|Year : 2019 | Volume
| Issue : 1 | Page : 28-34
Voluntary jaw wiring in Nigeria: Reasons and treatment outcome
Mark C Nwoga1, Samuel N Maduakor2, Appolos C Ndukuba3
1 Oral Pathology Unit, Department of Oral and Maxillofacial Surgery, University of Nigeria, Nsukka, Enugu, Nigeria
2 Department of Preventive Dentistry, Faculty of Dentistry, University of Nigeria, Nsukka, Enugu, Nigeria
3 Department of Psychiatric Medicine, Faculty of Medical Sciences, University of Nigeria, Nsukka, Enugu, Nigeria
|Date of Web Publication||1-Aug-2019|
Dr. Mark C Nwoga
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ituku-Ozalla Campus, University of Nigeria, Nsukka, Enugu
Source of Support: None, Conflict of Interest: None
Background: Overweight and obese dental patients occasionally request jaw wiring. Aim: The aim of this study was to determine the reasons for requesting jaw wiring and to evaluate the outcome of the procedure. Materials and Methods: This is a retrospective study of adults, who requested jaw wiring treatments at two private dental facilities in Enugu and Lagos, Nigeria. The interventions consisted of jaw wiring with four interdental eyelets and two tie wires. The main outcome measures were reasons for the request, weight loss, and body mass index (BMI) change. The data were analyzed using SPSS, version 20.0. Results: Thirty-four patients, all female, requested jaw wiring. Majority were single (82.4% [28/34]). The mean (standard deviation [SD]) age was 28.1 (6) (confidence interval [CI]: 25.9–30.2). Simplicity of the procedure, weight-loss needs, and improved body shape were the main reasons for all the patients. Single women additionally included a “desire to attract a marriage mate” in 67.6% (23/34), “preparation for an engagement,” and “to fit a wedding gown,” 5.9% (2/34). Married women, 14.7% (5/34), additionally desired to “please a husband” or “achieve postpartum weight-loss.” Nineteen subjects completed the treatment and lost a mean (SD) weight of 8.3 (3.6) kg (95% CI: 6.5–10) over a mean (SD) duration of 45.0 (14.9) days (CI: 37.8–52.2). The mean BMI was lowered after treatment by 3.09kg/m2 (1.3; CI: 2.5–3.7). The posttreatment BMI classification improved for 52.6% (10/19) of the patients. Conclusions: Jaw wiring was desired by young women because of its simplicity, predictable weight loss, and marital and social concerns. Weight loss and lowered BMI were achieved.
Keywords: Jaw wiring, Nigerian, obesity, overweight, weight loss
|How to cite this article:|
Nwoga MC, Maduakor SN, Ndukuba AC. Voluntary jaw wiring in Nigeria: Reasons and treatment outcome. Int J Med Health Dev 2019;24:28-34
| Introduction|| |
The prevalence of overweight and obesity in Nigeria is in the range of 20.3%–35.1%, and 8.1%–22.2%, respectively. Overweight and obesity are measured by body mass index (BMI), where the weight in adults is considered normal, overweight, and obese when the BMI falls within 18.50–24.99kg/m2, 25.00–29.99kg/m2, and ≥30kg/m2, respectively. The super obese are subjects with BMI ≥50kg/m2.
People with weight problems engage in a variety of measures to control their weight. These include low-energy diet, physical exercise, anti-obesity drugs, behavioral therapy, obesity vaccine, intragastric balloons, bariatric surgery, liposuction, and jaw wiring.,,, The jaw wiring technique is based on the principle of interdental eyelet wiring (Ivy loop method) commonly used in maxillomandibular fixation of jaw fractures. Both conventional interdental eyelet wiring and orthodontic jaw wiring primarily restrict solid food intake, and lead to weight reduction. Earlier reported treatment involved extensive jaw wiring for long durations of 6–9 months, with complications of periodontal disease, limited mouth opening, mouth odor, and anxiety.,
The reasons for voluntary request of jaw wiring procedure in our environment, to the best of our knowledge, have not been reported. This study examines these reasons and the outcome of a shorter period of treatment with fewer wires. It is hoped that this study will highlight the role of the dentist in a multidisciplinary approach to management of overweight and obesity.
| Patients and Methods|| |
This is a retrospective study of patients who voluntarily requested jaw wiring treatment for weight loss. The period covered by the study was between January 2005 and December 2014. The patients attended two private dental clinics in southern Nigeria. The inclusion criterion was any adult patient who voluntarily requested the jaw wiring procedure.
The data retrieved from the case files included age, gender, height, reasons for requesting jaw wiring, pretreatment weight, pretreatment BMI, treatment duration, posttreatment weight, and posttreatment BMI. Each patient gave informed consent for the procedure. An institutional ethical approval was obtained from College of Medicine Research Ethics Committee, Directorate of Research and Publications, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.
All patients with jaw fractures and treated by jaw wiring were excluded. Super obese subjects (BMI >50kg/m2) were also excluded as there were concerns that this degree of obesity may be associated with morbidities requiring medical attention. Pregnant patients and those expecting to be pregnant during the period of treatment were also excluded. Their exclusion reduced the risk of medical complications such as nausea and vomiting. Patients with severe gingival or periodontal diseases were also excluded. Similarly, patients with major, complex, or unpredictable medical problems such as uncontrolled diabetes, bruxism, and history of mental illnesses were excluded.
The treatment process included the following stages: (a) consultation with clerking and dental examination; (b) counseling and obtaining consent; (c) preliminary weight and height measurements; (d) scaling and polishing procedure, and dental restorations if required; (e) jaw wiring procedure; (f) posttreatment and nutritional instructions; (g) jaw wire removal; (h) post-wiring oral examination with scaling and polishing; (i) post-wiring counseling; and (j) post-wiring weight measurement. The preliminary treatment processes from (a) to (f) took place in one visit or by the second visit if the patient fulfilled all the inclusion criteria.
Counseling before wiring of the Jaws
Prior to the jaw wiring, each patient was informed of the risks and also counseled on oral hygiene procedures including the care of the dentition and gum, such as brushing and rinsing after each meal as well as to use mouth washes after each meal. Each patient’s preferred diet of choice was not interfered with. Each patient was advised to ingest liquefied food and fluids during the period of jaw wiring. The frequency of eating was left to the preference of the patients. They were informed of possible discomfort in the early days after the placement of the four eyelet and tie wires. They were also encouraged to maintain or resume regular exercise during the period. The type and frequency of the exercises were left to the patients’ discretion and preference. There was no monitoring of the patients’ activity during the period of the jaw wiring. Each patient signed a formal consent for the jaw wiring procedure. Preliminary weight and height measurements were taken in kilograms and meters, respectively, using Zhezhong height measuring stand with weighing scale (Yongkang Zhezhong Weighing Apparatus Factory, YongkKang City, ZheZong Province, China). A preliminary BMI was calculated. The formula used was BMI = weight (kg)/Height² (m). Scaling and polishing procedure was performed while dental restorations, if required, were all done.
The jaw wiring procedure
All the processes before the jaw wiring procedure were first completed. The jaw wiring started with the use of four interdental eyelet wires and two tie wires made of 0.4- or 0.45-mm soft stainless steel. Surface interdental gingival anesthesia in a gel form was applied in areas with tight embrasure. Standard local anesthetic preparation (such as 2% xylocaine with adrenaline 1:100,000) was administered by infiltration of the free gingival tissue. The free end of eyelet wires held with wiring forceps was gently passed through the buccal embrasure, between the second premolar and the first molar. This emerged lingually or palatally. Where the second premolar or the first molar was missing or not suitable, the dentist used any other suitable adjacent teeth with embrasures that allowed easy passage of the wires.
The emergent ends of the wires were pulled through the embrasures with wiring forceps. The wires were separated and one of the wires was wound round the adjacent mesial tooth, and passed through the mesial embrasure to emerge bucally. The other wire was wound round the adjacent distal tooth and passed through the distal embrasures to emerge bucally, then passed through the loop of the buccally placed eyelet and joins the first mesially emerging wire. Using wiring forceps, both first and second wire ends were twisted clockwise until reasonably taut without snapping or causing pain to the patient. The excess twisted ends were carefully cut with a wire cutter, and tucked into an interdental embrasure to avoid traumatizing the buccal mucosa. The other three eyelet wires were prepared in a similar way in the remaining jaw quadrants.
Thereafter, as the patient was biting on a wooden spatula with the incisal teeth, a single short wire (tie wire) was passed through the two opposing eyelets of one side of the jaws. Wiring forceps were used to twist the two free ends of the wires tight [Figure 1]. The same process was repeated on the other side of the jaw. The wooden spatula was removed to reveal an inter-incisal space of 2mm. The excess twisted tie wires were cut and the ends were tucked toward the embrasures to avoid trauma to the buccal surface of the cheek and gums. Patients with anterior open bite did not use the wooden spatula. The eyelet wiring procedure lasted about 30 minutes.
|Figure 1: Patient with upper and lower eyelet interdental wires, with tie wire in place|
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Patients were encouraged to carry out labial and buccal surface tooth brushing after every meal, and daily mouth rinses with chlorhexidine gluconate–based oral solutions to reduce dental plaque formation. The patient was reminded that the recommended duration of eyelet wiring was 28 days. Each patient was required to visit the clinic the next day for a review and every 2 weeks or at any earlier time, until the wires were removed. During the subsequent dental visits, the following were considered and reviewed: patient compliance, dietary compliance, state of oral hygiene, presence of malposition of wire endings, and signs of gingival trauma or disease.
Patients were encouraged to consume meals in liquid and semiliquid forms such as pap, custard, yogurt, milk, smoothies (pureed vegetable or fruits such as mango, pawpaw, water melon, pineapple, apple, carrot, and cucumber). Semiliquid food can be taken with straws of variable sizes or diameter.
Removal of the wires
The tie wires and the eyelets were removed with wiring forceps at the end of treatment.
Post-wire removal measurements and oral examination
Each patient was weighed, and the posttreatment BMI as well as the duration of treatment were recorded. Immediate post-treatment dental evaluation was conducted for each patient. Standard methods of intraoral examination and evaluation of soft and hard dental tissues including presence of oral lesions, caries, gingival lesions, deposits of plaques and pocketing, irritations, ulcerations, and abscesses were carried out. Treatment was carried out where necessary, and referrals were made if required. Scaling and polishing was performed for each patient to remove plaque that had been deposited during the period of jaw wiring.
Counseling after removal of the wires
After the removal of the wires, patients were counseled to maintain good oral hygiene status to prevent the development of dental caries and periodontal disease. As the jaws had been immobilized for a minimum period of 28 days, mouth-opening exercises were performed to stimulate and enable proper mouth opening. If a patient had difficulty in opening the mouth, incremental insertion of stalked wooden spatulas between the mandibular and maxillary teeth was performed to improve mouth opening. Patients were referred to a dietician for dietary management of body weight.
The data was analyzed using SPSS version 20.0. (SPSS, Chicago, IL), and the test of significance was set at P < 0.05. The calculations of proportions, frequencies and percentages, mean and SD, and inferential statistics were carried out. In consideration of the non-normal distribution of the data, nonparametric tests were applied. Mann–Whitney U test was used to compare the means of the ages, pretreatment BMI, and weight of two groups: the patients who did not complete treatment, and the patients who completed treatment.
| Results|| |
Thirty-four patients (all female) presented with various reasons for requesting jaw wiring for weight loss during the period under review. Age ranged from 18 to 45 years with a mean (SD) of 28.1 (6) (confidence interval [CI]: 25.9–30.2) years. Majority of the patients were not married 82.4% (28/34). Among the unmarried patients, one patient was a single mother (3.6%; 1/28) whereas 14.3% (4/28) were engaged to be married. [Table 1] summarizes the pretreatment range, mean age, height, weight, and BMI of patients. Majority of patients were in the overweight (32.4% [n = 11/34]) and obesity class I (41.2% [n = 14/34]) categories [Table 2].,
|Table 2: Pretreatment BMI classification and marital status of patients (N = 34)|
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Reasons for requesting jaw wiring to lose weight
Patients expressed multiple and varied reasons for choosing jaw wiring procedure to achieve weight loss. All 34 patients desired weight loss through jaw wiring to improve physical appearance and body shape [Table 3]. Simplicity of the procedure was another reason for preference of jaw wiring. Single women, in addition to the aforementioned reason, wanted to “attract a mate for marriage.” Engaged women desired weight loss mainly as a “preparation for traditional marriage” and “to fit into a wedding gown.” Married women in the series desired to please their respective spouses or “achieve postpartum weight-loss.” Health concern was not expressed as a reason by the patients. Although patients manifested no objective health problem based on history and clinical observations, a few expressed concerns about the health risks of obesity.
Other reasons given by patients for choosing jaw wiring included recommendation by a friend, easy access to a dentist, simple procedure requiring minimal wires, fast treatment procedure, safety assurance of treatment procedure, and assurance of remarkable weight loss from jaw wiring procedure.
Non-completion of management processes
Although all 34 patients participated in the study, not all were fully managed. A total of 44.1% (15/34) of patients, for various reasons, failed to complete stages required for proper management. Two patients 5.9% (2/34) discontinued treatment as spouses objected to further management at the stage before placing of eyelet wires. These patients were examined for jaw wiring but actually never had the wires placed. Four patients, 11.8% (4/34), had jaw wires removed after 1–4 days due to complaints of discomfort. Nine patients, 26.5% (9/34), were lost to attrition or had missing records of post-wiring measurements of weight and duration.
Fully managed patients (n = 19)
A total of 19 patients (55.9%, 19/34) were fully managed. The mean (SD) age and height of these patients were 26.6 (4.8) years (CI: 24.3–29), and 1.7 (0.03) m (CI: 1.7–1.7), respectively. The pretreatment mean (SD) weight was higher in patients that completed the treatment (94.5kg ; 95% CI: 87.7–101.2), than in those who did not (84.80kg; CI: 77.8–92.2). The difference, however, was not statistically significant (P = 0.46 [CI: 95%]).
The mean (SD) duration of jaw wiring for those who completed the treatment was 45.0 (14.9; 95% CI: 37.8–52.2) days. All the 19 women experienced weight loss in the range of 4.0–15.0kg. Similarly, there was a healthier posttreatment BMI mean lowering of 3.09kg/m2. All had a healthy improvement in BMI values, with 47.4% (9/19) patients improving with a decline within the same BMI class, whereas 52.6% (10/19) moved to a healthier BMI class. [Table 4] shows the mean weight loss changes among the 19 patients who completed the treatment, considering the age group, marital status, and duration of treatment. Majority of those in obesity class I have dropped to the overweight category, 52.6% (10/19), [Table 5]. None of the patients presented with complaints or findings that suggested presence of periodontal disease, dental caries, temporomandibular joint disorder, or any new or exacerbated medical ailments. There was no incidence of limited mouth opening.
|Table 4: Mean weight loss outcome based on age group, marital status and duration of treatment (N = 19)|
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|Table 5: Proportion of patients with altered BMI after treatment (N = 19)|
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| Discussion|| |
This study observed that jaw wiring to limit mouth opening led to weight loss, which is primarily attributed to reduction in the quantity and frequency of the dietary intake, a common weight-loss strategy. As sole reliance on appetite to control energy consumption was not effective, the patients requested direct dietary intervention by jaw wiring to satisfy their individual needs. The resort to consumption of semi-solid food, pureed fruits, and vegetables by the patients contributed to the weight loss.
Simplicity, minimal cost, and predictable weight loss made jaw wiring attractive to patients in this study. Although the knowledge of other weight-loss therapies was not investigated, these patients chose jaw wiring over other more popular and conventional treatment options. In other studies, similar treatment restricting both mouth opening and calories consumption is advocated using orthodontic techniques and materials. One criticism of traditional jaw wiring for weight loss often focuses on the weight regained after wire removal. However, this ignores the possibility that some patients could intentionally desire a temporary weight loss to resolve personal or social needs. This observation is highlighted in some cases in this study, where reasons such as “preparation for traditional marriage,” “to fit into a wedding gown solely for the marriage ceremony,” or “boost postpartum weight-loss” expressed such temporary needs.
Another criticism highlighted the prolonged duration of jaw wiring and attendant periodontal complications in previous publications., In this study, a short duration of 28 days of jaw wiring was recommended to avoid its harmful effect on teeth and periodontal tissues. Only 26.3% of patients in the present series had their wires removed approximately 28 days after wiring. These patients had a higher mean weight loss than patients that overshot 28 days jaw wiring duration. Patients that overshot the 28-day post-wiring period failed to keep appointments for wire removal, and postponed appointments until individual weight-loss targets were achieved. These patients nevertheless had the wires removed within 73 days. The rate and extent of individual weight loss depended on variable factors such as the pretreatment weight, dietary habits, genetic traits, endocrinal functions, levels of motivation, and physical activity. The short duration recommended was sufficient to achieve the weight loss desired by most of the patients without oral and health complications. Such short-term weight losses desired by these patients can be achieved with caloric reduction alone. However, for successful long-term weight loss, understanding the mechanisms of weight balance and behavior-modification programs combined with caloric restriction would be required after jaw wiring treatment.,
Although intentional weight loss is known to result in lower mortality rates, health-related reasons were not a factor considered by patients for weight loss in our series. Our study implies that for the more obese patients, weight loss achieved could be a motivation or preparation for other forms of weight-loss therapy and weight maintenance treatment.
The more extensive wiring during jaw fracture treatment posed no common, late, or long-term harmful effects on the teeth and periodontal tissues. The extent of interdental wiring to restrict solid food intake is minimal when compared to that required for treatment of jaw fractures. The short treatment duration eliminated notable health complications observed in an earlier report. The absence of remarkable gingival or periodontal diseases observed in this study was due to adequate oral health education and practices among the patients. Our patients used regular mouth rinses with preparations of dilute chlorhexidine without side effects and maintained adequate external teeth surface brushing after each meal. Although the lingual and palatal surfaces of the teeth could not be brushed, it is possible that some cleansing was achieved by the rough dorsal surface of the tongue rubbing on these surfaces. Scaling and polishing routinely performed after wire removal eliminated plaque and calculus that were present.
The risk of pulmonary aspiration following jaw wiring is considered low in the treatment of any form of jaw fracture, and even lower in the treatment for weight loss., The risk is even remote because these patients treated were healthy, and maintained well-coordinated oral and deglutitive functions. They were also free of severe pain and swellings associated with jaw fractures, and therefore capable of painless mild mouth-opening and jaw movements. Medications and analgesics with potential side effects of nausea and vomiting were not administered, unlike in management of jaw fractures. Soft wires that were easy to cut with any sharp cutting instrument in an emergency were used.
Women were the only patients that approached dentists to request jaw wiring procedure. This corroborates the reported observation that women show more dissatisfaction or preoccupation with their weight. Women in the age range of 20–32 years constituted the majority of those requesting this form of dietary intervention. Majority were single and expressed desires “to attract a fiancé”. This may suggest exposure to family, cultural, or social pressures to shed excess weight, and be attractive to prospective suitors.
The absence of any male patient in this study could be explained by the wrong perception where overweight men assume they have a correct weight, contrary to the result of an objective BMI measurement. Similar perceptions exist among overweight and obese Caucasian males with a cross-cultural tendency to underestimate their weight status. Whether overweight and obese male Nigerians consider themselves free from social pressure to lose weight is a subject for further research.
Nineteen patients who completed management had a higher pretreatment mean weight than those that did not complete management. The higher pretreatment weight was probably the motivation to complete management. Similarly, among the 19 who completed the treatment, the younger age group (≤mean age 28.1 years, n = 14) experienced higher mean weight loss probably due to more motivation from the social pressure to maintain an attractive weight.
In conclusion, female gender, single marital status, and third decade of life were important characteristics of patients requesting jaw wiring. The main reasons given were desire for weight loss, attractive physical appearance, marital appeal, and social considerations. The decreased calorie intake resulted in the desired weight loss without complications. In addition, BMI values were lowered within the same obesity class, whereas others moved to a healthier BMI class. Some of their stated needs or targets were achieved.
The strength of the study is in evaluation of jaw wiring treatment from a different perspective in an African country with different cultural and social backgrounds. However, the small study population limits the extent of generalization of the findings. The reliance on case-file documentation presented problems of incomplete record of some cases. Further studies are required to evaluate the level of satisfaction of the motivating reasons for the requested treatment, whether there was positive dietary behavioral change after the wire removal and if the women repeated the procedure in the future.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her image and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Umuerri EM, Ayandele CO, Eze GU Prevalence and sociodemographic correlates of obesity and overweight in a rural and urban community of Delta State, Nigeria. Sahel Med J 2017;20:173-8.
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157-63.
Yoshizawa T, Ishikawa K, Nagasawa H, Takeuchi I, Jitsuiki K, Omori K et al
A fatal case super-super obesity (BMI >80) in a patient with a necrotic soft tissue infection. Intern Med 2018;57:1479-81.
Mathus-Vliegen EMH, Nikkel D, Brand HS Oral aspect of obesity. Int Dent J 2007;57:250-6.
Wolfe BM, Kvach E, Eckel RH Treatment of obesity: Weight loss and bariatric surgery. Circ Res 2016;118:1844-55.
Vyas D, Deshpande K, Pandya Y Advances in endoscopic balloon therapy for weight loss and its limitations. World J Gastroenterol 2017;23:7813-17.
ReShape and Orbera—two gastric balloon devices for weight loss. Med Lett Drugs Ther 2015;57:122-3.
Verma G Extended Eyelet Method: A new technique for maxillomandibular fixation. Glob J Surg 2013;1:41-3.
Al-Dhubhani MK, Al-Tarawneh AM The role of dentistry in treatment of obesity-review. Saudi J Dent Res 2015;6:152-6.
Benton D, Young HA Reducing calories intake may not help you lose body weight. Perspect Psychol Sci 2017;12:703-714.
Holt GM, Owen LJ, Till S, Cheng Y, Grant VA, Harden CJ, et al
. Systemic literature review shows appetite rating does not predict energy intake. Crit Rev Food Sci Nutr 2017;57: 3577-82.
Mohamed YK, Ghassan A, Bassel T Are dentists involved in the treatment of obesity? J Int Soc Prev Community Dent 2016;6:183-8.
Caterson ID Management strategies for weight control. Eating, exercise and behaviour. Drugs 1990;39:20-32.
Kritchevsky SB, Beavers KM, Miller ME, Shea MK, Houston DK, Kitzman DW, et al
. Intentional weight loss and all-cause mortality: A meta-analysis of randomized clinical trials. PLoS One 2015;10:e0121993.
Thor A, Andersson L Interdental wiring in jaw fractures: Effects on teeth and surrounding tissues after a one-year follow-up. Br J Oral Maxilloc Surg 2001;39:398-401.
Eik-Nes T, Romild U, Guzey I, Holmen T, Micali N, Bjornelv S Women’s weight and disordered eating in a large Norwegian community sample: The Nord-Trondelag Health Study (HUNT). BMJ Open 2015;5:e008125.
Robinson E, Oldham M Weight status misperceptions among UK adults: The use of self-reported vs. measured BMI. BMC Obes 2016; 3:21.
Robinson E, Hogenkamp PS Visual perceptions of male obesity: A cross-cultural study examining male and female lay perceptions of obesity in Caucasian males. BMC Public Health 2015;15:492.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]