TRAUMA: Mandibular Fracture Flashcards
Signs and symptoms of mandibular fracture?
- Maloclussion
- Sublingual hematoma
- Step deformity
- Paraesthesia
- Swelling and tenderness
- Pain
- Gingival laceration wound
Why is bilateral fractures of mandible symphyseal is an emergency situation?
It can cause airway obstruction. Because the mobile segment of the symphysis can be pulled and displaced posteriorly by the tongue and muscles on the floor of mouth causing falling back of the tongue obstructing the airway.
What is immediate management of mandibular frcture?
Maintaining patent airway
Ensure good ventilation
Control bleeding via obtaining reduction and sururing
Fracture is temporarily reduced and fixed with archbars and imf
Discuss briefly the principles of osteosynthesis for mandible
- Champy principle - load sharing osteosynthesis
- monocortical fixation with 2.0 diameter screw
- plates prebent to passively fit onto surface of mandible
- 2 plates in superior and inferior for mandible anterior to mental foramen- to prevent torsional effects of anterior mandibular muscles
- 1 plate along the maximal tension line (superior border)
- 1 plate along ext oblique ridge for angle fracture
- to prevent torsional effects of anterior mandibular muscles
- AO principle - load bearing osteosynthesis
Thicker stronger locking plate (recon plate)
Indications:
- comminution
- gaps with loss of bone segments
- atrophic mandible
- infected fracture site
- body fracture (plate along the inferior border)
AO principles of osteosynthesis
- Reduction and fixation to restore anatomical relationship
- Fixation provide absolute or relative stability following the “personality” of the fracture, patient and injury
- Preservation of blood supply to soft tissues and bone by gentle manipulation and careful handling
- Early mobilization and rehab
How do you treat symphyseal fracture?
- Miniplate at the inferior border with superior border miniplate or archbar
- Lag screws with lag screw technique with a gliding hole to allow compression of segments
How to treat angle of mandible #
- One miniplate at the superior border of ext oblique ridge
- One stronger & thicker locking plate at lateral surface (to prevent torsion)
- 2 miniplates at ext oblique ridge + basal region (if stability is inadequate or to reduce basal region)
- Recon plate if comminuted
- MMF if non to minimally displaced/contraindicated for GA or ORIF/
Indications of a recon plate in mandibular fracture
comminuted fracture
atrophic mandibles
gap between segments with loss of bony segment
Indication of conservative mx of condylar fracture
Intracapsular fracture minimally displaced Most fractures in children Undisplaced Minimally displaced without malocclusion Edentulous
Achieved by soft diet and close follow up
When do u treat condylar fracture by closed reduction
- Intracapsular fracture Causing severe maloclussion
- Peads fracture causing displacement and malocclusion
- Minimally displaced
- old age or patients unfit for surgery under GA
Indications of ORIF in condylar fracture
Absolute: Lateral extracapsular displacement Shortened ramus height - telescoping Displacement into middle cranial height Foreign body in joint capsule
Relative:
Bilateral condylar fractures - to stabilise one side to allow for mmf
Concomitant fracture on other segment that is also mobile
In patients that cannot tolerate mmf
How do you approach the condyle for ORIF
Retromandibular with transparotid approach
- skin incision below the tragus 2-4cm
- subcut tissue
- parotid capsule
- blunt dissection thru parotid parenchyma avoiding the facial nerve
- until reach mandible
- incise periosteum and expose fracture site
Preauricular with or without temporal extension
Submandibular approach
Existing laceration wound
How do u ORIF condylar fracture
Strong fixation to prevent rotational movement.
1) 2 miniplates.
- 1 4-hole miniplate at the anterior near sigmoid notch
- 1 4-hole miniplate at the posterior border of the condyle & ramus.
2) 1 lag screw/ bicortical screw
3) special designed condylar plates
Why need to use bite block after one screw is placed superior to fracture line of condyle
To keep the jaw open and aid fracture reduction,
This results in posterior vertical distraction and rotation of the mandible
What is post op management for condylar fracture
- Early mobilization
2. Aggressive physiotherapy with jaw and mouth opening exercise
Whats the principle of treating multiple fractures of mandible?
- Mandible has a lot muscular attachment that gives and exert forces in different direction and location
- Rigid fixation using Champy principles
Where osteosynthesis using miniplates at the tension and compression zones will stabilize and resist rotational forces exerted on the mandible.
- tension zone at the superior border
- compression zone at inferior
What are potential complications for orif of condyle?
Approach related
- Bleeding from internal maxillary artery
- Facial nerve injury
- Salivary fistula for transparotid approach
- Freys syndrome
ORIF related
- Malunion
- Ankylosis
- Infection - osteomyelitis
- Nonunion
What is Guardmans fracture?
A collection of injury sustained on a blow to the chin that causes
- Symphyseal fracture
- Bilateral condylar fracture
- Laceration wound on the chin
How do u treat Guardmans fracture
Reduce fracture to achieve occlusion with MMF
Reduce anatomically
Fixation of symphysis (teeth bearing region first) with 2 miniplates sup and inf using 4 holes plate 2.0 diameter screw
Condylar fracture
- Depending on level of fracture
- intracapsular and minimally displaced - MMF
- subcondylar, severely displaced - ORIF one side or both sides (unilateral fixation will require post op MMF depending on its severity of displacement
Why isit challenging to treat mandibular fractures in edentulous patients
Mandibular height
Muscle pull
Vascular compromise
Old age and comorbids
How do you treat edentulous mandibular fracture
Important element is adequate and complete stabilization of the segments
Lack of that will lead to nonunion esp when using splints, wires, miniplates.
Hence. Best option would be Recon plate.
Other option is
Gunning splint in edentulous
What do u need to assess when suspect mandibular fracture
- Malocclusion
- Paraesthesia
- Presence of decayed or fractured teeth along fracture line
- Displacement - key indicator for fracture stability (severe displacement leads tearing of mucoperiosteum- impair healing)
- Height of alveolar bone
- Comminution
From notes
Mx of mandibular fractures
Etiology:
Assault
Mva
Penetrating missile or sharps
Types: Simple closed Compound Comminuted Greenstick Pathologic
Location: Symphyseal - usually assoc with condylar Parasymphyseal - usually assoc with contralateral condylar / angle of mand Angle of mand Body Condylar Ramus Coronoid Dentoalveolar
Presentation:
Step deformity
Deranged occlusion
Sublingual hematoma
Premature contact at affected side of condyle fracture
Deviation of mouth opening towards fractured side
Imaging
Pa skull
- overview of mandible #
- can see body, symphyseal, condyles
- alsooo
Opg
- overview of mandible # (body angle ramus condyle)
Townes view
- see subcondylar fracture & direction of displacement
Ct scan
- gold standard for multiple facial injuries
Treatment
1) no tx
Non displaced
2) closed tx
Isolated body or symphyseal fracture
What are considerations in pediatric mandibular fracture
- Growth - skeletal maturity of maxilla and mandible (14-16 in female, 16-18 in males; skeletal maturity of orbit 7 yrs)
- Mixed dentition and tooth germs
- spacing in deciduous teeth - difficult to mmf
- developing tooth buds in the bone - Closed reduction
- method of choice (risdon cable - its like a customized archbar using wires)
- orif is ok but removal upon healing - second surgery - Usage of resorbable hardware
- disadvantage includes bulky and oversized, risk of damaging toothbuds, sterile abscess upon degradation
