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The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases

Sung-Suk Lee, Su-Gwan Kim, Seong-Yong Moon, Ji-Su Oh, Jae-Seek You

Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Korea

Abstract (J Korean Assoc Oral Maxillofac Surg 2014;40:91-95)

The posttraumatic complications of jaw fractures related to jaw function and facial deformity include nonunion, malunion, malocclusion, temporo-

mandibular joint dysfunction and facial asymmetry. This report presents cases referred to our department for revision of malunion and malocclusion

following inadequate reduction of jaw fractures. Three patients with posttraumatic malocclusions caused by malunion were treated with a LeFort I

osteotomy in one case and re-fracture in two cases. All of the patients exhibited stable results without further complications (e.g., malunion or maloc-

clusion). Accurate preoperative diagnosis and proper anatomical reduction of the fracture segments are essential to preventing post-surgical malunion

and malocclusion.

Key words: Fractures, Malunited, Malocclusion[paper submitted 2013. 12. 31 / revised 2014. 3. 17 / accepted 2014. 3. 31]

ment.Theformerconditioniscausedbyabonedefector

displacementandoverlapofthebonesegment,whereasthe

latterconditioniscausedbydecreasedvascularsupply,anu-

tritionaldisorder,inammationandinhibitingfactorsofbone

healing4.

Itisnecessarytoconsiderthelocationandcomplexityof

thefracture,theexistenceofteethonthefracturelineandin-

fectionpresentinginanopenfracture.Thepatientspoororal

hygienemaycauseinfection,whichwouldrequireadditional

surgery5.Additionalsurgerycauses thepatient increased

pain,recoverytimeandcostsforhospitalization,aswellas

interruptionofdailylife.Intreatingmandibularfractures,it

isnecessarytomaketheutmostefforttominimizecomplica-

tions6.

Thepurposeofthisstudywastointroducecasesinwhich

revisionsurgerywasnecessitatedbymalunionoccurringaf-

terreductionofamandibularfractureandtodiscussrelevant

complications.

II. Cases Report

Wefollowed theHelsinkiDeclaration throughout this

study.WeobtainedapprovalfromtheChosunUniversity

DentalHospitalClinicalTrialCenterInstitutionalReview

I. Introduction

Themandibularbonesustainsfracturemostfrequentlybe-

causeitislocatedinthecenterofthefaceatalocationprone

toexternalinjury1.Thegoalsoftreatmentaretoensurerapid

healingthroughaccuratereductionandfixationandtomini-

mizedisabilityandcomplications.Manytechniqueshave

beenintroducedovertheyears,includingmaxillomandibular

fixation,whichusesintraosseouswire,lagscrewfixation,ex-

ternalrigidfixationand,recently,internalrigidfixation,such

asstableinternalfixationusingametalplate2.Thesemethods

maycausesuchcomplicationsas infection,malunion,de-

layedunion,nonunion,hypoesthesia,malocclusionandfacial

deformity3.Inappropriateunionisattributabletothemechan-

icalenvironment,whichentailswidegapbetweensegments

andmovementofsegments,andapoorbiologicalenviron-

CASE REPORT

Su-Gwan KimDepartment of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, 309, Pilmun-daero, Dong-gu, Gwangju 501-759, KoreaTEL: +82-62-220-3815 FAX: +82-62-228-7316E-mail: sgckim@chosun.ac.kr

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

CC

Copyright 2014 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.

http://dx.doi.org/10.5125/jkaoms.2014.40.2.91pISSN 2234-7550eISSN 2234-5930

J Korean Assoc Oral Maxillofac Surg 2014;40:91-95

92

completed,thepatientreportedgoodocclusiononbothsides.

Thepatienthadhypoesthesiaofthelowerlipanddiscomfort

duringmouthopening.

2. Case 2

A22-year-oldmanwasdiagnosedwithanasoethmoidal

complexfracture,aLeFort II fractureandasubcondylar

fractureoftherightmandiblethatweresustainedinamo-

torcycleaccident.Thepatientwashospitalizedintheplastic

surgerydepartmentandopenreductionwasperformedon

thenasoethmoidalcomplexandmaxillausinganabsorbable

plate.Notreatmentwasperformedforthesubcondylarfrac-

ture.Fiveweekslater,thepatientvisitedthisdepartmentwith

theprimarycomplaintofmalocclusionandwasdiagnosed

withmalunionof themaxilla.(Fig.5.A)Theabsorbable

Board(CDMDIRB-1325-146).

1. Case 1

A50-year-oldmanwasadmittedtotheemergencyroom

ofthishospitalafterhefellathisworksitefromaheightof

2mandsustainedaninjurytothemaxillofacialarea.Based

on theclinicaland radiologicalexamination results, the

patientwasdiagnosedwithfracturesinbothlateralorbital

wallsandintheleftlowerandinteriororbitalwalls,azygo-

matico-maxillarycomplexfracture,aright temporalbone

fractureandamandibularsymphysisfracture,asshownin

theinitialpicture.(Fig.1)InDepartmentofOtolaryngology,

openreductionwasperformedforinternalfixationusinga

metalplateintheareaoftheleftorbitandatthesiteofthe

mandibularsymphysis; inthissurgicalapproach, thetem-

poralbonewasusedtopreservetherightfacialnerve.Two

monthslater,thepatientvisitedthishospitalwiththeprimary

complaintofmalocclusionandwastransferredtoourde-

partment.Duringexamination,spacingcausedbymalunion

wasfoundbetweenthecentralincisorsonbothsidesofthe

mandibularsymphysisandmalocclusionwasfoundonboth

sides.(Figs.2,3)Revisionsurgerytoadjust theocclusion

wasperformedundergeneralanesthesia.Theexistingmetal

platewasremoved,andachiselwasusedtore-fracturethe

mandibularsymphysissite.Aftertheocclusionwasadjusted

totheoriginalpositionasmuchaspossible,aminiplatewas

usedforthere-fixation,andanarchbarwasusedtoperform

themaxillomandibularfixation.(Fig.4)Afterthesurgerywas

Fig. 1. Three-dimensional computed tomography of the initial examination.Sung-Suk Lee et al: The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 2. Panoramic view two months after surgery in Department of Otolaryngology.Sung-Suk Lee et al: The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases. J Korean Assoc Oral Maxillofac Surg 2014

The treatment of malocclusion after open reduction of maxillofacial fracture

93

onthesubcondyleandparasymphysisbeforeaminiplatewas

usedforfixation.(Fig.7.B)

III. Discussion

Thegoaloftreatmentformandibularfractureisaccurate

reductionofthebonesegmentstorecoverthepre-traumatic

occlusionandtorestorenormalmasticatoryfunction,pro-

nunciation,shapeandsensation7.Itisnecessarytoperform

rigidfixationfortheformationofthecallusbecauseintegra-

tionoccursonlyundermechanicallystableconditions,and

plateswereremovedundergeneralanesthesia,andaLeFort

Iosteotomywasperformedformaxillomandibularfixation

toensureproperocclusionandaminiplatewasusedforre-

fixation.Thepatienthealedwithoutparticulardiscomfortor

complications.(Fig.5.B)

3. Case 3

Thethirdpatientwasa38-year-oldmanwhovisitedthis

hospitalafteratrafficaccident10monthspreviously.The

examinationshowedafractureontheleftparasymphysisand

asubcondylarfracture.(Fig.6)Afterre-fractureofthesub-

condylarandparasymphysissitesundergeneralanesthesia,a

miniplatewasusedforfixationwithablockbonegraft.(Fig.

7.A)Thepatentwaslethargicfromthetrafficaccident,and

itwasthereforedifficult toperformafollow-upexamina-

tion.Thepatientvisitedthehospitalforrevisionsurgerysix

monthslater.Theexaminationresultsdemonstratedmaloc-

clusionattributabletomalunion.Re-fracturewasperformed

Fig. 3. Computed tomography two months after surgery in Department of Otolaryngology.Sung-Suk Lee et al: The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 4. Panoramic view after revision surgery.Sung-Suk Lee et al: The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 5. A. Panoramic view after surgery in Department of Plastic Surgery. B. Panoramic view after revision surgery.Sung-Suk Lee et al: The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases. J Korean Assoc Oral Maxillofac Surg 2014

J Korean Assoc Oral Maxillofac Surg 2014;40:91-95

94

doesnottakeplaceinthat time11.Malunionoccursdueto

inappropriatereduction,agitationofthebonesegment,non-

complianceonthepartofpatientorimproperinternalfixa-

tion12.

Themandibleispronetocomplicationsthatoccurafterjaw

fracturereductionduetothefollowingreasons.Themandible

istheonlyboneinthefacialregionthatmovesandithasless

bonesupportthanthefacialbones;therefore,afractureofthe

mandiblegenerallyresultsingreaterdegreesofinstability.

Becauseofthemuscleattachedtothemandible,mandible

displacementmayoccurevenafterreductionandfixation.

Themandibleislocatedinthelowerpartoftheoralcavity,

whichincreasesthepossibilityofinfection.Themandiblehas

lowerbloodcirculationthanthemaxilla,whichcontributesto

theoccurrenceofinappropriateintegration4.

Physicianmisdiagnosis isanotherfactor thatcancause

complicationsaftermandiblesurgeryandisattributableto

inexperienceorinadequateradiologicalexaminationequip-

ment.Mandibular fracture isaccompaniedbyedemaand

hemorrhage,whichcausedifficultyinprecisediagnosis.The

mechanicalstabilityisalsoindispensabletovascularization

of theprimarycallus.Mechanicalstabilitycausesinternal

growthofthecapillaryprocessandremovesfibrocartilage,

whichleadtoosteonformation.Distortionandstressprevent

suchprocesses8.

Manytechniqueshavebeenstudiedanddevelopedtotreat

mandibularfracture,anditisnecessarytoconsiderpotential

complicationsforall techniques.Alpertetal.9 introduced

fourtypesofcomplicationsthatwereclassifiedasfollows:

1)complicationsthatappearafterpropertreatmentiscon-

ducted;2)complicationsthatareattributabletoinappropriate

treatment;3)complicationsthatareduetofailureofsurgical

treatment;and4)complicationsthatoccurbecausenotreat-

mentisconducted.

MathogandBoies10reportedthatthemostsignificantfac-

torscausingmalunioninmandibularfractureincludedinap-

propriatemovement, incompletereduction, infection,poor

bloodcirculation,andmetabolicchange.Theintegrationof

normalbonetypicallyoccursin4-8weeks,dependingonthe

ageofthepatient,andmalunionoccursifboneintegration

Fig. 6. Computed tomography at the hospital upon initial examination.Sung-Suk Lee et al: The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 7. A. Three-dimensional computed tomography after the first surgery. B. Skull posteroanterior view after the revi-sion surgery.Sung-Suk Lee et al: The treatment of malocclusion after open reduction of maxillofacial fracture: a report of three cases. J Korean Assoc Oral Maxillofac Surg 2014

The treatment of malocclusion after open reduction of maxillofacial fracture

95

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occurrenceofmultiplefracturescouldresultinaphysician

erroneouslyoverlookingsomebonefracturesites4.

Forsurgicalmanagementofsuchcomplications,a thor-

oughandcorrectiveexaminationpriortosurgeryisneces-

sary.Thepre-traumaticocclusionmustbeverified,andan

osteotomytoperforminternalfixationisrequired.Itmightbe

necessarytoperformanewosteotomyonsitesotherthanthe

malunionsitefortherecoveryofocclusion7.

Inthisstudy,malunionaftermandibularreductionledto

malocclusion,andrevisionsurgeryprovidedsatisfactory

results.Aprecisepre-operativeexaminationandappropriate

surgicalprocedurefollowedbyproperpost-operativeman-

agementarenecessarytopreventpost-surgicalcomplications

ofjawfracturefixation.Additionalstudiesarewarrantedto

investigatethesurgicalandnon-surgicalmanagementofsuch

complications.

Conflict of Interest

Nopotentialconictofinterestrelevanttothisarticlewas

reported.