J Oral Maxillofac Surg 69:e152-e154, 2011

A Novel Adjuvant to Treat Palatal Fractures

Chidambaram Kumaravelu, BDS, MDS,* Gnanasagar J. Thirukonda, BDS, MDS, and Praveena Kannabiran, BDS, MDS
Palatal fractures are relatively rare but generally occur along with maxillary fractures. The average incidence of palatal fractures combined with maxillary fractures ranges from 8% to 20%,1-4 although a much higher incidence has recently been reported (46.4%).5 Traditionally, anatomic reduction of palatal fractures is considered difcult. Although various techniques prevail, ranging from invasive open reduction and internal xation (ORIF),4,6 Kirschner wire xation,7 to noninvasive techniques such as stabilization of the maxillary arch using an arch bar, transpalatal wiring,2 intraosseous wiring, acrylic splints,4,8,9 and intermolar wiring,5 all have inherent difculties and drawbacks. ORIF requires a wide mucoperiosteal ap elevation, which is not so easy in the palate because of the tightly adherent mucoperiosteum, which might damage the soft tissue, partly jeopardizing the blood supply. It could also result in exposure of hardware10 and delayed nasal bleeding.3 Moreover, there is an inherent risk of occlusal disruption when not accompanied by maxillomandibular xation. Therefore, seeking an alternative for timeconsuming ORIF associated with many intricacies seems to be judicious. Intraosseous and transpalatal wiring techniques carry similar disadvantages at varying degrees. Techniques using the arch bar and splint aim at stabilization of the maxilla but unfortunately play only a passive role in bringing the fractured components together and are ineffective in minimizing the gap between the 2 fragments because compression is required to enable true bony union. Even the recent technique of intermolar wiring done in a transpalatal direction from the left molar to the right molar is not without problems. Because it is retained for 4 to 5 weeks, it can irritate the tongue, make oral hygiene difcult, and also can interfere with speech.5 The goal of every treatment modality is to provide the luxury of convenience to the operator and the benet of early healing, minimized morbidity, and a better quality of life to the patient. An innovative and easy technique was devised by Prof Kumaravelu for treating palatal fractures in an attempt to simplify treatment. Since 1986, he has treated more than 50 cases of palatal fracture at various Tamil Nadu government hospitals, including the Tamil Nadu Government Dental College and Hospital, Chennai, without any complication such as technical difculty, patient discomfort, or fracture nonhealing. This makes the gure-of-8 intermaxillary wiring technique a simple treatment option for treating palatal fractures. Case selection is the key factor for the success of any treatment. Simple sagittal and parasagittal fractures of the palate (types II and III)2 are best treated with gure-of-8 wiring when there are at least 2 adjacent teeth with tight contact areas bilaterally in both the arches. It is preferable to have 1 or 2 periodontally healthy molars in all 4 quadrants. The technique involves a gure-of-8 wiring between the maxillary and mandibular rst molars bilaterally. Two pieces of 20-cm long 24-gauge (0.4 mm) wire are prestretched. The 2 ends of 1 wire are fed above the interdental contact points into the mesial and distal gingival embrasures of the maxillary rst molar and brought out on the palatal side (Fig 1). The ends are criss-crossed, ie, the end from the mesial embrasure of the maxillary rst molar is fed into the distal embrasure of the mandibular rst molar and the distal end from the maxillary rst molar is fed into the mesial embrasure of the mandibular rst molar (Figs 2, 3). Similarly, the second wire is applied to the contralateral molars. The 2 ends of each wire are pulled buccally. Then, the teeth are brought into functional occlusion. The e152

*Professor and Head of Department, Thai Moogambigai Dental College and Hospital, Chennai, India. Lecturer, Department of Oral and Maxillofacial Surgery, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia. Lecturer, King Saud University, Riyadh, Saudi Arabia. Address correspondence and reprint requests to Dr Thirukonda: Department of Oral and Maxillofacial Surgery, Riyadh Colleges of Dentistry and Pharmacy, Olaya Rd, Olaya, Riyadh, Saudi Arabia; e-mail: drtjgp@gmail.com
2011 American Association of Oral and Maxillofacial Surgeons

0278-2391/11/6906-0061$36.00/0 doi:10.1016/j.joms.2010.12.053

KUMARAVELU, THIRUKONDA, AND KANNABIRAN

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FIGURE 3. Step 3. Kumaravelu, Thirukonda, and Kannabiran. Innovative Treatment of Palatal Fracture. J Oral Maxillofac Surg 2011. FIGURE 1. Step 1. Kumaravelu, Thirukonda, and Kannabiran. Innovative Treatment of Palatal Fracture. J Oral Maxillofac Surg 2011.

wire is tightened and twisted on the mesiobuccal side of the tooth bilaterally (Fig 4). The excess wire is cut and the remaining end is turned gingivally into the mesial embrasure (Fig 5). This can also be done between second molars or second premolars. Better control over the fragments and compression along the fragments towards the midline can be achieved when the wiring is done between the most posterior teeth available.

In normal static occlusion, the mediolateral curve of Wilson shows an inward inclination of the lower posterior teeth, with the lingual cusps lower than the buccal cusps on the mandibular arch; the buccal cusps are higher than the palatal cusps on the maxillary arch because of the outward inclination of the upper posterior teeth. Based on the principle of physics, when the wire is tightened, the intact mandible provides stationary anchorage to the fractured palate, exerting a compressive force on the maxillary segments towards the midline (Fig 6). Therefore, the fractured palatine fragments are forced towards each other along the midline, thus producing a good reduction. Furthermore, the cuspal inclines of the teeth provide a physiologic barrier preventing over-riding of the fragments (Fig 6). In general, the practical complexity in treating palatal fracture is the splaying of the posterior ends, especially when treated using suspension wiring.

FIGURE 2. Step 2. Kumaravelu, Thirukonda, and Kannabiran. Innovative Treatment of Palatal Fracture. J Oral Maxillofac Surg 2011.

FIGURE 4. Step 4. Kumaravelu, Thirukonda, and Kannabiran. Innovative Treatment of Palatal Fracture. J Oral Maxillofac Surg 2011.

e154 This technique counteracts the splaying of the posterior area of the fractured palatine fragments. The striking clinical advantages of gure-of-8 intermaxillary wiring are that it is less demanding on surgical expertise, is less time-consuming, and has minimal armamentarium requirements. Patient discomfort is reportedly minimal during the 4 weeks when the wiring is retained because it does not interfere with the tongue. Moreover, it can be performed intraoperatively to reduce the palatal fracture and address the concomitant midfacial fractures or as an alternative method for postoperative palatal stabilization. For more than 23 years now, this technique has shown satisfactory healing with no complications observed. In addition, it is a good option not only in remote hospitals, where expensive instruments and materials are not available, but also in established setups as a cost-cutting factor. The simplicity, reliability, and versatility of this technique have been evident for 24 years, denitely making it an attractive alternative to other conventional techniques. Hence, this simple technique is recommended as an additional valuable tool

INNOVATIVE TREATMENT OF PALATAL FRACTURE

FIGURE 6. Rationale of treatment. Kumaravelu, Thirukonda, and Kannabiran. Innovative Treatment of Palatal Fracture. J Oral Maxillofac Surg 2011.

for the oral and maxillofacial surgeon to treat palatal fractures forbidding the complex and comminuted fractures.

References
1. Denny AD, Celik N: A management strategy for palatal fractures: A 12-year review. J Craniofac Surg 10:49, 1999 2. Hendrickson M, Clark N, Manson PN, et al: Palatal fractures: Classication, patterns, and treatment with rigid internal xation. Plast Reconstr Surg 101:319, 1998 3. Park S, Ock JJ: A new classication of palatal fracture and an algorithm to establish a treatment plan. Plast Reconstr Surg 107:1669, 2001 4. Manson PN, Shack RB, Leonard LG, et al: Sagittal fractures of the maxilla and palate. Plast Reconstr Surg 72:484, 1983 5. Chen CH, Wang TY, Tsay PK, et al: A 162-case review of palatal fracture: Management strategy from a 10-year experience. Plast Reconstr Surg 121:2065, 2008 6. Grass J, Mackinnon S: Complex maxillary fractures: Role of buttress reconstruction and immediate bone grafts. Plast Reconstr Surg 78:9, 1986 7. Davis DG, Constant E: Transverse palatal wire for the treatment of vertical maxillary fractures. Plast Reconstr Surg 48:191, 1971 8. Manson PN, Hoopes JE, Su CT: Structural pillars of the facial skeleton: An approach to the management of Le Fort fractures. Plast Reconstr Surg 66:54, 1980 9. Manson P, Crawley W, Yaremchuk M, et al: Midface fractures: Advantages of immediate extended open reduction and bone grafting. Plast Reconstr Surg 76:1, 1985 10. Manson PN, Glassman D, Vanderkolk C, et al: Rigid stabilization of sagittal fractures of the maxilla and palate. Plast Reconstr Surg 85:711, 1990

FIGURE 5. Step 5. Kumaravelu, Thirukonda, and Kannabiran. Innovative Treatment of Palatal Fracture. J Oral Maxillofac Surg 2011.