FRAKTUR MANDIBULA

Anatomi Mandibula

Anatomic units of the

mandible

Muscles of Mastication
OUTER SURFACE

Muscles of Mastication
INNER SURFACE

Muscles of Mastication
4 muscles of mastication
Masseter
Temporalis
Medial pterygoid
Lateral pterygoid

Supplied by V3, testament to same

embryologic origin as the mandible
from the 1st branchial arch

Masseter
Divided into 3 heads

Superficial:

largest head
Arises anterior 2/3rds of the lower border of the
zygomatic arch
Wide insertion to angle, forwards along lower border and
upwards to lower part of ramus

Intermediate:

Middle 1/3 of the arch

Deep:

Deep surface of the arch

Action: elevator and drawing forward

the angle

Masseter
Intermediate and deep fuse and pass
vertically downwards to fuse with
ramus
Nerve and artery divide muscle
incompletely into 3 parts
Masseteric nerve (Br of anterior
division of V3) runs between deep
and intermediate
Br of superficial temporal and
transverse facial runs between
superficial and intermediate

Temporalis
Arises temporal fossa between
inferior temporal line and
infratemporal crest
Inserts at posterior border of the
coronoid process and ascending
ramus
Upper and anterior fibres elevate the
mandible
Posterior fibres (horizontal) retract
the mandible (only muscles that do

Medial pterygoid
2 heads:
Deep:
Larger
Medial surface of the lateral pterygoid plate
and the fossa between 2 plates
Superficial :
Tuberosity of the maxilla and pyramidal
process of palatine bones
Insert lower and posterior part of angle (with
masseter)
Action: upwards and forwards and medially

Lateral pterygoid
2 heads:

Superior:
Infratemporal fossa

Inferior:
Lateral surface of the lateral pterygoid

Fuse into a short thick tendon that

inserts into pterygoid fovea
the upper fibres passing into articular
disc and anterior part of the capsule
Action: side-to-side plus only muscle to open
jaw

Temporomandibular Joint
Articulation
Synovial joint between the condyle of
the mandible and the mandibular
fossa in the squamous part of the
temporal bone
Both bone surfaces covered with
layer of fibrocartilage identical to the
disc
No hyaline cartilage, therefore an
atypical joint

Temporomandibular Joint
Unique feature of the TMJs is the
articular disc.
Composed of fibrocartilaganeous tissue

Divides each joint into 2:

Inferior compartment
Superior compartment

Temporomandibular Joint
Inferior compartment
Allows for pure rotation of the
condylar head,
corresponds to the first 20 mm or so
of the opening of the mouth.
(opening and closing movements)
Superior compartment
involved in translational
movements
sliding the lower jaw forward or side
to side

Temporomandibular Joint

Temporomandibular Joint

Atypical synovial joint separated into upper and lower cavities by a

fibrocartilaginous disc
No hyaline cartilage
Capsule attached high on neck of mandible around articular margin,
then to transverse prominence or articular tubercle and as far
posteriorly as squamotympanic fissure
Fibrocartilage attached around periphery to capsule
Anteriorly near head of mandible, so mobile
Posteriorly near temporal bone, so more fixed
Thinner in middle than periphery, crinkled fibres to allow
movement and contouring
Lateral TM ligament is a stout fibrous band passing from zygomatic
arch to posterior border of neck and ramus, blending with capsule
Tightens with movements away from rest
Sphenomandibular ligament runs between sphenoid spine and
lingula of mandible
Remains constant tension through range of motion as the
lingula is the axis of rotation of the mandible
Sensation supplied by auriculotemporal nerve with some supply
from nerve to masseter (Hiltons law)

TMJ Ligaments
3 ligaments associated with the TMJ:
1) Temporomandibular ligament (Major)
is really the thickened lateral portion
of the capsule, and it has two parts:
an outer oblique portion (OOP) and
an inner horizontal portion (IHP)
Lower border of zygomatic arch to posterior
border of the neck and ramus

TMJ Ligaments
2) stylomandibular ligament (minor)
separates the infratemporal region from
the parotid region
runs from the styloid process to the
angle of the mandible

3) Sphenomandibular ligament
(minor)
runs from the spine of sphenoid to the
lingula of the mandible

TMJ Ligaments
The minor ligaments are important in
that they define the limits of
movements,
ie the farthest extent of movements of
the mandible.
Not connected to joint

However, movements of the

mandible made past these extents
functionally allowed by the muscular
attachments BUT will result in painful
stimuli

TMJ Ligaments

TMJ Ligaments

Nerve Supply
Inferior alveolar nerve branch of
the mandibular division of Trigeminal
(V) nerve, enters the mandibular
foramen and runs forward in the
mandibular canal, supplying
sensation to the teeth.
At the mental foramen the nerve
divides into two terminal branches:
Incisive nerve: supplies the anterior
teeth

Diagnosis Fraktur
Mandibula

 Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang

Anamnesis
Hupp et al:
Who
When
Where
How

Hupp JR, Ellis E, Tucker MR. Contemporary Oral and Maxillofacial Surgery. Ed. Ke-5. Mosby Elsevier. St. Louis. 2008.

a. Siapa pasien tersebut?

b. Kapan trauma itu terjadi?
c. Dimana trauma itu terjadi?
d. Bagaimana trauma itu terjadi?
e.Perawatan apa yang telah diberikan sejak
trauma terjadi (bila ada)?
f. Apakah ditemukan adanya gigi atau serpihan
gigi ditempat kejadian trauma?
g. Bagaimana status kesehatan umum pasien?
h.Apakah pasien mengalami mual, muntah,
pingsan, amnesia, sakit kepala, gangguan
penglihatan, atau kebingungan setelah
kejadian?

Pemeriksaan Fisik
Deformitas
Luka terbuka
Konfigurasi gigi
Maloklusi
Gigi hilang / fraktur

Inspek
si

Palpas
i

Nyeri pada TMJ

False movement

Pemeriksaan Penunjang
X foto cranium AP/L

 X-foto cranium lateral-oblique

 X-foto oclusal

 X-foto proyeksi Eisler

 X-foto proyeksi Townes

 X-foto proyeksi Reverse Townes

Penatalaksanaan Fraktur Mandibula

Prinsip penanganan awal :
Primary survey : jalan nafas (airway), pernafasan
(breathing), sirkulasi darah termasuk penanganan
syok (circulaation)
Secondary survey : pemeriksaan neurologis, scalp,
orbita, telinga, hidung, wajah, rongga mulut, oklusi
Tahap kedua adalah penanganan fraktur secara
definitif : reduksi/reposisi fragmen secara tertutup
(close reduction) dan secara terbuka (open reduction)
Tujuan utama penatalaksanaan fraktur:
mengembalikan oklusi yang stabil
mengembalikan bidang pergerakan yang adekuat
mengembaikan bentuk wajah dan lengkung
mandibula
mengembalikan fungsi tanpa sakit
mencegah internal derangement sendi

Reduksi Tertutup

Reduksi Tertutup
Penanganan fraktur mandibula secara konservatif,
yaitu dengan melakukan reposisi tanpa operasi
langsung pada garis fraktur dan imobilisasi dengan
interdental wiring atau eksternal pin fixation
Indikasi untuk reduksi tertutup (closed reduction)
Favorable fracture : closed reduction
mengurangi resiko keadaan tidak sehat
Comminuted fracture
Kurangnya soft tissue yang menutupi tempat
fraktur
Fraktur pada anak-anak
Fraktur koronoid
Fraktur kondilus

 Teknik yang digunakan secara closed reduction

adalah fiksasi intermaksiler
Fiksasi ini dipertahankan 3-4 minggu pada fraktur
daerah kondilus dan 4-6 minggu pada daerah lain
dari mandibula
Beberapa teknik fiksasi intermaksilaris :
Teknik Gilmer mudah dan efektif tetapi
mempunyai kekurangan yaitu mulut tidak
dapat dibuka untuk melihat daerah fraktur
tanpa mengangkat kawat

 Teknik eyelet (ivy loop) sedikit menimbulkan

kerusakan jaringan periodontal, rahang dapat
dibuka dengan mengangkat ikatan
intermaksilaris. Kerugiannya kawat mudah
putus

 Teknik continous loop (stout wiring) Terdiri

dari formasi loop kawat kecil yang mengelilingi
arkus dentis bagian atas dan bawah, dan
menggunakan karet sebagai traksi yang
menghubungkannya

 Teknik arch bar

Indikasi pemasangan arch bar: gigi kurang/
tidak cukup, disertai fraktur maksila,
didapatkan fragmen dentoalveolar pada salah
satu ujung rahang
Keuntungan penggunaan arch bar : biaya
murah, mudah adaptasi dan aplikasinya
Kerugiannya ialah menyebabkan keradangan
pada ginggiva dan jaringan periodontal

 Teknik Kazanjian : dengan menggunakan kawat

yang kuat untuk tempat karet dipasang
mengelilingi bagian leher gigi. Teknik ini untuk
gigi yang hanya sendiri atau insufisiensi pada
bagian dari pemasangan arch bar

 Teknik Bone Screw : potensi komplikasi pada

sistem ini adalah kondilus dapat tertarik dari
fossa pada pasien yang tidak memiliki gigi
geligi posterior jika kawat ditarik terlalu kuat

Reduksi terbuka
Open reduction adalah tindakan operasi untuk melakukan koreksi
defromitas-maloklusi yang terjadi pada patah tulang rahang bawah
dengan melakukan fiksasi dengan interosseus wiring atau dengan mini
plat+skrup serta imobilisasi dengan menggunakan interdental wiring.
Indikasi untuk open reduction antara lain :
a. Unfavourable fraktur pada sudut mandibula.
b. Unfavourable fraktur pada symphisis atau korpus mandibula.
c. Displaced fraktur kondilus bilateral
d. Perawatan tertunda dari fragmen fraktur non-contacting displaced.
e. Malunions diperlukan osteotomi.
f. Fraktur mandibula dimana maksila lawannya edentulous
g. Fraktur edentulous mandibula dengan displacement yang hebat.
h. Kasus dimana closed reduction merupakan kontra indikasi.

i. Medical compromised pasien.

j. Multiple fraktur tulang wajah
Daerah insisi saat pembedahan di pilih yang paling dekat dengan
fraktur dan yang paling sedikit menimbulkan kerugian.
.

Empat metode insisi di daerah wajah adalah :

1. Intraoral
a. Keuntungannya lebih mudah
dilakukan dan tidak menyebabkan
jaringan parut ekstra oral.
b. Kemungkinan komplikasi dan
infeksi persentasenya hampir sama
dengan pendekatan ekstra oral.
c. Fraktur simfisis dan parasimfisis
dapat diakses melalui insisi
genioplasti. Perhatikan serabut saraf
mentalis agar tidak terpotong.
d. Fraktur korpus, angulus dan
ramus dapat diakses melalui insisi
di vestibular yang dapat memanjang
hingga linea oblique setinggi
dataran oklusal mandibula

2. Submandibula
a. Sering disebut Risdon
Approach.
b. Insisi dilakukan 2 cm di
bawah sudut mandibula pada
lipatan kulit.
c. Lebar insisi sekitar 4-5 cm

3. Retromandibular
a. Pertama kali diperkenalkan
oleh Hinds dan Girotti (1967)
b. Insisi dilakukan kurang lebih
0,5 cm dibawah lubang telinga
dan meluas ke arah inferior 3
3.5 cm di daerah batas posterior
mandibula yang dapat
memanjang ke bawah sudut
mandibula.

4. Preaurikular
a. Pendekatan ini paling baik
untuk membuka daerah TMJ.
b. Insisi dilakukan pada lipatan
preaerikular, kurang lebih
sepanjang 2,5-3,5 cm.
d. Perhatikan agar tidak
melakukan insisi ke arah
inferior, karena dapat melukai
saraf fasialis yang masuk ke
batas posterior glandula parotis.

Ada dua macam fiksasi pada intermaksilar :

1. Wire Intraosteal Wiring (Wire osteosynthesis), tiga teknik dasar :
a. Simple straight wire
b. Figure-of-eight wire
c. Transosseous circum-mandibular wiring (Obwegesers technique)
2. Fiksasi dengan plat atau screw
a. Load bearing osteosynthesis
b. Load sharing osteosynthesis

Komplikasi yang dapat terjadi pada fraktur mandibula sebagai berikut :

a) Delayed union dan nonunion
b) Infeksi
c) Malunion
d) Ankilosis sendi temporomandibula
e) Trauma saraf alveolar inferior dan cabang-cabangnya

ABSTRACT

The article evaluates 12 cases of conservative treatment of

displaced mandibular fractures in adults.

Twelve cases of displaced mandibular fractures treated surgically,

either by closed reduction (IMF) or open reduction internal fixation
(ORIF) served as controls.

Occlusion, maximal mouth opening, lateral jaw movements,

neurological dysfunction (=sensory deficit), and bone remodeling
were evaluated and scored in both groups, and results were
compared.

No sig-nificant differences were found between the two groups in

all the evaluated parameters.

It is concluded that in certain cases, with displacement of 2 - 4

mm, where a surgical approach is not feasible, reasonable
spontaneous reduction and bone remodeling can occur. Meticulous
follow-up is mandatory.

Introduction

Fractures of the mandible are generally treated by closed or open

reduction.

The aim of the treatment is to re- duce the displaced fracture and
restore proper occlusion and facial contour.

The closed reduction methods involve intermaxillary fixation (IMF)

using splints, arch bars, or maxillomandibular fixation screws.

There are several disadvantages with IMF, including:

compromised airway,

poor oral hygiene,

speech difficulties,

impaired nutritional intake

disusing atrophy of the masticatory muscles.

Open reduction and internal fixation (ORIF) using wires, pins,

screws, or plates are among the common methods.

In some reports, closed reduction with IMF was considered as

Material and Methods

Twenty-four cases of mandibular fracture were included in the
present study. The control group (n = 12) was treated surgically
by either closed reduction (IMF) or open reduction (ORIF).
The experimental group (n = 12) was also advised to undergo
surgery, either closed or open reduction. How- ever, due to
personal or medical reasons, they were not operated on.
The first patient, who was the trigger for the present study, was a
34-year-old psychiatric female patient with a displaced fracture
of the mandible, who refused to stay at the hospital for surgery.
For some other participants in the experimental group, there
were medical contra-indications for general anes- thesia due to
comorbid conditions, the legal guardians were not available, or
they refused general anesthesia for some personal or religious
reasons.

 Clinical examination of the functional state of the

mandible was performed by one of the authors (LB) as
part of the standardized procedure followed for all jaw
trauma patients at the hospital.
The examination included:
occlusion, maximal mouth opening, lateral jaw movements, neurological dysfunction (=sensory deficit),
and bone remodeling.
Data were classified according to a numerical scale,
based on the clinical dysfunction index of Helkimo [19]
with modification [20].
The patients were classified as clinically symptom-free
(SF), having mild symptoms (MS), or having severe
symptoms (SS).
Patients in both groups were followed routinely in a
similar manner. The follow-up evaluation was done for
an average of 12 months post-treatment.

 Alpert et al. described four types of

complications:
Wound infection from ORIF
Malocclusion from improper treatment,
injury to the marginal mandibular nerve
due to technical mistakes,
malocclusion from no treatment

 In the present series, 12 patients were

treated conservatively.
The results are more than satisfactory, as
they are very similar to the results of
patients treated by closed (IMF) or open
reduction (ORIF).

 Conservative or non-surgical treatment,

consisting of observation and soft diet
only, has been reported as a treatment
option in greenstick or non-displaced
mandi- bular fractures with normal
occlusion [24,25].
Ellis et al., reports 687 patients, 32% of
the total sample of 2137 patients, did not
undergo surgery for correction of their
mandibular fracture and were observed for
4 - 6 weeks.
Ghazal et al. [25] reported on 28 cases of
mandibular fractures that were managed
by observation and soft diet only. This
conservative approach resulted in

 Conclusion Conservative treatment of

displaced fracture of the mandible carries
higher risk of complications compared to
IMF or ORIF.
However, in certain cases, with displacement of 2 - 4 mm where no other
treatment modality is feasible, it can be a
treatment option with respectable results.
Meticulous follow-up for these patients is
mandatory.

selesai

TERIMAKASIH.