INTRODUCTION

Mandibular fractures are one of the most common traumatic injuries treated by oral and
maxillofacial surgeons.1 Among facial bone fractures, the mandibular fracture has a highest
incidence next to nasal bone fracture.2 The important factors in the management of any
fracture is reduction and stabilization of the fracture segment which should be accomplished
by the simplest means possible, to achieve optimal results.

The ultimate goal of treating mandibular fracture is to restore the mandibular form and
function to its pre-traumatic condition. Intermaxillary fixation is an indispensable
requirement to achieve dental occlusion during preoperative, operative and postoperative
phase of treatment. The application of intermaxillary fixation (IMF) to the maxillofacial
skeleton has a key role in the management of trauma in this region.

Various modalities of IMF have been described in literature, including Erich arch bar, Eyelet
loops, skeletal suspension wires. Arch bars are time-proven method of applying IMF with
well-recognized advantages. Many clinicians elect the use of screw due to decreased risk of
penetration injury, ease of placement, and decreased operating time.

Two basic modalities for anchoring wires or elastics to establish MMF after craniofacial
trauma: tooth-borne devices or bone screws acting as skeletal fixation points has received
positive ratings, neither represents a perfect solution for MMF, and each has problems and
drawbacks. MMF screws are more invasive but a powerful means to achieve a reliable
temporary (intra- or perioperative) MMF in a time saving and economic manner. It appears
pointless to take a conservative stance in the debate on MMF screws, because the technique is
familiar and appealing.9

In our study, a comparison was made regarding the efficacy,advantages and disadvantages
associated with IMF screws and arch bars and also to record the incidence of complications
with both techniques.

MATERIALS AND METHODS

In this study, 20 dentulous patients who reported to the Department of Oral and Maxillofacial
Surgery and Dr. O. P. Chaudhary Hospital and Research Centre, Sardar Patel Post Graduate
Institute of Dental and Medical Sciences, Lucknow, with mandibular fractures and required
IMF followed by open reduction and internal fixation under general anesthesia as a part of
treatment plan were selected.

The patients between the age group of 21-46 years with isolated non communited fracture of
mandible, Patients with vital teeth in the area of self tapping screw fixation, Minimally
displaced favourable fractures of mandible, Requirement of open or closed reduction were
included in this study.
Pan facial fractures, Edentulous patient, Pathological fracture, patients with underlying
systemic disease (American Society of Anesthesiologists III and IV), comminuted fracture of
mandible, patients with multiple fractures (parasymphysis with angle, associated condylar
fractures, and maxillary fractures), comorbidities such as fractures in other bones of body
(pelvic bone fractures, femur fractures, etc), and patients having primary and mixed dentition
were excluded from the study.

The selection of the patients was done by simple randomized enveloped method and
designated as Group A and Group B. In this, the first patient of the study was selected by a
draw and allotted Group A, after this all subsequent patients were divided alternately into
Group A and Group B randomly without taking into consideration any parameter other than
the inclusion criteria. Group A patients received IMF with Erich arch bars and Group B
patients received IMF with IMF screws.

In Group A patients, After appropriate anesthesia, a prefabricated arch bar with hooks
incorporated on the outer surface with flat malleable stainless steel metal strip was cut
accurately to the length of both upper and lower dental arches. On the upper jaw, the hooks
were arranged in an upward direction and to the lower jaw in a downward direction. The arch
bar was adapted to the buccal surface of each arch and given shape of the arch by bending it,
starting from the mesial part of last tooth progressing past the midline and finishing at the
other end. It was fixed to each tooth, using prestretched 26-gauge stainless steel wire, which
is passed from mesial surface of tooth to the lingual side and back on the buccal side from the
distal surface of the tooth, making sure that one end of the wire is passing above the arch bar
and the other below it. After this, both ends of the wire were twisted together in a clockwise
manner and the arch bar was attached securely and firmly to the necks of each tooth on the
buccal surface of the arch.Arch bar was left in place for 4–6 weeks to enable the
postoperative traction to correct the small discrepancies in occlusion.

In Group B patients, IMF was achieved by the use of six stainless steel IMF screws of 2 mm
diameter and 8 mm or 10 mm length. After appropriate anesthesia, holes are drilled through
mucosa with 1.5 mm drill bits, without any gingival incision preferably between the canine
and first premolar teeth in each quadrant. IMFscrews were inserted through the predrilled
holes, taking care not to penetrate the lingual or palatal mucosa. IMF was achieved using
wires or elastic bands. Screws were left in place for 4–6 weeks. The placement of the screws
was evaluated immediately postinsertion, using a panoramic radiograph or intraoral
periapical radiographs,

The following parameters were recorded, tabulated and subjected to suitable statistical
analysis. Time required to achieve Intermaxillary Fixation between the two groups,
Incidence of needle stick type injury, Tooth morbidity, Stability of fixation , Patient
acceptance , Periodontal health and hygiene, Occlusion
The statistical analysis of follow-up was performed using mean, standard deviation,student
t-test, Chi-square test. P < 0.05 was considered statistically significant.

RESULTS

Mean age of patients of Group A (28.30+7.66 years) was found to be higher than that of
Group B (26.70+10.25) but this difference was not found to be statistically significant
(p=0.697).

Out of 20 patients enrolled in the study, 16 (80.00%) were males and rest 4 (20%) were
females, this indicate that prevalence of mandibular fractures was higher in males. Proportion
of females was significantly higher (p=0.006) in Group B as compared to Group A.

Proportional differences in aetiology of mandibular fractures in Group A and Group B

existed but difference in aetiology of mandibular fracture between the two groups was not
found to be statistically significant (p=0.503).

Proportional differences in site of mandibular fractures in Group A and Group B existed but
difference in site of mandibular fracture between the two groups was not found to be
statistically significant (p=0.491).

Perforation in the gloves was found in higher proportion in Group A (80.0%) as compared to
Group B (20.0%) and this difference was found to be statistically significant

Mean time taken in Procedure in Group A was 102.00+10.26 minutes which was found to be
higher than the time taken in procedure in Group B (21.40+2.17 minutes) and this difference
was found to be statistically significant (p<0.001).

From Day 1 to Day 7, adequate stability was observed in all the patients of both the groups.
On Day 15 stability was found to be adequate in higher proportion of Group B (100.0%)
patients as compared to Group A but this difference was not found to be statistically
significant (p=0.305). At 30th day, adequate stability was found in higher proportion in Group
A (80.0%) as compared to Group B (70.0%) but the difference was not found to be
statistically significant (p=0.606).

On 1st day and 3rd day, good oral hygiene was found in higher proportion of Group B (60.0%)
cases as compared to Group A (40.0%) and proportional difference in oral hygiene of Group
A and Group B was not found to be statistically significant (p=0.469). On 7 th day oral
hygiene was found to be good in higher proportion of Group B (70.0%) cases as compared to
Group A (30.0%). Proportional difference in oral hygiene of Group A and Group B was not
found to be statistically significant on 7 th day (p=0.165). On 15th day oral hygiene was found
to be good in higher proportion of Group B (70.0%) cases as compared to Group A (20.0%).
Proportional difference in oral hygiene of Group A and Group B was not found to be
statistically significant on 15th day (p=0.068). On 30th day oral hygiene was found to be good
in higher proportion of Group B (90.0%) cases as compared to Group A (20.0%).
Proportional difference in oral hygiene of Group A and Group B was found to be statistically
significant on 30th day (p=0.007).

On day 1 and day 3 tooth morbidity was found to be vital for all the patients of both the
groups (p=1.000). On day 7, Vital tooth morbidity was found in higher proportion of Group
A (100.0%) patients as compared to Group B (90.0%) but this difference was not found to be
statistically significant (p=0.305). On day 15 and 30, vital tooth morbidity was found in
higher proportion of Group A (100.0%) as compared to Group B (80.0%), and at these
intervals difference was not found to be statistically significant (p=0.136).

All the patients of Group B (100.0%) and only 20.0% patients of Group A had good patient
acceptability and majority of patients of Group B had Fair acceptability (60.0%). Good
patient acceptability was found to be higher in Group B as compared to Group A. Difference
in patient acceptability in both the groups was found to be statistically significant.

Occlusion was found to be intact for all the patient of both the groups hence no proportional
difference in occlusion status of both the groups was found.

DISCUSSION

The main goal in successfully treating mandibular fractures include: reduction of the fracture,
stabilization of the fracture, and to achieve proper dental occlusion. In the process of fully
satisfying these criteria, it is also advantageous to use techniques that reduce the risk of
percutaneous transmission of blood-borne diseases, operating time and duration of general
anaesthesia, and hospital costs.22
The treatment of maxillofacial fractures involves different methods from bandages and
splinting to methods of open reduction and internal fixation and usually requires control of
the dental occlusion with the help of intermaxillary fixation which is time consuming with
traditional methods.5
Numerous forms of IMF have been described in the literature (eg, eyelet loops, skeletal
suspension wires, and Erich arch bars), and few studies have compared them in a scientific
manner. Arch bars are a time-proven method of applying MMF with well-recognized
advantages; they are useful for reapproximating and immobilizing comminuted segments.
The bar itself serves as a tension band in the treatment of mandible fractures, and it is
versatile in directing complex vectors for fracture reduction. They remain the treatment
modality of choice in complex fracture cases. The shortcomings of arch bars include trauma
to the periodontium and buccal mucosa, poor oral hygiene, increased operative time for
placement and removal, and risk of penetrating injury to the surgeon.41
The insertion of MMF screws is a rapid and elegant technique to provide abutment for jaw
immobilization with wire or elastic loops and secure occlusal relationships. MMF screws are
claimed to improve the safety of the procedure, since only a few ligature wires are used as
jaw linking cerclages. Minimizing intraoral manipulation with sharp stainless steel wire tips
diminishes the rate of glove perforations and puncture injuries as risk factors for blood borne
virus transmission (hepatitis B, hepatitis C, HIV).7
The arch bar has been the mainstay for the management of maxillomandibular bony injuries
since World War I. The originators of this method, Sauer in Germany and Gilmer in US used
an ordinary round bar flattened on one side that was ligated to the teeth with brass ligature
wires. Blair and Ivy’s modification was a flattened on one side that was about 2 mm in width
to conform better to the teeth and provide greater stability18
The self tapping intermaxillary screws were first introduced by Arthur G and Berardo N19
in 1989 and later modified by Carl Jones with a Capstan shaped head design.5 He suggested
the use of threaded titanium screws of 2 mm diameter and 10–16 mm length. According to
him, screws with capstan style head are important as it allows the wires and elastics to be
held away from the gingival tissue. These screws are quick to insert and have fewer risks of
needle stick injury than conventional methods. The operating time is also reduced from 1 h to
15 min. He recommended the use of these screws for temporary intra-operative IMF and for
postoperative elastic traction. Self tapping intermaxillary fixation screws are not indicated for
severely communited fractures, extensive alveolar bone fractures and missile injuries to the
jaws.5
Henderson DK and Gerberdins JL (1989)20 found that the health care workers are at risk of
acquiring HIV infection subsequent to accidental sticks with needle contaminated with blood
from infected patients. In our prospective study we found that perforation in the gloves was
found in higher proportion in intermaxillary fixation done with Erich arch bar which was 80
% as compared to intermaxillary fixation done with self tapping IMF screws which was only
20% (Table 6).
Coburn DG (2002) reported iatrogenic damage to the root leading to tooth loss in 4% of
cases. None of the cases had damaged root. They suggested that this complication can be
avoided by selecting 2mm diameter screw instead of 2.5mm. Secondly during drilling initial
resistance is felt while penetrating the outer cortex followed by minimal resistance in
cancellous bone. In case of continuos resistance drilling may be abandoned and an alternative
site may be selected.31
Colletti D P, Salma A reported root fractures occurring during placement in 2 patients, due
to neither of which had available orthopantomogram.41 A similar complication was also
reported by Simon Holmes (2002) He advocated caution with use of bicortical screws and
suggested the technique of two forward turns followed by one backward turn to exclude the
shaft from the pitch of the screw during insertion and removal, where as no such case of
screw fracture was encountered in the present study.29
Steven key (2000) recommended a thorough clinical and radiographic assessment of the
adjacent teeth to the site of screw placement. The alignment of the teeth in three dimensions
should be fully appreciated. We recommend placing self tapping screws between the canine
and first premolar region at the mucogingival junction or placing it below the root apices of
the mandibular teeth or above the root apices of the maxillary teeth.56
Karlis V, Glickman R (1997) used titanium 2.0mm self tapping screws and they reported
that the length of the screw can vary, but they found 8mm to be adequate. They evaluated the
patients weekly for any changes in occlusion or loosening of the hardware. At the fifth week,
one patient experienced loosening of the maxillary screws. The hardware was removed
without negative sequelae.26
Biswas KP, Ahuja A, Singh VP presented a case report and concluded IMF screw insertion
is easy and takes approximately 10 minutes with significant intraoperative savings in both
time and cost, the screws are easy to remove, even without anaesthesia, the risk of prick
accidents is greately reduced, therefore reduces the risk of transmission of blood borne
diseases.33 In our study, the mean time taken to achieve intermaxillary fixation with Erich
arch bar was found to be 102.00+- 10.26 minutes which was found to be higher than the mean
time taken in achieving intermaxillary fixation with self tapping IMF screws which was
21.40+-2.17 minutes.

Sahoo N K, Mohan R treated 45 cases of mandibular fractures by open reduction over a

period of 24 months and reported that during transmucosal drilling one should be very
particular about coolant. The soft tissue acts as a cuff around the drill bit, preventing coolant
to reach the bone. It causes thermal necrosis and subsequent loosening of screw. In their
study they found loosening of five screws due to thermal necrosis.3
Bush RF (1994) used self tapping IMF screws in 67 patients in his 2 years study. He reported
periodontal abscess distant from screw site, one case of cellulitis around screw and one screw
was displaced into the maxillary sinus. In our study we have not come across such
complications. Author reported loss of fixation occurred in 6 patients. In our study adequate
stability was found in all the patients initially but at the end of 30 th day, three patients had
inadequate stability in which intermaxillary fixation was done by self tapping IMF screws
due to screw loosening. He mentioned the advantages of self tapping IMF screws, which
includes a reduced risk of percutaneous contamination, the technique was simple to learn and
use and operating time was reduced from one hour to 15 minutes. In our study, we found no
percutaneous contamination and the technique is simple as well as easy to use. 24Self tapping
IMF screws provided good fixation in all the 10 cases we treated. Post-operatively, there was
no incidence of infection, trauma to the sorrounding tissues and nerve injury. There was no
sign and symptoms of pain and edema at the screw site in all the cases by 7 th postoperative in
the present study.
Nandini G.D, Balakrishna R5 found Oral hygiene status to be good in 90 % and fair in 10
% of all the patients he treated with self tapping IMF screws. In our study oral hygiene status
of all the patients was satisfactory and infact it had improved postoperatively after meticulous
oral hygiene instructions. It was easier to maintain oral hygiene compared to arch bar. (Table
9)
CONCLUSION
The treatment of facial fractures has traditionally involved reestablishment of a functional
dental occlusion with various types of maxillo-mandibular fixation. There are two basic
modalities for anchoring wires or elastics to establish MMF after craniofacial trauma: tooth-
borne devices or bone screws acting as skeletal fixation points. Arch bars are time proven
method of applying IMF with well-recognized advantages, like re-approximating and
immobilizing communited segments. It is the treatment of choice in complex fracture cases.
Self tapping IMF screws reduces the operating time as well as the risk of needle stick injury
(30 %). Maintenance of oral hygiene and patient acceptance was good with IMF screws as
compared to arch bar however they cannot be used in severe communited fractures of the
mandible. Considering the result of the study it would be advantageous to use self tapping
IMF screws for the treatment of mandibular fracture. However further studies with a larger
sample size should be conducted to assess the efficacy, advantages/disadvantages of various
intermaxillary fixation techniques in the treatment of mandibular fractures.