We thank the readers very much for their interest in our paper entitled “Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate”, and their valuable comments. We respond to their concerns below.
We partly agree with the readers that most sagittal fractures of the maxilla and palate (SFMP) can be managed by the technique of intermolar wiring traction. Compared with our transpalatal screw traction method, the intermolar technique does have advantages, including the ability to visualize the occlusion while tightening the wires, decreased operation times and costs of the screws, and being more convenient in the emergency setting for stabilizing SFMP. As illustrated by the readers’ figure, the moment arm in the intermolar wiring situation will be larger than that of transpalatal screw traction, producing more torque and requiring less tractive force.
In fact, we also use intermolar wiring traction and fixation in the management of SFMP in some cases. However, because of the lack of rigid fixation in the hard palate, we and other authors introduced the transpalatal traction wire, which is usually kept in place for 4 or more weeks to help immobilize fractures and achieve primary bone union.
Obviously, the intermolar wiring technique also has associated disadvantages. Firstly, it increases the risk of dental injury. As known, passing a metal wire around the tooth neck and keeping it tight for a relatively long period of time may result in trauma to the periodontium, the danger of tooth avulsion and crown fracture, and even exert orthodontic forces leading to tooth extrusion. Secondly, during this traction period, many patients are likely to complain of postoperative discomfort such as tooth pain, oral hygiene compromise, and a tangible nuisance for the tongue. Thirdly, difficulties will occur in advanced periodontal disease and in the presence of metal ceramic or resin restorations or injured molars, in which the remaining teeth are loose and unsuitable for supporting a wire. In addition, the technique described would not be appropriate for managing SFMP in edentulous patients because there are no teeth present for placing the intermolar wire.
Compared with open reduction and internal fixation of the hard palate, both transpalatal screw traction and intermolar wiring traction constitute conservative therapies. Essentially, both techniques are intended to exert inward forces in the transverse direction to reduce the displaced fragments medially. In spite of being less rigid than plate and screw fixation, these techniques can achieve good outcomes in terms of bony union and occlusion, with few complications. The main difference between transpalatal screw traction and intermolar wiring fixation is that the former is a bone-supported device and the latter is a tooth-borne device. Based on the different anchoring modalities, each has advantages and drawbacks and neither may represent a perfect solution. Therefore, to achieve the best treatment outcome and minimize the potential morbidity, customized techniques should be selected according to the individual needs of the patient, depending on the traumatic condition, local anatomy, patient tolerance, etc.
Again, only a preliminary report of the transpalatal screw traction technique was presented in our paper. Further prospective clinical trials are required to compare the technique presented with other existing techniques.
This work was partly funded by the “Twelve-Five” Medical Research Projects of PLA (CWS12J066, CLZ11JB06).