Optimization of mandibular fracture treatment
Batbayar, Enkh-Orchlon
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Publication date: 2019
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Batbayar, E-O. (2019). Optimization of mandibular fracture treatment. University of Groningen.
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CHAPTER 4
DEVELOPMENT AND FEASIBILITY OF
A NEW REDUCTION FORCEPS FOR
MANDIBULAR FRACTURES: A TECHNICAL
INNOVATION
Enkh-Orchlon Batbayar, Joost de Beij, Ruud R.M Bos, Baucke van Minnen Submitted
ABSTRACT
This note reports a simple and effective method to reduce mandibular fractures with a newly designed fracture reduction forceps. Medical engineers and oral and maxillofacial surgeons discussed the problems related to existing reduction forceps and developed three forceps, specifically designed to use in fractures of the anterior and posterior mandible. Both forceps proved to be applicable for use in mandibular fractures when tested in clinical practice.
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Mandibular fracture reduction forceps
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INTRODUCTION
Mandibular fractures are routinely treated with open reduction and internal fixation with plate osteosynthesis. Prior to fixation, anatomical reduction of the fragments must be achieved. Intermaxillary fixation (IMF), manual reduction and reduction forceps are used to reduce the fragments of fractured mandibles. The use of reduction forceps has not been extensively investigated and is not widespread, but can be very effective1.
In the literature, some modified and newly designed reduction forceps have been recommended for the reduction of mandibular fractures1–3. These
forceps had a scissor-like profile, but the prongs differ from each other4. Most
of these forceps were proposed to be used in the (para)symphyseal region of the mandible and only a few for the posterior region. (Para)symphyseal region fractures are easier to reduce with a forceps compared to posterior fractures, when used via an intraoral approach. However, in the frontal region a complication such as lingual flaring still can occur.
In our department, there is a tendency to use reduction forceps more often. We routinely used a standard, commercially available forceps. However, as also mentioned in other studies, we experienced difficulties to apply reduction forceps to the mandibular fractures. The study presented in this report aimed to design and develop a new reduction forceps for any region of the mandible via intra-oral approach and to test their feasibility.
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THE FORCEPS AND TECHNIQUE
The authors designed and developed the first prototype of the forceps, and tested these in a cadaver. To do so, at first technicians and clinicians (authors) started with a problem analysis by demonstrating the anatomical situation on a fresh cadaver. Based on the findings a morphological overview was made (Fig 1) in which all possible options included. Thereafter a requirements package was defined which included user requirements, manufacturing, and environmental requirements. The best option was then calculated using the Kesselring method (Fig 2).
Fig 3. Proposed fracture reduction forceps. Anterior region forceps (A), and posterior region
forceps (B).
A
Subsequently, the forceps were manufactured by a professional company (KLS Martin, Tutlingen, Germany ) (Fig 3). We developed three forceps; one for the (para)symphyseal and a right and a left one for the posterior area. The (para) symphyseal region reduction forceps (Fig 3A) has sharp-curved long prongs, and these prongs can be positioned at various distances in order to prevent lingual flaring. The posterior region reduction forceps (Fig 3B) has a sliding mechanism which allows to minimize the size of the forceps. Both forceps have a long cremaillère (rack-and-pinion) to make locking of the forceps at various distances possible, and are made of stainless steel. Both forceps can be operated with one hand.
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Mandibular fracture reduction forceps
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The feasibility was tested in patients with mandibular fractures. The patient demonstrated here (Fig 4) had a symphyseal fracture due to a bike accident. The fracture was reduced using the anterior region forceps without intermaxillary fixation (IMF). After an intra-oral incision the fracture was exposed and two monocortical holes were made at 15 mm distance from the fracture line with 1.8 mm round bur taken into account that they should not interfere with the osteosynthesis plates and screws to be applied. Thereafter, the anterior region forceps was applied in the drill holes and the fracture anatomically reduced under compression of the forceps. Then the fracture was fixed with two four-hole mini-plates with the forceps still in situ (Fig 4). The forceps was removed after fixation of the fracture. The same procedure was applied in the angle forceps. The angle forceps not only serves to reduce the fracture but also to retract the soft tissues and provides enough room to apply the osteosynthesis.
DISCUSSION
We systematically developed a set of new fracture reduction forceps for fractures of the anterior as well as the posterior region of the mandible. The (para)symphyseal region forceps is easy to handle with a single hand, which could reduce the number of operation assistants. The design of the posterior region forceps is optimal for as the angel region, but also applicable in the posterior body regiondue to its sliding function and slim design. This provides good sight for the surgeon and enough room for application of osteosynthesis materials via an intraoral approach.
In our previous study, we reviewed the commercially available reduction forceps for mandibular fractures. According to this study, most of the proposed reduction forceps in the literature were only applicable in the (para)symphyseal region of the mandible due to their design3,5. Compared with these forceps,
our design is almost generally applicable because of its smaller dimensions and long cremaillère Besides, a study by Choi et al. concluded that, in order to prevent flaring, the optimum stress distribution over the fracture site is achieved when placing the prongs of the forceps at least 12 mm away from the fracture line6. Different angulations of the forceps’ prongs were proposed
by some authors2,5. However, in our experience, a sharp angulation of the
Our design of the posterior region reduction forceps has advantages over previous forceps that have been proposed by others 2,7,8. Besides that its
sliding mechanism minimizes the dimensions of the forceps our design is ideal for the posterior region compared to the design of the scissor-like forceps, because the prongs of our forceps can be positioned at the oblique ridge or at the lateral surface of the mandible through the mouth. However, in cases of very oblique, flat fractures without sufficient interfragmentary stability reduction with any kind of forceps may be impossible due to sliding of the fracture parts.
This project was undertaken to design, develop and evaluate new reduction forceps for mandibular fractures. We conclude that our proposed designs are applicable for the reduction of fractures of the anterior as well as the posterior region of the mandible.
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REFERENCE
1. Choi BH., Kim HJ., Kim MK., Han SG., Huh JY., Kim BY., et al. Management of mandibular angle fractures using the mandibular angle reduction forceps. Int J Oral
Maxillofac Surg 2005;34(3):257–61. Doi: 10.1016/j.ijom.2004.05.009.
2. Scolozzi P., Jaques B. Intraoral open reduction and internal fixation of displaced mandibular angle fractures using a specific ad hoc reduction-compression forceps: a preliminary study. Oral Surgery, Oral Med Oral Pathol Oral Radiol Endodontology 2008;106(4):497–501. Doi: 10.1016/j.tripleo.2008.01.018.
3. Rogers GF., Sargent L a. Modified towel-clamp technique to effect reduction of displaced mandible fractures. Plast Reconstr Surg 2000;105(2):695–7. Doi: 10.1097/00006534-200002000-00033.
4. Batbayar E-O., van Minnen B., Bos RRM. Non-IMF mandibular fracture reduction techniques: A review of the literature. J Cranio-Maxillofacial Surg 2017;45(8):1327– 32. Doi: 10.1016/j.jcms.2017.05.017.
5. Kluszynski BA., Wineland AM., Kokoska MS. Mechanical and clinical rationale of prototype bone reduction forceps. Arch Facial Plast Surg 2007;9(2):106–9. Doi: 10.1001/archfaci.9.2.106.
6. Choi BH., Park JH., Yoo TM., Huh JY., Suh CH. Evaluation of stress patterns generated by reduction forceps within a photoelastic mandibular model. J
Cranio-Maxillofacial Surg 2003;31(2):120–5. Doi: 10.1016/S1010-5182(02)00185-3.
7. Choi BH., Suh CH., Par JH., Yoo JH., Kim HJ. An effective technique for open reduction of mandibular angle fractures using new reduction forceps: technical innovations. Int J Oral Maxillofac Surg 2001;30(6):555–7. Doi: 10.1054/ ijom.2001.0158.
8. Kallela I., Ilzuka T., Laine P., Lindqvist C. Lag-screw fixation of mandibular parasymphyseal and angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol
