disclosure - ucsf otolaryngology update...–erich arch bar arch bars methods of mmf •ivy loops...
TRANSCRIPT
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University of California, San Francisco
Andrew H. Murr, MDProfessor and Chairman
Department of Otolaryngology-Head and Neck Surgery
Maxillomandibular Fixation: Not Your Father’s MMFUCSF Otolaryngology Update
November 1, 2019
Disclosure
• Board Member: AONA CMF• Received: honoraria and travel expenses
• Minor stockholder: IntersectENT
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MMF
• Establishes the Pre-traumatic Occlusion• May be a splint treatment method• Multiple ways of accomplishing this: modern
and ancient
Why?
• 1. Restoration of occlusion intraoperatively• 2. Postoperative method of producing
stability beneficial to creating acceptable occlusion
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Malocclusion
Contact Points
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If you cannot figure it out?• Find someone who can!• Stop and get some study
models: – CNC technology is becoming
highly disseminated
Methods of MMFAttached to/between teeth• Arch Bars
– Many different types– Erich Arch Bar
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Arch Bars
Methods of MMF
• Ivy Loops• Ernst Ligature• Embrasure wires• Others
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Ivy Loops
Ivy Loops
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Ernst Ligature
Embrasure Wire
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Zip Tie MMF
Skeletal MMF
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Skeletal MMF
Skeletal MMF
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Caution!
Is this tooth non-vital?
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Guiding Elastics
• Forced Adaptation• Condylar Fracture
– Intact vertical height– Unilateral fracture
• Ankylosis prevention• Patient must be
cooperative
Rehabilitation Device
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Endoscopic Condyle
Q:Must you maintain MMF post-operatively?A: Not if the fixation technique is engineered for functional load
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Anatomic Reduction and Arch Bars:Bone Clamp Application
Anatomic Reduction and Skeletal Screws
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Anatomic Reduction and No MMF
Pitfall of Anatomic Reduction
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When is MMF alone the Primary Treatment?
• Non-displaced fracture• Cooperative patient• Non-comminuted• Green Stick• Good bone contact
– No tooth loss• Intact Dentition• Special circumstances
– ICU– Periostium intact
When is MMF an adjunctive treatment?• When the repair is engineered to stand on its
own.
When is MMF not required?• When anatomic reduction produces perfect
reduction.
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Standard Order of Procedure
Old order1. Apply MMF2. Incision3. Exposure4. Assure Reduction5. Apply Fixation
Changed Order of ProcedureNew order1. Incision2. Exposure3. Anatomic reductionYes: apply fixation engineered for functionNo: Apply MMF• Ivy loops or Embrasure Wires• Assure reduction• Apply fixation engineered for function
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Advantages
• Restore correct occlusion• Extra pair of hands• Aids reduction of fracture (open or closed)• Can allow traction/training postoperatively• Cheap?• Can be applied under local anesthesia
Disadvantages
• Time• Operator dependent• Risk of needle stick injury• Airway compromise (postoperative)• Dental proglems• May complicate fracture reduction• Patients hate MMF
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Take Home Message
• Aim: restore occlusion• May be used primarily, intraoperatively only,
or postoperatively as well, or…not at all.• Multiple techniques
– Arch Bars– Eyelets – Screws
• Key: Stability
Aloha