Beruflich Dokumente
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Mandibular Fractures
Mandible is embryologically a membrane bent bone although, resembles physically long bone it has two articular cartilages with two nutrient arteries
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Mandible in trauma
Mandibular fracture is more common than middle third fracture (anatomical factor)
Anatomical considerations
Attached muscles: Masseter Temporalis Medial and lateral pterygoid Mylohyoid Geniohyoid and genioglosus anterior belly of digastrics
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Blood supply
Endosteal supply via the ID artery and vein Periosteal supply, important in aging due to diminishes and disappearance of alveolar artery
Bradley 1972
Nerve
Damage of inferior dental nerve Facial palsy by direct trauma to ramus Damage of facial nerve in temporal bone fracture
Goin 1980
Weakening areas of mandible (resorption and pathologyl) Direction of force of the blow
Age of the patient
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Types of fracture
Simple
Greenstick fracture (rare, exclusively in children) Fracture with no displacement (Linear) Fracture with minimal displacement
Displaced fracture
Comminuted fracture
Extensive breakage with possible bone and soft tissue loss
Compound fracture
Severe and tooth bearing area fractures
Pathological fracture
(osteomyelities, neoplasm and generalized skeletal disease)
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Sites of fractures
Condyle fracture
Intracapsular fracture Extracapsular fracture
High condyle neck fracture Low condylar fracture
Angle/ ramus fracture (body fracture) Canine region (parasymphesial fracture) Midline fracture (symphesis fracture) Coronoid fracture (rare)
Favourable or unfavourable
They can be vertically or horizontally in direction They are influenced by the medial pterygoidmasseter sling
If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled lingually If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled lingually
Condylar fractures
The most common mandibular fracture
Unilateral or bilateral Intracapsular or extracapsular
Antero-medial displacement is common but it may remain angulated with the ramus Dislocation of the glenoid fossa and fracture of petrous temporal bone which is very rare
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Condylar fractures
Condylar fractures
TMD
Staph infection with condylar backward displacement and external auditory meatus injury Meningitis with petrous temporal bone fracture and intracranial involvement
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Type II comminuted fracture Common in missile injuries and appears to be with little displacement due to effects of messeter and medial pterygoid muscles
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Involvement of IDN
Gingival tear if fracture in dentated area Tooth involvement and possible longitudinal split fracture
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Midline fracture
The most common missed fracture (always fine crack)
Midline fracture
Clinical Examination
Extroral
Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut wounds) Palpation for eliction of tenderness, pain, step deformity and malfunction
Intra- and paraoral bleeding, heamatoma, gingival tear, gagging of occlussion and step deformity and sensory and motor deficiency
Radiographs
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Radiographs
Plain radiograph
OPG Lateral oblique PA mandible AP mandible (reverse Townes) Lower occlusal
Principles of treatment
similar to elsewhere fractures in the body
Reduction of fragments in good position Immobilization until bony union occurs
Definitive treatment
Soft tissue repair
Debridment Irrigation with saline and antibiotics Closure in layers Dressing
Objective:
Restoration of functional alignment of the bone fragments in anatomically precise position utilizing the present teeth for guidance
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Close reduction
Arch bars
Jelenko Erich pattern German silver notched
Cap splints
Close reduction
Bonded brackets IMF screws Dental wiring:
Direct wiring Eyelet wiring Local anesthesia or sedation
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Gunnings splint
Old modality Edentulous patient Rigid fixation is not possible To establish the occlusion
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Rigid fixation
Intraossous wiring Plates and screws Kirchener wire Lag screws
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Reconstruction palate
Severe trauma Loss of part of the bone
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Condylar fractures
Intraoral approach Ramus incision Extraoral approach
Preauricular approach Retromandibular approach
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IMF
Transosseous wiring Circumferential wiring
Osteosynthesis
Non-compression small plates Compression plates
Miniplates
Lag screws Resorbable plates and screws
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Absolute indications
Longitudinal fracture Dislocation or subluxation from socket Presence of periapical infection Infected fracture line Acute pericoronitis
Relative indications
Functional tooth that would be removed Advanced caries or periodontal diseases Doubtful tooth which would be added to existing denture Tooth in untreated fracture presenting more than 3 days after injury
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