Beruflich Dokumente
Kultur Dokumente
on
Mandibular fractures
CONTENTS
HISTORY
ANATOMY
BIOMECHANICS
CLASSIFICATION
RADIOLOGIC EXAMINATION
CLINICAL FEATURES
FRACTURES
METHODS OF IMMOBILIZATION
COMPLICATIONS
CONCLUSION
REFERENCES
INTRODUCTION
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
prominent position in the facial skeleton. It is a common site of electron for
receiving intentional or unintentional violence.
The body of the mandible has got horeshoe or parabola shape. Two
rami project upward from the posterior aspect of the body. The condylar
processes of these rami articulate with the temporal bone to form the TMJ
joints. The mandible has been compared to an archery bow, which is strongest
at its center and weakest at its ends, where it often breaks.
The lower jaw is a movable body, which carries the alveolar process
and the teeth. The adult mandible is composed of a compact outer and inner
plate of cortical bone and a central portion of medullary bone (spongiosa),
whose trabeculae are distributed along the lines of maximum stress.
The lower portion of the body is heavy and thick and consist of dense
cortical bone with little spongiosa and changes very little during adult life.
The alveolar process has got lingual and buccal plate of compact but thin
bone. The body of mandible is naturally strengthened by a strong system of
buttresses which extend into the region of rami.
On the lateral surface strong external oblique ridge extends from the
body obliquely upward to the anterior border of the ramus. Medial surface is
thinner than the lateral thick compact bone. Here the myelohyoid line extends
from the area of the socket of the 3rd molar diagonally downwards and
forwards towards the genial tubercle at the midline. Bony clin is the most
vulnerable endangered targeted area, but it is naturally strengthened by the
mental protuberances. In childhood, body of the mandible is buds of
permanent teeth, but naturally protected due to resiliency of the bone.
The ramus consists essentially of two thin plates of compact bone,
separated by a narrow portion of cancellous bone. The posterior border of the
ramus is strong and rounded.
Blood supply :
Central blood supply through the inferior alveolar artery.
Peripheral blood supply through the periosteum.
In case of severely atrophic mandible, there is greater dependence on
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
sections in a sub-apical region reveal on average a thickness of 2.2 2.4 mm
at the symphysis and in the canine regions. From the host bicuspid to 1 st
molar the density increases from 2.5 to 3.4 mm. In the tooth bearing alveolar
process, the bone is of variable thickness.
Another important anatomic factor with references to fracture treatment
using internal fixation is the mandibular canal, including nemovascualr
bundle. The mandibular canal runs from the lingual of the mandible to the
mental foramen in a concave course directed upwards and forwards. The
distance between the canal and the outer cortical layer averages 4.0 mm in the
bicuspid regions increasing to 5.9 mm at the second molar. The distance
between the root apices varies from 3.4 mm (central incisor) to 6.3 mm (third
molar).
The maxillary and mandibular teeth, in occlusion form a very
sensitivity balanced system; Any displacement caused by fragments leads to
diminution of masticatory function and comfort. The main aim in fracture
treatment is therefore the restoration of normal occlusion.
Displacement of the fragments of the mandibular body is
predominantly the result of activity of muscles of mastication. From a
biomechanical point of view, the ideal method of osteosyhthesis would be to
nentralze these unfavourable forces. The mechanical characteristic of the
material used for this purpose should on one hand contain there forces and on
the other hand not be so rigid that stress shielding occurs and delays healing.
Champy et al ultimately developed the technique into a practicable
clinical method. Based on a methametical model of the mandible and taking
into account the active biting forces applied to the mandible and performing
different experimental evaluation, they were able to define the strains created
within the bone by muscular activity. Moments of flexion were found at the
upper border of the mandible, increasing progressively from the front of the
teeth to a maximum of approximately 600 N in the angles. Then are also
tortion movements between the canines, which increases in sleight towards
the middle to 1000 N.
They recommended that, behind the mental foramen only one plate
should be applied, immediately below the dental roots and above the inferior
alveolar canal. In front of the mental foramen, in order to neutralive higher
torsion forces between the canines another plate near the lower border of the
mandible is necessary in addition to the subapical plate.
Muscle attachments and displacement of fractures :
The periosteum is a most important structure in determining the
stability or otherwise of a mandibular fracture. The periosteum of the
mandible is stout and unyielding and gross displacement of fragments cannot
occur if it remains attached to the bone. Perisoteum may be stripped from the
bone ends by the extremity of the force applied, but frequently it yields to the
accumulation of blood seeping from the ruptured cancellous bone. Once the
periosteal splint has been removed displacement of the bone ends is free to
occur under the influence of the attached muscles.
Fractures at the angle of the mandible :
Fractures at the angle of the mandible are influenced by the medial
pterygoid-masseter sling of which the medial pterygoid is the stronger
component. Fractures in this region have been classified as vertically and
horizontally favourable or unfavourable. If the vertical direction of the
fracture line favours the unopposed action of the medial pterygoid muscle, the
posterior fragment will be pulled lingually. If the horizontal direction of the
fracture line favours the unopposed action of the masseter and medial
pterygoid muscle in an upward direction, the posterior fragment will be
displaced upwards. It must be remembered that vertically and horizontally
unfavourable fractures may be undisplaced if the periosteum is undisturbed.
The concept is only important when the periosteum has been ruptured or
stripped from the bone. A favourable facture line will, however, make the
reduced fragments easier to stabilize. The presence of an erupted tooth on the
posterior fragment will sometimes prevent gross displacement of this
fragment in an upward direction if its crown impacts on the opposing upper
tooth.
BANDAGES AND
EXTERNAL APPLIANCES:
acceptance as a standard of care when John Rhe Barton described his Barton
of the teeth and one on the undersurface of the mandible. A viselike device
was then used to apply pressure to the two splints, theoretically immobilizing
Gunning was the first to use a custom-fitted intraoral dental splint for
appliance. His splints could also be applied to both the maxilla and the
wire and to the Risdon wire of the early 1920s, monomaxillary wiring
were usually cast of metal and custom-fitted for the patient. Splints were
fabricated with the use of models made after reduction of the fragments.
Intermaxillary Wiring:
the first to use intermaxillary fixation. Gilmer, also credited with being the
first to use this technique, passed wires around individual teeth of both arches
described many methods of intermaxillary fixation that used bands and other
orthodontic techniques.
Open Reduction and Internal Fixation:
Sutures:
the use of wire ligature for the immobilization of mandible fractures. Using
this method, one would drill a hole on both sides of the fracture site and then
pass a wire. The wire, which was iron or silver, was then tightened
periodically by creating pigtails on each end of it. This method was hampered
Bone Plates:
used two heavy rods placed on either side of the fracture and wired together.
The rods were pushed through skin, mucous membrane, and bone and were
wired on both the mouth and the skin sides. Dorrance and Bransfield state
that the earliest reference to the use of true bone plates was that of Schede,
who, around 1888, used a solid steel plate held by four screws. During World
War I, Kazanjian used, wire sutures through bone fragments and tied the wire
used to allow for early passive and active function. Depending on the type
later time. Scher and colleagues (1988) and Merrit and Brown (1985) have
The use of resorbable plates and screws has been studied for nearly 20
healing was uneventful, without callus formation. They also reported that no
The dimensions of plates for these studies were usually large, when
compared to miniplates. This would limit their use in the maxillofacial region.
These materials have less strength, which would limit their use in loaded and
functional bone.
In the mid-1960s, Luhr pursued research in rigid fixation for the facial
rigid fixation and also contributed the self-threading screw. In the 1970s,
second tension-zone plate would be necessary, others, believed that arch bars
the mandible. When the screws closest to the fracture were tightened, the
miniplates were their thinness and the fact that they could be placed through
intraoral incisions.
by Baudens (1844), who used circumferential wiring to reduce and fix the
silver wire passed circumferentially around the mandible with a needles, and
tied the wire around a piece of lead that had been molded to the edentulous
mandible.
evaluate because of the many variables associated with the studies. Statistics-
accounted for only 15% of the fractures. The difference may be explained by
area. They demonstrated that altercations accounted for 47% of fractures, and
change in etiology when they mentioned that within a decades time the ratio
fractures, vehicular accidents and assaults are undoubtedly the primary causes
In the cases evaluated for fracture location, the mean percentages were
ramus (4%), and coronoid proces (1%). As discussed, the variables are
condyle, and angle do not differ much in incidence, and fractures of the ramus
automobile accidents were considered, the condylar region was the most
was the are most often affected. When assault was considered, the angle
patients with mandibular and midface fractures and those with mandibular
and other facial bone fractures. Of the patients reported, 15% had another
injuries. In the study of Ellis and colleagues, 90% of the patients had no other
injuries, probably because the etiology was primarily assault. olson and
1. Simple, or closed: A fracture that does not produce a wound open to the
periodontal membrane.
bone.
4. Greenstick: A fracture in which one cortex of the bone is broken, the other
bone disease.
6. Multiple: A variety in which there are two or more lines of fracture on the
7. Impacted: A fracture in which one fragment is firmly driven into the other.
edentulous mandibles.
involved. These areas are as follows: symphysis, body, angle, ramus, condylar
proces, coronoid process, and alveolar process. Dingman and Nativig defined
4. Body : From the distal symphysis to a line coinciding with the alveolar
6. Ramus : Bounded by the superior aspect of the angle to two lines forming
regions
were defined:
fracture line.
Class II: Teeth are present on only side of the fracture line.
stabilization.
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
A. Simple or closed
B. Compound or open
A. Incomplete
B. Greenstick
C. Complete
D. Comminuted.
IV. Localization
canines
molar region
E. Fractures of the mandibular ramus between the
relates to the direction of the fracture line and the effect of muscle action on
segment upward and medially when the fractures are vertically and
fractures. The farther forward the fracture occurs in the body of the mandible,
History:
A thorough history is imperative for the proper diagnosis of mandibular
fractures. The patients health history may reveal pre-existing systemic bone
disorders, nutritional and metabolic disorder, and endocrine disease that may
cause or be directly related to the fractured jaw. The history also reveals
from those sustained in personal altercations. Since the magnitude of the force
patient hit by a fist may sustain single, simple, non displaced fractures.
The object that caused the fractures can also influence the type and
may cause several fractures (e.g., symphysis and condyle) because the
impact of the force is sustained throughout the bone, whereas a smaller, well-
together at the moment of impact is more likely to have dental and alveolar
process fractures than moment of impact is more likely to have dental and
alveolar process fractures than basal bone fractures. Even knowing where the
engineering.
Clinical Examination :
Change in Occlusion :
Any change in occlusion is highly suggestive of mandibular fracture.
The clinician should ask the patient whether his or her bite feels different. A
premature posterior dental contact or anterior open bite may result from
Posterior open bite may occur with fractures of the anterior alveolar process
from midline symphyseal and condylar fractures with splaying of the posterior
mandibular segments.
can occur with effusion of the temporomandibular joints, and with protective
These examples are only a few of the multiple occlusal disharmonies that can
exist, but any change in occlusion has to be considered the primary diagnostic
nodisplaced fractures of the mandibular angle, body, and symphsis are not
coronoid process on the zygomatic arch either from fractures of the ramus
Inability to close the jaw can be the result of fractures of the alveolar process,
should examine the face and mandible for abnormal contours. A flattened
appearance of the lateral aspect of the face may be the result of a fractured
possibility of mandibular fracture. The same holds true for mandibular arch
form. If there is a deviation from the normal U-shaped curve of the mandible,
closure. The direction and type of fracture may be visualized directly through
the laceration, with the clinician thus gaining diagnostic information that may
enough to loosen teeth certainly can fracture than underlying bone. Multiple
fractured teeth that are firm indicate that the jaws were clenched during
traumatic insult, thus lessening the effect on the supporting bone. 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
methods.
Dolor, Tumor, Rubor and Color :
Pain, swelling, redness, and localized heat have been noted as signs of
inflammation since the time of the ancient Greeks. All these findings are
excellent primary sings of trauma and can greatly increase the index of
Radiologic Examination:
The following are types of radiologic studies that are helpful in the
Panoramic radiograph
Posteroanterior radiograph
Occlusal view
Periapical view
ability to visualize the entire mandible in one radiograph, and the generally
good detail. The disadvantages are as follows; The technique usually requires
the patient to be upright (machines that allow the patient to be prone are
joint area, the symphysis region (depending on type of equipment), and the
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
angle, body and symphysis. The condylar region is not well demonstrated on
this view, but midline or symphyseal fractures can be well visualized. The
distortion occur with this view. The mandibular occlusal view demonstrated
on this view, but midline or symphyseal fractures can be well visualized. The
distortion occur with this view. The mandibular occlusal view demonstrates
discrepancies in the medial and lateral position of body fractures and also
the condylar head. Periapical dental films show the most detail and can be
used for nondisplaced linear fractures of the dody as well as alveolar process
and dental trauma. Plain tomograms can be used in an anteroposterior and
lateral direction when greater detail is necessary. The CT scan is ideal for
condylar fractures that are difficult to visualize; however, greater expense and
radiation exposure limit its use to cases that cannot be diagnosed with plain
each another.
FRACTURES
mandible is capable of injuring any other organ system in the body. This fact
is obvious when dealing with massive crush injuries of the face with
noting a fractured cervical spine. The downward spiral to disaster can begin
of the mandible became apparent 48 hours after the injury. Gordon and
who developed symptoms of a ruptured spleen 5 day after the injury and 3
carefully and thoroughly evaluate the nature and extent of mandibular injuries.
Diagnosis on the basis of the history and local physical and radio logic
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
maintained at all costs. (d) Some teeth are not critical to restoration and can
how critical they may be. For example, a molar tooth may be split mesially
perhaps infection.
4. Re-establishment of occlusion is the primary goal in the
first.
The old adage inside out and from bottom to top applies to the
foundation on which the facial bones can be laid, it is proper that the
deviation from this principle can be allowed. All intraoral surgery should be
Too often, lip and skin wounds that have been meticulously closed in an
extraoral wounds, thus allowing definitive treatment to be carried out after the
patients age and health and the method used for reduction and
immobilization.
Historically, a period of 6 weeks of intermaxillary fixation has been
used to occur. however, this time is only empirical and should vary with the
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
mandibular fractures. For the reasons specified previously, open reduction can
bones will coalesce and heal if the associated periosteum is not disturbed.
flaps, micro vascular grafts, or (if the area is small) secondary granulation.
Wires, screws, and plates may decrease the chance of successful bone union
cancellous bone (with associated osteoblastic endosteum) for repair, and the
fractures usually occur in the elderly, in whom the normal healing potential
periosteum, which further inhibits osteogenesis. Closed reduction with the use
with primary bone grafting may be indicated, since proper alinment of the
developing tooth buds, which occupy a major portion of the mandible in,
fragments, fine wires should be placed at the most inferior border of the
mandbile, engaging only the cortex Closed reduction is indicated with special
Fractures of the coronoid process are rarely isolated and are usually
simple and linear with little displacement, although with extreme trauma the
bone may be displaced into the temporal fossa. Isolated fractures of the
coronoid process cause trismus and swelling in the region of the zygomatic
arch. There may be swelling in the retromolar area and a lateral crossbite.
mandibular movement.
Condylar Fractures :
parasympyseal fractures tend to open at the inferior border, with the superior
With medial rotation of the body of the mandible, the lingual cusps of all
premolars and molars move out of occlusal contact. If the constriction is not
of the face. If this procedure is not done, any type of suspension wiring, such
as that from th fronto zygomatic suture area to the mandible, would tend to
collapse and telescope the fractures of the midface and condyles, resulting in
Fracture Fragments
In fractures of an edentulous mandible with severe displacement of the
to the bone and the effect of an open surgical procedure on the compromised
fractures would eliminate the need for intermaxillary fixation, However, if the
When treatment has been delayed and soft tissue become interposed
withy time connective tissue grows between the bone fragments, inhibiting
Malunion
necessary, and open rigid fixation techniques can provide that option. For
4. Arch bars
5. Cap splints
7. Pin fixation.
2. Plating
3. Intramedullary pinning
4. Titanium mesh
5. Circumferential straps
6. Bone clamps
In recent years there has been a progressive move away from the
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.
When the teeth of a fractured jaw are fixed in the correct occlusion, the
reduced.
Provided that teeth of a suitable number, shape and quality are present
condyle will not necessarily be reduced by this method nor will they be
completley immobilised.
BUTTON WIRING :
The simple eyelet was frequently drawn into the interdental space, making
it difficult to use.
apply.
either jaw to be wired in such a manner that elastic traction can be used to
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
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.
occlusal reduction.
teeth in one jaw for eyelet wiring whilst an arch bar is used in the other. The
technique will not control separate edentulous fragments but may be used in
5) Cap Splints :
necessary laboratory facilities and time are available, cap splints are of great
assistance with fractures where standing teeth are present on one or all of the
them may considerably increase the operatingt ime and, as with eyelet wiring,
concentration. When combined with elastic traction, cap splints may obviate
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 :
because of :
the lips. Lacerations of the tongue and adjacent soft tissues or hemorrhage
from the fractures may produce blood clot and/or sufficient swelling to
pulps, or loose teeth may cause pain and contribute to a lock of patient
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
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
Splint dressings :
The splint dressing and positioning of the hooks depends upon the
overjet and overbite and the need or otherwise for extremely fixation.
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
required, a loop or a reversed hook is sited on the buccal aspect of the upper
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
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
them. The patients lips and , if present, moustache and beard should be
black powder and the acid fluid penetrate under the nails and into any
mixing slab to retard the setting time. The slab should be immersed in iced
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
surface using beeswax. Once the splint is positioned, these sticks are easily
properly.
develop a considerable edema where the cement has come into contact with
2. Cold-cure acrylic :
The working time for this material is much longer. Splint retention is
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
acrylic. These, however, clear in a few day without any permanent sequelae.
3.Polycarboxylate cement :
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
When possible this should be done on the dental chair with good,
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
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,
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.
Occasionally, a splint will become loose. This is of little consequence if
is not controlled by the remaining splints, it must be replaced after all the tie
Splint removal :
Provided the splint is not too thick, an upper premolar pattern dental
extraction forceps, aligned parallel to the occlusal plane, is used with one
blade on the occlusal surface and the other on the cervical margin of the
splint. A slow outward rotation of the forceps will usually break the bond
between cement and the splint in that are. This rotation is repeated elsewhere
around the mouth as required until the splint can be lifted off.
GUNNING-TYPE SPLINTS:
Indications :
loss, may not be suitable for this technique unless posterior displacement
membrane will heal normally under the gutta-percha lining of the splints.
technique. In the maxilla, per alveolar wires may cut out or be impossible to
suitable alternatives.
Splint technique:
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,
occlusion, they are generally suitable for use. The incisors and canine teeth
are removed from each denture together with the majority of the palate from
the upper denture. Two or three hooks in each quadrant are embedded with
Alternatively, groove of the appropriate width and depth is cut into the
buccal flange of each denture into which a length of Erich arch bar is secured
by quick-curing acrylic.
edema and, after being roughened, the fitting surfaces are lined with softened
of the alveolus, the technician will need to correct major misalignment of the
bone after sectioning the models. Any minor discrepancy remaining will be
vertical dimension and jaw relationship can be taken from the patient,
provision for this is made at the time of operation by creating a trough on the
occlusal surface of the acrylic blocks which occupy the molar areas of the
lower splint. The maxillary blocks are ridged or grooved so that, when
opposed after reduction of the fracture these fit into the softened gutta-
percha.
construction, `Gunning-type splints can be made from models cast from their
a. There must be separate splints for each jaw which enable immobilization
as soft acrylic or other polymers to prevent the ulceration which can occur,
they are big enough and their fitting surfaces are thickly lined with gutta
Disposable trays:
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
skeletal suspension.
Circumferential wiring:
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
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
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
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
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
Advantages of pins:
lines.
required.
avoided. The oral cavity is left free of apparatus, thus assisting feeding and
Disadvantages of pins:
irritated patient.
d) Bone grafting of the mandible when there has been extensive bone loss.
the facial skeleton when a rapid and relatively simple fixation is indicated.
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
Paris head cap if these more sophisticated craniofacial fixations are not
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
constructed from inert metals to prevent local osteitis which could otherwise
result from electrolytic action. Each operator usually prefers one of the
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
d) Moule pins are coarse threaded, tapered screw pins of different lengths
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.
the operator a clear idea of the depth of penetration of the drill point.
Operative technique:
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
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 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
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.
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
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
to the drill shafts. Only light pressure should be exerted, to avoid sudden
uncontrolled penetration of the inner plate, in view of the proximity of
The tubular soft tissue retractor or drill sleeve must be held securely
against the bone by the assistant while the drill is withdrawn. The Mould pin
is then inserted into the turnkey and the tip engaged in the drill hole. It may be
necessary to search for this if the soft tissue has moved slightly, and the
operator should be able to discern when the point catches the rim of the hole.
the pin is correctly orientated. The pin is screwed in until it is tight, but
caution should be exercised when the ramus is thin and atrophic to avoid over
penetration.
In locating the position for the second pin, the operator must assess the
soft tissue edema and the need to prevent the points of the pin shafts must not
shaft with a further one placed between them. The hole is drilled in
Pairs of holes are then drilled in the distal fragment. The fractures may
the nearest pin at least 2-3 cm away from the fracture line. With multiple
fractures it is important to prevent posterior collapse of the symphysis, and
more than two pairs of pins may be required. Great care must be taken to
avoid the inferior dental bundle, especially in the atrophic edentulous case,
and to prevent the drill from slipping under the lower border of the mandible.
Very occasionally, screwing pins too tightly into an atrophic mandible will
will result in skin necrosis, which continues if pressure of the skin against the
pin is allowed to persist and results in unsightly scarring,. Care is, therefore,
required to prevent skin distortion by inserting the pin to compensate for the
fractures. Should some slight heaping up of the skin against the shaft persist
after insertion, a minimal stab incision should be made to relieve the tension
figure-of-eight pattern around the base of the shaft. These dressings require
edema subsides. Although hey may be disturbed by the patient, the enry
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
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
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
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
penetration may occur. This usually does not matter, since the tip lies 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
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
The uncontrolled pin slipping beneath the lower border of the mandible
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.
ends of the pins and connecting bars. Most patients adopt a pattern of
remaining one which may not be involved in the hope that sufficient
parotid secretion does occasionally occur in the early days after the insertion
of pin. In most cases this cease spontaneously before the pin removal and the
fistula will usually repair itself once the pin has been removed.
ring, which has resulted either from overheating during the insertion of the pin
spontaneously within a week the area should be curetted using regional block
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.
1. The edentulous maxilla with an adequate number of suitable
mandibular teeth
It the upper denture is available and in one piece, hooks are set into the
buccal and labial aspect in cold-cure acrylic. The plate is either removed
palte for the passage of per alveolar wires. Undercuts shoul be removed from
the fitting surface of the denture, which can then be relining in situ with a
or piriform aperture wires, whilst the mandibular fractures are reduced and
fixed.
maxilla is not uncommon in the elderly. The anterior area of the upper jaw
may be extensively comminuted and, if any teeth are still present, they may
immobilization, e.g., by cap splints or arch bars, the majority of patients will
the denture.
b) Pinform aperture wires: Even in the elderly, the lateral aspect of the nasal
aperture affords better retention than the surrounding bone. The nasal aperture
mucosa is elevated from the area. The nasal mucosa is protected by the
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.
wire can than be passed through the loop and attached to apparatus in either
the upper or the lower jaw or to a circumferential wire which is passed
around the lower jaw. This has the advantage of allowing the jaws to be
ii) Occasionally piriform aperture wires cut out, particularly in the elderly.
the wire back through the alveolus into the plate bt a straight wire introducer.
This wire is then brought forwards and twisted with the other end over the
splint.
iii) Circumpalatal wiring may be use. The palate of the maxillary splint
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
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
The former may be used with intact zygomatic arches and the latter
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
Ltd), supraorbital bone pins, zygomatic bone pains or a plaster of Paris head
teeth:
joined to maxillary eyelet wires or arch bars by wires passed around the
combinations of such problems will be met by the clinician, who will adapt
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 and over : add 1or 2 weeks
d) Children and adolescents : subtract 1 week
Applying this guide it follows that a fracture of the symphysis in a 40-
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
denture-bearing area is reduced by approximately one-half and in some cases
by considerably more. The resistance of the bone to trauma is further reduced
by changes in the structure of the bone associated with the process of ageing.
The ageing process is also associated with significant changes in the
vascular architecture (Cohen, 1960; Bradley, 1975). The endosteal blood
supply from the inferior dental vessels begins to disappear and the bone
becomes increasingly dependent on the periosteal network of vessels.
The denture-bearing area of the edentulous mandible is therefore not
only more easily fractured, but also less well disposed to rapid and uneventful
healing.
In addition, the smaller cross-sectional area of bone at the fracture site
and the absence of the stabilizing influence of teeth means that the bone ends
are more easily displaced, and even after reduction the area of contact
between them may be insufficient for healing to occur easily. The more
atrophic the mandible the more significant these factors become and Bruce
and Strachen (1976), in a study of 146 fractures occurring in thin mandibles
treated by a variety of methods, reported a 20% incidence of non-union.
The edentulous state confers a few advantages. Fractures are, for
instance, much less frequently compound into the mouth than when teeth are
present. As a result whenever closed reduction is possible the risk of
subsequent infection of the fracture is negligible (Amaratunga, 1988). Again
the absence of teeth means that precise reduction, such as would be required
to restore the occlusion of natural teeth, is not necessary as any inaccuracy is
easily compensated by adjustment of dentures. For these reasons many
fractures in edentulous patients require no treatment at all. If the fracture is
simple with little or no displacement it will heal satisfactorily if the patient
refrains from unnecessary active movements and adjusts to a temporary soft
diet. Any subsequent discrepancy in the denture occlusion can be corrected in
most cases by relining with or without occlusal adjustment.
Reduction :
For the reasons already stated, precise anatomical reduction is not
necessary in fractures of the denture-bearing area. This is fortunate because
reduction is frequently difficult when there is over-riding of the bone ends.
Reduction and subsequent fixation become more difficult as the mandible
atrophies. The dilemma which often faces the clinician has been well
summarized by Marciani and Hill (1979). The reduced cross-section of bone
fractures of thin mandibles means that displacement occurs more readily and
in this situation open reduction may be the only way to restore adequate bone
contact. However, operative open reduction involves further disruption of the
periosteal attachment which interferes significantly with postoperative repair
of bone. Mature clinical judgement is required, the objective being to achieve
sufficient bone contact and alignment with the minimum direct operative
interference at the fracture site.
Methods of immobilization :
The fact that there is no uniformly accepted method of immobilizing
edentulous fractures is indicative of the fact that no completely satisfactory
method has yet been devised. There is no doubt, however, that the traditional
treatment by means of Gunning-type splints has been largely superseded in
recent years by methods which employ some form of direct or indirect
skeletal fixation. In order patients intermaxillary fixation is even less desirable
than in younger age groups. Nutritional requirements become difficult to
maintain and oral candidiasis commonly affects the oral mucosa causing
considerable discomfort during the active treatment period. The methods of
treatment currently in common use are :
1) 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) Indirect skeletal fixation :
a) Pin fixation.
b) Bone clamps.
3) Intermaxillary fixation using Gunning-type splints :
a) Used alone
b) Combined with other methods.
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
periosteum. Both compression and non-compression systems require an
adequate blood supply to achieve uncomplicated bony union (Rhinelander,
1974) and elevation of periosteum in the thinner mandible seriously
compromises the blood supply to the fracture site. It has been suggested that
in these circumstances plates should be applied with an intervening layer of
attached periosteum (Bradley, 1975), but in practice this is difficult to
accomplish.
Plates related to the denture-bearing part of the mandible are much
more likely to require removal at al later date than those used in the ramus or
in dentate fracture sites. Nevertheless they are currently the preferred method
of fixation for the majority of edentulous mandibular body fractures.
Transosseous wiring :
Many simple edentulous fractures can be satisfactorily immobilized by
direct transosseous wires but, in general, when a surgical exposure has been
made it is just as easy to apply a mini-plate if available. Transosseous wires
do not provide rigid osteosynthesis and supplementary fixation may be
necessary. They are somewhat easier to apply from an intra-oral approach
and, when placed near the upper border, are less likely to impinge on denture
flanges at a later date. In general less periosteal stripping is required on each
side of the fracture which may be advantageous when dealing with a very thin
mandible. When the neurovascular bundle crosses the fracture site it is easier
to avoid damage with a transosseous wire than a screwed plate.
The special instrumentation required for the application of miniaturized
plates in not universally available in all parts of the world where fractures
require treatment and wiring techniques continue to provide a simple and
reliable alternative.
Circumferential wiring or straps :
Oblique fractures of the edentulous mandible can be most effectively
and simply immobilized by circumferential wires. A modification of the
method illustrated in is recommended in order to avoid placing the upper part
of the wire immediately below the oral mucosa. Williams (1985) has
described the use of miniaturized circumferential nylon straps as a useful
alternative to wire.
Transfixation with Kirschner wires :
This method of fixation employs a 2mm Kirschner wire inserted within
the medullary cavity across the fracture site. When the edentulous mandible is
reasonably thick the wire can be introduced through a stab incision in the
overlying skin and a suitable point of insertion located on the cortex of the
distal fragment. A hole is drilled through the cortex at this point and the wire
directed into the medullary cavity and onwards across the reduced fracture
site. The wire is cut off at the skin entry point from where it can be withdrawn
when the fracture has healed.
In practice it is extremely difficult to insert a wire in this way without
damaging the inferior dental vessels and nerve. The most satisfactory method
of placing such a wire is to expose the fracture site by an external skin
incision. The transfixing wire is passed first into the proximal or distal
segment and drilled down the centre of the mandible to emerge through the
cortex and skin at a point where the curvature of the jaw prevents further
passage. The wire end attached to the drill will eventually come to lie
opposite the fracture site at which point the inserting drill is detached and the
direction of the wire reversed so that it is made to pass back down the other
fragment transfixing the fracture (McDowell et al., 1954; Vero, 1968).
When the wire is inserted under direct vision, as in this latter
technique, it can be usefully employed to immobilize fractures of the body of
thin edentulous mandibles where a plate would be too bulky. It is not
possible, however, to employ the technique in the ultra-thin mandible because
of the risk of damage to the inferior dental nerve.
Primary bone grafting :
In 1973 Obwegeser and Sailer suggested primary bone grafting as a
method of stabilizing and augmenting a fracture of the body of the ultra-thin
edentulous mandible. Wood et al. (1979) successfully treated nine such
fractures using autogenous rib grafts. A 5cm length of rib is obtained as an
authogenous graft. The rib is split and the two pieces are placed one on each
side of the fracture site in the manner of a first-aid splint applied to a limb.
The rib halves are lashed together by a series of circumferential wires
sandwiching the fractured bone ends between them. Iliac bone can be
employed in a similar fashion (James, 1976). Postoperative morbidity at the
donor site can be considerably reduce by controlled infusion of bupivacaine
through an epidural catheter.
Although the technique appears demanding for an elderly patient it is in
practice often less time consuming than bone plating and does often an
effective remedy for what is without doubt the most difficult of all jaw
fractures.
Indirect skeletal fixation :
A system of bone joined together by rods and universal joints can be
used in edentulous mandibular fractures in the same manner as when teeth are
present. The method is occasionally of practical use when there has been
extensive comminution of a long segment particularly if this involves the
symphysis.
Bone clamps such as the Brenthurst splint are theoretically of use to
immobilize a fracture in a thin edentulous mandible avoiding direct surgical
exposure of the fracture site. In view of the reported high incidence of non-
union following open reduction of fractures of the atrophic mandible
(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.
Properly constructed Gunning-type splints should hold the jaws in a slightly
over-closed relationship, as in this position fractures of the body of the
mandible are more effectively reduced. The edges of the splints should be
slightly over-extended around the sulcus in order to minimize food entry
under the fitting surface. When the jaws are immobilized over-extension does
not lead to ulceration of the mucosa as it would in a functioning denture.
Whenever possible the splints should be constructed on models from
impressions of the patients mouth. The necessary degree of over-extension of
the sulcus is achieved by using composition as an impression material which
is superior to other impression material for this one purpose. It is, however,
difficult to take an adequate impression when the mandible is badly fractured
and the alveolar ridge distorted by displacement of the fragments. It may be
possible to make use of the patients dentures if they are available but it
should be stressed that models constructed from the fitting surface of dentures
are usually inaccurate and under-extended.
The splints are constructed in acrylic resin and the fitting surface is
lined with black gutta percha. If the correct vertical dimension of the bite is
known or has been recorded the occluding surfaces can be made to fit
together satisfactorily in a slightly over-closed relationship. Alternatively a
trough can be cut in the occlusal surface of one splint and filled with gutta
percha. The opposing occlusal surface is then shaped to fit into the trough and
a satisfactory fit obtained at operation by softening the 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 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
unfortunately least efficient in those case s where closed reduction is most
desirable.
Scars :
Many mandibular fractures have associated soft-tissue injuries and
providing these wounds are carefully cleaned and sutured minimal scaring
occurs. At first all scars tend to be red and feel hard to the touch but during
the first year they soften and fade. Massage of the scar by the patient and the
scars also result from contamination of the original wound with dirt,
beneficial but should not be contemplated until at least 1 year has elapsed.
Unsightly scars can largely be prevented by adequate wound toilet and careful
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