Closed reduction is the restoration of fractured bone fragments to their original position without direct visualization of the fracture site. It involves techniques that do not open the skin or mucosa covering the fracture. Indications for closed reduction include non-displaced or comminuted fractures, while contraindications are unfavorable fractures of the angle or body of the mandible. Closed reduction techniques discussed in the document include manipulation, intraoral and extraoral traction methods, and various wiring techniques like Essig's, Gilmer's, and Risdon's wiring as well as arch bar fixation. Factors like fracture site, presence of teeth, patient age and infection risk determine the period of immobilization required.

1. Closed Reduction in
Mandibular Fracture
DEYA_49DDCH_2017

2. Introduction
 What is close reduction?
~ Restoration and alignment of the
fractured fragments to their original
anatomical position without visualization
of the fracture line is known as close
reduction.

3. Closed reduction
01
• Fracture reduction that involves techniques of
not opening the skin or mucosa covering the
fracture site.
02
• Fracture site heals by secondary bone healing.
03
• This is also a form of non-rigid fixation.

4. Indication of close reduction
 Non displaced favorable fractures
 Grossly comminuted fractures
 Fractures exposed with significant loss of
overlying soft tissues.
 Edentulous mandibular fractures

5. Indication
 Mandibular fracture in children
 Coronoid process fracture
 Condylar fracture

6. Contraindications of close
reduction
 Unfavorable fractures at the angle of the
mandible
 Unfavorable fractures at the symphysis or
body of the mandible
 Medically compromised patient

7. Contraindication
 Complex facial fracture
 Edentulous mandibular fracture
with severe displacement

8. Advantages of close reduction
 Inexpensive
 Only stainless steel wires needed (usually arch
wire also)
 Easy availability, convenient
 Short procedure, stable
 Gives occlusion some “ Leeway” to adjust itself

9. Advantages of close reduction
 Conservative
 Generally easy, no great operator skill needed
 No foreign object or material left in the body
 No operating room needed in most cases
 Callus formation allows bridging of small bony
gaps

10. Disadvantages of close
reduction
 Cannot obtain absolute stability (contributing
to nonunion & infection)
 Noncompliance from patient due to long
period of IMF
 Difficult nutrition

11. Disadvantage
 Complete oral hygiene impossible
 Possible temporomandibular joint sequelae (MPDS)
 Denervation of muscles, alteration in fiber types
 Myofibrosis
 atrophy and stiffness

12. Disadvantages
 Changes in temporomandibular joint cartilage
 Weight loss
 Irreversible loss of bite force
 Decrease range of motion of mandible
 Risk of wounds to operators manipulating
wires.

13. Methods used to achieve
close reduction
 ~ Reduction by manipulation
 ~ Reduction by traction
~ Intraoral traction method
~ Extraoral traction method

14. Reduction by manipulation
 Reduction by manipulation is done when
the fractured fragments are adequately
mobile without much overriding or
impaction and the patient comes for
treatment immediately after trauma.
Then the digital or hand manipulation for
reduction can be used .
 Specially designed instruments for
grasping the fragments are available like
disimpaction forceps, bone holding
forceps.

15. Reduction By Manipulation

16. Close reduction by traction
 Intraoral traction method :
In this method prefabricated arch bars
are attached to maxillary and mandibular
dental arches by means of interdental
wiring .The fracture fragments are
subjected to gradual elastic traction by
placing the elastics, from upper to lower
arch bars in a definite manner & direction
depending on the fracture line.

17. Intraoral traction method
The fracture
fragments are
subjected to gradual
elastic traction by
placing the elastics,
from upper to lower
arch bars in a
definite manner &
direction depending
on the fracture line.

18. Close reduction by traction
 Extraoral traction method :
In extraoral traction method,
anchorage is taken usually from the intact
skull of the patient & different types of
head gears are used for various
attachments.
Attachments are connected to the
arch bars by elastics & wires.

19. Fracture Healing in Close
Reduction
 Secondary bone healing refers to spontaneous healing
without surgical intervention and after semirigid fixation.
The phases in secondary bone healing:
~ Intial stage
~ Cartilaginous callus formation
~ Bony callus formation
~ Remodelling

20. Factor Affecting The Risk of
Failure of Close Reduction
 Presence of fractured tooth
 Total absence of teeth
 Inability of the patient to co-operate with
treatment
 Associated with fractures of the mandible
especially bilateral fractures of the condyles.

21. Management of Teeth Present
in line of fracture

22. Indications For Removal of
Tooth From Fractured Line
Absolute Indication
 Vertical fracture of the
root
 Pre-existing periapical
lesion
 Luxation and subluxation
of the tooth from the
socket
 Acute pericoronitis
 Teeth that prevent
reduction of fractures
should be removed
Relative Indications
 Advanced caries
 Advanced periodontitis
 Tooth which serves no
function
 Teeth involved in
untreated fractures
which are presented
more than 3 days after
injury

23. Teeth Which Need To Be In
The Fracture Line
 Shows no evidence of mobility or inflammation
 A second molar in the posterior segment of the fracture
should be protected to prevent superior displacement of
the posterior fracture segment during intermaxillary
fixation
 Attempt to save the cuspids, which are the cornerstone
of occlusion

24. Management of Retained
Teeth
 Administration of appropriate antibiotic therapy
 Splinting of the mobile teeth
 Endodontic treatment of the teeth in which the pulp is
exposed and subsequent follow-up for 1 year
 Immediate extraction if the pulp becomes necrotic

25. Period of Immobilization in Close
Reduction
Periods depends upon whether :
 site of the fracture
 Presence or otherwise of retained teeth in
the fracture line
 The age of the patient
 Presence or absence of infection

26. Period of Immobilization in
Close Reduction
 Young adult with fracture of angle
receiving early treatment in which tooth
removed from fractured line:
3 weeks

27. Period of Immobilization in
Close Reduction
 If tooth retained in fracture line : Add 1 week
 Fracture at symphysis : Add 1 week
 Age 40 years and over : Add 1 or 2 weeks
 Children and adolescents : Subtract 1 week

28. Different types of wiring
techniques
 Direct Interdental Wiring :
~ Essig’s Wiring
~ Gilmer’s Wiring
~ Risdon’s Wiring
 Indirect Interdental Wiring
~ Ivy Loop Wiring
 Multiple Loop Wiring
 Arch Bar Fixation

29. Closed Reduction of the
Dentulous Patient
 Erich’s arch bars. Can lead to periodontal inflammation
 Avoid fixating incisors as these teeth are moved by the
wires
 Ivy’s eyelet wiring

30. Closed Reduction of the
Partially Edentulous Patient
 Partial and circum wires or screws
 Acrylic partials with incorporated arch bar wires

31. Closed Reduction of the
Edentulous Patient
 Custom made splints
 Gunning splints

32. Closed Reduction in Mixed
Dentition Period
Fixation independent of the teeth
 Gunning type splint for the lower jaw
 Curcumferential wire
 A simple elasticated bandage chin support
Fixation utilizing the teeth
 Cap splint
 Eyelet wire / arch bar

33. Armamentarium for wiring
 Presterilized 26 gauge stainless steel wire
spool or wires cut into lengths of 20 cm
each.
 Two needle holders or wire holders
 Wire cutters

34. Essig’s wiring
 Essig’s wiring can be used to stabilize the
dentoalveolar fractures in individual dental
arches.
 Essig’s wiring can be used as anchoring device
for IMF.
 The luxated teeth can be stabilized using
essig’s wiring.

35. Essig’s Wiring
A 40 cm prestretched stainless steel wire is
used
The wire is passed interproximally between
two teeth present at least 3 teeth away from
the fracture line
The wires are passed around the teeth in the
figure manner until they reach 2-3 teeth away
from the fracture line
Now the wires are passed without looping to
the other side of the fracture line 2-3 teeth
away from the fracture line on the opposite
side.
Again the wires are taken around 2-3 teeth in
the figure manner
Now this acts as an arch bar on which the other
smaller wires are tightened to stabilize the
fracture

36. Gilmer’s Method
 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 choosen tooth
 Both the ends of the wire are brought out on the buccal
side and twisted

37. Gilmer’s wiring
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 is emergency situation

38. 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

39. Risdon’s wiring
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
the base wire is secured to individual teeth by
using additional interdental wires
This type of horizontal wiring offers strong
fixation

40. Ivy’s 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 length are
used
 A loop is found in center of wire around the beak of a towel
clip or shank of dental bur and twisted thrice with two tail
end. 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
fromed loop.

41. Ivy’s Eyelet Wiring
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.

42. Ivy’s Eyelet Wiring

43. Arch Bar Fixation
Indication of Arch Bar Fixation
 Stabilization of multi-fragment fracture
 Fixation of IMF

44. Arch Bars are preferred
 For temporary fragment stabilization in emergency
cases before definitive treatment
 As a tension band in combination with rigid internal
fixation
 For long-term fixation in conservative treatment
 For fixation of avulsed teeth and alveolar crest
fractures

45. Arch Bar: General
Considerations
 The occlusion must be checked
 There should be calculable tension forces on both bars
 Surgeon should aware of getting affected by bloodborne
infection from patient

46. 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 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.

47. Erich’s Arch Bar

48. Pre-Frabricated, Custom
Made, Acrylated Arch Bar

49. Arch Bars : Preparation
 Check occlusion
 Adjusting the shape

50. Arch Bars : Preparation
Trimming the bar

51. Arch Bars : Preparation
 Symmetric bar position
 Ligature preparation

52. Arch Bars : Preparation
Attaching the bar
Wire end

53. Arch Bars : Preparation
 Make sure the wire rosettes do
not protrude away from the
arch bar as this will be an
irritation to the patient

54. Arch bar fixation
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
15 cm of 26 guage wire is taken and starting
from 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 fracture site
and placed seperately.

55. Inter-maxillary Fixation with
Erich’s arch bar

56. Advantages of Arch Bar
Fixation
 Rigidly splint the teeth
 Provides good retention, stability and support
 Provides cross arch stabilization
 Positioned close to the alveolar bone

57. Disadvantages of Arch Bar
 Bulk of bar
 Plaque accumulation
 Wearing
 Soldering procedure

58. References
 Oral and maxillofacial surgery- Neelima Anil Malik – 3rd
edition
 Oral maxillofacial Surgery- S M Balaji
 Killey’s Fractures of the Mandible- Peter Banks – 4/E
 Mandible Fixation- AO Foundation
 Images- S.M. Balaji’s – Oral maxillofacial surgery, AO
foundation publication