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

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

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, particularly in the mandible. Note the tear in the mucosa and bleeding. A characteristic odor is associated with a fractured jaw, which perhaps results from a mixture of blood and stagnant saliva

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

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

 Pain

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

Maxilla is examined by: 1.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. If a complete fracture is present, the entire maxilla might move. An old fracture or one that has been impacted posteriorly will not move. The latter will be reflected in a malocclusion

 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. The patient usually has epistaxis and black eyes.

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

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

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

Maxillary fractures - Waters view (nose-chin position taken from a posteroanterior exposure) Zygomatic fracture - "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, notably alveolar process, midline maxilla, and symphyseal fractures.

ETIOLOGY OF JAW FRACTURES

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

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

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

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

6. Trismus - difficulty opening the mouth normally 7. Facial bruising 8. Facial swelling
y Jaw swelling

9. Jaw stiffness
y Very limited movement of the jaw (with

severe fracture) y Difficulty opening the jaw y Difficulty speaking y Difficulty swallowing

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

CLASSIFICATION AND TYPES

A. Mandibular

Fractures

essentially a bone with three joints Caused by dynamic factor, 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

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

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

Displacement Factors A. muscle pull - sling 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

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

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

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

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, split the palate, or fragment the maxilla

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

Le Fort III (Craniofacial dysfunction)

results

when horizontal forces are applied at a level superior enough to separate NOE complex, the zygomas, and the maxilla from the cranial base, which results in a so-called craniofacial separation

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

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

 results

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

 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.

TREATMENT OF MANDIBULAR FRACTURES

1.

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

2.

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; it does not involve direct opening, exposure, and manipulation of the fractured area.

 most

common technique: use of prefabricated arch bar that is adapted and circumdentally wired to the teeth or acid-etch bonded in each arch; the maxillary arch bar is wired to the mandibular arch bar thereby placing the teeth in their proper relationship. 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

 For

an edentulous patient; 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. The maxillary and mandibular dentures can then be wired together, which produces a type of IMF. After an appropriate period of healing (minimum of 4-6 weeks), new dentures can be fabricated.

 For

children, splinting technique can be used. 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.

3. Necessity

for an open reduction must be determined - when open reduction is performed, 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. Intraoral and extraoral approaches are possible.

 if

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

 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. These methods use bone plates, bone screws or both to fix the fracture more rigidly and stabilize the bony segments during healing. 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.

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)

In zygoma fractures, isolated zygomatic arch fractures and nasoorbital-ethmoid(NOE) fractures: restoration of the ocular, 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, lateral eyebrow or infraorbital approaches. If adequate stabilization is not possible by simple manual reduction, bone plating and zygomaticomaxillary buttress, zygomaticofrontal area and inferior orbital rim area may be necessary.

Isolated Zygomatic Fracture

Plate Stabilization of Zygomatic Complex Fracture

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

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

 In

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

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

- wires attached to the piriform rim area, infraorbital rims, zygomatic arch or frontal bone.

Bone plates - attempt to fixate individual fractures directly - titanium alloy plates range in thickness from 0.6 to 1.5mm and are secured by screws with 0.7 to 2.0mm external thread diameters - ability to obtain proper bony contours

Suspension Wiring Technique

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

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