Jaw wiring

Anatomy or system affected: Bones, gums, mouth, musculoskeletal system, teeth

Definition: A surgical procedure in which the upper and lower teeth are brought closely together and secured with wire in order to immobilize the jaw

Indications and Procedures

Jaw wiring, also known as maxillomandibular fixation, is often necessary to repair fractures in the jaw. The principles of treatment for facial fractures, in which bones need to be lined up and held in position until healing takes place, are the same as for a fractured arm or leg. Whereas an arm or leg fracture is reduced and cast to hold the bones in proper alignment, however, this method cannot be used for fractures of the face. Instead, once the fractures have been reduced (the bones have been restored to their proper positions), the jaws are wired shut to prevent the displacement of bone or bone fragments until they have healed.

Fractures of the face can involve any of the facial bones. The lower jawbone (mandible) is the most commonly fractured facial bone. Nevertheless, the upper jawbone (maxilla), the cheekbone (zygoma), the nasal bones, or the orbits (formed from bones of the cranium and face around the eyes) may also suffer fractures. A fracture may involve an individual bone or a combination of bones. One of the most common causes of facial fractures is blunt trauma. A blow to the face, the impact from an automobile or motorcycle accident, and a gunshot wound to the face are some examples of such trauma.

When considering fractures of the face, more than simply the bony structures must be evaluated. The skeletal structure encapsulates and protects organs that are vital to the functions of seeing, breathing, eating, talking, and swallowing. Early identification and treatment of fractures of the face are necessary to maintain the maximum function of these delicate organs. Therefore, even though facial fractures and related injuries to soft tissue are seldom fatal, they must be treated immediately since improper care could result in disfigurement, permanent sensory impairment, and lifelong disabilities.

In addition to facial fractures, jaw wiring is sometimes performed to correct malformations of the facial bones, certain birth defects, and acquired disfigurements as a result of trauma or growth-related imperfections. At times, jaw wiring is performed to correct malformations that have caused headaches, chewing disorders, and breathing and speech impairments. This type of surgery is referred to as orthognathic or jaw reconstruction surgery, part of which may involve jaw wiring. This procedure may also be performed as a weight-loss treatment for obese persons.

When a patient is hospitalized for elective facial surgery involving jaw wiring, or intermaxillary fixation, ample time can be given to preparing the patient for the surgical procedure and both preoperative and postoperative care. For the patient who sustains facial trauma, however, the same opportunity for surgical preparation may not be possible.

Facial fractures can often be reduced and immobilized by jaw wiring on the day of the injury. When there is marked facial edema (swelling), when other serious injuries are present, or when the person has eaten within a certain period of time prior to the trauma, however, the surgery will need to be delayed until a general anesthetic can be administered safely and the patient’s condition has stabilized to the point that the surgical procedure can be tolerated.

The purpose of jaw wiring is to reduce and stabilize the fracture in such a manner that proper alignment of the bone will be maintained until it has healed. If the surgery is for jaw reconstruction, then the bone is fractured and positioned by the surgeon. These surgical fractures also require stabilization so that they will heal in the intended position. Interosseous wiring (the wiring of one portion of bone to another) using stainless steel wire may be necessary to maintain proper bone alignment. Sometimes, compression plates are used to secure the bones together. At other times, a bite block splint is inserted between the teeth to provide stabilization. This splint resembles a denture plate. An appliance called an external fixation device may be needed to keep the bones in proper alignment until they are healed.

If the patient wears dentures, then the denture plates are wired to the bone, the lower plate to the mandible, and the upper plate to the maxilla, prior to the jaw-wiring procedure. If the patient has no teeth at all, a bite block splint must be wired to the mandible and the maxilla, similar to the way in which dentures would be wired into place.

Jaw wiring is accomplished by first attaching arch bars to the base of the teeth. Arch bars are pliable pieces of metal with small hooked attachments on one side. They come in precut lengths and can also be cut to fit the individual’s mouth. One fits along the base of the lower dental arch, and the other fits along the base of the upper dental arch. Thin pieces of stainless-steel wire are passed around the base of each tooth and brought out, then hooked around the arch bar and twisted firmly into place to secure the arch bar itself. The wires are cut, and their edges are tucked down between the teeth to prevent them from poking into gum or cheek tissue. If the patient wears dentures, the arch bar is either wired or glued to the denture plate with a special glue before the plate is wired to the bone structure.

Once the arch bars are positioned and secured, then special rubber bands are drawn around the hooked attachments from the upper to the lower bar. These bands are what actually hold the jaw tightly together. They are usually replaced with thin wires a few days after surgery when the danger of nausea and vomiting has passed. Wire cutters need to be kept within easy reach at all times in the event of vomiting. Should this happen, only the wires that hold the teeth together are clipped, and they will need to be reapplied by the physician.

Uses and Complications

Until the 1970s, orthognathic surgery carried a purely cosmetic connotation among the general public. Gradually, with surgical practice, documentation, research, and reports of the results of orthognathic surgery, people have come to understand the importance of such surgery in terms of proper physical functioning, as well as psychological and social functioning. Surgical reconstruction of the face can produce amazing results, but it also comes with a price. The process sometimes takes several years and teamwork by dentists, orthodontists, oral and/or plastic surgeons, and sometimes even psychiatrists to achieve these results. It can also be very costly because some insurance companies still consider orthodontia and corrective surgery cosmetic rather than functional and do not accept claims for these services.

Whatever the reason for jaw wiring, this process involves much more than a simple surgical procedure. Patients are usually hospitalized. Many of them are young, and others have had little hospital experience and may be anxious about the outcome. Lack of family support or financial concerns may increase this anxiety. Other injuries may be present in addition to the facial ones, some of which could be life-threatening and need to be attended to first.

Since jaw wiring usually means that the jaws are tightly wired shut, careful immediate postoperative monitoring by a nurse is needed to ensure that respiratory functioning is adequate, nausea and vomiting are controlled, mouth care is performed, nutritional intake of an all-liquid diet is satisfactory, and facial swelling and pain are reported to the surgeon, if necessary.

Before being discharged from the hospital, patients need to be shown proper mouth care techniques. Primary among them is the use of an electrical appliance that delivers pulsating jets of water, saline, or a mouth care solution to areas between the teeth and under the gum line. It rinses out food debris and harmful bacteria from the mouth. Mouth care is very important during the period of time when the jaws are wired so that healing is promoted and dental caries (cavities) are prevented.

Good nutritional habits are also important during this time. Since the patient’s diet must be liquid in form, concerns about weight loss, adequate food variations, appropriate nutrients for healing, management of food preparation, and possible nutritional supplementation need to be addressed and resolved before a patient is discharged. Patients should have a written diet plan to use at home. Medications needed for pain and nausea, vitamins, and sometimes antibiotics will also need to be obtained in liquid form. Instructions regarding how to administer emergency care, when to call the doctor, and how to cut wires if vomiting occurs must be given.

Follow-up care with the physician will be needed to evaluate progress and to arrange for the clipping of wires and the removal of the arch bars. These procedures are usually done in the physician’s office.

Perspective and Prospects

It is likely that attempts were made to treat fractures of the face from the time of the cave dwellers, but no records of such attempts were kept. The earliest known records relating to the treatment of jaw fractures are found in the Smith Papyrus, which is thought to have been written about 25 to 30 centuries BCE. The author advises against the treatment of compound (open) fractures but recommends that the dislocation of the mandible be treated. Definite proof of the art of dentistry was found among the Etruscans, an ancient people living in what is now Tuscany and part of Umbria, in about 600 to 500 BCE: skeletal remains with the teeth bound with gold wire have been discovered.

In the time of Hippocrates (ca. 460–ca. 370 BCE), the Greek physician known as the founder of medicine, writings bear evidence that facial injuries or fractures were treated with some method of wiring. A section of the Corpus Hippocraticum reads:

If the jaw is broken right across, which rarely happens, one should adjust it in the manner described [one thumb inside the mouth and the fingers outside, for reduction]. After adjustment one should fasten the teeth together as was described above [with gold wire or, lacking that, with linen thread], for this will contribute greatly to immobility, especially if one joins them properly and fastens the ends as they should be.

The use of bandages to treat facial maladies was also practiced by some ancient cultures. Galen of Pergamum (129–ca. 199 CE) and Soranus of Ephesus (98–138 CE) describe such methods. An ancient manuscript by Soranus of Ephesus illustrates the types of bandages used by the ancients to treat head and facial injuries.

Greek writings even suggested dietary practices in cases of jaw injury. When the mandible was fractured, liquid nourishment was recommended, and solid foods were withheld until bone healing was definite. Patients were also advised not to talk for a certain period of time.

In the thirteenth century, the Italian surgeon Guglielmo da Saliceto (ca. 1210–ca. 1277), also known as William of Saliceto, performed one of the first documented cases of jaw wiring, attaching the teeth of the lower jaw to the corresponding teeth of the upper jaw. He used linen and silk thread, twisting them together and then waxing the twist to keep it in place. In the next several centuries, however, medieval literature lacks any references to the management of facial bone fractures. Whether the work of earlier surgeons was unknown or whether such surgical practices remained standard during these years without notable progress remains a mystery. It was toward the end of the nineteenth century that the development of intermaxillary fixation by wiring was developed by an American physician and dentist, Thomas Lewis Gilmer (1849–1931).

Many great names are associated with the twentieth-century contributions to improved and refined methods of jaw-wiring techniques and patient care during this process. Much was learned about the nature of facial fractures themselves from the work of French physician Rene LeFort. LeFort conducted a series of experiments in the early twentieth century to study facial fracture combinations. He subjected cadaver skulls to violent blows under many conditions and at various angles and then described the outcomes.

A survey of the progress made in jaw wiring would be incomplete without recognition of the impact that antibiotic therapy, advanced anesthetic techniques, and blood replacement therapy have had on this procedure and on medical science as a whole. These achievements paved the way for open surgical procedures and internal fixation, which have led to dramatic results and remarkable changes for individuals undergoing jaw wiring. Although jaw wiring may seem like a risky and antiquated procedure, its beneficial role in helping to heal facial fractures, facilitating orthodontic changes, and allowing for the control of a patient's intake of food while making lifestyle changes remains relevant in the twenty-first century.

Bibliography

Biggers, Alana, and Marsha McCulloch. “Jaw Wired Shut: Benefits, Tips, and Foods.” Healthline, 31 Oct. 2018, www.healthline.com/health/jaw-wired-shut#recovery-time. Accessed 4 Aug. 2023.

Fonseca, Raymond J., et al., eds. Oral and Maxillofacial Trauma. 3d ed. St. Louis, Mo.: Saunders/Elsevier, 2005.

Jones, Pamela. "Corrective Jaw Surgery." Health Library, March 15, 2013.

Niamtu, Joseph, III. “Cosmetic Oral and Maxillofacial Surgery Options.” Journal of the American Dental Association 131, no. 6 (June, 2000): 756–764.

Proffit, William R., Raymond P. White, Jr., and David M. Sarver, eds. Contemporary Treatment of Dentofacial Deformity. St. Louis, Mo.: Mosby, 2003.

Rahpima, A., and A. Halaj Mofrad. "The Use of Maxillomandibular Fixation Screws with Essig Wiring in the Treatment of Symphyseal Fracture of Deep Bite Patients." Journal of Maxillofacial and Oral Surgery 8, no. 4 (2009): 375–376.

Reyneke, Johan P. Essentials of Orthognathic Surgery. Chicago: Quintessence, 2003.

Salter, Robert Bruce. Textbook of Disorders and Injuries of the Musculoskeletal System. 3d ed. Baltimore: Williams & Wilkins, 1999.

Watts, V., S. Madick, J. Pepperney, and C. Petras. “When Your Patient Has Jaw Surgery.” RN 48 (October, 1985): 44–47.

Yadav, Santosh Kumar, and Gopendra Deo. "Submental Intubation Including Extubation: Airway Complications of Maxillomandibular Fixation." Case Reports in Anesthesiology (2012): 1–3.