Massive trauma to mandible: treatment plan?

CRS - Thanks! I like the "old school" idea of a gunning splint. It's time to put the old awl back in action:-) It may be a more cost effective treatment compared to putting in a lot of hardware, but where I work these techniques are a lost art. Some more thoughts from a novice: To me it seems like the right side is grafted as well (vascular clips and bone opasity). I think we would consider using an extra-oral approach (probably some old scars that can be used/revised), then make an osteotomy in the right parasymphyseal region and put a short locking-plate with bicortical screws on the lower border (load-bearing), combined with a more cranially placed miniplate. This osteotomy is more similar to a mandibulotomy as for access to tumors of the floor of the mouth or the tounge base, than a true SSO. Making the osteotomy as sagittal as possible one should be able to derotate the hemimandible, fix it in anatomical position and still have good interproximal bone contact. I think we would pack the defect/diastasis created with cancellous bone from the iliac crest. Performing a unilateral SSO (Obwegeser, Dal Pont) would probably call for a concomitant distal osteotomy , or osteoplasty, to adress the bone "tenting" the oral mucosa. I would avoid excessive stripping of the intraoral mucoperiosteum in a case like this. I still think it would be necessary to strip the pterygomasseteric sling to free up the proximal segment of the mandible and facilitate repositioning. Regarding later implant treatment, the plate on the lower border can often be left in situ. But all these thoughts need to be rethinked after proper examination, scans, casts, discussion with the patient etc. As you said, the vertical relationship (inter occlusal dimension) between the jaws needs to be corrected, and this calls for some type of splint/"denture" in the mandible. It can be used at a later stage for the vestibuloplasty as well. I think your idea of a well made gunning splint should be considered.

CRS, thanks again. And thank you for a lot of valuable input on this case and a lot of others! And yes, I like using monocortical screws to stabilize splints and dentures. Guess you've got some insight in the world of an OMS resident of 2014:-) I'm soon getting ready for my boards, and I actually find a lot of interesting stuff on these pages when it comes to dental implants. Funny enough though, the regular "big posters" have not commented on this case.. Would love some input from a GP, perioguy or 'implantologist'. Like you said, we all share a dental background. As a resident in a surgical environment it can be easy to forget that, but sometimes we need to go back to the roots (yeah, to the place of my birth..) - get it?