De: Dr. Daniel Oreadi, DDS
*ORIF=Open Reduction Internal Fixation, which means that the surgeon has to cut through the skin in order to expose the bone fragments and reduce the fracture(s).
CRMMF=Close Reduction with Maxillo-Mandibular
Fixation, when the surgeon achieves good reduction of the bone fragments without
the need of cutting through the skin, using arch bars and wires (Erich Arches).
Word (.doc)
PowerPoint (.ppt)
ACCEPTED METHODS OF ORIF OF THE MANDIBLE
CLASSIFICATION
Displaced or Undisplaced: Which is influenced by the force and direction of
the blow and direction of the line of fracture and muscular forces which influences
the favorability of the fracture.
- Horizontally Favorable or Unfavorable
- Vertically Favorable or Unfavorable
CLASSIFICATION BY TYPE OF FRACTURE
Simple or closed: A fracture that does not produce a wound open to the external
environment, whether it be through the skin, mucosa, or periodontal membrane.
Compound or open: A fracture in which an external wound, involving skin, mucosa,
or periodontal membrane, communicates with the break in the bone.
Comminuted: A fracture in which the bone is splintered or crushed.
Greenstick: A fracture in which one cortex of the bone is broken, the other
cortex being bent.
Pathologic: A fracture occurring from mild injury because of pre-existing bone
disease.
Multiple: A variety in which there are two or more lines of fracture on the
same bone not communicating with one another.
Impacted: A fracture in which one fragment is firmly driven into the other.
Atrophic: A spontaneous fracture resulting from atrophy of the bone, as in edentulous
mandibles.
Indirect: A fracture at a point distant from the site of injury.
Complicated or complex: A fracture in which there is considerable injury to
the adjacent soft tissues or adjacent parts; may be simple or compound.
CLASSIFICATION BY SITE OF FRACTURE
Condylar Process Fracture: A fracture that runs from the mandibular notch to
the posterior border of the ramus of the mandible.
Ascending Ramus Fracture: A fracture in which the fracture line extends horizontally
through both the anterior and posterior borders of the ramus or that runs vertically
from the mandibular notch to the inferior border of the mandible.
Angle Fracture: Any fracture distal to the second molar, extending from any
point on the curve formed by the junction of the body and ramus in the retromolar
area to any point on the curve formed by the inferior border of the body and
posterior border of the ramus of the mandible.
Body Fracture: Any fracture that occurs in the region between the mesial portion
of the canine and the distal portion of the second molar and extends from the
alveolar process through the inferior border.
Symphysis Fracture: Any fracture in the region of the incisors that runs from
the alveolar process through the inferior border of the mandible. Some authors
define this area to also include the canine tooth.
Dentoalveolar Fracture: Fracture of the tooth-bearing portion of the jaw not
extending to the inferior border.
PERCENTAGE OF MANDIBULAR FRACTURE SITE
DISTRIBUTION
Body - 33%
Condylar Region - 29%
Angle - 23%
Symphysis - 8.4%
Coronoid - 4.8%
Dentoalveolar - 1.4%
PATTERNS OF MULTIPLE MANDIBULAR FRACTURE
SITES
Angle and Opposite Body
Bilateral Body
Bilateral Angle
Condyle and Opposite Angle
INDICATIONS FOR OPEN REDUCTION
Displaced unfavorable fractures through the angle of the mandible
Displaced unfavorable fractures of the body or the parasymphyseal region of
the mandible
Prolonged delay in treatment of the fracture with interpositional soft tissue
Complex and multiple facial fractures
INDICATIONS FOR OPEN REDUCTION
Concurrent condylar fracture associated with fractures elsewhere in the mandible
Midface fractures and displaced bilateral condylar fractures
Medically compromised patients
- Compromised pulmonary function (COPD), severe asthma
- Seizure disorders
- Gastrointestinal disorders
- Psychiatric or Neurologic problems
INDICATIONS FOR OPEN REDUCTION OF FRACTURES
OF THE MANDIBULAR CONDYLE
A. Limitation of function secondary to:
1. Fracture into middle cranial fossa
2. Foreign body within the joint capsule
3. Lateral extracapsular dislocation of condylar head
4. Other fracture dislocations in which a mechanical stop is present on opening,
which is confirmed radiographically
B. Inability to bring the teeth into occlusion for closed reduction
C. Bilateral condylar fractures with comminuted midface fractures in which rigid
internal fixation of the midface is not possible.
D. Situations when intermaxillary fixation (IMF) is not feasible as a result
of:
1. Medical restrictions
a. Poorly controlled seizure disorder
b. Psychiatric disorders
c. Severe mental retardation
d. Concomitant injuries such as head injury or chest injury (unless tracheotomy
is planned)
2. Displaced fractures where dentures or splints are not feasible because of
severe mandibular atrophy.
E. Bilateral fractures in which it is impossible to determine what the proper
occlusion is as a result of loss of posterior teeth or the presence of a pre-injury
skeletal malocclusion.
D. In fracture dislocations in adults to restore the position and function of
the meniscus (controversial).
SURGICAL APPROACHES
A. Transoral Approaches
- Symphysis and Parasymphysis
- Body, Angle and Ramus
B. Transfacial Approaches
- Submandibular (Access to Body and Angle)
- Retromandibular (Access to Ramus)
- Preauricular (Access to Condyle)
TECHNIQUES OF INTERNAL FIXATION
Transosseous wiring (wire osteosynthesis)
Application of bone plates
Application of screws and pins
TRANSOSSEOUS WIRING (WIRE OSTEOSYNTHESIS)
-Methods
Transalveolar or superior border wiring
Transosseous or lower border wiring
-Types
- Simple (Direct) wiring
- Figure of eight wiring
- Combination (Basket wire)
SCREWS AND PINS
-Lag screws, useful in oblique fractures and occasionally for condylar fractures
-Intramedullary pinning, inaccurate method which has fallen out of favor
BONE PLATES AND RIGID FIXATION
Rigid fixation:
Form of fixation that holds the bone fragments together with absolute stability
so that no motion can occur between themresulting in primary bone healing.
Plates constructed of stainless steel, vitallium or titanium
Moncortical miniplates (semirigid) popularized by Champy
Spiessl, Swiss Association for Internal Fixation described rigid fixation using:
- Bicortical screws
- Eccentric Dynamic compression plate of the inferior border of the mandible
- Tension band at the superior border
*Advantages
Primary bone healing
Early function
Avoidance of MaxilloMandibular fixation
Shorter absences from work
*Disadvantages
Need for transoral approach
Stress shielding
Damage to teeth roots, or the inferior alveolar nerve
Exacting technique, does not allow for occlusal adjustment
Possible need for future plate removal
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