Management of mandibular #

1. Management of mandibular #

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

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

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

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

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

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

8. Closed Reduction with IMF

9. Elastic traction

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

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

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

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

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

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

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

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

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

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

22. Eyelet - Ivy loops

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

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

25. Arch bar

26. Maxillomandibular fixation

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

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

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

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

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

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

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

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

38. miniplates

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

40. Lag Screw Technique

41. Lag Screw Technique

42. Lag Screw Technique

43. Lag screw

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

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

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

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

49. External skeletal fixation

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