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RECENT ADVANCES IN MANAGEMENT OF MANDIBULAR FRACTURES

DONE BY R.G.ASHWANTH DEEPAKCRRI

INTRODUCTION

• Mandible is a strong bone,force requiring to fracture ranges from 44.6 to 74.4 kg/m yet mandible gets mostly fractured because of its anatomical postion in the maxillofacial region.

Anatomy

BLOOD SUPPLY

NERVE SUPPLY

Muscle attachment

Signs and symptoms

• Pain• Swelling• Ecchymosis• Jaw stiffness• Trismus• Open bite • Airway blockage• bleeding

CLASSIFICATION

DINGMAN AND NATVIG CLASSIFICATION based on anatomic region1.Symphysis#(midline #)2.Parasymphysis#(canine#)3.Body of mandible#(between canine and angle#)4.Angle region#5.Ramus#6.Coronoid#7.Condylar#8.Dentoalveolar#

Classification: Kruger,Rowe and Killey,Dingman and natvig.

1.favourable:a.Horizontally favourableb.Vertically favorable2.unfavourable:a.Vertically unfavourableb.Horizontally unfavourable

HISTORY1844 ERICH AND AUSTIN PREANTIBIOTIC ERA,CLOSED REDUCTION

1847 BUCK TRANSOSSEOUS SILVER WIRING

1943 CORDON WIRE SUTURING,STAINLESS STEEL INTRAOSSEOUS WIRING PLUS MMF

1970 SPIESSEL AO/ASIF-COMPRESSION PLATE

1973 MICHELET NONCOMPRESSION MONOCORTICAL SCREWS WITH MINIPLATE SYSTEM

1978 CHAMPY IDEAL OSTEOSYNTHESIS LINES

MANAGEMENT OF MANDIBULAR FRACTURS IN ADULTSCURRENT LINE OF TREATMENT

• The purpose of all therapy of fracture is restoration of original from and function.

• SURGICAL APPROACH• REDUCTION• FIXATION• IMMOBILIZATION

SURGICAL APPROACHCURRENT TECHNIQUE

• PROPER INCISION(BLADE AND ELECTRO CAUTRY)• USE OF PRE EXSISTING LACERATIONa)INTRA ORAL APPROACH:*SYMPHYSIS AND PARASYMPHYSIS-DEGLOVING INCISION*BODY,ANGLE,RAMUS-TRANS BUCCAL INCISION*INTRA ORAL APPROACH TO CONDYLEb)EXTRA ORAL*SUB MANDIBULAR-RISDON’S INCISION*SUB MENTAL,SUB MANDIBULAR,RETRO MADIBULAR*Facelift (rhytidectomy) approach*PRE AURICULAR APPROACH

DEGLOVING INCISON

TRANSBUCCAL INCISION

RISDON’S INCISON

LACERATIONS

SUB MENTAL APPROACH

FACE LIFT APPROACH

PRE AURICULAR INCISION

SURGICAL APPROACH- LASERS IN INCISION

• LIGHT AMPLIFICATION BY STIMULATED EMISSION OF RADIATON

• MONOCHROMATIC AND COHERENTADVANTAGES:• INCRESED BONE HEALING • REDUCED RISK OF INFECTION• LESS NEED OF ANAESTHESIA• LESS BLEEDING,NOISE,POST OP PAIN• BETTER RESULTS

# REDUCTIONCOVENTIONAL TECHNIQUE

1.CLOSED REDUCTION a)EXTERNAL REDUCTION DEVICESb)INTRAORAL AND EXTRAORAL TRACTION2.OPEN REDUCTION a) RIGID AND NON RIGID FIXATION

EXTRA ORAL TRACTION

EXTRA ORAL REDUCTION DEVICES

CLOSED REDUCTION RECENT ADVANCEMENTS

Hollow 18-gauge needle taken from intravenous cannula for pediatric patientsInstead of coventional arch bar

An indigenous method for closed reduction of pediatric mandibular parasymphysis fracture

FIXATION(conventional methods)1.INDIRECT FIXATION(CLOSED FIXATION):• INTERMAXILLARY FIXATION OR MAXILLOMANDIBULAR FIXATION• CRANIOMAXILLARY OR MANDIBULAR SUSPENSION • EXTERNAL FIXATION2.DIRECT FIXATION(INTERNAL FIXATION):• SEMIRIGID FIXATION: a)TRANSOSSEOUS WIRING b)NONCPMPRESSION MINIPLATES• RIGID FIXATION: a)COMPRESSION PLATES b)LAG SCREWS c)RECONTRUCTION PLATES

INTERMAXILLARY FIXATION

MANDIBULAR SUSPENSION

EXTRA ORAL TRACTION TRANSOSSOEUS

WIRING MANDIBLE

NON COMPRESSION MINI PLATES

COMPRESSION PLATES

LAG SCREWS

RECONTRUCTION PLATES

GUNNING SPLINT

Champy’s ideal lines of osteosynthesis

• Champy performed a series of experiments with miniplate that delineated “ideal lines of osteosynthesis”within the mandible,they are the ideal areas for plates and screws placement.

• Masticatory muscles produce tension at upper border and compression at lower border.

• Torsional forces produced anterior to the canines

• Monocortical “tension banding “ osteosynthesis neutralizes distraction and torsion during physiologic stress,while normal basilar compression is restored

Conventional technique

• https://www.youtube.com/watch?v=lnySz_znca0

RECENT ADVANCEMENTS IN FIXATION

1.BIO RESORBABLE PLATES2.THREE DIMENTONAL PLATES

CONSEQUENCES OF NOT REMOVING THE PLATE1) PALPABLE OR PROMINENT

HARDWARE2) LOOSENING OF PLATES AND

SCREWS3) PAIN4) INFECTION5) WOUND DEHISCENCE6) THERMAL SENSITIVITY7) PLATE MIGRATION

BIO RESORBABLE PLATES• DESPITE TITANIUM PLATES AND SCREWS BEING GOLD STANDARD IT HAS

FEW DISADVANTAGES AS FOLLOWS(ESPECIALLY RIGID FIXATION):1) GROWTH DISTURBANCE 2) PLATE MIGRATION3) NEED FOR SUBSEQUENT REMOVAL4) INCOMPATIBLITY WITH FUTURE IMAGING NEEDS

5) LONG TERM PALPABILITY6) THERMAL SENSITIVITY7) MALUNION8) DIFFICULTY IN CONTROLLING POST OPERATIVE OCCLUSION

CHEMICAL COMPOSITION: A)Polyglycolic acidB)Polylactic acidC)Polyesterspolyparadioxanon

ALPHA compounds

• FEATURES :1) INCREASED TENSILE AND FLEX STRENGTH2) EASILY ADAPT 3) VARIETY OF SIZES AND SHAPES4) HEX DRIVE BREAK AWAY DELIVERY SYSTEM SIMPLIFIES SCREW PLACEMENT5) ELIMINATES GROWTH RESTRICTION AND IMPLANT MIGRATION6)RESORB COMPLETELY AND ELIMINATES SECOND SURGERY7)NO LATE STAGE INFLAMMATORY REACTION

• Biodegradable plate are strong,biocompatible,adaptable and has enough stability

• Resorb quickly without any foreign body reaction.

• MECHANISM OF ACTION: BIORESORBABLE PLATES

METABOLIZED BY LIVER

BULK HYDROLYSIS(COVERT INTO CO2 AND H2O)

ADVANTAGES

• SMALL • BIOCOMPATIBLE• ADAPTABLE• ADEQUATE STABILITY TO ACHIEVE BONE

UNION• RESORBS IN TIMELY FASHION

TITANIUM VS BIODEGRADABLE PLATES

TITANIUM PALTES BIO DEGRADEBLE PLATES

HARD AND STRONG SOFTER AND WEAKER

FIRM TIGHT PRESSURE FINGER TIGHT PRESSURE

RADIOGRAPHICALLY APPARENT NOT RADIOGRAPICALLY APPARENT

USES• FRACTURE FIXATION IN TOOTH BEARING REGION• A BONE ANCHORED METHOD OF MAXILLOMANDIBULAR FIXATION• VERY LOW LOAD BEARING AREAS• PEDIATRIC CRANIOFACIAL OSTEOTOMU FIXATIONS

BIO RESORBABLE PLATE FIXATION

• STEP 1: HEATING THE PALATE AND BENDING • STEP 2:PRE TAPPING SCREW HEADS BEFORE

TAPPING

BIO RESORBABLE CERAMIC MATERIALS

• European Research Project Develops New Resorbable Bioceramic Materials

#They closely match the mechanical requirements of the implant siteshttp://www.odtmag.com/contents/view_videos/2016-04-01/european-research-project-develops-new-resorbable-bioceramic-materials

Three dimensonal mini plates

• They are known for their good stability due to the closed quadrangular geometric shape.

• Ease of contouring and adapting• Better inter fragmentary stability

• No need for supplementary fixation• Immediate post op jaw fixation• Minimal surgical exposure • Decresed periosteal stripping • Decreased hardware complications.

• Plating System• Plates• Design:• Square plate (1 cm × 1 cm)• Rectangular plate (1 cm × 0.5 cm)• Continuous Square or Double Square

(2 cm × 1 cm)

Continuous rectangle or double rectangle (2 cm × 0.5 cm)Double rectangle with an intervening square (2 cm × 1 cm)Diameter of plate hole: 2 mmThickness: 1 mm (Standard plates)

• The treatment of mandibular fractures (symphysis, parasymphysis, and angle) with 3-dimensional plates provided 3-dimensional stability and carried low morbidity and infection rates.

• The only probable limitations of 3-dimensional plates were excessive implant material due to the extra vertical bars incorporated for countering the torque forces.

IMMOBILISATION

• INTERMAXILLARY FIXATIONOR MAXILLOMANDIBULAR FIXATION

• AVERAGE RECOMMED TIME FOR IMMOBILISATION: 6WEEKS FOR ADULTS(TILL BONY CALLUS STAGE OF SECONDARY BONE HEALING

MANGEMENT OF FRACTURE NON UNION OR MALUNIONS(ADVANCEMENTS)

•

RECOMBINANT BONE MORPHOGENIC PROTIEN

• BMPs are subfamily if TGF- super family• BMPs derived from osteoblasts,chondrocytesand platelets• BMPs induce osteogenisis,chondrogenesis and angiogenisis

and extracellularmatrix• Thus they induce denovo bone synthesis at the site where

they are implanted.OSTEOINDUCTIVE PROPERTIES:• Mesenchymal cell infiltration• Cartilage formation• Vascularisation• Bone formation• Remodelling of new bone

Complicatiions:

• Exaggerated inflammatory response• Ectopic bone formation• Non responders

ALLOPLASTIC GRAFTS

• Alloplastic grafts are made from hydroxyapatite, a naturally occurring mineral (main mineral component of bone), made from bioactive glass.

• Hydroxyapatite is a synthetic bone graft, which is the most used now due to its osteoconduction, hardness, and acceptability by bone.

• properties:1. resorbable in long run.2. Osteogenic potential.3. Bioactive.

Osteoconduction

•Osteoconduction occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. •Osteoblasts from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone.

Types of alloplastic materials

• Dimethysiloxane(silicone): Parasymphyseal and symphyseal non unions• Polytetrafluoroethylene• Polyethelene• Polyesters• Acrylics: polymethyl methacrylate,hard tissue

replacement,bioplant hard tissue replacement• Calcium phosphate ceramics

Bone healer and graft enhancer

• PRP gel: Platelet rich plasmaIt is a caogulated platelet made from persons

own blood bycentrifugation,sequesteration and concerntation platelets.

Preparation:

Stem cells

• One of the human body's master cells, with the ability to grow into any one of the body's more than 200 cell types

• Bone marrow stem cells

Hybrid graft

Enhance oesteogenic potential• Coral scaffold +marrow stomal cells=tissue engneered artificial bone.

Thank you