MANAGEMENT OF COMPLICATIONS OF IMPROPERLY TREATED MANDIBULAR FRACTURES

Presented by -Dr. Sheetal Kapse

Moderator -Dr. Rajasekhar G.

CONTENTS

• Introduction• Patient evaluation• Analysis of initial unsatisfactory results• Reoperation in post traumatic deformities1. Non-union2. Mal-union/malocclusion & condylar fractures3. Facial asymmetry

• Special consideration for condylar hyperplasia• Conclusion• References

Introduction• Mandibular fractures are one the most common maxillofacial injuries. Their

management has been traditionally regarded as one of the cornerstones of oral and maxillofacial surgery.

• Despite many technological and technical advances, to consistently return patients to their preinjury state remains one of the main challenges in the management of these injuries.

• Diagnostic errors, poor surgical technique, healing disorders, or complications may lead to the establishment of posttraumatic mandibular deformities.

Problem oriented Patient evaluation

A. HistoryB. Extraoral examination – facial height, width and symmetry & palpation

for bony deformity and mobility.C. Intraoral examination – occlusion, caries, D. Radiographs- plain films, 2D/ 3D CTE. Stereolithographic modelsF. Computer-assisted surgical simulationG. Craniomaxillofacial navigationH. Dental models –for occlusion evaluation, moc surgery & splint

fabrication.

Analysis of initial unsatisfactory results

Diagnostic Errors• Failure to recognize, either clinically or radiographically, the morphology of

the fracture or the presence of multiple mandibular fractures may lead to the selection of the wrong surgical approach and ultimately the wrong method of fixation.

• Certain clinical situations that are prone to posttraumatic deformities, such as multiple unilateral mandibular fractures, mandibular fractures in combination with segmental maxillary fractures, or severely atrophic mandibular fractures.

Diagnostic errors. Panoramic radiograph of a comminuted left mandibular angle/ramus fractures. Clinician failed to identify the presence of comminution and wrong fixation was selected. The patient subsequently developed an infection caused by fracture instability.

Poor Surgical TechniqueInadequate establishment of occlusion

• Failure to attain adequate occlusion is related to –

1. Missing or decayed teeth, 2. Multiple fractures, 3. Tight MMF that creates buccal tipping, 4. Loose MMF that produces an open bite,5. Inadequately reduced fractures.

Poor Surgical TechniqueInadequate fracture reduction

• Good visualization

• Poor reduction usually is associated with insufficient anatomic references such as inadequate dentition, multiple mandible fractures, dentoalveolar fractures, and segmental maxillary fractures.

• inadequate reduction of the mandibular segments may diminish the area of osseous contact, making mobility of the fracture fragments more likely.

• In the presence of multiple fractures, inadequate reduction and stabilization of one of the fractures may hinder the reduction and stabilization of the other.

Poor Surgical TechniqueInadequate fracture fixation

Common infringements of rigid fixation principles include-• a plate that is too small, • 1 plate instead of 2, • placement of a screw into the line of fracture, too few screws per side of

fracture, and inadequate plate bending• proper rigid fixation techniques• avoid bone overheating

Failed or failing rigid internal fixation cannot be repaired with antibiotics or MMF. It is basic that a foreign body that must be debrided from the fracture site.

Inadequate fracture fixation. A 46-year-old man with bilateral mandibular angle fractures that developed an infection on the left side before presentation to our institution. (A) Panoramic radiograph after incision, drainage, and extraction of tooth #17. (B) Postoperative radiograph after open reduction and internal fixation of both fractures. (C) Two-week follow-up panoramic radiograph of left failed fixation. Later surgery demonstrated the buccal plate holding the fixation fractured because of poor bone quality. (D) Panoramic radiograph after reoperation showing the placement of a larger reconstruction-type fixation plate.

Ellis E. Complications of rigid internal fixation for mandibular fractures. J Craniomaxillofac Trauma 1996;2(2):32–9.

Infectioncauses of postoperative infections are multifactorial –

• Instability, • Failed Hardware,• Teeth in the line of fracture, • Medically compromised patients, • Delay of treatment, and noncompliant patients

• Osteomyelitis - occurs in 1% to 6% of cases.• Surgical treatments include debridement, sequestrectomy, mandibular

resection, and immobilization of the fragments.

General algorithm for the management of infected mandible fracture after open reduction and internal fixation. (Modified from Alpert B. Management of the complications of mandibular fracture treatment. Operat Tech Plast Reconstr Surg 1998;5(4):325–33;

Healing disorders• Systemic disease - diabetes, anemia, human immunodeficiency virus (HIV)

infection, hyperparathyroidism, hyperthyroidism, osteomalacia, osteopetrosis, chronic renal disease, osteogenesis imperfecta, paget disease, vitamin B or C deficiencies, and chronic steroid or bisphosphonate use.

• Polysubstance abuse• Nutritional deficiencies, • Changes in general health, life style, and personal/oral hygiene• Overall compliance

REOPERATION IN

POSTTRAUMATICMANDIBULAR DEFORMITIES

• Non-union, • Malunion/malocclusion, • Facial asymmetry

Non-union• A nonunion is a fracture with arrested healing that requires further surgical therapy

to achieve union.

• Haug and Schwimmer considered a nonunion any mandibular fracture that exhibited mobility after 4 weeks without treatment or after 8 weeks with surgical management.

• Causes - soft tissue infection, osteomyelitis, fracture mobility, inaccurate reduction, delay in treatment, teeth in the line of fracture, alcohol and drug abuse, inexperienced surgeon, and poor patient compliance, early motion after fixation, hypoxic environment of the scar tissue, Large fracture gaps or comminuted fractures, Severely atrophic mandibular fractures.

• Diagnosis - persistent mandibular mobility or tenderness at the fracture site. Irregular radiolucency with mottled fracture ends and/or hardware loosening are radiographic findings.

Surgical Considerations

Extraoral approach & direct visualization of the

fracture site

Debridement of the area of any fibrous tissue,

necrotic bone, or failed hardware

Bleeding bone

Adequate occlusion and MMF

Fracture is reduced

If inadequate bone contact - exists, autogenous bone

grafting needs to be performed

Reconstruction-type plate -3–4 screws at each side of the fracture

& distance of screws from fracture line should be 7 to 10 mm

Mandibular nonunion. A 55-year-old man with a gunshot wound to the face that developed a mandibular nonunion. Reoperation was performed 5 months after the primary surgery. (A) Three-dimensional CT reconstruction of the original injury. (B) Intraoperative view of the primary mandibular repair. (C) Immediate postoperative 3-dimensional (3D) CT reconstruction. (D) Draining purulent fistula in the right chin 4 months after the original surgery. (E) Panoramic radiograph showing a persistent radiolucency at the fracture site.

(F) Intraoperative view of the mandibular nonunion after debridement. (G) Intraoperative view of the autogenous bone graft. (H) Immediate post-reoperative axial CT scan of the bone graft area. (I) Immediate post-reoperative 3D CT reconstruction. Maxillary reconstruction was achieved by placing zygoma implants.

Malunion/malocclusion• When segments heal in an improper alignment.

• Malunions typically follow inadequate establishment of occlusion, lack of accurate anatomic reduction, and poor adaptation of the fixation plate.

• The rigidity obtained prevents correction of technical errors without reoperation.

• Minor occlusal disparities - Orthodontic therapy or occlusal adjustments can be instituted.

Surgical Considerations

Approach from the previous incision

Removal of

hardware

Dental model and

splint fabrication

Osteotomies at the previous fracture sites, or sagittal split or vertical ramus osteotomies

Adequate occlusion and MMF with splint

If inadequate bone contact - exists,

autogenous bone grafting needs to be

performed

New rigid fixation

Occlusion is rechecked after

releasingthe MMF

Malunions/maloccusions and condylar fractures

• Ellis and Walker suggested that the most important factor is not whether the patient was treated open or closed but the quality of functional rehabilitation of the mandible.

• No treatment or unsuccessful treatment are the 2 main reasons of posttraumatic malocclusions secondary to condylar fractures.

• Minor occlusal disparities - orthodontics, prosthetics reconstruction, or occlusal adjustments.

Ellis E, Walker R. Treatment of malocclusion and TMJ dysfunction secondary to condylar fractures. Craniomaxillofacial Trauma Reconstruction 2009; 2(1):1–18.

Mandibular malunion/malocclusion. A 50-year-old man after work-related accident. He sustained bilateral mandibular body fractures that were repaired with open reduction and internal fixation. He presented to our institution after repair complaining of malocclusion. Reoperation was done 12 months after the original surgery. (A) Three-dimensional CT reconstruction of the original injury. (B) Preoperative photograph. (C) Preoperativephotograph of the occlusion. (D, E) Three-dimensional CT reconstructions obtained to preoperatively study the shape of the mandible and the status of the original repair. Model surgery was performed, and a surgical splint was then fabricated. (F) Intraoperative view of the surgical splint and predetermined occlusion.

(G) Intraoperative view of the right mandibular body osteotomy. (H) Intraoperative view of the left mandibular body osteotomy. Note the mental nerve lateralization. (I) Panoramic radiograph after reoperation. (J) Postoperative photograph 6 months after surgery. (K) Postoperative occlusion.

Surgical Considerations -

• The degree of mandibular ramus deformity is the most important aspect to consider when planning for reoperation of posttraumatic malocclusion after condylar fracture repair.

• If the remaining mandibular ramus is short and multi-fragmented and the patient requires large movements to obtain proper occlusion, TMJ reconstruction may be the preferred method.

• Additional aspects to be considered are unilateral versus bilateral condylar fractures, time between injury and treatment of the malocclusion, and availability of a stable dentition.

• Successful treatment of malocclusions can be achieved with functional therapy up to 3 months.

Condylar fractures

Unilateral

Unilateral / bilateral Sagittal split, or vertical ramus,

osteotomies - on the side of the fracture.

Bilateral

Le Fort I or mandibular osteotomies to correct anterior

open bites

Duration

long-standing malocclusions with

stable TMJ articulations

Orthognathicsurgery

Mandibular malocclusion and TMJ pain and dysfunction. A 35-year-old woman after an assault. She sustained a left subcondylar fracture that was originally treated with an open reduction and internal fixation. Patient presented to our institution 3 years after the original surgery, complaining of malocclusion and bilateral TMJ pain and dysfunction. (A) Preoperative radiograph showing severe resorption of the right condyle; note also degenerative changes on the left condyle. (B) Preoperative cephalometric radiograph showing the dentoskeletal deformity. Patient underwent a bilateral total TMJ replacement and a Le Fort I osteotomy. (C) Intraoperative view of the alloplastic total TMJ replacement. (D) Left condyle and coronoid. Comparison between planned and actual specimens. Note the severe resorption of the condyle. (E, F) Postoperative 3-dimensional CT reconstructions.

Facial asymmetry

• During the early phases of healing, clinical diagnosis is difficult because of

postoperative swelling, but if suspected, imaging such as anteroposterior

cephalometric radiography or CT scan can confirm the diagnosis.

• Combination of mandibular symphysis and subcondylar fractures. In these

cases, overtightening the MMF causes rotation of segments, with loss of

lingual contacts and flaring of the inferior border of the mandible.

• If a segmental maxillary fracture is also encountered, the ability to

reestablish an arch form is lost and facial widening or asymmetry may result.

Surgical Considerations -

• Facial asymmetry is treated similarly as malunions/ malocclusions.

• facial asymmetry is due to a symphysis fracture - pressing medially the mandibular rami until the buccal cortices begin to separate, indicating that the lingual cortices are in contact and proper reduction has been achieved.

• Established facial asymmetries are treated similar to orthognathic surgery.

• If the original injury included a maxillary fracture, a Le Fort I osteotomy might be necessary to correct the deformity.

(A, B) Three-dimensional CT reconstructions of the original injury. Note the displacement of the lingual cortices in the symphysis area. (C) Postoperative panoramic radiograph demonstrating good reduction and fixation of the symphysis fracture. (D) One-month follow-up photograph showing facial asymmetry and right “swelling that never goes away.”

A 16-year-old girl after a motor vehicle collision. She sustained a mandibular symphysis and right condylar fractures. Patient’s symphysis was treated with an open reduction and internal fixation, and the right condyle with a closed reduction. One month after the surgery, the patient complained of facial asymmetry with persistent right facial swelling but no malocclusion.

(E) Preinjury orthodontic records used to plan her reoperation

(F, G) Follow-up 3-dimensional(3D) CT reconstructions to study the cause of the facial asymmetry. Note the facial

widening and the poor reduction of the lingual cortices at the symphysis area. (H, I) Post-

reoperative 3D CT reconstructions. Lingualcortices were reduced by applying pressure on both

mandibular rami until the buccal cortices began to separate.Note the decrease of the intergonial distance. The

condylar fracture was treated closed. (J) Panoramic

radiograph 1 year after reoperation. (K) Photograph 18 months after reoperation with

good facial symmetry.

CONCLUSION

• Even with best efforts, unsatisfactory results such as nonunion,

malocclusion, and facial asymmetry occur during the management of

mandibular fractures.

• A clear understanding of the nature of these posttraumatic mandibular

deformities helps to avoid them.

• Furthermore, the clinician should be familiar with the reoperative techniques

used for the management of these deformities.

REFERENCES1. Luis G. Vega. Reoperative Mandibular Trauma Management of Posttraumatic

Mandibular Deformities. Oral Maxillofacial Surg Clin N Am 23 (2011) 47–61.

2. Ellis E. Complications of rigid internal fixation for mandibular fractures. J Craniomaxillofac Trauma 1996;2(2):32–9.

3. Alpert B. Management of the complications of mandibular fracture treatment. Operat Tech Plast Reconstr Surg 1998;5(4):325–33.

4. Ellis E, Tharanon W. Facial width problems associated with rigid fixation of mandibular fractures: case reports. J Oral Maxillofac Surg 1992;50(1): 87–94.