ORIGINAL ARTICLE
Interrami Intraoral Fixation Technique Utilized as a Conservative Approach to Edentulous/Atrophic Mandibular Fractures Sabri T. Shuker, MMSc, FDSRCS(UK) Abstract: Interrami intraoral Kirschner wire fixation (IRIF) technique is presented as new conservative successful indirect rigid fixation utilized for the reduction and fixation of edentulous/ atrophic mandible fractures. This technique is carried out under local anesthesia without the need for open reduction internal fixation, which can lead to a compromise in the blood supply of fracture region. It is also quicker, easier, requires fewer postoperative visits, and cheaper than small or large bone plate fixations. Five edentulous mandibular fractures, 2 of them atrophic, 2 nonatrophic, and 1 partial edentulous, were successfully treated. In all cases, the IRIF technique was utilized to establish an indirect rigid fixation using horseshoe-shaped Kirschner wire with a 2-mm diameter. No complication was reported during these cases. This technique prevails over the Gunning splint and external edentulous fracture fixation techniques as it provides adequate fracture site stability, is more comfortable, and is better tolerated for a longer period of time by the patient. In addition, there are fewer complications caused by malunions from direct intraoral or extraoral small and large plate fixation techniques. Other advantages of the IRIF technique are that it enables the mandible to function as a single unit and preserves its function and anatomical position immediately after surgery. In contrast, the Gunning splint acts only to preserve the balance of a single segment’s position. Key Words: Management of atrophic mandible fractures, indirect rigid fixation for edentulous mandible fractures, interrami intraoral fixation lower jaw fixation technique, geriatric fracture mandible treatment, edentulous atrophic mandible fractures, IRIF versus Gunning splint (J Craniofac Surg 2015;26: 677–679)
T
he loss of teeth decreases function of mastication on alveolar region, which leads in older patients to a subsequent loss of bone mass and strength. This loss of bone mass and diminished vascularity decreases the strength of the mandible making it more vulnerable to fracture during a traumatic event.1,2 Bradley3 hypothesized that the subperiosteal plexus is probably the major supply (to the mandible), and elevation of the periosteum From West Bloomfield, MI. Received July 26, 2014. Accepted for publication December 23, 2014. Address correspondence and reprint requests to Sabri T. Shuker, MMSc, FDSRCS(UK) Retired, West Bloomfield, MI; E-mail: sabrishuker@ yahoo.com The author reports no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001532
The Journal of Craniofacial Surgery
in the course of an operation may seriously impair the vascular supply to the bone resulting in nonunion of fractures treated by open reduction and direct osseous fixation. Adequate circulation is important for fracture healing, and thus an open reduction of a fracture may further compromise the already diminished vascularity to the mandible as a result of periosteal stripping.4,5 Controversy exists regarding the treatment of these mandibular fractures. One group believes that these fractures should be opened and fixed while the other believes that these fractures can be successfully treated with a closed reduction technique. Bone atrophy and advanced age favor conservative treatments due to the higher incidence of complications associated with open reduction surgery in geriatric patients. Conservative options would include the use of Gunning splints, existing dentures to stabilize the fracture, external fixation appliances, or even no treatment at all.6 In 1862, Thomas Brian Gunning was the first to use vulcanite in a custom-fitted splint to immobilize a fracture if the fracture was difficult to reduce, then a single vulcanite splint for both the jaws was used to provide intermaxillary fixation.7 Gunning-type splints are a superb fixation device and relatively quick and easy to apply for edentulous patients8 (Fig. 1). Skeletal pin fixation, advocated by Marciani,9,10 has also been used with some success in the atrophic mandibular fracture. Aside from the ungainly nature of the appliances, good results with these techniques are often easier to conceptualize than to achieve. Miniplates have been used widely; however, alternatives should be considered because the method of fixation can be a critical factor in influencing the clinical outcome of patients. Some authors believe that miniplate fixation for atrophic mandible fractures is insufficient and have recommended using a reconstruction plate instead.11,12 Although a large reconstruction plate has stronger mechanical strength compared to a smaller plate, it requires wider stripping of the periosteum for proper positioning and also decreases periosteal contact with bone after placement.13 In addition, large bicortical screws may violate the inferior alveolar nerve or be an instrument of further jaw fracture; therefore, other surgeons prefer miniplate osteosynthesis.13,14 Shuker15,16 was the first to use IRIF technique utilized and adapted as a horseshoe-shaped 2-mm K-wire to treat ballistic avulsion, severe lower jaw rifle fragmented bullet injury’s management, and comminuted mandibular fractures. In this paper, IRIF technique was successfully utilized as a conservative method to provide intraoral indirect rigid fixation for 5 geriatric edentulous patients with mandibular fractures. The biomechanics of load-sharing capacity of stress forces is along the Kwire with mandibular segments that acts as one unit, while traverse compression from functional resistance forces into the rami.
MATERIAL AND CONSERVATIVE PROCEDURE Five cases of elderly edentulous mandibular fractures are presented: 4 unilateral body fractures and 1 bilateral body/angle fracture. Of
Volume 26, Number 3, May 2015
677
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Shuker
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
FIGURE 1. Acrylic Gunning splint that has been used for over 150 years. FIGURE 3. Sketch presents large plating technique versus interrami intraoral fixation IRIF technique utilized for edentulous/atrophic mandibular fracture.
these cases, 2 are atrophic, 2 non-atrophic, and 1 partially edentulous mandible with edentulous upper jaw. Under local anesthesia, mucosal stab incisions in the middle of the retromolar fosse were made after the area to be stabbed palpated by the surgeon’s finger. Two holes, one on each side, are drilled through cortical bone at the level of the normal alveolar ridge using a no. 6 round bur. The anterior edge of the resorbed alveolar ridge is used as a guide to adapt a horseshoe-shaped K-wire 2 mm in diameter. In the case of an atrophic ridge, the K-wire was adapted to the posterior bend at the retromolar trigone region and directed towards the retromolar fossa followed by a final bend directed into the ramus. The bend at the trigone region was carried out because of the severe atrophy near the alveolar ridge, thus avoiding alveolar nerve injury during the final K-wire insertion approximately 1 cm inside the holes of the ramus. The 2 ends of the K-wire were wider posteriorly which provided a springing action against the lateral portion of the rami that acts against medial superior ramus segment by muscles of mastication pull. The ends of the wire were anchored by the lateral cortex of the rami. Proper positioning of the K-wire into its final position may require gentle tapping of a hammer on the K-wire anterior curvature (Figs. 2, 3). The mandibular segments are immobilized by 2 to 3 circumferential 0.5-mm stainless steel wires suspended from the K-wire. While loading the body of the mandible on the K-wire, fractured segments are manually molded into position under gentile palpation medial and lateral sulcus to the mandible lower border. Once the fractured mandible segments are loaded into their proper position, the stress forces are distributed across the entire length of the Kwire. The full arc acts as a fulcrum allowing the entire mandible to function as a single fixed unit (Figs. 4, 5).
FIGURE 2. Sketch showing techniques of mandibular fracture external/plating fixation versus interrami intraoral fixation IRIF technique.
678
DISCUSSION Conservative management of edentulous fractures utilizing the Gunning splint has historically proven to be a successful technique for the last 150 years. There are various reasons why such conservative methods of treatment were used in the past and why they still are viable, and perhaps advantageous, options in this age group. One factor is that with the decreased vascularity or blood flow to the mandible and the fracture site in these cases, an open reduction has the potential to further compromise the blood supply to the bone and soft tissue of the mandible.3,5,11 Despite these statements, we are currently in the era of modern plating techniques which produce a long list of small and large plates of varied types, shapes, and screw fixations. Treatment of edentulous mandible fractures with plates beneath the periosteum, above the periosteum, and even atop the mucosal surfaces have all been described.11,17 Some authors prefer an extraoral approach avoiding complete periosteal stripping of the mandible.13 Although all complications were associated with an intraoral approach, this approach is still preferred because it avoids the creation of extraoral scars and reduces the risk of injury of the facial nerve. Furthermore, this approach offers in high-risk patients the possibility of treatment of these fractures under local anesthesia.18 Clayman and Rossi19 found that miniplate fixation of fractures at the inferior border of severely atrophic mandibles are not only safe but adequately provides rigid fixation as well. Tiwana et al20 reported a single ‘‘ear-to-ear’’ plate was used; the distal screws in the symphysis region serve to both aid in fracture healing as well as improve functionality for the patient. The plates can be positioned at either the lateral aspect of the mandible or at the inferior border with good success.21
FIGURE 4. Photograph showing K-wire IRIF technique used as conservative indirect rigid fixation for partial edentulous mandible and total edentulous upper jaw.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
IRIF Technique of Atrophic Mandibular Fracture
REFERENCES
FIGURE 5. Photograph showing K-wire IRIF technique used as conservative indirect rigid fixation for edentulous/atrophic mandibular fracture.
To avoid damage to the subperiosteal plexus which is probably the major blood supply to the bone, a supraperiosteal dissection has been suggested and a supraperiosteal placement of plates and screws was recommended.11 The effect of this technique was questioned by Bruce and Ellis.22 The investigators stated that ‘‘a properly contoured bone plate would inhibit the blood supply to the underlying periosteum as much as if the periosteum were stripped from the bone.’’ An incidence of 20% nonunion has been reported by Bruce and Strachar23 in a large series with a wide diversity of treatment modalities. Shuker’s IRIF technique has the potential to successfully replace external fixation as well as small and large plate direct fixation techniques for edentulous/atrophic mandible management.15,16 Five edentulous mandible fractures, 4 of them unilateral body fractures and 1 bilateral fracture, were treated using IRIF technique. The edentulous alveolar ridge morphology was used to fashion a 2mm K-wire which ultimately led to successful patient healing. No single complication was reported in these cases regarding healings, alignment, and discomfort. The biomechanics according to Meyer et al24 and Champy and co-workers described a zone of tension in the alveolar part of the mandible and a zone of compression on the lower border.25 This information allowed for the identification and placement of ideal lines for mandibular plating and internal fixation along the lines of physiological tension. It also shows that the IRIF technique is placed along Champy’s zone on the mandibular alveolar ridge. Altogether, the load-sharing capacity of stress and functional forces is transported along the K-wire while compression resistance forces into the rami. Consequently, IRIF technique replaces the small and large plate fixation techniques utilized on the lateral or lower border of the mandible and uncomfortable Gunning splint. It is also quicker, easier, cheaper, less technically demanding, can be performed under local anesthesia, and does not carry the risk of blood vessel impairment or tissue morbidity or healing complications. In addition, it provides immediate preservation of functions of the mandible which acts to enhance osteogenesis and healing. Moreover, as a final step, K-wire removal is easily performed after pulling out the circumferential wires with or without a small amount of local anesthesia.
ACKNOWLEDGMENTS The author thanks Christopher Kassab for his assistance and the staff of West Bloomfield Library, West Bloomfield, MI, for their help.
#
2015 Mutaz B. Habal, MD
1. Friedman CD, Constantino PD. Facial fractures and bone healing in the geriatric patient. Otolaryngol Clin North Am 1996;25:1109 2. Ellis E, Moos KF, El-Attar A. Ten years of mandibular fractures: An analysis of 2,137 cases. Oral Surg 1985;59:120 3. Bradley JC. A radiological investigation into the age changes of the inferior dental artery. Br J Oral Surg 1975;13:82 4. Scott RF. Oral and maxillofacial trauma in the geriatric patient. In: Fonseca RJ, Walker RV, Betts NJ, eds. Oral and Maxillofacial Trauma, Vol 2. et al, eds. Oral and Maxillofacial Trauma, Vol 2. Philadelphia, PA: Saunders; 1997:1045–1072 5. Buchbinder D. Treatment of fractures of the edentulous mandible, 1943 to 1993: A review of the literature. J Oral Maxillofac Surg 1993;51:1174 6. Barber HD. Conservative Management of the Fractured Atrophic Edentulous Mandible. J Oral Maxillofac Surg 2001;59:789–791 7. Fonseca RJ. Oral and Maxillofacial Surgery. Philadelphia: Saunders; 2000:463–482 8. Fonseca RJ. Oral and Maxillofacial Surgery. Philadelphia: Saunders, 1997; 2nd edition Vol 1:474–478 9. Marciani RD, Hill OJ. Treatment of the fractured edentulous mandible. J Oral Surg 1979;37:569 10. Marciani RD. Invasive management of the fractured atrophic edentulous mandible. J Oral Maxillofac Surg 2001;59:792 11. Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression plating. J Oral Maxillofac Surg 1996;54:250 12. Sikes JW, Smith BR, Mukherjee DP. An in vitro study of the effect of bony buttressing on fixation strength of a fractured atrophic edentulous mandible model. J Oral Maxillofac Surg 2000;58:56 13. Iizuka T, Lindqvist C. Sensory disturbances associated with rigid internal fixation of mandibular fractures. J Oral Maxillofac Surg 1991;49:1264 14. Choi BH, Huh JY, Suh CH, et al. An in vitro evaluation of miniplate fixation techniques for fractures of the atrophic edentulous mandible. Int J Oral Maxillofac Surg 2005;34:174 15. Shuker S. Inter-rami intraoral fixation of severely comminuted mandibular war injuries. J Maxillofac Surg 1985;13:282–286 16. Shuker ST. Interrami intraoral fixation technique for severe mandibular rifle fragmented bullet injury management. J Craniofac Surg 2013;24:1168–1174 17. Iatrou I, Samaras C, Theologie-Lygidakis N. Miniplate osteosynthesis for fractures of the edentulous mandible: A clinical study 1989–96. J Craniomaxillofac Surg 1998;26:400 18. Wittwer G, Adeyemo WL, Turbani D, et al. Treatment of atrophic mandibular fractures based on the degree of atrophy—experience with different plating systems: a retrospective study. J Oral Maxillofac Surg 2006;64:230 19. Clayman L, Rossi E. Fixation of atrophic edentulous mandible fractures by bone plating at the inferior border. J Oral Maxillofac Surg 2012;70:883–889 20. Tiwana PS, Abraham MS, Kushner GM, et al. Management of atrophic edentulous mandibular fractures: the case for primary reconstruction with immediate bone grafting. J Oral Maxillofac Surg 2009;67:882 21. Van Sickels JE, Cunningham LL. Management of atrophic mandible fractures: are bone grafts necessary? J Oral Maxillofac Surg 2010;68:1392–1395 22. Bruce RA, Ellis E. The second Chalmers J. Academy Study of fractures of the edentulous mandible. J Maxillofac Surg 1993;51:904 23. Bruce RA, Strachan DS. Fractures of the edentulous mandible: 6. Xie Q, Ainamo A: Association of edentulousness with systemic factors in elderly people living at home. Community Dent Oral Epidemiol 1999;27:202 24. Meyer C, Serhir L, Boutemi P. Experimental evaluation of three osteosynthesis devices used for stabilizing condylar fractures of the mandible. J Craniomaxillofac Surg 2006;34:173–181 25. Wong RCW, Tideman H, Kin L, et al. Biomechanics of mandibular reconstruction: a review. Int J Oral Maxillofac Surg 2010;39:313–319
679
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Interrami Intraoral Fixation Technique Utilized as a Conservative Approach to Edentulous/Atrophic Mandibular Fractures Sabri T. Shuker, MMSc, FDSRCS(UK) Abstract: Interrami intraoral Kirschner wire fixation (IRIF) technique is presented as new conservative successful indirect rigid fixation utilized for the reduction and fixation of edentulous/ atrophic mandible fractures. This technique is carried out under local anesthesia without the need for open reduction internal fixation, which can lead to a compromise in the blood supply of fracture region. It is also quicker, easier, requires fewer postoperative visits, and cheaper than small or large bone plate fixations. Five edentulous mandibular fractures, 2 of them atrophic, 2 nonatrophic, and 1 partial edentulous, were successfully treated. In all cases, the IRIF technique was utilized to establish an indirect rigid fixation using horseshoe-shaped Kirschner wire with a 2-mm diameter. No complication was reported during these cases. This technique prevails over the Gunning splint and external edentulous fracture fixation techniques as it provides adequate fracture site stability, is more comfortable, and is better tolerated for a longer period of time by the patient. In addition, there are fewer complications caused by malunions from direct intraoral or extraoral small and large plate fixation techniques. Other advantages of the IRIF technique are that it enables the mandible to function as a single unit and preserves its function and anatomical position immediately after surgery. In contrast, the Gunning splint acts only to preserve the balance of a single segment’s position. Key Words: Management of atrophic mandible fractures, indirect rigid fixation for edentulous mandible fractures, interrami intraoral fixation lower jaw fixation technique, geriatric fracture mandible treatment, edentulous atrophic mandible fractures, IRIF versus Gunning splint (J Craniofac Surg 2015;26: 677–679)
T
he loss of teeth decreases function of mastication on alveolar region, which leads in older patients to a subsequent loss of bone mass and strength. This loss of bone mass and diminished vascularity decreases the strength of the mandible making it more vulnerable to fracture during a traumatic event.1,2 Bradley3 hypothesized that the subperiosteal plexus is probably the major supply (to the mandible), and elevation of the periosteum From West Bloomfield, MI. Received July 26, 2014. Accepted for publication December 23, 2014. Address correspondence and reprint requests to Sabri T. Shuker, MMSc, FDSRCS(UK) Retired, West Bloomfield, MI; E-mail: sabrishuker@ yahoo.com The author reports no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001532
The Journal of Craniofacial Surgery
in the course of an operation may seriously impair the vascular supply to the bone resulting in nonunion of fractures treated by open reduction and direct osseous fixation. Adequate circulation is important for fracture healing, and thus an open reduction of a fracture may further compromise the already diminished vascularity to the mandible as a result of periosteal stripping.4,5 Controversy exists regarding the treatment of these mandibular fractures. One group believes that these fractures should be opened and fixed while the other believes that these fractures can be successfully treated with a closed reduction technique. Bone atrophy and advanced age favor conservative treatments due to the higher incidence of complications associated with open reduction surgery in geriatric patients. Conservative options would include the use of Gunning splints, existing dentures to stabilize the fracture, external fixation appliances, or even no treatment at all.6 In 1862, Thomas Brian Gunning was the first to use vulcanite in a custom-fitted splint to immobilize a fracture if the fracture was difficult to reduce, then a single vulcanite splint for both the jaws was used to provide intermaxillary fixation.7 Gunning-type splints are a superb fixation device and relatively quick and easy to apply for edentulous patients8 (Fig. 1). Skeletal pin fixation, advocated by Marciani,9,10 has also been used with some success in the atrophic mandibular fracture. Aside from the ungainly nature of the appliances, good results with these techniques are often easier to conceptualize than to achieve. Miniplates have been used widely; however, alternatives should be considered because the method of fixation can be a critical factor in influencing the clinical outcome of patients. Some authors believe that miniplate fixation for atrophic mandible fractures is insufficient and have recommended using a reconstruction plate instead.11,12 Although a large reconstruction plate has stronger mechanical strength compared to a smaller plate, it requires wider stripping of the periosteum for proper positioning and also decreases periosteal contact with bone after placement.13 In addition, large bicortical screws may violate the inferior alveolar nerve or be an instrument of further jaw fracture; therefore, other surgeons prefer miniplate osteosynthesis.13,14 Shuker15,16 was the first to use IRIF technique utilized and adapted as a horseshoe-shaped 2-mm K-wire to treat ballistic avulsion, severe lower jaw rifle fragmented bullet injury’s management, and comminuted mandibular fractures. In this paper, IRIF technique was successfully utilized as a conservative method to provide intraoral indirect rigid fixation for 5 geriatric edentulous patients with mandibular fractures. The biomechanics of load-sharing capacity of stress forces is along the Kwire with mandibular segments that acts as one unit, while traverse compression from functional resistance forces into the rami.
MATERIAL AND CONSERVATIVE PROCEDURE Five cases of elderly edentulous mandibular fractures are presented: 4 unilateral body fractures and 1 bilateral body/angle fracture. Of
Volume 26, Number 3, May 2015
677
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Shuker
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
FIGURE 1. Acrylic Gunning splint that has been used for over 150 years. FIGURE 3. Sketch presents large plating technique versus interrami intraoral fixation IRIF technique utilized for edentulous/atrophic mandibular fracture.
these cases, 2 are atrophic, 2 non-atrophic, and 1 partially edentulous mandible with edentulous upper jaw. Under local anesthesia, mucosal stab incisions in the middle of the retromolar fosse were made after the area to be stabbed palpated by the surgeon’s finger. Two holes, one on each side, are drilled through cortical bone at the level of the normal alveolar ridge using a no. 6 round bur. The anterior edge of the resorbed alveolar ridge is used as a guide to adapt a horseshoe-shaped K-wire 2 mm in diameter. In the case of an atrophic ridge, the K-wire was adapted to the posterior bend at the retromolar trigone region and directed towards the retromolar fossa followed by a final bend directed into the ramus. The bend at the trigone region was carried out because of the severe atrophy near the alveolar ridge, thus avoiding alveolar nerve injury during the final K-wire insertion approximately 1 cm inside the holes of the ramus. The 2 ends of the K-wire were wider posteriorly which provided a springing action against the lateral portion of the rami that acts against medial superior ramus segment by muscles of mastication pull. The ends of the wire were anchored by the lateral cortex of the rami. Proper positioning of the K-wire into its final position may require gentle tapping of a hammer on the K-wire anterior curvature (Figs. 2, 3). The mandibular segments are immobilized by 2 to 3 circumferential 0.5-mm stainless steel wires suspended from the K-wire. While loading the body of the mandible on the K-wire, fractured segments are manually molded into position under gentile palpation medial and lateral sulcus to the mandible lower border. Once the fractured mandible segments are loaded into their proper position, the stress forces are distributed across the entire length of the Kwire. The full arc acts as a fulcrum allowing the entire mandible to function as a single fixed unit (Figs. 4, 5).
FIGURE 2. Sketch showing techniques of mandibular fracture external/plating fixation versus interrami intraoral fixation IRIF technique.
678
DISCUSSION Conservative management of edentulous fractures utilizing the Gunning splint has historically proven to be a successful technique for the last 150 years. There are various reasons why such conservative methods of treatment were used in the past and why they still are viable, and perhaps advantageous, options in this age group. One factor is that with the decreased vascularity or blood flow to the mandible and the fracture site in these cases, an open reduction has the potential to further compromise the blood supply to the bone and soft tissue of the mandible.3,5,11 Despite these statements, we are currently in the era of modern plating techniques which produce a long list of small and large plates of varied types, shapes, and screw fixations. Treatment of edentulous mandible fractures with plates beneath the periosteum, above the periosteum, and even atop the mucosal surfaces have all been described.11,17 Some authors prefer an extraoral approach avoiding complete periosteal stripping of the mandible.13 Although all complications were associated with an intraoral approach, this approach is still preferred because it avoids the creation of extraoral scars and reduces the risk of injury of the facial nerve. Furthermore, this approach offers in high-risk patients the possibility of treatment of these fractures under local anesthesia.18 Clayman and Rossi19 found that miniplate fixation of fractures at the inferior border of severely atrophic mandibles are not only safe but adequately provides rigid fixation as well. Tiwana et al20 reported a single ‘‘ear-to-ear’’ plate was used; the distal screws in the symphysis region serve to both aid in fracture healing as well as improve functionality for the patient. The plates can be positioned at either the lateral aspect of the mandible or at the inferior border with good success.21
FIGURE 4. Photograph showing K-wire IRIF technique used as conservative indirect rigid fixation for partial edentulous mandible and total edentulous upper jaw.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
IRIF Technique of Atrophic Mandibular Fracture
REFERENCES
FIGURE 5. Photograph showing K-wire IRIF technique used as conservative indirect rigid fixation for edentulous/atrophic mandibular fracture.
To avoid damage to the subperiosteal plexus which is probably the major blood supply to the bone, a supraperiosteal dissection has been suggested and a supraperiosteal placement of plates and screws was recommended.11 The effect of this technique was questioned by Bruce and Ellis.22 The investigators stated that ‘‘a properly contoured bone plate would inhibit the blood supply to the underlying periosteum as much as if the periosteum were stripped from the bone.’’ An incidence of 20% nonunion has been reported by Bruce and Strachar23 in a large series with a wide diversity of treatment modalities. Shuker’s IRIF technique has the potential to successfully replace external fixation as well as small and large plate direct fixation techniques for edentulous/atrophic mandible management.15,16 Five edentulous mandible fractures, 4 of them unilateral body fractures and 1 bilateral fracture, were treated using IRIF technique. The edentulous alveolar ridge morphology was used to fashion a 2mm K-wire which ultimately led to successful patient healing. No single complication was reported in these cases regarding healings, alignment, and discomfort. The biomechanics according to Meyer et al24 and Champy and co-workers described a zone of tension in the alveolar part of the mandible and a zone of compression on the lower border.25 This information allowed for the identification and placement of ideal lines for mandibular plating and internal fixation along the lines of physiological tension. It also shows that the IRIF technique is placed along Champy’s zone on the mandibular alveolar ridge. Altogether, the load-sharing capacity of stress and functional forces is transported along the K-wire while compression resistance forces into the rami. Consequently, IRIF technique replaces the small and large plate fixation techniques utilized on the lateral or lower border of the mandible and uncomfortable Gunning splint. It is also quicker, easier, cheaper, less technically demanding, can be performed under local anesthesia, and does not carry the risk of blood vessel impairment or tissue morbidity or healing complications. In addition, it provides immediate preservation of functions of the mandible which acts to enhance osteogenesis and healing. Moreover, as a final step, K-wire removal is easily performed after pulling out the circumferential wires with or without a small amount of local anesthesia.
ACKNOWLEDGMENTS The author thanks Christopher Kassab for his assistance and the staff of West Bloomfield Library, West Bloomfield, MI, for their help.
#
2015 Mutaz B. Habal, MD
1. Friedman CD, Constantino PD. Facial fractures and bone healing in the geriatric patient. Otolaryngol Clin North Am 1996;25:1109 2. Ellis E, Moos KF, El-Attar A. Ten years of mandibular fractures: An analysis of 2,137 cases. Oral Surg 1985;59:120 3. Bradley JC. A radiological investigation into the age changes of the inferior dental artery. Br J Oral Surg 1975;13:82 4. Scott RF. Oral and maxillofacial trauma in the geriatric patient. In: Fonseca RJ, Walker RV, Betts NJ, eds. Oral and Maxillofacial Trauma, Vol 2. et al, eds. Oral and Maxillofacial Trauma, Vol 2. Philadelphia, PA: Saunders; 1997:1045–1072 5. Buchbinder D. Treatment of fractures of the edentulous mandible, 1943 to 1993: A review of the literature. J Oral Maxillofac Surg 1993;51:1174 6. Barber HD. Conservative Management of the Fractured Atrophic Edentulous Mandible. J Oral Maxillofac Surg 2001;59:789–791 7. Fonseca RJ. Oral and Maxillofacial Surgery. Philadelphia: Saunders; 2000:463–482 8. Fonseca RJ. Oral and Maxillofacial Surgery. Philadelphia: Saunders, 1997; 2nd edition Vol 1:474–478 9. Marciani RD, Hill OJ. Treatment of the fractured edentulous mandible. J Oral Surg 1979;37:569 10. Marciani RD. Invasive management of the fractured atrophic edentulous mandible. J Oral Maxillofac Surg 2001;59:792 11. Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression plating. J Oral Maxillofac Surg 1996;54:250 12. Sikes JW, Smith BR, Mukherjee DP. An in vitro study of the effect of bony buttressing on fixation strength of a fractured atrophic edentulous mandible model. J Oral Maxillofac Surg 2000;58:56 13. Iizuka T, Lindqvist C. Sensory disturbances associated with rigid internal fixation of mandibular fractures. J Oral Maxillofac Surg 1991;49:1264 14. Choi BH, Huh JY, Suh CH, et al. An in vitro evaluation of miniplate fixation techniques for fractures of the atrophic edentulous mandible. Int J Oral Maxillofac Surg 2005;34:174 15. Shuker S. Inter-rami intraoral fixation of severely comminuted mandibular war injuries. J Maxillofac Surg 1985;13:282–286 16. Shuker ST. Interrami intraoral fixation technique for severe mandibular rifle fragmented bullet injury management. J Craniofac Surg 2013;24:1168–1174 17. Iatrou I, Samaras C, Theologie-Lygidakis N. Miniplate osteosynthesis for fractures of the edentulous mandible: A clinical study 1989–96. J Craniomaxillofac Surg 1998;26:400 18. Wittwer G, Adeyemo WL, Turbani D, et al. Treatment of atrophic mandibular fractures based on the degree of atrophy—experience with different plating systems: a retrospective study. J Oral Maxillofac Surg 2006;64:230 19. Clayman L, Rossi E. Fixation of atrophic edentulous mandible fractures by bone plating at the inferior border. J Oral Maxillofac Surg 2012;70:883–889 20. Tiwana PS, Abraham MS, Kushner GM, et al. Management of atrophic edentulous mandibular fractures: the case for primary reconstruction with immediate bone grafting. J Oral Maxillofac Surg 2009;67:882 21. Van Sickels JE, Cunningham LL. Management of atrophic mandible fractures: are bone grafts necessary? J Oral Maxillofac Surg 2010;68:1392–1395 22. Bruce RA, Ellis E. The second Chalmers J. Academy Study of fractures of the edentulous mandible. J Maxillofac Surg 1993;51:904 23. Bruce RA, Strachan DS. Fractures of the edentulous mandible: 6. Xie Q, Ainamo A: Association of edentulousness with systemic factors in elderly people living at home. Community Dent Oral Epidemiol 1999;27:202 24. Meyer C, Serhir L, Boutemi P. Experimental evaluation of three osteosynthesis devices used for stabilizing condylar fractures of the mandible. J Craniomaxillofac Surg 2006;34:173–181 25. Wong RCW, Tideman H, Kin L, et al. Biomechanics of mandibular reconstruction: a review. Int J Oral Maxillofac Surg 2010;39:313–319
679
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
