Various intermaxillary fixation techniques

VARIOUS INTERMAXILLARY
FIXATION TECHNIQUES
Presented By
Dr. Venu Sameera Panthagada
Postgraduate
Oral And MaxilloFacial Surgery

 Intermaxillary fixation techniques are one of the
treatment options of mandibular fractures.
 In this technique fractured fragments are fixed and
immobilized in their anatomically reduced position
by means of wires that are placed around the teeth
known as interdental wiring.
 Intermaxillary fixation techniques are done with
closed reduction process in which occlusion is
taken as a guide for the alignment .

Indications:
 Non displaced favourable fractures
 Grossly comminuted fractures
 Edentulous mandible which is severely
atrophic
 Fractures in children
 Condylar fractures

Contraindications:
 History of seizures
 Compromised pulmonary function
 Psychiatric conditions
 Gastro intestinal disorders

BASIC METHODS OF IMF TECHNIQUES
1.DIRECT INTERDENTAL WIRING
2.INDIRECT INTERDENTAL WIRING(EYELET
OR IVY LOOP)
3.CONTINUOUS OR MULTIPLE LOOP WIRING
4.ARCH BARS
5.CAP SPLINTS
6.GUNNIG TYPE SPLINTS
7.PIN FIXATION

COMMON RULES FOR WIRING
 Always use prestretched and work hardened wire
for wiring.
 While placing the wires on the lingual side,make
sure that wire passes below the cingulam region
for maximum stability of wires.
 While twisting wires always twist them in a
clockwise direction with an apical pull.
 After tightening the wires,make sure that the ends
are cut short and tucked towards the teeth or
gingiva to prevent injury to oral mucosa.

DIRECT INETRDENTAL WIRING(GILMER’S)
 This technique provides a simple and rapid
method of immobilisation of jaws.
 TECHNIQUE:
 A 15 cm length of prestreched 0.35 mm diameter
soft stainless steel wire passed around teeth
emerging through interdental spaces.
 With the wire placed
around the neck of the
two ends are twisted to tooth
produce 3 cm tail.

 Intermaxillary fixation is effected after
reduction of fracture by twisting separate tails
together obtaining crisscross bracing.
 Cut ends should be bent to avoid soft tissue
trauma.

ADVANTAGES:
Can be done when fast method of
immobilization is requird
DISADVANTAGES:
If one of the wires around the tooth breaks, it
may be necessary to release all the wires to be
able to replace the wire.

 This technique should only be considered as a
first aid method for achieving temporary
immobilization of fractured fragments.
 To overcome these disadvatanges, interdental
eyelet wiring is used.

INTERDENTAL EYELET WIRING (IVY LOOP
METHOD)
 BY DR.ROBERT H. IVY, USA
 Eyelet wiring is a simple and effective method of
reduction provided that teeth of a fractured
segment are of suitable number,shape and quality.
 Preparation of eyelets: 0.35 mm diameter soft
stainless steel wire is used.
 Wire should be stretched by 10% of original
length so as to prevent the loosening of wires after
insertion.

 Eyelet wires are made by twisting the middle
of each length of wire around the shaft of a
rod of 3mm diameter which is held in a vice.
 Three or four twists enough.
 Ends of the eyelet wires are cut off obliquely to
equalize their length so as to produce a sharp
point which will readily pass through
interdental space.

Technique:
The shafts of the preformed eyelet wire are
curved parallel to the contour of the palate to
facilitate their passage through interdental
space.
Both the ends have been passed through the
respective interdental spaces.
Distal end is passed through the eyelet and
passed beneath the mesial shaft.

End of the tie wire is formed in to a small hook
which is inserted through eyelet and then
passed through selected eyelet in lower jaw.
Clockwise twist is given.
Twisted ends are cut short , formed in to
loops and tucked away into interdental
spaces.
Tie wires form a V pattern so as to minimise
any lateral movements

HALLAM’S $ WILLIAM’S
MODIFICATION

Removal of eyelet wires:
 Normal period of immobilization is 6 weeks.
 Eyelets are removed after loosening the wire
twist by anticlockwise rotation so that labio
buccal wire can be cut.
 Distal portion can be sectioned by elevating
the labio buccal wire.
 Eyelet is then gripped by strong forceps with
continuous firm traction applied at right angle
to labiobuccal surface of tooth, wire will
usually be delivered.

Clove hitch method:
One shaft of the eyelet wire is formed into a
clove hitch.

 after placing the clovehitch over isolated tooth
,loops are tightened and wire is pushed down
beneath the neck of the tooth, the ends being
twisted in clockwise direction.

 A tie wire is passed through the eyelet in the
ususal manner and the end crossed close to
the eyelet around the upper distal pair of
teeth.

Drawbacks of eyelet
 Simple eyelet was frequently drawn into the
interdental space.
 Elastic traction using eyelets was time
consuming to apply.
 Tie wires could not be tightened without the
removal of throat pack, which left a
considerable time interval during which blood
pooled in oropharynx.

Button Wiring
 Leonard (1977)
considers that eyelet
wires have several
drawbacks.
 He described the use of
titanium buttons of 8mm
diameter,
inclusive of a 1mm rim,
and 2mm deep.

 Each button has two 1mm diameter holes with
1mm apart.
 The ends of the wire are passed through holes
and twisted twice.
 Similar to eyelet fixation, buttons are fixed and
distal wire is passed through twist at the
deeper aspect of button.

Drawbacks:
 It is inappropriate to use buttons where
patients have severe posterior crossbite and
marked anterior overbite.
 Also difficult to apply a button to single
standing tooth.

Continous wiring or multiple loop
wiring:
Stout described a technique which permits
blocks of teeth in either jaw to be wired in
such a manner that elastic traction can be
used to reduce the fracture.

Technique:
 A 30 cm length of wire is taken and one end is
laid along the buccal surface of teeth while the
other is passed around the most posterior teeth
below its contact point to emerge through
anterior space.
 Wire is back through same interdental space
passing around the buccal wire.

 A pliable rod of 5 cm length and 3 mm
diameter passed through wire loop and laid
along the buccal surface of segment parallel
to wire.
 Until the quadrant is enclosed, the wire on the
lingual aspect is passed in sequence through
interdental space.
 The ends of the wires lie on buccal aspect and
they are clipped.

 The rod is now withdrawn by forward pull.
 Loop is twisted by artery clip.
 Each loop is finally bent towards sulcus if
elastic traction is used or towards occlusal
surface if tie wire is used.
 The same procedure is followed in all the
quadrants and IMF is done.

ARCH BARS
 Many types of prefabricated arch bars like jelenko
krupps, erich, hamilton are available.
 But the most popular one and commonly used is
the Erich‘s arch bar.
 It is a prefabricated arch bar with hooks
incorporated on the outer surface with flat
malleable stainless steel metal strip.
 It provides an effective, quick and inexpensive
method of fixation.

Indications :
 When teeth are insufficient to allow efficient
eyelet wiring.
 Simple dentoalveolar fractures where multiple
tooth bearing fragments in jaw require
reduction into an arch form.
 As an integral part of internal skeletal
suspension in treatment of middle third of
facial skeleton.

 The bar is available in spool form.
 The bar should be cut accurately to the length
of the dental arch.
 Accuracy in this regard will prevent injury to
the adjacent soft tissues by protruding ends.
 Each arch bar is to be fixed to the upper and
lower dental arches.

 On the upper jaw, the hooks are arranged in
an upward direction.
 The bar is attached to the lower jaw with the
hooks in a downward direction.
 The arch bar should be adapted to the buccal
surface of each arch by giving a shape of the
arch by bending it. Bending of the arch bar
should start at the buccal side of the last tooth
progressing past the midline and finishing at
the other end.

 The arch bar is fixed to each tooth, with 26
gauge stainless steel wire, which is passed
from the mesial surface of a tooth to the
lingual side and back on the buccal side from
the distal surface of the tooth.
 One end of the wire is above the bar and the
other below.

By twisting the two ends of wire together, the bar is
attached securely and firmly to the necks of the teeth
on the buccal surface of the arch. The twisting of the
wires should be always done in a clockwise manner,
so that later on removal of wires can be done in
anticlockwise manner

 Advantages of the arch bar include less
trauma because of the thin wire and greater
stability in an arch, even if some teeth are
missing, because the edentulous gaps can be
spanned by this rigid appliance.
 If some wire is broken in between, the fixation
will not suffer and it can be replaced easily.
 The hooks are flat and do not irritate the
tissue.
 In case of displaced mandibular
body fractures, the arch bar can be divided
and placed on either side of the fracture line.

Risdons arch wire:
if an arch bar is unavailable, 1mm length of
stainless steel wire is passed around posterior
tooth on each side.

The ends of these wires are twisted on buccal side
until both overlap in the midline when they are in
turn twisted together.

Standing teeth are then secured to this arch bar.

Schuchardt acrylated arch bar:
 Metal arch bar is constructed from 2mm
diameter aluminium brass wire to which six
separate pieces of 1.4 mm thick wires are
soldered.
 These crosswires are positioned so that two
thirds will project to one side of arch bar and
one third to other.

 Arch bar is confirmed to the dental arch.
 Shorter ends of cross wires are turned over
occlusal surface of teeth.
 Arch bar is ligated to teeth with stainless steel
wire.
 The bar and ligature wires are covered by
cold cure acrylic resin.
once cold cure is set, clasps covering occlusal
surfaces are cut off, vestibular portion of cross
wires are used to provide attachment for IMF.

Stanhopes modification of schuchardt’s technique:

Figure of eight wiring:
 Used to stabilize dento alveolar fractures.
 In this technique wire is passed in a figure of
eight pattern around the teeth on either side of
fracture line and tightened on buccal aspect.

Essig’s wiring:
 This wiring technique is also used in the
management of dentoalveolar fractures.
 This is a better technique as compared to
figure of eight technique in giving a better
stability.
 In this technique wire is passed
interproximally between two teeth present a
little away from fracture line.

 The wire is then continued in the form of
figure of eight till the wire reaches two to three
teeth away from fracture line.
 Now the wire is passed straight back to the
starting point and again wire is continued in
the form of figure of eight till it reaches distal
tooth of fracture line and is twisted .
 This serves as an stay wire or arch bar .
 Now ligature wires are passed around teeth
either on fracture line and secured tightly.
 Finally IMF is done.

CUSTOM SPLINTS:
Custom made appliances are fabricated for
individual patient.
The splints can be constructed using acrylic
material or cast metal.

 Indications
 1. When the wiring of the teeth will not provide
adequate fixation.
 2. When horizontal splinting across the fracture
zone is required without closing the patient’s
mouth.
 3. When both the jaws are edentulous.
 4. In case of growing children, where mixed
dentition is present and number of firm teeth for
anchorage are not adequate.

Cast metal splint
These splints are fabricated in various metals
in the laboratories.
It requires impressions of both the arches.
The lower cast is sawed through the line of
fracture.

The cast is reassembled in proper occlusion and
fixed in position by pouring a base for the
cast. The splint is formed till the gingival
margins in 28 gauge sheet wax.
Occlusal relations are established in the
wax-up by checking the centric relation with
the opposite cast, while the wax is soft.

 Then the wax-up is sent for casting procedure
and the finished cast splint is obtained.
 This splint is used in adult patients with few
firm teeth available and the splint is cemented
to the reduced fractured jaw.

ACRYLIC SPLINTS:
 i. Lateral compression splint.
 ii. Gunning splint.

 Lateral compression splint : It is made
for the stabilization of mandibular arch.
 Mainly used in cases of children, where there
is mixed dentition and presence of developing
teeth buds (open reduction and direct fixation
is contraindicated).
 It can be also used in adult mandibular body
fracture, where the stability cannot be
obtained by means of other type of horizontal
wiring methods.

 Gunning splint : In edentulous jaws,
patient’s own dentures, suitably modified can
be used or specially constructed Gunning
splint can be used.
 Circumferential wiring is used to fix the splint
to the mandibular bone and or splint is fixed
to the maxilla by means of peralveolar wiring

•Preparation of acrylic block in centric
relation
•Preparation of cast/ mock surgery
•Acrylic bite block in molar region
•Space in anterior region
•Stainless steel hooks in molar region
Fabrication

Immobilization
Maxilla -Peralveolar wiring
- Circum zygomatic wiring
- With help of bone screws
Mandible - Circum mandibular wiring
Followed by IMF

PER ALVEOLAR WIRING
Two peralveolar wires are placed in the canine region on
either side for fitting patient’s own denture to alveolar
ridge.
The splint is firmly placed in the position in the upper
jaw. A kelsey-Fry bone awl introducer is pushed from
buccal to palatal aspect.

A 26 guage wire is threaded through the eye and
the wire is withdrawn with on the buccal surface.
Same procedure is repeated on opposite side and
then the splint is replaced in the mouth and wires
adjusted over it and twisted over the grooves and the
ends tucked inwards

CIRCUMMANDIBULAR WIRING
OBWEGESER’S PROCEDURE
It is used for fixation of lateral compression splint to
the mandibular bone.
Lower border of mandible is palpated in the canine
region and the skin is pierced beneath the lower border
of the mandible by Kelsey-Fry bone awl and it emerges
through the floor of mouth.

A 26 or 28 guage wire is inserted through the eye of the
awl and the awl is withdrawn till the lower border and
directed upward along the buccal surface of mandible to
pierce through the buccal sulcus.
The two ends of the wire are adjusted and the splint is
adjusted and the lingual and buccal wires are held
together and twisted in the region of canine grooves, cut
and finished inward.

Biphasic pin fixation
 Closed technique uses external fixation (Morris
appliance & Roger anderson appliance) for
management of comminuted mandibular fractures.
 screws placed - two on either side of the fracture
through stab incisions & holes drilled in the
mandible.

 Used in cases where compound, comminuted and
infected jaw fractures were present and required
remote immobilization
 Useful in cases with b/l edentulous posterior
fragments and where bone grafts need to be placed
 It also finds application in simultaneous treatment
of middle third fractures

 General principle is the use of 2 pins, joined to each other
by a transverse rod and 2 universal joints, inserted into
the principle anterior and posterior fragments of the jaw.
 Each pin assembly is then united by a further rod/rods
held by universal joints attached to the transverse bars
 Jaw immobilization if required is done by use of a ‘box
frame’, a Levant frame, a ‘halo’head frame .

 Generally, the pins are 7 cm long and 3 cm wide, to
overcome swelling due to edema and provide adequate
strength
 Pins are constructed of inert metals to prevent local
osteitis and inserted into the bone using hand power drills
 Types of pins:Clouston-Walker pins, East Grinstead type,
MacGregor pins, Moule pins, Toller pins

 It eliminates the need for IMF in most cases
and as the apparatus is extra-oral, oral
hygiene and feeding is not affected
 Modern antibiotics and surgical methods
have almost eliminated the use of pin
fixation

 However, cumbersomeness of the appliance,
difficulty in sleeping, patient non-compliance,
need for tightening of the universal joint,
difficulty in carrying out chores like shaving,
washing and the scarring associated with it have
led it out of favor

Complications:
 Anesthesia/paraesthesia of the lip due to Inf. alv. N
damage
 Involvement of fracture site/surrounding hematoma
by infection
 Widening of oblique fracture lines and displacement
of lingual cortex
 Over penetration/splitting of the bone

 Damage to adjacent structures due to improper
location of stab incision or slippage of drill/pin
beneath the inferior border
 Loosening of the pins due to functional movements
of the jaw/striking of apparatus on external objects
- failure of immobilization –
malunion/nonunion/infection
 Acute infection around the pins – removal of pins

 Intermaxillary fixation techniques for
management of mandibular fractures is
conservative procedure where none of the
complications associated with surgery will be
seen.

Intermaxillary fixation screws

IMF SCREWS
 Mandibulo-maxillary fixation (MMF) screws are
inserted into the bony base of both jaws in the
process of fracture realignment and
immobilisation.
 The screw heads act as anchor points to fasten
wire loops or rubber bands connecting the
mandible to the maxilla.

Screw placement
 The anatomical site for the placement of MMF
screws is chosen with respect to a given fracture
location, the dentition, the extent of surgical
exposure, the availability and the quality of bone
in the direct proximity of the fracture line.
 The anterior vestibular regions as well as the
anterolateral transitional zones (canine and
premolar regions) of both jaws are oftentimes
considered ideal, because these areas are
conveniently accessible and supply an
appropriate bone stock clear of tooth roots.

 In the anterior maxilla the piriform rim below
the nasal spine and above the dental apices
appears safe for setting MMF screws.
 A well fitting counterpart in the mandible just
as secure is the symphyseal and
parasymphyseal area underneath the apices of
the incisors and canines.
 Posteriorly the zygomatico-maxillary crest
and the solid oblique line buttressing the outer
mandibular cortex offer structural support for
MMF screws.

Risk factors
 dental roots in the lower front and in the dorsal
portion of the alveolar quadrants, notably
between the molars. Furthermore the molar roots
can be irregularly oriented in the bucco-lingual
direction and have polygonal axial cross sections.
 No attempt should be made to drive MMF screws
into the interradicular spaces of the mandibular
or maxillary molars due to the minute sagittal and
vertical bone dimensions. Moreover the palatine
roots of the upper molars would obviate the
horizontal insertion depth of the screws .

 In the mandibular premolar region, the loose soft
tissue envelope immediately surrounding the
mental foramen must be avoided in the placement
of MMF screws in order not to catch, twist or
sever the superficially emerging mental nerve
branches or the neurovascular bundle.
 The mucogingival line and the attached gingiva
immediately adjacent to it give a reliable
guidance to the intermediate third of the tooth
roots both in the mandible and the maxilla.
 The firmly adherent mucosal layer simplifies the
insertion of MMF screws in as much as
protruding soft tissues will not obscure the drill
hole if the contact to the bony surface is lost.

Technique
 MMF screws can be inserted under either local or
general anesthesia.
 In essence, a surface local anesthesia, e.g., by
application of a pump-spray or gel, will suffice
because only the gingiva and the periosteum are
responsible for pain transmission.
 The sensory feedback from deeper intraosseous
structures, particularly the periodontal ligaments
may be valuable for control of the direction of the
screw insertion and a potential need for
correction.

 MMF screws can then be inserted in various
ways:
 Through a perforation of the closed mucosa
or after an open approach exposing the bone
surface .

 In a transmucous procedure the soft tissues
(gingiva, vestibular mucosa) can be punctured
with an electrocautery needle, a No.11-blade
scalpel or a 1-mm punch at the insertion point.
When the screws are passed through an
excessive amount of moveable mucosa, the
exact entry point into the bone will be
uncertain. Reseating the MMF screw when it
has lost contact with the bony hole concealed
by abundant mucosa can be difficult.

 Holes for self-tapping MMF screws can be drilled
with a slow-speed hand-piece under copious
irrigation directly through the thin
mucoperiosteal layer. The mucogingival junction
is the most appropriate site for this procedure.
 The burr is passed through the outer cortex, the
medullary space and optionally into the lingual or
palatal cortices, depending on whether a
monocortical or bicortical placement is desired.
The burr hole reduces the force needed for the
insertion process.

 The cerclage wires between the mandibular and
maxillary MMF screws can be applied in different
patterns, depending on the number and position
of the screws. Temporary MMF is usually
achieved with 26 or 24 gauge (≈ diameter 0.4 or
0.5 mm) prestretched stainless steel wires ligated
around or through the heads of each screw.
 Essentially the wire loops can be put on in a
vertical or a diagonal direction, resulting either in
a straight line parallel order, in a zig zag
arrangement or a combination thereof. Avoid wire
loops running over the unprotected edges of the
upper incisors or the vestibular facet of the upper
cuspids, in particular when longstanding
postoperative MMF fixation is employed.

 Common problems encountered with MMF
screws relate to the three issues:
 Risk of injurying tooth roots
 Soft tissue burying of screw heads in the
anterior mandibular vestibulum19
 Interference of wire loops with the upper
incisor edges or canine facettes

 Numerous and distinctive advantages over traditional
methods were highlighted:
 The simplicity of technical handling
 The ease and speed of application resulting in abbreviated
operating times and cost-effectiveness
 A low risk of inadvertent skin punctures with decreased
risk of transmission of viral pathogens
 High stability of skeletal anchorage for precise
realignment of the preinjury occlusion when the dentition
is preserved
 Minimal amount of hardware in the oral cavity, improved
comfort for the patient and improved oral hygiene
 Compatibility with open reduction and bone plating
osteosynthesis
 Painless and fast removal in the office

A ) Internal Fixation-
1. Suspension Wires
2. Direct Osteosynthesis
B) External Fixation-
1. Craniomandibular
2. Craniomaxillary
Classification of methods of Maxillary Fracture
Fixation

Internal Fixation
Suspension Wires – non-rigid osteosynthesis -
i. Frontal-central or laterally placed
ii. Circumzygomatic
iii. Zygomatic
iv. Circumpalatal/palatal screw
v. Infraorbital
vi. Piriform Aperture
vii. Peralveolar

Internal Fixation
SuspensionWires- Circumzygomatic wiringby Obwegeser.

InternalFixation
SuspensionWires-
Circumzygomaticwiring by Obwegeser

Internal Fixation
SuspensionWires- Orbital rim wiring

Direct osteosynthesis using
intra osseous wires

Various intermaxillary fixation techniques

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