Mandibular Trauma

1. Mandibular Fractures
Presented by Dr. Mohammed haneef

2.  HISTORY
 ANATOMY
 INTRODUCTION
 CLASSIFICATION
 EXAMINATION AND DIAGNOSIS
 TREATMENT
 CONDYLAR FRACTURES

3. • The pre-Christian era
The first description of mandibular fractures dates to the 17th Century BC in
the ‘Edwin Smith papyrus’,
The Egyptians’ attitude to mandibular fractures was rather pessimistic:
“If thou examinest a man having a fracture in his mandible,
thou shouldst place thy hand upon it...and find that fracture
crepitating under thy fingers, thou shouldst say concerning
him: One having a fracture in his mandible, over which a
wound has been inflicted, thou will a fever gain from it. An
ailment not to be treated. Death usually followed, presumably
caused by infection”.
• Hippocrates – direct reapproximation of # segments with the use of
circum dental wires
• 1180, Textbook written in Salerno, Italy – importance of establishing a
proper occlusion.
• 1492, the book Cyrurgia by Guglielmo Salicetti – first mention of the use
of maxillomandibular fixation in treatment of mandibular #.
R. Mukerji et al. / British Journal of Oral and Maxillofacial Surgery 44 (2006) 222–228

4. History
• 1887, Gilmer reintroduced MMF in United States.
• Buck & Kinlock- first to do ORIF using wires.
• 1888 Schede- First to use stainless steel plate & screws.
• 1960, Luhr- first to use Vitallium compression plate
• 1970, Spiessl through AO/ASIF introduced principles of
rigid internal fixation.
• 1970, Michelet- introduced small bendable, non
compression plates- these were further modified by
Champy.
• 1987 – M.S. Leonard first to report use of lag screws
• Late 1990s – introduction of use of bioresorbable plates

7. Area of weakness
• Junction of Alveolar bone & Basal mandibular bone.
• Symphysis.
• Teeth
• Foramen
• Angle
• Condyle

9. Muscle Action
• Mylohyoid, Geniohyoid,
Genioglossus & Anterior belly of
omohyoid – postero-medial &
inferior displacement of # fracture
fragment.
• Pterygomassetric sling – Supero-
medial & anterior displacement of
fractured lesser fragment.
• Lateral Pterygoid muscle- Antero-
medial displacement of fractured
condyle.
• Temporalis – postero-superior
displacement of fractured
coronoid process.

10. • Zones of compression and tension
within the mandible are determined by
the muscles inserting and the forces
exerted by these muscles.
• Smaller arrows show direction of
muscular forces
• Larger arrows show the load placed
during function.
• This gives a zone of compression
along the lower border and a zone of
compression along the superior border
• Neutral axis about the level of the
canal.

11. Factors influencing displacement of
fracture
• Degree of force
• Resistance to the force offered by the facial bones
• Direction of force
• Point of application of force
• Cross-sectional area of the agent or object struck
• Attached muscles

12. # SYMPHYSIS AND PARASYMPHYSIS:-
Mylohyoid constitues a diaphragm b/w hyoid bone & mylohyoid ridge on
inner aspect of mandible
• Mylohyoid & geniohyoid -- stabilizing force symphysis transverse #
• Oblique # in this region tends to overlaps -- genio & mylohyoid diaphragm

13. Bucket handle
displacement
•B/L # of parasymphysis results from
force which disrupts the periosteum.
• displaced posteriorly under the
influence of genioglossus /
geniohyoid muscle
•Often removes attachment of tongue
& allows
TONGUE FALL BACK

14. ANGLE # :-
• medial pterygoid stronger component
• Vertical direction # favors the unopposed
action of the medial
pterygoid muscle,, post fragment pulled lingually
• Horizontal direction # line favors the unopposed
action of masseter and medial pterygoid muscle,,
post fragment displaced upwards

15. 15

16. Nerves
• The inferior dental nerve is frequently damaged in #
of body and angle
• The fibrous sheath provides considerable support for
contained vessels and nerves which accounts for
surprisingly low incidence of permanent nerve
damage after #
• Condyle may impact with such force against the
temporal bone and # which results in facial nerve
damage within follapian canal [Goin. 1980].
• Injury to facial nerve due to external trauma.

17. • Angle 110-140*
• Angle decreases with growth- changes in condylar process
,shape and size
Age Changes

18. Blood vessels
• Vascular damage to inferior dental artery and vein
• A large sublingual haematoma may result from
rupture of dorsal lingual veins medial to an angle.
• Hemorrhage from torn periosteum.
• The facial vessels are vulnerable to direct trauma
where they cross the lower border of the mandible at
anteroinferior margin of Masseter muscle.

19. • A tubular long bone, which is bent into a blunt V-shape.
• Mandible is strongest anteriorly in midline with
progressively less strength towards condyle .
• dentition
• Muscle attachments.
• Mandible is one of the strongest bones, the energy
required to # it being of the order of 44.6 –74.4 Kg /
M(425Lb) approximately 350- 400 kg (800-900lb),
which is about same as zygoma and about ½ that of
frontal bone
[Swearingen 1965, Hodgson 1967, Nahum 1975a, Luce et al 1979]
Mandible is embryologically a membrane bent bone although, resembles
physically long bone it has two articular cartilages with two nutrient
arteries.

20. FRACTURE :
Definition :
Fracture is defined as sudden violent solution in the
continuity of the bone which may be complete or incomplete
resulted from direct or indirect causes.
Mandibular fractures :
Fractures of the mandible are common in patients, who
sustain facial trauma.
SEX :
Most mandibular fractures are seen to occur in male patients.
Ratio is approximately 4.5 : 1
AGE :
35 % of mandibular fractures occur between the ages of
20 to 30 years.
Subodh et al, Clinical Study An Epidemiological Study on Pattern and Incidence of Mandibular
Fractures, Hindawi Publishing Corporation Plastic Surgery International, Volume 2012, Article ID
834364,7pages

21. AETIOLOGYOFMANDIBULARFRACTURES
• 1.Vehicular accidents
• 2.Altercation,assaults,interpersonnel violence
• 3.Fall
• 4.Sporting accidents
• 5.Industrial mishaps or work accidents
• 6.Pathological fractures or miscellaneous

22. Number of fractures per mandible.
The number of mandibular fractures per patient ranged from 1.5 to 1.8.
1. Unilateral , single - 53%
2. Bilateral , double - 37%
3. Multiple fractures - 10%
Fifty percent have more than one fracture.
Subodh et al, Clinical Study An Epidemiological Study on Pattern and Incidence of Mandibular
Fractures, Hindawi Publishing Corporation Plastic Surgery International, Volume 2012, Article ID
834364,7pages

23. Classification of mandibular fractures :
I. General classification
II. Anatomical locations
III. Relation of the fracture to site of injury
IV. Completeness
V. Depending on the mechanism
VI. Number of fragment
VII. Involvement of the integument
VIII.The shape or area of the fracture
IX. According to the direction of fracture and favourability for the
treatment
X. According to presence or absence of teeth
XI. AO classification – relevant to internal fixation

24. 1. Kruger's general classification
• Simple or Closed Fracture
• Compound or Open
• Comminuted
• Complicated or complex
• Impacted
• Greenstick fracture
• Pathological
Simple fracture Compound Fracture
Comminuted fracture
Impacted fracture
Greenstick fracture

25. 2. Rowe & Killey classification
• Fractures not involving basal bone
• Fractures involving basal bone of the mandible. Subdivided into following:
 Single Unilateral
 Double unilateral
 Bilateral
 Multiple
3. Dingman & Natvig classification
• Midline
• Parasymphyseal
• Symphysis
• Body
• Angle
• Ramus
• Condylar process
• Coronoid process
• Alveolar process

26. 4. Kruger & Schilli classification
I. Relation to the external environment
• Simple Or closed
• Compound or open
II. Types of fracture
• Incomplete
• Greenstick
• Complete
• Comminuted
III. Dentition of the jaw with reference to the use of splint
• Sufficiently dentulous patient
• Edentulous or insufficiently dentulous patient
• Primary and Mixed dentition
IV. Localization
• Fractures of the symphysis region between canines
• Fractures of the canine region
• Fractures of the body of the mandible
• Fractures of the angle
• Fractures of the mandibular ramus
• Fractures of the coronoid process
• Fractures of the condyle

27. 5. Kazanjian classification
Class – III : Patient is edentulolus
Class – I : teeth are present on both sides of
the fracture line
Class – II : Teeth are present on only one side of
fracture line

28. 6. According to direction of the fracture and favorability for
treatment ( Fry et al)
Horizontally favorable
Horizontally unfavorable
Vertically favorable
Vertically unfavorable

29. 7. Relation of the fracture to the site of injury
• Direct fracture
• Indirect fracture

30. 8. AO Classification(relevant to internal fixation):
1) F: Number of fracture or fragments
2) L: Location (site) of fracture
3) O: Status of occlusion
4) S: Soft tissue involvement
5) A: Associated fractures of facial skeleton

31. 9. Grades of severity: I-V
Grade I and II are closed fractures
Grade III and IV are open fractures
Grade V open fracture with a bony defect
(gunshot)

32. 10. AO-analogue classification system of mandibular fractures
• Each compartment is classified independently, describing the
degree of displacement and the presence of multifragmentation
or osseous defects.
• Each fracture is classified:
- type A, nondisplaced fractures
- type B, displaced fractures
- type C, multifragmentary/defect fractures
• Each fracture is divided into 3 groups,
specific to the mandibular unit.
Int.J.Oral Maxillofac.Surg.2008;37:1080-1088

33. Vertical unit

35. Horizontalunit

36. Centralhorizontalunit

37. • Direct violence
• Indirect violence
• Excessive muscular contraction.
• Pathological fractures
• Iatrogenic
• R.T.A’s
• Falls
• Fights
• Sport Injuries
• Industrial mishaps

38.  History
 Clinical Examination
 Radiological Examination
 Panoramic radiograph
 Lateral oblique Radiograph
 Posteroanterior Radiograph
 Occlusal view
 reverse towne’s view
 CT scan

39. History
• Focussed questioning should reveal following:
• Mechanism of injury
• Previous facial fracture
• H/O TMJ disorders
• Preinjury occlusion

40. Clinical examination
Examination of pt with # of mandible takes place in 3
stages:
A. Immediate assessment and treatment of any
condition constituting a threat to life.
B. General clinical examination of pt.
C. Local examination of mandibular #.

41. • Change in occlusion
• Anesthesia, Paresthesia or Dysesthesia of
lower lip
• Abnormal mandibular movements
• Change in facial contour and mandibular arch
form
• Laceration, Hematoma and Ecchymosis
• Loose teeth and crepitation on palpation
Clinical Examination

42. Clinical examination

43. Test for sensation

44. Signs and symptoms
• Tenderness +ve
• Occlusion changes - # teeth
- # alveolar process
- # mandible at any location
- # condyle
• Anterior open bite - B/L condylar #
• Posterior open bite - parasymphysis #
• Unilateral open bite - # ipsilateral angle
- # parasymphysis
• Posterior cross bite - midline symphysis #
- condylar #

45. Radiological examination
Ideally need 2 radiographic views of the fracture that are
oriented 90’ from one another to properly work up
fractures
• Single view can lead to misdiagnosis and
• complications with treatment

46. • Most informative
• Shows entire mandible and
direction of fracture (horizontal favorable, unfavorable)
Disadvantages:
• – Patient must sit up up-right
• – Difficult to determine buccal/lingual bone and
• medial condylar displacement
• – Some detail is lost/blurred in the symphysis, TMJ
and dentoalveolar regions

47. Posteroanterior (pa) radiograph:
Shows displacement of fractures in the ramus, angle, body, and
symphysis region
Disadvantage:
• Cannot visualize the condylar
region

48. Lateral oblique
• Used to visualize ramus, angle, and
body fractures
Disadvantage:
• Limited visualization of the condylar
region, symphysis, and body anterior to
the premolar

49. Occlusal radiograph
• Used to visualize fractures in the body in regards to medial or
lateral displacement
Used to visualize symphyseal fractures for anterior and posterior
displacement

50. Computed tomography ct:
Excellent for showing
intracapsular condyle fractures
axial and coronal views,
3-D reconstructions
Disadvantage:
• – Expensive
• – Larger dose of radiation
exposure compared to plain
film
• – Difficult to evaluate direction of
fracture from individual slices
(reformatting to 3-D overcomes
this)

51. 1. The patient’s general physical status should be carefully evaluated
and monitored prior to any consideration of treating mandibular
fracture.
2. Diagnosis and treatment of mandibular fractures should be
approached methodically not with an “emergency-type” mentality
3. Dental injuries should be evaluated and treated concurrently with
treatment of mandibular fractures
4. Re-establishment of occlusion is the primary goal in the treatment of
mandibular fracture.
5. With multiple facial fracture mandibular fracture should be treated
first.
6. Intermaxillary fixation time should vary according to the type,
location, number severity of the mandibular fracture as well as the
patient’s age and health.
7. Prophylactic antibiotics should be used for compound fractures.
General principles in the treatment of
mandibular fracture

52. Basic principles for Rx of Fracture
Reduction
• Closed
• Direct interdental
wiring Indirect
interdental wiring
(eyelet or Ivy loop)
• Continuous or multiple
loop wiring
• Arch bars
• Cap splints
• 'Gunning-type' splints
• Pin fixation
 Open
 Transosseous
wiring
(osteosynthesis)
 Plating
 Intramedullary
pinning
 Titanium mesh
 Circumferential
straps
 Bone clamps
 Bone staples
 Bone screws
Fixation
 Direct
 Indirect

53. Immobilization
• Methods of immobilization
• (a) Osteosynthesis without intermaxillary fixation
• (i) Non-compression small plates
• (ii) Compression plates
• (iii) Mini-plates
• (iv) Lag screws
• (b) Intermaxillary fixation
• (i) Bonded brackets
• (ii) Dental wiring
• Direct
• Eyelet
• (iii) Arch bars
• (iv) Cap splints
• (v) MMF screws
• (c) Intermaxillary fixation with osteosynthesis
• (i) Transosseous wiring
• (ii) Circumferential wiring
• (iii) External pin fixation
• (iv) Bone clamps
• (v) Transfixation with Kirschner wires

54. 1. Non-displaced favorable fractures
2. Grossly comminuted fractures
3. Fractures exposed by significant loss of overlying soft
tissue.
4. Mandibular fractures in children with developing dentition
5. Coronoid process fracture
6. Condylar fractures
IndicationforClosedReductionof Fractures

55. ADVANTAGES& DISADVANTAGESOF
CLOSEDREDUCTION
Advantages
• Inexpensive
• Only stainless steel wire
needed
• Convenient
• Gives occlusion
• Conservative
• O.T not required
• Generally easy ,no great
operator skill needed
Disadvantages
•Cannot obtain absolute
stability
•Difficulty nutrition
•Oral hygiene impossible
•Long period of IMF
•Changes in TMJ cartilage
•Weight loss
•Decrease range of motion of
mandible
•Risk of wounds to operator

56. CLOSED REDUCTION
• HISTORY
• William Saliceto(1210-1277) Tied the teeth (MMF)
• Thomas Gilmer(1849-1931) Reveiwed the tech,
introduced Arch Bars in 1907.
• Barton bandage by JOHN BARTON
• Lingual-Labial occlusal splint.
• Vaccum formed acrylic splint
• Royal Berkshire Haio Frame

57. Direct interdental wiring
• Gilmer's wiring
• simple & rapid method of
immobilization jaw
• first aid method
• temporary immobilization
of # fragment
Disadvantage
- complete removal of wires
- extrusion of teeth

58. IVLOOPMETHOD
IVY-LOOP METHOD
• quick and easy way of
obtaining maxillo-
mandibular fashion.
• 24 gauge wire
• simple and effective for
reduction and
immobilization of #

59. WILLIAM’S MODIFICATION

60. Clove hitch
• Incase of single tooth

61. Button Wiring
• Leonard (1977)
considers that eyelet
wires have several
drawbacks.
• He described the use
of titanium buttons
of 8mm diameter,
inclusive of a 1mm rim,
and 2mm deep.

62. Col. Stout wiring

63. Risdon’s wiring

64. Arch bars
• For temporary fragment stabilization in emergency cases
before definitive treatment
• As a tension band in combination with rigid internal fixation
• For long-term fixation in conservative treatment
• For fixation of avulsed teeth and alveolar crest fractures

65. • Different types of Arch bar
• Winters
• Jelenkos
• Dautrys Arch bar
• Berns titinium arch bars
• Burmachs arch bar
• Custom made

66. Screws
• Screws are quick to place
• Reduce the chance of needlestick injury from wires
• Can be used with heavily restored teeth
• Can be placed and removed rapidly
• Well tolerated by patient
• Allow oral hygiene to be easily maintained

67. Pre drilled Drill free
• When drilling the screw
holes, saline irrigation
assists bone debris removal
and cooling of tissues.
• There is a risk of the drill
damaging the roots of
adjacent teeth, especially in
inexperienced hands
• Cannot be used
• No irrigation required
• Less chance of damage
to adjacent teeth
• Drill free screws may
be used in comminuted
fractures

68. Cap Splints :
• Indications
 Advanced periodontal
disease
 #s of tooth bearing
segments & condylar neck
 Portion of body of
mandible missing
• Impression technique
• Fitting the splint
• Reduction of fracture

69. Biphasic pin fixation
• Closed technique uses external fixation (Morris
appliance & Roger anderson appliance) for
management of communited mandibular #.
• screws placed - two on either side of the fracture
through stab incisions & holes drilled in the
mandible.

70. • Once external pins are in position,
the fracture segments are manipulated to
achieve reduction.
• Then the pins are locked in reduced position by applying
of an acrylic mix that is placed over the ends of the pins
that are protruding out of the skin.
• The acrylic is allowed to harden while mandible is held in
reduced position.
• Steinmann pins or Kirshner wires can also be used as
external pins

71. Indications
• Edentulous fractures
• If IMF is not feasible
• Comminuted fractures
• Bone graft
requirements
• With a head frame
Contraindications
• Irradiated tissues
• Grossly contaminated
tissue
• Osteoporosis
• Osteosclerosis
• Atrophy

72. Advantages
• Control of the edentulous
fragments without
involving the fracture lines.
• under LA.
• avoidance of the need for
surgery at the fracture site,
• minimum operative time
• Simple surgical technique.
Disadvantages
• Conspicuous
uncomfortable
• uncooperative or cerebrally
irritated patient.
• Difficulty with washing
and shaving
• scars caused- pinholes
• risk of infection.

73. Acrylic splints take the form of
modified dentures with bite block in place of molar teeth &
space in the incisor area to facilitate feeding
Used in edentulous jaw fractures
Gunning splints

74. INDICATION
• - unilateral / bilateral # edentulous mandible
CONTRAINDICATIONS
• - unfavorable displaced #s lying out side denture
bearing areas
• - severe posterior displacement of #s of the anterior
part of mandible

75. •Preparation of cast/ mock surgery
•Preparation of acrylic block in centric
relation
•Acrylic bite block in molar region
•Space in anterior region
•Stainless steel hooks in molar region
Fabrication

76. Immobilization
Maxilla -Peralveolar wiring
- Circum zygomatic wiring
- With help of bone screws
Mandible - Circum mandibular wiring
Followed by IMF

77. Early
General supervision
Infection control
Pain control
Oral hygiene maintenance
Feeding
Post operative care
Late
Testing union & removal of fixation
Jaw physiotherapy

78. Houpert’s procedure
The operator should drill transfixion holes (in a
vestibulo‐lingual direction) with a tiny round burr in the crown
of the deciduous teeth away from the pulp and a safe distance
from the occlusal surface.
A 0.2‐mm stainless steel wire impregnated in silver nitrate is
introduced through the holes. Depending on the number of
teeth used, either bimaxillary or monomaxillary fixation can be
applied. Each hole should be filled with amalgam.
A variation of this technique (Ginestet) allows placing an
eyelet through each hole to fix both a vestibular and a
lingual/palatal hard, 0.5‐mm stainless steel wire, with the
possibility of a double splint device both in the vestibular and
at the lingual/palatal aspect of the dental arcade.

79. 1. Displaced unfavorable fracture through angle of the mandible
2. Displaced unfavorable fractures of the body or pasymphyseal region
3. Multiple fractures of the facial bones
4. Midface fractures and displaced Bilateral condyler fractures
5. Fractures of the edentulous mandible with severe displacement of
fragments
6. Edentulous maxilla opposing a mandibular fracture
7. Delay of treatment and interposition of soft tissue between noncontacting
displaced fracture fragments.
8. Malunion
9. Special systemic conditions contraindicating intermaxillaryfixation
Indications for open Reduction

80. Contraindications
• G.A / more prolonged procedure is not
advisable
• Gross infections at the # site
• Sever comminution with loss of soft
tissue
• Patients with difficult to control
seizures

81. Surgicalapproachesto the mandible
• Intraoral symphysis and
parasymphysis
Intraoral body, angle
and ramus –
Transbuccal approach

82. Degloving incision

83. Extraoral approaches
Submental Submandibular Retromandibular

84. Transalveolar / upper border wiring
Sir Williams Kelsey Fry
• To control the posterior fragment
• Use – vertically and horizontally unfavorable #
• Horizontal mattress wiring

85. Transosseous / lower border wiring
Hayton Williams 1958
• # fragments expose extraorally
• posterior fragment hole higher level then anterior
fragment
• both wires passes simultaneously through same hole
1973 Obwegeser :-
• Combined direct and figure of ‘8’ wiring with single stand
of wire

86. Transosseous or lower border wiring

87. Bone plate osteosynthesis
• Non compression plate with monocortical screw
• Compression plates with bicortical screw
- DCP - EDCP
• Bio degradable plates and screws
• Three dimensional plates
• Titanium miniplates

88. Principle of compressionplate osteosynthesis
• The holes for the screws
should be prepared at
the far ends of the plate
holes.
• When tightening the
screws the fracture ends
are approximated by the
effect of the spherically
shaped holes
Journal of Cranio-Maxillofacial Surgery 2008; 36: e251 - e259

89. Compression plates
•Axial compression b/w fractured bone ends
•Rigid fixation with intra-fragmentry compression
•Bone ends correctly opposed and maintained
•IMF is not needed post operatively
•Primary bone healing occurs by direct osteoblastic activity
within #
•AO/ASIF dynamic compression plates
Compression plate approach Eccentric dynamic compression plate

90. DCP EDCP
• The plate design is based on a screw head
that, when tightened, slides down an
inclined plane within the plate.
• Screw behaves as compression screw or the
static screw
• Compression is not achieved at the upper
border so tension band is required
• The EDCP is similar to the DCP in that
the inner holes are designed to produce
compression across the fracture site
• Two oblique outer eccentric compression
holes aligned at an angle oblique to the
long axis of the plate. The activation of
these outer holes produces a rotational
movement of the fracture segments with
the inner screws acting as the axis of
rotation
• Brings compression at the upper border
so tension band is not required

91. Mini plate Osteosynthesis :-
1973 MICHELET
1975 CHAMPY MODIFIED
- Under physiological strain, forces of tension along the
alveolar border & forces of compression along the lower
border of the mandible.
- With in the body of the mandible these forces produce,
predominantly, moments of flexion – angle strong & weak in
PM region.
- with in the symphysis – torsional moments
- Champy et al analysed these moments using a mathematical
model of the mandible – ideal line of osteosynthesis.
# symphysis 2 plates
# angle 1 plate
Monocortical screws 2 mm diameter and 5 to 10 mm length
Plate 2cm long, 0.9mm thick and 6mm wide

92. Advantages of monocortical miniplate
osteosynthesis over bicortical
compression plates.
Monocortical
• Requires minimal
dissection.
• Less technique
sensitive
• Less chances of
complications
Bicortical
• Extra oral approach
• Nerve injury
• Difficult to adapt

93. Compression plate Miniplates
• Bicortical plates
• Bulky and difficult to use
• Applied extraorally
• Cannot be used at the upper
border of the mandible
• Provides rigid fixation
• No interfragmentary
movement allowed
• Monocortical plates
• Easy to use
• Applied intraorally, small
incision , less soft tissue
dissection , less likely to be
palpable
• Can be used without any
associated complication
• Provides functionally stable
fixation
• Little interfragmentary
movement present, torsional
movement seen under
functional loading

94. Champy’s line of osteosynthesis

95. Locking vs Standard mini plates

97. 3-D plate ostesynthesis
DentalResearchJournal/Mar2012/Vol9/Issue2
• Titanium 3-D plating system was developed by Farmand to
meet the requirements of semi-rigid fixation with lesser
complications.
• The 3-D miniplate is a misnomer as the plates are not three
dimensional, but hold the fracture fragments rigidly by
resisting the forces in three dimensions, namely, shearing,
bending, and torsional forces.
• The basic concept of 3-D fixation as explained by
Farmand
is that a geometrically closed quadrangular plate secured with
bone screws creates stability in three dimensions. The stability is
gained over a defined surface area and is achieved by its
configuration and not by its thickness or length.

98. • The large free areas between the plate arms and minimal
dissection permit good blood supply to the bone.
• The newly introduced 3-D plating system provides definite
advantages over the conventional miniplates.
• The 3-D plating system uses fewer plates and screws as
compared to the conventional miniplates, to stabilize the bone
fragments. Thus, it uses lesser foreign material, and reduces
the operation time and overall cost of the treatment
• The 3-D plating system has a compact design and is
• easy to use. The 1.0-mm-thick 3-D plate is as stable
• as the much thicker 2.0 mm miniplate. This offers
• better bending stability and more resistance to out-ofplane
movement or torque.

99. Three dimensional plate

101. Advantages: -
• Improved handling characteristics,
• Increased stability,
• Shorter surgical time,
• Preservation of bony
perfusion,
• Decreased bone necrosis,
• Increased bony healing and regeneration.

102. Bioabsorbable Plates
Bioresorbable materials used for rigid fixation
• Polydioxanone
• Polyglycolic acid
• Polylactic acid
Strength inadequate to provide clinically acceptable
rigid fixation.
• Use of poly-L-lactide in 69 fractures by Kim et al
• 12% complication
• 8% infection
• No malunion
Plastic and Reconstructive Surgery, vol 110, july 2002, 25-31

103. Bioresorbable plates & screws
[RobertM. LaughlinJOMS2007;65:89-96]
Advantages:
• Provides the proper strength
when necessary and then
harmlessly degrades over
time.
• No need for an additional
removal operation.
• Reduce the total treatment
& rehabilitation time of the
patient.
• No bending pliers are
necessary.

104. Lag screw
Compress fracture fragments without the use of bone plate
Two sound bony cortices are required -- Shares the loads with
the bone
Uses:
• absolute rigid fixation
• Less hardware
• More cost effective
• Rigid method of internal fixation
• Insertion -quicker and easier
• Reduction more accurate

105. Lag screws
Placed indirection that is perpendicular
to the line of fracture to prevent
overriding
& displacement during
tightening of the screws.
INDICATIONS
• #s in edentulous parts
• Concomittant #s of body & condyle
• IMF contraindicated
• Saggital/oblique fractures
• Non/mal union

106. Lag Screw fixation.

107. Lag Screw technique
107

108. Anchor lag screwvs conventional lag
screw
Journaloforalbiologyandcraniofacialresearch3(2013)15e19
Loosening of screw, damage to bone, mobility of fragments, incidence of pain,
infection presence

109. Reconstruction plates
• For communited mandibular fractures
• Decreased post op morbidity
• Stabilization of entire communited complex
• Defect fractures can be treated
• 2.0 mm plate with bicortical screw used in conjuction with lag
screws or miniplates

110. Advantages of open
reduction.
• Accurate reduction &
fixation of fractures by
direct visualization.
• Better bone healing.
• Early return to normal
jaw function.
• Normal nutrition, no
weight loss.
• Patient can maintain
oral hygiene.
• Early return to work.
Disadvantages of
open reduction.
• Requires surgical
exposure.
• Requires general
anesthesia.
• Expensive.
• Compared to IMF
technique is difficult
and risky.
• Foreign body is left
in the tissues.
• Scarring.

111. Protocolfor treatmentof mandibular
fractures
(PhilipL.Maloney,JOralMaxillofacSurg,59:879-884,2001)
• Simple fractures of the condylar process and ramus -
closed reduction. MMF for 48 to72 hours - training
elastics and close observation
• No MMF is required for coronoid fractures; archbars and
training elastics are used only if a malocclusion is
present.
• Simple or compound fractures with a time delay from
injury to immobilization of < 72 hours are treated by a
closed reduction (CR) or, if indicated, open reduction
with rigid fixation (ORIF).

112. • Compound fractures - delay from injury to
immobilization of >72 hours - MMF and IV antibiotics .
• If the closed reduction is adequate, the patient is
continued on oral antibiotics for an additional 10 to
14days and maintained in MMF and on a blenderized
diet for 5 to 6 weeks from the time of closed reduction.
• If not, ORIF is performed, and MMF is maintained for
10 to 14 additional days.
• Edentulous patients are treated with rigid fixation, no
MMF, and a blenderized diet for 4 to 5 weeks.
• Teeth in the line of fracture are judged individually.

113. The goal of AO/ASIF is rigid internal fixation with
primary bone healing, under functional loading
Basic principals
• Reduction of bony fragments
• Stable fixation of the fragments
• Preservation of the adjacent blood supply
• Early functional mobilization

114. Bone healing
• Histomorphologic changes during fracture healing
Post fracture time Histology
Immediate Extravasation of blood
24 hrs Aseptic inflamm – clot
48 hrs Org of clot
4 days Intramemb bone formation
Subperiosteal bone formatn
5 to 10 days Hyaline cartilage

115. Fibrocartilage + calcification
30 days until of Trabecular bone formation
healing
Cortical bone formation

116. Generalprinciples in the treatmentof
mandibularfractures
• Patient’s general physical status
• Methodical approach -not “emergency-type” mentality.
• Dental injuries - evaluated & treated concurrently
with T/t of mandibular fractures.
• Re-establishment of occlusion -primary goal
• With multiple facial fractures, mandibular fractures
should be treated first.

117. • IMF time should vary
• Type
• Location
• Number
• Severity of mandibular fractures
• As well as the patient’s age & health
the method used for reduction & immobilization.
• Prophylactic antibiotics should be used for compound
fractures.
• Nutritional needs should be closely monitored
postoperatively.

119. Young adult with Fracture
of the angle receiving Early
treatment in which Tooth
removed from fracture line
3 weeks
Guide for time of immobilization
(a) Tooth retained in fracture line: add 1 week
(b) Fracture at the symphysis: add 1 week
(c) Age 40 years and over: add 1 or 2 weeks
(d) Children and adolescents: subtract 1 week
IF

120. Teeth in the line of fracture
• Potential impediment to healing
• Fracture is compound
• Tooth maybe damaged structurally subsequently become
necrotic
• Pre existing pathology – apical granuloma

121. Teeth in line of fracture
Indications for
removal
Absolute
• Longitudinal #
• Dislocation/subluxation of
tooth
• Periapical Infection
• Infection of the fracture line
• Acute pericoronitis
Relative
• Functionless tooth
• Advanced caries
• Periodontal disease
• Doubtful teeth
• Untreated # > 3
days

122. Managementof teethretainedin fracture
line
• Intra-oral periapical radiograph
• Systemic antibiotic therapy
• Splinting of tooth if mobile
• Endodontic therapy if pulp exposed
• Immediate extraction if fracture becomes infected
• Follow-up for 1 yr with endodontic therapy if there is
demonstrable loss of vitality.

123. Fracture healing
• With RIF the strain on the
bone is reduced
• Bone heals by direct
approximation
• Gap healing – minimal
callus
• healing – satisfactory
immobilisation
• Inflammatory stage
• Cartilagenous stage
• Bony callous stage
• Remodelling

124. Complications
Complications during primary treatment
Misapplied fixation
Infection
Nerve damage
Displaced teeth and foreign bodies
Pulpitis
Gingival and periodontal complications
Drug reactions

125. Late complications
Malunion
Delayed union
Non-union
Derangement of the temporomandibular joint
Late problems with transosseous wires and plates
Sequestration of bone
Trismus
Scars

126. Management of Infections

127. Intra oral ORIF

128. Management of TMJ complications

129. Thank you