Plastic Surgery Case Presentation

51 YEARS OLD MAN WITH SYMPHISIS

MANDIBLE

Compiled by :
Astarina Indah Apsari G99172050
Khoirunnisa G99181038
M. Yusuf Brilliant G991905036

Supervisor :
Amru Sungkar, dr., Sp. B Sp. BP-RE
IDENTITY
 Name : Mr. N
 Age : 51 years old
 Sex : Male
 Address : Karangpandan
 No. MR : 014xxx
 Hospitalized : November 5th 2019
 Examined : November 11th 2019
CHIEF COMPLAIN

 Lower jaw pain

 PRESENT ILLNESS
Unconsiusne Lower jaw
ss (-) pain (+)
Trauma RSDM
vomiting Dizziness
(-) (+)
 Pain in the lower jaw is felt after the patient fell from the motorcycle since
10 hours before hospitalized
 Patient fell from motorcycle when crushed by car from behind. Patient used
standard helmet
 Lower jaw pain is felt constantly and increases when he tries to open his
mouth. Mouth can not open widely and feel pain when biting
 Tooth loss
 Unconsiusness (+), vomiting (-), dizziness (+)
 After the incident the patient is brought to Dr Moewardi Hospital
PAST
ILLNESS
HT Denied

DM Denied

Allergy Denied

Operation
Denied
History
FAMILY HISTORY

HT Denied

DM Denied

Allergy Denied

Operation
Denied
History
SOCIAL ECONOMIC
HISTORY
 Patients lives with his wife and parents. Patients is
treating in RSDM by using BPJS. Patient is
entrepreneur.
PHYSICAL EXAMINATIONS
 PRIMARY SURVEY
1. Airway : clear

2. Breathing 18 times / min

Inspection : expansion of chest wall : right = left
Palpation : crepitus (- / -), pain (-/-)
Percussion : sonor / sonor
Auscultation : SDV (+ / +), ST (- / -)

3. Circulation : blood pressure 120/70 mm Hg, pulse 95 x/minute

4. Disability : GCS E4V5M6, light reflex (+/+),
pupil isokor, lateralization (-)
5. Exposure : temperature 36.6 ° C, injury (+) view the status of localist
 SECONDARY SURVEY
1. Head : mesocephal form
2. Eyes : periorbital edema (- / -), pale conjunctiva (- /-)
jaundice sclera (- / -), isochoric pupil (3mm / 3mm),
light reflexes (- / -), periorbital hematomas (- / - ),
diplopia (- / -)
3. Ears : secret (- / -), blood (- / -), mastoid tenderness (- / -),
4. Nose : symmetric, nasal lobe breath (-), secret (-), bleeding (-)
5. Mouth : cyanosis (-)
6. Neck : enlargement of the thyroid (-), enlargement of
lymph nodes (-), tenderness (-)
7. Thorax : normochest, backward motion (-), injury (+)
 SECONDARY SURVEY
 Heart
Inspection: ictus cordis is not visible
Palpation : ictus cordis is not strong enough to lift
Percussion : the heart of the impression does not widen
Auscultation : normal, regular, noisy heart sounds I-II (-)
 Pulmo
Inspection: the development of the right chest is the same as the left
Palpation : fremitus right touch equals left, tenderness (- / -)
Percussion : sonor / sonor
Auscultation : normal vesicular (+ / +) sounds, additional sounds (- / -)
 Abdomen
Inspection: distended (-)
Auscultation : bowel sounds (+) normal
Percussion : tympanic
Palpation : supple, tenderness (-), muscular defenses (-)
 SECONDARY SURVEY

 Genitourinaria : Normal, Bloody urine (-)

Pus discharge (-), pain (-)
 Extremities : cold (-/- -/-), strong pulsation,
see localis status
LOCALIST STATUS

 Mandibular Region
Look : appears vulnus has 5 vertices with silk 3.0 with
simple interrupted stitches
Feel : palpable discontinuity (+), tenderness (+), NVD
(-)
Move : Limitations of motion (+) on the
Temporomandibular joint
LOCALIST STATUS
ASSESSMENT 1

 Mild brain injury, GCS E4V5M6

 Trauma of thorax
 Fracture os radius (D) os ulna (D)
 Fracture os femur (S)
 PLAN 1
 O2 3 lpm
 IVFD NaCl 20 drops per minute
 Inj. Metamizole 1 gr/12 hours
 Inj. Omeprazole 40 mg/12 hours
 Blood Laboratory Examination
 Rontgen of Head AP/Lat, Cervical AP/Lat,
Antebrachii AP/Lat, Pelvis AP, Waters, Manus
AP/Obl, Thorax PA, Femur AP/Lat
 Head MSCT Scan non contrast
 Routin Blood Examination
Examination Result Unit Reference

HEMATOLOGY
Hemoglobin 12.2 g/dL 12.0 – 15.6
Hematokrit 38 % 33 - 45
Leukosit 14.0 thousand/uL 4.5 – 11.0
Trombosit 242 thousand/uL 150 – 450
Eritrosit 4.49 million/uL 4.10 – 5.10
Blood Type B    
HEMOSTASIS
PT 13.4 Secon 10-15.0
APTT 29.0 Secon 20-40.0
INR 1.040    
SEROLOGY HEPATITIS
HbsAg Nonreactive   Nonreactive
XRay Examination
Cervical AP/Lat,

 No visible fracture,
compression, or listhesis
 Cervical spondylosis
 Subcutis emphysema in the
submandibular region
Waters

 Fractures on the mandibular corpus to the

dve alveolar processus and the maxillary
corpus accompanied by soft tissue swelling
around it
 Left inferior nasal concha hypertrophy
Thorax PA

 No visible fracture or dislocation

 Cor and pulmo on normal range
Antebrachii AP/Lat,

 Right galeazzi fracture accompanied

by soft tissue swelling around it
Manus AP/Obl

 Right galeazzi fracture

accompanied by soft tissue
swelling around it
Pelvis AP

 No visible fracture or dislocation

Femur AP/Lat

 Comminutive complete fracture on 1/3

of the left femur os accompanied by soft
tissue swelling around it
Cruris AP Lat

 Incomplete fracture in the right

os femur medial condylus
accompanied by soft tissue
swelling around it
MSCT

 No visible fracture or dislocation

Assesment II

 Mild Brain Injury GCS E4V5M6

 CF distal radius (D)
 CF Shaft Femur (S) WH 3
 CF medial Condyle Femur S
 Mandibular symphysis fracture
Plan II

 NaCl infusion 20 dpm

 Inj Metamizole 1 gr / 12 hours
 Inj. Omeprazole 40 mg / 12 hours
 Oral Hygiene
 Liquid Diet
 Pro Elective ORIF
LITERATUR
E REVIEW
Anatomy of Mandibular

Processus Condylaris

Processus Coronoideus

Ramus Mandibulae

Angulus Mandibulae

Corpus Mandibulae
Foramen Mentale
Protuberantia Mentalis
Biomechanical of Mandibular
Horizontal axis rotation:
 Open/Close mouth movement (pure
rotation) / hinge movement.
Vertical axis rotation:
 Condylus move to anterior.
Sagital axis rotation:
Horizontal axis Vertical axis
 Condylus move to inferior

Rotation

Sagital axis
Biomechanical of Mandibular
Translation:
 When ramus, condylus, and teeth
move upward simultantly in a same
direction and speed.
 Occurred on superior cavity of joint
at discus articularis superior and
inferior surface of fossa articularis
(Between discus condylus complex
and fossa articularis).

Translation
BACKGROUND OF
MANDIBLE FRACTURE
 Mandible fractures are a frequent injury because of the mandible's prominence and
relative lack of support. As with any facial fracture, consideration must be given for
the need of emergency treatment to secure the airway or to obtain hemostasis if
necessary before initiating definitive treatment of the fracture.
Location of
mandibular fractures
BACKGROUND OF
MANDIBLE FRACTURE
 Mandible fractures are a frequent injury because of the mandible's prominence and
relative lack of support. As with any facial fracture, consideration must be given for
the need of emergency treatment to secure the airway or to obtain hemostasis if
necessary before initiating definitive treatment of the fracture.
 Diagnosis

Mechanism of
Anamnesis Present illness
trauma

deformity tooths
inspection
wound malocclusion

Physical
examination
TMJ ginggiva
palpation
False
tooths
movement
 False
movement
thumb in intraoral,
holds the corpus of
the mandible and then
moved up and down.
 IMAGING STUDIES
The following types of radiographs are helpful in
diagnosis of mandibular fractures:

Reverse
Panoramic Eisler
Towne’ view
X-ray
Temporomandibular
Skull PA/Lat Towne’s view
Joint

Complex
CT Scan maxillofacial
fracture
 IMAGING STUDIES
• Initial screening of patients is most effective with a
PANORAMIC RADIOGRAPH, since it shows the
entire mandible including the condyles.
• Since an accurate panoramic radiograph requires that
the patient is able to stand upright and without any
motion, achieving good quality films with severely
traumatized patients may be difficult. Traditional
lateral oblique views of the mandible can be used
when obtaining a panoramic radiograph is not
possible.
A. Panoramic radiograph

it shows the entire mandible

B. Lateral Skull X-ray

be used when obtaining a panoramic radiograph is not possible.

C. Posteroanterior Skull X-Ray

 Face flat on the film, mouth

closed
 To detect facial fracture
 D. Reverse Towne’s
 To see the mandibular condyle neck
fracture, especially those pushed
 To detect fracture of condyle medially and can also see the
neck maxillary lateral wall.
 Mouth open wih forehead
touching the film
E. Temporomandible joint (TMJ)
F. CT Scan
 Classification of
mandibular fractures
SIMPLE OR Fracture that does not produce a wound open to the
CLOSED external environment, whether it be through the skin,
mucosa, or periodontal membrane

Fracture in which an external wound, involving skin,

COMPOUND
OR OPEN mucosa, or periodontal membrane, communicates
with the break in the bone

COMMINUTE
D
Fracture in which the bone is splintered or crushed
GREENSTIC Fracture in which one cortex of the bone is broken
K and the other cortex is bent

Variety in which two or more lines of fracture on the

MULTIPLE
same bone are not communicating with one another

Fracture resulting from severe atrophy of the bone, as

ATROPHIC in edentulous mandibles

Fracture in which one fragment is driven firmly into

IMPACTED the other
Mandibular Fracture Biomechanical

Trauma  Mandibular 
Tension and Compression

Trauma
Tension happened on alveolar
Ten
sion region
Co
mp
re s si
on

Compression happened on basal

mandibular region
 Mandibular Fracture
Biomechanical
Because of many muscles stick
on symphisis mandibular

+ Tension and compression

Trauma Ten trajectory effect  Torsion
sion

Co
mp
res
s ion
Torsi
Torsion on symphisis 
Rotation
Handling of mandibular fractures is generally divided into 2 methods,
 Closed Repositioning
 Open Repositioning.
 Closed Repositioning

 Closed reduction of a mandible fracture is a conservative treatment by

repositioning without direct surgery on the fracture line and immobilizing with
interdental wiring or external pin fixation (Hosein, 2013).
 Indication
1. Kominutif fracture,
2. Fracture with soft tissue damage which is quite heavy,
3. Edentulous mandible
4. Fractures in children
5. Condylus fracture
 Open Repositioning

 Open repositioning is an operation to correct deformity-malocclusion that

occurs in lower jaw fractures by fixing with interosseus wiring and
immobilization using interdental wiring or with mini plates and screws
(Cillo and Ellis, 2014).
 Indication
1. fracture through angulus
2. fractures from the corpus or parasymphysis.
3. multiple facial bone fractures;
4. Midface fractures accompanied by displaced bilateral condylus fractures.
5. Malunion
 Complication
1. infection, with common pathogenic bacteria being staphylococcus, streptococcus and
bacterioides.
2. Malunion and delayed healing occur, usually caused by infection, inadequate
reduction, poor nutrition, and other metabolic diseases.
3. Parasthesia of the inferior alveolar nerve, mandibular marginal lesions. facial can
occur due to the incision is too high.
4. Orocutaneous fistula can occur in the continuation of the infection, especially in
patients with malnutrition so that wound healing is not good and wound deh licensing
occurs (Andreas et al., 2014).
THANKYOU …