Inter-Dental Wiring, Arch Bar Fixation, MMF Screws, Ernst Ligatures, Edentulous Mandible

1. EXERCISE MODULES
DR SUDIPTA CHANDRA
MBBS- NRSMCH KOLKATA 1998
MS (ENT)- MLNMCH ALLAHABAD 2005
AMA CERTIFICATION FOR MANUSCRIPT REVIEW 2007
EDITORIAL BOARD MEMBER IJDMR 2014
CONSULTANT ENT, HEAD NECK & MAXILLO-FACIAL
SURGEON
BELLE VUE CLINIC & HOSPITAL, KOLKATA

2. CLOSED REDUCTION
INDICATION
1) NONDISPLACED & FAVOURABLE FRACTURES
2) GROSSLY COMMINUTED FRACTURES
3) EDENTULOUS ATROPHIC MANDIBLE
4) CHILDHOOD FRACTURES
5) CONDYLAR FRACTURES
CONTRA-INDICATION
1) PATIENTS WITH POORLY CONTROLLED
SEIZURES
2) PATIENTS WITH COMPROMISED PULMONARY
FUNCTION
3) PATIENTS WITH PSYCHIATRIC/ NEUROLOGICAL
DISORDERSKumar PD. Wiring techniques in Maxillofacial Surgery

3. INDIRECT INTERDENTAL- IVY LOOP/ EYELET
INDICATION 1) STABILIZATION OF MULTI-FRAGMENT FRACTURE
2) FIXATION OF IMF
PRE-REQUISITE TWO ADJACENT TEETH HAS TO BE PRESENT IN EACH
QUADRANT BECAUSE 1 OR 2 EYELETS HAS TO BE
PLACED IN EACH QUADRANT
MATERIAL MULTIPLE 20 cm 26 gauze PRE-STRETCHED STAINLESS
STEEL WIRES

4. INDIRECT INTERDENTAL- IVY LOOP/ EYELET
METHOD 1) LOOPS ARE FORMED IN THE CENTRE OF WIRE
AROUND THE BEAK OF A TOWEL CLIP/ SHANK OF
DENTAL BURR & TWISTED THRICE WITH 2 TAIL
ENDS. THESE CAN BE PRE-FORMED & STORED IN COLD
STERILIZING SOLUTION FOR EMERGENCY USE. 2 TAIL
ENDS OF EYELET ARE PASSED THROUGH THE SELECTED
INTERDENTAL SPACE FROM BUCCAL TO LINGUAL SIDE.

5. INDIRECT INTERDENTAL- IVY LOOP/ EYELET
METHOD 2 & 3) ONE END OF THE WIRE IS PASSED AROUND
THE DISTAL TOOTH LINGUALLY & BROUGHT
THROUGH THE DISTAL INTERDENTAL SPACE TO
THE BUCCAL SIDE & THREADED THROUGH THE
PREVIOUSLY FORMED LOOP. THE OTHER WIRE TAIL IS CARRIED
AROUND THE MESIAL TOOTH LINGUALLY & BROUGHT OUT TO THE
BUCCAL SURFACE THROUGH THE MESIAL
INTERDENTAL SPACE, WHERE IT MEETS THE FIRST TAIL
END WIRE.

6. INDIRECT INTERDENTAL- IVY LOOP/ EYELET
METHOD 4) THE 2 WIRES ARE CROSSED & TWISTED
TOGETHER & THE LOOP IS ADJUSTED & BENT TOWARDS
GINGIVA. THE MANDIBULAR WIRE EYELETS CAN BE
SECURED TO MAXILLARY EYELETS BY JOINING WIRES.
ADVANTAGE 1) BRIDGING WIRES CAN BE REMOVED WHENEVER
REQUIRED WITHOUT DISTURBING THE MAIN WIRING.
2) EVEN WHEN THERE IS BREAKAGE OF WIRE DURING
FIXATION, ONLY THAT EYELET CAN BE REMOVED &
REPLACED.

7. ARCH BAR FIXATION
INDICATION 1) STABILIZATION OF MULTI-FRAGMENT FRACTURE
2) FIXATION OF IMF
PRE-REQUISITE BOTH SIDE 1ST MOLARS MUST BE PRESENT
MATERIALS ARCH BARS (FLAT STURDY STAINLESS STEEL BARS ON
WHICH FLEATS OR HOOKS ARE ATTACHED)
MULTIPLE 15 cm 26 gauze PRE-STRETCHED STAINLESS
STEEL WIRES
PRE-
FABRICATED
CUSTOM
MADE
ACRYLATED

8. ARCH BAR FIXATION
METHOD 1) THE ARCH BAR IS MEASURED TO FIT FROM 1ST
MOLAR TO 1ST MOLAR. IT IS PLACED IN SUCH A WAY
THAT THE FLEATS FACE TOWARDS THE GINGIVAL
MARGIN. NOW 15 cm WIRE IS TAKEN STARTING FROM
THE DISTAL TOOTH, THE WIRE IS PASSED FROM BUCCAL
TO LINGUAL SIDE BELOW THE ARCH BAR AND FROM
LINGUAL TO BUCCAL ABOVE THE ARCH BAR & TWISTED
TOGETHER.

9. ARCH BAR FIXATION
METHOD 2) NOW 15 cm WIRE IS TAKEN STARTING FROM THE
DISTAL TOOTH, THE WIRE IS PASSED FROM BUCCAL TO LINGUAL
SIDE BELOW THE ARCH BAR AND FROM LINGUAL TO BUCCAL
ABOVE THE ARCH BAR & TWISTED TOGETHER. THIS IS
CONTINUED FOR ALL THE TEETH & THE ARCH BAR IS SECURED.
ADVANTAGE WHILE PLACING AN ARCH BAR ACROSS A DEPRESSED
FRACTURE SEGMENT, IT IS CUT AT THE FRACTURE
SITE & PLACED SEPARATELY.

10. CLOSED REDUCTION
ADVANTAGES
1) MORE CONSERVATIVE PROCEDURE
2) NO MAJOR SURGICAL COMPLICATIONS
3) CAN BE DONE IN MEDICALLY COMPROMISED
PATIENTS
DISADVANTAGES
1) AIRWAY COMPROMISE DUE TO IMF
2) LOSS OF FUNCTION OF TISSUES
3) DECREASED NUTRITIONAL STATUS OF
PATIENTS
4) ONLY OCCLUSION IS TAKEN AS A GUIDE
5) DIFFICULTY IN SPEECH
6) SOCIAL INCONVENIENCE

11. EFFECTS OF PROLONGED IMF
1) FORMATION OF ADHESIONS IN THE
JOINTS
2) THINNING & NECROSIS OF
ARTICULAR CARTILAGE
3) DISUSE ATROPHY/ OSTEOPOROSIS
OF BONE
4) DISUSE ATROPHY/ WEAKENING OF
MUSCLES

12. MAXILLO-MANDIBULAR FIXATION SCREWS
INDICATIONS 1) LONG-TERM FIXATION OF MAXILLO-MANDIBULAR
FRACTURES
2) SIMPLE ALVEOLAR FRACTURE
3) TRANSVERSE PALATAL FRACTURES
4) ALVEOLAR FRACTURE IN EDENTULOUS PERSON
5) OPEN FRACTURES
PRE-REQUISITE INTACT ANTERIOR VESTIBULAR, CANINE & PREMOLAR
REGIONS
MATERIALS TITANIUM/ SS SCREWS WITH OR WITHOUT HANGER
PLATES, 26 GAUZE WIRE FOR TEMPORARY/ 22
GAUZE FOR LONG-TERM, DRILL

13. MAXILLO-MANDIBULAR FIXATION SCREWS
METHOD MMF SCREWS ARE INSERTED EITHER THROUGH
PERFORATION OF THE CLOSED MUCOSA OR AFTER AN
OPEN APPROACH AFTER EXPOSING THE BONY
SURFACE. THE SCREW TIP SHOULD NOT FULLY
PENETRATE THE INNER CORTICAL LAYER. SIMILAR LEVEL
SCREWS ARE ALSO INSERTED IN THE OTHER ALVEOLUS TOO. A
WIRE IS BENT AROUND BOTH THE SCREW HEADS AND
THE ENDS HELD TOGETHER, TWISTED & BURIED
INWARDS. THINNER WIRES WITH HANGER PLATES
MAY BE USED FOR LONG-TERM FIXATION. WIRES &
SCREWS ARE REMOVED WHEN THE NECESSAITY IS OVER.

14. MAXILLO-MANDIBULAR FIXATION SCREWS
CONTRA-INDICATIONS 1) ALVEOLAR FRACTURES NEEDING DENTAL
SPLINTING
2) SAGITTAL PALATAL FRACTURE (NEEDS
PLATING)
3) MULTIPLE MAXILLO-MANDIBULAR FRACTURES
4) SEVERE BONY ATROPHY
5) PATHOLOGICAL BONE
6) UNERUPTED TEETH/ DENTAL FOLLICULE
7) CONGENITAL/ ACQUIRED BLEEDING
DISORDERS

15. ERNST LIGATURES
INDICATION 1) TEMPORARY FIXATION PRIOR TO DEFINITIVE SURGERY
2) INTRA-OP MMF DURING SURGERY FOR SIMPLE
FRACTURE
PRE-REQUISITE 2 INTACT NEIGHBOURING TEETH PREFERABLY
PREMOLARS IN THE SAME SEGMENT OF ONE DENTAL ARCH,
NO JAW MALFORMATION
MATERIAL 15 cm 26 GAUZE STAINLESS STEEL WIRE
METHYL METHACRYLATE APPLICATOR
CONTRA-INDICATION 1) COMMINUTED & DISPLACED FRACTURE
2) UNSTABLE SEGMENTED FRACTURE
3) COMPLEX FRACTURES

16. ERNST LIGATURES
METHOD 1) 1 END OF THE WIRE IS PASSED THROUGH THE
INTERDENTAL SPACE BETWEEN 2ND PREMOLAR & 1ST
MOLAR. THEN IT IS THREADED BACK FROM LINGUAL
TO BUCCAL SURFACE THROUGH THE
INTERDENTAL SPACE BETWEEN 1ST & 2ND PREMOLAR. OTHER
END OF THE WIRE IS PASSED THROUGH THE INTERDENTAL
SPACE BETWEEN CANINE & 1ST PREMOLAR & THEN IT IS
THREADED BACK FROM LINGUAL TO BUCCAL SURFACE
THROUGH THE INTERDENTAL SPACE BETWEEN 1ST & 2ND
PREMOLAR. 1 END SHOULD BE ABOVE & THE OTHER END
SHOULD BE BELOW THE HORIZONTAL SEGMENT OF
WIRE.
C
M1

17. ERNST LIGATURES
METHOD 2) THE WIRE ENDS ARE TWISTED TOGETHER &
TIGHTENED. LIGATURES ARE ADDED IN THE SAME
WAY IN THE OTHER 3 SEGMENTS OF THE DENTAL
ARCHES TO FORM 2 SYMMETRICAL PAIRS. ALL THE
WIRE ENDS SHOULD BE AT LEAST 4-5 cm IN LENGTH.
THEN THE CORRECT OCCLUSION IS ASSURED & THE WIRE
ENDS OF EACH PAIR OF LIGATURES ARE TWISTED TOGETHER.
CARE SHOULD BE TAKEN NOT BREAK ANY WIRE AT THIS POINT.
THEN THE WIRE ENDS ARE CUT & BENT TOWARDS
THE TEETH TO PROTECT THE ORAL MUCOSA.
ADDITIONAL STABILIZATION CAN BE OBTAINED USING
METHYL METHCRYLATE TO REINFORCE THE
LIGATURE.

18. EDENTULOUS MANDIBULAR FRACTURE
 OBSERVATION & SOFT DIET- NONUNION
 CLOSED REDUCTION BY WIRING IN
PATIENT’S DENTURES OR FABRICATING
GUNNING STYLE SPLINTS WITH POST-
OP MMF- MALUNION/ NONUNION
 OPEN REDUCTION INTERNAL FIXATION-
BEST BUT DIFFICULT
 EXTERNAL FIXATOR- MALUNION/
NONUNION

19. EDENTULOUS MANDIBULAR FRACTURE