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New methods for immobilization of the mandible
Vol. 100 No. 2
ORAL AND MAXILLOFACIAL SURGERY
August 2005
Editor: James R. Hupp
This article originally appeared in Oral Surg Oral Med Oral Pathol 1948;1:98-106.
New methods for immobilization of the mandible Kurt H. Thoma, DMD (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:S5-10)
Immobilization of the mandible is important in many types of fractures. If the teeth are inadequate for intermaxillary fixation, either by direct wiring or the use of arch wire splints, such as the Jelenko or the Winter splint, or if the patient is edentulous, we must resort to other methods. Skeletal fixation has solved this problem only partly, since the method has only limited application; for example, it is not very effective in fractures at the angle or ramus of the jaw. In this issue, several cases have been reported which were treated by means of internal wiring fixation or by means of bone plates. These methods, as was pointed out, require additional immobilization of the jaw, since they should be used only as accessory measures to prevent displacement from muscle pull while the jaw is immobilized, but not displacement occurring from normal muscular force applied during mastication or speech. The oldest method recommended to immobilize the mandible is the Barton bandage. It has been designed especially for this purpose. It is not very satisfactory, however, because the bandage may stretch and loosen or become displaced. An improvement is obtained by the use of elastics applied on each side and held by adhesive tape placed under the chin and over the head. The ends turned over the elastics should be stapled as shown in Fig 1. At first, I thought the problem could be solved by means of skeletal fixation, by attaching a connecting rod extending from the fracture appliance used for fixation of the fracture to a pin inserted into the malar process of the maxilla, or the malar bone, to immobilize the mandible (Fig 2). If the patient has a bilateral fracture, this method may be used (Fig 3), but, as we will see later, 1 pin on each side is usually not sufficient to withstand 1079-2104/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.05.004
Fig 1. Barton’s bandage reinforced by elastic bands.
the force the patient may consciously or unconsciously apply. The methods described in the following paragraphs have been found more satisfactory. 1. External Craniomandibular Fixation. When this method is used, the jaws may be held in proper relationship by putting into occlusion teeth inadequate for intermaxillary fixation either because they are too few in number or not strongly enough embedded to withstand the strain. If no teeth are S5
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Fig 3. Skeletal fixation as described in Fig 2, front view.
Fig 2. Skeletal fixation applied for fixation of mandibular fracture and extension to pins inserted into malar bone for mandibular immobilization because of condylar fracture.
present, the patient may have dentures, which can be wired together and used as a splint. Often it is advisable to break out the upper incisors to make feeding easier. If no dentures are available, a Gunning splint may be constructed. The fixation is accomplished by one of the following methods: a. Plaster headcap connected to a Frac-Sure appliance attached to the mandible. The patient may have a fracture in the anterior part of the mandible, in addition to fractures at the neck of one or both condyles, or the angle of the jaw, where transosseous wiring fixation may be used or a bone plate applied. If skeletal fixation is used at the symphysis, the bars of the Frac-Sure appliance will serve to immobilize the mandible by means of a rod or Kirschner wire extended on both sides from wires on the side of the headcap. The rod is attached with Frac-Sure links on both bars. The Kirschner wire is attached with single links (Fig 4a and 4b). Sometimes, short horizontal rods have to be attached first to the wire of the skullcap to get a more vertical alignment of the connecting wires (Fig 4b). If the patient has no fracture in the anterior part of the mandible, half pins may be specially inserted for the attachment of the connecting rods (Fig 5). While this method has been found satisfactory in some cases, it was not so in others, because in muscular individuals the strain on a single pin is too great. In such cases, the method to be described next is more satisfactory.
b. Plaster headcap connected to Steinmann pin inserted tranversely through symphysis. This method was first described by Waldron.1 A Kirschner wire or Steinmann pin is drilled through the mental prominence by means of a Pincock pin guide, the technique having been described by Thoma et al (1946).2 The Kirschner wire is attached to the skullcap with connection rods, in a similar way as described previously (Fig 6). 2. Internal Maxillomandibular Fixation. This method was described by me in 1943.3 It may be used as then advocated for patients with full upper artificial dentures, who have at least anterior mandibular teeth. The method, however, can also be adapted for completely edentulous patients. It has the advantage that no external appliance and no headcap need be used and that, therefore, the patient is more comfortable and sooner able to take up his regular occupation without being embarrassed. a. Wires inserted through margin of piriform aperture and attached to arch wire applied to lower anterior teeth with upper denture inserted. This method gives very satisfactory results. The upper denture is so locked in that no food will penetrate beneath. If the posterior mandibular teeth have been lost and the patient is wearing a partial denture, this may be inserted as well, but the method can be used without it (Fig 7). The technique has been described before (Thoma, 1943).3 b. Wires inserted through margin of piriform aperture and attached to ends of circumferential wires placed to hold the mandibular end of a Gunning splint in place. In completely edentulous patients,
OOOOE Volume 100, Number 2
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Fig 4. Craniomandibular fixation in case of condylar fracture immobilizing mandible by means of Steinmann’s pins attached to rods extended from headcaps to Frac-Sure appliance used for fixation of fracture at symphysis. A Gunning splint may be inserted, if teeth are inadequate, to maintain occlusion.
Fig 5. Craniomandibular fixation by means of Frac-Sure connecting rod extended from headcap to single pins inserted into metal prominence.
Fig 6. Craniomandibular fixation by means of plaster headcap from which Frac-Sure extension rods are extended to a Steinmann pin inserted transversely through the symphysis.
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Fig 7. Internal maxillomandibular fixation, wires inserted through margin of piriform aperture and passed over denture to arch wire attached to anterior mandibular teeth. Fig 9. X-ray showing wiring of Gunning splint to upper and lower jaw before bone graft. Splint being made of acrylic does not show.
Fig 8. Acrylic splint wired to mandible and attached by means of wires inserted through margin of piriform aperture. Fig 10. Anteroposterior view showing nasal wires and mandibular circumferential wires holding splint between jaws.
a Gunning splint may be constructed, or if the patient has dentures, these may be wired together and used as a substitute. First the splint is attached to the mandible by means of circumferential wires inserted with a lumbar puncture needle in the usual manner. After inserting a 24-gauge stainless steel wire on each side of the anterior aperture of the splint, the splint is inserted and the wires are twisted to hold it in place. The ends are left long. Stainless steel wires, 25-gauge, are next inserted through the margin of the piriform aperture, which is exposed by oblique incision on each side, and perforated with a drill. After closing the incision with sutures, the wires are brought down over the maxillary flange of the splint, each being united with a set of circumferential
wires and twisted until the splint is firmly seated. The wires are then cut short and the ends turned to prevent irritation of the mucosa of the lip (Fig 8). SUMMARY The methods described have a decided advantage over bandages for craniomandibular fixation. The fixation is much more stable and positive. The external methods can be used with and without oral support by means of a Gunning splint, and the internal method of fixation has the still greater advantage that it eliminates all visible apparatus and the possibility of its disarrangement during sleep.
OOOOE Volume 100, Number 2
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Fig 13. Anteroposterior view showing bone graft. Fig 11. Rib graft inserted and held in contact with mandible by means of wire sutures.
Fig 12. Lateral view showing rib graft attached to anterior fragment with 2 stainless steel wires, to ramus by one.
Case N J. O’B., a 41-year-old coastguardsman, fractured his jaw 2 years ago. He could not remember what hit him. He was treated in another hospital by ‘‘wiring of the jaws.’’ Osteomyelitis resulted, with a great deal of bone loss, and, finally, he was discharged with nonunion, for which no treatment was recommended because he had no pain. He came to the Marine Hospital in Boston to have dentures made. The nonunion with marked displacement was discovered, and it was noted that the patient had pain in front of the ear when eating.
Examination showed a very strong and well-developed individual with evidence of severe acne having scarred his face. He has 2 linear scars in the left submaxillary region, probably resulting from incisions made for sequestrectomy and drainage. There were no fistulae in the mouth or face, and, therefore, it was assumed that the infection had been completely eliminated. Roentgen examination showed an edentulous upper and lower jaw, with an ununited fracture with marked displacement of the ramus by muscle pull, and considerable loss of bone. Immobilization of the mandible followed by bone graft was advised. The first operation consisted of the immobilization of the mandible by means of a Gunning splint and internal maxillomandibular fixation. With pentothal intravenous anesthesia and the usual premedication and preparation of the face and mouth, the previously prepared and sterilized Gunning splint was inserted to see whether it would fit. The place where the anterior aperture (left for feeding) ended was marked on the mucosa. Here, after removing the splint, a 24-gauge stainless steel wire was inserted around the mandible by means of a lumbar puncture needle as described. The splint was reinserted and the wires twisted over the mandibular component. Oblique incisions were next made under the upper lip in the labial sulcus and the piriform margin of the nose was exposed. With a small bur, a hole was drilled about 4 mm away from the bony margin, and a 25-gauge stainless steel wire was drawn through on each side, after which the incisions were closed with interrupted dermalon sutures. On each side, the wires from the nose were twisted with the ends of the circumferential wires until the upper and lower ridges were securely seated in the respective part of the splint. The mandible was found to be completely immobilized (Fig 8). X-ray
OOOOE August 2005
S10 Thoma examination showed the wires and position of the jaw but not the splint, since it was made of acrylic (Figs 9 and 10). Four days later, an operation was performed for reducing the displacement of the ramus and bridging the space with a rib bone graft. Cyclopropane, oxygen, and ether was administered through a nasal intratracheal tube, and combined with pentothal intravenous anesthesia. The orthopedic surgeon, with his team, removed a piece of the sixth rib on the left, while we made an incision extending from the mastoid process to the chin at a place which would be 1 cm below the inferior border of the jaw, if present. After tying several bleeding vessels beneath the skin and in the scar tissue, the external maxillary artery was cut and tied. The anterior segment of the jaw was dissected free from scar tissue, and, after incising the periosteum, the bone on the outer surface was laid bare. The ramus was not so easily located, since it was not only displaced upward but also inward. After tying the anterior facial vein, it was exposed and the periosteum incised. Now the ramus segment could be pulled into the wound with bone forceps. Scar tissue formed a bridge between the 2 fragments and was excised so as to make room for the bone graft. Both the separated anterior and posterior fragments were now decorticated on the outer side, and
the eburnated ends were rongeured to get bleeding surfaces. A neuroma was noticed in the end of the mandibular canal on the fracture surface of the ramus and was excised. The rib was now cut to fit; the ends were decorticated on the inside so that the raw surfaces of the graft could be placed on the bleeding surfaces of the jaw. The graft was attached by means of wire sutures of 25-gauge stainless steel (Fig 11). The periosteum was sutured over the anterior end, after which the wound was closed in layers, the skin with interrupted dermalon sutures. A pressure pack was applied over a petrolatum dressing and held in place by means of an ACE Barton’s bandage, which also served to prevent too much stress on the maxillomandibular fixation when vomiting while recovering from the anesthetic. Postoperative x-rays showed satisfactory reduction and position of the graft (Figs 12 and 13). REFERENCES 1. Waldron CW, Balkin SG. Fractures of the maxilla. Surgery 1942; 11:183. 2. Thoma KH, et al. Miscellaneous case reports. Am J Orthodontics and Oral Surg (Oral Surg Sect) 1946;32:282. 3. Thoma KH. A new method of intermaxillary fixation for jaw fractures in patients wearing artificial dentures. Am J Orthodontics and Oral Surg (Oral Surg Sect) 1943;29:433.
ORAL AND MAXILLOFACIAL SURGERY
August 2005
Editor: James R. Hupp
This article originally appeared in Oral Surg Oral Med Oral Pathol 1948;1:98-106.
New methods for immobilization of the mandible Kurt H. Thoma, DMD (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:S5-10)
Immobilization of the mandible is important in many types of fractures. If the teeth are inadequate for intermaxillary fixation, either by direct wiring or the use of arch wire splints, such as the Jelenko or the Winter splint, or if the patient is edentulous, we must resort to other methods. Skeletal fixation has solved this problem only partly, since the method has only limited application; for example, it is not very effective in fractures at the angle or ramus of the jaw. In this issue, several cases have been reported which were treated by means of internal wiring fixation or by means of bone plates. These methods, as was pointed out, require additional immobilization of the jaw, since they should be used only as accessory measures to prevent displacement from muscle pull while the jaw is immobilized, but not displacement occurring from normal muscular force applied during mastication or speech. The oldest method recommended to immobilize the mandible is the Barton bandage. It has been designed especially for this purpose. It is not very satisfactory, however, because the bandage may stretch and loosen or become displaced. An improvement is obtained by the use of elastics applied on each side and held by adhesive tape placed under the chin and over the head. The ends turned over the elastics should be stapled as shown in Fig 1. At first, I thought the problem could be solved by means of skeletal fixation, by attaching a connecting rod extending from the fracture appliance used for fixation of the fracture to a pin inserted into the malar process of the maxilla, or the malar bone, to immobilize the mandible (Fig 2). If the patient has a bilateral fracture, this method may be used (Fig 3), but, as we will see later, 1 pin on each side is usually not sufficient to withstand 1079-2104/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.05.004
Fig 1. Barton’s bandage reinforced by elastic bands.
the force the patient may consciously or unconsciously apply. The methods described in the following paragraphs have been found more satisfactory. 1. External Craniomandibular Fixation. When this method is used, the jaws may be held in proper relationship by putting into occlusion teeth inadequate for intermaxillary fixation either because they are too few in number or not strongly enough embedded to withstand the strain. If no teeth are S5
S6 Thoma
OOOOE August 2005
Fig 3. Skeletal fixation as described in Fig 2, front view.
Fig 2. Skeletal fixation applied for fixation of mandibular fracture and extension to pins inserted into malar bone for mandibular immobilization because of condylar fracture.
present, the patient may have dentures, which can be wired together and used as a splint. Often it is advisable to break out the upper incisors to make feeding easier. If no dentures are available, a Gunning splint may be constructed. The fixation is accomplished by one of the following methods: a. Plaster headcap connected to a Frac-Sure appliance attached to the mandible. The patient may have a fracture in the anterior part of the mandible, in addition to fractures at the neck of one or both condyles, or the angle of the jaw, where transosseous wiring fixation may be used or a bone plate applied. If skeletal fixation is used at the symphysis, the bars of the Frac-Sure appliance will serve to immobilize the mandible by means of a rod or Kirschner wire extended on both sides from wires on the side of the headcap. The rod is attached with Frac-Sure links on both bars. The Kirschner wire is attached with single links (Fig 4a and 4b). Sometimes, short horizontal rods have to be attached first to the wire of the skullcap to get a more vertical alignment of the connecting wires (Fig 4b). If the patient has no fracture in the anterior part of the mandible, half pins may be specially inserted for the attachment of the connecting rods (Fig 5). While this method has been found satisfactory in some cases, it was not so in others, because in muscular individuals the strain on a single pin is too great. In such cases, the method to be described next is more satisfactory.
b. Plaster headcap connected to Steinmann pin inserted tranversely through symphysis. This method was first described by Waldron.1 A Kirschner wire or Steinmann pin is drilled through the mental prominence by means of a Pincock pin guide, the technique having been described by Thoma et al (1946).2 The Kirschner wire is attached to the skullcap with connection rods, in a similar way as described previously (Fig 6). 2. Internal Maxillomandibular Fixation. This method was described by me in 1943.3 It may be used as then advocated for patients with full upper artificial dentures, who have at least anterior mandibular teeth. The method, however, can also be adapted for completely edentulous patients. It has the advantage that no external appliance and no headcap need be used and that, therefore, the patient is more comfortable and sooner able to take up his regular occupation without being embarrassed. a. Wires inserted through margin of piriform aperture and attached to arch wire applied to lower anterior teeth with upper denture inserted. This method gives very satisfactory results. The upper denture is so locked in that no food will penetrate beneath. If the posterior mandibular teeth have been lost and the patient is wearing a partial denture, this may be inserted as well, but the method can be used without it (Fig 7). The technique has been described before (Thoma, 1943).3 b. Wires inserted through margin of piriform aperture and attached to ends of circumferential wires placed to hold the mandibular end of a Gunning splint in place. In completely edentulous patients,
OOOOE Volume 100, Number 2
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Fig 4. Craniomandibular fixation in case of condylar fracture immobilizing mandible by means of Steinmann’s pins attached to rods extended from headcaps to Frac-Sure appliance used for fixation of fracture at symphysis. A Gunning splint may be inserted, if teeth are inadequate, to maintain occlusion.
Fig 5. Craniomandibular fixation by means of Frac-Sure connecting rod extended from headcap to single pins inserted into metal prominence.
Fig 6. Craniomandibular fixation by means of plaster headcap from which Frac-Sure extension rods are extended to a Steinmann pin inserted transversely through the symphysis.
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Fig 7. Internal maxillomandibular fixation, wires inserted through margin of piriform aperture and passed over denture to arch wire attached to anterior mandibular teeth. Fig 9. X-ray showing wiring of Gunning splint to upper and lower jaw before bone graft. Splint being made of acrylic does not show.
Fig 8. Acrylic splint wired to mandible and attached by means of wires inserted through margin of piriform aperture. Fig 10. Anteroposterior view showing nasal wires and mandibular circumferential wires holding splint between jaws.
a Gunning splint may be constructed, or if the patient has dentures, these may be wired together and used as a substitute. First the splint is attached to the mandible by means of circumferential wires inserted with a lumbar puncture needle in the usual manner. After inserting a 24-gauge stainless steel wire on each side of the anterior aperture of the splint, the splint is inserted and the wires are twisted to hold it in place. The ends are left long. Stainless steel wires, 25-gauge, are next inserted through the margin of the piriform aperture, which is exposed by oblique incision on each side, and perforated with a drill. After closing the incision with sutures, the wires are brought down over the maxillary flange of the splint, each being united with a set of circumferential
wires and twisted until the splint is firmly seated. The wires are then cut short and the ends turned to prevent irritation of the mucosa of the lip (Fig 8). SUMMARY The methods described have a decided advantage over bandages for craniomandibular fixation. The fixation is much more stable and positive. The external methods can be used with and without oral support by means of a Gunning splint, and the internal method of fixation has the still greater advantage that it eliminates all visible apparatus and the possibility of its disarrangement during sleep.
OOOOE Volume 100, Number 2
Thoma S9
Fig 13. Anteroposterior view showing bone graft. Fig 11. Rib graft inserted and held in contact with mandible by means of wire sutures.
Fig 12. Lateral view showing rib graft attached to anterior fragment with 2 stainless steel wires, to ramus by one.
Case N J. O’B., a 41-year-old coastguardsman, fractured his jaw 2 years ago. He could not remember what hit him. He was treated in another hospital by ‘‘wiring of the jaws.’’ Osteomyelitis resulted, with a great deal of bone loss, and, finally, he was discharged with nonunion, for which no treatment was recommended because he had no pain. He came to the Marine Hospital in Boston to have dentures made. The nonunion with marked displacement was discovered, and it was noted that the patient had pain in front of the ear when eating.
Examination showed a very strong and well-developed individual with evidence of severe acne having scarred his face. He has 2 linear scars in the left submaxillary region, probably resulting from incisions made for sequestrectomy and drainage. There were no fistulae in the mouth or face, and, therefore, it was assumed that the infection had been completely eliminated. Roentgen examination showed an edentulous upper and lower jaw, with an ununited fracture with marked displacement of the ramus by muscle pull, and considerable loss of bone. Immobilization of the mandible followed by bone graft was advised. The first operation consisted of the immobilization of the mandible by means of a Gunning splint and internal maxillomandibular fixation. With pentothal intravenous anesthesia and the usual premedication and preparation of the face and mouth, the previously prepared and sterilized Gunning splint was inserted to see whether it would fit. The place where the anterior aperture (left for feeding) ended was marked on the mucosa. Here, after removing the splint, a 24-gauge stainless steel wire was inserted around the mandible by means of a lumbar puncture needle as described. The splint was reinserted and the wires twisted over the mandibular component. Oblique incisions were next made under the upper lip in the labial sulcus and the piriform margin of the nose was exposed. With a small bur, a hole was drilled about 4 mm away from the bony margin, and a 25-gauge stainless steel wire was drawn through on each side, after which the incisions were closed with interrupted dermalon sutures. On each side, the wires from the nose were twisted with the ends of the circumferential wires until the upper and lower ridges were securely seated in the respective part of the splint. The mandible was found to be completely immobilized (Fig 8). X-ray
OOOOE August 2005
S10 Thoma examination showed the wires and position of the jaw but not the splint, since it was made of acrylic (Figs 9 and 10). Four days later, an operation was performed for reducing the displacement of the ramus and bridging the space with a rib bone graft. Cyclopropane, oxygen, and ether was administered through a nasal intratracheal tube, and combined with pentothal intravenous anesthesia. The orthopedic surgeon, with his team, removed a piece of the sixth rib on the left, while we made an incision extending from the mastoid process to the chin at a place which would be 1 cm below the inferior border of the jaw, if present. After tying several bleeding vessels beneath the skin and in the scar tissue, the external maxillary artery was cut and tied. The anterior segment of the jaw was dissected free from scar tissue, and, after incising the periosteum, the bone on the outer surface was laid bare. The ramus was not so easily located, since it was not only displaced upward but also inward. After tying the anterior facial vein, it was exposed and the periosteum incised. Now the ramus segment could be pulled into the wound with bone forceps. Scar tissue formed a bridge between the 2 fragments and was excised so as to make room for the bone graft. Both the separated anterior and posterior fragments were now decorticated on the outer side, and
the eburnated ends were rongeured to get bleeding surfaces. A neuroma was noticed in the end of the mandibular canal on the fracture surface of the ramus and was excised. The rib was now cut to fit; the ends were decorticated on the inside so that the raw surfaces of the graft could be placed on the bleeding surfaces of the jaw. The graft was attached by means of wire sutures of 25-gauge stainless steel (Fig 11). The periosteum was sutured over the anterior end, after which the wound was closed in layers, the skin with interrupted dermalon sutures. A pressure pack was applied over a petrolatum dressing and held in place by means of an ACE Barton’s bandage, which also served to prevent too much stress on the maxillomandibular fixation when vomiting while recovering from the anesthetic. Postoperative x-rays showed satisfactory reduction and position of the graft (Figs 12 and 13). REFERENCES 1. Waldron CW, Balkin SG. Fractures of the maxilla. Surgery 1942; 11:183. 2. Thoma KH, et al. Miscellaneous case reports. Am J Orthodontics and Oral Surg (Oral Surg Sect) 1946;32:282. 3. Thoma KH. A new method of intermaxillary fixation for jaw fractures in patients wearing artificial dentures. Am J Orthodontics and Oral Surg (Oral Surg Sect) 1943;29:433.