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CRANIOMAXILLOFACIAL TRAUMA

Is There Enough Evidence to Regularly Apply Bone Screws for Intermaxillary Fixation in Mandibular Fractures? Arjan Bins, DDS, PhD,* Marjolijn A. E. Oomens, DDS, MD,y Paolo Boffano, MD,z and Tymour Forouzanfar, DDS, MD, PhDx

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Purpose:

Intermaxillary fixation (IMF) is traditionally achieved with arch bars; however, this method has several well-known disadvantages and other techniques, such as bone screws, are available. This study evaluated current evidence regarding these IMF screws (IMFSs) for mandibular trauma and to assess whether this allows a change of treatment protocol for IMF.

Materials and Methods:

A systematic electronic literature search was conducted in the PubMed, Embase, and Cochrane databases. Titles and abstracts retrieved from the search were screened and evaluated for inclusion and exclusion criteria. The full text of all relevant articles was read and citation lists were checked for any missing references. All randomized controlled trials (RCTs) were subjected to a quality assessment. Included articles were checked for outcome measurements concerning occlusion, operative time, oral hygiene, root trauma, wire-stick injuries, and mucosa overgrowth.

Results:

Twenty-two articles (17 case series, 4 RCTs, and 1 cohort study) were included. None of the RCTs scored high methodologic results in the quality assessment. The results suggest IMFSs have similar malocclusion rates as arch bars, fewer wire-stick injuries, improved oral hygiene, and shorter operative time. Root damage is less likely to occur with self-drilling screws and seldom requires treatment.

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Conclusions: Although the methodologic quality of the included studies is poor, self-drilling IMFSs are recommended for temporary per-operative IMF of noncomminuted mandibular fractures. More highquality studies are required to allow an evidence-based change of protocol. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-7, 2015

The mandible is one of the most fractured anatomic sites resulting from facial trauma, with reported incidences of 24.3 to 75.0%.1,2 Although many studies on mandibular fracture treatment have been published and guidelines exist, treatment modalities often depend on the surgeon’s clinical experience and individual preferences.3 The main goal is to restore premorbid dental occlusion with appropriate bone healing and a normal

mouth opening. To decrease morbidity and lower costs, different techniques have been used.4,5 Traditionally, mandibular fracture treatment has consisted of intermaxillary fixation (IMF) followed by open reduction and internal fixation (ORIF).6 Depending on the location of the fracture (mandibular condyle, angle, body, or symphysis fracture) and the degree of fragmentation, IMF is continued with rigid fixation or elastics.

*Resident, Department of Oral and Maxillofacial Surgery/Oral

Address correspondence and reprint requests to Dr Bins: Depart-

Pathology, VU University Medical Center, Amsterdam, The

ment of Oral and Maxillofacial Surgery/Oral Pathology, VU University

Netherlands.

Medical Center, PO Box 7057, 1007 MB, Amsterdam, The

yResident, Department of Oral and Maxillofacial Surgery/Oral

Netherlands; e-mail: [email protected]

Pathology, VU University Medical Center/Academic Center for

Received January 6 2015

Dentistry Amsterdam (ACTA), The Netherlands. zResearch Associate, Department of Oral and Maxillofacial

Ó 2015 American Association of Oral and Maxillofacial Surgeons

Surgery/Oral Pathology, VU University Medical Center/Academic

0278-2391/15/00369-9

Center for Dentistry Amsterdam (ACTA), The Netherlands.

http://dx.doi.org/10.1016/j.joms.2015.03.072

Accepted March 29 2015

xHead, Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Center/Academic Center for Dentistry Amsterdam (ACTA), The Netherlands.

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IMF screws (IMFSs) are a relatively new method of achieving IMF; they were first described in 1989.7 Since introduced, these screws have undergone several changes in geometry to optimize treatment results. In contrast to self-tapping screws, selfdrilling screws require no predrilling of the screw insertion site. Multiple studies have reported advantages over traditional techniques, such as arch bars.8,9 The use of IMFSs can decrease operative time and costs considerably.10 Other advantages mentioned in the literature are improved oral hygiene, fewer wire-stick injuries, and better acceptance by patients.11-13 On the downside, IMFS are known to cause tooth root damage and screw failure has been reported.14,15 IMFSs can be used A) solely for a temporary peroperative IMF to allow internal fixation (ORIF), B) for an additional postoperative IMF after ORIF for elastic traction, or C) for a prolonged IMF as the main treatment without ORIF. The purpose of this review was to assess whether the current literature regarding IMFSs allows a change of treatment protocol for any of the indications mentioned earlier and to provide recommendations for future research. The authors hypothesized that IMFSs are superior to arch bars in achieving IMF intraoperatively. The specific aims of the study were to measure or compare the most relevant variables of interest for IMFSs, such as stable occlusion, complications, and time to apply.

Materials and Methods STUDY DESIGN

To address the research purpose, the authors performed a systematic literature search of the PubMed, Embase, and Cochrane database. To retrieve the maximum number of relevant studies, the broad search term was used: ((intermaxillary OR maxillomandibular OR transalveolar) AND (screw OR screws)). English was imposed as a restriction filter and no limitation on publishing data was applied. To qualify as a relevant study, studies had to involve mandibular fractures. To be included in the study sample, articles had to involve trauma patients and bone screws had to be used to achieve IMF as described in methods A, B, and C. Randomized controlled trials (RCTs), cohort studies, and case series were included in the study. Excluded were opinion articles, technical notes, review articles, and case reports. Also excluded were studies that did not adequately describe outcome measurements or did not use bone screws by direct wiring. References lists of all full-text articles were screened for any missing relevant articles.

VARIABLES

Outcome measurements were postoperative occlusion, operative time, and oral hygiene. Occlusion was measured as the percentage of patients who presented with postoperative malocclusion. Operative time in minutes was collected from the studies. Objective scoring systems comparing IMFSs with other techniques, such as plaque indices and gingival inflammation scales, assessed oral hygiene. Data on complications concerning root damage, wire-stick injuries, and mucosa overgrowth also were extracted from the studies. Root damage was considered any radiologically, clinically, or histologically confirmed lesion of the teeth roots. Wire-stick injuries concerned any glove- or skin-penetrating injury acquired during surgery. Mucosa overgrowth was measured as the percentage of screws covered by mucosa postoperatively. DATA EXTRACTION METHODS

All data were acquired by carefully reading the included articles and extracting data concerning the outcome measurements directly into an Excel spreadsheet (Microsoft, Redmond, WA). DATA ANALYSES

The included RCTs were evaluated for quality using a form constructed by the Dutch Cochrane Center for evidence-based medicine.16 Two independent investigators graded the methodologic quality of the RCT using this form. If any disagreement existed, a third investigator was consulted. The extracted data on different study outcome measurements were described and, if possible, compared with other techniques, such as arch bars. Pooling of most data was troublesome because of differences in study design, follow-up period, and recording of outcome measurements. This allowed the pooling of data only for root damage results.

Results LITERATURE SEARCH

The search resulted in 549 articles; after correction for duplicates, 324 articles remained. These articles were screened for relevance by reading the titles and abstracts, after which 52 articles remained that met the inclusion criteria. After screening these articles for the exclusion criteria, 28 studies remained and were selected for full-text reading. Also, the references of these 28 articles were read, as were their citations; this yielded no new relevant articles. After reading the full-text articles, 6 additional studies were excluded, leaving 22 studies for final analysis. A flowchart shown in Figure 1 depicts the

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BINS ET AL

FIGURE 1. Flowchart depicting study selection procedure. IMF, intermaxillary fixation.

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Bins et al. Bone Screws for Intermaxillary Fixation. J Oral Maxillofac Surg 2015.

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selection procedure for the articles that were included in the study. Seventeen studies were classified as prospective or retrospective case series, 4 studies were RCTs, and 1 study was a retrospective cohort study. Table 1 presents an overview of all included articles.5,8,9,11-15,17-29 All 4 trials scored poor methodologic results using the form provided by the Dutch Cochrane Center.16 An overview of this assessment of internal validity is presented in Table 2. Because of this lack of quality of the RCTs, their results are not discussed separately from the other studies in this review. All the available literature is described by the studied outcomes.

OCCLUSION

OPERATIVE TIME

Thirteen studies (59.1%) reported operative times when using IMFSs. Gordon et al12 and Fabbroni et al15 described combined operative times for appliance and removal of 25.8 and 15.0 minutes, respectively. Ten studies reported the time to apply the screws, ranging from 4.0 to 20.0 minutes.5,13 Sahoo and Mohan20 and Nandini et al11 were relatively fast, with mean times of 5.0 and 8.5 minutes, respectively. The remaining 6 articles described comparable results ranging from 13.0 to 18.67 minutes.9,10,17,18,23,26 Four studies described the time required for removal of the screws, ranging from 5.8 to 15.0 minutes.10,13,15,17

ORAL HYGIENE AND COMFORT

Fifteen articles (68.2%) presented data concerning postoperative occlusion results. The highest malocclusion rates were reported by Ingole et al,17 with 8.0% (minor) malocclusion at 4 weeks postoperatively. Satish et al18 reported a 1-week postoperative malocclusion rate of 0%, but 1 patient (8.3%) had to change to arch bars at day 3 because of a moderately deranged occlusion. Ansari et al19 reported an overall malocclusion rate of 7.5%, because of posterior mandibular fractures and cases treated with arch bars. Five studies reported no malocclusions, measured at different or unclear postoperative times.5,8,10,13,20 The remaining 7 studies reported malocclusion rates ranging from 1.6 to 4.4%.9,12,14,21-24

Seven studies (31.9%) contained information about oral hygiene during IMFS treatment. Three studies reported only subjective positive results concerning oral hygiene.13,25,26 In the study conducted by West et al,5 a periodontist graded the gingival inflammation using a 3-point Likert scale. All patients scored the most favorable inflammation score in this study. They also measured pain with a 10-cm visual analog scale (VAS), concluding that pain associated with IMFSs was minimal (score, 1.87 points; scale: 0 = no pain, 10 = intolerable pain). Overall reported quality of life based on the ability to carry out daily functions was good (score, 2.2 points; scale: 0 = good function, 10 = poor function).

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Table 1. STUDY OVERVIEW

Study

Study Type

IMF Usage

N

Screw Type

Screws, n

Site

Screw Pattern

Follow-Up

CS CS CS CS CS CS CS CS RCT CS RCT RCT CS CS CS CS CS CS CS CS RCT cohort

A A or B NS A or B or C A or B B or C NS NS B or C C B B or C B or C B or C B or C B B or C B NS A B or C A or B or C

53 36 67 49 54 29 73 15 25 50 10 60 62 40 200 45 12 19 521 23 20 123

SD ST ST SD ST ST NS ST ST SD ST SD ST SD ST ST ST ST ST ST SD ST/SD

NS 278 NS 229 232 116 373 60 104 NS NS 240 265 160 880 180 80 76 1,663 92 124 337/445

MGJ MGJ mucosa MGJ MGJ mucosa MGJ mucosa MGJ MGJ MGJ mucosa MGJ MGJ MGJ mucosa MGJ mucosa NS mucosa MGJ MGJ

$2  2 3-5  3-5 NS $2  2 $2  2 22 2  2 or 3  3 22 2  2 or 3  3 $2  2 NS 22 $2  2 22 $2  2 22 2  2 or 4  4 22 NS 22 3  3 or 4  4 NS

6 wk 3 mo NS 6-8 wk NS 6 wk 6-8 wk NS 4 wk 2 mo 6 wk 6 wk 6 mo 3 mo 6 mo 1 wk 1 wk 1-12 mo 10,3 mo 28-57 days 6 mo 12 mo

Ansari et al19 Bissada et al22 Busch25 Coletti et al14 Fabbroni et al15 Gordon et al12 Hashemi and Parhiz29 Imazawa et al13 Ingole et al17 Laurentjoye et al23 Nandini et al11 Rai10 Roccia et al21 Roccia et al8 Sahoo et al24 Sahoo and Mohan20 Satish et al18 Schneider et al26 Schulte-Geers et al27 Vartanian and Alvi9 West et al5 Widar et al28

Abbreviations: A, per-operative intermaxillary fixation with open reduction and internal fixation; B, postoperative intermaxillary fixation with open reduction and internal fixation; C, prolonged intermaxillary fixation without open reduction and internal fixation; CS, case series; IMF, intermaxillary fixation; MGJ, mucogingival junction; NS, not specified; RCT, randomized controlled trial; SD, self-drilling; ST, self-tapping. Bins et al. Bone Screws for Intermaxillary Fixation. J Oral Maxillofac Surg 2015.

Ingole et al17 measured the plaque index in an IMFS group and a control group with eyelet interdental wiring. Results showed statistically better oral hygiene in the IMFS group than in the control group. Treatment was carried out under local anesthesia and VAS pain scores were measured, showing statistically less pain in the IMFS group. Table 2. QUALITY ASSESSMENT OF RANDOMIZED CONTROLLED TRIALS ACCORDING TO THE DUTCH COCHRANE CENTER16

Nandini et al11 found statistically better oral hygiene, measured by the simplified oral hygiene index by Greene and Vermillion, in an IMFS group compared with an arch bar control group. Questionnaires found statistically better patient acceptance in the IMFS group. Rai et al10 also compared IMFS prospectively with an arch bar control group and stated that the IMFS group had statistically better oral hygiene as measured by the plaque index. ROOT TRAUMA

Ingole Nandini Rai West et al17 et al11 et al10 et al5 Randomization Blinding of randomization Blinding of patients Blinding of surgeons Blinding of interpreter Comparable groups Loss to follow-up Intention-to-treat analysis Comparable treatment

– – – – – – + + +

– – – – – – + + +

– – – – – – + + +

– – – – – + – + +

Bins et al. Bone Screws for Intermaxillary Fixation. J Oral Maxillofac Surg 2015.

Iatrogenic damage to tooth roots is frequently described; 19 studies (86.4%) reported data on this subject. Eleven studies concerning self-tapping screws adequately described the number of patients, the number and type of screws, root damage, and treatment.13,15,17,18,20-22,24,26-28 Five studies described the same data for self-drilling screws.5,8,10,14,28 Table 3 presents these cumulative data, suggesting self-drilling screws have a better safety profile. Nandini et al11 described 10 patients treated with self-tapping screws, of which 3 had radiologic tooth morbidity. Hashemi and Parhiz29 treated 73 patients with 373 undefined bone screws and found 24 teeth

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Table 3. CUMULATIVE ROOT DAMAGE DATA

Patients Screws Root damage Endodontic treatment Extraction Requiring treatment

Self-Tapping

Self-Drilling

Total

1,054 4,263 456 (10.7%) 36 (0.8%)

228 1,090 33 (3.0%) 0

1,355 5,726 513 (9.0%) 41 (0.7%)

4 (0.1%) 40 (0.9%)

2 (0.2%) 2 (0.2%)

14 (0.2%) 55 (1.0%)

Note: Total data also include those of Hashemi and Parhiz29 who did not report screw type. Bins et al. Bone Screws for Intermaxillary Fixation. J Oral Maxillofac Surg 2015.

(6.5%) were damaged. Five (1.3%) required endodontic treatment and 8 (2.1%) were extracted. Two other studies described and reported no incidence of root trauma or tooth loss.19,25 WIRE-STICK INJURY

Eight studies (36.4%) presented data regarding wirestick injury incidences. Five (62.5%) found no cases of wire-stick injury during surgery.9,12,13,22,26 Ingole et al17 and Nandini et al11 compared IMFSs with eyelet interdental wiring and arch bars, respectively, and reported statistically fewer less wire-stick injuries in the IMFS group.11,17 Satish et al18 reported 2 cases (16.7%) of wire-stick injuries using IMFSs. MUCOSA OVERGROWTH

Ten studies (45.5%) provided information on mucosa overgrowth using IMFSs. Gordon et al12 stated nearly all screws became imbedded in the mucosa and Schneider et al26 reported more than half the screws were covered by mucosa. Ingole et al17 reported that 43 screws (41.3%) were partially or totally covered by mucosa and Rai et al10 reported comparable results with 92 screws (38.3%) covered by mucosa after 4 weeks of follow-up.10,17 The remaining 6 studies reported less mucosa overgrowth (range, 1.2 to 6.6%).5,8,18,21,24,29

Discussion Mandibular fracture treatment can be a timeconsuming procedure with a great deal of discomfort for patients.30 Current standards for IMF, such as arch bars, are time consuming and can be damaging to the periodontium and painful during treatment, thus stimulating a growing demand for more costeffective and patient-friendly techniques.4,25,31 This study was conducted to evaluate the evidence supporting IMFSs as a new standard for IMF in

mandibular fracture treatment, hypothesizing that IMFSs are superior to arch bars to achieve intraoperative IMF. A systematic electronic search was performed using the PubMed, Embase, and Cochrane databases. To assess performance of the screws, several outcome measurements were reviewed. The present data suggest IMFSs have a superior profile, especially concerning operative time and oral comfort in patients compared with arch bars for intraoperative IMF in selected cases of noncomminuted mandibular fractures. Although some studies reported correcting minimal occlusal discrepancies by postoperative traction using IMFSs, arch bars seem to have a superior profile when prolonged traction is required. Ansari et al19 found that all patients in the posterior fracture group (12.5%) had malocclusion, suggesting posterior fractures are less favorable owing to anterior screw placement. West et al5 found no cases of malocclusion, which could be explained by their strict exclusion criteria, which included displaced fractures and condylar or subcondylar fractures. Although most studies reported that (sub)condylar fractures benefited less from IMFS treatment, some studies reported very acceptable malocclusion rates (0 to 4.4%) when treating nonsurgical condylar fractures.8,23 However, prolonged postoperative traction can be limited owing to premature screw loosening commonly reported in several studies.5,10,14,17,29 Various studies reported insufficient postoperative traction with IMFSs, sometimes followed by switching to arch bars for the correction of occlusal discrepancies.18,19,21,22 Loss of fixation and risk of additional surgery still seem to be unfavorable conditions for prolonged IMF with IMFSs. Malocclusion rates for mandibular fractures ranged from approximately 3.4 to 6.7% when using techniques as arch bars.6,32 With IMFSs averaging approximately 15 minutes to apply, all studies showed a decrease in operative time compared with the average of 45 minutes for the arch bar appliance.5,11,17,30 Oral hygiene is easier to maintain when less hardware is covering the teeth, resulting in better oral hygiene scores for IMFSs compared with arch bars or interdental wiring.10,11,17,33 Although an overall average incidence of 9.0% for root damage was found, only 0.9% of teeth required endodontic treatment or extraction (Table 1). This in in concordance with the findings of Alves et al34 who concluded in their systematic review that root damage most likely does not exhibit any clinical changes in teeth. Radiographs are often used to identify damage to roots postoperatively, but this could present an under-evaluation because studies showed that histologic analysis might lead to more cases of

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BONE SCREWS FOR INTERMAXILLARY FIXATION

root damage.35,36 Pulp chamber involvement or inflammatory infiltrate are unfavorable for regular healing.37 Self-drilling screws supposedly provide better tactile feedback on insertion, which could explain why the present data show that these screws produce less (3.0%) root damage than self-tapping screws (10.7%).8,14,37 Ayoub and Rowson33 reported a 27% rate of skinpenetrating injuries using arch bars, which is considerably higher than found in IMFS studies. Passing the wires interproximally produces a high risk for wire-stick injuries from an arch bar or Ernst ligature appliance but is not needed for IMFS.38 Most studies describing high rates of mucosa overgrowth placed their screws in the apical mucosal region.10,12,26 Placing screws at the mucogingival junction limits mucosa overgrowth.5,8 IMFSs are useful for simple mandibular fractures, but they are contraindicated for comminuted fractures and in pediatric or severely osteoporotic patients.39 In contrast to arch bars, IMFSs do not reliably approximate fractures and provide no concomitant splinting of the dental arch. Twenty-two studies were included in this review and most case series had limited data. In addition, most studies used a small study population. Four prospective RCTs were included, but none were of high methodologic quality. Taking this into account, the authors can state that the overall level of evidence is poor. Owing to differences in treatment modalities, followup, exclusion criteria, and screw geometry, it is difficult to compare or pool data.5,22,39 Furthermore, the present search might not have retrieved all relevant studies concerning IMFSs and the language restriction for English limits the search. Although this study presents a clear overview of the available evidence concerning IMFSs, the low level of evidence of the included studies and the high risk of bias indicate that the present results are not easily generalized and should be interpreted with caution. In conclusion, the authors can state that when prolonged IMF is needed, functional results for IMFSs seem to be inferior to arch bars, although oral hygiene and comfort are better with IMFSs. IMF using screws for a stable occlusion during surgery seems to have advantages over IMF using arch bars. In selected cases, IMFSs can be useful when costs and operative time need to be decreased. Although there is a lack of high-quality evidence, the authors recommend self-drilling IMFSs for the intraoperative IMF of noncomminuted fractures. Prospective randomized studies comparing IMFSs with other techniques must further determine the evidence to regularly use IMFSs intraoperatively or for postoperative traction.

References 1. Fasola AO, Nyako EA, Obiechina AE, et al: Trends in the characteristics of maxillofacial fractures in Nigeria. J Oral Maxillofac Surg 61:1140, 2003 2. Gassner R, Tuli T, H€achl O, et al: Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 31:51, 2003 3. Nasser M, Pandis N, Fleming PS, et al: Interventions for the management of mandibular fractures. Cochrane Database Syst Rev 7: CD006087, 2013 4. Shetty V, Atchison K, Leathers R, et al: Do the benefits of rigid internal fixation of mandible fractures justify the added costs? Results from a randomized controlled trial. J Oral Maxillofac Surg 66:2203, 2008 5. West GH, Griggs JA, Chandran R, et al: Treatment outcomes with the use of maxillomandibular fixation screws in the management of mandible fractures. J Oral Maxillofac Surg 72:112, 2014 6. van den Bergh B, Heymans MW, Duvekot F, et al: Treatment and complications of mandibular fractures: A 10-year analysis. J Craniomaxillofac Surg 40:108, 2012 7. Arthur G, Berardo N: A simplified technique of maxillomandibular fixation. J Oral Maxillofac Surg 47:1234, 1989 8. Roccia F, Rossi P, Gallesio C, et al: Self-tapping and self-drilling screws for intermaxillary fixation in management of mandibular fractures. J Craniofac Surg 20:68, 2009 9. Vartanian AJ, Alvi A: Bone-screw mandible fixation: An intraoperative alternative to arch bars. Otolaryngol Head Neck Surg 123: 718, 2000 10. Rai A, Datarkar A, Borle R: Are maxillomandibular fixation screw a better option than Erich arch bar in achieving maxillomandibular fixation? A randomized clinical study. J Oral Maxillofac Surg 69:3015, 2011 11. Nandini GD, Balakrishna R, Rao J: Self tapping screws v/s Erich arch bar for inter maxillary fixation: A comparative clinical study in the treatment of mandibular fractures. J Maxillofac Oral Surg 10:127, 2011 12. Gordon KF, Reed MJ, Anand VK: Results of intraoral cortical bone screw fixation technique for mandibular fractures. Otolaryngol Head Neck Surg 113:248, 1995 13. Imazawa T, Komuro Y, Inoue M, et al: Mandibular fractures treated with maxillomandibular fixation screws (MMFS method). J Craniofac Surg 17:544, 2006 14. Coletti DP, Salama A, Caccamese JF Jr.: Application of intermaxillary fixation screws in maxillofacial trauma. J Oral Maxillofac Surg 65:1746, 2007 15. Fabbroni G, Aabed S, Mizen K, et al: Transalveolar screws and the incidence of dental damage: A prospective study. Int J Oral Maxillofac Surg 33:442, 2004 16. The Dutch Cochrane Center, 2014. Available at: http://dcc. cochrane.org/sites/dcc.cochrane.org/files/uploads/RCT.pdf. Accessed August 27, 2014. 17. Ingole PD, Garg A, Shenoi SR, et al: Comparison of intermaxillary fixation screw versus eyelet interdental wiring for intermaxillary fixation in minimally displaced mandibular fracture: A randomized clinical study. J Oral Maxillofac Surg 72:958, 2014 18. Satish M, Rahman NM, Reddy VS, et al: Use of cortical bone screws in maxillofacial surgery—A prospective study. J Int Oral Health 6:62, 2014 19. Ansari K, Hamlar D, Ho V, et al: A comparison of anterior vs posterior isolated mandible fractures treated with intermaxillary fixation screws. Arch Facial Plast Surg 13:266, 2011 20. Sahoo NK, Mohan R: IMF screw: An ideal intermaxillary fixation device during open reduction of mandibular fracture. J Maxillofac Oral Surg 9:170, 2010 21. Roccia F, Tavolaccini A, Dell’Acqua A, et al: An audit of mandibular fractures treated by intermaxillary fixation using intraoral cortical bone screws. J Craniomaxillofac Surg 33:251, 2005 22. Bissada E, Abou-Chacra Z, Ahmarani C, et al: Intermaxillary screw fixation in mandibular fracture repair. J Otolaryngol Head Neck Surg 40:211, 2011

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23. Laurentjoye M, Majoufre-Lefebvre C, Siberchicot F, et al: Result of maxillomandibular fixation using intraoral cortical bone screws for condylar fractures of the mandible. J Oral Maxillofac Surg 67:767, 2009 24. Sahoo NK, Sinha R, Menon PS, et al: Retrospective study on efficacy of intermaxillary fixation screws. Med J Armed Forces India 65:237, 2009 25. Busch RF: Maxillomandibular fixation with intraoral cortical bone screws: A 2-year experience. Laryngoscope 104:1048, 1994 26. Schneider AM, David LR, DeFranzo AJ, et al: Use of specialized bone screws for intermaxillary fixation. Ann Plast Surg 44:154, 2000 27. Schulte-Geers M, Kater W, Seeberger R: Root trauma and tooth loss through the application of pre-drilled transgingival fixation screws. J Craniomaxillofac Surg 40:214, 2012 28. Widar F, Kashani H, Kanagaraja S, et al: A retrospective evaluation of iatrogenic dental root damage with predrilled vs drill-free bone anchor screws for intermaxillary fixation. Dent Traumatol 28:127, 2012 29. Hashemi HM, Parhiz A: Complications using intermaxillary fixation screws. J Oral Maxillofac Surg 69:1411, 2011 30. Fordyce AM, Lalani Z, Songra AK, et al: Intermaxillary fixation is not usually necessary to reduce mandibular fractures. Br J Oral Maxillofac Surg 37:52, 1999 31. Hsu E, Crombie A, To P, et al: Manual reduction of mandibular fractures before internal fixation leads to shorter operative

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duration and equivalent outcomes when compared with reduction with intermaxillary fixation. J Oral Maxillofac Surg 70:1622, 2012 Moreno JC, Fernandez A, Ortiz JA, et al: Complication rates associated with different treatments for mandibular fractures. J Oral Maxillofac Surg 58:273, 2000 Ayoub AF, Rowson J: Comparative assessment of two methods used for interdental immobilization. J Craniomaxillofac Surg 31:159, 2003 Alves M Jr., Baratieri C, Ara ujo MT, et al: Root damage associated with intermaxillary screws: A systematic review. Int J Oral Maxillofac Surg 41:1445, 2012 Asscherickx K, Vannet BV, Wehrbein H, et al: Root repair after injury from miniscrew. Clin Oral Implants Res 16:575, 2005 Chen YH, Chang HH, Chen YJ, et al: Root contact during insertion of miniscrews for orthodontic anchorage increases the failure rate: An animal study. Clin Oral Implants Res 19:99, 2008 Brisceno CE, Rossouw PE, Carrillo R, et al: Healing of the roots and surrounding structures after intentional damage with miniscrew implants. Am J Orthod Dentofacial Orthop 135:292, 2009 Avery CME, Johnson PA: Surgical glove perforation and maxillofacial trauma: To plate or wire? Br J Oral Maxillofac Surg 30:31, 1992 Cornelius C, Ehrenfeld M: The use of MMF screws: Surgical technique, indications, contraindications and common problems in review of the literature. Craniomaxillofac Trauma Reconstr 3:55, 2010

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Is There Enough Evidence to Regularly Apply Bone Screws for Intermaxillary Fixation in Mandibular Fractures?

Intermaxillary fixation (IMF) is traditionally achieved with arch bars; however, this method has several well-known disadvantages and other techniques...
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