Note: last updated before 2013

INDICATIONS

1. Maxillofacial Fractures Requiring Occlusal Control
   1. Maxillomandibular fixation (MMF)
   2. Temporary occlusal orientation for placement of rigid internal fixation
2. Extended Elastic Therapy
   1. Minor occlusal movements
   2. Guide/train mandibular motion (especially mandibular subcondylar fractures)
3. Oncologic or Trauma-related Discontinuity Defects Requiring Occlusal Control
4. Alveolar Fractures
   1. Dental stabilization

GENERAL ADVANTAGES

1. Rigidity
2. MMF Easily Applied
3. Easily Adaptable to Elastic Traction
4. May be Prefabricated or Adapted
5. Continuous Occlusal (superior tension band) Control

POTENTIAL DISADVANTAGES

1. High Profile
   1. Oral hygiene difficult
   2. Lip or gingival alteration
2. Improper Application
   1. Fracture displacement
   2. Orthodontic tooth movement
3. Not Good with Edentulous Arch Spans

NURSING CONSIDERATIONS

1. Room Setup
   See Basic Soft Tissue Room Setup
2. Instrumentation and Equipment
   1. Standard
      1. Dentistry Basic Instrument Tray
      2. Erich arch bars
      3. 0.018 inch (25-gauge) wire
      4. Ivy loops
3. Medications (specific to nursing)
   1. 2% xylocaine with 1:100,000 epinephrine
4. Prep and Drape
   1. No prep
   2. Drape
      1. Towels around mouth
      2. Split sheet
5. Drains and Dressings
   1. None
6. Special Considerations
   1. Appropriate retractors
      1. Lips: shearer
      2. Tongue: Weeder or Minnesota

ANESTHESIA CONSIDERATIONS

1. Attaining occlusion with an oral endotracheal tube may be difficult; nasotracheal intubation or tracheotomy may be needed.
2. General Anesthesia/Local
3. Intravenous Sedation/Local
4. Local Only (useful for arch bar removal)

SURGICAL TECHNIQUE

1. Arch Bar Adaptation
   1. Check model size preoperatively
   2. Check intraoperatively on dental arch (hemostat)
   3. Correct discrepancies in contour and dimension
   4. Bend arch bar ends to the contour of the last tooth bilaterally
   5. Section at fracture site if necessary
   6. Fracture fragment mobilization and reduction may be required to properly place the arch bar
2. Securing Arch Bar
   1. Recheck orientation (open hooks facing the gum line)
   2. Using individual wires, tie the arch bar to each tooth
   3. Use apical pull while twisting wire
   4. Use over/under (arch bar) technique
   5. Twist, cut, and rosette wires neatly into embrasures
   6. Place wires from left-to-right or right-to-left, instead of distal-to-mesial, to avoid maladaptation mesially
   7. Wires can safely be placed around stable incisor and canine teeth
3. Maxillomandibular Fixation (MMF)
   1. Remove throat pack if present
   2. Place into maxillomandibular fixation with wire or elastics
   3. Check occlusion
   4. Avoid tongue/occlusal impingement
   5. Secure full arch with a minimum of five wire loops

POSTOPERATIVE CONSIDERATIONS

1. MMF Precautions at Bedside
   1. Patient requires instruction as to care and precautions
   2. Wire cutters should be carried with patient in case of airway problems (oral swelling, vomiting)
   3. Suction at bedside
2. Oral Hygiene
   1. Brushing
   2. Oral rinses (Cepacol or Peridex)
3. Diet Consult
   1. High-calorie, high-protein full liquids; feeding tube and syringe

FOLLOW-UP

1. Use of dental wax may decrease lip trauma induced by the arch bars.
2. The arch bars should be removed only after the fractures are healed and stable.