This document discusses various techniques for closed reduction of mandibular fractures including direct and indirect interdental wiring methods like Essig's, Gilmer's, and Risdon's wiring. It also covers arch bar fixation, circummandibular wiring, perialveolar wiring, and suspension wiring techniques like frontal suspension and circumzygomatic wiring. The advantages of closed reduction are that it is more conservative than surgery and can be used for medically compromised patients, but disadvantages include airway compromise, loss of function, decreased nutrition, and effects of prolonged intermaxillary fixation like joint adhesions and osteoporosis.

2. INDICATIONS FOR CLOSED REDUCTION
 Non displaced and favourable fractures
 grossly communited fractures
 edentulous atrophic mandible
 fractures in children
 condylar fractures

3. CONTRA INDICATIONS
 patients with poorly controlled seizures
 patients with compromised pulmonary fn
 patients with psychatric or neurological disorders

4. VARIOUS TYPES OF WIRING
DIRECT INTERDENTAL WIRING:
 ESSIG’S WIRING
 GILMER’S WIRING
 RISDON’S WIRING
INDIRECT INTERDENTAL WIRING
 IVY LOOP OR EYELET WIRING
CONTINOUS OR MULTIPLE LOOP WIRING
ARCH BAR FIXATION

5. CIRCUM MANDIBULAR WIRING
PER ALVEOLAR WIRING
SUSPENSION WIRING
 CIRCUM ZYGOMATIC WIRING
 FRONTAL SUSPENSION
PIRIFORM APERTURE SUSPENSION
 ZYGOMATIC BUTRESS SUSPENSION
 INFRA ORBITAL SUSPENSION

6. DIRECT INTERDENTAL WIRING
ESSIG’S WIRING
 Used to stabilize dento alveolar fracture as well as it can be used as
anchoring device for IMF.
 There should be sufficient number of teeth on either side of the
fracture line.
 A 40 cm 26 guage prestretched stainless steel wire is used.
The wire is passed interproximally between two teeth present a little
away from fracture line.

8. The wires are passed around the teeth in a figure of 8 manner until
they reach 2 to 3 teeth away from the fracture line.
 Now the wires are passed without looping to the other side of the
fracture line and 2 to 3 teeth away from the fracture line on the
opposite side.
Again the wires are taken around 2 to 3 teeth in a figure of 8
manner.
Now this acts as an arch bar on which the other smaller wires are
tightened to stabilize the fracture.

9. GILMER’S WIRING
 It is used for IMF.
Most common and simple method.
Few firm teeth in the mandible as well as in maxilla are chosen.
At least one firm teeth must be chosen anterior and posterior to the
fracture line.
A pre stretched 20 cm long 26 guage wire is taken and passed around
the neck of the chosen tooth.
Both the ends of the wire are brought out on the buccal side and
twisted.

11. The same procedure is carried out for all the chosen teeth in the
individual arches.
Then the mandibular wires are twisted tightly with the
corresponding maxillary wires.The ends are cut short and sharp ends
are tucked in.
The main disadvantage of this wiring is that there may be extrusion
of the teeth as excess load is applied.
Another disadvantage is of requiring complete removal of the wires
to open the mouth in emergency situations.

12. RISDON’S WIRING
It is commonly used method of horizontal wire fixation.
This can be a substitute technique for arch bar.
In this method second molars are usually chosen for anchorage on
either side.
A 25 cm long 26 guage wire is passed around the neck of second molar
on each side and both the ends are brought in buccal side.

14. The ends are twisted for entire length thus forming a strong base
wire that comes towards the midline from each second molars.
Two base wires are grasped and twisted at mid line and adapted to
the necks of the teeth on the buccal side .
This base wire is secured to individual teeth by using additional
interdental wires.
This type of horizontal wiring offers strong fixation.

15. IVY EYELET WIRING
The Ivy loop embraces the two adjacent teeth.one or two Ivy eyelets
should be placed in each quadrant.
A 26 guage stainless steel wires cut in 20 cm lengths are used.
A loop is formed in center of wire around the beak of a towel clip or
shank of dental bur and twisted thrice with two tail ends. Such Ivy
loops can be preformed and stored in cold sterilizing solution for
emergency use.
The two tail ends of the eyelet are passed through the interdental
space of the selected two teeth from buccal to lingual side.
One end of the wire is passed around the distal tooth lingually and
brought out from the distal interdental space over the buccal side and
threaded through the previously formed loop.

17. The other wire tail end is carried around the lingual surface of the
mesial tooth and brought out on the buccal surface from the mesial
interdental space, where it meets the first tail end wire.
The two wires are crossed and twisted together and the loop is
adjusted and bend towards gingiva.
The mandibular wire eyelets can be secured to maxillary eyelets by
joining wires.
Advantage is that bridging wires can be removed whenever required
without disturbing the main wiring.
Even when there is breakage of wire during fixation only that eyelet
can be removed and replaced.

18. HALLAM MODIFICATION ( 1945 )

19. WILLIAM MODIFICATION ( 1968 )

20. CLOVE HITCH METHOD

21. STOUT’S MULTI LOOP WIRING
The posterior part of four quadrants are used for wiring.
4 pieces of 26 guage 20 cm long wires are required and piece of solder
is used for making loops.
The piece of solder wire is adapted to buccal surface of teeth.
The 20 cm long pre stretched wire is folded into two parts, one part
acts as the stationary wire and the other end is brought distal to the
second molar and taken around it on lingual side.

23. This working end is threaded through the mesial side of second
molar to the buccal side under the solder wire.
It is then looped around the stationary wire and solder wire and back
into the interdental space from buccal to lingual. The same procedure
is repeated for each tooth up to midline.
The solder wire is removed after the loops are formed and the loops
are twisted to form eyelets.
Finally the stationary and working ends of the wires are twisted
together.

24. ARCH BAR FIXATION
The arch bar is a flat, sturdy stainless steel bar on which fleats or
hooks are attached.
It is a effective, quick and inexpensive method of fixation.
The different types of arch bars are,
pre fabricated
custom made
acrylated arch bars
directly bonded arch bars
Of these the most commonly used are the pre fabricated Erich arch
bars.

25. CUSTOM MADE ACRYLATED ARCH BAR

26. The arch bar is measured to fit from first molar to first molar.
The arch bar is placed in such a way that the fleats or hooks face
towards the gingival margin.
Now 15 cm of 26 guage wire is taken and starting from the distal
tooth, the wire is passed from buccal to lingual side below the arch bar
and from lingual to buccal above the arch bar and twisted together.
This is continued for all the teeth and the arch bar is secured.
When placing an arch bar across a displaced fracture segment,it is
cut at the fracture site and placed seperately.

28. PER ALVEOLAR WIRING
Two peralveolar wires are placed in the canine region on either side for
fitting patient’s own denture to alveolar ridge.
The splint is firmly placed in the position in the upper jaw.
A kelsey-Fry bone awl introducer is pushed from buccal to palatal
aspect.
A 26 guage wire is thresded through the eye and the wire is withdrawn
with it the wire on the buccal surface.
Same procedure is repeated on opposite side and then the splint is
replaced in the mouth and wires adjusted over it and twisted over the
grooves and the ends tucked inwards.

30. CIRCUMMANDIBULAR WIRING
OBWEGESER’S PROCEDURE
It is used for fixation of lateral compression splint to the mandibular
bone.
Lower border of mandible is palpated in the canine region and the
skin is pierced beneath the lower border of the mandible by Kelsey-Fry
bone awl and it emerges through the floor of mouth.
A 26 or 28 guage wire is inserted through the eye of the awl and the
awl is withdrawn till the lower border and directed upward along the
buccal surface of mandible to pierce through the buccal sulcus.
The two ends of the wire are adjusted and the splint is adjusted and
the lingual and buccal wires are held together and twisted in the region
of canine grooves, cut and finished inward.

32. SUSPENSION WIRING

33. FRONTAL SUSPENSION
It is used for fracture of maxilla at the Le Fort II or III level
Arch bar is secured in the upper and lower arch
The frontozygomatic region is exposed with a small lateral eyebrow
incision.
A hole is drilled in the zygomatic process of frontal bone which is
5mm above the frontozygomatic suture.
A pre stretched 26 gauge SS wire is passed through this hole and bent
back so that an equal length protrudes on either side of this bur hole.
The two ends of wire are threaded through the eye of Rowe’s
zygomatic awl and crimped.

34. The awl is then passed downwards and forwards behind the frontal
process of the zygomatic bone deep to the zygomatic arch to pierce
through the oral mucosa in the upper buccal sulcus in the region of
upper molar teeth.
The wire ends are detached from the awl and secured nwith an
artery forceps while the awlm is withdrawn. These wire ends are to be
secured on arch bar.
A small SS wire which is threaded beneath the suspension wire and
the passes through the bone and is twisted is called Pull-out wire.
This wire negotiates the making of incision again to expose the wire.
Suspension wires are placed on both sides for uniform suspension
and occlusion is checked and the wire is then secured to the arch bar

35. CIRCUMZYGOMATIC WIRING
It is used for fixing a Le Fort I fracture.
The point of suspension is in the region of junction between the
frontal and temporal process of the zygomatic bone.
An awl is introduced either directly through the skin or through a
small stab incision made in that region.
The awl pierces the temporal fascia and passes medial to the
zygomatic bone and zygomatic buttress to pierce the buccal sulcus in
the region of first molar.

37. A pre stretched 26 gauge SS wire is then attached to the eye of the awl
and crimped.
The awl is withdrawn just above the zygomatic arch and reinserted
this time lateral to the zygomatic bone and directed downwards and
forwards to emerge through buccal sulcus. This makes wire loop
around zygomatic bone.
The wire ends are secured and adjusted so as they rest on zygomatic
bone.
The ends of the wire are then secured to the arch bar.

38. PIRIFORM APERTURE SUSPENSION
This can again be used for the fixation of a Lefort I fracture as the
piriform aperture is a stable bone present above the level of the
fracture level.
The piriform aperture is exposed by an intraoral incision and a hole is
drilled.
Wire is threaded through this hole and then attached to the arch bar.

39. ADVANTAGES OF CLOSED REDUCTION
 more conservative procedure
No complications associated with surgery is present
Can be done in medically compromised patients
DISADVANTAGES
 airway compromise due to IMF
Loss of function of tissues
 decreased nutritional status of patients

40.  only occlusion is taken as a guide
Difficulty in speech
Social inconvinience
EFFECTS OF PROLONGED IMF
Formation of adhesions in joint
Thinning and necrosis of articular cartilage
Osteoporosis of bone due to disuse
Atrophy and weakening of muscles due to disuse

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