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ORIGINAL RESEARCH
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 27-31

To compare the efficiency of maxillomandibular fixation screws over erich arch bar in achieving intermaxillary fixation in maxillofacial trauma: A clinical study


Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India

Date of Web Publication6-Jul-2018

Correspondence Address:
Dr. Ninad Rangnekar
Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_23_17

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   Abstract 


Introduction: Intermaxillary fixation (IMF) is regarded as a significant step in the management of maxillofacial trauma. Various techniques have been mentioned in the literature for achieving maxillomandibular fixation (MMF). The conventional methods such as arch bars and eyelet wiring are the most commonly used, but these methods have their own shortcomings. With the introduction of self-tapping MMF screws in 1989, many of the drawbacks with the use of arch bars can be eliminated. Hence, the aim of this study was to compare the efficiency of MMF screws over arch bars in achieving IMF. Materials and Methods: Thirty patients that required IMF as a part of their treatment and reported to the Department of Oral and Maxillofacial Surgery KLE VKIDS and Dr. Prabhakar Kore charitable hospital, K LE, Belgaum, were included in the study. Patients were divided randomly into two groups: Group A: Patients treated using MMF screws and Group B: Patients treated using arch bars. Statistical analysis was performed using the Mann–Whitney U-test and unpaired t-test. Results: There was a significant difference in oral hygiene index between the two groups at the end of the 14th postoperative day. The time taken for the placement of MMF screws was significantly less (mean 18.7 min) as compared to arch bars (mean 41.2 min). Screw loosening was seen in 4 (26%) out of 15 patients and 3 screws (4.5%) out of 66 screws used showed partial mucosal coverage at the end of 2 weeks. There were no cases of penetration injury in Group A, while in Group B, penetration injury to the surgeon was noted in 5 (33.3%) cases. Conclusion: MMF screws provided good intraoperative MMF. Placement of screws consumes less time and reduces the intraoperative period and also the risk of penetration injury to the surgeon. We also observed better oral hygiene, better patient compliance, and no major complications with the use MMF screws. Hence MMF screws proved to be an efficient alternative to the conventional methods of achieving IMF.

Keywords: Erich arch bars, intermaxillary fixation, maxillomandibular fixation screws


How to cite this article:
Balihallimath L, Jain R, Mehrotra U, Rangnekar N. To compare the efficiency of maxillomandibular fixation screws over erich arch bar in achieving intermaxillary fixation in maxillofacial trauma: A clinical study. J Int Clin Dent Res Organ 2018;10:27-31

How to cite this URL:
Balihallimath L, Jain R, Mehrotra U, Rangnekar N. To compare the efficiency of maxillomandibular fixation screws over erich arch bar in achieving intermaxillary fixation in maxillofacial trauma: A clinical study. J Int Clin Dent Res Organ [serial online] 2018 [cited 2018 Dec 15];10:27-31. Available from: http://www.jicdro.org/text.asp?2018/10/1/27/236091




   Introduction Top


Evolution has made humans quite susceptible to frontal impacts. Trauma to the facial region is common in road traffic accidents, sports-related injuries, and assaults. Maxillofacial trauma represents 42% of all injuries. In these, 70% are mandibular fractures and 30% are maxillary fractures. Since the ancient times, intermaxillary fixation (IMF) has been used alone to treat fractures of maxilla and mandible. This was achieved by attaching a metallic framework to the teeth to provide support to the fractured segments and then IMF was done with elastics or wires. Due to the lack of rigid fixation, the period of IMF was longer which used to cause discomfort to the patient.[1]

IMF/maxillomandibular fixation (MMF) is considered one of the most important steps in the management of maxillofacial trauma. It is required to register and secure the correct interach relationship of the occlusal surfaces and to maintain this relation for the proper reduction and fixation of fracture fragments.

Various methods to achieve IMF have been described in literature such as Ivy eyelet wiring, Risdon wiring, arch bars, metal splints, acrylic splints, gunning type splints for edentulous patients, bonded brackets, and more recently self-tapping and self-drilling MMF screws.

Erich arch bars have been considered as the standard for achieving MMF because of its rigidity and versatility.[2] Although they provide superior occlusion control and reliable fixation, they have many disadvantages including difficulty in maintaining oral hygiene, trauma to the periodontium, reduced patient compliance and discomfort, longer time required for placement, and risk of needle stick injury. Tooth avulsion during the twisting and tightening of the wire around the tooth has also been reported in literature. Furthermore, wires tightened during the application of arch bars around the teeth may cause ischemic necrosis of the mucosa and the periodontal membrane and if damage is extensive, tooth loss may result (Wilson and Hohmann, 1976).[3]

To overcome these problems, alternate techniques such as self-tapping IMF screws have been introduced. These screws provide a bone-borne support for the MMF wires to achieve IMF instead of a tooth-borne support in the case of arch bars. Due to this, many complications related to tooth-borne devices such as poor oral hygiene and periodontal health can be avoided.[4] The concept of direct transosseous wiring for MMF has been previously communicated in the literature but is no longer routinely used. However, with the use of cortical bone screws, these traditional techniques can be implemented more readily and effectively.

The purpose of this prospective study was to assess the efficacy of MMF screws in both maxillary and mandibular fractures and to compare it with Erich arch bars to identify the better method of achieving IMF and to record the complications related to both.

The parameters taken into consideration were the surgical time taken for placement and removal of both MMF screws and Erich arch bars and the complications related with both the techniques and effect on oral hygiene.


   Materials and Methods Top


The study was carried out on a total of thirty patients to compare the efficiency of MMF screws over Erich arch bars as a mean of IMF in the treatment of maxillary and mandibular fractures that reported to the Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences and KLES Dr. Prabhakar Kore Hospital, Belgaum. Patients were selected by random sampling and those aged 18 years and above and with fractures of maxilla and mandible which required IMF as a part of their treatment were included in the study.

Patients with dentoalveolar and panfacial fractures, having primary and mixed dentition, and patients having systemic diseases such as rheumatoid arthritis and bronchial asthma were excluded from the study.

Methodology

  • The selected patients were randomly divided into two groups of 15 each and designated as Group A and B
  • All the thirty patients were treated by open reduction and internal fixation under general anesthesia
  • In Group A, IMF was achieved by 4–6 stainless steel IMF screws
  • In Group B, IMF was achieved by Erich Arch Bar, with 26-gauge wire
  • Self-tapping IMF screws were 2 mm in diameter, 8 and 10 mm in length, and its head was 4 mm in length and 4 mm in diameter. The most preferred site is between the canine and first premolar in each arch. Attempts were made to orient the long axis of the screws at 90° from the roots of the adjacent teeth. The screw had a pointed tip and its head had a slot where the wire can be passed for IMF
  • After removal of the screws and arch bars, oral hygiene status was evaluated using Turesky-Gilmore-Glickman Modification of Quigley-Hein plaque index and also vitality of teeth adjacent to screws was checked with electrical pulp testing.
  • Postoperative instructions were given:


    • All Patients were asked to brush the teeth with soft baby toothbrush
    • Use mouthwash at least four times in a day
    • Regular follow-up.



   Results Top


Thirty patients reporting to the Department of Oral and Maxillofacial Surgery, KLE VKIDS Belgaum, presenting with the fracture of mandible or maxilla were selected for the study. The patients were divided into two groups of 15 each. Group A consisted of patients treated using MMF screws and Group B consisted of patients treated using arch bars.

Distribution of male and females

  • In Group A, all the 15 patients were males (100%)
  • In Group B among the 15 cases, there were 14 males (93.3%) and 1 female (6.7%).


Age distribution and mean age

One (3.3%) patient was below 20 years, 12 (40%) patients were between 20 and 30 years, 12 (40%) patients were between 30 and 40 years, and 5 (16.6%) patients were between 40 and 50 years of age.

In Group A, the mean age was found to be 33.53 (standard deviation [SD] 9.43) and in the group to the mean age was 32.6 (SD 9.6).

Diagnosis

Among the 30 patients, 4 (13.3%) had fracture of parasymphysis, 6 (20%) had Le Fort II fracture, 6 (20%) patients had angle and parasymphysis fracture, 3 patients (10%) had angle fracture, 2 (6.7%) had Le Fort II fracture, 2 (6.7%) patients had symphysis fracture, 2 (6.7%) patients had body of mandible fracture, 1 (3.3%) patient had Le Fort III fracture, 1 (3.3%) patient had body of mandible and angle fracture, 1 (3.3%) patient had angle and ZMC fracture, 1 (3.3%) patient had body of mandible and parasymphysis fracture, and 1 (3.3%) patient had parasymphysis and ZMC fracture.

Oral hygiene index

Plaque index score was calculated using Turesky-Gilmore-Glickman Modification of Quigley-Hein Plaque Index. The mean plaque index score in Group A was 0.95 (SD 0.26), and in Group B, the mean plaque index was 3.14 (SD 1.21). The results were statistically significant using Mann–Whitney U-test with P = 0.00001*.

Time taken

The mean time taken for the placement of MMF screws in Group A was 18.73 min (SD 3.26) and the mean time taken for the placement of arch bars in Group B was 41.27 min (SD 5.20). The results were statistically significant using unpaired t-test with P = 0.00001*.

Complications

Penetration injury to the surgeon

There were no cases of penetration injury in Group A, while in Group B, penetration injury to the surgeon was noted in 5 (33.3%) cases.

Complications encountered with the use of maxillomandibular fixation screws

Screw loosening was seen in 4 (26%) out of 15 patients. Out of the total number of screws placed (66) in our study, 7 (10.6%) screws became loose at the end of 2nd week.

Three screws (4.5%) out of 66 screws used showed partial mucosal coverage at the end of 2nd week.

No cases were reported with root damage and screw breakage.


   Discussion Top


IMF is an essential step to achieve temporary dental occlusion during operative and postoperative phase of treatment. However, in the present era of miniplate osteosynthesis, open reduction is preferred to reduce the duration of hospitalization with minimal discomfort to the patient and early return to the work.

The aim of this study was to find an improved technique for achieving IMF.

These screws were first introduced in the year 1989 by Arthur and Berardo to overcome the problems associated with tooth-borne devices.[5]

IMF screws are inserted into the alveolar process of the maxilla and mandible monocortically and act as an anchor point for MMF wires which passes through the holes incorporated in the specialized screw heads kept 4–5 mm above the alveolar mucosa. Transmucosal IMF screws were first described in a 4-point fixation pattern with at least one screw in each quadrant.[3] MMF screws can also be used in different patterns such as one screw in each quadrant and two in the midline or two screws in each quadrant with or without screws in the midline. The choice of different patterns of screw placement depends on the site of fracture and the time period for which IMF is required.

The MMF screws have various advantages over the arch bars:

  1. Requires much less time for placement hence shortens the operating time
  2. Easy to maintain good oral hygiene
  3. Minimal trauma to the periodontium
  4. Reduced risk of needlestick injury with the sharp wires
  5. Better patient compliance.


With the above-mentioned advantages, it also has demerits in cases where postoperative MMF is needed:

  1. Iatrogenic injury to the roots
  2. Screw loosening
  3. Mucosal coverage of screw, etc.


In the present study, we compared the plaque accumulation in both the groups to identify a technique with better ease of maintaining the oral hygiene. The mean plaque index value was found to be higher in Group B, i.e., patients treated using Erich arch bars. This implies that, with the use of MMF screws, maintenance of oral hygiene is improved, also the risk of periodontal diseases is significantly reduced. We also noticed better patient compliance with the use of MMF screws than arch bars.

Rai et al.,[6] in a comparative study also reported more plaque accumulation in patients treated using Erich arch bars as compared to MMF screws. They found a significant difference between the plaque index values of both the groups, and on the basis of this, they concluded that maintenance of oral hygiene is better in patients treated using MMF screws.

In this study, the time taken for the placement of arch bars and MMF screws was also noted. The data showed that maximum time (approximately 45 min) was required for the placement of Erich arch bars. The average time for the placement of MMF screws was found to be 18.7 min, which suggested reduced intraoperative time and shorter duration of general anesthesia.

Farr and Whear [7] reported a case of fracture of screw at the junction of screw head and threaded portion. In the present study, no such case of screw fracture was encountered. Another complication mentioned with the use of MMF screws was iatrogenic injury to the roots of the teeth adjacent to the site of screw insertion.

Coletti et al.,[8] advised the use of self-drilling screws as they have higher tactile feedback during placement. It can prevent root damage as it allows the surgeon to modify the insertion position of the screw in case of high resistance. Despite this, the author encountered root fracture during screw placement in 2 (4%) out of 49 patients. Both the teeth were eventually extracted. In this study, there were no occurrences of root damage associated with IMF screws. Hence, proper planning before the insertion of MMF screws is essential. The site for screw placement should be determined after comprehensive radiographic assessment with the use of Orthopantomographs and intraoral periapical radiographs. The three-dimensional relationship of the path of insertion of the screw with the surrounding dental structures should be carefully assessed to reduce the iatrogenic dental trauma.

In the present study, the most common complication that occurred with the use of MMF screws was screw loosening. At the 14th postoperative day, screw loosening was seen in 4 (26%) out of 15 patients. Out of the total number of screws placed (66) in our study, 7 (10.6%) screws became loose at the end of 2nd week.

Screw loosening mainly occurs due to the force exerted by the oral musculature, while the patient is in IMF. It can also occur when the direction of screw is not perpendicular to the occlusal plane.[6]

Another complication that occurred with the use of MMF screws was the coverage of the screw head with oral mucosa. Rai et al.[6] reported a high incidence of mucosal coverage of the screws. Out of the 240 screws used in the study, 44 (18.3%) screws were completely submerged in oral mucosa at the end of 4th week. Author stated that the cause behind the high occurrence of this complication was perhaps the IMF screws were placed high up in the movable alveolar mucosa rather than in the adherent mucosa.

In our study, the incidence of needlestick injury was also noted. We found 33% incidence of penetrating injury to the surgeon with the use of Erich arch bars. There was no such occurrence with the use of MMF screws.


   Conclusion Top


The study was conducted on thirty patients which reported to the department of oral and maxillofacial surgery that required IMF as a part of their treatment.

Based on this study, we can conclude that MMF screws provided good intraoperative MMF. Placement of screws consumes less time and reduces the intraoperative period. The risk of penetration injury to the surgeon with the use of sharp stainless steel wires is also reduced. We also observed better oral hygiene and better patient compliance with the use MMF screws. Postoperatively, there was no incidence of pain, infection, injury to adjacent tooth root, or nerve damage. The only complication encountered with the use of MMF screws was screw loosening at the end of 2nd week. Hence, if IMF is desired for a longer time period, MMF screws may not be the best choice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Fonseca RJ. Oral and Maxillofacial Trauma Pennsylvannia. 2nd ed. Vol. 1. New York: WB Saunders Company; 1991. p. 359-414.  Back to cited text no. 1
    
2.
Ring ME, Harry N, editor. Dentistry – A Illustrated History 1992. New York: Abrahams Inc. Publishers; 1992. p. 70.  Back to cited text no. 2
    
3.
Peter Banks. Killey's Fracture of Mandible. 4th ed. Bombay: Varhese Publishing House; 1993. p. 46.  Back to cited text no. 3
    
4.
Jones DC. The intermaxillary screw: A dedicated bicortical bone screw for temporary intermaxillary fixation. Br J Oral Maxillofac Surg 1999;37:115-6.  Back to cited text no. 4
    
5.
Arthur G, Berardo N. A simplified technique of maxillomandibular fixation. J Oral Maxillofac Surg 1989;47:1234.  Back to cited text no. 5
    
6.
Rai A, Datarkar A, Borle RM. Are maxillomandibular fixation screws a better option than erich arch bars in achieving maxillomandibular fixation? A randomized clinical study. J Oral Maxillofac Surg 2011;69:3015-8.  Back to cited text no. 6
    
7.
Farr DR, Whear NM. Intermaxillary fixation screws and tooth damage. Br J Oral Maxillofac Surg 2002;40:84-5.  Back to cited text no. 7
    
8.
Coletti DP, Salama A, Caccamese JF Jr. Application of intermaxillary fixation screws in maxillofacial trauma. J Oral Maxillofac Surg 2007;65:1746-50.  Back to cited text no. 8
    




 

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