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
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