Chapter 42: Basic principles of management of maxillofacial trauma

Q: Intermaxillary or Maxillomandibular fixation

 Refers to fixation of maxilla and mandible in MIP – with aid of wiring
 It is a type of indirect/closed fixation method
 Principle: when teeth of fractured segment are brought into occlusion – bone fragments supporting it
also reduced
 Suitable only for those with adequate teeth and size and shape of teeth
 Wires stretched 10% before wiring
 Types:

Type Features
Direct dental 1. Gilmer wiring:
wiring - Pre-streched 0.35 mm soft SS wire of 15cm is twisted to form plaited tail of 3cm – cut
ends are bent away from tissue or covered with wax
2. Ridson’s wiring
- 26 G 25cm wire is twisted around the ecks of mandibular 2nd molars on both sides and
twisted for entire length – ends are brought together at midline and final twisting done
adapting onto buccal surface of teeth – additional wires used to secure base wire
3. Button wiring
- Titanium buttons used
Interdental Preparation:
eyelet wiring - Prestreched 0.35mm SS wire of 3m is taken and cut into 15cm wires
- Eyelet wires made by twisting middle of ecach wire around a shaft of rod 3mm in
diameter (2.5 twists enough)
- Wires cut obliquely to get equal lengths
Procedure:
- Eyelets are passed through interdental spaces and twisted tight
- Wires on palatal/lingual side bent into W shape and passed through mesial and distal
interdental spaces of adjacent teeth
- Distal wire passed through the eyelet and twisted with mesial end
- 5 wires each on maxilla and mandible placed
- Fracture reduced by passing wires through eyelets of upper and lower jaws
- ‘Cross-bracing’ effect achieved to prevent mobility of mandible
- Any extraction and throat pack removed before wiring
- Tightening done from molar end of one side to incisor end of other side and then
beyond – to prevent crossbite
- Final tightening done after achieving proper occlusion
- Sharp ends tucked in to prevent ulceration
- Eyelets used in clove hitch method when edentulous space around tooth
Multiple loop - Blocks of teeth in either jaws are wired and elastic traction used to reduce the fracture
wiring

Arch bars Indications:

- When remaining teeth are insuffisient to allow efficient eyelet wiring
- Simple dentoalveolar fracture
- Interskeletal suspension
 - When external fixation is planned
Procedure:
- Arch bar adapted to buccal surface and secured using 0.35mm soft SS wire, passing over
bar mesially and under the bar distally, IMF by tie wires
Cap splints Indications
- Prolonged fixation of mandibular teeth with fracture of tooth bearing segment of
mandible and bilateral displaced fractures of condyle neck
- Missing portion of mandible with soft tissue loss
- Severe periodontal disease
- Extraoral fixation in complicated midface fractures
Gunning splint
Bonded - Used incase of minimal displacement
modified
orthodontic
brackets
IMF screws - Reduces risk of disease transmission
- Ex: HIV/AIDS

Q: Suspension wiring
 First described by Adams – 1943
 Lower jaw is connected to facial skeleton above the fracture line by soft SS wire 0.5mm in diameter
 Tightening is done after occlusion is established and MMF for 6 weeks

Technique Use
Frontal Lefort III/II (stable mandible)
Lateral Lefort II/III (unstable mandible)
Circum zygomatic Lefort II/I
Zygomatic buttress Lefort I
Lateral pyriform/ anterior nasal spine Lefort I

 Disadvantages:
- Incomplete fixation
- Insufficient visualization by closed
reduction
- Compression against cranial base to
wedge fracture segments
- Lasck of compensation of
dislocating forces directly posteriorly
- Patient discomfort
- Midface shortening and widening and retrusion of paranasala areas

Q: Direct/Internal fixation
 Surgical method of fixation – by direct visualization
 Using SS wires/plates/screws – by load bearing or load sharing osteosynthesis
 Semirigid fixation
Transosseous wiring  Direct wiring across fracture line
 Cheap, easy to use and biologically well tolerated
 Sites: (a) Frontonasal suture
(b) Frontozygomatic suture
(c) Orbital rim
(d) zygo,aticomaxillary suture
(e) Zygomatic bone
(f) Alveolar bone
 It does not provide 3 dimentional stability
 Micromovment of fractureTypes site – delayed wound healing
Noncompression miniplate  Champy lines and his coworkers – stated that a natural line of compression
osteosynthesis Semirigid fixation
exists along lower border of mandible Rigid fixation
 They determined ‘the ideal line(without
of osteosynthesis’ – where miniplate fixation is
IMF, with bone
(with supportive IMF) plates)
most stable
Champy’s line of osteosynthesis
Compression
Transosseous Noncompression Lag screws Reconstruction
- Cortical bone along external oblique ridge and inferior
plates plateregion of chin is
wiring miniplates
thick and dense – provides excellent anchorage for osteosynthesis screws
- However masticatory forces cause tensional ofrces in alveolar region and
compression forces at lower border – distraction of fractured segment
- Transitional zone between area of ension and compression – is line of
zero force along IAN where plates are placed along
Miniplates:
- Made of titanium
- Have self-tapping monocortical screws – 7mm long and 1.5mm in
diameter
- They provide 3D stability and resist a/p and rotary movment of fractured
segment
Areas of plate application
- Single noncompression miniplate  on superior border of mandibular
angle fracture on external oblique ridge
- Single plate fractures posterior to mental foramen below the roots and
above IAN
- Two plates  fractures anterior to mental foramen ; one in subapical
region and other along lower border of mandible – to neutralize the
torsional forces

Procedure
- Approaches – intraoral/extraoral/combination
- Intraoral incisons – periosteum elevated – scalpel used to divide muscle
attachment – reduction – plates inserted with 4 monocortical screws,
including 2 on each side of fracture line
Principles
- Temporary inoperative stabilization of fragments
 - Losse screws to be replaced with emergency screws
- Plates slightly overbent to close lingual aspect
- Minor bone recontouring can be done to facilitate better plate
adaptation
- Poor adaptation causes fracture displacement during placement and
tightening of screws
Rigid fixation
Goals of AO/ASIF technique
- Anatomic reduction of bone fragments
- Functionally stable fixation of fragments
- Preserving blood supply of fragments by atrumatic procedures
- Early, active and pain free mobilization
Compression plates 1. Dynamic compression plates (DCP)
- Produce 300 kPa/cm2 – less than compression strength of bone so no
bone necrosis
- Indications – nonoblique fractures with good bony apposition after
reduction
2. Eccentric dynamic compression plate (EDCP)
- Indicated – presence of impaced 3rd molar with an angle fracture,
edentulous mandible fractures, avulsion of bone from fracture site
- 2 inner screes placed creating compression at inferior border – holes
then drilled in ecentrc position and tightened – allows bony fragments to
rotate around axis of inner screw – produces compression at superior
border
- Advantage: even distribution of forces along the length of fracture

3. Lag screws
- For oblique fractures
- Screw glides through cortex of one fragment – engages the cortex of
opposite fragment with threads – draws the fragments together –
compresses them on tightening
- Gliding holes and thread holes to be coaxial
Fixation osteosynthesis
Reconstruction plates  Thick rigid plates
 Used in reconstruction following resection or multiple mandibular fractures
Titanium hollow screw  30mm thick with 4mm diameter screw
osseointegrated  consists of reconstruction plate and a anchor screw
reconstruction plate (THORP)  Anchor screw osseointegrates with bone – increased stability and decreased
friction with the hole in plate increased plate and fracture segments and
decreased bone resorption
Locking plate  Locking plates have screws with their thread at the screw head into the inner
thread of plate hole
 Acts like a single fixation unit