Mandible Fracture 01 31 08

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Thursday Morning Conference01/31/2008

Paul K. Holden, MD

UC IrvineUC IrvineOtolaryngology-Head & Neck Otolaryngology-Head & Neck

SurgerySurgery

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Case PresentationCase Presentation

You are called to assess a patient in the trauma bay s/p fall from motorcycle onto his face.

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Exam FindingsExam Findings

ABC – talking, slurred speech, hemodynamically stable.

Extensive degloving chin laceration communicates with oral cavity. Some dental step-off, obvious malocclusion.

No neck swelling or soft tissue injury.

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Additional Concerns?Additional Concerns?

Intoxication? Head Injury?

C-spine

“Open” fracture

Missing teeth? WHERE ARE THEY?

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Rest of ExamRest of Exam

PERRL/EOMi, no raccoon eyesMidface Stable, no septal hematoma, no

step-offs in midfaceFresh blood occluding EACs bilaterallyMalocclusion, 1.5 cm MICD due to painEcchymosis under tongue with minimal

retrodisplacement. FOL – airway clear.

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Studies DoneStudies Done

CT Head w/o contrast (very limited view)CT Face Axial/Coronal w/ 3-d recons

Prefer preoperative mandible series with panorex…why?

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Mandible FractureMandible Fracture

Very often more than one fracture present

May result in airway compromise (acute or delayed)

Elevated risk of c-spine injury

Almost always considered contaminated

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Immediate ManagementImmediate Management

Rule out other significant injury including brain and c-spine

Monitor for airway issues – repeat exam (may include FOL), monitored bed

Start antibiotics immediately (what type?)Pain managementDocument CN function (esp inf alveolar)

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Surgery

Considerations In Mandible Considerations In Mandible FxFx

Much of the morbidity of these injuries is attributed to improper management.

Infection risk increases with passage of time, substantially higher after 72h.

Risks of nonunion, malunion, malocclusion, plate fracture, plate extrusion, TMJ fixation, jaw restriction, poor cosmetic outcome

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Steps to Avoid ProblemsSteps to Avoid Problems

Proper diagnosisConsider Co-morbid ConditionsConsider Patient Personality/OccupationProper management plan for the

circumstancesProper technique (MMF, bending, drilling,

screw placement, nerves, tooth roots)When in doubt, use a LARGER plate.

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Concepts in ReductionConcepts in Reduction

Patient’s baseline occlusion is first priority.Class I, II, III … Crossbite?Observe wear facetsDo not force class I if it doesn’t line up with

wear facets.Verify occlusion at beginning, mid, end of

case. Remove MMF to verify if necessary.

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Surgery

Plate TypesPlate Types

What is…– A tension band?– A compression plate?– A lag screw?– A recon (UF) plate?– A locking plate?– Load sharing vs. load bearing plate?

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Know Champy LinesKnow Champy Lines

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Fracture TypesFracture Types

Condylar / SubcondylarRamusAngleBodyParasymphasealSymphasealAlveolar Ridge

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Type and ManagementType and Management

Symphaseal 2.0 L Compression + TB Lag Screws

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Type and ManagementType and Management

Comminuted Symphaseal 2.4 Locking Recon Plate + TBLeft Subcondylar

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Type and ManagementType and Management

Parasymphaseal Two Miniplates?

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Type and ManagementType and Management

Comminuted Parasymphaseal 2.4 Locking Recon Plate with TB

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Type and ManagementType and Management

Comminuted Body/Parasymph 2.4 Locking Recon Plate with MPs

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Type and ManagementType and Management

Symphaseal and Angle, 3rd Molar Single Champy MP at Angle

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Type and ManagementType and Management

Disloc Angle w/ Basal Triangle 2.4 Locking Recon Plate with 2.0 MP

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Special CaseSpecial Case

Edentulous Body Fracture 2.4 Locking Recon Plate, 4 screws

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Another Special CaseAnother Special Case

Infected Angle Fracture 2.4 Locking Recon Plate

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Other Special CasesOther Special Cases

Bilateral Parasymphaseal – Geniohyoid origin lost, tongue prolapses into airway.

Bilateral subcondylar – prone to TMD, loss of height, retrusion and increased width of mandible.

Pediatric Fractures – remove plates or use absorbable, minimize MMF.

Loss of Bone – from infection, severe trauma or nonunion.

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Controversies/DifficultiesControversies/Difficulties

When to perform ORIF on subcondylarTooth in the fracture lineStops for unilateral subcondylarMissing Teeth (but not edentulous)When to go extra-oral routeHow long to continue abx postop (Ali?)

U.C. Irvine - Otolaryngology-Head & Neck

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Back to Our PatientBack to Our Patient

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

Back to Our PatientBack to Our Patient

Comminuted Symphaseal

High right subcondylar fracture/dislocation

Non-displaced left subcondylar fracture

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

U.C. Irvine - Otolaryngology-Head & Neck

Surgery

No Mas!No Mas!