Mandibular fracture , also known as jaw fracture , is a breakthrough through the mandibular bone. About 60% of cases occur in two places. This can lead to a decrease in the ability to open the mouth completely. Often the teeth will not feel in tune properly or there may be bleeding in the gums. Mandibular fractures are most common in men in their 30s.
Mandibular fractures are usually the result of trauma. This can include falling to the chin or being hit from the side. Rarely they may be caused by osteonecrosis or tumors in bone. The most common fracture areas are condylus (36%), body (21%), angle (20%) and symphysis (14%). While diagnosis can sometimes be done with ordinary X-rays, modern CT scans are more accurate.
Immediate surgery is not necessary. Sometimes people can go home and follow up for surgery in the next few days. A number of surgical techniques may be used including maxillomandibular fixation and internal reduction reduction (ORIF). People often take antibiotics like penicillin for a short period of time. Evidence to support this practice; However, poor.
Video Mandibular fracture
Signs and symptoms
General
So far, the two most common symptoms described are the pain and the feeling that the teeth no longer meet properly (traumatic malocclusion, or disocclusion). The teeth are very sensitive to pressure (proprioception), so even small changes in the location of the teeth will produce this sensation. People will also be very sensitive to touching the broken jaw area, or in case of a condyle fracture in the area just in front of the tragus of the ear.
Other symptoms may include loose tooth (teeth on both sides of the fracture will feel loose due to fracture), numbness (because the inferior alveolar nerve runs along the jaw and can be compressed by the fracture) and trismus (difficulty opening the mouth)).
Outside the mouth, signs of swelling, bruising and deformities can all be seen. The deep condyle fracture, so rarely significant swelling though, trauma can cause bone fracture on the anterior aspect of the external auditory meatus so that bruising or bleeding can sometimes be seen in the ear canal. Oral opening can be reduced (less than 3 cm). There may be sensation of numbness or alteration (anesthesia/paresthesias in the chin and lower lip (mental nervous distribution).
Intraorally, if a fracture occurs in a tooth cavity area, a possible step between the teeth on both sides of the fracture or space may be seen (often mistaken for missing teeth) and bleeding from the gingiva in the area. There can be an open bite where the lower teeth, no longer fill the upper teeth. In the case of unilateral unilateral fracture the back teeth on the fracture side will meet and the open bite will be greater towards the other side of the mouth.
Sometimes a bruise will develop at the bottom of the mouth (sublingual eccymosis) and the fracture can be moved by moving both sides of the fracture segment up and down. For fractures that occur in areas of non-tooth bearings (condyls, ramus, and sometimes angles), open bite is an important clinical feature because nothing else, other than swelling, can be seen.
Condylar
This type of fractured mandible may involve a condyle (unilateral) or both (bilateral). Unilateral condyle fractures can cause limited jaw movement and pain. There may be swelling in the region of the temporomandibular joint and bleeding from the ear due to laceration to the external auditory meatus. The hematoma can spread down and behind the back of the ear, which may be confused with the Battle sign (skull fracture mark), although this is an uncommon finding so if any, intra-skull injuries should be ruled out. If the bones break and collide then there may be a shortening of the height of the ramus. This causes choking teeth on the cracked side (teeth meet too fast on the cracked side, rather than on the non-cracked side, the "open bite" which gets worse to the unaffected side). When the mouth is opened, there may be a jaw distortion toward the cracked side. Bilateral condylar fractures can cause signs and symptoms above, but on both sides. Limited malocclusion and jaw movements are usually more severe. Body fractures or bilateral fractures are sometimes called "flail mandible", and can cause involuntary posterior motion of the tongue with subsequent obstruction of the upper airway. Transfer of the condyle through the roof of the glenoid fossa and to the middle cranial fossa is rare. Other rare complications of mandibular trauma include internal carotid artery injury, and obliteration of the ear canal due to posterior condyle dislocations. Bilateral condylar fractures combined with symphyseal fractures are sometimes called guard fractures. The name comes from this injury occurring on soldiers who fainted in the parade and attacked the floor with their chins.
Maps Mandibular fracture
Diagnosis
Ordinary film radiography
Traditionally, mandibular plain films will be exposed but have lower sensitivity and specificity due to overlapping structures. Views include AP (for parasymphsis), lateral tilt (body, ramus, angle, coronoid process) and views of Towne (condyles). Condyl fracture can be very difficult to identify, depending on the direction of displacement or dislocation of the condyle so that some views of it are usually examined with two views at an angle perpendicular.
Panoramic radiography
Panoramic radiography is a tomogram in which the mandible is located in the focal trough and shows a flat image of the lower jaw. Because the mandibular curve appears in 2-dimensional images, fractures are more readily found leading to accuracy similar to CT except in the condyle region. In addition, broken, missing or not straight teeth can often be rewarded on panoramic images that are often lost in regular films. The medial/lateral displacement of the fracture segment and especially the condyle is difficult to measure so that the view is sometimes coupled with ordinary film radiography or computed tomography for more complex mandibular fractures.
Computed tomography
Computed tomography is the most sensitive and specific imaging technique. The facial bone can be visualized as a skeletal incision in either axial, coronal or sagittal plane. Images can be reconstructed into 3-dimensional views, to provide a better picture of the displacement of various fragments. 3D reconstruction, however, can cover smaller fractures due to average volume, spreading artifacts and surrounding structures only blocking views of the underlying area.
Studies have shown that panoramic radiography is similar to computed tomography in its diagnostic accuracy for mandible fractures and both are more accurate than ordinary film radiography. Indications for using CT for mandibular fractures vary by region, but do not appear to increase diagnosis or treatment planning except for comatose or avulsive fractures, though, there is better physician agreement on site and no fracture with CT compared with panoramic radiography.
Classification
There are various mandibular fracture classification systems used.
Locations
This is the most useful classification, because both the signs and symptoms, and also the treatment depends on the location of the fracture. The mandible is usually divided into the following zones for the purpose of describing the location of the fracture (see diagram): condyle, coronoid process, ramus, angle of the lower jaw, body (molar and premolar areas), parasphisis and symphysis.
Alveolar
This type of fracture involves the alveolus, also called the mandible's alveolar process.
Condylar
The condyle fracture is classified by location compared to the ligamentous capsule that holds the temporomandibular joint (intracapsular or extracapsular), dislocations (whether or not the condyle head is out of the socket (glenoid fossa) because the muscles (lateral pterygoid) tend to attract the anterior and medial condyle) and neck fracture of the condyle. For example. fracapsular, non-displaced, neck fracture. Pediatric condyle fractures have specific protocols for management.
Coronoid
Because the mandibular coronoid process lies deep into many structures, including the zygomatic complex (ZMC), rarely breaks in isolation. Usually occurs with other mandibular fractures or with complex fractures or zygomatic arches. Fractures isolated from coronoid processes should be seen with suspicion and fractures of ZMC should be ruled out.
Ramus
The fracture of the ramus is said to involve an area inferiorly bounded by a longitudinal slant from the third molar region (the molars) to the posteroinferior attachment of the masseter muscle, and which can not be better classified as a condyle or coronoid fracture.
Angle
The mandibular angle refers to the angle created by the body's mandibular and ramus arrangements. Angular fracture is defined as a fracture involving a triangular region bounded by the anterior border of the masseter muscle and a slash extending from the third molar region (wisdom tooth) to the posteroinferior attachment of the masseter muscle.
Body
Fractures of the mandibular body are defined as those involving an area bounded anterior by parasymphysis (defined as the vertical line only distal tooth canines) and posteriorly by the anterior margin of the masseter muscle.
Parasymphysis
Parasymphyseal fractures are defined as mandibular fractures involving an area bilaterally bounded by vertical lines right next to the canine teeth.
Symphysis
Symphyseal fractures are linear fractures that travel in the midline of the mandible (symphysis).
Fracture type
Mandibular fractures are also classified according to the categories that describe the condition of bone fragments at the site of the fracture and also the communication with the external environment.
Greenstick
Greenstick fracture is an incomplete flexible bone fracture, and for this reason it usually only occurs in children. This type of fracture generally has limited mobility.
Simple
A simple fracture represents complete transection of the bone with minimal fragmentation at the site of the fracture.
Comminuted
The opposite of a simple fracture is a comminuted fracture, in which the bone has crumbled into a fragment, or there is a secondary fracture along the main fracture line. High-speed injuries (eg caused by bullets, explosive device explosives, etc...) will often cause comminuted fractures.
​​â € <â €
A joint fracture is one that communicates with the external environment. In the case of mandibular fracture, communication can occur through the skin of the face or with the oral cavity. A mandibular fracture involving the jawbone part of the jaw is by the definition of a compound fracture, since there is at least some communication through periodontal ligaments with the oral cavity and with more shifting fractures there may be frank tears of the gingival and alveolar mucosa.
Dental engagement
When a fracture occurs in the mandibular tooth part, whether or not it is dentate or edentulous will affect the treatment. Dental care helps stabilize the fracture (either during osteosynthesis placement or as a treatment by itself), so the lack of teeth will guide the treatment. When the edentulous mandible (no tooth) is less than 1 cm high (as measured by panoramic radiography or CT scan) the added risk applies because the flow of blood from the marrow (endosseous) is minimal and the healing bone must depend on the blood supply from the periosteum surrounding the bone. If fractures occur in children with different dental treatment protocols are required.
Other fractures of the body, classified as open or closed. Because fractures involving teeth, by definition, communicate by mouth, this difference is largely lost to mandibular fractures. Condyl, ramus, and coronoid process fractures are generally closed while angular, body and parasymic fractures are generally exposed.
Moving
The extent to which segments are separated. The greater the separation, the harder it is to bring them back together (estimate the segment)
Favorability
For the angle and fracture of the posterior body, when the angle of the fracture line is tilted backward (more posterior to the top of the jaw and more anteriorly at the bottom of the jaw) the muscles tend to carry the fracture segments together. This is called profitable. When the angle of the fault points forward, it is not profitable.
Age fracture
While mandibular fractures have similar rates of complications either treated promptly or a few days later, older fractures are believed to have higher levels of non-union and infection although the data on this make it difficult to draw strong conclusions.
Treatment
Like all fractures, consideration should be given to other diseases that may harm the patient, then to reduce and fix the fracture itself. Except for avuliform type injuries, or where there may be airway compromises, a few days delay in the treatment of jaw fractures appears to have little impact on outcomes or complication rates.
General considerations
Because the mandibular fracture is the result of blunt object trauma on the head and face, other injuries need to be considered before the mandibular fracture. First and foremost is a compromise of the airway. While rare, unstable bilateral mandibular fractures can cause the tongue to fall back and block the airway. Fractures such as symphyseal or bilateral parasymphyseal can cause mobility of the central portion of the mandible where the genioglossus is attached, and allow the tongue to fall back and block the airway. In larger fractures, or from high-speed injuries, soft tissue swelling can block the airway.
In addition to the potential of airway compromise, the force given to break the jaw can be good enough to break the cervical spine or cause an intra-skull injury (head injury). It is common for both to be assessed with facial fracture.
Finally, vascular injury may occur (with special attention to the internal carotid and jugularis) of high-speed injury or mandibular fractures that are sedentary.
Loss of consciousness combined with aspiration of tooth fragments, blood and possibly dentures means that the airway can be threatened.
Reductions
Reduction refers to the broken bony ends approach. This is done by an open technique, where an incision is made, a fracture is found and manipulated physically into place, or a closed technique in which no incisions are made.
The mouth is unique, because the teeth are securely fastened to the end of the bone but come through the epithelium (mucosa). The legs or wrists, for example, do not have such structures to help with closed reduction. In addition, when the fracture occurs in the jawbone tooth area, aligning the teeth well usually produces a fracture segment alignment.
To align the teeth, the circumdental wiring is often used in which the wire strands (usually 24 gauge or 26 gauge) are wrapped around each tooth then affixed to the stainless steel curved rod. When the upper (upper) and lower jaw (lower jaw) teams are aligned together, this brings the fracture segment into place. Higher technological solutions are also available, to help reduce segments with curvature using bonding technology.
Fixation
A simple fracture is usually treated with closed reduction and indirect skeletal fixation, more commonly referred to as maxillary-mandibular fixation (MMF). Closed reduction described above. Indirect skeletal fixation is achieved by placing a bar arch, secured to the teeth on the maxillary and mandibular teeth, then securing the upper and lower arch bars with the wire loop.
Many alternatives exist to secure the maxillary tooth teeth and mandibles including resin bonded bar arches, Ivy loops (small hole wire), orthodontic bands and MMF bone screw where titanium screw with holes in their heads are screwed into the jawbone of the jaw. then secured with a wire.
Closed reduction with direct skeletal fixation follows the same premise as MMF except that the cable is passed through the skin and around the mandibular mandible and through the piriform rim or zygomatic support of the upper jaw and then joins together to secure the jaw. This choice is sometimes used when the patient is edentulous (has no teeth) and rigid internal fixation can not be used.
Open reduction with direct skeletal fixation allows the bone to be directly in the mandible through the incision so that the cracked ends meet, then they can be secured together rigidly (with screws or plates and screws) or not rigid (with transosseous wire). There are many combinations of plates and screws including compression plates, non-compression plates, lag-screws, mini-plates and biodegradable plates.
External fixation, which can be used with open or closed reduction using a pin system, where a long screw is passed through the skin and to one side of the fracture segment (usually 2 pins per side) is then secured in place using an external fixator. This is a more general approach when the bone is heavily caught (broken into small pieces, eg in bullet wounds) and when the bone is infected (osteomyelitis).
Regardless of the method of fixation, bone needs to remain relatively stable for a period of 3-6 weeks. On average, bones get 80% of their strength for 3 weeks and 90% of it by 4 weeks. There are great variations depending on the severity of the injury and the health of the wound and the patient
Recent clinical evidence
The 2013 Cochrane Review assesses clinical studies on surgery (open reduction) and non-surgical (closed reduction) mandibular fracture management that does not involve the condyle. This review finds insufficient evidence to recommend the effectiveness of any single intervention.
Special considerations
Condyle
The best treatment for condyle fracture is controversial. There are two main options, namely closed reduction or open reduction and fixation. Closed reduction may involve intermaxillary fixation, in which the jaws are put together in the correct position for several weeks. Open reduction involves surgical exposure of a fracture site, which can be done through an incision in the mouth or an incision outside the mouth above the condyle area. Open reduction is sometimes combined with endoscopic use to help visualize fracture sites. Although closed reduction carries the risk of healing bone out of position, with bite-induced changes or the formation of facial asymmetry, it does not risk temporary damage to the facial nerve or produce a facial scar accompanying open reduction. The systematic review can not find sufficient evidence of the superiority of one method over another in the management of the condyle fracture. Pediatric condyle fractures are particularly problematic, because of the potential for remaining growth and possible joint ankylosis. Early mobilization is often recommended as in Walker's protocol.
Edible mandibula
A broken jaw that has no teeth in it faces two additional problems. First, the lack of teeth makes reduction and fixation using a difficult MMF. Instead of placing the circumdental cord around the tooth, existing dentures can be left on (or splints, a kind of temporary denture) and mandibles glued to the upper jaw using skeletal fixation (circumlocular and circumzygomatic wires) or using MMF bone screws. More commonly, open reduction and rigid internal fixation are placed.
When the width of the lower jaw is less than 1 cm, the jaw loses its endosteal blood supply. In contrast, the blood supply mostly comes from the periosteum. Open reduction (which is usually a periosteum strip during surgery) can cause avascular necrosis. In this case, the oral surgeon sometimes selects external fixation, closed reduction, supraperiosteal dissection or other techniques to maintain periosteal blood flow.
High speed injuries
In high-speed injuries, soft tissue can be severely damaged away from the bullet wound itself due to hydrostatic shock. Because of this the airway should be carefully managed and the vessels examined properly. Because the jaw can be very comminuted, MMF and rigid internal fixation can be difficult. In contrast, external fixation is often used , .
Pathological Fracture
Fractures in which large cysts or tumors are present in the area (and weaken the jaw), where there is an area of ​​osteomyelitis or where osteonecrosis exists leads to special challenges for fixation and healing. Cysts and tumors can limit bone contact to the effective bone and osteomyelitis or osteonecrosis compromises the blood supply to the bone. In all situations, healing will be delayed and sometimes, resection is the only alternative to treatment.
Prognosis
The healing time for routine mandibular fracture is 4-6 weeks whether MMF or rigid internal fixation (RIF) is used. For comparable fractures, patients receiving MMF will lose weight and take longer to regain mouth opening, whereas, those receiving RIF have higher rates of infection.
The most common long-term complications are loss of sensation in the mandibular nerve, malocclusion and tooth loss in the fracture line. The more complicated the fracture (infection, comminution, displacement) the higher the risk of fracture.
The condyle fracture has a higher rate of malocclusion which in turn depends on the degree of displacement and/or dislocation. When intracapsular fracture there is a higher rate of long-term osteoarthritis and the potential for ankylosis although later it is a rare complication during early mobilization. Pediatric condyle fractures have higher rates of ankylosis and potential growth disturbances. ,
Rarely, a mandibular fracture can cause Frey's syndrome.
Epidemiology
The fracture of the mandible causes variation based on the time period and area under study. In North America, blunt trauma (blow) is a major cause of mandibular fracture whereas in India, motor vehicle collisions are now a major cause. On the battlefield, it is more likely to be a high-speed injury (bullets and shrapnel). Prior to the routine use of seatbelts, airbags and modern security measures, motor vehicle collisions are a major cause of facial trauma. The association with blunt trauma forces to explain why 80% of all mandibular fractures occur in men. A mandibular fracture is a rare complication of third molar extraction, and may occur during the procedure or thereafter. In relation to trauma patients, about 10% had some type of facial fracture, most of which came from motor vehicle crashes. When the person is not confined in the car, the risk of fracture rises 50% and when unwanted motorcyclists, the risk increases 4-fold.
History
Mandibular fracture management was mentioned in the early 1700 BC. at Edwin Smith Papyrus and later by Hippocrates in 460 BC, "Displaced but an incomplete mandibular fracture in which the continuity of the preserved bone should be reduced by pressing the lingual surface with the fingers...". The open reduction was described in early 1869. Since the late 19th century, modern techniques including MMF (see above) have been described with rigid-based internal fixation of titanium being common since the 1970s and biodegradable plates and screws available since the 1980s.
References
External links
Source of the article : Wikipedia
0 Comments