Intermaxillary Fixation Techniques Manual

7/21/2019 Intermaxillary Fixation Techniques Manual

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IntermaxillaryFixationTechniques

AnEACMFSworkbookonkeyingocclusionandrestoringbony

anatomybyintermaxillaryfixationtechniques

Editors

JosM.LpezArcas,MD,DDS,PhD

JulioAcero,MD,DMD,PhD,FEBOMFS

MauriceY.Mommaerts,MD,DMD,PhD,FEBOMFS

Bruges,2010


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TableofContents

PrefaceI ...............................................................................................................................................4

PrefaceII..............................................................................................................................................5

1.Introduction...................................................................................................................................6

2.A

history

of

the

management

of

maxillofacial

injuries.

The

development

of

intermaxillaryfixation. ..................................................................................................................7

3.Materialproperties .................................................................................................................. 123.1.Basicmaterialproperties ........................................................................................................ 12

3.2.Archwireproperties...............................................................................................................14

3.2.1.Preciousmetalalloys............................................................................................................... 14

3.3.Bands ..................................................................................................................................... 15

4.Protectionfromprickaccidents..........................................................................................17

5.Dentaltrauma ............................................................................................................................ 20

5.1.Acid

etch

resin

arch

wire

splint...............................................................................................20

5.2.Orthodonticbracketarchwiresplint ...................................................................................... 22

6.IMFtechniques...........................................................................................................................246.1.Ligaturewiring........................................................................................................................ 24

6.1.1.Gilmerwiring........................................................................................................................... 25

6.1.2.Kazanjianbutton ..................................................................................................................... 266.1.3.Eyelettechnique...................................................................................................................... 27

6.1.4.Intermaxillaryloopwiring(Stout) ........................................................................................... 33

6.1.5.Cablearchwire(Fig.21) ......................................................................................................... 34

6.1.6.Multipleloopwiring(Obwegesermethod) ............................................................................. 35

6.1.7.Leonardsbuttonwiring(Fig.25) ............................................................................................ 37

6.1.8.Banded

retention

appliance.................................................................................................... 38

6.2.Archbartechniques................................................................................................................ 39

6.2.1.Groningentypecustommadearchbar.................................................................................. 40

6.2.2.Ericharchbar .......................................................................................................................... 436.2.3.Schuchardtswire,acrylicarchbar ......................................................................................... 48

6.2.4.Dautreyarchbar ..................................................................................................................... 51

6.2.5.Bernstitaniumarchbar ......................................................................................................... 52

6.2.6.Baurmashsarchbar ............................................................................................................... 54

6.3.Capsplints .............................................................................................................................. 55

6.3.1.Castacrylicspintswithcuspsoftheteethexposed ................................................................ 56

6.3.2.Castsilvercapsplints .............................................................................................................. 57

6.4.Gunning

type

splints............................................................................................................... 61

7.IMFscrews................................................................................................................................... 65

8.IMFtechniquesinchildren.................................................................................................... 708.1.Houpertsprocedure............................................................................................................... 70

9.Wiresuspensiontechniques.................................................................................................729.1.Circummandibularwiring ....................................................................................................... 72

9.1.1.BlackIvyprocedure................................................................................................................. 72

9.1.2.T.Paoliprocedure(transalveolarwiring)................................................................................ 74

9.2.Pyriformaperturesuspension................................................................................................. 74

9.3.

Nasal

spine

suspension

(Ombredanne

Broadbent) ................................................................. 75

9.4.Inferiororbitalrimsuspension................................................................................................ 76

9.5.Circumzygomaticsuspension(Rowe Obwegeser).................................................................. 77

9.6.Supraorbitalrimsuspension ................................................................................................... 79

9.7.Kufnersuspension .................................................................................................................. 80

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10.ORTHODONTICAUXILIARYAPPLIANCESFORIMFINORTHOGNATHIC

SURGERY...........................................................................................................................................8110.1.Teethandbrackettypes ....................................................................................................... 81

10.1.1.Bracketwithhook(Fig.72) ................................................................................................... 8110.1.2.PowerPins(arms)(Fig.73FandG) ....................................................................................... 82

10.2.3.Buttons.................................................................................................................................. 82

10.2.Tie

or

ligature

appliances ...................................................................................................... 85

10.3.Archwireappliances.............................................................................................................86

10.3.1Solderedbrasshook ............................................................................................................... 86

10.3.2.Prepostedarchwires ........................................................................................................... 87

10.3.3.Crimpablehooks.................................................................................................................... 87

Acknowledgments......................................................................................................................... 90

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PrefaceI

Theideaforthisworkbookoriginatedin2007whenDr.LpezArcaswasanEACMFSfellowinBruges.HerequestedtoworkonalargescaleEuropeanproject.Ihadnoticedthatsurgeonsin

trainingacquireskillsintheirparticulartrainingcenterandremainoblivioustolessfashionable,oldtechniquesortechniquesusedatothercenters.Forexample,inthe1980s,theZurichschoolexclusivelyusedObwegeserwireloopsplints,whiletheBaselschoolexclusivelyappliedSchuchardtacrylicwiresplints.Personally,Ilearnedabouttheusefulnessofsilvercapsplintswithguidingwingsaftercondylarresections,butdidnotusethemfor20yearsuntilapatientpresentedwithbilateral

jointankylosisduetoa3monthintubationforburnsafteragasexplosion.Theonlywaytocontrolocclusionwasbyusingtheoldtechnique.Suspensionwireshavefallenoutoffavorinaneraofopenreductionandplateosteosynthesis,andindeedthedishfaceswithmandibularoverrotation

andpost

traumatic

retromaxillism,

telecanthus,

enophtalmia,

and

nasal

dorsum

flattening

have

disappeared.Still,Ifoundpyriformandzygomaticsuspensionwiresveryusefulinacaseofsubtotalresectionofajuvenileossifyingfibromaina3yearoldgirltosuspendanintraoperativelymadeprosthesistosupportthepack.Hence,IpresentedmyproposaltoorganizetheJohnLowryEducationCourseattheEACMFS2010Congresswithintermaxillaryfixationtechniquesasthemaintopic.Apermanentrecord,intheformofthisworkbook,wasproducedbyDr.LpezArcasandhisfriendDr.

JosMGarciaRielotowhomIamverygrateful.Mr.JohnWilliamswrotethechapteronhistory.

SpecialthanksalsogotothemaxillofaciallabsofDentaalTemaenRongofBrugge,LaboDegraeveinRoeselare,andtoHansHageroftheUniversityofZurichfordescriptionsand

iconographiesofspecialtechniques.

Prof.

Julio

Acero

supervised

the

project

and

persuaded

course

conductors

to

participate,

for

whichhedeservesmuchgratitude.

Ihopethetechniquesdescribedmaybeusefulinyourpractice!

MauriceMommaertsMDDMDPhDFEBOMFS

PresidentEACMFS20082010

PresidentEACMFSXXthCongress

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PrefaceII

AstheEACMFSEducationandTrainingOfficer,itisagreathonourtoendorsethismanualonintermaxillaryFixationTechniques.Inthepastwirefixationtechniquesplayedamajorroleinthetreatmentoffacialdeformitiesandcraniomaxillofacialtraumaandwasacornerstoneofourspecialty.Traineesurgeonsarenowadayslessexposedtothesemethodssincemaxillofacialtraumamanagementhasevolvedoverthepastdecadeswithtotheintroductionofnewtechniquessuchasrigidorsemirigidinternalfixation. ThepurposeofthishandbookistoreviewtheIMFtechniquescurrentlyavailableaswellastheclassicwiringtechniquesaimingtoprovideyoungspecialistsandtraineeswiththeknowledgeofclassicfixationtechniques,whichcanbehelpfulindifferentsituations.

Thismanualopenswithareviewofthehistoryofthemanagementofmaxillofacialinjuries

andthen

covers

the

fundamentals

of

IMF

and

wire

fixation

techniques,

including

concepts

on

materialsproperties,armamentarium,methods,advantagesanddrawbacks.Ashortreferencetotheindicationsofthesetechniquesinchildrenismade.Thefinalchapterprovidesdetailedreviewoftheuseoforthodonticappliancesforintermaxillaryfixation.

IgratefullythanktheauthorsfortheireffortinpreparingthiscomprehensivemanualwhichI

amcertainthatwillbeanusefulreferenceforspecialistsandresidentsinoralandcraniomaxillofacialsurgery.VeryspecialthanksgotoMauriceMommaerts,EACMFSPresident,andJosMLopezArcasfortheirenthusiasticinputandincrediblework,whichmadepossiblethisbook.

JulioAceroMDDMDPhDFDSRCSFEBOMFS

EACMFSEducationandTrainingOfficer

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1.Introduction

Manyoftheconventionalarchbarsorwiringtechniquesweredevelopedatatimewhenmost

facialfracturesweretreatedbyintermaxillaryfixation(IMF)onlyandthereforehadtobesufficiently

stabletomaintain immobilisationforaprolongedperiod.Sincethe introductionofopenreduction

andrigidosteosynthesis(ORIF)protocols,IMFhasbeenpredominantlyusedtoobtainnormocclusion

duringthesurgicalprocedureorforashortperiodpostoperativelyforsupportusingrubberbands.In

somecases,IMFbonescrewsmaybesufficient.Consequently,theindicationsforusingsimplerIMF

systemsareincreasing.

There are still situations in craniomaxillofacial (CMF) trauma in which stable IMF using

conventional arch bars with circumdental wire fixation is necessary. These conditions include

nonoperativetreatmentofdisplacedcondylar fracturesandfinalocclusaladjustmentusingguiding

elastics after open reduction internal fixation (ORIF) for comminuted mandibular fractures and

displacedfracturesofthemaxilla.

Other situations include partially edentulous jaws where it is difficult to find a proper

relationship between the dental archeswhen treating a complex fracture and in certain casesof

bonyreconstructionfollowingtumourresection. Inthesesituations,IMFusingbonescrewsorarch

bar fixationusingdirectbonding techniques tends tobeunstableoreven impossible tocarryout

becauseofthelackofteethandocclusion.

The

purpose

of

this

manual

is

to

show

the

surgeon

in

training

the

IMF

techniques

that

are

currently available as well as the classic wiring techniques that can be helpful in certain

circumstances.

Dr.JosM.LpezArcas Dr.JosMGarciaRielo

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2.Ahistoryofthemanagementofmaxillofacialinjuries.The

developmentofintermaxillaryfixation.

Although traumahasbeenwithus since thedawnof time, it isonly recently thatwehave

been able to approach it scientifically. For this reason, the original reports of treatment do not

necessarily follow any logicalpattern, amounting to a seriesof case reports containedwithin the

literature from the earliest preChristian times to Egypt in 2000 B.C. when a dislocation of the

mandible as well as a fracturedmandible were described. Hippocrates described reduction and

fixationofmandibular fractureswithstripsofcalicoglued to theskin immediatelyadjacentto the

fracture and laced together over the scalp. The ancient physicians of Alexandria and Rome also

mentioned the ligationof teethusing finegoldwireorCarthugian leatherstripsglued to theskin.

These principles laid down by Hippocrates extended through the literature as far as the first

millennium.

It was probably Salicetti in 1474 in Bologna who first described the simple expedient of

ligating the teeth of the lower jaw to the corresponding teeth of the upper jaw to affect

immobilisation of a fracture. Previously, itwas recognised thatwithin 3weeks, theunionofjaw

fractureswouldbecomplete.

The 16th and 17th centuries saw the introduction of gunpowder and the first reports of

gunshotwounds.ItwasAmbroisePartowhomwemustattributethefirstsignificantchangeinthe

managementoffacialwoundsviacopiousirrigationandtheapplicationofbalmsratherthantheuse

ofcauterisation.Hisparticularcareoffacialwoundsandhisapplicationofwhathedescribedasa

dry suture facilitated secondary healing of these wounds, particularly treatment of compound

wounds.

ThenextmilestonewasachievedbyRichardWiseman,asurgeoninthelatterpartofthe17th

century,whodescribedthemanagementofmaxillofacialinjuries.Aswellasdescribingthesignsand

symptoms of a fracture, he also described many individual cases, including a child with a

comminutedfractureofthecribriformprocessoftheethmoid.Healsodescribedthedisturbancein

occlusionandrelatedprotrusionorrecessionofthelowerjawandthedestructionofsofttissuesin

associationwith these injuries.These astute clinicalobservationswere added to those studiesof

anatomy and physiology at the Italian schools of Bologna and Padua in the early 18th century.

Together, they laid the foundation for serious advances in the systematic management of jaw

injuries.

Chopont & Desault (1780) were the first to describe a different type of approach by

introducingtheconceptofadentalsplintthatconsistedofashallowtroughofiron,invertedoverthe

occlusalsurfaceofthe lowerteeth,whichwereprotectedwithcorkon leadplates.Abarprojected

fromthefrontincisorregion,bentatrightangles,andfastenedbythumbscrewstoasubmandibular

plateofsheet iron.Movementof the fragmentswasthuspreventedbycompressionbetween the

occlusalsurfacesoftheteethandthelowerborderofthemandible.

Variationsof thisprinciplewereemployedduring thenext100 years andwere introduced

subsequentlyintoGermanybyRutenikin1799,whofurtherstabilisedtheheadharness,intoEngland

byLonsdalein1833,andintoHollandbyHartigs&Grebber(1840);however,eachwasamodification

of theoriginalprinciple that still foundemployment afterWorldWar II for the fixationof certain

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epithelial inlay splints in the edentulousmandible.Different formsof supportive bandagingwere

introduced,accompaniedbywedgesofcorkbetweentheocclusalsurfacesoftheteethtokeepthe

teeth apart and facilitate feeding. Earlier in 1825, Naysmith cooperated with Robert Liston to

provideacast,goldcapsplint.Thissplintwassolderedtogetherandaffixedtotheteethtoprevent

thedisplacementofthemandible inamandibulectomycaseuntilthemajorityoftheforcesofsoft

tissuecontraction

had

dissipated.

Thediscoveryofanaesthesiaallowed forasignificantadvancewhenFauchard inFranceand

Buck in theUSA began to use direct intraosseous silverwires. Resultswere variable due to the

developmentof sepsisand consequent sequestration.Avariationby Wheelhouse involveddriving

silverpinsthrougheachpieceofboneandwindingsilkthreadaroundeachpininafigureeightto

approximatetheboneends.

War has always provided opportunities for surgical developments, and so itwaswith the

AmericanCivilWarof18611865and theFrancoPrussianWarof18701871, inquick succession,

thatalargeproportionofmandibularfracturesarosefromhorsekicksorfallsontothechin.In1861,

Gunningproduced

his

splint,

although

he

was

probably

unaware

that

it

followed

the

same

principle

astheonedevelopedbyNaysmithin1825forusebythesurgeonListon.Fromdentalimpressions,a

monoblocconstructionwasproducedandbound to thejawsbyabandage thatpassedunder the

chinandoverthevertexoftheskull.Teeth inthe lineoffracturewereextracted.Later inthewar

(1864),Bean,whotreatedmanyfractures,madeasignificantadvancebysectioningdentalmodelsof

thejawsandcarefullyrealigningthembeforeconstructingaGunningtypeofsplint.

The firstreportsofswagedmetalsplintsappearedsimultaneouslybyAllport inAmericaand

HaywardinLondon.Allportsgoldsplintswereswagedtoleavetheocclusalandincisiveedgesfree,

and,havingcorrectlyalignedthem,thesplintsweresolderedtogether.Softguttaperchawasusedto

attachthe

splints

to

the

teeth.

Hayward

covered

the

occlusal

surfaces

of

the

teeth

and

used

soft

guttaperchaforattachment.Aseparatesubmentalguttaperchasplintwasplacedinpositionanda

bandageorrubberbandwasusedtoconnect ittotwoarmsprojectingfromthesplintandcurving

backwardaroundthecommissuresofthemouth.DespitefurthermodificationsbyKingsley,allthese

splintswereessentiallymodificationsoftheoriginalsplintbyChopartandDesaultin1780.

The inherentweakness in all these splintswas the lackof secure fixation to thejaws, and

variousattemptsweremade toovercome thisproblem. Initialdescriptionsby HamiltonAdams in

1871usedfinenutsandboltsthatpassedthroughtheinterdentalspaces.Some3yearslater,Moon,

inLondonusedfineinterdentalwirestoachievethesameresult.Itwasataboutthissametime,that

Woodward,

in

the

USA,

melted

down

silver

coins

(silver

and

copper)

to

produce

opencast,

metal

cap

splints,attachedtothecrownsoftheteethbysmallscrews.Thetwosplintswereconnectedtoone

another by lugs, and through themeans of eyelets soldered to them, thejaws could be wired

together,thusgivingIMF.Althoughasignificantadvance,theverycomplicatednatureoftheprocess

andthe lackofacementingmediumforattachingthesplintstotheteethmeantthatthesesplints

didnotcatchonrapidly.However,attention isnowshiftingtothe improvedaccuracyofreduction

providedbyfocusingontheocclusion.

DuringtheFrancoPrussianWar,Hammonddescribedtheuseofarchbarsonboththelingual

andbuccalaspects thatwere fixed to the teethby fine interdentaleyeletwires.Thisprocesswas

adapted forboth thewiringof thearchbarsand thecontinuous loopmethod.At the same time,

Suerson, in Berlin, who had been chiefly employing the Gunning principles, but when treating

malunions, conceivedof using separate splints for each section andofdrivingwedgesofhickory

wood of everincreasing thicknessesbetween these splints,which gradually realigned the arches.

Thisseemstobethefirstaccountofanattempttorealignthedisplacedarches.

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In1887, Gilmer returned toan almost forgotten technique, thedirectwiringof teeth.This

resurrectionofanoldprinciple,suitablymodified,wasasignificantadvanceandbecameincreasingly

importantasorthodontic techniquesbecameadaptedby surgeons for the treatmentof fractures.

Angle appliedhisprinciplesof fixed anchoragepoints and individualbands cemented to selected

teeth ineachjawasameanstorestoreacorrectlyaligneddentition.Sonow,forthefirsttime,we

seescience

applied

to

the

management

of

these

injuries.

This,

together

with

the

huge

advances

in

surgeryoccasionedbythe introductionofanesthesia,the institutionofantisepticand lateraseptic

techniques,and the introductionofXrays forclinicalpurposesby Roentgen in1895,changed the

scenedramatically.Othersignificantadvancesthatfollowedatthattime includethereconstructive

workofAbb,Estlander,andThiersch;thefirsttreatmentoffracturedzygomasbyMatas(1896)and

themidfacebyBouvet in1901;LeFortsworkonfracturepatterns;andthesurgicalapproachesto

thezygomaofLothrop(1906),Keen(1909),andManwaring(1913),whichleduptothecasualtiesof

the19141918warinEurope.

Thescaleoftheseinjuries,26millioncasualtiesofthe56millionindividualsinvolvedinarmed

conflict,was

due

largely

to

trench

warfare

and

the

destructive

nature

of

high

energy

explosives

that

renderedthefacepronetomoresevereinjurythanhadbeenseenpreviously.However,thesound

principles laiddownat the turnof thecenturydidnotundergoany radicalchanges; rather, there

were a series of refinements in techniques that often followed the application of orthodontic

principlestosplintconstruction.Circumferentialwireswereusedinsomecases,Gunningtypesplints

wereusedinothers(especiallyedentulouscases),andbothopen andclosedcastsilvercapsplintsin

dentatepatientswereused to a greaterextent thanhadbeenusedpreviously. Fresh caseswere

treatedbysectioningthemodels,restoringtheocclusioninthelaboratory,andforcingthesegments

intothesplintsatthetimeofreductionandimmobilisation.Incaseswheretreatmentwasdelayed,

reduction was achieved using orthodontic techniques. The use of interdental eyelet wires was

demonstratedby

Ivy

(1914)

as

an

effective

way

to

provide

IMF

in

the

dentate

patient

and

was

increasinglypractised.

Replacementofbothhardandsofttissueshadreachedaremarkabledegreeofsophistication

withsurgeonsdevelopingingenioustechniquestoachieveoutstandingresults,butsepsis,leadingto

gangrene,hospitalbased infections,aswellasothergeneral infections,allcontributed to thehigh

levelofmorbidityandmortalityof that time.Lister, followedbythe firstchemotherapeuticagent,

prontosil,made great strides to treat these severe complications.There followed certain, specific

improvementsinthesurgicalcareoffacialfractures.Notableamongthesewasthedevelopmentat

EastGrinstead of sectional splints, one for each segment, linked together by intraorally located,

lockingplates,

which

underwent

later

modification

to

be

located

extraorally.

Middle

third

fracture

managementalsounderwentimprovementswherecheekwires,firstdevelopedbyFederspiel,were

usedtofixtheposteriorregionofthemaxillatotheplasterofParisheadcap.

BytheendofWorldWarII in1945,therewasanincreasingrealisationthatwhenboneends

arebrought intocloseproximitywithoneanother,more rapidhealingoccurs.With theadventof

antibiotics, a greater use of direct approaches to the fracture sites led to the use of direct

interosseousbonewiringorosteosynthesis.Suchwiresweregenerallyappliedtoeithertheupperor

thelowerbordersofthemandibleandthefrontozygomaticsuture,allsolidpiecesofbone.During

this time, pin fixation was used, particularly in the treatment of compound, comminuted, and

frequently

infected

jaw

fractures.

Despite

a

reduction

in

its

use,

this

concept

was

retained

and

used

by Fordyce in the BoxFrame technique. A variety of pinswere used from the fine, threaded,

CloustonWalkerpin,modified for theEastGrinsteadpattern,and MacGregorpins, to the coarse,

threaded,tapered,Moulepin. Itwasnotuntil theVietnamWarthatAmerican forcescametouse

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biphasic pin fixation, popularised by Morris (1949), and external pin fixation again became the

treatmentmethodofchoice.

Withtheadventoftheantibioticera,recognitionofthevalueofdirectfixationbecamewidely

accepted inorthopaedicpracticeandwasadapted formaxillofacialpurposes. Initially,directbone

wiring was used to control 1) the edentulous posterior fragment; 2) multiple fragments in the

edentulousmandible;and3)thegrosslycomminutedmandibularfragmentsandthelowerborderof

themandiblewhere the upperjawwas already secured by one of the conventionalmethods of

fixationbutwherethelowerborderremainedinadequatelyreducedandimmobilised.

Althoughtheuseofboneplateshadpreviouslybeenattempted(Konig,1905;Lambotte,1907;

Lane,1914;Sherman,1924),itwasnotuntilRoberts(1964)andBattersby(1967)introducedstainless

steel,vitalliummonocorticalminiplatesthatthepresentuseofsurgerywasestablished.Thelackof

malleabilityoftheseinitialminiplateslimitedtheirusefulnessfortheybrokeassoonasanyattempt

wasmade tobend them.The initial introductionofmalleable stainless steel followedby titanium

enabled Champy (1976,1978) todevelopa scientificbasis for theapplicationofminiplates in the

treatmentof

mandibular

fractures.

Inevitably,

numerous

clinicians

and

manufacturers

provided

their

ownmodifications,buttheprinciplesofapplicationremainunchanged.

Bioresorbableplates,madeinitiallyofpolylacticacidand,morerecently,ofacombinationof

thisandothersuitablematerials,weredeveloped(Bos,1983;Rozema,1991;Suuronen,1992).Their

biodegradationtendstobeaccompaniedbyasignificantcollectionoffluidbeneaththeskin.

Thecompressionosteosynthesistechniquesusedbyorthopaedicsurgeonshavebeenapplied

tomaxillofacial surgeryby Luhr (1968,1972)and Becker& Machtens (1970).Theuseof specially

designedtapsandmatchingscrewsallowedbothcorticestobeengagedthat,whencombinedwith

the specially designed plates, produced firm opposition of the fractured bone ends under

compression.This

process

results

in

primary

bone

healing

by

direct

osteoblastic

activity

within

the

fractureasopposedtosecondarybonehealingthroughcallusformation.

Intramedullarypinningandtheuseoftitaniumaswellasnonmetallicmesh,particularlyinthe

treatmentofmalunionsandfracturesoftheedentulousmandible,allhaveimportantapplications.

REFERENCES

AdamsF.TheGenuineWorksofHippocrates.London,SydenhamSociety,1849.

AdamsWM. Surgery,12:523,1942.

CasseriusJ.TabulaeAnatomicaedevocisauditusqueorganishistoriaanatomica.Ferrara,1600.

SalicerriG.

Praxeos

Totius

Medicinae,

De

Chirurgia,

Venice,

1275.

TagliacozziG.DeCurtorumChirurgiaperInstitionem.Venice,1597.

OliverRT.JAMA54:1187,1910.

ParA.TheWorkesoftheFamousChirurgionAmbroiseParey.TranslatedoutoftheLatineandcomparedwith

theFrench.Johnson,T.London,CotesandYoung,1634.

WisemanR.SeveralChirurgicalTreatises.London,1686.

RutenickFG.Dis.defracturamandibulae,Berol,1823.

HartigFR, GreeberH.Beschrivingvaneennieuwtoestelvoordebreukvandeonderkaak.Amsterdam,1840.

GunningTB.NewYorkMedJ3:433,1866.

GunningTB.NewYorkMedJ4:514,1867

FauchardP.TraitdeChirurgieDentaire.Paris,Mariette,1728.

ChopartE,DesaultPJ.TraitdesMaladiesChirurgicales.Paris,1779.

MatasR.NewOrMedSurgJ49:139,1896.

GilmerTL.

Fractures

of

the

Inferior

Maxilla.

JDent

Sc

1:309,

1881.

LeFortR.RevdeChir1:208260,1901.

GilmerTL.ArchDent4:388,1887.

IvyRH.Surg,GynaecandObst52:849,1922.

EbyJD.JNatDentA7:771,1920.

GilliesHD,KilnerTP,StoneD.BritJSurg14:651,1927.

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McIndoeAH.ProcRSocMed34:267,1941.

MacintoshRB,ObwegeserH. Internalwiringfixation.OralSurg,OralMed,OralPath23:703,1967.

RobertsWR.BritJOralSurg1:200,1964.

RoweNL, Killey,HC.FracturesoftheFacialSkeleton.Edinburgh,E.andS.LivingstoneLtd:1968.

LambotteA.Letraitementdesfractures.Masson,Paris,1907.

ChampyM,LoddeJP. Synthsesmandibulaires.Localisationdessynthsesenfonctiondescontraintes

mandibulaires.RevStomatolChirMaxillofac77:971976,1976.

LuhrHG.

The

compression

osteosynthesis

of

mandibular

fractures

in

dogs.

A

histologic

contribution

to

primary

bonehealing,EurSurgRes1:157292,1971.

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3.Materialproperties

Before beginning to learn how to use a certain material (e.g., wires), it is important to

understandwhatthematerialismadeof,itsphysicalproperties,andhowtohandleit.

3.1.Basicmaterialproperties

Theelasticbehaviourof anymaterial isdefined in termsof its stressstrain response to an

externalload.Stressandstrainrefertotheinternalstateofthematerialbeingstudied:stressisthe

internal distribution of the load (defined as force per unit area), whereas strain is the internal

distortionproduced

by

the

load

(defined

as

deflection

per

unit

length).

Foranalyticalpurposes,wiresandspringscanbeconsideredbeams,supportedeitheronlyon

one end or on both ends (e.g., the segment of an archwire spanning between attachments on

adjacentteeth).Ifaforceisappliedtosuchabeam,itsresponsecanbemeasuredasthedeflection

(bendingandtwisting)producedby the force.Forceanddeflectionareexternalmeasurements. In

tension,internalstressandstraincanbecalculatedfromforceanddeflectionbyconsideringthearea

andlengthofthebeam.

Three major properties of beam materials are critical in defining their clinical usefulness:

strength, stiffness (or its inverse, springiness), and range. Each canbe definedby an appropriate

referenceto

aforce

deflection

diagram

(Fig.

1A).

A B

Figure1A.Atypicalforce(Y)deflection(X)curveforanelasticmateriallikea0.5mmwirewhereanaxial

pull(purestretch)isapplied.Thestiffnessofthematerialisgivenbytheslopeofthelinearportionofthecurve.

TherangeisthedistancealongtheXaxistothepointatwhichpermanentdeformationoccurs(usuallytakenas

theyieldpointatwhich0.1%permanentdeformationhasoccurred).Themoreverticaltheslope,thestifferthe

wire.

Figure1B.Stress(Y)andstrain(X)areinternalcharacteristicsthatcanbecalculatedfrommeasurements

offorceanddeflection,sothegeneralshapesoftheforcedeflectionandstressstraincurvesaresimilar.Three

differentpointsonastressstraindiagramcanbetakenasrepresentingthestrength.Theslopeofthestress

straincurve,E,isthemodulusofelasticitytowhichstiffnessandspringinessareproportional.

12


13/90

Threedifferentpointsonastressstraindiagramcanbetakenasrepresentativeofthestrength

ofamaterial(Fig1B).Theyrepresentthemaximumloadthatthematerialcanresist.

ProportionalLimit.

The

point

at

which

any

permanent

deformation

is

first

observed.Itcanalsobedefinedastheelasticlimit.

YieldStrength.Thepointatwhichadeformationof0.1%ismeasured.

Maximum Load. The point atwhich the ultimate tensile strength is reached after

somepermanentdeformationand is greater than the yield strength.Theultimate

strengthisimportantclinicallybecauseitdifferssignificantlybetweenthesteelwires

fromthenewertitaniumalloys.

Definitions

1. Springback.Thisisalsoreferredtoasmaximumelasticdeflectionormaximumflexibility.Itisrelated to the ratio of yield strength to themodulus of elasticity of thematerial (YS/E).Springback is a measure of how far a wire can be deflected without either causingpermanentdeformationorexceedingthelimitsofthematerial.

2. Formability.Highformabilityisabilityofawiretobendintodesiredconfigurations,suchasloops,withoutfracture.

3. Biocompatibilityandenvironmentalstability.Biocompatibilityisresistancetocorrosionand

tissuetolerancetoelementsinthewire.Environmentalstabilityensuresthemaintenanceofdesirable properties of the wire for extended times after manufacture, ensuring thepredictablebehaviorofthewirewheninuse.

4. Joinability. The ability to attach auxiliariesbyweldingor solderingprovides an additionaladvantagewhenincorporatingmodificationsintoanappliance.

Whenusing

wires

to

immobilize

bone

fragments

or

maintain

arigid

IMF,

it

is

important

to

maintainthephysicalpropertiesofthewiresasdescribedabove. It is importanttostretchortwist

thewires inanappropriate range toavoidexcessive springbackor failureof thewire. Ingeneral,

when using standard, soft stainless steel wire for IMF procedures, the wires should have been

stretched by 10% of the original length to prevent loosening of the wires after insertion.

Overstretchinghardensthewire,whichbecomesbrittleanddifficulttousebecauseitcanbeeasily

broken.

Ingeneral,thepropertiesofan idealwirematerial for IMFpurposesshouldbehighstrength,

lowstiffness(inmostapplications,notforsemirigidfixation),highrange,andhighformability.

Inthe

USA,

orthodontic

appliance

dimensions,

including

wire

sizes,

are

specified

in

thousandths

ofan inch (i.e.,0.016 inch). InEurope, appliancedimensions are specified inmillimeters.For this

range,acloseapproximationcanbeobtainedbydividingthedimensions inmilsby4andplacinga

decimalpointinfront(i.e.,0.016=16mils=0.4mm).

13


14/90

3.2.Archwireproperties

3.2.1.Preciousmetalalloys

Frequentlyusedbefore1950, the introductionof stainless steelmadepreciousmetalalloys

obsolete for surgical purposes.However, silver is still used as themain component of silver cap

splints.

3.2.1.1.Stainlesssteel

Stainless steelwith similar properties replaced preciousmetals in IMF surgery because of

considerablybetter strengthand springinesswithequivalent corrosion resistance.Stainless steels

rustresistanceresultsfromarelativelyhighchromiumcontent.AtypicalformulationforIMFusehas

18%chromiumand8%nickel(thus,thematerialisoftenreferredtoasan188stainlesssteelwire).

Steel is softenedby annealing andhardenedby coldworking.Annealing causes changesby

heatingtoabove therecrystallisation temperatureandmaintainingasuitabletemperaturebefore

cooling.Annealing isused to induceductility, softenmaterial, relieve internal stresses, refine the

structurebymakingithomogeneous,andimprovecoldworkingproperties.

Incasesofcopper,steel,silver,andbrass,thisprocess isperformedbysubstantiallyheating

thematerial(generallyuntilglowing)andallowingittocool.Unlikeferrousmetalslikestainlesssteel,

whichmustbecooledslowlytoanneal,copper,silver,andbrasscanbecooledslowlyinairorquickly

by

quenching

in

water.

In

this

fashion,

the

metal

is

softened

and

prepared

for

further

work,

such

as

shaping,stamping,orforming.

Steelwirematerialsareofferedinarangeofpartiallyannealedstatesinwhichyieldstrengthis

progressively enhanced at the costof formability.The steelwireswith themost impressive yield

strength (i.e., super grades) are almost brittle and will break if bent sharply. Fully annealed

stainless steelwiresare softandhighly formable.The ligaturesused to tieorthodonticarchwires

intobracketsontheteeth,Kobayashities,and IMFcerclagewiresaremadefromsuchdeadsoft

wirelikeRemanium(RemanitsoftWeich,Dentaurum).

3.2.1.2..Cobalt-chromium-nickelwires(Elgiloy)

Elgiloy,acobaltchromiumnickelalloy,hastheadvantagethatitcanbesuppliedinasofterand

thereforemoreformablestate,andthenitcanbehardenedbyheattreatmentafterbeingshaped.

Afterheattreatment,thesoftestElgiloybecomesequivalenttoregularstainlesssteel,whileharder

initialgradesareequivalent to thesupersteels.For regular IMFprocedures, this typeofalloy is

rarelyused.

3.2.1.3.Nickel-titanium(NiTi)alloy

Thenamenitinolwasderivedfromtheelementsthatmakeupthisalloy("ni"fornickeland

"ti" for titanium)and from itsplaceoforigin ("nol" forNavalOrdinance Laboratory).Orthodontic

14
http://en.wikipedia.org/wiki/Ductilityhttp://en.wikipedia.org/wiki/Cold_workhttp://en.wikipedia.org/wiki/Cold_workhttp://en.wikipedia.org/wiki/Cold_workhttp://en.wikipedia.org/wiki/Copperhttp://en.wikipedia.org/wiki/Steelhttp://en.wikipedia.org/wiki/Silverhttp://en.wikipedia.org/wiki/Brasshttp://en.wikipedia.org/wiki/Brasshttp://en.wikipedia.org/wiki/Silverhttp://en.wikipedia.org/wiki/Steelhttp://en.wikipedia.org/wiki/Copperhttp://en.wikipedia.org/wiki/Cold_workhttp://en.wikipedia.org/wiki/Ductility


15/90

wires are often made of this alloy, and a surgeon may encounter it during an orthognathic

procedure.

Thehighspringbackpropertyofnitinol isuseful incases that require largedeflectionsbut

lowforces.Nitinolwireshavegreaterspringbackandalargerrecoverableenergythanstainlesssteel

orbetatitaniumwireswhensubjectedtothesameamountofbendingortorquing.

Like stainless steelandmanyotheralloys,NiTicanexist inmore thanone formorcrystal

structure.Themartensiteformexistsatlowertemperatures,andtheausteniteformexistsathigher

temperatures. For steel and almost all other metals, the phase change occurs at a transition

temperatureofhundredsofdegrees.Bothshapememoryandsuperelasticityare related tophase

transitionswithintheNiTialloy.

3.3.Bands

Rubberbands

are

extensively

used

in

orthognathic

surgery

to

transmit

force

from

the

upper

jawtothelowerjawviathedentition.Rubberhastheparticularlyvaluablequalityofagreatelastic

range, so that the extreme stretching producedwhen a patient opens themouthwhilewearing

rubberbandscanbetoleratedwithoutdestroyingtheappliance.Thegreatestproblemwithalltypes

ofrubber isthattheyabsorbwateranddeteriorateunder intraoralconditions.Theelasticsweuse

aremadeoflatexinsteadofgumrubber,withausefulperformancethatis4to6timesaslong.Latex

allergyforcesustoalsousenonlatexrubberbands,whichhaveconsiderablylessdurability(Fig.2).

Figure2.Latex(beige left)andnonlatex(whitish right)bandswithanapplicationtool(bottom).

Smallelastomeric ligaturemodules (e.g.,Sanitie,GAC)replacewire ligature tiestoholdarch

wiresinbracketsformanyapplications.Thesemodulesaremosteasilyappliedwitheitheratwirlon

instrumentormosquito(Fig.3AandB).

15


16/90

Figure3A.Elastomericmodulesandmosquito.

Figure 3B. A module can be mounted using a mosquito (displayed, most convenient for

surgeons)orwithatwirloninstrumentorshooter(notdisplayed).

Like rubber,however, theseelastomericmodules tend todeteriorateaftera relatively short

timeinthemouth.

REFERENCES

Kusy RP, Diley GJ, Whitley JQ. Mechanical properties of stainless steel orthodontic archwires. Clin

Materials3:4159,1988

Miura F, Mogi M, Ohura Y. The superelastic property of the Japanese NiTi alloy wire for use in

orthodontics.AmJOrthod90:110,1986

KusyRP.Thefutureofothodonticmaterials:thelongview.AmJOrthodDentofacOrthop113:9195,1998

Josell

SD,

Leiss

JB,

Ekow

ED.

Force

degradation

in

elastomeric

chains.

Sem

Orthod

3:189

197,

1997

16


17/90

4.Protectionfromprickaccidents

Infectioncontrol is indicatedforallpatients,regardlessofthepresenceof infectiousdisease.

Suchpractices

aim

to

avoid

direct

contact

of

health

care

personnel

with

organic

materials.

This

is

achievedusingaprotectivebarrier,suchasgloves,topreventskincontactwithblood,secretions,or

mucosa.

Glove perforationsmay occur during surgical procedures, even though they often are not

noticed during the procedure. The rate of perforations is directly related to the duration of the

surgicalprocedure,thetypeofprocedureperformed,andthequalityofthegloveused. Inmaxillo

facialsurgicalprocedures,the incidenceofgloveperforationappearstobemorecloselyassociated

withthetypeofsurgicalprocedurethanwiththedurationofsurgery.

During IMF procedures, especially with wire splinting, there is an increased risk of prick

accidents.Handling

of

sharp

instruments

like

wires

heightens

the

risk

of

glove

perforation

so

drastically that often, perforations can be foundwithin a fewminutes after the start of surgery.

Additionally,manyoftheseproceduresareperformedbysurgeonsintrainingwhosometimeshave

neverbeentaughthowtoperformanIMFproceduresafely.

Toavoidthiskindofaccident,somebasicrulesshouldbefollowed:

Wheneverpossible,trytoperformthe IMFprocedure inasurgicalsettingwith

anassistant.

Alwaysusedoublegloveprotection (e.g., IndicatorglovesMlnlycke) (Figs.4

and5).

Payattention

to

all

sharp

edges.

Once

you

have

already

twisted

the

wires,

cut

themoffandtwistthetipswithaninstrumenttoavoidinadvertentpricks.

Duringtheprocedure,keepthepliersandtwistersawayfromthewirestoavoid

prickingduringinstrumenthandling.

Changingglovesat regular intervals is recommendedaswellaswheneverany

evidenceofaccidentalperforationissuspectedornoticed.

Take your time!! At the beginning, these proceduresmay be challenging for

inexperiencedsurgeonsbeforesufficientdexterityisachieved.

Manyauthorsrecommendchangingglovesevery120minutes;others likeGaujacetal.(2007)

suggestglovechangingafterErichsplintplacementineachdentalarch.

The lownumberofperforations inthe innerglovesdemonstratestheeffectivenessofdouble

glovingprotectionwitheithertwosterilesurgicalglovesoranonsterilegloveunderasterilesurgical

glove.Theuseof clean,nonsterileproceduregloves forminimally invasive surgicalprocedures is

viableandfreeofrisksorcomplications.

17


18/90

Figure4.Doubleglovingtechniquewithsterilegreen gloves(Indicator,Mlnlycke).

Figure5.Apunctureholeisreadilyvisibleinawetenvironment.

TheCounciloftheEuropeanUnionadoptedadirectiveaimedatachievingthesafestpossible

workingenvironmentforhealthcareworkersthroughpreventionfromsharpinjuries.Theaimofthe

directiveistoprotectworkersatriskfrominjuriesduetomedicalsharps(includingneedlesticks).

The directive provides for an integrated approach to risk assessment, risk prevention, training,

information,awareness

raising

and

monitoring,

and

for

response

and

follow

up

procedures.

The

new

directivemakestheframeworkagreementbetweentheemployersandtradeunionsofthehospital

andhealthcaresectorslegal.

REFERENCES

GaujacC,CecchetiMM,YonezakiF,GarcaJr.IR,PeresP.Comparativeanalysisof2techniquesofdoublegloving

protectionduringarchbarplacementforintermaxillaryfixation.JOralMaxillofacSurg65:19221925,2007

Molinari JA.Gloves: Continuing effectiveness, new technologies, and recommendations. Compendium 21:186,

2000

GiglioJA,RolandRW,LaskinDM,etal.Theuseofsterileversusnonsterileglovesduringoutpatientexodontia.

QuintessenceInt

24:543,

1993

AveryCME,Taylor J, JohnsonPA.Doubleglovingand system for identifyinggloveperforations inmaxillofacial

traumasurgery.BrJOralMaxillofacSurg37:316,1999

BurkeFJT,BaggettFJ,LomaxAM.Assessmentofriskofglovepunctureduringoralsurgeryprocedures.OralSurg

OralMedOralPatholOralRadiolEndod82:18,1996

PattonLL,CampbellTL,EversSP.Prevalenceofgloveperforationsduringdoublegloving fordentalprocedures.

GenDent43:22,1995

18


19/90

BaggettFJ,BurkeFJT,WilsonNHF.Anassessmentoftheincidenceofpuncturesingloveswhenwornforroutine

operativeprocedures.BrDentJ174:412,1993

OtisLL,CottoneJA.Prevalenceofperforations indisposable latexglovesduringroutinedentaltreatment.JAm

DentAssoc118:321,1989

PieperSP,SchimmeleSR,JohnsonJA,etal.Aprospectivestudyoftheefficacyofvariousglovingtechniquesinthe

applicationofEricharchbars.JOralMaxillofacSurg53:1174,1995

19


20/90

5.Dentaltrauma

Theaimof splinting is the stabilisationof the injured tooth in itsnormalanatomicalposition

duringthehealingperiod.Therequirementsforanacceptablesplintarethefollowing:

Thematerialstofabricatethesplintshouldbepartoftheofficearmamentarium.

Additionalmanipulationoftheinjuredtoothshouldbeminimal.

Thetoothshouldremaininitsnormalpositionthroughouttheimmobilizationperiod.

Affectingthegingivaltissueandinterferencewiththeocclusionshouldbeavoided.

Easyaccessshouldbeprovidedforendodontictreatment.

Teethshouldbepulptested.

Oralhygieneshouldbemaintained.

Removalshould

be

easy.

Thesplintsthatcomeclosesttofulfillingtheaboverequirementsaretheacidetchedresinarch

wire splints and theorthodonticbracket archwire splints.These,of course, aredifficult to apply

whenbloodandsalivacannotbeisolatedfromthefield,suchasinanemergencyroom.

Arigidsplint increasestheamountofexternalresorptionandeventualearly lossofthetooth.

Forthisreason,archbarsandotherformsofinterdentalwiringarelessthanoptimal.

Anacidetchresinsplint iseasytofabricatebutdoesnotallowmuchtoothmobility.Abetter

splintwould

be

an

acid

etch

resin

arch

wire

splint.

A splint should be left on the tooth for aminimal amount of time. Prolonged splintingwill

increase the amountof ankylosis.Theoptimal splintingperiod foradisplacedoravulsed tooth is

empiricallybased. Ideally,thesplintshouldbemaintainedfor710daysbecausethegingivalfibers

usuallyhealafter1week,andthistimeshouldprovideadequateperiodontalsupport.

Alveolarbonefractureswithreplantedteethmayrequireasplintfor34weeks, luxationmay

requireasplintfor28weeks,androotfracturesrequireasplintfor12weeks.

5.1.Acid

-etch

resin

arch

wire

splint

Armamentarium

Stainlesssteelwireloop,0.4mmindiameter

Lightcuringresin(KetacNanoorTransbond,3MESPE)

Bondingagent(AdperSingleBondDentalAdhesive,3MESPE)

Orthophosphoricacid(TransbondXTEtchingGelSystem,3MESPE)

Toothpicks

Thewire isconformed tothe facialsurfacesoftheteethtobe splinted (Fig.6). At leastone

toothoneithersideofthedisplaced toothorteethmustbe included.Toothpicks,whenavailable,

help to keep the labial part of thewire in themidportion of the crown and, at the same time,

20


21/90

decreasepapillarybleeding (Fig.7). It is important toensure that thedental toothpicks keep the

injuredtoothinaneutralpositionanddonotdisplacetheloosenedteeth.

Figure6.Atwisted0.014Kobayashitiehookof0.4mmRemaniumsoftwireservesasthebasisfortheresin

wiresplint.

Figure7.Toothpickshelptokeepthewireinthemidportionofthecrown.

Thefacialsurfacesofalltheteethtobesplintedareetchedwithphosphoricacidfor1minute,

afterwhichtheyarewashedanddried.Thebondingagentisapplied,andasmallamountofresinis

placedinthemiddleofthefacialsurface.Aflowing,lightcuredcompositeisappliedwithasyringe.

The composite is applied first on noninjured teeth. The injured tooth is supported by finger

pressure, and the twistedwire is repositioned, adding extra composite where required (Fig. 8).

Flexibilityofthesplintisachievedbyleavingsomefreewireinterdentally.Thesurgeonmustbesure

thatthedisplacedtoothisinthecorrectposition.Aradiographshouldbetakentoverifytheposition

afterthesplintisinplace.

21


22/90

Figure8.Acidetchwireresinsplint

The resinmaterial shouldnotcontact thegingivabecause itwillcausegingival inflammation.

Thepatient shouldbe instructed inproperoralhygiene, stressing the importanceof keeping the

gingivalcreviceaswellastherestoftheteethclean.Whenthesplintisremoved,thewirecanbecut

betweenthe

teeth;

however,

the

resin

should

be

kept

in

place

because

the

replanted

teeth

will

still

belooseandcanbedisplaced.After23monthswhentheteetharefirmlyattached,theresincanbe

removed.

5.2.Orthodonticbracketarchwiresplint

The useof anorthodonticbracket archwire splint is an excellent technique.Acidetched

bracketsareplacedonthedisplacedtoothorteethaswellasonatleastonesoundtoothoneither

side

of

the

displaced

tooth.

Sometimes,

it

is

necessary

to

extend

this

type

of

splint

by

banding

the

permanent firstmolars.Thisextensionmayoccur in themixeddentitionwhenpermanent lateral

incisors,canines,and/orpremolarsareabsentorthere isadeepoverbiteandadditionalteethare

necessaryforstabilisation.Thearchwirecanbeeitherroundorrectangularandisbenttoconform

to the facial surfacesof the teeth tobe splinted. Ligaturesareused tohold the archwire in the

brackets.Theadvantageof this typeof splintover the acidetch resinarchwire splint is that the

practitioner can remove theelastic ligatures and thewire to assess themobilityof thedisplaced

teeth.Ifthereisexcessivemobility,thesplintcanbereplaced.

Itshouldbenotedthatafairlyhighpercentageofteethinvolvedinalveolarprocessfractures

undergopulpalnecrosisaswellaseither internalorexternalresorption.Thismayoccurevenyears

later.Theteethmustbecarefullyobservedandendodonticinterventioninitiatedattheappropriate

time.

REFERENCES

FelicianoKMPC,deFrancaCaldas JrA.Asystematic reviewof thediagnosticclassificationsof traumaticdental

injuries.DentTraumatol22:7176,2006

Gassner R, Bsch R, Tuli T, Rdiger E. Prevalence of dental trauma in 6000 patients with facial injuries:

Implicationsforprevention.OralSurgOralMedOralPathol87:2733,1999

KasteLM,GiftHC,BhatM,SwangoPA.Prevalenceofincisortraumainpersons6to50yearsofage:UnitedStates,

19881991.JDentRes75:696705,1996

AndreasenJO.

Textbook

and

color

atlas

of

traumatic

injuries

to

the

teeth.

Copenhagen:

Munksgaard;

1994

Fried I,EricksonP.Anteriortoothtrauma intheprimarydentition: incidence,classification,treatmentmethods

andsequelae:areviewoftheliterature.ASDCJDentChild62:256261,1995

GutmanJL,GutmanMSE.Cause,incidence,andpreventionoftraumatoteeth.DentClinNorthAm39:113,1995

OikarinenKS.Clinicalmanagementofinjuriestothemaxilla,mandible,andalveolus.DentClinNorthAm39:113

131,1995

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23/90

KrasnerP,RankowHJ.Newphilosophyforthetreatmentofavulsedteeth.OralSurgOralMedOralPathol79:616

626,1995

ProtocoloftheInternationalDentalTraumaAssociation2007

23


24/90

6.IMFtechniques

Thefirstandmostimportantaspectofsurgicalcorrectionofmandibularfracturesistoreduce

thefractureproperly.Inthetoothbearingbones,itisofoutermostimportancetoplacetheteethin

apreinjury,occlusal relationship.Merelyaligning thebone fragmentsat the fracture sitewithout

firstestablishingaproperocclusalrelationshiprarelyresults insatisfactorypostoperativefunctional

occlusion.

With interdental fractures, fracturemodelsare important: impressionspoured inSnowWhite

plaster and sectioned at the fracture site allow the assessment of pretrauma occlusion.Missing

teeth,preexistingclassIIorIII,anddeepbitedeformitiesmayotherwisemisguidethesurgeon.

Toestablishaproperocclusal relationship,severaltechniqueshavebeendescribed,generally

referredtoasIMF.Themostcommontechniqueincludestheuseofaprefabricatedarchbarthatis

adaptedandcircumdentallywiredtotheteethoracidetchbondedtoeacharch;themaxillaryarch

bariswiredtothemandibulararchbar,therebyplacingtheteethintheirproperrelationship.Other

wiringtechniques,suchas Ivy loopsorObwegesercontinuous loopwiring,havealsobeenusedfor

thesamepurpose.

6.1.Ligaturewiring

Inmobilisation of fracturedjaw fragments and fixation in the correct dental relationship by

means of dental intermaxillarywiringwas first advocated in the USA by Gilmer in 1887. IMF or

maxillomandibular fixation consists of wiring the mandibular teeth to those of the maxilla in

adequateocclusalrelationships:thejawisimmobilisedinafixed,mouthclosedposition.

Forgeneralconsiderations, if immobilisationofthejaws isrequiredforashortperiodoftime,

relatively simple wiring methods are used. Such cases are normally performed under local

anaesthesiawithorwithoutsedation.Withanuncooperativepatientoramoredifficultfracturethat

requires immobilisation for several weeks, general anaesthesia and endotracheal intubation are

recommended.

Allproceduresshouldbeginbycleansingtheoralcavitywithasuitableantisepticsolutionsuch

as aqueous chlorhexidine. Good illumination, efficient suction, and soft tissue retraction are

necessary.Under general anaesthesia, a throat pack and cuffed endotracheal tube are essential.

Evenwith skilledassistance,acomplex IMFwiringprocedure, like fulleyeletwiringand IMF,may

take1hourorlonger.

Oneshouldacquirethehabitofalwaystwistingthewiresinasingledirection,usually

clockwise,toavoidconfusion.Thishabitalsoavoidsbreakage,whichmayoccurwhen

thewiresaretwistedfirstinonedirectionandthenintheother.

Itisusefultostretchthewire,sothatitwillhavenobendsoreasilyslipthroughthe

interdentalspaces.

Itisnecessarytogivethewiresafewadditionalturnsfortighteningpurposes.

24


25/90

Before tightening the IMFwires, ALWAYS REMOVE THE THROAT PACK OR ANY CLOTS OR

FOREIGNBODIES!

6.1.1.Gilmerwiring

Thistechniqueprovidesasimpleandrapidmethodtoimmobilisethejaws.However,thewires

tendtoloosen,andabroken,directwirecannotbereplacedwithoutfirstremovingandreplacingall

oftheotherwires.A15cmlengthofprestreched,0.4mmsoftstainlesssteelwireispassedaround

thenecksofalloftheavailableteeth,andtheendsofthewirearetwisted inaclockwisedirection

untilthewireistightlybound,leavinga3cmtail(Fig.9).

Figure9.Gilmerwirestwisted.

Anappropriatenumberofwiresisthusplacedaroundtheselectedteethinboththeupperand

lowerjaw.

Theteetharebroughtintoanadequateocclusalrelationship.IMFisachievedafterreductionof

the fracturebytwistingtheseparatewiretailstogether,obtainingcrossbracingwhereverpossible

(Fig.10).

Figure10.IMFwithGilmerwires.

Thecutendsshouldbebentintotheinterdentalspacestoavoidsofttissuetrauma.Sometimes,

thisisnotfeasible,andthenitisrecommendedtocoverthewiretwistswithorthodonticwax(Utility

waxstrips,Heraeus Kulzer).

The inconvenienceof thismethod is that thejawsmustbeconstantly immobilisedduring the

period of treatment and the mouth cannot be opened for either inspection or hygiene. This

25


26/90

procedure shouldonlybe considered toachieve temporary inmobilisationof fractured fragments.

Whenappliedtoolong,gravityandspeechwillinduceextrusionofteeth.

6.1.2.Kazanjianbutton

Thismethod isparticularlyusefulfor immobilisationby intermaxillaryorthodontictyperubber

bands,butshouldonlybeconsideredatemporarymethod.

Armamentarium

0.4mmstainlesssteelwire,stretched10%toa15cmlength

Wirecuttersandwiringforceps

Luniatschek1

Cheekandtongueretractors

Good

illumination

and

suction

device

Rubberbands

Usually,twoteethareutilisedtosupportthebutton.Awireispassedaroundtheneckofeachtooth

andtwistedtogether(Fig.11).

Figure11.WiresarepreparedtotwistintoaKazanjianbutton.

Thetwotwistedwiresarethenretwistedandcutapproximately2.5cmfromtheteeth(Fig.12).The

remainingendsofthewirearethenshapedintoasmallbutton(Fig.13).

26

1Luniatschek: Gauze packer; receives its name from a German dentist. It is very useful to

handle the wires as their tips terminate in double spikes that guide the wire.


27/90

Figure12.WirestwistedtoformtheKazanjianbutton.

Figure13.ElasticbandIMFonKazanjianbuttons.

Premolarteeth,orapremolarandamolar,formsubstantialanchorsforthebutton.Ifanterior

teethareselected,0.3mmstainlesssteelwireshouldbeused.Theupperand loweranteriorteeth

should be wired in pairs for additional strength, as described for intermaxillary wiring. All four

mandibularincisorsshouldbejoined.

6.1.3.Eyelet

technique

Provided that teethof a suitablenumber, shape, andquality arepresenton each fragment,

eyelet wiring (Eby, 1920; Ivy, 1922) is a simple and effective method for the reduction and

immobilisationofjaw fractures.Eyeletwiresmay alsobeused in combinationwithGunningtype

splintsinanopposingedentulousjaw,andarchbarsorcapsplintscanbeusedinapartiallydentate

jaw.RobertIvydescribedthewirepassingthroughtheloopoftheeyelet.

Thistechniquehastheadvantagethatfixationmaybereleasedbyremovaloftheintermaxillary

ligatures.

27


28/90

Armamentarium

10 and preferably 20 prepacked autoclaved eyeletwires of 0.4mm

stainlesssteelwire,stretched10%toa5cmlength

Bundle of 20 tie wires, 0.5mm diameter and 15cm long, of

prestretched,softstainlesssteelwire

Wirecutters

and

wiring

forceps

Luniatschek


Goodilluminationandsuctiondevice

Eyeletwires are usually constructed from 0.4mm diameter soft stainless steelwire,which

should be stretched by 10% of the original length so as to prevent loosening of thewires after

insertion.Overstretchinghardensthewire,whichthenbecomesbrittle.

Suitable lengths of the wire, for example, 1 meter, are cut and, with each end held by

hemostats,thewireisstretchedby10%orbyanadditional10cm.Itisthenfurtherdividedinto15

cmlengths.

Eyeletwiresaremadebytwistingthemiddleofeachlengthofwirearoundtheshaftofa3mm

diameterrod,whichisheldinavice(Fig.14).Threeorfourtwistssuffice,andtheendsoftheeyelet

wirearecutoffobliquelytoequalisetheirlengthsandproduceasharppoint,whichwillreadilypass

throughthe interdentalspace.Quantitiesofeyeletwiresarecollected inbundlesofapproximately

14bypassingasafetypinorprefabricatedwire loopthrougheacheyelet.Theseshouldbepacked

andautoclavedtobereadyforimmediateuse.

Figure14.Preparingeyelets.

Forgeneralconsideration, if immobilisationofthejaws is required forashorttime, relatively

feweyeletsarenecessary,forexample,oneortwoineachquadrant.

Thewireshaftsarefirstcurvedandthengrippedbyamodifiedhemostatorspecialclipatthe

midpoint of the curve so that they can be readily passed through the interdental spacewithout

engaging,ifpossible,theinterdentalpapillaeorthelingualorpalataltissues.

After selecting the teeth tobewired,bothendsof theeyeletwire are inserted through the

interdentalspacefromtheoutersurfacesoftheteeth(Fig.15A,15B).Asthewiresemergeonthe

lingual or palatal side, they are gripped by a second pair of forceps that ismanipulated by an

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assistantwho, afterbending them, passes thewiresback through the adjacentmesial anddistal

interdentalspaces.Theoperatorgripseachwireasitemergesfromthespaceandpullsitthrough.

A

1

B

Figure15Aand15B.IvyorEbyeyeletinsertedintotheinterdentalspace.

C D

Figure15C.Wirepassingthroughtheloopallowsforlesstighteningthanpassingbehindtheeyelet(Figure

15D).

Oneendisdrawnaroundthemedialtooth,andtheotherendisdrawnaroundthedistaltooth;

thedistalwireisinsertedthroughthe loopoftheeyelet(Fig.15C),andbothwireshaftsarepulled

tight inunison and then twisted tightly together as the assistantmaintains the lingualorpalatal

portionbelowthemaximumdiameterofthetwoteethwithasuitableinstrument(e.g.,Luniatschek)

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Alternatively,thewirecanbepassedbehindtheloopprovidingagreaterfixationfortheeyelet.(Fig.

15D).Intheupperjaw,theeyeletsshouldprojectabove,andinthelowerjaw,belowthehorizontal

twist;thispreventstheendsfromaffectingeachother(Figure16).

Figure16.Whenenougheyeletsaresetinplaceintermaxillaryfixationisaccomplishedbythreadingwire

ligaturesthroughtheeyelets.

Theendsofthewirearecutandbentintointerdentalspacestopreventirritationofthelipor

cheek,providednofurtherwiresaretobepassedthrough.Anumberofteethoneachsideofthe

jawarepreparedinthismanner.

Vertical, anteroposterior, and lateralmovements of thejaw must be controlled during the

periodof immobilisation. Forexample,with a full complementof teeth anddependingupon the

fracturesite,eyeletsmaybeinsertedbetweenthefirstandseconduppermolars,thepremolars,the

lateralincisor,andthecanineandcentralincisors;inthelowerjaw,eyeletsmaybeinsertedbetween

thecentralandlateralincisors,thepremolarteeth,andthefirstandsecondmolars.

The lower incisors do not have an ideal shape for eyeletwire retention and are frequently

overcrowded,making insertionofthewiresmoredifficult. Insuchcases,thewiringpatterncanbe

modified toavoidusing the lower incisor teeth.Patientswithadevelopmentalanterioropenbite

mayhaveexcessive traction applied to the lower anterior teeth,which canbe avulsed.Acquired

anterioropen

bites,

resulting

from

fracture/dislocation

of

the

mandibular

condyles,

should

not

cause

thisproblem,providedthatthepatientissufficientlyrelaxed.

When some teeth aremissingbutnotenough to require an archbar,or the fracture site is

unsuitable,awirecanbeattachedtoanisolatedtoothbyformingaclovehitchand,aftertightening

thewire loop,passingoneendof thewire through aneyelet in theopposingjawand twisting it

togetherwiththeotherend.

Clovehitch(Fig.17AC)

Althoughthe

use

of

asimple

clove

hitch

around

asingle

isolated

tooth

is

simple

and

rapid, ithas thedisadvantage that,shouldtheendof thewirethat isusedasa tie

wirebreak,thewholewiremustbereplaced.

Afterplacingtheclovehitchovertheisolatedtooth,theloopsaretightened,andthe

wire is pushed beneath the neck of the tooth and the ends then twisted in a

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clockwisedirection(FIG.17AB).Whenusingasimpleclovehitch,thelongershaftis

insertedthroughtheopposingtheeyelet,achievingbythiswaytheIMF.

Figure17A.Clovehitch. Figure17B.Clovewiretightened

Figure17C.ClovehitcheyeletIMF

Wheneverpossibleitisbettertouseaneyeletwireandseparatetiewires.Oneshaft

ofthewireisformedintoaclovehitchasshown(Fig17D,17E).

Atiewireispassedthroughtheeyelet,securedtothelowerfreestandingtooth,and

connectedtoaneyeletaroundanuppermesialoranteriorpairofteeth.Finally,the

crossedendsofthewireligaturesarethencutshortandtuckedintotheirrespective

upperinterdentalspaces(Fig17F).

D E

Figure17D.

Clove

hitch

with

eyelet.

Figure

17E.

Clove

hitch

with

eyelet

tightened.

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F

Figure17F.IMFwithawireligaturepassedthrougheyelets.

Afterinsertion,theeyeletandtiewiresmayloosenasaresultofminortoothmovementand/or

wirestretching,leadingtojawmobility.ThearrangementofthetiewiresinaVpatternminimises

thistendency.

Theopposingeyeletsareconnectedbypassingathirdwirethroughthemandtwistingthewire

todrawtheteethandjawstogetherorattachingorthodontictyperubberbands(Fig.18A,18B).A

0.5mmwireisused,oneendheldinaforcepsorarteryclipwhiletheotherendisbentintoasmall

hookordoubleangle that ispassed through theeyelet so that itcanbegrippedand thenpulled

throughbytheassistant.

Figure18A.IMFoneyelets.

Figure18B.

The

wire

ligature

fixing

apair

of

eyelets

is

shown

in

greater

detail.

Obviously,

atie

wireintriangularformationwoulddobetter.

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Beforetighteningthewires,itisessentialtoreducethefractures.Onceaproperocclusionhas

been achieved, theposterior teeth should be tightened to avoid excessive tractionon the lower

anteriorteeth.

Throughouttheperiodofjaw immobilisationcopiousoral lavage isrequired,particularlyafter

eachmeal.Toremovetheeyeletsaftertheimmobilisationperiod,itisadvisabletoremovefirstthe

tiewirestoenablea limitedamountofjawopeningto facilitatetheirremoval.Onemay leavethe

eyeletsevenforaweektocontrolbonyunionbycheckingtheocclusion.Afterwards,eyeletwiresare

removedafterlooseningthewirebytwistinginacounterclockwiserotationsothatthebuccalwire

canbecut.

6.1.4.Intermaxillaryloopwiring(Stout)

Thismethod(Stout,1942)requiresthepresenceofatleastthreeadjacentteeth.Thewiresform

anumberof loops along thebuccal sideof the alveolarprocess,which is especiallyusefulwhen

elasticbandsareusedfortraction.

Armamentarium

30cm lengthofsoft,0.5mmstainlesssteelwire,stretched10%toa15cmlength


Luniatschek



Thewireispassedthroughtheinterdentalspacebetweenthesecondandthirdmolars.

Figure19.Stoutwiring,wirepassingthroughtheinterdentalspacebetweenthesecondandthirdmolar.

Thebuccalportionofthewire isplacedagainst thegingivalmarginsoftheteethselected for

wiring,andasoftmetalbarorrod,about3mmindiameterand5cminlength,ispassedthroughthe

wire

loop

and

laid

along

the

buccal

surface

of

the

segment

parallel

to

the

buccal

wire

(Fig.

19A,

19B).

Thelingualportionofthewireispassedthrougheachinterdentalspaceinturn,formingaloopover

thebarandbuccalportionofthewire,andthen isreturned linguallythroughthesame interdental

space.

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Whentherequirednumberofteethhasbeenwired,theendsofthebuccalandlingualportions

of the wire are twisted together in either the bicuspid or cuspid region. The arch bar is then

removed, leavingaseriesof loopsonthebuccalside.Each loop istwistedtwice,firsttheposterior

andtheneachsucceedingloop,whicharethenbenttoformahook.Ifatoothismissing,thebuccal

andlingualarmsofthewirearetwistedtobridgethespace,andtheloopprocessiscontinued.

Figure20.ElasticbandsorwireIMFonStoutligatures.

Each loop is thentightened inturn,closelyadaptingthebuccalwire intothe interdental

spacesuntil rigid.Theseare finallybenttowards thesulcus ifelastictraction is tobeusedor

towardstheocclusalsurfaceofthetoothiftiewiresareintended(Fig.20).

6.1.5.Cablearchwire(Fig.21)

Astrandoffinegaugestainlesssteelwire(0.4mm) ispassedaroundtheneckofamolarand

twistedtightly(Fig.21A).Theendsareleftlongsincethewireactsasapivotforthefollowingwires

andmustextendtotheoppositemolar.Wires(0.30.4mm)arethensimilarlyanchoredtotheother

teeth(Fig.21B),andeachissuccessivelytwistedaboutthepivotwireforfourorfiveturns(Fig.21C).

Thisprocedureiscontinueduntilamolarontheoppositesideisreached(Fig.21D)

A B

Figure21A.Archwiretightedaroundthelastmolar Figure21B.Wireligaturesanchoredtotheteeth.

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C D

Figure21C.Cablearchwirebeingtightened. Figure21D.Cablearchwirecompleted.

6.1.6.Multiple

loop

wiring

(Obwegeser

method)

Armamentarium

0.5mmstainlesssteelwire,stretched10%toa30cmlength

Obwegessertemplate(MediconUSA:68.04.92)

Wirecuttersandwiringforceps(MediconUSA:68.04.90)

Silkligaturemaybeuseful

Luniastchek

Obwegeserwireloopclip(Stryker)

Cheek

and

tongue

retractors


A 30cm long, soft stainless steelwire, 0.5mm diameter, is bent to form an arcade,which

conformstothelingualorpalatalaspectsoftheselectedblockofteeth(Fig.22).Thedistalendisleft

longsothatitcanbepassedbetweenthelasttwomolars.Atemplatemaybeusefulforthebeginner

(Fig.23).

Figure22.Multipleloopsinsizesmatchingthecervices.

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Figure23.TemplateforObwegeserligature.

Pliersareappliedatthepointwherethewirebendsbacktofollowthecontouroftheadjacent

tooth, thus pinching the two portions tightly together. The projecting sections of the attached

ligaturesaregivenhalfaturntoalignthemvertically.

After

the

posterior

end

of

the

wire

has

been

passed

between

the

last

two

molar

teeth

and

broughtforwardanteriorlyonthebuccalaspect,thepreformedwireisinsertedintothemouth,and

thepinchedloopsaregentlypassedwithacurvedhemostatthroughtheinterdentalspaces(Fig.24A

andB)).

A B

Figure24A

and

B.

Loops

pinched,

turned

vertically,

and

passed

with

ahemostat

through

the

interdentalspaces.

Thelongendofthewireispassedthroughalloftheloops(Fig.24C).Bothendsofthewireare

twistedtogetheranteriorly.AspecialObwegeserwireloopforceps(Fig.24D)twistseachlooptightly

tothebuccalwire,thusadapting itclosetothe interdentalspace.The loopsarethenbenttoward

theocclusalsurfacesforthetiewires,orthegingivaforelastictractionasrequired(Fig.24E).

C D E

Figure24C. Thebuccalwireispassedtroughtheloops,fromposteriortoanterior.

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Figure 24D. A special wire twister is used to twist the loops into eyelets. Eyelet length is

controlledbyadjustingtheanteriortwistinbetweentwoeyelettwists.

Figure24E. Finaltighteningshouldbedonegently,aswirefractureforcesonetorepeatthe

wholeprocedure.

Usually,sixsegmentsarewired:caninetosecondmolaroneachside,caninetocanine inthe

front.Ittakessomeexperiencetobendthesegmentalwirestofitthedifferenttoothdiameterssuch

thattheeyelet isnottoo longandbecomesuselessfor intermaxillary ligaturewiring.Atemplate is

useful in this respect. The Obwegeser wire loop forceps is mandatory to tighten the wire and

maintaintheloopsatanappropriatesize.

6.1.7.Leonardsbuttonwiring(Fig.25)

Leonard(1977)consideredthateyeletwireshaveseveraldrawbacks:

Asimpleeyeletisfrequentlydrawnintotheinterdentalspace,makingitdifficult

touse.

Elastictractionusingeyelets,thoughpossible,istimeconsumingtoapply.

Leonarddescribedtheuseoftitaniumbuttonsof8mmdiameter,inclusiveofa1mmrim,and

2mmdeep.Eachbuttonhadtwo1mmdiameterholes,1mmapart.Theendsof15cm lengthsof

0.4mmwirearepassedthroughtheholesandthentwistedtwicetogetheronthedeepsurface.The

buttonisthenligatedtotheteethinasimilarmannertotheeyeletwires,leavingthebuttonoverthe

interdentalspace,andthedistalwire isbroughtforwardandpassedthroughthetwistonthedeep

aspect

of

the

button.

IMF

is

easily

achieved

using

stainless

steel

tie

wires

or

elastic

bands

fixed

aroundoppositebuttonsinanunusualpattern.

This technique is not amenable for patients with a severe posterior crossbite or marked

anterioroverbite,wherethereisalackofspaceforthebuttons.

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Figure25.Leonardsbutton.

6.1.8.Bandedretentionappliance

The methods of fixation described previously are readily available and applicable without

special dental or prosthodontic facilities.More precise types of appliancesmay be custommade

from impressions of the teeth. With careful and gentle techniques, and with the help of local

anesthesia, dental impressionsmay be taken ofjaw fractureswithout causing thepatient undue

discomfort.Bandsare supplied from the laboratorywithhooks soldered to thebuccal surface for

intermaxillarywiring; these canbeutilised toanchorarchbars.Suchappliancesmayalsoprovide

attachments

for

auxiliary

soft

tissue

support.

Oneofthemostusefultypesisthebandedretentionappliance(Fig.26A),apracticalapplication

oftheedgewisewireapplianceemployedbyorthodontists.Itconsistsofmetalbandsfittedaround

selected teeth and connectedwithwire. This type of appliance not only assures fixation of the

fragmentsbutalsopermitslowerjawfunction.Additionaladvantagesofthesedevicesarethatthey

are less bulky andmore hygienic than other appliances, andminimise possible injury to gingival

tissues.Suchadefinitivetypeofappliancecanbeconstructedrapidly.

Anotherpossibilityistheadjustablebandedarchbarforfixationofmandibularfractures.Inthis

case awireissolderedtobandtoserveasanarchbar.Then,teethareattachedtobarwithsimple

ligatures(Fig.

26B).

These

splints

can

be

prefabricated

and

held

in

readiness

for

use.

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Figure26A.Orthodontictypebandsarefittedto2adjacentteeth.Bandsareweldedtogetherbysolderandthehorizontaltubeisalsosolderedtobuccalsurfaceofbands.

Figure 26B. The adjustable banded arch bar retention device:An arch bar connected to orthodontic bands.

Teethareattachedtobarwithsimpleligatures.

6.2.Archbartechniques

Anothermethod,whichprovidesmonomaxillaryaswellasIMF,isthearchbartechnique.There

are

basically

two

varieties

of

arch

bars,

those

that

are

commercially

produced

and

those

that

are

custommade.

Generalindications:

Wheninsufficientteethremaintoallowefficienteyeletwiring.

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When the teeth present are so distributed that efficient IMF is otherwiseimpossible.

Whentherearesimpledentoalveolarfracturesorwheremultipletoothbearingfragments in either jaw require reduction into an arch form, before IMF is

applied.

Asan

integral

part

of

internal

skeletal

suspension

in

the

treatment

of

fractures

involvingthemiddlethirdofthefacialskeleton.

Toreducethepreoperativetimethatwouldotherwiseberequiredforcapsplint

preparation.

Theadvantageofcustommadearchbarsisthattheyarefashionedonfracturemodelsand

thereforecontributetothereductionaswellasstabilisationofthefractureatthelevelofthedental

crowns. They can be rapidly provided by an experienced technician and will not delay fracture

treatment.

HalfroundRemanium laboratorystainlesssteelcoils(1500N/mm2,Dentaurum)areshaped

aroundthedentalcervices.Remaniumballretainerclaspsofsimilarrigidityarepointsolderedtothe

mainarchbar.Thesolderpointisstrengthenedbywhiteyellowuniversalsolder.Thearchbaristhen

polished.

Preoperativeimpressionsoftheteetharetakensothatamaxillofacialtechniciancanassess

themodels todetermine the correctarticulationof the teeth.However,preoperative impressions

may be both painful and difficult, and separate impressions of each fracture segment may be

required. Disposable trays and reduced peripheral flanges, particularly on the lingual side, will

facilitatethisprocedure.

Custommadesplintssaveconsiderableoperativetimeanddifficulty.Alternatively, ifsucha

splintisnotavailable,varioustypesofcommerciallypreparedarchbarscanbeeasilyadaptedbythe

surgeonatthecostofprolongingtheoperationtime.ThetechniquetofixatetheGroningensplintis

similartothatdescribedfortheEricharchbar.

6.2.1.Groningen-typecustom-madearchbar

This arch bar is useful when extra rigidity is required, for example, in case of segmental

osteotomies.

Technique

Step1.Trimthemodelstoallowaccesstothecervicalareasandsmooththebuccalsulcus(Fig.27).

Drawthecervicalcontourswithathickpencil.Endpointsaresituatedatthelasttoothinthearch.

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Figure27

Step2.AdaptthemainarchbarwithWaldsachpliers.Thearchbarmustliepassivelyonthemodel.

(Fig.

28).

Figure28.Passivecontactofthearchbarandthecervices.

Step3.Distributeapproximatelyeighthooksof3to4mmbehindthecanineteeth,awayfromthe

interdentalspaces(Fig.29).

Figure29.Markingofthehookattheleveloftheinterdentalspaces.

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Step4.Withacarborandumdisc,makegroovesinthearchbarwherethehookwillbepointwelded

(Fig.30).Thehookmaynottouchthesulcus.

Figure30.Preparingtheweldingofthehooksbyrougheningthearchbar.

Withafine

flame,

fill

the

voids

between

the

arch

bar

and

the

hooks

by

welding

(Fig.

31).

Figure31.Weldingthehooks.

Step 5. Finish with the carborandum disk, with sandblasting (50 m), and again with red

carborandumstones(Fig.32).

Figure32.Polishingthearchbar.

Step6.Finishwithchromecobaltrubbersandpolishwithpumiceusinghighpolish formetal (Fig.

33).

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Figure33.Highlypolishedarchbar.

Armamentarium

Pointweldingdevice(Dentaurum)

Propane/compressedair

Waldsachpliers(Dentaurum)

Dentaurumwire:Remaniumhart2.40mm1.40mm/9455 (10

m)order#:38562400

PDuniversalsolderWhiteProduitsDentairesCH1800VeveySuisse

(630

680)

6.2.2.Ericharchbar

Prefabricatedarchbarsareavailablecommercially,themostpopularofwhichistheEricharch

bar.Thesearchbarsaremadeofarelativelysoftmetal,whichcanbemoldedandadaptedtothe

dentalarch.

Armamentarium(Fig.34A)

ErichArchBar(e.g.,HuFriedy codeWPAB,Stryker)

0.5 and0.4mmstainlesssteelwire,stretched10%toa15cmlength


Luniatchek



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Figure34A.BasicIMFarmamentarium

.

Eachbarhashooklikeprojections,whichareplaced inanupwarddirection in theupperjaw

andinadownwarddirectioninthelowerjaw(Fig.34B).

Figure34B.Erichbarfixedtotheupperdentition.

Technique

Ifsufficientteethareavailable, it isadvisabletoplaceandsecurethewiresawayfromthe

fracturesitetoavoidunexpectedsubluxationoftheteethadjacenttothefracturesite.Inaddition,

providingthereisadequatefixationofthearchbarintheposteriorsegments,itisrecommendedto

leavetheinferiorincisorsunattachedtothearchbartoavoidtheirextrusion.

The arch bar is initially cut to a suitable length and afterwards is bent to adapt to the

curvatureoftheteeth.Onehalfofthearchismeasuredwiththeendoftheloop,andthentwicethe

distanceiscutoff.

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The arch bar is fixed by passing 0.4mm (although some surgeons prefer 0.5mmwires,

especiallyfortheposteriorsegments)stainlesssteelwireligaturesaroundtheneckofeachavailable

tooth(keepthewiresbelowthegreatercircumferenceoftheteethbypressingthewireapicallywith

the aidof an assistantholding an instrument like the Luniatschekwhile tightening thewire).The

wiresaretwistedtightlytoanchorthebartothedentalarch.

Thereareseveralmethodstoperformthisprocedure:

Passing the wire around the lingual or palatal aspect of the tooth and

tighteningitoverthebar(Fig.34B).

Passingthewirecircumferentiallyaroundtheentiretoothbeforetighteningit

overthebar(Fig.35A,35B).

Bothendsof thewire looparepassedaround the tooth (Fig.35C);oneend

passes over the bar and is inserted through the loopwhile the other end

passesunder thebarand remains freeof the loop(Fig.35D,35E).The two

endsare

pulled

to

tighten

the

loop,

and

the

wires

are

then

twisted

over

the

bar(Fig.35F).

Bothendsofthewireloopmaybepassedeitheraboveorbelowthearchbar

and through a single interdental space (Fig.36A). The ends are then pulled

separatelyaroundtheteeth,lyingimmediatelymesiallyanddistally,oneover

and one under the bar, before being tightened (Fig. 36B). This method

distributestheloadovertwoteeth(Fig.36C).

Eachslightlymorecomplexmethodgivesanincreasingrigidityoffixation.

Figure34B.Wirepassedaroundthetooth,twisteddirectlyoverthebar.

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Figure35A.Wiretwistedcircumferentiallyaroundthetooth. Figure35B.WiretightenedovertheErichbar.

Figure35C.Bothendsofthewirearepassedaroundthetooth. Figure35D.Thebarispassedthroughthefirstloop.

Figure35D.Oneendpassesoverthebarandisinserted Figure35E.Thewireistightenedoverthebar.

throughtheloopwhiletheotherendpassesunderthebar.

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Figure36A.Bothendsofthelooppassedabovethebar. Figure36B.Wireendspulledmesiallyanddistallyoverthebar.

Figure36C.Wirestightenedoverthebaracrossseveralteeth.

IMF isobtainedbyplacingorthodonticelasticbandsorwiresbetweenthehooksoftheupper

andlowerarches.Thetiewiresarefirstpulled,tightened,andthencutsothattheendscanbebent

overthebar intoan interdentalspacetoavoidsofttissue injury.Releaseofthe IMF isobtainedby

removingtheintermaxillaryelasticbandsorwires(Fig.36D).

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Figure36D.IMFwithelasticbandsattachedtoanupperandlowerErichsplint.

Arch bars have the advantage that, after a reasonable period of total immobilization, the

mandiblecanbereleased,providedthatthefracturelinelieswithintheareaoftheteethfixedtothe

archbarandthefixationremainsrigid.Thearchbarisleftinsituforanormalperiodoftime.

Oralirrigationaswellaschlorhexidinerinsesandgelformulationappliedtothegingivaareused

tomaintaintheperiodontum.

Archbarsmayalsobeused for the fixationofsubluxated teeth,once these teethhavebeen

repositioned, with a similar technique to that described above. In these cases, it should be

consideredasecondoptionincaseawireresinsplintisnotfeasible.

6.2.3.Schuchardtswire,acrylicarchbar

Schuchardt(1956)andSchuchardt&Metz(1966)firstdescribedthisconcept.Theydesignedan

archbarconstructedfrom2mmdiameteraluminiumbrassalloyhalfroundwire,which iswiredto

theteethatthelevelofthemidcrownandismaintainedinthispositionbyhooks,whichfitintothe

spacebetweenthecrownsofadjacentteeth.Thehooksaremadeof1.4mmwireandaresoldered

atright

angles

separated

at

equal

intervals.

These

cross

wires

are

positioned

so

that

two

thirds

of

the

wireprojecttoonesideofthearchbarandonethirdprojectstotheother(Fig.37).

48

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Intermaxillary Fixation Techniques Manual

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