- Email: [email protected]
Kirschner wire stabilization of the horizontal ostectomy of the inferior border of the mandible
Kirschner wire stabilization of the horizontal ostectomy of the inferior border of the mandible Timothy A. Turvey, D.D.S.,* Dale A. Childers, D.D.S.,** Chapel Hill, N. C.
and Donald R. Nunn, D.D.S.,**
UNIVERSITY OF NORTH CAROLINA SCHOOL OF DENTISTRY
T
he horizontal osteotomy of the anterior, inferior border of the mandible is a commonly used procedure for augmenting, reducing, or altering the midline position of the chin. Previous descriptions of this surgical procedure suggest stabilization of the pedicled inferior border with direct transosseous wires. The technique described by McBride and Bell’ of employing three figure-of-eight wires for stabilization has proved satisfactory in most instances of sagittal augmentation or reduction. However, during procedures involving maximum advancement, transverse movements, or inferior repositioning of the *Associate Professor of Oral and Maxillofacial Surgery; CoDirector, Dentofacial Deformities Program. **Resident, Department OFOral and Maxillofacial Surgery.
Fig.
1.
pedicled segments as advocated by Epker and Wolford,* additional stabilization may be necessary. We have used small, unthreaded Kirschner wires to augment the stability of the pedicled mandibular segment in select cases of genioplasty. This procedure is particularly useful where maximum advancement of the free segment, beyond the anteroposterior dimension of the symphysis, is desired. We have also found the added stability obtained with the Kirschner wire to be advantageous in casesof major transverse movement of the pedicled segment and in cases in which lower one-third facial height is increased by downgrafting the pedicled segment. The Kirschner wire stabilization technique is also useful for providing rigid stability where conventional wire fixation proves inadequate.
Two Kirschner wires have been placed to provide added stability to a pedicled, maximally
advanced, and transversely repositioned genial segment.Note that the use of the Kirschner wires (large arrows) is adjunctive to the three figure-of-eight wires (small arrows) which did not provide adequate immobilization of the genial segment. 0030-4220/82/
1105 13 + 04$00.40/O @ 1982 The C. V. Mosby Co.
513
514
Turvey, Childers. and Nunn
Oral Surg.
November,1982
Fig. 2. Radiograph demonstrating the clinical situation described in Fig. 1. Note the maximum advancement and good stabilization of the segment by the Kirschner wires, as evidenced by the lack of inferior rotation of the pedicled segment.
3. This radiograph demonstratesthe use of a single Kirschner wire to maintain the increased vertical height following advancement and downgrafting of the genial segment. Homologous bone has been grafted into the defect to enhance consolidation of the segments.
Fig.
TECHNIQUE
Once the horizontal osteotomy has been performed and the pedicled segment is relocated in its desired position, interosseous wires may be placed in
areas of bone contact. (Usually this is in the cuspid regions bilaterally.)
These initial
wires aid in the
stabilization of the segment in its proper sagit tal position while the Kirschner wire is being placed A 0.045 inch, nonthreaded Kirschner wire is selected and secured in a hand twist drill. 14n appropriate position on the pedicled segment is selected, usually near the midline, and the wire is
Volume 54 Number 5
Kirschner wire stabilization
of horizontal
osteotomy
515
Fig. 4. A, The pedicled bone graft is advanced farther than the buccal cortex of the mandible. Stabilization is achieved with two nonparallel-placed Kirschner wires driven through the pedicled bone graft and into the mandible. In addition, the two figure-of-eight wires are used to stabilize the lateral aspects of the graft prior to placement of the Kirschner wire. B, The pedicled bone graft is rotated inferiorly to increase lower facial height. The graft is immobilized in the desired position with two Kirschner wires driven vertically through the graft and into the mandible. Care must be taken to avoid tooth roots with the Kirschner wire. After the pedicled graft is repositioned and stabilized, autogenous or homologous cancellous bone may be used to fill the defects.
driven through the buccal and lingual cortices while the segment is supported. Once the wire penetrates the lingual cortex of the pedicled segment, it continues into the buccal cortex of the mandible. When inferior repositioning of the genial segment is desired, the increased dimension is maintained by placing the wire in a more inferior-superior direction and using the medullary bone and lingual cortex of the mandible to anchor the wire. Care must be taken to avoid the apices of the mandibular anterior teeth to prevent devitalization and interference with future orthodontic movement. After placement, excesswire is removed as close to the cortical bone as possible,
anu the end is finished flush by means of a handpiece and bur. Multiple Kirschner wires may be placed to increase the stability of the repositioned segment when necessary.If two wires are used, they should be placed at different angles with respect to one another. This enhances their usefulness in preventing dislodgment of the pedicled segment. When osseous defects greater than 5 mm. are present between proximal and distal segments,autogenous or homologous bone grafting should be considered to assure consolidation of the proximal and distal segments. The Kirschner wire will aid in rigid stabilization of
516
Turvey, Childers, and Nunn
the repositioned segments in its vertical and transverse relationship. In addition, it will maintain the repositioned segment in its desired sagittal relationship. RESULTS
This technique has been used to stabilize pedicled genioplasties for correction of a variety of deformities. Success has been achieved in immobilizing segments which were inadequately stabilized by figure-of-eight wires alone. To date, fourteen such procedures have been performed without complications, and the postoperative course has been uneventful up to 2 years. Removal of the Kirschner wire has not been necessary during the postoperative period; nor do we expect the need to arise in the future. CONCLUSION
A technique of immobilizing a pedicled osteotomy of the anterior, inferior border of the mandible by means of a Kirschner wire is presented. The technical difficulties of this procedure are minimal, requir-
Oral Surg. November, 1982
ing little time and simple instrumentation. Because of the added stability gained with the Kirschner wire, maximum three-dimensional repositioning of the pedicled segment is possible. In addition, more latitude is achieved in sequencing the genioplasty when multiple osteotomiesof the maxilla and mandible are planned. We are not advocating this technique for routine use in stabilization of genioplasty procedures but as an adjunct to traditional wiring techniques where maximum stabilization is necessary. REFERENCES 1. McBride, K.L., and Bell, W.H.: Chin Surgery, In Bell, W.H., Proffit, W.R., and White, R.R., Surgical Correction of Dentofacial Deformities, Philadelphia, 1980, W.B. Saunders Company, pp. 1211-1279. 2. Epker, B.N., and Wolford, L.M.: Genioplasties, In Dentofacial Deformities: Surgical-Orthodontic Correction, St. Louis, 1980, The C.V. Mosby Company, pp. 119-147. firprint
requests
to.
Dr. Timothy A. Turvey Department of Oral and Maxillofacial Surgery University of North Carolina School of Dentistry Chapel Hill, N.C. 27514
and Donald R. Nunn, D.D.S.,**
UNIVERSITY OF NORTH CAROLINA SCHOOL OF DENTISTRY
T
he horizontal osteotomy of the anterior, inferior border of the mandible is a commonly used procedure for augmenting, reducing, or altering the midline position of the chin. Previous descriptions of this surgical procedure suggest stabilization of the pedicled inferior border with direct transosseous wires. The technique described by McBride and Bell’ of employing three figure-of-eight wires for stabilization has proved satisfactory in most instances of sagittal augmentation or reduction. However, during procedures involving maximum advancement, transverse movements, or inferior repositioning of the *Associate Professor of Oral and Maxillofacial Surgery; CoDirector, Dentofacial Deformities Program. **Resident, Department OFOral and Maxillofacial Surgery.
Fig.
1.
pedicled segments as advocated by Epker and Wolford,* additional stabilization may be necessary. We have used small, unthreaded Kirschner wires to augment the stability of the pedicled mandibular segment in select cases of genioplasty. This procedure is particularly useful where maximum advancement of the free segment, beyond the anteroposterior dimension of the symphysis, is desired. We have also found the added stability obtained with the Kirschner wire to be advantageous in casesof major transverse movement of the pedicled segment and in cases in which lower one-third facial height is increased by downgrafting the pedicled segment. The Kirschner wire stabilization technique is also useful for providing rigid stability where conventional wire fixation proves inadequate.
Two Kirschner wires have been placed to provide added stability to a pedicled, maximally
advanced, and transversely repositioned genial segment.Note that the use of the Kirschner wires (large arrows) is adjunctive to the three figure-of-eight wires (small arrows) which did not provide adequate immobilization of the genial segment. 0030-4220/82/
1105 13 + 04$00.40/O @ 1982 The C. V. Mosby Co.
513
514
Turvey, Childers. and Nunn
Oral Surg.
November,1982
Fig. 2. Radiograph demonstrating the clinical situation described in Fig. 1. Note the maximum advancement and good stabilization of the segment by the Kirschner wires, as evidenced by the lack of inferior rotation of the pedicled segment.
3. This radiograph demonstratesthe use of a single Kirschner wire to maintain the increased vertical height following advancement and downgrafting of the genial segment. Homologous bone has been grafted into the defect to enhance consolidation of the segments.
Fig.
TECHNIQUE
Once the horizontal osteotomy has been performed and the pedicled segment is relocated in its desired position, interosseous wires may be placed in
areas of bone contact. (Usually this is in the cuspid regions bilaterally.)
These initial
wires aid in the
stabilization of the segment in its proper sagit tal position while the Kirschner wire is being placed A 0.045 inch, nonthreaded Kirschner wire is selected and secured in a hand twist drill. 14n appropriate position on the pedicled segment is selected, usually near the midline, and the wire is
Volume 54 Number 5
Kirschner wire stabilization
of horizontal
osteotomy
515
Fig. 4. A, The pedicled bone graft is advanced farther than the buccal cortex of the mandible. Stabilization is achieved with two nonparallel-placed Kirschner wires driven through the pedicled bone graft and into the mandible. In addition, the two figure-of-eight wires are used to stabilize the lateral aspects of the graft prior to placement of the Kirschner wire. B, The pedicled bone graft is rotated inferiorly to increase lower facial height. The graft is immobilized in the desired position with two Kirschner wires driven vertically through the graft and into the mandible. Care must be taken to avoid tooth roots with the Kirschner wire. After the pedicled graft is repositioned and stabilized, autogenous or homologous cancellous bone may be used to fill the defects.
driven through the buccal and lingual cortices while the segment is supported. Once the wire penetrates the lingual cortex of the pedicled segment, it continues into the buccal cortex of the mandible. When inferior repositioning of the genial segment is desired, the increased dimension is maintained by placing the wire in a more inferior-superior direction and using the medullary bone and lingual cortex of the mandible to anchor the wire. Care must be taken to avoid the apices of the mandibular anterior teeth to prevent devitalization and interference with future orthodontic movement. After placement, excesswire is removed as close to the cortical bone as possible,
anu the end is finished flush by means of a handpiece and bur. Multiple Kirschner wires may be placed to increase the stability of the repositioned segment when necessary.If two wires are used, they should be placed at different angles with respect to one another. This enhances their usefulness in preventing dislodgment of the pedicled segment. When osseous defects greater than 5 mm. are present between proximal and distal segments,autogenous or homologous bone grafting should be considered to assure consolidation of the proximal and distal segments. The Kirschner wire will aid in rigid stabilization of
516
Turvey, Childers, and Nunn
the repositioned segments in its vertical and transverse relationship. In addition, it will maintain the repositioned segment in its desired sagittal relationship. RESULTS
This technique has been used to stabilize pedicled genioplasties for correction of a variety of deformities. Success has been achieved in immobilizing segments which were inadequately stabilized by figure-of-eight wires alone. To date, fourteen such procedures have been performed without complications, and the postoperative course has been uneventful up to 2 years. Removal of the Kirschner wire has not been necessary during the postoperative period; nor do we expect the need to arise in the future. CONCLUSION
A technique of immobilizing a pedicled osteotomy of the anterior, inferior border of the mandible by means of a Kirschner wire is presented. The technical difficulties of this procedure are minimal, requir-
Oral Surg. November, 1982
ing little time and simple instrumentation. Because of the added stability gained with the Kirschner wire, maximum three-dimensional repositioning of the pedicled segment is possible. In addition, more latitude is achieved in sequencing the genioplasty when multiple osteotomiesof the maxilla and mandible are planned. We are not advocating this technique for routine use in stabilization of genioplasty procedures but as an adjunct to traditional wiring techniques where maximum stabilization is necessary. REFERENCES 1. McBride, K.L., and Bell, W.H.: Chin Surgery, In Bell, W.H., Proffit, W.R., and White, R.R., Surgical Correction of Dentofacial Deformities, Philadelphia, 1980, W.B. Saunders Company, pp. 1211-1279. 2. Epker, B.N., and Wolford, L.M.: Genioplasties, In Dentofacial Deformities: Surgical-Orthodontic Correction, St. Louis, 1980, The C.V. Mosby Company, pp. 119-147. firprint
requests
to.
Dr. Timothy A. Turvey Department of Oral and Maxillofacial Surgery University of North Carolina School of Dentistry Chapel Hill, N.C. 27514