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CASE REPORT
Year : 2022  |  Volume : 40  |  Issue : 2  |  Page : 213-215
 

Self-drilling screws for the prevention of dental and skeletal injuries during open reduction and internal fixation of pediatric mandibular fractures


1 Department of Oral and Maxillofacial Surgery, SRM Dental College, Ramapuram Campus, Chennai, Tamil Nadu, India
2 Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission31-Mar-2022
Date of Decision12-Apr-2022
Date of Acceptance24-May-2022
Date of Web Publication15-Jul-2022

Correspondence Address:
Dr. Elavenil Panneerselvam
AF 39, 6th Street, 11th Main Road, Annanagar, Chennai - 600 040, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisppd.jisppd_159_22

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   Abstract 


Facial trauma in pediatric population predisposes the child to injury of both the developing skeleton and dentition. This article aims to highlight the experience of the authors through a case report, in using self-drilling screws for fixation of mandibular fractures in pediatric age group. The use of self-drilling screws minimizes the complications such as thermal and/or mechanical damage to the developing dentition and the bone. They also provide significant advantages including ease of availability and technique, superior anchorage with primary stability, and minimizing or avoiding permanent damage to the developing tooth germs in the site of fracture. The use of self-drilling screws for mandibular open reduction and internal fixation in children is an easy, reliable, and safe technique which may have significant value addition in preventing inadvertent injury to the developing tooth germs.


Keywords: Mechanical injury, pediatric mandibular fracture, self-drilling screws, thermal injury, tooth germ injury


How to cite this article:
Panneerselvam E, Parameswaran A. Self-drilling screws for the prevention of dental and skeletal injuries during open reduction and internal fixation of pediatric mandibular fractures. J Indian Soc Pedod Prev Dent 2022;40:213-5

How to cite this URL:
Panneerselvam E, Parameswaran A. Self-drilling screws for the prevention of dental and skeletal injuries during open reduction and internal fixation of pediatric mandibular fractures. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Oct 5];40:213-5. Available from: http://www.jisppd.com/text.asp?2022/40/2/213/351041





   Introduction Top


Pediatric facial trauma poses significant treatment challenges due to their miniaturized morphology and immature dental and skeletal components that make them highly sensitive to external insults.[1] Hence, priority in managing pediatric facial trauma lies in preventing growth/developmental disturbances in addition to restitution of form and function. Management protocols are therefore conservative with emphasis on minimizing surgical interventions.[1] Surgical intervention, especially open reduction and internal fixation (ORIF), is avoided due to the high risk of iatrogenic injuries (thermal and/or mechanical) to the developing dentition and mandible. However, when ORIF is absolutely indicated, operative techniques are modified to eliminate or minimize surgical morbidity. The authors advocate the use of self-drilling screws as one such safe modality, which has not been described before. A representative case is presented to highlight the advantages.


   Case Report Top


A 2½-year-old girl reported to the outpatient clinic with a history of a motor vehicle accident 3 days back. Primary complaints included pain and swelling in the left lower jaw region with an inability to close the mouth completely and difficulty in eating. External examination revealed a laceration (3 cm long) along the lower border of the mandibular body region on the left side, which had been sutured during primary care. Palpation of the lower border of the mandible elicited tenderness and a perceptible step in the lower border of the mandible. Intraoral examination revealed malocclusion, an anterior open bite with posterior gagging distal to 75 where the mandibular gum pad was impinging on the maxillary molar during occlusion. Mobility of fracture fragments was also evidenced distal to 75. The orthopantomogram revealed a fracture of the mandibular body between 75 and unerupted 36, with severe displacement [Figure 1]. It also demonstrated several tooth germs in the region of the fracture.
Figure 1: Presurgical OPG demonstrating a displaced fracture of the left mandibular body. OPG: Orthopantomogram

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A decision in favor of ORIF over the traditional circummandibular wiring was made considering the severity of fracture displacement and the absence of teeth in the proximal fragment.

Under general anesthesia, access and exposure of the fracture were achieved through a preexisting laceration along the lower border of the mandible. Anatomical reduction was done using the lower border of the mandible as guidance. Fixation was performed using a single, 2-mm miniplate and self-drilling screws (6-mm length) positioned along the lower border. The postoperative outcome was good with restitution of normal occlusion [Figure 2] and [Figure 3] as well as form and function of the mandible. The plate was removed after 3 months after confirming with a postsurgical orthopantomogram [Figure 4]. The patient was followed up periodically for a period of 2 years postoperative to assess the dental and skeletal development. Orthopantomogram taken 2 years after surgery [Figure 5] demonstrates normal growth and development of the mandible and the tooth germs.
Figure 2: Postoperative intraoral picture demonstrating good dental occlusion on the left side

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Figure 3: Postoperative intraoral picture demonstrating good dental occlusion on the right side

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Figure 4: Three-month postsurgical OPG showing ORIF with a single miniplate and self-drilling screws at the lower border of the mandible. OPG: Orthopantomogram, ORIF: Open reduction and internal fixation

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Figure 5: OPG taken 2 years postsurgery demonstrating good skeletal and dental status. OPG: Orthopantomogram

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Surgical technique

The surgical technique for ORIF mandible in children using self-drilling screws is performed in the following methods. (i) Surgical access to the fracture is generally through an intraoral approach in most cases. In rare instances, an extraoral access may be chosen depending on the indication. (ii) Subperiosteal dissection is performed to expose the fracture in its entirety. (iii) The choice of hardware may either be a 1.5- or 2-mm system depending on the displacement of fracture fractures and the rigidity of fixation required. A single miniplate is used to span the fracture and fixed preferably along the lower border of the mandible with minimal disturbance to the underlying tooth germs. (iv) Fixation is achieved using a minimum of two self-drilling screws on either side of the fracture line with gentle manual threading. (v) Closure of the wound is done in layers. The technique is illustrated with a case scenario.


   Discussion Top


ORIF techniques currently practiced for mandibular fractures in pediatric population include circummandibular wiring, transosseous wiring, and miniplate osteosynthesis (titanium/bioresorbable).[1],[2] However, they are associated with clinical limitations. (i) Circummandibular wiring is useful when the fracture line is in the dentate with the splint having anchorage on either side of the fracture. However, when the fracture line is distal to the dentition, then the splint does not provide adequate reduction of the bone under the gum pad. (ii) Transosseous wiring is nonrigid and may not provide adequate stabilization in displaced fractures, while (iii) miniplate osteosynthesis both titanium and bioresorbable use screws which require drilling and pose mechanical and thermal injury to the developing bone and tooth germs. Moreover, biodegradable implants are less rigid, expensive, technique sensitive and require special equipment.

The authors propose that the use of titanium miniplates with self-drilling screws may reduce/eliminate the abovementioned limitations. The technical advantages of self-drilling screws include ease of instrumentation with no requirement of drills or taps. The minimal force of insertion and manual driving cause the screws to deflect off any underlying tooth buds or roots, negating mechanical and thermal damage. They provide better anchorage and primary stability after fixation as compared to the self-tapping screws.[3],[4] Furthermore, even when compared with the bioresorbable systems, the self-drilling screws ensure distinct clinical advantages of superior strength, easy availability, and being drill free.[5] The technique may be more relevant in the current situation of the COVID-19 pandemic with more requirements for aerosol-free treatment methods and may be extrapolated to the general population where indicated.


   Conclusion Top


The use of self-drilling screws for ORIF of fractures in pediatric patients is an ideal method to reduce thermal or mechanical damage to the underlying tooth buds and bone.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal the patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Aizenbud D, Hazan-Molina H, Emodi O, Rachmiel A. The management of mandibular body fractures in young children. Dent Traumatol 2009;25:565-70.  Back to cited text no. 1
    
2.
Kocabay C, Ataç MS, Oner B, Güngör N. The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: A case report. Dent Traumatol 2007;23:247-50.  Back to cited text no. 2
    
3.
Bolm I, Goetze E, Kämmerer PW, Sader R, Klos M, Landes C, et al. Self-drilling and self-tapping miniscrews for osteosynthesis fixture after LeFort I osteotomy: An ex vivo trial for primary stability and a randomized clinical study. J Surg Res 2017;212:246-52.  Back to cited text no. 3
    
4.
Gupta N, Kotrashetti SM, Naik V. A comparitive clinical study between self tapping and drill free screws as a source of rigid orthodontic anchorage. J Maxillofac Oral Surg 2012;11:29-33.  Back to cited text no. 4
    
5.
Lim HY, Jung CH, Kim SY, Cho JY, Ryu JY, Kim HM. Comparison of resorbable plates and titanium plates for fixation stability of combined mandibular symphysis and angle fractures. J Korean Assoc Oral Maxillofac Surg 2014;40:285-90.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
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