Basic Principles of Treatment of a Fracture

The treatment of fractures involves a systematic approach to restore the normal anatomy and function of the affected bone. The basic principles of fracture treatment can be summarized in three key steps: reduction, fixation, and immobilization.

1. Reduction

Definition: Reduction is the process of restoring the fractured bone fragments to their original anatomical position.

• Methods of Reduction:

  • Closed Reduction: This technique involves realigning the bone fragments without direct visualization of the fracture line. It can be achieved through:
    • Reduction by Manipulation: The physician uses manual techniques to manipulate the bone fragments into alignment.
    • Reduction by Traction: Gentle pulling forces are applied to align the fragments, often used in conjunction with other methods.

• Open Reduction: In some cases, if closed reduction is not successful or if the fracture is complex, an open reduction may be necessary. This involves surgical exposure of the fracture site to directly visualize and align the fragments.

2. Fixation

Definition: After reduction, fixation is the process of stabilizing the fractured fragments in their normal anatomical relationship to prevent displacement and ensure proper healing.

• Types of Fixation:

  • Internal Fixation: This involves the use of devices such as plates, screws, or intramedullary nails that are placed inside the body to stabilize the fracture.
  • External Fixation: This method uses external devices, such as pins or frames, that are attached to the bone through the skin. External fixation is often used in cases of open fractures or when internal fixation is not feasible.

• Goals of Fixation: The primary goals are to maintain the alignment of the bone fragments, prevent movement at the fracture site, and facilitate healing.

3. Immobilization

Definition: Immobilization is the phase during which the fixation device is retained to stabilize the reduced fragments until clinical bony union occurs.

• Duration of Immobilization: The length of the immobilization period varies depending on the type of fracture and the bone involved:

  • Maxillary Fractures: Typically require 3 to 4 weeks of immobilization.
  • Mandibular Fractures: Generally require 4 to 6 weeks of immobilization.
  • Condylar Fractures: Recommended immobilization period is 2 to 3 weeks to prevent temporomandibular joint (TMJ) ankylosis.

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Piezosurgery

Piezosurgery is an advanced surgical technique that utilizes ultrasonic vibrations to cut bone and other hard tissues with precision. This method has gained popularity in oral and maxillofacial surgery due to its ability to minimize trauma to surrounding soft tissues, enhance surgical accuracy, and improve patient outcomes. Below is a detailed overview of the principles, advantages, applications, and specific uses of piezosurgery in oral surgery.

Principles of Piezosurgery

• Ultrasonic Technology: Piezosurgery employs ultrasonic waves to create high-frequency vibrations in specially designed surgical tips. These vibrations allow for precise cutting of bone while preserving adjacent soft tissues.
• Selective Cutting: The ultrasonic frequency is tuned to selectively cut mineralized tissues (like bone) without affecting softer tissues (like nerves and blood vessels). This selectivity reduces the risk of complications and enhances healing.

Advantages of Piezosurgery

1. Strength and Durability of Tips:

   • Piezosurgery tips are made from high-quality materials that are strong and resistant to fracture. This durability allows for extended use without the need for frequent replacements, making them cost-effective in the long run.

2. Access to Difficult Areas:

   • The design of piezosurgery tips allows them to reach challenging anatomical areas that may be difficult to access with traditional surgical instruments. This is particularly beneficial in complex procedures involving the mandible and maxilla.

3. Minimized Trauma:

   • The ultrasonic cutting action produces less heat and vibration compared to traditional rotary instruments, which helps to preserve the integrity of surrounding soft tissues and reduces postoperative pain and swelling.

4. Enhanced Precision:

   • The ability to perform precise cuts allows for better control during surgical procedures, leading to improved outcomes and reduced complications.

5. Reduced Blood Loss:

   • The selective cutting action minimizes damage to blood vessels, resulting in less bleeding during surgery.

Applications in Oral Surgery

Piezosurgery has a variety of applications in oral and maxillofacial surgery, including:

1. Osteotomies:

   • LeFort I Osteotomy: Piezosurgery is particularly useful in performing pterygoid disjunction during LeFort I osteotomy. The ability to precisely cut bone in the pterygoid region allows for better access and alignment during maxillary repositioning.
   • Intraoral Vertical Ramus Osteotomy (IVRO): The lower border cut at the lateral surface of the ramus can be performed with piezosurgery, allowing for precise osteotomy while minimizing trauma to surrounding structures.
   • Inferior Alveolar Nerve Lateralization: Piezosurgery can be used to carefully lateralize the inferior alveolar nerve during procedures such as bone grafting or implant placement, reducing the risk of nerve injury.

2. Bone Grafting:

   • Piezosurgery is effective in harvesting bone grafts from donor sites, as it allows for precise cuts and minimal damage to surrounding tissues. This is particularly important in procedures requiring autogenous bone grafts.

3. Implant Placement:

   • The technique can be used to prepare the bone for dental implants, allowing for precise osteotomy and reducing the risk of complications associated with traditional drilling methods.

4. Sinus Lift Procedures:

   • Piezosurgery is beneficial in sinus lift procedures, where precise bone cutting is required to elevate the sinus membrane without damaging it.

5. Tumor Resection:

   • The precision of piezosurgery makes it suitable for resecting tumors in the jaw while preserving surrounding healthy tissue.

Classification and Management of Impacted Third Molars

Impacted third molars, commonly known as wisdom teeth, can present in various orientations and depths, influencing the difficulty of their extraction. Understanding the types of impactions and their classifications is crucial for planning surgical intervention.

Types of Impaction

1. Mesioangular Impaction:

   • Description: The tooth is tilted toward the second molar in a mesial direction.
   • Prevalence: Comprises approximately 43% of all impacted teeth.
   • Difficulty: Generally acknowledged as the least difficult type of impaction to remove.

2. Vertical Impaction:

   • Description: The tooth is positioned vertically, with the crown facing upward.
   • Prevalence: Accounts for about 38% of impacted teeth.
   • Difficulty: Moderate difficulty in removal.

3. Distoangular Impaction:

   • Description: The tooth is tilted away from the second molar in a distal direction.
   • Prevalence: Comprises approximately 6% of impacted teeth.
   • Difficulty: Considered the most difficult type of impaction to remove due to the withdrawal pathway running into the mandibular ramus.

4. Horizontal Impaction:

   • Description: The tooth is positioned horizontally, with the crown facing the buccal or lingual side.
   • Prevalence: Accounts for about 3% of impacted teeth.
   • Difficulty: More difficult than mesioangular but less difficult than distoangular.

Decreasing Level of Difficulty for Types of Impaction

• Order of Difficulty:
  • Distoangular > Horizontal > Vertical > Mesioangular

Pell and Gregory Classification

The Pell and Gregory classification system categorizes impacted teeth based on their relationship to the mandibular ramus and the occlusal plane. This classification helps assess the difficulty of extraction.

Classification Based on Coverage by the Mandibular Ramus

1. Class 1:

   • Description: Mesiodistal diameter of the crown is completely anterior to the anterior border of the mandibular ramus.
   • Difficulty: Easiest to remove.

2. Class 2:

   • Description: Approximately one-half of the tooth is covered by the ramus.
   • Difficulty: Moderate difficulty.

3. Class 3:

   • Description: The tooth is completely within the mandibular ramus.
   • Difficulty: Most difficult to remove.

Decreasing Level of Difficulty for Ramus Coverage

• Order of Difficulty:
  • Class 3 > Class 2 > Class 1

Pell and Gregory Classification Based on Relationship to Occlusal Plane

This classification assesses the depth of the impacted tooth relative to the occlusal plane of the second molar.

1. Class A:

   • Description: The occlusal surface of the impacted tooth is level or nearly level with the occlusal plane of the second molar.
   • Difficulty: Easiest to remove.

2. Class B:

   • Description: The occlusal surface lies between the occlusal plane and the cervical line of the second molar.
   • Difficulty: Moderate difficulty.

3. Class C:

   • Description: The occlusal surface is below the cervical line of the second molars.
   • Difficulty: Most difficult to remove.

Decreasing Level of Difficulty for Occlusal Plane Relationship

• Order of Difficulty:
  • Class C > Class B > Class A

Summary of Extraction Difficulty

• Most Difficult Impaction:
  • Distoangular impaction with Class 3 ramus coverage and Class C depth.
• Easiest Impaction:
  • Mesioangular impaction with Class 1 ramus coverage and Class A dep

Maxillectomy

Maxillectomy is a surgical procedure involving the resection of the maxilla (upper jaw) and is typically performed to remove tumors, treat severe infections, or address other pathological conditions affecting the maxillary region. The procedure requires careful planning and execution to ensure adequate access, removal of the affected tissue, and preservation of surrounding structures for optimal functional and aesthetic outcomes.

Surgical Access and Incision

1. Weber-Fergusson Incision:

   • The classic approach to access the maxilla is through the Weber-Fergusson incision. This incision provides good visibility and access to the maxillary region.
   • Temporary Tarsorrhaphy: The eyelids are temporarily closed using tarsorrhaphy sutures to protect the eye during the procedure.

2. Tattooing for Aesthetic Alignment:

   • To achieve better cosmetic results, it is recommended to tattoo the vermilion border and other key points on both sides of the incision with methylene blue. These points serve as guides for alignment during closure.

3. Incision Design:

   • The incision typically splits the midline of the upper lip but can be modified for better cosmetic outcomes by incising along the philtral ridges and offsetting the incision at the vermilion border.
   • The incision is turned 2 mm from the medial canthus of the eye. Intraorally, the incision continues through the gingival margin and connects with a horizontal incision at the depth of the labiobuccal vestibule, extending back to the maxillary tuberosity.

4. Continuation of the Incision:

   • From the maxillary tuberosity, the incision turns medially across the posterior edge of the hard palate and then turns 90 degrees anteriorly, several millimeters to the proximal side of the midline, crossing the gingival margin again if possible.

5. Incision to Bone:

   • The incision is carried down to the bone, except beneath the lower eyelid, where the orbicularis oculi muscle is preserved. The cheek flap is then reflected back to the tuberosity.

Surgical Procedure

1. Extraction and Elevation:

   • The central incisor on the involved side is extracted, and the gingival and palatal mucosa are elevated back to the midline.

2. Deepening the Incision:

   • The incision extending around the nose is deepened into the nasal cavity. The palatal bone is divided near the midline using a saw blade or bur.

3. Separation of Bone:

   • The basal bone is separated from the frontal process of the maxilla using an osteotome. The orbicularis oculi muscle is retracted superiorly, and the bone cut is extended across the maxilla, just below the infraorbital rim, into the zygoma.

4. Maxillary Sinus:

   • If the posterior wall of the maxillary sinus has not been invaded by the tumor, it is separated from the pterygoid plates using a pterygoid chisel.

5. Specimen Removal:

   • The entire specimen is removed by severing the remaining attachments with large curved scissors placed behind the maxilla.

Postoperative Considerations

• Wound Care: Proper care of the surgical site is essential to prevent infection and promote healing.
• Rehabilitation: Patients may require rehabilitation to address functional issues related to speech, swallowing, and facial aesthetics.
• Follow-Up: Regular follow-up appointments are necessary to monitor healing and assess for any complications or recurrence of disease.

1. Radical Neck Dissection

• Complete removal of all ipsilateral cervical lymph node groups (levels I-V) and three key non-lymphatic structures:
  • Internal jugular vein
  • Sternocleidomastoid muscle
  • Spinal accessory nerve
• Indication: Typically performed for extensive lymphatic involvement.

2. Modified Radical Neck Dissection

• Similar to radical neck dissection in terms of lymph node removal (levels I-V) but with preservation of one or more of the following structures:
  • Type I: Preserves the spinal accessory nerve.
  • Type II: Preserves the spinal accessory nerve and the sternocleidomastoid muscle.
  • Type III: Preserves the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein.
• Indication: Used when there is a need to reduce morbidity while still addressing lymphatic involvement.

3. Selective Neck Dissection

• Preservation of one or more lymph node groups that are typically removed in a radical neck dissection.
• Classification:
  • Originally had named dissections (e.g., supraomohyoid neck dissection for levels I-III).
  • The 2001 modification proposed naming dissections based on the cancer type and the specific node groups removed. For example, a selective neck dissection for oral cavity cancer might be referred to as a selective neck dissection (levels I-III).
• Indication: Used when there is a lower risk of lymphatic spread or when targeting specific areas.

4. Extended Neck Dissection

•  Involves the removal of additional lymph node groups or non-lymphatic structures beyond those included in a radical neck dissection. This may include:
  • Mediastinal nodes
  • Non-lymphatic structures such as the carotid artery or hypoglossal nerve.
• Indication: Typically performed in cases of extensive disease or when there is a need to address additional areas of concern.

Ridge Augmentation Procedures

Ridge augmentation procedures are surgical techniques used to increase the volume and density of the alveolar ridge in the maxilla and mandible. These procedures are often necessary to prepare the site for dental implants, especially in cases where there has been significant bone loss due to factors such as tooth extraction, periodontal disease, or trauma. Ridge augmentation can also be performed in conjunction with orthognathic surgery to enhance the overall facial structure and support dental rehabilitation.

Indications for Ridge Augmentation

• Insufficient Bone Volume: To provide adequate support for dental implants.
• Bone Resorption: Following tooth extraction or due to periodontal disease.
• Facial Aesthetics: To improve the contour of the jaw and facial profile.
• Orthognathic Surgery: To enhance the results of jaw repositioning procedures.

Types of Graft Materials Used

Ridge augmentation can be performed using various graft materials, which can be classified into the following categories:

1. Autografts:

   • Bone harvested from the patient’s own body, typically from intraoral sites (e.g., chin, ramus) or extraoral sites (e.g., iliac crest).
   • Advantages: High biocompatibility, osteogenic potential, and lower risk of rejection or infection.
   • Disadvantages: Additional surgical site, potential for increased morbidity, and limited availability.

2. Allografts:

   • Bone grafts obtained from a human donor (cadaveric bone) that have been processed and sterilized.
   • Advantages: No additional surgical site required, readily available, and can provide a scaffold for new bone growth.
   • Disadvantages: Risk of disease transmission and potential for immune response.

3. Xenografts:

   •  Bone grafts derived from a different species, commonly bovine (cow) bone.
   • Advantages: Biocompatible and provides a scaffold for bone regeneration.
   • Disadvantages: Potential for immune response and slower resorption compared to autografts.

4. Alloplasts:

   •  Synthetic materials used for bone augmentation, such as hydroxyapatite, calcium phosphate, or bioactive glass.
   • Advantages: No risk of disease transmission, customizable, and can be designed to promote bone growth.
   • Disadvantages: May not integrate as well as natural bone and can have variable resorption rates.

Surgical Techniques

1. Bone Grafting:

   • The selected graft material is placed in the deficient area of the ridge to promote new bone formation. This can be done using various techniques, including:
     • Onlay Grafting: Graft material is placed on top of the existing ridge.
     • Inlay Grafting: Graft material is placed within the ridge.

2. Guided Bone Regeneration (GBR):

   • A barrier membrane is placed over the graft material to prevent soft tissue infiltration and promote bone healing. This technique is often used in conjunction with grafting.

3. Sinus Lift:

   • In the maxilla, a sinus lift procedure may be performed to augment the bone in the posterior maxilla by elevating the sinus membrane and placing graft material.

4. Combination with Orthognathic Surgery:

   • Ridge augmentation can be performed simultaneously with orthognathic surgery to correct skeletal discrepancies and enhance the overall facial structure.