Therapy of the lower jaw fractures

By Dr. Vishaal Bhat on Friday 30 November 2007 with 0 comments



Conservative therapy

Only absolutely non-dislocated fractures with sufficiently firm entanglement of fragments at their normal anatomical positions do not require any repositioning. Simple fractures of teeth-containing jawbones undergo a single manual reposition into a correct mutual position, after needed anesthesia. A gradual, slow repositioning by pulling with rubber hitches or orthodontic appliances is also feasible. In order to keep the resulting position of fragments, fixation by a dental splint is then used. A dental splint is made of a semiround or flat wire, either directly inside a patient’s mouth or indirectly on a dental model. It is necessary to apply a splint to as many firm teeth as possible, to which a splint is attached by wire ligatures (a steel wire 0.4 mm in diameter). A splint provides for fixation of fractures of the alveolar ridge or toothed parts of the jaw body. Sauer’s splint is the most commonly used type at present. Cast metal splints are very firm and functionally suitable, as well.


Mono-fixation.

If an applied splint is reinforced by a fast-hardening resin, it may itself provide for sufficient fixation of simple fractures of the body or alveolar ridge.


Intermaxillary fixation.

A firm intermaxillary fixation ensures a necessary rest needed for healing of fractures of jaws. Such rest can be achieved with the aid of dental splints, applied to both jaws and fitted with wire loops or hooking pins that connect them. Opening of the mouth is thus prevented, jaws are fixed together at an optimal occlusion. This way of fixing possesses a danger of aspiration of blood, vomits or food, however.


Feeding the patients.

During application of fixtures, the food has to be liquid - blended, supplied more often than a regular food, and substituting it sufficiently by its composition and nutritional values. A patient is fed by means of a glass tube or by drinking. Food can be swallowed normally after passing through retromolar spaces, even if a full number of teeth is present. In serious cases, especially at defective fractures of jaws, a patient receives food by a naso-gastric tube inserted through the nasopharynx. An intermaxillary fixation does not allow a patient to speak, it possesses a social handicap and requires a home stay in majority of cases.


Fixation of edentulous jaws by a mono-block.

If jaws are edentulous and dental splints cannot be used, immobilization of fragments is achieved by laboratory made resin blocks, that are interconnected inside the mouth thus forming a mono-block. Fixation has to be supplemented by an outside by “headstall” bandages - a rubber band or an elastic bandage.


Duration of immobilization.

Immobilization of jaw movements in cases of non-complicated fractures of the body, angle, alveolar ridge or ramus should be for 4 weeks (28 days). Fractures of the articular process should be immobilized for 3 weeks. For children, immobilization times shorter by one week are used. Duration of fixation by the dental splint itself should be determined by a fracture location, its nature and course of healing.


Rehabilitation.

After releasing the intermaxillar fixation, it is necessary to reestablish the mouth opening by chewing muscles exercises and movements of the mandibular joint. Heat effects (“Solux” lamp) and various mechanical mouth props are used.


Oral hygiene.

Wire attachments, splints and intermaxillar fixtures hamper self-cleaning abilities of the teeth and gums and urge a patient or medical personnel to do the teeth cleaning 6 to 8 times a day. A toothbrush and toothpaste are used regularly, an irrigation can be used if there is no injury to soft tissues. Patients who are immobilized or unconscious have to have their teeth cleaned chemically (Chlorhexidin).


Surgical therapy.

The aim of current therapy methods is exposing and release of bone fragments, repositioning them followed by fixation at a proper position, performed under a visual control.


Osteosynthesis.

Osteosynthesis means connecting fragments by means of artificial, mostly metal, materials. Connecting elements can be wires, bone splints, screws, clinches and other parts.


Osteo-sutures.

Bone fragments are most often joined together directly by bone wire stitches (a soft steel wire 0.3-0.4 mm in diameter). Stitches can be single, double, cross-like etc. They are inserted into apertures made at bone fragments edges. They should hold these fragments together in a mutual contact (adaptive osteosynthesis). Connection of bone fragments cannot be made firm enough to ensure keeping fragments together without dental splints or intermaxillary fixation.


Rigid osteosynthesis.

Bone splints that are fixed by screws ensure a firm connection so that no other supporting immobilization of jaws by intermaxillary fixation is needed. A danger of aspiration of foreign objects is thus eliminated and allow for suction from airways of unconscious patients or an intubation for general anesthesia, as well as better communication with a patient and good oral hygiene.


A.O. splints.

At the end of the sixties, efforts of Swiss orthopedists and engineers resulted in design of instruments for firm connections of broken bones with help of bone splints and screws fastened into screwed holes with sharp threads. This is the only way of preserving the “live” bony tissue around screws and maintaining a long-term stability of fixation. Splints and screws had been made of austenitic (stainless) steels originally. Today, they are made of almost pure titanium. Splints and screws are absolutely biologically inert for tissues. Due to their massiveness, they had to be removed from an organism after a fracture has healed.


Mono-cortical minisplints and screws.

Attempts to minimize bone splints and screws in use has led the authors to design of the miniplate fixation system (Champy, Pape and others) and to determine the most appropriate placement of splints at different types of the lower jaw fractures. Muscle attachments and draw effects of strong chewing muscles are limiting factors for placement, shape and number of splints. A splint is then fixed to a bone with screws, anchored in the compact tissue. Also these splints and screws are removed after a bone heals (4-5 months).



Other means of osteosynthesis.

If a fracture line slit runs oblique, e.g. at the body of a edentulous jaw, it is possible to perform osteosynthesis by a wire sleeve (circlage). It is also possible to connect fragments by a clinch or a nail (Kirschner’s wire) whose one end sticks out from the skin during healing period and facilitates its removal.

Category: Oro-Maxillo Facial Surgery Notes

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