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Mandible Fractures Flashcards

1
Q

What are the elevators of the mandible?

A

Temporalis
Medial Pterygoids
Lateral Pterygoids
Masseter

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2
Q

What are the depressors of the mandible?

A 
Supra hyoid group of muscles:
Stylohyoid
Mylohyoid
Geniohyoid
Digastric
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3
Q

What are the origin, insertion, function and innervation of temporalis?

A

O: temporal fossa
I: Coronoid, Anterior surface of rams
F: elevator
N: V3 mandibular branch

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4
Q

What are the origins, insertions and innervation of medial Pterygoid?

A

O: medial aspect of lateral pterygoid plate
I: lingual aspect of angle and ramus
Fx: powerful elevator, synergistic w masseter
N: V3 medial pterygoid br.

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5
Q

What are the origin, insertion, function and innervation of Masseter?

A

O: Z arch (superficial head ant 1/2, deep head post 2/3)
I: buccal aspect of body and rams
Fx: powerful elevator, synergistic with medial pterygoid
N: V3

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6
Q

What are the origin, insertion, function and innervation of lateral pterygoid?

A

O: Lateral aspect of lateral pterygoid plate
I: TMJ joint capsule
Fx: Protrusion, translation, side to side motion
N: V3 lateral pterygoid br.

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7
Q

What are the origin, insertion, function and innervation of mylohoid?

A

O: mylohoid line along mandible
I: hyoid
Fx: elevates hyoid
N: ION (mylohyoid br)

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8
Q

What are the origin, insertion, function and innervation of geniohyoid?

A

O: inferior mental line
I: Hyoid
Fx: elevate tongue
N: hypoglossus (CN12)

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9
Q

What are the origin, insertion, function and innervation of stylohyoid?

A

O: styloid
I: Hyoid
Fx: displaces hyoid posteriorly
N: Facial (CN7)

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10
Q

What are the origin, insertion, function and innervation of digastric?

A

O: Mastoid process (post belly), Digastric fossa of mandible (anterior belly)
I: hyoid intermediate tendon
F: hyoid elevation
N: Ant belly, V3, Post belly CN7

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11
Q

Describe the functions and course of the Inferior Alveolar nerve

A

Sensory Branch of V3 to lower teeth, lower lip, chin, vestibular gingiva
Motor branch to mylohyoid
Enters mandibular ION canal at lingual cortex, inferior to molar root and exits at mental foramen, located inferior to 2nd premolar

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12
Q

Describe your landmarks for the marginal mandibular nerve

A

80%: lies posterior to facial artery, at the level of the inferior mandibular border. Anterior to master, approx. 3cm from angle
20%: lies anterior to facial artery and will 100% be above mandible border.
It is never >1,5cm below the mandible border

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13
Q

How do you classify mandible fractures?

A

By:
1- Location
2- Open vs closed
3- Displacement
4- Dentition (class 1 - teeth both sides, class 2- teeth on one side, class 3 - no teeth on either side)
5- Favourability
6- isolated / segmental / comminuted (JP added this)

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14
Q

What is the blood supply to the mandible

A

Inferior alveolar artery (travels with IAN in mandibular canal)
Muscle attachments

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15
Q

What mandible fractures are favourable?

A

Ramus

Some angle

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16
Q

What mandible fractures are unfavourable?

A

Parasymphyseal/symphysis
Some angle
High condylar (medially displaced by lateral pterygoid)

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17
Q

What physical finding do you anticipate with a condylar fracture?

A

Contralateral open posterior bite and translation to ipsilateral side with mouth opening

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18
Q

What physical finding do you anticipate with a bilateral candela fracture?

A

Anterior open bite

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19
Q

What specific imaging do you order for mandible fracture assessment? (3 answers)

A

1- Panorex (PA, lateral, RLO, LLO, Townes, submentovertex)
2- Panorex - 80% sensitive
3- CT (2.5mm cuts) - 100% sensitive

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20
Q

What is non-operative management for a mandible F#

A

Soft diet

Close follow-up (weekly)

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21
Q

What type of mandible fracture can be considered for non-operative management?

A
  • minimal displacement
  • no malocclusion
  • normal ROM (no translation)
  • patient : elderly, paediatric w greenstick/incomplete
  • Location: condyle, ramus favorable, coronoid
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22
Q

What is centric occlusion?

A

Occlusion with maximal intercuspation of teeth

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23
Q

What is centric relation?

A

Occlusion with condyle seeded in glenoid fossa (in the most posterosuperior position)

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24
Q

What are methods of fixation for operative management of a mandible f#

A 
1- splints
2- Circumdental wiring and arch bars
3- MMF
4- Rigid internal fixation (Rigid stability AO/ASIF)
5- Non-rigid Fixation (champy)
6- External fixation
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25
Indications for ORIF of mandible F#
Mandible F#, malocclusion AND you are Desire to avoid MMF/uncooperative/head injured 1- Unable to hold fixation with teeth - Class 2 or Class 3 (or edentulous) - Edentulous mandible* OA/JF 2- Unable to obtain anatomic reduction - Comminuted - Bone Loss, Bone Discontinuity * OA/JF - Osteomyelitis 3- Unable to maintain reduction with a closed approach - Favorable or unfavourable Class 1 where stability is desired - Combination of Maxillary and mandibular F# - Displaced or likely to rotate ***
26
What is functional stability versus rigid stability in mandible fracture fixation
Rigid stability - stability achieved w fixation plates that allow no movement across F# site Functional stability - movement possible across f# gap but balanced by external forces within limits of what allow f# to heal Load sharing: functional stability achieved w plate in conjunction with stabilizing forces by anatomic abutment of non-communized fracture segments Load bearing - functional stability achieved by fixation system only
27
What are contraindications to MMF?
1- seizure disorder 2- Neurologic/psych disorder 3- Pulmonary compromise 4- Eating disorder
28
What are indications for Closed reduction and MMF ?
``` 1- non displaced F# 2- grossly communited F# 3- edentulous patients (using splint) 4- Pediatric F# (at mixed dentition) 5- Isolated condylar Fracture 6- Coronoid fracture ```
29
Indications//situations for External fixator for mandible f#
OLD school answers below (in reality today, OA/JF, no use for ex fix, just tx infected bone with locking recon plate) - Pathologic F# - Traumatic bone loss - Lack of soft tissue coverage - Infected/contaminated wound/OM - to maintain spatial relationships for cancer resection - edentulous mandible if atrophic mandible but sufficient to hold two screws
30
What are advantages of internal fixation with plating
- avoid MMF - rigid internal fixation (reliable fracture healing) -
31
What are the disadvantages of plating?
- risk of injury to IAN, mental n, mar mandibular n - risk of injury to tooth roots/buds - periosteal stripping (blood supply) - stress shielding (force transmitted to plate) - risk of OM
32
What are indications for internal fixation with plating for mandible f#
- class 2 and class 3 fractures - displaced f# - condylar f# dislocation >12yo - condylar # dislocation and another fracture - MMF contraindicated - edentulous patient
33
What are contraindications to internal fixation with plating?
- osteomyelitis - metabolic bone disorder (renal osteodystophy, hyperparathyroidism) - medically unfit for surgery
34
What are indications for Closed reduction
- medically unfit patient, unable to undergo fixation or open reduction - condylar fractures
35
What is the role of compression plating in mandible fractures?
- to increase fracture compression and contact
36
What other methods of fixation must you use in combination with compression for mandible f#?
Tension band or arch bars to prevent lingual cortex distraction
37
What is the role of locking plate?
More forgiving if plate not bent perfectly | Acts as internal exfix
38
What is the theory of nonrigid fixation (champy/load sharing/functional stability)
- Only tensile forces are terrible | - Miniplates (monocortical) can be placed along lines of osteosynthesis
39
Where do you place miniplates for non rigid fixation?
1- Posterior to first PREmolar, miniplates are effective in the midbody position 2- Anterior to first PREmolar, two plates are used 4-5mm apart
40
When is nonrigid fixation not possible as a management strategy?
comminution | Bone loss
41
What is the theory of rigid fixation?
no micromovement at fracture site allows for 1' bone healing
42
What are the AO principles?
- anatomic reduction - functionally stable fixation - atramatic operative technique - ealy active pain free mobility
43
What are options for fixation according to Ao principle
1- Tension band (miniplate) + larger bicortical inferior plate (>=2.3mm) to neutralize compression and torsion forces 2- Large recon plate (2.3-3-0mm) to neutralize tensile, compressive,torsional forces
44
Describe the transoral approach (LBS)
1- incise through mucoa w 1cm cuff | 2- avoid injury to mental nerve (anterior to 2nd PREmolar)
45
Describe transbuccal approach
external incision for trocar placement
46
Describe submental approach
external scar to expose and visualize the lingual cortex
47
Describe landmarks and position of structres to avoid in a submandibular approach (Risdon)
- 2cm below inferior border of mandible (to avoid marg mand br - located at border or up to 1.5cm below, lying over facial vessels) - identify entire plane of platysma, dissect under and carefully cut through platysma to reveal deep cervical fascia - facial vessels run anterior to masseter border - the premasseteric notch identifies where the CN7 branch may be inferior to border
48
Describe retromandibular approach
- below earlob at posterior border of ramu, incision through skin subcut, then incise through platysma protecting potnetial facial n br below - incise though perygomasseteric sling - release masseter sling
49
Specific f#: Alveolar f#
arch bar, tooth splint, circumdental wires, dentures wired to jaw
50
Indications for tooth extraction
- Root apex exposed or fractured - teeth preventing reduction - grossly mobile teeth with evidence of periapical injury or disease
51
Management specific F#: symphysis
CR and Fixation with MMF if stable - rare Usually ORIF b/c unstable or assocaited w condylar F# ORIF with compression/lag screws ORIF w compression plate at inferior border + tension or arch bar ORIF with two miniplates
52
Management specific F#: body
CR and fixation - MMF - rare!! Usually ORIF ORIF w compression or non compression plate inferior border + arch bar or tension band or two miniplates
53
Management specific F#: angle F#
CR and fixation with MMF is associated fractures (condyle/midface) USually ORIF with tooth etraction of 3rdmolar if diseased or preventing reduction Traditional AO - compression plate at inferior border, 2 bicortical screws per side + tension band/arch bar superiorly Miniplate- single 2.0mm miniplate on external oblique line -
54
Management specific F#- ramus F#
Undisplaced, maintianed V height w molars in place and reliable - soft diet 6wks and close observ Undisplaced, missing molars so no V height maintenance, MMF 4-6 wks w elastics Displaced, attempt CR and MMF If failed CR, ORIF w two miniplate and retomandibular approach
55
Management of condylar f#
Non- surgical (soft diet 6wks): - high neck or head (intracapsular) w no dislocation/malocclusion - condylar neck
56
What are absolute and relative indications for ORIF of a condylar F#?
Absolute - displacement into middle fossa - foreign body within joint - lateral extracapsular dislocation of condylar head - inability to get adequate occlusion with closed methods Relative - bilat subcondular F#, disaplced + midface - subcondylar f# with panface that needs re-established V height - shorted ascending ramus
57
Classificaiton of edentulous mandible
according to amount of bone in the body of mandible Mild atrophy - >20mm moderate atrophy 10-20mm Severe atrophy
58
Management minimally displaced edentulous mandible
- stable - conservative management | - unstable - MMF w circummandibular wire
59
Management displaced/comminuted edetulous manidble
- external approach - recon plate (load bearing) - minimal periosteal stripping - primary bone grafting
60
PEdiatric fracture - indication for nonsurgical amangemetn
- high neck/head (intracapsular) condylar f# - coronoid f# - BODY,angle F# with minimal displacement
61
Pediatric fracture - options for fixation
- interdental wiring (minimally displaced) - NOT if
62
Describe ORIF principles in pediatric mandible fractures
- minimal periosteal stripping - 1 miniplate 1-1.5mm inferior border only with monocortical screw - resorbable plate if
63
What are complications of mandible fractures?
- malocclusion - delayed union, non-union - infection - exposed hardware
64
What are cuases of malocclusion following mandible f# treatment
- failure to get centric relation b/c mandible is forced into occlusion wihtout seeding condyles - failure to get centric occlusion w MMF before ORIF - other f# missed - arch bar prior to exposure may shorten mandible segments - compression causing distraction of superior lingual cortex - poor plate contouring
65
What is treatment of malocclusion
- elastics if arch bar in place - orthodontics - repeat OR
66
What is definiton of delayed union?
- not clinically stable by 6wks
67
Wha is definition of non-union
not clinically stable at 10wks
68
Causes of non-union/delayed union
- unstable fixation - early MMF release - hardware failure - infection - damaged teeth
69
Treatemnt of non-union/delayed union
If unstable, ORIF w rigid fixation, graft if gap after reduction >2cm
70
Causes o finfection
DIrectly realted to stability - RIGID fixation decreases fixation
71
Treatment of infection
``` aspirate for culture antibiotics debridement of necrotic sequestrae rigid fixation +/- BG if gap drainge of collection ```
72
Causes of exposed hardware
minor exposure no infection - leave until f# heals then remove major exposure or infection - remove hardware and achieve rigid fixation.
73
What defines an angle fracture?
1st molar to angle
74
What defines a body fracture?
1st premolar to 1st molar
75
What defines a symphysis fracture?
between the canines
76
What defines a ramus fracture?
below sigmoid notch
77
What forces act on the mandible fracture?
tensile forces along alveolar ridge | compression and torsion forces along inferior border
78
What are landmarks for ION block?
5 mm below orbital rim, in line with medial limbus. If injecting intraoral, aim toward lateral canthus
79
What are landmarks for greater palatine block?
midway between midline and teeth, in line with 2nd molar
80
What are landmarks for Nasopalatine block?
midline, 5mm behind incisors
81
What are landmarks for Inferior Alveolar Nerve block?
1cm above occlusal plane and 1cm posterior to medial ramus
82
What muscle does IAN innervate?
mylohyoid

Head and Neck / CF (27 decks)

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