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| IMC Wiki | Conservative therapy

Conservative therapy

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Direct splints



Advantages
  • Created intraorally, hence immediately available
  • Low material cost
  • Feasible in all dentulous patients
#pic#

Disadvantages
  • Inaccurate fit, potentially with orthodontic impact on some teeth
  • Damage to the marginal periodontium
  • Prolonged use (six weeks)
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Types

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Indirect splints

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#pic#

Advantages
  • Fabricated in the laboratory on models
  • Accurate fit at the equator of the tooth
Disadvantages
  • Delay
  • Impression-taking
Types
  • Model-cast capping splint
  • Plastic splints

Intermaxillary fixation combined with dental arch bars

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  • Fractured mandible segment is fixed to the maxilla
  • elastic fixation results in fragment repositioning
  • Rigid fixation with wire
  • Fractured maxilla is fixated to the mandible for occlusal adjustment combined with craniofacial suspension

Intermaxillary fixation with Otten hooks

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Advantages
  • Always available
  • Even in edentulous patients
  • Rapid fixation
  • Particularly for TMJ fractures
  • Rigid and elastic fixation possible
Disadvantages

Additional swaged splint in the maxilla is necessary, otherwise teeth will become mobile

Combined therapy

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Mandible
  • Splint and circumferential wiring
  • Especially suitable in children

Craniofacial suspensions

All types of craniofacial suspension are merely emergency measures, to be taken when a surgical approach as first-line procedure cannot be performed due to systemic reasons (e.g. high Glasgow coma score).
  1. Zygomatic bone/arch suspension
  2. Laterofrontal suspension
  3. Nasofrontal suspension (Kufner)
  4. Craniofacial fixateuor
  5. Halo fixateur

1. Zygomatic bone/arch suspension

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Indication

Le Fort I/II fractures if zygomatic arch is intact

Advantages

Fast and simple immobilization, especially in the presence of bleeding combined with Belloque-tamponade* (to seal the pharyngeal area at the choanae for hemostatis) and
anterior nasal tamponade (to seal the nose from inside using a iodoform tamponade for hemostasis)

*(Posterior pharyngeal tamponade; first a gastric probe is inserted and passed out at the mouth. A thread is attached and passed out at the nose. The pull-out thread is passed out at the mouth. Then an anterior nasal tamponade is placed and the thread knotted around it).

Disadvantages
  • Risk of facial dislocation distalward and of vertical reduction
  • ”Dish face”
  • No anatomic repositioning
  • For emergency management only
Procedure
  • A splint is inserted into the maxilla and into the mandible, if necessary, for intermaxillary fixation using appropriate hooklets
  • Piercing with a Reverdin needle above the zygomatic floor, maintaining bone contact and manual control caudally to the zygomatic bone in intraoral direction, possibly distalward (Caution: parotid papilla!)
  • A wire is passed and withdrawn in cranial direction until the subcutis is reached, then the wire is once again pushed forward above the zygomatic bone in anterior direction (three-point support) Then the occlusion is adjusted via intermaxillary and maxillary fixation (Caution: overtightening of the suspension wires will reduce and dislocate the middle face!)

2. Laterofrontal suspension

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Indication

Le Fort II/III fractures, midface comminution

Advantages

Fast and simple immobilization, especially in the presence of bleeding combined with Belloque-tamponade (to seal the pharyngeal area at the choanae for hemostatis) and
anterior nasal tamponade (to seal the nose from inside using a iodoform tamponade for hemostasis)

Disadvantages
  • ”Dish face”
  • Risk of vertical reduction of the middle face
  • No anatomic repositioning
  • For emergency management only
Procedure
  • A splint is inserted into the maxilla and mandible for intermaxillary fixation using appropriate hooklets
  • Bilateral incision at the lateral orbita above the zygomaticofrontal suture
  • Insertion of screws on the left and right
  • Pearcing with a Reverdin needle in intraoral direction, distally below the zygomatic bone
  • The wire is inserted, pulled up around the screw and back in intraoral anterior direction, again below the zygomatic bone
  • The wire is tightened onto the maxillary splint
  • Maxillary fixation (Caution: reduction and dislocation of the midface!)

3. Nasofrontal suspension (Kufner)

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Indication

Le Fort II/III fractures, midface comminution

Advantages
  • Fast and simple immobilization, especially in the presence of profuse bleeding from the mouth and nose combined with Belloque-tamponade and anterior nasal tamponade
  • Advancement of the midface
  • reduced risk of “dish face” compared to laterofrontal suspension
Disadvantages
  • Risk of vertical reduction of the midface
    #pic#
  • No anatomic repositioning
  • For emergency management only
Procedure
  • Median incision above the frontonasal suture
  • Bilateral epiperiosteal piercing with Reverdin needle and wire
  • Retrieval intraorally at both sides
  • Care must be taken to avoid the lacrimonasal duct!

4. Craniofacial fixateur

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Indication

All midface fractures

Advantages

better vertical and sagittal adjustment

Disadvantages
  • for emergency management only
  • no anatomic repositioning
Procedure
  • median incision above the frontonasal suture
  • adaptation of the fixateur
  • passing through into the oral cavity
  • adjustment and fixation using screws

5. Halo-Fixateur

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Indication

All midface fractures

Advantages

better vertical and sagittal adjustment

Disadvantages
  • for emergency management only
  • no anatomic repositioning
Procedure
  • cranial screwing
  • intraoral splinting
  • intra- and extraoral fixation