Internal Fixation of the Mandible - A Manual of Ao/Asif Principles (English, German, Hardcover)
By comparison, the method has received very little attention in North America and the Anglo-Saxon countries. By and large, surgeons in these countries continue to treat mandibular fractures by intermaxillary fixation, possibly supplemented by the use of interosseous wires. Basel, September B. The colleagues of the past 20 years who have contributed to the case material upon which this manual is based are too numerous to credit by name.
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Internal Fixation of the Mandible - A Manual of AO/ASIF Principles | Bernd Spiessl | Springer
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When dealing with bilateral fractures, the plate must span from angle to angle, covering the entire lateral surface of the mandible. At least three screws on either side of the fracture are recommended. Often more screws are necessary due to the poor quality of the bone. The locking reconstruction plate is generally left in place and not removed unless clinical symptoms require hardware removal. However, when using small plates, plate fracture and displacement is very common secondary to the muscle pull involved in the atrophic edentulous mandible.
There are fractures involving the edentulous jaws which are not atrophic in nature. When there is sufficient bone to buttress the fracture and provide adequate healing, the surgeon may choose to use a smaller reconstruction plate. The locking plate system 2. Many surgeons have successfully used the locking system 2.
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The locking reconstruction plate combines all the advantages of a standard reconstruction plate with the locking principle. The thread in the plate holes provides rigid anchorage for the 2. The conventional 2. Wide angulation of the screw is possible which, in certain clinical situations, can be an advantage.
Click here for further details on the locking plate principles. It is very common to use large reconstruction plates that span from angle to angle. By using a template the bending process is facilitated. Click here for a detailed description of plate bending. It can be very helpful to reduce and stabilize the fracture with adaptation plates to allow appropriate bending of the template and reconstruction plate. This is particularly applicable in fractures that are widely displaced, mobile, or unstable.
The adaptation plates are placed on the inferior border to allow excellent reconstruction plate adaption to the lateral surface of the mandible. After the locking reconstruction plate has all planned screw holes used, the adaptation plates are removed. Perfect adaptation of the plate is not required as the locking reconstruction plate 2. The locking reconstruction plate 2. At least three screws must be present on either side of the fracture.
In the atrophic edentulous mandible fracture, the screws are generally placed in the symphyseal region and the angular region. The bone in the symphysis is very often dense cortical bone which may require tapping of the screw hole.
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Apply the plate and stabilize it either with digital pressure or plate-holding forceps. One of the benefits of using a locking reconstruction plate is that perfect adaptation is not required and small discrepancies can be tolerated. Place one screw on either side of fracture in the planned holes closest to the fracture. A threaded drill guide must be used to allow for centric placement of the drill hole for use with the locking screw. Copious irrigation must be applied to cool the bone. A depth gauge is used to determine the appropriate screw length. Click here for a detailed description of screw placement in a reconstruction plate.
Once the screws are placed on either side of the fracture on the first side the surgeon has the option of completing all screws on that one side or placing one screw on either side of the fracture on the opposite side before completing all screws. Due to the poor healing quality of the bone, an autogenous bone graft is often used to facilitate bony union. Common sites of bone graft harvest include the iliac crest or tibia. Autogenous cancellous bone grafts can be added to fracture sites and can be used to augment the native mandible to facilitate healing.
Postoperative x-rays are taken within the first days after surgery.
In an uneventful course, follow-up x-rays are taken after 4—6 weeks. The patient is examined approximately 1 week postoperatively and periodically thereafter to assess the stability of the fracture and to check for infection of the surgical wound. During each visit, the surgeon must evaluate the patients ability to perform adequate oral hygiene and wound care, and provide additional instructions if necessary. Follow-up appointments are at the discretion of the surgeon, and depend on the stability of the mandible on the first visit.
Weekly appointments are recommended for the first 4 postoperative weeks. Postoperatively, patients will have to follow three basic instructions: 1. Oral hygiene Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. A soft toothbrush dipping in warm water makes it softer should be used to clean the oral cavity. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth.
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The bubbling action of the hydrogen peroxide helps remove debris. Physiotherapy Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively.
If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite or tongue-blade training.