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Fractures of the jaws
FRACTURES
OF THE
JAWS
AN EXTERNAL TRACTION APPLIANCE HARRY L. BISNOFF, D.D.S., JAMAICA, N. Y. T IS the business and duty of military men to organize all forces for defense I and full offensive if necessary. In this effort, it is the civilian’s duty to be helpful directly and indirectly in every possible way. It is also important to be fully organized to treat and rehabilitate our military personnel in any emergency and for all contingent injuries. This must be done as speedily and efficiently as possible. This efficiency is enhanced if a given condition can be treated by the least number of attendants and with the least inconvenience of transportation of the injured. It is the duty also of those not privileged to serve with the armed forces to offer their talents or the products of their talents. We are confident that the principles of democracy, which forms the basic foundation of our government, are exercised by the officials of our armed forces whose duty it is to survey and appraise the possibilities of procedures or material offered. In the -progressive growth and changes of our war machinery and the large number of civilians directly engaged with military personnel, all offerings should be viewed from an objective, not a personal, point of view, regardless of whether the offering originates from a civilian or a military person. The present war again calls forth our resourcefulness to cope with the increased jaw and head injuries. The surgeon, orthopedist, and plastic surgeon, each alone and all together, have a grave responsibility to rehabilitate those unfortunates who have fallen victim to the blasting and destructive methods of modern warfare. Whether one is to rehabilitate the injured for return to military service, or to usefulness in civilian life, it is no less the dentist’s responsibility to coordinate his skill and knowledge with the others to help these sufferers. It is a sufficiently sad commentary on our modern age that slaughter and maiming is so widespread. It would be just as sad if modern science would not employ every possible and available means for aiding recovery and doing everything within its reach to return normal facial expressions and function to those who are injured. The drab records of the last war and the rosters of veteran hospitals give mute or vocal evidence of men who left active circles of society amidst cheers in the patriotic farewells, never to return to t.heir society circles except as objects of sympathy. A man who had part of his face or jaw shot away or who suffered severe fractures resulting in disfigurement becomes a hermit even in a metropolis. From the limited information available, the incidence of head injuries in the belligerent countries of Europe is high. The last war had its toll, but there is every reason to believe that with the magnitude of modern warfare the numbers will be higher and possibly, too, the injuries more severe, The writer has had occasion to see on the continent of Europe men whose facial deform96
Practures
of Jaws
97
ities were so grotesque, as a result of gunshot and other war injuries, that one wonders what determination these souls have to give them the impetus to fight on after the cloud of gunpowder and t,he insanity of hate had cleared. As a personal conclusion, I could say only that these men have faith. This faith which they had in those administering toward their cure giving rise to a faith accelerated by inherent hope that some day they may again face society as other human beings do, and that they too may exercise the functions of the jaws and not feel reluctant to show their facial features. There are numerous methods of treating jaw fractures. They vary in their application as does also the skill of those applying them. In the catastrophe and wholesale mauling which is now visited upon the military as well as civilian population, we must be prepared to treat facial and jaw injuries wherever and whenever they occur. Multiple injuries to the jaws, severance of continuity of the body from the ramus of the mandible, causing lack of control of the tongue, calls for quick treatment. Horizontally fractured maxillary bones, disconnected mandibular segments, or comminution of the symphysis may require the application of external appliances for traction, relief, coaptation, or to overcome occlusion of respiratory passages. No one method or appliance can be a panacea for all types of injuries. An experienced and skilled technician may by his resourcefulness substitute one method for another under necessity. Vulcanite, metal, or acrylic splints, arch bars, inter- or intramaxillary wiring, or the implantation of steel pins or screws into severed segments, all are as useful as the relative skill of the operator. Each of these have been used with numerous modifications and relative success. For each we can name advantages or disadvantages. The growing tendency has been to use such methods as will permit visibility and accessibility to the occlusion. Some splints have been useful for fixation, but resulted in a malocclusion which presented a problem parallel to the initial condition. Regardless of the choice or availability of intraoral methods for treating fractures of the jaws there has always been a need for external application of support or traction in some cases. Often such treatment is needed most urgently, and where technical facilities for individually constructed appliances are not easily accessible. The use of plaster head casts as cranial support for external traction wires in certain types of jaw injuries has played an important role in the treatment of maxillary and mandibular fractures. The use of this form of retention and traction requires special skill for construction. The wires have to be placed in position into the plaster while in the making and in such positions, as the operator predetermines in his mind’s eye, as to give the proper leverage for traction in the desired direction. These wires may require variation from original position, and unless auxiliary wires have been provided, such variations may be difficult or impossible. Numerous patients have been treated ingeniously by such experts as Ivy, Woodard, Richison (U. S. Navy), Stout (U. S. Army), Cope, Straith, Waldron, Balkin, who have used the plaster head casts and the general principle of cranial retention for traction support. They, however, like others, have over the years modified some advocated techniques and retained others. Numerous
98
Harry
It. Bisnof
attempts have been made by many, including the author, to create an appliance that could replace or modify the plaster cast as a cranial support for variable traction attachments. Some incorporated metal plates into plaster, or metal and leather or sponge rubber, or other bulk which did not eliminate but rather replaced the disadvantages of the cranial plaster cast. The basic requirements are for something light and flexible, an appliance that can be changed for varying head sizes, with basic major traction wires for most cases as outlined. An added advantage is the possibility that men with resourcefulness can easily make additional attachments of ordinary wire to fit into the headgear, if they wish. Today the world is faced with many changes. This war has created a need for quick action and mobility. Speed of changing positions of military placements requires procedures of therapy and treatment parallel to the needs. The treatment of special cases should not be limited to the skilled few. We need procedures that can be applied by many and do not require extensive special training. The appliance demonstrated here can shorten the time between injury and instituting treatment; it reduces the need for transporting injured to distant points for initial treatment; it makes possible the early application of treatment by men of average skill close to the scene of injury; it may be available for use wherever and whenever needed in one mobile unit; it can be used over again, and corrections or changes in angles of traction can be accomplished in a few moments if necessary. An outstanding advantage of this appliance is the fact that it eliminates the need for specially constructed plaster head casts as support for the traction wires. The construction of plaster casts is time consuming, requires special skill and facilities in making, may require shaving of the head, and at its best is not very desirable from a sanitary standpoint. In case of scalp injury, a plaster cast cannot always be applied except in certain cases where windows can be cut in the cast. In such cases treatment may have to be deferred, whereas with the headgear presented here, which leaves a good deal of the head uncovered and is easily removed for treatment, such delay is not necessary. Should tissue lacerations involve the part to be covered by the headgear, a treatment pad of felt or gauze laid around the periphery of the involved area, similar to an orthopedic or bunion pad, will permit wearing of the headgear over it. DESCRIPTION
OF APPLIANCE
The traction fracture appliance herewith ing parts, shown in Fig. 1:
presented
consists of the follow-
1. Leather headgear. 2. Retention pocket (leather) which is part of headgear and has perforations to receive traction wires. 3. Pocket which holds ligature and wire for ligating teeth or jaw for attachment to traction wires. 4-5. Shows back buckles for strapping on headgear. These are on swivel rivets to allow for variation. 6. Top straps, for use if necessary, to give added retention against sl.ipping. 7. Metal loops through which straps are placed.
B’ractures 8. 9. 10. 11. 12.
13.
14.
15.
of Jaws
99
Chin support-leather with felt base. Anterior strap for chin support attachment. Posterior strap for chin support attachment. Anterior traction bar. Dotted line shows how horizontally shaped end fits into pocket through perforation. Posterior traction angles of which there is a right and left; dotted line shows how longer horizontal part fits into pocket anteriorly, and shorter end posteriorly. Indicates end of wire, ligature, or any intraoral attachment which is attached to the teeth or jaw extends for attachment of traction wire or band. Elastic or wire traction from jaw to anterior bar. Similar traction can be applied from traction angle (12) to angle of jaw or ramus for posterior traction. Attachment wires which can fit into any desired position to provide traction of the maxilla in an upward position, varying as needed, close to the face or at a distance from it.
Fig.
1.
Directions for use of the appliance.-The headgear is strapped on the head and buckled with one hold under the occiput and the other over the back part of the crown. For anterior traction place the ends of the larger t.raction wire into the fifth hole on each side and insert into the leather pocket. The position may vary according to width of head. For lateral traction or traction at an angle off center, shift the wire to other holes, which would bring one side as many holes closer to the center as After the teeth are ligated with wire or ligathe other is moved backward. tures, or an arch wire is attached in a convenient way to the jaw or jaws, traction is created by twisting a connecting wire or by attaching a rubber band to the bar. If posterior traction is desired at the angle of the jaw or
100
Harry
L. Bisnof
ramus, place the traction angle into holes of headgear, inserting the longer end of the traction angle first, using the third or fourth hole from the back and pushing it into position toward the front of the head. The shorter end is placed in the nearest hole to the back into which it fits conveniently. The bars may be attached while the appliance is on or off of the head; it holds taut and provides a hold for anterior and posterior traction. The attachment from the rod to the part to which the force is to be applied may be with wire, elastic, or any form desired. Any or all of these attachments may be used at one time as the case warrants, and where necessary, the wires may be bent by hand to conform more accurately to specific head forms, though in most cases it may not be necessary.
Fig.
2.
Fig.
Fig.
3.
4.
The chin support is attached to the headgear with metal loops. The back one swivels, to permit change in direction of pull or hold. The shorter tape is first drawn through the back part of the buckles on right and left. The ends are brought through the loops on the swivel on both sides and returned to be attached to the buckles. This provides a firm grip under the chin.
Fractures
101
of Jaws
The following illustrations show the use of this appliance for various The distal as well purposes. Fig. 2 shows the application of the chin support. as the vertical tension can be varied. It also shows the use of posterior and anterior tractions. Fig. 3 shows the appliance adapted to exert anterior and posterior traction without the use of chin support. Fig. 4 shows the use of the appliance to give chin support only, and to apply traction forward. Fig. 5 shows the use for chin support without any traction rods, and Fig. 6 shows its use for chin support and lateral traction by means of an adjustment, placing the bar on the side. The position of this bar, of course, can be varied, placed anteriorly, distally, right and left.
Fig.
5.
Fig.
6.
SUMMARY
An appliance has been presented which will enable more men to exercise their talents in treating complicated jaw injuries. It is hoped that by the use of it, great benefit will accrue to the victims who with it can be treated more promptly and without the need of specially constructed appliances for each individual case. Furthermore, the treatment of such cases by many more men in our medical and dental corps will lessen the demand on the experts who are less numerous and not always available. With the call to service of so many men skilled in oral and plastic surgery, it would appear that a ready-made, mobile unit which may be available at casualty stations, ambulances, and hospitals, when needed, will facilitate the treatment of jaw injuries. 89 153~~ STREET
OF THE
JAWS
AN EXTERNAL TRACTION APPLIANCE HARRY L. BISNOFF, D.D.S., JAMAICA, N. Y. T IS the business and duty of military men to organize all forces for defense I and full offensive if necessary. In this effort, it is the civilian’s duty to be helpful directly and indirectly in every possible way. It is also important to be fully organized to treat and rehabilitate our military personnel in any emergency and for all contingent injuries. This must be done as speedily and efficiently as possible. This efficiency is enhanced if a given condition can be treated by the least number of attendants and with the least inconvenience of transportation of the injured. It is the duty also of those not privileged to serve with the armed forces to offer their talents or the products of their talents. We are confident that the principles of democracy, which forms the basic foundation of our government, are exercised by the officials of our armed forces whose duty it is to survey and appraise the possibilities of procedures or material offered. In the -progressive growth and changes of our war machinery and the large number of civilians directly engaged with military personnel, all offerings should be viewed from an objective, not a personal, point of view, regardless of whether the offering originates from a civilian or a military person. The present war again calls forth our resourcefulness to cope with the increased jaw and head injuries. The surgeon, orthopedist, and plastic surgeon, each alone and all together, have a grave responsibility to rehabilitate those unfortunates who have fallen victim to the blasting and destructive methods of modern warfare. Whether one is to rehabilitate the injured for return to military service, or to usefulness in civilian life, it is no less the dentist’s responsibility to coordinate his skill and knowledge with the others to help these sufferers. It is a sufficiently sad commentary on our modern age that slaughter and maiming is so widespread. It would be just as sad if modern science would not employ every possible and available means for aiding recovery and doing everything within its reach to return normal facial expressions and function to those who are injured. The drab records of the last war and the rosters of veteran hospitals give mute or vocal evidence of men who left active circles of society amidst cheers in the patriotic farewells, never to return to t.heir society circles except as objects of sympathy. A man who had part of his face or jaw shot away or who suffered severe fractures resulting in disfigurement becomes a hermit even in a metropolis. From the limited information available, the incidence of head injuries in the belligerent countries of Europe is high. The last war had its toll, but there is every reason to believe that with the magnitude of modern warfare the numbers will be higher and possibly, too, the injuries more severe, The writer has had occasion to see on the continent of Europe men whose facial deform96
Practures
of Jaws
97
ities were so grotesque, as a result of gunshot and other war injuries, that one wonders what determination these souls have to give them the impetus to fight on after the cloud of gunpowder and t,he insanity of hate had cleared. As a personal conclusion, I could say only that these men have faith. This faith which they had in those administering toward their cure giving rise to a faith accelerated by inherent hope that some day they may again face society as other human beings do, and that they too may exercise the functions of the jaws and not feel reluctant to show their facial features. There are numerous methods of treating jaw fractures. They vary in their application as does also the skill of those applying them. In the catastrophe and wholesale mauling which is now visited upon the military as well as civilian population, we must be prepared to treat facial and jaw injuries wherever and whenever they occur. Multiple injuries to the jaws, severance of continuity of the body from the ramus of the mandible, causing lack of control of the tongue, calls for quick treatment. Horizontally fractured maxillary bones, disconnected mandibular segments, or comminution of the symphysis may require the application of external appliances for traction, relief, coaptation, or to overcome occlusion of respiratory passages. No one method or appliance can be a panacea for all types of injuries. An experienced and skilled technician may by his resourcefulness substitute one method for another under necessity. Vulcanite, metal, or acrylic splints, arch bars, inter- or intramaxillary wiring, or the implantation of steel pins or screws into severed segments, all are as useful as the relative skill of the operator. Each of these have been used with numerous modifications and relative success. For each we can name advantages or disadvantages. The growing tendency has been to use such methods as will permit visibility and accessibility to the occlusion. Some splints have been useful for fixation, but resulted in a malocclusion which presented a problem parallel to the initial condition. Regardless of the choice or availability of intraoral methods for treating fractures of the jaws there has always been a need for external application of support or traction in some cases. Often such treatment is needed most urgently, and where technical facilities for individually constructed appliances are not easily accessible. The use of plaster head casts as cranial support for external traction wires in certain types of jaw injuries has played an important role in the treatment of maxillary and mandibular fractures. The use of this form of retention and traction requires special skill for construction. The wires have to be placed in position into the plaster while in the making and in such positions, as the operator predetermines in his mind’s eye, as to give the proper leverage for traction in the desired direction. These wires may require variation from original position, and unless auxiliary wires have been provided, such variations may be difficult or impossible. Numerous patients have been treated ingeniously by such experts as Ivy, Woodard, Richison (U. S. Navy), Stout (U. S. Army), Cope, Straith, Waldron, Balkin, who have used the plaster head casts and the general principle of cranial retention for traction support. They, however, like others, have over the years modified some advocated techniques and retained others. Numerous
98
Harry
It. Bisnof
attempts have been made by many, including the author, to create an appliance that could replace or modify the plaster cast as a cranial support for variable traction attachments. Some incorporated metal plates into plaster, or metal and leather or sponge rubber, or other bulk which did not eliminate but rather replaced the disadvantages of the cranial plaster cast. The basic requirements are for something light and flexible, an appliance that can be changed for varying head sizes, with basic major traction wires for most cases as outlined. An added advantage is the possibility that men with resourcefulness can easily make additional attachments of ordinary wire to fit into the headgear, if they wish. Today the world is faced with many changes. This war has created a need for quick action and mobility. Speed of changing positions of military placements requires procedures of therapy and treatment parallel to the needs. The treatment of special cases should not be limited to the skilled few. We need procedures that can be applied by many and do not require extensive special training. The appliance demonstrated here can shorten the time between injury and instituting treatment; it reduces the need for transporting injured to distant points for initial treatment; it makes possible the early application of treatment by men of average skill close to the scene of injury; it may be available for use wherever and whenever needed in one mobile unit; it can be used over again, and corrections or changes in angles of traction can be accomplished in a few moments if necessary. An outstanding advantage of this appliance is the fact that it eliminates the need for specially constructed plaster head casts as support for the traction wires. The construction of plaster casts is time consuming, requires special skill and facilities in making, may require shaving of the head, and at its best is not very desirable from a sanitary standpoint. In case of scalp injury, a plaster cast cannot always be applied except in certain cases where windows can be cut in the cast. In such cases treatment may have to be deferred, whereas with the headgear presented here, which leaves a good deal of the head uncovered and is easily removed for treatment, such delay is not necessary. Should tissue lacerations involve the part to be covered by the headgear, a treatment pad of felt or gauze laid around the periphery of the involved area, similar to an orthopedic or bunion pad, will permit wearing of the headgear over it. DESCRIPTION
OF APPLIANCE
The traction fracture appliance herewith ing parts, shown in Fig. 1:
presented
consists of the follow-
1. Leather headgear. 2. Retention pocket (leather) which is part of headgear and has perforations to receive traction wires. 3. Pocket which holds ligature and wire for ligating teeth or jaw for attachment to traction wires. 4-5. Shows back buckles for strapping on headgear. These are on swivel rivets to allow for variation. 6. Top straps, for use if necessary, to give added retention against sl.ipping. 7. Metal loops through which straps are placed.
B’ractures 8. 9. 10. 11. 12.
13.
14.
15.
of Jaws
99
Chin support-leather with felt base. Anterior strap for chin support attachment. Posterior strap for chin support attachment. Anterior traction bar. Dotted line shows how horizontally shaped end fits into pocket through perforation. Posterior traction angles of which there is a right and left; dotted line shows how longer horizontal part fits into pocket anteriorly, and shorter end posteriorly. Indicates end of wire, ligature, or any intraoral attachment which is attached to the teeth or jaw extends for attachment of traction wire or band. Elastic or wire traction from jaw to anterior bar. Similar traction can be applied from traction angle (12) to angle of jaw or ramus for posterior traction. Attachment wires which can fit into any desired position to provide traction of the maxilla in an upward position, varying as needed, close to the face or at a distance from it.
Fig.
1.
Directions for use of the appliance.-The headgear is strapped on the head and buckled with one hold under the occiput and the other over the back part of the crown. For anterior traction place the ends of the larger t.raction wire into the fifth hole on each side and insert into the leather pocket. The position may vary according to width of head. For lateral traction or traction at an angle off center, shift the wire to other holes, which would bring one side as many holes closer to the center as After the teeth are ligated with wire or ligathe other is moved backward. tures, or an arch wire is attached in a convenient way to the jaw or jaws, traction is created by twisting a connecting wire or by attaching a rubber band to the bar. If posterior traction is desired at the angle of the jaw or
100
Harry
L. Bisnof
ramus, place the traction angle into holes of headgear, inserting the longer end of the traction angle first, using the third or fourth hole from the back and pushing it into position toward the front of the head. The shorter end is placed in the nearest hole to the back into which it fits conveniently. The bars may be attached while the appliance is on or off of the head; it holds taut and provides a hold for anterior and posterior traction. The attachment from the rod to the part to which the force is to be applied may be with wire, elastic, or any form desired. Any or all of these attachments may be used at one time as the case warrants, and where necessary, the wires may be bent by hand to conform more accurately to specific head forms, though in most cases it may not be necessary.
Fig.
2.
Fig.
Fig.
3.
4.
The chin support is attached to the headgear with metal loops. The back one swivels, to permit change in direction of pull or hold. The shorter tape is first drawn through the back part of the buckles on right and left. The ends are brought through the loops on the swivel on both sides and returned to be attached to the buckles. This provides a firm grip under the chin.
Fractures
101
of Jaws
The following illustrations show the use of this appliance for various The distal as well purposes. Fig. 2 shows the application of the chin support. as the vertical tension can be varied. It also shows the use of posterior and anterior tractions. Fig. 3 shows the appliance adapted to exert anterior and posterior traction without the use of chin support. Fig. 4 shows the use of the appliance to give chin support only, and to apply traction forward. Fig. 5 shows the use for chin support without any traction rods, and Fig. 6 shows its use for chin support and lateral traction by means of an adjustment, placing the bar on the side. The position of this bar, of course, can be varied, placed anteriorly, distally, right and left.
Fig.
5.
Fig.
6.
SUMMARY
An appliance has been presented which will enable more men to exercise their talents in treating complicated jaw injuries. It is hoped that by the use of it, great benefit will accrue to the victims who with it can be treated more promptly and without the need of specially constructed appliances for each individual case. Furthermore, the treatment of such cases by many more men in our medical and dental corps will lessen the demand on the experts who are less numerous and not always available. With the call to service of so many men skilled in oral and plastic surgery, it would appear that a ready-made, mobile unit which may be available at casualty stations, ambulances, and hospitals, when needed, will facilitate the treatment of jaw injuries. 89 153~~ STREET