I read the article ‘Atraumatic placement of circummandibular wires: a technical note’ by T homas & Y uvaraj with great interest. The technique described by the authors using intravenous catheter stylet is not new and being practiced by many surgeons for many decades now. I learnt this technique during my residency in 1991 from my teachers Prof. J.N. Khanna and Prof. Neelima A. Malik at Nair Hospital Dental College, Mumbai, India. I vividly remember when Prof. Malik took table demonstration to explain this technique to us, a group of trainees, in great detail. She taught us how to use intravenous catheter stylet/lumbar puncture needle/spinal needle to pass circummandibular wires, how to remain close to bone to avoid damage to submandibular duct and other structures, and how to take care of puncture wound. My teachers never claimed it to be their technique and probably they had learnt it from their seniors and colleagues. I have been practicing this technique for 16 years and must have treated more than 150 cases. I have taught this technique to many maxillofacial surgery residents, Plastic surgeons and paediatric dentists. There can be a number of variations for this technique such as:
A double wire can be passed instead of single strand of wire that provides more stability to splint. In this way instead of passing three circummandibular wires, two wires can suffice preventing additional puncture site in midline.
A vertical groove can be made on the buccal aspect of acrylic splint which prevents slippage of wire.
There can be a number of variations in acrylic splint design like full coverage of teeth or partial coverage of teeth with occlusal aspect uncovered. There can be distal extension of the splint around the last molar teeth with just 18 G stainless steel wire without acrylic, thus allowing the patient to occlude properly.
This same technique, I have been using in selected undisplaced edentulous mandible fracture cases in elderly patients. In cooperative patients circummandibular wires can be passed under local anaesthesia. I have been using same stylet/lumbar puncture needle to pass circumzygomatic suspension wires in selected cases of maxillary fracture.
Another important aspect which authors have not discussed is removal of circummandibular wires. The mouth should be irrigated thoroughly before attempting removal to remove debris and plaque around wires. The wires during removal should be cut after slightly pulling, cutting it at that portion which was earlier embedded inside the soft tissue, to prevent wire tract infection. Infection can occur either immediately after insertion or on removal of wires. I have observed infection in six cases treated with this technique. In three cases infection occurred immediately after insertion, and in three cases immediately after removal of wires. Out of these six cases, three required incision and drainage to control infection.
These days’ trainees are not getting enough exposure to wire suspension techniques, external fixation techniques and various wiring methods of maxillomandibular fixation in trauma management, as more stress is being given to internal fixation techniques with bone plates. These older methods of maxillofacial fracture management still have a role in selected cases and it is the duty of senior surgeons to pass on the traditional knowledge to younger generation.