A fractured mandible, from initial operation to removal of tantalum mesh Report
of a case
Steven J. Goldberg, D.D.S.,* Robert P. Porper, D.M.D.,* Paul Chyzus, D.D.S.,” and Joel M. Friedman, D.D.S.,** Bronx, N. Y. ALBERT HOSPITAL
EINSTEIN
COLLRGE
OF
MEDICINE-BRONX
MUNICIPAL
CENTER
Report is made of a case of fracture of the angle of the mandible. Treatment was attempted with the Sampson pericortical bone clamp, but was unsuccessful. Routine use of intraosseous wire led to a localized osteomyelitis, without union of the fracture. Treatment then was made with a particulate marrow graft contained within a tantalum mesh screen. The screen was removed 30 months postoperatively.
T
he treatment of facial fractures has evolved from crude primitive techniques to present-day refinements. However, the basic principles of treatment-reduction and immobilization-espoused by Hippocrates in the fifth century B.C. are still closely adhered to today. In our attempt to return normal mandibular function and appearance to our patient, new techniques and devices have been developed. The use of two of these techniques will be discussed in the following report.
CASE
REPORT
On July 11, 1971, a 2%year-old man was seen in the emergency room following an alleged assault. Neurologic examination demonstrated that he was alert and well oriented, although he had been unconscious for 5 hours before being brought to the hospital. Clinical examination revealed a compound fracture through the left angle of the mandible. The proximal segment was extremely mobile, with the mandibular left second molar maintained within the bone. Radiographs confirmed the fracture of the left angle, with no other part of the facial skeleton involved (Fig. 1). The patient was admitted to the oral surgery
*Former **Director
32
Residents in Oral Surgery. of House Staff Education;
Diplomate,
American
Board
of
Oral
Surgery.
Volume Number
Fractured
41 1
Fig. 1. Preoperative
Fig. 8. Immediate
postoperative
mandible
33
radiograph.
view
of H wiring.
service and studied for open reduction of the fractured mandible. Use of the Sampson* pericortical bone clamp was planned for immobilization and fixation in order to allow the patient to function without intermaxillary fixation for the customary 6 to 8 weeks.
Operation On July 15, 1971, the patient was taken to the operating room, where anesthetic was administered to him through a nasoendotracheal tube. An incision, approximately 5 cm. in length, was made two fingerbreadths below the border of the left angle of the mandible. Dissection was made down to the periosteum, and all large vessels, including the facial artery and vein, were ligated with 3-O chromic sutures. The periosteum and part of the internal pterygoid-masseteric muscle sling were incised and reflected. The fracture site was identified and Kochers were placed on the proximal and distal segments. At this time the operative area was covered with towels, which had been predraped for *Sampson
Corporation,
Pittsburgh,
Pa.
34
Goldberg
Oral January,
et al.
Fig.
3. Dissolution
of bone
at fracture
Surg. 1976
site.
this purpose, and the oral cavity was entered in order to establish the occlusal relationship. Intermaxillary elastics were placed on the preoperatively wired arch bars. The external operative site was then reentered and the fractured segments were approximated. After numerous attempts to apply the pericortieal clamp, we realized that the clamp was not applicable to this segment of the mandible. A horizontal transverse intraosseous wire was used for reduction, with the use of four bur holes, two on the proximal and two on the distal segments. A 25-gauge stainless steel wire was then placed in an l-l shape, approximating and fixing the two segments.1 The operative area was covered and the occlusion was re-established, with the lower left second molar used as a posterior occlusal stop so that the proximal segment would not ride superiorly. The operative site was then irrigated with 1 L. of 50,000 units of bacitracin solution. Closure was obtained with 3-O chromic sutures on periosteum and muscle layers, 4-O plain sutures on subcutaneous tissue and 5-O silk on the skin. The mouth was then reentered for final adjustment of the fixation. The estimated 10s~ of blood was about 200 C.C. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.
Postoperative
course
During his stay in the hospital the patient was maintained on ampicillin, 500 mg. every 6 hours. The postoperative course was uncomplicated and he was discharged to his home on July 20. On July 29, when the patient was examined in the outpatient clinic, the clinical and radiographic findings revealed a normally healing operative site with good reduction and fixation (Fig. 2). On August 23, approximately 7 weeks postoperatively, the intermaxillary wires were removed, and the patient was scheduled to return to the clinic one week later for removal of the arch bars. When he returned, he was complaining of tenderness in the area of the fracture site. Examination revealed a seropurulent drainage intraorally from the mesial aspect of the second molar on the left side. Radiographic examination revealed dissolution around the intraosseous wires and the apex of the mandibular left second molar (Fig. 3). Under local anesthesia, a buccal flap was reflected in order to expose the superior aspect of the fracture site. The second molar was extracted along with a bony sequestrum. A quarter-inch Penrose drain and an acrylic stent were placed as a posterior stop, and inter-maxillary fixation was obtained. The patient was placed on clindamyoin, 300 mg. orally every 6 hours, and local irrigations. During the next 3 weeks, the bone around the wire continued to dissolve. The patient was maintained on this conservative regimen of antibiotics and local irrigation until the osteomyellitis was brought under control. On October 25, one
Volume Number
Fig.
month hospital
Fractured
41 1
4. Three
after for
months
after
insertion
of mesh. Note
the osteomyelitis was brought under treatment of nonunion of the fracture.
control,
that
some bone
the
patient
filling
was
mandible
35
is evident.
readmitted
to the
Operation On October 28, the patient, under general anesthesia, was prepared and draped for operation. The scar from the previous operation was excised and the incision was carried through the underlying fibrous tissue, with dissection down to bone. The fracture site was visualized. The bony sequestra, the previously inserted wire, and the granulation tissue were removed. The proximal and distal bony margins were then freshened with rongeur forceps in order to produce a vital surface. Next, the tantalum mesh implant was inserted over the host fragments and was adapted to conform closely to the bony contour. The moistened Millipore filter was then placed within the crib as a lining, and this prepared crib was filled with autogenous bone marrow and cancellous bone that had been obtained from the right iliac crest by a second surgical team. With the fragments held in position, bur holes were placed through the crib into the bony segments. By means of two screws in each segment the tantalum mesh bridge was fixed to the mandible, producing one solid mandible. The occlusion was checked and intermaxillary fixation was obtained. The incision was then closed in layers. Estimated loss of blood was 500 C.C. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.
Postoperative
course
The patient had an uneventful postoperative course except for a slight serosanguineous exudate from the incision site, which subsided after one week. He was maintained on clindamyein every 6 hours until discharge from the hospital one week later. Six months after the graft was placed there was radiographic evidence of bony bridging across the graft site (Fig. 4). The patient was then lost to follow-up for about 6 months before returning to the emergency room with a fracture of the contralateral mandibular angle. This fracture was treated successfully with intermaxillary fixation. The side of the bone graft demonstrated good bony filling except for a thin radiolucent line through the center. The patient was again lost to follow-up for 2 years, at the end of which time he returned to the clinic complaining of tenderness in the region of the mandible overlying the anterior screws. Examination disclosed no movement across the graft site. Radiographs revealed good bony filling up to a thin radiolucent line through the middle of the graft site (Fig. 5). The decision was made to remove the tantalum mesh, and provisions were made for an-
36
Goldberg et (11.
Fig. through
5. Three years middle of graft.
after
insertion
of mesh.
Good
bone
filling
except
for
radiolucent
line
The patient was taken to the operating room on other graft in the event of a nonunion. removal of the mesh was completed. The May 20, 1974, where, under general anesthesia, previous scar was excised and the incision was carried down to the tantalum mesh. With great difficulty, a thick, fibrous capsule was raised from the mesh. One proximal and one distal screw were found to be fractured when removal of them was attempted. The two other screws were removed and the mesh had to be forcibly pried away from the mandible. In the antegonial notch area a wedge of thick, fibrous tissue underlying the mesh was removed and sent for microscopic examination. The radiolueent line seen on the radiographs could not be found, and at no point along the graft site could a needle be passed into or through the mandible. There was no movement across the graft site after removal of the mesh. The site was irrigated and closed in three layers. The patient was placed on a postoperative regimen of clindamycin, 300 mg. every 6 hours for one meek. Recovery was uneventful. At the 3-month postoperative visit there were no complaints and no radiographic changes in the mandible (Fig. 6).
DISCUSSION
In spite of many technical refinements in the treatment of mandibular fractures, problems in therapy still have to be faced. In our case, a noncarious tooth was present in the line of fracture in the proximal segment and x-rays showed it to be an unfavorable fracture. The Sampson pericortical bone clamp was chosen for use in this case since it would allow the patient free movement of the mandible during the period of healing. It became apparent to US at the time of operation, but not before, that this clamp could not be used in this region of the mandible. The clamp works very much like a vise, consisting of two metal plates with a number of metal teeth on each face. The mandible is clamped between the metal plates as the clamp is tightened and the teeth engage the cortical plates. The inferior border of the mandible at the antegonial notch changes in thickness from approximately 7 to 10 mm. anteriorly to 3 to 4 mm. at the angle. Therefore, the sandwiching effect of the clamp cannot be accomplished in this region. The clamp cannot engage both the narrow and the wide
Volume 41 Number 1
Fig. 6. After removal of mesh. Fractured
Fractured
mandible
37
ends of screws are seen in mandible.
regions of the inferior border at the same time. The time spent trying to adapt the clamp to this area and the concomitant trauma may well have predisposed the area to infection. Others may argue that the nonunion of the fracture had its origin with the tooth in the line of fracture, which should have been removed in the initial operation, The tantalum mesh bone marrow graft pioneered by Boyne3 was chosen for reconstruction of the resultant defect. Boyne’s findings, which have been well supported by successive authors,4 are that this type of graft can be easily obtained with less morbidity than with the use of a piece of iliac crest or rib. In addition, bone marrow has a far greater osteogenic potential than cortical bone by itself. Cortical bone grafts must undergo resorption and redeposition of mineral, whereas the cells of the bone marrow directly lay down bone matrix which then mineralizes. The rigidity of the tantalum mesh is an additional advantage over cortical bone grafts which require rigid intermaxillary fixation for 6 to 12 weeks. We have found that use of the mesh is disadvantageous in cases of reconstruction subsequent to resection for ameloblastoma, since the mesh may mask recurrence of tumor in the underlying bone. Although this graft material has been used extensively in recent years, there are few reports in the literature dealing with removal of the mesh. Where there are prosthetic considerations, removal of the mesh may be necessary. In our case the patient developed an inflammatory reaction around one of the screws, which was found to be fractured on removal. This occurred 30 months postoperatively and did not affect the healing of the bone. The removal of the mesh at the time, however, did present a technical problem, since it was quite firmly locked to the underlying bone. Because the interpretation of the preoperative radiographs led us to believe that a nonunion was present, the surgical team was prepared to perform another graft. But when the graft was reached, a good, solid bony union was noted.
38
Goldberg
Oral .l:lnu:~ry,
et al.
surg. 1976
SUMMARY The high level of sophistication and technology which has been reached in the treatment of mandibular fractures still leaves questions to be answered. A case has been presented in which the Sampson pericortical clamp was unsuccessfully employed as the means of fixation of an angle fracture. Wire ligature was then used and led to osteomyelitis and nonunion of the fracture. This was treated by bone marrow graft, with removal of the metal mesh 30 months postoperatively. REFERENCES
1. Bruns, R.., and Boering, G.: Fractures of the Mandibular Body Treated by Stable Internal Fixation, J. Oral Surg. 28: 407, 1970. of Osteogenesis in the Dog 2. Richter, II. E., Sugg, W. F., and Boyne, P. J.: Stimulation Mandible by Autogenous Bone Marrow Transplants, ORAL SURG. 26: 396, 1968. 3. Boyne, P. J.: Transplantation, Implantation and Grafts, Dent. Clin. North Am. 15: 433, 1971. 4. Marble H. B., et al.: Grafts of Cancellous Bone and Marrow for Restoration of Avulsion Defects of Mandible: Report of Two Cases, J. Oral Surg. 28: 138, 1970. Reprint requests to: Dr. Joel M. Friedman Bronx Municipal Hospital Center Pelham Parkway and Eastchester Bronx, N. Y. 10461
Road
of a case
Steven J. Goldberg, D.D.S.,* Robert P. Porper, D.M.D.,* Paul Chyzus, D.D.S.,” and Joel M. Friedman, D.D.S.,** Bronx, N. Y. ALBERT HOSPITAL
EINSTEIN
COLLRGE
OF
MEDICINE-BRONX
MUNICIPAL
CENTER
Report is made of a case of fracture of the angle of the mandible. Treatment was attempted with the Sampson pericortical bone clamp, but was unsuccessful. Routine use of intraosseous wire led to a localized osteomyelitis, without union of the fracture. Treatment then was made with a particulate marrow graft contained within a tantalum mesh screen. The screen was removed 30 months postoperatively.
T
he treatment of facial fractures has evolved from crude primitive techniques to present-day refinements. However, the basic principles of treatment-reduction and immobilization-espoused by Hippocrates in the fifth century B.C. are still closely adhered to today. In our attempt to return normal mandibular function and appearance to our patient, new techniques and devices have been developed. The use of two of these techniques will be discussed in the following report.
CASE
REPORT
On July 11, 1971, a 2%year-old man was seen in the emergency room following an alleged assault. Neurologic examination demonstrated that he was alert and well oriented, although he had been unconscious for 5 hours before being brought to the hospital. Clinical examination revealed a compound fracture through the left angle of the mandible. The proximal segment was extremely mobile, with the mandibular left second molar maintained within the bone. Radiographs confirmed the fracture of the left angle, with no other part of the facial skeleton involved (Fig. 1). The patient was admitted to the oral surgery
*Former **Director
32
Residents in Oral Surgery. of House Staff Education;
Diplomate,
American
Board
of
Oral
Surgery.
Volume Number
Fractured
41 1
Fig. 1. Preoperative
Fig. 8. Immediate
postoperative
mandible
33
radiograph.
view
of H wiring.
service and studied for open reduction of the fractured mandible. Use of the Sampson* pericortical bone clamp was planned for immobilization and fixation in order to allow the patient to function without intermaxillary fixation for the customary 6 to 8 weeks.
Operation On July 15, 1971, the patient was taken to the operating room, where anesthetic was administered to him through a nasoendotracheal tube. An incision, approximately 5 cm. in length, was made two fingerbreadths below the border of the left angle of the mandible. Dissection was made down to the periosteum, and all large vessels, including the facial artery and vein, were ligated with 3-O chromic sutures. The periosteum and part of the internal pterygoid-masseteric muscle sling were incised and reflected. The fracture site was identified and Kochers were placed on the proximal and distal segments. At this time the operative area was covered with towels, which had been predraped for *Sampson
Corporation,
Pittsburgh,
Pa.
34
Goldberg
Oral January,
et al.
Fig.
3. Dissolution
of bone
at fracture
Surg. 1976
site.
this purpose, and the oral cavity was entered in order to establish the occlusal relationship. Intermaxillary elastics were placed on the preoperatively wired arch bars. The external operative site was then reentered and the fractured segments were approximated. After numerous attempts to apply the pericortieal clamp, we realized that the clamp was not applicable to this segment of the mandible. A horizontal transverse intraosseous wire was used for reduction, with the use of four bur holes, two on the proximal and two on the distal segments. A 25-gauge stainless steel wire was then placed in an l-l shape, approximating and fixing the two segments.1 The operative area was covered and the occlusion was re-established, with the lower left second molar used as a posterior occlusal stop so that the proximal segment would not ride superiorly. The operative site was then irrigated with 1 L. of 50,000 units of bacitracin solution. Closure was obtained with 3-O chromic sutures on periosteum and muscle layers, 4-O plain sutures on subcutaneous tissue and 5-O silk on the skin. The mouth was then reentered for final adjustment of the fixation. The estimated 10s~ of blood was about 200 C.C. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.
Postoperative
course
During his stay in the hospital the patient was maintained on ampicillin, 500 mg. every 6 hours. The postoperative course was uncomplicated and he was discharged to his home on July 20. On July 29, when the patient was examined in the outpatient clinic, the clinical and radiographic findings revealed a normally healing operative site with good reduction and fixation (Fig. 2). On August 23, approximately 7 weeks postoperatively, the intermaxillary wires were removed, and the patient was scheduled to return to the clinic one week later for removal of the arch bars. When he returned, he was complaining of tenderness in the area of the fracture site. Examination revealed a seropurulent drainage intraorally from the mesial aspect of the second molar on the left side. Radiographic examination revealed dissolution around the intraosseous wires and the apex of the mandibular left second molar (Fig. 3). Under local anesthesia, a buccal flap was reflected in order to expose the superior aspect of the fracture site. The second molar was extracted along with a bony sequestrum. A quarter-inch Penrose drain and an acrylic stent were placed as a posterior stop, and inter-maxillary fixation was obtained. The patient was placed on clindamyoin, 300 mg. orally every 6 hours, and local irrigations. During the next 3 weeks, the bone around the wire continued to dissolve. The patient was maintained on this conservative regimen of antibiotics and local irrigation until the osteomyellitis was brought under control. On October 25, one
Volume Number
Fig.
month hospital
Fractured
41 1
4. Three
after for
months
after
insertion
of mesh. Note
the osteomyelitis was brought under treatment of nonunion of the fracture.
control,
that
some bone
the
patient
filling
was
mandible
35
is evident.
readmitted
to the
Operation On October 28, the patient, under general anesthesia, was prepared and draped for operation. The scar from the previous operation was excised and the incision was carried through the underlying fibrous tissue, with dissection down to bone. The fracture site was visualized. The bony sequestra, the previously inserted wire, and the granulation tissue were removed. The proximal and distal bony margins were then freshened with rongeur forceps in order to produce a vital surface. Next, the tantalum mesh implant was inserted over the host fragments and was adapted to conform closely to the bony contour. The moistened Millipore filter was then placed within the crib as a lining, and this prepared crib was filled with autogenous bone marrow and cancellous bone that had been obtained from the right iliac crest by a second surgical team. With the fragments held in position, bur holes were placed through the crib into the bony segments. By means of two screws in each segment the tantalum mesh bridge was fixed to the mandible, producing one solid mandible. The occlusion was checked and intermaxillary fixation was obtained. The incision was then closed in layers. Estimated loss of blood was 500 C.C. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.
Postoperative
course
The patient had an uneventful postoperative course except for a slight serosanguineous exudate from the incision site, which subsided after one week. He was maintained on clindamyein every 6 hours until discharge from the hospital one week later. Six months after the graft was placed there was radiographic evidence of bony bridging across the graft site (Fig. 4). The patient was then lost to follow-up for about 6 months before returning to the emergency room with a fracture of the contralateral mandibular angle. This fracture was treated successfully with intermaxillary fixation. The side of the bone graft demonstrated good bony filling except for a thin radiolucent line through the center. The patient was again lost to follow-up for 2 years, at the end of which time he returned to the clinic complaining of tenderness in the region of the mandible overlying the anterior screws. Examination disclosed no movement across the graft site. Radiographs revealed good bony filling up to a thin radiolucent line through the middle of the graft site (Fig. 5). The decision was made to remove the tantalum mesh, and provisions were made for an-
36
Goldberg et (11.
Fig. through
5. Three years middle of graft.
after
insertion
of mesh.
Good
bone
filling
except
for
radiolucent
line
The patient was taken to the operating room on other graft in the event of a nonunion. removal of the mesh was completed. The May 20, 1974, where, under general anesthesia, previous scar was excised and the incision was carried down to the tantalum mesh. With great difficulty, a thick, fibrous capsule was raised from the mesh. One proximal and one distal screw were found to be fractured when removal of them was attempted. The two other screws were removed and the mesh had to be forcibly pried away from the mandible. In the antegonial notch area a wedge of thick, fibrous tissue underlying the mesh was removed and sent for microscopic examination. The radiolueent line seen on the radiographs could not be found, and at no point along the graft site could a needle be passed into or through the mandible. There was no movement across the graft site after removal of the mesh. The site was irrigated and closed in three layers. The patient was placed on a postoperative regimen of clindamycin, 300 mg. every 6 hours for one meek. Recovery was uneventful. At the 3-month postoperative visit there were no complaints and no radiographic changes in the mandible (Fig. 6).
DISCUSSION
In spite of many technical refinements in the treatment of mandibular fractures, problems in therapy still have to be faced. In our case, a noncarious tooth was present in the line of fracture in the proximal segment and x-rays showed it to be an unfavorable fracture. The Sampson pericortical bone clamp was chosen for use in this case since it would allow the patient free movement of the mandible during the period of healing. It became apparent to US at the time of operation, but not before, that this clamp could not be used in this region of the mandible. The clamp works very much like a vise, consisting of two metal plates with a number of metal teeth on each face. The mandible is clamped between the metal plates as the clamp is tightened and the teeth engage the cortical plates. The inferior border of the mandible at the antegonial notch changes in thickness from approximately 7 to 10 mm. anteriorly to 3 to 4 mm. at the angle. Therefore, the sandwiching effect of the clamp cannot be accomplished in this region. The clamp cannot engage both the narrow and the wide
Volume 41 Number 1
Fig. 6. After removal of mesh. Fractured
Fractured
mandible
37
ends of screws are seen in mandible.
regions of the inferior border at the same time. The time spent trying to adapt the clamp to this area and the concomitant trauma may well have predisposed the area to infection. Others may argue that the nonunion of the fracture had its origin with the tooth in the line of fracture, which should have been removed in the initial operation, The tantalum mesh bone marrow graft pioneered by Boyne3 was chosen for reconstruction of the resultant defect. Boyne’s findings, which have been well supported by successive authors,4 are that this type of graft can be easily obtained with less morbidity than with the use of a piece of iliac crest or rib. In addition, bone marrow has a far greater osteogenic potential than cortical bone by itself. Cortical bone grafts must undergo resorption and redeposition of mineral, whereas the cells of the bone marrow directly lay down bone matrix which then mineralizes. The rigidity of the tantalum mesh is an additional advantage over cortical bone grafts which require rigid intermaxillary fixation for 6 to 12 weeks. We have found that use of the mesh is disadvantageous in cases of reconstruction subsequent to resection for ameloblastoma, since the mesh may mask recurrence of tumor in the underlying bone. Although this graft material has been used extensively in recent years, there are few reports in the literature dealing with removal of the mesh. Where there are prosthetic considerations, removal of the mesh may be necessary. In our case the patient developed an inflammatory reaction around one of the screws, which was found to be fractured on removal. This occurred 30 months postoperatively and did not affect the healing of the bone. The removal of the mesh at the time, however, did present a technical problem, since it was quite firmly locked to the underlying bone. Because the interpretation of the preoperative radiographs led us to believe that a nonunion was present, the surgical team was prepared to perform another graft. But when the graft was reached, a good, solid bony union was noted.
38
Goldberg
Oral .l:lnu:~ry,
et al.
surg. 1976
SUMMARY The high level of sophistication and technology which has been reached in the treatment of mandibular fractures still leaves questions to be answered. A case has been presented in which the Sampson pericortical clamp was unsuccessfully employed as the means of fixation of an angle fracture. Wire ligature was then used and led to osteomyelitis and nonunion of the fracture. This was treated by bone marrow graft, with removal of the metal mesh 30 months postoperatively. REFERENCES
1. Bruns, R.., and Boering, G.: Fractures of the Mandibular Body Treated by Stable Internal Fixation, J. Oral Surg. 28: 407, 1970. of Osteogenesis in the Dog 2. Richter, II. E., Sugg, W. F., and Boyne, P. J.: Stimulation Mandible by Autogenous Bone Marrow Transplants, ORAL SURG. 26: 396, 1968. 3. Boyne, P. J.: Transplantation, Implantation and Grafts, Dent. Clin. North Am. 15: 433, 1971. 4. Marble H. B., et al.: Grafts of Cancellous Bone and Marrow for Restoration of Avulsion Defects of Mandible: Report of Two Cases, J. Oral Surg. 28: 138, 1970. Reprint requests to: Dr. Joel M. Friedman Bronx Municipal Hospital Center Pelham Parkway and Eastchester Bronx, N. Y. 10461
Road
