Miniplates for Osteosynthesis of Middle Facial Fractures

Mini shields for Osteosynthesis of Middle Facial FracturesINTRODUCTIONNumerous biomechanical studies bedeck the stability of the rigid infantile neutering for mandibular teddys4-6. However, undersized research has foc utilize on the maxilla, despite the event that Le Fort fractures and osteotomies ar parkland clinical postureations. For the treatment of Le Fort maxillary fractures, the introductoryhand aims include the restoration of pass up midfacial vertical height and frontal projection and restoration of occlusion. Nonetheless, the removal browse of the mini home plates and butts were approximately 50% in orthognathic surgery (Le Fort I osteotomy), out-of-pocket predominantly to transmission system or wound dehiscence7. The other problem is that patients sometimes complain of indistinct clenching subsequently the operation, therefore questions regarding minimum itemize of plates and stability following neutering stick out risen in recent times.Miniplate osteo synthesis, developed by Champy in 19751, is todays standard for the treatment of facial fracture. More recently resorbable plates2 and cuts and 3-dimensional miniplating system3, have been introduced for fastening of facial fractures. M only studies have proved the capability of three dimensional plating systems in mandible fractures but very little research have been carried out on midface fractures. We studied the efficacy of three dimensional plates in midface fractures and appoint them efficacious enough to stabilize the lift fragments during osteosynthesis.Three dimensional miniplating system was introduced by Farmand (1992)3. The basic imagination of three-dimensional fixation is that a geometric aloney closed quadrangular plate secured with bone screws creates stability in three dimensions. The three dimensional plates be positioned erect to the fracture line. The screws adapt each part of the plate sepa consecrately without any tension to the bone. The cross linking yields the stability to the system. Three dimensional miniplates are easy to adjust, requires token(prenominal) tissue dissection thus least disturbing the blood supply and beca habit of its design fixation points remain in the vicinity of fracture line. Its low profile design and space between plate holes permits excellent revascularization.The biomechanical and good advant dayss of three dimensional miniplate systems over two dimensional miniplate system promoted the current reading to evaluate the efficacy of the three-D atomic number 22 miniplates as a viable treatment modality in the osteosynthesis of middle triplet facial fractures.MATERIAL AND METHODSubjects for the point study were selected amongst the patients, attending the outpatients department and emergency services of section of Oral Maxillofacial Surgery, Kothiwal dental college and research centre,Moradabad.Study comprised of thirty patients, with isolated lefort I fracture,20 patients had bilateral fractu re and 10 patients had unilateral lefort I fracture . every(prenominal) patients were taken up randomly irrespective of age, conjure up caste and creed.Patients were diagnosed on the basis of clinical examination and radiographic interpretation. Preoperative evaluation included paying attention examination of the soft tissues and underlying skeleton. A thorough physical examination was carried out to exclude any other injuries.All selected patients were informed about the experimental nature of the study and the possible complications were explained. Their co-operation was solicited and informed respond was obtained. The patient received prophylactic antibiotic coverage and analgesics at the time of initial presentation.INVESTIGATIONSRadiographs The following radiographs were employd to confirm clinical diagnosis and to assess the exact location of fracture and degree of displacementOccipitomental fascinate and submentovertex view for midfacePA Mandible viewOPG view (Orthopan tomogram)CT scan as needed opposite investigationsRoutine Blood investigation Urine analysisUrine analysisTREATMENT PLANNINGAll patients were admitted to the hospital prior surgery. Erichs arch bar were placed on upper and lower stand up teeth to stabilize the fracture segment and to achieve occlusion before plating.ARMAMENTRIUM Basic instrument readiness for maxillofacial surgeryInstrument used for in endpointaxillary fixation3-DIMENSIONAL TITANIUM MINIPLATE 1.7 MM agreementPLATESDESIGN 4 different designs of three-dimensional titanium miniplates were included.22 holed square plate2 x 2 holed rectangular plates3 x 2 holed continuous rectangle or double rectangle42 holed continuous rectangle plateAll the plates had 1.7 mm diameter holes.PROFILE HEIGHT0.6 mm (low profile plates)SCREWSNon compression, self-tapping, monocortical screws with round head.Diameter 1.7 mm space 5mm, 7mm and 9 mmDRILL BIT Diameter 1.2 mmCONVENTIOANAL TITANIUM MINIPLATE 1.7 MM SYSTEM12 holed straight platePROFILE HEIGHT1.0mmSCREWSNon compression, self-tapping, monocortical screws with round head.Diameter 1.7 mmLength 5mm, 7mm and 9 mmDRILL BIT Diameter 1.2 mmACCESSORIESScrewdrivers tusk plate holding forcepsBone plate bending forcepsPlate cutting pliersOPERATIVE TECHNIQUE FOR three DIMENSIONAL MINIPLATESPatients were operated every under general anesthesia (Naso-tracheal intubations) or local anesthesia. Strict asepsis was followed.In this study, the fracture sites were uncovered through and through standard intraoral vestibular incision.(Fig.1),Following reduction of the fragments and temporary maxillomandibular fixation, a suitable 3D plate was selected and bent with a plate bending pliers to conform the proper adaptation of plates to bone surface.The three dimensional titanium miniplates were then positioned in such a way that the horizontal cross-bars were perpendicular to the fracture line and the vertical ones were par on the wholeel to it (Fig.2). Holding the plate p erpendicular to the reduced fracture, drilling was performed through the hole in the plate strictly perpendicular to the bone surface. The drilling was performed at slow-speed along with plenteous saline irrigation to prevent damage to the bone by heat. To avoid injury to the dental roots the sterling(prenominal) holes were drilled strictly monocortically, and directed into the space between the roots.Later screws of suitable length were selected for fixation of the plate. In each case the upper screws were tightened first, followed by the lower ones. For screw tightening the rotations were executed apply the screw-holding screw driver.Maxillomandibular fixation was released and occlusion was checked by moving the lower jaw. The site was closed using 3-0 silk suture material. No maxillomandibular fixation was required in any of the patient.OPERATIVE TECHNIQUE FOR THREE DIMENSIONAL MINIPLATESOperative technique for courtly plate was similar to the one used for three dimensional m iniplate.Intraoral vestibular incision was used in all the patients and after fracture reduction either conventional 2 dimensional L shaped plate was fixed at zygomaticomaxillary buttress region and 2 hole with gap miniplate was placed over nasomaxillary buttress region.POSTOPERATIVE MANAGEMENTPostoperative course of medicinal drug consisted of injection ceftriaxone 1gm 12 hourly (i.v.), injection metrogyl 100ml 8 hourly (i.v.) and analgesic and multivitamin facility continued till 5th operative day. All patients were put on liquid diet for first 2 workweeks. All patients were encouraged to maintained good oral hygiene. Sutures were removed on the 7th postoperative day. All patients were followed up at regular interval that is at 1st week, 3rd week, 6th week and 3 month postoperatively regarding restoration of function, stability of system used and any complication.Assessment of the patients was do under following parametersPain Visual Analogue Scale (VAS) (0-10)Swelling pr esent/absent.Occlusion sacrosanct/derangedMobility of fracture segment-present/ preoccupiedInfection/wound dehiscence -present/AbsentHardware failure present/AbsentSTATISTICAL ANALYSISThe following statistical tools were employed for the present studyMean, Standard Deviation, Studentt test, Pairedt test and Chi-square testRESULTSWe obtained following results in our studyPatients in the 31-40 years of age were the predominant age group presenting with midface fractures (50%).Males were most commonly affected with Lefort I fracture (92.84%).The most common cause of midface fracture was found to be road traffic accident (92.8%).There is significant cliff in pain at 3 WK, 6 WK and 3rd Months from the Baseline (1WK) for both the groupsSwelling was present in 15 patients (50%). It decreased importantly at 3W, 6WK, 3 MONTHS, from baseline (1WK)(fig.3)There is significant amelioration (75%) in post traumatic Parasthesia of infraorbital nerve following fixation with 3-D plating system. (Fig.4)Occlusion was achieved in all the patients after surgeryNo sign of infection and hardware failure was present in any patient.DISCUSSIONLe Fort I maxillary fractures are among the injuries encountered most frequently in patients who suffer facial trauma and it is common in orthognathic surgery. Fixation of maxillary Le Fort I fractures(/osteotomy) by RIF of the facial skeleton has become an accepted, and even expected, form of treatment. When the teeth of the maxilla and mandible are clenched, anatomic reward for the midface is provided through a series of buttresses or struts that distribute masticatory forces from the teeth to skull base.19-21 The vertical struts of the midface are clinicallythe most important in management of Le Fort I maxillary fractures. The 3 principal vertical buttresses of the maxilla are the nasomaxillary (medial) buttress, zygomaticomaxillary (lateral) buttress, and the pterygomaxillary (posterior) buttress.4 The internal fixation of Le Fort I fract ures should use miniplates and screws and be fixed at anterior and lateral buttresses for the ideal internal fixation, whereas the posterior buttress should be without fixation due to the surgical difficulty of the operative betterment.4 Surgical treatment of Le Fort I fracture according to the ideal internal fixation produces satisfactory results, but patients sometimes complain of weak clenching after the operation. Very few comparisons of the different maxilla fixation modalities and their behavior have been reported currently. In clinical Le Fort I fracture treatment, restoration of the correct midfacial vertical height and anterior projection and restoration of occlusion are critical.Therefore, questions have arisen regarding the stability and number of plates required of adequate fixation of lefort fractures.The fixation of 2 miniplates on each side as suggested by AO/ASIF, provides adequate stability and conventionally it has been the standard treatment for lefort fractures ,Farmand8 in 1992 developed new titanium miniplate system that takes advantage of biogeometry to provide enduring fixation and he called it as three dimensional plating system. A geometrically closed quadrangular plates secured with bone screws creates stability in three dimensions. .These plates have low profile design, excellent biocompatibility, and minimal confine after bending.The present study was carried on patients age group 10- 50 years with the mean being 33.14 years. The maximum number of patients were in a age group between 31- 50 years (nearly 50%).This is in accordance with the study of Khateeb T,Abdulla FM(2007)9.There was predominance of males in this study, male is to womanish ratio being 131,and percentage of male patients being 92%. .Motamedi MH (2003)10 observed in a retrospective study on 237 patients, percentage of male patients being 89% and that of female patients being 11%, our study is in accordance with this study.In this study road traffic accident (92 %) were found to be the major etiological factor for the fracture of the middle third of the facial skeleton .These findings coincides with the findings of, Iida S, Kogo M 11 who reported road traffic accident to be the most common cause of injury in a retrospective analysis of 1502 patients with facial fractures.In the present study it was observed that among the maxillary fractures, Lefort II fractures( approx78%) were most common, this finding is in accordance with the study Motagemi MH (2003)10 which reported the incidence of Lefort II fractures to be 54.6% among all maxillary fractures in a five year retrospective study on 237 patients .In the present study, post traumatic parasthesia of the infraorbital nerve was present was present in 4 cases (57.14%) (out of the 7 patients with zygomatic knotty fractures) which was clinically inferred as compression of nerve by fracture fragments .Anesthesia was relieved in 3(75%) out of 4 patients in a three month follow up period which fo und to be due to infra orbital nerve relieved from compression by means of reduction of fractured segments in to its correct position. c. Demen et al (1988)12 reported the presence of sensory disturbances of infraorbital nerve in 219 cases (80.2%) out of 273 patientsThe influence of treatment approach on the recovery of the injured infraorbital nerve is controversial in the literature .Several authors reported that frequency of retentive sensory disturbance is independent of the method of reduction and fixation of fracture. Deman and box (1993)12 state that reduction and fixation are important factors in recovery from sensory disturbances of infraorbital nerve. Taicher (1993)13, observed that there is higher recovery rate of infraorbital nerve with miniplate osteosynthesis than with other method of treatment .We report a (75%) recovery rate of in our study, Our results support these findings .This significantly high recovery rate with 3 D plate can be explained by the fact that fi xation with 3 D plate provides better stability to the complex in all the three dimensions of movement? However there is no study in the literature on the recovery of infraorbital nerve after fixation with 3-D plates.In the present study occlusion was achieved in all the patients after surgery. Conventional treatment with maxillomandibular fixation is associated with its well known limitations and disadvantages. Klotch DW(1987)14 studied internal fixation versus conventional therapy in midface fractures and found that a more stable occlusion is achieved with internal fixation .S Anand, Thangavelu (2004)15studied the use of three dimensional plate fixation of fractures and osteotomies and stated that satisfactory occlusion was achieved in all the patients after internal fixation with 3- plates and no patient required any maxillomandibular fixation. Claude Guimond(2005)16 studied the use of 3-D plate for fixation of mandibular factures and reported similar findings in their study. As three dimensional plates provide stability in three dimensions of movement the need for maxillomandibular fixation is greatly diminished or moreover eliminated. Our study is in accordance with these studies.No patient reported for any type of postoperative infection, wound dehiscence during the period of three month follow up. Lia G (1997)17 reported the similar results in his study .He found no post operative complications in 30 treated cases of 3 D titanium bone plating. S Anand, Thangavelu (2004)15 studied the role of 3-dimensional plating system and did not reported any infection in their study .Claude Guimond(2005)16studied the use of 3-D plating in mandibular fractures and reported a significantly low rate of infection as compared with other systems. Farmand(1995)3 studied the use of 3-D plates in fixation of fracture and osteotmies and reported an significantly low rate of post operative infection with 3-D plates. No infection in our cases could be attributed to the preoperat ive antibiotic therapy in all patients,and proper sterilization technique.In none of the patients plates need to be removed exhibiting there excellent biocompatibility in this short period of study. Farmand(1992)18, in their respective studies on the use of three dimensional plates in oral and maxillofacial region did not report any hardware failure with the use of these plates ,our study is in accordance with these studies.Thus as a result of clinical experience it can be inferred that the use of 3 D plates and screw system in the management of midfacial fractures give good results in term of function ,esthetic and acceptability. However, owing to fewer numbers of cases, no definitive conclusions can be drawn, for this studies with larger sample size and long term follow up are recommended.