Int. J. Oral Maxillofac. Surg.

2006; 35: 618–623

doi:10.1016/j.ijom.2006.01.010, available online at http://www.sciencedirect.com

Clinical Paper
Medicine

Perceived effectiveness and F. Behbehani1, H. Al-Aryan2,

A. Al-Attar3, N. Al-Hamad4
1
Department of Developmental and

side effects of intermaxillary Preventive Sciences, Kuwait University,

Kuwait; 2Ministry of Health, Kuwait;
3
Department of Restorative Sciences, Kuwait
University, Kuwait; 4Administration of Food

fixation for diet control and Nutrition, Ministry of Health, Kuwait

F. Behbehani, H. Al-Aryan, A. Al-Attar, N. Al-Hamad: Perceived effectiveness and

side effects of intermaxillary fixation for diet control. Int. J. Oral Maxillofac. Surg.
2006; 35: 618–623. # 2006 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Weight loss is one of the major side effects associated with intermaxillary
fixation (IMF) following orthognathic surgery or jaw fractures. The aim of this
study was to retrospectively interview patients treated with intermaxillary fixation
for diet control (IMFDC) to collect base-line information regarding: (1) perceived
effectiveness, patients’ compliance and patients’ satisfaction with the treatment; (2)
the frequency of side effects associated with IMFDC. The results show that IMFDC
significantly reduced weight by a mean of 6.8 kg during treatment, and a mean of
4.1 kg at a minimum of 1 month following IMFDC removal (P < 0.0001). Only
32.5% of the patients complied with the planned period of IMFDC treatment while
70% were satisfied with the treatment results. The most common side effects were
speech problems and oral–facial pain with a prevalence of 52.5 and 32.5%,
respectively. IMFDC treatment is not effective for long-term weight reduction and Key words: intermaxillary fixation; diet control.
may only be used for a very short period of time to initiate weight loss. Exercise and/
or special diet programs are healthier and better means to treat obesity and maintain Accepted for publication 17 January 2006
weight loss. Available online 28 February 2006

Obesity is a major public health problem
posing serious threats to the health of the
nation, and directly increasing morbidity
and mortality5,9. It is well recognized that
obesity is a significant risk factor for the
development of chronic non-communic-
able diseases, such as diabetes mellitus,
hypertension, coronary heart disease,
osteoarthritis, gall-bladder disease, stroke,
respiratory diseases and colon can-
cer9,12,17. Obesity may also have psycho-
logical consequences such as low self-
esteem and depression19.
The World Health Organization has
labelled obesity as a global epidemic21.
A recent report estimated that 1 billion
people worldwide are overweight and 300
million are obese22. Despite the scientifi-
cally proven fact that obesity is a major
threat to general health5,9,12,13,17,19,21,22,
several studies2,19 concluded that as little
as a 5–10% reduction in initial weight is
associated with significant improvements
in blood pressure, cholesterol levels, gly-
cemic control, physical performance and
wellbeing.
Several techniques and regimens have
been developed to treat obesity. Less inva-
sive regimens, such as diet-control pro-
grams, exercise programs and behavioural
therapy, have proved to be very effective
and safe methods to reduce weight. The
time, cooperation, commitment and
patience needed for these regimens, how-
ever, made them less popular with those
who want to reduce their weight quickly
and without extensive cooperation or
effort. Drug therapy 19 and more invasive
procedures like liposuction and gastric

0901-5027/070618 + 06 $30.00/0 # 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Perceived effectiveness and side effects of intermaxillary fixation 619

banding have also been used to reduce moderate-to-severe oral–facial pain. The surfaces of the teeth. The majority of the
weight, with a moderate-to-severe risk temporomandibular joint (TMJ) and the periodontal damage is limited to the soft
association. Although diet-control and muscles of mastication that are responsi- tissue and is reversible at short- and long-
exercise programs are very safe, cheap ble for mouth opening can barely function term follow-up evaluations10,14,15. There
and healthy methods to lose weight, the during the whole period of fixation, which is hardly any information regarding the
more invasive procedures started to gain a may result in muscular hypotrophy and effects of IMFDC treatment on speech as
lot of popularity because they require less thus in trismus (difficulty in mouth open- certain sounds associated with mouth
patient cooperation and are faster methods ing) and pain immediately after fixation opening may be difficult to produce during
to lose weight. removal7,20. The force of the mouth-open- the fixation period, or on the gastrointest-
Weight loss has been noted as one of the ing muscles will be transmitted to the inal (GI) system.
major side effects when intermaxillary ligated teeth, which may result in tooth IMFDC is a technique of the past
fixation (IMF) is used to treat patients with movement 7,14 and changes in patient which was abandoned decades ago;7,20
mandibular fractures3,8. IMF is an old occlusion, especially in patients present- however, since 2003 it has found its way
technique used in dentistry, before utiliza- ing with malocclusion14. into use again by some in Brazil18 and
tion of miniplates4,11, to stabilize and pro- Periodontal problems7,20 have been Kuwait. Recent use of IMFDC treatment
mote healing of fractured facial bones in associated with prolonged use of jaw fixa- in Kuwait has caused several controver-
cases of trauma or orthognathic sur- tion treatment as a consequence of impro- sial arguments regarding its effective-
gery8,16. Several surgeons have tried to per oral hygiene, especially at the lingual ness and side effects. Some think that
modify the IMF technique and use it as
a means to control intake in obese patients.
Intermaxillary fixation for diet control
(IMFDC) is a simple and an inexpensive
modification of the IMF technique for
those who want to lose weight quickly
and with minimal compliance effort.
When the teeth are ligated, the mouth
cannot be opened properly for chewing,
forcing the patient to be on a soft diet for a
temporary period of time until the desired
weight loss is achieved7,20.
Most of the studies on the effectiveness
of IMFDC had either a small sample
size6,18,20 or limited the sample to only
those with severe obesity or with medical
or surgical indications for weight reduc-
tion7,18. The samples used were all drawn
from patients referred to obesity clinics for
weight reduction, and the findings
reported were limited to patients who
underwent IMFDC treatment for at least
2 months7,20. It would be difficult to gen-
eralize the findings of these studies to
patients with moderate and minor obesity
problems or to patients who are not willing
to be treated with IMFDC for more than 2
months. There are also insufficient data on
patients’ compliance with the duration of
treatment as well as on patient satisfaction
with treatment.
IMFDC could have side effects similar
to those documented with IMF8. Oral–
facial complications presenting as signs
and symptoms of decreased muscular
extensibility and strength, increased mus-
cular fatigability, hypomobility and altera-
tion of the biomechanical efficiency and
length of the masticatory muscles were the
main side effects found in patients who
received orthognathic surgery followed by
IMF treatment1,8. The muscles of mastica-
tion that are responsible for mouth closure
are in contraction mode during the whole
length of the fixation period. This sus-
tained muscle contraction may result in Fig. 1. Questionnaire used for phone interviews.
620 Behbehani et al.
Fig. 1. (Continued ).
IMFDC may do more harm than good
for the patients, and therefore its use is
ethically questionable. The authors of
this study have never offered or pro-
moted IMFDC treatment for their
patients; however, they took advantage
of the availability of a moderate number
of patients treated recently with IMFDC
in Kuwait to use as a sample to conduct
this study.
The purpose of this study was to retro-
spectively interview patients treated with
IMFDC to collect base-line information
regarding: (1) the perceived effectiveness
of the technique with special emphasis on
acquired weight loss and patients’ compli-
ance as well as patients’ satisfaction with
the treatment; (2) the frequency of oral,
perioral and gastrointestinal side effects
that may be associated with IMFDC.
Materials and methods
Data collection
Ten private clinics were chosen randomly
and were asked to provide telephone num-
bers of patients treated with IMFDC. To
protect the privacy of their patients, the
private clinicians were asked to get per-
mission from their patients to release their
phone numbers to our research team. Out
of the 10 clinics contacted, only 5
responded that they offer IMFDC treat-
ment, and provided a total of 82 patient
names and phone numbers. From a total of
82 patients called, only 40 were inter-
viewed. The remaining 42 could not be
contacted either because there was diffi-
culty in telephone communication or
because they simply refused to participate
in the study. The same person made all the
phone interviews using a questionnaire
(Fig. 1). The questions were asked in
simple lay language.
Sample
A total of 3 males and 37 females with a
mean age of 25.6 (SD 7.4) years, who had
already received IMFDC treatment, were
interviewed by phone. The mean body
mass index (BMI) for the sample was
32.8 kg/m2 (SD 8.9) and 50% of the sam-
ple had a BMI ranging between 26.2 and
36.4 kg/m2.
All subjects had a history of IMFDC
treatment with a mean intermaxillary fixa-
tion period (treatment time) of 3.5 weeks
(SD 2.8). Fixation was achieved either by
directly inserting a stainless steel wire
under the interproximal contact areas of
the 2 upper and 2 lower teeth to be ligated,
or indirectly by bonding orthodontic
brackets to the teeth and inserting the wire
through the orthodontic brackets.
IMFDC treatment was initiated based
on patients’ desire as a response to adver-
tisements by dental clinics offering an
oral appliance for weight reduction. All
dentists instructed their patients to be on a
soft diet reinforced with supplemental
multivitamins either in soluble powder
form or as minced tablets to be taken with
water.
Data analysis
Frequencies (number and percentage) of
wire fixation method and orthodontic
bracket fixation method were calculated.
Mean and SD of initial weight (W1), weight
on day of IMFDC appliance removal (W2),
weight after a minimum of 1 month follow-
ing IMFDC treatment (W3), weight change
(W2 W1) weight change (W3 W1)
 Perceived effectiveness and side effects of intermaxillary fixation 621

Table 1. Weight reduction effect of IMFDC treatment was reduced during IMFDC treatment,
95% confidence and about 4.7% reduction of the initial
Mean (SD) interval weight was maintained at a minimum of
Initial weight W1 86.8 (22.9) 78.7–95.0 1 month following appliance removal
Final weight W2 80.1 (19.8) 73.0–87.1 (Table 1). With 95% confidence intervals,
Weight change (W2 W1) 6.8 (5.3) 4.9–8.6 it was found that patients with an average
Follow-up weight W3 82.8 (20.4) 75.5–90.0 BMI of 32.8 kg/m2 and average 3.5 weeks
Weight change (W3 W1) 4.1 (5.8) 2.0–6.1 of IMFDC treatment could lose up to
P value W1/W2 0.0001 8.6 kg, and maintain a weight reduction
P value W1/W3 0.0003 of up to 6.1 kg at a minimum of 1 month
Values are kilograms; n = 40. Mean treatment time was 3.5 weeks (SD 2.8); mean BMI following appliance removal (Table 1).
32.8 kg/m2.
Patients’ compliance and satisfaction
with IMFDC treatment
Table 2. Patients’ compliance with IMFDC treatment
Did you comply with the planned period of IMFDC treatment? Of the 40 patients included in the study,
Complied Did not comply only 13 (32.5%) complied with the
13 (32.5) 27 (67.5) planned period of intermaxillary fixation.
Who removed your appliance? Twenty-one patients (52.5%) removed
Dentist Myself/broke by itself their appliances at a dental office while
19 (47.5) 21 (52.5) 19 (47.5%) broke or removed their appli-
ances themselves. Nine (22.5%) had to
Did you make an emergency visit to remove your appliance?
make an emergency dental visit to remove
No Yes
31 (77.5) 9 (22.5) their appliances (Table 2).
Twelve patients (30%) felt that IMFDC
n = 40; values in parentheses are percentages. was not helpful for weight loss, while the
remaining 70% were satisfied with the
treatment. Twenty-one patients (52.5%)
Table 3. Main oral and perioral side effects, along with their respective severities, associated decided that they were willing to experi-
with IMFDC treatment ence IMFDC treatment in the future if
Minor to moderate Severe to very severe Total necessary, while 16 (40%) decided that
Pain during IMFDC treatment 8 (20.0) 5 (12.5) 13 (32.5) they would not experience IMFDC treat-
Pain after IMFDC treatment 11 (27.5) 1 (2.5) 12 (30.0) ment again in the future, and 3 (7.5%)
Difficulty in mouth opening 17 (42.5) 2 (5.0) 19 (47.5) were undecided.
Speech problems 20 (50.0) 1 (2.5) 21 (52.5)
Bite changes 4 (10.0) 0 (0.0) 4 (10.0)
Oral and perioral side effects that are
n = 40; values in parentheses are percentages. associated with IMFDC treatment
Speech difficulty during treatment was the
were calculated. Paired t-tests to determine ciated with IMFDC were scored according most common oral side effect (52.5%)
significant differences between initial to an ordinal scale of minor to moderate or followed by difficulty in mouth opening
weight and final weight, and between initial severe to very severe (Table 3). immediately after the removal of IMFDC
weight and follow-up weight were per- The data were collected by phone appliances (47.5%), with severity ranging
formed (Table 1). Frequencies (number interview with the patient using the ques- between minor and moderate for the
and percentage) of patients who complied tionnaire (Fig. 1). The BMI score was majority of the reported incidents
with the planned IMFDC treatment time calculated based on the patient’s weight (Table 3). About one-third of the patients
(Table 2) and patients satisfied with and height. Information about the type of reported oral–facial pain during and
IMFDC treatment were calculated. Fre- ligation method used was taken from immediately after IMFDC treatment, with
quencies (number and percentage) of oral, the dentist who provided the IMFDC severity ranging between minor and mod-
perioral and GI side effects associated with treatment. erate for the majority of the reported inci-
IMFDC treatment were calculated dents (Table 3). Only 4 patients (10%)
(Tables 3 and 4). The severity of oral–facial reported changes in their bite due to pos-
pain, difficulty in mouth opening, speech Results sible movement (extrusion) of the ligated
problems and bite changes that were asso- teeth (Table 3). Bad breath or bad taste
Type and effectiveness of IMFDC
was reported by only 10%, and gingival
treatment
bleeding was also reported by 10% of the
Table 4. Other oral side effects associated Thirty subjects (75%) received IMFDC patients (Table 4). Only 1 patient reported
with IMFDC treatment treatment by use of wire only, while 10 teeth staining and only 1 reported fracture
No other problems 30 (75.0) subjects (25%) received treatment by use of a tooth (Table 4).
Bad breath or bad taste 4 (10.0) of wire with orthodontic brackets. There
Bleeding gum 4 (10.0) was a highly significant (P < 0.001)
Stain on teeth 1 (2.5) GI side effects associated with IMFDC
weight reduction during treatment and 1
Other problems (fractured tooth) 1 (2.5) month after removal of IMFDC appliances The majority of patients did not experi-
n = 40; values in parentheses are percentages. (Table 1). About 7.8% of the initial weight ence any GI problems as a result of sudden
622 Behbehani et al.
Table 5. Gastrointestinal (GI) side effects
associated with sudden changes in diet during
and immediately after IMFDC treatment
Immediately
During after
IMFDC IMFDC
treatment treatment
No problem 33 (82.5) 35 (87.5)
Diarrhea 4 (10.0) 1 (2.5)
Constipation 3 (7.5) 3 (7.5)
GI pain 0 (0.0) 0 (0.0)
Other GI problems 0 (0.0) 1 (2.5)
n = 40; values in parentheses are percentages.
changes in diet during or immediately
after IMFDC treatment (82.5 and 87.5%
respectively). Sporadic incidents of GI
complications were reported (Table 5).
Discussion
The results of the present study confirm
previous findings7,18,20 that IMFDC treat-
ment is effective in short-term weight
reduction, but the percentage of weight
loss in this study (7.8%) was found to be
less than that reported earlier (20%)7,20.
One reason for this difference in weight
reduction rate is that previous stu-
dies7,18,20 limited their sample to only
those with severe obesity or with surgical
indications for weight reduction. Another
reason is that previous studies7,20 have
limited their findings to only those with
a minimum jaw-fixation period of 2
months. Also confirmed are previous find-
ings7,20 that minor and reversible10,15 gin-
gival bleeding occurs during IMFDC
treatment. When comparing our findings
to those of previous studies with a longer
IMFDC treatment time7,20, it becomes
clear that the time required to achieve
the desired weight varies. It may take
weeks for the overweight, but as long as
several months for heavier patients to
reach this goal. Bearing in mind that
patients can only be on soft or liquid diets
during the treatment period, the severity
and frequency of oral, perioral and GI side
effects will be greater in those undergoing
longer IMFDC treatment. It has been
documented that long-term use of IMFDC
may lead to anaemia, dizziness and men-
strual disturbance14.
The present findings indicate that about
2.7 kg had been regained at a minimum of
1 month following IMFDC appliance
removal, which represents about 40% of
the mean (6.8 kg) weight lost during the
treatment (Table 1). This is far more than
the 5% weight regain reported previously6
in 4–14 months of follow-up with conti-
nuation of special diet. The rapid, high
weight regain after removal of IMFDC
appliances in the present study indicates
that patients on IMFDC become highly
dependent on this device to control their
intake. They may be similar to patients
who depend on drug therapy, such as
appetite depressants, laxatives or lipase
inhibitors, for weight reduction. As soon
as the prescribed therapy is stopped,
weight is quickly regained. It can be con-
cluded, therefore, that IMFDC is not effec-
tive for long-term weight reduction and
should only be used for a limited period of
time to initiate weight reduction. Exercise
and/or special diet programs are healthier
and better means to treat obesity and
maintain weight loss.
Findings regarding patients’ compli-
ance and satisfaction with IMFDC treat-
ment, unique to this study, are
contradictory. Only 32.5% complied
with the planned treatment time and
about half of the patients (47.5%) broke
or removed their appliances themselves.
On the other hand, the majority of the
patients (70%) were satisfied with the
treatment results and 52.5% would be
prepared to experience IMFDC treatment
again in the future. This satisfaction rate
combined with a relatively low compli-
ance rate may indicate that the patients
perceive the benefits of IMFDC treat-
ment to overcome its compliance issues.
The prevalence of dental emergency vis-
its needed to remove IMFDC appliances
was 22.5%.
It was hard to convince the majority of
the 82 patients contacted to participate in
the study. This was to be expected,
because of the delicate subject matter
of their weight and their success or fail-
ure to reduce it. Also, about 20 min were
needed for the phone interview, which is
a relatively long time to spend on the
phone. Information, however, was gained
regarding 40 patients, which is more
than that reported in previous similar
studies7,18,20.
All the information reported in this
study, with the exception of BMI and
method of ligation which were obtained
from dentists, was based on phone inter-
views with patients already treated with
IMFDC. Clinical evaluation of patients
before, during and after IMFDC treatment
could give more accurate and reliable
information. The findings regarding the
effectiveness of IMFDC, and the fre-
quency of oral, perioral and GI side effects
associated with IMFDC treatment are
based solely on patients’ perception, and
may be used as base-line information to
acquire informed consent from patients for
treatment.
Acknowledgement. This research was sup-
ported by Kuwait University Grant
#DD01/04.
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