Bhaskaran M. et al., Med. Res. Chronicles.

, 8(2), XXXX 2021

Medico Research Chronicles

ISSN NO. 2394-3971
DOI No. 10.26838/MEDRECH.2021.8.2.487

Contents available at www.medrech.com

A NOVEL TECHNIQUE OF INFANT FEEDING TUBE MODIFICATION OF
TRANSPALATAL WIRING WITH CONVENTIONAL TRANSPALATAL WIRING IN
MANAGEMENT OF MAXILLARY PALATAL FRACTURE – A COMPARATIVE STUDY

Dr. Manoj Bhaskaran1, Dr. Arjun Shenoy2, *Dr. Himanshu Soni3, Dr. Joseph Lijo4, Dr. Yash
Chadha5, Dr. Chinmay Rao6
1. Oral and Maxillofacial Surgeon, Head of the Unit & Director of Centre for Excellence for
Fellowship in Cranio-Maxillo-Facial Trauma, Elite Mission Hospital, Thrissur, Kerala. India
2. Consultant Maxillofacial Surgeon, Fellow in Cranio-Maxillo-Facial Trauma Surgery, Elite
Mission Hospital, Thrissur, Kerala. India
3. Oral and Maxillofacial Surgeon, Fellow in Cranio-Maxillo-Facial Trauma Surgery, Fellow in
Head and Neck Surgical Oncology, Mahatma Gandhi Cancer Hospital, Maharashtra. India
4. Consultant Maxillofacial Surgeon, Elite Mission Hospital, Thrissur, Kerala. India
5. Oral and Maxillofacial Surgeon, Fellow in Cranio-Maxillo-Facial Trauma Surgery, Fellow in
Head and n\Neck Surgical Oncology, BL Kapur Hospital, Delhi, India
6. Oral and Maxillofacial Surgeon. Fellow in Cranio-Maxillo-Facial Trauma Surgery. MGM Dental
College and Hospital. Mumbai, India
ARTICLE INFO ABSTRACT ORIGINAL RESEARCH ARTICLE
Article History Traumatic injuries to the midface occasionally result in fractures of the
Received: April 2021
hard palate. These fractures may occur as isolated injuries but are more
Accepted: May 2021
commonly associated with severe midfacial fractures or panfacial
Keywords: Palatal
fractures. Open reduction and internal fixation with mini plate-and-
fracture, Maxillary palatal
screw fixation is a choice of treatment for mid-facial fractures. To
fractures, Transpalatal
overcome the drawbacks of open reduction and internal fixation with
Wiring, Infant Feeding
mini-plates and screws, which is exposure of the plate in the roof of the
Tube, Closed Reduction.
mouth, we describe a technique of transpalatal wiring with infant
feeding tube for displaced maxillary palatal fracture. Conventional
transpalatal wiring is a method of closed reduction of palatal fractures
which overcomes these complications. However, the exposed wires also
result in abrasions and lacerations over the dorsal aspects of the tongue
due to its frequent contact during mastication and speech. In this article
we describe the technique of infant feeding tube modification of
transpalatal wiring which protects the soft tissue and overcomes the
Corresponding author* disadvantages of traditional transpalatal wiring. This method has certain
Dr. H. C. Soni advantage of speech and swallowing, reduced pain in post-op phase and
prevention of tongue laceration.
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 Temkar A. B. et al., Med. Res. Chronicles., 8(2), 64-67 2021

INTRODUCTION modified the approach to this management by

One of the most common causes of recommending a palatal flap elevation in place
palatal fracture is from injuries to midface of an incision. To avoid the complications of
skeleton due to RTA. These fractures may manipulating the palatal mucoperiosteum (eg,
occur as isolated injuries but are more palatal fistulae, exposure of plates and screws)
commonly associated with severe midfacial use of locking plates as external fixator was
fractures or panfacial fractures.1 The literature proposed. In 2014, Ma et al described a
describes numerous methods of reduction and simpler approach to external fixation using a
fixation of the midface fracture. Classically, transpalatal wire anchored by 2 screws to
this problem has been handled by closed apply medial traction to the palatoalveolar
reduction or by suspension wires used with an segments.
acrylic splint and inter-maxillary fixation to Sign and symptoms of palatal bone
maintain the alignment of the maxillary fracture can be one or combination of the
dentition.1 More recently, many have following, palatal laceration, oral bleed upper
advocated the use of open reduction and lip laceration, deranged occlusion plane, loss
internal fixation with interosseous wires to of upper anterior or posterior teeth. Palatal
stabilize these complex fractures.1-2 ecchymosis is occasionally seen in cases of
Unfortunately, rotation of maxillary segment closed palatal bone fracture.
is still an unavoidable consequence in complex Aim
and comminuted fractures (type V) when open To evaluate effectiveness of infant
reduction is done due to intrinsic instability of feeding tube with transpalatal wiring for
fracture.1 In majority of other types of management of palatal bone fracture
fracture, good maxillary alignment and Objectives-
fixation is possible especially when the split 1. The assessment of restoration of form and
palate is reduced and fixed palatally after function – symmetry, mastication,
proper mobilization of the fracture fragments. swallowing, mouth opening and speech
Presence of delicate bone layout, 2. The assessment of incidence of
varying soft tissue thickness and forces with complication in the immediate and late
level and location of impact which determines postoperative period like laceration,
the pattern of fracture in midface further adds avascular necrosis, dehiscence, infection,
to complication. Due to lack of support from hemorrhage, non-union etc
midface skeleton sagittal retrusion and MATERIAL AND METHODOLOGY
flattening of the midface commonly occur Patients were divided into 2 groups –
after reconstruction. Tendency toward Group I – Patients subjected to conventional
malrotation and disinclination of the transpalatal wiring
palatoalveolar segments are also frequently Group II – patients Subjected to transplatal
encountered in cases of palatal bone fractures wiring with infant feeding tube
Early management of palatal fractures Inclusion criteria –
included wire fixation, Kirschner wires, open 1. Palatal bone fracture associated with
reduction and internal fixation with palatal Lefort, and other combination of fractures.
splints, and transverse palatal wiring. In 1983, 2. Various types of palatal fractures described
Manson et al described the combined use of by Hendrickson were included in the study.
open reduction with internal fixation, Exclusion criteria
mandibulomaxillary fixation, and a palatal 1. Alcoholic patients
splint, the necessity of which was challenged 2. Patient with neurological disorders. eg –
several years later by Gruss and Mackinnon. seizures, mental retardation
In 1998, Hendrickson et al described the 3. Patient with respiratory diseases
technique of rigid internal fixation using The inclusion period for study was
designer plates and screws with a limited from October 2018 through November 2019.
midline split incision. Denny and Celik All patients with palatal fractures had

1|P age
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 Temkar A. B. et al., Med. Res. Chronicles., 8(2), 64-67 2021

associated facial fractures. Fracture [Fig 2.3] A provisional diagnosis of panfacial

distribution according to the classification as fracture with complex midface fracture was
by Hendrickson, as well as frequency of made based on CT finding. In this case bottom
associated facial fractures, are shown in Table up inside-out approach was used. Mandible
1. Diagnosis was made based on careful was fixed with miniplate and screws which
clinical examination and CT scan. acts as a template for midafce in restoring
Surgical plan was formulated occlusion. Following which other midface
considering the associated fracture. Both fractures were addressed. [Fig 2.4] shows
“bottom-up inside out|” and “top down intraoral placement of transpalatal wiring with
outside-in” approach was advocated for infant feeding tube for palatal fracture, the size
panfacial fractures depending upon the of infant feeding tube used was no 8 [Fig C].
fracture site and intensity. In cases of lefort Patients were evaluated for 1st week, 2nd
fractures and complex midface fractures week and 4th week post-operatively. Post
occlusion was restored before fixation of operatively patient experienced no soft tissue
horizontal and vertical buttresses. All palatal injuries intraorally due to the wire and
fractures were managed with closed reduction significant reduction in difficulty during
in the form of transpalatal wiring which was speech and swallowing was noticed [Fig 2.5].
tunnelled through infant feeding tube. The technique is illustrated in [Fig A].
Case 1 Patient reported to ER with One end of a 25 to 30-cm long 26-gauge
history of road traffic accident. On stainless steel wire is passed bucally through
Examination there was presence of right the embrasure between the maxillary first
circum-orbital edema and echymosis. Oral premolar and first molar teeth on one side.
bleed positive with avulsion of upper lateral This end is then pulled palatally and reinserted
incisor and mobility with upper right from the palatal aspect through the embrasure
posterolateral dentoalveloar segment and between the first premolar and first molar on
lower mandibular dentoalveolar segment was the opposite side and is pulled buccally. Then
seen [Fig 1.2]. Occlusion was deranged with the wire is inserted between the embrasure of
presence of palatal laceration. CT showed first molar and second molar teeth on the
transversely running fracture line in the right buccal side and passed transpalatally to the
posterior third of hard palate with severe other side (Fig A showing schematic
communiation [Fig 1.3]. The provisional presentation of transpalatal wiring). Choosing
diagnosis of right ZMC fractutre maxillary molars and premolars for wiring helps to
with palatal bone fracture was made based on maintain the palatal width posteriorly, as the
CT scan. Under GA occlusion was restored tendency of splaying of the segments is greater
with MMF, following which vertical buttress in this region. Digital pressure is applied
was restored with miniplates and screws. bilaterally on the buccal cortex in the
Palatal bone fracture was addressed next with zygomatic maxillary buttress regions and the
transpalatal wiring tunnelled through infant two ends of the trans-palatal wire are twisted
feeding tube. together to stabilize the fractured fragments.
Case 2 patient reported to ER with This results in immediate
history of RTA. On examination there was approximation of the lacerated palatal mucosa
presence of bilateral periorbital edema and and palatal bones, prevention of nasal
ecchymosis, traumatic telecanthus, gross mid regurgitation of liquid or semisolid food. It
face edema, CSF leak, deranged occlusion alleviates the need for palatal vault fixation
with step deformity at lower jaw [Fig 2.1]. 3D and can be left in situ for 2–4weeks, until
recon images showed right side unilateral temporary stabilization of the fractured
lefort fractiure with infraorbital and zygomatic fragments. The only disadvantage of this
bone fracture and right parasymphysis technique is a minimal but temporary change
mandibular fracture [Fig 2.2]. On axial Ct scan in pronunciation and maintenance of oral
image, it shows parasaggital palatal fracture hygiene. Owing to the gauge of the wires used

2|P age
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their contact with the soft tissue result in solid and solid, food sticking to throat/ palate,
abrasion / or lacerations. To overcome this and loss of weight. At the end of 4th week
particular complication a novel technique of patients were evaluated for all 5 parameters.
covering the exposed wires with infant feeding Speech and Swallowing was evaluated
tube (Fig B) was devised. In this technique between group I and II and it was not
after passing wire buccally through the significant. Group I all 5 patient complained of
embrasure between 1st premolar and 1st molar difficulty in speech and swallowing. Group II
and pulling it palatally, the wire is tunnelled only 1 patient complained of difficulty in
through infant feeding tube and reinserted speech and swallowing. Group II patient had
from palatal aspect through the embrasure significant reduction in difficulty during
between 1st premolar and 1st molar on the speech and swallowing when with compared
opposite and is pulled bucally clinical (fig 1.4, with Group I.
2.4 clinical pictures & Fig-B which is shown Intra-oral laceration over the tongue
on dental model). Patient were evaluated at the and speech was evaluated clinically. Group I
end of 1st, 2nd and 4th week for soft tissue pout of 5 patients 4 patients complained of
injury, speech and swallowing [Fig 1.5, Fig intraoral laceration and pain over dorsum of
2.5]. the tongue. None of the patient showed
RESULTS evidenced of laceration over dorsum of the
Average time from injury to surgery tongue postoperatively in Group II. Post
was 48 hours. The patients included were 8 operatively patient experienced no soft
males and two females, with ages ranging tissue injuries, intraorally due to the wire
from 24 to 64 years old (average, 38.2). By and significant reduction in difficulty
far, the most common cause for fractures was during speech and swallowing was
motor vehicle accident (8 patients), followed noticed with group II
by interpersonal violence (two patient). Palatal DISCUSSION
fractures were managed with closed reduction In 1901 Rene Leforte was the first to
in all 10 patients with conventional describe about palatal fracture in his paper on
Transpalatal wiring group I and transpalatal maxillary fracture. These injuries continue to
wiring with infant feeding tube group II. be found primarily in conjunction with
Hardware was removed 4-6 weeks midfacial or panfacial fractures and rarely
postoperatively based on clinical signs of occur in isolation. All patients with palatal
fracture healing. All the patients in group I and fracture had an associated Le Fort I fracture in
II were evaluated at 1st, 2nd and 4th week post- the 1998 study conducted by Hendrickson et
operative period for pain, speech, swallowing, al.3 the findings of our study is similar to one
and intra-oral soft tissue injuries over dorsum conducted by Hendrickson. All 10 patients had
of the tongue. Uneventful healing was seen in an associated midface fracture component.
all 10 patients in our study. Furthermore, the incidence of palatal fractures
Pain was evaluated based on visual in patients with Le Fort fractures has been
analogue scale. All patient did complain of reported between 8% and 13.2%.2-4 Patients
pain in the 1st and second week post are typically in the second to fourth decades of
operatively which gradually reduced by 4th life, and there is a significant male
week, pain experienced by the patient was predominance.2,5,6 Midface fractures in
mild to moderate. Swallowing was evaluated children are less common due to elasticity and
based on custom made questionnaire which delay in synostosis of the palatal sutures.6,7,8
consist of five questions. Post-operative 1st Patients with these fractures classically have a
week patients were evaluated for difficulty in history of high-velocity impact; the most
swallowing and difficulty in swallowing common causes of injury are motor vehicle
liquid. Most of the patients in post of period and motorcycle accidents, whereas less
are on liquid diet. 2nd week patients were common causes include assault, falls, work
evaluated for difficulty in swallowing semi- accidents, and firearm injury.5,7,10

3|P age
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Numerous attempts have been made to One of the major advantages of this
classify palatal fractures. In 1998, technique is prevention soft tissue laceration
Hendrickson et al published a classification over the dorsum of the tongue. There was
system based on the location and anatomical significant reduction in swallowing difficulty.
characteristics of the injury. Hendrickson M et Postoperatively most of the patient did
al classified palatal fractures- complain of swallowing difficulty which was
Type Ia - Anterior alveolus multifactorial due to no. of fractures,
Type Ib –Postero-lateral alveolus physiologic healing of fracture site etc. Most
Type II - Sagittal of the patient had no problem in swallowing
Type III-Parasagittal liquid. At the end of second week seven
Type IV-Para-alveolar patient complained of difficulty in swallowing
Type V - Complex/comminuted solid and semi-solid food which was mild,
Type VI- Transverse which gradually improved at 4th week as
Oronasal communication is common healing progressed. 6 patients complained of
with lefort fractures involving maxilla and food sticking to palate/ throat at 2nd week.
palatal bone. To prevent functional Patients were motivated to maintain hygiene
impairment early fixation and stabilization of and use of mouth wash to overcome this
these fractures, avoids fatal complication, such difficulty. Loss of weight was experienced by
as hemorrhage from the traumatized nasal 7 patients which was mild and can be
mucosa and nasal regurgitation of food leading attributed to the catabolic events post-surgery.
to the risk of aspiration. Numerous At the end of 4th week only 2 patients
nonsurgical and surgical technique such as complained of weight loss.
palatal splint, the use of an arch bar, Inter A very simple, effective, quick, and
Maxillary Fixation, trans-palatal screw non-invasive technique for the management of
traction, and horizontal fixation at the palatal palatal fractures of the maxilla is presented
vault and/or across the basal bone of the herein. Although very rare but, this technique
pyriform aperture or alveolar ridge are can be performed in cases of isolated palatal
available.13-14. bone fracture with dentoalveolar fracture in
The management of palatal fracture the emergency room or in the outpatient
with Kirschner wire fixation, maxillary arch setting under LA. The technique is cost
stabilization with the arch bars, trans-palatal, effective and armamentarium easily available
intra osseous, inter-molar, figure of eight in any hospital based setting. The only
wiring was technique sensitive and having disadvantage of this technique is accumulation
poor patient compliance15. It is very difficult of food debris at the junction of the wire and
to achieve functional occlusion, proper tube over palatal side. Patient should be
stability and reduction when these techniques motivated to maintain oral hygiene and use of
are used in isolation. mouthwash to overcome this disadvantage.
The trans-palatal screw traction causes CONCLUSION
difficultly in speech and eating; most Palatal fractures are relatively common
important drawback of this technique was that and are associated with other midface fracture
it does not expose the fracture site and chances with significant rates of malocclusion and
of bone mismatch are very high16. Similarly, wound complications. These injuries are
the inter-molar wiring is retained for 4–5 typically managed with plate fixation of the
weeks which is done in a trans-palatal alveolar ridge with variable approaches to the
direction from left molar to the right molar. palatal vault. Closed reduction of the palatal
The wiring can interfere with speech, irritate vault with transpalatal wiring was found to
the tongue and it is very difficult to maintain impart fewer wound healing complications
the oral hygiene. All these disadvantages were relative to internal plate fixation, also with
not noticed while using infant feeding tube internal fixation there are complication
modification of transpalatal wiring involved which includes bone segment

4|P age
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 Temkar A. B. et al., Med. Res. Chronicles., 8(2), 64-67 2021

necrosis. In a given circumstance, closed and prevention of injuries to the soft tissues
reduction with traditional transpalatal has when compared to conventional transpalatal
shown to have certain disadvantages, wiring wiring. Although larger sample size and long-
with infant feeding tube has lower rates of term follow-up with comparative studies
complication when compared with other should be done to evaluate the therapeutic
conventional closed reduction. Infant feeding benefit of infant feeding tube modification of
tube modification of transpalatal wiring for trans-palatal wiring technique over
palatal fracture have shown demonstrated conventional technique.
benefits of improved speech and swallowing
Table 1- Types of Palatal Fractures According to Hendrickson et al1 and
Associated Facial Fractures
Type I II III IV V VI
LEFORT 1 3 - 1 - 1 -
LEFORT 2 - 1 - - -
LEFORT 3 - - - - - -
COMPLEX MIDFACE - - - - - -
FRACTURE
ZM COMPLEX - - - - - -
MANDIBULAR FRACTURE - - - - - -
PANFACIAL FRACTRURES 3 - 1 - - -
TOTAL 6 1 2 - 1 -

Conflicts of interest: NONE

Funding – NONE
Ethical Approval – Not applicable
Informed consent – obtained from all patients.

CASE 1

Fig 1.1-Clinical picture showing palatal laceration

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Fig 1.2 – Missing upper and lower lateral Incisor and with deranged occlusion

Fig 1.3 CT showing transversely running fracture line in the posterior third of hard palate with
severe communiation–type V and VI fracture

6|P age
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Fig 1.4- Intra-oral placement of transpalatal wiring with infant feeding tube and sutured
Lacerated palatal wound

7|P age
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Fig 1.5-Post-op after 4weeks

Case 2

Fig 2.1–Gross mid face edema with Raccon eyes, Csf leak

8|P age
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Fig 2.2 –Right unilateral lefort 1 fracture with mandibular fracture

Fig 2.3 –Axial Cut Shows Right Parasaggital Fracture–Type III Fracture By

Hendricknson

9|P age
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Fig 2.4–Intra-Oral Placement of Transpalatal Arch Wiring with Infant Feeding

Tube

Fig 2.5 – 4th week post-op healing.

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Fig A - Schematic presentation of conventional Technique of transpalatal wiring

Fig B – Demonstrating transpalatal wiring with Infant feeding tube on dental models

Fig C-Infant feeding tube

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Graph 1 shows 2 parameters evaluated at 1st week post-op

Graph 2- shows 3 parameters evaluated at 2nd week post-op

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Graph 3- shows 5 parameters evaluated at 4th week post-op

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