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Treatment of mandibular fractures by external fixation
Treatment of mandibular fractures by external fixation D. Zorman,” P.A. Godart,b B. Kovacs,b Y. Andrianne,” P. Daelemans,b and F. Burny,” Bruxelles. Belgium Hi)PITAL ERASME This series encompasses thirteen fractures of the mandible treated by external fixation. The indications were five fractures of edentulous mandible, four fractures through missile wounding, and four fractures without soft tissue lesion treated in Africa. Twelve patients were found to show good or excellent results. In our indications, this method is a successful approach to the treatment of the fractured jaw. (ORAL SURC ORAL MED ORAL PATHOL 1990;69:15-9)
I
n military as well as in civilian life, fractures of the jaw play an important part in the practice of the oral surgeon. Immobilization of the fractured jaw is usually achieved by intermaxillary fixation by direct wiring or the use of arch wire splints. If teeth are inadequate or if the patient is edentulous, other procedures must be performed. Internal fixation by transosseous wiring or bone plates has solved this problem only partly, since these methods often require additional immobilization of the jaw and represent a nonnegligible risk of infection in open fractures.‘, ’ External fixation, which has existed since the beginning of the century, has become a highly successful approach to the treatment of fractures. In 1946, GinesteP described external fixation for treatment of fracture of the mandible. This was an application of the method of Lambotte4 (1907) for other localizations.
tin beads to avoid infection. Those beads were removed 30 days after the first procedure. Radiologic consolidation was obtained after 68 days without bony graft, and the external fixation was then removed (Fig. 4, A and B). MATERIAL AND METHODS
Thirteen patients with fracture of the mandible were treated by external fixation. There were nine men and five women. The average age was 35 years (range, 22 to 64 years). Four patients had open cornminuted fractures through missile wounding, five patients were edentulous, and four patients were treated by one of us in Africa. Of these thirteen cases, two were infected and one was a nonunion fracture. Three casesrequired multiple surgical procedures. Bone grafting was performed in two cases. The details of the cases are shown in Table I. Surgical
CASE REPORT
A 57-year-old man was admitted to the hospital with a missile injury. He was admitted with a soft tissue avulsion of the lower jaw area and a comminuted fracture of the mandible (Fig. 1). There were no upper jaw teeth remaining that could have been used for immobilization purposes. Surgical repair was undertaken in emergency. The wound was cleaned with sterile water, and identifiable foreign bodies were removed. A half-frame external fixation was used (Figs. 2 and 3). The wound was closed over gentami“Hapita Erasme, Department of Orthopedics and Traumatology (Prof. F. Burny). bH6pital Erasme, Department of Maxillofacial Surgery (Dr. P. Daelemans) 7/n/10470
procedure
Having two surgeons is most desirable. The mouth is draped off from the extraoral site, and the one
surgeon inserts one hand within the mouth until all the pins are in position. The other surgeon penetrates the soft tissues with the pin held by the drill. On reaching the bone, he or she must consider position with respect to the lower border, and angulation of the drilling to avoid the roots of any teeth present, the alveolar nerves and vessels, and the pin from entering the oral cavity. Surgical complications may arise from the facial artery, the dental nerve, the facial nerve, and the parotid gland, We use halfframe configurations with 3 mm self-drilling Hoffmann-type pins or an adapted frame with minifixation clamps and rods on the same pins. After all pins 15
16
Zorman
et al.
Fig. ble.
Table
1. Panoramic
preoperative
radiograph
showing
comminuted
open fracture
of- mandi-
1. Details of the cases
Name
/
ARID BLLO CULO DEBA GOOS HENN KATU KIBW LEUS MBAY MERC RASS SHOU
Horiz.,
ORAL SURG ORAL MED ORAL PATHOL January 1990
horizontal
Gender
F F M M M F M M M M M M F
portion;
/ Age 64 22 42 28 41 48 30 28 46 2s 26 54
29
Polytr.,
/
Indication
Missile African Missile Missile Edentulous Edentulous African African Edentulous African Edentulous Missile Edentulous
polytrauma
/
Fracture
/
Infection
+
2 horiz. Horiz. 2 horiz. Angle Horiz. Horiz. Angle and chin Angle and chin Chin and polytr. Angle and chin Angle Chin 2 horiz., 2 condyles, and polytr.
/
Nonunion
+
/
No. P. 8
1 7 1 1
+
2 1
-
1 1 1 1 1 1
Hospital stay (days)
1 fz 3 2
302 10 120 5 6 99 12
15 207 15 6 5
190
patient; No. P., number of procedures.
are securely in position, the fracture is reduced by external and intraoral manipulation. Teeth in the line of fracture that prevent reduction should be removed. A careful examination of the occlusion of the teeth will guide the surgeon in accurate reduction. The frame is then firmly tightened in position. RESULTS
The course of all patients was followed until the pins were removed. Seven patients could be evaluat-
ed after a mean follow-up of 414 days (range, 210 to 670 days). Fracture healing was evaluated on radiographs and clinical examination. Twelve of the thirteen patients healed after a mean of 77 days (range, 50 to 145 days). One patient healed with a stable aseptic pseudoarthrosis after 150 days. Five complicatrons were observea: one refracture of a weak callus presenting a bone defect, one dysesthesia of the chin, two hypertrophic calluses, and one unsatisfactory occlusion. There were no
Volume Number
Treatment
69
Fig.
2. Half-frame external k&ion
of mandibular
fractures
by external jixation
I7
with 3 mm Hoffmann,,pins.
Pig. 3. Panoramic postoperative radiograph. nonesthetic scars related to the pins. In our opinion, excellent results were represented by union, normal mastication, and more than 35 mm opening of the mouth, good results were satisfactory functional results, and a final nonunion or infection was considered to be a poor result. Twelve patients (92%) were found to show good or excellent results. The details of the results are shown in Table II.
DISCUSSION
If the patient is edentulous, reduction and immobilization of the fractured mandible are easily obtained by external fixation. Missile wounds usually cause cornminuted fracture and bone defect with important soft tissue injury. 5,6 In such patients, swelling of the tongue and throat can impair respiration. External fixation will
18
Zorman
et al.
Fig.
ORAL SURG ORAL MED ORAL PATHOL January 1990
4A and 4B, Panoramicand intraoral radiographsdemonstratingconsolidationa.fter 68
days 1 ‘able II. Det .ails (If the results
Name
Union
(POD}
Follow-up MwJ
ARID
Aseptic nonunion 150
150
BILO CULO DEBA GOOS HENN KATU KIBW
65 120 53 60
360 120 53 440
145
145
15 60
15 370
50
670
on
210
60 68 15
60 320 530
LEUS hi(T)A” MERC RASS SHOU
Mouth
opening
Complications
? mm
>35 ? >35 >35 >35 >35 >35
mm mm mm mm mm
b-35 >35 >35 >35 <35
mm mm mm mm
mm
1
Result
?
Good
?
Excellent Good
No No Dysesthesia chin Refracture No Unsatisfactory occlusion Hypertrophic callus No No No Hypertrophic callus
Excellent Good Poor Excellent Good
-
Good Excellent bxceIlent Excellent Good
Volume Number
69 1
Treatment
allow movement of the jaw so that good oral hygiene can be maintained.7x8 The management of pathologic fractures is more difficult than that of traumatic fractures. In the majority of cases, pathologic fractures result from bone infection. Before the fracture is treated, sequestra, or foreign bodies, if present, must be removed and infection cleared up completely.9 In such cases, external fixation can be used safely with placement of the pins outside the septic area. Pathologic fractures are also represented by the damaging effects of bone cysts, bone tumors, and radionecrosis. In mandibular resections, space maintenance for secondary grafting is easily obtained by external fixation. In some countries where liquid food is difficult to obtain, external fixation permits immediate mobility of the jaw and allows the patient to take a well-balanced and adequate diet. CONCLUSIONS
External fixation is recommended by us for the following types of fractures: 1. Single or multiple fractures of the edentulous mandible, or if insufficient number of sound teeth are present for intermaxillary fixation. 2. Missile wounds with important soft tissue lesions. 3. Fractures complicated by osteomyelitis or cases of osteomyelitis with pathologic fracture. 4. Infected nonunion. 5. Cases with loss of bone to be repaired by a secondary bone graft.
of mandibular
fractures by external fixation
19
6. Cases that require immediate freedom of jaw movement. In our indications, this method is a successful approach to the treatment of traumatic fractures and pathologic fractures of the mandible. It has proved to be comfortable for the patient and allows him or her to resume a reasonably normal routine. REFERENCES 1. Thoma KH. New methods for immobilization of the mandible. ORALSLJRGORAL MEDORAL PATHOL 1948;1:98-107. 2. Thoma KH. Methods of jaw fractures and their indications. J Oral Surg 1948;6:125-34. 3. Ginestet G. Le tixateur externe dans le traitement des fractures du maxillaire inferieur. Rev Odont Stomat MaxilFat 1946;10:455-60. 4. Lambotte A. L’intervention operatoire dans les fractures recentes et anciennes. Bruxelles: Lamertin, 1907. 5. Converse JM. Early and late treatment of gunshot wounds of the jaws in French battle casualties in North Africa and Italy. J Oral Surg 1945;3:112-37. 6. Shuker S. Immediate management of severe facial war injuries. J Maxillofac Surg 1983;11:30-6. 7. Booth RM. Treatment of mandibular fractures by external fixation. J Oral Surg 1947;5:245-55. 8. Pasture1 A, Bellavoir A, Duboscq J-C, Perrot J, Jidal B. Fixateurs externes et traumatismes balistiques. Rev Fr Rehab Proth Maxil-Fat 1982;l:l l-7. 9. Bourgoyne JR. Fixation of pathologic fractures of the mandible. Am J Orthod Oral Surg 1945;31:492-500. Reprint requests to: Dr. D. Zorman Hopital Erasme, Cliniques Universitaires de Bruxelles Service d’orthopbdie-Traumatologie 808 Route de Lennik, 1070 Bruxelles, Belgium
I
n military as well as in civilian life, fractures of the jaw play an important part in the practice of the oral surgeon. Immobilization of the fractured jaw is usually achieved by intermaxillary fixation by direct wiring or the use of arch wire splints. If teeth are inadequate or if the patient is edentulous, other procedures must be performed. Internal fixation by transosseous wiring or bone plates has solved this problem only partly, since these methods often require additional immobilization of the jaw and represent a nonnegligible risk of infection in open fractures.‘, ’ External fixation, which has existed since the beginning of the century, has become a highly successful approach to the treatment of fractures. In 1946, GinesteP described external fixation for treatment of fracture of the mandible. This was an application of the method of Lambotte4 (1907) for other localizations.
tin beads to avoid infection. Those beads were removed 30 days after the first procedure. Radiologic consolidation was obtained after 68 days without bony graft, and the external fixation was then removed (Fig. 4, A and B). MATERIAL AND METHODS
Thirteen patients with fracture of the mandible were treated by external fixation. There were nine men and five women. The average age was 35 years (range, 22 to 64 years). Four patients had open cornminuted fractures through missile wounding, five patients were edentulous, and four patients were treated by one of us in Africa. Of these thirteen cases, two were infected and one was a nonunion fracture. Three casesrequired multiple surgical procedures. Bone grafting was performed in two cases. The details of the cases are shown in Table I. Surgical
CASE REPORT
A 57-year-old man was admitted to the hospital with a missile injury. He was admitted with a soft tissue avulsion of the lower jaw area and a comminuted fracture of the mandible (Fig. 1). There were no upper jaw teeth remaining that could have been used for immobilization purposes. Surgical repair was undertaken in emergency. The wound was cleaned with sterile water, and identifiable foreign bodies were removed. A half-frame external fixation was used (Figs. 2 and 3). The wound was closed over gentami“Hapita Erasme, Department of Orthopedics and Traumatology (Prof. F. Burny). bH6pital Erasme, Department of Maxillofacial Surgery (Dr. P. Daelemans) 7/n/10470
procedure
Having two surgeons is most desirable. The mouth is draped off from the extraoral site, and the one
surgeon inserts one hand within the mouth until all the pins are in position. The other surgeon penetrates the soft tissues with the pin held by the drill. On reaching the bone, he or she must consider position with respect to the lower border, and angulation of the drilling to avoid the roots of any teeth present, the alveolar nerves and vessels, and the pin from entering the oral cavity. Surgical complications may arise from the facial artery, the dental nerve, the facial nerve, and the parotid gland, We use halfframe configurations with 3 mm self-drilling Hoffmann-type pins or an adapted frame with minifixation clamps and rods on the same pins. After all pins 15
16
Zorman
et al.
Fig. ble.
Table
1. Panoramic
preoperative
radiograph
showing
comminuted
open fracture
of- mandi-
1. Details of the cases
Name
/
ARID BLLO CULO DEBA GOOS HENN KATU KIBW LEUS MBAY MERC RASS SHOU
Horiz.,
ORAL SURG ORAL MED ORAL PATHOL January 1990
horizontal
Gender
F F M M M F M M M M M M F
portion;
/ Age 64 22 42 28 41 48 30 28 46 2s 26 54
29
Polytr.,
/
Indication
Missile African Missile Missile Edentulous Edentulous African African Edentulous African Edentulous Missile Edentulous
polytrauma
/
Fracture
/
Infection
+
2 horiz. Horiz. 2 horiz. Angle Horiz. Horiz. Angle and chin Angle and chin Chin and polytr. Angle and chin Angle Chin 2 horiz., 2 condyles, and polytr.
/
Nonunion
+
/
No. P. 8
1 7 1 1
+
2 1
-
1 1 1 1 1 1
Hospital stay (days)
1 fz 3 2
302 10 120 5 6 99 12
15 207 15 6 5
190
patient; No. P., number of procedures.
are securely in position, the fracture is reduced by external and intraoral manipulation. Teeth in the line of fracture that prevent reduction should be removed. A careful examination of the occlusion of the teeth will guide the surgeon in accurate reduction. The frame is then firmly tightened in position. RESULTS
The course of all patients was followed until the pins were removed. Seven patients could be evaluat-
ed after a mean follow-up of 414 days (range, 210 to 670 days). Fracture healing was evaluated on radiographs and clinical examination. Twelve of the thirteen patients healed after a mean of 77 days (range, 50 to 145 days). One patient healed with a stable aseptic pseudoarthrosis after 150 days. Five complicatrons were observea: one refracture of a weak callus presenting a bone defect, one dysesthesia of the chin, two hypertrophic calluses, and one unsatisfactory occlusion. There were no
Volume Number
Treatment
69
Fig.
2. Half-frame external k&ion
of mandibular
fractures
by external jixation
I7
with 3 mm Hoffmann,,pins.
Pig. 3. Panoramic postoperative radiograph. nonesthetic scars related to the pins. In our opinion, excellent results were represented by union, normal mastication, and more than 35 mm opening of the mouth, good results were satisfactory functional results, and a final nonunion or infection was considered to be a poor result. Twelve patients (92%) were found to show good or excellent results. The details of the results are shown in Table II.
DISCUSSION
If the patient is edentulous, reduction and immobilization of the fractured mandible are easily obtained by external fixation. Missile wounds usually cause cornminuted fracture and bone defect with important soft tissue injury. 5,6 In such patients, swelling of the tongue and throat can impair respiration. External fixation will
18
Zorman
et al.
Fig.
ORAL SURG ORAL MED ORAL PATHOL January 1990
4A and 4B, Panoramicand intraoral radiographsdemonstratingconsolidationa.fter 68
days 1 ‘able II. Det .ails (If the results
Name
Union
(POD}
Follow-up MwJ
ARID
Aseptic nonunion 150
150
BILO CULO DEBA GOOS HENN KATU KIBW
65 120 53 60
360 120 53 440
145
145
15 60
15 370
50
670
on
210
60 68 15
60 320 530
LEUS hi(T)A” MERC RASS SHOU
Mouth
opening
Complications
? mm
>35 ? >35 >35 >35 >35 >35
mm mm mm mm mm
b-35 >35 >35 >35 <35
mm mm mm mm
mm
1
Result
?
Good
?
Excellent Good
No No Dysesthesia chin Refracture No Unsatisfactory occlusion Hypertrophic callus No No No Hypertrophic callus
Excellent Good Poor Excellent Good
-
Good Excellent bxceIlent Excellent Good
Volume Number
69 1
Treatment
allow movement of the jaw so that good oral hygiene can be maintained.7x8 The management of pathologic fractures is more difficult than that of traumatic fractures. In the majority of cases, pathologic fractures result from bone infection. Before the fracture is treated, sequestra, or foreign bodies, if present, must be removed and infection cleared up completely.9 In such cases, external fixation can be used safely with placement of the pins outside the septic area. Pathologic fractures are also represented by the damaging effects of bone cysts, bone tumors, and radionecrosis. In mandibular resections, space maintenance for secondary grafting is easily obtained by external fixation. In some countries where liquid food is difficult to obtain, external fixation permits immediate mobility of the jaw and allows the patient to take a well-balanced and adequate diet. CONCLUSIONS
External fixation is recommended by us for the following types of fractures: 1. Single or multiple fractures of the edentulous mandible, or if insufficient number of sound teeth are present for intermaxillary fixation. 2. Missile wounds with important soft tissue lesions. 3. Fractures complicated by osteomyelitis or cases of osteomyelitis with pathologic fracture. 4. Infected nonunion. 5. Cases with loss of bone to be repaired by a secondary bone graft.
of mandibular
fractures by external fixation
19
6. Cases that require immediate freedom of jaw movement. In our indications, this method is a successful approach to the treatment of traumatic fractures and pathologic fractures of the mandible. It has proved to be comfortable for the patient and allows him or her to resume a reasonably normal routine. REFERENCES 1. Thoma KH. New methods for immobilization of the mandible. ORALSLJRGORAL MEDORAL PATHOL 1948;1:98-107. 2. Thoma KH. Methods of jaw fractures and their indications. J Oral Surg 1948;6:125-34. 3. Ginestet G. Le tixateur externe dans le traitement des fractures du maxillaire inferieur. Rev Odont Stomat MaxilFat 1946;10:455-60. 4. Lambotte A. L’intervention operatoire dans les fractures recentes et anciennes. Bruxelles: Lamertin, 1907. 5. Converse JM. Early and late treatment of gunshot wounds of the jaws in French battle casualties in North Africa and Italy. J Oral Surg 1945;3:112-37. 6. Shuker S. Immediate management of severe facial war injuries. J Maxillofac Surg 1983;11:30-6. 7. Booth RM. Treatment of mandibular fractures by external fixation. J Oral Surg 1947;5:245-55. 8. Pasture1 A, Bellavoir A, Duboscq J-C, Perrot J, Jidal B. Fixateurs externes et traumatismes balistiques. Rev Fr Rehab Proth Maxil-Fat 1982;l:l l-7. 9. Bourgoyne JR. Fixation of pathologic fractures of the mandible. Am J Orthod Oral Surg 1945;31:492-500. Reprint requests to: Dr. D. Zorman Hopital Erasme, Cliniques Universitaires de Bruxelles Service d’orthopbdie-Traumatologie 808 Route de Lennik, 1070 Bruxelles, Belgium