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Fractures of the Jaw and Its Management

Fractures of the Jaw and Its Management

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FRACTURES OF THE JAW AND ITS MANAGEMENT

Cruz, Vianca Marie B. Domingo, Katrina Mari B. Elizes, Floridale Claire R. Manaloto, Pamela Rose G. Saguinsin, Jodie May M. DMD4A

EVALUATION OF TRAUMA PATIENT

Evaluation of Trauma Patient € Prime concern: The general condition of the patient and the presence or absence of more serious injuries € Asphyxia, shock, and hemorrhage are conditions that demand immediate attention € A history should be written. If the patient cannot give a good history, the relative, friend, or police officer should be asked for a statement.

Included in the record: € Relevant details of the accident € The events that took place between the time of the accident and the time of arrival at the hospital € The patient should be questioned regarding loss of consciousness, length of unconscious period if known, vomiting, hemorrhage, and subjective symptoms € Medications given before arrival at the hospital

drugs being taken and known drug sensitivity should be asked at once € To determine if jaw fracture is present and its location. direction. This will provide information about the type. look for areas of contusion. € . The contusion sometimes can hide severely depressed fractures by tissue edema.Questions regarding past illnesses. and force of the trauma. current medical treatment immediately preceding the accident.

€ Note the tear in the mucosa and bleeding.Teeth are examined € Displaced fractures in dentulous areas show a depressed or raised fragment and the associated break in the continuity of the occlusal plane. which perhaps results from a mixture of blood and stagnant saliva € . € A characteristic odor is associated with a fractured jaw. particularly in the mandible.

since it traumatizes the injured site further and allows outside infection to enter. 2. an alternate up-and-down motion is made with each hand.If no obvious displacement is present. Fracture will allow movement between the fingers. keeping them four teeth apart. 1. Such movement should be kept to a minimum. and the same movement is practiced. The fingers are moved around the arch. The forefingers of each hand are placed on the mandibular teeth with the thumbs below the jaw. and a peculiar grating sound (crepitus) will be heard. 4. 3. € . manual examination should be done. Starting with the right forefinger in the retromolar area of the left side and with the left forefinger on the left premolar teeth.

Note: If the condyles are situated in the glenoid fossae.within the mouth b.Palpation: a. anterior border of the vertical ramus and the coronoid process . The mandibular condyles . Unfractured condyles will leave the fossae when the jaw is opened. . they can be palpated.on the side of the face. The forefingers can be placed in the external auditory meatus with the balls of the fingers turned forward. It is done carefully and sparingly.

€ Unilateral condylar fracture is present when there is a shift of the midline toward the affected side upon opening.€ Pain upon opening of jaw or inability to open properly would indicate a fracture. .

Maxilla is examined by: 1. the entire maxilla might move. The latter will be reflected in a malocclusion .Placing the thumb and forefinger of one hand on the left posterior quadrant and rocking gently from side to side 2. Do the same on the right posterior quadrant and then on the anterior teeth 3. An old fracture or one that has been impacted posteriorly will not move. If a complete fracture is present.

€ The patient usually has epistaxis and black eyes.€ Unilateral maxillary fracture .has a line of ecchymosis on the palate near the midline € Alveolar fracture . .confined to the alveolar ridge. € A pyramidal fracture extending upward in the nasal area may be present in maxillary fracture.

and even a primary wound in the external auditory canal. a fracture of the mandibular condyle. several signs should be looked for before proceeding with manual examination: 1. . Bleeding from the ears.When a maxillary fracture is suspected. This requires differentiation between a middle cranial fossa fracture.

Neurological signs and symptoms. Cerebrospinal fluid will dry without starching. vomiting. Cerebrospinal rhinorrhea. Lethargy. and a dilated and widely fixed pupil or pupils are signposts that point to possible neurological trauma. If the cribriform plate of the ethmoid bone is fractured in a complicated maxillary fracture.Handkerchief under the nose and let the mucus dry. 3. cerebrospinal fluid will leak out the external nares. . . positive Babinski reflex.2. severe headache.

Radiographic examination € Three extraoral are films routinely made: € Posteroanterior jaw € Right lateral oblique jaws € Left lateral oblique jaws .

Waters view (nose-chin position taken from a posteroanterior exposure) € Zygomatic fracture . and symphyseal fractures."jug-handle" view is made with the tube near the patient's umbilicus and the cassette at the top of the head. € An opened frontonasal suture line strongly suggests a maxillary fracture. € . € Intraoral views sometimes show fractures that are not seen on the standard views. midline maxilla.Maxillary fractures . notably alveolar process.

ETIOLOGY OF JAW FRACTURES .

Major etiologic factors: motor vehicle accidents altercations automobile accidents work-related sporting accidents fist fight gunshot injuries to mandible .

Pain € Jaw pain € Facial pain € Dental pain .General Signs and Symptoms: 1.

Malocclusion € Upper and lower teeth do € not line up properly .2.

3. Numbness of the lip. Cracked tooth or missing teeth . numbness over the chin and numbness of the face (particularly the lower lip) 4. Bleeding from the mouth 5.

Facial swelling y Jaw swelling 9.6. Jaw stiffness y Very limited movement of the jaw (with severe fracture) y Difficulty opening the jaw y Difficulty speaking y Difficulty swallowing . Trismus . Facial bruising 8.difficulty opening the mouth normally 7.

Lump or abnormal appearance of the cheek or jaw 12. Jaw tenderness or pain.10. Tooth avulsion y Loss of a tooth . worse with biting or chewing 11.

CLASSIFICATION AND TYPES .

satisfactory factor condyles and the dental occlusion intraoperative use of intermaxillary fixation Semirigid fixation with miniplates is widely employed Titanium stainless steel.require removal and they are an occasional cause of metal allergy .A. Mandibular ‡ ‡ ‡ ‡ ‡ Fractures ‡ ‡ ‡ essentially a bone with three joints Caused by dynamic factor.

Dynamic factor € Characterized by the intensity of the blow and its direction € GREENSTICK or simple unilateral fracture € COMPOUND or heavy blow € A blow to the right of the chin may result to fracture in the mental foramen region on that side € Severe force may push the condylar fragments out the glenoid fossa .

Stationary factor € Has € Age € Boxers- to do with the jaw almost do not have jaw fractures because of increased calcification .

Ramus h. Symphysis f. Mental region e.least .Location In sequence a. Cuspid g. Molar region d. Angle b. Condyle c. Coronoid process.

Displacement Factors A. muscle pull - ³sling of the mandible´ -MASSETER AND MEDIAL PTERYGOID - displaces the posterior jaw fragment upward aided by the temporal muscle - SUPRAHYOID MUSCLES - displace the anterior fragments downward These muscles balance each other during fracture

--posterior fragment- move medially because of the pull of the medial Pterygoid muscle --if the condyle is fractured- the lateral pterygoid muscles move the fragments medially --mylohyoid muscles- displace the anterior fragments medially --symphysis fracture- difficult to fixate because of suprahyoid and digastric muscle

Direction of line of fracture
€ Depends

on whether or not the line of fracture was in such direction as to allow muscular distraction FRACTURE MANDIBULAR ANGLE FRACTURE± posterior fragments are pulled upward

€ UNFAVORABLE

€ FAVORABLE

FRACTURE inferior border fracture- anteriorly and the line of fracture extends in a distal direction toward the ridge angle fractures are HORIZONTAL UNFAVORABLE

€ Most

gunshot .Force Factors: a. location e. loss of substance. direction b. amount c. number d.

Clinical features € Swelling € Pain at the fracture site € Displacement € Malocclusion € Loosening of teeth € Ecchymosis € Salivation € Fetid breath .

€ fracture arises in the tooth bearing area. € such as in the mandibular body between the lingula and mental foramen. disruption of the inferior dental nerve is likely € Pain and crepitus € Trismus € Analgesia € Abnormal mobility € Laceration .

or III fractures € Zygomaticomaxillary complex fractures € Zygomatic arch fractures or NOE fractures . II.B. Mid-face Fractures Midfacial fractures include fractures affecting: € Maxilla € Zygoma € Nasoorbital-ethmoid (NOE) complex Midfacial fractures can be classified as: € Le Fort I.

split the palate. or fragment the maxilla € € .Le Fort Fractures Le Fort I (Low-level € frequently results from the Fracture) application of horizontal force to the maxilla. which fractures the maxilla through the maxillary sinus and along the floor of the nose the fractures separates the maxilla from the pterygoid plates and nasal zygomatic structures this type of trauma may separate the maxilla in one piece from the other structures.

Le Fort II (Pyramidal Fracture) € forces that are applied in a more superior direction € separation of the maxilla and the attached nasal complex from the orbital and zygomatic structures .

which results in a so-called craniofacial separation . the zygomas.Le Fort III (Craniofacial dysfunction) € results when horizontal forces are applied at a level superior enough to separate NOE complex. and the maxilla from the cranial base.

.

Signs and Symptoms of Le Fort Fractures € Pain € Swelling and edema € Step deformity € Mobility € Anaesthesia or parasthesia € Diplopia € Enophthalmus € Epistaxis .

CSF rhinorrhoea € Subconjunctival haemorrhage € Dish face deformity € Limitation of ocular movement € Difficulty of mouth opening € Disturbed occlusion € Cracked-pot sound on percussion € Occasional haematoma at the palate € Circumorbital ecchymosis € Lengthening of the face € Battle's sign € Orbital emphysema € Paralysis of facial muscles € .

. This complex € serves as a bony barrier.Zygomaticomaxillary Complex Fracture Zygomaticomaxillary Complex € functional and aesthetic unit of the facial skeleton. separating the orbital constituents from the maxillary sinus and temporal fossa.

or the orbital floor areas . the orbital rim.€ results when an object strikes the lateral aspect of the cheek € similar trauma can also result in isolated fractures of the nasal bones.

€ blunt trauma to the eye can result in compression of the globe and subsequent blow-out fracture of the orbital floor € 40% of the zygomatic bone fractures associated with ocular injuries .

Signs and Symptoms of ocular injury: € Pain € Swelling € Asymmetry € Periorbital haematoma € Subconjunctival haemorrhage € Limitation of ocular movement € Ecchymosis and tenderness over the area € Diplopia .

€ Enophthalmus € Dystopia € Epistaxis € Step deformity € Limitation of mandibular movement € Anasthesia € Gagging of occlusion € Flattening of the malar prominence € Changes in eyelid position .

By: Pamela Rose Manaloto .

BASIC SURGICAL PRINCIPLES Reduction of the fracture Fixation of the bony segments to immobilize segments at the fracture site € Preoperative occlusion must be restored € Any infection in the area of the fracture must be eradicated or prevented € € .

€ always better to treat an injury as soon as possible € edema progressively worsens over 2-3 days after an injury and frequently makes treatment of a fracture more difficult. .

FACIAL BUTTRESSES RESPONSIBLE FOR VERTICAL SUPPORTS OF THE FACE € Nasomaxillary € Zygomatic € Pterygomaxillary .

ANTEROPOSTERIOR SUPPORT € frontal € zygomatic € maxillary € mandibular .

.

€ .REASONS OF DELAYED TREATMENT OF FACIAL FRACTURES: patients have other injuries that demand more immediate treatment € delay of 1-2 days results in the presence of tissue edema that makes a further wait of 3-4 days necessary for elimination of the edema and easier fracture treatment.

.

-Place the teeth into preinjury occlusal relationship . Reduce the fracture properly or place the individual segments of the fracture into the proper relationship with each other.TREATMENT OF MANDIBULAR FRACTURES 1.

Establishing a proper occlusal relationship by wiring the teeth together is termed maxillomandibular fixation (MMF) or intermaxillary fixation (IMF).closed reduction ± treatment of fractures using only IMF. .2. it does not involve direct opening. exposure. . and manipulation of the fractured area.

. the maxillary arch bar is wired to the mandibular arch bar thereby placing the teeth in their proper relationship.€ most common technique: use of prefabricated arch bar that is adapted and circumdentally wired to the teeth or acid-etch bonded in each arch. € other wiring techniques: Ivy loops or continuous loop wiring.

Arch Bar Intermaxillary Fixation .

Ivy Loop Wiring Technique .

Ivy loop with 2 screws on maxilla and 2 screws on the mandible .

Continuous Loop Wiring Technique .

The maxillary and mandibular dentures can then be wired together. After an appropriate period of healing (minimum of 4-6 weeks).€ For an edentulous patient. which produces a type of IMF. . new dentures can be fabricated. mandibular dentures can be wired to the mandible with circummandibular wiring and the maxillary denture can be secured to the maxilla using wiring techniques or bone screws to hold the denture in place.

It is useful because of configuration of the deciduous teeth because of developing permanent teeth and because patient understanding and cooperation is difficult to obtain.€ For children. . splinting technique can be used.

3.when open reduction is performed. Necessity for an open reduction must be determined . Intraoral and extraoral approaches are possible. . direct surgical access to the area of the fracture must be obtained. This access can be accomplished through several surgical approaches. depending on the area of the mandible fractured.

€ indication for open reduction: continued displacement of the bony segments or an unfavorable fracture .€ if adequate bony reduction has occurred. IMF may provide adequate stabilization during the initial bony healing phase of approximately 6 weeks.

€ the traditional and still acceptable method of bone fixation after open reductions has been the placement of direct intraosseous wiring combined with a period of MMF ranging from 3 to 8 weeks. .

Wire osteosynthesis .

€ € - techniques for rigid internal fixation are widely used for treatment of fractures. . Advantages: decreased discomfort and inconvenience to the patient because IMF is eliminated or reduced improved postoperative hygiene greater safety for patients with seizures better postoperative management of patients with multiple injuries. bone screws or both to fix the fracture more rigidly and stabilize the bony segments during healing. These methods use bone plates.

Another example of titanium plates(black arrows) and screws in use .

Example of a fracture treated with titanium plates(white arrows) and screws to allow immediate function .

.

TREATMENT OF MIDFACE FRACTURES € FRACTURES THAT AFFECT OCCLUSAL RELATIONSHIP y Le Fort I y Le Fort II y Le Fort III € FRACTURES THAT DO NOT NECESSARILY AFFECT OCCLUSION: y Isolated zygoma fracture y Zygomatic arch y Nasoorbital ethmoid complex (NOE) .

lateral eyebrow or infraorbital approaches. isolated zygomatic arch fractures and nasoorbital-ethmoid(NOE) fractures: restoration of the ocular. zygomaticofrontal area and inferior orbital rim area may be necessary. nasal and masticatory function and facial esthetics. In isolated zygoma fracture (most common midfacial injury): open reduction is generally performed through some combination of intraoral. .€ € In zygoma fractures. If adequate stabilization is not possible by simple manual reduction. bone plating and zygomaticomaxillary buttress.

Isolated Zygomatic Fracture .

Plate Stabilization of Zygomatic Complex Fracture .

Elevation and reduction of the zygomatic arch should be performed within several days of the injury. an extraoral or an intraoral approach can be used to elevate the zygomatic arch and return it to its proper configuration.€ In zygomatic arch fracture. and it tends to collapse or drift to its injured position. . Longer delays make maintaining the arch in a stable supported configuration difficult. This approach eliminates the impingement on the coronoid process of the mandible and the subsequent limitation of mandibular opening.

medial canthal and infraorbital rim areas can be achieved through a variety of surgical approaches. Wide exposure to the suraorbital rim and nasal.€ In NOE fracture. which allows exposure of the entire upper facial and nasoethmoidal complex through a single incision that can be easily hidden in the hairline. open reduction of the NOE area is usually necessary. . The most popular approach currently in use is the coronal flap. Small boneplates and direct transnasal wiring appear to be the most effective in stabilizing and maintaining bony segments in these type of injuries.

it is important to reestablish a proper occlusal relationship by placing the maxilla into the proper occlusion with the mandible. as in mandibular fractures. . € Additional stabilization of the fracture sites is often required.€ In midfacial fractures involving a component of the occlusion.

attempt to fixate individual fractures directly .6 to 1.titanium alloy plates range in thickness from 0.ability to obtain proper bony contours .0mm external thread diameters .wires attached to the piriform rim area.Additional Stabilization Direct wiring ± attempt to fixate individual fractures directly € Suspension wiring ± provide stabilization of the fractured bones by suspending them to a more stable bone superiorly € .7 to 2.5mm and are secured by screws with 0. € Bone plates . zygomatic arch or frontal bone. infraorbital rims.

Suspension Wiring Technique .

Attempts must be made to reanastomose the duct. identify and perform a primary repair of the severed nerve. € Cleansing of the laceration and examination of the area for disruption of any vital structures is important.Lacerations Fractures of the facial bones are frequently associated with severe facial lacerations.e. salivary flow. . € Examination of these injuries before injection of local anesthesia or induction of general anesthesia is important because structural integrity and function (i. facial motion) may not be assessable for anesthesia. € Possible injuries include lacerations of Stensen¶s duct. facial nerve or major vessels. or manage all associated bleeding.

Some surgeons use antibiotic ointment. . All closure should be completed in layers to orient tissues properly and to eliminate any dead space within the wound to prevent hematoma formation. dry-occlusive dressings. Sutures from facial wounds should be generally removed in 5 to 7 days. from oral mucosa to the muscle to the subcutaneous tissue and skin. after which the surgeon should close areas where wound margins are not so clearly reapproximated. All wounds should be cleansed periodically using hydrogen peroxide. Easily identifiable landmarks or areas of the laceration that can be easily identified and properly repositioned should be sutured first.€ € € € € Lacerations should be closed from inside out. depending on the location of the wound and the amount of tension necessary to provide adequate wound closure.

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