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Pyriform aperture wiring in the treatment of mandibular fractures
P Y R I F O R M A P E R T U R E W I R I N G IN T H E T R E A T M E N T O F MANDIBULAR FRACTURES By G. L. FORDYCE,F.D.S.R.C.S.(Eng. & Ed.), L.D.S. Mount Vernon Centre for Plastic Surgery and Jaw Injuries, Mount Vernon Hospital, Northwood, Middlesex AN edentulous upper jaw invalidates many of the established methods of immobilising mandibular fractures. When an upper denture is available it can be employed to provide a guide to reduction of the mandibular fragments, and an occlusion to which the mandible may be held. In the Gunning splint the mandible is held against the joined dentures with a chin support. Further stability is achieved if the mandible is secured to the lower denture with circumferential wires. The rather ineffective and occasionally uncomfortable chin support can be discarded if the upper denture is fixed to the upper jaw with peralveolar or transalveolar wires. This is a simple surgical procedure, but is uncertain in its ability to withstand a prolonged strain--the wires tending to cut through the soft cancellous bone of the maxillae rendering the fixation ineffective. When gross alveolar resorption has occurred, peralveolar wiring may be virtually impossible. An alternative method of achieving intermaxillary fixation was described by K. H. Thoma (I943), and it is this method which has been employed in a clinical trial over a series of twenty cases. The relatively strong bony margin of the anterior nasal or pyriform aperture is used to carry a wire sling which is attached to the mandibular fixation. The method has the advantages of simplicity, reliability, and comfort for the patient and, in this series, has been free from complications. METHOD OF APPLICATION To ensure that the nasal cavity is not entered during the operation, 2 ml. of normal saline are injected to raise the mucosal lining of the inferolateral surface of the anterior nasal aperture. An incision is made in the buccal sulcus from the lateral incisor to the first premolar region, at a level approximately ~ in. above the reflection of the gingival to oral mucosa. This level varies relative to the bulbosity of the alveolus. The anterior nasal aperture is identified and the periosteum overlying this sharp bony margin is incised vertically. Subperiosteal dissection, both on the nasal and facial surfaces, then uncovers the bony margin. A hole, large enough to pass a 0.020 in. soft stainless steel wire, is drilled through the maxilla fully ff~ in. from the anterior margin (Fig. I). A dental burr or Archimedean drill is equally suitable. The wire is passed and the incision sutured. The same procedure is performed on the other side (Fig. 2). The upper denture is suitably modified in that any excess depth of buccal flange and food line are removed. With the upper denture in position the mandibular fragments can be held in articulation by securing the pyriform aperture wires to the mandibular fixation. It must be understood that the upper denture is not secured to the upper jaw by wires, but is wedged in position by the lower teeth or denture. The upper denture, however, should be attached to the mandibular fixation lest any postoperative disaster might allow the upper denture to be free in the mouth. The 304
PYRIFORM
APERTURE
WIRING
IN
THE
TREATMENT
OF
MANDIBULAR
FRACTURES
305
wires are r e m o v e d by cutting one end short as it emerges f r o m the m u c o u s m e m b r a n e and a firm pull on the remaining end extracts the wire. T h i s is n o t a painful p r o c e d u r e and m a y be carried out w i t h o u t ana:sthesia.
! FIG.
......
I
........ i~ii~ 7~ ~ i~i¸~ 7¸¸¸¸ i : i ~ FIG.
2
Fig. I.--See text. Fig. 2.--Pyriform wires attached to hooks embedded in the lower denture. The circumferential wires used to secure the lower denture to the mandible are suitably placed to immobilise a bilateral fracture in the bicuspid region. Elastic bands secure the upper denture to the mandibular fixation. CASE REPORTS Case x.--J. S., male, aged 7o years. Sustained facial injuries in a road accident and was referred for treatment five days later. The patient was edentulous and in possession of full dentures. Examination revealed bilateral fractures of the body of the mandible with considerable downward displacement of the anterior fragment (Fig. 3, A). A fracture of the right condyle neck, seen in Fig. 3, c, had resulted in some shortening of the ramus on that side. On the day following admission, under a general anmsthetic, the displacement of the mandibular fragments was manually corrected and the reduction maintained by the combined use of circumferential and pyriform aperture wires (Fig. 3, B, D, and E). The patient's dentures (having been suitably modified) were used as splints. Immobilisation by circumferential wiring of the lower denture to the mandible would have been insufficient to maintain reduction without the intermaxillary support of the pyriform aperture wires, and would not have corrected the displacement due to the condylar fracture. The fixation was removed thirty days later and the fractures were found to have united soundly. T h e fixation can be applied to cap splints or arch wires on the lower teeth. Case 2.--B. S., female, aged 32 years. During removal of an impacted left lower third molar, the jaw was fractured (Fig. 4, A). The patient was referred for treatment. The upper jaw was edentulous and the following mandibular teeth were present: 32I [ I2346. The patient gave a history of epilepsy, with frequent grand mal episodes. Immobilisation of the fracture was necessary--pin fixation was to be avoided because
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o f the epilepsy and direct interosseous fixation was contraindicated because of the c o m p o u n d nature of the fracture, and the desire to avoid external evidence of surgical interference as there was the possibility of medico-legal proceedings. It was deemed advisable to immobilise the main mandibular fragment by pyriform aperture wiring secured to a lower splint, the patient's denture being inserted to guide reduction and to
A
FIG. 3 A, Lateral projection radiographs of Case I, showing bilateral fracture of the body of the mandible with downward displacement of the anterior fragment. B, Post-operative lateral projection radiograph of Case I, showing position of the fragments and the fixation. effect immobilisation. The short posterior fragment was allowed to impact on the immobilised jaw. Post-operative radiographs (Fig. 4, S and c) revealed an acceptable position of the fragments, and following immobilisation for five and a half weeks the fracture was found to have united in good position. T h i s t y p e o f fixation simplifies the t r e a t m e n t o f m a n y fractures w h i c h are n o t o r i o u s l y difficult to maintain in a r e d u c e d position. Case i is an example, b u t
PYRIFORM APERTURE WIRING IN THE TREATMENT OF MANDIBULAR FRACTURES 307
C
D
E
FIG. 3 C, Postero-anterior radiograph of Case I. Bilateral fracture of the body of the edentulous mandible and a fracture of the fight condylar neck. D, Post-operative postero-anterior radiograph of Case I. E, Intraoral view of Case I, showing dentures and fixation in situ.
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A, Left lateral oblique radiograph off mandible of Case 2, showing fracture of the left body of the mandible.
B, Post-operative view showing acceptable position of the frag-ments in Case 2.
C, Postero-anterior view of Case 2~. showing position of fragments. and the fixation.
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FiG. 4
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perhaps more of a problem is the bilateral mandibular condylar fracture in the presence o f an edentulous maxilla. T h e shortening of the rami and resultant chinless deformity demand correction which is difficult to maintain. Pyriform wiring has been used in two such cases with success and says m u c h for the strength o f the fixation.
A
FIG. 5 A, Postero-anterior radiograph of mandible in Case 3. Bilateral fractures of condylar necks and the displaced condylar heads and a fracture of the left body of the mandible are visible. B, Post-operative radiographs of Case 3 showing the position of the fragments and the fixation.
Case 3.--M. F., female, aged 40 years, received facial injuries in a car smash on the day prior to admission. The bony injuries were bilateral fracture dislocation of the condyles and a fracture with displacement of the left body, involving the bicuspid teeth (Fig. 5, A). The patient was in possession of a fractured full upper denture with gum-fitted incisors and a fractured partial lower denture carrying the following teeth : 76541 ] I67. Following repair of the upper denture and repair of the lower partial denture
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by articulating its fragments to the upper denture, the displacement of the mandibular fragments was corrected manually under a general anaesthetic and immobilised by combined circumferential and pyriform wiring, the dentures being used as splints. An acceptable reduction was achieved (Fig. 5, B) and the fixation was maintained for thirty days. Sound clinical union was noted on the removal of the fixation and the dental articulation remained satisfactory. SUMMARY T h e technique o f pyriform aperture wiring is described as a means of, maintaining intermaxillary immobilisation in the treatment o f the fractured mandible in the presence o f an edentulous u p p e r jaw. In a series o f twenty cases it has been found to be a satisfactory m e t h o d worthy o f addition to our armamentarium. REFERENCE THOMA, K. H. (1943).
Amer. J. Orthodont., 29, 433.
PYRIFORM
APERTURE
WIRING
IN
THE
TREATMENT
OF
MANDIBULAR
FRACTURES
305
wires are r e m o v e d by cutting one end short as it emerges f r o m the m u c o u s m e m b r a n e and a firm pull on the remaining end extracts the wire. T h i s is n o t a painful p r o c e d u r e and m a y be carried out w i t h o u t ana:sthesia.
! FIG.
......
I
........ i~ii~ 7~ ~ i~i¸~ 7¸¸¸¸ i : i ~ FIG.
2
Fig. I.--See text. Fig. 2.--Pyriform wires attached to hooks embedded in the lower denture. The circumferential wires used to secure the lower denture to the mandible are suitably placed to immobilise a bilateral fracture in the bicuspid region. Elastic bands secure the upper denture to the mandibular fixation. CASE REPORTS Case x.--J. S., male, aged 7o years. Sustained facial injuries in a road accident and was referred for treatment five days later. The patient was edentulous and in possession of full dentures. Examination revealed bilateral fractures of the body of the mandible with considerable downward displacement of the anterior fragment (Fig. 3, A). A fracture of the right condyle neck, seen in Fig. 3, c, had resulted in some shortening of the ramus on that side. On the day following admission, under a general anmsthetic, the displacement of the mandibular fragments was manually corrected and the reduction maintained by the combined use of circumferential and pyriform aperture wires (Fig. 3, B, D, and E). The patient's dentures (having been suitably modified) were used as splints. Immobilisation by circumferential wiring of the lower denture to the mandible would have been insufficient to maintain reduction without the intermaxillary support of the pyriform aperture wires, and would not have corrected the displacement due to the condylar fracture. The fixation was removed thirty days later and the fractures were found to have united soundly. T h e fixation can be applied to cap splints or arch wires on the lower teeth. Case 2.--B. S., female, aged 32 years. During removal of an impacted left lower third molar, the jaw was fractured (Fig. 4, A). The patient was referred for treatment. The upper jaw was edentulous and the following mandibular teeth were present: 32I [ I2346. The patient gave a history of epilepsy, with frequent grand mal episodes. Immobilisation of the fracture was necessary--pin fixation was to be avoided because
306
BRITISH JOURNAL OF PLASTIC SURGERY
o f the epilepsy and direct interosseous fixation was contraindicated because of the c o m p o u n d nature of the fracture, and the desire to avoid external evidence of surgical interference as there was the possibility of medico-legal proceedings. It was deemed advisable to immobilise the main mandibular fragment by pyriform aperture wiring secured to a lower splint, the patient's denture being inserted to guide reduction and to
A
FIG. 3 A, Lateral projection radiographs of Case I, showing bilateral fracture of the body of the mandible with downward displacement of the anterior fragment. B, Post-operative lateral projection radiograph of Case I, showing position of the fragments and the fixation. effect immobilisation. The short posterior fragment was allowed to impact on the immobilised jaw. Post-operative radiographs (Fig. 4, S and c) revealed an acceptable position of the fragments, and following immobilisation for five and a half weeks the fracture was found to have united in good position. T h i s t y p e o f fixation simplifies the t r e a t m e n t o f m a n y fractures w h i c h are n o t o r i o u s l y difficult to maintain in a r e d u c e d position. Case i is an example, b u t
PYRIFORM APERTURE WIRING IN THE TREATMENT OF MANDIBULAR FRACTURES 307
C
D
E
FIG. 3 C, Postero-anterior radiograph of Case I. Bilateral fracture of the body of the edentulous mandible and a fracture of the fight condylar neck. D, Post-operative postero-anterior radiograph of Case I. E, Intraoral view of Case I, showing dentures and fixation in situ.
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JOURNAL
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A, Left lateral oblique radiograph off mandible of Case 2, showing fracture of the left body of the mandible.
B, Post-operative view showing acceptable position of the frag-ments in Case 2.
C, Postero-anterior view of Case 2~. showing position of fragments. and the fixation.
; IIII:I:II))I)LIII!III!; ¸ I ~i~(? i~i~ ~~i)~ ~ ~!i~~p~i!
FiG. 4
PYRIFORM APERTURE WIRING IN THE TREATMENT OF MANDIBULAR FRACTURES
309
perhaps more of a problem is the bilateral mandibular condylar fracture in the presence o f an edentulous maxilla. T h e shortening of the rami and resultant chinless deformity demand correction which is difficult to maintain. Pyriform wiring has been used in two such cases with success and says m u c h for the strength o f the fixation.
A
FIG. 5 A, Postero-anterior radiograph of mandible in Case 3. Bilateral fractures of condylar necks and the displaced condylar heads and a fracture of the left body of the mandible are visible. B, Post-operative radiographs of Case 3 showing the position of the fragments and the fixation.
Case 3.--M. F., female, aged 40 years, received facial injuries in a car smash on the day prior to admission. The bony injuries were bilateral fracture dislocation of the condyles and a fracture with displacement of the left body, involving the bicuspid teeth (Fig. 5, A). The patient was in possession of a fractured full upper denture with gum-fitted incisors and a fractured partial lower denture carrying the following teeth : 76541 ] I67. Following repair of the upper denture and repair of the lower partial denture
3Io
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
by articulating its fragments to the upper denture, the displacement of the mandibular fragments was corrected manually under a general anaesthetic and immobilised by combined circumferential and pyriform wiring, the dentures being used as splints. An acceptable reduction was achieved (Fig. 5, B) and the fixation was maintained for thirty days. Sound clinical union was noted on the removal of the fixation and the dental articulation remained satisfactory. SUMMARY T h e technique o f pyriform aperture wiring is described as a means of, maintaining intermaxillary immobilisation in the treatment o f the fractured mandible in the presence o f an edentulous u p p e r jaw. In a series o f twenty cases it has been found to be a satisfactory m e t h o d worthy o f addition to our armamentarium. REFERENCE THOMA, K. H. (1943).
Amer. J. Orthodont., 29, 433.