University of California, San Francisco

Andrew H. Murr, MDProfessor and Chairman

Department of Otolaryngology-Head and Neck Surgery

Maxillomandibular Fixation: Not Your Father’s MMFUCSF Otolaryngology Update

November 1, 2019

Disclosure

• Board Member: AONA CMF• Received: honoraria and travel expenses

• Minor stockholder: IntersectENT

MMF

• Establishes the Pre-traumatic Occlusion• May be a splint treatment method• Multiple ways of accomplishing this: modern

and ancient

Why?

• 1. Restoration of occlusion intraoperatively• 2. Postoperative method of producing

stability beneficial to creating acceptable occlusion

Malocclusion

Contact Points

If you cannot figure it out?• Find someone who can!• Stop and get some study

models: – CNC technology is becoming

highly disseminated

Methods of MMFAttached to/between teeth• Arch Bars

– Many different types– Erich Arch Bar

Arch Bars

Methods of MMF

• Ivy Loops• Ernst Ligature• Embrasure wires• Others

Ivy Loops

Ivy Loops

Ernst Ligature

Embrasure Wire

Zip Tie MMF

Skeletal MMF

Skeletal MMF

Skeletal MMF

Caution!

Is this tooth non-vital?

Guiding Elastics

• Forced Adaptation• Condylar Fracture

– Intact vertical height– Unilateral fracture

• Ankylosis prevention• Patient must be

cooperative

Rehabilitation Device

Endoscopic Condyle

Q:Must you maintain MMF post-operatively?A: Not if the fixation technique is engineered for functional load

Anatomic Reduction and Arch Bars:Bone Clamp Application

Anatomic Reduction and Skeletal Screws

Anatomic Reduction and No MMF

Pitfall of Anatomic Reduction

When is MMF alone the Primary Treatment?

• Non-displaced fracture• Cooperative patient• Non-comminuted• Green Stick• Good bone contact

– No tooth loss• Intact Dentition• Special circumstances

– ICU– Periostium intact

When is MMF an adjunctive treatment?• When the repair is engineered to stand on its

own.

When is MMF not required?• When anatomic reduction produces perfect

reduction.

Standard Order of Procedure

Old order1. Apply MMF2. Incision3. Exposure4. Assure Reduction5. Apply Fixation

Changed Order of ProcedureNew order1. Incision2. Exposure3. Anatomic reductionYes: apply fixation engineered for functionNo: Apply MMF• Ivy loops or Embrasure Wires• Assure reduction• Apply fixation engineered for function

Advantages

• Restore correct occlusion• Extra pair of hands• Aids reduction of fracture (open or closed)• Can allow traction/training postoperatively• Cheap?• Can be applied under local anesthesia

Disadvantages

• Time• Operator dependent• Risk of needle stick injury• Airway compromise (postoperative)• Dental proglems• May complicate fracture reduction• Patients hate MMF

Take Home Message

• Aim: restore occlusion• May be used primarily, intraoperatively only,

or postoperatively as well, or…not at all.• Multiple techniques

– Arch Bars– Eyelets – Screws

• Key: Stability

Aloha