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Transosseous wiring fixation of condylar fractures with infrafacial incision
TRANSOSSEOUS
LIEUTENANT
WIRING FIXATION WITH IN-FBAFACIAL _____
COLONEI,
WALTER
OF OONDYLAR INCISION
H. BECKER,* _______
FRACTURES
Four CLAYTON, CANAI~ ZONE
T
HE editor of ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY has suggested that more data should be published on the results of the treatment of fractures through the neck of the mandibular condyle. Various methods such as intermaxillary fixation with and without manipulation, or open reduction with transosseous wiring have been recommended. Having used the open operation for reduction of these fractures for more than eight years with satisfactory results, I shall be glad to present the method which I have found successful in approximately fifty cases. For fixation of the fracture, I have used wires, plates, and bars. As far as I know, all have done well. Case Report The patient, who stated that he had been attacked by an unidentified assailant near McArthur Bar in Panama, was admitted to the hospital on May 1, 1949, with cellulitis, acute, nonsuppurative type, in the region of the left maxilla and right side of the mandible, secondary to fractures of the left maxilla and right side of the mandible. Parker traction was applied, the patient received 50,000 units of penicillin to be repeated every three hours and was placed on a liquid diet. Warm saline mouthwashes and codeine, Q$ gr., for sedation were prescribed. X-rays of the head and right and left sides of the jaws were ordered. The x-rays revealed : 1. A complete fracture of the right side of the mandible in the region of the ascending ramus with considerable displacement (Fig. 1). 2. A complete fracture of the right side of the mandible in the region of the right symphysis without displacement. 3. An incomplete fracture of the left maxilla in the region of the infraorbital suture with no displacement,. The left maxillary sinus appeared somewhat cloudy, indicating that blood had entered it from the fracture. 4. The left upper first and second incisors were fractured and pulpitis had set in. It was recommended to give the following treatment: 1. Reduction and fixation of fractures with open reduction of fracture of right ramus. 2. Routine treatment for cellulitis. 3. Penicillin therapy. 4. Extraction of fractured teeth. ‘Chief
of Dental
Service,
7452nd
S. U.
(Station
284
Hospital).
TRANSOSSEOUS
WIRING
FIXATION
Fig.
Fig. l.-Anteroposterior Fig. Z.-Anteroposterior
OF CONDYLAR
FRACTURES
285
1.
Fig. 2. view of fracture at base of mandibular condyle. view showing fracture reduced and fixed by transosseous
u Wng.
286
WALTER
H. BECKER
In preparation for the operation, the second incisor was extracted uricler loca~1anesthesia, and multiple continuous loop fracture wires were applied on the right and left sides of the maxilla and mandible.
Fig.
3.-Lateral
Fig.
4.-Patient
view
showing
showing
wiring
operative
fixation.
scar.
On May 6, 1949, the operation was performed. Premeditation consisi ted norphine sulfate, yG gr., and atropine sulfate, 1/& gr., one-half hour befcBre.
TRANSOSSEOUS
WIRING
FIXATION
OF CONDYLAR
FRACTURES
287
Under endotracheal nitrous oxide, oxygen, and ether anesthesia, and intravenous Pentothal Sodium 2.5 per cent, the open reduction was performed with the help of the chief of the surgical service. An incision one inch in length was made just below the tragus of the ear extending downward parallel with the outline of the mandible. After dividing the skin and subcutaneous tissues, two of the lower branches of the facial nerve were exposed and identified and the tissue retracted to expose the fractured fragments. A hole was drilled into each fragment with a No. 6 dental bur and a wire inserted, after which the fracture was reduced and fixed by tightening the wire. The wound was closed in layers and a bandage applied. Elastics were attached to the loops of the arch wires previously applied to bring the teeth into occlusion and to serve as fixation of the other fractures. The patient left the operating room in good condition. The usual postoperative care was prescribed and given. On May 7, the elastics were replaced by wires. The bandage, which was changed frequently, was discarded on May 17. Postoperative x-rays showed reduction of the fracture, and both in the anteroposteridr view (Fig. 2) and the lateral exposure (Fig. 3)) the result appeared satisfactory, the fragments were seen held together by transosseous wires, and intermaxillary wires showed locking of the teeth in occlusion for the immobilization of the jaw. On June 24, 1949, all intermaxillary fixation was removed and the fracture tested. It was found firmly healed. On June 25, 1949, under a combination of intravenous, Pentothal Sodium, and nitrous oxide and oxygen anesthesia, an incision was again made at the angle of the jaw, The fracture was exposed and found well healed. The wire was removed and the wound closed in the usual manner. Bandage was applied. The patient was kept under observation from June 26 to July 7. The bandage was changed several times and finally discarded on July 3. New postoperative x-rays were taken, which showed conditions satisfactory. The patient was instructed to do masticatory exercises, and on July 7 was found to have normal excursions when opening and closing the jaw. The wound had healed well (Fig. 4).
Conclusion A case report which illustrates a method of transosseous wiring of condylar fractures has been published. This approach is especially valuable in low fractures of the condylar neck and subcondylar fractures of the ascending ramus, which cannot be easily reached by the preauricular incision described by Thoma (1945). Injury to the facial nerve is less likely to occur than with the preauricular approach.
Reference Thoma,
of the Mandibular K. H.: Fractures and Fracture Dislocations for Open Reduction and Internal Wiring and One for Skeletal port of Thirty-two Cases, J. Oral Surg. 3: 3, 1945.
Condyle; Fixation,
A Method With Re-
LIEUTENANT
WIRING FIXATION WITH IN-FBAFACIAL _____
COLONEI,
WALTER
OF OONDYLAR INCISION
H. BECKER,* _______
FRACTURES
Four CLAYTON, CANAI~ ZONE
T
HE editor of ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY has suggested that more data should be published on the results of the treatment of fractures through the neck of the mandibular condyle. Various methods such as intermaxillary fixation with and without manipulation, or open reduction with transosseous wiring have been recommended. Having used the open operation for reduction of these fractures for more than eight years with satisfactory results, I shall be glad to present the method which I have found successful in approximately fifty cases. For fixation of the fracture, I have used wires, plates, and bars. As far as I know, all have done well. Case Report The patient, who stated that he had been attacked by an unidentified assailant near McArthur Bar in Panama, was admitted to the hospital on May 1, 1949, with cellulitis, acute, nonsuppurative type, in the region of the left maxilla and right side of the mandible, secondary to fractures of the left maxilla and right side of the mandible. Parker traction was applied, the patient received 50,000 units of penicillin to be repeated every three hours and was placed on a liquid diet. Warm saline mouthwashes and codeine, Q$ gr., for sedation were prescribed. X-rays of the head and right and left sides of the jaws were ordered. The x-rays revealed : 1. A complete fracture of the right side of the mandible in the region of the ascending ramus with considerable displacement (Fig. 1). 2. A complete fracture of the right side of the mandible in the region of the right symphysis without displacement. 3. An incomplete fracture of the left maxilla in the region of the infraorbital suture with no displacement,. The left maxillary sinus appeared somewhat cloudy, indicating that blood had entered it from the fracture. 4. The left upper first and second incisors were fractured and pulpitis had set in. It was recommended to give the following treatment: 1. Reduction and fixation of fractures with open reduction of fracture of right ramus. 2. Routine treatment for cellulitis. 3. Penicillin therapy. 4. Extraction of fractured teeth. ‘Chief
of Dental
Service,
7452nd
S. U.
(Station
284
Hospital).
TRANSOSSEOUS
WIRING
FIXATION
Fig.
Fig. l.-Anteroposterior Fig. Z.-Anteroposterior
OF CONDYLAR
FRACTURES
285
1.
Fig. 2. view of fracture at base of mandibular condyle. view showing fracture reduced and fixed by transosseous
u Wng.
286
WALTER
H. BECKER
In preparation for the operation, the second incisor was extracted uricler loca~1anesthesia, and multiple continuous loop fracture wires were applied on the right and left sides of the maxilla and mandible.
Fig.
3.-Lateral
Fig.
4.-Patient
view
showing
showing
wiring
operative
fixation.
scar.
On May 6, 1949, the operation was performed. Premeditation consisi ted norphine sulfate, yG gr., and atropine sulfate, 1/& gr., one-half hour befcBre.
TRANSOSSEOUS
WIRING
FIXATION
OF CONDYLAR
FRACTURES
287
Under endotracheal nitrous oxide, oxygen, and ether anesthesia, and intravenous Pentothal Sodium 2.5 per cent, the open reduction was performed with the help of the chief of the surgical service. An incision one inch in length was made just below the tragus of the ear extending downward parallel with the outline of the mandible. After dividing the skin and subcutaneous tissues, two of the lower branches of the facial nerve were exposed and identified and the tissue retracted to expose the fractured fragments. A hole was drilled into each fragment with a No. 6 dental bur and a wire inserted, after which the fracture was reduced and fixed by tightening the wire. The wound was closed in layers and a bandage applied. Elastics were attached to the loops of the arch wires previously applied to bring the teeth into occlusion and to serve as fixation of the other fractures. The patient left the operating room in good condition. The usual postoperative care was prescribed and given. On May 7, the elastics were replaced by wires. The bandage, which was changed frequently, was discarded on May 17. Postoperative x-rays showed reduction of the fracture, and both in the anteroposteridr view (Fig. 2) and the lateral exposure (Fig. 3)) the result appeared satisfactory, the fragments were seen held together by transosseous wires, and intermaxillary wires showed locking of the teeth in occlusion for the immobilization of the jaw. On June 24, 1949, all intermaxillary fixation was removed and the fracture tested. It was found firmly healed. On June 25, 1949, under a combination of intravenous, Pentothal Sodium, and nitrous oxide and oxygen anesthesia, an incision was again made at the angle of the jaw, The fracture was exposed and found well healed. The wire was removed and the wound closed in the usual manner. Bandage was applied. The patient was kept under observation from June 26 to July 7. The bandage was changed several times and finally discarded on July 3. New postoperative x-rays were taken, which showed conditions satisfactory. The patient was instructed to do masticatory exercises, and on July 7 was found to have normal excursions when opening and closing the jaw. The wound had healed well (Fig. 4).
Conclusion A case report which illustrates a method of transosseous wiring of condylar fractures has been published. This approach is especially valuable in low fractures of the condylar neck and subcondylar fractures of the ascending ramus, which cannot be easily reached by the preauricular incision described by Thoma (1945). Injury to the facial nerve is less likely to occur than with the preauricular approach.
Reference Thoma,
of the Mandibular K. H.: Fractures and Fracture Dislocations for Open Reduction and Internal Wiring and One for Skeletal port of Thirty-two Cases, J. Oral Surg. 3: 3, 1945.
Condyle; Fixation,
A Method With Re-