Mandibulomaxillary Fixation

Author Credentials 

Kevin Caceres, MD
Resident Physician
Otorhinolaryngology
University of Texas Health ScienceCenter at Houston
Houston, TX

Module Summary

Arch bars can be used as definitive treatment of facial fractures or to provide a stable starting point from which to begin open reduction internal fixation. Pediatric fractures and fractures involving the condyle or subcondyle are ideal for definitive treatment with MMF. Placement of MMF arch bars can be tedious, and there are alternative methods of MMF such as IMF screws, but in capable hands it can be a useful surgical tool. It is also necessary to educate patients about the potential complications from MMF placement.

Module Learning Objectives 
  1. Understand indications for MMF.
  2. Review types of MMF.
  3. Demonstrate ability to apply MMF.
  4. Discuss duration of MMF.
  5. Recognize possible complications related to MMF placement.

Anatomy

Learning Objectives 

Understand tooth anatomy including vascular supply

  1. Tooth numbering
  2. Tooth anatomy
    1. Tooth types
      1. Molars
      2. Premolars
      3. Canine
      4. Incisors
    2. Crown
    3. Neck
    4. Root
  3. Tooth vascular supply
    1. Neurovascular bundle
    2. Periodontal ligament
  4. Mandible and maxilla anatomy
  5. Fracture patterns
    1. Lefort Classification
    2. Mandible fracture patterns
      1. Fracture locations
      2. Favorability of mandible fractures
References 
  1. Cornelius, C. P., Audigé, L., Kunz, C., Rudderman, R., Buitrago-Téllez, C. H., Frodel, J., & Prein, J. The comprehensive AOCMF classification system: mandible fractures-level 3 tutorial. Craniomaxillofacial Trauma and Reconstruction. 2014;7(S 01):S031-S043.

Basic Science

Learning Objectives 

Understand principles of fracture healing

  1. Types of bone
    1. Cortical bone
    2. Cancellous bone
  2. Steps of fracture healing
    1. Hematoma formation
    2. Fibrocartilaginous callus formation
    3. Bony callus formation
    4. Remodeling and addition of compact bone
References 
  1. Marsell R, Einhorn TA. THE BIOLOGY OF FRACTURE HEALING. Injury. 2011;42(6):551-555.

Patient Evaluation

Learning Objectives 
  1. Understand how to triage patients
    1. Airway
    2. Breathing
    3. Circulation
  2. Learn to evaluate quality of dentition
  3. Understand fracture types and patterns
  4. Recognize associated injuries
    1. Airway
    2. Soft tissue
    3. Dental injuries
  5. Differentiate between open and closed fractures
  6. Facial nerve function
    1. Facial sensation – V3
References 
  1. Lee J-S, Jeon E-G, Seol G-J, et al. Anatomical and Functional Recovery of Intracapsular Fractures of the Mandibular Condyle: Analysis of 124 Cases after Closed Treatment. Maxillofacial Plastic and Reconstructive Surgery. 2014;36(6):259-265.

Measurement of Functional Status

Learning Objectives 

Understand how fractures can affect function

  1. Trismus
    1. Maximum inter-incisal opening
  2. Occlusion
References 
  1. Gazal G. Evaluation of the effectiveness of early or delayed treatment upon healing of mandibular fractures: A retrospective study. European Journal of Dentistry. 2015;9(1):87-91.

Imaging

Learning Objectives 
  1. Learn to interpret Computer tomography of the facial skeleton and fractures
  2. Learn to interpret panorex films
References 
  1. PMCID: PMC4251726. Buitrago-Téllez CH, Cornelius C-P, Prein J, Kunz C, Ieva A di, Audigé L. The Comprehensive AOCMF Classification System: Radiological Issues and Systematic Approach. Craniomaxillofacial Trauma & Reconstruction. 2014;7(Suppl 1):S123-S130.

Treatment

Learning Objectives 
  1. Understand the principle of fracture fixation
    1. Rigid fixation
    2. Semi-rigid fixation
    3. Compression
    4. Approximation
  2. Indications for MMF
    1. Mandibular fractures
      1. Condylar fractures
      2. Pediatric fractures
      3. Favorable fractures
    2. Midface fractures
      1. Foundation principle
  3. Contraindications to MMF
    1. Mental status
    2. Follow-up
    3. Dentition
  4. Duration of MMF
    1. Timeline of bone healing
    2. Effects of prolonged MMF
      1. Trismus
      2. Oral hygiene
      3. Weight loss
References 
  1. PMCID: PMC3408273. Choi KY, et. al. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg. 2012;39(4):301-308.

Medical Therapies

Learning Objectives 
  1. Analgesics
    1. Opioid
    2. Non-opioid
    3. Local
  2. Antibiotics
    1. Indications
    2. Commonly used drugs
  3. Oral hygiene
    1. Mouth rinses
References 
  1. PMCID: PMC4329036. Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and Facial Fractures: Evidence-Based Recommendations Compared with Experience-Based Practice. Craniomaxillofacial Trauma & Reconstruction. 2015;8(1):64-78.

Surgical Therapies

Learning Objectives 
  1. Become familiar with types of MMF
    1. Arch bars
    2. Piriform wiring
    3. Circumzygomatic wiring
    4. Circum-mandibular wiring
    5. Intermaxillary Fixation screws
    6. Ernst Ligatures
    7. MatrixWAVE Synthes MMF system
    8. Stryker SMARTLock Hybrid MMF system
  2. Become proficient in arch bar placement
    1. Technique
      1. Direction of arch bars
      2. Measuring and cutting the bar
      3. Ligature preparation and placement
      4. Number of teeth to wire
      5. Wire twisting
      6. Wire loop placement
    2. Wire gauges
References 
  1. PMCID: PMC3052677. Cornelius C-P, Ehrenfeld M. The Use of MMF Screws: Surgical Technique, Indications, Contraindications, and Common Problems in Review of the Literature. Craniomaxillofacial Trauma & Reconstruction. 2010;3(2):55-80.
  2. PMCID: PMC4444724. Chhabra N, Chhabra S, Thapar D. Evaluation of Two Different Methods of Arch Bar Application: A Comparative Prospective Study. Journal of Maxillofacial & Oral Surgery. 2015;14(2):432-440.

Rehabilitation

Learning Objectives 

Trismus bite block

  1. Trismus
    1. Therabite
    2. Jaw exercises/stretches
References 
  1. PMCID: PMC3584250. Kamstra JI, Roodenburg JLN, Beurskens CHG, Reintsema H, Dijkstra PU. TheraBite exercises to treat trismus secondary to head and neck cancer. Supportive Care in Cancer. 2013;21(4):951-957.

Case Studies

  1. 11-year-old boy that fell off his bike and now has a right parasymphyseal fracture and a left subcondylar fracture.
    1. Arch bar placement for definitive treatment instead of open reduction internal fixation due to the fact he will continue to grow
    2. If ORIF would be performed the plates would have to be absorbable or would have to be removed later.
  2. 27-year-old man was assaulted and suffered a right subcondylar fracture and a left mandibular body fracture.
    1. The body fracture can be repaired using ORIF
    2. He can be left in MMF with arch bars as a splint to treat the subcondylar fracture.
References 
  1. PMCID: PMC3324216. Koshy JC, Feldman EM, Chike-Obi CJ, Bullocks JM. Pearls of Mandibular Trauma Management. Seminars in Plastic Surgery. 2010;24(4):357-374.
  2. PMCID: PMC3408272. Choi K-Y, Yang J-D, Chung H-Y, Cho B-C. Current Concepts in the Mandibular Condyle Fracture Management Part I: Overview of Condylar Fracture. Archives of Plastic Surgery. 2012;39(4):291-300.

Complications

Learning Objectives 
  1. Risk of penetrating injury to surgeon during placement of arch bars
  2. Increased surgical and anesthesia time.
  3. Injury to the periodontium
  4. Compromised oral hygiene.
  5. Vomiting postop with inability to cut MMF wires causing aspiration.
  6. Patient anxiety.
  7. Weight loss.
References 
  1. PMID: PMC4979336. Qureshi AA, et al. Intermaxillary fixation screws versus Erich arch bars in mandibular fractures: A comparative study and review of the literature. Ann Maxillofac Surg. 2016;6(1):25-30.

Review

Review Questions 
  1. What are the three main parts of a tooth? From where does a tooth derive is blood supply?
  2. Name 4 types of maxillomadibular fixation.
  3. What is one situation in which MMF can be used as definitive treatment?