Intermaxillary fixation (arch bars / IMF screws)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• jaws held together: liquid diet, difficulty speaking, weight loss
• choking or airway block if vomiting while wired (wire cutters kept at bedside)
• gum inflammation and injury from wires
• damage to tooth roots or the lower lip nerve from IMF screws
• loose or broken wires needing re-tightening
• bite not exactly as before (malocclusion)
• stiff jaw or reduced mouth opening after release
• need for open reduction and plating if the fracture does not stay reduced

Pre-operative details for this operation

1. IndicationClosed treatment of mandible fractureCondylar fracture (closed treatment)With ORIF (occlusion before plating)Temporary / first aidfracture site(s), displacement, favourable or not
2. Pre-injury occlusion and present occlusionpatient's own account; premature contact, open bite, deviation, midline
3. Mouth openinginter-incisal distance in mm
4. Dentitionmissing, mobile, carious or periodontally weak teeth; enough teeth in each quadrant?
5. ImagingOPGPA mandibleCT facefor IMF screws: roots and unerupted teeth at planned screw sites
6. Other facial fractures and head injurymidface fracture? head injury cleared?
7. Conditions that make IMF riskyepilepsy, alcohol use, asthma / chest disease, vomiting risk, poor compliance
8. Lower lip and chin sensationNormalReduced (side)

Anaesthesia and position

1. AnaesthesiaGA, nasotracheal tubeGA, submental intubation
2. Throat packPlaced
3. Positionsupine, head ring
4. Oral preparationantiseptic used for the mouth and face

Operative findings

1. Fracture mobility on examination under anaesthesiasite, mobile / not mobile
2. Occlusion obtainedPre-injury occlusion obtainedNear normal occlusionCould not be obtainedmolar relation, midline
3. Teeth in fracture linekept / extracted (which tooth, why)
4. Gingival or mucosal tearssite, sutured?

Procedure (steps)

1. Mouth cleaned, throat pack in place
2. Fixation deviceErich arch barsHybrid (screw-retained) arch barsIMF screwsIMF hooks / Leonard buttonsEyelet / tie wires
3. Upper arch barextent by tooth number, e.g. 16 to 26; hooks pointing upward
4. Lower arch barextent by tooth number, e.g. 36 to 46; hooks pointing downward
5. Circumdental wires24-gauge stainless steel26-gauge stainless steelplaced below the cingulum / around the tooth necks; incisors included or left out; wire ends turned in away from the gum and lip
6. IMF screws (if used)number, sites (between which roots), length; self-drilling, both cortices engaged; clear of the inferior alveolar nerve
7. Fracture reducedManual reductionNot needed (undisplaced)
8. Teeth brought into occlusioncheck molar relation and midline
9. IMF appliedWires (gauge, number of loops)Heavy elastics (number, sites)Light guiding elasticselastics rather than wires for condylar fractures; not so tight that the condyles are pulled out of the fossa
10. Occlusion and stability recheckedwires re-tightened, sharp ends tucked

Closure, drains and dressing

1. Mucosal or gingival tears suturedsuture used, or none
2. Throat pack removed and counted
3. Oropharynx suctioned; airway plan for extubationextubated awake / kept intubated; IMF released or elastics applied after extubation?
4. Wire cutter / scissors sent with patientYes
5. Pressure dressing / iceif applied

Specimens and implants

1. Arch barstype, number, make, lot number
2. IMF screwsnumber, diameter and length, make, lot number; sticker pasted
3. Extracted toothNoneDiscarded as anatomical wasteSent for HPE

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Airwaywire cutter / scissors at bedside at all times; nurse told which wires or elastics to cut if vomiting or airway block
2. Antiemeticdrug and dose; treat nausea early
3. Iceto the fracture site for the first 24 hours
4. Dietdiet ordered; nutrition consult if MMF is planned for more than 2 weeks
5. Oral hygienemethod and frequency as per unit protocol
6. Analgesia and antibioticdrug, dose, duration
7. Check X-rayOPG after IMF
8. Follow-upreview at 1, 3 and 6 weeks; check wires and occlusion each time
9. Release planplanned duration of IMF; guiding elastics and mouth-opening exercises after release; arch bar removal date

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery