DOI: 10.

17354/ijss/2015/442
Origina l A rti cl e

Role of Oral Prophylaxis with the Use of Erich Arch

Bars: A Randomized Controlled Trial
Parveen Akhter Lone1, Mohan Singh2, Varun Salgotra3, Harpreet Singh Johar4
1
Associate Professor, Department of Oral & Maxillofacial Surgery, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir,
India, 2Medical Superintendent Government Dental Hospital, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir, India,
3
Registrar, Department of Oral & Maxillofacial Surgery, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir, India, 4House
Surgeon, Department of Oral & Maxillofacial Surgery, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir, India

Abstract
Introduction: In the management of maxillofacial fractures intermaxillary fixation (IMF) is the basic and fundamental principle.
Various commonly used techniques for IMF include arch bars and various dental wirings. The aim is to report gingival inflammatory
changes after applying arch bars and reversal of inflammatory changes after removal of arch bars.
Materials and Methods: Patients were divided into two groups, Group A and Group B depending on the treatment plan indicated.
In Group A, 50 patients were treated with closed reduction and IMF was kept for 4-6 weeks. In Group B, 50 patients treated
with open reduction and internal fixation on Champy’s line of osteosynthesis under general anesthesia and the arch bar was
kept for 10 days. Half of the subjects of each group received the oral prophylaxis at the time of arch bar removal (Group A1
and Group B1). The patients were examined for injury to gums and cheek, avulsion of teeth and wire injuries to the operator
and assistant including needle stick injuries, perforation of gloves, fetid odor, coated tongue, iatrogenic injury to adjacent teeth,
orthodontic movement of teeth, ischemic necrosis of the periodontium and mucosa, oral hygiene index simplified, Papillary
bleeding index, and Russel periodontal index.
Results: Orthodontic tooth movement, iatrogenic injury to adjacent teeth and ischemic necrosis of the periodontium and mucosa
was reported with no statistical significant difference between groups and subgroups. There was a statistical significant difference
in oral hygiene index-simplified, papillary bleeding index and Russel periodontal index between the patients in Group A1 and
A2 and also between Group B1 and B2.
Conclusion: As per the observations of this study all the patients with arch bars suffer from gingival and periodontal injuries,
so it is recommended that oral prophylaxis after removal of arch bar should always be done for early recovery of gingival and
periodontal recovery.

Key words: Erich arch bar, Gingival inflammation, Maxillofacial injuries, Oral prophylaxis

INTRODUCTION etc. Arch bars have been used widely for management of
maxillomandibular injuries since World War 1.1,2 Carl3 in
The principles of management of fractures of hard Germany and Gilmer4 in the United States used ordinary
tissues are reduction, fixation, and immobilization of the round bar which was ligated to teeth with bass ligation
bony fragments. Mandibular fractures can be treated by wires. Blair and Ivy5 modified and flattened one side about
closed reduction (intermaxillary fixation [IMF]) and open 2 mm in width for better adaptation to dental arches for
reduction (osteosynthesis with or without IMF). IMF can greater stability, little has changed since the introduction
be achieved by eyelets, arch bars, and glimmers wiring, of arch bars. Application of arch bars with circumdental
Access this article online wiring is the most preferred method for IMF. Wire is passed
around the teeth for fixation of arch bars. This causes
Month of Submission : 08-2015 gingival and periodontal injuries, difficulty in maintaining
Month of Peer Review : 09-2015 the oral hygiene, threat to percutaneous injury to operator
Month of Acceptance : 10-2015 or assistant by wire ends, mucosal ulcerations orthodontic
Month of Publishing : 10-2015 movement of anterior teeth if mot adapted properly, high
www.ijss-sn.com
chances of serological transfer of pathogens like hepatitis
Corresponding Author: Dr. Parveen Akhter Lone, Department of Oral & Maxillofacial Surgery, Indira Gandhi Government Dental College,
Amphalla, Jammu, Jammu and Kashmir, India. Phone: +91-9419203131. E-mail: [email protected]

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 Lone, et al.: Oral Prophylaxis after Arch Bars

B virus, hepatitis C virus, and HIV.6,7 The introduction of

bone plating has reduced the prolonged periods of IMF.
However, there is need of temporary IMF intraoperatively
to assist reduction of fracture with teeth in occlusion and
post-operatively to correct minor occlusal discrepancies.
So, we decided to conduct a study at our tertiary care
institute to note the incidences of iatrogenic injuries and
complications/problem associated with the Erich arch
bar and to evaluate the need of oral prophylaxis after the
arch bar removal.

Figure 1: Erich arch bar placement

MATERIALS AND METHODS
The study group consisted of 100 patients of trauma
with history of RTA, fall, violence, etc., having fracture
mandible and dentoalveolar region who reported to the
Department of Oral and Maxillofacial Surgery, Indira
Gandhi Government Dental College, Jammu and required
IMF as part of treatment plan. After taking informed
consent, clinical and radiographic examination of the
patients was done and treatment plan formulated. Patients
were divided into two groups, Group A and Group B
depending on the treatment plan indicated. In Group A,
50 patients were treated with closed reduction and IMF was
kept for 4-6 weeks. In Group B, 50 patients treated with Figure 2: Gingival laceration after arch bar removal

Open Reduction and Internal Fixation on Champy’s line

of osteosynthesis under general anesthesia, and arch bar
was kept for 10 days. Randomly, half of the subjects of
both the groups received the oral prophylaxis at the time
of arch bar removal (Group A1 and Group B1) while in
the other half no oral prophylaxis was advised (Group A2
and Group B2). The Erich Arch bars were placed using
circumdental wiring and removed by a single team of
operator and assistant who were blinded of the groups
(Figure 1). The patients were examined for injury to gums
and cheek, avulsion of teeth during arch bar placement
and wire injuries to the operator and assistant including
needle stick injuries, perforation of gloves at the time of Figure 3: Periodontal inflammation after arch bar removal

arch bar placement. On the day of arch bar removal fetid

odor, coated tongue, iatrogenic injury to adjacent teeth,
orthodontic movement of teeth, ischemic necrosis of the
periodontium and mucosa, wire injuries to the operator and
assistant were noted (Figures 2 and 3). Oral hygiene index
simplified (OHI-S),8 papillary bleeding index9 and Russel
periodontal index10,11 was evaluated on 15th day, post arch
bar removal (Figure 4).

RESULTS
Of the 100 patients treated 82 were males and road traffic Figure 4: 15th day after arch bar removal
accidents was the most common cause of fractures. The
mean age of the patients was 29.2 years, and the most angle and condyle. There was no statistical significant
common fracture site was parasymphysis followed by difference in both the groups and subgroups based on

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 Lone, et al.: Oral Prophylaxis after Arch Bars

age, gender, etiology or site of the fracture. Almost all

the patients in both group and subgroups had injuries to
gums and cheeks during the arch bar placement (Table 1
and Graph 1). One patient in Group A1 had an avulsion
of teeth which was implanted back into the socket and
after 3 months Root canal treatment was done. The needle
stick injury to operator and/or assistant was reported in
2 patients in Group A1, 4 patients in Group A2, 2 patients
in Group B1 and 3 patients in Group B2 (Table 2 and
Graph 2). The glove perforation of operator and/or
assistant was reported in the remaining patients during arch
bar placement. No needle stick injury was reported during Graph 1: Injury to gums and cheek
arch bar removal. 100% of the patients in Group A1 and A2,
and 92% in Group B1, and 96% in Group B2 reported
coated tongue. The halitosis was reported 80% and 82%
in Group A1 and A2, respectively, and 72% and 64% in
Group B1 and B2, respectively (Table 3 and Graphs 3-5).
Orthodontic tooth movement, iatrogenic injury to adjacent
teeth and Ischemic necrosis of the periodontium and
mucosa was also reported with no statistical significant
difference between groups and subgroups. There was a
statistical significant difference in OHI-S, papillary bleeding
index and Russel periodontal index between the patients in
Group A1 and A2 and also between Group B1 and B2. The
patients whose oral prophylaxis were done at the time of
arch bar removal reported better OHI-S, papillary bleeding Graph 2: Needle stick injury to operator and/or operator,
perforation of gloves
index, and periodontal index in both Group A and Group B.

Table 1: Arch bar placement

Injury to gums Avulsion Wire injuries to the operator and
and cheeks of teeth assistant, perforation of gloves
Group A
1
23 1 7
2
22 0 12
Group B
1
24 0 9
2
23 0 8
Graph 3: Oral hygiene index - simplified

Table 2: Day of arch bar removal

Fetid Coated Iatrogenic injury Orthodontic Ischemic necrosis of the Wire injuries,
odor tongue to adjacent teeth movement of teeth periodontium and mucosa perforation of gloves
Group A
1
20 25 3 3 2 3
2
21 25 1 2 3 0
Group B
1
18 23 0 1 1 1
2
16 24 1 0 3 1

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 Lone, et al.: Oral Prophylaxis after Arch Bars

of blood-borne diseases, maintain proper oral hygiene in

Table 3: 15 days post arch bar removal
order to reduce gingival and periodontal diseases, prevent
Oral hygiene - OHI-S Gingival Gingival inflammation injuries to adjacent and supporting structures, reduce
bleeding - papillary and periodontal
bleeding index disease - periodontal operating time, and hospital costs.2,12,13 The treatment of
index (Russel) maxillofacial fractures involve different methods from
Group A bandages and splinting to methods of open reduction and
1 internal fixation, requiring control of the dental occlusion
71.25/25=2.85 48/25=1.92 78/25=3.12
with the help of IMF with the traditional methods.2 Various
2
105.5/25=4.22 65/25=2.6 113/25=4.52 methods have been used for IMF in the management of
Group B mandibular fractures. The most common technique is to
1 use eyelets or arch bars. The Erich arch bars have been used
47.5/25=1.9 27/25=1.08 46/25=1.84
2
mainstay in management of maxilla mandibular fractures
97.5/25=3.9 45/25=1.8 81/25=3.24 since World War 1.1
OHI-S: Oral hygiene index simplified
The most common and trusted method for mandibular
fracture is the application of Erich arch bar for IMF with
the help of circumdental wiring, yet circumdental wiring
has its own shortcomings. Nevertheless, it has following
disadvantages: wires have to pass below the gingival
margin to guarantee stability, chances of gingival injury
are more and compromises the health of periodontium,
rounded wire edges collects food debris and causes gingival
inflammation and difficulty in maintaining oral hygiene
result in fetid breath.1

Most of our patient had injuries to gums and cheeks

during the arch bar placement. During arch bar placement,
Graph 4: Papillary bleeding index optimum tension, and stable placement is a difficult task,
breakage of wires during and after placement of wire is
not uncommon which encounter instability of appliances.
Passing of dental wires in patient with reduced mouth
opening was also difficult. While passing of the wires and
manipulating the fracture fragments, there was incidences
of accidental pricking of the wire end to the hands of the
operator or the assistant, and perforation of gloves. The
most common site for perforation of gloves is the non-
dominant hand. The similar finding were also reported
in other studies.14,15 The rounded wire edges collected
food debris and caused gingival inflammation and there
was difficulty in maintaining oral hygiene which result in
fetid breath and coated tongue. Few patients also reported
Graph 5: Russel periodontal index the orthodontic tooth movement. The ill-fitting of Erich
arch bar and over tightening of wires caused orthodontic
DISCUSSION movement of anterior teeth. Ischemic necrosis of the
periodontium and mucosa and injury to adjacent teeth was
The management of maxillofacial injuries remains one possibly caused by the tension of the wire and the pressure
of the most demanding and rewarding aspect of surgery inserted on the gums. There was also an avulsion of tooth
because the patients with maxillofacial injuries not only because of application of inadvertently excessive force on
suffer from physical agony but slight disfigurement can the mobile tooth. Recent studies have reported needle-stick
become an emotional distress for his whole life.1 The injuries, the high plaque index, periodontal damage, and
main goals in successfully treating mandibular fractures movement of the teeth in lateral and extrusive direction.2,16-20
include reduction, fixation and immobilization and
achieving proper dental occlusion. It is also important to In our study, the patients in who oral prophylaxis was
use techniques that reduce the percutaneous transmission advised after the arch bar placement reported better oral

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 Lone, et al.: Oral Prophylaxis after Arch Bars

hygiene. The patients reported better scores of OHI-S, for inter maxillary fixation: A comparative clinical study in the treatment of
mandibular fractures. J Maxillofac Oral Surg 2011;10:127-31.
papillary bleeding index and Russel periodontal index in 3. Carl S. Deutsch monatsh. Zahnheilkd 1889;7:381.
both Group A and Group B in which oral prophylaxis 4. Gilmer TL. Lecturers in oral surgery. Chicago: ???; 1901.
have been performed. No previous study has evaluated 5. Blaire VP, Ivy RH. Essential of Oral Surgery. 4th ed. St. Louis: Mosby Co.;
1951. p. 171.
the oral hygiene and periodontal health indices with Erich 6. Gooch BF, Siew C, Cleveland JL, Gruninger SE, Lockwood SA,
arch bar placement and the role of use of oral prophylaxis Joy ED. Occupational blood exposure and HIV infection among oral and
in improving the oral hygiene of the patient. During the maxillofacial surgeons. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1998;85:128-34.
period of IMF, there was difficulty in maintaining the
7. Yamada T, Sumi Y, Okazaki Y, Ueda M. A new inter-maxillary fixation
oral hygiene, which resulted in coated tongue, fetid odor, method using adhesive cast splints for avoiding skin puncture. Aust Dent J
calculus and debris deposition which has detrimental 1998;43:167-9.
effect on the periodontium. The oral prophylaxis at the 8. Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent
Assoc 1964;68:7-13.
time arch bar removal of seems to reverse or reduce these 9. Saxer UP, Miihlemann HR. Motivation und aufklh lrung. Schweiz
effects. However, we did not evaluate the pre-operative Monatsschr Zahnheilkd 1975;85:905-19.
OHI-S, periodontal index or papillary bleeding index, the 10. Russell AL. A system of classification and scoring for prevalence surveys of
periodontal disease. J Dent Res 1956;35:350-9.
damage to periodontium/degradation of oral health with 11. Russell AL. The periodontal index. J Pedodontol 1967;38:586-91.
the placement of Erich arch bar could not be assessed. 12. Vartanian AJ, Alvi A. Bone-screw mandible fixation: An intraoperative
alternative to arch bars. Otolaryngol Head Neck Surg 2000;123:718-21.
13. Gordon KF, Reed JM, Anand VK. Results of intraoral cortical bone screw
CONCLUSION fixation technique for mandibular fractures. Otolaryngol Head Neck Surg
1995;113:248-52.
14. Gaujac C, Ceccheti MM, Yonezaki F, Garcia IR Jr, Peres MP. Comparative
As per the observations of this study all the patients with analysis of 2 techniques of double-gloving protection during arch
arch bars suffer from gingival and periodontal injuries, bar placement for inter-maxillary fixation. J Oral Maxillofac Surg
2007;65:1922-5.
so it is recommended that oral prophylaxis after removal 15. Pieper SP, Schimmele SR, Johnson JA, Harper JL. A prospective study of
of arch bar should always be done for early recovery of the efficacy of various gloving techniques in the application of Erich arch
gingival and periodontal recovery. However, further studies bars. J Oral Maxillofac Surg 1995;53:1174-6.
16. Falci SG, Douglas-de-Oliveira DW, Stella PE, Santos CR. Is the Erich arch
are required in which pre-operative evaluation and their
bar the best intermaxillary fixation method in maxillofacial fractures? A
comparison with final periodontal health can be made to systematic review. Med Oral Patol Oral Cir Bucal 2015;20:e494-9.
correctly assess the periodontal damage with the arch bar 17. Ghazali N, Benlidayi ME, Abizadeh N, Bentley RP. Leonard buttons:
placement. A reliable method of intraoperative intermaxillary fixation in bilateral
mandibular fractures. J Oral Maxillofac Surg 2012;70:1131-8.
18. Rai A, Datarkar A, Borle RM. Are maxillomandibular fixation screws a
better option than Erich arch bars in achieving maxillomandibular fixation?
REFERENCES A randomized clinical study. J Oral Maxillofac Surg 2011;69:3015-8.
19. Ayoub AF, Rowson J. Comparative assessment of two methods used for
1. Chandan S, Ramanojam S. Comparative evaluation of the resin bonded interdental immobilization. J Craniomaxillofac Surg 2003;31:159-61.
arch bar versus conventional Erich arch bar for intermaxillary fixation. 20. Park KN, Oh SM, Lee CY, Kim JY, Yang BE. Design and application of
J Maxillofac Oral Surg 2010;9:231-5. hybrid maxillomandibular fixation for facial bone fractures. J Craniofac
2. Nandini GD, Balakrishna R, Rao J. Self-tapping screws v/s. erich arch bar Surg 2013;24:1801-5.

How to cite this article: Lone PA, Singh M, Salgotra V, Johar HS. Role of Oral Prophylaxis with the Use of Erich Arch Bars:
A Randomized Controlled Trial. Int J Sci Stud 2015;3(7):18-22.

Source of Support: Nil, Conflict of Interest: None declared.

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