This is my topic about recent advancements in managment of mandibular fractures till 2016.Credits to oral and maxillofacial surgery.

2. RECENT ADVANCES IN
MANAGEMENT OF MANDIBULAR
FRACTURES
DONE BY
R.G.ASHWANTH DEEPAK
CRRI

3. INTRODUCTION
• Mandible is a strong bone,force requiring to
fracture ranges from 44.6 to 74.4 kg/m yet
mandible gets mostly fractured because of its
anatomical postion in the maxillofacial region.

4. Anatomy

6. BLOOD SUPPLY

7. NERVE SUPPLY

8. Muscle attachment

9. Signs and symptoms
• Pain
• Swelling
• Ecchymosis
• Jaw stiffness
• Trismus
• Open bite
• Airway blockage
• bleeding

10. CLASSIFICATION
DINGMAN AND NATVIG CLASSIFICATION
based on anatomic region
1.Symphysis#(midline #)
2.Parasymphysis#(canine#)
3.Body of mandible#
(between canine and angle#)
4.Angle region#
5.Ramus#
6.Coronoid#
7.Condylar#
8.Dentoalveolar#
Classification: Kruger,Rowe and Killey,Dingman and natvig.

11. 1.favourable:
a.Horizontally favourable
b.Vertically favorable
2.unfavourable:
a.Vertically unfavourable
b.Horizontally unfavourable

12. HISTORY
1844 ERICH AND AUSTIN PREANTIBIOTIC ERA,CLOSED REDUCTION
1847 BUCK TRANSOSSEOUS SILVER WIRING
1943 CORDON WIRE SUTURING,STAINLESS STEEL INTRAOSSEOUS
WIRING PLUS MMF
1970 SPIESSEL AO/ASIF-COMPRESSION PLATE
1973 MICHELET NONCOMPRESSION MONOCORTICAL SCREWS WITH
MINIPLATE SYSTEM
1978 CHAMPY IDEAL OSTEOSYNTHESIS LINES

13. MANAGEMENT OF MANDIBULAR FRACTURS IN ADULTS
CURRENT LINE OF TREATMENT
• The purpose of all therapy of fracture is
restoration of original from and function.
• SURGICAL APPROACH
• REDUCTION
• FIXATION
• IMMOBILIZATION

14. SURGICAL APPROACH
CURRENT TECHNIQUE
• PROPER INCISION
(BLADE AND ELECTRO CAUTRY)
• USE OF PRE EXSISTING LACERATION
a)INTRA ORAL APPROACH:
*SYMPHYSIS AND PARASYMPHYSIS-DEGLOVING INCISION
*BODY,ANGLE,RAMUS-TRANS BUCCAL INCISION
*INTRA ORAL APPROACH TO CONDYLE
b)EXTRA ORAL
*SUB MANDIBULAR-RISDON’S INCISION
*SUB MENTAL,SUB MANDIBULAR,RETRO MADIBULAR
*Facelift (rhytidectomy) approach
*PRE AURICULAR APPROACH

15. DEGLOVING INCISON
TRANSBUCCAL INCISION
RISDON’S INCISON

16. LACERATIONS
SUB MENTAL APPROACH
FACE LIFT
APPROACH
PRE AURICULAR
INCISION

17. SURGICAL APPROACH- LASERS IN INCISION
• LIGHT AMPLIFICATION BY STIMULATED
EMISSION OF RADIATON
• MONOCHROMATIC AND COHERENT
ADVANTAGES:
• INCRESED BONE HEALING
• REDUCED RISK OF INFECTION
• LESS NEED OF ANAESTHESIA
• LESS BLEEDING,NOISE,POST OP PAIN
• BETTER RESULTS

18. # REDUCTION
COVENTIONAL TECHNIQUE
1.CLOSED REDUCTION
a)EXTERNAL REDUCTION DEVICES
b)INTRAORAL AND EXTRAORAL
TRACTION
2.OPEN REDUCTION
a) RIGID AND NON RIGID FIXATION

19. EXTRA ORAL TRACTION
EXTRA ORAL REDUCTION DEVICES

20. CLOSED REDUCTION RECENT
ADVANCEMENTS
Hollow 18-gauge needle taken from intravenous
cannula for pediatric patients
Instead of coventional arch bar
An indigenous method for closed reduction of pediatric
mandibular parasymphysis fracture

21. FIXATION(conventional methods)
1.INDIRECT FIXATION(CLOSED FIXATION):
• INTERMAXILLARY FIXATION OR MAXILLOMANDIBULAR FIXATION
• CRANIOMAXILLARY OR MANDIBULAR SUSPENSION
• EXTERNAL FIXATION
2.DIRECT FIXATION(INTERNAL FIXATION):
• SEMIRIGID FIXATION:
a)TRANSOSSEOUS WIRING
b)NONCPMPRESSION MINIPLATES
• RIGID FIXATION:
a)COMPRESSION PLATES
b)LAG SCREWS
c)RECONTRUCTION PLATES

22. INTERMAXILLARY
FIXATION
MANDIBULAR
SUSPENSION
EXTRA ORAL
TRACTION TRANSOSSOEUS
WIRING MANDIBLE
NON
COMPRESSION
MINI PLATES
COMPRESSION PLATES

23. LAG SCREWS
RECONTRUCTION
PLATES
GUNNING SPLINT

24. Champy’s ideal lines of osteosynthesis
• Champy performed a series of experiments
with miniplate that delineated “ideal lines of
osteosynthesis”within the mandible,they are
the ideal areas for plates and screws
placement.

25. • Masticatory muscles produce tension
at upper border and compression at
lower border.
• Torsional forces produced anterior to
the canines
• Monocortical “tension banding “ osteosynthesis
neutralizes distraction and torsion during physiologic
stress,while normal basilar compression is restored

26. Conventional technique
• https://www.youtube.com/watch?v=lnySz_zn
ca0

27. RECENT ADVANCEMENTS IN FIXATION
1.BIO RESORBABLE PLATES
2.THREE DIMENTONAL PLATES

28. CONSEQUENCES OF NOT
REMOVING THE PLATE
1) PALPABLE OR PROMINENT
HARDWARE
2) LOOSENING OF PLATES AND
SCREWS
3) PAIN
4) INFECTION
5) WOUND DEHISCENCE
6) THERMAL SENSITIVITY
7) PLATE MIGRATION

29. BIO RESORBABLE PLATES
• DESPITE TITANIUM PLATES AND SCREWS BEING GOLD STANDARD IT HAS
FEW DISADVANTAGES AS FOLLOWS(ESPECIALLY RIGID FIXATION):
1) GROWTH DISTURBANCE
2) PLATE MIGRATION
3) NEED FOR SUBSEQUENT REMOVAL
4) INCOMPATIBLITY WITH FUTURE IMAGING NEEDS
5) LONG TERM PALPABILITY
6) THERMAL SENSITIVITY
7) MALUNION
8) DIFFICULTY IN CONTROLLING POST OPERATIVE OCCLUSION

30. CHEMICAL COMPOSITION:
A)Polyglycolic acid
B)Polylactic acid
C)Polyesterspolyparadioxanon
ALPHA
compounds

31. • FEATURES :
1) INCREASED TENSILE AND FLEX STRENGTH
2) EASILY ADAPT
3) VARIETY OF SIZES AND SHAPES
4) HEX DRIVE BREAK AWAY DELIVERY SYSTEM
SIMPLIFIES SCREW PLACEMENT
5) ELIMINATES GROWTH RESTRICTION AND
IMPLANT MIGRATION
6)RESORB COMPLETELY AND ELIMINATES SECOND
SURGERY
7)NO LATE STAGE INFLAMMATORY REACTION

32. • Biodegradable plate are strong,biocompatible,adaptable and
has enough stability
• Resorb quickly without any foreign body reaction.

33. • MECHANISM OF ACTION:
BIORESORBABLE PLATES
METABOLIZED BY LIVER
BULK HYDROLYSIS(COVERT INTO CO2 AND H2O)

34. ADVANTAGES
• SMALL
• BIOCOMPATIBLE
• ADAPTABLE
• ADEQUATE STABILITY TO ACHIEVE BONE
UNION
• RESORBS IN TIMELY FASHION

35. TITANIUM VS BIODEGRADABLE PLATES
TITANIUM PALTES BIO DEGRADEBLE PLATES
HARD AND STRONG SOFTER AND WEAKER
FIRM TIGHT PRESSURE FINGER TIGHT PRESSURE
RADIOGRAPHICALLY APPARENT NOT RADIOGRAPICALLY APPARENT
USES
• FRACTURE FIXATION IN TOOTH BEARING REGION
• A BONE ANCHORED METHOD OF MAXILLOMANDIBULAR
FIXATION
• VERY LOW LOAD BEARING AREAS
• PEDIATRIC CRANIOFACIAL OSTEOTOMU FIXATIONS

36. BIO RESORBABLE PLATE FIXATION
• STEP 1: HEATING THE PALATE AND BENDING
• STEP 2:PRE TAPPING SCREW HEADS BEFORE
TAPPING

37. BIO RESORBABLE CERAMIC MATERIALS
• European Research Project Develops New
Resorbable Bioceramic Materials
#They closely match the mechanical
requirements of the implant sites
http://www.odtmag.com/contents/view_videos
/2016-04-01/european-research-project-
develops-new-resorbable-bioceramic-materials

38. Three dimensonal mini plates
• They are known for their good stability due to the
closed quadrangular geometric shape.
• Ease of contouring and adapting
• Better inter fragmentary stability

39. • No need for supplementary fixation
• Immediate post op jaw fixation
• Minimal surgical exposure
• Decresed periosteal stripping
• Decreased hardware
complications.

40. • Plating System
• Plates
• Design:
• Square plate (1 cm × 1 cm)
• Rectangular plate (1 cm × 0.5 cm)
• Continuous Square or Double Square
(2 cm × 1 cm)

41. Continuous rectangle or double rectangle
(2 cm × 0.5 cm)
Double rectangle with an intervening square
(2 cm × 1 cm)
Diameter of plate hole: 2 mm
Thickness: 1 mm (Standard plates)

42. • The treatment of mandibular fractures
(symphysis, parasymphysis, and angle) with 3-
dimensional plates provided 3-dimensional
stability and carried low morbidity and
infection rates.
• The only probable limitations of 3-dimensional
plates were excessive implant material due to
the extra vertical bars incorporated for
countering the torque forces.

43. IMMOBILISATION
• INTERMAXILLARY FIXATIONOR
MAXILLOMANDIBULAR FIXATION
• AVERAGE RECOMMED TIME FOR
IMMOBILISATION: 6WEEKS FOR ADULTS(TILL
BONY CALLUS STAGE OF SECONDARY BONE
HEALING

44. MANGEMENT OF FRACTURE NON
UNION OR
MALUNIONS(ADVANCEMENTS)

45. RECOMBINANT BONE MORPHOGENIC
PROTIEN
• BMPs are subfamily if TGF-𝑏𝑒𝑡𝑎 super family
• BMPs derived from osteoblasts,chondrocytesand platelets
• BMPs induce osteogenisis,chondrogenesis and angiogenisis
and extracellularmatrix
• Thus they induce denovo bone synthesis at the site where
they are implanted.
OSTEOINDUCTIVE PROPERTIES:
• Mesenchymal cell infiltration
• Cartilage formation
• Vascularisation
• Bone formation
• Remodelling of new bone

46. Complicatiions:
• Exaggerated inflammatory response
• Ectopic bone formation
• Non responders

47. ALLOPLASTIC GRAFTS
• Alloplastic grafts are made from hydroxyapatite,
a naturally occurring mineral (main mineral
component of bone), made from bioactive glass.
• Hydroxyapatite is a synthetic bone graft, which is
the most used now due to its osteoconduction,
hardness, and acceptability by bone.
• properties:
1. resorbable in long run.
2. Osteogenic potential.
3. Bioactive.

48. Osteoconduction
•Osteoconduction occurs when the bone graft material
serves as a scaffold for new bone growth that is
perpetuated by the native bone.
•Osteoblasts from the margin of the defect that is being
grafted utilize the bone graft material as a framework upon
which to spread and generate new bone.

49. Types of alloplastic materials
• Dimethysiloxane(silicone):
Parasymphyseal and symphyseal non unions
• Polytetrafluoroethylene
• Polyethelene
• Polyesters
• Acrylics: polymethyl methacrylate,hard tissue
replacement,bioplant hard tissue replacement
• Calcium phosphate ceramics

50. Bone healer and graft enhancer
• PRP gel: Platelet rich plasma
It is a caogulated platelet made from persons
own blood bycentrifugation,sequesteration
and concerntation platelets.
Preparation:

51. Stem cells
• One of the human body's master cells, with the ability to grow into
any one of the body's more than 200 cell types
• Bone marrow stem cells
Hybrid graft
Enhance oesteogenic potential
• Coral scaffold +marrow stomal cells=tissue engneered artificial
bone.