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MAXILLOFACIAL INJURIES MANAGEMENT Primary management (ABCDE) Neurological assessment (GCS) Control of pain analgesics Control of infection antibiotics Surgical planning www.indiandentalacademy.com


INDIAN DENTAL ACADEMY Leader in continuing dental academy www.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES • Applied surgical anatomy • Classification • Clinical features • Radiological features • Management - immediate - definitive • Complications www.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Applied surgical anatomy

Curved bone Thickness of cortices Neurovascular bundle Dentition Attachment of Muscles GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Applied surgical anatomy Areas of weakness •teeth •foramen •alveolar bone •angle •ramus •Condyle

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Blood supply Nerve supply www.indiandentalacademy.com


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES •Applied surgical anatomy •Classification •Clinical features •Radiological features •Management - immediate - definitive •Complications www.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Classification Anatomical site

•symphysis •parasymphysis •body •angle •ramus •condyle •coronoidwww.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Classification Relation to site of injury -Direct -Indirect

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Classification Condition of fractured fragments Green Stick Simple Compound Comminuted www.indiandentalacademy.com GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Classification: type of displacement (angle) Angle of mandible Extra oral:Gonion Intraoral: Junction of alveolar bone and ramus

Fracture of angle mandible Greater fragment :teeth bearing segment Lesser fragment: ramus

GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES

Classification Angle # Displacement of Ramus (post edentulous fragment) Favorable: Minimal displacement Unfavorable: Gross displacement Viewed from side: Horizontal Viewed from www.indiandentalacademy.com above: Vertical GK / MAXFAC SDM DHARWAD


Horizontally Favourable

Unfavourable

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Vertically Favourable

Unfavourable

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Classification # with reference to dentition Dentulous Child Adult Edentulous Dentulous jaw with a posterior edentulous fragment

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Applied surgical anatomy Classification Clinical features Radiological features Management immediate definitive Complications www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Clinical Features Inspection Hemorrhage Pain Swelling Altered occlusion Sublingual ecchymosis Halitosis Paraesthesia www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Clinical Features Palpation Confirm inspectory findings Tenderness Fracture line/step Crepitation Paraesthesia Abnormal mobility www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES

Applied surgical anatomy Classification Clinical features Radiological features Management immediate definitive Complications GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Radiographic features OPG / Lateral oblique P A mandible Intra oral occlusal view

Confirms Site and severity of # Direction & displacement of # Condition of teeth in line of # Presence of bony pathology www.indiandentalacademy.com ( 2 radiographs @ 90 deg )

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Applied surgical anatomy Classification Clinical features Radiological features Management immediate definitive Complications www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management Objectives RESTORE FORM & FUNCTION Remember A B C D E Precise diagnosis Early reduction Adequate fixation and immobilization Rehabilitation / restoration of function www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management

Immediate (Primary) ABCDE Temp immobilization Analgesics Antibiotics Diet & OHI www.indiandentalacademy.com GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management Definitive Reduction Fixation Immobilization Rehabilitation www.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management

REDUCTION Closed Advantages No need for a G.A Can be used in comminuted # Continuity defects ( gun shot injuries)

Disadvantages Accuracy of reduction ambiguous Poor fracture alignment www.indiandentalacademy.com Inadequate reduction

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Mandibular fractures Closed reduction  Dental wiring  Arch bar  Cap splints  Gunning splints pin fixation  Extra-oralwww.indiandentalacademy.com

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MAXILLOFACIAL INJURIES

MANDIBULAR FRACTURES Management CLOSED REDUCTION

AIM : Immobilization (IMF for 6 weeks) •Ivy eyelet wiring •Direct wiring

GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES •Ivy eyelet wiring

GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES

MANDIBULAR FRACTURES Management CLOSED REDUCTION AIM : Immobilization (IMF) •Arch Bar Wiring

•Extra oral pin fixation GK / MAXFAC SDM DHARWAD

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CAP SPLINT

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Gunning splint

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management REDUCTION Open Exposure of fracture skin / mucosa Direct reduction and fixation - Transosseous Wiring - Plate & Screw Osteosynthesis

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GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management Open REDUCTION Plate & Screw Osteosynthesis (Titanium/Stainless steel) Compression plates Mini plates Lag Screws GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management Open REDUCTION Plate & Screw Osteosynthesis Stainless steel Mini plates

GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management REDUCTION Open Advantages Accurate reduction & fixation Alignment under direct visualization

Disadvantages Need for a G.A & Hospitalization www.indiandentalacademy.com Expenses !!!

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management Open REDUCTION Miniplate Osteosynthesis (Champy) Small malleable plate( 2 - 2.5 mm thickness) Trans oral approach No post op IMF www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management OPEN REDUCTION Miniplate Osteosynthesis Symphysis/Parasymphysis/body/angle Eyelets / Arch bars Temp IMF Intraoral Approach Exposure of fracture site(s) Curettage (haematoma) Reduction of Fracture Temporary Immobilization (IMF) www.indiandentalacademy.com GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management OPEN REDUCTION Miniplate Osteosynthesis

Clinical applications

Mini plate application & fixation Debridement & removal of IMF Recheck occlusion & Closure

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management

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Dynamic compression plates

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Lag Screw Fixation

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Management Postoperative management Control of pain Control of infection Post op radiographs Physiotherapy Diet Regular follow up www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Edentulous mandibles Simple #s Healing uncomplicated !!!! Displacement of # fragments variable Classification( Luhr et al) According to height of bone Class 1 : 16 - 20mm Class 2 : 11 - 15mm Class 3 : less than 10mm GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Edentulous mandibles Treatment Methods Closed Reduction & Fixation Intra oral appliances: gunning splints Dentures trimmed & relined (stabilized with Circumferential wiring) Extra-oral pin fixation Immobilization period 4-6 weeks www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Edentulous mandibles Treatment Methods Open Reduction & Fixation •Intra-osseous wiring •Mini-plate osteosynthesis Bilateral body #s ( bucket handle # ) (class 2 & 3) primary rib grafting reconstruction plate Precaution www.indiandentalacademy.com Excessive periosteal stripping

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Paediatric Considerations Growth Tooth buds Treatment Minimal immobilization Minimal intervention Cap splints Circum-mandibular wiring www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


CIRCUMMANDIBULAR WIRING

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Indirect injury - Chin Direct injury - Zygoma

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GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Anatomical: Intra / extra capsular Unilateral / bilateral Radiographic 2 radiographs @ Right angle OPG, PA mandible 1) Level of # 2) Relationship to mandible www.indiandentalacademy.com

3) Relationship to glenoid fossa

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Level of #

Head

HEAD (Intra capsular)

Neck Sub Condylar

NECK SUB CONDYLAR # www.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Relationship to mandible Undisplaced Deviated Displaced

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Relationship to glenoid fossa

Undisplaced

Displaced www.indiandentalacademy.com

Dislocated GK / MAXFAC SDM DHARWAD


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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Clinical features Pain & Tenderness Painful limitation in mouth opening Occlusal derangement Bleeding from ear www.indiandentalacademy.com GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Clinical features - Unilateral # condyle Deviation to affected side Midline shift Lateral movements limited

GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Clinical features - Bilateral # condyle Gagging of posterior teeth Anterior open bite Lateral movements limited GK / MAXFAC SDM DHARWAD

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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Radiographic investigations 2 radiographs @ right angles OPG, PA mandible Optional : Trans Pharyngeal Trans Cranial Trans Orbital C.T coronal views www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures

Management (Conservative) No active treatment Immobilization (7-10 days) Active physiotherapy www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures

Management (Surgical) Open reduction & fixation Grossly dislocated #s

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GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com

GK / MAXFAC SDM DHARWAD


MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Complications Malocclusion Damage to teeth TMJ pain Ankylosis Open reduction Scar Nerve damage Intra-operative haemorrhage www.indiandentalacademy.com Avascular necrosis

GK / MAXFAC SDM DHARWAD


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