Interosseous Wiring Research Articles

Refracture of untreated fractures of the zygomatic bone

Experience gained in the treatment of 16 patients with refracture of untreated fractures of the zygomatic bone is presented. Refracture, repositioning and wire fixation is the method of choice in the correction of facial deformity after untreated displaced fractures of the zygomatic bone. If necessary, osteoplasty of the orbital floor and raising of the globe by a thick iliac bone graft can be performed at the same time. Usually, it is not so difficult to perform refracture since at the site of fracture, where a large dislocated fragment exists, a solid callus is not formed but rather some kind of fibrous union. If the displaced bone is completely united then an osteotomy of the whole zygomatic bone is performed through the lateral part of the eyebrow, lower eyelid and a wide incision in the upper buccal sulcus, using a sharp chisel or a small round bur. Refracture of the zygomatic arch can be done through the mouth after making a wide incision in the upper buccal sulcus which enables exploration of the zygomatic arch, or by a hand saw after tunnelling from the eyebrow incision to the zygomatic arch. If the zygomatic arch is broken in two or more places then the refracture should be done through a short incision on the face followed by direct interosseous wire fixation.

External Fixation

External fixation of the mandible is required in complex fractures or to stabilize the mandibular segments during reconstruction. The method supplements interosseous wiring and intermaxillary fixation techniques.

Step Osteotomy

A scissoring deformity of the fingers frequently results from malunion of a phalangeal or metacarpal fracture. If union occurs with rotation, the injured digit will scissor with an adjacent digit on flexion of the hand. Malrotation can be corrected by a technique of step osteotomy of the metacarpal with removal of a longitudinal strip of bone. The placement of the transverse cuts of the osteotomy determines the direction of rotational correction and the width of dorsal strut determines the amount of rotational correction. Firm fixation with two interosseous wires ensures good bony union and allows early mobilization.

The effects of early Le Fort I osteotomies on craniofacial growth of juvenile Macaca nemestrina monkeys.

Le Fort I osteotomies were performed on three juvenile Macaca nemestrina monkeys with midface deficiencies from prior extraoral traction. The maxillas of these monkeys were moved anteriorly an amount necessary to achieve about 8 mm. of horizontal overjet. Interosseous wires were used to stabilize the segments; the animals were not placed in intermaxillary fixation. Craniofacial growth in the three experimental monkeys and in three control monkeys was monitored for 2 years with serial cephalometric radiographs. Compared to the controls, the maxillas of the experimental animals demonstrated less anterior growth, and this was manifested clinically in anterior dental cross-bite relationships. Histologic examination of the circummaxillary sutural complex revealed normal morphology. It is concluded, therefore, that early Le Fort I osteotomies significantly affect subsequent maxillary growth in monkeys and that this effect probably is due to formation of scar tissue.

A procedure for stabilization of the infraorbital rim in comminuted malar complex fractures.

A procedure to stabilize comminuted or unstable infraorbital fractures has been presented. This procedure can be of value in those situations in which direct interosseous wiring does not stabilize the fracture or where overlapping is present.

Fronto-facial advancement for Crouzon's and Apert's syndromes.

This paper reviews the evolution of the surgical approach to the facial deformities in Crouzon's and Apert's syndromes. Since the first high maxillary osteotomy performed via an extracranial approach, various procedures have been used. These procedures were, successively, the intracranial route permitting simultaneous advancement of the mid-face and frontal bone in adult; then the use of trephine holes to protect the dura and brain during osteotomies obviating the need for a craniotomy. Likewise, more precise craniofacial fixation by interosseous wiring and bone grafting frequently obviate the need for intermaxillary fixation. More recently the fronto-facial advancement in one piece has been used in children between 4 and 10 years of age. The advantages and disadvantages of this procedure are considered.

LATE COMPLICATIONS VS. METHOD OF TREATMENT IN A LARGE SERIES OF MID-FACIAL FRACTURES

The late presence of contour defects, as well as one eye being lower than the other, were directly related to a lack of interosseous wire fixation in this series of mid-facial fractures. In orbital floor fractures, the use of alloplastic material was found to give more satisfactory long-term results than bone grafts. The direct approach through the lower lid produced no complications of its own in this series. Associated injuries and preexisting disease were found in 61 percent of these patients, supporting the thesis that an M.D. should direct their care. The late presence of diplopia and/or enophthalmos was directly related to an underestimation and undertreatment of orbital floor fractures, or to treatment with bone grafts. The use of a shoulder strap, in conjunction with the lap belt, seems to almost completely prevent the occurrence of mid-facial fractures in automobile accidents.

ARTERIOVENOUS FISTULA AND PARALYSIS OF MANDIBULAR BRANCH OF FACIAL NERVE FOLLOWING DIRECT WIRING OF A JAW FRACTURE

We present a case in which interosseous wiring of the mandible resulted in an A-V fistula and an injury to the mandibular ramus of the facial nerve. These two complications can serve as a reminder to all who desire to use interosseous wiring in the treatment of mandibular fractures.

Management of Facial Fractures

Maxillofacial fractures are usually diagnosed easily by history, clinical findings, and standard roentgenograms. Emergency treatment centers around airway management; the conscious patient should be allowed to clear his own airway whenever possible. Treatment of lower and upper jaw fractures focuses on reducing the fragments so that dental occlusion is normal. Other midface fracture reductions require additional exact orbital rim alignment. Immobilization of fractures can require various combinations of intermaxillary fixation, interosseous wiring, suspensory wires from intraoral arch bars, transfacial Kirschner wires, occasional maxillary antral packs, and rare external fixation with headframes or external pins. Patients who may be comatose or seriously ill for several weeks should have a simple and safe compromise reduction and K-wire fixation done at the bedside. Management of blow-out fractures of the orbit and frontal sinus fractures is somewhat controversial. Naso-orbital central factial fractures are especially difficult to maintain in proper reduction. Listed are possible late postoperative complications after treatment of facial fractures.

Fractures of the edentulous maxilla and mandible.

An evaluation and treatment of fracture of the edentulous maxilla and/or mandible is presented. The Le-Fort classification of maxillary fractures is the foundation for the program of care. Immobilization techniques are based upon the support of a fracture by suspension from the adjacent stable segments to the modified prosthesis. The mandibular fractures are repaired by interosseous wire fixation in the body and symphysis region, the other fracture sites are supported by circumferential wiring to the prosthesis for immobilization. General principles of time of repair, diet, types of healing factors are reviewed.

External Fixation in Maxillofacial Surgery

The role of external fixation in the treatment of facial fractures is well defined. If standard open reduction and internal fixation techniques do not yield a satisfactory result, external fixation techniques may be required. Open reduction has the advantage of effecting precise approximation of fragments. However, this type of fixation may be inadequate, either because no stable point is available or because the angle of traction involved in fixation may result in displacement of the reduced fracture and subsequent malunion. When the facial skeleton is fractured, it tends to collapse inward, and if injury is severe, an external traction point anterior, lateral, or superior to the facial skeleton may be required to obtain a satisfactory result. There are occasions when intermaxillary fixation may be inadvisable, and in these instances external fixation techniques may be an appropriate means of immobilization. Finally external fixation techniques may be required in instances in which massive tissue loss precludes the use of standard open reduction and internal fixation techniques. It must be reemphasized that the methods of external fixation described here are not meant to supplant the standard techniques of open reduction and interosseous wiring, but when judicially employed complement them in achieving the desired result of precise reduction and firm fixation of the fractured facial skeleton.

Symposium on maxillo-facial trauma. 3. Pitfalls in the management of zygomatic fractures.

AbstractRecognition of various types of zygomatic fractures and their postreduction stability is essential for correct diagnosis and proper treatment of zygomatic fractures.It should be fully recognized that the zygoma, upon dislocation, may rotate around a vertical or longitudinal axis, and may be displaced medially, laterally, posteriorly or inferiorly, and that postreduction stability differs considerably depending upon the direction of rotation or displacement of the fractured zygoma.Diagnosis of the type of zygomatic fracture can be made on the three X‐ray views: Waters, submentovertical and Caldwell. The Waters view is the best single view for evaluation of zygomatic fractures. It should be noted, however, that posterior displacement of the zygoma may not be well shown in this view, because the zygoma is often displaced along the course of the X‐ray beam. The submentovertical view is indispensable for zygomatic arch fracture (Type II), posterior displacement (Type Vc), and medial and lateral rotation of the zygoma around the vertical axis (Type III, a and b). The Caldwell view is an important view for Type IV fractures which rotate around the longitudinal axis, and Type V fractures with medial (Va), lateral (Vb), and inferior (Vd) displacement. Diagnosis of zygomatic fractures should not depend upon the Waters view alone.Classical Temporal Approach. This approach is simple and most effective for depressed arch fractures but not effective for displacement or rotation of the zygomatic body. Elevation of the zygoma via this route may be hazardous for medial displacement (Type Va) and medial rotation around the vertical axis (Type IIIa). Transbuccal elevation is recommended as the standard initial method for all types of zygomatic fractures except for arch and rim fractures. This approach is particularly effective for posterior displacement (Type VC) and lateral rotation around the vertical axis (Type IIIb). Direct transorbital elevation via infraorbital and zygomatico‐frontal incisions should be used when the zygoma is impacted and cannot be reduced or when the fractured zygoma is unstable after reduction. This approach should also be used when there is a suspected blow‐out fracture of the orbit. This approach is particularly useful for fractures rotated around the vertical or longitudinal axis (Type III and IV) as well as for inferior displacement of the zygoma (Type Vd). Supraorbital elevation via an eyebrow incision is an effective method for posterior displacement Type Vc), but not for lateral or inferior displacement (Type Vb and Vd) or fractures rotated around the longitudinal axis of the zygoma (Type IV). Direct interosseous wiring is the most dependable and effective method of fixation of the zygoma.As a guide to treatment of zygomatic fractures, the Rowe and Killey classification is superior to the widely accepted Knight and North classification. The author proposes a modified Rowe and Killey classification which will more readily help to predict the postreduction stability and thus help to select the method of treatment according to the type of fracture.

Simplified interosseous wiring technique

Difficult interosseous wiring is an indication for the use of a length of nylon catheter as a flexible wire introducer. A simple technique has been described.

Condylar repositioning following osteotomies for correction of mandibular prognathism

SURGICAL repositioning of the mandible for correction of prognathism has become an increasingly popular procedure. Bilateral subeondylar vertical osteotomy is one of many techniques employed. The surgical procedure is relatively easy, and the reported resultP have been excellent. One of the factors which help simplify the technique is the observation that overlapping of the bony edges results in satisfactory osseous union (Fig. 1). Remodeling and healing proceed in a similar fashion, regardless of whether or not the appositional bone is decorticated.5, 6 Interosseous wiring is generally unnecessary if the condylar fragment is positioned lateral to the ramus of the mandible. Because of these observations, the ease and speed with which the operation can be performed have been greatly increased. The bone can be sectioned by either of two techniques : (1) The osteotomy can be performed through a submandibular incision by means of either a nasal saw or dental burs and engine. (2) It can also be performed via a “blind” approach, and the bone can be sectioned with a Gigli saw, It is natural to expect some compensatory changes following surgical intervention. The temporal, geniohyoid, digastric, and mylohyoid muscles are shortened as a result of the mandibular retrusion. The pull of the masseter and internal pterygoid muscles, if not lengthened, is at least altered in direction. The external pterygoid mm&e acts without opposition on the condylar fragment. Changes in the mandibular muscle complex would predispose to secondary mandibular adjustments and remodeling of bone. It was reported earlier* that when the mandible was positioned posteriorly,

Surgical correction of unilateral mandibular prognathism by intra-oral ostectomy of the symphysis

Summary An operation for the correction of unilateral mandibular prognathism caused by unilateral skeletal macrognathia is described. The mandible is remodelled after resection of a segment of the arch in front of the mental foramen to improve the occlusion and restore facial symmetry. The resection can be combined with any necessary reduction of the mental prominence. The operation is performed via an intra-oral approach and is relatively simple because the bone is easily accessible and the resection does not involve the inferior dental canal. Careful pre-operative preparation, particularly in the occlusal adjustments, is essential for a satisfactory result. The method has also proved successful in edentulous cases (Fig. 9), the fragments being immobilised after resection by upper and lower border interosseous wiring. Temporo-mandibular joint symptoms have not resulted from the altered relationship of the articular surfaces, in fact, severe joint symptoms have been relieved by the operation.

Surgical correction of prognathism: Angled osteoplasty of the mandibular rami

Summary Satisfactory results are reported by treating prognathism with Smith's technique. An easier personal procedure is also described, consisting of L-shaped osteotomies on the mandibular rami from the sigmoid notch across the condylar neck, followed by dorsal sliding of the mandible with bony superimposition of the fragments. There is no need for interosseous wiring.

Polyurethane polymer in the healing of experimentally fractured mandibles

An investigation was designed to determine the use of polyurethane as an immobilizing agent in experimentally produced mandibular fractures in dogs. All animals were rendered edentulous along the intended fracture site 5 to 7 weeks prior to creation of the fracture. The experimental fractures were immobilized with polyurethane, while in the control animals the fractures were reduced by direct interosseous wiring. In both groups, intermaxillary immobilization was limited to the first 48 hours following fracture. The results suggest the following: 1. 1. Where the polyurethane comes in immediate contact with the bone, it inhibits the process of repair and tends to delay the over-all healing process. 2. 2. The polyurethane, although spongelike in structure, does not allow any significant cellular or fibrillar infiltration within its confines. 3. 3. The potential advantages of the use of bonding substances in the treatment of jaw fractures warrant continued research in this desirable area.

Interosseous wiring of mandibular fractures: A follow-up of fifty cases: Anthony Ditchfield. Brit. J. Plast. Surg. 13: 146, July, 1960

Interosseous wiring of mandibular fractures: A follow-up of fifty cases: Anthony Ditchfield. Brit. J. Plast. Surg. 13: 146, July, 1960

Interosseous wiring of mandibular fractures: A follow-up of fifty cases

Interosseous wiring of mandibular fractures: A follow-up of fifty cases

Mandibular prognathism corrected by oblique ostectomy of the ramus: A new, precise, mechanically controlled technique

The importance of the growth of the ramus in normal development of the mandible has been recognized for many years. Sarnat [2] has shown the importance of condylar growth experimentally m monkeys. Ricketts [3] has demonstrated the importance of condylar growth in children using a special radiographic technique. No one has proved that prognathic mandibles develop by any mechanism or in a manner greatly different from that of normal mandibles. The prognathic mandible seems to be an expression of quantitative growth rather than of qualitative growth. The size and shape of the alveolar arches of prognathic patients are usually harmonious after their relationship has been corrected. Therefore, the configuration of the prognathic mandible seems to verify the fact that the overgrowth of bone occurs mainly in the ramus, perhaps greatly influenced by condylar growth, as in normal development. For these reasons we believe an operation in the subcondylar region, as close to the origin of overgrowth as possible, properly performed, will produce the best anatomic and physiologic results. Some of the operations used in the treatment of prognathism, such as those involving the overlapping of bone fragments, produce a second deformity while attempting to correct the original deformity. In the application of our technique we have followed sound orthopedic surgical principles in order to correct the prognathism, while producing a minimal disturbance of the normal anatomic position of the associated structures, thereby maintaining or enhancing proper function and improving esthetics. The submandibular approach, or modification thereof, has proved to be a very popular method of entree into the ramus. With proper precautions the two possible complications which have been mentioned in connection with this approach, i.e., injury to the mandibular branch of the facial nerve and parotid fistula, have not proved to be troublesome in a variety of maxillofacial procedures in which this approach has been used. The ever-present possibility of injury to the internal maxillary artery, and the inferior alveolar artery and nerve which exists in operations on the superior portion of the ramus has been eliminated by the presence of the protecting retractor. (Fig. 6.) At the same time accuracy is assured by the use of a precise cutting guide. By careful preoperative study on a stone articulator, as described herein, the relationship of the holes for interosseous wiring can be determined so as to allow for vertical as well as horizontal transposition of the anterior segment which bears the dental arch, and a balanced occlusion with a positively controlled edge-to-edge approximation of the bone fragments can be assured. We believe this new technique of oblique ostectomy of the ramus offers the following advantages: 1. 1. The operative area, as far as we can determine, is as near the anatomic origin of the deformity as possible. 2. 2. The subauriculomandibular approach offers adequate exposure for good visualization of, and access to, the operative area and leaves an inconspicuous scar. 3. 3. There is no oral contamination of the wounds and an aseptic surgical technique is possible. 4. 4. The special self-retaining retractor offers maximum protection to important blood vessels and nerves medial to the site of ostectomy. 5. 5. The preoperative study and precise cutting guide assures accuracy of ostectomy. 6. 6. At the site of operation the ramus is devoid of important blood vessels and nerves, and is relatively free of muscle attachments. 7. 7. The intact body of the mandible and its contiguous tissues are transposed as a unit. 8. 8. The edge-to-edge approximation of bone fragments, stabilized by interosseous wires, reduces the period of immobilization to a minimum and prevents an open bite deformity. 9. 9. The muscles of mastication, with the exception of the external pterygoid muscles, remain attached to the large, denture-bearing, anterior fragment of the mandible which further tends to stabilize the mandible and prevent an open bite deformity. 10. 10. There is minimal disturbance to or enhancement of the functional positions of the muscles of mastication, muscles of the floor of the mouth and the tongue. 11. 11. No teeth are sacrificed or devitalized, and the size of the alveolar arch is not diminished. 12. 12. The acuteness of the gonial angle is increased. 13. 13. The heads of the condyles are retained in their original positions, thereby maintaining the integrity of the intratemporomandibular joint anatomic relationships. 14. 14. By the removal of accurate sections of bone and interosseous wiring, proper alignment of the fragments is maintained. 15. 15. There is no danger of interposing soft tissue between the bone fragments, and healing of bone in the subcondylar region is excellent. 16. 16. The technique requires no elaborate or special method of intermaxillary fixation during the healing process, and is an excellent procedure for edentulous patients.