Beruflich Dokumente
Kultur Dokumente
DEPARTMENT OF
SEMINAR
on
Mandibular fractures
Presented By:
Dr. Satyajit Sahu
III MDS
CONTENTS
HISTORY
ANATOMY
BIOMECHANICS
CLASSIFICATION
DIAGNOSIS:
HISTORY
CLINICAL
EXAMINATION
RADIOLOGIC EXAMINATION
CLINICAL FEATURES
METHODS OF IMMOBILIZATION
COMPLICATIONS
CONCLUSION
REFERENCES
INTRODUCTION
Management of trauma has always been one of the surgical subsets in
which oral and maxillofacial surgeons have excelled over the years. More
particularly, our experience with dental anatomy, head and neck physiology
and occlusion provides us with unparalleled skills for the management of
mandibular fractures.
The mandible is the second most commonly fractured part of the
maxillofacial skeleton because of its prominence and its position. The
location and pattern of fractures are determined by the mechanism of injury
and the direction of the vector of force. In addition to this, the patients age,
the presence of teeth and the physical properties of the causing agent also
have a direct effect on the characteristics of the resulting injury.
The goals of treatment, are to restore proper function by ensuring union
of the fractured segments and reestablishing pre-injury strength; to restore any
contour defect that might arise as a result of the injury and to prevent
infection at the fractured site. restoration of the mandibular function, in
particular, as past of the stomatognathic system must include the ability to
masticate properly, to speak normally and to allow for articular movements as
ample as before treatment. In order to achieve these goals, restoration of the
normal occlusion of the patient becomes paramount for the treating surgeon.
ANATOMY :
Mandible is the largest, heaviest and strongest bone of the face. The
normal mandible provides a normal airway and proper facial contour. A solid
movable mandible allows normal chewing, swallowing and speech. Even
though, it is a very strong structure, it is prone to injury because of its
periosteal blood supply than the central supply. Therefore if open reduction is
planned, stripping of the periosteum is such that, it should be kept to a
minimum.
Nerve supply :
Damage to inferior alveolar nerve often fracture, results in the
parasthesia or anaesthesia of the lower lip on the affected side. If the nerve is
completely severed, then recovery by regeneration takes 3 to 12 months,
usually proceeded by tingling sensation, parasthesia and hyperanaesthesia of
the area. The rate of recovery depends on following:
1) Accurate approximation of the nerve ends. (proper reduction of
fragments).
2) Elimination of infection
3) Proper fixation
4) Absence of any intervening hard or soft tissue in the inferior dental
canal (muscle entrapment in the fracture line or foreign body or bone
fragments.
BIOMECHANICS :
The mandibular body is a parabola shaped curved bone composed of
external and internal cortical layers surrounding a central core of cancellous
bone. The outer cortical layer is particularly strong and gives good anchorage
for osteosynthesis devices. In the chin region the cortical bone is thickest at
the lower border, where as more posteriorly it is relatively thin. At the angle
stronger parts are found along the upper part, along the oblique line which
runs from the coronoid process to the molar region, forming a ridge cross
HISTORY OF
TREATMENT
BANDAGES
AND
EXTERNAL
APPLIANCES:
was then used to apply pressure to the two splints, theoretically immobilizing
and fixating the fractured segments.
Gunning was the first to use a custom-fitted intraoral dental splint for
immobilization. He used the splint in conjunction with an external head
appliance. His splints could also be applied to both the maxilla and the
mandible, resulting in intermaxillary fixation. An anterior space was provided
for nourishment. This basic principle of using splints for intermaxillary
fixation, although modified, is still used routinely in the treatment of
edentulous and partially edentulous mandible fractures.
Monomaxillary wiring, Bars, Arches, and Splints:
In the mid-1960s, Luhr pursued research in rigid fixation for the facial
skeleton and developed the Vitallium mandibular compression plate, using
glide screw principles. Throughout the 1960s. Luhr continued research on
rigid fixation and also contributed the self-threading screw. In the 1970s,
investigators, including Spiessl, studied AO/ASIF principles. They found that
adaptation of a compression plate on the lateral cortex, at the inferior border,
the superior border (tension zone) splayed. Many investigators thought a
second tension-zone plate would be necessary, others, believed that arch bars
in tooth-bearing areas were sufficient to limit the tension-zones splaying. In
1973, Schmocker and Speissl developed the eccentric dynamic compression
plate, which provided compression at the tension and compression zones of
the mandible. When the screws closest to the fracture were tightened, the
fracture line would be placed under compression. When the eccentric
terminals were tightened, the alveolar segment would be reduced.
In the early 1970s investigations were started to evaluate the use of
smaller plating systems. In 1973, Michelet and colleagues placed bendable,
monocortical miniplates to treat mandible fractures. The advantages of
miniplates were their thinness and the fact that they could be placed through
intraoral incisions.
Edentulous Mandibular Fractures :
between patients with mandibular and midface fractures and those with
mandibular and other facial bone fractures. Of the patients reported, 15%
had another facial bone fracture, along with the fractured mandible.
6. Multiple: A variety in which there are two or more lines of fracture on the
same bone not comunicating with one another.
7. Impacted: A fracture in which one fragment is firmly driven into the other.
8. Atrophic: A spontaneous fracture resulting from atrophy of the bone, as in
edentulous mandibles.
9. Indirect: A fracture at a point distant from the site of injury.
10.Complicated, or complex: A fracture in which there is considerable injury
to the adjacent soft tissues or adjacent parts; may be simple or compound.
fracture
line.
line.
Rowe and Killey divided mandibular fractures into two classes: (1) those not
involving basal bone and (2) those invovling basal bone. The first class
primarily comprised alveolar process fractures. The second class was divided
into single unilateral, double unilateral, bilateral, and multiple.
Kruger and Schilli took into account many of the aforementioned
classifications and developed four categories of mandibular fractures:
I.
II.
III.
IV.
Simple or closed
B.
Compound or open
Type of Fractures
A.
Incomplete
B.
Greenstick
C.
Complete
D.
Comminuted.
B.
C.
Localization
A.
canines
B.
C.
canine
third
E.
G.
Clinical Examination :
The signs and symptoms of mandibular fractures are as follows.
Change in Occlusion :
Although changes in sensation in the lower lip and chin may be related
to chin and lip lacerations as well a s blunt trauma, numbness in the
distribution of the inferior alveolar nerve after trauma is almost path
gnomonic of a fracture distal to the mandibular foramen. Conversely, most
nodisplaced fractures of the mandibular angle, body, and symphsis are not
characterized by anesthesia, so the clinicians must not use lip anesthesia as
the sole feature in diagnosis.
Abnormal Mandibular Movements:
The
clinician should palpate the mandible using both hands, with the thumb on the
teeth and the fingers on the lower border of the mandible. By slowly and
carefully placing pressure between the two hands, the clinician can detect
crepitation in a fracture.
Radiologic Examination:
The following are types of radiologic studies that are helpful in the
diagnosis of mandibular fractures :
Panoramic radiograph
Lateral oblique radiograph
Posteroanterior radiograph
Occlusal view
Periapical view
Reverse Townes view
Temporaomandibular joint, including tomograms
Computed tomography (CT) scan.
usually requires the patient to be upright (machines that allow the patient to
be prone are available), which may make it impractical in the severely
traumatized patient; it is difficult to appreciate buccal-lingual bone
displacement or medical condylar displacement; and fine detail is lacking in
the temporomandibular joint area, the symphysis region (depending on type
of equipment), and the dental and alveolar process region. A secondary but
important disadvantage is that panoramic radiographic equipment is not
present in all hospital radiology facilities.
The lateral oblique view of the mandible can be help in the diagnosis of
ramus, angle, and posterior body fracture. The technique is simple and can
be done in any radiology department. The condyle region is often unclear, as
is the bicuspid and symphysis region. The Caldwell posteroanterior view
demonstrates any medial or lateral displacement of fractures of the ramus,
angle, body and symphysis. The condylar region is not well demonstrated on
this view, but midline or symphyseal fractures can be well visualized. The
anteroposterior view is occasionally used for patients who cannot be
positioned in the supine position; however, considerable magnification and
distortion occur with this view. The mandibular occlusal view demonstrated
on this view, but midline or symphyseal fractures can be well visualized. The
anteroposterior view is occasionally used for patients who cannot be
positioned in the supine position; however, considerable magnification and
distortion occur with this view. The mandibular occlusal view demonstrates
discrepancies in the medial and lateral position of body fractures and also
shows anteroposterior displacement in the symphysis region.
The reverse
Banna also reported a case and reviewed the literature on posttraumatic thrombotic occlusion associated with an undisplaced body fracture
of the mandible became apparent 48 hours after the injury. Gordon and
colleagues described a patient with a unilateral body fracture of the mandible
who developed symptoms of a ruptured spleen 5 day after the injury and 3
days after arch bars had been placed.
2.
be
mentality.
concurrently
Teeth are often injured with mandibular fractures, and although the
teeth may not have to be restored immediately, dental knowledge is vitally
important in determining which teeth can and should be maintained. (a)
Fractured teeth can become infected and jeopardize bone union; however, an
intact tooth in the line of fracture that is maintaining bone fragments can be
intact tooth in the line of fracture that is maintaining bone fragments can be
protected with antibiotic coverage. (b) A second molar on an otherwise
edentuolus posterior fracture segment should be maintained to prevent
superior displacement of the fragment in intermaxillary fixation. (c)
Mandibular cuspids are the cornerstone of occlusion and should be
maintained at all costs. (d) Some teeth are not critical to restoration and can
be removed when their prognosis is doubtful and when maintenance may
adversely affect fracture treatment. For example, a lone mandibular incisor
adds little to future bridge or partial denture construction; however, a single
molar tooth in an otherwise edentulous posterior quadrant can be critical to
dental rehabilitation. (e) Some fractured teeth cannot be salvaged no matter
how critical they may be. For example, a molar tooth may be split mesially
and distally, so reconstruction would be impossible. Maintenance of this
tooth during intermaxillary fixation may result in severe discomfort and
perhaps infection.
4.
the
The old adage inside out and from bottom to top applies to the
proper sequence to follow when treating facial fractures. To build a
foundation on which the facial bones can be laid, it is proper that the
mandible be reconstructed first, although with the use of rigid fixation,
deviation from this principle can be allowed. All intraoral surgery should be
done prior to any extraoral open reductions or suturing of facial lacerations.
Too often, lip and skin wounds that have been meticulously closed in an
emergency room are inadvertently, or ever necessarily, reopened during the
treatment of mandiblular fractures. Gross debridement and control of
hemorrhage should be combined with temporary measures to reapproximate
extraoral wounds, thus allowing definitive treatment to be carried out after the
intraoral procedures are completed.
6.
the
type,
fractures.
With the current enthusiasm for open reduction and rigid fixation in the
treatment of mandibular fractures, it is important to remember that closed
reduction techniques have a long history of success. Although open
techniques have advantages, such as more exacting bone fragment
reapproximation and earlier return to function by the patient, significant
disadvantages exist as well. They may subject the patient to prolonged
anesthesia, may increase the risk of infection and metal rejection, may cause
damage to adjacent teeth and nerves, may result in lntra oral or extraoral
scarring, and may increase hospitalization time and cost.
Indications for Closed Reduction
Condylar Fractures :
Most condylar fractures can and should be treated via-clsoed
techniques if the occlusion is compromised. Early jaw mobilization and
physical therapy are indicated to prevent ankylosis or limited jaw movements.
movement is
necessary, and open rigid fixation techniques can provide that option. For
example, patients with difficult-to-control seizures, psychiatric or neurologic
problems, compromised pulmonary function, and eating or gastrointestinal
disorders could benefit from open rigid fixation techniques.
6. Bone clamps
7. Bone staples and Bone screws.
In recent years there has been a progressive move away from the
traditional use of predominantly closed or semiclosed indirect procedures in
the management of facial fractures towards a greater use of direct fixation
techniques.
of the jaws. However, the wires tend to loosen and a broken wire cannot be
replaced without first removing and then replacing all of the others.
2.
condyle will not necessarily be reduced by this method nor will they be
completley immobilised.
BUTTON WIRING :
Leonard (1977) considers that eyelet wires have several drawbacks.
The simple eyelet was frequently drawn into the interdental space, making
it difficult to use.
Elastic traction using eyelets, though possible, was time consuming to
apply.
Leonard described the use of titanium buttons of 8mm diameter,
inclusive of a 1mm rim, and 2mm deep.
3)
either jaw to be wired in such a manner that elastic traction can be used to
reduce the fracture.
If the patient wears a partial denture and this is available, it can be used
not only to restore the occlusion but also as a point of anchorage for the wires
or elastic bands to reinforce the intermaxillary fixation.
4)
Arch Bars :
Basically there are two varieties of arch bars, those that are
commercially produced and those which are individually made for a given
patient.
Barker (1986) described a precast arch bar for greater accuracy of
occlusal reduction.
Indications for use :
1. When insufficient teeth remain to allow efficient eyelet wiring.
2. When the teeth present are so distributed that efficient intermaxillary
fixation is otherwise impossible.
3. When there are simple dentoalveolar fractures, or where multiple
toothbearing fragments in either jaw require reduction into an arch form
before intermaxillary fixation is applied.
4. As an integral part of internal skeletal suspension in the treatment of
fractures involving the middle third of the facial skeleton; alternatively,
when external skeletal fixation is indicated, an anterior projection bar may
be attached to an individually made arch bar.
5. Where laboratory and technical facilities are inadequate or non-existent.
5)
Cap Splints :
them may considerably increase the operatingt ime and, as with eyelet wiring,
buccolingual rotation is not prevented. Furthermore, during the period of
immobilization, superficial dental caries may occur where there is plaque
concentration. When combined with elastic traction, cap splints may obviate
the need for a general anesthetic.
Acrylic splints :
Acrylic resin cap splints are easily and more cheaply fabricated. They
are particularly useful for the treatment of dislocated teeth and alveolar
segmental fractures.
Impressions :
Problems may be encountered in obtaining satisfactory impression
because of :
1.
a)
b)
form
posterior
relation
to
the lips. Lacerations of the tongue and adjacent soft tissues or hemorrhage
from the fractures may produce blood clot and/or sufficient swelling to
obscure much of the crowns of the posterior teeth.
3.
without
exposed
especially in chi8ldre.
Impression technique :
After the clinical and radiographic examination has determined the
location of the fractures, and the position and condition of the teeth on the
various fragments, the disposable trays are prepared. Blood clot and debris
should be removed from the mouth using gauze moistened in sodium
bicarbonate solution and, where necessary, exposed dental pulps should be
covered by sedative dressings. Impression are taken of each separate tooth
bearing fragment if it is impossible to obtain a satisfactory impression of all
the teeth in the jaw in one tray. Any impression which loses its attachment to
the tray should be repeated; however irritating this may be otherwise the
splints will not fit correctly.
Splint dressings
The splint dressing and positioning of the hooks depends upon the
overjet and overbite and the need or otherwise for extremely fixation.
Approximately three hooks are required on each quadrant unless an
alternative anchorage of the tie wires is proposed, such as the locking plate or
the connecting bar. The hooks should be positioned to allow the cross bracing
in a zigzag pattern of the tie wires or elastic bands. If internal suspension is
required, a loop or a reversed hook is sited on the buccal aspect of the upper
splint in the first molar region.
Preoperative procedures:
When possible, splints should be cemented on to the teeth an hour or
two before the operation so that the material can mature and harder, before
any stress is put upon it.
Cement media :
1.Black copper cement :
Provided that the teeth are dry and the cement is correctly mixed,
copper cement is the best long-term medium to use. The phosphoric acid
etches the surface of the enamel, thereby achieving a good bond and is, in
itself, bactericidal. Unfortunately the superficial enamel will be stained
temporarily and synthetic restorations permanently. Porcelain crown should
be protected by a thin smear of Vaseline to prevent cement from adhering to
them. The patients lips and , if present, moustache and beard should be
liberally coated with Vaseline.
It is advisable for the operator to wear surgeons gloves. If the fine
black powder and the acid fluid penetrate under the nails and into any
scratches or cuts they are difficult to remove.
The optimal working time for the cement is only 20-30 seconds. This
calls for extreme efficiency and, particularly in warm climates, a chilled
mixing slab to retard the setting time. The slab should be immersed in iced
water or placed in a refrigerator before use. An excess of cement must be
prepared each time so that all of the fitting surfaces of the splint are covered
by one mix. The powder is added to the fluid in small quantities and mixed by
rapid circular motions of the spatula until a light oily consistency is achieved.
Watery cement drips everywhere and thick cement will set before the splint
safe seated. The situation calls for considerable manual dexterity and a little
experience or guidance. Small splints may be difficult to manipulate and their
placement is facilitated by the attachment of `orange sticks to the occlusal
surface using beeswax. Once the splint is positioned, these sticks are easily
removed so that digital pressure can be applied to the splint to seat it
properly.
The phosphoric acid solution is a strong irritant and some patients
develop a considerable edema where the cement has come into contact with
the mucous membrane. Care should, therefore, be exercised to prevent this.
2.
Cold-cure acrylic :
The working time for this material is much longer. Splint retention is
achieved by the mechanical effect of the acrylic flowing into undercuts
around the teeth. No cement/tooth bond is achieved, however, so that oral
fluids will permeate into the interdental spaces and over the cervical margins
of the teeth and superficial carious lesions can occur. If the patient do not
complain of a fetor oris and foul tat during the period of splint wear, they
certainly do for a short time after removal of the splint. Commonly, local
areas of periodontal infection are found, usually associated with excess
acrylic. These, however, clear in a few day without any permanent sequelae.
3.Polycarboxylate cement :
This group of cements is considered by some surgeons to be cleaner
than the copper cements. However, they suffer from one important
disadvantage in that they do not etch the surface of the enamel and hence lack
the adhesion achieved by copper cement.
Cementing the splint:
When possible this should be done on the dental chair with good,
illumination and compressed air available. If the patient is bedridden, mobile
dental units are invaluable.
Reduction of the fracture:
Multiple fractures are more common in the lower jaw than the upper. A
sectional splint does not possess the retentive properties of a complete unit
and it is easy to dislodge it, even after the cement has completely hardened,
when manipulating the fragments, when tightening tie wires or during periods
of post anaesthetic nausea.
Postoperative care:
When the patients general condition permits and the edema has
subsided, the elastic bands, which become soggy, foul smelling and dirty, are
replaced by tie wires. Patients should be instructed about oral hygiene at the
earliest possible stage so that they can relieve the nursing staff of the task of
thorough oral lavage as has already been described. The cap splints rapidly
tarnish if oral hygiene is not satisfactory whereas, with reasonable care, the
labiobuccal aspect of the splints will retain their bright polished appearance.
Hooks causing soft tissue trauma must be turned inwards, loose screws
tightened and broken wires or elastics replaced. The sharp edges of splints,
screws or locking plates, or areas of dissimilar metals which cause
electrolytic ulceration in the first 2 or 3 days should be covered by softened
pink wax or gutta-percha. Wire twists which have not been bent sufficiently,
and therefore traumatize the soft tissue or catch the toothbrush, require
adjustment.
unilateral and
Contraindications:
Unfavourably displaced fractures lying outside the denturebearing
areas, or severe posterior displacement of fractures of the anterior part of the
mandible which will probably be inadequately controlled by this method
alone and will require additional fixation, e.g. transosseous wiring.
Projectile injuries, involving grossly comminuted soft tissue and bone
loss, may not be suitable for this technique unless posterior displacement
can be prevented, although open reduction is facilitated by the lacerations.
Provided that the wound edges are correctly approximated without
inversion and excess pressure is not applied, creations of the mucous
membrane will heal normally under the gutta-percha lining of the splints.
Extreme atrophy of the maxillae or mandible complicates this
technique. In the maxilla, per alveolar wires may cut out or be impossible to
insert. However, piriform apperture, per nasal or circumzygomatic wires are
suitable alternatives.
Splint technique:
Gunning splints may be constructed from :
The patients existing dentures suitably modified. These are often left at
the scent of the accident. They should be searched for and, even if broken,
can be repaired before use. Many edentulous patients have a usable
discarded set of dentures at home.
b. The splints must be lined with guttapercha or other suitable materials such
as soft acrylic or other polymers to prevent the ulceration which can
occur, even if the patients own dentures are used for immobilization.
c. There must be space anteriorly for feeding and breathing purposes.
Adaptation of old splints:
In an extreme urgency, previously used splints may be used provided
they are big enough and their fitting surfaces are thickly lined with gutta
percha to compensate for the discrepancies of the recipient mouth.
Disposable trays:
Under similar circumstances, after removal of the handles, these may
be lined with gutta percha, the jaw relationship being obtained by the use of
blocks of gutta percha placed in the buccal quadrants and allowed to harden
in situ. These splints are held in the mouth by the usual circumferential or per
alveolar wires, additional support being obtained if required from internal
skeletal suspension.
Circumferential wiring:
At this stage of the operation, the circumferential wires must be passed.
IF this procedure is carried out after the definitive reinsertion of the
mandibular splints, manipulation of the wires will result in displacement of
the bone ends. For this reason, the following sequence should be followed.
The point of a long curved awl is now placed externally in the desired
position inferior to the lower border of the mandible, where it will remain
remote from the fracture sites and will avoid injury to both the facial artery
and the area of the mental foramen. The operators middle or index finger of
the other hand lies in the lingual sulcus where it protects the submandibular
duct and lingual nerve and facilitates, by proprioception, the correct passage
of the instrument. The awl is then pushed through the skin until it reaches the
lower border of the mandible. With the point remaining in contact with the
bone throughout the procedure, the awl is advanced so that it emerges in
withdrawn so that the point can traverse the lower border of the mandible and
be pushed into the buccal sulcus, where the end of the wire is retrieved and
detached. At least two such wires should be inserted, their positioning
depending upon that of the fracture lines. The wire ends, secured by artery
forceps, are pulled to and fro until the bone is contacted to ensure that no soft
tissue remains between the wire and the bone. This procedure work-hardens
that portion of wire in contact with the bone. It is necessary, therefore, to
carry out this maneuver at one end of the wire before advancing it to the other
end. The work-hardened action is cut off and the artery forceps is reapplied.
The lingual ends are allowed to hang outside the mouth. In this way, free
access is provided for the next stage, which is reinsertion of the lower splint.
7. PIN FIXATION:
This technique was introduced during the Second World war for use
with compound, comminuted and frequently infected jaw fractures as a means
of controlling the fragments remote from the affected areas. Modern
antibiotics and improved surgical technique have reduced the need for pin
fixation but this method is still a valuable part of the armamentarium required
for the treatment of jaw fractures. The concept has been updated by the `box
frame method which was initially developed by Fordyce for the treatment of
middle third fractures of the facial skeleton. It is now of great assistance in
other problems of fixation involving the control of edentulous fragments when
a bone graft is required. Pin fixation is of particular value in the control of
bilateral edentulous posterior fragments, especially when the remainder of the
mandible has been lost and is to be replaced with a bone graft.
Advantages of pins:
a)
the fracture
lines.
b)
c)
fracture site,
time
required.
e)
surgical technique.
f)
fractures by
avoided. The oral cavity is left free of apparatus, thus assisting feeding and
minimizing the
Disadvantages of pins:
a)
because
cerebrally
irritated patient.
c)
since
by this means.
d)
e)
is
General principles:
Two pins, joined to each other by a transverse rod and two universal
joints, are inserted into the principal anterior and posterior fragments of the
jaw. Each pin assembly is then united by a further rod or rods held by
universal joints attached to the transverse bars. If jaw immobilization is
considered necessary and is not going to be provided intraorally, use may be
made of a `box frame, a Levant frame, a `head frame, or even a plaster of
Paris head cap if these more sophisticated craniofacial fixations are not
available. The pin fixation assembly in such cases is connected to this
apparatus by further vertical rods and universal joints.
Several varieties of pins and universal joints are available. Generally,
pins are 7 cm, long and 3mm wide, the length being sufficient to compensate
for severe edema whilst the width of the pain provides adequate strength. One
end of the pin is tapered obliquely to fit an Archimedean drill or hand
introducer, whilst the other is threaded and may have a cutting edge. Pins are
constructed from inert metals to prevent local osteitis which could otherwise
result from electrolytic action. Each operator usually prefers one of the
several varieties of pin available, some of which included:
a) Clouston-Walker pin-combines a spear point with a fine thread of
approximately 15 turns per cm
b) The East Grinstead pattern
c) The MacGregor pin is trochar-pointed with a shoulder formed by reducing
the diameter of the portion inserted into the bone to 2mm. Pins are
available in three sizes of 8mm, 10mm and 16mm as measured from the
point to the shoulder.
d) Moule pins are coarse threaded, tapered screw pins of different lengths
designed to be inserted by hand into a hole drilled by a 3 mm twist drill.
e) Toller pin constructed from titanium.
Several type of universal joints exits, constructed of various metals.
Because of the hazards incurred by using dissimilar metals in the pins,
universal joints and connecting pins, it is advisable to use joints made from
Tufnol, which act as insulators to break the circuit and thus prevent
electrolytic action.
Several
orthopaedic
hand
drills
are
available,
including an
Toller to produce a 1:1 ratio. The latter is helpful, for it turns slowly and gives
the operator a clear idea of the depth of penetration of the drill point.
Operative technique:
Landmarks may be difficult to locate because of soft tissue edema. If
this is severe, it is advisable for the operator to palpate the mandible
intraorally while he marks its periphery on the surface with a skin pen.
Radiographs will indicate the position and angulations of the fracture, which
is then drawn upon the skin and this gives an approximate guide to the
position of the inferior dental nerve. The amount of forward movement of the
posterior fragments should be carefully assessed. After this initial stage it is
essential to change gloves before proceeding.
The skin must be thoroughly prepared before surgery. It is helpful for
the fingers of one hand of the assistant to be placed within the mouth in order
to support the fragments, whilst the other hand supports the symphysis.
The following description applies to Moule pins which have been
found extremely satisfactory in use.
The posterior pins are first inserted into the area of the angle of the
mandible while the skin is pushed upwards and forwards by the surgeon to
restore the relationship between the displaced bone and undisplaced soft
tissues. The lower and posterior border of the angle of the mandible is
defined by palpation and a horizontal stab incision at the proposed site of pin
insertion is made with a No.15 scalpel blade.
As in the case of a carpenter inserting a screw into wood, so it is
necessary to drill a pilot hole before inserting the pin so as to avoid the risk of
splitting the bone. The diameter of the hole must be correctly matched to that
of the pin to ensure that the threads grip the bone with maximum retention.
The tissues are bluntly dissected with the tips of a hemostat down to the
surface of the bone and Moules tubular soft tissue retractor is inserted.
A twist drill of 2.25 mm (3/32) diameter is inserted into the chuck of
the drill and pushed down until the point comes into contact with the bone.
The drill point is moved about with its point in contact with the bone until the
operator is convinced of its position relative to the lower border and the angle
of the jaw. Having located a positioned approximately 1 cm from the angle,
the drill is positioned at right angles to the surface of the mandible and
drilling is commenced until the cortex is engaged. It is easy for the drill point
to slip and, to prevent this, drilling is continued in this manner but the
angulations is altered to 70 once the drill starts to penetrate. This is
continued, without any oscillation around the long axis of the drill, until the
inner cortex is just perforated. The revolutions of the drill must be slow
enough to allow the heat generated to dissipate, which is assisted by saline
being continuously applied to the drill shafts. Only light pressure should be
or,
wound and the underlying bone are rarely the caouse of troulbe Slight bone
infection may occur, but as the discharge drains away down the pin shaft
there is a minimum of symptoms. Surrounding whiskers must be cut by
scissors, although normal shaving is permissible in those areas to which the
patient ahs access.
Despite smoothing, the ends of the metal rods will still be prominent.
They may cause damage or injury or catch in materials but can be protected
by commercially made acrylic covers or by short lengths of polythene or
rubber tubing which is quite adequate.
COMPLICATIONS OF PIN FIXATION:
a) Anesthesia of the lip commonly results from the initial fracture. Insertion
of the pin into the inferior dental cancal will cause additional damage to
the vessels and lessen the chances of nerve regeneration. Severe pain may
result of the pin damages the nerve proximal to the fracture.
b) Involvement of the fracture line or its surrounding haematoma by incorrect
positioning of the pin may allow the entry of infection into the area.
c) Pin insertion into an oblique fracture line will cause a widening of the
fracture and the displacement of the lingula cortex despite the counter
pressure of an assistant. The looseness of the pin so positioned requires its
immediate resisting further away from the fracture.
d) Some areas of the ascending ramus are extremely thin and over
penetration may occur. This usually does not matter, since the tip lies in
the substance of the medial pterygoid muscle and no major vessel is in
close proximity. Over penetration rarely occurs with a Moule pin and is
less likely to occur with other varieties if the operator counts the
revolutions of drill with a known ration as the pins are inserted.
e) Damage to adjacent structures. The facial nerve and vessels are safe
unless a stab incision is carried too deeply because the pins will tend to
displace these structures rather than penetrate them.
The uncontrolled pin slipping beneath the lower border of the mandible
or behind its posterior border constitute a hazard to major vessels. Pressure
upon the drill should be increased slowly with the angulations of the pin kept
at right angles to the bone until penetration of the outer cortex has occurred.
Drills must be sharp so that excessive pressure is not required.
f)
minimal
to malunion or infection.
fixation
by
g)
people
with
the
ends of the pins and connecting bars. Most patients adopt a pattern of
behavior to prevent
h)
this.
controlled
number of patients present with facial fractures and other injuries which do
not lend themselves to the sole use of the basic techniques previously
described.
nasal aperture affords better retention than the surrounding bone. The nasal
aperture is exposed through a mucoperiosteal incision and the periosteum and
nasal mucosa is elevated from the area. The nasal mucosa is protected by the
insertion of a Howarths nasal periosteal elevator. The wires are inserted as
follows:
i)
A hole is drilled through the thickest part of the bone down on to the
elevator and a. 0.5 mm soft stainless steel wire is passed and brought out
through the pirifrorm aperture into the mouth. Both ends may then be twisted
around hooks processed into the upper splint or a hook in the lower splint.
Preferably, the wires should be twisted together to from a loop. A separate
wire can than be passed through the loop and attached to apparatus in either
should not be cut away and should incorporate a wire loop at the posterior
border in the midline. A long curved awl is passed along the floor of the nose,
above the mucosa, to the region along the floor of the nose, attached to the
posterior border of the hard plate. The handle is then elevated, causing the
point to penetrate the tissues and emerge in the mouth. A 10 cm length of 0.5
mm diameter soft stainless steel wire is passed through the loop processed
into the posterior border and bent back on itself to form two 5 cm lengths.
The ends of these are passed through the eye at the tip of the awl which is
then withdrawn to pull the wire ends forwards.
A finger placed in the labial sulcus palpates the anterior limit of the
nasal fossa and the tip of the introducer is then passed inferiorly to emerge in
the labial sulcus. The wire is then detached and the introducer withdrawn.
The double length of wire now runs from the loop on the posterior edge of the
splint along the floor of the nose and down into the labial sulcus. The two
ends are then twisted been encountered. Removal is accomplished very easily
by cutting the wire where it passes through the palatal loop and pulling both
strands forwards into the labial sulcus.
c)
when the zygomatic complex is fractured but the angular process and
supraorbital ridges are intact. The wires may be attached to either the upper
or lower jaw fixation but preferably they should be formed into a terminal
loop which is attached to the apparatuses by a separate wire. This allows the
jaw to be mobilized without untwisting the internal suspension wire and
risking its fracture.
d)
Immobilization :
Following accurate reduction of the fragments, the fracture site must be
immobilized to allow bone healing to occur. Orthopaedic surgeons have been
concerned for some time with the process of fracture healing when either
rigid or semi-rigid fixation is employed. The speed of repair of the weightbearing skeleton is of paramount importance in the eventual rehabilitation of
an injured patient. When semi-rigid fixation is used a fracture heals by
secondary intention which involves the formation and subsequent
organization of callus. This is a relatively slow process and weight bearing
must be delayed until full bone replacement has occurred. Even apparently
rigid fixation by means of non-compression plating or pinning leaves a gap
between the bone ends and bony union requires organization of a primary
callus. Key (1932) noted that healing of the arthrodesed knee was accelerated
when the opposing bony surfaces were compressed. Later experimental work
(Schenk and Willenegger, 1967; Hutzschenreuter et al., 1969; Perren et al.,
1969) has confirmed that compression osteosynthesis of both experimental
osteotomies and clinical fractures results in primary bone healing without the
formation of intermediate callus. This results in more rapid stabilization of the
fracture site and much earlier restoration of the mechanical strength of the
bone. Reitzik and Schoorl (1983) have compared rigid non-compression
osteosynthesis and semi-rigid wired osteosynthesis on either side of the same
mandible. Although non-compression plated osteotomies resulted in gap
healing with the formation of a small amount of intermediate callus, this was
still superior to semi-rigid osteosynthesis with demonstrably increased
mechanical strength on the plated side 6 weeks after surgery.
The question arises as to how relevant are these findings to the
treatment of mandibular fractures. Unlike a weight-bearing bone, it is only
necessary to immobilize the mandible until a stable relationship between the
fragments has been achieved. This period is considerably less than would be
required for full bony consolidation to take place. Some simple mandibular
fractures need no immobilization at all, particularly if a lack of teeth means
that precise restoration of the occlusion is not at a premium. Such fractures
remain mobile for some time if they are forcibly manipulated but eventually
proceed to full bony union. It is indeed difficult to prevent the fractured
mandible uniting and malunion is a more frequent complication than nonunion.
The overwhelming advantage of rigid fixation is the avoidance of
intermaxillary fixation. If that is not possible, bone plates offer no significant
gain to the patient either during treatment or in the eventual outcome. In view
of the fact that clinical union of mandibular fractures is much quicker than
most other bones, compression osteosynthesis must have a very dubious
place in any treatment plan.
Period of immobilization :
The period of stable fixation required to ensure full restoration of
function varies according to the site of fracture, the presence or otherwise of
retained teeth in the line of fracture, the age of the patient and the presence or
absence of infection. Juniper and Awty (1973) have shown that in favorable
circumstances stable clinical union can on average regularly be achieved after
3 weeks at which time fixation can be released.
In fractures of the body of the mandible the blood supply to the fracture
site is significant. Where endosteal vascularity is relatively poor as in the
ageing jaw, and particularly in the symphysis region, healing tends to be
prolonged. In contrast, the rich blood supply and exuberant osteoblastic
activity of the childs growing mandible ensures extremely rapid union.
A simple guide to the time of immobilization for fractures of the toothbearing area of the lower jaw is as follows :
Young adult
With
Fracture of the angle
3 weeks
receiving
Early treatment
in which
Tooth removed from fracture line
If :
a)
b)
c)
d)
year-old patient where the tooth in the fracture line is retained requires 6
weeks immobilization (basic 3 weeks + 1 week for less favourable site + 1
week allowed for age + 1 week for tooth retained in the line of fracture).
Rules such as these are designed for guidance only, and it must be
emphasized that the fracture must always be tested clinically before the
mandible is finally released. The temporally attachments to the dentition
should be retained for a further period so that reimmobilization can be carried
out if the union of the fracture is found to be inadequate after function has
been restored.
FRACTURES OF THE EDENTULOUS MANDIBLE :
Introduction :
The physical characteristics of the body of the mandible are altered
considerably following the loss of the teeth. In effect from the point of view
of treatment, the edentulous mandible becomes a different bone. Following
resorption of the alveolar process, the vertical depth of the subsequent
Direct osteosynthesis :
a) Bone plates
b) Transosseous wiring
c) Circumferential wiring or straps
d) Transfixation with Kirschner wires
e) Fixation using cortico-cancellous bone graft.
2)
3)
Direct osteosynthesis :
Bone plates :
Bone plates are particularly useful for displaced fractures of the
edentulous mandible, particularly those at the angle. They allow the fracture
to be stabilized without immobilization of the jaw as a whole. The patient is,
as a result, more comfortable during the period of healing of the fracture. The
main mandibular plating systems described are in general applicable to
edentulous fractures. The reduced depth of bone in the edentulous mandible
favours the use of non-compression mini-plates rather than the bulkier
compression plates in that the former are less likely to interfere with the edge
of a future denture. Bone plates are easier to apply in the edentulous state
than when teeth are present as there is no need to achieve the same degree of
precision in the reduction of the fracture. Any discrepancy in the eventual
occlusion of the pre-existing dentures is more easily corrected than when
natural teeth are involved.
The surgical technique is, however, more time consuming and requires
liberal exposure of the fracture site with extensive elevation of the
(Marciani and Hill, 1979), there would seem to be some merit in exploring
the clinical usefulness of this method of fixation in the future.
Intermaxillary fixation using Gunning-type splints :
The dental splint described originally by Gunning in 1866 was a
vulcanite overlay of the natural teeth which he used as a splint for the
fractured dentate mandible. A similar splint for the edentulous mandible
consisted of a type of removable monobloc resembling two bite blocks joined
together. The modern Gunning splint is therefore more correctly described as
a Gunning-type splint. These splints take the form of modified dentures with
bite blocks in place of the molar teeth and a space in the incisor area to
facilitate feeding. They can be used when the patient is edentulous in one or
both jaws. If the patient is completely edentulous immobilization is carried
out by attaching the upper splint to the maxilla by peralveolar wires and the
lower splint to the mandibular body by circumferential wires. intermaxillary
fixation can then be effected by connecting the two splints with wire loops or
elastic bands. When the patient is edentulous in one jaw intermaxillary
fixation is achieved by attaching the Gunning splint to whatever type of splint
is present in the opposing jaw.
these have been preserved. The fitting surface is ground away to an even
depth and replaced by a liberal lining of black gutta percha and pressing the
two splints together. Hooks are incorporated into each splint to allow
intermaxillary fixation to be applied.
When the facilities of a maxillofacial laboratory are not easily
available, splints can be made by modification, of the patients dentures if
these have been preserved. The fitting surface is black gutta percha. The
anterior teeth are removed to provide a space for feeding and approximately
positioned hooks are fitted using self-curing acrylic. The necessary materials
for modifying dentures in this way should always be carried along with other
fixation apparatus when called to treat a facial injury away from the main
base.
At operation the splints are adapted to the alveolus of each jaw after
reduction of the mandibular fracture. Gunning-type splints are frequently
employed as an adjunct to some other form of fixation and it may not be
possible to fit the lower splint until open reduction and other fixation has been
applied. The upper splint is fixed to the alveolus by using an awl to pass a
0.45 mm soft stainless steel wire through the alveolus high up in the canine
area on each side and then through an appropriately positioned hole in the
palatal portion of the splint. The two free ends on each side are twisted
together over the splint, cut short and bent in under one of the hooks or cleats.
The lower splint is attached to the reduced fractured mandible by
means of circumferential wires. care must be taken to avoid passing a
circumferential wire close to a fracture site as the wire may be pulled up into
the fracture when it is tightened. The most satisfactory method of passing
these wires it that described originally by Professor Obwegeser. A suitable
curved awl is pushed through the skin beneath the mandible and directed into
the mouth on the lingual side of the bone. One end of a length of 0.45 mm
soft stainless steel wire is passed through the tip of the awl which is then
carefully withdrawn to the lower border of the mandible but not out through
the skin. The tip of the awl with the attached wire is guided round the lower
border and pushed up into the buccal sulcus where the wire end is detached.
The instrument is then withdrawn through the original puncture wound in the
skin. The wire is applied close to the bone throughout its passage avoiding
the necessity of sawing it through the soft tissues.
After the splints have been attached to each jaw they are connected by
elastic bands or wire loops utilizing the hooks on the buccal surfaces of each
splint and intermaxillary fixation is established.
When treatment is completed, the peralveolar and circumferential wires
are removed by cutting each wire close to the buccal sulcus and pulling firmly
and rapidly. An anaesthetic is not required and if the wire is cut close to the
point of mucosal entry this avoids a length of contaminated wire passing
through the tissues. In spite of these precautions the passage of the wire
during removal occasionally causes infection and it is wise to prescribe
antibiotic cover for the procedure.
Gunning-type splints are still widely used as fixation for fractures of
the edentulous mandible which justifies describing the technique in some
detail. The method is useful for simple fractures treated by surgeons of
limited experience. It is, however, a technique which is far from ideal. The
splints become exceedingly foul during 4-6 weeks fixation as a result of food
stagnation between the poorly fitting surface of the splint and the mucosa.
Apart from the Candida-induced stomatitis which results, there is a significant
incidence of more serious infection of the wire track within the tissues. These
splints are inefficient as a method of immobilization and provide poor control
of mobile fractures, particularly when the mandible is very thin. They are
2)
3)
4)
5)
6)
7)
well defined than in adults whereas the ratio of bone to tooth substance is
high (Khosla and Boren, 1971). Incomplete dysjunction in the form of a
greenstick fracture is therefore more likely and there is a greater risk of
damage to developing teeth than in later years. Ranta and Ylipaavalniemi
(1973) carried out a long-term investigation of teeth involved in mandibular
fractures occurring before the age of 12 years, and observed disturbed
formation in 72% of teeth directly involved in the line of fracture. They also
noted from other surveys that between 25 and 48% of teeth involved in the
fracture line in adults exhibited pulp necrosis.
Keniry (1971) in a survey of the literature found that between 8.3%
and 15% of jaw fractures occurred in children under the age of 15 years.
According to MacLennan (1956) only 1% of the mandibular fractures
happened before the age of 6 years.
The treatment of mandibular fractures in children before puberty is
generally or a conservative nature because of the rapidity of healing and the
adaptive potential of the bone and its contained dentition.
There are a few special factors which need to be taken into account in
managing these injuries.
Interference with growth potential :
The normal growth of the mandible will be disturbed if unerupted
permanent teeth or teeth germs are lost, because the alveolus will not develop
normally in the areas affected. Damage to the growth potential will be more
severe in the event of infection of the fracture site.
McGuirt and Salisbury (1987) carried out a careful cephalometric
analysis of 28 children who had experienced mandibular fractures at sites
other than the condyle and found that mandibular unit length to be less than
expected in 67%. One-third of the patients with fractures in the tooth-bearing
portion of the mandible had specific dental complications.
Later complications :
Malunion :
Post reduction radiographs must always be taken and should these
reveal an unacceptable malposition of the fragments, this should be corrected
as soon as possible by a further operation if necessary.
When fixation is removed there should be no derangement of the
occlusion. Unfortunately from time to time some disturbance is found to be
present. Such minor malunion is more common after cap splits have been
employed and results either from failure to seat the splints evenly when
originally cemented into place, or from faulty laboratory technique producing
variation in the thickness of the metal casting. If fixation is removed at the
stage of clinical union when the callus is still soft, minor discrepancies in the
occlusion will often correct themselves as the patient starts to use the jaws
again. The process of readjustment may be helped by selective occlusal
grinding.
Occasionally cases may be seen where inadequate reduction has
resulted in gross derangement of the occlusion and deformity of the face. This
situation may also arise when a patient has had no treatment at all for the
fractured mandible, either because he did not seek treatment at the time of
injury, or because other more serious injuries prevented treatment or
diagnosis. The mandible has an impressive capacity to heal itself and
providing some bone contact is present, malunion is more likely than nonunion. Gross occlusal derangement and facial deformity requires operative
reconstruction usually in the form of refracture. Occasionally a formal
planned osteotomy or ostectomy may be required. When the jaw is
refractured to correct malunion it is wise to pack autogenous cancellous bone
chips obtained from the iliac crest around the newly approximated bone ends.
If this is not done the diminished blood supply at the site of the original injury
2. Inadequate immobilization.
3. Unsatisfactory apposition of bone ends with interposition of soft tissue.
The remaining causes of non-union may be impossible or very difficult to
overcome and are as follows :
1. The ultra-thin edentulous mandible in an elderly debilitated patient.
2. Loss of bone and soft tissue as a result of severe trauma, e.g., missile
injury.
3. Inadequate blood supply to fracture site, e.g. after radiotherapy.
4. The presence of bone pathology, e.g. a malignant neoplasm.
5. General disease, e.g. osteoporosis, severe nutritional deficiency,
disorders of calcium metabolism.
Treatment :
A moderate delay in union is treated by prolonging the period of
immobilization. Once non-union is accepted and if the bone ends are still
approximated, the fracture line should be explored surgically and any obvious
impediment to healing such as a sequestrum or devitalized tooth removed.
The bone ends are then freshened, the wound closed and the jaw is
immobilized once again. If there is any doubt concerning the health of the
bone ends autogenous cancellous bone chips should be obtained from the
iliac crest and packed around the fracture site.
If radiographs of a non-union show marked eburnation of the bone
ends or excessive bone loss, a formal bone graft of cortico-cancellous bone
will be required. It is important to eliminate active infection from the site
before employing a bone graft although if the obvious cause of the infection
has been eliminated, a bone graft inserted at the same operation will usually
be successful. In these circumstances metranidazole 500 mg every 8 hours
given intravenously in an infusion is a most useful prophylactic antibiotic.
Derangement of the temporomandibular joint :
state
of
malunion at
the
fracture
site.
Post-traumatic
Fractures with gross comminution of bone and loss of hard and soft
tissue :
Although this type of mandibular fracture can occur in civilian practice
from certain industrial injuries or injuries caused by fast-moving projectiles, it
is more commonly associated with missiles employed in war or civil
disturbance. The main differences between missile injuries of the mandible
and the type seen in civilian practice can be enumerated as follows:
1. The fracture is usually extensively comminuted.
2. It is always compound and contaminated by foreign matter and
bacteria.
3. The viability of the bone fragments and the extent of injury to teeth
cannot be accurately evaluated preoperatively from clinical and
radiographic examination.
4. Fracture treatment is complicated by soft-tissue injury or loss.
Bullets and other missiles traveling at high velocities cause this
extensive damage because of the release of kinetic energy at the point of
impact. Kinetic energy is proportional to the square of the velocity and it is
therefore the impact velocity of the missile which is the most important
factor. At impact there is deformation and sometimes fragmentation of the
missile. The release of energy produces temporary cavitation within the
tissues. These factors result in widespread damage adjacent to the missile
tract and an explosive exit wound although the entry wound may be
comparatively small.
Such extensive injuries of the mandible require protracted treatment
and the management can be divided into four main phases.
Immediate post-traumatic phase :
after
preliminary tracheostomy to
ensue
immediate
and
function is restored more quickly and the need for later bone grafting avoided.
Similarly, ingenuity in the use of local flaps during initial wound closure will
minimize the effects of skin loss.
Nevertheless some reconstruction is usually necessary. Skin may have
to be brought in and bone contour modified or re-established. Teeth need to
be replaced and many patients require special prostheses. The reconstructive
phase of treatment of these extensive disfiguring injuries may involve
numerous hospital visits and further operations over a considerable period of
time.
COMPLICATIONS :
Serious complications arising as a result of a fracture of the mandible
are rare providing the fracture has been competently treated. Minor
complications are, however, more common than is generally accepted
(Afzelius and Rosen, 1980). Complications may be considered under two
headings :
1. Complications arising during primary treatment.
2. Late complications.
Complications arising during primary treatment
Misapplied fixation
The increased use of bone plates, particularly in the tooth-bearing
portion of the mandible, has increased the complication rate during primary
treatment. Compression plates demand screws of sufficient length to impinge
on the inner cortex. Care is needed to avoid the inferior dental canal and to
avoid damage to the roots of teeth. The risk of damage to structures within
the body of the mandible is less when the screw engages only the outer cortex
as is the case with non-compression mini-plates.
Rigid osteosynthesis can distort the anatomical alignment of the
mandible leading to significant alteration of the occlusion. Should this occur a
decision must be made as to whether the malalignment can be corrected by
alter occlusal adjustment or whether a second corrective operation should be
performed.
Osteosynthesis by transosseous wires is technically easier and damage
to internal structures should be avoidable. Nevertheless ill-judged direction of
drill holes can cause problems. Circumferential wires, particularly those used
to retain Gunning-type splints, must be carefully located. If the
circumferential wire is close to a fracture line it may inadvertently be drawn
up into the fracture giving rise to displacement of the bone fragments, damage
to the inferior dental bundle and inadequate retention of the splint.
The correct insertion of pins fro external fixation is even more
hazardous in unskilled hands. The pins have to be inserted without the
advantage of direct exposure of the bone. They may impinge on nerves, blood
vessels or teeth. They may split the bone fragment if inserted too near the
lower border and they may fail to penetrate sufficient bone substance to
remain secure during the required period of fixation.
Infection :
Infection of the fracture site resulting in necrosis or osteomyelitis of the
mandible is rare. When teeth are retained in the fracture line there is always
some risk of infection and for this reason prophylactic antibiotic should be
prescribed. Lowering of the patients local or general resistance will
predispose to infection. Pathological fracture such as may be caused by the
presence of a benign or malignant neoplasm is a good example of diminished
local resistance to bacterial invasion. Debilitated patients, diabetics and
patients on steroid therapy are more likely to develop infected fracture sites
because of lowered general resistance.
Some of the most severe infections of fracture sites are seen as a result
of injudicious surgical interference, such as transosseous wiring of a fracture
already infected.
Nerve damage :
Anaesthesia of the lower lip as a result of neuropraxia or neurotmesis
of the inferior dental nerve is the most common complication of fracture of
the body of the mandible. The recovery of sensation in the lower lip depends
on the nature of the original damage to the nerve. While anaesthesia is present
the patient should be warned of the danger of burning the lower lip with hot
drinks or cigarettes.
Facial nerve damage may complicate some fractures of the ramus and
condyle, either as a result of a penetrating injury severing branches of the
nerve, or blunt trauma causing a neuropraxia. In the latter event recovery of
the resultant nerve weakness usually takes place fairly rapidly. If the facial
nerve is severed modern microsurgical techniques are often successful in
restoring function but it is most important to perform the repair at the same
time as the facial laceration is explored and sutured. It is much more difficult
to restore continuity and function as a later secondary procedure.
Displaced teeth and foreign bodies :
Teeth or portions of dentures are occasionally inhaled and, when
missing, must be accounted for. If this is not possible the chest must be
radiographed and if a foreign body is present it should be recovered by
bronchoscopy.
Fragments of teeth or glass are not infrequently buried in the soft
tissues of the lip. They may be difficult to locate in swollen tissues but may
become infected if left. If an abscess does occur, the site of pus formation
locates the foreign body which is ten usually removed easily when the
abscess is opened and drained.
Pulpitis :
Damaged teeth may develop pulpitis or apical infection during the
period of fixation. Such teeth are relatively easy to treat if arch bars or eyelet
wires have been employed. If a tooth becomes painful under a cap splint it is
occasionally necessary to remove the root portion via a buccal transalveolar
surgical approach. The tooth is sectioned at the cervical margin and the crown
left within the cap splint.
Gingival and periodontal complications :
Some degree of local gingivitis is inevitable when the fixation
employed involves interdental wires or cap splints. The gingival reaction may
be very severe when acrylic resin is used to attach cup splints to the teeth.
Gingivitis is usually not a serious problem and responds to local measures.
A more serious periodontal problem can result from applying too much
interdental force to individual teeth from eyelet wires or arch bars. The lower
incisors are most vulnerable and may be partially extruded or even lost. The
complication can be avoided by spreading the load more widely and evenly
by additional eyelets or arch bar ligatures, and by avoiding the application of
wires to suspect teeth.
Drug reactions :
Allergic reactions occur from time to time usually to antibiotics. These
are fortunately in the main fairly mild but the clinician must recognize the
complication at an early stage, discontinue all drugs which might be
incremented and prescribe an antihistamine such as oral chlorpheniramine
maleate (Piriton) 4mg t.d.s.
Later complications :
Malunion :
Post reduction radiographs must always be taken and should these
reveal an unacceptable malposition of the fragments, this should be corrected
as soon as possible by a further operation if necessary.
When fixation is removed there should be no derangement of the
occlusion. Unfrotunately form time to time some disturbance is found to be
present. Such minor malunion is more common after cap splits have been
employed and results either from failure to seat the splints evenly when
originally cemented into place, or from faulty laboratory technique producing
variation in the thickness of the metal casting. If fixation is removed at the
stage of clinical union when the callus is still soft, minor discrepancies in the
occlusion will often correct themselves as the patient starts to use the jaws
state
of
malunion at
the
fracture
site.
Post-traumatic
Lower border wires sometimes give rise to pain and discomfort if the
overlying skin is thin. In these circumstances they should be removed.
Bone plates, particularly the larger compression plates, may become
infected some time after the fracture has healed. Surgical removal of the plate
will lead to rapid resolution of the problem.
Sequestration of bone :
Comminuted fractures of the mandible, particularly those caused by
missile injuries, may be complicated by the formation of bone sequestra. A
sequestrum may be a cause of delayed union but often the fracture
consolidates satisfactorily and the sequestrum remains as an actual or
potential source of infection. Sequestra may then be extruded spontaneously
into the mouth with quite minimal symptoms but sometimes a localized
abscess forms and surgical removal of the dead bone becomes necessary. It is
important to be sure that a sequestrum has separated completely from the
healthy adjacent bone before surgical removal is contemplated. Very often an
infection can be treated with antibiotics and the dead bone allowed to extrude
spontaneously without surgical intervention.
Limitation of opening :
Prolonged immobilization of the mandible in intermaxillary fixation
will result in weakening of the muscles of mastication. If there has been
substantial haemorrhage within muscles a considerable amount of organizing
haematoma and early scar tissue ay be present when fixation is released. All
these factors combine to cause limitation of opening and a restricted
mandibular excursion. In the majority of cases full movement is restored in
time but as with other fractures, physiotherapy may accelerate the recovery
period. Simple jaw exercises and mechanical exercises may be employed
with advantage. Occasionally manipulation of the mandible under anaesthesia
may assist the breakdown of scar tissue within muscles.
REFERENCES
BOOK
OF
PLASTIC
MAXILLOFACIAL
AND