Need For Intermaxillary Fixation Research Articles

Mandibular fractures – what a difference 30 years has made

This single-centre retrospective study aimed to characterise the epidemiology, management, and outcomes of mandibular trauma presenting to the same tertiary trauma centre 30 years apart, including key paradigm shifts in management and techniques. A total of 393 patients presenting with 665 mandibular fractures were managed by the Oral and Maxillofacial Surgery department at The Royal Melbourne Hospital (RMH), Australia, between 2011 and 2016. Data from a previous RMH paper of 205 patients presenting with 376 mandibular fractures between January 1985 and April 1990 were compared. Results showed an increase in presentations (205 to 393 patients) with an increase in the incidence of mandibular trauma (p = 0.0001), females (12% to 14%), and mean age (29 to 31.1) years. Young males remained the dominant cohort (86%) and interpersonal violence (IPV) the most common aetiology (46% to 43%). Mandibular fractures remained commonly associated with other systemic injuries (49% to 42%), occurring most frequently on the left (49%), and at the angle (29.8%), with most occurring at two sites (53%). Significant paradigm shifts in the management of mandibular trauma saw a reduced need for intermaxillary fixation (76% to 30%, p = 0.0001), increased use of extraoral approaches to the fracture, and the use of semi-rigid internal fixation along ideal lines of osteosynthesis (29% to 87%, p = 0.0001). This demonstrated decreased complications including malocclusion, non-union and delayed union, and permanent nerve injury. There was no significant change in infection, dehiscence rates, and temporary nerve damage.

Accuracy of digital templates for guidance of custom-made total temporomandibular joint replacement

This study evaluated the application of digital templates to guide custom-made total temporomandibular joint (TMJ) replacement. Patients treated with a custom-made total TMJ prosthesis for TMJ osteoarthrosis, ankylosis, or tumours were included prospectively. Before surgery, two types of digital template (articular eminence and condyle neck templates) were designed to guide the bone osteotomy and prosthesis positioning. The reconstructive outcomes were assessed through clinical examinations and accuracy analysis by superimposing the postoperative three-dimensional craniomaxillofacial model onto the preoperative virtual plan. Thirty-seven patients (45 joints) underwent successful TMJ reconstruction with the custom-made TMJ prosthesis guided by the digital templates, without intermaxillary fixation. For all patients, the occlusal relationship was stable in reference to the preoperative state. There were significant improvements in pain and maximum inter-incisal opening. Through merging of the pre- and postoperative craniomaxillofacial models, the maximum implanted error was 1.17 ± 0.23 mm in linear measurement and 1.19 ± 0.14 mm in surface deviation. There was more deviation in the anteromedial part of the fossa and inferior part of the mandibular handle. The digital templates were able to assist in the accurate placement of the TMJ prosthesis without the need for intermaxillary fixation.

Surgical morbidities of sagittal split ramus osteotomy versus intraoral vertical ramus osteotomy for the correction of mandibular prognathism: a randomized clinical trial

The sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO) are two common orthognathic procedures for the treatment of mandibular prognathism. This randomized clinical trial compared the surgical morbidities between SSRO and IVRO for patients with mandibular prognathism over the first 2 years postoperative. Ninety-eight patients (40 male, 58 female) with a mean age of 24.4±3.5 years underwent bilateral SSRO (98 sides) or IVRO (98 sides) as part or all of their orthognathic surgery. IVRO presented less short-term and long-term surgical morbidity in general. The SSRO group had a greater incidence of inferior alveolar nerve deficit at all follow-up time points (P< 0.01). There was more TMJ pain at 6 weeks (P= 0.047) and 3 months (P= 0.001) postoperative in the SSRO group. The SSRO group also presented more minor complications, which were related to titanium plate exposure and infection. There were no major complications for either technique in this study. Despite the need for intermaxillary fixation, IVRO appears to be associated with less surgical morbidity than SSRO when performed as a mandibular setback procedure to treat mandibular prognathism.

Evaluation of Success of Transport Disc Distraction Osteogenesis and Costochondral Graft for Ramus Condyle Unit Reconstruction in Pediatric Temporomandibular Joint Ankylosis

The costochondral graft (CCG) is considered the reference standard for pediatric temporomandibular joint reconstruction. It has the disadvantages of unpredictable growth, donor site morbidity, and the need for intermaxillary fixation. It has been reported that transport disk distraction osteogenesis (TDDO) can result in the formation of a neocondyle and disc. We performed a randomized trial to measure and compare clinically relevant outcomes of ramus-condyle unit (RCU) reconstruction using CCG and TDDO for pediatric temporomandibular joint ankylosis (TMJA). In the present randomized controlled trial (block randomization with a variable block size), pediatric patients with unilateral, nonrecurrent TMJA aged 3 to 16years who had presented to our unit from December 2015 to June 2017 were enrolled. Instead of temporalis myofascial flap interposition, a buccal fat pad was used to fill the gap created by osteoarthrectomy. The primary outcome parameter was mouth opening. A mouth opening of at least 25mm at the median follow-up point was considered success. The secondary outcome parameters were occlusion, laterotrusion, protrusion, reankylosis, neocondyle, chin deviation, facial asymmetry, midline shift, and neo-disc formation. Data were analyzed using the independent t test and rank sum test. A total of 24 patients were enrolled in the CCG and TDDO groups (n=12 in each group). Trauma (40.9%) was the most common etiology with a slight male preponderance (59.09%). The mean age was 10.32±2.85years. The average distraction achieved in the TDDO group was 10.42mm. The median follow-up duration was 31.5months (range, 24 to 39months). The mean preoperative maximal incisal opening had improved from 8.5±4.1 and 9.5±7.1mm in the CCG and TDDO groups preoperatively to 35.7±2.7 and 34.4±8.9mm, respectively, at the median follow-up point (P<.005). RCU reconstruction with both modalities resulted in improvement in all the parameters; however, the intergroup comparison showed statistically non-significant differences. No reankylosis or open bite was found. The 3-hour delayed gadolinium-enhanced magnetic resonance imaging scan showed successful neo-disc formation. Similar success can be achieved in RCU reconstruction using either CCG or TDDO for pediatric TMJA. Both techniques have some advantages and disadvantages. RCU reconstruction using CCG or TDDO results in formation of a neocondyle, maintenance of occlusion, and correction of facial asymmetry.

Reinventing the wheel: a modern perspective on the bilateral inverted ‘L’ osteotomy

The bird-face deformity of a severe class II, high Frankfort–mandibular plane angle with significant retrogenia, often associated with diminutive condyles and reduced posterior face height, poses many challenges to the orthognathic surgeon. Of greatest concern in these patients is the degree of mandibular advancement required and the potential for relapse. The sagittal split osteotomy is the workhorse of mandibular surgery but does not allow significant lengthening of the ramus, which is desirable in this group of patients. An inverted ‘L’ osteotomy of the mandible to facilitate ramus lengthening is therefore indicated in the management of this group, but is a procedure that has largely fallen out of favour due to the need for an extraoral approach and intermaxillary fixation. The advent of distraction osteogenesis promised to be the answer for these cases, but with nearly 20 years of experience with these techniques, it is clear that it does not represent the panacea that was hoped for. We present a series of four cases of bimaxillary surgery consisting of maxillary osteotomy and bilateral inverted ‘L’ osteotomy of the mandible carried out via an intraoral approach (average advancement 10.5mm), where internal semi-rigid fixation was employed to obviate the need for intermaxillary fixation. We highlight the indications for this procedure and why it is ideally suited to this group of patients and argue that the procedure should be re-introduced to the armamentarium of the orthognathic surgeon.

Three-dimensional v/s standard titanium miniplate fixation in the management of mandibular fractures – A randomized clinical study

PurposeThe aim of this study was to compare treatment outcomes using three-dimensional and standard titanium miniplates in the management of mandibular fractures. Material and methodsA prospective study of 30 patients with mandibular fractures. Patients were randomly categorized into 2 groups with 15 patients in each group; patients in Group I were treated with 2.0 mm 3-dimensional titanium miniplate and screws and patients in Group II were treated with 2.0 mm standard plates and screws. Clinical parameters evaluated were: intra-operative assessment of reduction, intra-operative and post-operative assessment of stability of occlusion, mobility of fracture fragments and need for intermaxillary fixation. Radiographic parameters included pre-operative evaluation of displacement of fracture fragments and post-operative evaluation of bone union and plate fracture at different time intervals. ResultsIn Group I, 3 patients (20%) and in Group II, 8 patients (53%) had gap between fracture fragments during reduction. Six patients (40%) in Group I and 8 patients (53%) in Group II had mildly deranged occlusion on the 7th post-operative day. Two patients (13%) in Group I and 6 patients (40%) in Group II needed IMF till the end of the 1st month. No patients showed tissue dehiscence at the end of 1st and 3rd month post-operatively. Infection was not observed in any patient post-operatively. Five patients (33%) from Group I had displaced fracture fragments and 10 patients (67%) had severely displaced fracture fragments pre-operatively. Seven (47%) patients from Group II had displaced fracture fragments and 8 (53%) had severely displaced fracture fragments pre-operatively. Nine patients (60%) in Group I and 6 patients (40%) in Group II showed radiographic evidence of bone union after the 3rd month post-operatively. ConclusionThe use of 3D miniplate is a viable option for fixation of mandibular fractures routinely. 3D titanium miniplates showed comparable results compared to standard titanium miniplates.

Surgical protocols and outcome for the treatment of maxillofacial fractures in children: 9 years' experience

Trauma and facial fractures in a population of children have been analysed in several studies mainly regarding their incidence and much less their treatment modalities. The aim of this study was to retrospectively analyse the treatment methods and outcome of facial fractures in children and young adolescents during the last decade and to discuss findings and propose treatment protocols. Patients of the Paediatric Maxillofacial department, treated for fractures of the facial skeleton were included in the study. Open reduction and osteosynthesis plate fixation (titanium and resorbable material) was the main treatment method with conservative treatment saved for selected cases. Titanium plates were removed after bone healing. Intermaxillary fixation (IMF) was not used regularly in mandibular fractures, with the exception of condylar fractures. 156 children and young adolescents with 208 fracture sites in total were treated. 139 fracture sites (66.8%) were treated with open reduction and 69 conservatively. The mandible was affected in 49.0% of the cases, the maxilla in 21.2% (both with the alveolar process fractures included), the zygomatic complex in 10.1%, the orbital walls in 9.6%. There were 38 alveolar process fractures. The results of the fracture treatment verified the usefulness of open reduction and plate fixation in children. There was no need for wire suspension and only occasional need for IMF. Closed reduction was selectively applied in condylar fractures and dento-alveolar trauma.

The conservative treatment of mandibular fracture in a child with circummandibular wiring: case report

Maxillofacial injuries are less common in children than in adolescents and adults. This lower incidence is a result of the rela tively small size of mandible, the resilient nature of the bones, and a relatively protected environment, which distinguish the treatment principles of pediatric mandibular fractures from those of the adult. The bone of child is malleable, so pediatric fractures tend to be less displaced and rarely comminuted. Moreover, high regenera tion potential of the wound allows more conservative treatment modalities for the pediatric mandibular fracture. High risk of damaging unerupted toot h bud renders many clinicians to resort to more conservative treatment modality for the reduction of displaced segments. This case report describes two successful treatment cases using the circummandibular wiring which was applicated to the fractur e on parasymphysis of mandible. Circummandibular wiring can protect the tooth buds, and there is no need for intermaxillary fixation so that it pr events the possible complications of intermaxillary fixation such as the temporomandibular joint ankylosis and the facial growth disturbances. The acr ylic splint was removed after 3 weeks, which showed clinically good union across the fracture line without complications. They showed complete clinical and radiological bone healing with an optimum occlusion.

A comparison between 2.0-mm standard and 2.0-mm locking miniplates in the management of mandibular fractures

The purpose of this clinical study was to compare effectiveness of 2.0-mm locking miniplates and screws with 2.0-mm standard miniplates and screws in treating mandible fractures. A randomized prospective study comprising of 40 samples, where 20 patients (group 1) were treated with locking plates and 20 patients (group 2) were treated with standard miniplates. All the cases were evaluated for the type of fracture, need for the Intermaxillary Fixation (IMF) and its duration, duration of surgery, anatomic reduction, paresthesia / neurosensory changes, occlusal discrepancies, infection at the fracture site and any need for the removal of the plates and screws. In our study Road Traffic Accidents (RTA) accounted for the majority of patients 30 (70%). RTA was more prevalent (52.5%) in 21-30 age group, with assault being more common (67%) in 25-35 years. There was a significant difference between group 1 and 2 in postoperative occlusal discrepancy and need for IMF (p=0.008). There was no significant difference in complication rates between group 1 and group 2 patients. Locking plate/screw system proved to be more rigid than conventional plate/ screw system, thereby reducing the need and duration of IMF. However there was no significant difference in complication rates.

The need for intermaxillary fixation in sagittal split osteotomy setbacks with bicortical screw fixation

The aim of this study was to decide whether use of bicortical screw fixation provides sufficient stability to dispense with intermaxillary fixation (IMF). Eighty-six patients who had undergone surgical setback of the mandible using bilateral sagittal split ramus osteotomies were examined. Group 1 (15 patients) received miniplate fixation with IMF for 6 weeks, and group 2 (71 patients) received bicortical screw fixation and immediate postoperative function. The 2 groups were evaluated radiographically for postsurgical changes of the pogonion 24 months postoperatively. There was no significant difference in the magnitude of the relapse between the 2 groups over the 24-month postoperative period. The use of bicortical screw fixation after sagittal split setback of the mandible provides sufficient stability to dispense with IMF.

Surgically-assisted orthopedic protraction of the maxilla in cleft lip and palate patients

Fourteen children, aged 8 to 13 years, with unilateral or bilateral cleft lip and palate, were treated by an incomplete Le Fort I osteotomy without downfracturing the maxilla, followed by traction of the maxilla by face mask for twelve weeks. Our results revealed a mean maxillary forward, movement of 7.2 mm after three weeks of traction, followed by a retention period of nine weeks for callus maturation. There was an associated minor downward movement of the maxilla that caused a slight increase in the lower facial height, which improved the facial esthetics of the patients. The advantages of this method are: i) it allows for early skeletal advancement of the, maxilla with new bone formation in the osteotomy line, ii) there is no need for inter-maxillary fixation of young patients and no need for rigid fixation of the maxilla by miniplates that can damage teeth buds and roots at this age, and iii) it can be used in young patients to improve esthetic appearance, an important factor in the psychological development of adolescents.

Access to the Central Skull Base Via a Modified Le Fort I Maxillotomy: The Palatal Hinge Flap

We describe a modification of the standard Le Fort I maxillotomy in favor of a unilateral palatal hinge flap. Used in combination with a partial medical maxillectomy, submucous resection of the nasal septum, and contralateral inferior turbinectomy, this approach provides direct access to the entire nasal cavity, ipsilateral maxillary antrum, pterygopalatine fossa, nasopharynx, clivus, and first two cervical vertebrae. Use of the palatal hinge serves both to maintain palatal vascularity and eliminates the need for intermaxillary fixation. Facial incisions are avoided through a midfacial degloving approach. A variety of other surgical techniques used to access the central skull base are critically reviewed and compared with this new technique.

Enhanced Surgical Exposure for the High Extracranial Internal Carotid Artery

The need for enhanced surgical exposure for the high extracranial (Zone III) internal carotid artery is not uncommon. In certain circumstances, the posterior border and angle of the mandible may interfere with access to the distal internal carotid artery (ICA). The use of modified mandibular osteotomies has provided vascular surgeons in our institution with improved exposure of the ICA in selected cases. The intraoral sagittal split and extraoral vertical ramus osteotomies of the mandible allow manipulation of the posterior border and angle of the mandible with low morbidity and minimal postoperative complications. These procedures can be performed for both dentate and edentulous patients without the need for intermaxillary fixation. This paper introduces these modifications and discusses the benefits over previously described methods of mandibular manipulation.

Lag screws in sagittal split osteotomies: should they be removed?

The use of stainless steel lag screws to provide rigid internal fixation for sagittal split osteotomies was first described more than 17 years ago. It was shown that the need for intermaxillary fixation could be eliminated and that lower relapse rates could be produced. However a decade later, removal of the screws was still being advocated. In this study, 48 patients had a total of 259 screws inserted over a 5 year period. Twenty six screws were removed 10 months following insertion. Most of these were removed in the absence of any symptoms although a few were palpable or tender to touch. None of the screws removed were loose nor was there any evidence of infection or corrosion associated with them. The long term consequences of screw retention are discussed and it is suggested that they do not need to be removed routinely.

Monocortical Miniplate Fixation of Mandibular Angle Fractures

Noncompression monocortical miniplate fixation of mandibular fractures has become a reliable method of providing rigid fixation and eliminating the need for intermaxillary fixation. Recent studies, using a variety of internal fixation techniques, have described high complication rates at the mandibular angle. This article compares the use of one miniplate vs two miniplates in treatment of angle fractures. Since September 1985, 61 patients with 63 mandibular angle fractures have been treated with miniplates. Forty-four fractures were fixed with two miniplates. Six complications (3.1%) occurred, five of which were in the one-miniplate group. The complication rate in the double-miniplate group is the lowest reported of any plating technique. The use of two miniplates has proved to be an effective method of treating mandibular angle fractures.

Orofacial and Mandibular Reconstruction with the Iliac Crest Free Flap

Sixty vascularized iliac crest free-tissue transfers were used for oromandibular reconstruction, 46 as osteocutaneous and 14 as osseous flaps. Forty-one patients had preoperative radiotherapy, and 8 had failed previous attempts at reconstruction. Forty-nine of the 60 reconstructions were carried out primarily, most commonly following ablative surgery for radiorecurrent squamous carcinoma. Ages ranged from 19 to 85 years, and follow-up ranged from 2 months to 5 years. Flap survival was 95 percent. Eight-six percent of patients returned to their previous activities. There were 2 perioperative deaths, and 31 patients were alive at follow-up. Horizontal defects from 5 to 16 cm were reconstructed, and in 22 patients, both oral lining and skin coverage were replaced. Radiographic evidence of bone union was noted in 96 percent of synostoses, and clinical union was seen in all but one patient. One patient required bilateral hemimandibular reconstructions for sequential primaries at different operative sittings. Functional and cosmetic results were generally satisfactory and were excellent in bone-only reconstructions. Several surgical principles evolved to minimize bulk and eliminate the need for intermaxillary fixation or external fixation postoperatively. To improve results in large or more lateral through-and-through defects, an accessory pectoralis musculocutaneous flap proved advantageous. Cosmetic and functional results depend largely on three factors: the extent of the surgery, the leanness of the patient, and his or her position on the surgical learning curve.

The Luhr Fixation System for the Craniofacial Skeleton

The use of miniplates and screws in elective osteotomies or acute trauma of the craniofacial skeleton has revolutionized this field. In jaw surgery, rigid fixation has eliminated the need for intermaxillary fixation in most cases. Bone grafts and bone segments are more easily kept in place by screws or plates, rather than the balancing act that had to be done with wire fixation. This has decreased morbidity and the risks of postoperative airway obstruction. Thus, more complex procedures can be done and younger children treated. Most craniofacial surgeons now using plates and screws are finding less postoperative swelling after elective surgery. The reason for this is not immediately obvious, although supposition is possible. The disadvantages of the use of plates and screws are, first, that the surgery must be more precise than when wire fixation is used especially jaw surgery. Second, all the systems are more expensive than wires. However, in a well-organized insurance system, the cost is offset by decreased use of intensive care units, decreased hospital stay, greater safety and less morbidity for the patient, and probably fewer complications from slippage of bone segments or infection.

Osteosynthesis of mandibular fractures in the angle region.

The region of the angle of the mandible is one of the most frequent sites of fracture in external mandibular trauma. In 14 cases of fracture through the angle region, angled dynamic compression plates inserted through an extraoral route were used to provide rigid internal fixation. This method often obviates the need for intermaxillary fixation and suggests a technically simple technique by which direct and uncompromised healing of angle fractures with good resultant occlusion can be achieved in selected cases. We outline our current technique and the indications and limitations for using angled dynamic compression plates.

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.

Le Fort I ostectomy (using miniplates) for correction of the long face

The increased middle face height, with a short upper lip and visible upper alveolar process, is an indication for removing a slice of bone from the maxilla. Planning of the operation and operative procedures will be described. It is shown that osteosynthesis with mini-plates without the need for intermaxillary fixation is possible, provided that the planning is painstaking and that a precise operative technique is used.