## INTRODUCTION

The evaluation and management of the airway is a crucial component of any critically ill medical or trauma patient. Any airway has the potential to be challenging. Certain situations complicate our standard approach to securing the airway and warrant attention. Mandibular and maxillofacial trauma complicate the standard approach to securing an airway. Patients presenting with hardware in place due to previous mandibular and/or maxillofacial fixation and requiring airway protection and/or intubation represent a potentially challenging situation. The technique for emergent mandibular and/or maxillofacial fixation release to facilitate airway rescue will be discussed in this chapter.

## ANATOMY AND PATHOPHYSIOLOGY

Dental anatomy differs between pediatric and adult populations (Chapter 215). Variations among individuals are not uncommon. The basic anatomy of a tooth consists of the crown covered with enamel which sits above the gum line. The tooth root is embedded in the alveolar bone. The fully formed root apex present in adult patients consists of alveolar bone, periodontal ligament fibers, and the cementum cell layer.

The musculoskeletal anatomy of the mandible and maxilla is shown in Figure 216-1. Fractures of the mandible and/or maxilla can occur at several different locations (e.g., alveolar ridge, alveolar process, body, angle, and symphysis). The mandibular condyle interacts with the articular fossa of the maxilla to form the temporomandibular joint. The zygomatic process connects to the body of the maxilla superior to the alveolar process. Mandibular or maxillofacial trauma can cause instability at any of these sites.

Mandibular fixation with arch bars consists of a series of wires. These wires run horizontally across the alveolar bone of the mandible and maxilla to fixate and stabilize the dental arches (Figure 217-1). There are also vertical wires connecting the maxilla and mandible to eliminate any mandibular opening and closing motion (Figure 217-2). Cut the vertical fixation wires in the setting of airway compromise to facilitate emergent airway access or significant vomiting that may result in aspiration. The horizontal running arch bars are not involved in jaw separation and should be left intact.

###### FIGURE 217-1.

Arch bar horizontal fixation apparatus. (Courtesy of Phuc Ba Duong, DDS.)

###### FIGURE 217-2.

Arch bar complete horizontal and vertical fixation apparatus. (Courtesy of Phuc Ba Duong, DDS.)

The fixation technique (i.e., arch bars) used to stabilize mandibular and maxillary fractures carries a significant associated expense.1 This depends on the facility and specialist placing the hardware. The mean total charges can range from $13,000 to over$25,000. It can take between 0.6 to 1.4 hours to place arch bars depending on the specific injury.

## INDICATIONS

The decision to remove the hardware calls for careful consideration of the ...

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