[ S-shaped suction catheter for intraoperative intermaxillary fixation]

BACKGROUND

Orthognathic surgery for maxillofacial deformities and open reduction of mandibular fractures may require intermaxillary fixation during the surgical procedure. Extubation with intraoperative intermaxillary fixation is highly dangerous, because nasal bleeding and postoperative vomiting can cause airway obstruction and aspiration pneumonia. To prevent these complications, we routinely use an S-shaped suction catheter in patients with intraoperative intermaxillary fixation. The purpose of this study was to determine the optimal location for fixation of a catheter to allow effective suctioning.

METHODS

Fourteen adult volunteers participated in this study. A suction catheter was inserted into the oral cavity proper through the retromolar space in an intercuspal position. When the catheter could suction distilled water in the mouth, the distance from the tip of the catheter to the angle of the mouth was measured.

RESULTS

The distances of straight type catheters were 68+/-7 and 57+/-7 mm in males and females, respectively. The distances of angle type catheters were 72+/-10 and 58+/-7 mm in males and females, respectively.

CONCLUSIONS

The present study suggests that an S-shaped suction catheter is useful to suction oral secretions in patients with intraoperative intermaxillary fixation.

Closed reduction of the mandibular fracture

The search for the ideal method of treatment for mandibular fractures has continued for thousands of years. These injuries have unique and problematic features for adequate reliable wound healing. Oral and maxillofacial surgeons must learn and master several techniques for mandibular fracture treatment. The age-old successful management of these injuries using closed reduction techniques always should be considered when mandibular trauma presents. The closed reduction remains a mainstay of mandibular fracture treatment. An adequate knowledge of anatomy, multiple closed reduction techniques, and the physiology of fracture healing must be adequately understood and technically mastered by the oral and maxillofacial surgical team for the present and future of mandibular fracture management.

Management of the edentulous/atrophic mandibular fracture

Edentulous or atrophic mandible fractures are rare and potentially problematic for the oral and maxillofacial surgeon. With the loss of teeth, atrophy of the alveolar bony apparatus ensues, creating a mandible more prone to fracture. This article describes the management of edentulous/atrophic mandibular fractures.

Bicortical extraoral plating of mandibular fractures

The goal of bicortical fixation of mandibular fractures is to provide for undisturbed healing and immobility of fragments to facilitate primary bony union. This type of fixation should provide sufficient rigidity for fracture segments to resist any movement along the fracture line during normal function of the mandible. The decision of which technique to use for fixation of a particular mandible fracture depends on multiple factors, such as fracture location, favorability of fracture vectors, anatomic location of fractures, systemic health of the patient, timing of surgery, experience of the surgeon, age of the patient, and patient compliance. In this chapter, the authors discuss the indications and techniques of bicortical fixation of mandible fractures.

Fractures of the growing mandible

Oral and maxillofacial surgeons must constantly weigh the risks of surgical intervention for pediatric mandible fractures against the wonderful healing capacity of children. The majority of pediatric mandibular fractures can be managed with closed techniques using short periods of maxillomandibular fixation or training elastics alone. Generally, the use of plate- and screw-type internal fixation is reserved for difficult fractures. This article details general and special considerations for this surgery including: craniofacial growth & development, surgical anatomy, epidemiology evaluation, various fractures, the role rigid internal fixation and the Risdon cable in pediatric maxillofacial trauma. It concludes with suggestions concerning long-term follow-up care in light of the mobility, insurance obstacles, and family dynamics facing the patient population.

External fixation for mandible fractures

External fixation of mandible fractures is a useful technique when an open treatment is contraindicated because of extensive comminution, bone or soft tissue loss, and infection. This technique can also be used temporarily until definitive treatment is delivered. A uniphasic or biphasic system can be placed to reduce and stabilize mandibular fractures. These systems use surgically placed threaded pins and different types of connectors that can be manipulated to optimize the reduction of fractures. External fixation remains a quick, safe, and simple method to treat mandible fractures in selected clinical situations, and it should be part of the armamentarium in surgeons treating these injuries and fractures.

Maxillary expansion and stability in the orthodontic-surgical treatment of skeletal anterior open bites

OBJECTIVES

Evaluation of the surgical/orthodontic treatment's stability using rigid internal fixation.

METHODS AND MATERIALS

Seventeen patients presenting an anterior skeletal openbite, analyzed retrospectively to evaluate stability of surgical-orthodontic treatment using rigid internal fixation: mini plates and screws for maxillary fixation and bicortical screws for the mandible. The surgical procedures were Le Fort I osteotomy and bilateral sagittal split mandibular osteotomy. The patients were classified into 4 groups according to the characteristics described by Ellis (date): Group 1a (n = 4): Class II dental and skeletal malocclusions treated with one piece Le Fort I intrusion osteotomy and bilateral sagittal split mandibular advancement. Group 1 b (n = 4): Class II dental and skeletal malocclusions treated with multisegmental Le Fort I to expand surgically the maxillary width, intrusion osteotomy and bilateral sagittal split mandibular advancement. Group 2a (n = 5): Class III dental and skeletal malocclusions treated with one piece Le Fort I intrusion with/without advancement and bilateral sagittal split mandibular set-back. Group 2b (n = 4): Class III dental and skeletal malocclusions treated with multisegmental Le Fort I, expanding surgically the maxillary width, with/without advancement.

Outcome of postsurgical sequential functional exercise of jaw fracture

BACKGROUND

A large number of studies and clinical cases show that an ideal prognosis for mouth function cannot be obtained without sufficient and reasonable postsurgical functional exercise after jaw fracture. However, no unifying criteria exist on postsurgical functional exercise with jaw fracture. The study was designed to explore effective methods of postsurgical functional exercise of jaw fracture.

MATERIALS AND METHODS

One hundred seventeen inpatients with jaw fracture between August 2005 and August 2006 were subjects in this study. Sequential function exercise methods were used to recover patients' gape degree, chewing, and so on. Gape degree was recorded, and healing of the jaw was assessed using x-ray.

RESULTS

All 117 patients with jaw fracture who underwent surgery were involved in the analysis. After sequential function exercise, gape degree and chewing function improved; good occluding relations were retained. Gape degree was significantly improved at 8 or 12 weeks postsurgery compared with 1 or 4 weeks postsurgery (P < 0.01). However, no significant differences in gape degree were observed between 1 and 4 weeks postsurgery and between 8 and 12 weeks postsurgery (P > 0.05).

CONCLUSIONS

Sequential function exercise contributes much to patient recovery of mouth function. This method is effective for postsurgical functional recovery of jaw fracture.

The use of resorbable hardware for fixation of pediatric mandible fracture. Case report

The diagnosis and management of mandible fractures in the pediatric patient population can pose multiple challenges to the oral and maxillofacial surgeon. Resorbable plates and screws for fixation in this population are both well tolerated and effective. They enable realignment and stable positioning of rapidly healing fracture segments, while obviating any potential impediments to long-term metal retention.

Allergy to metal caused by materials used for intermaxillary fixation: Case report

A 21-year-old man with no history of contact allergy developed eczema over his entire body 2 days after he had had intermaxillary fixation (IMF) of a mandibular fracture. Patch testing showed a strong reaction to nickel so the arch bars and wires that had been used for fixation were removed and replaced with resin brackets, elastic bands, and a chin cap. The eczema disappeared 2 days later.

Use of straight and curved 3-dimensional titanium miniplates for fracture fixation at the mandibular angle

PURPOSE

The aim of this follow-up study was to evaluate the clinical usefulness of a new type of 3-dimensional (3D) miniplate for open reduction and monocortical fixation of mandibular angle fractures.

PATIENTS AND METHODS

In 20 consecutive patients, noncomminuted mandibular angle fractures were treated with open reduction and fixation using a 2 mm 3D miniplate system in a transoral approach. All patients were systematically monitored until 6 months postoperatively. Among the outcome parameters recorded were infection, hardware failure, wound dehiscence, and sensory disturbance of the inferior alveolar nerve.

RESULTS

The mean operation time from incision to wound closure was 65 minutes. Two patients had a mucosal wound dehiscence with no consequences. None developed an infection requiring a plate removal. All but 2 patients had normal sensory function 3 months after surgery. Plate fracture occurred in one patient in whom a preceding surgical removal of the third molar had been the reason for the mandibular fracture. In the absence of clinical symptoms, the patient declined plate removal. On final follow-up, fracture healing was considered clinically complete in all patients.

CONCLUSIONS

The 3D plating system described here is suitable for fixation of simple mandibular angle fractures and is an easy-to-use alternative to conventional miniplates. The system may be contraindicated in patients in whom insufficient interfragmentary bone contact causes minor stability of the fracture.

Evaluation of force degradation characteristics of orthodontic latex elastics in vitro and in vivo

OBJECTIVE

To evaluate the characteristics of force degradation of latex elastics in clinical applications and in vitro studies.

MATERIALS AND METHODS

Samples of 3/16-inch latex elastics were investigated, and 12 students between the ages of 12 and 15 years were selected for the intermaxillary and intramaxillary tractions. The elastics in the control groups were set in artificial saliva and dry room conditions and were stretched 20 mm. The repeated-measure two-way analysis of variance and nonlinear regression analysis were used to identify statistical significance.

RESULTS

Overall, there were statistically significant differences between the different methods and observation intervals. At 24- and 48-hour time intervals, the force decreased during in vivo testing and in artificial saliva (P < .001), whereas there were no significant differences in dry room conditions (P > .05). In intermaxillary traction the percentage of initial force remaining after 48 hours was 61%. In intramaxillary traction and in artificial saliva the percentage of initial force remaining was 71%, and in room conditions 86% of initial force remained. Force degradation of latex elastics was different according to their environmental conditions. There was significantly more force degradation in intermaxillary traction than in intramaxillary traction. The dry room condition caused the least force loss.

CONCLUSIONS

There were some differences among groups in the different times to start wearing elastics in intermaxillary traction but no significant differences in intramaxillary traction.

Application of Intermaxillary Fixation Screws in Maxillofacial Trauma

PURPOSE

The use of intermaxillary fixation (IMF) in the treatment of maxillofacial trauma represents the cornerstone of fracture reduction and immobilization. Many modalities of IMF have been described; recently IMF screws have been introduced into clinical practice, however, hardware failure can occur. We performed a retrospective study evaluating hardware-associated complications for self-drilling/tapping IMF screws.

MATERIALS AND METHODS

A retrospective study on 49 patients requiring IMF was performed. The diagnosis, duration of IMF, screw site, use of elastic or wire fixation, and associated complications were recorded. IMF screws were used to adjunct open reduction techniques, for definitive closed reduction, or fracture prevention following dentoalveolar surgery. Follow-up examinations were performed until fracture healing was complete (6 to 8 weeks).

RESULTS

A single adverse event occurred in 19 patients (39%) while 4 patients (8%) had more than 1 complication. The most common event was screw loosening; 29% of patients had at least 1 screw dislodged in the treatment period. Of the total number of screws placed (229), 15 (6.5%) became loose, and were equally distributed among the mandible and maxilla. The remaining complications noted were root fracture, 4% (2 of 49); loosened wires, 6% (3 of 49); screw shear, 2% (1 of 49); malocclusion, 2% (1 of 49); and ingested hardware, 2% (1 of 49).

CONCLUSIONS

Overall the IMF self-drilling/tapping screws have been shown to be a useful modality to establish maxillomandibular fixation. It is a safe, and time-sparing technique; however, it is not without limitations or potential consequences which the surgeon must be aware of in order to provide safe and effective treatment.

A comparison of lower lip hypoesthesia measured by trigeminal somatosensory-evoked potential between different types of mandibular osteotomies and fixation

PURPOSE

The purpose of this study was to compare objectively, the recovery of hypoestheia of the lower lip following orthognathic surgery using different procedures (sagittal split ramus osteotomy [SSRO]) and intra-oral vertical ramus osteotomy (IVRO)) and fixation methods (monocortical plate fixation and bi-cortical plate fixation). Hypoesthesia was evaluated using the trigeminal somatosensory-evoked potential (TSEP).

PATIENTS AND METHODS

The subjects consisted of 174 patients (348 sides) with mandibular prognathism with or without asymmetry, who underwent mandibular ramus osteotomies using different fixation types. The patients were divided into 4 groups. The OAM group consisted of 128 sides who had SSRO using the Obwegeser method with mono-cortical absorbable plate fixation, the ODTM group consisted of 84 sides who had the Obwegeser-Dal Pont method with mono-cortical titanium plate fixation, the OTB group consisted of 32 sides who had the Obwegeser method with bi-cortical titanium plate fixation and the VO group consisted of 104 sides who underwent IVRO according to the Bell method without fixation. Trigeminal nerve hypoestheia at the region of the lower lip was assessed bilaterally by the TSEP method. An electroencephalograph recording system (Neuropack Sigma; Nion Koden Corp., Tokyo, Japan) was used to analyze the potentials. Each patient was evaluated pre-operatively and then post-operatively at 1 and 2 weeks, 1, 3, and 6 months, and 1 year.

RESULTS

The mean measurable period and standard deviation of TSEP of the lower lip in the OAM group was 5.2 +/- 9.9 weeks, 10.9 +/- 13.1 weeks in the ODTM group, 7.8 +/- 4.5 weeks in the OTB group, and 2.5 +/- 6.3 weeks in the VO group. There were significant differences between the OAM and ODTM groups (P < .0001), the ODTM and OTB groups (P = .0001), the OTB and VO groups (P = .0221), the OAM and VO groups (P < .0001), and the ODTM and VO groups (P < .0001).

CONCLUSION

This study proved using objective measurements that the recovery period from hypoesthesia of the lower lip following orthognathic surgery was dependent on the surgical procedure. Recovery in lower lip hypoesthesia after IVRO was significantly earlier than SSRO.

The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: a case report

The use of rigid fixation in children is controversial and may cause growth retardation along cranial suture lines. Intermaxillary fixation for mandibular fractures should be used cautiously as bony ankylosis in the temporomandibular joint (TMJ) and trismus may develop. The high osteogenic potential of the pediatric mandible allows non-surgical management to be successful in younger patients with conservative approaches. In this case, successful conservative treatment of mandibular fracture of a 3-year-old patient is presented.

The Use of an Intermaxillary Fixation Screw for Mandibular Setback Surgery

PURPOSE

To assess skeletal stability after mandibular setback surgery with and without an intermaxillary fixation (IMF) screw.

PATIENTS AND METHODS

The subjects were 40 patients with mandibular prognathism. The subjects underwent sagittal split ramus osteotomy with titanium plate fixation and were divided into 2 groups, 1 with and 1 without an IMF screw. A lateral cephalogram was done preoperatively, immediately after surgery, and 1 month, 3 months, and 6 months postoperatively. The 2 groups were then compared statistically.

RESULTS

In the comparison of the time-course change between the 2 groups with repeated measure analysis of variance, there were significant differences in occlusal plane (between subjects, F = 2.517; df = 4; P = .0437) and convexity (between subjects, F = 4.048; df = 4; P = .0038). However, there was no significant difference in the other measurements.

CONCLUSION

This study suggested that in most measurements, there was no significant difference between 2 groups with and without an IMF screw in time-course skeletal change. However, use of IMF screws was helpful for orthognathic surgery as a rigid anchor of IMF.

The lingual splint: an often forgotten method for fixating pediatric mandibular fractures

Maxillofacial fractures are uncommon in the pediatric population, and their treatment is unique due to the psychological, physiological, developmental and anatomical characteristics of children. We present the case of a boy who was treated in an outpatient dental clinic using a lingual splint for the reduction, stabilization and fixation of a mandibular body fracture. This technique is a reliable, noninvasive procedure that dentists may consider in selected cases by referral to an oral and maxillofacial surgeon. It also limits the discomfort and morbidity that can be associated with maxillomandibular fixation or open reduction and internal fixation in pediatric patients.

Skeletal Stability Following Bilateral Sagittal Split Osteotomy (BSSO) With and Without Condylar Positioning Device

PURPOSE

The goal of this retrospective study was to investigate whether utilization of condylar positioning devices in comparison to the manual positioning technique has a favorable influence on skeletal stability after bilateral sagittal split osteotomy.

PATIENTS AND METHODS

Lateral cephalometric radiographs of 49 patients who had undergone bilateral sagittal split osteotomy or bimaxillary surgery at the Universitiy Hospital of Aachen between 1993 and 2003 were evaluated with the aid of analysis software (Adda Keph version 3.0, JR - datentechnik, Leipzig, Germany). As a criterion for skeletal stability the postoperative changes of SNB angle and Wits appraisal were determined. In 10 of 28 patients with mandibular advancement and in 10 of 21 individuals with mandibular setback, the Luhr positioning device was used intraoperatively to reproduce the condylar position. Mandibular joints of the remaining patients were positioned manually. The results were statistically worked up by means of unrelated t test at P = .05.

RESULTS

Neither in advancement nor in setback surgery did the positioning device technique result in better outcomes for postoperative changes of SNB angle and Wits appraisal. The confidence intervals rather suggest equivalence of the data in both groups.

CONCLUSION

The use of positioning appliances does not lead to an improvement of skeletal stability. With the manual technique, equally stable results can be attained in advancement as well as in setback surgery.

Evaluation of different miniplates in fixation of fractured human mandible with the finite element method

The objective of this study was to develop a 3-dimensional finite element model (FEM) to formulate biomechanical justification of the positioning of different plates to achieve stable fixation of a fractured mandible. Miniplate systems that give acceptable levels of rigidity were investigated, and recommendations about miniplate location, orientation, and type selection are made. A fracture near the body region was bridged with a variety of commonly used plate configurations. Number, positioning and type of the plate system parameters. The results of this fracture model support the advantage of 2-plate systems. Using a longer plate in the superior position and a shorter one in the inferior position produced a more stable condition. Number of screws or length of the miniplate had no significant effect on the stability of fractured segments. The results obtained from this study offer the choice of a particular plate size, thickness, design, or configuration for application and thus provide information for clinical use.

Traitement chirurgical des fractures du condyle mandibulaire de l'adulte en France en 2005

INTRODUCTION

The authors had for aim to present the latest trends in the surgical management of mandibular condylar fractures in France, in 2005.

MATERIAL AND METHODS

One hundred maxillofacial surgeons were questioned on the surgical management of condylar fractures and indications. Results were presented at the 41st Congress of Stomatology and Maxillofacial surgery.

RESULTS

The overall reply rate was 70%. Condylar fractures are generally managed in teaching hospitals. Open reduction and fixation was deemed appropriate in low subcondylar fractures in 76% of the cases, in 10% for diacapitular fractures. Therapeutic details and indications were a matter of huge variability.

DISCUSSION

This survey highlighted the absence of any consensus as far as condylar fractures are concerned. It seems that the higher the fractures are, the lesser they are approached.

Biomechanical testing of different osteosynthesis systems for segmental resection of the mandible

PURPOSE

This investigation assessed the mechanical behavior of 3 different locking and nonlocking reconstruction systems-Unilock 2.4, Reconstruction 2.4, and Reconstruction 2.7-with regard to plate and screw fracture.

MATERIALS AND METHODS

Five different plate/screw configurations (Unilock 2.4-locking screws, Unilock 2.4 -conventional screws, Reconstruction 2.4-conventional screws, Reconstruction 2.7-conventional screws, and Unilock 2.4-locking screws with a 1-mm gap; Synthes, Umkirch, Germany) were tested on synthetic mandibles. All mandibles were resected on the left side between the canine and third molar, reconstructed, and loaded cyclically between 30 and 300 N up to 250,000 cycles or until screw or plate failure occurred.

RESULTS

No screw fractures were observed. All plates fractured close to the distal fragment. The Unilock plates fixed with locking screws withstood significantly more cycles until failure than the Reconstruction plates 2.4 fixed with conventional MF-Cortex screws. No significant differences were found in the other groups. Only 2 of the 34 plates tested, both of the Reconstruction 2.7 system, reached the runout limit.

CONCLUSIONS

Unilock plates fixed with locking screws have a higher long-term stability than the Reconstruction 2.4 system. A 1-mm gap between the plate and mandible does not lead to early screw failure in the Unilock 2.4 system with locking screws. The Reconstruction 2.7 system seems superior if well contoured, because 2 of those plates reached the runout limit; however, this system is not as easy to handle as the 2.4 systems, and good contouring is difficult to achieve. Therefore, we consider the Unilock 2.4 system with locking screws the best choice.