I Oral Maxlllofac Surg i9:1031-1033.1991
WIRES vs SCREWSFOR MANAGEMENT OF MANDIBULAR FRACTURES
Rigid internal fixation has become a consumer-driven commodity, especially in orthognathic surgery. The patients are “demanding” it. It will not go away. If one will not provide this service for osteotomy patients, it is likely that the patient will choose a surgeon down the street who will. Why should patients who have sustained a fracture be subject to different constraints? There is no longer any reason to open a fracture and place anything short of whatever hardware is adequate to prevent the need for maxillomandibular fixation. What that hardware is, and how it is applied, has yet to be determined. Our article on the use of a lag screw is perhaps one stop on the long journey along a learning curve in the application of rigid internal fixation techniques which are safe, yet effective. To look at our results and determine that we should go back to the use of a transosseous wire and maxillomandibular fixation for those fractures requiring open reduction would be a tragic step backwards. Especially because others. as was stated in the article, have obtained much better results using the lag screw technique.’ The rate of complication reported in our study should also be evaluated relative to a comparable sample of patients treated with other open techniques; for instance, a transosseous wire and maxillomandibular fixation, as Dr Bingham suggests. Most studies in the literature. and our own results, show that irrespective of the treatment provided, the rate of complication is not significantly different for a given patient population.‘m7 Over a 3-year period, 13% of our patients treated for a mandibular fracture with either closed reduction or open reduction with a transosseous wire required further intervention because of some complication. This compares favorably to the results reported in our study. One must understand completely that the population from which our patients were drawn are extremely noncompliant. Most cut themselves out of maxillomandibular fixation and about half never return for removal of their arch bars. Dr Bingham claims to have treated “probably more mandibular fractures than anyone” with a “nil” complication rate. 1 feel certain that one of the principle reasons why his results are better than ours or anyone else’s in the literature is that he has an entirely different patient population and probably one over which he has much better control than we do. Importantly, our results are a stimulus to us to continue our reach for improved methods of managing mandibular fractures to the satisfaction of surgeon and patient alike.
To the Editor:-1 would like to comment on the article .n the March 1991 issue of the Journal concerning “Lag Screw Fixation of Mandibular Angle Fractures” by Drs Ellis and Ghali. From what was said in this article, I can see no justification for this procedure. They admitted to an unacceptably high postsurgical infection rate. They admitted to complications from lack of skill and competence. They admitted to having to use adjunctive prozedures along with the lag screws. They admitted to prolonged maxillomandibular fixation after surgery. I also wonder about permanent nerve damage and about the possibility of injury to blood vessels and other structures from overpenetration of the mandible. With these problems how can the procedure be justified? Most angle fractures can be treated so simply with intraoral placement of a stainless steel wire that I can’t see why one would want to complicate the treatment. If an open reduction is required, the same applies. There is a place for bone plates and screws, but when a simple procedure will suffice, one can hardly justify leaving behind a bunch of hardware attached to the bone. I have practiced the specialty longer than most and have probably treated more mandibular fractures than anyone. As far back as 1954, in an article published in the Journal, I referred to 2,000 fractures treated by me. My complication rate has been almost nil. Obviously, simple and conservative is better than elaborate and complicated. CHARLES B. BINGHAM, DDS
St George, Utah The authors rep/y:--I appreciate the objective remarks made by Dr Bingham and I respect the fine work that he has done through the years. But thankfully. things change. Oral and maxillofacial surgery now enjoys a wide spectrum of activity because of individuals who were willing to seek improvement in every aspect of our practice. Oral and maxillofacial surgery has advanced to the point where techniques are being refined that clearly improve results while increasing patient comfort and satisfaction. This is why the use of rigid internal fixation has become so popular for the treatment of osteotomies and maxillofacial trauma. There should be no doubt in any surgeon’s mind that the thing a patient fears most about many of our procedures is the “jaw wiring.”
EDWARD ELLIS III, DDS. MS Dallas. Texas
References 1.Niederdellmann H, Shetty V: Solitary lag screw osteosynthesis in the treatment of fractures of the angle of the mandible: A retrospective study. Plast Reconstr Surg 80:68. 1987
1031
WIRES vs SCREWSFOR MANAGEMENT OF MANDIBULAR FRACTURES
Rigid internal fixation has become a consumer-driven commodity, especially in orthognathic surgery. The patients are “demanding” it. It will not go away. If one will not provide this service for osteotomy patients, it is likely that the patient will choose a surgeon down the street who will. Why should patients who have sustained a fracture be subject to different constraints? There is no longer any reason to open a fracture and place anything short of whatever hardware is adequate to prevent the need for maxillomandibular fixation. What that hardware is, and how it is applied, has yet to be determined. Our article on the use of a lag screw is perhaps one stop on the long journey along a learning curve in the application of rigid internal fixation techniques which are safe, yet effective. To look at our results and determine that we should go back to the use of a transosseous wire and maxillomandibular fixation for those fractures requiring open reduction would be a tragic step backwards. Especially because others. as was stated in the article, have obtained much better results using the lag screw technique.’ The rate of complication reported in our study should also be evaluated relative to a comparable sample of patients treated with other open techniques; for instance, a transosseous wire and maxillomandibular fixation, as Dr Bingham suggests. Most studies in the literature. and our own results, show that irrespective of the treatment provided, the rate of complication is not significantly different for a given patient population.‘m7 Over a 3-year period, 13% of our patients treated for a mandibular fracture with either closed reduction or open reduction with a transosseous wire required further intervention because of some complication. This compares favorably to the results reported in our study. One must understand completely that the population from which our patients were drawn are extremely noncompliant. Most cut themselves out of maxillomandibular fixation and about half never return for removal of their arch bars. Dr Bingham claims to have treated “probably more mandibular fractures than anyone” with a “nil” complication rate. 1 feel certain that one of the principle reasons why his results are better than ours or anyone else’s in the literature is that he has an entirely different patient population and probably one over which he has much better control than we do. Importantly, our results are a stimulus to us to continue our reach for improved methods of managing mandibular fractures to the satisfaction of surgeon and patient alike.
To the Editor:-1 would like to comment on the article .n the March 1991 issue of the Journal concerning “Lag Screw Fixation of Mandibular Angle Fractures” by Drs Ellis and Ghali. From what was said in this article, I can see no justification for this procedure. They admitted to an unacceptably high postsurgical infection rate. They admitted to complications from lack of skill and competence. They admitted to having to use adjunctive prozedures along with the lag screws. They admitted to prolonged maxillomandibular fixation after surgery. I also wonder about permanent nerve damage and about the possibility of injury to blood vessels and other structures from overpenetration of the mandible. With these problems how can the procedure be justified? Most angle fractures can be treated so simply with intraoral placement of a stainless steel wire that I can’t see why one would want to complicate the treatment. If an open reduction is required, the same applies. There is a place for bone plates and screws, but when a simple procedure will suffice, one can hardly justify leaving behind a bunch of hardware attached to the bone. I have practiced the specialty longer than most and have probably treated more mandibular fractures than anyone. As far back as 1954, in an article published in the Journal, I referred to 2,000 fractures treated by me. My complication rate has been almost nil. Obviously, simple and conservative is better than elaborate and complicated. CHARLES B. BINGHAM, DDS
St George, Utah The authors rep/y:--I appreciate the objective remarks made by Dr Bingham and I respect the fine work that he has done through the years. But thankfully. things change. Oral and maxillofacial surgery now enjoys a wide spectrum of activity because of individuals who were willing to seek improvement in every aspect of our practice. Oral and maxillofacial surgery has advanced to the point where techniques are being refined that clearly improve results while increasing patient comfort and satisfaction. This is why the use of rigid internal fixation has become so popular for the treatment of osteotomies and maxillofacial trauma. There should be no doubt in any surgeon’s mind that the thing a patient fears most about many of our procedures is the “jaw wiring.”
EDWARD ELLIS III, DDS. MS Dallas. Texas
References 1.Niederdellmann H, Shetty V: Solitary lag screw osteosynthesis in the treatment of fractures of the angle of the mandible: A retrospective study. Plast Reconstr Surg 80:68. 1987
1031
