Etiology, pathogenesis, clinic of the mandible contractures, their classification. Prevention of contractures and orthopedic methods of treatment.

Etiology, pathogenesis, clinical and orthopedic treatment of fractures that are not properly fused. Causes of the false joints. Dental prosthetics.

Post-traumatic complications of lower jaw fractures.

Contracture – restriction of mobility in a joint. Congenital contractures are rare. They are shown in the form of a talipes. The got contractures can be neurogenic as a result of disease or a trauma of nervous system and posttraumatic (more often) owing to intraarticulate or about articulate damages, traumas or a combustion of soft tissues with the subsequent development of cicatrixes.

Orthopedic treatment of lower jaw fractures . Fractures of the mandible have atypical localization. Gunshot fractures, by contrast, have different locations. Incase of lower jaw fractures displacement of fragmentsis mostly caused by muscle traction, since there are chewing and facial muscles on the lower jaw.

Characteristics of fragments shift in fractures of the mandible.

 In case of fractures in the midline withpresenceofteethoneachfragmentandwithoutbonedefect, theshiftoffragmentscanbeor be nearly invisible, or completely invisible, dependingonevenmuscle traction of the front group on each fragment. Theremaybeaslightturn of the lower edge of the jaw outside,that is caused by traction of chewing muscles  As a result a small crack appears near the lower edge of the fracture line.

Forfracturesofthislocalizationincaseoflossofbonesubstance, shiftoffragmentsis rather visible. Both fragments shift to the midline, which is mostly evident when opening the mouth.

In case off racturea side from the midline (mentalfracture),without loss of bone substance, two fragment so funequal size with unequal muscle traction on each side appear. Thesmallerfragmentshiftsupbecauseofliftingmuscles(sometimesalmostup to the stop of teethoftheupperjaw), and simultaneously forward and inward as a result oftraction of lateral beams of jaw-hyoid muscle. Thebiggerfragments, beingjoinedwithmusclesthatliftandlowerthejawconducts a rotational movenebr in the joint, loweringitsfrontpartdown  and simultaneously shiftes infront a little, under the influence of lateral beams jaw-hyoid muscle. For unilateral mental fracture it is enough to use single-jaw tooth wire splint on crowns or rings

In case of bilateral mental  fracture, when three fragmnts are formed, there is danger of asphyxia caused by tongue falling in, that is shifted backwards down together wth the middle  fragment. An urgent reposition and fixation of fractions is necessary. While rendering first medical aid one should remember the need to extract the tongue and fixing it in a forward position with a large pin.

Among the possible ways of fragments immobilization for this type of fracture of lower jar the optimal one is intermaxillary fixation with Tooth Tire: wired molded or bent aluminum splints with toe loops, belt standard splints by Vasiliev, splints with with the toe lugs of the fast-hardening plastic. The choice depends of specific conditions, presence of material, technological possibilities and other factors.

 Treatment of fractures of the lower jaw with toothless alveolar ridge or with absence of many teeth is done with a help of splint by Vankevich with two planes that trace from the palatal surface of the splint to tongue surface of mandibular molars or toothless alveolar bone.

Technology of splint manufacturing. With an alginate mass an impression of both upper and lower jaws is obtained. The middle proportion of the jaws is defined and the models are molded to the occluder. The degree of moth opening is defined. The frame is bent and a splint of wax is made. The height of the planes is determined by the degree of mouth opening. When opening the mouth, planes must maintain contact with the toothless alveolar process or teeth. Wax is changed for plastic. This splint can be used for bone plasty of the lower jaw for fixing bone grafts. The splint by Vankevich was modified AI Stepanov, who replaced the palatal plate with the arc.

Fractures of the angle, jaw branches and condyle with a slight shift of fragments can also be treated with the above-mentioned devices that provide intermaxillary fixation. In addition to them for treatment of fractures with this localization other means are used. They have a hinge intermaxillary fixation. Such a structure eliminates horizontal displacement of a large fragment with vertical movements of the mandible.

 Pecularities of orthopedic treatment of patients with toothless jaws fractures. Fractures of toothless upper jaw is treated with a help of plate splint. Its construction resembles the basis of prosthesis for toothless jaw. Non-removable arches are attached to the splint, that are joined with a head cap. If there are some teeth on the upper jaw the splint looks like the basis for partial removable prosthesis. Fractures of toothless lower jaw or jaw with several teeth are treated with devices that consist of three parts: a splint, chin sling or chin splints and main caps. . For treatment of fractures of the edentulous mandible, monoblock is frequently used (splint by Port), that consists of two basis that covering the jaw and connecting ridges in the lateral areas of the alveolar processes. Rolls of the monoblock join both basis still.

Monoblock is used for smooth opening of the mouth.. Monoblock splints are made in three stages. The forst stage is obtaining an impression, then molding the models and making templates of wax for defining one’s bite. Then the models are plastered to occluder and splints of appropriate structure are modeled. For carrying the wax model to plastics, they are usually plastered in the cuvette together with the model. For treatment of such patients, preference should be given to surgical methods (bone joint, needle injecting, etc.)

 Posttraumatic complications of fractures of the lower jaw. infrastructure in response to physical forces. These processes work concurrently to complete the sequence of events in bone healing. Histologically, the hard callus is made up of woven bone, which is patterned after capillary ingrowth rather than the lines of force. A highly organized set of successive layers of lamellar bone replaces woven bone under the influence of functional stresses.

Cellular modules or units of osteoclasts and osteoblasts are activated

in sequences of both bone resorption and formation to convert the preliminary contours of the hard callus to the original bony architecture. First,osteoclasts resorb the excess irregular woven bone not subjected to strains or loads. Osteoblasts then deposit a new organic matrix of lamellar bone that later mineralizes, resulting iew struts of mature bone laid down along lines of stress. These sequences continue to cycle, re-establishing the marrow cavity as well as restoring the structure of normal, haversian system.

Once bony strength and structure are re-established, the processes of modeling and remodeling continue on a lesser scale as part of normal homeostatic mechanisms managing physiological demands on the bony skeleton.

Primary bone healing, or osteonal healing, referred to earlier, differs

histologically from the sequence of events just described, which is typically termed secondary healing. In the case of primary bone healing, mechanical factors such as lack of motion and close apposition of the fracture site, which typically occurs in the proper application of rigid compression plates,

allow direct internal remodeling and intracortical healing to take place. Primary bone healing occurs in fractures treated with open reduction and rigid internal fixation when the fractured bone ends are closely apposed and immobilized. This sequence of fracture repair lacks significant inflammation, a cartilaginous or mesenchymal intermediate (as found in endochondral or intermembranous healing), or callus formation. Existent osteoprogenitor cells differentiate into osteoblasts, and locally derived osteoclasts of osteogenic or hematological origin initiate bone healing. Units or cones of osteoclasts move across the fracture line, resorbing dead bone.

Another cone of osteoblasts trails behind, depositing woven bone parallel to the axis of the long bone. This process parallels the intramembranous ossification that occurs in embryological development of flat bones. Primary bone healing incorporates and connects haversian systems, remodeling bone at the fracture site. New osteons traverse the fragments of broken bone, culminating in direct osteonal union.

MIDFACE FRACTURE CLASSIFICATION

No description of the fracture patterns of the midface has succeeded that of Le Fort. Le Fort’s classification though, is not a pure maxillary fracture classification as many other facial bones are involved. However, it should be noted that the majority of maxillary fractures are seldom isolated and are usually comminuted, involve numerous combinations of Le Fort–type fractures. Le Fort described three zones of transverse weakness in the midfacial skeleton that resulted in predictable fracture patterns.

1. Le Fort I Fracture (30%):

A horizontal fracture pattern that extends in a transmaxillary

direction at the level of the piriform margin.

Bilateral iature and should result in a ‘‘floating palate’’ disconnecting the upper maxillary alveolus from the cranial base.

Frontal (A) and lateral-oblique (B) views of the skull, illustrating Le Fort fracture patterns. The Le Fort I fracture (I) is a transverse disruption of the midface through the pyriform aperture. The Le Fort II fracture (II) separates the central midface (i.e., the nasal and maxillary bones) from the rest of the craniofacial skeleton.

The Le Fort III fracture (III) dissociates the entire midfacial skeleton, including the central midface and orbitozygomatic complexes from the cranium. All maxillary fractures disrupt either the pterygoid plate (as shown by the dotted line in B) or pterygomaxillary junction.

Palatal fracture pattern classification: (I) dentoalveolar; (II) sagittal; (III) parasagittal; (IV) para-alveolar; (V) complex (not shown), i.e., involving multiple fractures; (VI) transverse.

2. Le Fort II Fracture (42%)

Pyramidal=subzygomatic fractures that produce dissociation of the central midface from the orbitozygomatic complex.

3. Le Fort III Fracture (28%)

Also termed ‘‘craniofacial disjunction.’’Fracture produces a separation through the frontozygomatic suture and nasofrontal junction. Vertical or palatal fractures of the maxilla have been comprehensively classified by Hendrickson et al. These fractures are rare, occurring in only 8% of Le Fort fractures. However, they are important to recognize as the disruption of the maxillary arch significantly increases the potential for malunion and malocclusion. Midfacial fractures very rarely cause airway obstruction but basic trauma management principles should be applied. Establishing an airway, controlling significant hemorrhage, and identifying and managing associated injuries (especially intracranial and cervical spine) are essential. Most patients do not require a surgical airway at time of presentation to the emergency room. Intraoperative airway management usually consists of a reinforced nasotracheal tube sutured to the nasal membranous septum to allow for fracture site exposure and intermaxillary fixation. If a nasal tube is contraindicated (e.g., severe nasal structural damage, significant skull base fracture), an oral endotracheal tube positioned behind the third molar and secured to a molar tooth with 26-gauge steel wire can be used. Rarely and usually in panfacial injuries is a tracheostomy required. Caution should always be used before passing any tube (nasogastric, etc.) through the nose of a patient with a midfacial fracture owing to the theoretical risk of an associated skull base fracture allowing the tube to be passed intracranially. Owing to the very significant midfacial blood supply, maxillary fractures can result in life-threatening hemorrhage. In addition, the bleeding can be occult iature with more blood passing from the nasopharynx into the oropharynx than is seen externally from the mouth or nose. Significant hypovolemia can develop before the extent of the bleeding is appreciated and often this is only following the violent emesis produced by large volumes of blood in the stomach. In the presence of severe bleeding, nasal packing can be lifesaving. Caution should be exhibited, however, in the presence of a displaced mobile maxilla as routine anterior nasal packing may further displace the segment and thus not offer any sustained pressure to control the bleeding. Posterior nasal packing using a Foley catheter inserted through both nares into the nasopharynx can be required. The catheter’s balloons should be air-inflated and are pulled anteriorly to close off the posterior choanae. The catheters are tied to one another externally, and in addition, the anterior nasal chambers are packed with a roll of gauze wadding to complete the tamponade. Should these measures fail to control hemorrhage, urgent selective angiography and embolization is indicated. Fractures of the mandible are common. The goal of treatment of mandible fractures should be to return the patient to a preinjury state of function and aesthetics. The treatment of these injuries has evolved from closed treatment to open techniques with wire osteosynthesis to open techniques with rigid internal fixation with the goal of avoiding maxillomandibular fixation. Insight into the biomechanics and the biology of primary bone healing has contributed to the current trends of mandibular fracture treatment.

DIAGNOSIS

The gold standard for diagnosing a mandible fracture is a thorough history and physical examination. Careful inspection and palpation will reveal fractures in most cases. The clinical evaluation is supplemented by radiographic imaging for diagnosis and treatment planning. Panoramic tomography is the standard imaging modality for evaluation of suspected mandibular fractures. The other methods include the mandible series, computed tomography, and zonography. Zonography is a tomographic technique used for imaging of the mandible with relatively good resolution; it is conducted with the patient in the supine position. This allows zonography to be applicable to the polytrauma patient, contrary to panoramic views, which are obtained with the patient in the upright position, thus limiting their use to ambulatory patients who can stand or sit upright.Panoramic views are considered to be superior in detecting fractures to both plain radiography and nonhelical CT scans.Wilson et al. showed the sensitivity of helical CT to be 100%, compared to 86% for panoramic tomography, for diagnosing mandibular fractures. Coronal and oblique parasagittal reformatted views of the mandible provide details of fractures that are not clearly visualized in the axial plane alone.

Though getting a helical CT on every suspected mandibular fracture would be prohibitively expensive, this modality is specially useful on a case-by-case basis especially for imaging the posterior mandible, involving the ramus and condylar region.

 CLOSED VERSUS OPEN TREATMENT OF MANDIBULAR FRACTURES

Mandibular fractures have been successfully treated by closed-reduction methods for hundreds of years. Maxillomandibular fixation (MMF) is used to immobilize the fractured segments and allow osseous healing.

When considering between open versus closed reduction of mandibular fractures the advantages should be weighed against the disadvantages.

Considerations include the site and characteristics of the fracture and the morbidities of the treatment. Unwanted results including bony ankylosis or decreased mouth opening can be prevented by early mobilization ofthe mandible. Early mobilization helps to prevent possible ankylosis especially in patients with intracapsular fractures of the condyle. It is preferred to avoid maxillomandibular fixation when fractures involve the temperomandibular joint (TMJ) because postoperative physiotherapy can be started much earlier.

Advantages of closed reduction include simplicity, decreased operative time, and avoidance of damage to adjacent structures. Disadvantages of maxillomandibular fixation include inability to directly visualize the reduced fracture, need to keep the patient on a soft diet, and difficulties with speech and respiration. Open reduction of fractures via a transoral or transfacial approach can lead to morbidity by causing damage to the surrounding structures as a result of obtaining access for fracture reduction and treatment.

The traditional length of immobilization of fractures when treated by closed reduction has been 6 weeks. Juniper and Awty found that 80% of mandibular fractures treated with open or closed reduction and maxillomandibular fixation had clinical union in 4 weeks. They were able to show a correlation between the age of the patient and the predictability of early fracture union. Armaratunga found that 75% of mandible fractures had achieved clinical union by 4 weeks. Fractures in children healed in 2 weeks whereas a significant number of fractures in older patients took 8 weeks to achieve clinical union.

Although maxillomandibular fixation has long been considered a benign procedure it can be associated with significant problems. An excellent review of the deleterious effects of mandibular immobilization on the masticatory system is provided by Ellis. Closed reduction of mandibular fractures can adversely affect bone, muscles, synovial joints, and periarticular connective tissues.The effects of immobilization on bone have been recognized in the orthopedic literature for many years as ‘‘disuse osteoporosis’’. Cortical and trabecular thinning, vascular distention, and increased osteoclastic activity have been described following joint immobilization. Changes involving the musculature include not only muscle atrophy but also changes in muscle length and function. Compression plates cause compression at the fracture site making primary bone healing more likely. These plates can be bent in only two dimensions because of their design and if they are not contoured properly they are unable to produce compression. It is important to avoid compressing oblique fractures. They also require bicortical screw engagement to produce even compression along the fracture line. This necessitates their placement at the inferior border to eliminate damage to the inferior alveolar neurovascular structures or the roots of the teeth. A higher incidence of complications has beeoted in fractures treated with compression plates.Because of the relatively small cross section of bone surface in some fractures, interfragmentary compression is ofteot possible.

 

A. Displaced left condyle fracture. B. Anterior open bite. C, D. Postoperative occlusion and radiograph

These fractures can be treated by either open or closed reduction methods. Closed techniques often entail wiring a mandibular prosthesis in place with circumandibular wires to stabilize the fracture. The second Chalmers J. Lyons Academy Study of fractures of the edentulous mandible reviewed 167 fractures in 104 edentulous mandibles. Fifteen percent of the patients developed a delayed fibrous union and 26% treated by closedreduction techniques had problems with union. The fewest complications occurred with the patients who received transfacial open reduction and internal fixation.

 

Because of the mandibular atrophy and the decreased number of osteoprogenitor cells associated with these fractures, an iliac crest bone graft is often performed to aid in healing. The benefits of grafting should be weighed against the morbidity of graft harvest in elderly patients.

The treatment of mandibular fractures has evolved with the experience gained and widespread acceptance of miniplates in mandibular fracture fixation. We retrospectively studied 32 male prisoners treated at our county facility who had a parasymphysis and contralateral mandible angle fracture.

These patients were operated on by a single surgeon (AP) with an intraoral approach and fixated with 2.0 miniplates (Synthes Maxillofacial, Paoli, PA). Preoperatively, 11 patients had paresthesia on the side of the parasymphysis fracture, eight on the side of the angle fracture, six 

 

bilaterally, and seven had no paresthesia. These patients were followed for 3 months postoperatively. If a third molar was present it was extracted prior to placement of the arch bars. The arch bars were then applied from first molar to first molar and the patient placed in maxillary mandibular fixation. The parasymphyseal fracture was exposed by a layered mucosal and muscular incision and access was obtained to the fracture, after careful dissection of the mental nerve which was identified in all cases. Two 2.0 miniplates, one at the inferior border of the mandible and the second above it, were placed. The inferior plate was fixated with bicortical screws and the superior plate stabilized with 4–6-mm monocortical screws. The superior plate was place above the mental foramen in 20 cases and there was

What is muscular disturbance?

Muscular disturbance plays a major role in Temporomandibular (TMJ) joint dysfunction. In many cases of TMJ syndrome, inflammation and muscle spasm occurs give rise to pain, inability to open the mouth wide(trismus), and in sever cases, jaw lock. TMJ joint dysfunction is a term to describe a collection of signs and symptoms pertaining to the Temporomandibular joint degneration and/or the disturbance of the muscle of mastications. Patient most often referred to these symptom as clicking, crepitus, tinitus, headache pains for a period of time, sore muscle and jaw. Occasionally, these symptoms come and go, and may be disappear after a while. This “silent stage” may be a precursor to the more serious joint degeneration, or just part of the adaptation which the joint-occlusion-muscle complex adapt to operate at the satisfactory threshold, borderline level. Nevertheless, patient will almost always benefit from early intervention in order to avoid possible joint degeneration. In many cases, symptom can be relieved or reduced greatly with treatment.

What are the muscles involved with the TMJ joint-occlusion complex?

The muscle of mastication work synchronously in pairs to help guiding masticatory movement such as opening and closing of the mandible.

The major muscle pairs that involve with opening (depressor muscles) are:

• Digastric: This is a sling muscle, arises from the mastoid notch, attached to the tendon on the hyoid bone, and sling forward to the digastric fossa of the mandible. Its contraction pulls the mandible down and back. This muscle will be exquisitely sensitive to palpation if the mandible is chronically posteriorized

• Inferior head of lateral pterygoid muscle: originates from the lateral surface of the lateral pterygoid plate and inserts at the neck of the condyle. Its contraction pulls the neck of condyle and cause the mandible to glide forward (This occurs after the condyle has rotated and mandible open about 21mm). This muscle will exhibits soreness and pain to palpation upon chronic dysfunction

The major muscle pairs that involve with the closure(elevator muscles) of the mandible are:

• Temporalis: Divided into the anterior portion which elevates the mandible and the posterior portion which retracts the mandible. Its middle portion both elevates and retracts. This muscle can be palpated and show tenderness in TMJ patient

• Masseter: Originates from the medial surface of zygomatic arch and inserts into the lateral surface of the ramus and angle of the mandible. Its contraction produces a powerful force to elevate the mandible. This muscle shows excessive tonus in clenching or bruxing patient

• Medial Pterygoid: Originates from the medial surface of the lateral pterygoid plate and inserts on the medial surface of the angle of the ramus of mandible forming the fascial sling with the masseter muscle

There are the suprahyoid muscles which plays minor role (except for the digastric muscles which depress the mandible) in guiding the movement of mandible and swallowing. They are: Geniohyoid, Mylohyoid, Platysma, and the Digastric.

The superior head of the lateral pterygoid muscle arises from the infratemporal surface of the greater wing of sphenoid and inserts on the anteromedial portion of the TMJ disc. In TMJ patient that exhibits clenching and bruxism, the superior head of the lateral pterygoid muscle contracts at the end of power stroking during closure of the mandible. Unilateral contraction of the inferior head of the lateral pterygoid contributes to the lateral movement of the mandible.

What happen to the muscle surrounding the osteroarthitic TMJ? The primary purpose for the muscle is to keep the parts of the joint they straddle in contact. With the disc no longer interposed between the condyle and eminence, these bones articulates against each other and degenerate. The degeneration brings about wearing down the articular surface and shorten, which causes the muscles straddling the joint to shorten its contracting length (the muscle pull distance is shortened). When the muscle pull distance is shortened, the strength increases and further rub the bones against each other and further wear down its articulating surface. This vicious cyle of shortening, break down, shortening, is established.

How is the splint designed to help balance the muscle involved in TMJ dysfunction patient?

The splint is designed to:

• position the mandible such that the muscle involved can be function in harmony by eliminating all the interference and stimulatory factor from the occlusion.

• artificially decompresses the tissue of the TMJ and allow the disc to function between the articulating surfaces of the condyle and the glenoid fossa.

• by discluding the teeth, the splint help to reduce the proprioception into the central nervous system and thus “deprogram” the mandible from its position. Now the mandible is positioned by the balancing and harmonious functioning of the muscles, not by the occlusion of the teeth.

• restores foreshortened masticatory muscles to their resting length. As this occurs, the electrical activity of muscles will decrease since the muscles are allowed to rest more between function.

• restores the component parts of the TMJ to the normal physiological position, allows for a normal range of function concerning condyle-disc-eminence complex, and stabilizes and limits TMJ functional movements to promote healing to the tear or fibrosed ligaments.

What are the various splint designs and their application? Maxillary appliances are popularized by crown and bridge restorative dentist due to the fact that they usually restored the mandibular teeth first and therefore want this arch to be unencumbered by the presence of the splint. However, it binds up with the maxillary and palatine bones and interfering with their movement. I always try to place the splint on the mandibular arch for this very reason. It is also unesthetic and therefore poor patient compliance. The followings are the available splint designs:

Maxillary appliances:

• Smooth surfaces – myalgia patients

• Central occlusion

• Pull forward (SVED)

• Distalization of the mandible

• Thompson (pivot) – for closed lock

• Palatal expansion

• Sagittal – for incisal interference

Mandibular appliances:

• Entirely flat – myalgia patients

• Pull forward – for bilateral reciprocal clicks, unilateral reciprocal clicks, and unilateral closed locks

• Pivot – for bilateral closed-lock TMJs

Others:

• Flexible nightguard

• Preformed nightguard

• Bionator

• Fillings on second molar or second premolar to increase the vertical

• Posture erector or correct forward head posture and chronic cervical extension

If the problem is musculature in nature with no joint derrangement (no clicking or popping or crepitus), a flat mandibular splint is used. In the case of unilateral or bilateral reciprocal clicks, a pull forward splint should be used, constructed at the point anterior to that at which the click occurs. In the case of bilaterally closed locked TMJ joints, pivotal splint is used to move both condyles inferiorly simultaneously. When the patient begin to click, the splint is converted to a pull forward splint constructed slightly anterior to the point of the click. Whenever patient exhibits a closed lock unilaterally, the pull forward splint will be deliverred with the use of the molt retractor with local anesthesia or manually to allow decompression of the tissues or in some case the disc will be able to pop into place. Finally, flat or pivotal splint for the unilateral or bilateral reciprocal clicking joint should be avoid because the mandible drops posteriorly during sleep causing the clicking joint to become closed-locked.

How do we know that the splint is working as expected? Often we need to change our splint design as the joint complex evolves into different stage during healing. Overally, these are the positive signs of a “working” splint design:

• No joint noise

• Interincisal opening of 48 mm or more

• No deflection or deviation from opening

• Working excursion of 12 mm or more

• Condyle centered or anterior of center of fossa, radiologically

• Condyle travel past eminence and is separated from it radiologically by 2mm (average thickness of the disc)

• New cortical bone formation if previously degenerated, radiologically

What else do we need to do after the splint therapy has deemed successful?  The next phase of TMJ treatment usually involves orthodontic therapy and crown and bridge. In extreme case, we may need orthonagthic surgery and/or orthodontics and crown and bridge. Rarely will the post treatment stabilization only require equilibration. Equilibration usually will only effective in short symptomatic period, young patient whom the joint complex has not undergone osseous change and his or her dentition does not develop compromising and pathological malocclusion.

What are the contraindication in long term usage of the splint without moving forward to reconstructing the occlusion? In many case, due to financial limitation, patient is unable to move forward into the second phase of reconstructive treatment. The splint will then act as part of the palliative treatment (supportive treatment) and the symptom may relapse due to many factors to be mentioned below. Long term usage of the splint will:

• Posterior open bite: this phenomena happened when the patient continously function with the splint and depressed the mandibular posterior teeth. Anterior disclusion will cause the anterior teeth to supraerupt and further worsen the posterior open bite.

• Fremitus: the phenomena which the anterior teeth contact prematurely during swallowing or functioning, results in traumatic occlusion to the opposing maxillary anterior teeth due to supraeruption of the mandibular anterior teeth. The fremitus will cause localized vertical bone loss, inflammation to the periodontium of the anterior teeth, and may result in periodontal abscess.

• Clicking, popping, and headache may return due to loss of vertical dimension (due to intruding mandibular posteriror) and supraeruption of anterior introducing interference and malocclusion.

I believe if the patient is unable to move to second phase, the splint should be worn intermittently to provide the teeth with antagonistic action and thus avoid these complications to occur. The splint now is function palliatively to alleviate the symptoms of TMJ dysfunction.

 

 

  A fracture is defined as a break in the bone.

TYPES OF FRACTURES

        Green stick fracture:  It is the fracture in the young bone of children where the break is incomplete, leaving one cortex intact .

        Closed fracture: A closed fracture is one whre the fracture haematoma does not communicate with the outside.

        Open fracture:  (Compound fracture)  This is one where the fracture haematoma communicates with the outside through an open wound.  A Compound fracture is a serious injury as infection may gain entrance into the body through the wound and thereby endanger the limb or even life.

        Pathological fracture:  It is a fracture occurring after a trivial violence in a bone weakened by some pathological lesion. This lesion may be a localised one, like a secondary malignant deposit or a generalised disorder like hyperparathyroidism or senile osteoporosis.

        Stress fracture :  It is a fracture occurring at a site in the bone subject to repeated minor stresses over a period of time.

        Birth fracture:  It is a fracture in the new born children due to child due to injury during delivery.

ANATOMICAL TYPES OF FRACTURES

        Various names are given to the fractures according to the types of the fracture lines as transverse, oblique and spiral fractures.

        Comminuted fracture : Here the bone is broken into than two fragments.

        Steallate fracture: This occurs in flat bones of the skull and in patella, where the fracture lines run in various directions from one point.

        Avulsion fracture: This is one, where a chip of bone is avulsed by the sudden and unexpected contraction of a powerful muscle from its point of insertion, e.g. the supraspinatus avulsing the greater tuberisuty of the humerus.

        Impacted fracture: This is one where a vertical force drives the distal fragment of the fracture into the proximal fragment.

        Depressed fracture: This occurs in the skull where a segment of bone gets depressed into the cranium.

MECHANISM OF FRACTURE

        A fracture can be caused by either by direct violence or indirect violence. Direct violence causes a fracture at the site if impact of the force. Indirect violence is one that is transmitted to a bone away from the site of impact producing fracture there.

        The nature of violence can be often inferred from the radiological appearances of the fracture. Direct violence often produces a comminuted fracture.

        Torsion produces an oblique or spiral fracture. It is important to understand the mechanism of fracture as it helps in deciding the manoeuvres for reduction  and the position for stable immobilisation of the fracture.

        When a man falls from a cocount tree or building top and lands on his heels, he often sustains a fracture calcaneum  and a fracture of the spine.  The fracture calcaneum is caused by the direct violence  is cased cased by cased by indirect violence.

CLINICAL TYPES

        From the clinical and treatment points of view, the following types must be recognised.

        Fresh fracture: (1) Closed fracture, (2) Open fracture, (3) Complicated fracture when the fracture is associated with injuries to the neighbouring vessels, nerves or joints.

        Malunited fracture: The patient comes with an old fracture united in a bad position.

        Un-united fracture: The patient presents with and old fracture where the fragments have failed to unite.

        Pathological fracture: This must be suspected when an old person presents with a fracture following minimal violence.

BIOLOGY OF FRACTURE HEALING

        It is important to understand the biological process of fracture healing and the factors influencing, as it helps one to understand the principles of treatment. This process varies in cortical and cancerous bone.

Fracture healing in cortical bone

        The process of healing of a fracture is in many respects similar to the process of healing of an incised wound. In the healing of an incised wound, the gap is first filled with blood which clots and later the haematoma is invaded and replaced  by granulation tissue. As the epithelium grows over the gap, the granulation tissue becomes a fibrous scar. In the healing of a fracture a similar staging can be seen in the earlier phases. However, the end result in the healing of a bone is the formation of mineralised mesenchymal tissue (callus) uniting the broken ends of bone.

        Fracture healing will be considered as a series of phases which occur in sequence but also overlap to a certain extent.

 (I) Inflammatory Phase.

a. Stage or haematoma formation.

b. Stage of granulation tissue.

 (II) Reparative Phase.

a. Stage of fibrocartilaginous callus.

b. Stage of bony callus.

(III) Remodelling Phase.

        Stage of Haematoma: When a bone breaks, the gap is filled with blood from the ruptured periosteal and endosteal vessels. This blood distends the soft tissues and clots to form a haematoma. This process takes about 1-2 days.

        Stage of granulation tissue: The soft tissues in the region undergo the usual changes of acute aseptic inflammation with vasodilatation and exudation of plasma and leucocytes. The clotted blood is invaded by fine capillaries and young connective tissue cells and converted into granulation tissue in about 2 weeks. The cellular element in this mass consists of multipotent mesenchymal cells which are capable of differentiating into fibroblasts, chondroblasts and osteoblasts.

        Stage of callus: The granulation tissue next matures into a fibrocartilaginous mass which holds the fragments together.

        Because of the peculiarities of microcirculation in cortical bone there is some degree of cellular death in the ends of the fracture bone. The fundamental healing response of bone to injury is by the primary callus response.

        Anchoring callus forms a little distance away from fracture site to stabilise the fragments. In order to bridge gaps, the bridging external callus forms to establish contact between fracture ends and promote union. Medullary callus forms late from the medullary cavity to unite with the callus from the opposite end. Thus, according to the situation and function of callus distributed around the fracture site the callus  is described as follows. a) Anchoring callus, b) Bridging callus, c) Uniting callus and d) Sealing callus.

        The fibrocartilaginous mass is converted first into spongy immature bone and later into mature lamellar bone, producing bony union between the fragments in about 8-12 weeks.  This conversion takes place in some areas by membranous ossification and in other areas by endochondral ossification. By this time clinical union of the fracture is complete.

        Stage of Remodeling: Once the fracture has been satisfactorily bridged, the newly formed bone adapts to its new function. The site of fracture undergoes remodeling by muscular and weight bearing stresses and any slight deformity gets corrected by moulding. This remodeling process takes up to a year and is seen better in children.

        Primary bone healing: Healing of fractures has also been achieved by artificial methods of mechanical compression between the fracture fragments. In this, external birdging callus is suppressed and healing is dependent one of the activity of medullary callus and  direct osteonal penetration. Hence, there is no radiologically visible callus. This has been called ‘Primary bone healing’ in the technique of compression plating of fractures.

Fracture healing in Cancellous bone

        In fractues at the metaphyseal ends of long bones and in solid bones like vertebrae, the healing process is different. There is no terminal bone death as in cortical fractures.

        When there is direct contact of fragments, healing occurs by the process of creeping substitution. New trabeculae formed by intramembranous ossification are laid down on the original trabeculae to produce bone between the two fragments. No bridging callus is formed. Once union is estabilished remodelling occurs.

FACTORS WHICH INFLUENCE FRACTURE HEALING

        Fracture treatment is not purely a question of effective fracture reduction and fixation built a complex biological process. The natural tendency for a fracture is to unite . When delay or failure of union occurs, the causes are either local factors at the site of fracture or defects in the methods employed in treatment. Causes interfering with the healing of fractures are:

a) Imperfect immobilisation: (i) Too little extent of immobilisation. and (ii) Too short a period of immobilisation.

b) Distraction : Too heavy a pull of the distal fragment by skeletal traction.

c) Surgical intervention : This empties the frcture haematoma and strips the periosteum, interfering with the blood supply and slowing the healing process.

Local causes

a) Infection : This is the commonest cause for delayed union or non-union in open fractures.

b) Inadequate blood supply to one fragment: Certain sites are notorious for slow union or non-union e.g. (i) Fracture neck of femur. The blood supply to the head of the femur is poor. (ii) Fracture scaphoid. The blood supply to the proximal fragment is poor.

c) Interposition of soft tissues between the fragment prevents bony apposition and interferes with healing.

d) Type of fracture: Transverse fractures unite slowly compared to oblique or spiral fractures.

e) Type of bone: Fracture at the cancerous ends of bone unite better than those in the mid shaft of long bones where cancellous bone is minimal.

General Causes

        Fractures in children unite very rapidly whereas delayed union is common in the aged.  Other factors like protein and vitamin deficiences, general diseases like syphilis and diabetes play only a small part in influencing the rate of healing.

        Bio-Compression at the fracture site through protected weight bearing at the proper time promotes healing of the fractures.

Fracture Clinics in Major Hospitals

        Separate fracture clinics are very essential for better care of patients with fractures in large hospitals. Ideally the entire management must be in one department from the initial treatment to the final medical rehabilitation.

Aim of Treatment

        The aim of the treatment is the restoration of a limb to be functionally and anatomically indistinguishable from the normal. While anatomical restoration is certainly desirable it is far more important to restore the function. It must be remembered that treatment is of the injured limb and the person and not merely of the fractures bone and the injured soft tissue must receive due attention, if the ultimate functional result is to be satisfactory.

Principles of Management:  The general principles of management of fracture patients are:

1. Efficient first aid:  This is down by a splitting. This relieves the pain and prevents complications.

2. Safe transport: This help to minimize complications in injures to the spine, fracture of the lower limbs, ribs etc.

3. Assessment of general condition of the patients for shock and other injuries.

4. Assessment of local condition of the injured limb regarding complications like vascular injury, nerve involvement and injury to neighboring joints and viscera.

5. Resuscitation.

6. Radiography of the part.

7. Reduction of the fracture.

8. Immobilisation of the fragments.

9. Early physiotherapy for the preservation of function of the limb.

10. Rehabilitation after union of the fracture to restore full muscle power and joint movements and to make the man fit for his original job.

TMJ

The temporomandibular joint is the joint of the jaw and is frequently referred to as TMJ. There are two TMJs, one on each side, working in unison. The name is derived from the two bones which form the joint: the upper temporal bone which is part of the cranium (skull), and the lower jaw bone called the mandible. The unique feature of the TMJs is the articular disc. The disc is composed of fibrocartilagenous tissue (like the firm and flexible elastic cartilage of the ear) which is positioned between the two bones that form the joint. The TMJs are one of the few synovial joints in the human body with an articular disc, another being the sternoclavicular  joint. The disc divides each joint into two. The lower joint compartment formed by the mandible and the articular disc is involved in rotational movement—this is the initial movement of the jaw when the mouth opens. The upper joint compartment formed by the articular disk and the temporal bone is involved in translational movement—this is the secondary gliding motion of the jaw as it is opened widely. The part of the mandible which mates to the under-surface of the disc is the condyle and the part of the temporal bone which mates to the upper surface of the disk is the glenoid (or mandibular) fossa.

Pain or dysfunction of the temporomandibular joint is commonly referred to as “TMJ”, when in fact, TMJ is really the name of the joint, and Temporomandibular joint disorder (or dysfunction) is abbreviated TMD. This term is used to refer to a group of problems involving the TMJs and the muscles, tendons, ligaments, blood vessels, and other tissues associated with them. Some practitioners might include the neck, the back and even the whole body in describing problems with the TMJs.

Temporomandibular joint disorder, TMJD (in the medical literature TMD), or TMJ syndrome, is an umbrella term covering acute or chronic pain, especially in the muscles of mastication and/or inflammation or the temporomandibular joint, which connects the mandible to the skull. The primary cause is muscular hyper- or parafunction, as in the case of bruxism, with secondary effects on the oral musculoskeletal system, like various types of displacement of the disc in the temporomandibular joint. The disorder and resultant dysfunction can result in significant pain, which is the most common TMD symptom, combined with impairment of function. Because the disorder transcends the boundaries between several health-care disciplines — in particular, dentistry and neurology — there are a variety of treatment approaches.

The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, neoplasia, and reactive lesions.

Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex, but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth. Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.

Symptoms associated with TMJ disorders may be:

■        Biting or chewing difficulty or discomfort

■        Clicking, popping, or grating sound when opening or closing the mouth

■        Dull, aching pain in the face

■        Earache (particularly in the morning)

■        Headache (particularly in the morning)

■        Hearing loss

■        Migraine (particularly in the morning)

■        Jaw pain or tenderness of the jaw

■        Reduced ability to open or close the mouth

■        Neck and shoulder pain

■        Dizziness

TMJ disorders

Temporomandibular joint and muscle disorders (TMJ disorders) are problems or symptoms of the chewing muscles and joints that connect your lower jaw to your skull.

TMD; Temporomandibular joint disorders; Temporomandibular muscle disorders

Causes, incidence, and risk factors

There are two matching temporomandibular joints — one on each side of your head, located just in front of your ears. The abbreviation “TMJ” literally refers to the joint but is often used to mean any disorders or symptoms of this region.

Many TMJ-related symptoms are caused by the effects of physical stress on the structures around the joint. These structures include:

•        Cartilage disk at the joint

•        Muscles of the jaw, face, and neck

•        Nearby ligaments, blood vessels, and nerves

•        Teeth

For many people with temporomandibular joint disorders, the cause is unknown. Some causes given for this condition are not well proven. These included:

•        A bad bite or orthodontic braces

•        Stress and tooth grinding. Many people with TMJ problems do not grind their teeth, and many who have been grinding their teeth for a long time do not have problems with their TMJ joint. For some people, the stress associated with this disorder may be caused by the pain as opposed to being the cause of the problem.

Poor posture can also be an important factor in TMJ symptoms. For example, holding the head forward while looking at a computer all day strains the muscles of the face and neck.

Other factors that might make TMJ symptoms worse are stress, poor diet, and lack of sleep.

Many people end up having “trigger points” — contracted muscles in your jaw, head, and neck. Trigger points can refer pain to other areas, causing a headache, earache, or toothache.

Other possible causes of TMJ-related symptoms include arthritis, fractures, dislocations, and structural problems present since birth.

Symptoms

Symptoms associated with TMJ disorders may be:

•        Biting or chewing difficulty or discomfort

•        Clicking, popping, or grating sound when opening or closing the mouth

•        Dull, aching pain in the face

•        Earache

•        Headache

•        Jaw pain or tenderness of the jaw

•        Reduced ability to open or close the mouth

Signs and tests

You may need to see more than one medical specialist for your TMJ pain and symptoms, such as your primary care provider, a dentist, or an ear, nose, and throat (ENT) doctor, depending on your symptoms.

A thorough examination may involve:

•        A dental examination to show if you have poor bite alignment

•        Feeling the joint and connecting muscles for tenderness

•        Pressing around the head for areas that are sensitive or painful

•        Sliding the teeth from side to side

•        Watching, feeling, and listening to the jaw open and shut

•        X-rays to show abnormalities

Sometimes, the results of the physical exam may appear normal.

Your doctor will also need to consider other conditions, such as infections, ear infections, neuralgias, or nerve-related problems and headaches, as the cause of your symptoms.

Treatment

Simple, gentle therapies are usually recommended first.

•        Learn how to gently stretch, relax, or massage the muscles around your jaw. Your doctor, dentist, or physical therapist can help you with these.

•        Avoid actions that cause your symptoms, such as yawning, singing, and chewing gum.

•        Try moist heat or cold packs on your face.

•        Learn stress-reducing techniques.

•        Exercising several times each week may help you increase your ability to handle pain.

Read as much as you can, as opinion varies widely on how to treat TMJ disorders. Get the opinions of several doctors. The good news is that most people eventually find something that helps.

Ask you doctor or dentist about medications you can use:

•        Short-term use of acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), or other nonsteroidal anti-inflammatory drugs

•        Muscle relaxant medicines or antidepressants

•        Rarely, corticosteroid shots in the TMJ to treat inflammation

Mouth or bite guards, also called splints or appliances, have been used since the 1930s to treat teeth grinding, clenching, and TMJ disorders.

•        While many people have found them to be useful, the benefits vary widely. The guard may lose its effectiveness over time, or when you stop wearing it. Other people may feel worse pain when they wear one.

•        There are different types of splints. Some fit over the top teeth, while others fit over the bottom teeth.

•        Permanent use of these items is not recommended. You should also stop if they cause any changes in your bite.

Failure of more conservative treatments doe not automatically mean you need more aggressive treatment. Be cautious about any nonreversible treatment method, such as orthodontics or surgery, that permanently changes your bite.

Reconstructive surgery of the jaw, or joint replacement, is rarely required. In fact, studies have shown that the results are often worse than before surgery.

Ankylosis (Temporomandibular Joint)

TMJ – 3D-CT computer image analysis. In this picture is presented TMJ ankylosis.

Ankylosis means fusion of a joint – the fusing together of the bones forming the joint or by the formation of calcium deposits around the ligaments – and can occur either unilaterally or bilaterally, depending on the cause. In the temporomandibular joint (TMJ), ankylosis is most frequently caused by poorly-healing severe trauma or infection. However, it can also occur congenitally, or secondary to severe rheumatoid arthritis or to tumors in the area of the TMJ. In congenital cases, or in children in whom the jaw is still growing, ankylosis can arrest the growth of the lower jaw and cause the face to become asymmetrical.

Symptoms

The chief symptom is a decrease in TMJ range of motion. This results in an inability to chew properly and can make oral hygiene very difficult. In very severe cases it can even cause problems with speech. Ankylosis does not usually cause pain, though pain may be experienced depending on the cause of the condition.

Diagnosis

A dentist or oral surgeon will diagnose the severity of ankylosis by observing the degree to which mouth opening is inhibited. X-rays or other imaging tests such as CT scans or MRI can determine abnormalities in the bony or soft tissue formations in the joint.

Treatment

Jaw exercises may temporarily help to decrease the immobility of the joint in some ankylosis cases, but in most cases treatment of ankylosis will require surgery.

Treatment of ankylosis of the jaw joint involves open surgery to remove the condyle, the rounded end of the lower jaw bone that forms the TMJ. The removed condyle is then replaced with a prosthetic condyle. After the surgery, extensive physical therapy usually plays a crucial role in restoring proper TMJ function.

At the maximum mouth opening, the distance between incisal edges of the middle incisor teeth should be about 3.5 to 4 cm. This distance varies individually, although if a patient cannot open his/her mouth to the distance of at least 3 cm, it can be felt as an unpleasant functional restriction. A restricted ability of the lower jaw to move is designated ascontracture which has several forms:

Inflammatory contracture has its origin at an inflammation around the mandibular elevators (mainly the m. pterygoideus medialis).

Muscular contracture appears by damage of the above mentioned muscle during mandibular anesthesia.

Arthrogenous contracture is caused by inflammations of the mandibular joint or by a chronic traumatization of the joint at occlusion defects.

Fibrous contracture is determined by fibrous changes at the mandibular joint area after traumas or burns.

Neurogenic contracture (trismus) appears at tetanus.

Therapy of restricted mouth opening should focus on elimination of underlying causes. In cases of an inflammation at the mandibular joint area, a temporary loose immobilization of jaws by a wire bonding has its place, besides the anti-inflammatory therapy. At other kinds of contractures, physical therapy (red Solux lamp), active and passive exercises and laser therapy are often used. Fibrous contractures need to be released surgically in some cases.

A total immobility of the mandibular joint is called ankylosis. It is a coalescence of the lower jaw articular process with the temporal bone. Its cause is usually the mandibular joint purulent inflammation associated with otitis or osteomyelitis during childhood, or an intra-articular fracture or contusion with the joint hematoma. It results at a significant restriction of mobility of the mandible. A diagnosis is confirmed by an X-ray examination at Schüller’s projection, or a computer tomography examination. Ankylosis is treated surgically – arthro-plastic surgery – that includes cutting out the bone bridge followed by insertion of other material (fascia, cartilage) into the neo-formed glenoid.

Mandible dislocation is the displacement of the mandibular condyle from the articular groove in the temporal bone. Different types of dislocations can result from traumatic and nontraumatic processes. Most dislocations are managed and reduced in the emergency department with elective follow-up. However, some situations require immediate consultation with an oromaxillofacial surgeon. This article focuses primarily on the diagnosis and management of mandible dislocations in adults.

Anterior dislocation

Posterior dislocation

Superior dislocation

Lateral dislocation

Anatomy

The temporomandibular joint (TMJ) (see the image below) is the articular surface between the mandibular condyles and the temporal bone. Synovial membranes line the space between the two bones. The joint acts with a hinge as well as a gliding mechanism.

The temporomandibular joint.

The temporomandibular ligament, sphenomandibular ligament, and capsular ligament support the joint. Blood supply is from the superficial temporal branch of the external carotid artery. Branches from the auriculotemporal and masseteric divisions of the mandibular nerve innervate the joint.

Closing of the mandible is performed by the masseter, temporalis, and medial pterygoid muscle. The jaw opens at the temporomandibular joint by traction on the mandibular neck by the lateral pterygoid muscle.

Pathophysiology

The mandible can dislocate in the anterior, posterior, lateral, or superior position. Description of the dislocation is based on the location of the condyle in comparison to the temporal articular groove.

Anterior dislocations are the most common and result in displacement of the condyle anterior to the articular eminence of the temporal bone. These dislocations are classified as acute, chronic recurrent, or chronic.

•        Acute dislocations can be seen after trauma or dystonic reactions, but they are usually a result of extreme mouth opening such as with yawning, general anesthesia, dental extraction, vomiting, or seizures. Anterior dislocations after endoscopic procedures have also been reported.

•        Anterior dislocations are usually secondary to an interruption in the normal sequence of muscle action when the mouth closes from extreme opening. The masseter and temporalis muscles elevate the mandible before the lateral pterygoid muscle relaxes resulting in the mandibular condyle being pulled anterior to the bony eminence and out of the temporal fossa. Spasm of the masseter, temporalis, and pterygoid muscles causes trismus and keeps the condyle from returning into the temporal fossa. These dislocations can be both unilateral and bilateral.

•        Acute chronic dislocations result from a similar mechanism in patients with risk factors such as congenitally shallow mandibular fossa, loss of joint capsule from previous mandible dislocations, or hypermobility syndromes.

•        Chronic dislocations result from untreated TMJ dislocations and the condyle remains displaced for an extended time period. Open reduction is often required.

Posterior dislocations typically occur secondary to a direct blow to the chin. The mandibular condyle is pushed posteriorly toward the mastoid. Injury to the external auditory canal from the condylar head may occur from this type of injury.

Superior dislocations, also referred to as central dislocations, can occur from a direct blow to a partially opened mouth. The angle of the mandible in this position predisposes upward migration of the condylar head. This can result in fracture of the glenoid fossa with mandibular condyle dislocation into the middle skull base. Further injuries from this type of dislocation can range from facial nerve injury, to intracranial hematomas, cerebral contusion, leakage of cerebrospinal fluid, and damage to the eighth cranial nerve resulting in deafness.

Lateral dislocations are usually associated with mandible fractures. The condylar head migrates laterally and superiorly and can often be palpated in the temporal space.

Epidemiology

Frequency

Mandibular dislocations are infrequent presentations to the emergency department. Lowery et al reported seeing 37 dislocations over a 7-year period in an emergency setting with approximately 100,000 annual visits. Anterior mandible dislocations are most common and often result from nontraumatic causes.

Mortality/Morbidity

Significant morbidity associated with isolated mandible dislocations is rare. However, fractures of the mandible, maxillofacial, or orbital bones are often seen with traumatic TMJ dislocations.

Mandibular dislocations may be associated with chronic recurrent dislocations, ischemic necrosis of the condylar head, traumatic damage to the articular disk, and mandibular osteomyelitis. Chronic untreated dislocations can result in permanent malocclusion.

Mortality in cases of mandibular dislocation is usually a result of concurrent serious traumatic injuries and not from the dislocation itself.

Treatment

Most temporomandibular disorders (TMDs) are self-limiting and do not get worse. Simple treatment, involving self-care practices, rehabilitation aimed at eliminating muscle spasms, and restoring correct coordination, is all that is required. Nonsteroidal anti inflammatory analgesics (NSAIDs) should be used on a short-term, regular basis and not on an as needed basis. On the other hand, treatment of chronic TMD can be difficult and the condition is best managed by a team approach; the team consists of a primary care physician, a dentist, a physiotherapist, a psychologist, a pharmacologist, and in small number of cases, a surgeon. The different modalities include patient education and self-care practices, medication, physical therapy, splints, psychological counseling, relaxation techniques, biofeedback, hypnotherapy, acupuncture, andarthrocentesis.

As with most dislocated joints, a dislocated jaw can usually be successfully positioned into its normal position by a trained medical professional. Attempts to readjust the jaw without the assistance of a medical professional could result in worsening of the injury. The health care provider may be able to set it back into the correct position by manipulating the area back into its proper position. Numbing medications such as general anesthetics, muscle relaxants, or in some cases sedation, may be needed to relax the strong jaw muscle. In more severe cases, surgery may be needed to reposition the jaw, particularly if repeated jaw dislocations have occurred.

Temporomandibular joint ankylosis (TMA) is a highly distressing condition in which the temporomandibular joint (TMJ) is replaced by scar tissue. The TMA can be classified using a combination of location (intra-articular or extra-articular); type of tissue involved (bone, fibrous, or fibro-osseous); and extent of fusion (complete or incomplete). TMA partially or totally prevents the patient from opening his or her mouth. This disabling condition causes speech impairment, difficulty with mastication, poor oral hygiene, and abnormalities of facial growth, generating significant psychological stress. TMA is most frequently associated with trauma, but local or systemic infection, tumors, degenerative diseases, intra-articular injection of corticoid, forceps delivery, and complication of previous TMJ surgery have also been implicated.

A number of surgical approaches have been devised to restore normal joint functioning and prevent reankylosis. Three basic techniques are used: (a) gap arthroplasty, where a resection of bone between the articular cavity and mandibular ramus is created without any interposition material; (b) interpositional arthroplasty, which adds interpositional material between the new sculptured glenoid fossa and condyle; and (c) joint reconstruction, when the TMJ is reconstructed with an autogenous bone graft or total joint prosthesis.

Surgical intervention for correcting TMA may include autogenous costochondral rib grafts after condylectomy, mainly used for children due to the potential to continuous growth. Gap arthroplasty with tissue interposition between the mandibular ramus and glenoid fossa has been performed mainly in adults. Appropriate interposition materials include: (I) autogenous tissues: meniscus, muscle, fascia, skin, cartilage, fat or a combination of these tissues; (II) allogeneic tissues: cartilage and dura; (III) alloplastic: sialastic materials like acrylic, proplast, and silicone; (IV) xenograft tissues: usually of bovine origin (collagen and cartilage). Gap arthroplasty without material interposition has also been performed. When preserved, the remaining TMJ disc, which has been displaced medially and anteroinferiorly, can be replaced and used as interpositional tissue for preventing reankylosis, in combination with the gap arthroplasty technique. In an alternative intervention described by Salins, no bone is removed from the ankylotic bony mass. The approach proposed by Salins to treat TMA is to convert it into a subcondylar fracture and create a pseudoarthrosis, using the temporal muscle flap and a block of autogenous cartilage or silastic as interpositional material. Partial or total prosthesis for TMJ reconstruction has been used with a variable success rate.

In this report, we present a modification of the conventional vascularized temporal muscle flap, and describe an alternative procedure using a muscle/fascia temporal graft as interpositional tissue for the gap arthroplasty.

Coronal CT slice of the left temporomandibular joint ankylosis.

In some cases, nasofibroscopy or tracheotomy requires general anesthesia; however, for this particular case, those procedures were not needed. A vaseline gauze was placed gently in the external auditory meatus and a preauricular incision was made as described by Al-Kayat & Bramley. An avascular tissue plane along the cartilaginous meatus was established using surgical scissors followed by blunt subcutaneous tissue dissection until reaching the superficial temporal fascia (STF). The STF fascia was then incised and retracted anteriorly to protect the facial nerve branches. The periosteum over the zygomatic was then incised and retracted with the STF, revealing the TMJ which was found fused to the temporal bone. The excess of bone was removed with a large round bur and chisel, beginning from the condylar neck at the level of the mandibular notch; the glenoid fossa was sculpted at the same level as the original fossa. The gap between condyle and glenoid fossa was then created, taking care to maintain at least 5 millimeters of distance between the skull base and all faces of the condyle. The mandible was then mobilized and the new sculptured condyle was checked verify complete release. At this point, an ipsilateral coronoidectomy was performed via intraoral approach.

(A) Intraoperative view of the temporomandibular joint ankylosis. (B) Deep temporal fascia and muscle sutured over the reshaped glenoid fossa. Observe the adequate bone removal and the gap between the skull base and the mandible.

A thin layer of temporal deep fascia and muscle was harvested from an area posterior and superior to the ear in order to avoid any branches of the facial nerve, taking care not to harm the deep temporal muscle blood vessels. The graft was inserted over the glenoid fossa and sutured with the zygomatic periosteu. The wound was then closed in layers, and there was no need to use a vacuum pump.

Soon after the procedure, a new CT was performed;physiotherapy was started 2 days after surgery and maintained for 4 months. During the five years of follow-up, no signs of ankylosis recurrence were observed; maximum mouth opening is currently 35 millimeters.

Postoperative 3D computed tomography of the left temporomandibular joint.

Management of TMJ ankylosis occurs mainly through surgical intervention; several authors agree that it is necessary to use an interpositional material to prevent TMJ re-ankylosis after arthroplasty. This particular aspect of the treatment has been the subject of numerous discussions. The temporalis muscle flap (TMF) has been used for about 100 years for restorations of the facial and craniofacial area; it is also the interposition material most commonly used for correcting TMA due to its ease of handling, proximity to the temporal joint, good functional results, successful clinical results, and minimal complications. However, the versatility of the TMF technique in supplying interpositional material is not certain and failures may occur. Inadequate removal of bone can result in reankylosis. Success in preventing reankylosis after TMJ reconstruction is dependent upon appropriate surgical technique and long-term patient compliance in undertaking frequent mandibular exercise.

The authors have proposed a slight modification of the temporal muscle flap technique, using a free graft of temporal muscle and fascia. Chossegros et al. compared a total full thickness skin graft with temporal muscle flap as interpositional material for treating temporomandibular joint ankylosis. They obtained better results (92% success) for skin graft compared with the traditional technique (83% success). The primary function of the interpositional material is to prevent re-ankylosis by eliminating contact between bone surfaces. This research suggests that a temporal muscle/fascia graft can be an option for interposition material since it is easy and faster to perform compared with the temporal muscle flap technique. Furthermore, it has the advantage of being harvested from the same surgical site.

In conclusion, the authors agree with the statement that the success in preventing reankylosis after TMJ gap arthroplasty is related primarily to the early postoperative physiotherapy, maintained long-term. The technique described above is associated with adequate bone removal and excellent intraoperative joint mobilization. A free graft harvested from temporal muscle and used as interpositional material is easy to obtain, reliable, and effective. Another advantage is minimal damage to the temporal muscle and low morbidity. Nevertheless, the findings presented here are based on a single case; controlled clinical trials must be performed to confirm this hypothesis.

Contracture of the mandible

Trismus may mean reduced opening of the jaws caused by spasm of the muscles of mastication, or it may generally refer to all causes of limited mouth opening. It is a common problem with a variety of causes, and may interfere with eating, speech, oral hygiene, and could alter facial appearance. There is an increased risk of aspiration. Temporary trismus is much more common than permanent trismus, and may be distressing and painful, and limit or prevent medical examination or treatments requiring access to the oral cavity.

Classically, the definition of trismus is an inability to open the mouth due to muscular spasm, but more generally it refers to limited mouth opening of any cause. Another definition of trismus is simply a limitation of movement. Historically and commonly, the term lock jaw was sometimes used as a synonym for both trismus and tetanus. Definitions from popular medical dictionaries vary, e.g.:

“a motor disturbance of the trigeminal nerve, especially spasm of the masticatory muscles, with difficulty in opening the mouth (lockjaw); a characteristic early symptom of tetanus.”

“a firm closing of the jaw due to tonic spasm of the muscles of mastication from disease of the motor branch of the trigeminal nerve. It is usually associated with general tetanus. Also called lockjaw.”

“a prolonged tonic spasm of the muscles of the jaw.”

“spasms of the muscles of mastication resulting in the inability to open the oral cavity; often symptomatic of pericoronitis.”

Normal mouth opening ranges from 35 to 45 mm.  Males usually have slightly greater mouth opening than females. Trismus is derived from the Greek word trismos meaning “a scream; a grinding, rasping or gnashing”

(40-60mm)=(avg-35mm). The Normal Lateral movement is (8-12mm).

Traditionally causes of trismus are divided into intra-articular (factors within the temporomandibular joint [TMJ]) and extra-articular (factors outside the joint)

Commonly listed causes of trismus

Intra-articular:

•        Internal derangement of TMJ / meniscus displacement.

•        Fractured mandibular condyle or intracapsular fracture.

•        TMJ dislocation.

•        Traumatic synovitis.

•        Septic arthritis.

•        Osteoarthritis.

•        Inflammatory arthritis (e.g. rheumatoid or psoriatic).

•        Ankylosis.

•        Osteophyte formation.

Extra-articular:

•        Trauma not involving the mandibular condyle (e.g. a fracture of another part of the mandible, fractures of the middle third of the facial skeleton, fractures of the zygoma or zygomatic arch).

•        Post surgical edema, e.g. removal of impacted lower wisdom teeth, or other dentoalveolar surgery.

•        Recent prolonged dental treatment (e.g. root canal therapy).

•        Following administration of inferior alveolar nerve block with local anesthetic (medial pterygoid).

•        Hematoma of medial pterygoid.

•        Acute infections of the oral tissues, especially involving the buccal space or muscles of mastication.

•        Odontogenic infection.

•        Peritonsillar abscess.

•        Acute parotitis, e.g. mumps.

•        Pericoronitis.

•        Submasseteric abscess.

•        Tetanus.

•        Tetany.

•        Local malignancy.

•        Myofascial pain / temporomandibular joint disfunction.

•        Radiation fibrosis.

•        Fibrosis from burns.

•        Submucous fibrosis.

•        Systemic sclerosis.

•        Myositis ossificans.

•        Coronoid hyperplasia.

•        Malignant hyperpyrexia.

•        Epidermolysis bullosa.

•        Drug associated dyskinesia.

•        Psychotic disturbances, hysteria.

Intra-Articular Causes

Ankylosis

•        True Bony Ankylosis: can result from trauma to chin, infections and from prolonged immobilization following condylar fracture

•        Treatment- several surgical procedures are used to treat bony ankylosis, E.g.: Gap arthroplasty using interpositional materials between the cut segments.

•        Fibrous Ankylosis: usually results due to trauma and infection

•        Treatment- trismus appliances in conjunction with physical therapy.

Arthiritis Synovitis

Meniscus Pathology

Extra-Articular Causes

Infection

•        Odontogenic- Pulpal

•        Periodontal

•        Pericoronal

•        Non-Odontogenic- Peritonsillar abscess

•        Tetanus

•        Meningitis

•        Brain abscess

•        Parotid abscess

•        The hallmark of a masticatory space infection is trismus. Or infection in anterior compartment of lateral pharyngeal space results in trismus. If these infections are unchecked, can spread to various facial spaces of the head & neck and lead to serious complications such as cervical cellulitis/ mediastinitis.

•        Treatment: Elimination of etiologic agent along with antibiotic coverage

•        Trismus or lock jaw due to masseter muscle spasm, can be a primary presenting symptom in tetanus, Caused by clostridium tetani, where tetanospasmin (toxin) is responsible for muscle spasms.

•        Prevention: primary immunization (DPT)

Dental Treatment

•        Dental trismus is characterized by a difficulty in opening the jaw. It is a temporary condition with a duration usually not longer than two weeks. Dental trismus results from some sort of insult to the muscles of mastication, such as opening the jaw for a period of time or having a needle pass through a muscle. Typical dental anesthesia to the lower jaw often involves the needle passing into or through a muscle. In these cases it is usually the medial pterygoid or the buccinator muscles.

•        Oral surgery procedures, as in the extraction of lower molar teeth, may cause trismus as a result either of inflammation to the muscles of mastication or direct trauma to the TMJ.

•        Barbing of needles at the time of injection followed by tissue damage on withdrawal of the barbed needle causes post-injection persistent paresthesia, trismus and paresis.

•        Treatment: in acute phase:

•        Heat therapy

•        Analgesics

•        A soft diet

•        Muscle relaxants (if necessary)

•        Note: When acute phase is over the patient should be advised to initiate physiotherapy for opening and closing mouth.

Trauma

Fractures, particularly those of the mandible and Fractures of zygomatic arch and zygomatic arch complex,Accidental incorporation of foreign bodies due to external traumatic injury Treatment: fracture reduction, removal of foreign bodies with antibiotic coverage

TMJ Disorders

•        Extra-capsular disorders – Myofascial Pain Dysfunction Syndrome

•        Intra-capsular problems – Disc Displacement, Arthritis, Fibrosis, .. etc.

•        Acute closed locked conditions – displaced meniscus

Tumors and Oral care

Rarely, trismus is a symptom of nasopharyngeal or infratemporal tumors/ fibrosis of temporalis tendon, when patient has limited mouth opening, always premalignant conditions like oral submucous fibrosis (OSMF) should also be considered in differential diagnosis.

Drug Therapy

Succinyl choline, phenothiazines and tricyclic antidepressants causes trismus as a secondary effect. Trismus can be seen as an extra-pyramidal side-effect of metaclopromide, phenothiazines and other medications.

Radiotherapy and Chemotherapy

•        Complications of Radiotherapy:

•        Osteoradionecrosis may result in pain, trismus, suppuration and occasionally a foul smelling wound.

•        When muscles of mastication are within the field of radiation, it leads to fibrosis and result in decreased mouth opening.

•        Complications of Chemotherapy:

•        Oral mucosal cells have high growth rate and are susceptible to the toxic effects of chemotherapy, which lead to stomatitis.

Congenital / Developmental Causes

•        Hypertrophy of coronoid process causes interference of coronoid against the anteromedial margin of the zygomatic arch.

•        Treatment: Roronoidectomy

•        Trismus-pseudo-camtodactyly syndrome is a rare combination of hand, foot and mouth abnormalities and trismus.

Miscellaneous disorders

•        Hysteric patients: Through the mechanisms of conversion, the emotional conflict are converted into a physical symptom. E.g.: trismus

•        Scleroderma: A condition marked by edema and induration of the skin involving facial region can cause trismus

Lock-jaw caused due to muscle rigidity.

•        Pericoronitis (inflammation of soft tissue around impacted third molar) is the most common cause of trismus.

•        Inflammation of muscles of mastication. It is a frequent sequel to surgical removal of mandibular third molars (lower wisdom teeth). The condition is usually resolved on its own in 10–14 days, during which time eating and oral hygiene are compromised. The application of heat (e.g. heat bag extraorally, and warm salt water intraorally) may help, reducing the severity and duration of the condition.

•        Peritonsillar abscess, a complication of tonsillitis which usually presents with sore throat, dysphagia, fever, and change in voice.

•        Temporomandibular joint dysfunction (TMD).

•        Trismus is often mistaken as a common temporary side effect of many stimulants of the sympathetic nervous system. Users of amphetamines as well as many other pharmacological agents commonly report bruxism as a side-effect; however, it is sometimes mis-referred to as trismus. Users’ jaws do not lock, but rather the muscles become tight and the jaw clenched. It is still perfectly possible to open the mouth.

•        Submucous fibrosis.

Other causes

•        Acute osteomyelitis

•        Ankylosis of the TMJ (fibrous or bony)

•        Condylar fracture or other trauma.

•        Gaucher disease which is caused by deficiency of the enzyme glucocerebrosidase.

•        Giant cell arteritis

•        Infection

•        Local anesthesia (dental injections into the infratemporal fossa)

•        Needle prick to the medial pterygoid muscle

•        Oral submucous fibrosis.

•        Radiation therapy to the head and neck.

•        Tetanus, also called lockjaw for this reason

•        Malignant hyperthermia

•        Malaria severa

•        Secondary to neuroleptic drug use

•        Malignant otitis externa

•        Mumps

•        Peritonsillar abscess

•        Retropharyngeal or parapharyngeal abscess

•        Seizure

Diagnostic approach

X-ray/ CT scan taken from the TMJ to see if there is any damage to the TMJ and surrounding structures.

Treatment

Treatment requires treating the underlying condition with dental treatments, physical therapy, and passive range of motion devices. Additionally, control of symptoms with pain medications (NSAIDs), muscle relaxants, and warm compresses may be used.

Splints have been used.

What is TMJ ?

TMJ is an abbreviation for the anatomic structure known as the temporomandibular joint. The TMJ is the jaw joint that is located in front of the ear. This is where the lower jaw (mandible) hinges at the base of the skull to allow the mandible to open and function.

In the TMJ the mandibular condyle fits into a socket (glenoid fossa) at the base of the skull. During initial opening of the jaw, the condyle rotates in the fossa. During wide opening of the jaw, the condyle slides forward out of the fossa. In between the condyle and the glenoid fossa is a thick fibrous disc that acts like a cushion between the condyle and the fossa. The TMJ disc normally rides in unison with the condyle as it rotates and slides.

The disc is attached to the superior head of the lateral pterygoid muscle in front. Part of the superior head of the lateral pterygoid and the inferior head of the lateral pterygoid attach to the mandibular condyle in front. These muscle attachments assist in wide opening of the jaw as they pull the disc and the mandibular condyle forward. In back, the disc is attached to loose connective tissue that contains nerves and blood vessels. The entire TMJ is surrounded by a fibrous capsule.

Too often the term “TMJ” is used as a diagnostic term. Many people with pain in the area of the TMJ are told that they have “TMJ”. That is like telling someone with abdominal pain that they have “appendix”.

There are a variety of possible causes for pain in the region of the TMJ. The following is a list of possible causes of pain in the region of the TMJ:

Possible Causes of Pain in the TMJ Region

muscle splinting/spasm (myofascial dysfunction)        muscle inflammation (myositis)

headache (migraine, cluster, etc…)   trigeminal neuralgia

trauma to the lower jaw (fracture, disruption)   unbalanced bite (malocclusion)

TMJ disc dislocation     inflammation of the TMJ (capsulitis)

arthritic changes of the mandibular condyle       tumor in the TMJ region

Only a thorough physical examination and diagnostic testing, if necessary, will reveal whether or not there is a problem with the actual TMJ itself.

TMJ disorders are characterized by functional limitations of the lower jaw. Typically patients complain of not being able to opeormally or report pain with opening, speaking, or chewing. Patients may experience locking of the jaw in the open or closed position and may frequently experience clicks, pops, or grinding in the TMJ region.

Pain, alone, without functional limitations is not diagnostic of a TMJ problem. The cause or etiology for pain in the head and neck region is sometimes hard to find. Too often, when the cause of pain in the TMJ region is not readily apparent, patients are told that they have “TMJ” by default.

If you are experiencing pain in the TMJ region,  only a thorough physical exam and diagnostic testing, if necessary, will determine the cause.

Most patients will initially see their general dentist about a TMJ problem. Typically the dentist will then refer the patient to an oral and maxillofacial surgeon for further evaluation and recommendations for treatment. Some general dentists are experienced with TMJ disorders and may choose to diagnose the TMJ disorder and to initiate treatment themselves.

Dental specialists such as prosthodontists and orthodontists may also provide diagnosis of TMJ disorders and be involved in treatment. Medical specialists such as Ear, Nose and Throat (ENT) doctors may do the same.

Ultimately, however, if a patient needs surgical management of a TMJ disorder, an oral and maxillofacial surgeon will be involved.

A proper TMJ evaluation starts with a thorough head and neck examination. A thorough medical history is also important. This includes any history of trauma to the jaw or history of previous TMJ problems and habits such as clenching and grinding the teeth.

If a TMJ problem is diagnosed, your doctor may order further tests to confirm the diagnosis and to determine the severity of the problem. The following table illustrates the tests used:

Arthrogram         X-ray sensitive dye is injected into the TMJ joint capsule and x-rays of the TMJ are taken. Superior test for determining disc dislocation and disc degeneration or perforation. Sometimes in cases of mild disc dislocations this test may be therapeutic in itself as the fluid dye allows the disc to “float” back into place.

Panorex X-ray     A panorex machine takes a two dimensional x-ray of the TMJ.     Can determine bony changes of the condyle and  fractures or severe dislocations of the condyle. Does not image soft tissue, so the position of the disc cannot be determined by this test.

Tomograms         A specially designed x-ray machine produces images that represent a “slice” through the TMJ.        Can determine bony changes of the condyle. Shows the relationship of the condyle to the fossa in an open and closed position. Does not image soft tissue, so the position of the disc cannot be determined by this test.

Magnetic Resonance Imaging Also known as an MRI. A non-invasive imaging technique for examining soft tissue structures.         Images the soft tissues of the joint. Used to verify dislocations of the disc. Perforations of the disc can sometimes be seen on an MRI.

How do you treat a TMJ problem?

Treatment of TMJ disorders depends upon the nature and severity of the TMJ problem. The following table illustrates the various ways TMJ problems are treated and the indications for those specific types of treatment.

Physical therapy Treatment by a physical therapist using  several modalities of treatment including stretching, heat, and muscle therapy.     Useful for muscular disorders that limit the range of motion of the jaw. Patients with severe TMJ conditions that require surgery often have secondary muscle splinting and spasm. Therefore, physical therapy is very useful in the pre and post-surgical period.

Splint therapy     A hard acrylic splint is used to balance the bite (occlusion) or to reposition the lower jaw in relation to the upper jaw. Useful for people who grind or clench their jaws. Splints may break up the habit of clenching and grinding. Repositioning splints may help “recapture” the disc if the disruption in the joint is relatively mild.

Arthrocentesis     A needle is inserted into the space above the disc (superior joint space) and fluid is injected into the space. An additional needle is then placed into the superior joint space and fluid is run through the joint.     A conservative surgical procedure that is useful  for acute disc dislocations of the TMJ. Inflating the joint with fluid helps to break up any inflammatory adhesions in the joint and allows the disc to float back into proper position. Not useful in severe inflammatory conditions of the joint or chronic disc dislocation with or without disc degeneration or perforation.

Open arthrotomy with disc repositioning The TMJ is opened up surgically through an incision made in front of the ear. The disc is then brought back and tacked down into proper position.  Indicated for disc dislocations with resultant dysfunction or severe pain. This treatment may be necessary for disc dislocations when conservative methods have failed.

Open surgery with meniscectomy    The TMJ is opened and the disc is removed.      This is necessary when the disc is severely deformed or perforated and beyond repair. If the joint architecture is otherwise normal, the disc does not need to be replaced. Scar tissue will form in the joint which will serve as a cushion between the condyle and the fossa.

Open surgery with silastic implant  When disc needs be removed, a silicone sheet is inserted into the joint space. A capsule forms around the silicone sheet. The silicone sheet is then removed in approximately 4 weeks through a small incision with local anesthesia. A capsule will have formed    This is indicated when there has been some degeneration of the condyle or the fossa. A capsule forms around the silicone implant which is left behind after the implant is removed. This capsule serves as a cushion between the condyle and the fossa.

Open surgery with dermal graft       When the disc needs to be removed, it can be replaced with a dermis graft. Dermis is the layer just underneath the skin. The graft is usually taken from the abdominal wall below the waistline. This is indicated when there has been some degeneration of the condyle or the fossa. The dermis graft acts as a cushion between the condyle and the fossa.

Arthroscopy*      Similar to arthroscopy of the knee, a scope can be inserted into the TMJ in order to visualize the joint internally and to perform limited repairs.          Arthroscopy is indicated for acute and chronic disc dislocations and inflammatory capsulitis. Relocating the disc using an arthroscope is challenging and treatment success depends on the operator’s skill with an arthroscope. Most useful for visualizing the TMJ internally without opening the joint surgically and for treating inflammatory capsulitis.

The nature and degree of complications related to TMJ surgery depend on the patient’s anatomy, the degree of degeneration within the joint, and the surgical procedure itself. Patients who have had previous TMJ surgery are at higher risk for complications if additional TMJ surgery is performed on the same joint.

As with any surgical procedure, swelling, discomfort, bruising, infection and bleeding may occur. Numbness, which is usually temporary, may occur around the incision site .

Because of the close relationship between the frontal branch of the facial nerve and the TMJ, paralysis of the upper half of the face may occur on the side where the surgery was performed. This leads to the inability to raise the brow and to close the eye tightly. While this is usually temporary, in some instances problems with the frontal nerve have been known to be permanent.

As with all surgical procedures, the benefits of surgery must be weighed against the risks of surgery. This can only be determined after a thorough examination and discussion with your doctor.

Dislocation of the Temporomandibular Joint (TMJ)

The temporomandibular joint (TMJ), located just in front of the lower part of the ear, allows the lower jaw to move. The TMJ is a ball-and-socket joint, just like the hip or shoulder. When the mouth opens wide, the ball (called the condyle) comes out of the socket and moves forward, going back into place when the mouth closes. TMJ becomes dislocated when the condyle moves too far and gets stuck in front of a bony prominence called the articular eminence. The condyle can’t move back into place. This happens most often when the ligaments that normally keep the condyle in place are somewhat loose, allowing the condyle to move beyond the articular eminence. The surrounding muscles often go into spasm and hold the condyle in the dislocated position.

Symptoms

The jaw locks in an open position and you cannot close your mouth. The condition can cause significant discomfort until the joint returns to the proper position.

Diagnosis

The dentist bases the diagnosis on the position of the jaw and the person’s inability to close his or her mouth.

Expected Duration

The problem remains until the joint is moved back into place. However, the area can be tender for a few days.

Prevention

TMJ dislocation can continue to happen in people with loose TMJ ligaments. To keep this from happening too often, dentists recommend that people limit the range of motion of their jaws, for example by placing their fist under their chin when they yawn to keep from opening their mouths too widely. Conservative surgical treatments can help to prevent the problem from returning. Some people have their jaws are wired shut for a period of time, which causes the ligaments to become less flexible and restricts their movement. In certain cases, surgery may be necessary. One procedure, called an eminectomy, removes the articular eminence so the ball of the joint no longer gets stuck in front of it. Another procedure involves injecting medications into the TMJ ligaments to tighten them.

Treatment

The muscles surrounding the temporomandibular joint need to relax so that the condyle can return to its normal position. Many people can have their dislocated jaw corrected without local anesthetics or muscled relaxants. However, some people need an injection of local anesthesia in the jaw joint, followed by a muscle relaxant to relax the spasms. The muscle relaxant is given intravenously (into a vein in the arm). Rarely, someone may need a general anesthetic in the operating room to have the dislocation corrected. In this case, it may be necessary to wire the jaws shut or use elastics between the top and bottom teeth to limit the movement of the jaw.

To move the condyle back into the correct position, a doctor or dentist will pull the lower jaw downward and tip the chin upward to free the condyle . The doctor or dentist then guides the ball back into the socket. After the joint is relocated, a soft or liquid diet is recommended for several days to minimize jaw movement and stress. People should avoid foods that are hard to chew, such as tough meats, carrots, hard candies or ice cubes, and be careful not to open their mouths too widely.

Prognosis

The outlook is excellent for returning the dislocated ball of the joint to the socket. However, in some people, the joint may continue to become dislocated. If this happens, you may need surgery.

Discussion and examination take place at the initial consultation appointment when the patient reports time of onset, duration and intensity of pain in the affected area. The examination explores the pattern of jaw movement to detect sounds and tenderness to gentle pressure.

Further diagnostic testing is indicated the presence of jaw joint dysfunction is suspected. Further testing is designed to properly diagnose the patient’s problem and to try to reduce the signs and symptoms of the dysfunction. To determine if the lower jaw and the disc of the TM joints are in the correct position, the following diagnostic tests are used:

•        Medical and Dental History as well as an examination of the teeth and the dental arches

•        TMJ Health Questionnaire

Patients are asked questions regarding possible TM dysfunction symptoms. If the patient answers “yes” to any of the symptoms and “yes” to clenching and bruxing, then further tests are required to confirm the presence of a jaw joint problem (TM disorder).

•        Range of Motion

Patients are checked for how wide they can open, slide left and right, move the jaw forward, and whether or not there is a deviation or deflection of the jaw upon opening. If there is a problem achieving normal range of motion, there is usually a structural problem within the joint.

•        Muscle Palpation

Excessive muscle contractions and trigger points indicate a problem with the chewing muscles of mastication. This causes the muscles of the head and neck to be sore when pressed by the dentist. This usually means that the lower jaw is not in the correct position.

•        TMJ X-Rays

TMJ x-rays are important to see if the condyles (top of the lower jaw bone) are too far back where they would be impinging on the nerves and blood vessels at the back of the socket where the jaw bone fits into the skull. In cases where the lower jaw is too far back, dentists find a significant reduction in the signs and symptoms of TM disorders when the jaw is repositioned forward with a splint or a functional orthopedic appliance.

•        Computerized Joint Vibration Analysis

This is specialized equipment used to take readings of the noises or vibrations occurring within the jaw joints upon opening and closing movements. The JVA is simply a 3-minute, non-invasive test where headphones are placed on both jaw joints and the patient is instructed to open and close six times. An abnormal or dislocated joint has distinctive vibrations which can be analyzed to help diagnose the seriousness of the problem.

There are basically 5 stages of disc displacement. Ideally, if there is a jaw problem you would hope that the patient is in Stage 1 or Stage 2 where the disc can be recaptured. If the JVA reveals that the patient is in Stage 3, 4 or 5, this is a much more serious problem and the prognosis is not as good for resolution of all the symptoms.

Our office has the knowledge and experience needed for proper, thorough diagnosis and treatment of temporomandibular joint dysfunction.

TREATMENT

Since the teeth, jaw joints and muscles can all be involved, treatment for this condition varies. Typically, treatment will involve several phases. The first goal is to relieve the muscle spasm and pain as well as establish normal range of motion of the lower jaw. Then, your dentist must correct the way the teeth fit together. Often a temporary device known as an orthotic or splint is worn over the teeth until the bite is stabilized. Permanent correction may involve selective reshaping of the teeth, building crowns on the teeth, orthodontics or a permanent appliance to cover the teeth. If the jaw joint itself is damaged, it must be specifically treated. Although infrequent, surgery is sometimes required to correct a damaged joint. Ultimately, your dentist will stabilize your bite so that the teeth, muscles and joints all work together without strain.

Once a thorough diagnosis has been made, the dentist will begin a personalized treatment program. Patients benefit from the non-surgical, conservative treatment our office provides. Individualized therapy will include muscle spasm reduction treatments in conjunction with an easy to wear, comfortable dental orthotic, referred to as a splint. The orthotic covers the lower teeth holding the jaw in proper alignment, reducing tension in the muscles of the jaw joint, allowing healing to take place. Once pain is controlled and the jaw joint is stabilized, the bite is balanced so the teeth, muscles and joints all work together in harmony.

It is important to assess the posture of each patient to determine whether or not the shoulders, pelvis and hips are level. Photos are taken of each patient to check for the above as well as to check for forward head posture. If there is a problem with the shoulders, hips or pelvis or if one leg is longer than the other, then a referral to a chiropractor would be necessary.

To solve the problem of forward head posture which can cause cervical (neck) problems, referral to a dentist or orthodontist who uses functional jaw orthopedic appliances should be made. These appliances such as the Twin Block, MARA or Herbst Appliance successfully reposition the lower jaw forward and eliminate the forward head posture.

For most patients, treatment is divided into two stages:

1.    Phase I Diagnostic Phase – Temporary Solution

         Diagnostic Splints

2. Phase II Treatment Phase – Permanent Solution

a)      Orthodontics      

b)      Crown & Bridge 

c)      Prosthetics

         Full Dentures      

         Partial Dentures  

d)      Composite buildups posterior teeth

PHASE I DIAGNOSTIC PHASE (Temporary Solution)

 Diagnostic Splints

If there is an improper relationship between the upper and lower jaws and/or the upper and lower teeth, the patient will be required to wear temporary oral appliances (orthotic or splint). This TMJ splint is usually worn over the lower teeth until the bite and position of the lower jaw is stabilized. The objective of the lower splint is to try and establish the correct position of the mandible to the maxilla in three dimensions; namely, transverse, sagittal and vertical. The goal is to try and find a comfortable position for the lower jaw so that the patient can get some relief from the pain and muscle spasms. If the patient has a denture or a partial denture, the splint may be constructed over them similar to the method with natural teeth.

Since most head, neck and shoulder pain originates from muscle instability or swelling and inflammation of the joints, we may employ various physical modalities to treat and help normalize these structures. This includes such things as transcutaneous electrical nerve stimulation (TENS), moist heat therapy, vapor coolant sprays, and infrared treatments. These joints often get very tight in people with dysfunctions and various types of mobilization or stretching techniques are employed to gaiormal function of these tissues.

Infrared Treatment for TMJ

Sometimes it will be necessary to refer patients to other health care practitioners to help relieve some of the muscle spasms including chiropractors, massage therapists, physical therapists, craniosacral therapists, etc. The patient must be made aware of the fact that, although the majority of patients do improve substantially, there are still a small number of patients whose treatment is not effective. The longer the disc is out of position anteriorly, the more the posterior ligaments get stretched and the more difficult it becomes for the posterior ligaments to reposition the disc to its correct position on the head of the condyle.

Some of these patients may have suffered traumatic injuries such as a blow to the head or have been involved in a car accident, which caused a whiplash injury. If the posterior ligaments, which help position the disc between the condyle and the temporal bone, have become stretched or torn as a result of a serious injury, then the prognosis for successful treatment is diminished. Obviously, the sooner the patient can be treated, the higher the success rate.

Near the end of Phase I, which usually lasts four months, the clinician and the patient will evaluate the success of the treatment. The patient will take the same diagnostic tests, clinical examinations, and fill out the appropriate TMJ progress report to see what improvement there is in the signs and symptoms of TM dysfunction. If the tests, including the Joint Vibration Analysis and the tomograms (TMJ x-rays), reveal that the condyle is related properly to the glenoid fossa of the temporal bone and the disc has been restored to its proper position, we would assume there would be a reduction of the signs and symptoms. A consultation appointment is held with the patient to discuss the success of Phase I and the various options for Phase II.

The vast majority of symptoms must be resolved in Phase I Diagnostic Phase prior to the initiation of Phase II Treatment Phase.

PHASE II TREATMENT PHASE JAW STABILIZATION

(Permanent Solution)

1.      Orthodontics

2.      Crown & Bridge

3.      Overlay Partial Dentures

4.      Complete Dentures

5.      Partial Dentures

1.      Orthodontics

         Following diagnostic splint therapy to solve the problem of dislocated jaw joints, most patients have a space between their back teeth. The jaw has been moved to a temporary position where it is pain free. If the patient moves the jaw back to the original pretreatment position, the pain will come back. Therefore, to obtain a more permanent solution, orthodontics is often the treatment of choice, placing braces on the teeth and using up and down elastics to allow the back teeth to touch so the patient will be able to chew properly and with no pain. This is a more permanent solution to jaw stabilization and TMJ health. This stage can last from 12 months to 18 months depending on the severity of the case. If the space between the back teeth is large (more than 3 mm.), then this is often the treatment of choice.

2.      Crown & Bridge

         If the space between the back teeth is minimal (less than 3 mm.) or if the back teeth have large restorations or missing teeth, then the best option might be to close the spaces between the back teeth with crowns and bridges.

3.      Overlay Partial Dentures

         If the patient has limited financial resources, often the treatment of choice would be the placement of an overlay partial denture over the lower back teeth in order to fill the spaces between the back teeth and to stabilize the jaw (TMJ).

4.      Complete Dentures

         If the patient has an old denture or dentures with the teeth all worn down, new dentures could be made with longer back teeth to fill in the spaces between the back teeth.

5.      Partial Dentures

         If the patient has missing back teeth, partial dentures could be made to fill in the spaces between the back teeth.

The important aim of correcting your bite is to ensure optimal long-term health. If you have any of the signs or symptoms mentioned, discuss them with your dentist.

Conventional Method

The physician, applying bimanual intraoral force on the mandibular molars of the patient in an inferior and then posterior direction, will reduce the dislocated condyle back into the glenoid fossa.

The physician places one hand on each of the patient’s cheeks. On one side, the thumb is placed just above the anteriorly displaced coronoid process, and the fingers are placed behind the mastoid process to provide a counteracting force. On the other side, the fingers hold the mandible angle and the thumb is placed over the malar eminence. To reduce the dislocated jaw, one side of the mandible angle is pulled anteriorly by the fingers, with the thumb over the malar eminence acting as a fulcrum. While the mandible angle is pulled anteriorly, steady pressure is applied on the coronoid process of the other side, with the fingers behind the mastoid process

providing counteracting force. The mandible is rotated by this maneuver and the dislocated TMJ is usually reduced on one side. Once one side of the dislocation is reduced, the other side will usually go back spontaneously.

 

In the new external method to reduce dislocated TMJ, each joint is reduced separately. Left side reduction is shown here: A, To reduce left side, the thumb is placed just above the anteriorly displaced coronoid process (black arrow),and the fingers are placed behind the mastoid process (gray arrow). B,

Simultaneously on the right side, the fingers hold and rotate anteriorly the mandible angle (black arrow) and the thumb is placed over the malar eminence as a fulcrum (gray arrow). Aftercare for all patients included restriction of wide mouth opening, soft diet, warm packing, and analgesics if necessary.

DIAGNOSIS OF FRACTURE

        The complete diagnosis of a fracture includes recognition of (a) the presence of fracture and its site (b) the nature of the fracture whether traumatic or pathological, recent or old and (c) the presence of complications.

        History: In cases of children the usual history is that of a fall but the exact nature of the fall is not known. In adults the mechanism of the fracture can be usually made out from the nature of the violence, either a direct injury on the bone or indirect injury by a twist, fall or muscular violence.

        Pain: The patients complain of pain and inability to use the limb.

        Deformity: The presence of deformity in along bones a after injury is a definite sign of fracture.

        Local bony tenderness: This is the most important clinical sign for the presence of a fracture. The tenderness must be localised in a particular point in the course of the bone.

        Credits:  Although creditus felt during the examination of the part diagnostic of fracture, it should not be purposely elicited as it causes severe pain and it may produce further displacement and injury of soft tissues.

        Abnormal mobility: Abnormal movement in a segment of the limb denotes fracture.

        Measurements:  Shortening of a segment of a limb after injury indicates a fracture with over riding of the fragments.

        Radiological examination: The injured part, including the joint above and below, should be radiographed in two views. The radiograph will confirm the presence of the fracture and will also show the displacement of the fragments.

CONSERVATIVE MANAGEMENT OF FRACTURES

        The principle of conservative management is 1) Closed reduction of the fracture by manipulation, 2) Maintenance of reduction.

Reduction of Fracture

        Reduction means the restoration of the normal anatomical alignment of fragments in fractures. This procedure should be painless and with relaxed muscles obtained by anesthesia.

        Before reducing a fracture, one should understand the mechanism of the violence that caused that fracture, the anatomical importance of the fracture site and the displacement of the fragments.

        The common types of displacement to be corrected are:

1. Angulation

2. Rotation of one fragment

3. Over riding and shortening

4. Lateral displacement

        Not all fractures need reduction. Crack fractures and those with very minimal displacement need not be manipulated but need only immobilization till union course.

Maintenance of reduction

        In the majority of fractures, the maintenance of the alignment of fragments is done by immobilisation with plaster of Paris casts.

        Some fractures of the lower extremity like fracture of the shaft of the femur need continuous traction to maintain the reduction and to immobilise the fragments. The methods are (i) Skin traction (ii) skeletal traction.

Immobilisation

        As a general rule, fractures  must be immobilised till the union is complete and this immobilisation is done by plaster casts. The common types of plaster casts are:

1.    Above Elbow plaster cast

2.    Below Elbow plaster cast

3.    U. plaster slab for humorous

4.    Below knee plaster cast

5.    Above knee plaster cast

        Plaster casts should be applied with great care. Never apply complete plaster casts a primary treatment after reduction of fracture. Only a padded plaster slab should be applied. The patient or the parent should be instructed to report immediately if the fingers develop circulatory insufficiency like edema, pallor or cyanosis with increasing pain. The nurse should be instructed to slit the tight bandage down to the skin from end to end and then report to the doctor. The cast should be completed only after 3 or 4 days when the reactionary swelling at their fracture site has subsided.

        In some situations, complete and extensive immobilisation of the part till the fracture units, does more harms than good by producing joint stiffness and loss of function of the part. The following are examples where plaster cast is not necessary is most cases.

        1) Fracture of the neck of the humors in elderly persons: Rigid and prolonged immobilisation of the shoulder in elderly person will lead to permanent stiffness of the shoulder. Movement of the shoulder should be encouraged in 2 or 3 weeks’ times as soon as the soft tissue swelling subsides.

        2) Crack fractures of metacarpal bones. Here rigid immobilisation of the hand in plaster leads to stiffness of all the finger joints, simple strapping of the hand, allowing all fingers free is sufficient.

        3) Crack fractures of metatarsals:  Immobilisation of the leg in plaster casts for such fractures leads to stiffness of the foot and pain on later weight bearing. If there is marked swelling of the foot, a posterior plaster slab and rest in bed for a few days will bring the swelling down. When the swelling has subsided strapping the foot and gradual weight bearing should make the person fit for normal walking in three to four weeks.

Post Reduction Management

        A check radiograph must always be taken after the reduction to confirm the satisfactory restoration of alignment. The restoration of function of the limb must be the one main concern immediately after the reduction and immobilisation of the fracture. All joints, which are not immobilised, should be actively exercised to prevent stiffness. This also keeps the muscles inside the plaster in good tone and minimises wasting.

        The plaster usually gets loose after two weeks, partly due to the subsidence of swelling and partly due to the wasting of muscles under the plaster. Such a plaster must be removed and reapplied in a close fitting manner to prevent and Angulation occurring inside the plaster. This is particularly important in fractures of the forearm bones.

Duration of immobilisation

        In children, the upper limb fractures unite in 3-4 weeks and lower limb fractures unite in 6 – 8 weeks. In adults, the upper limb fractures unite in 6-8 weeks and lower limb fractures unite in 12 – 16 weeks.

Diagnosis of Union of fracture

        When the plaster is removed, the site of fracture is tested for clinical union. The absence of localised bony tenderness at the site is the surest evidence of union of the fracture. The disappearance of the fracture lines in radiograph occurs much later than clinical union. The presence of tenderness and yielding at the fracture is not united. In such cases, if radiographs shown good callus formation, the fracture will unite if the immobilisation is continued for some more weeks. If no callus is seen, it may lead to non union of the fracture requiring surgery.

        If clinical union is present, the plaster is discarded. In the case of upper limb fractures, cuff and collar is kept for a week or two and gradual active movements started.  In lower limb fractures, the limb will sweel up when the plaster is removed. This edema is prevented by the application of an elastic crepe bendage and active movements of joints and graduated weight bearing is allowed under the supervison of a physiotherapist.

Physiotherapy and Rehabilitation

        A good physiotherapy department is essential for any hospital dealing with a large number of fracture patients. Here, therapaeutic exercise and other treatment is carried out by physiotherapists under the supervision of the orthopaedic surgeon.

        In the treatment of fractures, it is very important to restore the full function of the limb as well as that of person, in the shortest possible time. The common disabilities at the end of the fractrures treatment are muscle wasting and joints stiffness and this has been aptly named Fracture Disease. Even when the plaster is on, the patients are made to attend the physiotheraphy department and are taught exercises for the joints which are free. When the plaster is removed, the muscle strength is built up by graduated exercises, and joints are mobilised by active and assisted exercises.

FUNCTIONAL CAST BRACING (FCB)

        Functional cast bracing is a method of conservative management of fractures which permits functioning of the joints and muscles of the limb, while immobilising the fracture.

        Controlled motion physiologically induced is the single most important factor in osteogenesis (Sarmiento). This is the basic principle of all functional bracing .

        The main disadvantage of the plaster cast immobilisation of limb fractures is the stiffness of joints and circulatory stagnation due to prolonged immobilisation and disuse of the limb. This is avioded in functional cast bracing.

        It is generally used in the management of disphyseal fractures of long bones like tibia, humerus. In this method the primary management of the fracture is reduction and immobilisation in a plaster cast. At the end of 3 to 4 weeks when the soft tissue reaction has subsided and the fracture is stickly, the plaster cast is removed and the functional cast bracing is done as a second stag. The extent of the plaster is reduced, joint movements are permitted, and the muscle function is encouraged. Early weight bearing with the cast brace is allowed in the case of lower limb fractures.

        In the treatment of fracture tibia, the initial treatment is by reduction and immobilisation in an above knee plaster slab and cast. After about 3 weeks a Pateller tendon bearing type of below knee cast with an ankle hinge is applied and patient allowed weight bearing. A similar brace with the knee joint is used for fracture femur where the brace extends to the groin.

        This concept of functional cast bracing is a revival of the earlier methods of the 19^th century French school of Championere who practised minimal immobilisation of joints. It also resembles the still earlier splinting of fractures by Hippocrates. The Indian system of bone setting practised by Asans and usthads consists of manipulation and splinting with flat bamboo strips and local application of herbal leaves surrounding the limb and allowing gradual movements of neighbouring joints. This is seen to promote union of fractures in many cases. This is a form of functional cast bracing. Functional cast bracing has a place in selected cases of long bone fractures.

OPEN (SURGICAL) REDUCTION AND INTERNAL FIXATION

        The majority of the fractures could be satisfactorily treated by closed methods. However, some fractures where there is an inherent instability of the fragments or a tendency for delayed union or non-union are better treated by open reduction of the fracture by surgical method and internal fixation.

        Open reduction should be undertaken unless all facilities are available to deal with such cases and perfect aspectic techniques can be assured.

Principles of Open reduction

 1. Anatomically accurate realignment of fragments.

 2.  Rigid fixation with metalic implants.

Indications

        1. Cases where closed methods of treatment have failed to reduce and maintain the reduction.E.g. fracture of both bones of the forearm.

        2.  Fractures where one fragment is retracted by muscle pull e.g. fracture patella, olecranon.

        3.  Fractures where there is difficulty in holding the fragments rigidly in reduced position. e.g. Fracture neck of femur, Monteggia fracture dislocation of the forearm.

        4.  Fractures involving articular surface of joints e.g. Condylar fractures of the tibia femnur.

        5.  Fractures near a joint where a small fragment is displaced and is inaccessible for manual re-positioning e.g. fracture of the medial epicondyle of the humerus with displacement.

        6.  Multiple limb fractures where conservative treatment is difficult in practise and cumbersome to the patient e.g. Bilateral fracture femur or tibia. Fracture femur and tibia in the same leg.

7.    Pathological fracture.

           8. Fracture of distal femur or proximal tibia with vasular impairment in the leg.

        9. Open reduction is also done in the treatment of non-union. Methods of Internal Fixation of fractures

        After open reduction of fractures, the fragments are maintained in position by internal fixation by the following methods. 1) Screws only, 2) Plates and screws, 3) Wires and 4) Intra medullary nails.

        Screw: Screws alone are used to stabilise small fragments like medial malleolus of the ankle, lateral condyle of humerus. The types of screws available are cortical screws, cancellous screws, malleolar screws.

        Plates and Screws: These are widely used in the fixation of disphyseal fractures like fracture both bones forearm, fracture shaft of humerus and tibia. The earlier plates used like the Sherman and Eggers have been replaced by dynamic compression plates and semitubular plates.

        Wires : Wires are used in the fixation of fractures of the pattella and olecranon.

        Intra Medullary Nails : Diaphyseal fractures in the lower limbs are stabilised with intra medullary nail fixation. Example is fracture shaft of femur treated by Kuntscher Intra-medullary nailing.

        Advantages of Internal Fixation: The main advantage fixation is rigid immobilisation of the fragments which helps in earlier mobilisation and quicker restoration of function.

        Disadvantages: Internal fixation involves surgical opening of the fracture site which exposes the site top infection. The stripping of the periosteum during surgey causes interference with the blood supply to the fragments and delays the healing process. Trauma to the soft tissue also contributes to joint stiffness.

        Infection after an operation on bones is a disaster which could lead to chronic osteomyehtis and prolonged misery. Such an iatrogenic complication should be prevented at any cost.

COMPLICATIONS OF FRACTURE

        These complications can be immediate delayed or late. Many of these are preventable and hence great care should be taken to minimise their incidence.

Immediate complications 

        Immediate complications are usually caused by the violence producing the fracture and these occur at the time of fracture or immediately after. These can be general complications like shock or local complications like injury to vessels, injury to nerves or viscera in the vicinity.

Delayed complications

        These are complications, setting in after a few days upto a few weeks. Infection in open fractues causing non-specific wound infection or specific infections like tetanus and gas gengrene occur in the first few days. The other complications are Fat embolism, Volkmann’s ischaemia, delayed nerve injury and Myositis ossificans.

Late Complications

        These occur as late results of the injury or of its mismanagement. These include (1) Malunion, (b) Nonunion, (c) Cross union, (d) Stiffness and contracture of joints, (e) Post traumatic osteoarthrosis, (f) Late nerve palsy (Tardy paralysis).

        Sometimes the injuries to the nerves and vessles are caused by the lack of efficient splinting and injudicious handling of the fractured limb during transport. The most serious complications is an open fracture is infection. Some of the important complications are discribed below.

MYOSITIS OSSIFICANS

Definition

        Mysositis ossificans is a condition wherein there is new bone formation in soft tissues around joints following trauma.

        The name is a misnomer as it is not an inflammation of the muscles. It is better referred to as post traumatic ossification. This condition is quite different from the Myositis ossificans progressiva (described elsewhere) which is generalised.

Etiopathology

        This complication is very common following injuries around the elbow. Myositis ossificans can occur after reduction of the dislocation of the elbow or supracondylar fracture. Sometimes, it occurs even after minim al injuries like crack supracondylar fracture or crack fracture of the neck of the radius. In all these cases, the invariable cause is massage to the elbow and vigorous passive stretching to resore movements of the elbow, given by the bone setters or by well meaning relations of the patient.

        It also occurs around hip joints following head injuries and traumatic paraplegia.

        The exact mechanism of this type of new bone formation is unclear. Following trauma, there is hemorrhage around the periosteum, capsular ligaments as well as muscles surrounding the joint.  In some cases, in the reactionary stage, there is formation of new bone around these tissues. This is called myositis ossiicans.

Clinnical features

        In the early active stage, there is slight warmth with limitation of movements due to muscle spasm In the later consolidating stage a firm lumb is palpable is front of the elbow. In the final stages a bony hard lumb is flt surrounding the elbow with total loss of movement.

Radiological features

        In the early active stage a fussy ill defined radio opacity (cotton wool appearance) is seen in front of the elbow. In the later mature stage the radiograph shows a dense irregular radio opaque mass.

Treatment

        The best treatment is preventive. In all cases of elbow injuries, strict instructions must be giveot to give massage or passive stretching to the joint after removal of the plaster. Even in crack fractures of the lower end of the humerus or neck of the radius, it is a wise precaution to apply a plaster slab for a short time to prevent the elbow being massaged.

        In the active stage, the range or movement is recorded and the elbow is rested in a plaster slab for about 4 weeks. When the plaster is removed it will be found that movement has improved and that the shadow is smaller but denser. Immobilisation may be continued for another 3 weeks for maximum increase of range of movements. The radiograph may then show a dense well defined homogenous calcified mass. Thereafter, active exercise are encouraged.

        When the condition is well established and non progressive, surgical excision of the myositic mass may be done to restore mobility. Some cases may benefit by arthroplasty (excision or replacement ) of the elbow joint.

FAT EMBOLISM

        Fat embolism syndrome is a serious post traumatic complication causing sudden respiratory distress. It occurs within the first few days after major polytrauma or fracture of the pelvis or femur. It can also occur after fracture manipulation or intramedullary fixation operation.

Pathogenesis

        Free fat globules of microscopic sizes from the bone marrow, excape into the blood stream and cause embolic phenomena in the lungs, brain and skin.

Clinical features 

        The condition occurs usually in young adults and is of sudden onset, presenting with acute pulmonary or cerebral symptoms. The early symptoms are shortness of breath, followed by restlessness and confusion. The clinical signs are pyrexia, tachycardia and tachypnoea with dyspnoea and cyanosis. Characteristic petechial rashes develop in the chest, axillae, foot, neck and conjunctiva. Disorientation and coma follow in more severe case which may end fatally.

Investigations

        There is arterial hypoxemia due to pulmonary insufficiency and PA 02 values fall below 60 mm Hg. Thrombocytopenia also occurs. Urine may show sudanophilic granules. Fundoscopy reveals fat emboli in retinal vessels. Chest X ray shows snow storm appearance.

Treatment

        The only specific treatment off fat embolism is directed at improving the hypoxemia due to respiratory distress. Oxygen is administered by nasal tubing or face mask ventilator. Accurate monitoring of blood gases, fluid and electrolyte balance is essential. The use of massive steriod therapy has been found to be helpful. Mild or moderate cases recover in a week or ten days. Massive fat embolism is most often fatal.

NON-UNION

        Non-union is defined as failure of the fracture to unite by bony continuity. It is a difficult and challenging morbidity and needs surgical intervention active rehabilitation.

        Delayed union of a fracture is one where healing has not occurred at the expected time of union for the type and site of the fracture.

Etiology

        The causes of delayed and non-unionn are as follows.

1.     Soft tissue interposition between the fragments.

2.     Segmental fractures with impaired blood supply to the middle fragment.

3.     Comminuted fractures.

4.     Open fractures.

5.     Infected fractures.

6.     Pathological fractures.

7.     Inadequate immobilisation and

8.     Insecure fixation and premature weight bearing.

Pathology : There are two types of non-union.

        The hypertrophic type where the fracture ends are hypertrophic, sclerosed and vascular. There is a fibrous union and this has a biological capacity to unite. The second is the atrophic type where the fragments are inert and a avascular. The ends of the fragments are tapering, osteoporotic and very mobile with sometimes a false joint with even a synovial lining.

Clinical features

        It occurs in long bones like humerus, forearm or tibia. It occurs in intra capsular fracture of neck of femur and in fracture scaphoid. The characteristic sign is abnormal mobility or yielding at the fracture site without pain.

        Radiologically there is sclerosis of fracture surfaced and closure of the medullary canal in the hypertrophic type. There is osteoporosis and tapering of fracture ends in the atrophic type.

Treatment

        Established non-union is long bones has to be treated by operation. The fracture site freshened by excision of the scar tissue and the bones ends fixed by rigid internal fixation and supplemented by cancellous bone grafts to promote osteogenesis.

        Bone tissue has been shown to have natural Bioelectrical properties. Application of electrical current, constant or pulsed has been shown to stimulate osteogensis at the negative electrode. In recent years this technique has been used in cases of non-union, in conjunction with good reduction and immobilisation to promote union of the fracture.

MALUNION

        This means that the fracture has anatomically malunited with angulation, rotation or overriding of the fragments. This is due to failure to reduce the fragments into proper alignment or failure to hold them in position till union.

Clinical features

        The patient presents with a deformity at the fracture site. It commonly occurs at the shaft of long bones e.g. forearm, femur, tibia or at the end of bones e.g. supra conbdylar fracture humerus, Colles’ fracture. Radiology will show the degree of angulation, rotation or overriding of the fragments.

        If the deformity is minimal and the function of the limb is satisfactory the malunion can be accepted. In young children, malunion tends to correct itself by the remodelling at the fracture site. If the deformity is gross or functional disability is marked, malunion is surgically treated by osteotomy, realignment and internal fixation.

CROSS UNION

        This complication can occur in fractures of the shafts of the radius and ulna and in fractures of the tibia and fibula. The proximal fragment of one bone unites with the distal fragment of the other bone. When it occurs in the forearm, supination and pronation movements are lost. In the leg bones cross union is not of much significance.

FRACTURES IN CHILDREN

        Fractures in children are important as the presence of the epiphysis in the long bones makes them vulneravle to damage to the  growth plate, resulting in growth disorder and deformities. There are several difference between children’s and adult bones. Children’s bones are liable and withstand greater bending force than the rigit adult bone. As the periosteum is thick, it remains intact on one side cortex in moderate violence resulting in green stick fractures. Children’s fractures unite much faster than those in adults. In accurate in reduction with angulation can still heal in good shape due to remodelling. Shortening due to overlapping in long bone fractures as in femur, gets corrected upto 1/2 inch due to the stimulation of growth in the epiphysis.

        Injuries in children occurs as domestic injuries at home and at play, mostly due to fall. The types of injures are :

        i.  Birth fractures. Battered Baby fractures Epiphyseal fracture separation.

BIRTH FRACTURES

        These are seen iew born babies and are more common deliveries in breech presentation, particularly when there is difficulty in the labour. Immobilisation by simple strapping for a weeks is sufficient for these fractures. The following are common birth fractures.

        Fracture shaft of femur: This occurs when the obstetrician tries to bring the leg down in the breech delivery by hooking his finger around the groin of the body.

        Fracture shaft of humerus: This also occurs during extraction of the upper limb in breech delivries.

        Fracture chavicle: This occurs during difficult extraction of the after coming head in breech presentation. This is often associated with birth injuries to the brachial plexus. A crack fracture clavicle may be missed at birth and the baby may by brought two or three weeks later with the lumb in the clavicle due to callus formation.

PATHOLOGICAL FRACTURE

        Definition: It is a fracture occurring in a bone weakened by a pathological lesion following a trival injury.

Clinical features

        When a patient presents with a fracture, with a history of a minimal or trival violence, one should suspect pathological fracture. On careful questioning, the patient may admit of having had some local pain or discomfort even before the occurrence of the fracture. The pain at the site of fracture is usually less than that in a traumatic fracture. The causative pathology may be very obvious as in the case of advanced primary malignancy but sometimes the pathological fracture may be the first sign of an occult primary. The common causes of pathological fracture in the elderly is a secondary deposit from a primary malignancy elsewhere or multiple myeloma of bone. Secondaries in bone indicate advanced stage of the disease. Pathological fracture in the vertebrae often presents as an exacerbation of backache and the primary could be diagnosed only it one keeps the suspicion index high.

Radiological features

        The fracture line is often transverse and clean cut. The fracture line runs across a localised osteolytic area in the shaft of the bone. Sometimes the whole bone may show evidence of generalised rarefaction or osteosclerosis.

Causative Pathology

        The lesions which weaken a bone and make it susceptible to fracture could be classified as follows:

                I.  Generalised disorders

                      Children:

1.     Osteogenesis imperfecta

2.     2.  Rickets

            Adults:

3.     Osteomalacia

4.     Osteosclerosis

5.     Hyperparathyroidism

            Old Age:

6.     Generalised Osteoporosis of bone. (Senile or Postmenopausal.)

7.     Paget’s disease of bone.

8.     Carcinomatosis

9.     Multiple Myelomatosis.

                II. Local Lessions

                    Benign :

a.     Solitary bone cyst in children and adolescents.

b.     Parathyroid lesion (localised), Fibrous dysplasia.

c.      Enchondroma of bone in hand and feet.

d.     Osteomyelitis.

        Malignant:

a.     Secondary deposit in bone from primary lesion in Thyroid, Breast, Bronchus,

b.     Kidney or Prostate.

c.      Primary malignant tumor in bone, e.g. Ewing’s tumour.

Management

        A)  Confirm the diagnosis of pathological fracture. This is done by establishing the nature of the causative pathology by,

a)     Thorough clinical examination.

b)    Blood Biochemistry including Serum Calcium, Inorganic Phosphates, Serum Proteins,

c)     Electrophoretic pattern.

d)    Imaging techniques: Plain X ray, Tomography, Computerised Tomography (CT Scan)

e)     and Isotope bone scan, Magnetic Resonance Imaging (MRI).

f)      Biopsy at the site of fracture or any other accessible lesion.

        B) Treatment : This should include, (i) Treatment for the fracture (by reduction and retention of the fragment by immobilisation) (ii) Treatment for the disease. An operative curetting followed by internal fixation will help in establishing diagnosis, removal of the pathology and also treatment for the fracture. Most pathological fracture through a benign lesion like simple bone cyst or enchondroma is treated by surgical curettage and bone grafting with excellent results.

        Most often, the fracture through a maligment secondary deposit occurs in a geriatric patient, who is already debiliated by the primary disease. The management of such a patient needs the team work of the Orthopaedic surgeon, the Geriatric physician, the Oncologist and Radiotherapist so that the elderly person may spend the remaining months of his life free from the miseries of pain. The senior citizen is entitled to enjoy a pleasant quality of life as long as he lives and meet his with dignity.