Maxillomandibular Fixation: Understanding the Risks and Benefits of Contemporary Techniques in Adults.

Numerous techniques achieve maxillomandibular fixation (MMF), each with benefits and risks. While using Erich arch bars to achieve MMF has remained the gold standard through the last century, the technique has multiple limitations, which have spurred innovative approaches, such as intermaxillary fixation (IMF) screws, hybrid arch bars, embrasure wires, and dental occlusion ties. The surge in new MMF technologies over the past decade prompted this analysis to compare these techniques. A PubMed search was conducted to identify all current FDA-approved modern MMF technologies from 2005 through 2023, evaluating their advantages and limitations. Studies with controlled scientific comparisons of techniques were limited, precluding a systematic review. Analysis showed no definitive data exist to endorse one technique as a universal option. As multiple MMF options offer appropriate stability, a surgeon may choose an approach based upon numerous factors: comminution/instability; need for physiotherapy, including guiding elastics; safety; time of application/removal; and patient comfort. This article guides the selection between techniques based on these factors and presents a decision algorithm to assist surgeons in selecting the ideal MMF technique for each patient.

A Novel Minimally Invasive and Cost-Effective Internal Fixation of the Le Fort I Fracture by Using Intermaxillary Fixation Screw and Wire: A Technical Note.

Introduction: Le Fort I fractures represent a significant proportion of craniofacial trauma, often occurring alongside other injuries to the craniomaxillofacial region. Management options include open reduction and internal fixation (ORIF) or skeletal suspension, each with its limitations and considerations. Material and Methods: This technical note presents a novel technique for managing isolated Le Fort I fractures using intermaxillary fixation (IMF) screws, offering a minimally invasive alternative to ORIF. The technique involves the strategic placement of IMF screws in the stable zygomatic bone, coupled with arch bar fixation and wire manipulation for maxillary fragment reduction. Results: This approach is cost-effective, can be performed under local anesthesia, and provides stability without the need for prolonged maxillomandibular fixation (MMF). Conclusion: The simplicity and efficacy of this technique make it suitable for emergency settings and cases where traditional approaches may not be feasible. However, this technique is only feasible in isolated Le Fort I fractures and is contraindicated in comminuted Le Fort I fractures and in edentulous patients with upper jaw involvement.

Férulas de Gunning. Una alternativa de tratamiento que sigue presente. Reporte de 02 casos / Gunning's splints. An alternative treatment that is still present. A report of 02 cases

Las fracturas condilares continúan siendo un desafío para los cirujanos maxilofaciales, debido a los múltiples tipos de fracturas que pueden ocurrir y los tratamientos disponibles. El tratamiento de este tipo de fractura podría dificultarse si el paciente presenta edentulismo. Así, entre las opciones de tratamiento, el uso de una férula o la prótesis dental preexistente como medio de fijación se muestra como una opción viable. Se presentan 02 casos clínicos de pacientes masculinos de 36 y 83 años de edad que presentan un maxilar edéntulo y fracturande cóndilo mandibular de lado derecho; para su tratamiento se utilizó una férula de Gunning superior con fijación intermaxilar mediante el uso de tornillos de fijación intermaxilar y elásticos intermaxilares durante 4 semanas. Después de 3 meses de evolución, ambos pacientes presentaron una adecuada apertura bucal, sin desviaciones o limitación a la apertura bucal. Las férulas de Gunning, a pesar que actualmente son poco usadas, continúan siendo una opción apropiada para los casos de fractura del cóndilo mandibular en pacientes edéntulos.

Condylar fractures continue to be a challenge for maxillofacial surgeons, due to the multiple types of fractures that can occur and the treatments available. Treatment of this type of fracture could be difficult if the patient has edentulism. Thus, among the treatment options, the use of a splint or the pre-existing dental prosthesis as a means of fixation appears to be a viable option. Two clinical cases are presented of male patients aged 36 and 83 years who present an edentulous maxilla and fracture of the mandibular condyle on the right side; For treatment, an upper Gunning splint with intermaxillary fixation was used through the use of intermaxillary fixation screws and intermaxillary elastics for 4 weeks. After 3 months of evolution, both patients presented adequate mouth opening, without deviations or limitations to mouth opening. Gunning splints, although they are currently rarely used, continue to be an appropriate option for cases of fracture of the mandibular condyle in edentulous patients.

Simple Method for Re-tightening IMF Wires without Breakage.

AIM: This clinical technique aims to retighten intermaxillary fixation (IMF) wires when loosened intra/postoperatively. BACKGROUND: Intermaxillary fixation is one of the most important steps to obtain stable and functional occlusion in maxillofacial trauma. However, IMF wires tend to loosen over time. This loosened wire is generally removed and a new wire is used for IMF. Removal and refixation is time-consuming for surgeon and unconformable for the patient. TECHNIQUE: We recommend a simple technique for re-tightening IMF wires without breakage, with the use of shepherd's crook explorer by making a small circular loop. CONCLUSION: This technique of re-tightening by looping further stretches and tightens the wire to regain stabilized occlusion with maximal intercuspation. CLINICAL SIGNIFICANCE: This technique eliminates the need for removal and refixation of IMF wires, thereby improving patient comfort, yet obtaining stable occlusion over a long period of time. How to cite this article: Madhu SK, Dominic S, Baptist J, et al. Simple Method for Re-tightening IMF Wires without Breakage. J Contemp Dent Pract 2024;25(3):289-291.

Trends in Maxillomandibular Fixation Technique at a Single Academic Institution.

Study Design: Retrospective chart review. Objective: Restoration of premorbid occlusion is a key goal in the treatment of mandibular fractures. Placement of the patient in maxillomandibular fixation (MMF) is performed during mandibular fracture repair to help establish occlusion. A number of techniques are available to achieve MMF. We sought to examine trends in MMF technique at our institution. Methods: A retrospective chart review was conducted to evaluate patients who underwent surgical treatment of mandibular fractures between January 1, 2011 and March 31, 2021. Data including fracture characteristics, mechanism of injury, patient demographics, complication rates, and MMF technique utilized were collected. Results: One hundred sixty-three patients underwent MMF (132 males). The most common etiology of fracture was assault (34%). There was an increasing preference for rapid MMF techniques over time, as opposed to standard Erich arch bars. No significant difference in obtaining adequate fracture reduction as determined by postoperative imaging or complications were noted between those who underwent MMF with newer rapid techniques vs traditional MMF techniques. Conclusions: Our institution has demonstrated changing trends in the technique utilized for establishing occlusion intraoperatively, more recently favoring rapid MMF techniques, with similar rates of complications and ability to adequately reduce fractures.

Effective strategies in the management of anterior mandibular fractures: a comprehensive systematic review.

This review examines the prevailing modalities for fractures of the anterior mandible, which represent a significant proportion of the maxillofacial injuries commonly treated by oral and maxillofacial surgeons. The article traces the historical shift from conservative techniques to the dominant management strategies of open reduction and fixation. Encompassing a range of studies, the review, in accordance with PRISMA 2020 recommendations, meticulously examines various fixation methods, assessing their efficacy in achieving stability of fracture, early healing, and mobilisation. The comparison of these methods highlights their unique advantages and limitations, and demonstrates the need for more nuanced and precise approaches. The review emphasises evidence-based methodology in the management of anterior mandibular fractures (AMF), highlighting the benefits offered by innovative techniques such as 3D miniplates. It also acknowledges the advantages provided by older fixation devices such as lag screws. The importance of postoperative outcomes and the need for tailored treatment strategies are recognised, considering the complex nature of these fractures.

A finite element analysis of stress distribution with various directions of intermaxillary fixation using orthodontic mini-implants and elastics following mandibular advancement with a bilateral sagittal split ramus osteotomy.

OBJECTIVE: This finite element analysis (FEA) aimed to assess the stress distribution in the mandible and fixation system with various directions of the intermaxillary fixation (IMF) using mini-implants (MIs) and elastics following mandibular advancement with a bilateral sagittal split ramus osteotomy (BSSRO). MATERIALS AND METHODS: A total of nine mandibular advancement models were set according to the position of the MIs (1.6 mm in diameter, 8 mm in length) and direction of the IMF elastics (1/4 inch, 5 oz). Major and minor principal stresses in the cortical and cancellous bones, von Mises stresses in the fixation system (miniplate and monocortical screws), and bending angles of the miniplate were analysed. RESULTS: Compressive and tensile stress distributions in the mandible and von Mises stress distributions in the fixation system were greater in models with a Class III IMF elastic direction and a higher IMF elastic force than in models with a Class II IMF elastic direction and a lower IMF elastic force. The bending angle of the miniplate was negligible. CONCLUSIONS: Stress distributions in the bone and fixation system varied depending on the direction, amount of force, and position of IMF elastics and MIs. Conclusively, IMF elastics in the Class II direction with minimal load in the area close to the osteotomy site should be recommended.

Intermaxillary Fixation in the Primary and Mixed Dentition.

Anatomic differences of the primary dentition may hinder traditional methods of intermaxillary fixation. Furthermore, the presence of both the primary and permanent dentition can complicate establishing, and maintaining, the preinjury occlusion. The treating surgeon must be aware of these differences for optimal treatment outcomes. This article discusses and illustrates methods that facial trauma surgeons can use to establish intermaxillary fixation in children aged 12 years and younger.

Treatment of pediatric bilateral condylar fractures: A comprehensive analysis.

Pediatric bilateral condylar fractures (PBCF) is a rare clinical pathology, where the management is carried out with both conservative and surgical approaches. The purpose of this study was to analyze and compare these two treatment approaches and their associated long term complications in PBCF. An extensive literature review- through the search of online databases- was conducted to survey, collect, analyze and compare the reported outcomes of different treatment modalities for PBCF. The number of studies presenting PBCF case reports was 16, while the number of such retrospective studies included here was 19. Analyses of these studies revealed that the conservative treatment is preferred in PBCF patients younger than 12 years of age. Moreover, a composite approach where the open reduction and internal fixation (ORIF) is carried out for one side while the intermaxillary fixation (IMF) for the contralateral side is frequently reported for the management of PBCF cases; this approach appears effective in improving daily functioning of temporomandibular joint and reducing long term complications. Performing ORIF for one side while IMF for the contralateral side seems the most common treatment approach in PBCF. This study may help in rapid decision making for treatment selection of PBCF patients while minimizing the risk for late complications.

Efficacy of Locking Miniplates in Managing Mandibular Fractures without Intermaxillary Fixation.

Background: In maxillofacial trauma, the most commonly encountered are mandibular fractures requiring treatment. Managing these fractures with rigid fixation abolish the intermaxillary fixation (IMF) requirement with reduction and early return to function. Aims: The present trial was carried out to assess clinically the effectiveness of new locking bone plate screw system postsurgically in mandibular fracture cases without IMF. Materials and Methods: In 18 subjects, the fracture site was exposed, fracture segments were reduced and approximated keeping the occlusal relationship is desirable using locking 2 mm mini plates and screws without IMF. The subjects were followed every week for initial 4 weeks followed by evaluation for up to 6 months every month to assess clinical and radiographic healing and the results were formulated. Results: Road traffic accident was the cause in 10 subjects (55.5%), followed by assault in 22.2% (n = 4) subjects, and fall from height in 16.6% (n = 3) subjects. Parasymphysis was involved in 44.4% (n = 8), followed by symphysis in 11.1% (n = 2) subjects. A minor complication of wound dehiscence was seen in 5.5% (n = 1) subjects that were managed conservatively and a major complication of infection was also seen in 1 subject that required removal of the plate at 4 weeks of follow-up. Following plate removal, IMF was done for that subject. All other sites were healed uneventfully. Primary healing in bone was seen in 94.4% (n = 17) subjects and it was not seen in the case with infection. Conclusion: Within the limitations, the present study concluded that the locking miniplate system is highly effective and reliable in treating mandibular fractures with acceptable results and a very low postoperative complications rate.

Surgical Glove Perforation and Percutaneous Injury during Intermaxillary Fixation with 0.5 Mm Stainless Steel Wire.

INTRODUCTION: The risk of exposure of either the patient or the surgeon to pathogens when the surgical glove is perforated is significant. This is particularly so in jaw fractures when intermaxillary fixation is done with the stainless-steel wire as many perforations also result in percutaneous injury. MATERIAL AND METHOD: This study was carried out in two tertiary Hospitals in Abuja, Nigeria. Adult patients for intermaxillary fixation as a result of jaw fractures were consecutively recruited into the study. Similarly, surgeons and their trainees (assistants) were also recruited. Factors investigated included the method of gloving used by surgeons and trainees (single versus double gloving), glove perforations and percutaneous injury rates, years of operator's experience, among others. During surgical operations, percutaneous injuries were recorded and obviously perforated or torn gloves were labelled and changed. At the end of every surgical procedure, gloves used were investigated for perforation. RESULTS: A total of 564 gloves were investigated (Surgeons-337; Trainees-227) after use for wire intermaxillary fixation procedures. The frequency of glove perforations for the surgeons was 72 (21.4%). Forefinger perforations were most frequent; 40 (55.6%) cases. Assistants, had 35 (15.4%) cases of glove perforations. Percutaneous injury occurred in 9.7% (7/72) and 5.7% (2/35 cases) of cases for surgeons and assistants, respectively. CONCLUSION: The study revealed high risk for wire-based IMF procedures. Single gloving was more frequently associated with percutaneous injuries although double gloving was more associated with perforations with higher surgeon infection risk. Double gloving reduces the risk of percutaneous injuries and, therefore, the likelihood of exposure to blood-borne pathogens.

INTRODUCTION: Le risque d'exposition du patient ou du chirurgien à des agents pathogènes lorsque le gant chirurgical est perforé est important. Cela est particulièrement le cas dans les fractures de la mâchoire lorsque la fixation intermaxillaire est effectuée avec le fil en acier inoxydable, car de nombreuses perforations entraînent également des lésions percutanées. MATÉRIEL ET MÉTHODE: Cette étude a été réalisée dans deux hôpitaux tertiaires à Abuja, au Nigeria. Des patients adultes pour une fixation intermaxillaire à la suite de fractures de la mâchoire ont été recrutés consécutivement dans l'étude. De même, des chirurgiens et leurs stagiaires (assistants) ont également été recrutés. Les facteurs étudiés comprenaient la méthode de gloving utilisée par les chirurgiens et les stagiaires (simple versus double gloving), les perforations de gants et les taux de blessures percutanées, les années d'expérience de l'opérateur, entre autres. Au cours des opérations chirurgicales, des blessures percutanées ont été enregistrées et des gants manifestement perforés ou déchirés ont été étiquetés et changés. À la fin de chaque intervention chirurgicale, les gants utilisés ont été étudiés pour la perforation. RÉSULTATS: Au total, 895 gants ont fait l'objet d'une enquête (Surgeons-337; Stagiaires-227) après utilisation pour les procédures de fixation intermaxillaire du fil. La fréquence des perforations de gants chez les chirurgiens était de 72 (21,4 %). Les perforations de l'index étaient les plus fréquentes, 40 (55,6 %) cas. Assistant, avait 35 (15,4%) cas de perforations de gants. Des lésions percutanées sont survenues dans 9,7 % (7/72) et 5,7 % (2/35 cas) des cas chez les chirurgiens et les assistants respectivement. CONCLUSION: L'étude a révélé un risque élevé pour les procédures filaires du FMI. Le gloving simple était plus fréquemment associé à des blessures percutanées, bien que le double gloving soit plus associé à des perforations avec un risque d'infection plus élevé chez le chirurgien. Le double gloving réduit le risque de blessures percutanées et, par conséquent, la probabilité d'exposition à des agents pathogènes transmissibles par le sang. MOTS CLÉS: Fixation intermaxillaire, gants, Chirurgien, Lésion percutanée.

Pediatric Intermaxillary Fixation in a Child with Isolated Subcondylar Fracture under Local Anesthesia: A Technical Note and Case Report.

Pediatric subcondylar jaw fractures in the mixed dentition phase present a unique challenge as immobilization of the jaw is indicated but arch bars are contraindicated due to fear of damage to underlying tooth buds. No definite guidelines are present in the management of pediatric subcondylar jaw fractures. We report a case in which a patient in mixed dentition with undisplaced fracture of neck of condyle which was managed with Intermaxillary fixation. How to cite this article: Tirupathi SP, Rajasekhar S, Ganesh M, et al. Pediatric Intermaxillary Fixation in a Child with Isolated Subcondylar Fracture under Local Anesthesia: A Technical Note and Case Report. Int J Clin Pediatr Dent 2022;15(1):119-120.

Effect of a digital guide on the positional accuracy of intermaxillary fixation screw implantation in orthognathic surgery.

BACKGROUND: Intermaxillary fixation screw (IMFS) implantation is a common procedure in orthognathic surgery (OGS) performed to the temporary maxillary-mandibular fixation and stable bite relationships. The study aims to assess the accuracy of IMFS implantation with a digital guide to reduce the occurrence of root damage. METHODS: This prospective study involved 40 patients undergoing OGS at the Affiliated Hospital of Qingdao University from August 2017 to May 2021. The patients were randomly divided into two groups according to whether the IMFS implantation was with or without digital guide (20 patients in the experimental group and 20 controls). The digital guides used in the experimental group were designed according to a virtual implantation plan and printed using stereolithography. In the control group, IMFSs were directly implanted by a surgeon based on clinical experience. Postoperatively, cone-beam computed tomography was performed to compare root proximity of IMFSs between the two groups and verify the accuracy of IMFS placement. RESULTS: In the experimental group, there was no case of root damage, the incidence of the periodontal ligament (PDL) injured was 22.1%, and 77.9% IMFSs were placed without contacting adjacent anatomic structures. In the control group, the incidence of root damage had been up to 20.8%, 31.7% IMFSs injured the PDL, and only 47.5% IMFSs were placed between the roots (P < 0.001). CONCLUSION: IMFSs can be placed more accurately with surgical guides, reducing the incidence of root and PDL damages.

Use of Elastomeric Separators in Maxillofacial Fracture Reduction.

BACKGROUND: Management of maxilla and mandibular fractures are based on the principles of reduction, fixation and immobilization of the fracture segments. PURPOSE: One of the processes of reduction is to apply continuous and gradual elastic traction by placing elastics from the upper and lower arch bars in a definite manner and direction as per the fracture line. Orthodontic elastic separators are versatile, and the major advantage is the higher traction forces as compared to conventional elastics. METHODS: Prestretched separator elastics were guided over the arch bar or fixed orthodontic appliances to provide desired traction. RESULTS: Orthodontic elastic separators are therefore versatile, and the major advantage is the higher traction forces as compared to conventional elastics. They provide an edge over the use of wires as they tend to break off by work hardening. CONCLUSION: Therefore, we have adapted orthodontic separators and have used them in place of conventional elastics for the last 10 years with appreciable results after taking informed consent from the patients.

Is the Use of Intermaxillary Fixation Screws an Alternative to Erich Arch Bars for Maxillomandibular Fixation During Management of Maxillofacial Fractures? A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Maxillomandibular fixation (MMF) is a step of paramount importance during the management of maxillofacial trauma. Erich arch bars are being used for this purpose for decades but with advances in maxillofacial trauma management, intermaxillary fixation screws came into existence and are being used routinely. The present study was designed to identify if the intermaxillary fixation screws are really an alternative to Erich arch bars for management of maxillofacial trauma. METHODOLOGY: An exhaustive literature search was conducted in May 2020 on various electronic databases and studies comparing Erich arch bars and intermaxillary fixation screws were recruited for the analysis. Random-effects model with Mantel Haenszel statistics was used to analyze oral hygiene and duration of achieving MMF. RESULTS: A total of 96 studies were identified, out of which 8 studies were included in the meta-analysis. There was no statistically significant difference in oral hygiene status of the patients in both the groups. Intermaxillary fixations screws required statistically significantly less time in achieving MMF. Needle stick injury was prominently seen with the use of Erich arch bar whereas other complications like mucosal coverage, root injury, screw loosening and screw fracture makes the use of intermaxillary fixation screws questionable. CONCLUSION: The present meta-analysis suggests that there is not enough evidence to recommend the use of intermaxillary fixation screws as an alternative to Erich arch bars. Further research with large sample size, high quality evidence and better methodology is recommended in this direction.

Factors Influencing Clinical After Effects of Post Orthognathic Surgery - An Observational Clinical Study.

BACKGROUND: For maintaining the occlusion, screws to anchor bones are needed to be used in transalveolar manner to get the intermaxillary fixation in participants with no preoperative orthodontic treatment or participants with loose or broken appliances. AIMS: The present clinical trial was hence aimed to assess the postoperative complications following orthognathic surgical repair of skeletal malocclusion. MATERIALS AND METHODS: Forty-two participants were divided into two groups (n = 22). In Group I, predrill was done to create the holes in transalveolar position before screw insertion. For Group II, self-cutting screws were used without the drills. The radiographs were then taken to assess the associated root injuries. To evaluate the effect of different steroid doses on the pain, nerve healing, and swelling, the participants were divided into three groups (n = 14). Plate removal and associated factors were also evaluated. Collected data were statistically analyzed. RESULTS: In Group where no predrill was done, no root injuries were seen. Considerably less facial edema was observed in Group II and III compared to control Group I. This difference was statistically significant with a P value of 0.2057. At 1 week, 3 months, and 6-month postoperatively in Group II and Group III, no significant difference was seen. No significant difference in the postoperative pain between the groups was seen (P = 0.85103). Neurosensory Visual Analog Score measurement revealed no significant difference between three groups at 6 months with the P value of 0.81821. CONCLUSION: The present study concludes that risk for the root injury is possessed by the screws that require predrill, whereas the self-drilling screws had no risk for root injury.

Body Weight Loss After Orthognathic Surgery: Comparison Between Postoperative Intermaxillary Fixation with Metal Wire and Elastic Traction, Factors Related to Body Weight Loss.

INTRODUCTION: The aim of this study was to compare body weight loss between postoperative intermaxillary fixation with metal wire and elastic traction and to investigate factors related to body weight loss after orthognathic surgery. MATERIALS AND METHODS: Subjects were 59 patients with dentofacial deformity, comprising 31 patients treated with intermaxillary fixation (IMF) and 28 patients treated with elastic traction without IMF (ELT) just after surgery. Body weight loss was measured at 1 week (T1) and 2 weeks (T2) after surgery. Body weight loss was compared between IMF and ELT, and factors related to body weight loss were statistically analyzed. RESULTS: Body weight loss ratio was significantly increased in IMF (2.6%) rather than in ELT (1.4%) at T1, but only tended to be increased in both groups at T2, showing no statistical difference. Body weight loss ratio was significantly increased at T2 compared to T1 in both groups. Body weight loss was significantly greater at T2 than at T1. CONCLUSION: Both IMF and ELT cause body weight loss after orthognathic surgery, but IMF causes body weight loss earlier than ELT and increased early body weight loss increases continuous body weight loss after orthognathic surgery.