condyle

MAXILLOFACIAL INJURIES
MANAGEMENT
Primary management (ABCDE)
Neurological assessment (GCS)
Control of pain
analgesics
Control of infection
antibiotics
Surgical planning
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INDIAN DENTAL
ACADEMY
Leader in continuing dental academy


MANDIBULAR FRACTURES
• Applied surgical anatomy
• Classification
• Clinical features
• Radiological features
• Management
- immediate
- definitive
• Complications

GK / MAXFAC
SDM DHARWAD

Applied surgical anatomy

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


Areas of weakness
•teeth
•foramen
•alveolar bone
•angle
•ramus
•Condyle

GK / MAXFAC
SDM DHARWAD

Blood supply
Nerve supply

•Applied surgical anatomy
•Classification
•Clinical features
•Radiological features
•Management
- immediate
- definitive
•Complications

GK / MAXFAC
SDM DHARWAD

Classification
Anatomical site

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

GK / MAXFAC
SDM DHARWAD

Classification
Relation to site of injury
-Direct
-Indirect


GK / MAXFAC
SDM DHARWAD

Classification
Condition of fractured fragments
Green Stick
Simple
Compound
Comminuted
GK / MAXFAC
SDM DHARWAD

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



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


Vertically
Favourable

Unfavourable


Classification
# with reference to dentition
Dentulous
Child
Adult
Edentulous
Dentulous jaw with a posterior
edentulous fragment

GK / MAXFAC
SDM DHARWAD

Classification
Clinical features
Radiological features
Management
immediate
definitive
Complications

GK / MAXFAC
SDM DHARWAD

Clinical Features
Inspection
Hemorrhage
Pain
Swelling
Altered occlusion
Sublingual ecchymosis
Halitosis
Paraesthesia

GK / MAXFAC
SDM DHARWAD

Clinical Features
Palpation
Confirm inspectory findings
Tenderness
Fracture line/step
Crepitation
Paraesthesia
Abnormal mobility

GK / MAXFAC
SDM DHARWAD


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


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
( 2 radiographs @ 90 deg )

GK / MAXFAC
SDM DHARWAD

Management
Objectives
RESTORE FORM & FUNCTION
Remember A B C D E
Precise diagnosis
Early reduction
Adequate fixation and immobilization
Rehabilitation / restoration of function

GK / MAXFAC
SDM DHARWAD

Management

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

Management
Definitive
Reduction
Fixation
Immobilization
Rehabilitation

GK / MAXFAC
SDM DHARWAD

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
Inadequate reduction

GK / MAXFAC
SDM DHARWAD

Mandibular fractures
Closed reduction
 Dental wiring
 Arch bar
 Cap splints
 Gunning splints
 Extra-oral pin fixation


GK MAXFAC
SDM DHARWAD


Management
CLOSED REDUCTION

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

GK / MAXFAC
SDM DHARWAD


•Ivy eyelet
wiring

GK / MAXFAC
SDM DHARWAD



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

•Extra oral pin fixation
GK / MAXFAC
SDM DHARWAD


CAP SPLINT


GK MAXFAC
SDM DHARWAD

Gunning splint


GK MAXFAC
SDM DHARWAD

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


GK / MAXFAC
SDM DHARWAD

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


Management
Open REDUCTION
Plate & Screw Osteosynthesis
Stainless steel Mini plates

GK / MAXFAC
SDM DHARWAD


Management
REDUCTION Open
Advantages
Accurate reduction &
fixation
Alignment under direct
visualization

Disadvantages
Need for a G.A & Hospitalization
Expenses !!!

GK / MAXFAC
SDM DHARWAD

Management
Open REDUCTION
Miniplate Osteosynthesis (Champy)
Small malleable plate( 2 - 2.5 mm thickness)
Trans oral approach
No post op IMF

GK / MAXFAC
SDM DHARWAD

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)
GK / MAXFAC
SDM DHARWAD

Management
OPEN REDUCTION Miniplate Osteosynthesis

Clinical applications

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

GK / MAXFAC
SDM DHARWAD

Management

GK / MAXFAC
SDM DHARWAD

Dynamic compression plates

GK / MAXFAC
SDM DHARWAD

Lag Screw Fixation

GK / MAXFAC
SDM DHARWAD

Management
Postoperative management
Control of pain
Control of infection
Post op radiographs
Physiotherapy
Diet
Regular follow up

GK / MAXFAC
SDM DHARWAD

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


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

GK / MAXFAC
SDM DHARWAD

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
Excessive periosteal stripping

GK / MAXFAC
SDM DHARWAD

Paediatric Considerations
Growth
Tooth buds
Treatment
Minimal immobilization
Minimal intervention
Cap splints
Circum-mandibular wiring

GK / MAXFAC
SDM DHARWAD

CIRCUMMANDIBULAR
WIRING

GK / MAXFAC
SDM DHARWAD

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Etiology
Classification
Clinical features
Radiological investigations
Treatment options
Complications

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Etiology
Indirect injury - Chin
Direct injury - Zygoma


GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Classification
Anatomical: Intra / extra capsular
Unilateral / bilateral
Radiographic
2 radiographs @ Right angle
OPG, PA mandible
1) Level of #
2) Relationship to mandible

3) Relationship to glenoid fossa

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Classification
Level of #

Head

HEAD (Intra capsular)

Neck
Sub Condylar

NECK
SUB CONDYLAR #

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Classification
Relationship to mandible
Undisplaced
Deviated
Displaced

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Classification
Relationship to glenoid fossa

Undisplaced

Displaced

Dislocated
GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Clinical features
Pain & Tenderness
Painful limitation in mouth opening
Occlusal derangement
Bleeding from ear
GK / MAXFAC
SDM DHARWAD

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

GK / MAXFAC
SDM DHARWAD


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


Condylar Fractures
Radiographic investigations
2 radiographs @ right angles
OPG, PA mandible
Optional : Trans Pharyngeal
Trans Cranial
Trans Orbital
C.T coronal views

GK / MAXFAC
SDM DHARWAD

Condylar Fractures

Management (Conservative)
No active treatment
Immobilization (7-10 days)
Active physiotherapy

GK / MAXFAC
SDM DHARWAD

Condylar Fractures

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


GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Complications
Malocclusion
Damage to teeth
TMJ pain
Ankylosis
Open reduction
Scar
Nerve damage
Intra-operative haemorrhage
Avascular necrosis

GK / MAXFAC
SDM DHARWAD

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- confuse them

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