MANAGEMENT OF MANDIBULAR FRACTURE Caterine (0806324822) Goals of therapy: Restoring form and function Restoring stable occlusion.

lusion. Restore interincisal opening and mandibular excursive movements. Establish a full range of mandibular excursive movements. Minimize deviation of the mandible. Produce a pain-free articular apparatus at rest and during function. Avoid internal derangement of the temporomandibular joint on the injured or the Avoid the long-term complication of growth disturbance.

contralateral side.

Principles of mandibular fracture repair include: reduction, fixation, stabilization, and prevention of infection. Technique: 1. Closed Reduction Indication: o In all cases in which an open reduction is not indicated or contraindicated o When the patient is contraindicated to general anesthesia o Grossly comminuted fractures because using open reduction technique would jeopardize the blood supply to the small bone fragments and lead to an increased likelihood of infection; Gunshot wounds which are prone to infection o Fractures of severely atrophic edentulous mandible because the majority of the blood supply comes from the periosteum, so an open reduction further disrupts the blood supply thus nonunions may result. o In situations where there is a lack of soft tissue overlying the fracture site, the presence of bone plates, screws, and wires may increase the likelihood of infection under these circumstances.

o Fractures in children involving the developing dentition are difficult to manageby open reduction because of the possibility of damage to the tooth buds or partially erupted teeth. Maxillo-mandibular Fixation (MMF) Length of MMF: average immobilization period for mandibular fractures is 6 weeks, but this is not absolute time frame. The length of time has been based on the presence or absence of teeth, the type of fracture, and the age of the patient. - Methods: a. Intermaxillary techniques (IMF) Use 0.5 mm (25-gauge) soft stainless steel wires around the teeth and should passed and secured below the height of contour. When IMF is used it may be applied with either elastics or wires. Elastics can be used for fracture reduction and for IMF; however, they apply a constant pressure, which can lead to muscle spasm and pain, particularly in the masseter muscle, and they are difficult to keep clean. Wires, on the other hand, are easier to keep clean and are passive. However, they do loosen over time and may need to be tightened or replaced over the period of fixation Arch bars should be of proper length and well adapted

Ivy loops (interdental eyelet wiring)

Stout continuous wiring Cast cap splints IMF screws

b. Lingual or labial splint Lingual splints are useful to treat oblique fractures of the body of mandible, bilateral condylar fractures with an associated symphisis fracture that cause the angle to flare, and mixed dentition or partly edentulous patients who lack enough erupted teth for arch bar placement. To construct a lingual splint, an impression is taken (in both fracture arch and non) and a stone model is poured. The stone model is then sectioned at the fracture site, and using the opposing model as a guide, the correct occlusion is reconstructed. Then the sectioned model is waxed together in the correct relationship, and the lingual surface is relieved with a 1 mm thickness of wax. A hard acrylic splint is then made and holes drilled so that it can be wired to the teeth. Just before placement a thin coating of soft liner is applied. The fracture is reduced, and the splint is wired into position. c. External pin fixation Indication: Edentulous fracture sites in which there is bone loss secondary to gunshot injuries; pathologic fractures; or osteomyelitis (infected mandibular body fractures); in fractures of the atrophic edentulous mandible or in mandibular fractures associated with midface fractures when a quick and simple method of fixation is required. Advantage: External pins can be placed without the need for general anesthesia and thus are useful when treating mandible fractures in severely compromised patient.

Disadvantage: cosmetic limitations and scarring attendant d. In edentulous patients Closed reduction in edentulous patients is achieved with Gunnings splints or splints made from the patients own dentures

2. Open Reduction Indications: o Displaced unstable fracture segments o Associated midface fractures o Associated condylar fractures o When MMF is contraindicated or not possible e.g. inability to bring the teeth into occlusion for closed reduction o To eliminate the need for MMF for patient comfort o To facilitate the patients return to work or other activity o Bilateral fractures in which it is impossible to determine what the proper occlusion is as a result of loss of posterior teeth or the presence of a preinjury skeletal malocclusion Contraindications: o A general anesthesia or a more prolonged procedure is not advisable o Severe comminution is present o Bone at the fracture site is diffusely involved with infection o Patients refuse a more complex treatment approach Methods: three basic techniques: A simple straight wire across the fracture site. This should be placed so that the direction of pull of the wire is perpendicular to the fracture site. This is useful in the a. Wire ostheosynthesis can be placed either by an intra- or extraoral route using one of

angle region, where a third molar socket can be quickly and easily used for a simple straight buccal cortex wire. Figure-of-eight wire. This wiring technique has been shown to have increased strength compared with simple techniques at both the inferior and superior borders in angle fractures. Transosseous circum-mandibular wiring (Obwegesers technique). This is a useful wiring technique when the fracture runs obliquely compared with the inferior border of the mandible. If the fracture line is too vertical the wire could become displaced into the fracture line.

b.

Rigid mandibular fixation Lag screws Lag screw is commonly used to repair mandibular anterior fractures (more common) and in some instances Lag mandibular angle fractures.

screws are frequently used in conjunction with plates to secure fracture fragments. This method cannot be used in comminuted fractures or fractures with a gap defect. Compression plating Compression plating refers to technique of controlling mandibular fracture fragments with a compression plate along the inferior border and a

tension band (can be arch bars, miniplates, etc) along the superior border to create rigid fixation of a fracture. This method cannot be used in comminuted fractures or fractures with a gap defect Reconstruction plate Reconstruction plates are capable of temporary load bearing and are therefore useful in comminuted fractures, defect fractures, and infected fractures. Reconstruction plates must be accurately contoured to avoid fracture displacement the screws.

and

subsequent

malocclusion during tightening of

Miniplate fixation The miniplates are malleable

and are placed through the intraoral or transbuccal route with monocortical screws. The most common types of mandibular fractures treated with this technique include symphisisparasymphisis fractures, angle fractures, and body fractures.