Plating Techniques of Mandibular Fractures Karsten K. H. Gundlach, M.D., D. D. S., M. S.D.
The management of all these fractures will be discussed in the section on "Techniques."
Fractures of the mandible are most often caused by fighting or by traffic accidents. In rare cases one may also encounter so-called pathologic fractures PRINCIPLES OF TREATMENT due to tumors or cysts of the jaw. Most classifications The earlier a fracture can be reduced and fixed, the distinguish between: better. However, there is no need to hurry: Lesions of the cerebrum, neurologic symptoms, and injuries of Fractures of only the alveolar bone Fractures involving the basal bone of the mandible, the eyeball should be attended to first, of course. Antibiotics should be administered in all cases of that is, either fractures of the body or fractures compound fractures to lower the danger of infection. of the ramus In cases of delayed treatment preliminary stabilizaAmong the latter one may also find isolated fractures tion of the fragments and surgical repair of open wounds also reduces the likelihood of infection. of the condyle or of the coronoid process. Fractured teeth and teeth with major carious deIn addition,the fractures of the lower jaw are fects, advanced marginal periodontitis, or periapical sometimes subdivided into: radiolucencies (radicular cysts or granulomas) require extraction because they may lead to osteoSimple fractures Compound fractures, including an open wound or myelitis. Impacted teeth or molars (with two or more roots) that are located in wide-open fracture gaps affecting the periodontal space of a tooth Comminuted fractures (for example, following a should also be taken out, especially when the mandibular fracture cannot be taken care of on the same gunshot wound) Impacted fractures (these are rare, a typical example or the next day. The first measure taken in the repair of a fractured being intracapsular fractures of the mandibular mandible should always be restoration of (and securhead) ing) the normal occlusion. Various techniques are possible: circumdental or interdental wiring, appliFinally there are: cation of arch bars, and intermaxillary fixation. In Hamburg we do not apply cap splints. In patients Single fractures wearing dentures, the prostheses are wired or screwed Two (or more) unilateral fractures to the jaws after fixing arch bars to them using coldBilateral fractures Fractures of the mandible in combination with frac- curing acrylic resin. Then follows intermaxillary fixation. tures of the middle third of the face.
Reprint requests: Dr. Gundlach, Nordwestdeutsche Kiefer Klimik, Universitaetskronkenhaus Eppendorf, Martimistr. D-2000 Hamburg 20, Germany Copyright 01991 by Thierne Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: Universite de Sherbrooke. Copyrighted material.
CLASSIFICATION
FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Fractures of body and ramus of the mandible when only poor reduction of the basal bone was In Hamburg we routinely use acrylated arch bars achieved by intermaxillaryfixation alone (radioaccording to Schuchardt.1 These are stepladder-like grams in two planes) metal arch bars with pieces sticking out at right Fracture dislocations of the condyle in patients older angles at regular intervals. They are easy to bend and than 10 years of age to adapt to the upper and lower dental arches. After Fracture displacements of the condyle in patients the occlusal ends of the crossbars are bent onto the with additional fractures of the middle third of the facial skeleton (Le Fort I, 11, and 111) occlusal surfaces of two to three teeth on either side of the jaws, they are ligated to the teeth using 0.3 mm stainless steel wire (Fig. 1A). The occlusal ends thus A variety of bone plates are available today (see prevent the arch bar from sliding onto the gingiva. Siegert and Weerda in this issue of Facial Plastic After coating the arch bar with self-curing resin, the Surgery). They differ with respect to: occlusal ends are no longer necessary and are removed with a pair of pliers. The vestibular ends of The material they are made of the crossbars are now used for intermaxillary elastics Size (width, thickness, and strength) of the plates Type of holes in the plate (some have a gliding plane or wires (Fig. 1B). causing the screws to produce compression) Intermaxillary fixation is a must in every fracture of the jaws. In closed reduction cases it is the only Type of screws (some have a more horizontal thread, means for fixation and immobilization. In open resome are self-tapping) duction cases it is necessary for restoring normal occlusion, it is helpful in reducing the fragments, As to the material, we prefer titanium or Vitallium and it counteracts the tendency of a fracture to sepa- (a chrome-cobalt-molybdenum alloy) because these rate at its upper end, when plating the mandible at are not irritating and may be left in place for the rest the lower end. of the patient's life. In addition, titanium has the If not enough teeth are available to work with, advantage of not showing on and not irritating comdentures may be very helpful: They are altered and puted tomography (CT)scans. In many places of the used like Gunning-type splints. world biodegradable devices are presently being deThe methods just described are the only "old fash- veloped (see Ewers in this issue of Facial Plastic Surioned ones still in use. There is no longer any need gery). However, they are not yet fit for routine usage. for wire sutures or external skeletal suspension. ToThere are more or less three sizes of plates: microday all facial bones can be stabilized by means of plates, miniplates, and ordinary plates. Microplates bone plates. are ideal for the middle third of the face. They are not suited for osteosynthesis of the mandible. They are Bone Plates 0.50 to 0.55 mm thick (Fig. 2A). Miniplates, being The use of bone plates in fractures of the mandible somewhat thicker (approximately 0.7 mm), are now en vogue all over the world in craniomaxillofacial is indicated in: surgery. In the beginning they were used for periFractures of the body and ramus of the mandible in orbital fractures only but very soon it was noted that they were also suited for plating fractured mandibles.2 edentulous patients
..
Figure 1. A: Schuchardt arch bar bent to fit dental arch prior to acrylation. Occlusal ends of crossbars are still in place (plaster model). B: Acrylated Schuchardt arch bars in place. Vestibular ends of crossbars carrying elastics for intermaxillary fixation.
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Intermaxillary Fixation
PLATING MANDIBULAR FRACTURES-Gundlach
- - - - lines of equal tension
-
lines of equal pressure
Figure 2. A: The three sizes of maxillofacial bone plates (Luhr Fixation Systems): microplate, miniplate, conventional plate (bottom). B: Lines of equal tension, lines of equal pressure, muscular forces (arrows), mandibular canal, and optimum position of miniplate. (From Tillman et al. Dtsch Zahnarzth Z 38:285, 1983.
There are types invented only and simply for bone fixation and others that enable compression osteosynthesis (Siegert and Weerda in this issue of Facial Plastic Surgery).The latter are better for trauma cases (see later). When miniplates are applied for correct alignment of bony fragments, there are three things to be kept in mind: prior to plating the occlumeans of arch bars or the sion Irequires correc like. ~eiondly,miniplatesdhaveto be placed half-way between the root tips of the teeth and the mandibular canal with the alveolar nerve in it. (Screw diameter approximately 2 mm.) Normally tension is encountered in this site, such tension requiring counterbalance by the plate (Fig. 2B). Because this zone is very narrow, it can only carry miniplates. Some surgeons use monocortical screws as an additional measure to protect teeth and nerve.2 Thirdly one should always try to place the plate at a right angle to the line of fracture, if at all possible. Conventional bone plates being bigger than miniplates and being fixed with thicker screws offer the major advantage of exerting good axial compression to the fracture site. Thus, a good fit of the fragments is possible and primary bone healing is the result, without formation of a callus. Compression osteosynthesis and the resulting primary (that is, immediate) stability reduce the risks of postoperative infection, osteomyelitis, and pseudarthrosis3 (Fig. 3). However, due to the size of plate and screws, they have to be applied to the lower border of the mandible, inferior to the nerve canal. Mechanically, this is the wrong site because it is the site of impaction. It
2
1 ..... A-?
-9.
.
The management of all these fractures will be discussed in the section on "Techniques."
Fractures of the mandible are most often caused by fighting or by traffic accidents. In rare cases one may also encounter so-called pathologic fractures PRINCIPLES OF TREATMENT due to tumors or cysts of the jaw. Most classifications The earlier a fracture can be reduced and fixed, the distinguish between: better. However, there is no need to hurry: Lesions of the cerebrum, neurologic symptoms, and injuries of Fractures of only the alveolar bone Fractures involving the basal bone of the mandible, the eyeball should be attended to first, of course. Antibiotics should be administered in all cases of that is, either fractures of the body or fractures compound fractures to lower the danger of infection. of the ramus In cases of delayed treatment preliminary stabilizaAmong the latter one may also find isolated fractures tion of the fragments and surgical repair of open wounds also reduces the likelihood of infection. of the condyle or of the coronoid process. Fractured teeth and teeth with major carious deIn addition,the fractures of the lower jaw are fects, advanced marginal periodontitis, or periapical sometimes subdivided into: radiolucencies (radicular cysts or granulomas) require extraction because they may lead to osteoSimple fractures Compound fractures, including an open wound or myelitis. Impacted teeth or molars (with two or more roots) that are located in wide-open fracture gaps affecting the periodontal space of a tooth Comminuted fractures (for example, following a should also be taken out, especially when the mandibular fracture cannot be taken care of on the same gunshot wound) Impacted fractures (these are rare, a typical example or the next day. The first measure taken in the repair of a fractured being intracapsular fractures of the mandibular mandible should always be restoration of (and securhead) ing) the normal occlusion. Various techniques are possible: circumdental or interdental wiring, appliFinally there are: cation of arch bars, and intermaxillary fixation. In Hamburg we do not apply cap splints. In patients Single fractures wearing dentures, the prostheses are wired or screwed Two (or more) unilateral fractures to the jaws after fixing arch bars to them using coldBilateral fractures Fractures of the mandible in combination with frac- curing acrylic resin. Then follows intermaxillary fixation. tures of the middle third of the face.
Reprint requests: Dr. Gundlach, Nordwestdeutsche Kiefer Klimik, Universitaetskronkenhaus Eppendorf, Martimistr. D-2000 Hamburg 20, Germany Copyright 01991 by Thierne Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: Universite de Sherbrooke. Copyrighted material.
CLASSIFICATION
FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Fractures of body and ramus of the mandible when only poor reduction of the basal bone was In Hamburg we routinely use acrylated arch bars achieved by intermaxillaryfixation alone (radioaccording to Schuchardt.1 These are stepladder-like grams in two planes) metal arch bars with pieces sticking out at right Fracture dislocations of the condyle in patients older angles at regular intervals. They are easy to bend and than 10 years of age to adapt to the upper and lower dental arches. After Fracture displacements of the condyle in patients the occlusal ends of the crossbars are bent onto the with additional fractures of the middle third of the facial skeleton (Le Fort I, 11, and 111) occlusal surfaces of two to three teeth on either side of the jaws, they are ligated to the teeth using 0.3 mm stainless steel wire (Fig. 1A). The occlusal ends thus A variety of bone plates are available today (see prevent the arch bar from sliding onto the gingiva. Siegert and Weerda in this issue of Facial Plastic After coating the arch bar with self-curing resin, the Surgery). They differ with respect to: occlusal ends are no longer necessary and are removed with a pair of pliers. The vestibular ends of The material they are made of the crossbars are now used for intermaxillary elastics Size (width, thickness, and strength) of the plates Type of holes in the plate (some have a gliding plane or wires (Fig. 1B). causing the screws to produce compression) Intermaxillary fixation is a must in every fracture of the jaws. In closed reduction cases it is the only Type of screws (some have a more horizontal thread, means for fixation and immobilization. In open resome are self-tapping) duction cases it is necessary for restoring normal occlusion, it is helpful in reducing the fragments, As to the material, we prefer titanium or Vitallium and it counteracts the tendency of a fracture to sepa- (a chrome-cobalt-molybdenum alloy) because these rate at its upper end, when plating the mandible at are not irritating and may be left in place for the rest the lower end. of the patient's life. In addition, titanium has the If not enough teeth are available to work with, advantage of not showing on and not irritating comdentures may be very helpful: They are altered and puted tomography (CT)scans. In many places of the used like Gunning-type splints. world biodegradable devices are presently being deThe methods just described are the only "old fash- veloped (see Ewers in this issue of Facial Plastic Surioned ones still in use. There is no longer any need gery). However, they are not yet fit for routine usage. for wire sutures or external skeletal suspension. ToThere are more or less three sizes of plates: microday all facial bones can be stabilized by means of plates, miniplates, and ordinary plates. Microplates bone plates. are ideal for the middle third of the face. They are not suited for osteosynthesis of the mandible. They are Bone Plates 0.50 to 0.55 mm thick (Fig. 2A). Miniplates, being The use of bone plates in fractures of the mandible somewhat thicker (approximately 0.7 mm), are now en vogue all over the world in craniomaxillofacial is indicated in: surgery. In the beginning they were used for periFractures of the body and ramus of the mandible in orbital fractures only but very soon it was noted that they were also suited for plating fractured mandibles.2 edentulous patients
..
Figure 1. A: Schuchardt arch bar bent to fit dental arch prior to acrylation. Occlusal ends of crossbars are still in place (plaster model). B: Acrylated Schuchardt arch bars in place. Vestibular ends of crossbars carrying elastics for intermaxillary fixation.
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Intermaxillary Fixation
PLATING MANDIBULAR FRACTURES-Gundlach
- - - - lines of equal tension
-
lines of equal pressure
Figure 2. A: The three sizes of maxillofacial bone plates (Luhr Fixation Systems): microplate, miniplate, conventional plate (bottom). B: Lines of equal tension, lines of equal pressure, muscular forces (arrows), mandibular canal, and optimum position of miniplate. (From Tillman et al. Dtsch Zahnarzth Z 38:285, 1983.
There are types invented only and simply for bone fixation and others that enable compression osteosynthesis (Siegert and Weerda in this issue of Facial Plastic Surgery).The latter are better for trauma cases (see later). When miniplates are applied for correct alignment of bony fragments, there are three things to be kept in mind: prior to plating the occlumeans of arch bars or the sion Irequires correc like. ~eiondly,miniplatesdhaveto be placed half-way between the root tips of the teeth and the mandibular canal with the alveolar nerve in it. (Screw diameter approximately 2 mm.) Normally tension is encountered in this site, such tension requiring counterbalance by the plate (Fig. 2B). Because this zone is very narrow, it can only carry miniplates. Some surgeons use monocortical screws as an additional measure to protect teeth and nerve.2 Thirdly one should always try to place the plate at a right angle to the line of fracture, if at all possible. Conventional bone plates being bigger than miniplates and being fixed with thicker screws offer the major advantage of exerting good axial compression to the fracture site. Thus, a good fit of the fragments is possible and primary bone healing is the result, without formation of a callus. Compression osteosynthesis and the resulting primary (that is, immediate) stability reduce the risks of postoperative infection, osteomyelitis, and pseudarthrosis3 (Fig. 3). However, due to the size of plate and screws, they have to be applied to the lower border of the mandible, inferior to the nerve canal. Mechanically, this is the wrong site because it is the site of impaction. It
2
1 ..... A-?
-9.
.
