Page 92 - 2022 Spring JSOM

the Minnie Ties can be trimmed and excess tie cut off, using methods require additional instruments, such as wire drivers,
any normal pair of scissors, or cutting implement (Figure 17). wire cutters, screw drivers, screws, wires, arch bars, etc.
Because the clasp is one way, the Minnie Ties can be trimmed
against the clasp. One of the disadvantages of the Minnie Tie technique is the
fact that the patient needs a relatively full complement of
FIGURE 16 (LEFT) Technique of tightening; the clasp is stabilized dentition. Patients need solid interproximal contacts between
with a secondary instrument and a hemostat or wire driver used to
tightened. Ensure the tie is pulled directly out from the clasp and not teeth in order for this technique to be used successfully. Pa-
deviating up or down, or side to side, to ensure maximal results. tients with multiple missing teeth or advanced periodontal
disease with tooth mobility may not be good candidates for
FIGURE 17 (RIGHT) Minnie Ties placed on a patient, tightened, and
trimmed. this technique. However, there are some various applications
of Minnie Ties that can overcome some of these limitations.
Minnie Tie cannot be used on edentulous patients (no teeth) or
patients with no opposing teeth (missing all the top or bottom
teeth). Minnie Ties are only FDA approved to be left in place
for 3 weeks. However, many providers have used them for
longer in an “off-label” fashion without complications, and
with no appreciable loosening of the ties (we include for your
information but do not recommend using them off-label).
Minnie Ties may not be a suitable technique for a comminuted
As mentioned above, Minnie Ties can be easily cut with almost mandible fracture in which the maxilla or mandible is frac-
any scissor type. The authors recommend that anytime a pa- tured into multiple pieces, though more experienced provider
tient is placed into MMF (by any method), a pair of scissors can and do treat these types of fractures using Minnie Ties.
(or wire cutters if arch bars are used) are placed on a cord One noted problem is that they tend to floss between contacts
around the patients neck to wear like a necklace in the event when tightened, particularly if the teeth are mobile or the in-
that they require immediate removal. In the event that some- terdental contacts are not tight. This can be overcome by using
thing needs to be checked in the mouth or the airway accessed, more ties and using the larger-diameter ties. 16
the ties can be cut, the intervention or examination performed,
and then a new set reapplied. In the patient who is intubated Another pertinent consideration is the airway. In patients who
orally, the tube being between the teeth precludes any type of are unstable or have the potential to become quickly decom-
MMF. Therefore, providers can consider a nasal intubation, a pensated, we recommend caution with using the technique.
submental intubation, or a surgical airway, but the consider- On a patient who is otherwise stable, awake, oriented, and
ations for each of those are beyond the scope of this article. responsive, this is a safe technique, as well as on a patient with
These more complex situations are beyond the scope of the ar- a secured airway. An oral intubation would preclude this tech-
ticle, but worth discussing with a CMF surgeon in more detail nique since the tube would be between the teeth, but if a nasal
for any interested parties. tube, surgical airway, or submental intubation is present, then
this technique works on a secured airway. We recommend
on any patient to keep a set of scissors or wire cutters on a
Discussion necklace or loop of material around the patient’s neck so they
The use of this technique is FDA approved and indicated for can be quickly released if needed. Releasing the Minnie Ties is
establishment of MMF. It is novel in the sense that it has not easily accomplished by simply cutting them and should take
been brought to the military context or battlefield. It is used 15–30 seconds even by first-time users.
routinely in the authors’ clinical military hospital–based prac-
tice and is approved and available to order within the govern- Summary
ment ordering system as it has undergone the application and
approval process by the government. Fractures of the MMF complex are a common injury on the
modern battlefield. These fractures can be challenging as there
One of the advantages of Minnie Ties over traditional methods is often limited lighting, poor facilities, difficulty maintaining
of MMF is operator safety. The application of arch bars and sterility, and little or no radiology support. Additionally, when
ivy loops, as discussed above, places the operator at risk for treating local national patients, evacuation to higher levels of
sharp injuries as multiple wires are passed between the teeth, care may not be available, necessitating definitive care. Mili-
causing bleeding, and between the arches. The introducer of tary providers, particularly those assigned to SOF, often treat
the Minnie Tie is blunt, making them much safer than these patients in remote environments without the benefits of an
techniques. Patient safety is a third advantage, as there is less operating room, sterilization, specialist consults, or specialized
trauma to the gingival tissues and there is no risk of damaging equipment. Having access to a technique for treating maxillo-
roots as there is with the application of MMF screws or hybrid mandibular fractures that has minimal equipment requirements,
arch bars. A third advantage is ease of application. Erich arch does not require advanced knowledge of the anatomy of the fa-
bars and ivy loops are technique sensitive and time-consuming, cial skeleton, and is relatively easy to perform is ideal to the SOF
while Minnie Ties can be applied quickly and easily. One small provider. We believe the Minnie Tie fixation technique would be
case series showed an average placement time of 12–15 min- a valuable technique to add to the arsenal of any SOF provider.
utes. A detailed knowledge of the underlying anatomy of the
16
maxillomandibular complex, while essential to the placement Disclaimer
of MMF screws and bone supported arch bars, is not required. The views expressed herein are those of the authors and do
Fourth, Minnie Ties are small and lightweight and would be not reflect the official policy of the Department of the Army,
an ideal addition to a simple dental trauma kit, while all other Department of Defense, or the US Government.

90 | JSOM Volume 22, Edition 1 / Sping 2022