Authors of section

Authors

Ricardo Cienfuegos, Carl-Peter Cornelius, Edward Ellis III, George Kushner

Executive Editors

Marcelo Figari, Gregorio Sánchez Aniceto

General Editor

Daniel Buchbinder

Open all credits

ORIF, wire

1. Principles

The intraosseous wire must be placed to resist the upward and forward direction in which the ramus will tend to rotate. Therefore, it is prudent to place the hole through the proximal fragment superiorly to the hole in the distal fragment.

It is not necessary for the intraosseous wire to engage both buccal and lingual cortices on each side of the fracture. It is only necessary to engage the buccal cortices with the wire.
Because this is a nonrigid technique, 5–6 weeks of MMF must be applied after surgery.

Biomechanics of the mandible.

The intraosseous wire will help to prevent rotation of the mandibular ramus

Special considerations

2. Approach

For this procedure the intraoral approach to the angle is normally used.

revision orif

3. Fixation

Exposure of fracture

The fracture should be exposed and any extractions determined necessary be performed. Open reduction in dentate patients usually begins with fixation of the occlusion. However, MMF is not desirable when using intraosseous wire fixation until the wire is to be tightened. It is easier to drill the holes in the bone and to pass the wire while the patient’s jaws are open.

The fracture should be exposed and any extractions determined necessary be performed

Drill holes

A 1.5 mm hole is drilled through the buccal cortex of the distal fragment. A second hole, located more superiorly, is drilled through the buccal cortex of the proximal fragment.

In needed, further information on the transbuccal system can be found here.

If the terminal molar is extracted as part of the procedure, the holes enter the socket. If no tooth is extracted, the holes enter the medullary space and exit into the fracture.

The holes can be drilled with a drill inserted through the oral cavity or alternatively, a Steinmann pin can be inserted transcutaneously to drill the holes.

A 1.5 mm hole is drilled through the buccal cortex of the distal fragment

Applying internal wire fixation

A 0.5 mm wire (24 gauge) is passed through the holes and preliminarily twisted together. Prior to final tightening of the wire, the patient must be placed into occlusion and secured with MMF. The intraosseous wire is then tightened, cut, and twisted down to the bone.

Click here for further details on methods for applying MMF.

A 0.5 mm wire is passed through the holes and preliminarily twisted together

4. Case example

Panoramic and PA x-rays show left simple angle fracture associated with ...

Panoramic and PA x-rays show left simple angle fracture associated with an impacted third molar.

... an impacted third molar.

Panoramic and PA x-rays show left simple angle fracture associated with an impacted third molar.

Because it is anticipated that the second molar might be removed in addition to the third molar the soft-tissue incision is made as demonstrated.

the soft-tissue incision is made as demonstrated

Subperiosteal dissection exposes the fracture and the impacted third molar.

Subperiosteal dissection exposes the fracture and the impacted third molar

The impacted third molar is being removed because it interfered with fracture reduction.

The impacted third molar is being removed because it interfered with fracture reduction

The second molar is also removed because there is a large bony defect along the posterior root.

The second molar is also removed because there is a large bony defect along the posterior root

After making two holes, the wire is then passed from the extraction site out the hole in the proximal fragment.

The second molar is also removed because there is a large bony defect along the posterior root

The wire is then preliminarily tightened. Prior to final tightening, the patient should be placed into MMF.

The wire is then preliminarily tightened

The wire has been tightened, cut, and bent down to lay against the bone.

The wire has been tightened, cut, and bent down to lay against the bone

To facilitate closure over the second molar extraction site, the flap is undermined with scissors.

The flap is undermined with scissors

Note that the flap has now been mobilized.

The flap is undermined with scissors

The flap has been closed over the extraction site.

The flap is undermined with scissors

MMF is secured and left in position for 5–6 weeks. Note this patient’s preexisting malocclusion.

MMF is secured and left in position for 5–6 weeks.

Postoperative panoramic and PA x-rays show reduction of the fracture, ...

Postoperative panoramic and PA x-rays

... the position of the intraosseous wire, and MMF.

Postoperative panoramic and PA x-rays

5. Aftercare following ORIF of mandibular symphysis, body, angle and ramus fractures

If arch bars or MMF screws are used intraoperatively, they are usually removed at the conclusion of surgery if proper fracture reduction and fixation have been achieved. Arch bars may be maintained postoperatively if functional therapy is required or if required as part of the fixation.

Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken after 4–6 weeks.

The patient is examined approximately 1 week postoperatively and periodically thereafter to assess the stability of the occlusion and to check for infection of the surgical wound. During each visit, the surgeon must evaluate the patients ability to perform adequate oral hygiene and wound care, and provide additional instructions if necessary.

Adequate dental care is required in most patients having suffered a mandibular fracture.

If a malocclusion is detected, the surgeon must ascertain its etiology (with appropriate imaging technique). If the malocclusion is secondary to surgical edema or muscle splinting, training elastics may be beneficial. The lightest elastics as possible are used for guidance, because active motion of the mandible is desirable. Patients should be shown how to place and remove the elastics using a hand mirror.

If the malocclusion is secondary to a bony problem due to inadequate reduction or hardware failure or displacement, elastic training will be of no benefit. The patient must return to the operating room for revision surgery.

Follow-up appointments are at the discretion of the surgeon, and depend on the stability of the occlusion on the first visit. If a malocclusion is noted and treatable with training elastics, weekly appointments are recommended.

Postoperatively, patients will have to follow three basic instructions:

1. Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the discretion of the surgeon. Any elastics are removed during eating.

2. Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars and any elastics makes this a more difficult procedure than normal. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.

3. Physiotherapy
Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively. If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite or tongue-blade training.