Iatrogenic injury caused by intermaxillary fixation screws

Treatment of pediatric bilateral condylar fractures: A comprehensive analysis

Pediatric bilateral condylar fractures (PBCF) is a rare clinical pathology, where the management is carried out with both conservative and surgical approaches. The purpose of this study was to analyze and compare these two treatment approaches and their associated long term complications in PBCF. An extensive literature review- through the search of online databases- was conducted to survey, collect, analyze and compare the reported outcomes of different treatment modalities for PBCF. The number of studies presenting PBCF case reports was 16, while the number of such retrospective studies included here was 19. Analyses of these studies revealed that the conservative treatment is preferred in PBCF patients younger than 12 years of age. Moreover, a composite approach where the open reduction and internal fixation (ORIF) is carried out for one side while the intermaxillary fixation (IMF) for the contralateral side is frequently reported for the management of PBCF cases; this approach appears effective in improving daily functioning of temporomandibular joint and reducing long term complications. Performing ORIF for one side while IMF for the contralateral side seems the most common treatment approach in PBCF. This study may help in rapid decision making for treatment selection of PBCF patients while minimizing the risk for late complications.

Comparison between Erich arch bars and intermaxillary screws in maxillofacial fractures involving the dental occlusion: a meta-analysis

This systematic review aimed to compare the Erich arch bars (EABs) with intermaxillary fixation (IMF) screws in maxillofacial fractures involving dental occlusion on perioperative parameters. Four electronic databases were searched: MedLine (Pubmed), Web of Science, VHL, and Cochrane Library. Inclusion criteria comprised clinical trials comparing the two IMF methods, assessing at least one of the outcomes: occlusal stability, oral hygiene, quality of life, time to apply and remove IMF appliances, and complications. Risk of bias was evaluated through the Cochrane risk of bias tool. Fifteen papers were included in the qualitative analysis and 12 of those in the meta-analysis. Times for EABs application (mean difference (MD) 46.83; 95% confidence interval (CI): 30.63-63.02) and removal (MD 22.89; 95% CI 14.61-31.17) were longer compared with IMF screws. There is higher risk of glove perforation (risk ratio (RR) 3.81; 95% CI 2.41-6.04) and lower risk of iatrogenic injuries (RR 0.21; 95% CI 0.09-0.48) when placing EABs compared with IMF screws. No significant differences in plaque index were found (MD 1.07; 95% CI -0.17 to 2.31). The quality of this evidence ranged from very low to low and was mainly compromised by risk of bias assessment. Further studies are necessary to evaluate transurgical IMF stability and postoperative occlusal quality and quality of life when comparing EABs with IMF screws.

Comparison of intermaxillary fixation screw versus eyelet interdental wiring for intermaxillary fixation in minimally displaced mandibular fracture: a randomized clinical study

PURPOSE

The aim of the present randomized study was to evaluate the efficacy of intermaxillary fixation screw (IMFS) versus eyelet interdental wiring for intermaxillary fixation (IMF) in minimally displaced mandibular fractures.

MATERIALS AND METHODS

A total of 50 patients with a minimally displaced mandibular fracture were enrolled, with 25 patients randomly selected for each group. In group I (study group, n = 25), the patients were treated using IMFS, and in group II (control group, n = 25), they received eyelet interdental wiring. Both techniques were assessed for the following parameters: time required for placement and removal of each type of IMF technique, time required for placement of IMF wires, postoperative occlusion, stability of the IMF wire, local anesthesia requirement during removal of each fixation type, oral hygiene status, glove perforation rate, and complications associated with both techniques. The collected data were analyzed using Student's unpaired t test or χ2 test. P < .05 was considered significant and the Statistical Package for Social Sciences software, version 10, was used for analysis.

RESULTS

The average time required for placement in groups I and II was 17.56 and 35.08 minutes, respectively (P = .000). The time required for placement of the IMF wire in group I was 2.1 minutes and in group II was 6 minutes. The oral hygiene status was assessed, and the mean plaque index score for groups I and II was 1.44 and 2.12, respectively (P = .00). The glove perforation rate was much less in group I than in group II. Finally, the most common complication in both groups was mucosal growth.

CONCLUSIONS

The results established the supremacy of IMFS compared with eyelet interdental wiring. Thus, we have concluded that IMFS, in the present scenario, is a safe and time-saving technique. IMFS is a cost-effective, straightforward, and viable alternative to cumbersome eyelet interdental and other wiring techniques for providing IMF, with satisfactory occlusion during closed reduction or intraoperative open reduction internal fixation of fractures. In addition, oral hygiene can be maintained, and the glove perforation rate was very low using IMFS. The relatively small sample size and limited follow-up period were the study limitations.

The Use of MMF Screws: Surgical Technique, Indications, Contraindications, and Common Problems in Review of the Literature

Mandibulo-maxillary fixation (MMF) screws are inserted into the bony base of both jaws in the process of fracture realignment and immobilisation. The screw heads act as anchor points to fasten wire loops or rubber bands connecting the mandible to the maxilla. Traditional interdental chain-linked wiring or arch bar techniques provide the anchorage by attached cleats, hooks, or eyelets. In comparison to these tooth-borne appliances MMF screws facilitate and shorten the way to achieve intermaxillary fixation considerably. In addition, MMF screws help to reduce the hazards of glove perforation and wire stick injuries. On the downside, MMF screws are attributed with the risk of tooth root damage and a lack of versatility beyond the pure maintenance of occlusion such as stabilizing loose teeth or splinting fragments of the alveolar process. The surgical technique of MMF screws as well as the pros and cons of the clinical application are reviewed. The adequate screw placement to prevent serious tooth root injuries is still an issue to rethink and modify conceptual guidelines.

Management of paediatric mandibular condylar fractures with screw-based semi-rigid intermaxillary fixation

This study was designed to evaluate the feasibility and safety of screw-based semi-rigid intermaxillary fixation (IMF) combined with a specially designed occlusal splint in the conservative treatment of paediatric mandibular condylar fractures. Thirteen paediatric patients with 20 sides of condylar fractures treated with semi-rigid IMF were analyzed retrospectively. Semi-rigid IMF was achieved by inserting self-drilling IMF screws into the anterior alveolar bone of the maxilla and mandible suspended with elastic bands. An occlusal splint with a molar fulcrum was used for functional repositioning of the condylar fragment. After 4 weeks, the screws and occlusal splint were removed. During a mean period of 28.6 months' follow-up, the patients' maximal mouth opening increased to a mean of 37.69 mm. Clinical and radiological examinations revealed satisfactory results in facial symmetry and condylar remodelling. No clinical symptoms or radiographic evidence showed dental injuries associated with screw insertion. This study suggests that this method might be a safe, easy, and effective management of paediatric condylar fractures.

Self Tapping Screws v/s Erich Arch Bar for Inter Maxillary Fixation: A Comparative Clinical Study in the Treatment of Mandibular Fractures

INTRODUCTION AND OBJECTIVE

Numerous methods have been described for achievement of Intermaxillary fixation in the treatment of fractures of facial skeleton. Conventional methods like Erich arch bars and eyelet wires are currently most common methods for achieving intermaxillary fixation (IMF), but they have their own disadvantages. Since 1989, IMF using intraoral self tapping IMF screws has been introduced for treatment of mandibular fractures. The aim of this work was to compare the efficacy, advantages, disadvantages indications and potential complications associated with Erich archbar v/s self tapping IMF screws in the management of mandibular fractures.

METHODS

Twenty patients with mandibular fractures, reporting to Department of Oral and Maxillofacial Surgery, The Oxford Dental College, Bangalore were evaluated, to compare the efficacy of two techniques. The parameters considered were, time taken, perforations in the gloves, patient acceptance, oral hygiene, iatrogenic dental injuries, and needle stick injuries during IMF with Erich arch Bar and self tapping IMF screws.

RESULTS

The mean time taken for IMF was 8.52 ± 2.7 min with screws as compared to 100 min with Erich arch bars. Mean number of perforations were significantly more in Group II. Oral hygiene status was good in 90% and fair in 10% of Group I and 100% fair in Group II patients.

CONCLUSION

Use of self tapping IMF screws for intermaxillary fixation is a valid alternative to conventional Erich arch bars in the treatment of mandibular fractures. Iatrogenic injury to dental roots is the most important problem to this procedure, which can be minimized by careful radiographic evaluation and treatment planning.

Embrasure wires for intraoperative maxillomandibular fixation are rapid and effective

PURPOSE

The management of some mandible fractures requires maxillomandibular fixation (MMF) intraoperatively but not postoperatively. Intraoperative MMF with arch bars has significant disadvantages, including duration of application and risk of disease transmission. Some surgeons have sought to minimize these disadvantages, improve efficiency, and decrease cost by omitting formal MMF altogether and manually stabilizing the occlusion. Embrasure wires are a method of intraoperative MMF with significant potential advantages. The purpose of this investigation was to compare embrasure wires with Erich arch bars (Karl Leibinger Co, Mulheim, Germany) for intraoperative stabilization of mandible fractures.

PATIENTS AND METHODS

This retrospective case review comprised 50 patients with a primary diagnosis of mandible fracture requiring open reduction-internal fixation with intraoperative MMF. Patients were categorized into 2 groups: intraoperative MMF using embrasure wires (group A) or intraoperative MMF using arch bars (group B). In each group the time required to place the MMF was recorded in whole minutes. The success or failure of the technique to maintain stable MMF throughout the procedure was assessed.

RESULTS

Intraoperative MMF was used with embrasure wires in 27 of 50 patients (54%) and with arch bars in 23 of 50 (46%). The mean time required for placement of embrasure wire MMF (2.51 minutes) was significantly (P < .001) less than the mean time required for placement of arch bar MMF (25.47 minutes). The quality of MMF was judged to be stable for the duration of fixation in 24 of 27 patients (89%) in the embrasure wire MMF group and 22 of the 23 patients (96%) in the arch bar group. This difference was not significant (P = .61).

CONCLUSION

Embrasure wires can be placed in significantly less time than arch bars, and they provide a reliable form of intraoperative MMF during mandible fracture repair. For intraoperative MMF, embrasure wires offer significant advantages compared with arch bars by reducing application time. In addition, embrasure wires may reduce the risk of disease transmission by decreasing the number of wires required for MMF.

Predictable drill-free screw positioning with a graduated 3-dimensional radiographic-surgical guide: a preliminary report

INTRODUCTION

Mini-implants are placed in restricted sites, requiring an accurate surgical technique. However, no systematic study has quantified technique accuracy to reliably predict the surgical risks. Therefore, a graduated 3-dimensional radiographic-surgical guide (G-RSG) was proposed, and its inaccuracy and risk index (RI) were estimated.

METHODS

The sample consisted of 6 subjects (4 male, 2 female), who used mini-implant anchorage. Ten drill-free screws (DFS) were placed by using the G-RSG. The central point of the mesiodistal septum width (SW) was the selected implant site on the presurgical radiograph. The distances between DFS and the adjacent teeth (5-DFS and 6-DFS) were measured to evaluate screw centralization and inaccuracy degree (ID). These distances were statistically compared by independent t tests, and inaccuracy was determined by the expression ID = (5-DFS - 6-DFS)/2, which represents deviation of the mini-implant's final position regarding the central point initially selected. Then SW, ID, and screw diameter (SØ) were combined to estimate the surgical risk with RI expressed by RI = SØ/SW - ID.

RESULTS

The 5-DFS and 6-DFS distances were not significantly different. The ID of the G-RSG was 0.17 mm. The low ID ensured a safe RI (<1) in spite of the restricted SW.

CONCLUSIONS

The G-RSG accuracy allowed fine prediction of the final DFS position in the interradicular septum, with a low RI, which is a helpful tool to estimate surgical risks.

Effects of intentional damage of the roots and surrounding structures with miniscrew implants

INTRODUCTION

The purposes of the study were to evaluate the immediate damage to roots and periodontal structures after initial miniscrew implant (MSI) placement and the short- and long-term damage after MSIs were left in situ.

METHODS

The roots of the maxillary second, third, and fourth premolars of 7 mature beagle dogs were randomly assigned to undergo immediate, short-term (left for 6 weeks), or long-term (left for 12 weeks) damage. Intentional damage was inflicted with self-tapping screws (1.8 x 8 mm) placed with a stent. Alternating tetracycline and calcein labels were administered at 6-week intervals. Undecalcified sections were stained and evaluated histologically to determine the extent of damage; healing was evaluated by using fluorescence labels.

RESULTS

Histology showed damage to 73.8% of the teeth, ranging from displacement of bone into the periodontal ligament to invasion of the pulp chamber. Displacement of bone into the periodontal ligament and direct damage to the periodontal ligament occurred in 3 (7.2%) instances. Damage was isolated to the cementum of 8 (19.0%) teeth, whereas damage occurred in the dentin of 11 (26.2%) teeth. Loss of bone in the furcation was evident in 3 (7.2%) teeth, and severe damage into the pulp occurred in 6 (14.2%) teeth. No differences in the amounts of damage were evident between the immediate, short-, and long-term groups. Healing often occurred with cementum around the unloaded MSIs.

CONCLUSIONS

Extensive damage can be caused by MSIs, with little to no differences evident over time. Unloaded MSIs that remain in contact with roots of teeth can show varying degrees of healing.

Self-tapping and self-drilling screws for intermaxillary fixation in management of mandibular fractures

The current study evaluated the success and the possible complication of intermaxillary fixation with self-tapping and self-drilling screws (STSDSs) in nondislocated or slightly dislocated mandibular fractures.Forty patients with mandibular fractures, treated with intermaxillary fixation using STSDSs, were clinically assessed by means of a dental vitality test and evaluation of tooth mobility adjacent to the cortical screw holes, and radiologically by means of a panoramic dental radiograph upon removal of the screws.The main complication was screw loss in 4.4% of cases, followed by coverage by oral mucosa in 1.2% of cases. However, no dental root damage, screw breakage, malocclusion, or poor consolidation of mandibular fractures was observed.The use of STSDSs for intermaxillary fixation is a useful alternative to the use of arch bars in the treatment of some types of mandibular fractures. In addition, there is no risk of dental lesions as with self-tapping screws.

An audit of mandibular fractures treated by intermaxillary fixation using intraoral cortical bone screws

INTRODUCTION

During the last 10 years, intermaxillary fixation using intraoral cortical bone screws has been introduced for the treatment of mandibular fractures. The aim of this work was to evaluate the indications and possible complications of this method.

MATERIALS AND METHODS

Sixty-two patients with mandibular fractures, treated by intermaxillary fixation using these screws, were evaluated by preoperative and postoperative panoramic radiographs. Clinical testing was carried out for vitality and abnormal mobility of teeth adjacent to the site of screw insertions. To evaluate the efficacy of this method, different factors were considered such as possible iatrogenic dental injuries, loss, breakage or screw cover by oral mucosa and postoperative occlusion.

RESULTS

The most important complication was iatrogenic damage to dental roots (1.5%), 4.9% of the screws were covered by oral mucosa and 1.9% were lost, while none were broken. Malocclusion was observed in one patient (1.6%) and lack of consolidation of a displaced fracture of the mandibular body in another patient.

CONCLUSIONS

Use of intraoral cortical bone screws for intermaxillary fixation is a valid alternative to arch bars in the treatment of mandibular fractures. Iatrogenic injury to dental roots is the most important problem of this procedure, but can be minimized by an experienced surgeon.

A drill-free bone screw for intermaxillary fixation in military casualties

Drill-free bone screws are a simple and quick method of establishing intermaxillary fixation requiring a minimum amount of specialist training or equipment. These screws offer significant advantages over other methods of intermaxillary fixation and are well suited for use in military casualties.