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Malar fractures: Silicone wedge stabilisation
British Journal of Oral Sttrgery 17 (1979-80), 244-247
MALAR FRACTURES: SILICONE WEDGE STABILISATION J. M. GORMAN, M.D.S., F.D.S.R.C.S. (ENG.), F.F.D.R.C.S. (I)
The Ulster Hospital, Dundonald, Belfast Summary. A technique is described for the stabilisation of some malar fractures by means of silicone elastomer wedges.
Introduction
When reduction of malar fractures is delayed, as may occur when a patient's general condition does not allow operation, or when the diagnosis is made late, it becomes progressively more difficult. Late reduction can usually be undertaken within a few weeks of injury but instability is common as the fractured ends have become rounded off and, after elevation, the bone falls back into its displaced position (Killey, 1965). Where there is lack of stability it can be dealt with by a transosseous wire at the fronto-malar or inferior orbital fracture site with, if necessary, an antral pack (Rowe & Killey, 1968). A number of other means are, or have been used to obtain stabilisation. These methods include pin fixation to a headcap or a dental splint (Gillies & Millard, 1957), pin fixation to the supra-orbital margin, Kirschner wire fixation to the sound side (Brown et al., 1952), and the use of a Foley catheter within the antrum (Gutman et al., 1965). The purpose of this article is to describe a method of stabilisation using a wedge of silicone elastomer (Silastic - Dow Corning) placed at the malar buttress fracture site, and which has been used in ten cases over the past year. Indications
The silicone wedge technique is indicated in two differing types of fractured malar. The first is where a simple malar fracture is found to be unstable, usually as the result of delayed reduction. A simple fracture is one in which there has been inward displacement with a hinge movement at the fronto-malar fracture, and without either marked distraction or overlap at this site. In such fractures the wedge will give stability without the need for any orbital margin wiring. The second is where, in addition to the normal fracture pattern, there is a transverse fracture across the body of the malar separating it into upper and lower components. Here the wedge is used to support the lower component, and transosseous wiring may well be needed at other fracture sites. Method
Uncomplicated fractured malar The depressed malar is elevated by the temporal approach (Gillies et al., 1927) using a Bristow's lever. If the malar is found to be unstable the fracture in the region of the malar buttress (the zygomatic process of the maxilla) is exposed through an incision in the buccal sulcus. The incision, convex downwards, can extend to the (Received 6 January 1979; accepted 17 January 1979)
244
MALAR FRACTURES: SILICONE WEDGE STABILISATION
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alveolar ridge in edentulous cases, or include the gingival margin where teeth are present and the sulcus shallow. The fracture site is visualised, the reduction checked, and any small pieces of loose bone removed. Should further reduction be needed then a Howarth elevator can be inserted and the malar levered from below with, if necessary, further pressure on the Bristow's lever above. Once reduction is complete the width of wedge can be estimated, and then cut from firm Silastic block. The wedge resembles a half-slice of lemon, the curved wider outer edge being shaped to conform to the curve of the maxilla, the inner side being narrow to fit between the bone ends. When in place (Fig. 1) the wedge is firmly supported below by the base of the malar buttress, and its narrow side projects a short way within the antrum. The oral and temporal wounds are then closed. The radiographs (Figs 2 & 3) show the pre- and post-operative views of a fractured left malar. The patient, a 54-year-old woman, did not come to operation until 20 days after the injury. After reduction by the Gillies method the malar was very unstable. A silicone wedge was placed by the technique described, and this gave firm support and stability to the malar. Removal of the wedge is carried out under local anaesthesia, or under a short general anaesthetic, some six months later.
Complicated malar fractures If there is a transverse body fracture (Fig. 4) in addition to the usual fractures, then the oral approach will allow the elevation of the lower fragment out of the antrum, and a silicone wedge will provide stabilisation. In such a case this technique is used in combination with whatever manoeuvres are indicated to reduce the rest of the fractures, and to reconstruct the orbital margin and floor. The post-reduction view (Fig. 5)
FI6. 1. Silicone wedge in position. 17/3--~
246
B R I T I S H J O U R N A L OF ORAL S U R G E R Y
s h o w s a s a t i s f a c t o r y r e d u c t i o n w i t h a f r o n t o - m a l a r w i r e a n d silicone w e d g e b e i n g u s e d in c o m b i n a t i o n . A g a i n , t h e silicone w e d g e is r e m o v e d s o m e six m o n t h s later.
FiG. 2 (left) Case 1. Radiograph of fractured left malar, with medial displacement and slight rotation. Fro. 3 (right). Post-reduction radiograph. The silicone wedge is difficult to see against the thickened antral lining.
FIG. 4 (left) Case 2. Radiograph of fractured right malar, in which there is also a transverse body fracture. Separation at the fronto-malar fracture site is shown. Fro. 5 (right). Post-reduction radiograph. The silicone wedge has stainless steel wire placed in it to assist visualisation. The fronto-malar fracture has been wired.
MALAR FRACTURES: SILICONE WEDGE STABILISATION
247
Discussion
The dual external and internal approach is a possible disadvantage, as is the need to go back later to remove the silicone. With suitable antibiotic cover there has been no wound infection, or rejection of the wedge. At operation the visualisation of the fracture through the m o u t h helps reduction, and can be of value even when a wedge is not needed. The method has been particularly welcomed by those patients, especially female, who are already recovering from multiple facial wounds, and for whom approaches about the orbital margin may not be needed. The technique has not yet been used in combination with hook traction as described by Poswillo, (1976). An advantage of this method is that no temporal wound is needed. H o o k traction is said to be successful where reduction is delayed, although m a n y operators consider, as do Rowe and Killey (1968), that elevation from above 'permits a greater degree of controlled force to be exerted than any other method'. The silicone wedge provides stabilisation where it is most needed, and when in position it underpins the fractured bone. The method in m a n y cases makes frontomalar transosseous wiring unnecessary. References
Brown, J. B., Fryer, M. P. & McDowell, F. (1952). Plastic and Reconstructive Snrgery, 9, 276. Gillies, H. D. & Millard, D. R. (1957). The Principles and Art of Plastic Surgery. 1st Ed. London: Butterworth. Gillies, H. D., Kilner, T. P. & Stone, D. (1927). British Journal of Surgery, 14, 151. Gutman, D,, Laufer, D. & Neder, A. (1965). British Journal of Oral Surgery, 2, 153. Killey, H. C. (1965). Fractures of the middle third of the facial skeleton. 1st Ed. Bristol : Wright. Poswillo, D. (1976). British Journal of Oral Surgery, 14, 76. Rowe, N. L. & Killey, H. C. (1968). Fractures of the facial skeleton. 2nd Ed. Edinburgh and London: Livingstone.
MALAR FRACTURES: SILICONE WEDGE STABILISATION J. M. GORMAN, M.D.S., F.D.S.R.C.S. (ENG.), F.F.D.R.C.S. (I)
The Ulster Hospital, Dundonald, Belfast Summary. A technique is described for the stabilisation of some malar fractures by means of silicone elastomer wedges.
Introduction
When reduction of malar fractures is delayed, as may occur when a patient's general condition does not allow operation, or when the diagnosis is made late, it becomes progressively more difficult. Late reduction can usually be undertaken within a few weeks of injury but instability is common as the fractured ends have become rounded off and, after elevation, the bone falls back into its displaced position (Killey, 1965). Where there is lack of stability it can be dealt with by a transosseous wire at the fronto-malar or inferior orbital fracture site with, if necessary, an antral pack (Rowe & Killey, 1968). A number of other means are, or have been used to obtain stabilisation. These methods include pin fixation to a headcap or a dental splint (Gillies & Millard, 1957), pin fixation to the supra-orbital margin, Kirschner wire fixation to the sound side (Brown et al., 1952), and the use of a Foley catheter within the antrum (Gutman et al., 1965). The purpose of this article is to describe a method of stabilisation using a wedge of silicone elastomer (Silastic - Dow Corning) placed at the malar buttress fracture site, and which has been used in ten cases over the past year. Indications
The silicone wedge technique is indicated in two differing types of fractured malar. The first is where a simple malar fracture is found to be unstable, usually as the result of delayed reduction. A simple fracture is one in which there has been inward displacement with a hinge movement at the fronto-malar fracture, and without either marked distraction or overlap at this site. In such fractures the wedge will give stability without the need for any orbital margin wiring. The second is where, in addition to the normal fracture pattern, there is a transverse fracture across the body of the malar separating it into upper and lower components. Here the wedge is used to support the lower component, and transosseous wiring may well be needed at other fracture sites. Method
Uncomplicated fractured malar The depressed malar is elevated by the temporal approach (Gillies et al., 1927) using a Bristow's lever. If the malar is found to be unstable the fracture in the region of the malar buttress (the zygomatic process of the maxilla) is exposed through an incision in the buccal sulcus. The incision, convex downwards, can extend to the (Received 6 January 1979; accepted 17 January 1979)
244
MALAR FRACTURES: SILICONE WEDGE STABILISATION
245
alveolar ridge in edentulous cases, or include the gingival margin where teeth are present and the sulcus shallow. The fracture site is visualised, the reduction checked, and any small pieces of loose bone removed. Should further reduction be needed then a Howarth elevator can be inserted and the malar levered from below with, if necessary, further pressure on the Bristow's lever above. Once reduction is complete the width of wedge can be estimated, and then cut from firm Silastic block. The wedge resembles a half-slice of lemon, the curved wider outer edge being shaped to conform to the curve of the maxilla, the inner side being narrow to fit between the bone ends. When in place (Fig. 1) the wedge is firmly supported below by the base of the malar buttress, and its narrow side projects a short way within the antrum. The oral and temporal wounds are then closed. The radiographs (Figs 2 & 3) show the pre- and post-operative views of a fractured left malar. The patient, a 54-year-old woman, did not come to operation until 20 days after the injury. After reduction by the Gillies method the malar was very unstable. A silicone wedge was placed by the technique described, and this gave firm support and stability to the malar. Removal of the wedge is carried out under local anaesthesia, or under a short general anaesthetic, some six months later.
Complicated malar fractures If there is a transverse body fracture (Fig. 4) in addition to the usual fractures, then the oral approach will allow the elevation of the lower fragment out of the antrum, and a silicone wedge will provide stabilisation. In such a case this technique is used in combination with whatever manoeuvres are indicated to reduce the rest of the fractures, and to reconstruct the orbital margin and floor. The post-reduction view (Fig. 5)
FI6. 1. Silicone wedge in position. 17/3--~
246
B R I T I S H J O U R N A L OF ORAL S U R G E R Y
s h o w s a s a t i s f a c t o r y r e d u c t i o n w i t h a f r o n t o - m a l a r w i r e a n d silicone w e d g e b e i n g u s e d in c o m b i n a t i o n . A g a i n , t h e silicone w e d g e is r e m o v e d s o m e six m o n t h s later.
FiG. 2 (left) Case 1. Radiograph of fractured left malar, with medial displacement and slight rotation. Fro. 3 (right). Post-reduction radiograph. The silicone wedge is difficult to see against the thickened antral lining.
FIG. 4 (left) Case 2. Radiograph of fractured right malar, in which there is also a transverse body fracture. Separation at the fronto-malar fracture site is shown. Fro. 5 (right). Post-reduction radiograph. The silicone wedge has stainless steel wire placed in it to assist visualisation. The fronto-malar fracture has been wired.
MALAR FRACTURES: SILICONE WEDGE STABILISATION
247
Discussion
The dual external and internal approach is a possible disadvantage, as is the need to go back later to remove the silicone. With suitable antibiotic cover there has been no wound infection, or rejection of the wedge. At operation the visualisation of the fracture through the m o u t h helps reduction, and can be of value even when a wedge is not needed. The method has been particularly welcomed by those patients, especially female, who are already recovering from multiple facial wounds, and for whom approaches about the orbital margin may not be needed. The technique has not yet been used in combination with hook traction as described by Poswillo, (1976). An advantage of this method is that no temporal wound is needed. H o o k traction is said to be successful where reduction is delayed, although m a n y operators consider, as do Rowe and Killey (1968), that elevation from above 'permits a greater degree of controlled force to be exerted than any other method'. The silicone wedge provides stabilisation where it is most needed, and when in position it underpins the fractured bone. The method in m a n y cases makes frontomalar transosseous wiring unnecessary. References
Brown, J. B., Fryer, M. P. & McDowell, F. (1952). Plastic and Reconstructive Snrgery, 9, 276. Gillies, H. D. & Millard, D. R. (1957). The Principles and Art of Plastic Surgery. 1st Ed. London: Butterworth. Gillies, H. D., Kilner, T. P. & Stone, D. (1927). British Journal of Surgery, 14, 151. Gutman, D,, Laufer, D. & Neder, A. (1965). British Journal of Oral Surgery, 2, 153. Killey, H. C. (1965). Fractures of the middle third of the facial skeleton. 1st Ed. Bristol : Wright. Poswillo, D. (1976). British Journal of Oral Surgery, 14, 76. Rowe, N. L. & Killey, H. C. (1968). Fractures of the facial skeleton. 2nd Ed. Edinburgh and London: Livingstone.