INDEX

SL.NO CONTENTS PG.NO

1 INTRODUCTION 1-6

2 SURGICAL ANATOMY 7-23

3 AIMS AND OBJECTIVES 24

3 REVIEW OF LITERATURE 25-45

4 MATERIALS AND METHODOLOGY 46-54

5 ILLUSTRATIONS 55-56

6 RESULTS 57-68

7 DISCUSSION 69-75

8 CONCLUSION 76

9 REFERENCES 77-86
 LIST OF ILLUSTRATIONS

S.No. ILLUSTRATIONS PAGE NO.

Fig:1 Lateral view of the TMJ. 8

Fig:2 Anteroposterior view of the TMJ 8

Fig:3 Muscles of mastication 8

Fig:4 Maxillary artery and branches 9

Fig:5 IMF with Gilmer wires 15

Fig:6 Elastic band IMF on Kazanjian buttons 16

Fig:7 Eyelet technique 16

Fig:8 Clove hitch‐eyelet IMF 17

Fig:9 Elastic bands or wire IMF on Stout ligatures 17

Fig:10 Leonard’s button. 18

Fig:11 Highly polished arch bar. 18

Fig:12 Erich arch bar 19

Fig:13 Schuchardt’s wire, acrylic arch bar 19

Fig:14 20
Dautrey arch bar

Fig:15 Bern’s titanium arch bar. 20

Fig:16 Gunning splint 21

Fig IMF screw 22

:17

Fig:18 Smart Lock Hybrid Arch Bar 23

Fig:19 Armentarium for imf with SmartLock Hybrid arch bar 51

Fig:20 Armentarium for Imf with arch bar 53

Fig:21 Pre Operative and intra operative 55

Fig:22 Post operative Opg 55

Fig:23 Pre Operative and intra operative 56

 LIST OF TABLES

SL.NO TABLES PAGE.NO

1 Evaluation of proper occlusion achieved in both groups 60

2 Evaluation of needle prick injuries in both groups 61

3 Intergroup comparison of mucosal growth 62

4 Intergroup comparison of lip irritation 63

5 Intergroup comparison of root damage 64

6 OHIS (Oral hygiene index score) 65

7 Time taken for fixation of arch bar 66

8 Time taken for removal of arch bar 67

 LIST OF GRAPHS

SL.NO TABLES PAGE.NO

1 Evaluation of proper occlusion achieved in both groups 61

2 Evaluation of needle prick injuries in both groups 62

3 Intergroup comparison of mucosal growth 63

4 Intergroup comparison of lip irritation 64

5 Intergroup comparison of root damage 65

6 OHIS (Oral hygiene index score) 66

7 Time taken for fixation of arch bar 67

8 Time taken for removal of arch bar 68

 INTRODUCTION

Primate evaluation has made the human head very vulnerable to frontal impacts. The

vulnerability of the human head would have fewer consequences if we were less

pugnacious and less inventive. Wars, murders, and assaults are older than the recorded

history and in these conflicts, the face has always been a favoured target.[1]

Maxillofacial trauma, which may result from accidental or assault injuries to the

craniofacial complex represents 42% of all injuries[2]. In this, 70% are mandibular

fractures and 30% are maxillary fractures. Among the mandibular fractures, 43% were

caused by road traffic accidents, 34% assaults, 7% were work-related, 4% were sports-

related, and the remaining have miscellaneous causes[3]. The incidence of fracture

involving the mandibular condyle varies throughout the literature. Serial studies by

Kromer (1953) and Goldberg and Williams (1969) found that fractures of the condyles

account for 15% to 30% of all mandibular fractures [4]. Halazonetis (1968) and Ellis et al

(1985) reported that condyle is the commonest site for mandibular fracture [5].

Condylar fracture divided into condylar head, condylar neck, and sub condylar region

types according to anatomical location of fracture by Lindhals in 1977[6]. Condylar

fracture also classified as diacapitular (intra capsular), high condylar neck, low condylar

neck fractures [7].

Page 1
 INTRODUCTION

The management of mandibular condylar injuries is one of the most controversial area

in the treatment of facial trauma. Fractures involving the mandibular condyle are the

only facial bone fractures which involve a synovial joint. These injuries deserve special

consideration apart from those of the rest of the mandible due to their anatomic

differences, variations in clinical picture, unique management protocols and distinct

healing potential.[8]

There are two schools of thought in which condylar fractures should be treated with

closed reduction or open reduction. Condyle fracture throws great challenge to the

maxillofacial surgeon whether condylar fractures should be treated with open reduction

or closed reduction.

The treatment goal of condylar fracture are pain free mandibular motion, good occlusion

and symmetry and have said that as long as these goals can be achieved, it is prudent

that the easiest and the least invasive treatment method should be selected [9].

Page 2
 INTRODUCTION

There are certain situations that are almost always perceived as absolute indications for

ORIF of condylar fractures. Conversely, there are also clear indications for treating

some condylar fractures with closed reduction.

Indications for Open Reduction

ABSOLUTE INDICATIONS

• Condylar displacement into middle cranial fossa

• Invasion by foreign body

• Lateral extracapsular displacement of condyle

• Malocclusion not amenable to closed reduction (e.g., functional reduction of ramus

height)

STRONG EVIDENCE FOR OPEN REDUCTION

• Bilateral condylar fractures

• Gross condylar displacement > 45 degrees (severely displaced)

• Anatomic reduction of ramus height ≥ 2 mm

• Condylar fractures with an unstable base (associated midface fractures)

• Unstable occlusion (e.g., periodontal disease, less than three teeth per quadrant)

Page 3
 INTRODUCTION

• Condylar fractures for which adequate physiotherapy is impossible

Indications for closed reduction:

• Non-displaced or incomplete fractures

• Isolated intracapsular fractures

• Condylar fractures in children (except for absolute indications)

• Reproducible occlusion without dropback or with dropback that returns to midline on

release of posterior force

• Medical illness or injury that inhibits ability to receive extended general anesthesia.

Traditionally condylar fractures were managed by conservative methods. Surgeons who

prefer closed treatment claim that equally good result were produced with reduced

overall morbidity and lack of surgical complication.[10].

Mandibular fractures can be treated by intermaxillary fixation alone or by

osteosynthesis with or without intermaxillary fixation. Intermaxillary fixation can be

achieved by eyelets, arch bars, bonded brackets, cast metal splints, vacuum formed

splints, pearl steel wires, self-tapping intermaxillary screws and self-drilling

intermaxillary screws. Erich arch bars over time have been considered as the standard

for achieving IMF because of its rigidity and versatility. They provide superior occlusion

control and reliable fixation.[11]

Page 4
 INTRODUCTION

The arch bar has been the mainstay for the management of maxillomandibular bony

injuries since world war I. Conventional methods like arch bars and eyelets wires are

currently the common methods of achieving intermaxillary fixation but they have their

own disadvantages like the time consuming, difficulty to surgeon, and patient, the

incidence of glove perforation is more and it is difficult to maintain oral hygiene with

these methods.[12]

Wiring could be time consuming and has significant risk of skin puncture possibly

resulting in blood borne diseases to the operator. Previous studies has shown that pre

cutaneous injuries occur in 21% of treatment of maxillofacial fracture during IMF and

needle stick injuries for about 6 to 8 %.

To overcome these problems, the SMART LOCK HYBRID ARCH BAR has been

introduced. They are quick and easy to use and greatly shorten the operating time to

achieve maxillomandibular fixation. The risk of needle stick injuries associated with

using wires is also reduced. There is no trauma to gingival margins and gingival health

is easier to maintain

Page 5
 INTRODUCTION

This study was designed to compare the efficacy of smart lock hybrid arch bar and

Erich’s arch bars in the management of intra capsular condylar fractures of the

mandible.

Page 6
 SURGICAL ANATOMY

The mandibular condyle articulates with the squamous portion of the temporal bone to

form the temporomandibular joint (TMJ). The concavity on the temporal bone where the

mandibular condyle lies in the rest position is termed the glenoid fossa. Anteriorly is the

articular eminence, which the condyle translates down during function. Posterior to the

glenoid fossa is the tympanic plate, which tapers to the postglenoid tubercle[13].

It is stabilized by a complex ligamentous system and its motion is orchestrated by

a number of muscles, There are also a number of arteries, veins, and nerves in

this region that need to be recognized and unharmed if an open procedure is

considered, It has been said, “anatomy is destiny,”' When the normal anatomy and

function of the temporomandibular joint and surrounding structures are understood

it becomes easier to predict and manage the effects of trauma,

Temporomandibular joint disk

The TMJ disk lies between the mandibular condyle and temporal bone, separating the

joint into 2 compartments: superior and inferior (Fig. 1). It is thought that it forms under

compression during development from the posterior insertion of the lateral pterygoid

muscle to the Meckel’s cartilage. The disk is a biconcave structure composed of dense

fibrous connective tissue, and is commonly described as having 3 discrete zones: thick

anterior and posterior areas bridged by a thinner intermediate zone. The central portion

of the disk is devoid of vascular supply or innervations , which are supplied from the

periphery, predominately by the retrodiscal tissue.

7
 SURGICAL ANATOMY

Fig. 1 Lateral view of the TMJ.

Fig. 2 Anteroposterior view of the TMJ.

Muscles of mastication:

The 4 primary muscles of mastication that act on the TMJ are the lateral and

medial pterygoids, the masseter, and the temporalis (Fig. 3).

Fig. 3 Muscles of mastication. (A) Masseter muscle showing 2 heads. (B)

Temporalis muscle. (C) Medial pterygoid muscle and lateral pterygoid muscle.

8
 SURGICAL ANATOMY

BLOOD VESSELS

Although the temporomandibular joint itself is relatively avascular the soft tissue

surrounding the mandibular condyle and subcondylar region is highly vascular. The

external carotid artery bifurcates in the region of the parotid gland, developing into the

maxillary artery and superficial temporal arteries. (Figure 4).

Fig. 4 Maxillary artery and branches.

Relation of Tempomandibular joint:

Lateral realtions:

1. Lateral skin and fasciae

2. Parotid gland.

3. Temporal branch of facial nerve.

Medial:

1. The tympanic plate seperates the joint from the internal carotid artery.

2. Spine of the sphenoid, with upper end of the sphenomandibular ligament

attached to it.

3. Auriculotemporal and chorda tympani nerve.

4. Middle meningeal artery.

9
 SURGICAL ANATOMY

Anterior:

1. Lateral pterygoid

2. Masseteric nerve and artery

Posterior:

1. The parotid gland seperates the joint from the external auditory meatus.

2. Superficial temporal vessels.

3. Auriculotemporal nerve.

Superior:

1. Middle cranial fossae.

2. Middle meningeal vessels

Inferior:

1. Maxillary artery and vein.

Due to the presence of vital structures around the tempomandibualr joint and

condylar region oral maxillofacial prefer closed reduction in treatment of condylar

fracture to prevent the complication which occur in the open reduction of condylar

fracture due to presence of vital structure around the condylar region.

Evolution of Arch bar

Many of the conventional arch bars or wiring techniques were developed at a time when

most facial fractures were treated by intermaxillary fixation (IMF) only and therefore had

to be sufficiently stable to maintain immobilisation for a prolonged period. Consequently,

the indications for using simpler IMF systems are increasing [14].

History

10
 SURGICAL ANATOMY

Although trauma has been with us since the dawn of time, it is only recently that we

have been able to approach it scientifically. For this reason, the original reports of

treatment do not necessarily follow any logical pattern, amounting to a series of case

reports contained within the literature from the earliest pre‐Christian times to Egypt in

2000 B.C. when a dislocation of the mandible as well as a fractured mandible were

described. Hippocrates described reduction and fixation of mandibular fractures with

strips of calico glued to the skin immediately adjacent to the fracture and laced together

over the scalp. The ancient physicians of Alexandria and Rome also mentioned the

ligation of teeth using fine gold wire or Carthugian leather strips glued to the skin. These

principles laid down by Hippocrates extended through the literature as far as the first

millennium[15].

It was probably Salicetti in 1474[16] in Bologna who first described the simple

expedient of ligating the teeth of the lower jaw to the corresponding teeth of the upper

jaw to affect immobilisation of a fracture.

Chopont & Desault (1780)[17] were the first to describe a different type of

approach by introducing the concept of a dental splint that consisted of a shallow trough

of iron, inverted over the occlusal surface of the lower teeth, which were protected with

cork on lead plates.

War has always provided opportunities for surgical developments, and so it was

with the American Civil War of 1861‐1865 and the Franco‐Prussian War of 1870‐1871

[18], in quick succession, that a large proportion of mandibular fractures arose from

horse kicks or falls onto the chin. In 1861, Gunning produced his splint, although he was

11
 SURGICAL ANATOMY

probably unaware that it followed the same principle as the one developed by Naysmith

in 1825 for use by the surgeon Liston. From dental impressions, a monobloc

construction was produced and bound to the jaws by a bandage that passed under the

chin and over the vertex of the skull. Teeth in the line of fracture were extracted. Later in

the war (1864), Bean, who treated many fractures, made a significant advance by

sectioning dental models of the jaws and carefully realigning them before constructing a

Gunning type of splint[19].

The first reports of swaged metal splints appeared simultaneously by Allport in

America and Hayward in London. Allport’s gold splints were swaged to leave the

occlusal and incisive edges free, and, having correctly aligned them, the splints were

soldered together. Despite further modifications by Kingsley, all these splints were

essentially modifications of the original splint by Chopart and Desault in 1780.

During the Franco‐Prussian War, Hammond described the use of arch bars on

both the lingual and buccal aspects that were fixed to the teeth by fine interdental eyelet

wires.

In 1887, Gilmer returned to an almost forgotten technique, the direct wiring of

teeth. This resurrection of an old principle, suitably modified, was a significant advance

and became increasingly important as orthodontic techniques became adapted by

surgeons for the treatment of fractures[20].

The use of interdental eyelet wires was demonstrated by Ivy (1914) as an

effective way to provide IMF in the dentate patient and was increasingly practiced[21].

12
 SURGICAL ANATOMY

Middle third fracture management also underwent improvements where cheek

wires, first developed by Federspiel, were used to fix the posterior region of the maxilla

to the plaster of‐Paris headcap [22].

By the end of World War II in 1945, there was an increasing realisation that when

bone ends are brought into close proximity with one another, more rapid healing occurs.

With the advent of antibiotics, a greater use of direct approaches to the fracture sites led

to the use of direct interosseous bone wiring or osteosynthesis. Such wires were

generally applied to either the upper or the lower borders of the mandible and the

fronto‐zygomatic suture, all solid pieces of bone. During this time, pin fixation was used,

particularly in the treatment of compound, comminuted, and frequently infected jaw

fractures. Despite a reduction in its use, this concept was retained and used by Fordyce

in the “Box‐Frame” technique. A variety of pins were used from the fine, threaded,

Clouston‐Walker pin, modified for the East Grinstead pattern, and MacGregor pins, to

the coarse, threaded, tapered, Moule pin. It was not until the Vietnam War that

American forces came to use biphasic pin fixation, popularised by Morris (1949), and

external pin fixation again became the treatment method of choice[23].

Initially, direct bone wiring was used to control 1) the edentulous posterior

fragment; 2) multiple fragments in the edentulous mandible; and 3) the grossly

comminuted mandibular fragments and the lower border of the mandible where the

upper jaw was already secured by one of the conventional methods of fixation but

where the lower border remained inadequately reduced and immobilised.

13
 SURGICAL ANATOMY

Although the use of bone plates had previously been attempted (Konig, 1905;

Lambotte, 1907; Lane, 1914; Sherman, 1924), it was not until Roberts (1964) and

Battersby (1967) introduced stainless steel, vitallium monocortical miniplates that the

present use of surgery was established [24]. The lack of malleability of these initial

miniplates limited their usefulness for they broke as soon as any attempt was made to

bend them. The initial introduction of malleable stainless steel followed by titanium

enabled Champy (1976, 1978) to develop a scientific basis for the application of

miniplates in the treatment of mandibular fractures.

Bioresorbable plates, made initially of polylactic acid and, more recently, of a

combination of this and other suitable materials, were developed (Bos, 1983; Rozema,

1991; Suuronen, 1992).

The compression osteosynthesis techniques used by orthopaedic surgeons have

been applied to maxillo‐facial surgery by Luhr (1968, 1972) and Becker & Machtens

(1970) [25].

IMF techniques :

The first and most important aspect of surgical correction of mandibular fractures is to

reduce the fracture properly. In the tooth‐bearing bones, it is of outermost importance to

place the teeth in a pre‐injury, occlusal relationship. Merely aligning the bone fragments

at the fracture site without first establishing a proper occlusal relationship rarely results

in satisfactory postoperative functional occlusion.

14
 SURGICAL ANATOMY

To establish a proper occlusal relationship, several techniques have been

described, generally referred to as IMF. The most common technique includes the use

of a prefabricated arch bar that is adapted and circumdentally wired to the teeth or

acid‐etch bonded to each arch; the maxillary arch bar is wired to the mandibular arch

bar, thereby placing the teeth in their proper relationship. Other wiring techniques, such

as Ivy loops or Obwegeser continuous loop wiring, have also been used for the same

purpose.

1.Ligature wiring:

Inmobilisation of fractured jaw fragments and fixation in the correct dental relationship

by means of dental intermaxillary wiring was first advocated in the USA by Gilmer in

1887[26].

2.Gilmer wiring

This technique provides a simple and rapid method to immobilise the jaws. However,

the wires tend to loosen, and a broken, direct wire cannot be replaced without first

removing and replacing all of the other wires.

Fig 5: IMF with Gilmer wires.

3.Kazanjian button

15
 SURGICAL ANATOMY

This method is particularly useful for immobilisation by intermaxillary orthodontic‐type

rubber bands, but should only be considered a temporary method[27].

Figure 6. Elastic band IMF on Kazanjian buttons.

4. Eyelet technique:

Provided that teeth of a suitable number, shape, and quality are present on each

fragment, eyelet wiring (Eby, 1920; Ivy, 1922) is a simple and effective method for the

reduction and immobilisation of jaw fractures. Eyelet wires may also be used in

combination with Gunning‐type splints in an opposing edentulous jaw, and arch bars or

cap splints can be used in a partially dentate jaw. Robert Ivy described the wire passing

through the loop of the eyelet.

This technique has the advantage that fixation may be released by removal of the

intermaxillary ligatures.

Figure 7 . Wire passing through the loop allows for less tightening than passing behind

the eyelet.
16
 SURGICAL ANATOMY

5. Clove hitch:

Although the use of a simple clove hitch around a single isolated tooth is simple and

rapid, it has the disadvantage that, should the end of the wire that is used as a tie wire

break, the whole wire must be replaced.

Figure 8. Clove hitch‐eyelet IMF

6 .Intermaxillary loop wiring (Stout)

This method (Stout, 1942) requires the presence of at least three adjacent teeth. The

wires form a number of loops along the buccal side of the alveolar process, which is

especially useful when elastic bands are used for traction.

Figure 9. Elastic bands or wire IMF on Stout ligatures.

7.Leonard’s button wiring:

Leonard (1977) considered that eyelet wires have several drawbacks:

• A simple eyelet is frequently drawn into the interdental space, making it difficult to use.
17
 SURGICAL ANATOMY

• Elastic traction using eyelets, though possible, is time consuming to apply.

Leonard described the use of titanium buttons of 8‐mm diameter, inclusive of a 1‐mm

rim, and 2‐mm deep. Each button had two 1‐mm diameter holes, 1‐mm apart. The ends

of 15‐cm lengths of 0.4‐mm wire are passed through the holes and then twisted twice

together on the deep surface[28].

Figure 10. Leonard’s button.

8.Groningen type custom made arch bar:

This arch bar is useful when extra rigidity is required, for example, in case of segmental

osteotomies.

Figure 11. Highly polished arch bar.

18
 SURGICAL ANATOMY

9 .Erich arch bar:

Prefabricated arch bars are available commercially, the most popular of which is the

Erich arch bar. These arch bars are made of a relatively soft metal, which can be

molded and adapted to the dental arch.

Figure 12. IMF with elastic bands attached to an upper and lower Erich splint.

Schuchardt’s wire, acrylic arch bar

Schuchardt (1956) and Schuchardt & Metz (1966) first described this concept [29]. They

designed an arch bar constructed from 2‐mm diameter aluminium brass alloy half‐round

wire, which is wired to the teeth at the level of the mid‐crown and is maintained in this

position by hooks, which fit into the space between the crowns of adjacent teeth.

Figure 13: Schuchardt’s wire, acrylic arch bar

19
 SURGICAL ANATOMY

Dautrey arch bar

The Dautrey arch bar is made from soft stainless steel, 15 cm in length, which allows its

installation from second molar to second molar along the dental arch. Its main feature is

the presence of a significant number of hooks. Depending on how these hooks are

oriented during fixation, we may use the arch bar just for IMF; it can also serve as a

method of fixation of dentoalveolar fractures or teeth avulsions.

Figure 14. Stabilization of dentoalveolar fractures by positioning the Dautrey arch bar

upside down.

Bern’s titanium arch bar:

When a bar is needed only from first molar to first molar, the bar can easily be cut with a

conventional wire cutter. Each arch bar is fitted with 21 hooks, each separated by 6 mm.

Figure 15 . Bern’s titanium arch bar.

20
 SURGICAL ANATOMY

Cap splints:

Cap splints are designed to cover the occlusal surface and exposed parts of the teeth

down to the gingival margins. Cap splints are strong, resistant, well‐anchored, and

particularly useful in fractures of the mandible when few teeth are present.

Gunningtype splints

In edentulous patients, IMF procedures are definitively more complex because of the

absence of teeth to guide the occlusion or to serve as pillars to anchor the previously

mentioned wires, arch bars, cap splints, and because of the loss of vertical dimension

control.

Figure 16 . Gunning splint with rubber band IMF. Splints fixed with transalveolar and

circummandibular wires.

IMF screws

The major drawbacks of ligature wires and arch bars include the relatively long time to

apply and remove them, and the risk of prick accidents to the surgeon performing the

procedure. Finally, wires tightened during the application of arch bars around the teeth

21
 SURGICAL ANATOMY

may cause ischemic necrosis of the mucosa and make it difficult for the patient to

maintain gingival health (Wilson & Hohmann, 1976; Ayoub & Rowson, 2003)[30].

To overcome these problems, Dal Pont developed an IMF procedure in which he used

S‐shaped hooks inserted lateral to the pyriform aperture and at the inferior border of the

mandible under general anaesthesia (Dal Pont, 1967)[31]. Otten (1981) improved this

method using AO miniscrews inserted into the nasal spine and into the symphyseal

region of the mandible. These screws were used to attach elastic bands or wires for IMF

[32]. According to Manson, these screws neither provide the stability and flexibility

obtained from arch bars nor full IMF.

Figure 17:IMF wire passed through the hole in the screw neck.

To over come all the problems which are caused by using the above arch bars such as

difficulty in patient acceptance, time consuming, difficult to maintain oral hygiene. The

Stryker SMARTLock system is a maxillomandibular fixation device that was released in

2013.The system consists of the SMARTLock Hybrid MMF Plate (arch bar), which is

made of commercially pure titanium. The plate consists of an arch bar segment and

nine screw hole segments that project from the arch bars. This plate is secured with

monocortical titanium alloy screws placed through the oral mucosa into the supporting

22
 SURGICAL ANATOMY

bone in a fashion similar to maxillomandibular fixation screws. These screws are 2.0

mm in diameter and come in lengths of 6 and 8 mm. The system also includes a

screwdriver, plate cutter, plate bender, and screw spacer. The spacer is used to hold

the plate away from the oral mucosa until the screws lock into the plate.

Figure 18: Smart Lock Hybrid Arch Bar

23
 AIMS AND OBJECTIVE

AIMS:

The present study was performed to evaluate and compare the advantages, disadvantages and

potential complications of Arch bars & SMART LOCK HYBRID ARCH BAR in patients with

Condylar intracapscular fractures of mandible. 24 cases were selected for maxillomandibular

fixation and they were divided into two groups group A and group B. In group A,study 12

patients were included for SMART LOCK HYBRID ARCH BAR and group B, study 12 patients

were included for Erich arch bar fixation.

OBJECTIVES:

1. To compare the time taken for fixation.

2. To compare the Stability of the occlusion.

3. To compare the needle prick injury caused during the fixation of arch bar.

4. To compare the mucosal growth over the device.

5. To compare the lip irritation caused during the usage of the arch bar.

6. To compare the time taken for removal.

7. To compare the glove perforation following the treatment.

8. To compare the oral hygiene status of the patients following the treatment.

24
 Review of literature

1. Lello JL and Lello JE (1988)[33] conducted a study in 30 patients and evaluated clinically

the influence of inter dental loop wire splinting and intermaxillary fixation on marginal

gingiva. During the study it was seen that gingival inflammation occurred with standardized

oral hygiene regime including mouth rinse for duration of splinting period. All gingival

marginal changes were resolved 2 weeks following loop wire splint removal, apart from

mobility which did not retain preoperative level. Despite significant fall in plaque index

level after IMF release gingival inflammation only decreased after removal of loop wire

splinting.

2. GREGORY ARTHUR, NICHOLAS BERRARO (1989)[34] Their technique involves

placement of bone screws in the maxilla and mandible to be linked by a loop of wire,

thereby providing MMF. Generally, the sites for placement of the bone screws depend on the

anatomic structures in the area (ie, nerve trunks, nasal mucosa) and the position of the

fracture(s). Ideal maxillary sites include the pyriform rim area and zygomatic buttress region.

In the mandible, the entire region below the root apices and between the mental foramina is

an acceptable site. The technique involves the use of self- tapping bone screws of variable

length and generally 2 mm in diameter. A pilot drill is used, passed directly through stretched

mucosa into the bone of the selected site, and a hole is prepared. The self-tapping screw is

then inserted. sufficiently deep to allow stability and yet still permit a loop of wire to fit over

its head.

3. LAGVANKAR S.P. et al (1990)[35] described a simple and easy method for the fixation of

arch bar. It gives a consistently firm fixation even in difficult situations and doesn’t require

any sophisticated appliance.

25
 Review of literature

4. BOOTH P.A., COLLING I.G. et al (1990)[36] reported a technique for constructing acid

etched arch bars, this technique provides appropriate location of osteotomy segments in the

absence of orthodontic brackets. The arch bars can be applied preoperatively with a

subsequent economy of theatre time. This technique has been used in 32 cases.

5. GRAVEN P.M. et al (1990)[37] described a modified orthodontic bracket for use in

intermaxillary fixation. He used stainless steel wire which fits smugly into the bracket slot.

The wire was then bended to form a loop around the bracket and at least four spot welds were

used. This has overcome the difficulty of placing elastic bands for intermaxillary fixation.

6. WIN KKS et al (1991)[38] reported a technique of intermaxillary fixation using screws

anchored in the maxilla and mandible. Screws with diameter of 3.5mm and 12mm to 16mm

in length were inserted at the anteriolateral surface of maxilla and the buccal surface of

mandible. This technique was done under local anesthesia, a horizontal vestibular incision

was made from right to left molar region and bone was exposed ; a 2mm drill is used to make

a pilot hole. The upper and the lower dentures were put into the place to maintain occlusal

height followed by Intermaxillary fixation. This technique is particularly suitable for

mandibular fractures in denture wearing patients.

7. BUSH R.F., FRUNES .F et al (1991)[39] suggested the use of 2.7mm diameter intraoral

cortical screws instead of 2.0mm diameter suggested by AUTHOR and BERARDO. The

technique involves the use of 2.7mm self tapping bone screws with the length of 16 to 20mm

in maxilla while 24mm in mandible for fixation. In this technique a small stab incision is

used to expose the area, drill is used to make pilot hole and a mini driver is used to place the

screws. He concluded that with this technique have less HIV infections, less operating time,

minimal hardware with superior stabilization was achieved.

26
 Review of literature

8. BROWN et al (1991)[40] compared the cost effectiveness of intermaxillary fixation as

compared to miniplate osteosynthesis in the management of mandibular fractures. They

concluded that the use of miniplate is no more expensive than the use of IMF in the

management of mandibular fractures. In addition the use of IMF significantly increased the

operating time. In his study he also found that it is a risky procedure to the surgeon and

assistant and protection can be obtained by triple gloving technique. The use of triple gloving

is superior to double gloving.

9. Avery C M E and Johnson PA (1992)[41] has done study on 60 patients diagnosed with

mandibular fracture of which 30 patients treated with wiring and 30 patents with small plate

osteosynthesis and studied the surgical glove perforation acquired during mandibular

fractures by comparing the technique of interdental wiring and small-plate osteosynthesis

technique (SPO). They found that was a significant reduction in the incidence of skin

penetrating injuries was in the surgeon and assistant surgeon groups and very highly

significant reduction in the incidence of glove perforation in the assistant surgeon group in

those treated with SPO technique. The reduction in the surgeon group was not significant in

case of glove penetration and there was no difference noted in the scrub nurse group. It was

found that the small-plate osteosynthesis technique has the advantage of reducing the risk of

intraoperative cross infection transmitted by hand contamination or penetrating injury.

10. N. ZACHARAIDES, M. MEZITIS, G. RALLIS et al (1996)[42] in 9 year of the study

admitted 6546 patients, out of which 4197 were admitted for trauma. Of these 2380 were

mandibular fractures. Five hundred and six eighty mandibular fractures were treated with

intraosseous wiring and intermaxillary fixation, 443 with bone plates. There were five

postoperative facial nerve palsies and two cases of paresthesia of the inferior alveolar nerve

27
 Review of literature

in the plated group. They were all transient. During recent years intermaxillary fixation and

intraosseous wiring have gradually been abandoned.

11. KARLIS, VASILIKI, GLICKMEN, ROBERT et al (1997)[43] published a study

conducted in their department using 2.0mm titanium self tapping IMF screws followed by 24

gauge wires for intermaxillary fixation for 5 patients who sustained mandibular fractures.

Standard fracture protocol was followed and all patients received intraoperative antibiotics

and 5 days postoperative course of antibiotics. The patients were evaluated weekly for any

changes in occlusion or loosening of hardware. At the fifth post operative week, one patient

experienced loosing of intermaxillary fixation screws.

12. D.C. JONES et al (1999) [44] reviewed that IMF screws is adequate for temporary

intraoperative fixation and postoperative elastic traction, it is not strong to allow the

prolonged postoperative IMF [which in any event is rarely indicated today]. The use of these

screws with capstan heads is important as it allows the wires or elastics to be held away from

gingival areas, preventing local damage. Intermaxillary screws are quick to insert and carry

fewer risks of needle stick injury as compared to that of conventional arch bar or eyelet

wiring. They are particularly suitable for patients with extensive crown and bridgework.

13. A. ALDERHERI, J.L. BLANC et al (1999)[45] presented an easy, safe, rapid and cheap

MMF appliance called the pearl steel wire. The technique is best employed in the patients

with full complement of teeth. The presence of an interdental gap is the absolute

contraindication. Unlike arch bars, pearl steel wire can be safely used for the periodontium.

Although not effective for the treatment of all maxillofacial fractures, the pearl steel wire

provides the simple, fast, safe and cheap methods of MMF in many cases. It has been

28
 Review of literature

successfully used for mandibular fractures, in lefort I and II fractures with or without

mandibular fractures and in dentoalveolar fractures.

14. SIMON HOLMES, IAIN HUTCHISON et al (2000) [46]presented a report of 23 year old.

This shows moderately displaced fracture of right angle of mandible. In view of the degree of

displacement and the risk of cross infection. They decided to use threaded titanium screws

for temporary intermaxillary fixation.

15. A. JOHN VARTANIAN, AIJAZ ALVI (2000)[47] conducted a retrospective evaluation of

23 patients with 40 mandibular fractures. The result showed normal occlusion was observed

in 21 patients, class II malocclusion was noted in one patient. No complication related to use

of intermaxillary fixation were observed. Lower lip sensations were observed in 5 patients,

the remaining 18 patients had normal bilateral sensation. All the bone screw sites were well

healed, with mucosal tissue obscuring the actual screw placement site.

16. SCHNEIDER, ANDREW, DAVID et al (2000)[48] conducted a study on 19 patients with

mandibular fractures and treated them using new specialized intraoral bone screws that are

designed for the purpose of achieving intermaxillary fixation. All patients maintained stable

and accurate occlusion and had adequate healing. One patient continued to have paraesthesia

in mental nerve distribution after screw removal. Although there is potential for tooth and

nerve injury when screws are placed improperly, the IMF screw system seems to be safe and

reliable method of achieving secure mandibular fixation.

17. THOR, L. ANDERSON et al (2001) [49] in their study 392 teeth of 20 consecutive patients

treated for jaw fractures with interdental wiring were followed prospectively. They were

treated with either eyelet ligature or Erich type arch bar attached to circumferential dental

wiring and MMF. They have evaluated clinically and radiografically, the periodontal

29
 Review of literature

condition of wired teeth, their root and alveolar bone status and their mobility and sensitivity.

After one year follow up the result showed that the periodontal and pulpal health has restored

to normal both clinically and radiologically in 97% of patients. Progressive caries was seen

in two patients and were treated simultaneously. Loss of sensitivity was seen in 3 teeth

adjacent to the fracture site and one tooth loss was reported.

18. STEVEN KEY, ANDREW GIBBONS et al (2000)[50] placed 400 intermaxillary fixation

screws during three years of their study and the commonest problem encountered during the

placement is root damage and caused by inaccurate alignment of the screw. They concluded

the alignment of teeth in 3-D should be fully appreciated. If any resistance is encountered

whilst drilling beyond the outer cortical plate, then the IMF screw hole should be reinserted

in a new site. The use of bicortical screws is a valuable technique that greatly shortens the

operative time to achieve intermaxillary fixation but care should be taken to avoid the

damage to adjacent teeth.

19. D. G. Coburn, D. W. G. Kennedy, S. C. Hodder,(2002),[51]The use of the

dedicated bicortical bone screw for temporary intermaxillary fixation

provides many benefits to patients and surgeons. These benefits are

quick, easy and safe insertion; compatible with any plating system; no

discomfort to the patient; reduced trauma to the buccal mucosa; ideal for use

when teeth have been heavily restored; gingival health easier to maintain than

with arch bars and eyelet wires; reduced risk of needle stick injury. He

reviewed various complications seen like fracture of the shaft of the screw

intraoperatively, iatrogenic injury to the root of the associated teeth, avulsion

of teeth due to drilling of burr hole into the root of the teeth.122 patients

30
 Review of literature

with fractured mandibles had IMF screws placed intraoperatively as part of

their treatment. Five patients had six complications. Three had screw

fractures, one lost teeth and two had infections associated with IMF screws.

Poor operating technique is the likely explanation for these complications.

20. Ayoub AF and Rowson J (2003) ,[52] had compared the Dimac wires with

arch bars for interdental immobilization. This study was conducted on 50 patients

who had mandibular fractures and in whom intermaxillary fixation was required

as a part of the treatment. The time required for applying each method of fixation,

the needle-stick injuries that occurred during their application, and the periodontal

damage that followed interdental immobilization was investigated. They found

that the mean time required for the application of Dimac wires was significantly

less than that required for arch bars. The needle-stick injuries were significantly

less with Dimac wires. Patients reported difficulty with oral hygiene with arch

bars in place. This was associated with periodontal damage following removal of

fixation. Concluded by stating that Dimac wires is safer to use and less traumatic

to the periodontium than arch bar.

21.G. Fabbroni, S. Aabed, K. Mizen, D. G. Starr,(2004) ,[53] The incidence of

screw/tooth contact in the placement of transalveolar screws was prospectively

studied. The clinical significance of such contact when it occurred was assessed.

Patients with fractures of the mandible requiring intra- or post-operative control of

their occlusion with transalveolar screws were entered into the study. Over a 7-

month period, a series of patients with a fractured mandible in whom transalveolar

screws were placedwere entered into the study. 2.0 mm titanium capstan headed

31
 Review of literature

screws (Technovent, Bolton, UK) were used . On removal all adjacent teeth were

assessed radiographically. In the majority of cases this was with periapical

radiographs using the paralleling technique. A total of 232 screws were inserted.

There were 440 teeth adjacent to these screw sites. Twenty-six teeth had major

contacts, 37 teeth had minor contacts. It is reassuring, however, to note the

relatively minimal clinical significance of screw/root contact even in patients

where this is radiographically evident.

22. Fabio ROCCIA, Amedeo TAVOLACCINI, Alessandro DELL’ACQUA,

Massimo FASOLI (2005)[ 5 4 ] Their aim was to evaluate the indications and

possible complications of using intraoral cortical bone screws. Sixty-two patients

with mandibular fractures, treated by intermaxillary fixation using these screws,

were evaluated by preoperative and postoperative panoramic radiographs. Clinical

testing was carried out for vitality and abnormal mobility of teeth adjacent to the

site of screw insertions. To evaluate the efficacy of this method, different factors

were considered such as possible iatrogenic dental injuries, loss, breakage or

screw cover by oral mucosa and postoperative occlusion. Self-tapping titanium

screws 8mm long and 2 mm in diameter (Surgical Fixation Screw System, Walter

Lorenz Surgical, Jacksonville, USA) were inserted, at least one in each quadrant,

under local or general anaesthesia, into pre-drilled holes at the junction of the

attached and mobile mucosa. The screws were left in place for 2–3 weeks to

enable postoperative elastic traction to correct small discrepancies in occlusion.

Four screws each were placed in 58 patients (93.5%), while in three cases eight

screws were inserted, and in another case nine (a total of 265 screws). They were

32
 Review of literature

inserted under general anaesthesia in 44 patients and under local anaesthesia in the

other 18 patients.

23. DuPont JS and Brown CE (2006) ,[55]has published an article on occlusal

splints from the beginning to the present and they have tried to gather the

information and presented in the most concise form possible including history,

various splint modalities used today that is the present trend that is use of hard

acrylic appliance clinically covering full arch of teeth, also mentioned about the

action on the musculature, efficacy of splint for treatment sign and symptoms of

TMD and its effectiveness with this inter occlusal splint.

24. Domenick P. Coletti, Andrew Salama,(2007) ,[56] A retrospective study on

49 patients requiring IMF was performed. The diagnosis, duration of IMF,

screw site, use of elastic or wire fixation, and associated complications were

recorded. IMF screws were used to adjunct open reduction techniques, for

definitive closed reduction, or fracture prevention following dentoalveolar

surgery. Follow-up examinations were performed until fracture healing was

complete. The most common event was screw loosening; 29% of patients had at

least one screw dislodged in the treatment period. In relation to the total number

of screws placed, 15 of 229 (6.5%) screws became loose and were equally

distributed among the mandible and maxilla. The remaining complications noted

were root fracture, 4% (2 of 49); loosened wires, 6% (3of 49); screw shear, 2% (1

of 49); malocclusion, 2% (1 of 49); and ingested hardware, 2% (1 of 49). Overall

the IMF self-drilling/tapping screws have been shown to be a useful modality to

establish MMF. It is a safe, and time- sparing technique; however, it is not

33
 Review of literature

without limitations or potential consequences which the surgeon must be aware

of in order to provide safe and effective treatment.

25.Mark E. Engelstad, and Patricia Kelly, (2011) , [57] Embrasure wires are a

method of intraoperative MMF with significant potential advantages. The purpose

of this investigation was to compare embrasure wires with Erich arch bars (Karl

Leibinger Co, Mulheim, Germany) for intraoperative stabilization of mandible

fractures. This retrospective case review comprised 50 patients with a primary

diagnosis of mandible fracture requiring open reduction–internal fixation with

intraoperative MMF. Patients were categorized into 2 groups: intraoperative MMF

using embrasure wires (group A) or intraoperative MMF using arch bars (group

B). In each group the time required to place the MMF was recorded in whole

minutes. The duration of time required and the risks of percutaneous wire stick

and disease transmission are well-known disadvantages of the use of arch bars.

The embrasure wire technique also uses wires and therefore must also be

performed with caution. However, far fewer wires are required in comparison to

arch bars, which reduces the risk of wire stick and disease transmission.

Embrasure wires are placed relatively quickly, provide stable intraoperative MMF

for selected patients, and require no special materials or devices. Compared with

arch bars, using embrasure wires for intraoperative MMF may decrease operating

room time and health care costs while potentially minimizing the risk of disease

transmission.

26.G. D. Nandini , Ramdas Balakrishna ,Jyotsna Rao,(2011) ,[58] The aim of

this work was to compare the efficacy, advantages, disadvantages indications and

34
 Review of literature

potential complications associated with Erich archbar v/s self tapping IMF screws

in the management of mandibular fractures. The mean time taken for IMF was

8.52 ± 2.7 min with screws as compared to 100 min with Erich arch bars. Mean

number of perforations were significantly more in Group II. Oral hygiene status

was good in 90% and fair in 10% of Group I and 100% fair in Group II patients.

Self Tapping IMF screws of 2 mm diameter and 12–14 mm were placed after

drilling a hole using a 1.5 mm drill bit at the junction of attached and reflected

mucosa with one screw in each quadrant. They concluded that Intermaxillary

fixation with self tapping IMF screws is more efficacious method as compared to

the conventional Erich arch bars in the treatment of maxillofacial fractures.

27. Hashemi HM, Parhiz A.(2011) ,[59]A study was conducted to find out the

complications using intermaxillary fixation screws. They did a retrospective

study in 73 patients requiring IMF, the complications of IMF screws were

analysed. Bicortical screws of various brands (diameter, 2 mm; length, 8-12 mm)

were placed in the interproximal or edentulous spaces at the mucogingival

junction. The sites for screw insertion were determined on preoperative panoramic

radiography Complications were divided into 2 groups: dental and non-dental.

The most common complication was screw loosening before completion of the

IMF period (80% of them loosened after 5 weeks and the remainder loosened in

less than 5 weeks). This occurred in 28 screws in the maxilla (15%) and 11 screws

in the mandible (5.9%).Follow-up examinations included clinical and panoramic

radiographic examinations. They concluded that the use of IMF screws is simple

and decreases the time required for surgery, but because of their complications,

35
 Review of literature

they still require punctuality. Our experience in this study indicated that although

about one third of screws resulted in complications, most of these complications

can be avoided by inserting screws carefully.

28.Rai A, Datarkar A, and Borle RM(2011) ,[60] A study was conducted to see

the efficacy of maxillo-mandibular fixation screws with Erich arch bar and to

compare the plaque index between the two methods of intermaxillary fixation.

The study was a randomized clinical trial, the patients were assessed for the time

required in minutes for the placement and removal of screws and arch bar, post-

operative stability of both the groups after achieving intermaxillary fixation and

plaque index (TURESKY-GILMORE- GLICKMAN modification of QUIGLEY

HEIN index) was also assessed. Stainless steel, self-drilling/tapping screws of

2.0-mm diameter (12-mm length) and 26-gauge wire were used for achieving the

MMF. The most preferred site is between the canine and first premolar The

included patients were divided into 2 groups. Group I comprised 60 patients , who

were treated using stainless steel MMF screws and miniplates with or without

open reduction. Group II included 30 patients treated using an Erich arch bar.

They conclude that oral hygiene maintenance is better in patients with IMF

screws than with arch bars with fewer complications and less operating time.

29. Anshul Rai, Abhay Datarkar, ,Rajeev Borle,(2012),[61]The goal of this

study was to identify a better method for achieving IMF. Specifically, the intent

was to determine the efficacy of eyelet wiring in comparison with Gilmer wiring,

as well as to compare the plaque index between groups. Complications in the

form of soft tissue injury, glove puncture, and trauma to the operator’s finger were

36
 Review of literature

also recorded. The mean working time for placement and removal of eyelet

wiring (group I) was 18.00 minutes and 9.67 minutes, respectively. For direct

interdental wiring (group II), it was 30.50 minutes and 23.12 minutes,

respectively. They concluded that Eyelet wiring is preferable to direct interdental

wiring as evidenced by fewer complications, and requires a shorter operating time

in patients with minimally displaced fractures.

30. Christopher Knotts, Meredith Workman, Kamal Sawan,(2012) ,[62] We

present a novel technique to achieve MMF using rigid plates spanning the oral

cavity to fixate the maxilla to the mandible. A 55-year-old woman presented to

the trauma bay by helicopter from the scene of a single-vehicle rollover crash.

Facial computed tomography scans showed a bilateral Lefort 2 fracture, a left

mandibular body fracture . Once the midface was stabilized, gentle traction was

used to reduce the subcondylar fracture and estimate centric occlusion. The

appropriate distance between maxilla and mandible was verified by measuring the

occlusal relationship of the remains of denture fragments. The mandible and

maxilla were fixed together using 2.0 locking plates placed above the mucosa.

These spanning plates were placed in a superoanterior vector to compensate for

lack of rigid occlusion behind the left angle fracture. The process is rapid and

allows stability using the established principles of rigidity, external fixation, and

osteosynthesis. he MMF plates were removed at the bedside after 3 weeks, and

range of motion exercises began. This technique allows for a faster MMF than

with a Gunning splint and allows for easier oral hygiene.

31. De Quelroz SBF(2013) ,[63]A study was conducted by modifying Erich arch

37
 Review of literature

bar used in IMF in Oral and Maxillofacial Surgery and found out that this

technique is effective in attaining maxilla mandibular fixation which is time

effective and has advantages of both Erich’s arch bar as well as IMF screws since

the technique is a combination of both.

32.Thrupti DV, Choudhury S, Shah A and Singh M (2013),[64]conducted a

study to compare the clinical efficacy of vacuum formed splint and arch bar in

treating minimally displaced mandibular fractures .Forty patients were included in

two groups. Group I was treated with custom made splints and group II with

conventional arch bar. Patients were recalled on 3rd, 7th, 14th day and on the day

of removal of appliance. Periodontal status, stability of appliance and chair side

time were evaluated. It was concluded that the vacuum formed splints has better

advantages over arch bar with respect to chair side time, periodontal health,

patient’s compliance of maintaining oral hygiene, mastication and speech.

Vacuum formed splints avoid needle stick injuries. So they can be used for

intermaxillary fixation in minimally displaced mandibular fractures.

33.Pranav D. Ingole, Anoop Garg, S. Ramakrishna Shenoi (2014) ,[65] The

aim of the present randomized study was to evaluate the efficacy of intermaxillary

fixation screw (IMFS) versus eyelet interdental wiring for intermaxillary fixation

(IMF) in minimally displaced mandibular fractures. A total of 50 patients with a

minimally displaced mandibular fracture were enrolled, Both techniques were

assessed for the following parameters: time required for placement and removal of

each type of IMF technique, time required for placement of IMF wires,

postoperative occlusion, stability of the IMF wire, local anesthesia requirement

38
 Review of literature

during removal of each fixation type, oral hygiene status, glove perforation rate,

and complications associated with both techniques. stainless steel IMFSs 2 mm in

diameter and 8 or 10 mm in length were used (Orthomax, Baroda,India). IMFSs

were placed between the canine and first premolar or between 2 premolars, at the

junction of the attached and alveolar mucosa, after verifying the root position on

the orthopantomogram (OPG) radiograph. The average time required for the

placement of the IMFSs was 17.56 minutes and for the eyelets was 35.08 minutes.

In conclusion, IMFS application is an uncomplicated and rapid technique, useful

for intraoperative ORIF and long term for CR. Because IMFSs provide stable

occlusion, the technique is a viable alternative to eyelets and other interdental

wiring, with a significant reduction in operating time.

34. S B F De Queiroz (2013),[66] A conventional arch bar was modified by

making perforations in the spaces between the winglets along the entire extension

of the bar, using a No. 701 bur adapted to a high speed handpiece . In a patient,

the arch bar is adapted to the vestibular surface of the maxilla and mandible, close

to the cervical portion of the teeth, and a perforation is made in the inter radicular

spaces with a 1.1 mm bur, taking care to avoid perforation of the tooth roots.

After this, a 1.5 mm screw is placed to fix the bar.

35. Albert H. Chao, John Hulsen (2015) ,[67]They stated that titanium arch bars

that are directly fixated to the maxilla and mandible with self-drilling locking

screws combine features of Erich arch bars and bone-supported devices and

present an alternative method of intermaxillary fixation (IMF) that possesses

potential advantages over existing techniques. The objective of this study was to

39
 Review of literature

compare IMF using this device with Erich arch bars secured with circum-dental

wires. A retrospective cohort study was performed of patients who were

surgically treated for mandibular fractures from 2012 through 2013. The primary

predictor variable was fixation technique, which was IMF using Erich arch bars

secured with circum- dental wires (group I) or titanium arch bars fixated with

maxillary and mandibular screws (group II). The outcome variables were

complication rates, time necessary for device application and removal, glove

perforation rate, and cost. The study population was composed of all patients

presenting for evaluation and management of mandibular fractures from October

2012 through December 2013 at a single institution. In group I, Erich arch bars

were secured in place using 24- gauge round stainless steel circum-dental wires

placed around premolars and molars. In group II, arch bars were generally

fixated using 5 2.0- and 6-mm-long self-drilling locking screws in the maxilla

and 5 2.0- and 8-mm-long screws in the mandible. The number of screws placed

was based on ensuring there were at least 2 screws on either side of a fracture if

IMF was to function as a tension band and to ensure that the arch bars retained

their horizontal shape. Twenty-five consecutive cases involving IMF using Erich

arch bars secured with circum-dental wires (group I) and 25 consecutive cases

involving titanium march bars fixated with maxillary and mandibular screws

(group II) were reviewed. The results of this study suggest that titanium arch bars

fixated with maxillary and mandibular screws may be a comparable alternative to

Erich arch bars secured with circum-dental wires for IMF with respect to clinical

outcomes. Their use is associated with a shorter device application time, although

40
 Review of literature

device removal time, glove perforation rate, and cost are similar.

36 .Douglas E. Kendrick, Chan M. Park, Jesse M.(2016),[68]This study was

performed to determine the clinical application, complications, radiographic

findings, and cost effectiveness of the Smartlock system. A retrospective cohort

study was performed with the Smartlock system over 6 months. Demographics,

history, fracture location, placement/removal time, and complications were

obtained, along with cost analysis. The authors identified 35 patients with the

SMARTLock system. Twenty-four patients remained after exclusion criteria.

There were 19 male patients (79 percent) and five female patients (21 percent),

with a mean age of 30.7 years. The mean application time of the SMARTLock

system was 14.4 minutes, and the mean removal time was 10.5 minutes. These

screws are 2.0 mm in diameter and come in lengths of 6 and 8 mm. The system

also includes a screwdriver, plate cutter, plate bender, and screw spacer. Patients

retained the hybrid system until there was stable occlusion, clinical evidence of

healing, and maximum incisal opening of 40 mm or greater. following data were

collected for each patient: (1) age, (2) sex, (3) fracture location, (4) number of

minutes to place the SMARTLock system, (5) number of minutes to remove the

system, and (6) complications. Postoperative cone-beam computed tomographic

examination was performed on all patients on the day of surgery using i-CAT.

The mean age of the patients was 30.7 years. All patients were treated for trauma

to the maxilla or mandible. All patients were placed into either wire

maxillomandibular fixation or heavy elastics. The average duration of wire

maxillomandibular fixation or heavy elastics was 31.4 days. Cost analysis showed

41
 Review of literature

that the use of the SMARTLock system is comparable to that of traditional Erich

arch bars. Although the SMARTLock system is much more expensive, the overall

cost is comparable when factoring in the amount of time saved in the operating

room. This study supports the use of the Stryker SMARTLock Hybrid system as

an alternative to traditional Erich arch bars. Overall, the SMARTLock system

appears to be safe and easy to use, can be applied quickly, and has a cost similar

to that of Erich arch bars.

37. Qureshi AA, Reddy UK, Warad NM, Badal S, Jamadar AA and Qurishi

N(2016),[69] has conducted a comparative study of intermaxillary fixation screws

verses erich arch bars in mandibular fractures by comparing the advantages and

disadvantages of intermaxillary fixation screws over the Erich arch bars. Study

was done on 60 patients divided into 2 groups of 30 patients each that is Group A

and Group B. Group A included patients who received intermaxillary fixation

with Erich arch bars. Group B includes patients who received intermaxillary

fixation with IMF Screws. The parameters compared in both the groups included,

surgical time taken, gloves perforation, post-operative occlusion, IMF stability,

oral hygiene, patient acceptance and comfort and non-vitality characteristics it

was found that the average surgical time taken and gloves perforations were more

in Group A, the patient acceptance and oral hygiene was better in Group B.

38.Anna Rose Carlson ,Ronnie Labib Shammas, Alexander Christopher

Allori,(2017), [70] In this study, we report a novel method for the reduction of the

edentulous mandible fracture, via fabrication of modified Gunning splints using

existing dentures and SMARTLock hybrid arch bars. This technique dramatically

42
 Review of literature

simplifies the application of an arch bar to dentures, obviates the need for the

fabrication of impressions and custom splints, and eliminates the lag time

associated with the creation of splints. Furthermore, this method may be used with

or without adjunctive rigid internal fixation. This is a case report in which they

have used the patients existing dentures and SMARTLock arch bars were adapted

to fit the patient’s dentures. The arch bars were then fixated to the dentures using

four 4-mm screws on the mandibular denture and three 4-mm screws on the

maxillary denture, thus creating modified Gunning splints . Fabrication of these

splints required less than 10 minutes of operative time. The splints were then

fixated to the patient’s maxilla and mandible using 10-mm screws placed through

the denture flange. No complications were noted in the postoperative period.

Elastic MMF was maintained for a total of 6 weeks, after which the splints were

removed. Bone anchored arch bars combine 2 methods for reducing mandibular

fractures: conventional arch bars and MMF screws.

39. Balihallimath L, Jain R, Mehrotra U and Rangnekar N (2019),[71]

compared the efficiency of MMF screws over arch bars in achieving IMF. A

total of thirty patients who required IMF as a part of their treatment were

included in the study. Patients were divided into two groups: Group A: Patients

treated using MMF screws and Group B: Patients treated using arch bars.

Statistical analysis was performed using the Mann–Whitney U‑test and unpaired

t‑test. It was found that there was a significant difference in oral hygiene index

between the two groups at the end of the 14th postoperative day. The time taken

for the placement of MMF screws was significantly less (mean 18.7 min) as

43
 Review of literature

compared to arch bars (mean 41.2 min). Screw loosening was seen in 4 (26%) out

of 15 patients and 3 screws (4.5%) out of 66 screws used showed partial mucosal

coverage at the end of 2 weeks. There were no cases of penetration injury in

Group A, while in Group B, penetration injury to the surgeon was noted in 5

(33.3%) cases. They concluded that MMF screws provided good intraoperative

MMF. They also observed better oral hygiene, better patient compliance, and no

major complications with the use MMF screws. Hence MMF screws proved to be

an efficient alternative to the conventional methods of achieving IMF.

40.Bouloux G F (2018) ,[72] The author implemented a prospective randomized

non-blinded study on consecutive subjects presenting with mandibular fractures to

Grady Memorial Hospital. The primary predictor variable was the use of Hybrid

arch-bars versus Erich arch-bars. The primary outcome variable was the length of

surgery time. Secondary outcome variables include time to place the arch-bars and

fracture healing. Fifty patients were enrolled and completed the study. The mean

length of surgery was 108 minutes in the Hybrid group and 117 minutes in the

Erich arch-bar group (P=0.62). The mean time taken to place arch-bars was 14

and 37 minutes, in the Hybrid and Erich arch-bar group.

41. Brett J. King, Brian J. Christensen (2019),[73]They conducted a study in

which ninety patients were enrolled in the study. There were 43 patients

randomized to the Erich arch bar group and 47 patients randomized to the hybrid

arch bar group. The mean time for application of Erich arch bars was 31.3 ± 9.3

minutes and 6.9 ±3.1 minutes for the Hybrid arch bars (p<0.0001). There were

significantly more glove tears or penetrations during application for the Erich

44
 Review of literature

Arch Bar group (0.56 ±0.91per application) compared to the Hybrid group (0.11 ±

0.32 per application) (p=0.0025).

45
 MATERIALS AND METHODS

SOURCE OF DATA:

A randomized prospective study was conducted on 24 patients reporting to the

department of Oral and Maxillofacial Surgery at MNR Dental College and Hospital,

Sangareddy, with isolated intracapsular condylar fractures. These 24 intracapsular

condylar fracture patients who require closed reduction were randomly divided into two

equal groups. Group A (smart lock hybrid arch bar group) consists of 12 intracapsular

condylar fracture patients who were treated by closed reduction with smart lock hybrid

arch bar. Group B (Erich arch bar group) consists of 12 intracapsular condylar fracture

patients who were treated by closed reduction with Erich arch bar. In all these patients

the duration of intermaxillary fixation was 4 weeks.

CASE SELECTION

Inclusion criteria:

1. Patients with isolated Intracapscular condylar fractures of mandible.

2. Un displaced condylar fracture

3. Patients who gave consent for Intermaxillary fixation.

Exclusion criteria:

1. Edentulous patients .

2. Patients with systemic conditions contraindicated for Inter Maxillary Fixation

3. Extra capscular fractures

4. Dispaced condylar fractures.

5. Comminuted fractures of mandible

46
 MATERIALS AND METHODS

Preoperative evaluation of the patient:

1. Patients were free of any systemic diseases affecting bone healing.

2. A thorough clinical examination was performed in reference to

a. Abrasions, lacerations, ecchymosis

b. Site of fracture

c. Tooth / teeth with mobility

d. Occlusion

e. Mouth opening

f. Presence of infection

g. Any neurological disturbances

h. Routine blood examination was done to rule out any systemic diseases

3. Orthopantomogram was taken to diagnose fracture site and to correlate with

clinical findings.

4. Evaluation of oral hygiene was done with OHI-S INDEX by Greene and Vermillion,

1964.

It was used at the time of arch bar and screw removal of Smart Lock Hybrid arch

bar to evaluate the condition of plaque and calculus and scores given accordingly

to the following criteria:

Scoring criteria for debris index- simplified:

0. No debris or stain present

47
 MATERIALS AND METHODS

1. Soft tissue debris not more than one third of tooth surface, or presence of

extrinsic stains without other debris regardless of area covered

2. Soft tissue debris covering over one third but not more than two thirds, of

exposed tooth surface.

3. Soft debris covering more than two thirds of exposed tooth surface.

Scoring criteria for calculus index simplified:

0. No calculus present

1. Supragingival calculus covering more than one third of exposed tooth surface

2. Supragingival calculus covering more than one third but not more than two thirds

of exposed tooth surface or presence of individual flecks of subgingival calculus

around the cervical portion of the tooth.

3. Supragingival calculus covering more than two thirds of exposed tooth surface or

a continuous heavy band of subgingival calculus around the cervical portion of

the tooth.

Preoperatively:

1. Preoperatively a standard regimen of antibiotics and analgesics were started.

a. Cap. Amoxicillin 500mg

b. Tab. Metronidazole 400mg

c. Tab. Diclofenac sodium 50mg

d. Tab.Pantaprozole-D

Patient included in this study were randomly selected and divided into two groups.

48
 MATERIALS AND METHODS

Group A: 12 patients with intracapscular condylar fracture are treated by closed

reduction with Smart Lock Hybrid arch bar were included.

Group B: 12 patients with intracapscular condylar fracture are treated by closed

reduction with Erich arch bar were included.

Armentarium used for Imf with Smart Lock Hybrid arch bar:

The Smart Lock Hybrid arch bar which is used is made up of stainless steel with hooks

which are bendable or angulated for screw fixation and slugs are present for placement

of elastics and wires for intermaxillary fixation.

MATERIALS USED:

1. 2% Xylocaine with Adrenaline

2. Normal saline for irrigation

3. Stainless steel Smart Lock Hybrid arch bar.

4. Stainless steel screws 2*8 mm

5. Screw holder and screw driver 2.0mm

6. Straight surgical hand piece

7. 26 gauge stainless steel wire

8. Wire twister and cutter

9. 701 bur

PROCUDURE FOR SMART LOCK HYBRID ARCH BAR:

49
 MATERIALS AND METHODS

After careful clinical and radiographic examination, the exact site of screw placement is

determined taking care of the roots while screw is positioned interdentally. 2%

Lignocaine with Adrenaline is injected so that all quadrants are adequately

anesthetized. The screws are placed at the junction of attached and movable mucosa;

the exact site for the placement of screws was determined using radiograph.

The system consists of the SMART Lock Hybrid MMF Plate (arch bar), which is made of

stainless steel. The plate consists of an arch bar segment and nine screw hole

segments that project from the arch bars. This plate is secured with monocortical

titanium alloy screws placed through the oral mucosa into the supporting bone in a

fashion similar to maxillomandibular fixation screws. These screws are 2.0 mm in

diameter and come in lengths of 6 and 8 mm. The system also includes a screwdriver,

plate cutter, plate bender, and screw spacer. The spacer is used to hold the plate away

from the oral mucosa until the screws lock into the plate.

In the hybrid group, SMART Lock Hybrid arch bars were adapted to the maxilla and

mandible. The midline locking screw was typically the first screw placed on each arch

using a 701 bur and screw placement done with screw holder and tightened with driver.

Next, a series of additional self-drilling bone-borne locking screws were placed in each

arch, adapting the arch bar eyelets as needed to ensure placement in bone while

avoiding the roots of the dentition, with 5 screws used in each arch for a total of 10 bone

screws placed for both the upper and lower arches, except in cases in which additional

screws were placed as clinically indicated. Once the position of the screw placement is

determined the guiding hole is drilled into the bone approximately 90 degrees long axis

to the adjacent teeth, taking care to pass the drill between the roots of the teeth and

50
 MATERIALS AND METHODS

without penetrating the palatal and lingual mucosa using a straight surgical hand piece

and 701 bur with normal saline as an irrigant.

A small button hole can be made in the soft tissue either by a B.P blade prior to making

holes with 701 bur, screw is inserted into the drilled hole in clockwise direction. Some

pressure is required to penetrate the outer cortex but once it is within the cancellous

bone the passage should feel free. Slight resistance is felt in entering the lingual cortex.

If the roots of the teeth are encountered then the operator will feel the screw tip bend

against them. The screw should be removed or reinserted in the new site.

The screw is passed through the buccal and palatal or lingual cortices and inserted until

flat surface of the head fits snuggly against the buccal mucosa and IMF was achieved

with the help of 26 gauge wire, elastics can also be used to achieve the intermaxillary

fixation to reduce the needle stick injury. Care is taken that the screw does not

penetrate the lingual or palatal mucosa where it could cause soft tissue irritation.

51
 MATERIALS AND METHODS

Figure19: Armentarium for imf with SmartLock Hybrid arch bar:

ARMAMENTARIUM:

Erich arch bar is a flat sturdy material made of stainless steel material. It consists of

hooks for placement of elastics and wires for intermaxillary fixation.

Armamentarium for arch bar:

1. 2% Xylocaine with Adrenaline

2. Erich arch bar [Orthomax company]

3. Normal saline for irrigation

4. 26 stainless steel wire

5. Wire twister

6. Wire cutter

7. Curved hemostat

Procedure for arch bar placement:

Adequate anesthesia was achieved by using 2% Lignocaine with Adrenaline in 1: 80000

concentration .The arch bar is measured from 1 st molar to 1st molar on both sides for

both maxilla and mandible. The arch bar material is cut to the length of each dental arch

by taking sure not to extend the arch bar beyond the last tooth to avoid tissue

impingement. Firstly, the arch bar is adapted closely to the buccal surface of each arch

by giving a shape of the arch by bending it. The arch bar should be placed between the

dental equator and the gingival ensuring that the lugs of the arch bar are oriented away

from the occlusal plane (apically) .The arch bar was then secured to teeth using 26

52
 MATERIALS AND METHODS

gauge stainless steel round surgical wires which was passed from mesial surface of

tooth to the lingual side and back on the buccal side from the distal surface of the tooth

.One end of the wire was passed above the arch bar and other end was passed below

the arch bar and by twisting the two ends of the wire together the arch bar was attached

securely and firmly to the necks of the teeth on the buccal surface of the arch. The wire

is twisted and twisted ends are then trimmed and then looped down towards the

gingiva. After both upper and lower arch bar placement was completed patients was

placed into Intermaxilaary fixation by maintaining the occlusion with the help of 26

gauge wire.

Figure 20: Armentarium for Imf with arch bar:

POST OPERATIVE CARE:

53
 MATERIALS AND METHODS

1. Tab. Cefotaxim DT 400mg tid for 5 days

2. Tab. Ketarolac DT 10mg bid for 5 days

3. Syrup Metronidazole 10ml tid for 5 days

4. Betadine mouth gargle thrice daily after food

5. A liquid diet is recommended for first few days

The patients were followed up clinically after 24 hours and after 4 weeks.

THE FOLLOWING PARAMETERS WERE CHECKED.

1. Time taken for the placement of devices was recorded

2. Occlussion achieved or not achieved was recoded

3. Needle stick injury was recorded

4. Irritation which is caused by Erich arch bar and Smart Lock Hybrid arch bar also

recorded

5. Iatrogenic tooth damage

6. Mucosal growth over the device is also recorded

7. Time taken for the removal of the device is also recorded

8. Oral Hygiene Simplified Index by Greene and Vermillion

9. Patient acceptance

54
 ILLUSTRATION

Case-1 Group A

Pre Operative and intra operative (Figure:21)

Fig 22:Post operative Opg

55
 ILLUSTRATION

Case-2 Group B

Fig 23:Pre Operative and intra operative

56
 RESULTS

The study “smart lock hybrid arch bar v/s Erich’s arch bar” was performed in the

department of oral and maxillofacial surgery, MNR dental college and hospital,

sangareddy during the period 2018-2020.A total number of 24 patients diagnosed with

unilateral intracapsular condylar fractures were included in the study. These twenty four

patients were randomly divided into two groups Group A (smart lock hybrid arch bar

group) and Group B (Erich’s arch bar group) with 12 patients in each group.

The parameters assessed in the present study were occlusion stability, needle stick

injury, lip irritation, mucosal growth over the screw in Smart lock hybrid arch bar and

gingival hyperplasia in Erich’s arch bar, damage to the roots during placement of screws

in Smart lock hybrid arch bar ,oral hygiene, time taken for fixation of arch bar and time

taken for removal of arch bar .The entire results were tabulated and statistically

analyzed using SPSS version 23.Results were considered significant if P <0.05, not

significant if p>0.05 and highly significant if p<0.001.

In the present study the age range was 18 to 50 years with mean age of 29.63 years.

There was a predominance of male gender (75%) with 18 males and 06 females in the

study. The most common etiology of mandibular intracapsular condylar fracture were

road traffic accidents (73%) followed by assaults (16%) and fall (9%).

Stable occlusion:

In the present study evaluation of stable occlusion was compared in both the groups at

one month follow up period after IMF. Both Smart lock hybrid arch bar (Group A) and

Erich arch bar (Group B) achieved 91.7% stable occlusion after arch bar fixation at one

month follow up period table (1). Both Group A and Group B reported an occlusion

57
 RESULTS

discrepancy of 8.3% at one month follow up period which were corrected with guiding

elastics for a period of 15 days. There was no statistically significant difference noted

between both the groups in relation to occlusion stability (p value >0.05).

Needle stick injury:

In the present study evaluation of needle stick injury was compared in both the groups

during fixation and removal of arch bar. Patients treated with smart lock hybrid arch bar

(Group A) reported needle stick injury of 25% while that of Erich arch bar (Group B)

reported 91.66% needle stick injury table (2). There was statically significant difference

noted between both the groups in relation to needle stick injury (p value 0.029).

Mucosal growth:

In the present study evaluation of mucosal growth over the screw and interdental wire

was performed in both the groups at one month follow up period. Patients treated with

smart lock hybrid arch bar (Group A) reported 83.3% mucosal growth over the screw

while that of Erich arch bar (Group B) reported 25% mucosal growth over the

interdental wire table (3).There was no statically significant difference noted between

both the groups in relation to mucosal growth (p value 0.0178).

Lip irritation:

In the present study lip irritation was compared in both the groups at one month follow

up period. In Group A (smart lock hybrid arch bar group) 25% patients reported lip

irritation while that of Group B (Erich arch bar group) reported 41.7% lip irritation table

58
 RESULTS

(4).There was no statically significant difference noted between both the groups in

relation to lip irritation (p value 0.457).

Root damage:

In the present study root damage during screw fixation in smart lock hybrid arch bar

(Group A) was assessed using orthopantonogram after fixation of arch bar. The

incidence of root damage in Group A (smart lock hybrid arch bar group) was 16.7%

while that of Group B (Erich arch bar group) reported none table (5).There was no

statically significant difference noted between both the groups in relation to root damage

irritation (p value 0.140).

Oral hygiene:

In the present study evaluation of oral hygiene was performed in both the groups during

the removal of arch bar at one month follow up period. Patients treated with smart lock

hybrid arch bar (Group A) reported 50% good oral hygiene (mean oral hygiene index

score 0-1.2) and 50% fair oral hygiene (mean oral hygiene index score 1.3-3.0) while

that of Erich arch bar (Group B) reported 58.3% fair oral hygiene (mean oral hygiene

index score1.3-3.0) and 41.7% poor oral hygiene (mean oral hygiene index score 3.1-

6.0) table (6).There was statically significant difference noted between both the groups

in relation to oral hygiene (p value 0.004) with fair to good oral hygiene reported in

smart lock hybrid arch bar (Group A).

Time taken for fixation of arch bar:

59
 RESULTS

In the present study time taken for fixation of arch bar was compared between both the

groups . In Group A mean time taken for fixation of smart lock hybrid arch bar was

22.917 minutes while that of Group B mean time taken for fixation of Erich’s arch bar

was 91.667 minutes with a mean difference of 68.75 minutes table (7). There was a

statically highly significant difference noted between both the groups in relation to mean

time taken for fixation of arch bar (p value < 0.001) with lesser time taken for fixation of

smart lock hybrid arch bar. (Group A)

Time taken for removal of arch bar:

In the present study time taken for removal of arch bar was compared between both the

groups at one month follow up period. In Group A mean time taken for removal of smart

lock hybrid arch bar was 12.583 minutes while that of Group B mean time taken for

removal of Erich’s arch bar was 21.167 minutes with a mean difference of 8.58 minutes

table (8).There was a statically highly significant difference noted between both the

groups in relation to mean time taken for removal of arch bar (p value <0.001) with

lesser time taken for removal of smart lock hybrid arch bar (Group A).

Table 1: Evaluation of proper occlusion achieved in both groups

Group Group

A B

Occlusion N % N %

No 1 8.3 1 8.3

Yes 11 91.7 11 91.7

60
 RESULTS

Total 12 100.0 12 100.0

Chi sq 0 P 1 NS

value

NS – not significant (p>0.05)

There is no statistically significant difference present in obtaining proper occlusion

among both groups

Chart-1

Evaluation of occlusion
achived
91.791.7
100.0
Percentage

50.0
8.3 8.3
0.0
No Yes

Group A Group B

Table 2: Evaluation of needle prick injuries in both groups

Needle Group A Group B

Prick N % N %

Nil 8 66.7 1 8.3

1.0 3 25.0 2 16.7

2 1 8.3 4 33.3

3.0 0 0.0 1 8.3

4.0 0 0.0 0 0.0

61
 RESULTS

5.0 0 0.0 2 16.7

6.0 0 0.0 2 16.7

Total 12 100.0 12 100.0

Chi sq 12.444 P 0.029*

value

-significant (p<0.05)

There is statistically significant difference present in the needle prick instances among

the groups compared with higher incidence of needle prick in Group B

Chart-2

Needle Prick injury

100.0
Percentage

66.7
50.0 25.0 33.3
8.3 16.78.3 0.0
8.3 0.0 16.716.7
0.0 0.0 0.0
0.0
Nil 1.0 2 3.0 4.0 5.0 6.0

Group A Group B

Table 3: Intergroup comparison of mucosal growth

Group Group

A B

Mucosal N % N %

Growth

No 2 16.7 9 75

Yes 10 83.3 3 25

62
 RESULTS

Total 12 100.0 12 100.0

Chi sq 1.815 P 0.178 NS

value

NS- Not significant (p<0.05

Chart-3

Gingival Growth
100.0 83.3
Percehtage

58.3
50.0 41.7
16.7

0.0
No Yes

Group A Group B

Table 4: Intergroup comparison of lip irritation

Lip Group Group

Irritation A B

N % N %

No 9 75.0 7 58.3

Yes 3 25.0 5 41.7

Total 12 100.0 12 100.0

Chi sq 1.567 P 0.457

value NS

NS – Not significant (p>0.05)

63
 RESULTS

Chart-4

Lip Irritation
100.0 75.0
Percentage

58.3
41.7
50.0 25.0

0.0
No Yes

Group A Group B

Table 5: Intergroup comparison of root damage

Group Group

A B

Root N % N %

Damage

No 10 83.3 12 100.0

Yes 2 16.7 0 0.0

Total 12 100.0 12 100.0

Chi sq 2.182 P 0.140

value NS

NS- Not Significant (p>0.05)

64
 RESULTS

Chart-5

Root Damage
150.0
100.0
Percentage

100.0 83.3

50.0 16.7
0.0
0.0
No Yes

Group A Group B

Table 6: OHIS (Oral hygiene index score)

Group Group

A B

OHI N % N %

Good 6 50.0 0 0.0

Fair 6 50.0 7 58.3

Poor 0 0 5 41.7

Total 12.0 100.0 12 100.0

Chi sq 11.077 P 0.004*

value

*-Significant (p<0.05)

There is statistically significant difference present in oral hygiene with better oral

hygiene in Group A

65
 RESULTS

Chart-6

Oral hygiene index

80.0
58.3
Percentage

60.0 50.0 50.0

41.7
40.0
20.0 0.0 0
0.0
Good Fair Poor

Group A Group B

Table 7: Time taken for fixation of arch bar

Group N Minimum Maximum Mean Std. Mean P value

Deviation Difference

Group 12 19.0 28.0 22.917 3.0588 68.75 <0.001**

Group 12 88.0 95.0 91.667 2.1881

**-Highly significant (p<0.001)

There is statistically significant difference present in mean time taken for fixation of arch

bar in between both groups with lesser time taken in Group A

66
 RESULTS

Chart-7

Mean time taken for fixation

of arch bar
91.67
100.00
Mean

50.00 22.92

0.00
Group A Group B

Table 8: Time taken for removal of arch bar

Group N Minimum Maximum Mean Std. Mean P value

Deviation Difference

Group 12 11.0 14.0 12.583 1.1645 8.58 <0.001**

Group 12 19.0 24.0 21.167 1.6967

-Highly significant (p<0.001)

There is statistically significant difference present in mean time taken for removal of

arch bar in between both groups with lesser time taken in Group A

67
 RESULTS

Chart-8

Mean time taken for removal

of arch bar
30.00 21.17
20.00 12.58
Mean

10.00
0.00
Group A Group B

68
 DISCUSSION

The management of mandibular condylar injuries is one of the most controversial areas

in the treatment of facial trauma. Fractures involving the mandibular condyle are the

only facial bone fractures which involve a synovial joint. These injuries deserve special

consideration apart from those of the rest of the mandible due to their anatomic

differences, variations in clinical picture, unique management protocols and distinct

healing potential. Facial injuries are most commonly associated with falls, motor vehicle

accidents, sports-related trauma and interpersonal violence.

The incidence of fracture involving the mandibular condyle varies throughout the

literature and is influenced by factors such as age, geographic location and socio-

economic level of the study population. Serial studies by Kromer (1953) and Goldberg

and Williams (1969) found that fractures of the condyles account for 15% to 30% of all

mandibular fractures. Halazonetis (1968) and Ellis et al (1985) reported that condyle is

the commonest site for mandibular fracture. Oikarinen and Malmstrom (1969), in a

series of 600 mandibular fractures, found that 33.4% were in the subcondylar region.

Condylar fractures have been divided into intracapsular condyle fracture (condylar

head, condylar neck) and extracapsular condyle fracture (sub condylar fractures).

Closed reduction with maxillomandibular fixation (MMF) has been the traditional

approach for intracapsular condylar fractures and minimally displaced subcondylar

fractures. Immobilization and splinting of the mandible and maxilla have been used

throughout history for the treatment of maxillofacial patients. Maxillomandibular fixation

was first introduced in 1460 bc by Hippocrates, who treated mandible fractures by

external manipulation and placement of gold wire to hold the teeth in occlusion. Several

techniques and modifications of these techniques have developed over the past 2000

69
 DISCUSSION

years, including external bandages, splints, skeletal suspension wires, arch bars,

maxillomandibular fixation screws, orthodontic bands and brackets, and several

different techniques using stainless steel circumdental wires such as Ivy loop and Ernst

ligatures.

The use of stainless steel Erich arch bars remains the standard method of choice for

most maxillofacial surgeons because it promoted better occlusal stability than the other

methods available. The intermaxillary fixation time was about four to six weeks, and the

intermaxillary fixation method should be stable during all this time. The Erich arch bar

(EAB) and eyelets wire were the most commonly used methods of intermaxillary fixation

prior to the conception of open reduction and internal fixation.

According the study conducted by Saulo-Gabriel Falci et al in 2015[67] suggest that the

Erich’s arch bar exhibits better results when prolonged intermaxillary fixation is

required. According to different studies conducted by Albert H. Chao et al in 2015[67],

B. van den Bergh et al in 2015, Ahtesham Ahmad Qureshi[69], Umesh K. Reddy et al,

and kenderik et al in 2016[68] there were many disadvantages of using Erich’s arch bar

like time consumption during fixation and removal of arch bar, glove perforation which

leads to needle prick to the skin, trauma to periodontium and poor oral hygiene.

These disadvantages of Erich’s arch bar lead to the development of new materials and

technology along with the surgeon’s desire to use products that reduce operating time,

increase safety, and still have good surgical outcomes have created a marketplace for

newer methods such as the use of maxillomandibular fixation screws by Arthur and

Berardo in 1989[41]. The most recent development in maxillomandibular fixation is the

Smart lock system. The Smart lock system is a blend between traditional arch bars and

70
 DISCUSSION

modern maxillomandibular fixation screws by Stryker smart lock system was released in

2013. The plate consists of an arch bar segment and nine screw hole segments that

project from the arch bars. This plate is secured with monocortical titanium alloy screws

placed through the oral mucosa into the supporting bone in a fashion similar to

maxillomandibular fixation screws. These screws are 2.0 mm in diameter and come in

lengths of 6 and 8 mm. The smart lock Hybrid is a validated MMF system that seeks to

provide the advantages of an arch bar with the ease and speed of application,

decreased risk to surgeon.

The randomized prospective study was done to compare the efficacy of Smart lock

hybrid arch bar secured by bone-borne drilling screws with Erich’s arch bar secured by

circumdental stainless steel wires in the treatment of Intracapsular condylar fractures.

The parameters assessed in the present study are occlusion stability, needle stick

injury, lip irritation, mucosal growth over the screw in Smart lock hybrid arch bar and

gingival hyperplasia in Erich’s arch bar, damage to the roots in placement of screws in

Smart lock hybrid arch bar, oral hygiene, time taken for fixation and time taken for

removal of arch bar.

In the present study evaluation of stable occlusion was compared in both the groups at

one month follow up period after IMF. Both Smart lock hybrid arch bar (Group A) and

Erich arch bar (Group B) achieved 91.7% stable occlusion after arch bar fixation at one

month follow up period. This correlates with the studies conducted by Fabio Roccia et al

in 2005[54], Gordon et al, Kendrick et al in 2016[68] and Meade C. Edmunds et al in

2019[69].The reason for stable occlusion in smart lock hybrid arch bar group (Group A)

71
 DISCUSSION

was due to screws inserted directly into the bone provide more stability to the arch bar

where as in Erich’s arch bar group (Group B) was due to wires passed around each

tooth and twisted so that it provides proper stability to the arch bar.

Both Group A and Group B reported an occlusion discrepancy of 8.3% at one month

follow up period which were corrected with guiding elastics for a period of 15 days. This

correlates with the studies conducted by Fabio Roccia et al in 2005[54], Gordon et al,

and Meade C. Edmunds et al in 2019[69].This may be due to the loosening of screws in

smart lock hybrid arch bar group (Group A) and loosening of interdental wire in Erich’s

arch bar.

In the present study evaluation of needle stick injury was compared in both the groups

during fixation and removal of arch bar. Patients treated with smart lock hybrid arch bar

(Group A) reported needle stick injury of 25% while that of Erich arch bar (Group B)

reported 91.66% needle stick injury. This correlates with the studies conducted by

Berardo et al in 1989, CME Avery et al in 1992 [41] and Jones et al in 1999. The

majority of reported wire-stick injuries occurred while passing wire interproximally, by

snagging a glove upon an exposed wire in the forceps or upon an inadequately

positioned interproximal wire in Erich’s arch bar group (Group B).

In the present study evaluation of mucosal growth over the screw and interdental wire

was performed in both the groups at one month follow up period. Patients treated with

smart lock hybrid arch bar (Group A) reported 83.3% mucosal growth over the screw

72
 DISCUSSION

while that of Erich arch bar (Group B) reported 25% mucosal growth over the

interdental wire. This correlates with the studies conducted by Fabio Roccia et al in

2005[54], Rai et al in 2011[60], Ingole et al in 2014[65] and Kendrick et al in 2016[68].

The mucosal covering is common in both maxilla and mandible in smart lock hybrid arch

bar group (Group A).The reason for mucosal growth over the screw is because of

screws were placed in alveolar mucosa rather than in attached mucosa. Furthermore,

the reason for placement of screws high up in alveolar mucosa is due to the alveolar

bone loss, which is more prevalent in the Indian population due to periodontal disease

activity.

In the present study lip irritation was compared in both the groups at one month follow

up period. In Group A (smart lock hybrid arch bar group) 25% patients reported lip

irritation while that Group B (Erich arch bar group) reported 41.7% lip irritation .This

correlates with the studies conducted by Kendrick et al in 2016. Lip irritation is due to

falling of the lip over the large lugs in smart lock hybrid arch bar while in Erich’s arch bar

lip irritation is due to falling of the lip over the large lugs and twisted internal dental wire

loop ends.

In the present study root damage during screw fixation in smart lock hybrid arch bar

(Group A) was assessed using orthopantonogram after fixation of arch bar. The

incidence of root damage in Group A (smart lock hybrid arch bar group) was 16.7%

while that of Group B (Erich arch bar group) reported none. This correlates with the

studies conducted by Berardo in 1989, Hassemi et al in 2011[59],west et al in 2014 and

Kendrick et al in 2016[68].The root damage in smart lock hybrid arch bar group (Group

73
 DISCUSSION

A) was due to less amount of space available between two roots to accommodate the

diameter of the screw.

In the present study evaluation of oral hygiene was performed in both the groups during

the removal of arch bar at one month follow up period. Patients treated with smart lock

hybrid arch bar (Group A) reported 50% good oral hygiene (mean oral hygiene index

score 0-1.2) and 50% fair oral hygiene (mean oral hygiene index score 1.3-3.0) while

that of Erich arch bar (Group B) reported 58.3% fair oral hygiene (mean oral hygiene

index score1.3-3.0) and 41.7% poor oral hygiene (mean oral hygiene index score 3.1-

6.0) . This correlates with the studies conducted by Anshul Rai et al in 2011[61], Kumar

P et al in 2018.Oral hygiene was good in smart lock hybrid arch bar group due to less

collection of food debris around the screws and lugs of the arch bar and hence it was

easier to maintain good oral hygiene in smart lock arch bar group

In the present study time taken for fixation of arch bar was compared between both the

groups. In Group A mean time taken for fixation of smart lock hybrid arch bar was

22.917 minutes while that of Group B mean time taken for fixation of Erich’s arch bar

was 91.667 minutes with a mean difference of 68.75 minutes. This correlates with the

studies conducted by Kendrick et al.[68], Stryker Early Product Surveillance[68] and

Chao and Hulsen[67] . The time taken for fixation of smart lock hybrid arch bar was less

because only six screws are required to fix the arch bar in each arch where as the time

taken for fixation of Erich’s arch bar was more because interdental wires have to be

passed around 16 teeth in each arch.

74
 DISCUSSION

In the present study time taken for removal of arch bar was compared between both the

groups at one month follow up period. In Group A mean time taken for removal of smart

lock hybrid arch bar was 12.583 minutes while that of Group B mean time taken for

removal of Erich’s arch bar was 21.167 minutes with a mean difference of 8.58 minutes

.The results of the study coincides with studies conducted by Kendrick et al in 2016[68],

Stryker Early Product Surveillance[68] and Brett J. King et al in 2019[73].The time

taken for removal of Erich’s arch bar group (Group B) was more because the interdental

wire around the each tooth and lug of the arch bar has to be unwinded and removed for

16 teeth in each arch where as in smart lock hybrid arch bar group (Group B) only six

screws are required to be removed from the bone in each arch.

75
 SUMMARY AND CONCLUSION

The present study concludes that both smart lock hybrid arch bar and Erich’s arch bar

are equally effective in acheiving good occlusal stability in closed reduction of

intracapsular condylar fractures. Though Erich’s arch bar was widely used in closed

reduction of intracapsular condylar fracture, there are few disadvantages like wire prick

injury, lip irritation, poor oral hygiene and time taken for fixation and removal of Erich’s

arch bar was more when compared to smart lock hybrid arch bar. Though smart lock

hybrid arch bar placement is easy and quick and can be hazardous in inexperience

hands as there is danger of iatrogenic injury to the roots. Considering the advantages

and disadvantages, smart lock hybrid arch bar can be considered as a viable option for

closed reduction of intracapsular condylar fractures. A further detailed study with large

sample size is required to evaluate the efficacy of the smart lock hybrid arch bar in

closed reduction of intracapsular condylar fractures.

76
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 ANNEXURE 2

DEPARTMENT OF Oral And Maxillofacial Surgery,

MNR DENTAL COLLEGE, SANGAREDDY.

“SMARTLOCK HYBRID ARCH BAR VERSUS CONVENTIONAL ARCH BAR IN

THE MANAGEMENT OF INTRACAPSCULAR CONDYLAR FRACTURES A
COMPARATIVE STUDY”
PATIENT CONSENT FORM

To my knowledge I have given an accurate report of my personal, medical and drug

history. I have been informed the purpose and nature of the procedure for which I am
willingly giving my consent.

Name of the patient:

Date:
Signature/Thumb impression of patient:

పేషెంట్ అెంగీకారణ పత్రము

నాకు తెలిసినెంర వరకు నేను నా వయ క్త ిగర అలవాట్లు, ఆరోగయ సెంబెంధ

సమసయ లు మరియు మెందుల వాడకెం గురిెంచి ఖచిరమైన సమాచారెం
అెందెంచినాను. నాకు చేయబోయే పరీక్షల గురిెంచి వివరిెంచినారు. దానిక్త నేను
ఇష్పూ
ట రవ కెంగా అెంగికరిెంచుచునాా ను.

పేరు :

తేద :

పేషెంట్ సెంరకెం / వేలిముత్ర :