31 & 32.

FRACTURES MAXILLA AND MANDIBLE

DEFINITIONS
Fracture It is the structural break in normal continuity of bone.

Dislocation It is a complete disruption of a joint with no remaining contact between articular surfaces.

Subluxation It is a partial disruption of a joint with some contact remaining between articular surfaces.

Sprain It is a painful condition due to tearing of a ligament and soft tissue injury.

TYPES OF FRACTURES

Simple Fracture – no communication between site of fracture and exterior of body.

Compound Fracture- when there is a wound on the skin surface leading down to the site of fracture. In compound
fracture, there is a risk of contamination of fractured bone by outside organisms while a closed fracture is free from this
risk.

CLASSIFICATION OF FRACTURES

Classification Based on Etiology of Fractures

Traumatic fracture: It occurs in bones with normal strength. It may be caused by direct violence, e.g. fracture mandible
due to blow on face or by indirect violence, e.g. condylar fracture due to trauma over chin region.

Stress fracture (Fatigue fracture): It occurs due to repeated injury occurring at the same site. It occurs in bones with
normal strength. The mechanical structure of the bone gets fatigued due to repeated trauma and then bone breaks, e.g.
fracture second metatarsal bone due to prolonged marching in soldiers (march fracture).

Pathological fracture: It occurs in a bone already weakened by disease. The bone gets fractured due to trivial injury or
even spontaneously.

Classification of Patterns of Fracture

Transverse fracture: It is due to bending of bone along its long axis. It is unlikely to become redisplaced after reduction.

Spiral fracture: It is caused by twisting of long bone along its axis. It is prone to redisplacement after reduction.

Comminuted fracture: It is due to severe injury that breaks the bone into fragments.

Compression fracture: It is caused by force applied along the length of a bone and the bone collapses into itself, e.g.
compression fracture of vertebral body due to fall from a height. As the spongy bone is crushed so it cannot be restored
to its original form.

Avulsion fracture: It is caused by severe traction on a ligament that breaks the bone on which it is inserted. It is
commonly seen in small bones attached with strong muscles, e.g. patella (attached to quadriceps muscle).
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Greenstick fracture: It is seen in children whose bones are flexible. An angulation force bends the bone at one cortex and
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breaks it at the other thus producing an incomplete fracture.

HEALING OF A FRACTURE
As soon as the bone breaks, the fracture begins to heal. Various stages in healing of fracture in a tubular bone are:

Stage of hematoma: The torn vessels form a hematoma between and around the fracture surfaces. The ring of bone
immediately adjacent to each side of the fracture becomes ischemic and undergoes necrosis.
 Stage of subperiosteal and endosteal cellular proliferation: These cells are precursors of osteoblasts. They form a collar
of active tissue that grows towards the other fragment. The blood clot is pushed aside by the proliferating tissue and gets
absorbed.

Stage of callus: The proliferating cells give rise to osteoblasts that form the immature woven bone of fracture callus. This
mass of callus is visible in radiographs and can be felt as a hard mass surrounding the fracture site in superficial bones.

Stage of consolidation: The woven bone gradually transforms into mature bone that has typical lamellar structure.

Stage of remodeling: The bone is gradually strengthened along the lines of stress and surplus bone is resorbed outside
the lines of stress. Thus, the bone is restored to more or less of its original form. In cancellous bone, as the bone has
uniform spongy texture and no medullary canal, there is broad area of contact at fracture site. So healing occurs without
medium of callus. However, pathological events are similar to that of fracture tubular bone.

Q) GENERAL C/F AND MANAGEMENT OF FRACTURES

CLINICAL FEATURES AND DIAGNOSIS

History
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o Mostly there is history of injury except in pathological or stress fracture.

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o The patient complains of pain at site of fracture.

o There is loss of function in the injured area, e.g. in limb fracture, patient is reluctant to move it
o The patient may complain of weakness in the limb or loss of sensation due to neurological damage.

Examination

o Swelling and bruising at the site of injury.

o There may be external wound suggesting compound fracture.
o Localized tenderness at the site of fracture.
 o Local temperature is raised due to inflammatory response.
o On limb movement, abnormal mobility or crepitation may be elicited. However, vigorous efforts should not be
made to elicit this sign as it causes severe pain and further soft tissue damage and blood loss.
o Examine for neurovascular damage in the injured limb by checking distal circulation and any neurological
deficit.

Radiological Examination

o The X-ray should include the whole bone including the joint above and below.
o X-rays should be taken in two planes at right angle to each other (anteroposterior and lateral).
o Sometimes oblique view is also required to detect fracture.
o The information provided by X-ray
 Accurate localization of fracture site.
 Demonstrates dislocation if any.
 Demonstrates degree and direction of displacement.
 Provides evidence of underlying bone pathology.
 It may show a radiopaque foreign body.
 It may reveal an unsuspected injury.

MANAGEMENT

First Aid At the site of accident, the aim of management is to keep the patient alive and to minimize the chances of
further damage. The measures include:

• Maintenance of adequate airway and breathing.

• Maintenance of circulation by control of bleeding. The external bleeding is controlled by application of pressure
dressing (using cloth, bandage, handkerchief or manual pressure).
• The use of tourniquet should be avoided as it may only impair venous return causing increased bleeding.
Moreover, if it is kept for too long, it may cause ischemic limb damage.
• The limb should be splinted with whatever method is available (piece of wood, plastic, umbrella, etc.).
• If spinal injury is suspected, the patient should be moved without rotating and flexing the spine (log roll).

Definitive Management It is done in the hospital. It has two components:

1. General Management of the Patient

• Treatment of shock due to blood loss initially by intravenous crystalloids and colloids followed by blood
transfusion.
• Pain control by parenteral analgesics (diclofenac sodium, tramadol).
• Broad spectrum antibiotics are given parenterally especially in compound fractures to prevent wound infection.
• Prophylaxis against tetanus with tetanus toxoid injection.
• Management of associated injuries.
2. Local Management of the Fracture The aims of local treatment of fracture are:
• Pain relief.
• Reduction of fracture.
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• Immobilization to promote fracture healing

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• Preservation and restoration of function.

Treatment of Uncomplicated Closed Fractures The treatment includes:

Reduction-The reduction is done only if there is difficulty in union or risk of impairment in functions. The
reduction can be achieved by:
 o Closed manipulation under anesthesia: The fragments are grasped, disimpacted and then
adjusted to near normal position.
o Reduction by mechanical traction: The traction is applied by weights
o Operative reduction: During operation, the fragments are reduced under vision and fixed
internally to maintain the position.

Immobilization

The aims of immobilization are:

• To prevent movement
• To prevent displacement
• To relieve pain.

The methods of immobilization are:

o Plaster of Paris (POP) cast or splint

o Immobilization by continuous traction: It is required in spiral fracture to prevent
overlap of the fragments due to muscle pull
o Immobilization by internal fixation: It is done when POP cast or traction is unable
to give immobilization. Also, it is used in case fracture requires open reduction.

For internal fixation, the bone on either side of fracture site is exposed by dissecting soft tissues and immobilization is
achieved by one of the following ways:

• Plate held with screws

• Transfixation screws
• Intra-medullary nail
• Circumferential wires

Rehabilitation

The prolonged rest in an injured limb can lead to collection of edema fluid around fracture as well as in the whole limb.
Also there is muscle wasting and joint stiffness.

The aims of rehabilitation are:

• To preserve functions while fracture is uniting.

• To restore functions after fracture is united.

The two essential methods of rehabilitation are:

Active use implies that the patient should continue to use the injured part as naturally as possible.

Active exercises imply doing exercises of muscles and joints under supervision of a physiotherapist

When a fracture has soundly united, physiotherapy is intensified by carrying movements against gradually increasing
resistance until normal power is regained.
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Treatment of Open Fractures

The open fracture demands urgent attention so as to minimize the risk of wound infection. The principles of treatment
are:

i. Wound debridement: All extraneous material is removed. The dead and devitalized tissue is excised leaving
healthy and vascularized tissue.

ii. If wound is clean and is dealt within few hours of injury, it should be closed primarily.
 iii. In case of dirty, severely contaminated wound with delayed presentation (more than 8-10 hrs), it should
be left open and dressed regularly. Once wound becomes clean, delayed closure is done.

iv. Treatment of fracture: Principles of management are same as for closed fractures. However, open
reduction and internal fixation of the fracture should be avoided to prevent the risk of infection.

(5)

Q) CLASSIFY MAXILLOFACIAL FRACTURES & C/F AND MANAGEMENT OF LEFORT’S

FRACTURES

FRACTURE OF THE MAXILLA

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Patterns of Fracture Maxilla Rene Le Fort (French anatomist) classified these fractures by patterns created on cadaver
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skull by various degrees of force

Le Fort I Fracture (Horizontal Fracture) The fracture involves the dentoalveolar component of maxilla only. Fracture
line starts from anterolateral junction of pyriform aperture, passes through anterolateral surface of maxillary antrum
above canine fossa, moves down to zygomatic buttress and fractures the lower one third part of pterygoid plate Thus, it
separates the alveolus and palate from the facial skeleton above

Le Fort II Fracture (Pyramidal Fracture) The fracture line passes obliquely across the maxilla on each side. Starting from
the zygomatic process of maxilla, the fracture line goes upwards and medially to the infraorbital margin and then across
 the root of the nose to meet a similar fracture line from the opposite side. The orbital floor is always involved.
Posteriorly, the fracture line continues through the lateral wall of maxillary antrum at a higher level than Le Fort I to the
pterygoid plates at the back

Le Fort III Fracture (Craniofacial Dysjunction) The fracture line passes high up through back of the nose in ethmoid
area, back of both orbits and through both zygomatic arches. Posteriorly, the nasal septum is fractured high up and
likewise the pterygoid processes. There may be CSF rhinorrhea due to involvement of cribriform plate. There is
separation of facial skeleton from the base of the skull

Clinical features

Treatment of Fracture Maxilla

• Associated head injury, cervical spine injury or other serious injury should be given priority and treated first.
• However, fractures of middle third of face should be treated with minimum delay as they tend to fix rapidly in
their displaced position.
• The aim of treatment is fracture reduction (to restore normal occlusion), fixation and immobilization.
• In fresh fractures of Le Fort I type, closed reduction by manipulation can be done. It is done with Rowe’s
disimpaction forceps that grasps the palate between the nasal and palatal mucosa. Sometimes considerable force
is required in downward, forward and sideways movements to disimpact the maxilla). It is followed by
intermaxillary fixation for achieving occlusion with the mandible.
• In delayed cases, open reduction and internal fixation of the fracture is done.
• Bicoronal flap incision: It is used for stabilization of upper part of the face. The incision starts from the front of
one ear, goes across the vault of skull (high in the hair line) and then to the front of other ear. The flap is reflected
down till supraorbital ridges are exposed. This incision exposes nasal bones, lateral orbital rim, frontal bones and
zygomatic arches. All the fractured bones are reduced and fixed with stainless steel wires or titanium microplates.
The bone deficiencies can be filled with bone grafts or titanium mesh.
• Blepharoplasty or transconjunctival incision: It is used for stabilization of midface. The incision is made in the
lower eyelid or lower conjunctival sac. It exposes fractures of the infraorbital rim or orbital floor. The fractures are
reduced and fixed in the same way as described above.
• Vestibular incision: It is used for stabilization of lower part of maxilla. The incision is made in the gingival sulcus
above the maxillary teeth as far back as the second molar tooth. The fracture is reduced and fixed with plates and
wires. The dental arch is restored to its original shape and IMF is done using eyelet wires or dental arch bars to
achieve normal occlusion.
• With the availability of maxillofacial plating system, external fixation with pins, POP headcaps and haloframes are
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rarely used these days.

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• However, external fixation is still indicated in case of multiple and unstable fragments of maxilla. The mandible is
fixed to the cranium with the maxilla as a ‘sandwich’ between the two. Pins are used for cranial fixation and
mandibular fixation. Then all the cranial pins are connected to mandibular pins with connecting bars.

COMPLICATIONS OF MAXILLOFACIAL FRACTURES

• Infection of maxillary sinus.

• Osteomyelitis.
• Meningitis due to CSF leak.
• Cavernous sinus thrombosis.
• Malocclusion of teeth.
• Ankylosis of TM joint
• Anesthesia and paresthesia  In lower lip (inferior dental nerve injury).  In upper lip, side of nose, lower eyelid
(infraorbital nerve injury).
• Facial nerve injury.
• Superior orbital fissure syndrome: In malunited zygomatic complex fractures, there is damage to the contents of
superior orbital fissure. Third, fourth and fifth cranial nerves are affected leading to ophthalmoplegia, proptosis and
retrobulbar pain.
• Malunion, nonunion and delayed union.
• Nasal blockage due to deviated nasal septum.
• Epiphora due to damage to nasolacrimal duct.
• Anosmia due to olfactory nerve damage.

FRACTURE OF THE MANDIBLE

Patterns of Mandible Fracture

o The common sites of fracture are: Condylar neck, angle of the mandible and body through canine sockets
o Fractures may occur singly or in several combinations
o Most fractures in the tooth bearing portion of the mandible are compound into the mouth because the
mucoperiosteum is firmly attached to the bone and tears during injury.
o Displacement of fractured segments depend upon:  Direction of violence  Direction of muscle pull
o The muscles which elevate the mandible are all inserted behind the first molar, viz, masseter, medial pterygoid
and temporalis.
o The muscles which depress the mandible are all inserted in front of the first molar, viz. geniohyoid, mylohyoid
and digastric.
o Thus, most common displacement of posterior fragment is upwards and of anterior fragment downwards
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Another important factor deciding the displacement of angle fractures is the direction of fracture line
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o
o The condylar neck is the weakest and commonest site of fracture mandible.
o The condylar head is pulled forward by the lateral pterygoid muscle leading to lateral deviation of mandible
towards the side of fracture.
o If both condyles are fractured, the displacement of both heads causes the patient to gag on his molars giving an
‘open bite’ deformity
o A bilateral fracture through canine sockets detaches a midline segment from rest of the mandible (Butterfly
fracture). This free segment will be pulled down by digastric and genioglossus muscles and tongue will fall back
and occlude the airway.
 a. Dentoalveolar fracture Features (body of mandible)
• Horizontal fracture below the alveolar margin.
• Dentoalveolar segment will be freely mobile.
• Tooth may get split vertically/horizontally.
• Derangement in occlusion and alignment.
• Gingival laceration.
• Bleeding.
• Infection and late osteomyelitis of mandible.

Management
• Look for other injuries in face.
• X-ray face to see injuries.
• Dentoalveolar segment reduction and placing jaws in central occlusion position.
• Stabilization using interdental wires or arch bars.
• Liquid diet for 3-4 weeks.

TREATMENT OF MANDIBLE FRACTURE

I. Fracture of Tooth Bearing Segment

Closed Reduction with Indirect Fixation

• Fracture mandible is first reduced followed by fixation.

• Aim of reduction is to bring the teeth of the fractured segments into a normal relationship with those of
unfractured counterpart so as to restore pre-injury dental occlusion.
• Markedly displaced fractures require general anesthesia for the fracture reduction.
• Once correct occlusion is achieved after reduction, the mandibular teeth are fixed with intermaxillary fixation (IMF).

It can be achieved by:

a. Eyelet wiring: The fixing device is a stainless steel wire of 0.4 mm diameter that is doubled on itself and twisted
tightly 2-3 times leaving a small loop at the end. The double wire is passed inwards between the necks of two
adjacent teeth, two wires separated and passed outwards through the next interspace and twisted together with one
of the ends going through its own loop. Four or five eyelets are required for each dental arch. After eyelets have been
applied to both upper and lower teeth, connecting wires are threaded through the loops to join the jaws together

b. Arch wiring: An arch bar (flattened soft silver bar) is moulded round the alveolar arch on its outer aspect at level of
neck of the teeth to which it is wired. Similarly, an arch bar is applied to the maxilla and the two arch bars are wired
together for effective IMF (Fig. 21.18).

c. Cap splinting: In this technique cast-metal cap splints are made for the entire dentition that fit accurately over all
the teeth. The splints are cemented to the teeth and in this way, provide fixation without damaging gums and teeth

Open Reduction with Internal Fixation If displacement of the fracture is considerable, open reduction and internal
fixation (ORIF) of the fractured segments is done with wire loop or plate.
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To avoid malocclusion, IMF is also done for 3 weeks

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Various methods of ORIF are:

b. Tranosseous wiring
c. Mini plates
d. Lag screw fixation.
 Condylar fracture

In condylar fracture condylar head is pulled forward by the lateral pterygoid muscle.

When both condyles are fractured the displacements of both heads causes the patient to gag on his molars producing an open bite.

It is the commonest type of mandibular fracture.

Classification

• Fracture without displacement.

• Fracture with displacement with anterior overlap/with posterior overlap.
• Fracture with dislocation.
• Fracture with deviation.
• Extracapsular fracture condyle.
• Intracapsular fracture condyle

Clinical Features

Unilateral

• Condylar tenderness of the side. • Decreased condylar movement on the side. • Jaw deviation towards fracture site. • Tear in external
meatus and bleeding from ear of the side. • Preauricular swelling of the side.
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Bilateral
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• Condylar tenderness on both sides. • Absence of condylar movement. • Bleeding from both ears. • Preauricular swelling on both sides.
• Anterior open bite. Management • In children if it is intracapsular, active movements without immobilization is the only treatment. If it
is extracapsular, intermaxillary fixation for 10 days, later active movements is needed. • In adult if it is unilateral intracapsular and
painful, immobilization is advised for 2 weeks and later active movements are encouraged. If it is intracapsular bilateral condylar fracture
intermaxillary fixation for two weeks and later fixation with night
. Fracture of the Ramus or Angle of the Mandible

• If fracture is upwards and inwards, it is impacted and undisplaced. It is favorable fracture

• If fracture is downwards and outwards, it gets displaced and it is unfavorable fracture

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