Mandible Fractures

1. Mandible Fractures Karen Stierman, M.D. Byron J. Bailey, M.D., FACS June 14, 2000

2. Anatomy Mandible interfaces with skull base via the TMJ and is held in position by the muscles of mastication Divided into components with weakest sites being the third molar area, socket of the canine tooth, and the condyle.

3. Anatomic units of the mandible

4. Innervation Mandibular nerve through the foramen ovale Inferior alveolar nerve through the mandibular foramen Inferior dental plexus Mental nerve through the mental foramen

5. Anatomy - Mental foramen Teest note Teest note

6. Anatomy - Mandibular foramen

7. Arterial supply Internal maxillary artery from the external carotid Inferior alveolar artery through the mandibular foramen Mental artery through the mental foramen

8. Angle�s classification

9. Classification of teeth

10. Demographics

11. MANDIBLE FRACTURES CAN ALSO BE CLASSIFIED BY THE PRESENCE OR ABSENCE OF TEETH - CLASS I - TEETH ON BOTH SIDES OF THE FX. LINE DENTULOUS CLASS II - TEETH ON ONE SIDE OF THE FX. LINE PARTIALLY ENDENTULOUS CLASS III - NO TEETH , EDENTUOUSMANDIBLE FRACTURES CAN ALSO BE CLASSIFIED BY THE PRESENCE OR ABSENCE OF TEETH - CLASS I - TEETH ON BOTH SIDES OF THE FX. LINE DENTULOUS CLASS II - TEETH ON ONE SIDE OF THE FX. LINE PARTIALLY ENDENTULOUS CLASS III - NO TEETH , EDENTUOUS

12. Fracture Frequency

13. Mandibular Forces DEPRESSORS OF THE JAW: LATERAL PTERYGOID - ARISES FROM THE LAT. PTERYG. PLATE AND INSERTS ON THE CONDYLAR NECK AND THE TMJ JOINT CAPSULE MYLOHYOID - ARISES FROM THE MYLOHYOID LINE AND INSERTS INTO THE BODY OF THE HYOID DIGASTRIC - ARISES AT THE MASTOID NOTCH AND INSERTS INTO DIGASTRIC FOSSA GENOIHYOID - ARISES FROM THE INFERIOR GENIAL TURERCLE AND INSERTS INTO THE ANTERIOR HYOID BONE ELEVATORS OF THE JAW: MASSETER - ARISES FROM THE ZYGOMA AND INSERTS INTO THE ANGLE AND THE RAMUS TEMPORALIS - ARISES FROM THE INFRATEMPORAL FOSSA AND INSERTS ON THE CORONOID PROCESS AND RAMUS MED.PTERY - ARISES FROM THE MED.PTERY.PLATE AND PYRAMIDAL PROCESS OF THE PALATINE BONE ANDINSERTS ON THE INNER TABLE OF THE LOWER MANDIBLEDEPRESSORS OF THE JAW: LATERAL PTERYGOID - ARISES FROM THE LAT. PTERYG. PLATE AND INSERTS ON THE CONDYLAR NECK AND THE TMJ JOINT CAPSULE MYLOHYOID - ARISES FROM THE MYLOHYOID LINE AND INSERTS INTO THE BODY OF THE HYOID DIGASTRIC - ARISES AT THE MASTOID NOTCH AND INSERTS INTO DIGASTRIC FOSSA GENOIHYOID - ARISES FROM THE INFERIOR GENIAL TURERCLE AND INSERTS INTO THE ANTERIOR HYOID BONE ELEVATORS OF THE JAW: MASSETER - ARISES FROM THE ZYGOMA AND INSERTS INTO THE ANGLE AND THE RAMUS TEMPORALIS - ARISES FROM THE INFRATEMPORAL FOSSA AND INSERTS ON THE CORONOID PROCESS AND RAMUS MED.PTERY - ARISES FROM THE MED.PTERY.PLATE AND PYRAMIDAL PROCESS OF THE PALATINE BONE ANDINSERTS ON THE INNER TABLE OF THE LOWER MANDIBLE

14. FAVORABLE FX ARE THOSE FX WHERE MUSCLES TEND TO DRAW THE FRAGMENTS TOGHETHER. RAMUS FX ARE ALMOST ALWAYS FAVORABLE SECONDARY TO THE ELEVATING FORCES OF THE JAW ELEVATORS . UNFAV MOST ANGLE FX ARE HORIZONTALLY UNFAV. B/C OF THE PULL OF THE JAW ELEVATORS VERTICALLY UNFAVORABLE FX OF THE SYMPHYSIS AND PARASYMPYSIS TEND TO COLLAPSE INWARD IN A SISSOR LIKE FASHION SECONDARY TO THE JAW DEPRESSORS ESP. MYOHYOIDFAVORABLE FX ARE THOSE FX WHERE MUSCLES TEND TO DRAW THE FRAGMENTS TOGHETHER. RAMUS FX ARE ALMOST ALWAYS FAVORABLE SECONDARY TO THE ELEVATING FORCES OF THE JAW ELEVATORS . UNFAV MOST ANGLE FX ARE HORIZONTALLY UNFAV. B/C OF THE PULL OF THE JAW ELEVATORS VERTICALLY UNFAVORABLE FX OF THE SYMPHYSIS AND PARASYMPYSIS TEND TO COLLAPSE INWARD IN A SISSOR LIKE FASHION SECONDARY TO THE JAW DEPRESSORS ESP. MYOHYOID

15. Evaluation - History Mechanism of injury MVA associated with 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

16. Past Medical History Pmhx bone disease neoplasia arthritis, tmj (risk for ankylosis) collagen vascular disease, endocrine d/o nutrition and metabolic disorders, including alchohol abuse seizure d/o

17. 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.

18. Malocclusion Bilateral mandible fx(BODY) or expanding hematoma of fom can be associated with airway distress MAY NEED TO PULL JAW FORWARD OR LATERAL DECUBITUS ALSO WIRED OR PULL TOUNGE FOWARDBilateral mandible fx(BODY) or expanding hematoma of fom can be associated with airway distress MAY NEED TO PULL JAW FORWARD OR LATERAL DECUBITUS ALSO WIRED OR PULL TOUNGE FOWARD

19. 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 ANESTHESIA OF THE LOWER LIP IS PATHOGNOMONIC OF A FX. DISTAL TO THE MANDIBULAR FORAMEN.(CONVERSE NOT TRUE) CAN USE LACERATIONS TO ACCESS FX ECCHYMOSIS OF THE FOM IS SUSPICIOUS FOR BODY OR SYMPHYSEAL FX. MULTIPLE FX TEETH THINK ALVEOLAR FX. PALPATE MANDIBLE AND CSPINE - LOOKING FOR PT TENDERNESS - DR. QUINN ALSO LOOKING FOR CREPITUS *******CLEAR CSPINEANESTHESIA OF THE LOWER LIP IS PATHOGNOMONIC OF A FX. DISTAL TO THE MANDIBULAR FORAMEN.(CONVERSE NOT TRUE) CAN USE LACERATIONS TO ACCESS FX ECCHYMOSIS OF THE FOM IS SUSPICIOUS FOR BODY OR SYMPHYSEAL FX. MULTIPLE FX TEETH THINK ALVEOLAR FX. PALPATE MANDIBLE AND CSPINE - LOOKING FOR PT TENDERNESS - DR. QUINN ALSO LOOKING FOR CREPITUS *******CLEAR CSPINE

20. Evaluation - Panorex PANOREX SHOWS ENTIRE MANDBILE - IT IS THE SINGLE BEST XRAY TO GET BUT PT HAS TO BE UPRIGHT AND THIS CAN BE DIFFICULT FOR THE PATIENT WITH MULTISYSTEM TRAUMA ALSO GIVES POOR DETAIL IN THE TMJ AREA AND DOESN�T SHOW MEDIAL CONDYLAR DISPLACEMENT AND ALVEOLAR PROCESS FX. PANOREX SHOWS ENTIRE MANDBILE - IT IS THE SINGLE BEST XRAY TO GET BUT PT HAS TO BE UPRIGHT AND THIS CAN BE DIFFICULT FOR THE PATIENT WITH MULTISYSTEM TRAUMA ALSO GIVES POOR DETAIL IN THE TMJ AREA AND DOESN�T SHOW MEDIAL CONDYLAR DISPLACEMENT AND ALVEOLAR PROCESS FX.

21. Evaluation - Mandible films AP, LATERAL, REV. TOWNES, SUBMENTAL AP FILM SHOWS RAMUS AND CONDYLE WELL SUBMENTAL IS GOOD FOR SYMPHYSIS CT IS GOOD FOR CONDYLAR FX THAT ARE DIFFICULT TO VISUALIZE ON PANOREXAP, LATERAL, REV. TOWNES, SUBMENTAL AP FILM SHOWS RAMUS AND CONDYLE WELL SUBMENTAL IS GOOD FOR SYMPHYSIS CT IS GOOD FOR CONDYLAR FX THAT ARE DIFFICULT TO VISUALIZE ON PANOREX

22. Associated Injuries 40 - 60 % OF MANDIBLE FRACTURES ARE ASSOCIATED WITH OTHER INJURIES 10% OF THESE ARE LETHAL RARE - CONDYLAR FX CAN BE DISPLACED WITH FRAGMENT HERNIATING THROUGH TH E ROOF OF THE GLENOID FOSSA INTO THE FLOOR OF THE MIDDLE CRANIAL FOSSA CAN BE ASSOCIATED WITH DURAL TEAR - CALL NSGY40 - 60 % OF MANDIBLE FRACTURES ARE ASSOCIATED WITH OTHER INJURIES 10% OF THESE ARE LETHAL RARE - CONDYLAR FX CAN BE DISPLACED WITH FRAGMENT HERNIATING THROUGH TH E ROOF OF THE GLENOID FOSSA INTO THE FLOOR OF THE MIDDLE CRANIAL FOSSA CAN BE ASSOCIATED WITH DURAL TEAR - CALL NSGY

23. Cervical spine injury MOTOR VEHICLE ACCIDENTS ARE THE PREDOMINANT CAUSE OF CERVIAL SPINE INJURY IN ASSOCIATION WITH MANDIBLE FX. THOUGHT THE INCIDENCE OF CSPINE INJURY IS LOW (2.5%) ACCORDING TO A STUDY OUT OF ISREAL THAT LOOKED AT 424 MANDIBLE FX AND ASSOCIATED INJURY.. IT IS IMPORTANT TO RECOGNIZE SECONDARY TO POTENTIAL NUEROLOGICAL DAMAGE THAT IS IRREVIERSIBLE IF MISSED. C1 AND C2 MOST COMMONLY INVOLVEDMOTOR VEHICLE ACCIDENTS ARE THE PREDOMINANT CAUSE OF CERVIAL SPINE INJURY IN ASSOCIATION WITH MANDIBLE FX. THOUGHT THE INCIDENCE OF CSPINE INJURY IS LOW (2.5%) ACCORDING TO A STUDY OUT OF ISREAL THAT LOOKED AT 424 MANDIBLE FX AND ASSOCIATED INJURY.. IT IS IMPORTANT TO RECOGNIZE SECONDARY TO POTENTIAL NUEROLOGICAL DAMAGE THAT IS IRREVIERSIBLE IF MISSED. C1 AND C2 MOST COMMONLY INVOLVED

24. Cervical spine injury LATERAL VIEW SHOWING CPSINE FXLATERAL VIEW SHOWING CPSINE FX

25. General Principles of treatment Tetanus Nutrition Almost all can be considered open fx as they communicate with skin or oral cavity Reduction and fixation Post-op monitoring for N/V, use of wire cutters Oral care - H2O2 , irrigations, soft toothbrush Biweekly exam - hardware, occlusion, weight USUALLY WANT TO FIX SOON - DELAYED FIXING HAS NOT BEEN SHOWN TO INCREASE INFENCTION RATE ACCORDING TO BAILEY TXT. COMMON PATHOGENS, ORAL FLORA - SREPT , STAPH AND BACTEROIDES, CLINDA OR PCNUSUALLY WANT TO FIX SOON - DELAYED FIXING HAS NOT BEEN SHOWN TO INCREASE INFENCTION RATE ACCORDING TO BAILEY TXT. COMMON PATHOGENS, ORAL FLORA - SREPT , STAPH AND BACTEROIDES, CLINDA OR PCN

26. Treatment options No treatment Soft diet Maxillomandibular fixation Open reduction - non-rigid fixation Open reduction - rigid fixation External pin fixation Lag screw, DCP ISOLATEDNONDISPLACED FX OF THE CORONOID PORCESS DO NOT REQUIRE SPECIFIC TX - REALLY ONLY TIME YOU NEED TO TX IS IF IT IS IMPINGING ON THE ZYGOMA AND PT IS UNABLE TO OPEN MOUTH. UNILATERAL NONDISPLACED FX OF THE SUBCONDYLAR AREA OF THE MNADBILE AND NORMAL OCCLUSION - TX WITH SOFT DIET ONLY. PT�S WHO DEVELOP MALOCCLUSION AND/OR PERSISTANT PAIN SHOULD BE MANAGED WITH MMFISOLATEDNONDISPLACED FX OF THE CORONOID PORCESS DO NOT REQUIRE SPECIFIC TX - REALLY ONLY TIME YOU NEED TO TX IS IF IT IS IMPINGING ON THE ZYGOMA AND PT IS UNABLE TO OPEN MOUTH. UNILATERAL NONDISPLACED FX OF THE SUBCONDYLAR AREA OF THE MNADBILE AND NORMAL OCCLUSION - TX WITH SOFT DIET ONLY. PT�S WHO DEVELOP MALOCCLUSION AND/OR PERSISTANT PAIN SHOULD BE MANAGED WITH MMF

27. Maxillomandibular fixation CLASSICAL INDICATIONS FOR CLOSED REDUCTION: GROSSLY COMMINUTED FX - HEAL BETTER IF PERIOSTEUM INTACT BUT MAY NEED EXT. FIX OR RECON. BAR FX WITH SIGNIFICANT LOSS OF SOFT TISSUE EDENTULOUS MANDIBLES - CLOSED REDUCTION WITH A GUNNING SPLINT FX IN KIDS- OPEN REDUCTION CAN DAMAGE DEVELOPING TEETH CONDYLAR FX - EARLY JAW MOBILIZATION IS REQUIRED TO AVOID ANKYLOSIS OF THE TMJ. KIDS - WEEKLY, ADULTS BIWEEKLYCLASSICAL INDICATIONS FOR CLOSED REDUCTION: GROSSLY COMMINUTED FX - HEAL BETTER IF PERIOSTEUM INTACT BUT MAY NEED EXT. FIX OR RECON. BAR FX WITH SIGNIFICANT LOSS OF SOFT TISSUE EDENTULOUS MANDIBLES - CLOSED REDUCTION WITH A GUNNING SPLINT FX IN KIDS- OPEN REDUCTION CAN DAMAGE DEVELOPING TEETH CONDYLAR FX - EARLY JAW MOBILIZATION IS REQUIRED TO AVOID ANKYLOSIS OF THE TMJ. KIDS - WEEKLY, ADULTS BIWEEKLY

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

29. Alternative - Ivy loops IVY LOOPS - NOT AS STRONG AS THE ARCH BAR, USEFUL IN SELECTIVELY BRINGIN OCCLUSAL PAIRS OF TEETH TOGHETHER. APPLICATION IN KIDS WITH M IXED DENTITION, IN PARTIALLY EDENTULOUS PTS WHO WILL HAVE ADDITIONAL FORMS OF FIXATION, AND PTS WHO NEED TEMPORARY OCCLUSION WHILE OTHER METHODS ARE BEING APPLIED (PLATES OR EXT-FIX) TO MAKE; 26 GUAGE WIRE IS CUT TO 16 CM. SMALL LOOP IS FORMED HEMOSTAT. THE ENDS ARE INSERTED BETWEEN TWO SUITABLE TEETH. THE MESIAL END IS PASSE D THROUGH THE LOOP AND THEN TIGHTENED 28 GUAGE WIRES GO THROUGH THE EYE LITS FOR FIXATIONIVY LOOPS - NOT AS STRONG AS THE ARCH BAR, USEFUL IN SELECTIVELY BRINGIN OCCLUSAL PAIRS OF TEETH TOGHETHER. APPLICATION IN KIDS WITH M IXED DENTITION, IN PARTIALLY EDENTULOUS PTS WHO WILL HAVE ADDITIONAL FORMS OF FIXATION, AND PTS WHO NEED TEMPORARY OCCLUSION WHILE OTHER METHODS ARE BEING APPLIED (PLATES OR EXT-FIX) TO MAKE; 26 GUAGE WIRE IS CUT TO 16 CM. SMALL LOOP IS FORMED HEMOSTAT. THE ENDS ARE INSERTED BETWEEN TWO SUITABLE TEETH. THE MESIAL END IS PASSE D THROUGH THE LOOP AND THEN TIGHTENED 28 GUAGE WIRES GO THROUGH THE EYE LITS FOR FIXATION

30. Maxillomandibular fixation MMF IN A PATIENT, CAN USES WIRE OR ELASTICS IN DOING THIS YOU WANT TO AVOID FIXING THE INCISORS AS THESE CAN BE ORTHODONTICALLY MOVED BY THE WIRES. MMF IN A PATIENT, CAN USES WIRE OR ELASTICS IN DOING THIS YOU WANT TO AVOID FIXING THE INCISORS AS THESE CAN BE ORTHODONTICALLY MOVED BY THE WIRES.

31. Open reduction - nonrigid fixation CLASSICAL INDICATION FOR OPEN REDUCTION MALOCCLUSION DESPITE MMF DISPLACED UNFAVORABLE FX THROUGH THE ANGLE DISPLACED, UNFAVORABLE FX OF THE BODY OR THE PARASYMPHYSIS MULTIPLE FX OF THE FACIAL BONES - MANDIBLE IS FIXED FIRST PROVIDING A STABLE BASE FOR RESTORATION - BOTTOM UP MALUNION - OSTEOTOMIES AND ORIF ----- NON RIGID FIXATION MORE FORGIVING, EASIER TO PLACE. STILL REQUIRES MMT, USEFUL IN ANGLE AND PARASYMPHYSEAL FX. CAN GO EXTRAORAL OR TRANSORAL(FOR A HIGH WIRE) CLASSICAL INDICATION FOR OPEN REDUCTION MALOCCLUSION DESPITE MMF DISPLACED UNFAVORABLE FX THROUGH THE ANGLE DISPLACED, UNFAVORABLE FX OF THE BODY OR THE PARASYMPHYSIS MULTIPLE FX OF THE FACIAL BONES - MANDIBLE IS FIXED FIRST PROVIDING A STABLE BASE FOR RESTORATION - BOTTOM UP MALUNION - OSTEOTOMIES AND ORIF ----- NON RIGID FIXATION MORE FORGIVING, EASIER TO PLACE. STILL REQUIRES MMT, USEFUL IN ANGLE AND PARASYMPHYSEAL FX. CAN GO EXTRAORAL OR TRANSORAL(FOR A HIGH WIRE)

32. Open reduction - Rigid fixation ARCH BARS ARE ALWAYS PLACED FIRST THEN ORIF. CAN USE 2.4 AND 2.0 ,TWO 2.0 PLATES, COMBO�S OF THESE WITH ARCH BARS AS TENSION BANDS WHEN FITTING PLATES IT IS IMPORTANT THAT THE PLATE IS BENT SO THAT IF FITS THE CURVE OF THE MANDIBLE. DCP CAN B E USED(AS WITH LAG SCREW YOU WANT TO BE EXPERIENCED TO DO THIS AS IMPROPER PLACEMENT CAN LEAD TO MALUNION) IT CAN BE USED FOR MOST OF THE BODY, ANGLE, SYMPYSEAL OR PARASYMPHYSEAL FX. TO PUT IN DCP - FIT 4 HOLE PLATE WITH 2 HOLES ON EITHER SIDE OF FX. THE DCP IS SECURED BY DRILLING A HOLE AT THE OUTER EDGE OF THE INNER ECCENTRIC COMPRESSION HOLE. THIS IS REPEATED ON THE OTHER SIDE. THESE HOLES ARE DRILLED WITH A 2.1 MM DRILL BIT AND 2.7 MM SCREWS ARE PLACED SO THAT COMPRESSION IS OBTAINED. NEXT THE OTHER TWO LATERAL DRILL HOLES ARE DRILLED AND SCREWS PLACED IN A NORMAL FASHION. DISADVAT INCLUDE TRAUMATIC BONE LOSS, EXTENSIVE COMMUNUTION, AND SEVERE BONE ATROPHY CAN USE PERCUTANOUES SYSTEM FOR ANGLE AND BODY FXARCH BARS ARE ALWAYS PLACED FIRST THEN ORIF. CAN USE 2.4 AND 2.0 ,TWO 2.0 PLATES, COMBO�S OF THESE WITH ARCH BARS AS TENSION BANDS WHEN FITTING PLATES IT IS IMPORTANT THAT THE PLATE IS BENT SO THAT IF FITS THE CURVE OF THE MANDIBLE. DCP CAN B E USED(AS WITH LAG SCREW YOU WANT TO BE EXPERIENCED TO DO THIS AS IMPROPER PLACEMENT CAN LEAD TO MALUNION) IT CAN BE USED FOR MOST OF THE BODY, ANGLE, SYMPYSEAL OR PARASYMPHYSEAL FX. TO PUT IN DCP - FIT 4 HOLE PLATE WITH 2 HOLES ON EITHER SIDE OF FX. THE DCP IS SECURED BY DRILLING A HOLE AT THE OUTER EDGE OF THE INNER ECCENTRIC COMPRESSION HOLE. THIS IS REPEATED ON THE OTHER SIDE. THESE HOLES ARE DRILLED WITH A 2.1 MM DRILL BIT AND 2.7 MM SCREWS ARE PLACED SO THAT COMPRESSION IS OBTAINED. NEXT THE OTHER TWO LATERAL DRILL HOLES ARE DRILLED AND SCREWS PLACED IN A NORMAL FASHION. DISADVAT INCLUDE TRAUMATIC BONE LOSS, EXTENSIVE COMMUNUTION, AND SEVERE BONE ATROPHY CAN USE PERCUTANOUES SYSTEM FOR ANGLE AND BODY FX

33. External Fixation USUALLY NECESSARY IN COMMUNUTED FX. THOSE WHO CANNOT TOLERATE MMF OR GSWUSUALLY NECESSARY IN COMMUNUTED FX. THOSE WHO CANNOT TOLERATE MMF OR GSW

34. Lag screw LAG SCREW TECHNIQUE CAN BE USEFUL FOR THE OBLIQUE HORIZONTALLY DIRECTED ANGLE FX OR A PARASYMPHYSEAL FX. ONLY USE IF EXPERIENCED. FIRST THE OUTER SEGMENT OF BONE IS DRILLED WITH A 2.7 MM DRILL BIT, ONCE YOU REACH THE INNER CORTEX STOP AND USED A 2MM DRILL BIT THROUGH THE INNER CORTEX, THEM APPLY A SCREW SLIGHTLY LARGER THAN 2MM. TIGHTENING THE SCREW FORCES THE OUT FRAGMENT AGAINST THE HEAD AND THE DEEP FRAGMENT IN THEN BROUGHT UP INTO CONTACT WITH THE OUTER FRAGMENT SINCE LAG SCREW AND DCP COMPRESS THE BONE CAN RESULT IN ATROPHY AND MALUNIION. THOSE FX. THAT HAVE A STRAIGHT COURSE FROM THE BUCCAL TO THE LINGUAL CORTEX LEND THEMSELVES MORE TO COMPRESSION RATHER THAN THOSE FX THAT ARE OBLIQUE OR SAGITALL BETTER FOR LAG. DO NOT USE COMPRESSION IN CASES OF INFECTION OR COMMINUTION- USE LARGE RECON PLATES 2.4MMLAG SCREW TECHNIQUE CAN BE USEFUL FOR THE OBLIQUE HORIZONTALLY DIRECTED ANGLE FX OR A PARASYMPHYSEAL FX. ONLY USE IF EXPERIENCED. FIRST THE OUTER SEGMENT OF BONE IS DRILLED WITH A 2.7 MM DRILL BIT, ONCE YOU REACH THE INNER CORTEX STOP AND USED A 2MM DRILL BIT THROUGH THE INNER CORTEX, THEM APPLY A SCREW SLIGHTLY LARGER THAN 2MM. TIGHTENING THE SCREW FORCES THE OUT FRAGMENT AGAINST THE HEAD AND THE DEEP FRAGMENT IN THEN BROUGHT UP INTO CONTACT WITH THE OUTER FRAGMENT SINCE LAG SCREW AND DCP COMPRESS THE BONE CAN RESULT IN ATROPHY AND MALUNIION. THOSE FX. THAT HAVE A STRAIGHT COURSE FROM THE BUCCAL TO THE LINGUAL CORTEX LEND THEMSELVES MORE TO COMPRESSION RATHER THAN THOSE FX THAT ARE OBLIQUE OR SAGITALL BETTER FOR LAG. DO NOT USE COMPRESSION IN CASES OF INFECTION OR COMMINUTION- USE LARGE RECON PLATES 2.4MM

35. Injury to teeth Fractured teeth can become infected and cause malunion. Extraction necessary if root of tooth is fractured A tooth that is intact but in the line of the fracture can be left in place and protected by antibiotics may need extraction later

36. Treatment options for dentate patients CONDYLAR FRACURES MOST OFTEN TX WITH MMF ONLY - NONDISPLACED FOR 3 WKS, FOLLOWED BY ELASTICS X 2 WEEKS DISPLACED - 6 WEEKS OF IMF MAY NEED NOTHING OR MAY NEED ORIF TO AVOID ANKYLOSING THE TMJ NEED TO MOBILIZE EVERY 2 WEEKS IF ADULT. RAMUS FX ARE NATURALLY SPLINTED BY THE PTERYGOMASSETERIC MUSCLE SLING AND USUALLY GET MMF WITH SAME TIMEFRAME AS CONDYLAR. BODY- SEE ABOVE, ANGLE SEE ABOVE SYMP-PARA B/C NO OCCLUSAL STOPS IF CLOSED REDUCTION MAY NEED LINGUAL SPLINT IN ADDITION FOR THE ANLGE BODY OR SYM, PARASY CAN USE 2.4 AND 2.O OR 2.4 AND ARCH BAR OR TWO 2.O CONDYLAR FRACURES MOST OFTEN TX WITH MMF ONLY - NONDISPLACED FOR 3 WKS, FOLLOWED BY ELASTICS X 2 WEEKS DISPLACED - 6 WEEKS OF IMF MAY NEED NOTHING OR MAY NEED ORIF TO AVOID ANKYLOSING THE TMJ NEED TO MOBILIZE EVERY 2 WEEKS IF ADULT. RAMUS FX ARE NATURALLY SPLINTED BY THE PTERYGOMASSETERIC MUSCLE SLING AND USUALLY GET MMF WITH SAME TIMEFRAME AS CONDYLAR. BODY- SEE ABOVE, ANGLE SEE ABOVE SYMP-PARA B/C NO OCCLUSAL STOPS IF CLOSED REDUCTION MAY NEED LINGUAL SPLINT IN ADDITION FOR THE ANLGE BODY OR SYM, PARASY CAN USE 2.4 AND 2.O OR 2.4 AND ARCH BAR OR TWO 2.O

37. Special Considerations -Indications for ORIF of Condylar Fractures

38. Special considerations - Pedi Deciduous teeth vs. permanent Fractures with deciduous dentition can be treated with MMF for 2-3 weeks. Rigid techniques can harm the tooth bud. Growth center The most feared complication of a pedi mandible fx is ankylosing of the TMJ with impact on jaw growth that causes severe facial deformity- prevent with weekly mobilization

39. Special considerations - pedi IT IS HARDER TO PERIDONTAL WIRE LIGATURES AROUND DECIDOUS TEETH BECAUSE THE TOOTH IS CLOSER TO THE GINGIVAL MARGIN THAN THE CROWN OF THE PERMANENT TOOTH SO IT MAY BE NECESSARY TO SECURE THE WIRES TO THE PIRIFORM RIM AND MANDIBLE BY CIRCUMANDIBULAR WIRESIT IS HARDER TO PERIDONTAL WIRE LIGATURES AROUND DECIDOUS TEETH BECAUSE THE TOOTH IS CLOSER TO THE GINGIVAL MARGIN THAN THE CROWN OF THE PERMANENT TOOTH SO IT MAY BE NECESSARY TO SECURE THE WIRES TO THE PIRIFORM RIM AND MANDIBLE BY CIRCUMANDIBULAR WIRES

40. Special considerations - pedi

41. Special considerations - Edentulous patients Dentures Splint Cirumzygomatic and circumandibular fixation IF PT HAS DENTURES CAN BE WIRED TO THE JAW USING CIRCUMANDIBULAR OR CIRCUMZYGOMATIC WIRES SCREWS CAN ALSO BE USED TO FIXATE DENTURES INTO THE PALATE AND MANDIBLE IF NO DENTURES AVAILABLE, GUNNING SPLINTS WITH AN ARCH BAR INCORPORATED INTO THEM ARE USEDIF PT HAS DENTURES CAN BE WIRED TO THE JAW USING CIRCUMANDIBULAR OR CIRCUMZYGOMATIC WIRES SCREWS CAN ALSO BE USED TO FIXATE DENTURES INTO THE PALATE AND MANDIBLE IF NO DENTURES AVAILABLE, GUNNING SPLINTS WITH AN ARCH BAR INCORPORATED INTO THEM ARE USED

42. Splint fabrication FIRST MAKE AN IMPRESSIONFIRST MAKE AN IMPRESSION

43. Splint fabrication NEXT MAKE A CAST FROM THE IMPRESSION - USUALLY PLASTER OR STONE OF COMBONEXT MAKE A CAST FROM THE IMPRESSION - USUALLY PLASTER OR STONE OF COMBO

44. Splint fabrication NEXT ACRYLIC SPLINTS ARE MADE - GUNNING SPLINTS NOTE HOLES FOR WIRING AND GROOVES FOR CIRUMANDIBULAR WIRENEXT ACRYLIC SPLINTS ARE MADE - GUNNING SPLINTS NOTE HOLES FOR WIRING AND GROOVES FOR CIRUMANDIBULAR WIRE

45. Application of Splints FIXED WITH CIRCUMZYGOMATIC AND CIRCUMANDIBULARWIRESFIXED WITH CIRCUMZYGOMATIC AND CIRCUMANDIBULARWIRES

46. Application of splints THIS SLIDE SHOWS THE CIRCUZYGO AND MANDIBL. WIRES AND THE COMPLETED FIXATIONTHIS SLIDE SHOWS THE CIRCUZYGO AND MANDIBL. WIRES AND THE COMPLETED FIXATION

47. Denture preparation DENTURES WITH A CHANNEL FOR THE ARCH BAR AND CIRCUMANDIB. FIXATIONDENTURES WITH A CHANNEL FOR THE ARCH BAR AND CIRCUMANDIB. FIXATION

48. Complications Socioeconomic condition greatly affects outcome Infection - In a prospective study by James of 422 fx -infection rate was 7% of which 50 % were associate with fx or carious teeth, of the 177 fx requiring ORIF, 12 % became infected

49. Complications Delayed healing(3%) and nonunion(1%) most common cause in infection second most common cause is noncompliance inadequate reduction, metabolic or nutritional deficiency can play a role Nerve paresthesia�s (Inf. Alveolar nerve) occur in 2% Malocclusion and malunion TMJ problems

50. Complications A study out of UCSF showed no statistically significant difference in complication rate between pts treated with miniplates versus MMF and wire fixation Another study based on a group of patients with angle fx all treated at Parkland with nonrigid fixation or AO recon plate or lag screw or 2 - 2.0 dcp�s or 2 - 2.4 dcp�s, or 2 - 2.0 miniplates or one 2.0 miniplate showed the lowest complication rate with the one 2.0 miniplate with arch bar as tension band UCSF COMPLICATIONS WERE MALUNION, NONUNION, CN 7 PALSY, INFECTION AND PAIN UCSF COMPLICATIONS WERE MALUNION, NONUNION, CN 7 PALSY, INFECTION AND PAIN

51. 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

52. Case presentation 25 yom s/p assault present to ER with complaint of mandibular pain and malocclusion.

53. History PMHx: previously healthy Associated symptoms: denies neck pain Mechanism of injury - fist to jaw

54. Physical Exam Determine pre-injury occlusion- pt with slight overbite preoperatively C/o V3 paresthesia Trismus No loose teeth Point tenderness to palpation over the right angle and left parasymphyseal region Denies neck pain

55. Panorex CSPINE FILMS FIRSTCSPINE FILMS FIRST

56. Mandible Series

57. Mandible series

58. Mandible series

59. Treatment ORIF of both fractures sites Post op monitor for nausea/vomiting Mouth care Clinda or pcn D/C with wire cutters F/U in 2 weeks