixation Bonded brackets Dental wiring

Direct

Eyelet

Arch bar Cap splints

o Inter – maxillary fixation with osteosynthesis Trans – osseous wiring Circumferential wiring External pin fixation Bone clamps Trans – fixation with Krischner

wires.

Osteosynthesis can be achieved by o Rigid Fixation o Semi rigid fixation

Osteosynthesis; is the reduction and internal fixation of a bone fracture with implantable devices that are usually made of metal. It is a surgical procedure with an open or per cutaneous approach to the fractured bone.

o Internal fixation is an operation in orthopedics that involves the surgical implementation of implants for the purpose of repairing a bone.

Rigid fixation; o By means of non-compressing or

compressing plates, pins etc. o Non-compressing heals with secondary

intention. Callus formation occur

o Compressing, heals with primary intention. No callus formation

o More rapid stabilization of fracture site than semi - rigid fixation.

Semi – rigid fixation o By means of wires. o Heal by secondary intention with callus

formation

Period of Immobilization Period of immobilization depends on following

factors; o Site of fracture o Presence of retained teeth in fracture line o Presence or absence of infection

Fracture of mandible usually heal within 3 weeks on average in favorable circumstances.

A simple guide to the time of immobilization of fracture mandible;

Young Adult + Fracture of Angle + Early Treatment + Tooth Removed from Fracture

3 weeks

If… o Tooth is retained in fracture line; add 1 week

in above mentioned basic 3 weeks.

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o Fracture is at the symphysis: add 1 week in above mentioned basic 3 weeks.

They require much time because poor endosteal blood supply at symphysis region.

o Age 40 years or above; add 1 or 2 weeks in above mentioned basic 3 weeks.

o Children and adolescent; subtract 1 week from above mentioned basic 3 weeks. Because they heal rapidly due to

rich blood supply and high osteoblastic activity at that stage.

Example; fracture of symphysis in 40 – year old patient with retained tooth in fracture line. It will require 6 weeks of immobilization.

o Basic week 3 o Symphysis 1 o Retained tooth 1 o Age 1 o TOTAL 6 weeks

OSTEOSYNTHESIS WITHOUT INTER – MAXILLARY FIXATION OR RIGID OSTEO – SYNTHESIS This type of osteosynthesis can be achieved by use

of bone plates. Currently there are 3 systems of bone plates are

available; o Compression Plates

Swiss AO system (Arbeitsgemeinschaft fur Osteosynthese)

ASIF techniques (Association for the study of Internal Fixation)

o Non – compression plates AKA semi – rigid

ADVANTAGES; o Prevent the need for IMF o Patient can enjoy relatively normal diet o Rapid restoration of function o Maintain oral hygiene more easily

Rigid fixation with plates is carried out from intra oral approach.

Bone plates however do not achieve the fundamental objective of correct occlusion in repair of mandible fracture. This can be overcome by skillful hands of surgeon.

o So that’s why sometime, patients are still treated with IMF for short period of time along with plating.

The incidence of post-operative infection of bone plates is decreasing but still many plates have to be removed after treatment (DISADVANTAGE).

Plates are currently made of titanium. o Other material is stainless steel, chrome –

cobalt alloys.

INDICATIONS OF RIGID FIXATION; Fracture in an edentulous part of the body of

mandible. Concomitant fractures of the body and condyle

when early mobilization is indicated. Patient in whom IMF is contraindicated;

o Elder patients o Mentally disturbed patients

Fracture associated with closed head injury Continuity defects Fractures in which non – union or mal union has

occurred.

Non – Compression Small Plates In these small conventional orthopedic plates are

used. They are not used currently.

These plates are contoured according to bone surface.

Compression Plates They are applied to the convex surface of mandible

at its lower border using screws which engage the inner cortical plate.

These plate contain at least minimum of 2 pear shaped holes.

o Widest diameter of hole should lie towards the fracture line.

Screw is inserted in the narrow part and after tightening, head will rest in wider part of hole.

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Chief problem with compression plates; o Compression near the lower border open up

the fracture at the alveolar margin.

This problem can be overcome by following two methods;

01) Arch bar ligature to the teeth

02) Separate plate with screws

Disadvantages of Compression Plates Post –

operative removal due to bulkiness of the plate.

Opening & distortion of fracture at alveolar margins.

Stress shielding effect o reduction in bone density (osteopenia) as a

result of removal of typical stress from the bone by an implant

Mini Plates was introduced by Champy et al. (1978)

These are non-compression mini plates with screw fixation.

Can be placed anywhere These plates can be inserted intraorally below

periosteum with or without IMF. These plates can be left permanently, but

theoretically should be removed.

Lag Screws They are used for oblique

fractures. Thread of screw engages

only on the inner plate of bone. Hole drilled in outer cortex is made to a slightly

larger diameter than the threaded part. Minimum 2 screws are needed

INTERMAXILLARY FIXATION – [IMF] Done when sufficient numbers of teeth are

present.

Clinical union in approx. 4 weeks in nearly all cases.

Can be done without general anesthesia.

Different methods of IMF have been described in following headings.

Bonded Modified Orthodontic Brackets In this method, we apply the modified orthodontic

brackets on to the teeth of maxilla & mandible, each containing hooks.

o After application of brackets, inter – maxillary elastic bands are applied on the bracket to immobilize the mandible.

Usually performed in; o Fractures with minimal displacement & o Patients with good oral hygiene

Dental Wiring Is used when the patient has a complete or almost

complete set suitable shaped teeth. 0.45 mm stainless steel wire is used.

o This wire requires stretching before use to prevent loosing of wire after applying on teeth.

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There are two types of dental wiring for IMF o Direct Wiring o Interdental Eyelet wiring

DIRECT WIRING (GILMER WIRING) Most simple rapid technique.

In this technique, 6 inch (15cm) wire is taken and the middle portion of wire is twisted around a suitable tooth and then the free ends are twisted together to produce a 3 – 4 inch (7.5 – 10 cm) length of plaited wire (choti wangur)

It can be applied as “clove hitch” form for great stability and when few teeth are absent.

o CLOVE HITCH; a knot by which a rope is secured by passing it twice round a spar or another rope that it crosses at right angles in such a way that both ends pass under the

loop of rope at the front.

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

INTERDENTAL EYELET WIRING Eyelets are constructed by holding a 6 inch (15cm) length of wire by a pair of artery forceps at either end and giving the middle of the wire two turns around a piece of round bar 1/8 inch or 3mm in diameter which is fixed in upright position.

01) These eyelets are passed b/w two teeth from buccal to lingual/palatal.

02) The two arms passed back to buccal side through the adjacent distal and mesial interdental spaces

03) The distal arm is inserted through the loop.

04) Then two ends of the wires are twisted together.

05) Upper and lower jaw are connected by “Tie wire” passing through eyelets from upper

and lower jaw.

06) Before tightening the tie wire, extraction should be done if needed and everything is cleared from mouth because after tightening of tie wire, mouth will remain closed for some weeks.

Minimum 5 eyelets are placed in maxilla and 5 eyelets in mandible.

Evaluate normal pre-fracture occlusion before tightening, because some patients have abnormality of their occlusion and an attempt to achieve theoretically correct occlusion in such cases result in gross derangement of bony fragments.

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Tie wires should be tightened in molar area, first on one side and then on other, so working and moving round to incisor area.

o If wires are tightened on one side first, cross bite will develop.

o If anterior wire is tightened first, posterior open bite will develop.

Wires are twisted tightly on multi-rooted teeth, but care must be taken on anterior teeth, because tightening can result in extraction of anterior teeth.

After wiring is completed, finger is moved around mouth to check if there is any projection is left which can ulcerate the tissue.

ADVANTAGES o Tie wire can be removed without

disturbing eyelet. o If one eyelet is broken it can be replaced

easily without removing other eyelets.

ARCH BARS It is most versatile form of mandibular fixation.

Used, when; o Patients with insufficient number of teeth o Direct link across the fracture is required.

Technique Overview; o The fracture is reduced, and then teeth are

tied to a metal bar which has been bent to adapt to the dental arch.

Types of prefabricated Arch bars;

o Winter o Jelenko o Enrich

These bars are tied to teeth with;

o 6-inch length of either 0.45 mm or 0.35 mm stainless steel wire.

Technique for Arch Bar. 01) Check occlusion

a. Before inserting the arch bars, check the occlusion. There should be full interdigitating of the teeth with regular contacts.

b. Determine if the patient has a normal occlusion or a preexisting malocclusion before taking the patient to the operating room.

02) Adjust the shape of arch bar according to jaw; a. The prefabricated arch bar must be adjusted

in shape and length according to the individual situation. The arch bar should not damage the gingiva.

b. Firstly, the bar is adapted closely to the dental arch. The bar should be placed between the dental equator and the gingiva.

c. Methods to obtain length and curvature of arch;

i. Comparing with maxillary arch ii. From plaster model of similar size

03) Trimming the bar

The bar should be trimmed to allow ligation to as many teeth as possible. The bar should not extend past the most distal tooth or protrude into the gingiva as this will be an irritation to the patient.

“the hooks must be positioned symmetrically in the upper and lower jaw. This symmetry is essential for functional training with elastics.”

04) Ligature Preparation a. Insert wire in

similar manner to direct wiring method, but do not tie it.

05) Attaching the bar to teeth with wire a. Position the arch bar and fix it using the wire

twister. b. Start from midline and successively proceed

to backwards till last tooth.

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c. One end of the wire should be above the arch bar and the other end below it.

06) Cut the wire with

the cutter and turn the ends away from the gingiva to prevent damage.

a. Make sure the wire rosettes do not protrude away from the arch bar as this will be an irritation to the patient.

07) Joining of maxilla and mandible IMF; a. Can be done by either elastics or wires.

CAP SPLINTS These appliances are used less frequently now a

days and are indicated in few cases as mentioned below;

o Patients with extensive and advanced periodontal disease. In current practice, surgeons

usually extract these teeth and apply bone plates.

o To provide prolong fixation on the mandibular teeth in a patient with fractures of tooth – bearing segment and bilateral displaced condylar neck fracture

o When a portion of body of the mandible is missing together with soft tissue loss.

o Orthognathic surgery o Mid facial fractures along with mandible

fracture. It is constructed in laboratory and is time

consuming. Completely formed splint is tried first before

cementation. Cementation of splints can be achieved by;

o Black copper cement o Cold – cure acrylic

Gingival inflammation is major disadvantage.

Impression technique for cap splints Only teeth and small amount of alveolar margin is

recorded in the impression.

Use mandibular tray for both jaws. o Overcome the problem of limited mouth

opening in fracture.

Mouth and teeth must be cleaned.

Alginate is reliable material for inexperienced doctors.

Inter-maxillary fixation wiring techniques. A, Arch bar inter-maxillary fixation. B, Ivy loop wiring technique. C, Continuous loop wiring technique.

Inter – maxillary fixation with osteosynthesis In this mandible fractures are treated by combination of IMF & trans osseous wiring.

TRANS OSSEOUS WIRING In this method, direct wiring across the fracture is

used to immobilize the fracture of mandible. o Holes are drilled in the bone ends on either

side of the fracture line after which stainless steel wire of 0.45 mm is passed through holes & across the fracture & after reduction, free ends of the wire are twisted together & cut off.

Upper border wires are applied via an intra – oral approach and this approach is used for;

o Aligning edentulous posterior fragment o Stabilizing fracture at the angle.

Lower border wires are applied via intra – oral or extra – oral approach for;

o Grossly displaced fractures of body or angle. o Fractures at symphysis region

Wiring can be done by intro oral incision in anterior buccal sulcus.

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If single wire is to be applied on lower border, it should be applied in “figure 8” pattern.

If the line of fracture is very oblique in the vertical plain. In this condition, pass two wires separately directly through outer and inner cortical plate and twist the ends together under lower the lower border.

Advantages of trans osseous wiring Minimal specialized equipment

CIRCUMFERENTIAL WIRING It is used in oblique fractures in which wire of same

dimension as trans osseous wire is passed circumferentially around fracture.

EXTERNAL PIN FIXATION It is mostly used in comminuted fractures. In this method, a pair of 1/8 inch (3mm) titanium or

stainless steel pin is inserted into each bone fragments which are connected to each by a cross bar attached with universal joints.

This type of fixation is not rigid and so that’s why IMF is required.

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Another method of reinforcing the extra oral fixation is by self-curing acrylic resin in” bi phasic appliance”

An alternative to the modular technique is the biphasic pin fixation (also known as Joe Hall Morris fixation).

Subsequent to the first phase where fracture alignment is achieved with adjustable connecting rods between the pin pairs (not shown in the illustration), is the second phase when the aligned pins are covered with a silicon tube, e.g. endotracheal tube, injected with methyl methacrylate resin. Alternatively, the pins can be connected with a moldable plastic shield that hardens after application.

Indications of External Pin Fixation Missile injuries of mandible

Infected fracture line

Extensively comminuted fractures

Bi-maxillary fracture (box frame fixation)

BONE CLAMPS It is external fixation Example of appliance; Brent Hurst appliance

In this method clamps are attached to fragments of fractured bone which is then joined with external rods similar to external pin fixation.

TRANSFIXATION WITH KIRSCHNER WIRES (K – WIRES) Most commonly used in orthopedic. They provide temporary stabilization in

comminuted fractures. o The fracture is reduced; holes are drilled on

both side of fracture parts in which wire is passed.

It can be applied as single rod or horseshoe shaped for whole mandible.

Choice of Method of Immobilization. The fracture pattern Skill of operator Resources available General medical condition of patient Presence of other injuries Degree of comminution Soft tissue injury or loss.

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FRACTURE OF EDENTULOUS MANDIBLE

Effects of edentulous mandible Loss of vertical depth Decreased resistance of bone to trauma Diminishing of endosteal bone supply of IAA

o Increase demand from periosteal blood supply.

Easily fractured Slow healing with complications Increased chances of displacement of bone

fragments Non union

ADVANTAGES OF EDENTULOUS MANDIBLE Less chances of compound fracture in the mouth

because of absence of teeth. o That’s why risk of fracture line infection is

reduced Precise reduction of fractured parts not necessary.

o Inaccuracy of jaw is compensated by dentures.

Reduction Precise anatomic reduction is not necessary as

mentioned above. Reduction and fixation become more difficult as

the mandible atrophies.

Methods of Immobilization Traditional method for immobilization of

edentulous mandible was inter maxillary fixation with Gunning Splints, however they are now replaced with other methods as mentioned in below.

In older patients inter maxillary fixation is less desirable because of following reasons;

o Difficulty in nutrition o Oral candidiasis o Etc.

The methods of immobilization currently available for edentulous jaws.

o Direct osteosynthesis Bone plates Trans osseous wiring Circumferential wiring or straps Trans fixation with Krischner

wires

Fixation using cortico cancellous bone graft

o Indirect Skeletal Fixation Pin fixation Bone clamps

o Inter maxillary fixation using Gunning Type Splints Used alone Combine with other methods.

DIRECT OSTEO SYNTHESIS

Bone Plates Currently preferred method of fixation for the

majority of edentulous mandible body fracture. Allow the fracture to be stabilized without

immobilizing the whole jaw. o The patient is comfortable.

Cannot be used with very thing mandible. o They require extensive stripping of

periosteum which can damage the blood supply and prevent the healing.

Trans Osseous Wiring It is simple and reliable alternative to bone plates. Does not provide rigid osteosynthesis and

supplementary fixation may be necessary Easier to apply from intra oral approach Less periosteal stripping is required; advantage in

thin mandible.

Circumferential Wiring or Straps Effective in oblique fracture of edentulous

mandible.

Trans fixation with Kirschner Wire Used where sufficient amount of bone is present in

edentulous mandible Contraindicated in ultra-thin mandible

Primary Bone Grafting It is a method of stabilizing and augmenting the

fracture of the body of the ultra – thin edentulous mandible.

A 5 cm length of rib is obtained as autogenous graft, the rib is split and placed at fracture site which is again covered with circumferential wiring.

o Iliac bone can be taken as bone graft. Postoperative morbidity at donor site is reduced by

controlled infusion of bupivacaine through epidural catheter.

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INDIRECT SKELETAL FIXATION OR OSTEOSYNTHESIS Same as mentioned for dentate mandible.

INTER MAXILLARY FIXATION USING GUNNING TYPE SPLINTS They are vulcanite overlay of the edentulous

mandible, consists of bite blocks in place of molar teeth and a space in the incisor area to facilitate feeding.

They can be used if edentulous space is in one or both jaws.

o If both jaws are edentulous, immobilization is carried out by attaching the maxillary splint by pre alveolar wires & mandibular splints with circumferential wires in the jaws. In them, inter maxillary fixation occur by connecting the both splints with wire loops and elastic bands.

o If one jaw is edentulous & other is not, then that one gunning splint is attached with whatever type of splint present in the opposite jaw.

These gunning splints should hold the jaws in slightly over close relationship.

The edges of these splints should be overextended to prevent entrapment of food.

o Overextension does not cause ulceration of mucosa in immobilized jaw.

Gunning splints are constructed on models from impression of patients’ mouth.

o The degree of overextension can be obtained by using impression compound as impression material.

The splints are constructed in acrylic resin and fitting surface is lined with black Gutta Percha.

o Hooks are incorporated into each splint for IMF

If the OMFS laboratory is not available, gunning splint can be prepared from patient’s denture by;

o Grinding the fitting surface and filling the black Gutta Percha, & then removing the anterior teeth for feeding. Hooks applied with self – cure material.

If maxillary splint is not retaining, it can be attached to maxilla by help of awl wire of 0.45 mm passing through the alveolus high up in the canine area on each side and then through an appropriately positioned hole in the palatal portion of the splint, the two free ends on each side are twisted together over the splint, cut short and bent in one of the hooks or clefts.

The lower splint is attached with help of circumferential wire.

They are still widely used for fixation of fractures of edentulous mandible.

Method is useful for simple fractures treated by minor surgeons.

Splint become foul during 4 – 6 weeks due to stagnation of food.

Candida induced stomatitis & infection of wire are common.

They are however inefficient as a method of immobilization and provide poor control of mobile fractures, particularly with thin mandible.

Selection of Method of Fixation in Edentulous Mandible Reduction should be accomplished with minimal

exposure because of risk of non – union due to interference with periosteal blood supply

In fit patients, open reduction & direct osteosynthesis is the method of choice. Inter – maxillary fixation should be avoided whenever possible.

The most effective form of osteosynthesis in edentulous mandible is by non-compression mini plates.

The ultra-thin mandible should be treated with autogenous bone grafts if the patient’s medical condition permits.

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FRACTURE OF CONDYLAR REGION They are the only facial bone fracture which involve

a synovial joint. Trauma to this region is divided into 3 main types.

o Contusion CHARACTERIZED BY; Damage to capsular ligaments Synovial effusion Haemarthosis Tearing of meniscus

o Dislocation Anterior & Medial common Lateral, Posterior & Central rare.

o Fracture

Management of Condylar Fracture 1) Conservative Management of Condylar Fracture 2) Open Reduction of Condylar Fracture

CONSERVATIVE MANAGEMNT OF CONDYLAR FRACTURE IMF Functional therapy

o Passive mandibular movement exercise o Mouth opening exercise

Advantages of Conservative Treatment Safe treatment No injury to nerves & vessels No post-operative complications

Disadvantages of Conservative Tx. IMF cause injury to PDL & Buccal Mucosa

Poor oral hygiene

Pronunciation disorder

Imbalanced nutrition

Mouth opening disorder

Respiration disorder

Growth disorder

Mandibular deviation

Facial asymmetry

OPEN REDUCTION OF CONDYLAR FRACTURE

Indications of Open Reduction Condylar displacement into middle cranial fossa Impossibility of restoring occlusion Lateral extra capsular displacement of condyle

Invasion by foreign body. E.g. Missile Patients in whom IMF is contraindicated Bilateral fracture along with mid face fracture Bilateral fracture with sever open bite

Advantages of Open Reduction Reduction of displaced bony fragments to the most

ideal anatomical site by direct approach to fracture site.

Prevent complications such as; o Respiratory disorder o Pronunciation disorder o Sever nutritional imbalance

Disadvantages of Open Reduction Invasive treatment Injury of nerves & vessels Post-operative infection Permanent scar

Major Complications ANKYLOSIS OF T.M.J Most frequent causes or factors

o Fractures in children below age 10 o Intra capsular crushing of condyle o Damage to meniscus

DISTURBANCE IN GROWTH Failure of development of condylar process and a smaller mandible on the affected side.

Treatment of Condylar Fracture Classification of Condylar Fractures

1) Age of patient a. Under 10 years b. 10 – 17 years c. Adults

2) Surgical Anatomy a. Intra capsular b. Extra capsular

i. High condylar neck ii. Low condylar neck

3) Site a. Unilateral b. Bilateral

4) Occlusion a. Disturbed b. Undisturbed.

Children Under 10 years of Age More chances of growth disturbances and

limitations of movement in this group.

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Malocclusion if caused by condylar fracture will resolve spontaneously in this age group.

Use only conservative approach in this age group. o Careful follow-up and monitoring of growth

is required and mandibular development is reduced, it can be treated with myofunctional appliances.

Adolescents 10 – 17 years’ age Capacity of spontaneous correction of

malocclusion is less than above mentioned younger group.

Also conservative treatment is given only.

ADULTS

Unilateral intra capsular fracture If occlusion is not disturbed, go for conservative

treatment without mandible immobilization. If malocclusion is present, go for IMF with eyelets

for 2 -3 weeks.

Unilateral condylar neck fracture If fracture is un-displaced and occlusion is normal –

no treatment. If fracture is displaced with malocclusion & there is

low condylar neck fracture – open reduction is treatment.

If, there is high neck fracture, displacement & malocclusion – IMF for 3 – 4 wks.

Bilateral Intra capsular fracture Immobilization of mandible for 3 – 4 weeks

followed by jaw physiotherapy for prevention of limited movement.

Bilateral Condylar neck fracture Functional treatment is contraindicated. IMF for up to 6 weeks Open intervention Treatment is beyond our scope.

FRACTURES OF MANDIBLE IN CHILDREN They are uncommon in children because of strong

mandible at this stage which require a large amount of force to fracture it.

Greenstick fracture is more frequent. Greater risk of damage to teeth;

o Disturbed formation o Pulp necrosis

The treatment of mandibular fracture in children before puberty is generally of a conservative nature

because of rapidly healing and adaptive potential of the bone and its contained dentition.

The normal growth of mandible will not occur if unerupted permanent teeth or teeth germs are lost because the alveolus will not develop at that site.

Fixation in the Deciduous & Mixed dentition Period FIXATION INDEPENDENT OF THE TEETH In the very young with unerupted or very few

deciduous teeth – gunning splint is used for lower jaw alone.

When there is widespread caries or loose deciduous teeth, the mandible may be suspended by circumferential wires on each side linked to circumzygomatic wires from above. fixation utilizing the teeth

Cap splints in partially erupted teeth. Eye lit wire or arch bar in sufficient firm deciduous

& permanent teeth. o Use thin wire 0.35 stainless steel o Arch bar without hooks

Orthodontic brackets in simple fractures.

Healing & Remodeling Mandibular fractures in children heal very rapidly and some fractures are stable within a week and firmly united within 3 weeks.

POST OPERATIVE CARE 01) The immediate post – operative phase

a. When pt. is recovering from the G.A

02) The intermediate post – operative phase

a. Before clinical bony union established

03) The late post – operative phase

IMMEDIATE POST – OPERATIVE PHASE Good nursing care in ICU or in ward till recovery

from G.A Naso pharyngeal airway should be left in situ after

operation till patient gain consciousness. Physical control of tongue in an unconscious with

the suture in patients with; o Extensive soft tissue injury to oropharynx o Expected to remain cerebrally irritated after

recovery.

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Patients should be lying on their sides during recovery to enable saliva or blood to escape from mouth.

Post – operative vomiting should be avoided and should not occur.

INTERMEDIATE POST – OPERATIVE CARE GENERAL SUPERVISION Occlusion should be checked;

o Direct osteosynthesis carries with it a greater risk of malalignment.

o Unacceptable reduction should be corrected as early as possible.

Inspection of IMF o P.O reduction is maintained or not o Looseness of fixation

Post – operative radiographs o Confirmation of satisfactory reduction and

fixation. Pain, swelling or infection if visible, should be

corrected ASAP o Good reduced & immobilized fracture is

painless & post – operative edema has been subsided.

POSTURE Conscious patient with mandible fracture should

be nursed with sitting position with the chin forward.

o This position is contra indicated in those patient in whom fracture vertebrae is present.

Unconscious patient should be nursed lying on the side.

SEDATION Adequately treated mandible fracture patient will

experience very little pain & P.O analgesics are rarely indicated and should not be given routinely.

Morphine & its derivatives are contraindicated in patients with maxillofacial injuries because they;

o Depress respiratory center & cough reflex. o Mask the declining level of consciousness. o Obscure the pupillary changes which are

indicative or rise in intra cranial pressure; Coz of constriction of pupil

o Suppression of signs of injuries of injuries of other areas. Intra – abdominal bleeding

Patients who are cerebrally irritated; o Sedate them with IV diazepam

Restless in semi – conscious patient is due to airway difficulty or distended bladder.

PREVENTION OF INFECTION Penicillin is the drug of choice along with

metronidazole to the regime.

ORAL HYEGINE Conscious Patient

o If mouth can be opened – hot normal saline mouthwashes OR 0.2% chlorhexidine gluconate mouthwash

o If mouth closed during embolization – clean the wires with TOOTHBRUSH is usual manner.

Unconscious Patient o Cleaning of mouth by nursing staff with

normal saline solution after every meal by using “Higginson Syringe”

o Cap splints can be cleaned with 1 – 4% sodium bicarbonate solution by cotton swabs held in forceps or tweezers.

Contaminated rubber bands are changed frequently.

The lips and mouth should be cleaned with moist saline swabs at regular intervals and lips regularly lubricated with steroid – containing ointment (1% hydrocortisone ointment) or petroleum jelly.

Feeding The conscious cooperative pt.

o These patients can be fed by mouth a semi – solid or liquid diet with the help of feeder, feeding cup or straw.

The unconscious or uncooperative patient o There are two routes of feeding in these

patients; Enteral Route

Trans – nasal gastric tube

Naso – gastric tube Parenteral Route

IV Drip (fluid overloading is greatest risk in this method)

Late Post – Operative Care TESTING OF UNION AND REMOVAL OF FIXATION All plates & trans osseous wires should not be

removed unless they cause trouble.

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Indication for their removal; o Infection o Exposure to mouth o Close & prominent proximity to skin o Interference with denture.

When IMF is used, it is left there until clinical union occurs.

o Little movement at the time of removal or wires is acceptable.

o The mouth should be cleaned with 1% chlorhexidine gluconate solution before removal of wires.

Cap splints are removed with Upper Reid forceps.

ADJUSTMENT OF OCCLUSION Little or none adjustment of occlusion is required

with direct or eyelet wiring.

Adjustment of occlusion is always required in cap splints.

Slight derangement of occlusion can be corrected by allowing the patient to masticate normally.

More gross abnormalities of occlusion are treated by grinding the cusps.

Edentulous patients will require new denture after healing, because old ones are not going to fit.

MOBILIZATION OF TMJ Function of TMJ is adversely affected in condyle

fractures. Other fractures also reduce the overall mobility and

closing force of mandible.

ANESTHESIA & PARESTHESIA OF LIP If IAN is involved in fracture, the damage may take

following form & recovery depend on nature & degree of damage;

o Neuropraxia OR It is a disorder of the peripheral nervous

system in which there is a temporary loss of motor and sensory function due to blockage of nerve conduction.

Take 6 – 8 weeks for recovery.

o Neurotmesis (in Greek tmesis signifies "to cut") It is

the most serious nerve injury in the scheme. In this type of injury, both the nerve and the nerve sheath are disrupted. While partial recovery may occur, complete recovery is impossible.

May take 18 months. Area of lower lip which is supplied by IAN also has

accessory sensory supply from the mylohyoid nerve.

Damage to lingual nerve cause loss of sensation in the anterior 2/3rd of tongue.

TEETH AND SUPPORTING TISSUES Fixation methods which involve attachments to

teeth need to distribute the load so as to avoid excessive traction on individual segments of the dentition, otherwise irreversible damage to PDL may occur.

Teeth retained in the fracture line – need periodontal treatment.

Lost teeth – prosthetic treatment.

COMPLICATIONS OF MANDIBLE FRACTURE

Complication Arising During Primary Treatment Misapplied Fixation

o Bone plates – damage to roots or inferior dental canal, distortion of anatomical alignment & occlusion.

o Trans osseous wires – displacement of bone fragments, damage to inferior alveolar nerve, inadequate retention of cap splint.

o External pins – impinge on nerves, vessels or teeth, split the bone fragments, may become loos if not inserted properly.

Infection o Results in necrosis or osteomyelitis o Mostly occur in patient with;

Diminished local resistance to bacterial invasion

Debilitated patients, diabetics, patients on steroid therapy

Injudicious surgical interference Nerve Damage

o Inferior alveolar nerve damage Anesthesia of Lower Lip as A Result

of Damage to Inferior Alveolar Nerve Is the Most Common Complication of Fracture of Mandible.

o Facial nerve damage. Displaced teeth and foreign bodies embedded in

tissue may result in abscess Pulpitis Gingival and periodontal complications

o Local gingivitis always occurs in interdental wires & cap splints

o Partial extrusion or loss of teeth from applying too much interdental force

Drug Reaction o if drug reaction is suspected, discontinue all

drugs and prescribe antihistamine.

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Later Complications Mal – Union

o Minor mal – union is more common in cap splints and usually results from; Uneven cementing of splints Variation in thickness of metal

casting. o If fixation is removed during clinical union

when the callus is still soft, minor discrepancies in the occlusion will often correct themselves as the patient starts to use the jaws again or by occlusal grinding.

o CAUSES OF GROSS DERANGEMENT OF OCCLSUION & DEFORMITY OF FACE; Untreated fracture They will require operative or

surgical reconstruction. Delayed Union

o Causes Infection osteoporosis nutritional deficiency. Sequestered bone Devitalized tooth

o Treatment Moderate delay – prolong the

immobilization. Removal of sequestered bone &

tooth Autogenous cancellous bone

chips from iliac crest in the fracture line inserted.

Non – Union o Radiographs shows rounding off and

sclerosis of bone ends – eburnation. o CAUSES OF NON – UNION o Infection of fracture site o Inadequate mobilization o Unsatisfactory apposition of bone ends

with interposition of soft tissues. o The ultra – thin mandible in elderly

debilitated patient o Loss of bone and soft tissue as a result of

severe trauma o Inadequate blood supply to the fracture

site – after radiotherapy o Bone pathology – neoplasm o General diseases;

Osteoporosis Nutritional deficiency Disorder of calcium metabolism

o TREATMENT OF NON – UNION Bone graft

Derangement of Temporomandibular Joint Late Problems with Tran osseous wires

o Trans osseous wire at the upper border cause symptoms if covered by denture.

o Bone plates should not be placed near the mucosa to prevent their rupture

o Lower border wires cause pain and discomfort in thin skins

o Infection of bone plates Sequestration of Bone

o Mostly in comminuted fractures o Act as source of infection

Limitation of opening o CAUSES

Prolonged immobilization - result in weakening of muscles of mastication.

Hemorrhage within muscles – form scar

Fibrodyplasia ossificans – rare condition in which hematoma ossifies.

o TREATMENT Spontaneous recovery Physiotherapy Manual manipulation under

anesthesia to break the scar Excision in Fibrodyplasia

ossificans. Scars

Summary of Complications Early Complication Later Complications

Misapplied Fixation

Infection

Nerve Damage

Displaced Teeth & Foreign bodies

Pulpitis

Gingival & Perio Complications

Drug Reaction

Mal – union

Delayed union

Non – union

Derangement of TMJ

Bone Sequestration

Trismus

Scars

FRACTURES WITH GROSS COMMINUTION OF BONE & LOSS OF HARD AND SOFT TISSUES Caused by;

o Industrial injuries or fast moving projectiles o Missile injury (most common cause)

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These fractures are usually extensively comminuted, compound & contaminated by foreign matter & bacteria

This kind of damage is due to release of Kinetic energy from fast moving object;

o Kinetic energy is directly proportional to velocity of object

There are FOUR phases of management of these fractures;

01) Immediate pre – operative phase 02) Primary surgery 03) Immediate post – operative phase 04) Reconstructive phase

Immediate Pre – Operative Phase Mentioned in Preliminary Treatment above.

Primary Surgery Performed only after tracheostomy.

01) Wound Toilet a. it is cleaning of wound

02) Debridement a. it is removal of devitalized tissues

03) Management of Involved Teeth a. Extensively damaged & subluxed teeth

should be removed 04) Reduction & Fixation

a. Arch wire is best method along with minimal number of trans osseous wires

05) Closure of mucosa & skin a. oral mucosa is closed first after reduction

and it must be water tight and then jaws are immobilized and after that skin wound is sutured.

b. The rich blood supply of face makes it easy to raise flap from other areas of face.

06) Drainage a. Drains are applied to prevent & control the

infection of sequestrate bone.

Immediate Post – Operative Phase Sympathetic nursing to boost their confidence

regarding the future facial deformity. Special feeding devices and saliva shield is given to

prevent the escape of oral secretions. Active oral hygiene with mouth irrigation Nursing care of wounds.

Reconstructive Phase Bone grafting Skin grafting Dentures Etc.

THE END

AUTHOR

SARANG SURESH HOTCHANDANI Final Year BDS, Batch – 01 Bibi Aseefa Dental College SMBBMU Larkana, Sindh, PAKISTAN [email protected] Mob: 03154044802 - 03463361966 www.twitter.com/fetusdentista