closed reduction in mandibular fractures
TRANSCRIPT
Closed Reduction in Mandibular
FractureDEYA_49DDCH_2017
Introduction
What is close reduction?
~ Restoration and alignment of the fractured fragments to their original anatomical position without visualization of the fracture line is known as close reduction.
Closed reduction01
• Fracture reduction that involves techniques of not opening the skin or mucosa covering the fracture site.
02• Fracture site heals by secondary bone
healing.
03• This is also a form of non-rigid fixation.
Indication of close reduction
Non displaced favorable fractures
Grossly comminuted fractures
Fractures exposed with significant loss of overlying soft tissues.
Edentulous mandibular fractures
Indication
Mandibular fracture in children
Coronoid process fracture
Condylar fracture
Contraindications of close reduction
Unfavorable fractures at the angle of the mandible
Unfavorable fractures at the symphysis or body of the mandible
Medically compromised patient
Contraindication
Complex facial fracture
Edentulous mandibular fracture with severe displacement
Advantages of close reduction
Inexpensive
Only stainless steel wires needed (usually arch wire also)
Easy availability, convenient
Short procedure, stable
Gives occlusion some “ Leeway” to adjust itself
Advantages of close reduction
Conservative
Generally easy, no great operator skill needed
No foreign object or material left in the body
No operating room needed in most cases
Callus formation allows bridging of small bony gaps
Disadvantages of close reduction
Cannot obtain absolute stability (contributing to nonunion & infection)
Noncompliance from patient due to long period of IMF
Difficult nutrition
Disadvantage
Complete oral hygiene impossible
Possible temporomandibular joint sequelae (MPDS)
Denervation of muscles, alteration in fiber types
Myofibrosis
atrophy and stiffness
Disadvantages
Changes in temporomandibular joint cartilage
Weight loss
Irreversible loss of bite force
Decrease range of motion of mandible
Risk of wounds to operators manipulating wires.
Methods used to achieve close reduction
~ Reduction by manipulation
~ Reduction by traction
~ Intraoral traction method
~ Extraoral traction method
Reduction by manipulation
Reduction by manipulation is done when the fractured fragments are adequately mobile without much overriding or impaction and the patient comes for treatment immediately after trauma. Then the digital or hand manipulation for reduction can be used .
Specially designed instruments for grasping the fragments are available like disimpaction forceps, bone holding forceps.
Reduction By Manipulation
Close reduction by traction
Intraoral traction method :
In this method prefabricated arch bars are attached to maxillary and mandibular dental arches by means of interdental wiring .The fracture fragments are subjected to gradual elastic traction by placing the elastics, from upper to lower arch bars in a definite manner & direction depending on the fracture line.
Intraoral traction method
The fracture fragments are subjected to gradual elastic traction by placing the elastics, from upper to lower arch bars in a definite manner & direction depending on the fracture line.
Close reduction by traction
Extraoral traction method :
In extraoral traction method, anchorage is taken usually from the intact skull of the patient & different types of head gears are used for various attachments.
Attachments are connected to the arch bars by elastics & wires.
Fracture Healing in Close Reduction
Secondary bone healing refers to spontaneous healing
without surgical intervention and after semirigid fixation.
The phases in secondary bone healing: ~ Intial stage ~ Cartilaginous callus formation ~ Bony callus formation ~ Remodelling
Factor Affecting The Risk of Failure of Close
Reduction Presence of fractured tooth
Total absence of teeth
Inability of the patient to co-operate with treatment
Associated with fractures of the mandible especially bilateral fractures of the condyles.
Management of Teeth Present in line of fracture
Indications For Removal of Tooth From Fractured Line
Absolute Indication Vertical fracture of the root Pre-existing periapical
lesion Luxation and subluxation
of the tooth from the socket
Acute pericoronitis Teeth that prevent
reduction of fractures should be removed
Relative Indications
Advanced caries Advanced periodontitis Tooth which serves no
function Teeth involved in
untreated fractures which are presented more than 3 days after injury
Teeth Which Need To Be In The Fracture Line
Shows no evidence of mobility or inflammation
A second molar in the posterior segment of the fracture should be protected to prevent superior displacement of the posterior fracture segment during intermaxillary fixation
Attempt to save the cuspids, which are the cornerstone of occlusion
Management of Retained Teeth
Administration of appropriate antibiotic therapy
Splinting of the mobile teeth
Endodontic treatment of the teeth in which the pulp is exposed and subsequent follow-up for 1 year
Immediate extraction if the pulp becomes necrotic
Period of Immobilization in Close Reduction
Periods depends upon whether :
site of the fracture Presence or otherwise of retained
teeth in the fracture line The age of the patient Presence or absence of infection
Period of Immobilization in Close Reduction
Young adult with fracture of angle receiving early treatment in which tooth removed from fractured line:
3 weeks
Period of Immobilization in Close Reduction
If tooth retained in fracture line : Add 1 week
Fracture at symphysis : Add 1 week
Age 40 years and over : Add 1 or 2 weeks
Children and adolescents : Subtract 1 week
Different types of wiring techniques
Direct Interdental Wiring : ~ Essig’s Wiring ~ Gilmer’s Wiring ~ Risdon’s Wiring Indirect Interdental Wiring ~ Ivy Loop Wiring Multiple Loop Wiring Arch Bar Fixation
Closed Reduction of the Dentulous Patient
Erich’s arch bars. Can lead to periodontal inflammation
Avoid fixating incisors as these teeth are moved by the wires
Ivy’s eyelet wiring
Closed Reduction of the Partially Edentulous
Patient
Partial and circum wires or screws
Acrylic partials with incorporated arch bar wires
Closed Reduction of the Edentulous Patient
Custom made splints
Gunning splints
Closed Reduction in Mixed Dentition Period
Fixation independent of the teeth Gunning type splint for the lower jaw Curcumferential wire A simple elasticated bandage chin support
Fixation utilizing the teeth Cap splint Eyelet wire / arch bar
Armamentarium for wiring
Presterilized 26 gauge stainless steel wire spool or wires cut into lengths of 20 cm each.
Two needle holders or wire holders
Wire cutters
Essig’s wiring
Essig’s wiring can be used to stabilize the dentoalveolar fractures in individual dental arches.
Essig’s wiring can be used as anchoring device for IMF.
The luxated teeth can be stabilized using essig’s wiring.
Essig’s Wiring
A 40 cm prestretched stainless steel wire is usedThe wire is passed interproximally between two teeth present at least 3 teeth away from the fracture lineThe wires are passed around the teeth in the figure manner until they reach 2-3 teeth away from the fracture lineNow the wires are passed without looping to the other side of the fracture line 2-3 teeth away from the fracture line on the opposite side.Again the wires are taken around 2-3 teeth in the figure manner Now this acts as an arch bar on which the other smaller wires are tightened to stabilize the fracture
Gilmer’s Method
It is used for IMF Most common and simple method Few firm teeth in the mandible as well as in
maxilla are chosen At least one firm teeth must be chosen anterior
and posterior to the fracture line A pre-stretched 20 cm long 26 guage wire is taken
and passed around the neck of the choosen tooth Both the ends of the wire are brought out on the
buccal side and twisted
Gilmer’s wiring
The same procedure is carried out for all the chosen teeth in the individual archesThen the mandibular wires are twisted tightly with the corresponding maxillary wires. The ends are cut short and sharp ends are tucked inThe main disadvantage of this wiring is that there may be extrusion of the teeth as excess load is appliedAnother disadvantage is of requiring complete removal of the wires to open the mouth is emergency situation
Risdon’s wiring
It is commonly used method of horizontal wire fixation
This can be a substitute technique for arch bar In this method second molars are usually chosen
for anchorage on either side A 25 cm long 26 guage wire is passed around the
neck of second molar on each side and both the ends are brought in buccal side
Risdon’s wiring
The ends are twisted for entire length thus forming a strong base wire that comes towards the midline from each second molarsTwo base wires are grasped and twisted at mid line and adapted to the necks of the teeth on the buccal side the base wire is secured to individual teeth by using additional interdental wiresThis type of horizontal wiring offers strong fixation
Ivy’s Eyelet Wiring
The Ivy loop embraces the two adjacent teeth. One or two Ivy eyelets should be placed in each quadrant.
A 26 guage stainless steel wires cut in 20 cm length are used A loop is found in center of wire around the beak of a towel
clip or shank of dental bur and twisted thrice with two tail end. such Ivy loops can be preformed and stored in cold sterilizing solution for emergency use.
The two tail ends of the eyelet are passed through the interdental space of the selected two teeth from buccal to lingual side
One end of the wire is passed around the distal tooth lingually and brought out from the distal interdental space over the buccal side and threaded through the previously fromed loop.
Ivy’s Eyelet Wiring
The other wire tail end is carried around the lingual surface of the mesial tooth and brought out on the buccal surface from the mesial interdental space, where it meets the first tail end wireThe two wires are crossed and twisted together and the loop is adjusted and bend towards gingiva The mandibular wire eyelets can be secured to maxillary eyelets by joining wiresAdvantage is that bridging wires can be removed whenever required without disturbing the main wiringEven when there is breakage of wire during fixation only that eyelet can be removed and replaced.
Ivy’s Eyelet Wiring
Arch Bar Fixation
Indication of Arch Bar Fixation
Stabilization of multi-fragment fracture
Fixation of IMF
Arch Bars are preferred
For temporary fragment stabilization in emergency cases before definitive treatment
As a tension band in combination with rigid internal fixation
For long-term fixation in conservative treatment
For fixation of avulsed teeth and alveolar crest fractures
Arch Bar: General Considerations
The occlusion must be checked
There should be calculable tension forces on both bars
Surgeon should aware of getting affected by bloodborne infection from patient
Arch Bar Fixation
The arch bar is a flat, sturdy stainless steel bar on which fleats or hooks are attached.
It is a effective, quick and inexpensive of fixation The different types of arch bars are ~ pre fabricated ~ custom made ~ acrylated arch bars ~ directly bonded arch bars Of these the most commonly used are the pre
fabricated Erich arch bars.
Erich’s Arch Bar
Pre-Frabricated, Custom Made, Acrylated Arch Bar
Arch Bars : Preparation
Check occlusion
Adjusting the shape
Arch Bars : Preparation
Trimming the bar
Arch Bars : Preparation
Symmetric bar position
Ligature preparation
Arch Bars : Preparation
Attaching the bar
Wire end
Arch Bars : Preparation
Make sure the wire rosettes do not protrude away from the arch bar as this will be an irritation to the patient
Arch bar fixationThe arch bar is measured to fit from first molar to first molar.The arch bar is placed in such a way that the fleats or hooks face towards the gingival margin15 cm of 26 guage wire is taken and starting from distal tooth, the wire is passed from buccal to lingual side below the arch bar and from lingual to buccal above the arch bar and twisted together.This is continued for all the teeth and the arch bar is secured.When placing an arch bar across a displaced fracture segment, it is cut at fracture site and placed seperately.
Inter-maxillary Fixation with Erich’s arch bar
Advantages of Arch Bar Fixation
Rigidly splint the teeth
Provides good retention, stability and support
Provides cross arch stabilization
Positioned close to the alveolar bone
Disadvantages of Arch Bar
Bulk of bar
Plaque accumulation
Wearing
Soldering procedure
References
Oral and maxillofacial surgery- Neelima Anil Malik – 3rd edition
Oral maxillofacial Surgery- S M Balaji Killey’s Fractures of the Mandible- Peter Banks –
4/E Mandible Fixation- AO Foundation Images- S.M. Balaji’s – Oral maxillofacial surgery,
AO foundation publication