WIRING TECHNIQUES IN MAXILLOFACIAL

SURGERY

presented byp.dinesh kumar. Mds

frcs

INDICATIONS FOR CLOSED REDUCTION

Non displaced and favourable fractures

grossly communited fractures

edentulous atrophic mandible

fractures in children

condylar fractures

CONTRA INDICATIONS

patients with poorly controlled seizures

patients with compromised pulmonary fn

patients with psychatric or neurological disorders

VARIOUS TYPES OF WIRING

DIRECT INTERDENTAL WIRING:

ESSIG’S WIRING GILMER’S WIRING RISDON’S WIRING

INDIRECT INTERDENTAL WIRING IVY LOOP OR EYELET WIRING

CONTINOUS OR MULTIPLE LOOP WIRING

ARCH BAR FIXATION

CIRCUM MANDIBULAR WIRING

PER ALVEOLAR WIRING

SUSPENSION WIRING

CIRCUM ZYGOMATIC WIRING FRONTAL SUSPENSIONPIRIFORM APERTURE SUSPENSION ZYGOMATIC BUTRESS SUSPENSION INFRA ORBITAL SUSPENSION

DIRECT INTERDENTAL WIRING

ESSIG’S WIRING

Used to stabilize dento alveolar fracture as well as it can be used as anchoring device for IMF.

There should be sufficient number of teeth on either side of the fracture line.

A 40 cm 26 guage prestretched stainless steel wire is used.

The wire is passed interproximally between two teeth present a little away from fracture line.

The wires are passed around the teeth in a figure of 8 manner until they reach 2 to 3 teeth away from the fracture line.

Now the wires are passed without looping to the other side of the fracture line and 2 to 3 teeth away from the fracture line on the opposite side.

Again the wires are taken around 2 to 3 teeth in a figure of 8 manner.

Now this acts as an arch bar on which the other smaller wires are tightened to stabilize the fracture.

GILMER’S WIRING

It is used for IMF.

Most common and simple method.

Few firm teeth in the mandible as well as in maxilla are chosen.

At least one firm teeth must be chosen anterior and posterior to the fracture line.

A pre stretched 20 cm long 26 guage wire is taken and passed around the neck of the chosen tooth.

Both the ends of the wire are brought out on the buccal side and twisted.

The same procedure is carried out for all the chosen teeth in the individual arches.

Then the mandibular wires are twisted tightly with the corresponding maxillary wires.The ends are cut short and sharp ends are tucked in.

The main disadvantage of this wiring is that there may be extrusion of the teeth as excess load is applied.

Another disadvantage is of requiring complete removal of the wires to open the mouth in emergency situations.

RISDON’S WIRING

It is commonly used method of horizontal wire fixation.

This can be a substitute technique for arch bar.

In this method second molars are usually chosen for anchorage on either side.

A 25 cm long 26 guage wire is passed around the neck of second molar on each side and both the ends are brought in buccal side.

The ends are twisted for entire length thus forming a strong base wire that comes towards the midline from each second molars.

Two base wires are grasped and twisted at mid line and adapted to the necks of the teeth on the buccal side .

This base wire is secured to individual teeth by using additional interdental wires.

This type of horizontal wiring offers strong fixation.

IVY EYELET WIRING

The Ivy loop embraces the two adjacent teeth.one or two Ivy eyelets should be placed in each quadrant.

A 26 guage stainless steel wires cut in 20 cm lengths are used.

A loop is formed in center of wire around the beak of a towel clip or shank of dental bur and twisted thrice with two tail ends. Such Ivy loops can be preformed and stored in cold sterilizing solution for emergency use.

The two tail ends of the eyelet are passed through the interdental space of the selected two teeth from buccal to lingual side.

One end of the wire is passed around the distal tooth lingually and brought out from the distal interdental space over the buccal side and threaded through the previously formed loop.

The other wire tail end is carried around the lingual surface of the mesial tooth and brought out on the buccal surface from the mesial interdental space, where it meets the first tail end wire.

The two wires are crossed and twisted together and the loop is adjusted and bend towards gingiva.

The mandibular wire eyelets can be secured to maxillary eyelets by joining wires.

Advantage is that bridging wires can be removed whenever required without disturbing the main wiring.

Even when there is breakage of wire during fixation only that eyelet can be removed and replaced.

HALLAM MODIFICATION ( 1945 )

WILLIAM MODIFICATION ( 1968 )

CLOVE HITCH METHOD

STOUT’S MULTI LOOP WIRING

The posterior part of four quadrants are used for wiring.

4 pieces of 26 guage 20 cm long wires are required and piece of solder is used for making loops.

The piece of solder wire is adapted to buccal surface of teeth.

The 20 cm long pre stretched wire is folded into two parts, one part acts as the stationary wire and the other end is brought distal to the second molar and taken around it on lingual side.

This working end is threaded through the mesial side of second molar to the buccal side under the solder wire.

It is then looped around the stationary wire and solder wire and back into the interdental space from buccal to lingual. The same procedure is repeated for each tooth up to midline.

The solder wire is removed after the loops are formed and the loops are twisted to form eyelets.

Finally the stationary and working ends of the wires are twisted together.

ARCH BAR FIXATION

The arch bar is a flat, sturdy stainless steel bar on which fleats or hooks are attached.

It is a effective, quick and inexpensive method of fixation.

The different types of arch bars are, pre fabricated custom made acrylated arch bars directly bonded arch bars

Of these the most commonly used are the pre fabricated Erich arch bars.

CUSTOM MADE ACRYLATED ARCH BAR

The arch bar is measured to fit from first molar to first molar.

The arch bar is placed in such a way that the fleats or hooks face towards the gingival margin.

Now 15 cm of 26 guage wire is taken and starting from the distal tooth, the wire is passed from buccal to lingual side below the arch bar and from lingual to buccal above the arch bar and twisted together.

This is continued for all the teeth and the arch bar is secured.

When placing an arch bar across a displaced fracture segment,it is cut at the fracture site and placed seperately.

PER ALVEOLAR WIRINGTwo 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 thresded through the eye and the wire is withdrawn with it the wire 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.

SUSPENSION WIRING

FRONTAL SUSPENSIONIt is used for fracture of maxilla at the Le Fort II or III level

Arch bar is secured in the upper and lower arch

The frontozygomatic region is exposed with a small lateral eyebrow incision.

A hole is drilled in the zygomatic process of frontal bone which is 5mm above the frontozygomatic suture.

A pre stretched 26 gauge SS wire is passed through this hole and bent back so that an equal length protrudes on either side of this bur hole.

The two ends of wire are threaded through the eye of Rowe’s zygomatic awl and crimped.

The awl is then passed downwards and forwards behind the frontal process of the zygomatic bone deep to the zygomatic arch to pierce through the oral mucosa in the upper buccal sulcus in the region of upper molar teeth.

The wire ends are detached from the awl and secured nwith an artery forceps while the awlm is withdrawn. These wire ends are to be secured on arch bar.

A small SS wire which is threaded beneath the suspension wire and the passes through the bone and is twisted is called Pull-out wire. This wire negotiates the making of incision again to expose the wire.

Suspension wires are placed on both sides for uniform suspension and occlusion is checked and the wire is then secured to the arch bar

CIRCUMZYGOMATIC WIRING

It is used for fixing a Le Fort I fracture.

The point of suspension is in the region of junction between the frontal and temporal process of the zygomatic bone.

An awl is introduced either directly through the skin or through a small stab incision made in that region.

The awl pierces the temporal fascia and passes medial to the zygomatic bone and zygomatic buttress to pierce the buccal sulcus in the region of first molar.

A pre stretched 26 gauge SS wire is then attached to the eye of the awl and crimped.

The awl is withdrawn just above the zygomatic arch and reinserted this time lateral to the zygomatic bone and directed downwards and forwards to emerge through buccal sulcus. This makes wire loop around zygomatic bone.

The wire ends are secured and adjusted so as they rest on zygomatic bone.

The ends of the wire are then secured to the arch bar.

PIRIFORM APERTURE SUSPENSION

This can again be used for the fixation of a Lefort I fracture as the piriform aperture is a stable bone present above the level of the fracture level.

The piriform aperture is exposed by an intraoral incision and a hole is drilled.

Wire is threaded through this hole and then attached to the arch bar.

ADVANTAGES OF CLOSED REDUCTION

more conservative procedure

No complications associated with surgery is present

Can be done in medically compromised patients

DISADVANTAGES

airway compromise due to IMF

Loss of function of tissues

decreased nutritional status of patients

only occlusion is taken as a guide

Difficulty in speech

Social inconvinience

EFFECTS OF PROLONGED IMF

Formation of adhesions in joint

Thinning and necrosis of articular cartilage

Osteoporosis of bone due to disuse

Atrophy and weakening of muscles due to disuse

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