Page 90 - 2022 Spring JSOM

modern arch bar, wire osteosynthesis of fractured bones, and FIGURE 3 (LEFT) Exposed mandible fracture that has been reduced
return to the concept of MMF championed by Thomas Gilmer and plated, maxillomandibular fixation was achieved with arch bars
in 1887. Angle, one of the fathers of modern dentistry, de- prior to plating the fracture.
8
veloped a method of MMF by which fractures were reduced FIGURE 4 (RIGHT) Intraoral photo of the arch bar technique and
by placing bands around teeth adjacent to a fracture and wir- wired together to achieve maxillomandibular fixation.
ing them together, then wiring the jaws shut by placing bands
on the opposing dentition and wiring the jaws together for
immobilization.
What these pioneers in CMF trauma understood was that for
bones to heal, they must be first reduced to their anatomic
position and then immobilized. Stabilization of jaw fractures
reduces the bony fracture and prevents it from moving, which
decreases pain, minimizes damage from continued function, sharp wires are passed between most of the teeth. Even with
and stabilizes the patient until they can get to a higher level of profound local anesthesia, it results in significant patient dis-
care. Failure to stabilize jaw fractures was recognized to be a comfort and bleeding from lacerated gingiva, making it a very
source of long-term health problems, malunion or nonunion, difficult technique to use in any type of forward environment
potential infection, and even death. Many of the techniques and without extensive training. It also exposes the operating
developed over the past few centuries have been discarded, provider to the possibility of multiple sharps injuries and ex-
but many have been further developed and remain to this day. posure to blood borne pathogens. 10
Several other techniques are commonly used to achieve MMF.
Current Therapies of MMF Interdental wiring is a technique where a large wire is passed
between several teeth and tightened down. This is generally
While modern fixation techniques using plates have largely used as a very brief way to achieve MMF under ideal circum-
replaced a reliance on MMF to definitively treat mandibular stances (isolated fractures, minimal displacement, a full den-
fractures, MMF remains a mainstay of reestablishing the oc- tition with excellent occlusion). Ivy loops are another older
clusion prior to placement of plates and, in some cases, remains technique that involves making detailed wire loops, attaching
the definitive treatment of choice for some types of fractures, them to several teeth to serve as an anchor, and then wiring
such as high subcondylar fractures (Figure 3). Stabilizing the together loops on the top and bottom jaws. It is a difficult and
jaw bones is a difficult task, even in a controlled setting like technique sensitive method that is not commonly used, even
the operating room. It is dictated by the teeth and the patient’s among surgeons. 11,12
occlusion—that is the relationship of the top teeth and bottom
teeth and how they come together. There can be confounding There are some newer methods of MMF. MMF screws are
factors that can make this even more difficult, like missing a system where multiple screws are put into the maxilla and
teeth, periodontal disease resulting in tooth mobility, and the mandible and then wired together (Figure 5). While useful in
presence of multiple fractures. In general, all these techniques an operating room by an experienced surgeon, it is also tech-
use some combination of wires, screws, or rubber bands to nique sensitive and frankly requires a detailed understanding
immobilize the teeth and thus the keep the jaws shut, and all of the anatomy of the mandible and maxilla, which is typically
of these techniques are developments of techniques developed relegated to CMF surgeons. Without extensive knowledge,
by health care providers of the past. serious damage can be done with the screws to teeth, vari-
ous nerves, and blood vessels. MMF screws are also prone to
The gold standard technique and a main stay in the armamen- loosening over time, particularly in the maxilla, making long-
tarium of any head and neck surgeon is Erich arch bars, simply term MMF problematic using this technique. Hybrid, or
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called arch bars. Arch bars are a set of prefabricated metal bone-supported, arch bars are made by several companies and
braces that are adapted to both the top maxillary teeth and the are essentially a mix of arch bars but, instead of being wired
bottom mandibular teeth and then tied into all the teeth using to the teeth, are screwed into the bone, then tied together with
wires. Then, wires are used to tie together the metal braces, wire. This system, while faster than Erich arch bars, has the
providing MMF and immobilizing the teeth and jaws (Figure same limitations as other techniques which require the place-
4). This technique is the gold standard because it allows for ment of screws into bone. 14,15 This brings us to our newer tech-
full control of teeth and fractures, is excellent when multiple nique, using Minnie Ties to achieve MMF.
fractures are present that require piecing segments back to-
gether, and controls the bite after surgery. It can also be left in FIGURE 5 Intraoral photo
place for 6–8 weeks for closed reductions that do not require demonstrating maxillo-
opening and plating, allowing the bones to heal in their ana- mandibular screw fixation.
tomic position without movement. Two or more screws are placed
into bone in each jaw and used
The disadvantage of using arch bars is that they are technique to wire the jaws shut. The
sensitive and time consuming and require extensive training mandible fracture is seen and
to be done properly. Even with two experienced surgeons in plate fixation in place.
the controlled environment of an operating room, arch bars
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typically take 30–60 minutes to apply. Comminution of the Minnie Tie Application and Technique
fractures (multiple pieces), poor dentition, and inexperienced Minnie Ties are essentially an oral zip tie (Figure 6). Made
operators can make this time even longer. Doing it without by Invisian Medical in three sizes, with an FDA approval in
general anesthesia is even more difficult as it requires essen- 2017, each Minnie Tie is a braided polyester structure with a
tially anesthetizing the entire gingiva (gums) in the mouth as
bonded polypropylene coating, a blunt metal introducer tip,

88 | JSOM Volume 22, Edition 1 / Sping 2022