Self Tapping IMF Screws Technique

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ACKNOWLEDGEMENT I owe this piece of work to many people to whom I have my earnest gratitude. I place on record my profound gratitude to my teacher and guide Dr. Rajesh Kumar B.P. M.D.S., Professor, Department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere. His willingness to come forward at every stage of this study, unflinching guidance, unfailing support, untiring efforts, and constant encouragement has enabled me to complete this study. It is to him I extend my heartfelt gratitude for his efficacious guidance and altruistic co-operation and support through out my entire post graduation course. It is with sincerity and humble sense of gratitude that I acknowledge Dr. B. Praveen Reddy
M.D.S.,
Professor and Head of the Department of Oral and
Maxillofacial Surgery, College of Dental Sciences, Davangere. for his guidance and encouragement. His art of teaching which awakens the natural curiosity of young minds is an unmatched talent. He has always been very critical and analytical from a wholly constructive viewpoint, always making constructive suggestions to improve not only this study but also my entire approach to the subject and its practice. It is a privilege to learn under him. Words fall short to express my feelings of gratitude and indebtedness to Dr. Rajendra DesaiM.D.S., Senior Professor in the Department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere. His keen interest in teaching and vast knowledge in this field has helped me in a great way to complete this study. His vistas are encyclopedic. He has stimulated me to think, and his keenness and pliancy towards acquisition of knowledge has helped me mould concepts towards scientific excellence. I consider it pertinent to recount the wise counsel rendered by Dr. Srinivas Gosla Reddy. His stature and knowledge have been highly inspirational all through my career as a post graduate. I extend my special word of gratitude to Dr. UmashankarM.D.S., Reader, Dr. Kiran D.N.
M.D.S., M.D.S.,
and Dr. Shubhalakshami
Reader Department of Oral and Maxillofacial Surgery, College of Dental
Sciences, Davangere for their constant encouragement, valuable suggestions and ranking advice.
V
I congregate my gratification to Dr. Kiran Neswi
DA, DNB
Anaesthesiologist
for her contribution of valuable suggestion, encouragement, unhesitating helpful guidance, and motivation through out the study. My sincere gratitude to Dr. V.V. Subba Reddy, Dental Sciences, Davangere for facilitating my study. I am thankful to all the Sisters and Non technical staff of the Department of Oral and Maxillofacial Surgery. I am thankful to my friends, who have knowingly or unknowingly helped and supported me for the completion of this dissertation. A word of thanks to my dear colleagues Dr. Pranav, Dr. Charan, Dr. Praveen, Dr. Sridhar, Dr. Kishore; my juniors Dr. Johnathan, Dr. Irshad, Dr. Ibrahim, Dr Sonali Dr. Pramod , Dr. Vidya, Dr. Mamatha, Dr. Sudhakar, Dr. Sailesh, Dr. Rohit, Dr. Ashok, Dr. Vinay, Dr. Sandeep and Dr. Arun Priya , for their constant love and support. My special thanks to M/s Zen Computer Technology, M/s Amrutheshwera Xerox, M/s Raghavendra Colour Lab and M/s Itagi Printers who has helped in giving this study a final shape. I am grateful to Mr. Sangam, Biostatistician for helping me with the statistical analysis. On a personal note words fail to express my sincerest gratification to my parents, Dr. R. K. Malhotra , Mrs. Chitra Malhotra and my sister Neha Malhotra for their innumerable sacrifices and who have been a constant source of inspiration, spurring me to achieve greater heights and most of all their prayers which has brought me to where I am today. Time will not change the deepest affection and admiration I have for a special person, Dr. Abhilasha. Her love, support and constant encouragement have always been there for me in any of the circumstances. Above all I bow my head in gratitude to Almighty God for bestowing his blessing on me, for without his grace, no endeavour would ever be a success. Last but not the least I wish to thank all my patients who have been the subject of my study for their untiring compliance. Date: 18-04-06 Place: Davangere VI
M.D.S.,
Principal, College of
Dr. DIVYE MALHOTRA
LIST OF ABBREVIATION USED

AIDS : BP BT CT DFS FBS GA : : : : : : Acquired immunodeficiency syndrome Blood pressure Bleeding time Clotting time Drill free screws Fasting blood sugar General anaesthesia Hepatitis B virus Human immunodeficiency virus Intermaxillary fixation Maxillomandibular fixation Intra oral peri apical Local anaesthesia Orthopantomograph Road traffic accident
HBV : HIV IMF : :
MMF : IOPA : LA OPG RTA : : :
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ABSTRACT
Background and objectives: Numerous methods have been described for the achievement of Intermaxillary fixation in the treatment of fractures of facial skeleton. Conventional methods like arch bars and eyelet wires are currently most common methods for achieving intermaxillary fixation, but they have their own disadvantages. During last 10 years, intermaxillary fixation using intraoral self tapping IMF screws has been introduced for the treatment of mandibular fractures. The aim of this work was to evaluate efficacy, indications and potential complications associated with self tapping IMF screws in the management of mandibular fractures. Methods: Fifty patients with mandibular fractures, reported to Department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere were evaluated. To evaluate the efficacy of this method, different parameters were considered such as postoperative occlusion, pain, edema and oral hygiene, possible iatrogenic dental injuries, incidence of needle stick injuries and time taken for the intermaxillary fixation with self tapping IMF screws. Results: The most important complication was iatrogenic damage to dental roots
(2%), needle stick injuries were encountered in 3(6%) cases and mean time taken for intermaxillary fixation was 15.9 + 2.6 minutes. observed in 2(4%) cases. Interpretation and Conclusion: Use of self tapping IMF screws for intermaxillary fixation is a valid alternative to conventional methods in the treatment of mandibular fractures. Iatrogenic injury to dental roots is the most important problem to this procedure, but can be minimized by careful evaluation and treatment planning. Key words: intermaxillary fixation; self tapping IMF screws; mandibular fractures. Postoperative malocclusion was
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TABLE OF CONTENTS
Page No. 1. Introduction 1-2
2. Objectives
3. Review of Literature
4-13
4. Methodology
14-23
5. Results
24-35
6. Discussion
36-42
7. Conclusion
43
8. Summary
44
9. Bibliography
45-49
10. Annexures Proforma Master chart 50-54 55-57
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LIST OF TABLES
SL. NO.
TABLES
PAGE NO.
Table 1 Table 2 Table 3
Distribution of mandible fractures according to sex Age wise distribution of mandibular fractures Mandibular fractures distribution according to type of fracture
26 26 26
Table 4 Table 5 Table 6 Table 7
Distribution of mandibular fractures according to site Distribution of mandibular fractures according to etiology Occlusion over a period of one week Relationship between postoperative occlusion and type of fracture
27 27 28 28
Table 8 Table 9
Relationship between postoperative period and pain Oral hygienic over a period of one week
29 29
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LIST OF GRAPHS
SL. NO. GRAPHS PAGE NO. Graph 1 Graph 2 Graph 3 Distribution of mandible fractures according to sex Age wise distribution of mandibular fractures Mandibular fractures distribution according to type of fracture Graph 4 Graph 5 Distribution of mandibular fractures according to site Distribution of mandibular fractures according to etiology Graph 6 Graph 7 Occlusion over a period of one week Relationship between postoperative occlusion and type of fracture Graph 7a Postoperative occlusion Graph 8 Graph 9 Relationship between postoperative period and pain Oral hygienic over a period of one week 33 34 34 35 32 33 31 32 30 30 31
Graph 10 Incidence of injuries
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LIST OF PHOTOGRAPHS
SL. NO. FIGURES PAGE NO. Figure 1 Figure 2 Armamentarium Self tapping IMF screws with screw holder and screw driver Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Preoperative OPG Pilot hole Placement of screw Screws in place IMF with self tapping IMF screws - case I IMF with self tapping IMF screws - case II Screws in place 7th post operative day Post operative OPG 20 20 21 21 22 22 23 23 19 19
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Introduction
Introduction
INTRODUCTION
Primate evolution has made the human head very vulnerable to frontal impacts. The vulnerability of human head would have fewer consequences if we were less pugnacious and less inventive. Wars, murders and assaults are older than the recorded history and in these conflicts face has always been a favoured target. Maxillofacial trauma, which may result from accidental or assault injuries to the craniofacial complex represents 42% of all injuries. In these 70% are mandibular fractures and 30% are maxillary fractures. Among the mandibular fractures, 43% were caused by road traffic accidents, 34% by assaults, 7% were work related, 4% were sports related, and the remainder had miscellaneous causes1.
Edwin Smith, an ancient Greek, provides a clear cut documentation for the treatment of mandibular fractures dating back as early as 17th century. Between 25 BC and 11th century AD, surgeons and writers such as Sushruta (India), Celsus (Rome) and Avicenna (Middle East) described conservative means of treating jaw fractures. Sushruta advocated the use of manual manipulation and complicated bandaging to treat mandibular fractures. Avicenna (980 to 1037 AD) emphasized the importance of occlusion during the treatment of these injuries. He advocated the use of supportive dressing around the jaw as well as splints along the teeth. This is the fundamental unique feature of the management of jaw fractures when compared to any other bone in the body2. Mandibular fractures can be treated by intermaxillary fixation alone, or by osteosynthesis with or without intermaxillary fixation3. Intermaxillary fixation can be achieved by eyelets, arch bars, bonded brackets, cast metal splints, vacuum formed splints, pearl steel wires, self-tapping IMF screws and self drilling IMF screws3. The introduction of bone plating system has reduced the prolonged periods of
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Introduction intermaxillary fixation (IMF) or sometimes not required in a patient with the fracture of the mandible. However, there is often a need for temporary intermaxillary fixation intraoperatively to assist in reduction of fractures with the teeth in correct occlusion and post operatively to assist in fixation or to correct minor occlusal discrepancies.
Conventional methods like arch bars and eyelet wires are currently the most common methods of achieving IMF, but they have their own disadvantages. They are time consuming, irritating to surgeon and patient, incidence of needle stick injuries is more and it is difficult to maintain oral hygiene with these methods.4
To overcome these problems, self tapping IMF screws has been introduced. These screws are quick and easy to use and greatly shorten the operating time to achieve maxillomandibular fixation. The risk of needle stick injuries associated with using wires is also reduced. There is no trauma to gingival margins and gingival health is easier to maintain 5. This study is designed to evaluate the efficacy of self tapping IMF screws and their potential advantages in the management of mandibular fractures.
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Objectives
Objectives
OBJECTIVES
To evaluate the efficacy of self tapping IMF screws as a means of Intermaxillary fixation. To evaluate its potential advantages and disadvantages. To evaluate its indications and contraindications
3
Review of Literature
Review of Literature
REVIEW OF LITERATURE
Hippocrates (460-375 BC)6 was the first to mention bandages, as a method to immobilize fracture of jaw using leather straps with a paste so as to adhere them to the skin so that direct traction could be applied. Barton JR (1816)7 introduced Bartons bandage but it had a disadvantage that it tends to drive the mandible posteriorly resulting in many deformities and malunions. Buck (1846), Kinlock (1859)8 are credited with being the first to place an intraosseous wire for the mandibular fracture after the introduction of ether anesthesia. Buck used a simple loop of iron wire and Kinlock used silver wire loops. Gilmer (1887)9 introduced intermaxillary fixation. He passed wires around individual maxillary and mandibular teeth. Both ends of each wire twisted together tightly to prevent them from slipping over the crowns. Then intermaxillary fixation is achieved by cross bracing the twisted wires. Angle (1890), Schroeder (1911)10 described the banded dental arch wire appliance. A previously prepared band is held with the help of a nut and bolt and which includes a channel to receive arch wire and is applied to the last molar on each side. The two bands on the ends of the rows of teeth are connected with each other by an arch wire inserted into the channel. Ivy RH (1922)11 introduced the interdental eyelet wiring. He believed that if a fractured jaw was fixed in correct occlusion, the bone fragments, supporting them, in most cases will also be satisfactorily reduced. The disadvantage of this technique was
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Review of Literature that the eyelet was drawn into the interdental space as the wires were tightened and proved difficult to insert other wire through them. Risdon (1929)12 advised an alternate to arch bar. He used a 1mm or 0.5mm soft stainless steel wire passed around the posterior tooth on each side. The end of the wire was twisted on the buccal side until both overlap in the midline, which are then in turn twisted together. The standing teeth are then secured to this arch bar. Schuchardt (1956), Schuchardt, Metz (1966)13 described the acrylated arch bar technique. The advantage of this technique was prevention of arch bar from lying against gingival tissues, hence preventing stagnation or pressure necrosis of gingival tissue. Williams (1968)13 designed a double loop eyelet which overcame the problems of drawing the eyelet in interdental space after tightening the wire. Leonard (1977)13 described the use of titanium buttons to overcome the drawbacks of eyelet wiring. He used buttons of 8mm diameter, inclusive of 1mm rim and 2mm deep. Each button had two holes (1mm diameter) 1 mm apart. The ends of 15cm length of 0.4mm wire are passed through the holes and then twisted together in the deep surface of buttons. The button was then ligated on the teeth in a similar manner to the eyelet wires, leaving the button over the interdental space. Intermaxillary fixation was easily achieved by stainless steel wires or elastic bands fixed around opposite buttons. Maw RB (1981)14 stated that recognizing the inconvenience to patients of having their jaws immobilized for protracted period of time, mandibular fractures could be treated without maxillomandibular fixation.
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Review of Literature Shephard BC (1982)15 studied the oral effects of prolonged intermaxillary fixation in 106 severely obese patients. The principle complications during fixation were episodes of periodontal pain and tooth mobility. The post operative complication included gradual periodontal problems and mandibular limitations. Kane O (1986)13 pointed out that Leonard button was inappropriate where patients had a severe cross bite posteriorly or marked anterior over bite. Baurmash H (1988)16 mentioned the shortcomings of the conventional arch bars for the treatment of maxillamandibular injuries. They advocated the use of a mesh backed arch bar bonded to the teeth as a means of overcoming these problems. Arthur G, Berardo N (1989)17 suggested the use of 2mm diameter of titanium self-tapping bone screws of variable length through pilot drill for maxillomandibular fixation. The sites for placement of the bone screws depend on anatomic structures (i.e., nerve trunks, nasal mucosa etc) and the position of fractures. Ideal maxillary site include the pyriform rim area and zygomatic buttress region. In the mandible, the entire region below the root apices and between the mental foramina is an acceptable site. Also alveolar process of edentulous ridge is acceptable site. The advantages of this technique include minimal amount of hardware, decreased operative time, reduces the risk of inadvertent skin puncture of the surgeon while still achieving adequate maxillomandibular fixation. Henderson DK, Gerberding JL (1989)18 found that the health care workers are at risk of acquiring HIV infection subsequent to accidental sticks with needle contaminated with blood from infected patients.
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Review of Literature Lagvankar S.P. (1990)19 described a simple and easy method for the fixation of an arch bar. It gives a consistently firm fixation even in difficult situations and does not require any sophisticated appliances. Millar BG (1990)20 compared histologically the tissue response of stainless steel and titanium screws when inserted to the calvaria of eight beagle dogs. There were minimal fibrous reactions around both screw types with excellent long term bone healing. After 24 weeks, there was no discernable difference in the tissue reaction between the two types of screws. Williams JG, Cawood JI (1990)21 conducted a study to measure the pulmonary effects of intermaxillary fixation. They demonstrated that this technique produces a significant degree of airway obstruction. This presents danger to patients with limited respiratory reserve due to chronic obstructive air way disease. Booth PA, Collins IG (1990)22 reported a technique for constructing acid etched arch bars, this technique provides appropriate location of osteotomy segments in the absence of orthodontic brackets. The arch bars can be applied preoperatively with a subsequent economy of operating theatre time. This technique has been used in 32 cases with only failure caused by faulty etching technique. Graven PM (1990)23 described a modified orthodontic bracket for use in intermaxillary fixation. He used a stainless steel wire of a diameter, which fits snuggly in to the brackets slot. The wire was then bent to form a loop around the bracket and at least four spot welds were placed. This overcame the difficulty of placing elastic bands or wire for intermaxillary fixation.
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Review of Literature Win KKS (1991)24 reported that a technique of intermaxillary fixation using screws anchored in the maxilla and mandible has been described. AO (Synthes
(R)
screws with a diameter of 3.5mm and 12mm to 16mm in length were inserted at the anterio-lateral surface of the maxilla and the buccal surface of the mandible. In this technique, under local anesthesia, a horizontal vestibular incision was made from right to left first molar region after exposing the bone; a 2mm drill is used to make the pilot hole. The upper and lower dentures were put into the place to maintain the occlusal height. Intermaxillary fixation was applied. This technique is particularly suitable for mandibular fractures in denture wearing patients. Scully C, Porter S (1991)25 showed in their study that the occupational risk of HIV to dental staff is virtually nonexistent. There is abundant evidence to prove that close social contact with HIV infected individuals does not transmit HIV in the absence of exposure to infected blood or other body fluids. Major occupational risk for transmission of HIV is from sharp injuries. Brown JS (1991)26 compared the cost effectiveness of intermaxilary fixation as compared to mini plate osteosynthesis in the management of fractured mandible . They concluded that the use of miniplates is no more expensive than the use of IMF in the management of fractured mandible. In addition, the use of IMF significantly increased the time spent off work. In his study he also found that during certain high risk procedures, greater protection to the surgeon can be obtained by tripple gloving. The use of cut resistant glove lining or tripple layer latex gloving is superior to double layer latex gloving. Bush RF, Frunes F (1991)27 suggested the use of 2.7mm diameter intraoral cortical bone screws instead of 2.0mm diameter suggested by Arthur and Berardo.17
8
Review of Literature The technique involved the use of 2.7mm self taping bone screws of length 16 or 20mm is used for maxilla while 24mm is used for the mandible which were placed into the maxilla and mandible for 8 to 12mm depth in bone to provide points of fixation. In this technique, a small stab incision is used to expose the area, drill is used to make pilot hole and a mini driver is used to place the screws. He concluded that with this technique less HIV infections, less operating time, minimal hardware and superior stabilization was achieved. Smith AT (1993)28 describes the use of orthodontic elastomeric chain for a firm and resilient temporary intermaxillary fixation. The advantages of this technique includes time efficiency, relative safety compared to tie wring techniques and flexibility of direction of pull and ease with which the elastics can be removed. Busch RF (1994)29 in his editorial wrote that risk of transmission of acquired immunodeficiency syndrome (AIDS) from percutaneous inoculation of infected blood to be 0.36% (less than 1 in 250). These risks although low are significant for a disease with a predicted mortality rate of 100%. The risk of infection with HBV is probably greater than 20% after percutaneous inoculation of infected blood.
He used self-taping intermaxillary fixation screws in 67 patients in his two years study. He found that complications were relatively few. There was one case of periodontal abscess distant from screw site, one case of cellulites around screw and one screw is displaced in the maxillary sinus. Loss of fixation occurred in six patients. There were three reasons for loss of fixation: to allow oral intubation for another operative procedure, emesis, and personal desire by the patient to terminate fixation.
9
Review of Literature Karlis V, Glickman R (1996)30 utilized a titanium 2.0mm self tapping screw. The screw head was machined to a smooth polished surface, into which a hole was milled allowing for a 24 gauge stainless steel wire to pass through achieving intermaxillary fixation. The author used this technique in 5 patients with mandibular fracture with satisfactory results. The advantages of this system include easy placement and removal with minimal hardware, significant decrease in operative time from 45 minutes for arch bars to 10 minutes for IMF screws Zachariader K, Mezitis M, Rallis G (1996)31 in their 9 year study concluded that compression osteosynthesis gives the lowest rate of infection while comparing with intraosseous wiring or intermaxillary fixation. Heidemann W, Gerlach KL (1998)32 stated that use of self tapping screws in miniplate osteosynthesis have some potential disadvantages. Disadvantages include damage to the nerves, roots or tooth germs, thermal necrosis of bone and drill bit breakage. Recently developed form of osteosynthesis screw called as drill free screw (DFS) which enables screw to be inserted without drilling will avoid these problems. Aldegheri A, Blanc JL (1999)33 introduced an easy safe, rapid and cheap MMF appliance called the pearl steel wire. The pearl steel wire consists of a 26-gauge steel wire with a small necklace-like pearl attached to one end using resin. The pearl steel wires are passed into the interdental space from the lingual side to the vestibular side. MMF is achieved by connecting the ends of the maxillary and mandibular pearl steel wire and twisting it together. The best indication for pearl steel wire is cases in which MMF is not required after rigid osteosynthesis.
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Review of Literature Fordyce AM (1999)34 undertook a retrospective study of 115 isolated mandible fractures, which was treated by open reduction and internal fixation using titanium miniplate osteosynthesis. In his study, 66 patients had their fractures reduced manually to obtain anatomical reduction without the use of preoperative intermaxillary fixation. In rest 49 fractures were treated conventionally using preoperative intermaxillary fixation. The author came to the conclusion that overall there was significantly few occlusal discrepancies in the early postoperative period and that there was no difference in the final outcome of the occlusion between the two methods of fixation. The author stresses that avoidance of use of preoperative intermaxillary fixation is more economical in time and cost, and is safer for the operator and more comfortable for the patient. Jones DC (1999)35 suggested the use of threaded titanium screws 2mm in diameter and 10-16mm in length with a capstan head and inserted with a hexagonal headed central drive screwdriver. The use of screws with capstan style head is important as it allows the wires or elastic to be held away from the gingivae, preventing local damage. He suggested that bicortical screws were adequate for temporary intraoperative fixation and postoperative elastic traction. Heidemann W, Gerlach KL (1999)36 studied drill free screws of 1.5mm (micro) and 2mm (mini) diameter with length of 4mm and 7mm for miniplate osteosynthesis in 518 patients. They found that DFS was sufficient for the fixation of bone fragments in the central and lateral midface and in the mandibular anterior area. The application of DFS in the mandibular angle and comminuted fracture is not recommended. Disadvantages of DFS include, higher pressure is necessary perforating the bony surface and screw fractures may occur. Advantage are less
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Review of Literature damage to vital structures like nerve and root, less risk of stripping bone threads in cortical bone and quick insertion is possible. Holmes S, Hutchison I (2000)37 reported a case in which one threaded titanium 2.0mm capstan headed bicortical intermaxillary fixation screw sheared at bone level and hence advocate caution with use of these screws and suggested the technique of two forward turns accompanied by one backward turn to exclude the swarf from the pitch of the screw. Steven K, Gibbons A (2001)38 used 400 self-taping IMF screws during a period of 3 years. They highlighted the problem of grooving of adjacent tooth with occasional exposure of root canal. They recommended a thorough clinical and radiographic assessment of the teeth adjacent to the site of IMF screw placement. Mujumdar A (2002)39 reported a case of iatrogenic injury caused by predrilled type of intermaxillary fixation screws. He strongly advocated the importance of care to ensure correct placement of these screws in the canine premolar region to prevent any damage to teeth. Farr DR (2002)40 reported a case of fracture of screw at the junction of screw head and threaded portion. Coburn DG (2002)41 described the various complications encountered in the use of intermaxillary screws in the management of fractured mandibles. The most common complications encountered were screw breakage during insertion, injuries to the roots of adjacent teeth. They recommended that care be taken during the insertion of the screw, with regards to both positioning and insertion torque.
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Review of Literature Gibbons AJ, Hodder SC (2003)42 developed a self drilling IMF screws for intermaxillary fixation. Self-taping intermaxillary fixation screws are quick and easy to use and greatly shorten the operating time to achieve maxillomandibular fixation. They are relatively inexpensive and reduce the risk of needle stick-type-injuries associated with using wires. There is also no trauma to gingival margins and gingival health is easier to maintain compared with when arch bars or eyelets are used. But there are some disadvantages of self-taping IMF screws. To overcome these problems a self-drilling IMF screw has been developed. Huang W, Cao ZQ, Fang D, Hu ZY (2004)43 reported 41 cases of mandible fractures treated with the intermaxillary fixation screws. They advocated that application of intermaxillary fixation screws advanced the traditional methods of intermaxillary fixation. Fabbroni G, Aabed S, Mizen K, Starr DG (2004)44 studied the incidence of screw/tooth contact in the placement of transalveolar screws. They concluded that screw/tooth contact does occur using transalveolar screws; however, the incidence of clinically significant damage appears to be very low. Gibbons AJ (2005)45 reported an interesting case of arch bar support using self drilling intermaxillary screws In the treatment of mandibular fractures. Roccia F, Tavolaccini A, Dellacqua A (2005)46 evaluated the indications and possible complications of intraoral cortical bone screws. They concluded that intraoral cortical bone screws for intermaxillary fixation are a valid alternative to the arch bars in the treatment of mandibular fractures.
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Methodology
Methodology
METHODOLOGY
MATERIALS : This study was an attempt to evaluate the efficacy of self tapping IMF screws as a mean of intermaxillary fixation in the treatment of mandibular fractures carried out on a total of 50 patients. The criteria of selection of cases were those who had sustained mandibular fractures and reported to the department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere. Patients were selected by random sampling.
INCLUSION CRITERIA : 1. 2. 3. 4. Fractures of the dentulous mandible Undisplaced fractures of the mandible Minimally and moderately displaced fractures of the mandible Patients with fracture mandible in age group of 18 60 years
EXCLUSION CRITERIA : 1. Comminuted fractures of mandible 2. Severely displaced fractures 3. Children with erupting teeth 4. Fracture of edentulous mandible
The selected cases were treated by open reduction and fixation under GA. In these cases self-tapping IMF screws were used as a method of intermaxillary fixation intraoperatively. Intermaxillary fixation was achieved with 26 gauge stainless steel wire.
14
Methodology Self tapping IMF screws are 2.5mm in diameter, 8/10 mm in length and its head is 4mm in length and 6mm in diameter (Fig. 2). The screw has a pointed tip and its head having a slot where the wire can be passed for intermaxillary fixation.
MATERIALS USED : 1. 2% lignocaine hydrochloride 2. Visual analogue scale 3. Self tapping IMF screws 4. Screw holder and screw driver 5. Straight surgical hand piece 6. Straight fissure bur with 2mm diameter 7. Normal saline for irrigation 8. 26 gauge wire 9. Wire twister and cutter
METHODS : Procedure : After taking the detailed history, patients were thoroughly examined; radiographs and photographs were also taken for each patient. With the aid of orthopantomograph, the exact site of screw placement is determined taking care that the screws are positioned interdentally. Further care is also taken so that screw is not placed too far below the root apex as the screw is than covered by vestibule and making it difficult to put wires. Screws were inserted, at least one in each quadrant, under general anesthesia. The sites of placement of screws in maxilla includes the zygomatic buttress region and in between canines and first premolar.
15
Methodology In the mandible care is taken not to place the screw too far inferiorly as it may endanger the inferior dental nerve and vessels. Prior to placement of screws, 2% lignocaine with adrenaline is infiltrated both labially and lingually Once the position of screw placement is determined the guiding hole is drilled using a straight surgical hand piece and a straight fissure bur of 2mm diameter (Fig. 4). Care is taken that the bur enters the alveolar bone at right angles so as to avoid injuries to roots.
The screw is secured in a screw holder and inserted into previously drilled hole in a clockwise direction (Fig. 5). The screw is passed through the buccal and palatal/lingual cortices and inserted until the flat surface of the head fits snugly against the buccal mucosa (Fig. 6) and IMF is achieved with the help of 26 gauge wire (Fig. 7). Care is taken that the screw does not penetrate the palatal or lingual mucosa where it could cause soft tissue irritation.
Antibiotic therapy is maintained for five postoperative days. All patients are checked using a panoramic radiograph after the removal of the screws to evaluate any possible iatrogenic injury to the teeth. Screw removal is done after achieving satisfactory fixation. This procedure is painless and is usually done without local anesthesia.
The following post operative instructions were given : Patients were asked to brush the teeth with soft baby tooth brush. Have only liquid diet - 200ml/ 2 hourly. Use mouth wash at least 4 times in a day and after having liquid diet. Follow up regularly.
16
Methodology For the statistical convenience the etiology of fractures are divided into 4 types : Road traffic accidents Falls Assaults Sports related injuries Sex incidence of fractures was evaluated.
The patients who were treated were divided into 4 groups : < 20 years 21 - 30 years 31- 40 years > 40 years
The fractures were divided into 2 types : Undisplaced Displaced Minimally displaced Moderately displaced
The fracture sites were evaluated : Parasymphysis Angle of the mandible Body of the mandible Subcondylar and parasymphysis Angle and parasymphysis Angle and body Body and parasymphysis
17
Methodology The changes in occlusion over the period of one week were noted. The occlusion was scored as follows : Normal Mild derangement Moderate derangement Gross derangement
The changes in oral hygiene across one week were noted. The changes were scored as follows: Good Fair Poor
The changes in pain status across the one week were noted and scored as follows: No or mild pain Moderate pain Severe pain
The changes in edema at the screw site across one week were noted as follows : Absent Present
Time taken for intermaxillary fixation, incidence of needle stick injuries and iatrogenic injuries to teeth were also evaluated.
18
Photographs
19
20
21
22
23
Results
Results
RESULTS
Fifty patients reporting to the Department of Oral and Maxillofacial Surgery, College of Dental Sciences Dvangere, presenting with the fracture of mandible were selected to study the efficacy of self tapping intermaxillary fixation screws.
Among the 50 cases, there were 47 (94%) males and 3 (6%) females patients (Table-1, Graph-1). 4 (8%) patients were below 20 years, 21 (42%) were between 2030 years, 19 (38%) were between 30-40 years and 6 (12%) were above 40 years (Table-2, Graph-2). Among these, 35 (70%) were minimally displaced, 5 (10%) were moderately displaced and 10 (20%) were undisplaced (Table-3, Graph-3). Out of 50 cases 27 (54%) had fracture of parasmphysis, 9 (18%) had angle fracture, 2 (4%) had body fracture, 1 (2%) case reported with parasymphysis and subcondylar fracture, 7 (14%) cases had angle and parasymphysis fracture, 2 (4%) cases reported with angle and body fracture, 1 (2%) case had body and parasymphysis fracture and 1(2%) case reported with fracture of body and subcondylar (Table-4, Graph-4).
Occlusion was deranged in all displaced fractures. Cases treated included dentulous and partially edentulous patients. There were no cases of severely displaced fracture and edentulous patients. Etiology of mandibular fractures was also evaluated. 35 (70%) fractures were caused by road traffic accident, 2 (4%) fractures were result of fall, 11 (22%) fractures reported with history of assault and 2 (4%) fractures were result of sports related injury (Table-5, Graph-5).
In all the cases there was achievement of satisfactory occlusion intraoperatively. In 2 (4%) cases, there was occlusal discrepancy on first postoperative day. Out of these two cases 1 (2%) case had moderate derangement whereas 1 (2%) case had mild occlusal discrepancy (Table-6, Graph-6). At the end of 24
Results 7th postoperative day 48 (96%) cases had normal occlusion, 1 (2%) cases had mild occlusal discrepancy and 1 (2%) case had moderately deranged occlusion. All the cases with mild occlusal discrepancy showed statically significant improvement (Table-6, 7 Graph 7, 7a); over a period of one week and only 2 (4%) cases had postoperative malocclusion. Changes in the pain status were noted over a period of one week and statically significant improvement was observed. On first postoperative day all the patients had severe to moderate pain, whereas on 7 th postoperative day none of the patients had severe pain, only 2 (4%) patients had moderate pain and 48 (96%) patients reported with mild or no pain (Table-8, Graph-8). Changes in edema at the screw site across one week were noted with none of the patients showing any signs of edema on the 7th postoperative day. Over all, oral hygiene was good and improved after meticulous teaching of the patients to keep the oral cavity clean. Brushing was easier to perform and there was tremendous improvement in oral hygiene in cases where oral hygiene was poor. (Table-9, Graph-9) None of the cases reported infection, mobility or tenderness to teeth adjacent to screw placement and mobility of the fracture segments.
There was 1 (2%) case of root penetration with self tapping IMF screws and needle stick injuries were reported in 3 (6%) cases (Graph-10). Average time taken for the intermaxillary fixation with the help of self tapping IMF screws was 15.9 2.6 minutes with range of 12 23 minutes.
25
Graphs and Tables
Results TABLE 1 DISTRIBUTION OF MANDIBLE FRACTURES ACCORDING TO SEX Sex Male Female No. of cases 47 3 Percentage 94 6
TABLE 2 AGE WISE DISTRIBUTION OF MANDIBULAR FRACTURES Age group < 20 20-30 30-40 > 40 No. of cases 4 21 19 6 Percentage 8 42 38 12
TABLE 3 MANDIBULAR FRACTURES DISTRIBUTION ACCORDING TO TYPE OF FRACTURE Type of fractures Undisplaced Minimally displaced Moderately displaced No. of cases 10 35 5 Percentage 20 70 10
26
Results
TABLE 4 DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO SITE Site Parasymphysis Angle Body Subcondylar and Parasymphysis Angle and Parasymphysis Angle and Body Body and Parasymphysis Body and Subcondylar No. of cases 27 9 2 1 7 2 1 1 Percentage 54 18 4 2 14 4 2 2
TABLE 5 DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO ETIOLOGY Etiology RTA Falls Assault Sports related injuries No. of cases 35 2 11 2 Percentage 70 4 22 4
27
Results
TABLE 6 OCCLUSION OVER A PERIOD OF ONE WEEK 1st day Occlusion Normal Minimally deranged Moderately deranged Grossly deranged 1 2 1 2 1 2 1 2 n 48 1 % 96 2 n 48 1 3nd day % 96 2 n 48 1 5th day % 96 2 n 48 1 7 th day % 96 2
TABLE 7 RELATIONSHIP BETWEEN POSTOPERATIVE OCCLUSION AND TYPE OF FRACTURE Type of fractures n Undesplaced (10) Minimally displacement (35) Moderately displacement (5) Total (50) 10 34 4 48 Normal % 100 97.14 80 96 Deranged occlusion n 1 1 2 % 2.85 20 4
P < 0.001, highly significant.
28
Results
TABLE 8 RELATIONSHIP BETWEEN POSTOPERATIVE PERIOD AND PAIN Pain No or mild Moderate Severe X2 = 92.3 1st day 46 4 3rd day 33 16 1 5 th day 46 4 7th day 48 2 -
p < 0.001, Highly significant
TABLE 9 ORAL HYGIENIC OVER A PERIOD OF ONE WEEK Oral hygiene Good Fair Poor 1st day 3 46 1 3rd day 3 47 5 th day 8 42 7th day 8 42 -
P < 0.001, Highly significant
Needle stick injuries 3/50 (6%) Time taken for IMF 15.9 2.6 min (12-23 min) Iiatrogenic injury to teeth 1/50 (2%)
29
Results
GRAPH - 1 DISTRIBUTION OF MANDIBLE FRACTURES ACCORDING TO SEX
Male Female
47
GRAPH - 2 AGE WISE DISTRIBUTION OF MANDIBULAR FRACTURES
25
21 19
20
No. of cases
15
10 4 5
0 < 20 20-30 30-40 > 40 Age group
30
Results
GRAPH - 3 MANDIBULAR FRACTURES DISTRIBUTION ACCORDING TO TYPE OF FRACTURE

35 35 30
No. of cases
25 20 15 10 5 0 Undisplaced Minimally displaced Type of fractures Moderately displaced 10 5
GRAPH - 4 DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO SITE
30 25
No. of cases
27
20 15 10 5
Angle Parasymphysis
9 7 2
Body
1
Subcondylar / Parasymphysis Angle / Parasymphysis
2
Angle / Body
1
Body / Parasymphysis
1
Body / Subcondylar
Site
31
Results GRAPH - 5 DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO ETIOLOGY

35 35 30 25
No. of cases
20 15 10 5 0
RTA Falls Assault Sports related injuries
11
Etiology
GRAPH - 6 OCCLUSION OVER A PERIOD OF ONE WEEK
50 45 40 35 30 25 20 15 10 5 0
48
48
48
48
No. of days
Normal Minimally deranged Moderately deranged Grossly deranged 11 0 7th day
11 0 1st Day
11 0 3rd day
1 10 5th day
Occlusion
32
Results
GRAPH - 7 RELATIONSHIP BETWEEN POSTOPERATIVE OCCLUSION AND TYPE OF FRACTURE
34 35 30
No. of cases
25 20 15 10 5 0
Undesplaced Minimally displacement Moderately displacement
10 0 1 4 1
Type of fractures Normal Deranged Occlusion
GRAPH 7a POSTOPERATIVE OCCLUSION
Normal Deranged occlusion

48
33
Results
GRAPH - 8 RELATIONSHIP BETWEEN POSTOPERATIVE PERIOD AND PAIN

48
50 45 40
No. of cases
46
46
35 30 25 20 15 10 5 0 1st day 0 4
33 No or mild Moderate Severe
16
1 3rd day
4 0 5th day
2 0 7th day
GRAPH - 9 ORAL HYGIENIC OVER A PERIOD OF ONE WEEK
50 45 40 35
No. of cases
46
47 42 42
30 25 20 15 10 5 0 1st day 3rd day 5th day 7th day 3 1 3 0 8 0 8 0
Good Fair Poor
34
Results
GRAPH - 10 INCIDENCE OF INJURIES
46
No injury
Needle stick injuries
Iiatrogenic injury to teeth
35
Discussion
Discussion
DISCUSSION
Orofacial trauma surgery is the foundation from which the specialty of maxillofacial surgery arose, and significantly expanded over the last 50 years. 47
Management of fractured facial bones presents some challenges of its own: a need to restore a normal (pretrauma) occlusion, maintenance of facial symmetry and balance, and complex movements of temporomandibular joint. Recognition of existing problem is essential, followed by reduction of fracture(s), retention of the bony segment in reduced position, and rehabilitation during and after bone healing48. Surgery is discipline based on principles that evolved from both basic research and centuries of trial and error. The treatment of maxillofacial fractures involves different methods from bandages and splinting to recent methods of open reduction and internal fixation and usually requires control of the dental occlusion with the help of intermaxillary fixation which is time consuming at times.49
Introduction of bone plating system has reduced prolonged periods of intermaxillary fixation or sometimes not required in patients with fractures of the mandible.25 However, there is often a need for temporary intermaxillary fixation intraoperatively to check the occlusion and postoperatively to assist in fixation or to correct occlusal discrepancies by elastic traction. Arch bars and eyelet wires are currently the most common methods of achieving intermaxillary fixation, although other methods are described1. The disadvantage of eyelet wiring is that, as the eyelet is drawn into the interdental space and the wire is tightened, it proves difficult to insert other wires through the eyelet11. The placement of arch bar is time consuming and uncomfortable to the patient. Among the disadvantages of using arch bar include movement of teeth in lateral and extrusive direction, difficulty to secure arch bar in
36
Discussion isolated posterior teeth, periodontal tissue injury, difficulty in maintaining good oral hygiene and it is not suitable for dentition that carry extensive crown and bridge work4.
The self tapping intermaxillary screws were first introduced by Arthur and Berardo17 in 1989 and later modified by Carl Jones4 with a Capstan shaped head design17. He suggested the use of threaded titanium screws of 2mm diameter and 10 to 16 mm in length. According to him, screws with capstan style head are important as it allows the wires and elastics to be held away from the gingival tissue. These screws are quick to insert and have fewer risks of needle stick injury than conventional methods, the operating time is reduced from one hour to 15 minutes. The most suitable fractures are those that are undisplaced4. In the present study also none of the undisplaced fractures showed any occlusal discrepancy. Edentulous fractures are indicated if dentures or splints are available. They are suitable for patients with extensive crown and bridge work and maintenance of oral hygiene is not compromised with screws in place. He recommended the use of these screws for temporary intraoperative IMF and postoperative elastic traction. Self tapping intermaxillary fixation screws are not indicated for severely comminuted fractures, extensive alveolar bone fractures and missile injuries to the jaws. The authors used 2mm diameter self tapping screws of variable length. In our study we used 2.5mm diameter self tapping screws of 10mm length. While author used 24 gauge stainless steel wires for IMF, we used 26 gauge wires for IMF. We also came across the advantages mentioned by the author.
The use of double headed bicortical screws have been described by several authors. The advantages of this technique have been discussed by these authors. Self
37
Discussion tapping screws in miniplate osteosynthesis have some potential disadvantages which include damage to the nerves, roots or tooth germs, thermal necrosis of bone and drill bit breakage. Recently developed drill free screws avoid these problems35. Complication using self tapping intermaxillary fixation screws includes fracture of the screws on insertion, iatrogenic damage to teeth and bony sequestrum around the area of screws placement. Drill tip may break off in bone and if the speed of the drill is too fast surrounding mucosa and bone may be burnt, resulting in painful ulceration. If the screws are left in place postoperatively this overheating can cause thermal necrosis of bone around the screw and lead to loosening. Self tapping intermaxillary fixation screws may shear at bone level during insertion29. Farr DR (2002)40 reported a case of fracture of screw at the junction of screw head and threaded portion, where as no such case of screw fracture was encountered in the present study. Coburn DG (2002)41 also observed the similar complications. He recommended a careful drilling of bur hole, with slow bur speed and copious irrigation with sterile saline. He further suggested that the screw should be inserted at an even speed and should not be forced if resistance is encountered. A similar complication was also reported by Simon Holmes (2002)37. He advocated caution with use of bicortical screws and suggested the technique of two forward turns followed by one backward turn to exclude the shaft from the pitch of the screw. The second complication mentioned with self tapping screws was the injury to the roots of the teeth adjacent to the screw fixation site, although only one case of iatrogenic injury to the adjacent teeth was reported in the present study. Mujumdar (2002)39 also reported one case of root damage using self tapping screws. He mentioned his system include easy placement and removal with minimal
38
Discussion hardware, significant reduction in operating time from 45 minutes to 10 minutes and equal ease of application in dentate and non dentate patients. The above mentioned advantages were similar to our study. The operator must be confident that he/she has felt the bur drop in the medullary bone after having perforated the buccal cortex, before lingual/palatal cortex is encountered. If this change in resistance is not felt,
the possibility of bur being partly or fully in a tooth root should be considered. Steven Key (2000)38 recommended a thorough clinical and radiographic assessment of the adjacent teeth to the site of screw placement. The alignment of the teeth in three dimensions should be fully appreciated. We recommend placing self tapping screws between the canine and first premolar region at the mucogingival junction or placing it below the root apices of the mandibular teeth or above the root apices of the maxillary teeth.
Another complication associated with this method was the loosening of the screws. Busch RF (2000)27 also reported a similar complication in their study. They recommended use of greater diameter screws placed away from root apices. However no such complication was encountered in the present study.
In the present study, the time taken to achieve intermaxillary fixation with self tapping IMF screws was noted. According to the data, it is evident that the maximum time taken was for arch bar fixation (approximately 1 hour). The average time taken for IMF with the self tapping IMF screw was found to be 15.9 minutes in the present study. The data from various studies is in agreement with the present study which suggests that the time taken for arch bar fixation is considerably higher than the time taken for self tapping IMF screws27,30,35.
39
Discussion The incidence of needle stick injuries was also noted and it was inferred that incidence of needle stick injuries is much higher, in cases of arch bar and eyelet fixation when compared to self tapping IMF screws. Similar results were noted in the studies done by various authors30,35,37,45 Henderson DK and Gerberdins JL (1989)15 found that the health care workers are at risk of acquiring HIV infection subsequent to accidental sticks with needle contaminated with blood from infected patients. In our prospective study we use less amount of stainless steel wires i.e., only 3-4 wires for IMF as compared to arch bar and we have encountered only 3 (6%) cases of needle stick injuries. Win KKS et al (1991)24 used self tapping screws of diameter 3.5mm and 12mm/ 16mm in length. They used horizontal stab incision before using drill to make the pilot hole. He used self tapping IMF screws in three partially edentulous patients with dentures. In our study we are not placing any incisions before placing the self drilling screws. Bush RF and Frunes F (1991)27 used 2.7mm diameter self tapping IMF screws of length 16/20mm. They mentioned that this technique had less infections, reduced operating time, minimal hardware and superior stabilization than other techniques. Busch RF (1994)29 used self tapping IMF screws in 67 patients in his 2 year study. He reported periodontal abscess distant from screw site, one case of cellulitis around screw and one screw was displaced into the maxillary sinus. In our study, we have not come across such complications. Author reported loss of fixation occurred in 6 patients. In our study there was no case of loss of fixation. He mentioned the advantages of self tapping IMF screws, which includes a reduced risk of percutaneous contamination, the technique was simple to learn and use and operating time was
40
Discussion reduced from one hour to 15 minutes. In our study, we found no percutaneous contamination and the technique is simple as well as easy to use. Another complication associated with self tapping IMF screws is that, they become embedded in the soft tissue over a period of time and during their removal necessitate use of stab incision under local anesthesia. This complication was encountered in 2 patients in the present study. It is suggested that screws should not be placed very close to mucogingival junction to avoid their embedment in the soft tissue. The self tapping IMF screws some time poses problem for the plate positioning during immobilization of the fractured segments. In the present study similar problem was encountered in three cases of parasymphysis fracture of mandible. So it is suggested that plate positioning should also be considered prior to screw placement.
The controversy over whether to treat fractures of the skeleton by open method or closed procedures has been there for over 200 years. The advent of refined aseptic techniques to minimize infection and effective antibiotics have made open reduction method of fracture management more popular47.
In our study, self tapping intermaxillary fixation screws were used for open reduction and internal fixation. We treated all cases of mandibular fracture with open reduction and internal fixation under GA. Mean time taken for intermaxillary fixation with self tapping IMF screws was 15.9 minutes. Time taken for IMF was tremendously reduced when compared with arch bar. Self tapping IMF screws provided good intra operative fixation in all the 50 cases we treated. Post-operatively, there was no incidence of infection, trauma to the surrounding tissues and nerve injury. There was no sign and symptoms of pain and edema at the screw site in all the cases by the 7 th postoperative day in the present
41
Discussion study. Oral hygiene of all the patients was satisfactory and infact it had improved postoperatively after meticulous oral hygiene instructions. It was easier to maintain oral hygiene compared to arch bar. Roccia F, Amedeo T and Alessandro D (2005)46 used IMF screws in 62 patients and suggested that these screws are not indicated where the function of tension band and postoperative directional traction are required, as in multiple comminuted mandibular fractures. Contraindication to screws also includes pediatric patients with unerrupted teeth, and patients with severe osteoporosis. Thus the use of this method is mainly indicated in single or double mandibular fractures with minimal and moderate displacement, and compound condylar fractures46. In our study, post-operative occlusal discrepancy was noted in two cases. Arch bar was placed and elastic traction was given to settle the occlusion in these cases. This may be due to multiple and unfavorable fracture of mandible. In such conditions where postoperative elastic traction is necessary self tapping IMF screws may not be the ideal method of intermaxillary fixation. However, the percentage of malocclusion (4%) after treatment of mandibular fractures observed in this study was similar to that reported by other authors50, and indicates that this technique is a good alternative to conventional methods of intermaxillary fixation when correctly applied.
42
Conclusion
Conclusion
CONCLUSION
Intermaxillary fixation with self tapping IMF screws is a valid alternative to conventional methods in the treatment of mandibular fractures. Self tapping IMF screws offer good temporary fixation intra-operatively to check occlusion and postoperatively for intermaxillary fixation. Self tapping IMF screws are useful in fractures of mandible which are not grossly displaced or comminuted or having a dentoalveolar fracture. It reduces the operating time, the risk of needle stick injuries and damage to the periodontal tissues. This study reveals a low percentage (2%) of iatrogenic injuries to teeth and percentage of postoperative malocclusion (4%) similar to that reported in the literature. Considering the results it would be advantageous to use self tapping IMF screws for treatment of mandibular fractures and extending it to the treatment of other facial fractures i.e. fractures of middle third of face.
43
Summary
Summary
SUMMARY
Fifty patients reporting to the Department of Oral and Maxillofacial Surgery, College of Dental Sciences Davangere, presenting with the fracture of mandible were selected to study the efficacy of self tapping intermaxillary fixation screws.
In all the 50 cases there was achievement of satisfactory occlusion intraoperatively. In our study, post-operative occlusal discrepancy was noted in two cases, arch bars were placed additionally in these cases, elastic traction was given for one week followed by IMF for 4 weeks. In three cases there were needle stick injuries. There was one case of iatrogenic injury to the teeth. Average time taken for the intermaxillary fixation with this method was 15.9 minutes. There was no case of loosening of the screws. Self tapping screws were found to be superior to arch bar and cost effective when compared with self drilling screws. Self tapping IMF screws are indicated in case of displaced, undisplaced fractures of the mandible which are not comminuted or grossly displaced or contain a dentoalveolar fracture. Self tapping IMF screws are also indicated in partially or totally edentulous patients when dentures or splints are available. Screws are not indicated where the function of tension band and postoperative directional traction are required, as in multiple comminuted mandibular fractures. Contraindication to screws also includes pediatric patients with unerrupted teeth, and patients with severe osteoporosis. Thus the use of this method is mainly indicated in single or double mandibular fractures with minimal and moderate displacement, and compound condylar fractures.
44
Bibliography
Bibliography
BIBLIOGRAPHY
1. Fonseca RJ. Oral and maxillofacial trauma Pennsylvannia, WB Saunders Company, 2 nd Edition, Vol .1, 1991,359-414. 2. Ring M.E. Dentistry A illustrated history 1992; Harry N. Abrahams Inc. Publishers, New York; 70. 3. Peter Banks. Killeys fracture of mandible. Varhese publishing house, Bombay: 4th edition : 46. 4. Jones DC. The intermaxillary screw : a dedicated bicortical bone screw for temporary intermaxillary fixation. Br J Oral Maxillofac Surg 1999;37:115 -116. 5. Gibbons AJ, Hodder SC. A self drilling intermaxillary fixation screw. Br J Oral and Maxillofac Surg 2003;41:48-49. 6. Hippocrates. Qeuvres Completes. English translation by ET Withnington. Cambridge, MA. 1928. 7. Barton Jr. A systemic bandage for fracture of the lower jaw. Am Med Recorder Phila 1819;2:153 8. Buck G. Fracture of the lower jaw with replacement and interlocking of the fragments. Annalist NY 1846;1:245. 9. Gilmer TL. Fractures of the inferior maxilla. Ohio State J Dent Sci 1881-1882;1: 309; 2:14,57,112. 10. Eberhard K, Shillic W. Oral and maxillofacial traumatology Chicago, Questense publication, 1982,237-276. 45
Bibliography 11. Ward Peter Booth A. Maxillofacial Surgery. Hong Kong Churchill Living Stone, Vol. I, 1999,66-70. 12. Kurt H Thomas. Oral Surgery, Vol1. 4th ed. CV. Mosby Company, 1963,444-459. 13. Rowe, Williams. Maxillofacial injuries. Churchill Livingston, Vol.
1,1994,287,294 14. Maw RB 1981. A new look at maxillomandibular fixation of mandibular fractures. J Oral Surg 1981; 39:82- 83. 15. Brain Shepherd C. The oral effects of prolonged intermaxillary fixation by interdental eyelet wiring. Int J Oral Surg, 1982;11:292-298. 16. Baurmash, Farr D, Baurmash M. Direct bonding of Arch bars in the management of maxillo mandibular injuries. J Oral Maxillofac Surg 1985;46:813-815. 17. Gregory A, Berardo N. A simplified technique of maxillo mandibular fixation. J Oral Maxillofac Surg 1989;47:1234. 18. Handerson DK, Gerberding JL. Prophylactic zidovidine after occupational exposure to the human immunodeficiency virus - An interim analysis. J Infectious Disease 1989;160:321-327. 19. Lagvanger SP. A new method of arch bar fixation. Br J Oral Maxillofac Surg 1990;28:131-132. 20. Millar BG et al. A histological study of stainless steel and titanium screws in bone Br J Oral Maxillofac Surg 1990;28: 92-95.
46
Bibliography 21. William JG. Effect of intermaxillary fixation on pulmonary function. Int J Oral Maxilliofac Surg 1990;19:76-78. 22. Booth PA, Collins IG. Resin bonded arch bars. 1990;28:133-135. 23. Magemnis PA, Craven. Modification of orthodontic brackets for use in intermaxillary fixation. Br J Oral Maxillofac Surg 1991;20:283-284. 24. Win KKS. Intermaxillary fixation using screws- Report of a technique. Int J Oral Maxillofac Surg 1991;20:283-284. 25. Scully C, Porter S. The level of risk of transmission of human immunodeficiency virus between patients and dental staff. Br Dent J 1991;170:97-98. 26. Brown JS, Grew N. Intermaxillary fixation compared to miniplate osteosynthesis in the management of fractured mandible : an audit. Br J Oral Maxillofac Surg 1991;29:308-311. 27. Bush RF. Maxillomandibular fixation with intraoral cortical bone screws : A 2 yrs experience. Laryngoscope 1991 August;104. 28. Smith AT. 1993. The use of orthodontic chain elastics for temporary intermaxillary fixation. Br J Oral Maxillofac Surg 1993;103 (31):250-251. 29. Busch RF. Maxillomandibular fixation with intraoral cortical bone screws : a two year experience. Laryngoscope 1994;104:1048 1050. 30. Korlis V, Glickman R. An alternative to arch bar maxillo mandibular fixation. Plast and Reconstruct Surg 1996; 99(6):1758-1759. Br J Oral Maxillofac Surg
47
Bibliography 31. Zachariades K, Mezitus M. An audit of mandibular fractures treated by intermaxillary fixation, intraosseous wiring and compression plating. Br J Oral Maxillofac Surg 1996;34:293-297. 32. Heidemann W, Gerlach KL. Drill Free Screws : a new form of osteosynthesis screw. J Cranio-Maxillofac Surg 1998;26:163-68. 33. Aldegperi A. Pearl steel wire : a simplified appliance for maxillo mandibular fixation. Br J Oral Maxillofac Surg 1999;37:117-118. 34. Fordyce AM. Intermaxillary fixation is not usually necessary to reduce mandibular fracture. Br J Oral Maxillofac Surg 1999;37:52-57. 35. Jones DJ. Fixation screw for jaw fractures. J plastic and reconstructive surgery April 1999;101(5):50-58. 36. Heidemann W, Gerlach KL. Clinical applications of drill free screws in maxillofacial surgery. J Cranio-Maxillofac Surg 1999;27:252-55. 37. Holmes S. Caution in use of bicortical intermaxillary fixation screws. Br J Oral Maxillofac Surg 2000;574. 38. Stevan Key. Care in the placement of bicortical intermaxillary fixation screws. Br J Oral Maxillofac Surg 2001;484. 39. Majumdar A. Iatrogenic injury caused by intermaxillary fixation screws. Br J Oral Maxillofac Surg 2002;40:84-88. 40. Farr DR. Intermaxillary fixation screws and tooth damage. Br J Oral Maxillofac Surg 2002; 40:84-85.
48
Bibliography 41. Coburn DG. Complication with intermaxillary fixation screws in the management of fractured mandibles. Br J Oral Maxillofac Surg 2002;40:241-243. 42. Gibbons AJ. A drill free bone screws for intermaxillary fixation in military causalities. JR Army Med Corps 2003 March; 149:30-32. 43. Haung W, Cao ZQ and Fang D, Hu ZY. Applied research of intermaxillary fixation screw in the jaw fracture. Zhomghua Zheng Xing Wai Sep 2004;20(5):364-365. 44. Fabbroni G, Aabed S, Mizen K, Starr DG. Int J Oral Maxillofac Surg 2004;33:442-446. 45. A J Gibbons. Br J Oral Maxillofac Surg 2005Feb. 46. Fabio Roccia, Amdeo Tavolaccini, Alessandro Dellacqua. J Cranio Maxillofac Surg 2005;33:251-254. 47. John D. Langdon, Mohan F Patil. Mandibular osteosynthesis. 1998; Chapman and Hall Medical ; 339-346. 48. Sorel Benrand. Open versus closed reduction of mandibular fractures. Oral Maxillofac Surg Clin N Am 998;10:541- 565. 49. Ole T Jensen 1997. Maxillomandibular fixation with screws. Oral Surg Oral Med Oral Path 1997;83:418. 50. Gordon KF, Read JM, Anand VK. Results of intraoral cortical bone screw fixation technique for mandibular fractures. Otolaryngol Head and Neck Surg 1995;113:248-252.
49
Annexures
Annexures
SELF TAPPING IMF SCREWS, A SIMPLIFIED METHOD OF INTERMAXILLARY FIXATION-A CLINICAL STUDY
PROFORMA
NAME AGE SEX ADDRESS : : : : I.P.No OPD No. DOA DOO DOD : : : : :
OCCUPATION : 1. CHIEF COMPLAINT
2.
HISTORY - Cause of Trauma a. RTA b. Fall c. Assault H/O unconsciousness H/O vomiting H/O amnesia H/O bleeding from ear, nose, mouth Any Paraesthesia / Disesthesia / Anaesthesia Number of days lapsed after trauma Medical history CVS RS CNS Personal habits Family history 50
Annexures 2. CLINICAL EXAMINATION : GENERAL PHYSICAL EXAMINATION.
EXTRA ORAL a. Inspection Asymmetry Haemorrhage Laceration Tissue loss Abrasion Edema Ecchymosis CSF leak Diplopia Trismus Deviation of the jaw
b. Palpation Tenderness Step deformity TMJ movements
INTRA ORAL a. Inspection No. of teeth present Teeth in the line of fracture
51
Annexures Presence of infection Hematoma Ecchymosis Occlusion after the injury Oral Hygiene Status
b. Palpation Tenderness of tooth / teeth Tenderness at fracture site Step deformity Bimanual palpation Paraesthesia or anaesthesia of the involved nerve.
4. RADIOGRAPHIC EXAMINATION
5. CLASSIFICATION OF FRACTURE
6.
LABORATORY INVESTIGATIONS Haemoglobin % Bleeding time Clotting time Erythrocyte Sedimentation Rate Total Leukocyte count Differential Leukocyte count
52
Annexures Blood sugar RBS FBS PP
Blood urea Serum creatinine Blood group Australian antigen HIV Electrocardiogram
6. TREATMENT
Time taken for IMF with self tapping screws:
Occlusion achieved: -Good -Satisfactory -Bad Needles stick injuries during the procedure:
53
Annexures POST OPERATIVE EVALUATION OF THE SCREWS AND ITS EFFECT ON THE TISSUES 1st Day Occlusion Pain Odema Oral hygiene status 3rd Day 5th Day 7th Day
FOLLOW UP OF THE PATIENT AFTER REMOVAL OF THE SCREWS. 3 months
54
Annexures
MASTER CHART Needle stick injury 7 + + -
Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Name Suresh Kumar Prakash Saroja Kumar Jagdish Chandrappa Anjanappa Snakshalie Adarsh Pandu Siddappa Anjanappa Shivanna Vijaykumar Vasu Someshwar Suleman Shivshankarappa Sidramappa Soutanavar Veerabadrappa Chandranna Kariappa Raja Reddy
Age G-II G-I G-II G-III G-II G-III G-II G-II G-III G-II G-III G-III G-III G-II G-I G-II G-III G-II G-III G-III G-III G-IV G-III G-III G-IV
Sex M M M F M M M M M M M M M M M M M M M M M M M M M
Diagnosis A A P P P A P P P P A P P P A/P B/A P A/P A A B/S P P B/A P
Type of fracture D1 D1 D1 D1 U D1 U D1 D1 D1 D1 D1 D1 D1 D2 D2 D1 D1 D1 D1 D1 U U D1 U
Etiology RTA RTA RTA RTA AST RTA RTA RTA RTA RTA AST RTA RTA RTA RTA AST RTA RTA RTA RTA RTA AST AST AST FL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1
Occlusion 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 7 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 P1 P1 P1 P1 P P1 P1 P1 P1 P1 P1 P1 P1 P1 P1 P2 P1 P1 P1 P1 P1 P1 P1 P1 P1
Pain 3 P0 P0 P0 P0 P1 P0 P1 P0 P1 P0 P1 P0 P0 P0 P1 P1 P0 P0 P1 P0 P1 P0 P0 P0 P1 5 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P1 P0 P0 P0 P0 P0 P0 P0 P0 P0 7 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 P0 1 A B A A B B B B B B B B B B B B B B B B B B B B B
Oral Hygiene 3 A B A A B B B B B B B B B B B B B B B B B B B B B 5 A B A A A B B B B B B B B A A B B B B B B B B B B 7 A B A A A B B B B B B B B A A B B B B B B B B B B 1 + + + + + + + + + + + + + + + + + + + + + + + + +
Edema 3 + + + + + + + + + + + + 5 + + + -
Time taken for IMF 18min 15min 15min 16min 20min 14min 18min 14min 15min 15min 16min 14min 15min 12min 21min 22min 12min 15min 17min 16min 18min 18min 16min 16min 15min
55
Annexures
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Md-Jabeer Manjunath Parshuram Honumanthappa Basavraj Wasim Sashidhar Jaiprakash Mahantesh M. Naik Rangappa Ram Naik Siddappa Mala Rudrappa Manjunath Shekharappa Shivkumar Thippeswami Karibasappa Hrishikesh Krishnamurthy Thimmakka Ashok L Kamalamma
G-II G-II G-II G-II G-III G-I G-II G-II G-I G-II G-IV G-II G-III G-III G-IV G-II G-III G-II G-IV G-III G-II G-III G-IV G-II G-III
M M M M M M M M M M M M M F M M M M M M M M M M F
P P A/P A B B A/P P A/P P/S P P P B/P P P P A/P P P A A A/P P P
U U D1 D1 D1 D1 D1 D1 D2 D1 D1 D1 D1 U U D1 D1 D2 D1 D1 D1 D1 D2 U D1
AST AST RTA RTA RTA SPT RTA RTA RTA RTA RTA RTA RTA AST RTA RTA RTA RTA RTA AST SPT RTA AST FL RTA
1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
P1 P1 P1 P1 P1 P1 P1 P1 P2 P1 P1 P1 P1 P1 P1 P1 P1 P2 P1 P1 P1 P1 P2 P1 P1
B B B B B B B B B B B B B B B B B B B B B C B B B
B B B B B B B B B B B B B B B B B B B B B B B B B
B B B B B B B B A B B A B B B B B B B B B B B B B
B B B B B B B B A B B A B B B B B B B B B B B B B
+ + + + + + + + + + + + + + + + + + + + + + + + +
+ + + + + + + + -
+ + + + -
+ -
12min 16min 15min 16min 16min 14min 12min 14min 21min 16min 14min 15min 14min 20min 16min 14min 15min 23m 14min 15min 14min 15min 21min 14min 15min
56
Annexures
KEY TO MASTER CHART

G-I GII Age group < 20 Age group 20-30 Age group 30-40 Age group >40 Male Female Angle Parasymphysis Body Subcondylar and parasymphysis Angle and parasymphysis Angle and body Body and parasymphysis Body and subcondylar Undisplaced Minimally displaced Moderately displaced Road traffic accident Assault Falls Sports related Normal occlusion Minimally deranged Moderately deranged No or mild pain Moderate pain Severe pain Good oral hygiene Fair Poor
G-III G-IV M F A P B S/P A/P A/B B/P B/S U D1 D2 RTA AST FL SPT 1 2 3 P0 P1 P2 A B C -
57

Self Tapping IMF Screws Technique

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Professor and Head of the Department of Oral and

and Dr. Shubhalakshami

Reader Department of Oral and Maxillofacial Surgery, College of Dental

I congregate my gratification to Dr. Kiran Neswi

Dr. DIVYE MALHOTRA

LIST OF ABBREVIATION USED

HBV : HIV IMF : :

MMF : IOPA : LA OPG RTA : : :

Page No. 1. Introduction 1-2

10. Annexures Proforma Master chart 50-54 55-57

Table 1 Table 2 Table 3

Table 4 Table 5 Table 6 Table 7

Graph 10 Incidence of injuries

Graphs and Tables

P < 0.001, highly significant.

p < 0.001, Highly significant

P < 0.001, Highly significant

GRAPH - 1 DISTRIBUTION OF MANDIBLE FRACTURES ACCORDING TO SEX

GRAPH - 2 AGE WISE DISTRIBUTION OF MANDIBULAR FRACTURES

0 < 20 20-30 30-40 > 40 Age group

GRAPH - 3 MANDIBULAR FRACTURES DISTRIBUTION ACCORDING TO TYPE OF FRACTURE

25 20 15 10 5 0 Undisplaced Minimally displaced Type of fractures Moderately displaced 10 5

GRAPH - 4 DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO SITE

Results GRAPH - 5 DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO ETIOLOGY

GRAPH - 6 OCCLUSION OVER A PERIOD OF ONE WEEK

Normal Minimally deranged Moderately deranged Grossly deranged 11 0 7th day

GRAPH - 7 RELATIONSHIP BETWEEN POSTOPERATIVE OCCLUSION AND TYPE OF FRACTURE

Type of fractures Normal Deranged Occlusion

GRAPH 7a POSTOPERATIVE OCCLUSION

Normal Deranged occlusion

GRAPH - 8 RELATIONSHIP BETWEEN POSTOPERATIVE PERIOD AND PAIN

33 No or mild Moderate Severe

GRAPH - 9 ORAL HYGIENIC OVER A PERIOD OF ONE WEEK

30 25 20 15 10 5 0 1st day 3rd day 5th day 7th day 3 1 3 0 8 0 8 0

Good Fair Poor

GRAPH - 10 INCIDENCE OF INJURIES

Needle stick injuries

Iiatrogenic injury to teeth

OCCUPATION : 1. CHIEF COMPLAINT

Annexures 2. CLINICAL EXAMINATION : GENERAL PHYSICAL EXAMINATION.

b. Palpation Tenderness Step deformity TMJ movements

Annexures Blood sugar RBS FBS PP

Time taken for IMF with self tapping screws:

FOLLOW UP OF THE PATIENT AFTER REMOVAL OF THE SCREWS. 3 months

MASTER CHART Needle stick injury 7 + + -

Diagnosis A A P P P A P P P P A P P P A/P B/A P A/P A A B/S P P B/A P

P P A/P A B B A/P P A/P P/S P P P B/P P P P A/P P P A A A/P P P

KEY TO MASTER CHART

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