Maxillary fracture

Management of a tooth in the fracture line

The decision to preserve or extract a tooth located within the fracture line of a small fragment depends on the clinical presentation. Early extraction (in the first days after trauma) is extremely difficult: it is hard to manually fixate a mobile fragment while maintaining a high risk of additional injury to the inferior alveolar nerve or temporomandibular joint.

Absolute indications for immediate extraction include:

• pathology of the tooth itself (root fracture, cementum exposure, periapical granuloma);
• active inflammatory process refractory to antibiotic therapy;
• situations where the root physically impedes proper reduction of bone fragments.

In the absence of direct indications, delayed extraction is performed on days 12–14. The patient is pre-prescribed a course of antibiotic therapy. By this time, the fragments are stabilized due to primary callus formation, and the periodontal ligament weakens due to socket resorption and traumatic periodontitis. This makes extraction significantly less traumatic.

Osteosynthesis: classification and basic principles

Surgical fastening of bone fragments is called osteosynthesis. Direct indications for surgery include marked fragment displacement, pathological or comminuted injuries, and the presence of bone defects.

Depending on the surgical approach, two methods are distinguished:

1. Open osteosynthesis — performed with tissue dissection and bone exposure. It allows for ideal fragment alignment and removal of soft tissue interposition. Disadvantages: periosteal stripping causes tissue hypoxia, which can provoke endochondral osteogenesis (atypical callus formation via a cartilaginous stage), and scars remain on the skin.
2. Closed osteosynthesis — performed without incisions. Tissue microcirculation is not disturbed, but blind reduction of fragments is severely hampered.

In relation to the trauma zone, osteosynthesis is divided into focal (the fixation structure directly crosses the fracture line) and extrafocal (fixations are located on undamaged bone areas or over soft tissues).

Methods of bone fragment fixation

Various surgical tools and materials are used to keep fragments in the correct position:

• Osseous suture. Steel or titanium wire is used, passed through bur holes. Contraindicated in suppurative inflammation, osteomyelitis, and comminuted injuries.
• On-bone mini-plates. Their main advantage over wire sutures is the need for periosteal stripping from only one (vestibular) side, which better preserves the blood supply to the fracture zone.
• Kirschner wires. Used to fix difficult-to-reduce fragments; wire ends are left protruding 4–5 mm above the bone for subsequent removal.
• Shape-memory staples (Poleshchikin method). A nickel-titanium alloy staple is cooled with ethyl chloride and deformed for installation. Upon warming to body temperature, it assumes its original shape, compressing the fragments.
• Quick-setting plastics and glue. Plastic is packed into a specially carved inverted cone-shaped groove in the bone (Magarill method), or osteoplastic epoxy-resin glues are used.

Specific methods of maxillary fixation

Special immobilization protocols have been developed for the upper jaw (maxilla), which often require creating an additional support point on the cranial bones:

• Adams method. Suitable for fresh injuries. In Le Fort II or III fractures, the fixing wire is passed around the zygomatic arch, and in high fractures, through a hole in the orbital margin. The ends of the ligatures are brought down into the oral vestibule and attached to the dental splint.
• Federspiel–Dingman–Erich method. Used for chronic injuries. A plaster cap with a built-in external wire arch serves as support. Ligatures are passed through cheek punctures, connecting the intraoral splint to this external arch. The method is contraindicated in injuries to the cranial vault.
• Vignes-Billiet method. Used when a jaw fracture is combined with a frontal bone injury and requires trepanation (performed jointly with a neurosurgeon).
• Shvyrkov method. Used for significant fragment displacement: the lower jaw is used for traction and alignment of maxillary fragments, with rubber rings and ligatures fixed to its splint.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Indications and technique for applying a wire osseous suture.
• Closed extrafocal osteosynthesis: the Black method and circumferential wiring.
• Use of S-shaped and standardized hooks in periodontitis and adentia.
• Features of osteoplastic glues in maxillofacial surgery.

Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.