P Y R I F O R M A P E R T U R E W I R I N G IN T H E T R E A T M E N T O F

MANDIBULAR FRACTURES
By G. L. FORDYCE,F.D.S.R.C.S.(Eng. & Ed.), L.D.S.
Mount Vernon Centre for Plastic Surgery and Jaw Injuries,
Mount Vernon Hospital, Northwood, Middlesex
AN edentulous upper jaw invalidates many of the established methods of
immobilising mandibular fractures. When an upper denture is available it can
be employed to provide a guide to reduction of the mandibular fragments, and
an occlusion to which the mandible may be held. In the Gunning splint the
mandible is held against the joined dentures with a chin support. Further stability
is achieved if the mandible is secured to the lower denture with circumferential
wires. The rather ineffective and occasionally uncomfortable chin support can
be discarded if the upper denture is fixed to the upper jaw with peralveolar or
transalveolar wires. This is a simple surgical procedure, but is uncertain in its
ability to withstand a prolonged strain--the wires tending to cut through the
soft cancellous bone of the maxillae rendering the fixation ineffective. When
gross alveolar resorption has occurred, peralveolar wiring may be virtually
impossible. An alternative method of achieving intermaxillary fixation was
described by K. H. Thoma (I943), and it is this method which has been employed
in a clinical trial over a series of twenty cases.
The relatively strong bony margin of the anterior nasal or pyriform aperture
is used to carry a wire sling which is attached to the mandibular fixation. The
method has the advantages of simplicity, reliability, and comfort for the patient
and, in this series, has been free from complications.

METHOD OF APPLICATION
To ensure that the nasal cavity is not entered during the operation, 2 ml.
of normal saline are injected to raise the mucosal lining of the inferolateral surface
of the anterior nasal aperture. An incision is made in the buccal sulcus from
the lateral incisor to the first premolar region, at a level approximately ~ in. above
the reflection of the gingival to oral mucosa. This level varies relative to the
bulbosity of the alveolus. The anterior nasal aperture is identified and the
periosteum overlying this sharp bony margin is incised vertically. Subperiosteal
dissection, both on the nasal and facial surfaces, then uncovers the bony margin.
A hole, large enough to pass a 0.020 in. soft stainless steel wire, is drilled through
the maxilla fully ff~ in. from the anterior margin (Fig. I). A dental burr or
Archimedean drill is equally suitable. The wire is passed and the incision sutured.
The same procedure is performed on the other side (Fig. 2). The upper denture
is suitably modified in that any excess depth of buccal flange and food line are
removed. With the upper denture in position the mandibular fragments can
be held in articulation by securing the pyriform aperture wires to the mandibular
fixation.
It must be understood that the upper denture is not secured to the upper
jaw by wires, but is wedged in position by the lower teeth or denture. The upper
denture, however, should be attached to the mandibular fixation lest any post-
operative disaster might allow the upper denture to be free in the mouth. The
304
 PYRIFORM APERTURE WIRING IN THE TREATMENT OF MANDIBULAR FRACTURES 305

wires are r e m o v e d by cutting one end short as it emerges f r o m the m u c o u s

m e m b r a n e and a firm pull on the remaining end extracts the wire. T h i s is n o t
a painful p r o c e d u r e and m a y be carried out w i t h o u t ana:sthesia.

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FIG. I FIG. 2

Fig. I.--See text.

Fig. 2.--Pyriform wires attached to hooks embedded in the lower denture. The
circumferential wires used to secure the lower denture to the mandible are suitably
placed to immobilise a bilateral fracture in the bicuspid region. Elastic bands secure
the upper denture to the mandibular fixation.

CASE REPORTS
Case x.--J. S., male, aged 7o years. Sustained facial injuries in a road accident
and was referred for treatment five days later. The patient was edentulous and in
possession of full dentures. Examination revealed bilateral fractures of the body of the
mandible with considerable downward displacement of the anterior fragment (Fig. 3, A).
A fracture of the right condyle neck, seen in Fig. 3, c, had resulted in some shortening
of the ramus on that side. On the day following admission, under a general anmsthetic,
the displacement of the mandibular fragments was manually corrected and the reduction
maintained by the combined use of circumferential and pyriform aperture wires
(Fig. 3, B, D, and E). The patient's dentures (having been suitably modified) were used
as splints. Immobilisation by circumferential wiring of the lower denture to the
mandible would have been insufficient to maintain reduction without the intermaxillary
support of the pyriform aperture wires, and would not have corrected the displacement
due to the condylar fracture. The fixation was removed thirty days later and the
fractures were found to have united soundly.
T h e fixation can be applied to cap splints or arch wires on the lower teeth.

Case 2.--B. S., female, aged 32 years. During removal of an impacted left lower
third molar, the jaw was fractured (Fig. 4, A). The patient was referred for treatment.
The upper jaw was edentulous and the following mandibular teeth were present:
32I [ I2346. The patient gave a history of epilepsy, with frequent grand mal episodes.
Immobilisation of the fracture was necessary--pin fixation was to be avoided because
306 BRITISH JOURNAL OF PLASTIC SURGERY
o f the epilepsy and direct interosseous fixation was contraindicated because of the
c o m p o u n d nature of the fracture, and the desire to avoid external evidence of surgical
interference as there was the possibility of medico-legal proceedings. It was deemed
advisable to immobilise the main mandibular fragment by pyriform aperture wiring
secured to a lower splint, the patient's denture being inserted to guide reduction and to

FIG. 3
A, Lateral projection radiographs of Case I, showing bilateral
fracture of the body of the mandible with downward displace-
ment of the anterior fragment.
B, Post-operative lateral projection radiograph of Case I, showing
position of the fragments and the fixation.

effect immobilisation. The short posterior fragment was allowed to impact on the
immobilised jaw. Post-operative radiographs (Fig. 4, S and c) revealed an acceptable
position of the fragments, and following immobilisation for five and a half weeks the
fracture was found to have united in good position.
T h i s t y p e o f fixation simplifies the t r e a t m e n t o f m a n y fractures w h i c h are
n o t o r i o u s l y difficult to maintain in a r e d u c e d position. Case i is an example, b u t
PYRIFORM APERTURE WIRING IN THE TREATMENT OF MANDIBULAR FRACTURES 307

FIG. 3
C, Postero-anterior radiograph of Case I. Bilateral fracture of
the body of the edentulous mandible and a fracture of the
fight condylar neck.
D, Post-operative postero-anterior radiograph of Case I.
E, Intraoral view of Case I, showing dentures and fixation
in situ.
308 BRITISH JOURNAL OF PLASTIC SURGERY

A, Left lateral oblique radiograph off

mandible of Case 2, showing
fracture of the left body of the
mandible.

B, Post-operative view showing

acceptable position of the frag--
ments in Case 2.

C, Postero-anterior view of Case 2~.

showing position of fragments.
and the fixation.

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FiG. 4
 PYRIFORM APERTURE WIRING IN THE TREATMENT OF MANDIBULAR FRACTURES 309
perhaps more of a problem is the bilateral mandibular condylar fracture in the
presence o f an edentulous maxilla. T h e shortening of the rami and resultant
chinless deformity demand correction which is difficult to maintain. Pyriform
wiring has been used in two such cases with success and says m u c h for the strength
o f the fixation.

FIG. 5
A, Postero-anterior radiograph of mandible in Case 3. Bilateral
fractures of condylar necks and the displaced condylar heads and
a fracture of the left body of the mandible are visible.
B, Post-operative radiographs of Case 3 showing the position of the
fragments and the fixation.

Case 3.--M. F., female, aged 40 years, received facial injuries in a car smash on
the day prior to admission. The bony injuries were bilateral fracture dislocation of
the condyles and a fracture with displacement of the left body, involving the bicuspid
teeth (Fig. 5, A). The patient was in possession of a fractured full upper denture with
gum-fitted incisors and a fractured partial lower denture carrying the following teeth :
76541 ] I67. Following repair of the upper denture and repair of the lower partial denture
3Io BRITISH JOURNAL OF PLASTIC SURGERY

by articulating its fragments to the upper denture, the displacement of the mandibular
fragments was corrected manually under a general anaesthetic and immobilised by
combined circumferential and pyriform wiring, the dentures being used as splints.
An acceptable reduction was achieved (Fig. 5, B) and the fixation was maintained for
thirty days. Sound clinical union was noted on the removal of the fixation and the
dental articulation remained satisfactory.

SUMMARY
T h e technique o f pyriform aperture wiring is described as a means of,
maintaining intermaxillary immobilisation in the treatment o f the fractured
mandible in the presence o f an edentulous u p p e r jaw. In a series o f
twenty cases it has been found to be a satisfactory m e t h o d worthy o f addition to
our armamentarium.

REFERENCE
THOMA, K. H. (1943). Amer. J. Orthodont., 29, 433.