Wiring techniques in maxillofacial surgery

Wiring techniquesin maxillofacial surgery

Historic evolvation

Definition of imf & mmfIMFFixation of fracture of the mandible or maxilla by applying elastic bands or stainless steel wire between the maxillary and mandibular arch bars or other types of splint.MMFThe binding of maxillary and mandibular teeth together to immobilise the jaw in patient with a mandibular fracture.Indication for MmfNon-displaced # &favourable #Grossly communited #Edentulous atropic mandibular ## in childrenCondylar #

Contraindication for MmfPoorly controled seizuresCompromised pulmonary functionPsychatric & neurological disorderArnamentorium used for mmfNeedle holder, wire cutter, artery forceps, 26 gauge wire, arch bar,tweezer, shepherds hook probe

Precaution from wire injuryHigh risk of sero-transmission to operator during the placement of MMF wiring can be reduced by protecting our fingers with bandage before wearing the gloves.

Twisting dental wire

Wires in mmf26 gauge(0.45mm soft stainless steel) wire has been found effective.This wire require stretching(about 10%) before use.6 inch(15 cm) length wire is commonly used.Twisted portion should be parallel(in the long axis) to wire loop.if not wire will break.Care should be taken to hold the free end to avoid the eyeball injury during wire cutting.Over tightening may cause avulsion of tooth.Precaution in wiringRecognize the pre-existing occlusal abnormality like open bite , cross bite. Wire should be tugged inter dentally/towards occlusion.It should not impinge gingival soft tissue& it should not interfere occlusion.Finger should be run around patients mouth to ensure loose end & sharp end-they might ulcerate the mucosa.Always ensure tongue is not trapped between teeth.Types of wiring techniquesEssigs wiringGilmers wiringIvy eyelet wiringRisdons wiringArch bar Erichs arch bar Jelenko archbar Two german silver bar

Essigs wiring

Gilmers wiring

Risdons wiring

Ivy eyelet wiringWhenever required without distrubing the main wire joining wire can be removedWhen there is breakage only the eyelet can be removed and replace

Steps in ivy eyelet fixation

Erichs arch barIt is effective,quick&inexpensive method of fixation.Prefabricated,custom made,acraylated arch bar,erichs,jelanko,german two silver bar are types of arch bar.Prefabricated flat malleable ss metal strip.In upper jaw hook towards upward ,in lower jaw hooks towards downward direction.It should not cross the fracture line.

Steps in arch bar fixation

Semi circle arch bar

Bonded arch barArchbar is modified by micro-wiremesh incorporation in base surface & sand blasting to attain the rough surface to bind with resin for micro-mechanical bond.

Advantage & disadvantage of bonded arch barAdvantage1.oral hygeine2.safty to operator(from serotransmission of blood born virus HBV-30%,HCV-1.85,HIV-0.32%)4.injury to periodontium is reducedDisadvantageAttainment of moisture free enamel surface is difficult.Stability is lesser than conventional archbar.Comparison of frequently used wiring technique

BUTTONS as eyelet in mmf

Screw retained imf

Screw retained mMFAlternative to conventional MMF.Titanum screw fixed with maxilla or mandible.Safe time-sparing,patient comfortable,,no occlusal disturbance,oral hygeine maintenance are advantage.Screw loosening,root fracture,loosened wire,screw shear,malocclusion&ingested hardware are disadvantage.

Comparision between screw v/s erichs archbarSelf tapping screws are used faster than erichs arch bar.Screw need 8.52-11.2 minutes to fix IMF.Erichs arch bar need 100 minutes to fix IMF.Oral hygiene status is good in 90% of patient,fair in 10% of patient.Iatrogenic injury to root fracture is a disadvantage .Imf using thermoforming plateIn plaster model thermoforming (inner soft sheet-ethylene vinyl acetate,outer hard sheet-polycarbonate SCHEU-DENTAL.Co) adapted(like night guard,soft occlusal splint).In articulater after model surgery desiarable occlusion achieved(indirect method-in lab).TP is then transferred to patient mouth to do IMF.TP strength is appropriate in all case.Period range-12 days,next 7 days day/night alternatively imf is used.Rohtak dental college (rdc)techniqueIt is a simple,quick,economical &mininally invasive technique.Lesser periodontal problem,no specialized instrument or lab work is required for this technique.Indicated in minimally displaced #,orthognathic surgery & in tumor resection surgery.Could be used in mass casualties such as war injury or natural calamities.

Matrixwave mmf

BONE-BORN MMF system consist wave shaped plate attached to maxilla & mandible with self-drilling locking screws give additional anchorage.

Matrixwave mmf systemPlate can be stretched in plane.Occlusion is brought by wiring around the hooks & accessible screw heads.Used in age12 or higher(in whom permanent teeth have erupted).Designed to help avoid tooth loosening,for patient comfort.

Smart lock hybrid mmfA revolutionary system combines both ARCH BAR and MMF SCREW.Strength & rigidity of arch bar with safety & efficiency of MMF screw.This omit the need of securing wire placement , thereby reduce the chance of wire stick injuries.

Advantage of Smart lock hybrid mmfIt can be removed under LA.Safety to patient protect the gingival soft tissue & tooth roots.Placement doesnt contingent on existing dentition thereby reduce the risk of tooth avulsion.

Prevelance of mmf

Comparison of complication between open reduction & closed reduction (mmf)

Period of immobilizationYoung adult with # of angle : 3 weeks.Tooth retained in fracture line : add 1 week.Fracture at the symphysis : add 1 week.Age 40 years and over : add 1 or 2 weeks.Children and adolescents : subtract 1 week.Calculating the duration of mmfeg:- A 40-year old patient , symphysis fracture, where tooth in fracture line (base 3 weeks+1 week for less favorable site+1 week allowed for age+1 week for tooth retained in fracture line) require 6 weeks immobilization.

ADVANTAGE OF MMFMore conservative.In presence of sufficient teeth,a simple fracture is expected for clinical union within 4 weeksUseful in medically compromised patient.Complication of surgery is not present.Great skill(surgical skill) not required.

Pitfalls of mmf Can not be abtain absolute stability.Decreased nutritional status-weight loss.Oral hygiene maintenance is difficult.Thinning &necrosis of articular cartillage.TMJ sequelae (MPDS).Osteoporosis,adhesion in joints.Atrophy & weakening of muscles.

conclusionInspite of growing ethusiasm for ORIF, MMF remain a relevent technique in maxillofacial surgery.In some case are more cost effective than rigid fixation.By using recent advancement technique in MMF we can get a faster, safety, better stable fixation with patient comfortable & good oral hygeine. Thank you