Skeletal fixation of pathologic fractures of the mandible with extensive loss of substance

SKELETAL FIXATION OP’ PATHOLOGIC FRACTURES OF MANDIBLE WITH EXTENSIVE LOSS OF SUBST_4NCE

THE,

REPORTOF Two CARES THOMAS $1. MELOY, .JR., l).I).S.,*

-IA-D

JOHS 11. (~~swx,

l).D.S., ni1.n.f

N

ECROSIS, tumors, cysts, and trauma may cause extensive dest,ruction of osseous tissue. When these pathologic conditions exist within the mandible, causing an extensive loss of substance, a spontaneous fracture can occur. Treatment of a fracture of this sort must, of necessity, make allowance for (1) maintenance of proper contour, (2) accessibility for surgical treatment, (3) nutritional requirements of the patient,, and (4) in some cases, the early insertion of dentures.’ CASE

1

H&o?-Y.-W. W. was admitted to the Episcopal Hospital, March 2, 1943, suffering from extensive first, second, and third degree burns of the chest, arms: hands, face, and back. His family history and past medical history were irrelevant. He received active treatment for two months, during which his general condition improved with varying degrees of healing of the burned areas. On May 12, 1943, the patient complained of pain in the left jaw. Oral examination revealed that the left mandibular first molar had a large cavity apparently The tooth was loose, with pus escaping at the involving the pulp chamber. gingival margin. It,s removal was recommended. On July 12, 1943, Dr. I. M. Boykin, surgeon in charge, considered the patient’s condition satisfactory for removal of the tooth. The tooth was extremely loose and no difficulty was exAnesthesia was not necessary. On July 17, the patient’s jaw perienced. collapsed, and roentgenologic examination disclosed a displaced fracture of the left side of the mandible, accompanied by a decrease in the density of the boric suggestive of osteomyelitis. Subsequent examinations confirmed this diagnosis. The patient’s general condition precluded any consideration of intraoral tixation. The patient, had difficulty in obtaining adequate nourishment and was Permission was obtained from Dr. Boykin to use skelet,al loosing ground. fixation. Preoperative roentgenologic examination now disclosed an extension of the necrosis to include an area of about 4 cm. (first premolar to second molar). The right side of the mandible was displaced toward the median line with loss of occlusal contact. (Fig. 1.) Operation.-(Sept. 8, 1943.) Using heavy sedation and infiltration anesthesia, two Biglow screws were inserted into healthy bone along the posterior Oral gery, Oral pital,

*Instructor in Dental Surgery, Evans Institute, University of Pennsylvania ; Chief. and Dental Service. Episcopal Hospital, Philadelphia ; Instructor in Maxillo-Facial SurGraduate School of Medicine, Philadelphia, Pa. tProfessor of Dental Surgery, Evans Institute. University of Pennsylvania ; Consultant, and Dentai Service, Episcopal Hospital, Philadelphia: Asst. Oral Surgeon, Oncologic HosPhiladelphia, Pa.

Thomas $1. Meloy, Jr., and John II. Gulzter

Fig.

‘ig.

f.-Interrnaxillary

I.-Osteonecrosis


with

restored

collapse

with

of

the

Biglow

jaw.

appliance

in

place.

Of IlIt! l(‘l’t I’il11111S illIf IWO SI*I’(‘\VS ilIt Il~‘~lltll~ l)Ollcl illlt(‘l’i’)l’ t0 f II(’ canint~ on ihtl S;kmt’ side.’ The Riglo\~ iII~(~hICI I* i\FilS i~tljl~~t(d to c*(:~~~lt(~t, ~II(YV wrws and restore the normal illlcl,lllnsill;lr)rcl;rtiollshil). bCllCVPriL1 seqncstra ;lIld the interleft INUldi~~~llil~ secOllc1 molar w(lrc IhcW rc~movc~tl. NO Sll]~~~l~~llClltil1 maxillary wiring w:is used. ( Fig. 2. ) Postoperatiz:e Co7lr.sc.--Hecovel.~ w;~s uneventful. On the second day (Fig. 3.) His spirits and the patient was able to enjoy semisolid foods. general condition were greatly improved. This state of affairs continued until Oct. 7, 1943, when his kidneys suddenly began to fail and uremia developed. In spite of heroic medical treatment the paGent died on October 9. At time of death the Biglow appliance was still firm and tisslle regeneration was ljrogressing between the fragments. Comntelzt.-Had the patient survived his medical complications, we felt there was a good possibility of (Jomplelc bony rcgcncration ; otherwise, bone graft would have been considered. IKJlYlt’I’

CASE 2 IlistorU.-Mrs. C. K., aged 57 years, had visited her dentist complaining of pain in the right mandibular molar area. The first and second molars were extracted at this time. Pain subsided and the patient exhibited no further symptoms for several weeks, when she noticed a circumscribed smelling on the buccal surface of the right side of the jaw. The swelling continued to increase, and symptoms developed which caused the dentist to suspect osteomyelitis. He then referred her to t,he Episcopal Hospital. Intraoral examination revealed the absence of all teeth on the right side of the jaw posterior to the first premolar. This enlargement of the mandible cxtendcd from the second premolar to t,he anterior border of the ramus. There was some drainage in the molar region. Roentgenologic examination disclosed a large radiolucent area in the right, mandible extending from the second premolar area posteriorly to the ramus. All the bone had been destroyed with the exception of the alveolar crest. There was a pathologic fracture in the second molar region. (Fig. 4.) Preoperative I)i~~~zosis.--0steolytic tumor of the mandible accompanied by a pathologic fracture. Operation.-A skeletal fixation appliance designed by one of 11s (T. M. &I.) was applied as follows: Through stab incisions, vitalliurn screws were inserted in the usual manner into healthy boric beyond the limits of the tumor. A piece of clear acrylic, shaped to simulate the contour of the mandible, was held over the ends of the screws, and marks were made at the places the screws contacted the acrylic splint. Holes were then drilled through the splint at these points and the splint slipped on the screws. The nut,s were tightened, locking the appliance into position. (Fig. 5.) A n incision was niade beneath the mandible, and the osteolytic mass was cnncleated. No supplemental int,ermaxillary wiring was used. Postoperatitqe Co?Lrsc.-The patient ‘Y recovery is-as uneventful. Histologic examination of tissue removed proved it to be a- myeloma (plasma cell type). The patient is receiving radiation therapy, is free of pain and able to eat soft foods. She has no difficulty in performin, w the normal mandibular movements.

Fig.

4.-Preoperative

Fig.

Fig.

6.-Two

weeks

showing

x-rw

5.-Acrylic

following

extent

of

extraoral

operation.

osteolstic

splint

Patient

process

locked

can

open

in

with

pathologic

fracture.

position.

mouth

without

undue

difficulty.

J1’rucfwes

of Nmdiblc

With Loss of SuItsI(1twc

57 I

(Fig. 6.) At the time of this report the appliance has been in place for twelve weeks. It is still firm and has required no adjustment. The skin is healthy about t,he screws. A recent roentgenogram shows a slight change in the margins of the area suggestive of osteogenesis. (E’ig. 7.) The alveolar crest seems firm on palpation. The appliance will remain in plaw until there is conclusive radiographic evidence of regeneration of snfticient boric to maintain the fragments in their present position.

Fig.

‘I.-Twrlve

weeks

following

operation.

Evidcnc~

of

osteogenesis.

CollcZusio?~s.-Treatment, of fractSures of the mandible accompanied by a loss of substance requires ingenuity on the part of the operator. Skeletal fixation appliances are less complicated in their application than other methods that, have been designed to immobilize fractures of this typo. We have found that screws having heavy threads (wood screw 1ypc) remain firm in the bone over a longer period of time than those with fine threads. The acrylic cxtraoral splint, as described, presents a simple means of applying skeletal fixation to fractures of the mandible, particularly where there has been loss of substance.