TEKNIK OPERASI

FRAKTUR MANDIBULA

Ali Akbar Rahmani

2020
Key Points
The patient with facial fractures is a trauma
patient and requires a comprehensive evaluation
for calvarial, intracranial, and cervical spine
injuries.

Achieving normal occlusion is of primary

importance in the reduction of maxillary and
mandibular fractures.

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

Concepts in Facial Trauma
Mechanisms of injury vary and patients must first
be considered from a comprehensive trauma
standpoint.

The face is designed to act as a shock absorber

to help prevent trauma to these critical neurologic
structures.

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

Goals of CMF Trauma Care
Immediate or early restoration of both form and
function of all structures of the face and cranium,
with complete, predictable, and complication-free
healing

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Clinical Assessment
Systematic facial examination  avoid missing
injuries
Soft tissue
Skeletal
Nerve

Radiographic evaluation

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

Skeletal Injury
Upper facial fractures

Midfacial fractures

Lower facial fractures : The Mandible

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

Basic Science
https://surgeryreference.aofoundation.org/cmf/trauma/mandible/further-reading/anatomy#nerves
Champy Principles
✘ Miniplate fixed along the
ideal lines of
osteosynthesis.
✘ A form of load-sharing
osteosynthesis to be
applied in simple fracture
patterns with good amount
of bone stock
✘ Number miniplate fixation
used:
2 plates in symphysis
2 plates may be used in angle
1 plate only in body
https://surgeryreference.aofoundation.org/cmf/trauma/mandible/further-reading/anatomy#nerves
Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012
Hupp J et al. Contemporary Oral and Maxillofacial Surgery. 2014
Hupp J et al. Contemporary Oral and Maxillofacial Surgery. 2014
 Simple Fractures Complex Fractures

Basal triangle (wedge) Comminuted

Defect Segmental

https://surgeryreference.aofoundation.org/cmf/trauma/mandible/further-reading/anatomy#nerves
Hupp J et al. Contemporary Oral and Maxillofacial Surgery. 2014
Biological Reaction and Healing of Bone
1. Primary bone healing (contact or gap healing)

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Biological Reaction and Healing of Bone
2. Secondary bone healing via callus formation
(Hematoma)

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Biological Reaction and Healing of Bone
2. Secondary bone healing via callus formation
(Granulation tissue/connective tissue)

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Biological Reaction and Healing of Bone
2. Secondary bone healing via callus formation
(Fibrocartilage)

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Biological Reaction and Healing of Bone
2. Secondary bone healing via callus formation
(Bone replacement)

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Biological Reaction and Healing of Bone
3. No bone healing

- Nonunion (repair is primarily not possible and

surgery is required to bring about union)

- Delayed union (a prolonged healing period)

due to reduced blood supply, irradiation

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Biomechanics of Mandible
Stability of the Craniofacial Skeleton

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

 Superior portion: tension zone
Inferior portion: compression zone

Hoop of bone that deforms with

movement of muscles of mastication

https://surgeryreference.aofoundation.org/cmf/trauma/mandible/further-reading/anatomy#nerves
Principles of Management
Objective
Restoration of normal occlusion.

Anatomic reduction is a secondary goal.

Predictable, safe, undisturbed, and complication-

free healing

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012
Occlusion

Greenberg A et al. Craniomaxillofacial Reconstructive and Corrective Bone Surgery. 2002

Indications of Treatment
No Treatment & Non Surgical
incomplete and/or undisplaced fractures without
malocclusion, pain, or other functional
disturbances with no additional pathology
undisplaced condyle and condylar head fractures
associated with malocclusion, pain, or functional
deficits

Surgical Treatment
all fractures with more than minimal displacement
Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012
Treatment Planning
Detailed clinical examination
Personality, Age, Sex, Comorbidities
Adequate preoperative imaging
Data analysis and development of a treatment
plan including alternatives
Communication with the patient
Informed consent

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Four Sequential Surgical Steps
1) Adequate exposure
2) Fragment reduction
3) Adequate internal fixation
4) Meticulous wound closure

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Tips & Tricks
Stable, nondisplaced fractures may be treated
nonoperatively with a soft diet.

Tooth extraction is recommended whenever the

teeth partially luxated or the tooth roots are
fractured.

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

Fixation Materials
Types of Fixation
Rigid fixation (load-bearing)
no micromotion
useful if healing is delayed (atrophic bone, bony
defects, smokers, poor oral hygiene, or patients
with multiple comorbidities)

Functionally stable fixation (load-sharing)

micromotion is allowed
a bony callus forms during the process of
secondary bone healing
Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020
Locking vs. Non-locking Screws
Locking Screws
often desirable
lower risk of displacing the fracture fragments

Non-locking Screws
lag the plate into closer coaptation with the bone
can displace the fracture and lead to
malocclusion
used in oblique mandibular fractures / symphysis
Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020
 Bicortical
osteosynthesis

Load-bearing
osteosynthesis

Monocortical
osteosynthesis

Load-sharing
osteosynthesis

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012
Operative Techniques
Access Incisions
Numerous incisions are available to access
various regions of the facial skeleton.

Lacerations from the injury can also be used to

further improve access.

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

1. Symphyseal and Parasymphyseal Fractures

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020
Surgical Approaches

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Osteosynthesis Techniques

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Osteosynthesis Techniques

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Post Operative
A soft diet for approximately 4 weeks
postoperatively is recommended.

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Pitfalls
Damaging the tooth roots must be avoided
through proper screw placement.

Symphyseal or parasymphyseal mandibular

fractures in conjunction with bilateral displaced
condylar fractures, resulting result of posterior
widening (flaring)

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

2. Body and Angle Fractures

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020
Body and Angle Fractures

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Surgical Approaches

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Osteosynthesis Techniques

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Post Operative
Early restoration of full function including diet,
airway, and speech.

A brief period of soft-tissue rest in occlusion using

MMF may support soft-tissue healing

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Pitfalls
Failure to fully identify the fracture anatomy may
result in inappropriate fixation.

Screw placement into the mandibular canal can

be avoided through careful planning.

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

3. Condyle, Ascending Ramus, and
Coronoid Process Fractures

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020
Surgical Approaches

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Osteosynthesis Techniques

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Post Operative
Malocclusion and impaired TMJ function may
occur in condylar area fractures even after
treatment.

A prolonged functional therapy may be

necessary.

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Pitfalls
Injury to the facial nerve (especially the temporal
branch in preauricular incisions and the marginal
branch in submandibular incisions) or visible
scars

Avascular necrosis of the condylar head, leave

the lateral pterygoid muscle attached.

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

5. Extra : Wire Osteosynthesis

Hupp J et al. Contemporary Oral and Maxillofacial Surgery. 2014

5. Extra : External Fixation

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Complication
1. Malocclusion
Insufficient reduction or loss of reduction during
the healing process due to:
inadequate fixation,
poor bone quality, or
suboptimal patient compliance

May cause malunion or nonunion

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

2. Reduction-related Injuries
Injury to tooth roots can occur from drilling or
placement of bone screws.

Facial nerve injury may result from a Risdon

incision (marginal mandibular nerve) or condylar
approaches (main trunk or any of its branches)

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

2. Reduction-related Injuries
Paresthesias can occur if the inferior alveolar or
mental nerves are injured.

Stiffness of the TMJ can result from inadequate

seating of the condyle during fixation, condylar
head fracture, or prolonged MMF

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

2. Reduction-related Injuries
Hardware infection may be managed with a
period of observation and antibiotics with or
without surgical irrigation; ideally, hardware
removal is delayed until union occurs.

Chung KC et al. Grabb & Smith’s Plastic Surgery 8 th. 2020

Implant Removal
Removal Before Completion of Fracture
Healing
Indications:
problems caused by fractured plates,
malpositioned plates, or
loose hardware (like loose screws) with or without
consecutive infection.

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Removal After Fracture Healing
Absolute Indications:
fractured or loose plates and screws, problems
with infection, and/or penetration of the hardware
through the soft-tissue envelope.

Relative Indications:
potential interferences of implants with additional
surgical interventions
children (recommended)
individual patient’s concerns
Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012
Case Discussion
Mr. I
49 y.o.
Fracture of right mandible body post archbar & wiring
Plan : ORIF rignt mandible
Surgical Approaches

Ehrenfeld M et al. Principles of Internal Fixation of the Craniomaxillofacial Skeleton. 2012

Hatur Nuhun!