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ANATOMY
Mandible interfaces with skull base via the TMJ and is
Temporalis
Medial surface coronoid process, anterior surface of ramus down to occlusal plane Medial surface of ramus and angle of mandible
Two deep temporal branches of mandibular nerve (V), sometimes reinforced by middle temporal nerve Branch from main trunk of mandibular nerve
Elevates mandible, posterior fibres are the only muscle fibres to retract the mandible Pulls angle of mandible superiorly, anteriorly and medially Lateral movement, protrusion, important in active opening of the mouth
Pterygoid fossa, mainly medial surface of lateral pterygoid process Upper head from infratemporal surface of skull, lower head from lateral pterygoid plate
Upper head inserts into TMJ capsule, lower head into anterior surface of condylar neck
Geniohyoid
Pulls hyoid bone anterosuperiorly, shortens floor of mouth and widens pharynx Elevates hyoid bone, floor of mouth and tongue during swallowing and speaking Depresses mandible, raises hyoid bone and steadies it during swallowing and speaking
Mylohyoid
Digastric
Muscles of Mastication
OUTER SURFACE
Muscles of Mastication
INNER SURFACE
Muscles of Mastication
4 muscles of mastication
Masseter Temporalis
Medial pterygoid
Lateral pterygoid
Masseter
Divided into 3 heads
Superficial:
largest head Arises anterior 2/3rds of the lower border of the zygomatic
arch
Wide insertion to angle, forwards along lower border and
Intermediate:
Middle 1/3 of the arch
Deep:
Deep surface of the arch
Masseter
Intermediate and deep fuse and pass vertically
parts
Masseteric nerve (Br of anterior division of V3) runs
Temporalis
Arises temporal fossa between inferior temporal line
Medial pterygoid
2 heads:
Deep:
Larger
Superficial :
Tuberosity of the maxilla and pyramidal process of
palatine bones
masseter)
Action: upwards and forwards and medially
Lateral pterygoid
2 heads:
Superior:
Infratemporal fossa
Inferior:
Lateral surface of the lateral pterygoid
pterygoid fovea
the upper fibres passing into articular disc and
jaw
Temporomandibular Joint
Articulation
Synovial joint between the condyle of the mandible
and the mandibular fossa in the squamous part of the temporal bone
Both bone surfaces covered with layer of
Temporomandibular Joint
Unique feature of the TMJs is the articular
disc.
Composed of fibrocartilaganeous tissue
Divides each joint into 2:
Inferior compartment Superior compartment
Temporomandibular Joint
Inferior compartment
Allows for pure rotation of the condylar head, corresponds to the first 20 mm or so of the opening
Superior compartment
involved in translational movements sliding the lower jaw forward or side to side
Temporomandibular Joint
Temporomandibular Joint
Atypical synovial joint separated into upper and lower cavities by a fibrocartilaginous disc
No hyaline cartilage
Capsule attached high on neck of mandible around articular margin, then to transverse prominence or articular tubercle and as far posteriorly as squamotympanic fissure Fibrocartilage attached around periphery to capsule
Anteriorly near head of mandible, so mobile Posteriorly near temporal bone, so more fixed Thinner in middle than periphery, crinkled fibres to allow movement and contouring
Lateral TM ligament is a stout fibrous band passing from zygomatic arch to posterior border of neck and ramus, blending with capsule
Remains constant tension through range of motion as the lingula is the axis of rotation of the mandible
Sensation supplied by auriculotemporal nerve with some supply from nerve to masseter (Hiltons law)
TMJ Ligaments
3 ligaments associated with the TMJ:
1) Temporomandibular ligament (Major)
TMJ Ligaments
2) stylomandibular ligament (minor)
separates the infratemporal region from the parotid
region
runs from the styloid process to the angle of the
mandible
3) Sphenomandibular ligament (minor)
runs from the spine of sphenoid to the lingula of the
mandible
TMJ Ligaments
The minor ligaments are important in that they
these extents functionally allowed by the muscular attachments BUT will result in painful stimuli
TMJ Ligaments
TMJ Ligaments
Mandibular Forces
Nerve Supply
Inferior alveolar nerve branch of the mandibular
division of Trigeminal (V) nerve, enters the mandibular foramen and runs forward in the mandibular canal, supplying sensation to the teeth.
At the mental foramen the nerve divides into two
terminal branches:
Incisive nerve: supplies the anterior teeth mental nerve: sensation to the lower lip
Evaluation - History
Always remember ABCs of life along with
Posterior premature dental contact or an anterior open Posterior open bite is common with anterior alveolar Unilateral open bite is suggestive of an ipsilateral angle
fractures
Condylar neck # are assoc with open bite on opposite
Angles classification
Class I:
Normal Mesial buccal cusp of the upper 1st molar
Class II:
Retrocclusion, mandibular deficiency
Class III:
Prognathic occlusion, maxillary deficiency,
mandibular excess
Class I
Based on relationship of permanent 1st molars and to a lesser degree the permanent canines to each other
Molar relation
Canine relation
Mesiobuccal cusp of maxillary 1st molar is in line with buccal groove of mandibular 1st molar Buccal groove of mandibular 1st molar is distal to mesiobuccal cusp of maxillary 1st molar Buccal groove of mandibular 1st molar is mesial to mesiobuccal cusp of maxillary 1st
Maxillary permanent canine occludes with distal of mandibular canine and mesial half of mandibular 1st premolar Distal surface of mandibular canine is distal to mesial surface of maxillary canine by at least width of a premolar Distal surface of mandibular canine is mesial to mesial surface of the maxillary canine by at least the width of a
II
Div1 Overjet Div2 Lingual inclination
III
Malocclusion
Physical Exam
Anaesthesia of the lower lip
Abnormal mandibular movement
unable to open - coronoid fx
Physical Exam
Multiple fractures sites are common:
1 fracture: 50% 2 fractures: 40%
Dual patterns:
Angle contralateral body Symphysis and bilateral condyles
Aims of Management
1) Achieve anatomical reduction and stabilisation
2) Re-establish pre-traumatic functional occlusion 3) Restore facial contour and symmetry 4) Balance facial height and projection
Fracture Frequency
Class I: teeth both sides of fracture Class II: teeth one side of fracture Class III: edentulous
Favourable vs unfavourable
Treatment options
No treatment
Soft diet Maxillomandibular fixation Open reduction - non-rigid fixation Open reduction - rigid fixation External pin fixation
IMF
IMF
Islet IMF
External Fixation
Principles of fixation
Usually one plate with 4
Condylar fractures
Classification
Condylar
Intra- or extra-capsular
subcondylar
Watch for intracranial condylar head Condylar heads tend to dislocate anteromedially towards pterygoid plates due to pull from medial pterygoid Indications for open reduction are angulation > 30, fracture gap > 5mm, lateral override, bilateral fractures of head/neck
Risks avascular necrosis of condylar head, facial nerve injury, hypertrophic scarring (10%)
Alveolar fractures
Miller Grade 1 - < 1mm looseness Miller Grade 2 1-3mm looseness Miller Grade 3 - > 3mm looseness and loose superoinferiorly in socket
Important in fracture stability when using IMF Less important in fracture stability when plates used to fix fractures Reasons to extract the tooth Severe tooth loosening with chronic periodontal disease Fracture of the root of the tooth Extensive periodontal injury and broken alveolar walls Displacement of teeth from their alveolar socket Interference with bony reduction and reestablishing occlusion Third molars tend to cause the most controversy Third molars that are erupting normally need not be removed unless they are interfering with fracture reduction Impacted third molars can be removed as they are rarely a functional part of the occlusion Removal of third molars unnecessarily leads to increased conversion from closed reduction to open reduction
Edentulous mandible
No occlusal plane Lack of mandibular height due to atrophy Changed pattern of fracture body is more common as atrophy is greatest Changed position of inferior alveolar nerve and artery Changed pattern of blood supply more circumferential than radial Role of recon plates and bone grafting Role of dentures
Paediatric mandible
Often greenstick fractures that heal within 2-3 weeks
65% mandibular fractures in children < 10yo are in
Acrylic splint secured by circumferential wiring is safe Condyle is the major growth centre of the mandible and
Complications
Inadequate immobilisation, fracture alignment Inteposition of soft tissue or foreign body Incorrect technique
56%pre-treatment
19% post-treatment