Plastic Surgery Case Presentation

M FAKHRI KUSUMA W

LAKI LAKI 74 TAHUN DENGAN FRAKTUR SYMPHISIS MANDIBULA DAN

MALOCCLUSION

*Students of Clinical Rotation Program

Medical Faculty of Sebelas Maret University, Surakarta,
Indonesia
Adviser:
Amru Sungkar, dr., Sp.B, Sp.BP-RE(K).

CLINICAL WORK OF MEDICAL UNIT GROUP OF SURGERY

MEDICAL FACULTY OF UNS-REGIONAL PUBLIC HOSPITAL OF Dr.MOEWARDI
SURAKARTA
2019
PATIENT STATUS

• IDENTITY OF THE PATIENT

• Name : Mr. M
• Age : 74 years old
• Gender : Male
• Address : Temanggung, Jawa Tengah
• Admission date : 23 Agustus 2019
• Tanggal pemeriksaan : 29 Agustus 2019
• MR No. : 01473719
 Keluhan Utama

Nyeri pada rahang bawah 12 jam setelah kecelakaan

Riwayat Penyakit Sekarang

Pasien datang ke RSDM dengan keluhan nyeri pada rahang bawah dan
lengan kanan 1 hari setelah kecelakaan. Pasien mengaku nyeri terus
menerus dan tidak berkurang dengan istirahat dan obat dari dokter. Nyeri
bertambah ketika pasien beraktivitas dan mencoba untuk membuka mulut.
2 jam SMRS, pasien mengaku saat berjalan ditabrak dengan sepeda motor
dari arah belakang. Pasien terjatuh tetapi posisi jatuh tidak diketahui.
Pasien menyangkal pingsan (-) mual (-) muntah (-) kepala terasa pusing (+)
kejang (-).
Setelah kejadi pasien mengeluh nyeri pada rahang bawah. Kemudian oleh
penolong pasien dibawa ke RS Swasta di daerah Temanggung. Pasien
dipasang infus, diberikan obat-obatan tetapi tidak tahu jenis obatnya dan
dilakukan rontgen kepala. Karena keterbatasan sarana pasien dirujuk ke
RSDM
RIWAYAT PENYAKIT DAHULU

• Riwayat hipertensi : disangkal

• Riwayat diabetes melitus : disangkal
• Riwayat alergi : disangkal
• Riwayat operasi : disangkal
Riwayat Penyakit Keluarga

• Riwayat hipertensi : disangkal

• Riwayat diabetes melitus : disangkal
• Riwayat alergi : disangkal
• Riwayat operasi : disangkal
Anamnesa sistemik

• Mata : mata kuning (-), mata kemerahan (-)

• Telinga : darah (-), lendir (-), cairan (-), pendengaran berkurang
(-)
• Mulut : darah (-), gusi berdarah (+), maloklusi (+) crosbite
• Hidung : penciuman menurun (-), darah (-), sekret (-)
• Sistem Respirasi : sesak nafas (-), suara sengau (-), sering tersedak (-)
• Sistem Kardiovaskuler: nyeri dada (-), sesak saat aktivitas (-)
• Sistem Gastrointestinal : mual (-), muntah (-), nyeri perut (-), diare(-)
• Sistem Muskuloskeletal : nyeri otot (+), nyeri sendi (-), jari tangan kaku
(+)
• Sistem Genitourinaria : nyeri BAK (-), kencing darah (-)
Primary Survey

• Airway : bebas
• Breathing Inspeksi : pengembangan dada kanan = kiri,
pernafasan 20x/menit
• Palpasi : krepitasi (-/-)
• Perkusi: sonor/ sonor
• Auskultasi : SDV (+/+), ST (-/-)
• Circulation : tekanan darah 120/70 mmHg, nadi 80 x/menit
• Disability : GCS E4V5M6, reflek cahaya (+/+), pupil isokor
(3mm/3mm), lateralisasi (-)
• Exposure : suhu 37,1 ºC, jejas (+) lihat status lokalis
Secondary Survey

• General Survey : looks like severe pain

• Level of consciousness : somnolen
Secondary survey

• Kepala : bentuk mesocephal

• Mata : konjungtiva pucat (-/-), sklera ikterik (-/-), pupil
isokor (3mm/3mm), reflek cahaya (-/-), hematom periorbita (-/-),
diplopia (-/-)
• Telinga : sekret (-/-), darah (-/-), nyeri tekan mastoid (-/-),
• Hidung : bentuk simetris, napas cuping hidung (-), secret (-
), keluar darah (-)
• Mulut : maloklusi (+) crosbite, lihat status lokalis (+)
• Leher : pembesaran tiroid (-), pembesaran limfonodi (-),
nyeri tekan (-), JVP tidak meningkat
• Thorak : bentuk normochest, ketertinggalan gerak (-), jejas (-)
• Jantung
• Inspeksi : ictus cordis tidak tampak
• Palpasi : ictus cordis tidak kuat angkat
• Perkusi : batas jantung kesan tidak melebar
• Auskultasi : bunyi jantung I-II intensitas normal, regular, bising (-)
• Pulmo
• Inspeksi : pengembangan dada kanan sama dengan kiri
• Palpasi : fremitus raba kanan sama dengan kiri, nyeri tekan (-/-)
• Perkusi : sonor/sonor
• Auskultasi suara dasar vesikuler (+/+) normal, suara tambahan (-/-)
• Abdomen
• Inspeksi : distended (-)
• Palpasi : supel, nyeri tekan (-), defense muscular
(-)
• Perkusi : timpani
• Auskultasi : bising usus (+) normal
• Genitourinaria : BAK normal, BAK darah (-), BAK nanah (-
), nyeri BAK (-)
• Ekstremitas: nyeri (-) deformitas (-)
• AKRAL DINGIN EDEMA
LOCAL STATE

• Regio Midfacial
• Inspeksi : pendataran molar(-/-)
• Palpasi : krepitasi (-), hipoestesi (-)maloklusi (+) crosbite
• Regio Mandibula (s)
• Inspeksi : edema(+)
• Palpasi : NT(+),tragus Pain(-), Krepitasi (-)
CLINICAL PHOTO
ASSESMENT

• Fraktur symphisis mandibula

• Maloklusi
• Vulnus terhecting regio mandibula
PLANNING

• Pasang monitor
• Head up 30 derajat
• Oksigen 3 lpm nasal kanul
• Pasang jalur intravena dan infus RL
• Inj. Metamizole 1 amp/8jam
• Inj. Ceftriaxone 1 amp/12 jam
• Inj. Rantidine 1 amp/12 jam
• Cek lab, rontgen thorax, rontgen panoramic, CT scan
 Pemeriksaan Hasil Satuan Rujukan

LABORATORY
DARAH RUTIN
Hemoglobin 9.0 g/Dl 10.5 – 12.9
Hematokrit 29 % 33 – 41
Leukosit 10.0 ribu/µl 5.5 – 17,0
Trombosit 89 ribu/µl 150 – 450
Eritrosit 3,40 juta/µl 4,10 – 5,30
Golongan darah 0
HEMOSTASIS
PT 13,6 Detik 10-15.0
APTT 38,7 Detik 20-40.0
INR 1.100
KIMIA KLINIK
Albumin 3.5 3,5-5,2
Creatinin 0.6 0,6-1.1 Pemeriksaan
Ureum 15 <50
Laboratorium (
RSDM, 24 Agustus 2019)
ELEKTROLIT
Natrium 138 Mmol/L 129-147
Kalium 3,2 Mmol/L 3,6-6,1
Clorida 106 Mmol/L 96-106
ASSESSMENT

• Fraktur symphisis mandibula

• Maloklusi
• Vulnus terhecting regio mandibula
• Pro ORIF elektif
• Diet Cair
• Jaga oral hygiene
LITERATURE
REVIEW
Anatomy of Mandibular

Processus Condylaris

Processus Coronoideus

Ramus Mandibulae

Angulus Mandibulae

Corpus Mandibulae
Foramen Mentale
Protuberantia Mentalis
Biomechanical of Mandibular

Horizontal axis rotation:

• Open/Close mouth
movement (pure rotation)
/ hinge movement.
Vertical axis rotation:
Horizontal axis Vertical axis
• Condylus move to
anterior.
Sagital axis rotation:
Rotation
• Condylus move to inferior

Sagital axis
 Biomechanical of Mandibular

Translation:
• When ramus, condylus,
and teeth move upward
simultantly in a same
direction and speed.
• Occurred on superior
cavity of joint at discus
articularis superior and
inferior surface of fossa Translation
articularis (Between
discus condylus complex
and fossa articularis).
BACKGROUND OF
MANDIBLE FRACTURE
• Mandible fractures are a frequent injury because of the
mandible's prominence and relative lack of support. As
with any facial fracture, consideration must be given for
the need of emergency treatment to secure the airway
or to obtain hemostasis if necessary before initiating
definitive treatment of the fracture.
Location of
mandibular fractures
 Classification of
mandibular fractures
Fracture that does not produce a wound open
SIMPLE OR
to the external environment, whether it be
CLOSED
through the skin, mucosa, or periodontal
membrane

Fracture in which an external wound, involving

COMPOUND skin, mucosa, or periodontal membrane,
OR OPEN communicates with the break in the bone

COMMINUTED Fracture in which the bone is splintered or

crushed
 Fracture in which one cortex of the bone is
GREENSTICK broken and the other cortex is bent

Variety in which two or more lines of fracture on

MULTIPLE the same bone are not communicating with one
another

Fracture resulting from severe atrophy of the

ATROPHIC bone, as in edentulous mandibles

Fracture in which one fragment is driven firmly

IMPACTED into the other
Mandibular Fracture Biomechanical

Trauma  Mandibular 
Tension and Compression

Trauma
Tension happened on alveolar
region

Compression happened on basal

mandibular region
Mandibular Fracture Biomechanical

Because of many muscles

stick on symphisis
mandibular

+ Tension and compression

Trauma trajectory effect  Torsion

Torsi
Torsion on symphisis 
Rotation
Diagnosis
Mechanism Present
Anamnesis
of trauma illness

deformity tooths
inspection
wound malocclusion

Physical
examination
TMJ ginggiva
palpation
False
tooths
movement
 False
movement
thumb in intraoral,
holds the corpus of
the mandible and
then moved up and
down.
IMAGING STUDIES

The following types of radiographs are helpful in

diagnosis of mandibular fractures:
Reverse
Panoramic Eisler
Towne’ view
X-ray
Towne’s Temporomandibular
Skull PA/Lat
view Joint

Complex
CT Scan maxillofacial
fracture
IMAGING STUDIES

• Initial screening of patients is most effective with a

PANORAMIC RADIOGRAPH, since it shows the
entire mandible including the condyles.
• Since an accurate panoramic radiograph requires
that the patient is able to stand upright and
without any motion, achieving good quality films
with severely traumatized patients may be
difficult. Traditional lateral oblique views of the
mandible can be used when obtaining a panoramic
radiograph is not possible.
A. Panoramic radiograph

it shows the entire mandible

B. Lateral Skull X-ray

be used when obtaining a panoramic radiograph is not possible.

C. Posteroanterior Skull X-Ray

• Face flat on the film, mouth

closed
• To detect facial fracture
 D. Reverse Towne’s

• To detect fracture of condyle

neck
• Mouth open wih forehead
touching the film
E. Temporomandible joint (TMJ)
F. CT Scan
 TREATMENT
MEDICAL
THERAPY
TREATMENT

SURGICAL
THERAPY
 Medical Therapy
The use of preoperative and perioperative antibiotics in
the treatment of mandible fractures, especially in the
dentate portion is well established to reduce the risk of
infection
Surgical Therapy
Close
reduction
Surgery
Therapy
Open
reduction
Close Reduction
• Erich arch bars
• Bridle wire
• Ivy loops
• Etc…
Erich arch bars

• Initially, use a bar of sufficient length to accommodate

the maxillary and mandibular arches from first molar to
contralateral first molar.
• Next, use 24-gauge stainless steel circumdental wires at
the first bicuspid positions, one on each side of the arch
to secure the arch bar.
• At this point, tightly place circumdental wires along the
greater segment of the fracture. The greater segment is
the fracture segment; that is the most tooth-bearing
segment.
• Loosely place circumdental wires along the lesser
segment of the fracture. The lesser segment is the
fracture segment that bears the least amount of teeth.
• Then tightly place circumdental wires along the
opposing arch.
• Place the patient into his or her preinjury occlusion.
With the patient held into occlusion, tighten the looser
segment circumdental wires. This prevents arch bar
placement from interfering with proper occlusion.
• Place interarch 25-gauge stainless steel box wires along
the molar/premolar region and the premolar/canine
region bilaterally
• Placement of arch bars can be difficult when dentition
is poor, the fracture is unstable and comminuted, and
dentoalveolar fractures are present.
Bridle wire

• Bridle wire is used for temporary stabilization of a

fractured segment. This provides some patient comfort
by minimizing mobility of the fracture segments.
• Manually reduce the segments with the use of local
anesthesia.
• Loop two teeth (if available) with 24-gauge wire
anterior and posterior to the fracture segment. The
closest stable teeth can be used if the adjacent
dentition is poor or missing.
• Tighten the wire in a clockwise fashion while manually
reducing the segments.
• Ivy loops are used for intermaxillary fixation when full dentition is present
in good condition and the fracture is displaced minimally.
• Construct a loop in the middle of a 24-gauge wire.
• Pass the loose ends of the wire interproximal to two stable teeth.
• Loop the wire ends around the mesial and distal sides of the teeth.
• Pass the distal wire under or through the loop and then tighten it to the
mesial wire in an apical direction.
• Accomplish the same procedure on the opposite arch directly opposing the
first wire.
• The loops need to be short enough to allow for an interarch wire to be
tightened.
• Pass a 25-gauge interarch wire through the two opposing loops and tighten
it in a clockwise fashion.
• At least one ivy loop on each side is necessary.
OPEN REDUCTION

• Plate fixation
• Wire osteosynthesis
PLATE
Comminuted fracture
DEFECT FRACTURE
DOUBLE FRACTURE
WIRE
perpendicula
r

Number 8
CONCLUSIONS

The treatment of mandibular fractures

depends on the biologic character,
adaptive capability of the masticatory
system, and type of the fracture .
These will differ widely among
patients, and it is the lack of sound
biology and adaptation that can lead to
an unfavorable outcome.
Choi KY et al.2012