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J Oral Maxillofac Surg69: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 occuralong with maxillary fractures. The average incidence

of palatal fractures combined with maxillary fracturesranges from 8% to 20%,1-4 although a much higher

incidence has recently been reported (46.4%).5 Tradi-tionally, anatomic reduction of palatal fractures is

considered difficult. Although various techniques pre-vail, ranging from invasive open reduction and inter-

nal fixation (ORIF),4,6 Kirschner wire fixation,7 tononinvasive techniques such as stabilization of themaxillary arch using an arch bar, transpalatal wiring,2

intraosseous wiring, acrylic splints,4,8,9 and intermo-lar wiring,5 all have inherent difficulties and draw-

backs.ORIF requires a wide mucoperiosteal flap eleva-

tion, which is not so easy in the palate because of

the tightly adherent mucoperiosteum, which mightdamage the soft tissue, partly jeopardizing the

blood supply. It could also result in exposure ofhardware10 and delayed nasal bleeding.3 Moreover,

there is an inherent risk of occlusal disruption when not accompanied by maxillomandibular fixa-

tion. Therefore, seeking an alternative for time-consuming ORIF associated with many intricaciesseems to be judicious. Intraosseous and transpalatal

wiring techniques carry similar disadvantages atvarying degrees.

Techniques using the arch bar and splint aim atstabilization of the maxilla but unfortunately play onlya passive role in bringing the fractured components

together and are ineffective in minimizing the gap

between the 2 fragments because compression is re-

quired 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

difficult, 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

benefit 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 govern-

ment hospitals, including the Tamil Nadu Govern-

ment Dental College and Hospital, Chennai, without

any complication such as technical difficulty, patient

discomfort, or fracture nonhealing. This makes the

figure-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 frac-

tures of the palate (types II and III)2 are best treated

with figure-of-8 wiring when there are at least 2 adja-

cent 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 figure-of-8 wiring be-

tween the maxillary and mandibular first 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 intothe mesial and distal gingival embrasures of the

maxillary first 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 first

molar is fed into the distal embrasure of the man-

dibular first molar and the distal end from the max-

illary first molar is fed into the mesial embrasure of

the mandibular first 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

*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: [email protected]

2011 American Association of Oral and Maxillofacial Surgeons

0278-2391/11/6906-0061$36.00/0

doi:10.1016/j.joms.2010.12.053

e152
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wire is tightened and twisted on the mesiobuccalside of the tooth bilaterally (Fig 4). The excess wire

is cut and the remaining end is turned gingivallyinto the mesial embrasure (Fig 5). This can also bedone between second molars or second premolars.Better control over the fragments and compressionalong the fragments towards the midline can beachieved when the wiring is done between themost posterior teeth available.

In normal static occlusion, the mediolateral curve

of Wilson shows an inward inclination of the lowerposterior teeth, with the lingual cusps lower thanthe buccal cusps on the mandibular arch; the buc-cal cusps are higher than the palatal cusps on themaxillary arch because of the outward inclinationof the upper posterior teeth. Based on the principleof physics, when the wire is tightened, the intactmandible provides stationary anchorage to the frac-tured palate, exerting a compressive force on the

maxillary segments towards the midline (Fig 6).Therefore, the fractured palatine fragments areforced towards each other along the midline, thusproducing a good reduction. Furthermore, the cus-pal inclines of the teeth provide a physiologic bar-rier preventing over-riding of the fragments (Fig 6).In general, the practical complexity in treating pal-atal fracture is the splaying of the posterior ends,especially when treated using suspension wiring.

FIGURE 4. Step 4.

Kumaravelu, Thirukonda, and Kannabiran. Innovative Treat-ment of Palatal Fracture. J Oral Maxillofac Surg 2011.

FIGURE 1. Step 1.


FIGURE 2. Step 2.


FIGURE 3. Step 3.


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