Wiring techniques in maxillofacial surgery

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presented to our beloved students of RMDCH by P.DINESH KUMAR MDS

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Wiring techniques in maxillofacial surgery

  1. 1. INDICATIONS FOR CLOSED REDUCTION Non displaced and favourable fractures grossly communited fractures edentulous atrophic mandible fractures in children condylar fractures
  2. 2. CONTRA INDICATIONS patients with poorly controlled seizures patients with compromised pulmonary fn patients with psychatric or neurological disorders
  3. 3. VARIOUS TYPES OF WIRINGDIRECT INTERDENTAL WIRING: ESSIG’S WIRING GILMER’S WIRING RISDON’S WIRINGINDIRECT INTERDENTAL WIRING IVY LOOP OR EYELET WIRINGCONTINOUS OR MULTIPLE LOOP WIRINGARCH BAR FIXATION
  4. 4. CIRCUM MANDIBULAR WIRINGPER ALVEOLAR WIRINGSUSPENSION WIRING CIRCUM ZYGOMATIC WIRING FRONTAL SUSPENSIONPIRIFORM APERTURE SUSPENSION ZYGOMATIC BUTRESS SUSPENSION INFRA ORBITAL SUSPENSION
  5. 5. DIRECT INTERDENTAL WIRINGESSIG’S WIRING Used to stabilize dento alveolar fracture as well as it can be used asanchoring device for IMF. There should be sufficient number of teeth on either side of thefracture line. A 40 cm 26 guage prestretched stainless steel wire is used.The wire is passed interproximally between two teeth present a littleaway from fracture line.
  6. 6. The wires are passed around the teeth in a figure of 8 manner untilthey reach 2 to 3 teeth away from the fracture line. Now the wires are passed without looping to the other side of thefracture line and 2 to 3 teeth away from the fracture line on theopposite side.Again the wires are taken around 2 to 3 teeth in a figure of 8manner.Now this acts as an arch bar on which the other smaller wires aretightened to stabilize the fracture.
  7. 7. GILMER’S WIRING It is used for IMF.Most common and simple method.Few firm teeth in the mandible as well as in maxilla are chosen.At least one firm teeth must be chosen anterior and posterior to thefracture line.A pre stretched 20 cm long 26 guage wire is taken and passed aroundthe neck of the chosen tooth.Both the ends of the wire are brought out on the buccal side andtwisted.
  8. 8. The same procedure is carried out for all the chosen teeth in theindividual arches.Then the mandibular wires are twisted tightly with thecorresponding maxillary wires.The ends are cut short and sharp endsare tucked in.The main disadvantage of this wiring is that there may be extrusionof the teeth as excess load is applied.Another disadvantage is of requiring complete removal of the wiresto open the mouth in emergency situations.
  9. 9. RISDON’S WIRINGIt is commonly used method of horizontal wire fixation.This can be a substitute technique for arch bar.In this method second molars are usually chosen for anchorage oneither side.A 25 cm long 26 guage wire is passed around the neck of second molaron each side and both the ends are brought in buccal side.
  10. 10. The ends are twisted for entire length thus forming a strong basewire that comes towards the midline from each second molars.Two base wires are grasped and twisted at mid line and adapted tothe necks of the teeth on the buccal side .This base wire is secured to individual teeth by using additionalinterdental wires.This type of horizontal wiring offers strong fixation.
  11. 11. IVY EYELET WIRINGThe Ivy loop embraces the two adjacent teeth.one or two Ivy eyeletsshould be placed in each quadrant.A 26 guage stainless steel wires cut in 20 cm lengths are used.A loop is formed in center of wire around the beak of a towel clip orshank of dental bur and twisted thrice with two tail ends. Such Ivyloops can be preformed and stored in cold sterilizing solution foremergency use.The two tail ends of the eyelet are passed through the interdentalspace of the selected two teeth from buccal to lingual side.One end of the wire is passed around the distal tooth lingually andbrought out from the distal interdental space over the buccal side andthreaded through the previously formed loop.
  12. 12. The other wire tail end is carried around the lingual surface of themesial tooth and brought out on the buccal surface from the mesialinterdental space, where it meets the first tail end wire.The two wires are crossed and twisted together and the loop isadjusted and bend towards gingiva.The mandibular wire eyelets can be secured to maxillary eyelets byjoining wires.Advantage is that bridging wires can be removed whenever requiredwithout disturbing the main wiring.Even when there is breakage of wire during fixation only that eyeletcan be removed and replaced.
  13. 13. HALLAM MODIFICATION ( 1945 )
  14. 14. WILLIAM MODIFICATION ( 1968 )
  15. 15. CLOVE HITCH METHOD
  16. 16. STOUT’S MULTI LOOP WIRINGThe posterior part of four quadrants are used for wiring.4 pieces of 26 guage 20 cm long wires are required and piece of solderis used for making loops.The piece of solder wire is adapted to buccal surface of teeth.The 20 cm long pre stretched wire is folded into two parts, one partacts as the stationary wire and the other end is brought distal to thesecond molar and taken around it on lingual side.
  17. 17. This working end is threaded through the mesial side of secondmolar to the buccal side under the solder wire.It is then looped around the stationary wire and solder wire and backinto the interdental space from buccal to lingual. The same procedureis repeated for each tooth up to midline.The solder wire is removed after the loops are formed and the loopsare twisted to form eyelets.Finally the stationary and working ends of the wires are twistedtogether.
  18. 18. ARCH BAR FIXATIONThe arch bar is a flat, sturdy stainless steel bar on which fleats orhooks are attached.It is a effective, quick and inexpensive method of fixation.The different types of arch bars are, pre fabricated custom made acrylated arch bars directly bonded arch barsOf these the most commonly used are the pre fabricated Erich archbars.
  19. 19. CUSTOM MADE ACRYLATED ARCH BAR
  20. 20. The arch bar is measured to fit from first molar to first molar.The arch bar is placed in such a way that the fleats or hooks facetowards the gingival margin.Now 15 cm of 26 guage wire is taken and starting from the distaltooth, the wire is passed from buccal to lingual side below the arch barand from lingual to buccal above the arch bar and twisted together.This is continued for all the teeth and the arch bar is secured.When placing an arch bar across a displaced fracture segment,it iscut at the fracture site and placed seperately.
  21. 21. PER ALVEOLAR WIRINGTwo peralveolar wires are placed in the canine region on either side forfitting patient’s own denture to alveolar ridge.The splint is firmly placed in the position in the upper jaw.A kelsey-Fry bone awl introducer is pushed from buccal to palatalaspect.A 26 guage wire is thresded through the eye and the wire is withdrawnwith it the wire on the buccal surface.Same procedure is repeated on opposite side and then the splint isreplaced in the mouth and wires adjusted over it and twisted over thegrooves and the ends tucked inwards.
  22. 22. CIRCUMMANDIBULAR WIRINGOBWEGESER’S PROCEDUREIt is used for fixation of lateral compression splint to the mandibularbone.Lower border of mandible is palpated in the canine region and theskin is pierced beneath the lower border of the mandible by Kelsey-Frybone awl and it emerges through the floor of mouth.A 26 or 28 guage wire is inserted through the eye of the awl and theawl is withdrawn till the lower border and directed upward along thebuccal surface of mandible to pierce through the buccal sulcus.The two ends of the wire are adjusted and the splint is adjusted andthe lingual and buccal wires are held together and twisted in the regionof canine grooves, cut and finished inward.
  23. 23. SUSPENSION WIRING
  24. 24. FRONTAL SUSPENSIONIt is used for fracture of maxilla at the Le Fort II or III levelArch bar is secured in the upper and lower archThe frontozygomatic region is exposed with a small lateral eyebrowincision.A hole is drilled in the zygomatic process of frontal bone which is5mm above the frontozygomatic suture.A pre stretched 26 gauge SS wire is passed through this hole and bentback so that an equal length protrudes on either side of this bur hole.The two ends of wire are threaded through the eye of Rowe’szygomatic awl and crimped.
  25. 25. The awl is then passed downwards and forwards behind the frontalprocess of the zygomatic bone deep to the zygomatic arch to piercethrough the oral mucosa in the upper buccal sulcus in the region ofupper molar teeth.The wire ends are detached from the awl and secured nwith anartery forceps while the awlm is withdrawn. These wire ends are to besecured on arch bar.A small SS wire which is threaded beneath the suspension wire andthe passes through the bone and is twisted is called Pull-out wire.This wire negotiates the making of incision again to expose the wire.Suspension wires are placed on both sides for uniform suspensionand occlusion is checked and the wire is then secured to the arch bar
  26. 26. CIRCUMZYGOMATIC WIRINGIt is used for fixing a Le Fort I fracture.The point of suspension is in the region of junction between thefrontal and temporal process of the zygomatic bone.An awl is introduced either directly through the skin or through asmall stab incision made in that region.The awl pierces the temporal fascia and passes medial to thezygomatic bone and zygomatic buttress to pierce the buccal sulcus inthe region of first molar.
  27. 27. A pre stretched 26 gauge SS wire is then attached to the eye of the awland crimped.The awl is withdrawn just above the zygomatic arch and reinsertedthis time lateral to the zygomatic bone and directed downwards andforwards to emerge through buccal sulcus. This makes wire looparound zygomatic bone.The wire ends are secured and adjusted so as they rest on zygomaticbone.The ends of the wire are then secured to the arch bar.
  28. 28. PIRIFORM APERTURE SUSPENSIONThis can again be used for the fixation of a Lefort I fracture as thepiriform aperture is a stable bone present above the level of thefracture level.The piriform aperture is exposed by an intraoral incision and a hole isdrilled.Wire is threaded through this hole and then attached to the arch bar.
  29. 29. ADVANTAGES OF CLOSED REDUCTION more conservative procedureNo complications associated with surgery is presentCan be done in medically compromised patientsDISADVANTAGES airway compromise due to IMFLoss of function of tissues decreased nutritional status of patients
  30. 30.  only occlusion is taken as a guideDifficulty in speechSocial inconvinienceEFFECTS OF PROLONGED IMFFormation of adhesions in jointThinning and necrosis of articular cartilageOsteoporosis of bone due to disuseAtrophy and weakening of muscles due to disuse
  31. 31. THANK YOU

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