Closed Reduction in Mandibular Fractures

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


Young adult with fracture of angle receiving early treatment in which tooth removed from fractured line:

3 weeks


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.


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.


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


Trimming the bar


Symmetric bar position

Ligature preparation


Attaching the bar

Wire end


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

Health & Medicine

Closed Reduction in Mandibular Fractures