Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate

Abstract

Sagittal fractures of the maxilla and palate are uncommon in clinical practice. Current methods for the management of such fractures have advantages and limitations. The authors present the simple and practical technique of bilateral transpalatal screw traction to manage this fracture type.

Sagittal fractures of the maxilla and palate (SFMP), passing medially or paramedially through the palatal shelves and splitting the maxilla in a sagittal direction, usually occur in association with a Le Fort fracture. This type of fracture often causes maxillary arch expansion and buccal rotation. Traditional methods for managing such fractures include the use of Kirschner wire, acrylic splints, arch bars for maxillomandibular fixation, intermolar wire fixation, and the intermaxillary figure-of-eight wiring technique. However, each of these methods has inherent drawbacks and it is difficult to use these techniques alone to achieve ideal occlusal function, sufficient stability, and accurate reduction.

Clinicians are increasingly advocating the use of open reduction and internal fixation with a plate and screw system to treat such fractures. This technique obviously has several advantages, such as improving the stability, defining maxillary arch width, and limiting the rotation of the maxillary segments. However, it is sometimes associated with complications such as the development of palatal fistula and exposure of the plate and screws. Moreover, the operative procedure includes palatal incision, wide flap elevation, reduction of the maxillary fracture, and plate–screw fixation on the roof of the mouth. This procedure is time-consuming and may affect the blood supply of the fractured segments. Therefore, more simple and effective methods are needed.

We describe a simple technique to manage SFMP: bilateral transpalatal screw traction.

Technique

Images of a representative patient with SFMP are given in Figs. 1–3 .

Fig. 1
Preoperative malocclusion in a representative patient with sagittal fractures of the maxilla and palate (left). Axial (middle) and coronal (right) CT scans show the sagittal fractures of the maxilla and palate (arrows) before treatment.

Fig. 2
Intraoperative view showing the application of transpalatal screw traction.

Fig. 3
Postoperative view of the same patient showing the normal occlusion obtained (left). Axial (middle) and coronal (right) CT scans show the reduced fractures of the maxilla and palate (arrows) at 7 days after treatment.

Two self-drilling screws (each with a hole in its head) are inserted bilaterally into the bony palatal region between the upper first and second molars. A 24-gauge wire is pre-stretched and its ends are inserted into the screw holes on either side of the palate. The two ends of the wire are then criss-crossed and progressively twisted together ( Fig. 2 ). Tightening forceps produce a traction force in the direction of the median line to reduce displaced fractures. The transpalatal traction wire is kept in place to help immobilize fractures of the maxilla and palate. Intermaxillary fixation is applied on each side of the fracture line to restore normal occlusion. The fractures are then stabilized if needed.

Transpalatal screw traction can be used alone, or as an adjunct to other management methods, such as intermaxillary fixation, open reduction and internal fixation at the level of the piriform aperture, and stabilization of zygomaticomaxillary and nasomaxillary buttresses. The average time to the removal of the traction device is 4 weeks.

We have used this technique to treat 11 patients with SFMP over a period of 5 years. The fractures in this study were not isolated and all were associated with Le Fort fractures. The mean follow-up was 8 months. Ten patients achieved satisfactory occlusion. One patient developed bilateral posterior crossbite but had acceptable occlusion following orthodontic treatment. We observed that transpalatal screw traction is an effective method for achieving closed reduction and external fixation in patients with SFMP. Therefore, the use of open reduction and internal fixation of the hard palate is not recommended for the treatment of SFMP in our department.

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Jan 19, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate
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