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FRACTURAS

MANDIBULARES

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36%

2%

25%

20%

3%

14%

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Mandibular Stresses

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Bite

Force

Muscle pull

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Tension band (monocortical), Champy, MMF or interdental wiring

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monocortical

bicortical

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Tension band (monocortical), Champy, MMF or interdental wiring

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Anatomy Principles, BoneHealing, SurgicalApproaches and DCP

Principles

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Objectives

Review anatomy

Discuss bone healing

Explore principles of stable internalfixation

Delineate load sharing vs load bearing

osteosynthesis Review mandibular surgical approaches

Discuss proper plating techniques

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Adult panorex

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Child Panorex

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Bone Healing

Primary Secondary

No callus Callus

Direct bridging osteons

Bony deposition

Remodeling

Fracture hematoma

Progenitor deposition

Differentiation

Reduced risk for fibrous

malunion

Elevated risk for fibrous

malunion

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Bone Healing

Primary

Adequate stability

Secondary

Inadequate stability

No callus Callus

Direct bridging osteons

Bony deposition

Remodeling

Fracture hematoma

Progenitor deposition

Differentiation

Reduced risk for fibrous

malunion

Elevated risk for fibrous

malunion

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Bone Healing

How do we assure stability of fracture line?

1. Control of tension zone.

2. Fixation of compression zone.

3. Achieving appropriate occlusalrelationship.

4. All of the above.

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Bone Healing

How do we assure stability of fracture line?

1. Control of tension zone.

2. Fixation of compression zone.

3. Achieving appropriate occlusalrelationship.

4. All of the above.

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Control of mandibular stresses

Zone of Tension

Zone of Compression

Load Sharing Fixation

Load Bearing Fixation

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Load sharing vs Load bearingAbsolute bone-bone

contact in fracture line

Gaps in bone-bone

interface

Plate distributes

mandibular forces to

BONE

Miniplates adequate

Mandibular forces borne

by PLATE

Need strong plate

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Approaches

MMF Arch bars Ivy loops Circumandibularwires

Circumpiriform wires Ernst ligatures MMF screws

ORIF condyle

Endoscopic assist Open

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Approaches

Intraoral/buccalsulcus incision

Avoidance/preservation of mental nerve

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Approaches

ORIF Risdon incision

Extended risdon

Transbuccal trocarwith intraoralincision

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Approaches

MMF Arch bars

Ivy loops

ORIF Risdon incision

Intraoral/buccalsulcus incision

External fixator

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Case examples

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Naso-Orbital-Ethmoid Fracture

Central midline impact

Nasal fracture

Medial orbital fracture of medial canthaltendon bearing area

Ethmoid fracture

Telecanthus

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NOE

Type 1: Large attached fragment to MCTand stable central segment

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NOE

Type 2: Large attached fragment to MCTand cominuted central segment

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NOE

Type 3: Comminuted fragments withunattached MCT and comminuted centralsegment

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Fixation

Type 1 and some type 2 : miniplatereduction of large fragment with attached

MCT Type 3 or bilateral: Transnasal wiring

(difficult)

Anterior displacement of tendon and soft tissue

Usually err on placing canthus too low

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Thank you

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Difficult Cases