Executive Editor: Marcelo Figari, Gregorio Sánchez Aniceto General Editor: Daniel Buchbinder

Authors: Ricardo Cienfuegos, Carl-Peter Cornelius, Edward Ellis III, George Kushner

Mandible - Angle and ramus, simple - ORIF

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Glossary

1 Principles top

The intraosseous wire will help to prevent rotation of the mandibular ramus enlarge

Principles

The intraosseous wire must be placed to resist the upward and forward direction in which the ramus will tend to rotate. Therefore, it is prudent to place the hole through the proximal fragment superiorly to the hole in the distal fragment.

It is not necessary for the intraosseous wire to engage both buccal and lingual cortices on each side of the fracture. It is only necessary to engage the buccal cortices with the wire.
Because this is a nonrigid technique, 5–6 weeks of MMF must be applied after surgery.


Special considerations

Following special considerations may need to be taken into account:

Click on any subject for further detail.

2 Fixation top

The fracture should be exposed and any extractions determined necessary be performed enlarge

Exposure of fracture

The fracture should be exposed and any extractions determined necessary be performed. Open reduction in dentate patients usually begins with fixation of the occlusion. However, MMF is not desirable when using intraosseous wire fixation until the wire is to be tightened. It is easier to drill the holes in the bone and to pass the wire while the patient’s jaws are open.


A 1.5 mm hole is drilled through the buccal cortex of the distal fragment enlarge

Drill holes

A 1.5 mm hole is drilled through the buccal cortex of the distal fragment. A second hole, located more superiorly, is drilled through the buccal cortex of the proximal fragment.

If the terminal molar is extracted as part of the procedure, the holes enter the socket. If no tooth is extracted, the holes enter the medullary space and exit into the fracture.

The holes can be drilled with a drill inserted through the oral cavity or alternatively, a Steinmann pin can be inserted transcutaneously to drill the holes.


A 0.5 mm wire is passed through the holes and preliminarily twisted together enlarge

Applying internal wire fixation

A 0.5 mm wire (24 gauge) is passed through the holes and preliminarily twisted together. Prior to final tightening of the wire, the patient must be placed into occlusion and secured with MMF. The intraosseous wire is then tightened, cut, and twisted down to the bone.

Click here for further details on methods for applying MMF.

3 Case example top

Panoramic and PA x-rays show left simple angle fracture associated with an impacted third molar. enlarge

Panoramic and PA x-rays show left simple angle fracture associated with ...


Panoramic and PA x-rays show left simple angle fracture associated with an impacted third molar. enlarge

... an impacted third molar.


the soft-tissue incision is made as demonstrated enlarge

Because it is anticipated that the second molar might be removed in addition to the third molar the soft-tissue incision is made as demonstrated.


Subperiosteal dissection exposes the fracture and the impacted third molar enlarge

Subperiosteal dissection exposes the fracture and the impacted third molar.


The impacted third molar is being removed because it interfered with fracture reduction enlarge

The impacted third molar is being removed because it interfered with fracture reduction.


The second molar is also removed because there is a large bony defect along the posterior root enlarge

The second molar is also removed because there is a large bony defect along the posterior root.


The second molar is also removed because there is a large bony defect along the posterior root enlarge

After making two holes, the wire is then passed from the extraction site out the hole in the proximal fragment.


The wire is then preliminarily tightened enlarge

The wire is then preliminarily tightened. Prior to final tightening, the patient should be placed into MMF.


The wire has been tightened, cut, and bent down to lay against the bone enlarge

The wire has been tightened, cut, and bent down to lay against the bone.


The flap is undermined with scissors enlarge

To facilitate closure over the second molar extraction site, the flap is undermined with scissors.


The flap is undermined with scissors enlarge

Note that the flap has now been mobilized.


The flap is undermined with scissors enlarge

The flap has been closed over the extraction site.


MMF is secured and left in position for 5–6 weeks. enlarge

MMF is secured and left in position for 5–6 weeks. Note this patient’s preexisting malocclusion.


Postoperative panoramic and PA x-rays enlarge

Postoperative panoramic and PA x-rays show reduction of the fracture, ...


Postoperative panoramic and PA x-rays enlarge

... the position of the intraosseous wire, and MMF.

v1.0 2008-12-01