J. Maxillofac. Oral Surg.
https://doi.org/10.1007/s12663-021-01528-x
ORIGINAL ARTICLE
Are Embrasure Wires Effective and Reliable Method
for Intraoperative Maxillomandibular Fixation in Mandibular
Fractures?
Tejinder Kaur1 • Amit Dhawan1 • Ramandeep Singh Bhullar1 • Sarika Kapila1
Sakshi Gupta1 • Ritika Resham1
Received: 26 April 2020 / Accepted: 3 February 2021
 The Association of Oral and Maxillofacial Surgeons of India 2021
Abstract
Purpose Maxillomandibular fixation (MMF) is a basic and
fundamental principle in the management of the maxillo-
facial trauma patients. Some fractures require only intra-
operative MMF, during open reduction and internal
fixation but not in the postoperative period. The present
study was aimed to assess and compare the efficacy of
embrasure wire with Erich arch bar as methods of intra-
operative maxillomandibular fixation in the management of
mandibular fractures.
Materials and Methods The prospective randomized study
was undertaken in 30 patients who required intraoperative
maxillomandibular fixation for mandibular fractures.
Patients were randomly divided into two groups of 15 each
(Erich arch bar in Group A and embrasure wire in Group
B). The preoperative assessment included evaluation of
demographic data, fracture location, mechanism of injury,
degree of displacement of fracture and occlusion. Intra-
operative parameters assessed were the time consumed for
the application of MMF technique, injury to the operator/
assistant, injury to the patient, stability of MMF technique,
incidence of glove perforations and the cost of the MMF
device.
Results The mean time required for MMF and incidence of
glove perforation were significantly (P \ 0.001) less in
embrasure wire group than the Erich arch bar group. The
MMF technique maintained stable occlusion during open
reduction and internal fixation in both the groups.
& Tejinder Kaur
tkgumber@gmail.com
1 Introduction of arch bars by Erich in 1941 being used as
Department of Oral and Maxillofacial Surgery, Sri Guru Ram
Das Institute of Dental Sciences and Research, Mall Mandi,
GT Road, Amritsar 143001, India
•
Conclusion Embrasure wire is an effective, reliable alter-
native form of intraoperative MMF, as needle-stick injury
and time taken for placement were less as compared to the
Erich arch bar group. However, Erich arch bar wiring is a
versatile method and recommended where postoperative
maxillomandibular fixation is also required.
Keywords Maxillomandibular fixation
Embrasure wire

Erich arch bar
Mandibular fractures
Abbreviations
MMF Maxillomandibular fixation
ORIF Open reduction and internal fixation
Introduction
The treatment of maxillofacial injuries has a long history,
from ancient Egypt times to the present. Maxillo-
mandibular fixation (MMF) is a basic and fundamental
principle in the management of maxillofacial trauma
patients. It serves as a cornerstone for maxillofacial
reconstruction, providing a stable base from which facial
form and function can be restored. The introduction of
bone plating systems in maxillofacial trauma means that
prolonged periods of maxillomandibular fixation (MMF)
are no longer required in patients with fractures of the
mandible or maxilla; yet, there is often a need for tempo-
rary MMF intraoperatively to assist in the reduction of
fractures, with the teeth in correct occlusion.
the standard method applied to both dental arches provides
an effective and versatile means of MMF in terms of its
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simplicity and reliability. However, numerous problems
are associated with this method. In the never ending effort
to find alternatives, Hollows and Brennan [1] described a
simple form of intraoperative MMF that is called ‘‘em-
brasure wire MMF’’, especially used in cases of
mandibular fractures which require a short period of only
intraoperative maxillomandibular fixation during open
reduction and internal fixation (ORIF). The purpose of the
study was to assess and compare the efficacy of embrasure
wire with Erich arch bar as methods of intraoperative
maxillomandibular fixation in the management of
mandibular fractures.
Material and Methods
The prospective randomized study was undertaken in 30
patients (age range 15–47 years) with mandibular fractures
requiring open reduction and internal fixation who reported
to the Department of Oral and Maxillofacial Surgery, over
a period from June 2016 to October 2018. The Ethical
Committee of the Institute approved the design of the
study. Patients were randomized (using a table of Random
numbers) into two groups of 15 patients each. Patients were
selected irrespective of sex, caste, creed and socioeco-
nomic status. Informed consent for the procedure was
obtained from all the patients enrolled for the study.
The patients included were those who required intra-
operative maxillomandibular fixation for mandibular frac-
tures, secondly patients with an adequate number of
opposing maxillary and mandibular teeth with normal
interproximal contacts. Patients in the mixed dentition
stage, with extensive interproximal decay and generalized
spacing were excluded. Fractures were diagnosed on the
basis of detailed history, clinical examination and radio-
logical examination which included orthopantomogram
(OPG) and posteroanterior view mandible in open mouth
position.
Preoperative assessment of the patients included age and
gender of the patient, fracture location, mechanism of
injury, degree of displacement of fracture and occlusion
status. The degree of fracture displacement was evaluated
by tracing the orthopantomogram. In mandibular symph-
ysis, parasymphysis and body fractures the displace-
ment was evaluated by measuring the widest separation at
the fracture site with a ruler. Fracture displacement was
graded as minimal (\ or = 2 mm), moderate (2 to 4 mm)
and/or severe ([ 4 mm) [2]. However, in mandibular
angle, fracture displacement was determined by an
assessment of the alignment of the mandibular canal on
either side of fracture line which was graded as nondis-
placed, minimally displaced (malalignment of canal \
50% of the height of mandibular canal), moderately
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J. Maxillofac. Oral Surg.
displaced (malalignment [ 50% but less than the entire
height of mandibular canal) and severely displaced fracture
(malalignment greater than the height of mandibular canal)
[3]. The degree of displacement for condylar fractures was
graded according to the angle between the condylar frag-
ment and the posterior border of mandible. [Type I (\ 30),
Type 2 (30–60) and Type 3 ([ 60)] [4].
The surgical procedure was carried out with an aseptic
technique under general anesthesia/local anesthesia with
appropriate pre-medication. In all the patients, antibiotic
prophylaxis included I/V administration of Inj. Taxim 1 g/
12 hourly (Cefotaxime 1000 mg, Alkem Laboratories Ltd)
and IV infusion metrogyl 100 ml 8 hourly (Metronidazole
500 mg Flagyl, Piramal Healthcare, India) from the day of
hospitalization till second postoperative day. Subsequently,
oral administration of tab. Taxim-O 200 mg (Cefixime
200 mg, Alkem Laboratories Ltd) was given 12 hourly for
the next five days. All patients were instructed to rinse with
0.2% hexidine mouthwash (ICPA health products limited)
preoperatively. Fracture sites were exposed through an
intraoral or extraoral approach, depending upon anatomical
location of fracture and displacement of fracture fragments.
Intermaxillary fixation was achieved intraoperatively using
Erich arch bar in (Fig. 1), Group A and Embrasure wire in
(Fig. 2), Group B.
• In Group A, commercially available Erich arch bar was
contoured on the labial surfaces of the teeth and secured
for completion of fixation using retentive wires (26
gauge stainless steel wire). MMF was done using
prestretched stainless steel wires which were passed
around the hooks of upper and lower arch bar.
• In Group B, with the mouth open, bilaterally a single 22
gauze stainless steel wire (approximately 15 cm in
length) was introduced through the facial embrasure
between the maxillary premolars. The palatal end of the
wire was looped and then passed through the opposing
lingual embrasure in the mandible. Next, the fracture
segments were reduced appropriately after exposing the
fracture sites, and the teeth were brought into occlusion.
Both the embrasure wires were twisted together down
to the teeth until the fixation was rigid enough.
• Depending upon the fracture pattern and degree of
fracture displacement, additional embrasure wire was
used in maxillary and mandibular central incisors to
stabilize the occlusion whenever needed.
• After open reduction and internal fixation of fractures
with titanium miniplates (orthomax) based on Cham-
py’s principle, MMF applied for the reduction of
fracture was released in all patients immediate
postoperatively.
• Removal of embrasure wire For removal, the wires were
untwisted and cut on the buccal surface, and then
J. Maxillofac. Oral Surg.

Fig. 1 Erich arch bar group CLINICAL PHOTOGRAPHS

GROUP A – ERICH ARCH BAR

Preoperative occlusion Preoperative OPG

Erich arch bar MMF Postoperative OPG

Postoperative occlusion

pressure was placed on the chin to gently push the failure when there was gross separation of the occlusion
mandible away from the maxilla, creating a small gap during open reduction and internal fixation of fracture.
between the maxillary and mandibular dentition. After the completion of MMF, the used gloves were
Through this gap, a wire pusher was used to displace removed and checked for incidence of glove perfora-
the wires toward the tongue, making them simple to tions using the water-leak test EN55-1 method by single
remove. observer in both the groups.
• Intraoperatively, both Erich arch bar and embrasure
The data obtained were subjected to statistical analysis
wire groups were assessed for the time consumed for
using SPSS for windows (version 17.0; SPSS Inc., Chi-
the application of MMF technique, injury to the
cago, IL, USA) to compare the efficacy of embrasure wire
operator/assistant, injury to the patient—any mucosal
with Erich arch bar for intraoperative stabilization of
tear or lacerations during the placement of wires, cost of
mandibular fractures. An independent t test was used to
the MMF device and stability of MMF technique in
compare the time taken for placing MMF and number of
relation to their ability to maintain stable occlusion
glove perforations in both the groups. Results were con-
during reduction and fixation of fracture. Stability of the
sidered statistically significant if P \ 0.05.
MMF device during procedure was considered as

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Fig. 2 Embrasure wire group GROUP B – EMBRASURE WIRE GROUP
Preoperative Occlusion
Embrasure wire MMF
Results
Of the 30 patients, there were 27 male (94%) and 3 female
(6%) patients. The age of the patients ranged from 15 to
46 years (mean age 26.9 years), with the peak incidence of
fractures in the 21–30 years age group. A total of 50
fracture sites were encountered and their distribution is
shown in (Fig. 3).
Among 30 patients, most patients sustained injury due to
road traffic accidents (Fig. 4). Preoperatively, occlusion
was disturbed in more number of patients (66.66%) in
group B as compared to 53.33% patients in group A.
The degree of displacement for various fracture sites in
both groups is shown in Fig. 5. In Group A, there were a
more number of associated condylar fractures, majority of
which were undisplaced (24.13%) followed by Type I
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J. Maxillofac. Oral Surg.
Preoperative OPG
Postoperative occlusion
Postoperative OPG
(13.7%) and then Type II (6.8%) displaced fractures.
However, in Group B, there were more number of mini-
mally displaced (38.09%) fractures as compare to Group A
(13.7%). Regarding moderately and severly displaced
fractures, there was not much difference between both the
groups.
Regarding time taken for placement of maxillo-
mandibular fixation (Table 1), two groups were compared
by independent t test and P value for equal variances not
assumed was used. Difference in the time taken was proved
to be statistically highly significant (P \ 0.001). Range of
time in patients of group A and group B was
28.47–54.23 min and 2.60–5.75 min, respectively.
Data regarding the incidence of glove perforation were
checked for normality by Kolmagrov–Smirnov test as it
was normally distributed, so independent t test was applied
J. Maxillofac. Oral Surg.

Fig. 3 Distribution of fracture

sites DISTRIBUTION OF FRACTURE SITE
14

12

NO. OF PATIENTS
10

0
SYMPHYSIS PARASYMPHYSIS BODY ANGLE CONDYLE

FRACTURE SITE
GROUP A GROUP B

Fig. 4 Mechanism of injury MECHANISM OF INJURY

10%
13.3%
RSA
10%
66.6% Fall
Occupational Injury
Interpersonal violence

for comparison of the two groups. The arch bar group had
significantly more number of perforations than embrasure
wire. Perforations on index finger were 51.9% (n-40) in
group A with 82.5% (n-33) of these on non-dominant hand
and 17.5% (n-7) on dominant hand. However, perforations
on index finger were 55.5% (n-15) in group B with 86.67%
(n-13) of these on non-dominant hand and 13.33% (n-2) on
dominant hand followed by thumb with 20.77% in group A
and 22.22% in group B. Statistically significant difference
could not be demonstrated for the incidence of noticed
perforations (P = 0.235), scrub nurse group (P = 0.072)
and total number of gloves used (P = 0.313) where as
highly significant difference in the incidence of glove
perforation was observed between both the groups
regarding total perforations, unnoticed perforations and
perforations on both surgeon and assistant’s gloves
(P \ 0.001) (Fig. 6).
In group B, only two patients (13.33%) had lacerations
which involved distobuccal interdental papilla of left
mandibular first premolar while passing the embrasure wire
as compared to no injury to the patients in group A, with
arch bar application.
In both the groups, the MMF technique (arch bar and
embrasure wire) maintained stable occlusion during open
reduction and internal fixation (ORIF) of all fracture sites.
However, in two cases of embrasure wire group, additional
wire was used perioperatively in anterior region to attain
adequate reduction and stable occlusion during fixation of
fractures.
It was observed that cost factor increased six times in
group A as compared to group B.
Discussion
Traditionally MMF has been achieved with arch bars [5]. A
number of MMF methods have been suggested as an
alternative to the conventional Erich arch bars in order to
decrease the operation time and lower the risk of needle-
stick injury. These include orthodontic brackets, bracket

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 J. Maxillofac. Oral Surg.

DEGREE OF DISPLACEMENT OF FRACTURE

FRAGMENTS
9
27.5% 38.09% 27.5%
8
33.3%
7
NO. OF FRACTURE SITES

5
13.7% 13.7% 13.7%
4
10.3%
3
6.8%
2
4.7% 4.7%
1
0%
0
UNDISPLACED MINIMALLY MODERATELY SEVERELY TYPE I CONDYLE TYPE 2 CONDYLE
DISPLACED DISPLACED DISPLACED

DEGREE OF DISPLACEMENT
GROUP A GROUP B

Fig. 5 Degree of displacement of fracture fragments

Table 1 Time taken for

Mean time (minutes) Number of patients SD Std. mean error Sig. (two-tailed)
placement of MMF device (in
minutes) Group A 41.3267 15 8.32817 2.15033 \ 0.001
Group B 3.4733 15 0.85986 0.22201
P \ 0.001 statistically highly significant difference

bars bonded to the teeth, adhesive cast and thermoforming
splints, buttons or beads and wires, single wires through the
contact points of the premolars, intermaxillary screws,
dimac wires and rapid MMF.
One of the MMF techniques, i.e., embrasure wire was
introduced by Hollows and Brennan [1] which achieve the
same intraoperative treatment objective as Erich arch bars
but with a significant reduction in application time and cost
saving. These wires are placed relatively quickly, provide
stable intraoperative MMF and require no special material
or devices and also it minimizes the risk of disease trans-
mission. However, embrasure wires are useful for tempo-
rary intraoperative MMF only and are not as versatile as
arch bars [6].
Restoring pre-traumatic occlusion is the common aim
for optimization of masticatory functions. In the present
study, intraoperative occlusion was attained equivalent to
premorbid occlusion by maxillomandibular fixation using
Erich arch bar in group A and embrasure wire in group B
which is similar to the methods reported by Englested and
Kelly [6] and Satpute et al. [7] in their studies on
mandibular fractures.
Stability of maxillomandibular fixation technique was
regarded as failure by Englested and Kelly [6] whenever
there was gross separation of occlusion during open
reduction and internal fixation of mandibular fractures.
However, authors observed no significant difference in
stability between the two groups (96% in Erich arch bar
group as compared to 89% in embrasure wire group).
Embrasure wire MMF failure was attributed to the wire
passing through the dental contacts more easily. However,
arch bar wiring failure was due to intraoperative wire
distortion. They further explained that quality of immobi-
lization provided by embrasure wire group was superior to
arch bar because the wires are placed at the level of
occlusion, which provide rigid MMF without displacement
of flail fracture segment and wires used with this technique
are shorter in length, resist stretch, distortion and are
applied directly to teeth. Their findings are in accordance
with the present study in which both the MMF techniques
maintained stable occlusion during open reduction and

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J. Maxillofac. Oral Surg.
INCIDENCE OF GLOVE PERFORATIONS
80
NUMBER OF GLOVE PERFORATIONS
70
60
50
40
30
20
7
10 3 3
0
NOTICED
PERFORATIONS PERFORATIONS
Fig. 6 Incidence of glove perforation
internal fixation. However, in embrasure wire group,
additional wire was placed in anterior region to attain
satisfactory occlusion intraoperatively, in 2 cases with
bilateral involvement of jaw. Postoperatively, MMF was
done for a period of 3 weeks in associated condylar frac-
tures only. In contrast to our findings, Satpute et al. [7]
reported stable occlusion in 100% patients of Erich arch
bar group and 72% patients in embrasure wire group.
Authors further stated that occlusal stability depends upon
the type and displacement of fracture and attributed
unstable occlusion to those patients who had multiple
fractures, comminuted fracture and severely displaced
fractures.
Statistically highly significant difference was observed
between the two groups regarding time taken for the
application of MMF (P \ 0.001). The time required for
MMF with arch bar wiring (41.32 ± 8.32 min) in the
present study is consistent with the observations of Ayoub
and Rowson [8], Rastogi et al. [9] and Satpute et al. [7]
who reported the time for MMF as 34.6 ± 7.2 min,
45.05 ± 5.96 min and 48.08 min, respectively, in their
studies. In contrast, Englested and Kelly [6] reported less
time for MMF with Erich arch bar wiring, (25.47 min),
whereas Rai et al. [10] and Chhabra et al. [11] reported
significantly higher time 95.06 ± 14.17 min and
104.06 ± 02 min, respectively, for MMF with Erich arch
bar as compared to the findings of present study. However,
time required for MMF with embrasure wiring in our study
77
42
32
24
15
12
0
UNNOTICED SURGEON ASSITANT SCRUB NURSE
GROUP A GROUP B
(3.47 ± 0.85 min) is consistent to the findings of Englested
and Kelly [6] and Satpute et al. [7] who observed it to be
2.51 min and 3.48 min, respectively. In contrast, Rastogi
et al. [9] reported more time for embrasure wire MMF
(7.85 ± 0.81 min).
Regarding intraoperative injury, in group B, only two
patients (13.33%) had lacerations, which occurred while
passing the embrasure wire as compared to no injury to the
patients in group A, with Erich arch bar application.
However, no damage to dentition such as fractured teeth or
restorations was seen with embrasure wire, which is con-
current to the observations of Englested and Kelly [6]. In
contrast to present study, Satpute et al. [7] reported an
iatrogenic injury in 8 patients of Erich arch bar group and 2
patients in embrasure wire group. Author stated that by
using smaller gauze wire for embrasure wire MMF, more
force is generated which can lead to fracture or avulsion of
tooth.
In the present study, incidence of glove perforation in
both the groups was recorded. In group A, the mean rate
per surgical procedure for glove perforation (5.13 ± 1.30)
was similar to the findings of Pieper et al. [12], Avery et al.
[13] who observed it to be 5.07 and 4.62 ± 3.25, respec-
tively. In contrast, Gaujac et al. [14] observed a low rate
per operation as 2.45 in their study while using Erich arch
bar wiring for MMF. In our study, the rate per operation for
glove perforation was 1.80 ± 1.47 in group B which was
2.85 times less than that observed for arch bar wiring. This
123

implied that embrasure wire led to less number of glove
perforations as compared to Erich arch bars and thus
decreased the risk of disease transmission and occupational
injuries.
The perforations in both the groups were found mainly
on non-dominant hand (68.8% group A and 70.3% group
B) as it is used for support and protection of soft tissues,
which is in accordance to the findings of Gaujac et al. [14]
and Bali et al. [15] who reported 70.9% and100% perfo-
rations, respectively, on non-dominant hand in their
studies.
Regarding index finger glove perforations, our findings
are consistent with the incidence of perforations (52.4%
and 51.5%, respectively) as reported by Gaujac et al. [14]
and Sandhu et al. [16]. While using Erich arch bars for
MMF in their studies. In contrast, Rai et al. [10] reported
trauma to the operator’s finger as 18.18% when Erich arch
bar was used for MMF.
Gaujac et al. [14] stated that use of Erich arch bar for
MMF carried a significant risk of perforation and other
accidents due to the rough edges of the bar and the stainless
steel wires used for placement. Authors recommended
caution during arch bar placement, along with the proper
use of surgical instruments such as separators and tweezers,
instead of fingers to decrease the rate of glove perforation
and further stated that double gloving was effective in
protection against percutaneous injury. It is recommended
to change gloves whenever a perforation is suspected and
also on completion of one dental arch.
The cost of the MMF device was also assessed in the
present study. However, the cost effectiveness of treatment
modality depends on the cost of the device, anesthetic and
the operatory room cost. The cost factor increased to 6
times for group A as compared to group B. Various mod-
ifications have been reported in literature for conventional
wiring techniques to lower their cost factor. Aldegheri and
Blanc [17] used pearl steel wires (26 gauge) for MMF and
stated that it was a cost effective, quick and safe method.
Iizuka et al. [18] used titanium arch bar for MMF and
stated that it allowed excellent stability, easier and faster to
apply on the dental arches than the conventional arch bar.
The only disadvantage being the increased cost of the
material. Dimitroulis [19] reported approximately one hour
less operating time for mandibular fractures without using
Erich arch bars MMF and therefore cost saving in terms of
operating time, postoperative discharge and cost of the
material. Tracy and Gutta [20] also reported significantly
less intraoperative time (approx. 2 min) and reduced cost
for embrasure wire fixation than arch bar fixation.
The main limitations of embrasure wire MMF are that it
can’t be used for postoperative elastic traction to correct
occlusion discrepancy, in patients with severe periodontal
disease, patient with poor interproximal contacts and gross
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J. Maxillofac. Oral Surg.
dental mobility, in comminuted fractures and pediatric
patients where the roots of teeth are incompletely devel-
oped. However, in patients with severe periodontal disease
and poor interproximal contacts, transosseous wire can be
placed to obtain optimal occlusion contacts. For this the
wires can be passed through the alveolus after making an
entry point with a small drill bit. The occlusion can be
achieved by matching the opposing wear facets on the teeth
[20].
Conclusion
In conclusion, embrasure wire MMF is an effective alter-
native technique in majority of patients with moderately or
severely displaced mandibular fractures. These wires result
in rigid and stable immobilization, significant cost savings
in terms of decrease anesthesia time, can be placed safely
and relatively quickly. On the other hand, Erich arch bar
wiring is a versatile method as compared to embrasure wire
because it not only aids in intraoperative fracture reduction
rather can be used for postoperative maxillomandibular
fixation in patients with maxillofacial fractures. However,
more multicentric studies are required to determine the
efficacy of embrasure wire in various types of maxillofacial
fractures.
Funding No grants were used.
Declaration
Conflict of interest The author declares that they have no conflict of
interest.
Informed Consent Patients in the study have given informed con-
sent to participate in the study.
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