- Email: [email protected]
Fractures of the Mandible
FRACTURES OF THE MANDIBLE B y F r e d A . H e n n y , D .D .S ., D etroit, M ich .
I N C E the ad ven t o f oral surgery as a specialty, fractures o f the m an dible h a ve been extensively and m inutely studied, in a n attem pt to im prove b oth techn ic and results. O f re cen t years, the trend has been in the d irection o f sim plicity, n ot on ly sim plicity o f operation fo r the surgeon, b u t also sim plicity o f procedure fo r the patient. T h is trend has not caused end-results to be sacrificed one iota. T h e origin al principles o f treatm ent o f all fractures as outlined b y H ypocrates m ust still be fo llo w ed religiously. These principles w ere ve ry sim ple, b u t also ve ry dem anding. T h e y w e r e : first, place the fragm ents in correct a p p o sitio n ; second, retain the fragm ents in this position until union takes place. A lth o u gh these rules h ave not changed, the m ode o f treatm ent has been in a con stant state o f evolution, progressing from com plexity to sim plicity, from the u n scientific to the scientific and from cru d e ness to finesse. B y this v e ry evolution, results h a v e been vastly im proved. T o giv e us a b ackground fo r the en suing discussion, I shall digress fo r a m om ent to discuss some o f the p ecu liari ties o f the an atom y o f the area that in fluence fractu re diagnosis and treatm ent. T h e m andible is the on ly bone o f the skull th at is m ovable upon the others. It is a hard , brittle bone and ordinarily fractures in a fa irly straight line w ith little ten d en cy to com m inution. T h is tenden cy to fractu re in a fa irly straight
S
Read before the Section on O ral Surgery, Exodontia and Anesthesia at the Eighty-Third Annual M eeting of the American Dental As sociation, Houston, Texas, October 29, 1941. Jour. A .D .A ., Vol. 29, October 1, 1942
line is due largely to the presence of the teeth in th e ja w bone, com m inution b e in g m u ch m ore com m on in an edentulous fractu re. T h e an atom ic form o f the bone itself determ ines in part w here the bone shall break, the factors b ein g : ( 1 ) the teeth (in clu d in g im pacted third m olars) ; (2) th e m en tal fo ra m e n ; (3) the m an dibu lar foram en, and (4) the neck of the condyle. O th e r considerations are, o f course, the severity o f the traum a and the d irection in w h ich it is applied. D isplacem ent of the fragm ents m ay or m ay n ot take place. D isplacem ent occu r, rin g in the b egin nin g (prim ary) is caused by the origin al a ct o f violence. I f it comes abou t grad u ally, it m a y b e term ed secondary. T h is secondary displacem ent, instigated b y m uscular action, w ill alw ays take p lace unless there is a definite cou n teraction, w h ich m a y be supplied by early im m obilization, bevelin g o f the fractu re line or interdigitation o f the fragm ents. T h e muscles th a t en ter into the prob lem o f d isplacem ent are rou gh ly classified as elevators and depressors. The- elevator group includes the masseter, internal pterygoid, tem poral and buccinator. T h e depressor grou p is m ade up o f the geniohyoid, genioglossus, platysm a m yoides an d digastric. E xam in ation o f the muscles in this grou p in g w ill show th a t the elevators are grouped in the posterior p a rt o f the m an dible an d the depressors in the anterior. As a result, the fragm ents w ill, w ithout counteraction, b e d raw n u p in the pos terior portion and dow n w ard in the a n terior portion. T h e pu ll tow ard the m id line is supplied b y the m ylohyoid muscle. D isplacem ent can be corrected by 1840
H e n n y — F r a c t u r e s o f M a n d ib l e
m anipulating the fragm ents into norm al position, w ith retention in that position by interdental ligation ; or it m ay be sim ply and easily reduced by elastic trac tion. T h e adoption o f interm axillary rubber-band traction has been a long step in the righ t direction. It has m eant a procedure m ore easily endured b y the p a tient, and certain ly is prod u ctive of greater com fort durin g the period of convalescence. M o u th hygiene can be kept on a high plane during the period o f im m obilization, since the elastics can
Fig. 1.— D arcissac m ethod of controlling posterior edentulous fragm ent. Elastic trac tion is used if com plete reduction cannot be accom plished at the tim e of operation.
be rem oved period ically to allow cleans in g o f the area surrounded by the teeth. T ractio n can be so adjusted that some m otion is allow ed if desired. I t is routine in m y cases of fracture o f the condyle alone to a p p ly only enough traction to bring the occlusion back to norm al at rest. W ith this arrangem ent, the patient
1841
is allow ed a soft diet, w ith all o f its obvious benefits. M ore im portant than all o f these advantages, how ever, is the sim ple fa ct that results are m uch better w hen trac tion is correctly applied. Fractures that could not be com pletely reduced by m anipulation can now be slow ly, easily and painlessly reduced by grad u al trac tion. T h e problem now arises as to h o w the traction shall be applied. T h e on ly pre requisite is fixation o f lugs on a sufficient num ber o f teeth in all fragm ents. T hese lugs can be supplied b y any one o f sev eral m ethods, em p loyin g (1 ) alum inum disks, (2) w ire arch bars o r (3) S tou t’s m ultiple loop appliance. T h e alum inum disks and arch bars have been standard equipm ent for some tim e, and both h a ve been p o p u lar and useful. Stou t’s m ultiple loop appliance, w hich is o f fa irly recent developm ent, offers m any advantages over the disks and bars. It is strong, inexpensive, sim ple and rapid of application, and does not retain food particles. It is indeed a v a l uable contribution to the treatm ent o f fractures. E lastic traction fo r reduction can be used on an y fragm ents th at bear teeth. It can also be used in im m obilization of the m andible a fter fractu re o f the con dyloid process. A ll fractures o f the condyle can be handled in this m anner. D isplacem ent o f the head m ed ially and anteriorly is expected, being due to the contractu re o f the external pterygoid m uscle. T h e fra c tured part is draw n com pletely out of action and a new jo in t is fo r m e d ; in m any cases, b y the roundin g off and eburnation o f the b on y stum p. O p en reduction is not on ly unnecessary, but also dangerous. T reatm en t should con sist o f only enough elastic traction to bring the teeth to norm al occlusion w hen at rest. C om plete im m obilization is not required. I f a condyle is broken off and the low er ja w is com pletely edentulous,
1842
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
the problem is, of course, m agnified. In such a case, it is w ell to place the patient under observation fo r a tim e. I f no de form ity ensues, no treatm ent is necessary. I f a shift to the affected side develops, reduction is necessary. I t can be accom plished b y placin g a w ire around the sym physis o f the m a n d ib le ; and an ch or ing the w ire to a post attached to a pre viously constructed head cast. T h is w ire w ill p reven t or correct any foreshorten ing o f the affected side. T h e use of elastic traction is therefore seen to be lim ited to tooth-bearing fragm ents and
tial or circum m an dibular w ire tightly enough to im m obilize fractu rcd bone w ill very often m ean u lceration o f the m ucous m em brane o f the ridge under the denture. I f it is not draw n u p tigh tly and th e ridge is shallow, as it often is, displacem ent m ay take place secondarily. A t any rate, w hen this procedure is car ried out, the low er denture or splint is w ired in place for the duration o f treat m ent. Food collects and decays beneath it, and the result is not pleasant. T h e r e fore, I h a ve com pletely abandoned this m ode o f reduction. I f the fracture line
Fig. 2.— Intra-oral splint used where displacem ent is not marked. T h is m ethod w ill control the posterior fragm ent.
to the treatm ent o f fractured condyles. T h e problem of w h at to do in the fr a c ture o f the edentulous m andible or in fractures posterior to the last tooth is still one w hich causes m uch concern. M a n y practitioners w ould say that the treat m ent o f the fractu red edentulous m an dible has been com pletely solved b y the use o f circum feren tial w iring. Its m any disadvantages, how ever, to m y m ind ou t w eigh the single advantage of sim plicity of treatm ent. T o draw up a circum feren-
in an edentulous m andible is at such an angle as to discourage secondary dis placem ent by m uscle traction, the case can be follow ed w ithou t im m obilization, usu ally to a successful conclusion. If, how ever, there is prim ary displace m ent from the force o f the original blow or if the angulation o f the fractu re line is such as to fa v o r secondary displace m ent, reduction is accom plished b y open operation and direct ligation o f the fra g m ents. In fection in these cases has been
H e n n y :— F r a c t u r e s o f M a n d i b l e
elim inated large ly w ith the advent o f chem otherapy. W hen open reduction i.s perform ed, sulfanilam ide pow der should be placed in the area. I f there has been a com m unication w ith the m outh, pro vision for drainage should be m ade. I f not, the w ound can be tightly closed. T h e advantages o f this m ethod can be listed as follow s : 1. I t is certain to have good results if correctly perform ed. 2. It perm its im m ediate use of his jaw . 3. It assures postoperative com fort.
i8 43
It m ust be im m ediately assumed th at w e are to follow H ypocrates’ principles in deciding on the treatm ent. W e m ust insist th at the fragm ents be brought into apposition and be held so until union takes place. It is ju st as correct fo r the oral surgeon to perform an open red u c tion operation u pon a m andible, w hen indicated, as it is fo r an orthopedic surgeon to d irectly w ire a patella, w hich is considered a justifiable p ro cedure. It is not d iffic u lt: to the contrary, it
Fig. 3.— C ase in w h ich fractu re through body of edentulous m andible has been cared for by direct w irin g of the fragm ents. T h e fractu red condyle required no treatm ent w hatsoever beyond observation. A n y deviation resulting from the con dylar fractu re could have been cared for by a circum ferential w ire at the symphysis anchored to a post from a head cast.
4. T h ere are no encum brances either intra-orally or extra-orally. C ritics o f the m ethod say that it is too difficult a p ro c e d u re ; th at there is danger o f postoperative infection, and that it produces an unsightly scar on the face. T o this, I w ould answ er that if the case is correctly handled, all these difficulties can be elim inated or reduced to the m ini mum.
is very simple. T h e fragm ents are brought into direct view by the dissection, and th ey can therefore be com pletely approxim ated. T h e incision should be carefu lly placed so th at w hen the dissection is carried dow n to the bone, an equal am ount of each fragm en t is available. T o do this, the x-ra y and clinical exam ination must be concise and com plete. Excessive e x
1844
T
he
Journal
of th e
A
m e r ic a n
posure and excessive stripping o f the periosteum is not conducive to u n even t fu l healing. T h e drill holes should be kept about a centim eter a w a y from the fractu re line and the w ire should be of a fine gage. Hemostasis m ust be com plete before closure o f the w ound, to preven t form a tion o f a hem atom a in the incision. T h e periosteum is carefu lly approxim ated and the rem ainder of the incision closed in layers. E ith er an interrupted or a continuous in tracu ticu lar stitch is used prior to the placin g o f the final skin sutures. T h ese skin sutures m ust be fine and n on-capillary and m ust be placed on a non-traum atic needle. I f all o f these rules are follow ed m eticulously, a satis fa cto ry result is to be expected. Fractures posterior to the last tooth are am ong the m ost difficult to handle. H ere again, the angulation o f the' fra c ture line influences the type o f treatm ent. I f there is no prim ary displacem ent and the angulation is such as to oppose the muscles, simple im m obilization o f the m andible is sufficient. I f there is prim ary displacem ent or the angulation favors displacem ent, a d ifferent course o f action m ust be follow ed. T h e types o f treatm ent in this situation a r e : 1. D ire ct w irin g of the fragm ents. 2. T h e use o f intra-oral splints. 3. R eten tion o f a tooth in the fractu re line until callus form ation is sufficient to p reven t displacem ent. 4. M eth od o f Darcissac. E ach type has its ow n indications, a l though no definite rule can be laid dow n fo r the use o f a n y one. In general, if the posterior fragm en t is a lon g one, such as from the cuspid on back, and i f the fractu re line has not been grossly com pounded into the m outh, d irect w irin g o f the fragm ents is carried out. U su ally this is supported intra-orally b y light elastic traction. I f the fractu re is at the angle and there is little or no displace m ent, and most o f the teeth are present, an intra-oral splint is used, consisting of a half-round bar, fastened to the teeth
D
ental
A
s s o c ia t io n
w ith orthodontic bands. As it passes the posterior teeth, it dips dow nw ard, so that w hen it is in place, it w ill engage the anterior surface o f the ramus. A small stab w ound in the area o f contact at the ram us is m ade so that the bar directly en gages the bone. O ccasion ally, the fractu re line w ill pass through a fu lly erupted third m olar tooth, and it m a y extend in such a direc tion th at if the tooth w ere rem oved, dis placem ent could be expected. In such cases, it is p e rfe ctly justifiable to allow the tooth to rem ain in place for about tw o weeks or until sufficient union has taken place, and thus prevent displace m ent ; or the tooth can be extracted and one of the previously described splints be applied. H ow ever, i f the fractu re line extends through the angle and there is m arked displacem ent o f the ram us, the m ethod described b y D arcissac is the one of preference. In such cases, a plaster of Paris head cast w ith a b ar incorporated is placed before the operation. T h e bar extends from the h ead cast dow nw ard and posterior to the angle o f the m an dible. T h e angle o f the m andible is then exposed and a drill hole placed through the bone. S ilver w ire is threaded through the hole, and after the fragm en t has b e e n : pulled b ack to its correct position, it is, held there b y liga tin g the w ire to the post. T h e incision is closed in layers and su lf anilam ide pow d er is deposited in the w ound u nder the periosteum . I n old fractures or im pacted fractures, w here it is difficult to bring the fragm en t down, displacem ent can be corrected w ith elas tic traction betw een the silver w ire and the post. O f course, the age and the condition o f the patient, and other com plicating factors, m ust be considered before a de cision is reached as to the type o f re duction to be used. M a n y patients h a v ing fractures o f the m andible have a d ditional injuries, and it is often neces sary to w ait as lon g as a week or ten
T
ylm an—
A
c r y l ic s
: T
days before reduction. I f a general anes thetic is contraindicated, even open re duction can be carried out under local anesthesia if adequate preoperative seda tion is used ; or intra-oral ligation o f the bone fragm ents can be carried out if displacem ent is not m arked. A s w e all know , no clearcu t rule can be laid dow n fo r reduction o f each type o f fracture. Instead, it is a w iser policy to consider each case in d ivid u ally and
h e ir
P resen t S ta t u s
consider all facts carefu lly before a de cision is reached. It is o f suprem e im portance th at we consider these edentulous fractures and edentulous fragm ents w ith the utmost care. T h e y present a difficult problem , it is true, b u t it should be faced w ith reso lution. N o h a lfw a y m easures are ac ceptable if w e are to treat our patients honestly. Henry Ford Hospital.
ACRYLICS: THEIR PRESENT STATUS AND TECHNICS AS APPLIED TO CROWN AND BRIDGE PROSTHESIS* P A R T II B y S t a n l e y D . T y l m a n , M.S., D .D .S .,f C h ica g o , 111. Y E A R ago, I subm itted a progress report on the uses o f acrylic resins in crow n and bridge prosthesis. C on fusion existed at th at tim e in the minds o f m an y, and conflicting state m ents w ere m ade relative to the various m aterials then available, also in regard to the various technics em ployed in the m anipulation an d processing o f the resins^ T h e enthusiasm fo r acrylics sw eeping the profession constituted a threat to the continued use o f gold and porcelain. A few m en w ere not sw ept off their feet, but w ere w illin g to study and investigate the possibilities o f the new m aterial. T h e y w ere sufficiently interested to study
A
*This paper and the one by Drs. Peyton and Mann on acrylic and acrylic-styrene resins were presented as a symposium on acrylics. fProfessor of prosthetic dentistry, Univer sity of Illinois, College of Dentistry. Read before the Section on Partial, Crown, Bridge and Full Mouth Reconstruction at the Seventy-Eighth Annual Midwinter Meeting of the Chicago Dental Society, February 25,
1942 Jour. A .D .A., Vol. 29, October 1, 194.2
the physical properties o f the synthetic resins, also both the possible extent o f their clinical application and their behavior. D u rin g th e interven ing tw elve months, several groups o f investigators and teachers h a ve conducted extensive investigations, both ph ysical and clinical, and this sym posium is on ly one o f the several progress reports that are being m ade on the study o f synthetic resins. M o re com plete inform ation regarding the behavior and uses o f these m aterials can be obtained b y studying the bibliog rap h y o f this paper. A lth o u gh the synthetic resins, particu la rly the m eth yl m ethacrylates, have definite lim itations so fa r as their use in crow n and bridge prosthesis is concerned, their application in com plete denture prosthesis is sufficiently successful and encouraging to suggest a fu rth er study in their uses fo r sm aller restorations. O f the several types of synthetic resins available, the m eth yl m ethacrylate p o ly mer, w hen used eith er w ith the m on o
I N C E the ad ven t o f oral surgery as a specialty, fractures o f the m an dible h a ve been extensively and m inutely studied, in a n attem pt to im prove b oth techn ic and results. O f re cen t years, the trend has been in the d irection o f sim plicity, n ot on ly sim plicity o f operation fo r the surgeon, b u t also sim plicity o f procedure fo r the patient. T h is trend has not caused end-results to be sacrificed one iota. T h e origin al principles o f treatm ent o f all fractures as outlined b y H ypocrates m ust still be fo llo w ed religiously. These principles w ere ve ry sim ple, b u t also ve ry dem anding. T h e y w e r e : first, place the fragm ents in correct a p p o sitio n ; second, retain the fragm ents in this position until union takes place. A lth o u gh these rules h ave not changed, the m ode o f treatm ent has been in a con stant state o f evolution, progressing from com plexity to sim plicity, from the u n scientific to the scientific and from cru d e ness to finesse. B y this v e ry evolution, results h a v e been vastly im proved. T o giv e us a b ackground fo r the en suing discussion, I shall digress fo r a m om ent to discuss some o f the p ecu liari ties o f the an atom y o f the area that in fluence fractu re diagnosis and treatm ent. T h e m andible is the on ly bone o f the skull th at is m ovable upon the others. It is a hard , brittle bone and ordinarily fractures in a fa irly straight line w ith little ten d en cy to com m inution. T h is tenden cy to fractu re in a fa irly straight
S
Read before the Section on O ral Surgery, Exodontia and Anesthesia at the Eighty-Third Annual M eeting of the American Dental As sociation, Houston, Texas, October 29, 1941. Jour. A .D .A ., Vol. 29, October 1, 1942
line is due largely to the presence of the teeth in th e ja w bone, com m inution b e in g m u ch m ore com m on in an edentulous fractu re. T h e an atom ic form o f the bone itself determ ines in part w here the bone shall break, the factors b ein g : ( 1 ) the teeth (in clu d in g im pacted third m olars) ; (2) th e m en tal fo ra m e n ; (3) the m an dibu lar foram en, and (4) the neck of the condyle. O th e r considerations are, o f course, the severity o f the traum a and the d irection in w h ich it is applied. D isplacem ent of the fragm ents m ay or m ay n ot take place. D isplacem ent occu r, rin g in the b egin nin g (prim ary) is caused by the origin al a ct o f violence. I f it comes abou t grad u ally, it m a y b e term ed secondary. T h is secondary displacem ent, instigated b y m uscular action, w ill alw ays take p lace unless there is a definite cou n teraction, w h ich m a y be supplied by early im m obilization, bevelin g o f the fractu re line or interdigitation o f the fragm ents. T h e muscles th a t en ter into the prob lem o f d isplacem ent are rou gh ly classified as elevators and depressors. The- elevator group includes the masseter, internal pterygoid, tem poral and buccinator. T h e depressor grou p is m ade up o f the geniohyoid, genioglossus, platysm a m yoides an d digastric. E xam in ation o f the muscles in this grou p in g w ill show th a t the elevators are grouped in the posterior p a rt o f the m an dible an d the depressors in the anterior. As a result, the fragm ents w ill, w ithout counteraction, b e d raw n u p in the pos terior portion and dow n w ard in the a n terior portion. T h e pu ll tow ard the m id line is supplied b y the m ylohyoid muscle. D isplacem ent can be corrected by 1840
H e n n y — F r a c t u r e s o f M a n d ib l e
m anipulating the fragm ents into norm al position, w ith retention in that position by interdental ligation ; or it m ay be sim ply and easily reduced by elastic trac tion. T h e adoption o f interm axillary rubber-band traction has been a long step in the righ t direction. It has m eant a procedure m ore easily endured b y the p a tient, and certain ly is prod u ctive of greater com fort durin g the period of convalescence. M o u th hygiene can be kept on a high plane during the period o f im m obilization, since the elastics can
Fig. 1.— D arcissac m ethod of controlling posterior edentulous fragm ent. Elastic trac tion is used if com plete reduction cannot be accom plished at the tim e of operation.
be rem oved period ically to allow cleans in g o f the area surrounded by the teeth. T ractio n can be so adjusted that some m otion is allow ed if desired. I t is routine in m y cases of fracture o f the condyle alone to a p p ly only enough traction to bring the occlusion back to norm al at rest. W ith this arrangem ent, the patient
1841
is allow ed a soft diet, w ith all o f its obvious benefits. M ore im portant than all o f these advantages, how ever, is the sim ple fa ct that results are m uch better w hen trac tion is correctly applied. Fractures that could not be com pletely reduced by m anipulation can now be slow ly, easily and painlessly reduced by grad u al trac tion. T h e problem now arises as to h o w the traction shall be applied. T h e on ly pre requisite is fixation o f lugs on a sufficient num ber o f teeth in all fragm ents. T hese lugs can be supplied b y any one o f sev eral m ethods, em p loyin g (1 ) alum inum disks, (2) w ire arch bars o r (3) S tou t’s m ultiple loop appliance. T h e alum inum disks and arch bars have been standard equipm ent for some tim e, and both h a ve been p o p u lar and useful. Stou t’s m ultiple loop appliance, w hich is o f fa irly recent developm ent, offers m any advantages over the disks and bars. It is strong, inexpensive, sim ple and rapid of application, and does not retain food particles. It is indeed a v a l uable contribution to the treatm ent o f fractures. E lastic traction fo r reduction can be used on an y fragm ents th at bear teeth. It can also be used in im m obilization of the m andible a fter fractu re o f the con dyloid process. A ll fractures o f the condyle can be handled in this m anner. D isplacem ent o f the head m ed ially and anteriorly is expected, being due to the contractu re o f the external pterygoid m uscle. T h e fra c tured part is draw n com pletely out of action and a new jo in t is fo r m e d ; in m any cases, b y the roundin g off and eburnation o f the b on y stum p. O p en reduction is not on ly unnecessary, but also dangerous. T reatm en t should con sist o f only enough elastic traction to bring the teeth to norm al occlusion w hen at rest. C om plete im m obilization is not required. I f a condyle is broken off and the low er ja w is com pletely edentulous,
1842
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
the problem is, of course, m agnified. In such a case, it is w ell to place the patient under observation fo r a tim e. I f no de form ity ensues, no treatm ent is necessary. I f a shift to the affected side develops, reduction is necessary. I t can be accom plished b y placin g a w ire around the sym physis o f the m a n d ib le ; and an ch or ing the w ire to a post attached to a pre viously constructed head cast. T h is w ire w ill p reven t or correct any foreshorten ing o f the affected side. T h e use of elastic traction is therefore seen to be lim ited to tooth-bearing fragm ents and
tial or circum m an dibular w ire tightly enough to im m obilize fractu rcd bone w ill very often m ean u lceration o f the m ucous m em brane o f the ridge under the denture. I f it is not draw n u p tigh tly and th e ridge is shallow, as it often is, displacem ent m ay take place secondarily. A t any rate, w hen this procedure is car ried out, the low er denture or splint is w ired in place for the duration o f treat m ent. Food collects and decays beneath it, and the result is not pleasant. T h e r e fore, I h a ve com pletely abandoned this m ode o f reduction. I f the fracture line
Fig. 2.— Intra-oral splint used where displacem ent is not marked. T h is m ethod w ill control the posterior fragm ent.
to the treatm ent o f fractured condyles. T h e problem of w h at to do in the fr a c ture o f the edentulous m andible or in fractures posterior to the last tooth is still one w hich causes m uch concern. M a n y practitioners w ould say that the treat m ent o f the fractu red edentulous m an dible has been com pletely solved b y the use o f circum feren tial w iring. Its m any disadvantages, how ever, to m y m ind ou t w eigh the single advantage of sim plicity of treatm ent. T o draw up a circum feren-
in an edentulous m andible is at such an angle as to discourage secondary dis placem ent by m uscle traction, the case can be follow ed w ithou t im m obilization, usu ally to a successful conclusion. If, how ever, there is prim ary displace m ent from the force o f the original blow or if the angulation o f the fractu re line is such as to fa v o r secondary displace m ent, reduction is accom plished b y open operation and direct ligation o f the fra g m ents. In fection in these cases has been
H e n n y :— F r a c t u r e s o f M a n d i b l e
elim inated large ly w ith the advent o f chem otherapy. W hen open reduction i.s perform ed, sulfanilam ide pow der should be placed in the area. I f there has been a com m unication w ith the m outh, pro vision for drainage should be m ade. I f not, the w ound can be tightly closed. T h e advantages o f this m ethod can be listed as follow s : 1. I t is certain to have good results if correctly perform ed. 2. It perm its im m ediate use of his jaw . 3. It assures postoperative com fort.
i8 43
It m ust be im m ediately assumed th at w e are to follow H ypocrates’ principles in deciding on the treatm ent. W e m ust insist th at the fragm ents be brought into apposition and be held so until union takes place. It is ju st as correct fo r the oral surgeon to perform an open red u c tion operation u pon a m andible, w hen indicated, as it is fo r an orthopedic surgeon to d irectly w ire a patella, w hich is considered a justifiable p ro cedure. It is not d iffic u lt: to the contrary, it
Fig. 3.— C ase in w h ich fractu re through body of edentulous m andible has been cared for by direct w irin g of the fragm ents. T h e fractu red condyle required no treatm ent w hatsoever beyond observation. A n y deviation resulting from the con dylar fractu re could have been cared for by a circum ferential w ire at the symphysis anchored to a post from a head cast.
4. T h ere are no encum brances either intra-orally or extra-orally. C ritics o f the m ethod say that it is too difficult a p ro c e d u re ; th at there is danger o f postoperative infection, and that it produces an unsightly scar on the face. T o this, I w ould answ er that if the case is correctly handled, all these difficulties can be elim inated or reduced to the m ini mum.
is very simple. T h e fragm ents are brought into direct view by the dissection, and th ey can therefore be com pletely approxim ated. T h e incision should be carefu lly placed so th at w hen the dissection is carried dow n to the bone, an equal am ount of each fragm en t is available. T o do this, the x-ra y and clinical exam ination must be concise and com plete. Excessive e x
1844
T
he
Journal
of th e
A
m e r ic a n
posure and excessive stripping o f the periosteum is not conducive to u n even t fu l healing. T h e drill holes should be kept about a centim eter a w a y from the fractu re line and the w ire should be of a fine gage. Hemostasis m ust be com plete before closure o f the w ound, to preven t form a tion o f a hem atom a in the incision. T h e periosteum is carefu lly approxim ated and the rem ainder of the incision closed in layers. E ith er an interrupted or a continuous in tracu ticu lar stitch is used prior to the placin g o f the final skin sutures. T h ese skin sutures m ust be fine and n on-capillary and m ust be placed on a non-traum atic needle. I f all o f these rules are follow ed m eticulously, a satis fa cto ry result is to be expected. Fractures posterior to the last tooth are am ong the m ost difficult to handle. H ere again, the angulation o f the' fra c ture line influences the type o f treatm ent. I f there is no prim ary displacem ent and the angulation is such as to oppose the muscles, simple im m obilization o f the m andible is sufficient. I f there is prim ary displacem ent or the angulation favors displacem ent, a d ifferent course o f action m ust be follow ed. T h e types o f treatm ent in this situation a r e : 1. D ire ct w irin g of the fragm ents. 2. T h e use o f intra-oral splints. 3. R eten tion o f a tooth in the fractu re line until callus form ation is sufficient to p reven t displacem ent. 4. M eth od o f Darcissac. E ach type has its ow n indications, a l though no definite rule can be laid dow n fo r the use o f a n y one. In general, if the posterior fragm en t is a lon g one, such as from the cuspid on back, and i f the fractu re line has not been grossly com pounded into the m outh, d irect w irin g o f the fragm ents is carried out. U su ally this is supported intra-orally b y light elastic traction. I f the fractu re is at the angle and there is little or no displace m ent, and most o f the teeth are present, an intra-oral splint is used, consisting of a half-round bar, fastened to the teeth
D
ental
A
s s o c ia t io n
w ith orthodontic bands. As it passes the posterior teeth, it dips dow nw ard, so that w hen it is in place, it w ill engage the anterior surface o f the ramus. A small stab w ound in the area o f contact at the ram us is m ade so that the bar directly en gages the bone. O ccasion ally, the fractu re line w ill pass through a fu lly erupted third m olar tooth, and it m a y extend in such a direc tion th at if the tooth w ere rem oved, dis placem ent could be expected. In such cases, it is p e rfe ctly justifiable to allow the tooth to rem ain in place for about tw o weeks or until sufficient union has taken place, and thus prevent displace m ent ; or the tooth can be extracted and one of the previously described splints be applied. H ow ever, i f the fractu re line extends through the angle and there is m arked displacem ent o f the ram us, the m ethod described b y D arcissac is the one of preference. In such cases, a plaster of Paris head cast w ith a b ar incorporated is placed before the operation. T h e bar extends from the h ead cast dow nw ard and posterior to the angle o f the m an dible. T h e angle o f the m andible is then exposed and a drill hole placed through the bone. S ilver w ire is threaded through the hole, and after the fragm en t has b e e n : pulled b ack to its correct position, it is, held there b y liga tin g the w ire to the post. T h e incision is closed in layers and su lf anilam ide pow d er is deposited in the w ound u nder the periosteum . I n old fractures or im pacted fractures, w here it is difficult to bring the fragm en t down, displacem ent can be corrected w ith elas tic traction betw een the silver w ire and the post. O f course, the age and the condition o f the patient, and other com plicating factors, m ust be considered before a de cision is reached as to the type o f re duction to be used. M a n y patients h a v ing fractures o f the m andible have a d ditional injuries, and it is often neces sary to w ait as lon g as a week or ten
T
ylm an—
A
c r y l ic s
: T
days before reduction. I f a general anes thetic is contraindicated, even open re duction can be carried out under local anesthesia if adequate preoperative seda tion is used ; or intra-oral ligation o f the bone fragm ents can be carried out if displacem ent is not m arked. A s w e all know , no clearcu t rule can be laid dow n fo r reduction o f each type o f fracture. Instead, it is a w iser policy to consider each case in d ivid u ally and
h e ir
P resen t S ta t u s
consider all facts carefu lly before a de cision is reached. It is o f suprem e im portance th at we consider these edentulous fractures and edentulous fragm ents w ith the utmost care. T h e y present a difficult problem , it is true, b u t it should be faced w ith reso lution. N o h a lfw a y m easures are ac ceptable if w e are to treat our patients honestly. Henry Ford Hospital.
ACRYLICS: THEIR PRESENT STATUS AND TECHNICS AS APPLIED TO CROWN AND BRIDGE PROSTHESIS* P A R T II B y S t a n l e y D . T y l m a n , M.S., D .D .S .,f C h ica g o , 111. Y E A R ago, I subm itted a progress report on the uses o f acrylic resins in crow n and bridge prosthesis. C on fusion existed at th at tim e in the minds o f m an y, and conflicting state m ents w ere m ade relative to the various m aterials then available, also in regard to the various technics em ployed in the m anipulation an d processing o f the resins^ T h e enthusiasm fo r acrylics sw eeping the profession constituted a threat to the continued use o f gold and porcelain. A few m en w ere not sw ept off their feet, but w ere w illin g to study and investigate the possibilities o f the new m aterial. T h e y w ere sufficiently interested to study
A
*This paper and the one by Drs. Peyton and Mann on acrylic and acrylic-styrene resins were presented as a symposium on acrylics. fProfessor of prosthetic dentistry, Univer sity of Illinois, College of Dentistry. Read before the Section on Partial, Crown, Bridge and Full Mouth Reconstruction at the Seventy-Eighth Annual Midwinter Meeting of the Chicago Dental Society, February 25,
1942 Jour. A .D .A., Vol. 29, October 1, 194.2
the physical properties o f the synthetic resins, also both the possible extent o f their clinical application and their behavior. D u rin g th e interven ing tw elve months, several groups o f investigators and teachers h a ve conducted extensive investigations, both ph ysical and clinical, and this sym posium is on ly one o f the several progress reports that are being m ade on the study o f synthetic resins. M o re com plete inform ation regarding the behavior and uses o f these m aterials can be obtained b y studying the bibliog rap h y o f this paper. A lth o u gh the synthetic resins, particu la rly the m eth yl m ethacrylates, have definite lim itations so fa r as their use in crow n and bridge prosthesis is concerned, their application in com plete denture prosthesis is sufficiently successful and encouraging to suggest a fu rth er study in their uses fo r sm aller restorations. O f the several types of synthetic resins available, the m eth yl m ethacrylate p o ly mer, w hen used eith er w ith the m on o