Intraoral open reduction of a fracture of the mandible

Operative INTRAORAL

OPEN REDUCTION

Oral

Surgery

OF A FRACTURE

OF THE MANDIBLES’

JAMES 1,. BRADLEY, D.D.S., M.S.D., M.Sc.,“” ASD EDWARD R. HILDRETT-I, D.D.S.,** GREAT ILIKF,S, ILL,.

treatment of fractures of the mandible, one of the common problems is the management of the displacetl posterior fragment, As a general rnle, if the posterior molar is in the line of fracture and is displaced, its removal may be indicated. One method to consider is the intraoral technique of transwseous wiring of the fractured parts in association with intermaxillary ligation in securing the teeth in occlusion. There are many methods of immol~ilizing the distal fragment. A consideration of the intraoral transosseous reduction method is herewith presented. In the treatment of fr;Lctnres many oral surgeons, since the introduction of t.he ant~ibiot.ics, have Iwen rcsorkg to the open reduction of fractures of the mandible it\ which the lwsterior seginent had been displaced at, the angle. This technique has manly atlr;ultages alltl one can usnall~ 7 get good anatomical wcluctions with the nlininluln of tissue traulnil. IIo\rever, the extraoral open veduction technique does result in visible scar fot~l~l;LIiol~~and the extra contamiThere ma\. l)e tlrainage fro111 an oral nation of itI1 nlr*endy conrl)ounded injury. wound or laceration through the rsterIla1 incisioll. ‘l’hta patient Ili\s to lw hospitalixetl for ;I cwnaidelahle length of time \viih this tyl)e of trratnlent.

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room facilities in a hospitn.1. This technique eliminates the exbraoral cicatcis following the external open reduction procetlurc. Also manipulation of the [X3IfS” Cilll IIF nccot~~~)lisJid (‘ili+l,LF ])l'iclJ~ to the onset of swelling. c*eflnlitis, Or t rismus. Either general or local anesthesia may be used. 111pi1tient.s wit,h vonsideral)Je muscular displacement. generd ;Inesthesi;l by the endotrxchewl methocl

allo\vs for comt)lrtc ~truscular relaxation, facilitating the reduction of the fractured lnrrts. Ilowever, local anesthesia may be the method of choice. This being the case the procedure can be done in the orill surgery operating 1’00111,eslwlitillg t reatmcnt its it requires time for routine lal~~r~fory work-ut) atIc ;ltTi1l1~~l~l~lltS for utilizing one of ttif 11liliIl operating 3’00iiis in il hospital. The herllostasis affortletl by the use of local anesthesia is of consiclerablc import:m!e.

Operative Procedure.-l’he lmtient is prct)ared and dritt>ed a,nd intrnand mandibular rl~;lsillitt~l\l wires or arch l)ittas are placed on the maxillary arches. An incision is made in the retromolar area about I em. distal to t,he displaced tooth estcnding to almut the distal surface of the serond premolar. The Innc.ol)el~iostelu~~ is reflected and retracted with suit,able instruments. The ft*aettlt’c site is csposecl ant1 the displaced tooth remo\-ed. By the use of a No. 11 surgical burr in a contra-angle handpiece holes are placetl in each srg0.5 em. from the alveolar crest. Then transosseous Jvire of O.CK?O nrent ilhOllt itrch stainless steel is threndetl from one segment to the other. (Figs. I. 2. ::, illIt 4.) The clisplacecl segment is rctlucecl and impacted if possible. ,I y;~ltritl)le atljunet, in the reduction of the fractured parts is a U-shaped instrument \\hich (‘an l)e atlnpteil to the anterior lv)rcler of the ramtts. and by the npplication of backwarrl all<1 d~~rl~~:~rd lateral 01’ tnesial pressure the distal fragment v;irt 1)~ reduced ittr(l held agairrst the t~ttll pi’ 111eelel,;ttor muselrs (Fig. ,?‘I

The fracture may be reducetl and immobilizccl h-y twisting the transosseous line. The twisted wire is then cut lea\-ing about 0.5 wire RCI’OSS the fl’ilctlll7? em. estentlitrg through the socket or furt,her t,wisting it over into a loop into the cavitat,iotr. The nlucol)er,iosteuI~l is closet1 with interruptetl sutures of Ko. 000 Ikl~ltlill0ll. lSl;lstic: tractiotr is then appliecl to the t)re\.iously replaced arch I)illT or nrult.it)le loops anal the teeth inlniobilizetl in t)r’olwr oc~c~lrisiorr. I
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--Case 1. I’woycr;~ti\ c ruentgenogragh fronr it lmstcwantcriur ar fracture with wparation of the segments. roentgcnograph from a yosteroantt~rior -case 1. Postoperative iosseous u’ire in place and the parts in good apposition.

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Case Reports (li\S+: I. .- 1;. I\‘. \\:., :I 20~yc:1r-oltl whit,e man, snstnined :L b111w 111111~jit\\ \\-hih: cwgaging in athletics. l’l~ysical c‘xlminatiou the day following t.1~0injnlg rev~ale~l swelling and tenderness at the right ang11: of tile mxndiblo, with tlif?icuIty in opening his mouth. Hadiographie examination re\ ealed fractures of the mandible at the right angle and left l~remobtr regions with displacement of the segments. ‘J’he mandibular right third molar, in the linv of fracture, was displaced ill an upward position (Fig. 6). On Julv 19 ,‘71952 under ‘.. “ per c011t regional procaine anesthesia, continuous loops of 0.020 inch stainless steel wire were apAn incision n-a> made extending from about pIid to ill<+ maxillary and mandibular arches. I (~1. distal to t,he third molar to the first premolar region a11c1the mucoperioateum was reflected. There was :I separation of approximately 0.5 cm. at the fracture site. The third A hole was placed in each fragment with a No. 41 surgical burr molar was removed. With 0.020 ahout 0.5 cm. from the fracture line close to the crest of the alveolar process. inch stainless steel transosseous bvire the fracture at the angle n-as reduced and immobilized. The twisted out1 was layed into the socket of the third mo1a.r. The mucoperiosteum was repositioned and sutured with four Ko. 000 Dermal on interrupted sutures (Figs. i nnrl j:S’l Intermaxillary el:,stir traction \Vas applied to inllnol)ilize the teeth in ~~cc~luninn.

Fig.

8.-Case

1. Postoyerative the transosseous

roentgenograph from the lateral oblique projection wire in place and the parts in good apposition.

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Postopor,alivc radiographs showed the On August 15 the continuous wires were removetl. fractured mandible to be in good alignment and at discharge the patient had satisfactory fuuction of his jaws. C>,ISi: ?.-&I Sept. 8, 11(X!, 1-I. J. G., a 21.year-old white JIIUII, xxs struck at the left Two days later the patient presented angle of the mandible by an unknown assailant. with pain and swelling of the left side of the mandible and with numerous facial lacerat ions. It was impossible for the teeth to be occluded due to the lingual displacement of the left third molar. Xadiographic examination revealed an oblique fracture at the left angie with the third molar in the Iine of fracture (Fig. cji. ‘I’hrre w;ly an up\vard and medial tiisplaceme~~t of the dist.al fragment with about 1 cm. seimration of the parts. 0 11 September 12 the patient was prepared and draped in the usual manner and under 2 per cent regional pwcaine anesthesia mandibular and maxillary 1001~swere secured to the teeth with 0.020 inch stainless steel wire. An incision was made from the retromolar area IO the first premolar on the left and the mucoperiosteum was retiectetl. The third molar was rrmo\,e(l. One hole was placed in the posterior fragment and two in the anterior fragment

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Fi g. 9.the m 83 g. 1o.ttre t1YL”S<

1 I.--Case

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the 2. Postoperative mentgenograyh from the transosseous wire in plaw and the parts

lateral oblique projectiun in good apposition.

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