J. Nihon
Univ.
Case
Report
Sch.
Dent.,
Vol.
34. 224-229,
1992
Use of Two Miniplates for Intermaxillary Skeletal Fixation in the Treatment of Jaw Deformity and Fracture Minoru HORI, Yuichi NAKADA, Shinko MATSUNAGA, Hiroyuki TATSUHARA, Kimie SAKURAI, Hiromitsu YAMANOI, Toshiyuki KUNO, Mitsuhiko MATSUMOTO, and Hiroshi TANAKA (Received19 November1991and accepted25 February 1992) Key words:
intermaxillary skeletal fixation, miniplate fixation, jaw deformity, mandibular fracture Abstract
Special techniques of skeletal intermaxillary fixation are described, which may be used in edentulous patients or those with many missing teeth or multiple fractures of the jaw. Two such cases are described in which the usual fixation techniques could not provide sufficient stabilization because of linguoversion and mesioversion or lack of teeth, resulting in inability to maintain a vertical interocclusal relationship. Two long eight-hole Champy miniplates were therefore used distally to the canines on both sides. In the first case, they provided fixation following a sagittal ramus osteotomy to advance the mandible, and in the second case they were used in the treatment of a mandibular fracture. Introduction Intermaxillary fixation is an essential technique in the field of oral surgery, and is usually achieved through the use of arch bars or orthodontic bands[11. Sometimes, however, these methods cannot provide firm enough fixation or stabilization. In special cases, such as when all or many teeth are missing, or when there is an unsatisfactory intercuspal position, different methods of fixation must be used [2]. This paper describes two such special cases. In each one, intermaxillary fixation was performed by means of two miniplates, instead of the single miniplate described in previous case reports.
堀
稔,仲 田雄 一,松 永心 子,田 津 原 広行,桜 井 希 己江,山 野 井 弘 充,久 野敏 行,松 本 光 彦,田 中
博
Department of Oral Surgery, Nihon University School of Dentistuy. To whom all correspondence should be addressed: Dr Hiroshi TANAKA, Department of Oral Surgery, Nihon University School of Dentistry, 1-8-13 Kanda-Surugadai, Chiyoda-ku, Tokyo 101, JAPAN .
225
Case
report
Case 1 The patient, a 30-year-old Japanese woman, was examined for surgical treatment on November 11, 1990,at Nihon University Dental Hospital. The patient had been undergoing orthodontic treatment for one year to correct her initial malocclusion. Her chief complaint was the appearance of her teeth, which she wished to improve. From clinical evaluation and examination of the records at her private orthodontic clinic, a deficiency of mandibular growth was diagnosed, which had led to characteristic protrusion of the maxillary teeth and deficiencyof the chin. The facial appearance of the patient showed slight displacement of the chin to the right side. The lateral view revealed severe deficiency of the chin and increased lower facial height, resulting in "bird-face" deformity. Intra-oral examination showed that four teeth were missing: 3 1 36 6. The interocclusal the
relationship
molar
teeth,
linguoversion on
5 + 5
over-bite the (Fig.
of 6+ of
McNamara
6. -2
was
causing Fr,
and
class
severe a slightly
Cephalometric mm. line
The was
2, division
was
0 mm
and
anterior
open
evaluation ANB
1 malocclusion
linguoversion
12•‹ and at
point
bite.
showed the A
facial and
with
mesioversion There an
-32.5
of
were
over-jet
angle mm
was at
scissor
bonded of
2 mm,
bite
TO,
at
severe
brackets and
an
74•‹.
Divergence
from
the
pogonion
point
1).
Fig. 1
Treatment To plan and definitive
Preoperative lateral cephalogram (case 1)
the surgical treatment effectively, cephalometric predictive tracing model surgery were undertaken. To improve occlusion, the desirable
226
surgical procedure was advancement of the mandible, additional posterior segmental osteotomy and genioplasty. When performing model surgery for repositioning of the mandible on the articulator, the model cuts could be made in such a way as to aviod the apices or root surfaces of the teeth. However, when the posterior segment was placed in the desired position, bony interference with the required segmental movement was observed. By performing the osteotomy through the neurovascular canal, it would have been possible to achieve the desired result. However, it was decided that such a procedure in this case carried too high a risk of paralysis of the lower lip. Therefore, the attempt to right the mesially slanted mandibular molar teeth through a subapical osteotomy had to be abandoned, and thus optimal occlusion could not be achieved. It was therefore decided to perform a sagittal ramus osteotomy, and augmentative genioplasty with a hydroxyapatite block, through an intraoral approach. After surgery, two miniplates were adapted to achieve a correct interocclusal relationship and maintain the posterior vertical dimension, since the usual fixation techniques could not provide sufficient stabilization (Figs. 2 and 3).
Fig. 2
Fig. 3
I ntraoral photograph showing intermaxillary skeletal fixation after osteotomy for advancement of the mandible (case 1)
Postoperative panoramic radiograph showing intermaxillary skeletal fixation (case 1)
Case 2 The patient, a 44-year-old Japanese man, was brought to the medical hospital for emergency treatment following severe accidental injury to his face. He was first
227
examined by a neurological surgeon, who requested intervention by an oral surgeon four days later. Clinical evaluation by both surgeons led to a diagnosis of cerebral contusion, facial laceration, and fracture of the mandible. The patient's face was severely swollen. Intra-oral examination showed swelling of the mouth floor, so that the tongue was elevated. 6 was displaced, and 54 4567 were embedded in the surrounding soft tissue and fractured mandible. The body of the mandible and the alveolar process in the region of 3 3 was fractured, causing mesial displacement. The combined result of these injuries was severe malocclusion. Lacerations of the gingiva were also seen around the multiple fractures. Through bimanular palpation, the fractured fragments were found to be mobile. X-ray and CT findings revealed multiple fracture lines in the area of 6 to F6, and compound comminuted fractures in both the left and right premolar regions (Fig. 4).
Fig. 4
CT scan showing multiple fractures of the mandible (case 2)
Treatment Despite the initial cerebral contusion, the patient showed no signs of brain damage on the 8th day after injury. It was therefore decided to treat his oral injuries surgically. First, open reduction was accomplished through an extra-oral approach, thus exposing the fractured mandible. 654 456 were then extracted. Several fixation techniques were employed: osseous wiring, miniplates and circumferential wiring. Intermaxillary wiring fixation could not be performed because sufficient anchorage could not be provided due to the many missing teeth. Therefore, intermaxillary skeletal fixation was performed using miniplates to maintain the posterior vertical dimension (Figs. 5 and 6). Surgical technique First, bilateral vertical incisions approximately 1.5 cm long were made in the
228
Fig. 5
Intraoral photograph showing intermaxillary skeletal fixation after open reduction (case 2)
Fig. 6
Postoperative panoramic radiograph showing intermaxillary skeletal fixation (case 2)
vestibular flaps
fold were
of
the
elevated
canines
and
vertical
incisions
incisions
were
premolars were
avoid
the
to
fix
miniplates,
10 mm•~15
nerve.
mm.
The
and
Champy
miniplates
mandible.
The
in
the to
the
were
bone
then
screwed
the
simple
to
the
the
exposed
of
was
In
order
mandible long
surfaces
foramen
approximately
and Two
the
These
the
inferiorly.
maxilla
of bilateral
mandible. area
bone
wiring.
region
Secondly,
elevated of the
of
with
then
mesial
was
relationship
was
of
the
surface
apex
rims.
fold in
mucoperiosteal
the
nasal
vestibular the
Minimal
expose
lateral
exposed
temporarily
incision
canines. to
mucoperiosteum
of
occlusal
fixed
the
down The
area
the
bone
identify
placed
the
to
maxillary
directly
mental
reconfirmed,
distally
the and
carried
to
the
maxilla,
from
of
was
eight-holed
the
maxilla
and
fracture
and
sutured. Discussion
Intermaxillary orthognathic into
fixation surgical
two
types:
intermaxillary
Intermaxillary viduals In
dental
with
such
of
oral
many
cases,
Champy
surgery
fixation missing
the
miniplate
Skeletal
is
correction.
teeth,
because
has of
its
equipment
out
The
in
fixation,
is not
applicable
or
those
of
flexibility
and as
the
method
intermaxillary for
edentulous
unsatisfactory
fixation proved
mandibular
fixation and
with
skeletal recently
such
cases
intermaxillary
dental
intermaxillary system
fixation
carried
to ease miniplate
technique be of
extremely
is classified
skeletal
fixation.
patients
and
intercuspal is
indicated.
useful
indi-
position.
in
The the
field
fitting. system
forms
a normal
part
229
of an operating theater's resources and takes comparatively little time to install. Such intermaxillary skeletal techniques are therefore also very valuable in emergency oral surgery. The techniques and methods of intermaxillary skeletal fixation already reported in the literature include a combination of bilateral maxillary prealveolar wires and circummandibular wires[3], circumalveolar-mandibular wiring[4,5],use of bone screws in the maxilla and mandible, linked by a loop of wire[6], and a single miniplate system[7,8]. The use of a miniplate with screws for intermaxillary fixation is legitimate, and sufficient stabilization of the mandible may be expected. However, the use of a single miniplate has some disadvantages. For example, it may not be able to prevent the lateral, forward or rotational movement of the mandible. In addition, the screws may need to be tightened frequently during the fixation period. Because of the weaknesses of the single miniplate system, especially in edentulous patients and those with many missing teeth, as described above, the use of two miniplates can achieve better results. In both of the present cases, the miniplates did not loosen, and satisfactory stabilization was provided during the period of intermaxillary fixation. The use of two miniplates is relatively easy, and does not require lengthy surgery. The only possible disadvantage is the risk of postoperative infection. However, as with all forms of intermaxillary fixation, it is important to keep the teeth, gingiva and immobilization equipment as clean as possible. Good oral hygiene should prevent infections. In the two patients described here, there was no postoperative infection, and sufficient stabilization of the mandible was obtained. Conclusion A technique of intermaxillary skeletal fixation using two miniplates is described. It is convenient and useful in edentulous patients and individuals with many missing teeth or multiple fractures of the jaw. Two cases treated using this technique are discussed. References [1] ROWE,N. L. and WILLIAMS, J. Ll.: Maxillofacial Injuries, Vol. 1, 243-267,Churchill Livingstone,London, Great Britain, 1985 [2] ROWE, N. L. and WILLIAMS, J. Ll.: Facial Injuries,Vol. 1, 273-278,ChurchillLivingstone, London, Great Britain, 1985 [3] KOMORI, E., AIGASE, K., SUGISAKI, M. and TANABE, H.: Skeletal fixation versus skeletal relapse,Am. J. Orthodont.Dentofac.Orthop.,92, 412-421,1987 [4] BRIGGS, R. M. and WOOD-SMITH, D.: A simple techniquefor intermaxillaryfixation, Surg. Gynecol.& Obstet., 129, 1271-1274,1969 [5] TAJIMA S.: Plastic & ReconstructiveSurgery-Treatmentof MaxillofacialFracture, 28-29, KatsuseidoPublishersCo. Ltd., Tokyo, Japan, 1981(in Japanese) [6] ARTHUR, G. and BERADO, N.: A simplifiedtechniqueof maxillomandibularfixation,J. Oral Maxillofac.Surg., 47, 1234,1989 [7] BREMERHAVEN E. R. and BREMEN K. L.: VertikalePlattezur intermaxillarenFixation,Dtsch. Z. Mund. Kiefer. Gesichts.Chir., 9, 249-250,1985 [8] WOLFE S. A., LOVAAS, M. and MCCAFFERTY, L. R.: Use of a miniplateto provide intermaxillary fixationin the edentulouspatient, J. Cranio-Max.-Fac.Surg., 17, 31-33,1989
Univ.
Case
Report
Sch.
Dent.,
Vol.
34. 224-229,
1992
Use of Two Miniplates for Intermaxillary Skeletal Fixation in the Treatment of Jaw Deformity and Fracture Minoru HORI, Yuichi NAKADA, Shinko MATSUNAGA, Hiroyuki TATSUHARA, Kimie SAKURAI, Hiromitsu YAMANOI, Toshiyuki KUNO, Mitsuhiko MATSUMOTO, and Hiroshi TANAKA (Received19 November1991and accepted25 February 1992) Key words:
intermaxillary skeletal fixation, miniplate fixation, jaw deformity, mandibular fracture Abstract
Special techniques of skeletal intermaxillary fixation are described, which may be used in edentulous patients or those with many missing teeth or multiple fractures of the jaw. Two such cases are described in which the usual fixation techniques could not provide sufficient stabilization because of linguoversion and mesioversion or lack of teeth, resulting in inability to maintain a vertical interocclusal relationship. Two long eight-hole Champy miniplates were therefore used distally to the canines on both sides. In the first case, they provided fixation following a sagittal ramus osteotomy to advance the mandible, and in the second case they were used in the treatment of a mandibular fracture. Introduction Intermaxillary fixation is an essential technique in the field of oral surgery, and is usually achieved through the use of arch bars or orthodontic bands[11. Sometimes, however, these methods cannot provide firm enough fixation or stabilization. In special cases, such as when all or many teeth are missing, or when there is an unsatisfactory intercuspal position, different methods of fixation must be used [2]. This paper describes two such special cases. In each one, intermaxillary fixation was performed by means of two miniplates, instead of the single miniplate described in previous case reports.
堀
稔,仲 田雄 一,松 永心 子,田 津 原 広行,桜 井 希 己江,山 野 井 弘 充,久 野敏 行,松 本 光 彦,田 中
博
Department of Oral Surgery, Nihon University School of Dentistuy. To whom all correspondence should be addressed: Dr Hiroshi TANAKA, Department of Oral Surgery, Nihon University School of Dentistry, 1-8-13 Kanda-Surugadai, Chiyoda-ku, Tokyo 101, JAPAN .
225
Case
report
Case 1 The patient, a 30-year-old Japanese woman, was examined for surgical treatment on November 11, 1990,at Nihon University Dental Hospital. The patient had been undergoing orthodontic treatment for one year to correct her initial malocclusion. Her chief complaint was the appearance of her teeth, which she wished to improve. From clinical evaluation and examination of the records at her private orthodontic clinic, a deficiency of mandibular growth was diagnosed, which had led to characteristic protrusion of the maxillary teeth and deficiencyof the chin. The facial appearance of the patient showed slight displacement of the chin to the right side. The lateral view revealed severe deficiency of the chin and increased lower facial height, resulting in "bird-face" deformity. Intra-oral examination showed that four teeth were missing: 3 1 36 6. The interocclusal the
relationship
molar
teeth,
linguoversion on
5 + 5
over-bite the (Fig.
of 6+ of
McNamara
6. -2
was
causing Fr,
and
class
severe a slightly
Cephalometric mm. line
The was
2, division
was
0 mm
and
anterior
open
evaluation ANB
1 malocclusion
linguoversion
12•‹ and at
point
bite.
showed the A
facial and
with
mesioversion There an
-32.5
of
were
over-jet
angle mm
was at
scissor
bonded of
2 mm,
bite
TO,
at
severe
brackets and
an
74•‹.
Divergence
from
the
pogonion
point
1).
Fig. 1
Treatment To plan and definitive
Preoperative lateral cephalogram (case 1)
the surgical treatment effectively, cephalometric predictive tracing model surgery were undertaken. To improve occlusion, the desirable
226
surgical procedure was advancement of the mandible, additional posterior segmental osteotomy and genioplasty. When performing model surgery for repositioning of the mandible on the articulator, the model cuts could be made in such a way as to aviod the apices or root surfaces of the teeth. However, when the posterior segment was placed in the desired position, bony interference with the required segmental movement was observed. By performing the osteotomy through the neurovascular canal, it would have been possible to achieve the desired result. However, it was decided that such a procedure in this case carried too high a risk of paralysis of the lower lip. Therefore, the attempt to right the mesially slanted mandibular molar teeth through a subapical osteotomy had to be abandoned, and thus optimal occlusion could not be achieved. It was therefore decided to perform a sagittal ramus osteotomy, and augmentative genioplasty with a hydroxyapatite block, through an intraoral approach. After surgery, two miniplates were adapted to achieve a correct interocclusal relationship and maintain the posterior vertical dimension, since the usual fixation techniques could not provide sufficient stabilization (Figs. 2 and 3).
Fig. 2
Fig. 3
I ntraoral photograph showing intermaxillary skeletal fixation after osteotomy for advancement of the mandible (case 1)
Postoperative panoramic radiograph showing intermaxillary skeletal fixation (case 1)
Case 2 The patient, a 44-year-old Japanese man, was brought to the medical hospital for emergency treatment following severe accidental injury to his face. He was first
227
examined by a neurological surgeon, who requested intervention by an oral surgeon four days later. Clinical evaluation by both surgeons led to a diagnosis of cerebral contusion, facial laceration, and fracture of the mandible. The patient's face was severely swollen. Intra-oral examination showed swelling of the mouth floor, so that the tongue was elevated. 6 was displaced, and 54 4567 were embedded in the surrounding soft tissue and fractured mandible. The body of the mandible and the alveolar process in the region of 3 3 was fractured, causing mesial displacement. The combined result of these injuries was severe malocclusion. Lacerations of the gingiva were also seen around the multiple fractures. Through bimanular palpation, the fractured fragments were found to be mobile. X-ray and CT findings revealed multiple fracture lines in the area of 6 to F6, and compound comminuted fractures in both the left and right premolar regions (Fig. 4).
Fig. 4
CT scan showing multiple fractures of the mandible (case 2)
Treatment Despite the initial cerebral contusion, the patient showed no signs of brain damage on the 8th day after injury. It was therefore decided to treat his oral injuries surgically. First, open reduction was accomplished through an extra-oral approach, thus exposing the fractured mandible. 654 456 were then extracted. Several fixation techniques were employed: osseous wiring, miniplates and circumferential wiring. Intermaxillary wiring fixation could not be performed because sufficient anchorage could not be provided due to the many missing teeth. Therefore, intermaxillary skeletal fixation was performed using miniplates to maintain the posterior vertical dimension (Figs. 5 and 6). Surgical technique First, bilateral vertical incisions approximately 1.5 cm long were made in the
228
Fig. 5
Intraoral photograph showing intermaxillary skeletal fixation after open reduction (case 2)
Fig. 6
Postoperative panoramic radiograph showing intermaxillary skeletal fixation (case 2)
vestibular flaps
fold were
of
the
elevated
canines
and
vertical
incisions
incisions
were
premolars were
avoid
the
to
fix
miniplates,
10 mm•~15
nerve.
mm.
The
and
Champy
miniplates
mandible.
The
in
the to
the
were
bone
then
screwed
the
simple
to
the
the
exposed
of
was
In
order
mandible long
surfaces
foramen
approximately
and Two
the
These
the
inferiorly.
maxilla
of bilateral
mandible. area
bone
wiring.
region
Secondly,
elevated of the
of
with
then
mesial
was
relationship
was
of
the
surface
apex
rims.
fold in
mucoperiosteal
the
nasal
vestibular the
Minimal
expose
lateral
exposed
temporarily
incision
canines. to
mucoperiosteum
of
occlusal
fixed
the
down The
area
the
bone
identify
placed
the
to
maxillary
directly
mental
reconfirmed,
distally
the and
carried
to
the
maxilla,
from
of
was
eight-holed
the
maxilla
and
fracture
and
sutured. Discussion
Intermaxillary orthognathic into
fixation surgical
two
types:
intermaxillary
Intermaxillary viduals In
dental
with
such
of
oral
many
cases,
Champy
surgery
fixation missing
the
miniplate
Skeletal
is
correction.
teeth,
because
has of
its
equipment
out
The
in
fixation,
is not
applicable
or
those
of
flexibility
and as
the
method
intermaxillary for
edentulous
unsatisfactory
fixation proved
mandibular
fixation and
with
skeletal recently
such
cases
intermaxillary
dental
intermaxillary system
fixation
carried
to ease miniplate
technique be of
extremely
is classified
skeletal
fixation.
patients
and
intercuspal is
indicated.
useful
indi-
position.
in
The the
field
fitting. system
forms
a normal
part
229
of an operating theater's resources and takes comparatively little time to install. Such intermaxillary skeletal techniques are therefore also very valuable in emergency oral surgery. The techniques and methods of intermaxillary skeletal fixation already reported in the literature include a combination of bilateral maxillary prealveolar wires and circummandibular wires[3], circumalveolar-mandibular wiring[4,5],use of bone screws in the maxilla and mandible, linked by a loop of wire[6], and a single miniplate system[7,8]. The use of a miniplate with screws for intermaxillary fixation is legitimate, and sufficient stabilization of the mandible may be expected. However, the use of a single miniplate has some disadvantages. For example, it may not be able to prevent the lateral, forward or rotational movement of the mandible. In addition, the screws may need to be tightened frequently during the fixation period. Because of the weaknesses of the single miniplate system, especially in edentulous patients and those with many missing teeth, as described above, the use of two miniplates can achieve better results. In both of the present cases, the miniplates did not loosen, and satisfactory stabilization was provided during the period of intermaxillary fixation. The use of two miniplates is relatively easy, and does not require lengthy surgery. The only possible disadvantage is the risk of postoperative infection. However, as with all forms of intermaxillary fixation, it is important to keep the teeth, gingiva and immobilization equipment as clean as possible. Good oral hygiene should prevent infections. In the two patients described here, there was no postoperative infection, and sufficient stabilization of the mandible was obtained. Conclusion A technique of intermaxillary skeletal fixation using two miniplates is described. It is convenient and useful in edentulous patients and individuals with many missing teeth or multiple fractures of the jaw. Two cases treated using this technique are discussed. References [1] ROWE,N. L. and WILLIAMS, J. Ll.: Maxillofacial Injuries, Vol. 1, 243-267,Churchill Livingstone,London, Great Britain, 1985 [2] ROWE, N. L. and WILLIAMS, J. Ll.: Facial Injuries,Vol. 1, 273-278,ChurchillLivingstone, London, Great Britain, 1985 [3] KOMORI, E., AIGASE, K., SUGISAKI, M. and TANABE, H.: Skeletal fixation versus skeletal relapse,Am. J. Orthodont.Dentofac.Orthop.,92, 412-421,1987 [4] BRIGGS, R. M. and WOOD-SMITH, D.: A simple techniquefor intermaxillaryfixation, Surg. Gynecol.& Obstet., 129, 1271-1274,1969 [5] TAJIMA S.: Plastic & ReconstructiveSurgery-Treatmentof MaxillofacialFracture, 28-29, KatsuseidoPublishersCo. Ltd., Tokyo, Japan, 1981(in Japanese) [6] ARTHUR, G. and BERADO, N.: A simplifiedtechniqueof maxillomandibularfixation,J. Oral Maxillofac.Surg., 47, 1234,1989 [7] BREMERHAVEN E. R. and BREMEN K. L.: VertikalePlattezur intermaxillarenFixation,Dtsch. Z. Mund. Kiefer. Gesichts.Chir., 9, 249-250,1985 [8] WOLFE S. A., LOVAAS, M. and MCCAFFERTY, L. R.: Use of a miniplateto provide intermaxillary fixationin the edentulouspatient, J. Cranio-Max.-Fac.Surg., 17, 31-33,1989
