U.C.

Irvine - Otolaryngology-Head & Neck Surgery

UC Irvine
Otolaryngology-Head & Neck Surgery

INDIAN DENTAL ACADEMY

Leader in continuing dental education
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Case Presentation
You are called to assess a patient in the
trauma bay s/p fall from motorcycle onto
his face.
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Exam 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.
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Additional Concerns?
Intoxication? Head Injury?

C-spine

Open fracture

Missing teeth? WHERE ARE THEY?
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Rest of Exam
PERRL/EOMi, no raccoon eyes
Midface Stable, no septal hematoma, no
step-offs in midface
Fresh blood occluding EACs bilaterally
Malocclusion, 1.5 cm MICD due to pain
Ecchymosis under tongue with minimal
retrodisplacement. FOL airway clear.
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Studies Done
CT Head w/o contrast (very limited view)
CT Face Axial/Coronal w/ 3-d recons

Prefer preoperative mandible series with
panorexwhy?
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Mandible 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
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Immediate 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 management
Document CN function (esp inf alveolar)
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Considerations In Mandible Fx
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
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Steps to Avoid Problems
Proper diagnosis
Consider Co-morbid Conditions
Consider Patient Personality/Occupation
Proper management plan for the
circumstances
Proper technique (MMF, bending, drilling,
screw placement, nerves, tooth roots)
When in doubt, use a LARGER plate.
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Concepts in Reduction
Patients baseline occlusion is first priority.
Class I, II, III Crossbite?
Observe wear facets
Do not force class I if it doesnt line up with
wear facets.
Verify occlusion at beginning, mid, end of
case. Remove MMF to verify if necessary.
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Plate 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?
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Know Champy Lines
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Fracture Types
Condylar / Subcondylar
Ramus
Angle
Body
Parasymphaseal
Symphaseal
Alveolar Ridge
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Type and Management
Symphaseal 2.0 L Compression + TB Lag Screws
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Type and Management
Comminuted Symphaseal 2.4 Locking Recon Plate + TB
Left Subcondylar
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Type and Management
Parasymphaseal Two Miniplates?
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Type and Management
Comminuted Parasymphaseal 2.4 Locking Recon Plate with TB
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Type and Management
Comminuted Body/Parasymph
2.4 Locking Recon Plate with MPs
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Type and Management
Disloc Angle w/ Basal Triangle
2.4 Locking Recon Plate with 2.0 MP
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Special Case
Edentulous Body Fracture
2.4 Locking Recon Plate, 4 screws
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Another Special Case
Infected Angle Fracture
2.4 Locking Recon Plate
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Other 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.
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Type and Management
Pediatric Fractures remove plates or use
absorbable, minimize MMF.

Loss of Bone from infection, severe trauma or
nonunion.
Symphaseal and Angle, 3
rd
Molar Single Champy MP at Angle
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Controversies/Difficulties
When to perform ORIF on subcondylar
Tooth in the fracture line
Stops for unilateral subcondylar
Missing Teeth (but not edentulous)
When to go extra-oral route
How long to continue abx postop (Ali?)

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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Back to Our Patient
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
Back to Our Patient
Comminuted Symphaseal

High right subcondylar fracture/dislocation

Non-displaced left subcondylar fracture
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U.C. Irvine - Otolaryngology-Head & Neck Surgery
No Mas!
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U.C. Irvine - Otolaryngology-Head & Neck Surgery

Thank you

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