Int. J. Oral Maxillofac. Surg. 2015; 44: 670–673 available online at http://www.sciencedirect.com
Letters to the Editor Response to ‘‘Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate’’
Dear Editor, We read with interest the recently published paper by Ma et al.1 in which they reported the use of transpalatal screw traction for sagittal fractures of the palate and maxilla. The technique appears to be a modification of the well-known intermolar wiring in terms of anchorage.2 Sagittal or parasagittal fractures of the palate, as described, are characterized by posterior widening of the maxillary dental arch,3 and can be controlled easily using a simple intermolar wiring technique. We routinely use this technique by simply positioning the intermolar wire, then approximating the jaws and placing intermaxillary fixation (IMF) wires, but keeping them loose. The intermolar wire is then tightened (depending upon the increased width of the posterior maxilla) by directly visualizing the molar occlusion, followed by tightening of the IMF wires.
This popular technique allows for examination of the occlusion at the same time, i.e. while tightening the wires, which is not possible in the case of transpalatal screw traction. Moreover the intermolar wiring technique is more simple, costeffective, and versatile, and may be performed rapidly in the emergency situation to stabilize sagittal palatal fractures without the need for any extra equipment. This is particularly useful in the resource-limited settings of developing countries. In addition, the transpalatal screw traction technique carries a risk of damage to the molar roots, requires anaesthesia for removal, is less effective, and is cumbersome because of the comparative inaccessibility. During reduction, the sagittally fractured palate or maxilla will behave as a third-order lever similar to tweezers or tissue-holding forceps. The moment arm (Fig. 1, label a) will be larger in the intermolar wiring situation than in transpalatal screw traction (Fig. 1, label b), resulting in more torque production in the former case (Fig. 1, label E).4 The physical basis of the torque generated in each case is depicted in Fig. 1.
In our opinion, the technique described would be more appropriate for managing such fractures in partially or completely edentulous patients, in whom there are no teeth present for placing the intermolar wire. Funding
None. Competing interests
None declared. Ethical approval
Not required. Patient consent
Not required. J. Batra* G. Attresh B. Garg Post Graduate Institute of Dental Sciences, Pt. B.D Sharma UHS, Rohtak, Haryana India *Address: Jitender Batra, Senior Resident, Department of Oral & Maxillofacial Surgery, Post Graduate Institute of Dental Sciences, Pt. B.D Sharma UHS, Rohtak, Haryana 124001. India. Tel.: +91 8929956599. E-mail address: [email protected] (J. Batra) Accepted 21 January 2015 Available online 14 February 2015 References
Fig. 1. Torque generated (a, b = moment arm; F = fulcrum; L = load; E = effort). 0901-5027/050670 + 04
1. Ma D, Guo X, Yao H, Chen J. Transpalatal screw traction: a simple technique for the
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Letters to the Editor management of sagittal fractures of the maxilla and palate. Int J Oral Maxillofac Surg 2014;43:1465–7. 2. Chen CH, Wang TY, Tsay PK, Lai JB, Chen CT, Liao HT, et al. A 162-case review of palatal fracture: management strategy from a 10-year experience. Plast Reconstr Surg 2008;121:2065–73. 3. Hendrickson M, Clark N, Manson PN, Yaremchuk M, Robertson B, Slezak S. Palatal fractures: classification, patterns, and treatment with rigid internal fixation. Plast Reconstr Surg 1998;101:319–32. 4. Usher AP. A history of mechanical inventions. Harvard University Press; 1929: 94. (reprinted by Dover Publications, 1988). http://dx.doi.org/10.1016/j.ijom.2015.01.016
Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate Dear Editor, We thank the readers very much for their interest in our paper entitled ‘‘Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate’’,1 and their valuable comments.2 We respond to their concerns below. We partly agree with the readers that most sagittal fractures of the maxilla and palate (SFMP) can be managed by the technique of intermolar wiring traction. Compared with our transpalatal screw traction method, the intermolar technique does have advantages, including the ability to visualize the occlusion while tightening the wires, decreased operation times and costs of the screws, and being more convenient in the emergency setting for stabilizing SFMP. As illustrated by the readers’ figure, the moment arm in the intermolar wiring situation will be larger than that of transpalatal screw traction, producing more torque and requiring less tractive force. In fact, we also use intermolar wiring traction and fixation in the management of SFMP in some cases. However, because of the lack of rigid fixation in the hard palate, we and other authors introduced the transpalatal traction wire, which is usually kept in place for 4 or more weeks to help immobilize fractures and achieve primary bone union.3,4 Obviously, the intermolar wiring technique also has associated disadvantages.3,4 Firstly, it increases the risk of dental inju-
ry. As known, passing a metal wire around the tooth neck and keeping it tight for a relatively long period of time may result in trauma to the periodontium, the danger of tooth avulsion and crown fracture, and even exert orthodontic forces leading to tooth extrusion. Secondly, during this traction period, many patients are likely to complain of postoperative discomfort such as tooth pain, oral hygiene compromise, and a tangible nuisance for the tongue. Thirdly, difficulties will occur in advanced periodontal disease and in the presence of metal ceramic or resin restorations or injured molars, in which the remaining teeth are loose and unsuitable for supporting a wire. In addition, the technique described would not be appropriate for managing SFMP in edentulous patients because there are no teeth present for placing the intermolar wire. Compared with open reduction and internal fixation of the hard palate, both transpalatal screw traction and intermolar wiring traction constitute conservative therapies. Essentially, both techniques are intended to exert inward forces in the transverse direction to reduce the displaced fragments medially. In spite of being less rigid than plate and screw fixation, these techniques can achieve good outcomes in terms of bony union and occlusion, with few complications. The main difference between transpalatal screw traction and intermolar wiring fixation is that the former is a bone-supported device and the latter is a tooth-borne device. Based on the different anchoring modalities, each has advantages and drawbacks and neither may represent a perfect solution. Therefore, to achieve the best treatment outcome and minimize the potential morbidity, customized techniques should be selected according to the individual needs of the patient, depending on the traumatic condition, local anatomy, patient tolerance, etc. Again, only a preliminary report of the transpalatal screw traction technique was presented in our paper. Further prospective clinical trials are required to compare the technique presented with other existing techniques. Funding
This work was partly funded by the ‘‘Twelve-Five’’ Medical Research Projects of PLA (CWS12J066, CLZ11JB06). Competing interests
None.
671
Ethical approval
Not required. Patient consent
Not required. D. Ma* H. Yao Department of Oral and Maxillofacial Surgery, Lanzhou General Hospital of PLA, Lanzhou, China *Address: Dongyang Ma, Department of Oral and Maxillofacial Surgery, Lanzhou General Hospital of PLA, 333 BinHe South Road, Lanzhou 730052, China. Tel.: +86 931 89994437. E-mail address: [email protected] (D. Ma) Accepted 21 January 2015 Available online 11 February 2015
References 1. Ma D, Guo X, Yao H, Chen J. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate. Int J Oral Maxillofac Surg 2014;43:1465–7. 2. Batra J, Attresh G, Garg B. Response to ‘‘Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate’’. Int J Oral Maxillofac Surg 2015. 3. Chen CH, Wang TY, Tsay PK, Lai JB, Chen CT, Liao HT, et al. A 162-case review of palatal fracture: management strategy from a 10-year experience. Plast Reconstr Surg 2008;121:2065–73. 4. Cornelius CP, Ehrenfeld M. The use of MMF screws: surgical technique, indications, contraindications, and common problems in review of the literature. Craniomaxillofac Trauma Reconstr 2010;3:55–80. http://dx.doi.org/10.1016/j.ijom.2015.01.017
Setbacks of transoral temporomandibular joint ankylotic mass excision Dear Editor We read with interest the article by Rajan et al.1 reporting five cases of transoral gap arthroplasty. We would like to address some major setbacks of this procedure that may be of interest and importance, especially for those with limited experience in this area. One of the authors’ inclusion criteria was Sawhney grade I, II, and III temporomandibular joint (TMJ) ankylosis
Letters to the Editor Response to ‘‘Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate’’
Dear Editor, We read with interest the recently published paper by Ma et al.1 in which they reported the use of transpalatal screw traction for sagittal fractures of the palate and maxilla. The technique appears to be a modification of the well-known intermolar wiring in terms of anchorage.2 Sagittal or parasagittal fractures of the palate, as described, are characterized by posterior widening of the maxillary dental arch,3 and can be controlled easily using a simple intermolar wiring technique. We routinely use this technique by simply positioning the intermolar wire, then approximating the jaws and placing intermaxillary fixation (IMF) wires, but keeping them loose. The intermolar wire is then tightened (depending upon the increased width of the posterior maxilla) by directly visualizing the molar occlusion, followed by tightening of the IMF wires.
This popular technique allows for examination of the occlusion at the same time, i.e. while tightening the wires, which is not possible in the case of transpalatal screw traction. Moreover the intermolar wiring technique is more simple, costeffective, and versatile, and may be performed rapidly in the emergency situation to stabilize sagittal palatal fractures without the need for any extra equipment. This is particularly useful in the resource-limited settings of developing countries. In addition, the transpalatal screw traction technique carries a risk of damage to the molar roots, requires anaesthesia for removal, is less effective, and is cumbersome because of the comparative inaccessibility. During reduction, the sagittally fractured palate or maxilla will behave as a third-order lever similar to tweezers or tissue-holding forceps. The moment arm (Fig. 1, label a) will be larger in the intermolar wiring situation than in transpalatal screw traction (Fig. 1, label b), resulting in more torque production in the former case (Fig. 1, label E).4 The physical basis of the torque generated in each case is depicted in Fig. 1.
In our opinion, the technique described would be more appropriate for managing such fractures in partially or completely edentulous patients, in whom there are no teeth present for placing the intermolar wire. Funding
None. Competing interests
None declared. Ethical approval
Not required. Patient consent
Not required. J. Batra* G. Attresh B. Garg Post Graduate Institute of Dental Sciences, Pt. B.D Sharma UHS, Rohtak, Haryana India *Address: Jitender Batra, Senior Resident, Department of Oral & Maxillofacial Surgery, Post Graduate Institute of Dental Sciences, Pt. B.D Sharma UHS, Rohtak, Haryana 124001. India. Tel.: +91 8929956599. E-mail address: [email protected] (J. Batra) Accepted 21 January 2015 Available online 14 February 2015 References
Fig. 1. Torque generated (a, b = moment arm; F = fulcrum; L = load; E = effort). 0901-5027/050670 + 04
1. Ma D, Guo X, Yao H, Chen J. Transpalatal screw traction: a simple technique for the
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Letters to the Editor management of sagittal fractures of the maxilla and palate. Int J Oral Maxillofac Surg 2014;43:1465–7. 2. Chen CH, Wang TY, Tsay PK, Lai JB, Chen CT, Liao HT, et al. A 162-case review of palatal fracture: management strategy from a 10-year experience. Plast Reconstr Surg 2008;121:2065–73. 3. Hendrickson M, Clark N, Manson PN, Yaremchuk M, Robertson B, Slezak S. Palatal fractures: classification, patterns, and treatment with rigid internal fixation. Plast Reconstr Surg 1998;101:319–32. 4. Usher AP. A history of mechanical inventions. Harvard University Press; 1929: 94. (reprinted by Dover Publications, 1988). http://dx.doi.org/10.1016/j.ijom.2015.01.016
Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate Dear Editor, We thank the readers very much for their interest in our paper entitled ‘‘Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate’’,1 and their valuable comments.2 We respond to their concerns below. We partly agree with the readers that most sagittal fractures of the maxilla and palate (SFMP) can be managed by the technique of intermolar wiring traction. Compared with our transpalatal screw traction method, the intermolar technique does have advantages, including the ability to visualize the occlusion while tightening the wires, decreased operation times and costs of the screws, and being more convenient in the emergency setting for stabilizing SFMP. As illustrated by the readers’ figure, the moment arm in the intermolar wiring situation will be larger than that of transpalatal screw traction, producing more torque and requiring less tractive force. In fact, we also use intermolar wiring traction and fixation in the management of SFMP in some cases. However, because of the lack of rigid fixation in the hard palate, we and other authors introduced the transpalatal traction wire, which is usually kept in place for 4 or more weeks to help immobilize fractures and achieve primary bone union.3,4 Obviously, the intermolar wiring technique also has associated disadvantages.3,4 Firstly, it increases the risk of dental inju-
ry. As known, passing a metal wire around the tooth neck and keeping it tight for a relatively long period of time may result in trauma to the periodontium, the danger of tooth avulsion and crown fracture, and even exert orthodontic forces leading to tooth extrusion. Secondly, during this traction period, many patients are likely to complain of postoperative discomfort such as tooth pain, oral hygiene compromise, and a tangible nuisance for the tongue. Thirdly, difficulties will occur in advanced periodontal disease and in the presence of metal ceramic or resin restorations or injured molars, in which the remaining teeth are loose and unsuitable for supporting a wire. In addition, the technique described would not be appropriate for managing SFMP in edentulous patients because there are no teeth present for placing the intermolar wire. Compared with open reduction and internal fixation of the hard palate, both transpalatal screw traction and intermolar wiring traction constitute conservative therapies. Essentially, both techniques are intended to exert inward forces in the transverse direction to reduce the displaced fragments medially. In spite of being less rigid than plate and screw fixation, these techniques can achieve good outcomes in terms of bony union and occlusion, with few complications. The main difference between transpalatal screw traction and intermolar wiring fixation is that the former is a bone-supported device and the latter is a tooth-borne device. Based on the different anchoring modalities, each has advantages and drawbacks and neither may represent a perfect solution. Therefore, to achieve the best treatment outcome and minimize the potential morbidity, customized techniques should be selected according to the individual needs of the patient, depending on the traumatic condition, local anatomy, patient tolerance, etc. Again, only a preliminary report of the transpalatal screw traction technique was presented in our paper. Further prospective clinical trials are required to compare the technique presented with other existing techniques. Funding
This work was partly funded by the ‘‘Twelve-Five’’ Medical Research Projects of PLA (CWS12J066, CLZ11JB06). Competing interests
None.
671
Ethical approval
Not required. Patient consent
Not required. D. Ma* H. Yao Department of Oral and Maxillofacial Surgery, Lanzhou General Hospital of PLA, Lanzhou, China *Address: Dongyang Ma, Department of Oral and Maxillofacial Surgery, Lanzhou General Hospital of PLA, 333 BinHe South Road, Lanzhou 730052, China. Tel.: +86 931 89994437. E-mail address: [email protected] (D. Ma) Accepted 21 January 2015 Available online 11 February 2015
References 1. Ma D, Guo X, Yao H, Chen J. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate. Int J Oral Maxillofac Surg 2014;43:1465–7. 2. Batra J, Attresh G, Garg B. Response to ‘‘Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate’’. Int J Oral Maxillofac Surg 2015. 3. Chen CH, Wang TY, Tsay PK, Lai JB, Chen CT, Liao HT, et al. A 162-case review of palatal fracture: management strategy from a 10-year experience. Plast Reconstr Surg 2008;121:2065–73. 4. Cornelius CP, Ehrenfeld M. The use of MMF screws: surgical technique, indications, contraindications, and common problems in review of the literature. Craniomaxillofac Trauma Reconstr 2010;3:55–80. http://dx.doi.org/10.1016/j.ijom.2015.01.017
Setbacks of transoral temporomandibular joint ankylotic mass excision Dear Editor We read with interest the article by Rajan et al.1 reporting five cases of transoral gap arthroplasty. We would like to address some major setbacks of this procedure that may be of interest and importance, especially for those with limited experience in this area. One of the authors’ inclusion criteria was Sawhney grade I, II, and III temporomandibular joint (TMJ) ankylosis
