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Comprehensive surgical management of mandibular fractures.

Mandibular fractures are common facial injuries. Classifications are combined and correlated with specific treatment modalities. Combined classification of fractures indicates the difficulty of treatment required. Many surgical techniques have been used and accepted as proper methods for reduction and fixation of mandibular fractures. Most studies advocate one technique as superior to others. The range of procedures now available include observation, closed reduction with maxillomandibular fixation, transoral reduction, intraosseous wire fixation, miniplate rigid osseous fixation, compression rigid osseous fixation, and external skeletal fixation. Our evaluation of the specific advantages of each modality indicates that selection of a specific procedure is individualized according to combined classification of the mandibular fracture, the surgical procedure's advantages and disadvantages, the patient's desires, and the surgeon's ability and clinical judgment. Case presentations demonstrate the principles involved in comprehensive surgical management of mandibular fractures. The techniques advocated produce anatomic reduction and restoration of physiologic function and aesthetics, with rare complications.

Adolescent

Experience with the treatment of mandibular fractures.

Mandibular fractures belong to the most frequent injuries of the facial skeleton. The present study is a report on 770 patients treated from 1977 to 1986 at the Third Clinic of Stomatology with special regard to healing complications and their causes.

Adolescent

[Subcondylar mandibular fracture].

Mandibular fractures are frequent lesions which are classified into 6 groups according to the site of the fracture. Condylar fractures are primarily due to a direct blow to the symphysis menti. Medical imaging must be able to identify the type of fracture, its intra- or extra-articular site and the associated displacement of the condyle, the fundamental element in deciding treatment. The action of the masticatory muscles on one of the bone fragments may be responsible for an unstable fracture, leading to disturbances of consolidation (pseudarthrosis). Anterior bilateral fractures can be life-threatening due to ptosis of the tongue.

Adult

The fate of developing teeth in facial trauma: tooth buds in the line of mandibular fractures in children.

Mandibular fractures in children present the surgeon with a unique set of considerations. Tooth buds within the body and ramus of the mandible restrict the type of surgical intervention that may be used. In addition, the fate of nonerupted dentition in the direct line of the fracture remains unclear. Between July 1985 and June 1990, 30 patients in deciduous or mixed dentition presented with a total of 45 mandibular fractures. Of these 45 fractures, 33% (n = 15) involved 16 nonerupted teeth. Age at the time of fracture was 6.0 +/- 2.3 years (mean +/- SD). Thirty-three percent of patients were treated with open reduction and internal fixation of fractures; 67% of patients were treated with closed reduction and either intermaxillary fixation or a lingual splint. Normal eruption was exhibited by 82% (n = 9) of the tooth buds in the line of mandibular fracture. The results of this study indicate the following: (1) Mandibular fractures in children involve unerupted teeth directly in one-third of cases. (2) The majority of tooth buds (82%) in the line of mandibular fractures eventually erupt normally. And (3) a significant percentage of dentition (18%) may exhibit either delayed eruption or noneruption with resorption of the tooth bud if directly involved in the line of fracture.

Child

Pediatric mandibular fractures.

In spite of curiosity, facial fractures, particularly mandibular fractures, in the pediatric age group embrace only a modest proportion of facial fractures that occur within the general population. Several large series report an overall incidence of approximately 1% of all facial bone fractures. A considerable volume of literature has been generated describing the pattern of injury and treatment modalities for pediatric facial bone fractures. At our institution, which is an extremely busy university-based regional trauma center, we have witnessed a persistent escalation in the number of patients requiring repair of their facial bone fractures. During the period of January 1989 through January 1990, we treated a total of 204 patients for repair of mandible fractures. An analysis of the records of this group revealed only 3 patients who were younger than 4 years of age and 2 additional patients younger than 8 years. There were another 10 patients 17 years and younger, for a total incidence of 0.08%. Additionally, we found that within this seemingly small group, there was a surprisingly high incidence of severe, associated injuries.

Adolescent

Management of mandibular fractures using biphasic pins and mandibular splints.

Often the otolaryngologist is asked to manage the patient with facial trauma. Mandibular fractures make up 20 to 39% of all facial trauma cases, and thus necessitate a diversified and complete set of management tools. We have selected two seldom discussed modes of therapy for the complicated jaw fracture to present in this paper: 1. external fixation of Joe-Morrison Hall biphasic pins, and 2. mandibular dental appliances--splints. The advantage of the biphasic pin apparatus is that the fracture can be repaired and stabilized at a point remote from the infected fracture site. The high risk patients, endentulous patient, and patients with fractures from gunshot wounds all prove to be more easily managed by using the external appliances. The splint technique eliminates medial or lingual tip rotation and resultant postoperative malocclusion. Endentulous patients, pediatric patients, and those with multiple facial trauma also benefit from this procedure.

Acrylic Resins

Evaluation of metacarpal bone plates in the mandibular fracture.

Of 1587 mandibular fractures, 75 (4.7 per cent) were treated by open reduction with metacarpal bone plates. The plated fractures were reviewed and evaluated for failure. Seventeen plates of the 96 placed were removed (17.7 per cent). Infection was the major cause of failure (9.4 per cent). Operator error played a role in the failure of eight out of 17 plates (47.1 per cent). Various aspects were studied in order to find the significant factors present, and these are discussed.

Adult

Complicated mandibular fractures.

In many mandibular fractures, proper alignment of the fragments is only a portion of the management program. Consideration must be given to the possibility of numerous other complications, and the patient should be carefully evaluated for injuries of the cervical spine, skull, head, and chest. The medical background, age, and other factors, such as the patient's ability to cooperate and follow the physician's instructions, may determine the method of applied treatment.

Adolescent

Nasal spine suspension for reduction and immobilization of mandibular fractures.

Successful treatment of mandibular fractures involves proper fracture reduction and immobilization for an adequate length of time. A simple wire fixation technique that can be used in many situations involves suspension wiring from the base of the anterior nasal spine to a pair of circummandibular wires. The technique may be used alone or adjunctively with other methods of fixation. It offers several advantages over other methods, particularly in the treatment of pediatric mandibular fractures.

Bone Wires

Inferential therapy to promote union of mandibular fractures.

Non-union of mandibular fractures is uncommon, but when it does occur it requires protracted treatment including further surgery. Nine patients with factors known to predispose to non-union out of 150 consecutive mandibular fractures received interferential therapy (I.T.) during the fixation period; all fractures united satisfactorily. In a retrospective study of 150 consecutive mandibular fractures previously treated by the same surgeons without I.T., three fractures resulted in non-union requiring grafting. Thus the incidence of non-union was 0% when I.T. was used and 2% in the control group.

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