Authors of section

Author

Boaz Arzi

Executive Editor

Amy Kapatkin

General Editor

Frank Verstraete

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Circummandibular wiring and dental composite

1. Principles

The overall goal is to restore occlusion, normal anatomy and function.

Restoring and maintaining occlusion is the most important aspect of fixation of symphyseal separation and parasymphyseal fractures.

The mandibular bone at the level of the symphysis is almost completely occupied by dental roots. Therefore, invasive fixation is not recommended. Orthopedic wiring around the rostral mandibles or between the canine teeth provide adequate reduction and stabilization.

Dog mandible parasymphyseal simple fracture circummandibular wiring dental roots

Circummandibular wiring can be done in the absence of one or both canine teeth.

Pharyngeal intubation is not needed for this procedure.

Dog mandible parasymphyseal simple fracture circummandibular wiring

2. Positioning and approach

This procedure is performed through the rostral ventral approach, with the patient placed in dorsal recumbency.

dorsal recumbency   midface

3. Preliminary assessment

The fractured area is clipped to assess for penetrating injuries. If a penetrating wound is found, an exploratory surgery and debridement of the area is indicated to remove any foreign bodies (i.e. hair).

A comprehensive intraoral examination must be performed to assess for any injury affecting occlusion, teeth trauma and periodontal tissues.

Dental radiographs and a CT are obtained to provide details about the dentoalveolar structures in relationship to the fracture or separation.

4. Reduction

Reduction of the separation or fracture is done digitally, bringing the teeth into normal occlusion, which realigns the bones.

Dog mandible parasymphyseal simple fracture circummandibular wiring reduction

5. Fixation

Approach

The patient is placed in dorsal recumbency. A 10mm ventral incision is made over the symphysis.

Dog mandible symphyseal separation ventral approach skin incision

The wire should be passed as close to the bone as possible, to avoid soft tissue within the wire. Place a large gauge hypodermic needle from the ventral aspect of the symphysis directing it lateral to exit distal to the canine teeth.

Dog mandible parasymphyseal simple fracture circummandibular wiring with a large gauge hypodermic needle

Wire positioning

A pre-stretched orthopedic wire (gauge of wire depends on skull size) is passed through the needle.

Dog mandible parasymphyseal simple fracture circummandibular wiring wire positioning

The needle is removed and placed on the opposite side.

The orthopedic wire is passed through the needle on this side. This will result in the wire circling the rostral mandibles just distal to the canine teeth.

Dog mandible parasymphyseal simple fracture circummandibular wiring wire positioning

Wire tightening

While holding the incisor teeth in occlusion, the wire is pulled and twisted until it is fully tightened on the ventral aspect of the symphysis.

Dog mandible parasymphyseal simple fracture circummandibular wiring wire tightening

Wire tightening

The separation or fracture will be reduced and stable.

Dog mandible symphyseal separation circummandibular wiring wire tightening

The wire is cut at the skin edge, leaving three to four twists.

Dog mandible parasymphyseal simple fracture circummandibular wiring wire cut

Note: Care should be taken not to bend the wire due to loosening and loss of reduction.

Dog mandible parasymphyseal simple fracture circummandibular wiring wire not to be bent

Skin closure

The skin is sutured over the twisted wire.

Dog mandible parasymphyseal simple fracture circummandibular wiring closure

6. Application of the composite

Irrigate the teeth to be included in the composite. Acid-etch the teeth for 20-30 seconds. Thoroughly irrigate again and dry.

Note: it is paramount that the teeth remain dry throughout the application of the composite

Dog mandible parasymphyseal simple fracture acid etching

A composite temporization material is placed on the teeth and contoured to avoid sharp edges or projections. Care is needed to avoid contact with the gingiva.

Dog mandible parasymphyseal simple fracture circummandibular wiring composite placement

Once the composite solidifies, smooth the composite with a Goldie bur on a surgical handpiece or a diamond bur on a high-speed handpiece.

Dog mandible parasymphyseal simple fracture circummandibular wiring composite smoothening

7. Debridement and suturing

Wounds should be debrided followed by copious irrigation with sterile saline 0.9%. Soft tissue lacerations are sutured using 4.0 or 5.0 poliglecaprone 25 or other monofilament absorbable suture in a simple-interrupted fashion.

Note: in the oral cavity, due to abundant blood supply, aggressive debridement is rarely needed.

Dog mandible symphyseal separation interdental wiring debridement and suturing

8. Case example

Wiring of a parasymphyseal fracture, in the absence of the left mandibular canine tooth.

Note: the wire can be oblique if it is anchored behind a premolar tooth.

Dog mandible parasymphyseal fracture circummandibular wiring example

Fixation of parasymphyseal fracture and soft tissue reconstruction in a dog.

Dog mandible parasymphyseal fracture circummandibular wiring example fixation

9. Aftercare

The splint should be cleaned at least once daily using 0.12% chlorhexidine gluconate solution. Another option is to use a water-flossing device.

The patient should wear an Elizabethan collar until removal of the construct.

The wire is kept in place for 4-6 weeks and removed under general anesthesia.

A small skin incision is made exposing the wire twist. The wire is cut intraorally and straightened to prevent soft tissue damaging. The wire is gently pulled out on the ventral aspect from the twist knot.

circummandibular wiring

If composite was placed, a composite removing forceps are used.

The teeth involved in the fixation should receive periodontal cleaning as moderate to severe gingivitis is seen with the presence of an intraoral splint.

circummandibular wiring