1) Diagnosis and evaluation of patient

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a) History taking:  Accurate detail and proper history of patient should be taken.  If the patient is unable to give statement then the same should be recorded from accompanying person, relative, friends or police officers.  If will reveal about how the injury occurred, the type of injury and the severity of the injury. b) General Examination:  It should be carried out to look for any serious injury elsewhere in the body so that the appropriate specialist could be consulted.  Inspection and palpation of head for any soft tissue as well as bone injury.  Inspection and palpation of chest and abdomen for any injury. c) Regional Examination: The mouth and the face should be carefully cleaned for a proper examination.  Extra oral : -Inspection - Palpation  Intra oral - Inspection - Palpation d) Radiological examination:  Extra-oral Radiograph:  P/A view of mandible in open mouth position  Right and left lateral oblique view.  X-ray for TMJ in both opened and closed mouth position  OPG.  Occlusal vies

2) Definitive treatment:
(i) Conservative treatment: (When only fracture line seen but no displacement then conservative Rx done). a) Control of pain- A patient of fracture of mandible experiences extreme degree of pain and may go into shock because of service into lerable pain so IV Diazepam can be given in the does of 10 mg combined with (15-30)mg pentazocine as analgesics.

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b) Control of infection- Prevention of infection is of outmost importance so, antibiotics should be prescribed. c) Temporary stabilization of fractured part temporary splinting of the fractured fragments with the help of barrel bandage. Temporary stabilization in the form of horizontal wiring is and effective procedure. d) Soft diets. e) Oral hygiene Instructions: f) Advice to the patient that he / she shouldn’t move the jaw vigorously. g) Follow-up. ii) Active treatment / principles of treatment: (if displacement occur then active Rx. done). Reduction: It is the process of bringing the fractured fragments into alignment normal Position. Types: Closed reduction: It is usually done in simple fracture. 1. Whenever closed reduction is possible the risk of subsequent infection of the fracture is negligible. 2. Precise anatomical reduction is not necessary in fracture of denture bearing area. 3. Pulls or manipulate the bone under the intact skin until the fracture is in proper position. Open reduction: 1. If tooth remains undamaged, potentially functional should be retained with antibiotic administration. 2. If tooth is damaged & not functional. Fixation: It is the procedure by which the fractured bone ends are fixed in reduced position. a) Indirect fixation by IMF b) Direct fixation by bone plate, screws.

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Immobilization: The reduced and fixed fragments of the bone are immobilized for certain period for healing to occur. Fixation and immobilization are achieved together by the means of IMF or with the help of bone plates and screws. Rehabilitation / Physiotherapy: Treatment plan: Intracapsular Unilateral: Active movement No. IMF Extracapsular Unilateral: IMF (710) Days. (Not necessary if not displaced) Followed by active movement. Bilateral: IMF (710) Days, (Not necessary if not displaced Followed by active movement. IMF (4-6) weeks Open SOS. Intermittent IMF: 48 hours IMF then open then 24 hours IMF.

Children

Bilateral Active movement No. IMF

Adult

Occlusion OK No. IMF Painful Joint IMF-2 weeks.

IMF(3-4) weeks IMF only at night with elastics-4 Weeks

IMF-4 weeks open SOS.

TIME OF IMMOBILIZATION OF FRACTURED MANDIBLE Period of immobilization depends upon the site of fracture, presence or retained teeth in fracture line, age of patient and presence and absence of infection. A simple guide to the time of immobilization for the fracture of tooth bearing area of the lower jaw is follows: Young adult with fracture of the angle receiving early treatment in which tooth removed for the fracture line = 3 weeks.

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If : a) b) c) d) Tooth retained in the fracture line, add 1 week. Fracture at the symphysis, add 1 week Age 40 years & over, add 1 or 2 weeks. Children or adolescents; subtract 1 week.

Applying this guide it follows that a fracture of the symphysis in 40 years old patient when the tooth in the fracture line is retained requires 6 weeks immobilization (Basic 3 weeks) one week for less favorable site + one week allowed for age+1 week for tooth retained in the fractured line.)

Methods of immobilization: A) Intramaxillary Fixation: i) Dental wiring * Direct wiring / Glimmer’s direct method of wiring * Eyelet wiring / lvy Eyelet wiring/ Interdental eyelet wiring. ii) Arch bar wiring iii) Splints: Cast metal splint, Acrylic cap splint. iv) Circumferential wiring. B) Intermaxillary fixation with Osteosynthesis: i) Direct Intra-Osseous wiring / Trans-osseous wiring Upper border intra-osseous wiring Lower border intra-osseous wiring Figure 8 wiring Four hole system Two hole system ii) Transfixation with Kirschner’s wiring iii) External pin Fixation iv) Bone clamps v) Implants/ Grafts.

MAHMUD CD9

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