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Applications of immobilization of the mandible by nasomandibular wiring
Applications of Immobilization Mandible by Nasomandibular THOMAS RAY BROADBENT, M.D., From tbe University of Utah School of Medicine, Department of Surgery, Division of Plastic Surgery and the Latter-Day Saints Hospital, Salt Lake City, Utah.
RACTURES of the mandibular condyle are common. Their management in children and edentulous adults is in ways similar, for F
FIG. I. Subcondylar fracture; nasomandibular wire in pIace.
under some circumstances sources of anchorage and lixation of the mandibIe other than the teeth shouId be sought. Circumferential wiring about the mandible and fixation in occlusion to the nasal spine has resulted in good postoperative occlusion with a wide range of painless motion in five children and six adults with condylar fractures. In the edentuIous person sources of fixation other than the teeth must be used, and in the child one may prefer other sources in view of the instability of simple dental root attachments. Nasomandibular fixation is basically a modification of Thoma’s method of immobihzing the mandible to the lateral nasal process.’ A subcondylar fracture in this the weakest point of the mandible is common foIlowing a
of the Wiring*
Salt Lake City, Utab
blow on the chin. The fracture may be unilateral or bilateral. (Fig. I.) Nasomandibular fixation is easily accomplished (Fig. I) and in almost all instances it may be done under local anesthesia. A single wire is not uncomfortabIe and mouth care is simplified. Good postoperative occlusion with a wide range of painless motion can be expected if immobilization in good occlusion is maintained for three to live weeks. As illustrated previously,2 the nasal spine in the child and even the newborn is smaller than in the adult but is nonetheIess accessible and usable in this procedure. Immobilization of the mandible may be made easier in the partially edentuIous patient by modifying nasomandibular fixation. The nasal spine serves well as a fixed point in the individual with sound lower teeth to which loop wires or an arch bar may be attached. On the other hand, the circumferential mandibular wire is equally usable in anchoring the lower jaw to wires or a bar applied on sound maxillary teeth. Nasomandibular fixation is also effective in the immobilization of the fractured body and ramus of the mandibIe.2 Nasomandibular wire immobilization of the mandible during a healing period is of value in situations other than fractures. FolIowing a jaw resection the hemimandible and soft tissues may be retained in a normal position by one of several means. A space retainer such as a Kirschner wire may be placed between the bone ends at the time of resection, the teeth may be wired together or splints of various types may be used, etc. Fixation of the hemimandible by nasomandibular wiring is equally effective. It is particuIarIy useful in the edentulous patient and in the patient whose soft tissues have been sacriliced. Splints being at times difficult to obtain, Kirschner wires eroding and necessitating remova and the ease of nasomandibular wiring may make this means of fixation prefer-
* Read at the AnnuaI Meeting of the American Society of MaxiIIofacial Surgeons, ApriI ton, D. C.
25
to 28, 19~4, Washing-
Immobihation
of MandibIe
2B
2A
FIG. 2. A, operative defect foIIowing resection of the cheek, mandible and cervicle nasomandibuIar wire maintaining normal bone and soft tissue relationship.
Iymphatics.
B,
3A
3B
3C
3D
FIG. 3. A, disarticulation of the right mandible and resection past the midIine. B, remaining left mandibIe with marked deviation and Ioss of stabiIity. C, reconstruction of right mandible with rib bone graft; bone wedging and wire fixation to left mandibIe. C and D, nasomandibuIar wire immobiIization of hrmimandibIe and bone graft.
855
Immobilization
of MandibIe
4B
4A
FIG. 4. A, rib bone graft reconstruction of the right hemimandible. Note bone wedge and wire fixation of the graft, and nasomandibular wire immobikation. B, nasomandibular wire fixation foIIowing a bone graft to the right ramus and mandibuIar angIe.
resected past the midIine for an isoIated disease of the mandibIe. (Fig. 3A.) Five years Iater he was seen with deviation of the remaining mandibuIar fragment toward the midIine and without stability. (Fig. 3B.) A rib bone graft was used in the reconstruction of the right mandible. Union of the graft to the end of the mandibIe was by bone wedge and wire fixation. (Fig. 3C.) ImmobiIization of the hemimandibIe and graft by interdenta1 wiring was not suitabIe with onIy one tooth approaching occIusion. Immobilization was accompIished and maintained for six weeks with a nasomandibuIar wire. (Figs. 3C and D, and 4A and B.) HeaIing and bony union occurred without incident.
abIe even in the patient who is not edentulous. Retaining the hemimandibIe and therefore soft tissue in norma position is essentia1. Immobilization of the hemimandibIe is important when bone-grafting a mandibuIar defect. The bone graft is anchored to the mandibular fragment or fragments by accepted methods. The entire unit, graft and hemimandible may then be immobiIized simpIy by nasomandibuIar wiring. The brief mention of two cases indicates this application. CASE I. A forty-two year oId white woman was seen reIative to a maIignant tumor in the Ieft aIveoIus and adjacent bucca1 mucosa. PartiaI resection and x-ray therapy had faiIed to control the mass and a paIpabIe node had occurred at the angIe of the mandibIe in the cervical Iymphatic chain. The maIignancy was a mucoepidermoid tumor of ectopic saIivary gIand origin. RadicaI resection of the cheek, mandibIe and cervica1 Iymphatics en bloc was performed. (Fig. 2A.) The normal position of the remaining mandible was maintained by nasomandibuIar wiring for three weeks. (Fig. 2B.) Thereafter good occIusion and free motion persisted without bothersome deviation. Space retainers such as a Kirschner wire often erode the overIying soft tissue and have to be removed prematureIy or, as in this instance, cannot be used due to an absence of soft tissue. Wiring of the remaining teeth was not ideaI, for occIusion for the most part was with dentures. CASE II. A thirty-eight year oId white man had had his right mandibIe disarticuIated and
CONCLUSIONS I. ImmobiIization of the mandibIe by a singIe wire nasomandibuIar fixation is discussed. 2. Cases representing the foIIowing probIems are iIIustrated: (I) fractures of the condyIe of the mandible; (2) immobiIization of the remaining hemimandibIe foIIowing jaw resection for maintenance of norma space and proper position of tissues; (3) immobilization of the hemimandibIe and bone graft foIIowing reconstruction of the resected mandibIe with a bone graft. 3. NasomandibuIar wire fixation is easily performed and is highIy effective. It is particuIarIy appIicabIe to chiIdren and edentuIous aduIts. REFERENCES I. THOMA, K. H. Oral Surgery, vol. I, p. 659. St. Louis, 1948. C. V. Mosby Co,
856
Immobilization 2. BHOADBENT,T. R. Mandibular condyle fractures, a method of naso-mandibmar fixation in children and edentulous adults. Plast. Ed Reconstruct. Sure.
(in press). 3. WALDRON, C. W., KAZANJIAN, W. H. and PARKER, D. B. SkeIetaI tixation in the treatment of fractures of the mandible, a review. J. Oral Surg.,
1: 59-83, 194.3.
of Mandible 4. IVY, R. H. Operative treatment of losses of substance of the mandible with special reference to fixation of edentulous fragments. Surg., Gvnec. IY Obst., 52: 849-854, 1922. 5. BROWN, J. B., and YIICDOWELL, F. Internaf wire fixation for fracture of jaw. Surg., Gynec. CJ+Obst., 74: 227, 1942. 6. ADAMS, W. M. Internal wiring fixation of facial fractures. .%rgerV, 12: 523-540, 1942.
BLACK ET AL. studied the microscopic structure of gastric carcinomas and found that postoperative prognosis depended more on whether there was a “ Iymphocytic reaction in the stroma of the primary tumor and/or sinus histiocytosis of the regiona Iymph nodes” than on the presence or absence of Iymph node metastases or deIay in performing surgery, etc. When there was this Iymphocytic reaction and/or sinus histiocytosis, the patients Iived a greater number of years postoperativeIy. (Richard A.
Leonardo,
M.D.)
857
RACTURES of the mandibular condyle are common. Their management in children and edentulous adults is in ways similar, for F
FIG. I. Subcondylar fracture; nasomandibular wire in pIace.
under some circumstances sources of anchorage and lixation of the mandibIe other than the teeth shouId be sought. Circumferential wiring about the mandible and fixation in occlusion to the nasal spine has resulted in good postoperative occlusion with a wide range of painless motion in five children and six adults with condylar fractures. In the edentuIous person sources of fixation other than the teeth must be used, and in the child one may prefer other sources in view of the instability of simple dental root attachments. Nasomandibular fixation is basically a modification of Thoma’s method of immobihzing the mandible to the lateral nasal process.’ A subcondylar fracture in this the weakest point of the mandible is common foIlowing a
of the Wiring*
Salt Lake City, Utab
blow on the chin. The fracture may be unilateral or bilateral. (Fig. I.) Nasomandibular fixation is easily accomplished (Fig. I) and in almost all instances it may be done under local anesthesia. A single wire is not uncomfortabIe and mouth care is simplified. Good postoperative occlusion with a wide range of painless motion can be expected if immobilization in good occlusion is maintained for three to live weeks. As illustrated previously,2 the nasal spine in the child and even the newborn is smaller than in the adult but is nonetheIess accessible and usable in this procedure. Immobilization of the mandible may be made easier in the partially edentuIous patient by modifying nasomandibular fixation. The nasal spine serves well as a fixed point in the individual with sound lower teeth to which loop wires or an arch bar may be attached. On the other hand, the circumferential mandibular wire is equally usable in anchoring the lower jaw to wires or a bar applied on sound maxillary teeth. Nasomandibular fixation is also effective in the immobilization of the fractured body and ramus of the mandibIe.2 Nasomandibular wire immobilization of the mandible during a healing period is of value in situations other than fractures. FolIowing a jaw resection the hemimandible and soft tissues may be retained in a normal position by one of several means. A space retainer such as a Kirschner wire may be placed between the bone ends at the time of resection, the teeth may be wired together or splints of various types may be used, etc. Fixation of the hemimandible by nasomandibular wiring is equally effective. It is particuIarIy useful in the edentulous patient and in the patient whose soft tissues have been sacriliced. Splints being at times difficult to obtain, Kirschner wires eroding and necessitating remova and the ease of nasomandibular wiring may make this means of fixation prefer-
* Read at the AnnuaI Meeting of the American Society of MaxiIIofacial Surgeons, ApriI ton, D. C.
25
to 28, 19~4, Washing-
Immobihation
of MandibIe
2B
2A
FIG. 2. A, operative defect foIIowing resection of the cheek, mandible and cervicle nasomandibuIar wire maintaining normal bone and soft tissue relationship.
Iymphatics.
B,
3A
3B
3C
3D
FIG. 3. A, disarticulation of the right mandible and resection past the midIine. B, remaining left mandibIe with marked deviation and Ioss of stabiIity. C, reconstruction of right mandible with rib bone graft; bone wedging and wire fixation to left mandibIe. C and D, nasomandibuIar wire immobiIization of hrmimandibIe and bone graft.
855
Immobilization
of MandibIe
4B
4A
FIG. 4. A, rib bone graft reconstruction of the right hemimandible. Note bone wedge and wire fixation of the graft, and nasomandibular wire immobikation. B, nasomandibular wire fixation foIIowing a bone graft to the right ramus and mandibuIar angIe.
resected past the midIine for an isoIated disease of the mandibIe. (Fig. 3A.) Five years Iater he was seen with deviation of the remaining mandibuIar fragment toward the midIine and without stability. (Fig. 3B.) A rib bone graft was used in the reconstruction of the right mandible. Union of the graft to the end of the mandibIe was by bone wedge and wire fixation. (Fig. 3C.) ImmobiIization of the hemimandibIe and graft by interdenta1 wiring was not suitabIe with onIy one tooth approaching occIusion. Immobilization was accompIished and maintained for six weeks with a nasomandibuIar wire. (Figs. 3C and D, and 4A and B.) HeaIing and bony union occurred without incident.
abIe even in the patient who is not edentulous. Retaining the hemimandibIe and therefore soft tissue in norma position is essentia1. Immobilization of the hemimandibIe is important when bone-grafting a mandibuIar defect. The bone graft is anchored to the mandibular fragment or fragments by accepted methods. The entire unit, graft and hemimandible may then be immobiIized simpIy by nasomandibuIar wiring. The brief mention of two cases indicates this application. CASE I. A forty-two year oId white woman was seen reIative to a maIignant tumor in the Ieft aIveoIus and adjacent bucca1 mucosa. PartiaI resection and x-ray therapy had faiIed to control the mass and a paIpabIe node had occurred at the angIe of the mandibIe in the cervical Iymphatic chain. The maIignancy was a mucoepidermoid tumor of ectopic saIivary gIand origin. RadicaI resection of the cheek, mandibIe and cervica1 Iymphatics en bloc was performed. (Fig. 2A.) The normal position of the remaining mandible was maintained by nasomandibuIar wiring for three weeks. (Fig. 2B.) Thereafter good occIusion and free motion persisted without bothersome deviation. Space retainers such as a Kirschner wire often erode the overIying soft tissue and have to be removed prematureIy or, as in this instance, cannot be used due to an absence of soft tissue. Wiring of the remaining teeth was not ideaI, for occIusion for the most part was with dentures. CASE II. A thirty-eight year oId white man had had his right mandibIe disarticuIated and
CONCLUSIONS I. ImmobiIization of the mandibIe by a singIe wire nasomandibuIar fixation is discussed. 2. Cases representing the foIIowing probIems are iIIustrated: (I) fractures of the condyIe of the mandible; (2) immobiIization of the remaining hemimandibIe foIIowing jaw resection for maintenance of norma space and proper position of tissues; (3) immobilization of the hemimandibIe and bone graft foIIowing reconstruction of the resected mandibIe with a bone graft. 3. NasomandibuIar wire fixation is easily performed and is highIy effective. It is particuIarIy appIicabIe to chiIdren and edentuIous aduIts. REFERENCES I. THOMA, K. H. Oral Surgery, vol. I, p. 659. St. Louis, 1948. C. V. Mosby Co,
856
Immobilization 2. BHOADBENT,T. R. Mandibular condyle fractures, a method of naso-mandibmar fixation in children and edentulous adults. Plast. Ed Reconstruct. Sure.
(in press). 3. WALDRON, C. W., KAZANJIAN, W. H. and PARKER, D. B. SkeIetaI tixation in the treatment of fractures of the mandible, a review. J. Oral Surg.,
1: 59-83, 194.3.
of Mandible 4. IVY, R. H. Operative treatment of losses of substance of the mandible with special reference to fixation of edentulous fragments. Surg., Gvnec. IY Obst., 52: 849-854, 1922. 5. BROWN, J. B., and YIICDOWELL, F. Internaf wire fixation for fracture of jaw. Surg., Gynec. CJ+Obst., 74: 227, 1942. 6. ADAMS, W. M. Internal wiring fixation of facial fractures. .%rgerV, 12: 523-540, 1942.
BLACK ET AL. studied the microscopic structure of gastric carcinomas and found that postoperative prognosis depended more on whether there was a “ Iymphocytic reaction in the stroma of the primary tumor and/or sinus histiocytosis of the regiona Iymph nodes” than on the presence or absence of Iymph node metastases or deIay in performing surgery, etc. When there was this Iymphocytic reaction and/or sinus histiocytosis, the patients Iived a greater number of years postoperativeIy. (Richard A.
Leonardo,
M.D.)
857