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Fractures of the lower jaw
FRACTURES OF THE LOWER JAW ROBERT P. BAY,
M.D.,
Professor of OraI Surgery, University
P.A.C.S. of Maryland BALTIMORE,
F
RACTURES of the mandibIe occur most frequentIy because of trauma; those due to tumors and infections are rareIy seen. Traumatic injuries resuhing in fractures of the Iower jaw are usuaIIy produced in fist fights, automobile accidents and misceIIaneous faIIs. Less than 5 per cent of mandibuIar fractures resuIt from accidents which occur whiIe the individua1 is engaged in a gainfu1 occupation. Fewer than IOO cases have been reported in the Iast twenty years to the MaryIand State Accident Commission. When such injuries do occur in the course of empIoyment, it is in such peopIe as jockeys, due to faIIs from horses; stee1 workers, struck by air hammers; seamen and stevedores, injured by. various Iifting devices; and boxers, hit by a fist. The most frequent sites of fracture, in the order named, are: through the junction of the body and the ramus, the bicuspid region, the moIar region, and the symphysis. A fracture of the condyIoid process is usuaIIy associated with a fracture of the body of the mandibIe on the opposite side. Fractures of the coronoid process are rareIy seen. UniIateraI fractures occur twice as often as the biIatera1 type. Combinations of fracture sites in biIatera1 fractures are in the foIIowing order: bicuspid region on one side and at the junction of the body and ramus on the other; the body of the mandibIe on one side and neck of the condyIe on the other; and through the body of the mandibIe on each side. ‘The diagnosis of these fractures is not usuahy difficuh. There is a history of traumatic injury, with pain, sweIIing, improper occIusion of the teeth and a partia1 Ioss of function of the lower jaw. CIinicaI examination reveaIs abnorma1 mobiIity and crepitus. Radiographic examination
AND
BRICE
M.
Professor of Exodontia,
DORSEY, University
D.D.S. of MaryIand
MARYLAND
cIearIy discIoses the Iines of fracture. In the radiographic examination, Iateral jaw pIates are taken of both sides. If the fracture occurs through the condyIe, anteroposterior views are necessary to show any IateraI dispIacement, while if the fracture is an 0ccIusaI view is at the symphysis, taken with an intraora1 fiIm. The treatment of fractures of the mandible varies according to the site of fracture, and the presence or absence of teeth. In a11 cases, simpIicity of treatment is stressed. IntraoraI impressions, compIicated spIints, undue manipuIation of the parts, and cumbersome head apparatus are avoided. The fracture shouId be reduced as soon as possibIe foIIowing the injury. If reduction is compIeted before muscuIar contraction takes place, the operation is considerabIy simpIified. When muscuIar contraction and sweIIing has taken pIace, compIete reduction cannot be accompIished immediateIy; a gradua1 reduction must be resorted to. In fractures where teeth are present, the simpIe intermaxiIIary wire eyeIet method, using the coarse grade of angIes brass Iigature wire, is used. A smaI1 Ioop is made in the wire and the ends are passed through the embrasure formed by the bicuspid teeth. One end is then brought around the IinguaI side of the first bicuspid, and the other around the IinguaI side of the second bicuspid. Both ends of the wire are brought completeIy around the bicuspids and twisted tightIy together. This gives a wire Ioop firmIy attached to the two bicuspid teeth. This same procedure is fohowed on the opposite side of the jaw and aIso in the maxiha. Pieces of wire are then passed through the eyeIets which are attached to the maxiIIary and mandibuIar teeth on each side. This brings the teeth into occIusion, and makes the maxiIIary
NBW SERIES VOL.. XLII,
No.
3
Bay,
Dorsey-Jaw
teeth a spIint for the reduction of the lower jaw. The intermaxiIIary wires have a tendency to stretch, and must therefore be
FIG.
tightened every two or three days. The wires are kept in pIace for five or six weeks. By this method of reduction, proper occIusion of the teeth is insured, no time is Iost in making spIints, and no uncomfortabIe head bandage is necessary. Some patients with fracture of the mandible have many teeth missing, so that it is necessary to use other combinations of
Fractures
American
Journal
of Surgery
533
teeth for the wires. It is occasionaIIy necessary to pIace the eyelet wire on a singIe tooth instead of using two teeth; this can
I.
be accompIished by passing the wire around the tooth twice, and then twisting the ends together. Should it be desired to appIy traction anteriorIy or posteriorIy, the eyeIet wires can be so pIaced as to make this possibIe. If upper and Iower teeth are missing, which aIIows an upward dispIacement of a posterior fragment, a piece of denta impression compound is sIightIy
534
American Journal of Surgery
Bay,
Dorsey-Jaw
softened and pIaced over the fragment. The mouth is then cIosed and the fragment is manipuIated into its proper relationship. The compound is mouIded to hoId in position during fixation. If upper teeth are missing where an eyeIet shouId be pIaced, a piece of stainTess stee1 wire is twisted around the two teeth nearest one another, making a bridge of doubIe twisted wire over the space. The intermaxiIIary communicating wire is then pIaced over the bridging wire and through the eyeIet on the Iower teeth. This wiI1 satisfactoriIy immobilize the part if it is further supported by other wires as near the area as possibIe. In cases where a11upper teeth are missing and an artificia1 upper denture is present, the Iower teeth are wired to the upper denture and then supported by a Barton bandage and two inch strips of adhesive tape. The upper denture hoIds the Iower teeth in proper occIusion and the bandage gives the necessary additiona support. Where there is a fracture of the neck of the condyIe, a piece of impression compound or gutta percha, about 2 mm. thick, is pIaced between the teeth on that side and the jaw immobiIized by intermaxiIIary wires. The condyIe wiI1 aIways assume its proper position as soon as muscuIar reIaxation takes pIace. No troubIe has been experienced with ankyIosis, either partia1 or compIete. It is striking to note how few compIications and bad resuIts foIIow fractures of the mandibIe. There have been no cases of non-union and seIdom bad anatomic or functiona resuIts. In fractures of edentuIous mandibles, reduction and fixation are accompIished by the open reduction method. Under IocaI anesthesia, the mucous membrane on the bucca1 side is incised so as to reflect sufficient tissue to expose we11 the Iine of fracture. The IinguaI mucous membrane is then reflected away from the mandibIe. With a denta driI1, hoIes are bored through the bone, and either silver or stainIess stee1 wire is threaded through the openings. The wire is then twisted to hoId the parts
Fractures
DECEMBER, 1938
together, and the mucous membrane is sutured together with bIack siIk. This wire is not removed. In most cases it is not necessary to use any form of spIint or head bandage for additiona support. The ora cavity shouId be properry cIeansed before any fracture is reduced. AI1 remaining roots and excessive saIivary caIcuIus shouId be removed. A tooth in the direct Iine of fracture shouId be removed unIess it is the Iast remaining tooth and is needed to retain the posterior fragment in proper position. If the tooth is retained at the time of reduction, it shouId be removed rater, as soon as the heaIing is sufficient to maintain the posterior fragment in position. PracticaIIy a11 of these fractures are reduced under IocaI anesthesia, conduction injections of 2 per cent novocaine being given wherever possibIe. If considerabIe manipuIation is necessary, as in cases of deIayed treatment, intravenous evipa1 is the anesthetic of choice, since it is of short duration and leaves no nausea. AI1 fractures of the mandibIe where teeth are present, are compounded through the aIveoIus of the tooth sockets; however, osteomyeIitis is rare. If incision is indicated, it is best done extraoraIIy in order to estabIish better drainage and aIIow the mucous membrane within the mouth to hear. The appIication of heat by means of short wave diathermy has been of some advantage. The patient must be properIy nourished during the period of treatment whiIe the jaws are immobiIized, but naturaIIy, this must be done by means of Iiquids. The foIIowing is a sampIe menu of a Iiquid diet for patients with immovabIe jaws. It contains approximateIy 2,410 caIories, protein 80 Gm., fat 130 Gm., and carbohydrate 230 Gm.* 8 A.M. Grapefruit juice, 200 c.c., with I tabIespoon gIucose (karo). Eggnog made with 200 C.C. miIk, sugar, one egg, one teaspoon vaniIIa flavoring. * The menu outline was prepared by the Diet SchooI of the University
HospitaI,
Baltimore,
Maryland.
NEW SERIES VOL. XLII,
IO
A.M.
12 M.
2 P.M.
6
P.M.
P.M.
Bay,
Dorsey-
CereaI grue1 made with one-haIf cup oatmeaI or other cooked cereal, one-haIf cup milk, onehalf cup cream, one teaspoon sugar, or more if desired. Cocoa made with 200 C.C. miIk, one teaspoon cocoa, two teaspoons sugar. Strained vegetabIe soup, 200 C.C. Iced chocoIate made with 200 C.C. miik, one-haIf square chocoIate, two teaspoons sugar. Orange juice, 200 c.c., with one tabIespoon gIucose (karo). Eggnog, as above. Cream soup, 200 c.c., made with one-half cup vegetabIe puree, one-haIf cup miIk, one-haIf cup cream, one square butter, thinned with water if necessary. PineappIe juice or other fruit juice, 200
8
No. 3
C.C.
Cocoa, as above; maIted milk may be used occasionaIIy instead of cocoa and chocoIate miIk. Eggnog, as above. If additiona nourishment is needed, cream may be used with the miIk
-Jaw Fractures
American
Journal
of Surgery
535
in the preparation of miIk drinks. Tea and coffee have no food vaIue unIess cream and sugar are added. The cIear karo used in the fruit juice may be dissoIved in hot water. It is routine to add IO gr. of caIcium gIuconate and IO drops of drisdo1 to the daiIy ration throughout the six weeks of treatment. Most of these cases are ambuIatory, and after the second or third week are abIe to go back to their former occupations, if their work is not too strenuous. SUMMARY
OF
TREATMENT
I. EarIy diagnosis and treatment. SimpIicity of treatment with compIete reduction and fixation. 3, CompIete radiographic examination to Iocate a11 fractures. 4. SeroIogic test for Iues and urinaIysis for diabetes. Maintain proper mouth hygiene. Sufficient and proper nourishment. Proper eIimination. 2.
M.D.,
Professor of OraI Surgery, University
P.A.C.S. of Maryland BALTIMORE,
F
RACTURES of the mandibIe occur most frequentIy because of trauma; those due to tumors and infections are rareIy seen. Traumatic injuries resuhing in fractures of the Iower jaw are usuaIIy produced in fist fights, automobile accidents and misceIIaneous faIIs. Less than 5 per cent of mandibuIar fractures resuIt from accidents which occur whiIe the individua1 is engaged in a gainfu1 occupation. Fewer than IOO cases have been reported in the Iast twenty years to the MaryIand State Accident Commission. When such injuries do occur in the course of empIoyment, it is in such peopIe as jockeys, due to faIIs from horses; stee1 workers, struck by air hammers; seamen and stevedores, injured by. various Iifting devices; and boxers, hit by a fist. The most frequent sites of fracture, in the order named, are: through the junction of the body and the ramus, the bicuspid region, the moIar region, and the symphysis. A fracture of the condyIoid process is usuaIIy associated with a fracture of the body of the mandibIe on the opposite side. Fractures of the coronoid process are rareIy seen. UniIateraI fractures occur twice as often as the biIatera1 type. Combinations of fracture sites in biIatera1 fractures are in the foIIowing order: bicuspid region on one side and at the junction of the body and ramus on the other; the body of the mandibIe on one side and neck of the condyIe on the other; and through the body of the mandibIe on each side. ‘The diagnosis of these fractures is not usuahy difficuh. There is a history of traumatic injury, with pain, sweIIing, improper occIusion of the teeth and a partia1 Ioss of function of the lower jaw. CIinicaI examination reveaIs abnorma1 mobiIity and crepitus. Radiographic examination
AND
BRICE
M.
Professor of Exodontia,
DORSEY, University
D.D.S. of MaryIand
MARYLAND
cIearIy discIoses the Iines of fracture. In the radiographic examination, Iateral jaw pIates are taken of both sides. If the fracture occurs through the condyIe, anteroposterior views are necessary to show any IateraI dispIacement, while if the fracture is an 0ccIusaI view is at the symphysis, taken with an intraora1 fiIm. The treatment of fractures of the mandible varies according to the site of fracture, and the presence or absence of teeth. In a11 cases, simpIicity of treatment is stressed. IntraoraI impressions, compIicated spIints, undue manipuIation of the parts, and cumbersome head apparatus are avoided. The fracture shouId be reduced as soon as possibIe foIIowing the injury. If reduction is compIeted before muscuIar contraction takes place, the operation is considerabIy simpIified. When muscuIar contraction and sweIIing has taken pIace, compIete reduction cannot be accompIished immediateIy; a gradua1 reduction must be resorted to. In fractures where teeth are present, the simpIe intermaxiIIary wire eyeIet method, using the coarse grade of angIes brass Iigature wire, is used. A smaI1 Ioop is made in the wire and the ends are passed through the embrasure formed by the bicuspid teeth. One end is then brought around the IinguaI side of the first bicuspid, and the other around the IinguaI side of the second bicuspid. Both ends of the wire are brought completeIy around the bicuspids and twisted tightIy together. This gives a wire Ioop firmIy attached to the two bicuspid teeth. This same procedure is fohowed on the opposite side of the jaw and aIso in the maxiha. Pieces of wire are then passed through the eyeIets which are attached to the maxiIIary and mandibuIar teeth on each side. This brings the teeth into occIusion, and makes the maxiIIary
NBW SERIES VOL.. XLII,
No.
3
Bay,
Dorsey-Jaw
teeth a spIint for the reduction of the lower jaw. The intermaxiIIary wires have a tendency to stretch, and must therefore be
FIG.
tightened every two or three days. The wires are kept in pIace for five or six weeks. By this method of reduction, proper occIusion of the teeth is insured, no time is Iost in making spIints, and no uncomfortabIe head bandage is necessary. Some patients with fracture of the mandible have many teeth missing, so that it is necessary to use other combinations of
Fractures
American
Journal
of Surgery
533
teeth for the wires. It is occasionaIIy necessary to pIace the eyelet wire on a singIe tooth instead of using two teeth; this can
I.
be accompIished by passing the wire around the tooth twice, and then twisting the ends together. Should it be desired to appIy traction anteriorIy or posteriorIy, the eyeIet wires can be so pIaced as to make this possibIe. If upper and Iower teeth are missing, which aIIows an upward dispIacement of a posterior fragment, a piece of denta impression compound is sIightIy
534
American Journal of Surgery
Bay,
Dorsey-Jaw
softened and pIaced over the fragment. The mouth is then cIosed and the fragment is manipuIated into its proper relationship. The compound is mouIded to hoId in position during fixation. If upper teeth are missing where an eyeIet shouId be pIaced, a piece of stainTess stee1 wire is twisted around the two teeth nearest one another, making a bridge of doubIe twisted wire over the space. The intermaxiIIary communicating wire is then pIaced over the bridging wire and through the eyeIet on the Iower teeth. This wiI1 satisfactoriIy immobilize the part if it is further supported by other wires as near the area as possibIe. In cases where a11upper teeth are missing and an artificia1 upper denture is present, the Iower teeth are wired to the upper denture and then supported by a Barton bandage and two inch strips of adhesive tape. The upper denture hoIds the Iower teeth in proper occIusion and the bandage gives the necessary additiona support. Where there is a fracture of the neck of the condyIe, a piece of impression compound or gutta percha, about 2 mm. thick, is pIaced between the teeth on that side and the jaw immobiIized by intermaxiIIary wires. The condyIe wiI1 aIways assume its proper position as soon as muscuIar reIaxation takes pIace. No troubIe has been experienced with ankyIosis, either partia1 or compIete. It is striking to note how few compIications and bad resuIts foIIow fractures of the mandibIe. There have been no cases of non-union and seIdom bad anatomic or functiona resuIts. In fractures of edentuIous mandibles, reduction and fixation are accompIished by the open reduction method. Under IocaI anesthesia, the mucous membrane on the bucca1 side is incised so as to reflect sufficient tissue to expose we11 the Iine of fracture. The IinguaI mucous membrane is then reflected away from the mandibIe. With a denta driI1, hoIes are bored through the bone, and either silver or stainIess stee1 wire is threaded through the openings. The wire is then twisted to hoId the parts
Fractures
DECEMBER, 1938
together, and the mucous membrane is sutured together with bIack siIk. This wire is not removed. In most cases it is not necessary to use any form of spIint or head bandage for additiona support. The ora cavity shouId be properry cIeansed before any fracture is reduced. AI1 remaining roots and excessive saIivary caIcuIus shouId be removed. A tooth in the direct Iine of fracture shouId be removed unIess it is the Iast remaining tooth and is needed to retain the posterior fragment in proper position. If the tooth is retained at the time of reduction, it shouId be removed rater, as soon as the heaIing is sufficient to maintain the posterior fragment in position. PracticaIIy a11 of these fractures are reduced under IocaI anesthesia, conduction injections of 2 per cent novocaine being given wherever possibIe. If considerabIe manipuIation is necessary, as in cases of deIayed treatment, intravenous evipa1 is the anesthetic of choice, since it is of short duration and leaves no nausea. AI1 fractures of the mandibIe where teeth are present, are compounded through the aIveoIus of the tooth sockets; however, osteomyeIitis is rare. If incision is indicated, it is best done extraoraIIy in order to estabIish better drainage and aIIow the mucous membrane within the mouth to hear. The appIication of heat by means of short wave diathermy has been of some advantage. The patient must be properIy nourished during the period of treatment whiIe the jaws are immobiIized, but naturaIIy, this must be done by means of Iiquids. The foIIowing is a sampIe menu of a Iiquid diet for patients with immovabIe jaws. It contains approximateIy 2,410 caIories, protein 80 Gm., fat 130 Gm., and carbohydrate 230 Gm.* 8 A.M. Grapefruit juice, 200 c.c., with I tabIespoon gIucose (karo). Eggnog made with 200 C.C. miIk, sugar, one egg, one teaspoon vaniIIa flavoring. * The menu outline was prepared by the Diet SchooI of the University
HospitaI,
Baltimore,
Maryland.
NEW SERIES VOL. XLII,
IO
A.M.
12 M.
2 P.M.
6
P.M.
P.M.
Bay,
Dorsey-
CereaI grue1 made with one-haIf cup oatmeaI or other cooked cereal, one-haIf cup milk, onehalf cup cream, one teaspoon sugar, or more if desired. Cocoa made with 200 C.C. miIk, one teaspoon cocoa, two teaspoons sugar. Strained vegetabIe soup, 200 C.C. Iced chocoIate made with 200 C.C. miik, one-haIf square chocoIate, two teaspoons sugar. Orange juice, 200 c.c., with one tabIespoon gIucose (karo). Eggnog, as above. Cream soup, 200 c.c., made with one-half cup vegetabIe puree, one-haIf cup miIk, one-haIf cup cream, one square butter, thinned with water if necessary. PineappIe juice or other fruit juice, 200
8
No. 3
C.C.
Cocoa, as above; maIted milk may be used occasionaIIy instead of cocoa and chocoIate miIk. Eggnog, as above. If additiona nourishment is needed, cream may be used with the miIk
-Jaw Fractures
American
Journal
of Surgery
535
in the preparation of miIk drinks. Tea and coffee have no food vaIue unIess cream and sugar are added. The cIear karo used in the fruit juice may be dissoIved in hot water. It is routine to add IO gr. of caIcium gIuconate and IO drops of drisdo1 to the daiIy ration throughout the six weeks of treatment. Most of these cases are ambuIatory, and after the second or third week are abIe to go back to their former occupations, if their work is not too strenuous. SUMMARY
OF
TREATMENT
I. EarIy diagnosis and treatment. SimpIicity of treatment with compIete reduction and fixation. 3, CompIete radiographic examination to Iocate a11 fractures. 4. SeroIogic test for Iues and urinaIysis for diabetes. Maintain proper mouth hygiene. Sufficient and proper nourishment. Proper eIimination. 2.