Self Tapping IMF Screws Technique

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V

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., and Dr. Shubhalakshami

M.D.S., Reader Department of Oral and Maxillofacial Surgery, College of Dental

Sciences, Davangere for their constant encouragement, valuable suggestions and

ranking advice.




VI

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, M.D.S., Principal, College of

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 Dr. DIVYE MALHOTRA




VII

LIST OF ABBREVIATION USED

AIDS : Acquired immunodeficiency syndrome

BP : Blood pressure

BT : Bleeding time

CT : Clotting time

DFS : Drill free screws

FBS : Fasting blood sugar

GA : General anaesthesia

HBV : Hepatitis B virus

HIV : Human immunodeficiency virus

IMF : Intermaxillary fixation

MMF : Maxillomandibular fixation

IOPA : Intra oral peri apical

LA : Local anaesthesia

OPG : Orthopantomograph

RTA : Road traffic accident




VIII

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. Postoperative malocclusion was

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.




IX

TABLE OF CONTENTS

Page No.

1. Introduction 1-2

2. Objectives 3

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 50-54

Master chart 55-57




X

LIST OF TABLES

SL. NO. TABLES PAGE

NO.

Table 1 Distribution of mandible fractures according to sex 26

Table 2 Age wise distribution of mandibular fractures 26

Table 3 Mandibular fractures distribution according to type of

fracture

26

Table 4 Distribution of mandibular fractures according to site 27

Table 5 Distribution of mandibular fractures according to etiology 27

Table 6 Occlusion over a period of one week 28

Table 7 Relationship between postoperative occlusion and type of

fracture

28

Table 8 Relationship between postoperative period and pain 29

Table 9 Oral hygienic over a period of one week 29




XI

LIST OF GRAPHS

SL. NO. GRAPHS PAGE

NO.

Graph 1 Distribution of mandible fractures according to sex 30

Graph 2 Age wise distribution of mandibular fractures 30

Graph 3 Mandibular fractures distribution according to type of

fracture

31

Graph 4 Distribution of mandibular fractures according to site 31

Graph 5 Distribution of mandibular fractures according to

etiology

32

Graph 6 Occlusion over a period of one week 32

Graph 7 Relationship between postoperative occlusion and type

of fracture

33

Graph 7a Postoperative occlusion 33

Graph 8 Relationship between postoperative period and pain 34

Graph 9 Oral hygienic over a period of one week 34

Graph 10 Incidence of injuries 35




XII

LIST OF PHOTOGRAPHS

SL. NO. FIGURES PAGE

NO.

Figure 1 Armamentarium 19

Figure 2 Self tapping IMF screws with screw holder and screw

driver

19

Figure 3 Preoperative OPG 20

Figure 4 Pilot hole 20

Figure 5 Placement of screw 21

Figure 6 Screws in place 21

Figure 7 IMF with self tapping IMF screws - case I 22

Figure 8 IMF with self tapping IMF screws - case II 22

Figure 9 Screws in place 7th post operative day 23

Figure 10 Post operative OPG 23




Introduction




Introduction

1

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




Introduction

2

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.




Objectives




Objectives

3

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




Review of Literature





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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 Barton’s 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





5

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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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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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.





8

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





9

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.





10

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.





11

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





12

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.





13

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, Dell’acqua 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.




Methodology




Methodology

14

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. Fractures of the dentulous mandible

2. Undisplaced fractures of the mandible

3. Minimally and moderately displaced fractures of the mandible

4. 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.




Methodology

15

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.




Methodology

16

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.




Methodology

17

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




Methodology

18

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.




Photographs




19




20




21




22




23




Results




Results

24

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 20-

30 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




Results

25

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 7th 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.




Graphs and Tables




Results

26

TABLE 1

DISTRIBUTION OF MANDIBLE FRACTURES ACCORDING TO SEX

Sex No. of cases Percentage

Male 47 94

Female 3 6

TABLE 2

AGE WISE DISTRIBUTION OF MANDIBULAR FRACTURES

Age group No. of cases Percentage

< 20 4 8

20-30 21 42

30-40 19 38

> 40 6 12

TABLE 3

MANDIBULAR FRACTURES DISTRIBUTION ACCORDING TO TYPE OF

FRACTURE

Type of fractures No. of cases Percentage

Undisplaced 10 20

Minimally displaced 35 70

Moderately displaced 5 10




Results

27

TABLE 4

DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO SITE

Site No. of cases Percentage

Parasymphysis 27 54

Angle 9 18

Body 2 4

Subcondylar and Parasymphysis 1 2

Angle and Parasymphysis 7 14

Angle and Body 2 4

Body and Parasymphysis 1 2

Body and Subcondylar 1 2

TABLE 5

DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO

ETIOLOGY

Etiology No. of cases Percentage

RTA 35 70

Falls 2 4

Assault 11 22

Sports related injuries 2 4




Results

28

TABLE 6

OCCLUSION OVER A PERIOD OF ONE WEEK

1st day 3nd day 5th day 7th day

Occlusion n % n % n % n %

Normal 48 96 48 96 48 96 48 96

Minimally

deranged

1 2 1 2 1 2 1 2

Moderately

deranged

1 2 1 2 1 2 1 2

Grossly

deranged

- - - - - - - -

TABLE 7

RELATIONSHIP BETWEEN POSTOPERATIVE OCCLUSION AND TYPE

OF FRACTURE

Normal Deranged occlusion Type of fractures

n % n %

Undesplaced (10) 10 100 - -

Minimally displacement (35) 34 97.14 1 2.85

Moderately displacement (5) 4 80 1 20

Total (50) 48 96 2 4

P < 0.001, highly significant.




Results

29

TABLE 8

RELATIONSHIP BETWEEN POSTOPERATIVE PERIOD AND PAIN

Pain 1st day 3rd day 5th day 7th day

No or mild - 33 46 48

Moderate 46 16 4 2

Severe 4 1 - -

X2 = 92.3 p < 0.001, Highly significant

TABLE 9

ORAL HYGIENIC OVER A PERIOD OF ONE WEEK

Oral hygiene 1st day 3rd day 5th day 7th day

Good 3 3 8 8

Fair 46 47 42 42

Poor 1 - - -

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%)




Results

30

GRAPH - 1

DISTRIBUTION OF MANDIBLE FRACTURES ACCORDING TO SEX

GRAPH - 2

AGE WISE DISTRIBUTION OF MANDIBULAR FRACTURES

47

3

MaleFemale

4

2119

6

0

5

10

15

20

25

No.

of c

ases

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




Results

31

GRAPH - 3

MANDIBULAR FRACTURES DISTRIBUTION ACCORDING TO TYPE OF

FRACTURE

GRAPH - 4

DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO SITE

10

35

5

0

5

10

15

20

25

30

35N

o. o

f cas

es

Undisplaced Minimally displaced Moderatelydisplaced

Type of fractures

27

9

21

7

2 1 1

0

5

10

15

20

25

30

No.

of c

ases

Par

asym

phys

is

Ang

le

Bod

y

Sub

cond

ylar

/P

aras

ymph

ysis

Ang

le /

Par

asym

phys

is

Ang

le /

Bod

y

Bod

y /

Par

asym

phys

is

Bod

y /

Sub

cond

ylar

Site




Results

32

GRAPH - 5

DISTRIBUTION OF MANDIBULAR FRACTURES ACCORDING TO

ETIOLOGY

GRAPH - 6

OCCLUSION OVER A PERIOD OF ONE WEEK

35

2

11

2

0

5

10

15

20

25

30

35N

o. o

f cas

es

RTA Falls Assault Sports relatedinjuries

Etiology

48

1 1 0

48

1 1 0

48

1 1 0

48

11 005

101520253035404550

No.

of d

ays

1st Day 3rd day 5th day 7th day

Occlusion

NormalMinimally deranged Moderately derangedGrossly deranged

`




Results

33

GRAPH - 7

RELATIONSHIP BETWEEN POSTOPERATIVE OCCLUSION AND TYPE

OF FRACTURE

GRAPH – 7a

POSTOPERATIVE OCCLUSION

10

0

34

14 1

0

5

10

15

20

25

30

35

No.

of c

ases

Undesplaced Minimally displacement Moderately displacement

Type of fractures

Normal Deranged Occlusion

48

2

Normal

Derangedocclusion




Results

34

GRAPH - 8

RELATIONSHIP BETWEEN POSTOPERATIVE PERIOD AND PAIN

GRAPH - 9

ORAL HYGIENIC OVER A PERIOD OF ONE WEEK

0

46

4

33

16

1

46

40

48

2 0

0

5

10

15

20

25

30

35

40

45

50N

o. o

f cas

es

1st day 3rd day 5th day 7th day

No or mildModerateSevere

3

46

13

47

0

8

42

0

8

42

00

5

10

15

20

25

30

35

40

45

50

No.

of c

ases

1st day 3rd day 5th day 7th day

GoodFairPoor




Results

35

GRAPH - 10

INCIDENCE OF INJURIES

46

3 1

No injury Needle stick injuries Iiatrogenic injury to teeth




Discussion




Discussion

36

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




Discussion

37

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




Discussion

38

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




Discussion

39

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.




Discussion

40

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




Discussion

41

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 7th postoperative day in the present




Discussion

42

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.




Conclusion




Conclusion

43

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.




Summary




Summary

44

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.




Bibliography




Bibliography

45

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Annexures




Annexures

50

SELF TAPPING IMF SCREWS, A SIMPLIFIED METHOD OF

INTERMAXILLARY FIXATION-A CLINICAL STUDY

PROFORMA NAME :

AGE :

SEX :

ADDRESS :

OCCUPATION :

I.P.No :

OPD No. :

DOA :

DOO :

DOD :

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




Annexures

51

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




Annexures

52

- 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




Annexures

53

- 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:




Annexures

54

POST OPERATIVE EVALUATION OF THE SCREWS AND ITS EFFECT ON

THE TISSUES

1st Day 3rd Day 5th Day 7th Day

Occlusion

Pain

Odema

Oral hygiene status

FOLLOW UP OF THE PATIENT AFTER REMOVAL OF THE SCREWS.

3 months




Annexures

55

MASTER CHART

Occlusion Pain Oral Hygiene Edema Needle stick injury

Time taken for IMF Sl.

No. Name Age Sex Diagnosis Type of fracture Etiology

1 3 5 7 1 3 5 7 1 3 5 7 1 3 5 7 1 Suresh G-II M A D1 RTA 1 1 1 1 P1 P0 P0 P0 A A A A + - - - - 18min 2 Kumar G-I M A D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + + - - - 15min 3 Prakash G-II M P D1 RTA 1 1 1 1 P1 P0 P0 P0 A A A A + - - - - 15min 4 Saroja G-III F P D1 RTA 1 1 1 1 P1 P0 P0 P0 A A A A + + - - - 16min 5 Kumar G-II M P U AST 1 1 1 1 P P1 P0 P0 B B A A + + + - - 20min 6 Jagdish G-III M A D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 7 Chandrappa G-II M P U RTA 1 1 1 1 P1 P1 P0 P0 B B B B + + - - - 18min 8 Anjanappa G-II M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - + 14min 9 Snakshalie G-III M P D1 RTA 1 1 1 1 P1 P1 P0 P0 B B B B + + - - - 15min

10 Adarsh G-II M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 15min 11 Pandu G-III M A D1 AST 1 1 1 1 P1 P1 P0 P0 B B B B + + - - - 16min 12 Siddappa G-III M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 13 Anjanappa G-III M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 15min 14 Shivanna G-II M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B A A + - - - - 12min 15 Vijaykumar G-I M A/P D2 RTA 1 1 1 1 P1 P1 P0 P0 B B A A + + + - - 21min 16 Vasu G-II M B/A D2 AST 2 2 2 2 P2 P1 P1 P0 B B B B + + + - - 22min 17 Someshwar G-III M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - + 12min 18 Suleman G-II M A/P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 15min 19 Shivshankarappa G-III M A D1 RTA 1 1 1 1 P1 P1 P0 P0 B B B B + + - - - 17min 20 Sidramappa G-III M A D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 16min 21 Soutanavar G-III M B/S D1 RTA 1 1 1 1 P1 P1 P0 P0 B B B B + - - - - 18min 22 Veerabadrappa G-IV M P U AST 1 1 1 1 P1 P0 P0 P0 B B B B + + - - - 18min 23 Chandranna G-III M P U AST 1 1 1 1 P1 P0 P0 P0 B B B B + + - - - 16min 24 Kariappa G-III M B/A D1 AST 1 1 1 1 P1 P0 P0 P0 B B B B + + - - - 16min 25 Raja Reddy G-IV M P U FL 1 1 1 1 P1 P1 P0 P0 B B B B + - - - - 15min




Annexures

56

26 Md-Jabeer G-II M P U AST 1 1 1 1 P1 P1 P0 P0 B B B B + + - - + 12min 27 Manjunath G-II M P U AST 1 1 1 1 P1 P1 P0 P0 B B B B + + + - - 16min 28 Parshuram G-II M A/P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + + - - - 15min 29 Honumanthappa G-II M A D1 RTA 1 1 1 1 P1 P1 P0 P0 B B B B + + - - - 16min 30 Basavraj G-III M B D1 RTA 1 1 1 1 P1 P1 P0 P0 B B B B + + - - - 16min 31 Wasim G-I M B D1 SPT 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 32 Sashidhar G-II M A/P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 12min 33 Jaiprakash G-II M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 34 Mahantesh G-I M A/P D2 RTA 3 3 3 3 P2 P1 P1 P0 B B A A + + + - - 21min 35 M. Naik G-II M P/S D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 16min 36 Rangappa G-IV M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 37 Ram Naik G-II M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B A A + - - - - 15min 38 Siddappa G-III M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 39 Mala G-III F B/P U AST 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 20min 40 Rudrappa G-IV M P U RTA 1 1 1 1 P1 P1 P0 P0 B B B B + - - - - 16min 41 Manjunath G-II M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 42 Shekharappa G-III M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 15min 43 Shivkumar G-II M A/P D2 RTA 1 1 1 1 P2 P2 P1 P1 B B B B + + + - - 23m 44 Thippeswami G-IV M P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 45 Karibasappa G-III M P D1 AST 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 15min 46 Hrishikesh G-II M A D1 SPT 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 47 Krishnamurthy G-III M A D1 RTA 1 1 1 1 P1 P0 P0 P0 C B B B + - - - - 15min 48 Thimmakka G-IV M A/P D2 AST 1 1 1 1 P2 P1 P1 P1 B B B B + + + - - 21min 49 Ashok L G-II M P U FL 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 14min 50 Kamalamma G-III F P D1 RTA 1 1 1 1 P1 P0 P0 P0 B B B B + - - - - 15min




Annexures

57

KEY TO MASTER CHART G-I - Age group < 20

GII - Age group 20-30

G-III - Age group 30-40

G-IV - Age group >40

M - Male

F - Female

A - Angle

P - Parasymphysis

B - Body

S/P - Subcondylar and parasymphysis

A/P - Angle and parasymphysis

A/B - Angle and body

B/P - Body and parasymphysis

B/S - Body and subcondylar

U - Undisplaced

D1 - Minimally displaced

D2 - Moderately displaced

RTA - Road traffic accident

AST - Assault

FL - Falls

SPT - Sports related

1 - Normal occlusion

2 - Minimally deranged

3 - Moderately deranged

P0 - No or mild pain

P1 - Moderate pain

P2 - Severe pain

A - Good oral hygiene

B - Fair

C - Poor




Self Tapping IMF Screws Technique

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