YIJOM-2966; No of Pages 3
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.07.019, available online at http://www.sciencedirect.com
Case Report Trauma
Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate
D. Ma1,*, X. Guo2, H. Yao1, J. Chen1 1
Department of Oral and Maxillofacial Surgery, Lanzhou General Hospital of PLA, Lanzhou, China; 2First Department of Medical Technology, Lanzhou General Hospital of PLA, Lanzhou, China
D. Ma, X. Guo, H. Yao, J. Chen: Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Sagittal fractures of the maxilla and palate are uncommon in clinical practice. Current methods for the management of such fractures have advantages and limitations. The authors present the simple and practical technique of bilateral transpalatal screw traction to manage this fracture type.
Sagittal fractures of the maxilla and palate (SFMP), passing medially or paramedially through the palatal shelves and splitting the maxilla in a sagittal direction, usually occur in association with a Le Fort fracture.1,2 This type of fracture often causes maxillary arch expansion and buccal rotation.1,3 Traditional methods for managing such fractures include the use of Kirschner wire, acrylic splints, arch bars for maxillomandibular fixation, intermolar wire fixation, and the intermaxillary figure-ofeight wiring technique.1–5 However, each of these methods has inherent drawbacks and it is difficult to use these techniques alone to achieve ideal occlusal function, sufficient stability, and accurate reduction. Clinicians are increasingly advocating the use of open reduction and internal 0901-5027/000001+03
fixation with a plate and screw system to treat such fractures.1–4 This technique obviously has several advantages, such as improving the stability, defining maxillary arch width, and limiting the rotation of the maxillary segments. However, it is sometimes associated with complications such as the development of palatal fistula and exposure of the plate and screws.1,2 Moreover, the operative procedure includes palatal incision, wide flap elevation, reduction of the maxillary fracture, and plate–screw fixation on the roof of the mouth. This procedure is time-consuming and may affect the blood supply of the fractured segments.1,3 Therefore, more simple and effective methods are needed.
Keywords: screw; traction; sagittal fractures; maxilla; palate.. Accepted for publication 23 July 2014
We describe a simple technique to manage SFMP: bilateral transpalatal screw traction. Technique
Images of a representative patient with SFMP are given in Figs. 1–3. Two self-drilling screws (each with a hole in its head) are inserted bilaterally into the bony palatal region between the upper first and second molars. A 24-gauge wire is pre-stretched and its ends are inserted into the screw holes on either side of the palate. The two ends of the wire are then criss-crossed and progressively twisted together (Fig. 2). Tightening forceps produce a traction force in the direction of the median line to reduce displaced
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ma D, et al. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.019
YIJOM-2966; No of Pages 3
2
Ma et al.
Fig. 1. Preoperative malocclusion in a representative patient with sagittal fractures of the maxilla and palate (left). Axial (middle) and coronal (right) CT scans show the sagittal fractures of the maxilla and palate (arrows) before treatment.
Fig. 2. Intraoperative view showing the application of transpalatal screw traction.
fractures. The transpalatal traction wire is kept in place to help immobilize fractures of the maxilla and palate. Intermaxillary fixation is applied on each side of the fracture line to restore normal occlusion. The fractures are then stabilized if needed. Transpalatal screw traction can be used alone, or as an adjunct to other management methods, such as intermaxillary fixation, open reduction and internal fixation at the level of the piriform aperture, and stabilization of zygomaticomaxillary and nasomaxillary buttresses. The average time to the removal of the traction device is 4 weeks.
We have used this technique to treat 11 patients with SFMP over a period of 5 years. The fractures in this study were not isolated and all were associated with Le Fort fractures. The mean follow-up was 8 months. Ten patients achieved satisfactory occlusion. One patient developed bilateral posterior crossbite but had acceptable occlusion following orthodontic treatment. We observed that transpalatal screw traction is an effective method for achieving closed reduction and external fixation in patients with SFMP. Therefore, the use of open reduction and internal fixation of the hard palate is not recommended for the treatment of SFMP in our department.
Discussion
SFMP are uncommon in clinical practice, with an incidence ranging from 4% to 42% in maxillary fractures.1,2 Diagnosis of this type of fracture is mainly based on clinical evaluation and radiographic examination. Palatal mucosal laceration and malocclusion are typical clinical signs of SFMP. Since not all SFMP are apparent on Xrays, the radiographic diagnosis of these fractures can sometimes be difficult. By
contrast, computed tomography (CT) scans can display detailed images of the specific fractures.1 Therefore, a CT scan, especially an axial CT scan, is recommended to confirm the diagnosis of SMFP in suspected cases. As shown in the CT scan images in Fig. 1, paramedian SFMP can clearly be identified and were associated with Le Fort I and II fractures in this case. These detailed CT scan images were very helpful in designing the treatment plan for the patient. Since most SFMP occur in association with Le Fort fracture,2,6 the U-shaped maxillary arch is usually divided into two unstable segments, increasing the difficulty of the reduction procedure. Inward forces in the transverse direction are required to push the displaced fragments medially to achieve reduction of the sagittal fracture segment. Therefore, transpalatal screw traction is applied to reduce and fix the bilateral maxillary fragments. Compared to other methods currently used for the treatment of SFMP, this technique has several potential benefits. First, it is a simple and efficient method that produces good functional outcomes with minimal complications. Second, it has little impact on the patient’s oral hygiene, speech, and feeding
Fig. 3. Postoperative view of the same patient showing the normal occlusion obtained (left). Axial (middle) and coronal (right) CT scans show the reduced fractures of the maxilla and palate (arrows) at 7 days after treatment.
Please cite this article in press as: Ma D, et al. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.019
YIJOM-2966; No of Pages 3
Transpalatal screw traction during treatment. Third, compared to the use of tooth-supported appliances, the use of screws makes this device essentially a bone-supported appliance, reducing the risk of dental injuries. Furthermore, when open surgery is contraindicated in patients with certain conditions, such as severe cerebral injury, our technique can be used in the early management of such fractures to facilitate the primary replacement of displaced bone and to minimize the risk of complications. Our technique does not expose the sagittal fracture site and therefore may allow for minor bone mismatches or inaccurate reduction. However, the best way to achieve fracture reduction is first to restore the occlusion and then to stabilize the fracture segment if needed.4 Our results showed that normal occlusion can be established by transpalatal screw traction and maxillomandibular fixation. Therefore, the use of open reduction and internal fixation of the hard palate is not recommended for the treatment of SFMP in our department. As has been reported by other authors,2,6 the SFMP in our cases were often associated with Le Fort fractures. Obviously, the use of the transpalatal screw traction alone is not sufficient to achieve and maintain the stability of such associated fractures. Thus, this technique should be supplemented by other management methods, such as open reduction and internal fixation at the
piriform aperture, the zygomaticomaxillary buttress, the nasomaxillary buttresses, or the zygomaticofrontal suture. We have presented a preliminary report of this technique. Whether it is a superior method for the management of this type of fracture is therefore unknown. Further controlled clinical trials are required to compare this approach with existing techniques and to determine the advantages and disadvantages of this new method.
2.
3.
4.
Funding
This work was funded in part by the ‘‘Twelve-Five’’ Medical Research Projects of PLA (CWS12J066). Competing interests
None declared. Ethical approval
Not required. Patient consent
Not required. References 1. Manson PN, Glassman D, Vanderkolk C, Petty P, Crawley WA. Rigid stabilization of
5.
6.
3
sagittal fractures of the maxilla and palate. Plast Reconstr Surg 1990;85:711–7. 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. Pollock RA. The search for the ideal fixation of palatal fractures: innovative experience with a mini-locking plate. Craniomaxillofac Trauma Reconstr 2008;1:15–24. Werther JR. Fixation of sagittal fractures of the maxilla. Plast Reconstr Surg 1991;87: 198–9. Kumaravelu C, Thirukonda GJ, Kannabiran P. A novel adjuvant to treat palatal fractures. J Oral Maxillofac Surg 2011;69:e152–4. Hendrickson M, Clark N, Manson PN, Yaremchuk M, Robertson B, Slezak S, et al. Palatal fractures: classification, patterns, and treatment with rigid internal fixation. Plast Reconstr Surg 1998;101:319–32.
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 Fax: +86 931 89994437 E-mails: [email protected], [email protected]
Please cite this article in press as: Ma D, et al. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.019
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.07.019, available online at http://www.sciencedirect.com
Case Report Trauma
Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate
D. Ma1,*, X. Guo2, H. Yao1, J. Chen1 1
Department of Oral and Maxillofacial Surgery, Lanzhou General Hospital of PLA, Lanzhou, China; 2First Department of Medical Technology, Lanzhou General Hospital of PLA, Lanzhou, China
D. Ma, X. Guo, H. Yao, J. Chen: Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Sagittal fractures of the maxilla and palate are uncommon in clinical practice. Current methods for the management of such fractures have advantages and limitations. The authors present the simple and practical technique of bilateral transpalatal screw traction to manage this fracture type.
Sagittal fractures of the maxilla and palate (SFMP), passing medially or paramedially through the palatal shelves and splitting the maxilla in a sagittal direction, usually occur in association with a Le Fort fracture.1,2 This type of fracture often causes maxillary arch expansion and buccal rotation.1,3 Traditional methods for managing such fractures include the use of Kirschner wire, acrylic splints, arch bars for maxillomandibular fixation, intermolar wire fixation, and the intermaxillary figure-ofeight wiring technique.1–5 However, each of these methods has inherent drawbacks and it is difficult to use these techniques alone to achieve ideal occlusal function, sufficient stability, and accurate reduction. Clinicians are increasingly advocating the use of open reduction and internal 0901-5027/000001+03
fixation with a plate and screw system to treat such fractures.1–4 This technique obviously has several advantages, such as improving the stability, defining maxillary arch width, and limiting the rotation of the maxillary segments. However, it is sometimes associated with complications such as the development of palatal fistula and exposure of the plate and screws.1,2 Moreover, the operative procedure includes palatal incision, wide flap elevation, reduction of the maxillary fracture, and plate–screw fixation on the roof of the mouth. This procedure is time-consuming and may affect the blood supply of the fractured segments.1,3 Therefore, more simple and effective methods are needed.
Keywords: screw; traction; sagittal fractures; maxilla; palate.. Accepted for publication 23 July 2014
We describe a simple technique to manage SFMP: bilateral transpalatal screw traction. Technique
Images of a representative patient with SFMP are given in Figs. 1–3. Two self-drilling screws (each with a hole in its head) are inserted bilaterally into the bony palatal region between the upper first and second molars. A 24-gauge wire is pre-stretched and its ends are inserted into the screw holes on either side of the palate. The two ends of the wire are then criss-crossed and progressively twisted together (Fig. 2). Tightening forceps produce a traction force in the direction of the median line to reduce displaced
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ma D, et al. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.019
YIJOM-2966; No of Pages 3
2
Ma et al.
Fig. 1. Preoperative malocclusion in a representative patient with sagittal fractures of the maxilla and palate (left). Axial (middle) and coronal (right) CT scans show the sagittal fractures of the maxilla and palate (arrows) before treatment.
Fig. 2. Intraoperative view showing the application of transpalatal screw traction.
fractures. The transpalatal traction wire is kept in place to help immobilize fractures of the maxilla and palate. Intermaxillary fixation is applied on each side of the fracture line to restore normal occlusion. The fractures are then stabilized if needed. Transpalatal screw traction can be used alone, or as an adjunct to other management methods, such as intermaxillary fixation, open reduction and internal fixation at the level of the piriform aperture, and stabilization of zygomaticomaxillary and nasomaxillary buttresses. The average time to the removal of the traction device is 4 weeks.
We have used this technique to treat 11 patients with SFMP over a period of 5 years. The fractures in this study were not isolated and all were associated with Le Fort fractures. The mean follow-up was 8 months. Ten patients achieved satisfactory occlusion. One patient developed bilateral posterior crossbite but had acceptable occlusion following orthodontic treatment. We observed that transpalatal screw traction is an effective method for achieving closed reduction and external fixation in patients with SFMP. Therefore, the use of open reduction and internal fixation of the hard palate is not recommended for the treatment of SFMP in our department.
Discussion
SFMP are uncommon in clinical practice, with an incidence ranging from 4% to 42% in maxillary fractures.1,2 Diagnosis of this type of fracture is mainly based on clinical evaluation and radiographic examination. Palatal mucosal laceration and malocclusion are typical clinical signs of SFMP. Since not all SFMP are apparent on Xrays, the radiographic diagnosis of these fractures can sometimes be difficult. By
contrast, computed tomography (CT) scans can display detailed images of the specific fractures.1 Therefore, a CT scan, especially an axial CT scan, is recommended to confirm the diagnosis of SMFP in suspected cases. As shown in the CT scan images in Fig. 1, paramedian SFMP can clearly be identified and were associated with Le Fort I and II fractures in this case. These detailed CT scan images were very helpful in designing the treatment plan for the patient. Since most SFMP occur in association with Le Fort fracture,2,6 the U-shaped maxillary arch is usually divided into two unstable segments, increasing the difficulty of the reduction procedure. Inward forces in the transverse direction are required to push the displaced fragments medially to achieve reduction of the sagittal fracture segment. Therefore, transpalatal screw traction is applied to reduce and fix the bilateral maxillary fragments. Compared to other methods currently used for the treatment of SFMP, this technique has several potential benefits. First, it is a simple and efficient method that produces good functional outcomes with minimal complications. Second, it has little impact on the patient’s oral hygiene, speech, and feeding
Fig. 3. Postoperative view of the same patient showing the normal occlusion obtained (left). Axial (middle) and coronal (right) CT scans show the reduced fractures of the maxilla and palate (arrows) at 7 days after treatment.
Please cite this article in press as: Ma D, et al. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.019
YIJOM-2966; No of Pages 3
Transpalatal screw traction during treatment. Third, compared to the use of tooth-supported appliances, the use of screws makes this device essentially a bone-supported appliance, reducing the risk of dental injuries. Furthermore, when open surgery is contraindicated in patients with certain conditions, such as severe cerebral injury, our technique can be used in the early management of such fractures to facilitate the primary replacement of displaced bone and to minimize the risk of complications. Our technique does not expose the sagittal fracture site and therefore may allow for minor bone mismatches or inaccurate reduction. However, the best way to achieve fracture reduction is first to restore the occlusion and then to stabilize the fracture segment if needed.4 Our results showed that normal occlusion can be established by transpalatal screw traction and maxillomandibular fixation. Therefore, the use of open reduction and internal fixation of the hard palate is not recommended for the treatment of SFMP in our department. As has been reported by other authors,2,6 the SFMP in our cases were often associated with Le Fort fractures. Obviously, the use of the transpalatal screw traction alone is not sufficient to achieve and maintain the stability of such associated fractures. Thus, this technique should be supplemented by other management methods, such as open reduction and internal fixation at the
piriform aperture, the zygomaticomaxillary buttress, the nasomaxillary buttresses, or the zygomaticofrontal suture. We have presented a preliminary report of this technique. Whether it is a superior method for the management of this type of fracture is therefore unknown. Further controlled clinical trials are required to compare this approach with existing techniques and to determine the advantages and disadvantages of this new method.
2.
3.
4.
Funding
This work was funded in part by the ‘‘Twelve-Five’’ Medical Research Projects of PLA (CWS12J066). Competing interests
None declared. Ethical approval
Not required. Patient consent
Not required. References 1. Manson PN, Glassman D, Vanderkolk C, Petty P, Crawley WA. Rigid stabilization of
5.
6.
3
sagittal fractures of the maxilla and palate. Plast Reconstr Surg 1990;85:711–7. 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. Pollock RA. The search for the ideal fixation of palatal fractures: innovative experience with a mini-locking plate. Craniomaxillofac Trauma Reconstr 2008;1:15–24. Werther JR. Fixation of sagittal fractures of the maxilla. Plast Reconstr Surg 1991;87: 198–9. Kumaravelu C, Thirukonda GJ, Kannabiran P. A novel adjuvant to treat palatal fractures. J Oral Maxillofac Surg 2011;69:e152–4. Hendrickson M, Clark N, Manson PN, Yaremchuk M, Robertson B, Slezak S, et al. Palatal fractures: classification, patterns, and treatment with rigid internal fixation. Plast Reconstr Surg 1998;101:319–32.
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 Fax: +86 931 89994437 E-mails: [email protected], [email protected]
Please cite this article in press as: Ma D, et al. Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.019
