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DEFINITION OF FRACTURE: A break in normal continuity of bone with or without loss of bony contour when stretched or bent beyond its elastic limit due to any trauma or any pathology is referred to as fracture. This breaks in normal continuity results imbalance of bony architecture, muscular pull and overlying soft tissue. This is turn result in loss of function.
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INTRODUCTION OF MANDIBULAR FRACTURE: As the mandible is a hoop of bone articulating with the skull at its proximal ends by two joints and since the chin is a prominent feature of face, the mandible is prone to fracture. The mandible has been compared to an archery bow, which is the strongest at its center and weakest at its end, where it breaks often. Hence, the fracture occurring in any part of mandible refers to as mandibular fracture.
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INCIDENCE: Mandibular fracture is more common than middle third injury. The most common facial fractures areMandible Maxilla Zygoma Nas Nasal al bone bone
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: : : :
61% 46% 27% 19.5 19.5% %
AETIOLOGY: The causes of fracture are – Traumatic: Road traffic accident-Major cause Fall Assault •
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Sports injury, gun shot injury, industrial injury War Violence Blow Faulty tooth extraction
Pathological: Osteolytic lesion•
Osteo fibroma Fibrous Dysplasia
Paget’s diseases
Osteomyelitis Osteoporosis Osteogenic imperfecta Osteonecrosis Large cyst
Atrophic bony condition-
Other pathologies
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MANDIBULAR AREAS OF WEAKNESS:
im pected or 1. Presence of tooth/teeth bearing area-longest root of canine, impected 2. 3. 4. 5.
6. •
unerrupted 3 rd molar Neck Neck of of the the con condy dyle le Symphysis Symphysis & parasymphys parasymphysis is of the mandible mandible Angl Anglee of the the man mandi dibl blee Prese Presenc ncee of of fora forami mina na a) Ment Mental al foram foramin inaa b) Inferior dental foramina Mand Mandib ibul ular ar notc notch h
CLASSIFICATION:
The classification of mandibular fracture based on the following criteria: Based on anatomical location-
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Angle of the mandible-31% of all mandibular fracture fr acture Body of the mandible-36% Molar region -----------15% Mental region-----------14% Cuspid area--------------7% 3. Condylar process—About 18% of all mandibular fracture 4. Symphysis and parasymphysis ---8% 5. Ramus of the mandible—6% m andible—6% 6. Coronoid process—1% 7. DentoDento-alv alveol eolar ar region region
Fig: Sites of fracture B.
Based on the types of fracture: Simple Fracture:
When there is a break in continuity of bone without break in mucosa or skin that is the fracture fragments not exposed to the external environment.
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Fig: Simple fracture 2. Compound Fracture:
When the fracture ends of the bone are associate with the break in continuity of skin or mucous membrane there by communicating with external environment
Fig: Compound fracture 3. Communited fracture:
When the fractured fragments are more than two Simple communited fracture- when there is no external communication Compound communited fracture-when there is external communication
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Fig: Communited fracture
4. Greenstick Fracture:
It occurs mainly in children. The bone in the children is soft and elastic so a crack in the bone in which one cortex of the bone is fractured where as other cortex is bent only as in case of green stick of a tree.
Fig: Greenstick fracture 5. Pathological Fracture:
The fracture occurs from mild injury or as a result of normal degree of muscular contraction due to weakness caused by pre-existing bone pathology.
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Fig: Pathological fracture
C. Based on the causes of the Fracture: 1. Di Dire rect ct fr frac actu ture re::
If fracture occurs at the site of impact, it is referred to as direct Fracture 2. In Indi dire rect ct Frac Fractu ture re::
If the fracture occurs away from the site of impact, it is referred to as indirect fracture. 3. Exces Excessive sive mus muscular cular contr contractio action: n:
Sudden musculature contracture may also causes some fracture such as fracture of the Coronoid process because of the sudden reflex contracture of the Temporalis muscles & also fracture of the Condylar neck.
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Fig: Direct and indirect fracture D. Based an the direction of the fracture and favourability for treatment: 1. Favorable fracture:
A fracture is said to be favorable if the muscular pull resists the displacement of the fracture— a. Horizontally favorable fracture b. Vertically favorable fracture
A
B
Fig: A) Horizontally favorable fracture B) Vertically favorable f avorable fracture
2. Unfavorable Fracture:
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A fracture is said to be unfavorable if the muscular pull does not resists the displacement of the fracture— a. Horizontally unfavorable Fracture b. Vertically unfavorable Fracture
A
B
Fig: A) Horizontally unfavorable fracture B) Vertically unfavorable fracture E. Based on treatment points: 1. Unilateral Fracture: o
o o o
Unilateral Fracture of the body of the mandible
2. Bi Bila late tera rall fractu fracture re:: Angle of the mandible Canine region Condylar neck 3. Mu Mult ltip iple le Fra Fract ctur uree
The most common multiple fracture is caused by a fall on the mid point of the chin resulting in fracture of the Symphysis & both condyles. It is usually seen in epileptics, elderly patients and occasionally in soldiers. So it is Guardsman fracture. called – Guardsman 4. Comminuted fracture: o o
Symphysis & parasymphyseal region (most common) War missiles injuries
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F. Based on the presence or absence of teeth: 1. Class –I: When teeth are present on both side of the fractured line. 2. Class-II: When teeth are present on one side of the fractured line. 3. Class-III: When both the fragments of each side of the fractured line are
edentulous.
Fig: A) Class-I B) Class-II C) Class-III • ROLES ROL ES OF MUS MUSCLE CLE DI DISPL SPLAC ACEME EMENT NT OF MANDI MANDIBUL BULAR AR FRACTURE: 1. Mus Muscle cless of facia faciall expres expressio sion: n: They do not play any important role in the displacement of fracture of mandible, as the origin of these muscles from bone & insertion into the skin. To displace the bone the muscle should originate and insert into the bone only. 2. Mus Muscle cle of mas mastic ticati ation: on: Masseter, Medial pterygoid, Temporalis and Lateral pterygoid muscle help in opening and closing of the jaw. These muscles displace angle and condyle of the mandible Masset Masseter, er, Medial Medial pteryg pterygoid oid,, Tempor Temporali aliss muscle muscless displa displace ce fractu fractured red o ramus upward and medially Lateral pterygoid muscle helps in displace the neck of condyle anterio-medially. o
o
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3. Acc Access essory ory muscle muscless of mastica masticatio tion: n: o
o
Mylohyoid, Geniohyoid, Digastric & Genioglossus muscles pull the body of the mandible downward and medially. Mylo Mylohy hyoi oid, d, Geni Genioh ohyo yoid id,, Diga Digast stri ricc & Geni Geniog oglo loss ssus us musc muscle less pull pull the the Symphysis downward and backward.
Fig: Diagram showing muscular pull in mandible; A) lateral view B) medial side C) Horizontal views
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SIGN AND SYMPTOMS OF MANDIBULAR FRACTURE:
History of injury. Acute continuous pain with swelling of lower part of face. f ace. Discoloration of skin. Soft tissue laceration. Bleeding from the mouth. Break in the continuity of bone with the deformity of the facial symmetry. Break in the continuity of mucosa with swelling in the floor of the mouth. Break in the continuity of dental arch and loss mastication with abnormal mobility. Difficulty in chewing and swallowing.
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Inability to open the mouth and difficulty in closing of mouth leading to loss of function. Foul odour and excessive salivation as the patient can not clean the oral cavity. Abnormal occlusion. Anterior open bite and lateral cross bite. Devi Deviat atio ion n of mand mandib ible le durin during g move moveme ment nt main mainly ly seen seen in the the unilateral fracture. On palpation-a crepitus sound may be felt. A step deformity may be in the lower border of the mandible, occlusal surface and upper border of the mandible. Trismus mainly in the fracture of ramus Neurological defect.
MANAGEMENT OF FRACTURE OF THE MANDIBLE: Immediate or emergency treatment: Airway maintenan maintenance: ce:
1. Clear the mouth and throat of blood clot, tenacious salivary secretion, and foreign bodies like denture or luxated tooth with the help to powerful suction and wet swab. As there may be a back fall to tongue due to unfavorable bilateral parasymphyseal Fracture; so pulling the tongue forward should treat it and passing a stay suture through the tongue that can be stabilizing with the shire of the patient. 2.
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3. Patient sh s hould be b e pl p laced in i n th t he po p osition si s imilar to t o th t he reco recove very ry from from GA or sitt sittin ing g up with with head head held held forw forwar ard d with with adeq adequa uate te support. Continuous supervision of patient. Airway tube. Cricothyroidotomy Tracheostomy B. Bleeding control: 1. Pressure and pack is the best method to control haemorrhage.
2. Arterial Arterial haemorrhage haemorrhage should should be controll controlled ed with digital digital pressure pressure on the pressure point. Clamp the artery with forceps & ligate it. 3. Packing Packing with gauge gauge can contro controll haemorrhage haemorrhage from from the deep deep wounds wounds till other measure can be taken.
C.
Control of circulation:
Control of haemorrhage or neurogenic shock.
2. Diagnosis and evaluation of patient: History Taking:
1. Accurate Accurate detail detail and proper proper history of patient patient should should be taken taken as per clinical clinical or medico logical point of view. 2. If the patient patient is unable unable to give give statement statement then then the same same should should be recorded recorded from accompanying person, relative, friends or police officers. off icers. 3. It will reveal reveal about about how the injury injury occured, occured, the the type of of injury & the the severity severity of the injury. General examination: 1. It should be carried out to look for any serious injury elsewhere in the body
so that the appropriate specialist could be consulted. 12
2. Inspection Inspection & palpati palpation on of head for for any soft tissue tissue as well well as bone injury. injury. 3. Inspection Inspection & palpat palpation ion of chest chest & abdomen abdomen for for any injury. injury. Regional examination:
1. Ext Extra oral oral:: -Inspection -Palpation 2. Intra oral:
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Inspection Palpation
Radiological examination examination::
I. Extr Extraa-or oral al rad radio iogr grap aph: h: a. P/A view of mandible m andible in open mouth. b. Right and left lateral oblique view. c. X-ray for TMJ in both opened and closed mouth position. 4. OPG.
a. b.
II. Intra-oral radiograph: Periapical view. Occlusal view.
Fig: OPG shows fracture of the body of the mandible and right condylar region r egion 3. Def Defini initiv tivee tre treatm atment ent:: 1.
Con onsser erv vat atiive tre rea atm tmen ent: t:
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When fracture line seen but no displacement then conservative treatment is donea) Cont Contro roll of of pai painnA patient of fracture of mandible experiences extreme degree of pain and may go into shock because of severe pain so IV-Diazepam can be given in the dose of 10 mg combined with 20 mg Pentazocine as analgesic.
b) Contro Controll of Infect Infection ion-Preve Prevent ntio ion n of infe infect ctio ion n in case case of fract fractur uree or cont control rol of alre alread ady y establishe established d infection infection is of outmost outmost importance importance so, Antibiot Antibiotic ic should should prescribe c) Temporary Temporary stabilizat stabilization ion of of fractured fractured part: Temporary stabilization of splinting of the fractured fragments with the help help of barr barrel el band bandag age. e. Temp Tempor orar ary y stab stabil iliz izat atio ion n in the the form form of horizontal wiring is also a effective procedure. d) e) f) g)
Soft Soft diet dietss Oral Oral Hygie Hygiene ne inst instruc ructio tion n Advice Advice to the the patient patient to shouldn shouldn’t ’t move the the jaw vigoro vigorously usly Foll Follow ow-u -up. p.
Active treatment: If displacement occurs then active treatment is done. The treatment follows some principles.
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PRINCIPLES OF TREATMENT OF FRACTURE: A) Reduction: It is the process of bringing the fractured fragments into alignment.
Types of reduction: 1). Closed Reduction: It is usually done in simple fracture-
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a) When Whenev ever er clos closed ed reduc reducti tion on is poss possib ible le the the risk risk of subs subseq eque uent nt infection of the fracture is negligible. b) b) Preci Precise se anat anatom omic ical al redu reduct ctio ion n is not not nece necess ssar ary y in fract fractur uree of denture bearing area. c) Pulls Pulls or manipu manipulat latee the bone under under the intact intact skin skin to fractu fracture re in proper position.
B
A
Fig: A) Closed Closed reduction B) Extra-oral open open reduction 2. Open Reduction: a) If wide widely ly disp displa lace ceme ment nt occu occurs rs the the open open redu reduct ctio ion n must must be anatomically precise when teeth are involved which were previously in good occlusion. b) b) Open Open redu reduct ctio ion n and and immo immobi bili liza zati tion on is best best effe effect cted ed unde under r General Anesthesia- when severe compound fracture. c) Sometim Sometimes es open open reduct reduction ion done under under local local anesth anesthesi esiaa- when when fracture is not so severe.
B) Fixation: It is a procedure by which the fractured bone ends are fixed in reduced Position. Types:
a) Direct fixation (ex-mini plate, bone plate) b) Indirect fixation (ex- arch wiring)
C) Immobilization: The The redu reduce ced d and and fixe fixed d fragm fragmen ents ts of the the bone bone are are immo immobi bili lize zed d for for certain period for healing. 15
Healing of fracture: • Clotting of blood • Organization of haematoma • Formation of fibrous callus • Formation of primary callus o Uniting callus o Bridging callus o Anchoring callus Sealing callus o D) Rehabilitation Return to normal function and appearance is the goal of all clinical examination. •
TIMES OF IMMOBILIZATION OF FRACTURED MANDIBLE:
Period of immobilization depends upon the site of fracture, presence or retained teeth in fracture line, age of patient and presence or absence of infection. A simple guide to the time of immobilization for the fracture of tooth bearing area of the lower jaw is as follows. Young adult with fracture of the angle receiving early treatment in which tooth removed from fracture line – 3 weeks If: 1. 2. 3. 4.
If tooth tooth retained retained in in the fractu fracture re line, line, add 1 week Fractur Frac turee in the the Symphy Symphysis sis,, add 1 week week Age 40 40 years years or over over,, add 1 to 2 week weekss Children Child ren or or adolesc adolescents, ents, subtra subtract ct 1 week week..
Applying this guideline is follows that a fracture of the Symphysis in 40 years old pat patie ient nt when when the the toot tooth h in the the frac fractu ture re line line is reta retain ined ed requ requir ires es 6 week weekss immobilization. (Basic 3 weeks +1 week for less favorable site+ 1 week allowed for age+1 week for tooth retained in the fractured fr actured line) •
METHODS OF IMMOBILIZATION:
Intermaxillary fixation:
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Dental wiring: Direct wiring or glimmers direct method of wiring Eyelet wiring or Ivy Eyelet wiring or Interdental wiring. 2. Arch bar wiring: 2. Splints: Cast metal splint, acrylic cap splint and gunning splint.
Fig: Arch-wiring
Fig: Intermaxillary fixation
Intermaxillary fixation with osteosynthesis:
1. Direct Direct intra-oss intra-osseous eous wiring/ wiring/ trans-osseo trans-osseous us wiring wiring Upper border intra-osseous wiring Lower border intra-osseous wiring Figure ‘8’ wiring Four hole system Two hole system 2. Trans fixation fixation with Krischner’s Krischner’s wiring wiring 3. Circum Circumfere ferenti ntial al wirin wiring. g. 4. Exte Externa rnall pin fix fixat atio ion n 5. Bone one cla clamp mpss 6. Impla Implant nts/ s/ Graf Grafts ts
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Figure ‘8’ wiring
Two hole and four hole system
Fig: Intraosseous or transosseous wiring Osteosynthesis without Intermaxillary fixation: 1. Simple Simple or non comp compres ressio sion n bone plat platee 2. Compre Compressi ssion on bone bone plate plate 3. Mini ini pla plate te.. A
B
Fig: After reduction fixation with A) mini bone plate B) compression bone plate
EDENTULOUS JAW FRACTURE:
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Methods of immobilization: 1. Intermaxill Intermaxillary ary fixation fixation using using gunni gunning ng type type of splints splints Used alone Combine with other method
2. Direct Direct skelet skeletal al fixati fixation on Trans osseous wiring 18
Bone plate Trans fixation with Krischner’s wire- when body of the mandible is less than 10 mm in depth Cortico-cancellous bone grafting. 3. Indire Indirect ct skel skeleta etall fixat fixation ion External pin fixation Bone clamps
Fig: Edentulous fracture POSTOPERATIVE CARE:
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1. Imme Immedia diate te Posto Postoper perati ative ve Care: Care: When the patient is recovering from the general anesthesia: Instrument
of fixation and instruments such as, scissors, wire cutter, scre screwd wdri rive vers rs etc. etc. shou should ld be avai availa labl blee so that that the the fixa fixati tion on can can be removed emergency. Control of tongue in unconscious patient to additional safeguard, a tongue suture passed transversely across the dorsum of the tongue. An efficient suction apparatus should be at the patient’s bedside. 2.
Intermediate po post op opera rattive ca care: General supervision: Correction of unacceptable reduction Occlusion should be checked as early as possible Inspection of fixation
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Should lie on the lateral posture Sedation: on: With With Diazep Diazepam am (Dose (Dose is adjust adjusted ed accord according ing to the Sedati patient’s response to 5 mg increment) Prevention of infection- with prophylactic antibiotic. Oral Hygiene: Mouthwash with 0.2% chlorohexidine gluconate. The lips tends to stick together so the lips and mouth should be cleaned with moist saline swabs at regular intervals and the lips regu regula larl rly y lubr lubric icat ated ed with with ster steroi oid d cont contai aini ning ng oint ointme ment nt or petroleum jelly. Feeding- Liquid/soft diet/ (2000-2500) cal/day. - Fluid balance balance by daily daily intake intake about 3 L water. water. 3.
Late post operative care:
Testing of the union and removal of fixation. Adjustment of occlusion Mobilization of TMJ Micro neural repair of both inferior dental nerve & lingual nerve may be needed. Oral Hygien Hygiene, e, specifi specificc period periodont ontal al treatm treatment ent,, removal removal of Oral prosthesis may be part of care. •
COMPLICATIONS:
Infections: 1. Abscess Abscess resulting resulting in necrosis necrosis and Osteom Osteomyelit yelitis is 2. Fracture Fracture with chronic chronic facial facial fistula fistula due to to chronic chronic infection infection
Neurological defect: It occurs in damage damage of inferior dental nerve. Displaced tooth and foreign bodies. Misapplied fixation Pulpitis- Damaged tooth may develop pulpitis or apical infection during period of fixation. Gingival and periodontal complications: -Local gingivitis may occur. If too much interdental force to individual tooth is applied then periodontal problem may develop. Malnutrition Non-union, Delayed union, Mal-union, Fibrous union
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Ankylosis of temporomandibular Joint Sequestration of bone Incomplete closure of mouth due to fracture of Coronoid. Facial asymmetry and step defect Premature contact of tooth. Disturbance in occlusion Scars.
Fig: 1) Non-union 2) Bone grafting and fixation
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CONDYLAR FRACTURE:
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CLASSIFICATION:
Extra-capsular fracture
Unilateral Bilateral
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2. Intra capsular Fracture:
Unilateral Bilateral
3. According to displacement: No displacement Forward displacement Medial displacement Lateral displacement
Fig: A) No displacement B) Forward displacement C) Medial displacement D) Lateral displacement
PRINCIPLES OF TREATMENT OF CONDYLAR FRACTURE:
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A) In case of children:
Intra capsular Fracture treatment: a) Acti Active ve move moveme ment nt b) No immobil immobiliza izatio tion n c) No IMF d) Symptom Symptomati aticc trea treatme tment nt e) Anal Analge gesi sics cs f) Jaw Jaw mov moveme ement
a) b)
Extra-capsular fracture treatment: If disp displa lace ced d the then n IMF IMF for for 7-10 7-10 days days foll follow owed ed by acti active ve trea treatm tmen ent. t. If no displacement then no IMF. IMF.
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B
A
Fig: A) Reduction and fixation B) X-ray showing bilateral condylar fracture B) In Case of adult:
Intra capsular Fracture treatment: 1. Un Unil ilat ater eral al:: If occlusion is OK then IMF If painful joint then IMF for 2 weeks 2. Bi Bila late tera rall: Intermittent IMF IMF for 2 weeks IMF only at nights for 4 weeks Extra-capsular Fracture treatment: 1. Unilateral: IMF for 4 weeks Open reduction if necessary
2. Bi Bila late tera rall: IMF for 4-6 weeks Open reduction if necessary
3. Both Unilateral Unilateral and Bilateral: Bilateral: Intermittent fixation.
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POST OPERATIVE MANAGEMENT & INSTRUCTION:
1. To control control of post operat operative ive pain: pain: Analgesic Analgesicss for instanceinstance-Diclofena -Diclofenacc Sodium Sodium (Tab. Inflame-200-400m Inflame-200-400mg g twice daily. After After meal if necessary)
2. To control control post operative operative infectio infection-Ant n-Antibio ibiotic tic should should givengiven-Cap. Amoxicillin 500mg 8 hourly for 7-10 days. 3. As analgesics analgesics cause cause gastric gastric irritationirritation- an H2 blocker blocker should should prescribe. prescribe. 4. Patient Patient should should strictly strictly told not not to move mandib mandible le vigorousl vigorously y 5. If IMF done done than than nasogast nasogastric ric feeding feeding should should be given given 6. Soft Soft diet 7. Regu Regula larr foll follow ow up. up.
Based on Lectures of Asst. Professor Dr. Kazi Sazzad Hossain Department of Oral Surgery and Anaesthesiology
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BIBLIOGRAPHY:
Killey’s Fracture of the Mandible -by Peter Banks Text book of Oral and Maxillofacial surgery - by Vinod Kapoor Text book of Oral and Maxillofacial surgery - by Neelima Anil Malik. Contemporary Oral and Maxillofacial Maxillofacial surgery - by Peterson, Ellis, Hupp, Tucker. Text book of Oral and Maxillofacial surgery –by Gustav O. Kruger
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