“Bhola’s modified figure of eight wiring” for rapid intraoperative maxillomandibular fixation: A technical note

Open reduction and internal fixation have gained popularity and are the most accepted recent modality of treatment for cranio-maxillofacial trauma.[1] Compared to the conventional closed reduction treatment modality, it offers the advantages of early mobilization, short treatment duration, and is well tolerated by the patient.[2] However, to ease open reduction and internal fixation (ORIF), closed reduction is performed to stabilize the occlusion and to keep it in the pre-operative functional position. Various modalities of closed reduction were described in the literature. The most common and popular technique described is the usage of Erich’s arch bar.[3] This technique of Bhola’s modified figure of eight wiring can be used with ease in dentate patients; it is minimally invasive, inexpensive, and requires less surgical time.[4] Hence, this technique would be beneficial in procedures where short general anaesthesia time is mandated, as in medically compromised patients or in a combined procedure with multiple departments like neurosurgery, general surgery, where prolonged duration of anaesthesia can significantly increase postoperative complications. Armamentarium The Armamentarium for this technique includes 24-gauge pre-stretched wire Wire Twister Wire cutter The technique A 24-gauge pre-stretched wire passed from the buccal side to the palatal side, from the distal region of the upper first molar tooth The wire is then pulled and passed from the mesial aspect of the first lower premolar tooth, from the lingual side to the buccal side, so that the free end of the wire is now on the buccal side [Figure 1]Figure 1: Figure of eight technique demonstrationThe wire is then pulled to reach the distal aspect of the first lower molar tooth and passed from buccal to lingual side The free end of the 24-gauge wire is then passed from the mesial aspect of the upper first premolar tooth from palatal to the buccal side The two free ends of the wire were then twisted and tightened, and MMF secured Figure of Eight confirmed on the linguistic aspect [Figure 2]Figure 2: Intraoperative photographThe same procedure is carried out in the contralateral side as well This wire can be removed intraoperatively after the completion of the procedure. In three cases, we have used this technique. Case 1 was a known case of chronic liver disease diagnosed with left parasymphysis fracture. Case 2 was a combined surgery with the neurosurgery department, and Case 3 was a pregnant patient in the third trimester. In all three cases, rapid intermaxillary fixation was carried out using Bhola’s modified figure-of-eight wiring, following which the fracture was fixed. A wide variety of maxillofacial surgical procedures require the stabilization of occlusion intraoperatively.[5] In the treatment of cranio-maxillofacial trauma, the initial goal is to stabilize the occlusion to achieve appropriate function.[6] Also, in the management of any pathological lesion of the maxillofacial skeleton, be it benign or malignant, which requires resection or segmental mandibulectomy, it is imperative to secure the occlusion intraoperatively before reconstruction, for maximizing postoperative functional outcomes.[7] Hence, it is important to develop a rapid intraoperative technique for maxillomandibular fixation (MMF) for securing on-table occlusion. This technique is particularly indicated for cases of simple fractures of the mandible which are minimally displaced, or in patients where intra-operative time has to be reduced owing to their medical conditions and which require a near-stable occlusion for fixation. Erich’s Arch bar is the most popular technique for MMF even today. It has the advantage of providing stable occlusion in a simple and cost-effective way and can be used as a single modality treatment in compromised patients who cannot undergo ORIF.[8] However, the increased surgical time under general anesthesia, glove perforations, compromised periodontium, prolonged treatment time, aspiration of vomit, etc., are complications while using this technique.[9,10] Several modifications were described in the literature to overcome bulky and rigid arch bars. One such technique was described by Shenoi R, in which eyelets were modified to obtain both horizontal stabilization and MMF.[11] Ehrich’s arch bar with MMF is the superior technique to provide stable occlusion. However, the advantages of using Bhola’s modified figure of eight technique compared to Erich’s arch bar is to obtain a stable occlusion intra-operatively for fixation of mandibular fractures as in emergency cases like a combined neurosurgery maxillofacial case, patients who cannot be kept under general anesthesia for longer time period due to medical co-morbidities like pregnancy or any other generalized medical condition. Also, this technique is cost-effective and does not require a longer learning curve, which makes it feasible for younger surgeons to competitively perform the procedure. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.