Int. J. Oral Maxillofac. Surg. 2010; 39: 8385 doi:10.1016/j.ijom.2009.06.029, available online at http://www.sciencedirect.

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Technical Note Trauma

Atraumatic placement of circummandibular wires: A technical note

S. Thomas, V. Yuvaraj: Atraumatic placement of circummandibular wires: A technical note. Int. J. Oral Maxillofac. Surg. 2010; 39: 8385. # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Fractures of the mandible are relatively uncommon in children as compared to that of adults. When they occur, the problems associated with their management are complicated due to the presence of the tooth bud and potential growth disturbance. Various management protocols are discussed in the literature. Most authors agree that the ideal method is to use an acrylic splint because it is easy to place and reduces the risk to jaw growth. These splints are secured to the reduced jaw by circummandibular wiring, which is a relatively simple technique. The authors describe their experience with a new atraumatic technique for the placement of circummandibular wires using a 16 gauge intravenous cannula stillete.

S. Thomas, V. Yuvaraj
Department of Oral & Maxillofacial Surgery, Peoples College of Dental Sciences & Research Center, Bhanpur, Bhopal 462 023, India

Keywords: circummandibular wiring; pediatric mandibular fracture. Accepted for publication 29 June 2009 Available online 4 October 2009

Management of mandibular fractures in children differ from that in adults because of anatomical variation, rapidity of healing, degree of the patient co-operation and the potential for changes in mandibular growth1,4. The treatment of fractures in the paediatric mandible depends on the childs age and the stage of tooth development. In children, the mandibular cortex is thin and less dense than in adults, and the presence of the tooth buds throughout the body of the mandible must be considered when carrying out an open reduction. Trauma to the developing tooth buds and partially erupted teeth may occur when placing intraosseous wires or plates and screws for rigid xation3,4. Complications such as infection, sensitization and mutagenic effects5 warrant more surgery for plate removal. Many paediatric mandible fractures can be treated without surgical exploration of the fracture site7. In children, the frequent
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Fig. 1. IVCS inserted percutaneously, exited on the lingual side intraorally, and wire passed through the lumen.

# 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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Thomas, and Yuvaraj

IVCS was rotated such that the bevel was on the leading side and the wire on the non-leading side (Fig. 3).The needle and the excess wire within were removed after cutting the desired length of wire intraorally at the bevel (Fig. 4).
Case report

Fig. 2. IVCS railroaded on the wire and taken around lower border of mandible with bevel leading the insertion.

Four children who sustained parasymphysis fracture of the mandible (2 right and 2 left) underwent the technique described above. The average age of the patients was 8.7 years. Intraoral examination revealed deranged occlusion with step deformity. Panoramic radiographs were taken to conrm diagnosis and to rule out any other fractures. Variables such as; size of the entry and exit wounds, ease of penetrating tissue, postoperative swelling and resultant haematoma were observed.
Discussion

absence of the teeth due to primary teeth exfoliation and the poor retentive shape of deciduous teeth crowns make the traditional use of arch bars and interdental ligature impossible to apply. Splinting the fractured paediatric mandible with an acrylic splint, retained by circummandibular wires, remains a viable option2,5,6,8. The authors describe a new atraumatic technique for placing circummandibular wires using an intravenous cannula stillete (IVCS).
Technique

The treatment plan was to use an acrylic splint, retained by three circummandibular

wires, one in the anterior and two in the posterior region. The circummandibular wiring was carried out using a 16 gauge IVCS instead of the conventional awl. The IVCS was passed percutaneously from the submandibular region and exited in the lingual side close to the alveolus, a 26 gauge wire was passed through the lumen of the IVCS and clamped intraorally (Fig. 1). The tip of the IVCS bevel should always be opposite to that of the winglet. The needle was railroaded along the wire until the lower border of the mandible was felt (Fig. 2). The IVCS was then passed on the buccal side in proximity to the bone. During buccal insertion, the

Conventionally, circummandibular wiring is performed with a mandibular awl, but the wound created when using an IVCS is inconspicuous compared with that created when using an awl. When the awl travels through the tissue, with the wire crimped, the twisted end of the wire causes trauma to the surrounding soft tissue because of its sharpness and thickness. Repeated use of an awl causes it to lose its sharpness. When using an awl, the crimped wire, which is potentially contaminated by oral uids, is made to pass around the mandible. Using IVCS the section of wire exposed to the oral cavity never touches the tissue, but the tip of the IVCS is exposed to the oral cavity and enters the

Fig. 3. IVCS with wire exited buccally.

Fig. 4. Desired length of wire cut and IVCS with remaining wire removed.

Atraumatic placement of circummandibular wires: A technical note

tissue. All patients were followed up for 46 weeks. Fracture healing was uneventful and complications such as postoperative swelling and haematoma were not observed. An instrument that is sufciently sharp, leaves a smaller wound, is disposable, economical and freely available would be a welcome alternative to the conventional awl. This article describes the innovative technical modication of using a 16 gauge IVCS to place circummandibular wires. A randomized trial with a larger sample of patients would establish this new atraumatic technique of placing circummandibular wires.
Funding Ethical Approval

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Not required
References
1. Eppley BL. Use of resorbable plates and screws in paediatric facial fractures. J Oral Maxillofac Surg 2005: 63: 385391. 2. Graham GG, Peltier JR. The management of mandibular fractures in children. J Oral Surg 1960: 18: 416423. 3. James D. Maxillofacial injuries in children. In: Rowes NL, Williams Jl, eds: Maxillofacial injuries. Edinburgh: Churchill Livingstone 1985: 538558. 4. Kaban LB. Facial trauma II:dentoalveolar injuries and mandibular fractures. In: Kaban LB, ed: Paediatric oral and maxillofacial surgery. Philadelphia PA: W.BSaunders 2004: 441462. 5. Rudolf RM. Treatment of paediatric facial fractures: the case for metallic xation. J Oral Maxillofac Surg 2005: 63: 382384. 6. Senel FC, Tekin US, Imamoglu M. Treatment of mandibular fractures with

bioresorbable plates in an infant: report of a case. Oral Surg Oral Med Oral Path Oral Radiol Endod 2006: 101: 448 450. 7. Tanaka N, Uchide N, Suzuki K, Tashiro T, Tomitsuka K, Kimijima Y, Amagasa T. Maxillofacial fractures in children. J Craniofac Surg 1993: 21: 289293. 8. Zimmermann CE, Troulis MJ, kaban LB. Paediatric facial fractures: recent advances in prevention, diagnosis amd management. Int J Oral Maxillofac Surg 2006: 35: 213. Address: Dr. Shaji Thomas Department of Oral & Maxillofacial Surgery Peoples College of Dental Sciences & Research Center Bhanpur Bhopal 462 023 Tel.: +91 755 4005343(O) +91 9827433449 (Mob) fax: +91 755 4005315. E-mail: shajihoss@gmail.com

No funding obtained from any agencies.

Competing Interests

No conict of interest