 Using models and materials approximately four times the actual size, the technique of applying intramaxillary multiple-loop wiring is demonstrated. Minimum instrument requirements for this technique include a mouth mirror, a number one woodson plastic instrument, two seven-inch Hegger needle holders, one mosquito hemostat, and one number 150 wire cutter. The materials required include 0.16 inch stainless steel wire, medium-sized rosin core solder, about 10 to 12 gauge, and elastic bands. The technique of applying intramaxillary multiple-loop wiring is demonstrated using models and materials approximately four times the actual size. It is initiated by passing a wire of the desired length through the interproximal space from buckle to palatal. The wire is carried around the distal aspect of the second molar to the buckle surface and anteriorly, well past the last tooth to be included in the wiring. In this case, the canine. This wire is referred to as the horizontal wire. The other end of the single strand of wire is now passed through the same interproximal space, but this time it is above or occlusal to the horizontal wire. A loop is thus formed around the horizontal wire, around the horizontal wire. Lead solder is introduced to form and maintain uniform loops. The wires are tightened. First, the loop is drawn, taught around the solder. Then the horizontal wire is pulled tight around the second molar. The working end, or long end, which is used to form the loops, is now carried back through from palatal to buckle, under the horizontal wire and solder. It is then returned to the palatal aspect over or occlusal to the solder and horizontal wire. The same procedure is repeated through each interproximal space. The wire should be grasped by its end to prevent later breakage from nicks and bends. Following the original wiring technique, the solder is withdrawn from the first loop formed before the third one is completed. Thus, the solder is left in only two loops at a time, and its removal in one piece is easier. All loops are uniform, and the solder is removed. Flat nose pliers, number 104, instead of needle holders, were used in the original technique, in the preliminary twisting together of the horizontal and working wires at the mesial angle of the canine tooth. The horizontal wire is depressed into the interproximal embrasures using a ladmore plugger or any suitable instrument. One length of wire has been used to incorporate five teeth, distinguishing this multiple or continuous loop wiring from other methods. The course taken by the wire as it was applied is demonstrated. Loops are now completed by twisting in a clockwise direction. A three-quarter turn is given each loop. When using brass wire, it is important that these turns be done precisely to avoid breakage. Each loop is in a horizontal plane on completion of the three-quarter turn instead of its original vertical position. An additional one-half turn is given each loop, making a total of one and one-quarter turns. Uniform loops size and tightness at the neck of each tooth results from this standard procedure. If stainless steel wire is used, more tension can be applied and snug adaptation secured without danger of breakage. A total of one and one-quarter turns for each loop is ordinarily sufficient. Further twisting creates a hazard of breakage. Final tightening of the unit is completed. The twisted end is turned upon itself to eliminate the possibility of scratching the labial mucosa. The loops are now turned toward the soft tissue to form hooks, which hold the elastics for traction, reduction of the fracture, and fixation. This is the one-strand continuous multiple loop wiring. The fact that if a wire breaks, an entire section of the appliance is useless and must be replaced, has been considered a disadvantage. Use of stainless steel wire, careful deliberate handling and attention to the technique of application have overcome this single disadvantage. The wiring is uniform and snugly adapted to all teeth. When traction is applied, it will be evenly and widely distributed over the wired area. Occasionally, a tooth is missing or a space must be bridged with wiring. To demonstrate this, a second bicuspid is removed from the lower model. The horizontal wiring and the working or loop forming wire are crossed at an arbitrary point buckled to the tooth anterior to the space. The crossed wires are grasped with a haggar needle holder and the wire twisted down to the mesial buccal aspect of the molar. Tension must be kept on these wires as they are twisted to avoid kinking and breakage. If the wires have been crossed and grasped at the proper place and the twist properly gauged, the exact length of twisted wire will end at the distal buccal aspect of the tooth anterior to the space. The working wire is now carried around the bicuspid. The working wire always passes under the horizontal wire as it is carried to the buccal. A loop is formed between the bicuspid and cuspid. The wiring is tightened. Tension is always applied as these wires are twisted. With tension, no kinks, no breakage. The models are placed in occlusion. Intermaxillary elastic bands are applied to the hooks formed by the loops. The twisted wire bridging a space can often be utilized to afford an additional attachment for the elastic ligature if more evenly distributed traction is desired. A 20-year-old soldier was struck accidentally in the face with a handle of a shovel, sustaining fracture of the right mandible at the angle. Clinical examination reveals slight displacement of occlusion and slight deviation to the right upon opening. There is only slight limitation of opening and no crepitus or demonstrable mobility at the fracture site. There is pain associated with movement of the injured part. A complete fracture of the right mandible is demonstrated at the angle. There is no appreciable displacement. Immobilization by wiring is indicated. Although simple EVIV eyelet loops would probably suffice, continuous multiple loop wiring is applied with equal ease and with this more stability may be achieved. Preoperative medication with one one hundred and fiftieth grains of atrophin sulfate and one and one half grains of second all provides a dry mouth and a cooperative patient. Adequate sedation and a drying effect may also be secured with one hundred milligrams of demoral. Two percent novocaine with one to fifty thousand epinephrine infiltrated locally prevents any discomfort to the patient. Conduction anesthesia may be used if necessary to control pain to the injured part. The working or long end of the wire may be cut at an angle to provide a bevel which in cases where the contact point is broad and flat will facilitate its passage. Curving the end of the wire to simulate a three-eighths curved suture needle allows the end to be passed gingivally to the contact point of the teeth and out without entering the gingiva or cutting and tearing it. Whether the wiring is initiated from buckle or palatal does not matter, but it should be started whether there is less likelihood of injury to the dental papilla. In this case both ends are passed from the palate to buckle. The end emerging from between the second and third molar is carried forward and becomes the horizontal wire. Correct developing kinks before the wire is bent and weakened. The curved working end is passed back to the palatal side through the same interproximal space thus forming the first loop. Lead solder is inserted into the loop and the wire tightened around it. As the curved wire is passed back to the buckle, the assistant lowers the solder and horizontal wire in order that the working end may pass under easily. Note the talkness of the working wire and the counter pressure of the operator's other hand. The curved working end is easily passed back through to the palate and drawn tight. In the original technique the loop forming solder was withdrawn as the wiring progressed. Although demonstrated this technique is no longer recommended unless it is necessary to conserve the supply of solder. A number one Woodson plastic instrument is ideal for seeding the wire under the convexity of a crown. Flat nose pliers may be used to twist the wire ends after they have been cut. A ladmore plastic instrument is used to depress the horizontal wires into the interproximal embrasures prior to twisting the loops. This enabled the operator to twist the loops without becoming entangled with a horizontal wire. Each loop is given a three-quarter turn in a clockwise direction with flat nose pliers. An additional one-half turn is given each loop making a total of one and one-quarter turns. This precise number of turns is important when using brass wire to prevent breakage. Stainless steel wire will tolerate more stress but usually one and a quarter turns will suffice irrespective of the wire used. Final tightening of the ends is accomplished after all loops are formed and twisted. The loops are turned up to form hooks and to prevent irritation to the buckle mucosa. A modification of the original wiring method will be demonstrated on the left side of the maxillary arch. The smaller gauge of lead solder is used so that smaller loops will be formed. Ten gauges desirable. Wiring is begun in the same manner except that in this instance there is no third molar and the horizontal wire is simply looped around the distal aspect of the second molar and carried forward. Loops are formed in the same manner around the smaller size strip of lead solder. The solder and horizontal wire are moved out of the way as the working end is passed between the teeth. The working end of the wire is grasped by its end. Tension is applied. Counter pressure is exerted so that the jaw is not moved by the pull. In this modification the strip of lead solder is not removed as loops are formed. It remains in place until wiring is completed and the ends are twisted. The two ends are crossed and clamped with a 7-inch haggard needle holder. As the wire ends are twisted a continuous pull is applied so that the twist turns down to the tooth smoothly and evenly without kinking. The solder may be turned back to clearly visualize the degree to which the wire must be twisted to ensure a snug adaptation. The ends are cut with a number 150 wire nipper and turned back. With the wire cutters the lead solder is cut and removed from one loop. The loop is flattened slightly. It can now be grasped more easily with a haggard needle holder and twisted evenly as traction is applied. Counter traction with the other hand is exerted and the loop is twisted clockwise to the desired degree. The next section of solder is cut and removed from a loop. If the loop is slightly compressed it is more readily grasped with a force. Remember traction is always applied as the wire is twisted. This prevents kinking and irregularly formed loops. Note the small eyelet formed. The solder may be removed with wire cutters or needle holder with equal ease. The finger of the other hand now provides the counter pressure as traction is applied to the loop and it is twisted. In this instance the loops or eyelets are turned up for the application of intermaximal elastic traction. This small loop may be turned down for the application of intermaximal wires for complete immobilization. Although not essential, utilization of a well-trained assistance materially lessens the operating time and so minimizes trauma to the injured jaw. As the assistant retracts the cheek, the operator is better able to visualize the application of wiring. With the other hand the assistant holds the forceps clamped to the horizontal wire. The working wire is always clamped on its end before it is pulled taught. When the operator tightens wiring about the teeth, counter pressure is exerted with his other hand by firmly holding that part of the jaw upon which traction is being applied. Note the ease and speed with which the curved working end of the wire is passed through the interproximal spaces. After the wire has been passed through the interproximal space, the forceps is repositioned on the wire and final tightening is accomplished holding the wire end in the end of the forceps beak. Thus all bends and twists are pulled out of the wire each time it is passed between the teeth. Counter pressure must be applied each time any pull is made on the working wire. Wiring is thus placed securely without discomfort to the patient or further displacement of the fracture. Completed wiring on all four quadrants clearly illustrates the difference in size of the loops. They are uniformly equal on each side but the loops on the right are too large to be turned occlusally for the application of intermaxillary wires if complete immobilization is desired. Small elastics are applied for reduction and fixation. These are cut from tubing. Orthodontic elastics are too large and too soft for general use and become saliva soaked, losing their elasticity in a short time. The midline is now perfectly aligned. The facets are also in proper relation. Such elastic traction may be replaced by intermaxillary wiring when normal occlusion has been restored and muscular trismus has subsided. In this case complete quadrants have been incorporated in a single strand of stainless steel wire. Since the loops are small they may be turned occlusally and the jaws securely immobilized. Intramaxillary multiple loop wiring is an easy and effective procedure in the treatment of many traumatic injuries of the jaws. Case histories will serve to illustrate certain indications for intramaxillary multiple loop wiring in jaw fractures. In this case with little or no displacement and where immobilization will not be prolonged, this method of wiring is suitable even though there may be moderately advanced periodontosis. The wide disbursement of stress afforded by this method of wiring will allow clinical union without causing exfoliation of the periodontally involved teeth. This method of wiring is ideal as an immediate definitive type of treatment in cases where there is slight to moderate displacement. There was moderate displacement of bilateral fractures of the mandible. Reduction of the fractured parts to good opposition was secured by intermaxillary elastic traction and maintained with intermaxillary wiring. Intramaxillary multiple loop wiring will not suffice in all cases of fracture with moderate displacement. Bilateral fractures with moderate displacement are frequently seen. Removal of a tooth from the line of fracture in the cuspid or synthesis region is often indicated, following which collapse of the mandible may occur. The displacement may be reduced immediately by intramaxillary multiple loop wiring with elastic traction. The patient is made more comfortable immediately when the fracture is immobilized. To prevent crepitation, collapse, and non-union, a splint can be processed and inserted for definitive treatment. Severe displacement of a proximal or ramus fragment may be maintained in a reduced position by the simple application of wiring. In combination with a splint, intramaxillary multiple loop wiring provides absolute immobilization. From the splint, a posterior extension pin may be utilized to maintain complete reduction of the displaced ramus in fractures of the mandible at the angle. Intramaxillary multiple loop wiring may be effective in the early treatment of comminuted fractures of the mandible. In this case of gunshot wound, there is a severe comminuted fracture of the mandible without damage to the teeth. Immediate immobilization of the teeth into occlusion makes the patient more comfortable at once and permits his movement without further damage. During this movement, only one or two intramaxillary elastics are necessary for support. They are readily removed in case of emergency. Supplementary stability by the insertion of a cast-silver-lingual splint provides the final definitive treatment. In this case, another comminuted fracture, intramaxillary multiple loop wiring alone provided sufficient stability. In all cases, manipulation of the injured jaw must be minimal. Union was secured without splinting. Summary. Early oseous union and successful termination of the treatment of jaw fractures is most often dependent upon immediate reduction and fixation of the displaced parts. Intramaxillary multiple loop wiring has a method of treatment in jaw fractures, is simple to apply, provides maximum support. Its use alone may be definitive and it affords immediate emergency stability in cases requiring more definitive measures.