Mandibular fracture 3 / fixed orthodontic courses

INDIAN DENTAL ACADEMY
Leader in continuing dental education

www.indiandentalacademy.com


SURGICAL ANATOMY

Superior and Posterior view
Mandible showing relationship Of Body and
ramus

Section Of mandible at sysmphysis showing maximum
thickness at lower border

Section Of mandible
www.indiandentalacademy.comdistal to last molar
showing maximum thickness at Upper
border

Internal Architecture of bone : 1; Osteone, 2;Cortical and
Medullary bone, 3; A long Bone, 4; Loaded cylinder

Trajectories of Mandible
Joint Adaption for pressure bearing


BLOOD SUPPLY AND NERVE SUPPLY OF MANDIBLE

Inferior Alveolar Artery

Lateral View Of mandible

Inferior Alveolar neurovascular
Bundle, Sphenomandibular ligament
and mandibular foreman


CHANGES ASSOCIATED WITH AGE TO MANDIBULAR BLOOD SUPPLY
Cross section of mandibe of
87 yrs old male

Left carotid angiogram of 69
yrs old female showing
emply inferior dental canal
Right Carotid angiogram of a
28 yrs old female showing
normal Inferior dental artery

Cross section of mandibe of
16 yrs old male


AVERAGE MEASUREMENTS IN THE BODY OF THE MANDIBLE

P1

P2

M1

M2

M3

Distance between nerve and Lower
border of mandible (a)

8.6

8.0

8.0

8.0

8.5

Distance between nerve and inner
cortex (b)

3.2

3.2

2.0

2.9

3.0

Distance between nerve and buccal
cortex (c)

4.0

4.0

5.4

5.9

4.6

Position of section

I1

I2

C

Average Thickness of outer cortex
(d)

2.2

2.3

2.4

2.5

2.7

3.1

3.2

3.4

Distance between root apices and
outer cortex (e)

3.7

4.0

3.2

3.6

3.8

4.7

5.7

6.3

8.8

8.3

6.8

6.0

Distance between root apices and
outer cortex (f)


THE STRENGTH OF MANDIBLE
“The bone fracture at the site of tensile strength since its resistance to compressive strength is more”
- Hodgson ( 1967)

Distribution of strain lines as a result of
force applied over the symphysis menti
or mental foramen


THE DISPOSITION OF MANDIBULAR FRACTURE LINES

1.

Condylar region

Extracapsular And Intracapsular fracture of condyle
The relationship between the muscle attachments and
site of condylar fracture


2.

•

RAMUS AND CORONOID PROCESS

Fractures of the ramus exhibit very little displacement of the fragments as a result of being, to a

large extent, splinted by the presence of masseter muscle on the lateral aspect and the medial
pterygoid on the medial aspect.
• there is usually onlt minimal displacement of the coronoid process, since the fragment is
splinted by the tendinous insertion of the temporalis muscle.


3.

ANGLE OF THE MANDIBLE

Disposition of fracture lines at the angle

Thickness of cortex at the angle of mandibel in
the presence and absence of teeth

Change of angulation at
angle


Vertically favourable fracture line

Vertically unfavourable fracture line
Horizontally favourable & unfavourable
fracture line


FACTORS INFLUENCING DISPLACEMENT OF FRACTURE

1. Direction and intensity of the traumatic force
2. Site of fracture
3. Direction of fracture line
4. muscle pull exerted on fractured fragments.
5. Presence or absence of teeth.
6. Extent of soft tissue wound.


HISTORY
 Writings on mandible fractures appared as early as 1650 BC, when Egyptian described the examination, diagnosis and
treatment of mandible fractures.
 Hippocrates described direct reapproximation of the fracture segments with the use of circumdental wiring.
 1795, Chopart and Desault were the first to use dental prosthetic devices in an attempt to immobilize fracture segments

Chopart and Desault
 John Barton described his Barton Bandage in order to immbilize and stabilize fracture fragment


 1886, Thomas Brain Gunning was the first person to use a custom fitted intraoral dental splint for immobilization. He
used the splint in conjunction with an external head appliance.

 Glimer credited with being the first to use method of intermaxillary fixation.
 In 1881, Glimer described a method of mandibular fracture fixation that used two heavy rods placed on either side of the
fracture and wired together.


ETIOLOGY OF MANDIBULAR FRACTURE

1. Vehicular accident – 43%
2. Altercation, assault, interpersonal vilonce – 34%
3. Fall – 7%
4. Sporting accidents – 4%
5. Industrial mishaps or work accidents – 10%
6. Pathological fractures – 2%


LOCATION OF MANDIBULAR FRACTURE

 Body - 29%
 Condyle - 26%
 Angle - 25%
 Symphyses - 17%
 Ramus - 4%
 Coronoid - 1%


CLASSIFICATION OF MANDIBULAR FRACTURE
1.

Kruger's general classification

• Simple or Closed Fracture

• Compound or Open
• Comminuted
• Complicated or complex
• Impacted

Simple fracture

Compound Fracture

• Greenstick fracture
• Pathological

Comminuted fracture

www.indiandentalacademy.com Greenstick fracture
Impacted fracture

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

4.
I.

Kruger & Schilli classification
Relation to the external environment
•

Simple Or closed

•

II.

Compound or open
Types of fracture
•
•

Greenstick

•
III.

Incomplete

Complete

•
Comminuted
Dentition of the jaw with reference to the use of splint
•
•

Edentulous or insufficiently dentulous patient

•
IV.

Sufficiently dentulous patient

Primary and Mixed dentition

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 www.indiandentalacademy.com

•

5.

Kazanjian classification

Class – I : teeth are present on both sides of the fracture line

Class – II : Teeth are present on only one side of fracture line

Class – III : Patient is
edentulolus


DIAGNOSIS OF MANDIBULAR FRACTURE
 History

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

GENERAL PRINCIPLE IN THE TREATMENT OF MANDIBULAR FRACTURE

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.


PROTOCOL FOR TREATMENT OF MANDIBULAR FRACTURES
Philip L. Maloney,J Oral Maxillofac Surg,59:879-884, 2001
• Simple fractures of the condylar process and ramus are usually treated by closed reduction. Patients are

placed in maxillomandibular fixation (MMF) for 48 to72 hours, followed by training elastics and close
observation to ensure that a malocclusion does not occur.
• 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 less than 72 hours are
treated by a closed reduction (CR) or, if indicated, open reduction with rigid fixation (ORIF).
• Compound fractures where there is a delay from injury to immobilization of more than 72 hours are treated
with MMF and intravenous antibiotics for a period roughly equal to the time from injury to initialtreatment
(eg, a patient with a 5-day-old compound fracture receives intravenous antibiotics for 5 days). 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. If sound, firm, and the supportive tissues are intact,
they are retained except if an open reduction is to be performed; then, partially erupted and impacted third
molars in the line of fracture are removed.

INDICATIONS FOR CLOSED REDUCTION

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


INDICATIONS FOR OPEN REDUCTION

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


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
(c) Intermaxillary fixation with osteosynthesis
(i) Transosseous wiring
(ii) Circumferential wiring
(iii) External pin fixation
(iv) Bone clamps
(v) Transfixation with Kirschner wires

A GUIDELINE FOR TIME OF IMMOBILIZATION FOR FRACTURES OF TOOTH-BEARING
AREA OF THE LOWER JAW
- Peter bank (1991)

Young Adult
With

Fracture of the body of the mandible
Receiving

3 weeks

Early treatment
In which

Tooth removed from fracture line

If :
a.

Tooth retained in fracture line : add 1 week

b.

Fracture at the symphysis : add 1 week

c.

Age 40 years or above : add 1 or 2 weeks

d.

Children and Adolescents : Subtract 1 week


GILMER’S METHOD


IVY LOOP METHOD


WILLIAMS MODIFICATION(1968)


LEONARD BUTTON WIRING


STOUT METHOD(1943)

• Continous or Multiple
loop wiring


FULTON RISDON (1968)
• Twisted Labial Wire


OBWEGESER METHOD
•

Continous Multiple Loop Wiring


ARCH BARS

RISDON ARCH BAR
JELENKO ARCH BAR
ERICH ARCH BAR
KRUPPA ARCH BAR
ERICH ARCH BAR
HAMILTON (1967)


ACRYLATED ARCH BARS

schuchardt(1956)
schuchardt&metz(1966)
stanhope(1969)
clarke(1977)


FRACTURES OF EDENTULOUS MANDIBLE

• GUNNING TYPE
SPLINTS

THOMAS BRYAN
GUNNING-(1885)


TREATMENT MODALITIES FOR EDENTULOUS
MANDIBLE
PERALVEOLAR WIRING


CIRCUMMANDIBULAR
WIRING (Bradley-1975)


• INTER OSSEOS WIRING
• EXTRA ORAL PIN FIXATION
ROGER ANDERSON APPLIANCE
• PRIMARY RIB GRAFTING
- OBWEGER& SAILER (1973)


SURGICAL APPROACHES TO THE MANDIBLE

Intraoral symphysis and paarasymphysis

Intraoral body, angle
and ramus

EXTRAORAL APPROACHES

Submental

Retromandibular
Submandibular

SUBMANDIBULAR APPROACH


RETROMANDIBULAR APPROACH


TRANSOSSEOUS WIRING


COMPRESSION PLATE OSTEOSYNTHESIS THROUGH THE LUHR SYSTEM


COMPRESSION PLATE OSTEOSYNTHESIS THROUGH THE ASIF (Spiessel)
SYSTEM

Perren Sperical gliding principle


COMPRESSION PLATE OSTEOSYNTHESIS THROUGH THE BECKER SYSTEM


THE STRASBOURG MINIPLATE OSTEOSYNTHESIS

Ideal Osteosynthesis lines developed by Champy


LAG SCREWS


INTERMEDULLARY WIRING


COMPLICATIONS

•
•
•
•
•
•

Non-Union
Malunion
Fibrous Union
Paresthesia
Anesthesia
Infection


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Mandibular fracture 3 / fixed orthodontic courses

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