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| SHORT COMMUNICATION |
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| Year : 2020 | Volume
: 7
| Issue : 2 | Page : 91-93 |
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A modification of ward's incision for management of mandibular angle fracture
Uday Kiran Uppada
Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
| Date of Submission | 29-Feb-2020 |
| Date of Decision | 22-Apr-2020 |
| Date of Acceptance | 22-Apr-2020 |
| Date of Web Publication | 20-Jun-2020 |
Correspondence Address:
Uday Kiran Uppada
Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdrr.jdrr_18_20
It is a well-known fact that mandibular angle fracture is one of the most frequently encountered fractures in the facial skeleton. Lot of emphasis is given to the kind of fixation devices as well as number of fixation devices used in the management of these fractures. However, it is noteworthy that some of the distinguished complications are associated with the flap design and soft-tissue handling. This short communication highlights the fact that the Ward's incision without the distal release is a very valuable surgical approach in the management of these fractures.
Keywords: Angle fracture, flap design, Ward's incision
How to cite this article:
Uppada UK. A modification of ward's incision for management of mandibular angle fracture. J Dent Res Rev 2020;7:91-3 |
| Introduction | |  |
Mandibular fractures epitomize nearly two-thirds of all the maxillofacial fractures, among which 26%–35% is denoted by fractures of the mandibular angle region.[1],[2],[3] Decision pertaining to the surgical approach in the management of angle fractures is often dictated by the type of fracture, location of fracture, amount of displacement, and the surgeon's expertise.[4] Hamill et al. advocated that successful fixation method depends on the choice of approach.[5] The basic purpose of any surgical approach is to support rapid healing and restore the anatomical form and function with specific caution to recreate the functional occlusion and facial esthetics with minimal morbidity and complications.[4]
| Technique | | |
We advocate that the Ward's incision without the distal release is a very valuable surgical approach in the management of these fractures. Our modified incision has two limbs as shown in [Figure 1]. Limb A curves forward from the distobuccal corner of the crown of the second molar involving the interdental papilla of the lower second and third molars, runs downward and forward along the attached gingiva toward the vestibule, and ends with a small curvature in the vestibule, coinciding with the mesiobuccal line angle of that tooth. Limb B starts at the distobuccal corner of the crown of the second molar and runs all along the cervix of the third molar without any distal extension. Mucoperiosteal flap can be raised using a Molt's periosteal elevator from the interdental papilla running downward and backward to expose the fracture site as shown in [Figure 2]. Fracture reduction and fixation can be done as shown in [Figure 3]. Following surgical removal of the impacted third molar, two sutures are placed to close the wound. The first suture is placed by taking the interdental papilla and suturing it to the lingual soft tissue just distal to the second molar, and the second suture is placed across the anterior release incision. | Figure 2: Exposure of the fracture site using modified Ward's incision without distal release
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 | Figure 3: Fracture reduction and fixation using modified Ward's incision without distal release
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| Discussion | | |
Pain, trismus, and facial swelling following any surgical intervention are routine sequel due to inflammation.[6],[7] Majority of the tissue injury during surgical intervention of mandibular angle fractures via a transoral approach occurs while raising a mucoperiosteal flap to gain access to the tooth.[8] Our flap design is very conservative owing to a lesser degree of tissue reflection without compromising on the surgical exposure. It is simple to suture and allows for relatively tension-free closure in addition to the fact that the incision line lies only on a sound bone. This surgical approach has already been advocated for the surgical removal of impacted third molars.[9]
Excess striping of soft tissue in order to gain access can lead to inflammation and spasm secondary to the raising of a mucoperiosteal flap with the aid of a distal release incision, resulting in trismus in the postoperative phase. It can be advocated that surgical intervention for the management of mandibular angle fractures using our flap design eliminates this complication due to the absence of the distal extension and excessive soft-tissue stripping. Postoperative pain, on the other hand, is not directly influenced by flap design, considering the fact that the smaller incision used with lesser soft-tissue reflection in addition to good soft-tissue handling during the procedure can reduce the postoperative pain compared to the other flap designs.[9]
Literature states that flap design does not play a critical role in determining the periodontal health of the associated molars, particularly when bone is not removed adjacent to the tooth.[10] Thus, the effect of flap design has more relevance to the immediate postsurgical period rather than as a long-term concern.
This flap design can be indicated in simple and linear undisplaced mandibular angle fractures which do not communicate to the oral cavity as well as in clinical scenarios where there is a mandibular angle fracture running just distal to an erupted third molar and the third molar is not indicated for removal. However, it cannot be used for clinical scenarios where there is grossly comminuted fracture, unfavorably displaced fracture, or fracture line running through the socket necessitating the removal of the third molar.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his/her consent for his/her images and other clinical information to be reported in the journal. The patient understands that his/her name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Self-funded.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Kuriakose MA, Fardy M, Sirikumara M, Patton DW, Sugar AW. A comparative review of 266 mandibular fractures with internal fixation using rigid (AO/ASIF) plates or mini-plates. Br J Oral Maxillofac Surg 1996;34:315-21.  |
| 2. | Rix L, Stevenson AR, Punnia-Moorthy A. An analysis of 80 cases of mandibular fractures treated with miniplate osteosynthesis. Int J Oral Maxillofac Surg 1991;20:337-41. |
| 3. | Revanth Kumar S, Sinha R, Uppada UK, Reddy BV, Paul D. Mandibular third molar position influencing the condylar and angular fracture patterns. J Maxillofac Oral Surg 2015;14:956-61. |
| 4. | Devireddy SK, Kishore Kumar RV, Gali R, Kanubaddy SR, Dasari MR, Akheel M. Transoral versus extraoral approach for mandibular angle fractures: A comparative study. Indian J Plast Surg 2014;47:354-61. [ PUBMED] [Full text] |
| 5. | Hamill JP, Owsley JQ Jr., Kauffman RR, Blackfield HM. The treatment of fractures of the mandible. Calif Med 1964;101:184-7. |
| 6. | Penarrocha M, Sanchis JM, Saez U, Gay C, Bagan JV, Oral hygiene and postoperative pain after mandibular third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001 92:260-4. |
| 7. | Mangla M, Rajput L, Kumar A, Rathi V, Jain H, Kumar S. Lingual triangular flap vs. triangular flap: A pilot study. Int J Oral Health Med Res 2017;4:62-4. |
| 8. | Kirk DG, Tong DC, Love RM. Influence of two different flap design on incidence of pain, swelling, trismus, and alveolar osteitis in the week following third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e1-6. |
| 9. | Uppada UK. A modification of ward's incision for third molar surgery. J Dent Res Rev 2019;6:77. [Full text] |
| 10. | Bodh R, Jain A. The flap design of third molar surgery: An overview. Int J Med Health Res 2015;1:32-5. |
[Figure 1], [Figure 2], [Figure 3]
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