Professional Documents
Culture Documents
Smith
of the blow, when the posterior teeth are missing strated in this series. It should be mentioned that
and also when the m a n d i b l e is not fractured. the reported incidence, derived from patients re-
Clinically the bleeding is rather limited because porting to a casualty department, is more objec-
there are no m a j o r vessels in this area. tive than the incidence of the symptom in neuro-
A high incidence of external auditory meatus surgical or m a x i l l o - f a c i a l clinics where the inci-
laceration associated neither with basal skull dence of basal skull fractures or condylar head
fracture nor with condylar fracture was demon- fractures is increased accordingly.
References
Killey, H. C.: Fractures of the Mandible (2nd ed.).
Wright & Sons Ltd, Bristol 1971
Kristiansen, K.: Open or Compound Wounds of the
Head. In: G. F. Rowbotham: Acute Injuries of the Prof. Christos Martis, D.D.S., M.D.,
Head (4th ed.). Livingstone Ltd. Edinburgh 1964 Ass. Prof. Demetrius Karakasis, D.D.S., M.D.,
Rowe, N. L., H. C. Killey: Fractures of the Facial Department of Maxillo-Facial Surgery,
School of Dentistry,
Skeleton (2nd ed.). Livingstone Ltd. Edinburgh University of Thesaloniki,
1968 Thesalouiki, Greece
Ian Smith
Head of the Department of Maxillo-Facial and Oral Surgery
Johannesburg General Hospital and University of the Witwatersrand, South-Africa
establish the occlusion of the teeth, if teeth are skin. One must be aware of the variable anatomi-
present, eyelet wiring with intermaxillary fixa- cal design of the bone of the inferior margin of
tion is generally used. Occasionally cap splints the anterior nasal aperture. If teeth are present it
may be required to restore the occlusal relation- is advisable that the Kirschner wire pass between
ship of the teeth. In the edentulous jaw Gunn- the roots of the canine and lateral teeth at a point
ing Splints, or the patient's own dentures, are a third of the way down the root of the canine
inserted to guide the reduction and establish the from its apex.
correct relationship of the upper and lower jaws. The Kirschner wire is generally directed at an
The impacted fracture of the maxilla will require angle of 45 ° to the horizontal and sagittal planes
special attention. Whereas cap splinting and elas- of the maxilla.
tic traction assists in the reduction of the impacted In the edentulous case the Kirschner wire is
fracture. With this new method of treatment there inserted in a similar manner.
is no leeway and the impacted maxilla must be
completely reduced before the facial frame is Additional Kirschner Wires
locked. If difficulty is expeiqenced in maintaining
When required, additional Kirschner wires are
the occlusion then cap splinting with elastic trac-
inserted into mobile fragments for their specific
tion should be used in conjunction with this
immobilization. This additional fixation is gener-
method.
ally required when a very unstable zygomatic
component is present. To obtain the best purchase
Insertion of the Supraorbital pins and control, this Kirschner wire should be driven
into the bone from the front of the face.
A small incision is made in the eyebrow, gener-
ally in the outer third, and the supraorbital ridge
Re-establishment of the Occlusion or the
is exposed. Using a dental handpiece with a num-
intermaxillary relationship
ber 6 flat-fissure burr, a drill hole is made into
Prior to the final reduction of the facial fractures
the bone. The hole must be correctly sited and
the mandible must be immobilized to the maxilla.
angled at 45 ° to the coronal and sagittal planes
This is carried out by using any of the recognised
and should not be placed further than half an
methods of immobilization but, if teeth are pre-
inch (1.25 cm) from the orbital margin. Using a
sent, simple eyelet wiring is preferred. In the
hand drill, the titanium pin is carefully turned
edentulous mouth, if the mandible is intact, the
into the hole. Through the eyebrow incision which
patient's own dentures are inserted to control the
may have to be extended, nearby fracture lines
can be visualized and dealt with by direct bone reduction.
wiring when necessary. The incision is sutured
The reduction and immobilization o] the facial
and dressed.
fractures
The upper section of the frame is locked to the two
Insertion of the two Kirsehner wires into the titanium pins and the lower section to the two
maxilla Kirschner wires. The ends of the lower section of
Each Kirschner wire passes through the skin of the the frame are placed in close relationship to the
face in the upper end of the nasolabial skin fold vertical arms of the upper section. This design
lateral to the ala of the nose and is driven into allows for an upward as well as antero-posterior
the bone of the maxilla in the direction of the movement of fragments during the manipulation.
centre of the palate. The point of the Kirschner When the reduction of fragments is completed the
wire should come to rest under the palatal mucosa. two segments of the frame are lo&ed tightly
If it penetrates the mucosa it must be withdrawn together by means of universal clamps, which have
until it is no longer seen or felt. The point of entry been previously set in position.
of the wire into the bone can be visualized, if two
vertical stab incisions are made in the mouth at Experiences
the gingiva-mucosal reflection, over the roots of Within the last 18 months this new fixation appli-
the canine teeth, before it is pushed through the ance for immobilisation of mobile parts of the
Fractures of the Middle T h i r d of the Facial Skeleton 131
1. Le Fort II[ fracture with very unstable Face frame for middle third fracture. 7 weeks
(Fig. 2) left zygomatic component. Split palate. Additional Kirschner wire to support
Fracture of both condylar ne&s and left zygmnatic component. Eyelet wiring
comminuted fracture of left body of and intermaxillary immobilization
mandible
2. Le Fort Ill fracture with severely dis- Face frame and direct interosseous wir- Post-operative mobilization
(Figs. 3-4) placed left zygomatic fragment. Gra& ing of left zygomatic fragment in of mandible for 24 hours
fracture left canine region of mandible fronto-zygomatic suture region. Eyelet and then immobilization for
wiring with intermaxillary immobili- 3 weeks
zation
3. Le Fort I osteotomy for "dish-faced" Face frame. Cap splinting for inter- Post-operative mobilization
(Fig. 5) deformity and pseudo-prognathism maxillary immobilization for 24 hours and then immo-
in cleft pala|e case bilization for 2 weeks
4. Le Fort III fracture with left zygoma Face frame for middle third fracture. NIL
grossly displaced and left eye dis- Lower Gunning Splint with circum-
organised. Fractured symphysis of the ferential wiring for mandible
mandible
5. Le Fort III fracture. Fractured sym- Face frame for middle third fracture. 5 weeks
physis of the mandible Eyelet wiring with intermaxillary
immobilization
6. Le Fort III fracture with left zygoma Face frame for middle third fracture. 2 weeks
comminuted and comminution of outer On left side Moule's pin inserted in
half of left supraorbltal ridge. Left eye frontal sinus region along supra-
disorganised. Crack fracture left body orbital ridge. Eyelet wiring with inter-
of mandible maxillary immobilization
7. Le Fort III fracture with very unstable Face frame for middle third fracture. NIL
right zygomatic component. Mandible Additional Kirschner wire to support
intact right zygomatic component
8. Lc Fort I fracture with impaction. Face frame. Eyelet wiring with inter- NIL
Mandible intact maxillary immobilization for reduction
9. Le Fort Ill fracture. Impacted maxilla, Face frame. Eyelet wiring and inter- Post-operative mobilization
nasal complex and right zygoma, maxillary ilnmobilizatio n of mandible for 24 hours
Fracture right eoronoid process of and then immobilization for
mandible 3 days
10. Le Fort II fracture, impacted maxilla Face frame. Eyelet wiring and inter- NIL
and nasal component. Mandible intact maxillary immobilization for reduction
1I. Le Fort II fracture with split palate. Face frame. Eyelet wiring and inter- 7 days
Impacted maxilla. Mandible intact maxillary immobilization
12. Le Fort III fracture. MandibIe intact Face frame. Eyelet wiring and inter- Post-operative mobilization
maxillary immobilization of mandible for 24 hours
and then immobilization for
48 hours
13. Le Fort II fracture. Fracture left angle Face frame. Upper border wiring left 5 weeks
and right condyle angle fracture of mandible and eyelet
wiring and intermaxillary immobilization
14. Le Fort I osteotomy for malunited Face frame. Eyelet wiring for inter- Post-operative mobilization
fracture maxilla maxillary immobilization for 24 hours and then
immobilization 3 weeks
15. Lc Fort I fracture. Fracture of necks of Face frame. Upper Gunning Splint, NIL
both condyles of mandible with minimal lower cap splint for reduction
displacement
16. Le Fort III fracture. Mandible intact Face frame only. Reduction achieved NIL
without any intermaxillary immo-
bilization
17. Le Fort iII fracture. Mandible intact Face frame. Patient's own dentures used NIL
to guide reduction of fractures
132 I. Smith
Fig. 2 This full face photograph illustrates the new Fig. 4 The post-operative radiograph of case 2. The
method of immobilization. The photograph is of fracture at the left fronto-malar region has also been
case 1, and was taken on the 5th post-operative day. directly wired.
Fig. 5 a-c A full faced pre-operative photograph of a patient with a "dish-face deformity" associated with
a cleft lip and palate (case 3 in table 1). b) The full faced post-operative photograph of case 3 showing the
face frame in position after Le Fort I osteotomy for advancement of maxilla, c) The profile photograph
of case 3.
To date this method of treatment has proved most used the technique almost exclusively during the
satisfactory. It has allowed for one-stage defini- past 18 months.
tive treatment, and 23 patients who had sus- However, as with any method of treatment, diffi-
tained Le Fort I, II or I I I fractures of the middle culties do arise when additional or alternative
third of the facial skeleton have been treated by means of treatment have to be sought.
this method. This method of immobilization was
If the pins and wires are firmly inserted into the
also used for 4 patients who were treated for
bone and the fragments are correctly reduced, a
facial deformities which required Le Fort I
foreward position of the fragments is maintained
maxillary osteotomies for their correction.
when the frame is locked in position. However it
Within 24 hours of surgery all the patients were is essential at the conclusion of the operative
free of pain. None experienced more than slight procedure, when the anaesthetist's throat pack is
discomfort while the apparatus was in position. removed, to closely inspect the occlusal relation-
W h e n the apparatus was removed all the Kirsch- ship of the teeth. If there appears to be a slight
ner wires and titanium screws were still so firmly shift the intermaxillary links must be reapplied
embedded in the bone that a hand drill was re- and retained for a period of a few days, when the
quired to remove them. intact mandible is again mobilized for inspection.
In all but two cases the apparatus was removed W h e n fragments are firmly impacted and treat-
without subjecting the patient to an anaesthetic. ment has been delayed, it is preferable to use cast
Neither electrical reactions nor bone infections metal cap splints in conjunction with this tech-
were noted at any site where the Kirschner wires nique especially if difficulty is experienced in dis-
or screws were embedded in the bone. impacting the fractured segments.
In every case treated by this method the fractures If a split palate is encountered and it is obvious
were firmly united when the frame was removed that eyelet wiring with intermaxillary linkage
on the 4th post-operative week. will be incapable of closing the midline gap and
holding the fragments, cast metal cap splints are
used to provide the added stability.
Conclusion It has been my impression that the whip action of
This method of immobilization of fractures of tile the Kirschner wires on the maxilla produced a
middle third of the facial skeleton has proved to foreward leverage on the reduced nasal complex
be of great value, and I and my associates have and thus provides it with added support.
134 S. R. Mektubjian
If the supraorbital ridge is fractured in its outer of the face a n d should be placed beneath the
aspect, the Moule pin can be inserted into the anaesthetist's cathether mouth.
stable side of the rim in the region of the frontal
sinus. P r o v i d e d that the pin is correctly sited and Acknowledgement
angulated there is no danger of entry into the My thanks are due to Dr. M. Salmon, Superintendent
of the Johannesburg General Hospital and to Dr. J. de
anterior fossa of the skull. E n t r y into the frontal W. Becket, Superintendent of W.E.N.E.L.A. Hospital
sinus is without consequence. To insert the Moule for permission to publish, to my registrars, Dr. R. Lurie
pins into the tapped hole in the bone of the supra- and Dr. P. Uys for their unfailing assistance and to the
orbital ridge it only requires a few slow turns of photographic department of the Department of Sur-
gery, Medical School, for providing the photographic
the h a n d drill to obtain a firm hold of the pin.
prints.
W h e n the frame is being assembled the upper sec- Further information concerning the components of the
tion should be kept as close as possible to the skin face frame can be obtained frmn the author.
References
Lewmt, B. A., R. M. Cook, MacFarlane: Experience Dr. lan Smith,
103, Lancet Hall,
with the Levant Frame for Cranio Maxillary Fixa-
]eppe Street,
tion. Brit. J. Oral Surg. 11 (1973) 30 Johannesburg, 2001,
Mackenzi, D. L.: The Royal Berkshire Hospital "Halo". Transvaal,
Brit. J. Oral Surg. 8 (1971) 27 Republic of South A#ica